Gcounty Protocols PDF

Galveston Area Ambulance Authority
Medical Protocols
Medical Protocols
The Galveston Area Ambulance Authority(GAAA) Treatment Protocols are for the sole use of providers
that are providing care under the authority of GAAA or while deployed by GAAA in a disaster situation.
These protocols are valid from March 1, 2017 through March 31, 2018.
The GAAA protocols were written using the guidance of medical research and following accepted
national standards. The protocols were written by a committee of practicing paramedics at GAAA after
lengthy research and debate. The protocols were approved by Dr. James Vincent, medical director for
GAAA. This document is based upon current accepted medical practice and evidence. Due to the
evolving nature of medical standards this document is not a static piece of paper but is expected to be
used and revised as a dynamic document.
These protocols are a tool that providers will use with their assessment, knowledge, and experience to
provide exceptional patient care. Protocols are not meant to be blindly followed; instead providers
should understand the rationale behind the protocol pathways. All pathways are to be utilized only to
the degree that the patient requires. The pathways in the flowchart are used to facilitate the most
appropriate level of care for the patient. If a patient’s status does not require a certain pathway, it is
acceptable to omit or skip the treatment. Protocols are written for specific sets of symptoms and
conditions and can be combined in order to address the patient’s needs and complaints. The committee
and the medical director at GAAA recognize that in certain circumstances deviation from the protocols is
in the best interest of the patient. Protocol deviations should be a rare event and require detailed
documentation.
GAAA services a large area of Galveston County with multiple providers of various certification and
licensure levels. GAAA also utilizes first responders in the majority of our response districts and provides
non-emergency and emergency transfers originating in Galveston County and surrounding areas. With
the exception of Beach Patrol providers who are trained in the use of blind airway devices and basic first
aid, these protocols are not meant to provide authorization for providers outside of the GAAA system.
Any questions regarding who can practice under these guidelines should be referred to GAAA SOGs.
James Stephen Vincent M.D.
Medical Director
James Vincent M.D. Page 1

Medical Protocols
January 1, 2017
GAAA Field Staff:
I have been made aware of impending shortages of normal saline supplies, due to national shortages. In
the setting of limited supplies:
1. Do not give IV fluids indiscriminately or “reflexively” for any patient.

Consider holding IV fluids EXCEEPT for patients with a known or suspected volume-depleted
state.
2. Lactated Ringers (LR) may be used as a substitute for NS throughout the protocols when
indicated. As LR may be detrimental to patients in a shock or hypoperfusion state, carefully
weigh the risks of aggressive LR use, versus holding fluids and/or optimizing transport time to
the hospital, in these patients.
James Vincent, MD
Medical Director, GAAA
James Stephen Vincent M.D.
Medical Director

Medical Protocols
Fundamentals of Care
Patient Assessment 8
Documentation Guidelines 11
General System Guidelines 13
Air Medical Activation Guidelines 15
Specialty Care 17
On-Scene Medical Providers 18
Selected Age Definitions, Competency 19
Types of Consent 20
Treatment of Minors 21
Restraint / Transport against Patient Will 22
Refusals 23
Termination of CPR 24
Out of Hospital DNR 26
Hospice Patients 28
Scope of Practice 29
Inter-Facility Transfers 31
Expired Medications and Medication Shortages 34
Ebola Preparedness 35
Universal Treatment
Universal Treatment Guidelines 40
Rapid Sequence Induction 41
Failed Airway 42

Medical Protocols
Pain Management 43
Police Custody 44
Medical
Allergic Reaction 45
Anxiety 46
Behavioral Emergencies 47
Excited Delirium 48
COPD / Asthma 49
Diabetic Emergency 50
Hypotension 51
Nausea / Vomiting 52
Overdose 53
Respiratory Distress 54
Seizure 55
Stroke / CVA 56
Syncope 57
Cardiac
Acute Coronary Syndrome 58
Supra-Ventricular Tachycardia 60
A-Fib with RVR 61
Ventricular Tachycardia with a Pulse 62
Symptomatic Bradycardia 63
Adult Cardiac Arrest 64
Post Resuscitation 65
Post Resuscitation Induced Hypothermia 66

Medical Protocols
Hypertension 67
Congestive Heart Failure 68
Trauma
Selective Spinal Immobilization 69
Crush Injury 70
Major Trauma 71
Extremity Trauma 72
Extremity Hemorrhage or Amputation 73
Burns – Electrical / Chemical 74
Burns – Thermal 75
Marine Life Envenomation 76
Snake Bite 77
Drowning / Near Drowning 78
Pediatric
Active Labor 79
OB Emergencies 80
Neonatal Resuscitation 82
Pediatric Cardiac Arrest 83
Pediatric Diabetic Emergencies 84
Pediatric Pain Management 85
Pediatric Allergic Reaction 86
Pediatric Seizure 87
Pediatric Respiratory Distress 88
Pediatric Bradycardia 89
Pediatric Supra-Ventricular Tachycardia 90

Medical Protocols
Procedures
Capnography 91
Child Birth 94
CPAP 95
EZ-IO Intraosseous Infusion 96
Infection Control 98
Kendrick Extrication Device 99
King LTS Airway 100
Nasogastric / Orogastric Tube Insertion 101
Oral Tracheal Intubation 102
Needle Decompression 103
Spinal Immobilization 105
Taser Barb Removal 106
Injection: Subcutaneous / Intramuscular 107
Surgical Airway: Cricothyrotomy 109
Surgical Airway: Quick Trach 110
Tourniquet 111
Traction Splint 112
Transfers – Air Medical 113
Transfers – Trauma 114
Venti-Pac 117
Appendix A – Medication Formulary 118
Appendix B – Equipment List 159

Medical Protocols
EMT Basic Procedure-
EMT Basic Drug Administration-
EMT Intermediate Procedure-
EMT Intermediate Drug Administration-
Paramedic Procedure-
Paramedic Drug Administration-
See Protocol-
Important Note Regarding Protocol-
Pediatric Protocol Note-

Medical Protocols
Patient Assessment
A systematic approach to patient assessment allows for high quality and safe care that will be consistent
between providers and across a wide variety of patient encounters. The following outlines the expected
framework for the assessment, treatment, and communication which should occur for EVERY patient
encounter:
Primary Survey
1. Airway - is it patent? Identify and correct existing or potential obstruction, inclusive of advanced
airway management as indicated.
2. Breathing - rate and quality. Identify and correct existing or potential compromising factors
3. Circulation – pulse, rate, quality, and location. Control external bleeding.
4. Determine level of consciousness (use AVPU system, Glasgow Coma Scale, or other system as
indicated).
Secondary Survey
1. Reassure the patient and keep him/her informed about treatment.

2. Obtain a brief history from the patient, family and bystanders. Check for medical identification.
3. Perform a head-to-toe assessment.
4. Obtain and record vital signs as indicated by patient condition, to include heart rate, blood
pressure (indicating patient’s position), respiratory rate, temperature (measured in degrees
Celsius), skin color, cardiac monitor, blood glucose, SaO2 and ETCO2.
Treatment
Treat appropriately in order of priority. Refer to specific protocol.

