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Daytona State College Paramedic Program LAB Treatment Guidelines Revised 01/10/2018

DAYTONA STATE COLLEGE PARAMEDIC PROGRAM

TREATMENT GUIDELINES


These treatment guidelines have been developed to assist the

paramedic student with the management of various emergencies. They

are designed for use within the paramedic program skills lab classes.

While operating in the clinical setting, (i.e. hospital emergency

department, ambulance and fire department ride along, etc.), the

student is expected to follow the treatments outlined to them by their

respective field training officer or preceptor.

These treatment guidelines have been developed as a teaching

tool for the student to understand the interventions and sequencing

needed to manage various emergencies. Many options are presented

throughout, such as drugs for pain management. We recognize that

many different systems use different pieces of equipment and

medications. While the intent is to provide the student with options

and hopefully a better understanding of the management of various

emergencies, this book is not intended to list every option available.

These guidelines reflect the most current research available from

the American Heart Association, National Association of Emergency

Medical Technicians, Traumatic Brain Foundation, and the American

Academy of Pediatrics.


Contents AIRWAY MANAGEMENT ........................................................................................................................... 7

General Management Algorithm .......................................................................................................... 7

Pharmacology Assisted Intubation ....................................................................................................... 8

Rapid Sequence Induction with Paralysis ............................................................................................. 9

ADULT RESPIRATORY EMERGENCIES ...................................................................................................... 10

Airway Obstruction ............................................................................................................................. 10

Bronchospasm..................................................................................................................................... 11

CHF / Pulmonary Edema ..................................................................................................................... 12

Hyperventilation ................................................................................................................................. 13

ADULT CARDIAC DYSRHYTHMIAS ........................................................................................................... 14

Asystole ............................................................................................................................................... 14

Bradycardia ......................................................................................................................................... 15

Narrow Complex Tachycardia ............................................................................................................. 16

Premature Ventricular Contractions ................................................................................................... 17

Pulseless Electrical Activity ................................................................................................................. 18

Wide Complex Tachycardia ................................................................................................................. 19

Wide Complex Tachycardia without a pulse and Ventricular Fibrillation ........................................... 20

OTHER CARDIAC EMERGENCIES .............................................................................................................. 21

Cardiogenic Shock ............................................................................................................................... 21

Chest Pain / AMI / ACS ........................................................................................................................ 22

ADULT NEUROGENIC EMERGENCIES ...................................................................................................... 23

Acute Psychosis ................................................................................................................................... 23

Altered Mental Status ......................................................................................................................... 24

STROKE / TIA ....................................................................................................................................... 25

Seizures ............................................................................................................................................... 26

Syncope / Weakness ........................................................................................................................... 27

ADULT TOXICOLOGICAL EMERGENCIES .................................................................................................. 28

Suspected Overdose / Poisoning ........................................................................................................ 28

Suspected Overdose / Poisoning (continued) ..................................................................................... 29

ADULT OB/GYN EMERGENCIES ............................................................................................................... 32

Normal Labor and Delivery ................................................................................................................. 32

Childbirth with Complications ............................................................................................................. 33


Third Trimester Bleeding..................................................................................................................... 34

Toxemia of Pregnancy (Eclampsia) ..................................................................................................... 35

OTHER ADULT MEDICAL EMERGENCIES ................................................................................................. 36

Abdominal Pain ................................................................................................................................... 36

Allergic Reactions ................................................................................................................................ 37

GI Bleed ............................................................................................................................................... 38

Hyperglycemia/HONK/HHNC .............................................................................................................. 39

Hypoglycemia ...................................................................................................................................... 40

Nausea and Vomiting .......................................................................................................................... 41

SEPSIS Emergencies ............................................................................................................................ 42

Sickle Cell Emergencies ....................................................................................................................... 43

Suspected Kidney Stones .................................................................................................................... 44

ADULT ENVIRONMENTAL EMERGENCIES ............................................................................................... 45

SCUBA Diving Emergencies ................................................................................................................. 45

Cold Related Emergencies .................................................................................................................. 46

Heat Related Emergencies .................................................................................................................. 47

Drowning/Submersion ........................................................................................................................ 48

ADULT TRAUMATIC EMERGENCIES......................................................................................................... 49

Abdominal/Pelvic Trauma ................................................................................................................... 49

Burns (Thermal) .................................................................................................................................. 50

Burns (Chemical) ................................................................................................................................. 50

Burns (Electrical) ................................................................................................................................. 50

Chest Trauma ...................................................................................................................................... 51

Closed Head Trauma ........................................................................................................................... 52

Extremity Trauma................................................................................................................................ 53

Shock ................................................................................................................................................... 54

Spine Trauma ...................................................................................................................................... 55

Traumatic Cardiac Arrest .................................................................................................................... 56

PEDIATRIC PROTOCOLS ........................................................................................................................... 57

PEDIATRIC Airway Obstruction ........................................................................................................... 57

PEDIATRIC Asthma / Bronchiolitis ....................................................................................................... 58

PEDIATRIC Croup / Epiglottitis ............................................................................................................ 59

PEDIATRIC Asystole ............................................................................................................................. 60


PEDIATRIC Bradycardia ....................................................................................................................... 61

PEDIATRIC Narrow Complex Tachycardia ........................................................................................... 62

PEDIATRIC Pulseless Electrical Activity ............................................................................................... 63

PEDIATRIC Wide Complex Tachycardia ............................................................................................... 64

PEDIATRIC Wide Complex Tachycardia without a pulse and Ventricular Fibrillation ......................... 65

PEDIATRIC Altered Mental Status ....................................................................................................... 66

PEDIATRIC Seizures ............................................................................................................................. 67

PEDIATRIC Toxicology ............................................................................................................................. 68

Suspected Overdose / Poisoning ........................................................................................................ 68

Suspected Overdose / Poisoning (continued) ..................................................................................... 69

PEDIATRIC Bites and Envenomation ................................................................................................... 70

PEDIATRIC Abdominal Pain ................................................................................................................. 71

PEDIATRIC Allergic Reaction................................................................................................................ 73

PEDIATRIC GI Bleed ............................................................................................................................. 74

PEDIATRIC Hyperglycemia ................................................................................................................... 75

PEDIATRIC Hypoglycemia .................................................................................................................... 76

PEDIATRIC Nausea and Vomiting ........................................................................................................ 77

PEDIATRIC Sickle Cell Emergencies ..................................................................................................... 78

PEDIATRIC Cold Related Emergencies................................................................................................. 79

PEDIATRIC Heat Related Emergencies ................................................................................................ 80

PEDIATRIC Drowning ........................................................................................................................... 81

PEDIATRIC Abdominal/Pelvic Trauma ................................................................................................. 82

PEDIATRIC Burns ..................................................................................................................................... 83

Burns (Thermal) .................................................................................................................................. 83

Burns (Chemical) ................................................................................................................................. 83

Burns (Electrical) ................................................................................................................................. 83

PEDIATRIC Chest Trauma .................................................................................................................... 84

PEDIATRIC Closed Head Trauma ......................................................................................................... 85

PEDIATRIC Extremity Trauma .............................................................................................................. 86

PEDIATRIC Spine Trauma .................................................................................................................... 87

PEDIATRIC Shock ................................................................................................................................. 88

PEDIATRIC Traumatic Cardiac Arrest .................................................................................................. 89


AIRWAY MANAGEMENT General Management Algorithm

BVM as needed

o Consider use of a simple adjunct such as an OPA or NPA

Suction as needed

Intubation as needed

o Maximum of TWO attempts

o Confirm placement with all of the following

Negative gastric sounds

Positive bilateral breath sounds

Positive waveform capnography (preferred) or colormetric

capnometry

o Secure with a commercially made device

o Consider placing a cervical color on the patient to limit head movement

o Consider placement of an OG/NG tube to prevent/relieve gastric distension

If intubation is unsuccessful:

o Consider placement of one of the following:

