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EMT Intermediate Protocols


									      North College Hill Fire Department
           EMT-I 99 PROTOCOLS

Approved / Effective:   January 2010
Medical Director:       Amy Gutman MD;
Fire Chief:             Brian Fels FF, EMT-P

These protocols are in Compliance with current State of Ohio EMT-I 99 Guidelines, and
the Hamilton County Academy of Medicine protocols. They reflect the most up-to-date
and accepted standards of care for medical and trauma patient prehospital
management. All Basic Life Support Protocols and Policies are reflected in State of Ohio
and Cincinnati Academy of Medicine Guidelines and are to be followed by the EMT-I
practitioners in their care of the emergency patient

The completed information below verifies that the Mount Healthy and North College Hill
Emergency Medical Services Protocol Manual has been received and that the recipient
accepts the responsibility for knowing and practicing as an EMT-Basic or EMT-
Intermediate in accordance with these protocols.

__________________________________________                        _________________
Name of Recipient (Signature / Printed)                           Date Received

                                TABLE OF CONTENTS

GENERAL OPERATING GUIDELINES                                 4
HOSPITAL COMMUNICATIONS                                     11
DOCUMENTATION                                               12
DO NOT RESUSCITATE                                          13
REFUSAL OF MEDICAL ASSISTANCE (RMA)                         15
INITIAL ASSESSMENT AND MANAGEMENT                           18

HEMORRHAGIC SHOCK                                           23
MAJOR BURNS                                                 24
EYE INJURIES                                                25
HEAD AND SPINAL TRAUMA                                      26

ALTERED MENTAL STATUS                                       27
STROKE                                                      28
SEIZURES                                                    30
CHEST PAIN                                                  31
ARRYTHMIA PROTOCOLS                                         32
CARDIOGENIC SHOCK                                           39
HYPERTENSIVE EMERGENCY                                      40
RESPIRATORY DISTRESS (CHF)                                  41
RESPIRATORY DISTRESS (ASTHMA OR COPD)                       42
ANAPHLAXIS / ALLERGIC REACTION                              44
TOXICOLOGICAL EMERGENCIES                                   45
HYPOTHERMIA                                                 46
IMMINENT DELIVERY                                           47
NEONATAL RESUSCITATION                                      49
NAUSEA AND VOMITING                                         50
PAIN MANAGEMENT                                             51

AIRWAY MANAGEMENT                                           52
CPAP                                                        56
PERIPHERAL ACCESS DEVICES                                   57
INTRAOSSEOUS DEVICES                                        58
INTRANASAL DEVICES                                          59
MARK-1 KIT ADMINISTRATION                                   60
PSYCHIATRIC PROTOCOL                                        61
RESTRAINT PROTOCOL                                          63
TOURNIQUET APPLICATION                                      64
NEEDLE THORACOSTOMY                                         65

PEDIATRIC ASSESSMENT                                        67
PEDIATRIC REFERENCE CHART                                   68
MEDICATION REFERENCES                                       69
REFERENCES                                                  86


•   These guidelines have been developed to be compliant and consistent with national, regional
    and State of Ohio guidelines for the practice of prehospital emergency medical services. The
    following guidelines are to be used by the Mount Healthy and North College Hill EMT-
    Intermediates (EMT-I) to ensure quality standardized medical care, and to establish auditing
    standards for prehospital quality improvement.

•   These guidelines are specific for advanced life support interventions and are to be used only
    by EMT-Is duly authorized to perform clinical care at that time by their sponsored agency. At
    no time will the members of the Mount Healthy or North College Hill Fire Departments act
    outside of their scope of practice. No procedure or medication shall be used that is beyond
    the training or certification level of the EMS personnel.

•   Basic Life Support Guidelines are always to be initiated in conjunction with the Advanced Life
    Support guidelines. EMS agencies sponsored at the EMT-I level agree to utilize a paramedic
    mutual aid protocol.

•   Treatment provided during transport must be continued during the transfer from the
    ambulance into the emergency department. All patients must be directly turned over to the
    staff in the emergency department; prehospital personnel are not to transport patients to in-
    hospital locations (i.e. OB, cardiac catherization lab).

•   All MH and NCH prehospital providers have met all licensure requirements, and are familiar
    with the prehospital protocols both locally and for the state of Ohio. The medical director is
    expected to: review the annual continuing medical education (CME) curriculum, personally
    provide at least 12 hours of CME, annually review and revise prehospital protocols, maintain
    documentation of medical direction at the state level (ODPS and pharmacy board) and
    actively participate in continuous quality initiatives.

•   The medical director will review each provider’s file to confirm current licensing and
    certification, as well as documentation of continuing educational requirements, and
    knowledge of current protocols. Each provider’s file, of which a copy is to be kept on the
    physical location of the respective fire department’s headquarters, shall contain the following:
         o Current Ohio EMS license in good standing.
         o Copies of CME hours.
         o Copy of the signed protocols and procedural guidelines.

1. OAC 4765-16-04 EMT-I Scope of Practice

(A) In addition to the skills listed in rule 4765-15-04 of the Administrative Code, and in accordance
with section 4765.38 of the Revised Code, an EMT-intermediate may perform the following
emergency medical services only pursuant to the written or verbal authorization of a physician or
of the cooperating physician advisory board, or authorization transmitted through a direct
communication device by a physician or registered nurse designated by a physician, or in
accordance with written protocols as specified in division (C) of section 4765.38 of the Revised
         (1) Cardiac monitor strip interpretation
         (2) Manual defibrillation
         (3) Obtaining blood specimens
         (4) Subcutaneous administration of epinephrine
         (5) Administration of intravenous lifeline and fluid
         (6) Intraosseous infusion
         (7) Saline lock initiation

(B) In addition to the emergency medical services described in paragraph (A) of this rule, and in
accordance with section 4765.38 of the Revised Code, an EMT-intermediate who has completed
a training program pursuant to this chapter of the Administrative Code may perform the following
emergency medical services only pursuant to the written or verbal authorization of a physician or
of the cooperating physician advisory board, or authorization transmitted through a direct
communication device by a physician or registered nurse designated by a physician, or in
accordance with written protocols as specified in division (C) of section 4765.38 of the Revised
         (1) Administration of the following medications:
                 (a) Sublingual nitroglycerin
                 (b) Dextrose fifty percent in water
                 (c) Diphenhydramine
                 (d) Benzodiazepines
                 (e) Bronchodilators
                 (f) Naloxone
                 (g) Glucagon
                 (h) Nitrous oxide
                 (i) Nalbuphine
                 (j) Morphine sulfate
                 (k) Ketorolac, meperidine, or other analgesics for pain relief
                 (l) Any additional drug approved by the board
         (2) Administration of nebulized medications
         (3) Administration of intranasal medications
         (4) Orotracheal intubation of the apneic patient
         (5) Dual lumen airway of the apneic patient
         (6) Supraglottic airway of the apneic patient
         (7) Needle decompression of the chest
         (8) Replacement of a tracheostomy tube through a stoma
         (9) Set up and application of a 12-lead electrocardiogram, in accordance with written
         protocols, in either of the following instances:
                 (a) When the EMT-intermediate is assisting an EMT-paramedic; or
                 (b) For the purpose of electronic transmission by the EMT-intermediate, provided
                 the following conditions are met:
                           (i) The EMT-intermediate does not interpret the electrocardiogram;
                           (ii) The EMT-intermediate minimizes any delay of patient transport to
                           obtain a 12-lead electrocardiogram;

                        (iii) The EMT-intermediate utilizes the 12-lead electrocardiogram in
                        conjunction with destination protocols approved by the local medical
        (10) Any other services pursuant to a research study approved by the board under rule
        4765-6-04 of the Administrative Code and within the parameters established by the board
        for such study.

(C) A physician or cooperating physician advisory board that serves as the medical director for
any EMS organization may limit, but not exceed the scope of practice for those EMT-
intermediates who provide emergency medical services under the auspices of the physician’s
certificate to practice medicine and surgery, or osteopathic medicine and surgery, issued under
Chapter 4731 of the Revised Code.

(D) An EMT-intermediate shall not perform emergency medical services within this rule unless the
EMT-intermediate has received training as part of an initial certification course or through
subsequent training approved by the board. If certain emergency medical services, within the
EMT-intermediate scope of practice, were not included in the training specified in this paragraph,
the EMT-intermediate must have received training regarding such services approved by the local
medical director before performing those services.

(E) Effective: 05/29/2008; R.C. 119.032 review dates: 03/23/2008; Promulgated Under: 119.03;
Statutory Authority: 4765.11; Rule Amplifies: 4765.38; Prior Effective Dates: 3/23/03

2. 4765-16-03 EMT-Intermediate Continuing Education

(A) Except as otherwise provided in section 4765.31 of the Revised Code and this chapter, when
applying for renewal of a certificate to practice, a person certified as an EMT-intermediate shall
comply with one of the four following continuing education requirements by the expiration date of
the current certificate:
        (1) Completion of a total of not fewer than 60 hours of continuing education, including all
        of the following:
                  (a) Eight hours on pediatric issues;
                  (b) Four hours on geriatric issues;
                  (c) Eight hours on trauma issues, to include completion of the trauma triage and
                  transportation protocols approved by the board.
        (2) Completion of both of the following:
                  (a) An EMT-intermediate refresher training program, as outlined in rule 4765-16-
                  01 of the Administrative Code, which will satisfy forty hours of the required sixty
                  hours of continuing education;
                  (b) Completion of the remaining twenty hours of continuing education.
        (3) Current registration with the national registry of emergency medical technicians at the
        EMT-intermediate or equivalent level, and completion of continuing education on trauma
        triage and transportation protocols approved by the board.

        (4) A passing score within three attempts on an examination approved by the board,
        pursuant to section 4765.10 of the Revised Code, to demonstrate competence to have a
        certificate to practice as an EMT-intermediate renewed without completing an EMS
        continuing education program. This examination may only be taken during the last six
        months of an EMT-intermediate’s current certification period or during a board approved

(B) An individual that receives an extension of time to complete continuing education
requirements listed in paragraph (A) of this rule, must complete the requirements and submit
application to the division, no later than the expiration date of the granted extension.


1. Protocol Revision and Review
   a. These guidelines will be reviewed annually and on an as-needed basis to keep current
       with changing medical standards, treatment modalities and patient population needs
       based on the QA/CQI data.
   b. Any recommendations for revisions, deletions or additions to the guidelines should be
       made in writing to the EMS Coordinator, Fire Chiefs, and / or the Medical Director
   c. Changes made to any guidelines will require written notification of all personnel and any
       applicable training will be done in a timely manner.

2. This policy establishes guidelines for the implementation of a program to support prehospital
   providers as they strive to provide excellent patient care. These policies provide direction to
   set measurable goals and define minimum performance standards for the individuals and
   service. This consistent, fair evaluation practice will provide the routine, and meets State of
   Ohio requirements.

3. The interaction of the physician, service leadership and providers is critical for the success of
   this CQI program. All staff must understand their role, responsibilities and duties as part of
   the CQI team. Every team member shall receive an initial policy orientation and be provided
   with an opportunity for input and updates when amended.

4. The medical director conducts CQI activities and appoints individuals to perform written
   audits of patient care reports, document procedural training, and provide action plans and
   follow-up / case resolution.

5. New staff shall complete a standard credentialing orientation process that includes baseline
   medical competencies. All staff shall maintain and document ongoing-competencies as
   defined by the medical director and service directors. The medical director and the EMS
   service representative shall describe the audit process in writing defining the type and
   frequency (Appendix___).

6. All CQI discussions are confidential and limited to current staff. Significant deviations from
   protocols or standards of care will be brought to the attention of the CQI auditor. CQI auditors
   and the medical director also perform written audits. The following are reviewed quarterly or
   on an as-needed basis:
   a. Significant deviation from written protocols or standards of care.
   b. Unexplained delay of response or treatment, or scene times greater than 20 minutes.
   c. Vehicle or equipment failure.
   d. System difficulty.
   e. All advanced airways, including utilization of CPAP.
   f. All medical and trauma resuscitations.
   g. 10% of random charts.

7. A CQI audit is complete when it is signed by the providers involved, reviewed by responding
   staff and the auditor is satisfied with the loop closure.

8. The medical director, in consultation with the staff, shall establish measurable outcomes
   consistent with strategic planning goals and unique needs of the local prehospital system to
   evaluate overall effectiveness and efficiency (see Appendix….) which will be reported in
   writing to the prehospital staff and medical director bi-annually.

9. The department will utilize a patient care report (PCR) that allows for the collection of:
   a. Patient demographic data
   b. EMS vehicle information, incident location and crew

    c.   Chief complaint
    d.   Patient condition and mechanism of injury
    e.   Any treatments and response to treatment
    f.   Record of medical control contact if utilized
    g.   Patient condition on arrival at the receiving facility

10. The department will track critical patient care procedures performed including:
    1. Advanced airway management (intubation, King LT, CPAP), Defibrillation / CPR
    2. Intraosseous usage
    3. Tourniquet usage
    4. Use of restraints

11. The Medical Director is responsible for a review of the following:
    1. Death of the patient during care
    2. Cardiopulmonary arrest
    3. Repeat runs for a patient within 24 hours
    4. Runs involving application of DNR protocols
    5. Runs about which there are inquiries or complaints
    6. 10% sample of random runs

12. A periodic and systematic audit of various performance parameters shall be made to define
    "normal" department functioning so that the "abnormal" can be detected and corrections
    made, including:
    1. Response times
    2. Times-on-scene
    3. Special procedures monitoring (i.e., AED, assist with medications, advanced airways).
         Patient contact, non-transport runs
         Out-of-hospital cardiac arrest survival
         Drug and Equipment Monitoring

13. Departmental standard operating procedures and policies shall be consistent with State and
    Regional protocols and procedures, including:
    1. Treatment authority
    2. Triage
    3. Transport
    4. Air medical evacuation
    5. DNR guidelines
    6. Mutual aid
    7. Infection control
    8. Refusal of medical assistance (RMA)
    9. Dead-on-arrival
    10. Multiple casualty incidents.

1. The purpose of this policy is to clarify the roles and responsibilities of those involved in the
   development and provision of prehospital medical control. "Medical Control" is the advice and
   direction provided by a physician or under the direction of a physician to prehospital
   personnel providing medical care at the scene of an emergency or en route to a health care
   facility. Indirect medical control includes the written policies, procedures, and protocols for
   prehospital emergency medical care and transportation developed by the state emergency
   medical advisory committee, set forth in the state of Ohio and MN / NCH operational
   guidelines as approved by the Medical Director and administrative officers. Direct medical
   control is communicated between the physician and provider in real time. If orders from
   Medical Control appear to be inappropriate or outside of the provider’s scope of practice the
   EMT-I must:
   a. Clarify the order and the patient’s condition.
   b. If the physician does not alter or retract the order, the EMT-I should carry out the order
        UNLESS the EMT-I is neither credentialed nor trained to provide the intervention
        ordered, or the intervention is not listed in the current protocol.
   c. Fully document the discussion with the physician.
   d. In all cases the EMT-I will bring this matter to the attention of the EMS Coordinator and
        the Medical Director.

2. A difficult situation is created by the arrival of a physician at the scene. A different set of
   responsibilities exists when that physician has established a previous doctor-patient
   relationship as opposed to when no such relationship exists. For a licensed physician who is
   not the service Medical Director to assume control on-scene, ALL of the following must take
    a. Proof of the physician's identity and current Ohio licensure provided to the EMT-I.
    b. The physician must agree to accompany the patient to the hospital.
    c. The on-line medical control physician must be notified and agree to relinquish control to
       the on-scene physician. This can usually best be accomplished by having the medical
       control physician speak directly with the physician at the scene.
    d. The physician at the scene must agree to sign their orders.

3. If a physician has established a doctor-patient relationship (i.e. at a MD’s office), it is
   necessary that providers perform an assessment and manage the patient just as would be
   done in any other location. If the physician wishes to control the patient's management, they
   may do so may do so if communication established between on-line medical control and the
   physician on-scene, and the scene physician agrees to accompany the patient to the ED as
   well as:
   a. The physicians' full name and license number must be recorded on the run report.
   b. Orders within the scope of training and practice of the EMT-I will be carried out.
   c. Orders outside the scope of training and practice of the EMT-I will be personally carried
       out by the on-scene physician.
   d. The on-scene physician must sign their orders.
   e. The on-scene physician must accompany the patient in the ambulance to the hospital
       unless released by the on-line medical control physician. If the physician on the scene
       does not accompany the patient to the hospital, then responsibility for that patient will
       revert to the medical control physician.
   f. If control of the emergency is given to the on-scene physician, then the physician can
       only issue orders within the scope of training and practice of the EMT-I.

4. In a mass casualty situation, the on-scene physician should use his best judgment about
   whether or not to accompany the patient to the hospital. It may be appropriate to stay at the

    scene and tend to the patients remaining. These decisions must be made in consultation
    with the medical control physician.

5. A call to medical control must be initiated:
   a. about any patient who is unstable
   b. when required to do so in the applicable management protocol
   c. when there is doubt about diagnosis, treatment, or disposition of the patient
   d. for multiple casualty incidents (greater than 5 victims)
   e. for radiation or other hazardous materials incidents are encountered.

6. A call MAY be initiated:
   a. when notification will speed or improve patient care or
   b. whenever it is thought necessary by the intermediate

7. When a call is not possible, these protocols shall act as standing orders for procedures which
   may be performed by EMT-I’s. Certain procedures and medications require physician
   consultation prior to performance of the procedure or administration of the medication. These
   procedures are noted in the individual protocols.


1. Timely and appropriate communications allow prehospital personnel to obtain online medical
   control and allow the receiving facility to plan for appropriate distribution of resources,
   activate clinical response guidelines, and improve overall hospital patient flow management.

2. In complex cases involving a high acuity patient or multiple patients, early notification with
   limited information is more important than a detailed report made just prior to arrival at the

3. Any incident involving >3 patients should be considered for implementation of an Incident
   Command System (ICS).

4. Protocol:
   a. Identify your department and unit.
   b. Identify whether you wish to give report to or consult with on-line medical control. If
       requesting to speak with medical control, obtain the name or ID of the physician.
   c. Identify any special circumstance qualifiers (i.e. STEMI, Stroke Alert, HazMat).
   d. Your report should include the following:
        1. Age and gender
        2. Chief complaint and immediate pertinent history
        3. Vital signs and pertinent positive and negative assessment findings
        4. Treatment initiated and patient response
        5. Estimated time of arrival
        6. Specific needs (i.e. security, lift assistance, etc.)


1. At a minimum, all patient care documentation shall be truthful, accurate, objective, pertinent,
   legible, and complete with appropriate spelling, abbreviations and grammar.

2. Documentation shall reflect the patient’s chief complaint and a complete history or sequence of
   events that led to their request for care, detail the assessment of the nature of the patient’s
   complaints and the rationale for that assessment, reflect physical findings, a complete set of
   vital signs, a summary of all assessments, interventions and the results of the interventions
   with appropriate detail so that the reader may fully understand and recreate the events, and
   include an explanation for why an indicated and appropriate assessment, intervention, or
   action that is consistent with current protocols did NOT occur.

