EMT Training Course Crown Point ALS and BLS System Protocol

INTRODUCTION
The FHCP EMS Guidelines are collectively composed of administrative and clinical guidelines, standing medical orders,
and other information of interest to EMS Personnel. They represent the cumulative efforts of many physicians, nurses, and
EMS Personnel who have served the community over many years. The Guidelines will continue to evolve to keep pace
with advances in the science and practice of emergency medical services.
The Guidelines provide Sponsored EMS Provider Organizations and personnel with clinical guidance in the provision of
care; they form a framework for the care of patients in the out-of-hospital environment. They also identify mechanisms of
system governance; establish practice prerequisites and requirements; and delineate procedures for training, certification,
and continuing education (including EMS audit and review). The laws of the State of Indiana and, specifically, the
Administrative Code of the Indiana EMS Commission form a basic reference. These Guidelines are additions to or
expansions of the Code and are the result of local physician and hospital guidance of out-of-hospital patient care.
These Guidelines are effective as of July 2022, with subsequent revisions as noted. They supersede and replace any prior
Guidelines and will be adhered to by all EMS Provider Organizations and personnel practicing under the authority of the
FHCP EMS Guidelines. Specific and detailed information about FHCP EMS sponsored education can be found in the
FHCP EMS Education Training Calendar.
It is the responsibility of Sponsored EMS Provider Organizations to make the Guidelines available to their EMS
Personnel. Under Indiana law, one copy must be kept at all times, in each state certified EMS vehicle. A downloadable
copy of the most current edition of the Guidelines (in .pdf Portable Document Format) and other information of interest to
FHCPEMS authorized EMS Personnel is available on the system app.
Color-Coded levels used in the Guidelines:
EMR EMT AEMT Paramedic
Because EMS Personnel in the FHCP System may function at any of four levels of EMS certification, licensure, and
authorization, color-coded symbols are used to differentiate the levels. Unless specifically noted, all Guidelines apply to
all levels of certification and authorization. Level-specific guidelines, or portions of them, are annotated with the
appropriate color, either at the top of the page (when applicable to the entire Guideline) or after the appropriate section
header or item (when applicable to a specific portion of a Guideline).
In the Standing Medical Orders, scenario-specific numbered interventions are preceded color and level indicating the
minimum level of certification necessary to perform that intervention. The color does not mean that an individual with a
higher level of certification should not perform the intervention if appropriate to the specific clinical encounter (see
Standing Medical Orders).
We would like to thank everyone who provided input that contributed to the 2022 guidelines/protocol updates.
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State of Indiana
Levels of EMS Certification/Licensure
Level Minimum Initial Scope of Treatment Skills ContinuingEducation
Training Hours
Caller interrogation
Emergency 24 classroom and skills
Triage decisions
24 hrs, including 12hrs of audit and
review, every 2 yrs
Medical Dispatcher Information transmission
(EMD) Telephone medical intervention
Logistics and resource coordination
Emergency 49.5 classroom and skills Scene and patient assessment 20 hrs, including
Automated defibrillation
Medical Responder CPR
(EMR) Oxygen therapy; OP and NP airways
BVM ventilatory support
Patient stabilization and movement
Splinting and bandaging
Newborn delivery
Intranasal Naloxone administration
Emergency 151-159 total hours All the 1st Responder skills plus: 40 hrs, including 6 hrs of audit and
Non-visualized airways; pulse oximetry review, plusverification of skill
Medical Technician Including 16 hours of mandatory clinical time.
Automatic Transport Ventilator (ATV) competency, every 2 yrs
(EMT) Manually Triggered Ventilator (MTV)
Spine immobilization
Traction Splinting
Medications (oral glucose, aspirin, epinephrine auto-
injectors and IM for anaphylaxis, activated
charcoal, certain patient assisted medications)
Mechanical CPR
IV line maintenance
Ambulance operations
Mechanical patient restraint
Blood glucose measurement
12-Lead ECG Acquisition & Transmission
Advanced EMT plus: All the EMT skills plus: 54 hrs, including 12 hrsof audit and
160 NES Core Hours Peripheral IV insertion review, plusverification of skill
Emergency Intraosseous insertion competency, every 2 yrs
2.5 12-Lead
Medical Technician 162.5 total hours, plus
IV/IO fluid administration
IV dextrose administration
~Administer 15 medications
IV naloxone administration
~Initiate 25 successful IV’s SQ or IM epinephrine for anaphylaxis
~Ventilate 20 live patients Inhaled beta agonist
~ Demonstrate the ability to perform an IM glucagon
assessment on: Nitrous Oxide for analgesia
x Pediatric
x Adult
x Geriatric
~Demonstrate ability to perform an adequate
assessment & formulate & implement a
treatment plan for:
x Chest Pain
x Respiratory Distress
x Altered Mental Status
Paramedic EMT plus: All the skills of an AEMT plus: 72 hrs, including 12 hrsaudit and
452 Hours. Including Internship, BiPAP/CPAP/PEEP review, plus verification of skill
course should range between Needle chest decompression competency every 2 yrs
1000-1300 Hours, to include Chest tube monitoring
~No fewer than 50 attempts at airway Percutaneous cricothyrotomy
management across all age levels, with a 90% EtCO2/Capnography
success rate utilizing endotracheal intubation NG/OG tube
in their last 10 attempts. Nasal and oral endotracheal intubation
~Must be 100% successful in the Airway obstruction removal via laryngoscopy
management of their last 20 attempts at ECG interpretation
airway management. Interpretive 12-Lead ECG
~Clinical experience must include operating Blood chemistry analysis
room, recovery room, ICU, coronary care Central line monitoring
department, labor and delivery room, Venous blood sampling
pediatrics, and emergency department. Endotracheal medication administration
~All students must have adequate exposure, IV/IO medication administration (push & infusion)
as determined by the program medical Rectal medication administration
director and advisory committee, to pediatric, Topical medication administration
obstetric, psychiatric, and geriatric patients. Accessing implanted central IV port
~All students must complete a Field Maintenance of blood administration
Internship and successfully manage, assess, Thrombolytic initiation
and treat patients. Minimum Team Leads Morgan lens
must be established by the program medical Cardioversion
director and advisory committee and Carotid massage
completed by every student. Manual defibrillation, cardioversion, pacing (TCP)
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FHCP EMS System Sponsored Departments
Dept Name Level Transport/Non-Transport
Cedar Lake Fire Dept ALS/Paramedic Transport
Crown Point Fire Dept ALS/Paramedic Transport
Franciscan Crown Point EMS ALS/Paramedic Transport
Keener EMS ALS/Paramedic Transport
Newton County EMS ALS/Paramedic Transport
New Carlisle EMS ALS/Paramedic Transport
St. John Fire Dept ALS/Paramedic Transport
Schererville Fire Dept ALS/Paramedic Transport
Tri Creek EMS ALS/Paramedic Transport
Valparaiso Fire Dept. ALS/Paramedic Transport
Cass County EMS ALS/Paramedic Transport
Hebron Fire Dept BLS Non-Transport
Lake Dale Fire Dept BLS Non-Transport
Lake Ride Fire Dept BLS Non-Transport
Lake Village Fire Dept BLS Non-Transport
Lowell Fire Dept BLS Non-Transport
Cedar Lake PD EMR/Law Enforcement Non-Transport

Crown Point PD EMR/Law Enforcement Non-Transport
Lake County Sheriff EMR/Law Enforcement Non-Transport
Jasper County Sheriff EMR/Law Enforcement Non-Transport
Newton County Sheriff EMR/Law Enforcement Non-Transport
Schererville PD EMR/Law Enforcement Non-Transport
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Infectious Disease Control
Sponsored EMS Provider Organizations, to which 29 CFR 1910.1030 and associated federal regulations apply, bear the
sole responsibility for complying with those regulations; they must provide and implement the documentation, training,
personal protective equipment (PPE), procedures, etc., that the regulations prescribe.
The FHCP EMS System is not responsible for ensuring Sponsored EMS Provider Organization compliance with
applicable federal regulations.
The FHCP EMS System is available for consultation on EMS matters and will endeavor to assist Sponsored EMS
Provider Organizations in complying with applicable federal regulations. The requirements of 29 CFR 1910.1030 include,
but are not limited to:
• Development of an exposure control plan to minimize the risk of occupational exposure. The plan must
contain the following elements:
o Exposure determinations for the purpose of ascertaining which personnel are at risk for sustaining
occupational exposure, and which tasks are likely to produce occupational exposure.
o The schedule and method of implementation for complying with the regulation.
o The procedure for the evaluation of exposure incidents.
• Institution of engineering and work practice controls to eliminate or minimize the risk of exposure, including
hand washing and glove requirements, needle handling requirements, use of appropriate “sharps” containers,
body fluid handling requirements, etc.
• Provision, care, and enforcement of the use of appropriate PPE.
• Maintenance of a clean and sanitary work site.
• Availability of hepatitis B vaccination to all personnel at risk for occupational exposure, and post-exposure
follow-up for all personnel who have an exposure incident.
• Development of a comprehensive plan for a confidential medical evaluation following the report of an
exposure incident.
STATEMENT REGARDING PHYSICIAN(S) ON SCENE
Medical Direction, from a Physician intervener present at the scene and in physical contact with the patient may
be accepted ONLY after ALL of the following criteria have been met:
x Intervener provides appropriate identification
x Confirmation has been received from the base physician
x Communication between intervener and base physician has taken place by radio, land line, or
cellular telephone
x Intervener agrees to accompany patient in the ambulance to the hospital
The Base physician may resume control at any time. The EMS provider will not serve as a mediator between
intervener and base physician.
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Table of Contents
INTRODUCTION FROM THE EMS MEDICAL DIRECTOR AND EMS DIRECTOR .................................. ii
1.0 CARDIAC EMERGENCIES ........................................................................................................................1
1.1 Cardiac Arrest: Termination of Resuscitation ..............................................................................................2
1.2 Cardiac Arrest: PEA and Asystole ...............................................................................................................3
1.3 Cardiac Arrest: V-Fib / Pulseless V-Tach ....................................................................................................4
1.4 Cardiac: Acute Coronary Syndrome ............................................................................................................5
1.5 Cardiac: Cardiogenic Shock .........................................................................................................................6
1.6 Cardiac: Wide Complex Tachycardia with a Pulse ......................................................................................7
1.7 Cardiac: Narrow Complex Tachycardia .......................................................................................................8
1.8 Cardiac: Symptomatic Bradycardia / Heart Blocks .....................................................................................9
1.9 Cardiac: Return of Spontaneous Circulation (ROSC) ..............................................................................10
2.0 MEDICAL EMERGENCIES......................................................................................................................11
2.1 Medical: Acute Abdominal Pain, Nausea/Vomiting ..................................................................................12
2.2 Medical: Combative Patient / Excited Delirium Syndrome ......................................................................13
2.3 Medical: Allergic Reaction / Anaphylaxis .................................................................................................14
2.4 Medical: Diabetic Emergencies .................................................................................................................15
2.5 Medical: Overdose or Toxic Exposure.......................................................................................................16
2.6 Medical: Non-Traumatic Pain Management ..............................................................................................17
2.7 Medical: Seizures .......................................................................................................................................18
2.8 Medical: Sepsis...........................................................................................................................................19
2.9 Medical: Heat Related Illness ....................................................................................................................20
2.10 Medical: Cold Related Illness Suspected Stroke......................................................................................21
2.11 Medical: Stroke…………………………………………………………………………………………22
3.0 RESPIRATORY EMERGENCIES ............................................................................................................23
3.1 Respiratory: Acute Asthma and Status Asthmaticus..................................................................................24
3.2 Respiratory: Acute Pulmonary Edema.......................................................................................................25
3.3 Respiratory: COPD Exacerbation ..............................................................................................................26
3.4 Respiratory: Rapid Sequence Airway .................................................................................................. 27-28
4.0 TRAUMA EMERGENCIES .......................................................................................................................29
4.1 Trauma: Trauma Transport Guidelines ......................................................................................................30
4.2 Trauma: Field Triage Guidelines of Injured Patients .................................................................................31
4.3 Trauma: Routine Trauma Care ...................................................................................................................32
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4.4 Trauma: Spinal and Head Injury ...............................................................................................................33
4.5 Trauma: Spinal Clearance .........................................................................................................................34
4.6 Trauma: Burns ............................................................................................................................................35
4.7 Trauma: Burn Rule of Nines ......................................................................................................................36
4.8 Trauma: Hemorrhagic Shock ....................................................................................................................37
4.9 Trauma: Musculoskeletal Injuries .............................................................................................................38
4.10 Trauma: Chest Trauma .............................................................................................................................39
4.11 Trauma: Crush Injuries.............................................................................................................................40
4.12 Trauma: Pregnancy and Trauma .............................................................................................................41
4.13 Trauma: Traumatic Arrest…………………………………………………………………………42-43
5.0 OB/GYN EMERGENCIES .........................................................................................................................44
5.1 OB/GYN Maternal Care ............................................................................................................................45
5.2 OB/GYN Childbirth ...................................................................................................................................46
5.3-5.6 OB/GYN Complications……………………………………………………………………………..47-50
5.7 OB/GYN Care of the Neonate ....................................................................................................................51
5.8 OB/GYN Vaginal Bleeding .......................................................................................................................52
5.9 OB/GYN Eclampsia....................................................................................................................................53
6.0 PEDIATRIC EMERGENCIES…………………………………………………………………………..54
6.1 Pediatric: Routine Pediatric Care ...............................................................................................................55
6.2 Pediatric: Cardiac Arrest: Asystole or PEA ...............................................................................................56
6.3 Pediatric: Cardiac Arrest: V-Fib / Pulseless V-Tach .................................................................................57
6.4 Pediatric: Bradycardia ................................................................................................................................58
6.5 Pediatric: Tachycardia ................................................................................................................................59
6.6 Pediatric: Acute Asthma.............................................................................................................................60
6.7 Pediatric: Anaphylaxis / Allergic Reaction ................................................................................................61
6.8 Pediatric: Diabetic Emergencies ................................................................................................................62
6.9 Pediatric: Hypoperfusion / Sepsis ..............................................................................................................63
6.10 Pediatric: Nausea and/or Vomiting ..........................................................................................................64
6.11 Pediatric: Overdose or Toxic Exposure ...................................................................................................65
6.12 Pediatric: Pain Management.....................................................................................................................66
6.13 Pediatric: Seizures ....................................................................................................................................67
6.14 Pediatric: Pediatric Trauma: Hypoperfusion / Hypovolemia ..................................................................68
6.15 Pediatric: Pediatric Trauma: Burns .........................................................................................................69
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7.0 SPECIAL SITUATIONS………………………………………...... ........................................................70
7.1-7.2 Special: Ventricular Assist Device ................................................................................................ 71-72
7.3 Special: Medical Device Dependent Transport ..........................................................................................73
7.4-7.5 Special: Mass Casualty Incidents/Start Triage .............................................................................. 75-76
7.7 Special: Ambulance Diversion ..................................................................................................................77
7.8 Special: Patient Refusal of Treatment, Transport or Procedure .................................................................78
7.9 Special: ALS Assist/Intercept ....................................................................................................................79
8.0 PROCEDURES ............................................................................................................................................80
8.1 Procedure: Airway Management ................................................................................................................81
8.2 Procedure: CPAP........................................................................................................................................82
8.3-8.4 Procedure: Single Lumen………………………………………………………………………...83-84
8.5 Procedure: Endotracheal Intubation:……………………………………………………………………85

8.6-8.7 Procedure: Rapid Sequence Airway Checklist: ........................................................................... 86-87
8.8 Procedure: Cricothyrotomy .................................................................................................................. …88
8.9 Procedure: Pediatric Needle Cricothyrotomy ............................................................................................89
8.10 Procedure: Pertrach Cricothyrotomy........................................................................................................90
8.11 Procedure: Needle Chest Decompression ................................................................................................91
8.12-8.13 Procedure: IO Access................................................................................................................. 92-93
8.14 Procedure: External Jugular Access .........................................................................................................94
8.15 Procedure: Intranasal Medication Administration ...................................................................................95
8.16-8.18 Procedure: Intramuscular Injection ........................................................................................... 96-98
8.19 Procedure: Subcutaneous Injection .........................................................................................................99
8.20-8.21 Procedure: 12 Lead EKG Acquisition .................................................................................. 100-101
8.22 Procedure: Buccal Administration of Glucose ......................................................................................102
8.23 Procedure: Taser Removal .....................................................................................................................103
9.0 MEDICATION FORMULARY..................................................................................................................97
9.1 Approved Mediations (page numbers on chart) ............................................................................... 105-145
10.0 FHCP SYSTEM POLICIES ...................................................................................................................146
10.1 Policy: Documentation ..........................................................................................................................147
10.2 Policy: System Entry Requirements .......................................................................................................148
10.3 Policy: Continuing Education………………………………………………………………………….149
10.4 Policy: EMT Continuing Education Requirements ................................................................................150
10.5 Policy: Advanced EMT Continuing Education Requirements ..............................................................151
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10.6 Policy: Paramedic Continuing Education Requirements .......................................................................152
10.7 Policy: Corrective Action .......................................................................................................................153
11.0 Canine Guidelines: ………………………………………………………………154-160
INTRODUCTION FROM THE EMS MEDICAL DIRECTOR AND EMS PROGRAM DIRECTOR
STATEMENT REGARDING PHYSICIAN(S) ON SCENE
Medical Direction, from a Physician intervener present at the scene and in physical contact
with the patient may be accepted ONLY after ALL of the following criteria have been met:
x Intervener provides appropriate identification
x Confirmation has been received from the base physician
x Communication between intervener and base physician has taken place by
radio, land line, or cellular telephone
x Intervener agrees to accompany patient in the ambulance to the hospital
The Base physician may resume control at any time. The EMS provider will not serve as a
mediator between intervener and base physician.
Our Commitment to EMS
Franciscan Health Crown Point Hospital EMS Staff will continue to evaluate current EMS and
Medical literature to update the protocols to optimize the outcomes of our patients. We will
continue to perform CQI audits of patient care to develop training programs that will improve
care as a whole throughout the region. We hope that these protocols make your job easier,
and assist you in the care of your patients.
We would like to thank everyone who provided input that contributed to the 2022 protocols
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Cardiac Guidelines 1.0
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Cardiac: Termination of 1.1

Resuscitation
Revised July 2022
 Resuscitative efforts for patients in cardiac arrest should NOT be initiated if:

Patient presents with significant dependent lividity, rigor mortis, decomposition and/or injuries incompatible
with life such as
 Evidence of massive blunt head, chest and or abdominal trauma
 Third degree burns over 90% of the total body surface area.
 Family presents a signed Out of Hospital DNR (Do Not Resuscitate)
 Family presents a signed Physician Orders for Scope of Treatment (POST)
 Health care facility Staff presents a signed DNR (Do not Resuscitate) order.
For all other patients in cardiac arrest, in whom appropriateness of resuscitation is questionable, the EMS provider
MUST start BLS care, including defibrillation while awaiting arrival of a paramedic unit.
EMERGENCY MEDICAL RESPONDER / EMT STOP
Consider Field termination of resuscitation ONLY if patient meets ALL of the following:
 Completed protocol appropriate for presenting rhythm with NO response to interventions

 Non-hypothermic
 Older than 18 years old
 No communication failure with family
 Family can understand what termination of resuscitation means.
 Consider “2 minute” warning to give family time to prepare for termination.
 If at any time during ALS care, appropriateness of resuscitation is questionable, consult MEDICAL CONTROL
physician for assistance
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3
Cardiac: PEA and Asystole 1.2
Revised July 2022

 Recognize absence of responsiveness and pulses. Call for ALS Assist.
 CPR and AED
 Insert OPA or NPA, provide ventilations via BVM with 100% oxygen at 2 breaths per 30 compressions. Do not over ventilate.
 Check for DNR
 Perform 2 minute cycles of high quality CPR (hard and fast) Rate should be at least 100-120 beats per minute. Should feel carotid pulses
to correspond with compressions if adequate.
 Rotate compressor at least every two minutes
 Secure airway with medically approved advanced non-visualized airway
 Ventilate at 1 breath every six seconds. No need to stop compressions for ventilations
 Vascular Access IV/IO
 Epinephrine 1:10,000 dose 1mg IV/IO; repeat every 3-5 minutes
 Cardiac Monitor
 Consider and treat Reversible Causes (H’s and T’s)
 Place advanced airway as appropriate after a minimum of 4 minutes (2 cycles) of CPR.
 Consider Sodium Bicarb. 1meq/kg IV/IO in cases of prolonged down time or renal patents only
Refer to the Cardiac: Termination
Key Points/Considerations
 IO access should be considered and may be established as initial access for patients in cardiac arrest.
 Do not allow IV/IO access, drug delivery, or advanced airway placement to cause delay > 10 sec. in chest compressions or
defibrillation
 Consider and possibly treat contributing factors including: Hypoxia, Hypovolemia, Hypothermia, Hyper-/Hypokalemia, Hy-
drogen Ion (Acidosis), Tension Pneumothorax, Cardiac Tamponade, Toxins, Thrombosis Coronary and/or Pulmonary
 Waveform Capnography/End-Tidal CO2 must be used for assessment of chest compression effectiveness( >10mmHg), ad-
vanced airway placement, and ROSC (abrupt increase in PET CO2 >40mmHg). Should feel carotid pulses to correspond
with compressions.
 Epinephrine needs to given as soon as possible as ROSC is reduced by 4% for every minute you delay in administering it.
 DO NOT administer Bicarb and Calcium chloride in the same site without flushing the line with 20cc of saline first.
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4
Cardiac: V-Fib / Pulseless V-Tach 1.3
Revised July 2022

 Recognize absence of responsiveness and pulses. Call for ALS Assist.
 CPR and AED
 Insert OPA or NPA, provide ventilations via BVM with 100% oxygen at 2 breaths per 30 compressions. Do not over venti-
late.
 Check for DNR
 Perform 2 minute cycles of high quality CPR (hard and fast) Rate should be at least 100-120 beats per minute
 Rotate compressor at least every two minutes
 Secure airway with medically approved advanced non-visualized airway
 Ventilate at 1 breath every six seconds. No need to stop compressions for ventilations
 Place advanced airway as appropriate after a minimum of 4 minutes (2 cycles) of CPR.
 Persistent V-Fib/V-Tach consider 300mg of Amiodarone. May repeat at 150mg.
 If no change with Amiodarone consider Lidocaine 1-1.5 mg/KG IV/IO every 10 min.
 Consider Sodium Bicarb. 1meq/kg IV/IO in cases of prolonged down time or renal patents only
 Consider Calcium Chloride: 10ml IV/IO in patients with renal failure
 Refer to the Cardiac: Termination of Resuscitation as needed
 IO access should be considered and may be established as initial access for patients in cardiac arrest.
 Defibrillate at 200j biphasic, subsequent doses should be equivalent and higher doses should be considered. Continue com-
pressions while device is charging. Follow shock, drug, shock drug regimen.
 Medications must be administered during 2 minute interval of compressions with 10cc NS Flush.
 Consider and possibly treat contributing factors including: Hypoxia, Hypovolemia, Hypothermia, Hyper-/Hypokalemia,
Hydrogen Ion (Acidosis), Tension Pneumothorax, Cardiac Tamponade, Toxins, Thrombosis Coronary and Thrombosis Pul-
monary
 Do not allow IV/IO access, drug delivery, or advanced airway placement to cause significant delay in chest compressions or
defibrillation
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5
Cardiac: Acute Coronary Syndrome 1.4
Revised July 2022

 ABC
 Apply appropriate oxygen therapy
 Vital signs
 Have AED available
 Acquire and send 12 lead EKG ASAP if available.

