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1

Bradycardia 

Unstable Bradycardia with Pulse (Systolic BP<90 AND chest pain, dyspnea or altered LOC):
NARROW COMPLEX BRADYCARDIA

• Monitor EKG
• 250 ml fluid bolus IV/IO without rales SO to maintain BP >90, MR SO
• Atropine 0.5 mg IV/IO for pulse <60 bpm SO. MR q3-5 minutes to max of 3 mg

SO

If rhythm refractory to a minimum of atropine 1 mg:

External cardiac pacemaker per SO
If capture occurs and systolic BP ≥100, consider medication for discomfort:

Treat per Pain Management Protocol (S-141)
For discomfort related to pacing not relieved with analgesics and BP ≥100:

Midazolam 1-5 mg IV/IO SO
Dopamine 400 mg/250 ml at 10-40 mcg/kg/min IV/IO drip, titrate to systolic BP >90 (after max atropine or initiation of pacing) BHO

WIDE COMPLEX BRADYCARDIA

• Monitor EKG
• 250 ml fluid bolus IV/IO with clear lungs SO to maintain BP >90, MR SO

External cardiac pacemaker per SO
If capture occurs and systolic BP ≥100, consider medication for discomfort:

Treat per Pain Management Protocol (S-141)
For discomfort related to pacing not relieved with analgesics and BP ≥100:

Midazolam 1-5 mg IV/IO SO
Dopamine 400 mg/250 ml at 10-40 mcg/kg/min IV/IO drip, titrate to systolic BP >90 BHO

(after initiation of pacing)

If external pacing unavailable,

May give atropine 0.5 mg IV/IO for pulse <60 SO. MR q3-5 minutes to max of 3 mg SO

2

SVT Superventricular Tachycardia 

Supraventricular Tachycardia (SVT):

• Monitor EKG
• 250 ml fluid bolus IV/IO without rales SO to maintain systolic BP >90, MR SO
• VSM SO. MR SO
• Adenosine 6 mg IV/IO, followed with 20 ml NS IV/IO SO (Patients with history of bronchospasm or COPD BHO )
• Adenosine 12 mg IV/IO followed with 20 ml NS IV/IO SO

If no sustained rhythm change, MR x1 in 1-2 minutes SO

If patient unstable OR rhythm refractory to treatment:
Conscious (Systolic BP <90 and chest pain, dyspnea, or altered LOC):

Midazolam 1-5 mg IV/IO prn pre-cardioversion . If age >60, consider lower dose with attention to age and hydration status.

Synchronized cardioversion at manufacturer’s recommended energy dose , MR

Unconscious:

Synchronized cardioversion at manufacturer’s recommended energy dose SO. MR x3 SO. MR BHO

3

Unstable AFIB/Aflutter

Unstable Atrial Fibrillation/Atrial Flutter (Systolic BP <90 AND chest pain, dyspnea or altered LOC):

• Monitor EKG/O2 Saturation prn
• 250 ml fluid bolus IV/IO without rales SO MR to maintain systolic BP >90 SO

In presence of ventricular response with heart rate >180: Conscious:

Midazolam 1-5 mg IV/IO prn pre-cardioversion BHPO. If age >60, consider lower dose with attention to age and hydration status.

Synchronized cardioversion at manufacturer’s recommended energy dose BHPO MR BHPO

Unconscious:
Synchronized cardioversion at manufacturer’s recommended energy dose SO. MR x3 SO. MR

4

Ventricular Tachycardia (VT)

Ventricular Tachycardia (VT):

• Monitor EKG
• 250 ml fluid bolus IV/IO without rales SO to maintain systolic BP >90, MR SO • Lidocaine 1.5 mg/kg IV/IO SO. MR at 0.5 mg/kg IV/IO q 8-10 minutes to max 3mg/kg (including initial bolus) SO OR
• Amiodarone 150 mg in 100 ml of NS over 10 minutes IV/IO SO MR x1 in 10 minutes SO

If patient unstable (Systolic BP <90 and chest pain, dyspnea or altered LOC): Conscious:

Midazolam 1-5 mg IV/IO prn pre-cardioversion SO. If age >60, consider lower dose with attention to age and hydration status.