3. Providers shall provide a clear describe the circumstances and findings associated with any
   complex call or extraordinary situations.

4. Documentation shall remain confidential and be shared only with legally acceptable entities,
   and must be produced on any patient call.

5. Run reports will be completed prior to departing the emergency department. In the event the
   report cannot be completed prior to the unit’s dispatch to another call, the run report will be
   completed and delivered as soon as possible after that call, within that shift.

6. A copy of the run report will be left with ED Unit Coordinator or nurse receiving the patient

1. All home care Do Not Resuscitate (DNR) orders must be dated and signed by the patient
   and at least two witnesses, or a valid Ohio DNR Comfort Care / Comfort Care Arrest (DNR-
   CC / DNR-CCA) document.

2. Home care DNR orders do not expire unless the document specifies an expiration date. If
   the patient lacks capacity to make informed health care decisions on the date the DNR
   expires, then the DNR continues in effect until the patient regains the capacity to make
   informed health care decisions. A DNR signed by both parents of a minor child or by the
   spouse of a patient in a terminal condition who is no longer able to make informed decisions,
   and signed by two witnesses, may be honored. DNR orders set forth in long-term care
   facility medical records shall be signed by the attending physician and dated. DNR orders
   set forth in long-term care facility medical records shall not expire unless the document
   specifies a time for expiration. If the patient lacks capacity to make informed health care
   decisions on the date the DNR would expire, then the DNR shall continue in effect until the
   patient regains the capacity to make informed health care decisions for himself.

3. In the event a DNR is presented to an EMT, communication with a base hospital physician,
   EMS medical advisor, family physician, or physician on the scene shall be established.
   a. A DNR may be honored in accordance with the provisions of this protocol where it is
        determined that the patient is in a terminal condition and the patient is no longer capable
        of making informed decisions.
    b. A DNR may not be honored where the patient is pregnant, where withholding CPR would
       terminate the pregnancy, and where it is probable that the fetus will develop to the point
       of live birth if treatment is provided.
    c.   If the EMT believes a DNR is valid, there is no need to commence CPR while waiting for
         physician orders. If the EMT has any doubt, the EMT need not comply with the DNR (and
         may commence CPR) unless and until a physician has verbally authorized compliance.
         Such authorization shall be documented by the EMTs in the run report.

4. In the case of any doubt or reservation as to the validity or authenticity of any DNR, and absent
     authorization by a base hospital physician, EMS medical advisor, family physician, or
     physician on the scene to withhold CPR, the EMT shall provide CPR to the patient and shall
     document the reasons for not complying with the DNR.

4. In the event resuscitation is initiated on a patient and then a valid DNR is subsequently
   identified, resuscitation may be terminated in compliance with that DNR upon specific verbal
   authorization from a base hospital physician, EMS medical advisor, family physician, or
   physician on-scene. Documentation shall be made on the run sheet indicating the events that
   happened set forth in chronological order, including the authorization to stop CPR in the field.
   In the event a DNR is identified after a patient has been intubated, the advanced airway shall
   not be removed in the prehospital setting. If the initial resuscitation has restored cardiac
   rhythm, the patient should be transported to the nearest appropriate medical facility with no
   further procedures or pharmacological measures undertaken, except by authorization from
   the base hospital physician, medical advisor, or attending physician. Communication with a
   physician must be established, and the name of the physician documented in the run report.

5. If possible, a copy of the DNR shall be attached to the medical record.

1. Procedure for determination of death for adults >age 15, non-mass casualty situations.

2. All clinically dead patients will receive all available resuscitative measures including
   cardiopulmonary resuscitation unless contraindicated by one of the exceptions defined below.
   A clinically dead patient is defined as any unresponsive patient found without respirations and
   without a palpable carotid pulse.

3. The provider with the highest level of valid prehospital certification, and who has direct
   communication with medical control, affiliated with an EMS organization present at the scene
   will be responsible for, and have the authority to direct, resuscitative activities.

4. In the event there is a personal physician present on-scene, who has an ongoing relationship
   with the patient, that physician may decide if resuscitation is to be initiated. The physician
   must produce identification showing his name and license number. That physician may
   pronounce death on a clinically dead patient in the presence of prehospital personnel. This
   physician pronouncement relieves the EMS personnel at the scene of responsibility to begin
   or continue resuscitative measures. Medical Control will be notified and the information
   documented on the PCR. If the physician decides resuscitation is to be initiated, usual
   procedures will be followed.

5. Resuscitation must be started on all patients who are found apneic and pulseless unless: The
   patient has a valid Do Not Resuscitate Order (DNR), shows signs of decomposition,
   decapitation, hemicorporectomy, or incineration, dependent lividity and / or rigor mortis. This
   does not apply in cases of hypothermia, lightning strike or drowning.

6. Reposition the airway and look, listen, and feel for at least 30 seconds for spontaneous
   respirations or auscultate for lung sounds. If ventilations are present, establish resuscitative
   care immediately. If respiration is absent: Palpate the carotid pulse for at least 30 seconds or
   auscultate for heart sounds. If pulses and/or heart sounds are present, establish resuscitative
   care immediately. If pulse or heart sound is absent: examine pupils of both eyes with a light.
   If pupils react, establish resuscitative care immediately. If both pupils are non-reactive this
   could be consistent with injuries incompatible with life and the patient requires additional

7. In cases of suspected sudden infant death syndromes (SIDS), where there are obvious signs
   of death (no vital signs, frosted corneas, mottling and cool skin, evidence of decomposition),
   notify the local police and the coroner. If possible, do not move the body or disturb the scene
   more than necessary for the initial assessment.

8. Consider the needs of survivors when considering the discontinuation of resuscitation,
   especially if crisis management services may be needed. Scene management may prevent
   withholding resuscitation, especially in cases where prehospital personnel may feel
   personally threatened by family members or bystanders.

9. Documentation of all encounters with the patient’s family, personal physician, medical
   examiner, law enforcement, and medical control should be on the PCR.


1. The non-transported patient remains one of the most litigious and dangerous patients
   encountered, as each of these patients has the potential to have a poor outcome due to
   limited medical assessment and management. Excellent and complete documentation is the
   key to limiting liability. All patients who have activated the prehospital system should be
   encouraged to complete their medical evaluation via transportation to an appropriate facility.

2. The U.S. Supreme Court recognized that a "person has a constitutionally protected liberty
   interest in refusing unwanted medical treatment" even if refusal could result in death.
   Although courts protect a patient's rights to refuse care, "preservation of life, prevention of
   suicide, maintenance of the ethical integrity of the medical profession, and protection of
   innocent third parties" also may be considered when evaluating a patient's wish to refuse
   treatment. Each case must be examined individually.

3. There are three components to a valid RMA. Absence of any of these components will likely
   result in an invalid RMA:
   A. Competence: In general, a patient who is an adult or a legally emancipated minor is
       considered legally competent to refuse care. A parent or legal guardian who is on-scene
       may refuse care on his or her minor children’s behalf.

    B. Capacity: In order to refuse medical assistance a patient must have the capacity to
       understand the nature of his or her medical condition, the risks and benefits associated
       with the proposed treatment, and the risks associated with refusal of care.

    C. Informed Refusal: A patient must be fully informed about his or her medical condition, the
       risks and benefits associated with the proposed treatment and the risks associated with
       refusing care.

4. Definitions:
   A. A “Person” is defined as any individual encountered by prehospital personnel who does
       not manifest any overt evidence of illness or injury and refuses any assessment by
       prehospital providers (i.e. called to scene of an “unconscious / unresponsive patient” to
       find a person sleeping on a bench). Refusals do not need to be signed on “persons”.

    B. A “Patient” is defined as any individual aged >18 encountered by prehospital providers
       who demonstrates suspected illness or injury, involved in an event with significant
       mechanism that could cause illness or injury, requests care or evaluation, or an altered
       level of consciousness. An adult includes “emancipated minors”, who are defined as
       persons under the age of 18 who are married, pregnant, or who is determined by a court
       of competent jurisdiction to be legally able to care for him or herself.

    C. A “Patient Relationship” exists as a result of EMS being summoned and prehospital
       personnel making contact with a patient.

   D. “Refusal of Service” is defined as applying to patients who are refusing any prehospital
       services including assessment, treatment, or transportation.
5. Any patient may decline all or part of assessment, treatments, or transportation by
   prehospital personnel in any legal adult, without the following: impaired capacity to
   understand the nature of their medical condition due to, but not limited to, alcohol, drugs or
   medications, mental illness, traumatic injury, or grave disability.

6. When it is determined that a patient has refused assessment, treatment, or transport, the
   provider will complete a refusal of EMS service form (see Appendix>>>>). In the event a

    patient is refusing services the provider with the highest medical authority on scene shall
    attempt the following and document all findings:
     Obtain a history of the event and prior medical history including medications.
     Perform a physical assessment including 2 sets of complete vital signs 15 minutes apart
        in time.
     Determine the patient is competent and has an understanding of the risks of refusal.
     Explain the risks of refusal of EMS service, including death.
     Explain the benefits of EMS service.
     Offer treatment and transportation to the nearest appropriate facility.
     Advise the patient to seek medical attention for complaint.
     Advise patient to call 911 if condition worsens or if they desire EMS Services.

7. For patients refusing part or all of the assessment, treatment, or transportation and who in the
   judgment of the providers, requires assessment, treatment, or transportation, consider:
   A. Have your partner offer assessment, treatment, or transportation.
   B. Contact medical control for assistance in further assessment of the patient.
       Communication with medical control may require communication between the physician
       and patient.
   C. For a patient meeting “trauma criteria,” a designated Trauma Center will be contacted in
       all cases of patient refusal of assessment, treatment, or transportation.
   D. If the patient is a danger to themselves or others, or the provider is concerned that the
       patient cannot make a competent decision, contact law enforcement officials as well as
       medical control.

8. If the patient meets all criteria to competently and legally sign a refusal form, complete and
   explain the refusal of EMS service form to the patient.
   A. A signature must be obtained from the patient and a witness if possible.
   B. If patient is a minor or incompetent, the legal guardian must be present prior to allowing
        the refusal to be signed.
   C. Each item described above shall be documented on the prehospital care report (PCR).
        1.) Patient’s Name, Date, Incident Number, and Incident Location
        2.) Criteria for refusing care
        3.) A signed refusal form, with the patient and witnesses’ signatures and date
        4.) If patient refused to sign, then a check box is necessary for “refusal to sign”, and must
            be accompanied by 2 witness signatures.
        5.) ID of provider, signature line, date, and ID number

1. Historical Findings:
   A. Decreased level of consciousness without suspected trauma.
   B. History of insulin-dependent diabetes mellitus.
   C. Following treatment, patient is conscious, alert and oriented to person, place, time, and
       events, and denies transport to hospital.
   D. No other associated findings of serious illnesses or circumstances that may have
       contributed to the hypoglycemic episode, including excessive alcohol consumption,
       shortness of breath, chest pain, headaches, etc.
   E. The patient’s history reveals circumstances that may have contributed to the
       hypoglycemic episode such as lack of oral intake or an insulin reaction.
   F. Not on oral hypoglycemic medication such as glypizide, glyburide, or chlorpropamide.

2. Physical and EKG Findings:
   A. Patient has a decreased level of consciousness.
   B. SBP equal to or greater than 90mmHg or child with normal perfusion.
   C. Rapid glucose test of less than 60mg/dl.
   D. EKG Findings: heart rate > 60 beats per minute, not VT or SVT.

3. Protocol:
   During treatment under the AMS protocol, the patient responds in <10 minutes to oral or IV
   glucose (D50W) to normal level of consciousness.
   A. Repeat rapid glucose test is at least 100mg/dl.
   B. The patient is given written instructions for follow-up care prior to being released.
   C. The patient is released to the care of a responsible adult who will remain with the patient
       as an observer for a reasonable period of time and can call 911 should the symptoms
4.   Notes:
     A. Patients with extensive PMH medical history or signs and symptoms unrelated to
        diabetes mellitus should be strongly encouraged to be transported.
     B. If the patient is on an oral hypoglycemic medication the hypoglycemic episode may last
        hours or days. Patients on oral hypoglycemic agents should be strongly encouraged to
        be transported, regardless of their response, to field treatment.
     C. When treating patients who warrant transportation based on the above criteria but who
        refuse transport, EMT-I shall contact medical control for assistance.
     D. Instructions for follow-up care should include the following:
            Take action to prevent a recurrent episode such as: remain in the care of an adult
             observer, consume a light meal to maintain a sufficient blood glucose level, monitor
             blood glucose, and advise personal physician of this episode.
            Watch for signs and symptoms of another episode including: personality change,
             weakness and fatigue, irritability, anxiousness, unable to awaken, dizziness, extreme
             hunger, trembling, impaired vision, pounding heartbeat, headache, excessive
             sweating, or dizziness. If another episode occurs, contact 911 immediately.
            EMS should provide the patient with both verbal and written instructions on follow-up
             care following patient refusal of transport.
     E. A signed and witnessed refusal must accompany any non-transported patients, as per
        the Non-Transport Policy.

1. Scene Evaluation
   A. Review of dispatch information
   B. Maintain appropriate BSI precautions. Assure scene safety in all patient encounters
   C. Determine mechanism of injury or nature of illness
   D. Obtain from parents/family/bystanders if necessary
   E. Determine number and location of patients
   F. Determine need for additional resources

2. Initial Assessment
   A. General impression of patient
   B. Assess mental status (GCS or AVPU).
   C. Maintain spinal immobilization as needed while assessing ABCDE
   D. Identify priority patients

3. Initiate Critical Treatment with a Simultaneous Secondary Assessment
   A. Rapid head-to-toe examination including a neurological assessment / GCS.
   B. Pupillary response
   C. Assess vital signs using age and size-appropriate equipment

4. Obtain a medical history (obtain from parents/family/bystanders if necessary)
    S - symptoms - assessment of chief complaint
    O – onset and location
    P – provocation
    Q – quality
    R – radiation, R – referred, R – relief
    S – severity
    T – time
    A - allergies
    M – medications
    P - past medical history
    L - last oral intake
    E - events leading to illness or injury

5. Other Assessment Techniques
   A. Glucose determination
   B. 12 lead EKG


1. The goal of any trauma patient assessment and transportation guideline is to facilitate
   "whatever gets the patient to the most appropriate level of care in the most expeditious
   manner.” There is strong evidence that shows that reducing the time interval from the
   moment of injury to delivery/arrival at a definitive care site will reduce morbidity and mortality.
   These guidelines were developed to assist the emergency responder to determine what
   constitutes a trauma patient and where to transport the trauma patient. In the prehospital care
   environment, time, distance, patient condition, and level of care are important variables when
   making decisions for transporting the trauma patient. These variables are frequently hard to
   assess in the field and are ever changing. These guidelines are meant to supplement, but not
   replace the judgment of the on-scene EMT. The Tri-state Trauma Coalition encourages all
   Fire and EMS Agencies and their personnel to review the Trauma Patient Assessment and
   Transportation guidelines on an annual basis.

2. These Assessment and Transportation Guidelines should be used to: determine if the patient
   qualifies as a trauma patient and determine where and how the trauma patient is to be
   transported. Rapid field evaluation, treatment, and transport are vital to the overall outcome
   of the trauma patient. After the trauma patient's extrication, the on-scene time should be
   limited to <10 minutes, except when there are extenuating circumstances.

3. Trauma Patients, as identified in this document, should be transported to the nearest trauma
   center. “Trauma Center” means a facility with a current ACS verification certificate, or a
   hospital meeting ACS guidelines with a known ACS verification in process. The Regional
   Trauma Plan is an inclusive model that integrates the resources of all facilities throughout the
   region in providing care to the severely injured trauma patient.
    A. Level I and II Trauma Centers offer the same level of care for the incoming trauma
       patient and may be used interchangeably. Level III Trauma Centers offer services,
       based on individual hospital resources that provide for initial assessment,
       resuscitation, and stabilization, which may include emergency surgery for the trauma
       patient. The Level III Trauma Center has established transfer agreements with the
       nearest regional Level I / II Trauma Centers.
    B. In the areas of the region where the Level III Trauma Center is the only verified
       trauma facility, (within 30 minutes ground transport time), this hospital will act as the
       primary receiving facility for the critically injured patient.
    C. In areas where the patient is in close proximity to a Level III Trauma Center and a
       Level I / II trauma center is within the 30 minute transport guidelines, the provider
       should exercise professional judgment as to whether the patient would benefit more
       from an immediate evaluation and stabilization at the proximate Level III trauma
       center or from direct transport to the Level I or II trauma center.
    D. Other general acute care hospitals not designated as Trauma Centers, but having
       24-hour ED capabilities, can and should be used in certain situations to stabilize the
       critically injured trauma patient. In areas where there are no verified Trauma Centers
       (within 30 minute ground transport time) the general acute care hospital will act as
       the primary receiving facility for all critically injured trauma patients. (See air medical
       utilization guidelines). General acute care hospital will have established Transfer
       Agreements with the nearest Level I and II Trauma Centers in the Region.
    E. The pediatric trauma patient should be transported to the nearest Pediatric Trauma
       Center (Children’s Hospital).
    F. All pregnant trauma patients should be transported to the nearest adult Trauma

4. Use of on-line, active medical control for medical direction in the field, particularly for difficult
   cases, is encouraged. Pre-arrival notification of the receiving facility is essential!

5. Adult Trauma Assessment and Transportation Guidelines
   A. Physiologic Criteria:
      1. Signs of shock accompanied by a pulse >120 and / or SBP <90. Geriatric patients
           may be in shock with a SBP >90.
      2. Airway or Breathing Difficulties including a respiratory rate of <10 or >30, or
           placement of an advanced airway.
      3. Neurologic Considerations: Evidence of Head Injury, GCS <13, AMS during
           examination or thereafter; LOC >5 minutes, Failure to localize pain or Suspected
           spinal cord injury (paralysis due to an acute injury; sensory loss)
    B. Anatomic Criteria:
       1. Penetrating trauma to the head, chest or abdomen, neck and extremities proximal to
          knee or elbow.
       2. Injuries to the extremities with the following physical findings: amputations proximal to
          the wrist or ankle, visible crush injury, fractures of two or more proximal long bones,
          evidence of neurovascular compromise
       3. Suspected tension pneumothorax
       4. Injuries to the head, neck, or torso with the following physical findings: visible crush
          injury, abdominal tenderness, distention, or seat belt sign, pelvic fracture, flail chest.
       5. Signs or symptoms of spinal cord injury.
       6. Burn injury >10% TBSA and potential for other associated traumatic injuries.
    C. Significant mechanisms of injury and / or age >60 years old should prompt a high index
       of suspicion for a serious underlying injury.

