(Cardiac) Paramedic Protocols PDF

The Charlotte Hungerford Hospital
Department of Emergency Medicine

Division of EMS
Sponsor Hospital Program
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Noorrtthh W
Weesstt C
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MSS R
Reeggiioonn V
V
Paramedic
Protocols
Revised 2005
Charlotte Hungerford Hospital
IMPORTANT CAUTION
The information contained in these protocols is compiled from sources believed to be reliable and
significant efforts have been expended to make sure there are no inaccuracies. However, this
cannot be guaranteed. Despite our best efforts there may be typographical errors or omissions.
The Region V EMS Council or Medical Advisory Committee is not liable for any loss or damage
that may result from these errors.
ON-LINE MEDICAL DIRECTION

It is agreed upon in Region V that prehospital providers will contact the receiving hospital
regarding obtaining patient care orders.
COMMUNICATION FAILURE
In the event of complete communication failure, these protocols will act as the parameters for prehospital patient care. If communication failure occurs the EMT-Paramedic (EMT-P) may follow
the guidelines to render appropriate and timely emergency care to the patient.
Upon arrival at the receiving hospital the EMT-P will immediately complete an incident report
relating to the communication failure describing the events including the patients condition and
treatment given. This incident report must be filed with the EMT-Ps sponsor hospital EMS
Medical Director and/or EMS Coordinator within 24 hours of the event. A copy of the patients
run form will also accompany the incident report.
PARAMEDIC PROTOCOL
Table of Contents
Subject
Adult Cardiac
Adult Respiratory
Adult Medical
Adult Trauma
OB/GYN Emergencies
Pediatric Medical
Pediatric Trauma
Appendix A: Procedures
Rule of 9s
Appendix B: Pharmacology
Appendix C: Spinal Assessment
and Immobilization Criteria
Pages
4-12
13-19
20-43
44-61
62-71
72-90
91-101
102-114
115&116
117-153
154
PARAMEDIC PROTOCOL

Paramedic Protocols
Cardiac Protocols
PARAMEDIC PROTOCOL
Description of Chest Pain

Cardiac disease can manifest itself in several ways. When assessing a patient suspected of suffering
cardiac disease, the paramedic should note each presenting complaint and obtain a history appropriate to
the presenting symptom. Common presenting symptoms of cardiac disease include:
Chest pressure or discomfort
Shoulder, neck or jaw pain
Dyspnea
Syncope
Palpitations
Chest pain or discomfort is a common presenting symptom of cardiac disease. Chest pain is the most
common presenting symptom of myocardial infarction. When confronted by a patient with chest pain,
obtain the following essential elements of the history:
Specific location of the chest pain (midsternal, etc.)
Radiation of pain, if present (e.g., to the jaw, back, or shoulders)
Duration of the pain
Factors that precipitated the pain (exercise, stress, etc.)
Type or quality of the pain (dull or sharp)
Associated symptoms (nausea, dyspnea)
Anything that worsens, intensifies or alleviates the pain (including medications, moving or
a deep breath)
Previous episodes of a similar pain (e.g., angina)
It is important to remember that chest pain has many causes other than cardiac disease. The history,
therefore, is an important determining factor.
Shoulder, arm, neck, or jaw pain or discomfort may also be an indicator of cardiac disease. Any of these
may occur with or without associated chest pain, especially in older patients or patients with diabetes. If
the patient has any of these symptoms and you suspect heart disease, obtain information similar to that
described above for chest pain.
PARAMEDIC PROTOCOL
Ischemic Cardiac Chest Discomfort

1. Oxygen Therapy (90-100%)
2. Aspirin 325mg or Baby Aspirin 4 tabs PO (81mg each); unless patient is allergic, on
coumadin, or with a history of ulcerative disease
3. Cardiac Monitor and 12 lead EKG
4. Establish IV NS @ KVO
5. Consider and inquire about Viagra use within 6 hours: If used do not administer
Nitroglycerin products.
6. Nitroglycerin (NTG) 0.4mg (1/150 gr.) sublingual or NTG spray (1) metered dose if B/P >
100 systolic
7. May be repeated every 5 minutes to a total of 3 doses, until symptom free or SB/P <100
8. Morphine Sulfate 1 to 4mg IVP

Establish Medical Control Possible Physician Orders:

Morphine Sulfate 1-4mg (up to 10mg) IVP, titrate to effect

Nitropaste 1 inch topically
Additional sublingual Nitroglycerine
Hold if SB/P <100
PARAMEDIC PROTOCOL
Routine Cardiac Arrest Care

1. Assess patients (ABCs)
2. Initiate CPR
3. Ventilate with Bag-Valve-Mask at 100%
4. Determine rhythm via quick look
5. Proceed to appropriate algorithm
6. Any changes in rhythm, follow appropriate protocol
NOTE: The following patient care guidelines are based upon the current American Heart
Association Guidelines for Advanced Cardiac Life Support 2000. Where there are notations that
refer to footnotes or additional information - please consult the AHA -ACLS 2000 Emergency
Cardiac Care Manual and note that specific algorithm.
PARAMEDIC PROTOCOL
Asystole Algorithm
ASYSTOLE
Primary ABCD Survey

Focus: basic CPR and Defibrillation
Check Responsiveness
Activate emergency response system
Call for defibrillator
A
B
C
C
D
Airway: Open the airway

Breathing: Provide positive pressure ventilation
Circulation: Give chest compressions
Confirm true asystole
Defibrillation: Assess for VF/ pulseless VT; shock if indicated
Rapid scene survey: is there any evidence that personnel should not attempt resuscitation (eg,
DNR order, signs of death)?
Secondary ABCD Survey

Focus: more advanced assessments and treatments
A Airway: Place airway device as soon as possible
B Breathing: Confirm airway device placement by exam plus confirmation device
B Breathing: Secure airway device; purpose made tube holders preferred
B Breathing: Confirm effective oxygenation and ventilation
C Circulation: Confirm true asystole
C Circulation: Identify rhythm monitor
C Circulation: Give medication appropriate for rhythm and condition
D Differential Diagnosis: search for and treat identified reversible causes
Transcutaneous pacing:
If considered perform immediately
Epinephrine
1mg IV push, repeat every 3-5 minutes
Atropine
1mg IV, repeat every 3-5 up to a total
of 0.04mg/kg
Consider ceasing resuscitation efforts

(see appendix for Termination of Resuscitation).
PARAMEDIC PROTOCOL
Bradycardia Algorithm
Assess ABCs
Review history
Administer oxygen
Obtain IV access
Monitor
Assess vital signs

Review history
Perform physical examination
12-Lead if possible
Bradycardia, either absolute

(<60beats/min) or relative
Serious signs or symptoms?a,b
No
Yes
Type II second-degree
A-V heart block?
Or
Third-degree AV heart block?e
No
Intervention sequence
Atropine 0.5-1.0mgc,d (I and IIa)
Transcutaneous pacing (I)
Dopamine 5-20g/kg/min (IIb)
Epinephrine 2-10g/min (IIb)
Yes
Observe
Pacer in place / standby

Establish Medical Control
Possible Physicians Orders
Transcutaneous pacing
Note: If patient has chronic renal failure contact Medical Control for a possible order of
Calcium Chloride 1Gm IV and/or Sodium Bicarbonate 1meg/kg.
If patient is on beta-blockers or possible beta-blocker overdose contact Medical Control for a
possible order of Glucagon 2mg IV.
PARAMEDIC PROTOCOL
Pulseless Electrical Activity
Pulseless electrical activity (PEA)

includes the following:
Electromechanical dissociation (EMD)
Pseudo-EMD
Idioventricular rhythms
Ventricular escape rhythms
Bradyasystolic rhythms
Postdefibrillation idioventricular rhythms
Continue CPR
Intubate at once
Obtain IV access
Assess blood flow using end-tidal CO2 detector
Consider possible causes

(possible therapies and treatments are given in parentheses)
Hypovolemia (volume infusion)

Drug overdoses, i.e.: tricyclics,
Hypoxia (ventilation/O2)
digoxin -blockers, etc.
Cardiac tamponade (volume infusion)
Hyperkalemiaa
Tension pneumothorax (needle
Acidosisb
decompression)
Massive myocardial infarction
Hypothermia
Pulmonary embolism (O2, STAT transport)
Epinephrine 1mg IVP,a,c

repeat 3-5 minutes
If absolute bradycardia (<60 beats/min) or

relative bradycardia, give Atropine 1mg IVP
Repeat Atropine 3-5 minutes to a total
doses of 0.03-0.04mg/kgd
Ventricular Fibrillation/Pulseless Ventricular Tachycardia Algorithm

PARAMEDIC PROTOCOL
10
Primary ABCD Survey

Focus: basic CPR and defibrillation
A
B
C
D
Check responsiveness
Activate emergency response system
Call for defibrillator
Airway: open the airway
Breathing: provide positive-pressure ventilations
Circulation: give chest compressions
Defibrillation: assess for and shock VF/pulseless VT, up to 3 times
(200J, 300J, 360 J, or equivalent biphasic) if necessary.
Rhythm after first 3 shocks?
Persistent or recurrent VF/VT
Secondary ABCD Survey
Focus: more advanced

assessments and treatments
Epinephrine 1 mg IV push, repeat every 3 to 5

minutes
or
Vasopressin 40 U IV, single dose, 1 time only
A Airway: place airway

device as soon as possible
B Breathing: confirm airway
device placement by exam
plus confirmation device.
B Breathing: secure airway
device; purpose-made tube
holders preferred.
B Breathing: confirm
effective oxygenation and
ventilation
C Circulation: establish IV
Access
C Circulation: identify
rhythm monitor
C Circulation: administer
drugs appropriate for
rhythm and condition
D Differential Diagnosis:
Search for and treat
identified reversible causes
Resume attempts to defibrillate

1 X 360 J (or equivalent biphasic) within 30 to 60
seconds
Consider antiarrhythmics:
Amiodarone (IIb for persistent or recurrent
VF/pulseless VT) *
Lidocaine (Indeterminate for persistent or recurrent
VF/pulseless VT)
Magnesium (IIb if known hypomagnesemic
state)
Procainamide (Indeterminate for persistent
VF/pulseless VT; IIb for recurrent VF/pulseless
VT
* The medical directors of Region 5 have elected
not to use Amiodarone in this protocol
Resume attempts to defibrillate
Tachycardia
PARAMEDIC PROTOCOL
11
Evaluate patient
Is patient stable or unstable?
Are there serious signs or symptoms?
Are signs and symptoms due to tachycardia?
Stable or Borderline
Stable patient: no serious signs or symptoms
Initial assessment identifies 1 of four types of
tachycardias
1. Atrial
Fibrillation
>150 BPM
12-Lead if Possible
Establish Medical
Control
Diltiazem (0.25mg/kg)
15-25mg slow IV push
2. Narrow
Complex
Tachycardia
12-Lead if Possible
Vagal Stimulation
Adenosine 6mg rapid
IVP with 30cc rapid
flush; if no response
Adenosine 12mg x1
(12mg)
Contact Medical
Control
Diltiazem (0.25mg/kg)
15-25mg Slow IVP
Unstable*
Unstable patient: serious signs or symptoms*
Establish rapid heart rate as cause of signs

and symptoms
Rate related signs and symptoms occur at
many rates, seldom <150 bpm
Prepare for immediate cardioversion
100j, 200j, 300j, 360j for VT, PSVT, A-Fib, AFlutter
3. Stable wide
complex
tachycardias:
unknown type
>140 bpm
Adenosine 6mg rapid
IV followed by 30cc
rapid flush
Lidocaine 1-1.5mg/kg
slow IVP may repeat in
5-10 min @ 0.5-0.75
mg/kg
Follow with IV Drip
Contact Medical
Control
4. Stable
monomorphic
and/or
polymorphic
VT
Lidocaine 1-1.5mg/kg
slow IVP may repeat in
5-10 min @ 0.5-0.75
Follow with drip
Establish Medical
Control
Procainamide
20mg/min IV
* Unstable conditions must be related to the tachycardia. Signs and symptoms may include: chest pain,
shortness of breath, decreased level of consciousness, low B/P, shock, CHF, pulmonary congestion, and
AMI
NOTE: Carotid sinus pressure is contraindicated in patients with carotid bruits or the elderly.
PARAMEDIC PROTOCOL
12
Paramedic Protocols
Respiratory Protocols
PARAMEDIC PROTOCOL
13
OXYGEN THERAPY
1.
GENERAL ADULT PATIENTS:

NO PATIENT IN RESPIRATORY DISTRESS IS TO BE DENIED OXYGEN THERAPY
All Priority 1 and 2 patients should be administered oxygen in a concentration of 100% until
medical control can be contacted.
2.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENTS:

Institution of oxygen therapy with COPD patients shall be as follows:
1.
Priority 1 or 2 patients who do or do not demonstrate shock or shock-like symptoms should be

administered oxygen concentrations of 100% via appropriate facemask until medical control can be
contacted. *
2. Patients who can not tolerate a facemask may be given oxygen via nasal cannula at 4-6 liters/min.
3. Priority 3 patients who are not in respiratory distress, who are on home oxygen therapy, should
continue at the same concentration consistent with their home does.
* If a patient is not breathing adequately on his own, the treatment of choice is VENTILATION, not just
oxygen.
Note: Monitor closely the patient receiving high concentrations of oxygen for signs of decreased level of
consciousness and/or increased respiratory distress. Be prepared to provide ventilations if
indicated.
PARAMEDIC PROTOCOL
14
ACUTE PULMONARY EDEMA

1. Assess ABCs
2. Oxygen Therapy (90-100%)
3. IV Normal Saline at KVO
4. If Systolic Blood Pressure >120 mmHg Nitroglycerin 0.4mg (1/150 gr.) SL*
5. May repeat every 3-5 minutes prn
6. If SBP<120 Establish Medical Control
7. Lasix 40 mg IVP
If patient usually takes Lasix and they have NOT taken their daily dose,
the paramedic may administer 2x their usual daily does up to 200 mg slow IVP.
8. Establish Medical Control
Possible Physician Orders:
9. Nitropaste 1-2 topically
10. Repeat SL Nitroglycerin
11. Repeat Lasix
12. Morphine Sulfate 2-5 mg IVP
13. CPAP see protocol
* SL = this may be either metered dose spray or tablet that dissolve under the tongue.
Note: Morphine may cause respiratory depression. Be prepared to assist ventilations or intubate
as indicated.
CHF Vs Pneumonia: if the clinical impression is unclear and transport time is not prolonged, consider
using nitroglycerin and withhold furosemide (Lasix) or contact Medical Control.
PARAMEDIC PROTOCOL
15
Continuous Positive Airway Pressure (CPAP)

The application of continuous positive airway pressure by facemask.
Indications:
Hypoxemia secondary to Congestive Heart Failure and Acute Cardiogenic Pulmonary Edema. For relief
of Hypoxemia and Shortness of Breath (SOB)/Dyspnea secondary to Pneumonia, Chronic Obstructive
Pulmonary Disease (Asthma, Bronchitis, Emphysema). An adequately, spontaneous breathing patient.
Follow pathology specific guideline for medication treatment
Contraindications:
Respiratory Arrest
Agonal Respirations
Unconscious
Shock associated with cardiac insufficiency
Pneumothorax
Penetrating chest trauma
Persistent nausea/vomiting
Facial Anomalies / Stroke Obtundation / Facial Trauma
Signs and Symptoms:
1. Dyspnea and Tachypnea.
2. Chest Pain, Hypertension, Tachycardia.
3. Anxiety, Restlessness, Altered L.O.C.
4. Rales and Often Wheezes, Frothy Sputum (severe cases)
Procedure:
1. Assess Vital Signs
2. Attach heart monitor and pulse oximeter
3. If BP <100 systolic contact Medical Control prior to beginning CPAP
4. Verbally instruct patient.
i.
Patient requires verbal sedation to be used effectively.
a. Example: Patient: I cant get air in! Care Giver: This will help you get air
in. This will help you breath easier as the pressure on the machine is
increased.
ii.
Start CPAP at ambient pressure (0 cmH2O).
iii.
Instruct patient to breath in through their nose slowly and exhale through their mouth
as long as possible (count slowly and aloud to four then instruct to inhale slowly).
iv.
Explain to the patient that you will begin to slowly increase the pressure and to
continue exhaling out against the pressure as long as possible before inhaling.
v.
Slowly titrate the pressure to:
a. CHF/ACPE 10cmH2O
b. All other SOB/Dyspnea 5 cmH2O
5. Treatment should be given continuously throughout transport to ED.

6. Vital Signs q5 minutes.
PARAMEDIC PROTOCOL
16
Continuous Positive Airway Pressure

7. In the event of life-threatening complications:
Stop treatment
Offer reassurance
Institute BLS/ALS support
Adverse reactions to therapy are to be documented using an Occurrence
Report. The Paramedic should immediately notify Medical Control and
ED staff upon arrival
8. Documentation in the runsheet narrative should include:
a. CPAP level
b. FiO2 100%
c. O2% Sat. q5 minutes
d. Vital Sign q5 minutes
e. Effects/Adverse reactions
PARAMEDIC PROTOCOL
17
COMPLETE AIRWAY OBSTRUCTION

Conscious
1. Assess to determine airway obstruction
2. Perform Heimlich Maneuver for conscious patient
3. Continue Heimlich Maneuver until airway is cleared or
4. patient is rendered unconscious
Unconscious
1. Assess to determine unresponsiveness.

2. Attempt to establish airway to determine airway obstruction.
3. Perform Heimlich Maneuver for unconscious patient.
4. If airway is still obstructed perform direct laryngoscopy.
5. Removal of any foreign body is attempted using Magill Forceps.
6. If airway is still obstructed, endotracheal intubation is attempted.
7. If airway is still obstructed consider Transtracheal Ventilation.
9. Possible physician order to push object into Right Main Stem Bronchi if obstruction is below
cricoid membrane.
PARAMEDIC PROTOCOL
18
RESPIRATORY DISTRESS
Wheezing
A patient who is experiencing moderate to severe respiratory distress with a respiratory rate > 24 with
wheezing presumed to be reactive airway disease.
Routine Paramedic Care - Initiate treatment based upon history and clinical presentation. If respirations
begin to decrease in rate or depth with a change in mental status, begin to assist ventilations immediately.
All that wheezes is not Asthma
- a wise man
Asthma
1. Routine Paramedic Care
2. Oxygen per protocol
3. Establish IV Normal Saline at KVO
4. Albuterol nebulizer Treatment 2.5 mg in 2.5 ml NS
5. Consider: In Severe cases Atrovent 2.5cc nebulizer treatment
6.
7.
NOTE: Do NOT use Atrovent in patients with known peanut allergy

Albuterol and Atrovent may be combined (Combivent)
8. May repeat updraft x 2

9.
10.
11.
12.
13.

