Protocols

Protocol 100: Medication Administration

1. FIRST, DO NO HARM:   Medication errors are the most common AVOIDABLE error that causes patients direct harm.  When in doubt, contact ON DUTY MEDICAL CONTROL for any questions concerning dosage.

2.  VERIFY “5 RIGHTS”:

• right patient
• right drug
• right dose
• right route (IV, IO, IM, SC, etc)
• right time (including rate of administration)

3.  DOCUMENTATION: document accurately all medications administered, any reaction to medication, repeat vital signs after administration, and any adverse events.

4. MEDICATION ERRORS: Any error in medication administration should be documented and reported immediately through the CQI process to the Medical Director / Liaison for review.  The goal of CQI review is to determine and minimize systemic contributions to causality of errors, not to take punitive action.

5.  PEDIATRICS:  Errors in pediatric medication dosing occur more often due to poor estimates of weight or infrequent use of pediatric doses.  Every effort must be made to obtain accurate weight estimates, accurate calculation of dose, and appropriate monitoring of patient response.  When in doubt, contact MEDICAL CONTROL for verification of dosage.  Standardized tools to determine dosing in critical situations, such as a ‘pedi-wheel’ or Broslow tape, are encouraged.

               *****When calculating pediatric doses, NEVER ROUND UP*****

Protocol 101:  IV Fluid Administration

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION: Isotonic crystalloids provide volume replacement to maintain blood pressure and perfusion.  The mechanism in trauma is far more complex, as aggressive fluid replacement often worsens blood loss and hypothermia.

INDICATIONS:  dehydration, syncope, sepsis, medication administration, right-sided myocardial infarction, undifferentiated cardiac arrest

CONTRAINDICATIONS: While small amounts of fluid may be used, large volume fluid administration should be avoided in acute CHF, major trauma, or dialysis patients.  Hyperkalemia is a relative contraindication for Lactated Ringers (LR), as there is a small amount of potassium in LR.  If there are signs of hyperkalemia on EKG, LR should not be used.

PRINCIPLES OF ADMINISTRATION:

1.       LR is the preferred volume replacement fluid for most situations. This is especially true for trauma and sepsis.

2.       Normal Saline, 0.9% NaCl, should be limited to use for mixing and administration of medications.

3.       In major trauma, limit fluid resuscitation to those indications noted in trauma protocols.

4.       Doses of fluids are specific to the medical/trauma indication, and the specific protocol should be referenced for amounts of fluid administration.

5.       D10% use is addressed specifically under dextrose protocol and hypoglycemia.

6.       D5%W may be utilized and transported by both AEMT and Paramedics under this protocol.

7.       This protocol applies to all 911 and Interfacility Transfers for both AEMT and Paramedics.

CONSIDERATIONS:

• If supply chain limitations prohibit the use of LR, normal saline may be substituted until such time that LR is available.
• This protocol is specific to 911 calls, as interfacility transports may require patient-specific orders from the sending provider.  

Protocol 102: Adenosine (Adenocard)

SCOPE:  Paramedic only

MECHANISM OF ACTION: temporary blockage of electrical conduction through the AV node in order to stop reentrant tachycardias involving the AV node  (AVNRT, PSVT).

ONSET: 1 second

DURATION: 10 seconds

INDICATIONS: NARROW-complex supraventricular tachyarrhythmia CONFIRMED on 12 LEAD EKG

CONTRAINDICATIONS: Irregular tachyarrhythmia (Atrial fibrillation with RVR), wide-complex tachycardia, heart transplant, heart blocks

ADVERSE REACTIONS: chest pain, dyspnea (asthmatics), diaphoresis, palpitations, syncope

DRUG-DRUG INTERACTIONS:

• large amounts of caffeine hinder effect of adenosine, contact MEDICAL CONTROL for higher dose
• Dipyridamole (Persantine) enhances effect of adenosine, requiring REDUCED DOSE (typically 6mg). This medication is a platelet inhibitor, commonly prescribed to people who have artificial HEART VALVE replacement surgery.
• Carbamazepine (Tegretol) enhances effect of adenosine, prolonging AV node blockage.  Consider REDUCED DOSE (typically 6mg)

DOSAGE:

ADULT:  -12 mg IV bolus **RAPID** IV PUSH WITH RAPID 10 cc SALINE FLUSH

• Repeat dose of 12 mg if no conversion
• Contact MEDICAL CONTROL for further direction after second dose

PEDIATRIC:  MEDICAL CONTROL APPROVAL is required for pediatric administration.

• Most children with SVT / AVNRT who are stable remain so and should be transported without medication / intervention.
• DOSE is 0.1mg/kg (max 6 mg initial dose), same **RAPID** administration as adults
• Repeat dose is 0.2mg/kg (max 12 mg)

CONSIDERATIONS:

• 12 LEAD should be printed before and after administration, with minimum of continuous 3 Lead documenting time of administration and response
• transient asystole or AV block should be expected right after administration
• for patients with unusual or atypical cardiac history (eg history of ablation, heart transplant) consider contacting MEDICAL CONTROL early for guidance and recommendations

Protocol 103: Albuterol Sulfate

SCOPE:  EMT-Basic, AEMT, Paramedic

MECHANISM OF ACTION: Selective Beta-2 adrenergic agonist, resulting in potent bronchodilation of bronchi and alveoli.

ONSET: 5 – 10 minutes after inhalation

DURATION: 3-4 hours, though positive effects may decrease within the first hour, requiring additional doses

INDICATIONS: acute bronchospasm (may be intrinsic asthma or allergic etiology)

CONTRAINDICATIONS: Age > 60 with Severe tachycardia (>200), or concern for Acute MI

ADVERSE REACTIONS: tachycardia, palpitations, dysrhythmias (rare), hypokalemia, chest pain, may lower seizure threshhold

DRUG-DRUG INTERACTIONS:

• Beta-Blockers may decrease effectiveness of albuterol
• Sympathomimetics (eg pseudophedrine) may exacerbate adverse reactions

DOSAGE:

ADULT:  OPTION 1 prescribed Metered Dose Inhaler        

• Assist patient with inhalation of two 90mcg/spray (two ‘puffs’) every 10-15 minutes to a maximum of 6 puffs in 30 minutes

OPTION 2 Nebulized 2.5mg / 3ml saline

• Administer by nebulizer mask with minimum oxygen flow rate of 8 lpm.
• 3 total doses
• In severe asthma, all 3 doses may be used together as a continuous nebulizer
• Waveform capnography should be monitored for effect with continuous nebs

PEDIATRIC:       (age > 1 year, or weight > 10 kg)

OPTION 1 prescribed Metered Dose Inhaler

• Assist patient with inhalation of two 90mcg/spray (two ‘puffs’) every 15-20 minutes to a maximum of 6 puffs in 45 minutes

OPTION 2 Nebulized 2.5mg / 3ml saline

• Administer by nebulizer mask with minimum oxygen flow rate of 8 lpm.
• 3 total doses
• Continuous nebulizer requires MEDICAL CONTROL approval

CONSIDERATIONS:

• Whenever possible, waveform capnography should be utilized to monitor degree of bronchospasm, CO2 retention and response to medication.
• EMT-Advanced and above should strongly consider concomitant use of Atrovent (Ipratropium) with initial nebulizer when indicated
• If patient presents with concern for hyperkalemia, contact MEDICAL CONTROL for authorization to use albuterol in these instances
• Albuterol is not the first line agent for anaphylactoid respiratory distress.  Refer to epinephrine protocol first.

In line nebulizers may be used by EMT-Paramedics for field-intubated patients, with waveform capnography.

Protocol 104: Amiodarone

SCOPE: AEMT, Paramedic

MECHANISM OF ACTION: Increases the refractory period of cardiac myocytes, prolongs Phase 3 repolarization by blocking potassium channels, decreases automaticity of ventricular and Purkinje fibers, prolongs AV conduction.

