IFT

Protocol 1001: Interfacility Transfers (IFT), General Principles

1. All IV drips or IV-administered medications ordered by a sending facility provider need to be provided to the transport crew in writing.  It is appropriate to refuse to transport patients if advanced medication orders are not prepared by the sending provider.
2. In the event a transfer is requested with a medication not authorized by these protocols, contact Medical Control.  If the medication is within scope of practice, it may be permitted in accordance with Kansas EMS regulations provided:
   1. The sending provider provides written orders for the medication requested,
   2. The initial bolus/drip is initiated and the drip rate is established by the sending facility,
   3. Medical Control maintains an open line of communication for the duration of the transfer.
3. It is appropriate to refuse to transport patients who are not stable enough for transport when immediate stabilizing interventions can be performed at the sending facility (eg patient currently in V Tach that has not been cardioverted/defibrillated).
4. It is appropriate to transport critically ill patients whose only chance of survival is to obtain interventions not available at the sending facility (eg traumatic abdominal bleed with hypotension) despite the possibility that they may arrest.
   1. Ensure the sending provider has provided a copy of EMTALA paperwork to the crew
   2. Ensure family are aware of the potential for arrest en route, and that the sending provider has advised them of the reasons for recommended transfer.
   3. Ensure the provider is aware of the limitations and certification levels of the transport team (eg that NWKS EMS does not have critical care transport capabilities at the same level as a flight team)
   4. If any conflict or uncertainty remains about the safety of transfer, contact medical control for further consultation.  This may include placing the on-line medical control provider in direct contact with the sending facility’s provider to discuss the case in greater detail.
5. All EMT-Basic, Advanced EMTs and Paramedics remain responsible for adhering to their Kansas state-identified scopes of practice, regardless of the request of any sending provider’s medical orders (eg an EMT-B / AEMT cannot transport a diltiazem drip).
   1. Patients that require ECG monitoring may NOT be attended solely by an EMT-Basic.
6. In the event a patient does go into cardiac arrest during transport, the transport should be diverted to the closest appropriate facility unless relatively close to destination facility.  Effort should be made to notify the receiving facility of incoming cardiac arrest.
7. In general, it is recommended to transport active STEMIs and similar time-sensitive critical patients emergently with lights and sirens, weather permitting. This decision remains at the ultimate discretion of the driver responsible for ensuring the safe arrival of the patient and the team.
8. On-line Medical Control remains available for consultation for complications or issues either prior to or during transport.  

Protocol 1002: IFT Pain Management

1. Opioid/ketamine pain management should be reviewed with the sending provider, especially if not indicated on the transfer orders.
2. Before giving ketamine, oral pain medication or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as Toradol or ibuprofen, confirm with sending facility that these are appropriate for the patient’s clinical condition.
3. It is strongly recommended to provide a copy of this pain management protocol to the sending facility whenever they request NWKS pain management ‘per protocol’.
4. Scope of practice: interfacility transfers do not change the scope of practice referenced in medication protocols.  Personnel may only administer medications relevant to their scope of practice.  If a higher level of medication is required, then the higher certified individual must attend on the patient.
5. Monitoring:
   1. At a minimum, patients receiving opioids/ketamine should have:
      1. Blood pressure and pulse rate monitoring q 15 minutes
      2. ALS attend (Paramedic for ketamine)
      3. Waveform EtCO2, pulse oximetry and 3 Lead ECG monitoring
6. Dosing:
   1. Fentanyl: 0.5 – 2mcg/kg IV/IO/IN every 30-60 minutes;
      1. May Titrate by 25mcg increments to achieve desired effect
      2. Titrate to effective pain control, or
      3. Decrease in level of consciousness, or
      4. Decrease in respiratory rate < 10, or
      5. Significant decrease in blood pressure
      6. Lower doses (0.5-1 mcg/kg) should be used for patients that have already received initial doses of opioids
      7. Higher doses (1-2 mcg/kg) should be used for major fractures or patients that have not yet received initial dose of opioids
      8. Fentanyl should not be given IM, as absorption is unpredictable
   2. Dilaudid: 0.25 – 1 mg IV/IO/IM every 1-2 hours;
      1. Titrate to effective pain control, or
      2. Decrease in level of consciousness, or
      3. Decrease in respiratory rate < 10, or
      4. Significant decrease in blood pressure
      5. Lower doses (0.25-0.5 mg) should be used for patients that have already received initial doses of opioids
      6. Higher doses (1mg) should be used for major fractures or patients that have not yet received initial dose of opioids
      7. Dilaudid may be given IM for longer duration of pain control.
      8. IV/IO access should still exist in case of clinical deterioration
      9. Doses for IM administration: 1-2mg every 2-4 hours
   3. Morphine: 2-5 mg IV/IO every 30-60 minutes;
      1. Titrate to effective pain control, or
      2. Decrease in level of consciousness, or
      3. Decrease in respiratory rate < 10, or
      4. Significant decrease in blood pressure
      5. Lower doses (2 mg) should be used for patients that have already received initial doses of opioids
      6. Higher doses (4-5 mg) should be used for major fractures or patients that have not yet received initial dose of opioids
      7. Morphine should NOT be given IM, as absorption is unpredictable.
   4. Tylenol: 15 mg/kg to a maximum of 1000 mg PO, once every 6 hours.  Adults may be given 500-1000mg once every six hours without weight measurement.
      1. EMT-Basics may also give this medication
   5. Ibuprofen: 10mg/kg to a maximum of 800 mg PO, once every 8 hours.  Adults may be given 400-600mg once every 8 hours without weight measurement.
      1. EMT-Basics may also give this medication
   6. Toradol: 0.5 mg/kg up to a maximum of 15mg IV or IM, once.
   7. Ketamine (Paramedic Only):
      1. Adults:
         1. 50mg IM or IN, repeat every 30 minutes as needed
         2. 20mg slow IO or IV, repeat every 20 minutes as needed
      2. Pediatric:
         1. 0.5-1 mg/kg IM or IN, repeat every 30-40 minutes as needed
         2. 0.1-0.3 mg/kg slow IO or IV, repeat every 20-30 as needed

Protocol 1003: IFT Anti-Emetics

1. Scope of practice: interfacility transfers do not change the scope of practice referenced in medication protocols.  Personnel may only administer medications relevant to their scope of practice.  If a higher level of medication is required, then the higher certified individual must attend on the patient.
2. Zofran- 4mg PO/ODT, IV, or IO may be given.  A repeat dose of 4mg, up to total of 8mg may be given for any patient that previously received one dose prior to transfer, or does not respond to the first dose during transfer.  Dosing beyond 8mg should not be considered for any transfer less than 6 hours long.
3. Phenergan- Generally given as a second line agent if Zofran fails to work.
   1. 12.5mg IM once every 6 hours, OR
   2. 6.25mg IV/IO once every 6 hours.  

Protocol 1004: IFT Benzodiazepines

1. Scope of practice: interfacility transfers do not change the scope of practice referenced in medication protocols.  Personnel may only administer medications relevant to their scope of practice.  If a higher level of medication is required, then the higher certified individual must attend on the patient.
2. Specific to transfers, if the sending facility requests PRN or repeat doses of benzodiazepines for transfer, and no other paramedic-level monitoring or medications are required, these transfers may be managed by Advanced EMTs, including administration of PRN benzodiazepines.
3. Advanced EMTs may administer PRN benzodiazepines for sedation at the below doses for transfers.
4. IV drip benzodiazepines require paramedic level certification.
5. IV benzodiazepines should not be mixed with opioid medications unless specifically ordered by the sending facility.
6. Monitoring:
   1. At a minimum, patients receiving benzodiazepines should have:
      1. Blood pressure and pulse rate monitoring q 15 minutes
      2. ALS attend
      3. Waveform EtCO2, pulse oximetry and 3 Lead ECG monitoring
7. Dosages:
   1. Midazolam, Adult:
      1. Sedation: 2 – 2.5mg IV/IO q 45-60 min
      2. Seizures: 2 – 2.5mg IV/IO q 3-5 minutes if active seizure with airway compromise
      3. Ventilator Sedation: Loading dose 0.01-0.1mg/kg IV bolus
         1. May initiate an uncalculated loading dose of 5mg bolus for adults > 50kg
         2. Infusion 0.02-0.1mg/kg/hr
         3. OR may re-bolus initial dose q 10-30 minutes
         4. OR as modified by sending provider
   2. Midazolam, Pediatric:
      1. Seizures: 0.1mg/kg IV/IO q 3-5 minutes or 0.2mg/kg IN/IM q 5-10 minutes if active seizure with airway compromise
   3. Lorazepam, Adult:
      1. Sedation: 1mg IV/IO q 45-60 min
      2. Seizures: 1-2mg IV/IO q 3-5 minutes if active seizure with airway compromise
      3. Ventilator Sedation: Loading dose 0.5-4.0mg IV bolus
         1. Infusion 0.02-0.1mg/kg/hr
         2. OR may re-bolus 3-5mg q 10-30 minutes
         3. OR as modified by sending provider
      4. Alcohol withdrawals:
         1. If CIWA score > 8: 1mg IV, rescore q 30 minutes
         2. If CIWA score > 13: 2mg IV, rescore q 30 minutes
         3. If CIWA score > 17: 3mg IV, rescore q 30 minutes
         4. CIWA score based on “CIWA-Ar” score from MDCalc.com
8. Lorazepam, Pediatric:
   1. Seizures: 0.05mg/kg q 3-5 minutes or 0.1mg/kg IN/IM q 5-10 minutes if active seizure with airway compromise

Protocol 1005: IFT RSI and Long-Term Sedation

1. Scope of practice: interfacility transfers do not change the scope of practice referenced in medication protocols.  Personnel may only administer medications relevant to their scope of practice.  If a higher level of medication is required, then the higher certified individual must attend on the patient.
2. RSI protocol for EMS 911 calls may also be utilized for emergent airways that occur during IFT transport.
3. RSI protocol similarly identifies long-term sedation and paralysis options for patients being transported on a ventilator:
   1. Long-Term Sedation and Paralysis
      1. Sedation
         1. Midazolam 2.5mg IV/IO every 5-10 minutes as needed
         2. Midazolam DRIP:
            1. Loading Dose: 0.01 to 0.05 mg/kg over 2-3 minutes
            2. Maintenance Infusion: 0.02 to 0.1mg/kg/hr (Max of 7mg/hr)
            3. Titrating An Additional Initial Bolus:  May need additional bolus of 2.5-5mg as infusion is started in case of inadequate sedation.
         3. Ketamine 0.25-0.5mg/kg IV/IO every 10-15 minutes as needed
      2. Pain Management
         1. Fentanyl 1mcg/kg IV/IO every 30 minutes as needed
         2. Fentanyl DRIP:
            1. Loading Dose: 25 to 100mcg
            2. Maintenance Infusion: 25 to 50mcg/hr, max of 200mcg/hr;
               1. up to max of up to 700mcg/hr ONLY IF GIVEN WRITTEN ORDERS FROM SENDING FACILITY
               2. Contact sending provider or Medical Control for titration above 200mcg/hr if not in written orders
         3. Ketamine 20mg-30mg IV/IO every 30 minutes as needed
      3. Paralysis (if patient attempting to self-extubate)
         1. Rocuronium 1mg/kg IV/IO every 45-60 minutes as needed
         2. Vecuronium 0.1mg/kg IV/IO every 45-60 minutes as needed
4. Sending provider should identify preferred medications for long-term paralysis and sedation:
   1. If it is a medication the paramedic is not trained to manage, the medic may either request a change to an appropriate medication or refuse the transfer.
   2. Dosages may be altered by sending provider so long as they are written on orders sheet, otherwise standing RSI doses in these protocols prevail.
   3. For pediatric patients, insist that the sending provider gives a specific weight AND weight-based dosage indications (and frequency of administration).  This burden of dosage decision-making is on the sending facility, not the medic.
5. Do not hesitate to involve Medical Control if any concerns about the safety or utilization of any sedative or paralytic for an IFT patient.

