PREHOSPITAL PROTOCOL

HANDBOOK
Dr.V.P.Chandrasekharan M.D., Dip (A&E)
Head of the Dept
Accident, Emergency and Critical Care Medicine
Vinayaka Mission Hospital
Salem

1
 EMERGENCY PARAMEDIC
TRAINING IN ICU PERFORMING CPR

PRACTICAL SESSION ON BASIC LIFE

MANAGEMENT OF A
SUPPORT
POISONED VICTIM

EMERGENCY PARAMEDICS PERFORMING

EMERGENCY PARAMEDICS SHIFTING ENDOTRACHEAL INTUBATION
A TRAUMA VICTIM

EMERGENCY PHYSICIAN INSTRUCTING THE

EMERGENCY PARAMEDICS TAKING PARAMEDICS ON TRAUMA PATIENT
THEIR WEEKLY EXAMINATION MANAGEMENT 2
FROM THE AUTHOR’S DESK

3
 INDEX- SECTION 1
TOPIC PAGE TOPIC PAGE

1. General instruction 21. Anaphylaxis

2. Body substance isolation 22. Altered mental status
3. Basic life support 23. Burns
4. IV access 24. Pulmonary edema/Cardiogenic
5. IV access procedure shock
6. Normal vitals 25. Pulseless arrest algorithm
7. Glasgow coma scale 26. Brady cardia algorithm
8. Initial ABC care 27. Tachycardia algorithm
9. Trauma 28. Acute coronary syndromes
10. Airway equipment algorithm
11. LMA 29. Shock
12. LMA insertion 30. Chest pain
13. Bag valve mask 31. Stroke
14. Ventilation with BVM 32. Head injury
15. BiPAP 33. Obstetric complications
16. Basic airway management 34. Pain of non cardiac origin
17. Steps of intubation 35. Poisoning/drug overdose
18. Fixing the endotracheal tube 36. Seizure
19. Foreign body obstruction 37. Drowning
20. Respiratory distress 38. Snake bite
39. Scorpion bite
40. Dog bite

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 INDEX –SECTION II
PAEDIATRICS

1. General instructions
2. Paediatric medical care
3. Trauma
4. Airway management
5. Facilitated Intubation
6. Fluid challenge
7. Acute Dyspnea
8. Airway Obstruction
9. Anaphylaxis

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 GENERAL INSTRUCTIONS

• All EMS personnel must be qualified

• EMS personnel should be well versed with driving.
• All EMS personnel must be vaccinated
• Whenever possible take advice from medical control
• When you need to go for interhospital transport you
need to fill the form and inform to medical control
• Documentation of data is a must
• An informed/written consent from the patient/
patient’s attenders should be obtained.
• Shift the patient from referring hospital only after that
hospital medical unit permits
• You can examine and shift the patient
• You must wear your ID and neat dress with shoes
when your are in duty
• Patient care is our prime duty

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 BODY SUBSTANCE ISOLATION

• Body substance isolation should be used for

all patient contacts if the health care provider
may be exposed to blood or other body
fluids. Body substance isolation assumes that
all patients are carriers of infectious
contagious diseases.
• General recommendation
– Gloves should be worn when handling
bloood, body fluids, mucus membranes,
nonintact skin and body tissues. New
gloves should be worn for each patient
contact. Hands must be washed after
glove removal and between patient
contacts
– If a splash of blood or body fluid is
anticipated a full face shield or goggles
and face mask should be worn.

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– If emergency ventilatory su[[oprt is
necessary, a resuscitation mask should be
used
– Do not recap needles. Promptly place
disposable sharps in a designated
puncture resistant container
– Place all soiled linen in a clear, plsatic bag
before sending to laundry
– Use a solution of 1 part household bleach
to 100 parts water to clean equipment,
clean up spills and decontaminate walls
and other objects soiled with blood or
body fluids
– If your skin has a break, cut, abrasion or
dermatitis use gloves and avoid any
contact with blood or body fluids
– Be vaccinated against Hepatitis B
– Exposure to and possible contamination
from blood or body fluids should be
reported to y our agency’s designated
officer
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 – Patients should be asked if they are
allergic to latex. Non latex equipment
should be utilized on all patients that have
latex allergies
• Since there is no reliable immediate means to
identify infected patients, prehospital care
providers should be equally cautious when
caring for all patients