ONSET: 2-3 Minutes

DURATION: 1 to 3 hours (variable absorption and elimination makes this highly variable)

INDICATION:

AEMT: Pulseless arrest with shock-refractory or recurrent VT/VF

Paramedic Only: stable (not hypotensive), regular wide complex tachycardia

Paramedic Only: Narrow complex tachycardia, refractory to Adenosine

CONTRAINDICATIONS:  A-V Heart blocks, cardiogenic shock, irregular wide complex tachycardia (obtain 12 Lead and contact MEDICAL CONTROL for consideration)

• do not use to treat PVCs, couplets or IVR rhythms

ADVERSE REACTIONS: hypotension, bradycardia

DRUG-DRUG INTERACTIONS:

• beta-blockers and calcium channel blockers may produce bradycardias or AV blocks,
• quinidine and propafenone (Rhythmol) may cause Torsades de pointes

DOSAGE:

ADULT:

AEMT: Pulseless VT / VF:  300mg IV bolus

• May administer ONE Additional 150mg IV bolus in 3-5 minutes if shock refractory or recurrent VF/VT

Paramedic Only: Stable (not hypotensive), regular wide complex tachycardia

• Obtain 12 lead first
• Contact MEDICAL CONTROL, if approved: 150mg IV bolus infusion over 10 minutes in 50 ml D5W/NS

Paramedic Only: Irregular wide complex tachycardia, Narrow complex tachycardia refractory to Adenosine, or Atrial Fibrillation with RVR

• Obtain 12 lead first
• Contact MEDICAL CONTROL, if approved: 150mg IV bolus infusion over 10 minutes in 50 ml D5W/NS

PEDIATRIC:

AEMT: Pulseless VT / VF:

• 5mg/kg IV bolus
• Additional doses require MEDICAL CONTROL approval

CONSIDERATIONS:  Obtain 12 lead before and after administration in non-arrest patients.

Protocol 105: Aspirin

SCOPE:  EMT-Basic, AEMT, Paramedic

MECHANISM OF ACTION: Inhibits platelet aggregation by blocking formation of thromboxane A-2

ONSET:  Approximately 20 minutes

DURATION:  Up to 96 hours

INDICATION:  suspected Acute Myocardial Infarction or chest pain

CONTRAINDICATIONS: ACTIVE GI Bleeds, blood clot disorder, known aspirin sensitivity, pregnancy, children under age 2

ADVERSE REACTIONS: nausea, vomiting, heartburn, stomach pain, allergic reactions, tinnitus, bronchospasm

DRUG-DRUG INTERACTIONS: Interactions with other blood thinners SHOULD NOT interfere with the administration of Aspirin in a suspected Acute Coronary Syndrome

DOSAGE:  324mg PO, usually given as four 81mg chewable tablets

CONSIDERATIONS:

• Unless the patient has an active GI bleed or known sensitivity to aspirin, give to all suspected myocardial infarctions without delay.
• If patient has already taken 81mg ‘baby’ aspirin, personnel may administer the remaining 243mg
• If patient is uncertain if they have taken any aspirin in the past 24 hours, give the full 324mg

For young children age 2 to 12, chest pain is rarely caused by a myocardial infarction. Consider contacting MEDICAL CONTROL before administering to young children for chest pain.

Protocol 106: Atropine Sulfate

SCOPE:  Paramedic Only

MECHANISM OF ACTION: Parasympatholytic blockage of vagus nerve tone to SA and AV nodes, resulting in increase heart rate.  As the Vagus nerve normally inhibits the heart rate from going too fast, removing this inhibition may increase heart rate SO LONG AS the SA-AV-Purkinje system is functioning normally (i.e. there are no AV blocks).  A secondary mechanism is seen with organophosphate poisoning, where atropine binds to acetylcholine receptors to decrease the effects of the excess acetylcholine caused by the poison.

ONSET:  1 minute

DURATION:  30-60 minutes (may last up to 3 hours in elderly patients)

INDICATION: Symptomatic bradycardia, heart blocks, organophosphate poisoning,

*** Epinephrine is First-Line medication for pediatric symptomatic bradycardia, Atropine is Second-Line.

CONTRAINDICATIONS:  STABLE bradycardia

Atropine is NO LONGER INDICATED in PALS for pediatric cardiac arrest: See Epinephrine Protocol.

ADVERSE REACTIONS: agitation, confusion, blurred vision, pupil dilation, tachycardia, flushed skin, arrhythmias, dry mouth, worsening myocardial infarction

DRUG-DRUG INTERACTIONS:

• sympathomimetics may potentiate tachycardia
• in emergent situations, there are no acute interactions that would alter the decision to administer atropine

DOSAGE:

ADULT BRADYCARDIA: 0.5mg IV/IO bolus.

• Repeat at 3-5 minute intervals to a maximum dose of 3mg, or until effective to achieve improved cardiac output (improved blood pressure and mentation)

PEDIATRIC BRADYCARDIA: SECOND LINE MEDICATION, after use of EPINEPHRINE

• 0.02mg/kg (minimum 0.1mg) IV/IO bolus.
• Maximum single dose of 0.5mg.
• May give up to 1mg in adolescent if weight > 50kg.
• Contact MEDICAL CONTROL for repeat doses.

ORGANOPHOSPHATE POISONING: CONTACT MEDICAL CONTROL for orders.  For adults, dosing regimen usually requires repeat doses of 2mg IV/IM every 10-15 min for moderate-to-severe toxicity that demonstrates respiratory compromise.

CONSIDERATIONS:

• Atropine should NOT be first-line medication in pediatric situations, consider epinephrine first.

• Dosing regimens to effectively treat organophosphate poisoning are often greater than the amount carried on an ambulance.  Ensure effective decontamination of any substance on the patient by the appropriate hazmat-trained personnel before transport, then ensure rapid transport and early MEDICAL CONTROL notification.

Protocol 107:  Atrovent (Ipratropium Bromide)

SCOPE:  EMT-Basic, AEMT, Paramedic

MECHANISM OF ACTION: Parasympatholytic blockage of vagus nerve tone to mainstem bronchi and bronchiolar airways.    When overstimulated by allergic or asthmatic reaction, vagal tone will result in cholinergic ‘flooding’ or excess acetylcholine production, which results in excess bronchiolar secretions, swelling and constriction.  By blocking the vagal tone to the lungs, Atrovent limits further ‘flooding’ of the airways.  It does NOT actively dilate the bronchi or alveoli, and therefore is only a ‘helper’ drug that should always be used in conjunction with Albuterol.

ONSET:  5 to 15 minutes.

DURATION:  6 to 8 hours (and therefore should only be given once with initial albuterol administration).

INDICATION: bronchospasm

CONTRAINDICATIONS: Peanut allergy, unless using nebulizer solution that does not have peanut allergen.

ADVERSE REACTIONS: Palpitations, tremors, dry mouth, tachycardia

DRUG-DRUG INTERACTIONS: sympathomimetics will further potentiate tachycardia

DOSAGE:  ADULT: 0.5mg in 2.5ml NS Nebulized  WITH ALBUTEROL

PEDIATRIC:

• 2-12 years: same as adult dose
• 1-2 years: 0.25mg in 2.5ml NS Nebulized WITH ALBUTEROL

CONSIDERATIONS:

• This medication is not indicated for repeat doses.
• This is only a ‘helper’ medication, and should always be given with Albuterol

Protocol 108:  Calcium Chloride 10%

SCOPE:  Paramedic Only

MECHANISM OF ACTION: In the cardiac myocyte, both beta blocker overdoses and hyperkalemia inactivate the critical sodium channels that are so important for the initial rush of sodium that causes depolarization of the cell, thereby leading to an action potential of electrical activity. Calcium is able to bypass the sodium channel and enhance depolarization of the cells by enhancing conduction through the L-type calcium channels.  In calcium channel blocker overdoses, the increase in quantity of calcium increases the direct competitive availability of calcium in the cardiac myocyte.