Communications
1. Radio or telephone information protocol during transport.

a. Identify transporting unit.
b. Patient's age and sex.
c. Chief complaint or problem.
d. Pertinent history as needed to clarify problem (medications, illnesses, allergies, mechanism
of injury, etc.).
e. Physical assessment findings.
f. Vital signs and level of consciousness.
g. Treatment given and patient's response.
h. Estimated time of arrival (ETA).
2. Advise ED of changes in patient's condition during transportation.
3. Give a verbal report to ED nurse and/or physician on arrival.
4. Complete electronic patient care report (e-PCR). See following section for further details.

Medical Protocols
Cardiac Monitoring
1. Patients experiencing possible cardiac symptoms must have a 12 lead EKG within 5 minutes of
patient contact whenever possible. Refer to the appropriate protocol for specific treatment.
(12 lead EKG is appropriate prior to and post administration of medications, tracings should be
attached to the e-PCR)
Indications for 12 Lead Monitoring
 Chest Pain or discomfort (radiating or non-radiating)
 Congestive Heart Failure (CHF)
 Syncope or near Syncope
 Unconscious
 Respiratory distress in patients >18 years of age
 Chest Trauma (blunt or penetrating)
 Non Traumatic GI bleeding
 Overdose
 CVA and or HTN
 Female >50 years presenting with abdominal arm or neck pain.
 Hypertension or Hypotension
 Altered Mental Status
 Post Resuscitation
2. Rhythms, dysrhythmias and 12-lead EKG's are to be documented and recorded as part of the
patient’s record. A hard copy of the 12-lead EKG shall be made:
a. The 12 Lead ECG must be uploaded and attached to the patients ESO e-PCR when
possible.
b. If/when electronic attachment is not possible due to technology failure, a paper copy
must be made and routed to the Mid County Annex EMS office and filed in patient
records.
c. The 12 lead must include;
i. The call run number
ii. Patient name
iii. Age
iv. Date of service
v. Receiving hospital

Medical Protocols
Respiratory Status Monitoring

Patients presenting with respiratory distress of any etiology should be assessed treated and monitored
throughout treatment and transport. End Tidal CO2 (ETCO2) monitoring is the gold standard and should
be utilized with these patients when available. SaO2 monitoring may be substituted when ETCO2
monitoring is not available.
The goal is to maintain ETCO2 between 35 - 45 mm/Hg and SaO2 at 97% or more.
Guidelines for Treatment of Respiratory Distress:

1. Oxygen Therapy. Consider limiting to 3 liters per minute in COPD or be prepared to actively
support ventilation.
2. Consider intubation, CPAP, or bag valve mask/ventilation as indicated by the patient’s condition.
3. Obtain IV/IO access.
4. Position of comfort, generally sitting if adequate blood pressure.
5. See specific protocols for further details and interventions.
6. Special Considerations:
1. Rule out obstruction.
2. Listen to lung sounds for presence of:
a. Rales, rhonchi, or wheezes.
b. Accentuated or diminished lung sounds.
3. Obtain pre and post treatment ETCO2 and or SaO2 and document in e-PCR.

Medical Protocols
Patient Assessment
A systematic approach to patient assessment allows for high quality and safe care that will be consistent
between providers and across a wide variety of patient encounters. The following outlines the expected
framework for the assessment, treatment, and communication which should occur for EVERY patient
encounter:
Primary Survey
1. Airway - is it patent? Identify and correct existing or potential obstruction, inclusive of advanced
airway management as indicated.
2. Breathing - rate and quality. Identify and correct existing or potential compromising factors
3. Circulation – pulse, rate, quality, and location. Control external bleeding.
4. Determine level of consciousness (use AVPU system, Glasgow Coma Scale, or other system as
indicated).
Secondary Survey
1. Reassure the patient and keep him/her informed about treatment.

2. Obtain a brief history from the patient, family and bystanders. Check for medical identification.
3. Perform a head-to-toe assessment.
4. Obtain and record vital signs as indicated by patient condition, to include heart rate, blood
pressure (indicating patient’s position), respiratory rate, temperature (measured in degrees
Celsius), skin color, cardiac monitor, blood glucose, SaO2 and ETCO2.
Treatment
Treat appropriately in order of priority. Refer to specific protocol.

Communications
1. Radio or telephone information protocol during transport.

a. Identify transporting unit.
b. Patient's age and sex.
c. Chief complaint or problem.
d. Pertinent history as needed to clarify problem (medications, illnesses, allergies, mechanism
of injury, etc.).
e. Physical assessment findings.
f. Vital signs and level of consciousness.
g. Treatment given and patient's response.
h. Estimated time of arrival (ETA).
2. Advise ED of changes in patient's condition during transportation.
3. Give a verbal report to ED nurse and/or physician on arrival.
4. Complete electronic patient care report (e-PCR). See following section for further details.

Medical Protocols
Cardiac Monitoring
1. Patients experiencing possible cardiac symptoms must have a 12 lead EKG within 5 minutes of
patient contact whenever possible. Refer to the appropriate protocol for specific treatment.
(12 lead EKG is appropriate prior to and post administration of medications, tracings should be
attached to the e-PCR)
Indications for 12 Lead Monitoring
 Chest Pain or discomfort (radiating or non-radiating)
 Congestive Heart Failure (CHF)
 Syncope or near Syncope
 Unconscious
 Respiratory distress in patients >18 years of age
 Chest Trauma (blunt or penetrating)
 Non Traumatic GI bleeding
 Overdose
 CVA and or HTN
 Female >50 years presenting with abdominal arm or neck pain.
 Hypertension or Hypotension
 Altered Mental Status
 Post Resuscitation
2. Rhythms, dysrhythmias and 12-lead EKG's are to be documented and recorded as part of the
patient’s record. A hard copy of the 12-lead EKG shall be made:
a. The 12 Lead ECG must be uploaded and attached to the patients ESO e-PCR when
possible.
b. If/when electronic attachment is not possible due to technology failure, a paper copy
must be made and routed to the Mid County Annex EMS office and filed in patient
records.
c. The 12 lead must include;
i. The call run number
ii. Patient name
iii. Age
iv. Date of service
v. Receiving hospital

Medical Protocols
Respiratory Status Monitoring

Patients presenting with respiratory distress of any etiology should be assessed treated and monitored
throughout treatment and transport. End Tidal CO2 (ETCO2) monitoring is the gold standard and should
be utilized with these patients when available. SaO2 monitoring may be substituted when ETCO2
monitoring is not available.
The goal is to maintain ETCO2 between 35 - 45 mm/Hg and SaO2 at 97% or more.
Guidelines for Treatment of Respiratory Distress:

1. Oxygen Therapy. Consider limiting to 3 liters per minute in COPD or be prepared to actively
support ventilation.
2. Consider intubation, CPAP, or bag valve mask/ventilation as indicated by the patient’s condition.
3. Obtain IV/IO access.
4. Position of comfort, generally sitting if adequate blood pressure.
5. See specific protocols for further details and interventions.
6. Special Considerations:
1. Rule out obstruction.
2. Listen to lung sounds for presence of:
a. Rales, rhonchi, or wheezes.
b. Accentuated or diminished lung sounds.
3. Obtain pre and post treatment ETCO2 and or SaO2 and document in e-PCR.