 Aspirin 324 mg (4 x 81 mg tabs)
 May withhold aspirin administration if patient has true allergy to ASA
 Assist patient with their own prescribed Nitroglycerin (up to 3 dose maximum), if systolic BP is greater than 90 mmHg prior
to each administration.
 Obtain Blood Glucose
 Maintain SPO2 greater than 90%
 Cardiac Monitor with 12 lead in 5-10 min of patient contact and  Must have IV with fluids hanging first. Check BP prior to each
transmit dose.
 Notify MEDICAL CONTROL physician AS SOON AS POSSI-  ONLY IF severe chest pain (> 8 on Pain Scale) administer the
BLE if STEMI identified following
 If elevation in Leads II, III, aVF check for more than 1mm of  Fentanyl 25 - 100 mcg slow IV
ST elevation V1 and or V2. If present, DO NOT give nitroglyc-
erin.  Additional IV access as needed while enroute if time permits
 Normal Saline 500 cc fluid bolus except in presence of pulmo-  Contact medical control for treatment of pain that is not severe,
nary edema less than 8/10
 If pulmonary edema present refer to cardiogenic shock protocol
 Nitroglycerin 0.4 mg SL; repeat every 5 minutes to max 3 dos-

es
 Focus on maintaining ABC, pain relief, rapid identification, rapid notification and rapid transport
 Stabilize patient, begin ALS interventions as found on scene prior to transitioning to the ambulance provided that the scene
is safe.
 Monitor lung sounds every 5 minutes for rales, if present, discontinue fluid bolus.
 Do not administer nitroglycerin if the patient has taken Sildenafil (Viagra) or Vardenafil (Levitra) within the last 6 hours or
Tadalafil (Cialis) within the last 48 hours
 Inferior= II, III, AVF, Lateral= I, AVL,V 5, V6, Anterior/septal= V1-V4
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Cardiac: Cardiogenic Shock 1.5
Revised July 2022

 ABC
 Vital signs
 Place patient supine unless dyspnea is present
 Call for ALS assist.
 Vascular access, .
 9NS 1000cc. Administer 250cc bolus increments until blood pressure is maintained at 90 systolic. 

 Maintain SPO2 of 94% to 99%,
 Consider CPAP, ventilate with BVM in order to maintain SPO2 of at least 94%.
 Consider intubation if patient is not benefitting from CPAP and or level of consciousness does not improve.
 12 lead ECG and transmit
 Notify Medical Control ASAP if STEMI present
 Consider Dopamine IV infusion 5-10 mcg/min. Maintain B/P >90 systolic.

If patient remains unstable following fluid bolus or the patient has pulmonary edema
Maintain Systolic BP of 90mmHg.
 UNSTABLE in relation to cardiogenic shock is defined as systolic BP less than 90 mmHg and/or decreased level of con-
sciousness.
 CPAP reduces Blood Pressure by increasing intrathoracic blood pressure and impairing blood return. Consider using lower
pressures if effective.
 Refer to appropriate Dysrhythmia protocol as needed
 Monitor lung sounds for every 5 minutes for rales if present hold fluid bolus
 Stabilize patient, begin ALS interventions as found on scene prior to transitioning to the ambulance provided that the scene
is safe.
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7
Cardiac: Wide Complex Tachycardia 1.6

with a Pulse
Revised July 2022
 ABC
 Vital signs, recognize HR of 150 BPM or greater, Request ALS Assist.
 Vascular access,
 .9NS 1000cc bag hanging slow KVO.
 .9NS with 1000cc bag hanging, KVO rate.
UNSTABLE
 If time permits administer Versed 5mg for sedation.
 Synchronized cardioversion at 100J; repeat to max X3 attempts.
 If cardioversion fails follow drug regiment for STABLE patient
STABLE
 If rhythm is converted, administer a loading dose of Amiodarone 150mg in a 100cc bag over 10 min.
Secondary Treatment:
 Procainamide 1gm in 50cc NS via 60gtt set. 1gtt per second until arrhythmia is suppressed, hypotension en-
sues, QRS widens by 50% or 17mg/kg adm.
 Magnesium Sulfate 2 grams diluted in 10mL NS over 5-10 minutes IV for Torsade de Pointes
 UNSTABLE is defined as ventricular rate greater than 150 bpm with symptoms of chest pain, dyspnea, altered mental sta-
tus, pulmonary edema, or hypotension (systolic BP less than 90 mmHg)
 Wide Complex is defined as a QRS complex greater than 0.12 seconds
 Cardioversion should be increased in a stepwise fashion at 100, 150 and 200 joules
 Initially may consider Adenosine only if regular and monomorphic – Initial dose 6mg, 2nd dose 12mg if unable to differen-
tiate between narrow and wide complex.
 Procainamide infusion should be started once arrhythmia converts. Refer to chart for clarification.
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Cardiac: Narrow Complex 1.7

Tachycardia
Revised July 2022
 ABC
 Vital signs, recognize HR of 150 BPM or greater, Request ALS Assist.
 .9NS 1000cc bag hanging slow KVO.
 Obtain 12 lead EKG and transmit
 Valsalva Maneuvers X3 attempts
 Cardiac Monitor Consider Wolff-Parkinson-White (WPW) if HR over 220 and young

age
IF UNSTABLE / symptomatic
 AVOID Adenosine and Cardizem
 Consider Versed 5mg IVP if time permits for sedation.
 Primary Treatment:
 Synchronized cardioversion; 50 J regular, 120 J irregular,
repeat to max 3 times  Amiodarone 150 mg diluted in 15 mL NS IV over 10 min
IF STABLE and symptomatic

 REGULAR Rhythm:
 Procainamide 20 mg/min; max 17 mg/kg
 Adenosine 6 mg rapid IV push followed by 20ml NaCl bolus
 Adenosine 12 mg rapid IV push; followed by 20ml NaCl

bolus
 IRREGULAR Rhythm: (Atrial Flutter or Atrial Fibrillation)
 Ventricular rate greater than150 bpm
 Cardizem 15-20mg via 100cc bag with 60dr tubing run open.
 Ventricular rate less than 150 bpm
 Consult MEDICAL CONTROL
 UNSTABLE is defined as a ventricular rate at or above 150 bpm with symptoms of any of the following: chest pain, dysp-
nea, AMS, pulmonary edema or hypotension (systolic BP less than 90 mmHg).
 Cardioversion should be administered at increasing doses of 50 to 100 joules increments.
 Treatment is indicated in acute presentations of Afib/Flutter only. CONTACT MEDICAL CONTROL rhythm onset is with-
in 48 hours or greater.
 Often Afib with RVR is the result of an underlying medical condition such as sepsis. Failure to identify and treat the under-
lying cause first will result in patient decompensation.
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Cardiac: Symptomatic Bradycardia / 1.8

Heart Blocks
Revised July 2022
 ABC
 Vital signs, Recognize if patient is symptomatic and call for ALS Assist.
 Vascular access, .
 9NS 1000cc bag hanging slow KVO.
IF UNSTABLE
 Begin external transcutaneous pacing beginning at 10 mA and 70 BPM increasing mA to effect. Maintain Systolic BP
of 90 mmHg.
 Consider Versed (Midazolam) 5 mg IVP for sedation if time permits
 Consider Fentanyl 25-50mcg slow IVP for pain management
IF STABLE
 Place patient on pacer pads and monitor V/S and LOC closely.
 If patient starts to deteriorate refer to above procedures.
 IF STABLE but symptomatic administer Atropine 1 mg every 3-5 minutes max 3mg.
 Epinephrine Infusion, start at 2mcg/min titrate to effect, max 10mcg/min.
 1mg epi 1:10,000 in 250cc NS with 60gtt set. Start at 30gtt/min (2mcg/min)
 Consider Dopamine IV infusion 5-10 mcg/min. Maintain B/P >90 systolic.
 UNSTABLE is defined as a ventricular rate at or above 150 bpm with symptoms of any of the following: chest pain, dysp-
nea, AMS, pulmonary edema or hypotension (systolic BP less than 90 mmHg).
 Cardioversion should be administered at increasing doses of 50 to 100 joules increments.
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Cardiac: Return of Spontaneous 1.9

Circulation (ROSC)
Revised July 2022
 Recognize return of central pulses at two minute rhythm check, Call for ALS assist
 Stop CPR
 Manage ABC, continue ventilations via rescue breaths if no spontaneous respirations.
 Maintain oxygen saturation greater than 94%
 Vital Signs every 5 minutes
 Elevate Head 30 degrees
 Remove clothing to patient undergarments, preserve dignity of the patient, cover with sheet.
 Obtain 12 lead EKG and transmit 

 Vascular Access .
 9 NS with 1000cc bag hanging KVO
 Place advanced airway if not already performed, do not hyperventilate.
 Provide one ventilation every 6 seconds.
 Maintain systolic BP greater than 90mmHg. If hypotensive:
 IV fluid bolus of 1-2L NS, monitor for pulmonary edema
 Consider Dopamine IV infusion 5-10 mcg/min. (check concentration)
 Address presence of shock or arrhythmia and reference appropriate protocol.
 Following ROSC several simultaneous and stepwise interventions must be performed to ensure positive outcome for the pa-
tient.
 Survival and neurological outcome depend on management of hypoxia, hyper/hypocapnia, hypotension and fever.
 Therapeutic Hypothermia or Targeted Temperature management has not shown to be a benefit in the pre-hospital setting.
CONTACT MEDICAL CONTROL for guidance
 Stabilize patient and initiate ALS interventions where patient is found and transfer to the ambulance provided that the scene
is safe.
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Medical Guidelines 2.0
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General Medical: Acute Abdominal 2.1

Pain, Nausea/Vomiting
Revised July 2022
 Determine symptoms are not the result of a traumatic origin, Otherwise refer to appropriate protocol.
 Maintain ABC
 Apply oxygen therapy as appropriate, maintain SPO2 94-99%
 Identify life threatening causes and treat accordingly, ALS Assist
 Provide suction as necessary
 Do not allow patient to eat or drink.
 Obtain Vascular access.

 .9 NS with 1000 cc bag hanging KVO.
 Consider Zofran 4mg ODT only if not actively vomiting.
 Obtain 12 lead EKG, If STEMI present refer to appropriate protocol and notify medical control ASAP.
 Administer NS 500cc IV bolus if hypovolemic and life threatening causes (hypoxia, AAA, and PE have been ruled out.
 Pain management:
 For acute presentations only. Patient shows signs of significant discomfort. Pain >8.
 Fentanyl 25-50 mcg slow IVP, monitor for respiratory depression.
 Nausea, vomiting, non productive vomiting (dry heaves): Ondansetron (Zofran) 4 mg IV or ODT. May repeat once in
10 minutes. Consider IM or IN administration if unable to obtain IV access.
· Life threatening causes of abdominal pain and vomi ng include cardiac ischemia, GI Bleed,ectopic pregnancy and AAA dissec on.
· Pay close a en on to cardiac e ologies especially in diabe cs and the elderly.
· Fluid bolus is contraindicated in the presence of AAA dissec on or pulmonary edema. Suspect AAA in pa ents over 50 unless confi-
dently ruled out. Document presence of pedalpulses.
· Ectopic pregnancy should be considered as primary cause in women of childbearing yearsunless confidently ruled out.
· Zofran is contraindicated in pa ents with known allergies and pa ents with known history ofprolonged Q-T syndrome.
· Consider underlying causes of vomi ng and ra onale to provide an an -eme c.
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General Medical: Combative Patient/ 2.2

Excited Delirium Syndrome
Revised July 2022
 Maintain situational awareness and scene safety, involve and coordinate with Law Enforcement.
 Verbal de-escalation tactics, attempt to reasonably resolve concerns
 Consider underlying medical causes and treat accordingly once safe to do so.
 If verbal de escalation tactics fail and patient is determined to be a danger to his or herself involve law enforcement.
 Consider soft restraints, ensuring safety of patient and EMS personnel.
 If there is a concern involving safe transport of the patient or patient exhibits signs of excited delirium, contact ALS.

 Obtain blood glucose, if <60 administer glucose or D50.
 Assess for excited delirium, continue de-escalation
 If de-escalation tactics fail, administer the following:
 Midazolam (Versed) 2 mg IV or 5 mg IM
 May repeat in 5 minutes for a max dose of 10mg. OR
 Haldol 5mg IV, IM and Benadryl 50mg IM, for extra pyramidal side effects of Haldol OR
 Ketamine 200mg IV/IM can repeat x1 with a MAX of 400mg OR
 Ativan 2mg IV Q10 if needed. May repeat up to 3 times.
 Reassess and maintain ABC post sedation, apply oxygen, maintain SPO2 94-99%.
 Medical causes for combativeness may include but will not be limited to hypoxia, hypoglycemia and head injury.
 If the patient is in police custody and/or has handcuffs on, they may be transported by EMS without officer if handcuff keys
are present in ambulance
 Patient must NOT be transported in a face-down position
 For patients at risk of causing physical harm to emergency responders, the public and/or themselves
 Excited Delirium is a serious medical emergency. Patients will present with hallucinations, paranoia, hyper aggressiveness,
tachycardia and hyperthermia,
 EMS personnel may only apply “soft restraints” such as towels, cravats or commercially available soft medical restraints
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General Medical: Allergic Reaction / 2.3

Anaphylaxis
Revised July 2022
 ABC Vital signs
 Identify symptoms as Mild, Moderate or Severe, Call for ALS Assist
 Moderate to Severe Symptoms
 Administer Epinephrine 1:1000, 0.3mg SQ or IM
 If patient is has active wheezing, EMT may administer DuoNeb (Albuterol 2.5 mg and Ipratropium bromide 0.5mg) via nebulizer if
Heart Rate is <120, second round of Albuterol 2.5 mg may be administered after 5 minutes if no change and if Heart Rate is <130.
 Monitor vital signs
 Vascular access, IV/IO

 Maintain BP of 90mmHg systolic, consider .9NS 500cc Fluid bolus if hypotensive.
 Epinephrine 1:1000, 0.3mg SQ or IM
 Asymptomatic-supportive care
 Mild symptoms: Urticaria, itching, nasal congestion, watery eyes, etc.
 Diphenhydramine (Benadryl) 25- 50 mg IV or IM
 Moderate symptoms: Wheezing, nausea, vomiting, diarrhea, flushing, swelling face, neck, tongue
 Methylprednisolone (Solu-Medrol) 125 mg IV, IM if no IV access
 Racemic EPI 0.5mg mixed with 9ML Saline Nebulized.
 Severe reaction: not relieved by initial treatment or patient presenting with stridor, hypotension (systolic BP less than 90
mmHg), and/or Altered Mental Status of previous intubations.
 Primary Treatment:
 If patient remains hypotensive: Administer Epinephrine 1:10,000 0.01 mg/kg (0.3 mg max) IV. If no other epi is given.
 High risk patients that suffer adverse outcomes from epinephrine are patients with known cardiovascular, cerebrovascular
disease and the elderly.
 Stabilize patient and initiate ALS interventions where found then transition to ambulance provided scene is safe..
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General Medical: Diabetic 2.4

Emergencies
Revised July 2022
 ABC
 Apply appropriate oxygen therapy, manage airway as needed.
 Vital signs
 Check Blood Glucose level
 If patient has a patent airway, patient is awake and alert, administer oral glucose 37.5g buccally
 If blood glucose is known or suspected to be low and patient is able to swallow on command, give oral glucose one unit dose.
 If blood glucose is over 150 and patient presents with AMS request ALS assist.
 Reassess blood glucose level and vital signs. Maintain blood glucose to 80-120 range with normal LOC for patient
 Vascular access, IV/IO
 Blood glucose level below 60 mg/dL and signs and symptoms of hypoglycemia
 Dextrose 50% 25 grams IV; repeat 10 minute
 Dextrose 10% 15 grams IV only using only microdot tubing; titrate to effect not to exceed 25 grams
 Unable to obtain vascular access, Glucagon 1 mg IM
 Repeat D50 if no effect to first 25g
 Monitor blood glucose and vital signs.
 Avoid excess fluids in the presence of pulmonary edema, be cautious concerning CHF patients.
 All patients that receive glucagon should be transported. Note that glucagon may not be effective in patients with a history
of liver disease.
 Do not wait on scene for patient to respond to glucagon as patients respond differently based on their own metabolic rate.
 Stabilize and initiate ALS interventions where found then move to the ambulance unless scene is unsafe.
 Do not give oral glucose to patients with diminished gag reflex or unresponsiveness.
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General Medical: Overdose or Toxic 2.5

Exposure
Revised July 2022
 Opiate OD: Naloxone 2mg IN give 1ml to each nares; for respiratory depression only
 Decontaminate as needed
 ABC
 Apply appropriate oxygen therapy, ventilate via BVM if needed and vital signs
 Attempt to determine what was taken, when, and how much, bring containers to ED
 Check blood glucose level if abnormal refer to Diabetic Protocol.
 Opioid OD: Naloxone (Narcan) 2mg IN
 Vascular access, with blood draw, .9NS with 1000cc bag hanging.
For symptomatic patients with known:
 Opiate OD: Naloxone (Narcan) 0.5 mg IV, IM, IN; repeat to max 2 mg for respiratory depression ONLY (avoid if intubated)
 Organophosphate poisoning: Atropine 2 – 5 mg IV,ET; repeat every 3-5 minutes
 Calcium channel blocker OD: Glucagon 1 mg IM, SQ, IV
 Beta blocker OD: Glucagon 1 mg IM, SQ, IV

 Tricyclic antidepressant OD: Sodium Bicarbonate 1 mEq/kg IV
 Sympathomimetic OD (cocaine/amphetamines): Midazolam (Versed) 2 - 5 mg IV, IM, IN
 Dystonic reaction: Diphenhydramine (Benadryl) 50mg IV,IO or IM
 Includes patients who are unconscious/unresponsive without suspected trauma or other causes
 Use caution with cancer patients, may be on large amounts of narcotics due to chronic pain.
 Dystonic reaction is uncontrolled muscle contractions of face, neck or tongue. Dystonic reactions may result from an allergic reaction to:
Phenergan, Compazine, Haldol
 Be prepared to restrain patient after administration of Naloxone (Narcan)
 Medics should be called for any OD
 Signs and symptoms of organophosphate poisoning consider SLUDGE - Salivation, Lacrimation, Urination, Diarrhea, Gastric cramps,
Emesis
 Max dose of Naloxone used is 8mg, any that is repeated or using more than 8mg you MUST contact Medical Control.
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General Medical: Non-Traumatic 2.6

Pain Management
Revised July 2022
 Maintain ABC
 Reassurance
 Position of comfort
 Vascular access.
 If nausea occurs Zofran 4mg ODT only.
 Toradol 15y-55y 30 mg IV. >55y will be 15mg IV. May be administered in NON-traumatic patients who have suspected renal
colic, biliary colic, or nontraumatic musculoskeletal pain. If Toradol is administered, see next bullet point.
 If Toradol is administered, You must explain to the patient the risks and benefits of Torodol and answer any question the
patient may have. Also the Paramedic MUST state the following in his narrative.
I explained the risks and benefits of the medica on Ketorolac aka Toradol with the pa ent. I explained it may lead to
increased risks of bleeding, kidney injury, and is not recommended in use for anyone who is pregnant or may be
pregnant. The pa ent also understands other pain medica ons are available to them. Knowing the poten al risks of
the medica on Toradol the pa ent chooses to have it administered in route to the hospital.
 Fentanyl 25-50 mcg for pain with increased anxiousness, heart rate, and B/P.
 If nausea occurs Zofran 4mg ODT unless actively vomiting may give 4mg IV.
 Toradol (Ketorolac) can not be used in any trauma patient, history of renal disease, dialysis or kidney transplant, history of
stomach ulcer or signs of Gi bleeding (melanotic or bright red stools or hematemesis), must not be used in any patient with
tearing chest or back pain, any history of AAA, or concern for AAA or aortic dissection clinically, must not be administered
in any patient on warfarin, or DOAC's (Xarelto, Pradaxa, Eliquis), must not be administered for headache, not for use of
chest pain.
 Be careful with women who could be pregnant. Patients that are 15–55 must be told the risks and benefits of the medication.
Explain that it may increase the risk of bleeding and kidney injury and that it is not recommended for use by anyone who is
pregnant or may become pregnant. The patient also understands that other pain medications are available to them. If the
patient is okay with having the medication, make sure your report reflects that.
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General Medical: Seizures 2.7
Revised July 2022

 ABC
 Suction as needed, protect patient from harm.
 Vital signs
 Check blood glucose level, if abnormal refer to Diabetic Protocol
 Place post ictal patient in lateral recumbent position
 Call for ALS assist
 If patient is actively having a seizure
 Ativan 2mg IV/ IM. May repeat up to 10mg
or
 ·Midazolam (Versed) 2-4mg IVP/IM/IN slow over one minute, may repeat every 5 minutes as needed to a max dose of 10mg.
 Most seizures are brief and require no treatment.
 IN administration of Versed is more appropriate for pediatrics however may be considered for adults.
 Consider any patient that sustains 30 minutes of recurrent seizures to be in status epilepticus.
 Protect patient from injury during the seizure.
 Consider underlying causes and treat accordingly.
 Monitor and manage respiratory status.
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General Medical: Sepsis 2.8
Revised July 2022

 ABC
 Apply appropriate oxygen therapy, maintain SPO2 of 94-99%
 Vital signs, Blood Glucose,
 Obtain temperature
 Recognize symptoms of sepsis
 Temperature greater than 100.4 F or less than 96.8 F.
 Respiratory Rate greater than 20 breaths per minute
 Heart Rate greater than 90.
 ALS Assist
 Vascular access, .9NS with 1000cc bag hanging

 If no pulmonary edema (rales): Normal Saline 500 cc fluid bolus.
 Maintain systolic BP of 90mmHg
 IVF should not exceed 1000cc .9NS or 2000cc .9NS for transport time greater than 20 minutes
 Monitor for decreased ETCO2 levels
 Manage airway to maintain Capnography of 35-40mmHg. SEPSIS ALERT, patient meets following 3 criteria.
 If B/P remain below 90 systolic after IV bolus and patient  Suspected infection
remains/becomes symptomatic consider Dopamine infu-
sion 5 mcg/kg/min, titrate to effect, not to exceed 20  ETCO2 less than or equal to 25mmHg.
mcg/kg/min
 AND at least two of the following
 Temperature greater than 100.4 F or less than 96.8 F.
 Respiratory rate greater than 20 breaths per minute
 Heart rate greater then 90 BPM
 Sepsis is a rapidly progressing, life threatening condition due to systemic infection which must be recognized early
and treated aggressively.
 Severe sepsis may cause hypoxia and inadequate organ perfusion. This result in elevated blood lactate levels and de-
creased ETCO2 levels.
 Monitor for signs and symptoms of pulmonary edema
 Consider causes of hypoperfusion, including anaphylaxis, toxic ingestions, cardiac rhythm disturbances, myocardial
infarction, sepsis, ruptured AAA, ectopic pregnancy, trauma, or others
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General Medical: Heat Emergencies 2.9
Revised July 2022

 ABC, Manage airway as appropriate, Maintain SPO2 94-99%.
 Remove from the environment into a temperature controlled area.
 Vital Signs
 Remove clothing to undergarments.
 Identify heat cramps, heat exhaustion, and heat stroke.
 Heat cramps- generalized weakness, normal to cool skin, diffuse cramping
 Encourage intake of commercial electrolyte beverage.
 Continue to passively cool.
 Heat Exhaustion- profuse sweating, elevated temp, headache, tachypnea
 Cover with wet sheet
 Passively cool, avoid shivering
 Heat stroke – Hot dry skin, increased temp, decreased LOC
 Cover with wet sheet, passively cool
 Consider cold packs to torso and axilla, prevent shivering
 ALS assist for decreased LOC and or Heat stroke.

