Protocols

Protocol 100: Medication Administration

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

2.  VERIFY “5 RIGHTS”:

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

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

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

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

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

Protocol 101:  IV Fluid Administration

SCOPE:  AEMT, Paramedic

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

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

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

PRINCIPLES OF ADMINISTRATION:

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

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

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

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

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

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

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

CONSIDERATIONS:

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

Protocol 102: Adenosine (Adenocard)

SCOPE:  Paramedic only

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

ONSET: 1 second

DURATION: 10 seconds

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

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

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

DRUG-DRUG INTERACTIONS:

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

DOSAGE:

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

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

PEDIATRIC:  MEDICAL CONTROL APPROVAL is required for pediatric administration.

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

CONSIDERATIONS:

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

Protocol 103: Albuterol Sulfate

SCOPE:  EMT-Basic, AEMT, Paramedic

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

ONSET: 5 – 10 minutes after inhalation

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

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

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

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

DRUG-DRUG INTERACTIONS:

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

DOSAGE:

ADULT:  OPTION 1 prescribed Metered Dose Inhaler        

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

OPTION 2 Nebulized 2.5mg / 3ml saline

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

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

OPTION 1 prescribed Metered Dose Inhaler

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

OPTION 2 Nebulized 2.5mg / 3ml saline

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

CONSIDERATIONS:

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

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

Protocol 104: Amiodarone

SCOPE: AEMT, Paramedic

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

ONSET: 2-3 Minutes

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

INDICATION:

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

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

Paramedic Only: Narrow complex tachycardia, refractory to Adenosine

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

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

ADVERSE REACTIONS: hypotension, bradycardia

DRUG-DRUG INTERACTIONS:

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

DOSAGE:

ADULT:

AEMT: Pulseless VT / VF:  300mg IV bolus

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

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

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

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

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

PEDIATRIC:

AEMT: Pulseless VT / VF:

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

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

Protocol 105: Aspirin

SCOPE:  EMT-Basic, AEMT, Paramedic

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

ONSET:  Approximately 20 minutes

DURATION:  Up to 96 hours

INDICATION:  suspected Acute Myocardial Infarction or chest pain

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

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

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

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

CONSIDERATIONS:

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

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

Protocol 106: Atropine Sulfate

SCOPE:  Paramedic Only

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

ONSET:  1 minute

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

INDICATION: Symptomatic bradycardia, heart blocks, organophosphate poisoning,

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

CONTRAINDICATIONS:  STABLE bradycardia

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

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

DRUG-DRUG INTERACTIONS:

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

DOSAGE:

ADULT BRADYCARDIA: 0.5mg IV/IO bolus.

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

PEDIATRIC BRADYCARDIA: SECOND LINE MEDICATION, after use of EPINEPHRINE

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

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

CONSIDERATIONS:

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

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

Protocol 107:  Atrovent (Ipratropium Bromide)

SCOPE:  EMT-Basic, AEMT, Paramedic

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

ONSET:  5 to 15 minutes.

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

INDICATION: bronchospasm

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

ADVERSE REACTIONS: Palpitations, tremors, dry mouth, tachycardia

DRUG-DRUG INTERACTIONS: sympathomimetics will further potentiate tachycardia

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

PEDIATRIC:

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

CONSIDERATIONS:

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

Protocol 108:  Calcium Chloride 10%

SCOPE:  Paramedic Only

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

ONSET:  2-5 minutes

DURATION:   30-60 minutes

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

CONTRAINDICATIONS: known hypercalcemia, digoxin toxicity, hypercalcemia

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

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

In presence of digitalis, may worsen cardiac output.

DOSAGE:   ADULT: Not given routinely for pulseless arrest

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

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

CONSIDERATIONS:

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

Protocol 109: Dextrose / Oral Glucose

SCOPE:  EMT-Basic, AEMT, Paramedic

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

ONSET:  30 seconds

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

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

CONTRAINDICATIONS:  Hyperglycemia

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

DRUG-DRUG INTERACTIONS: none in the emergent hypoglycemia setting

DOSAGE:

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

AEMT and Paramedic:

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

CONSIDERATIONS:

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

Protocol 110: Diphenhydramine (Benadryl)

SCOPE:  AEMT, Paramedic

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

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

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

INDICATION:  allergic reaction

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

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

DRUG-DRUG INTERACTIONS:

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

DOSAGE:

ADULT:  50mg IV/IO/IM

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

CONSIDERATIONS:

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

Protocol 111: Epinephrine

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

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

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

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

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

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

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

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

DOSAGE:

ADULT: 

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

PEDIATRIC:

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

             

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

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

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

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

CONSIDERATIONS:

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