Protocol 1006: IFT Ventilator Management

1. Scope of practice: interfacility transfers do not change the scope of practice referenced in medication protocols.  Personnel may only administer medications relevant to their scope of practice.  If a higher level of medication is required, then the higher certified individual must attend on the patient.
2. RSI protocol for EMS 911 calls may also be utilized for emergent airways that occur during IFT transport.  After RSI initiation, medics may utilize ventilators to support respiratory system.
3. CPAP may be also be considered as an alternative, as per EMS 911 protocol.
4. Standard initial vent settings for RSI en route:
   1. These may need to be modified for MODE specific to manufacturer's settings depending on type of ventilator equipment utilized
   2. For COVID patients requiring RSI en route:
      1. Assist/Control or Volume Control MODE
      2. TV of 6-8ml/kg IBW
      3. Rate 20/min to start
      4. PEEP 5cm H20
      5. FiO2 100% to start

Protocol 1007: IFT Intermittent Suctioning

1. AEMTs and Paramedics may initiate nasotracheal suctioning intermittently if requested by the sending facility.
2. Measurement of soft-tip catheter for nasotracheal suctioning is done by starting at the tip of the nose, measuring to the earlobe and then over to the cricothyroid membrane.  Lubricate the sides of the tip and insert to the full depth measured to obtain deep tracheal suctioning effectiveness.  This measurement works for adults, children and infants.
3. Paramedics may perform intermittent suctioning for intubated patients if requested by the sending facility, or if signs of a mucous plug are present that inhibit effective ventilation.
   1. Consider use of 5 ml of saline to loosen the mucous, flushed down the ET tube.
   2. Apply soft tip suction catheter for the full length of the ET tube, plus approximately 5 cm, suctioning as the catheter is removed, for no longer than 10 seconds at a time.

Protocol 1008: IFT CPAP/BiPAP

1. Scope of practice: AEMT, Paramedic.
2. interfacility transfers do not change the scope of practice referenced in medication protocols.  Personnel may only administer procedures relevant to their scope of practice.  If a higher level of medication is required, then the higher certified individual must attend on the patient.
3. CPAP may be initiated under EMS Protocol 207 during transport if the patient meets criteria. Since the sending provider knows the underlying condition of the patient best, every attempt should be made to discuss initiation of CPAP with the sending provider, either before or shortly after initiating CPAP, as there are respiratory conditions where it may appear useful but could inadvertently be detrimental to the patient.
4. BiPAP requires am AEMT or Paramedic to be in attendance.  Either the facility’s BiPAP machine or the agency’s ventilator on BiPAP settings may be used, provided the paramedic is familiar with and comfortable with the settings and operability of the machine.  In instances where the equipment appears significantly unfamiliar as to pose a risk of equipment failure during transport, the transport crew should consider either contacting Medical Control and/or declining the transfer.
   1. Sending facility should provide written BiPAP settings in written orders.
   2. Consideration of intubating the patient may be discussed with the sending facility in order to facilitate a safe transfer if BiPAP is not a reliable option.
   3. In an instance where the transferring paramedic is not comfortable with the available BiPAP machinery, and the sending facility is not willing to consider intubation/ventilation, contact Medical Control to discuss refusal of transfer or alternate strategy.

Protocol 1009: IFT Use of Ports, PICCs and Central Lines

1. All ports, PICCs and Central lines that have been accessed by the sending facility may be utilized by AEMTs and Paramedics during IFTs.
2. All ports should already be accessed by the sending facility, with appropriate sterile covers.  Double tape the IV line leading away from the port to ensure security during transport. If a heparin flush is required, the sending facility needs to provide the appropriate dose and written order indicating when the flush should be done.
3. PICCs should have appropriate sterile cover in place that should not be removed.  Double tape the IV line leading away from the PICC line to ensure the line remains secured during transport.   If a heparin flush is required, the sending facility needs to provide the appropriate dose and written order indicating when the flush should be done.
4. Central lines must be sutured in place by the sending provider.  A sterile covering should also be in place over the insertion site.  Double tape the IV lines leading away from the central line.
5. In the event a patient has a port that has not been accessed, it should NOT be accessed by the transfer crew for use of emergency medications.  In cases of acute decompensation, a new IV or IO should be used instead of attempting to access a port.
6. PICC lines and Central lines may be used by the transfer crew for emergency medications. If an IV drip is running, either:
   1. Ensure compatibility between the IV drip and the emergency medication, or
   2. stop the drip, flush with saline, then give the emergency medication, followed by another saline flush.

Protocol 1010: IFT Obstetric Transfers

1. AEMTs and Paramedics may take OB transfers.  When tocolytic medications are required, the scope of practice of medications guides the level of transfer as follows:
   1. If Magnesium Sulfate is being administered, AEMT and Paramedic may transfer.
   2. If Terbutaline or another medication is to be given by the crew, then a Paramedic is required.
2. OB transfers generally fall into one of three categories:
   1. High-Risk OB (aka “Hi-ROB”): premature rupture of membranes (PROM), premature labor, hemorrhage, pre-eclampsia/eclampsia.  These are typically not in active labor, but require transfer to a tertiary OB facility to address the underlying complication that makes the pregnancy high risk.
   2. Standard, Full-Term LATENT Labor:  patients at full term (at least > 36 weeks), without complications, with rupture of membranes or irregular contractions that are not consistent. The term LATENT means that while the early delivery process may be beginning, it is not progressing rapidly, and there is sufficient time to safely transfer to a tertiary facility with OB capabilities.
   3. Failure to Progress:  Active labor presenting with breech, cephalopelvic disproportion (head larger than pelvic opening and unable to pass), cord compression.  These are cases of active labor where the patient (sometimes both mother and fetus) is at risk and still requires emergent transfer to facility capable of emergent cesarean section.
   4. The determination of Active versus Latent labor, and safety of transfer, is a determination of the sending clinician, under EMTALA laws.  If there is any concern that the transfer shouldn’t be done, contact Medical Control and have them speak with the sending clinician directly.
3. During an OB IFT, it needs to be clearly understood that the patient ultimately needs to get to the tertiary care facility in order to have a safe outcome. That decision rests with the sending provider under federal EMTALA laws.
   1. The KEY instance in which a transfer should be diverted to a closer facility is when crowning of the head at the vaginal orifice presents.  If the patient is having more frequent contractions, that is not an immediate indication to divert to another critical access facility along the way to the destination.
   2. Any cardiac or pulmonary arrest of the mother remains an acute reason to divert to the closest facility as well.

Protocol 1101: IFT Maintenance of Urinary Catheters

SCOPE:  EMT-B, AEMT, Paramedic

1. All personnel may transport patients with indwelling urinary catheters, including Foleys and suprapubic catheters.
2. In general, these should not be flushed or removed by the transferring crew. Urinary catheter complications seldom require emergent removal that cannot wait until arrival at the facility. Even blood clots in the catheter cannot result in significant damage within the radius of transfers completed by NWKS.
3. In the event the transferring facility is requesting a transfer crew to manipulate or flush an indwelling catheter, this should be reviewed with Medical Control to ensure it is safely within scope of practice, comfort level and training of the attending crew members.
4. A patient may continue to receive whole bladder irrigation if it has been initiated by the transferring facility.  In the event of a complication during transport, effort should be made to contact the sending facility or Medical Control for further guidance (eg a catheter no longer flushing easily).
5. Crews may further secure or modify the securing devices of urinary catheters to ensure they are not snagged

Protocol 1111: IFT Magnesium Sulfate Drip

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION:  Reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction.

ONSET:  Immediate when administered by IV

DURATION:  30 min when administered by IV

INDICATION:  Pre-eclampsia, or post-seizure eclampsia after seizure activity is stopped, hypomagnesemia, status asthmaticus unresponsive to beta-adrenergic drugs

CONTRAINDICATIONS:  Any heart block or myocardial damage, hypotension

ADVERSE REACTIONS: hypotension, facial flushing, hyporeflexia (decreased reflexes), bradycardia, respiratory depression, diaphoresis.

DRUG-DRUG INTERACTIONS: Calcium is both a direct competitor that will lower effectiveness, and may also be used as a reversal agent if suspected magnesium toxicity occurs.

DOSAGE:

• Eclampsia- 4-6 grams IV drip, administered over 20-60 minutes, followed by 2 grams per hour, with a max dose of 30-40grams/day.
• Hypomagnesemia- 1-2 grams IV drip, administered over 1-2 hours.
• Status asthmaticus- 25-50 mg/kg IV (max of 2 grams) usually diluted in 100ml D5W/NS, administered over 30 minutes.

CONSIDERATIONS:

• If overdose is suspected, contact the sending facility for consideration of administering calcium as antidote, if available.  Often, discontinuing the drip may be sufficient for duration of the transfer provided there is no significant hypotension, respiratory depression or bradycardia

Protocol 1112: IFT Sodium Bicarbonate Drip

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION:  An alkalinizing agent that restores acid-base balance by binding to acids which are then further reduced to CO2 and H2O; competitive sodium channel activation for sodium channel blockade overdoses (tricyclic antidepressants, propranolol, benzonatate “Tessalon” perles)

ONSET:  Between 5 and 30 minutes, depending on underlying clinical condition being treated

DURATION:  1 to 2 hours

INDICATION:  salicylate overdose, sodium channel blocker overdose (TCAs, Tessalon perles, propranolol), hyperkalemia, severe ketoacidosis

CONTRAINDICATIONS:  congestive heart failure, alkalotic states, hypernatremia

ADVERSE REACTIONS: alkalosis, hypernatremia, cerebral acidosis, acute CHF exacerbation, hypokalemia, hypocalcemia, hyperosmolality (causes hypotension)

DRUG-DRUG INTERACTIONS: avoid administering with calcium or epinephrine

DOSAGE:  150mEq in 1 Liter of D5%W (after removing 150ml)

• Infusion rates vary based on condition being treated, typically 200mL(30mEq)/hr up to a maximum of 1L(150mEq)/hr
• Verify the dose, concentration and rate of administration by written order from sending facility

CONSIDERATIONS:

• Excessive sodium bicarbonate therapy inhibits release of oxygen in bloodstream.
• When administered shortly before, with or after IV epinephrine, it may inactivate.  Flush between administration of different medications.
• Will precipitate if mixed with calcium chloride

Protocol 1113: IFT Potassium Drips

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION:  participates in the contraction of skeletal, cardiac and smooth muscle; participates in the maintenance of renal function, acid-base balance and intracellular tonicity

ONSET:  30-60 minutes

DURATION:  Up to 8 hours

INDICATION:  hypokalemia; concomitant use of IV potassium-wasting diuretics (Lasix) or insulin

CONTRAINDICATIONS:  hyperkalemia, acute renal failure; use with caution in severe burn patients

ADVERSE REACTIONS:  abdominal pain, nausea, vomiting,

EKG changes: Tall, tented (peaked) T waves, depressed ST segments, prolonged PR intervals, flattened P waves, Prolonged QRS and QT intervals, heart blocks, ectopic beats, ventricular arrhythmias, or asystole.

DRUG-DRUG INTERACTIONS: Incompatible with atropine, phenergan, sodium bicarbonate, azithromycin, diazepam, phenytoin and sodium nitroprusside.

