Paramedic/A-EMT/Basic EMT

Approved 8.1.2013

1
This book is dedicated to the memory of Dr. Darren Bean, Medical Director for the
City of Madison Fire Department, who was instrumental in the development of the
ALS system and expanding Dane County EMS. Dr. Bean died on May 10, 2008 while
on duty transporting a patient in his capacity as a MedFlight physician.

It was Dr. Bean’s vision to have protocols and procedures that were consistent
throughout Dane County, and he worked tirelessly with the Dane County ALS
Service Providers and Dane County EMS to achieve this goal.

In memoriam, we thank Dr. Bean for his vision, energy, and dedication.

2
 Table of Contents-Protocols
Preliminary Information
Overview 6
Acknowledgements 6
Suppositions 6
Authorization 6
General Principles for Medical Care 7
Paramedic Intercept Guidance 10
Medical Transport Destination 11
Physician On Scene 12
Patient Care During Transport 13
Patient Care Standards During Interfacility Transport 14
Radio Report Format 15
Transfer of Care at Hospitals 17
DNR 18
Authorized Pharmaceuticals 19

Adult Protocols
General Approach to All Adult Patients 20
Abdominal Pain/GI Bleeding 23
Airway Emergencies:
Adult Dyspnea 25
Adult Airway Management 30
Rapid Sequence Airway 33
Allergic Reaction 40
Altered Mental Status 43
Behavioral Emergencies/Excited Delirium 46
Bites and Envenomations 48
Cardiac Arrest:
General Approach 50
Asystole 52
Pulseless Electrical Activity (PEA) 54
Ventricular Fibrillation/Pulseless Ventricular Tachycardia 56
Post-Resuscitation Care 58
Hypothermia: Therapeutic/Induced 60
Termination of Resuscitation 63
No Resuscitation Indicated 64
Cardiac Arrhythmias:
Atrial Fibrillation or Flutter 65
Bradycardia 67
Supraventricular Tachycardia 70
Wide-Complex Tachycardia 72
Polymorphous Ventricular Tachycardia (Torsades de Pointes) 75
Chest Pain 77

3
 Table of Contents-Protocols
Hazardous Material Exposures: 81
Cyanide Toxicity and Smoke Inhalation 84
Nerve Agent/WMD 87
Hypertensive Emergencies 89
Hyperthermia 91
Hypothermia 93
Intravenous Access 95
Obstetrics/Gynecology:
Perinatal Emergencies 96
Vaginal Bleeding 99
Childbirth/Labor 102
Overdose and Poisonings:
General Approach 104
Tricyclic and Tetracyclic Antidepressant Overdose 106
Cholinergic Poisoning/Organophosphates 107
Antipsychotics/Acute Dystonic Reaction 108
Beta Blocker Toxicity 109
Calcium Channel Blockers 110
Carbon Monoxide 111
Cocaine and Sympathomimetic Overdose 113
Opiate 114
Pain Management—Adult 115
Policy Custody 118
Taser 119
Refusal of Medical Care 120
Refusal of Transport After Treatment Given:
Bronchospasm Resolved After Nebulizer Treatment 122
Induced Hypoglycemia—Resolved 123
Sedation/Sedative Agent Use 124
Seizure 125
Shock (Non-Trauma) 128
Stroke—Suspected 131
Syncope 134
Trauma:
General Approach to All Patients 137
Burns—Thermal 140
Chest Injuries 143
Head Injuries 144
Eye Injuries 147
Extremity 148
Traumatic Cardiac Arrest 151
Sexual Assault 153
Spinal Immobilization—Indications: 154

4
 Table of Contents-Protocols

Pediatric Protocols
General Approach to All Pediatric Patients 159
Airway Emergencies:
Pediatric Dyspnea 160
Pediatric Airway Management 163
Allergic Reactions—Pediatric 166
Altered Mental Status—Pediatric 168
Apparent Life-Threatening Event (ALTE) 170
Cardiac Arrest:
General—Pediatric 171

Cardiac Arrhythmia:
Pediatric Bradycardia 176
Pediatric Wide Complex Tachycardia with Pulse 179
Pediatric Narrow Complex Tachycardia (SVT) with Pulse 180
Newborn Resuscitation 183
Overdose, Poisoning, or Ingestion—Pediatric 186
Pain Management—Pediatric 188
Seizure—Pediatric 191
Trauma:
Pediatric General 194
Pediatric Burns 196
Pediatric Head Trauma 200

Procedures 203
Pharmaceuticals 259
Abbreviations 316

5
Authorization
In accordance with Wisconsin Statute 256 and Chapter 110 of the Wisconsin Administrative Code,
effective 8/1/2013 the following medical treatment protocols are authorized by the Medical Director for use in
the Dane County EMS System. Changes to these protocols can be made only with authorization of the
Medical Director.

Michael T. Lohmeier, MD
Dane County Medical Director

Overview
The Dane County EMS Protocols contained within this document are intended to provide and ensure uniform
treatment for all patients who receive care from EMS agencies and provider participating in the Dane County
EMS System. These protocols apply exclusively to agencies responding to activation of the 911 system within
Dane County. Any other use must receive prior approval from the Medical Director of Dane County EMS.

While attempts have been made to address all patient care scenarios, unforeseen circumstances and patient
care needs will arise. For these instances medical personnel should follow the “General Approach” protocols
(or other appropriate protocol), exercise their own judgment, and contact Medical Control for additional
physician orders as needed. The patient’s best interest should be the final determinant for all decisions.

Acknowledgements
The Medical Director wishes to thank the following for their hard work and commitment during the
development of these protocols.

Dr. Christian Zuver Dr. Ankush Gosain Meriter Hospital

Dr. Lee Faucher Melissa Schultz St. Mary’s Hospital
Dr. Melissa Schultz Denise DeSerio Stoughton Hospital
Dr. Michael Kim Carrie Meier UW Hospital
Dr. Suresh Agarwal Dane County Medical Advisory Subcommittee VA Hospital

Suppositions
□ The term Advanced EMT is considered a licensed EMT – Intermediate Technician.
□ For the situation of drug shortages, any alternatives to the drugs listed in the protocols must be
approved by medical control before use.
□ BIAD – Blindly Inserted Airway Device. Examples include: King LTS-D – LMA - Combitube

6
The following measures shall be applied to help promote prompt and efficient emergency medical
care to the sick, ill, injured or infirmed. They shall be utilized by EMS personnel in the field, in the
Emergency Department, and when dealing with On-line Medical Control Physicians.

1) The Safety of EMS personnel is paramount. Each scene must be properly evaluated for crew
safety and hazards upon arrival and throughout patient care. Assess the need for additional
public safety resources as soon as possible after arrival.

2) Proper Personal Protective Equipment and Body Substance Isolation must be utilized
according to agency and industry standard.

3) A patient is any person who is requesting and/or in need of medical attention or medical
assistance of any kind.

4) A patient care encounter shall be considered any event when subjective or objective signs or
symptoms, or a patient complaint, results in evaluation or treatment.

5) All patients in the care of EMS shall be offered transport by ambulance to the nearest
appropriate hospital, regardless of the nature of the complaint. In the event a patient for whom
EMS has responded to refuses transport to the hospital, a properly executed refusal process
must be completed.

6) In accordance with system guidelines, the only appropriate transport destination for EMS
patients transported by ambulance is an Emergency Department. Exceptions to this are
outlined within the specific protocols. Additional details concerning hospital destination based
on clinical criteria are outlined in specific protocols.

7) For all 911 calls, upon initial patient contact, be prepared for immediate medical intervention
appropriate for the call level (defibrillation, airway management, drug therapy, etc.)

8) Upon arrival at a scene where an initial EMS crew is rendering patient care, all subsequent
arriving EMS crews should immediately engage the on-scene crew. The goal is to determine
the status of assessment and seamlessly assist in patient care.

9) Prior to the transfer of care between crews, the provider rendering initial care should directly
interface with the provider assuming care, to ensure all pertinent information is conveyed.

10) For all patients in cardiac arrest, call into dispatch with the “patient contact time” at the time of
initial patient contact, and with the “first shock time” at the time of initial defibrillation.

11) Try to always obtain verbal consent prior to treatment. Respect the patient’s right to privacy
and dignity. Courtesy, concern and common sense will ensure the best possible patient care.

Service MD Approval:______

General Principles 1 of 3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

7
Continued:

12) The provider should generally be able to decide within three (3) minutes after patient contact if
advanced life support (ALS) measures will be needed.
If identified by EMT Basic or Advanced, ALS should be requested immediately.
If identified by Paramedic, ALS measures should be instituted simultaneously with the initial
assessment. A comprehensive exam is appropriate after the patient has been stabilized.

13) Generally, initial assessment and therapy should be completed within 10 minutes after patient
contact. Except for extensive extrication, or atypical situations, trauma patients should be en
route to the receiving facility within 10 minutes and medical patients should be en route to the
receiving facility within 20 minutes. Additional therapy, if indicated, should be performed during
transport.

14) For all 911 calls where EMTs and Paramedics are in attendance, the Paramedic shall make
final patient care decisions.

15) Prior to the administration of medication, assess for the possibility of medication allergies. If
any questions arise in reference to medication allergies, contact on-line Medical Control prior to
giving any medications.

16) When caring for pediatric patients, use the Broselow-Luten® weight/length based system to
determine medication dosages and equipment sizes.

17) An EMS Patient Care Report will be generated at the conclusion of each patient encounter.
Patient care reports should be transmitted to the receiving hospital in accordance with state
requirements.

18) For cases that do not exactly fit into a treatment category, refer to the general illness protocol
and contact OLMC as needed.

19) Following training and successful competency assessment by their respective agencies, those
licensed at the EMT-Basic, Advanced and Paramedic level are authorized to:
□ Apply tourniquets
□ Utilize pulse oximetry
□ Utilize capnography monitoring devices
□ Perform blood glucose evaluations
□ Perform CPAP
□ Place and ventilate blind insertion airway devices (BIAD)
□ Place and utilize orogastric tubes via the gastric port of a BIAD
□ Acquire and transmit 12 Lead ECGs
Individual Agencies must request and receive State of WI approval prior to implementation of these
skills.

Service MD Approval:______

General Principles 2 of 3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

8
20) To perform as a Basic EMT/ A-EMT/ Paramedic, personnel must be knowledgeable and
proficient in the scope of practice described and taught in the National Scope of Practice
Standardized Curriculum, approved by the Wisconsin EMS Unit, and must maintain active
state licensure.

21) Members of your service who are credentialed with and function on your service with an RN,
PA, or MD license may only practice within the scope of the agency’s license.

22) Perform all procedures as per the Dane County EMS System Procedures manual. If a
procedure that is not addressed in the manual is deemed necessary, contact OLMC for orders
prior to proceeding.

23) If OLMC gives orders for performance of a procedure that is not covered in the Dane County
EMS system Procedures Manual, but is within the providers scope of practice, follow the
National Standard Curriculum.

24) For all patients requiring the administration of narcotics or sedative agents, continuous cardiac,
oxygen saturation, and ETCO2 monitoring shall be performed.

25) The Poison Control Center should be contacted when handling calls involving poisonous/
hazardous material exposures, overdoses or suspected envenomation. In the event that the
Poison Control Center gives recommendations or orders that are not contained within these
protocols, EMS providers are authorized to carry out their instructions. The Poison Control
Center can be reached at 1.800.222.1222

26) All defibrillators used in the Dane County EMS System must be able to deliver biphasic energy.

27) When using supplemental oxygen in accordance with adult or pediatric treatment protocols,
adhere to the following:
a) In patients who are non-critical, and have no evidence of respiratory distress, use
only the concentration of oxygen needed to achieve oxygen saturation over 93%.
Typically this may be accomplished by the use of a nasal cannula.
b) For patients with serious respiratory symptoms, persistent hypoxia, or where
otherwise specified by protocol, use 100% supplemental oxygen via non-
rebreather mask or BVM. Use caution in instances of rising end-tidal CO2.

28) Precautions:
Droplet precautions: standard PPE, a standard surgical mask for providers who accompany patients in the
back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be
utilized when influenza, meningitis, mumps, streptococcal pharyngitis, pertussis, and other illnesses spread via
large particle droplets are suspected.
Contact precautions: standard PPE, a gown, change of gloves after every patient contact, and strict
handwashing precautions. This level of precaution is utilized when multi-drug resistant organisms (ie. MRSA),
scabies, zoster (shingles), or other illness spread by contact are suspected.
Airborne precautions: standard PPE, N95 mask on EMS personnel and surgical mask or NRB O2 mask on
patient. This level is used if tuberculosis is suspected.
Service MD Approval:______

General Principles 3 of 3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

9
 Standards Policy

Policy:

To define the circumstances in which a Paramedic should be requested to intercept with an

ambulance not staffed with a Paramedic and to provide guidance for the intercept process.

If the Paramedic’s estimated time of arrival is longer than the time it would take to transport the
patient to the hospital via BLS ambulance, the patient should be transported without delay. In general
BLS should not wait on scene for ALS.

Types of Patient Problems that MAY require Paramedic Intercept:

a) Cardiopulmonary arrest
b) Unconsciousness that does not respond to glucose administration
c) Difficulty breathing/compromised airway
d) Multi-system trauma
e) Chest Pain – suspected cardiac
f) Diabetic with persistent altered level of consciousness
g) Patients with unstable or deteriorating vital signs
h) Active persistent seizures, first seizure, or seizure following head trauma
i) Significant allergic reaction
j) Childbirth complications
k) Any other situation in the opinion of the BLS provider or Medical Control that may
benefit from advanced level care.

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

10
 Standards Policy

All patients should be transported to the hospital of their choice (when operationally feasible) unless
the patient is unstable.

All patients whose condition is judged to be unstable will be transported to the closest appropriate
receiving facility.

If several hospitals are within the same approximate distance from the scene. Allow the patient, and/
or patients’ family to select the receiving facility of their choice.

For transport destination of Stroke, STEMI, Trauma, or OB (>20weeks) patients, refer to the
appropriate protocol.

At the time of protocol publication the following centers have appropriate credentialing:

Stroke:
Meriter
St. Mary’s – Madison
UW Hospital
VA Hospital

STEMI:
Meriter
St. Mary’s – Madison
UW Hospital
VA Hospital

Trauma:
UW Hospital

OB:
Meriter
St. Mary’s – Madison
Sauk Prairie

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

11
 Standards Policy

Policy:

The control of the scene of an emergency should be the responsibility of the individual in attendance
who is the most appropriately trained in providing pre-hospital stabilization and transport. As a
representative of the Medical Director of an EMS system, the pre-hospital provider fulfills that role.

Occasions will arise when a Physician on the scene will desire to direct prehospital care. A
standardized scheme for dealing with these contingencies will optimize the care given to the patient.

The Physician desiring to assume care of the patient must:

□ Provide documentation of his/her status as a physician (MD or DO) to include a current
copy of his/her license to practice medicine in Wisconsin.
□ Assume care of the patient and allow documentation of his/her assumption of care on
the patient care report.
□ Agree to accompany the patient during transport to the hospital.

Contact with Medical Control must be established as soon as possible. The Medical Control
Physician must agree and relinquish the responsibility of patient care to the physician on-scene, in
order for care to be transferred.

Orders provided by the Physician assuming responsibility for the patient should be followed as long
as they do not, in the judgment of the pre-hospital provider, endanger patient well-being. The pre-
hospital provider may request the Physician to attend to the patient during transport, if the suggested
treatment varies significantly from standing orders.

If the physician's care is judged by the pre-hospital provider to be potentially harmful to the patient,
the provider should:
□ Politely voice his/her objection.
□ Immediately place the on-scene physician in contact with the Medical Control Physician.

When conflicts arise between the physician on scene and the Medical Control Physician, EMS
personnel should:
□ Follow the directives of the Medical Control Physician.
□ Offer no assistance in carrying out the order in question; offer no resistance to the
physician performing this care.
□ If the physician on scene continues to carry out the order in question, offer no resistance
and enlist the aid of law enforcement.

All interactions with physicians on the scene must be completely documented in the Patient Care
Report, including the name and license number of the on-scene physician.

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

12
 Standards Policy

The following situation shall require > 1 attendant in the back of an ambulance.

Medical or Traumatic cardiac arrest or post-resuscitation care

Patients requiring active airway assistance (ETT, BIAD, BVM)
Imminent delivery
For scenarios not covered above:
□ if the provider requests a second attendant.

A second attendant is not required if there will be an unacceptable delay in transport.

NOTE: Only a student with a current training permit at the appropriate level of care may assist
with patient care.

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

13
 Standards Policy

This policy can ONLY be used if your agency has State approval to provide
Interfacility Transport.

Although primary responsibility is not for interfacility transports, situations may arise necessitating
such transport
Regardless of the provider, interfacility transport requires unique skills and capabilities, both in
clinical and operational coordination. Adhere to the following standards for all interfacility
transports:

□ Interfacility transport decisions (including but not limited to transport staffing, equipment and
transport destination) should be made on the patient’s medical needs.

□ Match provider skills and equipment with patient care needs

□ Coordination between hospitals and interfacility transporters is essential before transport is

initiated to ensure that patient care is provided at the appropriate level and does not exceed
the capabilities of the interfacility transport provider.

□ If EMS crewmembers are not capable/skilled in managing devices or medications, or if the

devices/medications are not listed in these protocols and must be continued during transport,
an adequately trained care provider from the transferring facility whose credentials are
acceptable to the transporting agency must accompany the patient during transport.

Contact Medical Control with any questions or concerns

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

14
 Standards Policy

For all patients transported by EMS, radio contact should be made with the receiving facility prior to
arrival. When possible, in order to provide sufficient notification of the patient’s condition and
estimated time of arrival, radio contact should be made at least 5 minutes prior to arrival.

Use the following triage categories and triage levels (colors) to assist the receiving facility in
prioritizing incoming calls.

TRIAGE CATEGORIES

Categories Definitions
Trauma indicates patient is a trauma patient
Medical indicates patient is a medical patient
Red High acuity of illness or injury, unstable or critical
Yellow Serious condition, but not critical or unstable
Green Low acuity of illness or injury
STEMI alert meets STEMI criteria per Chest Pain protocol
Stroke alert meets stroke alert criteria as per Stroke protocol
indicates patient is <12 years of age (medical) or less than
Pediatric 18 years of age (trauma)
Haz‐Mat indicates patient was involved in a Haz/Mat incident
PNB Cardiopulmonary Arrest
MD's Orders Indicates physican orders are needed

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

15
 Standards Policy

Radio Call to an Emergency Department

Begin each transmission with the following:

□ Agency name and unit number
□ Triage category and triage level (ie. Medical Red, STEMI alert)
□ Estimated time of arrival

After the receiving facility acknowledges the initial information, give a concise report which
includes the following:
□ Repeat the triage category and triage level
□ Age and gender of patient
□ Chief complaint or problem
□ Provide pertinent detail as to the following:
~vital signs
~glasgow coma score/level of consciousness
~mechanism of injury (if trauma)
~description of injuries (if trauma)
~treatment provided or under way
~any anticipated delay in transport (ie. extrication)

MEDICAL CONTROL CONTACT

Contact Medical Control for any additional orders or with questions needed to meet the patient’s
needs during on-scene care or transport
Any quality concerns involving Medical Control should be forwarded to the Dane County Medical
Director for review as soon as possible.

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

16
 Standards Policy

Once on hospital property, the receiving facility assumes responsibility for all further medical care
delivered to EMS transported patients. Dane County EMS personnel are not authorized to follow pre-
hospital protocols after arrival at an Emergency Department and OLMC should not be contacted for
orders.

Exceptions to this should occur only in the following circumstances:

Life-threatening situations such as cardiac arrest, airway emergencies or imminent delivery of

a newborn.
Continuation of treatment started prior to arrival (ie. Nebulizers, CPAP, IV fluids)
When specifically instructed to continue care by the ED physician (when possible document
the physician’s name and the time the verbal order was given)

To assure all known pertinent information is conveyed to the hospital staff, crews should interface with
nursing staff promptly to give a verbal report and written report**. Transporting personnel shall
provide to the receiving facility all known pertinent incident, patient identification and patient care
information at the time the patient is transferred. In addition turn over all pre-hospital 12 lead EKGs to
the ED staff. Patient care reports may be transmitted by physical (paper) means or electronic means.

NOTE: ** Administrative Rule 110.34(7) states, “...submit a written report to the receiving
hospital upon delivering a patient and a complete patient care report within 24 hours of patient
delivery. A written report may be a complete patient care report or other documentation
approved by the department and accepted by the receiving hospital.”

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

17
 Standards Policy

Policy:

To clarify State of Wisconsin Do Not Resuscitate:

If a patient is found to be wearing a Wisconsin “Do-Not-Resuscitate” DNR bracelet, no

resuscitative measure should be undertaken, including compressions, artificial
ventilation, defibrillation, or the use of advanced airways.

Emergency Provider as appropriate will provide: Emergency Provider will NOT provide:
Clear airway Control bleeding Perform chest compressions
Administer Oxygen Provide pain medication Insert advanced airways
Position for comfort Provide emotional support Administer cardiac resuscitation drugs
Splint Provide ventilatory assistance
Defibrillate

Any other forms must be validated by contacting

Medical Control before stopping any resuscitative efforts

Service MD Approval:______

Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

18
 Authorized Pharmaceuticals

Generic Name Trade Name Route Levels

Adenosine Adenocard IV/IO P
Albuterol Proventil Nebulized EMT, A, P
Amiodarone Cordarone IV/IO P
Aspirin PO EMT, A, P
Atropine IV/IO P
Calcium Chloride IV/IO P
Dextrose (5%, 12.5%, 25%, 50%) IV/IO A, P
Diazepam Valium, Diastat PR/IM P
Diltiazem Cardizem IV/IO P
Diphenhydramine Benadryl IV/IO/IM P
Dopamine Intropin IV/IO P
DuoDote Kit IM P
Epinephrine 1:1,000 Adrenaline IM EMT, A, P
Epinephrine 1:10,000 Adrenalin IV/IO P
Etomidate Amidate IV/IO P
Famotidine Pepcid IV/IO P
Fentanyl Sublimaze IV/IO/IN P
Glucagon GlucaGen IV/IM EMT, A, P
Glucose, Oral Glutose PO EMT, A, P
Haloperidol Haldol IM P
Hydroxocobalamin Cyanokit IV/IO P
Ipratropium Bromide Atrovent Nebulized EMT, A, P
Ketamine Ketalar IM P
Lidocaine 2% Xylocaine IV/IO P
Lorazepam Ativan IV/IM P
Magnesim Sulfate 10% IV/IO P
Mark 1 Kit IM P
Methylprednisolone Solu‐Medrol IV/IO P
Midazolam Versed IV/IM/IN P
Morphine Sulfate IV/IO P
Naloxone Narcan IV/IO/IM/IN A, P
Nitroglycerin Nitrostat, Nitrolingual SL A, P
Ondansetron Zofran IV/IO/ODT P
Rocuronium Zemuron IV/IO P
Sodium Bicarbonate 8.4%, 4.2% IV/IO/Nebulized P
Succinylcholine Anectine IV/IO P
Vassopressin Pitressin IV/IO P

19
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Scene Safety
-Bring all necessary equipment to patients side
‐Demonstrate professionalism and courtesy

PPE (consider contact, droplet, or airborne)

Initial Assessment
BLS Maneuvers
CARDIAC ARREST
Consider Spinal Immobilization

General Protocol
If Pediatric Patient – use Broselow Tape
Cardiac Arrest Protocol
Airway Protocol

Vital Signs**

Consider supplemental O2

Consider 12 Lead EKG* and/or

2013
cardiac monitor

IV Protocol if appropriate ***

Appropriate PROTOCOL
Patient doesn’t fit a protocol or you have
M exhausted standing protocols? M
Transport patient per Transport Destination policy Consult Medical Control

Service MD Approval:______

Pearls
RECOMMENDED EXAM: Vital signs, mental status with GCS and location of injury or complaint…..then to specific protocol
*12 Lead EKG should be done EARLY on a possible STEMI patient.
**Vital signs include
Blood Glucose Reading – if any weakness, altered mental status or history of diabetes.
Oxygen Saturation and Capnography if condition warrants
Nothing by mouth, unless patient is a known diabetic with hypoglycemia and able to self‐administer oral glucose paste or a
glucose containing beverage or unless indicated by specific protocol.
***if evidence of dehydration or BP<90mmHg systolic administer 250ml 0.9% NaCl and refer to appropriate protocol. If
hypoglycemic refer to altered level of consciousness protocol.
Any patient contact which does not result in an EMS transport must have a completed refusal form.
Required vital signs on every patient include blood pressure, pulse, respirations, pain‐severity.
Pulse oximetry and temperature documentation is dependent on the specific complaint
Timing of transport should be based on the patients clinical condition and the transport policy.
Never hesitate to consult medical control for patient who refuses
Orthostatic vital sign procedure should be performed in situation where volume status is in question.

General Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

20
 General Approach to All Adult Patients
The following measures will serve as the “General Patient Care Protocol—Adult”
and apply to the management of all adult patients.

All Providers
 Scene Safety
 PPE (consider contact, droplet, and/or airborne)
 Initial assessment (BLS maneuvers and consider c-spine immobilization)
 Establish patent airway
 Provide Supplemental oxygen to maintain SpO2 ≥ 93 %, or if any respiratory
signs or symptoms present
 Obtain, record and monitor vital signs
 Perform a 12-lead ECG if chest pain, abdominal pain above the umbilicus or
ischemic equivalent symptoms
 Record and monitor continuous O2 saturation and Capnography (if available)
if condition warrants
 Record Blood Glucose Level if any weakness, altered mental status or history
of diabetes
 Nothing by mouth, unless patient is a known diabetic with hypoglycemia and
is able to self-administer oral glucose paste, or a glucose containing
beverage:
 Glucose paste 15 g or other oral glucose agent (e.g. orange juice) if
patient alert enough to self administer oral agent
 Transport patient to nearest appropriate Emergency Department
 Minimize on-scene time when possible

Advanced EMT
 Consider IV 0.9% NaCl TKO/KVO or IV lock
 If evidence of dehydration (tachycardia, dry mucous membranes, poor
skin turgor) or hypovolemia, administer boluses of 0.9% NaCl at 250
ml (up to 500 ml total if no hypotension)
 If BP<90 mmHg systolic, administer boluses of 0.9% NaCl at 250 ml
until systolic BP>90 mmHg, max individual dose 2 L
▪ Contraindicated if evidence of congestive heart failure
(e.g. rales)
▪ If Hypoglycemic (Blood glucose < 70 mg/dL) with IV
access:

21
 o Dextrose 12.5-25g or D10W 100ml
 Repeat Dextrose once if blood glucose <70
mg/dL after 10 minutes
 If Hypoglycemic (Blood glucose < 70 mg/dL) without IV access
 Glucose paste 15 g or other oral glucose containing agent (e.g.,
orange juice) if patient alert enough to self administer oral agent
 If unable to take oral glucose administer Glucagon 1 mg IM

Paramedic

 When condition warrants (specified as “Full ALS Assessment and Treatment “

in individual protocols)
 Advanced airway/ventilatory management as needed
 Perform cardiac monitoring
 IV 0.9% NaCl TKO/KVO or IV lock
 If evidence of dehydration (tachycardia, dry mucous
membranes, poor skin turgor) or hypovolemia, administer
boluses of 0.9% NaCl at 250 ml (up to 500 ml total if no
hypotension)
 If BP<90 mmHg systolic, administer boluses of 0.9% NaCl at 250 ml
until systolic BP>90 mmHg, max individual dose 2 L
 Contraindicated if evidence of congestive heart failure
(e.g. rales)
 If Hypoglycemic (Blood glucose < 70 mg/dL) with IV
access:
o Dextrose 12.5g-25g IV or D10W 100mL IV
 Repeat Dextrose 12.5-25 g once if blood
glucose <70 mg/dL after 10 minutes

 If Hypoglycemic (Blood glucose < 70 mg/dL) without IV access

 Glucose paste 15 g or other oral glucose containing agent (e.g.,
orange juice) if patient alert enough to self administer oral agent
 If unable to take oral glucose administer Glucagon 1 mg IM

Contact Medical Control with any additional orders or questions

22
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Age Pain Pneumonia or PE
Past Medical/surgical history Tenderness Liver (hepatitis, CHF)
Medications Nausea Peptic Ulcer disease / Gastritis
Onset Vomiting Gallbladder
Provocation Diarrhea MI
Quality Dysuria Pancreatitis
Region / Radiation / Referred Constipation Kidney Stone
Severity 1‐10 Vaginal Bleeding/Discharge Abdominal Aneurysm
Time Pregnancy Appendicitis
Fever

Medical Protocol
Other Symptoms: Bladder/prostate disorder
Last meal eaten Fever, Headache, Pelvic
Last bowel movement Weakness, malaise, myalgias, Spleen enlargement
Menstrual history (pregnancy) cough, Diverticulitis
Headache, rash, mental status Bowel obstruction
change Gastroenteritis

General Approach to All Adult Patients

A IV Protocol A

2013
<90mmHg Blood Pressure

>90mmHg
Normal saline bolus
A 500 ml (max 2L)
A Nausea and/or vomiting Yes

If severe
No
P Ondansetron (Zofran) P
4 mg IV/IM/ODT
Consider
Chest Pain Protocol
Pain Control Protocol

Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Neck, Heart, Lung, Abdomen, Back, Extremities, Neuro
Nothing by mouth
If pain is above the umbilicus, perform 12‐Lead EKG, refer to CHEST PAIN PROTOCOL if indicated
Abdominal pain in women of childbearing age should be treated as ectopic pregnancy until proven otherwise
The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50
Repeat vital signs after each bolus
Appendicitis may present with vague, peri‐umbilical pain which migrates to the RLQ over time
Increased initial NS Bolus of 500ml approved by Medical Advisory subcommittee to accommodate volume loss from GI bleed.

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
23
 Abdominal Pain/GI Bleeding
All Providers
 General Patient Care Protocol—Adult
 Nothing by mouth
 If pain is above the umbilicus, perform 12-lead EKG, refer to Chest Pain
Protocol if indicated.

Advanced EMT
 Consider IV Protocol
 Consider Fluid Bolus-500ml NS (max 2 liters)

Paramedic
 Full ALS Assessment and Treatment
 For Patients with severe nausea or vomiting:
 Ondansetron (Zofran), 4 mg IV/IM/Oral Disintegrating Tablet (ODT)
 Refer to Pain Management Protocol if indicated

Contact Medical Control for any additional orders or questions

24
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

Differential
Asthma
Signs and Symptoms
History: Anaphylaxis
Shortness of breath
Asthma; COPD – Aspiration
Pursed lip breathing

Medical Protocol
chronic bronchitis, COPD (Emphysema,
Decreased ability to
emphysema, CHF Bronchitis)
speak
Home treatment Pleural effusion
Increased respiratory
(oxygen, nebulizer) Pneumonia
rate and effort
Medications Pulmonary embolus
Wheezing, rhonchi
(theophylline, steroids, Pneumothorax
Use of accessory
inhalers) Cardiac (MI and CHF)
muscles
Toxic exposure, smoke Pericardial tamponade
Fever, cough
inhalation Hyperventilation
Tachycardia
Inhaled toxin (Carbon
Monoxide, etc)

2013
Drowning/Near Drowning
Foreign body obstruction
Carbon monoxide poisoning

Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
* Online Medical Control if age >50, HR >150 or History of Coronary Artery Disease
**CPAP – start at 5cm of H2O and titrate up to maximum 15cm of H2O for effect
***Nitro contraindication use of Phosphodiesterase-5 (PDE-5) inhibitor within last 24 hours (Viagra,
Levitra); 48 hours (Cialis)
Position Patient for Comfort
If cardiac origin a possibility and no contraindication, administer Aspirin 324 mg PO

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

25
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

General Approach to all Adult Patients

Airway Adult Assess Airway Patency Airway Obstruction

APNEA OBSTRUCTION
Protocol Breathing Adequacy Procedure
INSUFFICIENT SUFFICIENT

Fatigue Consider CPAP

RR <10 or >20 VS, SpO₂, EtCO₂ EtCO₂ >45

Medical Protocol
Altered LOC Procedure**

NO YES SpO₂ <93%

Consider CPAP Supplemental O₂ NO

Procedure
Reassess VS, RR, SpO₂,
Consider Airway EtCO₂
Adult Protocol

Wheezing? NO History of CHF, rales,

peripheral edema,
YES HTN, pink sputum

2013
Acute Bronchospasm Albuterol 2.5mg/3ml YES
Ipratropium 0.5mg/2.5ml
Repeat Albuterol x2 (max 3 doses) Pulmonary
A IV Protocol A Edema
SEVERE

MethylPrednisolone No Speaking ASA 324mg PO

P 125mg IV P SEVERE
Little/no air movement 12 Lead EKG

NO Improvement SEVERE

Magnesium Sulfate 2g IV in Epinephrine 1:1,000* IV Protocol

P 100ml D5 over 20 min. P 0.3mg IM
A Nitroglycerin 0.4mg SL every A
AWAKE and following commands
3 minutes if SBP >90mmHg
and no PDE***
Consider CPAP AWAKE and
Procedure** following commands

Ondansetron 4mg IV/IO

Morphine 5‐10mg IV if SBP
P >150mmHg P
Dopamine 5‐20mcg/kg/min if
Consult Medical SBP <90mmHg
M Control M

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
26
 Airway Emergencies: Adult Dyspnea
All Providers
 General Patient Care Protocol—Adult
 Supplemental oxygen to maintain SPO2 > 93%
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer if wheezing or history of
Asthma/COPD. Albuterol may be repeated to a maximum of 3
administrations.
 If symptoms Severe (not speaking, little or no air movement) consider
 Epinephrine 1:1000, 0.3mg IM, if available
 OLMC if Age >50, HR>150 or History of CAD
 Perform obstructed airway procedures per BLS standards.
 Consider CPAP if available and symptoms are moderate to severe
 If history of Asthma or COPD, Start at 5cm of H2O and titrate up to
maximum 10 cm of H20 for effect
 If cardiac origin a possibility and no contraindication, administer Aspirin 324
mg PO

Advanced EMT
 Consider IV Protocol if indicated
Acute Pulmonary Edema Suspected
 (History of CHF, peripheral edema elevated SBP)
 Nitroglycerin 0.4 mg SL every 3 min:
o Contraindicated if SBP <90 mmHg
o Contraindicated if use of a Phosphodiesterase-5 (PDE-5) inhibitor
within last 24 hours (Viagra, Levitra); 48 hours (Cialis)
 Aspirin 324 mg PO
 Consider CPAP if symptoms moderate/severe:
o Start at 5cm of H2O and titrate up to maximum 15 cm of H20 for effect

27
Paramedic
 Full ALS Assessment and Treatment
 Observe for signs of impending respiratory failure: Refer to Airway
Management Protocol if indicated:
 Hypoxia (O2 sat < 90%) not improved with 100% O2
 Poor ventilatory effort
 Altered mental status/decreased level of consciousness
 Inability to maintain patent airway

Acute Bronchospasm (wheezing with or without history of Asthma or COPD)

 Mild Symptoms:
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer if not already given
 May repeat Albuterol (Proventil) PRN for continued wheezing
 Moderate Symptoms:
 As for mild symptoms, additionally:
 Methylprednisolone (Solumedrol) 125 mg IV if wheezing
persists after 1st nebulizer treatment
 Consider CPAP if symptoms moderate to severe
 Start at 5cm of H2O and titrate up to maximum 10 cm of H20 for
effect
 Severe Symptoms (not speaking, little or no air movement):
 As above, additionally:
 Epinephrine 0.3 mg 1:1000 IM
 OLMC if age >50, HR>150 or history of CAD
 Magnesium Sulfate 2 g IV in 100 ml D5W over 10 min
 Do not use if CHF or history of Renal Failure
Acute Pulmonary Edema Suspected
 (History of CHF, peripheral edema elevated SBP)
 Nitroglycerin 0.4 mg SL every 3 min:
 Contraindicated if SBP <90 mmHg
 Contraindicated if use of a Phosphodiesterase-5 (PDE-5) inhibitor
within last 24 hours (Viagra, Levitra); 48 hours (Cialis)
 Aspirin 324 mg PO
 Consider CPAP if symptoms moderate/severe:
 Start at 5cm of H2O and titrate up to maximum 15 cm of H20 for effect

28
  If SBP > 150 consider Morphine Sulfate 5-10 mg IV
 For Hypotension (systolic BP <90 mmHg):
 Consider Dopamine infusion at 5-20 mcg/kg/min titrated to maintain
SBP >90 mmHg
 If severe nausea or vomiting:
 Ondansetron (Zofran) 4 mg IV/IO/ODT
 For bronchospasm (wheezing) associated with Acute Pulmonary Edema:
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer
 May repeat Albuterol (Proventil) PRN for continued wheezing
 Consider Airway Management Protocol

Drowning/Near Drowning
 Full ALS Assessment and Treatment
 Spinal Immobilization if indicated
 Protect from heat loss
 Patients may develop delayed onset respiratory symptoms:
 Consider CPAP for patients with significant dyspnea or hypoxia
 Start at 5cm of H2O and titrate up to maximum 15 cm of H20 for
effect
 Airway Protocol as needed
 Refer to appropriate protocol if cardiac arrest present

Contact Medical Control for any additional orders or questions

 Acute Bronchospasm: Contact Medical Control prior to Epinephrine
administration if:
 Age > 50 years
 Heart Rate >150
 History of Coronary Artery Disease

29
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M Assess ABC’s
Basic Maneuvers First
-Respiratory Rate
Supplemental ‐open airway
‐Effort INADEQUATE
Oxygen ADEQUATE ‐suction
‐Adequacy
Maintain SPO2 >93%
‐nasal or oral airway
Pulse Oximetry
Awake and
Altered, Apneic
Protecting Airway

UNSUCCESSFUL BVM SUCCESSFUL Consider CPAP

Airway Protocol
OBSTRUCTION

P P Airway Obstruction Procedure SUCCESS

Continue BVM
BIAD OR RSA Maintain SpO₂ >93%
x2 x2

NO Resume BVM GOOD AIR EXCHANGE

Success < 2 attempts
NO AIR EXCHANGE
YES
NO CHEST RISE
LEMON
Confirm Airway Placement

2013
Look externally
ETCO2 and Exam
M Percutaneous Cricothyrotomy M Evaluate with the
3:3:2 rule
(surgical airway) Mallampati
Post Placement Management P Simultaneously Contact Medical Control P classification
Obstruction
Gastric Decompression Neck Mobility

Transport to Closest Facility

Consult Medical
M Control M
Pearls
If capnography is available it is expected to be used with all methods of intubation. Document results
If an effective airway is being maintained by BVM with continuous pulse oximetry values of >93%, it is acceptable to continue
with basic airway measures instead of using a Blind insertion device or intubation.
For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation
An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the
nasal passage
Ventilatory rate should be 10‐12 per minute to maintain an ETCO2 of 35‐45. Avoid hyperventilation
Quality assurance should always be completed after the use of blind insertion device or intubation
Maintain C‐spine immobilization for patients with suspected spinal injury
Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
Sellick’s and or BURP ( Backwards, Up, Rightward Pressure) maneuver should be used to assist with difficult intubations
Consider Endotracheal Introducer (Bougie) for incompletely visualized airway.
Hyperventilation in deteriorating head trauma should only be done to maintain an ETCO2 of 30‐35
Gastric tube placement should be considered in all intubated patients if available
It is important to secure the endotracheal tube well and consider c‐collar to better maintain ETT placement
Suction all debris, secretions from the airway if necessary
Service MD Approval:______

Airway Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

30
 Airway Emergencies: Adult Airway Management
All Providers
 General Patient Care Protocol—Adult
 Supplemental oxygen to maintain SPO2 > 93%
 If suspicion of trauma, maintain C-spine immobilization.
 Suction all debris, secretions from the airway if necessary
 Consider CPAP if protecting airway and awake
 If history of Asthma or COPD, Start at 5cm of H2O and titrate up to
maximum 10 cm of H20 for effect
 If no history of Asthma or COPD, Start at 5cm of H2O and titrate up to
maximum 15 cm of H20 for effect
 Perform Basic Airway Maneuvers: open airway, nasal/oral airway; BVM if
needed.
 BVM:
 Ventilate once every 5-6 seconds (10-12 times/minute)
 If signs of airway obstruction refer to appropriate protocol
 If patient does not respond to above measures or deteriorates consider
advanced airway placement
 Monitor oxygen saturation and end-tidal CO2 continuously

Advanced EMT
 Consider IV Protocol if indicated
Paramedic
 Full ALS Assessment and Treatment
 Follow algorithm if invasive airway intervention is needed (BIAD/ETT):
 Apnea
 Decreased level of consciousness with respiratory failure (i.e. hypoxia
[O2 sat < 93%] not improved by 100% oxygen, and/or respiratory rate
< 8)
 Poor ventilatory effort (with hypoxia not improved by 100% oxygen)
 Unable to maintain patent airway
 Follow appropriate procedure (Video Laryngoscopy, King LTS-D,
Direct Laryngoscopy, etc)

31
 Following placement of the ETT/BIAD confirm proper placement:
 Observe for presence of alveolar waveform on capnography
 Assess for absence of epigastric sounds, presence of breath sounds,
and chest rise and fall
 Record tube depth and secure in place using a commercial holder if
applicable
 Utilize head restraint devices (i.e. “head-blocks”) or rigid cervical collar
and long spine board as needed to help secure airway device in place

Capnography/ETCO2 Monitoring
 Digital capnography (waveform) is the system standard for ETCO2 monitoring.
 Only in the event digital capnography is not available due to on-scene
equipment failure, is continuous colorimetric monitoring of ETCO2 an
acceptable alternative.
 Continuous ETCO2 monitoring is a MANDATORY component of invasive
airway management.
 If ETCO2 monitoring cannot be accomplished by either of the above
methods, the invasive device MUST be REMOVED, and the airway
managed non-invasively.
 If an alveolar waveform is not present with capnography (i.e. flat line),
briefly check the filter line coupling to assure it is securely in place then
remove the ETT or BIAD and proceed to the next step in the algorithm.

32
 Under no circumstances should transport be
delayed for Rapid Sequence Airway (RSA) if the
P 2 PARAMEDICS ARE REQUIRED AT ALL TIMES P
additional time to perform the procedure is greater x2 Simultaneously Contact Medical Control x2
than the transport time.

Airway Protocol Unsuccessful

Airway Protocol
Preparation (T-8 minutes)
IV, O₂, EKG, SpO₂, BP
Service MD Approval:______ Check Laryngoscope, ETT, stylet, syringes
Check rescue airway device
Meds drawn up and labeled
Pearls
Indications:
Age >18 unless specific
PreOxygenate (T-5 minutes)
permission given prior to
procedure by Medical
100% O₂ x 5 minutes
Control 8 vital capacity breaths with 100% O₂ (BVM/NRB)

2013
Need for invasive airway
management in the setting
of an intact gag reflex or PreTreatment (T-3 minutes)
inadequate sedation to
Cricoid Pressure / Sellick’s maneuver
perform non‐
pharmacologically assisted Lidocaine 1.5mg/kg IV/IO IF head injured (max 150mg)
airway management (apnea,
decreased LOC with
respiratory failure, poor
ventilatory effort (with
hypoxia not improved by Paralysis and Induction (T+0 minutes)
100% O2), Unable to Etomidate 0.3 mg/kg (max 20mg)
maintain patent airway by Succinylcholine 2 mg/kg (max 200mg)
other means, Burns with
suspected significant
inhalation injury)
Contraindications: Placement with Proof (T+ 30 seconds)
Medication sensitivities ETCO₂ (continuous), Auscultation
Inability to ventilate via BVM Secure Device
Suspected Hyperkalemia
Myopathy or neuromuscular
disease SUCCESSFUL UNSUCCESSFUL
History of Malignant
Hyperthermia
Recent crush injury or major
burn (>48 hours after injury) Post Placement Airway Management (T+ 60 seconds) Continue BVM
End Stage Renal Disease Morphine 3 mg IV/IO and Midazolam 3 mg IV/IO Maintain SpO₂
Recent Spinal Cord Injury (72 Repeat x2 if necessary >93%
hours – 6 months) Rocuronium 1mg/kg IV/IO IF transport time >10 minutes

Airway Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
33
 Airway Emergencies: Rapid Sequence Airway
Under no circumstances should transport be delayed for RSA if the additional
time to perform the procedure is greater than the transport time.
2 PARAMEDICS ARE REQUIRED AT ALL TIMES

All Providers
 General Patient Care Protocol—Adult
 Preoxygenate with 100% oxygen
 Basic Airway maneuvers: open airway, nasal and/or oral airway; BVM

Paramedic
 Full ALS assessment and treatment
 Simultaneously contact OLMC
 Assess for Indications:
 Age ≥18 unless specific permission given prior to procedure by
medical control
 Need for invasive airway management in the setting of an intact gag
reflex or inadequate sedation to perform non pharmacologically
assisted airway management:
 Apnea
 Decreased level of consciousness with respiratory failure (i.e.
hypoxia [O2 sat < 90%] not improved by 100% oxygen, and/or
respiratory rate < 8)
 Poor ventilatory effort (with hypoxia not improved by 100%
oxygen)
 Unable to maintain patent airway by other means
 Burns with suspected significant inhalation injury
 Preoxygenate 100% oxygen at 15L/min for at least 5 min or 8 Vital Capacity
(deep) breaths with 100% O2
 Only assist ventilations with BVM if patient’s ventilations are
inadequate or if hypoxemic (O2 Saturation < 93% on supplemental
oxygen)
 Assisted ventilations increase risk of aspiration during laryngoscopy
 Patients cannot have any contraindications to succinylcholine or other RSA
drugs:
 Inability to ventilate via BVM
 Suspected Hyperkalemia

34
  Myopathy or neuromuscular disease
 History of Malignant Hyperthermia
 Recent crush injury or major burn (>48 hours after injury)
 End Stage Renal Disease
 Recent Spinal Cord Injury (72 hours-6 months)

Procedure
 Preparation (T-8 minutes):
 Monitoring (continuous ECG, SpO2, Blood Pressure)
 2 Patent IV’s required (IO is acceptable)
 Functioning laryngoscope and BVM with highflow O2
 Endotracheal Tube(s), stylet, syringe(s)
LEMON
Look  BIAD(s) and appropriate syringe(s)
externally  Alternative/rescue airway (LMA and surgical airway kit) immediately
Evaluate with available
the 3:3:2 rule  All medications drawn up and labeled (including post procedure
Mallampati sedation)
classification
Obstruction  Suction: on and functioning
Neck Mobility  End-Tidal CO2 device on and operational (colorimetric immediately
available as a back up only)
 Assess for difficult airway—LEMON
 Preoxygenation (T-5 minutes):
 100% oxygen via NRB for 5 minutes or 8 Vital Capacity breaths
(Deep breaths) via NRB or BVM.
 Minimize BVM to decrease gastric distention and risk of
vomiting/aspiration.
 Pretreatment (T-3 minutes):
 Evidence of head injury or stroke:
 Lidocaine 1.5 mg/kg IV/IO (max 150 mg)
 Begin cricoid pressure/Sellick’s maneuver
 Paralysis and Induction (T + 0 minutes):
 Etomidate 0.3 mg/kg IV/IO (max dose 20 mg)
 Succinylcholine 2 mg/kg IV/IO (max dose 200 mg)
 Placement with Proof (T + 30 seconds):
 Place BIAD or ETT
 Confirm with:
 End Tidal CO2 waveform

35
  Auscultation
 Physical findings
 Secure device, note position
 Post-Placement Airway Management (T + 60 seconds):
 Sedation
 Morphine Sulfate 3 mg IV/IO AND Midazolam 3 mg IV/IO after
tube confirmed with ETCO2 (check BP prior to administration):
 May repeat X 2 as needed for sedation
 If additional paralysis needed and transport time is > 10 minutes
consider:
 Rocuronium 1 mg/kg IV/IO
(long acting paralytics mandates sedation as above)

Contact Medical Control for any additional orders or questions

36
 SIMULTANEOUSLY CONTACT MEDICAL CONTROL

Preparation (T-8 minutes)

 Monitoring (continuous ECG, Sp02, Blood Pressure)
 2 patent IVs
 Functioning Laryngoscope and BVM with highflow O2
 Endotracheal tube(s), stylet, syringe(s)
 BIAD(s) and appropriate syringe(s)
 Alternative/Rescue Airway (LMA and surgical airway kit) immediately
available
 All medications drawn up and labeled (including post-procedure sedation)
 Suction--turned on and functioning
 End Tidal CO2 device on and operational (colorimetric immediately available
as back-up only)
 Assess for difficult airway--LEMON

Preoxygenate
100% O2 x 5 minutes (NRB) or 8 VC breaths with 100% O2 (BVM/NRB)

Pretreatment (T-3 minutes)

 Evidence of head injury or stroke
 Lidocaine 1.5 mg/kg IV/IO (max 150 mg)
 Begin cricoid pressure/Sellick’s maneuver

Paralysis and Induction (T=0)

 Etomidate 0.3 mg/kg (max 20 mg)
 Succinylcholine 2 mg/kg (max 200 mg)

Placement with Proof (T+30 seconds)

 Place BIAD/ETT
 Confirm with:
--End Tidal CO2 waveform
--Auscultation
--Physical Findings
 Secure Device, note position

Post-Placement Management (T+1 minute)

Sedation: Morphine 3 mg IV/IO AND Midazolam 3 mg IV/IO, repeat X2 as needed.
If additional paralysis needed and transport time > 10 minutes:
Rocuronium 1 mg/kg IV/IO

37
 Airway Emergencies: Failed Airway
When in failed airway scenario, immediate transport to the nearest
emergency department is required

Simultaneously Contact Medical Control

All Providers
 General Patient Care Protocol—Adult
 If ventilation ineffective with single person BVM, place nasal and/or oral airway
and begin two-person BVM.
 Attempt ventilation with BVM and oral and/or nasal airway:
 Acceptable air exchange:
 Continue with BVM, rapid transport indicated
 Monitor oxygen saturation, end tidal carbon dioxide and cardiac
parameters continuously
 If unable to ventilate effectively with basic airway maneuvers using BVM and
patient has no gag reflex, place advanced airway.