6. Geriatric Trauma Assessment and Transportation Guidelines
    A. Patients aged 70 or greater are classified as “Geriatric Trauma Patients”. Geriatric trauma
    patients should be triaged for evaluation in a trauma center for:
        a.   Glasgow Coma Score <15 with suspected traumatic brain injury
        b.   Systolic blood pressure <100 mmHg
        c.   Falls with evidence of traumatic brain injury (even from standing position)
        d.   Pedestrian struck by motor vehicle
        e.   Known or suspected proximal long bone fracture sustained in a motor vehicle crash
        f.   Multiple body regions injured
        g.   Special consideration for evaluation at a trauma center if they have diabetes, cardiac
             disease, pulmonary disease (COPD), clotting disorder (including anticoagulants),
             immunosuppressive disorder or require dialysis.

7. Pediatric Trauma Assessment and Transportation Guidelines
    A. Physiologic Criteria:
       1. Significant signs of shock (weak pulses, pallor) accompanied by: age-inappropriate
          tachycardia, bradycardia or hypotension
       2. Airway/Breathing difficulties including: the need for an advanced airway, tachypnea,
          stridor, hoarse voice or difficulty speaking, significant grunting, retractions, cyanosis or
          need for supplemental oxygen
       3. Neurologic considerations: Evidence of head injury, GCS ≤ 13 or less than “Alert” on
           the AVPU scale, AMS during examination or thereafter; LOC > 5 minutes, failure to
           localize pain, suspected spinal cord injury (paralysis or alteration in sensation)

   B. Anatomic Criteria:
      1. Penetrating trauma to the head, chest or abdomen, neck and extremities proximal to
         knee or elbow.
      2. Injuries to the extremities with the following physical findings: amputations proximal to
         the wrist or ankle, visible crush injury, fractures of two or more proximal long bones,
         evidence of neurovascular compromise
      3. Suspected tension pneumothorax
      4. Injuries to the head, neck, or torso with the following physical findings: visible crush
         injury, bdominal tenderness, distention, or seat belt sign, pelvic fracture, flail chest.
      5. Signs or symptoms of spinal cord injury.
      6. Burn injury >10% TBSA and potential for other associated traumatic injuries.

   C. Other considerations:
       1. Significant mechanism of injury should prompt a high index of suspicion and should
          be considered in the evaluation. Specific mechanisms include the improperly
          restrained child in MVC (airbag injuries included), and ATV collisions.
       2. Special situations that may require the resources of a pediatric trauma center:
          congenital defects, chronic respiratory illness, diabetes, bleeding disorder or
          anticoagulants, immunosuppression.
       3. Transport by ground to the Pediatric Trauma Center if less than <30 minutes via
          ground, with the exceptions of the uncontrolled airway or traumatic arrest.

8. General Principles of Ground Transport:
   A. If the patient is by ground transport <30 minutes from a Trauma Center, then proceed
      directly to that trauma center. If the patient is >30 minutes from a trauma center, proceed
      to the nearest appropriate facility. If there is an uncontrolled airway, high potential for an
      unstable airway (facial burns), or a blunt traumatic arrest that initially had vitals on scene,
      or CPR is in progress, proceed directly to the nearest appropriate facility.

   B. Patients should be transported to the nearest appropriate facility if any of the following:
      i. Airway is unstable and cannot be controlled/managed by conventional methods
      ii. Potential for unstable airway, (i.e., facial/upper torso burn)
      iii. Blunt trauma arrest (no pulses or respirations)
      iv. Patient does NOT meet criteria for a trauma patient as defined above.

9. General Principles of Air Medical Transportation:
   A. Prolonged delays at the scene waiting for air medical transport should be avoided. If air
      medical transportation is unavailable (i.e. weather conditions), the patient should be
      transported by ground guidelines as listed above.

   B. Air Medical Programs share the responsibility to educate EMS units and facilities on
      appropriate triage. They should also institute an active utilization and quality review
      program that provides feedback to EMS units.

   C. Patients with uncontrolled ABC's should be taken to the closest appropriate facility if that
      can be achieved prior to the arrival of air medical transport. Air transport, if dispatched to
      the scene, should be diverted to the hospital if the patient appeared appropriate for air
      transport but the decision was made to transport to the nearest facility (non-trauma
      center) in the interim.

   D. Traumatic cardiac arrest due to blunt trauma is not appropriate for air transport. Consider
      Air Transport in the following: Prolonged extrication, multiple patients, or time/distance

factors: If transportation time to a trauma center by ground is >30 minutes AND the
transport time by ground to the nearest trauma center is greater than the total transport
time to a trauma center by helicopter. Total transport time includes time at scene waiting
for helicopter and transport time to trauma center. In the rural environment, immediate
transfer with severely traumatized patients by air medical transport may be appropriate
and should be encouraged if it does not significantly delay intervention for immediate life-
threatening injuries.

I.   Historical Findings:
     A. History of or suspected hemorrhage.

II. Physical Findings:
    A. Active severe bleeding with signs of shock
    B. Signs of poor tissue perfusion such as AMS, cool clammy skin, delayed capillary refill,
       weak or absent radial pulse
    C. (Adult) SBP < 90 mmHg; (5 -10yo) SBP < 85 mmHg; (<5yo) SBP <75 mmHg

III. Protocol:
     A. The key to good prehospital care of the hemorrhagic shock patient is rapid transport to
        definitive care. Except when the patient is entrapped, scene time should not ordinarily
        exceed 15 minutes. A reasonable performance goal for a prehospital system is that 90%
        of patients who have traumatic shock and are not entrapped should be delivered to a
        definitive trauma care facility within 30 minutes from the time of injury.

     B. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use
        airway adjuncts as necessary. Administer high flow oxygen. Use 100% oxygen at high

     C. Identify and treat life-threatening breathing problems such as open chest wounds, and
        control active external bleeding. Monitor and begin transport immediately and call for
        paramedic backup if available. Patients with penetrating chest trauma and abnormal vital
        signs are especially in need of immediate transport to definitive care. Application and
        inflation of the MAST at the scene has been shown to add about 4 minutes to scene time
        without improving outcome. MAST use is contraindicated in penetrating chest trauma.

     D. If patient is a victim of blunt trauma or penetrating injury to the head or neck, provide
        spinal immobilization.

     E. Obtain vital signs, including GCS / AVPU and glucose and cardiac monitoring. Obtain 12
        lead EKG if possible.

     F. Without stopping transport, initiate 2 large bore IV or an IOs and consider a 500 bolus if
        the patient has AMS. In the child, 20 cc/kg is an appropriate bolus, followed by an
        additional 10cc/kg. Reassess vital signs, perfusion status, and lung sounds every 5
        minutes. Watch for signs of fluid overload.

     G. Contact medical control with an abbreviated report while en-route. Continue secondary
        and notify medical control of significant changes in patient status.


I.   Historical Findings:
     A. Any patient with a burn or electrical injury, including a lightening strike.
     B. Important historical information: any inhalation, chemical or closed space exposure,
         duration of exposure, time elapsed since burn, significant

II. Physical Findings:
    A. Second degree burns greater than 20% of body surface
       area, OR
    B. Third degree burns greater than 15% of body surface
       area, OR
    C. Singed nasal or facial hair, soot or erythema of mouth, or
       respiratory distress.

III. Protocol:
     A. Evaluate scene for safety, and remove patient from source
        of burn including clothing.
     B. Burn victims have often suffered other trauma. These patients should primarily be
        managed as multiple trauma patients.
     C. Maintain airway and administer oxygen at high flow and high concentration preferably by
        non-rebreather face mask at 12-15/min.
     D. If patient is unconscious or has any respiratory distress, provide an advanced airway.
     E. Obtain vital signs and place on cardiac monitor. Obtain a 12 lead if possible.
     F. Initiate IV of normal saline. While many burn patients will require large amounts of IV fluid
        over the first 24 hours, they do not require large boluses of IV fluid prior to arrival at the
        hospital. It is easy to fluid overload the bum patient.
     G. Remove all prostheses, rings, and constricting bands from all extremities.
     H. Cover burns with clean, dry sheet. Keep the burned patient warm. It is important to avoid
        hypothermia since the skin injury disables much of the body's heat conservation
        methods. Only burns of less than 10% of body surface area should be treated with local
        cooling such as wet dressings.
     I.   Consider the administration of IV/IM/IO morphine for pain               in   alert   and
          hemodynamically stable patients, per Pain Management protocol.
     J.   Transport patient to an appropriate facility capable of treating major burns, and notify the
          receiving facility. Patients should not be transported initially to Shriner’s Hospital until
          they have had a trauma evaluation.
     K. Consider carbon monoxide poisoning if the patient has headache, dizziness, nausea,
        vomiting, AMS, syncope, or chest pain or was trapped in a closed space.

I.   Historical Findings:
     A. An actual or suspected eye injury, foreign body sensation or pain in eye.

II. Physical Findings:
    A. Visible foreign body or visible globe laceration, light sensitivity, poorly reactive or non-
       reactive pupil.

III. Protocol:
      A. If there is an impaled object, stabilize it in place.
     B. If there is evidence of a penetrating eye injury such as visible globe laceration or fluid
        draining from the globe, cover the affected eye with a patch. Do not press on the globe.
     C. If the patient has a chemical exposure eye or a non-penetrating foreign body in the eye:
         1. Instill two drops of tetracaine into the affected eye.
         2. Warn the patient not to rub the eye while the cornea is anesthetized, since this may
            cause corneal abrasion and greater discomfort when the anesthesia wears off.
         3. If there has been a chemical exposure, begin eye irrigation by instilling copious
            amounts of tap water or normal saline solution.
         4. After 20 minutes, a second dose of tetracaine may be given if needed.
     D. Eye injuries can cause a great deal of patient anxiety. Provide reassurance and morphine
        IV/IM/IO as per the Pain Management Protocol.
     E. When not contraindicated by other injuries or need for spinal immobilization, then
        transport the patient with the head of the bed elevated at least 30 degrees.

I.   Historical Findings:
     A. Loss of consciousness following head injury
     B. History of MVC, diving accident, fall, or other trauma

II. Physical Findings:
    A. Head contusions, abrasions, or lacerations
    B. Fluid or blood from the nose, ears, or mouth
    C. AMS
    D. Loss of sensation or movement
    E. Pain in back or neck.
    F. Restlessness / anxiety, which can be related to both a head injury and hypoxia.
    G. No signs of shock. If shock present, refer to Hemorrhagic Shock protocol. Shock is not
       usually due to isolated head injuries. If patient is hypotensive, consider other causes.

III. Protocol:
     A. Rapidly assess airway adequacy and ventilation, administer high flow oxygen and
        support ventilations as needed. Position and open the airway maintaining C-spine
        immobilization. Use airway adjuncts as necessary.

     B. Obtain a full set of vital signs including GCS / AVPU, glucose and cardiac monitoring.
        Obtain a 12 lead EKG if possible. Repeat vitals every 5 minutes.

     C. If AMS, consider the need for an advanced airway after contact with medical control. If a
        head injury is present, consider gentle hyperventilate.

     D. Immobilize patient's C-spine with rigid cervical collar, long back board, and immobilize the
        head such that the patient's head is secured to the backboard. In any multiple trauma
        patient, spine trauma should be assumed until proven otherwise in an ED.

     E. Begin transport immediately and call for paramedic backup if available, and contact
        Medical Control.

     F. Establish large bore IV with Normal Saline at keep open rate.

I.   Historical Findings:
     A. Decreased level of consciousness without suspected trauma

II. Physical Findings:
    A. Decreased LOC
    B. SBP >90mmHg, or child with normal perfusion
    C. EKG findings: Heart rate greater than 60 beats per minute, no VT or SVT.

III. Differential Diagnosis:
     1. Shock                                                       7. Hypovolemia
     2. Electrolyte Imbalance (including abnormal glucose)          8. Hypoxia / Hypercarbia
     3. Ingestion (including toxins, drugs)                         9. Seizure
     4. Hypertension / Stroke                                       10. Infection
     5. Acute Coronary Syndrome / Arrhythmia                        11. Pulmonary Embolism
     6. Psychiatric Disorder                                        12. Other

     A. Although alcohol is a common cause of AMS, it is a rare cause of unresponsiveness. Do
        not let intoxication cloud your judgment. Assume that the intoxicated patient has a
        serious medical / traumatic problem and treat accordingly.
     B. If patient is on oral hypoglycemics the hypoglycemic episode may last days. Patients
        should be strongly encouraged to come to the hospital for evaluation, regardless of their
        response to treatment (See IDDM Refusal of Medical Assistance).

IV. Protocol:
    A. Maintain airway and administer oxygen as needed by cannula, NRB or BVM. Consider
        advanced airway if necessary.
     B. Place patient on monitor and obtain rhythm strip and if possible a 12 lead EKG. If
        arrhythmia present, proceed to appropriate protocol.
     C. Monitor vital signs every 5 minutes. Establish IV normal saline.
     D. Test glucose with rapid glucose assay.
     E. If rapid glucose test result is less than 60mg/dl, then administer:
            Adults: Glucose 1 ampule (25 grams) D50W
            Pediatrics between1-6 yo D25W 2cc/kg. Infants <1 yo D10W 2-4cc/kg IVP
            Prepare D25W by diluting 1cc/kg of D50W with 1cc/kg of sterile water = D25W with a
             volume of 2cc/kg. Prepare D10W by mixing 8cc of D25W with 92cc of normal saline.
     F. If rapid glucose test result is less than 60mg/dl and peripheral IV not obtained after 2
        attempts / 5 minutes, administer glucagon 1mg IM (pediatrics <6 yo = 0.5mg IM).
        Glucagon should improve the patient’s level of consciousness within 10 minutes. After
        glucagon administration, continue to attempt IV access.
     G. If the patient has a history of, or signs of, a possible narcotic overdose such as pinpoint
        pupils, slow respirations, needle tracks, or injection paraphernalia, administer naloxone
        (Narcan) 0.4-2.0mg IV/IM/IN/IO (pediatrics 0.01mg/kg up to 2.0mg). Consider patient
        restraints prior to Narcan for provider safety.
     H. Note patient response to medication and begin transport to hospital after contacting
        medical control.

I.    Historical Findings:
      A. Patient has altered mental status.
      B. Loss of clear speech.
      C. Altered neurological function without suspected trauma.
      D. MAY have past history of stroke, TIA or hypertension.

II. Physical Findings:
    A. Altered mental status. May range from dizziness to complete unresponsiveness.
    B. Speech disturbances - slurred, garbled, or incomprehensible speech or complete loss of
    C. Weakness or paralysis on ONE side of the body or weakness, paralysis, or loss of
       expression on ONE side of the face.
    D. Normal Glucose

III. Protocol:
     A. Maintain airway and administer oxygen at high flow and high concentration oxygen.
      B. If patient has an altered level of consciousness, place the patient in the left lateral
          recumbent position with the head and chest elevated. Place the patient's affected or
          paralyzed extremity in a secure and safe position during patient transport.
      C. Place patient on a cardiac monitor, and perform a 12 lead EKG.
      D. Establish IV saline lock.
      E. Determine the blood glucose. If blood glucose is < 60 mg/dl, administer 25 grams of 50%
          dextrose by intravenous push, or refer to AMS protocol for further instructions.
      F. Rapid transport and prehospital notification, including time of the onset of the patient's
          symptoms (when was the patient last seen being “normal”).
      G. Perform the Cincinnati Prehospital Stroke Scale
      H. Serial vitals every 5 minutes.

Cincinnati Prehospital Stroke Scale
CPSS must be combined with a rapid glucose test to rule out both hypoglycemia and stroke. Any
score that is not 0/3 is considered a potential stroke patient and should be rapidly transported.

                          Cincinnati Prehospital Stroke Scale (CPSS)
       Sign/Symptom               How Tested                   Normal                  Abnormal
                                                                                 One side of the face
                             Have the patient show      Both sides of the face
     Facial Droop                                                                does not move as well
                             their teeth or smile       move equally
                                                                                 as the other
                             The patient closes their                            One arm either does
                                                        Both arms move the
                             eyes and extends both                               not move or one arm
     Arm Drift                                          same or both do not
                             arms straight out for 10                            drifts downward
                                                        move at all
                             seconds                                             compared to the other

                             The patient repeats        The patient says         The patient slurs words,
     Speech                  “The sky is blue in        correct words with no    says the wrong words,
                             Cincinnati”                slurring of words        or is unable to speak

   1. Patients who experience transient ischemic attack (TIA) develop most of the same signs
       and symptoms as those who are experiencing a stroke. The signs and symptoms of TIAs
       can last from minutes up to one day. Thus the patient may initially present with typical
       signs and symptoms of a stroke, but those finding may progressively resolve. The patient
       needs to be transported to the hospital for further evaluation.
   2. Some patients who have had a stroke may be unable to communicate but can
       understand what is being said around them.
   3. Hypertension in stroke patients should not be treated in the prehospital setting.
       Observations show that hypertension in a stroke patient tends to improve without drug
   4. New therapies for stroke are now available. However, successful use is only possible
       during a short time window after the start of symptoms. Early notification of the receiving
       hospital and minimizing scene time are important parts of a strategy to treat patients

I.   Historical Findings:
     A. Patient is suspected to have had a grand mal seizure based upon description of
         eyewitnesses, incontinence of urine or stool, or history of previous seizures

II. Physical Findings:
    A. Witnessed or current seizure activity
    B. Decreased level of consciousness
    C. Bites to the lateral aspect of tongue
    D. Musculoskeletal trauma (if patient fell)

III. Protocol:
      A. Maintain airway, administer high flow-high rate O2 via non-rebreather mask. Use a
         nasopharyngeal rather than an oral airway if possible. Protect from aspiration.
     B. Immobilize c-spine if evidence for trauma is present; otherwise position the patient in the
        lateral recumbent position.
     C. Suction as needed.
     D. Obtain vital signs and apply cardiac monitor.
     E. Establish IV with normal saline at keep open rate.
     F. Check glucose level, if less than 60mg/dl, administer 25g D50W (child less than 6 years of
        age D25W 2cc/kg) IVP.
     G. If there is suspicion of narcotic overdose, then administer naloxone (Narcan) 2mg
        (children 0.1mg/kg, maximum of 2.0mg).
     H. If the ADULT patient is currently displaying seizure activity, administer Versed 2-4mg
        IV/IM/IN/IO until seizure resolves or a total of 8mg is given. Be prepared to support the
        patient’s respirations if necessary.
     I.   If the PEDIATRIC patient is currently displaying seizure activity, administer Versed
          0.1mg/kg IV/IM/IN/IO to a maximum of 5mg. Be prepared to support the patient’s airway
          and breathing if necessary.
     J.   Transport all patients experiencing first-time seizure activity, as well as patients with
          known seizure disorders if seizure is different than normal or continues longer than 3-5
     K. New seizures in patients over the age of 50 years of age are often caused by cardiac
        arrhythmias. Obtain an EKG if there are any concerns for underlying arrhythmia.
     L. Most patients with seizures need only oxygen and attention to airway management and
        will not need treatment with Versed.


