nassau county protocol roll out final version january … · 2014 updated january 20, 2014 1....

Nassau Regional Emergency Medical Services

Protocol Update

2014 updated January 20, 2014

Protocol Update

1


Advanced Life Support

Policy, Procedure, and Policy, Procedure, and

Protocol Manual

2014 2

Section III – Protocol - Table of Contents Approved/

Revised Effective

Airway Management / Respiratory Arrest III. A 10/30/13 4/01/14

Medication Facilitated Intubation III. B 10/30/13 4/01/14

Vascular Access III. C 10/30/13 4/01/14

Hypoperfusion / Shock III. D 10/30/13 4/01/14

Pain Management III. E 10/30/13 4/01/14

Procedural Sedation III. F 10/30/13 4/01/14

Severe Nausea / Vomiting III. G 10/30/13 4/01/14

Trauma III. H 10/30/13 4/01/14

Asthma / Bronchospasm III. I 10/30/13 4/01/14

COPD III. J 10/30/13 4/01/14

Acute Pulmonary Edema III. K 10/30/13 4/01/14

Anaphylaxis III. L 10/30/13 4/01/14

Acute Coronary Syndrome / Chest Pain III. M 10/30/13 4/01/14

Cardiac Arrest - VF / Pulseless VT III. N 10/30/13 4/01/14

Cardiac Arrest - Asystole / PEA III. O 10/30/13 4/01/14

Post Resuscitation - Return of Circulation III. P 10/30/13 4/01/14

Wide Complex Tachycardia w/ pulse III. Q 10/30/13 4/01/14

Narrow Complex Tachycardia III. R 10/30/13 4/01/14

Symptomatic Bradycardia III. S 10/30/13 4/01/14

Altered Mental Status III. T 10/30/13 4/01/14

Seizures / Status Epilepticus III. U 10/30/13 4/01/14

Stroke / Transient Ischemic Attack III. V 10/30/13 4/01/14

Behavioral Emergency III. W 10/30/13 4/01/14

Poisoning / OD / Toxic Exposure III. X 10/30/13 4/01/14

Obstetric / Pregnancy related III. Y 10/30/13 4/01/14

Hazardous Materials Treatment (Restricted Distribution) III. Z 10/30/13 4/01/04 3

Special Notes:

Currently, Nassau County REMSCO does not mandate Controlled Substances,

CPAP/BIPAP or Hypothermia procedures for ROSC. These items are considered the

standard of care and agencies are encouraged to adopt these items with approval of

their agency Medical Director.

Complete vitals must be assessed prior to the administration of any vaso-active

medications.

Nasal route of administration is preferred when the patient is violent, with seizures, or

if provider safety is compromised.

If D50 is unavailable - D10w may be used

4

Critical Care

& Paramedic Airway Management / Respiratory Arrest Protocol III. A

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o BLS airway management

o BLS foreign body obstruction techniques as appropriate

o Use a Magill forceps to remove possible obstruction

o Oxygen as appropriate o Oxygen as appropriate

o Pulse oximetry, waveform capnography, cardiac monitor as appropriate

o Endotracheal intubation *

- monitor waveform capnography throughout transport.

- use a colorimetric CO2 detector as a secondary device.

- 2 attempts only - consider alternate airway device.

o Establish IV access

o Naloxone (Narcan) 2.0 mg IV/IO/ IN - for suspected narcotic overdose

Paramedic

o Needle decompression - for suspected tension pneumothorax

5

Critical Care

& Paramedic Airway Management / Respiratory Arrest Protocol III. A

Approved: 10/30/13

Effective: 4/01/14

Medical Control Options:

o CPAP / BIPAP (if available)

Naloxone 2.0 mg IV/IO/ IN o Naloxone (Narcan) 2.0 mg IV/IO/ IN


o Needle cricothyroidotomy (Paramedic Only)

6

Protocol III. A – Updates

Standing Orders

Narcan 2mg IV/IO/IN

Paramedic Only

Needle Decompression

Medical Control Options

CPAP/BiPAP

Needle Cricothyroidotomy (Paramedic only)

7

Paramedic

ONLY Medication Facilitated Intubation Protocol III. B

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

Paramedic only

o BLS Airway management

o Obtain vascular access as appropriate

o Cardiac monitor as appropriate

o Pre-oxygenate, position the patient appropriately

o Contact Medical Control for sedation medications.

o Post - Endotracheal intubation

- monitor waveform capnography throughout transport.

- use a colorimetric CO2 detector as a secondary device.

- 2 attempts only - consider alternate airway device.

8

Paramedic

ONLY Medication Facilitated Intubation Protocol III. B

Approved: 10/30/13

Effective: 4/01/14

Medical Control Options: (if available)

o If the patient is conscious prior to performing endotracheal intubation,

contact medical control for prehospital sedation (if available)

• Diazepam (Valium) 5-10 mg IV/IO (if hemodynamically stable) • Diazepam (Valium) 5-10 mg IV/IO (if hemodynamically stable)

repeat dose may be given as necessary (max total dose 20 mg)

or

• Midazolam (Versed) 1-5 mg IV/IO/IN


or • Lorazepam (Ativan) 2-4 mg IV/IO/IN


or

• Etomidate (Amidate) 0.3 mg/kg rapid IV/IO push (max dose 20mg)

After intubation,

• Diazepam (Valium) 5mg IV/IO for continued sedation.

9

Protocol III. B – Updates

Medical Control OptionsParamedic Only

Diazepam 5-10 mg IV/IODiazepam 5-10 mg IV/IO

Lorazepam 2-4 mg IV/IO

Diazepam 5 mg IV/IO

Etomidate 0.3 mg/kg rapid IV/IO

Midazolam 1-5 mg IV/IO/IN

10

DIAZEPAM (Valium)

Class

Benzodiazepine

Interactions

Diazepam is incompatible with many medications. Whenever Diazepam

is given intravenously in conjunction with other drugs, the IV line should beis given intravenously in conjunction with other drugs, the IV line should be

adequately flushed.

Pharmacokinetics

Onset : 1-5 minutes IV; 15-30 minutes IM

Duration : peak effects 15-60 minutes

Dose / RouteAdult: Diazepam (Valium) 5-10 mg IV/IO (PR if no access) max 20 mg total

Pedi: Diazepam IV/IO slowly over 2 minutes, repeat (PR if no access)

Protocols Adult - III.B, III.F, III.P, III.U, III.W, III.X, III.Y Pedi - P9 11

MIDAZOLAM (Versed)

Class

Benzodiazepine

PharmacokineticsOnset : 1-3 minutes IV/IN; 15-30 minutes IMOnset : 1-3 minutes IV/IN; 15-30 minutes IM

Duration : Peak effects variable (30-60 minutes)

Dose / Route

Adult: Midazolam (Versed) 1- 5 mg IV/IO/IN (max total dose 5 mg)

Pedi: Midazolam, slowly over 2 minutes. If no response within 5 min. repeat

(PR if no access)

Protocols Adult - III.B, III.F, III.P, III.U, III.W, III.X, Pedi - P9

12

LORAZEPAM (Ativan)

Class

Benzodiazepine, anticonvulsant, sedative

Pharmacokinetics

Onset: 1-5 minutes IV; 15-30 minutes IM

Peak effects : 15-20 minutes IV; 2 hours IMPeak effects : 15-20 minutes IV; 2 hours IM

Duration: 6-8 hours

Dose / Route

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

(total max dose 4 mg)

Note: Lorazepam must be refrigerated at 2-8 degree Celsiusor 35-46 degree Fahrenheit. Per NYS Bureau of Narcotics

Enforcement and EMS regulation.

Protocols Adult - III.F, III.U, III.W, III.X, Pedi - P913

Class

Sedative hypnotic

Pharmacokinetics

Onset: 10-20 seconds

Peak effects < 1 minute

Etomidate (Amidate)

Peak effects < 1 minute

Duration: 3-5 minutes

Dose / Route

Etomidate (Amidate) 0.3mg/kg IV/IO

(total max dose 20 mg)

Protocols Adult - III.B, III.F, III.Y Pedi - NONE

14

Critical Care

& Paramedic Vascular Access / Fluid & Medication Management Protocol III. C

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Saline lock or KVO I.V. line with normal saline may be used.

o Patients that require rapid volume IV drip, at least one (1) large bore IV line

with normal saline should be established. with normal saline should be established.

o Peripheral veins should be used as a primary site. The external jugular vein

(EJ) may be used in extremis for adult patients if no other site is accessible.

o An intraosseous (IO) device may be used for patients in complete vascular

collapse via Proximal Tibia ONLY. Drug administration via this route utilizes

doses identical to those used for IV administration.

o In the absence of intravenous access, intranasal (IN) with an appropriate

atomizer device may be used if available.

The only drugs approved for this route are Naloxone (Narcan), Lorazepam (Ativan),

Midazolam (Versed) and Fentanyl .