Paramedic
 Full ALS Assessment and Treatment
 Simultaneously notify OLMC
 Failed Intubation/BIAD
 Attempt ventilation with BVM and oral and/or nasal airway:
 Acceptable air exchange:
 Continue with BVM, rapid transport indicated
 Monitor oxygen saturation, end tidal carbon dioxide and cardiac
parameters continuously
 Unacceptable air exchange:
 Place BIAD (if not previously attempted)
 Acceptable air exchange:

38
  Monitor oxygen saturation, end tidal carbon dioxide
and cardiac parameters continuously
 No air exchange:
 Can’t intubate/place advanced airway/can’t ventilate
situation
 Percutaneous Cricothyrotomy (Surgical
Airway)

39
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Onset and location Signs and Symptoms Urticaria (rash only)
Insect sting or bite Itching or hives Anaphylaxis (systemic effect)
Food allergy / exposure Coughing / wheezing Shock (vascular effect)
Medication allergy / exposure Respiratory distress Angioedema (drug induced)
New clothing, soap, detergent Chest or throat constriction Aspiration / Airway
Past history of reactions Difficulty swallowing obstruction
Past medical history Hypotension or shock Vasovagal event
Medication history Edema Asthma or COPD
CHF

Medical Protocol
General Approach to All Adult Patients

Mild Reaction Severe Reaction

Hives / Rash Only Evidence of Impending
No respiratory component Moderate Reaction Respiratory Distress or Shock
Dyspnea, Wheezing,
Chest Tightness Epinephrine 1:1000
Auto‐Injector * 0.3mg
Epinephrine 1:1000 IM
A IV Protocol A A *0.3mg
A

2013
Albuterol 2.5mg/3ml &
Ipratropium 0.5mg/2.5ml** Albuterol 2.5mg/3ml &
Ipratropium 0.5mg/2.5ml
Diphenhydramine A IV Protocol A
P 50 mg IV/IM/IO P
A IV Protocol A
Famotidine Diphenhydramine
P 20 mg in 100 ml D5W P P 50 mg IV/IM/IO P
Diphenhydramine
P 50 mg IV/IM/IO P
Famotidine
P 20 mg in 100 ml D5W P
Famotidine
P 20 mg in 100 ml D5W P
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Methylprednisolone
Heart, Lungs P 125 mg IV/IO P
*Contact Medical Control: prior to
Imminent Cardiac Continued Severe
administering epinephrine in patients who Arrest *** Symptoms
are >50 years of age, have a history of
cardiac disease, or if the patients heart rate
is >150. Epinephrine may precipitate
cardiac ischemia. These patients should Epinephrine 1:10,000 Epinephrine Infusion:
P 0.5mg IV P Mix 2mg (1:1000) in 250ml NS
receive a 12 Lead EKG MP Start at 2mcg/min PM
Famotidine, IV piggyback over 15 minutes (if
Simultaneously (max 10mcg/min)
not already given)
**May repeat Albuterol PRN for continued M Contact Medical M
wheezing – max 3 doses Control
The shorter the onset from symptoms to
contact, generally the more severe the
reaction
*** Severe bradycardia, unresponsive, no obtainable
blood pressure or radial pulse Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
40
 Allergic Reaction
All Providers
 General Patient Care Protocol—Adult
 Assist patient in self-administration of previously prescribed epinephrine
auto-injector (Epi-Pen)
 If wheezing present:
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer
 May repeat Albuterol PRN for continued wheezing (max 3
doses)

Mild Reaction (Itching/Hives)

 Advanced EMT
 Consider IV Protocol
 Paramedic
 Full ALS Assessment and Treatment
 Consider Diphenhydramine (Benadryl) 50 mg IV/IM/IO
 Consider Famotidine 20 mg in 100 ml D5W, IV Piggyback over
15 min

Moderate Reaction (Dyspnea, Wheezing, Chest Tightness)

As for mild symptoms, additionally:
 All Providers
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer, if not already given
 May repeat Albuterol PRN for continued wheezing (max 3
doses)
 Advanced EMT
 Consider IV Protocol
 Paramedic
 Diphenhydramine (Benadryl) 50 mg IV/IM/IO (if not already given)
 Famotidine 20 mg in 100 ml D5W, IV Piggyback over 15 min (if not
already given)

41
Severe Systemic Reaction (SBP <90mmHg, Stridor, Severe Respiratory Distress)
As for moderate symptoms, additionally:
 All Providers
 Epinephrine 1:1000, 0.3 mg IM (OLMC for approval if age>50,
HR>150, history of CAD)
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer
 May repeat PRN for continued wheezing (max 3 doses)
 Advanced EMT
 Consider IV Protocol
 Consider Fluid Bolus-500cc NS (max 2 liters)

 Paramedic
 Diphenhydramine (Benadryl) 50 mg IV/IM/IO (if not already given)
 Famotidine 20 mg in 100 ml D5W, IV Piggyback over 15 min (if not
already given)
 Methylprednisolone (Solumedrol) 125 mg IV/IO

Imminent Cardiopulmonary Arrest (severe bradycardia, unresponsive, no obtainable

blood pressure or radial pulse)
 Paramedic
 As for severe systemic reaction, additionally:
 Epinephrine 1:10,000, 0.5 mg IV
Cardiac Arrest
 Paramedic
 Refer to the appropriate protocol based on presenting rhythm
 In the setting of cardiac arrest, the following items should be performed in the
post-resuscitative phase, when time allows:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer
 May repeat PRN for continued wheezing (max 3 doses)
 Diphenhydramine (Benadryl) 50 mg IV/IO (if not already given)
 Famotidine 20 mg in 100 ml D5W, IV Piggyback over 15 min (if not already
given)
 Methylprednisolone (Solumedrol) 125 mg IV/IO (if not already given)

Contact Medical Control for any additional orders or questions

 Epinephrine Infusion:
 Mix 2 mg (1:1000) in 250 ml NS
 Start at 2 mcg/min, maximum 10 mcg/min

42
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M Signs and Symptoms
History: Decreased mental status Differential
Known Diabetic, Lethargy Head Trauma
Medic alert tag Change in baseline mental CNS (stroke, tumor, seizure,
Drugs, drug paraphernalia status infection)
Report of illicit drug Bizarre behavior Cardiac (MI, CHF)
Use or toxic ingestion Hypoglycemia (cool/ Hypothermia
Past medical history diaphoretic skin) Infection (CNS or other)
Medications Hyperglycemia (warm, dry Thyroid (hyper/hypo)
History of Trauma skin, fruity breath, kussmaul Shock (septic, metabolic, traumatic)
Change in condition respirations, signs of Diabetes (hyper/hypo)
Changes in feeding or sleep Toxicologic or Ingestion

Medical Protocol
dehydration
habits Irritability Acidosis/Alkalosis
Environmental exposure
Pulmonary (hypoxia)
General Approach to All Adult Patients Electrolyte abnormality
Psychiatric disorder

Glucose <70 Blood Glucose Glucose >70

A IV Protocol A
Consider
Consider Oral Glucose 15g if A *Naloxone 2mg IV/IO/IN**/IM A
awake and no risk of aspiration Every 3 minutes (max 8mg)

2013
Consider other causes: Head injury,
No Improvement in
If no IV, Glucagon 1mg IM if Altered Mental Status
OD/toxic ingestion, stroke, hypoxia,
unable to use glucose hypothermia
Dextrose 12.5‐25g
A Or D10W 100mL IV A P Assess Cardiac Rhythm P
Improved
12 Lead EKG

IV bolus 250 ml x1
A If clinically hypovolemic (orthostatic A
hypotension/dry mucous membranes)

M Contact Medical Control M

Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. Pay special attention to the head exam for
signs of bruising or other injury.
* Naloxone (Narcan) can be administered in 0.4 mg increments titrated to respiratory drive and level of consciousness
** for Intranasal administration A-EMT should administer 0.5mg per nare, total of 1mg and then proceed with additional doses as needed.
(Paramedics may give 1 mg per nare)
Be aware of AMS as presenting sign of an environmental toxin or Hazmat exposure and protect personal safety
It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or glucagon
Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia and may have unrecognized injuries
Low glucose (<70), normal glucose (70‐120), high glucose (>250)
Consider restraints if necessary for patients and/or personnel's protection per the restraint protocol

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
43
 Altered Mental Status
All Providers
 General Patient Care Protocol—Adult
 Blood Glucose
 If hypoglycemic (Blood glucose < 70mg/dL)
Glucose paste 15 g or other oral glucose agent (e.g. orange
juice) if patient alert enough to self-administer
If hypoglycemic and unable to take oral glucose:
 Consider Glucagon 1mg IM
 If Stroke suspected, see Stroke Protocol
 If Head Injury suspected, see Trauma/Head Injury Protocol
 If severely agitated and/or violent see Behavioral Emergencies Protocol
 If cardiac arrhythmia present see appropriate Cardiac Arrhythmia Protocol

Advanced EMT
 Consider IV Protocol
 If Drug (narcotic) overdose suspected:
 Naloxone (Narcan) 2 mg IV/IO every 3 minutes (maximum 8 mg)
▪ Naloxone (Narcan) can be administered in 0.4 mg increments
titrated to respiratory drive and level of consciousness
▪ If IV access has not been established, Naloxone (Narcan) 2
mg IM or 0.5 mg per nare IN (total 1.0mg per administration)
● If hypoglycemic
 Dextrose 12.5g-25g IV or D10W 100mL IV
▪ May repeat as needed every 5-10 minutes to blood glucose
>100 mg/dL
 If Clinically hypovolemic (orthostatic hypotension / dry mucous membranes)
IV bolus 250ml x1.

Paramedic
● Full ALS Assessment and treatment
● If hypoglycemic (Blood glucose < 70 mg/dL) with IV access:
 Dextrose 12.5g-25g IV or D10W 100mL IV
 May repeat as needed every 5-10 minutes to blood glucose
>100 mg/dL
● If hypoglycemic (Blood glucose < 70 mg/dL) without IV access:

44
  Glucose paste 15 g or other oral glucose agent (e.g. orange juice) if
patient alert enough to self administer
● If hypoglycemic and unable to take oral glucose:
 Glucagon 1 mg IM
● If Drug (narcotic) overdose suspected:
 Naloxone (Narcan) 2 mg IVP every 3 minutes (maximum 8 mg)
▪ Naloxone (Narcan) can be administered in 0.4 mg
increments titrated to respiratory drive and level of
consciousness
▪ If IV access has not been established, Naloxone
(Narcan) 2 mg IM or IN via mucosal atomizer device

Note: Patients presenting with altered mental status, who

respond to Narcan are not candidates for informed
refusal. Due to the relatively short half-life of Narcan,
these patients are at risk for return of symptoms. These
patients should be transported to the emergency
department, regardless of an apparently normal mental
status.

Contact Medical Control for any additional orders or questions

45
 Legend
EMT
A A‐EMT A (Excited Delirium)
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Situational crisis Anxiety, agitation, confusion See altered mental status
Psychiatric illness/medications Affect change, hallucinations differential
Injury to self or threats to Delusional thoughts, bizarre Alcohol intoxication
others behavior Toxin / substance abuse
Medic alert tag Combative / violent Medication effect / overdose
Substance abuse / overdose Expression of suicidal / Withdrawal syndromes
Diabetes homicidal thoughts Depression
Bipolar (manic‐depressive)
Schizophrenia
Scene Safety

Medical Protocol
Anxiety disorders

General Approach to All Adult Patients

Remove patient from stressful environment

Use verbal calming techniques (reassurance, calm, Paramedics should be considered EARLY
establish rapport) NEVER restrain in the PRONE position
GCS and Pupil Assessment on all patients

Go to appropriate protocol:
Altered Mental Status Protocol

2013
Overdose / Toxic Ingestion Protocol
Head Trauma Protocol
Service MD Approval:______

Altered Mental Status

Check glucose if any suspicion of hypoglycemia <70
Protocol
>70

Restraint Procedure *

Haloperidol 5mg IM if <60kg or 10mg IM if >60kg**

P Lorazepam 1‐2mg IM (can be combined with P OR M P Ketamine 4mg/kg IM P M
Haloperidol)
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lung, Neuro
IV Protocol SAFETY FIRST!
A 250 ml bolus (max 2L total)
A * Never retrain or transport in prone position
**Avoid if recent history of MAO inhibitor use (ie. Phenelzine,
Transylcypomine)
If Cocaine/Sympathomimetic toxicity
Consider Haloperidol for patients with history of psychosis
suspected:
P Lorazepam 1mg IV/IM P Do not overlook the possibility of associated domestic violence or child abuse
If patient in excited delirium suffers cardiac arrest, follow appropriate cardiac
Repeat 1mg IV/IM if needed arrest protocol.
All patients who receive either physical or chemical restraint MUST
continuously be observed by ALS personnel on scene or immediately upon
their arrival.
If patient refuses care Any patient handcuffed or restrained by law enforcement, law enforcement
M Contact Medical Control M must ride in ambulance
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
46
 Behavioral Emergencies/Excited Delirium
Strongly Consider Paramedic Assistance
All Providers
 General Patient Care Protocol—Adult
 Apply physical restraints if needed to ensure patient/crew safety. Adhere to
procedure on Physical Restraint of Agitated Patients when this process is
deemed necessary
 Blood Glucose Measurement-if < 70 mg/dl, refer to Altered Mental Status
Protocol
 Assess and treat for hyperthermia

Advanced EMT
 Consider IV Protocol

Paramedic
 When Chemical or Physical restraints are used, perform Full ALS
Assessment and Treatment
 For patients with severe agitation compromising patient/crew safety, or for
patients who continue to struggle against physical restraints:
 Haloperidol (Haldol) 5 mg IM if, 60 kg or 10mg IM if >60 kg
 Avoid if recent history of MAO inhibitor use (e.g. Phenelzine,
Tranylcypromine)
 Lorazepam (Ativan) 1-2 mg IM (can be combined in same syringe as
Haldol)
If concerns for Excited Delirium:
 250 ml bolus Normal Saline IV – x4 (2L max)
 If cocaine/sympathomimetic toxicity strongly suspected:
 Lorazepam (Ativan) 1 mg IV/IM
 Repeat Lorazepam (Ativan) 1 mg IM/IV if adequate sedation not
achieved on initial dose
 Note: NEVER restrain or transport in prone position!

Contact Medical Control for all refusals or non-transports

Contact Medical Control for any additional orders or questions
Paramedics - Ketamine 4 mg/kg IM with Medical Control
Permission

47
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
History:
Animal bite
Type of bite/sting Signs and Symptoms
Human bite
Description or bring creature/ Rash, skin break, wound
Snake bite (poisonous)
photo with patient for Pain, soft tissue swelling,
Spider bite (poisonous)
identification redness
Insect sting/bite (bee, wasp,
Time, location, size of bite/sting Blood oozing from the bite/
ant, tick)
Previous reaction to bite/sting wound
Infection risk
Domestic vs. wild Evidence of infection
Rabies risk
Tetanus and rabies risk
Tetanus risk
Immunocompromised patient

General Approach to All Adult Patients

Medical Protocol
Irrigate/Cleanse wound with 0.9%
NaCl (remove any large debris)

Remove stinger if wasp/bee

(if easily removed)

Mark edematous area with pen and

note time

Immobilize affected part and remove

distal jewelry

Refer to Pain Control Protocol if there is

significant pain
If there is allergic reaction refer to
Allergic Reaction Protocol
IV Protocol
A If SBP<90mmHg, consider 500 ml bolus NS (total 2L) A Service MD Approval:______

If no improvement from 2L fluid bolus

P Dopamine infusion at 5‐20mcg/kg/min titrated to P
Contact Medical maintain SBP>90mmHg
M Control M

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Extremities (location of injury), and a complete Neck, Lung, Heart, Abdomen, Back,
and Neuro exam if systemic effects are noted.
Human bites have higher infection rates than animal bites due to normal mouth bacteria
Carnivore bites are much more likely to become infected and all have risk of rabies exposure
Cat bites may progress to infection rapidly due to a specific bacteria (pasteurella multicoda)
Snake bites: amount of envenomation is variable, generally worse with larger snakes and early in spring, if no pain or swelling
envenomation is unlikely, it is NOT necessary to take the snake to the ED with the patient.
Black widow spider bites tend to be minimally painful, but over a few hours, muscular pain and severe abdominal pain may
develop (spider is black with red hourglass on belly)
Brown recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the
bite develops over the next few days (brown spider with fiddle shape on back).
An alternative to bringing the offender to the Emergency Department would be to take a picture of the animal/insect

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
48
 Bites and Envenomations
All Providers
 General Patient Care Protocol—Adult
 Irrigate/Cleanse wound with 0.9% NaCl (remove any large debris)
 Remove stinger if wasp/bee (if easily removed)
 Mark edematous area with pen and note time
 Immobilize affected part and remove distal jewelry
 Attempt to identify what caused bite and bring to Emergency Department if
dead (use caution when handling dead snakes as envenomation has
occurred secondary to reflex motor movement) – an alternative is taking a
picture of the animal/insect.
 Refer to Allergic Reaction Protocol as indicated
 Transport to closest appropriate facility

Advanced EMT
 Consider IV Protocol
 For hypotension (SBP<90 mmHg) consider 500 ml IV 0.9% NaCl fluid
boluses up to 2L.

Paramedic
 Full ALS Assessment and Treatment
 For hypotension (SBP<90 mmHg) not improved with fluid boluses up to 2L
0.9% NaCl, or when fluid boluses are contraindicated:
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain SBP>90
mmHg

Contact Medical Control for any additional orders or questions

49
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Signs and Symptoms
History: Differential
Unresponsive
Events leading to arrest Medical or Trauma
Apneic
Estimated downtime Vfib vs Pulseless Vtach
Pulseless
Past Medical History Asystole
Medications Pulseless electrical activity
Existence of terminal illness (PEA)
Signs of lividity, rigor mortis
DNR
General Approach to All Adult Patients

Cardiac Protocol
Withhold Resuscitation YES Criteria for Death/No Resuscitation Indicated
Call “patient contact” to dispatch when you arrive at
patients side
Continue compressions until
Defib pads in place and monitor YES Adequate Bystander CCR or CPR?
charged.
NO
AT ANY TIME
Return of spontaneous
Immediately perform compressions circulation ‐>

2013
at a rate of 100 compressions per Go to Post Resuscitation
minute for 2 minutes Protocol

Stop compressions for rhythm

analysis (<5seconds)

If VT or VF (or AED
If PEA/Asystole – (or
advises shock)
AED advises no shock)
DEFIBRILLATE A IV Protocol A
do NOT shock
(call 1st shock to dispatch)

Service MD Approval:______
Go to appropriate Protocol and
Resume compressions

Pearls
RECOMMENDED EXAM: Mental Status
Immediately after defibrillation, resume chest compressions with a different operator compressing. Do not pause for post‐shock rhythm
analysis. Stop compressions only for signs of life (patient movement) or rhythm visible through compressions on monitor or pre‐defibrillation
rhythm analysis every 2 minutes and proceed to appropriate protocol
CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac nature. It is not indicated in those situations
where other etiologies are probable (OD, drowning, hanging, etc.) In these instances CPR is indicated
CCR is not to be used on individuals less than 18 years of age.
Successful resuscitation requires planning and clear role definition
In the event a patient suffers cardiac arrest in the presence of EMS, the absolute highest priority is to apply the AED/Defibrillator and
deliver a shock immediately if indicated.
Reassess airway frequently and with every patient move.
DO NOT INTERRUPT CHEST COMPRESSIONS!
Designate a “code leader” to coordinate transitions, defibrillation and pharmacological interventions. “Code Leader” ideally should have no
procedural tasks.
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
50
 Cardiac Arrest: General Approach
General
 CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac
nature. It is not indicated in those situations where other etiologies are probable (overdose,
drowning, hanging etc.). In these instances CPR is indicated.
 CCR is not to be used on individuals less than 18 years of age.
 Successful resuscitation requires planning and clear role definition.
 In the event a patient suffers cardiac arrest in the presence of EMS (EMS witnessed
Cardiac Arrest), the absolute highest priority is to apply the AED/Defibrillator and
deliver a shock immediately if indicated.
 Reassess airway frequently and with every patient move.
 DO NOT INTERRUPT CHEST COMPRESSIONS!
 Designate a “code leader” to coordinate transitions, defibrillation and pharmacological
interventions. “Code Leader” should ideally not have any procedural tasks. If the “code
leader” is needed for a specific task, a new leader must be designated.
All Providers
 General Patient Care Protocol (including blood glucose)
 Check responsiveness and check for a carotid pulse
 Call “patient contact” to dispatch when you arrive at the patient’s side
 If adequate bystander compressions ongoing, continue compressions until monitor
pads in place and monitor charged. Stop compressions for rhythm analysis (< 5 sec)
 If VT or VF (or AED Advises Shock), defibrillate
 Call “first shock” time to dispatch
 If PEA/Asystole, go to appropriate protocol and resume compressions
 Immediately after defibrillation, resume chest compressions with a different operator
compressing. Do not pause for post-shock rhythm analysis. Stop compressions only
for signs of life (patient movement) or rhythm visible through compressions on
monitor or pre-defibrillation rhythm analysis every 2 minutes
 If compressions are not being performed upon arrival or if compressions are not
deemed adequate, immediately perform compressions at a rate of 100 compressions
per minute for 2 minutes.
Advanced EMT
 Consider IV Protocol
Paramedic
See Protocol based on presenting rhythm

51
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Past Medical History Medical or Trauma
Medications Signs and Symptoms Hypoxia
Events leading to arrest Pulseless Potassium (hypo/hyper)
End stage renal disease Apneic Drug Overdose
Estimated downtime No electrical activity on ECG Acidosis
Suspected hypothermia No auscultated heart tones Hypothermia
Suspected Overdose Device (lead) error
DNR Death

Cardiac Protocol
Cardiac Arrest Protocol

Withhold Resuscitation YES Criteria for Death / No resuscitation

NO

5 cycles of CPR unless arrest

2013
witnessed by AED equipped
AT ANY TIME personnel
Return of spontaneous
circulation ‐>
Go to Post Resuscitation
Protocol
A IV Protocol A
Epinephrine 1mg IV/IO
P every 3‐5 minutes P
Consider Correctable Causes
Hypoxia – secure airway and ventilate
Hypoglycemia – Dextrose 12.5‐25g or D10W 100ml IV/IO
Hyperkalemia – Sodium bicarbonate 1mEq/kg IV/IO
‐ Calcium Chloride 1g IV/IO
P Hypothermia – Active Rewarming P
Calcium Channel and B-Blocker OD – Glucagon 3mg IV/IO
Calcium Channel Blocker OD – Calcium Chloride 1g IV/IO
(avoid if patient on Digoxin/Lanoxin)
Tricyclic antidepressant OD – Sodium Bicarbonate 1mEq/kg IV/IO
Possible Narcotic OD – Naloxone 2mg IV/IO

Termination of After 20 Minutes

YES
Resuscitation Protocol Criteria for Discontinuation

NO

Pearls
RECOMMENDED EXAM: Mental Status Continue Epinephrine
When Asystole is seen on the cardiac monitor, confirmation of the rhythm shall and correctable causes
include a printed rhythm strip as well as interpretation of the rhythm in more than
one lead. Consult Medical
Low amplitude Vfib or PEA may be difficult to distinguish from asystole when using only M Control M
the cardiac monitor for interpretation.
Service MD Approval:______

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
52
 Cardiac Arrest: Asystole
Note: When Asystole is seen on the cardiac monitor, confirmation of the rhythm shall
include a printed rhythm strip, as well as interpretation of the rhythm in more than
one lead. Low amplitude V-Fib or PEA may be difficult to distinguish from asystole
when using only the cardiac monitor for interpretation.

All Providers
 Follow Cardiac Arrest—General Approach Protocol

Paramedic
 Consider and treat possible causes

Potential Causes of Asystole Treatment

 Hypoxia  Secure airway and ventilate
 Dextrose 25 g IV/IO; repeat as
 Hypoglycemia
needed to achieve blood glucose >70
 Hyperkalemia (end stage renal  Sodium bicarbonate 1 mEq/kg IV/IO
disease)  Calcium Chloride 1 g IV/IO
 Hypothermia  Active re-warming
 Tablets (drug overdose)  See below

 Epinephrine 1 mg IV/IO every 3-5 min during arrest

 Drug overdoses (see specific drug OD/toxicology section)
 Glucagon 3 mg IV/IO for calcium channel and B-blocker OD
 Calcium Chloride 1 g IV/IO for calcium channel blocker OD
 Avoid if patient on Digoxin/Lanoxin
 Sodium Bicarbonate 1 mEq/kg, IV/IO for Tricyclic antidepressant OD
 Naloxone (Narcan) 2 mg IV/IO for possible narcotic OD
 If no response to resuscitative efforts in 20 minutes (at least 2 rounds of
drugs) consider discontinuation of efforts (see Termination of Resuscitation
Protocol)

Contact Medical Control for any additional orders or questions

53
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
Hypovolemia (trauma, AAA,
other)
Cardiac Tamponade
History: Hypothermia
Past Medical History Drug Overdose (Tricyclics,
Signs and Symptoms Digitalis, Beta Blockers,
Medications
Pulseless Calcium channel blockers)
Events leading to arrest
Apneic Massive MI
End stage renal disease
Electrical activity on ECG Hypoxia
Estimated downtime

Cardiac Protocol
No heart tones on Tension pneumothorax
Suspected hypothermia
auscultation Pulmonary embolus
Suspected Overdose
DNR Acidosis
hyperkalemia

Cardiac Arrest Protocol

A IV Protocol A

2013
Epinephrine 1mg IV/IO
AT ANY TIME
P every 3‐5 minutes P
Return of spontaneous
circulation ‐>
Go to Post Resuscitation Do NOT discontinue
Protocol compressions unless there
is a definite pulse

Consider Correctable Causes

Hypovolemia (most common) – NS 1-2L IV/IO
Hypoxia – secure airway and ventilate
Hydrogen Ion (acidosis) – Sodium Bicarbonate 1mEq/kg IV/IO
Hyperkalemia – Sodium bicarbonate 1mEq/kg IV/IO
‐ Calcium Chloride 1g IV/IO
Hypothermia – Active Rewarming
P Calcium Channel and B-Blocker OD – Glucagon 3mg IV/IO P
Calcium Channel Blocker OD – Calcium Chloride 1g IV/IO
(avoid if patient on Digoxin/Lanoxin)
Tricyclic antidepressant OD – Sodium Bicarbonate 1mEq/kg IV/IO
Possible Narcotic OD – Naloxone 2mg IV/IO
Cardiac Tamponade – NS 1‐2 L IV/IO and expedite transport
Tension pneumothorax – Needle thoracostomy
Service MD Approval:______ Coronary or Pulmonary Thrombosis – Expedite Transport

Pearls
RECOMMENDED EXAM: Mental Status Consult Medical
Consider each cause listed in the differential: survival is based on identifying and
correcting the cause.
Control
Discussion with Medical Control can be a valuable tool in developing a differential M Termination of M
MResuscitation Protocol
diagnosis and identifying possible treatment options.
after 20 minutes

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

54
 Cardiac Arrest:
Pulseless Electrical Activity (PEA)
All Providers
 Follow Cardiac Arrest—General Approach Protocol
Paramedic
 Consider and treat possible causes

Potential Causes of PEA Treatment

 Hypovolemia (most common)  Normal Saline 1-2 liters IV/IO
 Hypoxia  Secure airway and ventilate
 Hydrogen Ion (acidosis)  Sodium Bicarbonate 1 mEq/kg IV/IO

 Sodium Bicarbonate 1 mEq/kg IV/IO

 Hyperkalemia (end stage renal disease)
 Calcium Chloride 1 g IV/IO

 Hypothermia  Active rewarming

 Tablets (drug overdose)  See below

 Normal Saline 1-2 liters IV/IO

 Tamponade, Cardiac
 Expedite transport

 Tension pneumothorax  Needle thoracostomy

 Thrombosis, Coronary  Expedite transport
 Thrombosis, Pulmonary  Expedite transport

 Epinephrine 1 mg IV/IO every 3-5 minutes

 Do not discontinue compressions unless there is a definite pulse
 Drug overdoses (see specific drug in OD/toxicology section)
 Glucagon 3 mg IV/IO for calcium channel and B blocker
 Calcium Chloride 1 g IV/IO for calcium channel blocker or suspected
hyperkalemia (dialysis patient)
▪ Avoid if patient on Digoxin/Lanoxin
 Sodium Bicarbonate 1 mEq/kg, IV/IO for Tricyclic antidepressant OD
 Naloxone (Narcan) 2 mg IV/IO for possible narcotic OD
 If no response to resuscitative efforts in 20 minutes (at least 2 rounds of
drugs) consider discontinuation of efforts (see Termination of Resuscitation
Protocol)

55
 Legend

A
EMT
A‐EMT A
Ventricular Fibrillation
P Paramedic P Pulseless Vent. Tachycardia
M Medical Control M
History: Signs and Symptoms Differential
Estimated down time Unresponsive, apneic, Asystole
Past medical history pulseless Artifact / Device failure
Medications Ventricular fibrillation or Cardiac
Events leading to arrest ventricular tachycardia on Endocrine / Metabolic
Renal failure / dialysis EKG Drugs
DNR or living will Pulmonary

Cardiac Arrest Protocol

Cardiac Protocol
AT ANY TIME
Defibrillate x1 *
Rhythm Changes to After defibrillation resume CCR without pulse check
Nonshockable Rhythm
Go to appropriate
Apply non‐rebreather as soon as other care activities will not be
protocol interrupted
After 2 minutes of CCR
Check rhythm – if VF/VT persists
Defibrillate – CCR immediatly

A Establish IV/IO A
Epinephrine 1mg IV/IO
P P

2013
AT ANY TIME
every 3‐5 minutes
Return of spontaneous Consider Vasopressin 40 units IV/IO
circulation ‐>
Go to Post Resuscitation
P with 1st or 2nd epi dose only P
Protocol
After 2 minutes of CCR
Check rhythm – if VF/VT persists
Defibrillate – CCR immediatly

Amiodarone 300mg IV/IO bolus Continue cycle

P For persistent VT/VF give Amiodarone P of compressions
150mg IV/IO bolus on second round and Drug,
rhythm check,
If Polymorphous VT or hypomagnesemic state‐ compressions
Magnesium Sulfate 2g IV/IO push over 1‐2 min shock etc.
P If suspected hyperkalemia or tricyclic OD P
Sodium Bicarbonate 1mEq/kg IV/IO
If suspected hyperkalemia – Calcium Chloride 1g IV/IO

Criteria for
Termination of
M Resuscitation Protocol M YES Discontinuation after
20 minutes

NO

Pearls
RECOMMENDED EXAM: Mental Status
*Call first defibrillation time to 911 Center
Consult Medical
Reassess and document advanced airway placement and EtCO2 frequently, after every
move, and at transfer of care.
M Control M
Treatment priorities are: uninterrupted chest compressions, defibrillation, then IV
access and airway control. Service MD Approval:______

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
56
 Cardiac Arrest: Ventricular Fibrillation/
Pulseless Ventricular Tachycardia
All Providers
 Follow Cardiac Arrest—General Approach Protocol
Defibrillate for persistent VF/VT
 use manufacturer recommended energy settings, typically 200J or 360 J
⇒ Continue Chest Compressions immediately after shock (do not stop for
pulse or rhythm check)
⇒ Call first defibrillation time to dispatch

 Analyze rhythm after 2 minutes of good CPR; If VF/VT persists:

 Defibrillate at 200 J (360 J if available)
 Continue compressions immediately after shock (do not stop for pulse
or rhythm check)
Paramedic
 Epinephrine 1 mg IV/IO every 3-5 min during arrest
 Vasopressin 40 Units IV/IO with 1st or 2nd Epinephrine doses only
 Analyze rhythm after 2 minutes of good CPR; If VF/VT persists:
 Defibrillate at 200 J (360 J if available)
 Continue Chest Compressions immediately after shock (do not stop for
pulse or rhythm check)
 Amiodarone 300mg IV/IO bolus
 For persistent VT/VF give Amiodarone 150 mg IV/IO bolus on second
round
 Continue cycle of Compressions & Drug  Rhythm Check  Compressions
 Shock  Compressions & Drug  Rhythm Check  Compressions 
Shock as needed
 Additional interventions to consider in special circumstances
 Magnesium Sulfate 2 g IV/IO push over 1-2 minutes only if suspected
Polymorphous VT (torsades de pointes) or hypomagnesemic state
(chronic alcohol or diuretic use)
 Sodium Bicarbonate 1 mEq/kg, IV/IO if suspected hyperkalemia
(dialysis patient) or tricyclic antidepressant OD
 Calcium Chloride 1 g IV/IO if suspected hyperkalemia (dialysis patient)

Contact Medical Control for any additional orders or questions

57
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Signs and Symptoms
Respiratory Arrest Continue to address specific
Return of pulse
Cardiac Arrest differentials associated with the
original dysrhythmia
Repeat Primary Assessment

P Consider Induced Hypothermia Protocol P

Continue Ventilatory Support
100% Oxygen

Cardiac Protocol
ETCO2 goal 40
RR <12
DO NOT HYPERVENTILATE
A IV Protocol A
P Cardiac Monitor P
Vital Signs (including PulseOx)
12 Lead EKG

Continue anti‐arrythmic if ROSC

was associated with its use

2013
Hypotension Re Arrest
SBP<90mmHg
Combative

Normal Saline bolus

A 250ml x2 A Lorazepam 1‐2 mg slow IV/IO may
repeat x1 (max dose 4mg) or
Follow appropriate
If not improved by NS bolus P Midazolam 1‐2 mg slow IV/IO may P arrest protocol
‐Dopamine infusion 5‐20 repeat x1 (max dose 4mg)
mcg/kg/min titrated to
P maintain SBP >90mmHg P
‐ Additional 250 ml bolus x2
to 2L max Consult Medical
M Control if needed M
Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase and must be avoided
at all costs. ETCO2 goal is 40mmHg.
Most patient’s immediately post resuscitation will require ventilatory assistance
The condition of post‐resuscitation patients fluctuates rapidly and continuously, and they require close monitoring. Appropriate post‐
resuscitation management may best be planned in consultation with medical control
Common causes of post‐resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and medication reaction to ALS
drugs

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
58
 Cardiac Arrest: Post Resuscitation Care
All Providers
 General Patient Care Protocol—Adult
 Maintain assisted ventilation as needed
 Supplemental 100% oxygen
 ETCO2 if available

Paramedic
 Full ALS Assessment and Treatment
 Monitor ETCO2, goal is 40mmHg, DO NOT HYPERVENTILATE
 For hypotension (systolic BP <90 mmHg) not improved by fluid boluses, or
when fluid administration is contraindicated:
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP
>90 mmHg
 If VF/pulseless VT occurred during arrest AND Amiodarone was
administered, no additional anti-arrhythmic is required unless arrhythmia
recurs.
 If VF/VT reoccurs after previous conversion with Amiodarone 300 mg:
 Defibrillate and administer Amiodarone 150 mg IV/IO
 If patient becomes combative, administer:
 Lorazepam (Ativan) 1-2 mg slow IV/IO may repeat X 1 (maximum dose
4 mg) or
 Midazolam (Versed) 1-2 mg slow IV/IO, may repeat X 1 (maximum 4
mg)
 Consider Therapeutic/Induced Hypothermia Protocol
 Transport to nearest appropriate facility

Contact Medical Control for any additional orders or questions

59
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Signs and Symptoms
Non‐traumatic cardiac arrests Continue to address specific
Cardiac Arrest
(drownings and hangings/ differentials associated with the
ROSC post‐cardiac arrest
asphyxiation are permissible in this original dysrhythmia
protocol)

ROSC Paramedic
12 Lead EKG Only
Assessment and document GCS Protocol

Cardiac Protocol
Criteria for Inclusion
Witnessed Cardiac Arrest with ROSC
Not Pregnant
Age = or >18
Transport No evidence of trauma or intracranial hemorrhage
and continue Does NOT Significant altered level of consciousness (not following commands, no
post Meet purposeful movement, incomprehensible speech)
criteria No known surgery within the preceding 2 weeks
resuscitation No history of bleeding disorder (warfarin/coumadin and heparin are
care NOT contraindications)
Patient must have airway secured (BIAD/ETT)

2013
MEETS CRITERIA

Perform RSA to secure airway (ETT/BIAD)

IF:
P 1) Airway not already in place P
AND
2) Airway placement will NOT delay transport

Administer Midazolam 1‐2

P mg every 3‐5 minutes IV/ P
IO to a max of 10mg

Administer 30 ml/kg of
Pearls
Must have secured airway to
P cool saline (4° C) to a max P
of 2L
undergo cooling
Most patients suffering from
cardiac arrest with ROSC die Apply Ice Packs to axilla, groin
with anoxic brain injury. and neck
Therapeutic hypothermia
serves to improve the chance of
If Shivering ‐
a good neuro outcome.
Closely monitor ventilation,
P Rocuronium 1 mg/kg IV/IO P
target ETCO2 to 40 mmHg, do
not hyperventilate
If Systolic BP<90mmHg
If at any time there is a loss of
Initiate Dopamine infusion
spontaneous circulation, P at 5‐20mcg/kg/min, titrate P
discontinue cooling and go to Consult Medical
the appropriate protocol.
to SBP >90mmHg M Control if needed M
Service MD Approval:______

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
60
 Cardiac Arrest: Hypothermia
Therapeutic/Induced

Most patients suffering from cardiac arrest with return of spontaneous circulation
(ROSC) die with anoxic brain injury. Therapeutic hypothermia serves to improve the
chance of a good neurologic outcome.
Criteria for inclusion:
 Witnessed cardiac arrest with ROSC
 Not pregnant
 Age  18 years
 No evidence of trauma or intracranial hemorrhage
 Significant altered level of consciousness
 Not following commands
 No purposeful movement
 Incomprehensible speech
 No known surgery within the preceding 2 weeks
 No history of bleeding disorder
 Warfarin/Coumadin and Heparin are NOT contraindications
 Patient must have airway secured (BIAD/ETT)

Paramedic
 Full ALS Assessment and Treatment
 12-Lead EKG
 Ensure all inclusion/exclusion criteria are met.
 If airway not secured and it will not delay transport to the appropriate
receiving facility, perform RSA, refer to Rapid Sequence Airway Protocol as
needed.
 Assess neurological status prior to intubation, document each of the three
GCS criteria.
 Once airway secured/sedated, expose patient and apply ice packs to axilla,
groin and neck.
 Administer Midazolam 1-2 mg every 3-5 minutes IV/IO to a max of 10 mg.
 Administer 30 ml/kg of cool saline (4°C) to a max of 2 liters IV.
 If shivering, administer Rocuronium 1 mg/kg IV/IO.

61
 If systolic blood pressure < 90 mmHg, initiate Dopamine infusion at 5-20
mcg/kg/min, titrate to SBP > 90 mmHg
 Closely monitor ventilation, target ETCO2 to 40 mmHg, do not hyperventilate.
 If at any time there is loss of spontaneous circulation, discontinue cooling and
go to the appropriate protocol.

Contact Medical Control for any additional orders or questions

62
Policy:

Unsuccessful cardiopulmonary resuscitation (CPR) and other advanced life support

(ALS) interventions may be discontinued prior to transport or arrival at the hospital
when this procedure is followed:

Note: When asystole is seen on the cardiac monitor, confirmation of the rhythm shall include a
PRINTED rhythm strip, as well as documented interpretation of the rhythm strip in more than one
lead. Low amplitude V-fib or PEA may be difficult to distinguish from asystole when using only the
cardiac monitor display for interpretation.

Procedure:
1) Discontinuation of CPR and ALS intervention may be implemented by a
Paramedic without Medical Control consultation in a non-hypothermic adult
provided all 7 criteria exist:

□ Arrest is presumed to be of cardiac origin

□ Initial rhythm is asystole, confirmed in two leads on a printed strip
□ Terminal rhythm is asystole confirmed in two leads on a printed strip
□ Secure airway confirmed by digital capnography (ETT/BIAD)
□ At least four doses of Epinephrine have been administered
□ Cardiac Arrest refractory to minimum of 20 minutes of ACLS
□ Quantitative EtCO2 value is <10mmHg with effective CPR, after 20 minutes of
ACLS

2) Field termination if the above 7 criteria aren’t met after 20 minutes of ACLS must
be approved by Medical Control.

3) The paramedic has the discretion to continue resuscitation efforts if scene

safety, location, patients age, time of arrest, or bystander input compels this
decision.
DO NOT TERMINATE RESUSCITATION IF PATIENT HAS BEEN MOVED TO THE
AMBULANCE OR IF TRANSPORT HAS BEEN INITIATED.

Contact Medical Control for any additional orders or questions.

Basic and A-EMT need to call Medical Control for Permission to Cease
Resuscitation!
Service MD Approval:______

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

63
Policy:

Resuscitation can be withheld in Medical Cardiopulmonary Arrest under the following

circumstances:
□ Adult patient >18 years of age AND
□ Pulseless, Apneic and no other signs of life present AND
□ Asystole verified in two (2) leads AND
□ Not exposed to an environment likely to promote hypothermia AND
□ The presence of one or more of the following:
*Rigor Mortis
*Decomposition of body tissues
*Dependent lividity OR
*When the patient has a valid State of Wisconsin DNR order/bracelet/
wristband

If unknown DNR status or questions regarding validity of DNR status, initiate

resuscitation and contact OLMC.