ONSET:  2-5 minutes

DURATION:   30-60 minutes

INDICATION: Calcium-channel blocker overdose, beta blocker overdose, cardiac arrest associated with hypocalcemia or hyperkalemia (such as patients with end-stage renal disease)

CONTRAINDICATIONS: known hypercalcemia, digoxin toxicity, hypercalcemia

ADVERSE REACTIONS: Extravasation causes tissue necrosis, rapid administration in patients with pulses can produce a slowing of cardiac rate

DRUG-DRUG INTERACTIONS: Must be given in a separate line from IV sodium bicarbonate to prevent formation of calcium carbonate in IV line.

In presence of digitalis, may worsen cardiac output.

DOSAGE:   ADULT: Not given routinely for pulseless arrest

• Pulseless arrest due to hyperkalemia, ADULT:  1gm slow IV push (over 2 minutes)
• Calcium channel blocker / beta blocker overdose:  Contact MEDICAL CONTROL for approval
• Adult: 1gm slow IV/IO push, may repeat every 10 minutes for total of 3 doses

PEDIATRIC: 20mg/kg, max of 1gm slow IV/IO push (over 2 minutes) , may repeat every 10 minutes for a total of 3 doses

CONSIDERATIONS:

• Calcium GLUCONATE has similar actions but different dosages.  If the ambulance service moves to purchase of Calcium GLUCONATE, this protocol does not establish dosing for that medication.
• Refer to IFT Calcium protocol for additional uses of this medication during interfacility transfers.
• Calcium chloride should NOT be used routinely in all cardiac arrests, only in those where specific indications are suspected.

Protocol 109: Dextrose / Oral Glucose

SCOPE:  EMT-Basic, AEMT, Paramedic

MECHANISM OF ACTION: Delivers immediate bolus of glucose for cellular metabolism, resulting in near-immediate improvement of brain function and level of consciousness for hypoglycemic patients.

ONSET:  30 seconds

DURATION: 5-45 minutes, depending on underlying cause of hypoglycemia

INDICATION: hypoglycemia; unconscious patient with unknown etiology (if finger stick glucose unavailable or glucose monitor error)

CONTRAINDICATIONS:  Hyperglycemia

ADVERSE REACTIONS: Requires a patent IV when given intravenously; extravasation leads to necrosis

DRUG-DRUG INTERACTIONS: none in the emergent hypoglycemia setting

DOSAGE:

EMT-Basic: If patient able to follow commands, give oral glucose (Glutose, 15gm oral solution)

AEMT and Paramedic:

• ADULT:  25gm IV/IO infusion
• may be given as 50 mL of a D50% solution (ampule) or 250ml of D10% solution
• PEDIATRIC: 5mL/kg of D10% solution (max of 250mL)

CONSIDERATIONS:

• attempt to draw finger stick glucose prior to administration whenever possible.
• Flush IV after use: glucose is a high irritant to veins
• May be given IO with a flush

Protocol 110: Diphenhydramine (Benadryl)

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION: Antihistamine used to block histamine-mediated symptoms of allergic reaction.

ONSET:  5 minutes when given intravenously; 15-30 minutes when given IM

DURATION:  3-4 hours for maximum effect, though may remain for up to 12 hours

INDICATION:  allergic reaction

CONTRAINDICATIONS: acute asthma, narrow-angle glaucoma, patients taking MAO Inhibitors

ADVERSE REACTIONS: flushing, tachycardia, dilated pupils, lethargy, dry mouth, urinary retention

DRUG-DRUG INTERACTIONS:

• CNS depressants and alcohol can potentiate lethargy
• MAO Inhibitors will worsen anticholinergic effects

DOSAGE:

ADULT:  50mg IV/IO/IM

PEDIATRIC:  1mg/kg slowly over 1-2 minutes IV/IO/IM (max of 50mg)

CONSIDERATIONS:

Benadryl is sometimes used for extrapyramidal or dystonic side effects of other medications. It is sometimes combined with other medications for sedative effect.  These uses require an order from MEDICAL CONTROL, and are not routinely anticipated for this medication

Protocol 111: Epinephrine

SCOPE:  EMT-Basic (allergic reaction only), AEMT, Paramedic

MECHANISM OF ACTION: Epinephrine is a catecholamine that agonizes alpha, beta-1 and beta-2 receptors, causing potent vasoconstriction, elevated heart rate, myocardial contractility and bronchodilation.

ONSET:  1 minute  (IV) 10-30 minutes (IM or SC)

DURATION:    5-10 minutes (IV)   30-45 min (IM or SC)

INDICATION:   pulseless arrest, anaphylaxis, asthma, pediatric symptomatic bradycardia

CONTRAINDICATIONS:  pulseless arrest doses (1mg) of epinephrine should not be given by IV to a patient with a pulse

ADVERSE REACTIONS: tachycardia, anxiety, angina, myocardial infarction, arrhythmias

DRUG-DRUG INTERACTIONS: None in the emergent setting; Epinephrine should not be given with sodium bicarbonate at the same time as the sodium bicarbonate will inactivate the epinephrine.

DOSAGE:

ADULT: 

1. (AEMT,Paramedic) Pulseless arrest:  1mg (generally 10ml of a 1:10,000 syringe) IV/IO bolus
   1. May repeat every 3-5 minutes.  In general, should not exceed a MAXIMUM of 3 doses before contacting MEDICAL CONTROL. Contact MEDICAL CONTROL for additional doses if patient demonstrates recurrent arrest after ROSC.
2. Adult Wheezing/asthma/allergic reaction: 0.3mg (1:1000) IM.
   1. May repeat x 1 after 15 minutes

PEDIATRIC:

1. (AEMT, Paramedic) Pulseless arrest:  0.01mg/kg IV/IO (0.1ml/kg of 1:10,000 solution)
   1. May repeat every 3-5 minutes to a MAXIMUM of 3 doses.   In general, should not exceed a MAXIMUM of 3 doses before contacting MEDICAL CONTROL. Contact MEDICAL CONTROL for additional doses if patient demonstrates recurrent arrest after ROSC.
2. (Paramedic Only) Symptomatic Bradycardia:  Contact MEDICAL CONTROL for authorization.
   1. -0.01mg/kg (0.1ml/kg of 1:10,000 solution)  IV/IO
3. Pediatric Wheezing/asthma/allergic reaction: 0.01mg/kg (1:1000 solution) IM (Maximum dose of 0.3mg).
   1. May repeat x 1 after 15 minutes.

             

               PUSH-DOSE and “Dirty Epi Drip” Alternatives (Paramedic Only):

Shock with Cardiovascular Collapse: “Dirty Epi Drip” 1mg in 1000ml LR or NS (or 0.5mg in 500ml LR/NS) run wide open and titrate to effect.

Refractory Hypotension: as an alternative to the “Dirty Epi Drip”, dilute 1mg in 250ml or 2 mg in 500ml to create a 4mcg/ml concentration.  Start infusion at 1 mcg/min (0.25ml/min) and double every 3-5 minutes, titrating to effect or maximum dose of 32mcg/min.

Push-Dose Epinephrine: as an alternative to IV drips, Push-Dose epinephrine can be invaluable, especially if needed as a ‘just in case’ option for intermittent hypotension during times patient is being off-loaded at destination facility.  Mix 1 ml of 1:10,000 Epinephrine (aka “Code Epi”), in 9ml of saline.  This creates a 10ml syringe with 100mcg (10mcg/ml).  Administer 2-3ml (20-30mcg) every 2-5 minutes as needed to maintain hemodynamic status.

CONSIDERATIONS:

• It is extremely important to know precise dosing of both 1:10,000 and 1:1,000 preparations, particularly for pediatric patients.
• There are additional uses of epinephrine that MEDICAL CONTROL may authorize under rare circumstances, racemic epinephrine substitute, or more frequent dosing for severe anaphylaxis or adult bradycardia.
• Various combinations of drug and fluid amounts may be safely used for epinephrine drips.  The 1mg/1000ml “Dirty Epi” drip ensures a ‘wide open’ flow rate would not exceed maximum safe dosage administration.  Pressure infusion bags may NOT be used with this option.  The 4mcg/ml concentration mix provides for ease of ‘doubling’ the dose to achieve desired effect safely, with fewest intervals between increased doses.
• Tachyphylaxis is a condition where, due to the patient’s ultimate neurologic and cardiovascular collapse, the body requires higher and higher doses of epinephrine each time it is administered to achieve the same hemodynamic effect.  While not specific, it indicates a poor prognosis. When noted, this information should be provided to receiving facility of the need for increasingly higher doses.