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BASIC LIFE SUPPORT

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 IV ACCESS

24G 22G 20G 18G 16G 14 G

Orange - 14GA 270ml/min

Grey - 16GA 180ml/min
Green - 18 GA 90ml/min
Pink - 20GA 61ml/min
Blue - 22 GA 31ml/min
Yellow - 24 GA 13ml/min
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IV ACCESS PROCEDURE

After back flow, Don’t push or pull the stylet, just push venflon through vein

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 Normal vitals

• Normal heart / pulse rate =

Adult = 60-100 BPM
Children = 80-120 BPM
Infant = 100-140 BPM
• Normal blood pressure =
120/80 mmhg
• Normal temperature =
98.6 degrees Fahrenheit or
37.0 degrees Celsius
• Normal respiratory rate =
Newborns: Average 44 BPM
Infants: 20–40 BPM
Children: 16–25 BPM
Adults: 12–20 BPM

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Glasgow coma scale

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 INITIAL ABC CARE -I

ABC STABILISATION

RESPONDING NOT RESPONDING

FOCUSSED HISTORY BLS/ACLS PROTOCOL

STABILIZE THE PATIENT

CHECK VITALS & CBG

ADMINISTER OXYGEN
15L /MIN VIA NRB MASK
TARGET SPO2 > 95%

ASSESS THE NEED FOR

INTUBATION

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INITIAL ABC CARE-2
Reassure patient and patient’s
relatives

Keep the following ready

Defibrillator,Cardiac monitor, Advanced
airway equipment, Suction, Oxygen &
Medication

Position patient
If unconscious: in left lateral position
If breathless :Head up position
If hypotension: head down and foot up
position

IV access. Hep saline lock

Monitor ECG

CONTACT MEDICAL CONTROL

FREQUENTLY
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 TRAUMA
AIRWAY
APPLY JAW THRUST ONLY
IF AIRWAY IS PATENT:
APPLY C-COLLAR OR MANUAL IMMOBILISATION
IF AIRWAY NOT PATENT: IMMOBILIZE MANUALLY

BREATHING
SUPPLEMENT OXYGEN BY NRBM WITH 15L O2/MIN
WATCH FOR ASYMMETRICAL BREATHING, TRACHEAL SHIFT, RESPIRATORYDISTRESS,
CREPITATIONS;
IF TENSION PNEUMOTHORAX: NEEDLE DECOMPRESSION
KEEP ADVANCED AIRWAY EQUIPMENT READY

CIRCULATION
CHECK VITALS , IV ACCESS, COMPRESSION BANDAGE & SPLNT
NS 1-2 L IV BOLUS AND D/W MEDICAL CONTROL
CONNECT TO MINITOR , DEFIBRILLATOR AND CHECK SPO2
STOP ALL EXTERNAL BLEED

KEEP ADVANCED AIRWAY EQUIPMENT READY

KEEP SUCTION READY
DOCUMENT EVERYTHING
CONTACT TO MEDICAL CONTROL FREQUENTLY

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 LOOK FOR S/O TENSION PNEUMOTHORAX:-
SEVERE RESPIRATORY DISTRESS
ABSENT LUNG SOUNDS ON AFFECTED SIDE
DIMINISHED LUNG SOUNDS ON OPPOSITE SIDE
HYPOTENSION
TACHYCARDIA
DISETENDED NECK VEINS
TRACHEAL DEVIATION AWAY FROM AFFECTED SIDE

ROUTINE MEDICAL OR TRAUMA CARE

CONFIRM AINDICATION FOR EMERGENCY CHEST DECOMPPRESSION

PARAMEDIC ONLY : NEEDLE DECOMPRESSION

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 AIRWAY EQUIPMENT

Ambubag with
face mask All size ET tubes

Oral Airway

Scope & Blade

LMA

Stylet Gel Magiil’s

Forceps Emergency Drugs
ET fixers
Scissor
10 ml Syringe
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 LMA
• The laryngeal mask airway (LMA) is a ventilatory
device with an inflatable silicone mask on the distal
end.
• The LMA is placed blindly, and the mask is inflated over
the larynx to provide a supraglottic seal.
• Its primary role is as a rescue device
• It can be used in difficult airways or distorted anatomy,
cervical spine injuries
• It’s inability to protect against aspiration of gastric
contents is the most common complication

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LMA Insertion

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 Bag-valve-mask
Adult Bag 1600ml
Child Bag 500ml
Infant Bag 240ml
bag

