EMS Clinical Protocols

Document Title: EMS Clinical Protocols

DOH/CEPAR/Protocols/EMS- Clinical
Document Ref. Number: Version: V1
Protocols/V1/2024

New / Revised: New

Publication Date: February, 2024

Effective Date: February, 2024

Document Control: DoH Strategy Sector

DoH licensed EMS clinicians.

Applies To:

Owner: Center of Emergency Preparedness and Response (CEPAR)

Revision Date: February, 2025

Revision Period: 1 year after publication date

Contact: [email protected]

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 1.Protocol Purpose and Brief

These Protocols are intended to help Abu Dhabi Emirate EMS systems ensure a standardized
approach to the practice of patient care, and to encompass evidence-based protocols (EBP)
as they are developed. This document, when combined with the Abu Dhabi Scope of Practice
document, will form a ceiling and floor for scope prehospital practice and patient care. At the
base level it will define the care that every patient must receive, yet still provide flexibility to
service providers to fit their unique circumstances and needs while remaining within their
scope of practice. The long-term goal is to develop a full range of evidence-based Clinical
Protocols for the practice of EMS medicine. However, until there is a sufficient body of
evidence to support this goal fully, there is a need for this interim expert, consensus-based
step.
Target Audience

While this material is intended to be integrated into an EMS system’s operational guidance
materials by its medical director and other leaders, it is written with the hope that it will be
consumed by field EMS clinicians. This material will form the foundational treatment
pathways for EMS professionals to use in their everyday environment as well as a source of
reference.
To the degree possible, it has been assembled in a format useful for quick reference.
Any set of Protocols must determine a balance between education and patient care. This
document purposefully focuses on the patient care aspect of EMS response. This does not
preclude the individual medical director from using these Protocols and including additional
education as well as incorporation of operational procedures.

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 2. Definitions and Abbreviations

No. Definition Definition

Evidence Based Protocols are guidelines that use
systematic reviews to inform specific clinical
1. EBP circumstances. They are not fixed protocols that must be
followed but are intended for health care professionals
and providers to consider.

2. NASEMOS National Association of EMS Officials

3. NEMSQA National EMS Quality Alliance

Abbreviations

No. Abbreviation Definition

2.1 ACS acute coronary syndrome

2.2 AED automatic external defibrillator

2.3 A-FIB atrial fibrillation

2.4 ALS advanced life support

2.5 AMS altered mental status

2.6 ASA aspirin

2.7 AV atrioventricular

AVPU alert, verbal, pain, unresponsive (neurological status

2.8 measure)

2.9 BiPAP bi-level positive airway pressure

2.10 BLS basic life support

2.11 BP blood pressure

2.12 BPM beats per minute

2.13 BSA body surface area

2.14 BSI body substance isolation

2.15 BVM bag-valve-mask

2.16 CABG coronary artery bypass graft

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2.17 CAD coronary artery disease

2.18 CARES Cardiac Arrest Registry to Enhance Survival

2.19 CC chief complaint

2.20 CDC Centers for Disease Control and Prevention

2.21 CHF congestive heart failure

2.22 CNS central nervous system

2.23 CO carbon monoxide

2.24 CO2 carbon dioxide

2.25 COPD chronic obstructive pulmonary disease

2.26 CP chest pain

2.27 CPAP continuous positive airway pressure

2.28 CPI continuous performance improvement

2.29 CPR cardiopulmonary resuscitation

2.30 C-SECTION caesarean section

2.31 C-SPINE cervical spine

2.32 CT cat scan, Cardiac Technician

2.33 CVA cerebrovascular accident (stroke)

DoH Department of Health – Abu Dhabi

2.34 D5W 5% dextrose in water

2.35 DKA diabetic ketoacidosis

2.36 DNI do not intubate

2.37 DNR do not resuscitate

2.38 DT delirium tremens

2.39 Dx diagnosis

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2.40 ECPR extracorporeal cardiopulmonary resuscitation

2.41 EEG electroencephalogram

2.42 EENT eye, ear, nose, and throat

2.43 EGD extraglottic device

2.44 EKG electrocardiogram

2.45 EMS emergency medical services

2.46 EMT emergency medical technician

2.47 ePCR electronic patient call/care record/report

2.48 ET endotracheal

2.49 ETA estimated time of arrival

2.50 EtCO2 end-tidal carbon dioxide; end-tidal capnography

2.51 ETOH ethanol (alcohol)

2.52 ETT endotracheal tube

2.53 FBAO foreign body airway obstruction

2.54 FiO2 fraction of inspired oxygen

2.55 g gram(s)

2.56 GI gastrointestinal

2.57 gtt drops

2.58 GU genitourinary

2.59 GYN gynecology (gynecological)

2.60 HFNC high flow nasal cannula

2.61 HR heart rate (hour)

2.62 ICU intensive care unit

2.63 IM intramuscular

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2.64 IO intraosseous

2.65 IPPB intermittent positive pressure breathing

2.66 IV intravenous

2.67 IVP intravenous push

2.68 J joules

2.69 JVD jugular vein distension

2.70 kg kilogram

2.71 KVO keep vein open

2.72 L liter

2.73 LMA laryngeal mask airway

2.74 LPM liters per minute

2.75 LR lactated Ringer’s

2.76 MAT multifocal atrial tachycardia

2.77 mcg microgram(s)

2.78 MED medicine

2.79 mg milligram(s)

2.80 mg/dL milligrams per deciliter

2.81 MI myocardial infarction (heart attack)

2.82 mL milliliter

2.83 mmHg millimeters of mercury

2.84 mmol millimole

2.85 MOLST medical orders for life-sustaining treatment

2.86 MS mental status

2.87 msec millisecond

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2.88 MVC motor vehicle crash

2.89 N/V nausea/vomiting

2.90 NC nasal cannula

2.91 NRB non-rebreather

2.92 NS normal saline

2.93 NSR normal sinus rhythm

2.94 OB/GYN obstetrics/gynecology

2.95 O2 oxygen

2.96 P pulse

2.97 PAC premature atrial contraction

2.98 PCR Patient call/care record/report

2.99 PE pulmonary embolus

2.100 PEA pulseless electrical activity

2.101 PO orally

2.102 POLST physician orders for life-sustaining treatment

2.103 PPE personal protection equipment

2.104 prn as needed

2.105 PVC premature ventricular contraction

2.106 q every (e.g., q 3-5 minutes)

2.107 RR respiratory rate

2.108 RSI rapid sequence intubation

2.109 Rx medicine

2.110 sat saturation

2.111 SBP systolic blood pressure

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2.112 SC subcutaneous

2.113 SCBA self-contained breathing apparatus

2.114 SCUBA self-contained underwater breathing apparatus

2.115 SGD supraglottic device

2.116 SL sublingual

2.117 SOB shortness of breath

2.118 ST sinus tachycardia

2.119 SVT supraventricular tachycardia

2.120 T temperature

2.121 TBSA total body surface area

2.122 TCA tricyclic antidepressants

2.123 TIA transient ischemic attack

2.124 TID three times a day

2.125 TKO to keep open

2.126 VF ventricular fibrillation

2.127 VS vital signs

2.128 VT ventricular tachycardia

2.129 y/o years old (years old)

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 3.Recommended Protocol

Acknowledgements
The first authors of the original NASEMQS documents that form the basis for the Protocols were NASEMSO
Medical Director Council members partnered with representatives of seven EMS medical director stakeholder
organizations. The stakeholder organizations are the American Academy of Emergency Medicine (AAEM), the
American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP), the American
College of Surgeons Committee on Trauma (ACS-COT), the Air Medical Physician Association (AMPA), and the
National Association of EMS Physicians (NAEMSP).
In honor and gratitude, the authors of the inaugural Abu Dhabi Emirate EMS Clinical Practice Protocols, the
Abu Dhabi Department of Health, Office of Critical Preparedness and Response (CEPAR), and the Office of the
Medical Director (CEPAR) are also included. Their invaluable contributions and experience building the
foundation of this evolutionary document will always be deeply respected and appreciated.
We are honored to present the first edition of the Abu Dhabi Emirate EMS and pre-hospital emergency Clinical
Protocols and want to thank the entire EMS pre-hospital emergency community for contributing to the
evolution of prehospital medicine in Abu Dhabi. This edition draws upon the skill and expertise of an
international collaboration of EMS professionals in the UAE and is modeled on the National Association of
State EMS Officials (NASEMSO) clinical Guidelines. The inaugural edition’s foundation is the NASEMSP
Guidelines modified, expanded, and tailored to the unique needs and patient population of Abu Dhabi. Great
effort was taken to ensure we considered the best practices of multiple international systems and how they
could be adapted to the UAE, rather than simply adopting the model of any individual country. These
Protocols are created to be a living document, constantly updated, and highly reflective of the state of the art
of prehospital medicine. This document, based on the most current evidence-based practice, reviewed, and
updated by an international panel of experts, will serve as the future model for patient care in prehospital
emergency medicine and transport.
In recognition of the need for a standardized approach to EMS and pre-hospital emergency, and to ensure all
agencies and professionals are practicing the most up to date, evidence-based medicine, the Abu Dhabi
Department of Health will take lead in ensuring these pages serve a functional Protocol for professionals,
professional organizations, hospitals, government, and commercial agencies in Abu Dhabi. It is hoped that
this first edition will serve as a template to be adopted and used across the UAE.
At the heart of prehospital medicine is the teamwork and collaboration between prehospital professionals,
medical directors, hospitals, government agencies, and the patients and population they serve. At the center
of everything we do is the patient, at its heart is a profession of service. This patient centered approach
connects the patient within our care delivery model from prehospital, to emergency, to hospital and
outpatient healthcare, ensuring patients receive the same high-quality evidence-based care regardless of who
or where they are.
It is with the utmost gratitude for the authors of this Protocol, the authors of the NASEMSO Guidelines, the
international EMS experts assembled by the Abu Dhabi Department of Health, the Center for Emergency
Preparedness and Response, and the EMS and pre-hospital emergency community of Abu Dhabi, we present
the 2023 Emergency Medical Services Clinical Practice Protocols.

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Content

The EMS Clinical Protocols can fill a significant gap in uniform clinical guidance for EMS patient care, while
also providing input to the EBP development process. These protocols will be maintained by the Abu Dhabi
Medical Director Office of the Center of Emergency Preparedness and Response (CEPAR) and will be reviewed
and updated periodically. As EBP material is developed, it will be substituted for the consensus-based
Protocols now comprising most of the content of this document. In the interim, additional consensus-based
Protocols will also be added as the need is identified. For Protocols to be considered for inclusion, they must
be presented in the format followed by all Protocols in the document (Annexes 1-11).
While some specific Protocols have been included for pediatric patients, considerations of patient age and
size (pediatric, geriatric, and bariatric) have been interwoven in the Protocols throughout the document.
Where IV access and drug routing are specified, it is intended to include IO access and drug routing when IV
access and drug routing is not possible. Generic medication names are utilized throughout the Protocols. A
list of these, along with respective brand names, may be found in Annex 10.

Accurate and quality data collection is crucial to the advancement of EMS and a critical element of EMS
research. Quality assurance (QA) and/or continued performance improvement (CPI) programs are an
indispensable element of medical direction as they facilitate the identification of gaps and potential avenues
of their resolution within an EMS system. This edition of the Abu Dhabi EMS Clinical Protocols incorporates
many of the NEMSQA performance measures into the key performance measures associated with each
clinical Protocol, and the Appendix contain data collection information and templates for uniform data
collection and registry.

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4.Key Stakeholder Roles and Responsibilities

4.1. CEPAR
4.1.1. Update and maintain these EMS Clinical Protocols for the Emirate of Abu Dhabi
4.1.2. Audit and inspect providers and monitor compliance with these protocols and other relevant
DoH Policies and Standards.
4.1.3. Request improvement actions from healthcare providers in cases where non-compliance is
identified.
4.1.4. Where risks to patient safety and quality are identified, impose sanctions for breaches of DoH
regulations and collaborate with providers to remedy and minimize quality and safety risks.
4.2. DoH-Licensed Emergency Medical Services / Ambulance Service Providers
4.2.1. Responsible for ensuring that their agencies adhere to the latest EMS Clinical Protocols
4.2.2. May either use the EMS Clinical Protocols from DoH or choose to create their own agency
protocols.
4.2.3. If an agency chooses to create their own clinical guidelines, the guidelines must adhere to the
latest EMS Clinical Protocols from DoH. Agency protocols may add or deviate if required by
unique needs or circumstances, these variations should be done in collaboration with the DoH
and approval of DoH CEPAR.
4.2.4. Have policies and procedures in place and the appropriate level of resources (professionals,
medical needs, and supplies) to provide high quality safe management and care of patients.
4.2.5. Comply with all DoH policies and standards for medical storage requirements.
4.2.6. Comply with all DoH policies and standards for medication management, supply, and control
of their use.
4.2.7. Ensure Medical devices are maintained, and quality tested According to manufacturer’s
specifications.
4.2.8. Ensure the secure management of narcotics, controlled and semi-controlled medication.
4.2.9. Cooperate with DoH authorized auditors, as and when requested for inspections and audits by
DoH.
4.2.10. Comply with DoH requirements for managing patient medical records, maintaining
confidentiality, privacy, and security of patient information, and educating patients and
fulfilling the requirements of patient consent and patients ‘rights and responsibilities charter.
4.2.11. A medical oversight mechanism shall be in place to oversee, manage and monitor system
effectiveness and to affect corrective actions and continuous improvements where necessary.
4.2.12. Comply with DoH requirements on adverse events management and reporting, managing
patient medical records, including developing effective recording systems, maintaining patient
records including consent, protecting the confidentiality, privacy, and security of patient
information, and educating patients and fulfilling the requirements of patients’ rights and
responsibilities charter, and comply with DoH requests to inspect and audit records and
cooperate with DoH authorized auditors.
4.2.13. Comply with all requirements of the DoH Medical Direction System for oversight of clinical
practice in EMS and prehospital care.

4.3. Health Care Providers

4.3.1. Healthcare facilities are responsible for ensuring that ambulance services (Be it through facility
owned and/or contracted services), are adhered to the EMS Clinical Protocols.

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 5.Relevant Reference Documents

Reference
No. Reference Name Relation Explanation / Coding / Publication Links
Date

National Association of
State Emergency Medical
Services Officials https://nasemso.org/wp-content/uploads/National-
(NASEMSO). National Model-EMS-Clinical-Guidelines_2022.pdf
Model EMS Clinical
Guidelines. Mar 2023.

6.Annexes

Annex Title
Clause No.
Annex 1 Revision Care
Universal Explanation (changes)

Annex 2 Cardiovascular

Annex 3 General Medical

Annex 4 Resuscitation

Annex 5 Pediatric-Specific Guidelines

Annex 6 Ob/Gyn

Annex 7 Respiratory

Annex 8 Trauma

Annex 9 Toxins And Environmental

Annex 10 Medications

Annex 11 Footnotes

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ANNEXURES- EMS Clinical Protocols
 Table of content

Annex Title Page

Clause No.
Annex 1 Revision Care
Universal Explanation (changes) 2

Annex 2 Cardiovascular 13

Annex 3 General Medical 31

Annex 4 Resuscitation 59

Annex 5 Pediatric-Specific Guidelines 70

Annex 6 Ob/Gyn 84

Annex 7 Respiratory 93

Annex 8 Trauma 107

Annex 9 Toxins And Environmental 132

Annex 10 Medications 140

Annex 11 Footnotes 158

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ANNEX 1: Universal Care

Aliases
1. Patient assessment
2. Primary survey
3. Patient history
4. Physical assessment Secondary survey

Patient Care Goals

Facilitate appropriate initial assessment and management of any EMS patient and link to appropriate
specific Protocols as dictated by the findings within the Universal Care Protocol

Patient Presentation
Inclusion Criteria
All patients encounters with and care delivered by EMS personnel.

Exclusion Criteria
None

Patient Management
Assessment
1- Assess scene safety.
a. Evaluate hazards to EMS personnel, patients, bystanders.
b. Safely remove patient from hazards prior to beginning medical care.
c. Determine number of patients
d. Determine mechanism of injury or potential source of illness
e. Request additional resources if needed and weigh the benefits of waiting for
additional resources against rapid transport to definitive care. MCI declarations
when appropriate.
2- Use appropriate personal protective equipment (PPE)
a. Consider suspected or confirmed hazards on scene.
b. Consider suspected or confirmed highly contagious infectious disease (e.g.,
contact [bodily fluids], droplet, airborne)
3- Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g.,
operations at night or in darkness, on or near roadways)
4- Consider cervical spine stabilization and/or spinal care if traumatic injury is suspected.
[See Spine Care Protocol]
5- Primary survey:
(Airway, Breathing, Circulation (ABC) is cited below; although there are specific
circumstances where Circulation, Airway, Breathing (CAB) may be indicated, such as
for cardiac arrest, or Massive hemorrhage, Airway, Respirations, Circulation,
Hypothermia and head injury (MARCH) may be indicated for trauma or major arterial
bleeding
a. Airway (assess for patency and open the airway as indicated) – go to Airway
Management Protocol:
Patient is unable to maintain airway patency—open airway.
I. Head tilt/chin lift
II. Jaw thrust.
III. Suction.
IV. Consider use of the appropriate airway management adjuncts and
devices: oral airway, nasal airway, supraglottic airway device or
endotracheal tube.

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 V. For patients with laryngectomies or tracheostomies, remove all objects
or clothing that may obstruct the opening of these devices, maintain
the flow of prescribed oxygen, and reposition the head and/or neck.
b. Breathing
I. Evaluate rate, breath sounds, accessory muscle use, retractions, patient
positioning, oxygen saturation.
II. Provide supplemental oxygen as appropriate to achieve the target of
94–98% oxygen saturation (SPO2) based upon clinical presentation
and assessment of ventilation (e.g., EtCO2).
III. Apnea (not breathing) – go to Airway Management Protocol
c. Circulation.
I. Control any major external bleeding [See General Trauma
Management Protocol and/or Extremity Trauma/External Hemorrhage
Management Protocol] .
II. Assess pulse:
 If none – go to Resuscitation Section
 Assess the rate and quality of carotid and radial pulses.
III. Evaluate perfusion by assessing skin color and temperature 1. Evaluate
capillary refill.
d. Disability
I. Evaluate patient responsiveness: AVPU (Alert, Verbal, Painful,
Unresponsive)
II. Evaluate gross motor and sensory function in all extremities.
III. Check blood glucose in patients with altered mental status (AMS) or
suspected stroke. If blood glucose is less than 60 mg/dL – go to
Hypoglycemia Protocol.
IV. If acute stroke suspected – go to Suspected Stroke/Transient Ischemic
Attack Protocol
e. Expose patient for exam as appropriate to complaint.
I. Be considerate of patient modesty.
II. Keep patient warm.

6- Assess the urgency of transport.

7- Secondary survey:
The performance of the secondary survey should not delay transport in critical
patients. See also secondary survey specific to individual complaints in other
protocols. Secondary surveys should be tailored to patient presentation and chief
complaint. The following are suggested considerations for secondary survey
assessment:
a. Head:
I. Pupils
II. Ears
III. Naso-orophraynx
IV. Skull and scalp
b. Neck:
I. Jugular venous distension
II. Tracheal position
III. Spinal tenderness
c. Chest:
I. Retractions
II. Breath sounds
III. Chest wall tenderness, deformity, crepitus, and excursion
IV. Respiratory pattern, symmetry of chest movement with respiration
d. Abdomen/Back:
I. Tenderness or bruising

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 II. Abdominal distension, rebound, or guarding.
III. Spinal tenderness, crepitus, or step-offs
IV. Pelvic stability or tenderness
e. Extremities:
I. Pulses
II. Edema
III. Deformity/crepitus
f. Neurologic:
I. Mental status/orientation
II. Motor/sensory
g. Evaluate for medical equipment (e.g., pacemaker/defibrillator, left ventricular
assist device (LVAD), insulin pump, dialysis fistula)
8- Obtain baseline vital signs (an initial full set of vital signs is required: pulse, blood
pressure, respiratory rate, neurologic status assessment and obtain pulse oximetry if
indicated)
A. Neurologic status assessment [See Footnote III. Neurologic Status
Assessment] involves establishing a baseline and then trending any change
in patient neurologic status:
I. Glasgow Coma Score (GCS) is frequently used, but there are often
errors in applying and calculating this score. With this in
consideration, a simpler field approach may be as valid as GCS.
Either AVPU or only the motor component of the GCS may more
effectively serve in this capacity
II. Sternal rub as a stimulus is discouraged.
B. Patients with cardiac or respiratory complaints
I. Pulse oximetry
II. 12-lead electrocardiogram (EKG) should be obtained promptly in
patients with cardiac or suspected cardiac complaints
III. Continuous cardiac monitoring, if available
IV. Consider waveform capnography for patients with respiratory
complaints (essential for critical patients and those patients who
require invasive airway management)
C. Patient with altered mental status
I. Check blood glucose. If low, go to Hypoglycemia Protocol
II. Consider waveform capnography (essential for critical patients and
those patients who require invasive airway management) or digital
capnometry.
D. Stable patients should have at least two sets of pertinent vital signs. Ideally,
one set should be taken shortly before arrival at the receiving facility.
E. Critical patients should have pertinent vital signs frequently monitored.
9- Obtain OPQRST history:
a. Onset of symptoms
b. Provocation: location; any exacerbating or alleviating factors
c. Quality of pain
d. Radiation of pain
e. Severity of symptoms: pain scale
f. Time of onset and circumstances around onset
10- Obtain SAMPLE history:
a. Symptoms
b. Allergies: medication, environmental, and foods
c. Medications: prescription and over the counter; bring containers to ED if
possible
d. Past medical history
I. Look for medical alert tags, portable medical records, advance
directives.

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 II. Look for medical devices/implants (some common ones may be
dialysis shunt, insulin pump, pacemaker, central venous access port,
gastric tubes, urinary catheter)
III. For females of childbearing age, inquire of potential or recent
pregnancy.
e. Last oral intake
f. Events leading up to the 911 call.
In patients with syncope, seizure, altered mental status, or acute stroke, consider
bringing the witness to the hospital or obtaining their contact phone number to provide
to ED care team.

Treatment and Interventions

1- Administer oxygen as appropriate with a target of achieving 94–98% saturation and
select the appropriate method of oxygen delivery to mitigate or treat hypercarbia
associated with hypoventilation.
2- Place appropriate monitoring equipment as dictated by assessment; these may include:
A. Continuous pulse oximetry
B. Cardiac rhythm monitoring
C. Waveform capnography or digital capnometry
D. Carbon monoxide assessment
3- Establish vascular access if indicated or in patients who are at risk for clinical
deterioration.
A. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of
lidocaine 0.1 mg/mL with slow push through IO needle to a maximum of
40 mg to mitigate pain from IO medication administration.
4- Monitor pain scale if appropriate.
5- Monitor agitation-sedation scale if appropriate.
6- Reassess patient.
Transfer of Care
1- The content and quality of information provided during the transfer of patient care to
another party is critical for seamless patient care and maintenance of patient safety.
2- Ideally, a completed electronic or written medical record should be provided to the next
caregiver at the time of transfer of care.
3- If provision of the completed medical record is not possible at the time of transfer of
care, a verbal report and an abbreviated written run report should be provided to the
next caregiver.
4- The information provided during the transfer of care should include, but is not limited
to:
A. Patient’s full name
B. Age
C. Chief complaint
D. History of present illness/Mechanism of injury
E. Past medical history
F. Medications
G. Allergies
H. Vital signs with documented times
I. Patient assessment and interventions along with the timing of any
medication or intervention and the patient’s response to such interventions
5- The verbal or abbreviated written run report provided at the time of transfer of care
does not take the place of or negate the requirement for the provision of a complete
electronic or written medical record of the care provided by EMS personnel.

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 Patient Safety Considerations
1. Routine use of lights and sirens is not warranted.
2. Even when lights and sirens are in use, always limit speeds to a level that is
safe for the emergency vehicle being driven and road conditions on which it is
being operated.
3. Be aware of legal issues and patient rights as they pertain to and impact patient
care (e.g., patients with functional needs or children with special healthcare
needs)
4. Be aware of potential need to adjust management based on patient age and
comorbidities, including medication dosages.
5. The maximum weight-based dose of medication administered to a pediatric
patient should not exceed the maximum adult dose except where specifically
stated in a patient care Protocol.
6. Medical direction should be contacted when mandated or as needed. If
uncertain, err on the side of contacting medical direction.
7. Consider air medical transport, if available, for patients with time-critical
conditions where ground transport time exceeds 30 minutes.

Notes/Educational Pearls
Key Considerations
1- Pediatrics: use a weight-based assessment tool (length-based tape or other
system) to estimate patient weight and guide medication therapy and adjunct
choice
I. Although the defined age varies, the pediatric population is
generally defined by those patients who weigh up to 40 kg or up
to 14 years of age, whichever comes first.
II. Consider using the pediatric assessment triangle (appearance,
work of breathing, circulation) when first approaching a child to
help with assessment.
2- Geriatrics: although the defined age varies, the geriatric population is generally
defined as those patients who are 65 years old or more
I. In these patients, as well as all adult patients, reduced medication dosages
may apply to patients with renal disease (i.e., on dialysis or a diagnosis of
chronic renal insufficiency) or hepatic disease (i.e., severe cirrhosis or end-
stage liver disease)
3- Co-morbidities: reduced medication dosages may apply to patients with renal
disease (i.e., on dialysis or a diagnosis of chronic renal insufficiency), hepatic
disease (i.e., severe cirrhosis or end-stage liver disease), or the elderly.
4- Vital Signs:
A. Oxygen
I. Administer oxygen as appropriate with a target of
achieving 94–98% saturation.
II. Supplemental oxygen administration is warranted to
patients with oxygen saturations below this level and
titrated based upon clinical condition, clinical response,
and geographic location and altitude.
III. The method of oxygen delivery should minimize or treat
hypercarbia associated with hypoventilation.
B. Normal vital signs (See Table 1. Normal Vital Signs)
I. Hypotension is considered a systolic blood pressure less
than the lower limit on the chart.
II. Tachycardia is considered a pulse above the upper limit
on the chart.
III. Bradycardia is considered a pulse below the lower limit
on the chart.

6
 IV. Tachypnea is considered a respiratory rate above the
upper limit on the chart.
V. Bradypnea is considered a respiratory rate below the
lower limit on the chart.
C. Hypertension. Although abnormal, may be an expected finding in
many patients:
I. Unless an intervention is specifically suggested based on
the patient’s complaint or presentation, the hypertension
should be documented, but otherwise, no intervention
should be taken acutely to normalize the blood pressure.
II. The occurrence of symptoms (e.g., chest pain, dyspnea,
vision change, headache, focal weakness or change in
sensation, altered mental status) in patients with
hypertension should be considered concerning, and care
should be provided appropriate with the patient’s
complaint or presentation.
5- Secondary Survey: if patient has critical primary survey problems, it may not
be possible to complete.
6- Critical Patients: proactive patient management should occur simultaneously
with assessment:
A. Ideally, one clinician should be assigned to exclusively monitor and
facilitate patient-focused care.
B. Other than lifesaving interventions that prevent deterioration en route,
treatment and Interventions should be initiated as soon as practical, but
should not impede extrication or delay transport to definitive care.
7- Air Medical Transport: air transport of trauma patients should generally be
reserved for higher acuity trauma patients where there is a significant time
saved over ground transport, where the appropriate destination is not accessible
by ground due to systemic or logistical issues, and for patients who meet
anatomic, physiologic, and situational high-acuity triage criteria. In selected
circumstances, air medical resources may be helpful for non-trauma care (e.g.,
stroke, STEMI when geographically constrained or when ground distances
would place patient outside of a treatment window).
8- Additional Protective Measures for the EMS Clinician: Due to suspected or
confirmed hazards and/or highly infectious contagious diseases, traditional
patient treatment and care delivery may be altered due to recommendations by
national, local or jurisdictional officials.

Quality Improvement
Key Documentation Elements
• At least two sets of vital signs should be documented for every patient.
• All patient interventions and response to care should be documented.
• All major changes in clinical status including, but not limited to, vital signs and data from
monitoring equipment, should be documented.

Performance Measures
• Abnormal vital signs should be addressed and reassessed.
• Response to therapy provided should be documented including pain scale, improvement or
deterioration in patient clinical status, or agitation-sedation scale (e.g., Richmond Agitation-
Sedation Scale (RASS)) reassessment if appropriate.
• Limit scene time for patients with time-critical illness or injury unless clinically indicated.
• Appropriate utilization of air medical services
• Blood glucose level obtained when indicated.
• Appropriate triage and transport to designated centers (e.g. trauma, STEMI) when indicated
• Compliance with provision of critical information during patient transfer of care

7
Table 1. Normal Vital Signs

Age Pulse-Awake Pulse-Sleeping Respiratory Rate Systolic BP

(beats/minute) (beats/minute) (breaths/minute) (mmHg)
Preterm less than 1 120–160 30–60 39–59
kg
Preterm 1–3 kg 120–160 30–60 60–76
Newborn 100–205 85–160 30–60 67–84
Up to 1 year 100–190 90–160 30–60 72–104
1–2 years 100–190 90–160 24–40 86–106
2–3 years 98–140 60–120 24–40 86–106
3–4 years 80–140 60–100 24–40 89–112
4–5 years 80–140 60–100 22–34 89–112
5–6 years 75–140 58–90 22–34 89–112
6–10 years 75–140 58–90 18–30 97–115
10–12 years 75–118 58–90 18–30 102–120
12–13 years 60–100 58–90 15–20 110–131
13–15 years 60–100 50–90 15–20 110–131
15 years or older 60–100 50–90 15–20 110–131
Source: Extrapolated from the 2020 American Heart Association Pediatric Advanced Life Support’s tables
from the Nursing Care of the Critically Ill Child, and from Web Box 1: Existing reference ranges for respiratory
rate and heart rate in the Annex of the article by Fleming, et al, published in Lancet
Note: While many factors affect blood pressure (e.g., pain, activity, hydration), it is imperative to rapidly
recognize hypotension, especially in children. For children of the ages 1–10, hypotension is present if the
systolic blood pressure is less than 70 mmHg + (child’s age in years x 2) mmHg.
Table 2. Glasgow Coma Scale
ADULT GLASGOW COMA SCALE PEDIATRIC GLASGOW COMA SCALE
Eye Opening (4) Eye Opening (4)
Spontaneous 4 Spontaneous 4
To Speech 3 To Speech 3
To Pain 2 To Pain 2
None 1 None 1
Best Motor Response (6) Best Motor Response (6)
Obeys Commands 6 Spontaneous Movement 6
Localizes Pain 5 Withdraws to Touch 5
Withdraws from Pain 4 Withdraws from Pain 4
Abnormal Flexion 3 Abnormal Flexion 3
Abnormal Extension 2 Abnormal Extension 2
None 1 None 1
Verbal Response (5) Verbal Response (5)
Oriented 5 Coos, Babbles 5
Confused 4 Irritable Cry 4
Inappropriate 3 Cries to Pain 3
Incomprehensible 2 Moans to Pain 2
None 1 None 1
Total Total
Source: https://www.cdc.gov/masstrauma/resources/gcs.pdf

8
Functional Needs
Aliases
1. Person of determination
2. Developmental delay
3. Special needs
4. Handicapped
5. Intellectual Disability
6. Disabled

Patient Care Goals

To meet and maintain the additional support required for patients with functional needs (person of
determination) during the delivery of prehospital care.

Patient Presentation
Inclusion Criteria
Patients who are identified by the World Health Organization’s International Classification of
Functioning, Disability, and Health have experienced a decrement in health resulting in some
degree of disability. This includes, but is not limited to, individuals with physical, sensory,
mental health, and cognitive and/or intellectual disabilities affecting their ability to function
independently without assistance.

Exclusion Criteria
None noted

Patient Management
Assessment
1. Identify the functional need by means of information from the patient, the
patient’s family, bystanders, medic alert bracelets or documents, or the patient’s
adjunct assistance devices
2. The physical examination should not be intentionally abbreviated, although
the way the exam is performed may need to be modified to accommodate the specific
needs of the patient

Treatment and Interventions

Medical care should not intentionally be reduced or abbreviated during the triage, treatment,
and transport of patients with functional needs, although the way the care is provided may
need to be modified to accommodate the specific needs of the patient

Patient Safety Considerations

For patients with communication barriers (language or sensory), it may be desirable to obtain
secondary confirmation of pertinent data (e.g., allergies) from the patient’s family,
interpreters, or written or electronic medical records. The family members can be an excellent
source of information and the presence of a family member can have a calming influence on
some of these patients

Notes/Educational Pearls
Key Considerations
1. Communication Barriers
a. Language Barriers:
i.Expressive and/or receptive aphasia
ii.Nonverbal
iii.Fluency in a different language than that of the EMS professional
iv.Examples of tools to overcome language barriers include:

9
 1. Transport of an individual who is fluent in the patient’s
language along with the patient to the hospital
2. Medical translation cards
3. Telephone-accessible services with live language
interpreters
4. Methods through which the patient augments his/her
communication skills (e.g., eye blinking, nodding) should be noted,
utilized as able, and communicated to the receiving facility
5. Electronic applications for translation
b. Sensory Barriers:
i.Visual impairment
ii.Auditory impairment
iii.Examples of tools to overcome sensory barriers include:
1. Braille communication card
2. Sign language
3. Lip reading
4. Hearing aids
5. Written communication
2. Physical Barriers:
a. Ambulatory impairment (e.g., limb amputation, bariatric)
b. Neuromuscular impairment
3. Cognitive Barriers:
a. Mental illness
b. Developmental challenge or delay

Pertinent Assessment Findings

1. Assistance Adjuncts. Examples of devices that facilitate the activities of daily living for the
patient with functional needs include, but are not limited to:
a. Extremity prostheses
b. Hearing aids
c. Magnifiers
d. Tracheostomy speaking valves
e. White or sensory canes
f. Wheelchairs or motorized scooters

Patient Refusals
Aliases
1. Against medical advice
2. Refusal of treatment
3. Refusal of transport

Patient Care Goals/Patient Presentation (Overview)

If an individual (or the parent or legal guardian of the individual) refuses secondary care and/or
ambulance transport to a hospital after prehospital clinicians have been called to the scene, clinicians
should determine the patient’s capacity to make decisions. Competency is generally a legal status of a
person’s ability to make decisions. One should consult with the respective EMS office of medical
director for clarification on legal definitions and patient rights.

Patient Management
Assessment
1. Decision-Making Capacity
a. An individual who is alert, oriented, and can understand the circumstances
surrounding his/her illness or impairment, as well as the possible risks associated

10
 with refusing treatment and/or transport, typically is considered to have decision-
making capacity
b. The individual’s judgment must also not be significantly impaired by illness,
injury, or drugs/alcohol intoxication. Individuals who have attempted suicide,
verbalized suicidal intent, or had other factors that lead EMS clinicians to suspect
suicidal intent, should not be regarded as having decision-making capacity and
may not decline transport to a medical facility

Treatment and Interventions

1. Obtain a complete set of vital signs and complete an initial assessment,
paying particular attention to the individual’s neurologic and mental status
2. Determine the individual’s capacity to make a valid judgment concerning the
extent of his/her illness or injury; if the EMS clinician has doubts about whether the
individual has the mental capacity to refuse or if the patient lacks capacity, the EMS
clinician should contact medical direction
4. If patient has capacity, clearly explain to the individual and all responsible
parties the possible risks and overall concerns with regards to refusing care and that
they may reengage the EMS system if needed
5. Perform appropriate medical care with the consent of the individual, refusal
of transport does not imply the patient is refusing all treatment
6. Complete the patient care report clearly documenting the initial assessment
findings and the discussions with all involved individuals regarding the possible
consequences of refusing additional prehospital care and/or transportation

Notes/Educational Pearls
Key Considerations
1- An adult who has demonstrated possessing sufficient mental capacity for making
decisions has the right to determine the course of his/her medical care, including the
refusal of care
2- Individuals must be advised of the risks and consequences resulting from refusal of
medical care to enable an informed decision regarding consent or refusal of
treatment.
3- An individual determined to lack decision-making capacity by EMS clinicians
should not be allowed to refuse care against medical advice or to be leased at
the scene. Mental illness, drugs, alcohol intoxication, or physical/mental impairment
may significantly impair an individual’s decision-making capacity. Individuals who
have attempted suicide, verbalized suicidal intent, or had other factors that lead EMS
clinicians to suspect suicidal intent, should not be regarded as having demonstrated
sufficient decision-making capacity.
4- The determination of decision-making capacity may be challenged by communication
barriers or cultural differences.
5- EMS clinicians should not put themselves in danger by attempting to treat and/or
transport an individual who refuses care. Law enforcement personnel should be
requested if needed.
6- Always act in the best interest of the patient. EMS clinicians, with the support of
direct medical oversight, must strike a balance between abandoning the patient and
forcing care.
7- Special Considerations – Minors
It is preferable for minors to have a parent or legal guardian who can provide consent
for treatment on behalf of the child:
Healthcare clinicians may provide emergency treatment when a parent is not
available to provide consent. This is known as the emergency exception rule or the
doctrine of implied consent. For minors, this doctrine means that the EMS clinician
can presume consent and proceed with appropriate treatment and transport if the
following six conditions are met:

11
 I. The child is suffering from an emergency condition that places their life or
health in danger.
II. The child’s legal guardian is unavailable or unable to provide consent for
treatment or transport.
III. Treatment or transport cannot be safely delayed until consent can be
obtained.
IV. The EMS clinician administers only treatment for emergency conditions that
pose an immediate threat to the child.
V. As a rule, when the EMS clinician’s authority to act is in doubt, EMS
clinicians should always do what they believe to be in the best interest of the
minor.
VI. If a minor is injured or ill and no parent contact is possible, the EMS clinician
may contact medical direction for additional instructions.

Quality Improvement
Key Documentation Elements
• Document patient capacity with:
I. Exam fields for “eExam.19—Mental Status” and “eExam.20—
Neurological Assessment”
II. Vitals for level of responsiveness and Glasgow Coma Scale
III. Alcohol and drug use indicators
IV. Blood glucose level (as appropriate to situation and patient
history)
• Patient Age
• Minors who and adults with a legal guardian: guardian name, contact, and relationship
• Any efforts made to contact guardians if contact could not be made
• What the patient’s plan is after refusal of care and/or transport
• Who will be with the patient after EMS departs
• Patient was advised that they can change their mind and EMS can be contacted again at any
time.
• Patient was advised of possible risks to their health resulting from refusing care and/or
transport.
• Patient voices understanding of risks. A quotation of the patient’s actual words, stating they
understand, is best
• Reason for patient refusing care. A quotation of the patient’s actual words, stating they
understand, is best
• Medical direction contact
• Any assessments and treatments performed.

Performance Measures
• Patient decision-making capacity was determined and documented.
• Medical direction was contacted if indicated by EMS agency protocol.
• Guardians contacted or efforts to contact the guardians for minor patients.

IX 1
ANNEX 1

12
ANNEX 2: Cardiovascular

Adult and Pediatric Syncope and Near Syncope

Aliases
Loss of consciousness

Patient Care Goals

1. Stabilize and resuscitate when necessary
2. Initiate monitoring and diagnostic procedures
3. Transfer for further evaluation

Patient Presentation
1. Syncope is heralded by both the loss of consciousness and the loss of postural tone and
resolves spontaneously without medical interventions. Syncope typically is abrupt in onset
and resolves equally quickly. EMS clinicians may find the patient awake and alert on initial
evaluation
2. Near syncope is defined as the prodromal symptoms of syncope. The symptoms that can
precede syncope last for seconds to minutes with signs and symptoms that may include
pallor, sweating, lightheadedness, visual changes, or weakness. It may be described by the
patient as “nearly blacking out” or “nearly fainting”. Near syncope should be treated as
syncope for the purpose of these Protocols
3. Rapid first aid during the onset may improve symptoms and prevent syncope

Inclusion Criteria
1. Abrupt loss of consciousness with loss of postural tone
2. Prodromal symptoms of syncope

Exclusion Criteria
Conditions other than the above, including:
1. Patients with alternate and obvious cause of loss of consciousness (e.g., trauma – See Head
Injury Protocol)
2. Patients with ongoing mental status changes or coma should be treated per the Altered
Mental Status Protocol
3. Patients with persistent new neurologic deficit [See Suspected Stroke/Transient Ischemic
Attack Protocol]

Patient Management
Assessment
1. Pertinent History
a. Review the patient’s past medical history including a history of:
I. Cardiovascular disease (e.g., cardiac disease/stroke, valvular disease,
hypertrophic cardiomyopathy, mitral valve prolapse)
II. Seizure
III. Recent trauma
IV. Active cancer diagnosis
V. Dysrhythmias including prior electrophysiology studies/pacemaker
and/or implantable cardioverter defibrillator (ICD)
VI. History of syncope
VII. History of thrombosis or emboli
b. History of Present Illness, including:

13
 I. Conditions leading to the event: after transition from recumbent/sitting
to standing; occurring with strenuous exercise (notably in the young
and seemingly healthy)
II. Syncope that occurs during exercise often indicates an ominous
cardiac cause. Patients should be evaluated in the emergency
department.
III. Patient complaints before or after the event including prodromal
symptoms
IV. History of symptoms described by others on scene, including seizures
or shaking, presence of pulse/breathing (if noted), duration of the
event, events that lead to the resolution of the event
c. Review of Systems:
I. Current medications (new medications, changes in doses)
II. Fluid losses (nausea/vomiting/diarrhea) and fluid intake iii. Last
menstrual period/pregnant
III. Occult blood loss (gastrointestinal (GI)/genitourinary (GU))
IV. Palpitations
V. Unilateral Leg swelling, history of recent travel, prolonged
immobilization, malignancy
d. Pertinent Physical Exam including:
I. Attention to vital signs and evaluation for trauma
II. Note overall patient appearance, diaphoresis, pallor
III. Detailed neurologic exam (including stroke screening and mental
status)
IV. iv. Heart, lung, abdominal, and extremity exam
V. Additional Evaluation:
a. Cardiac monitoring
b. Oxygen saturation (SPO2)
c. Ongoing vital signs
d. 12-lead EKG
e. Blood glucose level (BGL)

Treatment and Interventions:

1. Should be directed at abnormalities discovered in the physical exam or on additional
examination and may include management of cardiac dysrhythmias, cardiac
ischemia/infarct, hemorrhage, shock, etc.
a. Manage airway as indicated
b. Oxygen as appropriate
c. Evaluate for hemorrhage and treat for shock if indicated
d. Establish IV access
e. Fluid bolus if appropriate
f. Cardiac monitor
g. 12-lead EKG
h. Monitor for and treat arrhythmias (if present, refer to appropriate Protocol)

Patient Safety Considerations:

1. Patients suffering from syncope due to arrhythmia may experience recurrent
arrhythmias and should therefore be placed on a cardiac monitor
2. Geriatric patients suffering falls from standing may sustain significant injury
and should be diligently screened for trauma. [General Trauma Management
Protocol]

14
Notes/Educational Pearls
Key Considerations
1. By being most proximate to the scene and to the patient’s presentation, EMS
clinicians are commonly in a unique position to identify the cause of syncope.
Consideration of potential causes, ongoing monitoring of vitals and cardiac
rhythm and detailed exam and history are essential pieces of information to pass
on to hospital clinicians
2. For patients where a lower risk etiology is suspected, e.g., vasovagal syncope
with normal ecg, decisions regarding delayed or non-transport should be made
in consultation with medical direction
3. High-risk causes of syncope include, but are not limited to, the following:
a. Cardiovascular
I. Myocardial infarction
II. Aortic stenosis
III. Hypertrophic cardiomyopathy (consider in young patient with
unexplained syncope during exertion)
IV. Pulmonary embolus
V. Aortic dissection
VI. Dysrhythmia
VII. Mitral valve prolapse is associated with higher risk for sudden death
b. Neurovascular
I. Intracranial hemorrhage
II. Transient ischemic attack or stroke
III. Vertebral basilar insufficiency
c. Hemorrhagic
I. Ruptured ectopic pregnancy
II. GI bleed
III. Aortic rupture
4. Consider high-risk 12-lead EKG features including, but not limited to:
a. Evidence of QT prolongation (generally over 500 msec)
b. Delta waves
c. Brugada syndrome (incomplete right bundle branch block (RBBB)
pattern in V1/V2 with ST segment elevation)
d. Hypertrophic obstructive cardiomyopathy

Pertinent Assessment Findings

1. 12-lead EKG findings
2. Evidence of alternate etiology, including seizure
3. Evidence of cardiac dysfunction (e.g., evidence of congestive heart failure
(CHF), arrhythmia)
4. Evidence of hemorrhage
5. Evidence of neurologic compromise
6. Evidence of trauma
7. Initial and ongoing cardiac rhythm

Quality Improvement

Key Documentation Elements

o Presenting cardiac rhythm
o Cardiac rhythm present when patient is symptomatic
o Any cardiac rhythm changes
o Blood pressure
o Pulse

15
 o Blood glucose level (BGL)
o Symptoms immediately preceding event
o Patient status on EMS arrival: recovered or still symptomatic

Performance Measures
o Acquisition of 12-lead EKG
o Application of cardiac monitor

Chest Pain/Acute Coronary Syndrome (ACS)/ST-segment Elevation Myocardial

Infarction (STEMI)

Aliases
1. Heart attack
2. Myocardial infarction (MI)

Patient Care Goals

1. Identify ST-elevation myocardial infarction (STEMI) quickly 2. Determine the time of
symptom onset
3. Activate hospital-based STEMI system of care
4. Monitor vital signs and cardiac rhythm and be prepared to provide CPR and defibrillation
if needed
5. Administer appropriate medications
6. Transport to appropriate facility

Patient Presentation
Inclusion Criteria
1. Chest pain or discomfort in other areas of the body (e.g., arm, jaw, epigastrium) of
suspected cardiac origin, shortness of breath, associated or unexplained sweating,
nausea, vomiting, or dizziness. Atypical or unusual symptoms are more common in
women, the elderly, and diabetic patients. May also present with CHF, syncope, and/or
shock
2. Chest pain associated sympathomimetic use (e.g., cocaine, methamphetamine)
3. Some patients will present with likely non-cardiac chest pain and otherwise have
a low likelihood of ACS (e.g., blunt trauma to the chest of a child). For these
patients, defer the administration of aspirin (ASA) and nitrates per the Pain
Management Protocol

Exclusion Criteria
None noted

Patient Management
Assessment, Treatment, and Interventions
a. Signs and symptoms include chest pain, congestive heart failure
(CHF), syncope, shock, symptoms similar to a patient’s previous
MI
2. Assess the patient’s cardiac rhythm and immediately address
pulseless rhythms, symptomatic tachycardia, or symptomatic
bradycardia [See Cardiovascular Section and Resuscitation
Section]
3. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure,
EMS clinicians should administer oxygen as appropriate with a target of
achieving 94–98% saturation [Refer to Universal Care Protocol]

16
 4. The 12-lead EKG is the primary diagnostic tool that identifies a STEMI; it
is imperative that EMS clinicians routinely acquire a 12-lead EKG within 10
minutes for all patients exhibiting signs and symptoms of ACS
a. The EKG may be transmitted for remote interpretation by a
physician or screened for STEMI by properly trained EMS
clinicians or other healthcare providers with or without the
assistance of computer-interpretation
b. Advance notification should be provided to the receiving hospital
for patients identified as having a STEMI
c. Performance of serial EKGs is encouraged for symptomatic patients
with EKGs initially non-diagnostic for STEMI
d. All EKGs should be made available to treating personnel at the
receiving hospital, whether hand delivered as hard copy or
transmitted from the field
5. Administer aspirin; chewable, non-enteric-coated aspirin preferred
(162–325 mg)
6. Establish IV access
7. Nitroglycerin 0.4 mg sublingual (SL), can repeat every 3–5 minutes if SBP
greater than 100 mmHg
a. The use of nitrates should be avoided in any patient who has used a
phosphodiesterase inhibitor within the past 48 hours
b. Examples include sildenafil (Viagra®, Revatio®), vardenafil (Levitra®,
Staxyn®), tadalafil (Cialis®, Adcirca®) which are used for erectile
dysfunction and pulmonary hypertension. Also avoid use in patients
receiving intravenous epoprostenol (Flolan®) or treporstenil
(Remodulin®) which is used for pulmonary hypertension
c. Care should always be taken when giving nitroglycerin when the patient’s
blood pressure is marginal. If used in this setting, the clinician should
weigh the risk and benefit of nitrate administration over the
administration of an opiate analgesic and be ready to respond to
hypotension with fluid bolus
8. The location of the infarct does not preclude the use of nitrates. Right-sided leads
are of no additional value if an inferior STEMI has been diagnosed and such
findings (presumed RV infarct) do not preclude the use of nitroglycerin: however,
continually monitor the patient’s hemodynamic status and be prepared to
resuscitate if hypotension occurs
9. If the pain is unresponsive to nitrates, opiates are an acceptable alternative.
Morphine should be used with caution in unstable angina (UA)/non-STEMI due to
an association with increased mortality
10. Transport and destination decisions should be based on local resources and
system of care
11. Early notification to receiving facility of any changes in patient condition or serial
EKGs

Patient Safety Considerations

a. Observe for signs of clinical deterioration: dysrhythmias, chest pain,
shortness of breath, decreased level of consciousness/syncope, or other
signs of shock/hypotension
2. Perform serial 12-lead EKGs (especially if clinical changes are
noted) 3. Consider placing defibrillator pads on high-risk
patients
3. Consider configuring monitor/defibrillator to allow automatic VT/VF alert
4. Consider configuring monitor/defibrillator to allow ST-segment trending if available

17
Notes/Educational Pearls
Key Considerations
Acute coronary syndrome may present with atypical pain, vague or only generalized
complaints.