Synchronized cardioversion at manufacturer’s recommended energy dose SO. MR x 3 SO. MR BHO

Unconscious:

Synchronized cardioversion at manufacturer’s recommended energy dose

SO. MR x 3 SO. MR BHO

5

Reported/witnessed ≥x2 AICD firing, or ≥1 AED shock delivered

Reported/witnessed ≥x2 AICD firing, or ≥1 AED shock delivered:

• Monitor EKG
• 250 ml fluid bolus IV/IO without rales SO to maintain systolic BP >90, MR SO

If pulse >60:

• Lidocaine 1.5 mg/kg IV/IO SO. MR at 0.5 mg/kg IV/IO q8-10 minutes, to a max of 3 mg/kg (including initial bolus) SO

OR

• Amiodarone 150 mg in 100 ml of NS over 10 minutes IV/IO SO

6

VF/Pulseless VT

VF/Pulseless VT

• Monitor EKG

• Defibrillate when ready every 2 min while VF/VT persists

• Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation

• Capnography
• Rhythm check–minimize interruption of compressions less than

5 seconds
• IV/IO do not interrupt CPR
• Epinephrine 1:10,000 1 mg IV/IO q 3-5 minutes SO

• After 1st shock if still refractory, 300 mg Amiodarone IV/IO MR 150 mg (max of 450 mg) OR 1.5 mg/kg Lidocaine IV/IO MR x1 in 3-5 minutes (max 3 mg/kg) SO

• Document EtCO2 during BVM. If zero do not intubate; continue to ventilate with BVM

• Intubate/PAA SO without interrupting compressions

• NG/OG prn SO

• If persistent or shock refractory VF/VT after 3 rounds of drugs, contact base hospital for direction

ROSC
• Obtain 12 lead

• Ventilate with goal of EtCO2 of 40
• Check blood pressure
• Transport to closest STEMI Center regardless of 12 lead reading SO

7

PEA

PEA: IF PATIENT DOES NOT MEET TOR CRITERIA: • Monitor

• Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation

• Capnography
• Rhythm check–minimize interruption of compressions less than 5

seconds

• IV/IO do not interrupt CPR

• Epinephrine 1:10,000 1 mg IV/IO may repeat every 3-5 minutes SO

• Document EtCO2 during BVM, if zero do not intubate, continue to ventilate with BVM

• Intubate/PAA SO without interrupting compressions • NG/OG prn SO
• 250 ml Fluid Bolus IV/IO

If persistent PEA after 3 rounds of Epinephrine, contact base hospital for direction.

ROSC
• Obtain 12 lead

• Ventilate with goal of EtCO2 of 40
• Check blood pressure
• Transport to closest STEMI Center regardless of 12-lead

reading SO

8

Asystole

Asystole:

• Monitor EKG
• Charge monitor prior to rhythm checks, do not interrupt CPR while

charging for defibrillation

• Capnography

• Rhythm check–minimize interruption of compressions less than 5 seconds

• IV/IO do not interrupt CPR

• Epinephrine 1:10,000 1 mg IV/IO may repeat every 3-5 minutes SO

• Document EtCO2 during BVM, if zero, do not intubate, continue to ventilate with BVM

• Intubate/PAA SO without interrupting compressions

• NG/OG prn SO

ROSC
• Obtain 12 lead

• Ventilate with goal of EtCO2 of 40
• Check blood pressure
• Transport to closest STEMI Center regardless of 12 lead reading SO

Termination of Resuscitation (TOR) Criteria

If all these criteria have been met:

• Victim arrest was not witnessed by EMS AND

• No bystander witness of collapse AND

• No bystander CPR AND

• Never received a rescue shock AND

• Never had a return of pulses THEN

• If there is no improvement and patient is in asystole after continuous resuscitation of less than 20 minutes, base contact is necessary in order to terminate resuscitation BHPO.

• If asystolic after 20 minutes resuscitative efforts with no improvement may cease efforts SO. Document the Time of Apparent Death and the name of the paramedic.

• If all of the above criteria for TOR are met, Base Hospital Contact not required even if ALS interventions performed.