Patient valve Oxygen reservoir

Face Mask Reservoir valve

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 Technique
Open the airway
– Perform the head-tilt chin-lift maneuver or
the jaw thrust
Position the mask
– Hold the mask in place using the one-
hand or two-hand E-C technique

Head-tilt chin-lift Jaw thrust

One-hand E-C technique Two-hand E-C technique23

 Maintain cricoid pressure

• This pressure is meant to compress the

esophagus and reduce the risk of
aspiration
• Care must be taken to avoid excessive
pressure, which can result in
compression of the trachea

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 BIPAP
• It is non invasive ventilation or spontaneous
mode
INTIAL SETTINGS
• IPAP = Pressure support
• EPAP = PEEP
• Commonly IPAP set to 10cmH2O and EPAP to
5cmH2O
• Response to pressure should determine
future changes

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Steps of connecting BIPAP

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 Contraindications
Absolute Contraindications
• Age < 8
• Respiratory or Cardiac Arrest
• Agonal Respirations
• Severely depressed LOC
• Systolic Blood Pressure < 90
• Pneumothorax
• Major Trauma, esp. head injury with
increased ICP or significant chest
trauma
• Facial Anomalies (e.g. burns,
fractures)
• Vomiting

Relative Contraindications
• History of Asthma/COPD
• History of Pulmonary Fibrosis
• Decreased LOC
• Claustrophobia or unable to tolerate
mask (after initial 1-2 minutes) 27
BASIC AIRWAY MANAGEMENT

OPEN AIRWAY BY
JAW THRUST FOR TRAUMA PATIENTS
TRIPLE MANUEVER FOR OTHERS
Connect to Monitor,
Defibrillator, Check
SPO2 and Vitals
SUCTION IF NEEDED
INSERT GUDELS AIRWAY
CONNECT TO BM VENTILATIOR

NO CHEST RISE

INSERT LMA AND VENTILATE

PLAN FOR INTUBATION AFTER D/W

MEDICAL CONTROL

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 STEPS OF INTUBATION-I
IF DOUBTFUL : WAIT INDICATIONS FOR
INTUBATION NO INDICATIONS:
UNTIL HOSPITAL IS
KEEP REASSESSING
REACHED AIRWAY IMPATENCY
LOW GCS
POOR NECK HOLDING
INADEQUATE COUGH
REFLEX

IF INDICATIONS
PRESENT

PREOXYGENATION

NO BREATHING BREATHING

BMV WITH
RESPIRATORY BAG ADMINISTER O2 15L/MIN BY
NRBM
IF NO IMPROVEMENT IN
SATURATION START BMV
WITH RESPIRATORY BAG

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STEPS OF INTUBATION-II

PREASSESMENT
LOOK FOR
SHORT NECK
BUCK TEETH
BIG TONGUE
Check vitals

IF PRESENT TRY TO MANAGE WITHOUT

IF ABSENT PLAN INTUBATION AND TRY LMA
INTUBATION

IF LMA INSERTION FAILS

INTUBATE THE PATIENT
ELECTIVELY INTUBATE THE
PATIENT AFTER GIVING
APPROPRIATE PREMEDICATION

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 STEPS OF INTUBATION- III
PREMEDICATIONS

• No Neuro muscular blockers

• No dehydration and hypotension : 250ml
fluids and Propofol 100mg
• If pulmonary edema : Morphine and
Midazolam
• If hypotension : Give a fluid bolus and
administer Fentanyl 100 to 150 mcg with
Midazolam 3-5mg iv
• If no cardiac problems, no head pathology, no
hypertension : Ketamine with Midazolam

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 STEPS OF INTUBATION- IV
• Position the cot/trolley at the level of your
xiphisternum

• Place a towel under the patient’s occiput.

• Open the airway by head tilt chin lift

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• Clear the lips

• Insert scope from the right side of the mouth

• Look at the tongue and then the epiglottis as

you push the tongue to the left.

Stay at the vallecula

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• As you move the tongue to the left you can
avail more room to insert the ET tube

• Lift the scope. Do not lever it

• Watch the cords. Insert the ETT by looking at

the cord as you slowly hold it laterally and
advance it medially.

