SPECIAL CONSIDERATIONS

IV Therapy

1. All trauma patients should receive at least one, and

preferably two, IV's of lactated Ringer's via large bore (14
or 16 gauge) canula.
2. Trauma patients with a systolic blood pressure <90 mmHg
should be receive wide open fluids until the systolic blood
pressure is >90 mmHg.
3. Trauma patients with a systolic blood pressure >90 mmHg
should receive fluids at a "to keep open (TKO)" rate or as
directed in the applicable protocol.
4. Intraosseous infusion may be performed on pediatric
patients up to six years of age. This procedure should be
limited to cardiac arrest and unresponsive patients after 2
unsuccessful peripheral IV attempts.
5. All pediatric peripheral IVs should be started with a mini
drip administration set.
6. All IV attempts are to be peripheral. The external jugular
vein is considered a peripheral vein. Placement of an
intraosseous needle is permitted in children less than 6
years of age who have a life-threatening emergency where
 immediate fluid or medication administration is necessary.
This procedure should only be performed with permission
of medical control (except in the case of pediatric cardiac
arrest or pediatric multiple trauma.)
7. Access of indwelling central lines (i.e Hickman Catheters) is
permitted only in patients where peripheral IV attempts
have been unsuccessful and the needs of intended therapy
outweigh the risks. Note, many of these catheters require
special access needles. Do not attempt access if special
needles are required unless the patient has access needles
available.
8. Each IV bag should be labeled with the following data:
o Time and date of IV start
o IV cannula size
o Initials of paramedic who started the IV.
Endotracheal Intubation

1. Proper endotracheal tube placement must be documented

by at least three different methods. These include:
o presence of bilateral breath sounds
o absence of breath sounds over the epigastrium
o presence of condensation on the inside of the
endotracheal tube
o end-tidal carbon dioxide monitoring
o use of an endotracheal esophageal detector
o visualizing the tube passing through the cords

All three verification methods must be documented in the

medical record!!

2. Following endotracheal intubation, tube placement should

be re-verified every 5-10 minutes by noting bilateral breath
sounds and continuing end-tidal carbon dioxide readings.

Endotracheal Drug Administration

 1. Only the following four drugs can be administered via an
endotracheal tube:

L - Lidocaine
E - Epinephrine
A - Atropine Sulfate
N - Naloxone
Note: Diazepam (Valium) should NOT be administered via an
endotracheal tube.

2. When administering drugs via the endotracheal tube,

administer 2.0 - 2.5 times the IV dose. Also, dilute the drug
in enough lactated Ringer's or normal saline to result in a
total volume of at least 10 mL. This will facilitate
endotracheal instillation and aid in increased drug delivery
to the respiratory tissues.

CHEST PAIN
GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Must be >93%
3. ECG
4. CALL chest pain unit team
5. Attach cardiac monitor and pulse oximeter.
6. Place in position of comfort.
7. Initiate an IV take investigation (Cardiac enzyme (troponin,
CK-MB)CBC, RFTs+electrolyte, RBS,HbA1C, UG ,Lipid
profile , LFTs) give of lactated Ringer's or normal saline
8. Administer 1 Nitroglycerin tablet (1/150) sublingually if
systolic blood pressure greater than 100 mmHg. May be
repeated every 5 minutes until:
a. 3 tablets have been administered,
b. Pain is relieved, or,
c. Systolic blood pressure falls below 100 mmHg.
9. administer 1 Aspirin tablet (300 mg) PO or chew if patient
not allergic to Aspirin and does not have ulcer disease.

10.Treat dysrhythmias per protocols.

11.If pain not response to SLN consider Morphine 2 mg IVP

every 5 minutes to a maximum of 10 mg in 1 hour. Monitor
respirations and blood pressure closely.
12.Consider Phenergan 12.5 - 25.0 mg or Compazine 5- 10
mg IVP for nausea and vomiting.

13.Consider nitroglycerin drip for persistent or severe chest pain.

14.Minimize vein punctures.

15.Contact CONSULTANT or medical control for any questions

or problems.

CHEST TRAUMA
GUIDELINES FOR CARE
1. Assure ABCs.
2. Oxygen via non-rebreather mask. consider intubation and
hyperventilation with 100% oxygen for markedly decreased
Loss Of Consciousness., inability to maintain a patient
airway, or for GCS * 8.
3. Attach cardiac monitor and pulse oximeter.
4. Establish two large bore IVs take investigation CBC,UG
,Blood grouping others according to age then give lactated
Ringer's or Normal Salin to maintain systolic pressure > 90
mmhg.
5. If penetrating or sucking chest wound (look for bubbles,
listen for air leaks):
a. Place occlusive dressing during exhalation (tape on 3
sides).
b. Once occluded, monitor for tension pneumothorax.
c. Call consultant
6. If flail chest (unstable segment that does not expand with
the remainder of the chest on inspiration):
a. If conscious, stabilize flail segment with gauze pad, IV
bag, etc.
b. If unconscious, immobilize neck and intubate. ventilate
with 100% oxygen by A handheld squeeze bag,
attached to a face mask, used to assist in providing
artificial ventilation of the lungs..
c. Re-assess, if tension pneumothorax develops
7. If tension pneumothorax (unilateral absent breath sounds
with or without tracheal deviation or bilaterally absent
breath sounds:
o Perform needle decompression per protocol.
8.Call CONSULTANT
Continued inadequate ventilations and decreasing Loss Of
Consciousness:
a. Rapid secondary survey for additional injuries.
b. Immobilize neck.
c. Control hemorrhage.
d. Intubate with cervical stabilization.
e. Ventilate with 100% oxygen via A handheld squeeze
bag, attached to a face mask, used to assist in
providing artificial ventilation of the lungs..
f. Establish second IV lactated Ringer's wide open en
route if signs of shock.
o Cardiac compressions if pulseless.
o Call CCU doctor

 Impaled objects should be stabilized in place.

 Treat any dysrhythmias per protocols.

 Contact consultant or medical control for any

questions or problems.
 Glasgow Coma Score
Eye Opening Motor Response
Verbal Response (V)
(E) (M)
4=Spontaneous 5=Normal conversation 6=Normal
3=To voice 4=Disoriented 5=Localizes to pain
2=To pain conversation 4=Withdraws to
1=None 3=Words, but not pain
coherent 3=Decorticate
2=No words......only posture
sounds 2=Decerebrate
1=None 1=None
Total = E+V+M

CONGESTIVE HEART
FAILURE/PULMONARY EDEMA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask if no history of
COPD. If history of COPD, titrate oxygen delivery to
maintain SPO2 > 90%. Consider intubation and
hyperventilation with 100% oxygen for markedly
decreased Loss of conscious , inability to maintain a
patient airway, or for GCS * 8.
3. Initiate IV take investigation CBC, UG,
RFTs+electrolyte other according to age then give
lactated Ringer's .
4. Attach cardiac monitor and pulse oximeter.
5. Call consultant
6. If signs of severe hypoventilation:
a. Assist ventilations with A handheld squeeze
bag, attached to a face mask, used to assist in
providing artificial ventilation of the lungs with
100% oxygen.
b. Consider endotracheal intubation.
c. Contact consultant or medical control.
d. Call ICU DOCTOR
7. If history of CHF, and patient exhibiting tachypnea,
orthopnea, JVD, edema, moist breath sounds
(rales):
a. Place in seated position (semi-fowler's.)
b. Administer nitroglycerin 1/150 sublingually (if
BP >120 systolic.)
c. Administer Lasix 40-80 mg IV.
d. Consider Morphine 2-5 mg every 5 minutes (do
not exceed a total of 10 mg). Carefully monitor
blood pressure and respirations.
e. If systolic BP >100 mmhg, consider Dobutamine
at 2-20 µg/kg/min to maintain systolic blood
pressure >100 mmhg.
f. If systolic BP <100 mmhg, consider Dopamine
at 2-20 µg/kg/min to maintain systolic >100
mmhg.
g. Consider Norepinephrine 0.5 - 30.0 µg/min if
systolic <70 mmhg as ordered by medical
control.
h. Call ICU doctor for transport
 i. Contact CONSULTANT or medical control if not
responsive to therapy.

DIABETIC EMERGENCIES/HYPOGLYCEMIA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask.
 3. Initiate IV take investigation CBC, RBS, UG, other
according to age then give lactated Ringer'.
4. Attach cardiac monitor and pulse oximeter.
5. Determine serum glucose level with Glucometer o
a. If glucose < 80 mg/dl, administer 25 gms 50%
dextrose IV.
b. If glucose > 80 mg/dl and < 250 mg/dl, go to
step #6.
c. If glucose > 250 mg/dl, go to Hyperglycemia
Protocol.
6. If unable to establish IV, give Glucagon 1 mg IM.
7. Call consultant
8. Call ICU doctors .
9. Repeat glucose determination in 5 minutes:
o If glucose remains < 80 mg/dl, and no
significant change in mental status, administer
a second 25 gms 50% dextrose IV.
Provide supportive measures.
Contact consultant or medical control for any questions
or problems.

DIABETIC EMERGENCIES/HYPERGLYCEMIA
(KETOACIDOSIS)

GUIDELINES FOR CARE

1. Assure ABCs.
 2. Oxygen via non-rebreather mask. Consider intubation and
hyperventilation with 100% oxygen for markedly decreased
loss of conscious , inability to maintain a patient airway, or
for GCS * 8.
3. Initiate IV take investigation CBC, RBS, UG, other

according to age then give lactated Ringer'.