Epinephrine (1:1000) 0.3 mg (0.01mg/kg) SQ, or 0.3mg of 1:10,000 Slow IV*
Repeat Nebulizer updraft(s)
Solu-Medrol 125 mg Slow IVP
COPD - Emphysema
1.
2.
3.
4.
5.
6.
7.
Routine Paramedic Care

Oxygen per protocol
Establish IV Normal Saline at KVO
Albuterol nebulizer treatment 2.5 mg (0.5cc) with 2.5cc Atrovent 0.4%
Combivent as above is acceptable
May repeat updraft x 2
Possible Physician Orders

8. Epinephrine (1:1000) 0.3 mg (0.01 mg/kg) SQ*
9. Repeat nebulizer treatment
* Use with caution with preexisting dysrhythmias, hypertension, cardiac history, or history of ischemic cardiac chest
pain, and patients over the age of 50.
PARAMEDIC PROTOCOL
19
Paramedic Protocols
Medical Protocols
PARAMEDIC PROTOCOL
20
ROUTINE ALS MEDICAL CARE

PURPOSE: All patients, after receiving their initial assessment and priority assignment, are to receive
routine medical care followed by the initiation of the appropriate protocol.
1.
ABCs always first; Address life threats immediately per appropriate protocol
2.
Maintain and protect airway, using adjuncts as necessary
3.
Protect C-spine at all times if any possibility of injury
4.
Oxygen per protocol
5. PATIENT ASSESSMENT
6.
Develop a DIFFERENTIAL DIAGNOSIS. Avoid tunnel vision in your diagnostic impression !!
7.
Place patient in position of comfort unless otherwise contraindicated
8.
IV therapy as per protocol
9.
Cardiac monitoring as appropriate for patients presentation
10. Initiate pulse oximetry monitoring

11. Treat the patient based upon appropriate patient care protocol based upon diagnostic impression
12. Obtain and record vital signs every:
a.
b.
c.
15 minutes for stable patient

5 minutes for the unstable patient
After administration of medication or intervention
13. Destination hospital based upon patient condition, trauma regulation, request, or medical condition
14. Contact Medical Control as early as possible
PARAMEDIC PROTOCOL
21
PATIENT ASSESSMENT
PURPOSE: Each patient is to have an initial assessment as outlined in this section. Depending upon the
results of this patient assessment, the provider will advance to provide appropriate treatment.
Initial Patient Assessment
A. General Appearance
1.
2.
3.
Age and sex

General state of health
Amount of distress (mild, moderate, severe)
B. Objective Signs
1.
2.
3.
4.
5.
Level of consciousness: GCS/Trauma Score

Respiratory assessment
Skin: Temperature, color, moisture
Pupil status
Glasgow Coma Scale / Trauma Score if indicated
C. Vital Signs
1.
2.
3.
4.
5.
Pulse: rate, quality, and rhythm

Respiratory rate, character of breath sounds
Blood pressure
Cardiac monitor finding where indicated
Pulse oximetry if available
D. History of Episode (obtained from patient, family, or observer)

1.
2.
3.
4.
Chief complaint
Time of incident or onset of symptoms
Prior treatment if related to present illness or injury
Mechanism of injury if trauma
E. Pertinent Medical History

1.
2.
3.
4.
Previous medical problems or conditions

Routine medications
Allergies
Last menstrual period? Pregnancy
F. Other Pertinent History

1.
2.
3.
4.
Social (substance abuse, smoker, violence, etc.)

Family (cardiac, diabetic, asthma)
Sexual (GxPx, LMP)
Systems review focused to presentation
PARAMEDIC PROTOCOL
22
Abdominal Pain
Assessment: Assessing a chief complaint of abdominal pain, can be one of the most difficult
tasks for the prehospital provider, due to the lack of CT scan or ultrasound for clinical diagnosis.
Abdominal complaints may be vague, nonspecific, and vary from patient to patient. Any patient
where hemorrhage is suspected should be treated for shock and transported immediately.
1.
2.
3.
4.
Routine BLS Care

Routine ALS Care
Oxygen per protocol
Establish IV of Normal Saline
Renal Colic (Kidney Stones)

Patient must have a history of Kidney Stones with similar symptoms
1. Morphine Sulfate: >50kg 2-5mg IV, IM, or SC (<50kg 0.1mg per kg diluted with 5cc normal
saline, administer over 3 minutes.)
2. Contact On-Line Medical Control

PARAMEDIC PROTOCOL
23
ALLERGIC REACTION
DESCRIPTION
An allergic reaction is a hypersensitivity to a given antigen. It is usually not life threatening, merely
uncomfortable for the patient.
The patient is hemodynamically stable and complains of minor to moderate skin manifestation (erythema,
pruritus or urticaria) or mild inspiratory/expiratory wheezing.
ANAPHYLAXIS
DESCRIPTION
Anaphylaxis refers to the introduction of a foreign substance (antigen) into the body which, because of
patient sensitivity, produces a severe systemic reaction. This systemic reaction may include shock,
laryngospasm, angioedema, and/or respiratory distress. It can be fatal.
The patient may complain of respiratory symptoms, such as tightness in the chest, wheezing, or shortness
of breath. Other symptoms may include swelling, urticaria, nausea, vomiting, abdominal pain, or
diarrhea. These symptoms are due to the release of certain substances within the body, e.g., histamine,
SRSA (slow reactive substance of anaphylaxis) and bradykinin. Hypotension and bradycardia may also
result.
Anaphylaxis is a true emergency in that death may occur within minutes of the introduction of antigen.
PARAMEDIC PROTOCOL
24
ALLERGIC REACTION
Stable Hemodynamics (Blood pressure >90 mmHg systolic); with minor or moderate skin manifestations
and/or inspiratory/expiratory wheezing.
1.
Oxygen as per protocol
2.
Cardiac monitor
3.
4.
Establish IV with Normal Saline

Benadryl 1mg/kg IV or IM (max 50mg)
5.
6.
If wheezing is present:
Administer: Albuterol 0.5cc (2.5mg) via nebulizer
7.

Possible Physician orders:
a. Epinephrine 1:1,000 0.3mg SQ
b. Solu-Medrol 125mg slow IVP
ANAPHYLACTIC SHOCK
Unstable Hemodynamics with hypotensive patient or impending upper airway obstruction; stridor; severe
wheezing and/or respiratory distress.
1.
Airway management
2.
Epinephrine 1:1,000 0.3mg SQ
3.
Oxygen per protocol
4.
Cardiac monitoring
5.
IV Normal Saline titrated to a BP > 100 systolic
6. If patient remains unstable hemodynamically administer Epinephrine 1:10,000 0.3mg Slow IVP
or ET
7. Benadryl 1mg/kg Slow IVP (max. 50mg)
8. Albuterol 0.5cc via nebulizer for respiratory distress
9. Possible Physician orders:
a. Dopamine Drip
b. Repeat doses of Epinephrine
c. Epinephrine IV Drip (1mg mixed in 250cc of Normal Saline) run at 2-10
mcg/kg/min
d. Solu-Medrol 125mg slow IVP
PARAMEDIC PROTOCOL
25
ALTERED LEVEL OF CONSCIOUSNESS

DESCRIPTION
The arousability or wakefulness of a patient is described according to the patients response to various
types of verbal or painful stimuli. Various descriptions for these responses are used including, lethargic,
drowsy, stuporous, semicomatose, or comatose. Since interpretation of a single term can vary from one
person to another, it is always best to describe sensorium using the Glasgow Coma Scale or AVPU
system. A decreased level of consciousness at any of these levels is indication for following the
decreased level of consciousness protocol.
There are generally only two mechanisms capable of producing stupor or coma:
1.
Structural lesions that depress consciousness by destroying or encroaching upon

the substance of the brain (trauma, tumor, hemorrhage).
2.
Toxic-metabolic states involving either the presence of circulating toxins or

metabolites or the lack of metabolic substrates (oxygen, glucose, or thiamine);
these states produce diffuse depression of both cerebral hemispheres with or
without depression within the brainstem.
Protocol
1. Altered Mental Status: Unknown Etiology or Unresponsive
10.
11.
12.
13.
14.
15.
16.
17.
18.
Routine ALS Care

Oxygen therapy
Assess level of consciousness according to Glasgow Coma Scale
IV Normal Saline @ KVO with blood draw and diagnostic blood glucose level
Thiamine 100mg IVP
Dextrose 50% 25 Gm IVP if blood glucose level is <70.
When IV access is unavailable administer Glucagon 1.0 mg IM
Narcan (Naloxone) 1-2 mg IntraNasal (IN) or
Narcan 0.4-2.0 mg IVP or IM / ET

a. Additional Dextrose and/or Narcan
PARAMEDIC PROTOCOL
26
2. Opiate Overdose Strongly Suspected

1.
2.
3.
Routine ALS Care

Oxygen therapy
Assess level of consciousness and respiratory status (RR<12) initiate BVM support
4.
IV Normal Saline @ KVO
5.
Narcan 0.4-2.0 mg IVP or IM if no IV access
6.
Rapid glucose determination with Dextrose or Glucagon for low glucose level
7.
Reassess level of consciousness and respiratory status (RR<12) consider intubation
8.

a. Repeat Narcan
b. Repeat Dextrose
NOTE: All empty medicine containers or other potentially relevant items to be transported to
receiving facility with patient whenever possible.
PARAMEDIC PROTOCOL
27
HEAT EXPOSURE (HYPERTHERMIA)

DESCRIPTION
The bodys normal core temperature is regulated by a number of factors that balance heat loss and heat
production. As the bodys temperature rises, vasodilation will lead to heat loss by radiation, convection,
and conduction. However, if the temperature outside the body exceeds the temperature of the skin, this
process is ineffective and evaporation by diaphoresis is necessary. The bodys physiological response to
excessive temperatures includes tachycardia as the heart attempts to increase cardiac output; diaphoresis
with subsequent loss of fluid (dehydration) and electrolytes; and signs of decreased cerebral perfusion,
e.g., headache, decreased responses to verbal and/or painful stimuli.
Heat Cramps:
Pain in muscles due to loss of fluid and salt. Frequently affects lower
extremities and abdomen. Cool, moist skin, normal to slightly elevated
temperature; nausea.
Heat Exhaustion:
The state of more severe fluid and salt loss leading to syncope,
headache, nausea, vomiting, diaphoresis, tachycardia, pallor and/or weak
pulse.
Heat Stroke:
A very serious condition. The patient may present with hot and flushed
skin, strong bounding pulse and altered mental status. The situation may
progress to coma and/or seizures. CAUTION: Sweating may still be
present in 50% of heat stroke patients.
*Do not give patient oral fluids if patient is nauseated or confused.

*Place patient in cool environment and determine need for advanced life support.
*Determine patients past medical history and history related to present event.
PARAMEDIC PROTOCOL
28
HEAT RELATED EMERGENCIES

HEAT CRAMPS
1. Move patient to a cool environment
3. Establish IV Normal Saline
4. DO NOT MASSAGE CRAMPING MUSCLES
5. Monitor vital signs and record
HEAT EXHAUSTION
1. Move patient to a cool environment and elevate legs
2. Remove clothing as practical and fan moistened skin
5. Cardiac monitor
PARAMEDIC PROTOCOL
29
HEAT STROKE
1. Move patient to a cool environment
2. Remove as much clothing as possible
3. Cool the patient with a cool wet sheet
4. Apply cold packs under the arms, around the neck, and at the groin to cool large vessels
7. Cardiac monitor
Heat stroke is caused by a failure of the bodys normal temperature regulating mechanism. This results in
a cessation of sweating and subsequent surface evaporation. It generally results when the body
temperature reaches 105 F or more. A delay in cooling may result in brain damage or even death.
Vigorous efforts should be employed to decrease the temperature.
PARAMEDIC PROTOCOL
30
NEAR DROWNING
1. Routine ALS Care
2. While protecting the cervical spine, establish a patent airway appropriate to the clinical situation
3. If hypothermic, follow Hypothermic Protocol
4. Bronchodilator via nebulizer as required for bronchospasm
5. (follow Acute Respiratory Distress Protocol)
6. All near drowning victims must be transported to the hospital
Drowning:
Death by water immersion.
Near Drowning:
Refers to initial recovery after immersion.
Dry drowning:
Little or no aspiration of water (10-20% of victims). Asphyxia by

laryngospasm.
Wet drowning:
Aspiration of water accompanying drowning.
PARAMEDIC PROTOCOL
31
HYPOTHERMIA
DESCRIPTION
When the bodys core temperature decreases, the body will first respond by shivering. This is an attempt
by the body to generate heat from muscle activity. Vasoconstriction will shunt blood from the skin and an
increase in the patients metabolic rate will increase heat.
If these mechanisms cannot compensate for severe temperature drops and the bodys systems begin to fail,
i.e. respiratory function will deteriorate and lead to hypoxemia. The patient may also develop
dysrhythmias and cardiopulmonary arrest may occur.
Patients are particularly at risk for cardiac dysrhythmias during the warming phase of treatment.
GENERAL GUIDELINE FOR CARE:
Localized cold injury:
1. Follow BLS Guidelines.
2. Generalized Hypothermia:
3. Avoid rough handling or excessive movement
4. Remove patient from cold environment
5. Protect C-spine as necessary
6. Remove all wet clothing
7. Protect from further heat loss
8. Monitor cardiac rhythm
9. High flow oxygen
PARAMEDIC PROTOCOL
32
MODERATE HYPOTHERMIA
CLINICAL may include: Conscious, but often lethargic
Often shivering, skin pale and cold to touch
1. Follow General Hypothermic Care Guidelines

2. Hot packs wrapped in a towel may be applied to axillae, groin, abdomen
3. DO NOT DELAY TRANSPORT
4. Establish an IV Normal Saline (warmed) en route
5. Check blood glucose level with IV start
6.
7.
8.
9.

Dextrose 25 GMs IVP
Narcan 0.4-2.0mg IVP
PARAMEDIC PROTOCOL
33
SEVERE HYPOTHERMIA
CLINICAL may include: Unconscious or stuporous
Skin ice cold
Heart sounds inaudible; BP unobtainable
or severe hypotension; Pupils unreactive
Very slow or absent respirations
HANDLE VERY GENTLY: HEART MORE SUSCEPTIBLE TO FIBRILLATION

1. Maintain the airway
2. Administer humidified oxygen at 100%
3.
4.
5.
6.
Assist ventilations if respiratory rate is less than 5/minute,

but do not hyperventilate; keep rate of artificial
ventilations around 10/minute consider intubation
Normal Saline IV bolus (200-500ml) warmed if possible
7. Cardiac monitor
8. If CPR is required refer to Hypothermic Arrest Protocol
9. Transport the patient supine in a 10 head-down tilt
10.
11.
12.
13.

Dextrose 25 GMs IVP
Narcan 0.4-2.0mg IVP
Avoid:
1.
2.
3.
4.
Hyperventilation because an extreme drop in CO2 may cause ventricular fibrillation.

Rubbing the skin.
Rewarming frostbitten extremities until after the core is rewarmed to prevent vascular
complications to the limb and the transportation of cold blood and detrimental by
-products to the core.
All unnecessary rough movements as they may precipitate arrhythmia.
PARAMEDIC PROTOCOL
34
HYPOTHERMIC ARREST
A.
If spontaneous pulse and respirations are present or respirations are absent:

1.
2.
3.
B.
If pulse is absent and EKG monitor shows ventricular fibrillation/tachycardia:

1.
2.
3.
4.
5.
C.
Remove all wet clothing unless frozen to the skin.

Cover patient with blanket(s)-DO NOT ATTEMPT ACTIVE EXTERNAL
REWARMING.
If respirations are absent intubate and ventilate at 10/minute.
Defibrillate at 200 joules.

If no conversion, initiate CPR (deliver 40-50 compressions per minute).
Establish Medical Control for consideration of any further orders.
If no conversion, defibrillate at 300 joules.
If no conversion, defibrillate at 360 joules.
If pulse is absent:
1.
2.
3.
Initiate CPR (deliver 40-50 compressions/minute).

Establish Medical Control for consideration of any further orders.
Transport.
Do not administer medications unless directed to do so by Medical Control Physician.

Once you have started CPR - DO NOT GIVE UP !
THE HYPOTHERMIC PATIENT IS NOT DEAD UNTIL HE IS WARM AND DEAD !
NOTE: Severely hypothermic patients may be without detectable pulse, blood pressure, or respirations.
This may be physiologic for a hypothermic patient. Successful resuscitation with CNS complications has
been accomplished in patients with a core temperature less than 70F.
PARAMEDIC PROTOCOL
35
OVERDOSE/POISONINGS
SPECIAL INFORMATION
It is essential to obtain the following information on all drug overdoses and poisonings:
1.
2.
3.
4.
5.
Name and ingredients of the substance(s) taken.

The amount taken.
Approximate time substance was taken.
Method of substance abuse: ingestion, injection, inhalation, or topical transmission.
Look for the container(s) of substance ingested and if appropriate transport with
patient.
6. Reason for the ingestion: e.g., suicide, accidental overdose, or mixture of
incompatible substances.
7. Vomiting prior to arrival.
At the earliest convenience contact Poison Control directly or through Medical Control
Altered Level of Consciousness
1. Routine ALS Care
2. Establish and maintain airway
3. Support ventilations as needed
4. Oxygen as per protocol
5. Cardiac Monitor - Treat symptomatic rhythm according to protocol
6. Establish IV of Normal Saline
7. Fluid bolus if hypotensive
If a Narcotic Overdose is suspected see altered mental state-opiate protocol
8. If patient remains unresponsive:
9. Rapid glucose determination
10. Administer Dextrose 50% 25 Gm IV for glucose <100
a. Management specific for agent exposure
b. Additional Dextrose
Conscious Patient with oral ingestion - Overdose/Poison

PARAMEDIC PROTOCOL
36
12. Routine ALS Care

a. Activated Charcoal 30-50 Gms PO
Important: NEVER INDUCE VOMITING
OVERDOSE/POISONING
Inhalation or Topical Exposure of a Poisonous Substance
1. Evaluate the scene for safety consideration as a Hazmat Incident

2. Notify CMED as indicated
3. Follow BLS Hazmat Guidelines as indicated
4. Routine ALS Care
Specific exposure information for further treatment orders and specific arrival instructions
(e.g., use a specific hospital entrance)
PARAMEDIC PROTOCOL
37
SEIZURES
DESCRIPTION
There are many causes of seizures including, but not limited to trauma, epilepsy, hypoxemia, meningitis,
stroke, hypoglycemia, drug overdose, drug withdrawal or eclampsia.
Routine ALS Care: Initiate treatment based upon history and clinical presentation. It is important to
make the distinction between focal motor, general motor seizures, and status epilepticus. Not all seizures
require emergent intervention.
Types of Seizures:
General or Grand Mal Motor seizures are tonic and clonic movements that are usually followed by a
postictal state.
The components of a grand mal seizure include aura, loss of consciousness, tonic phase (extreme
muscular rigidity), clonic phase (rigidity and relaxation in rapid succession), postictal state altered level of
consciousness).
Partial or Focal Motor seizures usually involve unilateral motor activity, but may not cause changes in
consciousness. Partial seizures may progress to generalized seizures.
Psychomotor seizures consist of personality alterations, staring, or peculiar motor activity with periods of
bizarre behavior.
Status Epilepticus is present when (a) 2 or more general motor seizures without a lucid interval is
witnessed by EMS personnel or (b) there exists continuous seizure activity lasting for greater than 10
minutes.
PARAMEDIC PROTOCOL
38
SEIZURES
1. Routine ALS Care
CONSIDER: Trauma, Hypoglycemia, Overdose - Go to appropriate protocol
2. High flow oxygen
3. Protect the patient from personal injury
4. Establish an IV of Normal Saline @ KVO
5. Obtain blood glucose level and record
6. IF BLOOD GLUCOSE LEVEL IS LOW THEN ADMINISTER THE FOLLOWING:
a. Dextrose 50% 25 Gm IVP
b. Glucagon 1mg IM if IV access unavailable
a. Valium 2-5mg (0.03mg/kg) IVP (over 30 seconds) (or)
b. Versed 2-4mg IVP or IM (or)
c. Ativan 1-2mg (0.02mg/kg) IVP
PARAMEDIC PROTOCOL
39
SHOCK
DESCRIPTION
Shock is best defined as inadequate tissue perfusion at the cellular level. Common manifestations are
decreased level of consciousness, peripheral vasoconstriction, decreased urine output, diaphoresis and
decreased blood pressure.
Shock is frequently thought of as being divided into four types: (1) hypovolemic, (2) cardiogenic, (3)
vasogenic, and (4) anaphylactic. Hypovolemic shock means that there is insufficient blood or plasma in
the circulatory system to maintain adequate perfusion. Common causes are loss of blood (internal
bleeding, trauma, external bleeding) or loss of serum and plasma (burns, peritonitis). Cardiogenic shock
is due to the failure of the heart to pump effectively, as seen in serious myocardial infarctions. Vasogenic
shock means that the blood vessels are peripherally dilated and will not constrict appropriately to maintain
peripheral resistance and thereby maintain blood pressure. Common causes of vasogenic shock are sepsis
and so-called neurogenic shock, a type of vasodilation that occurs with spinal cord injury. Lastly,
anaphylaxis, an allergic reaction to an external antigen such as a bee sting or an ingested antigen such as a
drug (penicillin, etc.) can be viewed as a type of vasogenic shock. The reaction to the foreign antigen
releases histamine and other vasoactive chemicals in the body, which cause blood vessels to dilate and the
blood pressure to fall, resulting in shock.
PARAMEDIC PROTOCOL
40
HEMORRHAGIC/HYPOVOLEMIC/VASOGENIC SHOCK
1. Assess ABCs
2. Routine ALS Care
3. Control Obvious bleeding
5. Immediate and early transport of the patient
6. Establish large bore IV of Normal Saline
7. and titrate to a systolic BP > 100 mmHg
8. Establish second large bore IV line en route to the hospital
9. Continuously monitor and record vital signs
10. In trauma cases monitor Glasgow Coma Scale
CARDIOGENIC SHOCK
1. Assess ABCs
2. Routine ALS Care
4. Establish IV Normal Saline KVO
5. Treat any underlying arrhythmias as per protocol
a. Fluid Challenge of 300-500 ml
b. Dopamine 5 g/kg/min up to 20 g titrated to a systolic BP90 mmHg
Note: Lung sounds and respiratory status must be continuously monitored to avoid pulmonary
edema.
PARAMEDIC PROTOCOL
41
PAIN/ANXIETY RELIEF
The following medical control options may be utilized for the patient who has an isolated traumatic
extremity injury, painful paramedic initiated management (e.g. Transcutaneous Pacing), or psycho social
condition exhibiting extreme pain and/or anxiety, and who is hemodynamically stable.
This does not include the multiple trauma patient or a situation where multiple trauma may even
possibly apply.
1. Routine ALS Care
2. Morphine Sulfate 2 to 5mg IVP
a. Morphine Sulfate 2-5 mg IVP
b. Diazepam 2-5 mg IVP
c. Versed 2-4 mg IVP
d. Ativan 0.5-1.0 mg IVP
4. Repeat any of the above options as ordered
Paramedic Induced Pain / Painful Procedures

