CARE MANUAL contra costa county emergency medical services agency

contra costa county
emergency medical services agency
CARE MANUAL
for updates throughout the year, visit www.cccems.org
INSTRUCTIONS FOR USE
The Contra Costa EMS Agency Prehospital Care Manual contains both
treatment guidelines and additional reference materials relevant to EMS
care.
www.cccems.org
Updates and corrections to this manual will be posted at
Treatment guidelines are divided into
three main groupings, Adult, General
and Pediatric. The General Guidelines
include treatment guidelines that
pertain to both adult and pediatric
treatments.
Treatment Guidelines A1 (Adult Patient
Care) and P1 (Pediatric Patient Care)
address basic concepts of care that
are pertinent to all patients. This
information is not repeated in other
treatment guidelines.
More detailed information on
performance of specific patient procedures is posted at www.cccems.org
Policy summaries reflect critical information for field personnel. For full
policies, please refer to www.cccems.org
 
table of contents—adult treatment guidelines
A1—ADULT PATIENT CARE............................................................................................................... 3
A2—CHEST PAIN—SUSPECTED ACUTE CORONARY SYNDROME/STEMI..................4–5
A3—CARDIAC ARREST—INITIAL CARE AND CPR............................................................... 6–7
A4—VENTRICULAR FIBRILLATION— PULSELESS VENTRICULAR TACH.......................8–9
A5—PULSELESS ELECTRICAL ACTIVITY/ASYSTOLE........................................................ 10–11
A6—SYMPTOMATIC BRADYCARDIA.................................................................................. 12–13
A7—VENTRICULAR TACHYCARDIA WITH PULSES......................................................... 14–15
A8—SUPRAVENTRICULAR TACHYCARDIA....................................................................... 16–17
A9—OTHER CARDIAC DYSRHYTHMIAS........................................................................... 18–19
A10—SHOCK/HYPOVOLEMIA..............................................................................................20–21
A11—POST-CARDIAC ARREST CARE....................................................................................22–23
A12—PUBLIC SAFETY DEFIBRILLATION BLS/LAW ENFORCEMENT..........................24–25
§1
Adult Treatment Guidelines
Adult Treatment Guidelines
2§
A1–ADULT
ADULT PATIENT CARE
These basic concepts should be addressed for all adult patients (age 15 and over)
SCENE SAFETY
BSI
Use universal blood and body fluid precautions at all times
DETERMINE
PRIMARY
IMPRESSION
• Apply appropriate field treatment guideline(s)
• Explain procedures to patient and family as appropriate
SYSTEMATIC
ASSESSMENT
BASE
CONTACT
TRANSPORT
MONITORING
DOCUMENT
• Assure open and adequate airway. Management of ABCs
is a priority.
• Place patient in position of comfort unless condition
mandates other position (e.g. shock, coma)
• Consider spinal motion restriction if history or possibility
of traumatic injury exists
• Contact base hospital if any questions arise concerning
treatment or if additional medication beyond dosages
listed in treatment guidelines are considered
• Use SBAR to communicate with base
• Minimize scene time in critical trauma, STEMI, stroke,
shock, and respiratory failure
• Transport patient medications or current list of patient
medications to the hospital
• Give report to receiving facility using SBAR
• At a minimum, vital signs and level of consciousness
should be re-assessed every 15 minutes and should
be assessed after every medication administration or
following any major change in the patient’s condition
• For critical patients, more frequent vital signs should be
obtained when appropriate
Document patient assessment and care per policy
Adult Treatment Guidelines
§3
CHEST PAIN—SUSPECTED ACUTE
CORONARY SYNDROME/STEMI
A2–ADULT
OXYGEN
CARDIAC
MONITOR
ASPIRIN
12 – LEAD ECG
IV
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
325 mg po to be chewed by patient—DO NOT administer if
patient has allergies to aspirin or salicylates or has apparent
active gastrointestinal bleeding
Repeat ECGs are encouraged. Continue 12-lead monitoring.
TKO
If ECG Does Not Indicate Acute MI or STEMI
NITROGLYCERIN 0.4 mg sublingual or spray—May repeat every 5 minutes
until pain subsides, maximum 3 doses. Contact base
hospital if further dosages indicated. IV placement prior to
NTG recommended for patients who have not taken NTG
previously.
PRECAUTIONS: Do not administer NTG if:
• Blood pressure below 90 systolic;
• Heart rate below 50;
• Patient has recently taken erectile dysfunction (ED) drugs:
• Viagra, Levitra, Staxyn or Stendra within 24 hours, or
Cialis within 36 hours
Consider
FLUID BOLUS
500 ml NS if BP less than 90, lungs clear and unresponsive to
supine positioning with legs elevated. May repeat X 1
Consider
FENTANYL
50–200 mcg IV titrated in 25–50 mcg increments (consider
25 mcg increments in elderly patients). Consider earlier
administration to patients in severe distress from pain.
Titrate to pain relief, systolic BP greater than 90, and
adequate respiratory effort
4§
Adult Treatment Guidelines
A2–ADULT
CHEST PAIN—SUSPECTED ACUTE
CORONARY SYNDROME/STEMI
Acute MI / STEMI Noted by 12-Lead ECG
NITROGLYCERIN Do not administer Nitroglycerin if Acute MI/STEMI noted on
12-lead ECG.
Exception: Patients with suspected pulmonary edema
and STEMI should receive nitroglycerin if no other
contraindications (e.g. hypotension, bradycardia or use of
erectile dysfunction drugs)
STEMI ALERT
EARLY
TRANSPORT
FLUID BOLUS
Consider
FENTANYL
Transmit ECG to STEMI Center and contact as soon as possible
to notify facility of transport. Enter patient identifiers prior to
transmission
Minimize scene time
• 500 ml NS for Inferior MI (elevation in leads II, III, aVF) if
lungs clear (regardless of blood pressure)
• 500 ml NS if BP less than 90, lungs clear and unresponsive
to positioning. May repeat up to 3 times
50–200 mcg IV in 25–50 mcg increments (consider 25 mcg
increments in elderly patients). Consider earlier administration
to patients in severe distress from pain. Titrate to pain relief,
systolic BP greater than 90, and adequate respiratory effort.
Caution: If Inferior MI suspected, use 25-50 mcg increments
and observe carefully for hypotension
Key Treatment Consider ations
• Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw,
left shoulder or arm, nausea, diaphoresis, dyspnea (shortness of breath), anxiety
• Diabetic, female or elderly patients more frequently present atypically
• Atypical symptoms can include syncope, weakness or sudden onset fatigue
• Many STEMIs evolve during prehospital period and are not noted on initial
12-lead ECG
• ECG should be obtained prior to treatment for bradycardia if condition permits
• Transmit all 12-lead ECGs—whether STEMI is detected or not detected
§5
Adult Treatment Guidelines
A3–ADULT CARDIAC ARREST—INITIAL CARE AND CPR
ESTABLISH
TEAM LEADER
CONFIRM
ARREST
• First agency on scene assumes leadership role
• Leadership role can be transferred as additional
personnel arrive
• Unresponsive, no breathing or agonal respirations, no
pulse
COMPRESSIONS Begin Compressions:
• Rate —100–120 per minute. Use metronome
• Depth—2 inches in adults—allow full recoil of chest (lift
heel of hand)
• Rotate compressors every 2 minutes if manual
compression used
Minimize interruptions. If necessary to interrupt, limit to 10
seconds or less
• Perform CPR during charging of defibrillator
• Resume CPR immediately after shock (do not stop for
pulse or rhythm check)
Prepare mechanical compression device (if available)
• Apply with minimal interruption
• Should be placed following completion of at least one
2-minute manual CPR cycle or at end of subsequent cycle
AED or
• Apply pads while compressions in progress
MONITOR/
• Monitor/defibrillator should be in paddle mode
DEFIBRILLATOR
during resuscitation
• Determine rhythm and shock, if indicated
• Check rhythm every 2 minutes
• Follow specific treatment guideline based on rhythm
6§
Adult Treatment Guidelines
A3–ADULT CARDIAC ARREST—INITIAL CARE AND CPR
BASIC AIRWAY •  Open airway and provide 2 breaths after every 30 compressions
MANAGEMENT • Avoid excessive ventilation—no more than 8–10 ventilations
per minute
& VENTILATION
• Ventilations should be about 1 second each, enough to cause
visible chest rise
• Use two-person BLS Airway management (one holding mask
and one squeezing bag)
• If available, use ResQPOD with two-person BLS airway
management
IV/IO ACCESS • Intraosseous or antecubital IV are preferred sites for vascular
access
• Hand veins and other smaller veins should not be used in
cardiac arrest
ADVANCED • Placement of advanced airway is not a priority during the first
5 minutes of resuscitation unless NO ventilation is occurring
AIRWAY
with basic maneuvers
• Exception: If ResQPOD used, early use of King Airway is
appropriate
• Placement of King Airway or endotracheal tube should not
interrupt compressions for more than 10 seconds
• For endotracheal intubation, position and visualize airway
prior to cessation of CPR for tube passage. Immediately resume
compressions after tube passage
• Confirm tube placement and provide on-going monitoring
using end-tidal carbon dioxide monitoring
TREATMENT • Movement of a patient may interrupt CPR or prevent adequate
depth and rate of compressions, which may be detrimental to
ON SCENE
patient outcome
•  Provide resuscitative efforts on scene up to 30 minutes to maximize
chances of return of spontaneous circulation (ROSC)
• If resuscitation does not attain ROSC, consider cessation of
efforts per policy
§7
Adult Treatment Guidelines
A4–ADULT
VENTRICULAR FIBRILLATION—
PULSELESS VENTRICULAR TACHYCARDIA
INITIAL CARE
See Cardiac Arrest—Initial Care and CPR (A3)
CPR
For 2 minutes or 5 cycles between rhythm check
IO or IV
TKO. Should not delay shock or interrupt CPR
EPINEPHRINE
1:10,000—1 mg IV or IO every 3–5 minutes
DEFIBRILLATION 200 joules
VENTILATION/ • BLS airway is preferred method during first 5–6 minutes of CPR
AIRWAY
• If no visible chest rise occurring with basic maneuvers,
proceed to advanced airway
DEFIBRILLATION 300 joules
DEFIBRILLATION 360 joules
AMIODARONE 300 mg IV or IO
DEFIBRILLATION 360 joules as indicated after every CPR cycle
ADVANCED
AIRWAY
• Should not interfere with initial 5–6 minutes of CPR—
minimize interruptions
• Do not interrupt compressions more than 10 seconds to
obtain airway
Consider
If rhythm persists, 150 mg IV or IO, 3–5 minutes after
repeat
initial dose
AMIODARONE
TRANSPORT
Consider
SODIUM
BICARBONATE
If indicated. If return of spontaneous circulation (ROSC),
patient should be transported to a STEMI center. Patients
without ROSC who merit transport should be transported to
closest facility
1 mEq/kg IV or IO for suspected hyperkalemia or pre-existing
acidosis
If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)
8§
Adult Treatment Guidelines
A4–ADULT
VENTRICULAR FIBRILLATION—
PULSELESS VENTRICULAR TACHYCARDIA
Key Treatment Consider ations
• Uninterrupted CPR and timely defibrillations are the keys to successful
resuscitation. Their performance takes precedence over advanced airway
management and administration of medications
• To minimize CPR interruptions, perform CPR during charging, and
immediately resume CPR after shock administered (no pulse or rhythm
check)
• Rotate compressors every 2 minutes
• Avoid excessive ventilation. Provide no more than 8–10 ventilations per minute.
• Ventilations should be about one second each, enough to cause visible
chest rise
• If advanced airway placed, perform CPR continuously without pauses for
ventilation
• If available, ResQPOD impedance threshold device may be used with BLS
airway or King / ET tube
• If utilizing Endotracheal Tube, minimize CPR interruptions by positioning
airway and laryngoscope, and performing airway visualization prior to
cessation of CPR for tube passage. Immediately resume CPR after passage
• Confirm placement of advanced airway (King Airway or ET tube) with
end-tidal carbon dioxide measurement. Continuous monitoring with
ETCO2 is mandatory—if values less than 10 mm Hg seen, assess quality
of compressions for adequate rate and depth. Rapid rise in ETCO2 may be
the earliest indicator of return of circulation
• Prepare drugs before rhythm check and administer during CPR
• Follow each drug with 20 ml NS flush
• Fingerstick glucose determinations are unreliable during cardiac
arrest. Glucose checks should be reserved for patients with return of
spontaneous circulation
• Transmit “ALL” data to the monitor site identified by your provider agency
§9
Adult Treatment Guidelines
A5–ADULT
PULSELESS ELECTRICAL ACTIVITY/
ASYSTOLE
INITIAL CARE
See Cardiac Arrest—initial care and CPR (A3)
EPINEPHRINE
1:10,000 1 mg IV or IO every 3–5 minutes
Consider Treatable Causes-treat if Applicable:
Consider FLUID
BOLUS
VENTILATION
Consider SODIUM
BICARBONATE
Consider CALCIUM
CHLORIDE
Consider WARMING
MEASURES
Consider
NEEDLE
THORACOSTOMY
For hypovolemia: 500–1000 ml NS IV or IO
For hypoxia: Ensure adequate ventilation (8–10 breaths
per minute)
For pre-existing acidosis (e.g. kidney failure),
hyperkalemia, or tricyclic antidepressant overdose are
suspected:
• 1 mEq/kg IV or IO if indicated
• Should not be used routinely in cardiac arrest
For hyperkalemia or calcium channel blocker
overdose:
• 500 mg IV or IO—may repeat in 5–10 minutes
• Should not be used routinely in cardiac arrest
For hypothermia
For tension pneumothorax
If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)
10§
Adult Treatment Guidelines
A5–ADULT
Consider
TERMINATION OF
RESUSCITATION
TRANSPORT
PULSELESS ELECTRICAL ACTIVITY/
ASYSTOLE
Patients who have all of the following criteria are
highly unlikely to survive:
• Unwitnessed Arrest and;
• No bystander CPR and;
• No shockable rhythm seen and no shocks delivered
during resuscitation and;
• No return of spontaneous circulation (ROSC) during
resuscitation
Patients with asystole or PEA whose arrests are
witnessed and/or who have had bystander CPR
administered have a slightly higher likelihood of
survival. If unresponsive to interventions these patients
should be considered for termination of resuscitation.
Note: These criteria should not be applied if profound
hypothermia is present.
If indicated. If return of spontaneous circulation
(ROSC), patient should be transported to a STEMI
Center. Patients without ROSC who merit transport
should be transported to closest facility.
Key Treatment Consider ations
• Atropine is no longer used in cardiac arrest
• Pre-existing acidosis or hyperkalemia should be suspected in patients with
renal failure or dialysis or if suspected diabetic ketoacidosis
• In clear-cut traumatic arrest situations, epinephrine is not indicated in PEA
or asystole. If any doubt as to cause of arrest, treat as a non-traumatic
arrest (e.g. solo motor vehicle accident at low speed in older patients).
• Fingerstick glucose determinations are unreliable during cardiac
arrest. Glucose checks should be reserved for patients with return of
spontaneous circulation.
• Transmit “ALL” data to the monitor site identified by your provider agency
§11
Adult Treatment Guidelines
A6–ADULT
SYMPTOMATIC BRADYCARDIA
Heart rate less than 50 with signs or symptoms of poor perfusion (e.g., acute
altered mental status, hypotension, other signs of shock). Correction of hypoxia
should be addressed prior to other treatments.
OXYGEN
CARDIAC MONITOR
12-LEAD ECG
IV
Consider FLUID
BOLUS
BLS: High flow initially
ALS: Titrate to SpO2 of at least 94%
TKO. If not promptly available, proceed to external
cardiac pacing. Consider IO ACCESS if patient in extremis
and unconscious or not responsive to painful stimuli.
250–500 ml NS if clear lung sounds and no respiratory distress
TRANSCUTANEOUS
PACING
Set rate at 80. Start at 10 mA, and increase in 10 mA
increments until capture is achieved
Consider ATROPINE
May be used as a temporary measure while awaiting
transcutaneous pacing but should not delay initiation of pacing
Consider SEDATION
TRANSPORT
If pacing urgently needed, sedate after pacing initiated
• MIDAZOLAM—initial dose 1 mg IV or IO, titrated in
1–2 mg increments (maximum dose 5 mg), and/or
• FENTANYL 25–100 mcg IV or IO in 25–50 mcg
increments for pain relief if BP 90 systolic or greater
• 0.5 mg IV or IO if availability of pacing delayed or
pacing ineffective
• Consider repeat 0.5 mg IV or IO every 3–5 minutes
to maximum of 3 mg
Use with caution in patients with suspected ongoing
cardiac ischemia
Atropine should not be used in wide-QRS second—and
third-degree blocks
Related guideline: Chest Pain/Suspected ACS/STEMI (A2)
12§
Adult Treatment Guidelines
A6–ADULT
SYMPTOMATIC BRADYCARDIA
Key Treatment Consider ations
• Sinus bradycardia in the absence of key symptoms requires no specific
treatment (monitor/observe)
• Sinus bradycardia is often seen in patients with STEMI or ischemia. Early
12-lead ECG should be obtained to assess for STEMI
• Fluid bolus may address hypotension and lessen need for pacing or
treatment with atropine
• Sedation prior to starting pacing is not required. Patients with urgent
need should be paced first
• The objective of sedation in pacing is to decrease discomfort, not to
decrease level of consciousness. Patients who are in need of pacing are
unstable and sedation should be done with great caution
• Monitor respiratory status closely and support ventilation as needed
• Atropine is not effective for bradycardia in heart-transplant patients (no
vagus nerve innervation in these patients)
• Patients with wide-QRS second–and third–degree blocks will not have
a response to atropine because these heart rates are not based on vagal
tone. An increase in ventricular arrhythmias may occur
§13
Adult Treatment Guidelines
A7–ADULT
VENTRICULAR TACHYCARDIA
WITH PULSES
Widened QRS Complex (greater than or equal to 0.12 sec)—generally regular rhythm
Initial Ther apy
OXYGEN
CARDIAC MONITOR
12-LEAD ECG
IV
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
12–lead ECG pre-and post-treatment may be useful
for comparisons at hospital. The computerized rhythm
analysis on 12-lead printout should not be used for
determination of rhythm.
TKO
STABLE VENTRICULAR TACHYCARDIA
AMIODARONE
Consider Repeat
AMIODARONE
150 mg IV over 10 minutes (intermittent IV push or IV
infusion of 15 mg/min)
If rhythm persists and patient remains stable, 150 mg
IV over 10 minutes
UNSTABLE VENTRICULAR TACHYCARDIA
Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF
Consider
SEDATION
SYNCHRONIZED
CARDIOVERSION
Prepare for CARDIOVERSION: If awake and aware,
sedate with MIDAZOLAM—initial dose 1 mg IV, titrate
in 1–2 mg increments (max. dose 5 mg)
100 joules
200 joules
300 joules
360 joules
If VT recurs, use lowest energy level previously successful
14§
Adult Treatment Guidelines
A7–ADULT
VENTRICULAR TACHYCARDIA
WITH PULSES
Key Treatment Consider ations
• Document rhythm during treatment with continuous strip recording
• Rhythm analysis should be based on recorded strip, not monitor screen
• Be prepared for previously stable patient to become unstable
• Give AMIODARONE via Infusion or slow IV push only
• Caution with administration of AMIODARONE. May cause hypotension,
especially if given rapidly.
• AMIODARONE should not be used in unstable patients. Patients with
pre-existing hypotension should be considered unstable and should not
receive AMIODARONE.
• If sedation done for cardioversion, monitor respiratory status closely and
support ventilations as needed
§15
Adult Treatment Guidelines
A8–ADULT
SUPRAVENTRICULAR TACHYCARDIA
Heart rate greater than 150 beats per minute—regular rhythm usually with
narrow QRS complex
Initial Ther apy
OXYGEN
CARDIAC MONITOR
12-LEAD ECG
IV
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
12-lead ECG pre-and post-treatment may be useful for
comparisons at hospital. The computerized rhythm
analysis on 12-lead printout should not be used for
determination of rhythm.
TKO—Antecubital IV needed for rapid medication
administration
Stable Supr aventricular Tachycardia (SVT)
May have mild chest discomfort
VALSALVA
Consider
ADENOSINE
6 mg rapid IV—followed by 20 ml normal saline flush
If not converted, 12 mg rapid IV 1–2 minutes after
initial dose, followed by 20 ml normal saline flush
16§
Adult Treatment Guidelines
A8–ADULT
Unstable SVT
SUPRAVENTRICULAR TACHYCARDIA
• May need immediate synchronized cardioversion
• Signs of poor perfusion include moderate to severe chest pain, dyspnea,
altered mental status, blood pressure less than 90 or CHF
• If rhythm not regular, SVT unlikely
• If wide QRS complex, consider ventricular tachycardia
Consider
ADENOSINE
Consider SEDATION
SYNCHRONIZED
CARDIOVERSION
6 mg rapid IV—followed by 20 ml normal saline flush
If not converted, 12 mg rapid IV 1–2 minutes after
initial dose, followed by 20 ml normal saline flush
Prepare for CARDIOVERSION. If awake and aware,
sedate with MIDAZOLAM—initial dose 1 mg IV, titrate
in 1–2 mg increments (max. dose 5 mg)
100 joules
200 joules
300 joules
360 joules
Key Treatment Consider ations
• Document rhythm during treatment with continuous strip recording
• Rhythm analysis should be based on review of P and QRS waves on printed
strip, not monitor screen or computerized readout of 12-lead ECG
• Be prepared for previously stable patient to become unstable
• Proceed to cardioversion if patient becomes unstable
• Hypoxemia is a common cause of tachycardia. Initial evaluation should
focus on determining if oxygenation is adequate.
• Adenosine should not be administered to patients with acute
exacerbation of asthma
• If sedation used for cardioversion, monitor respiratory status closely and
support ventilation as needed
§17
Adult Treatment Guidelines
A9–ADULT
OTHER CARDIAC DYSRHYTHMIAS
SINUS TACHYCARDIA—Heart rate 100–160, regular
ATRIAL FIBRILLATION—Heart rate highly variable, irregular
ATRIAL FLUTTER—Variable rate depending on block. Atrial rate 250–350, “sawtooth” pattern.
Initial Ther apy
OXYGEN
CARDIAC MONITOR
Consider
12-LEAD ECG
Consider IV
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
12-lead ECG pre-and post-treatment may be useful for
comparisons at hospital. The computerized rhythm
analysis on 12-lead printout should not be used for
determination of rhythm
TKO
Unstable Atrial Fibrillation Or Atrial Flutter
Ventricular rate greater than 150, and BP less than 80, or unconsciousness/
obtundation, or severe chest pain or severe dyspnea
OXYGEN
Consider
SEDATION
SYNCHRONIZED
CARDIOVERSION
High flow. Be prepared to support ventilation.
Prepare for CARDIOVERSION. If awake and aware,
sedate with MIDAZOLAM—initial dose 1 mg IV, titrate
in 1–2 mg increments (max. dose 5 mg)
Atrial Flutter:
• Initial: 100 joules
• Subsequent: 200, 300, 360 joules
Atrial Fibrillation:
• Initial: 200 joules
• Subsequent: 300, 360 joules
18§
Adult Treatment Guidelines
A9–ADULT
OTHER CARDIAC DYSRHYTHMIAS
Key Treatment Consider ations
• Sinus tachycardia commonly present because of pain, fever, anemia, or
hypovolemia
• Atrial fibrillation may be well-tolerated with moderately rapid rates
(150–170) and often requires no specific treatment other than observation
(oxygen, monitoring and transport)
• If sedation used for cardioversion, monitor respiratory status closely and
support ventilation as needed
• Rhythm analysis should be based on review of P and QRS waves on printed
strip, not monitor screen or computerized readout of 12-lead ECG
• Computerized analysis for Acute MI (STEMI) may be incorrect with very
fast rhythms. If ***Acute MI Suspected*** or ***Meets ST-Elevation MI
Criteria*** message encountered, the patient’s heart rate is important
information to relate to the STEMI center at time of activation.
§19
Adult Treatment Guidelines
A10–ADULT
SHOCK/HYPOVOLEMIA
HYPOVOLEMIC OR SEPTIC SHOCK—Signs and symptoms of shock
with dry lungs, flat neck veins
• May have poor skin turgor, history of GI bleeding, vomiting or diarrhea,
altered level of consciousness
• May be warm and flushed, febrile, may have respiratory distress
• Sepsis patients may or may not have an associated fever
CARDIOGENIC SHOCK—Signs/symptoms of shock, history of CHF, chest pain,
rales, shortness of breath, pedal edema
HYPOVOLEMIA WITHOUT SHOCK—No signs of shock, but history of poor fluid
intake or fluid loss (e.g. vomiting, diarrhea).
• May have tachycardia, poor skin turgor.
OXYGEN
Consider CPAP
BLS/ALS: High flow. Be prepared to support ventilations
as needed
If suspected pulmonary edema/cardiogenic shock
ADDRESS
HYPOTHERMIA
Keep patient warm if suspected hypothermia
EARLY TRANSPORT
CODE 3
CARDIAC MONITOR
Treat dysrhythmias per specific treatment guideline
IV or IO
TKO only if suspected pulmonary edema
FLUID BOLUS
• For hypovolemic or septic shock, 500 ml NS bolus.
May repeat once.
• For hypovolemia (poor intake/fluid loss), 250 ml NS
bolus. May repeat once.
Do not administer bolus if pulmonary edema or
cardiogenic shock suspected
20§
Adult Treatment Guidelines
A10–ADULT
Consider 12-LEAD
ECG
SEPSIS SCREEN
BLOOD GLUCOSE
SHOCK/HYPOVOLEMIA
If cardiac etiology for shock suspected
Check temperature, use sepsis screening tool and
advise hospital of positive sepsis screen if indicated
A positive sepsis screen in adults occurs in the setting
of suspected infection when 2 of 3 conditions are met:
• Heart rate/pulse greater than 90;
• Respiratory rate greater than 20;
• Temperature above 100.4 or below 96
Check and treat if indicated
Related guidelines: Altered level of consciousness (G2), Respiratory Depression or
apnea (G12)
§21
Adult Treatment Guidelines
A11–ADULT
POST-CARDIAC ARREST CARE
Following resuscitation from cardiac arrest in adults
OXYGEN
END-TIDAL CO2
MONITORING
BLS: High flow initially
ALS: Titrate to SpO2 of at least 94%
Be prepared to support ventilations as needed.
Avoid excessive ventilation.
CARDIAC MONITOR
If intubated, monitor and maintain respirations to keep
ETCO2 between 35 and 40
Treat dysrhythmias per specific treatment guideline
TRANSPORT
Code 3 to STEMI Receiving Center
12-LEAD ECG
IV or IO
FLUID BOLUS
BLOOD GLUCOSE
Consider
THERAPEUTIC
HYPOTHERMIA
Evaluate for possible STEMI. Alert STEMI center if ECG
indicates ***ACUTE MI*** or equivalent STEMI message
If not previously established
For BP less than 90 systolic, begin infusion up to 1 liter
NS
Treat if indicated
See Indications and contraindications below:
Expose patient and apply eight (8) ice packs
• 2 on head, 2 on the neck over the carotid arteries,
1 on each axilla, 1 over each femoral artery
Discontinue ice packs if shivering occurs or increasing
level of consciousness.