 Manage airway as appropriate, maintain SPO2 of 94-99%
 Administer 500cc NS fluid bolus x2. Assess vitals and lung fields between boluses.
 May consider chilled fluids in presence of heat stoke.
 This protocol is not intended for the treatment of fever.
 Remember that certain medications or drugs may produce heat illness
 If patient in cardiac arrest, follow AHA guidelines
 Monitor for signs and symptoms of pulmonary edema.
 If chilled fluids are not available, wrap IV tubing around cold pack.
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General Medical: Cold Emergencies 2.10
Revised July 2022

 ABC, maintain SPO2 between 94-99%, Apply appropriate oxygen therapy.
 Remove from cold environment, move to heated area, avoid aggressive movement.
 Remove all wet clothing, cover with blankets, preserve heat.
 Recognize Localized vs. Systemic Hypothermia
 Localized Hypothermia includes frost bite and frost nip
 Apply dressings to affected areas. Do not break blisters, do not rub the area or allow refreezing.
 Systemic Hypothermia includes Moderate and Severe Hypothermia. ALS Assist
 Moderate Hypothermia- Core Temp 86-96F, Patient may be conscious or altered. Apply hot packs wrapped in towels to torso and axilla
 Severe Hypothermia- Core Temp < 86 F, Patient will be lethargic or unconscious, Apply Hot packs as above.
 If cardiac arrest occurs, Begin CPR, attach AED and provide only 1 shock if indicated.

 Manage airway as appropriate, maintain SPO2 of 94-99%.
 If cardiac arrest occurs
 Begin CPR
 Defibrillate x1 and withhold meds unless core temp greater than 86. Otherwise continue CPR, insert advanced airway and transport.
 These patients are not deceased until normal core temperature has returned to normal limits.
 All patients in cardiac arrest with a core temp of 95 F or less must be transported to the ED unless decomposition is present
or patient is frozen solid.
 V-Fib will result if patient is handled aggressively with low core temp at or near 88F
 Bradycardia should not be treated in these patients unless temp of 95 F or greater. Patient should be warmed first.
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General Medical: Stroke 2.11
Revised July 2022

 ABC
 Apply appropriate oxygen therapy,
 Vital signs
 Assess Cincinnati Stroke Scale
 Maintain SPO2 of 94-99%
 Elevate head 30 degrees
 Check blood glucose level, if low refer to diabetic protocol
 Protect paralyzed extremities
 Vascular access
 Manage airway as appropriate, maintain SPO2 of 94-99%.
 Maintain airway as appropriate.
 Document improvement or deterioration of symptoms.
 Notify stroke center of last known well and advise of Stroke Alert.
 Allow for permissive HTN. ONLY treat B/P > 220/110. In such cases you may administer 0.4mg NITRO SL and if not corrected pro-
gress to Metoprolol 5mg slow IVP ONLY if HR is >70.
 Hypoglycemia. Bells Palsy, Post Ictal Paralysis, Complex Migraine, Overdose and Trauma will often mimic stroke.
 Cincinnati Pre-Hospital Stroke Scale:
 Have the patient repeat “You can’t teach an old dog new tricks”. Assess for correct use of words, without slurring
 Have the patient smile, assess for facial droop
 Have the patient close eyes and hold arms straight out for 10 seconds. Assess for arm drift or unequal movement of one side
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Respiratory Guidelines 3.0
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Respiratory: Acute Asthma and 3.1

Status Asthmaticus
Revised July 2022
 ABC
 Vital signs
 Place patient in fowlers to high fowlers position.
 Assist patient with their own meter dose inhalation medications as appropriate
 Recognize Moderate and Severe Asthma symptoms
 Moderate- Dyspnea, Wheezing, Cough
 Severe- above symptoms to include speaking in one to two word sentences, agitation, cyanosis.
 Maintain SPO2 of 94-99%
 Call for ALS Assist
 Cardiac Monitor, 12 Lead ECG

 If SEVERE (Status Asthmaticus)
 Epinephrine 1:1000 dose 0.3 –0.5 mg IM, if severe distress with systolic BP greater than 90 mmHg.
 If systolic BP less than 90mmHg Epinephrine 1cc of 1:10,000 in 9cc NS IVP slow.
 Magnesium Sulfate 2 grams IV infusion over 20 minutes.
 2 grams Mag in 50cc NS at 30gtts/min with 15gtt set
 Remember, “All that wheezes is not asthma!” Consider allergic reaction, airway obstruction, Congestive Heart
Failure, pulmonary edema, COPD exacerbation, Acute Pulmonary Hypertension
 Caution in using Epinephrine for patients with history of CAD.
 Management goal is to correct hypoxia, reverse bronchospasm and reduce inflammation.
 Use extreme caution when intubating asthma patients. Avoid own PEEP by allowing full expiration and avoid-
ing hypoventilation.
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Respiratory: Acute Pulmonary Edema 3.2
Revised July 2022

 ABC
 Vital signs
 Sit patient upright, if possible
 Maintain SPO2 of 94% or greater
 Consider starting CPAP for moderate to severe disease
 Consider inline with CPAP at 15lpm if needed.
 Monitor ETCO2, Consider intubation if unable to maintain SPO2 greater than 94% with CPAP.
 Cardiac Monitor, 12 Lead ECG and transmit
 May administer Midazolam (Versed) 1-2mg IVP if anxiety present and patient unable to tolerate CPAP.
 Nitroglycerin 0.4 mg; repeat every 3 - 5 minutes, if systolic BP greater than 90 mmHg. If BP less than 90mmHg refer to
cardiogenic shock protocol
 Administer Aspirin 324mg PO if patient able to swallow and not contraindicated.
 Administer Lasix 40mg IVP, 80mg IVP if currently taking Lasix.
 Remember, “All that wheezes is not asthma!” Consider allergic reaction, airway obstruction, Congestive Heart Failure, pul-
monary edema, COPD exacerbation, Acute Pulmonary Hypertension
 Do not administer nitroglycerin if the patient has taken medications such as Viagra or Levitra within 6 hours or Cialis with-
in the las 48 hours
 May give 3 nitro, 1.2 mg SL if systolic BP is greater than 160 mmHg.
 Nitro and CPAP are the most beneficial treatments. Focus on lowering BP and improving Hypoxia.
 Every effort must be made to rule out pneumonia and or sepsis as patients receiving lasix will have poor outcomes.
 DO NOT administer Lasix if there is suspicion of or evidence or fever.
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26
Respiratory: COPD Exacerbation 3.3
Revised July 2022

 ABC
 Apply appropriate oxygen therapy, Never withhold oxygen from a pa ent in respiratory distress
 Vital signs
 Assist patient with their own meter dose inhalation medications as appropriate
 Maintain SPO2 greater than 92% in COPD patients
 Consider starting CPAP for moderate to severe disease
 If patient is has active wheezing, EMT may administer DuoNeb (Albuterol 2.5 mg and Ipratropium bromide 0.5mg) via
nebulizer if Heart Rate is <120, second round of Albuterol 2.5 mg may be administered after 5 minutes if no change and if
Heart Rate is <130.
 Call for ALS Assist.
 Vascular access, IV
 Monitor ETCO2
 Cardiac Monitor, 12 Lead ECG and transmit
 Remember, “All that wheezes is not asthma!” Consider allergic reaction, airway obstruction, Congestive Heart Failure, pul-
monary edema, COPD exacerbation, Acute Pulmonary Hypertension
 Caution in using Epinephrine for patients with history of CAD.
 COPD is particularly responsive to CPAP. This should be considered early in treatment if the patient shows signs of dis-
tress.
 Monitor pulse rate before during and after Albuterol neb. If pulse rate increases 30 BPM then discontinue treatment.
 PEEP at 6 cmH20 is recommended if patient requires assisted ventilations.
26
27
Respiratory: Rapid Sequence Airway 3.4
**Paramedic Only** Revised July 2022
 To facilitate intubation of the patient with a compromised airway when standard methods have failed and further
attempts to control airway would delay care.
 Respiratory failure with failure to protect and or maintain airway (GCS less than 9)
 Must be performed with Video assisted device, ETCO2 and waveform capnometry
Drug Assisted Intubation

 Provide high flow O2 via NRB at 15Lpm and NC at 3LPM for no less than 3 minutes pre sedation
 Safe pre oxygenation level is pulse Oximetry greater than 94 percent
 Cardiac Monitor, Pulse Oximetry, Prepare ETCO2 and waveform capnometry,
 IV Access, .9NS, 1000cc bag hanging, consider additional IV access.
 Prepare medications and backup airway devices

INDUCTION
Administer Etomidate (Amidate) 0.3mg/kg (30mg max) rapid IV push, Increase NC to
15Lpm
Onset 15-45 seconds, Duration 3-12 minutes
PARALYSIS
* Administer Succinylcholine 2mg/kg (150 mg max) IV push
Onset 10-60 seconds, Duration 4-12 minutes
Contraindicated in malignant hyperthermia history and known or
suspected hyperkalemia (new renal patients), also obvious Crush
injuries.
* If Succinylcholine is contraindicated:
Administer Ketamine 2mg/kg IVP up to 200mg
Administer Fentanyl 2mcg/kg IVP (max 200mcg)
INTUBATION
* Must be performed with video assisted device and bougie
* Successful attempt
* Attach ETCO2, waveform capnometry, confirm placement via at least
three methods and document.
* Secure with commercial device and apply c-collar
* Unsuccessful attempt
* Insert King Airway, ventilate accordingly and attach ETCO2 and capnometry
* If unable to adequately ventilate the patient, perform Cricothyrotomy only as a
last resort when all other Airway interventions have failed.
POST INTUBATION
* Administer Ketamine 2mg/Kg IV up to 200mg second Dose 10 min later if needed
Onset less than 30 seconds, Duration 5-15 minutes
Administer additional 50mg if needed for continued sedation.
* Consider Versed 5mg along with 100 mcg of Fentanyl for continued sedation if needed.
May repeat in 5-10 minutes
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28
Respiratory: Rapid Sequence Airway 3.6

Continued
Revised July 2022
 Be cautious with the use of Succinylcholine in patients with eye injuries, long standing crush injuries and skeletal muscle
myopathy, most frequently Duchene’s muscular dystrophy.
 It is mandatory to adequately pre oxygenate and monitor patient for changes
 Assess Vitals every 5 minutes and confirm ET placement whenever patient is moved.
 ET placement must be confirmed via visualization, ETCO2, Waveform Capnometry as well as bilateral auscultation of the
chest and gastric area. Document tube placement at the lip and reconfirm whenever patient is moved.
 Consider Atropine 0.5 IV for Bradycardia post intubation.
 Ventilate patient with 100% oxygen via BVM, ventilate once every six seconds. Use PEEP at 5 cmH2O. Increase as need-
ed.
 Contact medical control ASAP especially if initial attempt has failed or there is a need to request additional sedation.
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29
Trauma Guidelines 4.0
29
30
Trauma: Transport Guidelines 4.1
Revised July 2022
 Assess patient according to the Field Triage Guidelines of Injured Patients

 Airway or ventilation concerns that cannot be adequately stabilized by available EMS providers for the anticipat-
ed transport time to a Trauma Center should be transported to the closest appropriate acute care facility.
 Patients meeting Steps 1 or 2 should be transported to nearest Trauma Center

 Via Ground Transport if less than 30 minute transport time, 45 minutes in inclement weather:
 Via Aeromedical Transport if ground transport time more than 30 minutes and air transport time less
than 45 minutes:
 Exceptions in which patient should be transported via ground to the closest appropriate facility:
 Air transport time greater than 45 minutes
 Weather or other local conditions prohibit air travel to the scene or to the closest Trauma Center
 Scene wait time for aeromedical transport provider would exceed time required to transport the patient
to the closest appropriate acute care facility by ground. In this situation the air medical provider may
be diverted to the receiving acute care facility.
 Patients in cardiac arrest at the scene after blunt trauma should not be transported via aeromedical
transport.
 Patients meeting Step 3 and 4 criteria
This is a guideline and is not intended to specifically define every condition in which transport decisions concerning
ground transport vs. air medical services may be needed. Good clinical judgment should be used at all times.
The helicopter can be requested to respond to the scene when:
ALS personnel request the helicopter
BLS personnel request the helicopter, when ALS is delayed or unavailable.
When EMS arrives, they must assess the situation. If it is determined by the most highly trained EMS provider ON
THE SCENE that the helicopter is not needed, it should be cancelled as soon as possible.
NEVER delay transport to wait for the helicopter. Especially if the patient is packaged, ready for transport and the
helicopter ETA is greater than the transport time to the hospital.
30
31
Field Triage Guidelines of Injured 4.2

Patients
Revised July 2022
31
32
Trauma: Routine Trauma Care 4.3
Revised July 2022

 Spinal precautions
 Maintain ABCDE with special attention to airway and spinal precautions
 Obtain and reassess GCS.
 High Flow Oxygen 12-15 lpm via NRB, maintain SpO2 of 94-99%
 Conduct complete trauma assessment and manage critical hemorrhage. This includes removing clothes to affect part or the whole body.
 Vital signs every 5 minutes unstable and 15 minutes stable patients
 Keep patient warm, avoid hypothermia
 Obtain IV access, maintain systolic BP of 90 mmHg.
 Cardiac Monitor; obtain 12 lead ECG and transmit
 Manage pain as appropriate
Complete thorough ALS trauma assessment, manage life threats
 Treatment priorities should focus on spinal precautions, managing ABCDE, controlling hemorrhage and preventing hypo-
thermia.
 Manage airway and maintain spinal precautions
 Control exsanguination with direct pressure, pressure dressings, packing wounds with combat gauze and application of tour-
niquet for life threatening uncontrolled hemorrhage.
 Assess breathing with direct auscultation and palpation of the chest. Manage flail chest segments with bulky dressings, ten-
sion pneumothorax with needle decompression and sucking chest wounds with partial occlusive dressings
 When assessing circulatory status note skin temperature, presence of peripheral pulses and capillary refill.
 Determine mentation using the AVPU method and note any sensory motor deficits
 Expose injuries, preserve dignity, prevent hypothermia.
 Place Pelvic Binder for unstable pelvis.
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33
Trauma: Spinal and Head injury 4.4
Revised July 2022

 Routine Trauma Care
 Spinal Precautions and manage ABCDE
 Determine LOC and document initial GCS, Monitor for changes
 GCS less than 8, prepare to manage airway.
 Determine level of spinal injury through focused head to toe exam
 Call for ALS intercept
 Vascular access x2 with 1000cc bags of NaCl hanging, Maintain systolic BP of 90 mmHg.
 Provide 500cc NaCl bolus to maintain systolic BP of 90 mmHg, may repeat x1, be cautious in presence of pulmonary edema.
 Fluid administration should be avoided or provided very slow KVO in the presence of hypertension.
 Complete thorough trauma assessment, GCS less than 8, prepare to intubate.
 Ventilate at 20 breaths per minute in the presence of Cushing’s Triad
 Transport Safely
 Cervical Spine Injuries at the level of C6 result in upper extremity deficit. C6=can’t make a six shooter.
 Deficit at below the nipple line suggests a T4 injury and deficit below the level of the umbilicus suggests injury to T10.
 Indications for spinal immobilization include mechanism of injury, spinal tenderness, neurological deficit, altered mental
status. When in doubt, immobilize.
 Cushing’s Triad is a sign of increasing intracranial pressure in the presence of a head injury and presents as increasing
systolic BP, irregular or slow respiratory patterns and bradycardia.
 Cervical Spine Injuries above the level of C4 result in Quadriplegia and will require assisted ventilations.
 Do not give atropine to a patient with bradycardia and hypertension.
33
34
Trauma: Spinal Clearance 4.5
Revised July 2022

 Maintain manual C-spine while conducting assessment
 Patient does not require immobilization if the following are met.
 Patient must be:
 Involved in a low risk mechanism of injury
 Alert and oriented
 Not legally intoxicated
 Able to speak English or able to actively participate in the spinal clearance exam
 Physical Exam:
 No pain on palpation of cervical vertebra
 No neurological deficits at time of exam or at any time since the injury
 No pain with axial load of c-spine
 Active ROM without pain
 Intact motor function and sensation in all extremities
 No distracting injuries
 Documentation
 Absence of exclusionary criteria
 Examination of the c-spine
 No neurological deficits
Key Points/Considerations  MVC of 60mph or greater

 Exam must be conducted by a paramedic  Car vs. motorcycle
Exclusionary Criteria  Fatality on scene
 Ejection When in doubt immobilize
 Roll over
 Extrication from vehicle
 Falls greater than 3 feet
 Pedestrian vs. vehicle
 Mechanism of injury to suggest spinal trauma,
34
35
Trauma: Burns 4.6
Revised July 2022

 Stop the burning process. Remove any clothing, jewelry, etc.
 ABC
 High Flow Oxygen 12-15 lpm via NRB, maintain SpO2 of 94-99%
 Vital signs
 Consult MEDICAL CONTROL physician for direct transport to a Burn Center via aeromedical transport service if needed
 Use dry sterile dressings or appropriate specialized burn dressings
 Avoid wetting the patient due to the danger of hypothermia
 Burns to the eye require copious irrigation with Normal Saline — do not delay irrigation
 Vascular access x2 ASAP with 1000cc bags of NaCl hanging, Maintain systolic BP of 90 mmHg. (IV, IO,)
 If patient has signs of airway involvement be prepared to intubate
 Consider Fentanyl 25mcg slow IVP to 100mcg. May be repeated x1 for total dose of 200mcg. Monitor for respiratory depression
 May start parkland formula if time allows
 Be alert for other injuries, including cardiac dysrhythmias
 Be alert for smoke inhalation.
 Assure 100% oxygen. Oxygen saturation readings may be falsely elevated.
 If hazardous materials involved, notify the destination hospital immediately to allow for decontamination
 When considering total area of a burn, DO NOT count first degree burns
 Burns are only to be dressed with simple sterile dressings once burning process has been stopped
 Consider Cyanide Toxicity and Carbon Monoxide poisoning
Parkland Formula, 4ml x %BSA x weight KG : Half given in first 8 hrs
35
36
Trauma: Burn Rule of Nines 4.7
Revised July 2022
Parkland Formula, 4ml x %BSA x weight KG : Half given in first 8 hrs
36
37
Trauma: Hemorrhagic Shock 4.8
Revised July 2022

 Treat all life threatening injuries as soon as possible: seal sucking chest wound, stabilize flail chest segments, stabilize impaled or pro-
truding objects from the head, neck eye chest or abdomen and initiate rapid transport.
 Elevate the legs, maintain systolic BP of 90mmgh or greater.
 Consider application of second tourniquet proximal to first tourniquet if unable to manage external hemorrhage. Pack wounds with com-
bat gauze.
 Do not delay transport waiting for ALS.
 Manage airway appropriately, maintain SpO2 of 94-99%
 Vascular access x2 with 1000cc bags of NaCl hanging
 Do not delay transport to obtain IV access, perform venipuncture while enroute to the trauma center.
 Maintain systolic BP of 90 mmHg by providing 250cc boluses to a max of 2000cc.
 Manage airway appropriately, maintain SpO2 of 94-99%
 Vascular access x2 with 1000cc bags of NaCl hanging
 Do not delay transport to obtain IV access, perform venipuncture while enroute to the trauma center.
 Maintain systolic BP of 90 mmHg by providing 250cc boluses to a max of 2000cc.
 May administer TXA 1g mixed with 100 ML NS via microdrip tubing over 10 minutes.
 TXA criteria must be met prior to administration
 Must have obvious bleeding external wounds neck to mid-thigh or suspected internal injuries from blunt or penetrating trau-
ma
 Trauma must have occurred within the last 3 hours
 Must have sustained tachycardia of 110 beats per minute or greater and or sustained hypotension with systolic blood pres-
sure 90 mmgHg or less.
 TXA must be infused slow over ten minutes. Complications of rapid infusion include but are not limited to hypotension and
vomiting.
37
38
Trauma: Musculoskeletal Injuries 4.9
Revised July 2022

 Wound Care
 Use appropriate PPE as needed
 Control hemorrhage with direct pressure, elevation
 Gentle irrigation with saline to remove gross debris only
 Cover open wounds with saline soaked gauze, wrap with dry sterile dressings
 Splinting of Fractures
 Immobilize joint above and below fracture
 Check PMS before and after immobilization
 Straighten severely angulated fractures if distal extremity has signs of decreased perfusion.
 Amputation Care
 Clean amputated part with saline, wrap in in saline moistened gauze
 Place part in air tight container and place on ice
 Cover stump with saline moistened gauze then cover with dry dressing
 Vascular access with 1000cc bag of NaCl hanging, Maintain systolic BP of 90 mmHg.
 Continued routine trauma care
Manage Pain as appropriate
 Preferred: Consider Fentanyl 25-50 mcg slow IV/IO/IN every 5 minutes to 100mcg. prior to splinting. May be repeated x1 for total
dose of 200mcg after splint is applied. Monitor for respiratory depression.
 Use caution when irrigating wounds as not to wash away clotting factors
 Apply hemostatic agent in the presence of uncontrolled hemorrhage and use tourniquet if needed.
 Note time of placement, Apply as close to the injury as possible and DO NOT Remove once applied.
 Patient must show signs of intolerance to pain. Not all injuries require pain management
 Do not manage chronic pain such as low back pain without consulting medical control.
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39
Trauma: Chest Trauma 4.10
Revised July 2022

 ABC
 Apply appropriate oxygen therapy, maintain SpO2 of 94-99%
 Vital signs
 Keep patient warm.
 If sucking chest wound, cover with gloved hand then partial occlusive dressing; if dyspnea increases release the dressing momentarily
during exhalation
 Manage flail chest segments with blanket or pillow to affected area and secure
 ALS Intercept
 Vascular access x2 via .9 NaCl with 1000cc bags hanging, obtain blood draw; use the side opposite the injury if possible
Maintain Systolic BP of at 90 mmHg via 250cc NaCl boluses
 Manage Tension Pneumothorax with Needle decompression if patient has signs and symptoms consistent with Tension Pneumothorax
AND hemodynamic compromise
 Prepare 14 gauge. 3.25 inch catheter, alcohol prep/Betadine
 Locate 2nd intercostal space midclavicular line, insert over the third rib
 Alternate site 5th intercostal space mid-axillary line insert over the 4th rib.
 Begin transportation as soon as possible, avoid prolonged scene times.
 Signs and symptoms of a Tension Pneumothorax: Absent lung sounds on one side, extreme dyspnea, jugular vein distention
(JVD), cyanosis (even with 100% oxygen), tracheal deviation AND hypotension
 Hemodynamic compromise is defined: hypotension, narrowed pulse pressures and tachycardia
 Thoracic decompression is a serious medical intervention that requires a chest tube in the hospital
 Consider aeromedical transport for severe multi-system trauma if transport time is greater than 20 minutes
39
40
Trauma: Crush Injuries 4.11
Revised July 2022