DOSAGE:  10mEq/hr is the standard rate of IV administration.

• KCl infusion must be initiated by the sending facility.
• KCl infusions may vary in concentration, but should not exceed 40mEq in 1 liter of 0.9% Normal Saline.
• Greater rates of infusion may be administered through central lines (typically no more than 20mEq/hr); contact Medical Control for guidance in these instances.

CONSIDERATIONS:

• Cardiac monitoring is required for all patients receiving IV potassium.  Drip should be halted if any ECG signs of hyperkalemia (particularly a widening QRS) are detected.
• Patients may experience pain at the site of administration.  If discomfort is significant enough to warrant discontinuing the infusion, contact sending facility or Medical Control for further guidance.  

Protocol 1114: IFT Hypertonic Saline (3%) Drips

(Includes 23.4% saline and 7.5% saline for cerebral edema)

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION:  1) Direct replacement of sodium in hyponatremic patients.  Direct sodium channel agonist when treating sodium-channel blocking overdoses (tricyclic antidepressants, propranolol, benzonatate “Tessalon” perles, etc).

ONSET:  30 minutes to 2 hours, depending on use and rate

DURATION:  Over 24 hours

INDICATION:  Symptomatic hyponatremia, sodium-channel blocker overdoses (TCAs, propranolol, Tessalon), Addisonian crisis, diabetic coma with true severe hyponatremia (after accounting for pseudohyponatremia)

CONTRAINDICATIONS:  hypernatremia, acute congestive heart failure, kidney failure

ADVERSE REACTIONS:  pulmonary edema, irreversible central pontine myelinolysis “locked-in syndrome”

DRUG-DRUG INTERACTIONS: binds with lithium, reducing serum lithium levels

DOSAGE:

• Hyponatremia with Severe Neurologic Deficits:  100ml over 10 min IV; repeat up to 2 doses until symptoms resolve, then administer 100ml over 1 hour.
• Hyponatremia with Mild/Moderate Neuro Symptoms: 1-2ml/kg/h, rechecking sodium level every 1-2 hours before repeat dosing.   
• Sodium Channel Blocker Overdose: 100ml IV bolus, repeat every 10 minutes up to a total of 3 doses.  Usually given only in cases of refractory hypotension resistant to vasopressors.
• Aneurysmal Subarachnoid Hemorrhage with Herniation: 250ml infused over 20-30 minutes.
• Cerebral Edema with Herniation: 3ml/kg IV bolus over 20 minutes.
• Note: in cases of cerebral edema, different concentrations of hypertonic saline (23.4% saline or 7.5% saline) may be used.
  • 23.4% NaCl: 30ml IV bolus over 20-30 minutes, Max of 2 doses.
  • 7.5% NaCl: 1ml/kg IV bolus over 20 minutes.
  • In all cases, the exact concentration, dose and duration of the drip should be provided in writing by the sending facility. The transfer crew should not be responsible for mixing or initiating these drips unless it is in written orders to have repeat doses while en route.

CONSIDERATIONS:

• The exact dose should be calculated, written in orders for the EMS crew, and initiated by the sending facility at all times.  Rate should not be changed during transport.

Protocol 1120: IFT Antibiotic Drips

SCOPE:  AEMT, Paramedic

MECHANISM OF ACTION:  Various classes of antibiotics have different mechanisms of action.  The purpose of IV administration is a more rapid, systemic administration that is not reliant upon GI tract for uptake and distribution.

ONSET:  varies by class of antibiotic

DURATION:  varies by class of antibiotic

INDICATION:  sepsis, infection, prophylaxis or empiric coverage for potential life-threatening infections that have not been definitively ruled out by available testing (e.g. bacteremia or meningitis)

CONTRAINDICATIONS:  Known allergy to the antibiotic or class of antibiotics

ADVERSE REACTIONS: nausea, vomiting, diarrhea, fevers, allergic reactions, rashes, Stevens-Johnson syndrome, laryngeal edema, anaphylaxis, Toxic Epidermal Necrolysis, renal failure (aminoglycosides)

DRUG-DRUG INTERACTIONS: IV compatibility should be verified by sending facility for any other drips or electrolytes going through the same IV.

DOSAGE:  varies by antibiotic, must be verified by sending facility for each specific transport.  Most antibiotics are administered over 30-60 minutes, though several classes including aminoglycosides and vancomycin are often slow, multi-hour administrations.

CONSIDERATIONS:

• Antibiotic therapy must be initiated by the sending facility.
• Verify dose, concentration and drip rate, to be provided by the sending facility.
• Verify all patient allergies before assuming care of antibiotic drips.
• All antibiotic drips should be infused using an IV infusion pump, at a rate to be specified by the sending facility provider or RN.  A written order from the sending provider should accompany the medication.
• In event of any sign of allergic reaction, stop the antibiotic and notify either the sending facility or Medical Control for further instructions.  Anaphylaxis may be addressed by the AEMT/Paramedic as per existing protocols.  

Protocol 1200: IFT Paramedic/RN-level IV Drip/Push Medications

1. These protocols list all IV drips that NWKS paramedics and RNs should be trained and competent to monitor en route during an interfacility transport.
2. The sending facility should, at all times, have initiated any initial bolus and starting IV drip rate.  NWKS personnel are trained to continue, maintain and monitor, but are not authorized to initiate these medications.
3. NWKS personnel should ensure there are written orders specifying the dosage, concentration, drip rate, and the ordering provider’s name and credentials.
4. ANY concerns by the sending facility about needing to initiate their own ordered medications, and NKWS personnel should immediately contact online medical control or the medical director liaison.
5. These protocols are designed to provide guidance for the maintenance of medications provided by the facility.  In order for NWKS personnel to do so, the facility will still need to provide full and appropriate amounts of the ordered medication drips for the duration of transport, as these medications are not carried by the NWKS service.
6. ANY concerns by the sending facility about the content or requirements of these protocols should be forwarded to the medical direction liaison.  

Protocol 1201: IFT Blood Product Administration

SCOPE:  Paramedic

MECHANISM OF ACTION:  Blood administration may be required to restore circulating blood volume, improve oxygen-carrying needs, or correct specific coagulation or inflammation components.  The blood product may be in the form of:

1. Whole Blood
2. Packed Red Blood Cells
3. Platelets
4. Fresh Frozen Plasma
5. Cryoprecipitate
6. Albumin
7. Plasma Protein Fractions (albumin, globulins)
8. Synthetic Blood Substitutes
9. Complement Factors

INDICATION:  hemorrhagic hypovolemia, symptomatic anemia, insufficient clotting factors, pre-surgical prophylaxis, familial angioedema (Complement Factors)

CONTRAINDICATIONS:  Inaccurate blood type, sufficient hemoglobin/hematocrit

BLOOD TRANSFUSION REACTIONS: ANAPHYLAXIS, HEMOLYTIC REACTION, DISSEMINATED INTRAVASCULAR COAGULATION, TRANSFUSION REACTION, INFECTION

KEY SIGNS OF COMPLICATIONS:

1. Body temperature elevating more than 2 degrees Fahrenheit above baseline temperature
2. Hives, itching, rashes
3. Swelling, soreness or hematoma at venous site
4. Flank pain
5. Tachycardia
6. Respiratory distress
7. Hypotension
8. Bleeding from various sites or previously clotted wounds
9. Hematuria
10. Anaphylaxis
11. Nausea and vomiting

DRUG-DRUG INTERACTIONS: Do not mix with D5%W (causes hemolysis), Lactated Ringers (causes clotting) or any medications.  Have a second line available if medications need to be administered.

ADMINISTRATION:

1. Verify with the transferring nurse the blood bank paperwork that demonstrates it is the correct product for the correct patient.
2. Sending facility should have initiated and monitored the first 15 minutes of administration for any signs of complications prior to transport.
3. Confirm written order for rate of administration by IV pump.
4. Assess baseline vital signs and temperature.
5. Ensure adequate venous access for IV blood products, plus additional site if needed for additional or PRN medications during transport.
6. Flush primary tubing with normal saline.
7. Connect to blood tubing, may either piggyback into IV line of normal saline or substitute in place of saline line.
8. Monitor every 5 minutes for adverse symptoms
9. Document vital signs including temperature every 10 minutes for first hour, then every 30 minutes until blood product is complete.
10. Document time blood initiated and completed, and deliver all blood bank paperwork and empty product unit bags to receiving facility.

CONSIDERATIONS:

• In the event of a blood transfusion reaction, consider the primary presentation:
  • Respiratory distress with rales is likely fluid overload. Contact medical control to consider oxygen and diuretics (if available).
  • Urticaria and hypotension is likely anaphylaxis. Consider Anaphylaxis protocol 318.
  • Treat fever with antipyretics (Tylenol 1 gram orally).
  • Treat hypotension with IV fluid bolus.
  • Immediately Discontinue the transfusion.
  • Notify sending, receiving, or Medical Control provider as soon as possible, depending on your proximity to destination.
• In the event an emergent transfer does not permit for initial 15min/50ml administration prior to transport, notify Medical Control or Medical Direction Liaison as soon as possible after transport (e.g. critical pediatric trauma requiring emergent surgery).

Protocol 1202: IFT Insulin Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Insulin combines with glucose and potassium to transport glucose molecules into cells for metabolism.  IV insulin requires an adequate store of potassium to be present before IV insulin can be used.

ONSET:  30 minutes with peak effect at 1 hour

DURATION:  3 to 6 hours

INDICATION:  diabetic ketoacidosis

CONTRAINDICATIONS:  hypokalemia, insulin allergy

ADVERSE REACTIONS: hypokalemia, hypoglycemia

DRUG-DRUG INTERACTIONS: Insulin must be administered through it’s own IV line.

DOSAGE:  varies by patient size, insulin sensitivity.  Sending facility needs to provide initial / current dosage.

Follow the below dosing adjustment chart for adjustments during transport, unless provided with a different adjustment chart by the sending facility:

BGL	Units/hr	D5NS
<70	OFF	250ml/hr
70-109	0.5units/hr	250ml/hr
110-119	1 unit/hr	250ml/hr
120-149	1.5 units/hr	150ml/hr
150-179	2 units/hr	125ml/hr
180-209	3 units/hr	100ml/hr
210-239	4 units/hr	75ml/hr
240-269	5 units/hr	50ml/hr
270-299	6 units/hr	OFF
300-329	7 units/hr	OFF
330-359	8 units/hr	OFF
> 360	10 units/hr	OFF

CONSIDERATIONS:

• Check patient’s BGL at time of transferring insulin drip to your IV pump.
• Check BGL every hour thereafter.
• Insulin dose adjustments should only be done every hour unless signs of hypoglycemia are present.
• Regular insulin is the ONLY kind of insulin for IV administration.
• Initiate D5%NS or D5 ½ NS when blood glucose reaches 269 or less, per chart above.
• DO NOT start or continue insulin if potassium is less than 3.2 mEq/L on labs.
• Patients with a potassium level below 4.0 typically require additional potassium to prevent halting insulin drip due to low potassium levels.  Confirm with sending facility the current potassium level and amount of replacement potassium given.  If any concerns, contact Medical Control.  

Protocol 1203: IFT Proton Pump Inhibitor Drips

(Protonix, Nexium)

SCOPE:  Paramedic

MECHANISM OF ACTION:  Suppresses gastric acid secretion by inhibition of hydrogen-potassium-ATPase pump in the gastric parietal cell.

