Download CHAFFEE COUNTY EMS

Pre-Hospital Treatment Protocols
Version 10.0
This document has been approved by the Medical Director for Chaffee County Emergency Medical Services
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Table of Contents
Acknowledgment Form
Introduction
Acts Allowed
6
7
8
Operating Policies
Trauma Team Activation
Roles and Responsibilities
Standard of Care
Operating Guidelines
Patient Restraint
Resuscitation and DNR Orders
Field Pronouncement Guidelines
13
14
17
18
19
21
Treatment Protocols
Cardiac Emergencies
Cardiac Arrest, Medical
Therapeutic Hypothermia
Acute Coronary Syndrome
STEMI Alert
Thrombolytic Checklist
Dysrhythmias
Hypertension
22
26
27
28
29
31
36
Medical Emergencies
Abdominal Pain
Anaphylaxis
Behavioral Disorders
Cerebral Vascular Accident (CVA)
CO Monitoring, Exposure, & Treatment
Hyperglycemia
Hypoglycemia
Hyperthermia
Hypothermia Generalized
Hypothermia Localized
Poisoning/Overdose
Seizures
Shock
Septic Shock Alert
Syncope
Unconscious Patient
Adrenal Insufficiency
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38
39
40
43
44
45
46
47
48
49
52
53
54
57
58
66
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Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Treatment Protocols
Pulmonary / Respiratory Emergencies
Respiratory Distress, General
Asthma
CHF
COPD
Pediatric Dyspnea
59
60
61
62
63
Obstetrics / Gynecological Emergencies
Childbirth
Neonatal Resuscitation
Pregnancy Induced Hypertension &Eclampsia
Vaginal Bleeding
67
69
70
71
Trauma Emergencies
Trauma Arrest
Amputation Injuries
Burns
Chest Pain, Traumatic
Fractures, Dislocations, and Sprains
Head Trauma
Hemorrhage
Spinal Trauma
Selective Spinal Immobilization Tool
Crush Injury
Drowning/Near Drowning
72
75
76
77
79
80
82
83
84
86
87
Procedure Protocols
Airway
OPA/NPA
Extra-Glottic Airways
Endotracheal Intubation, Nasal
BAAM
Endotracheal Intubation, Oral
Endotracheal Intubation, RSI
Awake Look
Airway Assessment
Failed Airway
Percutaneous Cricothyrotomy
Breathing
Continuous Positive Airway Pressure
Apneic Oxygen
Chest Decompression
88
89
90
91
92
93
95
96
97
98
100
101
102
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Circulation
Peripheral IV Insertion
Law Enforcement Blood Draw
Venous Blood Draw
External Jugular Cannulation
Inter Osseous Cannulation
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103
104
105
106
107
Cardiac
Semi-Automated Cardiac Defibrillator
Defibrillation
Pacing
Cardioversion
108
109
110
111
Skills and Monitoring
Pulse Oxymetry
Capnometry
Automated Transport Ventilator
Glucometer
Pain Management
Bandaging / Bleeding Control
Splinting / Immobilization
Selective Spine Immobilization
Medication Administration
Foley Catheter Placement
NG / OG Tube Placement
114
115
116
127
128
129
130
132
134
136
137
Pharmacology / Medication Administration Protocols
Assisted Medications
Metered Dose Inhaler (MDI)
EpiPen
Nitroglycerine (NG)
139
140
141
Medications
Acetylsalicylic Acid (ASA)
Adenosine
Albuterol
Amiodarone
Atropine
Calcium
Dextrose
Diazepam
Diltiazem
Diphenhydramine
Epinephrine
Epinephrine Drip
Fentanyl
Furosemide
Glucagon
142
143
144
145
146
147
148
149
150
151
152
154
156
157
158
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January 1, 2016
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Glucose, Oral
Hydromorphone
Ketamine
Ipratropium
Lidocaine
Magnesium
Methylprednisolone
Midazolam
Morphine
Naloxone
Nitroglycerine
Ondansetron
Oxygen
Phenylephrine
Promethazine
Sodium Bicarbonate
Succinylcholine
Tetracaine
Vecuronium
159
160
161
162
163
164
165
166
167
168
169
170
172
173
174
175
176
177
178
Over the Counter Medications
EMT-I Direct Order Exception
Interfacility Transfer Medications
Intravenous Solutions
179
180
181
185
Revisions from previous edition
Critical Care Protocols
186
187
Addendum
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Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
CHAFFEE COUNTY EMERGENCY MEDICAL SERVICES
MEDICAL PROTOCOL ACKNOWLEDGEMENT FORM
I, _________________________________, acknowledge that I have received a copy of the Chaffee County
Emergency Medical Services Medical Protocols version 10. I understand that I also have access to the Chaffee
County Medical Protocols at either station, or in any ambulance, at any time.
I have received the protocols in the form of: (Please circle one)
Hard copy
CD
Electronic copy
In addition, I agree to review these protocols and accept the responsibility for knowing and practicing as a provider
in accordance with them, when appropriate. I further agree to review any additional additions and/or changes that
may be made to the protocols as they are distributed.
Name (Print):__________________________________________________
Signature: _______________________________ Date: _________________
Agency: ______________________________________________________
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Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
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Introduction
This manual is intended to outline the Standard of Emergency Medical Care for the personnel of Chaffee County
Emergency Medical Services. As a Standard of Care, this manual is to be used by members certified at the EMT-Basic,
EMT-Basic/IV, EMT-Intermediate, Paramedic, and Paramedic – Critical Care Endorsement levels, as a means of
determining the level of care to be administered in any given situation. It is also the standard used by the Medical
Director to evaluate and guide care throughout the system
Not all medical skills, acts allowed, and medications are included in the initial education for various EMS provider levels.
Every attempt will be made by Chaffee County Emergency Medical Services and the Medical Director to provide
additional education, but it is the responsibility of the individual provider to seek additional education if it is needed.
Each individual within the emergency medical services system is responsible for the following:
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Performing to the Standard of Care for his/her level of certification
Obtaining additional training, beyond initial education, if needed
Maintaining current certification
Participating in continuing education
These protocols are a guideline and are unable to account for every patient condition, patient presentation, and
situation. Deviation from these protocols should be done only with the patient’s best interest in mind and backed with
sound clinical judgment. Any deviation must be thoroughly documented and submitted for review
If questions arise concerning a patient’s condition or treatment modalities, contact with the Base Physician should be
initiated without hesitation
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Acts Allowed
The Medical Director has determined the Acts Allowed for each certification level within Chaffee County Emergency
Medical Services
The Acts Allowed for EMT-B’s, EMT-B/IV’s, EMT-I’s, and Paramedics are accordance with the Acts Allowed as
determined by the Colorado Department of Public Health and as outlined in Rules Pertaining to EMS Education and
Certification, 6 CCR 1015-3, Chapter Two or through approved medical waivers. Providers must be certified to provide
patient care in the state of Colorado
Performing an Act that is beyond a provider’s Scope of Practice is considered “practicing without a license” and is not
acceptable. Any provider that performs an Act that is beyond his/her Scope of Practice will be subject to disciplinary
action that will be determined at the discretion of the Medical Director
A provider may administer a medication that is beyond his/her Scope of Practice only under the direct visual
supervision of a provider that has a Standing Order for that medication and to patients in extremis
Certain procedures that are not covered in this document may be performed if adequate training has been obtained
and with Base Physician approval. This does not apply to controlled medications
Not all medical skills, acts allowed, and medications are included in the initial education for various EMS provider levels.
Every attempt will be made by Chaffee County Emergency Medical Services and the Physician Medical Director to
provide additional education, but it is the reasonability of the individual provider to seek additional education if it is
needed
X=
Standing Order. Can be performed without on-line approval from the Base Physician or the provider of a
higher level who has Standing Order allowance for the procedure/medication
DO =
Direct Order. Express verbal permission must be obtained from the Base Physician before performing
procedure. A provider of a higher level, that has Standing Order allowance, may issue the Direct Order
Procedures
Level of Certification
Patient Assessment
EMT-B
EMT-BIV
EMT-I
Paramedic
x
x
x
x
x
x
x
x
x
x
Airway Management
Suction (Powered or Manual)

Pharyngeal suction
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Tracheal suction
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Extra-glottic device suctioning
x
x
x
x
x
x
x
x
Basic Life Support Airways
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Oropharyngeal placement
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Nasopharyngeal placement
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x
x
x
x
x
x
x
x
x
x
Extra-Glottic Airways (King-LTD, King LTSD, LMA)
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Extra-Glottic Airways
Endotracheal Intubation
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Oral intubation
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Nasal intubation
x
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Rapid sequence intubation (Waivered)
x
Cricothyrotomy (Surgical, needle guided)
x
Oxygen Administration

Nasal cannula (NC)
x
x
x
x
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Non-rebreather mask (NRB)
x
x
x
x
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Bag valve mask (BVM)
x
x
x
x
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Small volume nebulizer (SVN)
DO
DO
x
x
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Continuous positive airway pressure (CPAP)
DO
DO
x
x

Blow-by oxygen
x
x
x
x
x
x
Chest decompression (Needle)
Circulation Management
CPR
x
x
x
x
Soft tissue management
x
x
x
x
Fractures/dislocations
x
x
x
x
Spinal immobilization
x
x
x
x
Shock management
x
x
x
x
Hemorrhage control

Direct Pressure
x
x
x
x
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Bandaging
x
x
x
x

Tourniquet
x
x
x
x
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Hemostatic Agents (Celox)
x
x
x
x
x
x
x
Intravascular Access
IV initiation

Peripheral IV
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External jugular cannulation
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Saline lock
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x
x
x
x
x
Buritrol/Volutrol
x
x
x
Blood Y
x
x
x
x
x
x
IV monitor/use/maintenance

Peripheral IV

External jugular IV
x
x

Central venous catheter
x
x
IV fluid administration

Normal Saline
x
x
x

D5W
x
x
x

Medication drip
DO
x
x
x
IO insertion
Patient Monitoring
Vital signs

Non-invasive blood pressure
x
x
x
x

Pulse rate
x
x
x
x
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Pulse oximetry
x
x
x
x

CO monitoring & treatment
x
x
x
x
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End tidal C02 detection
x
x
x
x
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Temperature
x
x
x
x
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Glucometer
x
x
x
x
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Lactate monitor
x
x
x
x
Miscellaneous Skills
NG / OG tube placement
x
Foley catheter placement
x
Cardiac Management
Automatic external defibrillation
x
x
x
x
ECG/12 lead monitoring
x
x
x
x
ECG/12 lead interpretation
x
x
Manual defibrillation
x
x
Transcutaneous cardiac pacing
x
x
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Synchronized cardioversion
x
Therapeutic hypothermia
DO
x
Medication Administration Routes
Nebulized (SVN)
DO
DO
x /DO
x
Intra nasal (IN)
x
x
x /DO
x
Intra muscular (IM)
x /DO
x
Sub cutaneous (SC)
x /DO
x
x /DO
x
x /DO
x
Intra venous
x
Intra osseous
Oral/Buccal/Lingual
x/DO
x/DO
x/DO
x
Medication Administration
Medication:
Assisted medications:

EpiPen/EpiPen Jr
DO
DO
DO
x

MDI
DO
DO
DO
x

NTG
DO
DO
x
x

Acetylsalicylic acid/Aspirin
x
x
x
x

Adenosine/Adenocard
DO
x

Albuterol
DO
x

Amiodarone
DO
x

Atropine
DO
x

Calcium

Dextrose 10%

Diazepam/Valium

Diltiazem/Cardizem

Diphenhydramine/Benadryl

Dopamine/Inotropin

Epinephrine

DO
DO
x
x
x
x
DO
x
x
DO
x
x
x/DO
x
Epinephrine drip
DO
x

Fentanyl/Sublimaze
DO
x
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Furosemide/Lasix
DO
x
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Glucagon/Glucogen
x/DO
x
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Ipratropium bromide/Atrovent
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Ketamine/Ketalar
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Lidocaine/Xylocaine (Bolus for procedure)
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Lidocaine/Xylocaine (Antidysrhythmic)
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Magnesium Sulfate
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DO
x
x
x
x
DO
x
DO(OB)
x
Methylprednisolone/SoluMedrol
DO
x
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Midazolam/Versed
DO
x

Morphine
DO
x
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Naloxone/Narcan
x
x

Nitroglycerine/Nitrostat
x/DO
x

Ondansetron/Zofran

x
x
DO(ODT)
DO(ODT)
x
x
Oral glucose
x
x
x
x

Oxygen
x
x
x
x

Phenylephrine/Neosynephrine

Promethazine/Phenergan

Vecuronium Bromide

Sodium Bicarbonate

Succinylcholine Chloride

Tetracaine/Opthaine

Specified OTC medications
x
DO
x
x
DO
x/DO
x
x
x
x
x
x
x
Interfacilty Transport - Procedures

Chest tube monitoring
x

Ventilator – Automated Transport Ventilator
x

IV Pump
x
x
Interfacility Transport - Medications

See Specific Protocol
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Trauma Team Activation
The Trauma Team at Heart of the Rockies Regional Medical Center consists of the ED physician, trauma surgeon,
EDRN, respiratory therapy technician, radiology technician and laboratory technician
The emergency department, prior to the arrival of patients who meet the criteria listed, will notify the team. Any
pre-hospital provider, EDRN, MD, EDMD or surgeon may activate the Trauma Team for patients who meet criteria.
The trauma surgeon, when available for consult, will respond within 10 minutes of the arrival of the patient who
meets activation criteria


Trauma Team Activation – Major
o
GCS <13 due to trauma
o
o
o
o
o
o
o
o
o
BP <90 systolic, or pulse >120 in an adult patient
BP <70, or pulse >150, or capillary refill time >3 seconds in an pediatric patient (0-12 yrs old)
Respiratory rate <10 or >29
Flail chest
Penetrating injury to neck, chest, or abdomen
Spinal cord injury with neurological deficit
Multisystem injury (>2 systems injured)
Burns >15% TBSA and/or associated injury including inhalation potential
Falls >20 feet
Trauma Team Activation – Minor
o
o
o
o
o
o
o
o
o

GCS <14 due to trauma
Pulseless extremity
High speed MVA w/ significant vehicle damage
Unrestrained occupant of MVC
Auto vs. pedestrian / bicycle at speeds >20mph or thrown > 15 feet
Separation from conveyance (Includes: horse, ATV, snowmobile, bicycle etc)
Death of same car occupant
Lightning or electrical injury
Contra lateral fractures
A trauma team activation may be called at the pre-hospital provider’s discretion even if a patient does
not meet the above stated criteria
***Please note that the Trauma Team Activation with surgeon applies only when the trauma surgeon is on call and
present for consultation in our facility. All other times, State Trauma Protocol for Trauma and Transfer criteria
takes precedence ***
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Roles and Responsibilities
The Board of Medical Examiners has promulgated Rule 800 which allows EMS workers to function under the license
of a physician who is termed a Medical Director. Each Medical Director is responsible for preparing local protocols to
govern field performance according to Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter 2.
Chapter 2 defines the roles and responsibilities of Medical Directors and describes the Acts Allowed by EMT-B’s, EMTBIV’s, EMT-I’s, and Paramedics
It is important for all providers to remember that they are required to work under a physician’s license. Personnel
who do not comply with any portion of this policy shall have their patient care privileges suspended until further
notice
Emergency Medical Technician - Basic (EMT-B)
Providers certified at EMT-B level may be responsible for rendering care in conjunction with providers of a higher
certification level or as a sole provider. Requirements to provider care in Chaffee County include:
 Maintain current certification in BLS for the Health Care Provider
 Completion of a recognized EMT-Basic course
 Colorado EMT-B certification
 Continuing education as required to maintain certificate
 Provide copies of all certifications
 Sponsorship from the Medical Director
IV Certifications by EMT-B’s
Providers certified at the EMT-B level may obtain an IV certification. In addition to the above requirements, the
following are required for an EMT-B to start IV’s within Chaffee County:
 Present proof of completion of a recognized initial IV training course
 Maintain documentation of a minimum of six (6) successful IV starts every six (6) months. IVs may be started
on patients in the field, on colleagues during training sessions, or at clinical sessions in a hospital setting. IV
starts must be documented by an R.N., MD/DO, EMT-B, EMT-BIV, EMT-I or Paramedic
Emergency Medical Technician – Intermediate /99 (EMT-I)
Providers certified at EMT-I level may be responsible for rendering care in conjunction with providers of a higher
certification level or as a sole provider. Requirements to provider care in Chaffee County include:
 Completion of a recognized initial EMT-I course
 Colorado EMT-I certification
 Continuing education as required to maintain certificate
 Provide copies of all certifications
 Current CPR for the Health Care Provider certification
 Current ACLS certification
 Current PEPP or PALS certification
 Sponsorship from the Medical Director
Emergency Medical Technician – Paramedic/EMT-Intermediate Trainee (Paramedic/EMT-I Trainee)
A Paramedic/EMT-Intermediate Trainee is defined as a provider who is presently in Paramedic or EMT- Intermediate
school and has sufficiently progressed with the didactic and field education so that the individual can efficiently
operate in the field as an ALS provider. The transition from EMT- Basic to Paramedic/EMT-Intermediate Trainee is
generally at the time at which the individual has completed the didactic portion of the program. Requirements to
provider care in Chaffee County as a Trainee include:
 Currently attending an approved Paramedic or EMT-Intermediate school
 Have authorization from the clinical coordinator of the school the Trainee is attending
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Sponsorship from the Medical Director
Work with a Paramedic at all times in order to operate as a Trainee
A Trainee may perform all of the skills of a Paramedic/EMT-Intermediate under supervision of an approved
Paramedic
Paramedic
Providers certified at Paramedic level may be responsible for rendering care in conjunction with providers of a higher
certification level or as a sole provider. Requirements to provider care in Chaffee County include:
 Completion of a recognized initial Paramedic course
 Colorado Paramedic certification
 Continuing education as required to maintain certificate
 Provide copies of all certifications
 Current CPR for the Health Care Provider certification
 Current ACLS certification
 Current PEPP or PALS certification
 Sponsorship from a Medical Director
Medical Director
The Board of Medical Examiners and the State Health Department define the roles of the Medical Director. The
following description is taken from the State of Colorado Board of Medical Examiners Rules Pertaining to EMS
Education and Certification, 6 CCR 1015-3, Chapter Two, Section 4
A medical director shall possess the following minimum qualifications:
 Be a physician currently licensed to practice medicine in the State of Colorado
 Be trained in Advanced Cardiac Life Support.
 Physicians acting as medical directors for Department-recognized EMS education programs must possess
authority under their licensure to perform any and all medical acts to which they extend their authority to
EMS Providers, including any and all curricula presented by EMS education programs
The duties of a medical director shall include:
 Be actively involved in the provision of emergency medical services in the community served by the EMS
Service Agency being supervised. Involvement does not require that a physician have such experience prior
to becoming a medical director, but does require such involvement during the time that he or she acts as a
medical director. Active involvement in the community could include, by way of example and not limitation,
those inherent, reasonable and appropriate responsibilities of a medical director to interact with patients,
the public served by the EMS Service Agency, the hospital community, the public safety agencies, and the
medical community, and should include other aspects of liaison oversight and communication normally
expected in the supervision of EMS Providers
 Be actively involved on a regular basis with the EMS Service Agency being supervised. Involvement does not
require that a physician have such experience prior to becoming a medical director, but does require such
involvement during the time that he or she acts as a medical director. Involvement could include, by way of
example and not limitation, involvement in continuing education, audits, and protocol development. Passive
or negligible involvement with the EMS Service Agency and supervised EMS Providers does not meet this
requirement
 Notify the Department on an annual basis of the EMS Service Agencies for which medical control functions
are being provided in a manner and form as determined by the Department
 Establish a medical continuous quality improvement (CQI) program for each EMS Service Agency being
supervised. The medical continuous quality improvement program shall assure the continuing competency
of the performance of that agency’s EMS Providers. This medical continuous quality improvement program
shall include, but not be limited to, appropriate protocols and Standing Orders and provision for medical
care audits, observation, critiques, continuing medical education and direct supervisory communications
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Submit to the Department an affidavit that attests to the development and use of a medical continuous
quality improvement program for all EMS Service Agencies supervised by the medical director. As set forth
below in section 4.3, the Department may review the records of a medical director to determine compliance
with the CQI requirements in these rules
Provide monitoring and supervision of the medical field performance of each supervised EMS Service
Agency’s EMS Providers. This responsibility may be delegated to other physicians or other qualified health
care professionals designated by the medical director. However, the medical director shall retain ultimate
authority and responsibility for the monitoring and supervision, for establishing protocols and Standing
Orders and for the competency of the performance of authorized medical acts
Ensure that all protocols issued by the medical director are (1) appropriate for the certification and skill level
of each EMS Provider to whom the performance of medical acts is delegated and authorized, and (2)
compliant with accepted standards of medical practice
Be familiar with the training, knowledge and competence of EMS providers under his or her supervision and
ensure that EMS providers are appropriately trained and demonstrate ongoing competency in all skills,
procedures and medications authorized
Be aware that certain skills, in procedures and medication authorized may not be included in the national
EMS educations standards and ensure appropriate additional trains Is provided to supervised EMS providers
Ensure that any data and/or documentation required by these rules are submitted to the Department
Notify the Department within fourteen business days excluding state holidays prior to his or her cessation of
duties as medical director
Notify the Department within fourteen business days excluding state holidays of his or her termination of
the supervision of an EMS Provider for reasons that may constitute good cause for disciplinary sanctions
pursuant to the Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter One. Such
notification shall be in writing and shall include a statement of the actions or omissions resulting in
termination of supervision and copies of all pertinent records
Physicians acting as medical directors for EMS education programs recognized by the Department that
require clinical and field internship performance by students shall be permitted to delegate authority to a
student-in-training during their performance of program-required medical acts and only while under the
control of the education program
Abuse/Neglect Reporting
Any employee of Chaffee County Emergency Medical Services, as described in C.R.S. 19-3-304, is by law a
mandatory reporter if they suspect child or elder abuse or neglect. This applies if:


Provider has reasonable cause to know or suspect that a child or elderly person has been subjected to
abuse or neglect
Provider observed the child or elderly person being subjected to circumstances or conditions that would
reasonably result in abuse or neglect
The mandatory reporter shall immediately upon receiving such information report to the Chaffee County
Department of Human Services, the local law enforcement agency, or through the child abuse reporting hotline
system. If appropriate, law enforcement should be called to the scene
Child Abuse Hotline: 1-844-264-5437
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Standard of Care
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Policy
o
o
o
The Standard of Care is defined as "The minimum acceptable care, based on state laws and the
protocols set forth by the Chaffee County Medical Director”
The Standard of Care will be used to determine which Acts are to be allowed for each level of
certification. It will also allow the individual to understand what is expected of him or her
These Protocols are to be used as guidelines not “the law”. Each emergency is different and
requires a provider to make judgments and decisions that may not fit directly into one specific
protocol. Knowing this, the protocols should be used as guidelines and a tool to help the EMS
personnel provide medical care to their patients

Provision of care
o EMS personnel are expected to perform to the level of their training at all times. Care will not be
modified or altered based on the patient's race, religion, beliefs, or medical prognosis or condition
unless the patient is refusing care due to personal or religious beliefs and the patient is determined
to be mentally competent
o Responsibility for patient care is delegated to the individual with the highest level of medical
training. The hierarchy of medical control on scene is as follows:
 First Aid/ Wilderness First Aid
 First Responder/Wilderness First Responder
 Emergency Medical Responder
 Emergency Medical Technician - Basic (EMT-B)
 Emergency Medical Technician – Basic with IV certification (EMT-BIV)
 Advanced Emergency Medication Technician
 Emergency Medical Technician - Intermediate (EMT-I)
 Emergency Medical Technician – Paramedic (EMT-P)
 Paramedic
 Paramedic with Critical Care Endorsement
 Medical Director or Base Physician

The patient should receive the most appropriate level of care available in all situations. Denying a patient
Advanced Life Support in favor of Basic Life Support care in an Advanced Life Support situation constitutes
an act of willful negligence and is not in the best interests of the patient's welfare. Knowingly withholding or
denying advanced levels of care is a serious act. Failure to abide by this policy will result in immediate
corrective action
The patient should be evaluated by the personnel on scene who has the highest level of training. The
ultimate responsibility of patient care falls upon the highest level medical provider on scene
Under no circumstances, (except when ALS care is not available), is a patient who falls under the ALS
category to be solely attended by or transported by BLS personnel. This is detrimental to the patient's wellbeing and places the EMS personnel and the medical director in legal jeopardy
This policy has not been designed to stifle, limit or curtail the experiences of BLS personnel. Our primary goal
is to ensure that optimal patient care is being rendered. With this in mind, we encourage BLS personnel to
be as involved with the delivery of ALS care or act as primary attended when deemed appropriate. This
enhances their learning experience and improves their EMS skills
In some cases, it is feasible for a BLS unit to transport a patient to a medical facility. This can be very perilous
if the patient should deteriorate en-route and ALS care is not available. The decision to bypass ALS care
should be made by the primary attendant. If questions arise, contact the ALS unit or Base Physician
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Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Patient Restraint
It may be necessary to restrain a patient to ensure the safety of the patient and the EMS personnel
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Your personal safety is of paramount importance and is the first priority
Use chemical restraint when appropriate
The type of physical restraints used should restrict the movement of the patient without causing injury.
Types of acceptable methods include Kerlix and soft restraints
Have enough resources available. Call for additional resources if they are needed
Do not use excessive force in restraining a patient
Once restraints have been applied, it is important to constantly monitor the patient. An attendant must be
physically present with the patient at all times while the patient is restrained. Distal circulation must be
checked and documented every 15 minutes if extremities are restrained
Many patients with abnormal behavior have an organic etiology. Do not overlook the possibility of head
injuries, hypoxia, drug ingestion, hypoglycemia, or neurological disorders by assuming the patient's only
problem is a psychiatric one
Always check the patient for weapons. Keep in mind that just about anything can be a weapon such as
cowboy boots, jewelry, belt buckles, flashlights, etc
Document the reason for restraining a patient, the location and the type of restraints used. Documentation
should also reflect the inadequacies of less restrictive means of control such as medication or verbal
interaction
Avoid transporting the patient prone due to possibility of respiratory effort being impaired
If a patient is handcuffed during transport, a law enforcement officer must be present during transport
Criteria to necessitate patient restraint:
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
Patient is a danger to themselves or others
o Threat of self-harm
o If patient is a danger to others, law enforcement assistance must be requested
Patient is a minor with potentially life threatening injury or illness, with no guardian present
o If patient is a minor with potential life threatening injury or illness, and a guardian is refusing care,
request law enforcement involvement and consult Base Physician
Patient is mentally incompetent to refuse treatment
Always consult Base Physician prior to restraining a patient unless there is a threat of immediate harm to the patient
or the provider. Law enforcement involvement strongly encouraged
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DNR Orders
A DNR Order is a written document in which the physician, in the best interest of the patient, and after consultation
with the patient and/or family, has deemed it appropriate that the patient should not be resuscitated in the setting of
a cardiopulmonary arrest
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A signed, valid, DNR must be present to withhold resuscitation efforts
Bracelets, necklaces, or other DNR notification devices can be acknowledged as valid DNR orders
Verbal DNR orders from a family member or medical power of attorney require Base Physician contact prior
to withholding resuscitation efforts or termination of efforts
The following procedures should NOT be performed on DNR patients who are in cardiopulmonary arrest:
o CPR
o Intubation
o Defibrillation
o "CORE" drug administration
o Cardiac pacing
o IV/IO placement
Contact with Base Physician should be made to confirm DNR order or if questions arise
A DNR may be revoked at any time by the patient or the patient’s healthcare power of attorney
Living Wills
A Living Will is a document that expresses the patient’s wishes concerning what medical care should be render if the
patient is rendered incapable of doing so. Most Living Wills will specifically express what procedures may or may not
be performed
Some Living Wills will state “Comfort measures only”. The following procedures may be performed depending upon
clinical judgment and consultation with the patient, the private physician, or the Base Physician
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Position of comfort
Airway control such as manual positioning and use of bag valve mask. Intubation and extra-glottic devices
are specifically excluded
Suction
IV line for hydration
Foley catheter for urinary retention
Oxygen for dyspnea and hypoxia
Treatment of injuries or illness that are not a cardiac arrest situation
Analgesics and sedatives
Treatment of acute injury or illness
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Pre-Hospital Treatment Protocols
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Candidates for Resuscitation:
All patients in cardiac and/or pulmonary arrest without a valid DNR order will be resuscitated with the following
exceptions:
 Those patients who are obviously dead and beyond any chance of resuscitation. This includes patients who
are pulseless, apneic and, but not limited to:
o Are decapitated
o Have rigor mortis
o Tissue decomposition
o Massive blunt trauma
o Dependent lividity
o Third degree burns to 90% of the body
o Extended down time without CPR
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
The safety of the EMS personnel must also be taken into consideration if the resuscitation attempt might
endanger the rescue personnel
Upon a verbal order from an attending physician who is present at the time. You must be able to verify that
this person is, in fact, the attending physician who knows this patient well. Should there be any question
concerning this physician, you should proceed with resuscitation and immediately contact the Base Physician
at Heart of the Rockies Regional Medical Center
Cardiac arrest due to trauma:
Current data shows that a number of victims of penetrating trauma to the neck or torso, who are found without
signs of life, may be successfully resuscitated. Therefore, resuscitation should be initiated on all patients found in
full arrest secondary to penetrating trauma. Exceptions may exist in the following circumstance:
 Patients found pulseless and apneic with penetrating or blunt trauma if the provision of ALS has been
unavailable for at least 10 minutes proceeding the time EMS personnel initiate on-scene assessment
 Multi-causality incidents when there are more viable patients that require care
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Field Pronouncement Guidelines
A patient may be pronounced in the field under the following circumstances:
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Valid DNR order
Obvious death
Blunt traumatic arrest
Medical arrest when:
o Patient has received 30 minutes of ALS care with no return of spontaneous circulation with no
treatable or reversible causes identified
o Patient has received 30 minutes of BLS measures with AED present and no shocks have been
delivered
o Patient has received extended BLS care and providers are not able to continue efforts until an
AED or ALS is available due to, but not limited to, fatigue, adverse/dangerous conditions, etc.