Protocol 112: Glucagon

SCOPE:  EMT-Basic, AEMT, Paramedic

MECHANISM OF ACTION: Converts stored glycogen in the liver into available sugar in the blood.  Relies heavily on patient’s liver having ample storage of glycogen.

ONSET:  Highly variable, 5 – 30 minutes

DURATION:  Highly variable depending on patient’s available liver stores of glycogen, typically 15-30 minutes

INDICATION: Hypoglycemia with altered level of consciousness, when IV access is unavailable or anticipated to be significantly delayed

CONTRAINDICATIONS: Hyperglycemia, alert mental status (give oral glucose instead)

ADVERSE REACTIONS: tachycardia, headache, nausea and vomiting

DRUG-DRUG INTERACTIONS: None in the emergent setting

DOSAGE:

ADULT:  1mg IM

PEDIATRIC: 0.5mg IM if weight < 25kg

• 1mg IM if weight > 25kg  

CONSIDERATIONS:

• This medication may be utilized for suspected beta blocker or calcium channel blocker overdoses.  Contact MEDICAL CONTROL for authorization and dosing regimen.
• This medication is a ‘bridge’ medication, and is designed for TEMPORARY increase in blood glucose, which buys time to give the patient a more definitive treatment such as oral glucose, IV dextrose, or other more significant sustenance.  This medication is not long-acting enough to allow for a Refusal or AMA release.  As such, it is highly recommended this medication be administered while preparing the patient for transport.

Protocol 113: Ondansetron

SCOPE:  EMT-Basic, AEMT, Paramedic Only

MECHANISM OF ACTION: Selective serotonin 5-HT3 receptor antagonist that results in decreased emesis.

ONSET:  1-2 minutes, peak effect in 10 minutes

DURATION: 4 hours

INDICATION:  nausea and/or vomiting

CONTRAINDICATIONS: History of prolonged QT Interval

ADVERSE REACTIONS: prolonged QT interval

DRUG-DRUG INTERACTIONS: May interact with Haldol and other antipsychotic medications to prolong QT interval with fewer doses.

DOSAGE:

ADULT:  

EMT-Basic: 4mg ODT PO, for ONE dose only

AEMT/Paramedic: 4mg IV/IM

• May repeat x 1 (total of 8mg) if patient is not on any other antiemetic/antipsychotic medication

PEDIATRIC > 1 year of age: Not approved for EMT-Basic

AEMT/Paramedic: 0.15mg/kg (max of 4mg) IV/IM/PO/ODT for one dose only

CONSIDERATIONS:

• In first trimester pregnancy, this medication should be used with caution, limited to one dose, and limited to use for patients with severe, intractable vomiting

Protocol 114: Phenergan

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION: Anticholinergic central and peripheral H-1 type histamine antagonist that results in antiemetic and sedative effects.

ONSET:  20-30 minutes (IM)

DURATION: 4-6 hours, though effects may persist up to 10-12 hours

INDICATION:  Nausea and vomiting refractory to Zofran; second line agent behind Zofran; may only give first line if patient has Zofran allergy or ordered by MEDICAL CONTROL

CONTRAINDICATIONS: pediatric patients (under age 12 or less than 50kg); patients with altered mental status

ADVERSE REACTIONS: hypotension, CNS depression, confusion/altered mentation, extrapyramidal symptoms, urinary retention, agitation

DRUG-DRUG INTERACTIONS: Do not mix with other CNS depressants or anti-psychotics

DOSAGE:  ADULT:  12.5mg IM only

CONSIDERATIONS:

• Drowsiness is very common, and will worsen any underlying lethargy, avoid in patients that appear altered, intoxicated, or lethargic
• Consider half dose of 6.25mg for elderly (> age 65) patients
• avoid use in pregnant patients
• Anticipate rare occurrence of dystonia and akathisia, contact MEDICAL CONTROL for consideration of treatment with benadryl

Protocol 115: Narcotic Analgesia (Fentanyl, Morphine, Dilaudid)

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION: Opioids target pain receptor sites, most significantly the Mu receptors in the brain and spinal cord, resulting in significant analgesia, euphoria and sedation.  These also significantly increase the frequency AND severity of respiratory depression and hypotension.  Morphine causes significant peripheral histamine-mediated vasodilation, increasing risk of hypotension.

ONSET:  1-2 minutes (IV)

DURATION:  Fentanyl 30-60 minutes (IV), Dilaudid 1-2 hours (IV), Morphine 3-4 hours (IV)

INDICATION:

• FENTANYL and DILAUDID: Moderate to severe pain due to trauma or medical conditions.
• MORPHINE: Acute Congestive Heart Failure

CONTRAINDICATIONS: Hypotension, shock or respiratory depression

ADVERSE REACTIONS: Chest wall rigidity (fentanyl), respiratory depression and/or arrest, nausea/vomiting

DRUG-DRUG INTERACTIONS:

• Adding an opioid to a benzodiazepine has a compounding effect that greatly magnifies BOTH medications. This is considered CONSCIOUS SEDATION, and requires MEDICAL CONTROL approval.
• Opioids should be avoided in any patient that appears under the influence of alcohol, benzodiazepines, or other CNS depressants
• Avoid use with Benadryl or phenergan

DOSAGE:

FENTANYL:  0.5 – 2 mcg/kg, IN, IO or IV

may be given in 25mcg increments, especially for geriatric patient, narcotic naïve patient, or patient with low body mass index.  If desired effect is achieved prior to reaching 0.5mcg/kg, the remainder of the dose does not have to be given. 

dosage for adults may be rounded to closest 20mcg or 25mcg increments to allow for ease of administration.

• initial dose is generally 1 mcg/kg for medical emergencies,
• initial dose for long bone fractures should be closer to 1.5 – 2mcg/kg
• maximum of 2mcg/kg (max 200mcg adult, 100mcg < age 16, 50mcg < age 12)
• only fentanyl is approved for pediatric patients
• For transport durations greater than 30 minutes, may repeat initial dose every 30 minutes

DILAUDID: 0.5mg IV/IO only, may repeat every 15 minutes to a total of 1.5mg IV/IO

MORPHINE: 2-4 mg IV/IO, repeat x 2 every 10 minutes to a total of 10mg IV/IO

CONSIDERATIONS:

• Morphine carries significant risk of hypotension, and has no specific benefit for Acute Coronary Syndromes.  Fentanyl and Dilaudid are preferred for suspected ACS, STEMI and NSTEMI cases.
• Morphine should be considered in cases of acute CHF, both to treat ‘air hunger’ and for the vasodilatory effect to shunt fluid from the lungs.
• These medications require ECG, pulse oximetry and preferably waveform capnography to be in place once administered.  BLS transport may NOT be performed once pain meds have been given.
• Fentanyl is preferred in pediatric patients, and may be given IN or IV
• Consider a half dose in elderly (>60yo) patients
• Once a particular pain medication has been chosen, personnel should generally not switch to different opioid medications without discussing with MEDICAL CONTROL

Protocol 116: Benzodiazepines (Lorazepam and Midazolam)

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION: Benzodiazepines increase GABA activity in the brain, which is an inhibitory neurotransmitter, resulting in significant sedation, relaxant and amnestic effects.