In the event of a painful procedure (i.e. Cardioversion and Transcutaneous Pacing) the paramedic may
administer:
OR
2. Diazepam 2-4mg IV
3. Versed 2mg IV
4. Ativan 0.5-1.0mg IV
Contact On-Line Medical Control
5. Possible Physician Orders:
a. Repeat any of the above treatment options
PARAMEDIC PROTOCOL
42
DYSTONIC REACTION
DESCRIPTION
This is an idiosyncratic reaction to a neuroleptic and antiemetic medication. It frequently involves acute
onset of involuntary muscle spasm, which is painful and uncontrollable, possibly leading to respiratory
compromise. Spasms of the neck muscles and the face are common presentations. There is also
commonly difficulty with speech, swallowing, and breathing. Individuals may have ingested these
medications unknowingly, especially having purchased them on the street or given by family as a
sleeping pill. Clinically dystonia can give the appearance of anxiety reactions, tetanus, strychnine
toxicity, or atypical seizures.
Management
1. Routine ALS Care
2. Benadryl 25-50 mg IVP or IM
PARAMEDIC PROTOCOL
43
Paramedic Protocols
Adult
Trauma Protocols
>13 years Old
PARAMEDIC PROTOCOL
44
Specific Thoracic Injuries

Flail Chest: When several ribs or the sternum (or both) are fractured in more than one place a
segment of the chest wall will lose integrity. The flail chest segment may collapse during
inspiration and expand during expiration (paradoxical movement).
Pneumothorax: Presence of air in the pleural space, causing partial or complete lung collapse.
Hemothorax: Presence of blood in the pleural space.
Tension Pneumothorax: Results from air leaking into the pleural space (through an injury in the
lung or chest wall) that cannot escape.. This leads to shift of the mediastinum (tracheal shift may
be noticed) away from the injured side and an inhibition of the venous return to the right side of
the heart.
Sucking Chest Wound or Open Pneumothorax: Results from air being drawn into the pleural
space from an open chest wound by negative pressure during inhalation.
Myocardial Contusion: Bruising of the myocardium which may produce dysrhythmias.
Cardiac Tamponade: Accumulation of blood in the pericardial sac. It may be produced by blunt
or penetrating trauma. This accumulation may be sufficient enough to produce inadequate cardiac
filling, poor cardiac output, muffled heart sounds, decreased systolic blood pressure, distended
neck veins, and respiratory distress. Another result may be pulses paradoxus which is a drop in
the systolic blood pressure or more than 10-20 mmHg during inspiration.
Laceration or Rupture of the Aorta: The aorta is particularly susceptible to laceration or even
transection as a result of a deceleration impact or compression of the chest. The most common
location for rupture is the aortic isthmus, which is close to the ligamentum arteriosum and the
origin or the subclavian artery.
PARAMEDIC PROTOCOL
45
INJURED PATIENT TRIAGE PROTOCOL*

When transport to a Level I or II Trauma facility is indicated, but the ground transport time to that hospital is judged
to be greater than twenty (20) minutes, determination of destination hospital shall be in accordance with medical
control.
Measure vital signs and level of consciousness:
Glasgow Coma Scale
12 or less
Systolic blood pressure
<90, or
Respiratory rate
<10 or >29
If Yes
If No
Assess anatomy of injury
1. Gunshot wound to chest, head, neck, abdomen or groin
2. Third degree burns >15% BSA or third degree burns of
face or airway involvement
3. Evidence of spinal cord injury
4. Amputation other than digits
5. Two or more obvious proximal long bone fractures
Take to Level I or II
Trauma Facility
If Yes
If No
Assess mechanism of injury and other factors
1. Mechanism of injury:
a. Falls >20 feet
b. Apparent high speed impact
c. Ejection of patient from vehicle
d. Death of same car occupant
e. Pedestrian hit by car >20MPH
f. Rollover
g. Significant vehicle deformity-especially steering wheel
2. Other factors:
a. Age<5 or >55
b. Known cardiac disease or respiratory distress
c. Penetrating injury to thorax, abdomen, neck or groin
other than gunshot wounds
Trauma Facility
If Yes
If No
Call Medical Control for direction
Evaluate as per usual protocols
Severely injured patients<13 years should be taken to a Level I or II facility with pediatric resources including
pediatric ICU.
All EMS providers transporting trauma patients to hospitals shall provide receiving hospital with a complete OEMS
approved patient care form prior to departing from the hospital.
WHEN IN DOUBT, CONSULT WITH MEDICAL CONTROL

*State of Connecticut Regulation of Department of Public Health and Addiction Services Concerning Statewide
Trauma System: Sections 19a-177-5.
PARAMEDIC PROTOCOL
46
INITIAL ASSESSMENT AND MANAGEMENT OF THE TRAUMA PATIENT

I.
PRIMARY SURVEY
A.
Airway and Cervical Spine Control

1.
Maintain in-line cervical immobilization
2.
Manual
a. Chin Lift
b. Jaw Thrust
3.
Mechanical
a. Suction
b. Oropharyngeal Airway
c. Nasopharyngeal Airway
d. Pocket Mask
e. Orotracheal tube with in-line immobilization
f. Nasotracheal tube with in-line immobilization
g. Transtracheal Airway with in-line immobilization
Hypoxia is common in the trauma patient and correcting it is of the highest priority. A spinal injury may
be present and the airway should be managed as if C-spine instability exists. Concern about a spinal
injury must not delay institution of adequate ventilation and oxygenation. The neck should be
maintained in a neutral position. If an endotracheal tube is required, neutral stabilization of the spine
must be maintained throughout its insertion, so that the mandible and tongue are moved forward and the
head is not tilted backwards.
B.
Breathing
1.
Ventilation
a. Mouth to mask
b. Bag-valve-mask
2.
Flail Chest
a. Airway management
3.
Open Pneumothorax
a. Partially occlusive dressing (3-sided)
b. Assist ventilations as needed with supplemental O2
4.
Tension Pneumothorax
a. Decompression
i. Large bore needle with plastic catheter (angiocath)
ii. Second intercostal space (ICS) in Midclavicular Line, superior
aspect of the Third Rib
iii. Fifth ICS in Midaxillary Line
PARAMEDIC PROTOCOL
47
TRAUMA PATIENT CONT

C.
Circulation and Bleeding Control

1.
Evaluation
a. Pulse
i. Rate
ii. Strength
iii. Location
b. Skin
i. Color
ii. Moisture
iii. Temperature
2.
Cardiac compressions as indicated
3.
Hemorrhage control
a. Direct pressure on wound and/or pack wound with sterile gauze
b. Pressure points (usually not required)
c. Tourniquet (seldom, if ever, indicated)
d. Traction splint
e. PASG (for unstable pelvic fracture with hypotension in the adult >13 yrs.)
Pale skin color and pulse characteristics are accurate parameters used in assessing the status of tissue
perfusion. Blood pressure is obtained later in the patients assessment. Hemorrhage control in the
primary survey is used only for massive bleeding. Minor bleeding takes a lesser priority. For patients
with an unstable femur fracture, application of a traction splint is the most important field technique for
control of this type of hemorrhage. Patients with open book pelvic fracture will benefit from
stabilization and direct pressure from the PASG.
D.
Disability
1.
Glasgow Coma Scale

a.
Eye Opening:
4 - spontaneous
3 - to voice
2 - to pain
1 - none
b.
Verbal response
5 - oriented
4 - confused
3 - inappropriate words
2 - incomprehensible words
1 - none
c.
Motor response
6 - obeys commands
5 - localizes pain
4 - withdrawal (pain)
3 - flexion (pain)
2 - extension (pain)
1 - none
PARAMEDIC PROTOCOL
48
TRAUMA PATIENT cont

E.
Exposure of the body for examination

It may be necessary to partially or completely expose the body to control hemorrhage
and perform lifesaving procedures. It is important to consider modesty and to respect
the individuals needs. Nothing should be done to delay transport of the critically
injured patient.
II.
RESUSCITATION
A.
Supplemental oxygen should be delivered @100% for all multisystem trauma patients.
B.
Volume replacement
1.
2.
Blood pressure should be monitored

a.
systolic/diastolic
b.
pulse pressure
Venous access
a.
peripheral IV
i.
Large bore catheters
ii.
Two sites preferred
b.
Fluid(s) Normal Saline
Excess time should not be spent in the field with multiple attempts to start an IV. Critically injured
patients should be placed as rapidly as possible in the ambulance and IVs started enroute to the hospital.
III.
SECONDARY SURVEY
A systematic evaluation of the patient beginning at the head and proceeding to the neck, thorax, abdomen,
and extremities should be completed. Unnecessary delay in order to carry out diagnostic procedures that
do not produce information concerning direct treatment in the pre-hospital phase should not be attempted.
Rapidly identify those patients who, because of the critical nature of their situation, require rapid transport
to an appropriate facility. These patients should be stabilized and transported immediately.
A.
Head
1.
2.
3.
Airway
a. reevaluate
b. correct problems
Open Wounds
a. control hemorrhage with direct pressure
b. apply clean dressings to all wounds
Eyes
a. protect from further injury
b. irrigate to remove contaminants and debris (Morgan Lens if
appropriate)
c. do not remove foreign bodies
PARAMEDIC PROTOCOL
49
TRAUMA PATIENT CONT

4.
Nose and ears

a. pre-hospital evaluation for fluid (blood, CSF)
b. treatment usually not required
Most injuries to the face and head require hospital treatment - therefore delay in evaluation other than
hemorrhage control is usually not necessary. Lacerations of the scalp may have a fracture beneath;
therefore, unnecessary pressure is to be avoided. Use only enough pressure to control hemorrhage.
Transportation to the hospital should not be delayed other than to correct life threatening airway
problems.
B.
Neck
1.
Spinal immobilization; indications

a. any blunt injury above the clavicle
b. unconscious patient
c. multiple trauma
d. high speed crash
e. neck pain
f. complaints of extremity numbness/tingling
g. gunshot wound involving the torso
2.
Wounds
a. leave foreign bodies in place, but stabilized
b. use direct pressure to control hemorrhage
Spinal immobilization should be accomplished without using the chin as a point of control. If the patient
vomits into a closed mouth, aspiration almost inevitably results. Studies have shown that the cervical
collar does not provide immobilization; therefore, a rigid cervical collar is used in conjunction with a long
or short backboard and other head immobilization devices. A patient should never be secured to a
backboard by the head alone. If such a patient became uncooperative, severe damage to the C-spine could
result.
Wounds of the neck should not be probed. Frequently a clot will have formed on the carotid artery or
jugular vein, which probing could dislodge, causing severe hemorrhage. Compression dressing should not
be tight enough to restrict blood flow to or from the brain and should not be circumferential.
C.
Thorax
1.
2.
Ventilation
a. Assure adequacy of ventilation
b. Reevaluate injuries identified and managed in the primary
survey
Myocardial contusion
a. EKG monitoring
b. Treat dysrhythmias according to ACLS
PARAMEDIC PROTOCOL
50
TRAUMA PATIENT cont

3.
Chest wall injuries

a. Simple isolated rib fractures, no pre-hospital management necessary
b. Flail chest
i. airway/ventilation management as necessary
c. Hemothorax
i.
fluid replacement to treat shock
ii.
ventilatory support as necessary
d. Open pneumothorax
i.
three-sided dressing
e. Tension pneumothorax
i.
needle decompression
f. Cardiac tamponade
i.
fluid bolus
With the exception of myocardial contusion and pericardial tamponade, most of the chest conditions that
result from trauma are either managed when identified during the primary survey or at the hospital. Chest
injuries are the second leading cause of death and disability and these patients need to have a high
transport priority as part of their treatment plan.
D.
Abdomen
1.
2.
3.
4.
Evisceration
a. Clean, moist dressing
Foreign body
a. Do not remove except by direct order of medical control
b. Stabilize foreign body to prevent further injury during transport
Intra-abdominal hemorrhage
a. Intravenous fluids
Pelvic fracture
a. Long backboard immobilization
b. Consider PASG stabilization
Prolonged evaluation of the abdomen for signs of an acute abdomen by checking for guarding, rebound
tenderness or bowel sounds requires extra delay and should be avoided. Most patients with intraabdominal injuries require hospitalization, evaluation, and treatment so delay to perform such diagnostic
techniques is not indicated.
E.
Extremities
1.
Examine for swelling and deformity
2.
Check for neurovascular function
3.
Apply direct pressure to control bleeding
4.
Splint-reassess neurovascular status after splinting
5.
Consider PASG for multiple lower extremity fractures
PARAMEDIC PROTOCOL
51
TRAUMA PATIENT cont

F.
Neurologic - Head, spinal cord, and peripheral nerve trauma

1.
Suspect associated C-spine injury and treat accordingly
2.
If GCS <9 consider intubation and ventilation to protect/manage airway
3.
Serial GCS determinations at least every 10 minutes
4.
Pupillary evaluation
a. Reactivity
b. Equality
c. Size
5.
Reassess motor and sensory function
6.
IV fluids should be restricted unless shock is present
7.
If shock is present, look for other causes of blood loss, as brain injury
alone is usually not the cause
IV.
TRANSPORTATION
It is impossible to fully stabilize the unstable patient in the pre-hospital setting. There must be a
balance of lifesaving skills (such as endotracheal intubation) with minimizing scene time (<10
minutes) and rapid transport in order to reduce the time from injury to definitive surgical
treatment.
Early trauma notification to the receiving hospital is essential to ensure the immediate
availability of an appropriate in-hospital response.
See Appendix C
*Committee on Trauma; American College of Surgeons; Resources for Optimal Care of the
Injured Patient.
PARAMEDIC PROTOCOL
52
DESCRIPTION OF BURNS
For prognostic and management reasons burns are classified in several different ways.
1.
Mechanism of burn: thermal, chemical, electrical or inhalation (e.g., smoke,
monoxide, chemicals).
2.
Depth of burn wound:

a. Superficial (1st degree) involvement of superficial layers of the skin, producing
redness and pain.
b. Partial thickness (2nd degree) penetration to deeper layers of the skin producing pain,
blistering, and edema.
c. Full thickness (3rd degree) involvement of all skin layers and can also involve
underlying muscle, bone, and/or other structures. Lack of pain is characteristic.
3.
Extent (size) of burn wound; this is expressed as percent of total body surface area and
can be calculated using the Rule of Nines. Palm rule (patients palm=1% TBSA).
4.
Location of burn wound: Burns of the face, neck, hands, feet, perineum, and
circumferential burns carry a higher risk of morbidity than burns of similar size in other
locations. Facial burns are often accompanied by upper airway edema; be prepared to
intubate this patient.
5.
For every patient suspected of carbon monoxide or other inhalation injury (particularly
in closed space environmental fires, presence of singed nasal hairs or carbonaceous
sputum), begin oxygen at highest possible flow rate.
carbon
BURN PATIENTS ARE OFTEN VICTIMS OF MULTIPLE TRAUMA. TREATMENT OF ALL

MAJOR TRAUMATIC INJURIES TAKES PRECEDENCE OVER BURN WOUND MANAGEMENT.
AT ALL TIMES PROTECT YOURSELF FROM EXPOSURE.
Note: Rule of Nines graphic is located in the appendix.
PARAMEDIC PROTOCOL
53
THERMAL BURNS
Evaluate the causative agent before initiating treatment. Stop the burning process by removal of the
patient from the source of exposure or eliminate the source as per guidelines noted below. Evaluate the
degree and estimate the BSA (Body Surface Area) of the burn injury.
1. STOP THE BURNING PROCESS
2. Routine ALS care
3. Airway/oxygen per protocol
4. Check for the presence of signed facial or nasal hair; hoarseness, wheezing, cough, stridor and
document.
5. Assess percentage of Total Body Surface Area Burned.
6. Establish IV Normal Saline (in area not affected by burn) run at 200ml/Hr. Titrate to SBP
7. Remove loose clothing and jewelry/constriction hazards.
8. Apply clean dry towels or sheets to area. If the burns are less than 10% and are superficial or
partial thickness you can moisten the towels or sheets with sterile normal saline for comfort.
9. Cardiac monitor
a. Morphine Sulfate IVP
b. Versed 2-4mg IV
c. IV Fluid rate for resuscitation
d. Intubation
11. Transport to appropriate facility
DO NOT BREAK BLISTERS INTENTIONALLY. DO NOT APPLY CREAMS, OINTMENTS OR

ANTIBIOTICS TO BURN. DO NOT REMOVE ANY LOOSE TISSUE OR SKIN.
PARAMEDIC PROTOCOL
54
CHEMICAL BURNS
Consider any chemical burn situation as a Hazmat situation.
If potential Hazmat situation exists, notify receiving hospital ASAP
Personal Safety
1. Identify the situation if possible (including the type and amount of chemical)
2. Upon receiving the patient consideration that they may still be contaminated is key.
3. Airway/oxygen as per protocol
4. Remove affected clothing (if not already done)
5. Again, try and obtain name of the chemical or its I.D.
6. Flush with copious amounts of water or saline unless contraindicated. Irrigate burns to the eyes
with a minimum of 1 liter of normal saline. Alkaline burns should receive continuous irrigation
throughout transport. Consider the Morgan Lens for eye irrigation, (see below).
7. IV Normal Saline TKO
8. Cardiac monitor
a. Morphine Sulfate IVP
b. Versed 2-4mg IV
*Phosphorus burns should not be irrigated, brush chemical off thoroughly.
*Hydrofluoric Acid burns - be aware of cardiac implications due to induced hypocalcemia and the
need for immediate contact with Medical Control.
PARAMEDIC PROTOCOL
55
OPHTHALMIC CHEMICAL BURNS