The following patients found pulseless and apneic warrant resuscitation efforts beyond 30 minutes and
should be transported:
o Hypothermic or cold water drowning (H2O temp <50 deg F.) with core temperature of <91F that
preceded the cardiac arrest
o Pregnant and estimated to be 20 weeks or later in gestation
o A reversible cause has been identified that may not be rectified in the field
In the case of an obviously deceased patient, or if an arrest is called in the field, the Chaffee County Coroner's Office
asks the following:
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Do not run an ECG strip on obviously deceased patients
Do not remove any medical devices from the body. This includes endotracheal tubes, NG tubes, IV lines,
combo pads, etc.
Be aware of the scene and the surroundings. Do not destroy, tamper with, or remove anything from the
scene. This is considered evidence and will be used in the investigation
Do not change the location or position of the body if there are signs of obvious death, or after the
resuscitation efforts have been terminated
Under no circumstances is the deceased patient to be used for practice procedures
Base Physician contact is required to terminate resuscitation efforts, accept a DNR Order, or to withhold resuscitation
efforts
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Cardiac Arrest - Medical
This protocol serves as a guide in the treatment of a patient in cardiac arrest from a medical cause
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Initiate CPR (Follow current AHA guidelines)
x
x
x
x
Ventilate with BVM and high flow O2
x
x
x
x
Suction as needed
x
x
x
x
Insert OPA/NPA
x
x
x
x
Monitor cardiac rhythm and if the patient is in a shockable rhythm:

Consider 2min of CPR prior to defibrillation
x
x
x
x
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Defibrillate manually or with AED (Certification level dependent)
x
x
x
x
x
x
x
x
x
x
x
x
IV: 1-2 IV with Normal Saline 20ml/kg
IO if unable to obtain IV with Normal Saline 20ml/kg
Administer medications as indicated
Insert advanced airway: Extra-glottic Device or Oral ETT (Do not stop
compressions to insert an advanced airway)
x
x
x
x
Consider and treat reversible causes of cardiac arrest
x
x
x
x
If ROSC:

Begin transport
x
x
x
x
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Monitor vital signs
x
x
x
x
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Perform 12-lead ECG
x
x
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Treat hypotension and arrhythmias as indicated
x
x

Begin passively cooling if indicated
DO
x

Consider sedation if advanced airway is in place and the patient
shows signs of neurologic function
DO
x
x
x
Notes:
 See Hypothermia, Traumatic Cardiac Arrest, and Neonate Resuscitation for specific Protocol
 Prioritize treatments during cardiac arrest. Do not interrupt compressions unnecessarily. Advanced airway
insertion allows continuous compressions
 Swap compressors every two minutes, if possible
 If ROSC occurs, consider an appropriately extended scene time to ensure that all needed interventions
are complete; and that enough personnel are present if the patient rearrests to provide needed
treatments
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Pre-Hospital Treatment Protocols
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Pre-Hospital Treatment Protocols
January 1, 2016
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Targeted Temperature Management
Authorizations:
Protocol:
EMT-I, and Paramedic
Paramedic - Standing Order
EMT-I – Direct Order
Targeted Temperature Management is the process of preventing fever in a patient who had a Return of
Spontaneous Circulation following treatment per ACLS guidelines.
Indications:
 Patients who have ROSC after cardiac arrest and:
o Non-traumatic cardiac arrest
o ROSC within 60min
o GCS <8, no withdrawal from painful stimuli
o Intubated
Contraindications:
 Active bleeding or suspicion of internal hemorrhage
 Evidence of intracranial hemorrhage
 Active, life-threatening arrhythmias
 Refractory hypotension
 Sepsis
 Pregnancy
 Age < 12 y/o
 Hypothermia < 89.6F
Precautions:
 Monitor for hyperkalemia
Procedure:
 Document time of ROSC and time cooling is initiated
 Obtain core temperature (If time permits or the patient may be hypothermic)
 Obtain IV/IO access if not already obtained
 Place cold packs on neck, axilla, and groin
 Reassess temperature every 15m
o Temperature goal: 34-36C (93.2 – 96.8F)
 Sedate as indicated
 Prevent shivering as indicated
Notes:
 Initiate for witness and unwitnessed cardiac arrests that meet the indications
 Efforts should be limited to passive, external cooling only
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Acute Coronary Syndrome
This protocol serves as a guide to the treatment of a patient who is having cardiac, or suspected cardiac, chest pain or
other signs/symptoms associated with Acute Coronary Syndrome
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, hypotensive, or
titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs
x
x
x
x
Administer Aspirin as indicated
x
x
x
x
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV noninterpretive)
x
x
x
x
Serial 12-lead ECGs with consideration of right-sided or posterior
leads as indicated
x
x
Determine if the patient meets STEMI Alert criteria
x
x
x
x
x
x
x
DO/x
x
(Assisted
DO)
x
x
Administer opioid of choice as indicated
DO
X
Treat dysrhythmias as indicated
DO
X
IV: 1-2, and draw blood if possible (Dark green top)
x
IO if unable to obtain IV and the patient is unstable
Maintain systolic BP ≥ 90mmHg with fluid or a vasopressor as
indicated
Administer Nitroglycerine as indicated
Notes:
 Consider BGL evaluation as well as bi-lateral blood pressure determination
 Appropriate pain and anxiety control may significantly improve patient outcomes
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ST segment Elevation Myocardial Infarction (STEMI) Alert
This criteria is to determine when to call a Cardiac/ STEMI Alert
Indication (All criteria must be met):
 Noted 1mm or more of ST segment elevation in two or more anatomically contiguous leads on the 12 lead
ECG (ST elevation that does not meet this criteria may suffice if the provider is familiar with more subtle
MI patterns that may present)
 Patients presenting with active chest pain/ discomfort or other symptoms consistent with Acute Coronary
Syndrome
 (Optional criteria) Corresponding reciprocal depression in opposite or nearby leads on the 12 lead ECG.
Reciprocal changes may be noted in the following locations:
o Anterior MI: Posterior leads
o Inferior MI: High-lateral leads
o High/Low-lateral MI: Inferior leads
o Posterior MI: Anterior leads
Contraindications:
 Presence of Left Bundle Branch Block
o Unless provider is comfortable applying modified Sgarbossa’s Criteria
 ≥ 1mm concordant ST elevation in two or more anatomically contiguous leads
or
 ≥ 1mm concordant ST depression in V1, V2, or V3
 Ventricular paced rhythms
Procedure:
 Treat the patient according to the Acute Coronary Syndrome Protocol
 Contact receiving hospital and request a “STEMI Alert”
o Provide call in patient care report
 Complete Thrombolytic Checklist if time permits
STEMI Mimics:
 Left Ventricular Hypertrophy (LVH)
o Choose largest S wave in V1 or V2 add it to the largest R wave in V5 or V6.
o If >35mm = LVH
o Strain indicated by a ST segment slanting the opposite direction as the R or S wave deflection
 Hypothermia
o Osborne waves
 Pericarditis
o Global or near global ST segment elevation and PR segment depression
 Early Repolarization
o ST segment elevation with no reciprocal changes
o J-point notching
o PR depression
o Concave ST segment elevation
o Normal R wave progression
o 12-lead does not change over time
 Ventricular paced rhythms
 Hyperkalemia
 Interventricular conductions delays/defects
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Thrombolytic Checklist:
This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions
should be NO
* * * * * Remove sheet and provide to receiving hospital * * * * *
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Chest pain <15min or >12hrs
Systolic BP > 180mmHg
Diastolic BP > 110mmHg
Right arm vs. Left arm BP difference > 15mmHg systolic
History of structural CNS disease
Head/Facial trauma within 3mos
Major trauma, surgery, GI bleed within 6wks
Taking blood thinners
Coagulopathy
Pregnancy
CPR > 10min
Advanced cancer, severe liver or renal disease
Patient Name
Date of Birth
Age
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Time of onset? ___
Systolic BP?
___
Diastolic BP? ___
If “Y”, see below
Duration of CPR if performed? ___
Weight (kg)
Medications:
Medical History:
Allergies:
Other:
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Thrombolytic Checklist:
This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions
should be NO
* * * * * Remove sheet and provide to receiving hospital * * * * *
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Chest pain <15min or >12hrs
Systolic BP > 180mmHg
Diastolic BP > 110mmHg
Right arm vs. Left arm BP difference > 15mmHg systolic
History of structural CNS disease
Head/Facial trauma within 3mos
Major trauma, surgery, GI bleed within 6wks
Taking blood thinners
Coagulopathy
Pregnancy
CPR > 10min
Advanced cancer, severe liver or renal disease
Patient Name
Date of Birth
Age
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Time of onset? ___
Systolic BP?
___
Diastolic BP? ___
If “Y”, see below
Duration of CPR if performed? ___
Weight (kg)
Medications:
Medical History:
Allergies:
Other:
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Dysrhythmias
This protocol serves as a guide to the treatment of a patient who is experiencing cardiac dysrhythmias
Procedure
EMTB
EMTBIV
EMT-I
Paramedic
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, hypotensive, or titrated to
SPO2 ≥ 94%
x
x
x
x
Monitor vital signs and cardiac rhythm
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x/DO
x
IV: 1- 2, and draw blood if possible (Dark green top)
IO if unable to obtain IV and the patient is unstable
See Acute Coronary Syndrome Protocol if signs of ACS
x
If unstable with systolic BP ≤ 90mmHg:

Consider fluid bolus

Administer appropriate pharmacological intervention, if
indicated

Synchronized cardioversion if indicated

Overdrive pacing
x
x
x
x
x
x/DO
x
If stable with systolic BP > 90mmHg:

Consider fluid bolus

Administer appropriate pharmacological intervention, if
indicated

Consider synchronized cardioversion if indicated

Consider overdrive pacing
x
x
x
x
Notes:
 Consult Base Physician for advice if needed
 Wide complex tachycardias can be very difficult to differentiate. If unable to differentiate and perfusion is
adequate, administer Adenosine first. If this is not effective, treat the dysrhythmia as ventricular tachycardia.
If the patient is hypotensive with associated signs/symptoms, synchronized cardioversion is indicated
 If pulses are not palpable and the patient is unconscious, begin CPR and treat accordingly
 Many dysrhythmias are caused by or enhanced by hypoxia. Be sure that the patient is receiving high flow O2
and ventilating adequately
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Adult Tachycardia (With pulse)
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Adult Bradycardia (With pulse)
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Pediatric Tachycardia (With pulse)
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Pediatric Bradycardia (With pulse)
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Hypertension
This protocol serves as a guide to the treatment of a patient who is hypertensive
Procedure
EMTB
EMTBIV
EMT- I
Paramedic
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs
x
x
x
x
x
x
x
x
x
IV : 1-2, and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Perform stroke evaluation
x
x
x
x
If systolic BP > 200mmHg or diastolic BP > 130mmHg, and symptomatic, without stroke like symptoms:

Consider Diltiazem

Consider Morphine
x
DO
x
Notes:
 Hypertension secondary to stress or pain will usually have high systolic pressures but not high diastolic
pressures. These rarely need to be treated in the field
 Causes of hypertension include: pulmonary edema, CHF, CVA, hypoglycemia, myocardial infarctions, head
injuries, seizures, drugs or stress. Treat the underlying cause first if possible
 Using a BP cuff that is too small can give false elevations
 When attempting to lower the diastolic blood pressure, the goal is a range of 90-100mmHg
 Prior to therapeutic intervention, the blood pressure should be auscultated multiple times, on both sides, to
ensure that the hypertension was not a transient event
 Hypertension secondary to a CVA or head injury should not be treated in the field. Elevated BP in these
instances is a compensatory response to maintain blood flow to the brain, lowering the blood pressure will
worsen cerebral ischemia
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Abdominal Pain
This protocol serves as a guide to the treatment of a patient who has abdominal pain
Procedure
EMTB
EMTBIV
EMT-I
Paramedic
Place the patient in position of comfort (See Pregnancy Protocol or
Acute Coronary Syndrome Protocol as indicated)
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, hypotensive, titrated to
SPO2 ≥ 94%, or if significant bleeding is present
x
x
x
x
Monitor vital signs
x
x
x
x
x
x
x
x
x
x
x
DO
x
x
x
IV : 1-2, and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV noninterpretive)
x
x
Opioid of choice as indicated
If unstable with systolic BP ≤ 90mmHg:

Fluid bolus to maintain systolic BP ≥ 90mmHg:
x
Notes:
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Allergic Reaction, Anaphylaxis, and Anaphylactic Shock
This protocol serves as a guide to the treatment of a patient who is experiencing an allergic reaction, anaphylaxis, or
anaphylactic shock
Procedure
EMT-B
EMT-BIV
EMT-I
Paramedic
Remove injection mechanism if a bee or wasp sting
x
x
x
x
Remove the patient from allergen or allergen from the
patient
x
x
x
x
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath,
hypotensive, or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs
x
x
x
x
x
x
x
x
x
IV :1-2, and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Allergic Reaction (Localized reaction with no airway or vascular involvement)

Diphenhydramine (Consider IM
administration while obtaining IV/IO access)
DO
x

Solu-Medrol
DO
x
Anaphylaxis (With airway or vascular compromise)

Albuterol

Epinephrine (Consider IM administration
while obtaining IV/IO access)


DO
DO
DO
x
Assisted
DO
Assisted
DO
DO
x
Diphenhydramine (Consider IM
administration while obtaining IV/IO access)
DO
x
Solu-Medrol
DO
x
x
x
x
Assisted
DO
DO
x
Anaphylactic Shock (Hypotension due to anaphylaxis)

Fluid bolus as indicated

Epinephrine (Consider IM administration
while obtaining IV/IO access)

Diphenhydramine (Consider IM
administration while obtaining IV/IO access)
DO
x

Solu-Medrol
DO
x

Consider Glucagon administration
Assisted
DO
x
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Behavioral and Psychiatric disorders
This protocol serves as a guide to the treatment of a patient who has suffering, or potentially suffering, from a
behavioral or psychiatric disorder
Procedure
EMTB
EMTBIV
EMT- I
Paramedic
Place the patient in position of comfort
x
x
x
x
Restrain if necessary (Refer to Patient Restraint Protocol)
x
x
x
x
DO/x
x

Consider administration of Diazepam or Midazolam as
indicated
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥
94%
x
x
x
x
Monitor vital signs
x
x
x
x
x
x
x
x
x
If unstable or potentially unstable:
IV :1-2, and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV noninterpretive)
x
x
x
x
Check blood glucose level (Glucometer)
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x

Administer Oral Glucose if indicated

Administer Dextrose if indicated

Administer Glucagon if indicated
Consider Narcan administration
x
x
Notes:
 Psychiatric patients and/or patients with abnormal behavior may have an organic etiology. Do not overlook
the possibility of head injuries, hypoxia, hypoglycemia, drug ingestion, or neurological disorders by assuming
that it is just a psychiatric disorder
 If the patient is suicidal, do not leave them alone. Either remove dangerous objects or have someone else
remove them. Keep in mind, just about anything can be a weapon
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Cerebral Vascular Accident – Stroke and Stroke Alert
This protocol serves as a guide to the treatment of a patient who has suffering, or potentially suffering, from cerebral
vascular accident
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs
x
x
x
x
x
x
x
x
x
IV : 1-2, and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Check blood glucose level (Glucometer)
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x

Administer Oral Glucose if indicated

Administer Dextrose if indicated

Administer Glucagon if indicated
Notify receiving facility of Stroke Alert and complete Thrombolytic
Checklist
x
x
Notes:
 HRRMC is now using tPA for patients that meet strict criteria. With suspected CVA the highest prehospital priorities should include treatment of life threats, immediate transport, and a obtaining a
thorough history. Immediate transport is important because if tPA is to be used it must be given within 3
hours of the onset of the CVA. If the patient exhibits symptoms suggestive of a CVA do not delay transport
to obtain a patient history, however when dealing with an aphasic patient, a few minutes spent on scene
obtaining a description of events and last time the patient was normal from family or bystanders is
important and may save time in the long run in terms of patient care
 If the patient requires artificial ventilation, do not hyperventilate the patient. Hyperventilation will decrease
the patient’s level of carbon dioxide and cause cerebral vasoconstriction and further ischemia.
 Alert HRRMC that you are en-route with a potential stroke patient as soon as possible. Even if the patient
has been symptomatic for up to 12 hours, they may be eligible for interventions
 If the CVA causes an increase in intracranial pressure, the signs and symptoms will mimic a closed head
injury. These patients will present the same as a patient suffering from a traumatically induced injury by
displaying possible combativeness, posturing, and Cushing's triad. Refer to "Head Injury Protocol" for
additional information
 Do not treat hypertension of suspected CVA patient
 The ultimate goal with a CVA patient is to get the patient to definitive care while protecting the airway and
increasing cerebral oxygenation
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Thrombolytic Checklist:
This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions
should be NO
* * * * * Remove sheet and provide to receiving hospital * * * * *












Chest pain <15min or >12hrs
Systolic BP > 180mmHg
Diastolic BP > 110mmHg
Right arm vs. Left arm BP difference > 15mmHg systolic
History of structural CNS disease
Head/Facial trauma within 3mos
Major trauma, surgery, GI bleed within 6wks
Taking blood thinners
Coagulopathy
Pregnancy
CPR > 10min
Advanced cancer, severe liver or renal disease
Patient Name
Date of Birth
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Time of onset? ___
Systolic BP?
___
Diastolic BP? ___
If “Y”, see below
Duration of CPR if performed? ___
Age
Medications:
Medical History:
Allergies:
Other:
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Thrombolytic Checklist (Duplicate):
This check list aids in determining if a patient is a candidate to receive thrombolytics. The answer to all questions
should be NO
* * * * * Remove sheet and provide to receiving hospital * * * * *












Chest pain <15min or >12hrs
Systolic BP > 180mmHg
Diastolic BP > 110mmHg
Right arm vs. Left arm BP difference > 15mmHg systolic
History of structural CNS disease
Head/Facial trauma within 3mos
Major trauma, surgery, GI bleed within 6wks
Taking blood thinners
Coagulopathy
Pregnancy
CPR > 10min
Advanced cancer, severe liver or renal disease
Patient Name
Date of Birth
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Time of onset? ____
Systolic BP?
____
Diastolic BP? ____
If “Y”, see below
Duration of CPR if performed? ___
Age
Medications:
Medical History:
Allergies:
Other:
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Carbon Monoxide Monitoring, Exposure, and Treatment
This protocol serves as a guide to the treatment of a patient who is suffering from Carbon Monoxide poisoning
Procedure
EMT-B
EMT-BIV
EMT -I
Paramedic
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 via NRB if symptomatic
x
x
x
x
Monitor Carboxyhemoglobin level if available
x
x
x
x

If the patient is asymptomatic and reading:
o
0-5%: No further medical evaluation needed
o
>5%: Administer oxygen and reassess after 15min. Consult Base Physician if reading
remains >5%

If the patient is symptomatic: Treat and transport the patient

If the patient is pregnant or could be pregnant and reading >5%: Treat and transport the patient
Monitor vital signs
x
x
x
x
Continuously monitor ECG
x
x
x
x
DO
DO
x
x
x
x
x
x
x
CPAP if symptomatic and/or >20%
IV :1-2, and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Notes:
 The fetus of a pregnant woman is at high risk when exposed to carbon monoxide. Fetal hemoglobin has a
greater affinity for CO than adult hemoglobin. A pregnant woman maybe asymptomatic while the fetus
may be in danger or distress.
Classifications of CO Poisoning:
 <15-20% Headache, nausea, vomiting, dizziness, blurred vision
 21-40% Confusion, syncope, chest pain, dyspnea, tachycardia, tachypnea, weakness
 41-59% Dysrhythmias, hypotension, cardiac ischemia, palpitations, respiratory arrest, pulmonary
edema, seizures, coma, cardiac arrest
 >60% Fatal
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Hyperglycemia
This protocol serves as a guide to the treatment of a patient who is hyperglycemic
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, hypotensive or titrated to
SPO2 ≥ 94%
x
x
x
x
Monitor vital signs
x
x
x
x
x
x
x
x
x
IV: 1-2, and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Check dextrose level (Glucometer)
x
x
x
x
x
x
x
Fluid bolus as indicated
Notes:
 Hyperglycemia is often a slow onset. It usually develops over a period of days, not hours
 The buildup of ketones can sometimes be detected on the patient's breath. There may be an odor of
acetone or fruity smell
 Because of the dehydration, DKA and HHNK patients may have a rapid, weak pulse, decreased blood
pressure, orthostatic changes, and dry, flushed, warm skin
 Be aware of the upper limits of glucometer. If reading is above that limit, glucometer may read “Hi”
 Slightly elevated blood glucose levels may be due to any hypermetabolic state or sympathetic response
 The determination between HHNK and DKA can only be made with blood chemistry and is unimportant in
the field
 If possible, attempt to determine the cause of hyperglycemia, such as an acute infection
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Hypoglycemia
This protocol serves as a guide to the treatment of a patient who is hypoglycemic
Procedure
EMTB
EMT –
BIV
EMT –
I
Paramedic
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥
94%
x
x
x
x
Monitor vital signs
x
x
x
x
Check blood glucose level (Glucometer)
x
x
x
x
x
x
x
x
Establish IV and draw blood if possible
x
x
x
Administer D50%, D25%, or D10% as indicated
x
x
x
Consider Glucagon administration
x
x
IO if the patient condition does not change with Glucagon
x
x
x
x
If the patient is hypoglycemic:
Administer oral glucose if indicated
If unable to establish IV:
Recheck blood glucose stick after Dextrose or Glucagon
administration
x
x
Notes:
 Infiltration of IV Dextrose will cause severe tissue necrosis. Dilution of D50% is required
 Hypoglycemia can present as: seizures, coma, diaphoresis, chest pain, behavioral disorders, alcohol
intoxication, confusion or stroke-like with neurological deficits (particularly in elderly patients).
 Patients who are elderly or who have been hypoglycemic for prolonged periods of time may be slower to
regain normal mental status
 Administration of dextrose in the malnourished patient with depleted thiamine stores may precipitate
Wernicke's or Korsakoff's syndrome. However, do not withhold dextrose from a patient who is
hypoglycemic
 Do not give to possible CVA or head injury patients without documented hypoglycemia
 Patients who are on oral hypoglycemic medications should be transported. Patients who do not have a
responsible party present should be transported. The medication/reason that the patient’s blood glucose
level is below acceptable limits may cause a second drop in blood glucose
 Hypoglycemia is considered to be any reading <50mg/dL, approximately, in a newborn
 BGL may not raise, or may have a secondary drop, after Glucagon administration
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Hyperthermia
This protocol serves as a guide to the treatment of a patient who is hyperthermic due to an environmental cause
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Remove from hot environment and place the patient in a position of
comfort
x
x
x
x
Remove clothing as needed. Cool with cool water or cold packs in the groin,
neck and armpits. Be careful not to chill the patient. Fan the patient if
needed
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, hypotensive, titrated to
SPO2 ≥ 94%
x
x
x
x
Monitor vital signs, including temperature
x
x
x
x
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
DO
x
x
x
IV: 1-2 and draw blood if possible
IO if unable to obtain IV and the patient is unstable
Normal Saline bolus as indicated
x
Treat seizures with benzodiazepine of choice
Check blood glucose level
x
x
Notes:
 Do not let cooling in the field delay your transport
 When cooling a patient, be careful not to chill him/her. Shivering will increase the body temperature and
exacerbate the problem
 Heat Cramps is due to electrolyte imbalance causing muscle spasms in the legs and abdomen. Severe pain
nausea and vomiting are normal. Patient will not be hypotensive and have a normal core temperature
 Heat Exhaustion is an emergency and is the result of depletion of water and salt resulting in hypovolemic
shock; monitor for signs of shock. Pale and diaphoretic skin, dilated pupils, headache, nausea, and altered
level of consciousness are normal symptoms. Temperature will be between 98.6F and 104F. Treat patient for
shock and cool
 Heat Stroke is due to failure of the normal cooling mechanisms failing. Skin may be hot, dry, and flushed.
Patient may have mental status changes, nausea, vomiting, seizures, and hypotension. Temperature will be
greater than 104F. Treat the patient for shock and cool aggressively. Treat for seizures as needed
 Hyperthermia should only be treated with cooling if due to environmental or exertional causes
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Hypothermia
This protocol serves as a guide to the treatment of a patient who is hypothermic
Procedure
EMTB
EMTBIV
EMTI
Paramedic
x
x
x
x
Re-warm the patient passively. Cover with warm blankets, place in warm
environment, and consider heat packs on the chest, abdomen, axilla, neck,
or groin areas
x
x
x
x
Start CPR if pulses are not palpable
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, hypotensive, or titrated to
SPO2 ≥ 94%
x
x
x
x
Monitor vital signs, including core temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
DO
x
x
x
Remove from cold or windy environment and remove
wet clothing

Limit defibrillation to 1 shock

Extend period between drug administrations and limit to 2 rounds

Refer to specific cardiac arrest protocol for additional information
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Treat seizures with benzodiazepine of choice
Monitor blood glucose level
Notes:







x
x
Mild hypothermia: 90 - 95F
Moderate hypothermia: 82 - 89.9F
Severe hypothermia: < 82F
Shivering will stop when the body temperature drops below 90F
It is crucial that the patient be handled gently. The heart becomes very irritable when it is cold and will
fibrillate easily. It is most likely to fibrillate between 84-88F and does not convert readily until the patient's
temperature is above 86F (30C)
When possible, rewarming should be left for the hospital setting
Successful resuscitation has been documented in a patient with a core temperature as low as 64.4F. When in
doubt, begin CPR and be prepared for extended resuscitation times. All patients with a core temperature
<91F should be transported unless cardiac arrest preceded the hypothermia or obvious signs of death are
present
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Hypothermia – Frost Bite
This protocol serves as a guide to the treatment of a patient who has frost bite
Procedure
EMT-B
EMT-BIV
EMT-I
Paramedic
Remove from cold or windy environment and remove
wet clothing
x
x
x
x
Protect areas from pressure, trauma or friction. Do not break any blisters
present. Do not allow the patient to ambulate if possible. Do not attempt
to rewarm in the field
x
x
x
x
DO
DO
DO
x
Cover the patient with warm blankets, place in warm environment, and
consider heat packs on the chest, abdomen, axilla, neck, or groin areas
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs, including core temperature
x
x
x
x
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
DO
x
Under extenuating circumstances, such as prolonged or complicated
transport, rewarm by submersion in warm water (100 degrees) for 20
minutes
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Monitor blood glucose level
Treat pain as indicated with opioid of choice
x
x
Notes:
 Do not allow a limb to thaw if there is a danger it will refreeze. Partial rewarming or refreezing will cause
further tissue damage. Thawing should only be done under controlled conditions
 Patients with frostbite will often be hypothermic
 Signs of cold injury to an extremity range from red skin to completely frozen tissue
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Poisons and Overdoses
This protocol serves as a guide to the treatment of a patient who has suffered an overdose or poisoning
Procedure
EMT-B
EMT-BIV
EMT- I
Paramedic
Remove contaminate from the patient if possible/safe to do so
x
x
x
x
Place the patient in position of comfort
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath, hypotensive or titrated to
SPO2 ≥ 94%. If the patient has been exposed to a simple or chemical
asphyxiant, administer high-flow O2
x
x
x
x
Monitor vital signs including, but not limited to: BP, ECG, SPO2, SPCO,
BGL, and core temperature
x
x
x
x
x
x
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Treat specific poising/overdose/exposure as indicated
x
x
x
x
Obtain information on specific treatment if needed
x
x
x
x
Notes:
 POISON CONTROL CENTER TELEPHONE NUMBER: (303) 629-1123 or (800) 222-1222
 Ensure that scene is safe during all overdoses, poisoning, and exposures
 If the patient has intentionally overdosed or poisoned themselves, strongly consider transport for a mental
health evaluation
 Many poisonings, overdoses, and exposures are treated symptomatically with airway, breathing, and
circulatory support
 Do not induce vomiting or administer an antidote unless instructed to do so by Poison Control or the Base
Physician
Specific emergencies
Type of exposure
General information
Signs/symptoms
Treatment
Alcohol overdose
CNS depressant, chronic
use causes GI bleeds, liver
failure, and cerebral
degeneration
Slurred speech, decreased
respirations, altered LOC,
nausea, vomiting, and
coma
Support airway,
breathing, and circulation
Alcohol withdrawal
Occurs 12-24 hours after
last ingestion
Seizures, tremors, coma,
and hallucinations
Support airway,
breathing, and circulation.
Treat seizures with
benzodiazepine of choice
Aspirin (salicylate acid)
Over the counter
analgesic and antiinflammatory
Ringing in the ears,
lethargy, nausea, GI
bleeding,
Support airway,
breathing, and circulation.
Consider Sodium
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hyperventilation, seizures,
coma, metabolic acidosis,
and pulmonary edema
Bicarbonate for acidosis.
Consider Benzodiazepine
of choice for seizures
Acetaminophen
Over the counter
analgesic and sleep
medication
Nausea, vomiting,
diaphoresis, RUQ pain,
and liver failure
Support airway,
breathing, and circulation
Barbiturates
CNS depressant, sedation,
deep coma,
anticonvulsant
medication
Slurred speech, altered
LOC, dilated pupils,
decreased respirations,
pale, cool skin.
Support airway,
breathing, and circulation
Benadryl
Over the counter
antihistamine
Dry mouth, dilated pupils,
flushed dry skin,
tachycardia, and
anticholinergic effects
Support airway,
breathing, and circulation
Benzodiazepine
CNS depressant and
tranquilizer
Sedation, coma,
anticonvulsant, slurred
speech, altered LOC,
dilated pupils, decreased
respirations, pale, cool
skin.
Support airway,
breathing, and circulation
Beta Blocker or Calcium
Channel Blocker
Negative inotrope and
negative chronotrope
Decreased LOC,
hypotension,
bradycardias, and
pulmonary edema.
Support airway,
breathing, and circulation.
Consider Glucagon,
Dopamine, and/or
Epinephrine drip.
Consider TCP
Carbon Monoxide
CO binds to the
hemoglobin in the blood
and causes cellular
asphyxia
Headache, dyspnea,
angina, syncope, seizures,
coma, cherry red skin.
Support airway,
breathing, and circulation.
Administer high-flow
oxygen. See specific
protocol
Cocaine/ CNS stimulants
Vasoconstrictor, and CNS
stimulation
Euphoria, agitation,
psychosis, seizures, MIs,
CVAs, dyspnea, increased
HR and BP, dilated pupils.
Support airway,
breathing, and circulation.
Consider Benzodiazepine
of choice. Do not
administer
antiarrhythmics.
Caustics
The caustics will burn soft
tissue
1st, 2nd and 3rd degree
burns to any tissue
contacted
Support airway,
breathing, and circulation
Hallucinogens
Causes auditory and visual
hallucination.
Psychosis, dilated pupils,
headache, secondary
trauma.
Support airway,
breathing, and circulation.
Consider Benzodiazepine
of choice.
Opioids
Analgesic that acts as a
CNS depressant
Sedation, pinpoint pupils,
respiratory depression,
Support airway,
breathing, and circulation.
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bradycardia, pulmonary
edema
Consider Narcan
administration
Tricyclic anti-depressant
Prescription
antidepressant
Anticholinergic response,
tachycardia, dry, flushed
skin, dilated pupils, coma,
seizures, hypotension,
wide-complex QRS.
Support airway,
breathing, and circulation.
Consider Sodium
Bicarbonate and
Dopamine administration
Anticholinergic toxidrome
Antihistamines, TCA,
phenothiazines,
Nightshade, Mandrake,
Moonflower
Flushed skin, psychosis,
hyperthermia, dry
mucosa, dilated pupils,
and tachycardia
Support airway,
breathing, and circulation.
Consider Benzodiazepine
of choice administration
Cholinergic toxidrome
Organophosphates
Salivations, lacrimation,
urination, defecation,
bronchosecretions,
bronchoconstriction, and
bradycardia
Support airway,
breathing, and circulation.
Consider Atropine
administration
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Seizures
This protocol serves as a guide to the treatment of a patient who has suffered or is suffering a seizure
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively seizing, administer high flow O2
x
x
x
x
Continuously monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Consider specific cause of seizure and attempt to reverse if possible
x
x
x
x
Consider spinal immobilization if injuries are consistent w/ spinal
immobilization criteria
x
x
x
x
Check blood glucose level (Glucometer)
x
x
x
x
DO
x
x
x
If seizure activity persists (status):