ONSET: 1-3 minutes (IV), 5-10 minutes (IN), 15-30 minutes (IM)

DURATION: 30 minutes to 6 hours, highly dependent on patient condition and method of administration

INDICATION:

AEMT: ACTIVE tonic-clonic seizures with potential for airway compromise, - OR-

• sedation and excited delirium (in consultation with Medical Control)

Paramedic: sedation for procedural cardioversion or transcutaneous pacing, excited delirium

CONTRAINDICATIONS: hypotension, respiratory depression

ADVERSE REACTIONS: apnea, loss of airway control, bradycardia, acute delirium

DRUG-DRUG INTERACTIONS:

• Adding an opioid to a benzodiazepine has a compounding effect that greatly magnifies BOTH medications. This is considered CONSCIOUS SEDATION, and requires MEDICAL CONTROL approval.
• Adding this medication to other sedatives, such as Benadryl, Phenergan or antipsychotics may result in compounding sedation and relaxed gag reflex.  This requires MEDICAL CONTROL approval.

DOSAGE:      

MIDAZOLAM, ADULT:

• ACTIVE Seizure (AEMT): 2-2.5mg IV/IO or 5mg IN/IM, up to 3 doses every 2-3 minutes for status seizures.
• Sedation, Procedure or Excited Delirium:
  • 2.2.5mg IV/IO or 5mg IN/IM
  • For Excited Delirium, dose may be repeated up to 2 times over 10 minutes.
  • Contact MEDICAL CONTROL for further dosing or alternative medication

MIDAZOLAM, PEDIATRIC:

• ACTIVE Seizure (AEMT): 0.1mg/kg, maximum of 2mg IV, up to 3 doses every 2-3 minutes for status seizures.
  • IN/IM dosing is 0.2mg/kg.  INTRANASAL ROUTE PREFERRED
  • PR (rectal) DIASTAT may be used as alternative if prescribed to the patient
• Sedation, Procedure or Severe Agitation in a child (Paramedic): Contact MEDICAL CONTROL

LORAZEPAM, ADULT:

• ACTIVE Seizure (AEMT): 1 mg IV/IO or 2 mg IN/IM, up to 3 doses every 2-3 minutes for status seizures.
• Sedation, Procedure or Excited Delirium (Paramedic):
  • 1 mg IV/IO or 2 mg IN/IM
  • For Excited Delirium, dose may be repeated up to 2 times over 10 minutes.
  • Contact MEDICAL CONTROL for further dosing or alternative medication

LORAZEPAM, PEDIATRIC:

• ACTIVE Seizure (AEMT): 0.05mg/kg, maximum of 1 mg IV, up to 3 doses every 2-3 minutes for status seizures.
  • IN/IM dosing is 0.1mg/kg.  INTRANASAL ROUTE PREFERRED
  • PR (rectal) DIASTAT may be used as alternative if prescribed to the patient
• Sedation, Procedure or Severe Agitation in a child (Paramedic): Contact MEDICAL CONTROL

CONSIDERATIONS:

• CNS depression is significantly amplified when benzodiazepines are given in combination with alcohol or other benzodiazepines.  It should not be done unless there are active seizures with loss of consciousness.
• All patients receiving these medications should be placed on ECG, pulse oximetry and waveform capnography.
• Once these medications are administered, these patients may not be transported without the AEMT or Paramedic as the attendant.
• Consider half doses for elderly patients (>65yo)
• Do not use these medications for pain control, except with pacing/cardioversion.
• For patients with significant agitation and altered mentation presumably due to drug use or overdose, contact MEDICAL CONTROL for dose recommendation.
• Use of these medications in conscious patients may require intubation when adverse reactions or unintended oversedation occurs due to the patient’s underlying condition. This is particularly likely in patients with significant alcohol intoxication.

Protocol 117: Lidocaine 2%

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION: Local anesthetic for IO infusion

ONSET:  2 – 5 minutes

DURATION: 15-45 minutes

INDICATION:  pain control for IO in a conscious or disoriented patient

CONTRAINDICATIONS: allergy to anesthetics

ADVERSE REACTIONS: seizures, tachycardia, arrhythmias, hypotension

DRUG-DRUG INTERACTIONS: None in the emergent setting

DOSAGE:  ADULT:  50mg slow IO push

CONSIDERATIONS:

• elderly (>65) and patients with significant CHF or liver disease are more likely to experience adverse reactions, as this medication is metabolized through the liver.
• due to lower therapeutic-to-toxic threshold of dosing, this medication is not available for pediatric   (age < 12, weight < 60kg) consideration without MEDICAL CONTROL approval

Protocol 118: Magnesium Sulfate

SCOPE:  Paramedic Only

MECHANISM OF ACTION: Torsades de Pointes- membrane stabilizer through stabilization of cardiac myocyte potassium channels, allowing for shortening of QT interval and correction of associated repolarization abnormalities. Asthma- while exact mechanism is uncertain, literature indicates magnesium in acute asthma acts as a weak bronchodilator with associated membrane stabilization of bronchioles.

ONSET:  10 seconds when given as a bolus for Torsades de Pointes

DURATION:  30 minutes

INDICATION:  pulseless multifocal ventricular tachycardia (Torsades), asthma exacerbation refractory to other first line medications

CONTRAINDICATIONS: None in the emergent setting

ADVERSE REACTIONS: bradycardia, hypotension, respiratory depression, ‘flushed’ sensation, palpitations

DRUG-DRUG INTERACTIONS: No significant interactions that prevent use in emergent setting

DOSAGE:  ADULT- Torsades: 2gm IV/IO rapid bolus

• Refractory bronchospasm: 2gm IV/IO over 5 minutes, may administer in 100cc D5W fluid bolus
• Pediatric dosing not indicated for this medication

CONSIDERATIONS:

• This medication also has uses for pre-eclampsia and high-risk obstetrics during inter-facility transports that extend beyond the scope of this protocol.  Contact MEDICAL CONTROL for any such consideration in a pre-hospital, 911 situation.

Protocol 119: Methylprednisolone

SCOPE: AEMT, Paramedic

MECHANISM OF ACTION: Steroid suppression of acute inflammatory response, with secondary effect of vascular and respiratory smooth muscle relaxation.

ONSET:  1 hour

DURATION:  highly variable, roughly 4-6 hours of peak effect

INDICATION:  severe asthma, anaphylaxis

CONTRAINDICATIONS: Active GI bleed

ADVERSE REACTIONS: minimal in the acute single dose administration; transient hyperglycemia, agitation

DRUG-DRUG INTERACTIONS: none in the acute emergency setting

DOSAGE:

ADULT: 125mg IV/IO bolus over 2 minutes

PEDIATRIC: 2mg/kg IV/IO bolus over 2 minutes (Max 125mg)

CONSIDERATIONS:

• This is a ‘helper drug’.  The purpose of giving this medication is to help the stabilization process of the acute bronchospasm.  It is not a first line medication, and takes a significant time to have an effect.
• The benefit of pre-hospital administration of this medication is that is allows emergency department personnel to see if they stabilize sooner, depending on the severity of the underlying condition, providing a clearer clinical picture in a shorter period of time.  It does not result in reversal of acute bronchospasm during the initial 30-60 minutes, and therefore should never be a priority to administer before other medications (oxygen, epi, albuterol, Atrovent, etc), nor should transport EVER be delayed in order to administer this on scene.

Protocol 120: Naloxone

SCOPE:  EMT-B, AEMT, Paramedic

MECHANISM OF ACTION: competitive opioid receptor antagonist

ONSET: 2 – 5 minutes

DURATION: 1 – 4 hours (varies depending on type and quantity of narcotic)

INDICATION:  Reverse respiratory depression associated with opioid overdose; coma of unknown etiology

CONTRAINDICATIONS:  Do not give to a conscious, breathing patient. Only use if respiratory depression is present.

ADVERSE REACTIONS: tachycardia, nausea/vomiting, pulmonary edema

DRUG-DRUG INTERACTIONS: no significant interactions in the acute emergency setting

DOSAGE:

ADULT: 0.5 to 2mg IV/IO/IM/IN, repeat until reversal of respiratory depression.