 ABC
 Apply appropriate oxygen therapy, maintain SpO2 of 94-99%
 Vital signs every 5 minutes
 Maintain body heat, keep patient warm
 Apply a tourniquet above the site of the injury if extremity is deemed unsalvageable or significant blood loss is suspected upon extrica-
tion. .
 Contact ALS for intercept immediately
 Obtain Vascular x2 via NaCl with 1000cc bags hanging,
 Maintain systolic BP of 90 mmHg.
 Administer 1 liter .9 NS for those <65 y/o to prevent hypokalemia
 Cardiac Monitor; obtain 12 lead and transmit
 12 Lead ECG; repeat at 30 minute intervals
 Pain Management if hemodynamically stable
 Preferred: Fentanyl, 25 mcg IVP slow to 100mcg. May repeat x1 to max of 200mcg.
 Alternate: Ketamine 0.2mg/kg IVP slow over 1 minute.
 If one complete extremity is crushed more than 2 hours or two extremities crushed more than 1 hour: Sodium Bicarbonate 50 mEq IV administered 1
minute prior to extrication via dedicated IV line.
 Consider Calcium Chloride 1gm slow IVP if patient develops ventricular ectopy post extrication. DO NOT use same IV line as bicarb
 Contact the aeromedical transport at scene if anticipated prolonged extrication.
 Use one dedicated IV for Sodium Bicarbonate, the other IV for all other medications
 After extrication immobilize the extremity and apply cold therapy. Do not elevate the extremity.
 If patient needs Rapid Sequence Intubation (RSI), use caution with Succinylcholine
 Hyperkalemia will manifest itself as peaked T waves and widened QRS on the EKG.
40
41
Trauma: Pregnancy and Trauma 4.12
Revised July 2022

 Routine Patient Care
 Remember to treating the mother is treating the infant
 Estimate Gestational Age (EGA)
 Note fundal height by palpating the abdomen, if uterus is at the umbilicus the EGA is at least 22 weeks.
 Fundal height below the umbilicus (less than 22 weeks)
 Priority is the mother
 Transport all patients with any thoracic, abdominal, pelvic injury or complaint.
 Fundal height at or above the umbilicus (22 weeks or older)
 Priority is the Mother although you need to consider that you have two patients.
 Transport in left lateral recumbent position or elevate the LSB 15-30 degrees to the left side if patient is immobilized.
 Notify receiving facility of EGA
 Treat for shock as appropriate, maintain BP of 90mmHg minimum
 Assess for abdominal contractions and vaginal bleeding
 Vascular access, Maintain systolic BP of 90 mmHg via 250cc boluses of NaCl.
 Continued routine trauma care
 Obtain and transmit 12 lead if suspected blunt chest trauma.
 Transport all immobilized patients with 22 weeks EGA in left lateral recumbent position.
 Liberal use of oxygen is indicated as the fetus is susceptible to hypoxia.
 Normal maternal vital signs are not an indicator of fetal well being.
 Interpret vitals with caution as pregnant patients have increased heart rate, decreased blood pressure and increased blood
volume.
 Patients with any thoracic, abdominal or pelvic complaint may require prolonged fetal monitoring in hospital even if asymp-
tomatic at time of evaluation and for seemingly minor mechanism.
 Will need to manually displace abdomen to the left if performing CPR.
41
42
Trauma: Traumatic Arrest 4.13
Revised July 2022

 Rapid scene and primary survey to find possible cause(s) of arrest.
 Apply tourniquet(s) ** to any extremity with major bleeding.
 If MVC and still in vehicle; rapid extrication.
 Initiate CPR.
 100% Oxygen/BVM
 Place an advanced airway** if any difficulty ventilating with BVM.
 Immobilize spine if indicated
 Start 2 large bore IVs or IO**. Do not delay transport attempting to start
 If IV/IO established, run normal saline bolus until B/P reaches 90/systolic
 If chest trauma present and suspect tension pneumothorax: perform needle pleural decompression. Needle pleural decom-
pression. 2nd-3rd intercostal space (above 3rd or 4th rib), midclavicular line on affected side. If patient does not stabilize,
repeat in the 5th or 6th intercostal space, anterior axillary line on the affected side.
 Treat dysrhythmia according to appropriate Protocol.
There are a number of studies that show that attempts at resuscitation of traumatic arrests are futile in certain
situations. In these futile situations a patient should be considered D.O.A. and there should be no further
resuscitation efforts.
All traumatic pulseless non-breathers will undergo full resuscitation efforts unless:
 All trauma with a significant mechanism of injury – If on the first arrival of EMS the patient is pulseless, apneic,
and without other signs of life (pupil reactivity, spontaneous movement) or is asystole, then the patient is not
resuscitatable.
 If the injuries are incompatible with life (e.g. Decapitation), the patient is not resuscitatable.
 Any patient not meeting one of the above criteria should have attempted resuscitation – Begin CPR. Follow ap-
propriate Cardiac Arrest, PEA/Asystole protocol.
42
43
Trauma: Traumatic Arrest 4.14
Revised July 2022
43
44
OB/GYN Guidelines 5.0
44
45
1 OB/Gyn: Maternal Care 5.1
Revised July 2022

 ABC
 Apply appropriate oxygen therapy, Maintain SpO2 of 99%
 Vital signs
 Obtain history
 Determine delivery status (crowning vs not crowning)
 Crowning present
 Place patient on flat surface and prepare for delivery
 Assemble Equipment
 Reference emergency delivery protocol
 Monitor closely for crowning
 Changes and transport in position of comfort
 IV access
 Determine the estimated date of expected birth, the number of previous pregnancies and number of live births, difficulties
with previous births/pregnancies.
 Determine if the amniotic sac (bag of waters) has broken, if there is vaginal bleeding or mucous discharge, or the urge to
bear down.
 Determine the duration and frequency of uterine contractions
 Examine the patient for crowning. If delivery is not imminent, transport as soon as possible. If delivery is imminent, prepare
for an on-scene delivery.
 If multiple births are anticipated but the subsequent births do not occur within 10 minutes of the previous delivery transport
immediately.
 Every attempt should be made not to separate expectant or newly delivered moms and their family. Even when transporting.
45
46
OB/Gyn: Childbirth 5.2
Revised July 2022
 Cutting the cord is not an emergency but must be done with sterile technique.
 Delivery of the entire placenta is vital post birth and occurs within 30 minutes. Upon delivery of the afterbirth ensure that it
is completely intact and transport with baby.
46
47
OB/Gyn: Childbirth Complications 5.3
Revised July 2022
Birthing Complications
Contact Medical Control as soon as any complicaƟon is discovered.
Breech Delivery – Footling Breech (one or both feet delivered first) and Frank Breech (buƩocks are presenƟng part)

When feet or bu ocks are first noted at the vaginal opening during a contrac on, there is normally me to transport pa ent to nearest
facility.
If upper thighs or bu ocks have passed out of vagina, delivery is imminent and baby should be delivered on‐scene/in the house.
Breech Infant Delivery Guidelines:
Gather equipment – OB kit, oxygen, BVM, towels, blankets, large dressings, cot and PPE.
Place pa ent on cot or floor on her back with knees and hips flexed.
If me permits, drape mother with towels in OB kit.
Don sterile gloves, gown and face shield.
Allow baby to deliver with contrac ons while suppor ng the body. The posterior or bo om bu ock and hip usually deliver first, then
the anterior hip.
A er leg delivery, hold onto pelvis with both hands to support the body which will naturally turn to deliver the shoulders.
If the shoulders do not deliver easily, apply gentle trac on of the body un the axilla become visible. Then guide the infant’s body up‐
ward to deliver the posterior (bo om) shoulder. Guide the infant downward to deliver the anterior (top) shoulder.
As the head passes the pubis, usually face down, put one hand on the face and the other on the back of the neck, apply gentle upward
trac on un l the mouth appears.
If the baby’s body has delivered and the head appears to be caught in vagina, the EMT must support the baby’s body and insert two
fingers into the vaginal opening along the baby’s neck un l the chin is located. At this point, the two fingers should be placed between
the chin and the vaginal wall and advanced past the mouth and nose.
A er achieving this posi on, a passage for air must be created by pushing the vaginal wall away from the baby’s face. The air passage
must be maintained un l the baby is completely delivered, no ma er how long that takes.
A er delivery follow rou ne neonatal assessment
Shoulder Dystocia – aŌer delivery of the head, top/anterior shoulder gets stuck and delivery is halted.
If unable to deliver anterior shoulder, have mother flex hips and bring knees to her chest to change the angle of the pelvis (McRoberts
Maneuver)
Have an assistant put moderate pressure on abdomen just above the symphis pubis.
If this does not assist in delivery of shoulder, the transport immediately.
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48
OB/Gyn: Childbirth Complications 5.4
Revised July 2022
Birthing Complications
Excessive Bleeding Pre-Delivery
Follow Hypovolemic Shock Protocol in addition to normal delivery guidelines.

 left side and follow Hypovolemic Shock Protocol
If delivery is not imminent, patient should be transported on her
Excessive Bleeding Post-Delivery
Start IV normal saline. Administer 500-1000 mL bolus and repeat as needed.

Typically caused by uterine atony. If placenta has been delivered, massage uterus and put baby to mother’s breast.
If the uterus has inverted and is extending through the cervix it must be replaced quickly to limit profound hemorrhage. With
the palm of the hand, push the fundus of the inverted uterus toward the vagina. If this does not turn the uterus right-side out,
cover the uterus with moistened towels and transport immediately.
Prolapsed Cord – the umbilical cord has passed through the vagina and is exposed.
Patient should be transported with hips elevated or in knee-to-chest position. Place moist dressing around the cord.
If umbilical cord is seen or felt in the vagina, insert two fingers to elevate presenting part away from the cord to stop baby
from crushing its own blood/oxygen supply; distribute pressure evenly when occiput presents.
Do NOT attempt to push the cord back.
High flow oxygen and transport immediately while maintaining elevation of presenting part.
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49
OB/Gyn: Childbirth Complications/ 5.5

Special Consideration
Revised July 2022
Special Considerations Birthing Complications
Approximately 10% of newborns require some assistance to begin breathing at birth. About 1% require extensive resuscita-
tion measures. Adequate OXYGENATION is at the core of neonatal resuscitation!
Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following
3 characteristics: 
*Term gestation?
*Crying or breathing?
*Good muscle tone?
If the answer to all 3 questions is “yes,” the baby does not need resuscitation and should not be separated from the mother.
*Baby should have mouth then nose suctioned if necessary, be dried, placed skin-to- skin with the mother, and covered with
dry linen to maintain temperature
*Observation of breathing, activity, and color should be ongoing
If the answer to any of the assessment questions is “no” the infant should receive one or more of the following four cat-
egories of action in sequence:
*Initial steps in stabilization (provide warmth, clear airway, dry, stimulate)
*Ventilation
*Chest compressions
*Administration of epinephrine and/or fluid boluses
Approximately 60 seconds are allotted for completing the initial steps, reevaluating, and beginning ventilation of required
(see algorithm below)
The decision to progress beyond the initial steps is determined by simultaneous assessment of two vital characteristics: respi-
rations (apnea, gasping, or labored or unlabored breathing) and heart rate (whether greater than or less than 100 or 60 beats
per minute)
Per AHA guidelines – it is recommended that suctioning mouth then nose immediately following birth (including suctioning
with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require
positive-pressure ventilations
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50
OB/Gyn: Childbirth 5.6
Revised July 2022
Special Considerations Birthing Complications
For babies born with meconium-stained amniotic fluid, endotracheal suctioning is only indicated for depressed in-
fants.
 minute. Compression-to- ventilation ratio is 3:1, with

Rescue breathing is delivered at a rate of 40-60 breaths per
90 compressions and 30 ventilations delivered in one minute (120 events per minute). If cardiac arrest is suspected
to be of primary cardiac etiology, compression-to-ventilation ratio of 15:2 may be considered, but most cardiac
arrests in neonates are respiratory in etiology. Oxygenation is everything in NRP.
APGAR scores are done at 1 and 5 minutes after delivery. Scoring should not delay any interventions.
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51
OB/Gyn: Care of the Neonate 5.7
Revised July 2022

 Place infant on a dry blanket, cover the head and stimulate. Replace towels/blankets as they become wet. Once complete,
wrap in warm blanket. If stable, place on mother skin to skin to preserve warmth. Put baby to breast.
 Evaluate respirations and pulse ( within 30 seconds post delivery)
 If Breathing, Pulse is greater than 100, color is pink, Observe and transport
 If Breathing, Pulse is greater than 100, color is cyanotic, provide O2 via blow by method
 If Apneic or pulse less than 100, suction and provide bag mask ventilations at a rate of 40-60 breaths per minute.
 If HR is less than 60 begin compressions with ventilations using a ratio of 3 compressions to 1 ventilation
 Obtain APGAR Score at 1 and 5 minutes after birth.
 IV/IO access .9 NaCl, administer 10ml/kg bolus.
 If pulse remains less than 60 after treatments as above
 Intubate if no improvement after 3 minutes of CPR
 Administer Epinephrine .01 mg/kg (1:10:000)IV, IO
 Administer Epinephrine .1mg/kg (1:1000) via ETT if no IV access
 Consider Narcan .1mg/kg and or Dextrose 10% per medical control
 Notify destination hospital ASAP, and support the mother.
 Drugs are rarely indicated in the resuscitation of the newborn, Bradycardia is usually the result of hypoxia
 Do not withhold resuscitative efforts to obtain APGAR score.
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52
OB/GYN: Vaginal Bleeding 5.8
Revised July 2022

 Use appropriate PPE
 ABC
 Apply appropriate oxygen therapy, maintain SPO2 of 99%
 Place patient in left lateral recumbent if in the third trimester of pregnancy. If not in the third trimester and exhibits signs of shock place in trendelen-
burg position.
 Vital signs, maintain systolic BP greater than 90 mmHg.
 In the event of post partum hemorrhage from the vagina, apply a firm uterine massage starting from the pubis toward the umbilicus in a clockwise mo-
tion.
 Premature Delivery less than 20 weeks
 Ensure that the fetus is pulseless and apneic if so resuscitative measures are not indicated. Cut the cord, provide supportive care to mother
 If there is a question as to the approximate gestation of the fetus provide resuscitative measures.
 If the fetus presents with spontaneous respirations and pulses provide resuscitative measures and transport.
 Premature Delivery greater than 20 weeks
 Provide resuscitative measures and transport.
 Request ALS intercept.
 .9 NaCl with 1000cc bag hanging.
 If signs of shock provide fluid bolus in the amount of 250cc increments to maintain systolic BP of 90mmHg to a max of 2000cc.
 Placenta previa (painless vaginal bleeding), Placental abruption ( severe abdominal pain with minimal dark blood)
 In reference to miscarriage of a non viable fetus of less than 20 weeks it is necessary to provide emotional support to the
mother. It is perfectly ethical to dry the fetus and ask if the mother would like to hold it during transport.
 Notify the receiving hospital ASAP.
 Obtain gestational age, prenatal care, number of pregnancies and live births, difficulties with previous pregnancies.
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53
OB/Gyn: Eclampsia 5.9
Revised July 2022

 ABC
 Avoid overstimulation such as bright lighting, loud noises etc.
 Apply oxygen to maintain SPO2 of 94-99%
 Obtain history to include due date, number of pregnancies and live births, prenatal care and problems associated with previ-
ous pregnancies.
 Vital signs, Specifically BP, Check for peripheral edema.
 Check blood glucose level, if level is abnormal refer to Adult Diabetic Protocol
 Vascular access .9 NaCl.
If Seizure Activity
 Administer Versed 2-5mg IV/IO, 5mg IM, 10mg IN (5mg each nostril) to control seizure.
 Administer Ativan 2 mg IV
 Follow up with administration of Magnesium Sulfate 4gm over 2 minutes IV infusion if eclampsia is suspected.
 Transport and monitor for respiratory depression.
 Pre-eclampsia is defined as BP greater than 140/90 in a pregnant patient (or one who has recently given birth) with severe
headache, confusion, light sensitivity and pedal edema.
 Eclampsia includes the above information and includes seizure activity
 Commonly occurs in non white first time mothers between 16-24 years of age and 35 and over or previous history of ec-
lampsia.
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54
Pediatric Guidelines 6.0
54
55
Pediatric: Routine Pediatric Care 6.1
Revised July 2022

 Obtain an initial impression (visual assessment) observing appearance, breathing circulation.
 Appearance- assess for reactiveness to parents or environment. abnormal cry, presence of tears, floppy extremities, poor
muscle tone.
 Breathing,- assess for nasal flaring, grunting, abdominal breathing noisy breathing
 Circulation- assess for paleness, mottling, cyanosis
 Primary Assessment to include ABCDE. Treat life threats
 Support airway, ventilation, and perfusion.
 Provide oxygen to maintain SpO2 of 94-99%
 Obtain vital signs, every 5 minutes for unstable and 15 minutes for stable patients.
 Pulse less than 60 with poor perfusion despite adequate oxygenation and ventilation will require CPR, 30:2 if alone, 15:2
with a partner.
 Blood Glucose if indicated. (Altered LOC, Shock)

 Complete toe to head assessment
 Obtain Broselow tape color and relay to ED phone or radio report
 Obtain Vascular access only if IV fluids needs. NS .9 NaCL
 Cardiac monitor
 Continuous assessment and reassessment. Evaluate, Identify Intervene
 Pediatric patients can decompensate quickly. Aggressive management of ABCDE is essential.
 Keep them pink, warm, dry. Cover their bodies especially the head and remember to obtain a finger/heel stick BG.
Age Respirations Pulse Systolic BP

Newborn 30 – 60 100 - 180 >60
Infant (< 1 year) 30 – 60 100 - 160 >60
Toddler (1 – 3 years) 24 – 40 90 - 150 >70
Preschooler (3 – 5 years) 22 – 34 80 - 140 >75
School-aged (6 – 8 years) 18 – 30 70 - 120 >80
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56
Pediatric Cardiac Arrest: Asystole or 6.2

PEA
Revised July 2022
 Routine pediatric care
 Begin compressions and ventilations if pulseless and apneic per AHA guidelines
 Apply AED and follow prompts. If no shock advised and no pulses continue CPR
 Perform 2 minute cycles of high quality CPR, push hard and fast.
 Obtain Blood glucose and Broselow color.
 Insert advanced airway if appropriate for age, (King or Combi tube)
 Call for ALS
 Normal Saline 20 mL/kg IV/IO bolus as needed. Up to 2 boluses
 Consider and treat Reversible Causes (H’s and T’s) as appropriate
 Epinephrine 1:10,000 dose 0.01 mg/kg IV,IO; repeat every 3-5 minutes
 Place advanced airway within first 4 minutes of CPR as appropriate
 Consult MEDICAL CONTROL physician and begin transport to the closest hospital as soon as possible
 Confirm asystole in more than 1 lead
 Secure airway ASAP
 Consider and possibly treat contributing factors including: Hypoxia, Hypovolemia, Hypothermia, Hyper-/Hypokalemia, Hy-
drogen Ion (Acidosis), Tension Pneumothorax, Cardiac Tamponade, Toxins,
 Follow pediatric ABDCE model: A=airway, B=BVM, C=Compressions, D=Drill, E=Epi.
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57
Pediatric Cardiac Arrest: V-Fib / 6.3

Pulseless V-Tach
Revised July 2022
 CPR per AHA guidelines
 Attach AED ASAP and follow prompts
 Perform 2 minute cycles of high quality CPR (hard and fast)
 Normal Saline 20 mL/kg IV/IO bolus, as needed. Up to 3 boluses
 Initial defibrillation at 2 J/kg, then 4J/kg, 6J/kg, PRN
 Epinephrine 1:10,000 dose 0.01 mg/kg IV/IO; (0.1cc/Kg) repeat every 3 – 5 minutes prn.
 Administer Amiodarone (Cordarone) 5 mg/kg IV/IO. Max 300mg
 Place advanced airway within first 4 minutes of CPR as appropriate
 Consult MEDICAL CONTROL physician and begin transport to the closest hospital as soon as possible
 Do not interrupt compressions for placement of an advanced airway during the first 4 minutes of CPR
 Use the small (pediatric) pads for patients less than 10 kg
 V-fib cardiac arrest is rare in children. Consider toxic ingestions including tricyclic antidepressants or long QT syndromes.
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Pediatric Cardiac: Bradycardia 6.4
Revised July 2022

 Routine Pediatric Care
 Provide appropriate oxygen therapy.
 Vital signs.
 If heart rate is less than 60 bpm and patient’s mental status and respiratory rate are decreased, ventilate with BVM
 Start CPR (if no improvement with ventilations)
 Normal Saline 20 mL/kg IV bolus, as needed
 Epinephrine 1:10,000 dose 0.01 mg/kg IV/IO; (0.1cc/Kg) repeat every 3-5 minutes
 If bradycardia is due to increased vagal tone or primary AV block give atropine before giving epinephrine
 Atropine 0.02 mg/kg (0.1 mg min dose) IV/IO; repeat 5 minutes to max 0.04 mg/kg
 Transcutaneous pacing,
 Use peds pads if less than 10kg. May use adult pads if the pads do not touch. Otherwise anterior/posterior pad placement is preferred.
 Start at 70 PPM and begin at 1mA and increase to 5 mA until electromechanical capture is achieved.
 Place advanced airway as appropriate
 Consult MEDICAL CONTROL physician as soon as possible

 Newborn/Infant bradycardia -- pulse less than 60- 80 bpm start CPR; child over 1 year of age bradycardia -- pulse less than
60 bpm
 Symptomatic includes poor systemic perfusion, hypotension, respiratory difficulty or altered level of consciousness
 Do not treat asymptomatic bradycardia. Consult MEDICAL CONTROL physician.
 Bradycardia in kids is almost always respiratory in nature. Always treat airway first.
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59
Pediatric Cardiac: Tachycardia 6.5
Revised July 2022

 Routine Pediatric Care
 ABC
 Vital signs
 Identify critical tachycardia as below
 ALS assist
 Vascular access;
 Normal Saline 20 mL/kg IV bolus, as needed
 Cardiac Monitor; obtain 12 lead and transmit when appropriate
UNSTABLE
 Synchronized cardioversion 0.5 – 1.0 J/kg; repeat once at 2J/kg if unsuccessful
 Sedation: Versed .05mg/kg IV/IO/IM/IN do not delay cardioversion
 If unsuccessful post 2J/kg, transport and contact medical control.
STABLE Wide QRS:
 Administer Amiodarone (Cordarone) 5 mg/kg IV over 30 minutes
 If not successful move to cardioversion
STABLE Narrow QRS:
 Valsalva Maneuvers (ice to face, blow through occluded tubing)
 Adenosine (Adenocard) 0.1 mg/kg IV,IO follow by 10cc NS flush
 May repeat in 1-2 minutes at 0.2 mg/kg IV, IO follow by 10cc NS flush
 If unsuccessful move to cardioversion
 Newborn/Infant SVT = pulse greater than 220 bpm;
 child over 1 year of age SVT = pulse greater than 180 bpm, no discernable p-waves
 UNSTABLE includes cardio-respiratory compromise, hypotension, or altered level of consciousness
 The most common causes of Sinus Tachycardia in children are fever, pain and dehydration. Treat for these first.
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60
Pediatric: Acute Asthma 6.6
Revised July 2022

 Routine pediatric care.
 Determine if patient has been given his/her own asthma medications
 Assist with patient prescribed metered dose inhaler x1
 ALS Assist
Heart Rate is <120, second round of Albuterol 2.5 mg may be administered after 5 minutes if no change and if Heart Rate is <130
 If patient not improving, obtain vascular access
 Epinephrine 1:1000 dose 0.01 mg/kg IM (0.5 mg max), if in severe distress
 Methylprednisolone (Solu-Medrol) 1-2 mg/kg IV/IO, IM if no IV access
 If patient presents with signs and symptoms of Croup
 Nebulized Racemic Epinephrine 0.5mg mixed with 9ML saline.
 Symptoms of croup include barking cough, hoarseness, runny nose and fever
 Signs of severe respiratory distress with impeding respiratory failure include but are not limited to the following
 Agitation
 Tripod positioning
 Accessory muscle use
 Grunting, head bobbing, seesaw breathing
 Decreased respiratory effort.
 Treat and address hypoxia in children aggressively.