Administer Benzodiazepine of choice

Consider endotracheal intubation
Notes:
 Control of the airway can be very difficult during a seizure because the jaws are often closed. Do not attempt
to force the teeth open. This can cause oral trauma and bleeding which will obstruct the airway. NPAs and
nasal intubation are useful in this situation. In addition, consideration should be given to Rapid Sequence
Intubation
 Protect the patient from harm during the seizure. Restrain the patient only if needed to prevent injury
 A patient who has a first time seizure should be transported by ambulance
 A pediatric patient who has suffered a suspected febrile seizure should be transported by ambulance
 Causes of seizures include: hypoxia, hypotension, hypoglycemia, CVA, fever, pregnancy (hypertension),
medication overdose, medication under dosage, ETOH withdrawal, tumor, and epilepsy
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Shock
This protocol serves as a guide to the treatment of a patient who is in a state of inadequate perfusion
Procedure
EMTB
EMT-BIV
EMTI
Paramedic
Control bleeding
x
x
x
x
Place the patient in position of comfort/indicated position
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%.
If the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Monitor blood glucose level
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
x
x
x
x
x
x
x
x
x (Fluid
Bolus)
x/DO
x
IO if unable to obtain IV and the patient is unstable
Consider spinal immobilization if indicated
x
Treat for specific type of shock

Consider repeated fluid boluses and vasopressor of choice for
septic/distributive shock

Consider Epinephrine infusion for cardiogenic shock

Control bleeding, warm, and transport for hemorrhagic shock.
Consider fluid boluses to systolic BP 80mmHg

Needle decompression for obstructive shock due to a tension
pneumothorax
x
x
x
x
x
x
x
Notes:
 Hypotension should be treated. Attempt to maintain a systolic blood pressure of 90mmHg or MAP of ≥
65mmHg
 Hypotension is a late sign of shock. Monitor for: altered mentation, agitation, restlessness, unexplained, or
tachycardia. Consider history and assessment
 Consider the cause of rales/rhonchi prior to withholding fluid bolus. A patient with pneumonia may have
isolated, unilateral, rales; in this patient fluid is safe, if indicated
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Septic Shock Alert
This criteria has been developed in conjunction with Heart of the Rockies Regional Medical Center to assist in the
early recognition and goal directed therapy in the treatment of patients who are in septic shock
Inclusion criteria (All three criteria must be present):
 Suspected infection
 Systemic Inflammatory Response Syndrome (SIRS) criteria:
o Must have 2 or more of the following:
 Temperature ≥ 100.9F or ≤96.8F
 Heart rate ≥90/min
 Respiratory rate ≥20/min
 Signs of hypoperfusion:
o Venous lactate ≥4.0mmol/L
o Systolic blood pressure <90mmHg
o MAP <65mmHg
If the patient meets criteria for a Septic Shock Alert:






Notify receiving facility as early as possible
Maximize oxygenation by providing supplemental oxygen (NC 4-6lpm or NRB 10-15lpm)
Established vascular access and begin Normal Saline administration to 20mL/kg regardless of BP if breath
sounds/fluid status permits
If MAP <65mmHg after initial fluid bolus, administer Epinephrine infusion to maintain MAP ≥65mmHg
Complete checklist/information sheet if time permits
Treat other signs, symptoms, and conditions as indicated
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Septic Shock Alert Checklist:
* * * * * Remove sheet and provide to receiving hospital * * * * *

Suspected infection

Systemic Inflammatory Response Syndrome (SIRS) criteria:
o Must have 2 or more of the following:
 Temperature ≥ 100.9F or ≤96.8F
 Heart rate ≥90/min
 Respiratory rate ≥20/min
Signs of hypoperfusion:
o Venous lactate ≥4.0mmol/L
o Systolic blood pressure <90mmHg
o MAP <65mmHg

Patient Name
Possible location/cause of suspected infection? _______________
Date of Birth
Age
Temperature in *F? ________
Heart rate? _______________
Respiratory rate? __________
Venous lactate? ___________
Blood pressure? ____________
MAP? ____________________
Weight (kg)
Medications:
Medical History:
Allergies:
Other:
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Septic Shock Alert Checklist:
* * * * * Remove sheet and provide to receiving hospital * * * * *

Suspected infection

Systemic Inflammatory Response Syndrome (SIRS) criteria:
o Must have 2 or more of the following:
 Temperature ≥ 100.9F or ≤96.8F
 Heart rate ≥90/min
 Respiratory rate ≥20/min
Signs of hypoperfusion:
o Venous lactate ≥4.0mmol/L
o Systolic blood pressure <90mmHg
o MAP <65mmHg

Patient Name
Possible location/cause of suspected infection? _______________
Date of Birth
Age
Temperature in *F? ________
Heart rate? _______________
Respiratory rate? __________
Venous lactate? ___________
Blood pressure? ____________
MAP? ____________________
Weight (kg)
Medications:
Medical History:
Allergies:
Other:
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Syncope
This protocol serves as a guide to the treatment of a patient who has suffered a syncope event
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort
x
x
x
x
Consider spinal immobilization if indicated
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Monitor blood glucose level
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
x
x
x
IO if unable to obtain IV and the patient is unstable
x
x
Obtain 12-lead if syncope is suspected of being cardiac in origin
x
x
Treat dysrhythmias as appropriate
x
x
x
x
Treat hypotension as appropriate
x
x
x
x
Treat underlying cause as indicated
x
x
x
x
Notes:
 Syncope by definition is a transient state of unconsciousness from which the patient regains consciousness
 Syncope that occurs when the patent sits up or stands up is often due to hypovolemia such as a GI bleed or
dehydration. Syncope at rest or while recumbent is often caused by cardiac arrhythmias
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Unconscious Patient
This protocol serves as a guide to the treatment of a patient who is unconscious upon arrival of EMS
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Consider specific cause of unconsciousness and attempt to reverse if
possible
x
x
x
x
Consider spinal immobilization if injuries are consistent w/ spinal
immobilization criteria
x
x
x
x
Notes:
 Attempt to determine cause of unconsciousness so that treatment can be focused
 If no cause can be determined, continue supportive treatment and transport
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Respiratory Distress - General
This protocol serves as a general guide to the treatment of a patient with respiratory distress
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs including: HR, BP, ETCO2, SPO2, ECG, and
temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Consider specific cause of shortness of breath and treat per protocol
x
x
Notes:
 Consider and treat specific cause if possible
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Respiratory Distress - Asthma
This protocol serves as a general guide to the treatment of a patient with respiratory distress due to asthma
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Remove extrinsic stressor if possible
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs including: HR, BP, SPO2, ETCO2
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
IV: 1-2 with NS
x
x
x
Consider administration of Normal Saline bolus to help thin secretions
x
x
x
x
x
DO
x
Consider Atrovent (May mix with Albuterol)
DO
x
Consider Solu-Medrol if more than one Albuterol treatment is needed
DO
x
Consider Epinephrine when asthma is refractory to inhaled
bronchodilators
DO
x
x
x
IO if unable to obtain IV and the patient is unstable
Consider Albuterol
Consider CPAP
DO
DO
DO
DO
Consider Magnesium Sulfate in severe cases
Monitor for pneumothorax
x
x
x
x
x
Notes:
 Asthma consists of three components: spasms of the bronchial smooth muscles, increased mucous
secretions and inflammation of the bronchial tissue
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Respiratory Distress - Congestive Heart Failure
This protocol serves as a general guide to the treatment of a patient with respiratory distress due to congestive heart
failure
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
(Upright with legs dependent, if possible)
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs including: HR, BP, SPO2, ETCO2
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Treat cardiac arrhythmias as indicated
x
x
12- Lead ECG if indicated
x
x
x
x
x
x
DO
x
x
x
IV: 1-2 with buff cap, D5W, or NS TKO
x
IO if unable to obtain IV and the patient is unstable
Consider Nitroglycerine administration
Consider CPAP
DO
DO
Consider Dopamine administration if the patient is hypotensive
x
Consider Morphine administration
DO
x
Consider Lasix administration
DO
x
Consider Albuterol administration if significant, documented,
bronchospasm is present and pulmonary edema is treated
DO
x
Notes:

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Respiratory Distress - COPD
This protocol serves as a general guide to the treatment of a patient with respiratory distress due Chronic Obstructive
Pulmonary Disease
Procedure
EMTB
EMT-B
IV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Remove extrinsic stressor if possible
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs including: HR, BP, SPO2, ETCO2
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
IV: 1-2 with NS
x
x
x
Consider administration of NS to help thin secretions
x
x
x
x
x
DO
x
Consider Atrovent (May mix with Albuterol)
DO
x
Consider Solu-Medrol if more than one Albuterol treatment is needed
DO
x
Consider Epinephrine when bronchoconstriction is refractory to inhaled
bronchodilators
DO
x
x
x
IO if unable to obtain IV and the patient is unstable
Consider Albuterol
Consider CPAP
DO
DO
DO
DO
Consider Magnesium Sulfate in severe cases
Monitor for pneumothorax
x
x
x
x
x
Notes:

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Pediatric Respiratory Distress
This protocol serves as a general guide to the treatment of a pediatric patient with respiratory distress due to some
common causes
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Avoid stressing the patient if possible
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs including: HR, BP, SPO2, ETCO2, temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
x
x
DO
x
DO
x
DO
x
Bronchiolitis
IV: 1-2 with NS if the patient is unstable
IO if unable to obtain IV and the patient is unstable
Assist ventilations with BVM if needed
x
x
Consider intubation for patients in profound distress or near respiratory
failure
Consider nebulized Racemic Epinephrine
Consider nebulized saline, and/or Albuterol(Limited effectiveness)
Consider Atrovent (Limited effectiveness)
DO
DO
Consider Magnesium Sulfate (Limited effectiveness)
Consider Solu-Medrol administration if IV/IO has been previously
established
x
DO
x
Notes:
 Bronchiolitis is a viral infection of the bronchioles. It is caused primarily by the Respiratory Syncytial Virus
(RSV) but influenza and the Rhino virus can also be the cause
 Children <6mo old that are exposed to other children, like a day care environment, are at the greatest
risk. Other risk factors include: premature delivery, exposure to smoke and congenital abnormalities.
 Signs and symptoms include: low grade fever, tachypnea, tachycardia, dyspnea, and runny nose
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Procedure
January 1, 2016
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EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Avoid stressing the patient if possible
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs including: HR, BP, SPO2, ETCO2, temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Assist ventilations with BVM if needed
x
x
x
x
x
x
x
x
x
x
Epiglottitis
Consider intubation for patients in profound distress or near respiratory
failure and BVM ventilation is ineffective (Oral). If intubation fails
(cricothyrotomy)
Extra glottic airways will not be effective and should not be attempted
IV: peripheral access with Normal Saline if the patient is unstable
IO if unable to obtain IV and the patient is unstable
x
Notes:
 Epiglottitis is a life threatening bacterial infection of the upper airway causing the Epiglottis to swell and
occlude the larynx. Is most commonly caused by the Haemophilus Influenza Type B (Hib) but can be
caused by other bacterial and viral infections as well as trauma related causes.
 Children 2-6yrs are most commonly affected, but any may occur at any age. Due to pediatric vaccinations
Epiglottitis is becoming less frequent but it remains a concern. Risk factors include: weakened immune
systems, crowded conditions such as day care, and congenital abnormalities
 Signs and symptoms include: High fever, sore throat, painful swallowing, dyspnea, drooling, and cyanosis
 Palliative treatment is the preferred pre-hospital course of action. Invasive procedures such as IV, and
advanced airway management should be a last resort and performed by the most proficient provider on
scene. Typically the provider will only have one chance at an advanced airway and extra-glottic devices
will be ineffective
 Nebulized medications can be detrimental and are rarely effective
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Procedure
January 1, 2016
Version 10
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/position to best maintain airway
x
x
x
x
Avoid stressing the patient if possible
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
DO
x
Croup
Nebulized Racemic Epinephrine (If the patient has stridor at rest)
Monitor vital signs including: HR, BP, SPO2, ETCO2, temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
x
x
DO
x
IV: with NS if the patient is unstable
IO if unable to obtain IV and the patient is unstable
Assist ventilations with BVM if needed
x
x
Consider intubation for patients in profound distress or near respiratory
failure
Consider Solu-Medrol if IV/IO has been previously established
Consider nebulized NS (Limited effectiveness)
Consider nebulized Albuterol (Limited effectiveness)
Consider nebulized Atrovent (Limited effectiveness)
x
x
x
x
DO
DO
DO
x
DO
x
Notes:
 Croup, laryngotracheobronchitis, is caused by a viral infection typically the parainfluenza virus, and is
usually not serious
 Children <5yrs are the most commonly affected with the most severe cases in children <3yrs. Premature
deliveries are at a greater risk due to their smaller airways
 Signs and Symptoms of Croup include: Barking cough (Seal Bark), high fever >103f, dyspnea, and difficulty
swallowing
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Adrenal Insufficiency
This protocol serves as a guide to the treatment of a patient who has suspected adrenal insufficiency
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort/Indicated position
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Monitor blood glucose level and treat as indicated
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
x
x
x
x
x
DO
x
x
x
IO if unable to obtain IV and the patient is unstable
Consider Solu-Medrol administration
Monitor for hypotension and hyperkalemia. Treat as indicated
x
x
Notes:
 Patients at risk include: Addison’s Disease, Chronic Adrenal diseases, and chronic steroid use
 Hypotension is a late sign of shock. Monitor for: altered mentation, agitation, restlessness, unexplained, or
tachycardia. Consider history and assessment
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Childbirth
This protocol serves as a general guide to the treatment of a female patient with imminent childbirth and neonatal care
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort
x
x
x
x
If delivery is not imminent, transport immediately with the patient on her left
side
x
x
x
x
Obtain prenatal and maternal history. Consider immediate transport if
pregnancy has complications
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 to achieve SPO2 100% (NC as NRB will probably not be
tolerated)
x
x
x
x
Monitor vital signs including: HR, BP, and SPO2
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
x
IV: 1-2 with NS TKO
IO if unable to obtain IV and the patient is unstable
Treat maternal bleeding, hypotension, chest pain, decreased level of
consciousness, respiratory distress, or any other condition/symptom as
indicated
x
If delivery is imminent, (crowning, feeling of a bowel movement, or urge to push):

Warm ambulance/delivery area
x
x
x
x

Place the patient on her back with knees flexed
x
x
x
x

Remove clothing to waist and establish clean delivery area
x
x
x
x

Prepare neonatal resuscitation and delivery equipment
x
x
x
x

Visualize vaginal opening and identify presenting part
c
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
o
Cord prolapse

o
One foot or one arm presentation

o
Place mother in a knee to chest/face down
position and begin immediate transport. Attempt
to manually relieve pressure on the cord to
maintain fetal perfusion
Place mother in a knee to chest/face down
position and begin immediate transport
Breach: Buttock, both arms, or both legs presenting

Begin immediate transport. Urge mother not to
push, but assist with delivery if delivery proceeds.
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Presentation complicates delivery, but field
delivery is possible
o
Cephalic presentation

o
x
x
x
x
x
x
x
x
Proceed with field delivery. Assess for nuchal cord
as soon as possible
Additional complications:

Nuchal cord: Attempt to remove cord from neck.
If unable to do so, clamp thr cord and cut it

Cephalopelvic disproportion/Shoulder dystocia:
Attempt McRobert’s Maneuver
To perform field delivery:

Support the infant’s head as it emerges, using gentle pressure,
prevent the infant from an explosive delivery
x
x
x
x

Wipe mouth and nose. Have bulb suction available
x
x
x
x

Support infant as it rotates to allow shoulder delivery
x
x
x
x

When infant is delivered, clamp cord in two places
x
x
x
x
o
Approximately 8-10 inches from the infant and cut the cord
in between. Use only sterile materials

Dry and stimulate the infant. Place in blanket and place cap on
infant. DO NOT ALLOW INFANT TO BECOME HYPOTHERMIC
x
x
x
x

Place infant on mother's chest to warm and allow it to nurse (May
not be realistically achieved during transport)
x
x
x
x

Prepare for multiple deliveries if needed
x
x
x
x
Placenta normally delivers within 30 minutes. Do not delay transport or attempt to force delivery of the placenta
See neonatal resuscitation flow chart if infant does not begin spontaneous breathing, spontaneously crying, has
decreased level of responsiveness, or is distressed
Use bulb suction only if infant has respiratory distress
x
x
x
x
Note meconium if present. Suction only if infant has respiratory distress
x
x
x
x
x (IV)
x
x
Asses BGL and administer D10% through IV or IO if indicated. Reassess BGL
frequently in distressed infants
Administer Narcan if indicated (Consider IN administration)
x
x
x
x
Ensure infant is kept warm
x
x
x
x
Notes:
 Withhold supplemental oxygen, from the infant, during routine deliveries
 DO NOT pull on the cord; it may cause the placenta to abrupt or the cord may tear loose from the placenta
and either condition may cause catastrophic hemorrhage
 Babies are slippery. It is unacceptable to drop one
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January 1, 2016
Version 10
Pregnancy Induced Hypertension and Eclampsia
This protocol serves as a general guide to the treatment of a female patient with pre-eclampsia or eclampsia
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort
x
x
x
x
Attempt to remove all stimuli: Dim lights, do not use siren, allow mother to
cover her eyes, keep the patient calm and relaxed
x
x
x
x
Transport the patient on her left side
x
x
x
x
Obtain prenatal and maternal history
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 to achieve SPO2 100% (NC as NRB will probably not be
tolerated)
x
x
x
x
Monitor vital signs including: HR, BP, ECG and SPO2
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
Administer Benzodiazepine of choice
DO
x
Administer Magnesium Sulfate
DO
x
IV: 1-2 with NS TKO
IO if unable to obtain IV and the patient is unstable
If the patient experiences a seizure:
Support airway and breathing
x
x
Notes:
 Pre-eclampsia is a pregnancy-induced hypertension. The patient will have a history of a rapid weight gain in
the second and third trimester. Hypertension of greater than 140/100 will be present in these patients
 Eclampsia is the onset of seizures. These are often set off by loud noises and bright flashing lights. Be sure to
turn off the emergency lights on the ambulance and rescue vehicles
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Vaginal Bleeding
This protocol serves as a general guide to the treatment of a female patient with vaginal bleeding
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Place the patient in position of comfort
x
x
x
x
If pregnant and >20wks gestation, transport the patient on her left side
x
x
x
x
Obtain prenatal and maternal history
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 to achieve SPO2 100% (NC as NRB will probably not be
tolerated)
x
x
x
x
Monitor vital signs including: HR, BP, ECG and SPO2
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
DO
x
IV: 1-2 with NS TKO
IO if unable to obtain IV and the patient is unstable
Administer fluid bolus as indicated
Administer Fentanyl as indicated
x
Notes:
 Always consider pregnancy as a cause of vaginal bleeding
 Ectopic pregnancies can be life threatening. If it is located in the fallopian tubes, rupture of the tube and
peritoneal hemorrhage will usually occur 3-8 weeks after conception
 Consider placenta previa and placenta abruptio as a possible causes of vaginal bleeding
 Absorb blood but do not pack the vagina
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Cardiac Arrest - Trauma
This protocol serves as a guide in the treatment of a patient in cardiac arrest
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Perform triage as indicated
x
x
x
x
Determine patient viability (Field Pronouncement Guidelines. <10min since
loss of vital signs/signs of life
x
x
x
x
Established manual/spinal immobilization
x
x
x
x
Initiate CPR ( Follow current AHA guidelines)
x
x
x
x
Ventilate with BVM and high flow O2
x
x
x
x
Suction as needed
x
x
x
x
Insert OPA/NPA
x
x
x
x
Monitor cardiac rhythm and if the patient is in a shockable rhythm:

Consider 2min of CPR prior to defibrillation
x
x
x
x

Defibrillate manually or with AED (Certification level dependent)
x
x
x
x
x
x
x
x
x
x
Perform bilateral needle decompression
IV: 1-2 IV with Normal Saline 500-1000mL
x
IO if unable to obtain IV with Normal Saline 500-1000mL
Administer medications as indicated
x
x
x
x
Insert advanced airway: Extra-Glottic or Oral ETT ( Do not stop
compressions to insert an advanced airway)
x
x
x
x
x
x
If there is no response to treatment, consult Base Physician and terminate
resuscitation efforts
If ROSC:

Begin transport
x
x
x
x

Monitor vital signs
x
x
x
x

Treat hypotension and arrhythmias as indicated
x
x
x
x
Notes:
 Swap compressors every two minutes, if possible
 Trauma arrests carry over 99% mortality. Blunt trauma carries 100% mortality If there are multiple patients,
these patients should be bypassed in order to treat viable patients. Triage should not be circumvented or
delayed by focusing on traumatic arrests
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Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
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Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Amputation Injuries
This protocol serves as a guide in the treatment of a patient who has suffered an amputation injury
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Control bleeding
x
x
x
x
Place the patient in position of comfort/indicated position
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Bandage wound with sterile, moistened, gauze
x
x
x
x
Preserve amputated tissue by wrapping in moist gauze and keeping cool
x
x
x
x
x
x
x
x
x
x
x
Consider pain control as indicated with opioid of choice
DO
x
Consider anxiety control as indicated with benzodiazepine of choice
DO
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Consider spinal immobilization if indicated
x
x
Notes:
 Time is of great importance in attempts to reattach the severed part. If transport time will be delayed,
consider sending the amputated part to the hospital ahead to be prepared for reattachment
 Partial amputations should be dressed and splinted in anatomical position to insure optimal blood flow.
Avoid twisting or crushing the damaged parts.
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Burns
This protocol serves as a guide in the treatment of a patient who has suffered a burn injury
Procedure
EMT-B
EMT-BIV
EMT-I
Paramedic
Remove source of burn and any clothing/jewelry that is removable
x
x
x
x
Place the patient in position of comfort/indicated position
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer high flow O2
x
x
x
x
Keep the patient warm and cover with sterile dressing
x
x
x
x
If burn is <10% TBSA: A moist dressing may be used
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Preserve amputated tissue by wrapping in moist gauze and keeping cool
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x/DO
x
DO
x
IV: 1-2
IO if unable to obtain IV and the patient is unstable
Begin fluid resuscitation at :

500ml/hr if age >14yrs

250ml/hr for age 3-14yrs

125ml/hr if age <3yrs
Determine age as close as possible
Consider spinal immobilization if indicated
Consider pain control as indicated with opioid of choice
Consider anxiety control as indicated with benzodiazepine of choice
x
Notes:
 Burn patients with airway injury are at risk for obstruction due to edema. Consider early airway control if:
stridor/wheezing is present, significant airway/facial burns or noted, or time is extended from time of burn
injury
 Consider carbon monoxide and other poisonous gas inhalation if burns occurred during a fire in a confined
space
 Consider MIs in firefighters or patients who have collapsed during a fire
 Consider helicopter transport for critical or pediatric burns
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Chest Pain - Traumatic
This protocol serves as a guide in the treatment of a patient who is suffering chest pain from a traumatic injury
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Control bleeding
x
x
x
x
Place the patient in position of comfort/indicated position
x
x
x
x
Consider spinal immobilization if indicated
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Assess anterior and posterior breath sounds
x
x
x
x
Seal open chest/neck wounds with chest seal
x
x
x
x
x
x
x
x
x
x
x
Consider pain control as indicated with opioid of choice
DO
x
Consider anxiety control as indicated with benzodiazepine of choice
DO
x
x
x
Consider chest decompression for tensions pneumothorax
DO
x
If ventricular ectopy is present due to possible cardiac contusion, consider
antiarrhythmic of choice
DO
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Stabilize fractured ribs as indicated
Impaled objects should be stabilized in place unless that interfere with the
airway
x
x
x
x
Notes:
 Consider rapid transport to nearest trauma center and limit scene time if possible
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Specific emergencies
Type of injury
Signs/symptoms
Vital signs/ breath
sounds
Specific Treatment
Rib fractures: fractures
can be linear, or
comminuted.
Localized pain that
increases on respiration
and palpation.
Vital signs are often
elevated due to the pain,
breath sounds shallow.
Stabilize injury, control
pain with opioid of choice,
assess for further injury
Flail segment: 2 or more
ribs broken in 2 or more
places.
Localized pain that
increases on respiration,
paradoxical movement.
Vital signs are often
elevated due to pain,
breath sounds shallow.
Stabilize injury, control
pain with opioid of choice,
assess for further injury
Pneumothorax: air from
either an internal or
external wound fills the
pleural space.
Shortness of breath,
dyspnea, breath sounds
will be diminished on the
effected side.
Vital signs elevated due to
increased respiratory
effort.
Stabilize injury, control
pain with opioid of choice,
assess for further injury
Tension pneumothorax:
Dyspnea, jugular venous
distension, tracheal shift
(late signs).
HR: increased
Needle thoracotomy,
stabilize injury, control
pain with opioid of choice,
assess for further injury
Hemothorax: Blood in the
pleural space causes
dyspnea and
hypovolemia.
Dyspnea, vitals signs will
indicate shock. no JVD will
be present
HR: increased
Pulmonary contusion:
bruising to the lung tissue
causes it to swell and
interferes with gas
exchange.
Dyspnea, chest wall pain
on respiration, low pulse
ox readings.
BS: rales present over
injured area.
Control pain with opioid
of choice, assess for
further injury
Cardiac contusion:
HR: varies
bruising to the heart
tissue.
Chest pain, symptoms
similar to MI. signs of
chest wall trauma.
Control pain with opioid
of choice, assess for
further injury, consider
antiarrhythmic of choice
Pericardial tamponade:
Fluid present in the sac
surrounding the heart.
Dyspnea, jugular venous
distention, narrowing of
pulse pressures.
HR: rapid and weak
Traumatic asphyxia:
JVD, bulging eyes and
tongue, facial cyanosis.
Usually presents as a
cardiac arrest.
Treat as indicated by
patient condition
Dyspnea, air bubbles or
air movement present in
wound.
Vital signs are often
elevated due to the
increased effort of
respirations.
Monitor for tension
pneumothorax, seal chest
wound with occlusive
dressing
Crushing forces prevent
respiration.
Sucking chest wound:
External wound in chest
wall allows air to flow
through it
BP: decreased
BS: decreased or absent
over the effected side.
BP: decreased
BS: diminished over
effected side.
BP: varies
BS: clear
BP: decreased
Stabilize injury, control
pain with opioid of choice,
assess for further injury
and shock. Fluid bolus as
indicated
Transport and treat for
shock as indicated
BS: clear
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Fractures, Dislocations, and Sprains
This protocol serves as a guide in the treatment of a patient who has suffered an injury to a bone or joint
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Consider spinal immobilization if indicated
x
x
x
x
Control bleeding
x
x
x
x
Place the patient in position of comfort/indicated position
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Assess for circulation and neurologic function in extremity. Reposition as
needed to restore circulation if absent
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
Apply sterile dressing to open fractures or open wounds
x
x
x
x
Splint injured extremity
x
x
x
x
Elevate and apply ice packs
x
x
x
x
x
x
x
x
x
Consider pain control as indicated with opioid of choice
DO
x
Consider anxiety control as indicated with benzodiazepine of choice
DO
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Notes:
 Do not apply ice or cold packs directly to skin or use them under bandages as this will cause tissue damage
 Fractures do not necessarily lead to loss of function. For example, impacted fractures may cause pain but
little or no loss of function.
 When splinting, evaluate the patient's pulse, movement and sensation before and after applying the splint.
Document findings
 Fractures should be splinted in the position they are found unless there is diminished distal circulation or the
position prevents transportation. If an angulated fracture is to be realigned, gentle traction should be used
to return it to the anatomical position. Document the neurovascular exam before and after the realignment.
Dislocations should not be relocated in the field. If the distal circulation is impaired, contact the Base
Physician for advice.
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Head Trauma
This protocol serves as a guide in the treatment of a patient who has suffered a traumatic injury to the head
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Consider spinal immobilization if indicated
x
x
x
x
Control bleeding
x
x
x
x
Place the patient in position of comfort/Indicated position
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%
x
x
x
x
Monitor vital signs including: HR, BP, ECG, BGL, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
DO
x
X
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Consider benzodiazepine of choice if the patient experiences a seizure
or is combative
Monitor blood glucose level
X
X
Notes:
 Ventilate the patient at a rate to achieve EtCO2 of 35-45mmHg if the patient requires ventilation. Do not
hyperventilate unless the patient exhibits signs of herniation; then ventilate to 30mmHg EtCO2
 Early signs of increased intracranial pressure include: confusion, restlessness, anxiety, combativeness,
headache and nausea. Late signs are changes in vital signs, posturing and changes in pupils. Do not wait until
the patient is unconscious before you suspect a head injury
 If a patient has trauma to the head, and is taking Coumadin or another blood thinner, the patient should be
encourage to consent to transport. An AMA refusal must be obtained if the patient refuses transport.
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Specific emergencies
Type of injury
Signs/symptoms
Vital signs
Special considerations
Concussion: temporary
loss of neurological
function, no tissue
damage.
Loss of consciousness,
amnesia, headache,
altered mentation.
Vital signs will not be
affected and should be
within normal limits.
All signs and symptoms
should be resolved within
24 hours.
Contusion: bruising to the
brain results in swelling of
the tissue.
Loss of consciousness,
amnesia, headache,
altered mentation.
If ICP increases:
bradycardia,
hypertension, abnormal
respirations, posturing
and pupil changes.
Severe swelling can result
in brain damage and
death.
Epidural hematoma:
arterial bleed occurs in
the epidural space.
Associated with skull
fractures.
Associated with a “lucid
interval” followed by a
loss of consciousness,
amnesia, headache,
altered mentation.
If ICP increases:
bradycardia,
hypertension, abnormal
respirations, posturing
and pupil changes.
Associated with skull
fractures, especially in the
temporal and sphenoid
area. Carries a high
mortality rate.
Subdural hematoma:
venous bleed occurs in
the subdural space.
Loss of consciousness,
amnesia, headache,
altered mentation, dilated
pupils, and hemiparesis.
If ICP increases:
bradycardia,
hypertension, abnormal
respirations, posturing
and pupil changes.
Can be acute, or chronic
as seen in the elderly and
alcoholics.
Subarachnoid hematoma:
bleeding occurs in the
subarachnoid space.
Loss of consciousness,
amnesia, headache,
altered mentation, neck
or back stiffness or pain.
If ICP increases:
bradycardia,
hypertension, abnormal
respirations, posturing
and pupil changes.
CSF is found in the subarachnoid space. Blood
will irritate the meninges
causing neck or back pain.
Basilar skull fracture: the
base of the skull is
broken.
Head pain, raccoon's
eyes, battle signs, CSF in
ears, nose or mouth.
Vital signs may vary.
Open skull fracture: brain
matter will be visible in
the wound.
Associated with large
amounts of bleeding.
Vital signs may vary.
Keep any exposed brain
tissue covered with a
sterile dressing moistened
with Normal Saline.
Depressed skull fracture:
bone in which fragments
are driven into the brain.
Depressed deformity to
skull, often a comminuted
fracture.
Vital signs may vary.
Do not use direct pressure
to control bleeding on
these areas.
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Hemorrhage
This protocol serves as a guide in the treatment of a patient who has suffered an injury and is bleeding
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Consider spinal immobilization if indicated
x
x
x
x
Control bleeding with:
x
x
x
x