Advise Emergency Department that hypothermia has
been initiated
22§
Adult Treatment Guidelines
A11–ADULT
POST-CARDIAC ARREST CARE
Ther apeutic Hypothermia—Indications And
Contr aindications
INDICATIONS
All the following must be present:
• Must be age 18 or greater
• Return of spontaneous circulation for at least five
minutes
• GCS < 8
• Unresponsive without purposeful movements.
Brainstem reflexes and posturing movements may
be present
• Blood pressure 90 systolic or greater
• Pulse oximetry–85% or greater
• Blood glucose–50 or greater
CONTRAINDICATIONS • Traumatic cardiac arrest
• Responsive post-arrest with GCS 8 or greater or
rapidly improving GCS
• Pregnancy
• DNR or known terminal illness
• Dialysis patient
• Uncontrolled bleeding
Consider and treat other potential causes of altered level of consciousness (e.g.
hypoxia or hypoglycemia)
Key Treatment Consider ations
• Transmit “ALL” data to the monitor site identified by your provider agency
§23
Adult Treatment Guidelines
A12-ADULT
PUBLIC SAFETY DEFIBRILLATION BLS/
LAW ENFORCEMENT
SCENE SAFETY/BSI
Use universal blood and body fluid precautions at all times
COMPRESSIONS
• Begin compressions at a rate of 100–120 per minute
• Compress chest at least 2 inches and allow full recoil of
chest (lift heel of hand)
• Change compressors every 2 minutes
• Minimize interruptions in compressions. If necessary to
interrupt, limit to 10 seconds or less.
• Stop compressions for analysis only—resume
compressions while AED is charging
• Resume compressions immediately after any shock
• If available, place mechanical compression device after
first rhythm analysis or after subsequent rhythm analysis
(LUCAS or Auto-Pulse)
CONFIRM
AUTOMATED
EXTERNAL
DEFIBRILLATOR
(AED)
Unconscious, pulseless patient with no breathing or no
normal breathing
• Priority of second rescuer is to apply pads while
compressions are in progress
• With infants and children, use pediatric pads if available.
Adult pads may be used with usual placement position
if pads do not touch. Adult pads may be placed anteriorposterior if usual placement would cause the pads to
touch.
• (*) Allow AED to analyze heart rhythm
• If the rhythm is shockable
• 
Resume compressions until charging of unit is
complete
• 
Clear bystanders and crew (stop compressions)
• 
Deliver shock
• 
Resume CPR for 2 minutes, beginning with chest
compressions—then return to (*)
• If the rhythm is NOT shockable (“No Shock Advised”)
• 
Resume CPR for 2 minutes, beginning with chest
compressions – then return to (*)
24§
Adult Treatment Guidelines
A12-ADULT
BASIC AIRWAY
MANAGEMENT
AND VENTILATION
PUBLIC SAFETY DEFIBRILLATION BLS/
LAW ENFORCEMENT
Open airway and provide 2 breaths after every 30
compressions
• avoid excessive ventilation—Provide no more than
8–10 ventilations per minute
• Ventilations should be about one second each, enough
to cause visible chest rise. Use two-person BLS Airway
management (one holding mask and one squeezing
bag—compressor can squeeze the bag)
CHECK BLOOD
PRESSURE
DOCUMENTATION
If patient begins to breathe or becomes responsive:
• Maintain airway
• Assist ventilations as necessary
If patient begins to breathe or becomes responsive:
• Check blood pressure if equipment available
• Complete AED Use Report
• Forward report to EMS whenever an AED is used (whether
shock administered or not)
• Upload AED data for EMS review if upload capability
available
§25
Adult Treatment Guidelines
26§
table of contents—general treatment guidelines
 G1–ANAPHYLAXIS/ALLERGY.................................................................................................28–29
G2–ALTERED LEVEL OF CONSCIOUSNESS........................................................................30–31
G3–BEHAVIORAL EMERGENCY........................................................................................... 32–33
G4–BURNS..................................................................................................................................34–35
G5–CHILDBIRTH—ROUTINE OR COMPLICATED............................................................36–37
G6–DYSTONIC REACTIONS.......................................................................................................... 38
G7–ENVENOMATIONS (BITES, STINGS)................................................................................... 39
G8–HEAT ILLNESS/HYPERTHERMIA...................................................................................40–41
G9–HYPOTHERMIA..................................................................................................................42–43
G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC)........................................ 44–45
G11–POISONING—OVERDOSE............................................................................................ 46–48
G12–RESPIRATORY DEPRESSION OR APNEA.....................................................................50–51
G13–RESPIRATORY DISTRESS.................................................................................................52–53
G14–SEIZURE/STATUS EPILEPTICUS................................................................................... 54–55
G15–STROKE................................................................................................................................56–57
G16–TRAUMA—GENERAL.................................................................................................... 58–59
G16–TRAUMA—HEAD INJURY.................................................................................................... 60
G16–TRAUMA—EXTREMITY.........................................................................................................61
G17–VOMITING AND SEVERE NAUSEA..............................................................................62–63
G18–INTERFACILITY TRANSFER OF STEMI PATIENTS........................................................... 64
G19–INTERFACILITY TRANSFER OF INTUBATED PATIENTS................................................ 65
G20–INTERFACILITY TRANSFER OF STROKE PATIENTS............................................... 66–67
§27
General Treatment Guidelines
G1–GENERAL
ANAPHYLAXIS/ALLERGY
• Systemic reactions (anaphylaxis) include upper and lower respiratory tracts,
gastrointestinal or vascular system. Symptoms include dyspnea, stridor, change
in voice, wheezing, anxiety, tachycardia, tightness in chest, vomiting, diarrhea,
abdominal pain, dizziness or hypotension
•  Serious systemic reactions may involve hypotension alone without respiratory or skin findings
• Skin and mucous membrane reactions (swelling of face, lip, tongue, palate), may be
seen in either uncomplicated allergic reactions or in anaphylaxis
OXYGEN
EPI-PEN
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
May assist with administration of patient’s auto-injector
CARDIAC MONITOR
If systemic reaction (anaphylaxis):
EPINEPHRINE 1:1000 • Adult—0.3–0.5 mg IM (use 0.3 mg in elderly, small
patients or mild symptoms)
IM
ALBUTEROL
IV
Consider
FLUID BOLUS
 Pediatric—0.01 mg/kg IM—maximum dose 0.3 mg
May repeat in 15 minutes if systemic symptoms persist.
Lateral thigh site should be used for IM injection (fastest
absorption)
Adult and pediatric—5 mg/6 ml saline via nebulizer—may
repeat as needed
TKO
• Adult—wide-open NS if hypotensive. Recheck vitals after
every 250 ml
 Pediatric—20 ml/kg NS bolus if hypotensive, may repeat X 2
If skin or mucous membr ane reactions (itching, hives
or facial/or al swelling), consider:
DIPHENHYDRAMINE • Adult—50 mg slow IV or IM. Consider 25 mg dose if
patient has taken po diphenhydramine
 Pediatric—1 mg/kg IV or IM—Maximum dose 50
mg Consider 0.5 mg/kg dose if patient has taken po
diphenhydramine
28§
General Treatment Guidelines
G1–GENERAL
ANAPHYLAXIS/ALLERGY
If serious progression of symptoms after treatment
with IM epinephrine:
• Includes profound hypotension, absence of palpable pulses, unconsciousness,
cyanosis, severe respiratory distress or respiratory arrest
Consider IO
If IV access not immediately available
Consider
EPINEPHRINE
1:10,000 IV
If patient not responsive to IM epinephrine treatment
in 5–10 minutes:
• Adult—titrate in 0.1 mg doses slow IV or IO to a
maximum dose of 0.5 mg. Use extreme caution
with patients with cardiac history, angina,
hypertension
 Pediatric—titrate in up to 0.1 mg doses slow IV or IO
to a maximum of 0.01 mg/kg
FLUID BOLUS
• Adult—wide open NS. Recheck vitals after every 250 ml
 Pediatric—20 ml/kg NS bolus, may repeat X 2
Key Treatment Consider ations
• Epinephrine IM administered early is the cornerstone of treatment in anaphylaxis
• Epinephrine is well tolerated in pediatric patients and healthy young adults
• In patients with prior history of coronary artery disease (angina, MI, stent
placement), use of epinephrine IM is still indicated if symptoms are moderate
to severe. If symptoms mild, careful observation is prudent. Consider base
contact if any questions
• Diphenhydramine and albuterol are secondary considerations in anaphylaxis
• Up to 20% of anaphylaxis patients may present without any skin findings (e.g.
hives)
• Gastrointestinal symptoms may predominate in some patients, especially with
serious reactions to food
• In pediatric patients, hypotension is late sign of shock
 Use length-based tape for pediatric weight determination. See Pediatric Drug
Chart for dose.
§29
General Treatment Guidelines
G2–GENERAL
ALTERED LEVEL OF CONSCIOUSNESS
Glasgow Coma Scale less than 15 —uncertain etiology. Consider AEIOU/TIPPS
OXYGEN
ORAL GLUCOSE
CARDIAC MONITOR
BLS: High flow initially.
ALS: Titrate to SpO2 of at least 94%.
Be prepared to support ventilations as needed.
Consider if known diabetic, conscious, able to sit upright, able to
self-administer
•  Adult—30 g po
 Pediatric—15–30 g po
BLOOD GLUCOSE
Check level
IV
TKO
EARLY TRANSPORT
In patients with ALOC without low blood sugar
DEXTROSE 10%
If glucose 60 or less:
• Adult—DEXTROSE 10% 100 ml IV
 Pediatric—DEXTROSE 10% 0.5 g/kg IV (5 ml/kg) —
maximum initial dose 10g (100 ml)
GLUCAGON
BLOOD GLUCOSE
DEXTROSE 10%
If unable to establish IV (at least 2 attempts or if unable to find
suitable site):
• Adult—1 mg IM
 Pediatric—24 kg or more–1 mg IM
 Pediatric—Less than 24 kg–0.5 mg IM
Recheck if symptoms not resolved. If GLUCAGON has been
administered, change in glucose/mentation may require 15
minutes or more.
Give additional DEXTROSE 10% 150 ml IV if glucose remains
60 or less.
 Pediatric—Give additional DEXTROSE 10% in 50 ml
increments to total 150 ml if Glucose remains 60 or less
Related guideline: Respiratory Depression or Apnea (G12)
30§
General Treatment Guidelines
G2–GENERAL
ALTERED LEVEL OF CONSCIOUSNESS
Key Treatment Consider ations
•  Naloxone should not be given as treatment for altered level of consciousness in the absence of
respiratory depression (respiratory depression = rate of less than 12 breaths per minute)
•  After treatment(s) for hypoglycemia, recheck glucose before considering repeat treatment
•  Mental status improvement may lag behind improved glucose levels (especially in elderly
patients or prolonged hypoglycemia). Further treatment when glucose is 60 or above is not
indicated
•  Oral glucose is the preferred treatment when patient is able to take medication orally
•  Dextrose 10% is the preferred treatment when patient is unable to take oral medication
•  Glucagon should not be administered if patient is able to take oral glucose and should be
administered only if IV starts are unsuccessful or no suitable IV sites found. It may not be
effective in patients with starvation, poor oral intake, alcoholism or alcohol intoxication
•  Glucagon may take 10–15 minutes or longer to increase glucose level (peak effects in 45–60
minutes)
•  Wait for 10–15 minutes and recheck glucose before considering additional treatment
•  For diabetics with insulin pumps, the amount of insulin administered by the pump is very small
and should not impede treatment of hypoglycemia. Insulin pumps should not be discontinued
because of the development of hypoglycemia
•  The presence of the pump should be identified during patient report at the hospital
•  Transport is highly recommended in patients with hypoglycemia as a result of oral diabetic
medications and patients over 65 years of age (higher risk of recurrent hypoglycemia)
•  Transport is also highly recommended for any hypoglycemic patient who is not a diabetic
(may occur with renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders,
aspirin overdoses and sulfa drugs or following bariatric surgery)
•  Consider transport earlier in patients with poor vascular access who are not responding to
glucagon or have reasons listed above for possible impaired response to glucagon
 Use length-based tape for pediatric weight determination.
See Pediatric Drug Chart for D10 dose
§31
General Treatment Guidelines
G3–GENERAL
BEHAVIORAL EMERGENCY
• A behavioral emergency is defined as combative or irrational behavior not
caused by medical illnesses such as hypoxia, shock, hypoglycemia, head
trauma, drug withdrawal, intoxicated states or other conditions
• Combative or irrational behavior may be caused by psychiatric or other
behavioral disorder
• History of event and past history are important in patient evaluation
• Past history of psychiatric condition does not eliminate need to assess for
other illnesses
SCENE SAFETY
ASSESS PATIENT
VITAL SIGNS
Consider OXYGEN
CARDIAC MONITOR
Consider BLOOD
GLUCOSE
• Many patients merit a weapons search by law
enforcement
• Physical restraints may be needed if patient exhibits
behavior that presents a danger to him/herself or
others
• Assess for evidence of hypoxia, hypoglycemia,
trauma
• Consider other medical causes for behavioral
symptoms
Obtain vital signs as possible
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
Place as possible/safe
Obtain as possible/safe
32§
General Treatment Guidelines
G3–GENERAL
Consider CHEMICAL
RESTRAINT
MONITOR PATIENT
BEHAVIORAL EMERGENCY
Despite verbal de-escalation and physical restraint,
if adult patient (15 years or older) remains extremely
combative and struggling against restraints, consider:
• MIDAZOLAM 5 mg IM. Lower doses should be
considered in elderly or small patients (under 50 kg).
• MIDAZOLAM 1–3 IV mg in 1 mg increments if IV
established and patent. Contact base if further
medication needed.
Monitor closely for respiratory compromise. Assess and
document mental status, vital signs, and extremity
exams (if restrained) at least every 15 minutes.
Related guidelines: Altered Level of Consciousness (G2), Trauma (G16)
Key Treatment Consider ations
•  Calming measures may be effective and may preclude need for restraint in some
circumstances
•  Utilize a single person to establish rapport. Separate patient from crowd and seek quiet
environment if possible, but maintain contact with other personnel and ability to exit
rapidly.
•  Avoid violating patient’s personal space, making direct eye contact or sudden movements.
Frequent reassurance and calm demeanor of personnel are important.
•  Enlist assistance of law enforcement if restraint needed. Never transport patient in prone
position.
•  Assure adequate resources available to manage patient’s needs. Restraint may require up to
five persons to safely control patient.
•  Patients with past history of violent behavior are more likely to exhibit recurrent violent
behavior
•  In pediatric patients, consider child’s developmental level when providing care
•  Sedation with Midazolam intended for adult patients only (age 15 and over)
•  Not all patients will respond to Midazolam. Repeat dosage is not recommended—requires
base order.
§33
General Treatment Guidelines
G4–GENERAL
BURNS
• Damage to the skin caused by contact with caustic material, electricity, or fire
• Second or third degree burns involving 20% of the body surface area, or
those associated with respiratory involvement, are considered major burns
SCENE SAFETY
Move patient to safe area
OXYGEN
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
STOP BURNING
PROCESS
BURN CARE
ASSESS FOR
INJURIES
• Remove contact with agent, unless adhered to skin
• Brush off chemical powders
• Flush with water to stop burning process or to
decontaminate
Protect the burned area. Do not break blisters. Cover
with clean dressings or sheets. Remove restrictive
clothing/jewelry if possible.
Assess for associated injuries if other trauma suspected
Consider IV or IO
TKO
Consider
FENTANYL
Intranasal
If IV or IO access not available:
• Adult—100 mcg Intranasal—may repeat once in 15
minutes
 Pediatric—1.5 mcg/kg Intranasal—See Pediatric
Drug Chart
Consider
FENTANYL IV
For pain relief in the absence of hypotension (systolic BP
less than 90), significant other trauma, altered level of
consciousness:
• Adult—50–200 mcg IV or IO, titrated in 25–50 mcg
increments (consider 25 mg increments in elderly
patients).
 Pediatric—1 mcg/kg IV—See Pediatric Drug Chart
34§
General Treatment Guidelines
G4–GENERAL
Consider
FENTANYL IM
BURNS
If IV or IO access not available and intranasal route not
advisable:
• Adult—50–100 mcg IM—may repeat once in
15 minutes
 Pediatric —1 mcg/kg IM—See Pediatric Drug Chart
Key Treatment Consider ations
• Airway burns may lead to rapid compromise of airway (soot around nares,
mouth, visible burns or edematous mucosa in mouth are clues)
• Transport to closest receiving facility for advanced airway management if
it cannot be done on scene in a timely manner. Do not wait for helicopter
(air ambulance) if airway patency is a concern and care can be provided
more rapidly at a receiving facility
• Do not apply wet dressings, liquids or gels on burns. Cooling may lead to
hypothermia
• Refer to Rule of Nines to determine burn surface area (in Policy and
Hospital Reference section)
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose
§35
General Treatment Guidelines
G5–GENERAL
CHILDBIRTH—ROUTINE
IMMINENT DELIVERY—Regular contractions, bloody show, low back pain, feels
like bearing down, crowning
PREPARE FOR
DELIVERY
Consider IV
DELIVER INFANT
CLAMP/CUT CORD
WARMING
MEASURES
Reassure mother, instruct during delivery
TKO if time allows
• As head is delivered, apply gentle pressure to
prevent rapid delivery of the infant
• Gently suction baby’s mouth, then nose, keeping
the head dependent
• If cord is wrapped around neck and can’t be slipped
over the infant’s head, double-clamp and cut
between clamps
Immediately double-clamp cord 6–8 inches from baby
and cut between clamps (if not done before delivery)
Dry baby and keep warm, placing baby on mother’s
abdomen or breast
PLACENTA DELIVERY If placenta delivers, save it and bring to the hospital
with mother and child. DO NOT PULL ON UMBILICAL
CORD TO DELIVER PLACENTA
POST-DELIVERY
OBSERVATION
TRANSPORT
Observe mother and infant frequently for
complications. To decrease post-partum hemorrhage,
perform firm fundal massage, put baby to mother’s
breast.
Prepare mother and infant for transport. Neonatal care
or resuscitation as indicated.
36§
General Treatment Guidelines
G5–GENERAL
CHILDBIRTH—COMPLICATED
BREECH DELIVERY—Presentation of buttocks or feet
OXYGEN
DELIVERY
TRANSPORT
BLS/ALS: High flow
• Allow delivery to proceed passively until the baby’s
waist appears
• Rotate baby to face-down position (DO NOT PULL)
• If the head does not readily deliver in 4–6 minutes,
insert a gloved hand into the vagina to create an air
passage for the infant
Early transport if available—notify receiving hospital as
soon as possible
PROLAPSED CORD—Cord presents first and is
compressed, compromising infant circulation
OXYGEN
BLS/ALS: High flow
POSITION PATIENT
Place mother in trendelenburg position with hips
elevated
MANAGE CORD
TRANSPORT
• Insert gloved hand into vagina and gently push
presenting part off of the cord
• Do not attempt to reposition the cord
• Cover cord with saline soaked gauze
Early transport if available—notify receiving hospital as
soon as possible
§37
General Treatment Guidelines
G6–GENERAL
DYSTONIC REACTIONS
• History of ingestion of phenothiazine or related compounds, primarily antipsychotic and anti-emetic medications (for nausea/vomiting). Symptoms
include restlessness, muscle spasms of the neck, jaw, and back, oculogyric crisis.
Consider OXYGEN
IV
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
TKO
DIPHENHYDRAMINE • Adult— 25–50 mg IV or 50 mg IM if unable to
establish IV access
 Pediatric—1 mg/kg IV or 1 mg/kg IM if unable to
establish IV access
Key Treatment Consider ations
Common drugs implicated in dystonic reactions include many anti-emetics
and anti-psychotic medications:
• Prochlorperazine (Compazine)
• Haloperidol (Haldol)
• Metoclopromide (Reglan)
• Phenergan (Promethazine)
• Fluphenazine (Prolixin)
• Chlorpromazine (Thorazine)
• Many other antipsychotic and anti-depressant drugs
• Rarely benzodiazepine drugs have been implicated as a cause of
dystonic reaction
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
38§
General Treatment Guidelines
G7–GENERAL
ENVENOMATIONS (BITES, STINGS)
SNAKE BITES
• If the snake is positively identified as non-poisonous, treat with basic wound care
INSECT STINGS
• Symptoms of stings usually occur at the site of injury and have no specific
treatment
• Allergic reactions can be severe, and may cause anaphylactic shock
CALM PATIENT
With snake bite, keep patient still and calm
WOUND
MANAGEMENT
Snake bite: Splint extremity and keep at level of heart
ASSESS
EXTREMITIES
OXYGEN
CONSIDER CARDIAC
MONITOR
CONSIDER IV
Remove rings, bracelets or other constricting items
from affected extremity
Insect Stings: Flick stinger off—do not squeeze stinger.
Apply cold pack.
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%.
Be prepared to support ventilation.
Consider if patient potentially unstable
TKO
Related guidelines: Shock/Hypovolemia (A10, P9), Anaphylaxis/Allergy (G1)
§39
General Treatment Guidelines
G8–GENERAL
HEAT ILLNESS/HYPERTHERMIA
HEAT EXHAUSTION
• Presentation: Flu-like symptoms, cramps, normal mental status
HEAT STROKE
• Presentation: Altered level of consciousness, absence of sweating,
tachycardia, and hypotension
OXYGEN
COOLING
MEASURES
IV
Consider
FLUID BOLUS
Consider
BLOOD GLUCOSE
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
• Move patient to cool environment
• Promote cooling by fanning
• Remove clothing and splash/sponge with water
• Place cold packs on neck, in axillary and inguinal
areas
TKO. Perform if heat stroke or marked symptoms with
heat exhaustion
If hypotensive or suspected heat stroke:
• Adult—500 ml NS bolus May repeat X 1
 Pediatric—20 ml/kg NS bolus. May repeat X 1
Check level if altered level of consciousness, treat as
indicated
40§
General Treatment Guidelines
G8–GENERAL
HEAT ILLNESS/HYPERTHERMIA
Related guidelines: Altered Level of Consciousness (G2), Seizure (G14)
Key Treatment Consider ations
• Seizures may occur with heat stroke—treat as per treatment guideline for
seizure
• Increasing symptoms merit more aggressive cooling measures. With mild
symptoms of heat exhaustion, movement to cooler environment and
fanning may suffice.
• Conditions that may lead to or worsen hyperthermia include:
• Psychiatric Disorders
• Heart Disease
• Diabetes
• Alcohol
• Medications
• Fever
• Fatigue
• Obesity
• Pre-existent dehydration
• Extremes of age (Elderly and pediatric)
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
§41
General Treatment Guidelines
G9–GENERAL
HYPOTHERMIA
MODERATE HYPOTHERMIA
• Conscious and shivering but lethargic, skin pale and cold
SEVERE HYPOTHERMIA
• Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to
absent respirations
• Severe hypothermia patients may appear dead. When in doubt, begin
resuscitation.
OXYGEN
SPINAL
PRECAUTIONS
WARMING
MEASURES
CARDIAC MONITOR
BLS: Low flow unless ALOC/respiratory distress/shock.
ALS: Titrate to SpO2 of at least 94%
Use warm humidified oxygen if available
For patients with possible trauma or submersion
Gently move to sheltered area (warm environment)
Minimize physical exertion or movement of the patient
Cut away wet clothing and cover patient with warm,
dry sheets or blankets
Consider
EARLY TRANSPORT
Do not delay transport if patient unconscious
BLOOD GLUCOSE
Check and treat if indicated
IV
TKO
CONSIDER
NALOXONE
If respiratory rate less than 12 and narcotic overdose
suspected
CONSIDER
ADVANCED AIRWAY
Only if unable to ventilate using BVM
42§
General Treatment Guidelines
G9–GENERAL
HYPOTHERMIA
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or
Apnea (G12)
Key Treatment Consider ations
• Avoidance of excess stimuli is important in severe hypothermia as the
heart is sensitive and interventions may induce arrhythmias. Needed
interventions should be done as gently as possible.
• Check for pulselessness for 30–45 seconds to avoid unnecessary chest
compressions
• Defer ACLS medications until patient warmed
• If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present,
shock X 1 and defer further shocks
• Patients with prolonged hypoglycemia often become hypothermic—blood
glucose check is essential
• Patients with narcotic overdose may develop hypothermia
§43
General Treatment Guidelines
G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC)
• Patients of all ages expressing verbal or behavioral indicators of pain shall
have an appropriate assessment and management of pain
• Fentanyl should be given in sufficient amount to manage pain but not
necessarily to eliminate it
Consider
OXYGEN
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
IV
TKO
PAIN RELIEF
MEASURES
• Psychological measures and BLS measures,
including cold packs, repositioning, splinting,
elevation, and/or traction splints, are important
considerations for patients with pain
• If pain cannot be managed using above measures,
consider FENTANYL, especially in patients reporting
pain levels of 5 or greater
ASSESS PAIN
Consider
FENTANYL IV
Consider
FENTANYL
Intranasal
Consider
FENTANYL IM
• Assess and document the intensity of the pain using
the visual analog scale
• Reassess and document the intensity of the pain
after any intervention that could affect pain intensity
See contraindications and cautions on next page:
For pain relief:
• Adult—50–200 mcg IV, titrated in 25–50
mcg increments to pain relief (consider 25 mg
increments in elderly patients)
 Pediatric—1 mcg/kg IV—See Pediatric Drug Chart
If no IV access:
• Adult—100 mcg Intranasal. May repeat once in 15
minutes.
 Pediatric—1.5 mcg/kg Intranasal—See Pediatric
Drug Chart
If no IV access and intranasal route not suitable:
• Adult— 50–100 mcg IM. May repeat once in 15
minutes.
 Pediatric—1 mcg/kg IM—See Pediatric Drug Chart
44§
General Treatment Guidelines
G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC)
Contr aindications and Cautions for Fentanyl
CONTRAINDICATIONS FOR FENTANYL:
• Closed head injury
• Altered level of consciousness
• Headache
• Respiratory failure or worsening respiratory status
• Childbirth or suspected active labor
• Hypotension
• Adults—Systolic BP less than 90
• Pediatric—Hypotension or impaired perfusion (e.g. capillary refill > 2
seconds)
• 
Infants 1 mo–1 yr systolic—BP < 60 mmHg
• 
Toddler 1–4 yrs systolic—BP < 75 mmHg
• 
School age 5–13 yrs systolic—BP < 85 mmHg
• 
Adolescent >13 yrs systolic—BP < 90 mmHg
CAUTIONS FOR FENTANYL:
• Use with caution in patients with suspected hypovolemia
• Older patients may be more sensitive to Fentanyl—consider 25 mcg
increments IV initially
Key Treatment Consider ations
• Have Naloxone available to reverse respiratory depression should it occur
• Preferred route of administration for Fentanyl is IV
• Intranasal route is preferred if IV not available and patient does not have
suspected hypovolemia
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
§45
General Treatment Guidelines
G11–GENERAL
POISONING—OVERDOSE
• If possible, determine substance, amount ingested, time of ingestion.
Bring in container or label.