(this is the preferred route for violent patients, seizures, or if provider safety is compromised)

15

Protocol III. C – Updates

Intra Nasal Drugs: Narcan , Lorazepam, Midazolam, Fentanyl

16

Critical Care

& Paramedic Hypoperfusion / Shock Protocol III. D

Approved: 10/30/13

Effective: 4/01/14

Do Not delay transport

Standing Orders:

o Airway management

o Vascular access

o Cardiac monitor

o IV fluid bolus - titrate to SBP 90

(No more than 2 liters unless ordered by medical control)

If adrenal cortical insufficiency (Addison's) / hyperplasia is confirmed *

o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)

Paramedic

o Needle Decompression - for suspected tension pneumothorax

17

Critical Care

& Paramedic Hypoperfusion / Shock Protocol III. D

Approved: 10/30/13

Effective: 4/01/14


o Dopamine drip 5-20 mcg/kg/min IV/IO

o Norepinephrine (Levophed) (2-4 mcg/min- initial dose) IV/IO (max 30 mcg/min) - large vein if possible

Continue IV Drip beyond 2 Liters o Continue IV Drip beyond 2 Liters

o Hospital Diversion

o Needle Decompression - for suspected tension pneumothorax

o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)

NOTE: Adrenal insufficiency / hyperplasia is confirmed by patient record,

family or medic alert tag

18

Protocol III. D – Updates

Standing OrdersHydrocortisone Sodium Succinate 2 mg/kg IV/IO

Paramedic OnlyNeedle DecompressionNeedle Decompression


Hydrocortisone Sodium Succinate 2 mg/kg IV/IO

Dopamine Drip 5-20 mcg/kg IV drip IV/IO

Norepinephrine 2-4 mcg/min IV/IO

19

Class

Sympathetic agonist

Pharmacokinetics

Onset: Immediate

Peak effect: 1-2 minutes

Norepinephrine (Levophed)

Peak effect: 1-2 minutes

Duration: N/A

Half-life: Short 1-2 minutes

Dose / Route

Norepinephrine (Levophed) 2-4 mcg/min IV/IOMaximum 30 mcg/min

Large vein access- if possible

Protocols Adult - III.D, III.K, III.L, III.P, Pedi - NONE20

Norepinephrine (Levophed)

ClassCorticosteroid and anti-inflammatory

Pharmacokinetics

Onset: Immediate

Peak effect: 4-6 Hours

Hydrocortisone (Solu-Cortef)

Peak effect: 4-6 Hours

Duration: 24-36 hours

Dose / Route

Hydrocortisone (Solu-Cortef ) 2 mg/kg IV/IO Adult

Maximum dose 100 mg

2 mg/kg IV/IO Pediatric

Protocols Adult - III.D Pedi – P11

22

Critical Care

& Paramedic Pain Management (Non-cardiac) Protocol III. E

Approved: 10/30/13

Effective: 4/01/14

To provide relief from severe pain for patients with:

• Burns without hemodynamic compromise

• Isolated extremity fractures/dislocations with severe pain and long

transport or disentanglement time

• Any other condition deemed appropriate by Medical control.

Standing Orders:

o Airway management

o Vascular access

o Cardiac monitor

o Ketorolac (Toradol) 30 mg IV (over 1 minute) / IM (ages 14- 65 only)

Paramedic

o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IM (if available)

o Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - for respiratory depression

If nausea or vomiting occurs - refer to protocol III. G 23

Critical Care

& Paramedic Pain Management (Non-cardiac) Protocol III. E

Approved: 1/16/13

Effective:


o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IM (max 20mg total) (if available)

o Ketorolac (Toradol) 30 mg IV (over 1 minute) / IM (ages 14-65 only)

o Fentanyl 1mcg/kg IV/IO/IM/IN (max 100 mcg)

If Hypoventilation after Morphine administration

o Naloxone (Narcan) 0.4-2.0 mg IV/IO/IM/ IN

24

Protocol III. E – Updates

Standing Orders

Paramedic Only

Morphine Sulfate 2- 10 mg (0.1 mg/kg) IV/IM

Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - for respiratory Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - for respiratory

depression


Fentanyl 1mcg/kg IV/IO/IN/IM

Narcan 0.4 -2 mg IV/IO/IN/IM

25

Class

Narcotic analgesic

Pharmacokinetics

Onset: Immediate (IV), 15-30 min (IM)

Duration: 2-7 hours

Morphine Sulfate

Duration: 2-7 hours

Dose / Route

Morphine Sulfate 2-10 mg (0.1mg/kg) IV IM

Maximum 20mg Total

Often administered with antiemetic to prevent nausea/vomiting

Protocols Adult - III.E, III.F, Pedi - NONE26

Critical Care

& Paramedic Procedural Sedation Protocol III. F

Approved: 10/30/13

Effective: 4/01/14

Conscious patients requiring synchronized cardioversion or pacing

Standing Orders:

o Airway management

o Vascular access o Vascular access

o Cardiac monitor

27

Critical Care

& Paramedic Procedural Sedation Protocol III. F

Approved: 10/30/13

Effective: 4/01/14

Medical Control Options: (if available)

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

o Midazolam (Versed) 1-5 mg IV/IO/IN

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

o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IO o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IO

o Etomidate (Amidate) 0.15 mg/kg IV/IO (max 10mg total)

o Fentanyl 1mcg/kg IV/IO//IN (max 100 mcg)

If nausea or vomiting:

o Ondansetron (Zofran) 4 mg IV/IO , may be repeated

28

Protocol III. F – Updates


Fentanyl 1 mcg/kg IV/IO/IN/IM

Ondansetron 4 mg IV/IO

Diazepam 5-10 mg IV/IO

Midazolam 1-5 mg IV/IO/IN

Lorazepam 2-4 mg IV/IO/IN

Etomidate 0.15 mg/kg IV/IO

Morphine Sulfate 2-10 mg IV/IO

29

Critical Care

& Paramedic Severe Nausea / Vomiting Protocol III. G

Approved: 10/30/13

Effective: 4/01/14

Adult patients with persistent vomiting or severe nausea

Consider and treat any underlying cause (i.e. poisoning , Myocardial ischemia, etc.)

Standing Orders: Standing Orders:

o Airway management

o Vascular access

o Cardiac monitor

Paramedic

o Ondansetron (Zofran) 4 mg IV/IO, over 2 minutes (may be repeated one time)


o Ondansetron (Zofran) 4 mg IV/IO, may be repeated 30

Protocol III. G – Updates

Standing Orders

Paramedic OnlyOndansetron 4mg IV/IO


Ondansetran 4mg IV/IO

31

Class

Antiemetic

Pharmacokinetics

Onset: Immediate

Peak effect: 15-30 Minutes

Ondansetron (Zofran)

Peak effect: 15-30 Minutes

Duration: 4-8 Hours

Dose / Route

Ondansetron (Zofran) 4 mg IV/IO

Over two (2) minutes

Protocols Adult - III.E, III.F, III.G, Pedi - NONE32

Class

Narcotic analgesic

Pharmacokinetics

Onset: Immediate

Peak effects: 3-5 min

Fentanyl

Peak effects: 3-5 min

Duration: 30- 60 minutes

Dose / Route

Fentanyl 1 mcg/kg IV/IO/IM/IN- Pain Management

1 mcg/kg IV/IO/IN – Procedural Sedation, ROSC

(Max 100 mcg total)

Protocols Adult - III.E, III.F, III.M, III.P, Pedi - NONE33

Critical Care

& Paramedic TRAUMA Protocol III. H

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o BLS trauma measures as appropriate

o Airway management

o Treat for shock - per protocol o Treat for shock - per protocol

o Pain management - per protocol

Paramedic

o Needle decompression if tension pneumothorax

34

Critical Care


Approved: 10/30/13

Effective: 4/01/14

Standing Orders (continued):

Burns: (thermal & electrical)

o Transport to a Burn Center if there is a manageable airway

o Cover with sterile / clean dry dressing or may use Water-Jel (or equivalent) if < 10% body surface area

Crush injuries: for patients with entrapment / compression of greater than one hour,

especially when a large muscle mass/group is involved.

Treatment should begin BEFORE the patient is removed if possible.

o Monitor for dysrhythmias during the period immediately after release.

o Consider Albuterol 0.083% 2.5 mg for possible hyperkalemia (peaked T-waves / wide QRS)

wheezing or bronchospasm.

o Keep affected limb at level of the heart.

35

Critical Care


Approved: 10/30/13

Effective: 4/01/14


o Continue normal saline bolus 500 ml - 1000 ml

o Sodium Bicarbonate 1 mEq/kg IV/IO (at 10 minute intervals)

o Calcium chloride 1gm IV/IO o Calcium chloride 1gm IV/IO

o Needle decompression if tension pneumothorax

NOTE: Administration of narcotic analgesics is contraindicated in patients with burns

involving the face and/or airway.