Combitube

LMA

King LTA

I-gel





capnometry


o Consider placing a cervical collar on the patient to limit head movement

o If you are still unable to secure the airway AND the patient cannot be

ventilated adequately perform a needle Cricothyrotomy

You may skip directly to this step after an intubation attempt for

conditions such as airway closure due to toxic gas inhalation, severe refractory asthma, or severe allergic reactions


Pharmacology Assisted Intubation YOU MUST BE ABLE TO MANAGE THE AIRWAY WITH A BVM PRIOR TO

ATTEMPTING PHARMACOLOGY ASSISTED INTUBATION

Prepare Equipment

Pre-oxygenate the patient for at least two minutes

Pretreat as necessary

o Lidocaine 1 mg/kg IV/IO (if suspected ICP issues) 2-5 minutes prior to

intubation

o Opioid (if needed to assist with sedation)

Fentanyl 1 mcg/kg IV/IO SLOWLY over 2-3 minutes

o Sedate the patient (pick one and allow at least two minutes for drug to take

effect)

Ativan (Lorazepam) 2-4 mg IV/IO/IM

Versed (Midazolam) 2-2.5 mg IV/IO

Etomidate 0.2-0.6 mg/kg IV/IO

Ketamine 1-2 mg/kg IV/IO

Protect the airway

o BURP maneuver

o Position the patient

Placement of the ET tube

Post Intubation management





capnometry


o Consider placing a cervical collar on the patient to limit head movement o Consider placement of an OG/NG tube to prevent/relieve gastric distension


Rapid Sequence Induction with Paralysis YOU MUST BE ABLE TO MANAGE THE AIRWAY WITH A BVM PRIOR TO

ATTEMPTING RAPID SEQUENCE INDUCTION

Prepare Equipment

o Assess LEMON

Pre-oxygenate the patient for at least two minutes

Pretreat as necessary

o Lidocaine 1 mg/kg IV/IO (if suspected ICP issues) 2-5 minutes prior to

intubation

o Opioid (if needed to assist with sedation)

Fentanyl 1 mcg/kg IV/IO SLOWLY over 2-3 minutes

o Sedate the patient (pick one and allow at least two minutes for drug to take

effect)

Ativan (Lorazepam) 2-4 mg IV/IO/IM

Versed (Midazolam) 2-2.5 mg IV/IO

Etomidate (Amidate) 0.2-0.6 mg/kg IV/IO

Ketamine 1-2 mg/kg IV/IO

Paralyze the patient

o Succinylcholine (Anectine) 1-2 mg/kg RAPID IV/IO

Protect the airway

o BURP maneuver

o Position the patient

Placement of the ET tube

Post Intubation management


Negative gastric sounds, Positive bilateral breath sounds


capnometry


o Consider placing a cervical collar on the patient to limit movement

o Consider placement of an OG/NG tube to prevent/relieve gastric distension

o Administers long lasting paralytic

Pancuronium 0.06-0.1 mg/kg

Vecuronium 0.1-0.2 mg/kg

Rocuronium 0.6-1.2 mg/kg


ADULT RESPIRATORY EMERGENCIES Airway Obstruction

Follow current AHA standards for relief of foreign body (Heimlich maneuver)

Attempt use of Magill forceps using direct visualization of airway as needed

If unable to remove obstruction and respiratory compromise is severe, consider

needle Cricothyrotomy o See airway management guidelines


Bronchospasm Provide supplemental oxygen as needed to maintain SpO2 above 94%

o If necessary, assist ventilations with BVM

Administer a bronchodilator (choose one)

o Albuterol (Proventil) 2.5 mg nebulized

o Levalbuterol (Xopenex) 2.5 mg nebulized

May add Atrovent (Ipratropium) 0.5 mg to Albuterol or Levalbuterol

May repeat as needed as long as heart rate remains below 140

Administer a Steroid (choose one):

o Solu-medrol (Methylprednisolone) 1-2 mg/kg

o Solu-Cortef (Hydrocortisone) 4 mg/kg IV

o Decadron (Dexamethasone) 10-100 mg SLOW IV

Consider the use of CPAP

o Use a setting of 5 cm H2O

If bronchospasm persists after three breathing treatments, consider Magnesium

Sulfate 1-2 gm over 15-30 minutes IV infusion

If bronchospasm persists or worsens consider Epinephrine 1:1000 0.3-0.5 mg IM

and prepare to intubate


CHF / Pulmonary Edema Provide supplemental oxygen as needed to maintain SpO2 above 94%

o Usually this will require high concentrations of oxygen (i.e. NRBM)


Administer Nitroglycerin 0.4mg SL

o Blood pressure must be above 90 mmHg systolic

o Assure no Phosphodiesterase-5 inhibitor (Viagra or Levitra) use within 24

hours

o Assure no Cialis use within 48 hours

o May repeat up to three doses administered as needed

If CPAP has been applied, the CPAP mask SHOULD NOT BE REMOVED

to give additional nitroglycerin

As soon as possible and if available apply CPAP

o Use a setting of 7.5-10 cm H2O

o Consider intubation if patient will not tolerate CPAP

Administer Lasix (Furosemide) 0.5-1.0 mg/kg IV


o Assure patient does not have pulmonary infection (i.e. pneumonia)

If patient does not improve, call for: (choose one)

o Morphine Sulfate 2-4 mg IV/IO

Blood pressure must be above 90 mmHg systolic

May repeat up to a maximum of 10 mg administered as needed

o Fentanyl 1mcg/kg to a maximum of 50 mcg IV/IO/IN

May be repeated once as needed

If hypotension occurs, (SBP < 90 mmHg)

o Establish a Dopamine (Intropin) infusion at 5-20 mcg/kg/min

Titrate infusion to maintain a systolic BP between 90 and 100 mmHg


Hyperventilation Provide supplemental oxygen as needed to maintain SpO2 above 94%

Continuous monitoring of SpO2, EtCO2, and ECG is necessary

Search for underlying causes of hyperventilation

o Airway closure / obstruction

o Metabolic acidosis

o Toxic gas inhalation o Cellular hypoxia


ADULT CARDIAC DYSRHYTHMIAS Asystole

Initiate CPR; continuous CPR is the key

Epinephrine 1mg IV/IO 1:10,000 every 3-5 minutes

Consider possible etiology

o Hypoxemia

Assure ventilation with 100% oxygen

o Hypovolemia

Administer fluid boluses (Start at 500 cc)

o Hydrogen ions (Acidosis)

Correct ventilator insufficiency, then

Consider Sodium Bicarbonate 1 mEq/kg IV/IO

o Hyper/Hypokalemia

For Hyperkalemia, administer Sodium Bicarbonate 1 mEq/kg IV/IO

and Calcium Chloride 1 gm IV/IO

o Hypoglycemia

Administer Dextrose 50% 25 gm IV/IO if BGL is less than 60 gm/dL

o Hypothermia

Active rewarming

o Toxins

Follow appropriate Poisoning/Overdose treatment

o Cardiac tamponade

Perform pericardiocentesis

o Tension pneumothorax

Perform pleural decompression

o Pulmonary or coronary thrombus

Rapid transport

o Trauma

Treat as appropriate


Bradycardia If hemodynamically STABLE

o Obtain 12-lead ECG

o Observe

If hemodynamically UNSTABLE

o Consider Atropine 0.5 mg IV/IO

May skip to transcutaneous pacing if high degree heart block

o If Atropine does not work attempt one of the following:

Transcutaneous pacing

Consider premedication prior to procedure (choose one)

o Lorazepam (Ativan) 2-4 mg IV/IO/IM

Can be given IV if diluted 50:50

o Midazolam (Versed) 2-2.5 mg IV/IO/IN

o Diazepam (Valium) 5-15 mg IV/IO

Set to normal heart rate (60-80 bpm)

Set to lowest mA (10-20mA)