4. Attach cardiac monitor and pulse oximeter.
1. Determine serum glucose level with Glucometer
2. if glucose < 80 mg/dl, go to Hypoglycemia Protocol.
3. if glucose > 80 mg/dl and < 250 mg/dl, go to step #6.
4. if glucose > 250 mg/dl, go to #7.
5. Call consultant
5. Call ICU doctor
6. If glucose > 250 mg/dl, and patient exhibiting altered mental
status, Kussmaul respirations, dry skin with poor turgor,
and/or ketotic breath:
a. Open lactated Ringer's wide open.
b. Contact medical control for Insulin and bicarb orders.
c. Call ICU doctor
Contact consultant or medical control for any questions or
problems.
Consider NG tube placement.
Consider thiamine 100 mg IVP.
CVA / STROKE

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. consider
intubation and hyperventilation with 100% oxygen
for markedly decreased loss of continuous , inability
to maintain a patient airway, or for GCS * 8.
3. Initiate IV take investigation CBC, RBS, UG,
RFTs+electrolyte other according to age then give
lactated Ringer's.
4. Attach cardiac monitor and pulse oximeter.
5. Elevate head of bed if possible.
6. Determine serum glucose level with Glucometer
a. If glucose < 80 mg/dl, administer 25 gms 50%
dextrose IV.
b. If glucose > 80 mg/dl and < 250 mg/dl, go to
step #7.
c. If glucose > 250 mg/dl, go to Hyperglycemia
Protocol.
7. Place in recovery position (unless spinal injury
suspected).
8. Prepare to suction and manage airway.
 9. Repeat vital signs frequently. if hypertensive, go to
Hypertensive Crisis Protocol.
10. Treat seizures with 5-10 mg Valium IVP.
contact medical control if no response to Valium.
11. Control agitation with Valium 2-5 mg IVP. may
repeat every 10 minutes to a maximum of 10 mg.
12. If the patient is able to swallow, administer 300
mg aspirin PO (chewed or swallowed).
13. Call Icu to transport
14. Consider Mannitol 0.5-1.0 gm/kg given IVP
over 5-10 minutes for signs and symptoms of
increased intracranial pressure.

DIVING EMERGENCIES (DECOMPRESSION

SICKNESS)

GUIDELINES FOR CARE

1. Assure ABCs.
2. Administer oxygen via non-rebreather mask.
3. Place the patient in a supine head-down left lateral
decubitus position.
4. Attach monitor and pulse oximeter.
5. Start an IV take investigation CBC, RBS, UG,
RFTs+electrolyte other according to age then give
of lactated Ringer's.
6. Protect against hypothermia and hyperthermia.
7. Monitor closely for complications (pneumothorax,
shock, seizures) and treat per standing
orders/protocols.
8. Contact medical control if analgesics indicated.
9. Assess vital signs, including temperature, every 10
minutes.
10. Contact medical control for any questions or
problems.
ALCOHOL EMERGENCIES
GUIDELINES FOR CARE
1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider
intubation and hyperventilation with 100% oxygen
for markedly decreased LOC, inability to maintain a
patient airway, or for GCS * 8.
3. Initiate IV take investigation then give lactated
Ringer's.
4. Attach cardiac monitor and pulse oximeter.
5. Determine serum glucose level with Glucometer
o If glucose < 80 mg/dl, administer 25 gms 50%
Dextrose IV.
o If glucose > 80 mg/dl and < 250 mg/dl, go to
step #6.
o If glucose > 250 mg/dl, go to Hyperglycemia
Protocol.
6. If history suspicious for alcoholism, administer 100
mg thiamine IV OR IM.
7. If history of drug abuse, and patient has constricted
pupils or respiratory depression, administer Narcan
1.0-2.0 mg IV.
8. If history of possible Benzodiazepine usage,
administer 0.3 mg of Flumazenil (Romazicon) IVP
over 30 seconds. Repeat as needed to a maximum
dose of 1.0 mg.
9. Provide supportive measures.
10. Contact Medical Control for any questions or
problems
 ALTERED MENTAL STATUS/COMA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider
intubation and hyperventilation with 100% oxygen
for markedly decreased LOC, inability to maintain a
patient airway, or for GCS * 8.
3. Initiate IV lactated Ringer's.
4. Attach cardiac monitor and pulse oximeter.
5. Determine serum glucose level with Glucometer
o If glucose < 80 mg/dl, administer 25 gms 50%
Dextrose IV.
o If glucose > 80 mg/dl and < 250 mg/dl, go to
step #6.
o If glucose > 250 mg/dl, go to Hyperglycemia
Protocol.
6. If history suspicious for alcoholism, administer 100
mg thiamine IV OR IM.
7. If history of drug abuse, and patient has constricted
pupils or respiratory depression, administer Narcan
1.0 - 2.0 mg IV.
8. If history of possible Benzodiazepine usage,
administer 0.3 mg of Flumazenil (Romazicon) IVP
over 30 seconds. Repeat as needed to a maximum
dose of 1.0 mg.
9. Provide supportive measures.
10. Contact Medical Control for any questions or
problems.
AMPUTATIONS
GUIDELINES FOR CARE
1. Assure ABCs.
2. Control bleeding.
3. Oxygen via non-rebreather mask.
4. Large bore IV take investigation then give lactated
Ringer's solution at appropriate rate to maintain
systolic > 90 mmHg.
5. Treat for shock, if indicated.
6. Rinse amputated part with normal saline to remove
loose debris. DO NOT SCRUB.
7. Wrap amputated part in gauze moistened with
saline.
8. Place wrapped part in plastic bag and seal. Label
with NAME, DATE, and TIME.
9. Place sealed bag in container filled with water and
several ice cubes.
10. Consider Morphine 2-5 mg IVP for pain control.
May repeat in 5 minutes up to a maximum of 10
mg.
11. If partial amputation, place in anatomical
position to facilitate the best vascular status and
wrap in bulky dressings. If the vascalarity to the
distal part is compromised, wrap the distil part and
apply ice. (Consider placing the pulse oximeter
probe on a finger or toe of the affected extremity
to monitor the vascular status of the injured
extremity.)
12. Call consultant
 13. Contact medical control for any questions or
problems.

ANAPHYLAXIS/ALLERGIC REACTIONS

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider
intubation and hyperventilation with 100% oxygen
for markedly decreased LOC, inability to maintain a
patient airway, or for GCS * 8.
3. Attach cardiac monitor and pulse oximeter.
4. IV of take investigation then give lactated Ringer's
TKO.
5. If blood pressure normal:
o Consider Benadryl 50 mg IM or slow IV push.
6. If hypotensive (systolic <90 mmHg) and patient has
mild - moderate respiratory distress:
o Open IV and infuse fluid bolus (500 ml for
adults or 20 ml/kg for children.)
o Apply uninflated PASG and elevate legs.
o administer Epinephrine 1:1,000
subcutaneously. (Adult: 0.3 ml / Pedi: 0.01
ml/kg.)
o Transport.
o Contact medical control en route.
7. If refractory hypotension, or sever repspiratory
distress:
o Administer Epinephrine 1:1,000
subcutaneously (Adult: 0.3 ml / Pedi: 0.01
ml/kg.)
 o Transport.
o Contact medical control en route.
o Consider Epinephrine 1:10,000 3-5 ml
intravenously.
o Consider Dopamine drip starting at 2
µg/kg/minute and titrate to effect.
8. Contact medical control for any questions or
problems

AORTIC ANEURYSM / DISSECTION

GUIDELINES FOR CARE
1. Assure ABCs.
2. Oxygen via non-rebreather mask. Consider
intubation and hyperventilation with 100% oxygen
for markedly decreased LOC, inability to maintain a
patient airway, or for GCS * 8.
3. Attach cardiac monitor and pulse oximeter.
 4. Establish two large bore IVs take investigation then
give of lactated Ringer's to maintain systolic
pressure > 90 mmHg.
5. If blood pressure normal:
o Consider Morphine 2-5 mg IVP for pain relief.
6. If hypertensive, go to Hypertensive Crisis Protocol.
7. Call consultant.
8. Contact medical control for any questions or
problems.