Medical Protocols
Documentation Guidelines
While our first and most important job is to provide patient care, all patient care and assessments must
be accurately recorded. This includes the patient s primary complaint; the patient’s presenting signs
and symptoms (assessment); and all treatments and interventions, both attempted and successful.
Deviations from protocol must also be documented, to include the reason the deviation occurred.
Protocol deviation narrative should also include the method used to notify supervising staff and/or the
medical director.
High-risk medicolegal situations require additional and thorough narrative, such as cases involving: an
unexpected death in the field or death of a young person; a prolonged resuscitation; a complex multi-
casualty incident with multiple patients and involvement of outside services; situations where law
enforcement personnel are also on scene due to violence or other civil disturbances; or cases when the
patient or family are visibly displeased with care provided. Additional details are useful to hospital-
based providers, are important during quality reviews, and may confer protection in the case of a
lawsuit.
All patient care reports (PCR’s) must be completed by the end of shift.
There are 5 main reasons to document EMS call Clinical, Legal, Operational, Financial, and Compliance.
10 items that must be in ePCRs
1. Times and dates: Make sure that all times and dates are recorded and correct.
2. Addresses of scene and destination: should include city and county.
3. Patient’s complaint on arrival: What was the patient’s primary complaint? Use patients own
words to describe the complaint when possible. Patient describes pain as “Crushing sensation in
the center of chest”.
4. Patient assessment: A primary assessment, including vital signs, must be completed on every
patient contact. This includes transports and patient refusals. All refusals’ need to 2 sets of vital
signs.
5. Patient demographics: Accurately record patient’s name, mailing address, DOB, SSN, and
telephone number. If unable to ascertain the patient’s name, state is requiring that UNKNOWN,
UNKNOWN for both last and first name.
6. Patient history, medications, and allergies: Obtain a list of the patient’s past medical history, all
medications taken by patients and list any allergies.
7. Treatments: A complete listing of all interventions and medications including time given. How
did patient response to treatment? Be sure to include both successful and unsuccessful
attempts. Including movement of patient. ( draw sheet, S.L.I.P., or bariatric equipment used)
8. Billing information: Every attempt should be made to obtain the patients insurance
information. Ask for a face sheet at the ER or get a copy made of insurance card.
9. Mileage: Total loaded mileage must be documented on every transport.

Medical Protocols
10. Signatures: A signature is required for all patients. If patient is unable to sign, a family member
of care giver can sign for patient. If a family member or care giver is not available, you will need
to note why patient is unable to sign, for example “patient is unable to sign due to AMS”.
ePCRs Specialty Patient Section
The following six sub-sections forward important data to GAAA QA and DSHS:
1. Cincinnati Stroke Scale

2. Obstetrical
3. Spinal Immobilization
4. Burns
5. CPR
6. Motor Vehicle Collision
Non-Emergency Transfers
In addition to the above guidelines, non-emergency transfers require additional documentation

specifying why the patient requires a stretcher. Relevant history, exam, and past medical history items
which support the patient’s condition as being bed-confined or non-ambulatory should be included. All
of the following must be attested and documented:
1. Unable to get up from bed without assistance, and

2. Unable to ambulate, and
3. Unable to sit in a chair or wheel chair,
4. Unable to maintain oxygenation without assistance.
Common Documentation Errors
Spelling and grammar (i.e. capital letters, punctuations, and complete sentences) are extremely
important components of the patient care narrative, both for professionalism and medicolegal reasons.
Do not use unapproved abbreviations. Most abbreviations are upper and lower case sensitive. If you
are not sure whether an abbreviation is acceptable or not, write it out.
Unacceptable Acceptable Abbreviation for

PT Pt. Patient
CC Write out Chief complaint
AOS Write out Arrived on scene
Cp CP Chest pain
MSO MSO4 Morphine Sulfate
If you give treatment to a patient like a public assist, or bandage a wound you must fill out an ePCR.
All refusals must have 2 sets of vital signs, and document that you have explained the possible
consequences of the patient not seeking medical attention.

Medical Protocols
General System Guidelines
Transfer of Care to a Provider of a lower skill level
 Leaving patients on-scene should not be a routine procedure. It is to be considered only when a
patient requires immediate transport in order to maximize potential outcome.
 The transport provider may transfer patient care to a provider of a lower skill level while
awaiting additional transport resources when transfer of established care is not beyond the
scope and/or training of the provider.
 When a patient presents without need for MICU level care and a BLS/ALS unit is available,
patient care may be transferred at the discretion of the on-duty shift supervisor.
 Mass and multi-casualty incident transport decisions will be made by the transport officer.
Cancellation or Alteration of a Response
 Units may not respond non-emergency to a call for service for the sole reason that the caller
requests “No Lights and Sirens.”
 Police, fire and other first responders can disregard responding units, but may not do so in order
to contact another transport provider.
 Off-duty GAAA providers may downgrade or disregard responding units.
 Dispatch may not disregard units when a caller requests EMS cancel their response; the
responding units must continue to the scene.
Mutual Aid:
 When providers are requested to respond through an official channel for mutual aid; these
protocols remain in effect.
 If a provider is dispatched on a radio channel separate from GAAA’s primary radio channel, the
responding unit must advise GAAA dispatch and the on-duty supervisor that they are responding
to a mutual aid request.
Level of Response to 9-11 Calls
 Emergency traffic is the use of lights and sirens to respond to a location.

 Non-emergency traffic is traveling without the use of emergency lighting or warning devices.
 GAAA does not operate utilizing a tiered or EMD system.
 When responding to emergency calls responders should use emergency traffic unless
downgraded or otherwise directed.
 Providers may respond non-emergency to certain types of calls:
o Calls that are dispatched as a public assist without injuries
o Calls that require staging for scene safety and the provider can make the location in less
than 7 minutes driving non-emergency.
o Calls that are requested to incoming vessels or aircraft that have a known ETA that is

Medical Protocols
provided by dispatch and that the crew can make location prior to the arrival of the
vessel or aircraft.
o When directed to do so by the on duty supervisor.
On-Line Medical Consultation (OLMC): Providers have several options for OLMC:
 Contact the receiving facility where the patient is being transported and speak with an ER
physician.
 Contact the GAAA medical director, Dr. James Vincent.
 At certain times it may be appropriate to contact the patient’s regular treating physician.
 For inter-facility transports the provider should obtain written orders specific to the patient for
any treatments that are outside the provider’s standard scope of practice.
 Nurses and other ancillary staff may not give providers treatment orders.
Once OLMC has been established the provider should follow the orders given by the physician that is
assuming care of the patient. However in cases that the provider feels the prescribed treatment would
violate accepted medical standards, supervisory guidance should be requested and the provider should
not follow those directives that may cause harm to the patient. In the event of a disaster situation or
other extreme circumstance, even if expressly directed by an OLMC physician, providers are prohibited
from performing field C-sections or field amputations.
Flight Operations: GAAA responds when dispatched to PHI out of Scholes field to provide medical care
to offshore locations such as ships and oil-rigs in the Gulf of Mexico. Providers may transport to a
variety of facilities along the US Gulf Coast.
 For safety, GAAA providers are required to wear long pants and boots on all flights.
 Additional equipment is located in the supply lockers at Scholes field in the PHI terminal.
 Flight physiology will affect patient’s condition and require differing techniques to care for the
patient than ground based transport.
o Patients may require supplemental oxygen
o IV fluids will not flow in the absence of pressure infusers
o Entrapped air may expand in the patient’s body cavities.
 OLMC is typically not available for providers responding off-shore; so Team Captains are
required on all flights.
 If the shift supervisor is required to maintain system status by sending a non-team captain
paramedic on an offshore flight, that provider is permitted to utilize all treatment pathways,
including those at Team Captain level skills.