ONSET:  15-30  minutes

DURATION:  Effect of suppression lasts up to 24 hours depending on the dose

INDICATION:  Zollinger-Ellison lesion, GI bleed, Peptic Ulcer disease

CONTRAINDICATIONS:  allergic reaction

ADVERSE REACTIONS: nausea, vomiting, heartburn, stomach pain, allergic reactions, dizziness, headache, joint pain

DRUG-DRUG INTERACTIONS: multiple incompatibilities with other IV medications.  Any concomitant IV drips should be confirmed for compatibility with sending facility.

DOSAGE

• Protonix: 80mg IV Push, followed by 8mg/hour infusion for 72 hours.
• Nexium: 80mg IV Push, followed by 8mg/hour infusion for 72 hours.
• Initial push dose and initiation of drip should be started by sending facility.

CONSIDERATIONS:

• This medication may at times be paused by a sending facility in order to allow for a lower (AEMT or BLS) level of transfer. The level of anemia and/or GI bleeding are key factors in whether this can be done.  

Protocol 1204: IFT Histamine H2 Antagonist Drips

(ranitidine, famotidine, cimetidine)

SCOPE:  Paramedic

MECHANISM OF ACTION:  Competitive inhibition of histamine at H2-receptors of the gastric parietal cells, which inhibits gastric acid secretion and hydrogen ion concerntraion.  Has a secondary effect of blocking histamine reactions that propagate gastrointestinal components of allergic reactions.

ONSET:  60 minutes

DURATION:  4 to 10 hours

INDICATION:  GI bleeds, Zollinger-Ellison lesion, pain related to GI ulcers, allergic reactions

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

ADVERSE REACTIONS: arrhythmias with rapid IV administration, confusion, dizziness, hallucinations, vertigo, rashes, abdominal pain, diarrhea, nausea, vomiting, anemia, hepatitis, jaundice, pain at injection site, blurry vision, arthalgias, renal failure, angioedema

DRUG-DRUG INTERACTIONS: Use with caution in patients with antiarrhythmics or in conjunction with other medications that can cause renal failure

DOSAGE:       

• ranitidine (Zantac): IV intermittent bolus of 50mg over 3-4 minutes every 6-8 hours or infusion of 6.25mg/hour;
• famotidine (Pepcid): IV bolus of 20mg over 2 minutes every 12 hours or infusion of 100mg/hour for 1 hour.
• cimetidine (Tagamet): IV infusion of 300mg over 15-20 minutes, or 900mg in 1 Liter of normal saline infused over 24 hours.

CONSIDERATIONS:

• There is wide variability in how these medications can be mixed, from 50ml to 1000ml bags.  They can be bolused slowly or infused gradually.  They should never be given by rapid IV push, and any drips should always be by IV pump.
• Use with caution, and at decreased infusion rate in elderly patients with renal insufficiency.

Protocol 1205: IFT Octreotide IV Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Slows splanchnic and GI tract blood flow, thereby reducing pressure on any bleeding esophageal varices.

ONSET:  Approximately 20 minutes

DURATION:  Up to 96 hours

INDICATION:  GI Bleeding from esophageal varices

CONTRAINDICATIONS:  allergic reaction

ADVERSE REACTIONS: dizziness, nausea, constipation, irregular heartbeat, bradycardias, headache, joint pain, rash, cold sensation, hoarseness

DRUG-DRUG INTERACTIONS: some beta blockers and antiarrhythmics, methadone

DOSAGE:  50mcg IV bolus, then 25-50mcg/hour.  Bolus should be completed by sending facility, and drip should be initiated prior to transport.

CONSIDERATIONS:

• This medication is not typically used for generic GI bleeds, only those associated with esophageal varices.

Protocol 1206: IFT Terbutaline (SC)

SCOPE:  Paramedic

MECHANISM OF ACTION: Beta-2 adrenergic agonist that relaxed uterine myometrium, slowing rate of contractions.  As a beta-2 adrenergic agonist, can also be used for bronchodilation in refractory asthma.

ONSET:  Approximately 15 minutes

DURATION:  Up to 6 hours

INDICATION:  premature contractions, refractory asthma

CONTRAINDICATIONS:  Use must be limited to short term, less than 48 hours, due to worsening cardiotoxicity in cumulative doses.

ADVERSE REACTIONS: nervousness, tremors, headaches, tachyarrhythmias, hallucinations, cardiac arrest, hypotension

DRUG-DRUG INTERACTIONS: Certain antidepressants can worsen side effects of terbutaline; beta blockers can limit the effects.

DOSAGE:  0.25mg Subcutaneous injection.  Repeat every 20 minutes to a maximum of 0.75mg in 1 hour period.

CONSIDERATIONS:

• This medication received a black box warning in 2011 from the FDA for repeated or prolonged use in pregnant patients due to the toxic side effects of cumulative doses.  Repeat doses should be confirmed in written orders from the sending provider, including frequency and total number of maximum doses.  

Protocol 1207: IFT Acetaminophen (IV)

SCOPE:  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, hypertension, infusion site pain

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

DOSAGE:

• 1,000mg in 100ml over 15-30 minutes, may repeat every 6 hours.
• Alternative 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 1208: IFT TPN

(includes other parenteral nutritional elements)

SCOPE:  Paramedic

MECHANISM OF ACTION: Provides nutritional fats, lipids, proteins and carbohydrates by IV administration.

ONSET:  Gradual over 1 hour

DURATION:  Duration of the IV drip

INDICATION:  Patients unable to maintain sustenance to sustain life; prolonged hypermetabolic state, coma or surgical candidates

CONTRAINDICATIONS: Severe Hyperlipidemia, pancreatitis due to hyperlipidemia, hypersensitivity to any component (eg egg or soybean proteins)

ADVERSE REACTIONS: headache, flushing, dizziness, chest pain, back pain, hypersensitivity reactions, hyperthermia, irritation at injection site, nausea/vomiting, sweating

DRUG-DRUG INTERACTIONS: Cannot be given with any other medications.

DOSAGE:

• Patient size and condition cause this to vary greatly; Initial dose typically 1 to 1.5 gm/kg/day,
• at rate of 0.5ml/min for first 30 minutes, then may be increased gradually to rate of 0.5ml/kg/hr
• not to exceed 500ml of 20% Intralipid on first day. Max of 2.5Gm/kg/day.

CONSIDERATIONS:

• Intralipid 30% cannot be given by direct IV infusion, therefore the bulk packaged lipids must be combined and diluted with amino acids and dextrose by the sending facility so total fat content does not exceed 20%.
• Requires use of a 1.2-micron in-line filter, to be provided by the sending facility.
• Do not use if there appears to be an ‘oiling-out’ separation of layers of the emulsion

Protocol 1211: IFT Heparin Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Potentiates the action of antithrombin III and thereby inactivates thrombin and activated coagulation factors IX, X, XI, XII, and plasmin, and prevents the conversion of fibrinogen to fibrin, thus halting the clotting cascade from forming further clots.

ONSET:  Approximately 20 – 60 minutes

DURATION:  2 to 6 hours

INDICATION:  NSTEMI, ACS, PE, extremity thrombus or emboli

CONTRAINDICATIONS: ACTIVE GI Bleeds, blood clot disorder, trauma, intracranial bleeds, recent surgery

ADVERSE REACTIONS: nausea, vomiting, stomach pain, allergic reactions, bleeding, headaches, arthralgias

DRUG-DRUG INTERACTIONS: May be given with/after aspirin, but rarely in patients who are already anticoagulated.  Requires it’s own IV line due to many incompatible IV drug interactions.

DOSAGE:       

• Cardiac: 60 u/kg bolus (Max of 4000 u), followed by 12u/kg/hr;
• Pulmonary Emboli: 80 u/kg bolus (Max of 8000 u), followed by 18u/kg/hr;
• Bolus and initial drip rate should be initiated by sending facility.
• NOTE:  Patients who have been in a facility for more than 4-6 hours of heparin infusion may have different infusion rates due to results of coagulation studies (aPTT) which direct the fine-tuning of heparin dosing periodically.  Therefore, the paramedic should always inquire as to what the current rate of flow is.

CONSIDERATIONS:

• There are several other rare uses of heparin outside of cardiac and PEs.  If any uncertainty, contact Medical Control to discuss rates and doses.
• Heparin must be infused through its own IV.
• Monitor any recent surgical sites, mental status, vital signs for any signs of hemorrhage.  These patients require regular mental status and vital sign monitoring for the duration of transport

Protocol 1212: IFT Nitroglycerin Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Vasodilator and vascular smooth muscle relaxant; reduces preload (primarily venous) and afterload (at higher doses,through arteriodilatation)

ONSET:  1-2 minutes

DURATION:  20-25 minutes

INDICATION:  NSTEMI, unstable angina, acute CHF exacerbation, hypertensive emergencies

CONTRAINDICATIONS:  sensitivity to nitrates, increased intracranial pressure, hypovolemia, use of erectile dysfunction medications within past 48 hours, right-sided Myocardial Infarction

ADVERSE REACTIONS: irregular heart rate, dizziness, lightheadedness, headache, tired/weak, dyspnea, cyanosis, hypotension

DRUG-DRUG INTERACTIONS: erectile dysfunction medications, calcium channel blockers, beta blockers

DOSAGE:       

• ACS/angina: 5-50mcg/minute, titrated by increments of 5 mcg/minute every 5 minutes until effect or drop in blood pressure.  Maximum of 200mcg/minute.
• Acute CHF  “flash Pulmonary Edema”:  50mcg to 200mcg/minute, maximum of up to 800mcg/minute.  These high doses are necessary to achieve significant reduction in afterload through arteriodilatation, which requires much stronger doses.  This dosing regimen should only be initiated by the sending facility, never by EMS personnel during transport.  
• *** In the event hypotension begins to develop, the IV drip should not be suddenly stopped, but should be titrated down in 10mcg increments every 3-5 minutes unless shock develops.

CONSIDERATIONS:

• Oral nitroglycerin is insufficient as a substitute for high dose IV nitroglycerin.
• As there is wide dosing variability depending on the condition being treated, the medic needs to be certain to have written orders from the sending facility indicating increments and upper limit of dosing.  
• IV drip nitroglycerin is one of the few medications that IS COMPATIBLE with IV heparin, and can be administered through the same IV line.  

Protocol 1213: IFT Thrombolytics

                                               (Alteplase “tPA”, Tenecteplase “TNK”)

SCOPE:  Paramedic

MECHANISM OF ACTION:  Attaches to fibrin clot and activates plasminogen to break up the clot.  TNK is 14 times more fibrin specific than tPA, with a longer half-life in the body.

ONSET:  30-60 minutes

DURATION:  30-90 minutes (tPA) 3-4 hours (TNK)

INDICATION:  embolic stroke, Acute MI, Massive Pulmonary Embolism

CONTRAINDICATIONS:  allergy, bleeding diathesis, internal bleeding, intracranial hemorrhage, intracranial neoplasms or arteriovenous malformations/aneurysms, recent surgery/head trauma/stroke within 3 months, severe uncontrolled hypertension

ADVERSE REACTIONS: intracranial hemorrhage, GI bleed, pericardial effusion/tamponade, stroke, seizure, pulmonary edema, cardiac dysrhythmia, anaphylaxis/angioedema

DRUG-DRUG INTERACTIONS: Extremely high risk of bleeding is associated with combination of thrombolytics with other blood thinners.