Service MD Approval:______

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

64
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Medications Tachycardia Heart Disease (WPW, Valvular)
(Aminophylline, diet pills, QRS <0.12 sec Sick sinus syndrome
thyroid supplements, Dizziness, CP, SOB Myocardial Infarction
decongestants, Digoxin) Potential presenting rhythm Electrolyte imbalance
Diet (caffeine, chocolate) Sinus tachycardia Exertion, pain, emotional stress
Drugs (nicotine, cocaine) Atrial fibrillation/flutter Fever
Past medical history Multifocal atrial tachycardia Hypoxia
History of palpitations/heart racing Hypovolemia or Anemia
Drug effect / OD (see HX)

Cardiac Protocol
Hyperthyroidism
Pulmonary embolus
General Approach to all Adult Patients

A IV Protocol A
HR <150
And no symptoms
HR >150, Afib on monitor
Serious signs and symptoms
Monitor BP <90mmHg, Altered LOC
and HR >150, Afib on
monitor
Transport and

2013
SBP >90mmHg
and mild symptoms Sedation if patient condition allows and SBP >90mmHg
Fentanyl 25‐50 mcg and Midazolam 1‐2 mg IV/IO/IN
P Titrate to max total dose of Fentanyl 200 mcg and P
12 Lead EKG Midazolam 4mg

Synchronized Cardioversion
No History of WPW
First Energy Level: 100 Joules
Diltiazem 0.25 mg/kg IV over 5 minutes
If no response: 200 J
P (max 20 mg per dose)
If unsuccessful afer 10 min and SBP P P If no response: 200 J (300 J if available) P
If no response: 200 J (360 J if available)
>100mmHg
Diltiazem 0.35 mg/kg IV (max 20mg)

History of WPW
Amiodarone 150mg IV in 100ml Consult Medical
P D5W over 10 minutes
P M Control M
May repeat 1x if SBP >100mmHg
Service MD Approval:______

After rate control/conversion

12 Lead EKG

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Repeat Blood Pressure after Diltiazem administration.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
65
 Cardiac Arrhythmias:
Atrial Fibrillation or Flutter
All Providers
 General Patient Care Protocol-Adult
 12 Lead EKG

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment
 Do not delay treatment if patient is unstable by obtaining 12-lead ECG unless
diagnosis is in question
Stable or borderline – Systolic BP >90 mmHg and mild symptoms (chest pain, SOB
or lightheadedness)
 No history of WPW:
 Diltiazem 0.25 mg/kg IV over 5 min (Max 20 mg per dose)
 If unsuccessful after 10 min and SBP >100 mmHg
 Diltiazem 0.35 mg/kg IV (max 20mg)
 History of WPW
 Amiodarone 150 mg IV in 100 ml D5W over 10 min
 If unsuccessful and SBP>100 mmHg, may repeat one time
Unstable (serious signs and symptoms-pulmonary edema, BP<90 mmHg systolic,
altered consciousness) AND atrial fibrillation at a rate >150 beats/minute
 Sedation if patient condition and time allows (hold if SBP <90mmHg):
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg
 Synchronized Cardioversion
 1st energy level: 100 Joules
 If no response: 200 J
 If no response: 200 J (300 J if available)
 If no response: 200 J (360 J if available)

Contact Medical Control for any additional orders or questions

66
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
History: Signs and Symptoms Acute Myocardial Infarction
Past medical history HR <60/minute with hypotension, Hypoxia
Medications acute altered mental stufs, chest Pacemaker failure
‐Beta Blockers pain, acute CHF, seizures, syncope, Hypothermia
‐Calcium Channel blockers or shock secondary to bradycardia Sinus Bradycardia
‐Clonidine Chest Pain Athletes
‐Digoxin Respiratory distress Head Injury (elevated ICP) or
Pacemaker Hypotension or Shock Stroke
Altered mental Status Spinal Cord Lesion

Cardiac Protocol
Syncope Sick sinus syndrome
AV Blocks (1°, 2°, 3°)
Overdose
General Approach to All Adult Patients

12 Lead EKG

A IV Protocol A

Hypotension ‐ SBP <90mmHg,

Altered Mental Status or NO Monitor

2013
Chest Pain

YES

A IV NS Bolus 250ml A Transport

No Improvement

Medication Atropine 0.5mg IVP, repeat every 3

Overdose?
P minutes as needed (max 3.0mg/kg P
No Improvement

Appropriate Overdose
Protocol P Dopamine 5‐20mcg/kg/min IV P Unstable
External Pacing
No Improvement P Procedure P
Epi Infusion 2‐10mcg/min titrate to Unstable
P HR>60, SBP <180 (max 10mcg/min) P Continuous
Improved Monitoring

Pearls Continuous Sedation

RECOMMENDED EXAM: Mental Status, Neck, Heart, Monitoring P Protocol P
Lungs, Neuro
*Start at lowest MA’s, increase until electrical capture with
pulses achieved Transport
Start rate at 70 or default and increase rate to achieve Midazolam
Fentanyl
systolic BP >90mmHg (maximum 100 beats/min) 1‐2mg
25‐50mcg
Therapies are only indicated when serious signs and P IV/IO (max P P IV/IO (max P
symptoms are present. If symptoms are mild, 4mg)
provide supportive care and expedite transport.
200 mcg)
Consult
In wide complex slow rhythm consider hyperkalemia
Be sure to aggressively oxygenate the patient and M Medical M
support respiratory effort Control
Service MD Approval:______

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
67
 Cardiac Arrhythmias:
Bradycardia

All Providers
 General Patient Care Protocol-Adult
 12 Lead EKG

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment
 Do not delay transport if patient is unstable by obtaining a 12 lead ECG
unless diagnosis is in question

Note: The following therapies are indicated only when serious signs and
symptoms are present. If symptoms are mild, provide supportive care and
expedite transport.

Symptomatic (SBP<90mmHg, altered mental status or severe chest pain)

 Atropine 0.5 mg IVP, Repeat every 3 minutes as needed (Maximum dose
3mg)
 If symptoms persist after Atropine or any delay in establishing IV:
 Initiate transcutaneous pacing using demand mode
 Start at lowest MA’s; increase until electrical capture with pulses
achieved
 Start rate at 70 and increase rate to achieve systolic BP >90mmHg
(Maximum 100 beats/minute)
 Sedation if patient condition and time allows (hold if SBP<90 mmHg):
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg
 For hypotension (systolic BP <90 mmHg) and/or Bradycardia (HR<60)
not improved by above
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain HR
>60 and SBP >90 mmHg but SBP <180 mmHg.
 If above unsuccessful:

68
  Epinephrine infusion at 2-10 mcg/min titrated to maintain HR>60
and SBP >90 mmHg but SBP <180mmHg.
 If drug induced, treat for specific drug overdose
 Calcium Chloride 1g IV/IO for calcium channel blocker OD
 Contraindicated if patient on Digoxin/Lanoxin
 Glucagon 3mg IV/IO for calcium channel blocker
OD if no response to Calcium Chloride
 Glucagon 3mg IV/IO for Beta Blocker OD
 Naloxone (Narcan) can be given in 0.4 mg increments titrated to
level of consciousness and respiratory drive
 If IV access has not been established, Naloxone
(Narcan) 2 mg IM or via Mucosal Atomizer Device
 Sodium Bicarbonate 1 mEq/kg IV/IO for Tricyclic antidepressant
OD

Contact Medical Control for any additional orders or questions

69
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Medications HR >150 bpm Heart Disease (WPW, Valvular)
(Aminophylline, diet pills, QRS <0.12 sec (if QRS >0.12 sec, Sick sinus syndrome
thyroid supplements, go to V‐Tach protocol Myocardial Infarction
Decongestants, Digoxin) If history of WPW, go to V‐Tach Electrolyte imbalance
Diet (caffeine, chocolate) protocol Exertion, pain, emotional stress
Drugs (nicotine, cocaine) Dizziness, CP, SOB Fever
Past medical history Potential presenting rhythm Hypoxia
History of palpitations/heart Atrial/Sinus tachycardia Hypovolemia or Anemia
racing Atrial fibrillation/flutter Drug effect / OD (see HX)

Cardiac Protocol
Syncope / near syncope Multifocal atrial tachycardia Hyperthyroidism
Pulmonary embolus
General Approach to all Adult Patients

A IV Protocol A
Stable Unstable
Ventricular rate >150 Ventricular rate >150

12 Lead EKG Adenosine Phosphate 6mg rapid IVP over 1‐3 seconds
P with 20 cc NS flush ‐ (repeat with 12mg rapid IVP if no
response in 2 min) May repeat x1.
P

2013
Vagal Maneuvers
P (Valsalva or Cough) P If NO Response

Sedation if patient condition allows and SBP >90mmHg

Adenosine Phosphate 6 mg rapid Fentanyl 25‐50 mcg and Midazolam 1‐2 mg IV/IO
IVP over 1‐3 seconds with 20 cc P Titrate to max total dose of Fentanyl 200 mcg and P
NS flush Midazolam 4mg
P (repeat with 12mg rapid IVP if no P
response in 2 min)
May repeat x1. Synchronized Cardioversion
First Energy Level: 50 Joules
If no response: 100 J
P If no response: 200 J P
M Consult Medical Control M If no response: 200 J (300 J if available)
If no response: 200 J (360 J if available)

Diltiazem 0.25mg/kg slow IV over 5 min

(max 20mg)
M P (NOT for use with or hx of WPW) P M
Service MD Approval:______
Amiodarone 150mg IV over 10 min

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
If patient has a history or 12 Lead EKG reveals Wolfe Parkinson White (WPW), NO NOT administer Calcium Channel Blocker (Diltazem) or Beta
Blockers
Adenosine will not terminate non SVT rhythms such as Afib or Aflutter..
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Continuous pulse oximetry is required for all SVT patients
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
70
 Cardiac Arrhythmias:
Supraventricular Tachycardia
All Providers
 General Patient Care Protocol—Adult
 12 Lead EKG

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment
 Do not delay treatment if patient is unstable by obtaining 12-lead ECG
unless diagnosis is in question
Stable or borderline (Ventricular rate >150)
 Vagal maneuvers (Valsalva or Cough)
 Adenosine Phosphate (Adenocard) 6 mg rapid IVP over 1-3 seconds with 20
ml Normal Saline flush
 If no response in 2 minutes, Adenosine Phosphate (Adenocard) 12 mg
rapid IVP over 1-3 seconds with 20 ml Normal Saline flush.
 If no response in 2 minutes, may repeat Adenosine Phosphate
(Adenocard) 12mg rapid IVP x1.
Unstable with serious signs and symptoms (Ventricular rate >150)
 May give brief trial of Adenosine 6mg rapid IVP over 1-3 seconds with 20 cc
Normal Saline flush
 Sedation if patient condition and time allows (hold if SBP<90mmHg)
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg
 Synchronized Cardioversion
 First energy level: 50 Joules
 If no response: 100 J
 If no response: 200 J
 If no response: 200 J (300 J if available)
 If no response: 200J (360 J if available)

Contact Medical Control for any additional orders or questions

 Diltiazem 0.25mg/kg slow IV over 5 min (Max 20mg)
 NOT FOR USE WITH OR HISTORY OF WPW
 Amiodarone 150mg IV over 10 min
71
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms
Differential
Past Medical History / Ventricular tachycardia on ECG
Artifact / Device failure
medications, diet, drugs (Runs or sustained)
Cardiac
Syncope / near syncope Conscious, rapid pulse
Endocrine / Metabolic
CHF Chest pain, shortness of breath
Drugs
Palpitations Dizziness
Pulmonary
Pacemaker Rate usuaally 150‐180bpm for
Allergies: lidocaine / novacaine sustained Vtach
QRS >.12 sec

Cardiac Protocol
General Approach to all Adult Patients
Vfib/
Pulseless Palpable pulse?
NO
Vtach (Paramedics: Wide, regular rhythm with QRS >0.12sec)
Protocol
YES

A IV Protocol A
Unstable
Stable and SVT highly likely 12 Lead EKG With serious signs and
(Rate >150) symptoms

2013
Stable and unknown
Wide complex or Vtach
Sedation if patient condition allows and
Likely (Rate >150) SBP >90mmHg
Fentanyl 25‐50 mcg and Midazolam
P 1‐2 mg IV/IO/IN P
Titrate to max total dose of Fentanyl 200
Adenosine mcg and Midazolam 4mg
Phosphate 6mg
rapid IVP over Amiodarone 150mg
1‐3 seconds with in 100ml D5W IV
20 cc NS flush Piggyback over 10
P (repeat with 12mg
P No
Response P minutes P
Synchronized Cardioversion **
First Energy Level: 100 Joules
rapid IVP if no
response in 2 min)
May repeat every 15 P If no response: 200 J P
min If no response: 200 J (300 J if available)
May repeat x1. (Max 450mg total) If no response: 200 J (360 J if available)

IF wide complex tachy reoccurs

Following cardioversion
If hyperkalemia suspected in any wide complex
tachycardia (ie. Renal failure patient)
M Contact Medical Control M P Calcium Chloride 1g IV/IO* P
Sodium Bicarbonate 1mEq/kg IV/IO
Pearls
-RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
* Calcium Chloride Contraindicated for patient on Digoxin/Lanoxin
Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful.
Service MD Approval:______
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Continuous pulse oximetry is required for all SVT patients
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.
** If delays in synchronization occur and condition is critical, go immediately to unsynchronized shocks

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
72
 Cardiac Arrhythmias:
Wide‐Complex Tachycardia
All Providers
 General Patient Care Protocol-Adult
 12 Lead EKG

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment
 Do not delay treatment by obtaining 12-lead ECG unless diagnosis is in
question
 In general, assume unknown wide complex tachycardia, at rates over 150
represent ventricular tachycardia

Stable and unknown wide complex or ventricular tachycardia likely

(rate >150)
 Consider Adenosine Phosphate (Adenocard) 6 mg rapid IVP over 1-3
seconds with 20 ml Normal Saline flush
 For atypical presentation of SVT
 If no response after first dose and patient still stable move to
Amiodarone.
 Amiodarone 150 mg in 100 ml D5W IV Piggyback over 10 minutes
 Repeat Amiodarone 150 mg in 100ml D5W IV Piggyback over 10
minutes every 15 minutes (Maximum of 450 mg total)
Unstable wide complex tachycardia (rate >150)
 Sedation if patient condition and time allows (hold for SBP <90 mmHg)
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg

73
 Synchronized Cardioversion:
 1st energy level 100 Joules
 If no response 200 J
 If no response 200 J (300 J if available)
 If no response 200 J (360 J if available)
 If delays in synchronization occur and condition is critical, go immediately to
unsynchronized shocks
 If wide complex tachycardia reoccurs following electrical cardioversion:
 Amiodarone 150 mg in 100 ml D5W IV Piggyback, over 10 minutes,
every 15 minutes (maximum 450 mg cumulative total dose)
 If hyperkalemia suspected in any wide complex tachycardia (e.g. renal failure
patient) administer the following medications:
 Calcium Chloride 1g IV/IO
 Contraindicated if patient on Digoxin/Lanoxin
 Sodium Bicarbonate 1mEq/kg IV/IO

Contact Medical Control for any additional orders or questions

74
 History: Signs and Symptoms
Differential
Past Medical History / Ventricular tachycardia on ECG
Artifact / Device failure
medications, diet, drugs (Runs or sustained)
Cardiac
Syncope / near syncope Conscious, rapid pulse
Endocrine / Metabolic
CHF Chest pain, shortness of breath
Drugs
Palpitations Dizziness
Pulmonary
Pacemaker Rate usuaally 150‐180bpm for
Allergies: lidocaine / novacaine sustained Vtach
QRS >.12 sec

Legend

Cardiac Protocol
General Approach to all Adult Patients
Vfib/ EMT
Pulseless
NO
Palpable pulse? A A‐EMT A
Vtach (Paramedics: Wide, regular rhythm with QRS >0.12sec)
Protocol P Paramedic P
YES M Medical Control M
A IV Protocol A
STABLE 12 Lead EKG UNSTABLE

2013
Magnesium Sulfate 2g Sedation if patient condition allows and
P slow IV in 10ml NS over P SBP >90mmHg
1‐2 min Fentanyl 25‐50 mcg and Midazolam 1‐2
P mg IV/IO P
NO Response Titrate to max total dose of Fentanyl 200
mcg and Midazolam 4mg
No Response
And
UNSTABLE
Amiodarone
150mg in 100ml Synchronized Cardioversion
D5W IV Piggyback First Energy Level: 100 Joules
over 10 minutes If no response: 200 J
P P If no response: 200 J (300 J if available)
May repeat every
15 min
P If no response: 200 J (360 J if available) P
(Max 450mg If delays in synchronization occur and
total) condition is critical, go immediately to
unsynchronized shocks

M Contact Medical Control M

Pearls
-RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
* Calcium Chloride Contraindicated for patient on Digoxin/Lanoxin
Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful. Service MD Approval:______
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Continuous pulse oximetry is required for all SVT patients
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.

Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
75
 Cardiac Arrhythmias:
Polymorphous Ventricular Tachycardia
(Torsades de Pointes)
All Providers
 General Patient Care Protocol-Adult
 12 Lead EKG

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment
 Do not delay treatment if patient is unstable by obtaining a 12-lead
ECG unless diagnosis is in question
Stable
 Magnesium Sulfate 2 g slow IV in 10 ml NS over 1-2 minutes
 If no response, Amiodarone 150 mg in 100 ml D5W IV Piggyback over 10
minutes
 Repeat Amiodarone 150 mg in 100 ml D5W IV Piggyback over 10
minutes every 15 minutes (Maximum of 450 mg total)
Unstable-or if no response to the above measures:
 Sedation if patient condition and time allows (hold if SBP < 90mmHg)
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg
 Synchronized Cardioversion:
 1st energy level 100 Joules
 If no response 200 J
 If no response 200 J (300 J if available)
 If no response 200 J (360 J if available)
 If delays in synchronization occur and condition is critical, go immediately to
unsynchronized shocks

Contact Medical Control for any additional orders or questions

76
 Legend
EMT
A A‐EMT A
P Paramedic P
Medical
M Control M
History: Differential
Age Signs and Symptoms
CP (pain, pressure, aching, Trauma vs. Medical
Medications Angina vs. MI
Viagra, Levitra, Cialis vice like tightness)
Location (substernal, Pericarditis
Past Medical History (MI, Angina, Diabetes, Pulmonary embolism
epigastric, arm, jaw, neck,
post menopausal) Asthma / COPD
shoulder)
Allergies (ASA, morphine, lidocaine) Pneumothorax
Radiation of pain
Recent physical exertion Aortic dissection or aneurysm
Pale, diaphoresis
Palliation/Provocation GE reflux or hiatal hernia
Shortness of Breath
Quality (crampy, constant, sharp, dull, etc. Esophogeal spasm
Nausea, vomiting, dizziness
Region/Radiation/Referred Chest wall injury or pain

Cardiac Protocol
Time of Onset
Severity (1‐10) Pleural pain
Time (onset/duration/repitition) OD (Cocaine) or Methamphetamine

General Approach to All Adult Patients

IF symptoms for <12 hours, and any of the following:
Obtain and Transmit 12 Lead EKG within 5 minutes of Paramedic interprets ST segment elevation >1mm in two
arrival or more contiguous leads
Defib interpretation of “**ACUTE MI**” on EKG
Aspirin 324 mg PO New Left BBB (confirmed by comparing to prior EKG)

IV Protocol
A 250ml if hypotensive A
Patient assisted Nitroglycerin 0.4mg STEMI ALERT

2013
SL, repeat every 5 minutes as needed
M if SBP >90mmHG and not M Transport to PCI (Percutaneous Coronary Intervention) capable
contraindicated* hospital
University of WI Hospitals and Clinics
Nitroglycerin 0.4mg SL if IV*** Meriter Hospital
established, repeat every 5 minutes St. Marys Hospital (not Sun Prairie ED)
A as needed if SBP >90mmHG and not A VA Hospital
(patient preference should be taken into account)
contraindicated*
For hypotension (<90mmHg) not Notify facility EARLY
improved by fluid or if fluid
P contraindicated – Dopamine infusion P
at 5‐20 mcg/kg/min titrated to
maintain SBP >90mmHg
Morphine Sulfate 2‐4mg slow IVP,
repeat every 5 minutes as needed
P (max 15mg) or Fentanyl 25‐50 mcg P Service MD Approval:______
slow IV, repeat every 5 minutes (max Pearls
200mcg)** RECOMMENDED EXAM: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back,
Extremities, Neuro
If Runs of Vtach:
*Nitro Contraindications: SBP<90, Use of a Phosphodiesterase-5 (PED5)
Amiodarone 150 mg in 100 ml D5W inhibitor within last 24 hours (Viagra [Sildenafil] or Levitra [Vardenafil]) and
P IV piggyback over 10 minutes P 48 hours for Cialis (Tadalifil)- Use with caution in Acute Inferior Wall MI, or
(isolated PVCs do not require Right Ventricular infarct (ST elevation in V4R)
treatment) Patient Assisted Nitro -send EKG and have OLMC determine if Nitro
appropriate
Nausea or Vomiting **Morphine contraindicated if SBP<90mmHg, use with caution in right
P Ondansetron (Zofran) 4 mg slow IV P ventricular or posterior wall MI (ST elevation in posterior leads with marked
depression in V1-V4)
*** If unable to establish IV, send EKG and contact OLMC for permission to
proceed with Nitro
Elderly patients, diabetics, and woman are more likely to experience angina
(cardiac chest pain) in an atypical fashion – presenting as vague weakness,
SOB, arm, back or jaw discomfort, etc.
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
77
 Chest Pain
All Providers
 General Patient Care Protocol—Adult
 Obtain and transmit 12-lead ECG within 5 minutes of arrival
 Aspirin 324 mg PO chewed if patient is able to swallow and Aspirin is not
contraindicated or taken within the last hour.
 Assist patient in self-administration of previously prescribed Nitroglycerin
 Contact Medical Control for consultation regarding 12 Lead EKG
interpretation prior to assisting with patient Nitro.
 Contraindicated if systolic BP < 90 mmHg
 Contraindicated if use of a Phosphodiesterase-5 (PED5) inhibitor
within last 24 hours (Viagra [Sildenafil] or Levitra [Vardenafil])
 This contraindication extends to 48 hours for Cialis (Tadalifil)
 Repeat patient assisted Nitroglycerin administration every 5 minutes as
needed for continued chest pain (provided SBP remains > 90 mmHg) with
assessment of patient before and after each NTG dose
 See STEMI alert information below

Advanced EMT
 IV Protocol
 For suspected cardiac chest pain:
o Aspirin 324 mg PO chewed if patient is able to swallow and Aspirin is
not contraindicated or given already
o Nitroglycerin 0.4 mg SL, every 5 minutes as needed for chest pain
 IV access must be secured before Nitroglycerin
administration (if unable, contact Medical Control)
 Contraindicated if systolic BP < 90 mmHg
 Contraindicated if use of a Phosphodiesterase-5 (PED5)
inhibitor within last 24 hours (Viagra [Sildenafil] or Levitra
[Vardenafil])
 This contraindication extends to 48 hours for Cialis (Tadalifil)
o Use with caution in Acute Inferior Wall MI, or Right Ventricular infarct
(ST elevation in V4R)
o Be prepared to administer IV NS boluses at 250 mL if hypotension
develops

78
Paramedic
 Full ALS Assessment and Treatment
 Obtain 12-lead ECG within 5 minutes of arrival
 Identify the presence of ECG changes suggestive of Acute Myocardial Infarct
(AMI)
 See STEMI Alert below
 Prior to transport notify receiving hospital as per STEMI Alert Criteria
 For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or
when fluid boluses are contraindicated
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP
> 90 mmHg

 For suspected cardiac chest pain:

o Aspirin 324 mg PO chewed if patient is able to swallow and Aspirin is
not contraindicated or given already
o Nitroglycerin 0.4 mg SL, every 5 minutes as needed for chest pain
 IV access must be secured before Nitroglycerin
administration (If unable, contact Medical Control)
 Contraindicated if systolic BP < 90 mmHg
 Contraindicated if use of a Phosphodiesterase-5 (PED5)
inhibitor within last 24 hours (Viagra [Sildenafil] or Levitra
[Vardenafil])
 This contraindication extends to 48 hours for Cialis (Tadalifil)
 IV access must be secured before Nitroglycerin
administration (If unable, contact Medical Control)
o Use with caution in Acute Inferior Wall MI, or Right Ventricular infarct
(ST elevation in V4R)
o Be prepared to administer IV NS boluses at 250 mL if hypotension
develops
o Morphine Sulfate 2-4 mg slow IVP; repeat every 5 minutes as needed
(Maximum 15 mg) or Fentanyl 25-50 mcg slow IV; repeat every 5
minutes (Maximum 200 mcg)
 Contraindicated if systolic BP < 90 mmHg
 Use with caution in right ventricular or posterior wall MI
(ST elevation in posterior leads with marked depression
in V1-V4)
 Runs of Ventricular Tachycardia:
 Amiodarone 150 mg in 100 ml D5W IV piggyback over 10 minutes
 Isolated PVCs do not require treatment

79
  For patients with severe nausea or vomiting:
 Ondansetron (Zofran) 4 mg slow IV

All Providers

STEMI Alert (ST Segment Elevation Myocardial Infarction)

 A STEMI Alert will be instituted for patients having chest pain or ischemic
equivalent symptoms for < 12 hours, and any of the following
 Computer interpretation of “**ACUTE MI**” on 12-lead ECG (EMT
Basic or Advanced)
 Paramedic Interprets - ST segment elevation  1mm in two or more
contiguous leads
 Paramedic Interprets - New Left Bundle Branch Block (confirmed by
comparing to prior ECG)
 Patients meeting STEMI Alert criteria should be transported to a PCI
(Percutaneous Coronary Intervention) capable hospital
 PCI Capable hospitals in the Madison Area:
 University of Wisconsin Hospitals and Clinics
 Meriter Hospital
 St. Mary’s Hospital Madison
 VA Hospital
 Patient preference should be taken into account when determining the
transport destination.
 Early notification/ECG transmission to the receiving facility is imperative.
 Activation of the STEMI Process must be documented in the Patient Care
Run Sheet

Contact Medical Control for any additional orders or questions

80
Assure your local Fire Department is dispatched to assist if necessary.
Consult Emergency Response Guidebook (ERG) before attempting to handle any toxic chemical exposure patient
Upon identifying a possible toxic exposure or overdose: Contact the Regional Poison Control Center (1‐800‐222‐1222)
Upon identifying a possible hazmat exposure: Contact City of Madison HIT for chemical information via the 911
Communications Center

Chemical Burns and Dermal Exposure

All Providers
General Patient Care Protocol—Adult
Refer to the Burn Protocol

Special Response Protocols

Stop the burning process
Remove all clothing prior to irrigation
If a caustic liquid is involved, flush with copious amounts of water
For chemical burns with eye involvement, immediately begin flushing the eye with normal
saline and continue throughout assessment and transport
If a dry chemical is involved, brush it off, then flush with copious amount of water
Do not use water to flush the following chemicals:
Elemental metals (sodium, potassium, lithium), and phenols
Remove obvious metallic fragments from the skin
Cover the burn with mineral oil or cooking oil
Phenols penetrate the skin more readily when diluted with water
If available, dilute with the following (listed in order of efficacy)
Polyethylene glycol (PEG)
Glycerol
Vegetable Oil
As a last resort use extremely large amounts of soap and water with continuous
irrigation until all phenols are removed
Apply a burn sheet or dry sterile dressing to burn areas
For inhaled toxin with acute bronchospasm:
Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and
Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer
Advanced EMT
Consider IV Protocol
Paramedic
Full ALS assessment and treatment
Observe for signs of impending respiratory failure; Refer to Contact Medical Control for any
additional orders or questions
the Airway Management Protocol if needed For persistent burning sensation of
Refer to Pain Management Protocol if needed the airways (after Albuterol/
Atrovent) in the setting of Chlorine/
Chloramine exposure:
Other possible #’s for assistance: 4.2 % Sodium Bicarbonate
Chemtrec: 1-800-424-9300 5ml via nebulizer
Mix 2.5 ml of 8.4 % Sodium
Chemtell: 1-888-255-3924
Bicarbonate with 2.5 ml of 0.9 %
Infotract: 1-800-535-5053 Normal Saline for a 5 ml nebulizer
3E: 1-800-451-8346

Special Response Protocol

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

81
 Hazardous Material Exposures:
Basic Approach
Assure that local Fire Department is responding with EMS if appropriate.

Consult Emergency Response Guidebooks (ERG) before attempting to handle

any toxic chemical exposure patient

Upon identifying a possible toxic exposure or overdose:

Contact the Regional Poison Control Center (1-800-222-1222)

Upon identifying a possible hazmat exposure: Contact City of Madison HIT for
chemical information via the 911 Communications Center

Other possible #’s for assistance:

Chemtrec: 1-800-424-9300
Chemtell: 1-888-255-3924
Infotract: 1-800-535-5053
3E: 1-800-451-8346

Chemical Burns and Dermal Exposure

All Providers
 General Patient Care Protocol—Adult
 Refer to the Burn Protocol
 Stop the burning process
 Remove all clothing prior to irrigation
 If a caustic liquid is involved, flush with copious amounts of water
 For chemical burns with eye involvement, immediately begin flushing the eye
with normal saline and continue throughout assessment and transport
 If a dry chemical is involved, brush it off, then flush with copious amount of
water

82
  Do not use water to flush the following chemicals:
 Elemental metals (sodium, potassium, lithium), and phenols
 Remove obvious metallic fragments from the skin
 Cover the burn with mineral oil or cooking oil
 Phenols penetrate the skin more readily when diluted with water
 If available, dilute with the following (listed in order of efficacy)
 Polyethylene glycol (PEG)
 Glycerol
 Vegetable Oil
 As a last resort use extremely large amounts of soap and water with
continuous irrigation until all phenols are removed
 Apply a burn sheet or dry sterile dressing to burn areas

 For inhaled toxin with acute bronchospasm:

 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium Bromide
0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS assessment and treatment
 Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol if needed
 Refer to Pain Management Protocol if needed

Contact Medical Control for any additional orders or questions

 For persistent burning sensation of the airways (after
Albuterol/Atrovent) in the setting of Chlorine/Chloramine
exposure:
 4.2 % Sodium Bicarbonate 5ml via nebulizer
 Mix 2.5 ml of 8.4 % Sodium Bicarbonate with 2.5 ml
of 0.9 % Normal Saline for a 5 ml nebulizer

83
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M Signs
Altered mental status
Symptoms Seizures or coma
Headache Dyspnea/tachypnea
Confusion Respiratory distress/apnea
Shortness of Breath Hypertension (early)
Chest Pain or tightness Hypotension (late)
Nausea/Vomiting Cardiovascular collapse/Cardiac Arrest

General Approach to All Patients

Special Response Protocols

Scene Safety – SCBA if toxic inhalation suspected

Remove patient from contaminated area

Administer 100% Oxygen

A IV Protocol A

*Administer Cyanokit® 5g
IV/IO over 15 minutes
P P
Use NaCl 0.9% as the dilutent for Cyanokit® as per
manufacturer instructions

Expedite transport and treat other Service MD Approval:______

conditions as per appropriate protocol

Consult Medical Control

If severe symptoms persist (patient in extremis)
M contact OLMC for consideration
M
of repeat dosing

Pearls
*Contraindicated in patients with known anaphylactic reactions to hydroxocobalamin or cyanocobalamin
Cyanide poisoning may result form inhalation, ingestion or dermal exposure to cyanide containing compounds, including smoke form closed‐space
fires. The presence and extent of the poisoning are often unknown initially. Treatment decisions must be made on the basis of clinical history and
signs and symptoms of cyanide intoxication.
Not all patients who have suffered smoke inhalation from a closed space fire will have cyanide poisoning. Other conditions such as burns, trauma
or other toxic inhalations (ie. Carbon monoxide) may be the cause of symptoms. When smoke inhalation is the suspected source of cyanide
exposure assess the patient for the following:
● Exposure to fire or smoke in an enclosed space ● Presence of soot around the mouth, nose or oropharynx ● Altered Mental Status

Special Response Protocol

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
84
 Hazardous Materials Exposure:
Cyanide Toxicity and Smoke Inhalation
Cyanide poisoning may result from inhalation, ingestion or dermal exposure to
cyanide containing compounds, including smoke from closed-space fires. The
presence and extent of the poisoning are often unknown initially. Treatment
decisions must be made on the basis of clinical history and signs and symptoms of
cyanide intoxication.

Not all patients who have suffered smoke inhalation from a closed-space fire will
have cyanide poisoning. Other conditions such as burns, trauma or other toxic
inhalations (e.g. carbon monoxide) may be the cause of symptoms. When smoke
inhalation is the suspected source of cyanide exposure assess the patient for the
following:

 Exposure to fire or smoke in an enclosed space

 Presence of soot around the mouth, nose or oropharynx
 Altered mental status

Common Signs and Symptoms of Cyanide Toxicity

Symptoms Signs
 Headache  Altered mental status
 Confusion  Seizures or coma
 Shortness of breath  Dyspnea/tachypnea
 Chest Pain or tightness  Respiratory distress/apnea
 Nausea/Vomiting  Hypertension (early)
 Hypotension (late)
 Cardiovascular collapse/cardiac arrest

All Providers
 General Patient Care Protocol—Adult
 Supplemental 100% Oxygen

Advanced EMT
 Consider IV Protocol

Paramedic
 Perform Full ALS Assessment and Treatment
 When clinical suspicion of Cyanide poisoning is high
 Administer Cyanokit 5 g IV/IO over 15 minutes

85
  Use NaCl 0.9% as the diluent for Cyanokit as per manufacturer
instructions
 Contraindicated in patients with known anaphylactic reactions to
hydroxocobalamin or cyanocobalamin
 Expedite transport and treat other conditions as per appropriate protocol

Contact Medical Control for any additional orders or questions

 If severe symptoms persist (patient in extremis) contact
OLMC for consideration of repeat dosing of Cyanokit

86
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M Differential Signs and Symptoms
Nerve agent exposure (ie. VX, Sarin, Visual Disturbances
Soman, etc.) Headache
History: Organophosphate exposure Nausea/vomiting
Exposure to chemical, biologic, (pesticide) Salivation
radiologic or nuclear hazard Vesicant exposure (ie. Mustard gas) Lacrimation
Potential exposure to unknown Respiratory irritant exposure (ie. Respiratory distress
substance/hazard Hydrogen sulfide, ammonia, Diaphoresis
chlorine, etc.) Seizure activity
Respiratory arrest
M Alert Medical Control Immediatly M

Special Response Protocol

Ensure Scene Safety and SCBA if toxic inhalation suspected
General Approach to All Patients

Obtain history of exposure

Observe for specific toxidromes
Initiate triage and/or decon as indicated

Assess Symptoms
MAJOR*
MINOR* Must show symptoms before treatment

A IV Protocol A
Adult Adult
Atropine 2mg IV/IO/IM every 5min **MARK 1 kit x3 immediately
until symptoms resolve
P Pediatric P Repeat Atropine 2mg IV/IO/IM every 5 min
Until symptoms resolve
Atropine 0.02mg‐0.05mg/kg IV/IO/IM
every 5min until symptoms resolve Lorazepam 1‐2mg IV/IO/IM or
Diazepam Auto Injector 10mg IM

P Pediatrics P
<7 – 1 MARK 1 kit
8‐14 – 2 MARK 1 kits
Monitor and Reassess >15 – 3 MARK 1 kits
Repeat Atropine 0.02mg‐0.05mg/kg
IV/IO/IM every 5 min until symptoms resolve

Re‐ Contact
M Medical Control M Lorazepam 0.1mg IV/IO/IM

Service MD Approval:______

Pearls
* Minor: salivation, lacrimation, visual disturbances
Major: altered mental status, seizure, respiratory distress, respiratory arrest
** MARK 1 and DuoDote kits carried on response vehicles are for Responders ONLY. There use referenced above
implies that the WMD stockpile has been released and delivered to the scene. Trained EMT Basic and
Advanced may also assist with Mark 1 IM injections
Follow local HAZMAT protocols for decon and use of PPE
For patients with major symptoms, there is no limit for atropine dosing
The main symptom that the atropine addresses is excessive secretions so atropine should be given until salivation improves.

Special Response Protocol

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
87
 Hazardous Materials Exposure: Nerve Agent/WMD
SIMULTANEOUSLY ALERT OLMC
All Providers
 General Patient Care Protocol—Adult
 Ensure Scene safety and proper PPE
 Obtain history of exposure, observe for toxidromes
 Initiate triage/Decontamination
 Consider need for additional resources
 Mark 1 Kit/DuoDote as below
 Mark 1 and DuoDote Kits carried on response vehicles are for
Responders ONLY. There use referenced below implies that the WMD
stockpile has been released and delivered to the scene

Paramedic
 Full ALS Assessment and Treatment
 Assess symptoms
 Minor symptoms: salivation, lacrimation, visual disturbances
 Adults-
 Atropine 2 mg IV/IO/IM every 5 minutes until symptoms
resolve
 Pediatrics-
 Atropine 0.02-0.05 mg/kg every 5 minutes until
symptoms resolve
 Major symptoms: altered mental status, seizures, respiratory distress,
respiratory arrest
 Adults-
 MARK 1 Kit X 3 IM IMMEDIATELY
o Repeat Atropine 2 mg IV/IO/IM every 5 minutes
until symptoms resolve
 Lorazepam 1-2 mg IV/IO/IM or Diazepam Auto-injector
10mg IM
 Pediatrics
 ≤ 7 years old 1 MARK 1 Kit
 8-14 years old, 2 MARK 1 kits
 ≥ 15 years old 3 MARK 1 Kits
o Repeat Atropine 0.02-0.05 mg/kg IV/IO every 5
minutes until symptoms resolve
 Lorazepam 0.1mg/kg IM/IV/IO

Contact Medical Control for any additional orders or questions

88
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

Signs and Symptoms

History: Differential
One of these
Documented Hypertension Hypertensive encephalopathy
Systolic BP 200 or greater
Related diseases: diabetes, Primary CNS injury (Cushings
Diastolic BP 110 or greater
CVA, renal failure, cardiac response = bradycardia with
And at least one of these
Medications (compliance ?) hypertension)
Headache
Erectile dysfunction medication Myocardial Infarction
Nosebleed
Pregnancy Aortic dissection (aneurysm)
Blurred vision
Pre‐eclampsia/Eclampsia
Dizziness

Medical Protocol
General Approach to All Adult Patients

Check BP in both arms

If Respiratory Distress Consider

Adult Dyspnea Protocol

2013
Consider
Chest Pain Protocol

12 Lead EKG

If Altered Mental Status, Stroke, Pulmonary

Edema, Chest Pain or Elevated Blood
Pressure
Refer to Specific Protocol

A IV Protocol A

Consult Medical
M Control if needed M

Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs Abdomen, Back, Extremities, Neuro
Never treat elevated blood pressure based on one set of vital signs
Symptomatic hypertension is typically revealed through end organ damage to the cardiac, CNS, or renal systems
All symptomatic patients with hypertension should be transported with their head elevated.

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
89
 Hypertensive Emergencies
Focus on addressing the manifestations of hypertensive emergencies, such as chest
pain or heart failure. Prehospital treatment of isolated hypertension may result in
critical reductions in target organ perfusion due to uncontrolled lowering of blood
pressure.

All Providers
 General Patient Care Protocol—Adult

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment

Symptomatic:
 Chest Pain present, refer to the specific protocol
 For patients with altered mental status, signs of stroke or pulmonary edema,
who are found to have elevated blood pressure, refer to the specific protocol
Asymptomatic:

 Provide supportive care

Contact Medical Control for any additional orders or questions

90
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Signs and Symptoms
Age Fever (Infection)
Altered mental status or
Exposure to increased temperatures Dehydration
unconsciousness
and/or humidity Medications
Hot, dry or sweaty skin
Past medical history / medication Hyperthyroidism (Storm)
Hypotension or shock
Extreme exertion Delirium tremens (DT’s)
Seizures
Time and length of exposure Heat cramps
Nausea
Poor PO intake Heat Exhaustion
Fatigue and/or muscle cramping Heat stroke
CNS lesions or trauma

General Approach to All Adult Patients

Medical Protocol
Move patient to cooler enviroment

HEAT EXHAUSTION
HEAT CRAMPS Dizziness, lightheaded, headache, irritability, HEAT STROKE
Painful spasms of the extremities or normal or decreased LOC, normal or
Marked alteration in LOC, extremely high
abdominal muscles, normal mental status decreased BP, tachycardia, normal or
temperature (often >104°F)may be sweating
and vitals) elevated temperature
or have red/hot/dry skin

Keep patient supine Semi‐reclining with head

Oral fluids 100% oxygen elevated 15‐30°
Sponge with cool water Remove clothing 100% oxygen
Sponge with cool water and fan Rapid cooling (prevent shivering as it
increases temperature)
Cold packs, sponge with
cool water, fan
A IV PROTOCOL A
A IV PROTOCOL A
Overdose
YES Cocaine or sympathomimetic
Protocol
toxicity suspected?
Transport
NO

Contact Medical
M Control M
Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Neuro
Extremes of age are more prone to heat emergencies (ie. Young and old)
Predisposed by use of: tricyclic antidepressants, phenothiazine, anticholinergic medications, and alcohol.
Cocaine, Amphetamines, and Salicylates may elevate body temperatures.
Sweating generally disappears as body temperature rises above 104°F (40°C)
Intense shivering may occur as patient is cooled.
Heat Cramps consists of benign muscle cramping 2° to dehydration and is not associated with an elevated temperature
Heat Exhaustion consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea, and vomiting. Vital
signs usually consist of tachycardia, hypotension, and an elevated temperature
Heat Stroke consists of dehydration, tachycardia, hypotension, temperature >104°F (40°C), and an altered mental status

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

91
 Hyperthermia
All Providers
 General Patient Care Protocol—Adult
 Move patient to cooler environment

Heat Cramps (Painful spasms of the extremities or abdominal muscles, normal

mental status and vital signs)
 Oral fluids as tolerated
 Sponge with cool water

Heat Exhaustion (Dizziness, light-headedness, headache, irritability, normal or

slightly decreased LOC, normal or decreased BP [hypovolemia], tachycardia, normal
or slightly elevated temperature)
 Keep patient supine
 Supplemental 100% oxygen
 Remove clothing
 Sponge with cool water and fan

Heat Stroke (Marked alteration in LOC, extremely high temperature [often > 104]
may be sweating or have red/hot/dry skin)
 Semi-reclining with head elevated 15-30
 Supplemental 100% oxygen
 Rapid cooling (prevent shivering as it increases body temperature)
 Cold packs, sponge with cool water, fan

Advanced EMT
 Consider IV Protocol

Paramedic
 If symptoms are moderate to severe, perform Full ALS Assessment and
Treatment
 Hyperthermia may result from cocaine or sympathomimetic toxicity
 If cocaine/sympathomimetic toxicity strongly suspected, refer to the
Cocaine/Sympathomimetic Protocol
 Expedite Transport

Contact Medical Control for any additional orders or questions

92
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Past medical history Signs and Symptoms
Sepsis
Medications Cold, clammy
Environmental exposure
Exposure to environment even in normal Shivering
Hypoglycemia
temperatures Mental status changes
CNS dysfunction
Exposure to extreme cold Extremity pain or sensory abnormality
Stroke
Extremes of age Bradycardia
Head Injury
Drug use: alcohol, barbituates Hypotension or shock
Spinal Cord Injury
Infections / sepsis
Length of exposure/ wetness

General Approach to All Adult Patients

Medical Protocol
Remove Wet Clothing

Measure Temperature
>95°F
<95°F
(35°C)
(35°C)

Handle Gently Appropriate

Apply Warm blankets/hotpacks Protocol
Based on patient
symptoms
IV PROTOCOL
A Warm fluid if available A
max 2L
Contact Medical
M Control M

Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Neuro
If cardiac arrest occurs with core temp >88°F: refer to appropriate protocol, prolong interval between drugs to 5 minutes, if
defibrillation is necessary, limit to one shock, continue CPR
If cardiac arrest occurs with core temp <88°F contact Medical Control
NO PATIENT IS DEAD UNTIL WARM AND DEAD
Extremes of age are more susceptible (young and old)
With temperatures less than 30°C (86°F) ventricular fibrillation is a common cause of death. Handling patients gently may prevent
this from occuring.
If the temperature is unable to be measured, treat the patient based on the suspected temperature
Hypothermia may produce severe bradycardia so take at least 45 seconds to palpate a pulse
Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly
against the patients skin.
Consider withholding CPR if patient has organized rhythm or has other signs of life. Discuss with medical control
Intubation can cause ventricular fibrillation so it should be done gently by the most experienced person.
Do not hyperventilate the patient as this can cause ventricular fibrillation

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
93
 Hypothermia
All Providers
 General Patient Care Protocol—Adult
 Remove wet clothing
 Measure temperature, If < 95F (35C), handle gently
 Warm blankets/warm temperature

Advanced EMT
 Consider IV Protocol
 If available, and no contraindications, administer warmed 0.9% Normal saline
(max 2L)

Paramedic
 Full ALS Assessment and Treatment
 If available, and no contraindications, administer warmed 0.9% Normal saline
(max 2L)
 If Cardiac Arrest occurs with a temp > 88F
 Refer to appropriate protocol
 Prolong interval between drugs to 5 minutes
 If defibrillation is necessary, limit to one shock
 Continue CPR
 If cardiac arrest with temp < 88F
 Contact OLMC

Contact Medical Control for any additional orders or questions

94
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

Advanced EMT/Paramedic

Assess need for IV to administer IV Fluids, Medications in emergent or potentially emergent

conditions

Peripheral IV is the access of choice, lower extremity peripheral IV should rarely be utilized

General Protocols
Place catheter per procedure manual

When possible utilize 20g or larger on medical patients and 16 gauge or larger in trauma or
hypovolemic shock patients.

If peripheral IV attempts are unsuccessful, reconsider need for IV access. If life threatening
situation place intraosseous line

Once access obtained, monitor infusion site, unless administering fluid boluses, either
saline lock the catheter or place at TKO rate.

Consider intraosseous access for any life-threatening event

Paramedic

If extremity IV attempts are unsuccessful, reconsider need for IV access.

If patient hypotensive, but alert and responsive to pain – consider external jugular vein IV
access.

● If patient unstable, go directly to Intraosseous access.

General Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

95
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Past medical history Signs and Symptoms Pre‐eclampsia / Eclampsia
Hypertension meds Seizures Placental Previa
Prenatal care Hypertension Placenta abruption
Prior pregnancies / births Severe headache Spontaneous abortion
Gravida / Para Visual changes
Edema of hands and face

Pediatric and OB Protocols

General Approach to all Adult Patients

Blood Glucose Measurement <70

>70
Oral Glucose 15g* or Glucagon 1mg
IM
A IV Protocol A
IV Protocol
A if Glucose <70 A
Dextrose 12.5g‐25g slow IVP or D10W
If Seizure activity or SBP >160mmHg on 100mL
two readings
P Magnesium Sulfate 4g in 100ml D5W IV P
over 10 minutes

2013
Continued Seizure

Lorazepam 1‐2mg, slow IV/IO

Or
P Midazolam 5mg IV/IO/IM/IN P
(Max dose Lorazepam 4.0mg,
Midazolam 10.0mg)

Seizure not controlled by above OR

Seizure reoccurs

Lorazepam 1‐2mg, slow IV/IO

Or
P Midazolam 5mg IV/IO/IM/IN P
(Max dose Lorazepam 4.0mg,
Midazolam 10.0mg)

Pearls
RECOMMENDED EXAM(of mother): Mental Status, Heart, Lungs, Abdomen, Neuro
* If alert enough to self administer Glutose
Pregnancy induced hypertension, pre‐eclampsia and eclampsia are conditions typically encountered in late 2nd or Service MD Approval:______
3rd trimester pregnancy, and less commonly in the postpartum period. Clinical manifestations may include elevated
blood pressure (SBP>160mmHg), headache, confusion or agitation..

OB Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
96
 Obstetrics / Gynecology
Perinatal Emergencies
Pregnancy-induced hypertension, pre-eclampsia and eclampsia are conditions
typically encountered in late 2nd or 3rd trimester pregnancy, and less commonly in the
postpartum period. Clinical manifestations may include elevated blood pressure
(SBP > 160 mmHg), headache, confusion or agitation.