• Be careful not to contaminate yourself and others
DECONTAMINATION
OXYGEN
CARDIAC MONITOR
Consider IV
Remove contaminated clothing, brush off powders,
wash off liquids. Irrigate eyes if affected
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%.
Be prepared to support ventilation.
TKO if unstable patient or suspected serious ingestion
Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of
Consciousness (G2), Seizures (G14), Shock/Hypovolemia (A10, P8)
TRICYCLIC ANTIDEPRESSANT OVERDOSE
Frequently associated with respiratory depression, usually tachycardia. Widened
QRS complexes and associated ventricular dysrhythmias are generally signs of a
life-threatening ingestion.
SODIUM
BICARBONATE
For adults only: For life-threatening hemodynamically
significant dysrhythmias, 1 mEq/kg slow IV or IO
ORGANOPHOSPHATE POISONING
Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea,
muscle weakness, small/pinpoint pupils, muscle twitching, and/or seizures may
occur
ATROPINE
For adults only: 1–2 mg IV
• Repeat every 3–5 minutes as necessary until relief
of symptoms
• Large doses of Atropine may be required
46§
General Treatment Guidelines
G11–GENERAL
POISONING—OVERDOSE
HYDROFLUORIC ACID EXPOSURE
CALCIUM CHLORIDE For adults only: For tetany or cardiac arrest, 500mg IV
(5 ml of 10% solution)
Consider
FENTANYL IV
Consider
FENTANYL
Intranasal
Consider
FENTANYL IM
For adults only: In the absence of hypotension,
significant other trauma or altered level of
consciousness: 50–200 mcg IV, titrated in 25–50 mcg
increments to pain relief (consider 25 mg increments in
elderly patients)
For adults only: If no IV access, 100 mcg intranasal. May
repeat once in 15 minutes.
For adults only: If no IV access, 50–100 mcg IM. May
repeat once in 15 minutes
Key Treatment Consider ations
• Few overdoses have specific antidotes. Supportive care is the mainstay of
treatment
• Contact Base Hospital for other suspected overdoses that may have
specific treatment (e.g. Calcium Channel Blocker overdose)
 Contact Base Hospital if any questions concerning treatment of overdose
in pediatric patients
• Poison Control Center can offer information but cannot provide medical
direction to EMS
§47
General Treatment Guidelines
G11–GENERAL
POISONING—OVERDOSE
SUSPECTED CARBON MONOXIDE POISONING
• Symptoms may be diverse and often non-specific. Headache, dizziness,
fatigue and nausea are most common symptoms.
• Neurologic symptoms may include confusion, lethargy, drowsiness, agitation,
coma, syncope, seizure or bizarre neurologic symptoms.
• Other symptoms may include chest pain, palpitations, dyspnea, weakness, or
flu-like symptoms.
• Evaluate for CO poisoning in suspected smoke inhalation
• Suspect and evaluate in situations when multiple patients have symptoms
• Consider evaluation when other causes for symptoms are not obvious
OXYGEN
CARDIAC MONITOR
CO-OXIMETRY
12-LEAD ECG
Consider
BASE CONTACT
TRANSPORT
IV
BLS/ALS: High flow. Be prepared to support ventilations
as needed
Measure using manufacturer’s recommendation. May
be unreliable if low perfusion, excessive patient motion,
or excessive ambient light.
Contact base if patient has significant symptoms (e.g.,
altered level of consciousness, arrhythmia), has CO level
greater than 20% or if patient is pregnant to determine
appropriate destination.
TKO
Related Guidelines: Chest Pain/Suspected ACS (A2), Seizure (G14)
48§
General Treatment Guidelines
§49
General Treatment Guidelines
G12–GENERAL RESPIRATORY DEPRESSION OR APNEA
Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest
BVM VENTILATION
Assist ventilation or provide ventilation if no
spontaneous respirations
OXYGEN
BLS: High flow initially
ALS: Titrate to SpO2 of at least 94%.
Be prepared to support ventilations as needed
ETCO2
MONITORING
In borderline cases, non-invasive ETCO2 monitoring (when
available) may be valuable in detection of hypoventilation and can
help follow respiratory trend before and after treatment. ETCO2
monitoring is not reliable in patients with hypotension or poor
perfusion.
CARDIAC MONITOR
NALOXONE
INTRANASAL OR IM
• Adult not in shock: 2 mg IN (intranasal) if narcotic
overdose suspected
• Adult not in shock but unsuitable for IN (copious
secretions): 1–2 mg IM
 Pediatric—0.1 mg/kg IM—maximum dose 2 mg
Consider IV
TKO if intravenous treatment indicated
Repeat NALOXONE
IV or IM if no response and narcotic overdose suspected
—maximum dose 10 mg
NALOXONE IV
Consider TITRATION
OF DILUTED
NALOXONE IV
ADVANCED AIRWAY
If patient in shock, if IN or IM routes ineffective (within 3
minutes), or if IV access already available for another reason:
• Adult— 1–2 mg IV
 Pediatric—0.1 mg/kg IV—maximum dose 2 mg
Consider for patients with chronic narcotic use
for terminal disease or chronic pain: Dilute 1:10
with normal saline and administer in 0.1 mg (1 ml)
increments—titrate to increased respiratory rate
Consider when indicated—only if naloxone ineffective
and BVM ventilation not adequate
50§
General Treatment Guidelines
G12–GENERAL RESPIRATORY DEPRESSION OR APNEA
Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13)
Key Treatment Consider ations
SAFETY WARNING!
Naloxone will cause acute withdrawal symptoms in patients who are habituated
users of narcotics (whether prescribed or from abuse)
• Use of diluted Naloxone IV and titration with small increments may help
decrease adverse effects of naloxone in patients who have chronic narcotic
usage for terminal disease or pain relief
• Naloxone treatment should only be given to patients with respiratory
depression (rate less than 12)
• Patients who are maintaining adequate respirations with decreased level of
consciousness do not generally require Naloxone for management
• Naloxone can cause cardiovascular side effects (chest pain, pulmonary
edema) or seizures in a small number of patients (1–2%)
• Older patients are at higher risk for cardiovascular complications
• Be prepared for patient agitation or combativeness after naloxone reversal of
narcotic overdose
• In patients without hypotension or poor perfusion, ETCO2 readings
below 45 generally do not require treatment with naloxone for respiratory
depression. ETCO2 should be used to help monitor respiratory trend.
 Use length-based tape for pediatric weight determination. See Pediatric Drug
Chart for dose.
§51
General Treatment Guidelines
G13–GENERAL
RESPIRATORY DISTRESS
• Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema
• Rales may be present in pneumonia, pulmonary edema, and many other
conditions
INITIAL THER APY
OXYGEN
CARDIAC MONITOR
Consider CPAP
Consider IV
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
If respiratory rate greater than 25, accessory muscle
use, pulse ox less than 94%
TKO. Do not delay transport for vascular access if in
extremis.
ASTHMA
ALBUTEROL
Adult and Pediatric—5 mg in 6 ml NS via nebulizer.
Repeat as needed.
Consider
For use in asthma only: Use only if respiratory status
EPINEPHRINE 1:1000 deteriorating despite repeat treatment with Albuterol
SC (subcutaneously) and transport time more than 10 minutes
Do not use in patients with history of coronary artery
disease or hypertension
• Adult—0.3 mg SC
 Pediatric—0.01 mg/kg SC—max dose 0.3 mg
Never give Epinephrine 1:1000 intravenously!
EPINEPHRINE 1:1000 If respiratory arrest from asthma or bronchospasm:
IM
• Adult—0.3 mg IM
 Pediatric—0.01 mg/kg IM—max dose 0.3 mg
COPD EX ACERBATION
ALBUTEROL
5 mg in 6 ml NS via nebulizer. Repeat as needed.
52§
General Treatment Guidelines
G13–GENERAL
RESPIRATORY DISTRESS
SUSPECTED PULMONARY EDEMA (ADULTS ONLY)
NITROGLYCERIN
0.4 mg sublingual if systolic BP between 90 and 149
0.8 mg sublingual if systolic BP 150 or greater
Repeat every 5 minutes until symptoms improve
Maximum dose 4.8 mg (12–0.4 mg doses)
Discontinue if hypotension develops
Caution: Do not administer if patient has taken erectile
dysfunction medications Viagra, Levitra, Staxyn or
Stendra within prior 24 hours or Cialis within 36 hours
Related guidelines—Chest pain/Suspected ACS (A2), Shock (A10)
Key Treatment Consider ations
•  CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate
depth of respiration will need assistance with BVM
•  Patients requiring advanced airway management in these situations are best handled in the
hospital setting and CPAP may be a valuable “bridge” in care to potentially delay need for
emergent intubation
•  Patients with potential respiratory failure should be transported emergently
•  IV access should not delay transport
•  For patients with significant anxiety or claustrophobia with CPAP, consider base contact for
midazolam. Midazolam should be administered in 0.5–1 mg increments and patients should
be monitored carefully for potential respiratory depression
•  For suspected pulmonary edema, re-evaluate blood pressure between each dose of
nitroglycerin. If blood pressure initially over 150, then between 150 and 90 after treatment,
lower dosage to 0.4 mg
•  Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no
other contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs)
•  Consider cardiac etiology for diabetic patients with respiratory distress
 Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.
§53
General Treatment Guidelines
G14–GENERAL
SEIZURE/STATUS EPILEPTICUS
• Tonic-clonic movements followed by a period of unconsciousness (post-ictal period)
• A continuous or recurrent seizure is defined as seizure activity greater than
10 minutes or recurrent seizures without patient regaining consciousness
OXYGEN
BLS: High flow initially
ALS: Titrate to SpO2 of at least 94%
PROTECT PATIENT
Do not forcibly restrain but protect from injuring self
Consider IV
TKO
Consider
MIDAZOLAM IV
For continuous or recurrent seizures:
• Adult—initial dose 1 mg IV - titrate in 1–2 mg
increments—max. dose 5 mg
 Pediatric—titrate in up to 1 mg IV increments—up
to 0.1 mg/kg
CARDIAC MONITOR
BLOOD GLUCOSE
Consider
MIDAZOLAM IM
MONITOR PATIENT
Check and treat if indicated
If IV access unavailable:
• Adult—0.1 mg/kg IM—maximum dose 5 mg
 Pediatric—0.1 mg/kg IM—maximum dose 5 mg
Carefully observe vital signs, respiratory status—
support ventilations as needed
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or
Apnea (G12)
SAFETY WARNING:
• Use caution when treating with Midazolam in pediatric patients previously
treated by family or caretaker with rectal diazepam (Valium, Diastat) as a
higher incidence of respiratory depression may occur
• Wait five (5) minutes after last rectal dose to determine effect and need
for further treatment. Consider using reduced dosage of Midazolam
54§
General Treatment Guidelines
G14–GENERAL
SEIZURE/STATUS EPILEPTICUS
Key Treatment Consider ations
• Most seizures are self-limiting and do not require prehospital medication
• Seizures may appear frightening to observers. Provide reassurance to
parents/family.
• Consider spinal motion restriction if history of fall or trauma
• Early administration of Midazolam IM is preferable to IV route in smaller
children and in other patients with potential difficult intravenous access
• Febrile seizures in children are generally self-limiting
• For febrile patients, remove or loosen clothing, remove blankets to address
cooling measures
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
§55
General Treatment Guidelines
G15–GENERAL
STROKE
• Sudden onset of weakness, paralysis, confusion, speech disturbances, visual
field deficit—may be associated with headache
• Determination of time of onset of symptoms is the most crucial historical
information needed
• If patient awoke with symptoms, time patient last seen normal is the time
that should be noted
OXYGEN
CARDIAC MONITOR
STROKE SCALE
TRANSPORT
BLOOD GLUCOSE
IV
Consider FLUID
BOLUS
CONTACT
STROKE CENTER
OR RECEIVING
HOSPITAL
ENSURE FAMILY/
GUARDIAN
COMMUNICATION
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%.
Be prepared to support ventilation.
Note findings of stroke scale and time of onset of
symptoms
Minimize scene time
Check and treat if indicated
TKO
250–500 ml if hypotensive or poor perfusion—reassess
Stroke Alert is indicated only when Cincinnati Stroke
Scale (CSS) findings are abnormal and onset (time last
seen normal) is less than 4 hours from time of patient
contact. Report time last seen normal (clock time), ETA,
physical exam and findings of CSS using SBAR format.
If family member/patient guardian available, ensure
their availability by either transporting them in
ambulance, telling them to go immediately to the
hospital or obtain phone number to allow physician to
contact them
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or
Apnea (G12), Seizure (G14)
56§
General Treatment Guidelines
G15–GENERAL
STROKE
CINCINNATI STROKE SCALE
If any one of the three tests are abnormal and is a new finding, the Stroke
Scale is abnormal and may indicate an acute stroke
FINDING
Facial Droop
Arm Weakness
Speech
Abnormality
PATIENT ACTIVITY
Ask patient to smile and
show teeth or grimace
Ask patient to close both
eyes and extend both
arms out straight for
10 seconds
Have the patient say the
words, “The sky is blue in
Cincinnati”
INTERPRETATION
Normal: Symmetrical smile
or face
Abnormal: Asymmetry (one
side droops or does not move)
Normal: Both arms move
symmetrically or do not move
Abnormal: One arm
drifts down or arms move
asymmetrically
Testing with patient holding
palms upward is most sensitive
way to check. Patients with
arm weakness will tend to
pronate (turn from palms up to
sideways or palms down).
Normal: The correct words are
used and no slurring of words
is noted
Abnormal: If the patient slurs
words, uses the wrong words,
or is unable to speak (aphasia)
§57
General Treatment Guidelines
G16–GENERAL
TRAUMA—GENERAL
SPINAL MOTION
RESTRICTION
As indicated
EARLY TRANSPORT
Limit scene time to less than 10 minutes when possible.
Load and go if high risk.
OXYGEN
WOUND/GENERAL
CARE
Consider NEEDLE
THORACOSTOMY
IV
Consider FLUID
BOLUS
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
Place splints, cold packs, dressings and pressure
on bleeding sites as needed. Keep patient warm—
minimize exposure after assessment
Evaluate for and treat tension pneumothorax if
indicated
TKO. If patient critical, DO NOT DELAY ON-SCENE FOR
IV OR IO ACCESS.
Fluid resuscitation appropriate in adults if:
• Head injury and hypotension (BP < 90 or unable to
detect peripheral pulses)
• No head injury but markedly hypotensive and
unable to converse due to shock
Administer 250–500 ml NS, recheck vitals. Titrate to
presence of peripheral pulses.
BLOOD GLUCOSE
CARDIAC MONITOR
In pediatric patients with signs of poor perfusion or
shock:
 Pediatric—20 ml/kg NS. If continued poor perfusion,
may repeat X2
Test if GCS less than 15. See Altered Level of
Consciousness (G2).
58§
General Treatment Guidelines
G16–GENERAL
TRAUMA—GENERAL
INDICATIONS AND PRECAUTIONS FOR FENTANYL USE
Fentanyl may be used for relief of pain in the absence of head trauma,
hypotension (age-specific), poor perfusion or ALOC. Use with caution in
elderly patients.
FENTANYL IV
See precautions above
• Adult—50–200 mcg IV in 25–50 mcg increments. Titrate
to pain relief and systolic BP greater than 100.
 Pediatric —1 mcg/kg IV—See Pediatric Drug Chart
FENTANYL Intranasal
See precautions above
If no IV access:
•  Adult—100 mcg intranasal—may repeat once in 15 minutes
 Pediatric—1.5 mcg/kg intranasal—See Pediatric Drug Chart
FENTANYL IM
See precautions above
IF no IV access and intranasal route not suitable:
• Adult—50–100 mcg IM—may repeat in 15 minutes
 Pediatric—1 mcg/kg IM—See Pediatric Drug Chart
Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12)
Key Treatment Consider ations
• ALS procedures in the field (IV or advanced airway) do not improve
outcome in critical trauma patients
• IV starts should be done en route on these patients
• Advanced airway should only be done if patient is unable to be
ventilated via BLS maneuvers
• Repeated IV attempts in non-critical pediatric patients should be avoided
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
§59
General Treatment Guidelines
G16–GENERAL
AIRWAY CONTROL
VENTILATION
CONTROL
HEMORRHAGE
TREAT
HYPOTENSION
PATIENT POSITION
Consider
ONDANSETRON
TRAUMA–HEAD INJURY
• Basic airway management is preferred unless unable
to manage with BLS maneuvers. Utilize jaw thrust
technique to open airway.
• Intubation in head injury patients is best addressed at
the hospital or with RSI (aeromedical capability)
• King Airway should be used only in arrest unless no other
method to ventilate
• Avoid hyperventilation if BVM used or patient with
advanced airway.
• Support respiratory rate to 10–12 per minute if slow.
• Monitor patient with pulse oximetry and end-tidal CO2.
Ideal ETCO2 is 35 mm Hg—may be unreliable if multiple
system trauma or poor perfusion.
• In patients with a dilated pupil on one side or decerebrate/
decorticate posturing indicating impending brainstem
herniation, modest hyperventilation (rate of 12–16 per
minute) is appropriate (keep ETCO2 30 or above)
Scalp hemorrhage can be life threatening. Treat with direct
pressure and pressure dressing.
In adult patients, in the setting of hypotension (systolic BP
90 or less or absence of peripheral pulses), administer NS
250–500 ml. Repeat if necessary.
In pediatric patients with signs of poor perfusion or shock:
 Pediatric—20 ml/kg NS. If continued poor perfusion, may
repeat X 2
Elevate head 30 degrees unless contraindicated. Position
patient on side if needed for vomiting/airway protection
Adults—for vomiting/nausea, 4 mg IV/IM. May repeat every
10 minutes to a total dose of 12 mg.
 Pediatric—Limited to patients 4 years of age or older—4
mg IV/IM. For patients 40 kg and greater only, may repeat
every 10 minutes to a total dose of 12 mg
60§
General Treatment Guidelines
G16–GENERAL
Consider
TOURNIQUET
DISLOCATION
AMPUTATIONS
PAIN RELIEF
TRAUMA–EXTREMITY
If vigorous hemorrhage not controlled with elevation
and direct pressure on wound. May be used in pediatric
patients. May be appropriate for hemorrhage control in
multi-casualty situations.
If dislocation suspected or noted, splint in position found
• For partial amputations, splint in anatomic location
and elevate extremity
• If complete amputation, place amputated part in a
dry container or bag and place on ice. Seal or tie off
bag and place in second container or bag. DO NOT
place amputated part directly on ice or in water.
Elevate extremity and dress with dry gauze.
Consider Fentanyl as directed in G16 Trauma—General Guideline
CRUSH INJURY SYNDROME
• Caused by muscle crush injury and cell death. Most patients have an
extensive area of involvement such as a large muscle mass in a lower
extremity and/or pelvis. May develop after 1 hour in severe crush, but usually
requires at least 4 hours of compression
• Hypovolemia and hyperkalemia may occur, particularly in extended entrapments
• Hyperkalemia should be suspected if ECG monitor reveals peaked ‘T’ waves,
absent ‘P’ waves or widened QRS complexes
FLUID BOLUS
IF ECG CHANGES
SUGGEST
HYPERKALEMIA:
20 ml/kg NS prior to release of compression
ALBUTEROL—5 mg in 6 ml NS continuously via nebulizer
CALCIUM CHLORIDE—1 gm slow IV over 60 seconds.
Note: Flush tubing after administration of calcium
chloride to avoid precipitation with sodium bicarbonate
SODIUM BICARBONATE—1 mEq/kg IV. Additionally,
consider 1 mEq/kg added to IV 1L NS—use second IV
line as other medications may not be compatible
§61
General Treatment Guidelines
VOMITING AND
SEVERE NAUSEA
G17–GENERAL
Vomiting or nausea may be due to viral illness (gastroenteritis) or other medical
conditions including acute coronary syndrome, stroke, head injury, or toxic
ingestion. It may be associated with a number of painful abdominal conditions,
and may also occur as a result of treatment of pain with Fentanyl.
Consider OXYGEN
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
POSITION PATIENT
Position patient to avoid aspiration
NON-INVASIVE
MEASURES
Fresh air, oxygen, and removal of noxious odors may
lessen nausea
Consider IV
TKO
12-LEAD ECG
Consider FLUID
BOLUS
Cardiac ischemic events are often accompanied by
gastrointestinal symptoms. 12-lead ECG appropriate in
all patients age 35 and over.
Consider if patient has prolonged history of vomiting
or poor intake, if vital signs or exam suggest volume
depletion (rapid pulse, low blood pressure, dry mucous
membranes, poor skin turgor, or capillary refill greater
than 2 seconds)
• Adult—250–500 ml.
Recheck vitals—may repeat X 1
 Pediatric—20 ml/kg.
Recheck vitals —may repeat X 1.
62§
General Treatment Guidelines
G17–GENERAL
Consider
ONDANSETRON
VOMITING AND
SEVERE NAUSEA
For severe nausea or persistent vomiting:
• Adult—4 mg IV, IM, or po (oral disintegrating
tablet–ODT). May repeat every 10 minutes to a total
of 12 mg.
 Pediatric—limited to patients 4 years of age or
older—4 mg IV, IM, or po (ODT). For patients 40 kg
and greater only, may repeat every 10 minutes to a
total of 12 mg
NOTE: Administer IV dosage over 1 minute. Ondansetron is
contraindicated if patient has a history of hypersensitivity
to other similar drugs: dolasetron (Anzemet), granisetron
(Kytril), or palonosetron (Aloxi)
Related guidelines: Shock/Hypovolemia (A10), Pain Management (Non-Traumatic) (G10)
Key Treatment Consider ations
• Rapid administration of ondansetron has been associated with increased
incidence of side effects—most notably syncope. Ondansetron must be
administered intravenously over 1 minute
• Rare side effects of ondansetron include headache, dizziness, tachycardia,
sedation, hypotension, or syncope. Rarely QT prolongation has been seen
(with higher doses and rapid administration)
• Ondansetron can be used in pregnancy and with breast-feeding mothers
• Oral disintegrating tablets should be handled with care as moisture may
cause premature breakdown of tablets before administration
• Oral disintegrating tablets can be placed on tongue and do not need to be
chewed. Medication will dissolve and be swallowed with saliva
 Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose
§63
General Treatment Guidelines
G18–GENERAL
INTERFACILITY TRANSFER
OF STEMI PATIENTS
Patients with ST-elevation Myocardial Infarction (STEMI) needing interventional
cardiac care require timely transfer. A scene time of 10 minutes or less at the
sending facility is ideal.
OXYGEN
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
MONITOR IV
Maintain TKO or other existing flow rate
PROMPT
TRANSPORT
Transfer for definitive care is the priority in STEMI
patients
Consider
FENTANYL IV
50–200 mcg IV in 25–50 mcg increments (consider
25 mcg increments in elderly patients). Patients
with STEMI often do not get complete relief with
medication.
Caution: If Inferior MI suspected, use 25–50 mcg
increments and observe carefully for hypotension
Key Treatment Consider ations
Treatment during interfacility transfer varies from field approach to chest
pain/ACS:
• Confirmatory ECG for STEMI has been done by hospital and does not need
repeat prior to transfer or en route to accepting facility
• Nitroglycerin treatment is not required and generally ineffective in
patients with confirmed STEMI
• Aspirin or other anti-platelet treatment if indicated should be
administered by sending hospital prior to patient departure
• Patients generally will be directed directly to catheterization laboratory
• Outcome in STEMI patients is directly related to timeliness of intervention to
relieve coronary artery blockage. Minimizing time delay in transfer is essential.
64§
General Treatment Guidelines
INTERFACILITY TRANSFER OF
INTUBATED PATIENTS
G19–GENERAL
Patients requiring specialty care (most commonly trauma or neurosurgical care)
may be transferred with an established endotracheal tube. Sedation may be
required if patient agitation present because of risk of inadvertent extubation.
NOTE: This treatment guideline pertains to sedation of intubated patients
during interfacility transport only (not for patients with field response who are
intubated).
OXYGEN
VENTILATION
CARDIAC MONITOR
END-TIDAL CO2
MONITORING
PULSE OXIMETRY
Consider
MIDAZOLAM
MONITOR PATIENT
100%
As needed if patient with apnea or inadequate
respiratory rate or effort
• Continuous monitoring with waveform
capnography is required and must be established
prior to departure from sending facility.
• Maintain end-tidal CO2 between 35 and 45.
ETCO2 may not be reliable in patients with shock or
significant lung injury. Maintain at least a minimum
respiratory rate of 8–10 breaths
per minute.
For sedation in agitated or uncooperative patient: 2–5
mg IV in up to 2 mg increments. Repeat dosing with
base contact only.
Follow vital signs and ETCO2 closely. If Midazolam
administered, anticipate potential respiratory depression.
Key Treatment Consider ations
• Some patients may need paralysis and require additional nursing or
physician staff to administer these medications
• If inadvertent extubation occurs, manage with basic airway maneuvers
unless ventilation cannot be adequately maintained
§65
General Treatment Guidelines
G20–GENERAL
INTERFACILITY TRANSFER
OF STROKE PATIENTS
Patients with acute stroke that may not qualify for thrombolytic therapy or that
may not respond to thrombolytic therapy, necessitating transfer for potential
interventional care
OXYGEN
CARDIAC MONITOR
MONITOR VITAL
SIGNS
MONITOR IV
PROMPT
TRANSPORT
BLS: Low flow unless ALOC/respiratory distress/shock
ALS: Titrate to SpO2 of at least 94%
• Monitor blood pressure and Glasgow Coma Scale at
least every 15 minutes.
• Use pulse oximetry—consider non-invasive endtidal carbon dioxide monitoring if any respiratory
difficulty.
Maintain TKO or other existing flow rate
Transfer for definitive care is the priority in stroke
patients. Minimizing time delay is essential.
66§
General Treatment Guidelines
G20–GENERAL
INTERFACILITY TRANSFER
OF STROKE PATIENTS
Key Treatment Consider ations
• Stroke patients who are transferred may have already received
thrombolytic therapy or may not have qualified for thrombolysis based on
length of time from stroke onset or other medical contraindications
• Ongoing administration of thrombolytic therapy requires additional
qualified staff (nurse or physician) for transport
• Thrombolytic therapy in stroke patients is associated with around a 6%
incidence of symptomatic intracerebral hemorrhage, and around a 1% of
serious hemorrhage elsewhere
• Close monitoring is important. Significant changes in patient vital signs/
GCS during transport should be reported immediately to receiving facility
staff as it may affect immediate treatment:
• Hypotension may occur because of external or internal hemorrhage
• Hypertension may be related to acute intracranial process or
underlying disease
• Respiratory depression or airway compromise may occur due to stroke
or intracerebral hemorrhage
• Decreasing level of consciousness may occur due to stroke or
intracerebral hemorrhage
Cardiac dysrhythmias may occur in stroke patients (bradycardia or
tachyarrhythmia)
Observe for external hemorrhage in patients with prior administration of
thrombolytics. Place direct pressure if hemorrhage noted.