36

Protocol III. H – Updates

Standing Orders

Paramedic OnlyNeedle Decompression


Albuterol Sulfate 2.5mg (Crush Injury - hyperkalemia, wheezing or

bronchospasm)

Sodium Bicarbonate 1mEq/kg IV/IO

Calcium Chloride 1gm IV/IO

37

Critical Care

& Paramedic Asthma / Bronchospasm Protocol III. I

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Airway management

o Vascular access as appropriate


o Albuterol 0.083% 2.5 mg and Ipratropium (Atrovent) 0.02% 500 mcg via Nebulizer o Albuterol 0.083% 2.5 mg and Ipratropium (Atrovent) 0.02% 500 mcg via Nebulizer

o Repeat Albuterol 2.5 mg via Nebulizer

o CPAP/ BIPAP (if available)

Paramedic

For severe presentation:

o Epinephrine 1:1000 0.3 mg IM/SQ

o Dexamethasone 12 mg IV/IO/IM

or o Methylprednisolone 125 mg IV/IO/IM

38

Critical Care

& Paramedic Asthma / Bronchospasm Protocol III. I

Approved: 10/30/13

Effective: 4/01/14


o Albuterol 2.5 mg via Nebulizer

o Ipratropium (Atrovent) 500 mcg via Nebulizer

o Epinephrine 1:1000 0.3 IM/SQ o Epinephrine 1:1000 0.3 IM/SQ

o Magnesium sulfate 2 gm IV/IO - (over 10-20 minutes)



o Methylprednisolone 125 mg IV/IO/IM

39

Protocol III. I – Updates

Standing OrdersCPAP / BiPAP

Paramedic Only

Epinephrine 1:1,000 0.3mg IM/SQEpinephrine 1:1,000 0.3mg IM/SQ

Dexamethasone 12mg IV/IO/IM

Methylprednisolone 125mg IV/IO/IM


CPAP / BiPAP

Epinephrine 1:1,000 0.3mg IM/SQ


Methylprednisolone 125mg IV/IO/IM

Magnesium Sulfate 2gm IV/IO 40

Critical Care

& Paramedic C.O.P.D. Protocol III. J

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Airway management - including waveform capnography



o Albuterol 0.083% 2.5 mg and Ipratropium (Atrovent) 0.02% 500 mcg via Nebulizer

o Repeat Albuterol 2.5 mg via Nebulizer


Paramedic

For severe presentation:


or o Methylprednisolone 125 mg IV/IO

41

Critical Care

& Paramedic C.O.P.D. Protocol III. J

Approved: 10/30/13

Effective: 4/01/14


o Albuterol 2.5 mg via Nebulizer

o Ipratropium (Atrovent) 500 mcg via Nebulizer



o Methylprednisolone 125 mg IV/IO

42

Protocol III. J – Updates

Standing OrdersCPAP / BiPAP

Paramedic Only


Methylprednisolone 125mg IV/IO


CPAP / BiPAP



43

Critical Care

& Paramedic Acute Pulmonary Edema Protocol III. K

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Airway management

o Vascular access

o Cardiac monitor / 12 lead ECG

o Nitroglycerin 0.4 mg SL or SL spray

If Systolic B/P is ≥ 120 or ≥ 100 with IV access


44

Critical Care

& Paramedic Acute Pulmonary Edema Protocol III. K

Approved: 10/30/13

Effective: 4/01/14



o Furosemide 40-100 mg IV/IO

o Dopamine drip 5-20 mcg/kg/min IV/IO (titrated to effect)

o Norepinephrine 2-4 mcg/min- IV/IO o Norepinephrine (Levophed) 2-4 mcg/min- initial dose IV/IO (max 30 mcg/min)

- large vein if possible

o CPAP/ BIPAP ( if available)

NOTE: Patients who have used medications for erectile dysfunction within the last 72 hours

should not be given Nitroglycerin unless otherwise directed by Medical control.

45

Protocol III. K – Updates

Standing Orders

CPAP / BiPAP


CPAP / BiPAP


46

Critical Care

& Paramedic Anaphylaxis Protocol III. L

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Airway management

o Vascular access

o Cardiac monitor

o Epinephrine 1:1000 0.3 mg IM

or o Epinephrine Autoinjector 0.3 mg IM

o IV fluid bolus (No more than 2 liters unless ordered by medical control)

o Albuterol 0.083% 2.5 mg via Nebulizer - for bronchospasms

o Repeat Albuterol 2.5 mg via Nebulizer (max 3 doses)

o Diphenhydramine 50 mg IV/IO/ IM


or o Methylprednisolone 125 mg IV/IO

47

Critical Care

& Paramedic Anaphylaxis Protocol III. L

Approved: 10/30/13

Effective: 4/01/14


o Epinephrine 1:1000 0.3 mg IM

o Albuterol 2.5 mg via nebulizer

o Diphenhydramine 50 mg IV/IO/IM o Diphenhydramine 50 mg IV/IO/IM

o Continue Fluid challenge beyond 2 liters


o Methylprednisolone 125 mg IV/IO

o Epinephrine drip 2-10 mcg/min IV/IO


o Dopamine drip 5-20 mcg/kg/min IV/IO (only if Epinephrine or Norepinephrine is unavailable)

48

Protocol III. L– Updates

Standing Orders

Epinephrine 1:1,000 0.3mg IM or Epi Auto injector .3 mg

Albuterol Sulfate 2.5 mg nebulizer

Diphenhydramine 50 mg IV/IO/IM Diphenhydramine 50 mg IV/IO/IM

Dexamethasone 12 mg IV/IO/IM

Methylprednisolone 125 mg IV/IO




Dexamethasone 12 mg IV/IO/IM49

Class

Corticosteriod

Pharmacokinetics

Onset: 1 Hour

Peak effect : 1 hour

Dexamethasone (Decadron)

Peak effect : 1 hour

Duration: Variable

Dose / Route

Dexamethasone (Decadron) 12 mg IV/IO/IM

Protocols Adult - III.I, III.J, III.L, Pedi – P4

50

Class

Corticosteriod and anti-inflamatory

Pharmacokinetics

Onset: Immediate


Methylprednisolone (Solu-Medrol)


Dose / Route

Methylprednisolone (Solu-Medrol) 125 mg IV/IO Adult

2 mg/kg IV/IO Pediatric

Protocols Adult - III.I, III.J, III.L, Pedi – P4, P6, P7

51

Critical Care

& Paramedic Acute Coronary Syndrome / Chest Pain Protocol III. M

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Airway management


o Aspirin 325 mg. (chewed)

o Cardiac monitor / 12 lead ECG *

o Nitroglycerin 0.4 mg SL or SL spray - (If SBP ≥ 120 or ≥ 100 with IV)*

Caution with inferior wall MI's

52

Critical Care

& Paramedic Acute Coronary Syndrome / Chest Pain Protocol III. M

Approved: 10/30/13

Effective: 4/01/14


o Transport to nearest PCI capable hospital *

o Aspirin 325 mg (chewed)


o Morphine Sulfate 2-10 mg IV/IO o Morphine Sulfate 2-10 mg IV/IO

o Fentanyl 1mcg/kg IV/IO/IM/IN (max 100 mcg)

o Fluid challenge

o Dopamine drip 5-20 mcg/kg/min IV/IO (titrated) - for hypotension


* NOTES:

Medical Control Physician will make the determination to divert to PCI center based on transmitted 12-lead.

If transmission is NOT possible, advise Physician of machine interpretation or field interpretation.

Patients who have used medications for erectile dysfunction within the last 72 hours should not be given

Nitroglycerin unless otherwise directed by Medical control.

53

Protocol III. M– Updates


Fentanyl 1mcg/kg IV/IO/IM/IN

Norepinephrine 2- 4 mcg/min IV/IONorepinephrine 2- 4 mcg/min IV/IO

Dopamine Drip 5-20mcg/kg/min IV/IO

54

Critical Care

& Paramedic Cardiac Arrest - VF / Pulseless VT Protocol III. N

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o CPR per AHA guidelines - limit interruptions in chest compressions*

o If NO CPR in progress - perform 2 minutes - check pulse /rhythm

o Defibrillate (max joules) - repeat every 2 minutes if no rhythm change o Defibrillate (max joules) - repeat every 2 minutes if no rhythm change

o Establish IV/IO access - without CPR interruption (≥18g if possible)

o Epinephrine 1:10,000 1 mg IV/IO - repeat every 3-5 minutes May use Vasopressin 40 units IV/ IO (1

st or 2

nd dose) - if available

o Airway management - including waveform capnography (keep ETCO2 >10)

o Cardiac monitor

o Amiodarone 300 mg IV/IO

Contact medical control

55

Critical Care

& Paramedic Cardiac Arrest - VF / Pulseless VT Protocol III. N

Approved: 10/30/13

Effective: 4/01/14


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

o Defibrillate (max joules)

o Amiodarone 150 mg IV/IO (2nd dose)

o Magnesium sulfate 1-2 gm IV/IO o Magnesium sulfate 1-2 gm IV/IO

o Sodium bicarbonate 1 mEq/kg IV/IO

o Calcium chloride 1 gm IV/IO

NOTE: CPR should not be paused for procedures or to administer medications.

Continue CPR while defibrillator charges. If possible - rotate chest compressors q 2 min.

All medications should be followed by a normal saline flush.