All Providers
 General Patient Care Protocol-Adult
 Blood Glucose measurement
 If hypoglycemic (Blood glucose < 70mg/dL)
Glucose paste 15 g or other oral glucose agent (e.g. orange
juice) if patient alert enough to self-administer
If hypoglycemic and unable to take oral glucose:
 Consider Glucagon 1mg IM

Advanced EMT
 Consider IV Protocol
 Blood Glucose measurement
If < 70 mg/dL administer Dextrose 12.5g-25g slow IVP or D10W 100mL

Paramedic
 Full ALS Assessment and Treatment
 Blood Glucose measurement
 If < 70 mg/dL administer Dextrose 12.5g-25g slow IVP or D10W
100mL
 Administer Magnesium Sulfate 4 g in 100 ml D5W IV over 10 minutes for
either of the following:
 Systolic BP > 160 mm Hg on two readings
 Seizure activity
 For active seizures, in addition to Magnesium Sulfate choose one of the
following options:
 Lorazepam (Ativan) 1-2 mg, slow IV/IO
-OR-
 Midazolam (Versed) 5 mg IV/IO/IM/IN

97
 For seizure not controlled by the above, or if seizure reoccurs after initial
control, choose one of the following:
 Lorazepam (Ativan) 1-2 mg, slow IV/IO
-OR-
 Midazolam (Versed) 5 mg IV/IO/IM/IN
Max dose of Lorazepam is 4 mg and Max dose of Midazolam is 10 mg

Contact Medical Control for any additional orders or questions

98
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Past medical history Signs and Symptoms
Pre‐eclampsia / Eclampsia
Hypertension meds Vaginal Bleeding
Placental Previa
Prenatal care Abdominal pain
Placenta abruption
Prior pregnancies / births Spontaneous abortion
Gravida / Para

Pediatric and OB Protocols

General Approach to all Adult Patients

Trimester in Pregnancy?

1st or 2nd Trimester or UNKNOWN 3rd Trimester

Position of Comfort Left lateral recumbant

Left lateral recumbant position if position
hypotensive

Blood Pressure Blood Pressure

<90mmHg
<90mmHg

Normal Saline Bolus 250 ml

Normal Saline Bolus 250 ml A A

2013
A until BP >90mmHg A until BP >90mmHg
X4 (max 2L) >90mmHg
>90mmHg

Transport to hospital Complaint of Labor? YES

Does not need to be a OB
receiving facility NO
Childbirth Protocol

Transport to hospital
OB receiving facility*

Service MD Approval:______
M Contact Medical Control M

Pearls
RECOMMENDED EXAM(of mother): Mental Status, Heart, Lungs, Abdomen, Neuro
* Imminent deliver or medically unstable mother: Transport to nearest ED (not nearest OB receiving facility)
Non‐traumatic abdominal, pelvic or back complaints, vaginal bleeding, spotting or any vaginal fluid leak or discharge: Transport to closest OB receiving
facility.

Whenever possible, transport to patient’s requested OB receiving facility (ie. High risk pregnancy with pre‐selected OB destination) if patient not having
imminent delivery.

OB Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
99
 Vaginal Bleeding
All Providers

1st or 2nd trimester or unknown pregnancy status

Position of comfort, consider lateral recumbent position if hypotensive

3rd Trimester Bleeding (>26 weeks)

Lateral recumbent position
Do not place finger or hand inside birth canal during assessment

 If gestational age known to be < 20 weeks, transport to closest hospital

 If gestational age known or possibly ≥ 20 weeks, transport to nearest OB
receiving facility

Advanced EMT
 Consider IV Protocol
 If BP<90 mmHg systolic, administer boluses of 0.9%NaCl at 250 ml until
systolic BP>90 mmHg

Paramedic
 If bleeding moderate or heavy, perform Full ALS Assessment and Treatment

Contact Medical Control for any additional orders or questions

100
 Obstetrical Transport Destination
Patient known to be < 20 weeks gestation
 1st day of last menstrual period < 20 weeks ago
 Available information verifying gestational age < 20 weeks (e.g., known due
date)
 Refer to Medical Transport Destination for more information

Does not have to be an OB receiving facility

Patient known or possibly ≥ 20 weeks gestation

 Imminent delivery or medically unstable mother:
 Transport to nearest ED (not nearest OB receiving facility)
 Non-traumatic abdominal, pelvic or back complaints, vaginal bleeding,
spotting or any vaginal fluid leak or discharge:
 Transport to closest appropriate obstetric receiving facility
 Contact appropriate obstetric facility ED for radio report and any additional
direction/assistance

Whenever possible, transport to patient’s requested obstetric receiving facility

(e.g. high risk pregnancy with pre-selected obstetrical destination) if patient
not having imminent delivery

Contact Medical Control for any additional orders or questions

101
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
History: Signs and Symptoms Abnormal presentation
Due Date Spasmodic pain Buttock
Time contractions started /how often Vaginal discharge or bleeding Foot
Rupture of membranes Crowning or urge to push Hand
Time / amount of any vaginal bleeding Meconium Prolapsed cord
Sensation of fetal activity Placenta previa
Past medical and delivery history Abruptio placenta
Medications

Pediatric and OB Protocols

Gravida / Para Status
High Risk Pregnancy General Approach to all Adult Patients

Supplemental Oxygen

Inspect perineum
(No digital vaginal exam)

Presenting part NOT the Crowning

head
Activate ALS Meconium
present

2013
Delivery:
Begin Transport ‐Slow, controlled delivery of head; apply gentle
immediately to nearest perineal pressure
OB receiving facility ‐Observe for meconium staining
‐If present, suction oral pharynx and nose as

Refer to OB Procedures

Double clamp cord 10‐12 inches from abdomen

Newborn Resuscitation
Cut cord between clamps
protocol maintain body temperature **

Begin Transport to
nearest OB receiving
M Contact Medical Control M facility

Pearls
RECOMMENDED EXAM(of mother): Mental Status, Heart, Lungs, Abdomen, Neuro
Document all times (delivery, contraction frequency, and length)
If maternal seizures occur, refer to the Obstetrical Emergencies protocol
**Allow spontaneous delivery of the placenta; do not apply traction to umbilical cord for placental delivery. If
placental delivery occurs, package in biohazardous waste bag and hand over to hospital staff upon arrival
Service MD Approval:______
Gently massage abdominal wall overlying the uterine fundus until firm.
Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal.
Record APGAR at 1 minute and 5 minutes after birth.

OB Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
102
 Obstetrics / Gynecology: Childbirth
All Providers
 General Patient Care Protocol-Adult
 Supplemental oxygen
 Do not place fingers or hand inside the birth canal for assessment
 If presenting part is not the head (i.e., foot-, arm-, or buttock-first),
immediately begin transport to the nearest OB receiving facility while further
care continues

Delivery
 Slow, controlled delivery of head; apply gentle perineal pressure
 Observe for meconium staining
 If present, suction oral pharynx and nose as soon as head is delivered
 Following delivery, follow newborn resuscitation protocol
 Double clamp cord 10-12 inches from abdomen
 Cut cord between clamps
 Maintain body temperature
 Allow spontaneous delivery of placenta; do not apply traction to umbilical cord
for placental delivery
 If placental delivery occurs, package in biohazardous waste bag and
hand over to hospital staff upon arrival

Postpartum
 For neonate, see Newborn Resuscitation Protocol
 Assess for postpartum hemorrhage
 Gently massage abdominal wall overlying the uterine fundus until firm
 Transport to nearest OB receiving facility
 See newborn resuscitation for care of the neonate

Contact Medical Control for any additional orders or questions

103
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History:
Ingestion or suspected ingestion of Differential
a potentially toxic substance Signs and Symptoms Tricyclic antidepressants (TCAs)
Substance ingested, route, Mental Status Changes Acetaminophen (Tylenol)
quantity Hypotension / Hypertension Aspirin
Time of ingestion Decreased respiratory rate Depressants
Reason (suicidal, accidental, Tachycardia, dysrhythmias Stimulants
criminal) Seizures Anticholinergic
Available medications in home Cardiac medications
Post medical history, medications Solvents, alcohols, cleaning
agents

Medical Protocol
Insecticides (organophosphates)
General Approach to All Adult Patients

Nothing by Mouth

12 Lead EKG

A IV Protocol A

2013
Refer to specific protocol once agent has been identified
or is strongly suspected

Consult Medical
M Control if needed M

Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro
* for Intranasal administration A-EMT should administer 0.5mg per nare, total of 1mg and then proceed with additional doses as needed
Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or any weapons
Bring bottles, contents, and emesis to ED
Tricyclic : 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert to death
Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure
Aspirin: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal dysfunction, liver failure
and/or cerebral edema among other things can take place later
Depressants: decreased HR, decreased BP, decreased temperature, decreased respirations, non‐specific pupils
Stimulants: Increased HR, increased BP, increased temperature, dilated pupils, seizures
Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes
Cardiac Medications: dysrhythmias and metal status changes
Solvents: nausea, coughing, vomiting, and mental status changes Service MD Approval:______
Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils
Consider restraints if necessary for patient's and or personnel’s protection per the restraint procedure
Consider contacting poison control center for advice 1-800-222-1222
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
104
 Overdose and Poisonings:
General Approach

For any overdose or poisoning, contact should be made with the Regional Poison
Control Center (RPCC) 1-800-222-1222. Whenever possible, determine the
agent(s) involved, the time of the ingestion/exposure, and the amount ingested.
Bring empty pill bottles, etc. to the receiving facility.

All Providers
 General Patient Care Protocol-Adults
 Nothing by mouth
 12 Lead EKG

Advanced EMT
 Consider IV Protocol

Paramedic
 Refer to the specific protocol when an agent has been identified or is strongly
suspected

Contact Medical Control for any additional orders or questions

105
 Legend
EMT
A A
Tricyclic &Tetracyclic
A‐EMT
P Paramedic P
Antidepressant
M Medical Control M

Advanced EMT
Consider IV Protocol

Medical Protocol
Paramedic
Full ALS Assessment and Treatment
For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or when fluid
resuscitation is contraindicated:
Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90
mmHg
If wide QRS complex (≥ 0.10 sec), hypotension, or any arrhythmias:
Sodium Bicarbonate 1 mEq/kg IV/IO
Repeat Sodium Bicarbonate 1 mEq/kg IV/IO in 5-10 minutes
If any of the following conditions occur, refer to the appropriate protocol:
Polymorphous Ventricular Tachycardia

2013
Altered Mental Status
Seizures

Consult Medical
M Control if needed M

Category Drugs Overdose Effects

● Amitriptyline (Elavil, Endep, Vanatrip, Levate) ● Hypotension

● Clomipramine (Anafranil) ● Anti-cholinergic
● Doxepin (Sinequan, Zonalon, Tridapin) effects(tachycardia,
Tricyclic ● Imipramine (Tofranil, Impril) seizures, altered mental
Antidepressants ● Nortryptyline (Aventyl, Pamelor, Norventyl) status, mydriasis)
● Desipramine (Norpramin) ● AV conduction blocks
● Protriptyline (Vivactil) (prolonged QT interval, wide
● Trimipraine (Surmontil) QRS)
● Amitriptyline+Chlordiazepoxide (Limbitrol) ● VT and VF
● Maprotiline (Iudiomil)
● Similar to tricyclics
Other Cyclic ● Amoxapine (Asendin)
Antidepressants ● Buproprion (Wellbutrin)
● Seizures
● Trazadone (Desyrel, Trazorel)
● Citalopram (Celexa) ● Hypertension,
Selective Serotonin ● Fluoxetine (Prozac) tachycardia, agitation,
Reuptake Inhibitors ● Fluvoxamine (Luvox) diaphoresis, shivering,
(SSRIs) ● Paroxetine (paxil)
● Malignant Hperthermia
● Sertraline (Zoloft)

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

106
 Legend
EMT
A
P
A‐EMT
Paramedic
A
P
Cholinergic Poisoning /
M Medical Control M Organophosphates

All Providers
General Patient Care Protocol-Adult
Wear protective clothing including masks, gloves and eye protection

Medical Protocol
Toxicity to ambulance crew may result from inhalation or topical exposure
Supplemental 100% oxygen
Decontaminate patient
Remove all clothing and contain run-off of toxic chemicals when flushing

Advanced EMT
Consider IV Protocol

2013
Paramedic
Full ALS Assessment and Treatment
For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or when fluid
resuscitation is contraindicated
Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90
mmHg
If severe signs of toxicity, (severe respiratory distress, bradycardia, heavy respiratory
secretions) do not rely on pupil constriction to diagnose or titrate medications:
Atropine 2 mg IVP every 5 minutes, titrate dosing by assessing improvement
in respiratory effort/bronchial secretions
Consider Mark 1 Kit, see Nerve Agent protocol
If any of the following conditions occur, refer to the appropriate protocol:
Altered Mental Status
Seizures
Consult Medical
M Control if needed M

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
107
 Legend
EMT
A A
Antipsychotics / Acute Dystonic
A‐EMT
P Paramedic P
Reaction
M Medical Control M

Haloperidol

Medical Protocol
Prolixin
Thorazine
Prochlorperazine (Compazine)
Promethazine (Phenergan)

Advanced EMT
Consider IV protocol

2013
Paramedic
Full ALS Assessment and Treatment
For Dystonic reactions, administer
Diphenhydramine (Benadryl) 25 mg IV
Repeat Diphenhydramine 25 mg IV if inadequate response in 10 minutes

Consult Medical
M Control if needed M

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

108
 Legend
EMT
A A‐EMT A
P P
Beta Blocker Toxicity
Paramedic
M Medical Control M

Examples of commonly used Beta Blocker medications:

Medical Protocol
Single Agent Medication Combination Medication
● Proprandolol (Inderal) ● Corzide (Nadolol/bendroflumethlazide)
● Atenolol (Tenormin) ● Inderide (Propranolol/HCTZ)
● Metroprolol (Lopressor, Toprol) ● Lopressor HCT (Metoprolol/HCTZ)
● Nadolol (Corgard) ● Tenoretic (Atenolol/Chlorthalidone)
● Timolol (Blocadren) ● Timolide (Timolo/HCTZ)
● Labetolol (Trandate) ● Ziac (Bisoprolol/HCTZ)
● Esmolol (Brevibloc)

2013
Advanced EMT
Consider IV Protocol

Paramedic
Full ALS Assessment and Treatment
For all patients with cardiovascular toxicity, defined by:
Chest Pain, SBP < 90 mmHg or altered mental status, AND
Heart Rate < 60 or 2nd or 3rd degree heart blocks
Administer the following agents:
Atropine 0.5 mg IV/IO, may repeat X 2
use with caution in the setting of 2º or 3º heart block
If no response, Glucagon 3 mg IV/IO
If vomiting after Glucagon, administer Ondansetron (Zofran) 4
mg IV
If no response, begin Transcutaneous Pacing

Consult Medical
M Control if needed M

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

109
 Legend
EMT
A A‐EMT A
P P
Calcium Channel Blockers
Paramedic
M Medical Control M

Examples of commonly used Calcium Channel Blocker medication:

Amlodipine (Norvasc)
Felodipine (Plendil, Renedil)

Medical Protocol
Isradipine (DynaCirc)
Nicardipine (Cardene)
Nifedipine (Procardia, Adalat)
Verapamil (Calan)
Diltiazem (Cardizem)

Advanced EMT
Consider IV Protocol

2013
Paramedic
Full ALS Assessment and Treatment
For all patients with cardiovascular toxicity, defined by:
Chest Pain, SBP < 90 mmHg or altered mental status, AND
Heart Rate < 60 or 2nd or 3rd degree heart blocks
Administer the following agents
Atropine 0.5 mg IV/IO, may repeat X 2
use with caution in the setting of 2º or 3º heart block
If no response, administer Calcium Chloride 1 g IV/IO
Contraindicated if patient taking Digoxin (Lanoxin)
If no response, may repeat Calcium Chloride 1 g IV/IO
no response, begin Transcutaneous Pacing

Consult Medical
M Control if needed M

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

110
History: Signs and Symptoms
Differential
Known or suspected CO exposure Altered mental status / dizziness
Effects of other toxic fire by product
Suspected source/duration exposure Headache, Nausea/Vomiting
Acute cardiac event
Age Chest Pain/Respiratory distress
Acute neurological event
Known or possible pregnancy Neurological impairments
Flu/GI illness
Reason (accidental, suicidal) Vision problems/reddened eyes
Acute intoxication
Measured atmospheric levels Tachycardia/tachypnea
Diabetic Ketoacidosis
Past medical history, medications Arrhythmias, seizures, coma
Headache or non‐toxic origin

General Approach to All Adult Patients

Legend

Special Response Protocols

EMT
Scene Safety – SCBA if toxic inhalation suspected
A A‐EMT A
Remove patient from contaminated area P Paramedic P
Administer 100% Oxygen M Medical Control M

Appropriate Protocol based on

COHb% (SpCO) Measurement Available? Not available
symptoms

SpCO<5% SpCO>5%

No treatment for CO required SpCO >5%

Appropriate Protocol based on

symptoms SpCO <15% SpCO >15%
SpO2 >90% SpO2 <90%

Symptoms of CO 100% Oxygen via

and/or hypoxia? YES NRB Service MD Approval:______
NO Transport to ED

No treatment for CO required* If cardiac/

Recommend evaluation of home/ respiratory/
work environment for presence of neurological
CO symptoms are also
present, go to
appropriate
protocol

M Consult Medical Control M

Pearls
*Fetal hemoglobin has a greater attraction for CO than maternal hemoglobin. Females who are known to be pregnant or who could be pregnant
should be advised that EMS-measured SpCO levels reflect the adults level and that fetal COHb levels may be higher. Recommend Hospital
evaluation for any CO exposed pregnant person.
The absence (or low detected levels of) COHb in not a reliable predictor of firefighter or victim exposure to other toxic byproducts of fire – also
consider Cyanide Poisoning Protocol
Attempt to evaluate other correctable causes when possible

Special Response Protocol

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
111
 Overdose and Poisonings:
Carbon Monoxide

All Providers
 General Patient Care Protocol—Adult
 Wear appropriate PPE (SCBA) as indicated
 Remove the patient from the contaminated source
 Supplemental 100% oxygen, document time oxygen started
 If CO monitoring available
 Document initial CO level
 Follow Carboxyhemoglobin SpCo Monitoring Procedure

Paramedic
 Full ALS Assessment and Treatment
 For smoke inhalation patients also consider Cyanide poisoning (See Hazardous
Materials—Basic Approach Protocol)

Contact Medical Control for any additional orders or questions

112
 Legend
EMT
A A‐EMT A
P P
Cocaine and Sympathomimetic
Paramedic
M Medical Control M

All Providers
General Patient Care Protocol—Adult

Medical Protocol
Advanced EMT
Consider IV Protocol

Paramedic
Full ALS Assessment and Treatment
For patients with Sympathomimetic toxidrome (e.g. hypertension, tachycardia, agitation):
Lorazepam (Ativan) 1-2 mg, slow IV

2013
If no IV access, Midazolam (Versed)
5 mg IM/IN if < 60 years old
2.5 mg IM/IN if > 60 years old
Repeat either medication once in 5-10 minutes if signs and symptoms continue
If seizures occur, refer to Seizure Protocol
Refer to Behavioral Emergency Protocol

Consult Medical
M Control if needed M

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

113
 Legend
EMT
A A‐EMT A
P P
Opiates
Paramedic
M Medical Control M

All Providers
General Patient Care Protocol—Adult
Airway Protocol for respiratory depression

Medical Protocol
Advanced EMT
Consider IV Protocol
For patients with opiate toxidrome (ie. Coma, pinpoint pupils, respiratory depression)
□ Naloxone (Narcan) 2 mg IV/IO every 3 minutes
Naloxone (Narcan) can be administered in 0.4 mg increments titrated to
respiratory drive and level of consciousness
If IV access has not been established, Naloxone (Narcan) 2 mg IM or
Advanced EMT ‐ 0.5 mg per nare IN (total 1.0mg per administration),
Paramedics - 1.0 mg per nare (total 2.0mg per administration)
□ Repeat every 3 minutes if signs and symptoms continue (max 8.0mg)

2013
● If respiratory depression not improved, refer to Airway protocol
Consult Medical
M Control if needed M

Overdose and Poisoning:

Opiates

Single Agent Medication Combination Medication Long Acting*

● Oxycodone ● Vicodin ● Oxycontin
● Hydrocodone ● Norcodin ● MS Contin
● Morphien ● Percocet ● Methadone
● Heroin ● Darvocet
● Dilaudid ● Vicoprofen * May Need Repeat Dosing
● Fentanyl
● Codeine

Service MD Approval:______

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

114
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
Signs and Symptoms
Per the specific protocol
History: Severity (pain scale)
Musculoskeletal
Age Quality (sharp, dull, etc)
Visceral (abdominal)
Location Radiation
Cardiac
Duration Relation to movement,
Pleural / Respiratory
Severity (1‐10) respiration
Neurogenic
Past medical history Increased with palpation
Renal (colic)
Medications
Drug Allergies

Medical Protocol
General Approach to All Adult Patients

Patient care according to PROTOCOL

Based on specific complaint

Pain Severity >6 out of 10

Pulse Oximetry

2013
A IV Protocol A Continuous Respiratory
Morphine Sulfate 2‐5mg slow IVP every 5 min until relief achieved monitoring
(max 15mg)* SPO₂ and End Tidal CO₂
OR
Fentanyl 50‐75mcg slow IVP every 5 min until relief achieved After each dose:
P (max 200mcg)* If available consider Intranasal administration,
P Reassess pain level
same dose as above divided between nares
Ondansetron 4mg slow IV for severe nausea or vomiting

Contact Medical Control for

additional orders or questions
M OLMC must authorize a M
change in Opiate once Service MD Approval:______
administration has begun.

Pearls
RECOMMENDED EXAM: Mental Status, Area of pain, Neuro
* Contraindicated if SBP <90mmHg
Analgesic agents may be administered under standing orders for patients experiencing moderate / severe pain (typically >6/10)
Common Complaints: trauma/isolated extremity injury, Burns (without airway, breathing or circulation compromise), sickle crisis,
Acute chest pain (follow protocol), Kidney stone highly suspected (follow abdominal pain protocol)
Vitals and pain scale should be documented before and after every medication dose.

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

115
 Pain Management—Adult

All Providers
 General Patient Care Protocol
 Assess baseline pain level (0-10 scale: 0=no pain, 10=worst pain)

Advanced EMT
 Consider IV Protocol

Paramedic
 Analgesic agents may be administered under standing orders for patients
experiencing moderate/severe pain (typically ≥ 6/10)
 Common complaints:
 Trauma/isolated extremity injury
 Burns (without airway, breathing or circulation compromise)
 Sickle crisis
 Acute Chest Pain, in accordance with the Chest Pain protocol
 Kidney stone highly suspected, in accordance with the Abdominal Pain
protocol

Agents for pain control

 Morphine Sulfate 2-5 mg slow IVP every 5 minutes until pain relief achieved
(Maximum 15 mg)
-OR-
 Fentanyl 50-75 mcg slow IVP every 5 minutes until pain relief achieved
(Maximum 200 mcg)
 Both are contraindicated if SBP  90 mmHg
 If available consider Intranasal administration, same dose as above
divided between nares.
 After each drug dosage administration
 Reassess and document the patient’s pain level (0-10 scale)
 Note adequacy or ventilation and perfusion
 Assess and document vital signs
 Continuously monitor oxygen saturation and end tidal CO2
 For severe nausea or vomiting, Ondansetron (Zofran) 4 mg slow IV

116
 Contact Medical Control for any additional orders or questions

Medical Control must authorize a change in Opiate once administration

has begun. Listed maximum dosages pertain unless other orders given
by medical control

117
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

When called to a scene to assess a person in police custody, perform all assessment and
treatment consistent with the standards set for the typical, non-detained patient. EMS personnel
are not equipped to perform formal medical clearance for patients in police custody prior to jail

Special Response Protocol

transport.

After assessing the patient and treating any obvious conditions, transport to the ED should
be offered in a manner consistent with the Dane County EMS System General Guidelines.
If the detained patient refuses transport, execute a standard refusal process as detailed in
protocol.
Advise the Law Enforcement Officer (LEO) of the patient’s decision, and if all criteria are
met, release the patient to the LEO.
If the patient does not meet refusal criteria, advise the LEO that transport is
indicated and coordinate a safe transport of the detained patient in accordance
with Agency SOPs.
If the LEO requires EMS transport in a scenario where the patient has refused,
comply with the LEO’s request and transport the patient to the nearest
appropriate ED.

In scenarios where a LEO is unwilling to allow transport of a detained patient after EMS personnel

2013
have determined transport is indicated (i.e. requested transport, is not a candidate for refusal, or
obvious medical necessity) adhere to the following:
Assure that the LEO understands transport is indicated and that medical clearance prior to
incarceration is not a procedure performed by EMS.
Contact On-Line Medical Control for further input and assistance as needed.
If these actions fail to resolve the issue, defer to the officer’s legal authority to retain custody
of the patient.
Document the interaction well, including the law enforcement agency and officer involved.

Contact Medical Control for any additional orders or questions

Service MD Approval:______

Special Response Protocol

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

118
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

For patients who have been controlled by law enforcement via a Taser device, follow this protocol

Special Response Protocol

in conjunction with any protocol that applies to underlying conditions (e.g. behavioral emergencies,
cocaine/sympathomimetic toxicity, agitated delirium)

All Providers
Confirm scene safety with law enforcement
Turn patient supine if found in a prone position
Secure the taser prongs in place if not removed by law enforcement
Do not remove the prongs if lodged in the patient and left in place by law
enforcement unless there is interference with important patient care measures

Paramedic
If the patient requires Chemical or Physical restraints, perform Full ALS Assessment and
Treatment
For patients with severe agitation resulting in interference with patient care or patient/crew

2013
safety, or for patients who continue to struggle against restraints refer to Behavioral
Emergencies Protocol
Transport patient supine or lateral recumbent position only

Patient transport in the prone position is not authorized!

Contact Medical Control for any additional orders or questions

Service MD Approval:______

Special Response Protocol

Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
119
General guidelines for patient refusal of treatment and/or transport:
A patient is any person who is requesting and/or is in need of medical attention or medical
assistance of any kind.
All patients shall be assessed and offered transport by ambulance to the nearest appropriate
emergency department, regardless of the nature of the complaint.
In the event a patient, or his/her guardian, refuses transport to the hospital, a properly
executed refusal process must be completed.

Three-Step Process for EMS personnel when accepting a refusal of care:

Step 1: Determine if the patient is legally recognized as an
informed decision maker.
Step 2: Determine if the patient’s decision making capacity
appears to be intact.
Step 3: Document the interaction well.

Step 1
To undergo the informed refusal of medical care process, the patient should be one of the following:
A person 18 years of age
A court-emancipated minor
A legally married person of any age
An unwed pregnant female < 18 years of age only when the medical concern relates to her
pregnancy
A parent (of any age)/ or legal guardian on behalf of their child when the refusal of care does
not place the child at risk
Involve OLMC for any refusal involving a minor when the parent/legal guardian cannot be
contacted

Step 2
To undergo the informed refusal of medical care process, the patient or his/her guardian’s decision-
making process cannot be impaired by medical or psychiatric conditions:

All of the following must be present:

Awake, alert and oriented to person, place, time and situation (A+OX4)
Is not experiencing a medical condition which may interfere with informed decision
making capacity (e.g. hypoxia, hypoglycemia, head injury, sepsis etc.)
Does not appear clinically intoxicated or under the influence of substances which may
impair decision making and judgment
Does not express suicidal or homicidal ideations, and does not otherwise pose an
obvious threat to themselves or others
Is not experiencing hallucination or other apparent thought disorder

continued -

120
 Refusal of Medical Care ‐ continued
Step 3

The following items should be documented for every refusal:

A mental status examination as detailed in Step 2 above
A physical examination (including vital signs)
Perform blood glucose level and oxygen saturation when appropriate

Pediatric Refusals
The following scenarios require OLMC contact prior to completing the refusal process:
Refusals involving patients less than 1 year old
Pediatric refusals where significant vital sign/ or physical exam abnormalities are
present
In the event a parent or guardian refuses medical care for a minor when there is reasonable
concern that this decision poses a threat to the well-being of the minor:
Contact the OLMC Physician for input
Enlist the aid of law enforcement personnel for patient and crew safety
If an immediately life threatening condition exists, transport the patient to the nearest
appropriate emergency department.

Refusal of Transport After ALS Initiated:

Contact OLMC for refusal situations that arise after advanced life support measures have
been initiated
Exceptions to this requirement are:
Bronchospasm, resolved after nebulizer treatment (see protocol)
Insulin-induced hypoglycemia, resolved after glucose administration (see protocol)

Consult Medical
M Control if needed M

121
 Refusal of Transport After Treatment Given

Bronchospasm Resolved After Nebulizer Treatment

After treatment of bronchospasm, and return to an asymptomatic state, some patients will refuse
transport to the hospital. The following items should be accounted for and included in the assessment
and documentation:

The presentation is consistent with a mild exacerbation of asthma

No severe dyspnea at onset
No pain, sputum, fever or hemoptysis
Not clinically hypoxic (oxygen saturation > 92%)
Significant improvement after a single nebulizer treatment
Complete resolution of symptoms
Vital signs within normal limits after treatment (BP, pulse, respiratory rate and oxygenation)

Additional patient safety measures that should be considered:

A family member or caregiver should be available to stay with the patient and assist if a relapse
occurs
Assure the patient understands transport has been offered and subsequently refused
Inform the patient to follow-up with their physician as soon as possible and/or to re-contact 911
if symptoms reoccur

If the above are accounted for, a properly executed refusal of medical care can be accepted
from the patient or custodian without contacting Medical Control.

Consult Medical
M Control if needed M

122
 Refusal of Transport After Treatment Given
Insulin-Induced Hypoglycemia—Resolved

This protocol applies only to insulin dependent diabetic patients refusing transport after the resolution
of insulin-induced hypoglycemia by the administration of intravenous glucose. This protocol cannot
be used if the patient takes any oral diabetes medications. After treatment of insulin-induced
hypoglycemia and return to an asymptomatic state, some patients will refuse transport to the hospital.
The following items should be accounted for and included in the assessment and documentation.

The patient is on Insulin only (does not take any oral diabetes medications)
The presentation is consistent with hypoglycemia
Rapid improvement, and complete resolution of symptoms after glucose
Vital signs within normal limits after glucose given (BP, pulse, respiratory rate, oxygenation and
blood sugar > 70)
There is no indication of an intentional overdose or dosing error

Additional patient safety measures that should be considered:

A family member or caregiver should be available to stay with the patient and assist if a relapse
occurs
Assure the patient understands transport has been offered and subsequently refused
Inform the patient to follow-up with their physician as soon as possible and/or to re-contact 911
if symptoms reoccur

If the above are accounted for, a properly executed refusal of medical care can be accepted
from the patient or custodian without contacting Medical Control.

Consult Medical
M Control if needed M

123
 Sedation/Sedative Agent Use
Because sedation is a continuum, it is not always possible to predict how an individual patient
receiving an agent with sedative properties will respond. This protocol is to be used in conjunction
with any protocol that involves the use of medication given by any route, which may result in sedation.
Examples of medications that may result in sedation are narcotics, benzodiazepines, haloperidol,
diphenhydramine, and ketamine.

Minimal Sedation (anxiolysis): A drug induced state in which patients respond normally to verbal
commands. Although cognitive function and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected.

Moderate sedation (“conscious sedation”): A drug-induced depression of consciousness during which

patients respond purposefully to verbal commands, either alone or accompanied by light tactile
stimulation. Airway patency, spontaneous ventilations, gag reflex, and cardiovascular function are
maintained.

Deep Sedation: Only to be used in patients with a secured airway. A drug induced depression of
consciousness, during which patients cannot be easily aroused but respond purposefully after
repeated or painful stimulation. The ability to independently maintain ventilatory function may be
impaired. Patients will require assistance in maintaining a patent airway and spontaneous ventilations
may be inadequate.

The goal of sedative agent use is to produce the minimal degree of sedation that achieves the
desired clinical effect. Sedative agent use should ideally result in minimal or moderate
sedation only.

Paramedic
Full ALS Assessment and Treatment
Continuously monitor the following:
Patency of airway
Vital signs
Oxygen saturation and capnography
Cardiac rhythm
Level of consciousness and ability to follow commands
Assure that appropriate equipment and personnel are immediately available for care and
resuscitation if problems arise
Document the indications for sedation

Consult Medical
M Control if needed M

124
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
History: CNS (Head) Trauma
Signs and Symptoms Tumor
Reported/witnessed seizure
Decreased Mental Status Metabolic, Hepatic, or Renal Failure
activity
Sleepiness Hypoxia
Previous seizure history
Incontinence Electrolyte abnormality (Na, Ca, Mg)
Medical alert tag information
Observed seizure activity Drugs, Medications, Non‐compliance
Seizure medications
Evidence of trauma Infection/Fever
History of Trauma
Unconscious Alcohol withdrawal
History of Diabetes
History of Pregnancy Eclampsia
Stroke

Medical Protocol
Hyperthermia
General Approach to all Adult Patients Hypoglycemia
Supplemental O2 – Protect Patient from Injury

Blood Glucose – treat if appropriate

A IV Protocol A

Active Seizure Assess Patient Not seizing

Monitor vitals and transport

2013
Lorazepam 1‐2mg IV/IO
(max dose 4mg)
Or
Midazolam Seizure Re-occurs
P 5mg IV/IO/IM/IN if <60 P
years old
2.5 mg IV/IO/IM/IN if >60 Lorazepam 1‐2mg IV/IO (max dose 4mg)
years old Or
(max dose 10mg) Midazolam
P 5mg IV/IO/IM/IN if <60 years old P
2.5 mg IV/IO/IM/IN if >60 years old
P Diazepam rectal gel if available* P (max dose 10mg)
YES Service MD Approval:______

Still Seizing?
NO Consult Medical Control for
Monitor vitals and P M additional Benzodiazepines M P
transport
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro
Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency
requiring rapid airway control, treatment and transport
Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma * Diazepam
Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness 12+ Years (0.2mg/kg)
Jacksonian seizures are seizures which start as a focal seizure and become generalized Weight Dose
Be prepared for airway problems and continued seizures
(kg) (lb) (mg)
Assess possibility of occult trauma and substance abuse
14-27 30-60 5
Be prepared to assist ventilations especially if diazepam or midazolam is used
28-50 61-111 10
For any seizure in a pregnant patient, follow the OB emergencies protocol
51-75 112-166 15
Diazepam is not effective when administered IM. It should only be given rectally.
76-111 167-244 20
Midazolam is well absorbed when administered IM.

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
125
 Seizure
All Providers
 General Patient Care Protocol—Adult
 Supplemental 100% oxygen
 Nasal cannula is sufficient if no active seizures and no respiratory
signs or symptoms
 Protect patient from injury

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment
 If Blood Glucose < 70 mg/dL, treat per Altered Mental Status/Hypoglycemia
Protocol
 For active seizures choose one of the following options:
 Lorazepam (Ativan) 1-2 mg IV/IO
- OR -
 Midazolam (Versed)
 5 mg IV/IO/IM/IN if < 60 years old
 2.5 mg IM/IN/IO/IV if > 60 years old
- OR -
 Diazepam rectal gel (Diastat) if available

12 + Years (0.2mg/kg)
Weight Dose
(Kg) (Lb) (mg)
14-27 30-60 5
28-50 61-111 10
51-75 112-166 15
76-111 167-244 20

126
 For seizure not controlled by the above, or if the seizure re-occurs after initial
control, choose one of the following:
 Lorazepam (Ativan) 1-2 mg IV/IO
- OR -
 Midazolam (Versed)
 5 mg IV/O/IM/IN if < 60 years old
 2.5 mg IM/IN if > 60 years old
Maximum dose of Lorazepam is 4 mg
Maximum dose of Midazolam is 10 mg
 If hypoxic seizures, drug induced seizures, seizures from head trauma, stroke
or eclampsia suspected
 Treat as above and refer to appropriate protocol for further care

Contact Medical Control for any additional orders or questions

 Additional Benzodiazepines

127
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Blood Loss – vaginal or GI Signs and Symptoms Shock
bleeding, AAA, ectopic Restlessness, confusion Hypovolemic
Fluid loss – vomiting, diarrhea, Weakness, dizziness Cardiogenic
fever Weak, rapid pulse Septic
Infection Pale, cool, clammy skin Neurogenic
Cardiac Ischemia (MI, CHF) Delayed capillary refill Anaphylactic
Medications Hypotension Ectopic Pregnancy
Allergic reaction Coffee‐ground emesis Dysrhythmias
Pregnancy Tarry stools Pulmonary Embolus
History of poor oral intake Tension pneumothorax

Medical Protocol
Medication effect / OD
Vasovagal
General Approach to All Adult Patients Physiologic (pregnancy)

A IV Protocol A
Trauma Cardiac

Non Cardiac
Non Trauma

2013
Treatment per appropriate Normal Saline fluid bolus‐250mL Treament per appropriate
Trauma Protocol A May repeat until SBP>90mmHg or max 2L A Cardiac Protocol

If no improvement after 4th fluid

bolus ‐ Consider Dopamine
P 5‐20 mcg/kg/min IV titrated to SBP P
>90mmHg

Consult Medical
M Control if needed
M Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Hypotension can be defined as a systolic blood pressure of less than 90
Consider performing orthostatic vital signs on patients in non-trauma situation if suspected blood or fluid loss
Consider all possible causes of shock and treat per appropriate protocol
Reassess for pulmonary edema after each fluid bolus (lung sounds, respiratory distress, EKG)
For non-cardiac, non-trauma hypotension, Dopamine should only be started after 1 liter of NS have been given.

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

128
 Shock (Non‐Trauma)
Shock is defined as a state of inadequate organ perfusion and tissue oxygenation.
It is evidenced by the presence of any of the following signs and symptoms:
 Hypotension  Mottled skin appearance
 Narrow pulse pressure  Diaphoresis
 Tachypnea  Cool clammy skin
 Tachycardia  Pallor
 Delayed capillary refill  Altered mental status
Signs and symptoms vary depending upon the stage of shock, which may be
compensated (normal perfusion maintained) or decompensated (unable to maintain
normal perfusion).
Categories of shock
 Obstructive shock: Caused by an obstruction that interferes with return of
blood to the heart (e.g. tension pneumothorax, cardiac tamponade, massive
pulmonary embolus)
 Hypovolemic shock: Caused by decreased blood or water volume.
Hypovolemic shock may be hemorrhagic or non-hemorrhagic
 Distributive shock: Caused by abnormal distribution of blood resulting from
vasodilaton, vasopermeability or both. Distributive shock may result from
anaphylactic reactions, sepsis, or spinal cord injury
 Cardiogenic shock: Caused as a result of cardiac pump failure, usually
secondary to severe Left Ventricular failure. May result from massive MI
Perform the following in conjunction with protocols that apply to the specific etiology
of the shock state (e.g. allergic reactions, STEMI, etc.):

Advanced EMT
 Consider IV Protocol
 Do not delay transport for IV insertion
 IV 0.9% NaCl en route (if not contraindicated):
 Administer 250 ml boluses until systolic BP > 90 mmHg
 Total amount of IVF should not exceed 2 L
 Boluses may be given in rapid succession if systolic remains < 90
mmHg

Paramedic
 Full ALS Assessment and Treatment
 Do not delay transport for IV insertion
 IV 0.9% NaCl en route (if not contraindicated):

129
  Administer 250 ml boluses until systolic BP > 90 mmHg
 Total amount of IVF should not exceed 2 L
 Boluses may be given in rapid succession if systolic remains < 90
mmHg
 If systolic BP remains < 90 mmHg after 4th bolus (1000ml):
 Consider Dopamine infusion at 5-20 mcg/kg/min, titrated to maintain
SBP > 90 mmHg

Contact Medical Control for any additional orders or questions

130
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Signs and Symptoms
History: Altered mental status
Differential
Previous CVA, TIA’s Weakness / Paralysis
See Altered Mental Status
Previous cardiac,/vascular Blindness or other sensory loss
TIA (Transient Ischemic Attack)
surgery Aphasia / Dysarthria
Seizure
Associated diseases: diabetes, Syncope
Hypoglycemia
hypertension, CAD Vertigo / Dizziness
Stroke
Atrial Fibrillation Vomiting
Thrombotic Embolic (~85%)
Medications (blood thinners) Headache Hemorrhagic (~15%)
History of Trauma Seizures Tumor
Respiratory pattern change Trauma

Medical Protocol
Hypertension / Hypotension

General Approach to all Adult Patients

If Positive and
Blood Glucose Symptoms <24 hour,
Glucose <70 Glucose >70
early notification of
Positive
Stroke Alert and rapid
transport to stroke
Altered Mental Status Cincinnati Stroke Scale center
Protocol*

2013
Negative

12 Lead EKG

Consider other protocols as indicated:

Altered Mental Status
Hypertension
Hypotension
Seizure
Overdose / Toxic Ingestion

Service MD Approval:______

Consult Medical
M Control M
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro
* Reassess for Stroke if no improvement with Altered Mental Status Protocol
Remember FAST in radio report: Facial Droop, Arm Strength, Speech, Time last normal
Cincinnati Stroke scale in procedure section
Supplemental oxygen via nasal only if O2 saturation <93%
Keep head of stretcher at 30-45° elevation (unless clinical condition will not allow)
Spinal immobilization if indicated; elevate head of backboard 15-30°
Do NOT delay transport to start IV
Onset of symptoms is defined as the last witnessed time the patient was symptom free (ie awakening in the morning with stroke symptoms would
be defined as an onset time of the previous night when patient was symptom free)
Be alert for airway problems (swallowing difficulty, vomiting/aspiration)
Hypoglycemia can present as a localized neurologic deficit, especially in the elderly
Document the stroke scale (including the EMD stroke scale results if available)

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
131
 Stroke—Suspected
Early recognition and transport of stroke is essential to good patient outcomes. Any
patient presenting with a normal blood glucose (> 70 mg/dL), a positive Cincinnati
Pre-Hospital Stroke Screen and onset of symptoms (when last seen normal) less
than 24 hours should have early notification of the stroke center (STROKE ALERT)
and rapid transport.

All Providers
 General Patient Care Protocol-Adult
 Supplemental oxygen via nasal cannula only if O2 saturation < 93%
 Keep head of stretcher at 30-45 elevation (unless clinical condition will not
allow)
 Spinal Immobilization if indicated; elevate head of backboard 15-30
 Check Blood Glucose
 Give nothing by mouth (oral glucose is permitted if patient is able to self
administer)
 Cincinnati Pre-Hospital Stroke Screen
 If patient blood glucose is ≥ 70 mg/dl, Cincinnati Pre-Hospital Stroke Screen
is positive and onset of symptoms (when last seen normal) is < 24 hours,
immediately notify ED (STROKE ALERT) and commence rapid transport.

Advanced EMT
 Consider IV Protocol
 If hypoglycemic (<70 mg/dL) with IV access
 Dextrose 12.5g-25g slow IV push or D10W 100mL
 May repeat as needed every 5-10 minutes to blood glucose >
70 mg/dL
 If hypoglycemic (< 70 mg/dL) without IV access
 Glucose paste 15 g or other oral glucose agent (e.g., orange juice) if
patient alert enough to self administer oral agent
- OR -
 Glucagon 1 mg IM

 DO NOT DELAY TRANSPORT TO OBTAIN IV ACCESS

Paramedic
 Full ALS Assessment and Treatment
 Check blood glucose

132
 For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses or
when fluid resuscitation is contraindicated
 Dopamine infusion 5-20 mcg/kg/min titrated to maintain systolic BP >
90 mmHg

Contact Medical Control for any additional orders or questions

133
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
Vasovagal
History: Signs and Symptoms Orthostatic hypotension
Cardiac history, stroke, seizure Loss of consciousness with Cardiac syncope
Occult blood loss (GI, ectopic) recovery Micturation / Defecation syncope
Females: LMP, vaginal bleeding Lightheadedness, dizziness Psychiatric
Fluid loss: nausea, vomiting, Palpitations, slow or rapid pulse Stroke
diarrhea Pulse irregularity Hypoglycemia
Past Medical History Decreased blood pressure Seizure
Medications Shock (see shock protocol)
Toxicologic (alcohol)

Medical Protocol
Medication effect (Hypertension)

General Approach to all Adult Patients

Altered Mental Status

Blood Glucose Glucose <70
Protocol

>70

IV Protocol ‐ NS bolus 250ml to

A A

2013
maintain SBP >90mmHg (max 2L)

12 Lead EKG

If SBP <90mmHg not improved by

fluid
P Dopamine infusion 5‐20 mcg/kg/min P
titrated to maintain SBP >90mmHg

AT ANY TIME
If relevant signs / symptoms found
Consult Medical
Go to appropriate protocol: M Control M
DYSRHYTHMIA
ALTERED MENTAL STATUS
Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Assess for signs and symptoms of trauma if associated or questionable fall with syncope
Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope.
Spinal Immobilization Protocol if appropriate
.

Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
134
 Syncope
All Providers
 General Patient Care Protocol-Adult
 12 Lead EKG

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Assessment and Treatment
 For hypotension (systolic BP < 90 mmHg) not improved by NS fluid boluses
or when fluid resuscitation is contraindicated
 Dopamine infusion 5-20 mcg/kg/min titrated to maintain systolic BP >
90 mmHg
 If hypoglycemic (< 70mg/dL), treat per Altered Mental Status/Hypoglycemia
Protocol
 If ECG rhythm is bradycardia, heart block or dysrhythmia see specific protocol
 If Altered Mental Status persists, or if Acute Stroke suspected, refer to
appropriate protocol.

Contact Medical Control for any additional orders or questions

135
136
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential
History: Chest
Time and mechanism of injury Signs and Symptoms
Pain, swelling Tension Pneumothorax, flail chest,
Damage to structure or vehicle pericardial tamponade, open chest
Location in structure or vehicle Deformity, lesions, bleeding
Altered Mental Status or unconscious wound, hemothorax
Others injured or dead Intra‐abdominal bleeding
Speed and details of MVC Hypotension or shock
Arrest Pelvis/femur fracture
Restraints/ protective equipment Spine fracture / Cord injury
Past medical history Head injury (see head trauma)
medications Extremity fracture/dislocation
HEENT (Airway Obstruction)
Hypothermia
General Approach to All Adult Patients

Trauma Protocol
Presentation or Mechanism Consistent with Trauma
YES NO
Appropriate Medical
Assess ABC’s
Protocol
INADEQUATE ADEQUATE

Airway, Adult Spinal Immobilization Protocol

Protocol
Obvious Bleeding?
YES NO

Direct Pressure Disability and GCS

Complete Head to Toe

Service MD Approval:______ Pressure Point Survey

Tourniquet for uncontrolled Abnormal** Vital Signs Normal

extremity hemorrhage
Pearls IV Protocol Notify receiving
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, A 250ml bolus NS x2 A hospital
Abdomen, Extremity, Back, Neuro
* Pleural Decompression should only be preformed when all 3
criteria are present: Tension
NO
1-severe respiratory distress with hypoxia Pneumothorax?
2-unilateral decreased or absent lung sounds (may see YES
tracheal deviation away from collapsed lung)
3-evidence of hemodynamic compromise (ie. Shock, Pain Control
hypotension, tachycardia, altered mental status)
P Decompress* P Protocol
** Abnormal: hypotension, Tachycardia, Hypoxia
If indicated perform pleural decompression at the 2nd
intercostal space, mid-clavicular line
High suspicion severe injury
Assess all patients for major trauma criteria. Major trauma Contact Medical
patients should have transport initiated within 10 minutes of M Control M Facility/Provider discretion

arrival on scene whenever possible. In the setting of major

trauma, DO NOT prolong scene time to perform procedures
unless immediately necessary to stabilize patient (ie.
Rapid Transport to Trauma
Hemorrhage control). Initiate all other procedures while
enroute to the trauma center. Receiving Facility <10 minutes
Disability – assessment neurological deficits: paralysis,
weakness, abnormal sensation, etc.
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
137
 Trauma:
General Approach to All Trauma Patients
Assess all patients for major trauma criteria. Major trauma patients should have
transport initiated within 10 minutes of arrival on scene whenever possible. In the
setting of major trauma, DO NOT prolong scene time to perform procedures unless
immediately necessary to stabilize patient (e.g. hemorrhage control). Initiate all
other procedures en-route to the trauma center.