Start pacing

Adjust pacer output (mA) up until electrical capture is attained

Verify mechanical capture

Epinephrine Infusion 2-10 mcg/min

Dopamine (Intropin) infusion 5-20 mcg/kg/min


Narrow Complex Tachycardia Obtain 12-lead ECG

o A-Fib/A-Flutter

If hemodynamically STABLE

Consider vagal maneuvers

Cardizem 0.25 mg/kg IV/IO

If no changes within 15 minutes Cardizem 0.35 mg/kg IV/IO


Cardioversion (don’t forget to SYNC)

o A-Fib

120-200J or manufacturer’s recommendation

Repeat as necessary with escalating doses

o A-Flutter

50-100J or manufacturer’s recommendation







o SVT

If hemodynamically STABLE


Adenosine 6 mg IV/IO (rapid)

If no changes within 5 minutes Adenosine 12 mg IV/IO (rapid)





o SVT

50-100J or manufacturers recommendation








Premature Ventricular Contractions SYMPTOMATIC (PVCs causing hemodynamic instability) with

Couplets or more

Runs of V-tach

Multifocal

R on T phenomenon

o Administer Lidocaine 1.0-1.5 mg/kg IV/IO

Repeat doses of Lidocaine 0.5-0.75 mg/kg IV/IO, every 5-10 minutes if

rhythm persists to a maximum of 3 mg/kg o Once eliminated establish a Lidocaine infusion at 1-4 mg/min


Pulseless Electrical Activity Initiate CPR; continuous CPR is the key

Administer Epinephrine 1mg IV/IO 1:10,000 every 3-5 minutes


o Hypoxemia


o Hypovolemia

Administer fluid boluses (Start at 500 cc)


Correct ventilator insufficiency, then

Consider Sodium Bicarbonate 1 mEq/kg IV/IO

o Hyper/Hypokalemia

For Hyperkalemia, administer Sodium Bicarbonate 1 mEq/kg IV/IO

and Calcium Chloride 1 gm IV/IO

o Hypoglycemia

Administer Dextrose 50% 25 gm IV/IO if BGL is less than 60 gm/dL

o Hypothermia

Active rewarming

o Toxins


o Cardiac tamponade





Rapid transport

o Trauma

Treat as appropriate


Wide Complex Tachycardia If hemodynamically STABLE

o Obtain 12-lead ECG prior to treatment

o Consider vagal maneuvers

o Administer one of the following:

Lidocaine 1.0-1.5 mg/kg IV/IO

Repeat doses of Lidocaine 0.5-0.75 mg/kg IV/IO, every 5-10

minutes if rhythm persists to a maximum of 3 mg/kg

Once converted establish a Lidocaine infusion at 1-4 mg/min

Amiodarone 150 mg IV over 10 minutes (15mg/min)

Continue with Amiodarone 360 mg over 6 hours (1mg/min)

Finish with 540 mg over 18 hours (0.5 mg/min)

Procainamide 20 mg/min IV Infusion

Once converted, follow with a maintenance infusion of 1-4

mg/min

If TORSADES is suspected

Magnesium Sulfate 1-2 grams over 10 minutes


o Attempt to obtain 12-lead ECG

o Cardioversion (don’t forget to SYNC)

VT (wide complex, regular)

100J or manufacturers recommendation


Torsades (wide complex, irregular)

Defibrillate 360J (120-200J if biphasic)

o Consider premedication prior to procedure (choose one)

Lorazepam (Ativan) 2-4 mg IV/IO/IM


Midazolam (Versed) 2-2.5 mg IV/IO/IN Diazepam (Valium) 5-15 mg IV/IO


Wide Complex Tachycardia without a pulse and Ventricular Fibrillation If witnessed IMMEDIATE Defibrillation

o 360J or manufacturers recommendations (120-200J biphasic)

Initiate CPR; continuous CPR is the key; only stop for electrical therapy

Epinephrine 1mg IV/IO 1:10,000

Repeat every 3-5 minutes throughout cardiac arrest OR

Defibrillate 360J or manufacturers recommendations (120-200J biphasic)

Give an antidysrhythmic (PICK ONE ONLY)

o Lidocaine 1.0-1.5 mg/kg IV/IO

o Amiodarone 300 mg IV

o Magnesium Sulfate 1-2 grams over 1-2 minutes if TORSADES is suspected


Repeat Epinephrine 1mg IV/IO 1:10,000


Repeat antidysrhythmic (USE SAME ONE AS EARLIER)

o Lidocaine 0.5-0.75 mg/kg IV/IO, every 5-10 minutes if rhythm persists to

a maximum of 3 mg/kg

o Amiodarone 150 mg


If the patient is converted to a perfusing rhythm hang an infusion of whichever

antidysrhythmic was used to convert the rhythm

o Lidocaine 1-4 mg/min

o Amiodarone 1 mg/min for the first 6 hours

0.5 mg/min for the next 18 hours


OTHER CARDIAC EMERGENCIES Cardiogenic Shock

Support respirations as appropriate

Fix arrhythmia problems as appropriate

IF LUNG SOUNDS ARE CLEAR, administer a fluid bolus of 500 ml of Normal Saline

o May repeat up to 1000cc total

Dopamine (Intropin) infusion at 5-20 mcg/kg/min

o Titrate infusion to maintain a systolic BP between 90 and 100 mmHg


Chest Pain / AMI / ACS Provide supplemental oxygen as needed to maintain SpO2 above 94%


Monitor SpO2, EtCO2, ECG

Administer Aspirin 162-325mg PO

Obtain 12-lead ECG as quickly as possible

o If right ventricular involvement is suspected (Inferior Wall), obtain right side

12-lead or at a minimum V4R

o Initiate STEMI alert

Must have ST Elevation is identified in two or more anatomically

contiguous leads

No imposters present

Time frame from onset is < 12 hours

Administer Nitroglycerin 0.4mg SL


o Assure no Viagra use within 24 hours

o Assure no Cialis or Levitra use within 48 hours

o May repeat up to three doses administered as needed

Administer Morphine Sulfate 2-4 mg IV/IO (up to 10 mg total) if patient still has

chest pain after three nitroglycerin (Use with caution in the patient with RV

involvement)

If Morphine is not effective, considers the use of Fentanyl 1 mcg/kg or Ketamine 0.5

mg/kg

For patients with vomiting administer one of the following:

o Ondansetron (Zofran) 4 mg IV/IO SLOWLY

o Metoclopramide (Reglan) 10 mg IV/IO SLOWLY

o Promethazine (Phenergan) 12.5 mg IV/IO SLOWLY

o Prochloroperazine (Compazine) 2.5-10 mg IV/IO SLOWLY

o Vistaril (Hydroxyzine) 25 mg IM ONLY


ADULT NEUROGENIC EMERGENCIES Acute Psychosis

SAFETY IS PARAMOUNT

o Try to keep the patient calm

Provide supplemental oxygen as needed to maintain SpO2 above 94%


If sedation is necessary, administer one of the following:

o Haldol (Haloperidol) 2-5 mg IM (repeat as needed)

o Ativan (Lorazepam) 2-4 mg IV/IO/IM

o Versed (Midazolam) 2.5 mg IM mixed with the Haldol (Haloperidol) o Geodon (Ziprasidone) 10 mg IM


Altered Mental Status Provide supplemental oxygen as needed to maintain SpO2 above 94%


Consider the possible causes of Altered Mental Status and follow the appropriate

protocol

o Alcohol intoxication

o Epilepsy (Seizures)

o Insulin (Hyper- or Hypoglycemia)

o Overdose

o Uremia (Renal failure)

o Trauma

o Infection

o Psychosis o Stroke / Shock


STROKE / TIA Provide supplemental oxygen as needed to maintain SpO2 above 94%


Spinally immobilize the patient if suspicion of fall or significant trauma

Monitor SpO2, EtCO2, BGL, ECG, 12-lead ECG

o Only treat hypoglycemia if BGL is < 50 mg/dL

Assess for facial droop, arm drift, grip strength, slurred speech

o If any one criteria are found to be abnormal, initiate a Stroke Alert

Symptom onset must be less than 5 hours

No seizure activity

No trauma

Initial BGL > 50 mg/dL








Seizures Take deliberate measures to protect the patient from injury during the seizure