Related guidelines: Shock/Hypovolemia (A10), Altered level of consciousness (G2),
Respiratory Depression or apnea (G12)
§67
General Treatment Guidelines
68§
table of contents—pediatric treatment guidelines
P1–PEDIATRIC PATIENT CARE........................................................................................................70
P2–APPARENT LIFE-THREATENING EVENT (ALTE)..................................................................71
P3–CARDIAC ARREST—INITIAL CARE AND CPR.............................................................72–73
P4–NEONATAL CARE AND RESUSCITATION.....................................................................74–75
P5–VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA........76–77
P6–PULSELESS ELECTRICAL ACTIVITY/ASYSTOLE..........................................................78–79
P7–SYMPTOMATIC BRADYCARDIA............................................................................................ 80
P8–TACHYCARDIA....................................................................................................................82–83
P9–SHOCK................................................................................................................................. 84–85
§69
Pediatric Treatment Guidelines
P1–PEDIATRIC
PEDIATRIC PATIENT CARE
Pediatric patient is defined as age 14 or less. Neonate is 0–1 month.
These basic treatment concepts should be considered in all pediatric patients
SCENE SAFETY
BSI
SYSTEMATIC
ASSESSMENT
DETERMINE
PRIMARY
IMPRESSION
BASE CONTACT
TRANSPORT
MONITORING
DOCUMENT
Use universal blood and body fluid precautions at all times
• Management and support of ABCs are a priority
• Identify pre-arrest states
• Assure open and adequate airway
• Place in position of comfort unless condition
mandates other position
• Consider spinal motion restriction if history or
possibility of traumatic injury exists
• Assess environment to consider possibility of
intentional injury or maltreatment
• Apply appropriate field treatment guidelines
• Explain procedures to family and patient as appropriate
• Provide appropriate family support on scene
• Contact base hospital if any questions arise concerning
treatment or if additional medication beyond dosages
listed in treatment guidelines is considered
• Use SBAR to communicate with base
• Minimize scene time in pre-arrest patient, critical
trauma, shock or respiratory failure
• Transport patient medications or current list of
patient medications to the hospital
• Give report to receiving facility using SBAR
• At a minimum, vital signs and level of consciousness
should be re-assessed every 15 minutes and should
be assessed after every medication administration or
following any major change in the patient’s condition
• For critical patients, more frequent vital signs
should be obtained when appropriate
Document patient assessment and care per policy
70§
Pediatric Treatment Guidelines
P2–PEDIATRIC
APPARENT LIFE-THREATENING
EVENT (ALTE)
An Apparent Life-Threatening Event (ALTE) is an event that is frightening to
the observer (may think the infant has died) and involves some combination
of apnea, color change, marked change in muscle tone, choking, or gagging.
It usually occurs in infants less than 12 months of age, though any child with
symptoms described under 2 years of age may be considered an ALTE.
Most patients have a normal physical exam when assessed by responding
personnel. Approximately half of the cases have no known cause, but the
remainder of cases have a significant underlying cause such as infection,
seizures, tumors, respiratory or airway problems, child abuse, or SIDS.
Because of the high incidence of problems and the normal assessment usually
seen, there is potential for significant problems if the child's symptoms are not
seriously addressed.
OBTAIN DETAILED
HISTORY
ASSESSMENT
TREATMENT
TRANSPORT
• Obtain history of event, including duration and
severity, whether patient awake or asleep at time
of episode, and what resuscitative measures were
done by the parent or caretaker
• Obtain past medical history, including history
of chronic diseases, seizure activity, current or
recent infections, gastroesophageal reflux, recent
trauma, medication history
• Obtain history with regard to mixing of formula
if applicable
Perform comprehensive exam, including general
appearance, skin color, interaction with environment,
or evidence of trauma
Treat identifiable cause if appropriate
If treatment/transport is refused by parent or
guardian, contact base hospital to consult prior to
leaving patient. Document refusal of care.
§71
Pediatric Treatment Guidelines
P3–PEDIATRIC
ESTABLISH TEAM
LEADER
CONFIRM ARREST
COMPRESSIONS
AED OR MONITOR/
DEFIBRILLATOR
CARDIAC ARREST—
INITIAL CARE AND CPR
• First agency on scene assumes leadership role
• Leadership role can be transferred as additional
personnel arrive
• Unresponsive, no breathing or agonal respirations,
no pulse
• Begin compressions at a rate of 100–120 per
minute. Use metronome.
• Compress chest approximately 1/3 of AP diameter of chest:
• In children (age 1–8)—around 2 inches
• In infants (under age 1)—around 1 1/2 inches
• Allow full chest recoil (lift heel of hand)
• Change compressors every 2 minutes
• Minimize any interruptions in compressions. If
necessary to interrupt, limit to 10 seconds or less.
• Do not stop compressions while defibrillator is
charging
• Resume compressions immediately after any shock
• Apply pads while compressions in progress
• Determine rhythm and shock, if indicated
• Follow specific treatment guideline based on rhythm
BASIC AIRWAY
• Open airway—For 2-person CPR:
• Provide 2 breaths: 30 compressions for children
MANAGEMENT AND
over age 8
VENTILATION
• Provide 2 breaths: 15 compressions for infants >
1 month & children to age 8
• Avoid Excessive Ventilation
• Ventilations should last one second each, enough to
cause visible chest rise
• Use 2-person BLS Airway management (one holding
mask and one squeezing bag)
72§
Pediatric Treatment Guidelines
P3–PEDIATRIC
MEDICATIONS AND
DEFIBRILLATION
ADVANCED AIRWAY
MANAGEMENT and
END-TIDAL CO2
MONITORING
BLOOD GLUCOSE
PREVENT
HYPOTHERMIA
TRANSPORT
CARDIAC ARREST—
INITIAL CARE AND CPR
• Use length-based tape to determine weight
• If child is obese and length-based tape used to
determine weight, use next highest color to
determine appropriate equipment and drug dosing
• See Pediatric Drug Chart for medication dose and
defibrillation energy levels
For patients 40 kg or greater only:
• Placement of advanced airway is not a priority
during the first 5 minutes of resuscitation unless no
ventilation is occurring with basic maneuvers.
• Placement of endotracheal tube or King Airway
should not interrupt compressions for a period of
more than 10 seconds
• For endotracheal intubation, position and visualize
airway prior to cessation of CPR for tube passage.
• Confirm tube placement and provide ongoing
monitoring using end-tidal carbon dioxide
monitoring
Treat if indicated. Glucose may be rapidly depleted in
pediatric arrest.
Move to warm environment and avoid unnecessary
exposure
• Pediatric arrest victims are at risk for hypothermia
due to their increased body surface area, exposure
and can be exacerbated by rapid administration of
IV/IO fluids
Consider rapid transport to definitive care
§73
Pediatric Treatment Guidelines
P4–PEDIATRIC NEONATAL CARE AND RESUSCITATION
WARM PATIENT
CLEAR AIRWAY
DRY AND
STIMULATE
EVALUATE
RESPIRATIONS,
HEART RATE AND
COLOR
REASSESS/BEGIN
CPR IF INDICATED
Provide warmth—move to warm environment
immediately
If needed, position airway or suction. Rapidly suction
secretions from mouth or nares.
Dry child thoroughly, stimulate, reposition if needed,
place hat on infant
• If breathing, heart rate above 100 and pink,
observational care only
• If breathing, heart rate above 100 and central
cyanosis—OXYGEN 100% by mask—reassess in
30 seconds
• If cyanosis resolves (skin pink)—observational
care only
• If persistent central cyanosis after oxygen,
initiate bag mask ventilation at rate of
40–60/minute
• If apneic, gasping, or heart rate below 100—initiate
bag mask ventilation at a rate of 40–60/minute
with OXYGEN 100%—reassess in 30 seconds
• If heart rate increases to above 100 and patient
ventilating adequately, discontinue bag mask
ventilation and continue close observation
• If heart rate persists below 100 continue bag
mask ventilation
If heart rate less than 60 despite ventilation with
oxygen for 30 seconds, begin CPR (3:1 ratio—
90 compressions and 30 ventilations/minute).
Reassess in 30 seconds.
74§
Pediatric Treatment Guidelines
P4–PEDIATRIC NEONATAL CARE AND RESUSCITATION
If heart r ate remains less than 60 despite adequate
ventilation and chest compressions:
IV/IO
EPINEPHRINE
Consider FLUID
BOLUS
TKO. 100–500 ml NS bag (use care to avoid inadvertent
fluid administration). Do not delay transport for
IV or IO access.
1:10,000–0.01 mg/kg IV or IO. Repeat every 3–5
minutes if heart rate remains below 60.
10 ml/kg NS IV or IO. May repeat once if needed.
Consider NALOXONE 0.1 mg/kg IV or IO if depressed respiratory status
despite efforts. Avoid use if long-term use of opioids
during pregnancy known or suspected.
Key Treatment Consider ations
• For uncomplicated deliveries, treatment priorities are to warm, dry, and
stimulate the infant
• Anticipate complex resuscitation if not term gestation, amniotic fluid not
clear, if newborn is not breathing or crying or if newborn does not have
good muscle tone
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
§75
Pediatric Treatment Guidelines
VENTRICULAR FIBRILLATION
P5–PEDIATRIC PULSELESS
VENTRICULAR TACHYCARDIA
INITIAL CARE
DEFIBRILLATION
CPR
BVM VENTILATION
IO or IV
DEFIBRILLATION
EPINEPHRINE
DEFIBRILLATION
AMIODARONE
TRANSPORT
See Cardiac Arrest—Initial Care and CPR (P3)
2–4 joules/kg
• Use manual defibrillator if available
• If AED utilized, use pediatric pads if available. Adult
pads may be used with usual placement position
if pads do not touch. Adult pads may be placed
anterior-posterior if usual placement would cause
the pads to touch.
For 2 minutes or 5 cycles between rhythm check
For patients 40 kg and over, defer advanced airway
unless BLS airway inadequate
TKO. Should not delay defibrillation or interrupt CPR.
4 joules/kg
1:10,000–0.01 mg/kg IV or IO every 3–5 minutes
4 joules/kg. Higher energy levels may be considered—
not to exceed 10 joules/kg or the adult maximum.
5 mg/kg IV or IO
If Return of Spontaneous Circulation—see guidelines for Shock (P9) if treatment
indicated
76§
Pediatric Treatment Guidelines
VENTRICULAR FIBRILLATION
P5–PEDIATRIC PULSELESS
VENTRICULAR TACHYCARDIA
Key Treatment Consider ations
• Uninterrupted CPR and timely defibrillations are the keys to successful
resuscitation. Their performance takes precedence over advanced airway
management and administration of medications.
• To minimize CPR interruptions, perform CPR during charging, and
immediately resume CPR after shock administered (no pulse or rhythm
check)
• Avoid excessive ventilation with BLS airway management, which may
cause gastric distention and limit chest expansion. Provide breaths over 1
second, with movement of chest wall as guide for volume needed.
• If advanced airway placed (40 kg and over), perform CPR continuously
without pauses for ventilation
• Confirm placement of advanced airway with end-tidal carbon dioxide
measurement. Continuous monitoring with ETCO2 is mandatory—if
values less than 10 mm Hg seen, assess quality of compressions for
adequate rate and depth. Rapid rise in ETCO2 may be the earliest indicator
of return of circulation.
• Prepare drugs before rhythm check and administer during CPR
• Give drugs as soon as possible after rhythm check confirms VF/pulseless
VT (before or after shock)
• Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly
for patient size (20 ml in adolescents).
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for medication dose and defibrillation energy levels.
• Transmit “ALL” data to the monitor site identified by your provider agency
§77
Pediatric Treatment Guidelines
PULSELESS ELECTRICAL ACTIVITY/
ASYSTOLE
P6–PEDIATRIC
INITIAL CARE
BVM VENTILATION
IV OR IO
EPINEPHRINE
See Cardiac Arrest—Initial Care and CPR (P3)
Defer advanced airway (for patients 40 kg and over)
unless BLS airway inadequate
TKO
1:10,000–0.01 mg/kg IV or IO every 3–5 minutes
Consider treatable causes—treat if applicable:
Consider
FLUID BOLUS
VENTILATION
Consider WARMING
MEASURES
Consider NEEDLE
THORACOSTOMY
BASE CONTACT
20 ml/kg NS—may repeat X 2 for hypovolemia
Ensure adequate ventilation (8–10 breaths per minute)
for hypoxia
For hypothermia
For tension pneumothorax
To determine treatment for other identified
potentially treatable causes—Hydrogen Ion (Acidosis),
Hyperkalemia, Toxins
If Return of Spontaneous Circulation—see guidelines for Shock (P9) if treatment
indicated
78§
Pediatric Treatment Guidelines
P6–PEDIATRIC
PULSELESS ELECTRICAL ACTIVITY/
ASYSTOLE
Key Treatment Consider ations
• Uninterrupted CPR is key to successful resuscitation. This takes precedence
over advanced airway management and administration of medications
• If advanced airway placed in patients 40 kg and over, perform CPR
continuously without pauses for ventilation
• Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute,
administered over one second
• Prepare drugs before rhythm check and administer during CPR
• Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly
for patient size (20 ml in adolescents)
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
• Transmit “ALL” data to the monitor site identified by your provider agency
§79
Pediatric Treatment Guidelines
P7–PEDIATRIC
SYMPTOMATIC BRADYCARDIA
• 90% of pediatric bradycardias are related to respiratory depression and
respond to support of ventilation
• Only unstable, severe bradycardia causing cardiorespiratory compromise will
require further treatment
• Signs of severe cardiorespiratory compromise are poor perfusion,
delayed capillary refill, hypotension, respiratory difficulty, altered level of
consciousness
OXYGEN
CARDIAC MONITOR
IV or IO
Consider CPR
EPINEPHRINE
BLS: High flow initially
ALS: Titrate to SpO2 of at least 94%
TKO. Use IO only if patient unstable and requires
medication. Use 100–500 ml NS bag.
If heart rate remains less than 60 with poor perfusion
despite oxygenation and ventilation, perform CPR
1:10,000–0.01 mg/kg IV or IO. Repeat every 3–5 minutes.
SAFETY WARNING: Atropine should be considered only after adequate oxygenation/ventilation
has been ensured
Consider ATROPINE
0.02 mg/kg IV, IO (0.1 mg minimum dose). Maximum
single dose 0.5 mg. If continued heart rate less than 60,
repeat 0.02 mg/kg IV or IO
Key Treatment Consider ations
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
80§
Pediatric Treatment Guidelines
§81
Pediatric Treatment Guidelines
P8–PEDIATRIC
TACHYCARDIA
Sinus tachycardia is by far the most common pediatric rhythm disturbance
UNSTABLE SINUS TACHYCARDIA (narrow QRS less than or equal to 0.09)
• ‘P’ waves present/normal, variable R-R interval with constant P-R interval
• Unstable sinus tachycardia is usually associated with shock and may be pre-arrest
UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less or equal
to 0.09)
• ‘P’ waves absent/abnormal, heart rate not variable
• History generally vague, non-specific and/or history of abrupt heart rate changes
• Infants’ rate usually greater than 220 bpm, Children (ages 1–8) rate usually
greater than 180 bpm
UNSTABLE—POSSIBLE VENTRICULAR TACHYCARDIA—(Wide QRS greater than 0.09 sec)
• In some cases, wide QRS can represent supraventricular rhythm
INITIAL THER APY— ALL TACHYCARDIA RHYTHMS
OXYGEN
CHECK PULSE and
PERFUSION
CARDIAC MONITOR
IV or IO
FLUID BOLUS
BLS: Low flow unless ALOC/respiratory distress/shock.
ALS: Titrate to SpO2 of at least 94%.
Be prepared to support ventilation.
Determine stability:
• Stable—Normal perfusion: Palpable pulses, normal
LOC, normal capillary refill, and normal BP for age
• Unstable—Poor perfusion: ALOC, abnormal pulses,
delayed cap. refill, difficult/unable to palpate BP. If
unstable, transport early and treat as below.
Run strip to evaluate QRS Duration
TKO. Use 100–500 ml bag NS
20 ml/kg NS if hypovolemia suspected. May repeat X1
82§
Pediatric Treatment Guidelines
P8–PEDIATRIC
TACHYCARDIA
UNSTABLE SUPR AVENTRICULAR TACHYCARDIA
(narrow QRS less or equal to 0.09)
VAGAL MANEUVERS Consider if will not result in treatment delays. ICE PACK
to face of infant/child.
BASE CONTACT

SYNCHRONIZED
CARDIOVERSION
If unable to obtain IV access, prepare for Synchronized
Cardioversion. Do NOT delay cardioversion to obtain IV
or IO access or sedation.
ADENOSINE
Consider SEDATION
SYNCHRONIZED
CARDIOVERSION
For all treatments listed below:
0.1 mg/kg rapid IV push followed by 10–20 ml NS flush
(maximum dose 6 mg). If not converted, 0.2 mg/kg rapid
IV push followed by 10–20 ml NS flush (maximum dose
12 mg)
Consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in
1 mg maximum increments (maximum dose 5 mg)
0.5–1 joule/kg. If not effective, repeat at 2 joules/kg.
UNSTABLE—POSSIBLE VENTRICULAR TACHYCARDIA
(Wide QRS greater than 0.09 sec)
BASE CONTACT

Consider SEDATION
If IV/IO access has been obtained, consider
MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg
maximum increments (maximum dose 5 mg)
SYNCHRONIZED
CARDIOVERSION
SYNCHRONIZED
CARDIOVERSION
For all treatments listed below:
Prepare for CARDIOVERSION while attempting IV/IO access,
but do not unduly delay care for IV access or medications
0.5–1 joule/kg. If not effective, repeat at 2 joules/kg.
Key Treatment Consider ations
• Early transport appropriate in unstable patients.
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose.
§83
Pediatric Treatment Guidelines
P9–PEDIATRIC
SHOCK
• Altered level of consciousness; cool, clammy, mottled skin; capillary refill
greater than 2 seconds; tachycardia; blood pressure less than 70 systolic
• Listless infant or child with poor skin turgor, dry mucous membranes, history
of fever may indicate sepsis, meningitis
OXYGEN
PREVENT
HYPOTHERMIA
CARDIAC MONITOR
BLS/ALS: High flow. Be prepared to support ventilations
as needed.
Move to warm environment. Avoid unnecessary
exposure.
EARLY TRANSPORT
CODE 3
FLUID BOLUS
20 ml/kg NS—may repeat X2
IV or IO
BLOOD GLUCOSE
Check and treat if indicated
Related guidelines: Altered level of consciousness (G2), Tachycardia (P8)
84§
Pediatric Treatment Guidelines
P9–PEDIATRIC
SHOCK
Key Treatment Consider ations
Successful pediatric resuscitation relies on early identification of the
pre-arrest state
• Normal blood pressure, delayed capillary refill, diminished peripheral
pulses and tachycardia indicates compensated shock in children
• Hypotension and delayed capillary refill > 4 seconds indicates impending
circulatory failure
• Systolic blood pressure in children may not drop until the patient is
25–30% volume depleted. This may occur through dehydration, blood loss
or an increase in vascular capacity (e.g. anaphylaxis)
• Decompensated shock (Hypotension with > 5 seconds capillary refill) may
present as PEA in children
• Sinus tachycardia is the most common cardiac rhythm encountered
• Supraventricular tachycardia should be suspected if heart rate greater
than 180 in children (ages 1–8) or greater than 220 in infants
• Hypoglycemia may be found in pediatric shock, especially in infants
• Pediatric shock victims are at risk for hypothermia due to their increased
body surface area, exposure and rapid administration of IV/IO fluids
 Use length-based tape for pediatric weight determination. See Pediatric
Drug Chart for dose
§85
Pediatric Treatment Guidelines
86§
table of contents—ems policy summaries
Policy 9–DESTINATION DETERMINATION—BASIC PROCEDURE.................................... 89
Policy 9–DESTINATION DETERMINATION—5150/OBSTETRIC........................................ 90
Policy 9–DESTINATION DETERMINATION—DIALYSIS/ROSC/BURN..............................91
Policy 10–DECLINING MEDICAL CARE OR TRANSORT (AMA)...........................................92
Policy 13–TRAUMA TRIAGE—ACTIVATION CRITERIA............................................................93
Policy 13–TRAUMA TRIAGE—DESTINATION CRITERIA.................................................94–95
Policy 19–DETERMINATION OF DEATH.................................................................................... 96
Policy 20–DNR AND POLST ORDERS..........................................................................................97
Policy 23–ABUSE REPORTING RESPONSIBILITIES...........................................................98–99
Policy 30–RESTRAINTS................................................................................................................100
Policy 33c–HELICOPTER TRANSPORT CRITERIA................................................................... 101
Policy 36–HAZARDOUS MATERIALS—EXPOSURE MANAGEMENT................... 102–103
Policy 39–911 ACTIVATION FOR NON-EMERGENCY
TRANSPORT PROVIDERS...........................................................................................104–105
§87
Policy Summaries
88§
Policy Summaries
EMS POLICY 9
SUMMARY
DESTINATION DETERMINATION—
BASIC PROCEDURE
• Field personnel shall assess a patient to determine if the patient is
unstable or stable
• Patient stability must be considered along with a number of additional
factors in making destination and transport code decisions
FACTORS TO
CONSIDER
• Patient or family’s choice of receiving hospital and
ETA to that facility
• Recommendations from a physician familiar with
the patient’s current condition
• Patient’s regular source of hospitalization or health care
• Ability of field personnel to provide field
stabilization or emergency intervention
• ETA to the closest basic emergency department
• Traffic conditions
• Hospitals with special resources
• Hospital diversion status
UNSTABLE PATIENTS • Usually transported to the closest appropriate acute
care hospital emergency department or specialized
care centers if indicated
• If the patient or family requests, or if other factors
exist which indicate that another facility be
considered, field personnel are to contact the base
hospital and present their findings, including ETAs
to both facilities. Base personnel will assess the
benefits of each destination and may direct field
personnel to a facility other than the closest.
STABLE PATIENTS
• Stable patients are transported to appropriate acute
care hospitals within reasonable transport times
based on patient’s/family preference
• If a patient does not express a preference, the
hospital where the patient normally receives health
care or the closest ED is to be considered
§89
Policy Summaries
EMS POLICY 9
SUMMARY
PATIENTS ON
5150 HOLDS
OBSTETRIC
PATIENTS
DESTINATION DETERMINATION—
5150/OBSTETRIC
A patient placed on a 5150 hold in the field shall be assessed
for the presence of a medical emergency. Based upon
the history and physical examination of the patient, field
personnel shall determine whether the patient is stable or
unstable.
Stable patients on 5150 holds shall be transported to Contra
Costa Regional Medical Center. Unstable patients on 5150
holds shall be transported to the closest acute care hospital:
• A patient with a current history of overdose of
medications is to be considered unstable
• A patient with history of ingestion of alcohol/illicit street
drugs is considered unstable if:
• Significant alteration in mental status (e.g.,
decreased LOC or extremely agitated); or
• Significantly abnormal vital signs; or
• Any other history or physical findings that suggest
instability (e.g. chest pain, shortness of breath,
hypotension, diaphoresis)
A patient is considered “Obstetric” if pregnancy is estimated
to be of 20 weeks duration or more. Obstetric patients
should be transported to hospitals with in-patient OB
services in the following circumstances:
• Patients in labor
• Patients whose chief complaint appears to be related to
the pregnancy, or who potentially have complications
related to the pregnancy
•  Injured patients who do not meet trauma criteria or guidelines
Obstetric patients with impending delivery or unstable
conditions where imminent treatment appears necessary
to preserve the mother’s life should be transported to the
nearest basic emergency department
Stable obstetric patients should be transported to the
emergency department of choice if their complaints are
clearly unrelated to pregnancy
90§
Policy Summaries
EMS POLICY 9
SUMMARY
DIALYSIS PATIENTS
CARDIAC ARREST
PATIENTS WITH
ROSC
DESTINATION DETERMINATION—
DIALYSIS/ROSC/BURN
Dialysis patients often require definitive care at
a center that provides acute dialysis services. The
preferable destination for this type of patient is the
hospital at which the patient has received dialysis care
(if applicable). Patients in extremis will need transport
to the closest ED.
Cardiac arrest patients who have return of spontaneous
circulation (ROSC) should be transported to the closest
STEMI Receiving Center.
BURN PATIENT DESTINATION
GENERAL
DESTINATION
PRINCIPLES
PATIENT SELECTION
FOR INITIAL
TRANSPORT TO
BURN CENTER
PROCEDURE FOR
BURN CENTER
DESTINATION
• Burned patients with unmanageable airways should
be transported to the closest basic ED
• Patients with minor burns and moderate burns can
be cared for at any acute care hospital
• Adult and pediatric patients with burns and
significant trauma should be transported to the
closest appropriate trauma center
The following patients may be appropriate for initial
transport to a Burn Center:
• Partial thickness (2nd degree) greater than 20% TBSA
• Full thickness (3rd degree) greater than 10%
• Chemical or high voltage electrical burns
• Smoke inhalation with external burns
• Contact Burn Center prior to transport to confirm
bed availability
• Consult base hospital if any questions regarding
destination decision
§91
Policy Summaries
EMS POLICY
10 SUMMARY
DECLINING MEDICAL CARE OR
TRANSPORT (AMA)
All qualified persons are permitted to make decisions affecting care, including
the ability to decline care
PATIENT
COMPETENCY
QUALIFIED PERSON
BASE CONTACT
REQUIREMENTS
Any person encountered by EMS personnel who
demonstrates any known or suspected illness or injury OR is
involved in an event with significant mechanism that could
cause illness or injury OR who requests care or evaluation
The ability to understand and to demonstrate an
understanding of the nature of the illness/injury and the
consequence of declining medical care
A competent person making decision for him/herself or
another qualified by:
•  An adult patient defined as a person who is at least 18 years old;
• A minor (under 18 years old) who qualifies based on one
of the following conditions:
• A legally married minor;
• A minor on active duty with the armed forces;
• A minor seeking prevention / treatment of
pregnancy or treatment related to sexual assault;
• A minor, 12 years of age or older, seeking treatment
of contact with an infectious, contagious or
communicable disease or sexually transmitted disease;
•  A self-sufficient minor at least 15 years of age, living apart
from parents and managing his/her own financial affairs;
• An emancipated minor (must show proof); OR
• The parent of a minor child or a legal representative
of the patient (of any age). Spouses or relatives cannot
consent to or decline care for the patient unless they are
legally designated representatives.
• When, in the field personnel’s opinion, patient’s decision
to decline care poses a threat to his/her well being
• If the patient’s competency status is unclear (neither
competent nor clearly incompetent) and treatment or
transport is felt to be appropriate
• Any other situation in which, in the field personnel’s
opinion, that base contact would be beneficial in resolving
treatment or transport issues
92§
Policy Summaries
EMS POLICY
TRAUMA ACTIVATION CRITERIA
13 SUMMARY (DIRECT TRAUMA CENTER TRANSPORT)
The following meet activation criteria and merit direct transport to the
trauma center:
PHYSIOLOGIC
CRITERIA
• BP < 90 in adults
• GCS 13 or below if not pre-existing
ANATOMIC CRITERIA • Penetrating injury to head, neck, torso, groin, pelvis or
MECHANISM
CRITERIA
COMBINED CRITERIA
(COMBINED
MECHANISM AND
PHYSICAL FINDINGS)
buttocks
• Fracture of femur
• Fracture of long bone(s) resulting from penetrating
trauma
• Traumatic Paralysis
• Amputation above wrist or ankle
• Major burns associated with trauma
• Crushed, mangled, or degloved extremity
• Motor vehicle crash with:
• Extrication > 20 minutes
• Fatalities in the same vehicle
• Ejection
• Unrestrained motor vehicle crash with:
• Head on mechanism > 40 mph
• Extrication required
• Fall 15 feet or greater
• Auto vs. pedestrian/bicyclist thrown, run over, or struck
with significant impact (>20 mph)
Note: In the absence of significant symptoms or physical
findings with these mechanisms, call base hospital for
destination determination
• Motorcycle crash with:
• Abdominal or chest tenderness, or
• Suspected loss of consciousness
• Unrestrained motor vehicle crash with abdominal
tenderness
Note: Patients with unmanageable airways or traumatic arrest not meeting field
determination criteria should be transported to the closest receiving facility.