Direct pressure and bulky dressing
x
x
x
x

If bleeding persists, apply tourniquet
x
x
x
x

Consider a hemostatic agent if it is not possible to control bleeding
with a tourniquet
x
x
x
x
Bandage wounds and splint as needed
x
x
x
x
Ensure the patient does not become hypothermic
x
x
x
x
Place the patient in position of comfort/indicated position
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
Consider pain control as indicated with opioid of choice
DO
x
Consider anxiety control as indicated with benzodiazepine of choice
DO
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Notes:
 The vast majority of hemorrhage will be controlled with aggressive direct pressure to the injury. If the initial
dressing soaks through continue with pressure and add more dressing. Ten minutes or more may be
required for an adequate clot to form
 Patients taking ASA, anti coagulants or with coagulopathy may need longer periods of direct pressure or
more aggressive control techniques
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Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Spinal trauma
This protocol serves as a guide in the treatment of a patient who has suffered a spinal injury
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Manually stabilize cervical spine
x
x
x
x
Move the patient to supine if indicated
x
x
x
x
Apply cervical collar and maintain manual stabilization as indicated
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Restrict spinal movement as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
Consider pain control as indicated with opioid of choice
DO
x
Consider anxiety control as indicated with benzodiazepine of choice
DO
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Consider antiemetic administration
DO
Notes:
 Be prepared to tip the entire board to the side if the patient begins to vomit. The patient must be secured to
the board or scoop with straps across the torso
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January 1, 2016
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Selective Spinal Immobilization
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-I, and Paramedic - Standing Order
EMT-B, EMT-BIV - Direct Order
Introduction:
Scientific evidence has shown limited, if any, benefit from the use of spinal immobilization devices in traumatically
injured patients; evidence has shown potential harm from spinally immobilizing patients
The tool provided below will assist providers in deciding when or when not to immobilize a patient. If at any time a
provider is uncomfortable withholding immobilization, immobilization should be performed and the situation
documented in the PCR for review
Implementation:
Determine required immobilization technique using tool provided below or determine that no immobilization is
indicated
 If full spinal immobilization is indicated:
o Immobilize the patient on a Long Spine Board, Scoop Board, or Vacuum Mattress
o Place properly sized C-collar
o Ensure that the patient is adequately padded to avoid further injury

If a C-collar is to be placed:
o Place properly sized C-collar
o Coach the patient to restrict spinal movement.
o If the patient is ambulatory, assist patient in moving to the gurney. If the patient is able to selfextricate after a MVC, this is acceptable and preferred
o If the patient is not ambulatory, a Scoop Board should be used to facilitate movement to the gurney

If no C-collar or immobilization is indicated:
o Treat patients injures and conditions as indicated, but do not spinally immobilize the patient
General:
 Log rolling patients should be avoided unless the patient is found in a prone position or there is suspected
injury to the posterior aspect of the patient
 Withhold C-collar placement if it is difficult to place, poorly fitting, or might impair airway management.
Other methods of cervical immobilization may be used
 Risk of aspiration should be considered prior to fully immobilizing a patient. Prophylactic antiemetic
administration may be used
 A properly padded Scoop Board may be left in place during transport to HRRMC to facilitate movement of
the patient. If padding is not used, Scoop Board should be removed prior to transport
 Forcefully restraining a patient to initiate spinal immobilization may cause more harm than forgoing
immobilization. Sedation may be used if needed (Refer to Patient Restraint Protocol). Base Physician contact
should be initiated
 Properly securing a patient to the gurney is mandatory. Seatbelts should be implemented for adults, and
proper pediatric restraint devices for pediatric patients
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Selective Spinal Immobilization Flow Chart
Clinical assessment suggests the
potential for spinal injury?
Yes
Patient is unconscious, has
significantly altered mental
status, or unable to follow
commands due to acute
No
condition?
No
Yes
Patient does not require placement on a
long spine board
Harm likely
Consider harm vs. benefit to providing
full spinal immobilization:
 Patient will resist immobilization
 Extended transport time
No significant harm likely
Does the patient:
 Have CTLS spine pain
 Have neurologic deficits
 Have distracting injuries
No
Yes
Immobilize with LSB/Scoop/Vacuum
Mattress & C-collar & Spider Straps &
Head blocks
Place on gurney with C-collar in place
and coach patient to restrict movement
No C-collar or immobilization
indicated
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Chaffee County Emergency Medical Services
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January 1, 2016
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Crush Injury
This protocol serves as a guide in the treatment of a patient who has suffered a traumatic crush injury
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Control bleeding as indicated
x
x
x
x
Place the patient in position of comfort/indicated position
x
x
x
x
Consider spinal immobilization if indicated
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Continuously monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
x
x
Consider pain control as indicated with opioid of choice
DO
x
Consider anxiety control as indicated with benzodiazepine of choice
DO
x
DO
DO
DO
x
IV: x 2
IO if unable to obtain IV
Fluid bolus of 20ml/kg
x
If the patient has:

Compression of a full upper or lower extremity for greater than 4 hours

Compression of chest or abdomen for greater than 4 hours

Has signs of hyperkalemia
Administer 1meq/kg Sodium Bicarbonate diluted in 250mL D5W just
prior to extrication
Administer 5mg Albuterol
DO
DO
Consider Calcium Chloride
Treat hypotension as indicated. Control airway and breathing as
indicated
x
x
x
x
x
Notes:
 Contact Base Physician for all crush injuries
 Avoid Succinylcholine administration
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Drowning / Near Drowning
This protocol serves as a guide in the treatment of a patient who has drowned or had a near drowning event
Procedure
EMTB
EMTBIV
EMTI
Paramedic
Manually stabilize cervical spine if indicated
x
x
x
x
Immobilize as indicated
x
x
x
x
Initiated CPR if needed: Refer to Cardiac Arrest Protocol
x
x
x
x
Support airway and breathing as indicated
x
x
x
x
Administer O2 if the patient is short of breath or titrated to SPO2 ≥ 94%. If
the patient is actively bleeding or hypotensive, administer high flow O2
x
x
x
x
Monitor vital signs including: HR, BP, ECG, and temperature
x
x
x
x
Monitor cardiac rhythm (EMT-B, EMT-BIV non-interpretive)
x
x
x
x
x
x
x
x
x
IV: 1-2 with Normal Saline bolus as indicated
IO if unable to obtain IV and the patient is unstable
Monitor for hypothermia: Refer to Hypothermia Protocol
x
x
x
x
Consider CPAP administration
x
x
x
x
Notes:
 Consider transport of all near-drowning patient. Even if the patients initially appear fine, they can
deteriorate
 Beware of neck injuries - they often go unrecognized
 Under current ACLS standards, Heimlich maneuver is not indicated
 Contact Medical Control Via Cell phone or radio if service is available. See “Field Pronouncement”
protocol for further guidelines.
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Pharyngeal Airways – Oral and Nasal
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
Placement of airway adjuncts in the nasopharynx or oropharynx to displace the soft tissues of the pharynx and ease
ventilation. An oropharyngeal (OPA) airway can be placed in a patient who is unconscious without a gag reflex.
Nasopharyngeal airways (NPA) can be placed in patients who are conscious and/or have a gag reflex
Indications:
 To ease spontaneous respiration by a patient that is semi-conscious
 To assist oxygenation and ventilating a patient
 To prevent gastric distention
Contraindications:
 OPA – known intact gag reflex
Precautions:
 Insert airways gently to avoid airway trauma
 NPA –Basilar skull fractures
Procedure:
 OPA placement
o Size the OPA from the corner of the mouth to the angle of the jaw
o Place the patient with the head in midline, neutral position. (Cervical collar may be in place)
o Introduce the OPA into the mouth upside down or sideways (Pediatrics: sideways) When the tip of
the OPA reaches the back of the throat, insert the OPA into the pharynx with a twisting corkscrew
motion
o If the patient begins to gag, immediately remove the OPA

NPA placement
o Size the NPA from the corner of the nares to the angle of the jaw
o Lubricate the NPA with a water soluble lubricant if needed
o With gentle steady pressure, advance the NPA through the nares into the posterior pharynx. The
beveled edge should be against the nasal septum, to avoid trauma to the turbinates
o If the patient begins to gag, withdraw the NPA a few centimeters
Notes:
 Never force the placement of an airway adjunct.
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Extra-Glottic Airways
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic-Standing Order
To improve ability to ventilate and provide a more secure airway than OPA/NPA in patients that require ventilation
Indications:
 Patients:
o With no intact gag reflex
o Who require ventilation
o When Bag-Valve-Mask ventilation is not adequate or indicated
 Back up airway after endotracheal intubation is unsuccessful in RSI
 Cardiac arrest when an endotracheal tube can not be placed without interruption in chest compressions
Contraindications:
 Intact gag reflex
 Known esophageal disease
 Ingestion of caustic substances
 Upper airway obstruction
 See manufactures recommendations
Procedures:
 Maintain C-spine immobilization if needed
 Preoxygenate/ventilate the patient
 Prepare equipment including suction
 Test cuffs by inflating to full volume and inspect for leaks
 Place head should be in neutral position
 Perform tongue-jaw lift
 Choose appropriate size of tube for patient, per manufacture recommendations
 Insert tube per manufacture recommendations
 Inflate balloons/cuffs
 Confirm tube placement with continuous waveform capnography (Mandatory)
 Secure tube
 Maintain continuous waveform capnography, upload to report, and asses for breath sounds
Notes:
• Chaffee County Emergency Medical Services currently carries King-LT/LTDs and LMAs.
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Endotracheal Intubation - Nasotracheal
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
This procedure is to serve as a guide to the placement of an endotracheal tube to protect a patient’s airway and
ensure ventilation
Indications:
 To secure and protect the airway in a compromised patient who has an intact gag reflex and is
spontaneously breathing
Contraindications:
 Suspected basilar skull fracture
 Apnea
Precautions:
 The head must be midline for successful intubation
 May cause bleeding and thus complicate patient care
Procedure:
 Ventilate the patient prior to starting intubation if spontaneous ventilations are inadequate or oxygenate
 Place phenylephrine into the nares
 Lubricate tube and/or nares with viscous Lidocaine
 Choose endotracheal tube size based on size of nares
 Consider the use of a BAAM or ETCO2 detector to assist with placement
 Place the patient with the head in midline, neutral position. (Cervical collar may be placed)
 With gentle steady pressure, advance the tube through the nares into the posterior pharynx. The beveled
edge should be against the nasal septum to avoid trauma to the turbinates. Pass the tube along the floor of
the nasopharynx, perpendicular to the head
 Keeping curve of tube exactly in midline, continue advancing slowly, listening for air exchange through the
tube
 Wait for an inhalation, exhalation, or cough to advance the tube through the glottis into the trachea. A slight
resistance will be felt just before entering the trachea
 Advance about 1" further, then inflate cuff
 Ventilate and check for breath sounds bilaterally. Confirm endotracheal tube placement
 Continuous capnography after placement is mandatory and must be uploaded to report

Secure tube
Notes:
 Consider other means of airway management
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Beck Airway Airflow Monitor (BAAM)
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
The BAAM is a plastic cap that when placed on an endotracheal tube will be activated by the patient’s respirations
and magnify airway airflow sounds facilitating blind nasotracheal intubation
Indications:
 Assist nasotracheal intubation placement
Contraindications:
 None during nasotracheal intubation
Precautions:
 A BAAM can only be used in a patient who has spontaneous respirations with a tidal volume strong enough
to create airflow through the device
 The BAAM will only confirm placement in the bronchial tree, it will not determine if the tube tip is placed at
the carina or in a bronchial main stem
 An unobstructed endotracheal tube with its tip located in the pharynx can produce the whistle sound. It is
important to know the length of the endotracheal tube within the patient
Procedure:
 Connect the BAAM to a 15 mm endotracheal connector.
 When the tube is advanced into the posterior nasopharynx, the patient's breathing will activate the BAAM
and a whistling sound will be produced with inhalation and exhalation
 The tube is then advanced into the larynx and trachea, which will increase the intensity and pitch of
whistling sound
 Deviation out of the airflow tract, esophageal intubation will result in immediate diminution or loss of the
whistle sound. The tube should be withdrawn until the whistle sound is audible, and the tube should be
redirected and reinserted
 Once tube is thought to be placed, remove BAAM and confirm correct tracheal intubation
Notes:
 A BAAM is single-use only
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Endotracheal Intubation - Orotracheal
Authorization:
Protocol:
EMT-I and Paramedic
EMT-I and Paramedic - Standing Order
This procedure is to serve as a guide to the placement of an endotracheal tube to protect a patient’s airway and
ensure ventilation
Indications:
 To secure and protect the airway in a patient without a gag reflex
 To allow continuous compressions during CPR
Contraindications:
 Patient has intact gag reflex
Precautions:
 Never use intubation as a primary treatment of respiratory arrest in the field. Airway management should
be accomplished with BVM ventilation and pharyngeal airways
 Patients with suspected neck injuries. If oral intubation is attempted, the head should be held in midline
position with manual traction. However, airway management takes precedence over everything, including
spinal immobilization
 Do not pry the laryngoscope against the teeth
Procedure:
 Ventilate the patient
 Assemble the equipment: Tube, syringe, suction, laryngoscope, ect.
 Choose the appropriate tube size (see following Notes)
 Position the patient. Pad under shoulders/head as needed
 Insert laryngoscope and place endotracheal tube
 Ensure SPO2 is adequate during attempt
 Inflate cuff with 5 - 10 cc of air and remove the stylette if used
 Place capnography detector and: listen to breath sounds, listen to the epigastrum, and check for chest rise
during ventilation
 Continuous ETCO2 monitoring is mandatory and must be uploaded to report
 Secure endotracheal tube
Notes:
 Esophageal intubation should be avoided by using direct visualization of the vocal cords if possible
 Consider using a Bougie Flex-Tip ET tube inducer
 Intubation of the right main stem bronchus is very common. If there are not any breath sounds on the left
or they are diminished, withdraw the tube slightly until bilateral breath sounds are heard
 To determine tube size in children: Utilize Broselow tape (Another "rule of thumb" is to use the tube with a
diameter nearest to the diameter of the patient's little finger.)
 If there is a question as to the placement of the tube, remove it and re-intubate. Do not ever leave a tube in
place that is questionable.
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Endotracheal Intubation – Rapid Sequence Intubation
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
The use of sedative and paralytic medications to facilitate direct laryngoscopy and orotracheal intubation
Indications:
 In a patient with an intact gag reflex that:
o Is unable to protect their own airway
o Will potentially be unable to protect their own airway without intervention
o Who is at risk for airway swelling and obstruction without intervention
o Airway compromise with trismus
Contraindications:
 Patients <12yrs
 Patients who can be adequately oxygenated/ventilated by less invasive means with no potential for
airway compromise
Precautions:
 RSI is a procedure that has a high potential for significant complications. This procedure should be
reserved patients who have, or will most likely develop, airway compromise that cannot be adequately
managed by other means
 A adequate number of personnel should be on hand to assist
Procedure:
 Ensure that indications are present for RSI
 Asses for predicated difficult BVM, intubation, EGD, and cricothyrotomy:
o Consider an “Awake Look” utilizing atomized Lidocaine
o Sedation with Versed may be used if needed
 Obtain BP and continuous SPO2, ECG, and ETCO2 (If indicated)
 Place a nasal cannula on patient for apneic oxygenation, even if patient is on a NRB
 Established IV/IO
 Prepare intubation equipment, extra-glottic device, and cricothyrotomy equipment
 Consider premedication with:
 Fentanyl - 3µg/kg
 Lidocaine for head injury – 1.5mg/kg
 For patients with increased ICP, CAD, or vascular disease
 Administer induction agent:
 Ketamine - 1.5mg/kg
 If the patient is hypotensive consider 1mg/kg
----------OR--------- Midazolam - 0.3mg/kg
 Administer paralytic of choice:
 Succinylcholine - 1.5mg/kg
----------OR--------- Veccuronium - 0.1mg/kg
 Attempt endotracheal intubation with VL or DL technique
 Ensure that adequate SPO2 is maintained during/between attempts. If endotracheal intubation is
unsuccessful, the patient desaturates with inability to ventilate with a BVM, or after 3 intubation
attempts, place extra-glottic device if indicated. (See Failed Airway)
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Verify endotracheal tube placement
 Continuous ETCO2 monitoring is mandatory and must be uploaded to report
Secure endotracheal tube
Maintain sedation: Versed and/or Ketamine
Maintain pain control: Fentanyl
The need for re-paralysis should only be considered once adequate sedation and analgesia have been
ensured
 Veccuronium – 0.1mg/kg IV
Place NG or OG tube
Complete all documentation per agency and state requirements and submit for review within 24hrs
Notes:
 If the patient is hypotensive or at risk to become hypotensive, have vasopressor of choice available and
attempt to correct hypotension prior to induction
 If the patient is hypoxic and unable to correct prior to induction and paralysis, consider placement of an
EGD with oral ETI at a later time
 If the patient is acidotic, consider placement of an EGD with oral ETI at a later time. Ensure ETCO2 does
not rise from pre-induction value
Plan in place? (RSI, Awake, RSA)
Consider increased/decreased BP/SP02/pH
Intubation equipment ready
Suction on and available
Asses for EGD placement/ready
Asses for cricothyrotomy. Mark/ready
Preoxygenate/denitrogenate
NC for apneic oxygenation in place
Pre-treatment with Fentanyl
Ketamine drawn up
Paralytic drawn up
Post intubation medications drawn up
Vasopressor available
Patient monitors in place
Position patient: ramp/ear to sternal notch with proper lighting
Team briefed on plan, roles and back up plans
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Awake Look - Laryngo-Tracheal Mucosal Atomization Device
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Should be used to assist in oral intubation if the patient has an intact gag reflex
Indications:
 In a patient with an intact gag reflex that:
o Is unable to protect their own airway
o Will potentially be unable to protect their own airway without intervention
o Is determined to be, or potential be, a difficult intubation
Contraindications:
 Patient does not require intubation
 See Lidocaine Protocol
Precautions:
 See Lidocaine Protocol
 Only to be used in patients that require endotracheal intubation and are determined to have or potential
have a difficult airway
 The patient must be able to gag, cough, and protect their airway
Procedure:
 Explain procedure to the patient
 Obtain BP and continuous SPO2, ECG, and ETCO2 (If indicated)
 Established IV/IO
 Prepare intubation equipment including suction
 Assemble atomization device and draw up 2% Aqueous Lidocaine
 Preoxygenate the patient
 Have the patient open mouth and pass device as far posterior and inferiorly as the patient will allow.
Consider the use of a tongue depressor
 Firmly press syringe to spray Lidocaine on the mucosa
o Numbing the posterior tongue and then re-administering posteriorly may be needed
 Once the patients gag reflex is no longer intact, pass the laryngoscope, preferably video laryngoscope,
gently into the patient’s mouth and attempt to visualize the vocal cords
 If the patient will allow, gently place an endotracheal tube. See Endotracheal intubation – Oral for further
procedure and confirmation procedure
 If endotracheal tube is placed, consider sedation and paralyzation
 If endotracheal tube is not placed, consider RSI or alternate means of airway control as indicated
 If sedation is need to reduce anxiety during “Awake Look”, consider dose of sedative of choice
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Airway Assessment
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I and Paramedic
EMT-B, EMT-BIV, EMT-I and Paramedic - Standing Order
This protocol is a tool that can be used by all providers to evaluate a patient’s airways for difficulty in performing
procedures
LEMONS for intubation:
 L = “Look” – Look at body habitus, neck, beard & clinical situation
 E = “Evaluate” - 3:3:2 Rule
o Can 3 of the patient’s fingers fit in the mouth opening
o Is the hyomental distance greater than 3 of the patient’s fingers
o Is the thyrohyoid distance greater than 2 of the patient’s fingers
 M = “Mallampatti” – Classify the oropharynx.
 O = “Obstruction” – Check for airway obstruction (Teeth, blood, edema ect.)
 N = “Neck” Immobility – Known or expected
 S = “Saturation” – Check ability to oxygenate blood prior to procedure
MOANS for ventilation:
 M = “Mask” – Evaluate for beard, difficult anatomy, or other feature that might impair mask seal
 O = “Obstruction”
 A = “Age”
 N = “No” (teeth (replace dentures for Bag Valve Mask ventilation)
 S = “Stiff” lungs requiring increased ventilatory pressures (Asthma, COPD, ARDS, term pregnancy)
SHORT for cricothyrotomy:
 S = “Surgery” distorting the airway and tracheal access
 H = “Hematoma”, infection or mass in the path of the cricothryotomy
 O = “Obesity” or fixed flexion deformity of the neck
 R = “Radiation” to the neck
 T = “Tumors” involving the airway or in vicinity
RODS for extra-glottic airway placement:
 R = “Restricted” mouth opening
 O = “Obstruction” of the upper airway or larynx
 D = “Distorted” or disrupted airway
 S = “Stiff” lungs requiring increased ventilatory pressures (Asthma, COPD, ARDS, term pregnancy)
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Failed Airway
Unable to intubate the patient with RSI,
unable to oxygenate/ventilate, or unable
to intubate the patient after three
attempts
Place extra-glottic device
Assess for adequate oxygenation/ventilation
 Ventilation compliance
 Waveform capnography
 SpO2 monitoring
 Auscultation of breath sounds
If oxygenation/ventilation is inadequate or
extra-glottic device is/may become inadequate
to protect airway
 Perform Percutaneous Cricothyrotomy
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Percutaneous Cricothyrotomy
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Percutaneous Cricothyrotomy is the establishment of an airway through the cricothyroid membrane
Indications:
 The inability, or potential inability, to oxygenate or ventilate a patient by other means
Contraindications:
 Ability to oxygenate or ventilate the patient by less invasive means
Precautions:
 Bleeding is likely, be prepared to perform the procedure “blind”
 Subcutaneous air may indicated improper placement or tracheal damage
 Procedure should be performed in a well-lit and stable environment
Procedure:
Needle cricothyrotomy (Patient < 4yrs of age)
 Ensure that procedure is indicated. See Failed Airway Protocol
 Position the patient in a supine position, with in-line spinal immobilization if indicated
 Cleanse the site
 Choose 16ga or 14ga angiocatheter as appropriate
 Insert chosen needle through the cricothyroid membrane in a caudal direction at a 45-degree angle
 Procedure until a “pop” is felt or air is readily aspirated. Advance needle a short distance more, and
advance catheter
 Remove syringe or needle and syringe as indicated
 Place a 2.5mm ETT/BVM adapter onto the angiocatheter
 Ventilate with BVM and 100% oxygen
 Confirm placement with continuous waveform capnography
 Secure catheter
 Allow longer exhalation period to avoid barotrauma
Surgical cricothyrotomy (Patient >4yrs of age)
 Ensure that procedure is indicated. See Failed Airway Protocol
 Position the patient in a supine position, with in-line spinal immobilization if indicated
 Cleanse the site and consider marking the location
 Open package, maintaining asepsis
 Inflate cuff with 10mL of air. Deflate fully
 Locate landmark over cricothyroid membrane digitally
 Make vertical incision with scalpel
 Performing blunt or digital dissection
 Perforate cricothyroid membrane with scalpel or use forceps
 Insert tracheotomy hook and secure tracheal ring caudally from incision site
Or
 Insert Gum Elastic Bougie in a caudal direction
 Insert provided endotracheal tube into incision or over Bougie in a caudal direction approximately ½ to
1inch
 Inflate cuff with 5-10mL of air
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Ventilate with BVM and 100% oxygen
Confirm placement with continuous waveform capnography
Secure tube and control bleeding as needed
Notes:
 Identifying landmarks to locate the cricothyroid membrane is difficult, especially in the female and
pediatric patient
 If landmarks can be identified, a stabbing motion with the scalpel is preferred
 It is recommended to stabilize the instrument hand on the sternum of the patient
 It may be helpful to identify structures in a downward direction using the “handshake” method:
o Hyoid Bone
o Thryroid cartilage
o Cricoid membrane
o Cricoid cartilage
 The reason for performing this procedure must be documented and submitted for review to the Medical
Director or designee within 24 hours
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Continuous Positive Airway Pressure (CPAP)
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-I, and Paramedic - Standing Order
EMT-B, and EMT-BIV – Direct Order
CPAP provides constant pressure during exhalation and inhalation. This provided benefits through “splinting” of the
small airways and increased intraaveolar pressure
Indications:
 Shortness of breath due to:
o Congestive heart failure
o Pulmonary edema
o COPD
o Pneumonia
o Near drowning
 Caron Monoxide poisoning with levels >20% or symptomatic
 RSI preoxygenation
Contraindications:
 Patient unable to protect airway
 Apnea
 Hypotension (Systolic < 90mmHg)
 Dyspnea secondary to trauma, pneumothorax, or penetrating injury
 Nausea and vomiting or other risk of aspiration
Precautions:
 Cardiac chest pain
 Altered level of consciousness
 Inability to achieve mask seal
Procedure:
 Explain the procedure to the patient
 Monitor the patient’s vital signs: HR, BP, ECG, SPO2, and ETCO2
 Attach device to oxygen with flow rate of 15/lpm
 Place mask on the patient’s face and secure with harness if tolerated
 Ensure mask seals to patient’s face
 Continue to coach the patient to keep mask in place and readjust as needed
 Treat medically as indicated
 Advise receiving facility of CPAP initiation
 If respiratory status deteriorates or does not improve, remove device and consider intermittent positive
pressure ventilation via BVM and/or advanced airway placement
Notes:
 A patient that requires CPAP is a mandatory ALS if an ALS personnel is available
 CPAP therapy needs to be continuous and should not be removed unless the patient deteriorates or other
complications develop
 Watch the patient for gastric distention
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Apneic Oxygenation
Authorization:
Protocol:
EMT-I, and Paramedic
EMT-I, and Paramedic - Standing Order
Apneic oxygenation is the process of introducing oxygen into the pharynx via the nasopharynx. Due to oxygen
absorption at the alveolar level and the created negative pressure, oxygen is drawn into the alveoli and made
available for absorption
Indications:
 RSI preoxygenation through apneic period
 Any apneic patient as an adjunct until definitive ventilation and airway control can be obtained
Contraindications:
 None
Precautions:
 Apneic oxygenation does not remove CO2. Great caution should be taken to ensure that hypercarbia will not
harm the patient
 Does not eliminate the need for airway or ventilatory control
Procedure:
 Place an ETCO2 Nasal Cannula on the patient
 Set flow rate to 10-15lpm
Notes:
 Apneic oxygenation throughout the apneic period during an RSI has become the standard of care and should
be utilize on all patients
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Chest Decompression
Authorization:
Protocol:
EMT-I and Paramedic
EMT-I and Paramedic - Standing Order
A needle is introduced into the pleural space to allow the escape of air that has built accumulated secondary to a
break in the chest wall or integrity of the lungs
Indications:
 Tension pneumothorax (Pneumothorax with signs of obstructive shock)
 Hypotensive patient with multisystem trauma and no apparent hypovolemia
Contraindications:
 Simple pneumothorax without signs of shock
Precautions:
 Tension pneumothorax is a rare condition, but can occur either traumatically or spontaneously. If it is
present, it may rapidly lead to death if left untreated
Procedure:
 Expose the chest
 There are two sites that can be used; however the lateral location is preferred:
o The second or third intercostal space on the anterior midclavicular line
o The third or fourth intercostal space on the mid-axillary line
 Clean the site to be used vigorously
 Using a 14 gauge or a 10-gauge angiocath, insert the needle into the pleuritic cavity over the top of the rib
 If the air is under tension, air will vent out of the angiocath. Advance the catheter and remove the needle
 Secure catheter
 Procedure may be performed multiple times as indicated
Notes:
 Complications include: creation of a pneumothorax if one did not exist previously, laceration of blood vessels
and nerves, and infection
 The procedure may be painful, especially when piercing the pleura. Even so, if indicated, the procedure
should be done as soon as possible
 A tension pneumothorax can be precipitated by sealing a sucking chest wound. If the patient deteriorates
after a dressing is in place on an open chest wound, remove the dressing and have the patient cough. This
will relieve the pressure
 The use of positive pressure ventilation will rapidly accelerate the development of tension pneumothorax if
there is a simple pneumothorax present due to lung injury. Therefore, monitor closely for the development
of a tension pneumothorax any time you use positive pressure ventilation especially in the trauma setting
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Peripheral IV Insertion
Authorization:
Protocol:
EMT-BIV, EMT-I, and Paramedic
EMT-BIV, EMT-I, and Paramedic
IV access allows a blood draw to be obtained, and fluid/medications to be administer or potentially administered
Indication:
 Any patient requiring or potentially requiring:
o A blood draw
o Fluid administration
o Medication administration
Contraindications:
 None
Precautions:
 Do not start an IV distal to a fracture site or through skin damaged with more than erythema or superficial
abrasions
 Make certain the IV solution on hand is the desired solution
 Check expiration dates and clarity of fluid
 Do not delay maintaining Airway, Breathing, or other methods of maintaining Circulation to attempt IV
access
Procedure:
 Explain the procedure to the patient
 Prepare the equipment
o Determine correct fluid to be administered
o Choose correct administration set or extension set
o If possible, use extension set when using an administration set
o Assemble equipment per accepted procedure ensuring asepsis
 Cleanse site
 Once venous cannulation is achieved, perform Venous Blood Draw if indicated
 Attach administration set and/or extension set
 Administer fluid at appropriate rate
Notes:
 IV’s in patients younger than 12 should be run through a volumetric infusion device (i.e., Volutrol, Buretrol)
to prevent fluid overload or use an extension set alone
 Pyrogenic reactions due to contaminated fluids become evident in about 30 minutes after starting the IV.
The patient will become febrile. Chills, vomiting, nausea, headache, backache and general malaise are
indications. If observed, stop and remove IV and immediately save the solution so it may be cultured
 Complications: hematoma formation, infection, thrombosis, phlebitis, skin necrosis, sepsis, pulmonary
embolus, catheter fragment embolus, fluid overload, pulmonary edema, cardiac failure, fiber embolus from
solution in IV
 The incidence of phlebitis is particularly high in the leg. Avoid use of lower extremity if possible.
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Law Enforcement Blood Draw
Authorization:
Protocol:
EMT-BIV, EMT-I, and Paramedic
EMT-BIV, EMT-I, and Paramedic – Standing Order
Blood draw to obtain samples of venous blood to be used by a law enforcement agency
Indications:
 At the request of the Colorado State Patrol
 At the request of the Chaffee County Sheriff’s Office
 At the request of the Salida Police Department
 At the request of the Buena Vista Police Department
Contraindications:
 None
Precautions:
 May be performed on a patient that is not transported
 Do not delay treatment/transport of a critically ill or injured patient to obtain blood draw
Procedure:
 Assemble equipment from seal package provided by the law enforcement officer
 Cleanse site with iodine. Do not use alcohol
 Obtain blood samples
 Remove needle, if used, and hold pressure. Apply bandage if needed
 Complete required paperwork
Notes:
 The required paperwork includes the following questions
o Does the person want any medical care or treatment from CCEMS personnel?
o Is the person voluntarily consenting to having g their blood drawn by CCEMS personnel?
o Was the sealed venipuncture kit(s) provided by the requesting officer?
o Was the blood drawn using all of the materials from the sealed kit(s)?
o Was the venipuncture site(s) cleaned using only non-alcoholic antiseptic wipe(s) from the provided
kit?
o Blood specimen obtained using:
o Did you witness the sealing of each blood tube?
o Did you witness the initialing of all seals?
o How many venipuncture attempts were made?
o Home many kits were use?
o Venipuncture site
 Obtain officer’s signature
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Venous Blood Draw
Authorization:
Protocol:
EMT-BIV, EMT-I, and Paramedic
EMT-BIV, EMT-I, and Paramedic – Standing Order
A blood draw obtains samples of venous blood, in various tubes, that can be used for testing at the receiving hospital
Indications:
 Any patient who receives a peripheral IV or EJ in the field
o A blood draw may be forgone altogether or withheld until a second IV is place at the providers
discretion
Contraindications:
 None
Precautions:
 Treatment of unstable patients should not be delayed to obtain blood samples
Procedure:
 After initiating an IV and removing the needle, attach the vacutainer holder to the hub of the IV catheter.
(This is accomplished using the Luer adaptor attached to the vacutainer holder.)
 Fill all the desired blood tubes in appropriate order per system requirements
 Tubes should be gently inverted. Do not shake the tube, as this could cause hemolysis, which could interfere
with test results
 Tubes should be placed in bag and kept with the patient
 Provide tubes to receiving facility
Notes:
 Pediatrics receiving an IV should have at least a red tube and lavender top tube drawn. The red top may
be filled only halfway and the lavender only 1/4 of the way to do the needed tests. If available, red and
lavender pediatric tubes may be used
 The blue top tube must be filled exactly to be usable; the amount of vacuum in the tube is pre-established to
draw the proper amount of blood into the tube.
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External Jugular IV Insertion
Authorization:
Protocol:
EMT-I, and Paramedic
EMT-I, and Paramedic - Standing Order
Indications:
 Provider choice when peripheral IV access is not obtainable
Contraindications:
 Hematoma, trauma, or other abnormality over site
 Patient does not require an IV
Precautions:
 Complications from an EJ attempt can be severe
 Consider IO placement
Procedure:
 Position the patient: supine with the patient's head turned to opposite side from procedure.
 Cleanse the site with alcohol prep
 Align the cannula in the direction of the vein with the point aimed toward the ipsilateral shoulder (on same
side)
 Make the puncture midway between the angle of the jaw and the midclavicular line, tamponade the vein
lightly with one finger above the clavicle
 Attach IV tubing to catheter
 Secure tubing to patient's neck with tape.
Notes:
 Complications: hematoma formation, infection, thrombosis, phlebitis, skin necrosis, punctures of internal
jugular vein or carotid artery, sepsis, pulmonary embolus, catheter fragment embolus, fiber embolus from
solution in IV
 This should never be attempted as a “blind stick”
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Intraosseous Cannulation
Authorization:
Protocol:
EMT-I, and Paramedic
EMT-I, and Paramedic - Standing Order
A metal catheter is placed into a bone, usually the tibia or humeral head, so that fluids or medications can be infused
into the bone marrow
Indications:
 Any situation in which IV/IO access is needed and IV access is unobtainable or will require extended time to
establish
Contraindications:
 Fracture of same bone
 Patient is stable, with no indication of potential instability
 Replacement of joint on side of procedure
Precautions:
 Limit IO attempt to only one per extremity
 Conscious patients require Lidocaine administration for local anesthetic
 Osteoporosis (Insecure placement)
Procedure:
 Assemble equipment
 If the patient is conscious, flush extension set with Lidocaine and attach to flushed drip set, if a drip set is
needed
 Choose appropriate IO cannula
 Locate landmarks for the tibial (Preferred) or humeral insertion sites
 Scrub the insertion site with Iodine and then alcohol prep
 Insert the needle through the skin at a 90 degree angle on the tibial plateau or at the greater tubercle of the
humeral head
 Place needle into the marrow cavity with gentle, constant pressure. If drill slows, too much pressure may
being applied
 There will be a slight "pop" when the needle goes into the marrow cavity. Stop as soon as the needle flange
contacts the patient’s skin or a sudden decrease in resistance is felt as the needle enters the medullary canal
 Attach extension set and/or administration set
 Ensure adequate flow with no extravasation of fluid. IO should be be flushed to ensure flow or pressure
infuser may be used
 Secure IO cannula
Notes:
 Refer to IV Infusion or specific treatment protocol for more information
 At this time, any drug that may be given IV may also be given IO and have the same efficacy
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Semi-Automated External Defibrillator
Authorization:
Protocol:
EMT-B, EMT-BIV EMT-I, and Paramedic with current SAED authorization
EMT-B, EMT-BIV EMT-I, and Paramedic - Standing Order
The SAED analyses cardiac rhythm for the presence of ventricular fibrillation or rapid ventricular tachycardia,
charges to preset energy levels, and allows the user to deliver a defibrillation shock. The user must follow strict
patient selection criteria. The user must be currently authorized as an AED provider
Indications:
 A patient found unresponsive, apneic, and pulseless
Contraindications:
 Do note place on the patient that:
o Is breathing
o Is responsive
o Has a pulse
 ALS providers should use Manual Defibrillation to avoid delays is defibrillation
Precautions:
 Everyone must be clear of physical contact with the patient during analysis and defibrillation.
 Patients who are wet or are in any form of water must be moved to a dry surface and the chest must be
dried prior to application of electrode patches.
 All medication patches (such as nitroglycerin) should be removed from the patient's chest prior to
defibrillation
 Patients with suspected hypothermia resulting in cardiac arrest may only be given one shock, then must
be transported with continuous CPR to a hospital for re-warming before further defibrillation attempts
 If devices, such as implanted pacemaker or ICD is visualized, place SAED electrodes so as to avoid
shocking through the device
Procedure:
 Each provider must be familiar with the operation of the SAED that their agency carries
 Provide CPR per current AHA recommendations
 Operate SAED per manufacture recommendations
Notes:
 Unless the SAED is analyzing or a shock is being delivered, someone must be doing chest compressions
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Manual Defibrillation
Authorization:
Protocol:
EMT-I and Paramedic
EMT-I and Paramedic - Standing Order
Passage of electrical current through the heart tissue to cause a uniform depolarization to occur and the normal
intrinsic pacers of the heart to resume at normal rates and sequences
Indications:
 Ventricular fibrillation in a pulseless and apneic patient
 Ventricular tachycardia in a pulseless and apneic patient
 Uncontrolled A-Fib with suspected WPW (Wide complex, and irregularly irregular tachycardia)
Contraindications:
 Patient condition does not meet indications
Precautions:
 Do not treat the monitor strip alone - treat the entire the patient! A patient who is talking to you is not in
ventricular fibrillation, whatever the monitor shows. Check another lead and confirm that the electrodes are
attached
 Ensure that chest is clean and dry
 Avoid any direct physical contact with the patient during defibrillation
 Defibrillation may not be successful in ventricular fibrillation due to hypothermia until core temperature is
above 88F (31C)
 Defibrillation is not the first treatment in fibrillation due to hypovolemia (trauma situation). CPR and fluids
take precedence
 Do not defibrillate over any medication patch. Remove the patch first
 Do not defibrillate over any implanted pacemaker or defibrillator. Move pad/paddle one inch from device
Procedure:
 Perform CPR per ACLS guidelines. Refer to the specific Cardiac Arrest Protocol
 Attach ECG limb leads and multi-function pads. Correct pad placement will increase chance of successful
conversion. Hard paddles can also be used if needed
 Defibrillate per manufacture recommendations
Notes:
 ALS providers should use Manual Defibrillation, not SAED mode to avoid long pauses in chest compressions
 Remember that the hypoxic or acidotic heart may not respond to defibrillation. Chest compressions will, to
some degree, reverse hypoxia and acidosis. Any underlying condition should be treated appropriately
 Do not forget to start CPR by preoccupation with defibrillation. Continue compressions while charging
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Transcutaneous Cardiac Pacing
Authorization:
Protocol:
EMT-I and Paramedic
EMT-I and Paramedic – Standing Order
An externally applied electrical current is passed through the heart tissue causing cardiac depolarization
Indications:
 Symptomatic bradycardias when Atropine is ineffective or contraindicated
 Tachycardia that cannot be treated by pharmacological means (EMT-Intermediate)
Contraindications:
 None
Precautions:
 Capture may not be possible with severe ischemia and necrosis
 Patients who are conscious will experience discomfort. Consider benzodiazepine or opioid administration
Procedure:
 Place limb leads on the patient and multi-function pads on the chest
 Turn the pacer on
 Set initial energy setting to 60mA and the rate at 80 BPM
 Increase energy setting in 10 mA increments until capture occurs up to 200 mA.
 Once capture occurs, check for a femoral pulse. If it is not present, consider a fluid challenge, attempt to
increase by 10mA, or begin vasopressor of choice
 Place pleth wave in one channel of Life Pak and press print to document pulse
Notes:
 An Epinephrine drip or Dopamine drip can be administered while TCP is being performed if indicated
 The figures below are example of pacing artifact. Figures are copied from a Medtronic user manual
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Synchronized Cardioversion
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Passage of electrical current through the heart tissue to cause a uniform depolarization to occur and the normal
intrinsic pacers of the heart to resume at normal rates and sequences
Indications:
 Unstable cardiac tachy-dysrhythmias
 Cardiac tachy-dysrhythmias when pharmacological treatment is not indicated
Contraindications:
 Sinus tachycardia
Precautions:
 All of the precautions for defibrillation apply
 Patients that are stable, with a tachydysrhythmia, should be treated with medication, first if indicated
 Patients with a-fib, and a ventricular response <140bpm, will not cardiovert easily and are almost certainly
decompensated for another reason
 Sinus tachycardia is a symptom of an underlying problem. The patient must be treated for the underlying
cause. Initial treatment should be for shock if perfusion is poor. Cardioversion is not indicated
 Digitalis toxicity
Procedure:
 Apply limb leads and multi-function pads onto chest. Correct pad placement may increase chance of
achieving conversion
 Press “Sync”
o If the Sync function will not mark each QRS complex, try selecting a different lead or turning up the
QRS amplitude
o Ensure that each QRS complex is marked with a marker (Not T-waves, ect.)
 Set desired Joules. Follow current AHA recommendations. A default 200j for adult patients may be used
 Consider sedation with benzodiazepine of choice prior to cardioversion
 Press “Charge”
 Clear the patient
 Hold “Shock” until synchronizer discharges
o If the Sync function does not function properly, deactivate and consider unsynchronized
cardioversion at a higher energy setting
Notes:
 If sinus rhythm is achieved only transiently with cardioversion, subsequent cardioversion at a higher energy
setting will be of no additional value. Leave the energy setting the same and consider alteration of other
variables.
 If V-Fib occurs, see Defibrillation protocol
 Cardioversion is rarely indicated in children.
 Ventricular fibrillation and asystole are rare as complications of cardioversion and usually occur in the setting
of a digitalis-toxic patient
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Pulse Oximetry
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
Pulse oximetry combines the principles of optical plethysmography (light absorption), and spectrophotometry to
determine the percentage of arterial hemoglobin oxygen saturation (SaO2). The actual measurement is the percent
of hemoglobin that is bound. The machine cannot differentiate between what gas the hemoglobin is bound with
Indications:
 Routine assessment on every patient
Contraindications:
 None
Precautions:
 Use plethwave to determine quality of reading; patient motion can interfere with the signal giving a false low
reading
 Poor perfusion caused by hypoperfusion, vasoconstriction, or cold extremities may not generate an
acceptable waveform
 Dyshemoglobinemias will give false high readings. This occurs when another molecule such as carbon
monoxide binds to the hemoglobin. Carboxyhemoglobin and methemoglobin will both render the pulse
oximeter readings inaccurate
 Anemia is the result of low hemoglobin or RBC levels. The pulse oximeter will give inaccurate or misleading
readings
Procedure:
 The probe from the pulse ox unit must be placed in an area where the red and infrared light emissions can
pass through a vascular bed into a light sensor. The most commonly used sites are digits such as fingers or
toes, ear lobes or the bridge of the nose
 Sensor may function on a heel or forehead
 The pulse oximeter unit must indicate that it is sensing adequate amplitude of a pulsating waveform
otherwise the readings are inaccurate.
 Nail polish should be removed prior to application of the probe
 Titrate oxygen administration to a saturation of 94-99% if indicated
Special Notes:
 A probe that is too tight, either too small or taped/strapped on, can impeded venous circulation and cause
venous pulsations that will give a false low readings
 Often a patient in respiratory distress will have normal or elevated oxygen saturation due to the
hyperventilation and increased tidal volume. Treat the patient and not the pulse oximeter
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End-Tidal CO2 Waveform Capnography
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic – Standing Order
Waveform capnography provides vital tool in the evaluation of metabolism, circulation, and respiration. Also provide
almost absolute confirmation of tube placement during endotracheal intubation, extra-glottic airway use, and
cricothyrotomy
Indications:
 Confirmation of advanced airway placement
 Detect ROSC during CPR
 Any metabolic/respiratory acidosis or alkalosis
 Overdose
 Respiratory distress or respiratory depression
Contraindications:
 None
Precautions:
 Numerical value must be evaluated in context with the patient’s condition
 Airway secretions can block detector causing a loss of wave form. Replace detector if this occurs
Procedure:
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Choose side stream or inline detector as indicated
Attach orange connector to port on LP-12
Place cannula on the patient or adapter on 15mm connecter
Use selector knob dial to the third channel of the home screen and push in selector knob
Select “Waveform” then “Source” and “ETCO2”. Press “Home” to exit
After intubation/extra-glottic placement, use BVM to ventilate for six breaths. Assure corresponding
waveform and numerical equivalent
Continuous waveform capnography is mandatory after advanced airway placement
Notes:
 After six breaths a positive waveform is 100% confirmation of correct advanced airway placement
 The loss of wave form requires a cause be identified
 If no waveform or number appears on home screen check all connections. If it is determined that the
equipment is working correctly, consider esophageal intubation and remove advanced airway
 Do not withhold oxygen to place cannula detector; use a non-rebreathing mask instead or a nasal cannula
with oxygen can be placed in the patient’s mouth. Some nasal cannula CO2 detectors have an O2
attachment. Be familiar with the equipment and alternatives
 Normal end-tidal CO2 readings are 35-45mmHg
 Head injury patients should be ventilated to 30mmHg
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Automated Transport Ventilator
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
May be used for any patient during an interfaculty transport that requires mechanical ventilation
Indications:
 Any patient that requires ventilator support for an extended period of time
Contraindications:
 Patient <12yrs
Precautions:
 Patient should have NG/OG tube in place
 Patient should be stable prior to transport
Side effects:
 Ventilator associated pneumonia
 Barotrauma
 Hypotension
Procedure:
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Ensure that adequate high pressure oxygen is available for transport, that the ventilator battery is charge,
that the AC adapter is present, and that the ventilator is properly set up and ready for use
A ventilator circuit should be pre-made with a:
o Double male connector
o Circuit – Either adult or pediatric
o Suction adapter with sterile suction catheter
o Inline EtCO2 collector
o Flex fitting
All paperwork must be present prior to transport, to include, but not limited to:
o Face sheet
o EMTALA Form
o Physician certified statement
o Patient chart and medication record
o Current labs and ABG
o Radiographic studies as appropriate
Perform a physical assessment and record:
o Assessment findings
o Vital signs
o Ventilator settings
o Medication drips including rate and dose –confirm how/when to titrate or discontinue
medications drips if needed
Ensure that the patient has at least two points of IV access, with one currently open for medication
administration
Label each line at point of entry with medication being administered and ensure compatibility/proper
infusion method
Determine Predicted Ideal Body Weight and Initial Tidal Volume using chart or formula
o Males = 50 + 2.3 [height (inches) - 60]
o Females = 45.5 + 2.3 [height (inches) -60]
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Place ventilator on test lung to facilitate setup
Place ventilator in Assist/Control Mode and adjust settings as described in flow chart
Place the patient on the Automated Transport Ventilator and allow 5-10min to ensure that settings are
adequate/appropriate prior to transport. Consult sending physician/RT as needed
All medication infusions except Normal Saline, Lactated Ringers, and blood products must be on placed on
an IV infusion pump provided by the sending facility
Move the patient to gurney and place head of gurney at a minimum of a 30 degree angle, with NG/OG
tube in place, and suction oral secretions as needed to prevent ventilator associate pneumonia
Secure the patient as appropriate
Empty urinary catheter and transfer remaining pumps/equipment
Ensure that all equipment is functioning correctly each time the patient is moved
Monitor endotracheal tube cuff during transport for appropriate pressure
Administer medications as indicated/ordered
Document vital signs, medications, and setting s at a minimum every 15min
Patient should be administered 1-2 mcg/kg of Fentanyl every 60 minutes and 0.1mg/kg Versed every 30
minutes as blood pressure allows. If patient HR or BP increase, or patient discomfort is noted, the
interval between administrations should be shortened or doses increased. Only administer paralytics
during transport after assuring adequate analgesia and sedation needs are met.
Notes:
 Every patient will require different treatment and their condition may change during transport. This
protocol serves as a guide to assist in proper treatment, not an absolute list of rules
 This protocol cannot account for every eventuality that may be encountered
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Obstructive Ventilator Strategy
The obstructive ventilator strategy should be employed when obstructive lung disease is present in the patient
being ventilated. These conditions include, but are not limited to: COPD, Asthma, and Emphysema
Set initial Tidal Volume (Vt)
 8ml/kg (PBW)
 May lower to 4-6ml/kg if pPlat >30cmH2O
Set Respiratory Rate (RR)
 Calculate ideal RR: 120mL/kg/min. (Example: 120x PBW in kg / Vt)
 May lower to 60ml/kg/min to achieve adequate exhalation time
 Titrate respiratory rate to maintain baseline EtCO2. Patients with
COPD live in a hypercapnic state. Hypercapnea is permissible
Under direct supervision of RT:
 Lower inspiratory time if needed to achieve I:E ratio of at least 1:4-5