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Pediatric: Anaphylaxis / Allergic 6.7

Reaction
Revised July 2022
 Determine if patient has been given his/her own Epi Pen
 Administer .15mg Epi 1:1000 IM/SQ for moderate to severe reaction.
 Call for ALS Assist.
 Vascular access; Normal Saline 20 mL/kg IV/IO bolus as needed (up to 3 boluses)
 Cardiac Monitor Severe reaction: Stridor, hypotension with poor perfusion

and/or Altered Mental Status
 Asymptomatic: Supportive care
 Cardiovascular collapse: Epinephrine 1:10,000 dose 0.01 mg/kg (0.5
Mild symptoms: Urticaria, itching, nasal congestion, watery mg max)
eye
 Diphenhydramine (Benadryl) 1 – 2 mg/kg (25 mg max) IV/IO or IM
Moderate symptoms: Wheezing, nausea, vomiting, diar-

rhea, flushing, swelling face, neck, tongue
 Albuterol 2.5 mg via nebulizer
 Diphenhydramine (Benadryl) 1 – 2 mg/kg (25 mg max) IV/IO or IM
 Epinephrine 1:1000 concentration dose 0.01 mg/kg (0.5 mg max)
 ·If not already administered by BLS crew.
 Methylprednisolone (Solu-Medrol) 1 - 2 mg/kg IV
 A patient cannot refuse treatment once an epi pen has been administered
 Absence of breath sounds, AKA “silent chest” can be indicative of status asthmaticus. Be prepared for imminent respiratory arrest.
 DO NOT administer epinephrine if epi pen has been administered by BLS unless unsure it was administered properly.
 Use caution in consideration to second dose of albuterol as this can cause increased HR resulting and worsening hypoxia.
 Be aggressive in managing hypoxia in pediatric patients.
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Pediatric: Diabetic Emergencies 6.8
Revised July 2022

 ABC
 Vital signs
 Check finger or heel stick Blood Glucose level
 If blood glucose is known or suspected to be low (<60) and patient is able to swallow saliva on command, give oral glucose one unit
dose
 Call for ALS Intercept if patient is unable to swallow saliva on command, or mental status is altered.
If blood glucose below normal range 60-80 and patient is showing signs and symptoms of hypoglycemia:
 Glucagon 1 mg IM (if unable to establish IV/IO access)
 If blood glucose if above 400 and if signs of dehydration are present, fluid bolus:
 0 - 1 years old, 10 mL/kg .9 NS, may repeat x1
 1 year old – Puberty, 20 mL/kg.9 NS , may repeat on BSO
Patient’s Age Amount of Dextrose

Less than 1 year old D10 – 0.5 gm/kg IV/IO
1 – Puberty D25 – 0.5 gm/kg IV/IO
 To make D10, add 12cc of D50 into 50ml NS if shortage of medication
 Be cautious with fluid boluses in DKA as excess fluids may cause cerebral edema.
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Pediatric: Hypoperfusion/Sepsis 6.9
Revised July 2022

 ABC
 Vital signs
 Call for ALS assist ASAP
 Normal Saline 20 mL/kg IV/IO bolus, as needed (up to 3 boluses)
 Indicated for patients with hypovolemia due to bleeding, vomiting, diarrhea or septic shock.
 Consult MEDICAL CONTROL physician if you suspect cardiogenic shock.
 Diagnostic criteria for hypotension includes: capillary refill time greater than 2 seconds, cool, clammy or mottled skin, ina-
bility to recognize parents, restlessness, listlessness, tachycardia, tachypnea, systolic BP less than 70 mmHg (2 years and
older) or systolic BP less than 60 mmHg (less than 2 years old).
 20ML/KG Fluid consideration for Pediatrics
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Pediatric: Nausea and/or Vomiting 6.10
Revised July 2022

 ABC
 Vital signs
 Vascular access;
 Normal Saline 20 mL/kg IV/IO bolus, as needed
 Ondansetron (Zofran) 0.1 mg/kg IV/IM
 Patient age should be greater than 6 months of age
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65
Pediatric: Overdose or Toxic 6.11

Exposure
Revised July 2022
 Decontamination as needed
 ABC
 Vital signs
 Check blood glucose level. If level is abnormal refer to Pediatric: Diabetic Emergencies protocol
 Determine what was taken, when and how much, if possible
 Consider contacting Poison Control 1-800-222-1222 for additional information and treatment options
 Opiate overdose: Naloxone (Narcan) 0.1 mg/kg IV,IO,IN; Repeat to max 2 mg
For symptomatic patient with:
 Opiate overdose: Naloxone (Narcan) 0.1 mg/kg IV,IO,IN; Repeat to max 2 mg
 Organophosphate poisoning: Atropine 1 mg IV; repeat every 3 – 5 minutes until secretions dry and patient able to handle their oral secretions
 Dystonic reaction: Diphenhydramine (Benadryl) 1 mg/kg (25 mg max) IV,IO or IM
 Beta blocker OD: Glucagon 1 - 2 mg IM/IV
 Sympathomimetic ingestion (cocaine/amphetamine): Midazolam (Versed) 0.1 mg/kg IV,IO,IM, or ETT
 Calcium channel blocker OD: Glucagon 1 - 2 mg IM (if hypotensive, 20 mL/kg NS bolus) ON BSO ONLY
 Tricyclic Antidepressants: Sodium Bicarb 1 mEq/kg if wide complex arrhythmia and prolonged QRS duration (if hypotensive, 20 mL/kg NS bolus)
 Dystonic reaction is uncontrolled contractions of face, neck or tongue
 Cocaine/Methamphetamine signs and symptoms Seizures, hypertension, tachycardia
 Signs and symptoms of organophosphate poisoning consider SLUDGE
 Salivation, Lacrimation, Urination, Diarrhea, Gastric cramps, Emesis
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Pediatric: Pain Management 6.12
Revised July 2022

 ABC
 Vital signs
 Administer ONE of the following narcotic analgesics
 Fentanyl 0.5 – 1 mcg/kg Slow IV, IM, IN
 Ondansetron (Zofran) 0.1 mg/kg IV/IO, if patient becomes nauseous
ONLY for patients with:
 Severe burns without hemodynamic compromise
 Suspected isolated extremity injuries, fractures or dislocations with severe pain
 For all other painful conditions, providers must consult MEDICAL CONTROL physician for orders
 Contraindications to pain management protocol: altered mental status, hypoventilation, hypotension, other traumatic injuries
 Consult MEDICAL CONTROL physician for additional Fentanyl, or Zofran,
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Pediatric: Seizures 6.13
Revised July 2022

 ABC
 Vital signs
 If child is warm, remove blanket or loosen clothing
 Check blood glucose level, if level is abnormal refer to Pediatric: Diabetic protocol
 ****DO NOT DELAY TREATMENT OF SEIZURE TO OBTAIN BGL****
 Ativan 0.05—0.1 mg/kg IV/IM up to 2mg at a time. Repeat up to 3x.
OR
 Midazolam (Versed) 0.05 mg/kg IV, IM, IN (max .1mg/kg)
 Place advanced airway and or O2 necessary.

 Protect the patient and EMS crew from injury during the seizure
 Paramedic may assist the patient’s family or caregivers with administration of seizure medications rectally
 IN administration of benzodiazepines is as effective as IV
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Pediatric Trauma: Hypoperfusion / 6.14

Hypovolemia
Revised July 2022
 ABC
 Vital signs
 Vascular access; Normal Saline 20 mL/kg IV bolus, may repeat x2 prn
 Cardiac monitor
 Maintain stable B/P and pulse
 If patient has a known Cardiac History, fluid challenge of 10ML/KG must be used.
 Diagnostic criteria for UNSTABLE includes: capillary refill time greater than 2 seconds, cool, clammy or mottled skin, ina-
bility to recognize parents, restlessness, listlessness, tachycardia, tachypnea, systolic BP less than 70 mmHg (2 years and
older) or systolic BP less than 60 mmHg (less than 2 years old).
 A falling BP is a
LATE sign of shock
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Pediatric Trauma: Burns 6.15
Revised October 2021

 Stop the burning. Remove any clothing, jewelry, etc.
 ABC
 High Flow Oxygen 12-15 lpm via NRB
 Vital signs
 Use dry sterile dressings or appropriate specialized burn dressing.
 Avoid wetting the patient due to the danger of hypothermia
 Burns to the eye require copious irrigation with Normal Saline — do not delay irrigation
 Vascular access at 2 sites
 Normal saline 20 mL/kg IV bolus, may repeat once
 May consider IV/IO through burned tissue as last resort only
 If patient has signs of airway burns be prepared to intubate
 Be alert for other injuries, including cardiac dysrhythmias
 Be alert for smoke inhalation.
 Assure 100% oxygen. Oxygen saturation readings may be falsely elevated.
 If hazardous materials, notify the destination hospital immediately to allow for decontamination
 When considering total area of a burn, DO NOT count first degree burns
 Burns are only to be dressed with simple sterile dressings.
 Consider Cyanide Toxicity and Carbon Monoxide poisoning
 Keep patient warm avoid hypothermia
69
70
Special Guidelines 7.0
70
71
Special: Ventricular Assist Device 7.1

Failure
Revised July 2022
Paramedic
71
72
Special: Ventricular Assist 7.2

Device Failure
Revised July 2022
Paramedic


72
73
Special: Medical Device Dependent 7.3

Transport
Revised July 2022
EMT
The Emergency Medical Services Commission recognizes the increasing numbers of medical‐device‐
dependent pa ents. EMTs may transport these pa ents. The followingrepresents the EMS Commission’s
“Non Rule Policy”
Long‐term care providers should stop central venous and enteral on‐going infusions prior totransport by the EMT.EMTs
shall not manipulate these devices unless directed to do so by medical control.
EMTs may transport any of the following under control of the provider organiza on’s medicaldirector:
 PCA Pump with any medica on or fluid infusing through a peripheral IV
 Medica on infusing through a peripheral IV or con nuous subcutaneous catheter via aclosed, locked sys‐
tem
 A central catheter that is clamped off (subclavian, Hickman, PICC, and Passport)
 A pa ent with a feeding tube that is clamped off
 A pa ent with a Holter monitor
 A pa ent with a peripheral IV infusing vitamins
 IV fluids infusing through a peripheral IV via gravity or an infusing system that allows thetechnician to
change the rate of infusion are limited to NS, Lactated Ringers, Sodium Chloride (0.9% or less), Potassium
Chloride (20mEq or less for EMTs)
The following are determined by the Emergency Medical Services Commission to requireParamedic level transporta on:
 Medica on infusing through a peripheral or central IV or fluid infusing through a centralIV via gravity or
an infusing system that allows the operator or assistant to change the rate of infusion
 A pa ent with a chest tube
 A pa ent with a con nuous feeding tube
 A vent dependent pa ent
73
74
Special: Mass Casualty Incidents 7.4
Revised July 2022
Purpose:
The purpose of this protocol is to provide structure to the triage and treatment of persons involved in multiple or mass casualty inci-
dents or multiple patient scenes. EMS personnel must contact the closest receiving facility as soon as possible for reasons of early
notification and preparation of resources.
Definitions:
A mass casualty incident is defined as an incident that involves more victims than the initial EMS providers arriving on scene.
Incident Commander
Responsible for the overall incident and personnel on scene.
Medical Command
Responsible for the patients, highest scope of practice on scene.
Assigns treatment officers to secondary triage tarps
Contacts local hospitals and disseminates patients.
Triage
The process of sorting and categorizing patients based on the severity of their symptoms. Patients will be categorized into the four
following groups. Each group has a color designation to assist in the rapid sorting of triaged patients.
Red- critically injured patients who must be transported as soon as resources allow
Yellow-Severely injured patients who must be evaluated and treated yet may not need immediate treatment.
Green- Those patients who need minor treatment
Black- Patients who are or will be deceased with or without appropriate treatment.
Procedure:
Patients will be triaged according to the SMART and JUMP START triage criteria during every MCI
The first providers on scene will begin the triage tag process spending no more than 30 seconds with each patient. Initial treatment is
BLS. (Primary Triage)
Additional providers will assist with primary triage, the incident commander and medical commander will be designated, secondary
triage will be set up. (Colored Tarps)
Once primary triage has been completed on all victims, patients will be moved to designated colored tarps in order of criticality.
(Secondary Triage)
Medical Command will designate a treatment officer for each tarp who will direct the treatment of patients assigned to each tarp.
Secondary triage will take place once as patients arrive at their designated tarps. The patients will be evaluated based on secondary
triage assessment findings.
Medical command or his/her designee will be responsible for contacting local hospitals to determine the number of patients each
hospital can accommodate.
Patients will be transported in order of severity of symptoms.
74
75
Special: Mass Casualty Incidents Start 7.5

Triage
Revised July 2022
75
76
Special: Mass Casualty Incidents Start 7.6

Triage Child
Revised July 2022
76
77
Special: Ambulance Diversion 7.7
Revised July 2022
Purpose:
To provide safe, appropriate and timely care of patients who continue to enter theEMS system during periods of diver-
sion.
Definitions:
Ambulance Diversion:
An alert from an overwhelmed hospital to EMS Providers to divert patients thatwould normally be transported to
that hospital to the next closest hospital due to concerns of patient safety.
Procedure:
 Hospitals will notify the dispatch center that the facility is on Ambulance diversion
 Dispatch center will provide diversion status notification to EMS Providers.
 EMS providers will divert non critical patients to the next closest facility.
 The hospital staff will update dispatch every four hours concerning diversion status.
Transporting against diversion
* EMS providers may transport against diversion in the following instances

 Unable to maintain airway or properly ventilate the patient
 Unremitting Shock
 Severe critical nature of the patient determines that the patient must betransported against diver-
sion.
 Patient meets STEMI, Stroke or Trauma criteria.
 Patient refuses to be transported to an alternate facility.
 Patient must be informed that their treatment will be delayed as well asimpact the timeliness of necessary hos-
pital admittance.
 EMS staff will obtain a refusal form to show that the patient is making aninformed consent to be transported
against diversion.
 The patients condition is paramount in honoring diversion

 Any incident involving a receiving hospitals ED staff member or physician should bereported to the EMS director
 immediately.
 EMS refusal to honor diversion will be submitted for audit and review for CQIpurposes as with other protocol
deviations.
77
78
Special: Patient Refusal of Treatment 7.8

and or Transport
Revised July 2022
PURPOSE:
To establish guidelines for the management and documentation of situations where refusal of treatment or transportation is requested.
II. COMMUNICATION GUIDELINES
A. Communication and documentation will comply with agency and/or medical direction authority specific policy when a patient is refusing EMS
intervention. Such refusals may include, but are not limited to:
1.Refusal of treatment or assessment

2. Refusal of procedures
3. Refusal of transport .
III. WHO MAY REFUSE ASSESSMENT, TREATMENT OR TRANSPORT
Decisional capacity to refuse treatment or transportation must be determined and documented. Individuals who do not demonstrate decisional capacity
cannot refuse assessment, treatment or transport.
A. The patient with decisional capacity has the right to refuse assessment, treatment or transport.
B. Parent
1.A custodial parent (i.e. a parent with a legal right to custody of a minor child) may refuse care on behalf of a minor child. If the parent is not on
scene, the parent may designate another adult to assume care of the minor or the minor may be left in the care of law enforcement.
2. A minor (i.e. under 18 years of age) may refuse care for his or her child
3. May get permission from parent over the phone, along with medical control approval.
3. Emancipated minors must show legal proof of emancipation
C. Guardian
1. A legal guardian is one who is appointed by a court to act as “guardian of the person” of an individual who has been found by a court to be inca-
pacitated
2. Legal guardian may also be appointed by the court in lieu of parents for a minor
D. Medical Power of Attorney
1. A person appointed by the patient to make healthcare decisions.

2. This document only comes into effect if the patient loses decisional capacity regarding healthcare
E. Patients under the age of eighteen (18) years of age cannot refuse medical attention. The patient’s parent or guardian must assume responsibility for the
patient. Caretakers/school officials are not considered guardians for refusal of care.
IV. PROCEDURE:
A. Conduct assessment and determine decisional capacity. If decisional capacity is questionable, use the Cognitive Decision Screening Tool.
B. EMS personnel shall provide an explanation of possible risks and dangers associated with not accepting medical intervention to the patient or other au-
thorized responsible party.
C. If EMS personnel need assistance in determining a patients’ decisional capacity, the EMS personnel will contact their medical direction authority.
D. The on-line physician may ask to speak directly to the patient and explain the risks of refusing care. Transporting a patient against their will is a physician
decision according to ARS § 36-524 (Application for emergency admission for evaluation; requirements) and ARS § 13-403 (Justification: use of physical
force).
V. EMS documentation should include but is not limited to:

A. Determination of decision making capacity
B. The patient acknowledges an understanding of the risks of refusing transport or treatment including the possibility of permanent disability
and death.
C. Administrative medical director or agency specific guidelines for patient refusals
VI. SPECIAL CIRCUMSTANCES:

A. If patient does not have the mental capacity to refuse care, and no other individual is authorized to refuse care for the patient, all reasonable
steps to se cure treatment and transportation without placing EMS providers in jeopardy should be taken.
B. If law enforcement personnel insist on asserting medical responsibility for patient, EMS personnel should contact their medical direction au-
thority. EMS personnel should document the law enforcement officer’s name and badge number on the patient care report.
78
79
Special: ALS Assist / Intercept 7.9
Revised July 2022
IntroducƟon:
It is impera ve that advanced life support is provided in a mely fashion to pa entsthat will benefit from it. This ad‐
vanced level of care is readily available throughout our area. ALS should be requested as soon as possible to ensure
the pa ent receives the maximum benefit from the ALS provider.
Criteria:
The following type of calls will benefit from rapid ALS response
. while BLS ini atescare:
 Cardiac Arrest
 Unresponsiveness
 Cardiac Chest Pain / STEMI
 Difficulty Breathing
 Anaphylaxis
 Severe Pain
 Major Burns
 Major Trauma
 Drowning or Near Drowning
 Drug Overdose
 Severe Hypothermia
 Mul ple or Ongoing Seizures

Procedure:
 Once dispatched, ALS should ini ate contact with reques ng agency and give an ETA.
 Addi onal communica ons should occur to give pa ent updates, and routes of travel iftransport is ini ated prior to
ALS arrival and the intent is to intercept enroute.
 DO NOT delay transport wai ng for ALS. Arrange intercept if ready to transport.
 Once ALS unit arrives the paramedic will be provided a verbal report to include vital signs and pa ent assessment
findings. BLS staff with assist ALS crew with ongoingpa ent care as requested.
 If a er a thorough assessment, it is determined that ALS care is not needed, then ALScan be cancelled. It is encouraged
for our agencies to u lize the responding ALS crewor medical control to assist with assessment ques ons.
 All downgrades/cancella ons need to be documented and will be reviewed by the medical director. Cancella on
of EMD ac vated ALS can only be made a er an onscene assessment of the pa ent by an EMS provider.
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80
Procedure Guidelines 8.0
80
81
Procedure: Airway Management 8.1
Revised July 2022

 Oxygen therapy: The goal of oxygen therapy is to achieve adequate tissue oxygenation using the lowest possible
FiO2
 Non-rebreather mask 12 - 15 lpm, NRB
 Nasal cannula, 2 - 6 lpm
 Nasopharyngeal and/or Oropharyngeal airways
 BVM assisted ventilation
 Medical Director approved nonvisualized single lumen airway.

 Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway
 IV Access
*Oral endotracheal intubation in unresponsive Adults and Pediatric patients

*Waveform and Quantitative Capnography must be used and documented with all intubated patients
*RSA
Surgical airway procedure: (older than 10 yo) Quick Cric/Quick Trach should be used before considering surgical airway.
 Prepare (scalpel, size 6 ET tube or smaller, alcohol preps, and hemostat)
 Cleanse site, make a vertical ½ inch incision through skin and cricothyroid membrane
 Insert knife handle and rotate 90 degrees, insert hemostat, spread the opening
 Insert a size 6 ET tube and inflate cuff
 Attached BVM and ventilate
 Observe for signs of subcutaneous emphysema, severe hemorrhage, and poor oxygenation
Key Point/ Considerations

 The goal of oxygen therapy is to achieve adequate tissue oxygenation using the lowest FIO2 with consideration for other respiratory
function effectors (CO2 levels, Hypoxic Drive, etc.)
 Intubation must be attempted x1 only and if unsuccessful a medically approved non visualized airway must be utilized with a BVM
 The use of a C-Collar should be considered for all intubated patients
 Tube placement should be confirmed via three methods at a minimum.
 Pediatric Needle cricothyrotomy (Less than 10 yo)
 Prepare (alcohol preps, 14 ga IV catheters, 22mm connector, 3 cc syringe)
 Extend head and place towel under shoulders
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82
Procedure: CPAP 8.2
Revised July 2022
EMT AEMT Paramedic
82
83
Procedure: Non-visualized Single Lu- 8.3

men Airway Device
Revised July 2022
EMT AEMT Paramedic
83
84
Procedure: Non-visualized Single Lu- 8.4

men Airway Device
Revised July 2022
EMT AEMT Paramedic
84
85
Procedure: Endotracheal Intubation 8.5
Revised July 2022
Paramedic
85
86
Procedure: Rapid Sequence Airway 8.6

Checklist
Revised July 2022
Paramedic
Plan
RSA Indicated—Pre-Oxygenated started– Team Briefing– Assess Airway—Back up plan
Position
Ear to sternal level—Head of Cot Elevated—DO NOT LAY PATIENT FLAT
Preoxygenation
Two O2 Sources (main turned on) NC @ 6L to 15L—PEEP and Co2 on BVM—Safe
Preoxygenated level is >94% for 3 min.
Prepare
IV/IO Access x2—B/P cuff on—Pulse Ox attached—Capnography
attached—Medications drawn—Suction ready—King Vision present—ET
tested and loaded with Bouige—Tube holder ready—Oral airways
present—King tube ready for back up airway.
Pause
Is preoxygenation effective (correct) - Is patients V/S stable (correct) - EMS team ready
PARALYZE
Push Medications—Record times– Asses for medication effects– Turn NC
up to 15lpm—Team Monitoring V/S,SPO2,Capnography—INTUBATE
Post Intubation
Confirm ET placement—Secure tube—C-Collar to keep head mobilized—COUNTINUS AS-
SESSMENT FOR SEDATION—ASSESS V/S EVERY 5 MIN– REASSESS
86
87
Procedure: RSA Medications and 8.7

Glasgow Coma Scale
Revised July 2022
Paramedic
87
88
Procedure: Cricothyrotomy 8.8
Revised July 2022
Paramedic
88
89
Procedure: Pediatric Needle 8.9

Cricothyrotomy
Revised July 2022
Paramedic
89
90
Procedure: Pertrach Cricothyrotomy 8.10
Revised July 2022
Paramedic
90
91
Procedure: Needle Chest 8.11

Decompression
Revised July 2022
Paramedic
91
92
Procedure: Intraosseous Access 8.12
Revised July 2022
AEMT Paramedic
92
93
Procedure: Intraosseous Access 8.13
Revised July 2022
93
94
Procedure: External Jugular Access 8.14
Revised July 2022
AEMT Paramedic
94
95
Procedure: Intranasal Medication 8.15

Administration
Revised July 2022
EMT AEMT Paramedic
95
96
Procedure: Intramuscular Injection 8.16
Revised July 2022
EMT AEMT Paramedic
96
97
Revised July 2022
EMT AEMT Paramedic
97
98
Revised July 2022
EMT AEMT Paramedic
98
99
Procedure: Subcutaneous Injection 8.19
Revised July 2022
EMT AEMT Paramedic
99
100
Procedure: 12 Lead EKG Acquisition 8.20
Revised July 2022
EMT AEMT Paramedic
100
101
Procedure: 12 Lead EKG Acquisition 8.21
Revised July 2022
Paramedic
101
102
Procedure: Buccal Administration of 8.22