Ischemic burden time is a risk for morbidity and mortality, EMS can help decrease first
medical contact to intervention time/reflow by efficient training and of safely
minimizing on scene time

Pertinent Assessment Findings

A complete medication list should be obtained from each patient. It is especially
important for the treating physician and healthcare providers to be informed if the patient
is taking beta-blockers, calcium channel blockers, clonidine, digoxin, blood thinners
(anticoagulants), and medications for the treatment of erectile dysfunction or pulmonary
hypertension

Quality Improvement
Key Documentation Elements
• The time of symptom onset
• The time of patient contact by EMS to the time of 12-lead EKG acquisition
• The time aspirin (ASA) administered, or reason why not given
• The time of STEMI notification

Performance Measures
• The time of patient contact by the first medical provider to the time of 12-lead EKG
acquisition within 10 minutes
• The time from first diagnostic 12-lead EKG to STEMI notification
• Confirmation patient received ASA (taken prior to EMS arrival, advised by
dispatch, given by EMS, or substantiated by other pertinent negatives)
• The time of a STEMI patient’s ultimate arrival to a receiving hospital
*The time of EMS notification to the time of activation of a cardiac catheterization
laboratory
*The time of arrival at the percutaneous coronary intervention (PCI) center to the time of
cardiac catheterization (door-to-balloon time) or if patient not transported directly to PCI
center, the time of arrival at receiving hospital to thrombolytics
*The time of prehospital 12-lead EKG acquisition to the time of device deployment
(formerly EKG-to-balloon time)

18
Bradycardia

Aliases
1. Heart block
2. Junctional rhythm

Patient Care Goals

1. Maintain adequate perfusion
2. Treat underlying cause:
a. Hypoxia
b. Shock
c. Second- or third-degree atrioventricular (AV) block
d. Toxin exposure (beta-blocker, calcium channel blocker, organophosphates,
digoxin)
e. Electrolyte disorder
f. Hypoglycemia
g. Increased intracranial pressure (ICP)
h. Other

Patient Presentation
Inclusion Criteria
1. Heart rate less than 60 beats per minute (BPM) with either symptoms (altered
mental status (AMS), chest pain (CP), congestive heart failure (CHF), seizure,
syncope, shock, pallor, diaphoresis) or evidence of hemodynamic instability
2. The major EKG rhythms classified as bradycardia include:
a. Sinus bradycardia
b. Second-degree AV block
i. Type I-Wenckebach/Mobitz II
ii.Type II-Mobitz II
c. Third-degree AV block, complete heart block d. Ventricular escape rhythms
3. See additional inclusion criteria for pediatric patients

Exclusion Criteria None noted

Patient Management
Assessment, Treatment, and Interventions
1. Adult Management
a. Manage airway as necessary
b. Administer oxygen as appropriate with a target of achieving 94–98% saturation
c. Initiate monitoring and perform 12-lead EKG
d. Establish IV access
e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Protocol and
Hyperglycemia Protocol
f. Consider the following additional therapies if bradycardia and symptoms or
hemodynamic instability continue:
i.Atropine 1 mg IV every 3–5 minutes (maximum total dose of 3 mg)
ii.Vasopressor medications (in order of preference)
1. Epinephrine (Adrenaline) IV drip 0.02–0.2 mcg/kg/min titrated to a
MAP greater than 65 mmHg OR
2. Epinephrine (Adrenaline) by push dose (dilute boluses): for example,
prepare 10 mcg/mL by adding 1 mL of 0.1 mg/mL epinephrine to 9 mL of
normal saline, then administer 10–20 mcg boluses (1–2 mL) q 2 minutes
titrated MAP greater than 65 mmHg OR
3. Norepinephrine (Noradrenaline) 0.02–0.4 mcg/kg/minute IV titrated
to a MAP greater than 65 mmHg

19
 iii. Transcutaneous Pacing – If pacing is performed, consider sedation or pain control
2. Pediatric Management
Treatment is only indicated for patients who are symptomatic (pale/cyanotic, diaphoretic,
altered mental status, hypoxic)
a. For infants and newborns, initiate chest compressions for heart rate less than
60 BPM and signs of poor perfusion (altered mental status, hypoxia, hypotension,
weak pulse, delayed capillary refill, cyanosis)
b. Manage airway and assist ventilations as necessary with minimally
interrupted chest compressions using a compression-to-ventilation ratio 15:2 (30:2
if single clinician is present)
c. Administer oxygen as appropriate with a target of achieving 94–98%
saturation
d. Initiate monitoring and perform 12-lead EKG
e. Establish IV access
f. Check blood glucose and treat hypoglycemia per the Hypoglycemia Protocol
g. Consider the following additional therapies if bradycardia and symptoms or
hemodynamic instability continue:
i.Epinephrine (Adrenaline) by push dose (dilute boluses). For example, prepare
10 mcg/mL by adding 1 mL of 0.1 mg/mL epinephrine to 9 mL of normal
saline, then administer 0.01 mg/kg (0.1 mL/kg) maximum single dose 10 mcg
(1 mL) q 3–5 minutes titrated to MAP greater than 65 mmHg
ii.Also consider atropine 0.01–0.02 mg/kg IV with minimum dose of 0.1 mg if
increased vagal tone or cholinergic drug toxicity to maximum initial dose of 0.5
mg (maximum total dose of 3 mg)
iii.Transcutaneous pacing: If pacing is performed, consider sedation or pain
control
iv.Epinephrine (Adrenaline) may be used for bradycardia and poor perfusion
unresponsive to ventilation and oxygenation
1. It is reasonable to administer atropine for bradycardia caused by increased vagal
tone or cholinergic drug toxicity

Patient Safety Considerations

If pacing is performed, consider sedation or pain control

Notes/Educational Pearls
Key Considerations
1. Observe for signs of decreased end-organ perfusion: chest pain (CP), shortness of breath
(SOB), decreased level of consciousness, syncope, or other signs of shock/hypotension
2. Patients who have undergone cardiac transplant will not respond to atropine
3. Consider potential culprit medications including beta-blockers, calcium channel blockers,
sodium channel blockers/anti-depressants, digoxin, and clonidine
a. If medication overdose is considered, refer to appropriate Protocol in the Toxins and
Environmental Section
4. The differential diagnosis includes the following: myocardial infarction (MI), hypoxia,
pacemaker failure, hypothermia, sinus bradycardia, athletes, head injury with increased
intracranial pressure (ICP), stroke, spinal cord lesion, sick sinus syndrome, AV blocks,
overdose, cholinergic nerve agents
5. Consider hyperkalemia in the patient with wide complex bradycardia
6. Bradycardia should be managed via the least invasive manner possible, escalating care as
needed
a. Third-degree heart block or the denervated heart (as in cardiac transplant) may not
respond to atropine and in these cases, proceed quickly to chronotropic agents (such
as epinephrine or dopamine) or transcutaneous pacing
b. Dopamine is not indicated for pediatric patients

20
 c. In cases of impending hemodynamic collapse, proceed directly to transcutaneous
pacing d. For shock that is suspected to be from sepsis, norepinephrine is preferred
over dopamine due to its reduced risk of arrhythmias and its lower mortality rate
7. Be aware of acute coronary syndrome as a cause of bradycardia in adult patients
8. When dosing medications for pediatric patients, dose should be weight-based for non-
obese patients and based on ideal body weight for obese patients

Pertinent Assessment Findings

None noted

Quality Improvement
Key Documentation Elements
• Cardiac rhythm/rate
• Time, dose, and response of medications given
• Pacing: Time started or stopped, rate, joules, capture, and response rate0
• Patient weight
• Pediatric length-based tape color (for pediatrics who fit on tape)
• History of event supporting treatment of underlying causes

Implantable Ventricular Assist Devices

Aliases
1. Biventricular assist device (BiVAD)
2. Right ventricular assist device (RVAD)
3. Left ventricular assist device (LVAD)
4. Ventricular assist device (VAD)

Patient Care Goals

1. Rapid identification of, and interventions for, cardiovascular compromise in patients
with VADs 2. Rapid identification of, and interventions for, VAD-related malfunctions
or complications

Patient Presentation
Inclusion Criteria
1. Adult patients that have had an implantable ventricular assist device (VAD),
including a left ventricular assist device (LVAD), right ventricular assist device
(RVAD), or biventricular-assist device (BiVAD) and have symptoms of
cardiovascular compromise
2. Patients with VADs that are in cardiac arrest
3. Patients with VADs that are experiencing a medical or injury-related event not
involving the cardiovascular system or VAD malfunction

Exclusion Criteria
Adult patients who do not have a VAD in place

Patient Management
Assessment
1. Assess for possible pump malfunction
a. Assess for alarms
b. Auscultate for pump sound “hum”
c. Signs of hypoperfusion including pallor, diaphoresis, altered mental status
2. If the VAD pump has malfunctioned:

21
 a. Utilize available resources to troubleshoot potential VAD malfunctions and to
determine appropriate corrective actions to restore normal VAD function:
i. Contact the patient’s VAD-trained companion, if available
ii. Contact the patient’s VAD coordinator, using the phone number on the
device iii. Check all the connections to system controller
iv. Change VAD batteries, and/or change system controller if indicated
v. Have patient stop all activity and assess for patient tolerance
vi. Follow appropriate cardiovascular condition-specific protocol(s) as indicated

Treatment and Interventions

1. Manage airway as indicated
2. Cardiac monitoring
3. IV access
4. Acquire 12-lead EKG
5. If patient is experiencing VAD-related complications or cardiovascular problems,
expedite transport to the medical facility where VAD was placed if patient’s
clinical condition and time allows
6. If patient has a functioning VAD and is experiencing a non-cardiovascular-related
problem, transport to a facility that is appropriate for the patient’s main
presenting problem without manipulating the device
7. If patient has a functioning VAD and is hypoperfused:
a. Administer IV fluids (30 mL/kg isotonic fluid; maximum of 1 liter) over less
than 15 minutes, using a push-pull method of drawing up the fluid in a syringe
and pushing it through the IV
8. If patient is in full cardiac arrest:
a. The decision whether to perform CPR should be made based upon best clinical
judgment in consultation with the patient’s VAD-trained companion and the
VAD coordinator (or direct medical oversight if VAD coordinator unavailable)
b. CPR may be initiated only where:
i. You have confirmed the pump has stopped and troubleshooting efforts to
restart it have failed, and
ii. The patient is unresponsive and has no detectable signs of life

Notes/Educational Pearls
1. You do not need to disconnect the controller or
batteries to:
a. Defibrillate or cardiovert
b. Acquire a 12-lead EKG
2. Automatic non-invasive cuff blood pressures may be difficult to obtain due to the
narrow pulse pressure created by the continuous flow pump
3. Flow though many VAD devices is not pulsatile, and patients may not have a
palpable pulse or accurate pulse oximetry
4. The blood pressure, if measurable, may not be an accurate measure of perfusion
5. Ventricular fibrillation, ventricular tachycardia, or asystole/PEA may be the patient’s
“normal” underlying rhythm. Evaluate clinical condition and provide care in
consultation with VAD coordinator. If not normal for patient it may be necessary to
provide intervention (e.g. signs of hypoperfusion such as altered mental status)
6. The patient’s travel bag should always accompany them with back-up controller
and spare batteries
7. If feasible, bring the patient’s power module, cable, and display module to the
hospital
8. All patients should carry a spare pump controller with them
9. The most common cause for VAD alarms is low batteries or battery failures

22
 10. Although automatic non-invasive blood pressure cuffs are often ineffective in
measuring systolic and diastolic pressure, if they do obtain a measurement, the
MAP is usually accurate
11. Other VAD complications:
a. Infection
b. Stroke/Transient ischemic attack (TIA)
c. Bleeding
d. Arrhythmias
e. Cardiac tamponade
f. Congestive heart failure (CHF)
g. Aortic insufficiency

Quality Improvement
Key Documentation Elements
• Information gained from the VAD control box indicating any specific device
malfunctions
• Interventions performed to restore a malfunctioning VAD to normal function
• Time of notification to and instructions from VAD-trained companion and/or VAD
coordinator

Performance Measures
• Identify and mitigate any correctable VAD malfunctions
• Perform CPR for patients in cardiac arrest when indicated

Tachycardia with a Pulse

Aliases
1. Atrial fibrillation (A-FIB)
2. Supraventricular tachycardia (SVT)
3. Torsades
4. Atrial flutter
5. Multifocal atrial tachycardia (MAT)
6. Ventricular tachycardia

Patient Care Goals

1. Maintain adequate oxygenation, ventilation, and perfusion
2. Control ventricular rate
3. Restore regular sinus rhythm in unstable patient 4. Search for underlying cause:
a. Medications (caffeine, diet pills, thyroid, decongestants) b. Drugs (cocaine,
amphetamines)
b. History of dysrhythmia
c. congestive heart failure (CHF)

Patient Presentation
Patients will manifest elevated heart rate for age and may or may not also present with associated
signs or symptoms such as palpitations, dyspnea, chest pain, syncope/near-syncope, hemodynamic
compromise, altered mental status, or other signs of end organ malperfusion

Inclusion Criteria
Heart rate greater than 100 BPM in adults or relative tachycardia in pediatric patients

Exclusion Criteria
Sinus tachycardia

23
Patient Management
Assessment, Treatments, and Interventions
1. Adult Management
a. Manage airway as necessary
b. Administer oxygen as appropriate with a target of achieving 94–98% saturation
c. Initiate monitoring and perform 12-lead EKG
d. Establish IV access
e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Protocol
f. Consider the following additional therapies if tachycardia with signs and symptoms or
hemodynamic instability continues:
i.Regular Narrow Complex Tachycardia – Stable (SVT)
1. Perform vagal maneuvers
2. Adenosine 6 mg IV (proximal site) followed by 10 mL fluid bolus
a. If tachycardia continues, give adenosine 12 mg IV
b. A third dose of adenosine, 12 mg IV, can be given
3. Diltiazem 0.25 mg/kg slowly IV over 2 minutes
a. After 15 minutes, a second dose of diltiazem 0.35 mg/kg IV may be
given if needed
b. For patients older than 65 years old, recommend maximum initial dose of
diltiazem 10 mg IV and a maximum second dose of 20 mg
4. Metoprolol 5 mg IV given over 1–2 minutes. May repeat as needed q 5
minutes for a total of 3 doses
5. Verapamil 2.5–5 mg IV given over 2 minutes. May repeat with verapamil 5–
10 mg after 15–30 minutes.
ii. Regular Narrow Complex Tachycardia – Unstable
1. Deliver a synchronized shock based on manufacturer’s recommendations
2. For responsive patients, consider sedation and analgesia
iii. Irregular Narrow Complex Tachycardia – Stable (atrial fibrillation (A-FIB),
atrial flutter, multifocal atrial tachycardia)
1. Diltiazem 0.25 mg/kg slowly IV over 2 minutes
a. After 15 minutes, a second dose of diltiazem 0.35 mg/kg IV may be
given if needed
b. For patients older than 65 years old, recommend maximum initial dose of
diltiazem 10 mg IV and a maximum second dose of 20 mg
2. Metoprolol 5 mg IV given over 1–2 minutes. May repeat as needed q 5
minutes for a total of 3 doses
iv. Irregular Narrow Complex Tachycardia – Unstable
1. Deliver a synchronized shock based on manufacturer’s recommendation
2. For responsive patients, consider sedation
v. Regular Wide Complex Tachycardia – Stable (ventricular tachycardia,
supraventricular tachycardia, atrial fibrillation/flutter with aberrancy, accelerated
idioventricular rhythms, pre-excited tachycardias with accessory pathways)
1. Amiodarone 150 mg IV over 10 minutes a. May repeat once as needed
2. Procainamide 20–50 mg/min until arrhythmia suppressed, hypotension
ensues, QRS duration increases greater than 50%, or maximum dose 17
mg/kg given
a. Maintenance infusion: 1–4 mg/min b. Avoid if prolonged QT or CHF
3. Lidocaine 1–1.5 mg/kg IV
a. May be repeated at 5-minute intervals for a maximum dose of 3 mg/kg
IV
4. Adenosine 6 mg IV (proximal site) followed by 10 mL fluid bolus
a. If monomorphic tachycardia continues, give adenosine 12 mg IV
vi. Regular Wide Complex Tachycardia – Unstable
1. Deliver a synchronized shock based on manufacturer’s recommendation
2. For responsive patients, consider sedation

24
 vii. Irregular Wide Complex Tachycardia – Stable (A-FIB with aberrancy, pre-
excited A-FIB (i.e., A-FIB using an accessory pathway), multifocal atrial
tachycardia (MAT) or polymorphic VT/torsades de pointes
1. Procainamide 20–50 mg/min until arrhythmia suppressed, hypotension
ensues, QRS duration increases greater than 50%, or maximum dose 17 mg/kg
given
a. Maintenance infusion: 1–4 mg/min
b. Avoid if prolonged QT or CHF
2. If torsades, give magnesium 1–2 g IV over 10 minutes
3. Amiodarone 150 mg IV over 10 minutes
a. May repeat once as needed
b. Administration of amiodarone, if needed, should follow procainamide in
patients with Wolff–Parkinson–White syndrome
viii. Irregular Wide Complex Tachycardia – Unstable
1. Deliver a synchronized shock based on manufacturer’s
recommendation 2. For responsive patients, consider sedation

2. Pediatric Management
a. Manage airway as necessary
b. Administer oxygen as appropriate with a target of achieving 94–98% saturation c.
Initiate monitoring and perform 12-lead EKG
d. Establish IV access
e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Protocol
f. Consider the following additional therapies if tachycardia and symptoms or
hemodynamic instability continue:
i. Regular Narrow Complex Tachycardia – Stable (SVT)
1. Perform vagal maneuvers
2. Adenosine 0.1 mg/kg (maximum of 6 mg)
a. If unsuccessful, may repeat with 0.2 mg/kg (maximum of 12 mg)
ii. Regular Narrow Complex Tachycardia – Unstable
1. Deliver a synchronized shock: 0.5–1 J/kg for the first dose
2. Repeat doses should be 2 J/kg
iii. Regular, Wide Complex Tachycardia — Stable
1. Consider adenosine 0.1 mg/kg (maximum of 6 mg) for SVT with aberrancy
2. Otherwise give amiodarone 5 mg/kg IV (maximum of 150 mg) over 10
minutes
iv. Regular, Wide Complex Tachycardia – Unstable
1. Synchronized cardioversion 0.5–1.0 J/kg

Notes/Educational Pearls
Key Considerations
1. Causes:
a. Hypovolemia
b. Hypoxia
c. Hydrogen (acidosis)
d. Myocardial infarction
e. Hypokalemia/Hyperkalemia
f. Hypoglycemia
g. Hypothermia
h. Toxins/Overdose
i. Tamponade
j. Tension pneumothorax
k. Thrombus – central or peripheral
l. Trauma
m. Hyperthyroidism

25
2. A-FIB rarely requires cardioversion in the field. As it is difficult to ascertain the onset of
this rhythm, the risk of stroke needs to be considered prior to cardioversion
3. A wide-complex irregular rhythm should be considered pre-excited A-FIB; extreme care
must be taken in these patients
a. Characteristic EKG findings include a short PR interval and, in some cases, a delta
wave
b. Avoid AV nodal blocking agents such as adenosine, calcium channel blockers,
digoxin, and possibly beta-blockers in patients with pre-excitation A-FIB (e.g.,
Wolff-Parkinson-White Syndrome, Lown-Ganong-Levine Syndrome) because these
drugs may cause a paradoxical increase in the ventricular response
c. Blocking the AV node in some of these patients may lead to impulses that are
transmitted exclusively down the accessory pathway, which can result in ventricular
fibrillation
d. Amiodarone or procainamide may be used as an alternative
4. Amiodarone or procainamide can be used as a rate-controlling agent for patients who are
intolerant of or unresponsive to other agents, such as patients with CHF who may not
otherwise tolerate diltiazem or metoprolol
a. Caution should be exercised in those who are not receiving anticoagulation, as
amiodarone can promote cardioversion
5. Administer metoprolol to patients with SBP greater than 120 mmHg
a. Worsening CHF, chronic obstructive pulmonary disease (COPD), asthma, as well as
hypotension and bradycardia can occur with use of metoprolol
6. Biphasic waveforms have been proven to convert A-FIB at lower energies and higher rates
of success than monophasic waveforms
a. Strategies include dose escalation (70, 120, 150, 170 joules (J) for biphasic or 100,
200, 300, 360 J for monophasic) versus beginning with single high energy/highest
success rate for single shock delivered
7. Studies in infants and children have demonstrated the effectiveness of adenosine for the
treatment of hemodynamically stable or unstable SVT
8. Adenosine should be considered the preferred medication for stable SVT
a. Verapamil may be considered as alternative therapy in older children but should not
be routinely used in infants
b. Procainamide or amiodarone given by a slow IV infusion with careful hemodynamic
monitoring may be considered for refractory SVT

Pertinent Assessment Findings

None noted

Patient Safety Considerations

1. Only use one antidysrhythmic at a time
2. Patients who receive beta-blockers (e.g., metoprolol) with calcium channel blockers (e.g.,
diltiazem) are at increased risk for hypotension and bradycardia
3. If using cardioversion, consider sedation and pain control
4. With irregular wide complex tachycardia (A-FIB with aberrancy such as Wolff-Parkinson-
White and Lown-Ganong Levine), avoid use of AV nodal blocking agents (e.g.,
adenosine, calcium channel blockers, beta-blockers)
5. Patients with Wolff–Parkinson–White should be given procainamide prior to amiodarone

26
Quality Improvement
Key Documentation Elements
• Initial rhythm and all rhythm changes
• Time, dose, and response to medications given
• Cardioversion times, synchronization, attempts, joules, and response
• Obtain monitor strips after each intervention
• Patient weight
• Pediatric length-based tape color (for pediatrics who fit on tape)
• History of event supporting treatment of underlying causes

Performance Measures
• Time to clinical improvement from patient contact
• Blood sugar obtained
• Correct medication(s) and dose given for patient condition, age, and weight
• Correct cardioversion joules delivered given patient weight and/or condition
• Use of sedation for responsive patient

27
Suspected Stroke/Transient Ischemic Attack

Aliases
1. Cerebrovascular accident (CVA)
2. Transient ischemic attack (TIA)

Patient Care Goals

1. Detect neurological deficits
2. Determine eligibility for transport to a stroke center
3. Identify patients who have potentially sustained a stroke involving a large vessel occlusion
(LVO)

Patient Presentation
1. Neurologic deficit such as facial droop, localized weakness, gait disturbance,
slurred speech, altered mentation, sudden onset of dizziness/vertigo
2. Hemiparesis or hemiplegia
3. Dysconjugate gaze, forced or crossed gaze (if patient is unable to voluntarily respond
to exam, makes no discernible effort to respond, or is unresponsive)
4. Severe headache, neck pain/stiffness, difficulty seeing

Inclusion Criteria
Patient has signs and symptoms consistent with stroke or transient ischemic attack (TIA)

Exclusion Criteria
1. If glucose less than 60 mg/dL (deciliter), treat per the Hypoglycemia Protocol
2. If trauma and Glasgow Coma Score (GCS) less than or equal to 13, treat per the
Head Injury Protocol and General Trauma Management Protocol

Patient Management
Assessment
1. Use a validated prehospital stroke scale that may include, but is not limited to:
a. Facial smile/grimace – ask patient to smile
b. Arm drift – close eyes and hold out arms for count of 10 seconds
c. Speech – ask patient to say “You can’t teach an old dog new tricks”
2. Use a validated prehospital stroke severity scale that may include, but is not limited to:
a. Vision changes
b. Sensory neglect
c. Aphasia
3. Pertinent historical data includes:
a. History – “last known well” and source of that information
b. Neurologic status assessment [See Footnote III. Neurologic Status Assessment]
c. Patient is taking warfarin or any anticoagulant medication
d. History of recent trauma
e. History of recent seizure
f. History of recent surgery
g. History of recent hemorrhage (e.g., GI bleed)
4. Evaluate for the presence of stroke mimics including:
a. Hypoglycemia
b. Seizure
c. Sepsis
d. Migraine
e. Intoxication

28
 Treatment and Interventions
1. Determine “last known well” time
2. Administer oxygen as appropriate with a target of achieving 94–98% saturation
3. If seizure activity present, treat per Seizures Protocol
4. Check blood glucose level (BGL)
a. Treat only if glucose less than 60 mg/dL
5. Acquire 12-lead EKG, not delaying transport
6. Early hospital notification per local stroke plan that should include any suspected large
vessel occlusion (LVO) stroke

Patient Safety Considerations

1. Prevent aspiration – elevate head of stretcher 15–30 degrees if systolic BP greater than
100 mmHg
a. Maintain head and neck in neutral alignment, without flexing the neck
2. Protect paralyzed limbs from injury
3. Avoid multiple IV attempts

Notes/Educational Pearls
Key Considerations
1. Transport and destination decisions should be based on local resources and stroke system
of care
a. Destination hospitals may include:
i. Stroke Ready
ii. Primary Stroke Center
iii. Thrombectomy-capable Stroke Center
iv. Comprehensive Stroke Center
2. Time of onset of stroke or last known well is critical data for patient treatment
a. Positive stroke scale with time of onset or last known well less than 6 hours may be
eligible for thrombolytic agents
b. Positive stroke severity scale with time of onset or last known well less than 24 hours
may be eligible for mechanical thrombectomy
i. Consider transport to hospital capable of mechanical thrombectomy per local
stroke plan
3. Do not treat hypertension
4. Place on cardiac monitor
5. Pediatrics:
a. Treatment principles remain the same
b. Although rare, pediatric patients can have strokes
c. Stroke scales are not validated for pediatric patients
d. The EMS crew should call ahead to make sure that the hospital can manage the
patient

Quality Improvement
Key Documentation Elements
● “Last known well” must be as specific as possible
o If the patient was last known well prior to bedtime the night before, this is the time to
be documented (not time the patient woke up with symptoms present)
● Blood glucose results
● Specific validated stroke scale used and findings
● Time of notification to receiving hospital

Performance Measures
● Documentation of time “last known well”
● Use of validated stroke scale
● Blood glucose level obtained

29
● Minimize EMS scene time
● Hospital stroke team pre-arrival alert or activation occurred as early as possible after
positive stroke assessment finding.

30
ANNEX 3: General Medical

Abdominal Pain

Aliases None noted

Patient Care Goals

1. Improve patient comfort
2. Identify life-threatening causes of abdominal pain

Patient Presentation
Inclusion Criteria
Abdominal pain or discomfort related to a non-traumatic cause

Exclusion Criteria
1. Abdominal pain due to trauma [See General Trauma ManagementProtocol]
2. Abdominal pain due to or related to pregnancy [See OB/GYN Section]

Patient Management
Assessment
1. Perform airway assessment and management per the Airway Management Protocol
2. Obtain vital signs including pulse, blood pressure, respiratory rate, neurologic status
assessment
3. Obtain blood glucose if hyperglycemia is suspected per Hyperglycemia Protocol
4. Provide evaluation and management of pain per the Pain Management Protocol
5. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation
6. Assess for life-threatening causes of abdominal pain, which may include:
a. Signs and symptoms of ischemic, necrotic, or perforated bowel
I. Severe tenderness
II. iAbdominal pain with motion or palpation of the abdomen iii. Fever
III. Bloody stool
IV. Nausea and vomiting
V. Absence of passage of stool or gas
VI. Abdominal distention, with tympany to percussion
b. Signs and symptoms of dissecting or ruptured abdominal aortic aneurysm(AAA)
i. Unequal femoral or distal lower extremity pulses
ii. “Pulsatile” abdominal mass
iii. Associated back pain and/or chest pain
iv. Known history of abdominal aortic aneurysm
c. Signs and symptoms of ruptured ectopic pregnancy
i. Vaginal bleeding
ii. Recently diagnosed pregnancy
iii. Recent missed period/menstrual cycle in women of childbearing age
d. Signs and symptoms of appendicitis
i. Focal right lower quadrant tenderness, possibly with rebound and guarding
ii. Right lower quadrant tenderness noted during palpation of the left lower
quadrant (positive Rovsing’s sign)
iii. Peri-umbilical or diffuse abdominal tenderness with palpation of the
abdomen/pelvis
iv. Fever
v. Nausea, vomiting.
vi. Lack of appetite

31
 e. Signs and symptoms of acute cholecystitis
I. Right upper quadrant or epigastric tenderness
II. Fever
III. Nausea and vomiting
IV. History of gallstones
f. Signs and symptoms of pyelonephritis
i. Fever
ii. Nausea, vomiting
iii. Urinary frequency/urgency
iv. Dysuria
v. Hematuria
vi. Back/flank pain
vii. Costovertebral angle tenderness to percussion
7. Assess for signs of shock
a. If shock is present, provide treatment per appropriate ShockProtocol
8. Assess for other non-life-threatening causes of abdominal pain
a. Signs and symptoms of kidney stone
i. Unilateral flank pain
ii. Nausea, vomiting.
iii. Hematuria

Treatment and Interventions

1. Medication Administration:
a. Provide analgesia per the Pain Management Protocol
b. Administer antiemetics per the Nausea-Vomiting Protocol
c. Provide transport to an appropriate receiving facility. Consider specialty destination
centers for conditions such as suspected abdominal aorticaneurysm and aortic
dissection
d. Reassess vital signs and response to therapeutic interventions throughout transport

Patient Safety Considerations

Abdominal pain in older adults, patients with bleeding disorders, patients on anticoagulation
medications, children less than 2 years old and patients that are immunocompromised may be
a harbinger for severe illness.

Notes/Educational Pearls
Key Considerations
1. Assess for life-threatening causes of abdominal pain
2. Provide appropriate treatment for pain, vomiting, and shock

Pertinent Assessment Findings

1. Rebound tenderness
2. Guarding
3. Abdominal distension
4. Abdominal tympany to percussion
5. Tenderness focal to a specific abdominal quadrant
6. Presence of “pulsatile” abdominal mass
7. Absence of or significant inequality of femoral or distal arterial pulses in lower extremities
8. Hyper or hypothermia
9. Rectal bleeding, hematemesis, vaginal bleeding 10. Jaundice

32
Quality Improvement
Key Documentation Elements
• Assessment of abdomen to include findings on palpation/percussion including presence or
absence of masses and presence and nature of tenderness/pain
• Treatment and response to treatment

Performance Measures
• Assessment for life-threatening etiology
• Mitigation of pain per the Pain Management Protocol

Abuse and Maltreatment

Aliases
1. Maltreatment of vulnerable populations
2. Non-accidental trauma

Definitions
1. Abuse/Maltreatment: Any act or series of acts of commission or omission by a caregiver
or person in a position of power over the patient that results in harm, potential for harm, or
threat of harm to a patient of any age group. EMS clinicians should have a heightened
awareness for vulnerable populations which include, but is not limited to, children,
elderly, and adults with mental or physical disabilities
2. Child Abuse/Maltreatment: Child maltreatment includes any act or series of acts of
commission or omission by a parent or other caregiver that results in harm, potential for
harm, or threat of harm to a child. An act of commission (child abuse) is the physical,
sexual, or emotional maltreatment or neglect of a child or children. An act of omission
(child neglect) includes, but is not limited to, failure to provide for the child’s needs (e.g.,
physical, emotional, medical/dental, and educational neglect) and failure to supervise (e.g.,
inadequate supervision or safety precautions, lack of appropriate car seat use, and
exposure to violent or dangerous environments)
3. Human Trafficking: when people are abducted or coerced into service (e.g., being forced
into servitude without compensation and/or prostitution). Signs may include, but are not
limited to, patient with branding/tattoos and environmental clues such as padlocks and/or
doorknobs removed on interior doors and intact windows that are boarded up

Patient Care Goals

1. Recognize any act or series of acts of commission or omission by a caregiver or person in a
position of power over the patient that results in harm, potential for harm, or threat of
harm to a patient
2. Take appropriate steps to protect the safety of the responders as well as bystanders 3.
Remove the patient from immediate danger
4. Assess any patient injuries that may be the result of acute or chronic events
5. Attempt to preserve evidence whenever possible; however, the overriding concern should
be providing appropriate emergency care to the patient
6. Complete all mandatory reporting requirements per Protocols and local laws, rules, and
regulations

Patient Presentation
1. Clues to abuse or maltreatment can vary with age group of the patient and type of abuse
2. Not all abuse or maltreatment is physical
3. EMS role is to:
a. Document concerns
b. Assess potentially serious injuries
c. Disclose concerns to appropriate authorities

33
 d. Initiate help to get the patient and any other vulnerable individuals at the scene into a
safe situation
e. Not to investigate or intervene beyond the steps above
f. Leave further intervention to law enforcement personnel

Inclusion/Exclusion Criteria
Absolute inclusion/exclusion criteria are not possible in this area. Rather, clues consistent with
different types of abuse/maltreatment should be sought:
1. Potential clues to abuse/maltreatment from caregivers or general environment:
a. Caregiver apathy about patient’s current situation
b. Caregiver overreaction to questions about situation
c. Inconsistent histories from caregivers or bystanders regarding what happened
d. Information provided by caregivers or patient that is not consistent with injury patterns
e. Injuries not appropriate for patient’s age or physical abilities (e.g., infants with injuries
usually associated with ambulatory children, elders who have limited mobility with
injury mechanisms inconsistent with their capabilities)
f. Caregiver not allowing adult patient to speak for themselves, or who appears
controlling – pay special attention to patients who cannot communicate due to young
age or language and/or cultural barriers
g. Inadequate safety precautions or facilities where the patient lives and/or evidence of
security measures that appear to confine the patient inappropriately
2. Potential clues to abuse or maltreatment that can be obtained from the patient:
a. Multiple bruises in various stages of healing
b. Age-inappropriate behavior (e.g., adults who are submissive or fearful, children who act
in a sexually inappropriate way)
c. Pattern burns, bruises, or scars suggestive of specific weaponry used
d. Evidence of medical neglect for injuries or infections
e. Unexplained trauma to genitourinary systems or frequent infections to this system
f. Evidence of malnourishment and/or serious dental problems
3. Have a high index of suspicion for abuse in children presenting with a Brief Resolved
Unexplained Event (BRUE) [See Brief Resolved Unexplained Event (BRUE) & Acute
Events in Infants Protocol]

Patient Management
Assessment
1. Primary survey and identify any potentially life-threatening issues
2. Document thorough secondary survey to identify clues of for potential abuse/maltreatment
3. Assess physical issues and avoid extensive investigation of the specifics of abuse or
maltreatment, but document any statements made spontaneously by patient
a. Avoid asking directed questions of a child

Treatment and Interventions

1. Address life-threatening issues
2. Remove the patient to a safe place even if no medical indication for transport
3. Report concerns about potential abuse/maltreatment to law enforcement, in accordance with
local law
4. For patients transported, report concerns to hospital and/or law enforcement personnel
(including Child Protective Services agencies where appropriate)

Patient Safety Considerations

1. If no medical emergency exists, the next priority is safe patient disposition/removal from
the potentially abusive situation
2. Do not confront suspected perpetrators of abuse/maltreatment. This can create an unsafe
situation for EMS and for the patient

34
Notes/Educational Pearls
Key Considerations
1. Clues to abuse or maltreatment can vary depending on the age group of the patient and on
the nature of the abuse. Remember that not all abuse or maltreatment involves physical
harm. EMS clinicians are often unique in being the only members of the medical team to
observe the home environment or injury scene. It is important to realize that the job of
EMS is to document their concerns, assess the patient for potentially serious injuries,
make sure that their concerns are disclosed to the appropriate legal authorities, and work
towards getting the patient into a safe situation. EMS personnel should not take it upon
themselves to investigate, interview, or intervene above and beyond those concepts and
should leave further intervention to the appropriate law enforcement personnel
2. Abuse and maltreatment can happen to patients of all ages
3. Patients may be unwilling or unable to disclose abuse or maltreatment, so the responsibility
falls on EMS personnel to assess the situation, document appropriately, and take
appropriate action to secure a safe place for the patient
4. Document findings by describing what you see and not ascribing possible causes (e.g., “0.5-
inch round burn to back” as opposed to “burn consistent with cigarette burn”)

Pertinent Assessment Findings

As noted above

Quality Improvement
Key Documentation Elements
Meticulous documentation of any statements by the patient and any physical findings on the
patient or the surroundings are critical in abuse or maltreatment cases

Performance Measures
None noted

Agitated or Violent Patient/Behavioral Emergency

Aliases
1. Acute psychosis
2. Patient restraint
3. Agitated Delirium

Patient Care Goals

1. Provision of emergency medical care to the agitated, violent, or uncooperative patient
2. Maximizing and maintaining safety for the patient, EMS personnel, and others

Patient Presentation
Inclusion Criteria
Patients of all ages who are exhibiting agitated or violent behavior, are a danger to self or
others and in the assessment of the EMS clinician require physical and/or pharmacologic
restraint to mitigate injury to self or others

Exclusion Criteria
1. Patients exhibiting agitated or violent behavior due to medical conditions including, but not
limited to:
a. Head injury
b. Metabolic disorders (e.g., hypoglycemia, hypoxia)

35
Patient Management
Assessment
1. Note medications/substances on scene that may contribute to the agitation, or may be
relevant to the treatment of a contributing medical condition
2. Maintain and support airway
3. Note respiratory rate and effort – If possible, monitor pulse oximetry and/or capnography
4. Assess circulatory status:
a. Blood pressure (if possible)
b. Pulse rate
c. Capillary refill
5. Assess mental status
a. Check blood glucose (if possible)
6. Obtain temperature (if possible)
7. Assess for evidence of traumatic injuries
8. Use a validated risk assessment tool such as RASS (Richmond Agitation Sedation Score),
AMSS (Altered Mental Status Score), or BARS (Behavioral Activity Rating Scale) to risk
stratify violent patients to help guide interventions

Treatment and Interventions

1. Establish patient rapport
a. Attempt verbal reassurance and calm patient prior to use of pharmacologic and/or
physical management devices
b. Engage family members/loved ones to encourage patient cooperation if their presence
does not exacerbate the patient’s agitation
c. Continued verbal reassurance and calming of patient following use of
chemical/physical management devices
2. Pharmacologic management
a. Notes:
i. Selection of medications for pharmacologic management should be based upon
the patient’s clinical condition, current medications, and allergies in addition to
EMS resources and medical direction
ii. The medications are annotated to indicate when they are preferred for patients that
are particularly high-risk for violence as assessed by a validated scale – note that
the dosing can be adjusted to achieve different levels of sedation
iii. The numbering of medications below is not intended to indicate a
hierarchy/preference of administration
b. Benzodiazepines
i. Diazepam
1. Adults:
a. 5 mg IV; 2–5 minute onset of action
OR
b. 10 mg IM; 15–30 minute onset of action
2. Pediatrics:
a. 0.05–0.1 mg/kg IV (maximum dose is 5 mg)
OR
b. 0.1–0.2 mg/kg IM (maximum dose is 10 mg)
ii. Lorazepam
1. Adults:
a. 2 mg IV; 2–5 minute onset of action
OR
b. 4 mg IM; 15–30 minute onset of action
2. Pediatrics:
a. 0.05 mg/kg IV (maximum dose is 2 mg)
OR
b. 0.05 mg/kg IM (maximum dose is 2 mg)

36
 iii. Midazolam
1. Adults:
a. 5 mg IV; 3–5 minute onset of action
OR
b. 5 mg IM; 10–15 minute onset of action
OR
c. 5 mg IN; 3–5 minute onset of action
2. Pediatrics:
a. 0.05–0.1 mg/kg IV (maximum dose 5 mg)
OR
b. 0.1–0.15 mg/kg IM (maximum dose is 5 mg)
OR
c. 0.3 mg/kg IN (maximum dose is 5 mg)
c. Antipsychotics
i. Droperidol (option for high violence risk)
1. Adults:
a. 2.5 mg IV; 10-minute onset of action
OR
b. 5–10 mg IM; 20-minute onset of action
2. Pediatrics: Not routinely recommended
ii. Haloperidol
1. Adults:
a. 5 mg IV; 5–10 minute onset of action
OR
b. 5–10 mg IM; 10–20 minute onset of action
2. Pediatrics: Age 6–12 years old: 1–3 mg IM (maximum dose 0.15 mg/kg)
iii. Olanzapine
(Note: Concurrent use of IM/IV benzodiazepines and olanzapine IM is not
recommended as fatalities have been reported)
1. Adults:
a. 10 mg IM; 15–30 minute onset of action
b. 10 mg ODT PO or SL
2. Pediatrics:
a. Age 6–11 years old: 5 mg IM (limited data available for pediatric use)
b. Age 12–18 years old: 10 mg IM
c. Age 6–18 years old: 5 mg ODT PO or SL
iv. Ziprasidone
1. Adults: 10 mg IM; 10-minute onset of action
2. Pediatrics:
a. Age 6–11 years old: 5 mg IM (limited data available for pediatric use)
b. Age 12–18 years old: 10 mg IM
d. Dissociative Agents (provide sedation and anesthesia) i. Ketamine (option for high
violence risk)
1. Adults:
a. 2 mg/kg IV; 1 minute onset of action OR
b. 4 mg/kg IM; 3–5 minute onset of action 2. Pediatrics:
a. 1 mg/kg IV OR
b. 3 mg/kg IM
3. Physical Management Devices
a. Body
i. Stretcher straps should be applied as the standard procedure for all patients during
transport
ii. Physical management devices, including stretcher straps, should never restrict the
patient’s chest wall motion

37
 iii. If necessary, sheets may be used as improvised supplemental stretcher straps.
Other forms of improvised physical management devices should be discouraged
iv. Supplemental straps or sheets may be necessary to prevent flexion/extension of
torso, hips, legs by being placed around the lower lumbar region, below the
buttocks, and over the thighs, knees, and legs
v. Patients should never be placed in prone position
b. Extremities
i. Soft or leather devices should not require a key to release them
ii. Secure all four extremities to maximize safety for patient, staff, and others
iii. Secure all extremities to the stationary frame of the stretcher
iv. Multiple knots should not be used to secure a device

Patient Safety Considerations

The management of violent patients requires a constant reevaluation of the risk/benefit balance
for the patient and bystanders to provide the safest care for all involved. These are complex
and high-risk encounters. There is no “one size fits all” solution for addressing these patients
1. Don PPE
2. Do not attempt to enter or control a scene where physical violence or weapons are present
3. Dispatch law enforcement immediately to secure and maintain scene safety
4. Urgent de-escalation of patient agitation is imperative in the interest of patient safety as well
as for EMS personnel and others on scene
5. Uncontrolled or poorly controlled patient agitation and physical violence can place the
patient at risk for sudden cardiopulmonary arrest due to the following etiologies:
a. Delirium with agitated behavior: A postmortem diagnosis of exclusion for sudden
death thought to result from metabolic acidosis (most likely from lactate) stemming
from physical agitation or physical control measures and potentially exacerbated by
stimulant drugs (e.g., cocaine, captagon) or alcohol withdrawal
b. Positional asphyxia: Sudden death from restriction of chest wall movement and/or
obstruction of the airway secondary to restricted head or neck positioning resulting
in hypercarbia and/or hypoxia
6. Apply a cardiac monitor as soon as possible, particularly when pharmacologic management
medications have been administered
7. All patients who have received pharmacologic management medications must be monitored
closely for the development of hypoventilation and oversedation
a. Utilize capnography if available
8. Patients who have received antipsychotic medication for pharmacologic management must
be monitored closely for the potential development of:
a. Dystonic reactions (this can easily be treated with diphenhydramine/benzodiazepines)
b. Ataxia
c. Cessation of perspiration
d. Cardiac arrhythmias (particularly QT prolongation)
9. Patients who require physical management should also receive pharmacological treatment
for agitation to prevent consequences of delirium with agitated behavior
10. Placement of stretcher in sitting position prevents aspiration and reduces the patient’s
physical strength by placing the abdominal muscles in the flexed position
11. Patients who are more physically uncooperative should be physically secured with one arm
above the head and the other arm below the waist, and both lower extremities individually
secured
12. The following techniques should be expressly prohibited for use by EMS clinicians:
a. Secure or transport in a prone position with or without hands and feet behind the
back (hobbling or “hog-tying”)
b. "Sandwiching” patients between backboards
c. Techniques that constrict the neck or compromise the airway (e.g. prone
positioning)

38
 13. Concurrent use of IM/IV benzodiazepines and olanzapine IM is not recommended as
fatalities have been reported

Notes/Educational Pearls
Key considerations
1. Direct medical direction should be contacted at any time for advice, especially when
patient’s level of agitation is such that transport may place all parties at risk
2. Transport by air is not advised
3. Stretchers with adequate foam padding, particularly around the head, facilitates patient’s
ability to self-position the head and neck to maintain airway patency
4. For patients with key-locking devices, applied by another agency, consider the following
options:
a. Remove device and replace it with a device that does not require a key
b. Administer pharmacologic management medication then remove and replace device
with another non-key-locking device after patient has become more cooperative
c. Transport patient accompanied in patient compartment by person who has device key
d. Transport patient in the vehicle of person who has the device key if medical condition
of
patient is deemed stable, direct medical direction so authorizes, and law allows

Pertinent Assessment Findings

1. Continuous monitoring of:
a. Airway patency
b. Respiratory status with pulse oximetry and/or capnography
c. Circulatory status with frequent blood pressure measurements
d. Mental status and trends in level of patient cooperation
e. Cardiac status, especially if the patient has received pharmacologic management
medication
f. Extremity perfusion with capillary refill in patients in physical management device

Quality Improvement
Key Documentation Elements
• Etiology of agitated or violent behavior if known
• Patient’s medications, other medications or substances found on scene
• Patient’s medical history or other historic factors reported by patient, family, or
bystanders • Physical evidence or history of trauma
• Adequate oxygenation by pulse oximetry
• Blood glucose measurement
• Measures taken to establish patient rapport
• Dose, route, and number of doses of pharmacologic management medications
administered • Clinical response to pharmacologic management medications
• Number and physical sites of placement of physical management devices
• Duration of placement of physical management devices
• Repeated assessment of airway patency
• Repeated assessment of respiratory rate, effort, pulse oximetry/capnography
• Repeated assessment of circulatory status with blood pressure, capillary refill, cardiac
monitoring
• Repeated assessment of mental status and trends in the level of patient cooperation •
Repeated assessment of capillary refill in patient with extremity securing devices
• Communications with EMS medical direction
• Initiation and duration of engagement with law enforcement

Performance Measures
• Incidence of injuries to patient, EMS personnel, or others on scene
• Incidence of injuries to patient, EMS personnel, or others during transport

39
 • Medical or physical complications (including sudden death) in patients
• Advance informational communication of EMS protocols for the management of agitated
and violent patients to others within the emergency care system and law enforcement
• Initiation and engagement with EMS medical direction
• Initiation and duration of engagement with law enforcement

Anaphylaxis and Allergic Reaction

(Adapted from an evidence-based Protocol created using the National Prehospital Evidence-Based
Prehospital Protocol Model Process)

Aliases Anaphylactic Shock

Patient Care Goals

1. Provide timely therapy for potentially life-threatening reactions to known or suspected
allergens to prevent cardiorespiratory collapse and shock
2. Provide symptomatic relief for symptoms due to known or suspected allergens

Patient Presentation
Inclusion Criteria
Patients of all ages with suspected allergic reaction and/or anaphylaxis

Exclusion Criteria None noted

Patient Management
Assessment
1. Evaluate for patent airway and presence of oropharyngeal edema
2. Auscultate for wheezing and assess level of respiratory effort
3. Assess for adequacy of perfusion
4. Assess for presence of signs and symptoms of anaphylaxis
a. Anaphylaxis – More severe and is characterized by an acute onset involving:
i. The skin (urticaria) and/or mucosa with either respiratory compromise or
decreased BP or signs of end-organ dysfunction
OR
ii. Hypotension for that patient after exposure to a known allergen
1. Adults: Systolic BP less than 90
2. Pediatrics: See Footnote IV. Abnormal Vital Signs
OR
iii. Two or more of the following occurring rapidly after exposure to a likely
allergen:
1. Skin and/or mucosal involvement (urticaria, itchy, swollen tongue/lips)
a. Skin involvement may be ABSENT in up to 40% of cases of
anaphylaxis
2. Respiratory compromise (dyspnea, wheezing, stridor, hypoxemia)
3. Persistent gastrointestinal symptoms (vomiting, abdominal pain, diarrhea)
4. Hypotension or associated symptoms (syncope, hypotonia, chest tightness,
incontinence)
b. Non-anaphylactic Allergic Reaction
i. Signs involving only one organ system (e.g., localized angioedema that does not
compromise the airway, or not associated with vomiting; hives alone)

40
 Treatment and Interventions
1. If signs of allergic reaction without signs of anaphylaxis, go to Step 8
2. Epinephrine (Adrenaline) administration is the primary treatment for anaphylaxis. If signs
of anaphylaxis, administer epinephrine (Adrenaline) 1 mg/mL at the following dose and
route:
a. Adult (25 kg or more) 0.3 mg IM in the anterolateral thigh
b. Pediatric (less than 25 kg) 0.15 mg in the anterolateral thigh
c. Epinephrine (Adrenaline) 1 mg/mL may be administered from a vial or via auto-
injector, if available
3. If respiratory distress with wheezing is present, consider administering
a. Albuterol 2.5–5 mg nebulized
AND/OR
b. Epinephrine (Adrenaline) 1 mg/mL, 5 mL nebulized
4. If stridor is present, consider administering epinephrine (Adrenaline) 1 mg/mL, 5 mL
nebulized
5. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine
(Adrenaline), additional IM epinephrine (Adrenaline) can be repeated q5–15 minutes at
above noted doses
6. For signs of hypoperfusion, also administer 20 mL/kg isotonic fluid (normal saline or
lactated Ringer’s) rapidly (over 15 minutes) via IV or IO, and repeat as needed for
ongoing hypoperfusion
7. Consider an epinephrine (Adrenaline) IV drip (0.5 mcg/kg/minute) when cardiovascular
collapse (hypotension with altered mental status, pallor, diaphoresis and/or delayed
capillary refill) is present despite repeated IM doses of epinephrine (Adrenaline) in
conjunction with at least 60 mL/kg isotonic fluid boluses
8. For urticaria or pruritus, administer a diphenhydramine 1 mg/kg, up to maximum dose of 50
mg IM, IV, or PO)
a. The IV route is preferred for the patient in severe symptoms
b. As a supplement to diphenhydramine given for urticaria, any H2-blocking
antihistamine (e.g., famotidine, cimetidine) can be given IV or PO in conjunction
with diphenhydramine
9. Transport as soon as possible, and perform ongoing assessment as indicated. Cardiac
monitoring is not required, but should be considered for those with known heart problems
or who received multiple doses of epinephrine

Patient Safety Considerations

1. Time to epinephrine (Adrenaline) delivery
2. Concentration of epinephrine (Adrenaline) in relation to route
3. Weight-based dosing of medications

Notes/Educational Pearls
Key Considerations
1. When anaphylaxis is suspected, EMS personnel should always consider epinephrine
(Adrenaline) as first-line treatment
2. Allergic reactions and anaphylaxis are serious and potentially life-threatening medical
emergencies. It is the body’s adverse reaction to a foreign protein (e.g., food, medicine,
pollen, insect sting or any ingested, inhaled, or injected substance). A localized allergic
reaction (e.g., urticaria or angioedema that does not compromise the airway) may be
treated with antihistamine therapy. Cardiovascular collapse may occur abruptly, without
the prior development of skin or respiratory symptoms. Constant monitoring of the
patient’s airway and breathing is essential
3. Contrary to common belief that all cases of anaphylaxis present with cutaneous
manifestations, such as urticaria or mucocutaneous swelling, a significant portion of
anaphylactic episodes may not involve these signs and symptoms on initial presentation.