§93
Policy Summaries
EMS POLICY
13 SUMMARY
BASE CONTACT
REQUIRED FOR
DESTINATION
DETERMINATION
MECHANISMS OF
INJURY
TRAUMA— DESTINATION CRITERIA
If not meeting activation criteria (direct transport), base
contact should be made in the following situations to
determine destination:
• High-energy mechanisms of injury
• Low-energy mechanisms with risk factor(s) and/or
symptoms/physical findings
• Uncertain mechanism with risk factor(s) and/or
symptoms/physical findings
• EMS Provider Concern
High-energy mechanisms include:
• Motor vehicle crash with one or more of the
following:
• Intrusion of passenger space by one foot
or greater
• Impact estimated 40 mph or greater
• Person requiring disentanglement
• Vehicle rollover with unrestrained occupant
• Person struck by vehicle (less than 20 mph)
• Person ejected from moving object (motorcycle,
horse, etc.)
• Blunt assault with weapon (e.g. pipe, bat)
Lower energy mechanisms of injury include:
• Ground level or short fall
• Blunt assault without weapon
• Lower-speed motor vehicle crash
• Other blunt trauma (e.g. sports injury)
Other:
• Uncertain trauma mechanism but trauma
suspected
• Patients with trauma remote to time of EMS call
(e.g. several hours)
94§
Policy Summaries
EMS POLICY
13 SUMMARY
RISK FACTORS
SYMPTOMS AND
PHYSICAL FINDINGS
TRAUMA—DESTINATION CRITERIA
• Age 60 and over
• Patient taking anticoagulants or known bleeding disorder
• Pregnancy over 20 weeks
• Communication barrier with patient (e.g. age,
language, psychiatric or developmental issues)
Significant signs or symptoms of injury, including:
Vital Signs:
• Any concerns due to hypotension, tachycardia, or
tachypnea
• Systolic BP under 110 in patient age 60 or over
• Pain level greater than 5 related to torso, head or
neck injury
Head Injury:
• Loss of consciousness
• Repetitive questioning
• Abnormal or combative behavior
• New onset of confusion
• Vomiting
• Headache
Torso Injury:
• Tenderness to palpation of abdomen, chest/ribs or
back/flank
• Suspected hip dislocation or pelvis injury
§95
Policy Summaries
EMS POLICY
19 SUMMARY
OBVIOUS DEATH
MEDICAL ARREST
DETERMINATION OF DEATH
Pulseless, non-breathing patients with any of the following:
• Decapitation, Total Incineration, Decomposition
• Total destruction of the heart, lungs, or brain, or
separation of these organs from the body
• Rigor mortis or post-mortem lividity without evidence
of hypothermia, drug ingestion, or poisoning. In patients
with rigor mortis or post-mortem lividity:
• Attempt to open airway, assess for breathing for at
least 30 seconds; assess pulse for 15 seconds
• Rigor, if present, should be noted in jaw and/or upper
extremities
• If any doubt exists, place cardiac monitor to
document asystole in 2 leads for 1 minute
• Mass casualty situations
Definition: Cardiac arrest with total absence of observers
or witness information; or cardiac arrest in which witness
information states arrest occurred greater than 15 minutes
prior to arrival of prehospital personnel and no resuscitative
measures have been done.
Procedure:
• BLS personnel—Follow Public Safety defibrillation guideline
• ALS personnel—Do not initiate CPR; Assess for presence
of apnea, pulselessness (no heart tones/no carotid or
femoral pulses), document asystole in 2 leads for 1
minute
Does not apply if hypothermia, drug ingestion or poisoning
is suspected
TRAUMATIC ARREST Definition: Blunt or penetrating traumatic arrest
Procedure:
• BLS personnel—Follow Public Safety defibrillation
guideline
• ALS personnel—Do not initiate CPR; Assess for presence
of apnea, pulselessness (no heart tones/no carotid or
femoral pulses), document asystole or wide-complex
pulseless electrical activity (PEA) at rate of 40 or less
96§
Policy Summaries
EMS POLICY
20 SUMMARY
DNR AND POLST ORDERS
VALID DNR ORDERS
• A California EMSA/CMA Prehospital DNR Form
• A California/EMSA POLST form in which Section A (Do
Not Attempt Resuscitation/DNR) has been chosen
• An Advanced Health Care Directive (includes living will or
Durable Power of Attorney for Health Care) presented by
an agent of the patient empowered to make health care
decisions for the patient
• An EMS-approved standard DNR medallion/bracelet e.g.
Medi-Alert
• A DNR order in the medical record of a licensed
healthcare facility (e.g. acute care hospital, skilled nursing
facility, hospice or intermediate care facility) signed by
a physician. Electronic physician orders are considered
signed and will be honored.
• A verbal DNR order given by the patient’s physician who
is present at the scene
COMPLYING WITH
AN HONORED DNR
ORDER
• Verify identity of patient
• Perform no life-saving measures
• Cancel the responding ambulance
COMPLYING WITH A • Verify identity of patient. Review section B.
•  If “Full Treatment” marked, patient receives full care
POLST ORDER (NOT
• If “Limited Additional Interventions” or “Comfort
IN ARREST)
NO VALID DNR
ORDER PRESENT
AND REQUEST
MADE FOR NO
RESUSCITATION
Measures Only” is marked, no advanced airway
should be done
• Section C does not apply to pre-hospital setting
If the patient presents with advanced or terminal disease
and incomplete forms or no forms are presented and an
immediate family member, agent, or conservator requests
no resuscitation, resuscitative measures may be withheld
if there is complete agreement of family and providers on
scene. Immediate family members include spouse, domestic
partner, adult child(ren) or adult sibling(s) of the patient.
No base contact is required. If any question of circumstances or
disagreement of family or providers, proceed with resuscitation.
§97
Policy Summaries
EMS POLICY
23 SUMMARY
ABUSE REPORTING RESPONSIBILITIES
EMS personnel are mandated reporters. Report when there is reason to
suspect abuse, which may be of a physical, sexual, or financial nature, or may
involve neglect or domestic violence toward a child, elder, or dependent adult.
BASIC ACTIONS
CHILD ABUSE
REPORTING
ELDER ABUSE
REPORTING
(LONG-TERM CARE
FACILITY)
• Notify the appropriate law enforcement agency
immediately if the scene is unsafe or it is suspected
that a crime has been committed
• Make reasonable efforts to transport the patient to
a receiving hospital for evaluation, and advise the
receiving hospital staff of abuse/neglect suspicions
• Document observations and findings on the patient
care report
• Contact the appropriate reporting agency by
telephoning immediately or as soon as reasonably
possible to provide a verbal report
• Call Children & Family Services Screening Unit: (all
numbers are 24 hours/day) at 1-877-881-1116
• Complete a Suspected Child Abuse Report Form
within 2 working days (SS 8572) (available online at
http://www.ag.ca.gov/childabuse/pdf/ss_8572.pdf )
If the alleged abuse has occurred in a long-term care
facility:
• Call Ombudsman Services of Contra Costa
(925) 685-2070 to make a verbal report
• 24-Hour Crisis Line: 1-800-231-4024
• Complete a Suspected Dependent Adult/Elder
Abuse Form within 2 working days (SOC 341).
Available at: http://www.dss.cahwnet.gov/cdssweb/
entres/forms/English/SOC341.pdf
98§
Policy Summaries
EMS POLICY
23 SUMMARY
ELDER ABUSE
REPORTING – (ALL
OTHER SITES)
SEXUAL ASSAULT
DOMESTIC
VIOLENCE
ABUSE REPORTING RESPONSIBILITIES
(CON'T)
If the alleged abuse has occurred anywhere else (not
at a long-term care facility):
• Call Adult Protective Services (925) 646-2854 or
1-877-839-4347 to make a verbal report
• Complete a Suspected Dependent Adult/Elder
Abuse Form within 2 working days (SOC 341).
Available at: http://www.dss.cahwnet.gov/cdssweb/
entres/forms/English/SOC341.pdf
Sexual assault shall be reported as above in situations
involving elder, dependent adult, child, or domestic
violence.
• It is recommended to transport patients who have
been sexually assaulted to Contra Costa Regional
Medical Center for evaluation and evidentiary
exam; however, the patient may be transported
to the receiving hospital of choice or if medically
unstable to the most appropriate facility for
medical care
• Discourage any activity that would compromise
evidence collection prior to transport such as
bathing, brushing teeth, brushing hair, urinating,
defecating or changing clothes
• Reporting responsibilities are fulfilled by notifying
the local law enforcement agency, and by reporting
suspicions and patient findings to receiving hospital
staff (if transported)
§99
Policy Summaries
EMS POLICY
30 SUMMARY
RESTRAINT TYPES
RESTRAINT ISSUES
RESTRAINTS
• Leather or soft restraints may be used during transport
• Handcuffs may only be used during transport if law
enforcement accompanies the patient in the ambulance.
Patients may not be handcuffed to the gurney
• Chemical restraint
•  Patients shall be placed in Fowler’s or Semi-Fowler’s position
•  Patients shall not be restrained in hogtied or prone position
• Method of restraint should allow for monitoring of vital
signs and respiratory effort and should not restrict the
patient or rescuer’s ability to protect the airway should
vomiting occur
•  Restrained extremities should be monitored for circulation,
motor and sensory function every 15 minutes
LAW ENFORCEMENT • Law enforcement agencies are responsible for capture
and/or restraint of assaultive or potentially assaultive
ROLE
TRANSPORT ISSUES
patients
• Law enforcement agencies retain responsibility for safe
transport of patients under arrest or on 5150 holds
• Patients under arrest or 5150 hold should undergo a
weapons search by law enforcement personnel
• Patients under arrest must be accompanied by law
enforcement personnel
• If an unrestrained patient becomes assaultive during
transport, ambulance personnel shall request law
enforcement assistance, and make reasonable efforts to
calm and reassure the patient
• If the crew believes their personal safety is at risk, they
should not inhibit a patient's attempt to leave the
ambulance. Every effort should be made to release the
patient into a safe environment. Ambulance personnel are
to remain on scene until law enforcement arrives to take
control of the situation.
100§
Policy Summaries
EMS POLICY
33C SUMMARY
HELICOPTER TRANSPORT CRITERIA
USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA ARE MET
TIME CRITERIA
CLINICAL CRITERIA
USE AND
CANCELLATION
• Helicopter transport generally should be used only when
it provides a time advantage. Helicopter field care and
transport time (which includes on-scene time, flight
time, and transport from helipad to the emergency
department) is optimally 20–25 minutes in most cases.
• Also consider: Time to ground transport to a rendezvous
site, or a time delay in helicopter arrival
• Exception: Patients with potential need for advanced
airway intervention (GCS 8 or less, trauma to neck
or airway, rapidly decreasing mental status) may be
appropriate even when time criteria not met
• Trauma patients who meet activation criteria according
to EMS trauma triage policy, except for:
• Stable patients with isolated extremity trauma
• Patients with mechanism but no significant physical
exam findings
• Trauma patients who do not meet activation criteria but
by evaluation of mechanism and physical exam findings,
appear to have potential significant injuries that merit
rapid transport
• Patients with specialized needs available only at a remote
facility such as burn victims/critical pediatric
• Critically ill or injured patients whose conditions may
be aggravated or endangered by ground transport (e.g.
limited access via ground ambulance or unsafe roadway)
The decision to use or cancel a helicopter rests with the
Incident Commander (IC). If criteria not met, helicopter
should be cancelled.
Considerations for IC:
• Patient need
• Estimated ground transport time versus air response and
transport
• Proximity of a helispot or need for a helicopter/
ambulance rendezvous site
• ETA of the helicopter
§101
Policy Summaries
EMS POLICY 36
HAZARDOUS MATERIALS—
SUMMARY
EXPOSURE MANAGEMENT PRINCIPLES
HAZMAT
RECOGNITION WHILE
RESPONDING
HAZMAT
RECOGNITION WHILE
ON SCENE
If alerted to a known or suspected hazmat exposure
prior to scene arrival:
• Request from dispatch the location and safe
route to staging area or IC
• If no staging area, determine location and safe
route to report to IC
• Do not enter contaminated areas or approach
contaminated patients until cleared to do so by
Incident Commander or designee
• Decontaminate patient—Appropriately trained
personnel shall perform decontamination in a
designated area
• Obtain clearance from IC prior to transport
• Obtain MSDS for chemical if available
• After patient decontamination, provide care as
indicated per treatment guidelines
• Provide early alert to hospital—repeat
decontamination may be needed
If EMS personnel become aware that a patient
in their care may have been contaminated by a
unknown or suspected hazardous material:
• EMS personnel should consider themselves
contaminated
• Minimize exposure by evacuating to an uphill/
upwind safe location
• If in cloud, travel crosswind until out of cloud
• Notify fire/medical dispatch and IC of exposure
• Request Hazardous Materials response team
through Sheriff’s Dispatch
• Request backup Fire/Transport as needed for
affected EMS personnel and patients
102§
Policy Summaries
EMS POLICY
HAZARDOUS MATERIALS—
36 SUMMARY EXPOSURE MANAGEMENT PRINCIPLES
HAZMAT
RECOGNITION
WHILE ON SCENE
(CONTINUED)
HAZMAT
RECOGNITION
WHILE
TRANSPORTING
• Remain in safe area until Incident Commander
arrives and provides further instructions
• Prepare to be decontaminated
• Decontaminate EMS personnel and patient(s)—
Appropriately trained personnel shall perform
decontamination in a designated area.
If EMS personnel become aware while transporting
that a patient may have been contaminated by a
known or suspected hazardous material:
• EMS personnel should consider themselves
contaminated
• Determine if safe to drive (e.g. rescuers with or
without symptoms)
• If not safe to drive, immediate decontamination
is needed. Stop transport, notify Fire/Medical
Dispatch and request CCHS HazMat response.
Request Fire/Transport backup as needed.
Protect from further exposure and prepare to be
decontaminated.
• If safe to drive (decontamination is not immediately
indicated), proceed to hospital decontamination
staging area. Alert hospital early of the HazMat
situation. Request staging site if not known. Prepare
to be decontaminated.
GENERAL
• Provide prehospital medical care as soon as it is safe
GUIDELINES FOR ALL • All precautions should be taken to prevent
SITUATIONS
contamination of hospital emergency department
and personnel
§103
Policy Summaries
POLICY 39
SUMMARY
9-1-1 ACTIVATION FOR NON-EMERGENCY
TRANSPORT PROVIDERS
Criteria for upgrade to advanced life support (ALS) for non-emergency
transport providers
DEFINITIONS
•  Unstable: A patient who has life- or limb-threatening condition
requiring immediate and definitive care. An unstable patient
may have respiratory distress, airway compromise, neurological
changes from baseline, signs of actual or impending shock or
may meet criteria for transport directly to a trauma center.
•  Non-emergency ambulance provider: An ambulance provider
holding a valid Contra Costa non-emergency ambulance permit
•  9-1-1 ambulance provider: An ambulance provider holding
a valid Contra Costa emergency ambulance permit and/or
contracting with the County to provide advanced life support
ambulance response to 9-1-1 requests
•  Code 3: Responding to a location and/or transporting to a
receiving facility using red lights and sirens
UNSTABLE PATIENTS
•  A patient, determined to be unstable and/or needing Code 3
transportation to a hospital shall be transported by a 9-1-1
provider, whenever possible.
•  Non-emergency ambulance providers may transport an
unstable patient to the closest/appropriate facility, if they can
do so safely and the time from arrival on scene to arrival at
the hospital is less than 10 minutes. In all other cases the nonemergency ambulance crew shall activate the 9-1-1 system and
request an ALS response.
•  Any non-emergency ambulance provider transporting a patient that
becomes unstable during transport should divert to the closest/
appropriate ED per the Patient Destination Determination Policy
(Policy #9). Receiving facilities should receive notification as soon as
possible of the need for diversion, patient status and the ETA to that
facility.
•  All transports by non-emergency ambulance providers
of unstable patients, and/or transports requiring Code 3
transportation are considered an unusual occurrence. For each
such occurrence an EMS Event report must be completed and
submitted to the EMS Agency within 24 hours of the call.
104§
Policy Summaries
POLICY 39
SUMMARY
ON-VIEWS
9-1-1 ACTIVATION FOR NON-EMERGENCY
TRANSPORT PROVIDERS
• In the event that a non-emergency ambulance provider
arrives on the scene of a collision, illness or injury by
coincidence, the crew shall provide appropriate care and
immediately activate the 9-1-1 system
§105
Policy Summaries
106§
table of contents—procedures and patient care
12-LEAD—MONITORING AND LEAD PLACEMENT............................................................. 109
12-LEAD—LOCALIZING SITE OF INFARCT.............................................................................. 110
12-LEAD—STEMI RECOGNITION AND DESTINATION........................................................111
12-LEAD—STEMI REPORT............................................................................................................ 112
12-LEAD—TRANSMISSION OF MONITOR DATA.................................................................. 113
BLS AIRWAY MANAGEMENT.............................................................................................114–115
INTRAOSSEOUS INFUSION IN ADULTS.........................................................................116–117
INTRAOSSEOUS INFUSION IN ADULTS—HUMERAL SITE................................................ 118
INTRAOSSEOUS INFUSION—PROXIMAL AND DISTAL TIBIA.......................................... 119
INTRAOSSEOUS INFUSION IN CHILDREN.............................................................................. 120
KEY PROCEDURES................................................................................................................ 121–126
NON-INVASIVE MONITORING OF END-TIDAL CO2.......................................................... 127
OXYGEN THERAPY......................................................................................................................... 128
OXYGEN TITRATION AND PULSE OXIMETRY MONITORING........................................... 129
PAIN ASSESSMENT AND MANAGEMENT.............................................................................. 130
PAIN ASSESSMENT TOOLS.......................................................................................................... 131
PEDIATRIC ASSESSMENT............................................................................................................. 132
PEDIATRIC VITAL SIGNS/GLASGOW COMA SCALE............................................................ 133
PEDIATRIC MEDICATION ADMINISTRATION........................................................................ 134
RULE OF NINES—BURN SURFACE AREA................................................................................ 135
SEPSIS SCREENING........................................................................................................................ 136
SPINAL INJURY ASSESSMENT.................................................................................................... 137
SPINAL MOTION RESTRICTION (SMR).................................................................................... 138
VASCULAR ACCESS........................................................................................................................ 139
VENTRICULAR ASSIST DEVICES (VAD).................................................................................... 140
§107
Procedures and Patient Care Reference
108§
Procedures and Patient Care Reference
12-LEAD MONITORING AND LEAD PLACEMENT
sternal angle
Limb Lead Placement:
• Place limb leads on distal extremities if
possible
• Confirm correct lead placement for each
limb
• May be moved to proximal if needed (if
motion artifact)
Chest Lead Placement: To begin placement
of chest leads, locate sternal angle (2nd
ribs are adjacent) then count down to 4th
interspace (below 4th rib)
V1—4th intercostal space at the right sternal border
V2—4th intercostal space at the left sternal border
V4—5th intercostal space at left midclavicular line
Note: Place V4 lead first to aid in correct placement of V3
V3—Directly between V2 and V4
V5—Level of V4 at left anterior axillary line
V6—Level of V4 at left mid-axillary line
IMPORTANT: Careful skin preparation prior to lead placement (rub with gauze or
abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG
12-lead monitoring should continue throughout call to assess for potential
changes.
§109
Procedures and Patient Care Reference
LOCALIZING SITE OF INFARCT
• Localization of an infarct pattern adds to the accuracy of ECG
interpretation
• A STEMI will have 1 mm or more ST-segment elevation in 2 or more
contiguous leads (which means findings noted in the same anatomical
location of the infarct)
• Contiguous leads for inferior infarction include II, III, and aVF
• Contiguous leads for anterior infarction include V1–V4 (V1–V2
elevation also called septal infarction)
• Contiguous leads for lateral myocardial infarction include Leads I, aVL,
V5, and V6
• Lateral MI findings may be in addition to anterior or inferior MI
patterns (anterolateral or inferolateral)
I–LATERAL
aVR
V1–SEPTAL or
ANTERIOR
V4–ANTERIOR
(V4R–RVMI)
II–INFERIOR
aVL–LATERAL
V2–SEPTAL or
ANTERIOR
V5–LATERAL
III– INFERIOR
aVF–INFERIOR
V3–ANTERIOR
V6–LATERAL
110§
Procedures and Patient Care Reference
STEMI RECOGNITION AND DESTINATION
STEMI
RECOGNITION
• Patients who have ECGs of acceptable quality with
the following messages are candidates for transport
to STEMI Receiving Centers:
• ***Acute MI Suspected*** (LIFEPAK 12)
• ***Meets ST-Elevation MI Criteria*** (LIFEPAK15)
• The 12-lead ECG should be inspected prior to
initiation of a STEMI Alert—a steady baseline in all
12-leads and a tracing free of artifact is critical for
accurate interpretation
• Causes of artifact include patient motion or tremor,
poor lead contact, or electrical interference
• Good skin preparation is essential for optimal lead
contact and clear 12-lead tracings
• If artifact is noted the ECG should be repeated
• Paced rhythms may cause false readings—the
pacemaker spike is not always detected by the
computer algorithm. Inform facility if patient has a
pacemaker during report.
STEMI REPORT
If a STEMI is noted on 12-lead ECG, the receiving STEMI
facility should be notified as soon as possible following
completion of the ECG
DESTINATION
POLICY
Patients with an identified STEMI shall be transported
to a STEMI Receiving Center (SRC)
• Patients shall be transported to the closest SRC
unless they request another facility
•  A SRC that is not the closest facility is an acceptable
destination if estimated additional transport time
does not exceed 15 minutes
• Patients with cardiac arrest and return of
spontaneous circulation shall be transported to the
closest SRC regardless of 12-lead results.
• Patients with unmanageable airway en route shall be
transported to the closest available emergency department
§111
Procedures and Patient Care Reference
STEMI REPORT
• A patient with a computer interpretation of ***Acute MI Suspected***
(LP-12) or ***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for
transport to a STEMI Receiving Center
• Verify that 12-lead tracing has good tracings and baseline in all 12-leads
and does not have significant baseline artifact or other deficit before
initiating a STEMI Alert
SITUATION
BACKGROUND
ASSESSMENT
RX – RECAP
• Identify the call as a “STEMI Alert”
• Estimated time of arrival (ETA) in minutes
• Patient age and gender
• Report ECG computer interpretation has a STEMI
message (as listed above)
• Report if subsequent ECG findings are variable
or if ECG quality not optimal (e.g., if no ***Acute
MI*** findings noted in tracings without significant
artifact)
• Verify that 12-lead ECG Transmission has been
completed and received
• Presenting chief complaint and symptoms
• Pertinent past cardiac history
• History of pacemaker (important—paced rhythms
may give false ECG interpretations)
• General assessment
• Pertinent vitals (especially heart rate and BP) and
physical exam
• Cardiac rhythm
• Pain level
• Prehospital treatments given
• Patient response to prehospital treatments
112§
Procedures and Patient Care Reference
TRANSMISSION OF MONITOR DATA
• 12-Lead ECG transmission is an enhancement to the STEMI system that allows facilities
to interpret 12-lead data prior to patient arrival, appropriately prepare, and appropriately
activate resources when indicated
• Transmission of cardiac arrest monitor data and data related to treatment of
dysrhythmias and patient intubations allows appropriate documentation and review of
care provided in those situations
12-Lead ECG Tr ansmission
12-LEAD
TRANSMISSION
IDENTIFIERS
HOSPITAL
NOTIFICATION
REVIEW
• Any 12-Lead ECG that indicates that a patient is having a STEMI
should be transmitted to the STEMI receiving center where the
patient is being transported
• For other patients who have 12-Lead ECGs done, at least one
should be transmitted to the destination hospital or other
monitor site identified by your provider agency
At a minimum, 12-Lead ECG labeling should include initials of the
first and last name of the patient. Provider agencies may require
additional labeling
Once a STEMI 12-Lead has been transmitted to a STEMI receiving
facility, that facility should be notified as soon as possible following the
transmission of the ECG to verify receipt and to complete STEMI alert
Not all hospitals have ability to review transmitted ECGs and some
may filter out normal or non-acute appearing ECGs. Hard copies of
ECGs also must be left at all receiving facilities.
Tr ansmission of Cardiac Arrest and Other Monitor Data
INDICATIONS FOR
TRANSMISSION
TRANSMISSION
REVIEW
• Cardiac arrests
• Any calls that involve the treatment of a cardiac dysrhythmia
(medication, cardioversion or pacing)
• Any call involving monitoring of intubated patients
• Any other call in which the paramedic believes data review may
add to PCR documentation of events
• Transmit "ALL" data to the monitor site identified by your
provider agency
• This data is transmitted to the provider agency and to EMS for review
but does not go to hospitals for immediate access. Code summaries
should be printed and left at receiving facilities.
Note: Optimally, a single monitor should be used to gather data, particularly with regard to
cardiac arrest or continuous monitoring of intubated patients
§113
Procedures and Patient Care Reference
BLS AIRWAY MANAGEMENT
GOALS
The goal of airway management is to ensure
adequate ventilation and oxygenation. Initial airway
management should always begin with BLS Maneuvers
VENTILATION RATES Avoid excessive ventilation. In non-arrest patients,
AND DELIVERY
ventilation rates:
• Adults—10/minute
• Children—20/minute
• Infants—30/minute
Deliver ventilations over one second to produce visible
chest rise and to avoid distention of the stomach (do
not squeeze hard or fast). Ventilation volumes will vary
based on patient size.
PREFERRED
MANEUVERS
Two-person technique is the preferred method to
ventilate patients using bag-valve mask device
Maneuvers—Use “JAWS”
J—Jaw thrust maneuvers to open airway
A—Airway—Use oral or nasal airway
W—Work together—Ventilation using a bag-valve
mask should include two rescuers—one to hold mask
and other to deliver ventilations
S—Slow and small ventilations to produce visible chest rise
114§
Procedures and Patient Care Reference
BLS AIRWAY MANAGEMENT
AIRWAY
POSITIONING
Position the patient to optimize airway opening and
facilitate ventilations (see below)
• Use the sniffing position with head extended (A)
and neck flexed forward (B) unless suspected
spinal injury
• Position with head/shoulders elevated—anterior
ear should be at the same horizontal level as the
sternal notch (C). This is especially advantageous in
larger or morbidly obese patients.