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• Do not advance the ETT along the barrel as
you fail to get a clear vision of the cords

• Confirm ETT position by

– 5 point auscultation over the chest wall
– Looking for the fog which can be noticed
on the walls of the tube
– Increase in SPO2

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• Fix with a strong plaster

• Check vitals post intubation

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Fixing ET Tube

With Moustache

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 FOREIGN BODY OBSTRUCTION
• Give abdominal thrust as shown in the Fig to
dislodge the FB
• If patient is unconscious : Initiate BLS

Foreign Body

Not impacted Impacted

Not visualised Could be visualised Bimanual method

one hand externally at
the neck and the fingers
of the other hand into
Use Magell’s the mouth
Vocal cords could
Forceps and
be seen ?
remove it

Inutbate and push

it into Right main
bronchus

Ventilate with 100% oxygen or perform

a needle cricothyrotomy if intubation
fails

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RESPIRATORY DISTRESS

Support ABCS
oxygen by NRBM
Head end up
IV access

Pt is conscious Pt is unconscious

BiPAP Basic airway

management

Plan intubation

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 Auscultate chest

Wheeze present Decreased air

Crepts present
: COPD entry

Nebulisation
Pulmonary edema : with salbutamol Rule out
Give and O2 support Tension
continuously Pneumothorax.
Lasix If present
Morphine Needle
Dobutamine Decompression

Infection :
Give Oxygen with NRBM @ 15 L/min

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 ANAPHYLAXIS

• Support ABCs
• Check vitals
• Removal of foreign substance
• If situation permits talk with medical control
• Inj.Epinephrine 0.3-0.5mg
• If patient is stable :Systolic BP > 100 mm Hg,
Peripheral pulses felt and warm body : Give
Epinephrine by SC or IM route
• If patient is unstable: Feeble/thready pulse,
cold clammy extremities : Dilute Epinephrine
in 10 ml NS and administer slow IV
• Add 1 amp to drip and titrate as needed
• Adjuncts : Avil, Hydrocortisone and Rantac
• Contact medical control and inform

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ALTERED MENTAL STATUS
Support ABCs

Correct hypotension
Check CBG
Watch for Focal neurological
deficits

Correct if needed
with 25% Dextrose If vitals stable and
patient is restless

Thiamine if
available Inj. Serenace 5 +5 mg
Inj. Lorazepam 4mg IV

RULE OUT 6Hs AND 5Ts

HYPOGLYCEMIA Give 25% Dextrose

Fluid challenge. If no response start inotropic

HYPOTENSION
support

HYPOKALEMIA/HYPERKALEMIA Beyond the scope of prehospital care

H+ IONS (ACIDOSIS) Beyond the scope of prehospital care

HYPOTHERMIA Cover the patient with a blanket. Switch off AC

Give Oxygen @15l/min with NRBM if breathing or

HYPOXIA
Bag mask ventilation if not breathing

TOXINS Give Activated charcoal after D/W medical control

TAMPONADE,CARDIAC Beyond the scope of prehospital care

THROMBUS Thrombolyze if criteria are met

TENSION PNEUMOTHORAX Needle Decompression

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TRAUMA Prevent bleeding, Splint, Spine care, IV Fluids
 BURNS
• Initial ABC care
• Oxygen @ 15L/min by NRBM
• IV access : 1-2 units of fluid bolus
• Check vitals
• Calculate % of BSA
• Fentanyl 100-150 mcg stat
• Midazolam 2-4mg IV stat
• Cover with cold blanket to prevent
hypothermia
• Basic airway control
• Inform about inhalation burns and facial
burns

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 PULMONARYEDEMA /
CARDIOGENIC SHOCK

• Initial ABC approach

• Head end elevation
• Oxygen by NRBM
• NTG spray
• Inj.Lasix 40mg Iv stat
• Morphine 4-8mg IV stat
• If patient conscious and stable: BiPAP
• If unconscious/hypotension :Plan for
intubation
• Dobutamine : If systolic BP > 100mm Hg
• Dopamine : If systolic < 90mm Hg with signs
of shock
• Noradreanline: if Systolic < 70mm Hg
• Monitor pupils, SPO2
• Inform medical control

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PULSELESS ARREST ALGORITHM

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BRADY CARDIA

46
TACHY CARDIA

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ACUTE CORONARY SYNDROMES

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 SHOCK
• Initial ABC care
• 1-2 l bolus of NS titrate with chest signs, JVP
and CVP if possible

Tachyarrythmia Bradyarrythmia
noticed on ECG noticed on ECG

External
Cardioversion
Pacemaker.