41
 Moreover, most fatal reactions to food-induced anaphylaxis in children were not
associated with cutaneous manifestations
4. A thorough assessment and a high index of suspicion are required for all potential allergic
reaction patients – consider:
a. History of Present Illness
i. Onset and location
ii. Insect sting or bite
iii. Food allergy/exposure
iv. New clothing, soap, detergent
v. Past history of reactions
vi. Medication history
b. Signs and Symptoms
i. Itching or urticaria
ii. Coughing, wheezing, or respiratory distress
iii. Chest tightness or throat constriction
iv. Hypotension or shock
v. Persistent gastrointestinal symptoms (nausea, vomiting, and diarrhea)
vi. Altered mental status (AMS)
c. Other Considerations
i. Angioedema (drug-induced)
ii. Aspiration/airway obstruction
iii. Vasovagal event
iv. Asthma or chronic obstructive pulmonary disease (COPD) v. Heart failure
5. Gastrointestinal symptoms occur most commonly in food-induced anaphylaxis, but can
occur with other causes
a. Oral pruritus is often the first symptom observed in patients experiencing food-
induced anaphylaxis
b. Abdominal cramping is also common, but nausea, vomiting, and diarrhea are frequently
observed as well
6. Patients with asthma are at high-risk for a severe allergic reaction

Pertinent Assessment Findings

1. Presence or absence of angioedema
2. Presence or absence of respiratory compromise
3. Presence or absence of circulatory compromise
4. Localized or generalized urticaria
5. Response to therapy

Quality Improvement
Key Documentation Elements
• Medications given
• Dose and concentration of epinephrine given
• Route of epinephrine administration
• Time of epinephrine administration
• Signs and symptoms of the patient

Performance Measures
• Percentage of patients with anaphylaxis that receive epinephrine for anaphylaxis:
o Via the IM route (vs. other routes)
o Via the IM route in the anterolateral thigh (vs. other locations)
• Percentage of patients with anaphylaxis who receive:
o Epinephrine within 10 minutes of arrival
o The appropriate weight-based dose of epinephrine
• Percentage of patients that require airway management in the prehospital setting (and/or
the emergency department)

42
Altered Mental Status

Aliases
1. Altered level of consciousness
2. Confusion

Patient Care Goals

1. Identify treatable causes
2. Perform appropriate assessment and diagnostics (e.g., oxygen saturation, glucose check,
monitor)
3. Protect patient from complications of altered mental status (e.g., respiratory failure, shock,
cardiopulmonary arrest)

Patient Presentation
Inclusion Criteria
Impaired decision-making capacity

Exclusion Criteria Traumatic brain injury

Patient Management
Assessment
Look for treatable causes of altered mental status (AMS):
1. Airway: Make sure airway remains patent; reposition patient as needed
2. Breathing: Look for respiratory depression; check SPO2, EtCO2, and CO detector readings
3. Circulation: Look for signs of poor perfusion
4. Glasgow Coma Score and/or AVPU 5. Pupils
6. Head and neck: Evaluate for signs of trauma
7. Neck: Rigidity or pain with range of motion
8. Stroke assessment tool including focal neurologic findings
9. Blood glucose level
10. EKG or cardiac monitor: arrhythmia limiting perfusion
11. Breath odor: Possible unusual odors include alcohol, acidosis, ammonia
12. Chest/Abdominal: Intra-thoracic hardware, assist devices, abdominal pain or distention,
signs of trauma
13. Extremities/skin: Track marks, hydration, edema, dialysis shunt, temperature to touch (or
if able, use a thermometer), signs of trauma
14. Signs of infection: Fever, cough, skin changes, dysuria
15. Environment: Survey for pills, paraphernalia, substance use, medication patches, medical
devices, ambient temperature, sun exposure, social indicators of neglect, carbon
monoxide exposures, multiple casualties with same complaint

Treatment and Interventions

1. Oxygen [Refer to Universal Care Protocol]
2. Glucose [Refer to Hypoglycemia Protocol or Hyperglycemia Protocol]
3. Naloxone [Refer to Opioid Poisoning/Overdose Protocol]
4. Restraint: physical and chemical [See Agitated or Violent Patient/Behavioral Emergency
Protocol]
5. Anti-dysrhythmic medication [See Cardiovascular Section for specific dysrhythmia
Protocols]
6. Active cooling or warming [See Hypothermia/Cold Exposure Protocol or
Hyperthermia/Heat Exposure Protocol]
7. IV fluids [See fluid administration doses in Shock Protocol and Hypoglycemia Protocol or
Hyperglycemia Protocol]
8. Vasopressors [See Shock Protocol]

43
Patient Safety Considerations
1. With depressed mental status, initial focus is on airway protection, oxygenation, ventilation,
and perfusion
2. The violent patient may need pharmacologic and/or physical management to insure proper
assessment and treatment
3. Hypoglycemic and hypoxic patients can be irritable and violent [See Agitated or Violent
Patient/Behavioral Emergency Protocol]

Notes/Educational Pearls
Key Considerations
1. History from bystanders and caregivers
2. Age of the patient
3. Development age and baseline functional status
4. Consider the following differential using the mnemonic AEIOU-TIPS:
A – Alcohol, Abuse, Atypical migraine
E – Epilepsy, Electrolytes
I – Insulin (hypoglycemia)
O – Oxygen, Overdose
U – Uremia (kidney failure)
T – Trauma, Tumor, Temperature
I – Infection
P – Psych, Poisoning
S – Seizure, Subarachnoid hemorrhage, Sepsis
5. Environment where patient found
6. Recent complaints (e.g., headache, chest pain, difficulty breathing, vomiting, fever)
7. Medical alert tags and accessory medical devices
8. Evaluate for reduced PO intake and/or vomiting and/or diarrhea or dehydration as a cause of
AMS in the pediatric and geriatric populations
9. Evidence of ingestion or topical placement (e.g., pill bottles/medications, patches, detergent
pods)
10. Medications a child may have access to including but not limited to (includes patches,
drops, pills, injectables):
a. Analgesics
b. Antidepressants
c. Antihypertensives/Cardiac medications
d. Oral hypoglycemic
e. Opioids
f. Benzodiazepines
g. Antiepileptics
h. Prenatal vitamins
11. Substance use in the home (e.g., tobacco, marijuana, cocaine, amphetamines, PCP,
alcohol) 12. Use of herbal or holistic medications

Pertinent Assessment Findings

1. Track marks
2. Breath odor
3. Skin temperature
4. Rash and/or petechiae
5. Evidence of trauma
6. Focal neurologic changes
7. Location

44
Quality Improvement
Key Documentation Elements
• Glasgow Coma Score (GCS) or AVPU description
• Baseline developmental status and change from baseline
• Temperature was taken when able
• Patient and medic safety were considered • Pupil and neck exam were done
• Evaluation of perfusion and skin exam were performed
• IV fluids given for poor perfusion

Performance Measure
• Hypoglycemia considered and treated appropriately
o Blood glucose level obtained
• Sepsis considered as a possible cause of hypotension
• Hypotension appropriately treated
• Naloxone is used as therapeutic intervention, not a diagnostic tool
• CO detector is used when available

Back Pain

Aliases None noted

Patient Care Goals

1. Improve patient discomfort
2. Identify life-threatening causes of back pain

Patient Presentation
Inclusion Criteria
Back pain or discomfort related to a non-traumatic cause

Exclusion Criteria
1. Back pain from spinal trauma [See Trauma Section]
2. Back pain due to sickle cell pain crisis [See Sickle Cell Pain Crisis Protocol]
3. Back pain from suspected labor [See OB/GYNSection]

Patient Management
Assessment
1. Perform airway assessment and management, per the Airway Management Protocol
2. Obtain vital signs including pulse, blood pressure, respiratory rate, neurologic status
assessment, pulse oximetry, temperature
3. Provide evaluation and management of pain, per the Pain Management Protocol
4. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation
5. Assess for life-threatening causes of back pain, which may include:
a. Spinal cord compression (e.g., from spinal epidural abscess, malignancy, spinal
epidural hematoma for patients on anticoagulants)
i. Urinary and/or bowel incontinence
ii. Inability to walk due to weakness
iii. New neurologic deficits in extremities
iv. Loss of sensation in saddle distribution
b. Aortic dissection or ruptured abdominal aortic aneurysm
i. Unequal femoral or distal lower extremity pulses
ii. “Pulsatile” abdominal mass
iii. Associated abdominal pain and/or chest pain
iv. Known history of abdominal aortic aneurysm or dissection

45
 c. Pyelonephritis
i. Fever
ii. Nausea, vomiting
iii. Urinary frequency/urgency
iv. Dysuria
v. Hematuria
vi. Abdominal pain
vii. Costovertebral angle tenderness to percussion
6. Assess for signs of shock. If shock is present, provide treatment per appropriate Shock
Protocol
7. Assess for other non-life-threatening causes of back pain
a. Kidney stone
i. Unilateral flank pain
ii. Nausea, vomiting
iii. Possible hematuria
iv. History of kidney stones

Treatment and Interventions

1. Medication Administration
a. Provide analgesia, per Pain Management Protocol
b. Administer antiemetics, per Nausea-Vomiting Protocol
c. Provide transport to an appropriate receiving facility. Consider specialty destination
centers for conditions such as suspected aortic emergency
d. Reassess vital signs and response to therapeutic interventions throughout transport

Patient Safety Considerations

None noted

Notes/Educational Pearls
Key Considerations
1. Assess for life-threatening causes of back pain
2. Provide appropriate treatment for pain, vomiting, and shock
3. Consider transport to appropriate specialty center if aortic emergency suspected
4. Back and abdominal pain can often coexist with similar disease processes
5. Identify patients on anticoagulants since they are higher risk for spinal epidural hematoma
or retroperitoneal hemorrhage which can present as back pain
6. Identify patients with intravenous drug abuse (IVDA) history and/or impaired immune
system since they are higher risk for spinal epidural abscess
7. Identify patients with a history of cancer or with one suspicious for cancer – spinal
metastases can cause spinal cord compression
8. Identify older adults or patients with prolonged use of corticosteroids at risk for vertebral
body compression fracture

Pertinent Assessment Findings

1. Midline back tenderness
2. Back erythema or swelling
3. Motor and/or sensory loss in arms or legs
4. Loss of perianal sensation
5. Absence of or significant inequality of femoral or distal arterial pulses in lower extremities
6. Hyper or hypothermia
7. Rectal bleeding or hematemesis

46
Quality Improvement
Key Documentation Elements
• Assessment of back and abdomen to include findings on palpation/percussion including
presence or absence of masses and presence and nature of tenderness/pain
• Assesses initial and changes in neurologic status
• Assesses initial and changes in perfusion/pulses

Performance Measures
• Assessment for life-threatening etiology
• Mitigation of pain, per the Pain Management

End-of-Life Care/Hospice Care

Aliases None noted

Patient Care Goals

1. When providing care for a patient near end-of-life:
a. Provide relief from pain and other distressing symptoms
b. Affirm dying as a normal process
c. Integrate psychological and spiritual aspects of patient care
d. Offer a support system to help the family cope during the patient’s illness and in their
own bereavement

Patient Presentation
Inclusion Criteria
Patients enrolled in hospice or end-of-life care, or who have advance care directives,
experiencing complaints related to the illness for which the patient is receiving those services

Exclusion Criteria
Complaints unrelated to the illness for which the patient is receiving those services

Patient Management
Assessment, Treatment, and Interventions
1. Perform general patient management
2. Engage with the patient’s hospice or end-of-life care team or their primary care physician if
possible. If not a viable option, contact medical direction
3. If the patient can communicate and has the capacity to make decisions regarding treatment
and transport, consult directly with the patient before treatment and/or transport
4. If the patient lacks the capacity to make decisions regarding treatment and/or transport,
identify any advanced care planning in place for information relating to advanced care
planning and consent for treatment
a. Advance directives
b. Medical/Physician Order for Life-Sustaining Treatment (MOLST/POLST) or similar
directing forms
c. Guardian, power of attorney, or other accepted healthcare proxy
5. If the patient requires pain relief [See Pain Management Protocol]
a. Opioid medications are frequently the most appropriate choices for pain
management
b. Multimodal analgesia may be required for pain relief

47
 c. Do not withhold opioids for fear of respiratory depression as patient comfort is the
primary goal for hospice and end-of-life care
6. If the patient is experiencing severe respiratory distress, consider:
a. Oxygen and bedside/handheld fan
b. Noninvasive ventilation (BiPAP/CPAP) if aligned with patient care goals
c. Opioids are the drug of choice for dyspnea for hospice and end-of-life care. If
symptoms are unrelieved, follow written hospice orders or contact medical direction
d. Anxiolytic if needed for anxiety
7. If the patient has nausea [See Nausea-Vomiting Protocol]
8. If the patient has excessive secretions or aspiration, provide suctioning
9. If the patient is anxious or has delirium, consider nonpharmacologic interventions such as
creating a quiet environment, frequent reassurance, touch and verbal orientation
10. If the patient appears dehydrated
a. Encourage PO fluid intake if patient can swallow
b. If available, offer ice chips and swabs soaked in ice water
11. In collaboration with hospice or end-of-life care clinician, coordinate with guardian, power
of attorney, or other accepted healthcare proxy if non-transport is considered

Patient Safety Considerations

1. Careful and thorough assessments should be performed to identify complaints not related to
the illness for which the patient is receiving hospice or end-of-lifecare
2. Care should be delivered with the utmost patience and compassion

Notes/Educational Pearls
Key Considerations
1. Social interactions with family may affect end-of-life care
2. Scene safety should be considered when deciding on management

Pertinent Assessment Findings

1. Vital signs
2. Pain score
3. Neurologic exam
4. Lung sounds

Quality Improvement
Key Documentation Elements
• Interaction with hospice or end-of-life care clinician
• Confirmation of advanced directive or similar documentation
• Pain score if applicable

Performance Measures
• If patient in pain, pain score change
• If patient is nauseated, symptom relief

48
Hyperglycemia
Aliases
• Diabetes
• Diabetic ketoacidosis (DKA)
• Hyperosmolar hyperglycemic state (HHS)

Patient Care Goals

1. Limit morbidity from hyperglycemia by:
a. Appropriate use of glucose monitoring
b. Appropriate hydration for hyperglycemia

Patient Presentation
Inclusion Criteria
1. Adult or pediatric patient with altered level of consciousness [See Altered Mental Status
Protocol]
2. Adult or pediatric patient with stroke symptoms (e.g., hemiparesis, dysarthria) [See
Suspected Stroke/Transient Ischemic Attack Protocol]
3. Adult or pediatric patient with seizure [See Seizures Protocol]
4. Adult or pediatric patient with symptoms of hyperglycemia (e.g., polyuria, polydipsia,
weakness, dizziness, abdominal pain, tachypnea)
5. Adult or pediatric patient with history of diabetes and other medical symptoms

Exclusion Criteria Patient in cardiac arrest

Patient Management

Assessment
1. Monitoring:
a. Check blood glucose level
2. Secondary survey pertinent to altered blood glucose level:
a. Constitutional: assess for tachycardia, hypotension, and tachypnea
b. Eyes: assess for sunken eyes from dehydration
c. Nose/mouth/ears: assess for dry mucous membranes or tongue bite from seizure
d. Abdominal pain including nausea and vomiting especially in children
e. Neurologic:
i. Assess Glasgow Coma Score (GCS) and mental status
ii. Assess for focal neurologic deficit: motor and sensory
3. Evaluate for possible concomitant sepsis and septic shock [See ShockProtocol]
4. Obtain 12-lead EKG to assess for findings consistent with hyperkalemia or acute
coronary syndrome

Treatment and Interventions

1. If altered level of consciousness, stroke, or sepsis/septic shock, treat per Altered Mental
Status Protocol, Suspected Stroke/Transient Ischemic Attack Protocol, or Shock Protocol
accordingly
2. If glucose greater than 250 mg/dL with symptoms of dehydration, vomiting, abdominal
pain, or altered level of consciousness:
a. Provide volume expansion with normal saline bolus
i. Adult: Normal saline 20 mL/kg at rate of 1000 mL/hr; if symptoms of
hypovolemic shock, follow Shock Protocol.

49
 ii. Pediatric: Normal saline 10 mL/kg bolus IV, reassess, and repeat up to 40 mL/kg
total; if symptoms of hypovolemic shock, follow Shock Protocol.
3. If findings of hyperkalemia are present, administer IV fluids and consider administration
of:
a. Calcium chloride: 1 gm IV/IO over 5 minutes, ensure IV patency and do not exceed
1 mL per minute
OR
b. Calcium gluconate: 2 gm IV/IO over 5 minutes, with constant cardiac monitoring
4. If findings of hyperkalemia, consider administration of sodium bicarbonate 1 mEq/kg (max
dose of 50 mEq) IV bolus over 5 minutes and consider albuterol 5 mg via nebulizer (can
be repeated if no response is seen) to the two places in the document where the
administration of albuterol is suggested for the treatment of hyperkalemia
5. Reassess patient
a. Reassess vital signs (pulse, blood pressure, respiratory rate, neurologic status
assessment), mental status, and signs of dehydration
b. If mental status changes, reassess blood glucose level and provide appropriate
treatment if hypoglycemia has developed
6. Disposition
a. Transport to closest appropriate receiving facility

Patient Safety Considerations

1. Overly aggressive administration of fluid in hyperglycemic patients may cause cerebral
edema or dangerous hyponatremia. Cerebral edema is a leading cause of death in children
with DKA but is very rare in adults
a. Closely monitor for signs of altered mental status, increased intracranial pressure,
and immediately discontinue IV fluids and elevate head of bed if signs of increased
ICP develop
b. Reassess and manage airway as needed
2. Asymptomatic hyperglycemia poses no risk to the patient while inappropriately aggressive
interventions to manage blood sugar may harm patients

Notes/Educational Pearls
Key Considerations
1. New onset DKA in pediatric patients commonly presents with nausea, vomiting, abdominal
pain, and/or urinary frequency
2. Consider causes for hyperglycemia by thinking about the 3I’s:
a. Insulin: This refers to any medication changes for insulin or oral medications
including poor compliance or malfunctioning insulin pump
b. Ischemia: This refers to hyperglycemia sometimes being an indication of physiologic
stress in a patient and can be a clue to myocardial ischemia in particular
c. Infection: Underlying infection can cause derangements in glucose control

Pertinent Assessment Findings

1. Concomitant trauma
2. Abdominal pain, “fruity breath,” and rapid-deep respirations (Kussmaul respirations) may
be associated with DKA. Kussmaul respirations are indicative of severe acidosis in
patients with DKA

Quality Improvement
Key Documentation Elements
• Document reassessment of vital signs and mental status after administration of IV
fluids
• Document glucose level (if in scope of practice) when indicated

Performance Measures

50
 • When in scope of practice, point of care blood glucose checked for all patients with
symptoms of altered level of consciousness, seizure, stroke, or hyperglycemia
• When hyperglycemia documented, appropriate volume replacement given while avoiding
overzealous repletion before insulin therapy at receiving center
• 12-lead EKG obtained

Hypoglycemia

Aliases
None noted

Patient Care Goals

1. Limit morbidity from hypoglycemia by:
a. Describing appropriate use of glucose monitoring
b. Treating symptomatic hypoglycemia

Patient Presentation
Inclusion Criteria
1. Patients with blood glucose less than 60 mg/dL with symptoms of hypoglycemia
2. Patients with altered level of consciousness [See Altered Mental Status Protocol]
3. Patients with stroke symptoms (e.g., hemiparesis, dysarthria) [See Suspected
Stroke/Transient Ischemic Attack Protocol]
4. Patients with seizure [See Seizures Protocol]
5. Patients with history of diabetes and other medical symptoms
6. Patients with suspected alcohol ingestion
7. Patients with metabolic disorders (glycogen storage disease, fatty oxidation or organic acid
disorders, maple syrup urine disease)
8. Patients who appear to be intoxicated

Exclusion Criteria
Patient in cardiac arrest
Patient with normal mental status in absence of inclusion criteria listed above

Patient Management
Assessment
1. Monitoring:
a. Check blood glucose level
2. Secondary survey pertinent to altered blood glucose level:
a. Evaluate for presence of an automated external insulin delivery device (insulin
pump)
b. Constitutional: assess for tachycardia and hypotension
c. Eyes: assess for sunken eyes from dehydration
d. Nose/mouth/ears: assess for dry mucous membranes or tongue bite from seizure
e. Neurologic:
i. Assess GCS and mental status
ii. Assess for focal neurologic deficit: motor and sensory

Treatment and Interventions

1. If altered level of consciousness or stroke, treat per Altered Mental Status Protocol or
Suspected Stroke/Transient Ischemic Attack Protocol accordingly
2. If blood glucose is 60 mg/dL or less administer one of the following:
a. Conscious patient with a patent airway:
i. Glucose, oral (in form of glucose tablets, glucose gel, tube of cake icing,etc.)
1. Adult Dosing: 25 g
2. Pediatric Dosing: 0.5–1 g/kg

51
 b. Unconscious patient, or patients who are unable to protect their ownairway:
i. Dextrose IV – administer in incremental doses until mental status improves or
maximum field dosing is reached (if available, D10% is preferred)
1. Maximum field adult dosing: 25 g of 10–50% dextroseIV
a. 50 mL of 50% dextrose
b. 100 mL of 25%dextrose
c. 250 mL of 10%dextrose
2. Maximum field pediatric dosing: 0.5–1 g/kg of 10–25% dextroseIV a. 2–4
mL/kg of 25% dextrose for those greater than 8 years old b. 5–10 mL/kg of
10% dextrose (newborns 2 mL/kg)
ii. Glucagon IM/IN – an option for patients for whom IV access cannot be
established
1. Adult dosing: 1 mg IM/IN (or prefilled 3 mg dry powder IN or prefilled IM
autoinjector)
2. Pediatric dosing:
a. 1 mg IM/IN if ≥ 20 kg (or ≥ 5 years old (or prefilled 4 mg dry powder IN
for patients greater than 4 years old or prefilled IM autoinjector)
b. 0.5 mg IM/IN if less than 20 kg (or less than 5 years old)
iii. Remove or disable insulin pump if above treatments cannot becompleted
c. For patients with an insulin pump who are hypoglycemic with associated altered
mental status (GCS less than 15):
i. Stop the pump, disconnect, or remove at insertion site if patient cannot ingest oral
glucose or ALS is not available
ii. Leave the pump connected and running if able to ingest oral glucose or receive
ALS interventions
3. Reassess patient
a. Reassess vital signs (pulse, blood pressure, respiratory rate, neurologic status
assessment) and mental status
b. Repeat check of blood glucose level if previous hypoglycemia and mental status has not
returned to normal
i. It is not necessary to repeat check of blood glucose level blood sugar if mental
status has returned to normal
c. If maximal field dosage of dextrose solution does not achieve euglycemia and
normalization of mental status:
i. Initiate transport to closest appropriate receiving facility for further treatment of
refractory hypoglycemia
ii. Evaluate for alternative causes of altered mental status
iii. Continue treatment of hypoglycemia using dextrose solutions as notedabove
4. Disposition
a. If hypoglycemia with continued symptoms, transport to closest appropriate receiving
facility
b. Hypoglycemic patients who have had a seizure should be transported to the hospital
regardless of their mental status and response to therapy
c. If symptoms of hypoglycemia resolve after treatment, release without transport should
only be considered if all the following are true:
i. Repeat glucose is greater than 80 mg/dL
ii. Patient takes insulin or metformin to control diabetes and does not take long-
acting oral sulphunylurea agents (e.g., glipizide, glyburide, or others)
iii. Patient returns to normal mental status, with no focal neurologic signs/symptoms
after receiving glucose/dextrose
iv. Patient can promptly obtain and will eat a carbohydrate meal
v. Patient or legal guardian refuses transport and EMS clinicians agree transport not
indicated
vi. A reliable adult will be staying with patient

52
 vii. No major co-morbid symptoms exist, like chest pain, shortness of breath, seizures,
intoxication
viii. A clear cause of the hypoglycemia is identified (e.g., missed meal)

Patient Safety Considerations

1. Dextrose 10% can be safely used in all ages ofpatient. Dextrose 10% works as effectively
and quickly as other concentrations
2. Dextrose 50% can cause local tissue damage if it extravasates from vein and may cause
hyperglycemia. Dextrose 50% carries risk for little clinical gain. EMS systems may
consider carrying no more than 25% concentration of dextrose for treating hypoglycemia
in adults
3. For children less than 8 years old, dextrose concentration of no more than 25% should be
used
4. Forneonates andinfants less than 1monthofage, dextrose concentration ofnomore than 10–
12.5% should be used
5. Sulfonylureas (e.g., glyburide, glipizide) have long half-lives ranging from 12–60 hrs.
Patients with corrected hypoglycemia who are taking these agents are at particular risk for
recurrent symptoms and frequently require hospital admission

Notes/Educational Pearls
A formula for calculating a 0.5 g/kg dose of IV dextrose:
(____% concentration of glucose) x (_____mL/k g) = 50

Key Considerations
1. Using 10% dextrose is as effective and safer than other stronger concentrations
2. Consider contribution of oral diabetic medications to hypoglycemia
3. If possible, have family/patient turn off insulin pump
4. Consider potential for intentional overdose of hypoglycemic agents
5. Avoid overshoot hyperglycemia when correcting hypoglycemia. Administer dextrose-
containing IV fluids in small doses until either mental status improves or a maximum field
dose is achieved

Pertinent Assessment Findings

1. Concomitant trauma
2. Diaphoresis or hypothermia may be associated with hypoglycemia

Quality Improvement
Key Documentation Elements
• Document reassessment of vital signs and mental status after administration of
glucose/dextrose/glucagon
• Document point of care glucose level (if in scope of practice) whenindicated

Performance Measures
• When in scope of practice, blood glucose is checked for all patients with symptoms of
altered level of consciousness, seizure, stroke, or hypoglycemia
• If patient released at scene, criteria documented for safe release

53
Nausea-Vomiting

Aliases
1. Emesis
2. Gastroenteritis

Patient Care Goals

Identify hypoglycemia or hyperglycemia
Prevent dehydration

Patient Presentation
Inclusion Criteria
Currently nauseated and/or vomiting

Exclusion Criteria
None noted

Patient Management
Assessment
1. Routine patient care (e.g., vital signs)
2. History and physical examination focused on potential causes of nausea and vomiting (e.g.,
gastrointestinal, cardiovascular, obstetric, gynecologic, hypoglycemia, hyperglycemia,
neurologic, oncologic, psychogenic, or toxidrome) as well as medications that may
prolong the QT interval
3. Obtain glucose level

Treatment andInterventions
1. Antiemetic medication administration
a. Isopropyl alcohol: Allow patient to inhale vapor from isopropyl alcohol wipe 3 times
q (que, every) 15 minutes as tolerated
b. Ondansetron (contraindicated for suspected or known diagnosis of prolonged QT
syndrome)
i. Adult:
1. 4 mg IV/PO/SL
OR
2. 4 or 8 mg SL of the ODT formulation
ii. Pediatric (6 months – 14 years old):
1. 0.15 mg/kg IV/PO (maximum dose of 4 mg)
OR
2. 2 mg SL for ages 1–5 years old; age 6 and older use 4 mg of the ODT
formulation c. Metoclopramide
i. Adult: 10 mg IV/IM
ii. Pediatric (greater than 2 years old only and greater than 12 kg):
1. 0.1 mg/kg IM
OR
2. 0.1 mg/kg IV (maximum 10 mg)
a. May repeat x 1 in 20–30 minutes if no relief
d. Prochlorperazine
i. Adult: 5 mg IV/IM
ii. Pediatric (over 2 years old only and greater than 12 kg):
1. 0.1 mg/kg slow IV
OR
2. 0.1 mg/kg deep IM (maximum 10 mg)
e. Droperidol

54
 i. Adult: 1.25 mg IV/IM (contraindicated for suspected or known diagnosis of
prolonged QT syndrome)
f. Diphenhydramine
i. Adult: 12.5–25 mg IV/IM/PO
ii. Pediatric (over 2 years old only and greater than12 kg): 0.1 mg/kg IV (maximum
25 mg)

Patient Safety Considerations

1. Ondansetron should not be administered to patients who have a prolonged QT interval as it
can cause torsades.
2. For very young pediatric patients, ondansetron can be sedating
3. Dystonic and extrapyramidal symptoms are possible side effects of antiemetics – If
encountered, consider diphenhydramine:
a. Adult: 25–50 mg IV/IM/PO
b. Pediatric: 1 mg/kg IV/IM/PO (maximum dose 50 mg)
4. Medications that prolong the QT interval may alter treatment options.

Notes/Educational Pearls

Key Considerations
1. Ondansetron is preferred in children for the treatment of nausea and vomiting
2. Metoclopramide has fewer adverse effects than prochlorperazine in children
3. Prochlorperazine and metoclopramide (phenothiazines) have an increased risk of dystonic
reactions
a. Some phenothiazines also have an increased risk of respiratory depression when
used with other medications that cause respiratory depression, and some
phenothiazines can cause neuroleptic malignant syndrome
b. Prochlorperazine carries a black box warning for use in elderly patients with dementia-
related psychosis.
4. IV form of ondansetron may be given PO in same dose
5. Nausea and vomiting are symptoms of illness – in addition to treating the patient’s nausea
and vomiting a thorough history and physical are key to identifying what may be a disease
in need of emergent treatment (e.g., bowel obstruction, myocardial infarction, pregnancy)

6.
While ondansetron has not been adequately studied in pregnancy to determine safety,
women should be counseled regarding the available data. In the first trimester of
pregnancy, the administration of metoclopramide 5–10 mg IV with diphenhydramine 25
mg IV is recommended over the administration of ondansetron

Pertinent Assessment Findings

1. Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)
2. Risk factors for heart disease/EKG if applicable
3. Pregnancy status
4. Abdominal exam
5. Blood glucose levels

Quality Improvement
Key Documentation Elements
• Patient age
• Patient weight and/or length-based weight measure for pediatric patients
• Medications given, including time, clinician level, dose, dose units, route, response, and
complications
• Vital signs before and after medication administration

55
 • History and physical regarding etiology of nausea/vomiting
• EKG performed and interpretation documented if cardiac risk factors are present

Performance Measures
• In patients with nausea and vomiting, appropriate medication(s) was/were administered
(including proper dosage) and the patient's response to treatment is documented
• Any event where complications occurred, such as a dystonic reaction, should have event
and appropriate responsive interventions performed and documented he administration of
ondansetron

Pain Management

Aliases
1. Analgesia
2. Pain control

Patient Care Goals

1. Compassionately manage all patients with pain
2. Minimize adverse events in the treatment of pain

Patient Presentation
Inclusion Criteria
Patients who are experiencing pain regardless of transport interval

Exclusion Criteria
Pregnancy with active labor

Patient Management
Assessment, Treatment, and Interventions
1. Choice of medication class, route of administration, dosing and frequency are based on pain
severity and the need for escalation from oral to parenteral routes
2. The dosing Protocols apply to patients of all ages except where noted 3. Determine patient’s
pain score assessment using standard pain scale
a. Less than 4 years old or those with cognitive impairment unable to self-report: i.
Observational Scales
1. Faces, Legs, Arms, Cry, Consolability (FLACC)
2. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)
b. 4–12 years old:
i. Self-report scale
1. Wong Baker Faces
2. Faces Pain Scale (FPS)
3. Faces Pain Scale Revised (FPS-R)
c. Greater than 12 years old:
i. Self-report scale
1. Numeric Rating Scale(NRS)
4. Non-pharmacologic pain management options include
a. Placement of the patient in a position of comfort
b. Application of ice packs and/or splints for pain secondary to trauma
c. Verbal reassurance to control anxiety
5. Minor pain or as an adjunct for moderate/severe pain consider the following non-opioid
analgesic options:
a. Paracetamol (acetaminophen) 15 mg/kg PO or IV (maximum dose 1 g)
b. Nonsteroidal anti-inflammatories
i. Ibuprofen 10 mg/kg PO for patients greater than 6 months of age (maximum dose
800 mg) OR

56
 ii. Ketorolac
1. Adult: 30 mg IM or 15 mg IV
2. Pediatric age 2–16 years old: 0.5 mg/kg (maximum dose of 30 mg IM or 15 mg
IV)
c. Nitrous Oxide
6. For Moderate to Severe pain, analgesics include:
a. Morphine sulfate:
i. 0.1 mg/kg IM, IV or IO (maximum initial dose is 10 mg)
b. Fentanyl:
i. 1 mcg/kg IN, IM, IV or IO (maximum initial dose of 100 mcg)
c. Hydromorphone:
i. 0.015 mg/kg IM, IV, or IO (maximum initial dose 2 mg; maximum cumulative
dose of 4 mg)
d. Ketamine:
i. 0.25 mg/kg IM, IV or IO (maximum initial dose 25 mg; maximum cumulative
dose 100 mg)
7. Use of non-invasive capnography is an earlier predictor of hypoventilation than pulse
oximetry if opioid medications are administered
8. Consider administration of oral, sublingual, or IV antiemetics to prevent nausea [See
Nausea/Vomiting Protocol]
9. If indicated based on pain assessment, and vital signs allow, repeat pain medication
administration (excluding paracetamol and nonsteroidal anti-inflammatory medicines)
after 5 minutes of the previous dose
10. Transport in position of comfort and reassess as indicated

Patient Safety Considerations

1. All patients should have drug allergies identified prior to administration of pain
medication
2. Administer opioids with caution to patients with Glasgow Coma Score (GCS) less than 15,
hypotension, identified medication allergy, hypoxia (SPO2 less than 90%) after maximal
supplemental oxygen therapy, or signs of hypoventilation
3. Opioids are contraindicated for patients who have taken monoamine oxidase inhibitors
(MAOI) during the previous 14 days
4. Avoid non-steroidal anti-inflammatory medications such as ibuprofen and ketorolac in
patients with NSAID allergy, aspirin-sensitive asthma, renal insufficiency, pregnancy, or
known peptic ulcer disease
5. Ketorolac should not be used in patients with hypotension (due to renal toxicity)
6. Use of splinting techniques and application of ice should be done to reduce the total
amount of medication used to keep the patient comfortable

Notes/Educational Pearls
Key Considerations
1. Intranasal routes of opioid analgesia are preferred as the initial dosing route in pediatrics
where IV access may be problematic; consider in other patient populations when an IV in
not otherwise indicated
2. Onset of action is dependent on the pharmacokinetics of the drug class as well as route of
administration; oral analgesics are effective for pain control but have a slower onset of
action so plan accordingly
3. Pain severity scores should be recorded before and after analgesic medication
administration and upon arrival at destination
4. Patients with acute abdominal pain should receive analgesic interventions – Use of
analgesics for acute abdominal pain does not mask clinical findings or delay diagnosis
5. Opiates may cause a rise in intracranial pressure

Pertinent Assessment Findings

57
 1. Mental status (Glasgow Coma Score (GCS) and pain level)
2. Respiratory system (tidal volume, chest rigidity)
3. Gastrointestinal (assess for tenderness, rebound, guarding, and nausea)

Quality Improvement
Key Documentation Elements
• Documentation of patient vital signs (pulse, blood pressure, respiratory rate, neurologic
status assessment) with pulse oximetry
• Acquisition of patient’s allergies prior to administration of medication
• Documentation of initial patient pain scale assessment
• Documentation of medication administration with correct dose
• Documentation of patient reassessment with repeat vital signs and patient pain scale
assessment

Performance Measures
• The clinical efficacy of prehospital analgesia in terms of adequacy of dosing
parameters
Table 1. Adult Nonverbal Pain Scale University of Rochester Medical Center

Source: Odhner M, Wegman D, Freeland N, Ingersoll G. Evaluation of a newly developed non-verbal pain scale
(NVPS) for assessment of pain in sedated critically ill patients.

58
ANNEX 4: Resuscitation

Cardiac Arrest (VF/VT/Asystole/PEA)

Aliases
1. Arrest
2. Full arrest
3. Heart attack

Patient Care Goals

1. Return of spontaneous circulation (ROSC)
2. Preservation of neurologic function
3. High-quality chest compressions/CPR with minimal interruption from recognition of
cardiac arrest until confirmation of ROSC or termination of care

Patient Presentation
Inclusion Criteria
Patients with cardiac arrest

Exclusion Criteria
1. Patients suffering cardiac arrest due to severe hypothermia [See Hypothermia/Cold
Exposure Protocol]
2. Patients with identifiable Do Not Resuscitate (or equivalent such as POLST) order
3. Patients in arrest due to traumatic etiology [See General Trauma Management Protocol]

Patient Management
Assessment
1. The patient in cardiac arrest requires a prompt balance of treatment and assessment
2. In cases of cardiac arrest, assessments should be focused and limited to obtaining enough
information to reveal the patient is pulseless
3. Once pulselessness is discovered, treatment should be initiated immediately, and any
further history must be obtained by bystanders while treatment is ongoing

Treatment and Interventions

The most important therapies for patients suffering from cardiac arrest are prompt cardiac
defibrillation for shockable rhythms and minimally interrupted effective chest compressions 1.
Initiate chest compressions in cases with no bystander chest compressions or take over
compressions from bystanders while a second rescuer is setting up the AED or
defibrillator
a. If adequate, uninterrupted bystander CPR has been performed or if the patient arrests
in front of the EMS clinicians, immediately proceed with rhythm analysis and
defibrillation, if appropriate
b. It is realistic for EMS clinicians to tailor the sequence of rescue actions to coincide the
most likely cause of arrest
c. There is insufficient evidence to recommend for or against delaying defibrillation to
provide a period of CPR for patients in VF/pulseless VT out-of-hospital cardiac
arrest
d. For adults and children with unwitnessed cardiac arrest or for whom an AED is not
immediately available, it is reasonable that CPR be initiated while the defibrillator
equipment is being retrieved and applied and that defibrillation, if indicated, be
attempted as soon as the device is ready for use

59
2. The maximum setting on the defibrillator should be used for initial and subsequent
defibrillation attempts. Defibrillation dosing should follow manufacturer’s
recommendation in the case of biphasic defibrillators. If the manufacturer’s
recommendation is unknown, use highest setting possible. In the case of monophasic
devices, the setting should be 360J (joule) (or 4 J/kg for children)
3. Chest compressions should resume immediately after defibrillation attempts with no
pauses for pulse checks for 2 minutes regardless of the rhythm displayed on the cardiac
monitor
4. All attempts should be made to prevent avoidable interruptions in chest compressions,
such as pre-charging the defibrillator and hovering over the chest, rather than stepping
away during defibrillations
5. If feasible, IV or IO access should be obtained. Administer epinephrine during the first or
second round of compressions. Prioritize early administration of epinephrine for non-
shockable rhythms
6. Continue the cycle of chest compressions for 2 minutes, followed by rhythm analysis and
defibrillation of shockable rhythms; during this period, the proper strategy of airway
management is currently not defined and many options for airway management exist.
Regardless of the airway management and ventilation strategy, consider the following
principles:
a. The airway management strategy should not interrupt compressions
b. Successful resuscitation from cardiac arrest depends primarily on effective, minimally
interrupted chest compressions and prompt defibrillation if the patient is in pulseless
VT/VF. As opposed to children, an adult’s airway management is of secondary
importance and should not interfere with compressions and defibrillation. Options for
airway management include:
i. Passive ventilation:
1. High flow oxygen is applied via a non-rebreather mask with an oropharyngeal
airway
2. Some oxygen will be entrained with each decompression of the chest
3. This may be applied for the first 3–4 compression cycles (6–8 minutes), after
which one may consider BVM ventilation or placement of an advanced
airway
ii. BVM ventilation at 10 breaths per minute (1 breath every 10 compressions),
applied during the upstroke between compressions, without interrupting the
compressions, targeting a ventilatory volume of 500 mL (adults)
iii. BVM ventilation with 30:2 ventilation to compression ratio: Each 30
compressions, the compressions are paused briefly to allow 2 BVM ventilations,
then compressions immediately resumed
1. Pediatric Consideration: For multiple rescuer CPR in children, 15:2 is the
recommended compression-to-ventilation ratio (30:2 for single rescuer)
2. Pediatric Consideration: For neonates, 3:1 is the recommended
compression-to-ventilation ratio
iv. Advanced airway placement:
1. Either a supraglottic airway or an endotracheal tube may be placed without
interruption of compressions
2. Ventilations are provided at 10 breaths/minute for adults
3. Pediatric Consideration: for children, 1 breath every 3–5 seconds is
recommended (12–20 breaths/minute)
4. Pediatric Consideration: deliver volume needed to achieve chest rise
7. Consider use of antiarrhythmic for recurrent VF/Pulseless VT
a. The principal objective of antiarrhythmic drug therapy in shock-refractory VF and
pulseless VT is to facilitate the restoration and maintenance of a spontaneous
perfusing rhythm in concert with the shock termination of VF/VT; some
antiarrhythmic drugs have been associated with increased rates of ROSC and hospital

60
 admission, but none have yet been proven to increase long-term survival or survival
with good neurologic outcome
i. Amiodarone (5 mg/kg IV, max of 300 mg) may be considered for VF/pulseless
VT that is unresponsive to CPR, defibrillation, and a vasopressor therapy
ii. Lidocaine (1 mg/kg IV) may be considered as an alternative to amiodarone for
VF/pulseless VT that is unresponsive to CPR, defibrillation, and vasopressor
therapy
iii. The routine use of magnesium for VF/pulseless VT is not recommended in adult
patients unless it is refractory, polymorphic VT, or Torsades de pointes.
b. There is inadequate evidence to support the routine use of lidocaine and beta-blockers
after cardiac arrest by EMS. There is insufficient evidence to recommend for or
against the routine initiation or continuation of other antiarrhythmic medications after
ROSC from cardiac arrest
c. For torsades de pointes, give magnesium sulfate 2 g IV administered over 1–2
minutes (or 25–50 mg/kg for pediatrics). There is insufficient evidence to
recommend for or against the routine administration during cardiac arrest
8. Consider reversible causes of cardiac arrest which include the following:
a. Hypothermia – additions to care include attempts at active rewarming [See
Hypothermia/Cold Exposure Protocol]
b. The dialysis patient/known hyperkalemic patient – Additions to care include the
following:
i. Calcium gluconate 10% 1 g IV bolus over 2 minutes (for pediatrics, the mg/kg
which is 1 mL/kg), can repeat the dose if no response OR
ii. Calcium chloride 10% 1 g IV bolus over 2 minutes (for pediatrics, the dose is 20
mg/kg which is 0.2 mL/kg)
iii. Sodium bicarbonate 1 mEq/kg IV
c. Tricyclic antidepressant overdose. Additions to care include sodium bicarbonate 1
mEq/kg IV
d. Hypovolemia. Additions to care include normal saline 2 L IV (or 20 mL/kg, repeated
up to 3 times for pediatrics)
e. If the patient is intubated at the time of arrest, assess for tension pneumothorax and
misplaced ETT
f. If tension pneumothorax suspected, perform needle decompression. Assess ETT, if
misplaced, replace ETT
9. If at any time during this period of resuscitation the patient regains return of spontaneous
circulation, treat per Adult Post-ROSC (Return of Spontaneous Circulation) Care Protocol

Patient Safety Considerations

1. Performing manual chest compressions in a moving vehicle may pose a clinician safety
concern
2. In addition, manual chest compressions during patient movement are less effective in
regard to hands on time, depth, recoil and rate
3. Ideally, patients should be resuscitated as close to the scene as operationally possible
4. Risks and benefits should be considered before patient movement in cardiac arrest
situations

Notes/Educational Pearls
Key Considerations
1. Effective chest compressions and defibrillation are the most important therapies to the
patient in cardiac arrest. Effective chest compressions are defined as:
a. A rate of greater than 100 and less than 120 compressions/minute
b. Depth of at least 2 inches (5 cm) and less than 2.4 inches (6 cm) for adults and
children or 1.5 inches (4 cm) for infants; adolescents who have entered puberty should
receive the same depth of chest compressions as an adult
c. Allow for complete chest recoil (avoid leaning)