• EMT-Basic: Intranasal administration is authorized
• IF respiratory arrest or airway compromise, may bolus 2 mg as initial dose
• Anticipate need for repeat doses depending on type and quantity of opioid involved

PEDIATRIC (age < 12): 0.2 mg IV/IO/IM/IN, up to 2 mg total

CONSIDERATIONS:

• Patients receiving Narcan should generally be transported to the ER for evaluation given high likelihood of recurrent CNS depression and loss of airway, or concern of other intoxicants.
• Patients who, after receiving Narcan, have the ability to demonstrate decision-making capacity, and have no concern for polysubstance abuse, alcohol intoxication, or suicidal ideation, may have the legal right to refuse transport.  This should be considered and Against Medical Advice refusal, and every effort should be made to encourage transport for ER evaluation.  If unsuccessful, recommend contacting MEDICAL CONTROL for attempt by the clinician to speak with the patient about the risks of recurrent CNS depression.
• When given to a patient that does NOT have respiratory depression, Narcan can potentiate sudden, severe withdrawal symptoms. This should be avoided.

Protocol 121: Nitro Sublingual

SCOPE:  EMT-Basic, AEMT, Paramedic

MECHANISM OF ACTION: peripheral venous dilation that decreases cardiac preload and afterload

ONSET:  1-2 minutes

DURATION: 20-30 minutes

INDICATION:  pain due to suspected MI, acute pulmonary edema due to CHF

CONTRAINDICATIONS: Hypotension, suspected Right-sided MI, erectile dysfunction medications

ADVERSE REACTIONS: hypotension, headache, syncope, sudden cardiac arrest (right side MI)

DRUG-DRUG INTERACTIONS: Cannot be mixed with erectile dysfunction medications.

DOSAGE:

ADULT: 0.4mg SL tablet every 5-10 minutes for 3 doses

• For acute pulmonary edema, MEDICAL CONTROL may order additional doses after first 3 doses
• This medication is not authorized for pediatric use

CONSIDERATIONS:

• If any evidence of hypotension or borderline hypotension, withhold this medication.
• There is evidence that supports the use of higher doses of nitro SL for acute CHF exacerbation.
• This medication protocol is considered distinct and separate from Nitroglycerin drip preparations.

• Erectile dysfunction medications have many different trade names, generic names, and increasingly more common international names as medications are ordered online from outside the U.S.  If any doubt as to the type of medication, look up the medication or contact MEDICAL CONTROL before giving Nitro SL.

Protocol 122: Oxygen

SCOPE: EMT-Basic, AEMT, Paramedic

MECHANISM OF ACTION: provide additional supplemental oxygen required for cellular metabolism.  Importantly, the cell of the brain do not have an anaerobic (non-oxygen) way of functioning like other parts of the body.  As a result, brain cell death results in minutes without adequate oxygen.

ONSET: 1-2 minutes

DURATION:  Condition dependent.  Some acute respiratory conditions may desaturate as soon as high-flow oxygen is removed

INDICATION:  low oxygen, chest pain, shock, anticipated airway or respiratory compromise, pre-procedural oxygenation,

CONTRAINDICATIONS: None in the emergency setting.

ADVERSE REACTIONS: None in the emergency setting (COPD-related apnea is extremely rare)

DRUG-DRUG INTERACTIONS: None in the emergency setting

DOSAGE:

• Consider use of high flow (>10lpm by NRB) for acute airway or respiratory compromise.
• For suspected stroke, intracranial hemorrhage, or acute coronary syndromes, consider only 2-4 L by NC unless there is potential for airway or respiratory compromise
• For pre-intubation preparation, use high flow dosing.

CONSIDERATIONS:

• May be used for carbon monoxide poisoning, but use high dose.
• When oxygen is indicated, so is monitoring.  ECG, pulse oximetry and waveform capnography should be considered.

Protocol 123:  Sodium Bicarbonate

SCOPE:  Paramedic Only

MECHANISM OF ACTION: Sodium bicarb binds with hydrogen (H+) ions to form water and carbon dioxide, which helps to alkalinize the pH of the blood to further neutralize acids.  It also plays a role in competitive antagonism of sodium channels during acute overdoses such as tricyclic antidepressants.

ONSET:  1-2 Minutes, but result is highly variable, depending on underlying metabolic conditions

DURATION: 8-10 minutes, depending on underlying metabolic conditions

INDICATION:  Pulseless arrest suspected due to hyperkalemia (dialysis, renal disease)

• Tricyclic antidepressant overdose with hypotension or EKG evidence of widening QRS

CONTRAINDICATIONS: alkalosis, hypocalcemia, hypokalemia

ADVERSE REACTIONS: unintentional metabolic alkalosis, hypernatremia, CNS intracellular acidosis

DRUG-DRUG INTERACTIONS: AVOID GIVING WITH CALCIUM

• May decrease effectiveness of vasopressors

DOSAGE:

ADULT OR CHILDREN: 1mEq/kg slow IV push, repeated every 5 minutes up to 3 doses.

• TCA overdoses should be treated based on the QRS width.  If it narrows to <100msec, hold further doses.  It may require more than 3 doses to correct.  In these instances, measure the QRS before and after administration, and contact MEDICAL CONTROL for further guidance.

CONSIDERATIONS:

• TCA overdoses may require larger amounts of sodium bicarbonate.  At times, multiple doses may be given almost simultaneously.  If the QRS is wide, consider contacting MEDICAL CONTROL early as they may guide you to treat more aggressively.
• TCA overdoses are not the only medications that cause sodium channel blockade in the heart.  Other medications may result in the use of this protocol, as directed by MEDICAL CONTROL.
• Sodium Bicarb should NOT be routinely used for prolonged cardiac arrest.

Protocol 124: Furosemide

SCOPE:  Paramedic Only

MECHANISM OF ACTION: As a LOOP diuretic, furosemide results in significant fluid redistribution into the urinary tract.

ONSET:  5 minutes; Peak effect at 20-30 minutes

DURATION: Up to 2 hours

INDICATION:  Acute Congestive Heart Failure

CONTRAINDICATIONS: febrile (Temp >100 or infectious pattern) patients, kidney disease, hypokalemia, dialysis, hypotension

ADVERSE REACTIONS: hypokalemia, renal failure, hypotension

DRUG-DRUG INTERACTIONS: may cause significant hypotension when combined with other antihypertensives

DOSAGE:  ADULT: 40mg SLOW IV push over 2-3 minutes x 1 dose only

• Not indicated for pediatric use

CONSIDERATIONS:

• Many EMS systems are removing this medication from pre-hospital use, as there is a high rate of renal complications and/or unintentional misuse in respiratory conditions that are erroneously assumed to be CHF.  Before giving this medication, thoughtful consideration should be given to the likelihood of CHF and fluid overload as the principle acute cause of respiratory distress.

• Should not be given in the setting of suspected sepsis
• Should not be given if patient has a borderline or low blood pressure
• Often CHF requires multiple medications and therapies, including morphine, nitroglycerin, furosemide, CPAP, oxygen, etc. Do not consider furosemide as a solitary option in the treatment of Acute CHF.

Protocol 125: Tranexamic Acid

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION: Displaces plasminogen from fibrin, resulting in inhibition of fibrinolysis, which preserves the initial clot formation.  Secondarily, inhibits proteolytic activity of plasmin.

ONSET:  2-5 minutes; Peak effect at 5-10 minutes

DURATION: Up to 2 hours

INDICATION: Massive Truncal (chest, abdomen, pelvis) trauma with signs of hemorrhagic shock, including

SBP < 90mmHg or resting HR > 110bpm

CONTRAINDICATIONS: not approved for pediatric < age 12, suspected CVA, MI, PE or hypersensitivity to medication

ADVERSE REACTIONS: hypotension, nausea/vomiting, blurry vision, clot formation, seizures

DRUG-DRUG INTERACTIONS: no acute drug interactions in the emergent setting

DOSAGE:  ADULT:  1 gram administered over 10 minutes, mixed in 100ml of Normal Saline

• A second dose of 1 gram administered over 10 minutes may be administered if no hypersensitivity is noted after the first dose
• Not indicated for pediatric use

CONSIDERATIONS:

• This protocol was developed with input from the Centura Trauma System’s medical direction and with consideration towards standards of care identified in the Rural Trauma Team Development Course, from the American College of Surgeon’s Committee on Trauma.