Administer an anticonvulsant (choose one):

o Valium (Diazepam) 5-10 mg IV/IO


o Versed (Midazolam) 2-2.5 mg IV/IO/IN

If seizure is due to eclampsia, administer Magnesium Sulfate 2-4 grams IV over 20-

30 minutes

Consider spinal immobilization if suspicion of fall or significant trauma

Obtain SpO2, EtCO2, BGL, and ECG

o Treat any abnormalities found by appropriate guideline


Syncope / Weakness Provide supplemental oxygen as needed to maintain SpO2 above 94%


Obtain SpO2, EtCO2, BGL, ECG, and 12-lead ECG


Perform a stroke assessment

Consider orthostatic vital signs

Consider spinal immobilization if suspicion of fall or significant trauma


ADULT TOXICOLOGICAL EMERGENCIES Suspected Overdose / Poisoning





If antipsychotic overdose is suspected (dystonic reaction)

o Administer Diphenhydramine (Benadryl) 25-50 mg IV/IO/IM

If benzodiazepine overdose is suspected and respirations are compromised

o Administer Flumazenil (Romazicon) 0.2 mg IV/IO

o If no changes within 5 minutes administer 0.3 mg IV/IO

o If no changes within 5 minutes administer 0.5mg IV/IO

If beta blocker overdose (bradycardia, AV blocks, hypotension, decreased LOC) is

suspected

o Administer Atropine 0.5 mg IV/IO

May repeat up to 3 doses

o If no response, administer Glucagon 5 mg IV/IO

o If no response, begin transcutaneous pacing

If calcium channel blocker (bradycardia, AV blocks, hypotension, decreased LOC)

overdose is suspected

o Administer Atropine 0.5 mg IV/IO


o If no response, administer Calcium Chloride 500-1000 mg IV/IO

o If no response, administer Glucagon 5 mg IV/IO


If carbon monoxide poisoning is suspected

o This patient will require 100% oxygen regardless of SpO2 readings

o Transport patient to a facility with a hyperbaric chamber

If CNS stimulant overdose (dilated pupils, agitation, paranoia, tachycardia,

hypertension, hyperthermia, seizures) is suspected

o Keep the patient calm

o Treat seizure per seizure guidelines


Suspected Overdose / Poisoning (continued) If cyanide poisoning (headache, confusion, short of breath, hypertension,

hypotension, seizures, coma) is suspected

o Call for orders to administer Cyanokit (Hydroxocobalamin) 5 gm IV/IO over

15 minutes

If digitalis toxicity (bradycardia, AV blocks with RVR, SVT, VT, wide PR intervals,

peaked t-waves) is suspected and

o Tachycardic dysrhythmias present, follow tachycardia algorithm

o Bradycardia present with wide QRS, administer Sodium Bicarbonate 1

mEq/kg IV/IO and follow bradycardia algorithm

If opioid/opiate overdose is suspected and respirations are compromised

o Administer Naloxone (Narcan) 0.4 – 2.0 mg IV/IO/IM/IN until breathing is

adequate

If organophosphate overdose is suspected

o Administer Atropine Sulfate 2-4 mg IV/IO until atropinization occurs

o Administer Pralidoxime Chloride (2-PAM) 1-2 grams IV infusion over 10-30

minutes

o May use MARK I kits in the immediate setting

If tricyclic or tetracyclic antidepressant overdose (hypotension, anticholinergic

effects, AV blocks, prolonged QT interval, widened QRS, VT, VF) is suspected

o Administer Sodium Bicarbonate 1 mEq/kg IV/IO

If selective serotonin reuptake inhibitor overdose (hypertension, tachycardia,

agitation, tremors, muscle rigidity, hyperthermia) is suspected

o Administer Sodium Bicarbonate 1 mEq/kg IV/IO


Antipsychotics:

Haloperidol (Haldol)

Prolixin

Thorazine

Prochloroperazine (Compazine)

Promethazine (Phenergan)

Ziprasidone (Geodon)

Benzodiazepines:

Alprazolam (Xanax)

Chlordiazepoxide (Librium)

Clonazepam (Klonopin)

Clorazepate (Tranxene)

Diazepam (Valium)

Flunitrazepam (Rohypnol)

Lorazepam (Ativan)

Midazolam (Versed)

Triazolam (Halcion)

Beta Blockers:

Propranolol (Inderal)

Atenolol (Tenormin)

Metroprolol (Lopressor)

Nadolol (Corgard)

Labetalol (Trandate)

Esmolol (Brevibloc)

Calcium Channel Blockers:

Amlodipine (Norvasc)

Nicardipine (Cardene)

Nifedipine (Procardia)

Verapamil (Calan)

Diltiazem (Cardizem)

CNS Stimulants:

Amphetamine

Methamphetamine

Ecstasy

Cocaine

Crack

Digitalis:

Digoxin (Lanoxin)

Digitoxin (Crystodigin)

Opioids / Opiates:

Codeine

Butorphanol (Stadol)

Dextromethorphan

Diacetylmorphine (Heroin)

Fentanyl (Sublimaze, Duragesic)

Hydromorphone (Dilaudid)

Hydrocodone (Lortab, Vicodin)

Meperidine (Demerol)

Methadone (Dolophine)

Morphine (Astramorph, Duramorph, Roxanol)

Nalbuphine (Nubain)

Oxycodone (Percodan, Percocet, Tylox, Roxicodone)

Pentazocine (Talwin)

Propoxyphene (Darvon)

Sedative hypnotics:

Estazolam (Prosom)

Etomidate (Amidate)

Propofol (Diprivan)

Zolpidem (Ambien)

Selective Serotonin Reuptake Inhibitors:

Citalopram (Celexa)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Tricyclic and other antidepressants:

Doxepin (Adapin, Sinequan, Zonalon, Triadapin)

Amitriptyline (Elavil, Endep)

Protriptyline (Vivactil)

Chlordiazepoxide & amitriptyline (Limbitrol)

Clomipramine (Anafranil)

Amoxapine (Asendin)

Disepramine (Norpramin)

Nortriptyline (Pamelor)

Bupropion (Wellbutrin)

Bites and Envenomation




o If allergic reaction develops, follow allergic reaction treatment guidelines

For SNAKE BITES:

o Cleanse wound

o Splint affected extremity

o Remove jewelry on affected limb

o Mark edematous area with a pen

Reassess and mark every 15 minutes

o Attempt to identify snake if it is safe to do so

o Contact Poison Control for further directions (1-800-222-1222)

For MARINE ENVENOMATIONS:

o Cleanse wound with seawater or hot water

o Irrigate with vinegar if available






For SPIDER / SCORPION BITES:

o Cleanse wound





o Call for orders for a benzodiazepine for severe muscle spasms


For INSECT STINGS:

o Cleanse wound

o Remove stinger by scraping it away

Do not pull or squeeze







ADULT OB/GYN EMERGENCIES Normal Labor and Delivery



If contractions are less than 5 minutes apart, prepare to deliver at the scene

If presenting part is not the head, immediately begin transport to the nearest OB

equipped facility

Control the delivery with gentle pressure on the baby’s head

If the amniotic sac has not ruptured, gently pinch it between your fingers and

remove it from around the baby’s head

Check for nuchal cord

o If present, gently slip cord over head

o If unable to do so, clamp the cord and cut between clamps

Check for meconium

o Be ready to perform tracheal suctioning and secure the airway with an

endotracheal tube as needed (depressed neonate)

Suction the airway with a bulb syringe (mouth, then nose)

Clamp cord in two places about 8” from the baby

o Cut the cord between the clamps

Following delivery, follow newborn resuscitation treatment guidelines

o Dry, warm, and tactile stimulation

o Blow by oxygen

o BVM

o CPR

o Medications

Assess APGAR scores at 1 and 5 minutes

o Appearance

o Pulse

o Grimace

o Respirations

o Activity

Allow for normal delivery of the placenta

To control excessive post-partum hemorrhage

o Perform fundal massage

o Allow baby to nurse

o Call for orders to administer Oxytocin (Pitocin) 20-40 milliunits/min

Mix 10 units into a 1000cc IV bag and infuse at 2-4cc/min

Maximum cumulative dose is 10 units


Childbirth with Complications Provide supplemental oxygen as needed to maintain SpO2 above 94%