9

ABDOMINAL DISCOMFORT/GI/GU (NON-TRAUMATIC)

BLS

Ensure patent airway

O2 Saturation prn

O2 and/or ventilate prn

NPO

Transport suspected symptomatic aortic aneurysm to facility with surgical resources immediately available

10

ABDOMINAL DISCOMFORT/GI/GU (NON-TRAUMATIC)

ALS

• Monitor EKG
• IV/IO SO adjust prn
• Treat pain as per Pain Management Protocol (S-141)

Suspected volume depletion:
• 500 ml fluid bolus IV/IO SO

Suspected AAA:
• 500 ml fluid bolus IV/IO SO, for BP <80 to maintain a

BP of 80, may repeat x1 SO

For nausea or vomiting:
• Zofran 4 mg IV/IM/ODT SO, MR x 1 q10” SO

11

AIRWAY OBSTRUCTION (Foreign Body) 

BLS

For a conscious patient:

• Reassure, encourage coughing • O2 prn

For inadequate air exchange: airway maneuvers (AHA)

• Abdominal thrusts
• Use chest thrusts in the obese or

pregnant patient

If patient becomes unconscious or is found unconscious:

• Begin CPR

Once obstruction is removed:

• High flow O2, ventilate prn • O2 Saturation prn

12

AIRWAY OBSTRUCTION (Foreign Body)

ALS

If patient becomes unconscious or has a decreasing LOC:

• Direct laryngoscopy and Magill forceps SO. MR prn

• Capnography SO prn

Once obstruction is removed:

• Monitor/EKG
• IV/IO SO adjust prn

13

ALLERGIC REACTION/ANAPHYLAXIS

BLS

  Ensure patent airway

  O2 Saturation prn

  O2 and/or ventilate prn

  Remove stinger/injection mechanism

  May assist patient to self-medicate own prescribed epinephrine auto- injector or MDI ONE TIME ONLY. Base Hospital contact required prior to any repeat dose.

If available and trained:
 Epinephrine auto-injector 0.3mg IM x1

14

ALLERGIC REACTION/ANAPHYLAXIS

ALS

 Monitor EKG
 IV/IO SO adjust prn
 Capnography SO prn

Hives (Urticaria)

 Benadryl 50 mg IV/IM SO Anaphylaxis

Anaphylaxis:

  Epinephrine 1:1,000 0.3 mg IM per SO. MR x2 q5 minutes SO

then

  500 ml fluid bolus IV/IO for systolic BP <90 SO. MR to maintain systolic BP >90 SO

  Benadryl 50 mg IM/IV SO

  Albuterol 6 ml 0.083% via nebulizer SO. MR SO for

respiratory involvement

  Atrovent 2.5 ml 0.02% via nebulizer added to the first

dose of Albuterol SO for respiratory involvement

  Epinephrine 1:10,000 0.1 mg IV/IO BHO. MR x2 q3-

5 minutes BHO

 Dopamine 400 mg/250 ml @ 10-40 mcg/kg/min IV/IO drip. Titrate systolic BP >90 BHO

Anaphylaxis criteria (may include any):
1. Unknown exposure: Skin and respiratory and/or

cardiovascular
2. Likely allergen exposure (e.g. bee sting, peanut,:

2/4 systems involved (skin, GI, respiratory,

cardiovascular)
3. Known allergen exposure

Angioedema: lip/tongue/face swelling/difficulty swallowing/throat tightness, hoarse voice

15

ALTERED NEUROLOGIC FUNCTION (NON-TRAUMATIC)

ALS

 Monitor EKG
 Capnography SO prn
 IV/IO SO adjust prn
 Monitor blood glucose prn SO

Symptomatic suspected opioids OD (with respiratory rate <12):
(Use caution in opioid dependent pain management patients)

 Naloxone 2 mg IN/IM/IV SO. MR SO, titrate IV dose to effect, to drive the respiratory rate.

 If patient refuses transport, give additional Naloxone 2 mg IM SO

Hypoglycemia: Symptomatic patient with altered LOC or unresponsive to oral glucose agents:

D50 25GmIVSOifBS<60mg/dL
 If patient remains symptomatic and BS remains

<60 mg/dL MR SO
 If no IV: Glucagon 1 ml IM SO if BS <60 mg/dL

Hyperglycemia:
Symptomatic patient with diabetic history

 500 ml fluid bolus IV/IO if BS >350 or reads high SO, x1

Seizures:

For:

Ongoing generalized seizure lasting >5

minutes (includes seizure time prior to arrival

of prehospital provider) SO

Recurrent tonic-clonic seizures without lucid

interval SO

Eclamptic seizure of any duration SO

Give:
 Versed IN/IM/IV/IO SO to a max dose of 5 mg

(d/c if seizure stops) SO, MR x1 in 10 minutes SO. Max 10 mg total.