1. Immediate and continuous flushing of the affected eye is performed using Normal Saline. If
contact lenses are known to be in the patients eyes, an attempt should be made to remove them
and continue flushing.
2. Unless contraindicated instill 1 or 2 drops of ophthalmic anesthesia
3. Continuously flush while in route to the hospital
4. Place the Morgan Lens in the affected eye(s) when possible
Note: Morgan Lens is not indicated in patients under six (6) years or age, or uncooperative
patients.
5. Advise patients not to touch/rub their eye(s) after instillation of anesthesia drops.
ELECTRICAL BURNS
1. Without placing self at risk, remove patient from the source of electricity or have the power cut
off.
2. Routine ALS Care
3. Suspect spinal injury secondary to tetanic muscle contraction
4. airway/oxygen as per protocol
5. IV Normal Saline
6. Cardiac Monitor
7. Treat any cardiac rhythm disturbances per protocol
8. Treat any trauma secondary to electrical insult as per protocol
PARAMEDIC PROTOCOL
56
SPINAL CORD INJURY

1. Routine ALS Care
2. Airway/oxygen as per protocol
3. Proper assessment, evaluation, and packaging of patient to include:
4. Movement/sensation of all four extremities before and after packaging patient
5. Rigid cervical/extrication collar
6. Long backboard/full body vac-u-splint or other immobilization device as the situation dictates
7. Continually reassess patient for any changes
8. IV Normal Saline TKO

9. If the patient is hypotensive administer 250ml fluid bolus
PARAMEDIC PROTOCOL
57
Emergency Incident Rehabilitation Recommended Practices & Protocol

Section 1: Recommended Practices for Fire/EMS Agencies
NOTE: These recommendations are based primarily on the DRAFT (November 2002) NFPA
1584 document entitled Recommended practice on rehabilitation for members operating at
incident scene operations and training exercises, 2003 edition.
Responsibilities:
1. Incident Commander: Implementation of formal emergency incident rehabilitation (EIR) is at
the discretion of the Incident Commander (IC). The IC should consider the circumstances of each
incident, and make adequate provisions early in the incident for the rest and rehabilitation of all
members operating at the scene. These provisions may include: physical and mental rest; fluid
and food replenishment; relief from extreme climatic conditions and other environmental
parameters of the incident; and medical evaluation, treatment, and monitoring.
2. Rehab Officer: An EMT-B, EMT-I, EMT-P, or Sponsor Hospital Physician or Medical Advisor
should be assigned to the rehab area, and if appropriate may be designated by the IC as the Rehab
Officer (RO). If available and practical, it is preferred that ALS-level personnel and equipment be
present, as indicated in NFPA 1500. Rehab sector medical personnel and other assets should be
dedicated to support of firefighters and other operational emergency responders, and should be
assigned no other responsibilities. The RO will typically report to the IC, although he/she may
report to the Logistics Officer at larger-scale incidents.
3. Rehab Team: The Rehab Team should include sufficient personnel to perform rehab sector
functions for the maximum number of personnel anticipated to be in the Rehab Area at any given
time. Generally, a ratio of one Rehab Team member for every ten personnel on scene is
recommended. The team should include sufficient EMS personnel to perform medical monitoring
tasks, but may include non-EMS personnel also. BLS is the minimum level of care needed at the
Rehab Area; ALS is considered preferable.
4. Supervisors / Company Officers: All supervisors and company officers should maintain their
awareness of the condition of each member operating within their span of control, and ensure that
adequate steps are taken to provide for each members safety and health. The ICS structure
should be utilized to request relief and/or reassignment of fatigued crews.
5. Personnel: Any member who believes that his or her level of fatigue or exposure to heat or cold
is approaching a level that could affect his or her performance or the operation in which he or she
is involved should advise his or her supervisor or company officer. Personnel should also remain
aware of the health and safety of other members of the crew.
PARAMEDIC PROTOCOL
58
Establishing the Rehabilitation Sector

1. The IC should establish a Rehab Sector or Group when conditions indicate that rest and
rehabilitation is needed for personnel operating at an incident scene or training exercise. This
determination should be made based upon the anticipated duration of the operation, level of
physical exertion, and environmental conditions, including temperature, humidity, and wind-chill.
Guidelines to consider include:
a. Heat stress index >90 degrees Farenheit (see table)
b. Wind chill index <10 degrees Farenheit (see table)
c. Personnel have completed (or will complete) exertional work with second 30 min SCBA
cylinder
d. Personnel have utilized (or will utilize) SCBA for >45 minutes of exertional work
2. It is recommended that an EMS vehicle not otherwise involved in emergency operations at the
scene be posted at the Rehab Area. If required, an additional ambulance should be requested to
the scene for this purpose. Except under extreme circumstances, this ambulance should not be
used for transport of civilian patients.
3. The location of the Rehab Area will be designated by the IC and/or the RO, and should:
a. Be far enough from the scene to allow personnel to safely remove (and leave outside the
area) SCBA and turnout gear, and remove personnel from the urgency of the scene, yet
close enough to allow prompt re-entry into the operation on completion of rehab.
b. Provide adequate protection from environmental conditions and exhaust fumes
c. Be easily accessible by EMS units
d. Be large enough to accommodate several crews
e. For extreme heat conditions, have shaded areas, misting systems and/or fans, and an area
to sit down
f. For extreme cold and/or wet conditions, have dry protected areas, heated areas, and dry
clothing
g. Be integrated with departmental system for personnel accountability, utilizing a single
entry and exit point when feasible.
Examples of sites that have been utilized include a nearby building, garage, or lobby; a school bus
or large van; or an open, shaded area. See attached example sketch of a typical rehab and
treatment area.
Rehab Operations
1. Resources: The RO should secure, through the IC or Logistics Officer, all necessary resources
to properly supply the sector. These may include oral fluids, foods, medical supplies, paperwork,
lighting, heaters, fans, a means of access to toilet facilities, and other assets as appropriate to the
incident.
2. Rotation of Personnel/Accountability: Companies and units will be assigned to the Rehab
Sector by the IC, or his/her designee e.g. Operations Officer. Whenever possible, the entire
company or unit should be assigned to the Rehab Sector as a group. The crew designation, names
PARAMEDIC PROTOCOL
59
of members, times of entry and exit, and appropriate medical information should be documented
by the Rehab Officer or designee on the EIR form (see attached) or similar document. Personnel
rotated to the Rehab Sector shall not leave until directed by the RO. If any member requires
transport to a medical facility, the IC shall be notified immediately.
3. Hydration: During exertional activity, in both hot and cold weather, personnel should consume
at least one quart per hour of water, activity beverage, or combination. Carbonated and
caffeinated beverages should be avoided. During a typical 20-minute rehab cycle, 12 to 32 oz of
fluids are recommended.
4. Nutrition: Food should be provided whenever operations exceed three hours. Fatty and salty
foods should be avoided.
Section 2: Protocol for EMS personnel operating in the rehab sector
Medical Evaluation
1. EMS personnel shall ask members arriving at the Rehab Area if they have any symptoms of
dehydration, heat/cold stress, physical exhaustion, cardiopulmonary abnormalities, or
emotional/mental stress. EMS personnel shall complete a medical evaluation, and appropriate
treatment and/or transport, for all members who report such symptoms.
2. A medical evaluation, with appropriate treatment and/or transport, shall also be completed for
any member meeting any of the following criteria:
a. The RO or Rehab Sector EMS staff observe evidence of one of the above conditions
displayed by a member
b. Another member, officer, or supervisor indicates he/she does not appear well.
c. The member had to leave an evolution for reasons of excessive fatigue or symptoms
3. Medical Treatment: Standard treatment and/or transport shall be provided in accordance with
regular CHH protocols.
4. When treating a member with signs or symptoms of dehydration or fatigue (such as vomiting
without evidence of toxic exposure or climate conditions producing multiple cases of mild heat
stress), with absence of chest pain, change in mental status, or other indicators of a medical
condition requiring emergent care, a paramedic or Sponsor Hospital Physician or Medical Advisor
working in the Rehab Sector may elect to perform a trial of intravenous rehydration if the
following resources are available:
a. 12-lead ECG, with appropriate interpretation training
b. Tympanic thermometer, with appropriate training
The member may be considered a candidate for non-transport if, following the intravenous
infusion of at least one liter of crystalloid, he/she has all of the following:
a. Complete resolution of symptoms
b. Vitals signs within the following ranges
1) Systolic blood pressure >90 and <200 mmHg
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60
2) Pulse rate >50 and <100 beats per minute

3) Respirations >12 and <24 per minute
4) Temperature < 100.5 F
Even if the member is not transported to the hospital, he/she may not return to active duty for the
duration of that duty cycle or 24 hours, whichever is longer. If the members condition does not
improve, or worsens at any time during the trial of rehydration, the member shall be transported to
the hospital.
PARAMEDIC PROTOCOL
61
Paramedic Protocols
OB/Gyn Protocols
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62
COMPLICATIONS OF PREGNANCY
ANTEPARTUM HEMORRHAGE
Placenta Previa - placenta overlying the cervix.
Abruptio Placenta - separation of the placenta from the uterine wall, often but not
necessarily associated with abdominal pain.
Uterine Rupture - sudden severe abdominal pain and shock.
DO NOT DELAY - TRANSPORT IMMEDIATELY TO THE HOSPITAL
2. Use a wedge to tilt patient to the left to move fetus off Inferior Vena Cave
3. IV Normal Saline wide open - titrate SBP >100
4. Keep patient warm
5. Elevate lower extremities
*Remember - Rapid Transport MUST be initiated anytime bright red vaginal bleeding is
present
Note: To quantitate bleeding use a pad count on any type of vaginal bleeding.
PARAMEDIC PROTOCOL
63
PREGNANCY INDUCED HYPERTENSION AND SEIZURES

(ECLAMPSIA / TOXEMIA)
Assess patient, careful consideration should be paid to the CNS and Cardiorespiratory function.
Verify by either history or observation the presence of tonic/clonic activity. Determine the
gestational age of the fetus (will be 2nd or 3rd trimester and pregnancy should be apparent) and
previous history of pregnancy induced hypertension.
1. Routine ALS Care

2. If hypoglycemia or drug overdose induced status epilepticus is suspected, treat according
to appropriate protocol.
Magnesium Sulfate 4 Gms in 20 ml normal saline Slow IVP (over 5 minutes)
Follow with infusion of Magnesium Sulfate @ 1 - 2 Gms/Hour
Valium 5 - 10 mg Slow IVP (or)
Versed 2 - 4 mg IVP or IM
Ativan 0.5 1.0 mg IVP
Be alert for respiratory depression, if this occurs, stop medication, support respiration, and
contact medical control !
If seizures recur or do not subside, contact medical control for repeat of above.
PARAMEDIC PROTOCOL
64
OBSTETRIC EMERGENCIES
Although a number of medical emergencies may arise as a result of pregnancy, prehospital
intervention is often limited.
Emergencies which may arise include: Imminent Birth, Spontaneous Abortion, Vaginal Bleeding,
Breech Presentation Birth, Prolapsed Umbilical Cord, Limb Presentation Birth, Antepartum
Hemorrhage, Postpartum Hemorrhage, and Eclampsia.
Necessary Information to Determine Pre-delivery:

1. Due Date (EDC) or suspected length of pregnancy
2. Gravida=number of pregnancies; Para=number of live births
3. Expected multiple births
4. Membranes ruptured (time / color / odor)
5. Last Menstrual Period (LMP)
6. Prenatal Care
7. Signs of imminent delivery
a. Crowning
b. Urge to push (need to move bowels)
c. Time between contractions
8. Pertinent medical history
9. Current medications
10. Unusual complications (eclampsia)
Necessary Information to Determine Post-Delivery:

1.
2.
3.
4.
5.
6.
Time of delivery
Whether or not there was a cord around the neck
Note appearance of amniotic fluid (clear, green, brown, blood streaked)
Time placenta was delivered and condition
APGAR Score(s) One minute and Five minute
Any infant resuscitation and the infants response must be documented on the infants
PCR (Run Form)
Do not perform an internal or digital vaginal examination.
PARAMEDIC PROTOCOL
65
EMERGENCY CHILDBIRTH
1. Routine ALS Care
3. Establish IV Normal Saline at KVO rate
No Crowning or urge to push
Crowning or urge to push
Transport and re-evaluate every 2-3 minutes
Prepare for childbirth
Imminent Delivery
1. Control delivery with the palm of the hand so the infant does not explode out of the
birth canal. Support the infants head as it emerges and support perineum with gentle hand
pressure.
2. Support and encourage the mother to control the urge to push.
3. Tear the amniotic membrane, if it is still intact and visible outside the vagina.
4. Check for cord around the neck.
5. Gently suction mouth and nose (with bulb syringe) of infant as soon as head is
delivered.
a. Note the presence or absence of meconium staining. If meconium is present in the
airway suction extremely well. If necessary intubate and suction airway for thick
meconium. When possible use a meconium aspirator.
6. As shoulders emerge, guide head and neck slightly downward to deliver anterior shoulder,
then the posterior shoulder.
7. The rest of the infant should deliver with passive participation. Get a firm hold on the
baby.
8. Repeat gentle suctioning then proceed to postpartum care of infant and mother.
9. Dry and keep infant warm. If possible skin to skin contact with the mother while covering
the infant with a blanket provides a good warming source.
10. Establish date and time of birth and record, do APGAR at 1 and 5 minutes.
PARAMEDIC PROTOCOL
66
DELIVERY COMPLICATIONS
Nuchal Cord
(cord around babys neck)
1. Slip two fingers around the cord and lift over babys head.
2. If unsuccessful: Double clamp cord, cut cord between clamps with sterile scissors (blunt side next
to baby, never use a scalpel) allow cord to release from babys neck.
3. Continue with normal delivery protocol.
Prolapsed Cord
(cord presenting before the baby)
1. Elevate mothers hips in knee-chest position or left side down in Trendelenberg position.
2. Protect cord from being compressed by placing a sterile gloved hand in vagina and pushing up
firmly on the presenting part of the fetus.
3. Palpate cord for pulsation
4. Keep exposed cord moist and warm.
5. Keep hand in position and transport immediately to approved OB facility.
6. Do not remove hand until relieved by OB personnel.
Breech Birth
(legs or buttocks presenting first)
1. Never attempt to pull baby from the vagina by the legs or trunk.
2. After shoulders are delivered, gently elevate the trunk and legs to aid in delivery of head (if face
down)*
3. Head should deliver in 30 seconds* if not, reach 2 fingers into the vagina to locate the babys
mouth. Fingers in mouth will flex babys head and should assist in spontaneous delivery. If not:
Press vaginal wall away from the babys mouth to create an airway. If head does not deliver in 2
minutes, keep your hand in position and transport ASAP.
ESTABLISH MEDICAL CONTROL
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67
DELIVERY COMPLICATIONS
cont
Extremity Presentation
1. Proceed immediately to the hospital
1. Do not attempt out of hospital delivery
2. Encourage mother to perform slow deep breathing
Post Partum Hemorrhage

May be due to placental fragments not being delivered
1. Routine ALS Care
2. Massage the Fundus
3. Put the infant to breast
4. STAT Transport
a. Methergine 0.2mg IM
Postpartum Care of the Mother
1. Placenta should deliver within a few minutes to up to 30 minutes. DO NOT pull on cord to
facilitate placental delivery. If delivered bring the placenta to the hospital, do not delay on scene
waiting for the placenta to deliver.
2. If the perineum is torn and bleeding, apply direct pressure with trauma dressing to outside of
vagina only. DO NOT PACK VAGINA.
3. Observe for excessive bleeding. Titrate IV to maintain SBP >100 mm Hg.
PARAMEDIC PROTOCOL
68
POST PARTUM CARE OF THE INFANT

1.
2.
3.
4.
Note time and date of delivery.

Dry the infant immediately and keep warm.
Continue gentle bulb suctioning of the mouth and nose.
Stimulate baby by rubbing its back or flicking the soles of its feet, this should be enough to
stimulate the baby to begin crying and breathing.
5. *Spontaneous respirations should begin within 30 seconds after stimulation. If not, begin
artificial ventilations at 30 - 40 breaths/minute with infant B-V-M. Watch for chest rise. If no
pulse, or pulse< 80 bpm, begin CPR and follow appropriate Cardiac Algorithm (PALS).

6. If baby is cyanotic but breathing spontaneously, place an pediatric face mask approximately 4
inches from the babys face and run oxygen at 15 l/min. until color improves. Gentle suctioning
as needed.

(if not already done so)
7. Obtain 1 minute APGAR score
8. Clamp cord 6 to 8 from infants body. Cut cord with sterile scissors (blunt side next to infant)
between clamps. Clamping of cord is not critical, and does not need to be done immediately, but
keep the infant level with mom if cord is not clamped. This will prevent infant CHF (blood from
mom to baby) or infant anemia (blood from baby to mom).
9. If there is any bleeding from the cord clamp, reclamp again in close proximity to the leaking
clamp.
10. Allow mother to hold baby next to her if her condition does not contradict this. Wrap both baby
and mother together in blanket to diminish heat loss.
11. Obtain 5 minute APGAR score
*If meconium is present, perform deep aggressive tracheal suctioning until airway is clear before
stimulation of infant.
PARAMEDIC PROTOCOL
69
NEONATAL RESUSCITATION
1) Routine ALS Level Care.
2) Transport Immediately.
3) Position infant on his/her back with head down. Check for meconium. Suction mouth and
nose with bulb syringe. If thick meconium, aggressively suction until clear using ET tube
IMMEDIATELY FOLLOWING BIRTH. When possible use a meconium aspirator.
4) Dry infant and keep warm.
5) Stimulate infant by rubbing his/her back or flicking the soles of the feet.
6) If the infant shows decreased LOC, mottling or cyanosis, and/or presents with a heart rate
below 100 beats per minute:
a) Reassess effectiveness of:
b) Drying
c) Suctioning
d) Stimulation
e) Temperature
f) Airway and Ventilation
g) If the infant still shows little or no response:
h) If spontaneous respiration is <40 assist with B-V-M ventilations.
i) If pulse is <80 assist by performing chest compressions until responsive.
7) IV/IO access
8) 10-20 ml/kg Normal saline bolus
9) Epinephrine 0.01 mg/kg (1:10,000) IV/IO; 0.1 mg/kg (1:1,000) ET
10) Consider maternal condition including medications - Narcan 0.1 mg/kg IM/IV/IO/ET
11) Obtain blood glucose level
12) Possible Physician orders:
a) Repeat Epinephrine, Narcan
b) Dextrose 5% 5-10 ml/kg over 20 minutes
PARAMEDIC PROTOCOL
70
TRAUMA IN PREGNANCY
The most common cause of fetal death is maternal death.
1) Rapidly assess fetal viability - is uterus (fundus) above (viable) or below the umbilicus (non-viable
fetus).
2) Fetus may be in jeopardy while mothers vital signs appear stable.
3) Treat mother aggressively for injuries based on mechanism of injury.
4) Follow Trauma Protocol with the following considerations.
5) Oxygen per protocol
6) Check externally for uterine contractions.
7) Check externally for vaginal bleeding and amniotic fluid leak (Broken water).
8) If patient becomes hypotensive while supine on blackboard elevate right side of backboard (to relieve
pressure on the inferior Vena Cava by uterus).
9) Early and rapid transport is essential
PARAMEDIC PROTOCOL
71
Paramedic Protocols
Pediatric Medical
Protocols
PARAMEDIC PROTOCOL
72
PEDIATRIC INITIAL ASSESSMENT