ASTHMA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask if no history of COPD. If
history of COPD, administer oxygen at 2-3 lpm via nasal
cannula. Consider intubation and hyperventilation with
100% oxygen for markedly decreased LOC, inability to
maintain a patient airway, or for GCS * 8.
3. Initiate IV lactated Ringer's
4. Attach cardiac monitor and pulse oximeter.
5. If signs of severe hypoventilation:
a. Assist ventilations with A handheld squeeze bag,
attached to a face mask, used to assist in providing
artificial ventilation of the lungs with 100% oxygen.
b. Consider endotracheal intubation.
c. Contact medical control.
6. If history of asthma, and patient exhibiting wheezing,
cough, tachypnea, or retractions:
a. Administer salbutamol breathing treatment (Adult 0.5
mL). (salbutamol can be readministered every 10
minutes. Discontinue therapy if patient develops
marked tachycardia or chest pain.)
b. Consider Epinephrine 1:1,000 0.3 mg
subcutaneously. (pediatric dose = 0.01 mL/kg) if
ordered by medical control.
c. If patient has received an salbutamol treatment in the
last two hours, then
d. Ipratropium (Atrovent) (Adult 500 µg) may be added to
the initial nebulizer treatment with salbutamol
e. Consider hydrocortisone 50-100 mg IVP
f. Contact medical control for any questions or problems
7. Contact medical control for any questions or problems.
BURNS

GUIDELINES FOR CARE

1. Assure ABCs.
2. Extinguish any flames on patient, remove
smoldering clothing (leather), and any constricting
jewelry.
3. Remove from harmful environment and limit injury:
a. CHEMICAL:Flush with water or normal saline.
Brush off dry chemicals.
 b. TAR: Cool with water or normal saline (do not
attempt to remove tar.)
c. ELECTRICAL: Remove from contact with current
source if equipped to do so. (Note any
secondary fractures and Exit wounds caused by
current.)
4. If respiratory distress, or airway burns exist,
prepare to intubate.
5. If pulseless or apneic, go to Cardiac Arrest Protocol.
6. If additional injuries, go to Trauma Management
Protocol.
7. If significant 2° or 3° burns (> 20% (BSA)Burn
Surface Area):
a. Oxygen via non-rebreather mask
b. Establish two large bore IVs of lactated
Ringer's.
Administer 4 ml X patient's weight (kg) X % BSA
burned
Give 1/2 in the first 8 hours post-burn,
 Give 1/4 in the second 8 hours,
Give 1/4 in the third 8 hours.
c. Contact medical control
d. Consider Morphine 2-5 mg IVP. May repeat in
five minutes to a maximum of 15 mg.
8. If altered LOC and/or signs of head injury (consider
carbon monoxide poisoning if closed space burn):
a. Oxygen via non-rebreather mask.
b. Immobilize cervical spine.
c. IV lactated Ringer's.
d. Contact medical control.
9. Transport all significantly burned patients on sterile
dry sheets.
10. Consider Foley catheter insertion.
11. Monitor urine output. If output drops to less
than 30-60 ml/hour (adults) OR 1.0 ml/kg/hour
(pediatric), increase the IV fluids to maintain urine
output at these levels.
 12. Contact medical control for any questions or
problems.

CARDIOGENIC SHOCK

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask if no history of
COPD. If history of COPD, titrate oxygen delivery to
maintain SPO2 > 90%. Consider intubation and
hyperventilation with 100% oxygen for markedly
decreased LOC, inability to maintain a patient
airway, or for GCS * 8.
3. Initiate IV lactated Ringer's. If hypotensive, consider
250 mL fluid bolus.
4. Attach cardiac monitor and pulse oximeter.
5. Treat dysrhythmias per the appropriate protocol.
6. If signs of severe hypoventilation occur:
a. Assist ventilations with A handheld squeeze
bag, attached to a face mask, used to assist in
providing artificial ventilation of the lungs(BVM
)with 100% oxygen.
b. Consider endotracheal intubation.
c. Contact medical control
d. Intubated patients with severe pulmonary
congestion may require PEEP to maintain
oxygenation status.
7. Monitor I&O closely.
8. If systolic BP >100 mmHg, consider Dobutamine at
2-20 µg/kg/min to maintain systolic blood pressure
> 100 mmHg.
 9. If systolic BP <100 mmHg, consider Dopamine at 2-
20 µg/kg/min to maintain systolic >100 mmHg.
10. Consider Norepinephrine 0.5 - 30.0 µg/min if
systolic <70 mmHg as ordered by medical control.
11. Contact medical control if not responsive to
therapy.

DYSPNEA

GUIDELINES FOR CARE

1. Assure ABCs.
2. Oxygen via non-rebreather mask if no history of
COPD. If history of COPD, titrate oxygen delivery to
maintain SPO2 > 90%. consider intubation and
hyperventilation with 100% oxygen for markedly
 decreased LOC, inability to maintain a patient
airway, or for GCS * 8.
3. Initiate IV lactated Ringer's.
4. Attach cardiac monitor and pulse oximeter.
5. If signs of severe hypoventilation:
a. Assist ventilations with BVM with 100%
oxygen.
b. Consider endotracheal intubation
c. Contact medical control
6. If history of COPD (emphysema/chronic bronchitis):
o Obtain baseline peak expiratory flow rate
(PEFR) while preparing nebulizer.
o Administer salbutamol breathing treatment
(adult 0.5 ml). salbutamol can readministered
every 10 minutes. discontinue therapy if
patient develops marked tachycardia or chest
pain.
o If patient has received an salbutamol
treatment in the last two hours, then
 o Ipratropium (Atrovent) (adult 500 µg) may
added to the initial nebulizer treatment with
salbutamol
o Contact medical control for any questions or
problems.
If history of fever and/or productive cough:
o Place in position of comfort.
If allergen exposure, edema, rash, and wheezing:
o Go to Anaphylaxis/Allergic Reaction Protocol
o Contact medical control
If history of pulmonary embolism:
o Place in position of comfort (preferably with
extremities lower than level of heart)
o Consider Morphine 2-5 mg IVP for pain. may
repeat to a maximum of 10 mg.
o Consider Valium 2-5 mg IVP for anxiety.
If history of CHF, and patient exhibiting tachypnea,
orthopnea, JVD, edema, moist breath sounds (rales):
o Place in seated position (semi-fowler's)
o Administer Nitroglycerin 1/150 sublingually (if
BP >120 mmhg systolic).
o Administer Lasix 40-80 mg IV.
o Consider Morphine 2-5 mg every 5 minutes (do
not exceed a total of 10 mg.) carefully monitor
blood pressure and respirations.
o If systolic BP >100 mmhg, consider Dobutamine
at 2-20 µg/kg/min to maintain systolic blood
pressure > 100 mmhg.
o If systolic BP <100 mmhg, consider Dopamine
at 2-20 µg/kg/min to maintain systolic >100
mmhg.
o Consider Norepinephrine 0.5 - 30.0 µg/min if
systolic <70 mmhg as ordered by medical
control.
o Contact medical control if not responsive to
therapy.
If history of asthma, and patient exhibiting wheezing,
cough, tachypnea, or retractions:
o Administer salbutamol breathing treatment
(adult 0.5 ml). salbutamolcan readministered
every 10 minutes. discontinue therapy if
patient develops marked tachycardia or chest
pain.
o Consider Epinephrine 1:1,000 0.3 mg
subcutaneously. (pediatric dose = 0.01 ml/kg) if
ordered by medical control.
o If patient has received an salbutamoltreatment
in the last two hours, then
o Ipratropium (Atrovent) (adult 500 µg) may
added to the initial nebulizer treatment with
salbutamol.
o Consider hydrocortisone 50-100 mg IVP.
o Contact medical control for any questions or
problems.
12. contact medical control for any questions or
problems
DYSRHYTHMIAS

GUIDELINES FOR CARE

Care of cardiac dysrhythmias is based on standards
established by the American Heart Association
committee on emergency cardiac care. please look to
the specific protocol which follows for:
 Asystole
 Bradycardia (symptomatic)
 Narrow Complex Tachycardia (symptomatic)
  Pulseless Electrical Activity (electromechanical
dissociation)
 Ventricular Fibrillation
 Ventricular Tachycardia (with pulse)
 Ventricular Tachycardia (without pulse)
 Premature Ventricular Contractions
Other points to remember include:
1. Always treat the patient, not the monitor.
2. Cardiac arrest due to trauma is not treated by
medical protocols.
3. Protocols for cardiac arrest situations presumes
that the condition under discussion continually
persists, that the patient remains in cardiac arrest,
and that CPR is always performed.
4. Adequate airway, ventilation, oxygenation, chest
compressions, and defibrillation are more
important than administration of medications and
take precedence over initiating an intravenous line
or injecting medications.
 5. Remember, Lidocaine, Epinephrine, Atropine, and
Naloxone can be administered via the endotracheal
tube.
6. After each intravenous medication, give a 20- to 30-
ml bolus of intravenous fluid and immediately
elevate the extremity. this will enhance delivery of
the drug to the central circulation

DYSRHYTHMIAS (ASYSTOLE)
GUIDELINES FOR CARE

1. Assure ABCs.
2. Initiate and continue CPR.
3. Intubate at once.
4. Initiate IV of lactated Ringer's.
5. Confirm asystole in more than one lead.
6. Consider possible causes:
o Hypoxia
o Hyperkalemia (increased potassium)
 o Hypokalemia (decreased potassium)
o Pre-existing Acidosis
o Drug overdose
o Hypothermia
7. Consider immediate transcutaneous cardiac pacing, if
available.
8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5
minutes IV. follow each intravenous drug bolus with 20
milliliters of IV fluid and elevate extremity. if unable to
establish IV access, administer Epinephrine endotracheally.
9. Administer Atropine 1 mg IV. may repeat every 3-5 minutes
up to:
o 2 mg for patients weighing less than 110 pounds (<50
kg)
o 3 mg for patients weighing 110-165 pounds (50-75 kg)
o 4 mg for patients weighing 165-220 pounds (75-100
kg)
10. Contact medical control for further direction.
11. Contact medical control for any questions or problems
DYSRHYTHMIAS (BRADYCARDIA--
SYMPTOMATIC)

GUIDELINES FOR CARE

1. Assure ABCs.
2. Administer oxygen.
3. Attach monitor.
4. Start IV of lactated Ringer's.
5. Assess vital signs.
6. If heart rate < 60 per minute and patient exhibits any of the
following signs or symptoms:
o Chest pain
o Shortness of breath
o Decreased level of consciousness
o Low blood pressure
 o Shock
o Pulmonary edema
o Congestive heart failure
o Acute MI

administer 0.5 mg Atropine intravenously.