I. Historical Findings:
     A. Age >25 years old. Be aware that congenital and drug-related causes of chest pain exist
          in the pediatric patient.
    B. Chest pain description suggests cardiac origin (heaviness, pressure, and tightness, dull)
       and may be accompanied by shortness of breath, diaphoresis, nausea, vomiting, or
       weakness and is not clearly pleuritic or musculoskeletal. If doubt exists, treat as cardiac.
II. Physical Findings:
    A. Pulse between 60 and 140 beats per minute.
III. Differential Diagnosis:
      A. Non-cardiac chest pain, Respiratory, Gastrointestinal, Pulmonary Embolus, Cardiogenic
          shock, COPD, Arrhythmia
IV. Protocol:
    A. Assure airway patency and administer 02 at high flow and high concentration, preferably
       by non-rebreather facemask at 12-15/min.
    B. Place patient on cardiac monitor and run a rhythm strip. If not a sinus rhythm between
       60-140bpm, go to Arrhythmia Protocols.
    C. Monitor vital signs every 5 minutes.
    D. Perform a 12 Lead ECG and transmit the ECG if capable to the receiving hospital. If
       unable to transmit the ECG then notify if there is a STEMI alert on the interpretation line.
    E. Determine whether the patient has taken any Erectile Dysfunction medications i.e.
       sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis) in the previous 24 - 72 hours.
       For sildenafil (Viagra) nitroglycerine may be given after 24 hours. If the patient has taken
       vardenafil (Levitra) nitroglycerin may be given after 48 hours. If the patient has taken
       tadalafil (Cialis) nitroglycerine may be given after 72 hours.
    F. If the patient has not taken any of the above medications in the previous 24–72 hours
       depending on the medication taken, administer nitroglycerin 0.4 mg SL as long as the BP
       >100 systolic. If no relief of chest pain after 5 minutes and SBP >100, administer a
       second nitroglycerin. If no relief after another 5 minutes and SBP >100, administer a third
       nitroglycerin. If the EKG indicates an inferior wall MI, be aware hypotension is common
       with nitroglycerin administration. Be prepared to administer a fluid bolus. If chest pain
       persists after three nitroglycerin (0.4mg) doses notify the receiving hospital.
    G. If patient not allergic to aspirin or non-steroidal anti-inflammatory drugs, then
       administer chewable aspirin 325 mg (4 baby ASA) orally. Aspirin should be withheld if
       patient has had GI bleeding, active ulcer disease, hemorrhagic stroke, or major trauma
       within the past 2 weeks or has taken a dose of aspirin within the previous 24 hours.
    H. Establish IV access with a saline lock or normal saline at a keep open rate. NOTE: If
       IV unsuccessful after three attempts, transport as below.
    I. Begin transport
    K. Morphine sulfate 2-4 mg may be given IV/IM/IO over 2 minutes as long as SBP >100
       and pain persists. May repeat to a total of 8 mg.

I.   Historical Findings:
     A. Unconscious patient greater than 15 years old

II. Physical Findings:
    A. Patient is unresponsive, pulseless

III. EKG Findings:
     A. Electrical activity other than VT or VF

IV. Differential Diagnosis (H’s and T’s)
    A. Hypovolemia, Hypoxia, Hydrogen Ion (acidosis), Hypo/Hyperkalemia, Hypoglycemia,
    B. Toxins-Drug overdose, Tamponade (cardiac), Tension Pneumothorax, Thrombosis
         (cardiac or pulmonary), Trauma

V. Adult Protocol:
   A. Consider immediate paramedic intercept. Do not delay on scene.
     B. Begin CPR and maintain adequate airway. Chest compressions should be interrupted for
        as short of a time period as possible. Begin the performance of 5 cycles (approximately
        2 minutes) of CPR (30 compressions to 2 respirations) at a rate of 100 beats per minute.
     C. Apply quick look paddles if not already monitored, or attach monitor leads
     D. Establish advanced airway and ventilate at 8-10 breaths per minute. A main cause of
        PEA is hypoxia, and the effectiveness of ventilation should be evaluated constantly.
     E. Initiate large bore IV/IO of saline; may bolus 1L if hypovolemia suspected.
     F. Search for possible causes of Asystole/PEA as listed above.
     G. Recheck rhythm after every 5 cycles of CPR are complete. Interruption in CPR to
        conduct a rhythm analysis ideally should not exceed 10 seconds.
     H. Consider a needle thorocostomy (see Procedures).
     I.   Rapidly transport patients to the nearest receiving hospital after a brief notification call.

VI. Pediatric Protocol:
    A. Historical Findings of unconscious / unresponsive patient aged 14 or under.
     B. Physical Findings of no respirations, no pulse.
     C. EKG Findings of asystole or PEA. If there is any organized cardiac rhythm with QRS
        complexes the patient is in PEA. Consider the “H’s and T’s”
     D. Consider immediate paramedic intercept. Do not delay on scene.
     E. Ensure airway and begin ventilation with BVM with 100% oxygen. Begin CPR and
        aggressively manage airway, including use of an advanced airway. The most common
        cause of pediatric cardiac arrest is hypoxia with ischemic insult. Therefore airway and
        breathing are especially important.
     F. Monitor and begin transport immediately if no paramedic on scene. DO NOT DELAY ON
        SCENE! Rapidly call medical control.
     G. Attempt IV / IO.
     H. Reassess airway and breathing. Update medical control as needed.


  I.   Historical Findings: Unconscious patient greater than 15 years old

  II. Physical Findings: Patient is unresponsive, pulseless

  III. EKG Findings: VF or VT

       Ventricular Fibrillation

       Ventricular Tachycardia

  IV. Adult Protocol:
      A. Consider immediate paramedic intercept. Do not delay on scene.
       B. If arrest witnessed by EMS or bystander CPR for >2 minutes go to step 3.
       C. Begin performance of 5 cycles / 2 minutes of CPR (30 compressions to 2
          respirations) at a rate of 100 beats per minute before defibrillation. Assure that good
          CPR is being performed with adequate uninterrupted compressions and rise and fall
          of chest with ventilation.
       D. Apply quick look paddles or pads if not already monitored. Do immediately if arrest
          witnessed by EMS or bystander CPR is in progress upon arrival.
       E. If rhythm is VF or VT, defibrillate immediately at 360J or biphasic equivalent.
       F. Resume CPR without a pulse or rhythm check indicated. Chest compressions should
          be interrupted for as short of a time period as possible. Perform CPR for 5 cycles
          (approximately 2 minutes).
       G. Establish an advanced airway if possible; ventilate at 8-10 breaths per minute.
       H. Initiate IV/IO with normal saline at keep open rate.
       I.   Recheck rhythm after 5 cycles of CPR are complete. Interruption in CPR to conduct a
            rhythm analysis ideally should not exceed 10 seconds.
       J.   If rhythm has converted to a perfusing rhythm, hold compressions. If rhythm is still VF
            or VT, defibrillate again at 360J or biphasic equivalent and continue with protocol.
       K. Recheck rhythm after 5 cycles of CPR are complete.
       L. If rhythm still VF or VT, defibrillate again at 360J (or biphasic equivalent).
       M. Continue CPR, monitor, transport, and contact receiving hospital.

     1. Quality uninterrupted CPR is the mainstay of therapy for Cardiac Arrest.
     2. If patient develops a perfusing rhythm, the AHA recommends that CPR be continued
         for 5 more cycles to support cardiac output.
     3. Always consider H’s and T’s (see PEA Protocol).

  I.   Historical Findings:
       A. Patients >15 yo complaining of chest pain or shortness of breath.

  II. Physical Findings:
      A. Palpable pulse with a rate > 150.
      B. SBP < 90 mmHg
      C. The patient is “Unstable” if there are signs of inadequate perfusion such as acute
         heart failure, delayed capillary refill, diaphoresis, or altered mental status are present.
         Be prepared for rapid decompensation and cardiac arrest.
      D. The patient is “Stable” if there are no signs of inadequate perfusion, however the
         patient still has a significant chance for rapid decompensation.
      E. If the patient becomes unstable, then proceed to the appropriate protocol.

  III. EKG Findings:
       A. Rate > 150
       B. Wide QRS (> 0.12 sec or 3 little blocks)
       C. Absent P waves


  IV. Protocol:
      A. Consider immediate paramedic intercept. Do not delay on scene.
       B. Assure airway patency and administer 02 at high flow and high concentration,
          preferably by non-rebreather facemask at 12-15/min.
       C. Maintain cardiac monitoring at all times. Obtain 12 lead ECG.
       D. Initiate large bore IV with normal saline to run at keep open rate.
       E. Rapid transport to receiving facility after a prehospital notification.

I.   Historical Findings:
     A. Patient greater than 15 years old
     B. No chest pain or shortness of breath.

II. Physical Findings:
    A. Tachycardia
    B. SBP > 90mmHg
    C. The patient is “Unstable” if there are signs of inadequate perfusion such as acute heart
       failure, delayed capillary refill, diaphoresis, or altered mental status are present. Be
       prepared for rapid decompensation and cardiac arrest. These patients may have a faster
       heart rate (150 – 300) as well.
    D. The patient is “Stable” if there are no signs of inadequate perfusion, however the patient
       still has a significant chance for rapid decompensation.
    E. If the patient becomes unstable, then proceed to the appropriate protocol.

      A. Rapid (140-250) ventricular rate, regular atrial rate.
      B. Normal QRS duration of less than 0.12 seconds.
      C. P waves are usually absent.

Supraventricular Tachycardia

Sinus Tachycardia

IV. Protocol:
    1. Consider immediate paramedic intercept. Do not delay on scene.
    2. Assure airway patency and administer 02 at high flow and high concentration, preferably
       by non-rebreather facemask at 12-15/min.
    3. Maintain cardiac monitoring at all times. Obtain 12 lead ECG.
    4. Initiate large bore IV with normal saline to run at keep open rate.
    5. Have patient perform a Valsalva maneuver
    6. Rapid transport to receiving facility after a prehospital notification.

I.   Historical Findings:
     A. Age >14.
     B. Older child may complain of chest pain or rapid heart rate.

II. Physical Findings:
    A. Tachycardia under age 2 is >220bpm.
    B. Tachycardia between the ages of 2-14 is 150-250bpm.
    C. The patient is “Unstable” if there are signs of inadequate perfusion such as acute heart
       failure, delayed capillary refill, diaphoresis, or altered mental status are present. Be
       prepared for rapid decompensation and cardiac arrest. These patients may have a faster
       heart rate (150 – 300) as well.
    D. The patient is “Stable” if there are no signs of inadequate perfusion, however the patient
       still has a significant chance for rapid decompensation.
    E. If the patient becomes unstable, then proceed to the appropriate protocol.

III. EKG Findings:
     A. QRS duration = 0.12 sec (3 little boxes).
     B. P waves may or may not be seen.

IV. Protocol:
    1. Consider immediate paramedic intercept. Do not delay on scene.
    2. Ensure airway and apply 100% oxygen.
    3. Place cardiac monitor, obtain 12 lead, and contact medical control.
    4. Reassess airway, breathing and circulation.
    5. Consider a Valsalva or vagal maneuver; WARNING: Vagal maneuvers (e.g. ice bag) in
       young infants may cause asystole
    5. Attempt IV or IO. Do not delay transport to start an IV.
    6. Children without underlying heart disease or myocardial dysfunction will tolerate the
       rhythm for up to 24 hours without compromise but do require rapid transport for
    7. Update medical control with any changes in the patient’s condition. If the child
       decompensates, prepare to perform CPR.

I.   Historical Findings
     A. Patients greater than 15 years old
     B. Chest pain, shortness of breath or inability to give history due to alteration in level of
         consciousness which is thought to be related to the slow heart rate.
II. Physical Findings
    A. Pulse rate < 60.
    B. SBP < 80 mmHg, cardiogenic shock, or pulmonary edema.
    C. Signs of inadequate perfusion such as acute heart failure, delayed capillary refill,
       diaphoresis, or altered mental status.
III. EKG Findings: ventricular rate <60bpm

Sinus Bradycardia

IV. Protocol:
    1. Consider immediate paramedic intercept. Do not delay on scene.
    2. Apply quick look paddles if not already monitored. Obtain an EKG.
    3. Assure airway patency and administer 02 at high flow and high concentration, preferably
       by non-rebreather facemask at 12-15/min.
    4. Check vital signs every 5 minutes
    5. Initiate IV/IO of normal saline at keep open rate.
    6. Notify receiving hospital.

I.   Historical Findings:
     A. Age >14 yo

II. Physical Findings:
    A. AMS
    B. Weak pulses / poor perfusion or other signs of uncompensated shock such as poor
       perfusion or delayed capillary refill.
    C. Though in the adolescent bradycardia may be a sign of a healthy heart, in the younger
       pediatric patient it is usually a sign of profound respiratory compromise or impeding
       cardiovascular collapse. Be prepared for rapid decompensation.

III. EKG Findings:
     A. Sinus bradycardia for child's age.

IV. Protocol:
    1. Consider immediate paramedic back-up. Do not delay on scene. Immediately contact
        medical control.
    2. Ensure airway, apply 100% oxygen, assist ventilations as needed, and recheck pulse.
        The most common cause of bradycardia in the child is hypoxia. Therefore attention to
        airway is the most important intervention.
    3. Place on cardiac monitor. If heart rate is less than 60 in an infant and/or a child, begin
        chest compressions at a rate of at least 100.
    4. Reassess airway and breathing.
    5. Place an IV / IO while en-route. If hypotensive, administer saline 20cc/kg.

I.   Historical Findings:
     A. Age > 15.
     B. History of chest pain suggestive of cardiac origin and/or dyspnea.
     C. No evidence or history of trauma or bleeding.

II. Physical Findings:
    A. Systolic blood pressure ≤ 80 mm Hg supine, OR
    B. Systolic blood pressure 80-100 mm Hg and one of the following:
       1. Pulse greater than 120,
       2. Skin changes suggestive of shock, OR
       3. Altered level of consciousness, agitation, or restlessness.

III. Protocol:
     A. Consider immediate paramedic intercept. Do not delay on-scene.
     B. Maintain airway and administer oxygen at high flow and high concentration preferably
        by non-rebreather facemask at 12-15/min.
     C. Place patient on monitor and obtain rhythm strip and a 12 lead EKG. If arrhythmia
        is present, proceed to the appropriate protocol.
     D. Monitor vital signs frequently.
     E. Transport as soon as possible and notify the receiving hospital.
     F. Initiate large bore IV and administer 500cc normal saline fluid challenge.


I.   Historical Findings:
     A. Age > 14.
     B. Patient is NOT a victim of trauma or pregnant. Hypertension associated with severe head
         trauma may be protective and field treatment should be aimed at the head injury not BP
     C. Patient has headache, AMS, vomiting, blurred vision, CP, or shortness of breath.
         Completely asymptomatic patients do not necessarily require emergency treatment of
         their hypertension. Remember to treat the patient, not the number.

II. Physical Findings:
    A. Diastolic blood pressure of 130 or above, AND
    B. Systolic blood pressure of 180 or above.

III. Protocol:
     A. Administer high flow, high rate O2.
     B. Place patient at rest and reassure.
     C. Repeat BP in both arms, place on cardiac monitor and obtain a 12 lead EKG.
     D. Establish IV.
     E. Treat arrhythmias per protocol.
     F. Treat chest pain, respiratory distress, seizures, or coma per protocol.
     G. Contact medical control.
     H. Determine whether the patient has taken Sildenafil (Viagra) in the previous 24 hours. If
        the patient has not taken Sildenafil in the previous 24 hours, the patient may be given a
        dose of nitroglycerin, 0.4mg SL. This dose can be repeated every 5 minutes x 2 more

I.   Historical Findings:
     A. Patients older than 15 years of age.
     B. Patient complains of severe shortness of breath.
     C. Patient has a past medical history of heart disease.

II. Physical Findings:
    A. Respiratory rate > 20.
    B. Systolic blood pressure > 100 mm Hg.
    C. Rales on lung exam.
    D. Patient has evidence of respiratory insufficiency such as air hunger, accessory muscle
       use, or altered mental status.
     E. Patient MAY have jugular venous distention or peripheral edema.
     E. EKG Findings: Normal sinus rhythm or sinus tachycardia. If an arrhythmia is present,
        proceed to appropriate arrhythmia protocol.

III. Protocol:
     A. Maintain airway and administer oxygen at high flow and high concentration
        preferably by non-rebreather facemask at 12-15/min.
     B. If appropriate, attempt CPAP placement (see CPAP Protocol). Place an advanced airway
        if necessary. Transport to the hospital should be initiated immediately if the patient's
        airway is compromised or the patients advanced airway management, including CPAP>
        Otherwise, transport should be initiated as soon as possible taking into account the time
        required to begin pharmacologic therapy.
     C. Allow patient to sit up in position of comfort.
     D. Obtain vital signs and apply cardiac monitor. Obtain a 12 lead ECG on all patients.
     E. Determine whether the patient has taken any Erectile Dysfunction medications i.e.
        sildenafil (Viagra); vardenafil (Levitra); or tadalafil (Cialis) in the previous 24 - 72 hours. If
        the patient has not taken any of the above medications in the previous 24 - 72 hours,
        then administer nitroglycerin 0.4 mg sublingual as long as the BP > 100 systolic. For
        sildenafil (Viagra) nitroglycerine may be given after 24 hours. If the patient has taken
        vardenafil (Levitra) nitroglycerin may be given after 48 hours. If the patient has taken
        tadalafil (Cialis) nitroglycerine may be given after 72 hours.
     F. Initiate a saline lock.
     G. If patient is already taking Lasix or a similar drug, then the patient's normal oral
        dose is recommended. Otherwise, a starting dose of approximately 40 mg is
        frequently appropriate.
     H. Morphine sulfate 2-4 mg IV every 5 minutes up to a total of 8 mg if systolic blood
        pressure >100 mm Hg may be given.

I.   Historical Findings:
     A. Patients older than 15 years of age
     B. Patient complains of worsening shortness of breath, AND
     C. Patient has a past medical history of asthma, emphysema, or COPD.

II. Physical Findings:
    A. Lung exam has wheezing, decreased breath sounds, or poor air exchange.
    B. Use of accessory muscles of respiration.
    C. MAY have retractions, rapid respiratory rate, or pursed lip breathing.
    D. EKG findings: Normal sinus rhythm, sinus tachycardia, or atrial fibrillation with controlled
       ventricular response. If other rhythm present, proceed to appropriate arrhythmia protocol.

