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Criteria for Deviation from the Protocol

It is recognized that the EMS protocols cannot address every possible scenario. Therefore, two concurring paramedics are given the authority to deviate from the ALS protocols as required. Good judgment and the patient’s best interest must be considered at all times. When deviating from the protocols always document the reason clearly. When possible the EMS Captain should be contacted and will provide input to this decision.
1. Two concurring paramedics
2. When possible EMS 17 should be consulted



• Allergies and Adverse reactions: Prior to administering any medication, inquire about
medication allergies or adverse reactions to medications.
• Medication Integrity: Check the medication’s name, date of expiration, color and clarity before administration.
• Timing of medication administration during cardiac arrest: Medications administered during cardiac arrest should be administered during compressions and followed by a 10mL Normal Saline flush.
• Allergy: A true allergy to a medication causes a rash, SOB, swelling of the tongue, face and/or throat.
• Fluid resuscitation: shall be limited to 1L of Normal Saline and administered as follows: 500mL bolus, may repeat 1x. Check lung sounds before and after each 500mL bolus. Monitor these patients carefully as they are at risk for fluid overload (pulmonary edema).


Medication Administration

• An IO should be placed for patients with emergency medical conditions that require urgent vascular access in whom an IV is not immediately obtainable or is deemed to have insufficient access. IO is the preferred method of vascular access during cardiac arrest.
• All medications administered to patients with a pulse should be given slow IV/IO (over 2 minutes), unless otherwise stated.


Medication Administration
• Infants and Children

use a 23 gauge 1 inch needle. The injection site is the lateral thigh 1.25mL maximum. If greater than 1.25 mL needs to be administered, split the dose between both thighs.


Medication Administration
Adults and large Children

use a 21 gauge 1.5 inch needle. The injection site is the lateral thigh (4mL maximum) or deltoid. If greater than 4mL needs to be administered, split the dose between both thighs.


Medication Administration

• Versed, Narcan, and Fentanyl can all be administered via the MAD.
• Ideal dose is 0.5mL per nostril. Maximum of 1mL per nostril


Medication Administration
INTRAOSSEOUS SITES (EZ-IO) ADULTS ( In order of Preference)

1. Proximal Humerus, 2. Proximal Tibia


Medication Administration

1. Distal Femur, 2. Proximal Tibia 3. Proximal Humerus (only if the surgical neck can be palpated)


Medication Administration

Mix 9 mL of Normal Saline with 1 ml of Epi 1:10,000 = Epi (1:100,000) 10 ml solution

Adult: EPINEPHRINE: titrate slowly 1 ml every 30 seconds IV/IO (titrate to SBP over 100). May repeat 2x Max total dose 0.3mg

Peds: EPINEPHRINE: titrate slowly 1 ml every 30 seconds IV/IO (titrate to age appropriate SBP). May repeat 2x Max total dose 0.3mg

* Titrate to age appropriate blood pressure


Medication Administration
BENADRYL for Pediatrics

BENADRYL ADMINISTRATION IV/IO: Dilute with 9 mL of Normal Saline to make a 5mg/ml solution


Medication Administration

All IV Ketamine must be diluted 500mg in 50ml NS to make a 10mg/ml solution


Pain Management IV Ketamine: Remove 1ml Saline from a 10ml saline syringe and then, pull 1ml of 100mg/ml of Ketamine. This creates a concentration of 10mg/ml.


Medication Administration

Diluted for pediatrics patients when given IV/IO, 2ml (or 100mcg) in 8ml NS to make a 10mcg/ml solution


Medication Administration
Sodium Bicarbonate:

Diluted for infants and neonates- 8.4% - 25ml and mix with 25ml NS to make a 4.2% sodium bicarbonate solution


Medication Administration
Adult Drug Infusions
Amiodarone (for stable VT-Pt with pulse)

150mg in 50ml NS over 10 min
60 gtts/min with a 10gtt set, 1 gtt every sec = 6ml/min = 10min


Medication Administration
Adult Drug Infusions
Magnesium Sulfate (Eclampsia, Asthma, and Torsades)

4 ml or 2g in 50ml over 10 min
60 gtts/min with a 10gtt set, 1 gtt every sec = 6ml/min = 10min


Medication Administration
Pediatric Drug Infusions
Amiodarone (Stable SVT)

5mg/kg #ml (as per Per Med tool) in 50ml NS max of 3ml (150mg) for infusion

20gtts/min with a 10gtt set, 1 gtt every 3 secs =2ml/min =25 min


Medication Administration
Magnesium Sulfate (Severe Asthma, Stable Torsades)

40mg/kg #ml (as per Per Med tool) in 50ml NS max of 4ml (2g)

60gtts/min with a 10gtt set, 1gtt/sec =6ml/min =10 min.