61
 d. Minimize interruptions in compressions
e. Avoid rescuer fatigue by rotating rescuers at least every 2 minutes. Some EMS pit
crew approaches use a clinician on either side of the chest, alternating compressions
every minute or every 100 compressions to avoid fatigue
2. Avoid excessive ventilation and consider delayed airway management – If no advanced
airway, consider:
a. Passive ventilation using an NRB with 3–4 cycles of uninterrupted chest
compressions (for arrests of suspected cardiac etiology). Consider BVM ventilation or
advanced airway after 3–4 cycles
b. BVM ventilation every 10–15 compressions with cycles of uninterrupted chest
compressions. Upstroke ventilation between compressions.30:2 ventilation to
compression ratio for adults, and 15:2 for children when 2 rescuers are present
c. If an advanced airway is placed, ventilations should not exceed 10 breaths/minute (1
breath every 6 seconds or 1 breath every 10 compressions) in adults. Pediatric
Consideration: For children with an advanced airway, 1 breath every 3–5 seconds is
recommended (equivalent to 12–20 breaths/minute)
3. Quantitative end-tidal capnography (EtCO2) should be used to monitor effectiveness of
chest compressions
a. If EtCO2 less than 10 mmHg during the initial phases of resuscitation, attempt to
improve chest compression quality
b. Consider additional monitoring with biometric feedback which may improve
compliance with suggested Resuscitation Section
4. Chest compressions are usually the most rapidly applied therapy for the patient in cardiac
arrest and should be initiated as soon as the patient is noted to be pulseless. If the patient
is being monitored with pads in place at the time of arrest, immediate defibrillation should
take precedence over all other therapies. However, if there is any delay in defibrillation
(e.g., in order to place pads), chest compressions should be initiated while the defibrillator
is being applied. There is no guidance on how long these initial compressions should be
applied; however, it is reasonable to either complete between 30 seconds and 2 minutes of
chest compressions in cases of no bystander chest compressions or to perform
defibrillation as soon as possible after chest compressions initiated in cases of witnessed
arrest
5. There is insufficient evidence to recommend the routine use of extracorporeal CPR
(ECPR) for patients with cardiac arrest. In settings where it can be rapidly implemented,
ECPR may be considered for select cardiac arrest patients for whom the suspected
etiology of the cardiac arrest is potentially reversible during a limited period of
mechanical cardiorespiratory support
6. Chest compressions should be reinitiated immediately after defibrillation as pulses, if
present, are often difficult to detect and rhythm and pulse checks interrupt compressions
7. Continue chest compressions between completion of AED analysis and AED charging
8. The effectiveness of chest compressions decreases when moving patients
a. Patients should therefore be resuscitated as close to the point at which they are first
encountered and should only be moved if the conditions on scene are unsafe or do not
operationally allow for resuscitation
b. Chest compressions are also less effective in a moving vehicle
c. It is also dangerous to EMS clinicians, patients, pedestrians, and other motorists to
perform chest compressions in a moving ambulance
d. For these reasons and because in most cases the care provided by EMS clinicians is
equivalent to that provided in emergency departments, resuscitation should occur on
scene
9. The maximum setting on the defibrillator should be used for initial and subsequent
defibrillation attempts. Defibrillation dosing should follow manufacturer’s
recommendation in the case of biphasic defibrillators. If the manufacturer’s
recommendation is unknown, use highest setting possible. In the case of monophasic
devices, the setting should be 360 J (joule) (or 4 J/kg for children)

62
10. IV or IO access without interrupting chest compressions
11. Administer epinephrine (0.1 mg/kg, maximum dose 1 mg) IV/IO during the first or
second round of compressions
12. At present, the most effective mechanism of airway management is uncertain due to some
systems managing the airway aggressively and others managing the airway with basic
measures and both types of systems finding excellent outcomes. Regardless of the airway
management style, consider the following principles:
a. Airway management should not interrupt chest compressions
b. Carefully follow ventilation rate and prevent hyperventilation
c. Consider limited tidal volumes
d. There is uncertainty regarding the proper goals for oxygenation during resuscitation
i. Current recommendations suggest using the highest flow rate possible through
NRB or BVM
ii. This should not be continued into the post-resuscitation phase in which the goal
should be an oxygen saturation (SpO2) of 94–98%
e. Pediatric Considerations: Special attention should be applied to the pediatric
population and airway management/respiratory support. Given that the most likely
cause of cardiac arrest is respiratory, airway management may be considered early in
the patient’s care
i. However, the order of Circulation-Airway-Breathing is still recommended as the
order of priority by the American Heart Association for pediatric resuscitation to
ensure timely initiation of chest compressions to maintain perfusion, regardless of
the underlying cause of the arrest
ii. In addition, conventional CPR is preferred in children, since it is associated with
better outcomes when compared to compression-only CPR
13. Special Circumstances in Cardiac Arrest
a. Trauma, treat per the General Trauma Management Protocol
b. Pregnancy
i. The best hope for fetal survival is maternal survival
ii. Position the patient in the supine position with a second rescuer performing
manual uterine displacement to the left to displace the gravid uterus and
increase venous return by avoiding aorto-caval compression
iii. If manual displacement is unsuccessful, the patient may be placed in the left
lateral tilt position at 30°. This position is less desirable than the manual
uterine displacement as chest compressions are more difficult to perform in
this position
iv. Chest compressions should be performed slightly higher on the sternum than
in the non-pregnant patient to account for elevation of the diaphragm and
abdominal contents in the obviously gravid patient
v. Defibrillation should be performed as in non-pregnant patients
c. Arrests of respiratory etiology (including drowning). In addition to the above,
consider early management of the patient’s airway. Passive ventilation with a
NRB is not indicated for these patients
14. Application of the “pit crew” model of resuscitation
a. Ideally, clinicians in each EMS agency will use a “pit crew” approach when using
this protocol to ensure the most effective and efficient cardiac arrest care.
Training should include teamwork simulations integrating first responders, BLS,
and ALS crewmembers who regularly work together. High-performance systems
should practice teamwork using “pit crew” techniques with predefined roles and
crew resource management principles. For example (the Pennsylvania State EMS
Model for Pit Crew):
i. Rescuer 1 and 2 set up on opposite sides of patient’s chest and perform
continuous chest compressions, alternating after every 100 compressions to
avoid fatigue

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 ii. Use a metronome or CPR feedback device to ensure that compression rate is
100– 120/minute
iii. Chest compressions are only interrupted during rhythm check (AED analysis
or manual) and defibrillation shocks – Continue compressions when
AED/defibrillator is charging
iv. Additional rescuer obtains IO (or IV) access and gives epinephrine. For IO
access:
1. The proximal humerus is the preferred site for adults
2. The tibial site is preferred for infants and children
v. During the first four cycles of compressions/defibrillation (approximately 10
minutes) avoid advanced airway placement
vi. One responding clinician assumes code leader position overseeing the entire
response vii. Use a CPR checklist to ensure that all best practices are followed
during CPR
b. For efficient “pit crew” style care, the EMS agency medical director should
establish the options that will be used by clinicians functioning within the EMS
agency. Options include establishing:
i. The airway/ventilation management, if any, that will be used
ii. The initial route of vascular access
15. The EMS agency must perform a Quality Improvement (QI) review of care and
outcome, overseen by the agency medical director, for every patient that receives
CPR
a. The QI should be coordinated with local receiving hospitals to include hospital
admission, discharge, and condition information. This EMS agency QI can be
accomplished by participation an organized cardiac arrest registry
b. The QI should be coordinated with local dispatch centers to review opportunities
to assure optimal recognition of possible cardiac arrest cases and provision of
dispatch-assisted CPR (including hands-only CPR when appropriate)

Quality Improvement
Key Documentation Elements
• Should be tailored to any locally utilized data registry but may include as a minimum the
following elements:
O Resuscitation attempted and all interventions performed o Arrest witnessed
O Location of arrest
O First monitored rhythm o CPR before EMS arrival
O Outcome
O Any ROSC
O Presumed etiology

Performance Measures
• Time to scene
• Time to patient
• Time to first CPR
• Time to first shock
• Time of ROSC
• Review of CPR quality
o Compression fraction
o Average and longest peri-shock pause o Rate and depth of compressions

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Adult Post-ROSC (Return of Spontaneous Circulation) Care

Aliases
None noted

Patient Care Goals

The immediate ROSC period is critical in stabilizing patients and preparing for transport. The goal is
therefore to maximize survival and optimize neurologic and cardiovascular function following a return
of spontaneous circulation by the following steps:
Secure airway
Obtain vascular access Maximize blood pressure
Identify ST-elevation myocardial infarction (STEMI) or reversible causes of arrest
Recognize pending re-arrest
Consider appropriate destination choice

Patient Presentation
Inclusion Criteria
Patient returned to spontaneous circulation following cardiac arrest resuscitation

Exclusion Criteria
None noted

Patient Management
Assessment, Treatment, and Interventions
1. Perform general patient assessment attempting to identify cause of cardiac arrest.
2. Support life-threatening problems associated with airway, breathing, and circulation.
a. For example, most of the pediatric cardiac arrest occurs due to non-cardiac causes
such as respiratory failure (hypoxemia) or shock (hypovolemia).
3. Monitor closely for recurrence of cardiac arrest using clinical and adjunctive criteria such
as cardiac monitoring, EtCO2 monitoring, and physical signs of perfusion
4. Administer oxygen as appropriate with a target of achieving 94–98% saturation. Do not
hyperoxygenate.
5. Do not hyperventilate. Maintain a ventilation rate of 8–10 breaths per minute, targeting
an EtCO2 of 35–45 mmHg.
6. For hypotension (SBP less than 90 mmHg or MAP less than 65 in adults) see Shock
Protocol
7. Perform serial 12-lead EKGs to assess for evidence of reversible cause of arrest such as
STEMI or electrolyte derangement (e.g., hyperkalemia)
8. Post-cardiac arrest patients with evidence or interpretation consistent with ST elevation
myocardial infarction (STEMI/acute MI) should be transported preferably to a facility
capable of emergent cardiac catheterization or, as a secondary option, to a STEMI
receiving facility based upon local resources and system of care
9. Check blood glucose
a. If hypoglycemic, treat per Hypoglycemia Protocol
b. If hyperglycemic, notify hospital on arrival
10. If patient seizes, treat per Seizures Protocol
11. Consider transporting patients to an age-appropriate facility which offers specialized
adult or pediatric post-resuscitation care

65
 Patient Safety Considerations
1. Avoid hyperthermia (temperature greater than 37.5° C or 99.5° F) by avoiding excessive
environmental heat exposure, warm blankets, etc.
a. Beyond interventions to prevent hyperthermia or fever, prehospital initiation of
therapeutic hypothermia (targeted temperature management) is not routinely
recommended

Notes/Educational Pearls
Key Considerations
1. Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in
the post resuscitation phase and must be avoided. Similarly, hypoventilation (suggested by
an EtCO2 greater than 40–45) contributes to worsening acidosis and may precipitate re-
arrest
2. Most patients are comatose immediately after resuscitation and will require airway
management and ventilatory assistance
3. Many patients experience “stunning” of the cardiac muscle after ROSC. Hypotension is
common, and volume resuscitation or vasopressor support is often required. Refer to the
[Shock Protocol] for further recommendations
4. Common non-cardiac causes of post-resuscitation hypotension include hyperventilation,
hypovolemia, and traumatic pneumothorax from chest compressions
5. The condition of post-resuscitation patients fluctuates rapidly and continuously requiring
close monitoring. A significant percentage of post-ROSC patients will re-arrest
6. Current research has demonstrated that care of patients with ROSC at specialized centers is
associated with both decreased mortality and improved neurologic outcomes
7. Maintain mechanical CPR device in place in preparation for re-arrest
8. A moderate number of adult post-ROSC patients may have transient ST-elevation on EKG
Consider performing serial EKGs. Post-ROSC patients should preferentially be transported
to centers capable of managing STEMI, whenever possible

Pertinent Assessment Findings

Assess post-ROSC rhythm, lung sounds, and for signs of hypoperfusion

Quality Improvement
Key Documentation Elements
• Immediate post-arrest rhythms, vital signs (pulse, blood pressure, respiratory rate,
neurologic status assessment) and oxygen saturation
• Post-ROSC 12-lead EKG

Performance Measures
• Percent of ROSC patients transported to appropriate facility as defined by the EMS system

Resuscitation in Traumatic Cardiac Arrest

Aliases
Traumatic Cardiac Arrest (TCA)

Patient Care Goals

1. Return of spontaneous circulation
2. Treatment and resolution of the underlying pathophysiology leading to the traumatic
cardiac arrest
3. When appropriate, transport to the closest and most capable hospital within the defined
trauma system

66
Patient Presentation
Inclusion Criteria
Patients suffering blunt or penetrating trauma with cardiac arrest after arrival of EMS
clinicians or while under the care of EMS clinicians (witnessed arrest or recent arrest with
continued signs of life)

Exclusion Criteria
1. When the mechanism of injury does not correlate with the clinical condition, suggesting a
nontraumatic cause of cardiac arrest, standard resuscitative measures should be followed.
In such cases, refer to the Resuscitation Section
2. In victims of blunt or penetrating trauma with pulses or other signs of life on EMS clinician
assessment refer to the General Trauma Management Protocol
3. In victims of blunt or penetrating trauma with rigor mortis, lividity, or evidence of injuries
incompatible with life (including decapitation, hemicorporectomy).

Patient Management
Assessment
1. Management of traumatic cardiac arrest requires a balance of rapid, focused evaluation
followed by prompt treatment of reversible life threats, including management of massive
hemorrhage, airway management, decompression of tension pneumothorax, and
resuscitation
2. Assess for signs of life, including pulses, respiratory effort, and evaluation of other signs of
life
3. Assess for evidence of massive hemorrhage
a. Including evidence of massive external hemorrhage
b. Evidence of pelvic injury (such as instability)
4. Assess the patient’s airway
5. Assess the patient’s respiratory effort, if present, or for evidence of tension pneumothorax
6. Assess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

Treatment and Interventions

Manage massive hemorrhage. Hemorrhage management takes priority in traumatic cardiac

arrest. Refer to General Trauma Management Protocol for complete list of therapies for the
treatment of massive hemorrhage, including the following:
a. Place tourniquets for wounds amenable to tourniquet placement
b. Use a combination of wound packing and direct pressure for junctional wounds or
junctional tourniquets if available
c. Place a pelvic binder on all patients with blunt or blast trauma suffering traumatic
arrest
2. Manage the patient’s airway. Refer to the Airway Management Protocol
3. Perform bilateral, rapid chest decompression 4. Establish intravenous access
5. Initiate volume resuscitation and adjunctive hemorrhage control measures (such as
tranexamic acid (TXA)) en route to the hospital

Patient Safety Considerations

None noted

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Notes/Educational Pearls
Key Considerations
1. Survival from traumatic cardiac arrest requires careful coordination between rapid
prehospital assessment, EMS clinician treatment of reversible causes of traumatic cardiac
arrest and transport that is rapid, but also allows maintenance of necessary therapies in a
manner that is effective for patients as well as safe for EMS clinicians
2. Evidence for the benefit of CPR in traumatic cardiac arrest is limited. Treatment priorities
should initially focus on control of massive hemorrhage (including management of pelvis
fractures), airway management, and consideration of bilateral needle thoracostomy. If CPR
is performed at all, it should be performed en route to the hospital but only if it can be
performed in a safe and effective manner by EMS clinicians
3. Unless there is an immediate and correctable cause, patients suffering traumatic cardiac
arrest have the best chance for survival when arrival time to a hospital is within minutes
4. If transport is initiated, consider the ACS-COT’s Once the above treatments and
interventions have been performed, patients should be transported to the closest appropriate
hospital within the defined trauma system
5. In an effort to reduce on-scene time, consider IV/IO access and initiation of resuscitation
during transport
6. Optimal choices for resuscitation are (in descending order as available) as follows: whole
blood, balanced blood products (red blood cells (RBC), plasma), packed red blood cells
alone, liquid, or freeze-dried plasma alone, no fluid resuscitation. Excessive crystalloid and
colloid have little to no value and may in fact be harmful in hemorrhagic shock

Pertinent Assessment Findings

1. Evidence of injuries incompatible with life
2. Evidence of signs of life

Quality Improvement
Key Documentation Elements
● Mechanism of injury
● Primary survey findings
● Secondary survey findings
● Scene time
● Procedures performed and patient response

Performance Measures
● Scene time
● Appropriateness of procedures, including airway management, hemorrhage control, needle
thoracostomy, intravenous access and resuscitation

1. Manage massive hemorrhage. Hemorrhage management takes priority in traumatic cardiac

arrest. Refer to General Trauma Management Protocol for complete list of therapies for the
treatment of massive hemorrhage, including the following:
a. Place tourniquets for wounds amenable to tourniquet placement
b. Use a combination of wound packing and direct pressure for junctional wounds or
junctional tourniquets if available
c. Place a pelvic binder on all patients with blunt or blast trauma suffering traumatic
arrest
2. Manage the patient’s airway. Refer to the Airway Management Protocol
3. Perform bilateral, rapid chest decompression 4. Establish intravenous access
5. Initiate volume resuscitation and adjunctive hemorrhage control measures (such as
tranexamic acid (TXA)) en route to the hospital

Patient Safety Considerations

None noted

68
Notes/Educational Pearls
Key Considerations
1. Survival from traumatic cardiac arrest requires careful coordination between rapid
prehospital assessment, EMS clinician treatment of reversible causes of traumatic cardiac
arrest and transport that is rapid, but also allows maintenance of necessary therapies in a
manner that is effective for patients as well as safe for EMS clinicians
2. Evidence for the benefit of CPR in traumatic cardiac arrest is limited. Treatment priorities
should initially focus on control of massive hemorrhage (including management of pelvis
fractures), airway management, and consideration of bilateral needle thoracostomy. If CPR
is performed at all, it should be performed en route to the hospital but only if it can be
performed in a safe and effective manner by EMS clinicians
3. Unless there is an immediate and correctable cause, patients suffering traumatic cardiac
arrest have the best chance for survival when arrival time to a hospital is within minutes
4. If transport is initiated, consider the ACS-COT’s Once the above treatments and
interventions have been performed, patients should be transported to the closest appropriate
hospital within the defined trauma system
5. In an effort to reduce on-scene time, consider IV/IO access and initiation of resuscitation
during transport
6. Optimal choices for resuscitation are (in descending order as available) as follows: whole
blood, balanced blood products (red blood cells (RBC), plasma), packed red blood cells
alone, liquid, or freeze-dried plasma alone, no fluid resuscitation. Excessive crystalloid and
colloid have little to no value and may in fact be harmful in hemorrhagic shock

Pertinent Assessment Findings

1. Evidence of injuries incompatible with life
2. Evidence of signs of life

Quality Improvement
Key Documentation Elements
● Mechanism of injury
● Primary survey findings
● Secondary survey findings
● Scene time
● Procedures performed and patient response

Performance Measures
● Scene time
● Appropriateness of procedures, including airway management, hemorrhage control, needle
thoracostomy, intravenous access and resuscitation.

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 ANNEX 5: Pediatric-Specific Protocols

Brief Resolved Unexplained Event (BRUE) & Acute Events in Infants

Aliases
Apparent Life-Threatening Event (ALTE)

Patient Care Goals

1. Recognize patient characteristics and symptoms consistent with a BRUE
2. Promptly identify and intervene for patients who require escalation of care
3. Choose proper destination for patient transport

Patient Presentation
Inclusion Criteria
1. Suspected BRUE: An event in an infant less than 1 year old reported by a bystander as
sudden, brief (less than 1 minute), unexplained, and completely resolved upon EMS
arrival that includes one or more of the following:
a. Breathing change (absent, decreased, or irregular)
b. Color change (central cyanosis or pallor)
c. Marked change in muscle tone (hyper- or hypotonia)
d. Altered level of responsiveness (increased, irritability, or decreased)

Exclusion Criteria
1. Any signs or symptoms suggestive of underlying or acute illness or injury present upon
EMS evaluation, such as:
a. Abnormal vital signs for age (including fever)
b. Vomiting
c. Signs of trauma
d. Noisy or labored breathing
2. Identifiable cause for the event, such as:
a. Gastric reflux (spitting up)
b. Swallowing dysfunction
c. Nasal congestion or excessive secretions from the nose and/or mouth
d. Periodic breathing of the newborn
e. Breath-holding spell
f. Change in tone associated with choking, gagging, crying, feeding
g. Seizure (e.g., eye deviation, nystagmus, tonic-clonic activity)
h. Hypoglycemia
i. Significant past medical history (e.g., congenital heart disease, pulmonary disease,
VP shunt, or seizure disorder)
j. Need for IV medication administration
3. History or exam concerning for child abuse or neglect
4. Color change that involved only redness (e.g., in the face) or isolated hands/feet cyanosis

70
Patient Management
Assessment
1. History
a. History of circumstances and symptoms before, during, and after the event,
including duration, interventions done, as well as patient color, tone, breathing,
feeding, position, location, activity, and level of consciousness
b. Other concurrent symptoms (e.g., fever, congestion, cough, rhinorrhea, vomiting,
diarrhea, rash, labored breathing, fussy, less active, poor sleep, poor feeding)
c. Prior history of BRUE (ever, including past 24 hours)
d. Past medical history (e.g., prematurity, prenatal/birth complications, gastric reflux,
congenital heart disease, developmental delay, airway abnormalities, breathing
problems, prior hospitalizations, surgeries, or injuries)
e. Family history of sudden unexplained death or cardiac arrhythmia in other children
or young adults
f. Social history: those living at home, recent household stressors, exposures to
toxins/drugs, sick contacts
g. Considerations for possible child abuse (i.e., multiple/changing versions of the story
or reported mechanism of injury does not seem plausible, especially for child’s
developmental stage) [See Abuse and Maltreatment Protocol]
2. Exam
a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status
assessment)
b. General assessment:
i. Signs of respiratory distress or increased work of breathing (e.g., tachypnea,
grunting or other abnormal breath sounds, nasal flaring, retracting, or head
bobbing)
ii. Color, both central and peripheral (pallor, cyanosis, redness, or normal), capillary
refill iii. Mental status (alert, tired, lethargic, unresponsive, or irritable)
c. Head to toe exam, including:
i. Physical exam for signs of trauma or neglect ii. Pupillary response and
anterior fontanelle

Treatment and Interventions

1. Monitoring (all patients with possible BRUE)
a. Continuous cardiac monitor
b. Continuous pulse oximetry
c. Serial observations during transport for change in condition
d. Check point-of-care (POC) blood glucose and treat symptomatic hypoglycemia [See
Hypoglycemia Protocol]
2. Airway
a. Give supplemental oxygen for signs of respiratory distress or hypoxemia — escalate
from a nasal cannula to a simple face mask to a non-rebreather mask as needed [See
Airway Management Protocol]
b. Suction excessive secretions from the nose and/or mouth (using bulb syringe or
suction catheter) [See Pediatric Respiratory Distress (Bronchiolitis) Protocol]
3. Utility of IV placement and fluids
a. Routine IVs should not be placed on all suspected BRUE patients
b. IVs should be placed only for clinical concerns of shock or to administer IV
medications
4. Transport the patient to the appropriate facility even if they appear well or have returned to
their baseline

Patient Safety Considerations

1. Regardless of the patient’s well appearance, all infants with a history of signs or symptoms
suggestive of BRUE should be transported for further evaluation

71
 a. By definition, infants who are not completely well-appearing at EMS evaluation do
not meet the definition of possible BRUE and should be treated and transported
according to local Protocols
2. Destination considerations
a. All patients should be transported to facilities with at least baseline pediatric
readiness, i.e., appropriate equipment, resources, and trained staff capable of
providing initial emergency care and stabilization to pediatric patients prior to
hospital admission or interfacility transfer, if feasible
b. Consider transport to a facility with pediatric critical care capability for patients with
any high-risk criteria:

I. Less than 2 months of age

II. History of prematurity (less than or equal to 32 weeks gestation)
III. More than one BRUE, now or in the past
IV. Event duration greater than 1 minute
V. CPR or resuscitation by caregivers or trained rescuers

Notes/Educational Pearls
Key Considerations
1. BRUE is a group of symptoms, not a disease process
2. If the infant is not completely well upon EMS arrival, this excludes possible BRUE event:
a. Treat and transport according to local Protocols
3. Avoid using “BRUE”, “ALTE”, “SIDS” (sudden infant death syndrome), or “near-miss
SIDS” terminology with parent/guardian
4. EMS clinicians play a unique and important role in obtaining an accurate history soon after
the event and in observing, documenting, and reporting environmental, scene and social
indicators that may point to an alternate diagnosis
5. High-risk patients with a possible BRUE have worse outcomes and may require emergency
department (ED) or inpatient testing, intervention, and/or follow-up
6. The determination of a BRUE is made only after hospital evaluation, not in the field:
a. A few of these infants will die even after hospital evaluation and treatment
7. All patients should be transported to an ED
8. Contact medical direction if parent/guardian is refusing medical care and/or transport,
especially if any high-risk criteria are present

Quality Improvement
Key Documentation Elements
• Document key aspect of history
o The event:
▪ Breathing (apnea or respiratory distress)
▪ Color change (central and/or peripheral)
▪ Change in muscle tone
▪ Level of responsiveness
▪ Event duration
▪ Witnessed?
o Pre-event circumstances and history
▪ Event associated with feeding or other activity
▪ History of prematurity
▪ Prior BRUE events (ever or in past 24 hours)
▪ Past medical history, especially cardiac, respiratory, gastrointestinal,
neurologic
o Caregiver resuscitation efforts
o Post-event symptoms and circumstances
• Document key aspects of the exam and assess for changes after each
intervention:

72
 o Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic
status assessment), temperature, and O2 saturation
o Respiratory effort
o Mental status including pupillary reaction and pediatric Glasgow Coma Score
(GCS) or AVPU
o Color (central and peripheral) and capillary refill
o Presence of signs of abuse, trauma, or neglect
• Document environmental and scene/social clues, especially those suggesting
abuse, neglect, non-accidental trauma, or unsafe sleeping practices

Performance Measures
• Complete set of vital signs recorded
• Appropriate transport destination relative to risk criteria

Pediatric Respiratory Distress (Bronchiolitis)

(Adapted from an evidence-based Protocol created using the National Prehospital Evidence-Based
Protocol Model Process)

Aliases
None noted

Patient Care Goals

1. Alleviate respiratory distress
2. Promptly identify respiratory distress, failure, and/or arrest, and intervene for patients
who require escalation of therapy
3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory
distress

Patient Presentation
Inclusion Criteria
Child less than 2 years of age typically with diffuse rhonchi and/or wheezing with a viral or
other undifferentiated illness characterized by rhinorrhea, cough, fever, tachypnea, and/or
respiratory distress

Exclusion Criteria
1. Anaphylaxis
2. Croup
3. Epiglottitis
4. Foreign body aspiration
5. Submersion/drowning
6. Asthma

Patient Management
Assessment
1. History
a. Onset of symptoms
b. Concurrent symptoms (e.g., fever, cough, rhinorrhea, tongue/lip swelling, rash,
labored breathing, foreign body aspiration)
c. Sick contacts
d. History of wheezing
e. Respiratory and other treatments given
f. Number of emergency department visits in the past year
g. Number of admissions in the past year

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 h. Number of intensive care unit (ICU) admissions ever (including pediatric ICU (PICU)
and neonatal ICU (NICU))
i. History of prematurity
j. Family history of asthma, eczema, or allergies
k. Change in feeding patterns and/or number of wet diapers
2. Exam
a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status
assessment) temperature, and O2 saturation
b. Air entry (normal vs. diminished)
c. Breath sounds (wheezes, crackles, rales, rhonchi, diminished, clear)
d. Signs of distress (grunting, nasal flaring, retracting, accessory muscle use)
e. Weak cry or inability to speak full sentences (sign of shortness of breath)
f. Color (pallor, cyanosis, normal)
g. Mental status (alert, tired, lethargic, unresponsive)
h. Hydration status (+/- sunken eyes, delayed capillary refill, mucous membranes (moist
vs. tacky), fontanel (flat vs. sunken))

Treatment and Interventions

1. Pulse oximetry and end-tidal capnography (EtCO2) should be routinely used as an adjunct
to other forms of respiratory monitoring
2. Perform EKG only if there are no signs of clinical improvement after treating respiratory
distress
3. Airway
a. Give supplemental oxygen – escalate from a nasal cannula to a simple face mask to a
non-breather mask as needed, to maintain normal oxygenation (goal SpO2 94–98%)
b. Suction the nose and/or mouth (via bulb or suction catheter) particularly if excessive
secretions are present
4. Inhaled medications – nebulized epinephrine 5 mg (5 mL of 1 mg/mL solution) should be
administered to children in severe respiratory distress with bronchiolitis in the prehospital
setting if other treatments (e.g., suctioning, oxygen) fail to result in clinical improvement;
if immediate reassessment after treatment does not demonstrate clinical improvement,
airway management should be escalated as necessary (see below and refer to Airway
Management Protocol)
5. Utility of IV placement and fluids. IVs should only be placed in children with respiratory
distress for clinical concerns of dehydration, or when administering IV medications.
Otherwise, IV access is not routinely needed in bronchiolitis.
6. Steroids are not efficacious and should not be given
7. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts:

a. High flow nasal cannula (HFNC) or continuous positive airway pressure

(CPAP) can be administered, when available, for severe respiratory
distress
b. Bag-valve-mask ventilation should be utilized in children with respiratory
failure or impending respiratory failure

8. Supraglottic devices and intubation

a. Supraglottic devices and intubation should be utilized only if bag-valve-mask (BVM)
ventilation fails
b. The airway should be managed in the least invasive way possible

74
 Patient Safety Considerations
Routine use of lights and sirens is not recommended during transport

Notes/Educational Pearls
Key Considerations
1. Suctioning can be a very effective intervention to alleviate distress since infants are obligate
nose breathers
2. Heliox should not be routinely administered to children with respiratory distress
3. Insufficient data exist to recommend the use of inhaled steam or nebulized saline
4. Although albuterol and steroids have previously been a consideration, the most recent
evidence does not demonstrate a benefit in routine use of albuterol or steroids for
bronchiolitis
5. Ipratropium and other anticholinergic agents should not be given to children with
bronchiolitis in the prehospital setting
6. Although nebulized hypertonic saline has been shown to decrease hospital length of stay
when used for bronchiolitis, it does not provide immediate relief of distress and should not
be administered to children in respiratory distress in the prehospital setting

Pertinent Assessment Findings

Frequent reassessment is necessary to determine if interventions have alleviated signs of
respiratory distress.

Quality Improvement
Key Documentation Elements
Document key aspects of the exam to assess for a change after each intervention:
• Respiratory rate
• Oxygen saturation
• Use of accessory muscles
• Breath sounds
• Air entry
• Color
• Mental Status

Performance Measures
• Supplemental oxygen, high flow oxygen by nasal cannula (HFNC), time to administration
of specified interventions in the protocol
• Rate of administration of accepted therapy (whether certain medications/interventions
were given)
• Change in vital signs (pulse, blood pressure, respiratory rate, neurologic status
assessment) temperature, O2 saturation and capnography values)
• Time to administration of specified interventions in the protocol
• Number of advanced airway attempts
• Mortality

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Pediatric Respiratory Distress (Croup)

(Adapted from an evidence-based Protocol created using the National Prehospital Evidence-Based
Protocol Model Process)

Aliases
None noted

Patient Care Goals

1. Alleviate respiratory distress
2. Promptly identify respiratory distress, respiratory failure, respiratory arrest, and intervene
for patients who require escalation of therapy
3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory
distress

Patient Presentation
Inclusion Criteria
Suspected croup (history of stridor or history of barky cough)

Exclusion Criteria
1. Presumed underlying cause that includes one of the following:
a. Anaphylaxis
b. Asthma
c. Bronchiolitis (wheezing in a patient less than 2 years of age)
d. Foreign body aspiration
e. Submersion/drowning
f. Epiglottitis

Patient Management
Assessment
1. History
a. Onset of symptoms (history of choking)
b. Concurrent symptoms (fever, cough, rhinorrhea, tongue/lip swelling, rash,
labored breathing, foreign body aspiration)
c. Sick contacts
d. Treatments given
e. Personal history of asthma, wheezing, or croup in past
2. Exam
a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic
status assessment) temperature, and O2 saturation
b. Presence of stridor at rest or when agitated
c. Description of cough
d. Other signs of distress (grunting, nasal flaring, retracting, use of accessory
muscles)
e. Color (pallor, cyanosis, normal)
f. Mental status (alert, tired, lethargic, unresponsive)

Treatment and Interventions

1. Monitoring
a. Pulse oximetry and EtCO2 should be routinely used as an adjunct to other forms of
respiratory monitoring
2. Airway
a. Give supplemental oxygen. Escalate from a nasal cannula to a simple face mask to a
non-breather mask to SPO2 94-98%

76
 b. Suction the nose and/or mouth (via bulb or suction catheter) if excessive secretions
are present
3. Inhaled medications should be administered to all children with croup in respiratory
distress with signs of stridor at rest—these medications should be repeated at this dose
with unlimited frequency for ongoing respiratory distress
a. Epinephrine 5 mg (5 mL of 1 mg/mL solution) nebulized (may repeat in 20 minutes
as needed), or
b. Racemic epinephrine 0.5 mL of 2.25% solution mixed in 2.5 mL NS (may repeat in
20 minutes as needed)
c. Humidified oxygen or mist therapy is not indicated
4. Dexamethasone 0.6 mg/kg oral, IV, or IM to maximum dose of 16 mg should be
administered to patients with suspected croup
5. Utility of IV placement and fluids. IVs should only be placed in children with respiratory
distress for clinical concerns of dehydration or when administering IV medications
6. Improvement of oxygenation and/or respiratory distress with non-invasive airway
adjuncts
a. Heliox for the treatment of croup can be considered for severe distress not
responsive to more than 2 doses of epinephrine
b. Continuous positive airway pressure (CPAP) should be administered for severe
respiratory distress
c. BVM ventilation should be utilized in children with respiratory failure
7. Supraglottic devices and intubation — should be utilized only if BVM ventilation
fails. The airway should be managed in the least invasive way possible

Patient Safety Considerations

1. Routine use of lights and sirens is not recommended during transport
2. Patients who receive inhaled epinephrine should be transported to definitive care

Notes/Educational Pearls
Key Considerations
1. Upper airway obstruction can have inspiratory, expiratory, or biphasic stridor
2. Foreign bodies can mimic croup, it is important to ask about a possible choking
event
3. Impending respiratory failure is indicated by:
a. Change in mental status such as fatigue and listlessness
b. Pallor
c. Dusky appearance
d. Decreased retractions
e. Decreased breath sounds with decreasing stridor
4. Without stridor at rest or other evidence of respiratory distress, inhaled medications
may not be necessary

Pertinent Assessment Findings

1. Respiratory distress (retractions, wheezing, stridor, accessory muscle use)
2. Decreased oxygen saturation
3. Skin color
4. Neurologic status assessment
5. Reduction in work of breathing after treatment 6. Improved oxygenation after
breathing

Quality Improvement
Key Documentation Elements
• Document key aspects of the exam to assess for a change after each
intervention:

77
 O Respiratory rate
O Oxygen saturation
O Use of accessory muscles or tracheal tugging
O Breath sounds
O Air entry
O Mental status
O Color

Performance Measures
• Time to administration of specified interventions in the protocol
• Frequency of administration of specified interventions in the protocol

78
Neonatal Resuscitation

Aliases
None noted

Patient Care Goals

1. Plan for resources based on number of anticipated patients (e.g., mother and newborn
or multiple births)
2. Provide routine care to the newly born infant
3. Perform a neonatal assessment
4. Rapidly identify newly born infants requiring resuscitative efforts
5. Provide appropriate interventions to minimize distress in the newly born infant
6. Recognize the need for additional resources based on patient condition and/or
environmental factors

Patient Presentation
Inclusion Criteria
Newly born infants

Exclusion Criteria
Documented gestational age less than 20 weeks (usually calculated by date of last menstrual
period). If any doubt about accuracy of gestational age, initiate resuscitation

Patient Management
Assessment
1. History
a. Date and time of birth
b. Onset of symptoms
c. Prenatal history (prenatal care, substance abuse, multiple gestation, maternal illness)
d. Birth history (maternal fever, presence of meconium, maternal bleeding, difficult
delivery (e.g., shoulder dystocia, prolapsed or nuchal cord, breech))
e. Estimated gestational age (may be based on last menstrual period)
2. Exam
a. Respiratory rate and effort (strong, weak, or absent; regular or irregular)
b. Signs of respiratory distress (grunting, nasal flaring, retractions, gasping, apnea)
c. Heart rate (fast, slow, or absent)
i. Precordium, umbilical stump, or brachial pulse may be used
(auscultation of chest is preferred since palpation of umbilical stump is less accurate)
d. Muscle tone (poor or strong)
e. Color/Appearance (central cyanosis, acrocyanosis, pallor, normal)
f. APGAR score (Appearance, Pulse, Grimace, Activity, Respiratory effort) — may be
calculated for documentation, but not necessary to guide resuscitative efforts
g. Estimated gestational age (term, late preterm, premature)
h. Pulse oximetry should be considered if resuscitative efforts are initiated or if
supplemental oxygen is administered

Treatment and Interventions

1. If immediate resuscitation is required and the newborn is still attached to the mother,
clamp the cord in two places and cut between the clamps. If no resuscitation is required,
warm/dry/stimulate the newborn, and then cut/clamp the cord after 60 seconds or the cord
stops pulsating
2. Dry, warm, and stimulate
a. Wrap infant in dry towel or thermal blanket to keep infant as warm as possible during
resuscitation; keep head covered if possible

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 b. If strong cry, regular respiratory effort, good tone, and term gestation, infant should
be placed skin-to-skin with mother and covered with dry linen
3. If weak cry, signs of respiratory distress, poor tone, or preterm gestation then position
airway (sniffing position) and clear airway as needed. If signs of respiratory distress with
airway obstruction, suction mouth then nose; routine suctioning is not recommended
4. Apply cardiac monitor, if available
5. If heart rate greater than 100 BPM
a. Monitor for central cyanosis — provide blow-by oxygen as needed
b. Monitor for signs of respiratory distress. If apneic or in significant respiratory
distress:
i. Ventilate: BVM ventilation with room air at 40–60 breaths per minute
1. Positive pressure ventilation (PPV) with bag-mask device may be initiated
with room air (21% oxygen) in term and late preterm babies; otherwise use
100% oxygen
2. Goal: SPO2 at 10 minutes is 85–95%
ii. Consider endotracheal intubation per local Protocols
6. Evaluate: If heart rate less than 100 BPM
a. Initiate BVM ventilation with room air at 40–60 breaths per minute for 90 seconds
with room air
i. Primary indicator of effective ventilation is improvement in heart rate
ii. Evaluate heart rate every 30 seconds
iii. Rates and volumes of ventilation required can be variable, only use the minimum
necessary rate and volume to achieve chest rise and a change in heart rate; can
control rate and volume by saying “squeeze, release” – squeeze the bag just until
chest rise is indicated then release to allow for exhalation
b. If no improvement after 90 seconds, change oxygen
delivery to 30% FiO2 (fraction of inspired oxygen) if blender available, otherwise
100% FiO2 until heart rate normalizes
c. Consider endotracheal intubation or supraglottic airway per local Protocols if BVM
ventilation is ineffective
7. Resuscitate: If heart rate less than 60 BPM:
a. Ensure effective ventilations with supplementary oxygen and adequate chest rise
b. If no improvement after 30 seconds, initiate chest compressions — two-thumb-
encircling-hands technique is preferred
c. Coordinate chest compressions with positive pressure ventilation (3:1 ratio, 90
compressions and 30 breaths per minute)
d. Consider endotracheal intubation or supraglottic airway per local Protocols
e. Administer epinephrine (Adrenaline) (0.1 mg/mL) 0.01 mg/kg IV/IO (preferable if
access obtained) or 0.1 mg/kg via the ETT (if unable to obtain access) q 3–5 min if
heart rate remains less than 60 BPM
8. Consider checking a blood glucose for ongoing resuscitation, maternal history of
diabetes, ill appearing or unable to feed
9. Administer 20 mL/kg normal saline IV/IO for signs of shock or post-resuscitative
care

Patient Safety Considerations

1. Hypothermia is common in newborns and worsens outcomes of nearly all post-natal
complications
a. Ensure heat retention by drying the infant thoroughly, covering the head, and
wrapping the baby in dry cloth
b. When it does not encumber necessary assessment or required interventions,
“kangaroo care” (i.e., placing the infant skin-to-skin directly against mother’s chest
and wrapping them together) is an effective warming technique
c. Newborn infants are prone to hypothermia which may lead to hypoglycemia,
hypoxia, and lethargy. Aggressive warming techniques should be initiated including

80
 drying, swaddling, and warm blankets covering body and head. When available,
radiant warmers or other warming adjuncts are suggested for babies who require
resuscitation, especially for preterm babies. Check blood glucose and follow
Hypoglycemia Protocol as appropriate
2. During transport, neonate should be appropriately secured (e.g., secured to mother with
approved neonatal restraint system, car seat or isolette) and mother should be
appropriately secured

Notes/Educational Pearls
Key Considerations
1. Approximately 10% of newly born infants require some assistance to begin breathing at
birth and 1% require resuscitation to support perfusion
2. Most newborns require only drying, warming, and stimulating to help them transition from
fetal respiration to newborn respiration. The resuscitation sequence can be remembered as
Dry, Warm, and Stimulate – Ventilate – Evaluate – and Resuscitate

3. Deliveries complicated by maternal bleeding (placenta previa, vas previa, or placental

abruption) place the infant at risk for hypovolemia secondary to blood loss
4. Low birth weight infants are at high-risk for hypothermia due to heat loss

5. Measuring the pulse oximetry on the right hand provides the most accurate oxygen
saturation (SpO2) in infants that are transitioning from fetal to normal circulation. At 60
seconds, 60% is the target with an increase of 5% every minute until 5 minutes of life
when pulse oximetry is 80–85%

6. Both hypoxia and excess oxygen administration can result in harm to the infant. If
prolonged oxygen use is required, titrate to maintain an SPO2 of 85–95%

81
 7. While not ideal, a larger facemask than indicated for patient size may be used to provide
BVM ventilation if an appropriately sized mask is not available. Avoid pressure over the
eyes as this may result in bradycardia
8. Increase in heart rate is the most reliable indicator of effective resuscitative efforts 9. A
multiple gestation delivery may require additional resources and/or clinicians
10. There is no evidence to support the routine practice of administering sodium bicarbonate
for the resuscitation of newborns
11. APGAR scoring is not critical during the resuscitation, although it may be prognostic
after 20 minutes if the APGAR Score remains “0” despite resuscitation

Pertinent Assessment Findings

1. It is difficult to determine gestational age in the field – if there is any doubt as to viability,
resuscitation efforts should be initiated
2. Acrocyanosis, a blue discoloration of the distal extremities, is a common finding in the
newly born infant transitioning to extrauterine life – this must be differentiated from
central cyanosis

Quality Improvement
Key Documentation Elements
• Historical elements
O Prenatal complications
O Delivery complications
O Date and time of birth
O Estimated gestational age
• Physical exam findings
O Heart rate
O Respiratory rate
O Respiratory effort o Appearance
O APGAR score at 1 minute and 5 minutes

Performance Measures
• Prehospital on-scene time
• Call time for additional resources
• Arrival time of additional unit
• Time to initiation of interventions
• Use of oxygen during resuscitation
• Presence of advanced life support (ALS) versus basic life support (BLS) clinicians
• Hypothermia on arrival in the emergency department
• Hypoglycemia evaluated and treated

82
• ROSC (return of spontaneous circulation) and/or normalization of heart rate
• Length of stay in neonatal intensive care unit
• Length of stay in newborn nursery
• Length of stay in hospital
• Knowledge retention of prehospital clinicians
• Number of advanced airway attempts
• Mortality

83
ANNEX 6: OB/GYN

Childbirth

Aliases
• Birth
• Delivery
• Labor

Patient Care Goals

1. Obtain necessary history to plan for birth and resuscitation of the newborn 2.
Recognize imminent birth
2. Plan for resources based on number of anticipated patients (e.g., mother and child or
multiple births)
3. Assist with uncomplicated delivery of term newborn
4. Recognize complicated delivery situations (e.g., nuchal or prolapsed umbilical cord,
breech delivery, shoulder dystocia) and plan for management and appropriate transport
destination
5. Apply appropriate techniques when an obstetric complication exists

Patient Presentation
Inclusion Criteria
Imminent delivery with crowning

Exclusion Criteria
1. Vaginal bleeding in any stage of pregnancy [See Obstetrical/Gynecological
Conditions Protocol]
2. Emergencies in first or second trimester of pregnancy [See
Obstetrical/Gynecological Conditions Protocol]
3. Seizure from eclampsia [See Obstetrical/Gynecological Conditions Protocol
and Eclampsia/Pre-Eclampsia Protocol]

Patient Management
Assessment:
1. Signs of imminent delivery:
a. Crowning or other presentation in vaginal opening
b. Urge to push
c. Urge to move bowels
d. Mother’s sense of imminent delivery
2. Signs of active labor
a. Contractions
b. Membrane rupture
c. Bloody show

Treatment and Interventions

1. If patient in labor but no signs of imminent delivery, transport to appropriate
receiving facility
2. Delivery should be controlled to allow a slow controlled delivery of infant –
This will prevent injury to mother
a. Support the infant’s head as needed and apply gentle counterpressure to help
prevent the head from suddenly delivering
3. Check for nuchal cord (i.e., around the baby’s neck)

84
 a. If present, slip it over the head
b. If unable to free the cord from the neck, double clamp the cord and cut
between the clamps
4. Do not routinely suction the infant’s airway (even with a bulb syringe) during delivery
5. Grasping the head with hand over the ears, gently guide head down to allow delivery of the
anterior shoulder
6. Gently guide the head up to allow delivery of the posterior shoulder
7. Slowly deliver the remainder of the infant
8. After 1 minute or once the cord stops pulsating, clamp cord about 5–6 inches from the
abdomen with two clamps; cut the cord between the clamps
a. If resuscitation is needed, the baby can still benefit from a 1-minute delay in
cord clamping. Start resuscitation immediately after birth and then clamp and cut
the cord at 1 minute
b. While cord is attached, take care to ensure the baby is not significantly higher
positioned than the mother to prevent blood from flowing backwards from baby
to placenta
9. Dry, warm, and stimulate infant, wrap in towel and place on maternal chest unless
resuscitation needed
10. Resuscitation takes priority over recording APGAR scores. Record APGAR scores at 1
and 5 minutes once neonate is stabilized
11. After delivery of infant, suctioning (including suctioning with a bulb syringe) should be
reserved for infants who have obvious obstruction to the airway or require positive
pressure ventilation (follow Neonatal Resuscitation Protocol for further care of the infant)
The placenta will deliver spontaneously, often within 5–15 minutes after the infant is
delivered
a. Do not force the placenta to deliver; do not pull on the umbilical cord
b. Contain all tissue in plastic bag and transport
12. After delivery, massaging the uterus (should be located at about the umbilicus) [fundal
massage] and allowing the infant to nurse will promote uterine contraction and help
control bleeding
a. Estimate maternal blood loss
b. Treat mother for hypovolemia as needed
13. Transport infant secured to mother with approved neonatal restraint system, in car seat or
isolette unless resuscitation is needed
14. Keep infant warm during transport
15. Most deliveries proceed without complications – If complications of delivery occur, apply
high flow oxygen to mother and expedite transport to the appropriate receiving facility.
Maternal resuscitation is critical for best fetal outcome. Contact medical direction and/or
closest appropriate receiving facility for direct medical oversight and to prepare the
receiving team. The following are recommendations for specific complications:
a. Shoulder dystocia – if delivery fails to progress after head delivers, quickly
attempt the following
i. Hyperflex mother’s hips to severe supine knee-chest position (i.e., McRoberts’
maneuver)
ii. Apply firm suprapubic pressure to attempt to dislodge shoulder. This often
requires two EMS clinicians to perform and allows for delivery in up to 75% of
cases
iii. Attempt to angle baby’s head as posteriorly as possible but NEVER pull
iv. Continue with delivery as normal once the anterior shoulder is delivered
b. Prolapsed umbilical cord
i. Placed gloved hand into vagina and gently lift head/body off the cord
1. Assess for pulsations in cord, if no pulses are felt, lift the presenting part off
the cord
2. Wrap the prolapsed cord in moist sterile gauze
3. Maintain until relieved by hospital staff