16

ALTERED NEUROLOGIC FUNCTION (NON-TRAUMATIC)

BLS

 Ensure patent airway, O2 and/or ventilate prn  O2 Saturation prn
 Spinal stabilization prn
 Secretion problems, position on affected side  Do not allow patient to walk

 Restrain prn
 Monitor blood glucose prn (if trained and

available)

Symptomatic suspected opioids OD (with respiratory rate <12)*:
(Use caution in opioid dependent pain management patients)

 Naloxone nasal spray 4mg preloaded single dose device

 Administer full dose in one nostril OR

 Naloxone assemble 2 mg syringe and atomizer

 Administer 1 mg (1 ml) into each nostril

Hypoglycemia (suspected) or patient’s glucometer results read <60 mg/dL

 If patient is awake and able to swallow, give 3 oral glucose tabs or paste (15 g total). Patient may eat or drink, if able.

 If patient is unconscious, NPO

CVA/Stroke:

See S-144 Stroke/Transient Ischemic Attack for details.

Seizures:

 Protect airway, and protect from injury  Treat associated injuries

Behavioral Emergencies (S-422 and S-142)

17

BURNS

ALS

• Monitor EKG

• IV/IO SO adjust prn

• Treat pain as per Pain Management Protocol (S-141)

For patients with >20% partial thickness or >5% full thickness burns and >15 yo:

• 500 ml fluid bolus IV/IO then TKO SO

In the presence of respiratory distress with bronchospasm:

• Albuterol 6 ml 0.083% via nebulizer SO. MR SO

18

BURNS

BLS

• Move patient to a safe environment
• Break contact with causative agent
• Ensure patent airway, O2 and/or ventilate prn • O2 Saturation prn
• Treat other life threatening injuries
• Carboxyhemoglobin monitor prn, if available

Thermal burns:

• Burns of <10% body surface area, stop burning with non-chilled water or saline

For burns >10% body surface area, cover with dry dressing and keep warm

Do not allow the patient to become hypothermic

Toxic Inhalation (CO exposure, smoke, gas, etc.):

Move patient to safe environment

100% O2 via mask

Consider transport to facility with hyperbaric

chamber for suspected carbon monoxide poisoning for unconscious or pregnant patient

Chemical burns:

• Brush off dry chemicals
• Flush with copious amounts of water

Tar burns:

• Cool with water, transport; do not remove tar

19

DISCOMFORT/PAIN OF SUSPECTED CARDIAC ORIGIN

ALS

Monitor EKG

IV SO adjust prn

Obtain 12 Lead EKG and transmit (if capable).

If STEMI, notify base immediately and transport to

appropriate STEMI center*

ASA 324 mg chewable PO SO

If systolic BP >100:
• NTG 0.4 mg SL SO. MR q3-5 minutes SO
• NTG ointment 1 inch SO
• Treat pain per Pain Management Protocol (S-141)

If systolic BP <100:
• NTG 0.4 mg SL BHO. MR BHPO
• Treat pain per Pain Management Protocol (S-141)

Discomfort/Pain of suspected Cardiac Origin with Associated Shock:

• 250 ml fluid bolus IV/IO without rales SO. MR to maintain systolic BP >90 SO

If BP refractory to second fluid bolus:

• Dopamine 400 mg/250ml @ 10-40 mcg/kg/min IV/IO drip. Titrate to systolic BP >90 BHO

20

DISCOMFORT/PAIN OF SUSPECTED CARDIAC ORIGIN

BLS

Ensure patent airway

O2 Saturation prn

Only use supplemental O2 to maintain O2 saturation 94-98%

O2 and/or ventilate prn.

Do not allow patient to walk

If systolic BP >100, may assist patient to self-medicate own prescribed NTG SL (maximum 3 doses, including those patient has taken)

May assist with placement of 12 lead.

May assist patient to self-medicate own prescribed Aspirin (81 mg to max dose of 325 mg)

21

ENVENOMATION INJURIES

BLS

• O2 and/or ventilate prn. Jellyfish sting:

Liberally rinse with salt water, for at least 30 seconds.

Scrape to remove stinger(s).