III. Differential Diagnosis:
     A. Primary cardiac disease
     B. Other pulmonary disease (i.e. CHF)
     C. Foreign body aspiration
IV. Protocol:
    A. Maintain airway and administer oxygen at high flow and high concentration preferably
       by non-rebreather facemask at 12-15/min. If respiratory effort and respiratory rate are
       normal for age and a pulse oximeter is available with saturation reading greater than
       95%, then oxygen administration is optional. Oxygen should be administered as needed
       to raise oxygen saturation to at least 95%.
     B. If the patient is in impending respiratory failure, consider CPAP if appropriate or
        advanced airway placement.
     C. Allow patient to sit up in a position of comfort.
     D. Obtain vital signs and apply cardiac monitor. Obtain a 12 lead on all patients. Establish a
        saline lock.
     E. Perform patient assessment.
     F. Administer albuterol aerosol 0.5 ml in 2.5 ml normal saline via hand held nebulizer. The
        same dose should be given to all patients. With moderate to severe asthma/COPD,
        consider for first treatment adding 1 vial atrovent (0.5 mg of 0.017%) to the albuterol
        aerosol. May substitute Duoneb (premixed albuterol plus Ipratropium bromide that is
     G. Begin transport.
     H. Consider epinephrine 1:1000 solution IM (0.3ml IM) in patients <40 yo with no
          known coronary artery disease.
     I.   Consider repetitive albuterol (only) treatments if needed, up to a total of three treatments.

   A. When attempting to differentiate between COPD and CHF the medication history will
       usually give more valuable information than the physical exam.
   B. Do not withhold high concentrations of oxygen from the COPD patient if oxygen is
       needed. The risks of oxygen therapy in these patients are usually overemphasized. Any
       rise in PCO2, which may occur is frequently more than offset by the beneficial effects of
       increased oxygen delivery to the tissue.
   C. Ipratropium is an anticholinergic medication and may cause tachycardia. Do not use in
       patients with narrow angle glaucoma or history of urinary retention.

I.   Historical Findings:
     A. Patients older than 15 years of age.
     B. Patient complains of shortness of breath or cannot speak because of airway obstruction.
     C. MAY have history suggestive of foreign body aspiration such as sudden onset of
         shortness of breath while eating.

II. Physical Findings:
    A. Airway exam has little or no air movement, stridor, or decreased breath sounds.
    B. MAY have use of accessory muscles of respiration.
    C. MAY have fever or drooling.
    D. MAY have retractions or rapid respiratory rate.
     E. EKG Findings: Normal sinus rhythm, sinus tachycardia, or atrial fibrillation with controlled
        ventricular response. If other rhythm present, proceed to appropriate arrhythmia protocol.

III. Differential Diagnosis:
     A. CHF, aspiration, asthma, epiglottitis, croup (in a child)

IV. Protocol:
     A. If the patient is alert, awake, and breathing on their own maintain airway and administer
        oxygen at high flow and high concentration preferably by non-rebreather facemask at 12-
        15/min. If patient is a young child, have the parent help administer the oxygen. Allow
        patient to sit up in a position of comfort. Go to step # D.
     B. If the patient is alert but obviously choking from a presumed foreign body:
         1. Have the patient cough forcefully, if possible.
         2. Perform the Heimlich maneuver until successful
         3. If successful, go to step # C.
     C. If the patient is unconscious or becomes unconscious:
         1. Begin CPR and BVM ventilate while preparations are made to place an advanced
            airway (see Advanced Airway Protocol)
         2. Using the laryngoscope, visualize the posterior pharynx and vocal cords for evidence
            of a foreign body.
         3. Remove any foreign bodies very carefully with a suction device or Magill forceps.
         4. If no foreign body is seen or patient does not begin breathing spontaneously, intubate
            the trachea. If you suspect a foreign body is below the vocal cords but above the
            carina, it may be necessary to push the foreign body down the right mainstem
            bronchus with the ET tube in order to aerate at least the left lung.
     D. Obtain vital signs, apply cardiac monitor and initiate a saline IV lock
     E. Perform patient assessment.
     F. Begin transport and notify the receiving facility.
     G. If wheezing consider an albuterol nebulizer treatment

I.   Historical Findings:
     A. Suspected exposure to an allergen (insect sting, medications, foods, or chemicals)
     B. Patient complains of itching, shortness of breath, tightness in chest or throat, weakness,
         or nausea.

II. Physical Findings:
    A. Flushing, hives, or swelling
    B. Wheezing or stridor
    C. Anxiety or restlessness
    D. Tachycardia. Patients on beta blockers may not manifest the usual tachycardia or
       sympathetic adrenergic response to allergic stimuli.
    E. SBP <90mmHg in an adult or relative hypotension in a child

III. Protocol:
     A. Secure scene and assess safety. Remove allergen from patient if possible. Maintain
        airway and administer high flow and high rate oxygen.
     B. Monitor cardiac rhythm and check vital signs frequently. Obtain a 12 lead EKG.
        Administer epinephrine 0.3ml (child 0.01ml/kg) 1:1000 solution subcutaneously only if
        patient is less than 40 years of age, and either hypotension or severe respiratory distress
        is present. Administration of epinephrine to the patient with known cardiovascular disease
        should be avoided unless the patient is in extremis.
     C. Begin transport with early hospital notification.
     D. If bronchospasm or wheezing is present, administer albuterol aerosol 0.5ml in 2.5ml NS
        along with Atrovent 2.5ml via HHN, or a Duoneb treatment.
     E. Initiate IV of normal saline at keep open rate. If patient is hypotensive, bolus 1L saline
        (child 20ml/kg) IV wide open.
     F. Administer Benadryl 25mg - 50mg (child over 9 months old: 1mg/kg) PO/IV/IO/IM.
     G. Continue rapid transport. Be prepared for rapid decompensation.
         1. Be aware of patients on β-Blockers. They may not manifest the usual tachycardia or
            sympathetic adrenergic response to allergic stimuli.

I.   Historical Findings:
     A. History of actual or possible poisoning either through ingestion, inhalation, or skin

II. Physical Findings:
    A. Patient does NOT have AMS. If there is AMS, see the AMS protocol.
    B. SBP = 90 mm Hg in an ADULT
    C. Age < 5yo (SBP >75 mmHg); Age 5-10 (SBP >85 mmHg)

III. Protocol:
     A. Evaluate scene for provider safety.
     B. Administer high flow high rate oxygen.
     C. Monitor vital signs frequently, including placing on a cardiac monitor, evaluate breath
        sounds and level of consciousness.
     D. If toxin remains on patient, wash / brush off as appropriate. If in doubt contact medical
        control for clarification.
     E. If there is eye exposure, flush the eyes with normal saline (see Eye Trauma Protocol).
     F. If patient has ingested medication or other substance, obtain container(s), if available and
        bring them with the patient.
     G. Begin transport immediately and call for paramedic backup if available.
     H. Contact medical control. Because of the wide variety of possible adverse effects of
        assorted toxins, it is not practical to detail the management of various toxic exposures.
        Consultation with medical control can enhance the prehospital care of patients with
        potentially dangerous exposures and is encouraged.
     I.   Obtain IV / IO access.
     J.   Reassess vital signs, perfusion status and level of consciousness every 5 minutes. If
          there is any change in these findings, notify medical control.

I.   Historical Findings:
     A. Exposure to an environment colder than normal body temperature. Can occur in the
         summer as well as in colder seasons.
     B. High risk groups: elderly, infants, outdoor workers, alcoholics.
     C. Predisposing factors:
         1. Increased loss of body heat due to: Prolonged exposure to cold, Inadequate clothing,
             Intoxication. Illness or injury
         2. Decreased heat production due to: Malnutrition, Endocrine disorders
         3. Impaired thermoregulation due to: Hypoglycemia, Drugs (alcohol, barbiturates,
             phenothiazines), Sepsis, Central nervous system disorders.

II. Physical Findings:
    A. Variable presentation with range of presenting symptoms from mild nonspecific
       complaints to unresponsiveness.
    B. Mild symptoms include decreases in coordination, reflexes, and alertness.
    C. If unresponsive, may appear pulseless, with pupils fixed and dilated.
    D. EKG and pulse rate may show severe bradycardia, to the point of appearing pulseless or
       asystolic. A radial pulse may be very difficult to palpate. The pulse rate should be
       obtained with palpation of a central pulse (carotid or femoral) for at least 3 minutes.
    E. Extremities may be stiff resembling rigor mortis, or may be cyanotic or edematous.

III. Differential Diagnosis:
     A. Cardiac arrest.
     B. Coma.
     C. Severe shock.
     D. Narcotic abuse.

IV. Protocol:
    A. Gentle handling of the patient is important to avoid inducing ventricular fibrillation.
     B. Begin transport immediately and call for paramedic backup if available.
     C. Do NOT massage extremities (causes increased cutaneous vasodilation and decreases
        shivering). Gently remove wet clothing. Do NOT use hot packs. Place warm blankets
        over and around the patient. Immobilize if necessary to avoid excessive patient
     D. If pulse and breathing are absent after a 3 minute, begin CPR. Begin transport
        immediately and notify medical control.
     E. Apply cardiac monitor. If the rhythm is ventricular fibrillation or ventricular tachycardia,
        then defibrillate up to a total of three shocks, starting at 200 joules (2 joules/kg for child),
        then 300 joules, and then 360 joules.
     F. If the patient fails to respond to initial defibrillation attempts or initial drug therapy,
        subsequent defibrillation or additional boluses of medication should be avoided until core
        temperature rises above 30°C (86°F).
     G. Rapidly assess airway adequacy and ventilation. Position and open the airway. Use
        airway adjuncts as necessary and administer high flow oxygen.
     H. If the patient has spontaneous respirations, monitor the cardiac rhythm and rapidly
        assess airway adequacy and ventilation. Position and open the airway. Use airway
        adjuncts as necessary. Administer high flow, high rate oxygen.
     I.   Establish IV / IO if possible.
     J.   Notify the receiving hospital so that preparations can be made to warm the patient.

I.    Historical Findings:
      A. Pregnant woman who is in active labor as defined by regular, frequent uterine
          contractions and who feels the urge to push.
      B. Rapidly obtain the following information: time of onset of contractions, interval
          betweencontractions, due date, vaginal discharge, last oral intake, presence of fetal
          movement, previous pregnancy history including complications and C-sections, and
          complications of current pregnancy (i.e. high-risk, pre-ecclampsia)

II.   Physical Findings:
      A. Crowning of fetal part at vaginal opening with imminent delivery. If there is no crowning,
         then delivery is not imminent.

III. Protocol:
     A. Administer high flow oxygen. Obtain vital signs and begin transport to hospital if not
        already en route. Position mother on left side unless baby is crowning.
      B. Early hospital notification and consider paramedic back-up. Transport to appropriate
         hospital of patient's choice or to a hospital with obstetrics. If a complication such as
         massive bleeding or neonatal distress occurs, proceed to nearest appropriate hospital.
      C. If time permits, establish large bore IV with Normal Saline.
      D. Check for crowning. If delivery appears imminent, open OB pack, apply sterile gloves,
         and drape abdomen. In the absence of a breech presentation or prolapsed umbilical
         cord, do not attempt to prevent or delay delivery.
           1. If there is a breech presentation, coach the mother to perform shallow breathing and
              avoid pushing.
           2. If there is a prolapsed umbilical cord, place gloved fingers into the vagina to hold the
              vaginal wall away from the cord.
           3. If there is massive hemorrhage, hypotension, or shock, place the mother in the left
              lateral recumbent position and bolus 1 L saline.
           4. If baby is delivered in malpresentation (e.g. foot or arm), elevate hips of mother and
              transport immediately
      E. Control rate of delivery of head using palm of your hand, applying gentle pressure to
         protect perineum
      F. When head is delivered, compress bulb suction device and place into mouth to suction
         mouth then repeat for nose. Limit suction to ten (10) seconds.
      G. Check to see if cord is wrapped around baby’s neck. If so, gently attempt to slip cord over
         the baby’s head if cord is semi-loose. If cord cannot be slipped over head or cord is tight,
         clamp two sites on the cord and cut between clamps – Use of scissors is preferred over
      H. Gently guide head and neck down to allow delivery of upper shoulder, then guide head
         and neck up to deliver lower shoulder and body
      I.   When baby delivers, grasp ankles in one hand and hold head with the other.
      K. Prevent heat loss - Provide warm environment, dry baby, and wrap baby in clean blanket.
         Slightly extend head to facilitate patent airway. Suction mouth then nose.
      J.   Continue to maintain an open airway and assess breathing rate and effort. Provide tactile
           stimulation as needed to facilitate normal respiratory effort, continually reassessing
           airway patency.

    L. Assess circulation. If heart rate <100 beats per minute, provide artificial respirations at a
       rate of 40-60 breaths per minute and continue to monitor heart rate. The primary
       measurement of adequate initial ventilation is prompt improvement in heart rate. If heart
       rate <60 beats per minute, refer to Pediatric Bradycardia Guidelines or Neonatal
       Resuscitation Guidelines as necessary.
    M. Place baby lower than placenta and assess cord pulsations. After pulsations have
       ceased, double clamp cord at 7-10” from baby and cut between clamps.
    N. Assess baby for APGAR scoring at 1 and 5 minutes after recording time of birth.

        APGAR Score

    O. If baby is premature (<36 weeks gestation), prepare for neonatal resuscitation and early
    P. Continue transport prior to delivery of placenta if possible.
    Q. If significant post delivery bleeding is present, massage fundus abdominally to stimulate
       uterine contraction and/or allow baby to breast-feed. If perineum is torn/bleeding, apply
       direct pressure with gauze.


I.   Historical Findings:
     A. Newborn infant.

II. Physical Findings:
    A. Central cyanosis, poor or no respiratory effort, or limp muscle tone.

III. Protocol:
     A. Consider early paramedic intercept. Do not delay on scene. Immediately contact medical
     B. Ensure adequate airway. Suction mouth, oropharynx, then nose.
     C. Dry infant to provide stimulation and prevent chilling. Keep the infant warm, especially the
        head. Monitor and begin transport immediately. Newborn infants lose heat rapidly and
        need to be kept warm to decrease oxygen demands and prevent acidosis.
     D. Check heart rate. If <100, ventilate with 100% oxygen at a rate of 40-60bpm. If heart rate
        remains less than 100 after 15 to 30 seconds of assisted ventilation, reassess airway and
        begin chest compressions If heart rate <60 beats/min, begin CPR.
     E. Check color. If central cyanosis, provide 100% oxygen and assist ventilations.
     F. Provide medical control with patient update while rapidly transporting the patient.

Ideally, if there is thick meconium present in the amniotic fluid at the time of delivery, the infant
should be intubated and any meconium present in the airway should be suctioned prior to

1. Indications:
   A. Prevention and treatment of nausea and vomiting in the adult (>15 yo) patient

2. Contraindications:
   A. Known allergy to Zofran or 5-HT(3) receptors such as Kytril and Aloxi.

3. Protocol:
   A. Assess the need for medication administration
   B. Administer Zofran IM/IV/IO 4mg push.
   C. May repeat 4mg dose in 5 minutes if symptoms have not resolved.
   D. If possible, start a peripheral line and run normal saline at 100 / hr.

I.   Historical Findings:
     A. Adults >15 years of age
     B. Pain due to isolated extremity deformity, burns or chest pain.
     C. No history of allergy to Morphine Sulfate (MSO4)
     F. For other painful conditions, initiate online medical control.

II. Physical Findings:
    A. SBP >100 mmHg.
    B. No altered level of consciousness, mental status change, or suspected head injury.
    C. No signs or symptoms of circulatory shock.

III. Protocol:
     A. Perform continuous pulse oximetry and closely monitor patient's respiratory status.
     B. May administer Morphine Sulfate 5mg IV/IM/IO. Pain medications may be given prior to
        splinting if the patient is hemodynamically stable.
     C. Recheck blood pressure, respirations, and mental status. If patient's pain is not relieved
        and SBP remains >100 mmHg, may repeat Morphine Sulfate 5mg.
     D. In PEDIATRIC patient administer single dose of Morphine Sulfate 0.1 mg/kg IV/IM/IO to a
        maximum dose of 5 mg. If patient’s pain is not relieved or for subsequent doses, contact
        online medical control.
     E. If patient experiences persistent respiratory depression, Naloxone (Narcan) can be
        administered 0.1 mg/kg IV or IM (maximum dose 2mg).


1. If spontaneous breathing is present without compromise:
         a. Monitor breathing during transport
         b. Administer O2 via nasal cannula (2-6 L/min) for adults, blow-by for pediatrics.

2. If spontaneous breathing is present with compromise:
         a. Maintain open airway in in-line position. Position pediatrics with padding under torso.
         b. Administer oxygen via non-rebreather mask (10-15 L/min).
         c. If unconscious, insert oropharyngeal or nasopharyngeal airway as needed. Provide
           either head-tilt / chin-lift or jaw thrust as appropriate.
         d. Assist ventilations with BVM as needed; newborns should have BVM ventilation done
           with pop-off valve. All other children should have BVM ventilation without pop-off valve.
         e. Suction as needed

3. If spontaneous breathing absent compromised
         a. Maintain airway in in-line position. Position pediatrics with padding under torso.
         b. Administer oxygen via non-rebreather mask (10-15 L/min).
         c. If unconscious, insert oropharyngeal or nasopharyngeal airway as needed.
         d. Assist ventilations with BVM as needed; newborns should have BVM ventilation done
           with pop-off valve. All other children should have BVM ventilation without pop-off valve.
         e. Suction as needed

4. Endotracheal Intubation can be considered in the unconscious, unresponsive patient.
    a. Pre-oxygenation prior to intubation should be accomplished via BVM.
    b. Oral intubation with in-line cervical immobilization is the best choice for a trauma patient
         requiring definitive airway control.
    c. Prepare suction.
    d. Intubation should take < 30 seconds to complete. If visualization difficult, stop and re-
         ventilate before trying again. Careful visualization with the laryngoscope is required.
    e. Protocol:
         1. While pre-oxygenating, assemble equipment and choose tube size
         2. Introduce the stylet and be sure it stops ½” short of the tube’s end.
         3. Assemble laryngoscope and check light.
         4. Connect and check suction.
         5. Position patient: neck flexed forward, head extended back.
         6. Have an assistant apply gentle cricothyroid pressure to prevent aspiration and assist in
            visualization of vocal cords (BURP).
         7. Gently insert laryngoscope to right of midline. Move it to midline, pushing tongue to left.
         8. Lift straight up on blade (no levering) to expose posterior pharynx.
         9. Identify epiglottis: tip of curved Macintosh blade should sit in vallecula (anterior to
            epiglottis); straight Miller blade should slip over epiglottis.
         10. With gentle further traction to straighten the airway, identify trachea from arytenoid
             cartilages and vocal cords.
         11. Insert tube from right side of mouth, along blade into trachea under direct vision.
         12. Advance tube so cuff is 1-1½" beyond cords. Inflate cuff with 5-10cc of air. Confirm
             placement via: bilateral breath sounds and chest rise, no epigastric sounds, positive
             color change on ETCO2 detector and continuous waveform monitoring, and rise of
             pulse oximetry.
                   A. Colorimetric ETCO2 detectors used to assess proper placement of
                       advanced airway. All intubated patients require a colorimetric detector or a
                       continuous ETCO2 monitoring device. Monitoring used to determine if an ETT
                       has become displaced.
                   B. Contamination with blood and secretions may render colorimetric ETCO2
                      detectors ineffective. Device may be ineffective or inaccurate in patients
                      without spontaneous circulation.