Set initial % Oxygen (FiO2)
 Start at 40%
 Titrate up as needed to maintain SPO2 92-99%
Set PEEP
 0-2cmH2O. Do not raise above 2cmH2O
Set sensitivity:
 Set sensitivity as high as needed to avoid triggering due to movement
Set alarms:
 High pressure: 10cmH2O greater than average PIP
 Low pressure: 10cmH2O less than average PIP

Use Inspiratory Hold to asses Peak Plateau Pressure (pPlat):
 pPlat should be <30cmH2O
 If >30cmH2O
o Lower Vt to 6ml/kg
o Decrease RR
o Lower Vt to 4ml/kg
o Asses for other cause of increased pPlat
Provide appropriate medical interventions as needed. (Drips, infusions, nebulizers, etc.)
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Injury Ventilator Strategy
The injury ventilator strategy should be used for any patient that does not have an obstructive pulmonary disease
Set initial Tidal Volume (Vt)
 8ml/kg (PBW)
 May lower to 4-6ml/kg if pPlat >30cmH2O
Set Respiratory Rate (RR)
 Calculate ideal RR: 120mL/kg/min. (Example: 120 x PBW in kg / Vt)
 Titrate respiratory rate to an EtCO2 of 35-45cmH2O
In setting of acute metabolic acidosis (pH <7.30) due to ketoacidosis, severe
lactic acidosis, ingestion, etc.
 Double calculated ideal RR above
 Titrate respiratory rate to an EtCO2 25-30cmH2O or baseline if lower
Under direct supervision of RT:
 Lower inspiratory time to achieve I:E ratio of 1:2-3
Set initial % Oxygen (FiO2)
 Start at 40%
 Titrate up with PEEP, per chart, to maintain SPO2 of 92-99%
Set PEEP
 5cmH2O
 Titrate up with FiO2, per chart, to maintain SPO2 of 92-99%
Set sensitivity:
 Set sensitivity as high as needed to avoid triggering due to movement
Set alarms:
 High pressure: 10cmH2O greater than average PIP
 Low pressure: 10cmH2O less than average PIP
Use Inspiratory Hold to asses Peak Plateau Pressure (pPlat):
 pPlat should be <30cmH2O
 If >30cmH2O
o Lower Vt to 6ml/kg
o Decrease RR
o Lower Vt to 4ml/kg
o Asses for other cause of increased pPlat
Provide appropriate medical interventions as needed. (Drips, infusions, nebulizers, etc.)
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Injury Ventilator Strategy – FiO2 and PEEP Chart
Titrate up/down as needed to maintain SPO2 of 92-99%
FiO2
30%
40%
40%
50%
50%
60%
70%
70%
70%
80%
90%
90%
90%
100%
PEEP
5
5
8
8
10
10
10
12
14
14
14
16
18
18-24
Acidosis/Alkalosis Guide
Remember that electrolyte concentrations will change with changes in pH, and vice versa. Particularly, if pH
decreases, serum K+ will increase. If pH increases, serum K+ will decrease.
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Predicted Body Weight and Tidal Volume - Males
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Predicted Body Weight and Tidal Volume - Females
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Time
@
sending
Time
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Record every 15 minutes during transport or every time a change is made
SPO2 EtCO2
HR
BP
RR
Temp
Vt
FiO2
pPlat
Fentanyl
Versed
Vecc
1-2mcg/kg/hr
0.1mg/kg
or
5mg
q 30min
0.1mg/kg
Age and Sex:
If needed
DOB:
Weight in Kg:
Height in Inches:
Predicted Body Weight in Kg:
¼ q 15min
PEEP
Name:
Medication Infusions and Notes:
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Patient condition declining potentially
due to ventilator or increased
PIP/pPlat
Assess
Peak Inspiratory Pressure
(PIP)
PIP Decreased:
 Leak
 Dislodgment
 Decreased BP
PIP Increased:
PIP No Change:
 Low O2 pressure
 Pulmonary embolus
Assess pPlat
pPlat No Change:
 Mucus plug
 Kink
 Asynchronous
breathing
 Bronchoconstriction







pPlat Increased:
Auto PEEP
Pneumothorax
ARDS
Pulmonary edema
Gastric distension
Asynchronous
breathing
Bronchoconstriction
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Alarms
APNEA XX bpm
(Should not occur in
Assist/Control Mode)
APNEA
BAT EMPTY
BATTERY LOW
DISC/SENSE
HIGH PRES
Vent INOP
LOW MIN VOL
Time since last breath exceeds the
set Apnea Interval
Reevaluate the patient’s condition
An Apnea Alarm has occurred and
cleared
Battery charge is critically low
Battery charge is low
Patient curciut has become
dissconected, pinched, or occluded
Reevaluate the patient’s condition
The circuit sense lines may be
pinched or occulded
Refference troubleshooting flow
chart
Occurs when ventilator is switched
on, or ventilator is innoperable
Exhaled minut volume is less than
the Low Minute Volume alarm
LMV OFF
Low Minute Volume alarm is off
LOW PRES
Possible leak in the circuit
Sense lines pinched or occluded
POWER LOST
Occurs when the extenal power and
voltage drops below the usable level
Occurs when the extenal power and
voltage drops to the low leve
POWER LOW
Attach AC or DC power
Attach AC or DC power
Check cuciut for discconects
Check sense lines for occulsions
Check circuit and sense lines for
occlusions or pinch
If occurs during operation, remove
the patient for the ventilator
Check all connections
Check sense lines
Is setting appropriate for patient?
Reevalutate the patient’s condition
Set Low Minute Volume alarm, or
ignore
Check all connections
Check sense lines
Is setting appropriate for patient?
Reevalutate the patient’s condition
Attach AC or DC power
Attach AC or DC power
Definitions
PIP
MAP
PEEP
f
Vte
VE
I:E
Vcalc
Vt
SIMV
Peak Inspritory Pressure
Mean Airway Pressure
Positive End Expritory Pressure
Total Breath Rate
Exhaled Tidal Volume
Exhaled Minute Volume
Inspritory/Expritory Ratio
Calculated Peak Flow
Tidal Volume
Synchornized Intermittent Mandatory Ventilation
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Diagnostic Capillary Blood Tests – Blood Glucose & Blood Lactate
Authorization:
Protocol:
Glucose - EMT, EMT-BIV, EMT-I, and Paramedic
Lactate – EMT-I, and Paramedic
Glucose - EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
Lactate – EMT-I, and Paramedic – Standing Order
Indications:
 Blood Glucose
o Any patient who:
 Has a history of diabetes
 Has suffered a possible CVA
 Is unconscious
 Has a decreased LOC
 Is suspected to be under the influence of any intoxicating substances
 Has abnormal respiratory patterns (Kussmaul) with other signs and symptoms of
hyperglycemia
o Any critically ill or injured pediatric patient
o Any patient whose condition could alter their blood glucose level significantly

Blood Lactate
o Any patient that may be in a state of decreased cellular perfusion or be producing lactate
Contraindications:
 None
Precautions:
 Ensure test strips are not expired and that the machine is calibrated to the strip
 Do not rely solely on diagnostic tests to direct treatment of patient
Procedure:
 Place sample strip in machine making sure calibration number on machine matches number on strip
container
 Using aseptic technique, obtain blood sample with lancet from patient’s distal tip of finger or forearm. It is
also acceptable to obtain drop of blood from IV catheter after obtaining IV access, blood draw hub, or other
aseptic source
 Place drop of blood on end of strip, allowing blood to soak up into test area
 After reading number, dispose of strip, lancet, hub or other sharp in a sharps container
Notes:
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Pain Management
Authorization:
Protocol:
EMT-I, and Paramedic
EMT-I, and Paramedic – See specific medication protocol
A bandage is used to protect and control the bleeding of injuries to the soft tissue
Indications:
 Any patient experiencing pain from:
o Traumatic injury
o Acute Coronary Syndrome
o Abdominal pain
o Other painful conditions or procedures
Contraindications:
 None
Precautions:
 Ensure proper blood pressure, ventilation, and oxygenation are maintained
Procedure:
 Obtain a full set of vital signs as indicated including: SPO2, HR, BP, and ETCO2
 Monitor at a minimum: SPO2, HR, and BP. If situation allows, monitor continuous ETCO2
 Administer indicated analgesia via appropriate route
 Administer oxygen as indicated to maintain SPO2 >92%
Notes:
 In adult patients, use and document pain on a 0-10 scale. In pediatrics, a Faces or other scale can be used to
indicate level of discomfort
 In general, all patients that are in moderate to severe pain should receive adequate analgesia to reduce pain
to a tolerable level. In adults, this is usually a 2-3/10 or until patient states that they require no further
analgesia
 If continuous ETCO2 cannot be monitored, such as in a backcountry setting, careful administration of
analgesics is acceptable if resuscitation equipment and reversal medications are available and close
monitoring of the patient is feasible
 Each medication has a specific dose, considerations, and precautions
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Bandaging/Bleeding Control
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
A bandage is used to protect and control the bleeding of injuries to the soft tissue
Indications:
 Wounds should be bandage to protect the injury from further damage or contamination and to control
bleeding
Contraindications:
 None
Precautions:
 Ensure proper BSI
Procedure:
 Bandaging
o Evaluate the site and expose the area
o Choose the appropriate dressing material: sterile 4x4s, trauma dressing etc
o Place the dressing over the wound.
o Secure the dressing with Kerlix and tape
o Moisten the dressing for burns (Less than 10% TBSA), eviscerations and abrasions. This will prevent
the tissue from drying and adhering to the wound
o Ensure that circulation is not impaired due to bandaging
 Bleeding control
o Attempt direct pressure to control bleeding
o In bleeding cannot be controlled with direct pressure, place tourniquet
o Consider hemostatic agent if a tourniquet cannot be placed
Notes:
 Cold packs and elevation will slow the swelling process. Use care with cold packs so that the soft tissue is not
damaged by the cold
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Splinting/Spinal Immobilization
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
Standing Order
A splint is a device that immobilizes an injury to the musculoskeletal system
Indications:
 Pain, edema or deformity in the skeletal system which includes the extremities, head, torso and spine should
be splinted to decreases the pain and protect the blood vessels, nerves, and soft tissue from further trauma
Contraindications:
 None
Precautions:
 Splinting in multisystems trauma, or critical patients, should be done with a long spine board. Splinting of
individual injuries should not delay transport
 Spinal immobilization can cause the patient harm. Do not immobilize the patient unless it is indicated
Procedure:
 Splinting extremities
o Expose the injured site
o Check for distal pulse, movement, and sensation
o Dress and bandage any wounds prior to splinting
o Severely angulated fractures may need to be straightened if there are no distal pulses present or if
the position prevents extrication or transportation
o Joint injuries should be immobilized in the position found
o Retraction of bone ends in open fractures is not advisable but may be unavoidable
o Immobilize the joint above and below the fracture site
o There are a variety of splints that can be used. The type of splint will be dependent on the type and
location of the fracture.
o The splint should be secured. It should be secure enough to immobilize the limb but not impair
circulation.
o After the splint has been applied, the patient should be evaluated for distal pulse, movement and
sensation

Traction splints (Kendrick, HARE, or Slishman)
o Ensure that fracture is closed midshaft femur without fractures to the pelvis or lower leg
o Expose the fracture site
o Check for distal pulse, movement and sensation
o Dress and bandage any wounds prior to splinting
o Place splint according to manufacturer’s recommendations
o Secure the leg straps. Avoid placing straps over the fracture site or the knee
o After the splint has been applied, the patient should be evaluated for distal pulse, movement and
sensation
o Consider immobilization of the spine

Spinal immobilization
o See Selective Spinal Immobilization Protocol
o Apply manual stabilization to the head and neck as soon as possible
o Check distal circulation, motor and sensation
o Place a cervical collar of the appropriate size
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Pad voids and behind the patient’s head
Place the patient onto the long spine board or a scoop with method indicated (Standing placement,
logroll, ect.)
Attach the torso to the board with straps
Attach the head and cervical spine to the board with head rolls and tape. Do not use sand bags
Check distal circulation, motor, and sensation
Notes:
 Cold packs and elevation will slow the swelling process. Use care with cold packs so that the soft tissue is not
damaged by the cold
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Selective Spinal Immobilization
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-I, and Paramedic - Standing Order
EMT-B, EMT-BIV - Direct Order
Introduction:
Scientific evidence has shown limited, if any, benefit from the use of spinal immobilization devices in traumatically
injured patients; evidence has shown potential harm from spinally immobilizing patients
The tool provided below will assist providers in deciding when or when not to immobilize a patient. If at any time a
provider is uncomfortable withholding immobilization, immobilization should be performed and the situation
documented in the PCR for review
Implementation:
Determine required immobilization technique using tool provided below or determine that no immobilization is
indicated
 If full spinal immobilization is indicated:
o Immobilize the patient on a Long Spine Board, Scoop Board, or Vacuum Mattress
o Place properly sized C-collar
o Ensure that the patient is adequately padded to avoid further injury