85
 ii. If previous techniques are not successful, mother should be placed in prone knee-
chest position or extreme Trendelenburg with hips elevated
c. Breech birth
i. Place mother supine, allow the buttocks, feet, and trunk to deliver spontaneously,
then support the body while the head is delivered
ii. If needed, put the mother in a kneeling position which may assist in the delivery
of the newborn
iii. Assess for presence of prolapsed cord and treat as above
iv. If head fails to deliver, place gloved hand into vagina with fingers between
infant’s face and uterine wall to create an open airway. Place your index and ring
fingers on the baby’s cheeks forming a “V” taking care not to block the mouth
and allowing the chin to be tilted toward the chest flexing the neck
v. When delivering breech, you may need to rotate the baby’s trunk clockwise; or
sweep the legs from the vagina
vi. Once the legs are delivered support the body to avoid hyperextension of the head;
keep the fetus elevated off the umbilical cord
vii. NEVER pull on the body, especially a preterm or previable baby – just support
the baby’s body while mother pushes when she feels the urge to
d. The presentation of an arm or leg through the vagina is an indication for immediate
transport to hospital
e. Nuchal cord
i. After the head has been delivered, palpate the neck for a nuchal cord, if present,
slip over the head
ii. The cord can be doubly clamped and cut between the clamps; the newborn should
be delivered promptly
f. Excessive bleeding during active labor may occur with placenta previa or placental
abruption
i. Obtain history from patient – known previa, recent pre-eclampsia symptoms,
hypertension history, recent trauma, drug use especially cocaine
ii. Placenta previa most likely will prevent delivery of infant vaginally iii. Place
large bore IV and administer IV fluids as indicated
iv. If available, transfusion or the administration of whole blood as indicated
v. C-Section most likely needed – transport emergently
g. Postpartum hemorrhage
i. Obtain history from patient – history of prenatal or delivery complications, recent
trauma, prescription anticoagulants, drug use especially cocaine
ii. Perform fundal massage
iii. Initiate IV fluid resuscitation and, if approved by medical direction, transfuse
blood products
iv. Consider administration of tranexamic acid (TXA)
v. Although recommended following all deliveries, if postpartum hemorrhage
occurs following delivery, consider administration of oxytocin
h. Maternal cardiac arrest
i. Apply manual pressure to displace uterus from midline
ii. Treat per the Cardiac Arrest Protocol (VF/VT/Asystole/PEA) for resuscitation
care (defibrillation and medications should be given for same indications and
doses as if non-pregnant patient)
iv. Transport as soon as possible if infant is estimated to be over 24 weeks
gestation (perimortem Cesarean section (also known as resuscitative
hysterotomy) at receiving facility is most successful if started within 5
minutes of maternal cardiac arrest)

86
 Patient Safety Considerations
1. Supine Hypotension Syndrome:
a. If mother has hypotension before delivery, place patient in left lateral recumbent
position or manually displace gravid uterus to the left in supine position
b. Knee-chest position may create safety issues during rapid ambulance transport
2. Do not routinely suction the infant’s airway (even with a bulb syringe) during delivery
3. Newborns are very slippery, take care not to drop the infant
4. Dry, warm and stimulate all newborns to facilitate respirations and prevent hypothermia
5. Do not pull on the umbilical cord while the placenta is delivering
6. If possible, transport between deliveries if mother is expecting twins

Notes/Educational Pearls
1. OB assessment:
a. Length of pregnancy
b. Number of pregnancies
c. Number of viable births
d. Number of non-viable births
e. Due date (calculate gestational age in weeks)
i. If unknown gestational age, rough estimated gestational age with palpation of
the uterine fundus at the umbilicus is 20 weeks
f. Last menstrual period
i. Only ask for estimated last menstrual period (first day of last period) if patient
has not had prenatal care/ultrasound and does not know their due date.
g. Prenatal care
h. Number of expected babies (multiple gestations)
i. Drug use and maternal medication use
j. Any known pregnancy complications – hypertension, gestational diabetes, placenta
previa, premature labor, history of fetal demise, fetal anomalies/birth defects, etc.
k. Signs of imminent delivery (e.g., crowning, urge to push, urge to move bowels,
mother feels delivery is imminent)
l. Location where patient receives care (considered a preferred destination if time delay
is not an issue and based on local protocols)
2. Notify medical direction/receiving facility if:
a. Antepartum hemorrhage
b. Postpartum hemorrhage
c. Breech presentation
d. Limb presentation
e. Complicated nuchal cord (around neck) – unable/difficult to reduce
f. Prolapsed umbilical cord
g. Shoulder dystocia
h. Maternal cardiac arrest
i. If anticipated transport time is greater than 30 minutes
3. Some light bleeding/bloody show (blood-tinged mucus/fluid) is normal with any
childbirth
a. Large quantities of blood/clots or profuse bleeding are abnormal

87
 Table 1. APGAR Score

Quality Improvement

Key Documentation Elements

• Document all times (delivery, contraction frequency and length)

Performance Measures
• Recognition of complications
• Documentation of APGAR scores
• Maternal reassessment

Eclampsia/Pre-Eclampsia

Aliases
Pregnancy induced hypertension
Pregnant seizures
Toxemia of pregnancy

Patient Care Goals

1. Recognize serious conditions associated with pregnancy and hypertension
2. Prevention of eclampsia-related seizures
3. Provide adequate treatment for eclampsia-related seizures

Patient Presentation
Inclusion Criteria
1. Female patient, more than 20-weeks’ gestation, presenting with hypertension and
evidence of end organ dysfunction including renal insufficiency, liver involvement,
neurological, or hematological involvement
2. May occur up to 6 weeks postpartum but is rare after 48 hours post-delivery
a. Often the presenting symptom of postpartum pre-eclampsia is headache or
SOB
3. Severe features of pre-eclampsia include:
a. Severe hypertension (SBP greater than 160, DBP greater than 110)
b. Headache
c. Confusion/altered mental status
d. Vision changes including blurred vision, spots/floaters, loss of vision (these
symptoms are often a precursor to seizure)
e. Right upper quadrant or epigastric pain
f. Shortness of breath/Pulmonary edema
g. Ecchymosis suggestive of low platelets (bruising, petechiae)

88
 h. Vaginal bleeding suggestive of placental abruption
i. Focal neurologic deficits suggesting hemorrhagic or thromboembolic stroke
4. Eclampsia
a. Any pregnant patient who is seizing should be assumed to have eclampsia
and treated as such until arrival at the hospital
b. Seizure in any late term pregnancy or postpartum patient
5. Eclampsia/pre-eclampsia can be associated with abruptio placenta and fetal loss

Exclusion Criteria
None noted

Patient Management
Assessment
1. Obtain history
a. Gestational age in weeks or recent post-partum
b. Symptoms suggestive of end organ involvement such as headache, confusion,
visual disturbances, seizure, epigastric pain, right upper quadrant pain,
nausea/vomiting, stroke symptoms, shortness of breath
c. Previous history of hypertension or known pre-eclampsia
2. Monitoring
a. Vital signs including repeat blood pressures every 10 min
3. Secondary survey pertinent to obstetric issues:
a. Constitutional: vital signs, skin color
b. Abdomen: distension, tenderness, uterine rigidity
c. Genitourinary: visible bleeding
d. Neurologic: mental status, focal deficits

Treatment and Interventions

1. Severe hypertension (SBP greater than 160 or DBP greater than 110) lasting more than 15
min with associated preeclampsia symptoms
a. Severely elevated blood pressures must be treated to reduce the risk of maternal
stroke
b. However, goal blood pressure should be roughly 140/90 to maintain uterine perfusion
and to keep fetus well-oxygenated
c. Goal BP is approximately 140/90 to reduce stroke risk but maintain uterine
perfusion
i. Labetalol 20 mg IV over 2 minutes
1. May repeat every 10 minutes X 2 doses for persistent severe hypertension with
preeclampsia symptoms
2. Goal is to reduce MAP by 20–25% initially
3. Ensure that HR is greater than 60 BPM prior to administration OR
ii. Hydralazine 5 mg IV
1. May repeat 10 mg after 20 minutes for persistent severe hypertension with
preeclampsia symptoms
2. Goal is to reduce MAP by 20–25% initially OR
iii. Nifedipine 10 mg immediate release PO
1. May repeat 10–20 mg by mouth every 20 minutes X 2 doses for persistent
severe hypertension with pre-eclampsia symptoms
2. Goal is to reduce MAP by 20–25% initially
d. Magnesium sulfate: 4 g IV over 5–10 min, followed by 2 g/hr
e. Reassess vital signs every 10 minutes during transport
2. Seizure prophylaxis and seizure management, associated with pregnancy greater than 20-
weeks gestation
a. Magnesium sulfate

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 i. Seizure prophylaxis: 4 g IV over 20–30 minutes, followed by 2 g/hr IV if
available
ii. Seizure Management: 6 g IV over 5–10 minutes or 8 g IM (4 grams in each
buttock) to prevent seizure
b. Benzodiazepine, per Seizures Protocol, for active seizure not responding to
magnesium. Caution: respiratory depression
3. IV fluids:
a. NS or LR – keep continuous infusion with maximum rate of fluids to 80 mL/hr
4. Administer high flow oxygen as indicated
5. Disposition
a. Transport emergently to closest appropriate receiving facility – notify en route if
possible so the receiving team can prepare
b. Patients in second or third trimester of pregnancy should be transported on left side or
with uterus manually displaced to left to ensure adequate uterine perfusion

Patient Safety Considerations

1. Magnesium toxicity (progression)
a. Hypotension followed by
b. Loss of deep tendon reflexes followed by
c. Somnolence, slurred speech followed by
d. Respiratory paralysis followed by
e. Cardiac arrest
2. Treatment of magnesium toxicity
a. Stop magnesium drip
b. Give calcium gluconate 3 g IV or calcium chloride 1 g IV in cases of pending
respiratory arrest
c. Support respiratory effort

Notes/Educational Pearls
Key Considerations
1. Delivery of the placenta is the only definitive management for pre-eclampsia and
eclampsia
2. Early treatment of severe pre-eclampsia with magnesium for seizure prophylaxis and anti-
hypertensive significantly reduces the rate of eclampsia. Use of magnesium encouraged
if signs of severe pre-eclampsia present to prevent seizure
3. Patients with a history of chronic hypertension may have superimposed pre-eclampsia
4. Although less frequent, eclampsia, including eclampsia-related seizures, can occur in
postpartum patients

Pertinent Assessment Findings

1. Vital signs assessment with repeat blood pressure monitoring before and after treatment
2. Assessment of deep tendon reflexes after magnesium therapy
3. Examination for end organ involvement
4. Evaluate fundal height

Quality Improvement
Key Documentation Elements
Document full vital signs and physical exam findings

Performance Measures
• Patients with signs of hypertension and greater than 20-week gestation or recent
postpartum should be assessed for signs of pre-eclampsia
• Recognition and appropriate treatment of eclampsia

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Obstetrical and Gynecological Conditions

Aliases
None noted

Patient Care Goals

1. Recognize serious conditions associated with hemorrhage during pregnancy even when
hemorrhage or pregnancy is not apparent (e.g., ectopic pregnancy, abruptio placenta,
placenta previa)
2. Provide adequate resuscitation for hypovolemia

Patient Presentation
Inclusion Criteria
1. Female patient with vaginal bleeding in any trimester
2. Female patient with pelvic pain or possible ectopic pregnancy
3. Consider pregnancy in any female between the ages of 10–60 years of age

Exclusion Criteria
1. Childbirth and active labor [See Childbirth Protocol]
2. Postpartum hemorrhage [See Childbirth Protocol]

Differential Diagnosis
1. Abruptio placenta: Most frequently occurs in third trimester of pregnancy; placenta
prematurely separates from the uterus causing intrauterine bleeding
a. Lower abdominal pain, uterine rigidity (often not present until abruption is
advanced)
b. Vaginal bleeding – this symptom may not occur in cases of concealed abruption
c. Clinical index of suspicion for abruption (history of trauma, maternal hypertension,
maternal drug use especially cocaine)
d. Shock, with minimal or no vaginal bleeding
2. Placenta previa: placenta covers part or all of the cervical opening
a. Generally, late second or third trimester
b. Painless vaginal bleeding, unless in active labor
c. For management during active labor [See Childbirth Protocol]
3. Ectopic pregnancy
a. First trimester
b. Abdominal/pelvic pain with or without minimal bleeding
c. Shock is possible even with minimal or no vaginal bleeding
4. Spontaneous abortion (miscarriage)
a. Generally, first trimester
b. Intermittent pelvic pain (uterine contractions) with vaginal bleeding/passage of clots or
tissue

Patient Management
Assessment
1. Obtain history
a. Obstetrical history [See Childbirth Protocol]
b. Abdominal pain – onset, duration, quality, radiation, provoking or relieving factors
c. Vaginal bleeding – onset, duration, quantity (pads saturated)
d. Syncope/lightheadedness
e. Nausea/vomiting
f. Fever or history of recent fever
2. Monitoring

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 a. Monitor EKG if history of syncope or lightheadedness
b. Monitor pulse oximetry if signs of hypotension or respiratory symptoms
3. Secondary survey pertinent to obstetric issues
a. Constitutional: vital signs, skin color
b. Abdomen: distension, tenderness, peritoneal signs
c. Genitourinary: visible vaginal bleeding
d. Neurologic: mental status

Treatment and Interventions

1. If signs of shock or orthostasis:
a. Position patient supine or in the left lateral recumbent position if third trimester and
keep patient warm
b. Place large bore IV
c. Volume resuscitation: crystalloid 1–2 liters IV wide open
d. Reassess vital signs and response to fluid resuscitation
e. Save all possible tissue so that the receiving team can assess
2. Disposition – transport emergently to closest appropriate receiving facility – notify en route
if possible so the receiving team may prepare

Patient Safety Considerations

1. Patients in third trimester of pregnancy should be transported on left side or with uterus
manually displaced to left if hypotensive
2. Do not place hand/fingers into vagina of bleeding patient except in cases of prolapsed cord
or breech birth that is not progressing

Notes/Educational Pearls
Key Considerations
Syncope can be a presenting symptom of intraabdominal hemorrhage from ectopic pregnancy
or antepartum hemorrhage from spontaneous abortion, placental abruption, or placenta previa

Pertinent Assessment Findings

1. Vital signs to assess for signs of shock (e.g., tachycardia, hypotension)
2. Abdominal exam (e.g., distension, rigidity, guarding)
3. If pregnant, evaluate fundal height

Quality Improvement

Key Documentation Elements

Document full vital signs and physical exam findings

Performance Measures
o Patients with signs of hypoperfusion or shock should not be ambulated to stretcher.
o If available, IV should be initiated on patients with signs of hypoperfusion or
shock
o Recognition and appropriate treatment of shock

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ANNEX 7: Respiratory

Airway Management

Patient Care Goals

1. Maintain a patent airway
2. Provide effective oxygenation and adequate ventilation using the least invasive possible
method to achieve those goals paired with pulse oximetry and end-tidal capnography
(EtCO2) data
3. Anticipate, recognize, and alleviate respiratory distress
4. Provide necessary interventions quickly and safely to patients with the need for respiratory
support
5. Anticipate, identify, and plan for a potentially difficult airway
6. Optimize the patient for any advanced airway attempts

Patient Presentation
Inclusion Criteria
1. Patients with signs of severe respiratory distress/respiratory failure
2. Patients with evidence of hypoxemia or hypoventilation with medical or traumatic
etiology
3. Patients with tracheostomies (See Tracheostomy Management Protocol)
4. Patients with acute foreign body airway obstruction

Exclusion Criteria
1. Chronically ventilated patients
2. Newborn patients

Patient Management
Implement emergent interventions and monitoring [Refer to Universal Care Protocol]
Assessment
1. History – Assess for:
a. Time of onset of symptoms
b. Associated symptoms and triggers for dyspnea (e.g., exertion, exercise, lying flat)
c. History of asthma or other breathing disorders
d. Choking or other evidence of upper airway obstruction
e. History of trauma
f. Prior similar episodes (e.g., prior intubation, prior ICU stay, prior airway surgery
including tracheostomy, anaphylaxis, angioedema). If prior episodes, what has helped
in the past (meds, interventions) Home interventions for symptoms (e.g., increased
home oxygen, nebulizer)
g. Severity of shortness of breath, sensation of dyspnea
2. Physical Examination – Assess for:
a. Abnormal respiratory pattern, rate and/or effort
b. Use of accessory muscles
c. Ability to speak words/sentences
d. Quality of air exchange, including depth of respiration and equality of breath sounds
e. Abnormal breath sounds (e.g., wheezing, rhonchi, rales, or stridor)
f. Cough
g. Skin color (cyanosis or pallor), presence of diaphoresis
h. Mental status, including anxiety
i. Airway obstruction with foreign body or swelling (e.g., angioedema, posterior
pharyngeal and laryngeal infections)

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 j. Signs of a difficult airway (short jaw or limited jaw thrust or mobility, small
thyromental space, upper airway obstruction, large tongue, obesity, large tonsils, large
neck, craniofacial abnormalities, excessive facial hair, tracheostomy scar or evidence
of other neck/facial surgery, trismus)
k. Signs of fluid overload (e.g., ascites, peripheral edema)
l. Traumatic injuries impairing upper and lower airway anatomy and physiology:
i.Facial injuries
ii.High spine injury (affecting phrenic nerve/intercostals)
iii.Neck injury (expanding hematoma, tracheal injury)
iv.Chest wall injury (bruising), including rib and sternal fracture, paradoxical
chest motion, subcutaneous air, sucking chest wound

Monitoring
1. Patients with significant respiratory distress should have continuous pulse oximetry and
waveform capnography monitoring for both assessment and for guiding therapy
2. Pulse oximetry is indicated to assess oxygenation
3. Quantitative waveform capnography:
a. Is indicated:
i.For assessment and monitoring of ventilatory status in patients with
significant respiratory distress, with or without airway adjuncts
ii.To assist in decision-making for patients with respiratory difficulty of
unclear cause (e.g., bronchospasm vs. pulmonary edema) and to help direct
therapy
iii.To evaluate acid-base status in critically ill patients
b. Is not indicated for every patient with shortness of breath. Rather, it is a monitoring
and decision-making tool for patients with significant respiratory distress where
interpretation of the capnography waveform and EtCO2 values assist in determining
the appropriate course of treatment for the patient as well as the patient’s response

Treatment and Interventions

1. Generally, the approach is to implement the interventions below in an escalating fashion to
meet the patient care goals above
2. Administer oxygen if needed for air hunger or respiratory distress and titrate to a target
SPO2 of 94–98%. Depending on patient presentation, this may be accomplished with nasal
cannula, nonrebreather, BVM, NIV
a. Even in apneic patients, starting passive oxygenation while escalating
interventions are implemented may be useful
b. During CPR, maximal oxygen supplementation should be provided
c. Consider humidified oxygen for patients with tracheostomy (See
Tracheostomy Management Protocol)
3. Open and maintain patent airway. If needed,
a. Provide head tilt/chin lift, or jaw thrust if concern for potential spinal injury
b. Suction airway: for significantly contaminated airways, consider utilizing a
suction assisted laryngeal airway decontamination (SALAD) technique
c. Oropharyngeal airways (OPA) or nasopharyngeal airways (NPA) can be
placed if needed to maintain a patent airway and make BVM ventilation more
effective
i. OPA are used for patients without gag reflex
ii. NPA are used for patients with gag reflex
d. Patient positioning can significantly impact respiratory mechanics. Patients with
severe bronchospasm should be left in the position of comfort (perhaps tripod)
whenever possible. Elevating the head or padding (shoulders, occiput) can assist with
opening airway and respiratory mechanics. This can both improve the ability to
ventilate and limit aspiration

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 e. For patients with tracheostomy in respiratory distress, see Tracheostomy Management
Protocol
4. Use bag-valve-mask (BVM) ventilation in the setting of respiratory failure or arrest.
Whenever possible, the patient’s head should be elevated up to 30 degrees
a. Two-person, two-thumbs-up BVM ventilation is preferred
b. PEEP should be used with BVM
i.5 cmH20 is generally an appropriate initial PEEP setting
ii.Increase PEEP in stepwise fashion (2–3 cmH20 at a time) as necessary,
allowing time for the patient to equilibrate with each change before further
adjustments are made. The goal is to reach the lowest PEEP needed to
adequately ventilate the patient. Higher PEEP results in greater negative
hemodynamic impact. Generally, physician consultation should be considered
for higher PEEP levels (greater than 10–15 cmH20)
c. Continuous wave-form capnography monitoring should be placed in line
i. In patients without primary pulmonary pathology (i.e., acute respiratory distress
syndrome (ARDS), COPD), maintain EtCO2 of no less than 35 and up to 40
mmHg. Patients with specific disease processes such as acute acid-base
disorders (i.e., DKA, lactic acidosis due to severe sepsis or trauma), acute
respiratory failure due to primary pulmonary pathology, or post-cardiac arrest
will have different EtCO2 parameters due to their underlying disease
ii. In patients with severe head injury with signs of herniation (unilateral dilated
pupil or decerebrate posturing), modest hyperventilation to EtCO2 no less than
30 mmHg may be considered for a brief time
d. Tidal volume:
i. Ventilate with just enough volume to see chest rise, approximately 6–8 mL/kg
ideal body weight
ii. Over-inflation (e.g., excessive tidal volume) and overventilation (e.g.,
excessive minute ventilation) are both undesirable and potentially harmful
e. Rate
i.Adult: 10–12 breaths/minute
ii.Child: 20–30 breaths/minute
iii.Infant: 20–30 breaths/minute
f. Continuously monitor EtCO2 to guide tidal volume and minute ventilation
5. Non-invasive ventilation (NIV) should be considered early for severe respiratory distress
or impending respiratory failure
a. NIV options include continuous positive airway pressure (CPAP), bilevel
positive airway pressure (BiPAP), bilevel nasal CPAP, and high flow oxygen by
nasal cannula (HFNC)
b. NIV can also be used to improve oxygenation pre-intubation in some patients
with respiratory failure
6. Supraglottic airways (SGA): Consider the use of an appropriately sized SGA if BVM
(with OPA/NPA) alone is not effective in maintaining oxygenation and/or ventilation.
This is especially important in children as prehospital endotracheal intubation is an
infrequently performed skill in this age group and has not been shown to improve
outcomes over prehospital BVM or SGA
7. Endotracheal intubation
a. When less-invasive methods (two-person BVM, SGA placement) are
ineffective or inappropriate, consider endotracheal intubation to maintain
oxygenation and/or ventilation. Other indications may include potential airway
obstruction, severe inhalation burns, multiple traumatic injuries, altered mental
status with loss of normal protective airway reflexes
b. Optimize patient for first-pass success with pre-procedure resuscitation,
preoxygenation, positioning, sedatives and paralytics as indicated by patient
presentation

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 i.A bougie may be a helpful adjunct to successful airway placement, especially
when video laryngoscopy is unavailable and the glottic opening is difficult to
visualize with direct laryngoscopy
ii.For experienced EMS clinicians, video laryngoscopy may enhance intubation
success rates and should be used when available
c. Monitor clinical signs, pulse oximetry, cardiac rhythm, blood pressure, and waveform
capnography for the intubated patient
d. For adults, the largest tube size possible should be placed in the patient to limit
difficulty with mechanical ventilation and high airway pressures. Absent significant
airway swelling or underlying anatomic abnormalities, initial tube size (internal
diameter in millimeters) for adult females should be 7.5, adult males 8.0. For
pediatrics, cuffed tubes are now recommended
8. Post-intubation management
a. Inflate endotracheal tube cuff with minimum air to seal airway. An ETT cuff
manometer can be used to measure and adjust the ETT cuff pressure to the
recommended 20 cmH20 pressure
b. Confirm placement of advanced airway (endotracheal tube, SGA) with
waveform capnography (most reliable), absent gastric sounds, and bilateral breath
sounds
c. Secure tube manually. Once proper position is confirmed, secure the tube
with tape, twill, or commercial device
i.Note measurement of tube at incisors or gum line and assess frequently for
tube movement/displacement using continuous waveform capnography and
visual inspection
ii.Cervical collar and/or cervical immobilization device may help reduce neck
movement and risk of tube displacement
d. Continuously monitor correct airway placement with waveform capnography
during treatment and transport, paying particular attention to reassessing after
each patient movement
e. Manual ventilation (see above for rate and tidal volume guidance)
f. Mechanical ventilation should be considered following advanced airway
placement
g. Intubated patients should be provided appropriate sedation with sedative or
opioid medications, and sedation titrated to an appropriate target level using
RASS score or similar scale
h. Consider PEEP adjustment to achieve oxygenation and ventilation goals (see
above)
9. Gastric decompression can improve oxygenation and ventilation, so it should be
strongly considered in any patient with an advanced airway and positive pressure
ventilation
10. When patients cannot be oxygenated/ventilated effectively using the above interventions,
or when conventional airway approaches are impossible, surgical airway management is
a reasonable option if the clinician has competency in the procedure and risk of death for
not escalating airway management seems to outweigh the risk of a procedural
complication
11. Transport to the closest appropriate hospital for airway stabilization when respiratory
failure cannot be successfully managed in the prehospital setting

Patient Safety Considerations

1. Suctioning to limit aspiration is a priority, since it is associated with development of
hospital acquired pneumonia and related increases in ICU stay and mortality.
2. Avoid excessive pressures or tidal volumes during BVM ventilation. The goal is to avoid
barotrauma as well as overventilation and related reduction of venous
return/preload/cardiac output.

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 3. Routine use of sedation is not recommended for treatment of anxiety in patients on NIV.
Anxiety should be presumed due to hypoxia or inadequate minute ventilation and treated
primarily with ventilatory support.
4. Endotracheal intubation should only be used if less invasive methods do not meet patient
care goals.
5. Once a successful SGA placement or intubation has been performed, obstruction or
displacement of the tube can have further negative effects on patient outcome. Tubes
should be secured with either a commercial tube holder or tape.
6. Meticulous attention should be paid to avoiding hypoxia and hypotension during intubation
attempts to limit patient morbidity and mortality.
7. Waveform capnography should be placed prior to the first breath through an invasive
airway to confirm placement.
8. Drug Assisted Airway Management (DAAM) should be reserved for specialized clinicians
on operating within a comprehensive program with adequate resources, ongoing training
and quality assurance measures, and close EMS physician oversight.
9. Once initiated and patient is tolerating mask, DO NOT discontinue CPAP/BiPAP until
patient is on the emergency department stretcher and hospital CPAP/BiPAP is
immediately available for patient to be switched over, or physician is at bedside and
requesting CPAP/BiPAP be discontinued. Breaking the mask seal causes a significant
decrease in airway pressures and may lead to abrupt decompensation due to atelectasis
and alveolar collapse.
10. If patient deteriorates on CPAP/BiPAP (e.g., worsened mental status, increasing EtCO2,
vomiting), remove CPAP/BiPAP and escalate airway management options as above.
11. If an endotracheal tube becomes dislodged, SGA should be strongly considered.
12. Pediatric airway management requires appropriately sized tools and adjuncts based on
patient size/age. A method for determining appropriate sizing should be available to all
EMS clinicians.
a. Skill in BVM ventilation and NIV application should be emphasized in
pediatrics. b. SGA are reasonable primary and secondary adjuncts if needed.
b. Pediatric endotracheal intubation has unclear benefit in the prehospital
setting.
c. Pediatric endotracheal tube placement and maintenance requires significant
training to achieve and maintain competency.

Notes/Educational Pearls
Key Considerations
1. Oxygen is a drug with an appropriate dose range and undesirable effects from both too
much and too little supplementation. Effective oxygenation meets the oxygen saturation
(SpO2) target set for that specific patient in the context of their acute and chronic medical
condition(s). Permissive hypoxia (SPO2 ≥ 90%) may be appropriate in patients with
COPD or other complex respiratory pathology
2. Adequate ventilation provides sufficient minute ventilation to meet the patient’s acute
respiratory and metabolic needs and is generally titrated to an EtCO2 goal
3. Paramedics are less likely to attempt endotracheal intubation in children than adults with
cardiac arrest and are more likely to be unsuccessful when intubating children.
Complications such as malposition of the ET tube or aspiration can be nearly three times
as common in children as compared to adults
4. Continuous waveform capnography is an important adjunct in the monitoring of patients
with respiratory distress, respiratory failure, and those treated with positive pressure
ventilation. It should be used as the standard to confirm placement of all advanced
airways. It can also be helpful in the respiratory distress patient without an invasive
airway to assess for causes of respiratory distress, adequacy of ventilation, progression
toward respiratory failure, monitoring of BVM ventilation, as well as numerous other
applications that provide insight into acute metabolic and infectious disease processes.
Continuous waveform capnography:

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 a. Should be used for patients with invasive airways for
i. initial verification of correct airway placement
ii.continuous evidence of correct tube placement
iii.to adjust ventilatory rate
1. to maintain EtCO2 35–45 in most patients
2. to appropriately but not excessively hyperventilate patients with signs of
herniation only to maintain EtCO2 30–35 (no lower than 30)
3. to gradually decrease EtCO2 in chronically and acutely severely hypercarbic
patients including post-arrest
b. Is strongly encouraged in patients in cardiac arrest
i. to monitor quality of CPR
ii.as an early indicator of ROSC (rapid increase of 10–15 in EtCO2)
iii.to assist in evaluating prognosis for survival
c. Should be used in spontaneously breathing patients who are:
i. on NIV
ii.in severe respiratory distress (e.g., receiving epinephrine, magnesium
therapy)
d. In spontaneously breathing patients, waveform capnography can help with
assessment of critically ill patients, for example:
i.assessment of adequacy of ventilation and change in ventilatory status in
response to treatment
ii.differentiating between severe bronchospasm (shark fin waveform) and other
causes of respiratory distress (normal waveform, pulmonary edema)
iii.hypotension due to sepsis or unclear cause (metabolic acidosis with/without
compensatory respiratory alkalosis)
iv.status epilepticus to evaluate ventilatory and acid/base status
v.evaluation for acidosis in patients with altered mental status and potential
diabetic ketoacidosis (metabolic acidosis)
5. Bag-valve-mask (BVM) ventilation (for cardiac arrest patients see Cardiac Arrest
Protocol):
a. Appropriately sized masks should completely cover the nose and mouth and maintain
an effective seal around the cheeks and chin
b. Ventilations should be delivered with only sufficient volume to achieve chest rise.
Overventilation is undesirable
i. In children, ventilating breaths should be delivered over one second,
with a two second pause between breaths
c. Ventilation rate:
i.Adult
1. Support spontaneous respirations if the patient is hypoventilating
2. For apnea, provide one breath every 6 seconds adjusting based on pulse
oximetry and digital capnometry or capnography (with the goal of 35–45
mmHg)
ii.Pediatric – infant/child
1. Support spontaneous respirations if the patient is hypoventilating
2. For apnea, provide 1 breath every 2–3 seconds adjusting based on pulse
oximetry and digital capnometry or capnography (with the goal of 35–45
mmHg)
6. PEEP improves oxygenation or decreases risk of developing hypoxemia, by increasing
functional residual capacity (FRC), and tidal ventilation and may assist in meeting airway
goals by decreasing intrapulmonary shunting of blood and better matching perfused lung
to ventilated lung tissue, thus improving arterial oxygenation. It does not open fully
collapsed alveoli but re-expands partially collapsed ones. It does not decrease
extravascular lung water but redistributes it
a. Higher levels of PEEP are particularly useful in patients with acute
respiratory distress syndrome (ARDS)

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 b. PEEP should be increased slowly by 2–3 cmH20 from 5 cmH20 to a max of
15 cmH20 closely monitoring response and vital sign changes
c. Excessive PEEP over distends alveoli, increases dead space and work of
breathing, reduces lung compliance, and compresses alveolar capillaries,
reducing oxygenation and risking pulmonary barotrauma
d. Increased intrathoracic pressure can progressively decrease cardiac output
and is most notable when PEEP is greater than 15 cmH20. The higher the level of
PEEP (over 5 cmH20), the more likely the patient will experience a variety of
adverse consequences, both ventilatory and hemodynamic
7. Noninvasive ventilation (NIV) (e.g., CPAP or BiPAP):
a. NIV goals of therapy will vary based on patient presentation and history. More
support than is needed to relieve symptoms or “normal” is not necessarily better in
these patients. Goals of care may include:
i.Decreased air hunger
ii. SPO2 of ≥ 94%. Chronic COPD patients tolerate hypoxia better, and an SPO2 of
90% may relieve their symptoms and be adequate
iii. Normalization of respiratory rate (decreased tachypnea)
iv. Normalization of EtCO2. This means a downward trend in a patient with
increased EtCO2. Patients who have end stage COPD may have chronically
elevated EtCO2 as high as 50s–60s, and thus tolerate elevated EtCO2 better so
normalization may not be a good target
b. The key to successful use of NIV in a patient who has not used it before is coaching
and explanation of the process and reassurance of the patient
c. For any patient on NIV, focus on maintaining a continuous mask seal is essential to
maximizing the positive impact of PEEP, particularly at higher levels. Breaking the
circuit or removing the mask should be meticulously avoided, as the significant
atelectasis will occur which will take time to reverse
d. Nebulized medications may be administered through a CPAP or BiPAP mask. A
specialized T-connector with a spring valve assembly is required to allow
maintenance of positive airway pressure
8. Orotracheal/Endotracheal intubation (ETI)
a. Checklist use and use of protocolized interventions to optimize the patient
physically and physiologically have been shown to both improve success rates of
orotracheal intubation as well as decrease peri-intubation complications.
Preparation should also include a promptly available plan for alternate airway
placement if ETI unsuccessful.

b.
Endotracheal tube sizes (cuffed tubes preferred in pediatrics)
c. Approximate depth of insertion = (3) x (endotracheal tube size)

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 d. In addition to preoxygenation, apneic oxygenation (high-flow oxygen by
nasal cannula) may prolong the period before hypoxia during an intubation
attempt
e. Positive pressure ventilation after intubation can decrease preload and
subsequently lead to hypotension
f. Significant attention should be paid to adequate preoxygenation to avoid peri-
intubation hypoxia and hypoxic cardiac arrest
g. Routine use of cricoid pressure is not recommended in pediatric or adult
intubation
h. Prompt suctioning of soiled airways before intubation attempt may improve
first pass success and limit morbidity and mortality
i. Confirm successful placement with waveform capnography. Less optimal
methods of confirmation include bilateral chest rise, bilateral breath sounds, and
maintenance of adequate oxygenation. Color change on EtCO2 is less accurate
than clinical assessment, and wave-form capnography is superior. Misting
observed in the tube is not a reliable method of confirmation. Re-visualization
with video laryngoscopy, when available, may assist in confirming placement
when unclear due to capnography failure or conflicting information
j. Video laryngoscopy may be a useful tool for endotracheal intubation in the
hands of a practiced clinician
6. Manual vs. Mechanical ventilation: If mechanical ventilation is available, it is preferred
to manual ventilation due to the increased consistency of tidal volume and ventilatory
rate, and its ability to limit risk of overventilation. [See Mechanical Ventilation
(Invasive) Protocol]
7. For patients being transferred from a hospital ventilator to a transport ventilator, the
patient’s current ventilator settings are generally a reasonable starting point if the patient
is being adequately oxygenated and ventilated based on pulse oximetry and capnography
8. Currently, there is limited experience with high-flow nasal cannula in the EMS
environment, so evidence-informed recommendations are not included in this Protocol
9. Anxiety should be presumed due to hypoxia or inadequate minute ventilation and treated
primarily with ventilatory support. Routine use of sedation is not recommended for
treatment of anxiety in patients on NIV

Pertinent Assessment Findings

1. Ongoing assessment is critical when an airway device is in place.
2. Acute worsening of respiratory status or evidence of hypoxemia can be secondary to
displacement or obstruction of the airway device, pneumothorax, or equipment failure

Quality Improvement
Key Documentation Elements
• Initial vital signs and physical exam
• interventions attempted including the method of airway intervention, the size of
equipment used, and the number of attempts to achieve a successful result
• Indications for advanced airway management
• Subsequent vital signs and physical exam to assess for change after the interventions
• Occurrence of peri-intubation hypoxia (less than 90% SPO2), bradycardia (per age),
• hypotension (SBP less than 90mmHg or lowest age-appropriate SBP) or cardiac
arrest. The peri-intubation period encompasses the time from sedative administration to
up to 10 minutes post any invasive airway attempt
• Post-intubation with advanced airway, EtCO2 value and capnograph should be
documented immediately after airway placement, with each patient movement (e.g., into
and out of ambulance), and at the time of patient transfer in the ED
• Recordings of video laryngoscopy may be useful for quality improvement purposes

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 Performance Measures
• Percentage of clinicians that have received hands-on airway training (simulation or
non-simulation-based) for basic and advanced airway adjuncts and skills within the past
year
• Percentage of patients with initial hypoxia who improve to target saturation of 94–
98% by arrival at hospital
• Percentage of patients with respiratory chief complaints for whom both oxygen
saturation (SpO2) and respiratory rate are measured and documented
• Rate of NIV use in respiratory distress (COPD, congestive heart failure (CHF))
patients with GCS 15
• Documentation of PEEP use with assisted ventilation
• Percentage of patients with advanced airway placement with capnographic
verification of correct placement within 1 minute
• Percentage of patients with advanced airway placement who have documentation of
waveform capnography for both initial confirmation and repeated verification of
placement during transport and at hospital arrival
• Percentage of intubated patients with endotracheal tube verified in proper position
upon turnover to receiving facility
• Rate of advanced airway (ETT or SGA) success without hypoxia or hypotension
• First pass success rate and number of intubation attempts

Respiratory Distress (includes Bronchospasm, Pulmonary Edema)

Patient Care Goals

1. Assure adequate oxygenation and ventilation
2. Recognize impending respiratory failure
3. Promptly identify and intervene for patients who require escalation of therapy
4. Deliver appropriate therapy by differentiating likely cause of respiratory distress
5. Alleviate respiratory distress

Patient Presentation
Inclusion Criteria
1. Patients aged 2 and older with respiratory distress due to disease processes including:
a. Asthma exacerbation
b. Chronic obstructive pulmonary disease (COPD) exacerbation
c. Wheezing/bronchospasm from suspected pulmonary infection (e.g., pneumonia, acute
bronchitis)
d. Pulmonary edema of cardiac (i.e., heart failure) or non-cardiac etiology

Exclusion Criteria
1. Respiratory distress related to acute trauma
2. Respiratory distress due to a presumed underlying cause that includes one of the
following:
a. Anaphylaxis
b. Bronchiolitis (wheezing in patients less than 2 years of age)
c. Croup
d. Epiglottitis
e. Foreign body aspiration
f. Submersion/drowning
g. Lower airway obstruction from malignancy (very rare)

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Patient Management

Assessment
1. History
a. Onset of symptoms
b. Concurrent symptoms (e.g., fever, cough, rhinorrhea, tongue/lip swelling, rash, labored
breathing, foreign body aspiration)
c. Usual triggers of symptoms (e.g., cigarette smoke, change in weather, upper
respiratory infections, exercise)
d. Sick contacts
e. Treatments prior to EMS: Oxygen, inhaler, nebulizer, other treatments, chronic or
recent steroids
f. Hospitalizations: Number of emergency department visits in the past year, number of
hospital admissions in the past year, number of ICU admissions (ever), previously
intubated (ever)
g. Family history of asthma, eczema, or allergies
2. Exam
a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status
assessment), temperature, and O2 saturation. Consider temperature and waveform
capnography
b. Air entry (normal vs. diminished, prolonged expiratory phase)
c. Breath sounds (wheezes, crackles, rales, rhonchi, diminished, clear)
d. Skin color (pallor, cyanosis, mottling, normal) and temperature (febrile, diaphoretic)
e. Mental status (alert, tired, lethargic, unresponsive)
f. Signs of distress include:
i.Apprehension, anxiety, combativeness
ii.Hypoxia (less than 90% oxygen saturation)
iii.Intercostal/subcostal/supraclavicular retractions, accessory muscle use
iv.Grunting, stridor, inability to speak full sentences
v.Nasal flaring
vi.Cyanosis

Treatment and Interventions

1. Airway: See Airway Management Protocol for additional specifics
a. Give supplemental oxygen for dyspnea to a target of 94–98% saturation. Escalate
from a nasal cannula as needed to reach this goal
b. BVM ventilation should be utilized in children with respiratory failure
c. Non-invasive ventilation (NIV) should be administered for severe respiratory distress
via BVM, continuous positive airway pressure (CPAP) or bi-level positive airway
pressure (BiPAP)
d. If indicated, bronchodilators should be administered in line with NIV
2. Monitoring
a. Pulse oximetry and EtCO2 should be routinely used as adjuncts to other forms of
monitoring in patients with respiratory complaints
b. Continuous cardiac monitoring may be indicated in patients with respiratory distress
associated with suspected acute or decompensated congestive heart failure (CHF) or
dysrhythmia
c. 12-lead EKG may be indicated to assess for dysrhythmia or ischemia, particularly in
patients with risk factors for coronary artery disease and/or presentation consistent
with CHF
3. IV Access and Fluids – IV access should be placed when IV medication administration is
indicated, or when there are clinical concerns of dehydration so that IV fluids can be
administered
4. Suspected bronchospasm, asthma, COPD:
a. Inhaled Medications

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 i. While albuterol 2.5 mg nebulized is usually sufficient for mild wheezing without
clinical distress, albuterol 5 mg nebulized (or 6 puffs metered dose inhaler)
should be administered to all patients in respiratory distress with signs of
bronchospasm (e.g., known asthmatics, quiet wheezers). Repeat at this dose with
unlimited frequency for ongoing respiratory distress
ii. Ipratropium 0.5 mg nebulized should be given up to 3 doses in conjunction with
albuterol
b. Steroids should be administered in the prehospital setting
i. PO steroid options for patients not critical enough to require IV placement
include:
1. Dexamethasone (0.6 mg/kg, maximum dose of 16 mg) PO solution or IV
solution given PO, or
2. Prednisolone/prednisone (1 mg/kg, maximum dose 60 mg) PO
ii. IV steroid options for critically ill patients include:
1. Dexamethasone (0.6 mg/kg, maximum dose of 16 mg) IV/IM, or
2. Methylprednisolone (2 mg/kg, maximum dose 125 mg) IV/IM
iii. Other steroids at equivalent doses may be given as alternatives
c. Magnesium sulfate (40 mg/kg IV, maximum dose of 2 g) over 10–15 minutes should
be administered for severe bronchoconstriction and concern for impending respiratory
failure. Consider decreased dose of 1 g IV for geriatric patients
d. Epinephrine (0.01 mg/kg of 1 mg/mL solution IM, maximum dose of 0.3 mg) should
only be administered for impending respiratory failure as adjunctive therapy when
there are no clinical signs of improvement with the above treatments
5. Adults with suspected pulmonary edema due to acute heart failure or fluid overload (such
as dialysis noncompliance):
a. Restoration of adequate oxygenation and ventilation should precede or be
accomplished simultaneously with other medication therapies below
i. CPAP/BiPAP: See Airway Management Protocol for goals of care and escalation
of interventions
b. SBP less than 100 mmHg
i. IV fluid bolus 250–500 mL
ii. Consider vasopressor: Norepinephrine 0.02–2 mcg/kg/min
c. SBP less than 160 mmHg
i. Nitroglycerin
1. 0.4 mg SL, can repeat every 5 minutes for SBP greater than 100 mmHg
d. SBP >= 160 mmHg or MAP greater than 120
i. Nitroglycerin
1. 0.8 mg SL, can repeat every 5 minutes for SBP greater than 100 mmHg 2.
Consider IV nitroglycerin infusion titrated to blood pressure
6. Suspected pulmonary edema due to other noncardiogenic causes (such as irritant
inhalation, abrupt opioid withdrawal). Provide supportive care to promote adequate
oxygenation.
a. Inhaled Medications
i. While albuterol 2.5 mg nebulized is usually sufficient for mild wheezing without
clinical distress, albuterol 5 mg nebulized (or 6 puffs metered dose inhaler)
should be administered to patients in respiratory distress with signs of
bronchospasm (e.g., known asthmatics, quiet wheezers). Repeat at this dose with
unlimited frequency for ongoing respiratory distress
ii. Ipratropium 0.5 mg nebulized should be given up to 3 doses in conjunction with
albuterol

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 Patient Safety Considerations
1. Normal EtCO2 (35–45 mmHg) with tachypnea and respiratory distress is an indicator of
impending respiratory failure
2. The use of nitrates should be avoided in any patient who has used a phosphodiesterase
inhibitor within the past 48 hours. Examples are sildenafil (Viagra), vardenafil and
tadalafil, which are used for erectile dysfunction and pulmonary hypertension. Also avoid
use in patients receiving intravenous epoprostenol or treporstenil which are used for
pulmonary hypertension
3. Invasive airways do not improve bronchospasm. The airway should be managed in the
least invasive way possible. Supraglottic devices and endotracheal intubation should be
considered only if BVM ventilation fails
4. Positive pressure ventilation in the setting of bronchoconstriction, either via a
supraglottic airway or intubation, increases the risk of air trapping which can lead to
pneumothorax and cardiovascular collapse. These interventions should be reserved for
situations of respiratory failure
5. The following medications should not be administered to manage bronchospasm as there
is no evidence of patient benefit:
i. Inhaled magnesium sulfate
ii. Heliox

Notes/Educational Pearls
1. The combination of ipratropium with albuterol may decrease the need for hospital
admission in certain patients
2. Magnesium sulfate may cause hypotension that will usually respond to a fluid bolus
3. Patient with acute heart failure and hypotension have high mortality
4. When assessing for cause of respiratory distress, CHF tends to be associated with lower
levels of EtCO2 compared to COPD. EtCO2 values that are extremely low and high are
markers of poor outcomes and need for intubation or ICU admission

Key Considerations
1. Nebulizer droplets can carry viral particles and other airborne pathogens, so additional
PPE should be considered, including placement of a surgical mask over the nebulizer (if
feasible) to limit droplet spread
2. Factors that have been shown to be associated with increased mortality from asthma
include:
a. Severe asthma as evidenced by at least one of the following:
i. Prior near-fatal asthma (e.g., ICU admission or intubation/mechanical
ventilation)
ii. Prior admissions for asthma or repeated ED visits, particularly if in the last year
iii. Heavy use of beta-agonist medications, or requiring three or more classes of
asthma medication
b. Together with one or more behavioral or psychosocial contributors:
i. Medication noncompliance
ii. Alcohol or drug abuse
iii. Obesity
iv. Psychosis, depression, other psychiatric illness, or major tranquilizer use
v. Employment or income difficulties
vi. Severe domestic, marital, or legal stressors
3. Single dose dexamethasone has been found equally effective as several days dosing of
other steroids, so dexamethasone is preferred over other po steroids
4. Acute heart failure is a common cause of pulmonary edema – other causes include:
a. Opioid overdose
b. High altitude exposure
c. Kidney failure or dialysis noncompliance
d. Lung damage caused by gases or severe infection

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 5. Nitroglycerin reduces left ventricular filling pressure primarily via venous dilation. At
higher doses the drug variably lowers systemic afterload and increases stroke volume and
cardiac output
6. Pulmonary edema is more commonly a problem of volume distribution than total body
fluid overload, so administration of diuretics such as furosemide provide no immediate
benefit for most patients and can cause significant harm. Inducement of inappropriate
diuresis can lead to increased morbidity and mortality in patients with other disease
processes such as pneumonia and sepsis
7. Nitrates provide both subjective and objective improvement, and might decrease
intubation rates, incidence of MIs, and mortality. High-dose nitrates can reduce both
preload and afterload and potentially increase cardiac output and blood pressure
8. If available and trained, ultrasound is useful to distinguish pulmonary edema from other
causes of respiratory distress (including pneumothorax)
9. Pulmonary edema due to irritant gas inhalation (i.e., chlorine) generally is best managed
by supportive care and escalation of airway interventions as above once the patient is
appropriately decontaminated. Early poison center consultation should be strongly
considered for guidance
10. Pulmonary edema due to high altitude should be managed as described in Altitude Illness
Protocol