All Providers
 General Patient Care Protocol—Adult
 Secure airway/spinal immobilization if indicated
 Supplemental 100% oxygen if any respiratory symptoms
 Examine patient for obvious bleeding
 Control active bleeding with direct pressure
 Assess disability-neurologic status/record Glasgow coma score
 Head to toe examination to assess for injuries
 Restrain as needed

Paramedic
 When conditions warrant (specified as “Full ALS Assessment and Treatment”
in individual protocol)
 Advanced airway/ventilatory management as needed
 Perform cardiac monitoring
 Record and monitor O2 saturation
 Microstream capnography if any acute respiratory symptoms
 IV 0.9% NaCl TKO/KVO or IV lock
 If SBP < 90 mmHg, administer boluses of 0.9%NaCl at 250 ml
until SBP > 90 mmHg
 Assess for Tension Pneumothorax
 Tension pneumothorax should be suspected in patients who
exhibit
 Severe respiratory distress with hypoxia
 Unilateral decreased or absent lung sounds (may see
tracheal deviation away from collapsed lung field)
 Evidence of hemodynamic compromise (e.g. shock,
hypotension, tachycardia, altered mental status)

138
  Pleural decompression for tension pneumothorax should only
be preformed when all 3 of the above criteria are present; If
indicated perform pleural decompression at the 2nd intercostal
space, mid-clavicular line
 Refer to Pain Management Protocol as needed

Contact Medical Control for any additional orders or questions

139
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Type of exposure (heat, gas, chemical) Burns, pain, swelling Superficial (1st degree) red and painful
Inhalation injury Dizziness Partial thickness (2nd degree) blistering
Time of injury Loss of consciousness Full thickness (3rd degree) painless/charred or leathery skin
Past medical history and medications Hypotension/shock Thermal
Other trauma Airway compromise/distress Chemical
Loss of consciousness Singed facial or nasal hair Electrical
Tetanus/immunization status Hoarseness/wheezing Radiation

General Approach to All Adult Patients

Transport to Burn Center

Trauma Protocol
2nd degree burns greater than 10% total body surface area or
those on hands, feet, face or groin
3rd degree burns
Electrical burns (spinal immobilization if high voltage, monitor for
cardiac arrhythmias, initiate fluid resuscitation immediately
Chemical burns (remove clothing, brush away dry powder before
irrigating, flush with copious warm water on scene and continue
irrigation enroute, eyes: remove contacts and irrigate
continuously with NS for at least 30 minutes, avoid hypothermia

ABC’s

*Airway Protocol

Remove or cool heat source if present

Remove all clothing, contact lenses,

and jewelry (especially rings)
If inhalation injury – place patient on
Maintain core temperature 100% O2, monitor ETCO2 continuously
Cover burn with plastic wrap, plastic chucks, or
clean dry dressings
IV Protocol
Large bore in unburned skin if possible
A If burn is >20%TBSA 2nd/3rd degree burns – NS at 500ml/hr A
If burn is >30%, place 2 large bore IVs

Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Lung, Heart, Abdomen, Extremities, Back,
and Neuro Consider Pain Management Protocol
Burn patients are trauma patients, evaluate for multisystem trauma
Assure whatever has caused the burn, is no longer contacting the injury (stop the burning process)
Early intubation is required when the patient experiences significant inhalation injuries
Potential CO exposure should be treated with 100% oxygen.
Circumferential burns to extremities are dangerous due to potential vascular compromise Contact Medical
secondary to soft tissue swelling M Control M
Burn patients are prone to hypothermia – never apply ice or cool burns, must maintain normal
body temperature
Evaluate the possibility of child abuse with children and burn injuries
*Signs and symptoms of inhalation injury: carbonaceous sputum, facial burns or edema,
hoarseness, singed nasal hairs, agitation, anxiety, cyanosis, stupor or other signs of hypoxia Service MD Approval:______

Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
140
 Trauma: Burns—Thermal
All Providers

 General Patient Care Protocol – Adult

o Stay focused on ABC’s, don’t get side tracked by burn!
o DON’T BECOME A SECOND VICTIM!
 Remove or cool heat source if present (e.g. clothing, tar)
o Cool burns with room temperature water for 3-5 minutes only except
for tar burns which will take an extended time to cool.
o NEVER COOL WITH ICE! The goal is to bring burns to room
temperature, not cold.
 Remove all clothing, contact lenses, and jewelry, especially rings
 Maintain core temperature. Keep patient warm and dry with sheets and
blankets. Cover burns with plastic wrap, plastic chucks, or clean, dry
dressings.
 If inhalation injury is suspected
o Place patient on 100% oxygen – DO NOT DECREASE
o Monitor ETCO2 continuously (if available)
 Estimate Total Body Surface Area (TBSA)
o Rule of Nines
o For scattered burns, use the size of patient’s hand, including fingers, to
equal 1% burn.

INDICATIONS FOR TRANSFER TO A BURN

CENTER
 2nd Degree burns greater than 10% total
body surface area or those on hands, feet,
face, or groin
 3rd degree burns
 Electrical burns
- Spinal immobilization if high voltage
electrical injury
- Monitor for cardiac arrhythmias
- Initiate fluid resuscitation immediately
 Chemical burns
- Remove clothing
- If dry powder is present, brush away
before irrigating
- Flush with copious warm water on
scene and continue irrigation enroute
to UW Hospital
- Chemical injuries to eyes are an
EMERGENCY. Remove contacts and
irrigate continuously with normal saline
for at least 30 minutes.
- Avoid hypothermia

141
Advanced EMT
 Consider IV Protocol
 Place large bore peripheral IV’s in unburned skin if possible
 If TBSA % greater than 20% of 2nd and 3rd degree burns, initiate fluid
resuscitation with 0.9% Normal Saline at 500ml/hour
 If TBSA greater then 30%, place 2 large bore peripheral IV’s

Paramedic
 Observe for signs of impending loss of airway; Refer to the Airway
Management Protocol as needed:
 Hypoxia
 Poor ventilatory effort
 Altered Mental status/decreased level of consciousness
 Inability to maintain patent airway
 Signs or Symptoms of Inhalation injury
 Carbonaceous sputum
 Extensive facial burns or facial edema
 Hoarseness
 Singed nasal hairs
 Agitation, anxiety, cyanosis, stupor or other signs of hypoxia
● If inhalation injury is suspected
 Place patient on 100% oxygen-DO NOT DECREASE
 Monitor ETCO2 continuously
 Consider Airway Management Protocol
 If moderate to severe pain, see Pain Management Protocol

Contact Medical Control for any additional orders or questions

142
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

Trauma: Chest Injuries

All Providers

Trauma Protocol
General Patient Care Protocol—Adult
Assess breath sounds frequently
Assess for ventilatory compromise and assist with BVM as needed
For open/sucking chest wounds, apply occlusive dressing sealed on three (3) sides or
commercially available chest seal
Remove temporarily to vent air if respiratory status worsens

Paramedic
Full ALS Assessment and Treatment
Assess for flail segment
Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol as needed:
Hypoxia
Poor ventilatory effort
Altered mental status/decreased level of consciousness
Inability to maintain patent airway

Contact Medical Control for any additional orders or questions

Service MD Approval:______

Trauma Protocol
Any local EMS Agency changes to this document must follow the
76 DCEMS Protocol Change Policy and be approved by WI EMS
143
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Type of injury Pain, swelling, bleeding Skull fracture
Mechanism (blunt vs. penetrating) Altered mental status Brain injury (concussion, contusion,
Loss of consciousness Unconscious hemorrhage, or laceration)
Bleeding Respiratory distress / failure Epidural hematoma
Past medical history Vomiting Subdural hematoma
Medications Major traumatic mechanism of injury Subarachnoid hemorrhage
Evidence of multi‐trauma seizure Spinal injury
Abuse

General Approach to All Adult Patients

Trauma Protocol
Restrain as needed
Spinal Immobilization Protocol
elevate head of backboard to 15°‐30°
(if normotensive or hypertensive)

Obtain and Record GCS

A IV Protocol A

Airway Protocol

Maintain Pulse Ox >93%

EtCO2 target 40

Seizure Protocol YES

Seizure? Service MD Approval:______
NO

Lorazepam 1‐2mg IV/IO (max 4mg) Severe Agitation/Combative?

P Or P YES
Midazolam 1‐2mg IV/IO (max 4mg) NO

Contact Medical
Monitor and Reassess M Control M
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro
If GCS <12 consider Air transport or Rapid Transport
Airway interventions can be detrimental to patients with head injury by raising intracranial pressure, worsening hypoxia (and secondary brain
injury) and increasing risk of aspiration. Whenever possible these patients should be managed in the least invasive manner to maintain O2
saturation >90% (ie. NRB, BVM with 100% O2)
Acute herniation should be suspected when the following signs are present: acute unilateral dilated and non‐reactive pupil, abrupt deterioration in
mental status, abrupt onset of motor posturing, abrupt increase in blood pressure, abrupt decrease in heart rate.
Only in suspected acute herniation – hyperventilate (rate 20/minute) and target EtCO2 30‐35mmHg
Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushings response)
Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively
Most important vital sign to monitor and document is level of consciousness (GCS)
Concussions are periods of confusion or LOC associated with trauma which may have resolved by the time EMS arrives. Any prolonged confusion or
mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated ASAP by
a physician.

Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
144
 Trauma: Head Injuries
All Providers
 General Patient Care Protocol-Adult
 Supplemental oxygen
 Restrain as needed
 Spinal Immobilization
 If normotensive or hypertensive
 Elevate head of backboard 15 - 30

Paramedic
 Full ALS Assessment and Treatment
 Advanced airway/ventilatory management as needed
Note: Airway interventions can be detrimental to patients with head injury
by raising intracranial pressure, worsening hypoxia (and secondary brain
injury) and increasing risk of aspiration. Whenever possible these patients
should be managed in the least invasive manner to maintain O2 saturation
> 93% (i.e. NRB, BVM with 100% O2)
 Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol if needed:
 Hypoxia
 Poor ventilatory effort
 Altered mental status/decreased level of consciousness
 Inability to maintain patent airway

For patients with assisted ventilation

 Administer eucapneic (normal rate 12-15/min) ventilations
 Titrate to target an ETCO2 of 40 mmHg
 Acute herniation should be suspected when the following signs are present:
 Acute unilateral dilated and non-reactive pupil
 Abrupt deterioration in mental status
 Abrupt onset of motor posturing
 Abrupt increase in blood pressure
 Abrupt decrease in heart rate
 Hyperventilation (ventilatory rate of 20) is a temporizing measure which is
only indicated in the event of acute herniation
 If signs of herniation develop, increase ventilatory rate to 20/minute and target
an ETCO2 of 30-35 mmHg

145
 If severely agitated/combative and unable to de-escalate by any other means,
consider:
 Lorazepam 1-2 mg IV/IO, max 4 mg
OR
 Midazolam 1-2 mg IV/IO, max 4 mg

Contact Medical Control for any additional orders or questions

 Additional sedation for combative patients

146
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

Trauma: Eye Injuries

Trauma Protocol
All Providers
General Patient Care Protocol—Adult
Measure visual acuity
If injury is secondary to a chemical exposure:
Remove patient from source if safe to do so
Remove contact lenses if appropriate; transport with patient
Irrigate the eyes with 0.9 % Normal Saline for a minimum of 20 minutes
Determine chemical involved, bring MSDS sheet if available
If eye injury is due to trauma:
Stabilize any penetrating objects
Do not remove any impaled object
Protective metal shield unless impaled object precludes
Prevent patient bending or standing
If blood observed in anterior chamber, transport with head elevated 60

Contact Medical Control for any additional orders or questions

Service MD Approval:______

Trauma Protocol
Any local EMS Agency changes to this document must follow the
76 DCEMS Protocol Change Policy and be approved by WI EMS

147
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Differential
Type of injury Signs and Symptoms Abrasion
Mechanism: crush/penetrating/amputation Pain, swelling Contusion
Time of injury Deformity Laceration
Open vs. closed wound / fracture Altered sensation/motor function Sprain
Wound contamination Diminished pulse/capillary refill Dislocation
Medical history Decreased extremity temperature Fracture
medications Amputation

General Approach to All Adult Patients

Trauma Protocol
Wound care
Control Hemorrhage with Pressure
Splinting as required**

If hemorrhage can not be controlled by direct

pressure and is life threatening then consider
Tourniquet procedure*

IV Protocol
If life or limb threatening event or if pain medication needed
A A
250 ml NS bolus to maintain SBP >90mmHg (max 2L)

Pain Control Protocol

If amputation: clean amputated part and wrap part in sterile dressing soaked in NS and
Service MD Approval:______
place in an air tight container, place container on ice if available

Contact Medical
M Control M

Pearls
RECOMMENDED EXAM: Mental Status, Extremity, Neuro
*Apply commercially available tourniquet device as proximal on extremity as possible, commercial must be at least 1.5 inches wide, non-commercial
must be at least 2 inches wide. Tighten tourniquet until bright red bleeding has stopped. Secure in place and expedite transport to Level 1 trauma
center. Document time of placement in patient care report and on device (if possible). Notify medical control of tourniquet use.
**Check distal pulses, capillary refill, sensation/movement prior to splinting: If pulse present, splint in position found if possible; If pulse absent, attempt
to place the injury into anatomical position
Open wounds/fractures should be covered with sterile dressings and immobilized in the presenting position
Dislocations should be immobilized to prevent any further movement of the joint
Check distal pulses, capillary refill and sensation after splinting
Peripheral neurovascular status is important (CMS)
In amputations, time is critical. Transport and notify medical control immediately.
Hip dislocations and knee and elbow fracture/dislocations have a high incidence of vascular compromise.
Urgently transport any injury with vascular compromise
Blood loss may be concealed or not apparent with extremity injuries
Lacerations must be evaluated for repair within six hours from the time of injury

Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

148
 Trauma: Extremity
All Providers
 General Patient Care Protocol—Adult
 Remove or cut away clothing to expose area of injury
 Control active bleeding
 For uncontrollable hemorrhage (heavy bleeding despite aggressive
direct pressure):
 Apply commercially available tourniquet device as proximal on
extremity as possible, minimum 2” proximal to the hemorrhage
site.
 Do not place over a joint
 Commercial Tourniquets must be at least 1.5 inches wide
 Non-Commercial Tourniquets must be at least 2 inches
wide
 Tighten tourniquet until bleeding has stopped
 Secure in place and expedite transport to Level 1 Trauma
Center
 Document time placed on chart and on device (if possible)
 Notify receiving center of presence, time placed, and location of
tourniquet
 Check distal pulses, capillary refill, sensation/movement prior to splinting
 If pulse present, splint in position found if possible
 If pulse absent, attempt to place the injury into anatomical position
 Open wounds/fractures should be covered with sterile dressings and
immobilized in the presenting position
 Dislocations should be immobilized to prevent any further movement of the
joint
 Check distal pulses, capillary refill and sensation after splinting

Advanced EMT
 Consider IV Protocol
Paramedic
 Full ALS Assessment and Treatment
 For isolated extremity trauma:
 Stabilize BP (SBP  90 mmHg)
 Refer to the Pain Management protocol as needed

Contact Medical Control for any additional orders or questions

149
 Trauma: Traumatic Amputations
All Providers
 General Patient Care Protocol—Adult
 For uncontrollable hemorrhage (heavy bleeding despite aggressive direct
pressure):
 Apply tourniquet device as proximal on extremity as possible, a
minimum of 2” proximal to the hemorrhage site.
▪ Do not place over a joint
▪ Commercial Tourniquet must be at least 1.5 inches wide
▪ Non-Commercial Tourniquet must be 2 inches wide
 Tighten tourniquet until bleeding has stopped
 Secure in place and expedite transport to Level 1 Trauma Center
 Document time placed on chart and on device (if possible)
 Notify receiving center of presence, time placed, and location of
tourniquet
 If amputation incomplete:
 Attempt to stabilize with bulky pressure dressing
 Splint inline
 If amputation complete:
 Cleanse amputated part with sterile saline
 Wrap in sterile dressing moistened in sterile saline
 Place in plastic bag if possible
 Attempt to cool with cool pack during transport

Advanced EMT
 Consider IV Protocol

Paramedic
 For isolated extremity trauma:
 Stabilize BP (SBP 90 mmHg)
 Refer to Pain Management protocol as needed

Contact Medical Control for any additional orders or questions

150
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Patient who has suffered traumatic injury Evidence of penetrating trauma Medical condition preceding traumatic
and is now pulseless Evidence of blunt trauma event as cause of arrest.
Tension Pneumothorax
Hypovolemic Shock
External hemorrhage
General Approach to All Adult Patients Unstable pelvic fracture
Displaced long bone fracture(s)
Hemothorax
Intra‐abdominal hemorrhage
PNB and: (one or more of the following) Retroperitoneal hemorrhage
Injuries Incompatible with life? (Incineration,
decapitation, hemicorporectomy) OR
Rigor Mortis OR

Trauma Protocol
Decomposition of body tissue OR
Dependent Lividity OR Criteria does not apply for:
Evidence of significant time lapse Lightening or other high voltage injury,
PNB after blunt or penetrating trauma and: Drowning, Suspected Hypothermia,
pulseless and apneic Cardiac Arrest Inconsistent with arrest
lack of pupillary reflexes and spontaneous movement due to trauma, or Transport has been
Asystole or agonal rhythm <20 on monitor initiated
PNB after traumatic injury when transport to nearest
ED is >15 minutes and:
pulseless and apneic
lack of pupillary reflexes and spontaneous movement
Asystole or agonal rhythm <20 on monitor

YES NO

Withhold Resuscitative Efforts Appropriate Cardiac Arrest Protocol Service MD Approval:______

Contact Law Enforcement and/or

Medical Examiner Contact Medical
M Control M

Pearls
Injuries obviously incompatible with life include decapitation, massively deforming head or chest injuries, or other features of a particular patient
encounter that would make resuscitation futile, when in doubt, place patient on the monitor.
Consider using medical cardiac arrest protocols if uncertainty exists regarding medical or traumatic cause of arrest.
As with all major trauma patients, transport should generally not be delayed for these patients
Where the use of spinal immobilization interferes with performance of quality CPR, make reasonable efforts to manually limit patient movement

Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

151
 Trauma: Indications for Withholding Resuscitation
in Traumatic Cardiopulmonary Arrest
CPR can be withheld in Traumatic Cardiopulmonary Arrest under the following
circumstances:
 Pulseless, apenic, and no other signs of life present AND
 The presence of one or more of the following:
 Rigor Mortis
 Decomposition of body tissues
 Dependant Lividity
 Injuries incompatible with life (e.g. incineration, decapitation,
hemicorporectomy)
 Evidence of significant time lapse since pulselessness
- OR -
 Patients who present pulseless after blunt trauma or penetrating trauma
provided that all other signs of life are absent:
 Pulseless and Apenic
 Lack of pupillary reflexes and spontaneous movement
 Asystole or agonal rhythm < 20 on cardiac monitor
- OR -
 Patients who become pulseless after severe traumatic injury when transport
to the NEAREST ED cannot be accomplished within 15 minutes (i.e.,
prolonged extrications), provided that all other signs of life are absent and
transport has not been initiated:
 Pulseless and apenic
 Lack of pupillary reflexes and spontaneous movement
 Asystole or agonal rhythm < 20 on cardiac monitor

This criteria does not apply in the following scenarios:

 When the Cardiac Arrest is inconsistent with Cardiac Arrest due to trauma
 Lightning or other high voltage injuries
 Drowning
 Suspected hypothermia
 Transport has been initiated

Contact Medical Control for any additional orders or questions

152
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

Trauma Protocol
Trauma: Sexual Assault

General Patient Care Protocol

For victims of sexual assault who meet major trauma criteria, transport to Level 1 Trauma
Center
For all other cases, transport to nearest appropriate Emergency Department
□ If medically stable and appropriate consider transport to SANE
(Sexual Assault Nurse Examiner) capable facility.
Provide supportive care as indicated by patient’s condition
Preserve evidence
□ Paper bags are preferred to plastic in evidence preservation.
□ If present, defer to law enforcement for proper chain of custody.

Contact Medical Control for any additional orders or questions

Service MD Approval:______

Trauma Protocol
Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS
153
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Determining the need for spinal immobilization requires a careful assessment of the injury, the patient’s complaints and overall condition,
and the patient’s ability to recognize and convey the presence of spinal injury symptoms. It is not feasible to “clear” the spine in the
prehospital setting. Spinal immobilization should always be applied when any doubt exists as to the possibility of spinal trauma. The
following algorithms (Blunt and Penetrating Trauma) can be used to assist EMS in making the most appropriate decision about the need for
spinal immobilization.

Blunt Trauma If in Doubt - Immobilize Penetrating Trauma

Altered Level of Consciousness?

GCS <15
Presence of neurologic deficit or complaints₂ ?

Trauma Protocol
Test Motor functioning both upper and lower extremities
YES NO
(entire extremity)
Any of the following: Test sensation in both upper and lower extremities (start
▪ spinal pain or tenderness ₁ proximal and work towards hands and feet)
Ask about numbness and tingling in extremities.
YES ▪neurologic deficit or complaint₂
Immobilize ▪anatomical deformity of the spine

YES NO YES

Concerning Mechanism of NO
YES
Injury*?
NO
Any of the following:
▪ Evidence of (significant) clinical Immobilize
intoxication
▪ Distracting Injury₃
▪ Inability to communicate₄ Immobilization not indicated

NO

Immobilization not indicated Medical Control Service MD Approval:______

M If Needed M
Pearls
₁ Tenderness to the midline posterior neck and back, including the paraspinal musculature
₂ Examples are numbness, focal weakness, focal sensory deficit, parasthesias
₃ Examples are long bone fractures, dislocations, large lacerations, degloving injuries, serious burns or any other injury causing functional impairment.
₄ Examples include language barrier, hearing or speech impairment, dementia and age (young children)
* Concerning MOI:
‐Any mechanism that produces a violent impact on the head, neck, torso or pelvis
‐Incidents that produce sudden acceleration or deceleration, including lateral bending forces
‐ Any fall, especially in the elderly
‐ Ejection or fall from a moving mode of transportation
‐ Shallow‐water drowning or diving injuries – must immobilize
‐ High voltage electrical injuries – must immobilize
If spinal immobilization is indicated but refused by the patient:
Advise the patient of the indication for immobilization and the risks of refusing the intervention.
If the patient allows, apply the cervical collar even if backboard is refused.
Maintain spinal alignment as best as can be achieved during transport.
Clearly document refusal of immobilization
For patients who cannot tolerate supine position due to clinical condition: apply all elements the patient can tolerate, maintain spinal alignment as best
as can be achieved during transport, clearly document clinical condition that interfered with full immobilization.
Determining the presence of neurological signs and symptoms requires careful assessment and history taking.
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
154
 Spinal Immobilization: Indications
Determining the need for spinal immobilization requires a careful assessment of the
injury, the patient’s complaints and overall condition, and the patient’s ability to
recognize and convey the presence of spinal injury symptoms. It is not feasible to
“clear” the spine in the prehospital setting. Spinal immobilization should always be
applied when any doubt exists as to the possibility of spinal trauma. The following
algorithms (Blunt and Penetrating Trauma) can be used to assist EMS in making the
most appropriate decision about the need for spinal immobilization.

Blunt Trauma
Assess for concerning mechanism of injury:
 Any mechanism the produces a violent impact on the head, neck, torso or
pelvis
 Incidents that produce sudden acceleration or deceleration, including lateral
bending forces
 Any fall with neck pain, back pain, altered mental status and/or neurologic
deficit, especially in the elderly
 Ejection or fall from a moving mode of transportation
 Shallow-water drowning or diving injuries
 High-voltage electrical injuries

Assess patient’s ability to clearly communicate and/or comprehend the

nature of their injuries:
 Altered level of consciousness
 GCS < 15
 Evidence of significant intoxication
 Dementia
 Speech or hearing impairment
 Age (young children)
 Language barrier

Assess for physical signs or symptoms of spinal trauma:

 Spinal pain or tenderness, including paraspinal muscles
 Neurologic deficit or complaint, including parasthesia, paralysis, or weakness
 Anatomical deformity of the spine

155
Assess for presence of distracting injuries, including but not limited to:
 Long bone fractures
 Joint dislocations
 Abdominal or thoracic pain, or obvious visceral injury
 Large lacerations, degloving injuries or crush injuries
 Any injury producing acute functional impairment
 Craniofacial injuries

IF ANY OF THE ABOVE MENTIONED FEATURES ARE PRESENT,

OR IF ANY QUESTION, IMMOBILIZE!

Contact Medical Control for any additional orders or questions

156
Immobilize all patients with the following conditions:
 High voltage electrical injuries (does not include Taser use)
 Shallow water drowning or diving injuries

If spinal immobilization is indicated but refused by the patient:

 Advise the patient of the indication for immobilization and the risks of refusing
the intervention.
 If the patient allows, apply the cervical collar even if backboard is refused.
 Maintain spinal alignment as best as can be achieved during transport.
 Clearly document refusal of immobilization.

For patients who cannot tolerate supine position due to clinical condition:
 Apply all elements of spinal immobilization that the patient will tolerate.
 Maintain spinal alignment as best as can be achieved during transport.
 Clearly document the clinical condition that interfered with full immobilization.

Contact Medical Control for any additional orders or questions

157
158
The following measures will apply to the management of all pediatric patients:
A Child shall be defined as:
Age <12 years of age or weight <40 kg (if age unknown)
No signs of puberty if age/weight not able to be determined
For PALS resuscitation <8 years
For Major Trauma <18 years
All Providers
Ensure scene safety
Scene survey to determine environmental conditions, mechanism of injury or illness and potential for hazardous

Pediatric Protocol
conditions
Form general impression of patient’s condition
Establish patient responsiveness
Immobilize spine if cervical or other spine injury suspected
Assess airway and breathing, manage as appropriate
Supplemental 100% Oxygen if any respiratory signs or symptoms
Assess circulation and perfusion by measuring heart rate, and observing skin color, temperature, capillary refill and the
quality of central/peripheral pulses.
□ For children with absent pulses, initial cardiopulmonary resuscitation
Control hemorrhage using direct pressure or a pressure dressing
Measure Blood Pressure in children older than 3
Evaluate mental status including pupil reaction, motor function and sensation

2013
Vital Signs for Children
□ For mental status, use the AVPU scale:
• A‐ The patient is alert and oriented (age appropriate) Respiratory Systolic Blood
• V – The patient is responsive to verbal stimulus Age Group
Newborn
Rate
30-60
Heart Rate
120-180
Pressure
>60
• P – The patient is responsive to painful stimulus Infant
(1-12 Months) 20-40 100-140 >70
• U – The patient is unresponsive to any stimulus Toddler
Expose the child only as necessary to perform further assessments (1-3 years) 20-34 90-130 >75
Preschooler
Maintain the child’s body temperature throughout assessment (3-5 Years) 20-30 80-120 >80
Utilize the Broslow‐Luten® system for estimating patient weight School Age
(6-12 Years) 18-30 70-110 >80
Advanced EMT Adolescent
(13+ Years) 12-20 60-100 >90
● Consider IV Protocol
Paramedic
● When condition warrants (specified as “Full Pediatric ALS Assessment and Treatment” in individual
protocols):
□ Airway/ventilatory management as needed
□ Perform cardiac monitoring
□ Record and monitor O2 saturation
□ Record and monitor End‐tidal CO2
□ If symptoms severe or for medication access IV 0.9% NaCl TKO/KVO or IV Lock
● If signs of shock administer boluses of 0.9% NaCl at 20 ml/kg until signs of shock resolve or 60 ml/kg total
● If signs of severe cardiopulmonary compromise (poor systemic perfusion, hypotension, altered consciousness
and/or respiratory distress/failure) and IV attempts unsuccessful (max 2 attempts) in a child consider
intraosseous access
□ If a child’s condition is critical or unstable, initiate transport without delay
● Perform procedures, history and detailed physical exam en route to the hospital
● Unless specified in protocol, all medication dosages and equipment sizes should be calculated using the Broselow‐
Luten system
□ Reassess the patient frequently
Contact Medical Control for any additional orders or questions
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

159
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History:
Signs and Symptoms Differential (Life Threatening)
Time of arrest
Wheezing or stridor Allergic reaction
Possibility of foreign body
Respiratory retractions Asthma
Medical history
Increased heart rate Aspiration
Medications
Altered level of Foreign body
Fever or respiratory infection
consciousness Infection
Other sick siblings
Anxious appearance Pneumonia, croup, epiglotits
History of trauma
Congenital heart disease

Pediatric and OB Protocols

Medication or toxin
General Approach to all Pediatric
Trauma
Patients

Ventilatory Insufficiency
Assess ABC’s Stridor? YES
Respiratory Failure
NO

Airway, Pediatric Drooling, Dysphonia, Fever,

Pulse Ox and Lung Sounds
Protocol “Toxic Appearing”
NO YES

NO Allergic Position of
YES Wheezing?
Supplemental O₂ Reaction Comfort
Keep SpO₂ >93% Suspected?
Supplemental O₂ Supplemental O₂
YES
Keep SpO₂ >93% As tolerated
NO Epi IM**
0.01mg/kg Transport
Albuterol 2.5mg/3ml

2013
WORSENING (0.3max) Rapidly
Ipratropium 0.5mg/2.5ml
May repeat Albuterol (total 3
doses)*** A IV Protocol A
IMPROVED UNCHANGED Methylprednisolone 2mg/kg IV or IM (max dose 125mg)
P Magnesium Sulfate 50mg/kg IV (max 2g) in 100ml D5W P
over 5‐10min*
Comfort and
transport P Consider Inhaled Epi P
As appropriate M 3ml of 1:1,000 mixed in 3ml NS M
Service MD Approval:______
M Contact Medical Control M
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
*Magnesium sulfate contraindicated if history of renal failure
** Epi Pen Jr. .15mg <60pounds, Epi Pen .30mg >60pounds.
*** If Basic or A-EMT is needing to provide additional Albuterol, Medical Control or Paramedics should be consulted.
Whenever available utilize capnography
Pulse oximetry should be monitored continuously if initial saturation is <96%, or there is a decline in patient status despite normal pulse oximetry
readings.
Do not force a child into a position. They will protect their airway by their body position
The most important component of respiratory distress is airway control
Bronchiolitis is a viral infection typically affecting infants which results in wheezing which may not respond to beta‐agonists. Consider Epinephrine if
patient <18 months and not responding to initial beta‐agonist treatment
Croup typically affects children <2years of age. It is viral, possible fever, gradual onset, no drooling is noted.
Epiglotitis typically affects children >2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patient wants to sit up to keep airway
open, drooling is common. Airway manipulation may worsen the condition.

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
160
 Airway Emergencies: Pediatric Dyspnea
All Providers
 General Patient Care Protocol—Pediatric
 Supplemental 100% oxygen
 For Bronchospasm:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium Bromide
0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer (if additional Albuterol
needed, contact Medical Control or Paramedic Intercept)
 If severe:
 Hypoxia: < 93%, severe respiratory distress, anaphylactic shock, stridor
 Assist with patient-prescribed Epinephrine auto-injector (e.g. Epi-Pen or
Epi-Pen Jr.)
 If foreign body obstruction is suspected refer to foreign body protocol
 If partial upper airway obstruction or stridor without severe respiratory distress
 Do nothing to upset the child
 Perform critical assessments only
 Have parent administer blow by supplemental oxygen
 Place patient in position of comfort
 Do not attempt vascular access
 Expedite transport

 If complete airway obstruction or severe respiratory distress, failure or arrest

 Airway/ventilatory management as needed

Advanced EMT
 Consider IV Protocol
 For Bronchospasm:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium Bromide
0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer (if additional Albuterol
needed, contact Medical Control or Paramedic Intercept)
 If patient shows signs of worsening respiratory distress, inadequate ventilations
or respiratory failure in the setting of bronchospasm or a history of asthma
 Epinephrine 1:1000 at 0.01 mg/kg (max 0.3 mg) IM

161
Paramedic
 Full Pediatric ALS Assessment and Treatment
 For Bronchospasm:
 Albuterol (Proventil) 2.5mg/3ml via nebulizer every 15 minutes (max 3
treatments)
 If patient shows signs of worsening respiratory distress, inadequate ventilations
or respiratory failure in the setting of bronchospasm or a history of asthma
 Epinephrine 1:1000 at 0.01 mg/kg (max 0.3 mg) IM
 May repeat epinephrine every 15 minutes X 2 additional doses (3
total) if severe symptoms present
 May administer at same time nebulizer is being administered
 Methylprednisolone (Solu-Medrol) 2 mg/kg IV or IM (Maximum individual
dose 125 mg)
 Magnesium Sulfate 50mg/kg IV (max individual dose 2g) in 100 ml D5W
over 20 minutes; contraindicated if history if renal failure

Drowning/Near Drowning
 Ventilatory management as indicated/100% O2 as indicated
 Spinal Immobilization if indicated
 Protect from heat loss
 Patients may develop delayed onset respiratory symptoms
 Refer to appropriate protocol if cardiac arrest present

Paramedic - Contact Medical Control for any additional orders or

questions
 Nebulized Epinephrine

162
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
Assess ABC’s
-Respiratory Rate
Supplemental Oxygen
ADEQUATE ‐Effort
Maintain SPO2 >93%
‐Adequacy
Pulse Oximetry
INADEQUATE

Pediatric and OB Protocol

Basic Maneuvers First
‐open airway
UNSUCCESSFUL ‐suction OBSTRUCTION
‐nasal or oral airway
‐BVM
If > 4 feet, Blind insertion LONG TRANSPORT SUCCESSFUL
airway device(Paramedic‐ if OR NEED
<4feet LMA) TO PROTECT Airway Obstruction Procedure
Only one attempt
AIRWAY Continue BVM SUCCESSFUL (per AHA standards)

Or UNSUCCESSFUL
P Endotracheal Intubation P Laryngoscope and Magill
Only one attempt forceps
Resume BVM
UNSUCCESSFUL
Attempt LMA or BIAD
Confirm with ETCO2 and exam UNSUCCESSFUL

2013
Perform needle cricothyrotomy and
SUCCESSFUL M P jet insufflation P M
If available, consider gastric Consult Medical
decompression M Control M
Service MD Approval:______

Pearls
If Capnography is available it is expected to be used with all methods of airway placement. Document results
If an effective airway is being maintained by BVM with continuous pulse oximetry values of >93, it is acceptable to continue with
basic airway measures instead of using a Blind insertion device or intubation.
For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation
An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal
passage
Ventilatory rate should be 30 for neonates, 25 for toddlers, 20 for school age children, and 12 for adolescents. Maintain an ETCO2 of
30‐35. Avoid hyperventilation
Quality assurance should always be completed after the use of blind insertion device or intubation
Maintain C‐spine immobilization for patients with suspected spinal injury
Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
Sellick’s and or BURP maneuver should be used to assist with difficult intubations
Hyperventilation in deteriorating head trauma should only be done to maintain an ETCO2 of 30‐35
Gastric tube placement should be considered in all intubated patients if available
It is important to secure the endotracheal tube well and consider c‐collar to better maintain ETT placement
Suction all debris, secretions from the airway if necessary

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

163
Airway Emergencies: Pediatric Airway Management
All Providers
 General Pediatric Patient Care Protocol
 If suspicion of trauma, maintain c-spine immobilization
 Suction all debris, secretions from airway
 Bag valve mask ventilate as needed
 Ventilate at a rate of 20 breaths/minute for all ages
 Supplemental 100% O2
 Have assistant apply cardiac monitor as soon as possible
 Monitor end-tidal CO2 and oxygen saturation continuously

Advanced EMT
 Consider IV Protocol

Paramedic
 Have assistant apply cardiac monitor as soon as possible
 Address cardiac rhythm abnormalities per appropriate protocol
 Monitor end-tidal CO2 and oxygen saturation continuously
 Follow sequence listed below (use Broselow-Luten® tape to select appropriate
equipment)

164
 Following placement of ETT or LMA confirm proper placement
 Assess epigastric sounds, breath sounds and chest rise and fall
 Observe for presence of alveolar waveform on capnography
 Record tube depth and secure in place using a commercial tube holder (if
available)
 Utilize head restraint device (i.e. “head blocks”) or rigid cervical collar and
long spine board as needed to help secure airway in place

Capnography/ETCO2 Monitoring
 Digital capnography (waveform) is the system standard for ETCO2 monitoring.
 Only in the event digital capnography is not available due to on-scene
equipment failure, is continuous colorimetric monitoring of ETCO2 an
acceptable alternative.
 Continuous ETCO2 monitoring is a MANDATORY component of invasive
airway management.
 If ETCO2 monitoring cannot be accomplished by either of the above
methods, the invasive device MUST be REMOVED, and the airway
managed non-invasively.
 If an alveolar waveform is not present with capnography (i.e. flat line),
briefly check the filter line coupling to assure it is securely in place then
remove the ETT/LMA or LTA and proceed to the next step in the
algorithm.

Foreign Body Airway Obstruction

 Immediate transport is indicated
 If unresponsive open airway using a head tilt/chin lift (if no trauma)
 If < 1 year old, administer up to 5 back blows and 5 chest thrusts
 If  1 to 8 years, administer compressions and attempts at ventilation until
the foreign body is dislodged
 If ventilation is unsuccessful (O2 saturations cannot be kept > 93 %) perform in
the following order:
 Reposition airway and attempt bag valve mask assisted ventilation again
 If unsuccessful, establish direct view of object with laryngoscope and
attempt to remove it with Magill forceps
 If unsuccessful, re-attempt BVM ventilation; If oxygen saturation > 93%
with BVM proceed no further and expedite transport
 If patient cannot be ventilated/oxygenated with the above measures,
Paramedics- simultaneously contact medical control and perform needle
cricothyrotomy and needle jet insufflation as a last resort.
 Expedite transport to nearest emergency department

Contact Medical Control for any additional orders or questions

165
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
Differential
History: Signs and Symptoms Urticaria (rash only)
Onset and location Itching or hives Anaphylaxis (systemic effect)
Insect sting or bite Coughing / wheezing Shock (Vascular effect)
Food allergy / exposure Or respiratory distress Angioedema (drug induced)
Medication allergy / exposure Chest or throat constriction Aspiration / Airway
New clothing, soap, detergent Difficulty swallowing obstruction
Past history of reactions Hypotension or shock Vasovagal event
Past medical history Edema Asthma or COPD
Medication history CHF

Pediatric Protocol
General Approach to All Pediatric Patients

Allergic Reaction suspected – history/exposure to allergen

Severe Reaction
Mild Reaction Anaphylactic shock, Stridor, lip swelling
Hives / Rash Only Severe respiratory distress
No respiratory component Moderate Reaction
Dyspnea, Wheezing,
Chest Tightness Epinephrine 1:1000 Auto‐Injector *
0.3mg >60lb 0.15mg <60lb
Epinephrine 1:1000 IM*
A Consider IV Protocol A A .01mg/kg (max 0.3mg)
A

2013
Albuterol 2.5mg/3ml** &
Ipratropium 0.5mg/2.5ml Albuterol 2.5mg/3ml** &
Ipratropium 0.5mg/2.5ml
Diphenhydramine A Consider IV Protocol A
P 1mg/kg IV/IM (max 50mg) P IV Protocol
A NS Bolus 20ml/kg if hypotensive
A
Diphenhydramine
Worsening P 1mg/kg IV/IM (max 50mg) P
Diphenhydramine
Worsening P 1mg/kg IV/IM (max 50mg) P
Epinephrine 1:1000 Auto‐Injector * Methylprednisolone
0.3mg >60lb 0.15mg <60lb P 2 mg/kg IV/IM (max 125mg) P
Epinephrine 1:1000 IM*
A A
.01mg/kg (max 0.3mg) No Improvement
M Repeat Epinephrine M
Pearls Severe
RECOMMENDED EXAM: Mental Reactions
Improvement
Status, Skin, Heart, Lungs
* Online Medical Control if HR
>150 or History of Coronary Artery For severe reactions:
Disease Famotidine 0.5mg/kg in 100ml
**May repeat Albuterol PRN for MP D5W IV Piggyback (max dose P M
continued wheezing – max 3 M Contact Medical Control M 20mg) over 15 minutes
doses
The shorter the onset from
symptoms to contact, generally
the more severe the reaction
*** Severe bradycardia, unresponsive, no
obtainable blood pressure or radial pulse
Service MD Approval:______

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
166
 Allergic Reactions: Pediatric
All Providers
 General Patient Care Protocol-Pediatrics
 Nothing by mouth
 Moderate Reaction (Dyspnea, Wheezing, Chest Tightness)
 As above plus:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium
Bromide 0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer
 May repeat Albuterol in 15 minutes for continued wheezing

 Severe Systemic Reaction (Anaphylactic shock, Stridor, Severe respiratory

distress)
 As above plus:
 Epinephrine 1:1000 solution, 0.01 mg/kg IM (Max dose 0.3 mg)
 Massage injection site vigorously for 30-60 seconds

Advanced EMT
 Consider IV Protocol

Paramedic
 If moderate or severe symptoms, perform Full Pediatric ALS Assessment and
Treatment
 Mild Reaction (hives)
 As above plus: Diphenhydramine (Benadryl) 1 mg/kg IV (maximum 50 mg)
 May be administered IM if no IV access available

 Severe Systemic Reaction (Anaphylactic shock, Stridor, Severe respiratory

distress)
 As above plus:
Methylprednisolone (Solumedrol) 2 mg/kg IV or IM (Maximum
individual dose 125 mg)

Contact Medical Control for any additional orders or questions

 All Providers –Repeat epinephrine if signs of severe reaction or shock
persist after initial dose
 Paramedics - For severe reactions, Famotidine 0.5mg/kg in 100 ml D5W
IV Piggyback (max dose 20mg) over 15 minutes.

167
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
Signs and Symptoms
History: Differential
Decreased mental status or
Known Diabetic Head Trauma
Lethargy
Drugs, Drug Paraphernalia CNS (stroke, tumor, seizure,
Change in baseline mental
Report of illicit drug status infection)
use or toxic ingestion Cardiac (MI, CHF)
Bizarre behavior
Past medical history Hypothermia
Hypoglycemia (cool/
Medications Infection (CNS or other)
Diaphoretic skin)
History of trauma Thyroid (hyper/hypo)
Hyperglycemia (warm, dry
Change in condition Skin, fruity breath, kussmaul Shock (septic, metabolic, traumatic)
Changes in feeding or sleep respirations, signs of Diabetes (hyper/hypo)
habits Toxicologic or Ingestion

Pediatric Protocol
dehydration
Irritability Acidosis/Alkalosis
Environmental exposure
Pulmonary (hypoxia)
General Approach to All Pediatric Patients Electrolyte abnormality
Psychiatric disorder

Glucose Level Glucose Level

2months‐12years <70 Blood Glucose 2months‐12years >70
<2months <40 <2months >40

A Consider IV Protocol A
Naloxone 0.1 mg/kg IV/IO/IN*
Glucagon A (max dose 2.0mg)
A
<1 year old – 0.5 mg IM

2013
>1 year old – 1.0 mg IM Consider other causes: Head injury,
OD/toxic ingestion, stroke, hypoxia,
hypothermia
Dextrose 10% at 4ml/kg
A (max 250mL) IV A P Assess Cardiac Rhythm P
NO

Return to baseline?

YES

Refusal of transport after Consult Medical

treatment given M Control M
protocol

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. Pay
special attention to the head exam for signs of bruising or other injury.
* for Intranasal administration A-EMT should administer 0.5mg per nare, total of 1mg and then proceed
with additional doses as needed
Be aware of AMS as presenting sign of an environmental toxin or Hazmat exposure and protect
personal safety
It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after
Dextrose or glucagon
Consider restraints if necessary for patients and/or personnel's protection per the restraint protocol
Service MD Approval:______

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
168
 Altered Mental Status: Pediatric
This protocol is intended for pediatric patients with new altered mental status of
unknown etiology.

All Providers
 General Pediatric Patient Care Protocol
 If trauma suspected, stabilize spine
 Supplemental 100% oxygen
 Blood glucose check
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
 Glucagon - <1 year old – 0.5mg or >1 year old – 1.0mg IM

Advanced EMT
 Consider IV Protocol
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4ml/kg to max of 250 mL
- OR -
 Glucagon <1 year old = 0.5mg or >1 year old = 1.0mg if IV or IO
access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a neonate)
after treatment or unable to determine blood glucose and no change in mental
status.
 If patient has continued altered mental status:
 Naloxone at 0.1 mg/kg (maximum individual dose 2 mg) via IV/IO
 If no IV access, administer IN via mucosal atomizer device (MAD),
with one-half of dose administered to each nostril.

Paramedic
 Full Pediatric ALS Assessment and Treatment

Contact Medical Control for any additional orders or questions

169
 Legend
EMT
A A‐EMT A
P
M
Paramedic
Medical Control
P
M
(ALTE)

Apparent Life-Threatening Event (ALTE)

An Apparent Life Threatening Event (ALTE), often referred to as a “near miss SIDS”, is an episode
that is frightening to the observer/caregiver, and involves some combination of the following:
Apnea (central or obstructive)

Pediatric Protocol
Color change (cyanosis, pallor, erythema, plethora)
Marked change in muscle tone (e.g. limpness/rigid)
Choking or gagging

All Providers
Assume the history given is accurate and reliable
Determine the severity, nature and duration of the episode
Obtain a medical history:
Known chronic diseases
History of preterm delivery
Evidence of seizure activity
Current or recent infections
Gastroesophageal reflux
Inappropriate mixture of formula
Recent trauma
Perform a thorough physical assessment that includes the general appearance, skin color,
level of interaction with environment and evidence of trauma and blood glucose check
Transport to the nearest appropriate receiving facility

For patients < 1 year of age

If the parent/guardian is refusing medical care and/or EMS transport, OLMC must be
contacted prior to accepting a refusal.