Medical Protocols
Air Medical Activation Guidelines
Overview: Air medical transport is an important adjunct to the overall care of the severely ill or injured
patient. Air medical provider (AMP) resources should be utilized in accordance with the regional trauma
plan.
Purpose: These AMP activation guidelines are intended to provide a framework for each RAC to develop
a standardized method for ground emergency medical service providers to request a scene response by
an AMP, to reduce delays in providing optimal care for severely ill or injured patients, and to decrease
mortality and morbidity.
Decision Criteria: AMP activation/scene response should be considered when it can reduce
transportation time for severely ill or injured patients meeting activation criteria. Should there be any
question whether or not to activate regional AMP resources, on-line or receiving facility medical control
should be consulted for a final decision.
Guidelines for Activation:
1. The ground emergency medical service provider may, when one or more of the
elements of the activation criteria exist, request a scene response by an AMP and assist
with transportation to an appropriate acute care facility.
2. Ground emergency medical service providers should not remain on scene awaiting AMP
arrival if ground transport time will be less than the combined arrival and return time of
the AMP.
3. Ground emergency medical service providers should activate the AMP as early as
possible, including prior to their arrival at the scene if the mechanism of injury or scene
report meets criteria.
4. The EMS provider should comply with RAC-approved triage criteria (such as that listed
below) to activate AMP transport.
5. Other factors that should be considered are:
a) Location of incident
b) Number of patients
c) Age of patients
d) The total AMP response time (response time+ scene time +transport time) will
result in delivery of the patient(s) to the most appropriate facility faster than
transport by ground ambulance.
e) Weight of patients
f) AMP activation will provide access to advanced life support interventions critical for
patient survival that are not available on scene (and more quickly than ground EMS
can arrive at the nearest hospital).
g) Special circumstances & patient injuries (transport of suspected spinal injury over
rough terrain) where patient outcome would be improved by AMP transport.
6. In all instances the available AMP that best meets the needs of the patient will be
utilized.
Other considerations: Trauma patients meeting criteria for AMP dispatch should be transported to a
Level I, II, or III Trauma Center. Severely ill medical patients should be transported to the nearest
appropriate acute care facility.

Medical Protocols
Air Medical Activation Criteria:
1. Severely injured or ill patients located in a remote or off-road area not readily accessible
to ground ambulance.
2. Ground resources with acceptable response time exhausted or exceeded in the region.
3. Reduction in transport time to a trauma center compared to ground transport for the
seriously injured trauma patient.
4. Motor vehicle collisions involving:
a. Ejection
b. Rollover
c. Death in same patient compartment
d. Patient extrication of 20 minutes or greater
5. Falls from a distance of greater than 20 feet
6. Auto-pedestrian injury with significant impact (> 20 mph)
7. Physiologic:
a. Glasgow Coma Scale of less than 10
b. Systolic blood pressure of < 90 with signs/symptoms of shock
8. Anatomic:
a) All penetrating injuries to the head, neck, torso, and/or extremities proximal to the
elbow and knee
b) All penetrating injuries to the head, neck, torso, and/or extremities proximal to the
elbow and knee
c) Flail chest
d) Combination trauma with burns of 20% involving face or inhalation injuries
e) Major burns including:
i. Inhalation
ii. 2nd or 3rd degree burns > 20% BSA
iii. Combination trauma with burns
f) Two or more proximal long-bone fractures
g) Pelvic fractures
h) Traumatic paralysis
i) Amputation proximal to the wrist or elbow
j) Depressed or open skull fractures
9. Multiple severely injured patients on scene
10. No available trauma center within one hour of ground transportation.

Medical Protocols
Specialty Care:
T r a n s p o r t decisions for specialty problems such as Trauma, Stroke, ACS/STEMI, Pediatric Care
and Burns will be made with attention to local hospital and regional protocols. Evidence-based
support fueling national quality initiatives to bring a patient to a certified/accredited specialty
center will be weighed against the need to bring a critically unstable patient to the closest
available facility.
Trauma: Patients with acute traumatic injuries will be transported to an appropriate

Trauma Center per RAC guidelines. (See “Transfers – Trauma” under Procedures Section).
Local Stroke Resources: Patients presenting with acute stroke symptoms less than 6 hours
in onset will be preferentially taken to a stroke center when possible. Air medical
transport may be considered for select patients with symptom onset less than 2 hours in
order to facilitate time-dependent lytic therapy.
ACS/STEMI: Patients experiencing acute STEMI are best managed in facilities with active
cath lab programs and should be preferentially taken to these centers. The receiving
hospital emergency department physician should be notified while en route. The field EKG
demonstrating the STEMI should be transmitted electronically to the receiving hospital
when possible, in order to facilitate activation of the cath lab before arrival when
appropriate.
Pediatric Care: Children with critical illness or injury and children with chronic underlying
medical conditions should be preferentially transported to a facility capable of caring for
the child’s critical illness or special needs. The parents should be enlisted to assist with
destination decisions whenever possible.
Burn Care: Patients fulfilling criteria for major burns (see burn care protocol) should be
transported to a burn center whenever possible.

Medical Protocols
On-Scene Medical Providers:
(Per the Texas State Board of Medical Examiners (TSBME), the licensing body for physicians in Texas.)
Control at the scene of a medical emergency shall be the responsibility of the individual in attendance
who is most appropriately trained and knowledgeable in providing prehospital emergency stabilization
and transport.
 Physician On-Scene/General Guidelines

 The credentialed provider on-scene is responsible for management of the
patient(s) and acts as the agent of the medical director or OLMC.
 In order to participate in care physicians must present a valid Texas Board of
Medical Examiner’s License (all physicians are issued a wallet card) or be
recognized as a physician by the provider.
 Patient’s Personal Physician On-Scene
 If the patient's personal physician is present and assumes care, the provider
should defer to the patient’s personal physician. That physician shall provide the
provider with written orders if they deviate from this document.
 If there is a serious disagreement between the patient’s personal physician and
the system SOGs, the physician shall be placed in direct communication with
OLMC. If the patient’s personal physician and the on-line physician disagree on
treatment, the patient’s personal physician must either continue to provide
direct patient care and accompany the patient to the hospital, or must defer all
remaining care to the on-line physician.
 Intervener Physician On-Scene
 If an intervener physician is present at the scene, has been satisfactorily
identified as a licensed physician (by showing a valid copy of his/her Texas
medical license), and expressed willingness to assume responsibility for care of
the patient, OLMC should be contacted. The on-line physician has the option to:
 manage the case exclusively
 work with the intervener physician
 allow the intervener physician to assume complete responsibility for the
patient
 If there is a disagreement between the intervener physician and OLMC, the
provider will take direction from the on-line physician and place the intervener
physician in contact with the on-line physician.
 The intervener physician must document his or her interventions and/or orders
on the EMS patient care record.
 The decision of the intervener physician to not accompany the patient to the
hospital shall be made with the approval of the on-line physician.