Breech (feet first)

o Allow for normal delivery

DO NOT PULL

o If head has not delivered within 3 minutes of shoulders, insert a gloved hand

into the vagina and create a “V” to allow for the baby to breathe

Breech (all other presentations)

o DO NOT ATTEMPT DELIVERY IN THE FIELD

o Immediately begin transport to the nearest OB equipped facility

Prolapsed Umbilical Cord

o Place patient supine

o Encourage the patient to pant (prevents bearing down)

o Insert a gloved hand to gently push the baby off the cord

You need to maintain this position throughout transport

o Wrap exposed portion of cord with moist saline dressings

o Immediately begin transport to the nearest OB equipped facility

Multiple Births

o Follow normal delivery procedure

o Expect smaller babies

o There may be more than one placenta


Third Trimester Bleeding Provide supplemental oxygen as needed to maintain SpO2 above 94%


Loosely dress the vaginal opening to stop blood flow

Place patient supine

o Elevate the legs if signs of shock are present

Administer fluid boluses of Normal Saline to maintain normal blood pressure


Toxemia of Pregnancy (Eclampsia) Provide supplemental oxygen as needed to maintain SpO2 above 94%


First stop the seizure (Pick One)

o Valium (Diazepam) 5-10 mg IV/IO


o Versed (Midazolam) 2-2.5 mg IV/IO/IN

Then

o Magnesium Sulfate 2-4 grams over 20-30 minutes


OTHER ADULT MEDICAL EMERGENCIES Abdominal Pain



Obtain 12-lead ECG for any abdominal pain above the umbilicus





o Prochloroperazine (Compazine) 2.5-10 mg IV/IO SLOWLY o Vistaril (Hydroxyzine) 25 mg IM ONLY


Allergic Reactions Provide supplemental oxygen as needed to maintain SpO2 above 94%


Mild (only cutaneous involvement)

o Benadryl 25-50 mg IV/IO/IM

Moderate (cutaneous and minor respiratory involvement)

o Albuterol 2.5 mg or Levalbuterol 0.63 mg nebulized (X3)

o Atrovent 250-500 mcg nebulized (X1)

o Steroids (Pick One):

Solu-medrol (Methylprednisolone) 1-2 mg/kg

Solu-Cortef (Hydrocortisone) 5 mg/kg IV

Decadron (Dexamethasone) 10-100 mg SLOW IV

o Benadryl (Diphenhydramine) 25-50 mg IV/IO/IM

Severe / Anaphylaxis (cutaneous, significant respiratory and circulatory involvement)

o Epinephrine 1:1000 0.3 mg IM

Can give 1:10,000 0.1 – 0.5 mg IV in EXTREME cases

o Fluid boluses as needed (up to 2-4 liters)

If fluids don’t work, consider

Dopamine 5 ug/kg/min and titrate to adequate perfusion

(generally a BP between 90-100 systolic)


o Atrovent 250-500 mcg nebulized (X1) - may be mixed with Albuterol




Decadron (Dexamethasone) 10-100 mg SLOW IV

o Histamine Blockers: Use one H1 and one H2

H1

Benadryl (Diphenhydramine) 25-50 mg IV/IO/IM

H2

Tagamet (Cimetidine) 300mg IV infusion over 10-15 minutes

Pepcid (Famotidine) 20mg IV infusion over 10-15 minutes

Zantac (Ranitidine) 50mg IV infusion over 10-15 minutes

o Consider Glucagon 1-2 mg IV/IM every 5 minutes if the patient is on Beta

blockers


GI Bleed Provide supplemental oxygen as needed to maintain SpO2 above 94%


SpO2, EtCO2, ECG and 12-lead ECG monitoring are necessary

Treat for hypovolemic shock as needed

o Administer fluid boluses of 500 cc to maintain adequate perfusion (generally

a BP between 90-100 systolic) o VASOPRESSOR USE IS CONTRAINDICATED


Hyperglycemia/HONK/HHNC Provide supplemental oxygen as needed to maintain SpO2 above 94%


Call for fluid boluses of 500 cc


Hypoglycemia Provide supplemental oxygen as needed to maintain SpO2 above 94%


If blood glucose is less than 60mg/dL (<50 mg/dL for suspected stroke)

o Oral Glucose 10 -25 gm PO if the patient is alert enough to self-administer

o Thiamine 100 mg IV/IO/IM if suspected malnourishment

o D50 12.5 - 25 gm IV/IO if unable to give Oral Glucose

o D10 250 mL infusion (25 gm) o Glucagon 1 mg IM if unable to give D50 or D10


Nausea and Vomiting Provide supplemental oxygen as needed to maintain SpO2 above 94%








SEPSIS Emergencies Initiate a SEPSIS ALERT for patient with a suspected infection and:

A Systolic BP of less than 90mmHg

OR any two of the following criteria:

Heart rate > 90 beats per minute; Temperature < 96.8 degrees F or > 100 degrees F; Respiratory rate > 20 breaths per minute; Acute altered mental status; Increased serum lactate levels (> 4 mmol/L)

Treatment:



Establish at least one large bore IV and infuse NORMAL SALINE at 1 liter over 30

minutes

o Do not use Lactated Ringers (lactate with alter the lab tests)

o May administer up to two liters prehospital

May administer more as needed to maintain adequate perfusion








Sickle Cell Emergencies Provide supplemental oxygen as needed to maintain SpO2 above 94%


CALL FOR ONE:

o Morphine Sulfate 2-4 mg (up to 10 mg total)

o Demerol (Meperidine) 25-50 mg SLOW IV/IO

o Dilaudid (Hydromorphone) 0.25-0.5 mg SLOW IV/IO

o Fentanyl (Sublimaze) 1 mcg/kg IM/IN or SLOW IV/IO (up to 150 mcg)

o Butorphanol (Stadol) 0.5-2 mg IV/IO

o Ketamine (Ketalar) 0.5 mg/kg IV/IO or IM

o Nalbuphine (Nubain) 5-10 mg IV/IO

o Nitrous Oxide 50:50 mix self-administered








Suspected Kidney Stones Provide supplemental oxygen as needed to maintain SpO2 above 94%


CALL FOR ONE:

o Ketorolac (Toradol) 15-30 mg IV (30-60 mg IM/IN)















ADULT ENVIRONMENTAL EMERGENCIES SCUBA Diving Emergencies



For drowning follow drowning treatment guidelines

Be alert for a possible pneumothorax

Consider transport to a facility with a hyperbaric chamber

Reminder: Arterial Gas Emboli usually causes cerebral dysfunction (i.e. loss of

consciousness) within 10 minutes of surfacing. DCS usually will present muscular skeletal

(type I), or pulmonary, cardiovascular, or nervous system (usually spinal cord) (type II).

Treatment is the same.


Cold Related Emergencies Provide supplemental oxygen as needed to maintain SpO2 above 94%


Move patient to a warm environment

Monitor ECG for Osborn waves as needed

Superficial frostbite

o Passive rewarming of the affected areas

Deep frostbite

o Leave frozen

o Do NOT massage frozen parts o Rapid transport


Heat Related Emergencies Provide supplemental oxygen as needed to maintain SpO2 above 94%


Move patient to a cool environment

Remove excessive clothing

Use fans and/or cool water to lower body temperature

Monitor SpO2, EtCO2, BGL, and ECG due to possible electrolyte abnormalities

Administer oral electrolyte solutions unless the patient is vomiting or a decreased

LOC where they cannot follow commands.