Consider & treat underlying causes if possible:

Hypoxia, Hypovolemia, Hypothermia, Hyper / Hypokalemia, Hydrogen Ion (acidosis)

Trauma, Tension pneumothorax, Tamponade, Toxin/Overdose, Thrombosis/Embolus

56

Protocol III. N – Updates

Standing Orders

Vasopressin 40 units IV/IO

Medical Control OptionsMedical Control Options


Calcium Chloride 1 gm IV/IO

57

ClassNonadrenergic vasoconstrictor, Pituitary antidiuretic hormone

Pharmacokinetics

Onset: 1- 3 minutes IV

Vasopressin (Pitressin)

Onset: 1- 3 minutes IV

Duration: 30-60 minutes IV

Dose / Route

Vasopressin (Pitressin) 40 Units Single Dose

Replaces 1st or 2nd dose Epi in Cardiac Arrest

Protocols Adult - III.N, Pedi - NONE

58

Critical Care

& Paramedic Cardiac Arrest - Asystole / PEA Protocol III. O

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o CPR per AHA guidelines - limit interruptions in chest compressions*

o If NO CPR in progress - perform 2 minutes - check pulse /rhythm

o Establish IV/IO access - without CPR interruption (≥18g if possible)

o Epinephrine 1:10,000 1 mg IV/IO - repeat every 3-5 minutes o Epinephrine 1:10,000 1 mg IV/IO - repeat every 3-5 minutes May use Vasopressin 40 units IV/ IO (1

st or 2

nd dose) - if available

o Airway management - including waveform capnography (keep ETCO2 >10)

o Cardiac monitor

Paramedic


Contact Medical Control

59

Critical Care

& Paramedic Cardiac Arrest - Asystole / PEA Protocol III. O

Approved: 10/30/13

Effective: 4/01/14Medical Control Options:

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

o Fluid challenge

o Naloxone (Narcan) 2.0 mg IV/IO/IN

o Dextrose (D50) 25gm IV/IO bolus (if blood glucose ≤ 60 mg/dl)

o Sodium bicarbonate 1 mEq/kg IV/IO o Sodium bicarbonate 1 mEq/kg IV/IO


o Glucagon 1mg IV/IO


o Termination of resuscitation.

Any of the above orders may be repeated as per Physician's discretion

NOTE: CPR should not be paused for procedures or to administer medications.

Continue CPR while defibrillator charges. If possible - rotate chest compressors q 2 min.

All medications should be followed by a normal saline flush.

Consider & treat underlying causes if possible:

Hypoxia, Hypovolemia, Hypothermia, Hyper / Hypokalemia, Hydrogen Ion (acidosis)

Trauma, Tension pneumothorax, Tamponade, Toxin/Overdose, Thrombosis/Embolus 60

Critical Care

& Paramedic Post Resuscitation / Return of circulation (ROSC) Protocol III. P

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Airway management including waveform capnography (EtCO2 35-45)

o If hypoperfusion persists - see Hypoperfusion /shock protocol

o Treat other medical/trauma conditions as appropriate

Maintain a waveform capnography value of 35 - 45 mmHg o Maintain a waveform capnography value of 35 - 45 mmHg

o Perform 12-lead ECG - evaluate for STEMI criteria

o If patient is Comatose/Unresponsive initiate hypothermic procedures (if available)

� Use ≥ 18g device (IV/IO)

� Start rapid infusion of ice cold (4 Celsius) normal saline via IV/IO

to a total of 30ml/kg (max total = 2 liters) (use pressure infusion sleeve)

o Contact medical control for transport to nearest STEMI / Hypothermia

capable hospital.

61

Critical Care

& Paramedic Post Resuscitation / Return of circulation (ROSC) Protocol III. P

Approved: 10/30/13

Effective: 4/01/14


o Hospital diversion

o Dopamine drip 5-20 mcg/kg/min IV/IO o Dopamine drip 5-20 mcg/kg/min IV/IO


o Midazolam (Versed) 1-5 mg IV/IO - for shivering

o Diazepam (Valium) 5 mg IV/IO

o Fentanyl 1mcg/kg IV/IO (max 100 mcg)

62

Protocol III. P – Updates

Standing Orders

Rapid infusion ice cold Normal Saline (4 degree Celsius) 30ml/kg

Medical Control OptionsMedical Control Options

Fentanyl 1mcg/kg IV/IO

Norepinephrine 2- 4 mcg/min IV/IO

Dopamine Drip 5-20mcg/kg/min IV/IO

Diazepam 5 mg IV/IO

Midazolam 1-5 mg IV/IO

63

Critical Care

& Paramedic Wide Complex Tachycardia - with Pulse Protocol III. Q

Approved: 10/30/13

Effective: 4/01/14

treat only if symptomatic Standing Orders:

o Airway management

o Vascular access

o Cardiac monitor / 12 lead ECG o Cardiac monitor / 12 lead ECG

(Paramedic)

o Synchronized cardioversion 50-360 j - if unstable (consider procedural sedation)

o Amiodarone 150 mg (in 100ml D5W) IV/IO - over 10 min.

o Fluid challenge - as appropriate

64

Critical Care

& Paramedic Wide Complex Tachycardia - with Pulse Protocol III. Q

Approved: 10/30/13

Effective: 4/01/14


o Amiodarone 150 mg (in 100ml D5W) IV/IO - over 10 min..

o Magnesium sulfate 1-2 gm IV/IO - over 10 min o Magnesium sulfate 1-2 gm IV/IO - over 10 min

o Synchronized cardioversion 50-360 j - (consider procedural sedation)

o Fluid challenge



65

Protocol III. Q – Updates

Standing OrdersDelete Lidocaine

Paramedic OnlySynchronized cardioversion 50-360 joulesSynchronized cardioversion 50-360 joules

Amiodarone 150mg in 100ml D5W IV/IO


Amiodarone 150mg in 100ml D5W IV/IO


Calcium Chloride 1 gm IV/IO

66

Critical Care

& Paramedic Narrow Complex Tachycardia Protocol III. R

Approved: 10/30/13

Effective: 4/01/14

treat only if symptomatic Standing Orders:



o Cardiac monitor / 12 lead ECG as appropriate o Cardiac monitor / 12 lead ECG as appropriate

o Valsalva maneuvers (such as bearing down) while preparing for other treatments

(Paramedic)

o Synchronized cardioversion 50-360 j - if unstable (consider procedural sedation)

o Adenosine 6mg IV/IO push - (20 ml flush) - if conscious & alert

o Adenosine 12mg IV/IO push - (20 ml flush) - second dose

o For stable A-fib / A-flutter - contact medical control

67

Critical Care

& Paramedic Narrow Complex Tachycardia Protocol III. R

Approved: 10/30/13

Effective: 4/01/14


o Valsalva maneuver

o Adenosine 6mg IV/IO push - (20 ml flush)

o Adenosine 12mg IV/IO push - (20 ml flush) - second dose o Adenosine 12mg IV/IO push - (20 ml flush) - second dose

o Synchronized cardioversion 50-360 j (consider procedural sedation)

o Fluid challenge

o Amiodarone 150 mg (in 100ml D5W) IV/IO - over 10 minutes.

o Diltiazem (Cardizem) 0.25 mg/kg slow IV (over 2 minutes) - (for A-fib / A-flutter)

68

Protocol III. R – Updates


Amiodarone 150 mg in 100 ml D5W over 10 min IV/IOAmiodarone 150 mg in 100 ml D5W over 10 min IV/IO

Diltiazem 0.25mg/kg slow IV/IO for A Fib/A Flutter

69

Class

Calcium Channel Blocker

Pharmacokinetics

Onset: 3 minutes

Half-life: 3-8 Hours

Diltiazem (Cardizem)

Half-life: 3-8 Hours

Dose / Route

Diltiazem (Cardizem) For patients in A Fib & A Flutter 0.25mg/kg IV/IO

Slow over 2 minutes

Protocols Adult - III.R, Pedi - NONE

70

Critical Care

& Paramedic Symptomatic Bradycardia Protocol III. S

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:



o Cardiac monitor / 12 lead ECG as appropriate

o Atropine 0.5 mg IV/IO IF - second degree (type II) or third degree block, start pacing

o Transcutaneous pacing - (start at 60 PPM) - (consider procedural sedation III.F)

o Atropine 0.5-1.0 mg IV/IO - Repeat q 5 min x 2 if needed

o Fluid challenge - if hypotensive

71

Critical Care

& Paramedic Symptomatic Bradycardia Protocol III. S

Approved: 10/30/13

Effective: 4/01/14


o Atropine 0.5-1.0 mg IV/IO

o Fluid challenge - if hypotensive

o Dopamine drip 5-20 mcg/kg/min IV/IO o Dopamine drip 5-20 mcg/kg/min IV/IO

o Epinephrine drip 2-10 mcg/min IV/IO



o Transcutaneous pacing - (start at 60 PPM) - (consider procedural sedation III.F)

o Hospital diversion - if STEMI

72

Protocol III. S – Updates

Standing Orders

Atropine Sulfate 0.5mg IV/IO if 2nd (Type2) or 3rd degree Heart Block

begin pacingbegin pacing

Repeat 0.5 mg to 1mg every 5 minutes X2 if needed

Transcutaneous Pacing ( start at 60 BPM)


Calcium Chloride 1gm IV/IO

Sodium Bicarbonate 1 mEq/kg IV/IO

73

Critical Care

& Paramedic Altered Mental Status Protocol III. T

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:



Cardiac monitor as appropriate o Cardiac monitor as appropriate

o Naloxone (Narcan) 0.4 mg - 2.0 mg (titrated) IV/IO/IM/IN - if signs/history of narcotic use with respiratory depression. (give prior to dextrose if OD is suspected) May repeat x 2

o Assess blood glucose - treat if ≤ 60 mg/dl

o Oral glucose, juice, etc. - if patient is alert enough to swallow with intact gag reflex

o Dextrose (D50) 25 gm IV/IO

o Glucagon 1 mg IM (if no IV access)