An organized pediatric assessment is imperative for the delivery of good medical care. The initial
assessment of a pediatric patient should include: Appearance, the work of breathing, and circulation to the
skin. Often times this can be done prior to actual hands on contact with the patient. Rapid assessment
is essential to determine the urgency for treatment and transport.
Points to consider with any ill child are: what are the symptoms, when did they begin, and how long have
they lasted.
Pediatric patients will compensate their respiratory or shock deficiencies. Once the pediatric
patient is unable to compensate, cardiopulmonary failure/arrest will follow.
He outcome of cardiac arrest in pediatric patients is poor, so prevention by early recognition and
treatment etiologies, whether respiratory or shock is essential. Rapid assessment of pediatric ABCs
would be synonymous with the following:
1.
2.
Airway = Ventilation
Clear
No airway assistance needed
Maintainable
Head positioning
Suctioning
Supplemental oxygen
Unmaintainable
B-V-M
Intubation only for patients who cannot be adequately
ventilated with B-V-M
Breathing = Oxygenation
Observe
Expose
Auscultate
3.
Facial expression, nasal flaring, neck muscle usage

Chest to observe effort, rate, and effectiveness
Effectiveness of ventilation
Circulation = Perfusion
Place patient in the supine position with feet at or equal to the level of the heart
and assess the following:
A. Pulses Palpate femoral and pedal pulses and
note quality and rate
B. Capillary refill Normal is less than 3 seconds
C. Note level of consciousness Alert
Failure to recognize parents
Failure to respond to pain
PARAMEDIC PROTOCOL
73
PEDIATRIC ASSESSMENT cont

A global deficit in oxygenation, ventilation or perfusion may result in bradycardia, a change to an
ineffective respiratory pattern, and/or change in neuro status. Remember - taking the work of
breathing away from a decompensated pediatric patient by assisting each breath with 100% oxygen
via a bag-valve-mask will result in turning that patient into a compensated patient for a while
longer.
Vital signs of a pediatric patient should be consistent with the ABCs of initial assessment. The blood
pressure of a pediatric patient is a poor indicator for the perfusion status. The blood pressure will be well
maintained during the compensatory phase and will not decrease until the child is in the decompensated
phase. Therefore, a low blood pressure is a late sign of hypoprofusion.
Lower Limits of Normal Systolic Blood Pressure

Age
0 to 1 month
1 month to 1 year
> 1 year
Pressure
> 60mm Hg
> 70mm Hg
> 70 + (2x age in years) mm Hg
Normal Heart Rates for Age

Age
0 to 1 month
1 month to 1 year
1 year to 3 years
3 to 5 years
5 to 10 years
>10 years
Rate
120-160
120-140
100-140
100-120
80-100
60-100
It is the standard of care that one should employ the use of a Pediatric Resuscitation Tape which
by measurement of the length of the child determine the childs weight, appropriate emergency
equipment, and medication doses. This is more accurate, efficient, and safer than attempting to
estimate and calculate these values. Document use of the tape on the Patient Care Record (PCR).
PARAMEDIC PROTOCOL
74
PEDIATRIC PATIENT ASSESSMENT

Evaluate Airway
Not Patent
Patent
Follow Pediatric Airway Algorithm
Evaluate Breathing and Circulation
(see page )
No Problem
Continue Transport
Reassess as necessary
Problem with Either
BVM with 100% O2
Problem Corrected
Problem with Circulation

Establish IV/IO and administer 20ml/kg Normal Saline
Reassess
May repeat fluid infusion X 1
PARAMEDIC PROTOCOL
75
PEDIATRIC AIRWAY ALGORITHM

Assess Patient
Clear no assistance needed

Transport and reassess
Maintainable
Position Head
Suction
Supplemental O2
Unmaintainable
Factors Favoring B-V-M
Factors Favoring Intubation
Unresponsive
Absent gag reflex
Combativeness
Long extrication or transport times
Strong gag reflex
Presence of trismus (spasm of jaw muscle)
Short on-scene and transport times
Inability to ventilate with BVM

Limited personnel available to assist
during transport

Possible Physician Order:
Needle Cricothyroidotomy
PARAMEDIC PROTOCOL
76
GENERAL GUIDELINES for PEDIATRIC RESPIRATORY DISTRESS

Respiratory distress can be a life-threatening emergency. It may require immediate assessment
and management. Although the etiology of respiratory distress in the pediatric patient may vary,
the clinical manifestations are similar. The smaller tracheal diameter contributes to an easily
compromised airway. Respiratory distress may occur as a result of upper airway obstruction
(croup, foreign body, epiglottitis, congenital anomalies, edema, and allergic reactions) or from
lower respiratory airway obstruction (asthma, pneumonia).
Rapid assessment is essential. Do this by checking the patency of the airway: properly position
the airway, provide positive pressure ventilation using a B-V-M with 100% oxygen. Immediately
institute ventilatory support in severe respiratory distress or failure. Endotracheal intubation is
indicated only if there is an inability to secure a patent airway and ventilate the patient
adequately by B-V-M. Most children can be managed with B-V-M ventilation. Base the
decision to intubate on the response to limited ventilatory support and the distance from the
destination hospital.
Upper Airway Obstruction
Stridor and hoarseness are signs of upper airway distress. Croup and foreign body aspirations are
the most frequent causes. Rarely, epiglottitis may occur. Epiglottitis usually occurs in a two to
six year old child. The onset is usually abrupt and is associated with stridor, severe dysphagia,
high fever, and a toxic appearance. Epiglottitis also can occur in an infant or an adolescent.
Croup (laryngotracheal bronchitis) usually occurs in the infant or toddler. Its onset is more
gradual and is associated with low-grade fever, a barking cough, rapid respiratory rate, and
stridor. Foreign-body obstruction may present as stridor, dysphagia or respiratory arrest.
Lower Airway Obstruction
Wheezing is the hallmark of lower airway obstruction. Decreased, unequal or absent breath
sounds also can occur. The respiratory rate is generally rapid (although when expiration becomes
prolonged, the rate may fall, an ominous sign). Bronchiolitis, asthma, and foreign-body
obstruction should be considered.
Respiratory distress patients regardless of etiology, follow these general guidelines and see
other protocols as appropriate.
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77
PEDIATRIC RESPIRATORY DISTRESS

1) Initial Assessment
2) Determine the appropriate weight of the patient
a) if more than 50 kg (110 pounds), treat as an adult.
b) (Use pediatric resuscitation tape if weight unavailable)
3) Ensure patency of airway
4) Assess respiratory rate and effort
5) If airway is obstructed follow Obstructed Airway Protocol
6) (see page 73)
7) Assess for sign of respiratory distress

a) Use of accessory muscles, stridor, retractions, nasal flaring or noisy respirations
8) Administer oxygen in the least irritating manner possible
9) Allow the child to assume the most comfortable position for themselves as practical and safe
during transport
10) See protocols for Croup/Epiglottitis or Asthma if indicated
11) If patient requires ventilatory assistance, remember:

a) DO NOT OVER EXTEND NECK
b) Ventilate with a B-V-M first
12)
Follow airway algorithm (see page 68)
13) Early transporting of the pediatric patient is critical

PARAMEDIC PROTOCOL
78
PEDIATRIC ASTHMA
1) General Pediatric Respiratory Distress Guidelines
2) In all patients six (6) months of age or older with asthma or wheezing:
3) Albuterol nebulizer treatment: 2.5mg (0.5cc) in 1.5ml Normal saline at 6 L/min O2
a) May repeat X 1
If patient is under six (6) months of age:
Albuterol 1.25mg (0.25cc) in 2ml Normal saline at 6 L/min O2
May repeat X 1

4) Possible Physician Orders:
a) Establish IV Normal saline - administer Bolus
b) Repeat Nebulizer treatment
c) Epinephrine 0.01 ml/kg/dose Sub-Q (1:1,000)
Endotracheal Intubation should be avoided if possible
SUSPECTED CROUP or EPIGLOTTITIS

Obtain history and assess respiratory status to include:
presence of stridor
respiratory rate and effort
drooling or mouth breathing
degree of cyanosis
increased skin temperature
DO NOT LOOK IN THE MOUTH !!!
IMPORTANT KEEP PATIENT CALM AND UPRIGHT
Allow child to achieve position of comfort
PARAMEDIC PROTOCOL
79
SUSPECTED CROUP or EPIGLOTTITIS
Cont
If respiratory status warrants, attempt to administer humidified 100% oxygen via mask held by
mother or significant other 4 inches in front of childs face, but ONLY if well tolerated by child.
1) DO NOT ATTEMPT TO ESTABLISH AN IV
2) Transport ASAP
a) Nebulized Epinephrine (4.5ml of 1:1,000) if trying to achieve racemic epinephrine effect)
in 2.5-3ml NS for updraft
IF RESPIRATORY ARREST OCCURS FROM OBSTRUCTION
4) Rapid initial transport is imperative
5) Attempt ventilation with pediatric B-V-M
6) ?If ineffective, may use adult B-V-M?
7) If still ineffective, endotracheal intubation may be indicated
NOTE: In an unconscious patient, if there is strong suspicion for epiglottitis and if the patient is
unable to be ventilated with a B-V-M and if an enlarged epiglottis is visualized, ONE attempt at
intubation is allowed if the airway is able to be visualized.
Consider using a smaller size tube than you normally would.
8) If unsuccessful
9) Needle Cricothyrotomy if under 8 years of age
PARAMEDIC PROTOCOL
80
PEDIATRIC OBSTRUCTED AIRWAY

1) If patient can breath, cough, cry or speak (color pale or pale-pink):
2) Routine BLS medical care and general pediatric respiratory distress protocol.
3) Oxygen 100% by face mask held adjacent to face
4) Transport with parent, keeping child warm
5) If patient is conscious, but totally obstructed perform BLS airway clearing maneuvers
appropriate to age
6) If patient is unconscious or unable to ventilate and/or cyanotic with no air exchange:
7) Perform BLS airway clearing maneuvers appropriate to age
8) ALS Intervention - Open airway, attempt direct visualization with laryngoscope, and attempt
removal of foreign body using Magill forceps as needed
NOTE: In an unconscious patient, if there is a strong suspicion for epiglottitis and if the patient is
unable to be ventilated with a B-V-M and if an enlarged epiglottis is visualized, ONE attempt at
intubation is allowed if the airway is able to be visualized. Consider using a smaller size tube than
you normally would.
9) If unsuccessful, transport keeping the child warm, continuing BLS airway clearing maneuvers,
trying to ventilate with high pressure.
10) If unsuccessful with above airway maneuvers and child is over the age of 8 years consider
surgical cricothyroidotomy. If child is under the age of 8years, consider needle
cricothyroidotomy. Needle size is dependent upon the age/size of the child.
11)
?pushing the object into the right mainstem bronchi?
PARAMEDIC PROTOCOL
81
PEDIATRIC ALLERGIC REACTION

Stable Hemodynamics - no problem with ventilation, oxygenation or perfusion. Minor to
moderate skin manifestations and/or respiratory distress. No stridor.
1) Routine ALS Care
2) Oxygen per protocol
If mild to moderate respiratory distress:
3) Epinephrine 1:1,000 0.01 mg/kg to a total dose of 0.3 mg. Sub-Q
4) Albuterol nebulizer treatment
5) Establish IV Normal saline only if patient condition indicates.
6) Do not delay contacting Medical Control to establish IV

7) Benadryl 1 mg/kg IM or IV push (over one minute). Maximum dose 50 mg.
a) Epinephrine (1:1,000) 0.01 mg/kg Sub-Q
PARAMEDIC PROTOCOL
82
PEDIARTIC ANAPHYLAXIS
Unstable Hemodynamics - hypotensive patient according to normal values for age and weight;
pending upper airway obstruction with wheezing and/or stridor; or severe obstruction with
wheezing and/or stridor; or severe respiratory distress.
1) Routine ALS Care
2) Oxygen and airway management per airway protocol
3) In the event there is severe respiratory distress, B-V-M then intubation in the pre-hospital
setting is indicated.
4) Epinephrine (1:1,000) 0.01 mg/kg Sub-Q
5) Establish IV access
6) If bronchospasm, administer Albuterol nebulized treatment (0.5 ml in 1.5 ml NS)
7) Benadryl 1mg/kg IV push (over one minute) IM if no IV access. Maximum dose 50 mg.
8) If above treatment does not improve patient status:
9) Epinephrine (1:10,000) 0.01 mg/kg slow IV push
Establish medical Control
a) If no IV access IO for children <6 years old
b) Repeat Epinephrine Sub-Q or IV doses q 5 minutes
c) Epinephrine infusion 0.1 to 0.3 g/kg/min increasing to 1.0 g/kg/min as necessary
d) Solu-Medrol 2mg/kg infusion over 15 minutes
e) Fluid Bolus 20ml/kg of Normal saline
Reminder: Cardiac monitor is indicated for all patients receiving epinephrine.
PARAMEDIC PROTOCOL
83
PEDIATRIC ALTERED MENTAL STATUS/HYPOGLYCEMIA/COMA

1) Routine BLS / ALS Care
2) Consider etiology (trauma, hypoglycemia, overdose, seizure, hypoxemia, etc.)
3) Treat according to appropriate protocol
4)
5)
6)
7)
Support airway per protocol

Determine GCS
Establish IV access and check Blood Glucose Level
If:
Glucose <60 or
If glucose not available and patient is known diabetic or
History consistent with hypoglycemia:
8) Administer Dextrose 25% 0.5 Gm/kg IV push
9) If IV access cannot be readily established administer Glucagon 0.02 mg/kg up to 1mg IM
10) If a narcotic overdose is suspected or unknown and respiratory insufficiency is present:
11) Administer Narcan 0.4 mg IV or IM. May repeat to a maximum dose of 2.0 mg.
a) If no IV access IO in child <6 years old
b) Repeat D25%
c) Repeat Narcan
13) Transport/destination decision
PARAMEDIC PROTOCOL
84
PEDIATRIC SEIZURES/STATUS EPILEPTICUS

Most seizures do not require emergent intervention.
1) Routine BLS/ALS Care
2) Initiate treatment based on history and clinical presentation. It is essential to make the
distinction between focal motor, general motor seizures, and status epilepticus.
3) Perform an initial assessment. Attempt to determine the etiology i.e. whether the patient has a
history of diabetes, seizure disorder, narcotic use, head trauma, poisoning or fever.
4) If post-traumatic Transport Now
a) Cervical and full spinal immobilization as appropriate while maintaining airway
5) Closely assess respiratory activity. Use blow-by oxygen.
6) Assist ventilations with B-V-M and 100% O2 as necessary.
7) Suction as necessary.
8) Consider IV access.
9) Consider hypoglycemia, check blood glucose level.
a) If glucose level <60 administer: Dextrose 25% 0.5 Gm/kg
10) Cardiac monitor
IF THE SEIZURE PERSISTS BEYOND 10 MINUTES (from onset) (Status epilepticus):
11) Administer:
a) Valium 0.25 mg/kg (up to 3 mg) IVP (or)
b) Ativan 0.1 mg/kg (up to 2mg) IVP
12) if unable to establish IV access administer:
a) Versed 0.1 mg/kg (up to 2 mg) IM
b) OR: Valium per rectum (see addendum)
a) Repeat administration of anti-seizure medications
b) Repeat Dextrose 25%
NOTE: If the seizure is controlled by one of the benzodiazepines, continuous assessment of
respiratory status is critical as respiratory arrest can occur with use of these medications.
PARAMEDIC PROTOCOL
85
PEDIATRIC CARDIAC RHYTHM DISTURBANCES

The EKG of all critically ill or injured children should be continuously monitored, although
primary cardiac events are unusual in the pediatric age group. Pediatric arrhythmias are more
frequently the consequences of hypoxemia, acidosis, and decreased cardiac output. There are
three groups of rhythms based on the rate of and the presence or absence of a pulse. These
classifications are bradycardias, tachycardias (narrow or wide complexes), and absent (PEA or
asystole).
Pediatric cardiac algorithms are based upon Pediatric Advanced Life Support from the
American Heart Association.
PARAMEDIC PROTOCOL
86
PEDIATRIC BRADYCARDIA
Most pediatric bradycardias are due to inadequate tissue oxygenation secondary to ventilation.
Supporting the airway may resolve the bradycardia.
Assess ABCs
Secure airway, ventilation, and administer 100% oxygen
Symptomatic / Severe Cardiorespiratory Compromise
Poor perfusion
Hypotension
Respiratory Difficulty
No
Observe
Support ABCs
Transport
Yes
Begin chest compression if despite
oxygenation and ventilation heart rate
<60 in an infant / child.
Establish IV/IO
Epinephrine IV/IO 0.01 mg/kg (1:10,000)
ET 0.1 mg/kg (1:1,000)
Repeat every 3-5 minutes
Atropine 0.02 mg/kg (minimum dose 0.1 mg
Maximum single dose:
0.5 mg - child
1.0 mg - adolescent
May repeat X 1
Pacing, other modalities
Note: Dosage differs with route of administration IV/IO vs. ET.
PARAMEDIC PROTOCOL
87
Pediatric Tachycardia
Rapid heart rate with adequate perfusion
Obtain 12-Lead EKG
if possible
Evaluate QRS duration
QRS duration
normal for age =0.08 sec.
QRS duration
Wide for age =0.08 sec.
Evaluate rhythm
Probable sinus tachycardia

Identify and treat possible
causes:
Fever, shock, hypoxia
hypovolemia, drug ingestion
pneumothorax
Probable SVT
Establish vascular access
Adenosine 0.1-0.2 mg/kg
follow with rapid NS flush
May repeat X 1 double dose
Maximum dose 12 mg.
Establish vascular access
Lidocaine 1 mg/kg IV
May repeat X 2
Termination
Yes
No
If Lidocaine is successful
start infusion at 20 to
50 g/kg/min
PARAMEDIC PROTOCOL
Adenosine 0.1-0.2 mg/kg

follow with rapid NS flush
May repeat X 1 double dose
Maximum dose 12 mg.
88
PEDIATRIC TACHYCARDIA
Rapid heart rate with poor perfusion
Assess and maintain airway
Administer 100% oxygen
Ensure effective ventilation
Pulse present ?
No
Yes
Begin CPR
See Asystole and pulseless
arrest decision tree
Evaluate QRS duration
Is vascular access present

or rapidly available?
Yes
Treat rhythm as related to QRS
see PALS Fig 6
No
Synchronized cardioversion
0.5-1.0 J/kg
May repeat as needed
Establish vascular access if possible
PARAMEDIC PROTOCOL
89
PEDIATRIC PULSELESS ARREST

Determine pulselessness and begin CPR
Confirm cardiac rhythm in more than one lead
Ventricular Fibrillation
Pulseless ventricular tachycardia
Asystole
Pulseless electrical activity

EMD
Identify and treat causes

Severe hypoxemia
Severe acidosis
Severe hypovolemia
Tension pneumothorax
Cardiac tamponade
Profound hypothermia
Continue CPR
Secure airway
Hyperventilate with 100% O2
IV/IO access
but do not delay defibrillation
Defibrillate up to 3 times is needed

2 J/kg, 4 J/kg, 4 J/kg
Epinephrine, first dose

IV/IO: 0.01 mg/kg (1:10,000)
ET: 0.1 mg/kg (1:1,000)
Continue CPR
Secure airway
Hyperventilate w/100% O2
IV/IO access
Defibrillate 4 J/kg 30-60 seconds

after each medication
Epinephrine, first dose

IV/IO: 0.01 mg/kg (1:10,000)
ET: 0.1 mg/kg (1:1,000)
Lidocaine 1 mg/kg IV/IO

Defibrillate 4 J/kg 30-60 seconds
after each medication
Epinephrine, second and subsequent doses
repeat q 3-5 minutes @ 0.1 mg/kg (1:1,000)
Lidocaine 1 mg/kg
Defibrillate 30-60 seconds after each medication
@4 J/kg
Epinephrine, second and

subsequent doses:
IV/IO/ET 0.1 mg/kg (1:1,000)
repeat q 3-5 minutes
PARAMEDIC PROTOCOL
90