DOSAGE:       

• tPA (Alteplase):    Acute MI > 67KG: 15mg bolus over 1-2 min, then 50mg IV over 30 min, then 35 mg over next 60 min ( 100mg total over 90 minutes)
  • Acute MI < 67KG: 15mg IV bolus over 1-2 min, then 0.75mg/kg (max 50 mg) IV over 30 min, then 0.5mg/kg over 60 min (max 35mg)
  • Acute Ischemic Stroke: 0.9mg/kg IV (max 90mg total); 10 % of dose is given as a bolus, the rest over 60 minutes IV drip
  • Massive PE: 100mg IV over 2 hr OR 0.6mg/kg over 2 min
  • Massive PE WITH Cardiac Arrest: 50mg IV over 2 min, followed by 50mg IV push after 15 minutes, if needed
• TNK (Tenecteplase): Acute MI:      
  • <60kg: 30mg IV bolus over 5 seconds
  • 60-69kg: 35mg IV bolus over 5 seconds
  • 70-79kg: 40mg IV bolus over 5 seconds
  • 80-89kg: 45mg IV bolus over 5 seconds
  • >90kg: 50mg IV bolus over 5 seconds
  • Massive PE: 50mg IV bolus or 0.5mg/kg bolus
  • Acute Embolic Stroke: 0.25mg/kg bolus

CONSIDERATIONS:

• Initial bolus should be completed by transferring facility.  In the case of TNK, no IV drip is warranted after the bolus.
• Various stroke alert protocols may have more specific doses for a patient where a weight was obtained.  Those protocols remain within these dosing regimens, but provide a chart of more specific weight amounts.  Verify the written order for any ongoing tPA drip at time of transfer.
• These patients require frequent neurologic and vital sign monitoring.  Contact the sending provider or Medical Control immediately if there is a sudden change.  

Protocol 1214: IFT Glycoprotein IIb/IIIa Platelet Inhibitors

(Tirofiban “Aggrastat” and Eptifibatide “Integrilin”)

SCOPE:  Paramedic

MECHANISM OF ACTION: Antagonist of platelet receptors that prevent fibrinogen from binding to platelets, thereby preventing formation of further fibrin clot onto the platelets.  Further works to inhibit platelet aggregation.    

ONSET:  10 minutes

DURATION:  Up to 8 hours

INDICATION:  Non-ST Elevation MI, Unstable angina

CONTRAINDICATIONS: hypersensitivity, thrombocytopenia (low platelet count), active internal bleeding or recent bleeding diathesis, major surgery or severe physical trauma within the past month.

ADVERSE REACTIONS: Bleeding, bradycardia, dizziness, edema, nausea, pelvic pain, sweating, vasovagal syncope

DRUG-DRUG INTERACTIONS: Increases risk of bleeding when given with other anticoagulants or NSAIDS.

DOSAGE:       

• Tirofiban (Aggrastat): Loading Dose of 25mcg/kg over 5 minutes, followed by Maintenance Infusion of 0.15 mcg/kg/min for up to 18 hours.  Dose may be adjusted lower for those with renal insufficiency.
• Eptifibatide (Integrilin): Loading Dose of 180mcg/kg over 2-3 minutes, followed by Maintenance Infusion of 2mcg/kg/min for up to 96 hours.  Dose may be adjusted lower for those with renal insufficiency.

CONSIDERATIONS:

• These medications, when used, may be combined with Aspirin, Heparin, clopidogrel, or a combination of these.  The combination or addition of these medications is a determination made by the sending provider in consultation with the receiving cardiologist, based upon a combination of factors including EKG findings, past medical history, prior cardiac procedures, length of time of the myocardial injury, and length of time until the appropriate procedure can be safely performed.  

Protocol 1221: IFT Calcium Chloride/Gluconate

SCOPE:  Paramedic

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), hypocalcemia due to multiple blood products administered during Mass Transfusion Protocols for trauma patients.

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:   NOTE:         MORE POTENT: Calcium Chloride contains 13.4mEq per 1 gram of CaCL 10%.

LESS POTENT: Calcium GLUCONATE contains 4.3 mEq per 1 gram of CaGlu, so is roughly 1/3 the total calcium dose of Calcium Chloride.

• Calcium Chloride:  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:  1 gram slow IV push, up to 3 doses, by central line or large antecubital peripheral line, or may follow first dose by infusion of 60 – 150mg/kg/hr.
  • Mass Transfusion Protocol: 1 gram of IV calcium chloride for every 5-6 units of blood.  Sending provider may order additional doses based upon ionized calcium results.
• Calcium GLUCONATE:
  • Calcium channel blocker/beta blocker overdose: 3 grams slow IV push, may be given through a peripheral IV.  May repeat up to 3 doses.
  • Infusion may be initiated after initial dose at 5.5mg/kg/hr, up to a maximum of 21 mg/kg/hr, or bolus dose may be repeated every 6 hours.
  • Mass Transfusion Protocols:  In absence of ionized calcium, it is appropriate to give 1 gram of Calcium GLUCONATE (not chloride) after every 2-3 units of blood product transfusion.  This should be by written order of the sending provider, and the facility should provide any medication not carried on the ambulance.
• ANY TITRATION OR INCREASE IN AN ONGOING CALCIUM INFUSION SHOULD BE APPROVED BY THE SENDING PROVIDER, EITHER BY WRITTEN ORDER PRIOR TO TRANSFER OR BY PHONE/RADIO CONTACT PRIOR TO INCREASING THE RATE OF TITRATION.
• PEDIATRIC: Calcium chloride: 20mg/kg, max of 1gm slow IV/IO push (over 2 minutes) ,
  • may repeat every 10 minutes for a total of 3 doses.
  • IV infusion rate is 30-60mg/kg initial bolus followed by infusion at 8mg/kg/hr to a maximum of 13 mg/kg/hr.
  • Bolus rate should not exceed 100mg/min in pediatric patients.

CONSIDERATIONS:

• Calcium infusions are very high risk, and should not be titrated (increased) unless specifically directed by the treating provider. While this is an electrolyte, because of the many different types of doses and the high potential for adverse effects, it requires paramedic or RN level for transfers.
• Calcium chloride should NOT be used routinely in all cardiac arrests, only in those where specific indications are suspected.
• Calcium chloride should be administered through a central line, PICC line, port or large peripheral line in the antecubital.
• With calcium chloride use, there is a greater chance of overshooting the calcium levels in the body.   If the sending facility has ordered repeat doses without being able to provide an ionized calcium level, contact Medical Control to arrange discussion with the sending provider about the amount of calcium to be administered by the paramedic during transport.  

Protocol 1222: IFT Lipid Infusion

SCOPE:  Paramedic

MECHANISM OF ACTION: Binds to tricyclic antidepressants (which are highly lipid-soluble), to decrease amount of circulating toxin during an overdose.  May be used in a similar manner for other overdoses with medications that are highly lipid-soluble, including anesthetics, beta blockers, calcium channel blockers, herbicides and some psychotropic medications.

ONSET:  less than 10 minutes

DURATION:  Some effect up to 6 hours

INDICATION:  Overdose of toxin that is lipophilic (binds to lipids)

CONTRAINDICATIONS: Severe Hyperlipidemia, pancreatitis due to hyperlipidemia, hypersensitivity to any component (eg egg or soybean proteins)

ADVERSE REACTIONS: headache, flushing, dizziness, chest pain, back pain, hypersensitivity reactions, hyperthermia, irritation at injection site, nausea/vomiting, sweating

DRUG-DRUG INTERACTIONS: Cannot be given with any other medications.

DOSAGE:

• OVERDOSE: 1.5ml/kg IV bolus over 2-3 minutes. Repeat x 1 if still unstable.
• Maintenance infusion: ILE 20% 15ml/kg over 60 minutes.

CONSIDERATIONS:

• Intralipid 30% cannot be given by direct IV infusion, therefore the bulk packaged lipids must be combined and diluted with amino acids and dextrose by the sending facility so total fat content does not exceed 20%.
• Requires use of a 1.2-micron in-line filter, to be provided by the sending facility.
• Do not use if there appears to be an ‘oiling-out’ separation of layers of the emulsion.

Protocol 1223: IFT Pit Viper Antivenom Antidote

(CroFab, AnaVip)

SCOPE:  Paramedic

MECHANISM OF ACTION:  CroFab and AnaVip are a venom-specific fragment (FAB) of immunoglobulin G (IgG) that binds to and neutralizes venom toxins.  AnaVip has twice the number of binding sites and lasts for up to 130 hours.

ONSET:  Within 1 hour

DURATION:  1-2 days (Cro-Fab), 5 days (AnaVip)

INDICATION:  suspected envenomated snake bite by pit viper species (rattlesnake, copperhead, cottonmouth water moccasin)

CONTRAINDICATIONS:  papaya allergy, known hypersensitivity

ADVERSE REACTIONS: urticaria, rash, nausea, itching, back pain

DRUG-DRUG INTERACTIONS: beta-blockers can increase the severity and duration of any anaphylactic reactions during administration of CroFab. This doesn’t mean it cannot be given, but providers should be aware of any beta blocker usage prior to administration.

DOSAGE:       

• CroFab:
  • Mild envenomation: 4 vials
  • Moderate: 4-6 vials
  • Severe: 8-12 vials
  • Initial dose should be diluted in 250mL of 0.9% normal saline.  Infusion starts slowly at 25-50ml/hr for 10 min, and if tolerated, infuse the remainder of the dose within 1 hour.
  • Repeat dose with 4-6 vials if control is not achieved with the initial dose.
  • 2 Vials every 6 hours up to 18 hours until all labs and signs have normalized.
• AnaVip:
  • 10 Vials.
  • Repeat Dose only if continued symptoms: 4 vials.

CONSIDERATIONS:

• This dosing regimen means that a transferring medic may assume care at various points along the dosing regimen.  Clarify what has been given so far, and how often repeat doses are indicated on written orders from the sending provider.
• Any sign of developing anaphylaxis, and the infusion should be stopped immediately.  Contact the sending provider or Medical Control.  Standard anaphylaxis treatment (as per 911 protocols) is appropriate in response to any acute anaphylactic emergency.

Protocol 1224: IFT N-AcetylCysteine (Mucomyst)

SCOPE:  Paramedic

MECHANISM OF ACTION:  Protects the liver from acetaminophen metabolite toxicity by replenishing hepatic stores of glutathione, the principle enzyme that binds to acetaminophen metabolites.

ONSET:  30-60 minutes

DURATION:  Up to 48 hours

INDICATION:  Acute acetaminophen overdose.

CONTRAINDICATIONS:  Chronic acetaminophen overdose where liver damage is already present.

ADVERSE REACTIONS: facial flushing, rash, urticaria, tachycardia, nausea, vomiting, allergic reactions, bronchospasm

DRUG-DRUG INTERACTIONS: No known specific interactions.

DOSAGE:  NAC or Mucomyst is a 3 dose regimen:

1. Loading dose of 150mg/kg in 200ml over 1 hour
2. Second dose of 50mg/kg in 500ml over 4 hours
3. Third dose of 100mg/kg in 1,000ml over 16 hours.

CONSIDERATIONS:

• Clarify with sending facility how much has already been given, and which of the 3 phases are currently underway.  Transfer crews may need to initiate second or third dose of regimen during transport.

Protocol 1225: Narcan Drip

SCOPE:  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:        Calculate Total Effective Initial Dose (T.I.E.D): the total amount of Narcan given to achieve reversal of respiratory depression.

1. IV maintenance drip is determined by calculating 2/3 (two-thirds) of the T.I.E.D. This 2/3 amount is the amount given over 1 hour by IV drip, every hour for a period of 4 to 6 hours.
2. IV drip is made for 6 hour time frame, therefore 6 x T.I.E.D. is the amount mixed into IV drip bag of NS or D5W.