74

Critical Care

& Paramedic Altered Mental Status Protocol III. T

Approved: 10/30/13

Effective: 4/01/14



o Naloxone (Narcan) 0.4 - 2.0mg - IV/IO/IM/IN

o Glucagon 1 mg IM o Glucagon 1 mg IM

75

Protocol III. T – Updates

Standing Orders

Access Glucose level treat if < 60 mg/dl

Naloxone 0.04 mg to 2mg (titrated) IV/IO/IM/IN (if history of narcotics

use with respiratory depression present) may repeat 2X

Administer prior to dextrose if opioid is suspected

Oral glucose if patient able to swallow Glucose < 60 mg/dl OR

D 50 – 25 gm IV/IO

76

Critical Care

& Paramedic Seizures / Status Epilepticus Protocol III. U

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:




o Assess blood glucose - treat if ≤ 60 mg/dl



o Diazepam (Valium) 5 mg IV/IO/IM/PR

or o Midazolam (Versed) 1-5 mg IV/IO/IM/IN

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

77

Critical Care

& Paramedic Seizures / Status Epilepticus Protocol III. U

Approved: 10/30/13

Effective: 4/01/14


o Diazepam (Valium) 5 mg IV/IO/IM/PR o Diazepam (Valium) 5 mg IV/IO/IM/PR

o Midazolam (Versed) 1-5 mg IV/IO/IM/IN

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



o Magnesium sulfate 2 gm IV/IO (over 10 minutes) - if eclampsia

78

Protocol III. U – Updates

Standing Orders

Access blood glucose treat if <60mg/dl

Dextrose (D50) 25 gm IV/IODextrose (D50) 25 gm IV/IO

Glucagon 1mg IM (if no IV access)

Diazepam 5 mg IV/IO/IM/PR

Midazolam 1-5 mg IV/IO/IM/IN

Lorazapam 2-4mg IV/IO/IM

79

Protocol III. U – Updates (continued)


Diazepam (Valium) 5 mg IV/IO/IM/PR

Midazolam (Versed) 1-5 mg IV/IO/IM/IN

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

Dextrose (D50) 25 gm IV/IO

Glucagon 1 mg IM (if no IV access)

Magnesium sulfate 2 gm IV/IO (over 10 minutes) – if eclampsia

80

Critical Care

& Paramedic Stroke / Transient Ischemic Attack Protocol III. V

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:




Assess blood glucose - treat if ≤ 60 mg/dl o Assess blood glucose - treat if ≤ 60 mg/dl



o Cincinnati stroke score or other stroke symptom assessment

o Obtain the "time of onset" of symptoms

o Transport to a "stroke center" hospital with notification

81

Critical Care

& Paramedic Stroke / Transient Ischemic Attack Protocol III. V

Approved: 10/30/13

Effective: 4/01/14




o Hospital diversion / stroke team activation o Hospital diversion / stroke team activation

82

Protocol III. V – Updates

Standing OrdersAccess Blood Glucose treat if < 60 mg/dl


Glucagon 1mg IM (if no IV access)Glucagon 1mg IM (if no IV access)

Obtain Cincinnati Stroke Scale / Obtain time of onset of symptoms

Transport to Stroke Center with notification

Medical Control OptionsDextrose (D50) 25 gm IV/IO


Hospital diversion / Stroke team activation

83

Critical Care

& Paramedic Behavioral Emergency/Agitation Protocol III. W

Approved: 10/30/13

Effective: 4/01/14

Contact medical control if unable to treat

Standing Orders:

o Airway management


o Cardiac monitor

o Additional assistance / restraints as needed * (Check circulation frequently / document application time if restraints are used)

o Transport to appropriate hospital - (prior notification if possible)

84

Critical Care

& Paramedic Behavioral Emergency/Agitation Protocol III. W

Approved: 10/30/13

Effective: 4/01/14


o Diazepam (Valium) 2-10 mg IV/IO/IM

o Midazolam (Versed) 1-5 mg IV/IO/IM/IN o Midazolam (Versed) 1-5 mg IV/IO/IM/IN

o Lorazepam (Ativan) 1-2 mg IV/IO/IM/IN

o Haloperidol (Haldol) 2-5 mg IM

* NOTE: In order to protect the patient's airway, consider placing patient in a

lateral recumbent position.

NO restrained patient shall be transported prone.

85

Protocol III. W – Updates

Standing Orders

Airway/Cardiac Monitor/Vascular Access

Additional assistance/ Restraints as required

Transport to appropriate hospital


Diazepam (Valium) 2-10 mg IV/IO/IM

Midazolam (Versed) 1-5 mg IV/IO/IM/IN

Lorazepam (Ativan) 1-2 mg IV/IO/IM/IN

Haloperidol (Haldol) 2-5 mg IM

86

Class

Antipsychotic and neuroleptic

Pharmacokinetics

Onset: Within minutes

Peak effect : 20 minutes IM

Haloperidol (Haldol)

Peak effect : 20 minutes IM

Duration: 2-6 hours

Dose / Route

Haloperidol (Haldol) 2 - 5mg IM

Protocols Adult - III.W, Pedi - NONE

87

Critical Care

& Paramedic Poisoning / OD / Toxic Exposure Protocol III. X

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

oIf external contamination - Patient must be decontaminated prior to transport

oAirway management - including waveform capnography

oVascular access as appropriate

oCardiac monitor as appropriate

oAssess blood glucose - treat if ≤ 60 mg/dl

oNaloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - If respiratory depression.

If (opiates suspected) May repeat x 2

oOral glucose, juice, etc - if patient can swallow (intact gag reflex)

oDextrose (D50) 25 gm IV/IO

oGlucagon 1 mg IM (if no IV access)

88

Critical Care


Approved: 10/30/13

Effective: 4/01/14


Cocaine, amphetamines, sympathomimetics, or ETOH withdrawal

oMidazolam (Versed) 1- 5 mg IV/IO/IM/IN

oDiazepam (Valium) 2-10 mg IV/IO

oLorazepam (Ativan) 1- 2 mg IV/IO/IM

Organophosphates, nerve agents

oAtropine 2 mg IV/IM (or autoinjector) (repeat as needed)

oPralidoxime (2PAM) 600 mg autoinjector IM (max 3 autoinjector)

oDiazepam (Valium) 2-10 mg IV/IO/PR (max total dose 20 mg)

Opiates

oNaloxone (Narcan) 0.4- 2.0 mg IV/IO/IM/IN

Tricyclic antidepressant ( w/ QRS > 10 m/sec)

oSodium Bicarbonate 1 mEq/kg IV/IO89

Critical Care


Approved: 10/30/13

Effective: 4/01/14

Medical Control Options:Calcium channel blocker

o Calcium chloride 1gm IV/IO

Beta blocker

o Glucagon 1-2 mg IV/IO

Eye InjuryEye Injury

o Tetracaine eye drops - 2 drops in affected eye(s) before irrigation

Cyanide (including smoke inhalation)

o Obtain blood samples prior to medication administration (a red & lime green tube)

o Hydroxocobalamin 5g IV (over 10 min.) * needs dedicated IV

o Start a second I.V. line

o Sodium Thiosulfate 25% sol. 12.5g IV/IO (50ml NS - over 10 min.) *

o Dopamine drip 5-20 mcg/ kg /min IV/IO

90

Protocol III X – Updates

Standing Orders

Access Blood Glucose treat if < 60 mg/dl

Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - If respiratory Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - If respiratory

depression. If (opiates suspected) May repeat x 2

Administer oral glucose if patient can swallow




REFER TO PROTOCOL FOR PARTICULAR SUBSTANCE OVERDOSE

91

Class

Topical Anesthetic

Pharmacokinetics

Onset: Immediate


Tetracaine


Dose / Route

Tetracaine Hydrochloride 0.5% solution 2 drops in effected eye before irrigation

Protocols Adult – III.X, Pedi – None

92

Critical Care

& Paramedic Obstetric / Pregnancy Related Protocol III. Y

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o BLS childbirth management

o Airway management - including capnography - Oxygen 100% via NRB

o Vascular access ( ≥ 18g device)

o Contact medical control for diversion to "obstetric" receiving hospital.

o Rapid transport - Do not delay on scene o Rapid transport - Do not delay on scene

Postpartum hemorrhage

o IV Bolus - 1 liter Normal saline

o Massage fundus firmly & consider allowing infant to nurse

Placenta previa or Placenta abruption

o IV bolus - 1 liter Normal saline - if hypotensive

Eclampsia (Seizures) or

Pre-eclampsia (SBP ≥ 160 / DBP ≥ 110 and/or severe headache, visual disturbances,)

(acute pulmonary edema, upper abdominal tenderness)

o Transport carefully - with lights dimmed.

o Contact Medical control for Magnesium sulfate or Diazepam order. 93

Critical Care

& Paramedic Obstetric / Pregnancy Related Protocol III. Y

Approved: 10/30/13

Effective: 4/01/14


o Magnesium sulfate 2gm (in100ml NS) - IV/IO (over 10 minutes) - for seizures

o Diazepam (Valium) 5 mg IV/ IM - for refractory seizures

o Fluid challenge - hypotension / bleeding

o Hospital diversion to "obstetric" receiving hospital

94

Protocol III. Y – Updates

Standing Orders

Consider diversion to “Obstetric” receiving hospital

If Postpartum Hemorrhage- 1 liter Normal Saline bolus

massage fundus, consider allowing infant to nurse

If placenta previa or abruption – 1 liter Normal Saline bolus if hypotensive

If eclampsia or Pre-eclampsia – Contact medical control for Diazepam or

Magnesium Sulfate, transport with lights dimmed


Magnesium Sulfate 2gm (in 100 ml NS) IV/IO over 10 minutes for seizures

Diazepam 5mg IV/IM for refractory seizures95



2014


Pediatric Protocol Manual

96

PEDIATRIC ADVANCED LIFE SUPPORT PROTOCOLS

TABLE OF CONTENTS

Approved Effective

Newborn Resuscitation P 1 10/30/13 4/01/14

Respiratory Arrest P 2 10/30/13 4/01/14

Obstructed Airway P 3 10/30/13 4/01/14

Respiratory Distress / Failure (Croup/Epiglottitis) P 4 10/30/13 4/01/14

Non-Traumatic Cardiac Arrest P 5 10/30/13 4/01/14Non-Traumatic Cardiac Arrest P 5 10/30/13 4/01/14

Asthma/Wheezing P 6 10/30/13 4/01/14

Anaphylactic Reaction P 7 10/30/13 4/01/14

Altered Mental Status P 8 10/30/13 4/01/14

Status Eilepticus P 9 10/30/13 4/01/14

Decompensated Shock P 10 10/30/13 4/01/14

Traumatic Cardiac Arrest P 11 10/30/13 4/01/14

For Nassau County protocols, pediatric patients are as defined by the AHA, children

without secondary signs of puberty.