        13. Document proper tube position and secure tube with appropriate methods.
        14. Reconfirm whenever patient is moved.

    g. Complications
        1. Esophageal intubation: common when tube not visualized as it passes through cords.
           The greatest danger is in not recognizing the error.
        2. Intubation of right mainstem bronchus.
        3. Upper airway trauma due to excess force with laryngoscope or to traumatic placement
        4. Vomiting and aspiration during intubation of patient with intact gag reflex
        5. Hypoxia due to prolonged intubation attempts
        6. Cervical spine trauma.
        7. Arrhythmias from airway stimulation.
        8. Induction of pneumothorax.

5. The KingLT supraglottic rescue airway is an alternative to intubation for airway management in
   patients greater than 4 feet tall to secure a patent airway and deliver ventilations.
    a. Contraindications
         1. Responsive patients with an intact gag reflex.
         2. Patients with known esophageal disease.
         3. Any patients that have ingested caustic substances.
         4. Patients who are less than 4 feet tall.

    b. Protocol
        1. Assemble equipment and continue BVM. Choose tube size based on patient’s height.
             a. 4 to 5 feet tall = size 3
             b. 5 to 6 feet tall = size 4
             c. > than 6 feet tall = size 5
        2. Check inflatable cuffs for leaks.
        3. Apply water soluble lubrication to the tip.
        4. Prepare and turn on suction.
        5. Apply chin lift and introduce the King airway in to the corner of the mouth.
        6. Advance tip under the base of the tongue while rotating the tube back to midline.
        7. Without excessive force, advance tube until base of connector aligned with patient’s
           teeth or gums. Get the distal tip of the King airway around the corner in the posterior
           pharynx under the base of the tongue. A chin lift along with the lateral approach helps
           facilitate tube placement. A laryngoscope or tongue depressor can be used to lift the
           tongue anteriorly to allow easy advancement of the King tube into the proper position.
           Insertion can also be accomplished using a midline approach by applying a chin lift
           and sliding the distal tip along the palate and into position in the hypopharynx. Head
           extension may also be helpful.
        8. Inflate cuff based on tube size.
           a. Size 3 = 50 ml
           b. Size 4 = 70 ml
           c. Size 5 = 80 ml
        9. Attach BVM. While gently bagging slowly withdraw the tube until ventilation is easy to
          administer a large tidal volume with minimal airway pressure. Adjust cuff inflation, if
          necessary, to obtain an airway seal at peak ventilation pressure.
        10. Assess for proper tube placement.
           a. Assess breath sounds.
           b. Assure chest rise and fall
           c. Attach patient to continuous end tidal CO monitoring.
          d. Maintain the tube midline after it is advanced around the corner in the posterior
             pharynx. Keeping the tip at the midline assures the distal tip is properly placed in the
             hypopharynx/upper esophagus.
          e. Depth of insertion is key to proper tube placement. With deeper initial insertion only
             withdrawal is required to accomplish a patent airway. A shallow inflation requires cuff

           deflation to advance the tube deeper.
       f. During ventilation the epiglottis or other tissue can be drawn into the distal ventilatory
          opening resulting in obstruction. Advancing the tube 1-2 cm or initiating deeper
          placement normally eliminates the obstruction.
    11. Continue to reassess that tube is properly placed and patient ventilation is easy and
         free flowing with chest rise and adequate breath sounds.
    12. If unsure of proper placement, deflate cuff, remove and use BVM for ventilation.
    13. Secure tube using appropriate device/methods.
    14. Document proper tube position and secure tube with appropriate methods.
F. Medications cannot be administered directly through this airway.
G. To remove the King airway:
    1. Suction above the cuff in the oral cavity if indicated.
    2. Fully deflate both cuffs before removal
    3. Remove the tube when the gag reflex has returned.

Advanced Airway Decision-Making Guidelines


Continuous Positive Airway Pressure (CPAP) works by “splinting” the airways with a constant
pressure of air, reducing the work of breathing. In CHF it forces the excess fluid out of the alveoli
and interstitial space back into the vasculature as well as decreases venous return to the heart
thereby lessening its workload. In asthma, it splints the constricted airways open allowing air
exchange. CPAP can be a palliative intervention for patients with DNR orders due to the non-
invasion nature of pressure support versus advanced airway support.

I.   Indications:
     A. Age > 15 years old.
     B. Patient is awake and oriented and ability to maintain an open airway.
     C. Systolic blood pressure above 90 mmHg.

II. Contraindications:
     A.   Respiratory arrest.
     B.   Suspected pneumothorax.
     C.   Tracheostomy or facial trauma
     D.   Patient is at risk for aspiration i.e.: vomiting, foreign body airway occlusion.
     E.   The patient is intubated. (The CPAP device is not configured for use with ETT).

III. Physical Findings:
     A. Acute Respiratory Distress due to Congestive Heart Failure or asthma.
     B. Inclusion criteria (>2)
        1. Respiratory rate > 25 breaths per minute or SaO2 < 94% at any time.
        2. Retractions, accessory muscle use, fatigue, wheezing, rales, diminished breath
        3. Respiratory Failure of any etiology if a valid DNR is present.

IV. Protocol:
    A. CPAP should be applied as soon as indicated, and procedure explained to the patient.
    B. Ensure that the patient is on the cardiac monitor and pulse oximetry.
    C. Ensure adequate oxygen supply and assemble CPAP mask, circuit, and device.
        Assemble required equipment and personnel for intubation in the event the patient
        deteriorates or is unable to tolerate CPAP.
    D. Attach quick connect device to a portable or fixed oxygen source. Place mask over the
        mouth and nose and secure the mask with straps.
    E. Check for air leaks and adjust mask as needed. Do not break the mask seal to
        administer nitroglycerin (nitro-lingual) SL.
    F. Continuously coach patient to keep mask in place, however if patient experiencing
        increasing anxiety versed 1 mg IV/IO/IM may be administered.
    G. Reassess patient’s vital signs and response to CPAP every 5 minutes.
    H. If patient’s status improves continue CPAP until patient transferred to receiving hospital.
        If status deteriorates discontinue CPAP and prepare to provide an advanced airway.
    I. Notify destination hospital that CPAP has been used. CPAP is only to be removed at the
        receiving hospital only when personnel are present to transfer the patient to their
        equipment, or the receiving ED physician present and requests CPAP be discontinued.

I.   Indication:
     A. All critically ill patients
     B. When fluid and/ or medication resuscitation may be necessary.
     C. Respiratory distress or arrest
     D. Unconscious / Unresponsive
     E. Altered mental status
     F. Chest pain or Stroke symptoms

II. Procedure:
     A. Perform only two attempts at venous cannulation. May proceed directly to IO if patient Is
         critically ill.
     B. Unless patient entrapped, IV access should be initiated en-route to the hospital.
     C. Standing order sites for IV administration
        1) Forearm
        2) Antecubital space
        3) Dorsum of the hand
     D. Sites that are contraindicated
         1) Lower extremities
         2) Neck veins
         3) CVA patient’s affected side
         4) Extremities that have massive edema, burns, or injury
         5) Areas of cellulitis
         6) Extremities with an indwelling fistula (i.e. dialysis shunt)
         7) Upper extremities on the same side of a mastectomy
     E. Approved sizes: 16g, 18g, 20g, 22g
     F. Time Considerations
        1) An IV is instituted early, but only AFTER standard BLS patient assessment and
           intervention have been performed.
        2) The starting of an IV must not cause any delay transport.
     G. Document
        1) Site
        2) EMT-I who performed IV
        3) Number of attempts and complications (if any).
        4) Catheter size


1. Indication is to allow a means of vascular access when intravenous access (IV) is
   unavailable. This protocol specifically utilizes the EZIO.

2. Historical findings:
    A. Patient requiring vascular access and unable to obtain IV access.
    B. For patients deemed to be critical, entrapped, or for patients undergoing resuscitation it
       may be appropriate to place an IO without searching for an IV site at the discretion of
       the providers. Consider consult with medical control. It is common practice to
       look/attempt IV access without success in at least 2 locations before establishing IO
       access but is not required.

3. Physical Findings:
   A. Fracture or previous orthopedic procedure at site.
   B. Previous IO at the same site within 24 hours prior.
   C. Unable to distinguish site due to patient anatomy or significant edema.
   D. Infection at the insertion site.
    E. Patient is alert (relative contraindication). Patients do not need to be unconscious for
       insertion, but be wary of the psychological effects of the procedure of establishing IO

4. Protocol:
   A. Explain procedure and apply anesthetic, if available, in alert patients.
   B. Ascertain the site to be used and prepare the site using sterile technique.
   C. Follow all device specific protocols for insertion of catheter.
       a. Humeral Head
       b. Tibial
       c. Medial Malleolus
   D. Confirm device placement and proper positioning. Attach extension tubing.
    E. Administer 2% Lidocaine (preservative free) for conscious patients prior to flushing or
       administering fluids/drugs. Slowly administer 10cc 2% Lidocaine (adults) or 0.5mg/kg 2%
       Lidocaine (pediatrics). Lidocaine is administered because conscious patients have
       reported pain with infusion; one study found that 23% of patients with a GCS of 8 or
       greater rated the pain 10/10.
    F. Flush with 10cc (adults) or 5cc (pediatrics) normal saline. It is important to flush the IO
       after attaching an extension, a common complication of poor flow is thought to be due to
       failure to immediately flush the catheter.
    G. Attach IV tubing, secure catheter, and check surrounding area for extravasation.
    H. Establish a “keep open” rate for fluids when not administering medication/fluids.
       1. All medication administrations should be followed with a 10cc saline flush.
       2. For bolus rates, utilize a pressure infusion device or BP cuff to increase rate.
       3. If flow appears to have stopped, administer a 10cc saline flush to reopen catheter
       4. Continuously monitor patient for complications to the procedure.
        5. When transferring patient to another medical provider highlight the use of and ensure
           that they are familiar with the specific IO device used.

I.   Indications:
     A. Providing appropriate and protocol-approved medications for the treatment of seizures
         and AMS when there is no readily available IV or IO access.

II. Contraindications:
    A. Nasal trauma or recent nasal surgery.

III. Protocol:
     A. Assess ABCs, obtain vital signs, and if possible place on cardiac monitor.
     B. For pulseless patients, proceed to appropriate guidelines
     C. For seizure and altered mental status patients, follow appropriate protocols.
     D. Load syringe with appropriate milliliter volume of medication; add enough saline to make
         a total volume of 1cc (1ml). If total volume exceeds 1cc, consider using 2 atomizers.
     E. Attach nasal atomizer and place atomizer within the nostril
     F. Briskly compress syringe to administer 1/2 of the volume as atomized spray.
     G. Remove and repeat in other nostril, so all the medication is administered
     H. Continue ventilating patient as needed. Attempt IV access.
     I. If seizures or AMS persists 3 minutes post treatment, consider repeating ½ dose of
         intranasally, intramuscularly or intravenously. Secure airway if necessary.

1. Purpose
        a) Emergency antidote administration to providers in the event of a nerve agent release.

2. Indication
         a) Mark 1 kits are to be used when personnel are exposed to nerve agents (Sarin,
            Suman, Tabun, VX) with signs and symptoms of nerve agent exposure.
         b) SLUDGEM acronym for parasympathetic response to organophosphate or nerve agent
            exposure: salivation, lacrimation, urination, defecation, GI aggravation, emesis,
            muscular twitching. Response symptoms proportional to the degree of exposure.

3. Procedure
        a) Remove antidote kit from foam carrying case.
        b) With your non-dominant hand, hold autoinjector
           by the plastic clip so the larger autoinjector is
           top and both are positioned in front of you at
           eye level.
        c) With your dominant hand grasp atropine
           autoinjector with the thumb and first two
             fingers. DO NOT cover or hold the needle end
             with your hand, thumb, or fingers. The
             atropine is the shorter of the autoinjectors and
             has a green needle port.
        d) Pull injector out of the clip with a smooth
           motion. Ensure that the yellow safety cap has
           been removed. The autoinjector is now armed.
        e) Position green (needle) end of the injector
        against the injection site (thigh or buttock).
        f) Apply firm, even pressure (not jabbing motion) to the injector until it pushes the needle
            into thigh or buttocks. Using a jabbing motion may result in improper injection or injury
        g) Hold the injector firmly in place for at least 10 seconds.
        h) Carefully remove the autoinjector from the injection site.
        i) Place used injector carefully between the little finger and the ring finger of the hand that
             is holding the remaining autoinjector and the clip.
        j) Pull 2 PAM CL injector out of the clip. Ensure the gray safety cap has been removed.
        k) Inject yourself in the same manner as you did with the atropine, holding the black
           (needle) end against your outer thigh or buttocks. Massage the injection sites.
        l) After administering one set of injections, initiate decontamination procedures.


I.   Historical Findings:
     Medically stable patient who is manifesting unusual behavior including violence, aggression,
     altered affect, or psychosis.

II. Physical Findings:
    A. Patient demonstrates behavior including violence, delirium, altered effect, or psychosis.
     B. If obtainable, serum blood sugar ≥ 60 mg/dl (if assessment cannot be obtained prior to
        physical restraint, then measurement should occur after patient restraint whenever safe
        or feasible to do so).
     C. If obtainable, SBP ≥90 mm Hg and ≤180 mm Hg (if assessment cannot be obtained prior
        to physical restraint, then measurement should occur after patient restraint whenever
        safe or feasible to do so).
     D. If obtainable, heart rate ≥50 bpm (if assessment cannot be obtained prior to physical
        restraint, then measurement should occur after patient restraint whenever safe or feasible
        to do so).
     E. Differential Diagnosis:
        1. Anemia                                 9. Hypoxia
        2. CVA                                    10. Infection (i.e. meningitis / encephalitis)
        3. Drug / Alcohol intoxication            11. Metabolic disorders
        4. Arrhythmias                            12. Myocardial ischemia / infarction
        5. Electrolyte imbalance                  13. Pulmonary Embolism
        6. Head Trauma                            14. Seizure
        7. Hypertension                           15. Shock
        8. Hypoglycemia                           16. Toxicological ingestion
III. Protocol:
     A. If prehospital providers have advance knowledge of a violent or potentially dangerous
        patient or circumstance, consideration should be given to staging in a strategically
        convenient but safe area prior to police arrival. If staging is indicated and implemented,
        dispatch should be notified that EMS is staging, the location of the staging area, and to
        have police advise EMS when scene is safe for EMS to respond.
     B. If EMS intervention is indicated for the violent or combative patient, patients should be
        gently and cautiously persuaded to follow prehospital provider instructions. If EMS has
        cause to believe the patients ability to exercise and informed refusal is impaired by an
        existing medical condition, EMS shall, if necessary cause the patient to be restrained for
        the purpose of providing the EMS intervention indicated. Such restraint shall whenever
        possible, be effected with the assistance of police personnel (See Restraint Protocol). It
        is recognized that urgent circumstances may necessitate immediate action by EMS prior
        to the arrival of police. Urgent circumstances requiring immediate action are defined as
        the patient presents an immediate threat to the safety of self or others including the
        prehospital personnel.
     C. Urgent circumstances authorize, but do not obligate, restraint by EMS personnel prior
        to police arrival. The safety and capabilities of EMS are a primary consideration. Police
        shall immediately be requested by EMS in any urgent circumstance requiring restraint
        of a patient by EMS personnel.
     D. If police initiate restraint inconsistent with the medical provisions of the restraint
        protocol, with the intent that EMS will transport the patient, police must prepare to
        submit an APPLICATION FOR EMEGENCY ADMISSION in accordance with Section
        5122.10 ORC, or the patient must be placed under arrest with medical intervention
        indicated. Police shall, in either instance, accompany EMS to the hospital. Application

    for emergency admission can be applied for by a: psychiatrist, Licensed clinical
    psychologist, Licensed physician, Health or police officer, Sheriff or deputy sheriff.
E. EMS shall not be obligated to transport, without an accompanying police officer, any
   patient who is currently violent, exhibiting violent tendencies, or has a history indicating a
   reasonable expectation that the patient will become violent.
F. If the patient is medically stable then he/she may be transported by police in the following
    1. Patient has normal orientation to person, place, time, and situation.
    2. No evidence of medical illness or injury
    3. Patient has exhibited behavior consistent with mental illness.


1. This protocol is intended to address the need for medically indicated and necessary
   restraint. It shall not apply to regulate, or restrict in any way, operational guidelines adopted
   by a provider agency addressing use of force related to non-medical circumstances (i.e. civil
   disturbances, legitimate self-defense relative to criminal behavior).

2. Soft restraints are to be used only when necessary in situations where the patient is violent or
   potentially violent and may be a danger to themselves or others. Prehospital providers must
   remember that aggressive violent behavior may be a symptom of a medical pr traumatic
   condition as per the AMS protocol.

3. Protocol:
   A. Patient management remains the responsibility of the provider. The method of restraint
      shall not restrict the adequate monitoring of vital signs, ability to protect the patient's
      airway, compromise peripheral neurovascular status or otherwise prevent appropriate
      and necessary therapeutic measures. It is recognized that the evaluation of many patient
      parameters requires patient cooperation and thus may be difficult or impossible.
   B. The least restrictive means shall always be employed.
   C. Verbal de-escalation
      1. Validate the patient’s feelings by verbalizing the behaviors the patient is exhibiting
          and attempt to help the patient recognize these behaviors as threatening.
      2. Openly communicate, explaining everything that has occurred, everything that will
          occur, and why the imminent actions are required.
      3. Respect the patient’s personal space (i.e. asking permission to touch patient, etc).

4. Physical Restraints
    A. All restraints should be easily removable by EMS personnel.
    B. Restraints applied by law enforcement (i.e. handcuffs) require law enforcement officer to
       remain available to adjust restraints as necessary for the patient's safety. The policy is
       not intended to negate the need for law enforcement personnel to use appropriate
       restraint equipment to establish scene control.
    C. To ensure adequate respiratory and circulatory monitoring and management, patients
       shall NOT be transported in a face down prone position.
    D. Restrained extremities should be monitored for color, nerve, and motor function, pulse
       quality and capillary refill at the time of application and at least every 15 minutes.
    E. Any patient restraints shall be well-documented on the run sheet and at a minimum
       address all of the following appropriate criteria
       1. That an emergency existed and the need for treatment was explained to the patient,
            regardless of competence.
       2. That the patient refused treatment or was unable to consent to treatment.
       3. Evidence of the patient’s incompetence to refuse treatment.
       4. Failure of less restrictive methods of restraint.
       5. The restraints were used for the safety of the patient or others.
       6. The reasons for restraint were explained to the patient (regardless of competence).
       7. The type/method of restraint used and which limbs were restrained
       8. Injuries that occur during the restraint procedure.
       9. Which agency(s) placed the restraints and which agency assisted (i.e. PD, FD)
       10. Serial vital signs, and ongoing assessment of PMS (distal to the restraints) and the
            patient’s ability to breathe.