If a C-collar is to be placed:
o Place properly sized C-collar
o Coach the patient to restrict spinal movement.
o If the patient is ambulatory, assist the patient in moving to the gurney. If the patient is able to selfextricate after a MVC, this is acceptable and preferred
o If the patient is not ambulatory, a Scoop Board should be used to facilitate movement to the gurney

If no C-collar or immobilization is indicated:
o Treat the patient’s injures and conditions as indicated, but do not spinally immobilize the patient
General:
 Log rolling patients should be avoided unless the patient is found in a prone position or there is suspected
injury to the posterior aspect of the patient
 Withhold C-collar placement if it is difficult to place, poorly fitting, or might impair airway management.
Other methods of cervical immobilization may be used
 Risk of aspiration should be considered prior to fully immobilizing a patient. Prophylactic antiemetic
administration may be used
 A properly padded Scoop Board may be left in place during transport to HRRMC to facilitate movement of
the patient. If padding is not used, Scoop Board should be removed prior to transport
 Forcefully restraining a patient to initiate spinal immobilization may cause more harm than forgoing
immobilization. Sedation may be used if needed (Refer to Patient Restraint Protocol). Base Physician contact
should be initiated
 Properly securing a patient to the gurney is mandatory. Seatbelts should be implemented for adults, and
proper pediatric restraint devices for pediatric patients
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Selective Spinal Immobilization Flow Chart
Clinical assessment suggests the
potential for spinal injury?
Yes
Patient is unconscious, has
significantly altered mental
status, or unable to follow
commands due to acute
No
condition?
No
Yes
Patient does not require placement on a
long spine board
Harm likely
Consider harm vs. benefit to providing
full spinal immobilization:
 Patient will resist immobilization
 Extended transport time
No significant harm likely
Does the patient:
 Have mid-line CTLS spine pain
 Have lateral cervical spine pain
 Have neurologic deficits
 Have distracting injuries
No
Yes
Immobilize with LSB/Scoop/Vacuum
Mattress & C-collar & Spider Straps &
Head blocks
Place on gurney with C-collar in place
and coach patient to restrict movement
No C-collar or immobilization
indicated
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Medication Administration
Authorization:
Protocol:
Refer to individual route
Refer to individual route
Medication can be administered in a variety of methods: intramuscular (IM), intravenous (IV), by mouth (PO),
intraosseous (IO), intranasal (IN), underneath the tongue (SL), onto the tongue (L), or onto the cheek (Buccal)
An EMT-B, EMT-BIV, or EMT-I may administer a medication, which is not in his/her Scope of Practice, under the direct
supervision of a provider that has Standing Order or Direct Order authorization for that medication if the patient is in
cardiac arrest or extremis via the IV or IO route. The EMT-B, EMT-BIV, or EMT-I must have been trained in the
administration of the medication they are to administer and may only administer the medication at the discretion of
the provider that has authorization for that medication
Indications:
 Any illness or injury, which requires medication to improve or maintain the patient's condition
Contraindications:
 See each individual route of administration
Precautions:
 Certain medications can be given by only one route, others by several. If you are uncertain about the drug
you are giving, consult the specific protocol or consult the Base Physician
 Certain medications require a different concentration/dilution for each route. Consult the specific protocol
or consult the Base Physician if questions arise
 Make certain that the medication you want to give is the one in your hand. Always double check the
medication and the concentration before administration
 PO, IM, and SQ routes are unpredictable and the medication is absorbed erratically via these routes; or may
not be absorbed at all if the patient is seriously ill
Procedure:
 Draw medication:
o Use syringe just large enough to hold appropriate quantity of medication, unless further dilution is
required
o Attach a needle to the syringe. If a large volume is being drawn up, use an 18ga needle
o Break ampule (With 4x4 or alcohol prep), open cap, or cleanse multi-dose vial with alcohol prep
o Using sterile technique, draw up the appropriate amount of medication into syringe
o When using a medication from an ampule, a filter needle should be used to draw the medication
from the ampule
o Dispel air from syringe and ensure that appropriate dose is still present
o Cover needle with safety as appropriate
o Consider labeling syringe with name of medication and dose

Alternate methods:
o Assemble CarpuJect as recommended by manufacture and expel air
o Remove cap from pre-filled syringe and expel air
o Assemble luerjet as recommended by manufacture and expel air

Intravenous technique (EMT-BIV, EMT-I, and Paramedic):
o Draw appropriate medication, dose, and expel air
o Check the medication: confirm medication, indications, no contraindications, dose, concentration
and amount
o Cleanse the IV tubing injection port with alcohol
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Attach syringe to IV set at needleless port
Pinch the IV tubing closed between IV bag and the syringe
 Consider allowing IV to flow during administration if further dilution is required
Inject at rate appropriate for medication and condition of the patient
Remove syringe and release tubing to restore flow
Record the medication given, dose, effects and time

Sublingual/Buccal/Lingual technique (EMT-B, EMT-BIV, EMT-I, and Paramedic):
o Check the medication: confirm medication, indications, no contraindications, dose, concentration
and amount
o Have the patient open their mouth
o Place the medication in the mucosa at base of tongue, onto the tongue, or onto the cheek as
indicated
o Have the patient lower their tongue and close their mouth
o Record medication given, dose, effects and time

Intramuscular technique (EMT-I, and Paramedic)
o Draw appropriate medication, dose, and expel air
o Check the medication: confirm medication, indications, no contraindications, dose, concentration
and amount
o Use 21-22 gauge needle, which is long enough to reach the muscle (1 to 1.5 inches)
o Select injection site:
 Vastus lateralis in adult and pediatric patients
 Deltoid in adults patients
 Other site as indicated
o Cleanse the site with alcohol prep
o Stretch the skin over the injection site
o Insert the needle at a 90 degree angle through the skin into the muscle.
o Pull back on the syringe to aspirate and, if there is not a blood return, inject the medication.
o Remove the needle and put pressure over injection site with sterile swab
o Record the medication given, dose, effects and time

Intra Nasal technique (EMT-B, EMT-BIV, EMT-I, and Paramedic)
o Draw appropriate medication, dose, and expel air
o Check the medication: confirm medication, indications, no contraindications, dose, concentration
and amount
o Attach MAD (mucosal atomizing device) to syringe
o Insert MAD into patient’s nares and aggressively depress plunger to deliver ½ the dose
o Repeat in the other nares for second ½ of dose

Intraosseous technique (EMT-I, and Paramedic):
o Draw appropriate medication, dose, and expel air
o Check the medication: confirm medication, indications, no contraindications, dose, concentration
and amount
o Cleanse the IV tubing injection port with alcohol
o Attach syringe to IV set at needleless port
o Pinch the IV tubing closed between IV bag and the syringe
 Consider allowing IV to flow during administration if further dilution is required
o Inject at rate appropriate for medication and condition of the patient
o Remove syringe and release tubing to restore flow
o Record the medication given, dose, effects and time
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Assist with Urinary Catheter Placement
Authorizations:
Protocol:
Paramedic
Paramedic - Standing Order
A urinary catheter should be placed to assist a patient with urination or to control flow of urine
Indications:
 Assist the patient with a pre diagnosed need for catheterization
Contraindications:
 Obstruction or resistance during procedure or history of difficult catheter insertion
 Blood present in the urethral meatus in the trauma patient
 Scene conditions that do not facilitate the performance of a sterile procedure
Precautions:
 Close proximity to definitive care facility
Procedure:
 Utilize only intact kit maintaining sterility
 Follow standard of practice for catheterization utilizing one sterile hand and one “dirty” hand
 Clean the urethral opening and surrounding tissue with provided iodine utilizing circular motion in the
male patient and anterior to posterior motion in the female patient
 Insert catheter until urine “flash” is observed
 Insert catheter fully and inflate cuff, gently withdraw cuff until resistance is felt and catheter is “seated”
 Secure catheter to the patient’s leg and document initial output of urine
 Consider the use of viscous Lidocaine as a topical analgesic
Notes:
 Monitor for hypovolemia, hypotension, or bradycardia if patient’s urine output is ≥ 1000mL
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NG / OG tube Insertion
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
NG/OG tubes should be utilized to decompress gastric distention thus minimizing the risk of airway compromise
due to vomiting and decrease intrathoracic pressure during/post cardiac arrest
Indications:
 Patients requiring reduction of gastric distention
o Prolonged Bag-Valve-Mask ventilations
o During or post cardiac arrest
 Patients with advanced airways placed
o Endotracheal intubation or extra-glottic device
 Patients at risk of aspiration from emesis
o Paralyzed patients (induced or caused by injury
o Overdose/poisoned patients
o Patient with decreased level of consciousness
 Prior to interfacility transport when patient is on ATV
Contraindications:
 NG placement should not be performed in the patient with maxial facial injury (LaFort Fracture) or
evidence of basilar skull fracture
 OG placement should not be performed on patient’s with an intact gag reflex
Precautions:
 None
Procedure:
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Prepare equipment
o Suction equipment, lubricant, Neo-Synephrine, and cloth tape
Measure tube for proper placement
o Place the distal tip of the NG/OG tube at the distal tip of the xyphoid process, lay the tube up
the sternum and around the patient’s ear, extend the tube from the superior aspect of the
auricle to the tip of the nose (NG) or to the lips (OG). Mark this location with tape or marker
NG placement
o Pre medicate the larger naris with Neo-Synephrine
o Lubricate distal 4cm of tube with lubrication jelly or viscous Lidocaine
o Place the patient in a neutral position or with slight flexion of neck
o Insert tube into naris directly posteriorly or with a slight caudal angle, pass tube through the
upper airway and have the patient “swallow” if possible. Pass tube to the depth of your mark and
secure.
o Test tube by aspiration of gastric contents, auscultation, and relief of distention
o If tube gets “hung up”, the patient experiences coughing or tube is seen in the mouth, remove
tube, reposition the patient and retry placement
OG placement
o Place the patient in a neutral position or with slight flexion of neck
o Insert tube into the mouth, or suction port on extra glottic device, and pass posteriorly with a
slight inferior angle. Pass the tube to the depth of your mark and secure
o Test tube by aspiration of gastric contents, auscultation, and relief of distention
Notes:
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Assisted Medication Administration – Albuterol Prescribed Inhaler
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
Paramedic - Standing Order
EMT-B, EMT-BIV, and EMT-I - Direct Order
Albuterol is a beta-adrenergic agent that stimulates the Beta 2 receptor sites of the sympathetic nervous system. This
causes smooth muscle dilation, which relieves bronchospasms
General Information:
 EMT-B, and EMT-B/IV may provide assistance in the administration of a patient own physician prescribed
Metered Dose Inhalers (MDI) in situations where the patient is unable to self-administer the medication due
to circumstances including lack of training, poor understanding of prescription use or lack of physical access
to the medication. Providers may not initiate administration of MDI’s administer medication that is not
specifically prescribed for the patient or administer MDI’s to patients who do not meet the criteria listed
below
Effects:
 Bronchodilation
Indications:
 Respiratory distress due to asthma, or COPD
Contraindications:
 None
Precautions:
 Use with care in patients who are hypertensive, severely tachycardic, or have coronary artery disease, CHF
or a known sensitivity to beta agonist.
 Bronchoconstriction secondary to pulmonary edema may cause wheezing. Albuterol can be detrimental to
these patients
Side effects:
 Slight increase in heart rate and blood pressure
 Anxiety
Dose/Administration:
 Check medication, assure medication is prescribed for the patient, and check the expiration date
 Call Base Physician for Direct Order
 Shake the inhaler vigorously
 Instruct the patient to exhale deeply and place their lips around the spacer or MDI mouthpiece
 Fully depress the inhaler and instruct the patient to breathe deeply and hold their breath for 1-2secs
 Document time, dose, base Physician and response to the inhaler
 Repeat as instructed by Base Physician
Notes:
 Albuterol must reach the alveoli in order to be absorbed. Patients who are in severe distress and have low or
minimal tidal volume will not benefit from Albuterol since the drug cannot reach the alveoli
 Do not delay transport/ALS rendezvous to administer
 Beta blocker use may limit effectiveness
 Pregnancy category: C
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Assisted Medication Administration – Epinephrine (Adrenaline, EpiPen) Auto
Injector
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
General Information:
 Epinephrine is an endogenous catecholamine that is secreted by the adrenal medulla, which has potent
alpha and beta adrenergic effects.
Effects:
 Vasoconstriction
 Bronchodilation
Indications:
 Anaphylaxis, with airway involvement, and Anaphylactic shock
Contraindications:
 None
Precautions:
 MAOI use
 Cardiac/ Coronary artery disease
 Hypertension
 Advanced age
 Increased cardiac oxygen demand can precipitate angina and/or an MI in susceptible individuals
 Should be used with caution in patients with peripheral vascular/cerebral vascular insufficiency
 Hyperthyroidism
Side effects:
 Tachydysrhythmias
 Angina/MI
 Hypertension
 Anxiety and nausea/vomiting
Dose/Administration:
 Check medication for name, expiration date, cloudiness
 Remove safety cap and place tip of injector firmly against the mid-lateral thigh until the mechanism activates
(up to 10 seconds)
 Remove needle from site and inspect injector to insure medication was delivered. Place in sharps container
 Document injection, time, response, and initiate transport
Notes:
 Epinephrine may have serious side effects and should only be used on patients experiencing lifethreatening implications of a serious anaphylactic reaction. Airway management, oxygenation,
ventilation, circulatory support and rapid transport should not be be delayed in favor of epinephrine autoinjector
 Should not be used for allergic reactions unless circulatory or respiratory compromise is present
 Wheezing in an elderly patient is often pulmonary edema or a pulmonary embolus. Thoroughly evaluate
the patient and remember that epinephrine’s side effects, especially in the elderly, can be severe
 Beta blocker use may limit effectiveness
 Pregnancy category: C
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Assisted Medication Administration - Nitroglycerin
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-I, and Paramedic - Standing Order
EMT-B, and EMT-BIV - Direct Order
Nitroglycerine is a prodrug that metabolizes into nitric oxide. Exact mechanism of action is not well understood
General Information:
 EMT-B/BIVs may provide assistance in the administration of a patient’s own physician prescribed sublingual
Nitroglycerine in situations where the patient is unable to self-administer the medication due to
circumstances including lack of training, poor understanding of prescription use or lack of physical access to
the medication. EMT-B/BIVs may not initiate administration of Nitroglycerine, administer medication that is
not specifically prescribed for that patient, or administer Nitroglycerine to patients who do not meet the
criteria listed below
Effects:
 Vasodilation including coronary arteries
 Decreased preload and afterload
Indications:
 Cardiac chest pain
Contraindications:
 Hypotension (Systolic BP < 90mmHg)
 HR > 100bpm or < 50bpm
 Phosphodiesterase 5 inhibitor use:
o Viagra (sildenafil), Levitra (vardenafil), or Stendra (avanafil) within 24hrs
o Cialis (tadalafil) within 48hrs
o Other PDE5 inhibitors are currently in clinical trials and may become available in the USA
Precautions:
 Inferior wall MI
Side effects:
 Hypotension and tachycardia
 Headache
Dose/Administration:
 Establish IV with Normal Saline (EMT-BIV and above only)
 Check medication, assure medication is prescribed for the patient, check expiration date
 Blood pressure must be taken and recorded before and after administration
 Call Base Physician for Direct Order
 Administer 0.4mg sublingual nitroglycerin by tablet or spray
o May repeat after 5min to a total of 3 doses or until pain is relieved, BP decreases or ALS arrives
 Repeat vital signs every 5min after administration
 Document indications, Base Physician, all vital signs, and response to medication on patient report
Notes:
 Do not delay transport/ALS rendezvous to administer
 Onset within 2min and duration of 30min
 Pregnancy category: C
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Aspirin (Acetylsalicylic acid /ASA)
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
ASA inhibits the formation Cyclooxygenase, thus inhibiting the formation of Thromboxane A2 and Prostaglandins
Effects:
 Inhibition of platelet aggregation
Indications:
 Acute Coronary Syndrome
 Symptoms suspected of being Acute Coronary Syndrome in origin
Contraindications:
 Contraindicated in patients allergic to ASA or ASA products
Precautions:
 Active GI bleeding or other severe bleeding
 Use with caution in patients with asthma
 Not to be given for analgesic purposes such as headaches or orthopedic injuries
 Use with caution in patients with liver dysfunction and impaired renal function
Side Effects:
 May precipitate an asthma attack in patients with asthma
 May cause GI upset
Dose/Administration:
 324mg (PO)
o Administer 4 chewable 81mg aspirin (PO), if the patient is able to protect his or her own airway
o If patient has taken ASA, for the event, prior to EMS arrival, supplement patient dose up to 324mg
Notes:
 Patients who normally take regular doses of ASA or ASA compounds can have gastrointestinal disorders such
as GI hemorrhage
 Patients taking warfarin (Coumadin), clopidogrel (Plavix), or other anti-coagulant/antiplatelet medications
may be given ASA
 Pregnancy category: D
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Adenosine (Adenocard)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic - Standing Order
EMT-I – Direct Order
Adenosine in an endogenous nucleoside that is used to treat reentry supraventricular tachycardias by slowing
conduction through the AV node
Effects:
 Interrupts reentry pathway abnormalities in AVNRT, AVRT, SNRT, and allows the normal sinus pathway to
function by slowing conduction at the AV node
 Interrupts SA node function
Indications
 Paroxysmal supraventricular tachycardias (AVNRT, AVRT, SNRT)
 Tachycardias that are: Undifferentiated, wide-complex, monomorphic, and regular
Contraindications:
 Contraindicated in hypotensive or unstable patients
 Contraindicated in patients with known history of 2nd degree block, 3rd degree block, or sick sinus
syndrome, without a functioning pacemaker in place
 Atrial fibrillation is an absolute contraindication. Rhythm must be regular to administer
 Tachycardias secondary to sympathomimetic/CNS stimulant use
Precautions:
 Known hypersensitivity to Adenosine
 Do not re-administer if an arrhythmia other than PSVT persists
 Patients on Dipyridamole (Permole, Persantine) for cardiac and vascular disease should be given ¼ of the
normal dose since a full dose will cause prolonged adverse effects
Dose/Administration:
 12mg repeated in 1 - 3min if rhythm has not converted
o Each bolus of Adenosine is administered as a fast push and flushed with a 20mL Normal Saline
bolus
o 24mg max dose
 Pediatric dose: 0.1mg/kg (IV, IO). Repeat x2 at 0.2mg/kg in 1-3min if rhythm has not converted
o Max single dose not to exceed adult dose
o Each bolus of Adenosine is administered as a fast bolus and flushed with Normal Saline
Side effects:
 Side effects should quickly pass and include: HA, anxiety, chest pain, hypotension, and arrhythmias
Notes:
 Patients who take Methylxanthine compounds, such as caffeine or Theophylline, will require higher doses to
achieve conversion
 Safe in WPW (AVRT) with either antidromic or orthodromic conduction
 Will not convert A-flutter or most VT
 Pregnancy category: C
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Albuterol (Proventil, Ventolin)
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
Paramedic - Standing Order
EMT-B, EMT-BIV, and EMT-I – Direct Order
Albuterol is a beta-adrenergic agent that stimulates the Beta 2 receptor sites of the sympathetic nervous system. This
causes smooth muscle dilation, which relieves bronchospasms
Effects:
 Bronchodilation
Indications:
 Respiratory distress due to pneumonia, asthma, anaphylaxis or COPD
 Suspected hyperkalemia (Paramedic only)
Contraindications:
 None
Precautions:
 Use with care in patients who are hypertensive, severely tachycardic, have coronary artery disease, CHF or a
known sensitivity to beta agonists.
 Bronchoconstriction secondary to pulmonary edema may cause wheezing. Albuterol can be detrimental to
these patients
Side effects:
 Slight increase in heart rate and blood pressure
 Anxiety
Dose/Administration:
 2.5mg (SVN)
o Set the O2 at 6-8 liters/minute
o May repeat as needed or provide continuous nebulization
o May use inline nebulizer on CPAP, ETT, or extra-glottic device
 Pediatric dose: 2.5mg (SVN)
o Max: 10mg
Notes:
 Albuterol must reach the alveoli in order to be absorbed. Patients who are in severe distress and have low or
minimal tidal volume will not benefit from Albuterol since the drug cannot reach the alveoli. Consider
epinephrine IM or IV
 Coach patient to breathe deeply and hold their breath as long as possible. Consider having the patient rinse
mouth with water if previous treatments have been administered
 Beta blocker use may limit effectiveness
 Pregnancy category: C
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Amiodarone (Cordarone)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic - Standing Order
EMT-I - Direct Order
Amiodarone has Class I, II, III and IV antiarrhythmic properties
Effects:
 Prolongation of the action potential duration and the refractory period
Indications:
 Pulseless VT or VF refractory to defibrillation
 Stable VT or wide complex tachycardias (Rapid infusion method) or symptomatic runs of VT
 Following successful defibrillation/synchronize cardioversion if tachyarrhythmias or ectopy persist
Contraindications:
 None in cardiac arrest with VF or VT
 2nd or 3rd degree AV block
 Sick Sinus Syndrome
 Cardiogenic shock/Hypotension
 Bradycardia (Including ventricular escape beats of IVR/AIVR)
 Tachycardias secondary to sympathomimetic/CNS stimulant use
Precautions:
 Wide complex, irregular rhythms (With pulse)
Side effects:
 Hypotension and bradycardia
o Treat initially by slowing the infusion rate but may require Atropine, pacing, vasopressors, and
volume expansion. These side effects are usually rate of infusion, not dose related
Dose/Administration:
 300mg (IV, IO) bolus in cardiac arrest
o May administer 150mg (IV, IO) bolus after 3-5min if VT/VF refractory
 Pediatric cardiac arrest: 5mg/kg (IV, IO) bolus. Contact Base Physician for additional dose
 150mg (IV, IO) over 10min for stable wide complex tachycardias, runs of VT, or post arrest, after successful
conversion, if ectopy/tachyarrhythmias persist
o May repeat 150mg dose
o Rapid infusion over 10min: 150mg in 100mL NS run @ 100 macro gtts/min or dilute in syringe and
administer in flowing (IV,IO) over 10min
 Pediatric stable wide complex tachycardia, runs of VT, or post arrest after successful conversion: 5mg/kg (IV,
IO) over 20-60min
o Place in 100mL NS run @ 15-60 macro gtts/min. Contact Base Physician for additional doses
Notes:
 Compatible at the Y-site with the following ACLS drugs: Dopamine, and Nitroglycerine
 Do not administer in same line as Sodium Bicarbonate
 12-lead should be performed when applicable
 Pregnancy category: D
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Atropine Sulfate
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic - Standing Order
EMT-I - Direct Order
Atropine is an acetylcholine antagonist that inhibits the effects of the parasympathetic nervous system by blocking
muscarinic receptors
Effects:






Increases SA and AV node conduction
Reduces the motility of the GI tract
Reduces the action of the urinary system
Causes pupil dilation
Dries mucosal membranes
Dilation of the bronchioles
Indications:
 Symptomatic bradycardia
 Improve the conduction in 2nd Degree Type I AV blocks
 Reverse effects from organophosphate and nerve gas poisonings
Contraindications:
 A-Fib and A-Flutter
Precautions:
 Bradycardias in the setting of a myocardial infarction
 Do not treat bradycardias unless the patient is symptomatic to the bradycardia: chest pain, hypotension,
altered LOC, or other symptom
 Closed angle glaucoma
Side effects:
 Anticholinergic toxidrome
 HA
 Altered vision
Dose/Administration:
 Bradycardia: 0.5 - 1.0mg (IV, IO) bolus
o Repeat every 5min to a max dose of 3mg
 Organophosphate and nerve gas poisonings: 2-4mg (IV, IO) bolus
o Repeat every 5min until patient is no longer symptomatic
 Pediatric dose: 0.02mg/kg (IV, IO)
o Repeat at 0.04mg
o Pediatric: Min single dose 0.1mg. Max dose not to exceed adult dose
Notes:
 Small doses or slow administration may cause a paradoxical bradycardia
 Pregnancy category: C
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Calcium Chloride
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Each gram of CaCl² contains 273mg of elemental calcium. Calcium stabilizes the myocardial cells and will improve
inotropy
Effects:
 Increased inotropy
 Stabilization of the myocardial cell membrane (Mechanism in hyperkalemia)
Indications:
 Cardiac arrest potentially caused by hyperkalemia
 Calcium channel or beta blocker overdose
 Hyperkalemia causing widening QRS or bradycardia with AV blocks
 Hydrofluoric acid exposure
Contraindications:
 Digitalis use
 Non-patent IV line
Precautions:
 Will cause severe tissue necrosis if infiltration occurs. Ensure that line is patent and use the most proximal
line possible
 Pediatric patients
 Do not use in same line as Sodium Bicarbonate
Side effects:
 There is little potential for severe side effects if used in a patient that is unstable or in cardiac arrest
Dose/Administration:
 1gm (IV,IO) over 2-10 minutes
o Ensure that line is patent and dilute during administration
 Pediatric: 20mg/kg (IV,IO) over 2-10 minutes
Notes:





Calcium Chloride is supplied as 10mL of a 10% solution. Each 10mL contains 1 gram of Calcium Chloride
Effectiveness when administered for a calcium channel blocker overdose may be limited; do not forgo
other treatments if indicated
Calcium Chloride is not indicated for use in routine cardiac arrest
ECG changes that may be seen during hyperkalemia include: widened QRS, sinusoidal waveform,
symmetrically peaked T-waves, AV blocks, escape rhythms, V-fib, and asystole. Patient history should
indicated a potential for hyperkalemia due to highly variable ECG findings
Pregnancy category: C
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Dextrose
Authorization:
Protocol:
EMT-BIV, EMT-I, and Paramedic
EMT-BIV, EMT-I, and Paramedic - Standing Order
Dextrose is a 6-carbon sugar, which is the principle form of carbohydrates used by cells for energy
Effects:
 Raise blood glucose level
 Lower blood potassium level (Paramedic only. Limited effectiveness)
Indications:
 Hypoglycemia
 Unconscious patients (Consider obtaining BGL reading prior to administration)
 Medical cardiac arrest (Consider obtaining BGL reading prior to administration)
 Hypothermia (Consider obtaining BGL reading prior to administration)
 Hyperkalemia (Paramedic only)
Contraindications:
 Non-patent IV line
Precautions:
 Ensure IV is patent before and during administration
 Use with caution in patients with suspected hypokalemia
 Chronic malnutrition (Wernicke’s and Korsakoff’s)
Side effects:
 Tissue necrosis with extravasation
 Vascular necrosis
Dose/Administration:
 25g (250mL of D10%) (IV, IO) slow infusion
o Administer through IV or IO until patient mentation returns or 250mL administered
o Recheck blood glucose level
o Stop administration when patient mentation returns to desired level
o If infiltration does occur, stop administration immediately and notify receiving facility
 Pediatrics dose:
o Newborn – 12yrs: 2-4mL/kg D10%
 Use buretrol or administer with a syringe to allow proper dosing
Notes:




Patient may require repeat doses
Frequently asses BGL on pediatric patients that are distressed. Their BGL may lower quickly
Hypoglycemia is considered to be any reading <50mg/dL, approximately, in a newborn
Pregnancy category: C
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Diazepam (Valium)
Authorization:
Protocol:
EMT-Iand Paramedic
Paramedic - Standing Order
EMT-I - Direct Order*
(*EMT-I – May be administered under Standing Order when the safety of the patient or
the EMT is at risk)
Valium is a member of the Benzodiazepine family. Effects are due to an increase of GABA activity in the brain
Effects:




Anxiolytic
Skeletal muscle relaxant
Sedation and amnesia
Suppresses the spread of seizure activity within the motor cortex of the brain
Indications:
 Status epilepticus
 Major motor seizures
 Anxiolysis prior to procedure: cardioversion and external cardiac pacing
 Relieve muscle spasm
 Relieve anxiety
 Sedation secondary to behavioral emergencies
Contraindications:
 None
Precautions:
 Respiratory depression
 Hypotension
 Opioid administration
Side effects:
 Respiratory depression
 Hypotension
 Sedation
 Agitation
Dose/Administration:
 2.5-10mg slow (IV, IO). Repeat every 5 - 15min as needed. Max dose 20mg
o Administer over 2-5min
 Pediatric dose: 0.1mg/kg slow (IV, IO)
o Administer over 2-5min
Notes:
 IM administration should be avoided due to slow/inconsistent absorption
 Most likely to produce respiratory depression in patients who have taken other sedative drugs, especially
alcohol and barbiturates
 Pregnancy category: D
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Diltiazem (Cardizem)
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Diltiazem is a non-dihydropyridine, Class IV antiarrhythmic, which is relatively selective to cardiac Ca++ channels
Effects:
 Decreased heart rate (Decreased chronotropy)
 Decreased rate of conduction (Decreased dromotropy)
 Decreased force of contractility (Decreased inotropy)
Indications:
 Hypertensive crisis (Systolic pressure > 200 or diastolic blood pressure >130, without stroke like symptoms)
 Symptomatic, stable, narrow complex, A-Fib and A-Flutter with ventricular response >150bpm
 Stable, regular, monomorphic PSVT refractory to Adenosine
 Thyroid Storm
Contraindications:
 Hypersensitivity
 Sick Sinus Syndrome
 2nd or 3rd degree AV blocks (Unless an artificial pacemaker is in place)
 Blood pressure <90mmHg systolic
 History of recent MI or congestive heart failure
 Use of Rifampin (Antitubercular)
 Wide complex, irregular rhythms
 Tachycardias secondary to sympathomimetic/CNS stimulant use
Precautions:
 Hepatic or renal impairment (use a ½ dose)
 Pregnant, lactating, or pediatric patients
 Use of other antihypertensives
 Use of beta blockers, digoxin, or phenytoin
 Accessory cardiac pathways
Side effects:
 Bradycardia
 AV heart blocks
 Hypotension
 Anxiety
 Headache and dizziness
Dose/Administration:
 5mg (IV, IO) over 2-5min
o Repeat dose every 5-10min as needed up to 0.25mg/kg
o If patient becomes hypotensive or bradycardic at any time, discontinue administration
 Pediatric dose: Contact Base Physician
Notes:
 Monitor ECG, blood pressure, and lung sounds
 Pregnancy category: C
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Diphenhydramine (Benadryl)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I – Direct Order
Diphenhydramine is an inverse H1 agonist that has antimuscarinic, antiparkinsonian, and serotonin reuptake inhibitor
properties
Effects:




Antihistamine
CNS depressant (Sometimes CNS stimulant)
Decrease GI motility
Antiparkinsonian
Indications:
 Anaphylaxis
 Severe allergic reactions
 Counteract acute dystonic reactions due to antipsychotic drugs
 Sedation (Paramedic only)
 Antiemetic (Paramedic only)
Contraindications:
 None
Precautions:
 May have synergistic effect with alcohol or other CNS depressants
 Asthma and COPD (Will dry bronchosecretions)
 Glaucoma
 Pregnancy
 MAOI use may prolong/intensify anticholinergic effects
Side effects:
 Sedation
 Anticholinergic effects
 Hypotension
Dose/Administration:
 25-50mg (IV, IO) slow push or deep (IM) injection
 Pediatric dose: 2mg/kg (IV, IO) slow push or deep (IM) injection
Notes:
 Diphenhydramine is not the first-line drug for anaphylaxis/anaphylactic shock
 Treats dystonic reactions, including, oculogyric crisis, acute torticollis, and grimacing; Can be caused by
certain antipsychotic drugs known as phenothiazines (Such as Haldol, Thorazine, and Compazine)
 Pregnancy category: B
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Epinephrine (Adrenaline)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I - Cardiac arrest Standing Order, all other indications by Direct Order
Epinephrine is an endogenous catecholamine that is secreted by the adrenal medulla, which has potent alpha and
beta adrenergic effects.
Effects:





Increased heart rate (Increased chronotropy)
Increased rate of conduction (Increased dromotropy)
Increased force of contractility (Increased inotropy)
Vasoconstriction
Bronchodilation
Indications:
 Pulseless cardiac arrest including: Ventricular fibrillation, Asystole, and PEA
 Anaphylaxis, with airway or circulatory compromise, and Anaphylactic shock
 Asthma refractory to Albuterol
 Pediatric Dyspnea with stridor at rest
 Obstructive pulmonary disease refractory to inhaled bronchodilators (Use cautiously in elderly patients)
Contraindications:
 None
Precautions:
 MAOI use
 Cardiac/ coronary artery disease
 Hypertension
 Advanced age
 Increased cardiac oxygen demand can precipitate angina and/or an MI in susceptible individuals
 Should be used with caution in patients with peripheral vascular/cerebral vascular insufficiency
 Hyperthyroidism
Side effects:
 Tachydysrhythmias
 Angina/MI
 Hypertension
 Anxiety
 Nausea/vomiting
Dose/Administration:
 Cardiac arrest: 1mg (10mL of 1:10,000 solution) (IV, IO) every 3- 5min
 Obstructive pulmonary/anaphylaxis/anaphylactic shock: 0.3mg (0.3mL of 1:1,000 solution) (IM) or 0.3mg
(3mL of 1:10,000 solution) (IV, IO)
o Consider further dilution prior to (IV,IO) administration
o Consider Epinephrine Drip if condition is refractory or requires continuous treatment
 Pediatric dose for cardiac arrest: 0.01mg/kg (0.1mL/kg of 1:10,000 solution) (IV, IO) every 3- 5min
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Pediatric dose for obstructive pulmonary/anaphylaxis/anaphylactic shock: 0.01mg/kg (0.01mL/kg of 1:1,000
solution) (IM) or 0.01mg/kg (0.1mL/kg of 1:10,000 solution) (IV, IO)
o Max single pediatric dose not to exceed adult dose
o Consider further dilution prior to (IV,IO) administration
o Consider Epinephrine Drip if condition is refractory or requires continuous treatment
Pediatric dyspnea with stridor at rest: 0.5mL via SVN of racemic epinephrine
Notes:
 Should not be used for allergic reactions unless circulatory or respiratory compromise is present
 Wheezing in an elderly patient is often pulmonary edema or a pulmonary embolus. Thoroughly evaluate
the patient and remember that epinephrine’s side effects, especially in the elderly, can be severe
 Inactivated by alkaline solutions and exposure to light. Do not mix with Sodium Bicarbonate
 Beta blocker use may limit effectiveness
 Pregnancy category: C
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Epinephrine Drip/Push Dose
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I – Direct Order
Effects:
 See Epinephrine protocol
Indications:
 Symptomatic bradycardia refractory to Atropine
 Symptomatic bradycardia in patients when Atropine is contraindicated
 Symptomatic bradycardia in patients that capture is not obtained during TCP
 Maintenance treatment of bronchospasm (Status asthmaticus, anaphylaxis, COPD, etc.)
o Patient should be refractory to inhaled bronchodilators
 Obstructive pulmonary/anaphylaxis/anaphylactic shock that is refractory to other treatments or requires
continuous treatment
 Cardiogenic shock
 Distributive shock
Contraindications:
 See Epinephrine protocol
 Hypovolemic shock
Precautions:
 Use judiciously as a vasopressor due to the Beta adrenergic effects of epinephrine.
 See Epinephrine protocol
Side effects:
 See Epinephrine protocol
Dose/Administration:
 2-10mcg/min continuous infusion or slow IV/IO push
o Mix 4mg Epinephrine 1:1000 (4mL) into 250mL D5W to achieve a concentration of 16mcg/mL
 A higher dose of 0.1-0.5mcg/kg/min may be needed
o Mix 4mg Epinephrine 1:1000 (4mL) into 250mL D5W to achieve a concentration of 16mcg/mL
 Pediatric: 0.1-0.5mcg/kg/min
Drip
16mcg/ml
Micro drops/minute
Dose/minute
7gtts/min
2mcg/min
15gtts/min
4mcg/min
22gtts/min
6mcg/min
30gtts/min
8mcg/min
37gtts/min
10mcg/min
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Push Dose
This method should only be used as a temporary measure until a vasopressor drip can be established or in cases
when hypotension is expected to resolve quickly


Discard 9mL of Epinephrine 1:10,000. Draw 9mL of NS into the medication syringe. This will produce
Epinephrine 1:100,000 with a concentration of 10mcg/ml
Administer via slow IV/IO push
0.1-0.5 (Desired dose) x Patient weight in kg x 60 (Drip factor) = gtts/min
16 (Concentration)
Epinephrine Infusion (gtts/min)
16mcg/mL Concentration
Desired
Dose
Weight in Kilograms
20 kg
30 kg
40 kg
50 kg
60 kg
70 kg
80 kg
90 kg
100 kg
0.1 mcg
7.5
11.25
15
18.75
22.5
26.25
30
33.75
37.5
0.2 mcg
15
23
30
37.5
45
52.5
60
67.5
75
0.3 mcg
22.5
24.25
45
56.25
67.5
78.75
90
90.25
112.5
0.4 mcg
30
46
60
75
90
105
120
135
150
0.5 mcg
37.5
47.75
75
93.75
112.5
131.25
150
157.75
187.5
Notes:
 Should be considered primary vasopressor in anaphylactic shock. Epinephrine also stabilizes mast cells
and basophils, which can be beneficial in the setting of anaphylactic shock
 AHA recommends TCP, a Dopamine drip, or an Epinephrine drip for symptomatic bradycardia that is
refractory to Atropine or if Atropine is contraindicated. AHA currently does not prefer one treatment over
another. The provider’s choice should be guided by patient assessment, ECG, and patient history
 Peak action is delayed up to 20min
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Fentanyl Citrate
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic - Standing Order
EMT-I - Direct Order
Fentanyl is an opioid analgesic
Effects:
 Analgesia
 Decrease sympathetic tone
Indications:
 Pain relief due to stable traumatic or medical causes (Cardiac chest pain, extremity trauma, acute abdomen,
etc.)
 Premedication for RSI / post intubation analgesia (Paramedic only)
 Blunt sympathetic response during Acute Coronary Syndrome (Paramedic only)
 During ventilation with ATV (Paramedic only)
Contraindications:
 Myasthenia Gravis
Precautions:
 CNS and respiratory depression
 Hypotension
 Closed head injury
Side effects:
 Hypotension
 Respiratory depression
 Sedation
 Bradycardia
 Chest wall rigidity (Rapid administration)
Dose/Administration:
 1-2mcg/kg (IV, IO, IN, IM, SVN) Repeat as indicated
o Administer over 2-5min (IV, IO)
 Pediatric Dose: 1-2mcg/kg (IV, IO, IN, IM, SVN) Repeat as indicated
o Administer over 2-5min (IV, IO)
 (IN, IM, SVN) dosing of Fentanyl requires close monitoring of vital signs
Notes:





Effects increased by other CNS depressants (Alcohol, benzodiazepines, muscle relaxants, opiates, etc.)
Continuous patient monitoring is required. Frequent evaluation of the patient’s vital signs is also
recommended
Patients may develop apnea without manifesting significant mental status changes
Fentanyl does not cause a histamine reaction
Pregnancy category: C
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Furosemide (Lasix)
Authorization:
Protocol:
EMT-I and Paramedic
EMT-P - Standing Order
EMT-I – Direct Order
Furosemide is a potassium wasting, loop diuretic that inhibits sodium reabsorption
Effects:
 Diuretic
 Vasodilation
Indications:
 Acute pulmonary edema
 Congestive heart failure with pulmonary edema
Contraindications:
 Pneumonia
 Hypotension
 Shock
 Pregnancy/ breast feeding
Precautions:
 Contact Base Physician if urine is bloody. Trauma to the kidneys and urinary system makes the use of
Furosemide hazardous
 Age <12yrs
Side effects:
 Hypotension
 Hypovolemia
 Hyponatremia/hypokalemia
 Hearing loss (Rapid administration)
Dose/Administration:
 20-40mg (IV, IO) over 2min
o Patients on home Lasix may require higher doses. Double home dosage
 Pediatric dose: Contact Base Physician
Notes:
 A majority of patients experiencing acute, cardiogenic, pulmonary edema are euvolemic and will not require
diuresis. Other pharmacological treatment may be preferable
 Induced hypokalemia is of significant concern in digitalized patients and particularly those who have digitalis
toxicity
 Patient must be placed on a cardiac monitor prior to administration
 If the patient is unconscious, a urinary catheter must be placed
 Onset 30-60min, duration 2hrs
 Pregnancy category: C
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Glucagon
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I – Hypoglycemia by Standing Order, beta/Ca++ blocker overdose by Direct Order
Glucagon is a hormone that stimulates the liver to release glycogen, thus raising the level of glucose in the blood and
causes smooth muscle relaxation. At higher doses, increases inotropy and chronotropy due to increase in cAMP
Effects:




Increase blood glucose level
Smooth muscle relaxation
Increased heart rate (Increased chronotropy)
Increased force of contractility (Increased inotropy)
Indications:
 Symptomatic hypoglycemia when IV access is unsuccessful
 Symptomatic beta-blocker or calcium channel blocker overdose unresponsive to Normal Saline bolus
 Esophageal spasm (Paramedic only)
 Anaphylaxis (Paramedic only)
Contraindications:
 Known hypersensitivity to this drug
Precautions:
 Use with caution in patients with a history of cardiovascular disease, renal disease, pheochromocytoma or
insulinoma
Side effects:
 Tachycardia
 Headache
 Nausea/vomiting
 Hyperglycemia
Dose/Administration:
 Hypoglycemia:
o Adult dose 1mg (IM, IN)
o Pediatric dose: 0.1mg/kg (IM, IN)
 Single dose should not exceed adult dose
 Beta blocker/Ca++ channel blocker OD and anaphylaxis:
o Adult dose: 2mg (IV, IO) repeat as needed
o Pediatric dose: 0.1mg/kg (IV, IO) repeat as needed
 Single dose should not exceed adult dose
 Esophageal Spasm: 1mg (IV, IO, IM, IN). Over 2min
Notes:
 In the presence of beta blocker and Ca++ blocker overdose, Glucagon has limited effectiveness. Other
treatments should be used concomitantly. Use in refractory anaphylaxis may improve patient condition
 Pregnancy category: B
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Glucose, Oral
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
Oral glucose is a simple sugar will raise the blood glucose level
Effects:
 Hypoglycemia
Indications:
 Hypoglycemia with blood sugar of 70mg/dl or less with signs and symptoms of hypoglycemia
Contraindications:
 Dysphagia
 Inability to swallow
 Inability to protect airway
 Patient who has decreased level of consciousness
Precautions:
 Can cause choking/aspiration if the patient unable to protect airway
Side effects:
 See precautions
Dose/Administration:
 15g (PO)
 Pediatric dose: 15g (PO)
 Squeeze tube, releasing a reasonable amount of medication towards inside of cheek. Give the patient a
chance to swallow medication and repeat until tube is empty
Notes:




Make sure that the patient is sitting in an upright position to help protect airway
Re-check blood sugar after administration
Sugary foods/drinks, such as soda, may be of benefit and contain higher amounts of sugar
Will raise blood glucose level slowly
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Hydromorphone (Dilaudid)
Authorization:
Protocol:
Paramedic
Paramedic – Standing Order
Dilaudid is semi-synthetic opioid analgesic
Indications:
 Pain relief due to isolated, traumatic, injuries
Contraindications:
 Hypotension
 Multisystem trauma
Precautions:
 Head injury
 Renal impairment (2-fold effect)
 Hepatic impairment (4-fold effect)
Side effects:
 Hypotension
 Respiratory depression
Dose/Administration:
 Adult: 0.5(IM, IN, IV, IO) May repeat as needed
Notes:
 1mg Dilaudid has, approximately, the same effectiveness as 10mg of Morphine
 Caution should be exercised to avoid causing respiratory depression. Narcan or resuscitative equipment
should be available prior to administration
 Consider dilution prior to (IV) administration
 Dilaudid has been shown to be as effective (IN) as it is (IV)
 Onset 5min, peak 15-60min, duration 1-4hrs
 Pregnancy category: C
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Ketamine
Authorization:
Protocol:
Paramedic
Paramedic – Standing Order
Ketamine is a variety of effects, including: anesthesia, analgesia, hallucinogen, and sympathetic stimulation. The exact
mechanism of action is unknown
Effects:
 Sedation
 Analgesia
Indications:
 Induction agent for RSI
 Post intubation sedation (Critical Care only)
Contraindications:
 Patient <12yrs
Precautions:
 Pregnancy
 Significant hypotension (Decrease dose by ½)
Side effects:
 Hallucinations
 Increased airway secretions
Dose/Administration:
 1.5mg/kg (IV, IO, IM, IN)
Notes:
 Safe in patients who are: hypotensive, septic, hypovolemic and who have increased ICP
 Onset 30-45secs, duration 10-20min
 Pregnancy category: B
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Ipratropium Bromide (Atrovent)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I – Direct Order
Antagonist of the muscarinic acetylcholine receptors in the bronchi/bronchioles
Effects:
 Bronchodilation
 Anticholinergic
Indications:
 Bronchospasm due to asthma, and COPD
Contraindications:
 Hypersensitivity to this drug, Atropine (Anticholinergics), or bromide
Precautions:
 Children < 2yrs
 Use cautiously in patients with coronary artery disease
 Use cautiously in patients with glaucoma
 Pneumonia
Side effects:
 Tachycardia
 Headache
 Anxiety
 Dry mucus membranes
 Can cause paradoxical bronchospasm. If this occurs, discontinue treatment
Dose/Administration:
 0.5mg ( > 2yrs) (SVN)
 Pediatric (< 2yrs) dose: 0.25mg (SVN)
o Draw 1.25mL into a syringe and place into SVN
 Dose may be repeated after 20min
 May be administered as Duo-Neb in conjunction with Albuterol
Notes:
 Pulse, blood pressure, and ECG must be monitored
 Soy and peanut allergy applies to MDI use and does not apply to SVN Ipratropium Bromide
 Pregnancy category: B
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Lidocaine (Xylocaine)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I –Direct Order
Lidocaine is a Class IB antidysrhythmic that blocks the fast sodium channels. This shortens the action potential and
stabilizes the cell membrane. Lidocaine also has local anesthetic effects
Effects:
 Antidysrhythmic
 Local anesthetic
Indications:
 Intraosseous cannulation in a conscious patient
 Nasal intubation (Viscous Lidocaine. Paramedic only)
 Oral intubation – “Awake Look” (Paramedic only)
 Premedication in RSI (Paramedic only)
Contraindications:
 Hypotension
 High degree AV blocks
 Bradycardia
 IVR or ventricular escape rhythms
Precautions:
 AV blocks
 Liver disease
Side effects:
 Seizure
 Neurologic changes (Alterations in speech, tingling, visual changes, etc.)
 AV blocks
 Hypotension (At toxic doses)
Dose/Administration:
 IO infusion analgesic: 18mg bolus. May repeat x1
o Flush saline lock with Lidocaine prior to attaching to IO
o Currently our extension sets hold 0.9mL. 0.9mL of 2% Lidocaine is 18mg
 Pediatric dose for IO infusion: 0.5mg/kg. Max not to exceed adult dose. May repeat x1
 Oral intubation: 1mg/kg up to 50mg (Atomized). May repeat dose up to total of 1.5mg/kg
 Nasal intubation: 1-2mL in each naris and lubricate ETT with Viscous Lidocaine
Notes:




Effect of bolus will last 20minutes
½ dose in liver disease, CHF, or over the age of 70
Seizures due to Lidocaine toxicity usually resist treatment
Pregnancy category: B
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Magnesium sulfate
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic - Standing Order
EMT-I – Direct Order for Eclampsia
Magnesium is an electrolyte that has a variety of effects including smooth muscle relaxation, calcium channel
blockage, CNS depression, prolongs action potential, and shortens the QT interval
Effects:
 Bronchodilation
 Decrease blood pressure and relieve cerebral vasospasm
 Shorten QT interval
Indications:
 Seizures secondary to eclampsia
 Polymorphic Ventricular Tachycardia (Paramedic only)
 Cardiac arrest due to hypomagnesaemia (Paramedic only)
 Status asthmaticus (Refractory to other treatments) (Paramedic only)
Contraindications:
 AV heart blocks (Except in Torsade’s and cardiac arrest)
Precautions:
 Hypotension
 Respiratory depression
 Bradycardia
 CNS depression
 Digitalis toxicity
 Renal failure
Side effects:
 See precautions
 AV heart blocks
 Flushing/sweating
Dose/Administration:
 Cardiac: 2g (IV, IO) over 2-5min
 Eclampsia: 4g (IV, IO)
o Mix in 100mL Normal Saline. Drip over 20-30min
o With 10gtt set, administer at 30-50gtts/min
 Respiratory: 2g (IV, IO) over 2-5min
 Pediatric dose: 25-50mg/kg. Drip over 20-30min
Notes:
 Be prepared to assist ventilations
 Monitor for hypotension. Discontinue administration if hypotension occurs
 Pregnancy category: A
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Methylprednisolone (Solu-Medrol)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I – Direct Order
Methylprednisolone is a synthetic steroid that stimulates the increased release of anti-inflammatory mediators and
decreases the production of pro-inflammatory mediators. Also decreased the degranulation of mast cells/ the lysis of
other leukocytes
Effects:
 Anti-inflammatory
 Suppresses the immune/allergic response
Indications:
 Anaphylaxis
 Asthma/COPD
 Croup/Bronchiolitis – If IV/IO previously established
 Suspected Addisonian crisis (Cardiovascular collapse in patient at risk for adrenal insufficiency)
 Acute mountain sickness (When rapid descent is not achievable)
Contraindications:
 Hypersensitivity to methylprednisolone
 Active GI bleeding
Precautions:
 None with short-term treatment/use
 History of diabetes – Will increase blood glucose levels
Side effects:
 None with short-term treatment/use
Dose/Administration:
 125mg (IV, IO, IM)
o Use promptly after reconstitution
 Pediatric dose: 2mg/kg (IV, IO, IM)
Notes:
 Be aware that the effect of methylprednisolone is generally delayed for approximately 1hr. Administer as
early in the course of treatment as appropriate, but do not delay transport or other treatments to
administer
 Avoid routine administration for croup/bronchiolitis. The effect of stressing the child due to a needle may
outweigh the benefit of administration in the pre-hospital setting
 Pregnancy category: C
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Midazolam (Versed)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic - Standing Order
EMT-I - Direct Order*
(*EMT-I – May be administered under a standing order when the safety of the patient or
the EMT is at risk)
Versed is a benzodiazepine that increases GABA activity in the brain
Effects:




Inhibit neuronal excitability
Sedation
Anxiolysis
Skeletal muscle relaxation
Indications:
 Chemical restraint for combative patients
 Rapid Sequence Intubation maintenance or if Ketamine is contraindicated/unavailable for induction
(Paramedic only)
 Seizures
 Relief of muscle spasm
 Anxiolysis
Contraindications:
 Hypotension (Except for prior to procedure)
 Respiratory depression (Except for prior to procedure/RSI, or if unable to establish airway control due to
combativeness)
Precautions:
 Age > 70yrs ( Consider lower dose)
 CNS/respiratory depression
 Hypotension
Side effects:
 Hypotension
 Respiratory depression
Dose/Administration:
 RSI induction adult: 0.3mg/kg (IV, IO)
o Maintenance: 1-5mg (IV,IO) repeat as needed
 All other indications adult: 1-5mg (IV, IO, IN, IM)
o Use lower dosage for (IV, IO) administration
 All other indications pediatric: 0.05-0.1mg/kg (IV, IO, IN, IM)
o Use lower dosage for (IV, IO) administration
Notes:
 Onset 2-5min, duration 15-90min
 IN administration of Versed has shown to be very effective in the treatment of seizures
 Pregnancy category: D
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Morphine sulfate
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I - Direct Order
Morphine is an opiate analgesic. Morphine has vasodilatory properties due to release of histamine after administration
Effects:
 Narcotic analgesic
 Peripheral vasodilatation
 Decreased myocardial oxygen demand and decreased cardiac workload
Indications:
 Cardiac chest pain
 Extremity fractures
 Pulmonary edema
 Severe pain of non-traumatic origin (Back spasms or kidney stones)
Contraindications:
 Hypotension
 Hypovolemia or severe bleeding
 Head, chest or abdominal injures
 Undiagnosed abdominal pain
Precautions:
 CNS/respiratory depression
 Liver disease
Side effects:
 Hypotension
 CNS/respiratory depression
 Nausea/vomiting
Dose/Administration:
 2-4mg (IV, IO, IM) over 2min
o May repeat after 5min as needed
o Max dose: 30mg
 Pediatric dose: 0.1mg/kg (IV, IO, IM) over 2min
o Max single dose should not exceed adult dose
Notes:
 Morphine has limited effectiveness in the treatment of pulmonary edema
 Diphenhydramine may be administered to counteract the symptoms of the histamine release that may occur
after Morphine administration
 Pregnancy category: C
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Naloxone (Narcan)
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
Competitive opioid antagonist
Effects:
 Reversal of opioid effects
Indications:
 Narcotic/suspected narcotic overdose
 Catapres (Clonidine) overdose (Paramedic only)
Contraindications:
 None
Precautions:
 Narcotic addiction/abuse
 Chronic pain – If used in a patient who is habituated to narcotics, the patient may develop condition
consistent with narcotic withdrawal
Side effects:
 Sudden narcotic withdrawal
o Nausea/vomiting
o Combativeness
o Pulmonary edema
 Soreness/headache (If narcotics are not present)
Dose/Administration:
 2mg (IV, IN, IO, IM) repeat as needed
o Consider dilution and titration if the patient is not in respiratory arrest
 Pediatric dose: 0.1mg/kg (IV, IN, IO, IM) repeat as needed
o Max single pediatric dose not to exceed adult dose
 Titrate dose to reverse respiratory depression, not to achieve full reversal of effects
Notes:







The duration of some narcotics is longer than Narcan (1-4hrs). Repeated doses of Narcan may be required
Patients who have received this drug must be transported
Large doses (16-20mg) may be needed to reverse Propoxyphene (Darvon) overdose
Demerol (Meperidine) will not cause pupillary constriction
The number of opioid analgesics, and medications that include an opioid, is extensive. Physical exam and
patient assessment is the most useful tool in determining whether or not a patient might have overdosed on
an opioid
Catapres (Clonidine) is an A2 adrenergic agonist whose effects will be reversed with Narcan
administration
Pregnancy category: C
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Nitroglycerine
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I - Cardiac chest pain by Standing Order, Direct Order for all other indications
Nitroglycerine is a prodrug that metabolizes into nitric oxide. Exact mechanism of action is not well understood
Effects:
 Vasodilation (Including coronary arteries)
 Decreased preload and afterload
 Generalized smooth muscle relaxation
Indications:
 Cardiac chest pain
 Pulmonary edema
 Esophageal spasm (Paramedic only)
Contraindications:
 Hypotension (Systolic BP < 90mmHg)
 Right ventricular MI
 Phosphodiesterase 5 inhibitor use:
o Viagra (sildenafil) within 24hrs
o Cialis (tadalafil) within 48hrs
o Levitra (vardenafil) within 24hrs
o Stendra (avanafil) within 24hrs
o Other PDE5 inhibitors are currently in clinical trials and may become available in the USA
Precautions:
 Inferior MI (V4R or right-sided 12-lead required prior to administration)
 HR >100 or <60bpm
Side effects:
 Hypotension and tachycardia
 Headache
Dose/Administration:
 0.4mg (1/150gr) (SL, lingual, buccal)
o May repeat every 5min as long as the systolic BP is >90 mmHg
o Time between doses may be shortened when administered for CHF as needed and as BP allows
o Administration is still allowed, if indicated, even if the patient has taken prior to our arrival
Notes:




Blood pressure should be taken and recorded before and after each administration
Nitroglycerine is thought to have a cumulative effect
Onset 2min, duration 30min
Pregnancy category: C
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Ondansetron (Zofran)
Authorization:
Protocol:
EMT-I and Paramedic
EMT-I, Paramedic - Standing Order
Blocks serotonin receptors in the chemoreceptor trigger zone that is located in the medulla oblongata
Effects:
 Antiemetic
Indications:
 Nausea and/or vomiting
 Potential for nausea and/or vomiting
Contraindications:
 Hypersensitivity
Precautions:
 Children < 3yrs
 Pregnancy/breast feeding
Side effects:
 Headache
 Dizziness
 Fatigue
Dose/Administration:
 4mg (IV, IO, IM, IN)
 Pediatric dose: 0.15mg/kg (IV, IO, IM, IN)
o Max pediatric dose not to exceed adult dose
Note:


Usually will not cause sedation
Pregnancy category: B
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Ondansetron (Zofran) ODT
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-I, Paramedic - Standing Order
EMT-B, and EMT-BIV – Direct Order
Blocks serotonin receptors in the chemoreceptor trigger zone that is located in the medulla oblongata
Effects:
 Antiemetic
Indications:
 Nausea and/or vomiting
 Potential for nausea and/or vomiting
Contraindications:
 Hypersensitivity
 Children <3yrs
Precautions:
 Pregnancy/breast feeding
Side effects:
 Headache
 Dizziness
 Fatigue
Dose/Administration:
 4mg (ODT)
o May repeat once as needed by ODT or use parenteral Zofran
Note:



Usually will not cause sedation
Effect may be delayed over parenteral administration
Pregnancy category: B
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Oxygen
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
Required by for aerobic metabolism
Effects:
 Saturate hemoglobin with oxygen
 Hasten disassociation of CO from hemoglobin
Indications:
 Hypoxia (SPO2 < 94%)
 Shortness of breath
 Hypotension/shock states
 Significant bleeding
 Pregnancy with complications and during childbirth
 CO/suspected CO poisoning
 Poisonous inhalation
Contraindications:
 None
Precautions:
 MI/stroke with SPO2 > 94% and no shortness of breath
 Patients with COPD/other chronic lung disease may have “normal” SPO2 < 94%
Side effects:
 Drying of nasal mucosa
Dose/Administration:
 Nasal cannula: 1-6L/min
o 4-6L/min will quickly dry mucosa. Consider NRB use instead of NC
o 15L/min for apneic oxygenation during RSI
 Non-rebreather mask: 10-15L/min
o Ensure that reservoir is full prior to placement on the patient
o >15L/min for denitrogenation during RSI
 Bag-valve-mask: 10-15L/min
o Ventilate at appropriate rate
o Used with mask, endotracheal tube, or extra glottic device
 Small volume nebulizer: 6-8L/min
o EMT-BIV, EMT-I, and Paramedic only. See specific protocol
o Use same volume/min of oxygen when SVN on mask. Ensure that one-way valves are removed
 CPAP: 15L/min
o EMT, EMT-BIV, EMT-I, and Paramedic only. See specific protocol
 Automated transport ventilator: high pressure oxygen required
o Paramedic only
Notes:
 Oxygen supports combustion. Be aware of possible sources of ignition
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Phenylephrine (Neo-Synephrine)
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Alpha1 adrenergic agonist
Effects:
 Vasoconstriction
 Nasal decongestion
Indications:
 Prior to nasal intubation
 May relieve ear blockage and pressure/pain associated with altitude changes
 Epistaxis (Patient should be transported)
Contraindications:
 None
Precautions:
 Hypertension
 Hyperthyroidism
 Cardiovascular disease
Side effects:
 Hypertension
Dose/Administration:
 0.5 - 1 .0mL in each nares (One to two sprays)
 Pediatric dose: 0.5mL in each nares (One spray)
Notes:
 When used to relieve otitic barotrauma, the best results are from pretreatment before descending from
altitude
 Pregnancy category: C
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Promethazine (Phenergan)
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Standing Order
EMT-I - Direct Order
Phenothiazine with H1 antagonist and anticholinergic properties
Effects:
 Antiemetic
 Sedation (Particularly when administered with opioids)
Indications:
 Nausea and/or vomiting
 Potential for nausea and/or vomiting
Contraindications:
 CNS depression
 Hypersensitivity to “sulfite” (Not sulfa drugs)
 Children < 2yrs of age
Precautions:
 Acutely ill or dehydrated patients
 Age > 70yrs
 Pregnancy/breast feeding
Side effects:
 Use in children may cause paradoxical hyper-excitability and apnea
 Sedation
 Hypotension
 Confusion
 Tissue necrosis (With extravasation)
Dose/Administration:
 6.25 mg (IV, IO) over 2min. May repeat every 15min
o Dilution is required prior to (IV/IO) administration – See note
o IV must be patent
 6.25mg (IM). May repeat every 15min
 Pediatric dose (2yrs < - <12yrs): Consult Base Physician
Notes:
 (IV /IO) Promethazine is highly damaging to tissue with/without extravasation. It is currently recommended
that single doses not exceed 6.25mg, the dose be pushed over 2 minutes, and the dose be diluted with
Normal Saline. Dilution may be done in a syringe and/or by running saline wide open through drip set during
administration
 IM administration may cause local irritation and pain
 Pregnancy category: C
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Sodium Bicarbonate
Authorization:
Protocol:
EMT-I and Paramedic
Paramedic – Direct Order for crush injury, Standing Order for all other indications
EMT-I - Direct Order
Sodium Bicarbonate is an alkalotic sodium solution that binds to hydrogen ions to become carbonic acid. Carbonic
acid readily disassociates into CO2 and water. Sodium Bicarbonate will increase the pH of the urine and increase
serum sodium
Effects:
 Increase sodium concentration in the blood
 Minimal increase in serum pH
Indications:
 Cardiac arrest preceded/potentially preceded hyperkalemia
 Known hyperkalemia (Paramedic only)
 Tricyclic antidepressant overdoses with QRS >0.12ms, dysrhythmias, ectopy, or hypotension (Paramedic
only)
 Massive crush injuries (Paramedic only)
Contraindications:
 Metabolic alkalosis
 Respiratory acidosis
Precautions:
 Routine use
Side effects:
 Metabolic alkalosis
 Paradoxical cerebral/intracellular acidosis
Dose/Administration:
 1mEq/kg (IV, IO)
o Repeat dose of 0.5mEq/kg after 15min if indicated
 Pediatric dose: 1mEq/kg (IV, IO) diluted by 50% with D5W
o Repeat dose of 0.5mEq/kg diluted by 50% with D5W after 15min if indicated
 Crush injury
o 1mEq/kg (IV,IO) diluted in 250mL D5W administered over 10min
Notes:
 Avoid mixing with Normal Saline for drip administration
 Per the American Heart Association, "The value of Sodium Bicarbonate is questionable during cardiac arrest,
and it is not routinely recommended for the routine cardiac arrest sequence."
 Adequate and effective ventilation is the mainstay of treatment for acidosis
 Carbon dioxide is generated after administration. Effective ventilation is essential to remove the CO2 from
the body
 Must be administered in separate line than catecholamines and Calcium Chloride
 Pregnancy category: C
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Succinylcholine Chloride
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Depolarizing acetylcholine nicotinic receptor antagonist
Effects:
 Paralysis
Indications:
 RSI
Contraindications:
 Known hyper-sensitivity to any component
 Personal or family history of malignant hyperthermia
 Acute narrow angle glaucoma or penetrating eye injuries
 Inability to ventilate/oxygenate the patient if intubation is not successful
 Patient <12yrs
Precautions:
 Known or potential hyperkalemia or metabolic acidosis
 Pregnancy/breast feeding
 Burns
 Liver disease
 Anemia
 Malnutrition
 Quinidine or Digitalis use
 Increased dose may be needed if the patient is hypotensive
Side effects:
 Hyperkalemia
 Muscle fasciculation
 Arrhythmias (Particularly pediatric patients)
Dose/Administration:
 1.5mg/kg (IV, IO)
o Use RSI cards for assistance with dosing
Notes:
 Succinylcholine Chloride does not affect pain or anxiety – administer sedative first
 Onset within 30secs, duration 4-6min
 Pregnancy category: C
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Tetracaine/Opthaine
Authorization:
Protocol:
EMT-I and Paramedic
EMT-I and Paramedic – Standing Order
Tetracaine inhibits sodium influx through neuronal cell membranes
Effects:
 Topical ophthalmic analgesic
Indication:
 Pain caused by superficial trauma to the eyes
 Provide analgesia to facilitate flushing after chemical or foreign body
 UV burn to the eye
Contraindications:
 Penetrating trauma to the eye
 Globe not intact
Precautions:
 Patient must be transported
Side effects:
 Tearing
 Transient burning sensation
 Blurred vision
Dose/Administration:
 1-2 drops in to the affected eye
o Medication may be administered prior to flushing eye with Normal Saline or sterile water
o Cover both eyes, after administration, to reduce movement of globe
Notes:
 Pregnancy category: B
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Vecuronium Bromide
Authorization:
Protocol:
Paramedic
Paramedic - Standing Order
Non-depolarizing, nicotinic, acetylcholine receptor antagonist
Effects:
 Paralysis
Indications:
 Maintenance of chemical paralysis after RSI
 RSI if Succinylcholine is contraindicated/unavailable
Contraindications:
 Inability to ventilate/oxygenate if intubation is unsuccessful
 Patient <12yrs
Precautions:
 Inability to oxygenate/ventilate the patient
 Increased dose may be needed if the patient is hypotensive
Side effects:
 None
Dose/Administration:
 0.1mg/kg (IV, IO)
o See RSI cards for assistance with dosing
Notes:





Onset is within 1min, duration is up to 45min
Continuous end tidal CO2 and pulse oximetry monitoring is mandatory
Does not provide analgesia or sedation
Consider withholding long term paralysis if the patient condition warrants. Ensure that appropriate
sedation and analgesia are provided
Pregnancy category: C
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Over-the-Counter Medications
Authorization:
Protocol:
EMT-B, EMT-BIV, EMT-I, and Paramedic
EMT-B, EMT-BIV, EMT-I, and Paramedic - Standing Order
Overview:
This protocol has been established to outline a basic guideline for when and under what circumstances a provider
may administer an over-the-counter medication to a patient that is under his/her care
Circumstances:
Over the counter medications may only be administered under the following circumstances:
 In a “wilderness” setting. Defined as:
o No access by 2-wheel drive vehicle
o Extended access by 4-wheel drive vehicle
o Access only by ATV, motorcycle, or snowmobile
o Access only by foot or other non-mechanized means of conveyance
 When access to the other medications covered in these protocols are not available or not appropriate
 When deemed, by the provider, that the patient requires the medication to:
o Relieve swelling from isolated extremity injuries in stable patients
o Reduce pain from isolated extremity injuries in stable patients
o Treat MI
o Treat an allergic reaction
Medications:
Only commonly available, over-the-counter, medications may be administered. Use of a prescription medication by a
person other than the person that the medication is prescribed for is illegal and strictly forbidden
 Pain relief/swelling reduction
o NSAIDs
 Aspirin, Ibuprofen, or Naproxen
 Generic, Advil, Motrin, Aleve, Ascriptin, Bayer, or Ecotrin
o Acetaminophen
 Tylenol or Generic
 Treat MI
o Aspirin
 Allergic reaction
o Benadryl or generic Diphenhydramine
Doses:
 Aspirin for MI
o Adult: 324mg (PO)
All other medications should be given as instructed on the label. Do not deviate from the recommended dosing
Pediatric patients may be given the medications that have a specific pediatric use and dose on the label
Notes:
 Myocardial infarction, cardiac chest pain, allergic reactions, multisystem trauma, long bone fractures and
other serious trauma/medical are extremely serious conditions. Transfer to definitive care should not be
delayed and helicopter use should be strongly considered
 Medications should only be used if they are in their original packaging with instructions, dosing information,
and drug information readily available
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EMT – Intermediate Direct Order Exception
Authorization:
Protocol:
EMT-I
EMT-I - Standing Order
This protocol serves to allow an EMT-Intermediate that had received adequate training and education, and is
currently employed with Chaffee County Emergency Medical Services, to administer certain medications, in certain
situations, without a verbal Direct Order from the receiving physician
6 CCR 1015-3, Chapter Two. Section 14.22 allows “…specific exception criteria are established by the supervising
physician. Exception criteria may include, but are not limited to, cardiac arrest, behavioral management, or
communications failure. “
The following are the specific exception criteria. Providers should reference specific protocols for further information
Communications Failure
 An EMT-I may administer any medications that they feel is appropriate for the patient condition, and have
Direct Order authorization for, under a Standing Order if:
o Communication with the Base Physician via radio has failed
o Communication with the Base Physician via phone has failed
o The patient’s life may be threatened if the EMT-I withholds the medication
 Communication with the Base Physician should be established as soon as possible after the administration
and the communications failure be thoroughly documented in the patient care report
Fentanyl Citrate
 An EMT-I may administer Fentanyl Citrate (Sublimaze) under Standing Order if the following criteria are
met:
o The patient has suffered an isolated traumatic injury or has pain likely due to Acute Coronary
Syndrome
o All Contraindications for Fentanyl Citrate (Sublimaze) are absent
o All Precautions for Fentanyl Citrate (Sublimaze) have been considered
 This protocol only allows an exception for the Direct Order for Fentanyl Citrate (Sublimaze), under the
above conditions, no other component of any other protocol
Benzodiazepine – Midazolam (Versed) or Diazepam (Valium)
 An EMT-I may administer Midazolam (Versed) or Diazepam (Valium) under Standing Order if the following
criteria are met:
o The patient or provider’s well-being is at risk if medication administration is delayed
o All Contraindications for the selected Benzodiazepine are absent
o All Precautions for the selected Benzodiazepine have been considered
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Interfacility Transfer Medications
Authorization:
Protocol:
EMT-I and Paramedic
EMT-I and Paramedic - Direct Order by sending physician
Purpose:
Some patients will require the administration of medications that are only allowed to be administered under the
following conditions:
 During a ground, interfacility transport, when other transfer options are not available
 Under the direct, written, order of a sending physician
 When specifically allowed below
General Procedures:
 The following apply to each medication or infusion covered in this protocol:
o Providers certified as FA/CPR, FR, EMT-B, and EMT-BIV may not be the sole attendant when a
medication is being infused
o Only medication infusions approved below may be maintained by Chaffee County Emergency
Medical Services EMT-I’s and Paramedics
o EMT-I may only maintain medications specifically approved
o A provider may not initiate administration of these medications unless specifically authorized in
other sections of this Protocol Manual (i.e. dopamine)
o IV/IO medications must be administered via an infusion pump. Other routes of administration must
comply with physician order. Blood products do not require the use of an infusion pump
o If any adverse reactions/conditions occur, discontinue administration and contact sending physician
 The following apply to prior/during/after transport:
o The EMT-I or EMT-P must ensure the patency of the IV/IO
o A second route of access should be established, if it has not already, prior to leaving sending facility
o The patient must be placed on the cardiac monitor
o The concentration of the drug solution must be recorded and documented
o The infusion rate and dose must be recorded and documented
o Vital signs must be obtained and recorded at least every 15min
o If an IV/IO infiltration occurs during infusion, reinitiate the infusion through an available access
point and notify the sending physician immediately
Approved Medications and Blood Products:
 Diltiazem HCI (Paramedic)
 Heparin (Paramedic)
 Nitroglycerin (Paramedic)
 Blood/Blood products (Paramedic)
 Solu-Medrol (Paramedic)
 Vitamins (EMT-I, and Paramedic)
 Electrolytes (Paramedic)
o Magnesium sulfate - Maximum rate of 4g/hr
o Potassium chloride - Maximum rate of 10mEq/hr
 Lidocaine (EMT-I, and Paramedic)
 Dopamine (Paramedic)
 Amiodarone (EMT-I, and Paramedic)
 Antibiotic infusions (EMT-I, and Paramedic)
 Mannitol (Paramedic)
 Oxytocin (Paramedic)
 Total Parenteral Nutrition (EMT-I, and Paramedic)
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 Glycoprotein Inhibitors (Paramedic)
 Nicardipine (Paramedic)
 Magnesium (Paramedic)
 Sodium Bicarbonate (Paramedic)
 Insulin (Paramedic)
 Methylprednisolone (Paramedic)
 Octreotide (Paramedic)
 Pantoprazole (Paramedic)
Specific Procedures and Precautions:

Diltiazem HCL (Cardizem)
o Indications: See protocol
o Contraindications: See protocol
o Precautions: See protocol
o Complications: See protocol
o Procedure: Follow the sending physician’s orders
o Usual dose: 5-15 mg/hr. Maximum rate of 15mg/hr

Heparin
o Indications: Heparin is frequently administered as an anticoagulant to prevent blood clotting in the
setting of ischemic coronary disease, pulmonary embolism, or peripheral vascular conditions
o Contraindications: Severe thrombocytopenia and active bleeding
o Precautions:
o Complications: Hemorrhage from any site may occur, or hypersensitivity reaction
o Procedure: Usually 20,000 to 40,000 units of Heparin are added to 1000cc NS.
o Usual dose: 1,000units/hr in adults

Insulin
o Indication: Insulin is used to treat patients with diabetic ketoacidosis or hyperglycemia. It may also
be used with dextrose solutions to treat patients with hyperkalemia
o Contraindications: Hypoglycemia, or hypokalemia.
o Precautions: Alcohol and salicylates may potentiate the effects of insulin.
o Complications: Attention must be paid to any signs of hypoglycemia (diaphoresis, weakness,
tachycardia, confusion, nausea). The transporting ambulance must have a functional Glucometer
for evaluation of blood sugar during transport
o Procedure: Document on the patient care report if the patient received (and how much) a loading
dose of insulin. Blood glucose checks are mandatory every 30 minutes during transport. A
decrease in blood sugar of 3-50 mg/dl/hr should be anticipated on average
o Usual dose: 0.1 units/kg/hour

Nitro glycerin
o Indications: Ischemic coronary state and hypertension
o Contraindications: Hypotension and shock
o Precautions: The patient should be observed clinically for pain relief, blood pressure changes, and
other signs of poor perfusion. Decrease the infusion rate by half if signs of poor perfusion (pallor,
sweating, decreased capillary refill, or mental alertness) occur in conjunction with systolic BP<100.
Notify the sending physician immediately. Rapid withdrawal of nitroglycerin infusion may result in
worsening of ischemia and should be avoided. Infusion rates may be increased only through direct,
sending physician, order if the patient develops worsening ischemic chest pain or hypertension
o Complications: Nitroglycerin absorbs into plastic IV tubing, so the dose that the patient receives
maybe be lower than the dose shown on the IV pump
o Procedure: A dilution of 50 – 100 mcg/ml is typical
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Usual dose: 50-200mcg/min

Blood/Blood Products
o Indications: Hemorrhage and certain anemic states and for other disorders of the hematologic
system
o Contraindications: The sending physician will have considered the contraindications to blood
transfusion
o Precautions: Some patients may object to the transfusion of blood products for religious reasons.
For problems, contact the sending physician
o Complications: Transfusion reactions and hypersensitivity reactions can occur after the onset of
blood product infusion. Symptoms may include fever, restlessness, anxiety, flushing, chest or
lumbar pain, tachycardia, tachypnea, nausea, and shock. Occasionally bleeding from coagulopathy
may develop. If any of the signs or symptoms listed above develop after the onset of the
transfusion, the transfusion should be discontinued and the sending physician be contacted
immediately
o Procedure: Maintain infusion rate as indicated by the sending physician. All blood products should
be administered through tubing with a blood filter. Document blood product number (with pen or
sticker) to permanent medical record and pre-hospital trip sheet left at receiving facility
o Usual dose: Determined by sending physician

Solu-Medrol/Methylprednisolone
o Indications: See protocol. In addition, may be administered in patients with spinal cord injury
o Contraindications: See protocol. In addition, premature infants
o Precautions:
o Complications: Rare instances of bronchospasm, bradycardia, and other cardiac arrhythmias have
been reported after large rapid IV administration. If complications develop, discontinue the
infusion and notify the sending physician immediately
o Procedure:
o Usual dose: 5.4 mg/kg/hr for 23 hours

Vitamins/Electrolytes
o Indications: Vitamins or electrolytes may be infused when there is a confirmed or suspected
deficiency. Most commonly, multivitamin infusions (MVI) will be given to patients suspected of
being malnourished (e.g. chronic alcoholics)
o Contraindications: These will have been previously considered by the sending physician
o Precautions: None
o Complications: Exceeding the prescribed rate of potassium solutions may result in cardiac
conduction abnormalities. Infusion rate should be slowed if any burning or irritation occurs at the
infusion site and sending physician should be contacted immediately
o Procedure: All patients being given IV Potassium must be on a cardiac monitor
o Usual dose: Varies with vitamin/electrolyte

Lidocaine
o Indications: See protocol
o Contraindications: See protocol
o Precautions: CHF, liver disease, bradycardia, and AV heart blocks. Lidocaine may speed the
ventricular rate in patients with atrial fibrillation.
o Complications: Signs and symptoms of Lidocaine toxicity include dizziness, tinnitus (ringing in the
ears), tremulousness, seizures, agitation, and exacerbation of heart block, hypotension, and
bradycardia. In cases of Lidocaine toxicity the medication drip should be discontinued immediately
and the patient should be treated with supportive measures (e.g., Atropine in the case of heart
block, diazepam in the case of seizure) and contact sending physician immediately
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Procedures: Typically a maintenance infusion of Lidocaine is 1 gram or Lidocaine in 250cc of D5W
Usual dose: 1-4mg/min

Amiodarone
o See individual drug protocol

Dopamine
o Indications: Hypotension, bradycardia, or renal protection
o Contraindications: Hypovolemia (relative)
o Precautions: MAOI use, tachyarrhythmias, infusion should be decreased or stopped
o Procedure: Usually premixed, use infusion pump to administer 2-20mcg/kg/minute
o Dose: 2-10mcg/kg/min (IV, IO) drip for cardiogenic shock and bradycardia
10-20mcg/kg/min (IV, IO) drip for distributive shocks

Mannitol
o Indications : Treatment of increased intraocular or intracranial pressure
o Contraindications :Hypersensitivity, anuria, dehydration, or active intra cranial bleeding
o Precautions: Pregnancy
o Complications: Hypotension, confusion, headache, nausea, vomiting, blurred vision, rhinitis, or
electrolyte imbalance
o Procedure: Usually premixed. Must be administered through filter set and warm
o Usual dose: 0.25 – 2 g/kg over 30-60min

Nicardipine
o Indications: Hypertension and BP management in CVA / hemmorhage
o Contraindications: Aortic stenosis
o Precautions: Pregnancy class C. Monitor BP closely
o Complications: Hypotension, headache, weakness, flushing
o Usual dose: 5mg /hr slow infusion (IV, IO). May be increased by 2.5mg/hr every 15 minutes. Do not
exceed 15mg/hr

Oxytocin
o Indications: Control of post-partum hemorrhage
o Contra indications: Hypersensitivity, or non vaginal delivery
o Precautions:
o Complications: Coma, seizure, or hypotension
o Procedure:
o Usual dose: 0.5 – 2 milliunits/min. Max dose of 20 milliunits/min
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IV/IO Solutions
Authorization:
Protocol:
EMT-BIV, EMT-I and Paramedic
EMT-BIV, EMT-I and Paramedic - Standing Order
Chaffee County Emergency Medical Services currently carries two crystalloid IV/IO solutions
General:
 Normal Saline – Contains Na+, and Cl- and is isotonic
 Primary IV fluid for resuscitation purposes
 D5W – Contains 5% dextrose in water and is hypotonic
 D5W diffuses into the tissue three times faster than NS and is inefficient as a volume
expander. Should be used for drip medication administration and in patients that
circulatory overload is a concern
Precautions:
 In hemorrhagic shock, volume expansion with crystalloid solutions is efficient in raising intravascular volume
but does not increase oxygen carrying capacity. Can be used temporarily to maintain blood pressure
 Volume overload is a constant danger. Ensure that the IV/IO is at the desired rate throughout transport.
Excess fluid can be detrimental
 Do not use D5W in suspected Cerebral Vascular Accidents
Administration:
 Establish an IV or IO line using technique outlined in each specific protocol
 Use either a macro drip set, micro drip set, or saline lock as appropriate
 Rate should always be set at a TKO rate unless a fluid bolus is indicated
 The rate that fluid can be infused is dependent on the diameter and length of the catheter used
o A 24 gauge is the smallest and a 14 gauge is the largest that can be used in the field
o For volume expansion, a large catheter should be used, such as a 16 or 14 gauge
o Aim for security and accuracy, not size. Do not try to force a large bore needle into a small vein
Notes:
 Administer boluses in small increments, such as 250mL, up to 20mL/kg, assessing breath sounds, changes in
vital signs, and patient condition frequently. May repeat as indicated
 Be careful of administering large amounts of fluid (>2 liters) as circulator overload may develop
o Signs and symptoms of overload include dyspnea, orthopnea, rales, JVD, polyuria and hypertension
o If fluid overload occurs, immediately turn the IV to a slow TKO and advise the Base Physician
o The elderly, pediatrics, and those with kidney and heart problems are particularly vulnerable to
fluid overload
 Refer to the individual protocol to determine in which situations an IV/IO should be initiated and what
patient conditions might require fluid administration
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Revisions
Version 10
 Calcium Chloride added - Page #147
 Dextrose changed from D50% to D10% for all ages - Page #148
 12mg Adenosine – Removed 6mg dose for adults - Page #143
 200J – Optional starting point for all cardioversion/defibrillation of adult patients - Page #111
 SPO2 added to TCP – To prove capture with pulse - Page #110
 Sepsis protocol updated with new criteria - Page #54
 Dopamine moved to IFT and removed from prehospital protocols
 Critical care protocols added - Page #188
 Nicardipine added to transfer medications - Page #182
 Ketamine modified for CC paramedics - Page #161
 Added consider lidocaine to RSI protocols - Page #93
 Removed TIH and added TTM – Page #26
 Apneic Oxygen – Page #101
 Pain control protocol - Page #128
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Critical Care Protocols
Requires Critical Care Endorsement in the state of Colorado
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Acetylcysteine (Mucomyst)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Acetylcysteine is used in the treatment of acetaminophen overdose. Acetylcysteine maintains and/or
replenishes depleted glutathione reserves in the liver which inactivates hepatotoxic metabolites of
acetaminophen metabolism
Effects:
 Protects the liver against toxic metabolites of acetaminophen toxicity
 Mucolytic agent for use in cystic fibrosis
Indications:
 Acetaminophen overdose
 Mucolytic therapy
Contraindications:

Allergy (relative) – treat with diphenhydramine and continue infusion if benefit > risk
Precautions:
 Can cause bronchospasm
 Increase in bronchial secretions
Side effects:
 May cause rash, urticaria and pruritus
 Nausea
Dose/Administration:

Adult and Pediatric dose IV/IO:
o Loading Dose: 150 mg/kg in 200 mL of 5% dextrose intravenously over 60 minutes
(maximum: 15 g)
o Second Dose: 50 mg/kg in 500 mL 5% dextrose intravenously over 4 hours (maximum: 5
g)
o Third Dose: 100 mg/kg in 1000 mL of 5% dextrose intravenously over 16 hours
(maximum: 10 g)
Notes:




Use may be dictated by the Rumack-Matthew nomogram (See next page)
If plasma levels cannot be obtained it is reasonable to treat based on suspected acetaminophen
overdose
Some formulations of acetaminophen may be extended release
Pregnancy category: B
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Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
189
Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Dobutamine (Inotropin)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Dobutamine increases inotropy by stimulation of β1
Effects:
 Increases cardiac output via increased inotropy
Indications:
 Cardiogenic shock
 Need for increased inotropy
 As an adjunct to other vaso-active medications
Contraindications:

Dobutamine hydrochloride is contraindicated in patients with idiopathic hypertrophic subaortic
stenosis and in patients who have shown previous manifestations of hypersensitivity to
dobutamine injection
Precautions:

Increase in myocardial oxygen demand
Side effects:




Hypertension
Angina
Arrhythmia. May cause rapid ventricular response in patients with atrial fibrillation
Nausea
Dose/Administration:

Adult and Pediatric 2.5 - 20 mcg/kg/min (IV, IO)
Notes:

Pregnancy category: B
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Esmolol (Brevibloc)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Esmolol is a selective β1 blocker that will decrease inotropy, HR, and BP
Effects:
 Slows Ventricular rate
 Decreases Blood Pressure
Indications:
 SVT (including atrial fib / atrial flutter / Non-Compensatory sinus tach (Ex: POTS)
 Hypertension
Contraindications:
 Severe sinus bradycardia
 Heart block greater than first degree
 Sick sinus syndrome
 Decompensated heart failure
 Cardiogenic shock
 Co-administration of IV cardiodepressant calcium-channel antagonists (e.g. verapamil) in close
 proximity to BREVIBLOC injection
 Pulmonary hypertension
 Known hypersensitivity to esmolol
Precautions:
 Use with caution in patients with reactive airway diseases
 May raise serum potassium
 Avoid in Prinzmetal’s angina as it may cause unopposed alpha stimulation
 Not recommended for sympathomimetic overdose
Side effects:
 Hypotension
 Bradycardia
 Heart blocks
Dose/Administration:

Supraventricular tachycardia (SVT) or noncompensatory sinus tachycardia
• Optional loading dose: 500 mcg per kg infused over one minute
•Then 50 mcg per kg per minute for the next 4 minutes
• Adjust dose as needed to a maximum of 200 mcg per kg per minute.
Notes:

Pregnancy category: C
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Fosphenytoin (Cerebyx)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Fosphenytoin is an anticonvulsant drug that is believed to work by sodium channel blockade
The dose, concentration, and infusion rate of CEREBYX should always be expressed as phenytoin sodium
equivalents (PE). There is no need to perform molecular weight-based adjustments when converting
between fosphenytoin and phenytoin sodium doses. CEREBYX should always be prescribed and dispensed
in phenytoin sodium equivalent units (PE
Effects:
 Anti-convulsant
 Seizure prophylaxis
Indications:

Control and prevention of seizures
Contraindications:
 Hypersensitivity
 Sinus bradycardia
 AV blocks (type 1-3)
 Adams-Stokes syndrome
Precautions:
 May cause hypotension
 May cause arrythmias, maintain continuous ecg monitoring
Side effects:
 Hypotension
 Arrhythmias
 Purple glove syndrome
 Ataxia / stupor
Dose/Administration:
ALL DOSES ARE IN PE UNITS.
Prior to IV infusion, dilute CEREBYX in 5% dextrose or 0.9% saline to a concentration of 1.5 to 25 mg
PE/mL. The loading dose of CEREBYX is 15 to 20 mg PE/kg administered at 100 to 150 mg PE/min
Because of the risk of hypotension, CEREBYX should be administered no faster than 150 mg PE/min
Maintenance dose is 4 – 6 mg PE/kg/day in divided doses
Notes:



Always dilute before administration
All doses expressed in phenytoin equivalents (PE)
Pregnancy category D
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Labetalol (Normodyne)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Labetalol is a mixed α and β adrenergic antagonist that is used to treat hypertension.
Effects:

Lowered BP by α and β blockade
Indications:
 Hypertension
 Pheochromocytoma
Contraindications:

Hypersensitivity
Precautions:

Use with caution in the presence of severe reactive airway disease
Side effects:
 Nausea
 Bradycardia
 Side effect
Dose/Administration:
 Initial dose 20 mg (0.25 mg/kg) by slow IV injection over a 2 minute period
 Continuous infusion (dilute to 1 - 1.5mg/ml ) administer @ 1mg/minute -2mg/minute
Notes:

Pregnancy category: C
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Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Levitiracetam (Keppra)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Levitiracetam is an anticonvulsant drug believed to work by blocking pre-synaptic calcium channels
Effects:

Anti-convulsant and seizure prophylaxis
Indications:
 Seizures
 Prophylaxis of seizures
Contraindications:
 Hypersensitivity
 Adjust dose if patient has renal impairment
Precautions:
 Dosing adjustments required for patients with impaired renal function
 MUST BE DILUTED IN 100ML OF NS
Side effects:

Somnolence
Dose/Administration:



MUST BE DILUTED IN 100ML OF NS
500 – 1500 mg (IV, IO) over 15 minutes BID
Pediatric dose:
o 1 month to < 6 months Initiate at 7 mg/kg twice and day and titrate to 21 mg/kg twice a
day
o 6 months to 4 years Initiate at 10 mg/kg twice and day and titrate to 25 mg/kg twice a
day
o 4 year to 16 years initiate 20 mg/kg in 2 divided doses (10 mg/kg twice daily)
Notes:

Pregnancy class: C
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Metoprolol (Lopressor)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Metoprolol is β1 selective antagonist that lowers blood pressure and slows heart rate
Effects:
 Lowers blood pressure
 Lowers heart rate
 Decreases myocardial oxygen demand
Indications:
 Hypertension
 Tachycardias
 Myocardial infarction
 Hyperthyroid / Thyroid storm
 Angina Pectoris
Contraindications:
 Hypersensitivity
 Cardiogenic shock
 Sick sinus syndrome, Bradycardia / AV blocks in absence of pacemaker
Precautions:
 May worsen heart failure
 May effect reactive airway disease
 Do not use in Cocaine overdose
 Do not use in untreated pheochromocytoma
Side effects:
 Bradycardia
 Wheezing
 Fatigue
Dose/Administration:
 3 IV boluses of 5 mg each at 2-minute intervals.
 Pediatric dose: safety and efficacy not established in children
Notes:

Pregnancy category: C
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Norepinephrine (Levophed)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Norepinephrine is an α and β agonist that increases inotropy and causes vasoconstriction
Effects:
 Vasoconstriction
 Increased cardiac output
Indications:

Hypotension
Contraindications:
 Hypersensitivity
 Do not give in the same IV line as NaHCO3 (sodium bicarbonate)
Precautions:
 Use with extreme caution in concurrent MAOI use
 May cause arrhythmias
Side effects:
 Bradycardia (not an issue in hypotensive patients, bradycardia points to over-medication)
 Nausea
Dose/Administration:
 Hypotension 2-30mcg/minute
 Pediatric dose: 0.05 – 0.1mcg/kg/minute (max 1-2mcg/kg/minute)
Notes:


Pregnancy category: C
Frequent checks for extravasation required
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Phenytoin (Dilantin)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
Phenytoin is an anticonvulsant
Effects:


Anti-epileptic
Seizure prophylaxis
Indications:



Seizures
Seizure prophylaxis
Indication
Contraindications:




Hypersensitivity
AV block (type II and type III)
Adams-Stokes syndrome
Sinus bradycardia
Precautions:


Administration should not exceed 50 mg/minute in adults or 1 to 3 mg/kg/minute
May Cause Hypotension
Side effects:



Hypotension
Bradycardia
Nystagmus / visual disturbance
Dose/Administration:


10 to 15 mg/kg IV loading dose (at a rate not exceeding 50 mg/minute)
Pediatric dose: same as adult
Notes:

Pregnancy category: D
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
Propofol (Diprivan)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic– Standing Order
Propofol potentiates GABA receptors, sodium channel receptors and other receptors to cause sedation
and amnesia
Effects:
 Sedation
 Amnesia
Indications:

Mechanically ventilated patients
Contraindications:
 Allergy to eggs
 Allergy to Soy
 Not for use in pediatric patients
Precautions:
 May cause pain at injection site
 May lower blood pressure
 Prolonged high dose infusions may cause Propofol infusion syndrome.
 Abrupt discontinuation may cause anxiety and agitation
Side effects:
 Possible hypotension
 Propofol infusion syndrome
Dose/Administration:


Notes:


Maintenance of sedation in adults: 5mcg/kg/minute – 50mcg/kg/minute titrated to effect (IV,
IO)
For induction: 1.5mg/Kg – 3Mmg/Kg IV Push
Pregnancy category: B
Consider lower dose in hemodynamically compromised patient.
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Table of Contents
Chaffee County Emergency Medical Services
Pre-Hospital Treatment Protocols
January 1, 2016
Version 10
tPA (Alteplase)
Authorization:
Protocol:
Critical Care Paramedic
Critical Care Paramedic – Standing Order
tPA is an enzyme that aids in dissolution of blood clots
Effects:

Converts plasminogem in to plasmin aiding in clot breakdown
Indications:

Ischemic stroke
Contraindications:

See tPA screening checklist
Precautions:

See tPA screening checklist
Side effects:
 Bleeding, especially from gums / nose
 Intracerebral hemorrhage
Dose/Administration:

The recommended dose is 0.9 mg/kg (max, 90 mg) infused over 60 min with 10% of the total dose
administered as an initial IV bolus over 1 min
Notes:

Pregnancy category: C
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