Patient who have a medical emergency and lack capacity to refuse transport shall be transported to the appropriate Emergency Department for evaluation.
Emergency examination and treatment of incapacitated persons.—
(1) No recovery shall be allowed in any court in this state against any emergency medical technician, paramedic, or physician as defined in this chapter, any advanced registered nurse practitioner certified under s. 464.012, or any physician assistant licensed under s. 458.347 or s. 459.022, or any person acting under the direct medical supervision of a physician, in an action brought for examining or treating a patient without his or her informed consent if:
(a) The patient at the time of examination or treatment is intoxicated, under the influence of drugs, or otherwise incapable of providing informed consent as provided in s. 766.103;
(b) The patient at the time of examination or treatment is experiencing an emergency medical condition; and
(c) The patient would reasonably, under all the surrounding circumstances, undergo such examination, treatment, or procedure if he or she were advised by the emergency medical technician, paramedic, physician, advanced registered nurse practitioner, or physician assistant in accordance with s. 766.103(3).
Examination and treatment provided under this subsection shall be limited to reasonable examination of the patient to determine the medical condition of the patient and treatment reasonably necessary to alleviate the emergency medical condition or to stabilize the patient.
(2) In examining and treating a person who is apparently intoxicated, under the influence of drugs, or otherwise incapable of providing informed consent, the emergency medical technician, paramedic, physician, advanced registered nurse practitioner, or physician assistant, or any person acting under the direct medical supervision of a physician, shall proceed wherever possible with the consent of the person. If the person reasonably appears to be incapacitated and refuses his or her consent, the person may be examined, treated, or taken to a hospital or other appropriate treatment resource if he or she is in need of emergency attention, without his or her consent, but unreasonable force shall not be used


Patient Assessment/Treatment
AIRWAY Positioning

Head-tilt/chin-lift or modified jaw thrust for suspected spinal cord injury.


Patient Assessment/Treatment
Airway Semi-conscious patient

with an intact gag reflex shall have a nasopharyngeal airway inserted, unless contraindicated.


Patient Assessment/Treatment
Airway Unresponsive patient

without a gag reflex shall have an oropharyngeal airway inserted, unless contraindicated. If ventilation is required for more than two minutes, an IGELor ETTshould be inserted (Adults).


Patient Assessment/Treatment
Airway Pediatric:

The preferred method for ventilating pediatric patient is with a BVM in conjunction with anoral or nasal airway. Pediatric patients who can not protect their airway, are unable to maintain oxygen saturation despite BVM ventilation, and/or can not be effectively ventilated with a BVM, should be upgraded to an advanced airway. Infants and children who have an advanced airway placed during CPR should be ventilated at a rate of 1 breath every 6 seconds.


Patient Assessment/Treatment Airway Pediatric Patients in respiratory distress, who have had a recent illness accompanied by fever, drooling, or stridor:

should not have an NPA or OPA inserted. DO NOT STRESS Patient.


Patient Assessment/Treatment
Airway Recovery position

for spontaneously breathing patients: Altered mental status, postictal, suspected drug overdose, etc., if no suspected spinal cord injury.


Patient Assessment/Treatment

• Oxygen should ONLY be administered in order to maintain SpO2of 95% or 90% for COPD & asthma patients. Do not withhold oxygen if the patient is dyspneic, tachypneic or hypoxic.
• Traumatic Brain Injury(TBI) patients shall receive 15 Lpm via NRB.
• Pregnancy 3rd trimester trauma patients shall receive 15 Lpm via NRB.
• Pulse oximetry should be documented (pre and post oxygen administration) and applied for continuous monitoring on all ALS patients.
• If oxygen saturation cannot be maintained, ventilatory support should be provided.


Patient Assessment/Treatment

• Ventilatory support shall be accomplished via BVM (with either an NPA/OPA), IGEL, or ETT intubation.
• Oxygenation Goal is to maintain an SpO2of 95% and EtCO2 levels between 35-45 mmHg (with the exception of COPD and asthma patients).
• Endotracheal intubation shall be confirmed by: visualization of the ETT passing through the vocal cords, auscultation, and continuous EtCO2 monitoring.


Patient Assessment/Treatment
Ventilatory Rates

• Adults: 10 breaths/minute (1 breath every 6 seconds) with a pulse.
• Adults: 6 breaths/minute ( 1 breath every 10 seconds) without a pulse
• Children: 20 breaths/minute (1 breath every 3 seconds) with a pulse.
• Children: 10 breaths/minute ( 1 breath every 6 seconds) without a pulse
• Neonates: 40 breaths/minute


Patient Assessment/Treatment

• Carotid and radial pulse present, assess capillary refill, assess skin color, condition and temperature.
• Apply AED/LP/ZOLL on all unconscious patients.
• Perform MICCR on all cardiac arrest patients and defibrillate as needed.
• After BVM- oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates (birth to 1 month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor perfusion (AMS).


Patient Assessment/Treatment
EtCO2 Monitoring

• The following patients should be monitored if the EtCO2 nasal cannula sampling device is available:
• In respiratory distress
• With an altered mental status
• Sedated patients or patients receiving pain medication
• Patient administered Ketamine
• Seizure patient
• Requiring ventilatory support (ETT, IGEL, CPAP, etc)


Patient Assessment/Treatment
ECG Monitoring

• All ALS patients shall be continuously monitored in lead II.
• Patients who present with any of the following cardiac or possible cardiac symptoms shall have a 12
lead ECG performed:
• Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort
• Palpitations
• Syncope, lightheadedness, general weakness, or fatigue
• CHF, SOB, or hypotension
• Unexplained diaphoresis or nausea
• 12 lead ECGs shall be repeated every 5 minutes and upon a ROSC (if transporting leave cables
connected until patient is turned over to the ED staff).