• Patients with an identified hypercoagulable state should receive only the initial dose, then contact MEDICAL CONTROL
• The use of this medication requires signs of significant internal bleeding, including but not limited to unstable vitals, altered LOC, and mechanism of truncal traumatic injury.
• This medication is not approved for routine non-traumatic use, but may be ordered by MEDICAL CONTROL for certain life-threatening medical indications such as postpartum or post-operative hemorrhage.

Protocol 126: Ketamine

SCOPE:  Paramedic Only

MECHANISM OF ACTION: Ketamine is a dissociative anesthetic agent, structurally similar to phencyclidine (PCP).  At  low doses it provides analgesia, at higher doses it produces amnesia and sedation. It’s therapeutic side effects include beta-adrenergic stimulation, including an increase in blood pressure (beta-1 agonist) and bronchodilation (weak beta-2 agonist).

ONSET:  45-60 seconds; Peak effect at 3-5 minutes

DURATION: Up to 1 hour

INDICATION: induction for rapid sequence intubation, analgesia for severe trauma, sedation for maintenance of intubation with or without mechanical ventilation

CONTRAINDICATIONS: known hypersensitivity; penetrating eye trauma; severe hypertension (>200 SBP, >120 DBP), tachyarrhythmias

ADVERSE REACTIONS:  laryngospasm, vomiting, hypersalivation, severe emergence reaction (awaken with hallucinations), jaw trismus

DRUG-DRUG INTERACTIONS: no acute drug interactions in the emergent setting

DOSAGE:        ADULT:

• Induction: 1-2 mg/kg IV
• Maintenance after Induction: 0.25-0.5 mg/kg IV every 5-10 minutes
• Agitation/excited delirium: 4mg/kg IM. Ensure access to airway at all times regardless of restraints.
• Analgesia for major trauma:
  • 50mg IM or IntraNASAL, repeat every 30 minutes as needed
  • 20mg slow IO or IV, repeat every 20 minutes as needed

PEDIATRIC:

• Induction/maintenance: contact Medical Control
• Analgesia for major trauma:
  • 0.5-1 mg/kg IM or IN, repeat every 30-40 minutes as needed
  • 0.1-0.3 mg/kg slow IO or IV, repeat every 20-30 as needed

CONSIDERATIONS:

• Excited delirium is a condition where the patient is in acute psychosis and cannot make rational decisions, requiring a combined approach by EMS and law enforcement to, at times, restrain the patient for the sake of their safety and the safety of the crew.  In these instances, a higher dose of IM injection is used that can result in airway compromise, jaw trismus, and respiratory arrest.  It is always advisable to involve Medical Control as soon as possible in the decision to administer this medication for this condition.

Protocol 127: Haloperidol

SCOPE:  Paramedic Only

MECHANISM OF ACTION:  Antipsychotic medication that blocks dopamine receptors, resulting in sedation and tranquilization.  Secondary effects include a mild alpha-adrenergic blockade, peripheral vasodilation, and QT prolongation.

ONSET:  2-5 minutes IV; 10 minutes IM; Peak effect at 5-10 minutes IV, 30 minutes IM

DURATION: Up to 2-4 hours

INDICATION: Severe agitation, combative patient, significantly combative intoxicated patient unable to refuse due to lack of mental capacity.

CONTRAINDICATIONS: suspected acute MI, hypotension, respiratory or CNS depression, pregnancy

ADVERSE REACTIONS:  hypotension, tachycardia, QT prolongation, restlessness, hyperactivity or anxiety. Rare instanced of neuroleptic malignant syndrome (high fever with muscular rigidity). Extrapyramidal reactions including spasm of muscles of tongue, face, neck and back (this may be treated with IV Benadryl).

DRUG-DRUG INTERACTIONS:  Avoid combination with other QT prolonging antipsychotics and antiemetics (Zofran).

DOSAGE:  ADULT: 5-10mg IM.  Use a half dose in patients whose age are > 65.

• Contact Medical Control for administration to patients under the age of 16.

CONSIDERATIONS:

• May combine with Benadryl, and either Ativan or versed (if EtOH is not suspected), but should be done with extreme caution and cardiac/airway monitoring.
• Ideal for use with intoxicated patients who should not receive benzodiazepines.

Protocol 128: Rapid Sequence Intubation Medications

SCOPE: PARAMEDIC ONLY.  (Note: This protocol is not the procedure protocol, it only lists the medication considerations, order of administration and dosages for RSI.)

• SEDATE first- choose one of the following, use IDEAL Body Weight for estimated dosing:
  • Etomidate 0.3mg/kg IV/IO, or
  • Etomidate 0.1mg/kg IV/IO (if concern for potential hypotension), or
  • Ketamine 1.5mg/kg IV/IO (recommended for asthma or unstable, hypotensive patients), or
  • Midazolam (Versed) 0.2-0.3mg/kg IV/IO (Max 10mg), or
  • (Adults Only) Fentanyl 50mcg PLUS Versed 2-2.5mg IV/IO
• Paralyze last- choose one of the following, use IDEAL Body Weight for estimated dosing:
  • Avoid paralysis if suspected diabetic ketoacidosis
  • Succinylcholine 1-2mg/kg IV/IO
  • Rocuronium 1 mg/kg IV/IO
  • Vecuronium 0.15-0.2mg/kg IV/IO
• Long-Term Sedation and Paralysis
  • Sedation
    • Midazolam 2.5mg IV/IO every 5-10 minutes as needed
    • Ketamine 0.25-0.5mg/kg IV/IO every 10-15 minutes as needed
  • Pain Management
    • Fentanyl 1mcg/kg IV/IO every 30 minutes as needed
    • Ketamine 20mg-30mg IV/IO every 30 minutes as needed
  • Paralysis (if patient attempting to self-extubate)
    • Rocuronium 1mg/kg IV/IO every 45-60 minutes as needed
    • Vecuronium 0.1mg/kg IV/IO every 45-60 minutes as needed

Protocol 129: Toradol

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION:  NSAIDs like Toradol decrease pain by inhibiting cyclooxygenase enzymes, thereby blocking prostaglandin production.  This reduces overall inflammation and swelling (which is often a cause of pain).

ONSET 5 minutes; Peak effect at 60 minutes

DURATION: Up to 4 hours

INDICATION: Acute treatment of moderate or severe pain due to suspected kidney stones, chronic pain or musculoskeletal pain.

CONTRAINDICATIONS: allergies to NSAIDs or aspirin, pregnancy, GI bleeds, kidney disease, bleeding disorder or taking anticoagulant medication, acute head injury, age less than 16 or greater than 65 years, severe dehydration.

ADVERSE REACTIONS:  allergic reactions, vomiting, GI bleeds, worsening kidney injury

DRUG-DRUG INTERACTIONS:  do not administer with any other NSAIDs or anticoagulants

DOSAGE:  ADULT (Age 16 or greater for this medication):  15mg IV or IM x 1 dose

                       Not approved for pediatric patients under age 16.

CONSIDERATIONS:

• Generally it is best to avoid this medication with patients who present with extreme tenderness in the abdomen that may require surgery (eg appendicitis or cholecystitis). 
• This medication should not be used in patients with acute truncal trauma.

Protocol 130: Neosynephrine or Phenylephrine

SCOPE:  EMT-Basic, AEMT, and Paramedic

MECHANISM OF ACTION:  Alpha-adrenergic vasoconstrictor.  When administered intranasally, it vasoconstricts superficial blood vessels in the nasal mucosa, reducing the degree of bleeding and swelling.