A tourniquet is a constricting or compressing device used to control venous and arterial
circulation to an extremity for a period of time. Pressure is applied circumferentially to the skin
and underlying tissues of a limb; this pressure is transferred to the vessel walls causing a
temporary occlusion. There are a number of commercially available tourniquets available for
prehospital and hospital patients of exsanguinating extremity trauma. While there are potential
risks involved in the utilization of tourniquets, clinically appropriate application in the presence of
potentially life threatening hemorrhage is in keeping not only with the standards of medical
professionals, but with the best interests of the patient.

1. Indication:
   Life-threatening extremity hemorrhage from an extremity that cannot be controlled by direct
   pressure and elevation. A mass casualty incident may be an indication for the use of
   tourniquets for temporary control of hemorrhage while the situation is brought under control.

2. Contradictions:
   A. Never use a tourniquet for more than the recommended period of time (product-specific).
      With any extrication plus transport time of less than 180 minutes, there is minimal risk of
      developing an ischemic limb.
    B. An amputation with hemorrhage does not necessitate the use of a tourniquet; most
       bleeding from these injuries are controllable through use of direct pressure, elevation and
       packing of the wound. If these actions do not achieve hemostasis, then tourniquet use is
    C. Never apply a tourniquet over an impaled object.

4. Procedure:
    A. Check neurovascular status prior to tourniquet application (pulse, sensation, motor
       function distal to hemorrhage).
    B. Apply tourniquet proximal to the area of bleeding, at least 3–5 centimeters from the
       wound margins. Tourniquets should not be applied over joints. Application of the cuff
       over the peroneal nerve (knee or ankle) or ulnar nerve (the elbow) may result in nerve
       damage or paralysis. Do not apply tourniquet directly to the skin (gauze, ABD
       dressing). Tourniquets should not be applied over clothing. Any limb with an applied
       tourniquet should be fully exposed with removal of all clothing, and the tourniquet
       should never be covered with any other bandage.
    C. Secure the tourniquet in place; continue to tighten the tourniquet until hemorrhage is
       controlled – avoid “over tightening” the tourniquet. Use only the minimal effective
       pressure required to reliably maintain arterial occlusion throughout the procedure.
    D. Elevate the extremity if possible.
    E. Note the time the tourniquet was applied. Reassess neurovascular status every five
       minutes post application.
    F. Notify the receiving hospital that a tourniquet is in place. Once tourniquet is in place, do
       not remove prior to transferring patient to the emergency department staff. A tourniquet
       should not be loosened in any patient with obvious signs of shock or amputation that
       necessitated use of the device


I.    Indication:
      A. Tension pneumothorax is rare, but rapidly leads to death without treatment.
      B. Though usually associated with trauma, sudden onset of chest pain and shortness of
          breath in a normal individual may also be caused by a pneumothorax (particularly in
          patients with COPD or asthma).
      C. Signs and Symptoms:
          1. Respiratory distress (progressive)
          2. Chest pain
          3. Decreased or absent breath sounds on affected side to auscultation of chest
          4. Subcutaneous crepitation
          5. Tympanitic percussion note on affected side
          6. Hyperexpanded chest on affected side
          7. Tracheal shift away from affected side
          8. Distended neck veins
          9. Hypotension and shock
          10. If patient is intubated, increasing difficulty in bagging

II.   Technique:
         A. Place oxygen on patient.
         B. Expose entire chest and clean with betadine or alcohol swab.
         C. Insert an angiocath (14g or larger in adult; 18g in children) with syringe attached, in
              the 4th or 5th intercostal space, midaxillary line (horizontal "nipple line" in children).
              Alternatively, the angiocath may be inserted between the 2nd and 3rd intercostal
              space, midclavicular line.
         D. Hit the rib, then slide above it (“VAN” Vein / Artery / Nerve).
         E. If air is under tension, barrel will pull easily and "pop" out the back. Remove syringe,
              advance catheter and remove needle.
         F. Secure catheter in place. Place dressing on chest and secure on 3 sides with tape.
         G. Only one attempt to be done per side.

III. Complications:
        1. Creation of pneumothorax if none
             existed previously
        2. Laceration of lung or blood vessels
        3. Pain
        4. Infection


1. All patients with potential or actual injury to any part of the spine. Airway and ventilation are
   paramount, and none of the guidelines listed below are intended to compromise or prevent
   maintenance of these vital functions.

2. Indications for immobilization:
   A. Significant multi-system trauma. "Significant mechanism of injury" refers to "violent
       impact forces that are clearly capable of damaging the bony spinal column" such as a
       high velocity vehicle crash, a fall from 3 times patient’s height, or a high velocity gunshot
       wound near the spine”. All of these patients should be immobilized regardless of the lack
       of signs and symptoms.
   B. Inability to conduct a reliable history and physical (i.e. presumed intoxication, non-English
       speaking, mental disability) and significant mechanism of injury.
   C. Obvious neurological deficit.
   D. Midline vertebral tenderness or deformity
   E. Age >70 with minor trauma, even a fall from standing height. The elderly may have
       altered perception of pain and therefore may not report the same intensity of symptoms
       as younger patients. Therefore extra caution is in order when assessing elderly patients.

3. A patient does NOT need c-spine immobilization if ALL of the following are present:
   A. Age >16, < 64 years old
   B. Normal mental status, no signs of intoxication, GCS 15, A&Ox4.
   C. No distracting injuries (obvious fracture/dislocation, suspected fracture requiring splint,
       injury requiring administration of pain medication)
   D. No neurological deficit, no midline spine tenderness on palpation of spinous processes.
   E. Patients who do not meet all of these omission criteria may not need immobilization,
       based on provider judgment (examples: restrained 12 year-old in minor MVC without
       complaint, Spanish-speaking male with isolated ankle injury after fall).

4. Procedure:
    A. The neck must be maintained in a neutral position at all times by direct manual and/or
       mechanical means, never applying traction.
    B. While maintaining the neutral position, apply an approved mechanical adjunct to further
       stabilize the neck prior to or upon placing the patient on a long immobilizer.
    C. As soon as practical, the patient will be placed supine on a long immobilizer. The
       following such devices are approved: Scoop stretcher, Long spine board (wood or
       equivalent radiolucent material), Stokes litter, Full body vacuum splint.
    D. Straps must also be placed across the patient's chest, pelvis, and legs to secure their
       body to the long immobilizer. CAUTION: It is DANGEROUS to secure the head if the
       BODY is allowed to move on the long immobilizer. This will subject the neck to
       unacceptable torque and bending.
    E. Airway secretions and vomitus are to be cleared using suction devices. If necessary, the
       patient may be log rolled together with the immobilization equipment for the purpose of
       airway maintenance. Keep in mind that patients who are immobilized properly on a long
       immobilization device with cervical immobilization will not be able to reliably protect their
       airways in the event they vomit. Therefore it is imperative that a working suction device
       be handy to clear vomit from the patient's upper airway.
    F. Once the patient is on the long immobilizer so they cannot slip around on it, lateral neck
       supports such as towel rolls, Head bed, or equivalent must be applied and the patient's
       head taped across the forehead and collar.

Indication: Lack of understanding by the patient, poor cooperation, pain and fear often limits your
ability to assess the pediatric patient completely in the field. Children often cannot verbalize what
is bothering them, so it is important to do a systematic survey which covers areas that the patient
may not be able to tell you about. Any observations about spontaneous movements of the patient
and areas that the child protects are very important.

A. General:
        1. Level of alertness, eye contact, attention to surroundings
        2. Muscle tone: normal, increased, or weak and flaccid
        3. Responsiveness to parents, caregivers; is the patient playful or irritable?
B. Head:
        1. Signs of trauma
        2. Fontanels, if open: abnormal depression or bulging
C. Face:
        1. Pupils: size, symmetry, reaction to light
        2. Hydration: brightness of eyes; is child making tears? Is the mouth moist?
D. Neck:
        1. Note stiffness, pain, deformity
E. Chest:
        1. Stridor, retractions or increased respiratory effort.
        2. Auscultate the chest:
        3. Breath sounds: symmetrical, rales, wheezing?
        4. Heart: rate, rhythm
F. Abdomen:
        1. Distention, rigidity, bruising, tenderness
G. Extremities:
        1. Brachial pulse
        2. Signs of trauma
        3. Muscle tone, symmetry of movement
        4. Skin temperature and color, capillary refill
        5. Areas of tenderness, guarding or limited movement
H. Neurologic exam
        1. Alertness (AVPU)
        2. Any motor or sensory deficits


 Age                          0-3 m    6m     7m-2y     3y       6y       8y     10 y   12 y    >14y
                              6-7 /                                              60/            100/
Weight        lbs / kg                11/5    20/ 10   30/15    40/ 20   50/25          80/40
                                3                                                30              50
                              60-              70-
                                                       75-80     80 /     80 /   85 /   85/     90
          Low Limit SBP /      70/    70/10    75/
Vitals                                                  / 80-    70-      70-    60-    60-     60-
              Pulse           100-    0-180    90-
                                                         140     130      130    120    120     120
                              118              160
                              3.0-             4.0-
Airway       ETT size                  3.5              5.0      5.5      6.0    6.5     7.0    7.0
                              3.5              4.5
         Diphenhydramine                                                         30      40     50
Drugs                                         10 mg    15 mg    20 mg    25 mg
             IM/IV/IO                                                            mg      mg     mg
           Dextrose 25%*
                              6 mL    10 mL   20 mL
           Dextrose 50%                                                          30      40     50
                                                       15 mL    20 mL    25 mL
               IV/IO                                                             mL      mL     mL
            Epinephrine        0.3     0.5              1.5               2.5    3
                                              1 mL              2 mL                    4 mL    5 mL
         1:10,000 IV/IO/ETT    mL      mL               mL                mL     mL

         Epinephrine 1:1000           0.05     0.1     0.15      0.2     0.25    0.3     0.3    0.3
                IM                     mL      mL       mL       mL       mL     mL      mL     mL

                               0.5     0.5     0.5      0.5                      1
            Glucagon IM                                         1 mg     1 mg           1 mg    1 mg
                               mg      mg      mg       mg                       mg
           Lidocaine 1%                                                          30      40     50
                              3 mg    5 mg    10 mg    15 mg    20 mg    25 mg
              ET/IV/IO                                                           mg      mg     mg
           Midazolam 0.1       0.3     0.5              1.5               2.5    3
                                              1 mg              2 mg                    4 mg    5 mg
           mg/kg IV/IM/IO      mg      mg               mg                mg     mg
          Morphine sulfate                              1.5               2.5    3
                                                                2 mg                    4 mg    5 mg
         0.1 mg/kg IV/IM/IO                             mg                mg     mg
             Naloxone          0.3     0.5              1.5                      2
                                              1 mg              2 mg     2 mg           2 mg    2 mg
            ET/IV/IO/IM        mg      mg               mg                       mg
          Ondansetron 0.1                               1.5               2.5    3
                                                                2 mg                    4 mg    4 mg
            mg/kg IV/IM                                 mg                mg     mg
Fluid                                  100     200      300      400      500    600    800
         Saline (20 mL/kg)    60mL                                                              1L
Bolus                                  mL      mL       mL       mL       mL     mL     mL
Defib    Round to closest #    6J     10 J    20 J     30 J      40J      50J    60J    80J     100J

How to Size a Pediatric ET Tube
• Predicted Size Uncuffed Tube = (Age / 4) + 4
• Predicted Size Cuffed Tube = (Age / 4) + 3

Albuterol (Proventil)
      Class
           •    Sympathomimetic
           •    Relatively selective beta-2 adrenergic bronchodilator
           •    Relaxes smooth muscles of the bronchial tree and peripheral vasculature by
                stimulating adrenergic receptors of the sympathetic nervous system.
      Description
           • B-Agonist / sympathomimetic, selective for beta-2 adrenergic receptors.
           • Relaxes smooth muscles of the bronchial tree peripheral vasculature by
                stimulating adrenergic receptors of the sympathetic nervous system.
      Onset & Duration
           • Onset: 5-15 minutes
           • Duration: 3-4 hours
      Indications
           • Relief of bronchospasm due to asthma, anaphylaxis, or allergic reactions
           • Prevention of exercise-induced bronchospasm
           • Protocols: Respiratory Distress
      Contraindications:
           • Prior hypersensitivity reaction to B-agonists
           • Cardiac arrhythmias associated with tachycardia
           • Tachycardia caused by digitalis overdose
      Adverse Reactions
           • Tachycardia / Palpitations / Arrhythmias / Chest Pain
           • Restlessness / Anxiety
           • Headache
           • Dizziness
           • Nausea
           • Hypertension
           • Hypokalemia
      Drug Interactions
           • Sympathomimics may exacerbate adverse cardiovascular effects.
           • Antidepressants may potentiate the effects on the vasculature.
           • Beta blockers may antagonize B-Agonists.
           • B-Agonists may potentiate diuretic-induced hypokalemia.
      Dosing
           • Adult: One unit dose bottle of 3.0 ml, by nebulizer, at a flow rate (6-8 lpm) to
                deliver solution over 15 minutes. May be repeated twice.
           • Pediatric: One unit dose bottle of 3.0 ml, by nebulizer, at a flow rate (6-8 lpm) to
                deliver solution over 15 minutes. May be repeated twice.
      Special considerations
           • Pregnancy safety: Category C
           • Should be used with caution in patients with diabetes mellitus, hyperthyroidism,
                prostatic hypertrophy, or seizure disorder
           • Duonebs contain both albuterol and atrovent.

Aspirin / Acetyl-Salicylic Acid

• Platelet Aggregator Inhibitor, Anti-Inflammatory Agent

• Anti-inflammatory agent, inhibitor of platelet function. Useful in treatment of thromboembolic
   diseases such as AMI. Inhibits blood clotting, specifically the formation of thromboxane A2, a
   platelet aggregating, vasoconstricting prostaglandin. Platelet aggregation has been
   implicated in the pathogenesis of atherosclerosis contributing to the acute episodes of
   transient ischemic attacks, unstable angina, and acute myocardial infarction. This has been
   linked to anginal episodes. Beneficial in decreasing sudden cardiac death and myocardial
   infarction in patients with unstable angina. It has also been shown to be of added benefit in
   maintaining vessel patency after thrombolytic therapy

Onset & Duration
• Onset:15 minutes
• Duration: 4 days

• Chest pain suggestive of acute myocardial infarction (AMI)
• Signs and symptoms suggestive of recent stroke (CVA); call medical control
• Protocols: chest pain

• Allergy to aspirin.
• Relatively contraindicated in patients with active ulcer disease and asthma, bleeding
   disorders, hemorrhagic CVA, children.

Adverse Reactions
• Heartburn / GI bleeding / Nausea / Vomiting
• Wheezing
• Prolong bleeding.

• 81mg tablets

• Four 81mg tablets orally to conscious patients who can chew and swallow

Drug Interactions
• When administered together, aspirin and other anti-inflammatory agents may cause an
   increased incidence of side effects and increased blood levels of both drugs. Administration
   of aspirin with antacids may reduce the blood level of the drug by decreasing absorption.
• Patients on Coumadin can be given aspirin.


• Carbohydrate, hypertonic solution

• Six-carbon sugar d-glucose, principal carbohydrate used by the body. Used to treat
   hypoglycemia and to manage coma of unknown origin.

Onset & Duration
• Onset: 1 minute
• Duration: Depends on the degree of hypoglycemia.

• Hypoglycemic states (i.e., insulin shock in the diabetic)
• Unconscious patient with unknown history. Any focal or partial neurologic deficit or altered
    state of consciousness, which may be due to hypoglycemia
• Non-traumatic seizure patients who show no improvement in post-ictal state
• Patients in status epilepticus not responsive to Versed
• Children with alcohol exposure, suspected sepsis, hypoperfusion or AMS
• Protocols: Altered Mental Status, Seizures, Syncope, Poisoning/Overdose,
    Psychiatric/Behavioral, Neonatal Resuscitation

• Intracerebral bleeding or hemorrhagic CVA.

Adverse Reactions
• Warmth, pain, burning from medication infusion
• Thrombophlebitis
• Rhabdomyolysis

Drug Interactions
• No significant drug interactions with other emergency medications.

Special Considerations
• Test glucose before administration if possible.
• Extravasation may cause tissue necrosis; use a large vein and aspirate to ensure route
• D50 may precipitate severe neurological symptoms (Wernicke's encephalopathy) in thiamine-
   deficient patients such as alcoholics. This can be prevented by administering 100 mg. IV of
• Use D25% with pediatric or D50% and dilute 1:1 with NS.
• Adult: 25 grams D50W IVP
• Peds >1yr: 0.5-1.0g/kg D25W IVP
• Peds <1yr: 2ml/kg D10W IVP
• To prepare D25W mix 25ml of D50W with 25 ml of normal saline
• To prepare D10W mix 8ml of D25W with 92ml of normal saline
• Oral glucose can be given to patients who can swallow

Diphenhydramine (Benadryl)

• Antihistamine

• Antihistamine that blocks H1 and H2 histamine receptors.

Mechanism of Action
• Blocks effects of H1 receptor stimulation (bronchoconstriction, visceral contractions) and H2
   receptor stimulation (peripheral vasodilation, secretion of gastric acids). Useful in the
   treatment of dystonic reactions accompanying phenothiazine or antipsychotic use (i.e Haldol).
   Direct CNS effects, which may be stimulating or depressing, depending on individual

• Anaphylaxis, allergic reactions
• Dystonic (extrapyramidal) reactions due to phenothiazines.
• Protocol: Allergic Reaction / Anaphylaxis

• Asthma, nursing mothers
• Hypersensitivity
• Lower respiratory diseases, i.e. asthma or COPD (relative contraindication)
• Narrow-angle glaucoma
• Bladder obstruction

Adverse Reactions
• Dose-related sedation
• Dries bronchial secretions
• Blurred vision and dilated pupils
• Headache
• Palpitations/Tachycardia
• Potentiation with other CNS depressants, antihistamines, narcotics, and alcohol.

• The primary treatment of severe allergic reactions is epinephrine, as it reverses the effects of
   histamines. Diphenhydramine blocks histamine receptors, preventing subsequent stimulation.
• MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines.
• Dose
    Adults: 50 mg IV/IM bolus
    <8 years: 1-2 mg/kg slow IV bolus/IM (not to exceed 50 mg)

Epinephrine 1:1000 (Racemic Epinephrine)

• Sympathomimetic

• Stimulates alpha, beta-1, and beta-2 adrenergic receptors.
• Initial drug of choice for treating bronchoconstriction and hypotension resulting from
   anaphylaxis as well as all forms of cardiac arrest. It is useful in managing reactive airway
   disease, but beta-adrenergic agents are often used initially because of their bronchial
   specificity and oral inhalation route. Rapid injection produces a rapid increase in systolic
   pressure, ventricular contractility, and heart rate. In addition, epinephrine causes
   vasoconstriction in the arterioles of the skin, mucosa, and splanchnic areas and antagonizes
   the effects of histamine.