Pertinent Assessment Findings

1. Severe respiratory distress may manifest with hypoxia, altered mentation, diaphoresis, or
inability to speak more than 2–3 words
2. In the setting of severe bronchoconstriction, wheezing may not be heard. Patients with
known asthma with severe dyspnea should be empirically treated, even if wheezing is
absent
3. A “shark fin” on waveform capnography suggests significant bronchospasm and
obstructive physiology
4. Etiology of respiratory distress:
a. Bronchospastic etiology (e.g., asthma, COPD) is suggested by:
i.Wheezing on auscultation
ii.“Shark fin” waveform capnograph or prolonged expiratory phase
iii.History of asthma/COPD
b. Fluid overload etiology (e.g., CHF, pulmonary edema) is suggested by:
i.Jugular venous distention
ii.Rales on auscultation
iii.Peripheral edema
iv.History of CHF, diuretic therapy, dialysis noncompliance, hypertension

Quality Improvement
Key Documentation Elements
Document key aspects of the exam at baseline and after each intervention:
• Respiratory rate
• Oxygen saturation
• EtCO2/waveform shape
• Use of accessory muscles
• Breath sounds and quality
• Mental status
• Response to interventions

Performance Measures
• Use of pulse oximetry and capnography for patients with moderate-severe respiratory
distress (RR greater than age-appropriate normal, SPO2 less than 90%)
• Percentage of patients with abnormal pulse oximetry, respiratory rate, EtCO2 value with
normalization on final set of vital signs

105
• Time to administration of oxygen in hypoxic patients
• Time to bronchodilator administration in patients with wheezing
• Percentage of asthma/COPD patients receiving steroids and bronchodilators
• Time to improved SPO2 and/or decreased respiratory rate
• Normalizing change in vital signs (pulse, blood pressure, respiratory rate, neurologic
status assessment) temperature, O2 saturation, and capnography values with treatment
• Time to initiation of non-invasive positive pressure ventilation
• Number of CPAP/BiPAP patients who require intubation
• Documentation of blood pressure reassessment in patients receiving nitrates

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ANNEX 8: Trauma

General Trauma Management

Aliases
None noted

Patient Care Goals

1. Rapid assessment and management of life-threatening injuries
2. Recognition of when to rapidly transport
3. Transport to the appropriate level of trauma care
4. Safe movement of patient to prevent worsening injury severity

Patient Presentation
Inclusion Criteria
1. Patients of all ages who have sustained an injury due to mechanical trauma,
including:
a. Blunt injury
b. Penetrating injury
c. Blast
d. Burns

Exclusion Criteria
Not an acute traumatic injury

Patient Management
Initial Assessment
1. Primary survey (Use “MARCH” algorithm)
a. Massive Hemorrhage
i. Initial visual and body sweep to assess for penetrating wounds and severe life-
threatening hemorrhage [See Extremity Trauma/External Hemorrhage
Management Protocol]
b. Airway
i. Assess airway patency by asking the patient basic questions to assess for stridor
and ease of air movement
ii. Look for injuries that may lead to airway obstruction including unstable facial
fractures, expanding neck hematoma, blood or vomitus in the airway, facial
burns/inhalation injury
iii. Evaluate mental status for ability to protect airway (patients with a Glasgow Coma
Score (GCS) less than or equal to “8” are more likely to require airway
protection)
c. Respiratory/Breathing
i. Assess respiratory rate and pattern
ii. Assess for tracheal deviation
iii. Assess symmetry of chest wall movement
iv. Listen bilaterally on lateral chest wall for breath sounds
d. Circulation
i. Assess blood pressure and heart rate
e. Head injury/Hypothermia
i. Perform initial neurologic status assessment of GCS/AVPU (Alert, Verbal,
Painful, Unconscious) and pupillary size and responsiveness [See Footnote III.
Neurologic Status Assessment and Head Injury Protocol]
ii. Assess for gross motor movement of extremities

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 iii. Evaluate for clinical signs of traumatic brain injury with herniation including:
1. Unequal pupils
2. Lateralizing motor signs
3. Posturing
iv. Prevent hypothermia

Immediate Treatment and Interventions

1. Massive or exsanguinating hemorrhage control
a. First stop severe external and extremity hemorrhage with extremity tourniquets or
appropriate wound packing with hemostatic gauze. Be sure to roll patient and examine
the back as well. [See Extremity Trauma/External Hemorrhage Management
Protocol]
b. Utilize junctional tourniquets if needed for junctional area hemorrhage
2. Airway
a. If impending airway obstruction or altered mental status resulting in inability to
maintain airway patency, immediately ensure patent airway. [See Airway
Management Protocol and Spinal Care Protocol]
b. Consider airway adjuncts as appropriate avoiding nasal airway adjuncts in patents with
oral or other facial injuries. [See Airway Management Protocol]
3. Respiratory/Breathing
a. If absent or diminished breath sounds in a hypotensive trauma patient, especially
those with chest trauma and/or tracheal deviation, consider tension pneumothorax and
perform needle decompression of side without breath sounds or side opposite tracheal
deviation; may need second or third needle decompression on same side if there is a
rush of air but patient again has symptoms
i. Authorized sites are the 4th or 5th Intercostal Space (ICS) at the anterior axillary
line (AAL) or the 2nd ICS at the mid-clavicular line (MCL)
ii. 4th or 5th ICS at the AAL is preferred over the 2nd ICD at MCL.
b. For open chest wound, place semi-occlusive dressing
c. Monitor oxygen saturation (SpO2) and, if indicated, provide supplemental oxygen to
maintain SPO2 greater than 94% and respiratory support if needed. [See Respiratory
Section]
4. Circulation
a. If pelvis is unstable, place pelvic binder or sheet to stabilize pelvis
b. Establish IV access if needed (large bore preferred)
c. Fluid resuscitation
i. Adults
1. If SBP greater than 90 mmHg and heart rate less than 120 BPM, no IV fluids
required
2. If SBP less than 90 mmHg or HR greater than 120 BPM, initiate resuscitation:
a. Blood products are recommended if available
b. If blood products not available, consider 500 mL bolus of IV fluid, repeat
as needed for persistent signs and symptoms of shock
i. If signs and symptoms of shock persist after a total of 1 L crystalloid
bolus, contact online medical direction
c. Trauma resuscitation target SBP 90 mmHg (palpable radial pulse or alert
mental status)
d. Reassess SBP after bolus given
3. Head injury: target SBP greater than110 mmHg. Hypotension should be
avoided to maintain cerebral perfusion
ii. Pediatrics
1. If patient demonstrates tachycardia for age with signs of poor perfusion (low
BP, greater than 2-second capillary refill, altered mental status, hypoxia, weak
pulses, pallor, or mottled/cool skin), give 20 mL/kg crystalloid bolus and
reassess. Repeat as needed for persistent signs and symptoms of shock

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 a. If signs and symptoms of shock persist after a total of 60 mL/kg crystalloid
bolus, contact online medical direction
2. Target normal BP for age [See Footnote IV. Abnormal Vital Signs]
d. Blood product administration may be considered based on local availability and
protocols
e. Tranexamic acid (TXA) administration may be considered within three hours of injury
and signs of hemorrhagic shock
5. Disability/Head/Hypothermia
a. If clinical signs of traumatic brain injury [See Head Injury Protocol]
b. Avoid/treat hypothermia
i.Remove wet clothing
ii.Cover patient to warm and/or prevent further heat loss
6. NOTE: Patients with major hemorrhage, hemodynamic instability, penetrating torso
trauma, or signs of traumatic brain injury often require rapid surgical intervention. Minimize
scene time (goal is under 10 minutes) and initiate rapid transport to the highest level of care
within the trauma system
7. Repeat primary assessment or secondary assessment should be conducted en route to the
trauma center
8. Decisions regarding transport destination should be based on the ACS-COT 2022 National
Protocol for the Field Triage of Injured Patients

Secondary Assessment, Treatment, and Interventions

1. Assessment
a. Obtain medical history from patient or family including:
i. Allergies
ii. Medications
iii. Past medical and surgical history
iv. Last meal
v. Events leading up to the injury
b. Secondary survey: Head to toe physical exam including re-assessment of
interventions from primary survey
i. Head/Face
1. Palpate head and scalp and face and evaluate for soft tissue injury or bony
crepitus indicating injury to skull or facial bones
2. Assess for globe injury and subjective change in vision
3. See Facial/Dental Trauma Protocol
ii. Neck
1. Check for:
a. Contusions
b. Abrasions
c. Hematomas
d. Jugular vein distention (JVD)
e. Tracheal deviation
2. Palpate for crepitus
3. Spinal assessment per Spinal Care Protocol
iii. Chest – See Initial Treatment
1. Palpate for instability/crepitus
2. Listen to breath sounds
3. Inspect for penetrating or soft tissue injuries
iv. Abdomen
1. Palpate for tenderness
2. Inspect for penetrating or soft tissue injuries
3. Cover eviscerated abdominal contents with moist dressings
v. Pelvis
1. Inspect for penetrating or soft tissue injuries

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 2. If pelvic pressure suspected, apply pelvic stabilization device
vi. Back
1. Maintain spinal alignment. Refer to Spinal Care Protocol
2. Inspect for penetrating or soft tissue injuries
vii. Neurologic status assessment [See Footnote III. Neurologic Status
Assessment]
1. Serial assessment of mental status
2. Gross exam of motor strength and sensation in all four extremities
viii. Extremities
1. Assess for fracture/deformity – See Extremity Trauma/External
Hemorrhage Management Protocol
2. Assess peripheral pulses/capillary refill
c. Additional treatment considerations
i. Maintain spine precautions per the Spinal Care Protocol
ii. Splint obvious extremity fractures per the Extremity Trauma/External
Hemorrhage Management Protocol
iii.Provide pain medication per the Pain Management Protocol

Patient Safety Considerations

1. Life-threatening injuries identified on primary survey should be mitigated immediately with
rapid transport to a trauma center
2. Monitor patient for deterioration over time with serial vital signs (pulse, blood pressure,
respiratory rate, neurologic status assessment) and repeat neurologic status assessment
[See Footnote III. Neurologic Status Assessment]
a. Patients with compensated shock may not manifest hypotension until severe blood
loss has occurred
b. Patients with traumatic brain injury may deteriorate as intracranial swelling and
hemorrhage increase. [See Head Injury Protocol]
3. Anticipate potential for progressive airway compromise in patients with trauma to head and
neck

Notes/Educational Pearls
Key Considerations
1. Optimal trauma care requires a structured approach to the patient emphasizing first control
of massive hemorrhage using MARCH (Massive hemorrhage, Airway,
Respiratory/Breathing, Circulation, Head injury/Hypothermia)
2. Target scene time less than 10 minutes for unstable patients or those likely to need surgical
intervention
3. Clinician training should include the ACS-COT 2022 National Protocol for the Field Triage
of Injured Patients
4. Frequent reassessment of the patient is important
a. If patient develops difficulty with ventilation, reassess breath sounds for development
of tension pneumothorax
b. If extremity hemorrhage is controlled with pressure dressing or tourniquet, reassess for
evidence of continued hemorrhage
c. If mental status declines, reassess ABCs (Airway, Breathing, Circulation) and repeat
neurologic status assessment [See Footnote III. Neurologic Status Assessment]

5. Use structured communication tool for patient handoff to higher level care such as AT-
MIST
a. Age
b. Time of incident or onset of symptoms
c. Mechanism

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 d. Injuries noted
e. Symptoms/Signs
f. Treatments provided

Quality Improvement
Key Documentation Elements
• Mechanism of injury
• Primary and secondary survey
• Serial vital signs including neurologic status assessments
• Scene time
• Procedures performed and patient response

Performance Measures
• Monitor scene time for unstable patients
• Monitor appropriateness of procedures
• Monitor appropriate airway management

Blast Injuries

Aliases
None noted

Patient Care Goals

1. Maintain patient and clinician safety by identifying ongoing threats at the scene of an
explosion
2. Identify multi-system injuries which may result from a blast, including possible toxic
contamination
3. Prioritize treatment of multi-system injuries to minimize patient morbidity

Patient Presentation
Inclusion Criteria
1. Patients exposed to explosive force. Injuries may include any or all the following:
a. Blunt trauma
b. Penetrating trauma
c. Burns
d. Pressure-related injuries (barotrauma)
e. Toxic chemical contamination
f. Chemical, biological, radiological, nuclear, and explosive devices, or agents

Exclusion Criteria
None noted

Patient Management
Assessment
1. Hemorrhage Control
a. Assess for and stop severe hemorrhage [See Extremity Trauma/External Hemorrhage
Management Protocol]
2. Airway
a. Assess airway patency
b. Consider possible thermal or chemical burns to the airway
3. Breathing
a. Evaluate the adequacy of respiratory effort, oxygenation, quality of lung sounds, and
chest wall integrity
b. Consider possible pneumothorax or tension pneumothorax (because of penetrating/blunt
trauma or barotrauma)

111
 c. Continually reassess for blast lung injury
4. Circulation
a. Look for evidence of hemorrhage
b. Assess BP, pulse, skin color/character, and distal capillary refill for signs of shock
5. Disability
a. Assess patient responsiveness (e.g., AVPU) and level of consciousness (e.g., GCS)
[See Footnote IV: Neurologic Status Assessment]
b. Assess pupils
c. Assess gross motor movement of extremities
6. Exposure
a. Rapid evaluation of entire skin surface, including back (log roll), to identify blunt or
penetrating injuries

Treatment and Interventions

1. Hemorrhage control:
a. Control any severe external hemorrhage [See Extremity Trauma/External
Hemorrhage Management Protocol]
2. Airway:
a. If thermal or chemical burn to the airway is suspected, early airway management is
vital
b. Secure airway, utilizing airway maneuvers, airway adjuncts, supraglottic device, or
endotracheal tube [See Airway Management Protocol]
3. Breathing:
a. Administer oxygen as appropriate with a target of achieving 94–98% saturation.
b. Assist respirations as needed
c. Cover any open chest wounds with a semi-occlusive dressing
d. If the patient has evidence of tension pneumothorax, perform needle decompression
4. Circulation:
a. Establish IV access with two large bore IVs or IOs
i. Administer resuscitative fluids, per the General Trauma Management
Protocol
ii. If the patient is burned, administer normal saline (NS) or lactated Ringer’s (LR)
per the Burns Protocol
5. Disability:
a. If evidence of head injury, treat per the Head Injury Protocol
b. Apply spinal precautions, per the Spinal Care Protocol
c. Monitor GCS during transport to assess for changes
6. Exposure:
a. Keep patient warm to prevent hypothermia

Patient Safety Considerations

1. Ensuring scene safety is especially important at the scene of an explosion
a. Always consider the possibility of subsequent explosions
b. Structural safety, possible toxic chemical contamination, the presence of poisonous
gasses, and other hazards might cause a delay in patient extraction
2. Remove patient from the scene as soon as is practical and safe
3. If the patient has sustained burns (thermal, chemical, or airway), consider transport to a
specialized burn center

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Notes/Educational Pearls
Key Considerations
1. Scene safety is of paramount importance when responding to an explosion or blast injury
2. Patients sustaining blast injury may sustain complex, multi-system injuries, including blunt
and penetrating trauma, shrapnel, barotrauma, burns, and toxic chemical exposure
3. Consideration of airway injury, particularly airway burns, should prompt early and
aggressive airway management
4. Minimize IV fluid resuscitation in patients without signs of shock. Consider injuries due to
barotrauma
a. Tension pneumothorax
i. Hypotension or other signs of shock associated with decreased or absent breath
sounds, jugular venous distension, and/or tracheal deviation
b. Tympanic membrane perforation resulting in deafness which may complicate the
evaluation of their mental status and their ability to follow commands
5. Primary transport to a trauma or burn center is preferable, whenever possible

Pertinent Assessment Findings

1. Evidence of multi-system trauma, especially:
a. Airway injury/burn
b. Barotrauma to lungs
c. Toxic chemical contamination

Quality Improvement
Key Documentation Elements
• Airway status and intervention
• Breathing status:
o Quality of breath sounds (equal bilaterally)
o Adequacy of respiratory effort
o Oxygenation
• Documentation of burns, including Total Burn Surface Area (TBSA) [See Burns
Protocol]
• Documentation of possible toxic chemical contamination

Performance Measures
• Airway assessment and early and aggressive management
• Appropriate IV fluid management
• Transport to trauma or burn center

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Burns

Aliases
None noted

Patient Care Goals

Minimize tissue damage and patient morbidity from burns

Patient Presentation
1. Patient may present with:
a. Airway – stridor, hoarse voice
b. Mouth and nares – redness, blisters, soot, singed hairs
c. Breathing – rapid, shallow, wheezes, rales
d. Skin – Estimate Total Burn Surface Area (TBSA) and depth (partial vs. full thickness)
e. Associated trauma – blast, fall, assault

Inclusion Criteria
Patients sustaining thermal burns

Exclusion Criteria
Electrical, chemical, and radiation burns [See Toxins and Environmental Section]

Special Transport Considerations

1. Transport to most appropriate trauma center when there is airway or respiratory
involvement, or when significant trauma or blast injury is suspected
2. Consider air ambulance transportation for long transport times or airway management needs
beyond the scope of the responding ground medic
3. Consider transport directly to burn center if partial or full thickness burns (TBSA) greater
than 10% and/or involvement of hands/feet, genitalia, face, and/or circumferential burns

Scene Management
1. Assure crew safety:
a. Power off
b. Electrical lines secure
c. Gas off
d. No secondary devices
e. Hazmat determinations made
f. Proper protective attire including breathing apparatus may be required

Patient Management
Assessment
1. Circumstances of event – Consider:
a. Related trauma in addition to the burns
b. Inhalation exposures such as carbon monoxide (CO) and cyanide (CN)
c. Pediatric or elder abuse
2. Follow ABCs (Airway, Breathing, Circulation) of resuscitation per the General Trauma
Management Protocol
3. If evidence of possible airway burn, consider aggressive airway management
4. Consider spinal precautions for those that qualify per the Spinal Care Protocol
5. Estimate TBSA burned and depth of burn
a. Use “Rule of 9’s” [See burn related tables in Footnote II. Burn and Burn Fluid
Charts]
b. First-degree/superficial burns (skin erythema only) are not included in TBSA
calculations

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6. Document pain scale

Treatments and Interventions

1. Stop the burning
a. Remove wet clothing (if not stuck to the patient)
b. Remove jewelry
c. Leave blisters intact
2. Minimize burn wound contamination
a. Cover burns with dry dressing or clean sheet
b. Do not apply gels or ointments
3. Monitor SPO2, EtCO2 and cardiac monitor
4. High flow supplemental oxygen for all burn patients rescued from an enclosed space
5. Establish IV access, avoid placement through burned skin
6. Evaluate respiratory status in patients with circumferential thoracic burns due to the risk for
ventilatory compromise and potential need for escharotomy
7. Evaluate distal circulation in circumferentially burned extremities due to increased risk of
circulatory compromise and potential need for escharotomy
8. Consider early management of pain and nausea/vomiting
9. Initiate fluid resuscitation – Use lactated Ringer’s or normal saline
a. If patient in shock:
i. Consider other cause, such as trauma or cyanide toxicity
ii. Administer IV fluid per the Shock Protocol
b. If patient not in shock:
i. Begin fluids based on estimated TBSA [See Footnote II. Burn and Burn Fluid
Charts as appropriate to patient weight]
ii. Pediatric patients weighing less than 40 kg, use length-based tape for weight
estimate and follow
c. For persons over 40 kg, the initial fluid rate can also be calculated using the “Rule of
10”:
i. Calculate the TBSA (round to nearest 10%)
ii. Multiply TBSA x 10 = initial fluid rate (mL/hr) {for persons between 40–80
kg}
iii. Add 100 mL/hr for every 10 kg of body weight over 80 kg
10. Prevent systemic heat loss and keep the patient warm

Special Treatment Considerations

1. If blast mechanism, treat per the Blast Injury Protocol
2. Airway burns can rapidly lead to upper airway obstruction and respiratory failure. After
performing the appropriate airway management measures, the administration of nebulized
epinephrine, bronchodilators, nebulized n-acetylcystine, and nebulized heparin, if
available, can be considered to reduce edema of the laryngeal and pulmonary tissues and
airway occlusion from secretions and blood.
3. Have a high index of suspicion for cyanide poisoning in a patient with depressed GCS,
respiratory difficulty, and cardiovascular collapse in the setting of an enclosed-space fire.
Give the antidote (hydroxocobalamin), if available, in this circumstance
4. Particularly in enclosed-space fires, carbon monoxide toxicity is a consideration and pulse
oximetry may not be accurate [See Carbon Monoxide/Smoke Inhalation Protocol]
5. For specific chemical exposures (cyanide, hydrofluoric acid, other acids, and alkali) [See
Topical Chemical Burn Protocol]
6. Consider decontamination and notification of receiving facility of potentially contaminated
patient (e.g., methamphetamine (meth) lab incident)
7. Burns that involve significant sloughing or loss of skin can result in uncontrolled heat loss.
These patients should be monitored closely for the development of hypothermia and
appropriate preventative measures should be taken

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Notes/Educational Pearls
1. Onset of stridor and change in voice are sentinel signs of potentially significant airway
burns, which may rapidly lead to airway obstruction or respiratory failure.
2. If the patient is in shock within one hour of burn, it is not from the burn. Evaluate the
patient carefully for associated trauma or cyanide toxicity.
3. If the patient is not in shock, the fluid rates recommended above will adequately maintain
patient’s fluid volume.
4. Pain management is critical in acute burns.
5. End-tidal capnography (EtCO2) monitoring may be particularly useful to monitor
respiratory status in patients receiving significant doses of narcotic pain medication.
6. Cardiac monitor is important in electrical burns and chemical inhalations.
7. TBSA is calculated only based on percent of second- and third-degree burns – First
degree/superficial burns are not included in this calculation

Quality Improvement
Burn trauma is relatively uncommon. Clinicians should receive regular training on burn assessment
and management.

Key Documentation Elements

• Initial airway status
• Total volume of fluid administered
• Body surface area of second- and third-degree burns (TBSA)
• Pulse and capillary refill exam distally on any circumferentially burned extremity
• Pain scale documentation and pain management

Performance Measures
• Patient transported to most appropriate hospital, preferably a burn center
• Pain scale documented and pain appropriately managed
• Airway assessment and management appropriately documented

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Crush Injury/Crush Syndrome

Aliases
Compartment syndrome
Crush

Patient Care Goals

1. Recognizing traumatic crush injury mechanism
2. Minimize systemic effects such as rhabdomyolysis, hyperkalemia, acute kidney injury

Patient Presentation
Inclusion criteria
Traumatic crush mechanism of injury
Non-traumatic injuries that may cause compartment syndrome include prolonged
immobilization, prolonged compression of the torso/limbs, electrical injury, or burns

Exclusion criteria
None noted

Patient Management
Assessment
1. Identify any severe hemorrhage
2. Assess airway, breathing, and circulation
3. Evaluate for possible concomitant injury (e.g., fractures, solid organ damage, or spinal
injury)
4. Monitor for development of compartment syndrome (pain out of proportion to clinical
exam,
tense swelling, pain with passive stretch, muscle weakness, absent pulses, parasthesias)

Treatment and Interventions

1. The treatment of crushed casualties should begin as soon as they are discovered
2. If severe hemorrhage is present, see Extremity Trauma/External Hemorrhage Management
Protocol
3. Establish IV access. IV fluids should be administered prior to releasing the crushed body
part. Administer 1000 mL normal saline (NS) bolus. Avoid lactated Ringer’s solution as it
contains potassium. Crush injury without adequate fluid resuscitation develops into crush
syndrome
4. For significant crush injuries or prolonged entrapment of an extremity, consider sodium
bicarbonate 1 mEq/kg (maximum dose of 50 mEq) IV bolus over 5 minutes
5. Attach cardiac monitor. Obtain/interpret 12-lead EKG, if available. Carefully monitor for
dysrhythmias or signs of hyperkalemia before and immediately after release of pressure
and during transport (e.g., peaked T waves, wide QRS, lengthening QT interval, loss of P
wave)
6. For pain control, consider analgesics [See Pain Management Protocol]

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 7. Consider the following post extrication
a. Continued resuscitation with normal saline (500–1000 mL/hr for adults, 10 mL/kg/hr
for children)
b. If EKG suggestive of hyperkalemia or if findings of hyperkalemia, administer IV fluids
and consider administration of:
i. Calcium chloride – 1 gm IV/IO over 5 minutes, ensure IV patency and do not
exceed 1 mL per minute (Pediatric: 10% 20 mg/kg, max 1 g, IV.IO over 5
minutes.
OR
ii. Calcium gluconate – 3 gm IV/IO over 5 minutes with constant cardiac monitoring
(Pediatric: 10% 50 mg/kg (0.5 mL/kg), max 2 gram, IV over 5 minutes
c. If not already administered, for significant crush injuries with EKG suggestive of
hyperkalemia, administer sodium bicarbonate 1 mEq/kg (max dose of 50 mEq) IV
bolus over 5 minutes
d. If EKG suggestive of hyperkalemia, consider albuterol 5 mg via small volume nebulizer
(can be repeated if no response is seen)

Patient Safety Considerations

Scene safety for both rescuers and patients are of paramount importance.

Notes/Educational Pearls
1. Causes of mortality in untreated crush syndrome:
a. Immediate
i. Severe head injury
ii. Traumatic asphyxia
iii. Torso injury with damage to intrathoracic or intra-abdominal organs
b. Early
i. Sudden release of a crushed extremity may result in reperfusion syndrome (acute
hypovolemia, electrolyte abnormalities, and subsequent lethal arrhythmia)
ii. Hyperkalemia (potassium is released from injured muscle cells)
iii. Hypovolemia/shock
c. Late
i. Acute kidney injury (from release of toxins from injured muscle cells)
ii. Coagulopathy and hemorrhage
iii. Sepsis

Key Considerations
1. Rapid extrication and evacuation to a definitive care facility (trauma center preferred)
2. A patient with a crush injury may initially present with very few signs and symptoms.
Maintain a high index of suspicion for any patient with a compressive mechanism of
injury
3. A fatal medical complication of crush syndrome is hyperkalemia. Suspect hyperkalemia if
T-waves become peaked, QRS becomes prolonged (greater than 0.12 seconds), absent P
wave, prolonged QTc, or sine wave. Continue fluid resuscitation through extrication and
transfer to hospital

Pertinent Assessment Findings

1. Mental status/Glasgow Coma Scale (GCS)
2. Evaluation for fractures and potential compartment syndrome development (neurovascular
status of injured extremity)
3. Examination of spine
4. Evidence of additional trauma, potentially masked by with other painful injuries

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Quality Improvement
Key Documentation Elements
• Time of tourniquet application, if applied
• Neurovascular status of any crushed extremity • EKG findings consistent with
hyperkalemia
• Amount of IV fluid administered

Performance Measures
• Initiation of fluid resuscitation prior to extrication
• EKG/monitor to monitor for dysrhythmias or changes related to hyperkalemia
• Treatment of hyperkalemia if evidence is noted on EKG

Extremity Trauma/External Hemorrhage Management

Aliases
None noted

Patient Care Goals

1. Minimize blood loss from extremity hemorrhage
2. Avoid hemorrhagic shock due to extremity hemorrhage
3. Minimize pain and further injury due to fractures, dislocations, or soft-tissue injuries

Patient Presentation
Inclusion Criteria [Refer to Crush Injury and Crush Syndrome Protocol]
1. Traumatic extremity hemorrhage (external hemorrhage) due to blunt or penetrating injury
2. Known or suspected extremity fractures or dislocations

Exclusion Criteria
None noted

Patient Management
Assessment
1. Assess degree of extremity/external bleeding/blood loss
2. Vascular status of extremity:
a. Pallor
b. Pulse
c. Capillary refill and skin temperature
3. Evaluate for obvious deformity, shortening, rotation, or instability
4. Neurologic status of extremity:
a. Sensation to light touch
b. Distal movement of extremity

Treatments and Interventions

1. Manage bleeding:
a. Expose the wound and apply direct pressure to bleeding site, followed by a pressure
dressing
b. If direct pressure/pressure dressing is ineffective or impractical:
i. If the bleeding site is amenable to tourniquet placement, apply a commercial
tourniquet to extremity:
1. Tourniquet should be placed 2–3 inches proximal to wound, not over a joint,
and tightened until bleeding stops and distal pulse is eliminated
2. If bleeding continues, place a second tourniquet proximal to the first
3. For thigh wounds, consider placement of two tourniquets, side-by-side, and
tighten sequentially

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 c. Wound packing:
i. Indications: Groin/axillary (“junctional”) injury or any limb wound with
persistent bleeding despite direct pressure and/or application of commercial
tourniquet(s)
ii. Materials: hemostatic gauze, regular gauze, or any available material
iii. Procedure: pack tightly and fully to the depth of the wound until bleeding stops
(may require significant packing for deep, large wounds), then apply direct pressure
and/or pressure dressing; do not remove packing to assess bleeding
1. Pack around (do not remove) bone fragments or foreign objects
d. Junctional tourniquets may be considered for groin or axillary wounds, if available
e. Consider tranexamic acid (TXA) for injury associated with hemorrhagic shock if within
three hours of injury
2. Manage pain [See Pain Management Protocol]
a. Pain management should be strongly considered for patients with tourniquets and
suspected fractures
b. Do not loosen tourniquet to relieve pain
3. Stabilize suspected fractures/dislocations:
a. Strongly consider pain management before attempting to move a suspected fracture
b. If distal vascular function is compromised, gently attempt to restore normal anatomic
position, and reassess perfusion status
c. Use splints as appropriate to limit movement of suspected fracture
d. Elevate extremity fractures above heart level whenever possible to limit swelling
e. Apply ice/cool packs to limit swelling in suspected fractures or soft tissue injury, but do
not apply ice directly to bare skin
f. Reassess distal neurovascular status after any manipulation or splinting of
fractures/dislocations
g. Dress open wounds associated with fractures with saline-moistened gauze
4. Remove wet or blood-soaked clothing and use measures to prevent heat loss
5. Remove jewelry and potentially constricting clothing from the injured limb
6. Do not remove impaled foreign bodies

Patient Safety Considerations

1. If improvised tourniquet has been placed by bystander, reassess, and consider placing
commercial tourniquet proximal to it
2. If tourniquet is placed:
a. Ensure that the tourniquet is sufficiently tight to occlude the distal pulse
b. Ensure that the tourniquet is well marked and visible, and that all subsequent clinicians
are aware of the presence of the tourniquet
c. Do not cover the tourniquet with clothing or dressings
3. Mark the time of tourniquet placement prominently on the patient and in the patient care
report
4. Without removing the tourniquet or dressing, reassess frequently for signs of ongoing or
renewed bleeding, such as:
a. Blood soaking through dressing
b. Bleeding distal to tourniquet

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Notes/Educational Pearls
Key Considerations
1. Tourniquets should be applied to bare skin, 2–3 inches proximal to the wound
2. Tourniquet should be reassessed at every stage of patient movement to ensure ongoing
hemorrhage control.
3. Survival is markedly improved when a tourniquet is placed before shock develops
4. Properly-applied tourniquets in conscious patients are painful – treat pain with analgesics,
but do not loosen a tourniquet to relieve discomfort
5. Arterial pressure points may not be effective in controlling hemorrhage; however, may help
slow bleeding while tourniquet is applied
6. Amputated body parts should be transported with patient for possible re-implantation
a. It should remain cool but dry
b. Place the amputated part in a plastic bag
c. Place the bag with the amputated part on ice in a second bag
d. Do not let the amputated part come into direct contact with the ice
7. Pediatric considerations:
a. External hemorrhage control to prevent shock is critical in infants and young
children, due to their relatively small blood volume
b. Most commercial tourniquets can be used effectively on children over 2 years of age
c. Stretch-wrap-tuck elastic-type tourniquets can be used on any age patient
d. Direct pressure and wound packing may be more suitable for infants and young
children
e. Consult with local online medical direction regarding use of traction splints for femur
fractures in young children, to avoid risk of possible nerve damage

Quality Improvement
Key Documentation Elements
• Vital signs and vascular status of extremity after placement of tourniquet, pressure
dressing, packing, and/or splint
• Time of tourniquet placement
• Documentation of signs/symptoms of possible compartment syndrome

Performance Measures
• Proper placement of tourniquet (location, cessation of bleeding)
• Proper marking and timing of tourniquet placement and notification of tourniquet
placement to subsequent EMS clinicians and ED personnel
• Appropriate splinting and padding of fractures

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 Graphic 1. Prehospital
External Hemorrhage Control Protocol

* Use of tourniquet for extremity hemorrhage is strongly recommended if sustained direct pressure is
ineffective or impractical; Use a commercially produced, windlass, pneumatic, or ratcheting device,
which has been demonstrated to occlude arterial flow and avoid narrow, elastic, or bungee-type devices;
Utilize improvised tourniquets only if no commercial device is available; Do not release a properly
applied tourniquet until the patient reaches definitive care
# Apply a topical hemostatic agent, in combination with direct pressure, for wounds in anatomic areas
where tourniquets cannot be applied and sustained direct pressure alone is ineffective or impractical;
Only apply topical hemostatic agents in a gauze format that support wound packing; Only utilize topical
hemostatic agents which have been determined to be effective and safe
Source: Bulger et al. 2014

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Facial/Dental Trauma

Aliases
None noted

Patient Care Goals

1. Preservation of a patent airway
2. Preservation of vision
3. Preservation of dentition

Patient Presentation
Inclusion Criteria
Isolated facial injury, including trauma to the eyes, nose, ears, midface, mandible, dentition

Exclusion Criteria
1. General Trauma [See General Trauma Management Protocol]
2. Burn trauma [See Burns Protocol]

Patient Management
Assessment
1. Overall trauma assessment
2. ABCs (Airway, Breathing, Circulation) with particular focus on ability to keep airway
patent
a. Stable midface
b. Stable mandible
c. Stable dentition (poorly anchored teeth require vigilance for possible
aspiration)
3. Bleeding (which may be severe – epistaxis, oral trauma, facial lacerations)
4. Patient medications with focus on blood thinners/anti-platelet agents
5. Cervical spine pain or tenderness [See Spinal Care Protocol]
6. Mental status assessment for possible traumatic brain injury [See Head Injury Protocol]
7. Gross vision assessment
8. Dental avulsions
9. Any tissue or teeth avulsed should be collected, if possible
10. Specific re-examination geared toward airway and ability to ventilate adequately

Treatment and Interventions

1. Administer oxygen as appropriate with a target of achieving 94–98% saturation. Use EtCO2
to help monitor for hypoventilation and apnea
2. IV access, as needed, for fluid or medication administration
3. Pain medication per the Pain Management Protocol
4. Avulsed tooth:
a. Avoid touching the root of the avulsed tooth. Do not wipe off tooth
b. Pick up at crown end. If dirty, rinse off under cold water for 10 seconds
c. Place in milk or saline as the storage medium. Alternatively, an alert and
cooperative patient can hold tooth in mouth using own saliva as storage medium
5. Eye trauma:
a. Place eye shield for any significant eye trauma
b. If globe is avulsed or enucleated, do not put back into socket. Cover eye socket with
moist saline dressings and then place eye shield over it
6. Mandible unstable:
a. Expect patient cannot spit/swallow effectively and have suction readily available
b. Preferentially transport sitting up with emesis basin/suction available (in the absence of
a suspected spinal injury.) [See Spinal Care Protocol]

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 7. Epistaxis: squeeze nose (or have patient do so) for 10–15 minutes continuously
8. Nose/ear avulsion:
a. Recover tissue, if possible
b. Transport with tissue wrapped in dry sterile gauze in a plastic bag placed on ice
c. Severe ear and nose lacerations can be addressed with a protective moist sterile
dressing

Patient Safety Considerations

1. Frequent reassessment of airway
2. Maintenance of a patent airway is the highest priority; therefore, conduct cervical spine
assessment for field clearance (per Spinal Care Protocol) to enable transport sitting up for
difficulty with bleeding, swallowing, or handling secretions

Notes/Educational Pearls
Key Considerations
1. Airway may be compromised because of fractures or bleeding
2. Lost teeth not recovered on scene may be in the airway
3. After nasal fractures, epistaxis may be posterior and may not respond to direct pressure over
the nares with bleeding running down posterior pharynx, potentially compromising
airway
4. Protect avulsed tissue and teeth
a. Avulsed teeth may be successfully re-implanted if done so in a very short period after
injury
b. Use moist sterile dressing for ear and nose cartilage
5. For penetrating eye injuries, do not remove foreign bodies. Splint in place. Cover uninjured
eye or ask patient to close eye to prevent conjugate movement of injured eye
6. Consider administration of antiemetics to prevent increases in intraocular pressure due to
nausea and vomiting in penetrating and blunt trauma to the eye [See Nausea – Vomiting
Protocol]

Pertinent Assessment Findings

1. Unstable facial fractures that can abruptly compromise airway
2. Loose teeth and retro-pharynx bleeding

Quality Improvement
Key Documentation Elements
• Airway patency and reassessment
• Degree and location of hemorrhage
• Mental status (GCS or AVPU)
• Technique used to transport tissue or teeth
• Eye exam documented, when applicable
• Assessment and management of cervical spine
• Patient use of anticoagulant medications

Performance Measures
• Appropriate airway management and satisfactory oxygenation
• Eye shield applied to eye trauma

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Head Injury

Aliases
None noted

Patient Care Goals

1. Limit disability and mortality from head injury by limiting secondary brain injury through
a. Promoting adequate oxygenation and preoxygenating to protect against unanticipated
deterioration
b. Promoting good cerebral perfusion and avoid hypotension
c. Preventing hypocapnia (by avoiding hyperventilation and overventilation)

Patient Presentation
Inclusion Criteria
Adult or pediatric patient with blunt or penetrating head injury – loss of consciousness or
amnesia not required

Exclusion Criteria None noted

Patient Management
Assessment
1. Maintain cervical stabilization [See Spinal Care Protocol]
2. Primary survey per the General Trauma Management Protocol
3. Monitoring:
a. Continuous pulse oximetry
b. Frequent systolic and diastolic blood pressure measurement
c. Initial neurologic status assessment [See Footnote III. Neurologic Status Assessment]
and reassessment with any change in mentation
d. Moderate/severe head injury: apply continuous waveform EtCO2, if available
4. Secondary survey pertinent to isolated head injury:
a. Head: Gently palpate skull to evaluate for depressed or open skull fracture
b. Eyes:
i. Evaluate pupil size and reaction to light to establish baseline
ii. Reassess pupils if decrease in mentation
c. Nose/mouth/ears: evaluate for blood/fluid drainage
d. Face: evaluate for bony stability
e. Neck: palpate for cervical spine tenderness or deformity
f. Neurologic:
i. Perform neurologic status assessment (GCS or AVPU)
ii. Evaluate for focal neurologic deficit: motor and sensory

Treatment and Interventions

NOTE: These are not necessarily the order they are to be done, but are grouped by conceptual
areas
1. Airway:
a. Administer high-flow oxygen via NRB (non-rebreather) as a precaution against
unanticipated deterioration
b. If patient unable to maintain airway, consider oral airway (nasal airway should not be
used with significant facial injury or possible basilar skull fracture)
c. BVM (bag-valve-mask) ventilation if high flow oxygen (HFO)/non-rebreather (NRB)
inadequate to maintain good airway and/or oxygenation
d. Place supraglottic airway or
perform endotracheal intubation or if BVM ventilation ineffective in maintaining

125
 oxygenation or if airway is continually compromised. Endotracheal intubation
(ETI)/supraglottic airway (SGA) should only be used in systems that have continuous
EtCO2 monitoring
2. Breathing:
a. For patients who cannot maintain adequate oxygenation with HFO/NRB, BVM
ventilation (15 years old or older: 10 breaths per minute; 2–14 years old: 20 breaths
per minute; less than 2 years old: 25 breaths per minute) with gentle manual bagging.
Consider flow-controlled bags and ventilation rate timers to help prevent hyper-
/overventilation
b. SGA placement or ETI should only be performed if BVM ventilation fails to maintain
adequate oxygenation. With advanced airways, manage with a target EtCO2 of 40
(normal range 35–45 mmHg)
c. Do not induce hypocapnia through hyper-/overventilation
3. Circulation:
a. Wound care
i. Control bleeding with direct pressure if no suspected open skull injury
ii. Moist sterile dressing to any potential open skull wound
iii. Cover an injured eye with moist saline dressing and place cup over it
b. Moderate/severe closed head injury
i. Blood pressure: avoid hypotension
1. Adult (age greater than 10 years): maintain SBP greater than or equal to 110
mmHg
2. Pediatric: maintain SBP:
a. Age less than 1 month: greater than 60 mmHg
b. Age 1–12 months: greater than 70 mmHg
c. Age 1–10 years: greater than 70 + 2x age in years
c. Closed head injury
i. Administer normal saline (NS)/lactated Ringer’s (LR) fluid boluses to maintain
SBP above threshold. Do not wait until after the patient is already hypotensive—
prevent hypotension
d. Do not delay transport to initiate IV access
4. Disability:
a. Evaluate for other causes of altered mental status — check blood glucose during
transport
b. Spinal assessment and management, per Spinal Care Protocol
c. Perform and trend neurologic status assessment (GCS or AVPU scale)
i. Early signs of deterioration:
1. Confusion
2. Agitation
3. Drowsiness
4. Vomiting
5. Severe headache
d. Severe head injury – Elevate head of bed 30 degrees
5. Transport destination specific to head trauma
a. Preferential transport to highest level of care within trauma system:
i. GCS 3–13, P (pain) or U (unresponsive) on AVPU scale
ii. Penetrating head trauma
iii. Open or depressed skull fracture

Patient Safety Considerations

1. Do not hyperventilate patients: Maintain all patients in EtCO2 range of 35–45 mmHg
2. Assume concomitant cervical spine injury in patients with moderate/severe head injury
3. Geriatric Consideration: Elderly patients with ankylosing spondylitis or severe kyphosis
should be padded and immobilized in a position of comfort and may not tolerate a cervical
collar

126
 4. Pediatric Consideration: Children have disproportionately larger heads. When securing
pediatric patients to a spine board, the board should have a recess for the head, or the body
should be elevated approximately 1–2 cm to accommodate the larger head size and avoid
neck flexion when immobilized

Notes/Educational Pearls
Key Considerations
1. Head injury severity Protocol:
a. Mild: GCS 14–15/AVPU = (A)
b. Moderate: GCS 9–13/AVPU = (V)
c. Severe: GCS 3–8/AVPU = (P) or (U)
2. Important that clinicians be specifically trained in accurate neurologic status assessment
[See Footnote III. Neurologic Status Assessment]
3. If endotracheal intubation or invasive airways are used, continuous waveform capnography
is required to document proper tube placement and assure proper ventilation rate and
minute volume (preventing both hyperventilation [too fast] and overventilation [too
much])
4. Herniation is difficult to diagnose in the prehospital setting. Hyperventilation results in
vasoconstriction which further decreases blood flow to the brain and worsens the
secondary brain injury.