Glucose
Revised July 2022
102
103
Procedure: Taser Removal 8.23
Revised July 2022
EMT AEMT Paramedic
103
2022 EMT/AEMT/Paramedic Drug List
Revised 2022
9.0
9.1 Medications
MEDICATION PAGE SPECIAL INFO. EMT - MEDIC Concentration
Adenosine 106 MEDIC 6mg/2ml
Albuterol (Proventil) 107 Light Sensitive AEMT-MEDIC 2.5 mg/ 3ml
Amiodarone 108 MEDIC 300mg 150mg
Baby Aspirin 109 EMT-AEMT- 81mg
MEDIC
Atropine Sulfate 110 MEDIC 2mg/ml
Calcium Chloride 111 MEDIC 10ml (10%)
Dextrose 112 AEMT-MEDIC D50, D25. D5W. D10
Diltiazem (Cardizem) 113 Keep Cold or 60 MEDIC 25mg
Day renew
Diphenhydramine (Benadryl) 114 MEDIC 50mg
Dopamine (Intropin) 115 MEDIC 800mg/250ml
Epinephrine (Adrenalin) 1:10,000 116 AEMT-MEDIC 1mg
Epinephrine (Adrenalin) 1:1000 117 EMT-AEMT- 1mg
MEDIC
Racemic Epinephrine 118 MEDIC 2.25% in 0.5ml
Etomidate 119 MEDIC 30mg
Fentanyl 120 MEDIC 100mcg
Furosemide (Lasix) 121 MEDIC 40mg
Glucagon 122 AEMT-MEDIC 1mg
Haldol 123 MEDIC 5mg
Ipratropium (Atrovent) 124 Light Sensitive AEMT-MEDIC 0.5mg/3ml
Ketorolac (Toradol) 125 MEDIC 30mg
Ketamine 126 MEDIC 500mg
Lidocaine 2% 127 MEDIC 100mg
Lorazepam (Ativan) 128 Keep Cold or 60 MEDIC 2mg
Day renew
Magnesium 129 MEDIC 1gm
Methylprednisolone (Solu-Medrol) 130 MEDIC 125mg
Metoprolol 131 MEDIC 25mg
Midazolam (Versed) 132 MEDIC 5mg
Naloxone (Narcan) 133 EMR-EMT-AEMT- 2mg
MEDIC
Nitroglycerine Tablets 134 Light Sensitive AEMT-MEDIC .04mg tabs
Oral Glucose 135 EMR-EMT-AEMT- 50grams
MEDIC
Procainamide 136 MEDIC 100mg
Sodium BiCarb 137 MEDIC 50ml
Succinylcholine 138 Keep Cold or 60 MEDIC 250mg
Day renew
TXA 139 MEDIC 1gram
Oxygen 140 EMR-EMT-AEMT- 2 lpm-20 lpm
MEDIC
0.9 Normal Saline 144 AEMT-MEDIC 50ml, 100ml,
250ml,500ml
105
Adenosine (Adenocard)
Class: Misc. antidysrhythmic, endogenous nucleoside
Action: Decreases electrical conduction through the AV node without causing negative
inotropic effects
Indications: Supraventricular tachycardias (SVT/PSVT)
Contraindications: Hypersensitivity, bradycardia, drug induced tachycardia, 2nd or 3rd degree

heart blocks, A-Fib, A-Flutter, V-Tach, WPW with A-Fib/flutter.
Onset/Duration:
Onset: Immediate
Duration/half-life: 10 seconds
Dose/Route:
Adult: 6 mg rapid IV/IO push followed by 20 cc saline flush. May repeat in 1-2 min at 12
mg rapid IV push followed by 20 cc saline flush.
Peds: 0.1mg/kg (max 6mg) IV/IO followed by 5-10 cc saline flush. May repeat in 1-2 min
at 0.2 mg/kg (max 12mg) IV/IO followed by 5-10 cc saline flush.
Side Effects: dizziness, headache, shortness of breath, hypotension, flushing, palpitations,

chest pain, nausea/vomiting
Note: Methylxanthine classified stimulants (caffeine & theophylline) usage will antagonize
adenosine
106
Albuterol (Proventil)
Class: Sympathomimetic, bronchodilator, beta-2 agonist
Action: Sympathomimetic that is selective for Beta-2 adrenergic receptors/ Relaxes smooth
muscles of the bronchial tree and peripheral vasculature by stimulating adrenergic receptors of
sympathetic nervous system.
Indications: Asthma, bronchospasms, reversible obstructive airway disease
Contraindications: Hypersensitivity, caution with pts with cardiac dysrhythmias
Onset/Duration:
Onset: 5-8 min
Duration: 2-6 hours
Dose/Route:
Adult/Peds: 2.5 mg diluted in 3 mL of Normal Saline
Side Effects: Tremors, tachycardia, hypertension, anxiety, nausea, headache, palpitations,

cough, dizziness
Note: Albuterol may precipitate angina & cardiac dysrhythmias. Use with caution in pt’s with
cardiovascular disorder, diabetes, seizure disorder, hyperthyroidism.
107
Amiodarone (Cordarone)
Class: Class III antidysrhythmic
Action: Prolongs duration of the action potential and prolongs the refractory period, also has
beta adrenergic receptor and calcium channel blocking activity. Works on both the ventricles
and the atria
Indications: V-Fib, hemodynamically unstable V-Tach, treatment for some stable atrial rhythms
Contraindications: CHF, cardiogenic shock, bradycardia, 2nd or 3rd degree heart blocks with no
pacemaker present, hypersensitivity to amiodarone or iodine
Onset/Duration: Onset: within minutes and Duration: Variable but considered 30 – 45 days
Dose/Route:
Adult: Pulseless V-Tach/V-Fib arrest - 300mg IV/IO may repeat once at 150mg IV/IO. V-
Tach with a pulse 150mg IV drip over 10 minutes up to max of 2.2g in 24 hours
Peds: Pulseless V-Tach/V-Fib arrest - 5mg/kg IV/IO. V-Tach with a pulse 5mg/kg IV drip
over 20-60 minutes with a max of 15mg/kg/day.
Side Effects: Bradycardia, hypotension, headache, CHF, abnormal liver/thyroid functions. In

rare cases can cause pulmonary fibrosis
108
Aspirin (Salicylate)
Class: Analgesic, nonsteroidal anti-inflammatory drug (NSAID), antipyretic, and antiplatelet
Action: Inhibits prostaglandins involved in the production of inflammation, pain and fever.
Dilates peripheral vessels and also inhibits platelet aggregation by blocking the formation of
thromboxane A2.
Indications: Acute coronary syndrome (ACS) such as myocardial infarction, ischemic chest pain
or angina, and given for mild to moderate pain or fever.
Contraindications: GI bleeding, hemorrhagic stroke, active gastric ulcers, bleeding disorders,

asthma, hypersensitivity to salicylates, children
Onset/Duration:
Onset: 15-30 min
Duration: 4-6 hours
Dose/Route:
Adult: Mild pain/fever – 325-650 mg PO every 4 hours. ACS – 2 to 4 baby chewable

aspirin, 162-324 mg OR 1 adult aspirin, 325mg PO.
Peds: Not indicated in pre-hospital setting
Side Effects: Stomach irritation, GI bleeding, Nausea/vomiting
Note: Children under 12 should not be given Aspirin as they may develop Reye’s syndrome.
109
Atropine Sulfate
Class: Anticholinergic, Parasympatholytic
Action: Inhibits actions of acetylcholine (mostly at muscarinic receptor sites) causing decreased
salivation and bronchial secretions, increased heart rate and decreased gastric motility.
Indications: Hemodynamically unstable bradycardia, organophosphate or nerve gas poisoning
Contraindications: Tachycardia, hypersensitivity, avoid use with hypothermic pts, caution in

pts with an active MI and hypoxia
Onset/Duration:
Onset: Rapid
Duration: 2-6 hours
Dose/Route:
Adult: Bradycardia – 0.5 mg IV/IO q 3-5 min up to max total of 3 mg

Organophosphate poisoning – 1 to 5mg IV/IM/IO repeated 3-5 min until cessation of
bronchial secretions
Peds: Bradycardia NOT responding to Epi- 0.02mg/kg IV/IO (min dose of 0.1 mg and max
single dose 0.5 mg) with maximum total of 1 mg for a child and 3 mg for an adolescent.
Organophosphate peds < 12 yrs old - 0.05mg/kg IV/IM/IO may be repeated every 20-30
mins until cessation of bronchial secretions.
Side Effects: Tachycardia, paradoxical bradycardia if given too slow or too small of dose,
mydriasis (dilated pupils), dysrhythmias, headache, nausea/vomiting, headache, dizziness,
flushed, anticholinergic effects (dry mouth/nose/skin, blurred vision, urinary retention,
constipation)
Note: Effects of atropine may be potentiated by antihistamines, procainamide, quinidine,

antipsychotics, antidepressants, and thiazides
110
Calcium Chloride
Class: Electrolyte, hypertonic solution
Action: It is an essential element for regulating the excitation threshold of nerves and muscles,
normal cardiac contractility, and blood coagulation.
Indications: Hyperkalemia, hypocalcemia, hypermagnesemia, calcium channel blocker

overdose
Contraindications: V-Fib during cardiac resuscitation, digitalis toxicity, hypercalcemia
Onset/Duration:
Onset: 5-15 min
Duration: Dose dependent but may last up to 4 hours
Dose/Route:
Adult: 1-2 g (10-20 ml) slow IV of 10% solution
Peds: 60 mg/kg slow IV of 10% solution
Side Effects: Bradycardia, hypotension, Metallic taste in mouth, local necrosis if given IM or IV
infiltration
111
Dextrose 50%, 25%, 10%
Class: Carbohydrate, hypertonic solution
Action: Dextrose increases available blood sugar to be used as energy by the body
Indications: Hypoglycemia. If protocol allows also for altered ALOC, coma, and seizure of
unknown origin
Contraindications: Intracranial hemorrhage, increased intracranial pressure, known or

suspected stroke in the absence of hypoglycemia
Onset/Duration:
Onset: 1 min
Duration: Variable depending on degree of hypoglycemia
Dose/Route:
Adult: 12.5-25 g slow IV (25-50 ml 50% dextrose; 125-250 ml 10% dextrose)
Peds: 0.5-1 g/kg (2-4 ml/kg) IV of 25% dextrose
Neonates: 0.5-1 g/kg (2-4 ml/kg) IV of 10% dextrose
Side Effects: Hyperglycemia
Note: If given through infiltrated IV, will cause tissue necrosis so use large vein and flush with
saline to ensure IV patency. D50 may cause Wernicke’s encephalopathy in thiamine deficient
patient (alcoholics and malnourished pts) so if these conditions are suspected, administer 100
mg Thiamine IV prior to administering D50.
112
Diltiazem (Cardizem)
Class: Calcium channel blocker
Action: Inhibits calcium ion influx through slow channels into the cell of myocardial and arterial
smooth muscle. Slows SA and AV nodal conduction. Dilates coronary arteries and arterioles
thus inhibits coronary artery spasms.
Indications: A-Fib and A-Flutter. Multifocal atrial tachycardias. SVT/PSVT refractory to

Adenosine.
Contraindications: Hypersensitivity, 2nd and 3rd degree heart block, hypotension, cardiogenic
shock, ventricular rhythms, sick sinus syndrome, Wolf-Parkinson-White syndrome, AMI, V-Tach.
Onset/Duration:
Onset: 2-5 min
Duration: 1-3 hours
Dose/Route:
Adult: 15-20 mg IV over 2 min, may be repeated in 15 min at 20-25 mg IV over 2 min.
Maintenance infusion 5-15 mg/hr titrated to HR.
Peds: Not recommended in the prehospital setting
Side Effects: Headache, dizziness, hypotension, 1st and 2nd degree heart block, bradycardia,
palpitations, CHF, chest pain, ventricular rhythms.
Note: Use caution with renal/liver impaired pt’s and those taking beta blockers.
113
Diphenhydramine (Benadryl)
Class: Antihistamine
Action: Blocks histamine H1 receptor sites thereby inhibiting actions of histamine release.
Indications: Allergic reactions, anaphylaxis, acute extrapyramidal reaction (dystonia)
Contraindications: Hypersensitivity, pt’s taking MAO inhibitors, caution with glaucoma.
Onset/Duration:
Onset: 5-15 min with max effects in 1-3 hrs
Duration: 6-12 hrs
Dose/Route:
Adult: 25-50mg IV/IM/PO with a max of 400 mg/day
Peds: 1 mg/kg IV/IM/PO with a max of 300 mg/day
Side Effects: Drowsiness, palpitations, hypotension, tachycardia or bradycardia, disturbed

coordination, dry mouth/throat, thickening of bronchial secretions.
Note: Use with caution in CNS depressed pts and pts with lower respiratory tract diseases such
as asthma.
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Dopamine (Intropin)
Class: Sympathomimetic, vasopressor
Action: Acts primarily on alpha-1 and beta-1 adrenergic receptors. At low doses (2-5
mcg/kg/min), it may act on dopaminergic receptors causing renal, mesenteric, and cerebral
vascular dilation. At moderate doses (5-10 mcg/kg/min), dopamine stimulates mostly beta 1
receptors causing increased cardiac contractility and output. At high doses (10-20 mcg/kg/min)
dopamine has mostly alpha-1 stimulation effects causing peripheral arterial and venous
constriction.
Indications: Hemodynamically significant hypotension in the absence of hypovolemia such as

in cardiogenic shock, neurogenic shock, septic shock. Second line pharmacological treatment
for bradycardia after atropine.
Contraindications: Hypovolemia, trauma, tachydysrhythmias, V-Fib, pt’s with

pheochromocytoma.
Onset/Duration:
Onset: 2-4 min
Duration: 10-15 min
Dose/Route:
Adult: 2-20 mcg/kg/min IV Drip and titrate to desired effect
Peds: Same as adult
Side Effects: Tachycardia, hypertension, anxiety, headache, nausea/vomiting, increased

myocardial oxygen demand, mydriasis, dose-related tachydysrhythmias
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Epinephrine (Adrenalin)
Class: Sympathomimetic
Action: Endogenous catecholamine that directly stimulates both alpha-1, beta-1 and beta-2
adrenergic receptors. The effects this will have on the heart include increased contractile force,
increased rate, and increased cardiac output. Epinephrine is also a potent vasoconstrictor as
well as a bronchodilator. Other effects include slowing of gastric motility, miosis, and pale skin.
Indications: Anaphylaxis, cardiac arrest, asthma, bradycardia (first line in peds), shock not
caused by hypovolemia, severe hypotension accompanied with bradycardia when pacing and
atropine fail.
Contraindications: Hypovolemic shock. Caution should be used in patients with known

cardiovascular disease or pts > 45 y/o
Onset/Duration:
Onset: 1-2 min IV, 5-10 mins SQ
Duration: 5-10 min IM
Dose/Route:
Adult: Cardiac arrest – 1 mg 1:10,000 IV/IO every 3-5 min with no max.
Anaphylaxis/asthma – 0.3-0.5 mg SQ/IM 1:1,000. If no response, some protocols give
0.3-0.5 mg IV 1:10,000. Post cardiac arrest or for bradycardia with severe hypotension –
2-10 mcg/min IV drip and titrate to effect.
Peds: Cardiac arrest – 0.01 mg/kg 1:10,000 IV/IO max of 1 mg every 3-5 mins.
Anaphylaxis/asthma – 0.01 mg/kg 1:1,000 SQ/IM with a max single dose 0.3 mg.
Side Effects: Tachycardia, hypertension, anxiety, cardiac dysrhythmias, tremors, dyspnea
Note: Always use epinephrine 1:1,000 when given SQ/IM and 1:10,000 when given IV/IO.
Giving concurrently with alkaline solutions such as sodium bicarbonate will cause crystallization
of fluid.
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Epinephrine, Racemic (Micronefrin)
Class: Sympathomimetic
Action: Racemic Epinephrine is an inhaled version of epinephrine that is used as a

bronchodilator and as an anti-inflammatory to treat laryngeal/tracheal swelling and edema. Its
actions are the same as epinephrine but since it is inhaled it has both systemic and localized
effects.
Indications: Laryngotracheobronchitis (croup), asthma, bronchospasms, laryngeal edema
Contraindications: Hypertension, epiglottitis. Use caution in patients with known

cardiovascular disease or in pts > 45 y/o.
Onset/Duration:
Onset: 5 min
Duration: 1-3 hrs
Dose/Route:
Adult: Not usually given to adults. Contact medical control
Peds: All doses given via aerosolized neb. For pts < 6 months – 0.25 ml 2.25% diluted in
3 ml NS. For pts > 6 months – 0.5 ml 2.25% diluted in 3 ml NS.
Side Effects: Tachycardia, hypertension, anxiety, cardiac dysrhythmias, tremors
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Etomidate (Amidate)
Class: Anesthetic, hypnotic
Action: Etomidate is a very potent drug that acts on the central nervous system to produce a
short-acting anesthesia with amnesic properties. Etomidate has very little effect on respiratory
drive which makes it ideal for certain procedures.
Indications: Premedication prior to procedures such as endotracheal intubation, synchronized

cardioversion, conscious sedation for bone dislocation relocation.
Contraindications: Hypersensitivity, labor and delivery
Onset/Duration:
Onset: < 1 min
Duration: 5-10 min
Dose/Route:
Adult: 0.3mg/kg IV over 30-60 sec, limited to one dose
Peds: 0.3mg/kg IV over 30-60 sec with a max dose of 20 mg
Side Effects: Hypotension, hypertension, dysrhythmias, hypoventilation, nausea/vomiting,

cortisol suppression
Note: Primarily used for Rapid Sequence Intubation/induction (RSI) in the prehospital setting
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Fentanyl (Sublimaze)
Class: Synthetic Opioid analgesic
Action: Combines with the receptor sites in the brain to produce potent analgesic effects.
Indications: Pain and sedation
Contraindications: hypersensitivity to opiates, hypotension, head injury, respiratory

depression, cardiac dysrhythmias, myasthenia gravis
Onset/Duration:
Onset 1-2 min IV
Duration 30-60 min
Dose/Route:
Adult: 50-100 mcg/kg IV/IN over 2 mins, q 5 min, max single dose of 100 mcg, max
totaldose of 300 mcg.
Peds: mcg/kg IV/IN over 2 mins, q 5 min, max single dose of 100 mcg, max totaldose
of 3 mcg/kg.
Side Effects: Respiratory depression, hypotension or hypertension, bradycardia,

nausea/vomiting, and rigidity of chest wall muscles
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Furosemide (Lasix)
Class: Loop diuretic
Action: Furosemide is a potent diuretic that inhibits the reabsorption of sodium and chloride in
the proximal tubule and loop on Henle. IV doses can also reduce cardiac preload by increasing
venous capacitance.
Indications: Pulmonary edema (CHF) with SBP > 90, hypertensive emergencies, hyperkalemia
Contraindications: Anuria, hypersensitivity, hypovolemia, hypokalemia
Onset/Duration:
Onset: 15-20 min IV
Duration: 2 hrs
Dose/Route:
Adult: 20-40 mg IV over 1-2 min. If no response double dose up to 2 mg/kg over 1-2 min.
Most services allow up to a max of 40-80 mg IV.
Peds: 1 mg/kg/dose IV over 1-2 min with a total max of 6 mg/kg
Side Effects: Tinnitus and hearing loss (if given too quickly), hypotension, hypokalemia,
hyponatremia, hypocalcemia, hyperglycemia
Note: Must give slowly or may cause permanent hearing problems.
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Glucagon
Class: Pancreatic hormone
Action: Glucagon stimulates the liver to breakdown glycogen into glucose resulting in an
increase in blood glucose. Also stimulates glucose synthesis.
Glucagon also has a positive inotropic action on the heart even in the presence of beta
blockade or calcium channel blockade which makes it useful for beta blocker or calcium channel
blocker overdose.
Glucagon also relaxes smooth muscle of the GI tract, primarily the esophagus which makes it
useful for esophageal obstruction.
Indications: Hypoglycemia (when IV access is not available), beta blocker overdose, calcium
channel blocker overdose, esophageal obstruction
Contraindications: Hypersensitivity (usually to proteins)
Onset/Duration:
Onset: 10-20 min IM, 1 min if IV
Duration: 60-90 min
Dose/Route:
Adult: Hypoglycemia – 1 mg IM/IN may repeat in 10 min if protocol allows. Calcium

channel or beta blocker overdose – 3-10 mg IV over 3-5 min followed by an infusion at
3-5 mg/hr.
Peds: < 20 kg – 0.5 mg IM/IN, > 20 kg - 1.0 mg IM/IN
Side Effects: Tachycardia, hypotension, nausea/vomiting, urticaria
Note: Glucagon requires glycogen stores in the liver to increase blood glucose. If patient is
malnourished glucagon may not work.
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Haloperidol (Haldol)
Class: Antipsychotic, neuroleptic
Action: Blocks dopamine type-2 receptors in the brain thereby altering mood and behavior.
Indications: Acute psychotic episodes, emergency sedation of severely agitated or delirious pts
Contraindications: Hypersensitivity, CNS depression, pregnancy, Parkinson’s disease, seizure

disorder, liver or cardiac disease
Onset/Duration:
Onset: 30-60 min IM
Duration: 12-24 hrs
Dose/Route:
Adult: 5 mg IV or 10 mg IM, q 5-10 min, max of 15 mg.
Peds: Not recommended
Side Effects: Dose-related extrapyramidal reactions, hypotension, nausea/vomiting, blurred

vision, drowsiness.
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Ipratropium (Atrovent)
Class: Anticholinergic, bronchodilator
Action: Ipratropium blocks interaction of acetylcholine at receptor sites on bronchial smooth

muscle resulting in bronchodilation, reduced mucus production, and decreased levels of cyclic
guanosine monophosphate.
Indications: Persistent bronchospasms, asthma, COPD exacerbation
Contraindications: Hypersensitivity to ipratropium, atropine, soybean protein, or peanuts
Onset/Duration:
Onset: < 15 min
Duration: 2-4 hrs
Dose/Route:
Adult: 0.5 mg diluted in 2.5 ml NS via nebulizer. May repeat dose twice per most
protocols
Peds: Not typically given prehospital. 250-500 mcg diluted in 2.5 ml saline via nebulizer
every 20 mins up to 3 doses
Side Effects: Mydriaisis, tachycardia, blurred vision, nausea/vomiting, headache, anxiety,

blurred vision.
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Ketorolac (Toradol)
Class: nonsteroidal anti-inflammatory drug (NSAID)
Action: Binds with lysine sites on plasminogen, preventing conversion of plasminogen to

plasmin and ultimately inhibiting the breakdown of fibrin during bleeding episodes.
Indications: Mild to Moderate pain. Good for kidney stones and headaches.
CONTRAINDICATIONS
Do not use Toradol if the patient is allergic to ASA or NSAIDs, may be pregnant, or if they are
taking any blood thinning or anticoagulants.
Do not use if they have:

- severe renal disease or kidney transplant
- a bleeding or blood clotting disorder
- a closed head injury or bleeding in brain
- a stomach ulcer or a history of stomach or intestinal bleeding
- patient needing surgery
- a surgical candidate with open fracture or fracture deformities
- if breast-feeding a baby
Onset/Duration:
Onset: 5-10 min
Duration: 2-5 H
Dose/Route:
Adult: Administer 30mg IV/IM
Side Effects: nausea, vomiting, Abd pain, dizziness
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Ketamine (Ketalar)
Class: Nonbarbiturate anesthetic
Action: Acts on the limbic system and cortex to block afferent transmission of impulses
associated with pain perception. It produces short-acting amnesia without muscular relaxation.
A derivative of phencyclidine (PCP).
Indications: Pain, sedation and sometimes used as an adjunct to nitrous oxide
Contraindications: Stroke, hypersensitivity, severe hypertension, cardiac instability. Caution

with schizophrenia.
Onset/Duration:
Onset: 30 sec
Duration: 5-10 min up to 1-2 hours
Dose/Route:
Adult: Sedation - 1-2 mg/kg IV over 1 min or 4 mg/kg IM. Pain – 0.3 mg/kg IV/IO/IM/IN
Peds > 2 y/o: 1-2 mg/kg IV over 1 min. Pain – 0.3 mg/kg IV/IO/IM/IN
Side Effects: Hypertension, increased heart rate, hallucinations, delusions, explicit dreams.
Note: Common street use these days in conjunction with narcotics because they potentiate
each other for a longer/higher euphoria. Giving Narcan will only affect the narcotic NOT the
Ketamine therefore only a minimal short-lasting effect.
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Lidocaine (Xylocaine)
Class: Class 1B Antidysrhythmic
Action: Lidocaine is a sodium channel blocker that acts primarily on the ventricles of the heart
during phase 4 diastolic depolarization which decreases automaticity, suppresses premature
ventricular complexes, and raises the V-Fib threshold.
Indications: Significant ventricular ectopy with ischemia/MI, pulseless V-tach or V-Fib cardiac
arrest, stable V-tach with a pulse
Contraindications: Hypersensitivity, prophylactic use in an acute MI, 2nd or 3rd degree heart
block in the absence of a pacemaker, Stokes-Adams syndrome
Onset/Duration:
Onset: 30-90 sec
Duration: 10-20 min
Dose/Route:
Adult: Cardiac arrest - 1-1.5 mg/kg IV/IO bolus may be repeated in 5-10 mins at 0.5-0.75
mg/kg with a total max of 3 mg/kg. Bolus is followed by a maintenance infusion drip of
1-4 mg/min post-cardiac arrest. For PVC’s or V-tach with a pulse – 0.5-0.75 mg/kg IV/IO
up to 1-1.5 mg/kg IV/IO and may be repeated with a total max dose of 3 mg/kg
Peds: 1 mg/kg IV/IO bolus followed by maintenance infusion drip of 20-50 mcg/kg/min
IV/IO post-cardiac arrest. For PVC’s or V-tach with a pulse – 1 mg/kg IV/IO.
Side Effects: Blurred vision, dizziness, hypotension, bradycardia, seizures, altered LOC
Note: Use caution in patients with impaired liver/renal function and the elderly. May half initial
dose for pts >70 y/o.
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Lorazapam (Ativan)
Class: Benzodiazepine
Action: Increases the activity of the inhibitory neurotransmitter GABA, thereby producing a
sedative effect, relaxing skeletal muscles, and raising the seizure threshold.
Indications: Seizures, agitation, anxiety, alcohol withdrawal.
Contraindications: Hypersensitivity, hypotension, respiratory depression, CNS depression.
Onset/Duration:
Onset: 2-10 min IV
Duration: 6-8 hrs
Dose/Route:
Adult: 1-4 mg IM/IV, every 15-20 min up to 8 mg max total dose.
Peds: 0.1 mg/kg IV/IO/IM/PR/IN over 2 min, can be repeated once in 5-10 min up to 4
mg.
Side Effects: Respiratory depression, hypotension, tachycardia, bradycardia, CNS depression,

blurred vision.
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Magnesium Sulfate
Class: Electrolyte, anticonvulsant
Action: Reduces striated muscle contractions and blocks peripheral neuromuscular

transmission by reducing acetylcholine release at the myoneural junction.
Indications: Seizures due to eclampsia after seizure activity is stopped, torsades de pointes,
unstable V-Tach attributed to digitalis toxicity, hypomagnesemia, status asthmaticus
unresponsive to beta-adrenergic drugs
Contraindications: Any heart block or myocardial damage, hypotension
Onset/Duration:
Onset: Immediate IV
Duration: 30 min IV
Dose/Route:
Adult: Pulseless arrest (hypomagnesemia and torsades de pointes) and status

asthmaticus – 1-2 g diluted in 10 ml D5W/NS IV/IO. Torsades de pointes or
hypomagnesemia WITH A PULSE – 1-2 g in 100ml D5W/NS over 5-60 min IV. Eclampsia –
4 g IV drip over 20 min, with a max dose of 30-40 g/day
Peds: Pulseless arrest or hypomagnesemia/torsades with a pulse – 25-50 mg/kg IV/IO

(max 2 g) over 10-20 mins. Status asthmaticus - 25-50 mg/kg IV/IO (max 2 g) diluted 100
ml D5W/NS over 15-30 mins.
Side Effects: Hypotension, facial flushing, hyporeflexia (decreased reflexes), bradycardia,

respiratory depression, diaphoresis.
Note: If overdose is suspected (indicated by decreased deep tendon reflexes) may give calcium
chloride or calcium gluconate to reverse effects.
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Methylprednisolone (Solu-Medrol)
Class: Corticosteroid, Glucocorticoid
Action: Synthetic steroid that suppresses acute and chronic inflammation. It also potentiates
vascular smooth muscle relaxation by beta-adrenergic agonists and may alter airway
hyperactivity.
Indications: Anaphylaxis, asthma unresponsive to bronchodilators, adrenal insufficiency
Contraindications: Caution in pt’s with GI bleeding, diabetes, severe infection
Onset/Duration:
Onset: 1-2 hrs
Duration: 8-24 hours
Dose/Route:
Adult: 125 mg IV
Peds: 1-2 mg/kg IV
Side Effects: hypertension, hypokalemia, headache, alkalosis, sodium and water retention
Note: Use in spinal injury and shock is controversial
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Metoprolol (Lopressor)
Classification: Beta antagonist (β1 selective)
General:
Metoprolol is a β1 (cardiac) selective beta antagonist and thereby reduces sympathetic

stimulation of the heart resulting in decreases in the heart rate, cardiac output, and AV
conduction. Metoprolol reduces myocardial oxygen consumption. Metoprolol is classified as
a Class 2 antiarrhythmic agent. Like other cardioselective beta antagonist, metoprolol loses its
cardioselectivity at higher doses and will inhibit β2 receptors. Metoprolol is used in the chronic
management of angina, hypertension, tachyarrhythmias, and heart failure. Acutely, metoprolol
is used for ventricular rate control (supraventricular tachycardia, atrial fibrillation/flutter),
hypertension and thyrotoxicosis. It may also be used in the management of recurrent and
refractory ventricular fibrillation or tachycardia. The onset of action following IV administration
is within 5 minutes with a peak effect in less than 1 hour and a duration of action of 5 to 8 hours.
Protocol Indication(s):
1. Stroke and Hypertensive crisis.
Contraindications:
1. Known hypersensitivity
2. Heart rate <60
3. AV block >1 degree in the absence of a pacemaker
4. Hypotension (SBP <100 mmHg)
5. Acute decompensated heart failure
Precautions:
1. Metoprolol should be used cautiously in combination with other nodal agents (diltiazem)
and this combination should be avoided whenever possible.
2. In response to hypoglycemia the sympathetic nervous system stimulates an increase in
blood glucose via β receptors. Antagonism of β receptors will result in the blood glucose
remaining low. Antagonism of the β receptors will also suppress the sympathetic signs
associated with hypoglycemia.
3. The hypotensive effects of metoprolol may be enhanced in patients receiving amiodarone
or antihypertensive agents.
4. Metoprolol may enhance the CNS depressive effects of benzodiazepines.
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Significant adverse/side effects:
1. Hypotension
2. Bradycardia
3. AV block
4. Dizziness
5. Bronchospasm
6. Heart failure
Midazolam (Versed)
Class: Benzodiazepine
Action: Increases the activity of the inhibitory neurotransmitter GABA, thereby producing a
sedative effect, relaxing skeletal muscles, and raising the seizure threshold.
Indications: Seizures and anxiety. Premedication for intubation, cardioversion or conscious

sedation procedures.
Contraindications: Hypersensitivity, shock, respiratory depression, depressed VS. Use caution

with CNS depressants including barbiturates, alcohol, and narcotics and glaucoma.
Onset/Duration:
Onset: 1-3 min IV
Duration: 2-6 hours IV
Dose/Route:
Adult: 2-5 mg IV/IO/IM/IN, every 5 min up to 10 mg max total dose.
Peds: 0.2 mg/kg IV/IO/IM/IN, every 5 min up to 5 mg max single dose.
Side Effects: Hypotension, respiratory depression or arrest, CNS depression, hiccups,

oversedation, blurred vision.
Note: May be given IM since Midazolam is water based. Should be given with analgesic for
painful procedures.
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Naloxone (Narcan)
Class: Opioid antagonist
Action: Narcan is a competitive opiate antagonist used in known or suspected opioid overdose.
Indications: Suspected or known opioid overdose with respiratory depression.
Contraindications: Hypersensitivity. Caution with narcotic dependent pt’s who may experience
withdrawal syndrome to include neonates of narcotic-dependent mothers. Avoid use with
Meperidine induced seizures.
Onset/Duration:
Onset: 2 min
Duration: 30-120 min
Dose/Route:
Adult: 0.4 – 2mg IV/IO/IM/IN may repeat up to 10 mg max
Peds: 0.1 mg/kg IV/IO/IM/IN, max single dose of 2 mg
Side Effects: Withdrawal symptoms, dysrhythmias, nausea/vomiting, hypertension,

tachycardia, seizures, blurred vision.
Note: Titrate to control airway and breathing, should NOT be used to completely reverse
narcotic effects due to complications with withdrawal syndrome, combativeness, etc.
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Nitroglycerin (Nitro-Stat)
Class: Nitrate, vasodilator
Action: Nitroglycerin is an organic nitrate and potent vasodilator. It relaxes vascular smooth
muscle resulting in coronary artery dilation while also reducing blood pressure, preload,
afterload, and myocardial oxygen demand.
Indications: Chest pain, acute coronary syndromes (ACS), pulmonary edema associated with
CHF, hypertensive emergencies
Contraindications: Hypersensitivity, pts that have taken erectile dysfunction drugs (Cialis,
Levitra, Viagra, etc.) within the last 24-72 hours, head injury, SBP < 100, cerebral stroke or
hemorrhage, extreme bradycardia or tachycardia, right ventricular infarction, volume
depletion.
Onset/Duration:
Onset: 1-3 min
Duration: 25 min SL
Dose/Route:
Adult: 0.4 mg SL, every 3-5 min up to three total doses for 1.2 mg
Peds: Not recommended in prehospital setting
Side Effects: Headache, hypotension, palpitations, dizziness, reflex tachycardia,

nausea/vomiting, postural syncope, diaphoresis.
Note: NTG must be kept in an airtight container and, if exposed to light, air or heat, it
decomposes which is why most pt’s own prescription doesn’t relieve their symptoms since pt’s
need to refill every 30 days if opened/used.
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Ondansetron (Zofran)
Class: Antiemetic
Action: First selective serotonin blocking agent to be marketed. Blocks the serotonin 5-HT3
receptors that are found centrally in the chemoreceptor trigger zone and peripherally at the
vagal nerve terminals in the intestines which in turn minimizes nausea and vomiting.
Indications: Nausea and vomiting
Contraindications: Hypersensitivity, GI obstruction, long QT wave, and use caution with liver
disease pt’s.
Onset/Duration:
Onset: 15-30 min
Duration: 3-6 hr
Dose/Route:
Adult: 4 mg IV/IO/IM
Peds: 0.15 mg/kg IV/IO/IM
Side Effects: ECG irregularities (rare), dizziness, headache, hiccups, pruritus, chills, drowsiness
134
Oral Glucose
Class: Carbohydrate
Action: Directly increases blood glucose levels
Indications: Known or suspected hypoglycemia
Contraindications: Unconscious, unable to swallow, unable to protect airway. Use caution with
ALOC.
Onset/Duration:
Onset: 10-20 min
Duration: Variable depending on dose
Dose/Route:
Adult: 15 g buccal, variable depending on manufacturer
Peds: Same as adult
Side Effects: Hyperglycemia, nausea/vomiting
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Procainamide
Class: Class 1A antidysrhythmic
Action: Suppresses phase 4 depolarization in normal ventricular muscle and Purkinje fibers,
reducing the automaticity of ectopic pacemakers. Suppress reentry dysrhythmias by slowing
intraventricular conduction.
Indications: Stable V-Tach, reentry SVT not controlled by adenosine/vagal maneuvers, A-Fib
with a rapid rate in WPW syndrome
Contraindications: Hypersensitivity, 2nd & 3rd degree heart blocks without functioning artificial
pacemaker, digitalis toxicity, torsades de pointes, tricyclic antidepressant overdose.
Onset/Duration:
Onset: 10-30 min
Duration: 3-4 hr
Dose/Route:
Adult: 20 mg/min slow IV infusion drip with a total dose of 17 mg/kg. Maintenance drip
post cardiac arrest of 1 gm in 250 ml D5W or NS and infuse at 1-4 mg/min
Peds: Loading dose 15 mg/kg IV/IO and infuse over 30-60 min
Side Effects: Hypotension, bradycardia, reflex tachycardia, AV block, widening QRS complex,
prolonged P-R or QT interval, PVC’s, V-Tach/V-Fib/Asystole, seizures, CNS depression.
Note: Stop IMMEDIATELY for the following: reached max of 17 mg/kg, QRS widens >50%,
dysrhythmia resolves, or hypotension.
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Sodium Bicarbonate
Class: PH buffer, alkalizing agent, electrolyte supplement
Action: Sodium bicarbonate is a short acting, potent acid buffer. The bicarbonate (HCO3) binds
to hydrogen ions (H+) to make carbonic acid (H2CO3). This is broken down in the lungs and
exhaled as water (H2O) and carbon dioxide (CO2). Plasma hydrogen ion concentration decreases
causing blood pH to rise.
Indications: Tricyclic antidepressant (TCA) overdose, management of metabolic acidosis,

prolonged cardiac arrest down time, known preexisting hyperkalemia, DKA, alkalinization
treatment for specific intoxications/rhabdomyolysis
Contraindications: Hypocalcemia, suspected metabolic and respiratory alkalosis, hypokalemia,

hypernatremia, pt’s with chloride loss due to vomiting and GI suction, severe pulmonary edema
Onset/Duration:
Onset: Rapid
Duration: 8-10 min
Dose/Route:
Adult: 1 mEq/kg IV
Peds: Same as adult but infuse slowly and only if ventilations are adequate
Side Effects: Metabolic alkalosis, seizures, electrolyte disturbance.
Note: Should not be given at the same time as other electrolytes or vasopressors, be sure to
flush IV thoroughly or use separate IV sites. Not recommended for and ineffective in
hypercarbic acidosis such as seen in cardiac arrest and CPR without intubation
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Succinylcholine (Anectine)
Class: Depolarizing neuromuscular blocker
Action: Succinylcholine is a short acting, depolarizing neuromuscular blocking agent that binds
to acetylcholine receptor sites. This produces complete muscle paralysis but since it is a
depolarizing agent it causes fasciculations and muscular contractions making it the drug of
choice for rapid sequence intubation.
Indications: To facilitate endotracheal intubation, terminate laryngospasm, muscle relaxation.
Contraindications: Hypersensitivity, burns or crush injuries > 72 old, skeletal muscle

myopathies, inability to control the airway or support ventilations with O2 and positive
pressure (BVM), family or personal history of malignant hyperthermia, rhabdomyolysis. Use
with caution in pt’s that may have hyperkalemia (renal failure, trauma/burns, electrolyte
disturbances, crush injury etc.)
Onset/Duration:
Onset: less than 1 min
Duration: 5-10 min
Dose/Route:
Adult: 2 mg/kg IV/IO for RSI
Peds: 1 mg/kg IV/IO for RSI
Infants: Not indicated
Side Effects: Fasciculations, bradycardia, hypotension, tachycardia, hypertension, dysrhythmias,

malignant hyperthermia, hyperkalemia, respiratory depression, excessive salivation,
hyperkalemia
Note: Although after administering Succinylcholine it may appear that the patient is not
conscious, it has NO effect on the central nervous system, so the patient will be completely
aware of procedures unless appropriate sedation is also given.
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Tranexamic Acid (TXA)
Class: Antifibrinolytic, hemostatic agent
Action: Binds with lysine sites on plasminogen, preventing conversion of plasminogen to

plasmin and ultimately inhibiting the breakdown of fibrin during bleeding episodes.
Indications: Trauma, hemorrhage following surgery or dental procedures, excessive menstrual

bleeding.
Contraindications: Hypersensitivity, thromboembolic disorders, certain vision disorders, onset

of bleeding > 3 hrs.
Onset/Duration:
Onset: Unknown
Duration: 7-8 hrs
Dose/Route:
Adult: Administer 1 g diluted in 100 ml NS over 10 min.
Peds: 10 mg/kg IV
Side Effects: Seizures, headache, visual changes, hypotension, thromboembolism.
139
Oxygen (O2)
Classification: Elemental gas
General:
Oxygen is an odorless, tasteless, colorless gas that supports combustion. It is present in ambient
air at a concentration of 21%. Oxygen is required by the body to facilitate the breakdown of
glucose (aerobic metabolism) into a useable form, without oxygen, the breakdown of glucose is
ineffective and incomplete (anaerobic metabolism). All cells require oxygen to survive and
function. The majority of oxygen in the body is transported to the cells bound to hemoglobin
(Hb), a protein molecule contained in erythrocytes (red blood cells). A small percentage (2-4%)
of oxygen is dissolved in blood plasma. The binding of oxygen and Hb is reversible. The
oxyhemoglobin dissociation curve (below) demonstrates the ability of Hb to combine with
oxygen and relates oxygen saturation (SaO2/SpO2) and partial pressure of oxygen in the arterial
blood (PaO2). Because the affinity of Hb for oxygen is affected by many variables, the position
of the curve changes. Acidosis (decreased pH), increased CO2, increased body temperature, and
increased levels of DPG (a substance which binds reversibly with Hg and facilitates the release of
oxygen) cause the curve to shift to the right. When the curve is shifted to the right, the affinity
of Hb for oxygen is decreased and the off-loading of oxygen occurs more easily. Conversely,
conditions that are opposite of those which result in a rightward shift of the curve result in a
leftward shift of the curve. These conditions include alkalosis (increased pH), decreased CO2,
decreased body temperature, and decreased levels of DPG. When the curve is shifted to the
left, the affinity of Hg for oxygen is increased and the off-loading of oxygen is more difficult.
140
Note that the curve contains a steep slope below a PaO2 of 60 mmHg, but beyond a PaO2 of 60
mmHg, the curve is almost flat, indicating that small changes in the PaO2 in this range will result
in little change in saturation above this point. But, at a PaO2 of less than 60 mmHg the curve is
very steep, and small changes in the PaO2 greatly increase or reduce the SaO2. The time to
desaturate from a 90% to 0% is dramatically less than the time to desaturate from 100% to 90%.
During the preoxygenation phase of rapid sequence intubation, oxygen is administered to create
an oxygen reservoir in the lungs, blood and tissues. During preoxygenation, oxygen replaces the
predominantly nitrogenous mixture of room air and oxygen in the functional residual capacity
(FRC) with 100% oxygen. The establishment of an oxygen reservoir permits several minutes of
apnea to occur prior to arterial oxygen desaturation to less than 90%.
1. Patient with dyspnea/shortness of breath, chest pain/discomfort presumed to be of

cardiac etiology and/or with a SpO2 of <94%
2. Pediatric patient with asthma, reactive airway disease, bronchiolitis, croup and a
SpO2 of < 92%
3. Cardiac arrest
4. Preoxygenation prior to suctioning or intubation
5. Sickle cell crisis
6. Obstetrical delivery/complications
7. Carbon monoxide exposure
8. Diving emergencies (pulmonary over pressure syndrome, arterial gas embolism,
decompression sickness, nitrogen narcosis)
Contraindications:
1. Paraquat toxicity (may potentiate harmful superoxide formation)
2. Bleomycin use (may increase injury associated with pulmonary toxicity)
Precautions:
1. Oxygen is a drug and should be administered only when an indication for administration
is present. The longstanding EMS practice of empiric “high flow/concentration” oxygen
in normoxic patients must be abandoned.
141
Precautions:
2. The use of oxygen in patients with chronic obstructive pulmonary disease (COPD)
commonly carries a precautionary warning and is the subject of discussion and debate in
the pulmonary medicine literature. Most concerns are related to decreased minute
ventilation (depressed ventilation) and increased CO2 levels associated with the
administration of supplemental oxygen to patients with COPD, particularly those with
chronic hypercapnia “CO2 retainers”. In such patients, the central chemoreceptors
become less sensitive to these changes. The stimulus for ventilation then originates from
peripheral chemoreceptors located in the carotid bodies and the aortic arch. These
receptors are stimulated by low arterial oxygen levels, transmitting signals to the
respiratory center in the medulla. This leads to an increased minute ventilation, with a
low arterial oxygen level, and a reduced minute ventilation with a high arterial oxygen
level. Oxygen administration may also result in increased CO2 levels from changes in
ventilation and perfusion (V/Q) matching and a phenomenon known as the Haldane
effect (the binding of oxygen to Hb displaces CO2). Both of these topics are beyond the
scope of this reference guide. Information regarding these two concepts should easily be
found in any physiology textbook. The best approach to the administration of oxygen to
patients with COPD is to tolerate lower SpO2 levels, but never withhold oxygen from a
seriously ill hypoxic patient due to fear of cause hypercapnic respiratory failure. Should
ventilator depression occur, it should be managed accordingly.
3. There is concern regarding possible hyperoxic injury secondary to supranormal arterial
oxygen levels. Hyperoxic injury may affect multiple organ systems (lungs, heart, and
brain). Recently published data demonstrated worse outcomes with hyperoxia after
resuscitation from cardiac arrest. The exact mechanism of injury is unclear, but
hyperoxic injury may be mediated by reactive oxygen species (ROS), hyperoxia-induced
vasoconstriction, or amplified reperfusion injury. For this reason, the lowest possible
concentration of oxygen should administered. In the post cardiac arrest patient, the
FiO2 should be titrated to the minimum concentration required to maintain the SpO2
≥ 94%, but less than 100%. Care should be taken when titrating oxygen concentrations
to avoid hypoxia.
4. In patients with suspected or proven acute coronary syndromes and the absence of
hypoxia, the benefit of oxygen therapy is uncertain, and in some cases oxygen therapy
may be harmful.
5. The routine use of supplemental oxygen is not recommended in acute stroke patients
who are not hypoxic.

1. Hyperoxic injury
2. Retinopathy of prematurity
142
Notes:
• An arterial saturation (SpO2) of 90% correlates to a PaO2 of 60 mmHg.