C
§115
Procedures and Patient Care Reference
INTRAOSSEOUS INFUSION IN ADULTS
INDICATIONS
•  Cardiac arrest
•  When IV access unsuccessful or after evaluation of potential
sites it is determined that an IV attempt would not be
successful in the setting of:
•  Shock or evolving shock, regardless of cause
•  Impending arrest or unstable dysrhythmia
CONTRAINDICATIONS
•  Fracture of the targeted bone
•  IO within the past 48 hours in the targeted bone
•  Infection at the insertion site
•  Burns that disrupt actual bone integrity at insertion site
•  Inability to locate landmarks or excessive tissue over the
insertion site
•  Previous orthopedic procedure near insertion site (prosthetic
limb or joint)
INSERTION SITE
•  Proximal humerus (preferred in patients with perfusing rhythm)
•  Proximal tibia
•  Distal tibia (if proximal humerus or tibia unavailable)
PROCEDURE
1. Locate insertion site:
•  The proximal humerus site is the greater tubercle,
identifiable as a prominence on the humerus when the arm
is rotated inward and the patient’s hand is on the abdomen
•  The proximal tibia site is on the flat medial aspect of the
tibia 2 finger-breadths below the lower edge of the patella
and medial to the tibial tuberosity
•  The distal tibia site is 2 finger-breadths above the most
prominent aspect of the medial malleolus (inside aspect of
ankle) in the midline of the shaft of the tibia
2. Prep the insertion site with chlorhexidine and let air dry
3. Select and load the appropriately sized needle on the driver
•  For humeral access the 45 mm (yellow) needle is used
except in adult patients less than 40 kg
•  For proximal and distal tibial access the amount of soft
tissue should be gauged to determine if a 25mm (blue) or 45
mm (yellow) needle is appropriate
116§
Procedures and Patient Care Reference
PROCEDURE
INTRAOSSEOUS INFUSION IN ADULTS
4. Introduce the intraosseous needle through the skin as follows without pulling
trigger of the power driver:
•  For humeral site, the direction of the needle should be placed
perpendicular to the skin, directed at a downward angle of 45
degrees from the frontal plane, heading slightly downward
toward the feet (see images);
•  For tibial sites, the direction of the needle should be at a 90 degree
angle to the flat surfaces of the tibia (see images).
5. Once the needle has touched the bone surface, assess to see if the black
line on the needle is visible. If it is not visible, either a larger needle is
needed or (in the case of use of 45 mm needle) the soft tissue is too thick
to allow use of the IO.
6. With firm pressure, insert needle using power driver. In most cases, the
hub should be flush or touching the skin. Verify that needle is firmly seated
in the bone (should not wobble).
7. Remove stylet and instill lidocaine if patient not in arrest:
•  For adult patients not in arrest, 40 mg (2 ml) of lidocaine
2% should be infused slowly over 1–2 minutes and allow
one additional minute before starting flush.
•  For patients in arrest, no lidocaine is necessary initially but
may be needed if patient regains consciousness.
8. Flush with 10 ml saline. In conscious patients, flush with 5 ml saline
initially and repeat if necessary (may cause less patient discomfort).
9. Attach stabilizer to skin.
10. Attach IV tubing to intraosseous hub, and begin infusion using pressure
bag on IV bag.
11. If painful, an additional 20 mg (1 ml) of lidocaine 2% can be infused over
30 seconds, and after another minute, infusion should be restarted.
12. Monitor site for swelling or signs of infiltration and monitor pulses distal to
area of placement.
13. Place wristband included with IO set on patient.
§117
Procedures and Patient Care Reference
INTRAOSSEOUS INFUSION IN ADULTS—HUMERAL SITE
118§
Procedures and Patient Care Reference
INTRAOSSEOUS INFUSION—
PROXIMAL AND DISTAL TIBIA
§119
Procedures and Patient Care Reference
INTRAOSSEOUS INFUSION IN CHILDREN
Indications and contraindications same as adult procedure. Use only proximal
tibial site in children.
PROCEDURE
1. Locate the insertion site—for pediatric patients the location of proximal tibial
site is on the flat medial aspect of the tibia 2 finger-breadths below the lower
edge of the patella and medial to the tibial tuberosity.
2. Prep the insertion site with chlorhexidine and let air dry.
3. Select and load the appropriately sized needle onto the driver:
•  The 15 mm (pink hub) needle is appropriate in infants or
in small children with thin amounts of soft tissue in the
proximal tibial site;
4. Introduce the intraosseous needle at a 90 degree angle to the flat surface
of the tibia without pulling the trigger of the power driver.
5. Once the needle has touched the bone surface, assess to see if the black
line on the needle is visible. If it is not visible, remove needle, switch to
a longer needle set and reinsert (again without pulling the trigger of the
power driver).
6. With mild to firm pressure, insert needle using power driver. For small
children, once a “give” is sensed as the outer bony cortex is penetrated,
remove finger from power driver trigger to stop insertion (do not withdraw
driver when stopping). The IO hub may not be against the skin.
7. Remove stylet and instill lidocaine if patient not in arrest:
•  For pediatric patients not in arrest, 0.5 mg/kg of lidocaine
2% should be infused slowly over 1–2 minutes and allow
one additional minute before starting flush. See pediatric
drug chart for weight-based dose.
•  For patients in arrest, no lidocaine is necessary initially but
may be needed if patient regains consciousness.
8. Flush with 5 ml saline
9. Attach stabilizer to skin
10. Attach IV tubing to intraosseous hub:
•  Utilize stopcock and syringe to administer appropriate fluid
dose in smaller children
•  Pressure bag may be used in larger children (>50 kg).
11. Monitor site for swelling or signs of infiltration and monitor pulses distal to
area of placement
12. Place wristband included with IO set on patient.
120§
Procedures and Patient Care Reference
SKILL
12-Lead ECG
KEY PROCEDURES
INDICATIONS/CONTRAINDICATIONS/COMMENT
INDICATIONS:
•  Chest pain or suspected Acute Coronary Syndrome (ACS)
•  Atypical ACS or anginal equivalents:
•  Symptoms include shortness of breath, diaphoresis,
syncope, dizziness, weakness, and altered level of
consciousness
•  Elderly patients, females and diabetics are more likely to
present atypically
•  Dysrhythmias (both pre- and post-conversion)
•  Suspected cardiogenic shock
•  Cardiac arrest after return of spontaneous circulation
CONTRAINDICATIONS:
•  Uncooperative patient
•  Any condition in which delay to obtain ECG would compromise
immediately needed care (e.g. arrhythmia requiring immediate shock)
AUTOPULSE
(SRVFPD)
INDICATIONS:
•  Cardiac Arrest in Adults
CONTRAINDICATIONS:
•  Pediatric patients
•  Trauma patients
•  Patients too small or large for the compression band
BLOOD GLUCOSE
TESTING
INDICATIONS:
•  Altered level of consciousness
•  Patients with signs and symptoms of hypoglycemia (may
include diaphoresis, weakness, hunger, shakiness, anxiety)
CONTRAINDICATIONS:
•  Patients not meeting any indication
CO-OXIMETRY
(CARBON
MONOXIDE)
INDICATIONS:
•  Suspected carbon monoxide poisoning
CONTRAINDICATIONS:
•  None
COMMENT:
•  May be unreliable with poor perfusion, excessive patient
motion or excessive ambient light
§121
Procedures and Patient Care Reference
SKILL
CONTINUOUS
POSITIVE AIRWAY
PRESSURE (CPAP)
ENDOTRACHEAL
INTUBATION
KEY PROCEDURES
INDICATIONS/CONTRAINDICATIONS/COMMENT
INDICATIONS:
The patient is awake, able to maintain airway and follow commands
and has 2 or more findings:
•  RR >25
•  Pulse ox <94%
•  Use of accessory muscles
CONTRAINDICATIONS:
•  Unconscious or unable to follow commands
•  Respiratory arrest / apnea
•  Pneumothorax
•  Vomiting
•  Major head, facial or chest trauma
INDICATIONS:
•  Patient with decreased sensorium (GCS less than or equal to 8)
and apneic (adults)
•  Patient with decreased sensorium (GCS less than or equal to 8)
and ventilation unable to be maintained with BLS airway
CONTRAINDICATIONS:
•  Pediatric patients under 40 kg
•  Suspected hypoglycemia or narcotic overdose
•  Maxillo-facial trauma with unrecognizable facial landmarks
•  Seizures
•  Patients with an active gag reflex
COMMENT:
•  In non-arrest patients, allow no more than 2 interruptions of
ventilation lasting up to 30 seconds during laryngoscopy or
intubation attempts
•  Monitor intubated patients continuously using end-tidal carbon
dioxide waveform capnography (ETCO2)
•  Patients with perfusing pulses should be managed with BLS
airways unless unable to successfully ventilate (e.g. trauma,
respiratory insufficiency)
122§
Procedures and Patient Care Reference
SKILL
EXTERNAL
CARDIAC PACING
KEY PROCEDURES
INDICATIONS/CONTRAINDICATIONS/COMMENT
INDICATIONS:
Symptomatic bradycardia
CONTRAINDICATIONS:
•  Cardiac arrest
•  Hypothermia
•  Pediatric Patients
COMMENT:
Use careful titration with midazolam or fentanyl if required for relief
of discomfort
HELMET REMOVAL
INDICATIONS:
Helmet should be removed if:
•  Interferes with airway management or spinal motion restriction
•  Improper fit, allowing head to move within helmet
•  Patient in cardiac arrest
CONTRAINDICATIONS:
•  Patient airway and spinal motion restriction can be addressed
without helmet removal
COMMENT:
Face mask of sports helmets can be removed to facilitate easy
airway access. If helmet removed, shoulder pads (if worn) must also
be removed to maintain neutral spinal alignment
IMPEDANCE
THRESHOLD DEVICE
(ITD)—ResQPOD
(SRVFPD)
INDICATIONS:
Patients 9 years of age in cardiac arrest
CONTRAINDICATIONS:
•  Age below 9 years
•  Perfusing pulse or spontaneously breathing
•  History of traumatic cardiac arrest due to blunt chest trauma
•  Flail chest
COMMENT:
•  If secretions encountered, clear device by removing
and shaking
•  Remove if patient resumes spontaneous breathing or
regains perfusing pulse
§123
Procedures and Patient Care Reference
SKILL
INTRANASAL
NALOXONE
KING AIRWAY
LUCAS CHEST
COMPRESSION
SYSTEM
KEY PROCEDURES
INDICATIONS/CONTRAINDICATIONS/COMMENT
INDICATIONS:
• Patient with altered mental status, respiratory rate less
than 12 and suspected opiate overdose
CONTRAINDICATIONS:
• Shock
• Copious nasal secretions or bleeding
• Patients with established vascular access
COMMENT:
May be less effective in patients with prior nasal mucosal
damage
INDICATIONS:
• Cardiac arrest
• Inability to ventilate non-arrest patient (with BLS airway
maneuvers) in a setting in which endotracheal intubation
is not successful or unable to be done
CONTRAINDICATIONS:
• Presence of gag reflex
• Caustic ingestion
• Known esophageal disease (e.g. cancer, varices, stricture)
• Laryngectomy with stoma (place ET tube in stoma)
• Height less than 4 feet
INDICATIONS:
Patients with medical cardiac arrest who properly fit device.
CONTRAINDICATIONS:
• Traumatic arrest
• Pregnant Patients
• Improper fit of device
• Too small—suction cup pad does not touch chest when
lowered as far as possible
• Too large—support legs of LUCAS cannot be locked to
back plate without compressing patient
124§
Procedures and Patient Care Reference
SKILL
NEEDLE
THORACOSTOMY
ORAL GLUCOSE
STOMAL
INTUBATION
KEY PROCEDURES
INDICATIONS/CONTRAINDICATIONS/COMMENT
INDICATIONS:
Signs and symptoms of tension pneumothorax:
• Altered level of consciousness
• Decreased BP
• Increased pulse and respirations
•  Absent breath sounds, hyperresonance to percussion on
affected side
• Jugular venous distention
• Difficulty ventilating
• Tracheal shift
CONTRAINDICATIONS:
• Any condition without signs and symptoms of tension
pneumothorax
INDICATIONS:
• Altered level of consciousness with known history of
diabetes. Patient is conscious and should be able to sit in an
upright position.
CONTRAINDICATIONS:
• Unconscious patient or unable to sit upright
COMMENT:
• Administer up to 30 grams in the patient’s mouth.
Optimally the patient will self-administer.
• If patient has difficulty swallowing, discontinue
procedure and assure open airway
INDICATIONS:
Patients requiring intubation who have mature stoma and do not
have a replacement tracheostomy tube available
CONTRAINDICATIONS:
Patients without mature stoma
COMMENT:
Pass tube until cuff is just past stoma. If inserted further,
mainstem bronchus intubation may occur as carina is only
around 10 cm from stoma.
§125
Procedures and Patient Care Reference
SKILL
TOURNIQUET
(COMBAT
APPLICATION
TOURNIQUET)
KEY PROCEDURES
INDICATIONS/CONTRAINDICATIONS/COMMENT
INDICATIONS:
• External hemorrhage from extremity that cannot be
controlled with application of dressings with direct
pressure
• May be appropriate for use for hemorrhage control in
multi-casualty settings
CONTRAINDICATIONS:
• Hemorrhage that can be controlled with pressure or
dressings
INDICATIONS:
TRACHEOSTOMY
TUBE REPLACEMENT • Dislodged tracheostomy tube (decannulation)
• Tracheostomy tube obstruction not resolved by suction
CONTRAINDICATIONS:
• Recent tracheostomy surgery (less than 1 month)
• Inadequately sized tract or stoma for insertion of new
tube (use endotracheal tube instead)
126§
Procedures and Patient Care Reference
NON-INVASIVE MONITORING OF END-TIDAL CO2
NON-INVASIVE
ETCO2
MONITORING
INDICATIONS
FOR ETCO2
MONITORING
ETCO2 FINDINGS
• In patients without shock (normal perfusion), use of
non-invasive end-tidal carbon dioxide measurement
(ETCO2) can be valuable in monitoring respiratory
rate and ventilation
•  ETCO2 measurements are an earlier indicator of
respiratory depression than pulse oximetry
• Patients at risk for inadequate ventilation may
include:
• Patients with borderline respiratory rates
(8–12) from overdose or other cause (may help
determine if naloxone appropriate)
• Patients who have received medications such
as fentanyl or midazolam that may depress
respiratory rate.
• Patients with chronic lung disease and chronic
hypoxia—many patients have elevated ETCO2
levels to begin with and rapidly increasing
levels may indicate that a patient has decreased
respirations due to oxygen therapy (loss of
hypoxic drive)
•  ETCO2 readings may be unreliable if there is shock
or poor perfusion
• Normal ETCO2 levels range from 32–36, but
this may vary based on the patient’s underlying
respiratory and metabolic status
•  ETCO2 levels that rise from a normal baseline to
above 40 generally indicate hypoventilation is
occurring
• Patient stimulation, use of BVM, or use of naloxone
may be appropriate based on the situation
§127
Procedures and Patient Care Reference
OXYGEN THERAPY
OXYGEN SAFETY
INITIAL
INDICATIONS FOR
OXYGEN
BLS OXYGEN
ADMINISTRATION
OXYGEN DELIVERY
• Oxygen has the potential to be harmful to patients
—the general goal is to have normal oxygen levels
(normoxemia)—high levels are not better than
normal levels. When pulse oximetry can be used,
an SpO2 of 94% is considered adequate.
• Conditions in which high levels may be dangerous
include stroke, patients who have return of
circulation following cardiac arrest, and patients
with severe chronic lung disease
Supplemental oxygen is indicated in the following
conditions:
• Altered Level of Consciousness (e.g. overdose,
seizure, stroke)
• Cardiac Arrest
• Chest Pain or other suspected cardiac problem
(rapid or irregular pulse)
• Respiratory Distress/Respiratory Depression or Apnea
• Shock
• Smoke or other chemical Inhalation
• Suspected carbon monoxide exposure
• Trauma (major)
Follow specific treatment guidelines where applicable
In general, patients in distress should receive high-flow
oxygen initially
• Chest pain and stroke patients without respiratory
distress or shock should receive low-flow oxygen
Low flow—Use nasal cannula with 4 L/min initial flow
High-flow—Non-rebreather mask with 15 L/min flow
Supplement with BVM if patient is apneic or has
shallow respirations
128§
Procedures and Patient Care Reference
OXYGEN TITRATION AND PULSE
OXIMETRY MONITORING
PULSE OXIMETRY
PULSE OXIMETRY
PITFALLS
ALS OXYGEN
TITRATION
• Utilize pulse oximetry in all patients with oxygen
therapy or suspected hypoxia
• Pulse oximetry is a tool to measure oxygenation,
but must be combined with other assessments and
skills to determine best patient care
• Pulse oximetry readings can be misleading
with poor perfusion (shock) or cold extremities,
hypothermia, anemia or in carbon monoxide
poisoning.
• Readings may be difficult to obtain or unreliable
during with excessive patient movement
(e.g.seizures) or if nail polish is present.
• High flow oxygen should be maintained in patients
with shock and in those with severe respiratory
distress or profound hypoxia
• In most conditions, titration of oxygen should occur
to assure an SpO2 of at least 94%
• Titration may involve decreasing the oxygen flow
for either nasal cannula or non-rebreather masks, or
switching from high to low flow devices
• Stable patients without distress who have SpO2
readings of 94% or greater without therapy do not
need supplemental oxygen
• Some patients with chronic lung problems will not
be able to attain an SpO2 of 94% and in fact may
be at baseline with readings of 90% or less
• The patient’s level of distress is an important
finding in these cases—patients may be
without distress at lower baseline levels and do
not require high-flow oxygen
§129
Procedures and Patient Care Reference
PAIN ASSESSMENT AND MANAGEMENT
Relief of pain and suffering is an important component of quality EMS field care.
Pain assessment is the 5th vital sign and should be performed on each patient
using an age appropriate pain scale. Pain is a subjective experience for the patient
and should be treated following the appropriate pain treatment guideline.
Patients in pain should be assessed before and after pain medication is
administered. Appropriate efforts should be made to alleviate pain using
both pharmacologic (e.g, Fentanyl, Nitroglycerin for cardiac cases) and nonpharmacologic (e.g., splinting, spinal motion restriction) measures.
• Assess blood pressure, heart rate, respiratory rate and pain scale during
initial assessment and 5 minutes after every medication administration
• Assess pain using the same pain scale before and after pain administration
and document
• Dramatic drops in systolic blood pressure and respiratory rate can occur
once pain is relieved. Administer medication cautiously and monitor patient.
• Use narcotics cautiously in the elderly. Increased sensitivity to drugs and
slowed drug metabolism can alter patient response. Allow 10 minutes
to assess the full effect of the medication prior to additional narcotic
administration.
130§
Procedures and Patient Care Reference
FACES PAIN RATING
SCALE (AGES 3 TO
ADULT)
0–10 NUMERIC
PAIN RATING SCALE
(AGES > 9 YO)
PAIN ASSESSMENT
IN THE VERY
YOUNG, NONVERBAL INFANT
AND CHILD
PAIN ASSESSMENT TOOLS
See pain scale and English/Spanish chart on back cover
of field manual
• Point to each face using the words to describe the
pain intensity
• Ask the patient to choose the face that best
describes how they are feeling. A person does not
have to be crying to have the worst pain.
Explain scale (0 means no pain and 10 is the most
severe pain they have ever had). Ask patients what
number on a scale of 0–10 they would give as the level
of pain currently.
Pain assessment in infants, non-verbal young children
or developmentally delayed children is more complex
and presents special challenges. Despite this, pain
medication should be considered in cases where the
infant or child is in severe pain. This includes evidence
of painful mechanisms such as burns, limb fractures or
other events. Using pain medication in these children
requires judgment and caution. Signs and symptoms of
pain in non-verbal young or developmentally delayed
children include:
• Inconsolable crying, screaming that cannot be
distracted from by a caregiver
• High pitched crying
• Any pain face expression that is continual, such as
grimace or quivering chin
• Constant tense/stiff body tone and/or guarding
“ Whatever is painful to adults, is painful to children
until proven otherwise ”
§131
Procedures and Patient Care Reference
PEDIATRIC ASSESSMENT
Begin interventions immediately and transport promptly if life-threatening
conditions are identified in general visual assessment or primary assessment
PEDIATRIC ASSESSMENT TRIANGLE—GENER AL VISUAL
ASSESSMENT
APPEARANCE
WORK OF
BREATHING
CIRCULATION
ASSESSMENT
ABNORMAL
Assess TICLS: Tone,
Interactiveness, Consolability,
Look/Gaze, Speech/Cry
Any abnormality
Assess for skin color
Abnormal skin color or
external bleeding
Assess effort
Increased or decreased effort
or abnormal sounds
PREHOSPITAL PRIMARY ASSESSMENT
ASSESSMENT
SIGNS OF LIFETHREATENING CONDITION
AIRWAY
Assess patency
Complete or severe airway obstruction
CIRCULATION
Assess heart rate, pulses,
capillary refill, skin color and
temperature, blood pressure
Tachycardia, bradycardia,
absence of detectable pulses,
poor blood flow (increased
capillary refill, pallor, mottling,
or cyanosis), hypotension
BREATHING
DISABILITY
EXPOSURE
Assess respiratory rate and
Apnea, slow respiratory rate,
effort, air movement, airway and very fast respiratory rate or
breath sounds, pulse oximetry
significant work of breathing
Assess AVPU response, pupil
size and reaction to light,
blood glucose
Decreased response or abnormal
motor response (posturing) to
pain, unresponsiveness
Assess skin for rash or trauma Hypothermia, rash
(petichiae/purpura)
consistent with septic
shock, significant bleeding,
abdominal distention
132§
Procedures and Patient Care Reference
PEDIATRIC VITAL SIGNS/GLASGOW COMA SCALE
AGE
NORMAL RR NORMAL HR
TERM NEONATE
INFANT (<1 YR)
TODDLER (1–3 YR)
PRESCHOOLER (4–5 YR)
SCHOOL AGE (6–12 YR)
ADOLESCENT (13–18 YR)
30–60
100–205
30–60
100–190
24–40
90–150
22–34
80–140
18–30
70–120
12–20
60–100
HYPOTENSION BY
SYSTOLIC BP
Neonate: Less than 60
mmHg or weak pulses
Infant: Less than 70
mmHg or weak pulses
1–10 yrs: Less than 70
mmHg + (age in yrs x 2)
Over 10: Less than 90
mmHg
PEDIATRIC GCS
INFANT
MOTOR RESPONSE Spontaneous
movements
Withdraws to touch
Withdraws to pain
Flexion
Extension
No response
SCORE
6
5
4
3
2
1
CHILD
SCORE
Obeys commands
Localizes
Withdraws
Flexion
Extension
No response
6
5
4
3
2
1
5
4
3
2
1
VERBAL RESPONSE Coos and babbles
5
4
3
2
1
Oriented
Confused
Inappropriate
Incomprehensible
No response
EYE RESPONSE
4
3
2
1
Opens spontaneously 4
Opens to speech
3
Opens to pain
2
Irritable cry
Cries to pain
Moans to pain
No response
Opens spontaneously
Opens to speech
Opens to pain
No response
No response
1
§133
Procedures and Patient Care Reference
PEDIATRIC MEDICATION ADMINISTRATION
Patient safety in medication administration is paramount. Accurate
administration of pediatric medications requires multiple steps. Follow each
of these steps in every case.
Remember the 6 Rights—Right patient, right drug (and
ASSESS PATIENT
indication), right dose, right route of administration,
right timing and frequency, right documentation
OBTAIN WEIGHT
ESTIMATE IN KG
DETERMINE
VOLUME ON DRUG
CHART
DRAW UP
MEDICATION
DOUBLE CHECK TO
CONFIRM VOLUME
ADMINISTER
MEDICATION
DOCUMENTATION
• Use Broselow tape in every child of appropriate
height to determine color range of weight
• Broselow applies to patients less than 147 cm
tall (4 feet 10 inches)
• If taller than Broselow tape, estimate weight by
patient/parent history or paramedic estimate and
ALWAYS convert to kg using conversion table
• Consult drug chart based on medication name to
determine volume in ml
• If 50 kg or greater, utilize adult dosages
• Verify drug being administered
• Utilize smallest syringe for volume (e.g. 1 ml or less,
use tuberculin syringe)
• When giving IM or intranasal medication, load
syringe only with amount to be administered
• Double-check volume and dose with drug chart in
hand—verbalize name of medication, volume, dosage
and route to another paramedic or EMT on scene
• Administer by appropriate route
• Observe patient for any signs of adverse reaction
• Always document drug dosages in chart by mg
(most drugs), grams (Dextrose), or mcg (Fentanyl)
• Document response to medication and any
observed adverse reaction
134§
Procedures and Patient Care Reference
RULE OF NINES—BURN SURFACE AREA
§135
Procedures and Patient Care Reference
SEPSIS SCREENING
• Sepsis is a life-threatening condition that can occur when a systemic reaction
known as Systemic Inflammatory Response Syndrome (SIRS) develops and is
related to an infection
• The inflammatory response may be the result of exposure to infectious
agents in the blood, urine, lungs, skin, or other organs
RISK FACTORS
INDICATIONS FOR
SCREENING
ASSESSMENT
CRITERIA FOR
POSITIVE SCREEN
HOSPITAL
REPORTING
Common risk factors for sepsis include elderly age, diabetes, and
immunocompromised states. Other risk factors include cancer,
renal disease, alcoholism, injection drug use, malnutrition,
hypothermia, or recent surgery or invasive procedure.
Sepsis screening should be done in adults in the setting of
suspected infection. Examples:
• Fever;
• Respiratory symptoms such as tachypnea, shortness of
breath, cough, sputum production;
• Abdominal symptoms such as vomiting, diarrhea, or
abdominal pain;
• Urinary symptoms such as flank pain or painful/frequent
urination;
• Skin infections (cellulitis or abscess);
• General weakness, altered level of consciousness or lethargy,
especially in the elderly
Sepsis screening includes assessment of pulse rate, respiratory
rate and temperature. It is important to note that an elevated
temperature may not be seen in sepsis, particularly in elderly
patients or advanced stages.
A positive sepsis screen in adults occurs in the setting of
suspected infection when two of the three following conditions
are met:
• Heart rate/pulse greater than 90;
• Respiratory rate greater than 20;
• Temperature above 100.4 or below 96.
If a positive sepsis screen is encountered, the receiving facility
should be notified as part of the report from the field. Report
the finding as a “positive sepsis screen.” Not all patients with
a positive screen will have sepsis but alerting the facility may
assist in calling attention to time-sensitive steps in evaluation
and care that are needed to be taken upon hospital arrival.