ONSET:  2-5 minutes; Peak effect at 5-10 minutes

DURATION 1-2.5 hours

INDICATION: epistaxis, nasal intubation

CONTRAINDICATIONS: none

ADVERSE REACTIONS:  rare if given intranasally

DRUG-DRUG INTERACTIONS:  no acute drug interactions in the emergent setting

DOSAGE:  ADULT: First, have patient blow nose to expel clots, then administer two sprays in to each nostril

• Not indicated for pediatric use

CONSIDERATIONS:

• Avoid accidental spray into the eyes. 
• This medication is often most effective when used in combination with nasal clamp after medication has been administered.

Protocol 131: Flumazenil (Romazicon)

SCOPE:  AEMT and Paramedic

MECHANISM OF ACTION:  Flumazenil is a selective GABA receptor antagonist that reverses the effects of benzodiazepines.

ONSET:  30-60 seconds; Peak effect at 5-10 minutes

DURATION: 30-50 minutes

INDICATION: oversedation for ventilator management with signs of hypotension, severe benzodiazepine overdose (requires Medical Control approval first)

CONTRAINDICATIONS: avoid in patients with known seizure disorders; because the risk of irreversible seizures is always a significant concern, it may be more appropriate to provide supportive treatment and ventilatory support while benzodiazepines are metabolized by the body.

ADVERSE REACTIONS:  cardiac dysrhythmias, prolonged seizures, aspiration, hypoxia, vomiting

DRUG-DRUG INTERACTIONS:  this medication blocks the effects of anti-seizure medications, especially benzodiazepines that would be used to correct a seizure.

DOSAGE:  ADULT:

For suspected benzodiazepine overdose on 911 scene, contact Medical Control first.

• Typical dose is 0.2mg IV/IO over 15-30 seconds, repeated once every 1-2 minutes up to a maximum dose of 1mg IV/IO.
• For adverse reaction to administered benzodiazepine: 0.2-0.4mg IV/IO once.
• Paramedic Only: For oversedation on ventilatory support:  in absence of hypotension or bradycardia, do not administer flumazenil.  If oversedation presents with accompanying circulatory system problems, administer 0.2-0.4mg IV/IO once.  May repeat every 1-2 minutes until resolution of complications up to a maximum of 2mg, taking care to keep ventilated patient sedated appropriately.

CONSIDERATIONS:

• There is a high risk of seizures with the administration of this medication. “Start low (dose), go slow (with repeat dosing)”.  Remember, this medication BLOCKS the medications typically used to stop seizures.  Therefore, in the event of a flumazenil-induced seizure, the normal anti-seizure medications will not work, and airway problems can become significantly prolonged, resulting in hypoxic brain injury.
• In general, if there is a concern of mixture of opiates and benzodiazepines, it is strongly preferred that Narcan be administered up to at least 2mg before considering this medication.
• If a patient requires intubation or a supraglottic airway for polypharmacy overdose (eg alcohol and benzodiazepines), it is generally best to place the airway and provide ventilatory support, and avoid use of flumazenil until evaluated in the emergency department.  In this instance, flumazenil should be reserved for patients with hypotension and/or failure to ventilate successfully with BVM +/- a supraglottic airway.

Protocol 132: Acetaminophen

SCOPE:  EMT-Basic, AEMT, and Paramedic

MECHANISM OF ACTION: Acetaminophen metabolizes to p-aminophenol, which can cross the blood-brain barrier where it acts on brain and spinal tissue at COX and opioid receptor sites, to lower fever and decrease pain.

ONSET:  Approximately 30 minutes

DURATION:  Up to 6 hours

INDICATION:  Fever, pain

CONTRAINDICATIONS: Liver failure, known sensitivity

ADVERSE REACTIONS: nausea, vomiting, Stevens-Johnson Syndrome, headache, anxiety, dyspnea, fatigue,

DRUG-DRUG INTERACTIONS: No acute interactions; chronic Tylenol use can interact with blood thinners and/or lead to liver toxicity.

DOSAGE:  Adult: 325mg to 1,000mg, may repeat every 6 hours.

• Pediatric or Alternative Adult dosing, weight-based: 10-15mg/kg every 4-6 hours.

CONSIDERATIONS:

• Acetaminophen is an ingredient in most combination pain medications (Norco, Vicodin, Percocet) and over-the-counter cold preparations.  The total maximum 24 hr dose should not exceed 4 grams in an adult when all acetaminophen components are added together.

Protocol 201: Initial BLS Airway

Scope: EMT-Basic, Advanced EMT and Paramedic

Indications:

• Unable to respond to commands
• Loss of consciousness
• airway compromise
• sonorous (“snoring”) respirations
• cardiac arrest

Contraindications:

• able to respond to commands
• intact gag reflex is a contraindication to oral pharyngeal airway
• facial fractures are a contraindication to a nasal pharyngeal airway

Procedure:

1. Open the airway
   1. Medical: jaw thrust/chin lift
   2. Trauma: modified jaw thrust
2. Visually EXAMINE the open airway
   1. Evaluate for swelling/edema, blood, teeth, vomitus
   2. Suction any fluid/blood
   3. AVOID suction if edema/swelling
   4. If evidence of solid obstruction, proceed to Obstructed Airway protocol
3. Identify Mallampati Airway Score
   1. Mallampati ONE = all structures visualized, space between uvula and tongue
   2. Mallampati TWO= all structures visualized, no space between uvula and tongue
   3. Mallampati THREE= only a portion of uvula visualized, soft palate still visible
   4. Mallampati FOUR= uvula not visualized; soft palate not fully visualized, tonsils not visualized
4. Insert oral pharyngeal airway (OPA)
   1. Measure from corner of mouth to tip of ear lobe for proper size
   2. Insert at 90 degree or 180 degree to glossus, rotating as it is seated in posterior pharynx
5. If gag reflex present, switch to lubricated nasopharyngeal airway (NPA)
   1. Measure from TIP of NOSE to tip of ear lobe
   2. NPA should be inserted perpendicular to back of head, not in line with nare
   3. If resistance, switch to other side
   4. If unsuccessful on both sides, maintain manual airway opening
   5. Avoid in facial fractures or with signs of basilar skull fracture
   6. VISUALLY CONFIRM NPA extends past base of tongue in posterior pharynx
6. If patient is unable to maintain their own airway, and condition does not permit OPA or NPA, the following options should be considered depending on the clinical context:
   1. Manual maintenance of jaw thrust/chin lift
   2. Insertion of supraglottic rescue airway device (eg King or iGel)
   3. Lateral recumbent positioning
   4. Request Paramedic response for advanced airway
7. Once airway is secured with BLS airway device, attach high-flow oxygen by mask
8. If patient is unable to maintain effective ventilation rate, VENTILATE with BVM
   1. Ventilation rate is 12-20 for adults
   2. Ensure tight seal around mouth/nose, may require two-handed technique for difficult airway
   3. VENTILATE with supplemental O2 attached as soon as possible
   4. If patient demonstrates some respiratory effort that is not adequate to sustain life, support breaths with BVM ventilation during inhalation effort (ie ‘poor man’s CPAP’ technique)
9. If still unable to ventilate despite all above efforts, declare a “FAILED AIRWAY”
   1. Rapid transport to ER, notifying ER of failed airway
   2. Paramedic intercept if available

Considerations:

• The higher the Mallampati score (3 or 4) the more likely the airway is to be difficult to manage.  Consider moving to more advanced airway maneuvers sooner, or dedicating two people to effective BVM seal/technique.
• The sound of SNORING means AIRWAY OBSTRUCTION due to the TONGUE.  Take action NOW!!!
• A “FAILED AIRWAY” is a critical emergency that requires rapid transport, ALS intercept and early ER notification.
• Some situations may require recurrent / near-continuous suction, such as GI bleed, posterior epistaxis, dental bleeding, etc.
• A Cervical Collar DOES NOT maintain airway in jaw thrust position.  If Manual jaw thrust is necessary, maintain manually IN ADDITION to the cervical collar.
• Brain cells die quickly without glucose and oxygen, beginning within several minutes. Permanent brain death begins in less than 4-6 minutes without effective oxygen.  Therefore, GOOD BLS AIRWAY management is vital to prevention of permanent anoxic brain injury during initial response.