Medical Protocols
Types of Consent
 Informed Consent: This is the legal standard regarding the process in which the patient refuses
or consents to medical care.
o The patient is competent and able to make a decision about their medical care.
o The patient is given all the necessary information a reasonable person would require to
make the decision including: risks, benefits and alternatives
o The patient is capable of deliberating and communicating their choice.
 Implied Consent: This type of consent regards the legal standard for consent during a life-
threatening emergency. Patients must be:
o Unable to communicate because of an injury, accident, illness, or unconsciousness and
suffering from what reasonably appears to be a life-threatening injury or illness
o OR suffering from impaired present mental capacity
o OR a minor who is suffering from what appears to be a life-threatening injury or illness
and whose parents, guardians or managing or possessory conservator are not present.
o Patients who are not mentally competent or have an impaired present mental capacity.
The latter case will generally require law enforcement assistance.
 Substituted Consent: When another person consents for the patient such as for minors,
incapacitated patients, incarcerated patients and those who have been deemed by a court of
law to be legally incompetent.

Medical Protocols
Consent and Treatment of Minors
A minor is able to consent or refuse medical care in a limited set of circumstances in Texas.
 Emancipation: This requires a court order in the state of Texas.
 Minors who are on active military duty with the US Military
 When consenting to the diagnosis and treatment of an infectious, contagious, or communicable
disease that is required by law or rule to be reported by the licensed physician or dentist to a
local health officer or the Texas Department of State Health Services
 Is consenting to examination and treatment for drug or chemical addiction, drug or chemical
dependency, or any other condition directly related to drug or chemical use
 A minor can consent to counseling for suicide prevention, chemical addiction or
dependency, or sexual, physical or emotional abuse
 Minors who are married are considered emancipated
Pregnancy:
 Minors may consent or refuse medical care related to the care of their unborn child or for their
pregnancy.
 Minors may also consent or refuse medical care and treatment of their child if they have
custody of that child.
Who other than the parents of a minor can consent to or refuse medical treatment?
Per Texas Statutes- Family Code §32.001
 Grandparent
 Adult brother or sister
 Adult aunt or uncle
 Any educational institution in which the minor is enrolled and has written
authorization from persons having power to consent
 Any adult who has actual care, control and possession of the minor and has written
authorization to consent for medical treatment.
 A court having jurisdiction over a suit affecting the parent-child relationship of which the child is
the subject
 A peace officer who has lawfully taken custody of minor, if the peace officer has reasonable
grounds to believe the minor is in need of immediate medical treatment.
 A managing or possessory conservator or guardian.
 A provider may be denied access to minor children by a parent or guardian if there is no obvious
immediate life threat to the patient. However, in general, parents or guardians cannot refuse
life-saving therapy for a child based on religious or other grounds.
 If the provider feels that the child is in immediate danger of a life threatening illness or injury
and the parent or guardian is refusing medical care, contact law enforcement for assistance in
treatment and transport.
In the event of an unaccompanied minor that requests refusal of medical care, consent may be obtained
via telephone by contacting the parent or guardian of the minor.

Medical Protocols
Termination of CPR
Termination of CPR is a difficult decision for clinicians. Termination of CPR should not be performed in
public locations with the exceptions of hospitals, nursing home, assisted living facilities and other
healthcare facilities. Termination may be performed in private residences and where the deceased and
family’s privacy can be respected. Termination efforts involve the entire family if present and after a
field termination care and guidance should be redirected to the family and friends present at the
resuscitation.
Resuscitation should not be initiated when any of the following is noted:
 Obvious appearance of death

 Decomposition
 Rigor mortis
 Obvious mortal wounds (massive burn injuries, severe traumatic injuries with obvious
signs of organ destruction such as brain, thoracic contents, etc.)
 Severe extremity damage, including amputation, should not be considered an obvious
mortal wound without coexistent injury/illness
 Other circumstances
 Patient submersion greater than 15 minutes after the arrival of first responders.
 Patients who are submersed in cold water do not have a definitive time that
resuscitation is futile and resuscitation should be initiated in the absence of other
obvious signs of death.
 Valid Out-Of-Hospital Do Not Resuscitate written order or device from any US State.
 A valid licensed physician on scene or by telephone orders no resuscitation efforts.
 Traumatic Cardiac Arrest:
o Arrival to the hospital time is greater than 10 minutes from time of arrest
o Asystole or PEA with a rate less than <40/minute. (Paramedic)
o This does not apply to isolated blunt traumatic arrest such as sudden blows to the chest
such as caused by a baseball or a strike with a fist. It does apply to severe crush injuries
to the torso.
o No evidence of signs of life
Any provider, in the following circumstances, may discontinue resuscitation efforts without OLMC:
 Resuscitation efforts were inappropriately initiated when criteria to not resuscitate were present.
 A valid OOH-DNR or advanced directive was discovered after resuscitative efforts were initiated.
 As per the limited termination of resuscitation(TOR) protocol (see below)
 For traumatic arrest only: when an EKG is applied after resuscitation is initiated and a PEA <40 or
asytole is noted. (Paramedic)

Medical Protocols
Termination of appropriate Resuscitation Efforts Utilizing OLMC: There are instances when a provider
must contact OLMC when considering discontinuation of resuscitation efforts. These include but are not
limited to the following circumstances:
 Attempts of 15 minutes or more using ACLS/PALS interventions with no return of spontaneous

circulation (ROSC).
 Patients who are found with presumed natural death and whose family request no interventions be
performed but do not have a DNR.
If the decision to terminate resuscitation efforts is made:
 Continue resuscitation while requesting an order to discontinue the resuscitative efforts.

 Contact OLMC (recorded line preferred).
 Document thoroughly per system and agency protocols.
Termination of appropriate Resuscitation Efforts without OLMC
This is permitted only by a Team Captain or higher level. This should not be performed if family is not
able to accept the death. Prior to initiating this protocol the provider should speak with the family
regarding the failed resuscitation efforts.
 Team Captain or higher only
 Adult patients
 Cardiac arrests that were not witnessed by GAAA providers or first responders.
 No bystander CPR
 15 minutes or more of continued asystole
 No defibrillation delivered during resuscitation and the patient is in asystole.
For offshore flights and no OLMC are available providers are permitted to cease resuscitation efforts
when:
 15 minutes of ACLS has been delivered without ROSC and in the presence of asystole
 Provider fatigue
 When the extrication time of the patient to the aircraft or to the provider would exceed 15
minutes and no bystander CPR has been delivered and the patient is confirmed to be pulseless
and apneic.