136§
Procedures and Patient Care Reference
SPINAL INJURY ASSESSMENT
ASSESSMENT
PRINCIPLES
• Careful motor/sensory and spine exams
• Consider reliability of patient
• Consider factors that elevate risk
PATIENT RELIABILITY Unreliable assessments if:
• Coma or altered level of consciousness (including
significant impairment by drugs or alcohol)
• Communication barrier
• Significant distracting injury
EXAMINATION AND
KEY FINDINGS
Examination should include:
• Wrist or finger extension of both hands
• Plantarflexion and dorsiflexion of both feet
• Gross sensation in all extremities
• Check for abnormal sensations to extremities
(paresthesias)
• Palpate vertebral column thoroughly
Key findings on examination include:
• Midline spinal tenderness on palpation
• Obvious deformity of spine
• Neurologic deficit of extremities
• Weakness, paralysis, sensory findings or
subjective sensory complaints (numbness or
tingling)
• Presence of priapism or spinal shock
RISK ASSESSMENT
• History of high-velocity blunt injury increases risk
• Axial load injury to the head (e.g. diving) increases risk
• Low-velocity injuries such as falls from standing
or lower-velocity motor vehicle accidents have
increased risk in older patients (65 and older)
§137
Procedures and Patient Care Reference
SPINAL MOTION RESTRICTION (SMR)
• The purpose of full spinal motion restriction is to protect patients from
potential further injury when an unstable spinal fracture exists.
• Full spinal motion restriction may cause airway or respiratory compromise,
lead to skin breakdown (decubiti) and may cause significant pain.
• Routine use of full spinal motion restriction should be avoided and should
be reserved for patients with confirmatory physical findings or high
suspicion of spinal fracture.
SPINAL MOTION RESTRICTION IN BLUNT TR AUMA
•  Cervical collar, head bed, concave or padded board, straps
FULL SPINAL MOTION
RESTRICTION METHODS •  Cervical collar with full-length vacuum splint
INDICATIONS FOR
FULL SPINAL MOTION
RESTRICTION (BLUNT
TRAUMA):
•  Major blunt trauma meeting criteria for trauma center activation
•  Presence of neurologic deficit (paralysis, weakness, numbness or
tingling), priapism or suspected spinal shock
•  Obvious anatomic deformity of spine
•  Significant tenderness on palpation of vertebral column
•  Significant blunt trauma mechanism when patient evaluation is
unreliable
•  Cervical collar only
MODIFIED SPINAL
MOTION RESTRICTION •  Cervical collar with padding to limit movement
•  Cervical collar with KED or half-length vacuum splint
METHODS
•  Blunt trauma not meeting above criteria but with pain complaints
INDICATIONS FOR
or concerns based on mechanism or patient risk
MODIFIED SPINAL
MOTION RESTRICTION •  Examples of patients may include those ambulatory after
self-extrication, low-velocity mechanisms, and those with no
(BLUNT TRAUMA)
neurologic findings.
SPINAL MOTION RESTRICTION IN PENETR ATING TR AUMA
INDICATIONS
FOR FULL
SPINAL MOTION
RESTRICTION
•  Spinal motion restriction should only be employed in
penetrating trauma if there is a neurologic deficit or an obvious
deformity of the spine
•  Patients who have both penetrating injury and a significant
blunt injury should be evaluated using blunt trauma criteria
•  Altered level of consciousness or presence of an entry/exit wound
in proximity of the spine are no longer indications for SMR
138§
Procedures and Patient Care Reference
VASCULAR ACCESS
SKILL
SALINE LOCK
ARM IV
ANTECUBITAL
IV
INDICATION/COMMENT
When medication alone is
being given or a potential for
medication is anticipated
No anticipated need for
prehospital medication or fluid
When fluids or medications
needed and patient not in
shock or arrest. Antecubital site
not ideal unless no other vein
available.
No anticipated need for
prehospital medication or fluid
• Shock
• Adenosine (rapid IV bolus)
• Cardiac arrest if easily
accessible
• Other peripheral sites not
available and medications or
fluids indicated
No anticipated need for
prehospital medication or fluid
INTRAOSSEOUS • Cardiac arrest
• Profound shock or unstable
ACCESS (IO)
EXTERNAL
JUGULAR IV
CONTRAINDICATION
dysrhythmia when rapid
IV access or suitable vein
cannot be rapidly located
• Use lidocaine for pain
control in non-arrest
patients PRIOR to IO
flush, fluid or medication
(Infusion is painful!)
• If no medication or fluid is
being administered (do not
use for prophylactic vascular
access)
• If patient stable
• When other routes for
medications available (IM,
IN)
Unstable patient needs
• Contraindicated in cardiac
emergent IV medication or
arrest unless IO and
fluids AND no peripheral site is
antecubital IV cannot be
available AND IO not appropriate
started (interrupts CPR)
(e.g. very alert patient)
• When other routes for
medications available (IM,
IN)—e.g. naloxone or use of
glucagon instead of dextrose
§139
Procedures and Patient Care Reference
VENTRICULAR ASSIST DEVICES (VAD)
BACKGROUND INFOR MATION
• A Ventricular Assist Device (VAD) is an implanted device used to partially or completely
replace the pumping function of a failing heart. VADs are used both as a bridge device
while patients are awaiting heart transplant, and now increasingly are used permanently
in patients who are not transplant candidates (referred to as destination therapy).
• VAD patients and their families/caretakers have been given training for their devices and
they should be capable of basic troubleshooting of the device. Hospitals that implant
VADs have 24-hour on-call coverage (VAD Coordinators) for families or responders
to contact in case of any issues. The contact phone number should be present on the
patient’s equipment and this person may be able to help the family or responding
personnel in assessing the device.
ASSESSMENT
• Depending on the type of VAD, a patient may or may not present with a palpable pulse,
and blood pressure may not be detected, particularly with automatic measurements.
Most newer VADs work without generating a pulse. The pulse, if present, may not
correspond to the patient’s heart rate on the monitor.
• In the absence the ability to detect pulse and blood pressure, patient evaluation of skin
signs, level of consciousness, oxygen saturation, non-invasive end-tidal carbon-dioxide,
and general appearance may give the best clues as to the patient’s clinical status.
TREATMENT
• Patients may be cardioverted or defibrillated if symptomatic, but asymptomatic
dysrhythmias do not require treatment
• VAD devices may become dislodged with chest compressions and this may lead to
massive hemorrhage. Do not perform chest compressions on patients with VADs, even if
the patient is unconscious.
• Treatment should otherwise follow appropriate treatment guidelines. Medical direction
is provided by the base hospital (VAD coordinators cannot provide medical direction).
DESTINATION and DISPOSITION
• In most circumstances, when transport is indicated the appropriate destination for the
patient is the hospital where the VAD was implanted and the patient is managed.
•  For very minor conditions (e.g. small laceration repair) local transport may be appropriate.
• Contact the base hospital if there are questions concerning destination.
• If possible, the patient’s family member or caregiver should accompany the patient
in the ambulance, and all related VAD equipment (e.g. spare batteries) should also be
transported with the patient.
• In arrest situations, determine if DNR/POLST or advance directives are available. Many
VAD patients have made end-of-life care decisions.
140§
Procedures and Patient Care Reference
table of contents—operational reference
RADIO COMMUNICATIONS....................................................................................................... 142
SBAR REPORTING........................................................................................................................... 143
EMT SCOPE OF PRACTICE.................................................................................................144–145
PARAMEDIC SCOPE OF PRACTICE..................................................................................146–147
PARAMEDIC SCOPE OF PRACTICE—LOCAL OPTIONAL SCOPE...................................... 148
BURN CENTERS............................................................................................................................... 149
CONTRA COSTA COUNTY HOSPITALS.......................................................................... 150–151
OUT-OF-COUNTY SPECIALTY CENTERS................................................................................. 152
§141
Operational and Regulatory Reference
RADIO COMMUNICATIONS
Four radio channels are designated for communications with hospitals in Contra
Costa County. Receiving hospital communications are done via XCC EMS 2,
whereas paramedic base hospital communications may occur via XCC EMS 2 or
XCC EMS 3, depending on location
XCC EMS 1
(formerly L9)
XCC EMS 2
(formerly L19)
T: 491.4375
R: 488.4375
T: 491.9125
R: 488.9125
Use for Sheriff’s Dispatch-toambulance communication
XCC EMS 3
T: 491.6125
R: 488.6125
XCC EMS 4
T: 491.6625
R: 488.6625
Primary channel for base contact for
paramedic units operating south of
Ygnacio Valley Road and west of I– 680
along Highway 24
Primary channel for base contact
for West County paramedic units.
Also used county-wide for BLS and
helicopter radio traffic
Primary channel for base contact for
paramedic units operating in East
County and Central County north of
Ygnacio Valley Road
Whenever possible, paramedic personnel should use the XCC EMS channel assigned to
the area in which they are responding, for ambulance-to-base hospital communications.
XCC EMS 2 is the county-wide backup ALS channel and should be used if XCC EMS 3 or
XCC EMS 4 is not available. Ambulance and helicopter personnel are to contact Sheriff’s
Dispatch on XCC EMS 1 to request the use of XCC EMS 2 prior to utilizing the channel. The
dispatcher shall be given unit identification and a description of current traffic (Code 2,
Code 3 or trauma destination decision).
No request for use is necessary for XCC EMS 3 or XCC EMS 4. However, each unit must
monitor the channel prior to use to ensure that other units are not already using the
channel. Radio identification procedures must be strictly followed, as more than one call
may be occurring at the same time. If traffic is in progress on a XCC EMS channel, other
ambulance personnel may either wait until current traffic is finished or find an alternate
means of contacting the desired hospital.
Any unit may, in cases such as trauma destination decisions, request that Sheriff’s
Dispatch break into current traffic on XCC EMS 2 to request temporary use of the channel.
Units using XCC EMS 3 or XCC EMS 4 may request use of the channel from a unit that is
currently on that channel. When making base contact for trauma destination only, the
initial transmission should make the purpose of the call clear. Cellular phones may also be
used as a means of communication.
142§
Operational and Regulatory Reference
SBAR REPORTING
SBAR is a tool that is recommended to assure timely, effective communication
during all patient-related communications between all health care providers.
SBAR assures that urgent issues and immediate needs get addressed up front.
SBAR is compatible with the trauma MIVT reporting. Routine use during base
contact and patient handoff supports safe and effective patient care.
SITUATION
KEY INFORMATION
SBAR REPORT EXAMPLE
• Identify yourself
• What is the situation?
• State urgent issues and
immediate needs up
front!
This is Unit 123 with a STEMI
alert. Patient is a 45 yo male
with 12 lead positive for ST
elevation
RR 28 labored B/P 160/98
Diaphoretic, Pain 9 out 10,
12 lead ***Acute MI*** no
significant artifact seen.
No significant change with
treatment. Airway stable.
BACKGROUND • What has happened up to
this point?
• What past history would
be important to know for
further patient treatment?
(e.g. high risk medications,
past medical history)
Patient started having chest
pain off and on the last 2
hours. Family called 911.
Patient has no history of
heart problems and takes
Lipitor and metformin.
ASSESSMENT
• How is the patient now?
• Improved or worse since
on scene?
• Patient stable or unstable?
Rx Recap
• What field care given?
• Was it effective?
• Concerns?
ASA and oxygen 4L nasal
cannula
STEMI alert
§143
Operational and Regulatory Reference
EMT SCOPE OF PRACTICE
"Emergency Medical Technician" or "EMT" means a person who has successfully
completed an EMT course which meets the requirements of this Chapter, has
passed all required tests, and who has been certified by the EMT certifying
authority.
100063. Scope of Practice of Emergency Medical Technician (EMT)
a. During training, while at the scene of an emergency, during transport of the sick or injured,
or during interfacility transfer, a certified EMT or supervised EMT student is authorized to do
any of the following:
1. Evaluate the ill and injured.
2. Render basic life support, rescue and emergency medical care to patients.
3. Obtain diagnostic signs to include, but not be limited to the assessment of
temperature, blood pressure, pulse and respiration rates, level of consciousness, and
pupil status.
4. Perform cardiopulmonary resuscitation (CPR), including the use of mechanical adjuncts
to basic cardiopulmonary resuscitation.
5. Administer oxygen.
6. Use the following adjunctive airway breathing aids:
A.
B.
C.
D.
Oropharyngeal airway;
Nasopharyngeal airway;
Suction devices;
Basic oxygen delivery devices for supplemental oxygen therapy including, but not
limited to, humidifiers, partial rebreathers, and venturi masks; and
E. Manual and mechanical ventilating devices designed for prehospital use including
continuous positive airway pressure.
7. Use various types of stretchers and body immobilization devices.
8. Provide initial prehospital emergency care of trauma, including, but not limited to
A.
B.
C.
D.
E.
F.
Bleeding control through the application of tourniquets;
Use of hemostatic dressings from a list approved by the Authority;
Spinal immobilization;
Seated spinal immobilization;
Extremity splinting; and
Traction splinting.
144§
Operational and Regulatory Reference
EMT SCOPE OF PRACTICE
9. Administer over the counter medications when approved by the medical director of the
LEMSA, including, but not limited to:
A. Oral glucose or sugar solutions; and
B.Aspirin (not currently allowed in Contra Costa County).
10. Extricate entrapped persons.
11. Perform field triage.
12. Transport patients.
13. Mechanical patient restraint.
14. Set up for ALS procedures, under the direction of an Advanced EMT or Paramedic.
15. Perform automated external defibrillation.
16. Assist patients with the administration of physician prescribed devices, including but
not limited to, patient operated medication pumps, sublingual nitroglycerin, and selfadministered emergency medications, including epinephrine devices.
17. In addition to the activities authorized by subdivision (a) of this section, the medical
director of the local EMS agency may also establish policies and procedures to allow
a certified EMT or a supervised EMT student in the prehospital setting and/or during
interfacility transport to:
A. Monitor intravenous lines delivering glucose solutions or isotonic balanced salt
solutions including Ringer’s lactate for volume replacement;
B. Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow
and turn off the flow of intravenous fluid; and
C. Transfer a patient who is deemed appropriate for transfer by the transferring
physician, and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks,
foley catheters, tracheostomy tubes and/or indwelling vascular access lines,
excluding arterial lines;
D. Monitor preexisting vascular access devices and peripheral lines delivering intravenous
fluids with additional medications pre-approved by the Director of the Authority (not
currently allowed in Contra Costa County).
§145
Operational and Regulatory Reference
PARAMEDIC SCOPE OF PRACTICE
California Code of Regulations, Title 22, Division 9, Chapter 4:
100145. Scope of Practice of Paramedic.
a. A paramedic may perform any activity identified in the scope of practice of an EMT in
Chapter 2 of the Division, or any activity identified in the scope of practice of an Advanced
EMT (AEMT) in Chapter 3 of this Division.
b. A paramedic shall be affiliated with an approved paramedic service provider in order to
perform the scope of practice specified in this Chapter.
c. A paramedic student or a licensed paramedic, as part of an organized EMS system, while
caring for patients in a hospital as part of his/her training or continuing education under
the direct supervision of a physician, registered nurse, or physician assistant, or while at the
scene of a medical emergency or during transport, or during interfacility transfer, or while
working in a small and rural hospital pursuant to section 1797.195 of the Health and Safety
Code, may perform the following procedures or administer the following medications when
such are approved by the medical director of the local EMS agency and are included in the
written policies and procedures of the LEMSA.
1. Basic Scope of Practice:
A. Utilize electrocardiographic devices and monitor electrocardiograms, including 12lead electrocardiograms.
B. Perform defibrillation, synchronized cardioversion, and external cardiac pacing.
C. Visualize the airway by use of the laryngoscope and remove foreign body(ies) with
forceps.
D. Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts,
the esophageal airway, perilaryngeal airways, stomal intubation, and adult oral
endotracheal intubation.
E. Utilize mechanical ventilation devices for continuous positive airway pressure
(CPAP), bi-level positive airway pressure (BPAP) and positive end expiratory
pressure (PEEP) in the spontaneously breathing patient.
F. Institute intravenous (IV) catheters, saline locks, needles, or other cannulae (IV
lines), in peripheral veins; and monitor and administer medications through preexisting vascular access.
G. Institute intraosseous (IO) needles or catheters.
H. Administer intravenous glucose solutions or isotonic balanced salt solutions,
including Ringer’s lactate solution.
146§
Operational and Regulatory Reference
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
PARAMEDIC SCOPE OF PRACTICE
Obtain venous blood samples.
Use laboratory devices, including point of care testing, for pre-hospital screening
use to measure lab values including, but not limited to: glucose, capnometry,
capnography, and carbon monoxide when appropriate authorization is obtained
from State and Federal agencies, including from the Centers for Medicare and
Medicaid Services pursuant to the Clinical Laboratory Improvement Amendments
(CLIA).
Utilize Valsalva maneuver.
Perform needle cricothyroidotomy. (not currently used in Contra Costa County)
Perform needle thoracostomy.
Perform nasogastric and orogastric tube insertion and suction. (not currently used
in Contra Costa County)
Monitor thoracostomy tubes.
Monitor and adjust IV solutions containing potassium, equal to or less than 40
mEq/L.
Administer approved medications by the following routes: IV, IO, intramuscular,
subcutaneous, inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or
topical.
Administer, using prepackaged products when available, the following
medications:
(1) 10%, 25% and 50% dextrose; (25%, 50% not currently used in Contra Costa
County)
(2) activated charcoal; (not currently used in Contra Costa County)
(3) adenosine;
(4) aerosolized or nebulized beta–2 specific bronchodilators;
(5) amiodarone;
(6) aspirin;
(7) atropine sulfate;
(8) pralidoxime chloride;
(9) calcium chloride;
(10) diazepam; (not currently used in Contra Costa County)
(11) diphenhydramine hydrochloride;
(12) dopamine hydrochloride; (not currently used in Contra Costa County)
(13) epinephrine;
(14) fentanyl;
§147
Operational and Regulatory Reference
PARAMEDIC SCOPE OF PRACTICE
(15) glucagon;
(16) ipratropium bromide (not currently used in Contra Costa County)
(17) lorazepam; (not currently used in Contra Costa County)
(18) midazolam
(19) lidocaine hydrochloride;
(20) magnesium sulfate; (not currently used in Contra Costa County)
(21) morphine sulfate; (not currently used in Contra Costa County)
(22) naloxone hydrochloride;
(23) nitroglycerin preparations, except IV, unless permitted under (c)(2)(A) of this
section;
(24) ondansetron
(25) sodium bicarbonate
2. Local Optional Scope of Practice:
A. Perform or monitor other procedure(s) or administer any other medication(s)
determined to be appropriate for paramedic use, in the professional judgment
of the medical director of the local EMS agency, that have been approved by the
Director of the Emergency Medical Services Authority when the paramedic has
been trained and tested to demonstrate competence in performing the additional
procedures and administering the additional medications.
CONTR A COSTA LOCAL OPTIONAL SCOPE
•  Impedance Threshold Device (ResQPOD)
•  Pediatric Endotracheal Intubation (limited to patients > 40 kg)
CONTR A COSTA LOCAL OPTIONAL SCOPE ITEMS
ITEMS LIMITED TO CRITICAL CARE TR ANSPORT PAR AMEDICS ONLY
•  Blood/Blood Product Infusion
•  Glycoprotein IIb/IIIa Receptor Inhibitor Infusion
•  Heparin Infusion
•  KCL Infusion
•  Lidocaine Infusion
•  Midazolam Infusion
•  Morphine Sulfate Infusion
•  Nitroglycerin Infusion
•  Sodium Bicarbonate Infusion
•  Total Parenteral Nutrition (TPN) Infusion
148§
Operational and Regulatory Reference
HOSPITAL
BURN CENTERS
SERVICES
PHONE
Santa Clara Valley
Medical Center
751 S. Bascom Avenue
San Jose CA
Adult and Pediatric
Burn Center
(408) 885-6666
UC Davis Medical Center
Regional Burn Center
2315 Stockton Blvd.
Sacramento CA
Adult and Pediatric
Burn Center
(916) 734-3636
St. Francis Burn Center
Adult and Pediatric
Burn Center
(No Helipad available)
(415) 353-6255
900 Hyde Street
San Francisco CA
§149
Operational and Regulatory Reference
CONTRA COSTA COUNTY HOSPITALS
Base Hospital
HOSPITAL
BASE PHONE
ED PHONE
Taped:
(925) 939-5804
Receiving Facility
Notification:
(925) 947-3379
ED:
(925) 939-5800
14524
SERVICES
ED PHONE
Contra Costa Regional
Medical Center
2500 Alhambra Avenue
Martinez CA 94553
Basic ED
OB/Neonatal
(925) 370-5971
XCC EMS 2
ALERT CODE
14574
Doctors Medical Center—
San Pablo
2000 Vale Road
San Pablo CA 94806
Basic ED
STEMI Center
Stroke Center
(510) 234-6010
13613
John Muir Health—
Concord Campus
2540 East Street
Concord CA 94520
Basic ED
STEMI Center
Stroke Center
(925) 689-0553
14214
John Muir Health—
Walnut Creek Campus
1601 Ygnacio Valley Rd
Walnut Creek CA 94598
Basic ED
OB/Neonatal
Trauma Center
STEMI Center
Stroke Center
Receiving Facility
Notification:
(925) 947-3379
ED:
(925) 939-5800
14524
John Muir Health—
Walnut Creek Campus
1601 Ygnacio Valley Road
Walnut Creek CA 94598
XCC EMS 2
ALERT CODE
Receiving Facilities
HOSPITAL
150§
Operational and Regulatory Reference
CONTRA COSTA COUNTY HOSPITALS
HOSPITAL
SERVICES
ED PHONE
XCC EMS
2 ALERT
CODE
Kaiser Medical Center —
Antioch
5001 Deer Valley Road
Antioch CA 94531
Basic ED
OB/Neonatal
Stroke Center
(925) 813-6099
14564
Kaiser Medical Center —
Richmond
901 Nevin Avenue
Richmond CA 94504
Basic ED
Stroke Center
(510) 307-1758
13653
Kaiser Medical Center —
Walnut Creek
1425 South Main Street
Walnut Creek CA 94596
Basic ED
OB/Neonatal
STEMI Center
Stroke Center
(925) 939-1788
14284
San Ramon Regional
Medical Center
6001 Norris Canyon Road
San Ramon CA 94583
Basic ED
OB/Neonatal
STEMI Center
Stroke Center
(925) 275-8338
13623
Sutter Delta Medical Center Basic ED
3901 Lone Tree Way
OB/Neonatal
Antioch CA 94509
STEMI Center
(925) 779-7273
14294
§151
Operational and Regulatory Reference
OUT-OF-COUNTY SPECIALTY CENTERS
HOSPITAL
TYPE
ED PHONE
Alameda County
Medical Center—
Oakland (Highland)
Trauma
(510) 535-6000
Alta Bates Medical Center
—Berkeley
Stroke
(510) 204-2500
Children’s Hospital—
Oakland
Trauma
(510) 428-3240
Eden Medical Center—
Castro Valley
Trauma
Stroke
(510) 889-5015
Kaiser Oakland
Stroke
(510) 752-7667
Kaiser South Sacramento
Trauma
(916) 688-6964
Marin General Hospital
Trauma
(415) 925-7203
San Francisco
General Hospital
Trauma
(415) 647-4747
Summit Campus—
Alta Bates Medical Center
—Oakland
STEMI
Stroke
(510) 869-8797
UC Davis
Medical Center—
Sacramento
Trauma
(916) 734-3892
(916) 734-5669
Valley Care—
Pleasanton
STEMI
(925) 416-6518
152§
Operational and Regulatory Reference
table of contents—drug reference
ADULT DRUG REFERENCE.................................................................................................155–161
PEDIATRIC DRUG REFERENCE..........................................................................................162–164
PEDIATRIC WEIGHT-BASED DOSING CHARTS...........................................................165–180
Adenosine................................................................................................................................ 165
Amiodarone............................................................................................................................. 166
Atropine.................................................................................................................................... 167
Defibrillation............................................................................................................................168
Dextrose 10%..........................................................................................................................169
Diphenhydramine................................................................................................................ 170
Epinephrine 1:10,000...........................................................................................................171
Epinephrine 1:1000............................................................................................................. 172
Intranasal Fentanyl.............................................................................................................. 173
Fentanyl IV/IM........................................................................................................................ 174
Fluid Bolus............................................................................................................................... 175
Glucagon................................................................................................................................. 176
Lidocaine................................................................................................................................. 177
Midazolam.............................................................................................................................. 178
Naloxone................................................................................................................................. 179
Weight Conversion.............................................................................................................. 180
§153
Operational and Regulatory Reference
154§
ADULT DRUG REFERENCE
DRUG
INDICATION
ADENOSINE
Paroxysmal SVT
ALBUTEROL
Bronchospasm
5 mg in 6 ml NS
nebulized
Crush Injury—
Hyperkalemia
5 mg in 6 ml
NS nebulized
continuously
Ventricular
Fibrillation or
Pulseless VT
300 mg IV or IO
bolus, repeat
150 mg bolus if
rhythm persists
Stable Ventricular
Tachycardia
150 mg IV
infusion or slow
IV push over 10
minutes (15 mg/
minute)
AMIODARONE
ADULT DOSAGE PRECAUTIONS/
COMMENTS
May cause transient
heart block or asystole.
Side effects include
chest pressure/pain,
2nd Dose—12 mg
palpitations, hypotension,
rapid IV push
dyspnea, or feeling of
impending doom. Use
Follow each dose
with rapid bolus of caution when patient is
taking carmbamazepine,
20 ml NS
dipyramidole, or
methylxanthines. Do not
administer if acute asthma
exacerbation.
1st Dose—6 mg
rapid IV
Repeat as needed for
bronchospasm Use
with caution in patients
taking MAO inhibitors
(antidepressants Nardil
and Parnate)
In patient with pulses,
may cause hypotension.
Do not administer if
patient hypotensive.
When creating infusion,
careful mixing needed
to avoid foaming of
medication (do not use
filter needle).
§155
Drug Reference
ADULT DRUG REFERENCE
DRUG
INDICATION
ASPIRIN
Chest Pain—
Suspected ACS
ATROPINE
ADULT DOSAGE PRECAUTIONS/
COMMENTS
4–81 mg tabs—
chewed
Contraindicated in aspirin
or salicylate allergy.
Coumadin or Plavix use is
not a contraindication
Symptomatic
Bradycardia
(not to be used in
wide QRS 2nd and
3rd degree blocks)
0.5 mg IV or
IO every 3–5
minutes up to
max. 3 mg
Atropine can dilate
pupils, aggravate
glaucoma, cause urinary
retention, confusion,
and dysrhythmias,
including V-tach and Vfib.
Doses less than 0.5 mg
can cause paradoxical
bradycardia. Increases
myocardial oxygen
consumption.
Organophosphate
poisoning
1–2 mg IV or IO—
repeat every 3-5
min. as needed
to decrease
symptoms
Remove clothing of victim
of organophosphate
poisonings, and flush skin
to remove traces of poison
156§
Drug Reference
ADULT DRUG REFERENCE
DRUG
INDICATION
CALCIUM
CHLORIDE
Hyperkalemia—
Arrest
ADULT DOSAGE PRECAUTIONS/
COMMENTS
500 mg IV or IO
slowly
May repeat in
5–10 minutes
Hyperkalemia—
Crush Injury
1 gm IV or IO
slowly over 60
seconds
Hydrofluoric Acid
Toxicity
500 mg IV or IO
slowly
Use cautiously or not at
all in patients on digitalis.