if pacing fails
Adrenale 2-10mcg/kg/min
Dopamine : 2-20 mcg/kg/min

Rule out 6Hs

and 5Ts

Sepsis Hypovolemia Anaphylaxis Pneumothorax

Noradrenaline Needle
Adrenlaine
Dopamine Fluids decompression

Foleys , monitor
urine output

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Discuss with medical control
 CHEST PAIN

• Initial ABC care

• Vitals SBP > 100mm Hg
• O: Oxygen
• N: NTG/Sorbitrate
• A: Aspirin
• M: Morphine/Fentanyl(100mcg)
• IV access
• Take ECG
• If signs of pulmonary edema present :
BiPAP and Head end elevation
• Discuss with medical control for further
assistance

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 STROKE
Initial ABC care

Features of stroke
Arm drift, facial droop
and abnormal speech

Check CBG
Alert stroke team

If < 80mg/dl treat with

25% Dextrose 100ml

Do not treat
hypertension

Observe for
neurological
deterioration or
seizures.

Discuss with medical

control.
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HEAD TRAUMA
TRAUMA CARE

TRANSPORT WITH SPINE

CARE

IV ACCESS, VITALS

UNEQUAL PUPILS : Mannitol ,

Lasix and Colloid

If convulsions : Eptoin and

Lorazepam

Basic airway management

Discuss with reaching hospital
Inform receiving doctor
Inform time line also
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OBSTETRIC COMPLICATIONS
Support ABCs
Check BP

Preeclampsia, Postpartum
Eclampsia haemorrhage

MgSO4 : 2gm in
10 ml NS IV push Mild Severe
over 10min

If seizures develop Put infant to

Fundal massage
or continue mothers breast

MgSO4; 4gm in
50ml NS over Fundal massage Fluid challenge
15min

Discuss with
medical control

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PAIN – NON CARDIAC IN
ORIGIN

INITIAL ABC CARE

VISUAL ANALOGUE SCALE

MINOR PAIN MAJOR PAIN

DOLO/TRAMADOL with Inj. FENTANYL with Inj.

Emeset Midazolam

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 POISONING/OVERDOSE

Initial ABC care

Any contraindication for gastric

lavage /charcoal

YES NO

Corrosive burns
Kerosene/petroleum poisoning Gastric lavage
Altered mental status Activated charcoal 1gm/kg
Unable to swallow

No gastric lavage/charcoal. Give

specific antidote after D/W
medical control

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 SEIZURES

Support ABCs

Assess Blood glucose levels

If > 80mg/dl If < 80mg/dl give Thiamine 100mg IV

Give Thiamine 100mg iv and 25% Dextrose 100ml iv

If seizures occur
Lorazepam 4mg Iv stat
Inj.Eptoin 20mg/kg Iv bolus
Discuss with medical control

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 DROWNING

Drowning

Conscious Unconscious
Aletered
sensorium
No cough Cough Initiate BLS
Oxygen 15L/min with
NRBM
Oxygen
No 15L/min wit IV access
additional NRBM Left lateral position
care Head end Check CBG
up
Reassessment
ABC care
Keep the victim warm

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 SNAKE BITE
• Reassurance
• Immobilisation and limb elevation
• Clean the wound
• Do not place any torniquet over/above the
wound
• Watch for
– Ptosis
– Gum bleeding
– Swelling > 5 cm
– Bleeding at the site
– Bradycardia
– Vomiting
• Start with 15 vials ASV and 1-2 vials (every 1-
6hrs)
• Keep airway instruments and emergency
drugs ready
• Adjuncts : Rantac, Avil, Hydrocortisone

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 SCORPION BITE

• Initial ABC care

• Reassure the victim and the attenders
• Apply cold pack at sting site
• Vomiting, Sweating, tachycardia, tachypnoea
and agitation : Give Prazosin 30mcg/kg
• If intense pain at the site : Local anaesthesia
infiltration with 2% Xylocaine
• If severe agitation : Inj. Midazolam 2mg if
victim is conscious and vitals are stable

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 DOG BITE

• Initial ABC care

• Local wound care: Wash with running water
and then with betadine
• Do not tape the wound
• Give Inj.TT 0.5ml IM over the deltoid
• Administer rabies immune globulin (20 IU/kg)
with as much of the dose as possible
infiltrated in and around the wound
• Administer the remaining IM in the gluteal
region (Discuss with medical control before
giving this drug)
• Administer rabies vaccine in the deltoid
region, with a dose of 1 mL on the day of
patient transport (usual order of doses: Day
0, 3, 7, 14, and 28)