Pertinent Assessment Findings

1. Neurologic status assessment findings
2. Pupils
3. Trauma findings on physical exam

Quality Improvement
Key Documentation Elements
• High-flow oxygen with non-rebreather (NRB) mask
• Airway status and management
• EtCO2 monitored and documented for all traumatic brain injury (TBI) patients with
advanced airway and strict avoidance of hyperventilation, overventilation, and
hypocapnia)
• Neurological status with vitals: AVPU, GCS
• Exams: Neurological and Mental Status Assessment pre- and post-treatment

Performance Measures
• No oxygen desaturation less than 90%
• No hypotension:
o Adults: less than 110 mmHg
o Pediatrics:
▪ Age less than 1 month: less than 60 mmHg
▪ Age 1–12 months: less than 70 mmHg
▪ Age 1–10 years: less than 70 + 2x age in years
• Assess the patient’s blood pressure prior to the administration of any medication that may
cause hypotension.
• EtCO2 target 40 mmHg (range 35–45 mmHg). Meticulous prevention of hypocapnia in all
patients
• Triage to the appropriate level hospital within the local trauma system

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Spinal Care

(Adapted from an evidence-based Protocol created using the National Prehospital Evidence-Based
Protocol Model Process)

Aliases
None noted

Patient Care Goals

1. Select patients for whom spinal motion restriction (SMR) is indicated
2. Minimize secondary injury to spine in patients who have, or may have, an unstable spinal
injury
3. Minimize patient morbidity from the unnecessary use of immobilization devices
4. Eliminate routine use of spinal immobilization devices without appropriate medical
indication

Patient Presentation
Inclusion criteria
Traumatic mechanism of injury

Exclusion criteria
None noted

Patient Management
Assessment
1. Assess the scene to determine the mechanism of injury
a. Mechanism alone should not determine if a patient requires spinal motion restriction
– however, mechanisms that have been associated with a higher risk of injury are:
i. Motor vehicle crashes (including automobiles, all-terrain vehicles, and
snowmobiles)
ii. Axial loading injuries to the spine
iii. Falls greater than 10 feet
2. Assess the patient in the position found for findings associated with spine injury:
a. Mental status
b. Neurologic deficits
c. Spinal pain or tenderness
d. Any evidence of intoxication
e. Other severe injuries, particularly associated torso injuries

Treatment and Interventions

1. Place patient in cervical collar and initiate spinal motion restriction in adults if there are any
of the following:
a. Patient complains of midline neck or spine pain
b. Any midline neck or spinal tenderness with palpation
c. Any abnormal mental status (including extreme agitation)
d. Focal or neurologic deficit
e. Any evidence of alcohol or drug intoxication
f. Another severe or painful distracting injury
g. Torticollis in children
h. A communication barrier that prevents accurate assessment
i. If none of the above apply, patient may be managed without a cervical collar
2. Patients with penetrating injury to the neck should not be placed in a cervical collar or
other spinal precautions regardless of whether they are exhibiting neurologic symptoms or

128
 not. Doing so can lead to delayed identification of injury or airway compromise and has
been associated with increased mortality
3. If extrication is required:
a. From a vehicle: After placing a cervical collar, if indicated, children in a booster seat
and adults should be allowed to self-extricate. For infants and toddlers already strapped
in a car seat with a built-in harness, extricate the child while strapped in his/her car seat
b. Other situations requiring extrication: A, preferably padded, long board may be used
for extrication, using the lift and slide (rather than a logroll) technique
4. Helmet removal
a. If an American football helmet needs to be removed, it is recommended to remove
the face mask followed by manual removal (rather than the use of automated devices)
of the helmet while keeping the neck manually immobilized — occipital and shoulder
padding should be applied, as needed, with the patient in a supine position to maintain
neutral cervical spine positioning
b. Evidence is lacking to provide guidance about other types of helmet removal
5. Do not transport patients on rigid long boards unless the clinical situation warrants long
board use. An example of this may be facilitation of immobilization of multiple extremity
injuries or an unstable patient where removal of a board will delay transport and/or other
treatment priorities. In these situations, long boards should ideally be padded or have a
vacuum mattress applied to minimize secondary injury to the patient
6. Patients should be transported to the nearest appropriate facility
7. Patients with severe kyphosis or ankylosing spondylitis may not tolerate a cervical collar.
These patients should be immobilized in a position of comfort using towel rolls or
sandbags

Patient Safety Considerations

1. Be aware of potential airway compromise or aspiration in immobilized patient with
nausea/vomiting or with facial/oral bleeding
2. Excessively tight immobilization straps can limit chest excursion and cause
hypoventilation
3. Prolonged immobilization on spine board can lead to ischemic pressure injuries to skin
4. Prolonged immobilization on spine board can be very uncomfortable for patient
5. Children are abdominal breathers therefore immobilization straps should go across chest
and pelvis and not across the abdomen
6. Children have disproportionately larger heads. When securing pediatric patients to a spine
board, the board should have a recess for the head or the body should be elevated
approximately 1–2 cm to accommodate the larger head size and avoid neck flexion when
immobilized
7. In an uncooperative patient, avoid interventions that may promote increased spinal
movement
8. The preferred position for all patients with spine management is flat and supine. There are
three circumstances under which raising the head of the bed to 30 degrees may be
considered:
a. Respiratory distress
b. Suspected severe head trauma
c. Promotion of patient compliance

Notes/Educational Pearls
Key Considerations
1. Evidence is lacking to support or to refute the use of manual stabilization prior to spinal
assessment in the setting of a possible traumatic injury when the patient is alert with
spontaneous head/neck movement. Clinicians should not manually stabilize these alerts
and spontaneously moving patients since patients with pain will self-limit movement and
forcing immobilization in this scenario may unnecessarily increase discomfort and
anxiety

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 2. Certain populations with musculoskeletal instability may be predisposed to cervical spine
injury. However, evidence does not support or refute that these patients should be treated
differently than those who do not have these conditions. These patients should be treated
according to the Spinal Care Protocol like other patients without these conditions
3. Pediatric considerations:
a. Age alone should not be a factor in decision-making for prehospital spine care, yet
the patient’s ability to reliably be assessed at the extremes of age should be
considered. Communication barriers with infants/toddlers or elderly patients with
dementia may prevent the clinician from accurately assessing the patient
b. There is no evidence that children experience non-contiguous multilevel injuries. The
existing evidence suggests that the rate of contiguous multilevel injuries is
exceedingly low at 1%
c. Because of variation in head size to body ratio, consider additional padding under the
shoulders to avoid excessive cervical spine flexion
4. Spinal precautions should be considered a treatment or preventive therapy
5. Patients who are likely to benefit from immobilization should undergo this treatment
6. Patients who are not likely to benefit from immobilization, who have a low likelihood of
spinal injury, should not be immobilized
7. Ambulatory patients may be safely immobilized on gurney with cervical collar and straps
and will not generally require a spine board. The role for standing take downs is extremely
limited, e.g., extrication of a patient with a high likelihood of a spinal cord injury from a
large body of water. Ambulatory patients may have a collar applied and walked to the
EMS gurney
8. Reserve long spine board use for the movement of patients whose injuries limit ambulation
and who meet criteria for the use of spinal precautions. Remove from the long board as
soon as is practical

Pertinent Assessment Findings

1. Mental status
2. Normal neurologic examination
3. Evidence of intoxication
4. Evidence of multiple traumas with other severe injuries

Quality Improvement
Key Documentation Elements
• Patient complaint of neck or spine pain
• Spinal tenderness
• Mental status/GCS
• Neurologic examination
• Evidence of intoxication
• Documentation of multiple trauma
• Documentation of mechanism of injury
• Document patient capacity with:
o All barriers to patient care in the NEMSIS element “Barriers to Patient Care”
(eHistory.01—required of all software systems)
o Exam fields for Mental Status and Neurological Assessment
o Vitals for Level of Responsiveness and Glasgow Coma Scale
o Alcohol and drug use indicators
• Patient age
• Patient who is underage and not emancipated: legal guardian name, contact, and
relationship

Performance Measures
• Percentage of patients with high-risk mechanisms of injury and/or signs or symptoms of
cervical spine injury who are placed in a cervical collar

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• Percentage of patients without known trauma who have a cervical immobilization device
placed (higher percentage creates a negative aspect of care)
• Percentage of trauma patients who are transported on a long backboard (target is a low
percentage)
• Percentage of patients with a cervical spinal cord injury or unstable cervical fracture who
did not receive cervical collar

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ANNEX 9: Toxins and Environmental

Poisoning/Overdose Universal Care

Aliases

Exposure, Overdose, Poison, Toxin

Patient Care Goals

1. Remove patient from hazardous environment. Decontaminate to remove continued sources of

absorption, ingestion, inhalation, or injection
2. Identify intoxicating agent by toxidrome or appropriate environmental testing 3. Assess risk
for organ impairments (heart, brain, kidney)
3. Identify antidote or mitigating agent
4. Treat signs and symptoms in effort to stabilize patient

Patient Presentation

1. Inclusion (suspect exposure) Criteria Presentation may vary depending on the

concentration and duration of exposure. Signs and symptoms vary, and may include,
but are not limited to, the following:
A. Absorption:
I. Nausea
II. Vomiting
III. Diarrhea
IV. Altered mental status
V. Abdominal pain
VI. Rapid heart rate
VII. Dyspnea
VIII. Wheezing
IX. Seizures
X. Arrhythmias
XI. Respiratory depression
XII. Sweating
XIII. Tearing
XIV. Defecation
XV. Constricted/dilated pupils
XVI. Rash
XVII. Burns to the skin

B. Ingestion:

I. Nausea
II. Vomiting
III. Diarrhea
IV. Altered mental status
V. Abdominal pain
VI. Rapid or slow heart rate

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 VII. Dyspnea
VIII. Seizures
IX. Arrhythmias
X. Respiratory depression
XI. Chemical burns around or inside the mouth
XII. Abnormal breath odors

C. Inhalation:

I. Nausea
II. Vomiting
III. Diarrhea
IV. Altered mental status
V. Abnormal skin color
VI. Dyspnea
VII. Seizures
VIII. Burns to the respiratory tract
IX. Stridor
X. Sooty sputum
XI. Known exposure to toxic or irritating gas
XII. Respiratory depression
XIII. Sweating
XIV. Tearing
XV. Constricted/dilated pupils
XVI. Dizziness
XVII. Injection:
XVIII. Local pain
XIX. Puncture wounds
XX. Reddening skin
XXI. Local edema
XXII. Numbness
XXIII. Tingling
XXIV. Nausea
XXV. Vomiting
XXVI. Diarrhea
XXVII. Altered mental status
XXVIII. Abdominal pain
XXIX. Seizures
XXX. Muscle twitching
XXXI. Hypoperfusion
XXXII. Respiratory depression
XXXIII. Metallic or rubbery taste

2. Toxidromes (constellations of signs and symptoms that add in the identification of certain classes
of medications and their toxic manifestations). These toxidrome constellations may be masked or
obscured in poly pharmacy events due to counteracting effects of the toxins

A. Anticholinergic

I. Red as a beet (flushed skin)

II. Dry as a bone (dry skin)
III. Mad as a hatter (altered mental status)
IV. Blind as a bat (mydriasis)
V. Hot as a pistol (hyperthermia)

133
 VI. Full as a flask (urinary retention)
VII. "Tacky" like a pink flamingo (tachycardia and hypertension)

B. Cholinergic (DUMBELS)

DUMBELS is a mnemonic used to describe the signs and symptoms of acetylcholinesterase inhibitor
agent poisoning. All patient age groups are included where the signs and symptoms exhibited are
consistent with the toxidrome of DUMBELS

I. Diarrhea
II. Urination
III. Miosis/Muscle weakness
IV. Bronchospasm/Bronchorrhea/Bradycardia (the killer Bs)
V. Emesis
VI. Lacrimation
VII. Salivation/Sweating

C. Opioids

I. Respiratory depression
II. Miosis (pinpoint pupils)
III. Altered mental status
IV. Decreased bowel sounds
V. Sedative Hypnotic
VI. Central nervous system depression
VII. Ataxia (unstable gait or balance)
VIII. Slurred speech
IX. Normal or depressed vital signs (pulse, blood pressure, respiratory rate, neurologic
status assessment)

E. Stimulants (Sympathomimetic)

I. Tachycardia, tachydysrhythmias
II. Hypertension
III. Diaphoresis
IV. Delusions/paranoia
V. Seizures
VI. Hyperthermia
VII. Mydriasis (dilated pupils)

F. Serotonin Syndrome (presentation with at least three of the following)

I. Agitation
II. Ataxia
III. Diaphoresis
IV. Diarrhea
V. Hyperreflexia
VI. Mental status changes
VII. Myoclonus
VIII. Shivering
IX. Tremor
X. Hyperthermia
XI. Tachycardia

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Exclusion Criteria:

None noted

Patient Management

Assessment

1. Make sure the scene is safe. Use environmental Carbon Monoxide (CO) detector on "first in" bag if
possible

2. Consider body substance isolation (BSI) or appropriate PPE

3. Assess ABCD and, if indicated, expose patient for assessment and then recover to assure retention
of body heat

4. Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) temperature, and
O2 saturation including temperature

5. Attach cardiac monitor and examine rhythm strip for arrhythmias (consider 12-lead EKG)

6. Check blood glucose level

7. Monitor pulse oximetry and end-tidal capnography (EtCO2) for respiratory decompensation

8. Perform carboxyhemoglobin device assessment, if available

9. When indicated, identify specific medication taken (including immediate release vs sustained
release), time of ingestion, dose, and quantity. When appropriate, bring all medications (prescribed
and not prescribed) found in the environment

10. Obtain an accurate ingestion history (as patient may become unconscious before arrival at the
emergency department (ED)):

a. Time of ingestion or exposure

b. Route of exposure
c. Quantity of medication or toxin taken (safely collect all possible medications or
agents)
d. Alcohol or other intoxicant taken

11. If bringing in exposure agent, consider the threat to yourself and the destination facility

12. Obtain pertinent cardiovascular history and other prescribed medications

13. Check for needle marks, paraphernalia, bites, bottles, or evidence of agent involved in exposure,
self-inflicted injury, or trauma

14. Law enforcement should have checked for weapons and drugs, but you may need to recheck

15. Obtain any other pertinent patient history

16. Perform remainder of physical examination

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Treatment and Interventions

1. Assure a patent airway

2. Administer oxygen as appropriate with a target of achieving 94–98% saturation, and if there is
hypoventilation noted, support breathing

3. Initiate IV access for infusion of treatment medication and/or lactated Ringer's or normal saline if
indicated, and obtain blood samples if EMS management might change based upon the value (e.g.,
glucose, lactate, cyanide)

4. Consider fluid bolus (20 mL/kg) if evidence of hypoperfusion

5. Administration of appropriate antidote or mitigating medication (refer to specific agent Protocol if

not listed below)

a. Paracetamol (Acetaminophen) overdose:

I. Consider activated charcoal without sorbitol (1 g/kg) PO only if within the first hour of
ingestion and prolonged transport to definitive care
II. Based on suspected quantity and timing, consider acetylcysteine (pediatric and adult), if
available
1. Loading dose is acetylcysteine 150 mg/kg IV; mix in 200 mL of dextrose 5% in water (D5W)
and infuse over 1 hr
2. After loading dose, give acetylcysteine 50 mg/kg IV in 500 mL D5W over 4 hrs.
3. If IV is not available, acetylcysteine 140 mg/kg PO

iii. If risk of rapidly decreasing mental status, do not administer oral agents

b. Aspirin overdose:

I. Consider activated charcoal without sorbitol (1 gm/kg) PO only if within the first hour of
ingestion
a. As ASA is erratically absorbed, charcoal is highly recommended to be administered
early
b. If altered mental status or risk of rapid decreasing mental status from polypharmacy,
do not administer oral agents including activated charcoal
II. In salicylate poisonings, let the patient breathe on their own, even if tachypneic, until there is
evidence of decompensation or dropping oxygen saturation. Acid/base disturbances and
outcomes worsen when the patient is manually ventilated

136
c. Benzodiazepine overdose:

I. Respiratory support
II. Consider fluid challenge (20 mL/kg) for hypotension
III. Consider vasopressors after adequate fluid resuscitation (1–2 liters of crystalloid in adult) for
the hypotensive patient

d. Caustic substances ingestion (i.e., acids and alkali):

I. Evaluate for airway compromise secondary to spasm or direct injury associated with
oropharyngeal burns

e. Dystonia (symptomatic), extrapyramidal signs or symptoms, or mild allergic reactions

I. Consider administration of diphenhydramine

a. Adult: diphenhydramine 25–50 mg IV or IM
b. Pediatric: diphenhydramine 1–1.25 mg/kg IVP/IO or IM (maximum single dose of 25
mg)

f. Monoamine oxidase inhibitor overdose (symptomatic, e.g., MAOI; isocarboxazid, phenelzine

selegiline, tranylcypromine)

I. Consider administration of midazolam for temperature control

II. Adult and Pediatric: Midazolam 0.1mg/kg in2mg increments slow IV push over one to two
minutes per increment with maximum single dose 5 mg — reduce by 50% for patients 69
years old or older

g. Opiate overdose, treat per the Opioid Poisoning/Overdose Protocol

h. Oral ingestion unknown poisoning:

I. If there is a risk of rapidly decreasing mental status or for petroleum-based ingestions, do not
administer oral agents
II. Consider administration of activated charcoal without sorbitol (1 g/kg) PO particularly if it is
within the first 1 hour after ingestion (including paracetamol) and there will be prolonged
transport to definitive care.
III. Patients who have ingested medications with extended release or delayed absorption may also
be administered activated charcoal

i. Selective serotonin reuptake inhibitors (SSRls):

I. Consider early airway management

II. Treat arrhythmias following Advanced Cardiac Life Support (ACLS) Protocols
III. Aggressively control hyperthermia with cooling measures
IV. Consider fluid challenge (20 mL/kg) for hypotension
V. Consider vasopressors after adequate fluid resuscitation (1–2 liters of crystalloid in adult) for
the hypotensive patient [See Shock Protocol]
VI. For agitation, consider midazolam
a. Adult: midazolam 0.1 mg/kg in 2 mg increments slow IV push over one to two
minutes per increment with maximum single dose 5 mg
b. Reduce by 50% for patients 69 years or older
c. Pediatric: midazolam 0.1 mg/kg in 2 mg increments slow IV push over one to two
minutes per increment with maximum single dose 4 mg or midazolam 0.2 mg/kg IN
to maximum single dose of 10 mg

137
VII. For seizures, treat per Seizures Protocol

j. Tricyclic Antidepressant (TCA)/Sodium Channel Blocker Overdose:

I. Consider early airway management

II. If widened QRS (100 msec or greater), consider sodium bicarbonate 1–2 mEq/kg IV, this can
be repeated as needed to narrow QRS and improve blood pressure
III. Consider fluid challenge (20 mL/kg) for hypotension
IV. Consider vasopressors after adequate fluid resuscitation (1–2 liters of crystalloid) for the
hypotensive patient [See Shock Protocol]
V. For agitation, consider midazolam
a. Adult: midazolam 0.1 mg/kg in 2 mg increments slow IV push over one to two
minutes per increment with maximum single dose 5 mg
b. Reduce by 50% for patients 69 years or older
c. Pediatric: midazolam 0.1 mg/kg in 2 mg increments slow IV push over one to two
minutes per increment with maximum single dose 4 mg or midazolam 0.2 mg/kg IN
to maximum single dose of 10 mg
VI. For seizure, treat per Seizures Protocol

Patient Safety Considerations

1. Scene/environmental safety for patient and clinician

a. Consider environmental carbon monoxide monitor use

2. Monitor patient airway, breathing, pulse oximetry, EtCO2 for adequate ventilation as they may
change over time

3. Repeat vital signs often

4. Monitor level of consciousness

5. Monitor EKG with special attention to rate, rhythm, QRS and QT duration

6. Maintain or normalize patient temperature

7. The regional poison center should be engaged as early as reasonably possible to aid in appropriate
therapy and to track patient outcomes to improve knowledge of toxic effects. The Abu Dhabi hotline
is available from 0700-2300 on weekdays and the number is 800424

Notes/Educational Pearls

Key Considerations

1. Each toxin or overdose has unique characteristics which must be considered in individual protocols

2. Activated charcoal (which does not bind to all medications or agents) is still a useful adjunct in the
serious-agent, enterohepatic, or extended-release agent poisoning if the patient does not have the
potential for rapid alteration of mental status or airway/aspiration risk. Precautions should be taken to
avoid or reduce the risk of aspiration

3. Ipecac is not recommended for any poisoning or toxic ingestion — the manufacturer has stopped
production of this medication

138
4. Flumazenil is not indicated in a suspected benzodiazepine overdose as it can precipitate
refractory/intractable seizures if the patient is a benzodiazepine dependent patient

Pertinent Assessment Findings

Frequent reassessment is essential as patient deterioration can be rapid and catastrophic

Quality Improvement

Key Documentation Elements

1. Repeat evaluation and documentation of signs and symptoms as patient clinical conditions
may deteriorate rapidly
2. Identification of possible etiology of poisoning
3. Initiating measures on scene to prevent exposure of bystanders when appropriate/indicated
4. Time of symptoms onset and time of initiation of exposure-specific treatments

Performance Measures

1. Early airway management in the rapidly deteriorating patient

2. Accurate exposure history
a. Time of ingestion/exposure
b. Route of exposure
c. Quantity of medication or toxin taken (safely collect all possible mediations or
agents)
d. Alcohol or other intoxicant taken
3. Appropriate protocol selection and management
4. Multiple frequent documented reassessments

139
ANNEX 10: Medications

Medical Director Approved Medications

The following table contains medications within the scope of practice of EMS professionals
in Abu Dhabi. The ability to use a medication depends on the scope and grade of the
healthcare practitioner as indicated in the table. Following this is a list of commonly
encountered prehospital medications and their various generic and trade names, classes,
indications, mechanisms, and contraindications. This list is meant to include both the
medications in the paramedic scope of practice as well as the larger body of medications
EMS personnel may encounter in various settings (e.g poisoning, interfacility, over the
counter medications).

EMR
Medical Director Approved
Medications
Adv Critical Care
EMT Paramedic
Paramedic Paramedic

Acetylsalicylic Acid √ √ √ √
Activated Charcoal √ √ √ √
Adenosine √ √ √
Adrenaline [Epinephrine] √ √ √
Adrenaline [Epinephrine] √#*
√#* √ √ √
Autoinjector*
Amiodarone Hydrochloride √#* √ √
Atropine Sulphate √ √ √
Beta 2 Adrenergic Stimulants
√ √ √ √
[Salbutamol/albuterol] (nebulized)
Calcium Chloride 10%
√ √ √
Calcium Gluconate 10%
Ceftriaxone √
Cimetidine √ √
Chlorpheniramine IV/
√#* √ √ √
Diphenhydramine IV/PO
Dexamethasone √#* √ √
Dextrose 5% Water [D5W] (for √#* √ √ √
medication infusion)
Dextrose 10% Water [D10W] (IV √#* √ √ √
solution)
Dextrose 25% √ √ √
Diazepam √ √ √
Diclofenac Sodium √ √ √
Dobutamine √
Etomidate √#*
Famotidine √ √

140
Fentanyl √ √ √
Furosemide √ √
Glucagon √#* √ √ √
Glucose Gel/Powder √ √ √ √
Glyceryl Trinitrate (Nitroglycerin) √ √ √
Haloperidol /Droperidol √ √
Helium gas mixture √#*
Heparin √
Hydralazine √#* √
Hydrocortisone √#* √ √
Hydroxocobalamin √ √ √
Hyoscine-N-butylbromide √
Ibuprofen √ √ √ √
Ipratropium Bromide √ √ √
Ketamine √ √
Ketorolac √ √ √
Labetalol √ √
Lidocaine HCI (Local Anesthetic) √
Lidocaine HCI (Systemic) √ √
Lorazepam √ √ √
Magnesium Sulphate √ √ √
Mannitol √ √ √
Medical Oxygen √#* √ √ √ √
Methoxyflurane √ √ √ √
Metoclopramide √ √ √
Monohydrochloride
Metoprolol √#* √ √
Midazolam √ √ √
Morphine Sulphate √ √ √
Naloxone Hydrochloride √#* √ √ √
Nifedipine √
Norepinephrine √#* √
Normal Saline 0.9% √#* √ √ √
Nitrous Oxide √#* √#*
Ondansetron (Oral for EMT-B) √ √ √ √
Paracetamol (oral for EMT-B, oral or √#* √ √ √
IV for other levels)
√ √ √
Procainamide
Prochlorperazine √ √
Promethazine √ √
Ranitidine √ √
Rocuronium √
Ringers Lactate/Hartmann’s √#* √ √ √
Sildenafil √
Sodium Bicarbonate 8.5% √ √ √
Suxamethonium Chloride √#*
Tenectaplase √#* √
Tranexamic Acid √ √ √

141
 (Symbol Reference)
**Cardiac arrest 1:10000 IV; anaphylaxis 1:1000 IM
#* Medical Director approved privilege based on demonstrated competence in this skill
*Epinphrine may be given by EMTs to patients in cardiac arrest when directed by a paramedic or
higher level professional as part of the team approach to cardiac arrest maangement

Medication Reference List

Reference: Trade names, class, pharmacologic action and contraindications (relative and absolute)
information from the website http://www.medscape.com, accessed October 23, 2021. Additional
references include the 2020 American Heart Association Protocols for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care, position statements from the American Academy of Clinical
Toxicology and the European Association of Poison Control Centers
(http://clintox.org/documents/positionpapers/Cathartics.pdf), and the article: Rodrigo GJ, Pollack CV,
Rodrigo C, Rowe BH. Heliox for non-intubated acute asthma patients. Cochrane Database of
Systematic Reviews 2006, Issue 4. Art. No.: CD002884.
NOTE: Not all contraindications were included for the purposes of this document. Contraindications
which were not pertinent to EMS clinicians were not included for the purposes of streamlining this
document.

Acetazolamide
Name — Diamox Sequels®
Class — Carbonic anhydrase inhibitors
Pharmacologic Action—Inhibits hydrogen ion excretion in renal tubule, increasing sodium,
potassium, bicarbonate, and water excretion and producing alkaline diuresis
Indications — Acute mountain sickness
Contraindications — Known hypokalemia/hyponatremia, hypersensitivity to acetazolamide or sulfa,
liver disease, renal disease, cirrhosis, long term administration in patients with chronic, noncongestive
angle-closure glaucoma

Paracetamol (Acetaminophen)
Name — There are multiple over-the-counter medications, as well as scheduled drugs, that include
paracetamol (acetaminophen, Tylenol®) as an active ingredient
Class — Analgesics, antipyretic, other
Pharmacologic Action—May work peripherally to block pain impulse generation; may also inhibit
prostaglandin synthesis in CNS
Indications—Pain control, fever control
Contraindications—Hypersensitivity, severe acute liver disease

Acetic acid (vinegar)

Name—Vinegar
Class — Other
Pharmacologic Action — Stabilizes nematocyst discharge in non-United States jellyfish thus
decreasing pain
Indications — Pain control for jellyfish envenomation (outside of the United States (US))
Contraindications — May increase nematocyst discharge for US jellyfish and therefore should be
used outside of the US only

142
Acetylcysteine
Name—Mucomyst®, Acetadote®
Class — Antidotes, other
Pharmacologic Action—Acts as sulfhydryl group donor to restore liver glutathione; may also
scavenge free radicals to prevent delayed hepatotoxicity as antioxidant; encourages sulfation pathway
of metabolism for paracetamol (acetaminophen)
Indications — Antidote for paracetamol (acetaminophen) overdose
Contraindications — Acute asthma
WARNING: Nausea and vomiting are common adverse effects following the oral administration of
acetylcysteine

Activated Charcoal
Name — Actidose-Aqua®
Class — Antidotes, other
Pharmacologic Action—Adsorbs a variety of drugs and chemicals (e.g., physical binding of a
molecule to the surface of charcoal particles); desorbtion of bound particles may occur unless the ratio
of charcoal to toxin is extremely high
Indications — Overdose and poisoning
Contraindications — Unprotected airway (beware of aspiration), caustic ingestions, intestinal
obstruction

Adenosine
Name — Adenocard®
Class — Antidysrhythmics
Pharmacologic Action—Slows conduction through AV node and interrupts AV reentry pathways,
which restore normal sinus symptoms
Indications — Conversion of regular, narrow complex tachycardia – stable supraventricular
tachycardia (SVT) or regular, monomorphic wide complex tachycardia
Contraindications — Hypersensitivity, second- or third-degree AV Block (except those on
pacemakers), sick sinus syndrome, atrial flutter or fibrillation, ventricular tachycardia

Albuterol
Name — Proventil®, Ventolin®, Proair®, Accuneb®
Class — Beta-2 agonist
Pharmacologic Action — Beta-2 receptor agonist with some beta-1 activity; relaxes bronchial smooth
muscle with little effect on heart rate
Indications — Bronchospastic lung disease
Contraindications — Hypersensitivity, tachycardia secondary to heart condition

Amiodarone
Name — Pacerone®, Cordarone®, Nexterone®
Class — Class III antidysrhythmics
Pharmacologic Action — Class III antidysrhythmic agent, which inhibits adrenergic stimulation;
affects sodium, potassium, and calcium channels; markedly prolongs action potential and
repolarization; decreases AV conduction and sinus node function
Indications — Management of regular wide complex tachycardia in stable patients, irregular wide
complex tachycardia in stable patients, and as antidysrhythmic for the management of ventricular
fibrillation (VF) and pulseless ventricular tachycardia (VT)
Contraindications — Hypersensitivity, Severe sinus node dysfunction, second degree or third-degree
heart block or bradycardia causing syncope (except with functioning artificial pacemaker), cardiogenic
shock
WARNING: Avoid during breastfeeding

143
Amyl Nitrite
Name — component of the Cyanide Antidote Kit®
Class — Cyanide antidote
Pharmacologic Action — Reacts with hemoglobin to form methemoglobin, an oxidized form of
hemoglobin incapable of oxygen transport but with high affinity for cyanide. Cyanide preferentially
binds to methemoglobin over cytochrome a3, forming the nontoxic cyanomethemoglobin
Indications — Acute cyanide toxicity
Contraindications — None in the case of suspected pure cyanide toxicity noted, documented
hypersensitivity, suspected or confirmed smoke inhalation and/or carbon monoxide poisoning
WARNING: There is a risk of worsening hypoxia due to methemoglobin formation

Aspirin
Name — Multiple over-the-counter medications, as well as scheduled drugs, include aspirin as an
active ingredient. These include, but are not limited to, Bayer Buffered Aspirin®, Alka-Seltzer with
Aspirin®, Ascriptin®, Bayer Women’s Low Dose®, Ecotrin®
Class — Antiplatelet agent, non-steroidal anti-inflammatory drug (NSAID)
Pharmacologic Action — Inhibits synthesis of prostaglandin by cyclooxygenase; inhibits platelet
aggregation; has antipyretic and analgesic activity
Indications — Antiplatelet agent for the care of patients suspected of suffering from an acute coronary
syndrome
Contraindications — Hypersensitivity to aspirin or NSAIDs (aspirin-associated hypersensitivity
reactions include aspirin-induced urticarial or aspirin-intolerant asthma), bleeding GI ulcers, hemolytic
anemia from pyruvate kinase (PK) and glucose-6-phosphate dehydrogenase (G6PD) deficiency,
hemophilia, hemorrhagic diathesis, hemorrhoids, lactating mother, nasal polyps associated with
asthma, sarcoidosis, thrombocytopenia, ulcerative colitis

Atropine
Name — Atropen®, a component of Mark I® kits and DuoDote®
Class — Anticholinergic, toxicity antidotes
Pharmacologic Action — Competitively inhibits action of acetylcholinesterase on autonomic
effectors innervated by postganglionic nerves
Indications — Management of nerve agent toxicity, symptomatic bradycardia (primary or related to
toxin ingestion), organophosphate and carbamate insecticide toxicity
NOTE: Ineffective in hypothermic bradycardia
Contraindications — No absolute contraindications for ACLS, documented hypersensitivity in nerve
agent/organophosphate scenarios
RELATIVE CONTRAINDICATIONS: Narrow-angle glaucoma, GI obstruction, severe ulcerative
colitis, toxic megacolon, bladder outlet obstruction, myasthenia gravis, hemorrhage w/cardiovascular
instability, thyrotoxicosis

Calcium Chloride
Name — Calcium Chloride
Class — Antidotes, other; calcium salts
Pharmacologic Action — Bone mineral component; cofactor in enzymatic reactions, essential for
neurotransmission, muscle contraction, and many signal transduction pathways
Indications — For use in topical burns (hydrofluoric acid) or for use in calcium channel blocker
overdose
Contraindications — Hypercalcemia, documented hypersensitivity, life-threatening cardiac
arrhythmias may occur in known or suspected severe hypokalemia
WARNING: There is a risk for digitalis toxicity. Be cautious of peripheral IV use as significant tissue
necrosis at injection site may occur

144
Calcium Gluconate
Name — Gluconate®
Class — Antidotes, other; calcium salts
Pharmacologic Action — Bone mineral component; cofactor in enzymatic reactions, essential for
neurotransmission, muscle contraction, and many signal transduction pathways
Indications — For use in topical burns (hydrofluoric acid) or for use in calcium channel blocker
overdose
Contraindications — Hypercalcemia, documented hypersensitivity, sarcoidosis, life-threatening
cardiac arrhythmias may occur in known or suspected severe hypokalemia
WARNING: There is a risk for digitalis toxicity

Cimetidine
Name — Tagamet®
Class — Histamine H2 antagonist
Pharmacologic Action — blocks H2-receptors of gastric parietal cells, leading to inhibition of gastric
secretions
Indications — For the management of gastric or duodenal ulcers, gastroesophageal reflux, as an
adjunct in the treatment of urticarial and/or pruritis in patients suffering from allergic reaction
Contraindications — Hypersensitivity to cimetidine or other H2-receptor antagonists

Dexamethasone
Name — Decadron®, Dexasone®
Class — Corticosteroid, anti-inflammatory drugs
Pharmacologic Action — Potent glucocorticoid with minimal to no mineralocorticoid activity
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and
reducing capillary permeability; stabilizes cell and lysosomal membranes, increases surfactant
synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory
cytokines; suppresses lymphocyte proliferation through direct cytolysis, inhibits mitosis, breaks down
granulocyte aggregates, and improves pulmonary microcirculation
Indications — Used in the management of croup and bronchospasm, as well as the management of
patients suffering from high altitude cerebral edema (HACE)
Contraindications — Documented hypersensitivity, systemic fungal infection, cerebral malaria

Dextrose
Name — D50W, DGlucose®, glucose
Class — Glucose-elevating agents; metabolic and endocrine, other
Pharmacologic Action — Parenteral dextrose is oxidized to carbon dioxide and water, and provides
3.4 kilocalories/gram of d-glucose
Indications — Used for the management of hypoglycemia
Contraindications — Hyperglycemia, anuria, diabetic coma, intracranial or intraspinal hemorrhage,
dehydrated patients with delirium, glucose-galactose malabsorption syndrome, and documented
hypersensitivity

Diazepam
Name — Valium®, Diastat®, AcuDial®
Class — Benzodiazepine, anticonvulsants, skeletal muscle relaxants, anxiolytic
Pharmacologic Action — Modulates postsynaptic effects of GABA-A transmission, resulting in an
increase in presynaptic inhibition. Appears to act on part of the limbic system, as well as on the
thalamus and hypothalamus, to induce a calming effect
Indications — For use in agitated or violent patients, as well as for the management of seizures
Contraindications — Documented hypersensitivity, severe respiratory depression

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Diltiazem
Name — Includes Cardizem®, Dilacor®, Diltiaz®
Class — Calcium channel blocker, antidysrhythmic type IV
Pharmacologic Action — Inhibits extracellular calcium ion influx across membranes of myocardial
cells and vascular smooth muscle cells, resulting in inhibition of cardiac and vascular smooth muscle
contraction and thereby dilating main coronary and systemic arteries; no effect on serum calcium
concentrations; substantial inhibitory effects on cardiac conduction system, acting principally at AV
node, with some effects at sinus node
Indications — For management of narrow complex tachycardias
Contraindications — Documented hypersensitivity, Wolff-Parkinson-White syndrome, Lown-
Ganong-Levine syndrome, symptomatic severe hypotension (systolic BP less than 90 mmHg), sick
sinus syndrome (if no pacemaker), second- and third-degree heart block (if no pacemaker present), and
complete heart block. Contraindications for IV administration: Use in newborns (because of benzyl
alcohol), concomitant beta-blocker therapy, cardiogenic shock, ventricular tachycardia (must
determine whether origin is supraventricular or ventricular)

Diphenhydramine
Name — Benadryl®
Class — Antihistamine — first generation
Pharmacologic Action — Histamine H1-receptor antagonist of effector cells in respiratory tract,
blood vessels, and GI smooth muscle
Indications — For urticarial and/or pruritis in the management of patients suffering from allergic
reaction as well as for the management of patents suffering from dystonia/akathisia Contraindications
— Documented hypersensitivity, use controversial in lower respiratory tract disease (such as acute
asthma), premature infants and neonates

Dopamine
Name — Intropin®
Class — Inotropic agent; catecholamine; pressor
Pharmacologic Action — Endogenous catecholamine, acting on both dopaminergic and adrenergic
neurons. Low dose stimulates mainly dopaminergic receptors, producing renal and mesenteric
vasodilation; higher dose stimulates both beta-1-adrenergic and dopaminergic receptors, producing
cardiac stimulation and renal vasodilation; large dose stimulates alpha-adrenergic receptors
Indications — As a pressor agent used in the management of shock
Contraindications — Hypersensitivity to dopamine, pheochromocytoma, ventricular fibrillation,
uncorrected tachyarrhythmias
WARNING: Dopamine is a vesicant and can cause severe tissue damage if extravasation occurs

Dobutatmine
Name - Dobutrex®
Class – Ionatropic agents
Pharmacologic Action - Strong beta1 and weak beta2/alpha effects, resulting in increased cardiac
output, blood pressure, and heart rate, as well as decreased peripheral vascular resistance
Indications – For use in patients in cardiogenic shock
Contraindications – Hypersensitivity, acute myocardial infarction, severe hypertension, severe
tachycardia, acute myocarditis, severe hypokalemia, hypertrophic subaortic stenosis,
pheochromocytoma, uncorrected tachyarrhythmias

Droperidol
Name — Inapsine®
Class — Antiemetic agents; antipsychotic
Pharmacologic Action — Antiemesis: dopamine receptor blockade in brain, predominantly
dopamine-2 receptor. When reuptake is prevented, a strong antidopaminergic, antiserotonergic
response occurs. Droperidol reduces motor activity, anxiety, and causes sedation; also possesses
adrenergic blocking, antifibrillatory, antihistaminic, and anticonvulsive properties

146
Indications — For use in the patient with acute delirium or psychosis
Contraindications — Hypersensitivity, known or suspected prolonged QT interval; QTc interval
greater than 450 msec in females or greater than 440 msec in males
WARNING: Use with caution in patients with bradycardia, cardiac disease, concurrent MAO inhibitor
therapy, Class I and Class III dysrhythmics or other drugs that prolong the QT interval and cause
electrolyte disturbances due to its adverse cardiovascular effects, e.g., QT prolongation, hypotension,
tachycardia, and torsades de pointes

Epinephrine
Name — EpiPen®, TwinJect®, Adrenaclick®, Auvi-Q, Adrenalin®, AsthmaNefrin®, Vaponefrin®
Class — Alpha/beta adrenergic agonist
Pharmacologic Action — Strong alpha-adrenergic effects, which cause an increase in cardiac output
and heart rate, a decrease in renal perfusion and peripheral vascular resistance, and a variable effect on
BP, resulting in systemic vasoconstriction and increased vascular permeability. Strong beta-1- and
moderate beta-2-adrenergic effects, resulting in bronchial smooth muscle relaxation
Secondary relaxation effect on smooth muscle of stomach, intestine, uterus, and urinary bladder
Indications — For use in the management of patients suffering anaphylaxis, shock, cardiac arrest,
bradycardia, or in the nebulized form for croup/bronchiolitis and IM form for refractory acute asthma
Contraindications — Hypersensitivity, cardiac dilatation and coronary insufficiency

Famotidine
Name — Pepcid®
Class — Histamine H2 antagonist
Pharmacologic Action — Blocks H2 receptors of gastric parietal cells, leading to inhibition of gastric
secretions
Indications — For the management of gastric or duodenal ulcers, gastroesophageal reflux, as an
adjunct in the treatment of urticarial and/or pruritus in patients suffering from allergic reaction
Contraindications — Hypersensitivity to famotidine or other H2-receptor antagonists

Fentanyl
Name —Currently only available in the generic form (formerly Sublimaze®)
Class — Synthetic opioid, opioid analgesics
Pharmacologic Action — Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain
pathways, thus altering response to pain; increases pain threshold; produces analgesia, respiratory
depression, and sedation
Indications — Management of acute pain
Contraindications — Hypersensitivity
WARNING: Should be used with caution in the elderly and in patients with hypotension, suspected
gastrointestinal obstruction, head injury, and concomitant CNS depressants

Glucagon
Name — GlucaGen®, Glucagon Emergency Kit®, GlucaGen HypoKit®
Class — Hypoglycemia antidotes, glucose-elevating agents, other antidotes (e.g., beta-blocker or
calcium channel blocker overdose)
Pharmacologic Action — Insulin antagonist. Stimulates cAMP synthesis to accelerate hepatic
glycogenolysis and gluconeogenesis. Glucagon also relaxes smooth muscles of GI tract
Indications — For the management of hypoglycemic patients as well as patients suffering
symptomatic bradycardia after beta blocker or calcium channel blocker overdose
Contraindications — Hypersensitivity, pheochromocytoma, insulinoma
WARNING: Nausea and vomiting are common adverse effects following the administration of
glucagon

147
Haloperidol
Name — Haldol®, Haldol Decanoate®, Haloperidol LA®, Peridol®
Class — First generation antipsychotic
Pharmacologic Action — Antagonizes dopamine-1 and dopamine-2 receptors in brain; depresses
reticular activating system and inhibits release of hypothalamic and hypophyseal hormones
Indications — For the management of acute psychosis or agitated/violent behavior refractory to non-
pharmacologic interventions
Contraindications — Documented hypersensitivity, Severe CNS depression (including coma),
neuroleptic malignant syndrome, poorly controlled seizure disorder, Parkinson’s disease
WARNING: Risk of sudden death, torsades de pointes, and prolonged QT interval from off-label IV
administration of higher than recommended dose. Continuous cardiac monitoring is required if
administering IV

Helium Gas Mixture

Name — Heliox®
Class — Optional method of oxygen delivery
Pharmacology — Less resistant than atmospheric air which may reduce the patient’s work of
breathing by increasing tendency to laminar flow and reducing resistance to turbulent flow
Indications — Persistent or severe bronchospasm in non-intubated patients with obstructive airway
disease or pediatric patients with croup that is unresponsive to all other evidence-based medical
interventions.
Contraindications — None

Hydralazine
Name — No listed brand name
Class — Vasodilator
Pharmacology — Direct vasodilator at the level of arterioles, with little effect on veins. Decreases
systemic resistance.
Indications — Severe hypertension with pre-eclampsia symptoms
Contraindications — Hypersensitivity, coronary artery disease, mitral valve rheumatic heart disease.
Use with caution in CVA, known renal disease, hypotension

Hydrocortisone succinate
Name — Cortef®, SoluCortef®
Class — Corticosteroid
Pharmacologic Action — Glucocorticoid; elicits mild mineralocorticoid activity and moderate anti-
inflammatory effects; controls or prevents inflammation by controlling rate of protein synthesis,
suppressing migration of polymorphonuclear leukocytes (PMNs) and fibroblasts, and reversing
capillary permeability
Indications — For the management of adrenal insufficiency
Contraindications — Untreated serious infections (except tuberculous meningitis or septic shock),
idiopathic thrombocytopenic purpura, intrathecal administration (injection), documented
hypersensitivity

Hydromorphone
Name — Dilaudid®
Class — Synthetic opiate, opioid analgesic
Pharmacology — Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain pathways,
thus altering response to pain; increases pain threshold; produces analgesia, respiratory depression, and
sedation
Indications — Management of acute pain
Contraindications — Hypersensitivity
WARNING: Should be used with caution in the elderly and in patients with hypotension, suspected
gastrointestinal obstruction, head injury, and concomitant CNS depressants

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Hydroxocobalamin
Name — Cyanokit®
Class — Cyanide antidote
Pharmacologic Action — Vitamin B12 with hydroxyl group complexed to cobalt which can be
displaced by cyanide resulting in cyanocobalamin that is renally excreted
Indications — For the management of cyanide toxicity
Contraindications — Documented hypersensitivity
WARNING: Will cause discoloration of the skin and urine, can interfere with pulse oximetry. Due to
its interference with certain diagnostic blood tests, the performance of prehospital phlebotomy is
preferable prior to the administration of hydroxocobalamin

Ibuprofen
Name — There are multiple over-the-counter medications that include ibuprofen, such as Advil®,
Motrin®
Class — Non-steroidal anti-inflammatory drug (NSAID)
Pharmacologic Action — Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2
cyclo-oxygenase (COX) isoenzymes, COX-1 and COX-2. May inhibit chemotaxis, alter lymphocyte
activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects
may contribute to anti-inflammatory activity
Indications — For the acute management of pain or as an antipyretic
Contraindications — Aspirin allergy; perioperative pain in setting of coronary artery bypass graft
(CABG) surgery; preterm infants with untreated proven or suspected infection; bleeding with active
intracranial hemorrhage or GI bleed; thrombocytopenia, coagulation defects, proven or necrotizing
enterocolitis, significant renal impairment, congenital heart disease where patency or the patent ductus
arteriosus (PDA) is necessary for pulmonary or systemic blood flow

Ipratropium
Name — Atrovent®
Class — Anticholinergics, respiratory
Pharmacologic Action — Anticholinergic (parasympatholytic) agent; inhibits vagally mediated
reflexes by antagonizing acetylcholine action; prevents increase in intracellular calcium concentration
that is caused by interaction of acetylcholine with muscarinic receptors on bronchial smooth muscle
Indications — For the management of asthma and chronic obstructive pulmonary disease (COPD)
Contraindications — Documented hypersensitivity to ipratropium, atropine, or derivatives.

Isopropyl Alcohol
Name — No brand name available
Class — Secondary alcohol
Pharmacology — In addition to traditional role as antiseptic, may be used as antiemetic
Indications — Nausea and vomiting
Contraindications — None

Ketamine
Name — Ketalar®
Class — General anesthetics, systemic
Pharmacologic Action — Produces dissociative anesthesia. Blocks N-methyl D-aspartate (NMDA)
receptor
Indications — For the management of agitated or violent behavior
Contraindications — Hypersensitivity
RELATIVE/CONTROVERSIAL CONTRAINDICATIONS: Head trauma, intracranial mass/hemorrhage,
hypertension, angina, and stroke, underlying psychiatric disorder
WARNING: Overdose may lead to panic attacks and aggressive behavior; rarely seizures, increased
ICP, and cardiac arrest. Very similar in chemical makeup to PCP (phencyclidine), but it is shorter
acting and less toxic

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Ketoralac
Name — Toradol®
Class — Non-steroidal anti-inflammatory drug (NSAID)
Pharmacologic Action — Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2
cyclo-oxygenase (COX) isoenzymes, COX-1 and COX-2. May inhibit chemotaxis, alter lymphocyte
activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects
may contribute to anti-inflammatory activity
Indications — For the acute management of moderately severe pain
Contraindications — Allergy to aspirin, ketorolac, or other NSAIDS; women who are in active labor
or are breastfeeding, significant renal impairment particularly when associated with volume depletion,
previous or current GI bleeding, intracranial bleeding, coagulation defects, patients with a high-risk of
bleeding

Labetalol
Name — Trandate®
Class — Beta-blockers, alpha activity
Pharmacology — Nonselective beta blocker with intrinsic sympathomimetic activity; also, alpha
blocker Indications — severe hypertension with pre-eclampsia symptoms
Contraindications — Asthma or obstructive airway disease, severe bradycardia, second-degree or
third-degree heart block (without pacemaker), cardiogenic shock, bronchial asthma, uncompensated
cardiac failure, hypersensitivity, sinus bradycardia, sick sinus syndrome without permanent
pacemaker; conditions associated with prolonged and severe hypotension. Use with caution in patients
taking calcium channel blockers. Hypotension with or without syncope may occur, monitor. Consider
pre-existing conditions, such as, sick sinus syndrome before initiating therapy. Use caution in patients
with history of severe anaphylaxis to allergens; patients taking beta-blockers may become more
sensitive to repeated challenges; treatment with epinephrine in patients taking beta-blockers may be
ineffective or promote undesirable effects. Use with caution in patients with myasthenia gravis,
psoriasis, or psychiatric illness (may cause or exacerbate CNS depression)

Lidocaine
Name — Lidocaine CV®, Lidopen®, Xylocaine®
Class — Class Ib antidysrhythmics
Pharmacologic Action — Class 1b antidysrhythmic; combines with fast sodium channels and thereby
inhibits recovery after repolarization, resulting in decreasing myocardial excitability and conduction
velocity
Indications — For the management of refractory or recurrent ventricular fibrillation or pulseless VT
Contraindications — Hypersensitivity to lidocaine or amide-type local anesthetic, Adams-Stokes
syndrome, SA/AV/intraventricular heart block in the absence of artificial pacemaker. nitro (CHF),
cardiogenic shock, second- and third-degree heart block (if no pacemaker is present), Wolff-
Parkinson-White Syndrome

Lorazepam
Name — Ativan®
Class — Anticonvulsants, other; antianxiety agent; anxiolytics; benzodiazepines
Pharmacologic Action — Sedative hypnotic with short onset of effects and relatively long half-life;
by increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory
neurotransmitter in the brain, lorazepam may depress all levels of the CNS, including limbic and
reticular formation Indications — For the management of seizures, uncontrolled shivering in
hypothermia, and for the management of agitated or violent patients suffering behavioral emergencies
Contraindications — Documented hypersensitivity, acute narrow angle glaucoma, severe respiratory
depression, sleep apnea

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Magnesium sulfate
Name — MgSO4
Class — Class V antidysrhythmic, electrolyte
Pharmacologic Action — Depresses CNS, blocks peripheral neuromuscular transmission, produces
anticonvulsant effects; decreases amount of acetylcholine released at end-plate by motor nerve
impulse. Slows rate of sinoatrial (SA) node impulse formation in myocardium and prolongs
conduction time. Promotes movement of calcium, potassium, and sodium in and out of cells and
stabilizes excitable membranes
Indications — For the management of torsades de pointes or for severe bronchoconstriction with
impending respiratory failure, seizure during the third trimester of pregnancy or in the postpartum
patient
Contraindications — Hypersensitivity, myocardial damage, diabetic coma, heart block,
hypermagnesemia, hypercalcemia

Methylprednisolone
Name — Medrol®, Medrol Dosepak®, DepoMedrol®, SoluMedrol®
Class — Corticosteroid, anti-inflammatory agent
Pharmacologic Action — Potent glucocorticoid with minimal to no mineralocorticoid activity.
Modulates carbohydrate, protein, and lipid metabolism and maintenance of fluid and electrolyte
homeostasis. Controls or prevents inflammation by controlling rate of protein synthesis, suppressing
migration of polymorphonuclear leukocytes (PMNs) and fibroblasts, reversing capillary permeability,
and stabilizing lysosomes at cellular level
Indications — For the management of acute bronchospastic disease as well as for adrenal
insufficiency Contraindications — Untreated serious infections, documented hypersensitivity, IM
route is contraindicated in idiopathic thrombocytopenic purpura, traumatic brain injury (high doses)

Metoclopramide
Name — Reglan®, Metozolv ODT®
Class — Antiemetic agent, prokinetic agent
Pharmacologic Action — Blocks dopamine receptors (at high dose) and serotonin receptors in
chemoreceptor trigger zone of CNS; and sensitizes tissues to acetylcholine; increases upper GI motility
but not secretions; increases lower esophageal sphincter tone
Indications — For the management of nausea and vomiting
Contraindications — Hypersensitivity to metoclopramide or procainamide, GI hemorrhage,
mechanical obstruction, perforation, history of seizures, pheochromocytoma. Other drugs causing
extrapyramidal symptoms (e.g., phenothiazines, butyrophenones)

Metoprolol
Name — Lopressor®, Toprol XL®
Class — Beta blocker, beta-1 selective
Pharmacologic Action — Blocks response to beta-adrenergic stimulation; cardio selective for beta-1
receptors at low doses, with little or no effect on beta-2 receptors
Indications — For management of narrow complex tachycardias
Contraindications — Hypersensitivity. When administered for hypertension or angina: Sinus
bradycardia, 2nd or 3rd degree AV block, cardiogenic shock, sick sinus syndrome (unless permanent
pacemaker in place), severe peripheral vascular disease, pheochromocytoma. When administered for
myocardial infarction: Severe sinus bradycardia with heart rate less than 45 beats/minute, systolic BP
less than 100 mmHg, significant first-degree heart block (PR interval at least 0.24 seconds), moderate-
to-severe cardiac failure
WARNING: May cause 1st, 2nd, or 3rd degree AV block

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Midazolam
Name — Versed®
Class — Anticonvulsants, other; antianxiety agent; anxiolytics; benzodiazepines
Pharmacologic Action — Binds receptors at several sites within the CNS, including the limbic
system and reticular formation; effects may be mediated through gabba-aminobutyric acid (GABA)
receptor system; increase in neuronal membrane permeability to chloride ions enhances the inhibitory
effects of GABA; the shift in chloride ions causes hyperpolarization (less excitability) and stabilization
of the neuronal membrane
Indications — For the management of seizures, uncontrolled shivering in hypothermia, and for the
management of agitated or violent patients suffering behavioral emergencies
Contraindications — Documented hypersensitivity, severe respiratory depression, sleep apnea
WARNING: May cause respiratory depression, arrest, or apnea