Contact Medical Control for any additional orders or questions

Service MD Approval:______

Pediatric Protocol
Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS

170
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
Differential (Life Threatening)
History: Signs and Symptoms Respiratory failure
Time of arrest Unresponsive Foreign body, secretions, infection (croup, epiglotitis)
Medical history Cardiac Arrest Hypovolemia (dehydration)
Medications
Congenital heart disease
Possibility of foreign body
Trauma
Hypothermia
Tension pneumothorax, cardiac tamponade, pulmonary
embolism
Hypothermia

Pediatric and OB Protocols

General Approach to all Patients Toxin or medication
Electrolyte abnormalities (glucose, K)
acidosis
CPR

Cardiac Monitor

Ventricular Fibrillation/Tachycardia Asystole/PEA

Give 1 shock
*Airway Protocol
Manual: 2J/kg
May use AED if >1year of age (use pediatric AED Check Blood Glucose and treat if appropriate
if possible for 1‐8 years old)
AED per manufacturer recommendation if <1 A IV Protocol A
Immediately start CPR, do not check for pulse Epinephrine IV/IO
*Airway Protocol 1:10,000 at 0.01mg/kg (max1mg)
AT ANY TIME P Repeat every 3‐5 minutes (flush P

2013
Check Blood Glucose and treat if appropriate Return of spontaneous with 10‐20 ml NS)
circulation ‐>
A IV Protocol A Treat per appropriate Continue CPR 5 cycles at time
Give 5 cycles CPR dysrhythmia protocol
Expedite Transport Check rhythm, between cycles
Check rhythm, check pulse Only check pulse between cycles of CPR and
Shockable rhythm? if there is a perfusing rhythm
YES

Give 1 shock 4J/kg or use AED as described above

Resume CPR immediately after shock
Epinephrine IV/IO Try to Identify and Treat the Cause:
Hypoxemia – assist ventilation
P 1:10,000 at 0.01mg/kg P Acidosis ‐
Repeat every 3‐5 minutes (flush with 10‐20 ml NS)
Volume depletion – 0.9%NaCl at 20ml/kg may repeat (max 60ml/kg)
Check rhythm, check pulse Tension pneumothorax **
Shockable rhythm? Hypothermia ‐ rewarm
Hypoglycemia – Dextrose 10% 4ml/kg
YES
Hypo or Hyperkalemia‐
Give 1 shock 4J/kg or use AED as described above
Resume CPR immediately after shock
Consider
P Amiodarone 5mg/kg IV/IO bolus(max dose 300mg) – Give during CPR P M Contact Medical Control M
Magnesium 50mg/kg IV/IO for suspected torsades de pointes(max 2g)
Pearls
RECOMMENDED EXAM: Mental Status Service MD Approval:______
In order to be successful in pediatric arrests, a cause must be identified and corrected
Airway is the most important intervention. This should be accomplished immediately. Patient survival is often dependent
on airway management success.
*Airway Management by BVM is sufficient in the pediatric arrest patient. A single attempt at intubation can be made
only if time allows. Do not prolong transport or scene time to attempt intubation.
**If unilateral decreased or absent lung sounds (may see tracheal deviation away from collapsed lung) and/or evidence of
hemodynamic compromise – perform pleural decompression at 2nd intercostal space, midclavicular line
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
171
 Cardiac Arrest, General: Pediatric
Airway management by BVM is sufficient in the pediatric arrest patient.
A single attempt at intubation can be made only if time allows. Do not prolong
transport or scene time to attempt intubation.

All Providers
 General Pediatric Patient Care Protocol
 Establish responsiveness
 If trauma suspected, stabilize spine
 Confirm apnea and pulselessness and administer CPR
 Apply AED as soon as available for  8 years old
 For children 1-8 years old use pediatric AED cables/electrodes if available
 As a last resort in a child 1-8 years old, apply AED with available
cables/electrodes
 If utilizing Defibrillator in Manual Mode and shockable rhythm - Defibrillate
at 2 J/kg (maximum of 200J)
 AED per manufacturer instructions for children < 1 year old
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg

Advanced EMT
 Consider IV Protocol
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum 250 mL

- OR –
 Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg
if IV or IO access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a
neonate) after treatment or unable to determine blood glucose and no
change in mental status.

172
Paramedic
 Full Pediatric ALS Assessment and Treatment
 Determine cardiac rhythm and refer to appropriate protocol for further
management actions
 Due to the child’s critical condition, initiate transport without delay

Contact Medical Control for any additional orders or questions

173
 Cardiac Asystole and PEA: Pediatric

Asystole and Pulseless Electrical Activity

Paramedic
 Follow Cardiac Arrest, General—Pediatric Protocol
 Confirm the presence of asystole in 2 leads
 Minimize any interruptions in compressions
 Using the most readily available route, administer (during CPR)
 Epinephrine 1:10,000 at 0.01 mg/kg IV/IO (max dose 1mg)
 Repeat Epinephrine as above every 3-5 minutes
 Flush medication with 10-20 ml of normal saline after each dose
 Treat any suspected contributing factors:
 If hypovolemic, administer 0.9% NaCl at 20 ml/kg IV/IO bolus, may repeat
twice (to a maximum of 60 ml/kg)
 If hypoxic, secure airway and assist ventilation
 If hypothermic, rewarm
 If hyperkalemia suspected (history of renal failure/dialysis)
 Calcium Chloride (10%), 20 mg/kg IV/IO (max 1 g)
 Sodium Bicarbonate 1 mEq/kg IV/IO (max dose 50 mEq)
 If narcotic suspected, Naloxone 0.1 mg/kg (max dose 2 mg) IM/IV/IO/IN
 If toxic ingestion, see specific toxin
 Assess for tension pneumothorax
 Unilateral decreased or absent lung sounds (may see tracheal
deviation away from collapsed lung)
 Evidence of hemodynamic compromise
 If tension pneumothorax suspected due to history or
condition, perform pleural decompression at 2nd intercostal
space, mid-clavicular line

Contact Medical Control for any additional orders or questions

174
 Cardiac Arrest: VF/VT: Pediatric

Ventricular Fibrillation or Pulseless Ventricular Tachycardia

Paramedic
 Follow Cardiac Arrest, General -Pediatric Protocol
 Confirm the presence of ventricular fibrillation/pulseless ventricular tachycardia
 Defibrillate at 2 J/kg (maximum of 200J)
 Continue compressions while defibrillator charges
 Immediately resume CPR after shock
 Check rhythm after 2 minutes of CPR
 Using the most readily available route (give drug during CPR)
 Epinephrine 1:10,000 at 0.01 mg/kg IV/IO
 Repeat Epinephrine as above every 3-5 minutes
 Flush medication with 10-20 ml of normal saline after each dose
 If shockable rhythm persists, Defibrillate at 4 J/kg
 Continue compressions while defibrillator charges
 Immediately resume CPR after shock
 Check rhythm after 2 minutes of CPR
 Amiodarone 5 mg/kg IV/IO bolus (give during CPR) (max dose 300mg)
 Magnesium 50 mg/kg IV/IO bolus for suspected torsades de pointes (max
dose 2g )
 If shockable rhythm persists, Defibrillate at 4 J/kg
 Continue compressions while defibrillator charges
 Immediately resume CPR after shock
 Check rhythm after 2 minutes of CPR
 Continue cycle

Contact Medical Control for any additional orders or questions

175
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential
Past medical history Decreased heart rate Respiratory failure
Foreign body exposure Delayed capillary refill or cyanosis Foreign body
Respiratory distress or arrest Mottled, cool skin Secretions
Apnea Hypotension or arrest Infection (croup, epiglotits)
Possible toxic or poison exposing Altered level of consciousness Hypovolemia (dehydration)
Congenital disease Congenital heart disease
Trauma

Pediatric and OB Protocols

Medication (maternal or infant)
Tension pneumothorax
Hypothermia
General Approach to all Patients Toxin or medication
Hypoglycemia
Acidosis
Heart rate in
Pediatric Airway Protocol
infant <60?

Poor perfusion
Decreased blood pressure YES CPR
Respiratory insufficiency

NO A IV Protocol* A
Monitor and reassess

If Blood glucose <40mg/dL if less than 2 months

Or if Blood glucose <70mg/dL 2 months‐12 years Epinephrine

2013
P 0.01mg/kg of a 1:10,000 solution IV/IO P
(max 1mg) repeat every 3‐5min
IF no IV, Glucagon
<1 year old = 0.5mg
Atropine
>1 year old = 1.0mg P 0.02mg/kg IV/IO P
(max individual dose 0.5mg) Repeat every 3‐5 min
IV Protocol Pulseless
Reassess NO
A D10 IV/IO A PULSE Arrest
Dextrose 10% at 4ml/kg Continue Compromise Protocol
(max 250 ml) May repeat x1 Improved If signs of severe compromise despite Epi/Atropine
Consider External Cardiac Pacing**
Lowest setting that provides ventricular capture 100bpm
M Contact Medical Control M P Sedation if time allows and BP >90mmHg P
Fentanyl 1.0mcg/kg and Midazolam 0.1 mg/kg IV/IO
(max Fentanyl 200mcg and Midazolam 4mg)

Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro
For all drug doses not specified in protocols, please refer to Broselow-Luten tape. If severe cardiopulmonary
* If unable to secure IV in three attempts or 90 seconds, acquire IO access compromise persists
Infant =<1 year of age P despite pacing: P
The majority of pediatric arrests are due to airway problems Dopamine infusion
Most maternal medications pass through breast milk to the infant 5‐20mcg/kg/min IV/IO
Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia
Pediatric patients requiring external transcutaneous pacing require the use of pads appropriate for pediatric
Service MD Approval:______
patients per the manufacturers guidelines.
Minimum Atropine dose is 0.1mg IV
** If weight >15kg, apply adult transcutaneous pacemaker, if weight <15kg use pediatric pads.

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
176
 Cardiac Arrhythmia: Pediatric Bradycardia
All Providers
 General Pediatric Patient Care Protocol
 Supplemental 100% oxygen
 Assist ventilation as needed with bag valve mask
 Look for signs of obstruction
 Absent breath sounds, tachypnea, intercostal retractions, stridor or
drooling, choking, bradycardia or cyanosis
 If foreign body obstruction is suspected refer to foreign body protocol
 Open airway using head tilt/chin lift if no spinal trauma is suspected and
modified jaw thrust if spinal trauma suspected
 If signs of severe cardiopulmonary compromise are present in an infant (< I year)
and the heart rate remains slower than 60 beats per minute despite oxygenation
and ventilation:
 Initiate chest compressions
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM

Advanced EMT

 Consider IV Protocol
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL

- OR –
 Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg
if IV or IO access unavailable

 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a

neonate) after treatment or unable to determine blood glucose and no
change in mental status

177
Paramedic
 Full Pediatric ALS Assessment and Treatment
 If signs of severe cardiopulmonary compromise persist (use first available route)
 Epinephrine 0.01 mg/kg of a 1:10,000 solution IV/IO (max 1 mg)
 Repeat dose every 3-5 minutes until either the bradycardia or severe
cardiopulmonary compromise resolves.

 Identify and treat possible causes of bradycardia:

 If hypoxia, open airway/assist breathing
 If hypothermic, rewarm
 If acutely deteriorating head injury, hyperventilate
 If heart bock or post heart transplant, apply transcutaneous pacer (see
below)
 If toxin ingestion, see specific toxin
 If signs of severe cardiopulmonary compromise persist despite Epinephrine and
above measures
 Atropine at 0.02 mg/kg IV/IO
 Minimum dose is 0.1 mg
 Maximum individual dose is 0.5 mg
 May repeat once after 3-5 minutes
 If signs of severe cardiopulmonary compromise persist despite
Epinephrine/Atropine apply transcutaneous pacemaker
 If weight  15 kg, apply adult transcutaneous pacemaker pads
 If < 15 kg use pediatric pads (small/medium electrodes) in the standard
configuration for adult size pacer pads
 Use the lowest setting that provides ventricular capture (pulse)
 Set rate to 100 beats per minute
 Sedation if patient condition and time allows (hold if SBP<90mmHg):
Fentanyl 1.0mcg/kg and Midazolam 0.1mg/kg IV/IO
Titrate to Max dose Fentanyl 200mcg and Midazolam 4mg.
 If severe cardiopulmonary compromise persists despite pacing:
 Dopamine infusion at 5-20 mcg/kg/min IV/IO

Contact Medical Control for any additional orders or questions

178
 Legend

A
EMT
A‐EMT A Wide Complex Tachycardia with
P Paramedic P
MMedical Control M Pulse - Pediatric
History: Signs and Symptoms Differential (Life Threatening)
Past medical history Heart Rate Heart Disease (congenital)
Medications or Toxic Ingestion Child >180bpm Infant >220bpm Hypo/hyper thermia
(Aminophyline, diet pills, thyroid Pale or Cyanosis Hypovolemia or anemia
supplements, decongestants, digoxin) Diaphoresis Electrolyte imbalance
Drugs (nicotine, cocaine) Tachypnea Anxiety / pain/ emotional stress
Congenital heart disease Vomiting Fever / infection / sepsis
Respiratory distress Hypotension Hypoxia
Syncope or near syncope Altered LOC Hypoglycemia

Pediatric and OB Protocols

Pulmonary congestion Mediation/toxin/drugs
syncope Pulmonary embolus
Trauma
Tension pneumothorax
General Approach to all Patients
Blood Glucose Measurement and Treat if appropriate

Continuous Cardiac Monitor

P Attempt to identify cause – narrow QRS duration <0.08 sec P
STABLE

A IV Protocol A
I
UNSTABLE
Amiodarone 5mg/kg IV over 10 Or No IV access
P minutes P
(max individual dose 150mg) Synchronized cardioversion at 0.5‐1.0 J/kg
If time allows: Consider sedation –

2013
Midazolam 0.1mg/kg IV/IO (max dose 2mg)
P P
May repeat Synchronized cardioversion at
1.0‐2.0 J/kg **

If rhythm changes go to appropriate If Torsade de Pointes is suspected::

protocol Magnesium Sulfate 50mg/kg in 100ml D5W
P IV/IO over 10 minutes P
(max individual dose 2mg)
M Contact Medical Control M

Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
**Max dose 360J
Carefully evaluate the rhythm to distinguish sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia
Separating the child from the caregiver may worsen the child's clinical condition
Monitor for respiratory depression and hypotension associated if diazepam or midazolam is used.
Continuous pulse oximety is required for all SVT patients if available
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention
As a rule of thumb, the max sinus tachycardia rate is 220 minus the patients age in years.

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

179
 Narrow Complex Tachycardia
Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
with Pulse (SVT)- Pediatric
History: Signs and Symptoms Differential (Life Threatening)
Past medical history Heart Rate Heart Disease (congenital)
Medications or Toxic Ingestion Child >180bpm Infant >220bpm Hypo/hyper thermia
(Aminophyline, diet pills, thyroid Pale or Cyanosis Hypovolemia or anemia
supplements, decongestants, digoxin) Diaphoresis Electrolyte imbalance
Drugs (nicotine, cocaine) Tachypnea Anxiety / pain/ emotional stress
Congenital heart disease Vomiting Fever / infection / sepsis
Respiratory distress Hypotension Hypoxia
Syncope or near syncope Altered LOC Hypoglycemia

Pediatric and OB Protocols

Pulmonary congestion Mediation/toxin/drugs
syncope Pulmonary embolus
Trauma
Tension pneumothorax
General Approach to all Patients

Continuous Cardiac Monitor

Paramedics: Attempt to identify cause – narrow QRS
duration <0.08 sec

A IV Protocol A
UNSTABLE – Severe Cardiopulmonary
STABLE
Compromise

Expedite Transport If time and condition allows attempt vagal maneuvers

If vascular access ready:
P Adenosine 0.1mg/kg IV/IO (max individual dose
6mg)
P

2013
May repeat twice at 0.2mg/kg if needed
(max individual dose 12mg)
UNSUCCESSFUL and Severe Cardiopulmonary Compromise

Synchronized cardioversion at 0.5‐1.0 J/kg

P sedation if time permits Midazolam 0.1mg/kg IV/IO (max 2.0mg) P
May repeat Synchronized cardioversion at 1.0‐2.0 J/kg **

If rhythm changes go to appropriate protocol

M Contact Medical Control M

Service MD Approval:______

Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
**Max dose 360J
Carefully evaluate the rhythm to distinguish sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia
Separating the child from the caregiver may worsen the child's clinical condition
Monitor for respiratory depression and hypotension associated if diazepam or midazolam is used.
Continuous pulse oximety is required for all SVT patients if available
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention
As a rule of thumb, the max sinus tachycardia rate is 220‐the patients age in years.

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
180
 Cardiac Arrhythmia: Pediatric Tachycardia
Note: Infants with heart rates < 220 and children with heart rates < 180
typically will respond when the precipitating cause is treated (e.g. fever,
dehydration)

All Providers
 General Pediatric Patient Care Protocol
 If trauma suspected, stabilize spine
 Supplemental 100% oxygen
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM

Advanced EMT
 Consider IV Protocol
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL

- OR -
 Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg if IV or IO
access unavailable

 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (< 40 in a

neonate) after treatment or unable to determine blood glucose and no
change in mental status

Paramedic
 Full Pediatric ALS Assessment and Treatment

Sinus Tachycardia
 Identify and treat possible causes

181
Supraventricular tachycardia with severe cardiopulmonary compromise
 If time and patient condition permits, attempt vagal maneuvers
 If vascular access is available, Adenosine (Adenocard) 0.1 mg/kg (Maximum
individual dose is 6 mg) via rapid IV/IO bolus (IV access in the antecubital space
is preferred)
 Repeat Adenosine (Adenocard) twice at 0.2 mg/kg if needed (maximum
individual dose is 12mg)

 If Adenosine is unsuccessful and patient still has severe cardiopulmonary

compromise:
 Synchronized Cardioversion at 0.5-1 J/kg
 Consider sedation if time permits
 Midazolam 0.1 mg/kg IV/IO (max dose 2 mg)
 May repeat synchronized cardioversion at double the initial energy
(maximal individual dose 360 J)

Ventricular Tachycardia with a pulse

 If vascular access is readily available OR the patient is stable:
 Amiodarone 5 mg/kg/IV over 10 minutes, (Max individual dose is 150 mg)
 If vascular access is not readily available AND the patient is unstable:
 Synchronized Cardioversion at 0.5-1.0 J/kg
 Consider sedation if time permits:
 Midazolam 0.1 mg/kg IV/IO (max dose 2 mg)
 May repeat at double the initial energy (maximal individual dose 360 J)
 If Torsade de Pointes is suspected:
 Magnesium Sulfate 50mg/kg in 100 ml D5W IV/IO over 10 minutes (max
dose 2 g)

Contact Medical Control for any additional orders or questions

 Paramedic - Failed response to 2 attempts at cardioversion

182
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
General Approach to all patients

Assign Provider to Call for additional

Twin Gestation? YES
care for mother help
NO
Treat per Thick meconium in Suction mouth then

Pediatric and OB Protocols

YES
appropriate amniotic fluid? nose – activate ALS
medical protocol NO
Dry infant/keep warm/stimulate Visualize
Bulb syringe suction mouth/nose hypopharynx and
Childbirth
Procedure if
P perform deep suction P
appropriate Repeat until free of
Note APGAR score meconium

Heart Rate Respirations

>100bpm 60-100bpm
------------------ <60 bpm

Crying Labored Breathing

Give report Assess Immediate Good Persistent Cyanosis
to receiving Respiratory CPR per Tone

2013
hospital Drive AHA Clear airway
Improved
SpO₂, supplemental O₂
Support with Peds
Monitor BVM Airway Support with BVM
Reassess At 40‐60
5 Minute
Protocol At 40‐60 breaths/
breaths/min Improved
APGAR min with 100%
with 100% Consider
oxygen A A oxygen
IV Protocol
No Change
Reassess Glucose Check and Consider Peds
Heart treat if appropriate
Rate
Airway

Naloxone** 0.01mg/kg
A Dextrose 10% at 4ml/kg**** A
Consider
A IV Protocol A
Epinephrine 0.01mg/kg of a
P 1:10,000 solution*** P Contact Medical Control
M Rapid Transport‐ OB M
Pearls receiving facility
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Extremities, Neuro
CPR in infants is 120 compressions/minute with a 3:1 compressions to ventilation ratio
Service MD Approval:______
It is extremely important to keep infant warm
* if no IV access after 3 attempts, or within 90 seconds – obtain IO access
**if respiratory depression in a newborn of a mother who received narcotics within 4 hours of delivery, use caution in infants born to opiate addicted
mothers.(Naloxone effective but may precipitate seizures)
***May repeat same dose of Epinephrine every 3‐5 minutes if no response.
****Consider hypoglycemia in infant and treat if glucose <40mg/dL ‐ D10=D50 diluted (1ml of D50 with 4ml NS).
Document 1 and 5 minute APGARS in PCR
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
183
 Newborn Resuscitation
All Providers
 Note gestational age, and if twin gestation is known
 Assess for presence of meconium
 Assess breathing or presence of crying
 Assess muscle tone
 Assess color
 Provide warmth
 Open airway and suction with bulb syringe as soon as infant is delivered.
 Suction mouth first then nasopharynx
 Dry, stimulate and reposition
 Administer supplemental blow-by oxygen
 Evaluate respirations, heart rate and color
 If apnea or HR < 100, provide positive pressure ventilation using BVM and 100%
oxygen
 If HR remain < 60, begin chest compressions
 Note APGAR scores at 1 and 5 minutes after birth and then sequentially every 5
minutes until VS have stabilized

Paramedic
 If the fluid contains meconium and the newborn has absent or depressed
respirations, decreased muscle tone or heart rate < 100 bpm
 Suction any visible meconium from the airway – refer to Childbirth
Complication Procedure as appropriate.
 After suctioning, apply positive pressure ventilation using a BVM and
100% oxygen

 If apnea, or HR < 100, provide positive pressure ventilations with 100% oxygen
 If HR 60-100, and no increase with positive pressure ventilations with 100%
oxygen
 Continue assisted ventilations
 Begin chest compressions
 Naloxone (Narcan) 0.01 mg/kg, IV/IO if respiratory depression in a
newborn of a mother who received narcotics within 4 hours of delivery,
use caution in infants born to opiate addicted mothers
 May Repeat Naloxone (Narcan) dose as needed to a max of 0.03 mg/kg

184
  Check blood glucose and treat glucose < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 If HR < 60 begin chest compressions
 IV 0.9% NaCl KVO or lock
 If no IV access obtained after 3 attempts, or within 90 seconds, obtain IO
access
 Naloxone (Narcan) 0.01 mg/kg, IV/IO if respiratory depression in a
newborn of a mother who received narcotics within 4 hours of delivery,
use caution in infants born to opiate addicted mothers
 May Repeat Naloxone (Narcan) dose as needed to a max of 0.03 mg/kg
 Epinephrine 0.01 mg/kg of a 1:10,000 solution
 Repeat Epinephrine (same dose) every 3 to 5 minutes if no
response
 Check blood glucose and treat glucose < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Rapid transport

Contact Medical Control for any additional orders or questions

185
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

For any overdose or poisoning, contact should be made with the Regional Poison Control
Center (RPCC), 1-800-222-1222. Whenever possible, determine the agent(s) involved, the
time of the ingestion/exposure and the amount ingested. Bring empty pill bottles, etc., to the
receiving facility.

All Providers

Pediatric Protocol
General Patient Care Protocol-Pediatric
Nothing by mouth

Advanced EMT
Consider IV Protocol
If respiratory depression is present and a narcotic overdose is suspected:
o Naloxone (Narcan) 0.1 mg/kg IV/IO/IM or IN via MAD (max. dose is 2 mg)

Paramedic
If any symptoms present, perform Full Pediatric ALS Assessment and Treatment

Treatment for specific toxic exposures is indicated only when patients are clearly
symptomatic. In the absence of significant symptoms, monitor closely and expedite
transport.

Organophosphates:
Dyspnea, bronchorrhea, lacrimation, vomiting/diarrhea, weakness, paralysis, seizures:
Atropine 0.02 mg/kg IV/IO (minimum dose 0.1 mg), repeat every 2 minutes if needed
X 3 doses
If seizures present, see Pediatric Seizure Protocol

Tri-cyclic Antidepressant:
Hypotension, arrhythmias, wide QRS complex (0.12 sec):
Sodium Bicarbonate 1 mEq/kg IV/IO
May be repeated in 10 minutes

Beta Blocker overdose:

Bradycardia, hypotension, heart blocks:
Atropine 0.02 mg/kg IV/IO (minimum dose 0.1 mg, maximum individual dose 0.5 mg)
for bradycardia
If the symptoms persist, Glucagon 0.1 mg/kg IV/IO (Maximum dose 1 mg)

Pediatric Protocol Service MD Approval:______

Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS

186
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M

Calcium Channel Blocker overdose:

Calcium Chloride 20 mg/kg slow IV/IO (maximum dose 1g)

Pediatric Protocol
Dystonic Reactions:
Acute uncontrollable muscle contractions
Diphenhydramine (Benadryl) 1 mg/kg IV or IM (maximum dose 25 mg)

Insulin Overdose:
Hypoglycemia or unknown blood glucose and altered mental status:
Determine blood glucose and treat:
Neonates ( 2 months) < 40 mg/dL
Dextrose 10% at 4 ml/kg
Child (2 months-12 years) <70 mg/dL
Dextrose 10% at 4 ml/kg , maximum of 250 mL

- OR –
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM if IV or IO access
unavailable
Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a neonate) after
treatment or unable to determine blood glucose and no change in mental status

Contact Medical Control for any additional orders or questions

Service MD Approval:______

Pediatric Protocol
Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS

187
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
History: Differential
Signs and Symptoms
Age Per the specific protocol
Severity (pain scale)
Location Musculoskeletal
Quality (sharp, dull, etc)
Duration Visceral (abdominal)
Radiation
Severity (1‐10) Cardiac
Relation to movement,
If child use Wong‐Baker faces Pleural / Respiratory
respiration
scale Neurogenic
Increased with palpation
Past medical history Renal (colic)
Medications
Drug allergies

Pediatric Protocol
General Approach to All Pediatric Patients

Patient care according to PROTOCOL

Based on specific complaint

Pain Severity >6 out of 10

Or Indication for IV/IM Medication

Pulse Oximetry and EndTidal CO₂

2013
A Consider IV Protocol A
Morphine Sulfate 0.1mg/kg slow IV/IO, may repeat in 10 min x1 After each dose:
OR
P Fentanyl 1.5mcg/kg IN half volume per nare (max 100mcg) may P Reassess pain level
Respiratory adequacy
repeat one half (½) the original dose after 10 min. if needed Vital signs (SPO2, EndTidal)

Service MD Approval:______

Contact Medical Control for

M additional orders or questions M
Fentanyl Concentration (50mcg/mL),
0.1ml=5mcg
Weight Dose Volume of 50 mcg/mL
(kg) (mcg) add 0.1 ml for dead space
3‐5 10 0.2+0.1=0.3mL
6‐10 20 0.4+0.1=0.5mL
11‐15 30 0.6+0.1=0.7mL
16‐20 40 0.8+0.1=0.9mL
Pearls 21‐25 50 1.0+0.1=1.1mL
RECOMMENDED EXAM: Mental Status, Area of pain, Neuro 26‐30 60 1.2+0.1=1.3mL
Analgesic agents may be administered under standing orders for patients 31‐35 70 1.4+0.1=1.5mL
experiencing moderate / severe pain (typically >6/10) 36‐40 80 1.6+0.1=1.7mL
Common Complaints: trauma/isolated extremity injury, Burns (without 41‐45 90 1.8+0.1=1.9mL
airway, breathing or circulation compromise), sickle crisis 2.0*mL (admin dose in
Vitals and pain scale should be documented before and after every two separate
medication dose. administrations 10 min
46‐50 100 apart)

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
188
 Pain Management: Pediatric
All Providers
 General Pediatric Patient Care Protocol
 Assess baseline pain level (0-10 scale: 0=no pain; 10=worst pain)

Advanced EMT
 Consider IV Protocol

Paramedic
 Full ALS Pediatric Assessment and Treatment if administering narcotics
 Analgesic agents may be administered under standing orders for patients
experiencing moderate/severe pain (≥ 6/10)
 Common complaints:
 Isolated extremity injury
 Burns (without airway, breathing, or circulation compromise)
 Sickle crisis
 Agents for pain control:
 Both are contraindicated if hypotensive:
 Morphine Sulfate 0.1 mg/kg IV/IO
 May repeat every 10 min x 1
OR
 Fentanyl 1.5 mcg/kg IN via MAD with one-half of the volume
administered to each nare (max. individual dose 100 mcg)
 May repeat one-half (½) the original dose after 10 minutes if
needed.

189
DOSING: Fentanyl Concentration (50 mcg/mL), 0.1 ml=5 mcg

Weight Dose Volume of 50 mcg/mL

(kg) (mcg) + 0.1 ml for dead space
3-5 10 0.2+0.1=0.3 mL
6-10 20 0.4+0.1=0.5 mL
11-15 30 0.6+0.1=0.7 mL
16-20 40 0.8+0.1=0.9 mL
21-25 50 1.0+0.1=1.1 mL
26-30 60 1.2+0.1=1.3 mL
31-35 70 1.4+0.1=1.5 mL
36-40 80 1.6+0.1=1.7 mL
41-45 90 1.8+0.1=1.9 mL
46-50 100 2.0* mL

* administer dose in two (2) separate administrations 10 minutes apart

 After each drug dosage administration:

 Reassess the patient’s pain level
 Note adequacy of ventilation and perfusion
 Assess vital signs
 Continuously monitor oxygen saturation and end tidal CO2

Contact Medical Control for any additional orders or questions

190
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
Differential (Life Threatening)
History:
Signs and Symptoms Fever
Fever
Observed Seizure activity Infection
Prior history of seizures
Altered mental status Head trauma
Seizure medications
Hot, dry skin or elevated body Medication or Toxin
Reported seizure activity
temperature Hypoxia or respiratory failure
History of recent head trauma Hypoglycemia
Congenital abnormality Metabolic abnormality / acidosis
Tumor

Pediatric and OB Protocols

General Approach to all Patients

Pediatric Airway Protocol

If <40 (<2 months of age) or
Blood Glucose <70 (2 months to 12 years of age)

Altered Level
of Consciousness
ACTIVELY
A IV Protocol A SEIZING
Lorazepam 0.05mg/kg slow IV/IO Assess Patient If no IV, Glucagon
(max 2mg) Glucagon
<1 year old.1mg/kg IM
– 0.5 mg IM
Or Evidence of Trauma? >1 year old – 1.0 mg IM
Midazolam 0.2mg/kg IV/IO/IN Pediatric Head Injury Protocol IV Protocol – D10
P (max 2mg) P A 4ml/kg (max 250ml) A
May repeat if seizure not Obtain Temperature
controlled or recurs
Or
Patient prescribed Diazepam FEBRILE

2013
I Seizure recurs
Blood Glucose
Cooling measures
If <40 (<2 months of age) or Glucose Level
<70 (2 months to 12 years of age) 2months‐12years >70
<2months >40 Service MD Approval:______
If no IV, Glucagon
<1 year old – 0.5 mg IM
>1 year old – 1.0 mg IM
D10
A 4ml/kg (max 250ml)
A M Contact Medical Control M

Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Extremities,
Neuro Patient Prescribed Rectal Diazepam (Diastat) if available:
Addressing the ABCs and verifying blood glucose is more important than stopping
the seizure
Avoiding hypoxemia is extremely important
Status Epilepticus is defined as two or more successive seizures without a period DIASTAT DIASTAT
of consciousness or recovery. This is a true emergency requiring rapid airway 2-5 Years (0.5 mg/kg) 6-11 + Years (0.3 mg/kg)
control, treatment, and transport Weight Dose Weight Dose
(kg) (lb) (mg) (kg) (lb) (mg)
Grand mal seizures (generalized) are associated with loss of consciousness,
6‐11 13‐25 5 10‐18 22‐41 5
incontinences, and tongue trauma 12‐22 26‐49 10 19‐37 42‐82 10
Focal seizures (petit mal) effect only a part of the body and do not usually result 23‐33 50‐74 15 38‐55 83‐122 15
in a loss of consciousness 34‐44 75‐98 20 56‐74 123‐164 20
Jacksonian seizures are seizures which start as a focal seizure and become
generalized
Be prepared to assist ventilations especially if a benzodiazepine is used.
If evidence or suspicion of trauma, spine should be immobilized
IN an infant, a seizure may be the only evidence of a closed head injury

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
191
 Seizure: Pediatric
All Providers
 Pediatric General Patient Care Protocol
 Supplemental 100% oxygen
 Nasal cannula is sufficient if no active seizures and no respiratory signs of
symptoms
 Protect patient from injury
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM

Advanced EMT
 Consider IV Protocol
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL
OR
 Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM
if IV or IO access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a
neonate) after treatment or unable to determine blood glucose and no
change in mental status.

Paramedic
 Full Pediatric ALS Assessment and Treatment
 Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL
OR

192
  Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM
if IV or IO access unavailable

 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a

neonate) after treatment or unable to determine blood glucose and no
change in mental status.
 For active seizures choose one of the following options:
 Lorazepam (Ativan) 0.05 mg/kg slow IV/IO via (max. individual dose 2 mg)
OR
 Midazolam (Versed) 0.2 mg/kg IV/IO/IN via MAD (Max individual dose 2
mg)
OR
 Patient-prescribed Diazepam rectal gel (Diastat) if available

2-5 Years (0.5 mg/kg) 6-11 + Years (0.3 mg/kg)

Weight Dose Weight Dose
(kg) (lb) (mg) (kg) (lb) (mg)
6-11 13-25 5 10-18 22-41 5
12-22 26-49 10 19-37 42-82 10
23-33 50-74 15 38-55 83-122 15
34-44 75-98 20 56-74 123-164 20

 For seizure not controlled by the above, or if the seizure recurs after initial
control, choose one of the following:
 Lorazepam (Ativan) 0.05 mg/kg slow IV (max individual dose 2 mg)
OR
 Midazolam (Versed) 0.2 mg/kg IV/IO/IN via MAD (max individual dose
2mg)

Contact Medical Control for any additional orders or questions

193
 Legend
EMT
A A‐EMT A
P Paramedic P
M Medical Control M
History: Signs and Symptoms Differential (Life Threatening)
Time and Mechanism of injury Pain, swelling Chest
Height of any fall Deformity, lesions, bleeding Tension pneumo, flail chest,
Damage to structure or vehicle Altered mental status pericardial tamponade, open chest
Location in structure or vehicle Unconscious wound, hemothorax
Others injured or dead Hypotension or shock Intra‐abdominal bleeding
Speed and details of MVS Arrest Pelvis / femur fracture
Restraints/protective equipment Spine fracture / cord injury
Car Seat, Helmet, Pads Head injury (see head trauma)
General Approach to all Pediatric

Pediatric and OB Protocols

Ejection Extremity fracture / dislocation
Past medication history Patients HEENT (airway obstruction)
Medications Pediatric = Anyone <18 years of age Hypothermia

Presentation or Mechanism consistent with trauma?

Go to appropriate
Assess ABC’s YES NO
medical protocol
INADEQUATE ADEQUATE

Pediatric Spinal
Airway Immobilization
Protocol Protocol

YES Obvious Bleeding? NO

Direct Pressure Disability and GCS (document)

2013
Pressure Point Complete head to toe exam
Vital
Hypotension, Tachy Signs Normal for
Hypoxia
Age
High suspicion severe
IV Protocol injury
A NS Bolus 20ml/kg A
Notify receiving hospital Facility/provider
discretion
Tension Pneumothorax?*
NO

YES Pain Management Protocol

Rapid Transport to
P Decompression P appropriate destination
M Contact Medical Control M Limit scene time to 10 minutes

Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro
*Pleural Decompression for tension pneumo ONLY if all 3 criteria present:
1) Severe respiratory distress with hypoxia 2) Unilateral decreased or absent lung sounds (may see tracheal deviation away from collapsed
lung field) 3) Evidence of hemodynamic compromise (shock, hypotension, altered mental status)
If indicated, pleural decompression at 2nd intercostal space, midclavicular line
Mechanism is the most reliable indicator of serious injury. Examine all restraints/protective equipment for damage.
In prolonged extrications or serious trauma consider air transport
Do not overlook the possibility of child abuse
Scene times should not be delayed for procedures. These should be performed enroute when possible
Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained about 93%
Disability – assessment of paralysis, weakness, abnormal sensation, etc. Service MD Approval:______

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
194
 Trauma: Pediatric
For major trauma criteria, a pediatric patient is anyone < 18 years of age

All Providers
 Pediatric Patient Care Protocol
 Stabilize spine
 Use modified jaw thrust if airway obstructed
 Supplemental 100% oxygen
 Control hemorrhage using direct pressure or pressure dressing
 Perform head-to-toe survey to identify injuries
 Splint obvious fractures of long bones
 Attempt to preserve body temperature

Advanced EMT
 Consider IV Protocol

Paramedic
 If moderate or severe injuries present, perform Full Pediatric ALS Assessment
and Treatment
 Assess for Pediatric Trauma Triage Criteria and initiate transport to Pediatric
Trauma Center
 Assess for Tension Pneumothorax
 Severe respiratory distress with hypoxia
 Unilateral decreased or absent lung sounds (may see tracheal deviation
away from collapsed lung field)
 Evidence of hemodynamic compromise (shock, hypotension, altered
mental status)
Pleural decompression for tension pneumothorax should only be performed
when all 3 of the above criteria are present!
 If indicated, perform pleural decompression at 2nd intercostal space, mid-
clavicular line
 Initiate transport to an appropriate trauma facility within 10 minutes of arrival on
the scene, unless extenuating circumstances (extrication)
 Perform procedures, history and detailed physical examination en route to the
hospital
 If moderate to severe pain, treat per Pediatric Pain Management Protocol
 Reassess frequently

Contact Medical Control for any additional orders or questions

195
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
History: Signs and Symptoms Differential
Type of exposure (heat, gas, chemical) Burns, pain, swelling Superficial (1st degree) red and painful
Inhalation injury Dizziness Partial thickness (2nd degree) blistering
Time of injury Loss of consciousness Full thickness (3rd degree) painless/charred or leathery skin
Past medical history and medications Hypotension/shock Thermal
Other trauma Airway compromise/distress Chemical
Loss of consciousness Singed facial or nasal hair Electrical
Tetanus/immunization status Hoarseness/wheezing Radiation

General Approach to All Pediatric Patients

Pediatric and OB Protocols

Transport to Burn Center

2nd degree burns greater than 10% total body surface area or
those on hands, feet, face or groin
3rd degree burns
Electrical burns (spinal immobilization if high voltage, monitor for
cardiac arrhythmias, initiate fluid resuscitation immediately
Chemical burns (remove clothing, brush away dry powder before
irrigating, flush with copious warm water on scene and continue
irrigation enroute, eyes: remove contacts and irrigate
continuously with NS for at least 30 minutes, avoid hypothermia

ABC’s

*Airway Protocol
If inhalation injury – place patient on
100% O2, monitor ETCO2 continuously
Remove or cool heat source if present
IV Protocol
Remove all clothing, contact lenses, Large bore in unburned skin if possible
and jewelry (especially rings) If burn is >20%TBSA 2nd/3rd degree burns –
Less than 5 years old, start 0.9 %Normal Saline at 125ml/hr
Maintain core temperature
A 6‐13 years old, start 0.9% Normal Saline at 250ml/hr A
14 years and older, start 0.9% Normal Saline at 500ml/hr
Cover burn with plastic wrap, plastic chucks, or Specific fluid resuscitation based on TBSA and weight will
clean dry dressings occur at initial hospital or Burn Center

Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Lung, Heart, Abdomen, Extremities, Back,
and Neuro
Burn patients are trauma patients, evaluate for multisystem trauma Consider Pain Management Protocol
Assure whatever has caused the burn, is no longer contacting the injury (stop the burning process)
Early intubation is required when the patient experiences significant inhalation injuries
Potential CO exposure should be treated with 100% oxygen.
Circumferential burns to extremities are dangerous due to potential vascular compromise Contact Medical
secondary to soft tissue swelling M Control M
Burn patients are prone to hypothermia – never apply ice or cool burns, must maintain normal
body temperature
Evaluate the possibility of child abuse with children and burn injuries
*Signs and symptoms of inhalation injury: carbonaceous sputum, facial burns or edema,
hoarseness, singed nasal hairs, agitation, anxiety, cyanosis, stupor or other signs of hypoxia Service MD Approval:______

Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
196
 Trauma: Pediatric Burns

All Providers
 General Pediatric Patient Care Protocol
o Stay focused on ABC’s, don’t get side tracked by burn.
o DON’T BE A SECOND VICTIM!
 Remove or cool heat source if present (e.g. clothing, tar)
o Cool burns with room temperature water for 3-5 minutes only except
for tar burns which will take an extended time to cool.
o NEVER COOL WITH ICE! The goal is to bring burns to room
temperature, not cold.
 Remove all clothing, contacts, and jewelry, especially rings
 Keep patient warm and dry with sheets and blankets. Cover burns with
plastic wrap, plastic chucks, clean, dry dressings, or aluminum foil.
 2nd Degree burns – greater than 10% of total body surface area or those
on hands, feet, face, or groin
 3rd Degree burns
 Electrical burns
- Spinal immobilization if high voltage electrical injury
- Monitor for cardiac arrhythmias
- Initiate fluid resuscitation immediately
 Chemical burns
- Remove clothing
- If dry powder is present, brush away before irrigating
- Flush with copious warm water on scene and continue irrigation
enroute to UW Hospital
- Chemical injuries to eyes are an EMERGENCY. Remove contacts and
irrigate continuously with normal saline – DO NOT STOP.
Assess for Pediatric Trauma Triage Criteria and initiate transport to Pediatric
Trauma Center if appropriate

Advanced EMT
 Consider IV Protocol
o Place a large bore peripheral IV in unburned skin if possible.
o If TBSA % greater than 30%, place 2 large bore peripheral IV’s.
o If greater than 20% TBSA of 2nd and 3rd degree burns, initiate volume
resuscitation with 0.9% Normal Saline
 Less than 5 years old, start 0.9 %Normal Saline at 125ml/hr
 6-13 years old, start 0.9% Normal Saline at 250ml/hr
 14 years and older, start 0.9% Normal Saline at 500ml/hr
 Specific fluid resuscitation based on TBSA and weight will occur
at initial hospital or Burn Center

197
Paramedic
 Perform Full Pediatric ALS Assessment and Treatment
 If not already done, consider IV Protocol
o Place a large bore peripheral IV in unburned skin if possible. If TBSA
% greater than 30%, place 2 large bore peripheral IV’s.
 Observe for signs of impending loss of airway; refer to the Airway
Management Protocol as needed
- Hypoxia
- Poor ventilatory effort
- Altered mental status or decreased level of consciousness
- Inability to maintain patent airway
- Signs or symptoms of inhalation injury
 Carbonaceous sputum
 Extensive facial burns
 Hoarseness
 Singed nasal hairs
 Agitation, anxiety, cyanosis, stupor, or other signs of hypoxia
 If moderate to severe pain, see Pain Management Protocol
 Estimate Total Body Surface Area (TBSA)
- Rule of Nines

Age
Body Part 0 yr 1 yr 5 yr 10 yr 15 yr
A = whole head 19 17 13 11 9
B = thigh 5½ 6½ 8 8½ 9
C = lower leg 5 5 5½ 6 6½

- If greater than 20% TBSA of 2nd and 3rd degree burns, initiate volume
resuscitation with 0.9% Normal Saline
 Less than 5 years old, start 0.9 %Normal Saline at 125ml/hr

198
  6-13 years old, start 0.9% Normal Saline at 250ml/hr
 14 years and older, start 0.9% Normal Saline at 500ml/hr
 Specific fluid resuscitation based on TBSA and weight will occur
at initial hospital or Burn Center

Contact Medical Control for any additional orders or questions

199
 Legend
EMT
A A‐EMT A
P Paramedic P
MMedical Control M
History: Signs and Symptoms Differential
Time of injury Pain, swelling, bleeding Skull fracture
Mechanism (blunt vs. penetrating) Altered mental status Brain injury (concussion, contusion,
Loss of consciousness Unconscious hemorrhage or laceration)
Bleeding Respiratory distress / failure Epidural hematoma
Past medical history Vomiting Subdural hematoma
Medications Major traumatic mechanism of injury Subarachnoid hemorrhage

Pediatric and OB Protocols

Evidence of multi‐trauma seizure Spinal injury
Abuse

General Approach to all Pediatric Patients

Isolated Head Trauma?