Onset & Duration
• Onset: (SQ) 5-10 min.; (IV) 1-2 min.
• Duration: 5-10 min.

• Bronchial asthma
• Acute allergic reaction

• Hypersensitivity
• Hypovolemic shock
• Narrow angle glaucoma

Adverse Reactions
• Headache
• Nausea
• Restlessness
• Weakness
• Arrhythmias / Chest pain / Precipitation of ACS
• Hypertension

Drug Interactions
• MAO inhibitors and bretylium may potentiate the effect of epinephrine.
• Beta-adrenergic antagonists may blunt inotropic response.
• Sympathomimetics and phosphodiesterase inhibitors may exacerbate arrhythmia response.
• May be deactivated by alkaline solutions (sodium bicarbonate, furosemide).

Special Considerations
• Pregnancy safety: Category C
• Syncope has occurred after epinephrine given to asthmatic children.
• May increase myocardial oxygen demand.


Class and Description
• Pancreatic hormone, insulin antagonist. Hormone secreted by the pancreatic alpha cells.
   When released, it elevates blood glucose by increasing breakdown of glycogen to glucose
   and inhibiting glycogen synthesis. In addition, glucagon exerts positive inotropic action on the
   heart and decreases renal vascular resistance. Only effective in treating hypoglycemia if liver
   glycogen is available, therefore ineffective in chronic hypoglycemia, starvation, and adrenal
   insufficiency. Relaxes GI tract smooth muscle.

Onset & Duration
• Onset: Within 1 min.
• Duration: 3-6 min.

• Intramuscular injection with hypoglycemia and without IV access
• AMS.
• Inotropic agent in patients with beta blockade.
• Protocol: AMS, Hypoglycemia, Seizures

• Hypersensitivity

Adverse Reactions
• Tachycardia
• Hypertension
• Nausea and vomiting

Special Considerations
• Pregnancy safety: Category B
• Should not be considered a first-line choice for hypoglycemia.
• Administer IV glucose if patient does not respond to second dose of glucagon.

Ipratropium Bromide (Atrovent)

Class and Description
• Anticholinergic (parasympatholytic) bronchodilator chemically related to atropine. Used in the
   treatment of respiratory emergencies. Causes bronchodilation and dries respiratory tract

Onset & Duration
• Onset:15 min. after inhalation
• Duration: 2 hr after inhalation

• Bronchial asthma
• Reversable bronchospasm associated with chronic bronchitis and emphysema.
• Protocol: Respiratory distress

• Prior hypersensitivity reaction to ipratropium, atropine or lecithins

Adverse Reactions
• Restlessness
• Apprehension
• Headache
• Dizziness
• Nausea
• Palpitations

Special considerations
• Pregnancy safety: Category B
• Caution should be used when administering to elderly patients and those with cardiovascular
   disease and hypertension.
• Can be given with albuterol as two separate medications or as a combination respiratory
   treatment “Duoneb”

Midazolam (Versed)

• Benzodiazepine tranquilizer.

• Potent but short-acting benzodiazepine used as a sedative and hypnotic. It is three to four
   times more potent than Diazepam. Amnestic properties, but no effect on pain.

Onset & Duration
• Onset: IM – 15 minutes, IV – immediate
• Duration: 2 to 6 hours

• Anti-convulsant
• Sedation
• Management of acute agitation
• Protocol: Seizure

• Known hypersensitivity to the drug
• Narrow-angle glaucoma
• Shock

Adverse Reactions
• Drowsiness
• Hypotension
• Amnesia
• Respiratory depression
• Apnea. Emergency resuscitation equipment should be available.
• Nausea / vomiting. Have suction ready (aspiration risk with unprotected airway).

Drug Interactions
• May potentiate the action of other CNS depressants, including opiate agonists or other
   analgesics, barbiturates or other sedatives, anesthetics, or alcohol. Erythromycin may double
   the half-life of midazolam.

Special Considerations
• Pregnancy Safety: Category D (unsafe)

Morphine Sulfate (MSO4)

• Opium alkaloid (schedule II, controlled).
• Increases peripheral venous capacitance and decreases venous return. It promotes
   analgesia, euphoria, and respiratory and physical depression. Morphine sulfate is a schedule
   II drug.

Onset & Duration
• Onset: Immediate
• Duration: 2-7 hr

• Chest pain of a likely cardiac origin
• Severe burns
• Cardiogenic pulmonary edema
• Isolated extremity injuries
• Pain management
• Protocols: Chest pain, Hypertension, Extremity Injuries, Burns

• Hypersensitivity
• Hypovolemia
• Hypotension (relative)
• Head injury or undiagnosed abdominal pain

Side effects
• Hypotension
• Nausea and/or vomiting
• Vasodilation (Tachycardia or bradycardia)
• Respiratory depression

Dosage and Administration
• Adult: 2–4mg IV/IO/IM Repeat doses of 2.0 mg, up to 10 mg.
• Pediatric: 0.1 mg/kg IV/IO/IM. Contact medical control for pediatrics receiving MSO4.

Special Considerations
• Vital signs, including pulse oximetry and cardiac monitor should be utilized. Naloxone and
   resuscitation equipment should be readily available

Naloxone (Narcan)

• Synthetic opioid antagonist

• Competitive narcotic antagonist used in the management and reversal of overdoses caused
   by narcotics and synthetic narcotic agents. Unlike other narcotic antagonists, which do not
   completely inhibit the analgesic properties of opiates, naloxone antagonizes all actions of

Onset & Duration
• Onset: Within 2 min.
• Duration: 30-60 min.

• >8yrs to Adult: titrated up to 2.0 mg IV/IM/IO/IN. Repeat dose of 2.0 mg may be given if no
   response is noted after 5 minutes.
• <8yrs: titrates up to 1.0mg IV/IM/IO/IN IN. Repeat dose of 1.0 mg may be given if no
   response is noted after 5 minutes.

• Complete or partial reversal of CNS and respiratory depression induced by opioids
• Decreased level of consciousness
• Coma of unknown origin
• Circulatory support in refractory shock (investigational)
• Protocol: AMS, Seizures, Resuscitation

• Hypersensitivity
• Use with extreme caution in narcotic-dependent patients who may experience withdrawal
   syndrome (including neonates of narcotic-dependent mothers). These patients may become
   extremely violent and unpredictable.

Adverse Reactions
• Tachycardia
• Hypertension
• Arrhythmias
• Nausea and vomiting
• Diaphoresis
• Blurred vision
• Seizures
• Violent and aggressive acute withdrawal

Drug Interactions
• Incompatible with bisulfate and with alkaline solutions.

Special Considerations
• Pregnancy safety: Category B
• May not reverse hypotension
• Caution should be exercised when administering naloxone to narcotic addicts (may
   precipitate withdrawal with hypertension, tachycardia, and violent behavior).
• May cause seizures
• Patients receiving Naloxone must be transported to a hospital

Nitroglycerine (NTG, Nitrostat, Nitroquick)

Class and Description
• Vasodilator originally believed that nitrates and nitrites dilated coronary blood vessels,
   thereby increasing blood flow to the heart. It is now believed that atherosclerosis limits
   coronary dilation and the benefits of nitrates result from dilation of peripheral arterioles and
   veins. The resulting reduction in preload and afterload decreases the work load of the heart
   and lowers myocardial oxygen demand.

Onset & Duration
• Onset: 1-3 min.
• Duration: 20-30 min.

• Ischemic chest pain
• Hypertensive emergency
• Congestive heart failure, acute pulmonary edema
• Protocols: Chest pain, hypertension, suspected pulmonary edema

• Systolic BP <100
• Hypersensitivity
• Pericardial Tamponade / Constrictive pericarditis / Restrictive cardiomyopathy
• Head injury / Cerebral hemorrhage
• Hypovolemia
• Aortic Stenosis
• Right ventricular MI
• Recent use of sildenafil (Viagra™), Vardenafil (Levitra™), or similar drugs for use in males or

Adverse Reactions
• Transient headache
• Postural syncope
• Reflex tachycardia
• Hypotension
• Nausea and vomiting
• Allergic reaction
• Muscle twitching
• Diaphoresis

Drug Interactions
• Other vasodilators may have additive hypotensive effects.

• 0.4 mg SL or spray, every 5 minutes, for a total of 3 doses. Vital signs must be re-assessed
   after each administration.
• Contact medical control for patients with a SBP <100 mmHg or if patient with continual CP
   post 3 NTG.

Special Considerations
• Pregnancy safety: Category C
• Susceptibility to hypotension in older adults increases.
• Nitroglycerine decomposes when exposed to light or heat.

Odansetron (Zofran)

• Selective 5-HT3 receptor antagonist. Mechanism of action not fully characterized.

• Nausea with concern for potential vomiting
• Vomiting
• Protocol: nausea and vomiting.

• Patients with a known hypersensitivity to odansetron.

• Ondansetron is listed as a category B with regard to use in pregnancy.
• Be cautious in patients with impaired liver function.
• Low incidence of side effect, but potential for: headache, dizziness, fever, urinary retention,
   rash, agitation, sedation, dystonia, bronchospasm, arrhythmias.
• Does not prevent motion sickness

• Adult: 4 mg IV/IO/IM
• Pediatric >1 year: under 40 kg: 0.1 mg/kg; over 40 kg: 4 mg IV/IO/IM

Oral Glucose (Insta-Glucose)

• Body's basic fuel and is required for cellular metabolism. A sudden drop in blood sugar level
   results in disturbance of normal metabolism, manifested clinically as AMS, sweating, and
   tachycardia. Further decreases in blood sugar may result in coma, seizures, and cardiac
   arrhythmia. Serum glucose regulated by insulin, which stimulates storage of excess glucose
   from the body's blood stream, and glucagon, which mobilizes stored glucose into the blood
   stream. The oral glucose paste is rapidly absorbed into the oral mucosa, thus elevating the
   body's blood glucose level.

Onset and Duration
• Onset: 30 seconds – 5 minutes
• Duration: 60 minutes

• Hypoglycemia
• Altered Mental Status with a history of (hypoglycemia) diabetes
• Protocols: Hypoglycemia, AMS, Seizures

• Inability to swallow
• Patient who may experience an airway obstruction from administration

• The dosage of oral glucose is one full tube.
• Squeeze 1/3 of the tube into patient's mouth between the cheek and gum. Repeat the
   procedure until one full tube of glucose has been administered.
• Reassess the vital signs and the patient's condition
• Be aware of possible airway obstruction. Have suction available.

Oxygen (O2)

• Oxygen added to the inspired air increases the amount of oxygen in the blood, increasing the
   amount delivered to the tissue. Tissue hypoxia causes cell damage and death. Breathing
   regulated by small changes in the acid-base balance and CO2 levels with large decreases in
   oxygen concentration or high increases in CO2 to stimulate respiration.

• Hypoxemia or respiratory distress
• Acute chest or abdominal pain
• Hypotensive states from any cause
• Trauma
• Acutely ill patients
• Suspected carbon monoxide poisoning
• Pregnant females

• If the patient is not breathing adequately, the treatment of choice is assisted ventilation, not
   just oxygen.
• A small percentage of patients with chronic lung disease breathe because they are hypoxic.
   Administration of oxygen will inhibit their respiratory drive. Do not withhold oxygen because of
   this possibility. Be prepared to assist ventilations if needed.
• Restlessness may be an ominous sign of hypoxia.
• Nasal prongs work equally well on nose and mouth breathers, except babies.
• Oxygen toxicity is not a hazard of short term use.

• 2-15 liters per minute
• Nasal Cannula: 2-4 lpm
• Simple Face Mask: 6-10 lpm
• Non-Rebreather: 10-15 lpm

Tetracaine Hydrochloride

• Rapidly acting topical anesthetic used to provide ophthalmic anesthesia.

Onset & Duration
• Onset: 20-30 seconds
• Duration: 15-30 minutes

• Actual or potential serious eye injuries
• Protocol: Eye trauma

• Global laceration/rupture injuries
• Allergy to local anesthetics (“Caines”)

Adverse Reactions
• Occasional burning/stinging can occur when initially applied, although this is usually transient
• No drug Interactions

• Instill two drops into affected eye x one dose. Contact medical control if further dosages
   required for pain control.

Special Considerations
• Be sure to warn patient not to rub eye.
• Each vial is for a single patient use. Unused portions are to be discarded and only new
   bottles are to be used.
• Do not administer until patient consents to transport and transport has begun
• Topical eye anesthetics should never be given to a patient for self-administration

CQI Guidelines ~ Important Points:
1. Improving overall patient care is the goal of any CQI process, not “making examples” of
2. With the exception of cases of suspected gross negligence, at no time will an individual’s
   livelihood (i.e. shift hours) be limited.
3. The Medical Director(s) will never be involved in any re-education recommendations other
   than what is covered generally in the CQI Levels of Response.
4. Though recommendations for each Level of Concern will be provided by the CQI officer and
   Medical Director(s), all re-education is overseen by the shift supervisor.
5. Any objections to the CQI Level or response can be mediated via due process, with
   representation that the EMT may request.

CQI Guidelines ~ Levels of Concern
Level 1:      Inadequate documentation of patient care.
              i.e. Significant amount of missing data preventing understanding of events and/
              or appropriate billing for level of service.

Level 2:        Unexplained delay on scene or in transport.
                i.e. >20 mins from time-on-scene to transport in patient with chest pain.

Level 3:        Obvious clinical pattern/ syndrome not recognized, resulting in delay or
                inadequate care.
                i.e. Unrecognized or untreated ST elevation myocardial infarction.

Level 4:        Standard of care disregarded.
                i.e. Airway placed without actual or documented confirmation of correct
                placement, resulting in unrecognized esophageal intubation.

Level 5:        Negligent-appearing behavior or blatant disregard for protocols.
                i.e. Performing skills above level of training, i.e. field thoracotomy.

CQI Guidelines ~ Response Levels
Level 1:      Inadequate documentation of patient care.
              1. The EMT will submit a PCR addendum within 7 days of the inquiry,
                  documenting deficiencies and care provided to the patient including
                  medications, interventions, and condition of the patients both at scene arrival
                  and at transfer to the receiving hospital.
              2. If the chart is inappropriately billed as “BLS” for an “ALS” run, this must be
                  noted in the addendum.

Level 2:        Unexplained delay on scene or in transport.
                1. The EMT will submit a PCR addendum within 7 days of the inquiry,
                   containing further documentation to explain any delays, i.e. “12 minute delay
                   from arrival at scene to initiation of treatment due to no officer on scene at
                   EMS arrival”.
                2. It must be clear what impact (if any) the delay had on patient care.

Level 3:        Obvious clinical pattern/ syndrome not recognized, resulting in delay or
                inadequate care.
                1. The EMT will submit a PCR addendum within 7 days of the inquiry including
                    a typewritten summary of the clinical pattern/ syndrome and the FD policy
                    regarding this clinical pattern/ syndrome. The addendum must clarify if a true
                    clinical existed that was not recognized, or that no true clinical syndrome
                    occurred (i.e. SVT in a patient that was hemodynamically stable, therefore no

              electrical cardioversion was necessary). It must be clear what, if any, impact
              was on patient care.
           2. The summary of the clinical syndrome and AOM protocols must be counter-
              signed by the Medical Director(s) and the CQI Officer.

Level 4:   Standard of care disregarded.
           1. The EMT will submit a PCR addendum within 7 days of the inquiry including
              a typewritten summary of the clinical pattern/ syndrome and the FD policy
              regarding this clinical pattern/ syndrome (i.e. summary of the signs/
              symptoms of tension pneumothorax, and summary of the AOM policy
              regarding field treatment) on a standard form. It must be clear what, if any,
              impact disregarding the standard of care had on patient care, as well as why
              the standard of care was disregarded; i.e. lack of protocol knowledge vs.
              knowledge but disregard of protocols.
           2. The summary of clinical syndrome and AOM protocols must be counter-
              signed by the Medical Director(s) and the CQI Officer.
           3. If the violation of standard of care is found to be related to “disregard for”
              rather than “knowledge of” standard of care, or reflects a pattern of
              inappropriate behavior, the involved parties’ supervisor will be notified by the
              CQI Officer.

Level 5:   Negligent-appearing behavior or blatant disregard for protocols.
           1. The EMT will submit a PCR addendum within 7 days of the inquiry including
              a typewritten summary of the clinical pattern/ syndrome and the FD policy
              regarding this clinical pattern/ syndrome (i.e. summary of the signs/
              symptoms of tension pneumothorax, and summary of the AOM policy
              regarding field treatment). It must be clear in the addendum what, if any,
              impact the behavior had on patient care.
           2. The summary of clinical syndrome and AOM protocols must be counter-
              signed by the Medical Director(s) and the CQI Officer.
           3. If the violation of standard of care is found to be related to a disregard for the
              standard of care, and/ or reflects a pattern of inappropriate behavior, the
              involved parties’ supervisor, lieutenant, and if necessary the Chief of EMS
              will provide input and recommendations.

o   Emergency Medical Services Clinical Practices and Systems Oversight. NAEMSP. 2009.
o   Emergency Medical Technician Provider Manual. Brady. 2008.
o   ACLS: Principles and Practices. American Heart Association. 2003. 135-173.
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o   Soliz, J; et al. Airway Management: A Review and Update. The Internet Journal of
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    difficult intubation. Anesthesia 2004 Jul;59(7):675-94.
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o   ATLS 7th Edition. 2004. American College of Surgeons. Pg. 57-58
o   Kendall JM, Reeves BC, Latter VS. Multicentre randomised controlled trial of nasal
    diamorphine for analgesia in children and teenagers with clinical fractures. BMJ. 2001;
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o   Denver Metr Barton, Ed, Colwell, et al. Efficacy of intranasal naloxone as a needleless
    alternative for treatment of opioid overdose in the prehospital setting. J Emerg Med 2005;
o   Kelly, A. M. and Z. Koutsogiannis (2002). "Intranasal naloxone for life threatening opioid
    toxicity." Emerg Med J 19(4): 375.
o   Loimer N, Hofmann P, Chaudhry HR. Nasal administration of naloxone is as effective as the
    intravenous route in opiate addicts. Int J Addict 1994; 29:819-27.
o   Wolfe, Tr, Macfarlane, Tc. Intranasal midazolam therapy for pediatric status epilepticus. Am J
    Emerg Med 2006; 24:343-6.
o   Holsti, Sill, et al. (2007). "Prehospital intranasal midazolam for the treatment of pediatric
    seizures." Pediatr Emerg Care 23(3): 148-53.
o   Denver Metropolitan Prehospital Protocol Manual. 2008.
o   Shreveport Fire Department EMS Policies and Procedures. 2007.
o   Stanford Connecticut Prehospital Protocol Manual. 2007.
o   Ohio Department of Public Safety.
o   Hamilton County Academy of Medicine.


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