Establish IV

o Administer fluid blouses of up to 500cc if dehydration is suspected

If decreased LOC is present (Heat Stroke suspected)

o Rapid cooling of the patient

o Place cold packs near groin, axilla

o Avoid overcooling (prevent shivering)

Treat seizures according to seizure treatment guidelines


Drowning/Submersion Provide supplemental oxygen as needed to maintain SpO2 above 94%


Follow cardiac arrest management as needed

Spinal immobilization is indicated if unknown or suspicious mechanism

ALL “Drowning” patients need to be evaluated at the emergency department


ADULT TRAUMATIC EMERGENCIES Abdominal/Pelvic Trauma



Spinal immobilization is necessary

SpO2, EtCO2, BGL and ECG monitoring are necessary

Establish vascular access

o At least one large bore IV

DO NOT REMOVE IMPALED OBJECTS

o Stabilize in place with bulky dressings


Burns (Thermal) Provide supplemental oxygen as needed to maintain SpO2 above 94%


Use moist dressings on minor (small) burns

Use dry sterile dressings on 2nd degree burns greater than 15% BSA

Use dry sterile dressings on all 3rd degree burns

For pain management call for one of the following:















Burns (Chemical) Provide supplemental oxygen as needed to maintain SpO2 above 94%


If it is a dry chemical brush it off

If it is a wet chemical irrigate with copious amounts of water

Follow appropriate toxicological protocol

Burns (Electrical) Provide supplemental oxygen as needed to maintain SpO2 above 94%


Monitor for and treat any dysrhythmias found


Chest Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


Spinal immobilization as necessary (blunt chest trauma or confirmed neurological

deficit)



Stabilize flail segments with bulky dressings

Dress all open wounds with occlusive dressings

Frequently reassess for developing tension pneumothorax

o Decompress as necessary

Treat for shock as needed


Closed Head Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


o TAKE DELIBERATE MEASURES NOT TO HYPERVENTILATE



Only if brain herniation is suspected (unilateral dilated, non-reactive pupil, abrupt

decrease in LOC, decorticate or decerebrate posturing)

o Hyperventilate at a rate of 20 breaths per minute

Maintain EtCO2 between 30 and 40 mmHg

o This is only a temporary measure

For seizures follow the seizure treatment guidelines


Extremity Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


Splint with appropriate materials











Shock Provide supplemental oxygen as needed to maintain SpO2 above 94%


Establish IV

For Hypovolemic, Distributive, and Obstructive shock

o IF LUNG SOUNDS ARE CLEAR, administer a fluid bolus of 500 ml of Normal

Saline

Repeat as needed

Typically, will not exceed 2000cc (1000cc in chest trauma)

For Cardiogenic shock

o IF LUNG SOUNDS ARE CLEAR, administer a fluid bolus of 100-200 ml of

Normal Saline

May repeat once

o Start Dopamine (Intropin) infusion at 5 mcg/kg/min

Titrate infusion to maintain adequate perfusion (usually a systolic BP between 90 and 100 mmHg)


Spine Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


Spinal immobilization is indicated


Frequently reassess dermatomes and mark level of paralysis on the patient

Frequently reassess distal PMS in all extremities


Traumatic Cardiac Arrest Follow ACLS treatment for cardiac arrest

Spinal Immobilization

Look for correctable causes such as airway obstruction, tension pneumothorax, or

hypovolemia

Most traumatic cardiac arrests are a futile effort, consider termination of

resuscitation if no response to aggressive treatment within a few minutes


PEDIATRIC PROTOCOLS PEDIATRIC Airway Obstruction

Follow current AHA standards for relief of foreign body (Heimlich maneuver)

Attempt use of Magill forceps using direct visualization of airway as needed

If unable to remove obstruction and respiratory compromise is severe, consider

needle airway o See airway management guidelines


PEDIATRIC Asthma / Bronchiolitis Provide supplemental oxygen as needed to maintain SpO2 above 94%


Administer a bronchodilator (choose one)

o Albuterol (Proventil) 2.5 mg nebulized

o Levalbuterol (Xopenex) 0.63 mg nebulized

May add Atrovent (Ipratropium) 250-500 mcg to Albuterol or

Levalbuterol

May repeat as needed as long as heart rate remains below 180

Administer a Steroid (choose one):

o Solu-medrol (Methylprednisolone) 1-2 mg/kg

o Solu-Cortef (Hydrocortisone) 1 mg/kg IV

o Decadron (Dexamethasone) 0.25-1 mg/kg SLOW IV

If bronchospasm persists after three breathing treatments, call for Magnesium

Sulfate 25-50 mg/kg over 10-20 minutes IV infusion

If bronchospasm persists or worsens call for Epinephrine 1:1000 0.01 mg/kg IM

and prepare to intubate


PEDIATRIC Croup / Epiglottitis Allow child to remain in a position of comfort

Takes deliberate action NOT to upset the child


o BLOW-BY humidified oxygen is preferred

Administers either:

o Racemic Epinephrine 5 mL nebulized in 5 mL saline (preferred) OR

o Epinephrine 2.5 mL 1:1000 nebulized with 3 mL saline


PEDIATRIC Asystole Initiate CPR; continuous CPR is the key

Epinephrine 0.01mg/kg (0.1mL/kg) IV/IO 1:10,000 every 3-5 minutes


o Hypoxemia


o Hypovolemia

Administer fluid boluses 10-20 cc/kg


Administer Sodium Bicarbonate 1 mEq/kg 8.4% (4.2% if less than 1

month old) IV/IO

o Hyper/Hypokalemia

For Hyperkalemia, administer Sodium Bicarbonate 1 mEq/kg 8.4%

(4.2% if less than 1 month old) IV/IO

Calcium Chloride 20 mg/kg IV/IO

o Hypoglycemia (BGL less than 60)

For children > 2 years old, administer Dextrose 50%, 1mL/kg IV/IO

For children > 1 month, administer Dextrose 25%, 2mL/kg IV/IO

For infants <1 month old, administer Dextrose 10%, 5mL/kg IV/IO

NOTE: D10 is acceptable for all age groups

o Hypothermia

Active rewarming

o Toxins


o Cardiac tamponade





Rapid transport

o Trauma Treat as appropriate


PEDIATRIC Bradycardia If hemodynamically STABLE

o Observe

If hemodynamically UNSTABLE and heart rate <60

o Aggressive oxygenation and ventilation

o If heart rate remains <60, begin CPR

o Epinephrine 0.01 mg/kg (0.1 mL/kg) 1:10,000 IV/IO

Repeat doses of epinephrine, every 3-5 minutes if rhythm persists

o Consider Atropine 0.02mg/kg if suspected increased vagal tone

May not work in infants due to lack of Vagus nerve innervation

o If Epinephrine does not work attempt transcutaneous pacing


Lorazepam (Ativan) 0.05 mg/kg IV/IO/IM

o Can be given IV if diluted 50:50

Diazepam (Valium) 0.2-0.5 mg/kg IV/IO

Set to normal heart rate (100 bpm)

Set to lowest mA (10-20mA)

Start pacing

Adjust pacer output (mA) up until electrical capture is attained

Verify mechanical capture

o If transcutaneous pacing does not work:

Epinephrine infusion 2-10 mcg/min OR

Dopamine (Intropin) infusion 5-20 mcg/kg/min


PEDIATRIC Narrow Complex Tachycardia SVT

o For an INFANT SVT is defined as a sustained rate of 220 with a narrow QRS

o For a CHILD SVT is defined as a sustained rate of 180 with a narrow QRS

o If hemodynamically STABLE


Adenosine 0.1 mg/kg IV/IO (rapid)

If no changes within 5 minutes Adenosine 0.2 mg/kg IV/IO (rapid)

o If hemodynamically UNSTABLE

May attempt vagal maneuvers or Adenosine without significant delay


0.5-1 J/kg or manufacturers recommendation



Lorazepam (Ativan) 0.05 mg/kg IV/IO/IM

o Can be given IV if diluted 50:50

Diazepam (Valium) 0.05-0.5 mg/kg IV/IO


PEDIATRIC Pulseless Electrical Activity Initiate CPR; continuous CPR is the key

Epinephrine 0.01mg/kg (0.1mL/kg) IV/IO 1:10,000 every 3-5 minutes


o Hypoxemia


o Hypovolemia

Administer fluid boluses 10-20 cc/kg


Administer Sodium Bicarbonate 1 mEq/kg 8.4% (4.2% if less than 1

month old)IV/IO

o Hyper/Hypokalemia

For Hyperkalemia, administer Sodium Bicarbonate 1 mEq/kg 8.4%

(4.2% if less than 1 month old) IV/IO

Calcium Chloride 20 mg/kg IV/IO

o Hypoglycemia (BGL less than 60)





o Hypothermia

Active rewarming

o Toxins


o Cardiac tamponade





Rapid transport

o Trauma Treat as appropriate


PEDIATRIC Wide Complex Tachycardia If hemodynamically STABLE

o Obtain 12-lead ECG prior to treatment

o Consider vagal maneuvers

o Consider Adenosine 0.1mg/kg if possible aberrancy

o Seek expert consultation


o Attempt to obtain 12-lead ECG

o Cardioversion (don’t forget to SYNC)