Other injuries
suspected YES
Pediatric Trauma Spinal Immobilization Protocol
Protocol if normotensive or hypertensive elevate backboard 15‐30°

A IV Protocol A
Check Blood Glucose and treat if appropriate

Assess and Record GCS

Able to manage airway Basic Airway maneuvers (O₂, NRB, BVM) Unable to manage airway
with basic maneuvers As needed to maintain O₂ sat >93% With basic maneuvers

2013
Transport to Secure Airway per
appropriate Pediatric Airway Protocol
emergency No signs of

department
herniation Continuous EtCO₂

If severely agitated/combative*
P consider Lorazepam 0.05mg/kg P
IV/IO (max 2.0mg)
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs, Monitor for signs of herniation:
Abdomen, Back, Extremities, Neuro ‐Abrupt increase in BP
* unable to deescalate by any other means, then consider ‐Abrupt decrease in HR
Lorazepam P ‐Acute unilateral dilated and non‐reactive pupil P
If GCS <12, consider air/rapid transport and if GCS <8 ‐Abrupt deterioration in mental status
airway control should be anticipated ‐Abrupt onset of motor posturing
Increased intracranial pressure (ICP) may cause
hypertension and bradycardia (Cushing’s Response)
Signs of herniation
Hypotension usually indicates injury or shock unrelated to
the head injury
The most important item to monitor and document is a Hyperventilate:
change in level of consciousness. <1 year – 35/min, >1 year – 25/min
Concussions are periods of confusion or LOC associated P Target EtCO₂ 30‐35 P
with trauma which may have resolved by the time EMS Contact Medical Control simultaneously
arrives. Any prolonged confusion or mental status
abnormality which does not return to normal within 15
minutes or any document loss of consciousness should be Contact Medical Control for additional
evaluated by a physician ASAP. M orders M
Service MD Approval:______

Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
200
 Trauma: Pediatric Head Injuries
All Providers
 Supplemental oxygen
 Stabilize spine
 Check blood glucose
 Apply physical restraints if needed to ensure patient/crew safety. Adhere to
procedure on Physical Restraint of Agitated Patients when this process is
deemed necessary
 If normotensive or hypertensive
 Elevate head of backboard 15-30

Paramedic
 Full Pediatric ALS Assessment and Treatment
 Advanced airway/ventilatory management as needed
Note: Airway interventions can be detrimental to patients with head injury by
raising intercranial pressure, worsening hypoxia (and secondary brain injury)
and increasing risk of aspiration. Whenever possible these patients should be
managed in the least invasive manner to maintain O2 saturation > 93% (i.e.,
NRB, BVM with 100% O2)
 Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol if needed:
 Hypoxia
 Poor ventilatory effort
 Altered mental status/decreases level of consciousness
 Inability to maintain patent airway

For patients with assisted ventilation:

 Administer ventilations at normal rate for age range
 Acute herniation should be suspected when the following signs are present:
 Abrupt increase in blood pressure
 Abrupt decrease in heart rate
 Acute unilateral dilated and non-reactive pupil
 Abrupt deterioration in mental status
 Abrupt onset of motor posturing
 Hyperventilation is a temporizing measure which is only indicated in the event of
acute herniation

201
 If signs of herniation develop, begin hyperventilation
 If < 1 year old, 35/minute
 If > 1 year old, 25/minute
 Target an ETCO2 of 30-35 mmHg
 If severely agitated/combative and unable to deescalate by any other means,
consider:
 Lorazepam 0.05 mg/kg IV/IO (max 2.0 mg)

Contact Medical Control for any additional orders or questions

 Paramedic - Any additional sedation

202
 Table of Contents

Legend 12‐Lead EKG 204

EMT
Airway Obstruction 205
A A‐EMT A Airway Orotracheal Intubation 206
P Paramedic P Airway Video Laryngoscopy 208
M Medical Control M
Airway Suctioning ‐ Basic 210
Airway Suctioning ‐ Advanced 211
Blood Glucose Analysis 212
Carboxyhemoglobin SpCO Monitoring 213
Cardioversion 214
CCR ‐ Cardiocerebral Resuscitation 215
Chest Decompression 220
Childbirth Procedure 221
Childbirth Complications 222
CPAP 223
CPR ‐ Cardiopulmonary Resuscitation 224
Cricothyrotomy 225
Decontamination 226
Defibrillation ‐ Automated 227
Defibrillation ‐ Manual 228
Endotracheal Tube Introducer 229
External Cardiac Pacing 230
LMA ‐ Laryngeal Mask Airway 231
MCI ‐ Mass Casualty Incident 234
MAD ‐ Mucosal Atomizer Device 235
Orogastric Tube Insertion 236
King LTS‐D 237
Pulse Oximetry 241
RSA ‐ Rapid Sequence Airway 242
Restraints 243
Spinal Immobilization 244
Spinal Immobilization ‐ Football Players 245
Splinting 247
Stroke Screen 248
Temperature Measurement 249
Tourniquet 250
Trauma Guidelines 252
Venous Access ‐ Existing 253
Venous Access ‐ Extremity 254
Venous Access ‐ Intraosseous 256
Wound Care 257
Service MD Approval:______

Procedure Section
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

203
 Procedure

Clinical Indications: EMT

Suspected cardiac patient A A‐EMT A
Suspected tricyclic overdose P Paramedic P
Electrical injuries
Syncope
CHF
Abdominal pain above the umbilicus
Undifferentiated respiratory complaints

Procedure:
1) Assess patient and monitor cardiac status
2) If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after
treatment, perform a 12-Lead EKG
3) Prepare EKG monitor and connect patient cable to electrodes
4) Expose chest and prep as necessary. Modesty of the patient should be respected.
5) Apply chest leads and extremity leads using the following landmarks:
-RA: Right arm or as directed by manufacturer
-LA: Left arm or as directed by manufacturer
-RL: Right leg
-LL: Left leg
-V1: 4th intercostal space at right sternal border
-V2: 4th intercostal space at left sternal border
-V3: Directly between V2 and V4
-V4: 5th intercostal space at midclavicular line
-V5: Level with V4 at left anterior axillary line
-V6: Level with V5 at left midaxillary line
6) Instruct patient to remain still
7) Press the appropriate button to acquire the 12-Lead EKG (complete age and gender questions
correctly)
8) Print data as per guidelines and attach a copy of the 12-Lead to the PCR. Place the name and
age of the patient on the paper copy of the EKG
Paramedic: If STEMI identified, notify STEMI Hospital immediately. Report STEMI alert and a
detailed report to follow. If able transmit the EKG as soon as possible.
Non-Paramedic: transmit the 12-Lead EKG as soon as obtained. If transmission does not work,
read the defibrillator interpretation that prints on the EKG to Medical Control.
11) Document the procedure, time and results on/with the PCR.
12) An EMT-Basic may perform a 12-Lead EKG; a Paramedic, however should review it before
implementing any treatment modalities.

Service MD Approval:______

Procedure 1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

204
 Procedure

EMT
A A‐EMT A
Clinical Indications: P Paramedic P
Complete or partial obstruction of the airway due to a foreign body.
Patient with unknown illness or injury who cannot be ventilated after proper opening of the airway.
Procedure:
Foreign Body Airway Obstruction - >1 year old, conscious
□ If coughing, wheezing and exchanging air, do not interfere with the victims efforts to expel the
foreign body.
□ If unable to speak, weak or absent cough or no air exchange
→ Use abdominal thrusts (Heimlich Maneuver) if victim > 1 year
▪make a fist with one hand
▪place the thumb side of your fist against the victims abdomen in midline, above the
navel but below the breastbone.
▪grasp your fist with your other hand and press your fist into the victims abdomen with
a quick, upward thrust.
▪ repeat steps above until the object is expelled or the victim becomes unresponsive.
Foreign Body Airway Obstruction - < 1 year old, conscious
□ If coughing, wheezing and exchanging air, do not interfere with the victims efforts to expel the
foreign body.
□ If unable to cry or speak, weak or absent cough or no air exchange
→ Support the victim in the head down position with your non-dominant hand and forearm.
→ Perform back blows with the heel of your dominant hand between the shoulder blades
→ Repeat the steps above until the object is expelled or the victim becomes unresponsive.
Foreign Body Airway Obstruction - unconscious
□ If patient was responsive and then became unresponsive
→ lower the victim to the ground and begin CPR, starting with compressions (do not check
for a pulse)
→ Every time you open the airway to give breaths, open the mouth wide and look for the
object
→ If you see an object that can easily be removed, remove it with your finger
→ If you do not see an object, continue CPR
→ If a foreign object is visualized but cannot be removed with finger, attempt to remove it
with the Magill forceps
___________________________________________________________________________________

PARAMEDICS: ▪ If the foreign body is not visualized or it cannot be retrieved, attempt endotracheal
intubation with appropriate size ET Tube or 0.5 smaller
▪ If ETT cannot pass and patient is > 1 year old but <12 years old perform needle jet
insufflation
▪If ETT cannot pass and patient is >12 years old perform cricothyrotomy with pertrach
per procedure section

Transport rapidly to the closest facility!

Service MD Approval:______

Procedure 2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

205
 Procedure

Clinical Indications:
Respiratory or Cardiac Arrest
P Paramedic P
Inadequate ventilation with Bag Valve Mask
Impending respiratory failure:
□ Decreased level of consciousness with hypoxia unimproved by 100% oxygen, apnea, and/or
respiratory rate <8
□ OR poor ventilatory effort (with hypoxia unresponsive to 100% Oxygen)
□ OR unable to maintain patent airway
Airway obstruction

Equipment:
Laryngoscope handle with appropriate size blade.
Proper size endotracheal tube (ETT) plus back up ETT 0.5-1.0 mm smaller
Water-soluble lubrication gel, (lubricate distal end of tube at cuff)
10cc syringe (larger syringe if low pressure cuff)
Stylet, (insert into ET tube and do not let stylet extend beyond tip of ET tube)
Tape or ETT securing device
Proper size oral pharyngeal airway
BVM
Oxygen source
Suction device
Stethoscope
Capnography
Oxygen saturation monitor

Procedure:
Patient/equipment preparation:
□ Maintain cervical alignment and immobilization, as necessary
□ Attach proper blade to laryngoscope handle and check light
□ Check endotracheal tube cuff
□ Raise gurney so that patient's nose is at intubator’s xiphoid (if possible)
□ Confirm patient attached to cardiac monitor and oxygen saturation monitor
□ Ready ETCO2 detection device
□ Specify personnel to:
~apply cricoid pressure
~ maintain cervical alignment and immobilization during procedure
~watch cardiac and oxygen saturation monitors

Continued on page 2

Service MD Approval:______

Procedure 3.1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

206
 Procedure

P Paramedic P
Intubation:
□ preoxygenate patient with 100% Oxygen (BVM or NRB) before intubation attempt to achieve O2
saturation >93% for 5 minutes or 8 vital capacity breaths. Have assistant apply cricoid pressure
(Sellicks’s maneuver) during entire procedure.
□ Remove all foreign objects, such as dentures, oral pharyngeal airways, etc. and suction the
patient’s airway if needed. (Do not remove an esophageal located ETT if in place from prior
attempt)
□ Grasp laryngoscope handle in left hand.
□ Grasp ET tube in right hand
□ Insert the blade into the right side of the patient’s mouth sweeping the tongue to the left side
□ Visualize the vocal cords while avoiding any pressure on the teeth
□ Insert the endotracheal tube until the cuff passes the vocal cords. (Insert far enough so that at
balloon port tubing is even with lips)
□ Typical depth = tube size (ID) x3 (example would be tube depth of 24 for a 8.0mm tube)
□ Remove the laryngoscope blade
□ Inflate the endotracheal cuff with the syringe with 5-10cc of air (low pressure cuff may require
larger volume) and remove the syringe from inflation valve
□ Confirm tube placement
□ Ventilate with BVM and:
~observe immediate (within 6 breaths) ETCO2 waveform and number with capnography
~watch for chest rise AND
~listen to abdomen to ensure tube is not esophageal
□ Then, listen for bilateral breath sounds
□ Observe oxygen saturation

Note: regardless of the apparent presence of lung sounds, tube misting and chest rise, or lack of gastric
sounds, if ETCO2 does not indicate proper tube location (alveolar waveform), ETT must be removed.

If unilateral right sided breath sounds are heard consider:

□ Right mainstem intubation
□ If present, deflate the cuff and withdraw tube 1-2cm
□ Repeat auscultation procedure as above for breath sounds
If bowel sounds heard with bagging or ETCO2 device does not indicate proper ETT placement,
deflate cuff, remove tube and ventilate with BVM for two minutes
If intubation attempt unsuccessful, refer to the next step in the Airway, Adult Protocol
If successful tube placement:
□ Secure tube using an endotracheal securing device
□ Document depth of tube
□ Reassess lung sounds and patient clinical status
□ Insert oral pharyngeal airway, or use ET tube holder with built in bite block (if available)
□ Ensure c-spine is immobilized
□ Continue ventilations
□ Document ETCO2 waveform and reading continuously at time of EACH patient movement,
including waveform and reading at time of transfer of care at the emergency department.
Procedure 3.2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
207
 Procedure

Clinical Indications:
Respiratory or Cardiac Arrest
P Paramedic P
Inadequate ventilation with Bag Valve Mask
Impending respiratory failure:
□ Decreased level of consciousness with hypoxia unimproved by 100% oxygen, apnea, and/or
respiratory rate <8
□ OR poor ventilatory effort (with hypoxia unresponsive to 100% Oxygen)
□ OR unable to maintain patent airway
Airway obstruction

Equipment:
Video Assisted Laryngoscope (VAL) with appropriate size blade.
Proper size endotracheal tube (ETT) and back up ETT 0.5-1.0 mm smaller
Water-soluble lubrication gel, (lubricate distal end of tube at cuff)
10cc syringe (larger syringe if low pressure cuff)
Stylet if compatible with VAL device (insert into ET tube and do not let stylet extend beyond tip of ET
tube)
Tape or ETT securing device
Proper size oral pharyngeal airway
BVM
Oxygen source
Suction device
Stethoscope
Capnography
Oxygen saturation monitor

Procedure:
Patient/equipment preparation:
□ Maintain cervical alignment and immobilization, as necessary
□ Attach proper blade to VAL device and ensure function of video screen
□ Check endotracheal tube cuff
□ Raise gurney so that patient's nose is at intubator’s xiphoid (if possible)
□ Confirm patient attached to cardiac monitor and oxygen saturation monitor
□ Ready ETCO2 detection device
□ Specify personnel to:
~apply cricoid pressure
~maintain cervical alignment and immobilization during procedure
~watch cardiac and oxygen saturation monitors

Continued on page 2

Service MD Approval:______

Procedure 4.1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

208
 Procedure

P Paramedic P
Intubation:
□ Preoxygenate patient with 100% Oxygen (BVM or NRB) before intubation attempt to achieve O2
saturation >93% for 5 minutes or 8 vital capacity breaths. Have assistant apply cricoid pressure
(Sellicks’s maneuver) during entire procedure.
□ Remove all foreign objects, such as dentures, oral pharyngeal airways, etc. and suction the
patient’s airway if needed. (Do not remove an esophageal located ETT if in place from prior
attempt)
□ Load ET tube into VAL device as per manufacturer recommendations
□ Grasp VAL device in left hand.
□ Insert the VAL device midline in the patient’s mouth
□ Visualize the vocal cords while avoiding any pressure on the teeth
□ Visualize the endotracheal tube passing the vocal cords until cuff is beyond the cords.
□ Typical depth = tube size (ID) x3 (example would be tube depth of 24 for a 8.0mm tube)
□ Remove the VAL device
□ Inflate the endotracheal cuff with the syringe with 5-10cc of air (low pressure cuff may require
larger volume) and remove the syringe from inflation valve
□ Confirm tube placement
□ Ventilate with BVM and:
~observe immediate (within 6 breaths) ETCO2 waveform and number with capnography
~watch for chest rise AND
~listen to abdomen to ensure tube is not esophageal
□ Then, listen for bilateral breath sounds
□ Observe oxygen saturation

Note: regardless of the apparent presence of lung sounds, tube misting and chest rise, or lack of gastric
sounds, if ETCO2 does not indicate proper tube location (alveolar waveform), ETT must be removed.

If unilateral right sided breath sounds are heard, then consider:

□ Right mainstem intubation
□ If present, deflate the cuff and withdraw tube 1-2cm
□ Repeat auscultation procedure as above for breath sounds
If bowel sounds heard with bagging or ETCO2 device does not indicate proper ETT placement, deflate
cuff, remove tube and ventilate with BVM for two minutes
If intubation attempt unsuccessful, refer to the next step in the Airway, Adult Protocol
If successful tube placement:
□ Secure tube using an endotracheal securing device
□ Document depth of tube
□ Reassess lung sounds and patient clinical status
□ Insert oral pharyngeal airway, or use ET tube holder with built in bite block (if available)
□ Ensure c-spine is immobilized
□ Continue ventilations
□ Document ETCO2 waveform and reading continuously at time of EACH patient movement,
including waveform and reading at time of transfer of care at the emergency department.

Procedure 4.2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
209
 Procedure

Clinical Indications:
Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient who
cannot maintain or keep the airway clear.
EMT
Procedure: A A‐EMT A
1) Ensure suction device is in proper working order with suction tip in place P Paramedic P
2) Preoxygenate the patient.

3) Explain the procedure to the patient if they are coherent.

4) Examine the oropharynx and remove any potential foreign bodies or material that may occlude the
airway if dislodged by the suction device.

5) If applicable, remove ventilation devices (ie. BVM) from the airway.

6) Use the suction device to remove any secretions, blood, or other substances
The alert patient may assist with this procedure.

7) Reattach ventilation device (ie. BVM) and ventilate or assist the patient.

8) Record the time and result of the suctioning procedure in the patient care report (PCR)

Service MD Approval:______

Procedure 5
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

210
 Procedure

Clinical Indications:
Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient
currently being assisted with an airway adjunct such as a LTA/LMA, endotracheal tube, tracheostomy
tube, or a cricothyrotomy tube.

Procedure:
1) Ensure suction device is in proper working order with suction tip in place P Paramedic P
2) Preoxygenate the patient.

3) Attach suction catheter to suction device, keeping sterile plastic covering over catheter.

4) For all devices, use the suprasternal notch as the end of the airway. Measure the depth desired
for the catheter (judgment must be used regarding the depth of suctioning with cricothyrotomy and
tracheostomy tubes).

5) If applicable, remove ventilation devices(ie. BVM) from the airway.

6) With the thumb port of the catheter uncovered, insert the catheter through the airway device.

7) Once the desired depth (measured in #4 above) has been reached, occlude the thumb port and
remove the suction catheter slowly.

8) Small volume (<10ml) of normal saline lavage may be used as needed.

9) Reattach ventilation device (ie. BVM) and ventilate or assist the patient.

10) Record the time and result of the suctioning procedure in the patient care report (PCR)

Service MD Approval:______

Procedure 6
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

211
 Procedure

Clinical Indications:
Patients with suspected hypoglycemia (diabetic emergencies, altered/change in mental status, bizarre
behavior, etc.).
EMT
Procedure: A A‐EMT A
1) Gather and prepare equipment P Paramedic P
2) Blood samples for performing glucose analysis should be obtained simultaneously with
intravenous access when possible

3) Place correct amount of blood on reagent strip or site on glucometer per the manufacturer’s
instructions.

4) Time the analysis as instructed by the manufacturer.

5) Document the glucometer reading and treat the patient as indicated by the appropriate protocol

6) If reading appears incorrect, redraw and repeat analysis.

7) Repeat glucose analysis as indicated for reassessment after treatment and as per protocol.

Service MD Approval:______

Procedure 7
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

212
 Procedure

Clinical Indications: EMT

Persons with suspected or known exposure to carbon monoxide A A‐EMT A
P Paramedic P
Procedure:
1) Apply probe to patient’s middle finger or any other digit as recommended by the manufacturer. If
near strobe lights, cover the finger to avoid interference and/or move away from lights if possible.
Where the manufacturer provides a light shield it should be used.
2) Allow machine to register percent circulating carboxyhemoglobin values
3) Verify pulse rate on machine with actual palpable pulse of the patient.
4) Record levels in patient care report or on the scene rehabilitation form.
▪ If CO <5%, assess for other possible illness or injury
▪ If CO >5% to <15% and symptomatic from Carbon Monoxide – treat per Carbon Monoxide
Exposure Protocol
Signs and Symptoms ‐ Altered mental status / dizziness, headache, nausea/vomiting, chest pain/respiratory
distress, neurological impairments, vision problems/reddened eyes, tachycardia/tachypnea, arrhythmias, seizures,
coma
▪ If CO >15% = Treat per Overdose and Poisoning: Carbon Monoxide Protocol and Transport.
5) Monitor critical patients continuously with pulseox and SpCO until arrival at the hospital.
6) Document percent of carboxyhemoglobin values every time vital signs are recorded during therapy
for exposed patients.
7) Use the pulse oximetry feature of the device as an added tool for patient evaluation. Treat the
patient, not the data provided by the device. Utilize the relevant protocol for guidance.
8) The pulse oximeter reading should never be used to withhold Oxygen from a patient in respiratory
distress
9) Factors which may reduce the reliability of the reading include:
□ Poor peripheral circulation (blood volume, hypotension, hypothermia)
□ Excessive external lighting, particularly strobe/flashing lights
□ Excessive sensor motion
□ Fingernail polish (may be removed with acetone pad)
□ Irregular heart rhythms (atrial fibrillation, SVT, etc.)
□ Jaundice
□ Placement of BP cuff on same extremity as pulse ox probe

Service MD Approval:______

Procedure 8
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

213
 Procedure

P Paramedic P
Clinical Indications:
Unstable patient with tachydysrhythmia (rapid atrial fibrillation, supraventricular tachycardia,
ventricular tachycardia)
Patient is not pulseless (pulseless patient requires unsynchronized cardioversion, ie. defibrillation).

Procedure:
1) Ensure the patient is attached properly to a monitor/defibrillator capable of synchronized
cardioversion.

2) Have all equipment prepared for unsynchronized cardioversion/defibrillation, if the patient fails
synchronized cardioversion and the condition worsens.

3) Consider the use of pain medication or sedatives per protocol.

4) Set energy selection to the appropriate setting

5) Set monitor/defibrillator to synchronized cardioversion mode

6) Make certain all personnel are clear of patient.

7) Press and hold the shock button to cardiovert. Stay clear of the patient until you are certain the
energy has been delivered. NOTE: It may take the monitor/defibrillator several cardiac cycles to
“synchronize”, so there may be a delay between activating the cardioversion and the actual
delivery of energy.

8) Note patient response and perform immediate unsynchronized cardioversion/defibrillation if the

patient's rhythm has deteriorated into pulseless ventricular tachycardia/ventricular fibrillation.
Follow the procedure for Defibrillation-Manual

9) If the patient’s condition is unchanged, repeat steps 2-8 above, using escalating energy settings
per protocol.

10) Repeat per protocol until maximum setting or until efforts succeed.

11) Note procedure, response, and times in the PCR.

Service MD Approval:______

Procedure 9
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

214
 Procedure

Clinical Indications: EMT

Age > 18 years of age ( CCR causes worse outcomes in the pediatric population) A A‐EMT A
Suspected cardiac cause of arrest (not respiratory-OD, drowning, etc.) P Paramedic P
It occurs with Ventricular Fibrillation or Pulseless Ventricular Tachycardia, with PEA and with Asystole. You must
assume there is no blood perfusing the brain and heart….which is bad for survival. Your patient needs both a pump (chest
compressions) and diastolic pressure support (to perfuse the coronary arteries). Time spend doing other things (such as
prolonged airway management) at the expense of not delivering pump support is not good for the patient.
Determine as close as possible when the patient collapsed, and document this. Also look for any signs of patient
gasping prior to and/or during resuscitation, and document this. If gasping is present, note pupil reaction and document also.
It is also important to remember that not all Pulseless patients are the result of cardiac related events. Other
mechanisms such as trauma, drowning, hypothermia, choking and other respiratory problems, etc. must be considered as a
possible cause for the arrest and should be addressed with immediate, appropriate airway intervention.

Key points in the Cardio Cerebral Resuscitation (CCR) approach:

Survival is determined by a functional recovery of two organs: the heart and the brain
□ without adequate blood flow neither organ will survive
□ that makes properly performed chest compressions (CC) the single most important determinant of
survival.
□ Anything that interrupts or otherwise decreases the quality of CC contributes to the death of your
patient.
□ This concept – continuous maximal quality CC – must become the foundation of all you think and
do during resuscitation.
All patients are treated the same during the first two minutes of the code.
□ They get uninterrupted continuous CC (CCC) while other interventions are performed.
□ The cardiac rhythm is irrelevant during this period.
The cardiac rhythm determines subsequent management.
□ It is analyzed (using manual interpretation) briefly AFTER each set of 200 CCC
□ It is either shockable or non-shockable - don’t make it more complicated than that.
CCCs are to be resumed immediately following a rhythm assessment + shock.
□ The rhythm observed after a shock is not – meaning NOT – to be treated.
□ Otherwise deadly pauses in CCC will be introduced in an attempt to gather information that is
irrelevant to survival!
The initial rhythm (after 200 CCC) determines subsequent treatments:
□ When to initiate invasive airway insertion and positive pressure ventilation.
□ Need for anti-arrhythmic medications
□ How long to remain on scene.
Success depends on:
□ Leadership
□ Delegation of a limited set of specific tasks
□ Timely focused completion of these specific tasks by rescuers

Service MD Approval:______

Procedure 10-1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

215
 Procedure

Interventions that are critical to survival MUST whenever possible be performed by two persons solely
dedicated to that task.
□ One to perform it and a second person to assure quality performance.
□ This applies especially to chest compressions and it is also important in the management of an
invasive airway + ventilations.

Code Commander:
Someone must assume the role of code commander. This person is responsible for delegating tasks,
is the only person interpreting the rhythm, and is responsible for monitoring/critiquing the overall
performance of the team.
Other members must work as a team and take direction from the code commander. They must focus
on their assigned tasks and let the code commander manage the overall response (in other words,
keep their noses out of other rescuers business)

Critical First Tasks: (delegated and performed in first two minutes if at all possible)
MCMAID – a prioritized sequence consisting of:
□ M = Metronome (100/min)
□ C = Chest compressions (focus on rate, recoil and depth)
□ M = Monitor (turn on in defib mode, pads on, joules set at maximum)
□ A = Airway (OPA, ensure patency, NRB @ 15/lpm)
□ I = Intravenous or Intraosseous access
□ D = Drugs (Epi, Vasopressin, Amiodarone) (be ready to administer when needed and monitor
timing for repeat doses)

Chest Compressions: MCMAID

Metronome should be turned on to assure a rate of 100/minute.
CCC should be started ASAP after arrival.
A two-person task if at all possible
□ Switch compressors rapidly/frequently (every 1-2 minutes)
□ The non-compressor continuously monitors the quality of CCC: rate, depth and recoil
CCC should be continuous = not interrupted
□ The only valid reasons for interrupting compressions are for analyzing the rhythm and shocking.
□ All other requests to pause CCC must be cleared by the code commander, and the reason and
duration documented in the run report.

Monitor/Defibrillator: MCMAID
Initial:
□ Turn unit on when compressions are started and set mode to defib.
□ Ensure joules are set to maximum allowed
▪ Place pads in sternum/apex position without interruption of chest compressions.

Service MD Approval:______

Procedure 10-2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

216
 Procedure

Defibrillation Process:
□ Charge defibrillator during the last 10 seconds of 200 CCC.
□ Ensure all rescuers will be clear if a shock is needed.
□ Pause a few seconds only for analysis – determine if it is shockable or not.
▪ If indicated, immediately deliver a single (not stacked) shock at maximum joules.
▪ If no shock is indicated, dump the charge by either decreasing the energy level and
immediately returning back to maximum energy setting (200J or 360J), OR switching the
mode to monitor and then quickly back to defib mode.
□ Immediately resume CCC after analysis + shock.
▪The pause from stopping CCC to resumption of CCC should be less than 5 seconds.

Airway: MCMAID
Initially:
□ Insert OPA, apply NRB @15 lpm (look for misting), ensure patency (listen for exhausted air with
compressions. If unsure, give one single breath with BVM, looking for chest rise and fall for
compliance).
When to insert invasive airway depends on the initial rhythm:
□ If non-shockable, initiate immediately after first rhythm analysis.
□ If shockable – ONLY after three cycles (2 min. of CCC + analysis + shock). NOT earlier, even if
second rhythm is non-shockable.
Once the invasive airway is in place, the airway persons sole task is to perform/monitor that task and
no other.
Invasive airway monitoring includes attention to:
□ Proper placement
□ Apply Capnography and verify waveform/presence of ETCO2.
□ Avoidance of any interruption of CCC
□ Ventilation rate of 6 per minute. Each breath must be timed – aim for 10 seconds between each
breath. Excessive ventilation rates are deadly!
□ Volume should be ~500cc.
□ Delivery of breath should be over one second.
Use an LTA if placing an endotracheal tube is met with any problems or delays.
If the initial rhythm is shockable, seriously consider using the LTA instead of an ETT because these
patient’s cannot tolerate even brief periods of less than optimal CCC.
Assure that oxygen is attached.

Intravenous/Intraosseous access: MCMAID

Consider intraosseous route whenever there are any delays in IV insertion.
Consider spiking a bag en route and having it ready on arrival.

Service MD Approval:______

Procedure 10-3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

217
 Procedure

Drugs: MCMAID
The individual assigned to the Drug “Task”:
□ Initially ensures medications are available and ready to administer.
□ Is responsible for:
▪ The rapid administration when indicated.
▪ Re-dosing at appropriate intervals.
▪ Detecting when V-Fib is persistent or recurrent, and therefore indicating the use of
Amiodarone.
▪ Accurate timing of when meds are to be given (to the second – using elapsed time since
defibrillator was turned on.)
Vasopressors should be given ASAP after analysis + shock, so their effect will be seen after the next
200 chest compressions.
Epinephrine first!
□ **The one exception is the patient who you suspect may get return of spontaneous circulation with
the first shock. Such patients may include those with short down times or those who have had
excellent chest compression generated perfusion. A clue to this is the presence of regular agonal
respirations (gasping). In these patients consider giving Vasopressin initially, and reserving
Epinephrine until the Code Commander observes persistent pulseless V-fib/Tach after the first
shock – or until another 200 CCC cycle has been completed.
□ Epi dose is 1mg IV/IO. Endotracheal administration is not to be utilized – start an IO instead
□ If repeating doses, administer every other cycle of 200 compressions. (equivalent to every 4 min)
Vasopressin: administer with first or second Epi dose as per protocol
□ Dose is 40 units (two vials of 20 U each)
□ Same dose is used for IV or intraosseous (IO) routes.

Amiodarone is administered for persistent or recurrent pulseless V-fib/Tach. This should be

administered immediately during the next 200 chest compression cycle if a second shock was indicated
and delivered at the time of analysis. The Code Commander may visualize return of fibrillation during
the 200 CCC and as such may order Amiodarone earlier since it has recurred.
□ Dose is 300mg IV/IO
□ Repeat doses are 150mg IV/IO

Additional Treatments to consider:

Consider possible renal failure (hyperkalemia) or suspected Tricyclic antidepressant overdose. If
suspected, administer Sodium Bicarbonate 1mEq/Kg. If renal failure is suspected, also administer
Calcium Chloride 1g IVP.
If rhythm is persistent shockable V-fib or Pulseless V-Tach, consider the possible use of Magnesium
Sulfate 2g IVP.

Service MD Approval:______

Procedure 10-4
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

218
 Procedure

Additional Treatments to consider (continued):

If the patient is successfully converted from V-Fib/Pulseless V-tach to a perfusing sustainable rhythm,
consider post resuscitation Amiodarone boluses.
□ Amiodarone bolus: 150mg
If rhythm is a non-shockable Asystole or PEA, seek out and treat any possible contributing factors.
Also consider external pacing: for PEA. Apply the pads in (or move them to) the anterior/posterior
position, attach the 4-Lead cable, and set the pacer at the maximum milliamps at a rate of 80/min. Do
NOT interrupt compressions while attempting pacing.

When to stop CCC:

If the patient shows signs of cerebral activity and the rhythm is non-shockable.
Use end-tidal CO2 as a marker for possible ROSC. Look for a dramatic increase.
Pulse checks are ONLY performed during brief rhythm analysis with location of carotid pulse
ascertained during chest compressions.
□ This may be modified by the Code Commander if cerebral function signs of life appear
□ The Code Commander is the only individual who can order a pulse check other than that
done during rhythm analysis.
□ The Code Commander must ensure the pulse checker is clear if a shock is indicated.

When to move the patient:

Remember that moving the patient inevitably results in compromised quality of compressions. If crew
safety is compromised or inadequate resuscitation space is available, patient should be quickly moved
to a safe or larger area. This should be done initially and not after resuscitation efforts have begun.
Initially shockable patients will live or die in the field!
□ Move is allowed after 3 cycles are completed and a non-shockable rhythm is identified at the 3rd
analysis
▪ If 3rd analysis is still shockable, continue resuscitation at the scene until a non-shockable
rhythm is encountered.
Initially non-shockable rhythms
□ Medical Control must make this determination, but these patients may deserve at least 3 cycles of
treatment with optimal quality compressions.

Avoid Excessive Pauses:

Rhythm analysis – ONLY the Code Commander pays attention to the rhythm (not everyone)
Resume CCC immediately after analysis + shock. The Code Commander must assure this happens
Charging – perform during last 10 seconds of 200 chest compressions
During Intubation – It is responsibility of both the Code Commander and the second airway person to
avoid pauses in CCC. This MUST be able to be performed without any interruption of compressions!
Consider using the LTA if unable to intubate effectively.
Pulse Checks – only performed during the rhythm analysis pause; must be correlated with rhythm

Service MD Approval:______

Procedure 10-5
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

219
 Procedure

P Paramedic P
Clinical Indications:
Tension pneumothorax should be suspected in patients who exhibit:
□ Severe respiratory distress with hypoxia
□ Unilateral decreased or absent lung sounds
□ Evidence of hemodynamic compromise (Shock, Hypotension, Tachycardia, Altered Mental
Status)
□ Tracheal deviation away from the collapsed lung field (less reliable than the above)
Pleural decompression for tension pneumothorax should only be preformed when at least 3 of the
above criteria are present.

Equipment:
14 gauge 2 inch – 2.5 inch over the needle catheter
Tape
Sterile gauze pads
Antiseptic swabs
Occlusive dressing

Procedure:
Locate decompression site
□ Identify the 2nd intercostal space in the mid-clavicular line on the same side as the
pneumothorax
Prepare the site with an antiseptic swab:
□ Firmly introduce catheter immediately above distal rib of selected site.
Insert the catheter into the thorax until air exits
Advance catheter and remove needle.
Secure the catheter taking care not to allow it to kink
Reassess lung sounds and patient condition
Dress area with occlusive dressing then cover with sterile gauze pad
Assess breath sounds and respiratory status.

Service MD Approval:______

Procedure 11
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

220
 Procedure

EMT
Clinical Indications:
A A‐EMT A
Active labor with perineal crowning ParamedicP P
Apply personal protective equipment and prepare for childbirth
Allow head to deliver passively and control delivery by placing palm of hand over occiput.
Protect perineum with pressure from other hand
If amniotic sac is still intact, gently pinch and twist to manually rupture.
Note presence or absence of meconium.
If meconium is present, see Complication of Childbirth
Once the head is delivered and passively turns to one side, suction mouth and nose
If nuchal cord present, gently lift cord from around infant’s neck
Gently apply downward pressure to infant to facilitate delivery of upper shoulder
Once upper shoulder has delivered, apply gentle upward pressure to deliver lower shoulder
Grasp the infant as it emerges from birth canal
Keep infant at level of perineum until cord stops pulsating and cord is clamped.

Care of the Newborn:

Double clamp cord 10-12 inches from abdomen, once it stops pulsating cut cord.
Suction mouth and nose
Dry and warm the neonate. Wrap in blankets
Stimulate infant by rubbing back or soles of feet
Refer to Neonatal Resuscitation Protocol if infant is hypoxic, not breathing properly or heart rate
<100.
Obtain APGAR Score 0 1 2
Appearance Blue Peripheral Cyanosis Pink
Pulse Absent <100/minute >100/minute
Grimace No response Grimace Cough/Sneeze
Activity Limp Minimal Movement Active Motion
Respiratory Effort Absent Weak Cry Strong Cry

Post Partum Care:

Allow placenta to deliver spontaneously while transporting patient to hospital. Do not pull on cord.
Apply direct pressure to any actively bleeding areas on the perineum
If blood loss significant or vaginal bleeding continues
□ Fluid bolus as needed
□ Massage top of uterus
□ Allow newborn to nurse / breast feed if stable

Service MD Approval:______

Procedure 13
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

221
 Procedure

Shoulder Dystocia:
Place mother in knee-chest position and reattempt delivery
EMT
If delivery fails, support child’s airway, provide supplemental oxygen.
A A‐EMT A
Breech Birth: Paramedic P P
Do not attempt to pull infant by trunk or legs.
Place mother in knee-chest position
If head does not deliver, push baby’s mouth and nose away from vaginal wall with two gloved fingers.
Provide supplemental oxygen to infant.

Prolapsed Cord:
Place mother in knee-chest position
Do not push cord back into birth canal
Insert gloved fingers into birth canal and keep pressure off prolapsed cord
Cover exposed cord with warm moist dressing

Meconium-Stained Amniotic Fluid:

Suction mouth and nose after delivery
If baby is vigorous (normal respiratory effort, muscle tone, and heart rate >100), provide supportive
care
If baby is not vigorous (depressed respirations, poor muscle tone, or heart rate <100) – REQUEST
ALS

Meconium-Stained Amniotic Fluid: P Paramedic P

Suction mouth and nose after delivery
If baby is vigorous (normal respiratory effort, muscle tone, and heart rate >100), provide supportive
care
If baby is not vigorous (depressed respirations, poor muscle tone, or heart rate <100), perform
endotracheal intubation and suction trachea while removing ET tube, may repeat one additional time.
Support ventilation and re-intubate with a clean tube

Service MD Approval:______

Procedure 12
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

222
 Procedure

Clinical Indications:
For patients with Acute Bronchospastic Disorders (acute or chronic bronchitis, emphysema, or asthma)
or Acute Pulmonary Edema, who have hypoxemia and/or respiratory distress that does not quickly
improve with pharmaceutical treatment.

Consider CPAP protocol if 2 or more are present:

Retraction of intercostals or accessory muscles EMT
Bronchospasm
Rales A A‐EMT A
Respiratory Rate >25 per minute P Paramedic P
Oxygen saturation <93% on high flow Oxygen

Contraindications:
Respiratory arrest
Agonal respirations
Unconsciousness or obtundation
Shock associated with cardiac insufficiency
Trauma
Persistent nausea and vomiting
Facial anomalies
Inability to cooperate with the procedure
Current tracheostomy

Equipment:
Medical Director approved Continuous Positive Airway Pressure (CPAP) device

Procedure:
Perform primary and secondary survey
Attach cardiac monitor, capnography if available, and pulse oximetry
Service MD Approval:______
Verbally instruct patient (this is a critical item)
□ Patient requires verbal sedation to use this device effectively
□ Setup CPAP device as per manufacturer’s instructions
□ Instruct patient to slowly breathe in through the nose and exhale through the mouth (exhalation
phase should be about 4 seconds)
Continue treatment throughout transport to ED - document CPAP level used and FiO2 level used
Record and monitor vital signs, ETCO2, and O2 saturation as needed/available
In the event of progressive respiratory failure:
□ Offer reassurance
□ Stop treatment if necessary
□ Institute BLS and ALS care per appropriate protocol
□ Document adverse reactions, and reasons why CPAP was discontinued, in PCR

Procedure 15
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
223
 Procedure

Clinical Indications: EMT

Pediatric Arrest A A‐EMT A
Suspected non-cardiac arrest/respiratory arrest in adult patients P Paramedic P
(ie. overdose, drowning)

Procedure:
1) Assess the patient’s level of responsiveness (signs of life)
2) If no response, open the patient’s airway with the head-tilt, chin-lift. Look, listen and feel for
respiratory effort. If the patient may have sustained c-spine trauma, use the modified jaw thrust while
maintaining immobilization of the c-spine. For infants, positioning the head in the sniffing position is the
most effective method for opening the airway.
3) If patient is an adult, go to step 4. If no respiratory effort in the pediatric patient, give two ventilations.
If air moves successfully, go to step 4. If air movement fails, proceed per AHA obstructed airway
guidelines.
4) Check for pulse (carotid for adults and older children, brachial or femoral for infants) for at least 10
seconds. If no pulse, begin chest compressions as directed below.

Age Location Depth Rate

Over sternum, between 1.5 inches (1/3 the
nipples (inter‐mammary anterior‐posterior chest
Infant line), 2‐3 fingers dimension At least 100/minute
2 inches (1/3 the anterior‐
Over sternum, between posterior chest
Child nipples, heel of one hand dimension At least 100/minute
Over sternum, just above
the xyphoid process, At least 2 inches (1/3 the
hadns with interlocked anterior‐posterior chest
Adult fingers dimension At least 100/minute

5) Go to Cardiac Arrest protocol

6) Chest compressions should be provided in an uninterrupted manner. Only brief interruptions are
allowed for rhythm analysis and defibrillation
7) Document the time and procedure in the PCR.

Service MD Approval:______

Procedure 16
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
224
 Procedure

P Paramedic P
If Possible Contact Medical Control Before Proceeding!

Clinical Indications:
When all airway management measures have failed and the patient needs an advanced airway
immediately, consider performing cricothyrotomy. The percutaneous approach is preferred.
If, in the paramedics judgment, the time necessary to contact medial control will compromise the
patient's chance of survival AND it is not possible to ventilate the patient with a bag-valve-mask
during transport, cricothyrotomy may be performed without Medical Control.

Relative Contraindications:
Ability to ventilate patient with an oral-pharyngeal/nasal-pharyngeal airway, BVM, LTA/LMA, or
endotracheal tube.

Procedure:
1) Cleanse anterior neck.
2) Identify and mark cricothyroid membrane
3) Fill a 10cc syringe with 5cc’s of 0.9% normal saline
4) Remove dilator from the package and sheath and advance into the tracheostomy tube
5) Penetrate the skin and cricothyroid membrane with the splitting needle perpendicular to the skin
while gently aspirating with the syringe. Air aspiration as evidenced by bubbles into syringe
should flow easily confirming tracheal airspace. Incline needle more than 45 degrees toward
carina and complete insertion of needle aspirating to ensure continued proper placement
6) Disconnect needle from syringe and advance tip of dilator into the hub of the splitting needle until
resistance is met.
7) Squeeze wings of needle together then, open them out completely to split the needle. Remove
needle, continuing to pull it apart in opposite directions, while leaving the dilator in the trachea.
8) Place thumb on dilator knob while first and second fingers are curved under flange of trachea
tube. By exerting pressure, advanced dilator and tracheostomy tube into position until flange is
against skin.
9) Remove dilator and inflate cuff until you have control of the airway (max 5cc’s). Attach ETCO2
and BVM. Secure tube around patient’s neck with twill tape.
10) Confirm placement with gentle ventilation via BVM, continuous capnography and physical means.
Be sure air movement is fluid with bilateral symmetric chest rise and that no visible neck soft-
tissue distortion is noted.
11) If tracheal placement is unclear, remove and transport immediately to the closest ER
12) Secure tube and consider sedation protocol
13) If not previously done, immediately notify Medical Control.

Service MD Approval:______

Procedure 17
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

225
 Procedure

EMT
A A‐EMT A
P Paramedic P
Clinical Indications:
Any patient who may have been exposed to significant hazardous materials, including chemical, biological,
or radiological weapons.

Procedure:
In coordination with HazMat and other Emergency Management personnel, establish hot, warm, and
cold zones of operation.
Ensure that personnel assigned to operate within each zone have proper personal protective
equipment.
In coordination with other public safety personnel, assure each patient from the hot zone undergoes
appropriate initial decontamination. This is specific to each incident; such decontamination may
include:
□ Removal of patient from hot zone
□ Simple removal of clothes
□ Irrigation of eyes
□ Passage through high-volume water bath (ie. Between two fire apparatus) for patients
contaminated with liquids or certain solids. Patients exposed to gases, vapors, and powders often
will not require this stop as it may unnecessarily delay treatment and/or increase dermal
absorption of the agent(s).
Initial triage of patients should occur after step #3. Immediate life threats should be addressed prior to
technical decontamination.
Assist patients with technical decontamination (unless contraindicated based on #3 above). This may
include removal of all clothing and gentle cleaning with soap and water. All body areas should be
thoroughly cleansed, although overly harsh scrubbing which could break the skin should be avoided.
Place triage identification on each patient Match triage information with each patient’s personal
belongings, which were removed during technical decontamination. Preserve these personnel affects
for law enforcement.
Monitor all patients for environmental illness. Service MD Approval:______

Transport patients per local protocol.

Procedure 18
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
226
 Procedure

EMT
Clinical Indications: A A‐EMT A
Patients in cardiac arrest (pulseless, non-breathing) P Paramedic P
Age <8 years, use pediatric pads if available

Contraindications:
Pediatric patients whose body size is such that the pads cannot be placed without touching one
another.

Procedure:
1) If multiple rescuers available, one rescuer should provide uninterrupted chest compression while
the AED is being prepared for use.
2) Apply defibrillator pads per manufacturer recommendations. Use alternate placement when
implanted devices (pacemakers, AICD’s) occupy preferred pad positions.
3) Remove any medication patches on the chest and wipe off any residue
4) If necessary, connect defibrillator leads: per manufacturer recommendations.
5) Activate AED for analysis of rhythm
6) Stop chest compressions and clear the patient for rhythm analysis. Keep interruption in chest
compressions as brief as possible
7) Defibrillate if appropriate by depressing the “shock” button. Assertively state “CLEAR” and
visualize that no one, including yourself, is in contact with the patient prior to defibrillation. The
sequence of defibrillation charges is preprogrammed for monophasic defibrillators. Biphasic
defibrillators will determine the correct joules accordingly.
8) Begin CPR/CCR immediately after the delivery of the shock beginning with chest compressions.
9) After 2 minutes of CPR/CCR, analyze rhythm and defibrillate if indicated. Repeat this step
every 2 minutes.
10) If “no shock advised” appears, perform CPR/CCR for two minutes and then reanalyze.
11) Transport and continue treatment as indicated.
12) Keep interruption of compressions as brief as possible. Adequate CPR/CCR is a key to
successful resuscitation.
Service MD Approval:______

If pulse returns: See Post-Resuscitation Protocol

Procedure 19
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
227
 Procedure

EMT
Clinical Indications: A A‐EMT A
Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia P Paramedic P
Procedure:
1) Ensure chest compressions are adequate and interrupted only when necessary
2) Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation
3) Apply hands-free pads to the patient’s chest in the proper position
4) Charge the defibrillator to the maximum energy level. Continue chest compressions while the
defibrillator is charging.
5) Pause compressions, assertively state, “CLEAR” and visualize that no one, including yourself, is in
contact with the patient.
6) Deliver the shock by depressing the shock button for hands-free operation.
7) Immediately resume chest compressions and ventilations for 2 minutes. After 2 minutes of CPR/
CCR, analyze rhythm and check for pulse only if organized rhythm.
8) Repeat the procedure every two minutes as indicated by patient response and EKG rhythm.
9) Keep interruption of compressions as brief as possible. Adequate compressions are the key to
successful resuscitation.

If pulse returns: See Post-Resuscitation Protocol

Service MD Approval:______

Procedure 20
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
228
 Procedure

Clinical Indications:
Patients meet clinical indications for oral intubation
Initial intubation attempt for medical indication unsuccessful P Paramedic P
Predicted difficult intubation

Contraindications:
ETT size less than 6.5mm.
Already failed twice on medical indicated intubation attempts or failed on one trauma intubation
attempt DO NOT UTILIZE BOUGIE.