Regional Paramedic Protocols
Pediatric
Trauma Protocols
<13 Years
PARAMEDIC PROTOCOL
91
TRIAGE DECISION SCHEME

When transport to a Level I or II Trauma facility is indicated, but the ground transport time to that hospital is judged
to be greater than twenty (20) minutes, determination of destination hospital shall be in accordance with medical
control.
Measure vital signs and level of consciousness:
Glasgow Coma Scale
12 or less
Systolic blood pressure
<90, or
Respiratory rate
<10 or >29
If Yes
If No
Assess anatomy of injury
1. Gunshot wound to chest, head, neck, abdomen or groin
2. Third degree burns >15% BSA or third degree burns of
face or airway involvement
3. Evidence of spinal cord injury
4. Amputation other than digits
5. Two or more obvious proximal long bone fractures
Trauma Facility
If Yes
If No
Assess mechanism of injury and other factors
1. Mechanism of injury:
a. Falls >20 feet
b. Apparent high speed impact
c. Ejection of patient from vehicle
d. Death of same car occupant
e. Pedestrian hit by car >20MPH
f. Rollover
g. Significant vehicle deformity-especially steering wheel
2. Other factors:
a. Age<5
b. Known cardiac disease or respiratory distress
c. Penetrating injury to thorax, abdomen, neck or groin
other than gunshot wounds
Trauma Facility
If Yes
If No
Call Medical Control for direction
Evaluate as per usual protocols
Severely injured patients<13 years should be taken to a Level I or II facility with pediatric resources including
pediatric ICU.
All EMS providers transporting trauma patients to hospitals shall provide receiving hospital with a complete OEMS
approved patient care form prior to departing from the hospital.
WHEN IN DOUBT, CONSULT WITH MEDICAL CONTROL

*State of Connecticut Regulation of Department of Public Health and Addiction Services Concerning Statewide
Trauma System: Sections 19a-177-5.
PEDIATRIC TRAUMA PATIENT

PARAMEDIC PROTOCOL
92
I.
PRIMARY SURVEY
A.
Airway and Cervical Spine Control
1.
Maintain in-line cervical immobilization, children <8yrs of age have larger occiputs and
require elevation of the upper torso to achieve appropriate in-line cervical spine
immobilization.
2.
Manual
a. Chin Lift
b. Jaw Thrust
3.
Mechanical
a. Suction
b. Oropharyngeal Airway
c. Nasopharyngeal Airway
d. Pocket Mask
e. Orotracheal tube with in-line immobilization
f. Nasotracheal tube with in-line immobilization
g. Transtracheal Airway with in-line immobilization
Hypoxia is common in the trauma patient and correcting it is of the highest priority. A spinal injury may
be present and the airway should be managed as if C-spine instability exists. Concern about a spinal
injury must not delay institution of adequate ventilation and oxygenation. The neck should be
maintained in a neutral position. If an endotracheal tube is required, neutral stabilization of the spine
must be maintained throughout its insertion, so that the mandible and tongue are moved forward and the
head is not tilted backwards.
B.
Breathing
Note degree of respiratory distress: increased respiratory rate, skin color change,
accessory muscle usage or noisy respirations.
Refer to Pediatric airway algorithm for management. Refer to Pediatric Medical protocols for
Norms in pediatric vital signs.
1.
2.
Ventilation
a. Mouth to mask
b. Bag-valve-mask
Age specific rates:
<3yrs 30
3-6yrs 25
>6yrs 20
Flail Chest
a. Airway management
PARAMEDIC PROTOCOL
93
TRAUMA PATIENT CONT
C.
3.
Open Pneumothorax
a. Partially occlusive dressing (3-sided)
b. Assist ventilations as needed with supplemental O2
4.
Tension Pneumothorax
a. Decompression
i. Large bore needle with plastic catheter (angiocath)
ii. Second intercostal space (ICS) in Midclavicular Line, superior
aspect of the Third Rib
iii. Fifth ICS in Midaxillary Line
Circulation and Bleeding Control

1.
Evaluation
a. Pulse
i. Rate
ii. Strength
iii. Location
b. Skin
i. Color
ii. Moisture
iii. Temperature
2.
Cardiac compressions as indicated
3.
Hemorrhage control
a. Direct pressure on wound and/or pack wound with sterile gauze
b. Pressure points (usually not required)
c. Tourniquet (seldom, if ever, indicated)
d. Traction splint
Pale skin color and pulse characteristics are accurate parameters used in assessing the status of
tissue perfusion. Blood pressure is obtained later in the patients assessment. Hemorrhage
control in the primary survey is used only for massive bleeding. Minor bleeding takes a lesser
priority. For patients with an unstable femur fracture, application of a traction splint is the most
important field technique for control of this type of hemorrhage. Patients with open book
pelvic fracture will benefit from stabilization and direct pressure from the PASG, in the
pediatric patient correct sizing is critical.
PARAMEDIC PROTOCOL
94
TRAUMA PATIENT CONT

D.
Disability
Glasgow Coma Scale
Eye Opening
Verbal Response
Motor response
CHILD
4 - opens spontaneously
3 - opens to speech
2 - opens to pain
1 - none
5 - oriented
4 - confused
3 - inappropriate words
2 - incomprehensible words
1 - none
6 - obeys commands
5 - localizes pain
4 - withdrawal to pain
3 - flexion (pain)
1 - none
INFANT
4 - opens spontaneously
3 - opens to speech
2 - opens to pain
1 - none
5 - coos and babbles
4 - irritable cry
3 - cries in pain
2 - moans in pain
1 - none
6 - spontaneous movement
5 - withdraws to touch
4 - withdraws to pain
3 - flexion (pain)
1 - none
Changes in neurologic status can be of significance to the trauma surgeon or to the neurosurgeon.
Significant alteration can change the outcome for the patient
E.
Exposure of the body for examination

It may be necessary to partially or completely expose the body to control hemorrhage
and perform lifesaving procedures. It is important to consider modesty and to respect
the individuals needs. Nothing should be done to delay transport of the critically
injured patient.
II.
RESUSCITATION
A.
Supplemental oxygen should be delivered @100% for all multisystem trauma patients.
B.
Volume replacement
Excess time should not be spent in the field attempting to establish and IV. Critically injured
patients should have rapid transportation to the trauma center and IV started enroute. Fluid
resuscitation is only indicated for patients with signs and symptoms of shock.
PARAMEDIC PROTOCOL
95
TRAUMA PATIENT CONT

1.
2.
III.
Blood pressure should be monitored

a.
systolic/diastolic
b.
pulse pressure
Venous access
a.
peripheral IV (IO indicated in child<6yrs with symptomatic shock)
i.
Large bore catheters
ii.
Two sites preferred
b.
Fluid(s) Normal Saline or Lactated Ringers; 20 ml/kg bolus
Repeat bolus per Medical Control
c.
Buretrol/volutrol should be used for children <25kg.
SECONDARY SURVEY
A systematic evaluation of the patient beginning at the head and proceeding to the neck, thorax,
abdomen, and extremities should be completed. Unnecessary delay in order to carry out
diagnostic procedures that do not produce information concerning direct treatment in the prehospital phase should not be attempted. Rapidly identify those patients who, because of the
critical nature of their situation, require rapid transport to an appropriate facility. These patients
should be stabilized and transported immediately.
A.
Head
1.
2.
3.
4.
Airway
a. reevaluate
b. correct problems
Open Wounds
a. control hemorrhage with direct pressure
b. apply clean dressings to all wounds
Eyes
a. protect from further injury
b. irrigate to remove contaminants and debris (Morgan Lens if
appropriate)
c. do not remove foreign bodies
Nose and ears
a. pre-hospital evaluation for fluid (blood, CSF)
b. treatment usually not required
PARAMEDIC PROTOCOL
96
TRAUMA PATIENT CONT

Most injuries to the face and head require hospital treatment - therefore delay in evaluation other
than hemorrhage control is usually not necessary. Lacerations of the scalp may have a fracture
beneath; therefore, unnecessary pressure is to be avoided. Use only enough pressure to control
hemorrhage. Transportation to the hospital should not be delayed other than to correct life
threatening airway problems.
B.
Neck
1.
Spinal immobilization; indications

a. any blunt injury above the clavicle
b. unconscious patient
c. multiple trauma
d. high speed crash
e. neck pain
f. complaints of extremity numbness/tingling
g. gunshot wound involving the torso
NOTE: For small children, an appropriate size collar may not be available. In the event that
collars available are too large, maintain cervical spine immobilization with an appropriate
pediatric immobilization board with head immobilizers or an appropriately padded KED may be
employed according to PEPP Guidelines.
2.
C.
Wounds
a. leave foreign bodies in place, but stabilized
b. use direct pressure to control hemorrhage
Thorax
1.
2.
3.
Ventilation
a. Assure adequacy of ventilation
b. Reevaluate injuries identified and managed in the primary
survey
Myocardial contusion
a. EKG monitoring
b. Treat dysrhythmias according to PALS
Chest wall injuries
a. Simple isolated rib fractures, no pre-hospital management necessary
b. Flail chest
i. airway/ventilation management as necessary
c. Hemothorax
i.
fluid replacement to treat shock
ii.
ventilatory support as necessary
PARAMEDIC PROTOCOL
97
TRAUMA PATIENT CONT

d. Open pneumothorax
i.
three-sided dressing
e. Tension pneumothorax
i.
needle decompression
f. Cardiac tamponade
i.
fluid bolus
D.
Abdomen
1.
2.
3.
4.
Evisceration
a. Clean, moist dressing
Foreign body
a. Do not remove except by direct order of medical control
b. Stabilize foreign body to prevent further injury during transport
Intra-abdominal hemorrhage
a. Intravenous fluids
Pelvic fracture
a. Long backboard immobilization
b. Consider PASG stabilization
E.
Extremities
1.
Examine for swelling and deformity
2.
Check for neurovascular function
3.
Apply direct pressure to control bleeding
4.
Splint-reassess neurovascular status after splinting
5.
Consider PASG for multiple lower extremity fractures
F.
Neurologic - Head, spinal cord, and peripheral nerve trauma

1.
Suspect associated C-spine injury and treat accordingly
2.
All unconscious patients should be considered to have an inadequate respiratory
status and should have aggressive airway management with C-spine control.
3.
If GCS <9 consider ventilation with B-V-M. Intubation (refer to airway algorithm)
4.
Serial GCS determinations at least every 10 minutes
5.
Pupillary evaluation
a. Reactivity
b. Equality
c. Size
6.
Reassess motor and sensory function
7.
IV fluids should be restricted unless shock is present
8.
If shock is present, look for other causes of blood loss, as brain injury
alone is usually not the cause.
PARAMEDIC PROTOCOL
98
TRAUMA PATIENT CONT

IV.
TRANSPORTATION
It is impossible to fully stabilize the unstable patient in the pre-hospital setting. There must be a
balance of lifesaving skills (such as endotracheal intubation) with minimizing scene time (<10
minutes) and rapid transport in order to reduce the time from injury to definitive surgical
treatment.
Early trauma notification to the receiving hospital is essential to ensure the immediate
availability of an appropriate in-hospital response.
Committee on Trauma; American College of Surgeons; Resources for Optimal Care of the
Injured Patient.
PARAMEDIC PROTOCOL
99
PEDIATRIC BURN PATIENT

The approach to the pediatric burn patient should be similar in your approach to any burn patient,
assuring your safety, the patients safety, stopping the burning process, and airway management
all remain paramount.
These protocols will deal with specific fluid resuscitation measures and special considerations.
Please refer to the appendix for the Rule of Nines. Please refer to the Adult Trauma - Burn
section of these protocols for your systems approach to patient care.
Fluid Resuscitation
1) IV Normal Saline
2) IO is indicated in the patient <6yrs who needs fluid replacement and an IV cannot be
established.
3) As with adults, IV or IO sites should not be through a burn site unless no other site exists.
4) Administer 20 ml/kg bolus
a) Repeat bolus of fluid
b) Morphine 0.05-0.1 mg/kg for pain management
c) Versed 0.05 mg/kg for anxiety
Special Considerations:
The anatomical map of the pediatric patient changes with age, if in doubt as to the Body Surface
Area involved in the burn see the Rule of Nines.
Be suspicious for burn patterns that may indicate child abuse, i.e. stocking or glove pattern
burns.
Ophthalmic Chemical Burns
The Morgan Lens may be utilized in children >6yrs who are cooperative. Care must be take to
prevent any child who has had topical ophthalmic anesthesia from rubbing their eye - additional
injury may occur since the pain receptors have been blocked.
PARAMEDIC PROTOCOL
100
PEDIATRIC SPINAL CORD INJURY

1) Routine ALS Care
2) Focus on patient packaging with proper spinal immobilization
3) May be necessary to aggressively manage airway and ventilatory support
4) IV Normal saline
5) Reassess neurological status to all extremities
6) monitor vital signs
7) If the patient is hypotensive and tachycardic administer fluid bolus 20 ml/kg
a) Additional boluses IV fluids at 20 ml/kg
If evidence suspicious for spinal cord trauma: do not delay transport
PARAMEDIC PROTOCOL
101
Appendix A
Procedures
PARAMEDIC PROTOCOL
102
Conscious Sedation
Conscious sedation should be considered for those patients who require advanced airway management
and prior attempts at oral / nasal tracheal intubation has failed due to intact gag reflex, combative
behavior, and/or involuntary muscle contraction.
1) Routine BLS Care
2) Utilize BVM to ensure ability to provide ventilation
3) Routine ALS Care
4) Be sure to treat underlying pathology
Repeat attempt at intubation
5) If the patient cannot be intubated using usual methods contact On-Line Medical Direction for the
following sedation guidelines. Using the term Medication Facilitated Intubation will cover all
medications
6) Ativan 1mg SIVP or Valium 3-5mg SIVP
7) Etomidate (Amidate) 0.3mg/kg SIVP
8) If no response or inadequate sedation occurs:
9) Ativan 2-4mg SIVP or Valium 3-5mg SIVP
10) There is no second dose for Etomidate
11) Perform Endotracheal Intubation
12) Place a Bite block/Oral Pharngeal Airway to protect Endotracheal Tube
13) Confirm Tube Placement and Secure
Unable to Intubate
14) Resume BVM Ventilations
15) If unable to effectively ventilate with BVM, place CombiTube as per protocol
16) Unable to intubate cannot ventilate perform alternative airway per protocol
Criccothyrodomy
PARAMEDIC PROTOCOL
103
Sedation to Manage Patient Airway Post-Intubation

Patient is intubated and being managed according to the proper protocol and begins to fight the
tube. In order to protect the patients airway and to manage the patient in a safe and effective
manner the follow protocol should be utilized.
1) Patient is intubated and has positive confirmation of tube placement.

2) Patient begins to buck or fight the tube.
3) If SBP > 100 may
a) Administer Versed 2-5mg slow IV to sedate patient or
b) Ativan 2-4 mg slow IV
4) Reconfirm tube placement in the usual manner.
5) Establish Medical Control
6) Possible Physician Orders:
a) Morphine 4mg IV
b) Additional Medication to sedate patient
PARAMEDIC PROTOCOL
104
Nasal-Tracheal Intubation
1.
NASOTRACHEAL INTUBATION
Nasotracheal intubation requires both skill and patience to perform correctly. It is
frequently more time-consuming than orotracheal intubation. Nasal intubation can have
serious complications including epistaxis, sinusitis, and increased intracranial pressure. It
should be reserved for the critically ill patient who has failed to respond to conventional
airway and pharmacological interventions such as 100% oxygen by bag-valve-mask
ventilation, nitroglycerin, and furosemide.
Indications
1. Breathing patients requiring intubation where direct visualization of the posterior pharynx
is difficult or impossible, e.g., the inability to open the patients jaw or blood or emesis in
the airway obscuring direct visualization of the vocal cords, OR
2. Breathing patients with severe respiratory distress indicated by decreasing level of
consciousness, cyanosis, ineffective or decompensating respiratory effort.
Contraindications
1. Apnea
2. Suspected epiglottitis characterized by a sore throat, fever, and drooling
3. Pediatric patients weighing less than 30 kg (8 years old). This group of patients is best
managed with orotracheal intubation or bag-valve-mask ventilation.
4. Suspected mid-facial fractures or suspected basilar skull fractures indicated by head or
facial trauma with nasal hemorrhage, periorbital ecchymosis or swelling, hemorrhage from
ear canals, or maxillary bone deformity and instability.
5. Head injury
6. History of bleeding disorders or current anticoagulation therapy with agent such as
warfarin (Coumadin).
7. Penetrating neck trauma or suspected laryngeal injury due to blunt trauma
Complications
1. Unrecognized esophageal intubation with subsequent hypoxic brain injury
2. Nasal bleeding
3. Turbinate avulsion
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4. Nasopharyngeal or retropharyngeal laceration

5. Injury to vocal cords, epiglottis, or other airway structures
6. Vomiting and subsequent aspiration
7. Sinusitis, otitis media, bacteremia
Protocol
1. Begin preoxygenation with 100% O2 prior to the procedure. If the patient is conscious,
explain what is about to happen. Ensure that the scene is calm enough to hear the air
exchange when advancing the tube.
2. Instill Neosynephrine, two or three drops or sprays into both external nares. Early
installation allows adequate time to effect vasoconstriction of the nasal mucosa.
3. Prepare suction. In addition to vomiting, bleeding in the posterior pharynx may occur due
to insertion of the endotracheal tube.
4. Choose an endotracheal tube. The primary criteria for tube size is the nasal canal diameter.
Often a 7.0 mm tube is the best size for adults. Rarely a tube less than 6.5 mm will be
necessary. ET tubes with attached pull-rings (Endotrol) are preferable for the procedure.
5. Lubricate the endotracheal tube with 2% lidocaine gel or 2% lidocaine viscous.
6. Position the patient with head in midline, sniffing position. Use neutral neck position with
a cervical immobilization collar in place if cervical spine injury is suspected. The patient
may be in a sitting or upright position; patients in severe respiratory distress should be
intubated in the upright position.
7. With gentle steady pressure, advance the tube perpendicular to the facial plane through the
nare to the posterior pharynx. The beveled edge of the tube is placed against the nasal
septum to reduce the risk of bleeding. Advancing the tube tip along the nasal floor avoids
the turbinates and reduces the incidence of epistaxis. Never force the tube. If resistance is
felt, the tube could be dissecting under the nasal or pharyngeal mucosa. Withdraw the tube
part way, redirect, and advance again with gentle steady pressure.
8. Keeping the curve of the tube exactly midline, continue advancing slowly while listening
to air movement and watching for condensation in the tube. When the tube tip is nearest
the trachea, air movement will feel the strongest and sound the loudest. It may be helpful
to obstruct the mouth and the opposite nare.
9. A slight resistance may be felt just prior to entering the trachea. At the onset of the next
inspiration, advance the tube into the trachea with a quick, controlled movement. Usually
the first sign of correct passage is a violent cough. Advance the tube approximately one
inch further and then inflate the cuff.
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10. If the patient develops laryngospasm or if the tube enters the esophagus, withdraw the tube
slightly. Reposition the tube tip above the level of the cords and wait until the patient
repeats inhalation. Re-attempt tube advancement. Application of cricoid pressure may
assist successful passage of the tube into the trachea.
11. If positive pressure ventilation with the bag-valve device produces sounds of air leakage
around the cuff, check the cuff inflation and the tube placement.
12. Ventilate and auscultate for bilateral breath sounds in the axillae and for the absence of
ventilatory sounds in the epigastrium.
13. Confirm proper placement with the use of a mechanical device such as Capnograghy,
Esophageal Bulb.
14. Tape or securely tie the tube with umbilical tape or other suitable material.
Notes
15. The attempt to nasotracheally intubate the patient should not exceed three minutes from
the time the ET tube is first introduced into the patients nare.
16. Whenever possible, pulse oximetry should be used during the procedure to monitor the
patients oxygenation status.
17. Some patients are best served by application of 100% oxygen by non-rebreather face mask
followed by urgent transport to a center capable of rapid sequence intubation. In general
most breathing head injury patients fall into this category because the adverse response to
the pain of nasotracheal intubation is likely more harmful than the short delay to definitive
placement of an endotracheal tube.
18. Documentation in the patients record should include at least the following:
a. Precautions taken (i.e. in-line stabilization)
b. Size of tube
c. Number of attempts where an attempt is defined as insertion of a endotracheal tube
into one of the nares
d. Depth of insertion (i.e "X" number of centimeters at the nares)
e. Complications
f. Method of confirmation of correct placement (e.g. esophageal intubation detector,
clinical exam).
19. When in doubt, take it out; and assure oxygenation by another attempt or method
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TUBE CONFIRMATION ADJUNCTS