Avoid extravasation
Rapid administration can
cause dysrhythmias or
arrest
DEXTROSE 10% Hypoglycemia
10 g initially (100
ml). If glucose
remains 60 or
below, give
additional 15 g
(150 ml)
Recheck glucose after
administration
DIPHENHYDRAMINE
25–50 mg IV or
IM
For allergy, consider lower
dose if patient has already
taken po dose in past two
hours for symptoms
Cardiac Arrest
1 mg IV or
IO every 3–5
minutes
Anaphylactic
Shock
0.1 mg
increments IV or
IO up to 0.5 mg IV
total dose
Alpha & beta
sympathomimetic.
May cause serious
dysrhythmias and
exacerbate angina.
Allergy—Hives/
Itching
Dystonic Reaction
EPINEPHRINE
1:10,000
Use only if
IM treatment
ineffective
§157
Drug Reference
ADULT DRUG REFERENCE
DRUG
INDICATION
EPINEPHRINE
1:1000
Allergy/
Anaphylactic
Shock
Asthma
FENTANYL
ADULT DOSAGE PRECAUTIONS/
COMMENTS
0.3–0.5 mg IM
Use lower dose
in smaller, older
patients
0.3 mg
subcutaneously
0.3 mg IM if
respiratory arrest
from asthma or
bronchospasm
Pain Control
50–200 mcg IV
(25-50 mcg
increments)
100 mcg
Intranasally
50–100 mcg IM
Sedation— Pacing 25–100 mcg IV
in 25–50 mcg
increments
Never administer
intravenously!
Do not use in asthma
patients with a history of
hypertension or coronary
artery disease. May cause
serious dysrhythmias and
exacerbate angina.
Can cause hypotension
and respiratory
depression. Recheck
VS between each dose.
Hypotension more
common in patients
with low cardiac output
or volume depletion.
Respiratory depression
reversible with naloxone.
Additional IV doses
(titration) can be given
every 5 minutes. IM and
intranasal doses can
be repeated once in 15
minutes.
158§
Drug Reference
ADULT DRUG REFERENCE
DRUG
INDICATION
GLUCAGON
Hypoglycemia
LIDOCAINE
MIDAZOLAM
ADULT DOSAGE PRECAUTIONS/
COMMENTS
1 mg IM
Effect may be delayed
5–20 min
IO Anesthesia
40 mg IO
Repeat dose 20
mg
Administer slowly over 1
minute
Not needed in arrest
situations
Seizure
Titrate 1–5 mg
IV in 1–2 mg
increments
With IV dosing, begin
with 1 mg dose. IV
increments should not
exceed 2 mg.
0.1 mg/kg IM
(max. dose 5 mg
IM)
Sedation for
pacing or
cardioversion
Titrate 1–5 mg
IV in 1–2 mg
increments
Sedation—
transfer of
intubated patient
Titrate 2–5 mg
IV in up to 2 mg
increments
Behavioral
Emergency
5 mg IM
Observe respiratory
status
Use with caution in
patients over age 60
1–3 mg IV in 1
mg increments if
IV available
§159
Drug Reference
ADULT DRUG REFERENCE
DRUG
INDICATION
ADULT DOSAGE PRECAUTIONS/
COMMENTS
NALOXONE
Respiratory
Depression
(Respiratory rate
less than 12) or
Apnea
Intranasal administration
preferred unless patient
in shock or has copious
secretion/blood in nares.
1–2 mg IV or IM
Shorter duration of
action than that of
For careful
most narcotics. Abrupt
titration in
withdrawal symptoms
chronic pain or
terminal patients, and combative behavior
may occur.
dilute 1:10 and
give 0.1 mg
increments
NITROGLYCERIN
Chest Pain—
Suspected ACS
0.4 mg sl or spray
up to 3 doses
Pulmonary Edema
0.4 mg sl or spray
if systolic BP
90–149
2 mg intranasally
(IN)
0.8 mg sl or spray
if systolic BP 150
or over
Max.dose 4.8 mg
ONDANSETRON
Vomiting and
Severe Nausea
4 mg IV, IM or po
(ODT)
May repeat q 10
min X 2
Can cause hypotension
and headache. Do not
give if BP less than 90
systolic or heart rate
below 50. Perform
12-lead ECG before
administration. Do not
give if STEMI detected. Do
not give if Viagra, Levitra,
Staxyn or Stendra taken
within 24 hours or if Cialis
taken within 36 hours.
Give IV over 1 minute—
may cause syncope if
administered too rapidly
160§
Drug Reference
ADULT DRUG REFERENCE
DRUG
INDICATION
SODIUM
BICARBONATE
Cardiac arrest
ADULT DOSAGE PRECAUTIONS/
COMMENTS
1 mEq/kg IV or IO
Assure adequate
ventilation. Can
precipitate or inactivate
other drugs. In cardiac
arrest, indicated for
treatment of suspected
pre-existing acidosis
(e.g. kidney failure),
hyperkalemia or arrest
due to tricyclic antidepressant overdose
Tricyclic
Antidepressant
OD
1 mEq/kg IV
Use only if lifethreatening,
hemodynamically
significant dysrhythmias
Crush injury
1 mEq/kg IV
For crush
injury, consider
additional 1 mEq/
kg added to 1L
NS using second
IV line
§161
Drug Reference
PEDIATRIC DRUG REFERENCE
DRUG
INDICATION
ADENOSINE
Paroxysmal SVT
PEDIATRIC
DOSAGE
1st Dose—0.1
mg/kg rapid IV
(max. 6 mg)
2nd Dose—0.2
mg/kg rapid IV
(max 12 mg)
Follow each dose
with rapid 10–20
ml NS bolus
ALBUTEROL
Bronchospasm
AMIODARONE
5 mg in 6 ml NS
nebulized
Ventricular
Fibrillation or
Pulseless VT
ATROPINE
5 mg/kg IV or IO
bolus
Maximum dose
300 mg
Symptomatic
Bradycardia
0.02 mg/kg IV
or IO
Minimum dose
0.1 mg
Maximum dose
0.5 mg
DEXTROSE 10%
Hypoglycemia
0.5 g/kg IV (5 ml/kg)
DIPHENHYDRAMINE
Allergy—Hives/
Itching
1 mg/kg IV or IM
Maximum dose
50 mg
PRECAUTIONS/
COMMENTS
Base Order Required:
May cause transient
heart block or asystole.
Side effects include
chest pressure/
pain, palpitations,
hypotension, dyspnea,
or feeling of impending
doom. Do not administer
if acute exacerbation of
asthma.
Repeat as needed
Bradycardia in pediatric
patients primarily
related to respiratory
issue—assure adequate
ventilation first
Recheck glucose after
Maximum 250 ml administration
Consider lower dose (0.5
mg/kg) if patient has
already taken po dose in
the past two hours for
symptoms
162§
Drug Reference
PEDIATRIC DRUG REFERENCE
DRUG
INDICATION
EPINEPHRINE
1:10,000
Cardiac Arrest
EPINEPHRINE
1:1000
PEDIATRIC
DOSAGE
0.01 mg/kg IV
or IO every 3–5
minutes
Max. dose 1 mg
Anaphylactic
Shock
Titrate in up
to 0.1 mg
increments slow
IV or IO to a max.
of 0.01 mg/kg
Allergy/
Anaphylactic
Shock
0.01 mg/kg IM
Asthma
0.01 mg/kg
subcutaneously
Max single dose
0.3 mg
Maximum dose
0.3 mg
PRECAUTIONS/
COMMENTS
In anaphylactic shock,
IM epinephrine 1:1000
should be administered
first and epinephrine
1:10,000 IV should
only be used if IM is
ineffective
Never administer
intravenously!
If respiratory arrest
from asthma or
bronchospasm,
administer IM
FENTANYL
Pain Control
GLUCAGON
See drug chart
Can cause hypotension
for exact dosage. and respiratory
1 mcg/kg IV or IM depression. Hypotension
is more common in
1.5 mcg/kg
patients with volume
Intranasal
depletion. Nausea may
occur.
Hypoglycemia
Weight less than
24 kg: 0.5 mg IM
Weight 24 kg or
more: 1 mg IM
Effect may be delayed
5–20 minutes—if
patient responds, give po
sugar
§163
Drug Reference
PEDIATRIC DRUG REFERENCE
DRUG
INDICATION
PEDIATRIC
DOSAGE
LIDOCAINE
IO Pain
MIDAZOLAM
Seizure
Titrate in up to 1 Observe respiratory
mg increments IV status carefully
up to 0.1 mg/kg
Maximum IV dose
dependent on patient
0.1 mg/kg IM
Maximum dose 5 weight (e.g. for 20 kg
patient, maximum dose
mg IM
2 mg). For patients 50 kg
and above, maximum IV
dose 5 mg
Sedation for
Cardioversion
0.1 mg/kg IV or
IO titrated in 1
mg increments
0.5 mg/kg IO.
Maximum dose
20 mg
PRECAUTIONS/
COMMENTS
Give slowly over one
minute.
Not needed in arrest
situations
Sedation and
cardioversion only with
base hospital order only.
Maximum dose
dependent on patient
weight (see above).
NALOXONE
Respiratory
Depression or
Apnea
Use IM route initially
unless shock present.
Shorter duration of
action than that of most
narcotics.
ONDANSETRON
0.1 mg/kg IM
or IV
Maximum dose
2 mg
May repeat as
needed
Vomiting and
Severe Nausea
4 mg IV, IM, or po
(ODT)
In patients 40
kg and over, may
repeat q 10 min
X2
For use in patients 4
years and up.
Administer IV over
1 minute. Rapid
administration may
cause syncope.
164§
Drug Reference
ADENOSINE
INDICATION: SUPRAVENTRICULAR TACHYCARDIA
Concentration = 3 mg/ml
1st Dose = 0.1 mg/kg IV 2nd Dose = 0.2 mg/kg IV
Base Order Only
COLOR
Gray
(3-5 kg)
Pink
(6-7 kg)
Red
(8-9 kg)
Purple (10-11 kg)
Yellow (12-14 kg)
White
(15-18 kg)
Blue
(19-23 kg)
Orange (24-29 kg)
Green (30-36 kg)
40 kg
45 kg
DOSES (mg)
0.45 mg
0.9 mg
0.66 mg
1.35 mg
0.9 mg
1.8 mg
1 mg
2 mg
1.35 mg
2.7 mg
1.7 mg
3.4 mg
2.1 mg
4.2 mg
2.7 mg
5.4 mg
3.3 mg
6.6 mg
4 mg
8 mg
4.5 mg
9 mg
GIVE (ml)
1 - 0.15 ml
2nd - 0.3 ml
1st - 0.22 ml
2nd - 0.45 ml
1st - 0.3 ml
2nd - 0.6 ml
1st - 0.33 ml
2nd - 0.67 ml
1st - 0.45 ml
2nd - 0.9 ml
1st - 0.6 ml
2nd - 1.2 ml
1st - 0.7 ml
2nd - 1.4 ml
1st - 0.9 ml
2nd - 1.8 ml
1st - 1.1 ml
2nd - 2.2 ml
1st - 1.3 ml
2nd - 2.7 ml
1st - 1.5 ml
2nd - 3 ml
st
Note: Follow with rapid bolus 10-20 ml NS
§165
Drug Reference
AMIODARONE
INDICATION – VENTRICULAR FIBRILLATION
Concentration = 50 mg/ml
Dose = 5 mg/kg IV
COLOR
DOSE (mg)
GIVE (ml)
Not given
Gray
(3-5 kg)
Pink
(6-7 kg)
35 mg
0.7 ml
Red
(8-9 kg)
45 mg
0.9 ml
Purple (10-11 kg)
50 mg
1 ml
Yellow (12-14 kg)
65 mg
1.3 ml
White
(15-18 kg)
80 mg
1.6 ml
Blue
(19-23 kg)
100 mg
2 ml
Orange (24-29 kg)
130 mg
2.6 ml
Green (30-36 kg)
170 mg
3.4 ml
40 kg
200 mg
4 ml
45 kg
225 mg
4.5 ml
166§
Drug Reference
ATROPINE
INDICATION – SYMPTOMATIC BRADYCARDIA
Concentration = 0.1 mg/ml
Dose = 0.02 mg/kg IV
Minimum Dose – 0.1 mg IV
Maximum Dose – 0.5 mg IV
COLOR
DOSE (mg)
GIVE (ml)
Gray
(3-5 kg)
0.1 mg
1 ml
Pink
(6-7 kg)
0.13 mg
1.3 ml
Red
(8-9 kg)
0.17 mg
1.7 ml
Purple (10-11 kg)
0.2 mg
2 ml
Yellow (12-14 kg)
0.25 mg
2.5 ml
White
(15-18 kg)
0.35 mg
3.5 ml
Blue
(19-23 kg)
0.42 mg
4.2 ml
Orange (24-29 kg)
0.5 mg
5 ml
Green (30-36 kg)
0.5 mg
5 ml
40 kg
0.5 mg
5 ml
45 kg
0.5 mg
5 ml
Assure adequate ventilation before considering atropine
Not indicated for asystole
§167
Drug Reference
DEFIBRILLATION
Energy Selection
PHYSIO-CONTROL LP-12 and LP-15
COLOR
First
Second
Maximum
Gray
(3-5 kg)
8J
15 J
30 J
Pink
(6-7 kg)
15 J
30 J
50 J
Red
(8-9 kg)
15 J
30 J
70 J
Purple (10-11 kg)
20 J
30 J
100 J
Yellow (12-14 kg)
30 J
50 J
125 J
White
(15-18 kg)
30 J
70 J
175 J
Blue
(19-23 kg)
30 J
70 J
200 J
Orange (24-29 kg)
50 J
100 J
250 J
Green (30-36 kg)
70 J
125 J
300 J
40 kg
70 J
150 J
360 J
45 kg
100 J
175 J
360 J
Note: Cardioversion energy dosages are equal to
first and second energy levels. Cardioversion in
pediatric patients requires base hospital direction.
168§
Drug Reference
DEXTROSE 10%
INDICATION – HYPOGLYCEMIA
Concentration = 0.1 g/ml
Dose = 0.5 g/kg IV up to 10g initially
COLOR
DOSE (g)
GIVE (ml)
Gray
(3-5 kg)
2g
20 ml
Pink
(6-7 kg)
3.5 g
35 ml
Red
(8-9 kg)
4.5 g
45 ml
Purple (10-11 kg)
5.5 g
55 ml
Yellow (12-14 kg)
6.5 g
65 ml
White
(15-18 kg)
8.5 g
85 ml
Blue
(19-23 kg)
10 g
100 ml*
Orange (24-29 kg)
10 g
100 ml*
Green (30-36 kg)
10 g
100 ml*
40 kg
10 g
100 ml*
45 kg
10 g
100 ml*
* Additional dosage of up to 150 ml (15g) may be
required based on repeat blood glucose
determination. Administer in 50 ml (5g)
increments.
§169
Drug Reference
DIPHENHYDRAMINE
INDICATION: ALLERGIC REACTION
(URTICARIAL RASH or ITCHING)
Concentration = 50 mg/ml
Dose = 1 mg/kg – Give IV or IM
COLOR
DOSE (mg)
GIVE (ml)
Gray
(3-5 kg)
5 mg
0.1 ml
Pink
(6-7 kg)
6.5 mg
0.13 ml
Red
(8-9 kg)
8.5 mg
0.17 ml
Purple (10-11 kg)
10 mg
0.2 ml
Yellow (12-14 kg)
12.5 mg
0.25 ml
White
(15-18 kg)
17.5 mg
0.35 ml
Blue
(19-23 kg)
20 mg
0.4 ml
Orange (24-29 kg)
25 mg
0.5 ml
Green (30-36 kg)
35 mg
0.7 ml
40 kg
40 mg
0.8 ml
45 kg
45 mg
0.9 ml
Utilize epinephrine 1:1000 IM first if serious systemic
reaction (anaphylaxis)
Consider giving one-half dosage diphenhydramine if patient
has taken/been given full dose within 1 hour
170§
Drug Reference
EPINEPHRINE 1:10,000
FOR CARDIAC ARREST
Concentration = 0.1 mg/ml
Dose = 0.01 mg/kg IV
COLOR
Gray
(3-5 kg)
DOSE (mg)
GIVE (ml)
0.04 mg
0.4 ml **
Pink
(6-7 kg)
0.06 mg
0.6 ml **
Red
(8-9 kg)
0.08 mg
0.8 ml **
Purple (10-11 kg)
0.1 mg
1 ml
Yellow (12-14 kg)
0.13 mg
1.3 ml
White
(15-18 kg)
0.17 mg
1.7 ml
Blue
(19-23 kg)
0.21 mg
2.1 ml
Orange (24-29 kg)
0.27 mg
2.7 ml
Green (30-36 kg)
0.33 mg
3.3 ml
40 kg
0.4 mg
4 ml
45 kg
0.45 mg
4.5 ml
Epinephrine 1:10,000 IV is also used in anaphylactic shock if
IM treatment ineffective
** In anaphylactic shock:
• Patients under 10 kg receive smaller increments (same
as single dose for cardiac arrest)
• For patients 10 kg and up, give 0.1 mg increments (1 ml)
§171
Drug Reference
EPINEPHRINE 1:1000
Anaphylaxis – use IM Route
Asthma – use Subcutaneous (SC) Route
NEVER GIVE EPINEPHRINE 1:1000 VIA IV ROUTE
Concentration = 1 mg/ml
Dose = 0.01 mg/kg IM or SC
Maximum Dose 0.3 mg IM / SC
COLOR
DOSE (mg)
GIVE (ml)
Gray
(3-5 kg)
0.04 mg
0.04 ml IM / SC
Pink
(6-7 kg)
0.06 mg
0.06 ml IM / SC
Red
(8-9 kg)
0.08 mg
0.08 ml IM / SC
Purple (10-11 kg)
0.1 mg
0.1 ml IM / SC
Yellow (12-14 kg)
0.13 mg
0.13 ml IM / SC
White
(15-18 kg)
0.17 mg
0.17 ml IM / SC
Blue
(19-23 kg)
0.21 mg
0.21 ml IM / SC
Orange (24-29 kg)
0.27 mg
0.27 ml IM / SC
Green (30-36 kg)
0.3 mg
0.3 ml IM / SC
40 kg
0.3 mg
0.3 ml IM / SC
45 kg
0.3 mg
0.3 ml IM / SC
172§
Drug Reference
INTRANASAL FENTANYL (IN)
INDICATION – PAIN MANAGEMENT
Concentration = 50 mcg/ml
Dose = 1.5 mcg/kg INTRANASAL (IN)
Intranasal dosing is single dose only –
base contact required for repeat doses
COLOR
DOSE (mcg)
GIVE (ml)
Gray
(3-5 kg)
Not given
Pink
(6-7 kg)
9 mcg
0.18 ml
Red
(8-9 kg)
12.5 mcg
0.25 ml
Purple (10-11 kg)
15 mcg
0.3 ml
Yellow (12-14 kg)
20 mcg
0.4 ml
White
(15-18 kg)
25 mcg
0.5 ml
Blue
(19-23 kg)
30 mcg
0.6 ml
Orange (24-29 kg)
40 mcg
0.8 ml
Green (30-36 kg)
50 mcg
1 ml
40 kg
60 mcg
1.2 ml*
50 kg
75 mcg
1.5 ml*
60 kg
90 mcg
1.8 ml*
70 kg or over
100 mcg
2 ml*
* DIVIDE DOSAGE OVER 1 ML BETWEEN BOTH NARES
§173
Drug Reference
FENTANYL IV / IM
INDICATION – PAIN MANAGEMENT
Concentration = 50 mcg/ml
Dose = 1 mcg/kg IV or IM
Single dose only – base contact required for
repeat doses
COLOR
DOSE (mcg)
GIVE (ml)
Gray
(3-5 kg)
Not given
Pink
(6-7 kg)
6 mcg
0.12 ml
Red
(8-9 kg)
8 mcg
0.16 ml
Purple (10-11 kg)
10 mcg
0.2 ml
Yellow (12-14 kg)
12.5 mcg
0.25 ml
White
(15-18 kg)
15 mcg
0.3 ml
Blue
(19-23 kg)
20 mcg
0.4 ml
Orange (24-29 kg)
25 mcg
0.5 ml
Green (30-36 kg)
35 mcg
0.7 ml*
40 kg
40 mcg
0.8 ml*
45 kg
45 mcg
0.9 ml*
*IV doses above 25 mcg can be titrated to effect
beginning with 25 mcg increment.
174§
Drug Reference
FLUID BOLUS
INDICATION – SHOCK / HYPOTENSION
NORMAL SALINE BOLUS = 20 ml/kg IV
Maximum single bolus = 500 ml
COLOR
GIVE (ml)
Gray
(3-5 kg)
80 ml
Pink
(6-7 kg)
130 ml
Red
(8-9 kg)
170 ml
Purple (10-11 kg)
210 ml
Yellow (12-14 kg)
260 ml
White
(15-18 kg)
340 ml
Blue
(19-23 kg)
420 ml
Orange (24-29 kg)
500 ml
Green (30-36 kg)
500 ml
40 kg
500 ml
45 kg
500 ml
§175
Drug Reference
GLUCAGON
INDICATION – HYPOGLYCEMIA
Concentration = 1 mg/ml
Dose = 0.5 – 1 mg/ml IM
COLOR
DOSE (mg)
GIVE (ml)
Gray
(3-5 kg)
0.5 mg
0.5 ml
Pink
(6-7 kg)
0.5 mg
0.5 ml
Red
(8-9 kg)
0.5 mg
0.5 ml
Purple (10-11 kg)
0.5 mg
0.5 ml
Yellow (12-14 kg)
0.5 mg
0.5 ml
White
(15-18 kg)
0.5 mg
0.5 ml
Blue
(19-23 kg)
0.5 mg
0.5 ml
Orange (24-29 kg)
1 mg
1 ml
Green (30-36 kg)
1 mg
1 ml
40 kg
1 mg
1 ml
45 kg
1 mg
1 ml
176§
Drug Reference
LIDOCAINE
INDICATION – PAIN MANAGEMENT FOR IO
(PATIENTS NOT IN ARREST)
Concentration = 2% (100 mg / 5 ml)
Dose = 0.5 mg/kg IO – 20 mg max
COLOR
DOSE
(mg)
GIVE (ml)
Gray
(3-5 kg)
Not given
Pink
(6-7 kg)
3 mg
0.15 ml
Red
(8-9 kg)
4 mg
0.2 ml
Purple (10-11 kg)
5 mg
0.25 ml
Yellow (12-14 kg)
7 mg
0.35 ml
White
(15-18 kg)
9 mg
0.45 ml
Blue
(19-23 kg)
10 mg
0.5 ml
Orange (24-29 kg)
14 mg
0.7 ml
Green (30-36 kg)
16 mg
0.8 ml
40 kg
20 mg
1 ml
45 kg
20 mg
1 ml
§177
Drug Reference
MIDAZOLAM
INDICATION – SEIZURE
Concentration = 5 mg/ml
Dose = 0.1 mg/kg IV or IM
Titrate IV dosage in 0.5-1 mg (0.1-0.2 ml)
increments to desired effect (seizure cessation)
or maximum dose listed
IM administration - single dose only
COLOR
DOSE (mg)
GIVE (ml)
Gray
(3-5 kg)
0.5 mg
0.1 ml
Pink
(6-7 kg)
0.75 mg
0.15 ml
Red
(8-9 kg)
0.85 mg
0.17 ml
Purple (10-11 kg)
1 mg
0.2 ml
Yellow (12-14 kg)
1.25 mg
0.25 ml
White
(15-18 kg)
1.75 mg
0.35 ml
Blue
(19-23 kg)
2 mg
0.4 ml
Orange (24-29 kg)
2.75 mg
0.55 ml
Green (30-36 kg)
3.25 mg
0.65 ml
40 kg
4 mg
0.8 ml
45 kg
4.5 mg
0.9 ml
178§
Drug Reference
NALOXONE
INDICATION – RESPIRATORY DEPRESSION
Concentration = 1 mg/ml
Dose = 0.1 mg/kg IV or IM
Maximum single dose = 2 mg (may be repeated)
Naloxone is available in other concentrations
This chart is correct for 1 mg/ml concentration
COLOR
DOSE (mg)
GIVE (ml)
Gray
(3-5 kg)
0.4 mg
0.4 ml
Pink
(6-7 kg)
0.7 mg
0.7 ml
Red
(8-9 kg)
0.9 mg
0.9 ml
Purple (10-11 kg)
1 mg
1 ml
Yellow (12-14 kg)
1.3 mg
1.3 ml
White
(15-18 kg)
1.7 mg
1.7 ml
Blue
(19-23 kg)
2 mg
2 ml
Orange (24-29 kg)
2 mg
2 ml
Green (30-36 kg)
2 mg
2 ml
40 kg
2 mg
2 ml
45 kg
2 mg
2 ml
§179
Drug Reference
WEIGHT
CONVERSION
Always Document Weight in kg
COLOR
Kg
Pounds
Gray
3-5 kg
6-11 lbs
Pink
6-7 kg
13-15 lbs
Red
8-9 kg
17-20 lbs
Purple
10-11 kg
22-25 lbs
Yellow
12-14 kg
27-32 lbs
White
15-18 kg
34-41 lbs
Blue
19-23 kg
42-52 lbs
Orange
24-29 kg
54-65 lbs
Green
30-36 kg
67-80 lbs
40 kg
40 kg
90 lbs
45 kg
45 kg
101 lbs
180§
Drug Reference
§181
Drug Reference
contra costa county
emergency medical services agency
1340 arnold drive, ste. 126
martinez ca 94553
925-646-4690 phone
925-646-4379 fax
www.cccems.org
182§
MULTICASUALTY INCIDENTS (MCI)
TIER DEFINITIONS and EXAMPLES
TIER ZERO
• Official notification of an incident that has the potential to result in activation
of the MCI plan at a higher tier, even when the number of known victims is zero
• Activation at this tier is required for a Community Warning System Level II or
Level III incident or any receiving hospital Emergency Department closure or
evacuation (not diversion or trauma bypass)
• Other examples of this might include active shooter where number of victims
unknown or cannot be confirmed, emergency landing at airport, actual or
potential significant hazmat incident, including transportation incidents
TIER ONE
• An incident involving 6–10 patients when the scene is contained and the
number of patients is not expected to rise significantly
• Examples include a multi-vehicle traffic collision, multiple known shooting
victims and no ongoing active shooter threat
TIER TWO
• An incident involving more than 10 patients OR an incident involving less than
10 patients when there is a substantial chance that the number of patients
may rise
• EMS Transportation Resource Ordering will be processed by EMS Operational
Area Communications Center (Sheriff’s Dispatch)
• Examples include a petrochemical incident with a dispersal cloud moving over
a populated area, passenger train derailment, or an active shooter with an
uncontained scene
TIER THREE
• Any incident involving more than 50 patients, mass casualties, or a reasonable
expectation of mass casualties
• EMS Transportation Resource Ordering will be processed by EMS Operational
Area Communications Center (Sheriff’s Dispatch)
• Examples include a significant explosion around occupied commercial or
multi-resident structure, or in a heavily populated area, or a large-scale
evacuation of a hospital or skilled nursing facility
PAIN RATING SCALE
0
1–2
MILD
3–4
5–6
MODERATE
7–8
9–10
SEVERE
ESCALA DE VALORACIÓN DE DOLOR
0
1–2
LEVE
3–4
5–6
MODERADO
7–8
9–10
SEVERO