Heat as tolerated (not to exceed 110 degrees)

Stingray or Sculpin injury:

• Heat as tolerated (not to exceed 110 degrees) Snakebites:

Mark proximal extent of swelling and/or tenderness

Keep involved extremity at heart level and immobile

Remove pre-existing constrictive device

22

ENVENOMATION INJURIES 

ALS

• IV/IO SO adjust prn

• Treat pain as per Pain Management Protocol (S- 141)

23

ENVIRONMENTAL EXPOSURE

BLS

• Ensure patent airway
• O2 Saturation prn
• O2 and/or ventilate prn
• Remove excess/wet clothing • Obtain baseline temperature

Heat Exhaustion:

• Cool gradually
• Fanning, sponging with tepid water
• Avoid shivering
• If conscious, give small amounts of fluids

Heat Stroke:

• Rapid cooling
• Spray with cool water, fan. Avoid shivering. • Ice packs to carotid, inguinal and axillary

regions

Cold Exposure:

• Gentle warming
• Blankets, warm packs
• Dry dressings
• Avoid unnecessary movement or rubbing • If alert, give warm liquids
• If severe, NPO
• Prolonged CPR may be indicated

Near Drowning:

• Spinal motion restriction when indicated

24

ENVIRONMENTAL EXPOSURE

ALS

• Monitor EKG
• IV/IO SO adjust prn

Severe Hypothermia with Cardiac Arrest:

• Hold medications
• Continue CPR
• If defibrillation needed, limit to 1 shock

maximum.

Suspected Heat Exhaustion/Heat Stroke:

• 500 ml fluid bolus IV/IO SO, without rales MR x1 SO

Near Drowning:

• CPAP at 5-10 cm H20 SO for respiratory distress

25

HEMODIALYSIS PATIENT

BLS

• Ensure patent airway • O2 Saturation prn
• Give O2
• Ventilate if necessary

26

HEMODIALYSIS PATIENT

ALS

• Monitor EKG
• Determine time of last dialysis

FOR IMMEDIATE DEFINITIVE THERAPY ONLY:

• IV access in arm that does not have graft/AV fistula SO. Adjust prn

• EJ/IO access prior to accessing graft

If Unable & no other medication delivery route available:

• Access Percutaneous Vas Catheter BHPO if present (aspirate 5 mL PRIOR to infusion)
OR

• Access graft/AV fistula BHPO Fluid overload with rales:

• Treat as per S-136 (CHF/Cardiac)

Symptomatic Patient with Suspected Hyperkalemia (widened QRS complex or peaked T-waves):

• Obtain 12 Lead EKG
If >72 hours since last dialysis:

• Continuous Albuterol 6 ml 0.083% via Nebulizer SO • CaCl2 500 mg IV/IO per SO
• NaHCO3 1 mEq/kg IV/IO x1 per SO

27

DECOMPRESSION ILLNESS/DIVING/ALTITUDE RELATED INCIDENTS

BLS

• 100% O2, and/or ventilate prn
• O2 Saturation prn
• Spinal stabilization when indicated

28

DECOMPRESSION ILLNESS/DIVING/ALTITUDE RELATED INCIDENTS

ALS

• Monitor EKG
• IV/IO SO adjust prn

29

OBSTETRICAL EMERGENCIES

BLS

MOTHER:

Ensure patent airway

O2 Saturation prn

O2 ventilate prn

If no time for transport and delivery is

imminent (crowning and pushing), proceed

with delivery.

If no delivery, transport on left side.

Routine Delivery:

• Massage fundus if placenta delivered. (Do not wait on scene)

Clamp and cut cord between clamps following delivery (wait 60 seconds after delivery prior to clamping and cutting cord)

Document name of person cutting cord, time cut, and address.

Place identification bands on mother and infant.

Post-Partum Hemorrhage:

• Massage fundus vigorously • Baby to breast

Eclampsia (seizures):

• Protect airway, and protect from injury

STAT transport for third trimester bleeding to facility with OB services per base hospital direction.

30

OBSTETRICAL EMERGENCIES

ALS

MOTHER:
• Monitor EKG

• IV/IO SO adjust prn
Direct to Labor/Delivery area per BHO gestation.

Eclampsia (seizures):

if >20 weeks

 

Give:
• Versed IN/IM/IV/IO SO to a max dose of 5 mg

(d/c if seizure stops) SO, MR x1 in 10 minutes SO. Max 10 mg total.