Medical Protocols
Out of Hospital Do NOT Resuscitate (OOH DNR)
Patients have a legal right to consent to, or refuse, recommended medical procedures, including
resuscitative efforts. The decision to honor, or not to honor, an OOH DNR must be made quickly and
accurately. Remember, it is our obligation to carry out the patient’s appropriately designated medical
choices.
 An OOH DNR order should NOT be honored and resuscitative efforts should be initiated in the
following circumstances:
o The patient or person who executed the order destroys the form and/or removes the
identification device.
o The patient or person who executed the order directs someone in their presence to
destroy the form and/or removes the identification device.
o The patient or person who executed the order tells the EMS providers or attending
physician that it is his/her intent to revoke the order.
o The attending physician or physician’s designee, if present at the time of revocation, has
recorded in the patient’s medical record the time, date, and place of the revocation and
enters “VOID” on each page of the DNR order.
o The patient is known to be pregnant.
o In the event that there is a question as whether to honor or not honor an OOH DNR or
Advanced Directive, contact OLMC as needed.
 Important Points to Remember
o Always rule out a non-traumatic etiology for what may be perceived as a traumatic
arrest (for example, primary ventricular fibrillation resulting in a minor car crash).
o Anytime a DNR is not honored, the reason must be documented in the patient care
record (PCR).
o An advanced directive does not imply that a patient refuses palliative and/or supportive
care. Care intended for the comfort of the patient should not be withheld based on a
medical power of attorney.
 When an EMS provider honors an appropriately executed DNR order, the law provides
protection against any charges of aiding in suicide 9Section 22.08 of the Penal Code -TAC
166.047.
 When in doubt, always initiate resuscitative efforts. Later termination can be implemented if
appropriate.

Medical Protocols

Medical Protocols
Hospice Patients
When a patient with a severe illness decides that curative measures are no longer appropriate or
effective, the option of hospice care is a compassionate, dignified and cost-effective end-of-life care
option. The address where a hospice patient resides will ideally be flagged from dispatch to allow for
appropriate identification of these patients. While a patient or legal surrogate may reverse a hospice
decision at any time, transport of these patients inappropriately to the hospital emergency room
generally will trigger loss of funding for the patient.
Our role when caring for a hospice patient includes:

 Confirming hospice status
 Providing comfort measures
 Addressing family concerns
 Coordinating care with the Hospice Team, which may include transport to the
hospital as a direct admission
As end-of-life issues are difficult for patients and healthcare professionals alike, the shift Supervisor or
Medical Director should be contacted immediately for assistance should any questions or concerns arise
during the care of these patients.

Medical Protocols
Scope of Practice
The State of Texas does not have a state-mandated scope of practice. Each system determines the
providers’ scope of practice.
The following skills/interventions are authorized by credential level in our system:
Emergency Medical Technician- Basic (EMT-B) Credentials
 Patient assessment  Assist patient with prescribed

 Spinal motion restriction medications
 CPR/AED application  Oxygen administration: Titrate to an
oxygen saturation of 92% or patient
 OPA/NPA
improvement by the use of NC, NRB,
 Oropharyngeal suction and BVM oxygen administration.
 Pulse Oximetry  End-tidal CO2 monitoring and
 BVM ventilations interpretation
 Blood glucose assessment  CPAP
 Oral glucose administration
 Bandaging/Splinting
 Emergency Childbirth
 Mark 1 Auto injector kits if available
 Medication administration: all
medications and routes as outlined in
ECA and EMT-B level Patient Care
Guidelines
 12-lead acquisition if appropriately
trained
 Small volume nebulizer
Members of Galveston Beach Patrol

 CPAP
 Combitube

Medical Protocols
Emergency Medical Technician- Intermediate (EMT-I) Credentials
All EMT-B skills/interventions plus:
 Medication administration: all  Orotracheal intubation

medications and routes as outlined in  Nasotracheal intubation
EMT-B, and IM, PO, IV, IN, SQ,
 Tracheal suctioning
nebulized medications as directed in
the protocols.  External jugular cannulation
 Peripheral intravenous access  EZ-IO
 Intraosseous access
Non Team Captain Paramedics
All EMT-B, and EMT-I skills/interventions plus:
 All routes of medication administration  Vagal maneuvers

(IV, IO, ET, SQ, SL, PR, IM and IN)  Defibrillation / Cardioversion
 Obtaining and interpreting ECG &  External cardiac pacing
12-leads.  Gastric tube insertion
 All cardiac related medications in a  Any other skill as directed by Team
cardiac arrest situation. Captain.
Team Captain Paramedics
 All skills listed above

 Chest decompression
 Surgical airway
 Pharmacologically Assisted Intubation
Supervisor
 All skills listed above

 All Therapies within the protocols including extended medical authorization and other special
procedural skills as developed.

Medical Protocols
Inter-facility Transfers:
When transferring a patient who requires transport to a higher level of care or for specialty services not
available at the sending facility the following guidelines should be used:
Consult with the on-duty shift supervisor for any patient care issues that cannot be resolved through this
document. If called to transport a patient that is potentially unstable for transport, assess and consult
with the treating physician.
Consistent with the intent of EMTALA, the transfer of a patient not stabilized for transport may be
preferable to keeping that patient at a facility incapable of providing stabilizing care. If the patient
requires advanced treatment or interventions that are beyond the scope of prehospital providers the
facility should provide appropriately trained staff to accompany the patient.
Additional staffing:
 If the staff member is an RN, he or she will maintain patient care responsibility and function
within his or her scope of practice and under the orders of the transferring physician. The GAAA
provider(s) and the RN will work together to provide patient care. If the patient deteriorates en
route the Paramedic will assume care outside the RN’s scope of practice.
 If the additional staff member is an RT, he or she will manage ventilator settings and all
treatment under his or her scope of practice. The paramedic will assist as needed and manage
the comprehensive patient care.
 If the additional staff member is a physician, then that physician will remain in charge of patient
care. The GAAA provider will assist as required.
 If the additional staff member is a flight paramedic, GAAA providers will assist as required and,
unless requested, the patient will remain in the care of the flight paramedic.
Due to the unique nature of inter-facility transports, providers will encounter medications and invasive
procedures that are not typically utilized in pre-hospital treatment. Providers should not monitor
medications or devices that they are not familiar with. Providers should not take possession of any
medication that is not from GAAA formulary to administer to the patient en route. Providers may
monitor and transport an extended formulary but should not institute or titrate any medications or
infusions not stated in this document. Limited titration can be performed by paramedics with written
orders.
Dial-a-flows are not appropriate for medication and infusion monitoring on inter-facility transfers.
EMT- Basics are permitted to transport and monitor all patients as noted in GAAA protocols and:
Monitor only:
Peripheral lines with a saline lock.
Personal Insulin infusion pumps that are maintained by the patient.
Feeding tubes and TPN solutions on an infusion pump.
Established (greater than 2 week placement) of tracheostomy patients on home ventilators with
pre-set ventilator settings.