Procedure:
1) Prepare, position, and oxygenate the patient with 100% Oxygen
2) Select proper ET tube without stylette, test cuff and prepare suction
3) Lubricate the distal end and cuff of the endotracheal tube (ETT) and the distal ½ of the
endotracheal tube introducer (Bougie) (note: failure to lubricate the Bougie and the ETT may
result in being unable to pass the ETT)
4) Using laryngoscopic techniques, visualize the vocal cords if possible using Sellick’s/BURP as
needed.
5) Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or
above the arytenoids if the cords cannot be visualized
6) Once inserted, gently advance the Bougie until you meet resistance or “hold-up” (if you do not
meet resistance you have a probable esophageal intubation and insertion should be re-attempted
or the failed airway protocol implemented as indicated.
7) Withdraw the Bougie ONLY to a depth sufficient to allow loading of the ETT while maintaining
proximal control of the Bougie
8) Gently advance the Bougie and loaded ET tube until you have hold-up again, thereby assuring
tracheal placement and minimizing the risk of accidental displacement of the Bougie.
9) While maintaining a firm grasp on the proximal Bougie, introduce the ET tube over the Bougie
passing the tube to its appropriate depth
10) If you are unable to advance the ETT into the trachea and the Bougie and ETT are adequately
lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER clockwise to turn
the bevel of the ETT posteriorly. If this technique fails, to facilitate passing of the ETT you may
attempt direct laryngoscopy while advancing the ETT (this will require an assistant to maintain the
position of the Bougie and , if so desired, advance the ETT)
11) Once the ETT is correctly placed, hold the ET tube securely and remove the Bougie
12) Confirm tracheal placement with capnography according to the intubation protocol. Inflate the cuff,
auscultate for equal breath sounds and reposition accordingly.
13) When final position is determined secure the ET tube, continuously record and monitor
capnography, reassess breath sounds and monitor patient to assure continued tracheal intubation.
14) If there is any question regarding placement of ETT (Esophageal vs. Tracheal) remove
immediately and ventilate with BVM.

Service MD Approval:______

Procedure 21
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

229
 Procedure

Clinical Indications:
Monitored heart rate less than 60 per minute with signs and symptoms of inadequate cerebral or
cardiac perfusion such as:
□ Severe chest pain
□ Hypotension P Paramedic P
□ Pulmonary edema
□ ALOC, disorientation, confusion, etc
PEA, where the underlying rhythm is bradycardic and reversible causes have been treated

Procedure:
1) Attach standard four-lead monitor
2) Apply defibrillation/pacing pads to chest and back:
□ One pad to left mid chest next to sternum, one pad to left mid posterior back next to spine
3) Choose pacing option
4) Adjust heart rate to 70 BPM for an adult, 100 BPM for pediatric patients
5) Note pacer spikes on EKG screen
6) Slowly increase output until capture of electrical rhythm on the monitor
7) If unable to capture while at maximum current output, stop pacing immediately
8) If capture observed on monitor, check for corresponding pulse and assess vital signs
9) Mechanical capture occurs when paced electrical spikes on the monitor correspond with palpable
pulse
10) Consider the use of sedation or analgesia if patient is uncomfortable, per protocol
11) Document the dysrhythmia and the response to external pacing with EKG strips in the PCR.

Service MD Approval:______

Procedure 22
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

230
 Procedure

Clinical Indications:
Inability to BVM ventilate
When an alternative airway device is needed in the management of respiratory failure

Contraindications: P Paramedic P
Pharyngeal pathology (abscess or hematoma)
Obstructive lesions below the glottis
Limited mouth opening
Intact gag reflex

Equipment:
Correctly sized laryngeal mask airway (see chart below)
Bag valve mask or automatic ventilator
Oxygen reservoir
Suction device
Bite block and/or endotracheal tube holder (if available)
25 and/or 35ml syringes for expanding cuff
End Tidal CO2 and oxygen saturation monitoring devices

Laryngeal Mask Airway Sizes

Patient weight Largest
Mask Size (kg) Age (years) Length (cm) Cuff volume (ml) ETT*
1 <5kg <0.5yrs 10cm 4 3.5mm
1.5 5‐10 10 5‐7
2 10‐20 .5‐5 11.5 7‐10 4.5
2.5 20‐30 5‐10 12.5 14 5
3 30‐60 10‐15 19 15‐20 6
4 60‐80 >15 19 25‐30 6.5
5 >80 >15 19 30‐40 7

*Appropriately sized endotracheal tube (internal diameter) that can be passed through LMA for blind
intubation if intubating LMA is inserted.

Service MD Approval:______

Procedure 23-1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

231
 Procedure

Procedure – Laryngeal Mask Airway Placement:

Pre-oxygenate patient with 100% Oxygen via bag valve mask to achieve O2 saturation of >93% if
possible
Remove the red tag from the balloon port
Check the integrity of the cuff and pilot balloon P Paramedic P
Tightly deflate the cuff with the syringe
□ The deflated cuff should appear BOAT shaped
Lubricate the posterior surface
Place patient in neutral sniffing position (if no c-spine/spinal injury suspected)
□ For patients with suspected c-spine injury, perform two person insertion technique:
•One person maintains manual in-line cervical spine stabilization while the other person
proceeds with procedure as below:
Pull mandible down to open mouth
Insert uninflated LMA into oral cavity with cuff facing away from hard palate
Guide LMA around curvature of the posterior pharynx into the hypopharynx until resistance is felt.
Resistance is due to the tip of the LMA stopping at the upper esophageal sphincter
If uninflated LMA insertion is difficult:
□ If the curvature of the posterior/hypopharynx is too acute, perform a jaw thrust, pulling the
tongue forward. Alternately, a laryngoscope may be used to lift the jaw/mandible to facilitate
insertion.
□ A slight inflation of the cuff to 1/3 – ½ of typical inflation volume may also increase ease of
insertion
□ Insert LMA with cuff facing hard palate, then rotate 180 degrees into the proper position after the
angel around the posterior aspect of the tongue has been cleared.
Inflate cuff without holding the tube
Ensure that the black line running the length of the LMA shaft is in the midline of the upper lip and
between the two central incisors (this will help maintain a seal)
Administer gentle positive pressure ventilation
Obtain end-tidal CO2 (waveform), listen for breath sounds bilaterally, look for chest excursion, and
check oxygen saturation.
Secure in the midline to help maintain a good seal over the Larynx
Place bite block, gauze or endotracheal tube holder (if available) between teeth to prevent biting tube.
Ensure c-spine is still immobilized
If repeated attempts are made, oxygenate with 100% O2 for 2 minutes between attempts

Endotracheal intubation using Intubating Laryngeal Mask Airway (ILMA):

Select correct size ILMA
Insert endotracheal tube into oropharynx at 90 degree angle (from corner of mouth)
During insertion and passage through the ILMA rotate ET tube 90 degrees so that the tip of the ET
tube will pass through the bars that traverse the distal opening of the ILMA.
Confirm placement as per endotracheal intubation procedure.

Service MD Approval:______

Procedure 23-2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

232
 Procedure

P Paramedic P

Service MD Approval:______

Procedure 23-3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

233
 Procedure

History:
Number of patients Signs and Symptoms: Differential:
Cause of Incident SLUDGE for chemical exposure Blast Response
Chemical, Biological, Radiological Respiratory Distress for Narcotic Exposure MCI penetrating trauma
contamination Nausea Vomiting for radiation MCI blunt trauma/MVC
Secondary Devices

Scene Safety –
If blast, wear N95 mask and full turnout gear
until advised to remove EMT
A A‐EMT A
Provide scene size‐up on radio; activate MCI plan P Paramedic P
if more than 5 patients

If not already accomplished, establish

Incident Command, Staging and Triage

Consider public transportation

Move all ambulatory patients to
to alternative receiving facility
safe area in cold zone for ambulatory patients

Move non‐ambulatory patients to

transportation as rapidly as possible.
Establish treatment areas only if there are
insufficient transport resources available Service MD Approval:______
for rapid transport.

Pearls
Task cards and job vest should be utilized by all personnel involved in a MCI
If blast injury with more than 5 patients, patient with SBP<90 and/or obvious external trauma to 4 or more body surface areas should go to the Level
1 Trauma Center. Other may be considered for transport to the other area hospitals.
Multiple patients may be transported in the same EMS unit if needed. When possible, patients of similar acuity should be transported in the same
unit to assist with appropriate transport destination.
Utilize state/local approved triage system.

Procedure 24
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
234
 Procedure

Purpose:
Administration of medication via a non-invasive route

Clinical Indications: EMT

Altered mental status, presumed or possible opiate overdose A A‐EMT A
Seizures
P Paramedic P
Pain management

Contraindications:
DO NOT USE on patient if:
Severe nasal/facial trauma
Active nasal bleeding or discharge

Procedure for medication administration via the MAD®:

1) Determine appropriate dose of medication per protocol

2) Draw medication into syringe and dispose of the sharps (add an additional 0.1 ml of medication
due to dead space), do not administer more than 1 ml per nostril.
3) Attach Mucosal Atomizer Device (MAD) to syringe
4) With one hand, control the patient’s head
5) Gently introduce MAD into nare, stop when resistance is met.
6) Aim slightly upwards and toward the ear on the same side.
7) Briskly compress the syringe to administer one-half of the medication, repeat the procedure with
the remaining medication on the other nare.
8) Document the results in the PCR.

Service MD Approval:______

Procedure 25
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

235
 Procedure

Clinical Indications:
Gastric decompression in adult intubated patients
After successful placement of an LTA or BIAD EMT
A A‐EMT A
Contraindications:
P Paramedic P
History of alkali ingestion, or esophageal disease (ie. stricture or cancer)
Comatose state with unprotected airway (as procedure will induce vomiting)
Penetrating cervical injuries in the awake trauma patient.

Procedure:

1) Measure the length of the tube from the umbilicus to ear lobe to corner of the mouth.
2) Lubricate the tube with a water based lubricant prior to insertion
3) Insert lubricated tube through the gastric port of the LTA or lift tongue/jaw anteriorly while passing
tip lateral to endotracheal tube.
4) Continue to advance the tube gently until the appropriate distance is reached.
5) Confirm placement by injecting 20cc of air and auscultate for the whoosh or bubbling of the air
over the stomach. If any doubt about placement, remove and repeat the insertion.
6) Secure the tube.
7) Decompress the stomach of air and food by connecting the tube to low continuous suction (green).
8) Document the procedure, time, and result (success) on/with the PCR.

EMT-B and EMT-A must have State approval to perform this skill

Service MD Approval:______

Procedure 26
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

236
 Standards Procedure

Purpose:
To establish control of the patient's airway and to facilitate EMT
ventilation for the listed indications. A A‐EMT A
P Paramedic P
Indications:
When an alternative airway device is needed in the management of respiratory failure in patients 4
feet tall or greater

Contraindications:
Intact gag reflex
Patients with known esophageal disease
Patients who have ingested caustic substances
Patient with known tracheal obstruction
Patient with a tracheostomy or laryngectomy
Patients less than 4 feet tall.

Equipment:
Correctly sized LTA (see chart below)
Bag valve mask
Oxygen reservoir
Suction device
Bite block and/or endotracheal tube holder (if available)
Appropriately sized syringes for expanding cuff
End Tidal CO2 and oxygen saturation monitoring devices
King LTS-D Airway Sizes
Patient Cuff Volume Gastric Tube
Airway Size Connector Color Height OD/ID (mm) (ml) (Fr.)
3 Yellow 4‐5 feet 18/10mm 45‐60 ml Up to 18
4 Red 5‐6 feet 18/10 60‐90 Up to 18
5 Purple >6 feet 18/10 70‐90 Up to 18

Procedure:
1) Pre-oxygenate patient with 100% Oxygen via Bag Valve Mask or spontaneous ventilation to
achieve O2 saturation of >93% if possible
2) Check the integrity of the cuff inflation system and pilot balloon
3) Tightly deflate the cuff with the syringe
4) Lubricate the posterior distal tip of the LTA with a water soluble lubricant
5) Place patient in neutral sniffing position (if no c-spine/spinal injury suspected)
□ For patients with suspected c-spine injury, perform two-person insertion technique
• One person maintains manual in-line cervical spine stabilization while the other
person proceeds with procedure
Service MD Approval:______

Procedure 27-1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

237
 Procedure

EMT
Procedure (Continued):
6) Pull mandible down to open mouth
A A‐EMT A
7) Insert uninflated LTA into oral cavity with midline or a lateral technique P Paramedic P
8) Advance the tip behind the base of the tongue while rotating tube back to midline so that the blue
orientation line faces the chin of the patient.
9) Without exerting excessive force, advance tube until base of the colored connector is aligned with
teeth or gums
10) Inflate the King with the appropriate volume:
□ If uninflated King Airway insertion is difficult, perform a jaw thrust, pulling the tongue
forward. Alternately, a laryngoscope may be used to lift the jaw/mandible to facilitate
insertion.
11) Attach the BVM to the King LTSD
12) While bagging the patient, gently withdraw the tube until ventilation becomes easy and free flowing
(large tidal volume with minimal airway pressure)
13) Adjust cuff inflation if necessary to obtain a seal of the airway at the peak ventilatory pressure
employed.
14) Obtain end-tidal CO2 (waveform), listen for breath sounds bilaterally, look for chest excursion, and
check oxygen saturation
15) Secure in the midline to help maintain a good seal over the Larynx
16) Place bite block, oral airway or endotracheal tube holder (if available) between teeth to prevent
biting tube.
17) Place orogastric tube and attach to low continuous suction as directed in the applicable procedure
to assist in gastric decompression.
18) Ensure c-spine is still immobilized
19) If repeated attempts are made, oxygenate
with 100% O2 for 2 minutes between attempts
20) **Follow manufacturers suggested
guidelines at all times**

Service MD Approval:______

Procedure 27-2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

238
 Procedure

EMT
A A‐EMT A
P Paramedic P

Service MD Approval:______

Procedure 27-3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

239
 Procedure

EMT
A A‐EMT A
P Paramedic P

Service MD Approval:______

Procedure 27-4
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

240
 Procedure

Indications: EMT
Patients with suspected hypoxemia, altered level of consciousness A A‐EMT A
respiratory issues, or as specified in protocol. P Paramedic P
Procedure:
1) Apply probe to patient’s finger or any other digit as recommended by the device manufacturer.
2) Allow machine to register saturation level.
3) Record time and initial saturation percent on room air if possible on/with the PCR
4) Verify pulse rate on machine or with actual manual pulse check of the patient
5) Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading,
monitor patients for a few minutes as oxygen saturation can vary.
6) Document percent of oxygen saturation every time vial signs are recorded and in response to
therapy to correct hypoxemia
7) In general, normal saturation is 97-99%. Below 93% suspect a respiratory compromise
8) Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data
provided by the device
9) The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory
distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings,
such as chest pain.
10) Factors which may reduce the reliability of the pulse oximetry reading include:
□ Poor peripheral circulation (blood volume, hypotension, hypothermia)
□ Excessive pulse oximeter sensor motion
□ Fingernail polish (may be removed with acetone pad)
□ Carbon monoxide bound to hemoglobin
□ Irregular heart rhythms (atrial fibrillation, SVT, etc.)
□ Jaundice
□ Placement of BP cuff on same extremity as pulse ox probe

Service MD Approval:______

Procedure 29
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
241
 Procedure

Indications:
Age >18 unless specific permission given prior to procedure by Medical Control Contraindications:
Need for invasive airway management in the setting of an intact gag reflex or Sensitivity to Succinylcholine or other RSA drugs
inadequate sedation to perform non‐pharmacologically assisted airway Inability to ventilate via BVM
management Suspected Hyperkalemia
□ Apnea Myopathy or neuromuscular disease
□ Decreased LOC with respiratory failure (ie. Hypoxia [O2 sat <90%] not History of Malignant Hyperthermia
improved by 100% Oxygen, and/or respiratory rate <8) Recent crush injury or major burn (>48 hours after injury)
□ Poor ventilatory effort (with hypoxia not improved by 100% Oxygen) End Stage Renal Disease
□ Unable to maintain patent airway by other means Recent Spinal Cord Injury (72 hours – 6 months)
□ Burns with suspected significant inhalation injury

TWO PARAMEDICS REQUIRED FOR THIS PROCEDURE

PREPERATION (T-8 minutes)

Monitoring (continuous EKG, SPO2, Blood Pressure) Double
2 patent IV’s P Paramedic P
Functioning Laryngoscope and BVM with highflow O2
Endotracheal tube(s), stylet, syringe(s)
LTA(s) and appropriate syringe(s)
Alternative/Rescue Airway (LMA and surgical airway kit) immediately available
All medications drawn up and labeled (including post-procedure sedation)
Suction – turned on and functioning
End Tidal CO2 device on and operational (colometric immediately available as backup only)
Assess for difficult airway – LEMON
PREOXYGENATE
100% O2 x5 minutes (NRB) or 8 vital capacity breaths with 100% O2 (BVM/NRB)
PRETREATMENT (T-3 minutes)
Evidence of head injury or stroke
Lidocaine 1.5mg/kg IV/IO (max 150mg)
Begin cricoid pressure / Sellick’s maneuver
PARALYSIS and INDUCTION (T=0)
Etomidate 0.3mg/kg (max 20mg)
Succinylcholine 2 mg/kg (max 200mg)
PLACEMENT with PROOF (T+30 seconds)
Place LTA/ETT
Confirm with:
□ End Tidal CO2 Waveform
□ Auscultation
□ Physical findings
Secure device, note position
POST-PLACEMENT MANAGEMENT (T+1 minute)
Sedation: Morphine 3mg IV/IO AND Midazolam 3mg IV/IO, repeat x2 as needed
If additional needed and transport time >10 minutes: Rocuronium 1mg/kg IV/IO Service MD Approval:______

Procedure 30
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
242
 Procedure

Clinical Indications:
Any patient who may harm himself, herself, or others may be gently restrained to prevent injury to the
patient or crew. This restrain must be in a humane manner and used only as a last resort. Other means
to prevent injury to the patient or crew must be attempted first. These efforts could include reality
orientation, distraction techniques, or other less restrictive therapeutic means. Physical or chemical
restraint should be a last resort technique.
EMT
A A‐EMT A
P Paramedic P
Procedure:
1) Attempt less restrictive means of managing the patient.
2) Ensure that there are sufficient personnel available to physically restrain the patient safely
3) Restrain the patient in a lateral or supine position. No devices such as
backboards, splints, or other devices will be on top of the patient.
4) The patient will never be restrained in the prone position
5) The patient must be under constant observation by the EMS crew at all times. This includes direct
visualization of the patient as well as cardiac, pulse oximetry and capnography monitoring as
indicated.
6) The extremities that are restrained will have a circulation check at least every 15 minutes. The first
of these checks should occur as soon after placement of the restraints as possible. This MUST be
documented on the PCR.
7) If the above actions are unsuccessful, or if the patient is resisting the restraints, consider chemical
restraint per protocol.
8) If a patient is restrained by law enforcement personnel with handcuffs or other devices EMS
personnel cannot remove, a law enforcement officer must accompany the patient to the hospital in
the transporting EMS vehicle.
9) Consider Behavioral protocol.
10) Restraining a patient in the prone position is never authorized.

Service MD Approval:______

Procedure 31
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
243
 Procedure

Clinical Indications: EMT

Need for spinal immobilization as determined by protocol A A‐EMT A
P Paramedic P
Procedure:
1) Gather a backboard, straps, c-collar appropriate for patient’s size, tape, and head rolls or similar
device to secure the head.

2) Explain the procedure to the patient.

3) Apply an appropriately sized c-collar while maintaining in-line stabilization of the c-spine.
This stabilization, to be provided by a second rescuer, should not involve traction or tension but
rather simply maintaining the head in a neutral, midline position while the first rescuer applies the
collar. This may be performed by any credentialed responder if indicated by protocol.

4) Once the collar is secure, the second rescuer should still maintain their position to ensure
stabilization (the collar is helpful, but will not do the job by itself).

5) If the patient is supine or prone, consider the log roll technique. For the patient in a vehicle or
otherwise unable to be placed prone or supine, place them on a backboard by the safest method
available that maximizes maintenance of in-line spinal stability.

6) Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is
secured to the backboard, the second rescuer may release manual in-line stabilization.

7) NOTE: Some patients, due to size or age, will not be able to be immobilized through in-line
stabilization with standard backboards and C-collars. Never force a patient into a non-neutral
position to immobilize them. Such situation may require a second rescuer to maintain manual
stabilization throughout the transport to the hospital.

8) Document the time of the procedure in the PCR.

Service MD Approval:______

Procedure 32
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

244
 Procedure

EMS providers must use extreme caution when evaluating and treating an injured football player, especially when
the extent of the injury remains unknown. Suspect any unconscious football player to have an accompanying
spinal injury until proven otherwise. If the football player isn’t breathing or the possibility of respiratory arrest
exists, its essential that certified athletic trainers and EMS providers work quickly and effectively to remove the
face mask and administer care. In most situations, the helmet should not be removed in the field. Proper
management of head and neck injuries includes leaving the helmet and shoulder pads in place whenever possible,
removing only the face mask from the helmet and developing a plan to manage head-and-neck injured football
players using well-trained sports medicine and EMS providers. EMT

Guidelines and Recommendations:

A A‐EMT A
The following guidelines and recommendations were developed by the P Paramedic P
Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete:

General Guidelines for Care Prior to Arrival of EMS

□ The Emergency Medical Services system should be activated.
□ Any athlete suspected of having a spinal injury should not be moved and should be managed as
though a spinal injury exists.
□ The athlete’s airway, breathing and circulation, neurological status and level of consciousness
should be assessed.
□ The athlete should NOT be moved unless absolutely essential to maintain airway, breathing and
circulation
□ If the athlete must be moved to maintain airway, breathing and circulation, the athlete should be
placed in a supine position while maintaining spinal immobilization
□ When moving a suspected spine injured athlete, the head and trunk should be moved as a unit.
one accepted technique is to manually splint the head to the trunk.

Face Mask Removal

□ The face mask should be removed prior to transpiration, regardless of current respiratory status
(see figure 1)
□ Those involved in the pre-hospital care of injured football players must have the tools for face
mask removal readily available.

Indications for Football Helmet Removal:

The athletic helmet and chin straps should only be removed if:
□ The helmet and chin strap do not hold the head securely, such that immobilization of the helmet
does not also immobilize the head
□ The design of the helmet and chin strap is such that even after removal of the face mask the
airway cannot be controlled, or ventilation be provided.
□ The face mask cannot be removed after a reasonable period of time
□ The helmet prevents immobilization fro transportation in an appropriate position.

Service MD Approval:______

Procedure 33-1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
245
 Procedure

EMT
A A‐EMT A
Helmet Removal: ParamedicP P
If it becomes absolutely necessary, spinal immobilization must be maintained while removing the
helmet.
□ Helmet removal should be frequently practiced under proper supervision by an EMS supervisor
or Training Division.
□ Due to the varying types of helmets encountered, the helmet should be removed with close
oversight by the team athletic trainers and/or sports medicine staff
□ In most circumstances, it may be helpful to remove cheek padding and/or deflate air padding
prior to helmet removal.

Spinal Alignment:
Appropriate spinal alignment must be maintained during care and transport using backboard, straps,
tape, head blocks or other necessary equipment.
□ Be aware that the helmet and shoulder pads elevate an athlete’s trunk when in the supine
position
□ Should either be removed, or if only one is present, appropriate spinal alignment must be
maintained.
□ The front of the shoulder pads can be opened to allow access for CPR and defibrillation.

Service MD Approval:______

Procedure 33-2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
246
 Procedure

EMT
A A‐EMT A
P Paramedic P
Clinical Indications:
Immobilization of an extremity for transport, either due to suspected fracture, sprain or injury.
Immobilization of an extremity for transport to secure medically necessary devices such as
intravenous catheters.

Procedure:
1) Assess and document pulses, sensation, and motor function prior to placement of the splint. If no
pulses are present and a fracture is suspected, consider reduction of the fracture prior to
placement of the splint.
2) Remove all clothing from the extremity
3) Select a site to secure the splint both proximal and distal to the area of suspected injury, or the
area where the medical device will be placed.
4) Do not secure the splint directly over the injury or device
5) Place the splint and secure with Velcro, straps or bandage material (ie. Kling, kerlex, cloth
bandage, etc.) depending on the splint manufacturer and design
6) Document pulses, sensation and motor function after placement of the splint. If there has been a
deterioration in any of these 3 parameters, reposition the splint and reassess. If no improvement,
remove splint.
7) If a femur fracture is suspected and there is no evidence of pelvic fracture or instability, place a
traction splint
8) Consider pain management per protocol
9) Document the time, type of splint, and the pre and post assessment of pulse, sensation and motor
function in the PCR.

Service MD Approval:______

Procedure 34
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
247
 Procedure

Clinical Indications: EMT

Suspected stroke patient.
A A‐EMT A
Procedure: P Paramedic P
1) Assess and treat suspected stroke patients as per protocol

2) The Cincinnati Stroke Screen should be completed for all suspected stroke patients

3) Establish the “time last normal” for the patient. This will be the presumed time of onset.

4) Perform the screen through physical exam:

□ Look for facial droop by asking the patient to smile
□ Have patient, while sitting upright or standing, extend both arms parallel to floor, close eyes, and
turn their palms upward. Assess for unilateral drift of an arm.
□ Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar
saying. Assess for the person to slur the words, get some words wrong, or inability to speak.

5) One of these exam components must be positive to answer “yes”

6) Evaluate Blood Glucose level results

7) If the “time last normal” is less than 24 hours, blood glucose is between 60 and 400, and at least
one of the physical exam elements is positive, follow the Suspected Stroke Protocol, alerting the
receiving hospital of a possible stroke patient as early as possible.

8) All sections of the Cincinnati screen must be completed.

9) The complete screening should be documented in the PCR.

Service MD Approval:______

Procedure 35
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS

248
 Procedure

EMT
A A‐EMT A
P Paramedic P
Clinical Indications:
Monitoring body temperature in a patient with suspected infection, hypothermia, hyperthermia, or to
assist in evaluating resuscitation.

Procedure:
1) If clinically appropriate, allow the patient to reach equilibrium with the surrounding environment.
2) Leave the device in place until there is indication of an accurate temperature acquisition (per the
“beep” or other indicator specific to the device)
3) Record time, temperature, method (tympanic, rectal or oral), and scale (C° or F°) in PCR

Service MD Approval:______

Procedure 36
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
249
 Procedure
(CAT‐Combat Application Tourniquet)
EMT
A A‐EMT A
P Paramedic P
Clinical Indications:
Extremity injury/amputation with uncontrollable hemorrhage despite aggressive direct pressure.

Procedure:
Apply tourniquet device as proximal on extremity as possible, minimum of 2" proximal to hemorrhage
site. (see procedure below)
Secure in place and expedite transport to Level 1 Trauma Center
Document time placed in patient care report and on device (if possible)
Notify receiving center of presence, time placed, and location of tourniquet

1) Route the Self-Adhering Band around the extremity and pass the free-running end of the band through
the inside slit of the friction adaptor buckle

2) Pass the band through the outside slit of the buckle, utilizing the friction adaptor buckle which will lock
the band in place.

Service MD Approval:______

Procedure 14-1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
250
 Procedure
(CAT‐Combat Application Tourniquet)
3) Pull the Self-Adhering Band tight and securely fasten the band back on itself. EMT
A A‐EMT A
P Paramedic P

4) Twist the rod until bright red bleeding has stopped.

5) Lock the rod in place with the Windlass Clip™

6) Hemorrhaging is now controlled.

Secure the rod with the strap: Grasp the
Windlass Strap™, pull it tight and adhere it
to the opposite hook on the Windlass Clip™

**IF needed a second tourniquet can be

added more proximal

Service MD Approval:______

Procedure 14-2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
251
 Procedure

EMT
A A‐EMT A
P Paramedic P
Patients with major trauma (one or more of the following) should be transported to UW Hospital:
Patient unresponsive to voice and/or GCS <12
Adult unstable vital signs (BP<90mmHg, HR >120 or <60, Respirations <10 or >30)
Pediatric unstable vital signs

Heart Rate Systolic BP Respirations

Less than 1 year <90 or >205 <60 <20 or >80
1 to 5 years <70 or >140 <70 <16 or >30
5 to 12 years <60 or >140 <80 <12 or >30

Clinical signs of shock

Penetrating injuries to head, neck, torso, groin or extremity with signs of distal vascular compromise
Flail chest or pelvic fracture
Burns >15% TBSA and/or airway involvement
Two or more proximal long bone fractures (humerus, femur)
Signs of spinal cord injury
Amputation injuries proximal to the wrist or ankle
Significant mechanism of injury in a pregnant patient

Consider transport to UW ED for patients with the following mechanisms of injury and medical
conditions:
Ejection from an automobile during a motor vehicle crash
Death of another patient in the same auto
Extrication time of greater than 20 minutes
Falls:
□ Children >10 feet (2-3x’s patient height)
□ Adults >20 feet
Victim of a high speed auto crash (impact speed of greater than 40 mph, major auto deformity, intrusion
of auto damage into the passenger compartment)
Auto-pedestrian or auto-bicycle injury with significant (>20mph) speed
Pedestrian thrown or run over
Motorcycle crash of greater than 20 mph, or separation of rider from bike
Age of less than 5 or greater than 55 years old
Patient with cardiac or respiratory disease
Major trauma patient with immune system problems
Major trauma patient with bleeding disorder, or currently taking an anticoagulant medication.

Note: Above reference is from the Wisconsin Trauma Field Triage Protocol Service MD Approval:______

Procedure 37
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
252
 Procedure

P Paramedic P
Clinical Indications:
Access of an existing venous catheter for medication or fluid administration in a life threatening
situation when no other access is available
Central venous access in a patient in cardiac arrest

Contraindications:
Non-externalized ports (subcutaneous or tunneled ports)

Procedure:
1) Clean the port of the catheter with alcohol wipe
2) Using sterile technique, withdraw 5-10cc of blood and place syringe in sharps box
3) Using 5cc normal saline, access the port with sterile technique and gently attempt to flush the
saline
4) If there is no resistance, no evidence of infiltration (ie. no subcutaneous, collection of fluid), and no
pain experienced by the patient, then proceed to step 5. If there is resistance, evidence of
infiltration, pain experienced by the patient, or any concern that the catheter may be clotted or
dislodged, do not use the catheter.
5) Begin administration of medications or IV fluids slowly. Observe for any signs of infiltration. If
difficulties are encountered, stop the infusion and reassess.
6) Record procedure, any complications, and fluids/medications administered in the PCR.

Service MD Approval:______

Procedure 38
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
253
 Procedure

A A‐EMT A
Clinical Indications: P Paramedic P
Patients requiring IV medications or fluids
Patients with any potential for deterioration (ie. seizures, altered mentation, trauma, chest pain,
difficulty)

Contraindications:
Child with partial airway obstruction (ie. Suspected epiglotitis) – when agitation from performing
procedure may worsen respiratory difficulty.

Equipment:
Appropriate tubing or IV lock
#14-#24 catheter over the needle, or butterfly needle
Venous tourniquet
Antiseptic swab
Gauze pad or adhesive bandage
Tape or other securing device

Procedure:
1) Saline locks may be used as an alternative to IV tubing and fluid at the discretion of the paramedic
2) Paramedics and A-EMT can use intraosseous access where threat to life exists as provided for in
the Venous Access – Intraosseous procedure.
3) Use the largest catheter bore necessary based upon the patient’s condition and size of veins
4) Fluid and setup choice is preferably:
□ Normal Saline with a macro drip (10-gtt/cc) for medical/trauma conditions.
□ Normal Saline with a micro drip (60gtt/cc) for medication infusions or for patients where fluid
overload is of concern.
5) Assemble IV solution and tubing:
□ Open IV bag and check for clarity, expiration date, etc.
□ Verify correct solution
□ Open IV tubing
□ Assemble IV tubing according to manufacturer's guidelines
6) Insertion
□ Explain to the patient that an IV is going to be started.
□ Place the tourniquet around the patient's arm proximal to the IV site, if appropriate
□ Palpate veins for resilience
□ Clean the skin with the antiseptic swab in an increasing sized concentric circle and follow it with
an alcohol swab
□ Stabilize the vein distally with the thumb/fingers
□ Enter the skin with the bevel of the needle facing upward
□ Enter the vein, obtain a flash, and advance the catheter into the vein while stabilizing the
needle.
□ Remove the needle while compressing the proximal tip of the catheter to minimize blood loss
Continued on next page- Service MD Approval:______

Procedure 39-1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
254
 Procedure

A A‐EMT A
6) Insertion (continued) P Paramedic P
□ Remove the tourniquet
□ Connect IV tubing to the catheter, or secure the IV lock to the catheter and flush with appropriate
solution (normal saline)
□ Open the IV clamp to assure free flow
□ Set IV infusion rate.
7) Secure the IV:
□ Secure the IV catheter and tubing
□ Recheck IV drip rate to make sure it is flowing at appropriate rate.
□ Troubleshooting the IV, (if the IV is not working well):
• Make sure the tourniquet is off
• Check the IV insertion site for swelling
• Check the IV tubing clamp to make sure it is open
• Check the drip chamber to make sure it is half full
• Lower the IV bag below IV site and watch for blood to return into the tubing

External Jugular IV Access:

Contraindications:
● Anterior neck hematoma P Paramedic P
● Anterior neck mass
● Medical appliance in place covering anterior neck
● Previous Surgical Procedure of anterior neck

□ If extremity IV attempts are unsuccessful, reconsider need for IV access.

□ If patient hypotensive, but alert and responsive to pain – consider external jugular vein IV access.
If patient unstable, go directly to Intraosseous access.
□ Monitor for complications
▪ Expanding hematoma
▪ Tracheal shift
▪ Difficulty breathing
▪ Increase in pain

Service MD Approval:______

Procedure 39-2
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
255
 Procedure

A A‐EMT A
Clinical Indications: P Paramedic P
Patients where rapid, regular IV access if unavailable with any of the following:
Cardiac Arrest
CCR – IO is preferable
Multisystem trauma with severe hypovolemia
Severe dehydration with vascular collapse and/or loss of consciousness
Respiratory failure/respiratory arrest

Contraindications:
Fracture proximal to proposed intraosseous site.
History of Osteogenesis Imperfecta
Current or prior infection at proposed intraosseous site
Previous intraosseous insertion or joint replacement at the selected site.

Procedure:
1) Identify anteromedial aspect of the proximal tibia (bony prominence below the knee cap). The
insertion location will be 1-2 cm (2 finger widths) below this.
2) Cleanse the site
3) For manual pediatric devices, hold the intraosseous needle at a 60-90° angle, aimed away form
the nearby joint and epiphyseal plate, twist the needle handle with a rotating grinding motion
applying controlled downward force until a “pop” or “give” is felt indicating loss of resistance. Do
not advance the needle any further
4) For the EZ-IO intraosseous device, hold the intraosseous needle at a 60-90° angle, aimed away
from the nearby joint and epiphyseal plate, power the driver until a “pop” or “give” is felt indicating
loss of resistance. Do not advance the needle any further.
5) Remove the stylette and place in an approved sharps container
6) Attach a 12cc syringe filled with 5cc NS; aspirate bone marrow to verify correct placement, then
inject 5cc of NS to clear the lumen of the needle.
7) Attach the IV line. Use a pressure bag
8) Stabilize and secure the needle with dressings and tape
9) Paramedics may administer 10-20mg (1-2cc) of 2% Lidocaine in adult patients who experience
infusion related pain.
10) Following the administration of IO medications, flush the IO line with 10cc of IV fluid to expedite
medication absorption.
11) Document the procedure, time, and result (success) on/with the PCR.

Service MD Approval:______

Procedure 40
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
256
 Procedure

Clinical Indications: EMT

Protection of open wounds prior to and during transport A A‐EMT A
P Paramedic P
Procedure:
1) If active bleeding, elevate the affected area if possible and hold direct pressure. Do not rely on
compression bandage to control bleeding. Direct pressure is much more effective.
2) Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate (this may
have to be avoided if bleeding was difficult to control).
3) Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to
ensure the bandage is not too tight.
4) Monitor wounds and/or dressing throughout transport for bleeding
5) Consider tourniquet use as indicated in protocol/procedure
6) Document the wound assessment and care in the PCR

Service MD Approval:______

Procedure 41
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
257
258
259
 Table of Contents: Authorized Pharmaceuticals
Overview...................................................................................................... D-3
Adenosine (Adenocard®) ............................................................................. D-4
Albuterol Sulfate (Proventil, Ventolin ) ........................................................ D-5
Amiodarone (Cordarone®) ........................................................................... D-6
Acetylsalicylic Acid (Aspirin®)....................................................................... D-8
Atropine Sulfate (As a Cardiac Agent) ......................................................... D-9
Atropine Sulfate (As an Antidote for Poisonings) ......................................... D-11
Calcium Chloride.......................................................................................... D-13
Dextrose ...................................................................................................... D-14
Diazepam..................................................................................................... D-15
Diltiazem (Cardizem®).................................................................................. D-16
Diphenhydramine Hydrochloride (Benadryl®) .............................................. D-18
Dopamine Hydrochloride (Intropin ®)............................................................ D-20
DuoDote Kit (see Mark 1 Kit) ....................................................................... D-43
Epinephrine Hydrochloride (1:1,000) ........................................................... D-23
Epinephrine Hydrochloride (1:10,000) ....................................................... D-25
Adult Epinephrine Dosing Summary ............................................................ D-27
Pediatric Epinephrine Dosing Summary ...................................................... D-27
Etomidate..................................................................................................... D-28
Famotidine (Pepcid®) ................................................................................... D-29
Fentanyl ....................................................................................................... D-30
Glucagon ..................................................................................................... D-32
Glucose (Oral).............................................................................................. D-33
Haloperidol (Haldol ®)................................................................................... D-34
Hydroxocobalamin (Cyanokit®) ................................................................... D-36
Ipratropium bromide (Atrovent®) .................................................................. D-37
Ketamine...................................................................................................... D-38
Lidocaine Hydrochloride (Xylocaine®).......................................................... D-39
Lorazepam (Ativan ®) ................................................................................... D-40
Magnesium Sulfate ...................................................................................... D-41
Mark 1 Kit..................................................................................................... D-43
Methylprednisolone (Solumedrol®)............................................................... D-44
Midazolam (Versed®) ................................................................................... D-45
Morphine Sulfate.......................................................................................... D-47
Naloxone (Narcan ®) .................................................................................... D-49
Nitroglycerin (Nitrostat ®).............................................................................. D-51
Ondansetron Hydrochloride (Zofran®).......................................................... D-53
Rocuronium ................................................................................................. D-54
Sodium Bicarbonate..................................................................................... D-55
Succinylcholine ............................................................................................ D-56
Vasopressin ................................................................................................. D-59

260
 Overview

The purpose of this document is to serve as a drug information supplement and to provide a brief
description of the prehospital drugs used. This document in no way represents the comprehensive
drug knowledge required for use of these medications by paramedic practitioners. The
comprehensive information about use of these medications by practicing paramedics, requires
reference to other sources, including, but not limited to, pharmacological textbooks, the DOT
curriculum, the Physician’s Desk Reference, paramedic text book (e.g. Prehospital Emergency
Care, Paramedic Care: Principles and Practice, BTLS, PHTLS), American Heart Association
publications (e.g., ACLS, PALS, NALS), etc.

Drugs are listed alphabetically, based on their generic names (brand names are shown in
parenthesis).

Michael T. Lohmeier, MD, FACEP

Medical Director
Dane County EMS

261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
A&Ox3 Alert and Oriented to Person, Place and Time
A&Ox4 Alert and Oriented to Person, Place, Time and Event
A‐FIB Atrial Fibrillation
AAA Abdominal Aortic Aneurysm
ABC Airway, Breathing, Circulation
ABD Abdomen
ACLS Advanced Cardiac Life Support
AKA Above the Knee Amputation
ALS Advanced Life Support
AMA Against Medical Advice
AMS Altereed Mental Status
AMT Amount
APPROX Approximately
ASA Aspirin
ASSOC Associated

BG Blood Glucose
BILAT Bilateral
BKA Below the Knee Amputation
BLS Basic Life Support
BM Bowel Movement
BP Blood Pressure
BS Breath Sounds
BVM Bag‐Valve‐Mask

C‐SECTION Caesarean Section

C‐SPINE Cervical Spine
C/O Complains Of
CA Cancer
CABG Coronary Artery Bypass Graft
CAD Coronary Artery Disease
CATH Catheter
CC Chief Complaint
CEPH Cephalic
CHF Congestive Heart Failure
CNS Central Nervous System
COPD Chronic Obstructive Pulmonary Disease
CP Chest Pain
CPR Cardiopulmonary Resuscitation
CSF Cerebrospinal Fluid
CT Cat Scan
CVA Cerebrovascular Accident (stroke)

316
D5W 5% Dextrose in Water L‐SPINE Lumbar Spine
DKA Diabetic Ketoacidosis L/S‐SPINE Lumbarsacral spine
DNR Do Not Resuscitate L&D Labor and Delivery
DOA Dead on Arrival LAT Lateral
DT Delirium Tremens lb pound
Dx Diagnosis LLQ Left Lower Quadrant
LMP Last Menstrual Period
EKG Electrocardiogram LOC Level of Consciousness (loss of consciousness)
EEG Electroencephelogram LR Lactated Ringers
ET Endotracheal LUQ Left Upper Quadrant
ETOH Ethanol (alcohol) MAST Military anti‐shock trousers
ETT Endotracheal Tube mcg microgram(s)
EXT External (extension) MED Medicine
mg miligram(s)
FB Foreign Body MI Myocardial Infarction (heart attack)
FLEX Flexion min minimum/minute
Fx Fracture MS Mental Status
MVC Motor Vehicle Crash
g gram(s) MVA Motor Vehicle Accident
GI Gastrointestinal
GSW Gunshot Wound N/V Nausea/Vomiting
gtts drops N/V/D Nausea/Vomiting/Diarrhea
GU Gastrourinary NAD No Apparent Distress
GYN gynecology (gynecological) NC Nasal Cannula
NEB Nebulizer
H/A Headache NKDA No Known Drug Allergies
HEENT Head, Eyes, Ears, Nose, Throat NRB Non‐Rebreather
HR Heart Rate (hour) NS Normal Saline
HTN Hypertension NSR Normal Sinus Rhythm
Hx History OB/GYN Obstetrics/Gynecology
PALP Palpation
ICP Intracranial Pressure PAC Premature Atrial Contraction
ICU Intensive Care Unit PE Pulmonary Embolus
IM Intramuscular PERRL Pupils Equal. Round, Reactive to Light
IV Intraveneous PMHx Past Medical History
JVD Jugular Vein Distension PO Orally
kg kilogram PRN as needed
KVO Keep Vein Open PT Patient
PVC Premature Ventricular Contraction

317
RLQ Right Lower Quadrant
RUQ Right Upper Quadrant
Rx Medicine

S/P Status Post

SOB Shortness of Breath
SQ Subcutaneous
ST Sinus Tachycardia
SVT Supraventricular Tachycardia
Sx Symptom
SZ Seizure

T‐SPINE Thoracic Spine

Temp Temperature
TIA Transient Ischemic Attack
TKO To keep Open
Tx Treatment

UOA Upon our Arrival

URI Upper Respiratory Infection
UTI Urinatry Tract Infection

VF Ventricular Fibrillation
VS Vital Signs
VT Ventricular Tachycardia

WAP Wandering Atrial Pacemaker

WNL Within Normal Limits

YO (YOA) Years Old (Years of Age)

+ Positive
‐ Negative
? Questionable
~ Approximately
> Greater Than
< Less Than
= Equal

318
319
12‐Lead EKG 204 Decontamination 226
Abdominal Pain 23 Defibrillation ‐ Automated 227
Acute Dystonic 108 Defibrillation ‐ Manual 228
Adult ‐ Airway Management 30 Destination 11
Adult ‐ Dyspnea 25 DNR 18
Airway Obstruction 205 Endotracheal Tube Indroducer 229
Airway Orotracheal Intubation 206 Envenomations 48
Airway Suctioning ‐ Advanced 211 Excited Delirium 46
Airway Suctioning ‐ Basic 210 External Cardiac Pacing 230
Airway Video Laryngoscopy 208 Extremity Trauma 148
Allergic Reaction 40 Eye Trauma 147
Altered Mental Status 43 GI Bleeding 23
Antidepressants 106 Hazardous Material 81
Antipsychotics 108 Head Trauma 144
Asystole 52 Hypertensive 89
Atrial Fibrillation 65 Hyperthermia 91
Atrial Flutter 65 Hypothermia 93
Behavioral 46 Induced Hypothermia 60
Beta Blocker 109 Intercept 10
Bites 48 Interfacility 14
Blood Glucose Analysis 212 Intravenous Access 95, 253, 254, 256
Bradycardia 67 King LTS‐D 237
Burns 140 Labor 102
Calcium Channel Blockers 110 LMA ‐ Laryngeal Mask Airway 231
Carbon Monoxide 111 MAD ‐ Mucosal Atomizer Device 235
Carboxyhemoglobin SpCO Monitoring 213 MCI ‐ Mass Casualty Incident 234
Cardiac Arrest 50 Nerve Agent 87
Cardiac Arrest ‐ Traumatic 151 Obstetrics 96
Cardioversion 214 Opiate 114
CCR ‐ Cardiocerebral Resuscitation 215 Organophosphates 107
Chest Decompression 220 Orogastric Tube Insertion 236
Chest Trauma 143 Overdose 104
Chest Pain 77 Pain 115
Childbirth 102 Paramedic 10
Childbirth Complications 222 Pediatric ‐ Burns 196
Childbirth Procedure 221 Pediatric ‐ Airway Management 163
Cholinergic 107 Pediatric ‐ Allergic Reactions 166
Cocaine 113 Pediatric ‐ Altered Mental Status 168
CPAP 223 Pediatric ‐ ALTE 170
CPR ‐ Cardiopulmonary Resuscitation 224 Pediatric ‐ Bradycardia 176
Cricothyrotomoy 225 Pediatric ‐ Cardiac Arrest 171
Cyanide 84 Pediatric ‐ Dyspnea 160
Pediatric‐ General 159
Pediatric ‐ Head Injuries 200 Tricyclic 106
Pediatric ‐ Narrow Complex Tachycardia (SV 180 Venous Access ‐ Existing 253
Pediatric ‐ Newborn Resuscitation 183 Venous Access ‐ Extremity 254
Pediatric ‐ Overdose, Poisoning, Or Ingestion 186 Venous Access ‐ Intraosseous 256
Pediatric ‐ Pain Management 188 Ventricular Fibrillation 56
Pediatric ‐ Seizure 191 Wide‐Complex Tachycardia 72
Pediatric ‐ Trauma 194 WMD 87
Pediatric ‐ Wide Complex Tachycardia 179 Wound Care 257
Perinatal Emergencies 96
Pharmaceuticals 259
Physician 12
Poisonings 104
Policy Custody 118
Polymorphous Ventricular Tachycardia 75
Post‐Resuscitation 58
Pulse Oximetry 241
Pulseless Electrical Activity (PEA) 54
Radio Report 15
Rapid Sequence Airway 33, 242
Refusal 120, 122, 123
Restraints 243
Sedation 124
Seizure 125
Sexual Assault 153
Shock (Non‐Trauma) 128
Spinal Immobilization ‐ Protocol 154, 244
Spinal Immobilization ‐ Football Players 245
Splinting 247
Stroke 131, 248
Supraventricular Tachycardia 70
Sympathomimetic 113
Syncope 134
Taser 119
Temperature Measurement 249
Termination of Resuscitation 63
Tetracyclic 106
Tourniquet 250
Trauma 137
Trauma Guidelines 252