VT (wide complex, regular)

1J/kg



PEDIATRIC Wide Complex Tachycardia without a pulse and Ventricular Fibrillation

If witnessed IMMEDIATE Defibrillation

o 2J/kg or manufacturers recommendations

Initiate CPR; continuous CPR is the key; only stop for electrical therapy

Administer Epinephrine 0.01mg/kg (0.1mL/kg) IV/IO 1:10,000

o Repeat every 3-5 minutes throughout cardiac arrest

Defibrillate 4J/kg or manufacturers recommendations

Administer an antidysrhythmic

o Amiodarone 5 mg/kg IV/IO OR

o Lidocaine 1 mg/kg IV/IO

Defibrillate 4-10J/kg or manufacturers recommendations



Administer previous antidysrhythmic

o Amiodarone 5 mg/kg IV/IO





Administer previous antidysrhythmic

o Amiodarone 5 mg/kg IV/IO






PEDIATRIC Altered Mental Status Provide supplemental oxygen as needed to maintain SpO2 above 94%


Consider the possible causes of Altered Mental Status and follow the appropriate

protocol

o Alcohol intoxication

o Epilepsy (Seizures)

o Insulin (Hyper- or Hypoglycemia)

o Overdose

o Uremia (Renal failure)

o Trauma

o Infection

o Psychosis o Stroke / Shock


PEDIATRIC Seizures Take deliberate measures to protect the patient from injury during the seizure



Administer an anticonvulsant (choose one):

o Valium (Diazepam) 0.5-1 mg/kg IV/IO/IM

o Ativan (Lorazepam) 0.05 mg/kg IV/IO/IM

Spinally immobilize the patient if suspicion of fall or significant trauma




PEDIATRIC Toxicology Suspected Overdose / Poisoning





If antipsychotic overdose is suspected (dystonic reaction)

o Administer Diphenhydramine (Benadryl) 1-2 mg/kg IV/IO/IM (MAX 50 mg)

If benzodiazepine overdose is suspected and respirations are compromised

o Provide airway and ventilator support as needed

If beta blocker overdose (bradycardia, AV blocks, hypotension, decreased LOC) is

suspected

o Administer Atropine 0.02 mg/kg IV/IO (minimum dose 0.1 mg)



If calcium channel blocker (bradycardia, AV blocks, hypotension, decreased LOC)

overdose is suspected

o Administer Atropine 0.02 mg/kg IV/IO (minimum dose 0.1 mg)


o If no response, administer Calcium Chloride 20 mg/kg IV/IO


If carbon monoxide poisoning is suspected

o This patient will require high concentrations of oxygen (i.e. NRBM)

regardless of SpO2 readings

o Transport patient to a facility with a hyperbaric chamber

If CNS stimulant overdose (dilated pupils, agitation, paranoia, tachycardia,

hypertension, hyperthermia, seizures) is suspected

o Keep the patient calm o Treat seizure per seizure guidelines


Suspected Overdose / Poisoning (continued) If cyanide poisoning (headache, confusion, short of breath, hypertension,

hypotension, seizures, coma) is suspected

o Call for orders to administer Cyanokit (Hydroxocobalamin) 70 mg/kg IV/IO

over 15 minutes

If digitalis toxicity (bradycardia, AV blocks with RVR, SVT, VT, wide PR intervals,

peaked t-waves) is suspected and

o Tachycardic dysrhythmias present, follow tachycardia algorhythm

o Bradycardia present with wide QRS, administer Sodium Bicarbonate 1

mEq/kg 8.4% (4.2% if less than 1 month old) IV/IO

If opioid/opiate overdose is suspected and respirations are compromised

o Administer Naloxone (Narcan) 0.1 mg/kg IV/IO/IM/IN (Maximum dose

0.8mg)

If organophosphate overdose is suspected

o Administer Atropine Sulfate 0.02 mg/kg IV/IO until atropinization occurs

o Administer Pralidoxime Chloride (2-PAM) 20-40 mg/kg IV infusion over 10-

30 minutes

If tricyclic or tetracyclic antidepressant overdose (hypotension, anticholinergic

effects, AV blocks, prolonged QT interval, widened QRS, VT, VF) is suspected

o Administer Sodium Bicarbonate 1 mEq/kg 8.4% (4.2% if less than 1 month

old) IV/IO

If selective serotonin reuptake inhibitor overdose (hypertension, tachycardia,

agitation, tremors, muscle rigidity, hyperthermia) is suspected

o Administer Sodium Bicarbonate 1 mEq/kg 8.4% (4.2% if less than 1 month

old) IV/IO


Antipsychotics:

Haloperidol (Haldol)

Prolixin

Thorazine

Prochloroperazine (Compazine)

Promethazine (Phenergan)

Ziprasidone (Geodon)

Benzodiazepines:

Alprazolam (Xanax)

Chlordiazepoxide (Librium)

Clonazepam (Klonopin)

Clorazepate (Tranxene)

Diazepam (Valium)

Flunitrazepam (Rohypnol)

Lorazepam (Ativan)

Midazolam (Versed)

Triazolam (Halcion)

Beta Blockers:

Propranolol (Inderal)

Atenolol (Tenormin)

Metroprolol (Lopressor)

Nadolol (Corgard)

Labetalol (Trandate)

Esmolol (Brevibloc)

Calcium Channel Blockers:

Amlodipine (Norvasc)

Nicardipine (Cardene)

Nifedipine (Procardia)

Verapamil (Calan)

Diltiazem (Cardizem)

CNS Stimulants:

Amphetamine

Methamphetamine

Ecstasy

Cocaine

Crack

Digitalis:

Digoxin (Lanoxin)

Digitoxin (Crystodigin)

Opioids / Opiates:

Codeine

Butorphanol (Stadol)

Dextromethorphan

Diacetylmorphine (Heroin)

Fentanyl (Sublimaze, Duragesic)

Hydromorphone (Dilaudid)

Hydrocodone (Lortab, Vicodin)

Meperidine (Demerol)

Methadone (Dolophine)

Morphine (Astramorph, Duramorph, Roxanol)

Nalbuphine (Nubain)

Oxycodone (Percodan, Percocet, Tylox, Roxicodone)

Pentazocine (Talwin)

Propoxyphene (Darvon)

Sedative hypnotics:

Estazolam (Prosom)

Etomidate (Amidate)

Propofol (Diprivan)

Zolpidem (Ambien)

Selective Serotonin Reuptake Inhibitors:

Citalopram (Celexa)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Tricyclic and other antidepressants:

Doxepin (Adapin, Sinequan, Zonalon, Triadapin)

Amitriptyline (Elavil, Endep)

Protripytline (Vivactil)

Chlordiazepoxide & amitriptyline (Limbitrol)

Clomipramine (Anafranil)

Amoxapine (Asendin)

Disepramine (Norpramin)

Nortriptyline (Pamelor)

Bupropion (Wellbutrin)

PEDIATRIC Bites and Envenomation Provide supplemental oxygen as needed to maintain SpO2 above 94%



o If allergic reaction develops, follow allergic reaction treatment guidelines

For SNAKE BITES:

o Cleanse wound





o Attempt to identify snake if it is safe to do so


For MARINE ENVENOMATIONS:

o Cleanse wound

o Irrigate with vinegar if available






For SPIDER / SCORPION BITES:

o Cleanse wound





o Call for orders for a benzodiazepine for severe muscle spasms


For INSECT STINGS:

o Cleanse wound

o Remove stinger by scraping it away

Do not pull or squeeze






PEDIATRIC Abdominal Pain Provide supplemental oxygen as needed to maintain SpO2 above 94%