7. Contact medical control.

8. May repeat intravenous Atropine every 3-5 minutes up to:
o 2 mg for patients weighing less than 110 pounds (<50
kg)
o 3 mg for patients weighing 110-165 pounds (50-75 kg)
o 4 mg for patients weighing 165-220 pounds (75-100
kg)
9. Consider transcutaneous cardiac pacing.
10. Contact medical control for any questions or problems.
DYSRHYTHMIAS (NARROW COMPLEX
TACHYCARDIA--SYMPTOMATIC)
GUIDELINES FOR CARE

1. Assure ABCs.

2. Administer oxygen.

3. Attach monitor. verify narrow complex tachycardia. if wide-

complex tachycardia, see Ventricular Tachycardia Protocol.

4. Assess vital signs.

5. Start IV of lactated Ringer's TKO.

6. If patient exhibits any of the following signs or symptoms:

o Chest pain

o Shortness of breath

o Decreased level of consciousness

 o Low blood pressure / shock

o Pulmonary edema / congestive heart failure

o Acute MI

consider patient to be unstable.

7. Attempt vagal maneuvers if not contraindicated.

8. If vagal maneuvers unsuccessful, administer Adenosine 6

mg rapid IV push over 1-3 seconds in medication port
nearest patient.
DYSRHYTHMIAS (PREMATURE VENTRICULAR
CONTRACTIONS)

GUIDELINES FOR CARE

1. Assure ABCs.

2. Administer oxygen.

3. Start IV of lactated Ringer's TKO.

4. Attach monitor. verify premature ventricular contractions.

5. Assess vital signs.

6. If patient is asymptomatic, transport with continued

monitoring en route.

7. If patient exhibits any of the following signs or symptoms:

o Chest pain

o Dizziness

o Symptoms of acute MI
and premature ventricular contractions are malignant:

o > 6 per minute

o Multi-focal

o Occurring in couplets

o Exhibiting "r on t phenomenon"

o Exhibiting runs of ventricular tachycardia

then, administer Lidocaine 1.0 - 1.5 mg/kg IV push (reduce

dosage by 50% if patient >70 years of age or has known liver
disease).

8. If, after 5 minutes, PVCs persist, repeat Lidocaine at 1/2

the initial dose. if PVC's suppressed, begin Lidocaine drip
at 2 mg/minute. contact medical control.

9. Consider Procainamide at 30 mg/minute to a maximum of

17 mg/kg if PVCs persist.

10. If patient at any time becomes pulseless, switch to

Pulseless Ventricular Tachycardia Protocol (or other
appropriate protocol).

11. Transport.

12. Contact medical control for any questions or problems.

DYSRHYTHMIAS (PULSELESS ELECTRICAL
ACTIVITY) [PEA]
GUIDELINES FOR CARE

1. Assure ABCs.

2. Initiate and continue CPR.

3. Intubate at once.

4. Initiate IV of lactated Ringer's wide open.

5. Confirm asystole in more than one lead.

6. Consider possible causes:

o Hypovolemia

o Hypoxia

o Hyperkalemia (increased potassium)

o Cardiac tamponade

o Pre-existing acidosis

o Drug overdose
 o Hypothermia

o Tension pneumothorax

o Massive pulmonary embolism

o Massive acute myocardial infarction

7. Administer 1 milligram of Epinephrine 1:10,000 every 3-5

minutes IV. follow each intravenous drug bolus with 20
milliliters of IV fluid and elevate extremity. if unable to
establish IV access, administer Epinephrine endotracheally.

8. If heart rate < 60 per minute, or relative bradycardia,

administer Atropine 1 mg IV. may repeat intravenous
Atropine every 3-5 minutes up to:

o 2 mg for patients weighing less than 110 pounds (<50

kg)

o 3 mg for patients weighing 110-165 pounds (50-75 kg)

o 4 mg for patients weighing 165-220 pounds (75-100

kg)

9. Contact medical control.

10. Consider sodium bicarbonate.

11. Consider transcutaneous cardiac pacing.

12. Transport.

13. Contact medical control for any questions or problems.

DYSRHYTHMIAS (VENTRICULAR
FIBRILLATION)
GUIDELINES FOR CARE

1. Assure ABCs.

2. Initiate and continue CPR until defibrillator attached.

3. Confirm ventricular fibrillation (VF) or non-perfusing

ventricular tachycardia (VT) on monitor.

4. Defibrillate up to 3 times as needed for persistent VF or VT:

o #1 at 200 joules

o #2 at 300 joules

o #3 at 360 joules

5. If VF or VT persists, continue CPR. If patient develops PEA

or asystole, go to appropriate protocol.

6. Intubate.

7. Start an IV of lactated Ringer's TKO.

8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5
minutes IV. follow each intravenous drug bolus with 20
milliliters of IV fluid and elevate extremity. If unable to
establish IV access, administer A
HREF="../glossary/drugs.htm#epinephrine">Epinephrine
endotracheally.

9. Defibrillate at 360 joules within 30-60 seconds following

administration of each drug.

10. Administer 1.5 mg/kg Lidocaine intravenously. repeat

every 3-5 minutes until a total of 3 mg/kg has been
administered. If unable to establish IV access, administer
Lidocaine endotracheally.

11. Consider Bretylium 5 mg/kg IV.

12. Contact medical control.

13. Consider Sodium Bicarbonate IV.

14. Transport.

15. Contact medical control for any questions or problems.

DYSRHYTHMIAS (VENTRICULAR
TACHYCARDIA--WITH PULSE)

GUIDELINES FOR CARE

1. Assure ABCs.

2. Administer oxygen.

3. Start IV of lactated Ringer's TKO.

4. Attach monitor. Verify ventricular tachycardia.

5. Assess vital signs.

6. If patient exhibits any of the following signs or symptoms:

o Chest pain

o Shortness of breath

o Decreased level of consciousness

o Low blood pressure

o Shock

o Pulmonary edema

o Congestive heart failure

o Acute MI
consider patient to be unstable.

7. Administer Lidocaine 1.0 - 1.5 mg/kg IV push.

8. Administer Lidocaine 0.50 - 0.75 mg/kg IV push every 5-10

minutes until ventricular tachycardia abolished or 3.0 mg/kg
of the drug has been administered.

9. Consider Procainamide at 30 mg/minute to a maximum of

17 mg/kg.

10. Consider Bretylium 5 - 10 mg/kg every 8-10 minutes to

a maximum of 30 mg/kg.

11. Consider synchronized cardioversion. If time permits,

premedicate with Valium 2-5 mg IVP, Versed 1-2 mg IVP,
or Morphine 2-5 mg IVP.

12. If patient at any time becomes pulseless, switch to

pulseless Ventricular Tachycardia Protocol (or other
appropriate protocol).

13. Transport.

14. Contact medical control for any questions or problems.

DYSRHYTHMIAS (VENTRICULAR
TACHYCARDIA--WITHOUT PULSE)

GUIDELINES FOR CARE

1. Assure ABCs.

2. Initiate and continue CPR until defibrillator attached.

3. Confirm ventricular fibrillation (VF) or non-perfusing

ventricular tachycardia (VT) on monitor.

4. Defibrillate up to 3 times as needed for persistent VF or VT:

o #1 at 200 joules

o #2 at 300 joules

o #3 at 360 joules

5. If VF or VT persists, continue CPR. if patient develops PEA

or asystole, go to appropriate protocol.

6. Intubate.

7. Start an IV of lactated Ringer's TKO.

8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5

minutes IV. Follow each intravenous drug bolus with 20
 milliliters of IV fluid and elevate extremity. If unable to
establish IV access, administer Epinephrine endotracheally.

9. Defibrillate at 360 joules within 30-60 seconds following

administration of each drug.

10. Administer 1.5 mg/kg Lidocaine intravenously. Repeat

every 3-5 minutes until a total of 3 mg/kg has been
administered. If unable to establish IV access, administer
Lidocaine endotracheally.

11. Contact medical control.

12. Consider Bretylium 5 mg/kg IV.

13. Consider Sodium Bicarbonate IV.

14. Transport.

15. Contact medical control for any questions or problems.

ECLAMPSIA
GUIDELINES FOR CARE

1. 1. Assure ABCs.

2. Oxygen via non-rebreather mask. consider intubation and

hyperventilation with 100% oxygen for markedly decreased
LOC, inability to maintain a patient airway, or for GCS * 8.

3. Secondary survey.

4. Establish IV of lactated Ringer's at 125 ml/hr.

5. Valium 5 - 10 mg IVP over 1 minute for seizures.

6. Monitor EKG, vital signs, fetal heart tones, level of

consciousness, patellar reflexes, respiratory rate,
oxygenation status every 5 minutes. If patellar reflexes are
absent, shut off the infusion and contact medical control
immediately.

7. Keep the patient in left lateral recumbent position.

8. Contact medical control for other hypertensive agent

orders.

9. Monitor urinary output if possible

10. Evaluate for pulmonary edema. if present, consider

Morphine 2-5 mg IVP over 1-2 minutes and/or Furosemide
20-40 mg IVP over 2-3 minutes.
 11. consider magnesium sulfate if ordered by medical
control. begin with a loading dose of 4 - 6 grams of
magnesium sulfate (8 ml of 50% solution) in 100 ml of LR
over 30 minutes. After loading dose, start magnesium
sulfate infusion. Place 10 grams of magnesium sulfate (20
ml of 50% solution) in 250 ml of LR and infuse at 50 ml/hr
(2 grams/hr). Remember, magnesium sulfate can cause
respiratory depression with cardiovascular collapse.
Antidote is calcium chloride IV over 5 minutes.