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PAEDIATRICS

61
GENERAL INSTRUCTIONS

• Always keep the child warm. Prevent

hypothermia
• Splint the IV access as the canula may get
dislodged easily
• Do not infuse with macrodrip set
• Always measure and administer IV fluids
• Watch carefully for signs of fluid overload
• Reassure the child and the attenders
• Keep mother next to the baby
• Calculate the dose according to age and
weight and administer drugs
• Babies are not just small adults

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PAEDIATRIC MEDICAL CARE

Initial ABC care. Keep all

necessary equipment ready

Reassure and properly position

the patient

Asses vitals

Manage airway, provide

ventilatory assistance and Oxygen

IV access
Monitor ECG

Discuss with medical control

63
PAEDIATRIC TRAUMA

Assess mechanism of injury

Place a cervical collar and

transport on a spine board

Assess vitals. If hypotensive

: Fluid challenge 20ml/kg
rapidly. Reassess for further
fluid requirement

Provide airway
management, ventilatory
assistance and oxygen

CONTACT MEDICAL CONTROL

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PAEDIATRIC AIRWAY
MANAGEMENT
MANUALLY OPEN THE
AIRWAY

SUCTION AS NEEDED

INSERT OROPHARYNGEAL
OR NASOPHARYNGEAL
AIRWAY

VENTILATE PATIENT WITH

BAG VALVE MASK AND
100% OXYGEN

PERFORM ENDOTRACHEAL
INTUBATION AS NEEDED.
Confirm tube position

DISCUSS WITH MEDICAL

CONTROL

65
FACILITATED INTUBATION
PATIENT IS COMBATIVE OR HAVE A
GAG REFLEX

CHECK VITALS, MONITOR SPO2,

GIVE OXYGEN IF NECESSARY

SPRAY THE HYPOPHARYNX WITH

LIGNOCAINE TOPICAL ANAESTHETIC
SPRAY

If > 10 yrs : Inj. Midazolam 4mg and

Inj.Fentanyl 100mcg. If intubation
unsuccessful repeat initial dose

CONFIRM ET TUBE PLACEMENT

After successful intubation:

Consider Diazepam 0.1mg/kg

66
 FLUID CHALLENGE
Confirm indications for fluid challenge : Altered mental
status, tachypneoa, tachycardia, diaphoresis, pallor,
capillary refill > 2sec, hypotension etc

Access saline lock with NS or

RL and macrodip set

Infuse 20ml/kg rapidly

Reassess and reconfirm

indications

Repeat rapid infusion of 20

Dopamine if indicated

Repeat procedure until

contraindicated
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 ACUTE DYSPNOEA
Initial ABC care.
Ascertain history

Wheezing or history of asthma Hoarseness, stridor, choking,

or bronchiolitis drooling or coughing

Salbutamol (2.5-5mg in 3ml

NS)
Administer 100% oxygen
Ipratropium : 500mcg in 2.5ml
NS Allow position of comfort
Administer via nebulizer

Salbutamol 2.5 mg in 3ml NS via

nebulizer Epinephrine 1:1000 5mg
Or Epinephrine 1:1000 of 0.01mg/kg Administer via nebulizer
SC to a total of 0.3mg May repeat once again
May repeat in 20min/whenever
needed

68
 AIRWAY OBSTRUCTION
Assess consciousness

If
conscious/crying/cou
If unconscious
ghing : encourage
coughing

If unable to cough :
Heimlich’s Basic airway support
maneuver

Use direct laryngoscopy and

magill forceps

If unsuccessful, insert an ET tube and attempt to

push through the obstruction or push into the right
mainstem bronchus

If unsuccessful, continue efforts and

transport

Perform needle
cricothyroidotomy

69
ANAPHYLAXIS/ALLERGIC
REACTION
Initial ABC care
Check vitals

Hypotensive or severe Normotensive and no

respiratory compromise respiratory compromise

Epinephrine 1:10000 0.01mg/kg IV Avil, Hydrocortisone

(max 0.5mg)
May repeat in 20 min

Adjuncts : Inj. Avil and

Hydrocortisone

If patient doesn’t improve give fluid challenge.

Discuss with medical control

70