Obtain 12-lead ECG for any abdominal pain above the umbilicus


o Ondansetron (Zofran) 0.15 mg/kg IV/IO SLOWLY


o Metoclopramide (Reglan) 0.1 mg/kg IV/IO SLOWLY

o Promethazine (Phenergan) 0.25-0.5 mg/kg IV/IO SLOWLY o Vistaril (Hydroxyzine) 0.5-1 mg/kg IM ONLY


PEDIATRIC Allergic Reaction Provide supplemental oxygen as needed to maintain SpO2 above 94%


Mild (only cutaneous involvement)

o Benadryl 1-2 mg/kg IV/IO/IM

Moderate (cutaneous and minor respiratory involvement)


o Atrovent 250-500 mcg nebulized (X1)




Decadron (Dexamethasone) 0.25-1 mg/kg SLOW IV

o Benadryl (Diphenhydramine) 1-2 mg/kg IV/IO/IM

Severe / Anaphylaxis (cutaneous, significant respiratory and circulatory involvement)

o Epinephrine 1:1000 0.01 mg/kg IM/SQ

Can give 1:10,000 0.01 mg/kg IV in EXTREME cases

o Fluid boluses as needed (up to 2-4 liters)

If fluids don’t work consider

Dopamine 5 ug/kg/min and titrate to adequate perfusion


o Atrovent 250-500 mcg nebulized (X1) - may be mixed with Albuterol or

Levalbuterol




Decadron (Dexamethasone) 0.25-1 mg/kg SLOW IV o Benadryl (Diphenhydramine) 1-2 mg/kg IV/IO/IM


PEDIATRIC GI Bleed Provide supplemental oxygen as needed to maintain SpO2 above 94%


SpO2, EtCO2, ECG and 12-lead ECG monitoring are necessary

Treat for hypovolemic shock as needed

o Administer fluid boluses of 20 cc/kg to maintain adequate perfusion

May repeat up to 2 additional times o VASOPRESSOR USE IS CONTRAINDICATED


PEDIATRIC Hyperglycemia Provide supplemental oxygen as needed to maintain SpO2 above 94%


Call for fluid boluses of 20 cc/kg


PEDIATRIC Hypoglycemia Provide supplemental oxygen as needed to maintain SpO2 above 94%


If blood glucose is less than 60mg/dL

o Oral Glucose 10 -25 gm PO if the patient is alert enough to self-administer

o Thiamine 10-25 mg IV/IO/IM if suspected malnourishment

o Administer Dextrose





o Glucagon 0.5-1 mg IM if unable to give Dextrose


PEDIATRIC Nausea and Vomiting Provide supplemental oxygen as needed to maintain SpO2 above 94%





o Promethazine (Phenergan) 1 mg/kg IV/IO SLOWLY

o Vistaril (Hydroxyzine) 0.5-1 mg/kg IM ONLY


PEDIATRIC Sickle Cell Emergencies Provide supplemental oxygen as needed to maintain SpO2 above 94%


CALL FOR ONE:

o Morphine Sulfate 0.1 mg/kg (up to 5 mg total)

o Demerol (Meperidine) 1-2 mg/kg SLOW IV/IO

o Dilaudid (Hydromorphone) 0.005 mg/kg SLOW IV/IO





o Promethazine (Phenergan) 1 mg/kg IV/IO SLOWLY

o Vistaril (Hydroxyzine) 0.5-1 mg/kg IM ONLY


PEDIATRIC Cold Related Emergencies Provide supplemental oxygen as needed to maintain SpO2 above 94%


Move patient to a warm environment

Monitor ECG for Osborne waves as needed

Superficial frostbite

o Passive rewarming of the affected areas

Deep frostbite

o Leave frozen

o Do NOT massage frozen parts o Rapid transport


PEDIATRIC Heat Related Emergencies Provide supplemental oxygen as needed to maintain SpO2 above 94%


Move patient to a cool environment

Remove excessive clothing

Use fans and/or cool water to lower body temperature

Rehydrate with oral fluids if patient is able to follow commands

Monitor SpO2, EtCO2, BGL, and ECG due to possible electrolyte abnormalities

Establish IV

o Administer fluid blouses of up to 20 cc/kg if dehydration is suspected

If decreased LOC is present (Heat Stroke suspected)

o Rapid cooling of the patient

o Place cold packs near groin, axilla

o Avoid overcooling (prevent shivering)

Treat seizures according to seizure treatment guidelines


PEDIATRIC Drowning Provide supplemental oxygen as needed to maintain SpO2 above 94%


Follow cardiac arrest management as needed

Spinal immobilization is indicated if unknown or suspicious mechanism

ALL “Drowning” patients need to be evaluated at the emergency department


PEDIATRIC Abdominal/Pelvic Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


Spinal immobilization as necessary


Establish vascular access

o At least one large bore IV

o Administer fluid boluses of 20 mL/kg if hypotension develops

DO NOT REMOVE IMPALED OBJECTS

o Stabilize in place with bulky dressings


PEDIATRIC Burns Burns (Thermal)



Use moist dressings on minor (small) burns

Use dry sterile dressings on 2nd degree burns greater than 15% BSA

Use dry sterile dressings on all 3rd degree burns




o Dilaudid (Hydromorphone) 5 mcg/kg SLOW IV/IO


Burns (Chemical) Provide supplemental oxygen as needed to maintain SpO2 above 94%


If it is a dry chemical brush it off

If it is a wet chemical irrigate with copious amounts of water

Follow appropriate toxicological protocol

Burns (Electrical) Provide supplemental oxygen as needed to maintain SpO2 above 94%


Monitor for and treat any dysrhythmias found


PEDIATRIC Chest Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


Spinal immobilization as necessary



Stabilize flail segments with bulky dressings

Dress all open wounds with occlusive dressings

Frequently reassess for developing tension pneumothorax

o Decompress as necessary

Treat for shock as needed


PEDIATRIC Closed Head Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


o TAKE DELIBERATE MEASURES NOT TO HYPERVENTILATE



Only if brain herniation is suspected (unilateral dilated, non-reactive pupil, abrupt

decrease in LOC, decorticate or decerebrate posturing)

o Hyperventilate at a rate of 20 breaths per minute

Maintain EtCO2 between 30 and 40 mmHg

o This is only a temporary measure

For seizures follow the seizure treatment guidelines


PEDIATRIC Extremity Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


Splint with appropriate materials




o Dilaudid (Hydromorphone) 5 mcg/kg SLOW IV/IO



PEDIATRIC Spine Trauma Provide supplemental oxygen as needed to maintain SpO2 above 94%


Spinal immobilization is indicated


Frequently reassess dermatomes

Frequently reassess distal PMS in all extremities


PEDIATRIC Shock Provide supplemental oxygen as needed to maintain SpO2 above 94%


Establish IV

For Hypovolemic, Distributive, and Obstructive shock

o IF LUNG SOUNDS ARE CLEAR, administer a fluid bolus of 20cc/kg of Normal

Saline (10cc/kg in newborns/neonates)

Repeat as needed up to three times

Call medical control for additional fluids

For Cardiogenic shock

o IF LUNG SOUNDS ARE CLEAR, administer a fluid bolus of 20cc/kg of Normal

Saline (10cc/kg in newborns/neonates)

May repeat once

o Start Dopamine (Intropin) infusion at 5 mcg/kg/min

Titrate infusion to maintain a radial pulses


PEDIATRIC Traumatic Cardiac Arrest Follow ACLS treatment for cardiac arrest

Spinal Immobilization

Look for correctable causes such as airway obstruction, tension pneumothorax, or

hypovolemia

Most traumatic cardiac arrests are a futile effort, consider termination of

resuscitation if no response to aggressive treatment within a few minutes

o Consider the circumstances

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