• An arterial saturation (SpO2) of 100% may correlate to a PaO2 anywhere between
approximately 80-500 mmHg.
• Administering oxygen in the setting of paraquat toxicity may potentiate harmful superoxide
formation. Superoxides are thought to be involved in the pathogenesis of pulmonary
damage. Oxygen should only be considered in cases associated with profound hypoxia.
143
Sodium Chloride 0.9% (NaCl 0.9%)
Classification: Crystalloid
General:
Sodium Chloride 0.9% is an unbalanced crystalloid fluid. While often referred to as “normal
saline”, it contains a supraphysiologic concentration of chloride (154 mEq/L, 1.5 times that of
plasma), 154 mEq/L of sodium, and it has a pH of 5.7 (the pH of plasma is 7.4). Simply stated,
“Normal saline is not normal”. Unlike Lactated Ringers solution (LR), it does not contain an
anion buffer. It has a strong ion difference (SID) of 0. The SID is the difference between the
concentrations of strong cations and strong anions. While a detailed explanation of the SID is
beyond the scope of this guide, it is useful to know that the administration of a resuscitation fluid
with a SID less than the serum bicarbonate level (normal range 22–26 mmol/L) will lead to a more
acidotic state (↓pH) and the administration of a resuscitation fluid with a SID greater than the
serum bicarbonate level leads to a more alkalotic state (↑pH). The table below compares the
electrolyte composition and SID of LR and NaCl 0.9% to human blood plasma (concentrations are
in mEq/L):
Sodium (Na+) Chloride (Cl-) Potassium (K+) Calcium (Ca++) Lactate SID
Plasma 140 100 4 5 1-2 +40
NaCl 0.9% 154 154 0 0 0 0
LR 130 109 4 3 28 +28
There is some recent data that suggests that outcomes may be worse in patients who receive
fluid resuscitation with NaCl 0.9% v. those who receive fluid resuscitation with LR or other
buffered resuscitation fluids. Specifically, resuscitation with NaCl 0.9% was associated with an
increase in acute kidney injury, hyperchloremic metabolic acidosis, and increased mortality. For
this reason, LR was chosen as the fluid of choice for patients requiring large volume fluid
resuscitation. NaCl 0.9% should only be used in patients requiring limited fluid administration.
1. Dehydration
2. Hypovolemia
3. Shock
4. Ocular irrigation
144
Contraindications:
1. Profound liver failure (LR may increase the lactate level, but it should be noted that the
lactate in LR is in the form of sodium lactate, not lactic acid and it will not make the
patientmore acidotic).
Precautions:
1. Fluids should be administered judiciously to patients with evidence of or a history of

heartfailure.
2. Because LR is slightly hypotonic, large volumes may increase intracranial pressure.
3. The calcium in LR can bind to the citrated anticoagulant in blood products and lead to
inactivation of anticoagulant and promote the formation of clots in donor blood. For
thisreason, LR is contraindicated as a diluent for red blood cell transfusions.

1. Fluid overload
2. Metabolic alkalosis
3. Increased intracranial pressure (large volumes, primarily of concern in patients
withalready increased intracranial pressure).
145
146
EMS System Policies 10.0
146
147
Policies: Documentation 10.1
Revised July 2022
Standard procedure: After completion of each patient transport, the following information needs to be
documented. A copy of the completed PCR needs to be submitted to the receiving ED within 24 hours.

Chief complaint: The patient's major presenting problem.
History of present illness or injury (HPI): This should include events leading up to the chief com-
plaint, a description of the onset of the problem, and further explanation of the chief complaint of
presenting symptoms. This would include the; Onset, Provocation or Palliation, Quality, Radia-
tion, Severity, and Time.
Past pertinent medical history: As it relates to the current problem, and any preexisting condi-
tions of the medical problem, current medications and known allergies. This is the; Symptoms,
Allergies, Medications, Past medical history, Last oral intake, and Events leading up to the inju-
ry or illness. The events section could be included in the HPI.
Physical exam: This would include the, Initial, Rapid, Focused, and Detailed assessment including,
all vital signs and ECG interpretations if appropriate. This should be very complete and detailed
to thoroughly describe the condition of the patient. All objective findings along with pertinent
negatives need to be included.
Treatment and response: All treatments must be documented, preferably chronologically. What
treatment was provided, the time, who performed the treatment, if pertinent the number of at-
tempts and successes, the patient response to the treatment and further assessment. If the treat-
ment has specific documentation requirements, then those must be included as well. Documenta-
tion of non- treatments is also required.
Transportation: The position in the mode of transportation. It is recommended that you document
the patient was secured on a stretcher and how the patient was secured. When the hospital was
contacted and how they were contacted. Any orders received or denied in the patient response to
any orders. Make sure document all times with these orders. Any changes in the patient condition
or changes would be included. Arrival at the hospital which room the patient was placed in and
whom you released care to at the receiving facility.
147
148
Policies: EMS System Entrance 10.2
Revised July 2022
EMT AEMT Paramedic

Each individual applying for employment as an Advance EMT (AEMT) or Paramedic in the Franciscan Health Crown Point
(FHCP) EMS System must complete the following criteria before functioning as an AEMT or paramedic in the system:
Obtain a System Entrance application. Complete background check  as provided. You must turn in the completed application
and all required documents at least twenty-four (24) hours in advanced of your scheduled protocol test.
Provide a Letter of Affiliation from an approved provider in the FHCP System. For Paramedics whom
have been functioning greater than two years, you must submit a letter of good
standing from your current system Medical Director or EMS coordinator. For those paramedics who
have been functioning less than two years as a paramedic in leu of a letter, you must submit a copy of
your transcripts or completed terminal competencies from paramedic training program.
Provide verification of the following credentials:

· State License and/ or National Registry
· BLS-CPR
· ACLS (paramedic only )
· PALS
· PHTLS
Schedule a System Entrance Testing date with the EMS Academy. You will be expected to successfully complete a FHCP
EMS Protocol Examination with a score of 80% or above. Failure to obtain an overall score of 80% will be considered a
failure of the exam.
You will be allowed ONE (1) retake on the protocol test. The retake of the exam will take place no sooner the fourteen (14)
calendar days from the first attempt. If a failure occurs on the second attempt, an interview evaluation will be scheduled with
the Medical Director. The Medical Director will determine if additional actions will be required. If another failure occurs
following the interview with the Medical Director, the applicant must wait a minimum of THREE (3) months, prior to ap-
plying for affiliation again.
It is the responsibility of each individual to become familiar with and have an understanding of the FHCP EMS Policies &
Procedures and Treatment Protocol
148
149
Policies: Continuing Education 10.3
Revised July 2022
EMT AEMT Paramedic
 Permitted:
 Hour-for-hour credit can be applied for standardized courses
 See attached National Continued Competency Program (NCCP) 2016 from National Registry
 Standard courses (non RQI) such as AHA BLS, ACLS, or NAEMT PHTLS, AMLS, GEMS, etc. can
be credited ONCE per renewal cycle in appropriate topic.
 Course hours maybe divided into two or more topic areas during the recertification cycle.
 College courses
 Must be related to your role as an EMS professional
 Examples include, but not limited to: anatomy, physiology, biology, chemistry, pharmacolo-
gy, psychology, sociology, medical terminology, communication, etc.
 1 college credit= 8 hours of continuing education. The 8 hours may be divided among topics.
Precepting

 EMT/EMR students- 1 hour/call – Max of 20 hours
 EMT Advance/Paramedic student- 2 hours/call- Max of 40 hours
 Preceptor may divide hours between continuing education & audit/review.
 If EMS student is NOT a FHCP student, preceptor must keep copy of clinical evaluation form
and/or run numbers for verification of patient contacts.
 Audit & Review-in house completed at department/service level
 Ten prehospital run reports = 1 hour of audit & review
 Provider must keep copy of the audit form to document compliance
 NOT Permitted*
 Clinical rotations which are not part of an EMS course program
 Instructor methodology courses
 Includes all courses to become and instructor or courses to achieve instructor level certifications
 Management/leadership courses
 Includes business management and leadership that are not Fire/EMS administrative courses
 Preceptor hours
 Courses in which an individual takes to become a preceptor or preceptor methodologies
 AHA RQI courses (BLS CPR, ACLS, PALS)
 May not count for CE hours or skills verification
 Can service as documentation of required course
 Duplicate Courses assigned to the same recertification application are NOT accepted.
 Duplicate course is a course which consist of the same content as another course & at least one of the follow-
ing:
 Same course title
 Same method of education
 Same instruction

*Experiences not permitted for continuing education CAN provide for skills verification for recertification.
149
150
Policies: EMT Continuing 10.4

Education
Revised July 2022
EMT
Purpose:
The purpose of this policy is to outline the Continuing Education Requirements for all affiliates of Francis-
can Crown Point System.
Indiana Certification Requirements: 

IAC 836 4-4-2 requires 34 hours of didactic and 6 hours of audit and review over a two year period in
order to maintain State EMT certification.
Didactic Hours
May be achieved through the individual affiliated EMS Provider and signed off by the
training officer and Chief officer.
Audit and Review
May be obtained through in house audit and review or by attending monthly CQI spon-
sored by FHCP.
Psychomotor Skills
May be obtained through affiliated EMS provider or assisting an IDHS Psychomotor
Exam.
Mandatory Psychomotor Skills
Supine and Seated Spinal Immobilization
Patient Assessment Trauma and Medical
Long Bone, Joint and Traction Splint Immobilization.
Cardiac Arrest Management/AED
Airway Management.
FHCP System Requirements:

CE book must be continually maintained and available for review at the discretion of the FHCP Medi-
cal Director or designee.
Indiana State Requirements as above to include the following:
Didactic
PHTLS
BLS Healthcare Provider CPR
EPC or PEPP
Psychomotor
King Airway, IN Narcan, Glucometer, 12 lead EKG lead placement and acquisition,
Recertification Requirements:
Completed CE documents with signatures must be presented to the department Training officer 30 days
prior to the certification date of expiration.
Training officer reviews CE documents for accuracy, provided documents are complete permission is
provided to access IDHS portal and recertify. Recertification on the portal without permission will
result in disciplinary action.
Audited CE documents must be submitted to the FHCP EMS office for review prior to submission to
IDHS.
Recertification on the portal without permission will result in disciplinary action
150
151
Policies: Advanced EMT 10.5

Continuing Education
Revised July 2022
AEMT
System Requirements
Must maintain these certifications while in the FHCP EMS System.
 Didactic: PHTLS, PEPP/EPC, BLS CPR
 Psychomotor: IV,IM,IN administration, 12 lead, King Airway, and Basic Mega Code
151
152
Policies: Paramedic Continuing 10.6

Education
Revised July 2022
Paramedic
Purpose:
The purpose of this policy is to outline the Continuing Education Requirements for all affiliates of Franciscan
Crown Point System. Recertification is an individual responsibility.
Indiana Certification Requirements:

IAC 836 4-9-5 requires a total of 72 hours including12 hours of audit and review over a two year period in
order to maintain State of Indiana Paramedic Licensure as well as certification in CPR and ACLS.
Didactic Hours (60)
Must include 16 hours ABC, 8 hours Medical, 6 hours Trauma, and 16 hours OB/Peds and 2
hours of Operations. (48)
The 12 additional hours may be obtained through EMS Commission approved courses.
Audit and Review
12 hours must be obtained through formal audit and review provided by the sponsoring hos-
pital. (Three per year)
Psychomotor Skills
Must be supervised by either the medical director or educational staff of the supervising hos-
pital.
Mandatory Psychomotor Skills
Trauma and Medical Patient Assessment
Ventilitory Management
Cardiac Arrest Management
Bandaging and Splinting
Medication Administration, IV/IO therapy and bolus.
Spinal Immobilization
OB/Gyn
Communication and Documentation
FHCP System Requirements:
CE book must be continually maintained and available for review at the discretion of the FHCP Medical Di-
rector or designee.
Indiana State Requirements as above to include the following:
Didactic
PHTLS
PALS
AMLS (recommended)
No more than 20 hours of online CE will be accepted at the discretion of the medical director
or designee.
Psychomotor
Recertification Requirements:
Completed IDHS CE documents with signatures and supporting documents must be presented to the FHCP
EMS office no later than 30 days prior to the date of certification expiration.
Documents received 25 days prior to the expiration date will result in a fine of $50 and no guarantee that the
document will be reviewed and signed within appropriate time.

152
153
Policies: Formal Corrective Action 10.7
EMT AEMT Paramedic Revised July 2022
Purpose
The intent of the EMS Staff is to have as many “teachable moments” as possible in order to properly remediate and educate EMS providers in
both the proper treatment of patients and policies and procedures required to function under the medical direction of FHCP. A point is reached
when those moments have either been exhausted, or, an incident occurs that is so severe that immediate corrective action is necessary.
Terms Defined:
 Warning
 A minor protocol or policy deviation has occurred that requires documentation.
 Individual or individuals involved will be remediated.
 Probation
 A serious protocol or policy deviation has occurred that requires documentation or affiliate has performed a protocol or policy de-
viation while on warning.
 Individual or individuals involved will be remediated to include participation in clinical time depending on the type of infraction. .
 May continue to function within the system under current certification or licensure.
 Requires mandatory reporting of the incident to the state EMS office.
 Suspension
 A severe protocol or policy deviation has occurred that requires documentation or affiliate has performed a protocol or policy vio-
lation while on probation.
 Individuals may be remediated, participate in clinical time and or precept with an equally certified or licensed system affiliate de-
pending on the type of infraction.
May not function within the system under current certification or licensure unless in a remedial role with a preceptor.
Procedure:
 The EMS affiliate will be notified along with their respective training officer when the EMS office is made aware of an infraction.
 Once the incident has been investigated and a final decision has been made the affiliate will be notified in writing.
 If the affiliate fails to meet the conditions of remediation further disciplinary action will be required.
 The state EMS office will be notified of probation and suspension decisions.
 The affiliate may request a system review in order appeal the disciplinary action. This must be performed in writing within 14 busi-
ness days of the original decision and submitted to the EMS clinical coordinator for review.
 System review committee is composed of one representative from each EMS provider under the FHCP EMS System and
shall be chaired by the FHCP EMS Director. .
Decision of the review committee is final.
Potential Causes for Corrective Action
Academic Clinical Professional

Re-certification Protocol Deviation Discrimination
Continuing Education Policy Deviation Substance Abuse
Mandatory Classes Skills Beyond Scope of Practice Abandonment
Cheating on Written or Practical Medical Misconduct Falsifying Reports
153
154
Canine Guidelines 11.0
154
155
Canine Definition 11.0
Revised July 2022
The 122nd Indiana General Assembly passed Type of Operational Canines:

House Enrolled Act 1201 (HEA 1201). HEA
1201 authorizes certain EMS responders, under
certain circumstances, to use emergency ambu-  An arson investigation dog
lance services to transport an operational ca-  A bomb detection dog
nine injured in the line of duty to a veterinary  A narcotic detection dog
hospital or clinic. IC 16-31-13.
 A patrol dog
 A military working dog

These best practices are intended for use by
qualified licensed or certified Emergency Med-  A search and rescue dog
ical Services (EMS) professionals, including
Emergency Medical Technicians (EMT), Ad-
vanced Emergency Medical Technicians
(AEMT) and paramedics, law enforcement of-
ficers and operational canine handlers who
have received hands-on training specific to the
canine species. Responders should only per-
form skills on operational canines that they
have been approved to perform and are profi-
ciently trained to perform on humans. There-
fore, no EMS professional should perform a
procedure on an operational canine that they
could not perform on a human being in their
underlying EMS certification/licensure status.
155
156
Canine : Routine Care 11.1
Revised July 2022
BSI: 
Even though the number of diseases that can be transferred between canines and humans is low,
Universal precautions should still be followed.
Handler:
Whenever possible, the Canine’s handler should be included with treatment and transport to the
Veterinarian. This will allow the handler to be a patient advocate, assist with restraining, and provide
baseline and normal vitals for the patient. If main handler is unavailable, consider another handler
from the same department.
Muzzle:
For safety, a muzzle should be on the canine during treatment and transport. If in pain, they will bite
anyone, even their handlers. A commercial muzzle that does not interfere with panting or breathing is
recommended, but an improvised can be used if needed. Muzzle may need to be removed if airway
problems or vomiting is present.
Handler Interventions:
Many handlers are trained to render aid to their canines, and some skills would be considered ALS if
performed on humans. (NCD, IV, Intubation, Etc.) State law says that the owner or representative of
the owning agency may perform medical interventions legally. We should assist with maintaining and
supporting any of those interventions to the best of our abilities.
156
157
Canine : Assessment 11.2
Revised July 2022

Pulse:
A palpable pulse can be felt high on the inside of the hind leg. If a pulse is felt there, the canine is
perfusing all the vital organs. (Systolic of 80-90)
Normal HR for working dogs 60-100.
Cap refill:
The gums are the best place to check cap refill, same as nail beds on a human.
<2 seconds is normal.
Temp:
Tympanic thermometers will not work on canines due to the shape of their ear canal. Rectal is the
most reliable. Many handlers carry thermometers and know how to use them on their dog. Utilize
their skills if possible.
99.5-102.5 normal resting temp.
Average Vitals for a working dog:

Pulse 60-100
Resp. 16-30
BP 100-120 Sys.
Glucose 80-110
Temp 99.5-102.5
157
158
Canine : Airway and Respiration 11.5
Revised July 2022
Ventilation: 
Manual ventilation can be performed as noted in the Cardiac Arrest Protocol.
Oxygenation:
Blow by oxygen can be given by a Human NRB or oxygen tubing held near the dogs nose. (can be
done through a muzzle)
Manually opening airway:
Lay the canine on its side, gently stretch the neck and head out trying to put the mouth, neck, and
shoulder all in line. Gently pull the tongue forward and let it lay off to the side, so it won’t block the
airway. **This should be done only in unresponsive dogs, to prevent being bitten.*
Sucking chest wounds:
The hair causes problems with creating an air tight seal. If possible, the hair can be shaved with
clippers. Shorter hair dogs may not be as much of a problem.
Commercial seals can be used. Once the seal is in place, “massage” it into place to create the best
seal possible with the fur.
Improvised seals can be made with plastic and tape. Sterile water based lube can be used to assist
with sealing the fur if needed.
158
159
Canine : Cardiac Arrest 11.3
Revised July 2022
CPR: 
Lay the canine on its side, place hands on the chest, behind the front leg. There is a “pocket” or indentation in the rib-
cage on most dogs that will serve as a landmark. (see photo)
Compress 1/3 to ½ of the depth of the chest, at a rate of 100 BPM.
Compression to breath ratio is 30:2.
Ventilation:
Canines can be ventilated with BVM and a special Pet style mask. If no mask is available, Mouth to snout ventilations
can be done.
Close the dog’s mouth, seal lips shut with hands. Place mouth over dog’s nose creating an air-tight seal. Ventilate un-
til chest rise noted. **Note, most working dogs have roughly the same lung capacity as an adult human.**
Rescue breaths every 6 seconds.
159
160
Canine : Trauma Care 11.7
Revised July 2022
Bandaging: 
Bandage wounds as you would a human patient. Bandages are easily secured with coban or vet wrap
if available. It will stick to itself, but not the dogs fur. Tape can be used if no other options are availa-
ble.
Splinting:
Malleable splints can be used for dogs if they will tolerate them. If the dog is able to carry the leg in
a way that does not cause pain, allow them to manage it themselves. The best way to manage a
fractured limb may be to have the dog lay on a stretcher and be as still and calm as possible.
Spinal Movement Restriction:

Suspected or known spinal injuries are best managed by keeping the dog calm. Attempts to immobi-
lize a canine will prompt resistance from the patient. If possible, put them on a cot, have the handler
assist in keeping them calm.
Evisceration:
Cover with a lightly dampened dressing and consider securing in place with kerlix or ace wrap.
Do not attempt to put the organs back in the cavity unless there is a life threat. (Cardiac or respiratory
compromise)
160
161
Canine : Hemorrhage 11.4
Revised July 2022
Extremity Hemorrhage:
Direct pressure, or a pressure dressing are the preferred interventions. This will control most if not all
bleeding. If they are ineffective at controlling the bleeding, and the canine is in danger of bleeding to
death, a tourniquet may be used.
Tourniquets are a last resort on canines. Due to their nerve anatomy, they may require amputation of
the limb if a tourniquet is applied. **Note, due to the shape of their legs, windlass style tourniquets
do not stay in place very well. (CAT, SOF-T, etc) Consider an elastic style tourniquet. (SWAT-T, ace
wrap, coban, etc.)
Junctional Hemorrhage
Wound packing may be performed with hemostatic or plain gauze. Once wound is packed, secure in
place with pressure bandage. Any hemostatic gauze that is used for humans can be used for canines.
161
162
Canine : Heat/Cold Emergencies 11.5
Revised July 2022
Hypothermia:
As with humans, dry them, wrap them in insulating material, and move to a heated area. Heat packs
may be applied in the “armpits” and groin area. Pad with a towel to prevent burns.
Hyperthermia:
Allow the canine to pant, make sure any muzzle that is in place is not restricting this!
Move to a cool area. A fan on moist fur, and the pads of their paws will help cool them. Also,
rubbing alcohol on the pads of their feet will cool them. Ice packs in the “armpits” and groin will
help as well.
162

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EMT Training Course Crown Point ALS and BLS System Protocol

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INTRODUCTION

Color-Coded levels used in the Guidelines:

EMR EMT AEMT Paramedic

Cedar Lake PD EMR/Law Enforcement Non-Transport

STATEMENT REGARDING PHYSICIAN(S) ON SCENE

8.5 Procedure: Endotracheal Intubation:……………………………………………………………………85

STATEMENT REGARDING PHYSICIAN(S) ON SCENE

Our Commitment to EMS

Cardiac Guidelines 1.0

EMR EMT AEMT Paramedic

Cardiac: Termination of 1.1

EMR EMT AEMT Paramedic

EMERGENCY MEDICAL RESPONDER / EMT STOP

 Completed protocol appropriate for presenting rhythm with NO response to interventions

 Consider “2 minute” warning to give family time to prepare for termination.

Cardiac: PEA and Asystole 1.2

Revised July 2022

 CPR and AED

 Check for DNR

 Rotate compressor at least every two minutes

 Secure airway with medically approved advanced non-visualized airway

 Vascular Access IV/IO

 Epinephrine 1:10,000 dose 1mg IV/IO; repeat every 3-5 minutes

 Consider and treat Reversible Causes (H’s and T’s)

 Epinephrine 1:10,000 dose 1mg IV/IO; repeat every 3-5 minutes

 Place advanced airway as appropriate after a minimum of 4 minutes (2 cycles) of CPR.

Cardiac: V-Fib / Pulseless V-Tach 1.3

Revised July 2022

 Vascular Access IV/IO

 Consider and treat Reversible Causes (H’s and T’s)

 Epinephrine 1:10,000 dose 1mg IV/IO; repeat every 3-5 minutes

 Place advanced airway as appropriate after a minimum of 4 minutes (2 cycles) of CPR.

 Persistent V-Fib/V-Tach consider 300mg of Amiodarone. May repeat at 150mg.

 Consider Calcium Chloride: 10ml IV/IO in patients with renal failure

 Refer to the Cardiac: Termination of Resuscitation as needed

Cardiac: Acute Coronary Syndrome 1.4

Revised July 2022

 Acquire and send 12 lead EKG ASAP if available.

 Vascular Access IV/IO

 If pulmonary edema present refer to cardiogenic shock protocol

 Nitroglycerin 0.4 mg SL; repeat every 5 minutes to max 3 dos-

Cardiac: Cardiogenic Shock 1.5

Revised July 2022

 Apply appropriate oxygen therapy

 Place patient supine unless dyspnea is present

 Call for ALS assist.

 12 lead ECG and transmit

 Notify Medical Control ASAP if STEMI present

 Consider Dopamine IV infusion 5-10 mcg/min. Maintain B/P >90 systolic.

Cardiac: Wide Complex Tachycardia 1.6

Cardiac: Narrow Complex 1.7

 Apply appropriate oxygen therapy

 Vital signs, recognize HR of 150 BPM or greater, Request ALS Assist.

 Have AED available

 Cardiac Monitor Consider Wolff-Parkinson-White (WPW) if HR over 220 and young

IF STABLE and symptomatic

 Adenosine 12 mg rapid IV push; followed by 20ml NaCl

 IRREGULAR Rhythm: (Atrial Flutter or Atrial Fibrillation)

 Ventricular rate greater than150 bpm

 Ventricular rate less than 150 bpm

 Consult MEDICAL CONTROL

Cardiac: Symptomatic Bradycardia / 1.8

 Apply appropriate oxygen therapy

 Have AED available