• Example A:  It takes 6mg to reverse respiratory depression in one adult patient, then the initial hourly dose is 2/3 of 6mg = 4mg per hour.   The sending facility should mix 6 hours x 4mg/hr for a total of 24 mg in any amount of NS or D5W, preferably a 100ml bag, for a concentration of 2.4mg/10ml, run at 16.7ml/hr.
• Example B: It takes 15mg to reverse respiratory depression in a patient that overdosed with oxycodone. The initial hourly dose is 2/3 of 15mg = 10mg per hour.  The sending facility should mix 6 hours x 10mg/hr for a total of 60mg in any amount of NS or D5W, preferably a 100ml bag, for a concentration of 6mg/10ml, run at 16.7ml/hr.

CONSIDERATIONS:

• The mixing of Narcan is a very infrequent event, and therefore there is very wide variation of how local ERs or pharmacists will mix this.  For this reason, confirm with the sending facility the concentration of drug (Quantity of Narcan in mg) mixed into IV solution (Quantity of D5W in ml), and the length of time the IV drip will last, in case of prolonged transport.  This may be mixed by the paramedic if approved by the sending provider.  Make certain you have sufficient amount of Narcan for the mix.
• When given to a patient that does NOT have respiratory depression, Narcan can potentiate sudden, severe withdrawal symptoms. This should be avoided.

Protocol 1231: IFT Epinephrine Drip and Push-Dose Epi

SCOPE:  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, septic shock, shock secondary to beta blocker/calcium channel blocker overdose

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: Epinephrine should not be given with sodium bicarbonate at the same time as the sodium bicarbonate will inactivate the epinephrine.  Similarly, epinephrine drips should not be infused with blood products for similar reasons of decreased effectiveness of the epinephrine.

Dosage:  NOTE: the only doses noted here are specific to IV push-dose or IV drips.  The EMS/911 protocol for epinephrine remains the primary protocol for any acute cardiac arrest, anaphylaxis, pediatric bradycardia, etc.

• 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:

• 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.

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Protocol 1232: IFT Dopamine Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  at Dopaminergic levels (2-5mcg/kg/min) causes blood vessels to relax and facilitates kidney perfusion, urine production and sodium secretion through kidneys (therefore known as the ‘renal dose’). At higher levels of 6-20 mcg/kg/min, is a direct alpha and beta-adrenergic agonist, resulting in increased cardiac contractility and peripheral vasoconstriction (venous and arterial).

ONSET:  1-5 minutes

DURATION:  effects cease almost immediately after infusion is shut off

INDICATION:  renal failure, poor perfusion due to sepsis, neurogenic shock, cardiogenic shock due to CHF or AMI, bradycardia with hypotension refractory to atropine and pacing

CONTRAINDICATIONS:  uncontrolled tachyarrhythmias, ventricular irritability, hypertension, shock due to volume loss (dehydration, hemorrhage, etc)

ADVERSE REACTIONS: tachycardia, ,hypertension, ventricular irritability, angina, anxiety, decreased peripheral perfusion, tissue necrosis with infiltration

DRUG-DRUG INTERACTIONS: Inactivated when added to sodium bicarbonate.  Cannot push any other IV push meds through a dopamine line.  Beta blockers can limit effects of dopamine.  Dilantin (phenytoin) may cause severe hypotension, bradycardia and seizures when given with dopamine.

DOSAGE:       

• Dopaminergic (renal) dose: 2-5 mcg/kg/min
• Beta agonist (cardiac) dose: 5-15mcg/kg/min
• Alpha agonist (vasopressor) dose: > 15mcg/kg/min
• Clarify with sending facility for which of the three purposes above dopamine is being given.  Drip
• should be initiated by sending facility and concentration/IV pump settings confirmed by transporting medic.

CONSIDERATIONS:

• Dopamine has the potential to cause ventricular or supraventricular tachyarrhythmias, and should be closely monitored.
• Dopamine IV Pump Formula for initial dose setup:

Dose (mcg/kg/min) x weight (kg) x Time Factor (60min/hr)

-----------------------------------------------------------------------------   = mL/hr

                         Concentration (mcg/mL)

Protocol 1233: IFT Dobutamine Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  A synthetic related to dopamine, dobutamine predominantly affects Beta adrenergic sites, with Beta – 1 (inotropy) > Beta – 2 (bronchodilation)

ONSET:  2-10 minutes

DURATION:  5-10 minutes

INDICATION:  septic or cardiogenic shock provided SBP > 80mmHg, often used as second agent along with dopamine or another vasopressor that was first used to increase SBP to this level.

CONTRAINDICATIONS:  severe hypotension, idiopathic hypertropic subaortic stenosis, hypertension, atrial fibrillation with RVR, severe CAD or ongoing AMI

ADVERSE REACTIONS: tachyarrhythmias, hypertension, myocarditis, PVCs, angina, dyspnea, fever, headache, nausea, palpitations, worsening MI, syncope, hypokalemia, worsening hypotension (as heart contractility increases, compensatory vasodilation may worsen as dobutamine has little to no peripheral vasoconstrictive effect).

DRUG-DRUG INTERACTIONS: use with caution with antibiotics, anticholinergics, beta-blockers, digoxin

DOSAGE:  0.5mcg/kg/min – 20 mcg/kg/min; maximum of 40mcg/kg/min

CONSIDERATIONS:

• Dobutamine is often used as the second agent of a 2 drug approach to hypotension, given it has a tendency to increase cardiac output but has no ability to stop compensatory vasodilation.  As a result, it’s often added to dopamine or other vasopressor after dopamine has reached maximum dose.  When run alone, watch closely for precipitous hypotension.  If any report of worsening chest pain, be quick to repeat 12 Lead EKG due to some cases of worsening infarct reported with dobutamine.  

Protocol 1234: IFT Norepinephrine (Levophed) Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Alpha-adrenergic drug that causes peripheral vasoconstriction, with somewhat weaker Beta 1 adrenergic stimulation that causes some increased contractility of the heart.

ONSET:  1-2 minutes

DURATION:  10 minutes

INDICATION:  hypotension, septic shock, shock that persists after volume replacement

CONTRAINDICATIONS:  hemorrhagic shock, vascular/mesenteric thrombosis

ADVERSE REACTIONS: anxiety, arrhythmias, chest pain, dyspnea, headache, ischemia, necrosis with extravasation, pallor, photophobia, seizures, vomiting.

DRUG-DRUG INTERACTIONS: causes hypotension/bradycardia with phenytoin; potentiated by amphetamines and antihistamines

DOSAGE:  0.05 – 0.15mcg/kg/min titrated to desired effect. Non-weight based administration may be done in adults weighing at least 80kg: 5 to 15mcg/min titrated to desired blood pressure.  Maximum of 30mcg/min.

CONSIDERATIONS:

• High risk of necrosis through peripheral line if blown, central line is ideal.  D
• Titration typically begins at 8mcg/min and titrated to SBP of >  90 or MAP > 65.
• Sepsis patients should have received 30cc/kg of crystalloid fluids to maximize effect of this medication.

Protocol 1235: IFT Milrinone (Amrinone) Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Phosphodiesterase inhibitor which results in increased inotropy (contractility) and peripheral vasodilation.

ONSET:  3-5 minutes

DURATION:  6 to 10 hours

INDICATION:  acute decompensated heart failure

CONTRAINDICATIONS:  hypersensitivity, atrial fibrillation with RVR, hypertrophic subaortic stenosis, severe obstructive aortic disease or pulmonary valvular disease

ADVERSE REACTIONS: arrhythmias, bronchospasm, chest pain, hypokalemia, severe hypotension, infusion site reactions, tremors

DRUG-DRUG INTERACTIONS: may cause profound hypotension when mixed with any drug that produces hypotension, including opioids and sedatives. FORMS AN IMMEDIATE PRECIPITATE WITH LASIX in an IV line.

DOSAGE:  Initial loading dose of 50mcg/kg.  Maintenance infusion of 0.375mcg/kg/min to 0.75mcg/kg/min.

CONSIDERATIONS:

• Renal dysfunction usually requires a modified dose.
• Sudden cardiac arrest has been reported with this medication.
• Torsades de Pointes and other ventricular arrhythmias have been seen with this medication.  Constant cardiac monitoring (and observation of the monitor by the attending technician) is essential with this medication.

Protocol 1241: IFT Amiodarone Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Class III antiarrhythmic agent that decreased number of VT/VF events by prolonging duration of action potentials, slowing conduction velocity through AV junction and exhibits some alpha and beta blockade activity.  Because of the ability to slow AV conduction, this drug is sometimes used in an off-label approach to Atrial Fibrillation with Rapid Ventricular Response, to slow the ventricular rate.

ONSET:  2-3 minutes, though full effect may take a day or more

DURATION:  IV maintenance drip may have a duration of effect greater than 9-10 days

INDICATION:  ventricular arrhythmias, Atrial Fib with RVR, post-ROSC

CONTRAINDICATIONS:  cardiogenic shock, AV blocks, sick sinus syndrome

ADVERSE REACTIONS: bradycardias, AV blocks, vision changes/loss, pulmonary toxicity (usually with long-term oral use, not short-term IV use)

DRUG-DRUG INTERACTIONS: High risk of prolonged QT syndrome with any medications that cause prolonged QT including Zofran, antiarrhythmics, antipsychotics, etc.

DOSAGE:  A Total of 1,000 mg over 24 hours in 3 distinct segments.

• 1^st segment (ACLS standard): Rapid Loading infusion: 150mg over 10 minutes.
• 2^nd segment: Slow loading infusion: 360mg at 1mg/min over 6 hours.
• 3^rd segment: 540 mg at 0.5mg/min over 18 hours.  Maintenance may be continued for up to 96 hrs depending on degree of ventricular arrhythmias that persist.

CONSIDERATIONS:

• Electrolyte abnormalities can play a role in the effectiveness of Amiodarone.  Hypokalemia, hypocalcemia and hypomagnesemia should be corrected prior to use.
• Be certain to clarify how much total mg dose has been given thus far, and which segment of the above administration schedule is currently underway before accepting an amiodarone drip for transfer.

Protocol 1242: IFT Diltiazem (Cardizem) Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Calcium channel blocker which directly slows rate of calcium infusion into cardiac and AV pacemaker cells, slowing the overall conduction rate of electrical impulses.

ONSET  2 to 3 minutes

DURATION:  1 to 3 hours (up to 10 hours if prolonged infusion > 24hrs)

INDICATION:  Atrial arrhythmias with rapid ventricular response rate

CONTRAINDICATIONS:  WPW syndrome, AV blocks, cardiogenic shock, severe hypotension, wide-complex tachycardias

ADVERSE REACTIONS: arrhythmias, bradycardias, nausea, headache, dizziness, dry mouth, constipation, chest pain, sweating, syncope

DRUG-DRUG INTERACTIONS: profound hypotension when combined with beta blockers

DOSAGE:  Initial bolus 10 – 20 mg IV bolus (or 0.25mg/kg) over 2 min, followed by infusion at 5mg/hr, titrate up by 2.5 – 5mg every 15 minutes, Max of 15mg/hr.

• Initial bolus and initial drip should be initiated by the sending facility.

CONSIDERATIONS:

• On small, elderly patients, sometimes the bolus can be omitted and the drip is started at the lowest dose for more gradual effect.
• Weight should never be estimated for the bolus as there is a very small therapeutic window for this medication.

Protocol 1243: IFT Lidocaine Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Antiarrhythmic that increases the electric stimulation threshold of the ventricle during diastole.   

ONSET  1 to 2 minutes

DURATION:  10 to 20 minutes, but cumulative doses can remain in bloodstream for several hours, increasing risk of toxicity.