12. Place NG tube if appropriate.

13. Contact medical control for any questions or problems.

ENVIRONMENTAL EMERGENCIES
(FROSTBITE)

GUIDELINES FOR CARE

1. Assure ABCs.

2. Administer oxygen via non-rebreather mask.

3. Cardiac monitor and pulse oximeter.

4. Check core temperature. if core temperature < 35° c, go to

Hypothermia Protocol.

5. Attend to injured areas:

o Protect injured areas from pressure, trauma, and

friction.
Do not rub or break blisters.

o Do not allow limb to thaw if there is a chance it will re-

freeze.

o Do not allow patient to ambulate once the limb has

started to thaw.

o Maintain core temperature by keeping victim warm

with blankets.

o Warm fluids may be administered orally to conscious

patients.

6. Consider using the pulse oximeter probe to detect

peripheral perfusion in affected tissues.
 7. Consider Morphine or Nalbuphine for pain control.

8. Transport.

9. Contact medical control for any questions or problems.

ENVIRONMENTAL EMERGENCIES
(HYPERTHERMIA)

GUIDELINES FOR CARE

1. Assure ABCs.

2. Administer oxygen via non-rebreather mask.

3. Start two large bore IVs of lactated Ringer's at TKO. bolus

as required to maintain systolic BP >90 mmhg.

4. Attach monitor and pulse oximeter.

5. Assess vital signs, including temperature, every 10

minutes.

6. If history suggestive of heat exhaustion or heat stroke:

o Remove to cooler environment

o Cool with ice packs or moist sheets (must have good

ambient air flow)

o Stop cooling measures when core body temp is 39° c.

7. If seizures are present, and suspected to be heat-related:

o Protect airway with appropriate airway adjuncts.

o Valium 2-5 mg IV.

8. For hypotension refractory to cooling and fluid boluses,

initiate Dopamine drip and titrate to maintain systolic BP >
90 mmhg.

9. Consider NG tube to low suction.

 10. Consider Foley catheter to monitor urine output.

11. Consider Mannitol 0.5 - 1.0 gm/kg for decreased urine

output or altered mental status.

12. Transport.

13. Contact medical control for any questions or problems.

ENVIRONMENTAL EMERGENCIES
(HYPOTHERMIA)

GUIDELINES FOR CARE

1. Actions for all patients:

o Remove wet garments

 o Protect against heat-loss and wind-chill

o Maintain horizontal position

o Avoid rough movement and excess activity

o Monitor core temperature

o Monitor cardiac rhythm

o Treat major trauma as the first priority and

hypothermia as the second.

2. Assess responsiveness, breathing, and pulse:

o If pulse/breathing absent, go to #3.

o If pulse/breathing present, go to #5.

3. If pulse/breathing absent:

o Start CPR.

o Defibrillate ventricular fibrillation/ventricular

tachycardia up to a total of 3 shocks (200 j, 300 j, and
360 j)

o Intubate.

o Ventilate with warm, humid oxygen.

 o Establish IV of lactated Ringer's and infuse at 150
ml/hour.

4. Determine core temperature:

a. If core temperature <30°c, then

I. Continue CPR.

II. Withhold IV medications.

III. Limit shocks to a maximum of 3.

IV. Transport to hospital.

b. If core temperature >30°c, then

I. Continue CPR.

II. Give IV medications based on dysrhythmia (but

at longer intervals.)

III. Repeat defibrillation for ventricular

fibrillation/ventricular tachycardia as core
temperature rises.

IV. Admission to hospital.

5. If pulse/breathing present, administer warm, humidified

oxygen, and initiate IV of lactated Ringer's at 150
ml/hour.
6. Determine serum glucose level with Glucometer or
DextroStix. If glucose < 80 mg/dl, give 25 gms d50w IVP
(0.5 gms/kg of d25w for children)
7. Begin external re-warming.

8.Contact medical control for any questions or problems.

FRACTURES (GENERAL)

GUIDELINES FOR CARE

1. Assure ABCs.

2. Secondary survey.

3. Document LOC and orientation.

4. Consider Nubain 5-10 mg IV or IM or Morphine 2-4 mg IV
before moving patient if no evidence of head or abdomen
injury.

5. Immobilize fracture.

6. Admission .

7. Contact medical control for any questions or problems.

FRACTURES (FEMUR)

GUIDELINES FOR CARE

8. Assure ABCs.

9. Administer oxygen via non-rebreather mask.

10. Start IV of lactated Ringer's at 250 ml/hour.

11. if evidence of shock (tachycardia, diaphoresis, hypotension,
etc), start second IV of lactated Ringer's and infuse wide-
open.

12. Attach monitor.

13. Assess vital signs.

14. Consider Nubain 5-10 mg IV or IM or Morphine 2-4 mg IV

before moving patient if no evidence of head or abdomen
injury.

15. Place traction device.

16. admission

17. Contact medical control for any questions or problems.

FRACTURES (PELVIS)
GUIDELINES FOR CARE

18. Assure ABCs.

19. Administer oxygen via non-rebreather mask.

20. Start IV of lactated Ringer's at 250 ml/hour.

21. if evidence of shock (tachycardia, diaphoresis, hypotension,
etc), start second IV of lactated Ringer's and infuse wide-
open.

22. Attach monitor.

23. Assess vital signs.

24. place PASG. Inflate if needed for immobilization or shock.

25. Admission .

26. Contact medical control for any questions or problems.

HEAD INJURY / SPINAL TRAUMA

GUIDELINES FOR CARE

27. Assure ABCs.

28. Maintain cervical spine immobilization.

29. Determine level of consciousness (AVPU).

30. Complete motor examination (paralysis, weakness,
posturing), if possible.

31. Pupillary examination (size, equality).

32. Complete sensory examination, if possible.

33. Open wounds which expose the brain tissue should be

covered with saline-soaked gauze.

34.Oxygen via non-rebreather mask. consider intubation and

hyperventilation with 100% oxygen for markedly decreased
LOC, inability to maintain a patient airway, or for GCS * 8.

35.if pulseless, apneic:

a. Intubate with neck in neutral position (stabilized with

traction by second EMT).

b. Hyperventilate with 100% oxygen.

c. CPR.

d. Apply and inflate PASG.

e. Admission .

f. Attempt IV lactated Ringer's en route.

g. Contact medical control en route.

36.if patient unresponsive: Hyperventilate with 100% oxygen.

 a. Intubate with neck in neutral position (stabilized with
traction by second EMT).
b. admission.
c. Attempt IV lactated Ringer's en route.
d. if BP <90 mmhg systolic, or signs of shock:

e.Administer oxygen via a non-rebreather mask.

i. Immobilize neck.

ii. Apply and inflate PASG.

iii. Transport.

iv. Attempt IV lactated Ringer's en route.

v. Contact medical control en route.

37.If combative, check airway, ensure oxygen delivery, and

restrain as needed.

a. Consider Mannitol 0.5 - 1.0 gm/kg IVP.

b. Anticipate seizures and possible combativeness.
c. Consider Valium 2 - 10 mg IVP for seizures and agitation.
be prepared to maintain the airway and ventilate the patient
as required.
d. Consider rapid sequence induction (RSI) and intubation for
combative patients. 0.08 - 0.10 mg Vecuronium (Norcuron)
 should be used for paralysis. May repeat Vecuronium 0.05
mg/kg for continued paralysis en route.

38.If spinal injury with neurological deficit present or suspected,

contact medical control for possible initiation of high-dose
corticosteroid therapy. Consider vasopressors for spinal shock if
ordered by medical control.

39.Contact medical control for any questions or problems.

HYPERTENSIVE CRISIS
GUIDELINES FOR CARE

1. Assure ABCs.
2. Administer oxygen via non-rebreather mask.
3. Cardiac monitor.
4. IV lactated Ringer's TKO.
5. If blood pressure greater than 200/130 mmhg and
asymptomatic; or blood pressure greater than 180/110 mmhg
and accompanied by tachycardia, headache, or confusion,
administer 10 mg Procardia sublingually (puncture capsule with
needle and place under patient's tongue or have patient chew
the capsule). Do not administer Procardia if patient exhibiting
symptoms of pulmonary edema.
6. Monitor vital signs every 3-5 minutes.
7. If little or no change in blood pressure following
administration of Procardia, contact medical control for
additional direction. consider Labetalol or similar agent.
8. If response to Procardia is too great and hypotension
ensues, elevate patient's feet and administer 250 ml fluid bolus
of lactated Ringer's. Notify medical control.
9. admission .
10. Contact medical control for any questions or problems.

INTRA-AORTIC BALLOON PUMP

GUIDELINES FOR CARE

1. Assure ABCs.
 2. Oxygen at 2-3 lpm via a nasal cannula. increase as needed
to maintain oxygen saturation > 90%.
3. Attach cardiac monitor and pulse oximeter.
4. Establish two large bore IVs of lactated Ringer's at TKO (IV
lines will typically be in place and initiated by transferring
facility).
5. Monitor vital signs, ECG, mental status, respiratory and
oxygenation status every 10 minutes.
6. treat dysrhythmias per the appropriate protocol.
7. Keep the mean arterial pressure (map) between 60-80
mmhg.
8. Do not elevate the head of the bed greater than 30
degrees. Aeromedical units should communicate with pilot
regarding angle of attack during landing and take-off.
9. Frequently reassess patient.
10. Contact medical control for any problems.