A "length/weight based" dosing device should be used on all pediatric patients to

assure the correct administration of medications.

97

Pediatric ALS Protocols NEWBORN RESUSCITATION Protocol P1Approved: 10/30/13

Effective: 4/01/14

Suction immediately after birth ONLY if there is an obvious obstruction to

spontaneous breathing or positive-pressure ventilation is necessary.

Standing Orders

o BLS Newborn Resuscitation procedures.

If newborn is depressed and meconium staining is present, delay drying and stimulation. o If newborn is depressed and meconium staining is present, delay drying and stimulation.

Suction airway before taking other resuscitative measures.

o Begin Newborn Resuscitation procedures only after the airway has been cleared of thick

meconium, as follows:

• Perform endotracheal intubation and directly suction the endotracheal tube via a

meconium aspirator/adapter while slowly withdrawing the endotracheal tube.

Note: Do not exceed 100-mmHg suction vacuum

• Repeat this procedure until little or no meconium is acquired or until the heart rate

indicates resuscitation must begin immediately.

• Do not replace the endotracheal tube once the airway has been cleared of thick

meconium unless the newborn remains limp, apneic, or pulseless.

98


Effective: 4/01/14

For all newborns requiring resuscitation once BLS Newborn Resuscitation procedures

have begun:

During transport, or if transport is delayed:

Standing Orders (continued)


o If the newborn appears to be in respiratory distress and the heart rate is below 120 BPM,

administer oxygen in as high a concentration as possible.


ventilate via BVM or mouth-to-mask with oxygen attached.


Perform Endotracheal Intubation, Ventilate via BVM or mouth to mask, begin CPR,

administer:

Epinephrine 1:10,000 0.01 mg/kg via IV/IO

99


Effective: 4/01/14

MEDICAL CONTROL OPTIONS

o Repeat Epinephrine every 3-5 minutes

o Endotracheal Intubation o

o Epinephrine 1:1000 0.1 mg/kg via Endotracheal tube

o Check for Blood Glucose - if < 60 mg/dl - Dextrose D10 IV / IO - (0.5 gm/kg)

o IV / IO infusion of Normal Saline (0.9% NaCl) 10 ml/kg.

Reassess & document after each bolus. Attempt IV or IO only once each.

100

Protocol P1 – Updates


• Check for Blood Glucose - if < 60 mg/dl - Dextrose D10 IV / IO - (0.5 gm/kg)

101

Pediatric ALS Protocols PEDIATRIC RESPIRATORY ARREST Protocol P2

Approved: 10/30/13

Effective: 4/01/14

For pediatric patients in actual or impending respiratory arrest, or who are unconscious and cannot

be adequately ventilated:

Standing Orders

o Open airway and begin ventilation as per BLS Pediatric Respiratory Distress/Failure

procedures. If narcotic overdose is suspected, refer AMS protocol (P8) procedures. If narcotic overdose is suspected, refer AMS protocol (P8)

o If an obstructed airway is suspected, refer obstructed airway protocol. (P3)

o Perform endotracheal intubation if BLS measures are not adequate.

Consider a supraglottic airway

o I.V. of Normal Saline (0.9% NaCl) KVO or a saline lock

Paramedic

During transport or if transport is delayed

o Administer Naloxone,

Patients ≥ 2 years old - titrate in increments of 0.1mg/kg- until effective (max 2 mg)

Patients < 2 years old - titrate to (max 1 mg)

102

Pediatric ALS Protocols PEDIATRIC RESPIRATORY ARREST Protocol P2

Approved: 10/30/13

Effective: 4/01/14


o IO infusion of Normal Saline (0.9% NaCl).

o Naloxone IV/ IO / ET / IN / IM as directed.

(No more than 2 attempts at vascular access) (No more than 2 attempts at vascular access)

Paramedic - If a tension pneumothorax is suspected consider orders to perform needle

decompression, using an 18-20 gauge catheter

103



• Paramedic Standing Orders

• Administer Naloxone• Administer Naloxone

• Pt greater than 2 y/o- titrate in increments of 0.1

mg/kg until effective- Maximum dose 2 mg

• Pt less than 2 y/o – titrate to max 1 mg

• Medical Control Options

• Naloxone IV / IO / ET / IN / IM as directed

No more than 2 attempts at vascular access104

Pediatric ALS Protocols PEDIATRIC OBSTRUCTED AIRWAY Protocol P3Approved: 10/30/13

Effective: 4/01/14

For pediatric patients who are unconscious or present with signs & symptoms of inadequate air

exchange:

Standing Orders

o Begin BLS Pediatric Obstructed Airway procedures.

o Perform direct laryngoscopy - attempt to remove the foreign body with appropriate size

Magill Forceps.

NOTE:

IF AN ENLARGED EPIGLOTTIS IS VISUALIZED - DO NOT ATTEMPT

ENDOTRACHEAL INTUBATION. USE BAG-VALVE-MASK (w/ pop-off disabled)

o Perform endotracheal intubation, if BLS measures are not adequate.

Consider a supraglottic airway

105

Pediatric ALS Protocols PEDIATRIC OBSTRUCTED AIRWAY Protocol P3Approved: 10/30/13

Effective: 4/01/14

Paramedic

If unable to ventilate despite confirmed intubation by direct visualization:

� Note the endotracheal tube depth

� Deflate cuff (if cuffed tube is used)

� Advance tube to its deepest depth - and return to original depth




� Advance tube to its deepest depth - and return to original depth

� Re-inflate tube cuff and attempt ventilation

� If unable to ventilate effectively - immediately initiate transport

106


• Paramedic

• If unable to ventilate despite a CONFIRMED tube

placement by direct visualization

• Note the ET tube depth• Note the ET tube depth

• Deflate cuff (if cuff tube is used)

• Advance tube to its deepest depth- and return

to original depth

• Re-inflate cuff and attempt visualization

• If unable to ventilate effectively- immediate

initiate transport107



Paramedic- If a tension pneumothorax is suspected consider

orders to perform needle decompression, using an 18-20 gauge

catheter

108

Pediatric ALS Protocols PEDIATRIC RESPIRATORY DISTRESS or Suspected Croup / Epiglottitis

Protocol P4

Approved: 10/30/13

Effective: 4/01/14

Standing Orders

•Begin BLS Pediatric Respiratory Distress / Failure procedures.

•If child is alert and oriented, transport in position of comfort with parent.

Offer cool mist 100% Oxygen if child will allow.

•If child presents with signs & symptoms of inadequate air exchange, refer to protocol (P3)•If child presents with signs & symptoms of inadequate air exchange, refer to protocol (P3)

________________________________________________________________________________________________________________

NOTE: DO NOT ATTEMPT ENDOTRACHEAL INTUBATION. USE BAG-VALVE-MASK

109

Pediatric ALS Protocols PEDIATRIC RESPIRATORY DISTRESS or Suspected

Croup / EpiglottitisProtocol P4

Approved: 10/30/13

Effective: 4/01/14


Racemic Epinephrine, 0.05 mg/kg in 3cc 0.9% saline (Max. 5 ml) via Nebulizer

(if unavailable, Epinephrine may be used at the same nebulizer dose)

Consider Endotracheal Intubation in acute epiglottitis with an ET tube one mm

smaller than calculated.

Dexamethasone (Decadron) 0.6 mg/kg IV / IO

Methylprednisolone (Solu-Medrol) 2 mg/kg IV / IO (max 60 mg)

Paramedic - If child is in respiratory arrest, perform needle cricothyrotomy.