Statement: There are a number of different types and brands of end-tidal CO2 detectors, it will
not be dictated by the Region which type or which brand to use. However, it is the policy in the
Region that each patient who is intubated will have an end-tidal CO2 and/or Esophageal
Intubation Detector (EID) used to confirm placement and to monitor placement.
Indications:
All intubated patients weighing > 15 kg.
Procedure:
1. Following oral or nasal intubation, confirmation via positive and equal breath sounds and the
absence of epigastric sounds an end-tidal CO2 and/or EID will be placed.
2. Usual ventilation of the patient will take place with 100% oxygen.
3. Depending upon the type/brand of end-tidal CO2 detector used the paramedic will
confirm tube placement by noting color change or CO2 numbers.
4. If the EID (Esophageal Intubation Detector) is used, a rapid reinflation will occur
with correct placement of the ETT.*
5. If confirmation that the tube is correctly placed is noted, ETT will be secured in place
in the usual manner and monitored en route to the hospital.
6. If the end-tidal CO2 detector or EID indicates incorrect ETT, immediate visualization
of tube placement should be done. If ETT is incorrectly placed, immediately remove
ETT, hyperoxygenate patient and reattempt intubation.
7. If visualization shows the ETT properly placed, secure tube in the usual manner and
continue to ventilate and monitor patient en route to the hospital. Report finding to
physician caring for patient.
Note: Proper documentation on the patients PCR should indicate use of end-tidal CO2
and/or use of EID and findings.
*It is possible to have a positive placement finding with the EID. If the tube tip is
at the level right above the vocal cords, but not through the cords rapid inflation
of the bulb may occur.
Once a patient has stopped cellular respiration (death) color change is not always
possible even with a properly placed ETT.
It is possible for an end-tidal CO2 detector to have a positive color change with an
esophageal intubation. This may occur for a limited time (usually on 4 or 5
ventilations) correct color change can be assured after this.
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INTRAOSSEOUS INFUSION
Indications:
1. Age 6 and under.
2. Unstable pediatric patient where IV access is unobtainable within 90 seconds, and:
i. Full arrest
ii Imminent arrest secondary to dysrhythmia or hypovolemic shock of any
etiology.
iii Status epilepticus not broken by medication given IM or rectal route.
3. Medications needed cannot be administered via an existing ET tube or other
medications or fluids are required.
Contraindications:
1. Fracture below the level of the insertion site.
2. Areas of cellulitis, burns or infections should be avoided.
Procedure:
1. Prep the skin with betadine or alcohol.
2. Identify the flat antero-medial surface of the tibia.
3. Move 1-3 cm below the tibial tuberosity.
4. Place the IO needle perpendicular to the skin and insert with a rotary twisting motion.
5. When decreased resistance (the pop) is noted, remove the stylet from the needle and
infuse 20 ml of Normal Saline push to clear the needle.
6. Observe the surrounding tissue for extravasation of fluid.
7. Connect the IV tubing and fluid to the intraosseous needle.
8. You may make two (2) attempts in the cardiac arrest setting.
Complications:
1.
2.
3.
4.
5.
Infection
Compartment syndrome.
Subcutaneous extravasation.
Clotting of marrow in needle.
Localized cellulitis increases with length of time the needle is in place.
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NEEDLE CRICOTHYROTOMY
Indication:
The inability to secure the patients airway by other invasive procedures, (endotracheal
intubation).
Cautions:
1. Needle cricothyrotomy is an invasive procedure and requires proper training and certification
through one of the Regional Sponsor Hospitals.
2. Carbon dioxide (CO2) build-up occurs rapidly. The procedure can be used only for a
short period of time (30 minutes maximum) at which time a definitive airway must be
established such as a Pertrach device.
3. The patient must have a patent airway or a means established to allow outflow of air
from the lungs.
Contraindications:
1. The ability to establish an easier and less invasive airway rapidly.
2. Acute laryngeal disorders such as laryngeal fractures that cause landmark distortion or
obliteration of landmarks.
3. Bleeding disorders.
4. Injury or obstruction below the level of the cricothyroid membrane.
Complications:
Pneumothorax
Subcutaneous emphysema
Catheter dislodgment
Hemorrhage
Esophageal or mediastinal injury
Hypercarbia
Equipment:
14 gauge over-the-needle catheter

10 cc syringe
3 cc syringe
15 mm adapter from a 7.0 ET tube
Bag-valve-mask
Oxygen
Providone iodine swabs
Adhesive tape
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NEEDLE CRICOTHYROTOMY CONt

Equipment:
Trauma shears
Suction equipment
Gloves
Goggles
Procedure:
Observe basic precautions
Prepare equipment: remove plunger from barrel of 3cc syringe. Attach 15mm
adapter from the 7.0 ET tube.
Palpate the thyroid cartilage, cricothyroid membrane, and suprasternal notch.
Prep the skin with two providone iodine or alcohol swabs.
You may attach the 10 cc syringe to the over-the-needle catheter, or you may elect to
use the catheter-needle assembly by itself. Puncture the skin over the cricothyroid
membrane.
Advance the needle at a 45-degree angle caudally (toward the feet).
Carefully push the needle until it pops into the trachea (aspirating on the syringe as
you advance the needle if you are using a syringe).
Free movement of air confirms you are in the trachea.
Advance the plastic catheter over the needle, holding the needle stationary, until the
catheter hub comes to rest against the skin.
Holding the catheter securely, remove the needle.
Reconfirm the position of the catheter. Securely tape the catheter.
Attach the 3 cc syringe with the 7.0ET adapter to the catheter hub. Attach the B-V-M
to the adapter and forcefully ventilate the patient. Forcefully squeeze the B-V-M over
one second to inflate and then remove the B-V-M to allow for exhalation (for 4
seconds).
Constantly monitor the patients breath sounds, ventilation status, and color.
Adequate exhalation never forcefully occurs with this technique. The patient may
develop hypercarbia (increased CO2) and increased air pressure in the lungs possibly
causing alveoli to rupture.
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NEEDLE THORACOSTOMY
Indication:
Tension pneumothorax associated with either traumatic or spontaneous lung collapse and
manifested by hypotension, severe respiratory distress, absent breath sounds with hyperresonance
on the affected side. There may be possible tracheal shift to the unaffected side.
Contraindications:
There are no contraindications for field use.
Procedure:
1. The patient is supine with head and chest to 30 degrees (semi-sitting position).
2. Explain procedure and rationale if patient is conscious. Bare the chest.
3. Select site for procedureusually the anterior second or third intercostal space in the
midclavicular line. The anterior axillary line in the 5th or 6th intercostal space is
another good site, and may be technically easier and safer than the midclavicular
approach.
4. Prepare the skin with Betadine.
5. Select needle or over-the-catheter needle size 14 gauge or larger.
6. Holding the needle/catheter perpendicular to the chest wall, insert it straight into the
thorax, going just above a rib when one is encountered. Insert until air is heard
escaping. Advance catheter and remove needle. This converts a tension
pneumothorax to a simple pneumothorax. A chest tube thoracostomy will need to be
placed in the ED.
7. Cover puncture site, stabilize catheter to transport. Although not mandatory, when
possible, attach tube to flutter valve or flap valve.
Pearls
Do not select a site near previous puncture site or scars.
Use the largest needle or catheter possible since plugging with tissue may occur.
Intercostal nerve or artery damage, be sure to go above not below it.
Injury to the diaphragm - site is too low or the patient is not positioned correctly.
Subcutaneous placement - insertion not perpendicular to chest wall (remember it is
curved not flat).
Infections - late complication - prevent this by prepping the skin well.
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ESOPHAGEAL-TRACHEAL COMBITUBE
Indication:
Apneic patient without a gag reflex in whom endotracheal intubation is unable to be established.
Contraindications:
1.
2.
3.
4.
5.
6.
Patient under the age of 16 years.

Patient under 50 or over 66 in height. (for patients under 50 there is a SA tube)
Ingestion of a caustic substance.
SA for short adult
Severe oral facial trauma.
Esophageal disease.
Patient with a stoma.
Procedure:
1. Use basic precautions including gloves and goggles.
2. Hyperoxygenate patient before attempting placement.
3. Test equipment while patient is being oxygenated.
4. If basic airway is in place remove it; Keep head in neutral or slightly flexed position.
5. With one hand, grab tongue/mandible and lift towards ceiling.
6. With the other hand place the Combitube so that it follows the natural curve of the
pharynx.
7. Insert to the tip of the mouth and advance gently until the printed ring is aligned with
the teeth.
8. Do Not Force. If the Combitube does not advance easily withdraw and reinsert.
9. Inflate the blue tube balloon with 100 cc of air. Inflate the white tube balloon with
15cc of air.
#1 Blue - will inflate the posterior pharyngeal balloon.
#2 White - will inflate the distal balloon.
10. Begin ventilation through the longer blue connecting tube. If auscultation of breath
sounds is positive and auscultation of gastric insufflation is negative, continue
ventilations.
11. IF NECESSARY, if auscultation of breath sounds is negative, and gastric insufflation
is positive, immediately begin ventilation through the shorter connecting clear tube.
Confirm tracheal ventilation by ausculation of breath sounds and absence of gastric
insufflation.
12. Removal of Combitube:
a.
b.
c.
d.
e.
Reassure patient
Have suction ready and roll patient on their side.
Remove 100cc of air from #1 (Blue line).
Remove 15cc of air from #2 (White line).
Gently withdraw Combitube, suction patient as necessary.
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MORGAN LENS
Indication:
For use in patients age 6 years and older who have sustained an exposure injury to the eye(s), (i.e.
dry or liquid chemical).
Equipment:
1.
2.
3.
4.
5.
6.
Gloves
1000ml IV bag Normal Saline
IV tubing (macro drip)
Morgan Lens
Tetracaine or other ophthalmic anesthetic
Towels or chux
Procedure:
Explain procedure to patient and give rationale.
Use BSI (Body Substance Isolation)
Unless contraindicated*, instill one or two drops of Tetracaine.
Instruct patient not to touch/rub eye(s).
Spike IV bag and attach/flush tubing, connect Morgan Lens, maintain sterile
environment of Morgan Lens.
Have the patient look down, insert the Morgan Lens under the upper lid, then have the
patient look up, retract lower lid and allow lens to drop into place.
Begin flow rate at wide open and maintain this rate per patient tolerance. Have plenty
of towels or chux to absorb flow.
*Contraindication: allergic reaction to local anesthetics, i.e. Novacaine, Lidocaine
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RULE of NINES ADULT
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RULE of NINES PEDIATRIC
Area
Age
10
15
A= of Head
B= of Thigh
C= of Leg
Lund and Browder method of calculating pediatric BSA for burns.
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Pediatric Rectal Valium Administration

1. Assure routine paramedic care
2. CONTACT ON-LINE MEDICAL CONTROL for the following
A. Administration of Diazepam for the clinical indication
B. Administration of the medication via the rectal route
It should be understood that permission for administering diazepam does not constitute
medical direction for administering per rectum.
Administering medication per rectum requires specific medical control.

Procedure:
1. Draw up contents of the vial into 2 tuberculin syringes. Each TB syringe will contain
5mgs in 1cc.
2. REMOVE THE NEEDLE FROM THE SYRINGE AND LUBRICATE THE TIP.
3. Gently insert the syringe into the patients rectum. This may facilitated by using a
finger.
4. Administer Diazepam. The dose should be 0.5mg/kg (0.1cc/kg) with a maximum dose
of 10mgs. No repeat doses may be administered.
5. Remove the syringe and squeeze the patients buttocks together for 5 minutes to
ensure medication does not leak out.
6. Monitor the patients respiratory status and vital signs, watching carefully for any
signs of respiratory depression or hypotension.
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Appendix B
PHARMACOLOGY
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118
Normal Saline (0.9% NaCl)

Class:
Isotonic electrolyte
Action:
Fluid and sodium replacement
Indications: IV access in emergency situations

Fluid replacement in hypovolemic states
Used as a dilutent for IVPB medications
Contraindications: None for field use
Precaution:
Fluid overload
Side Effect:
Rare
Dose:
Dependent upon patient condition and situation, TKO, fluid bolus,

wide open
Route:
IV infusion
Pediatric Dose:
TKO or 20ml/kg bolus
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Oxygen
Class:
Gas
Action:
Odorless, tasteless, colorless gas that that is necessary for life. Brought
into the body via the respiratory system and delivered to each cell via the
hemoglobin found in RBCs.
Indications: Any hypoxic patient or patient who may have increased oxygen demands
for any reason.
Contraindications:
None for field use
Precautions:
Patients with a history of COPD, however O2 should never

be withheld from any hypoxic patient.
Side effects:
None with field use
Dose:
Patient dependent 1 liter/minute to 100%
Route:
Inhaled, or delivered via supplemental respiratory drive.
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Adenocard
(Adenosine)
Class:
Endogenous nucleoside
Action:
Stimulates adenosine receptors; decreases conduction through the AV

node
Indication:
PSVT
Contraindication:
Patients taking Persantin or Tegretol.
Precaution:
Short half-life must administer rapid normal saline bolus immediately after
administration of drug. Use IV port closest to IV site.
Side effect:
Arrhythmias, chest pain, dyspnea, bronchospasm (rare)
Dose:
Adult - 6mg IV over 1-2 seconds; may repeat 12mg twice at 2 minute
intervals. Pedi - 0.1mg/kg, may repeat twice at 0.2mg/kg
Route:
IV push
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Atrovent
(ipratropium bromide)
Class:
Anticholinergic Bronchodilator
Action:
Relaxes bronchial smooth muscle
Effect:
Bronchodilation
Indication:
For use in severe COPD and Asthma cases after Albuterol
Dose:
2.5ml nebulizer
Route:
Nebulized updraft
Side effects: Tachycardia, palpitations, headache (most common)

Special Information: If patient has a know sensitivity to peanuts, soybeans do not give
them Atrovent. - Anaphylactic reaction.
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Aspirin
(acetylsalicylic acid)
Class:
Antiplatelet
Action:
Inhibitor of platelet aggregation
Effects:
Decrease clotting time
Indication:
Chest pain of cardiac origin
Dose:
325mg tab or 4-baby aspirin (81mg per tab)
Route:
PO
Side Effects: None with field use

Contraindication:
Sensitivity to ASA. Ulcerative disease and patients already on coumadin.
Note: GI upset is not a true allergy.
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Versed
(Midazolam HCL)
Class: Benzodiazepine (Short Acting)
Indications: Seizures, Sedation for Intubation and Pain Control (cardioversion and TCP)
Contraindications: Sensitivity to Versed or Benzodiazepines, Acute narrow angle glaucoma
Action: CNS Depressant
Effect: Sedation and Seizure Control
Onset: 1-3 minutes
Duration: 2-6 hours
Adverse Effects: Decreased Tidal Volume, Decreased Respiratory Rate, Respiratory Arrest,
Hypotension, Bradycardia, Pain During Injection, Site Tenderness, Hiccups, Nausea and
Vomiting, Oversedation, Potentiates Narcotics and dosages of both must be reduced.
Dosage Schedule: ADULT:
Seizures: 2-4mg IVP/IM may repeat as per MD Order.
Sedation for Pain and Anxiety: 2-4mg IVP/IM may repeat as per MD
Order.
Sedation to Aid or Post Intubation: 2mg IVP may repeat per MD Order.
NOTE: You will induce apnea prior to creating a flaccid patient.
PEDIATRIC:
Seizures: 0.1mg/kg (up to 2mg) slow IV/IM slow IV is given over 2
minutes. May be diluted normal saline or D5W for administration control.
NEONATES (0-6mo):
Seizures: 0.05 mg/kg Slow IV/IM slow IV is given over 2 minutes. May be
diluted normal saline or D5W for administration control.
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Methergine
(methylergonovine maleate)
Class:
Oxytocics
Action:
Increases motor activity of the uterus
Effect:
Causes the uterus to contract
Indication:
Postpartum hemorrhage caused by uterine atony
Dose:
0.2mg
Route:
IM
Side effects: Rare in the field; dizziness, headache, hypertension

Special information: On set of action 2-5 minutes after IM injection
If discolored - do not use
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ALBUTEROL
(Ventolin, Proventil)
Class:
2 Agonist
Synthetic sympathomimetic
Bronchodilator
Action:
Stimulates 2 receptors in the smooth muscle of the bronchial tree.
Indication:
Relief of bronchospasm.
Contraindication:
None for field use.
Precaution:
Patient with tachycardia.
Side effect:
Tachycardia
Dose:
2.5mg (0.5ml of the 0.5% solution) diluted to 3ml NS for nebulized updraft.
May repeat in 10-20 minutes.
Route:
Inhaled as a mist via nebulizer.
Pediatric Dose:
1.25mg (0.3 ml of 0.5% solution) to 2.5mg diluted to 3ml NS for nebulized

updraft. May repeat in 10-20 minutes.
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Ativan
(lorazepam)
Class: Benzodiazepine
Action: Decreases cerebral irritability; sedation
Effect:
Stops grand mal seizures; produces sedation
Common Indication: Status epilepticus, sedation for painful procedures

Dose:
1-2mg may repeat per MD orders
Route: IV push or IM
Side Effects: CNS and respiratory depressant
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ATROPINE
(Atropine Sulfate)
Class:
Antimuscarinic
Parasympathetic blocker
Anticholinergic
Action:
Blocks acetylcholine (ACh) at muscarinic sites
Indication:
Symptomatic bradyarrhythmias
Cholinergic poisonings
Asystole
Refractory bronchospasm
Contraindication:
none in emergency situations
Side effects: Tachyarrhythmias

Excerbation of Glaucoma
Precipitation of myocardial ischemia
Dose:
Bradyarrhythmias - 0.5mg -1.0mg MR q 3-5 minutes

Asystole - 1mg MR q 3-5 minutes (total max. dose 3mg)
Organophosphate poisonings - 1mg - 2mg MR prn
Route:
IV push
Pedi dose:
0.02mg/kg IV
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Benadryl
(diphenhydramine)
Class:
Antihistamine
H1 blocker
Action:
Blocks histamine receptor sites
Indication:
Systemic anaphylaxis
Drug induced extrapyramidal reactions
Contraindication:
None with emergency use
Precaution:
Asthma
Side effect:
Sedation
Hypotension
Dose:
25 -50mg
Route:
IV push, may also be given IM
Pedi Dose:
1mg/kg
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Calcium
Class:
Electrolyte
Action:
Facilitates the actin myosin interaction in the heart muscle.
Indication:
Hypocalcemia
Hyperkalemia
Calcium channel blocker intoxication
Contraindication:
Not to be mixed with any other medication - precipitates easily.
Precaution:
Patients receiving calcium need cardiac monitoring
Side effect:
Cardiac arrhythmias
Precipitation of digitalis toxicity
Dose:
Usual dose is 5-10ml of 10% Calcium Chloride in 10ml.
Route:
IV push
Pedi Dose:
0.2ml/kg of 10% concentration
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Activated Charcoal
Class:
Absorbent
Action:
Absorbs many drugs and poisons in the GI tract
Indication:
Toxic ingestions - not caustics or pure petroleums
Contraindication:
None for emergency use
Dose:
50-100 grams
Route:
PO - usually in liquid form to drink
Pedi dose:
1-2 grams/kg
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Dextrose
(D50)
Class:
Carbohydrate
Action:
Raises the blood sugar
Indication:
Diabetic patients with low blood sugar level

Altered mental states
Seizure
Contraindication:
Precaution:
none for field emergency use
Tissue necrosis if infiltration occurs
Side effects: As above-infiltration

Intracerebral hemorrhages in neonates with undiluted D50
Dose:
25 Gms Slow IV push, may repeat
Route:
IV slow, confirm IV placement prior to and during administration.
Pedi Dose:
1ml/kg of D50 slow IV push. Dilute 1 to 4 in those less than 1 week old
and 1 to 2 in those 1 week to 1 year.
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Dopamine
(intropin)
Class:
Naturally occurring catecholamine, adrenergic agents
Action:
Stimulates , 1 and dopaminergic receptors
Effects:
0.5 to 2 g/kg/min - Renal and mesenteric vasodilation.