MOTION SICKNESS
GUIDELINES FOR CARE

1. Assure ABCs.
 2. Oxygen via non-rebreather mask.
3. Attach cardiac monitor and pulse oximeter.
4. Initiate IV of lactated Ringer's at 125 ml/hr. Give 250 ml
fluid bolus if systolic pressure < 90 mmhg (20 ml/kg for
children).
5. Be alert for dysrhythmias.
6. Provide appropriate comfort measures (i.e cool cloth to
forehead).
7. If patient nauseated or has recently vomited, administer
Phenergan 12.5 - 25.0 mg IVP or IM. Do not repeat more
frequently than every 4 hours unless ordered by medical
control.
8. If patient complains of dizziness or motion sickness,
consider administering 25 - 50 mg of Dimenhydrinate
(Dramamine) IVP over 30 seconds.
9. Monitor ECG, vital signs, pulse oximetry, and level of
consciousness.
10. contact medical control for any problems.

MULTIPLE TRAUMA
SITUATIONAL GUIDELINES
1. The first paramedic on the scene will become the scene
director and others arriving later will follow his or her lead
until a formal incident command system (ICS) is in place.
2. Try to keep ambulance crews and equipment together to
minimize confusion when several ambulances are present
at the scene.
3. Notify dispatch of the need for more help when the
estimated number of injured can be determined.
4. Note any hazards (chemical spills, downed power lines,
etc.)
5. Begin rendering emergency care with airway being the first
priority, followed by oxygenation, and hemorrhage control.
6. Begin transporting severely injured, but salvageable,
patients first. Dead and hopelessly dying patients should
not be transported until salvageable patients are removed.
7. In airplane crashes, be sure to leave a marker noting the
position of the patient before removing them from the
scene.
8. If more than 6 patients, use start triage system and declare
a multiple casualty incident (see MCI Protocol.)
a. The following are considered "load and go" situations:
Airway obstruction that cannot be relieved by mechanical
methods
 i. Conditions which result in inadequate
respirations

ii. Large open chest wounds (i.e. sucking chest

wounds)

iii. Large flail chest

iv. Tension pneumothorax

v. Major blunt chest trauma

vi. Traumatic cardiac arrest

vii. Shock

viii. head injury with unconsciousness, unequal

pupils, or deteriorating neurological status.

ix. Tender, distended abdomen

x. Bilateral femur fractures

xi. Unstable pelvis

xii. Development of respiratory difficulty

If patient has unstable vital signs:

1. If patient is severely injured, with systolic blood pressure

<90 mmhg in adults, or children with capillary refill time >2
seconds:
 a. Airway with cervical spine control

b. Breathing

c. Circulation/perfusion with hemorrhage control

d. Disability determination (AVPU, motor, posturing)

e. Exposure

2. Perform a rapid, abbreviated full-body assessment in order

to identify any major injuries.

3. If extrication required, perform quickly with spinal

immobilization.

4. Place PASG and inflate if no contraindications.

5. Admission .

6. Start 2 IVs of lactated Ringer's en route and run wide open.

7. Contact medical control en route.

If the patient has stable vital signs

1. If the patient's systolic pressure is initially and continuously

stable, without significant signs or symptoms of shock,
more time may be taken for field assessment:

a. Airway with cervical spine control.

 b. Breathing.

c. Circulation/perfusion with hemorrhage control.

d. Disability determination (AVPU, motor, posturing).

e. Exposure.

2. Administer oxygen at 100% via non-rebreather mask.

3. Attach cardiac monitor and pulse oximeter.

4. Perform a rapid, full-body assessment in order to identify

any major injuries.

5. If extrication required, perform with spinal immobilization.

6. Start an IV of lactated Ringer's en route at 150 ml/hour.

7. Complete splinting and packaging.

8. If head or spinal injury present, see Head Injury/Spinal

Injury Protocol.

9. If pelvis or femur fractures present, see Fracture Protocols.

10. If chest trauma present, see Chest Trauma Protocol.

11. Admission .

12. Contact medical control for any questions or problems.

NAUSEA AND VOMITING
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via a nasal cannula at 2 liters per minute unless

higher concentrations warranted by patient condition.

3. Initiate IV of lactated Ringer's at 125 ml/hr.

4. Provide appropriate comfort measures (i.e cool cloth to

forehead).

5. If patient nauseated or has recently vomited, administer

Phenergan 12.5 - 25.0 mg IVP or IM. do not repeat more
frequently than every 4 hours unless ordered by medical
control.

6. If patient actively vomiting, administer 5 - 10 mg of

Compazine IVP or IM (adult patients only)

7. Monitor ECG, vital signs, pulse oximetry, and level of

consciousness.

8. Consider intubating patients with altered mental status who

are vomiting.
9. Consider NG tube placement for patients with altered
mental status and/or inability to maintain their airway.

10. Contact medical control for any problems.

NEAR-DROWNING
GUIDELINES FOR CARE

1. Assure ABCs.

2. Immobilize cervical spine.

3. Oxygen via non-rebreather mask.

4. Attach cardiac monitor and pulse oximeter.

5. IV of lactated Ringer's TKO.

6. If apneic:

a. Initiate and maintain mechanical ventilation with 100%

oxygen.

b. Endotracheal intubation (with in-line cervical

immobilization.)

c. Treat any dysrhythmias per appropriate protocol.

d. Transport and contact medical control en route.

7. Tf apneic and pulseless:

a. Initiate and maintain mechanical ventilation with 100%

oxygen.

b. CPR.
 c. Endotracheal intubation (with in-line cervical
immobilization.)

d. Treat any dysrhythmias per appropriate protocol.

e. Transport and contact medical control en route.

8. If hypotensive:

a. Elevate legs.

b. Administer 250 ml fluid bolus (20 ml/kg for children).

Repeat to maintain systolic BP >90 mmhg. Consider
starting a second IV of lactated Ringer's if multiple
boluses required.

c. Transport and contact medical control en route.

d. Initiate Dopamine drip if patient unresponsive to fluid

challenge. begin infusion at 2.0 µg/kg/min and titrate
to maintain systolic BP >90 mmhg.

9. Treat dysrhythmias per the appropriate protocol.

10. Consider NG tube at low suction.

11. Start passive re-warming if patient hypothermic.

12. Consider Mannitol 0.5 - 1.0 gram/kg for deteriorating

neurological status.
13. Obtain glucometer and administer 25 grams d50w if
glucometer <80 mg/dl.

14. Contact medical control for any questions or problems.

PEDIATRIC EMERGENCIES
GUIDELINES FOR CARE

1. Remember that children are not small adults. Treatments

vary as do drug dosages and fluid administration rates.

2. Cardiac arrest in children is not a sudden event. it is almost

always due to a respiratory problem which leads to
hypoxia, bradycardia, and eventually asystole. ventricular
fibrillation is a rare event in children. initial treatment should
be directed at establishment of an airway, administration of
supplemental oxygen, and mechanical ventilation.

3. EOAs, EGTAs, PTL airways, and esophageal combitubes

should not be used in children. the preferred method of
airway management is endotracheal intubation. demand
valves should not be used in children because of the
tendency to cause barotrauma.

4. The intraosseous route of fluid and medication

administration is available in children less than 6 years of
age.

5. Blood pressure is a late sign of shock in children. Instead,

you should evaluate end-organ perfusion.
Anticipating Cardiopulmonary Arrest
o All sick children should undergo a rapid cardiopulmonary
assessment.
o The goal is to answer the question, "Does this child have
pulmonary or circulatory failure that may lead to
cardiopulmonary arrest?"
o Recognition of the physiologically unstable infant is made
by physical examination alone.
o Children who should receive the rapid cardiopulmonary
assessment include those with the following conditions.

 respiratory rate greater than 60

 heart rate greater than 180 or less than 80 (under 5 years)

 heart rate greater than 180 or less than 60 (over 5 years)

 respiratory distress

 trauma

 burns

 cyanosis

 altered level of consciousness

 seizures
  fever with petechiae (small skin hemorrhages)

Rapid Cardiopulmonary Assessment

the rapid cardiopulmonary assessment is designed to assist you

in recognizing respiratory failure and shock, thus anticipating
cardiopulmonary arrest. the rapid cardiopulmonary assessment
follows the basic ABCs of CPR.

Airway Patency

inspect the airway and ask yourself the following questions.

 is the airway patent?

 is it maintainable with head positioning, suctioning, or

airway adjuncts?

 is the airway unmaintainable. if so, what action is required?

(endotracheal intubation, removal of a foreign body, and so on)

Breathing

evaluation of breathing includes assessment of the following

conditions.

 Respiratory rate. Tachypnea is often the first manifestation

of respiratory distress in infants. An infant breathing at a
rapid rate will eventually tire. Thus, a decreasing respiratory
 rate is not necessarily a sign of improvement. A slow
respiratory rate in an acutely ill infant or child is an ominous
sign.

 Air entry. The quality of air entry can be assessed by

observing for chest rise, breath sounds, stridor, or
wheezing.

 Respiratory mechanics. Increased work of breathing in the

infant and child is evidenced by nasal flaring and use of the
accessory respiratory muscles.

 color. Cyanosis is a fairly late sign of respiratory failure and

is most frequently seen in the mucous membranes of the
mouth and the nail beds. Cyanosis of the extremities alone
is more likely due to circulatory failure (shock) than
respiratory failure.