Morphine Sulfate
Name — MS Contin®, Avinza®, Depodur®, Duramorph®, Infumorph®, Astramorph®, Kadian®,
MSO4
Class — Opioid analgesic
Pharmacologic Action — Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain
pathways, thus altering response to pain; produces analgesia, respiratory depression, and sedation;
suppresses cough by acting centrally in medulla
Indications — Management of acute pain
Contraindications — Hypersensitivity, paralytic ileus, toxin-mediated diarrhea, respiratory
depression, acute or severe bronchial asthma, upper airway obstruction, GI obstruction (extended
release), hypercarbia (immediate release tablets/solution), upper airway obstruction
(epidural/intrathecal), heart failure due to chronic lung disease, head injuries, brain tumors, deliriums
tremens, seizure disorders, during labor when premature birth anticipated (injectable formulation),
cardiac arrhythmia, increased intracranial or cerebrospinal pressure, acute alcoholism, use after biliary
tract surgery, surgical anastomosis (suppository formulation)

Naloxone
Name — Narcan®
Class — Opioid reversal agent
Pharmacologic Action — Competitive opioid antagonist; synthetic congener of oxymorphone
Indications — Reversal of acute opioid toxicity
Contraindications — Hypersensitivity
WARNING: Administration of naloxone can result in the sudden onset of opiate withdrawal (agitation,
tachycardia, pulmonary edema, nausea, vomiting, and, in neonates, seizures)

Nifedipine
Name — Procardia®, Adalat CC®, Nifedical®
Class — Calcium channel blocker
Pharmacologic Action — Calcium-channel blocker; inhibits transmembrane influx of extracellular
calcium ions across myocardial and vascular smooth muscle cell membranes without changing serum
calcium concentrations; this results in inhibition of cardiac and vascular smooth muscle contraction,
thereby dilating main coronary and systemic arteries. Vasodilation with decreased peripheral
resistance and increased heart rate
Indications — For the management of high-altitude pulmonary edema (HAPE)
Contraindications — Hypersensitivity to nifedipine or other calcium-channel blockers, cardiogenic
shock, concomitant administration with strong CYP3A4 inducers (e.g., rifampin, rifabutin,
phenobarbital, phenytoin, carbamazepine, St. John's wort) significantly reduces nifedipine efficacy,
Immediate release preparation (sublingually or orally) for urgent or emergent hypertension

152
Nitrous Oxide
Name — N2O
Class — Weak inhalational anesthetic
Pharmacologic Action — Its analgesic mechanism of action is described as opioid in nature and may
involve a number of spinal neuromodulators. The anxiolytic effect is similar to that of benzodiazepine
and may involve gamma aminobutyric (GABA) receptors. The anesthesia
mechanism may involve GABA and possibly N-methyl-D-aspartate receptors as well.[6] In general,
the effect of nitrous oxide ceases as soon as the inhalation stops, with no residual effect
Indications — Analgesia in the patient who is capable of self-administration of this medication
Contraindications — Significant respiratory compromise, suspected abnormal air-filled cavities (e.g.,
pneumothorax, bowel obstruction, air embolism)
RELATIVE CONTRAINDICATIONS: History of stroke, hypotension, pregnancy, known cardiac
conditions, known vitamin B12 deficiency

Nitroglycerin
Name — Nitrostat®, Nitrolingual Pumpspray®, NitroQuick®
Class — Nitrates, anti-anginal
Pharmacologic Action — Organic nitrate which causes systemic venodilation, decreasing preload.
Cellular mechanism: nitrate enters vascular smooth muscle and converted to nitric oxide (NO) leading
to activation of cyclic guanosine monophosphate (cGMP) and vasodilation. Relaxes smooth muscle
via dose-dependent dilation of arterial and venous beds to reduce both preload and afterload, and
myocardial O2 demand. Also improves coronary collateral circulation. Lower BP, increases heart rate,
occasional paradoxical bradycardia
Indications — As an anti-anginal medication for the management of chest pain as well as a reducer of
preload for patients suffering from acute pulmonary edema
Contraindications — Hypersensitivity, acute myocardial infarction, severe anemia, recent use of
erectile dysfunction medications (sildenafil (Viagra® — within last 24 hours), tadalafil (Cialis® —
within last 48 hours), vardenafil (Levitra® — within last 48 hours), or other phopsphodiesterase-5
inhibitors). There is potential for dangerous hypotension, narrow angle glaucoma (controversial: may
not be clinically significant). Nitrates are contraindicated in the presence of hypotension (SBP less
than 90 mmHg or ≥30 mmHg below baseline), extreme bradycardia (less than 50 BPM), tachycardia in
the absence of heart failure (greater than 100 BPM), and right ventricular infarction

Norepinephrine
Name — Levophed®, Levarterenol®
Class — Alpha/beta adrenergic agonist
Pharmacologic Action — Strong beta-1 and alpha-adrenergic effects and moderate beta-2 effects,
which increase cardiac output and heart rate, decrease renal perfusion and peripheral vascular
resistance, and cause variable BP effects
Indications — As a pressor agent used in the management of shock
Contraindications — Hypersensitivity, hypotension due to blood volume deficit, peripheral vascular
thrombosis (except for lifesaving procedures)
RELATIVE CONTRAINDICATIONS: concomitant use with some general anesthetics: chloroform,
trichloroethylene, cyclopropane, halothane
All Rights Reserved V.08 -16 272
WARNING: Norepinephrine is a vesicant and can cause severe tissue damage if extravasation occurs.
Do not use in the same IV line as alkaline solutions as these may deactivate it

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Olanzapine
Name — Zyprexa®
Class — Antipsychotic, second generation, antimanic agents
Pharmacologic Action — May act through combination of dopamine and serotonin type 2 receptor
site antagonism
Indications — For the management of agitated or violent patients suffering a behavioral emergency
Contraindications — Documented hypersensitivity
WARNING: Patients are at risk for severe sedation (including coma) or delirium after each injection
and must be observed for at least 3 hours in registered facility with ready access to emergency
response services. Patients are at significant risk of severe sedation when olanzapine is administered
with benzodiazepines or to patients who have are taking benzodiazepines
Ondansetron
Name — Zofran®, Zofran ODT®, Zuplenz®
Class — Antiemetic, selective 5-HT3 antagonist
Pharmacologic Action — Mechanism not fully characterized; selective 5-HT3 receptor antagonist;
binds to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI tract. Has no effect
on dopamine receptors and therefore does not cause extrapyramidal symptoms
Indications — For the management of nausea or vomiting
NOTE: EKG monitoring is recommended in patients who have electrolyte abnormalities, CHF, or
bradyarrhythmias or who are also receiving other medications that cause QT prolongation
Contraindications — Hypersensitivity, coadministration with apomorphine; combination reported to
cause profound hypotension and loss of consciousness
WARNING: May cause dose-dependent QT prolongation, avoid in patients with congenital long QT
syndrome

Oxymetazoline
Name — Afrin®, Duramist Plus®, Dristan 12 Hr®, Sinarest 12 Hour®, Vicks Sinus 12 Hour®
Class — Decongestants, intranasal
Pharmacologic Action — Alpha-adrenergic agonist; stimulates alpha-adrenergic receptors and
produces vasoconstriction in the arterioles of the nasal mucosa
Indications — For the management of epistaxis in the patient suffering facial trauma
Contraindications — Hypersensitivity

Potassium iodide
Name — Pima Syrup®, SSKI®, ThyroSafe®, ThyroShield®
Class — Antidotes, other; antithyroid agents
Pharmacologic Action — As a thyroid protective agent: Systemically circulating potassium iodide is
readily taken up by thyroid gland by sodium/iodide transporter in basal membrane; blocking the
thyroid uptake of radioactive isotopes of iodine; concentration gradient of thyroid gland to plasma is
20—50:1 Indications — Indicated during environmental radiation emergency to block uptake of
radioactive iodine isotopes in thyroid and reduce risk of thyroid cancer
Contraindications — Iodine sensitivity (although allergy to radiocontrast media, contact dermatitis
from iodine-containing antibacterials, allergy to seafood should not be considered evidence of
potassium iodide allergy), hyperthyroidism, respiratory failure

Prednisone
Name – Deltasone®, Rayos®, Sterapred®
Class – Corticosteroid
Pharmacologic Action - Glucocorticosteroid which also elicits mild mineralocorticoid activity and
dose dependent moderate-to-significant anti-inflammatory effects
Indications – Multiple uses per protocols
Contraindications – Avoid in untreated severe infections, documented hypersensitivity, or active
varicella and fungal infections

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Prednisolone
Name – Pediapred®, FloPred®, Orapred®, Millipred®, Prelone Syrup®, Veripred®
Class – Corticosteroid
Pharmacologic Action - Glucocorticosteroid which also elicits mild mineralocorticoid activity and
dose dependent moderate-to-significant anti-inflammatory effects
Indications – Multiple uses per protocols
Contraindications – Avoid in untreated severe infections, documented hypersensitivity, or
active varicella and fungal infections

Pralidoxime chloride (2-PAM)

Name — Protopam®, 2PAM Antidote®, Pralidoxime Auto Injector®, a component of Mark I® kits
and DuoDote®
Class — Cholinergic, toxicity antidote
Pharmacologic Action — Binds to organophosphates and breaks alkyl phosphate-cholinesterase bond
to restore activity of acetylcholinesterase
Indications — For the management of toxicity caused by organophosphate insecticides and related
nerve gases (e.g., tabun, sarin, soman)
Contraindications — Documented hypersensitivity

Procainamide
Name — Pronestyl®, Procanbid®
Class — Class Ia antidysrhythmic
Pharmacologic Action — Class Ia (membrane stabilizing) antidysrhythmic agent; inhibits recovery
after repolarization resulting in decreasing myocardial excitability and conduction velocity. Direct
membrane depressant that decreases conduction velocity, prolongs refractoriness, decreases
automaticity and reduces repolarization abnormalities
Indications — For the management of stable patients with regular, wide complex tachycardia
Contraindications — Hypersensitivity to procainamide or other ingredients, complete heart block,
second- or third-degree AV block, systemic lupus erythematosus (SLE), torsades de pointes
RELATIVE CONTRAINDICATION: Patients with QT prolongation

Prochlorperazine
Name — Compazine®
Class — Antiemetic agent; antipsychotics, phenothiazine
Pharmacologic Action — Antiemetic: antidopaminergic effect, blocking dopamine receptors in the
brain, blocking vagus nerve in GI tract. Antipsychotic: Blocking mesolimbic dopamine receptors, and
blocking alpha-adrenergic receptors (D1 and D2) in brain
Indications — For the management of nausea and vomiting
Contraindications — Documented hypersensitivity to phenothiazines, coma, severe CNS depression,
concurrent use of large amounts of CNS depressants, poorly controlled seizure disorder, subcortical
brain damage, pediatric surgery, children less than 2 years or weighing less than 9 kg

Sildenafil
Name — Revatio®, Viagra®
Class — Pulmonary artery hypertension therapy, PDE-5 inhibitors; phosphodiesterase-5 enzyme
inhibitor
Pharmacologic Action — Inhibits PDE-5, increasing cyclic guanosine monophosphate (cGMP) to
allow smooth-muscle relaxation
Indications — As an adjunct to descent in the management of high-altitude pulmonary edema
(HAPE) Contraindications — Concomitant use of organic nitrates in any form (e.g., nitroglycerin,
isosorbide, illicit “poppers”) either regularly or intermittently, increases risk of severe or potentially
fatal hypotension, hypersensitivity
WARNING: Hypotension may occur due to vasodilation

155
Sodium Bicarbonate
Name — Bicarb
Class — Antidote, other
Pharmacologic Action — Increases blood and urinary pH by releasing a bicarbonate ion, which in
turn neutralizes hydrogen ion concentrations
Indications — For the management of cardiac arrest in cases in which either hyperkalemia or tricyclic
antidepressant (TCA) overdose are suspected as contributory, QRS prolongation in known or
suspected TCA overdose
Contraindications — Documented hypersensitivity, severe pulmonary edema, known alkalosis,
hypernatremia, or hypocalcemia

Sodium Nitrite
Name — Nithiodote®
Class — Cyanide antidote
Pharmacologic Action — Nitrites create methemoglobins to bind to cyanide
Indications — For the management of cyanide toxicity
Contraindications — Documented hypersensitivity, suspected or confirmed smoke inhalation and/or
carbon monoxide poisoning
WARNING: There is a risk of worsening hypoxia due to methemoglobin formation. In addition,
sodium nitrite can cause serious adverse reactions and death from hypotension and methemoglobin
formation. Monitor to ensure adequate perfusion and oxygenation during treatment with sodium
nitrite

Sodium Thiosulfate
Name— Nithiodote®
Class — Cyanide antidote
Pharmacologic Action — Thiosulfate is sulfur donor utilized by rhodanese to convert cyanide to less
toxic thiocyanate
Indications — For the management of cyanide toxicity
Contraindications — Documented hypersensitivity

Sorbitol
Name — Sorbitol
Class — Laxatives, osmotic
Pharmacologic Action — Polyalcoholic sugar with hyperosmotic effects
Indications — Administered for the management of patients suffering from toxic ingestions
Contraindications — Acute abdominal pain, nausea, vomiting, or other symptoms of appendicitis or
undiagnosed abdominal pain, documented hypersensitivity
WARNING: Sorbitol is no longer recommended to be given with activated charcoal

Tadalafil
Name — Cialis®, Adcirca®
Class — Pulmonary artery hypertension therapy, PDE—5 inhibitors; phosphodiesterase-5 enzyme
inhibitor
Pharmacologic Action — Pulmonary arterial hypertension (PAH): inhibits PDE-5, increasing cyclic
guanosine monophosphate (cGMP) to allow relaxation of pulmonary vascular smooth-muscle cells and
vasodilation of pulmonary vasculature
Indications — As an adjunct to descent in the management of high-altitude pulmonary edema
(HAPE) Contraindications — Concomitant use of any form of organic nitrates (e.g., nitroglycerin,
isosorbide dinitrate, isosorbide mononitrate, illicit "poppers"), either regularly or intermittently; may
potentiate hypotensive effect of nitrates. Hypersensitivity, including Stevens-Johnson syndrome and
exfoliative dermatitis
WARNING: Hypotension may occur due to vasodilation

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Ziprasidone
Name — Geodon®
Class — Second generation antipsychotic
Pharmacologic Action — Acts as antagonist at dopamine-2 and serotonin type 1 and 2 (5HT1D,
5HT2A) receptors; acts as agonist at serotonin 5HT1A receptor; moderately inhibits reuptake of
norepinephrine and serotonin; has alpha-blocking and antihistaminic activity
Indications — For the management of agitated or violent patients suffering a behavioral emergency
Contraindications — Documented hypersensitivity, any drugs or conditions that prolong QT interval,
recent acute myocardial infarction, uncompensated heart failure

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ANNEX 11: Footnotes

I. Universal Documentation Protocol

Patient Care Goals
1. Support continuity of patient care and continuous performance improvement (CPI) of
patient care through meeting minimum documentation standards for all EMS events
where a patient was encountered
2. This Protocol defines minimum standards and inclusions used and referenced throughout
this document under the “Quality Improvement” section of each Protocol
3. This Protocol can be used as a starting point for systems looking to more formally define
documentation requirements

Patient Presentation
Inclusion Criteria
All EMS events where a patient was encountered, and one or more clinical Protocol was used
to determine patient treatment and/or disposition.
Exclusion Criteria
None noted

Toolkit for Key Categories of Data Elements

Incident Demographics
1. Incident Demographics include the type of incident, location, time, dispatch information,
response resources and patient/incident disposition of the EMS event
a. This information will always apply and be available, even if the responding unit
never arrives on scene (is cancelled) or never makes patient contact
b. Incident demographics are important for filtering incident types and outcomes when
doing CPI reviews, providing aggregate descriptive data, and billing for
reimbursement
2. Minimum Incident Demographic Fields include:
a. Incident Times
i. eTimes.03—Unit Notified by Dispatch Date/Time (mandatory)
ii. eTimes.05—Unit En Route Date/Time (Unit responding)
iii. eTimes.06—Unit Arrived on Scene Date/Time (If arrived)
iv. eTimes.07—Arrived at Patient Date/Time (If patient contact made)
v. eTimes.09—Unit Left Scene Date/Time (Unit Transporting Time, if
applicable)
vi. eTimes.11—Patient Arrived at Destination Date/Time (If applicable)
vii. eTimes.13—Unit Back in Service Date/Time (NEMSIS mandatory)
b. eResponse.05—Type of Service Requested (i.e., 911 vs interfacility)
c. eResponse.07—Primary Role of the Unit (i.e., Transport or non-transport)
d. eDispatch.01—Complaint Reported by Dispatch (Dispatch reason from EMD)
e. Crew Responding:
i. eCrew.01—Crew Member ID (Crew name or license # depending on
software)
ii. eCrew.02—Crew Member Level (License level for this call)
iii. eCrew.03—Crew Member Response Role (i.e., Primary or secondary care giver)
f. eScene.09—Incident Location Type
i. Used for multiple purposes, including CARES (Cardiac Arrest Registry to
Enhance Survival)
g. Response Modes (e.g., lights and sirens)
i. eResponse.23—Response Mode to Scene
ii. eResponse.24—Additional Response Mode Descriptors h. Delays:
i. eResponse.09—Type of Response Delay
ii. eResponse.10—Type of Scene Delay

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Patient Demographics and Medical History
Patient demographics in this section include the minimum information required for CPI
review and do not include protected health information (PHI) or patient identifiable
information. Local systems may require additional PHI to support EMS reimbursement and
link local level CPI reviews to specific incidents or outcome data.
1. Minimum Patient Demographic and History Fields include:
a. ePatient.13—Gender
b. ePatient.15—Age
c. ePatient.16—Age Units
d. eHistory.06—Medication Allergies
e. eHistory.07—Environmental/Food Allergies
f. eHistory.08—Medical/Surgical History
g. eHistory.12—Current Medications
h. eHistory.17—Alcohol/Drug Use Indicators
i. eHistory.01—Barriers to Patient Care
j. eExam.01—Estimated Body Weight in Kilograms
k. eExam.02—Length-based Tape Measure

Patient Complaints and Symptoms

1. Patient and situational history for this EMS event generally addresses issues leading up to
EMS being requested and include patient complaints, SAMPLE history, signs or
symptoms, barriers and confounders, onset times, and trauma and cardiac arrest historical
information
2. Patient Complaints, Signs and Symptoms, and Key Related Times:
a. eSituation.02—Possible Injury
b. Patient Complaint Group
i. eSituation.03—Complaint Type
Ii. eSituation.04 – Complaint
iii. eSituation.05—Duration of Complaint
iv. eSituation.06—Time Units of Duration of Complaint
c. eSituation.07—Chief Complaint Anatomic Location
d. eSituation.08—Chief Complaint Organ System
e. Signs and Symptoms
i. eSituation.01—Date/Time of Symptom Onset
Ii. eSituation.09—Primary Symptom [Single Choice]
iii. eSituation.10—Other Associated Symptoms [Choose All that Apply]
f. eSituation.18—Date/Time Last Known Well (Stroke/CVA)

Situational History for this EMS Event

3. SAMPLE History
NOTE: Although many assessment Protocols refer to this history mnemonic, many
electronic patient care report (ePCR) systems do not collect this information in a tool
organized specifically in this group, but rather throughout the EMS record in the
appropriate areas to the topics
a. Symptoms
i. eSituation.09—Primary Symptom AND
ii. eSituation.10—Other Associated Symptoms
b. Allergies
i. eHistory.06—Medication Allergies AND
ii. eHistory.07—Environmental/Food Allergies
c. Medications
i. eHistory.12—Current Medications
d. Past medical and surgical history
i. eHistory.08—Medical/Surgical History

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 e. Last Oral Intake
i. eHistory.19—Last Oral Intake (if software configured to collect) and/or
ii. eNarrative.01—Patient Care Report Narrative
f. Events leading to activation of EMS
i. eSituation.17—Patient Activity and/or
ii. eNarrative.01—Patient Care Report Narrative
4. Barriers and Situational Confounders
a. eHistory.01—Barriers to Patient Care
b. eHistory.17—Alcohol/Drug Use Indicators
5. Stroke
a. eSituation.18—Date/Time Last Known Well (Stroke/CVA)
6. Trauma History and Situation
a. eSituation.02—Possible Injury (Yes/No—based on mechanism, not listing an actual
injury)
b. eInjury.01—Cause of Injury
i. Known to clinicians as Mechanism of Injury; values are from ICD-10
ii. Intent is included where possible in ICD-10, but is no longer a separate field as it
was in NEMSIS v2
c. eInjury.03—Trauma Center Criteria (per the ACS-COT 2022 National Protocol for
Field Triage of Injured Patients)
d. eInjury.04—Vehicular, Pedestrian, or Other Injury Risk Factor (per the ACS-COT 2022
National Protocol for Field Triage of Injured Patients)
e. eInjury.07—Use of Occupant Safety Equipment
f. Destination Pre-Arrival Alerts (e.g., trauma alerts)
i. eDisposition.24—Destination Team Pre-Arrival Alert or Activation
ii. eDisposition.25—Date/Time of Destination Pre-Arrival Alert or Activation
7. Cardiac Arrest History and Situation
NOTE: The following fields meet the needs of Utstein Criteria reports and many of the
fields
in CARES. CARES has additional custom fields that may be available from your software
vendor.
a. eArrest.01—Cardiac Arrest [Yes/No]
b. eArrest.02—Cardiac Arrest Etiology
c. eArrest.03—Resuscitation Attempted By EMS
d. eArrest.04—Arrest Witnessed By
e. eArrest.05—CPR Care Provided Prior to EMS Arrival
f. eArrest.06—Who Provided CPR Prior to EMS Arrival
g. eArrest.07—AED Use Prior to EMS Arrival
h. eArrest.08—Who Used AED Prior to EMS Arrival
i. eArrest.09—Type of CPR Provided
j. eArrest.11—First Monitored Arrest Rhythm of the Patient
k. eArrest.12—Any Return of Spontaneous Circulation
l. eArrest.14—Date/Time of Cardiac Arrest
m. eArrest.15—Date/Time Resuscitation Discontinued
n. eArrest.16—Reason CPR/Resuscitation Discontinued
o. eArrest.17—Cardiac Rhythm on Arrival at Destination
p. eArrest.18—End of EMS Cardiac Arrest Event
q. eScene.02—Other EMS or Public Safety Agencies at Scene
r. eScene.03—Other EMS or Public Safety Agency ID Number
s. eScene.04—Type of Other Service at Scene

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Clinician Impressions and Incident/Patient Disposition
1. Clinician Impressions (Clinician Field Working Diagnosis)
a. eSituation.11—Clinician's Primary Impression [Single Choice]
i. The word “Primary” causes a great deal of understandable confusion with this field,
this should be the diagnosis of the most acute (primary) problem NOT
NECESSARILY THE FIRST problem that was wrong with the patient, or their initial
complaint
b. eSituation.12—Clinician's Secondary Impression [Choose all that Apply]
2. Incident/Patient Disposition
a. eSituation.13—Initial Patient Acuity (Intended to be prior to EMS care)
b. eDisposition.19—Final Patient Acuity (Intended to be after EMS care)
c. eDisposition.12—Incident/Patient Disposition
d. eDisposition.16—EMS Transport Method
e. Transport Mode (i.e., use of lights and sirens)
i. eDisposition.17—Transport Mode from Scene
ii. eDisposition.18—Additional Transport Mode Descriptors f.
eDisposition.01—Destination/Transferred To, Name
i. Intended by NEMSIS to be the destination facility or the Agency transferred to,
although many ePCR systems only collect this as the destination facility because
of the complexity of mixing facilities and services in the same field

Assessments and Exams

1. Exams
By definition, use of NEMSIS eExam fields is optional; they are, however, available for
both state and local EMS system use.
a. Many systems do not require use of these fields as they can be time-consuming to
enter, often too detailed (i.e., there is no value for whole arm, it would need to be
entered as shoulder, upper arm, elbow, forearm and wrist with separate exam findings
for each component, meaning a single exam finding of paralysis for an arm would
take ten steps to enter) and the same information is often reflected in the clinician’s
narrative.
b. However, there is some utility in targeted use of these fields for certain situations such
as stroke, spinal exams, and trauma without needing to enter all the fields in each
record.
2. Capacity Assessment Group
This can be used to support documentation of patient capacity for refusal of care and/or
transport, participation in advanced spinal assessments, or support for treatment decisions
by EMS clinicians. NOTE: The Capacity Assessment Group does not provide a legal
definition of capacity and should not be used as such. It is intended only to assist the EMS
clinician in documenting the most basic exam and history findings in order to determine
capacity. Many additional factors must be considered when determining capacity
including the situation, patient medical history, medical conditions, and consultation with
medical direction.
a. Barriers and situational confounders [Both only single entry]
i. eHistory.01—Barriers to Patient Care
ii. eHistory.17—Alcohol/Drug Use Indicators
b. Glasgow Coma Score (GCS) Vitals Group [see Vitals section] [serial entries allowed]
c. eVitals.26—Level of Responsiveness (AVPU) [serial entries allowed]
d. eExam.19—Mental Status Assessment [serial entries allowed]
e. eExam.20—Neurological Assessment [serial entries allowed]
3. Stroke Assessments
a. Initial Vitals
b. eSituation.18—Date/Time Last Known Well (Stroke/CVA)
c. Stroke Score Group
d. eExam.19—Mental Status Assessment

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 e. eExam.20—Neurological Assessment (Speech, facial droop, arm drift, unilateral
weakness)
f. eVitals.31—Reperfusion Checklist (May not apply if service area does not use due to
lack of consensus on a standard reperfusion checklist, or acceptance by EMS if used)
4. Spinal Injury/Exam
a. Capacity Assessment Group
b. Back and Spine Assessment Group
i. eExam.13—Back and Spine Assessment Finding Location
ii. eExam.14—Back and Spine Assessment
c. Extremity Assessment Group
i. eExam.15—Extremity Assessment Finding Location
ii. eExam.16—Extremities Assessment
5. 12-lead EKG Acquisition
a. eTimes.06—Unit Arrived on Scene Date/Time
b. eTimes.07—Arrived at Patient Date/Time
c. EKG Rhythm Group [see Vitals section]
d. Attach 12-lead graphic ePCR (through direct integration linkage with EKG monitor or
attachment of scanned printout as allowed/available in software)
e. 12-lead-EKG Procedure-documented under Procedures Performed Group
6. Trauma/Injury
The exam fields have many useful values for documenting trauma (deformity, bleeding,
burns, etc.). Use of targeted documentation of injured areas can be helpful, particularly in
cases of more serious trauma. Because of the endless possible variations where this could
be used, specific fields will not be defined here. Note, however that the exam fields use a
specific and useful Pertinent Negative called “Exam Finding Not Present.” This can be
used to document that the clinician actually performed the assessment but did not find any
injury/abnormality.

Vitals
1. Vitals Date/Time Group
a. eVitals.01—Date/Time Vital Signs Taken
b. eVitals.02—Obtained Prior to this Unit's EMS Care
2. Glasgow Coma Score (GCS) Group
a. Vitals Date/Time Group
b. eVitals.19—Glasgow Coma Score-Eye
c. eVitals.20—Glasgow Coma Score-Verbal
d. eVitals.21—Glasgow Coma Score-Motor
e. eVitals.22—Glasgow Coma Score-Qualifier
f. eVitals.23—Total Glasgow Coma Score
3. EKG Rhythm Group
a. Vitals Date/Time Group
b. eVitals.03—Cardiac Rhythm/Electrocardiography (EKG)
c. eVitals.04—EKG Type
d. eVitals.05—Method of EKG Interpretation
4. Temperature Group
a. Vitals Date/Time Group
b. eVitals.24—Temperature
c. eVitals.25—Temperature Method
5. Pain Scale Group
a. Vitals Date/Time Group
b. eVitals.27—Pain Scale Score
c. eVitals.28—Pain Scale Type
6. Stroke Score Group
a. Vitals Date/Time Group
b. eVitals.29—Stroke Scale Score

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 c. eVitals.30—Stroke Scale Type
7. Additional Vitals Options
All should have a value in the Vitals Date/Time Group and can be documented
individually or as an add-on to basic, standard, or full vitals
a. eVitals.09—Mean Arterial Pressure
b. eVitals.13—Pulse Rhythm
c. eVitals.15—Respiratory Effort
d. eVitals.16—End Tidal Carbon Dioxide (EtCO2)
e. eVitals.17—Carbon Monoxide (CO)
f. eVitals.18—Blood glucose Level
g. eVitals.26—Level of Responsiveness (AVPU)
h. Vitals.32—APGAR
8. Routine Vitals – Includes the following vital signs:
a. Vitals Date/Time Group
b. Blood Pressure
c. eVitals.06—SBP (Systolic Blood Pressure)
d. eVitals.07—DBP (Diastolic Blood Pressure)
e. eVitals.10—Heart Rate
f. eVitals.12—Pulse Oximetry
g. eVitals.14—Respiratory Rate
h. eVitals.26—Level of Responsiveness (AVPU)
i. Pain Scale Group
9. Initial Vitals
a. Routine Vitals
b. eVitals.18—Blood glucose Level
c. Glasgow Coma Score (GCS) Group
d. Temperature Group
10. Full Vitals
a. Initial Vitals
b. eVitals.13—Pulse Rhythm
c. eVitals.15—Respiratory Effort
d. eVitals.16—End Tidal Carbon Dioxide (EtCO2) (If available and applicable)
e. EKG Rhythm Group (If available and applicable)

Medications Given
1. eMedications.01—Date/Time Medication Administered
2. eMedications.02—Medication Administered Prior to this Unit's EMS Care
3. eMedications.03—Medication Given
a. Pertinent Negatives (medication qualifiers) allowed
i. Contraindication Noted
Ii. Medication Already Taken
iii. Denied By Order
iv. Refused
v. Medication Allergy
vi. Unable to Complete
4. eMedications.04—Medication Administered Route
5. eMedications.05—Medication Dosage
6. eMedications.06—Medication Dosage Units
7. eMedications.07—Response to Medication [see Definitions of Medication Response
below]
8. eMedications.08—Medication Complication
9. eMedications.09—Medication Crew (Healthcare Professionals) ID (Name or license #)
10. eMedications.10—Role/Type of Person Administering Medication (License level)

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 Procedures Performed
1. eProcedures.01—Date/Time Procedure Performed
2. eProcedures.02—Procedure Performed Prior to this Unit's EMS Care
3. eProcedures.03 – Procedure
a. Pertinent Negatives Allowed
i. Contraindication Noted
ii. Refused
iii. Denied By Order
iv. Unable to Complete
4. eProcedures.04—Size of Procedure Equipment
5. eProcedures.05—Number of Procedure Attempts (This should always be “1” with each
attempt at a procedure documented separately with appropriate date/time stamp)
6. eProcedures.06—Procedure Successful
7. eProcedures.07—Procedure Complication
8. eProcedures.08—Response to Procedure [see Definitions for Response to Procedures
below]
9. eProcedures.09—Procedure Crew Members ID
10. eProcedures.10—Role/Type of Person Performing the Procedure
11. eProcedures.13—Vascular Access Location (If applicable)

Narrative
The use of the narrative is essential to an effective and complete Patient Care Record. It
summarizes the incident history and care in a manner that is easily digested between
caregivers for continuity of care and provides a place for EMS to document facts that do not
fit into fixed data fields [see Narrative Section under Notes/Educational Pearls (below) for
more detail]

Notes/Educational Pearls
Documenting Signs and Symptoms Versus Clinician Impressions
1. Signs and Symptoms
a. Signs and Symptoms should support the clinician impressions, treatment Protocols and
overall care given. A symptom is something the patient experiences and tells the clinician;
it is subjective. A sign is something the clinician sees; it is objective.
b. Symptoms should not be confused with clinician impressions. The clinician
impressions are the EMS working field diagnosis of the patient’s actual medical
condition.
2. Clinician Impressions
a. There is often a great deal of confusion on the part of EMS clinicians about the
difference between symptoms and clinician impressions. Clinician impressions should
be supported by symptoms but not be the symptoms except on rare occasions where
they may be the same (i.e., weakness when no etiology for the weakness can be
determined by the EMS clinician).
b. Correctly documenting impressions is essential to many aspects of EMS data use, such
as EMS reimbursement, reports of incident types, specialty registries (e.g., CARES)
and CPI reviews. EMS agencies could literally lose money or equipment and staffing
resources if the clinicians are incorrectly entering clinician impressions. Addressing
this issue should be an essential part of the record Quality Assurance and CPI process
and documentation training.
c. Example of documenting symptoms versus impressions:
i. An opiate overdose patient who received naloxone and had a positive
response. This patient would have possible Symptoms of altered mental status,
unconscious, respiratory distress, and respiratory failure/apnea. All 4 of these
symptoms are available as clinician impressions, however the correct impression
for this patient would be whatever variation of “Drug Overdose Opiates or

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 Heroin” impression(s) are setup in the local ePCR system being used. This
impression will specifically define the call as an overdose with opiates, rather
than a case where one of the symptoms was also used as an impression when the
use of naloxone and other assessments and diagnostic tools could not determine
an etiology for the symptom(s).
Narrative
The various data fields within the ePCR are important as they provide a means of uniformly
entering incident data that can be used for importing into billing software or hospital records,
transmitting between EMS systems or creating descriptive reports, or conducting research. In
most cases, at a local, state, or national level, if something wasn’t documented in the
appropriate data field, it didn’t happen or exist. However, the Narrative plays several essential
roles in the PCR.
1. Role of the Narrative
a. Provides an efficient and effective means to share patient information for continuity
of care between EMS services and EMS and hospital staff. The narrative summarizes
the incident history and care in a manner that is easily digested between caregivers.
b. Provides a place for EMS to document facts that do not fit into fixed data fields.
Specifically, this would include the detailed history of the scene, what the patient may
have done or said or other aspects that only the clinician saw, heard, or did. The
Narrative is the place for the EMS clinician to “paint the picture” for all others to
more fully understand the incident.
c. Provides a standard means to add essential details about medical history, exams,
treatments, patient response, and changes in patient condition that can’t otherwise be
effectively or clearly communicated.
2. Narrative Formats
Documentation by EMS clinicians demonstrates a wide variation of training and practice
reinforcement. Most training programs provide limited instruction on how to properly
document operational and clinical processes, and almost no practice. Most clinicians learn
this skill on the job, and often proficient mentors are sparse. Therefore, it is essential that
the EMS clinician uses a standard format to ensure they are consistent and complete in
their documentation. There are three standard formats for EMS documentation. EMS
clinicians should choose the best match for them, master the format, and be consistent in
its use.
a. Medical Narrative: This format is the one most new EMS clinicians use as it is
intuitive and easy to learn. Some more experienced clinicians use it as they find
telling the story from start to finish works best to organize their thoughts. A drawback
to this method is that it is easy to forget to include facts because of the lack of
structure.
b. SOAP: This format stands for Subjective, Objective, Assessment, Plan. This is a
format that is very common in the medical field.
c. CHART: This format stands for Complaint, History, Assessment, Rx (Treatment) and
Transport. Each section’s content is clearly defined and consistent in format. It
minimizes the likelihood of forgetting information and ensures documentation is
consistent between records and clinicians. CHART is the format most recommended
as best practice by EMS legal authorities and is considered the standard in many EMS
systems. A variation is DCHART, where the “D” stands for Dispatch (reason).

Medications Given Showing Positive Action Using Pertinent Negatives

For medications that are required by protocol (i.e., aspirin for cardiac chest pain), pertinent
negatives should be used to show that a medication protocol was considered but was satisfied
by other than clinician action.
Example: EMS is called to a patient for cardiac chest pain. The patient has already taken 324
mg of aspirin by the time EMS arrives per 911 pre-arrival instructions. EMS clinicians should
document this as a medication given, prior-to-arrival, with the best estimated time, and
qualify the medication as “Medication Already Taken” using the pertinent negative.

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Definitions for Response to Medications
1. Improved:
a. The medication had its intended therapeutic effect and the patient's symptoms
decreased or clinical condition improved or resolved (the word "effective" could
generally be substituted for "improved").
b. If a patient had the intended therapeutic response to the medication, but a side effect
that caused a clinical deterioration in another body system, then "Improved" should
be chosen and the side effects documented as a complication (i.e., nitroglycerin
improved chest pain but dropped the blood pressure).
2. Unchanged:
a. The medication was ineffective and had no intended therapeutic effect or had a sub-
therapeutic and unnoticeable effect,
AND
b. The patient condition did not deteriorate.
3. Worse:
a. The patient condition deteriorated or continued to deteriorate because either the
medication:
i. Was ineffective and had no intended therapeutic effect; OR
ii. Had a sub-therapeutic effect that was unable to stop or reverse the decline in
patient condition;
OR
iii. Was the wrong medication for the clinical situation and the therapeutic effect
caused the condition to worsen (i.e., giving glucose to a patient with
hyperglycemia/diabetic ketoacidosis).

Definitions for Response to Procedures

1. Not Applicable:
The nature of the procedure has no direct expected clinical response (i.e., patient
assessment, 12-lead EKG acquisition).
2. Improved:
a. The procedure performed had the intended effective outcome and/or the patient's
symptoms decreased, or clinical condition improved or resolved (i.e., defibrillation
resolved VF into a perfusing rhythm; intubation controlled the airway and allowed
effective management of breathing).
b. An effective procedure that caused an improvement in the patient condition may also
have resulted in a procedure complication and the complication should be
documented (i.e., intubation caused minor airway trauma, but the intubation
successfully secured the airway).
3. Unchanged:
a. The procedure performed did not have the clinical effect intended, but did not
directly worsen the patient's symptoms or clinical condition (i.e., attempted
defibrillation and the person remained in VF); or
b. Had a sub-therapeutic effect and the symptoms continued (i.e., a bandage applied to a
bleeding wound failed to stop the bleeding);
or
c. The nature of the procedure has no direct expected clinical response (i.e., patient
assessment).
NOTE: "Not Applicable" would also be appropriate to choose for these cases 4.
Worse:
a. The results of the procedure performed lead to a worsening of the patient's symptoms
or condition (e.g., defibrillation converted VF into asystole, application of a splint
caused significant increase in pain or loss of sensation and pulses).
b. In the case of worsening condition, documentation of the procedure complications may
also be appropriate.

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 c. NOTE: Just because a patient got worse, doesn’t necessarily mean the clinician
performed the procedure incorrectly.

NEMSIS Data Standards and Limitations

1. NEMSIS is a national dataset and standard used by all American EMS software systems.
(For additional information, go to www.nemsis.org.) Similar datasets are used
internationally in other high performance EMS systems. Currently there are three versions
of the data standard available for documentation and in which data is stored:
a. NEMSIS Version 2.2.1 (v2.2.1)
i. Adopted in 2006, there have been no changes since release
Ii. Most states or systems have used this standard since its release, and the majority
of most states’ data available since approximately 2016 is in this format.
iii. NEMSIS accepted v2.2.1 data through 12/31/2016, and some states may continue
to collect data in this standard until they transition to NEMSIS v3 standards.
b. NEMSIS Version 3 (v3)
i. NEMSIS v3 was created and finalized in 2011 to replace v2.2.1 in order to allow
the dataset to become more flexible for updates and adopt technical standards
making linkage to other health records possible.
1. NEMSIS v3.3.4 was released in March 2014 and was the first version in
production where live data was collected by services and states and
subsequently submitted to NEMSIS. NEMSIS will continue to accept v3.3.4
data until 12/31/2017.
2. NEMSIS v3.4, released in March 2015, included both changed elements and
many added values to existing elements. NEMSIS has been accepting data
from this version concurrently with V3.3.4 data. As of August 2021, v3.4 will
be the only standard and V3.3.4 will be phased out. All documentation
Protocols found in this document are based on the NEMSIS v3.4 dataset and
standard.
2. Mandatory and Required Elements
b. Mandatory: NEMSIS makes certain elements or fields mandatory so, if not included, the
record cannot be properly stored or moved electronically. These fields require real data
and do not accept Nil (Blank) values, Not Values, or Pertinent Negatives.
c. Required: NEMSIS requires these elements or fields to be completed or the record
cannot be properly stored or moved electronically. However, required fields allow Nil
(blank) values, Not Values, or Pertinent Negatives to be entered and submitted.
3. Not Values, Nil, and Pertinent Negatives
b. Not Values (NV), Nil, and Pertinent Negatives (PN) are values that are attributes of
certain NEMSIS elements designed to clarify a null data entry or qualify data entry
into the element with which the NV, Nil, or PN is associated.
c. Not Values available are “Not Applicable” and “Not Recorded”
i. Some NEMSIS rules require one of these values to be entered when data is
imported/exported if there is no other data in a field (e.g., at least one medication
given must have a value, if no medications are given, then the software system
must insert “Not Applicable” in the medications field when exporting)
Ii. At times the EMS clinician use of “Not Applicable” is appropriate
documentation (e.g., using “Not Applicable” under eInjury.03—Trauma Center
Criteria, per the ACS-COT 2022 National Protocol for the Field Triage of Injured
Patients, when transporting a patient with a simple sprained ankle)
d. Nil Values are blank values
i. Values can be left blank, which can either be an accidental or purposeful
omission of data.
ii. Value fields can appropriately and purposefully be left blank if there was nothing
to enter (e.g., a procedure field left blank if no patient was encountered).

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 e. Pertinent Negatives are attributes or qualifiers for both elements and fields. There are
11 possible Pertinent Negative values and the available list for each field varies as
appropriate to the field. Two examples of the use of Pertinent Negatives are:
i. Documenting non-administration of ASA for chest pain by the EMS clinician
with the Pertinent Negative of “Medication Already Taken” to show evidence that
this treatment requirement was met.
ii. Documenting assessment of, and lack of a gunshot wound to the chest with the
qualifier of “Chest --> gunshot wound --> Exam Finding Not Present” in the
examination section (previously you could only document a positive finding of a
gunshot wound with was no way to document that you looked and did not find
one).
4. NEMSIS Element and Value Name Formats
b. NEMSIS Elements/Fields are organized into groups with other related elements/fields
i. There are two parent datasets: Demographic (designated by a “d”) and EMS
(designated by an “e”). The majority of the documentation in any ePCR falls in
the “e” section. The Demographic dataset is intended to be descriptive of the
EMS agencies and system characteristics for correlation at a larger research level,
rather than for use in operational CPI reviews.
ii. The element numbering structure reflects the dataset and the text group name of
the element
5. Example: “eVitals.06—SBP (Systolic Blood Pressure)” where “e” is the EMS dataset and
“Vitals” is the dataset grouping for all elements related to Vitals and the number is the
number assigned to a specific element.
b. “eVitals.06” is used to store the data in the background and “SBP (Systolic Blood
Pressure)” is what clinicians and reviewers see.
c. Values are designated by a code and text name.
i. The codes are generally derived from various sources such as ICD-10,
SNOMED, or RxNorm and are used to store and move the data in the system’s
background.
ii. Codes are not seen by the EMS clinician in the ePCR, but rather the clinician will
see text names.
Some software systems allow the visible text name to be modified or relabeled to
meet local standards or nomenclature; This feature can help improve data quality
by making documentation easier for the clinician.
iii. An example of a value code and name for cardiac chest pain, found under the
element “eProtocols.01—Protocols Used” is “9914117 – Medical-Cardiac Chest
Pain”.
d. All minimum general documentation Protocol requirements are identified using the
NEMSIS element, values codes, and names to allow application across a variety of
ePCR software labels for these fields.
6. Custom Elements/Fields and Values
b. The NEMSIS Standard provides a data format for software vendors to create custom
elements or values requested by states or local systems.
c. States or local systems may create new elements or value extensions for existing
NEMSIS elements to meet regional needs (e.g., adding additional protocol name
values not on the NEMSIS list).

Airway Confirmation Fields

Specific use of the NEMSIS airway confirmation fields in documentation will not be detailed
at this time due to current operational and technical challenges all states, local systems, and
ePCR software vendors are experiencing.
The NEMSIS airway confirmation fields were closely modeled on the “Recommended
Protocols for Uniform Reporting of Data from Out-of-Hospital Airway Management: Position
Statement of the National Association of EMS Physicians” and the fields and values could
provide excellent and appropriately useful data to evaluate airway management. However, the

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technical structure of the fields has made their practical use limited as all the data is collected
as a separate, self-contained group, rather than as part of the procedures group. This means
EMS clinicians would need to enter much of the same information twice in the ePCR, in both
the procedures area and airway confirmation section (when, who did it, what device was used,
and complications). Furthermore, the airway group can only be entered once per ePCR, so the
fields cannot be used again if more than one airway was required (e.g., one airway became
ineffective and needed to be replaced with a different type of airway). Many states and ePCR
software vendors have been struggling with how to make these fields functional for use by
only using a portion of them or looking to add mirrored custom values that are directly linked
to procedures performed. However, solutions are currently far from practical, functional,
effective, or uniform in how they are being implemented or used across various systems

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II. Burn and Burn Fluid Charts
Burn Size Chart 1

Source: Used with permission, University of Utah Burn Center

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Burn Size Chart 2

Source: American Heart Association, Pediatric Advanced Life Support Textbook, 2013

Percentage of Total Body Surface Area by Age, Anatomic Structure, and Body Habitus

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Parkland Formula

For patients who require fluid resuscitation, consider use of the Parkland formula to calculate
the volume of normal saline or lactated Ringer’s solution that should be administered
intravenously to ensure hemodynamic stability.

Volume of Intravenous Fluid required in the first 24 hours (in mL) =

(4 X patient weight in kg) X (Percentage of total body surface area burned)

The first half of the volume of fluid should be administered over the first 8 hours following the
burn with the remaining fluid administered over the following 16 hours.

For pediatric patients, a weight-based assessment tool (length-based tape or other system)
should be used to provide a more accurate estimate of the patient’s weight. Likewise, the total
body surface area (BSA) estimates are different for pediatric patients compared to adults due
to larger head and trunk size. For children, the palmar surface of the hand (not including the
fingers is approximately equal to 1% BSA. The Protocols listed above will provide assistance
during the estimation of the percentage of total body surface area burned for patients of
various ages and body habitus.

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Burn Injury IV Fluid Rates
Infusion Rate > 30 KG

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Burn Injury IV Fluid Rates Fluid
Infusion Rate < 30 KG

Source: Used with permission, University of Utah Burn Center

(https://crisisstandardsofcare.utah.edu).

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III. Neurologic Status Assessment

Neurologic status assessment involves establishing a baseline and then trending any change in patient
neurologic status. Glasgow Coma Score (GCS) is frequently used, but there are often errors in
applying and calculating this score. With this in consideration, Glasgow Coma Score may not be more
valid than a simpler field approach. Either AVPU (Alert, Verbal, Painful, Unresponsive) or only the
motor component of the GCS may more effectively serve in this capacity.

Glasgow Coma Score

AVPU
A: The patient is alert
V: The patient responds to verbal stimulus
P: The patient responds to painful stimulus
U: The patient is completely unresponsive

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IV. Abnormal Vital Signs
Abnormal Vital Signs

V. Evidence-Based Protocols: GRADE Methodology

An Overview of GRADE Methodology
Although engagement in quality EMS research has increased significantly, the demand for
evidence-based quality prehospital research continues to exceed its availability. The need for
evidence-based prehospital patient care protocols was clearly recognized by the Institute of
Medicine of the National Academies and clearly stated in 2007 in The Future of Emergency Care:
Emergency Medical Services at the Crossroads.

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)

methodology is a transparent process where the available research is reviewed and assessed by a
panel of subject matter experts. Following this thorough review process, the available research is
reviewed and graded for its validity based upon the assessment of the workgroup, and an evidence-
based Protocol (EBG) is developed based upon the outcome of the workgroup.

The Federal Interagency Committee on Emergency Medical Services (FICEMS) and the National
EMS Advisory Council (NEMSAC) approved a National Prehospital Evidence-based Protocol
Model Process for the development, implementation, and evaluation of evidence-based Protocols.
This Model Process recommends the use of the GRADE methodology for the Protocol
development tool. The six process steps of the GRADE EBG development tool are:

• Assemble the expert panel and provide GRADE training

• Define the EBG content area and establish the specific clinical questions to address in patient,
intervention, comparison, and outcome (PICO) format
• Prioritize outcomes to facilitate systematic literature searches
• Create GRADE tables (or evidence profiles) for each PICO question
• Vet and endorse GRADE evidence tables and draft recommendations
• Synthesize recommendations into an EMS protocol and visual algorithm

Some evidence-based Protocols cited in this document were created for and released by NHTSA;
however, the GRADE methodology is not proprietary to NHTSA or any other organization. Local,
regional, and state EMS agencies and EMS systems are encouraged to support the ongoing need
for quality prehospital care, improved patient outcome, and the growing demand for EBGs for
EMS.

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VI. 2022 National Protocol for the Field Triage of Injured Patients

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