110



• Racemic Epinephrine, 0.05mg/kg in 3cc 0.9% saline (Max 5 ml) via nebulizer• Racemic Epinephrine, 0.05mg/kg in 3cc 0.9% saline (Max 5 ml) via nebulizer

(if unavailable, Epinephrine may be used at the same nebulizer dose)

• Consider ET in acute epiglottis with an ET tune one mm smaller than calculated

• Methylprednisolone ( Solu-Medrol) 2 mg/kg IV/IO (Max 60 mg)

• Dexamethasone (Decadron) 0.6 mg/kg IV / IO

111

Indications

Used to treat croup (laryngotracheobronchitis)

Interactions

Cardiac stimulation, vasodilation in skeletal muscle

Racemic Epinephrine (Vaponefrin, microNefrin)

Pharmacokinetics

Onset: 3-5 minutes

Duration: 1-3 hours

Dose / Route

Racemic Epinephrine 0.05mg/kg in 3 ml 0.9% Normal Saline via NebulizerMaximum 5 ml

Note: if unavailable, Epinephrine may be used at the same nebulizer dose

Protocols Adult - NONE Pedi – P4 112

Pediatric ALS Protocols NON–TRAUMATIC CARDIAC ARREST Protocol P5Approved: 10/30/13

Effective: 4/01/14Standing Orders

o Begin BLS Pediatric Cardiac Arrest procedures. Initiate CPR

Perform endotracheal intubation, if BLS airway measures are not adequate.

o Cardiac Monitoring.

• If in ventricular fibrillation or pulseless ventricular tachycardia, immediately defibrillate

at 2 joules/kg. Resume CPR immediately. - (2 min.) at 2 joules/kg. Resume CPR immediately. - (2 min.)

• If still in ventricular fibrillation or pulseless ventricular tachycardia, immediately repeat

defibrillation at 4 joules/kg. Resume CPR immediately - (2 min.)

• Epinephrine 1:10,000 0.01 mg/kg via IV or IO (Repeat every 3-5 minutes)

– OR Epinephrine 1:1,000 0.1 mg/kg via ET (only if no IV/IO) (Repeat every 3-5 minutes)

• If still in ventricular fibrillation or pulseless ventricular tachycardia, immediately repeat

defibrillation at 4 joules/kg. Resume CPR immediately - (2 min.)

o Begin transport

o IV or IO infusion of Normal Saline (0.9% NaCl) KVO.

o Contact Medical Control for additional medication orders. 113

Pediatric ALS Protocols NON–TRAUMATIC CARDIAC ARREST Protocol P5Approved: 10/30/13

Effective: 4/01/14

MEDICAL CONTROL OPTIONS:

• Increase energy settings up to 10 joules / Kg

• Amiodarone 5mg/kg IV/ IO if V-Tach or V-Fib (max. 300mg)

OR OR

• Lidocaine 1 mg/kg rapid IV/IO push if Amiodarone is not available.

• Dextrose D10 IV / IO - (0.5 gm/kg)

• Sodium Bicarbonate 1 mEq/Kg IV/IO/saline lock.

• Magnesium Sulfate 25-50 mg/kg (max. 2g) - for Torsades

114



• Increase energy setting up to 10 joules/kg

• Amiodarone 5mg/kg IV / IO if V-Tach or V- Fib (max 300 mg)• Amiodarone 5mg/kg IV / IO if V-Tach or V- Fib (max 300 mg)

orLidocaine 1mg/kg rapid IV / IO push if Amiodarone is not available

• Dextrose D10 IV / IO - (0.5 gm/kg)

• Sodium Bicarbonate 1mEq/Kg IV / IO / saline lock

• Magnesium Sulfate 25-50 mg/kg (max 2 g) for Torsades

115

ClassElectrolyte

Pharmacokinetics

Onset: Immediate IV/IO

3-4 Hours IM

Magnesium Sulfate

3-4 Hours IM

Duration: 30-60 minutes IV

Dose / Route

Magnesium Sulfate 25-50 mg/kg (max 2 g) for Torsades de Pontes

Protocols Adult - III.N, III.Q, III.U, Pedi – P-5

116

Pediatric ALS Protocols PEDIATRIC ASTHMA/WHEEZING Protocol P6Approved: 10/30/13

Effective: 4/01/14

For pediatric patients with acute asthma and/or active wheezing:

Standing Orders

o Begin BLS Pediatric Respiratory Distress/Failure procedures.

o Administer Albuterol Sulfate 0.083% -one unit dose of 3 ml - via nebulizer. o Administer Albuterol Sulfate 0.083% -one unit dose of 3 ml - via nebulizer.

patients < 6 months - ½ unit dose

If no response, 2nd unit dose to follow immediately.

If still no response, contact medical control immediately.

o Administer Ipratropium Bromide 0.02% (one unit dose of 2.5 ml for children ≥ 6 years)

(1/2 unit dose of 2.5 ml for children under 6), via nebulizer in conjunction with each

Albuterol Sulfate dose.

Patients ≥ 1 year, with severe respiratory distress, respiratory failure, and/or decreased breath sounds

o Epinephrine 1:1000 0.01 mg/kg IM (max. 0.3 mg)

o Intubation

o Consider IV/IO and rapid transport - if Patient unstable. 117

Pediatric ALS Protocols PEDIATRIC ASTHMA/WHEEZING Protocol P6Approved: 10/30/13

Effective: 4/01/14


o IV infusion of Normal Saline (0.9% NaCl) KVO, IV/ IO

o Repeat Albuterol Sulfate via nebulizer.

o Repeat Ipratropium Bromide 0.02% by nebulizer.

o Repeat Epinephrine 1:1,000 0.01 mg/kg IM (max 0.3 mg)

o Methylprednisolone (Solu-Medrol) 2 mg/kg IV/IO (max 60 mg)

118


Standing Orders

• Administer Albuterol Sulfate 0.083% (one unit dose of 3ml) via nebulizer

If patient > 6 months ½ dose of medication

• If no response, 2nd unit dose to follow immediately

• Administer Ipratropium Bromide 0.02% (one unit dose of 2.5 ml) for children > 6

years or ½ dose of 2.5 ml for children under 6, via nebulizer in conjunction with each

Albuterol Sulfate

• Patients > 1 year with severe respiratory distress, respiratory failure and or

decreased breath sounds

• Epinephrine 1:1000 0.01mg/kg IM (max 0.3 mg)

• Consider intubation

• Consider IV / IO and rapid transport- if patient unstable119



• IV infusion of Normal Saline ( 0.9% NaCl) KVO, IV /IO

• Repeat Albuterol Sulfate • Repeat Albuterol Sulfate

• Repeat Ipratropium Bromide 0.02% via nebulizer

• Repeat Epinephrine 1:1000 0.01mg/kg IM ( max 0.3mg)

• Methylprednisolone ( SoluMedrol) 2mg/kg IV / IO ( max 60 mg )

120

Pediatric ALS Protocols PEDIATRIC ANAPHYLACTIC REACTION Protocol P7

Approved: 10/30/13

Effective: 4/01/14

Standing Orders

o Begin BLS Anaphylactic Reaction procedures.

o Epinephrine 1:1000 0.01 mg/kg IM (max. 0.3 mg)

or or o Epinephrine Autoinjector JR. 0.15 mg IM

o Administer Albuterol Sulfate 0.083% one unit dose of 3 ml - via nebulizer. - if wheezing

patients < 6 months - ½ unit dose

If patient develops signs of respiratory failure or airway obstruction:

o Endotracheal intubation

o Initiate rapid transport.

121


Approved: 10/30/13

Effective: 4/01/14

Standing Orders (continued)

Paramedic

o Diphenhydramine 1mg/kg IV/ IO / IM


o IV infusion of Normal Saline (0.9% NaCl) via a large bore IV (18-22 gauge) to keep the

vein open, or a saline lock.

o IF PATIENT IS IN ANAPHYLACTIC SHOCK and IV cannot be established,

IO infusion of Normal Saline (0.9% NaCl) at KVO rate.

122


Approved: 10/30/13

Effective: 4/01/14


o Repeat any of the above standing orders.

o Begin rapid IV or IO infusion of Normal Saline (0.9% NaCl), 20 ml/kg.

Repeat as necessary. Repeat as necessary.

o Methylprednisolone (Solu-Medrol) 2 mg/kg IV/IO (max 60 mg)

123


Standing Orders

• Removed administering Diphenhydramine from EMT-CC Standing Orders

• Begin BLS Anaphylactic reaction procedures• Begin BLS Anaphylactic reaction procedures

• Administer Epinephrine 1:1000 0.01 mg/kg IM (Max 0.3mg)

OR

• Epinephrine Autoinjector JR> 0.15mg Deep IM injection

• Albuterol Sulfate 0.083Z% one unit dose of 3 ml for patients >6 months or

½ unit dose for patients < 6 months (IF WHEEZING)

• If patient develops signs of respiratory failure or airway obstruction

• Endotracheal intubation, Initiate rapid transport

124


Standing Orders

• Paramedic- Diphenhydramine 1mg/kg IV / IO / IM

During transport or if transport delayedDuring transport or if transport delayed

• IV infusion of Normal Saline via large bore (18-22 gauge) to KVO or a

saline lock

• If patient in Anaphylactic Shock and no IV established administer IO

infusion of Normal Saline at KVO rate

125



• Repeat any standing orders

• Begin rapid IV or IO infusion of Normal Saline at 20 ml/kg • Begin rapid IV or IO infusion of Normal Saline at 20 ml/kg

( repeat as necessary)

• Methylprednisolone ( Solu-Medrol) 2 mg/kg IV / IO ( Max 60 mg)

126

Pediatric ALS Protocols PEDIATRIC ALTERED MENTAL STATUS Protocol P8Approved: 10/30/13

Effective: 4/01/14

For pediatric patients in coma, with evolving neurological deficit, or with altered mental status of

unknown etiology:

NOTE: MAINTENANCE OF NORMAL RESPIRATORY AND CIRCULATORY

FUNCTION IS ALWAYS THE FIRST PRIORITY. PATIENTS WITH ALTERED

MENTAL STATUS DUE TO RESPIRATORY FAILURE OR ARREST,

OBSTRUCTED AIRWAY, SHOCK, TRAUMA, NEAR DROWNING OR OTHER OBSTRUCTED AIRWAY, SHOCK, TRAUMA, NEAR DROWNING OR OTHER

ANOXIC INJURY SHOULD BE TREATED UNDER OTHER PROTOCOLS.