Circulation

The cardiovascular assessment consists of the following

procedures.

 heart rate. Infants develop sinus tachycardia in response to

stress. Thus, any tachycardia in an infant or child requires
further evaluation to determine the cause. Bradycardia in a
 distressed infant or child may indicate hypoxia and is an
ominous sign of impending cardiac arrest.

 Blood pressure. Hypotension is a late and often sudden

sign of cardiovascular decompensation. even mild
hypotension should be taken seriously and treated quickly
and vigorously, since cardiopulmonary arrest is imminent.

 Peripheral circulation. The presence of pulses is a good

indicator of the adequacy of end-organ perfusion. The
pulse pressure (the difference between the systolic and
diastolic blood pressure) narrows as shock develops. Loss
of central pulses is an ominous sign.

 End-organ perfusion. The end-organ perfusion is most

evident in the skin, kidneys, and brain. Decreased
perfusion of the skin is an early sign of shock. A capillary
refill time of greater than 2 seconds is indicative of low
cardiac output. Impairment of brain perfusion is usually
evidenced by a change in mental status. The child may
become confused or lethargic. seizures may occur. Failure
of the child to recognize the parents' faces is often an
ominous sign. Urine output is directly related to kidney
perfusion. Normal urine output is 1-2 ml/kg/hr. urine flow of
less than 1 ml/kg/hr is an indicator of poor renal perfusion.
The rapid cardiopulmonary assessment should be repeated
throughout initial assessment

This will help you determine whether the patient's condition is

deteriorating or improving. any decompensation or change in the
patient's status should be immediately treated.
PEDIATRIC EMERGENCIES:
CARDIAC ARREST (medical)
GUIDELINES FOR CARE

1. Determine pulselessness and begin CPR.

2. Confirm cardiac rhythm in more than 1 lead.

3. If asystole:

a. Continue CPR

b. Secure airway

c. Hyperventilate with 100% oxygen

d. Obtain IV or IO access.

e. Epinephrine (first dose)

 IV or IO: 0.01 mg/kg of 1:10,000 solution.

 ET: 0.1 mg/kg of 1:1,000 solution.

f. Epinephrine (second and subsequent doses)

 IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution:

repeat every 3-5 minutes.
 g. Transport as soon as possible continuing resuscitation
en route.

4. If pulseless electrical activity:

a. Identify and treat causes including hypoxemia,

acidosis, hypovolemia, tension pneumothorax, cardiac
tamponade, or profound hypothermia.

b. Continue CPR.

c. Secure airway.

d. Hyperventilate with 100% oxygen.

e. obtain IV or IO access.

f. Epinephrine (first dose)

 IV or IO: 0.01 mg/kg of 1:10,000 solution.

 ET: 0.1 mg/kg of 1:1,000 solution.

g. Epinephrine (second and subsequent doses)

 IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution;

repeat every 3-5 minutes.

h. transport as soon as possible continuing resuscitation

en route.

5. if ventricular fibrillation/pulseless ventricular tachycardia:

 a. Continue CPR.

b. Secure airway.

c. Hyperventilate with 100% oxygen.

d. Obtain IV or IO access.

e. Defibrillate up to 3 times (2 j/kg, 4 j/kg, and 4 j/kg).

f. Epinephrine (first dose)

 IV or IO: 0.01 mg/kg of 1:10,000 solution.

 ET: 0.1 mg/kg of 1:1,000 solution

g. Lidocaine 1 mg/kg IV, IO, or ET.

h. Defibrillate at 4 j/kg 30-60 seconds after medication.

i. Epinephrine (second and subsequent doses)

 IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution;

repeat every 3-5 minutes.

j. Defibrillate at 4 j/kg 30-60 seconds after medication.

k. Lidocaine 1 mg/kg up to total dose of 3 mg/kg.

6. Contact medical control for any questions or problems.

PEDIATRIC EMERGENCIES
CARDIAC ARREST (trauma)
GUIDELINES FOR CARE

1. If patient is severely injured, and in cardiac arrest:

o Airway with cervical spine control.

o Breathing.

o Circulation/perfusion with hemorrhage control.

o Disability determination (AVPU, motor, posturing).

o Exposure

2. If extrication required, perform quickly with spinal

immobilization.

3. Perform endotracheal intubation with in-line stabilization of

cervical spine.

4. Admission immediately and attempt IV or IO en route. give

20 ml/kg fluid boluses of lactated Ringer's.

5. Contact medical control en route

6. Consider correctable causes:

o Severe hypoxemia
 o Cardiac tamponade

o Tension pneumothorax

o Severe acidosis

7. contact medical control for any questions or problems.

PEDIATRIC EMERGENCIES:
CROUP (LARYNGOTRACHEOBRONCHITIS)

GUIDELINES FOR CARE

1. Assure ABCs.

2. Administer humidified oxygen via non-rebreather mask.

3. Have equipment ready for endotracheal intubation.

4. Place in position of comfort.

5. Pulse oximetry and cardiac monitor.

6. Defer starting an IV if possible.

7. Contact medical control.

8. Consider Ventolin nebulizer or racemic Epinephrine

treatment as ordered by medical control.

9. Contact medical control for any questions or problems

10. Severe respiratory distress despite the above

measures requires intubation. Consider intubating with a
tube one full size smaller than would normally be used. use
an uncuffed tube.
 11. Consider inserting an NG tube for gastric
decompression if intubated.

12. If necessary, restrain the child to protect the ET tube.

Agitation may be treated with Valium 0.1 - 0.3 mg/kg IV
(with a maximum dose of 5.0 mg)

Do not examine pharynx as this may cause laryngospasm in

cases of epiglottitis.
PEDIATRICEMERGENCIES:EPIGLOTTITIS
GUIDELINES FOR CARE

1. Assure ABCs.
2. Administer humidified oxygen via non-rebreather mask
3. Have equipment ready for endotracheal intubation
4. Place in position of comfort
5. Pulse oximetry and cardiac monitor
6. Defer starting IV if possible
7. Contact medical control
8. Contact medical control for any questions or problems
9. Severe respiratory distress despite the above measures
requires intubation. Consider intubating with a tube one full
size smaller than would normally be used. use an uncuffed
tube.
10. Consider inserting an NG tube for gastric
decompression if intubated.
11. If necessary, restrain the child to protect the ET tube.
agitation may be treated with Valium 0.1 - 0.3 mg/kg IV
(with a maximum dose of 5.0 mg)

Do not examine pharynx as this may cause laryngospasm in

cases of epiglottitis.
PEDIATRIC EMERGENCIES:
SUDDEN INFANT DEATH SYNDROME
(SIDS)
GUIDELINES FOR CARE

1. Start CPR unless obvious rigor mortis, severe lividity, or

early tissue breakdown.

2. Note the condition of the child and the surroundings in

which the child was found.

3. Obtain a brief medical history from the parents or

guardians.

4. Use extreme tact and professionalism.

5. See Pediatric Cardiac Arrest (medical) Protocol.

6. Contact medical control en route.

7. contact medical control for any questions or problems.

POISONING / OVERDOSE
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via non-rebreather mask.

3. Obtain history:

o Type and amount of poison.

o How poisoned (ingested, inhaled, injected, surface

contamination.)

o Time poisoned.

o Has patient vomited? if so, when?

o History of drug or EtOH usage.

o Pre-existing medical problems.

4. Initiate IV lactated Ringer's TKO.

5. Attach cardiac monitor and pulse oximeter.

6. determine serum glucose level with Glucometer or

DextroStix.

o If glucose < 80 mg/dl, administer 25 gms 50%

dextrose IV.
 o If glucose > 80 mg/dl and < 250 mg/dl, go to step #7.

7. If inadequate air exchange:

o Initiate and maintain mechanical ventilation with 100%

oxygen.

o Treat any dysrhythmias per appropriate protocol.

o Transport and contact medical control en route.

8. If apneic:

o Initiate and maintain mechanical ventilation with 100%

oxygen.

o Endotracheal intubation.

o Treat any dysrhythmias per appropriate protocol.

o Transport and contact medical control en route.

9. If apneic and pulseless:

o Initiate and maintain mechanical ventilation with 100%

oxygen.

o CPR.

o Endotracheal intubation (with in-line cervical

immobilization.)
 o Treat any dysrhythmias per appropriate protocol.

o Transport and contact medical control en route.

10. If seizing:

o Go to Seizure Protocol.

11. If inhaled poison:

o Assure personal safety.

o Remove patient to fresh air.

o Administer 100% oxygen via non-rebreather mask.

12. If skin or eye contamination:

o Assure personal safety.

o Remove contaminated clothes.

o Irrigate with water or normal saline.

13. If blood pressure <90 mmhg, and/or if respirations <10

per minute, and/or possible narcotic overdose:

o Administer 100% oxygen via non-rebreather mask.

o Assist ventilations as needed

o Administer 1-2 mg Narcan IV push. may give IM or

endotracheally if unable to start IV.
14. If antidepressant OD (tricyclics):

o Contact medical control.

o Transport.

o Consider Sodium Bicarbonate.

15. if Benzodiazepine OD:

o Administer Flumazenil 0.3 mg IV over 30 seconds.

may repeat up to a total dose of 1.0 mg as needed.

16. Admission

17. Contact medical control for any questions or problems.

18. EMS units with cellular telephones may contact poison

control directly for any questions.