2 to 10 g/kg/min - Renal and mesenteric vasodilation persists and
increased force of contraction (FOC).
10 to 20 g/kg/min - Peripheral vasoconstriction and increased FOC (HR
may increase).
20 g/kg/min or greater - marked peripheral vasoconstriction (HR may
increase).
Indication:
Shock - Cardiogenic
- Septic
- Anaphylactic
Contraindication:
Pre-existing tachydysrhythmias or ventricular dysrhythmias.
Precaution:
Infuse in large vein only

Use lowest possible dose to achieve desired hemodynamic effects, because
of potential for side effects.
Do not D/C abruptly, effects of dopamine may last up to 10 minutes after
drip is stopped.
Do not mix with NaHCO3 as alkaline solutions will inactivate dopamine.
Side effect:
Tachydysrhythmias
Ventricular ectopic complexes
Undesirable degree of vasoconstriction
Hypertension relate to high doses
Nausea and vomiting
Anginal pain
Dose:
2.0 - 20. g/kg/min titrated to desired effect
Route:
IV drip
Pedi dose:
same as adult dose - titrate to effect
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Epinephrine 1:10,000
Class:
Natural catecholamine, adrenergic
Action:
Stimulates both alpha (a) and beta (1 and 2) receptors.
Indication:
Cardiac arrest
Severe anaphylaxis with shock
Contraindication:
Use in pregnant women should be conservative

Pre-existing tachydysrhythmias
Side effects: Tachydysrhythmias

Hypertension
May induce early labor in pregnancy
Headache, nervousness, decreased level of consciousness
Dose:
0.5 to 1.0 mg (usual)
Route:
IV, IO
ET if given this route the dose should be doubled
Pedi Dose:
0.01 mg/kg
PARAMEDIC PROTOCOL
134
Epinephrine 1:1,000
Class:
Same as Epi 1:10,000
Action:
Indication:
Severe allergic reaction

Angioneurotic edema
Bronchial edema
Contraindication:
Use with caution in the presence of:

pre-existing tachydysrhythmias
hypertension
significant cardiac history
pregnancy
Side effect:
Dose:
0.3 mg
Route:
Sub-Q
Pedi dose:
0.01 mg/kg to a max. 0.3 mg

see PALS guidelines
PARAMEDIC PROTOCOL
135
Etomidate
Trade Name: Amidate
Classification: Non-Narcotic, Non-Barbituate sedative hypnotic agent.
Mechanism: Etomidate produces deep hypnosis and sedation with an onset of 10-15 seconds and duration
of 5-15 minutes. It may lower intra-ocular and intra-cerebral pressure, and decrease cerebral oxygen
demand.
Dosage: 0.3mg/kg SIVP over 30-60 seconds.
Route: IV Only. Preferred site is ante-cubital as it may irritate the vasculature.
Indications: Conscious Sedation to facilitate intubation
Contraindications: Known Hypersensitivity. Under ten years of age.
Precautions: Hypoventilation and possible apnea in overdosage.
Myoclonus, or diffuse muscle contraction, which can be painful once the patient awakens. This
can be limited with the use of Ativan or Valium as premedication.
Side Effects: Pain at injection site, Hypotension, apnea, tachycardia, nausea/vomiting.
Note: Etomidate does not cause analgesia, therefore, reflex sympathetic hypertension and tachycardia
may be anticipated.
PARAMEDIC PROTOCOL
136
Lasix
(furosemide)
Class:
Loop diuretic
Action:
Blocks active reabsorption of chloride in the kidney, results in diuresis

Mild venodilation results in decreased preload
Indication:
Pulmonary edema
Contraindication:
Allergy to sulfa drugs

Children under 12 yrs
Pregnancy
Precaution:
Lasix bolus should be given over 1 minute

Lung sounds should be noted before and after administration of Lasix
Patients already taking diuretics may require a high dosage
Side effect:
Dehydration
Decreased circulating plasma volume
Decreased cardiac output
Loss of electrolytes K+ and Mg++
Transient hypotension
Dose:
0.5 - 1.0 mg/kg (usual dose 40 mg)
Route:
IV push - slow
PARAMEDIC PROTOCOL
137
Glucagon
Class:
Pancreatic hormone
Action:
Increases blood glucose by converting liver glycogen to glucose
Indication:
Hypoglycemic patient who does not have IV access

Beta-blocker or calcium channel blocker overdose
Food bolus impaction in the esophagus
Contraindication:
Known hypersensivity
Pheochromocytoma / insulinoma
Precaution:
Mix with own dilutent - do not mix with saline
Side effect:
Nausea / vomiting
Hyperglycemia
Dose:
1mg (1unit)
Route:
IM
Pedi dose:
0.5 - 1mg
PARAMEDIC PROTOCOL
138
Lidocaine
(Xylocaine)
Class:
Antiarrhythmic
Action:
Decreases ventricular irritability

Elevates fibrillation threshold
Indication:
Intractable ventricular fibrillation

Ventricular ectopy consisting of wide complex tachycardia including VT
After successful defibrillation to prevent the reoccurrence of VF
Contraindication:
AV blocks
Sensitivity to medication
Idioventricular rhythms
Sinus bradycardias, SA arrest or block
Ventricular conduction defects
Not used to treat occasional PVCs
Precaution:
Reduce dose in patients with CHF, renal or hepatic diseases
Side effect:
Early: Anxiety, apprehension, decreases LOC, tinnitus, visual

disturbances, euphoria, combativeness, nausea, twitching,
numbness, difficulty breathing or swallowing, decreased heart rate.
Late: Seizure, hypotension, coma, widening QRS complex, prolongation
of the P-R interval, hearing loss, hallucinations.
Dose:
1.0 -1.5 mg/kg, may repeat 3-5 minutes

IV - Drip usual dosage rate 2-4 mg/min
Route:
IV, IO
ET - double usual IV dose.
Pedi dose:
1.0mg/kg total pedi dose-3mg/kg
PARAMEDIC PROTOCOL
139
Magnesium Sulfate
Class:
Electrolyte
Action:
Facilitates the proper function of many enzyme systems in the body

Facilitates the Na-K magnesium dependent ATPase pump
Blocks calcium non-selectively
Indication:
Torsades de pointes
Refractory or recurrent VF or pulseless VT
Refractory seizures
Digitalis-induced cardiac arrhythmias
Pre-eclampsia
Documented hypomagnesemia
Contraindication:
none for field emergency use
Precaution:
Use with caution or not at all in the presence of renal insufficiency or high
degree AV block.
Side effect:
Hypotension - mild but common

Heart block - uncommon
Muscular paralysis, CNS and respiratory depression - toxic effects
Dose:
Torsades, refractory seizures, Digitalis, hypomagnesemia

- 2 grams over 1-2 minutes
Pre-eclampsia
- 4 grams over IV drip over hour
- if actively seizing as above
VF/VT
- 2 grams IV bolus
Route:
IV drip or IV push
PARAMEDIC PROTOCOL
140
Morphine Sulfate
Class:
Narcotic analgesic
Action:
Decreases pain perception and anxiety
Indication:
AMI
Pulmonary Edema
Burns
Injuries not involving mental status changes
Contraindication:
Head injury
Undiagnosed abdominal pain/injury
Multiple trauma
COPD/compromised respirations
Hypotension
Allergic to Morphine, Codeine, Percodan
Side effect:
Respiratory depression or arrest

Decreased LOC
Hypotension
Increased vagal tone (slowed heart rate)
Nausea/vomiting
Pin-point pupils
Increased cerebral blood flow
Urticaria
Dose:
2 to 15mg - dependent on patient situation.
Route:
IV push - slow
IO push - slow
IM
Pedi dose:
0.1mg/kg (usual dose)
PARAMEDIC PROTOCOL
141
Narcan
(naloxone)
Class:
Narcotic antagonist
Action:
Reverses the effects of narcotics by competing for opiate receptor sites.

Will reverse respiratory depression cause by narcotics
Indications: Suspected overdose with depression of sensorium and/or respiration

Diagnostic tool in coma of unknown origin
Contraindication:
none for emergency field use
Side effect:
Narcotic withdrawal
Dose:
0.4mg to 2.0mg IV - titrate to respiratory effort

Alternative route is Intranasal (IN)
Route:
IV push
IM
Pedi dose:
0.01mg/kg
PARAMEDIC PROTOCOL
142
Intra-Nasal Medication Delivery

Utilizing the Mucosal Atomization Device (MAD)
1) Draw Nalaxone into 3cc syringe.
a) Nalaxone concentration will be 1mg per 1cc.
b) Purge all air from syringe.
2) Remove and discard of needle in appropriate sharp proof container.
3) Attach Mucosal Atomization Device.
4) Place tip of MAD into nostril and deliver 1mg per nostril.
5) MAD can be reused on a single patient, and discarded after use.
6) Note medication delivery time.
7) If no response, proceed with intravenous access and intravenous medications.
8) Absorption may be inhibited by:
a) Epistaxis
b) Nasal Septum Deviation
c) Nasal Trauma.
If these conditions are suspected, do not utilize the MAD, proceed with IV access and IV
medication administration.
PARAMEDIC PROTOCOL
143
Neo-Synephrine
(phenylephrine)
Class:
Topical vasoconstrictor
Action:
Stimulates alpha (a) receptors in blood vessels of the nasal mucosa

causing vasoconstriction. Decreases risk and amount of nasal bleeding.
Indication:
Facilitation of nasotracheal intubation
Contraindication:
Precaution:
Administer prior to setting up equipment to allow medication a chance to

take effect.
Side effect:
Hypertension
Palpitations
Dose:
2-4 sprays each nostril
Route:
Nasal spray
PARAMEDIC PROTOCOL
144
Nitroglycerine
Class:
Vascular smooth muscle relaxant
Action:
Systemic vasodilator which decreases myocardial workload and oxygen

consumption.
Indication:
Angina Pectoris
Pulmonary edema
Contraindication:
Hypotension
Children under 12 yrs
Side effect:
Hypotension
Headache and facial flushing
Dizziness, decreased LOC
Dose:
0.4mg may repeat q 3-5 minutes, titrate to pain, effect and blood pressure
Route:
Sublingual - spray or tablet
PARAMEDIC PROTOCOL
145
Procainamide
(pronestyl)
Class:
Antiarrhythmic
Action:
Suppress ventricular activity. May be effective when lidocaine is not.
Indication:
Ventricular dysrhymias not controlled by lidocaine.

- recurrent VT
- refractory PSVT
- refractory VF/Pulseless VT
Contraindication:
Complete heart block

PVCs in conjunction with bradycardia
Precaution:
Hypotension following rapid injection

Widening of the QRS complex and lengthening of the PR or the QT
interval may induce AV conduction disturbances.
Use with caution in patients with AMI
IVP should not exceed 20mg/min. Not to exceed 1 gram total dose.
Side effect:
Hypotension
Heart blocks, asystole, VF
Anxiety
Nausea/vomiting
Seizures
Dose:
20mg/min until one of the following is observed:

- arrhythmia is suppressed
- hypotension ensues
- QRS complex is widened by 50% of its original width
- a total of 1 gram has been given
Route:
IV push
IV infusion (usual dose is 1-4 mg/min IV drip)
Pedi dose:
Not for use in the pediatric patient
PARAMEDIC PROTOCOL
146
Sodium Bicarbonate
(NaHCO3)
Class:
Alkalotic agent
Action:
Neutralizes acid in the blood. May help pH return to normal limits.
Indication:
Combat metabolic acidosis

Tricyclic medication overdose after hyperventilation
Contraindication:
Respiratory acidosis
Not to be used routinely in cardiac arrest
Side effect:
Metabolic alkalosis
Lowers K+ which may increase cardiac irritability
Worsens respiratory acidosis if ventilation is inadequate
Dose:
1.0 Meq/kg, may repeat if indicated at initial dose
Route:
IV push
PARAMEDIC PROTOCOL
147
Solu-Medrol
(methylprednisolone)
Class:
Steroid
Glucocorticoid
Anti-inflammatory
Action:
Thought to stabilize cellular and intracellular membranes
Indication:
Reactive airway disease

Anaphylactic reaction
Spinal cord injury
Contraindication:
Dose:
Reactive airway disease - 40 to 125mg

Spinal cord injury - 30mg/kg IV drip over 15-20 minutes
Route:
IV push - slow
IV drip (infusion)
Pedi dose:
Reactive airway disease - 2 to 4mg/kg
PARAMEDIC PROTOCOL
148
Tetracaine Ophthalmic Solution

Class:
Topical anesthetic for the eye only
Action:
Produces anesthesia in the eye approximately 30 seconds after application
Indication:
For pain control in burns to the eye
Contraindication:
Known allergic reaction to Tetracaine or Novacaine type

medications.
Dose:
1 or 2 drops to the affected eye
Route:
Topically to the eye
Pedi dose:
1 or 2 drops to the affected eye
PARAMEDIC PROTOCOL
149
Thiamine
(Vitamin B1)
Class:
Vitamin
Action:
Essential for normal metabolism of carbohydrates (glucose)
Indication:
Suspected malnourished or alcoholic patients receiving dextrose
Contraindication:
Dose:
100mg
Route:
IV push over one minute

May be given IM
PARAMEDIC PROTOCOL
150
Valium
(diazepam)
Class:
Benzodiazepine
Action:
Decreases cerebral irritability

Calms CNS
Indication:
Major motor seizures

Acute anxiety states
Pre-cardioversion
Contraindication:
Dose:
2 to 20mg to control seizure activity

2 to 5mg for anxiety or pre-cardioversion
Route:
IV push - slow
Pedi dose:
0.5mg/min to control seizure. Total dose 0.5mg/kg
PARAMEDIC PROTOCOL
151
Cardizem
(Diltiazem)
Class:
Calcium channel blocker
Action:
Partial blockade of AV node conduction
Indication:
Atrial fibrillation, atrial flutter, narrow complex tachycardia
Contraindication:
Hypotension
Hypersensivity to drug
Wide complex tachycardia
Known history of Wolf Parkinson White (WPW)
2 or 3 AV block
Relative contraindication: Already on Digoxin and Beta Blocker

Side effect:
May induce VF if given to patient with wide complex tachycardia that is due to
WPW.
May cause hypotension
Dose:
0.25mg/kg average dose 25mg per adult male
Route:
IV push (bolus) given over 2 minutes; reconstitute according to manufacturers

recommendation.
Pedi dose:
0.25mg/kg
Important points:
If patient is hypotensive secondary to drug administration:

- If bradycardia give Atropine
- If not in failure give fluids
- If CHF ensues or worsens administer Dopamine infusion
PARAMEDIC PROTOCOL
152
Hurricaine spray
(benzocaine)
Class:
Topical anesthetic
Action:
Blocks conduction of impulses at the sensory nerve endings.
Indication:
Nasal intubations or oral intubations where patient may still have gag reflex. To
improve patient comfort and tolerance of intubation.
Contraindication:
Known sensitivity to benzocaine products.

Children under 1 year of age.
Precaution:
Children under 6 years of age.
Side effect:
Rash
Dose:
2-3 short sprays to the posterior pharynx, allow approximately 20-30 for effect to
occur.
Route:
PO
PARAMEDIC PROTOCOL
153
REGION V M.A.C.
Spinal Assessment and Immobilization Criteria
Immobilize for ANY Yes Answer(s)
1. High Risk mechanism of Injury
Yes
No

Yes
No

3. Neck or Back pain/Tenderness? (Palpate Entire Spine)
Yes
No
4. Abnormal Sensory/Motor Exam
Yes
No

a. Patient Ejected from Vehicle?

b. Death in Same Passenger Compartment?
c. Fall Greater than 15 Feet or 3 Times Patient Height?
d. Vehicle Rollover (Patients Vehicle)?
e. High Speed1 Collision?
f. Vehicle Vs. pedestrian or Vehicle Vs. Bicycle Collision?
g. Motorcycle Collision/Accident?
h. Unresponsive or Altered Mental Status Following Fall/Collision?
i. Penetrating Injury to Head, Chest or Abdomen?
2. Unreliable Patient History/Exam

a. Confused or Disoriented?
b. Intoxicated2?
c. Psychological/Psychiatric Indications?
d. Head Injury?
e. Loss of Consciousness?
f. Distracting injury(ies)?
g. Unable to Communicate Adequately?
a. Inability to Move?
b. Asymmetrical Movement of Any Extremity?
c. Unable to Communicate Adequately?
d. Complaining of Burning, Tingling, or Numbness in Extremity?
PARAMEDIC PROTOCOL
154

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The Charlotte Hungerford Hospital

Department of Emergency Medicine

Charlotte Hungerford Hospital

Department of Emergency Medicine

ON-LINE MEDICAL DIRECTION

Charlotte Hungerford Hospital

Department of Emergency Medicine

Charlotte Hungerford Hospital

Department of Emergency Medicine

The Charlotte Hungerford Hospital

Charlotte Hungerford Hospital

Department of Emergency Medicine

Description of Chest Pain

Chest pressure or discomfort

Shoulder, neck or jaw pain

Specific location of the chest pain (midsternal, etc.)

Radiation of pain, if present (e.g., to the jaw, back, or shoulders)

Duration of the pain

Factors that precipitated the pain (exercise, stress, etc.)

Type or quality of the pain (dull or sharp)

Associated symptoms (nausea, dyspnea)

Previous episodes of a similar pain (e.g., angina)

Charlotte Hungerford Hospital

Department of Emergency Medicine

Ischemic Cardiac Chest Discomfort

8. Morphine Sulfate 1 to 4mg IVP

Morphine Sulfate 1-4mg (up to 10mg) IVP, titrate to effect

Charlotte Hungerford Hospital

Department of Emergency Medicine

Routine Cardiac Arrest Care

Charlotte Hungerford Hospital

Department of Emergency Medicine

Primary ABCD Survey

Airway: Open the airway

Secondary ABCD Survey

Consider ceasing resuscitation efforts

Charlotte Hungerford Hospital

Department of Emergency Medicine

Assess vital signs

Bradycardia, either absolute

Serious signs or symptoms?a,b

Pacer in place / standby

Charlotte Hungerford Hospital

Department of Emergency Medicine

Pulseless Electrical Activity

Pulseless electrical activity (PEA)

Consider possible causes

Hypovolemia (volume infusion)

Epinephrine 1mg IVP,a,c

If absolute bradycardia (<60 beats/min) or

Ventricular Fibrillation/Pulseless Ventricular Tachycardia Algorithm

Charlotte Hungerford Hospital

Department of Emergency Medicine

Primary ABCD Survey

Rhythm after first 3 shocks?

Persistent or recurrent VF/VT

Secondary ABCD Survey

Focus: more advanced

Epinephrine 1 mg IV push, repeat every 3 to 5

A Airway: place airway

Resume attempts to defibrillate

Resume attempts to defibrillate