Medical Protocols
NG/OG tubes.
Internal pacemakers.
Spinal stimulators.
Foley catheters.
Central venous access lines without infusions excepting patient controlled devices.
EMT-Intermediates: All skills and medications listed above and:
Peripheral lines containing plain isotonic or glucose solutions without medications added. May
adjust per the patient’s condition and/or written orders from the sending facility.
IV antibiotics running at a KVO rate or on an infusion pump if the medication has been initiated
by the sending facility.
Ventilator patients that do not require sedation, paralysis, EKG monitoring or other advanced
procedure.
EMT-Paramedics: All skills and medications listed above
Non-Team captain Paramedics will require written orders to administer sedation or paralysis
for intubated patients on ventilators.
Administer but not initiate glucose or isotonic IV fluids that are not standard GAAA formulary.
May monitor and adjust IV solutions containing potassium less than 20mEq/L.
Medications that GAAA providers may monitor without titration and administered through an
infusion pump. In the event of an infusion pump malfunction, the infusion should be stopped
and the appropriate facility contacted for guidance.
Heparin Magnesium
Anticoagulants or Antiplatelet agents Solutions with >20mEq/L of KCL
Electrolyte preparations Insulin
Antibiotics Mannitol
Sedatives in an infusion dose Paralytics as a continuous infusion
Sodium Bicarbonate infusions TPN/PPN
Anesthetic infusions IV steroids

Medical Protocols
The following medications may be titrated with written orders from the sending facility :
Insulin Propranolol and other beta-blockers
IV Nitrates Anti-dysrhythmics
Vasopressors Anti-hypertensive continuous infusions
Lidocaine
NOTE: Although the sending facility may have initiated medication(s), Paramedics MUST be familiar with
the medications that the patient may be receiving at the time of transfer. Reminder: interfacility
medications are not to be initiated by Paramedics.
Paramedics may monitor:
Ventilators
PIC Lines
Bladder Irrigation
Chest tubes
Femoral lines
ICP monitoring devices that are not in active use.
Blood products may be monitored by providers.
Paramedics may transport patients with femoral sheaths that are not currently accessed. Patients that
have arterial line monitoring, active ICP monitoring devices or Intra-aortic balloon pumps require
additional trained personnel from the sending facility to monitor and manage those devices.

Medical Protocols
Expired Medications and Medication Shortages
In the setting of national medication shortages, when it is deemed to be in the patient’s best interest to
use an expired medication, as opposed to either an inferior alternative or no medication, an expired
medication may be used. Additionally, providers will not be responsible for giving medications in any
protocol in which the medicine is unavailable due to national shortages or supply issues. Clinically
appropriate pharmacologic substitutions may be authorized on a case-by-case basis and communicated
directly to field staff by the medical director.

Medical Protocols
Ebola Preparedness Procedure

Dispatch Decision Tree for Ebola Screening
Does the
patient have a Proceed with normal
NO
fever > 38*C or call process
100.4*F
YES
Does the patient have severe

headache, muscle pain, vomiting, Proceed with normal
NO
diarrhea, abdominal pain or call process
unexplained bleeding?
If the answer to any of these questions is

YES
YES notify the crew immediately for Person
under Investigation of Ebola
In the past 21 days

In the past 21 days
has the patient been In the past 21 days Western Africa
been in residence or
in contact with blood handled bats or Countries:
traveled to a country
or body fluids of a nonhuman primates
where an Ebola
patient known to from a disease Guinea, Liberia,
outbreak is Nigeria, Sierra Leone
have or suspected to endemic area?
occurring?
have Ebola?

Medical Protocols
Section: UTMB On-Line Documentation 4.02 – Policy

Subject: Healthcare Epidemiology Policies and Procedures
Topic: 4.02 – Guidance for Emergency Medical Services (EMS) Systems for 9- 10.21.14
1-1 Public safety Answering Points (PSAPs) for Management of Patients with
Known or suspected Ebola Virus Disease (EVD) 2014 - Author
4.2 – Guidance for Emergency Medical Services (EMS)

Systems for 9-1-1 Public Safety Answering Points (PSAPs)
for Management of Patients with Known or suspected Ebola
Virus Disease (EVD)
Purpose To provide an integrated plan of operations between the University of Texas Medical
Branch (UTMB) Health System and any Emergency Medical Service in the safe transport
and healthcare for patients with diagnosed or possible Ebola Virus Disease.
Audience Healthcare personnel in the UTMB Emergency Department (ED) and personnel in the
EMS.
Policy and Procedures
I. Transport of patients with possible EVD based on 9-1-1 calls to the EMS
A. When calls come in to the dispatcher requesting Transport of a patient with possible
EVD, the dispatcher should ask the following questions:
1. Do they or someone else with them have a fever of greater than 38*C or
101.5*F and if they have additional symptoms such as severe headache,
muscle pain, vomiting diarrhea, abdominal pain or unexplained bleeding?
2. If the patient has symptoms of Ebola, then ask the patient about risk factors
within the past 3 weeks before the onset of symptoms, including:
a. Has the patient had contact with blood or body fluids of a patient
known to have or suspected to have EVD?
b. Has the patient had residence in-or traveled to a country where an
Ebola outbreak is occurring?
a. Guinea
b. Sierra Leone
c. Liberia
d. Nigeria
c. Has the patient handled bats or non-humans primates from the
disease-endemic areas?
d. If the dispatcher has information from the above queries suggesting
that the person may possibly have EVD, they should make sure that
the EMS personnel are made confidentially aware of the potential
for EVD so that responders can don appropriate PPE before they
arrive at the scene.
II. Transport of cases of possible EVD from UTMB outlying Clinics to the UTMB ED
A. Cases that present to UTMB Clinics with possible EVD will be screened using the
same screening protocol as that used by the UTMB ED.

Medical Protocols
Expired Medications and Medication Shortages
In the setting of national medication shortages, when it is deemed to be in the patient’s best interest to
use an expired medication, as opposed to either an inferior alternative or no medication, an expired
medication may be used. Additionally, providers will not be responsible for giving medications in any
protocol in which the medicine is unavailable due to national shortages or supply issues. Clinically
appropriate pharmacologic substitutions may be authorized on a case-by-case basis and communicated
directly to field staff by the medical director.

Medical Protocols
Ebola Preparedness Procedure

Dispatch Decision Tree for Ebola Screening
Does the
patient have a Proceed with normal
NO
fever > 38*C or call process
100.4*F
YES
Does the patient have severe

headache, muscle pain, vomiting, Proceed with normal
NO
diarrhea, abdominal pain or call process
unexplained bleeding?
If the answer to any of these questions is

YES
YES notify the crew immediately for Person
under Investigation of Ebola
In the past 21 days

In the past 21 days
has the patient been In the past 21 days Western Africa
been in residence or
in contact with blood handled bats or Countries:
traveled to a country
or body fluids of a nonhuman primates
where an Ebola
patient known to from a disease Guinea, Liberia,
outbreak is Nigeria, Sierra Leone
have or suspected to endemic area?
occurring?
have Ebola?