19. Consider administration of activated charcoal.

20. Do not induce emesis in any patient without express

orders from medical control.
PREECLAMPSIA - PREGNANCY INDUCED
HYPERTENSION
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via non-rebreather mask.

3. Secondary survey.

4. Establish IV of lactated Ringer's at 125 ml/hr.

5. monitor ECG, vital signs, fetal heart tones, level of

consciousness, patellar reflexes, respiratory rate,
oxygenation status every 5 minutes. If patellar reflexes are
absent, shut off the infusion and contact medical control
immediately.

6. Keep the patient in left lateral recumbent position.

7. Contact medical control for antihypertensive agent orders.

8. Monitor urinary output if possible

9. Evaluate for pulmonary edema. If present, consider

Morphine 2-5 mg IVP over 1-2 minutes and/or Furosemide
20-40 mg IVP over 2-3 minutes.
10. Consider magnesium sulfate if ordered by medical
control. Begin with a loading dose of 4 - 6 grams of
magnesium sulfate (8 ml of 50% solution) in 100 ml of LR
over 30 minutes. After loading dose, start magnesium
sulfate infusion. Place 10 grams of magnesium sulfate (20
ml of 50% solution) in 250 ml of LR and infuse at 50 ml/hr
(2 grams/hr). Remember, magnesium sulfate can cause
respiratory depression with cardiovascular collapse.
antidote is calcium chloride IV over 5 minutes.

11. Place NG tube if appropriate.

12. Contact medical control for any questions or problems.

PRE-TERM LABOR
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via non-rebreather mask.

3. Secondary survey.

4. Establish IV of lactated Ringer's at 125 ml/hr.

5. Consider fluid bolus as initial tocolytic therapy.

6. Position the patient in the left lateral recumbent position.

7. Record frequency, character and duration of contractions,

fetal heart tones, blood pressure, and pulse every 15
minutes.

8. Administer tocolytics as ordered.

9. Admission
PSYCHIATRIC EMERGENCIES
GUIDELINES FOR CARE

1. Assure personal safety. Call police.

2. Approach patient only when safe to do so.

3. Talk in an even, reassuring tone.

4. Restrain if suicidal or homicidal or if patient has a life-

threatening emergency (with police assistance only.)

5. Perform primary assessment

6. Perform secondary assessment:

o Look for medical or traumatic causes for the patient's

behavior.

o Note behavior.

o Note mental status.

o Obtain drug/alcohol/medical history/psychiatric history.

7. Administer oxygen at 6-10 lpm (if COPD, give 2 lpm via

nasal cannula.

8. IV lactated Ringer's TKO.

9. Determine serum glucose level with Glucometer or
DextroStix.

o if glucose < 80 mg/dl, administer 25 gms 50%

dextrose IV.

o if glucose > 80 mg/dl and < 250 mg/dl, go to step #10.

10. If history of alcoholism, or alcoholism suspected:

o administer Thiamine 100 mg IV or IM.

11. Admission

12. Consider Haldol 2-5 mg IM for sedation.

13. Contact medical control for any problems or questions.

PULMONARY EMBOLISM
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via non-rebreather mask if no history of COPD. if

history of COPD, titrate oxygen delivery to maintain SPO2
> 90%. consider intubation and hyperventilation with 100%
oxygen for markedly decreased LOC, inability to maintain a
patient airway, or for GCS * 8.

3. Initiate IV lactated Ringer's TKO.

4. Attach cardiac monitor and pulse oximeter.

5. If signs of severe hypoventilation:

o Assist ventilations with BVM with 100% oxygen.

o Consider endotracheal intubation

o Contact medical control

6. If history suspicious for pulmonary embolism:

o Place in position of comfort (preferably with

extremities lower than level of heart)
 o Consider Morphine 2-5 mg IVP for pain. may repeat to
a maximum of 10 mg.

o Consider Valium 2-5 mg IVP for anxiety

o Admission .

7. Contact medical control for any questions or problems.

SEIZURES
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via non-rebreather mask.

3. Initiate IV lactated Ringer's TKO.

4. If actively seizing, go to #7 below:

5. If not actively seizing:

a. Open airway and suction PRN.

b. Proceed with secondary survey.

c. Obtain history.

d. Apply cardiac monitor and pulse oximeter.

6. Determine serum glucose level with Glucometer or

DextroStix.

o If glucose < 80 mg/dl, administer 25 gms 50%

Dextrose IV.

If actively seizing:

. Protect patient from injury.

 a. Do not attempt to insert tongue blade or oral airway.

b. Suction prn.

c. Nasopharyngeal airway may be useful.

if seizures prolonged (>5 minutes):

. Draw blood tube, if possible.

a. Administer Valium 2-5 mg IV (adults.)

b. Determine serum glucose level. if glucose < 80 mg/dl,

administer 25 gms 50% dextrose IV.

c. contact medical control en route.

If recent seizure, and patient is post-ictal:

. Place in recovery position.

a. Suction prn.

b. Transport.

If patient is a child, and actively seizing:

. Protect patient from injury.

a. Contact medical control.

b. Consider Valium as ordered by medical control.

c. Contact medical control for any questions or problems.

SEXUAL ASSAULT
GUIDELINES FOR CARE

1. Assure ABCs.

2. Reassure patient and provide emotional support.

3. Perform secondary survey.

4. Treat all injuries appropriately, preferably with a relative

present.

5. Protect the scene and preserve evidence. Do not allow the

patient to bathe, change clothes, go to the bathroom, or
douche.

6. Notify police if not already informed.

7. Contact medical control for any questions or problems.

SNAKEBITE
GUIDELINES FOR CARE

1. Kill the snake, if practical, and bring the dead snake to the
emergency department (or identify). Do not mutilate the
snake's head.

2. Assure ABCs.

3. Administer oxygen via non-rebreather mask.

4. If bite on extremity, immobilize affected extremity in

dependent position. Patient should remain still. Place 1"
wide venous constricting band proximal to bite. Check for
arterial pulses before and after application. if no pulse,
loosen band until pulse returns.

5. Remove watches, rings, and jewelry from affected

extremity.

6. If signs of toxicity (local edema and hypotension):

o increase oxygen delivery to 100% via non-rebreather

mask

o start IV lactated Ringer's at 150 ml/hour (wide open if

signs of shock)
 7. Contact medical control.

8. Reassure and admission

9. Contact medical control for any questions or problems.

General Information:
Pit Vipers: rattlesnake, water moccasin, and copperhead
typically cause puncture wounds. There may be ecchymosis at
site, localized pain, swelling, weakness, tachycardia, nausea,
shortness of breath, dim vision, vomiting, or shock.
Coral Snakes: Usually chewed wound. There may be slight
burning pain, mild swelling, blurred vision, drooping eyelids,
slurred speech, drowsiness, salivation and sweating, nausea
and vomiting, shock, respiratory difficulty, paralysis, convulsions,
and coma.
SYNCOPE
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via non-rebreather mask.

3. Initiate IV of lactated Ringer's.

4. Cardiac monitor. If dysrhythmia, go to appropriate protocol.

5. Obtain vital signs. if BP <90 mmhg systolic:

a. Elevate legs.

b. Recheck blood pressure.

c. If still hypotensive, give 250 ml fluid bolus (20 ml/kg for

children)

6. Pulse oximetry.

7. Obtain pertinent history:

o Time of syncopal episode and length of

unconsciousness.

o Patient's position at time of syncope.

 o Symptoms preceding event (dizziness, nausea, chest
pain, headache, seizures, etc.)

o Medications / EtOH / drug usage.

o Relevant past medical history.

8.Determine serum glucose level with Glucometer

o If glucose < 80 mg/dl, administer 25 gms 50%

dextrose IV>

o If glucose > 80 mg/dl and < 250 mg/dl, go to step #9.

9.Place in recovery position.

10.Prepare to suction and manage airway.

11.Repeat vital signs frequently. watch for hypertension.

12.Contact medical control for any questions or problems.

WEAK AND DIZZY
GUIDELINES FOR CARE

1. Assure ABCs.

2. Oxygen via non-rebreather mask.

3. Attach cardiac monitor and pulse oximeter.

4. Initiate IV of lactated Ringer's at 125 ml/hr. Give 250 ml

fluid bolus if systolic pressure < 90 mmhg (20 ml/kg for
children).

5. Be alert for dysrhythmias.

6. Provide appropriate comfort measures (i.e cool cloth to

forehead).

7. If patient nauseated or has recently vomited, administer

Phenergan 12.5 - 25.0 mg IVP or IM. Do not repeat more
frequently than every 4 hours unless ordered by medical
control.

8. If patient complains of dizziness or motion sickness,

consider administering 25 - 50 mg of Dimenhydrinate
(Dramamine) IVP over 30 seconds.
9. Monitor ECG, vital signs, pulse oximetry, and level of
consciousness.

10. Contact medical control for any problems.

9. If, after 1-2 minutes, no response noted, administer

Adenosine 12 mg IV push over 1-3 seconds in medication
port nearest patient.

10. Consider synchronized cardioversion, especially if vital

signs deteriorating. if time permits, premedicate with Valium
2-5 mg IVP, Versed 1-2 mg IVP, or Morphine 2-5 mg IVP.2

11. If rhythm is atrial fibrillation or atrial flutter with rapid

ventricular response, consider Diltiazem 20 mg slow IVP
(over 2 minutes)