INDICATION:  Ventricular arrhythmias

CONTRAINDICATIONS:  WPW syndrome, AV blocks

ADVERSE REACTIONS: arrhythmias, bradycardias, nausea, headache, dizziness, hypotension, hyperthermia, methemoglobinemia, paresthesias, QRS widening, PR prolongation, respiratory depression, cardiac arrest

DRUG-DRUG INTERACTIONS: Administration with other antiarrhythmic agents may result in additive or antagonistic effects, rendering the other drug more potent and toxic, or less effective.    Beta blockers increase the effect of lidocaine.

DOSAGE:  Initial Dose of 1 to 1.5mg/kg IV bolus.  May repeat bolus dose of 0.5 to 0.75mg/kg every 5 to 10 minutes to a maximum of 3mg/kg.  Maintenance infusion of 1 to 4 mg/min (20 to 50mcg/kg/min).

CONSIDERATIONS:

• Lidocaine may be administered either by IV pump or by standard “Lidocaine clock” drip using a 60gtts/ml drip set.
  • For Lidocaine Clock administration method, Drip concentration must be 4mg/1ml.
  • 1 mg dose is run at 15 gtts/min
  • 2 mg dose is run at 30 gtts/min
  • 3 mg dose is run at 45 gtts/min
  • 4 mg dose is run at 60 gtts/min or 1 gtt/second.

Protocol 1251: IFT Nitroprusside Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  rapidly acting venous and arterial vasodilator, acts through relaxation of smooth muscle of the blood vessels

ONSET:  1-2  minutes

DURATION:  10 minutes

INDICATION:  hypertensive crisis, aortic dissection, acute heart failure (rare cases), hypertension during acute stroke

CONTRAINDICATIONS:  AV shunts, coarctation of the aorta, heart failure with reduced peripheral resistance, inadequate cerebral circulation

ADVERSE REACTIONS: hypotension, cyanide toxicity, abdominal pain, anxiety, bradycardia, platelet inhibition, diaphoresis, dizziness, flushing, headache, nausea, restlessness, palpitations.

DRUG-DRUG INTERACTIONS: Avoid use with Erectile Dysfunction medications

DOSAGE:  Initial dose of 0.3mcg/kg/min.  Titrate up in increments of 0.5mcg/kg/min.  Reassess effect for at least 5 minutes before increasing dose as small changes in dose can result in large movements of BP.

• 3mcg/kg/min is the average effective dose.  Max is 10mcg/kg/min.
• If 10 mcg/kg/min does not promote adequate BP reduction within 10 minutes, this medication should be discontinued in favor of another medication.  Cyanide toxicity can occur with as little as 2mcg/kg/min and could begin to occur after 10 minutes at the maximum dose of 10mcg/kg/min.

CONSIDERATIONS:

• WARNING: Cyanide toxicity can occur with this medication when infused for long enough duration as to allow the metabolites of thiocyanate or cyanide to bind to hemoglobin.  This presents with air hunger, bright red venous blood, confusion, lactic acidosis. If these signs are present, discontinue immediately and notify sending facility, medical control or receiving facility as soon as possible for further instruction.

Protocol 1252: IFT Nicardipine Drip

SCOPE:  Paramedic

MECHANISM OF ACTION: A dihydropyridine calcium channel blocker that functions as a pure arterial vasodilator

ONSET:  5 to 15 minutes

DURATION:  4 to 6 hours

INDICATION:  Hypertension in the following settings: Acute Ischemic Stroke, Aortic Dissection, Subarachnoid Hemorrhage, Cerebral Edema, Hypertensive Emergency, Eclampsia

CONTRAINDICATIONS:  Advanced Aortic Stenosis

ADVERSE REACTIONS: headache, hypotension, nausea, vomiting, tachycardia.  EKG abnormalities including AV blocks, ST depression, inverted T waves; confusion, fever, hypertonia, neck pain, edema, respiratory difficulty, tinnitus, urinary frequency, thrombocytopenia, hypophosphatemia.

DRUG-DRUG INTERACTIONS: May cause negative inotropic effects when combined with a beta blocker.  Cimetidine (Tagamet) increased oral concentration.  Synergistic with most antihypertensives, use with caution in any combination.

DOSAGE:  Initial dose of 5mg/hr.  May be increased by 2.5mg/hr every 15 minutes until desired PB reduction is achieved.  Maximum of 15mg/hr.

• *** In extreme cases, may be incrementally increased EVERY 5 MINUTES instead of every 15 minutes to rapidly reduce severe hypertension.  This should be in written orders from sending facility, otherwise should be increased more gradually.

CONSIDERATIONS:

• Use with caution in patients with heart failure, particularly when used in combination with a beta blocker
• Use with caution in patients with impaired hepatic or renal function
• This medication is not always appropriate for every type of intracranial hemorrhage.
• Should be administered through either a central line or large peripheral line (eg 20ga Antecubital) to be determined by the sending facility

Protocol 1253: IFT Hydralazine (IV Push)

SCOPE:  Paramedic

MECHANISM OF ACTION: Potent antihypertensive that lowers blood pressure by direct relaxation of smooth muscle of arteries and arterioles.

ONSET:  5 to 20 minutes

DURATION:  1 to 6 hours

INDICATION:  Severe hypertension, pregnancy-induced hypertension (eclampsia), peripheral vasodilation in rare cases of cardiogenic shock (reduces afterload pressure that the heart is pumping against)

CONTRAINDICATIONS:  coronary artery disease, mitral valve rheumatic heart disease

ADVERSE REACTIONS: anxiety, depression, dry mouth, flushing, headache, nausea, palpitations, paresthesias, tachycardia, unpleasant taste, vomiting

DRUG-DRUG INTERACTIONS: Potentiated by diuretics and beta-blockers; sometimes beta blockers are used in combination with hydralazine for intentional combination effect.  NSAIDs decrease effectiveness of hydralazine.

DOSAGE:  Initial dose 5-10mg IV push every 15-20 minutes until goal BP achieved.  Maximum of 40mg during initial treatment.   Over a 24hr period, maximum is 300 to 400mg/24hr.

• Eclampsia: if no effect after the initial 20mg, then another antihypertensive is recommended.

CONSIDERATIONS:

• As this medication is not carried by NWKS, ensure that the sending facility provides enough medication for the number of repeat doses they want the paramedic to administer en route to destination.
• Check blood pressure every 5 minutes until stabilized at the desired level, then every 15 minutes thereafter.  Average maximum decrease occurs from 10-80 minutes.  

Protocol 1254: IFT Beta Blockers

IV Drip: Labetalol and Esmolol

IV Push: Labetalol, Metoprolol and Propranolol

SCOPE:  Paramedic

MECHANISM OF ACTION: Beta adrenergic blockade that results in decreased inotropic and chronotropic cardiac effect.  Metoprolol is Beta-1 blocker only.  Propranolol is a non-selective (blocks Beta-1 and Beta-2) blocker, and the beta-2 blockade can lead to smooth muscle constriction in peripheral vasculature, bronchi, GI tract and GU tract.  Labetalol is a nonselective Beta blocker as well as a selective Alpha-1 blocker, which has the combined effect of decreasing the blood pressure without reflex tachycardia or significant reduction in heart rate.  Esmolol is a short-acting, Beta-1 selective blocker, hemodynamically similar to propranolol, but vascular resistance is not increased with Esmolol as it is with Propranolol.

ONSET:  5 minutes (Metoprolol, Labetalol)   1-2 minutes (Propranolol, Esmolol)

DURATION:  5 to 8 hours (Metoprolol)  4 hours (Propranolol) 6 to 16 hours (Labetalol)

10-30 minutes (Esmolol)

INDICATION:  tachyarrhythmias, aortic dissection, Acute ischemic strokes, cerebral edema, hypertensive emergencies, Acute MI, thyrotoxicosis, pheochromocytoma

CONTRAINDICATIONS:  Bradycardias, AV blocks, hypotension, bronchial asthma

ADVERSE REACTIONS: bradyarrhythmias, cardiac failure, cardiac standstill, hallucination, hypotension, laryngospasm, paresthesias, syncope, vertigo, vision changes, bronchospasm

DRUG-DRUG INTERACTIONS: Avoid use with clonidine, it may precipitate more severe rebound hypertension; anti-arrhythmics may worsen likelihood of hypotension but may still be used if closely monitored; avoid with use of calcium channel blockers.  Variable interference with insulin, recheck glucose frequently if the two are given together.

DOSAGE:

• IV Push Beta Blockers:       
  • Metoprolol: (Beta 1 selective)  Initial dose varies from 1.25mg to 5mg depending on the type of tachyarrhythmia or cardiac condition.  Initial dose should always be given by sending facility.  Subsequent doses of 2.5mg to 5mg slowly over 2-5 minutes up to a total dose of 15mg.  In rare circumstances, this dosing may be repeated every 3-6 hours if patient unable to take oral metoprolol.
  • Propranolol: (Non-selective) Initial dose of 1mg over 1 minute.  May repeat in 0.5mg to 1 mg increments up to a maximum of 3mg.  No further propranolol should be given for at least 4 hours.
• IV Drip Beta Blockers:        
  • Labetalol: Initial dose 20mg over 2 minutes.   After initial dose, there are two options for this medication: 1) repeat IV push, 10mg every 10 minutes until desired BP achieved, to a maximum of 150mg, OR 2) IF drip infusion of 2 to 8 mg/min, titrated slowly by 0.5mg/min every 10 minutes to achieve desired results.
  • Esmolol: Initial dose of 250-500mcg/kg over 1 minute. Infusion of 50mcg/kg/min, titrated by 50mcg/kg/min up to the maximum dose.  MAXIMUM DOSE is DIFFERENT for tachyarrhythmias versus hypertensive/neurologic emergencies:
  • MAX DOSE for tachyarrhythmias:  200mcg/kg/min
  • MAX DOSE for hypertensive/neuro: 300mcg/kg/min
  • Note: Treating MD/DO/NP/PA Provider has the option to repeat loading dose every 5 minutes after the infusion is started to aid in achieving expedited effect, but this should not be done by transferring paramedic, only by the sending facility.

CONSIDERATIONS:

• Use non-selective beta blockers (Propranolol, labetalol) with caution in asthmatics, as the bronchoconstriction can trigger asthma exacerbation.

Protocol 1261: IFT Keppra (Levetiracetam) Drip

SCOPE:  Paramedic

MECHANISM OF ACTION:  Precise mechanism is unknown.  An antiepileptic drug, in animal studies it inhibited epileptiform neuronal bursts, decreasing propagation of seizure activity.

ONSET:  Approximately 30-60 minutes

DURATION:  24 hours

INDICATION:  seizures or prophylactic seizure prevention (eg in patients with intracranial bleeding)

CONTRAINDICATIONS:  Known hypersensitivity

ADVERSE REACTIONS: somnolence, fatigue, ataxia, agitation, anger, disorientation, neuroses, suicidal thoughts, Stevens-Johnson syndrome, angioedema

DRUG-DRUG INTERACTIONS: When administered in patients taking methotrexate, renal failure can occur

DOSAGE:  250mg to 1,000mg every 12-24 hours, depending on weight and renal function.  Dose is typically IV infused in 15-45 minutes each time.

CONSIDERATIONS:

• This is not a ‘rescue’ medication, and therefore in the event of recurrent seizure while in transport, speeding up the administration will have no effect. Continue the current drip and administer benzodiazepines as per 911 EMS seizure protocols, and contact sending facility, receiving facility or medical control as needed for further guidance.  