Standing Orders

o Assess respiratory and circulatory status.

o Begin BLS Altered Mental Status procedures.

o IV of Normal Saline (0.9% NaCl) KVO, or a saline lock. Attempt IV only once.

Perform a glucometer test for blood sugar level. If less than 60 mg/dL administer dextrose

or glucagon and continue to monitor as needed after administration.

o Dextrose D10 IV / IO - (0.5 gm/kg)

OR

o Glucagon 0.1 mg/kg IM (if no IV established). 127

Pediatric ALS Protocols PEDIATRIC ALTERED MENTAL STATUS Protocol P8Approved: 10/30/13

Effective: 4/01/14


o Repeat any of the above orders.


o Naloxone 0.1mg/kg IV / IO / IM / IN - if there is no change in mental status

o Transport to a Pediatric specialty receiving facility

128



• Administer 0.1mg/kg Naloxone IV/IO/IM/IN if no

change in mental statuschange in mental status

• Transport to a pediatric specialty receiving facility

129

Pediatric ALS Protocols PEDIATRIC STATUS EPILEPTICUS Protocol P9Approved: 10/30/13

Effective: 4/01/14

For pediatric patients in Status Epilepticus:

Standing Orders

o Begin BLS Seizures procedure - cardiac monitor, pulse oximetry, waveform capnography.

Perform a glucometer test for blood sugar level. If ≤ 60 mg/dL: Perform a glucometer test for blood sugar level. If ≤ 60 mg/dL:

o IV / IO infusion of Normal Saline (0.9% NaCl) KVO

o Dextrose D10 IV / IO - (0.5 gm/kg)

OR

o Glucagon 0.1 mg/kg IM (if no IV established).

Paramedic

If patient is still seizing or blood sugar is normal:

o Midazolam 0.2 mg/kg IM / IN (max. 5 mg) Note: IN route is preferred

If seizures persist - contact Medical control of options.

130

Pediatric ALS Protocols PEDIATRIC STATUS EPILEPTICUS Protocol P9Approved: 10/30/13

Effective: 4/01/14



o Midazolam 0.2 mg/kg IM / IN (max. 5 mg) - Note: IN route is preferred

o Lorazepam 0.05 mg/kg IV/ IN/ IO (slowly over 2 minutes)

Repeat doses may be given if seizures persist

o Diazepam 0.1 mg/kg IV/ IO (slowly over 2 minutes)

Repeat doses may be given if seizures persist

If NO IV / IO:

o Repeat Midazolam 0.2 mg/kg IM / IN (max. 5 mg)

o Diazepam 0.1 mg/kg per rectum

NOTE: DO NOT ADMINISTER DIAZEPAM or MIDAZOLAM IF THE SEIZURES HAVE STOPPED.

FLUSH IV LINE BETWEEN GLUCOSE AND DIAZEPAM or MIDAZOLAM

131


Standing Orders• Begin BLS Seizure procedures

• Perform a glucometer for blood sugar. If <60 mg/dL start

• IV / IO infusion of normal saline KVO• IV / IO infusion of normal saline KVO

• Administer Dextrose D 10 IV / IO (0.5gm/kg)

ORGlucagon 0.1mg/kg IM (if no IV or IO established)

Paramedic Only

• If patient is still seizing or blood sugar is normal

Administer Midazolam 0.2 mg/kg IM / IN ( Max 5 mg ) IN preferred route

If seizure persists contact Medical Control for options 132



• IO infusion of Normal Saline

• Midazolam 0.2 mg/kg IM / IN (Max 5 mg) Note : IN preferred route

Paramedic ONLY

• Lorazepam 0.05 mg/kg IV / IN / IO (slowly over 2 minutes)• Lorazepam 0.05 mg/kg IV / IN / IO (slowly over 2 minutes)

Repeat doses may be given if seizure persist

• Diazepam 0.1mg/kg IV / IO ( slowly over 2 minutes )

Repeat doses may be given if seizure persist

IF NO IV / IO

Repeat Midazolam 0.2 mg/kg IM / IN ( Max 5 MG)

Diazepam 0.1 mg/kg per rectum

Do not administer Diazepam or Midazolam if the seizures have stopped

FLUSH IV line between Glucose and Diazepam or Midazolam133

Pediatric ALS Protocols PEDIATRIC DECOMPENSATED SHOCK Protocol P10Approved: 10/30/13

Effective: 4/01/14

Standing Orders

o Begin BLS Pediatric Shock procedures.

o If signs of hemorrhage or dehydration are not present, begin Cardiac Monitoring.

If adrenal cortical insufficiency (Addison's) / hyperplasia is confirmed *

o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg) o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)

NOTE: FOR PATIENTS IN SUPRAVENTRICULAR TACHYCARDIA OR VENTRICULAR

TACHYCARDIA WITH A PULSE, AND WITH EVIDENCE OF LOW CARDIAC OUTPUT,

CONTACT MEDICAL CONTROL FOR OPTIONS.


o Begin rapid IV Bolus of Normal Saline (0.9% NaCl) 20 ml/kg, via a large-bore IV (18-22

gauge) or IO catheter. Attempt IV or IO only once each.

o If signs of hemorrhage or dehydration are present, and the patient remains in decompensated

shock, begin second large bore IV and repeat bolus up to an additional 20 ml/kg,

(total of 40 ml/kg), Attempt second IV only once.

134

Pediatric ALS Protocols PEDIATRIC DECOMPENSATED SHOCK Protocol P10Approved: 10/30/13

Effective: 4/01/14


• Begin IO infusion

• Continue rapid IV or IO bolus of Normal Saline (0.9% NaCl) up to an additional 20 ml/kg

(total of 60 ml/kg).

• Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)

• If transport is delayed or extended, and the patient presents with:

1. Supraventricular tachycardia or ventricular tachycardia with a pulse, with evidence of low

cardiac output, perform synchronized cardioversion at 0.5-1 joules/kg, using pediatric pads. If

necessary, repeat at 1-2 joules/kg.

2. Supraventricular tachycardia with evidence of low cardiac output, if the Defibrillator is not able

to deliver a calculated dose, administer Adenosine 0.1 mg/kg, rapid IV or IO bolus (not to exceed 6

mg), followed immediately by 5-10 ml of Normal Saline (0.9% NaCl) flush. If necessary,

Adenosine may be repeated at 0.2 mg/kg, rapid IV or IO bolus (not to exceed 12 mg), followed

immediately by 5-10 ml Normal Saline (0.9% NaCl) flush.

135


Standing Orders

• Rapid IV / IO Bolus of Normal Saline @ 20 ml/kg may repeat if patient

remains in decompensated shock additional bolus @ 20 ml/kg (total 40

mg/kg

Medical Control Options• May continue additional rapid IV / IO bolus of Normal Saline 20 mg/kg

(total 60 mg/kg)

• Supraventricular Tachycardia or Ventricular Tachycardia with pulse and low

cardiac output perform synchronized cardioversion at 0.5 – 1 joules/kg

using pediatric pads. May repeat at 1-2 joules/kg

• If defibrillator is not able to deliver calculated dose- Administer Adenosine

0.1 mg/kg rapid IV / IO (not to exceed 6 mg) If necessary Adenosine may

be repeated at 0.2 mg/kg (not to exceed 12 mg).

All medications should be immediately followed by 5 – 10 ml Normal Saline 136

Pediatric ALS Protocols PEDIATRIC TRAUMATIC CARDIAC ARREST Protocol P11

Approved: 10/30/13

Effective: 4/01/14

Standing Orders:

o Initiate BLS stabilization procedures

o Perform ETI - if BLS measures not adequate (use caution with possible C-spine injury)

o Begin rapid transport

o Establish IV or IO access, administer bolus Normal Saline (0.9% NaCl) - 20 ml/kg

o Monitor ECG

o If continued signs of inadequate perfusion persist repeat a second IV bolus of 20 ml/kg (total of 40 ml/kg)

137

Pediatric ALS Protocols PEDIATRIC TRAUMATIC CARDIAC ARREST Protocol P11

Approved: 10/30/13

Effective: 4/01/14


o Continue Normal Saline (0.9% NaCl) up to an additional 20 ml/kg (total of 60 ml/kg).

o Hospital Diversion

o Epinephrine 1:10,000 0.01 mg/kg IV/IO



138


Standing Orders• Establish IV / IO access administer bolus Normal Saline at 20ml/kg unless

ordered by Medical Control

• If signs of inadequate perfusion persist repeat second bolus at 20ml/kg

(40ml max total) (40ml max total)


• Continue Normal Saline IV / IO drip up to 60 ml/kg total

• Epinephrine 1:10,000 at 0.01 mg/kg

• Paramedic only- if tension pneumothorax is suspected consider orders to

perform a needle decompression with 18-20 gauge catheter

139

QUESTIONS ?QUESTIONS ?

140

What comes What comes

next…

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