Protocol 1262: IFT Dilantin (Phenytoin) / Fosphenytoin

SCOPE:  Paramedic

MECHANISM OF ACTION:  Phenytoin is an anticonvulsant chemically similar to barbiturates, selectively raising the seizure threshold and depressing seizure activity in the motor cortex.  Fosphenytoin is a prodrug that gets converted to phenytoin, phosphate and formaldehyde after approximately 15 minutes.   Fosphenytoin is often used because it causes less IV site irritation, is more soluble in multiple IV solutions, can be given IM, and has a more rapid rate of administration.

ONSET:  Approximately 45 minutes

DURATION:  Up to 48 to 72 hours

INDICATION:  generalized seizures, prophylaxis in neurosurgical patients

CONTRAINDICATIONS:  Hypersensitivity to phenytoin, bradycardias, history of hepatotoxicity

ADVERSE REACTIONS: RATE OF ADMINISTRATION faster than stated below has resulted in arrhythmias and cardiovascular collapse.  Angioedema, hypotension, porphyria, DRESS syndrome, hepatotoxicity, bone marrow suppression, sensory disturbances and paresthesias, ataxia, dizziness, nystagmus, pruritus, purple glove syndrome, Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.  Confusion, delirium, psychosis have also been reported.

DRUG-DRUG INTERACTIONS: Phenytoin is highly protein-bound, and displaces many other medications that use protein binding, including antiarrhythmics, antiepileptics, antifungals, antibiotics, anticoagulants (!), methadone, calcium channel blockers, and can decrease the effectiveness of Rapid Sequence Intubation paralytics such as vecuronium and rocuronium.  

DOSAGE:       

• Dilantin (Phenytoin): Initial loading dose of 10 to 15 mg/kg.  Maintenance infusion of 100mg every 6 to 8 hours at a rate of 25 to 50mg/min.  DO NOT EXCEED 50 mg per minute.
• Fosphenytoin: Initial loading dose of: 100 to 150 PE (Phenytoin Equivalents) over 1 minute.  Maintenance infusion 15 to 20 mg PE/kg at a rate of 1 to 2 mg PE/kg/min.   DO NOT EXCEED 150 PE per minute.  Repeated every 12 hours.

CONSIDERATIONS:

• Contact medical control to review dosage for any pediatric patients under the size of 50 kilograms.  These are very high risk.
• These are not ‘rescue’ medications.  While they do work quickly to reduce rate or duration of seizures, if any active seizure occurs during transport, do not increase the rate, but add benzodiazepines as per the EMS 911 seizure protocol, and contact the sending facility, receiving facility or Medical Control.

Protocol 1263: IFT Precedex (Dexmedetomidine HCl)

SCOPE:  Paramedic

MECHANISM OF ACTION:  A central alpha-2 adrenergic agonist with sedative and some analgesic properties.

ONSET:  Approximately 5-10 minutes

DURATION:  Up to 8 hours

INDICATION:  sedation for intubated/ventilated patients, procedural sedation

CONTRAINDICATIONS:  none

ADVERSE REACTIONS: bradyarrhythmias, sinus arrest, hypotension, transient hypertension; if administered for more than 24 hours, removal of the medication can result in significant withdrawal symptoms and tachyphylaxis with increased frequency of dose-related cardiac effects.

DRUG-DRUG INTERACTIONS: Potentiated (made stronger) by sedatives, hypnotics, opioids and anesthetics.  Antihypertensives and beta- and calcium-channel blockers may potentiate profound hypotension and bradycardia.

DOSAGE:

• Initial dose of 1mcg/kg over 10 minutes, followed by maintenance infusion of 0.2 to 1.0 mcg/kg/hr,

not to exceed 24hrs of use.

CONSIDERATIONS:

• Titration of this medication to achieve desired sedation for an intubated patient should be done after consultation with either the sending provider or Medical Control.  

Protocol 1264: IFT Mannitol

SCOPE:  Paramedic

MECHANISM OF ACTION:  As an osmotic diuretic, this is a large sugar alcohol molecule that hinders tubular reabsorption of water and enhances excretion of sodium and chloride in kidneys.

ONSET:  1 to 3 hours

DURATION:  1.5 to 6 hours

INDICATION:  Reduction of intracranial pressure associated with edema or a brain mass.

CONTRAINDICATIONS:  Intracranial bleeding, hypotension, hypovolemia, hypersensitivity, pulmonary edema

ADVERSE REACTIONS: Sudden, severe hypersensitivity reactions; renal failure, hypotension, hyponatremia, CNS toxicity (increased likelihood with acidosis), electrolyte abnormalities

DRUG-DRUG INTERACTIONS: Potentiates neurotoxic drugs, diuretics and cardiac drugs that are sensitive to electrolyte changes (digoxin, lithium, paralytics)

DOSAGE:  0.25 Grams/kg over 30-60 minutes.  Repeat every 6 to 8 hours.

CONSIDERATIONS:

• Do not administer with blood products- can cause hemolysis or pseudoagglutination.

Protocol 1265: IFT Sodium Valproate (Depakote, Depacon)

SCOPE:  Paramedic

MECHANISM OF ACTION:  Increases GABA transmission in neurons, which inhibits seizures.  Also limits transmission of excitatory neurotransmitters, raising the electrical threshold (making it harder) for seizure activity.

ONSET:  30 to 60 minutes

DURATION:  2 to 4 days

INDICATION:  Seizure disorders

CONTRAINDICATIONS:  pregnancy or young women of child-bearing age (regardless of whether or not they are pregnant), due to high rate of birth defects with subsequent pregnancies; hypersensitivity, hepatic disease, mitochondrial disorders

ADVERSE REACTIONS: liver failure, lethargy, suicidal thoughts, abdominal pain, nausea/vomiting, clotting abnormalities, chest pain, blood abnormalities, hallucinations, anger/agitation/psychosis.

DRUG-DRUG INTERACTIONS: Avoid with drugs that induce hepatic enzymes, including phenobarbital, phenytoin, anti-virals, carbamazepine; this drug is highly protein bound, and serum levels are increased in presence of aspirin, certain antibiotics, sedatives, certain antidepressants and other anti-seizure medications.

DOSAGE:

• 10 to 15mg/kg/24hrs, divided into every 6 to 8 hours. May be gradually increased by 5mg/kg/day.
• Typical ‘safe’ recommended IV rate by Manufacturer: one dose over 60 minutes, not to exceed 20mg/min.  In emergent setting, ay give up to a 15mg/kg dose over 5 to 10 minutes.
• Example:  50 kg patient gets 10mg/kg/day = 500mg/day, divided into every 6 hours, or 125mg dose, usually given over 60 minutes.

CONSIDERATIONS:

• Confirm any doses that are at a rate exceeding 20mg/min.  They are not normal, but are occasionally necessary in the emergent setting. Ensure written orders accompany the medication for these rates.

Protocol 1271: IFT Vitamin K

(Phytonadione)

SCOPE:  Paramedic

MECHANISM OF ACTION:  Vitamin K is a fat-soluble vitamin used by the liver to produce four blood coagulation factors (II, VII, IX, and X).

ONSET:  1 hour

DURATION:  12 to 14 hours

INDICATION:  traumatic bleeding in patients taking coumadin, hypoprothombinemia due to other medical conditions or medications

CONTRAINDICATIONS:  Hypersensitivity to this medication.

ADVERSE REACTIONS: fatal allergic reactions can occur shortly after administration.

DRUG-DRUG INTERACTIONS: salicylates, NSAIDs, antibiotics may all inhibit or worsen the coagulation effect

DOSAGE:  2.5 to 10 mg for 1 dose.  Rarely, up to 50mg may be needed, but doses as low as 1 to 2mg are often effective.  Oral administration is preferred except in certain emergencies.  When IV administration must be done, rate is not to exceed 1mg/min, usually diluted in 50mL and given over 15 to 30 minutes.  TOO RAPID IV ADMINISTRATION CAN CAUSE SUDDEN SEVERE REACTIONS AND/OR DEATH.

CONSIDERATIONS:

• For IV infusions, written orders from the sending provider must always accompany the patient.

Protocol 1272: IFT Kcentra

(Prothrombin complex concentrate)

SCOPE:  Paramedic

MECHANISM OF ACTION:  A human-based concentrate of coagulation factors including factors II, VII, IX and X and the antithrombotic proteins C and S, which the body uses as part of the coagulation cascade to form clots.

ONSET:  10 minutes

DURATION:  6 to 8 hours

INDICATION:  Major bleeding in anticoagulated patients using coumadin.

CONTRAINDICATIONS:  hypersensitivity to any component, disseminated intravascular coagulation, heparin-induced thrombocytopenia

ADVERSE REACTIONS: anaphylaxis, acute thromboembolisms, headache, hypotension, nausea/vomiting, chest pain, dyspnea, acute pulmonary edema, internal hemorrhage, acute myocardial infarction

DRUG-DRUG INTERACTIONS: Unknown.

DOSAGE:       

• With INR Level:    2 to 4: 25 IU/kg, not to exceed 2,500 IU
  • 4 to 6: 35 IU/kg, not to exceed 3,500 IU
  • Greater than 6: 50 IU/kg, not to exceed 5,000 IU
  • Rate of administration:  0.12 ml/kg/min up to a maximum of 8.4ml/min.
• Without INR:       
  • Emergent initial dose:  1,500 IU for one dose, followed by lab draw of INR 30-60 minutes later to determine further dosing necessary.

CONSIDERATIONS:

• Given that this concentrate is full of coagulation components that require Vitamin K, both are usually given when this medication is indicated.
• This medication can cause sudden emboli to form. Any sudden change in patient’s mental status, or new changes in vitals or complaints should be taken seriously and investigated thoroughly (eg 12 Lead if complaint of chest pain, SpO2 if complaint of trouble breathing, neuro exam if stroke symptoms).  

Protocol 1273: IFT Andexxa

(Coagulation Factor Xa, Recombinant, Inactivated-zhzo)

SCOPE:  Paramedic

MECHANISM OF ACTION:  A genetically modified version of human factor Xa which binds to and inhibits the activity of tissue factor pathway inhibitors, increasing thrombin formation.

ONSET:  2 minutes

DURATION:  Up to 2 hours

INDICATION:  Overdose of oral anticoagulants (Xarelto or Eliquis), or internal bleeding in setting of these oral anticoagulants.

CONTRAINDICATIONS: hypersensitivity to any component, disseminated intravascular coagulation, heparin-induced thrombocytopenia

ADVERSE REACTIONS: anaphylaxis, acute thromboembolisms, headache, hypotension, nausea/vomiting, chest pain, dyspnea, acute pulmonary edema, internal hemorrhage, acute myocardial infarction

DRUG-DRUG INTERACTIONS: Unknown.

DOSAGE:

• Initial IV Bolus:          
  • LOW DOSE: 400mg at rate of 30mg/min, followed by 4mg/min up to 120 min.
  • High DOSE: 800mg at a rate of 30mg/min, followed by 8mg/min up to 120 min.
  • LOW DOSE is used when last dose of Rivaroxaban (Xarelto) is < 10mg or last dose of Apixaban (Eliquis) was < or = to 5mg.
  • High DOSE is used when last dose of Rivaroxaban is unknown amount or greater than 10mg, or when last dose of Apixaban is > 5mg.

CONSIDERATIONS:

• These medications have to be mixed/prepared very carefully, and should be prepared by the sending facility, not the paramedic.
• This medication can cause sudden emboli to form. Any sudden change in patient’s mental status, or new changes in vitals or complaints should be taken seriously and investigated thoroughly (eg 12 Lead if complaint of chest pain, SpO2 if complaint of trouble breathing, neuro exam if stroke symptoms).