Medical Protocols
Section: UTMB On-Line Documentation 4.02 – Policy

Subject: Healthcare Epidemiology Policies and Procedures
Topic: 4.02 – Guidance for Emergency Medical Services (EMS) Systems for 9- 10.21.14
1-1 Public safety Answering Points (PSAPs) for Management of Patients with
Known or suspected Ebola Virus Disease (EVD) 2014 - Author
4.2 – Guidance for Emergency Medical Services (EMS)

Systems for 9-1-1 Public Safety Answering Points (PSAPs)
for Management of Patients with Known or suspected Ebola
Virus Disease (EVD)
Purpose To provide an integrated plan of operations between the University of Texas Medical
Branch (UTMB) Health System and any Emergency Medical Service in the safe transport
and healthcare for patients with diagnosed or possible Ebola Virus Disease.
Audience Healthcare personnel in the UTMB Emergency Department (ED) and personnel in the
EMS.
Policy and Procedures
I. Transport of patients with possible EVD based on 9-1-1 calls to the EMS
A. When calls come in to the dispatcher requesting Transport of a patient with possible
EVD, the dispatcher should ask the following questions:
1. Do they or someone else with them have a fever of greater than 38*C or
101.5*F and if they have additional symptoms such as severe headache,
muscle pain, vomiting diarrhea, abdominal pain or unexplained bleeding?
2. If the patient has symptoms of Ebola, then ask the patient about risk factors
within the past 3 weeks before the onset of symptoms, including:
a. Has the patient had contact with blood or body fluids of a patient
known to have or suspected to have EVD?
b. Has the patient had residence in-or traveled to a country where an
Ebola outbreak is occurring?
a. Guinea
b. Sierra Leone
c. Liberia
d. Nigeria
c. Has the patient handled bats or non-humans primates from the
disease-endemic areas?
d. If the dispatcher has information from the above queries suggesting
that the person may possibly have EVD, they should make sure that
the EMS personnel are made confidentially aware of the potential
for EVD so that responders can don appropriate PPE before they
arrive at the scene.
II. Transport of cases of possible EVD from UTMB outlying Clinics to the UTMB ED
A. Cases that present to UTMB Clinics with possible EVD will be screened using the
same screening protocol as that used by the UTMB ED.

Medical Protocols
UNIVERSAL TREATMENT GUIDLINES
Scene Safety
EXPECATIONS FOR EVERY
PATIENT ENCOUNTER:
- GCHD Badge displayed Bring all necessary
- Appropriate dress code equipment to the patient
- Highest degree of
professionalism PPE As Needed
Initial Assessment
Airway Obstructed Respiratory Failure Cardiac Arrest Severe Neurologic

Disability
Suction Airway BVM Ventilation Begin High Quality

OPA/NPA Compressions Seizure
Protocol
RSI Protocol Cardiac Arrest

Heimlich Maneuver
Protocol Excited
Delirium
Protocol
CONSIDER DIAGNOSTIC ADJUNCTS:
 Pulse oximetry if available
 Consider BGL Measurement
 Consider supplemental oxygen if
O2 sat <92
 Consider ETCO2 monitoring
COMMUNICATION Secondary Survey

 Document PCR Detailed History
 Obtain signatures
AS NEEDED Proceed To
 Notify receiving Consider Establishing IV
Appropriate Protocol
hospital
 Transmit ECG
 Transmit pt. info Consider cardiac monitor
 Notify supervisor Consider 12 Lead ECG

Medical Protocols
RAPID SEQUENCE INDUCTION

Clinical Indications: Patients who require control of the airway due to airway compromise or the
potential for airway compromise.
PREOXYGENATE PT 100% O2
PEDI DOSAGES VIA BVM FOR 30-90 SEC INDICATORS OF SUCCESSFUL
Etomidate INTUBATION
0.3 mg/kg
ETOMIDATE 20MG  Visualization of tube going
Succinylcholine AND/OR through cords
1 mg/kg VERSED 5MG
 Audible and equal breath sounds
Rocuronium
 Lack of sounds over epigastrium
1mg/kg
SUCCINYLCHOLINE  POSITIVE END-TIDAL CO2
Versed 100 MG IV  Improvement in vital signs and
0.1 mg/kg color.
Vecuronium  ASSESS ALL OF THE ABOVE AFTER
INTUBATE PT EACH ATTEMPT
0.1 mg/kg
(CONSIDER KING VISION
WHEN AVAILABLE)
YES NO
SUCCESSFUL
VERSED 5 mg IV OXYGENATE PT 100% O2 VIA THREE

May Repeat X1 for BVM FOR 30-90 sec. CONSIDER UNSUCCESSFUL
SYSTOLIC BP >90 ATTEMPT BY SECOND PERSON NO ATTEMPTS
INTUBATE PT WITH
FENTANYL
PROPER SIZE ET TUBE YES
100 mcg IV
Consider Add’l SUCC 50mg IV

VECURONIUM
10 mg IV OR
YES SUCCESSFUL NO FAILED AIRWAY
ROCURONIUM
50 mg IV
MONITOR KING VISION, when available:

- REQUIRED for C-spine immobilized patients
ETCO2
- STONGLY RECOMMENDED for all intubations
Yes to any item?
 RSI is not indicated for deeply comatose patients.
 Monitor pulse oximetry when available. Ensure oxygen saturation remains > 90%.
Patient will require spinal motion
 A second medic should make the third attempt at intubation if 3 attempts are needed.
 Documentation should include patient’s GCS prior to intubation, indication forrestriction
intubation, and placement confirmation
James Vincent M.D.
methods. Page 41
 Paralyzing a patient without proper sedation is cruel and poor medical practice.
Medical Protocols
FAILED AIRWAY
Indications:
 BVM fails to maintain SpO2 >90% or becomes difficult to ventilate.

 Three failed total attempts at oral-tracheal intubation
SpO2 <90%
NO YES
Continue To Facial Trauma or Swelling

ventilate with
BVM
NO YES
SpO2 drops below <90% or
becomes difficult to ventilate
with BVM Announce over the Radio “Medic
______ Failed Air-way Protocol”
Surgical Airway QuickTrach

Place King Tube
Ventilate PT at a ≤ 12 / min,
keeping SpO2 above 90%
SpO2 <90% YES
 Continuous pulse oximetry when available and ETCO2 monitoring should be used in all
patients with inadequate respiratory function.
JamesVincent
NotifyM.D.
receiving Emergency Department ASAP about patients with failed air-way. Page 42
Medical Protocols
PAIN MANAGEMENT
Clinical Indications:
 Patients that need pain management and are unable to obtain adequate relief with non-
pharmaceutical measures
General Pain
Management
Fentanyl 50 – 100 mcg

IV/IM/IN May repeat X1
AND / OR
Morphine 2-5mg IV
May repeat X1
 For sickle cell patients, also consider 1 liter of Normal saline.

 For hemodynamically unstable patients, Fentanyl should be the first line treatment.
 Morphine should be administered only with systolic pressure >90 and when the pt is not
presenting with signs of imminent circulatory collapse.
 Morphine should not be used during active child birth.
 Consider administration of Zofran early when administering Morphine.
(See Nausea Protocol)
 In the elderly, patients with renal or severe liver disease reduce dosage by half.
 Our goal is not complete cessation of pain, aim for 50% reduction of pain.
 Fentanyl may be administered IV, IM, or IN.
 This is not the necessarily the order of administration, use patient needs and presentation
as a guideline.
 Consider 25 mcg IV dosages for elderly patients.
Medical Protocols
POLICE CUSTODY
History: Signs and Symptoms: Differential:
 Trauma  External Trauma  Agitated Delirium

 Drug Abuse  Taser Barbs  Traumatic Injury
 Foot Pursuit  Wheezing, SOB  Substance Abuse
 Pepper Spray  AMS  Psychiatric
 Taser  Palpitations Emergency
Evaluation  Intoxication/Substance  Traumatic brain
abuse injury
 Asthma
Exacerbation
 Cardiac
Universal Treatment Guidelines
Appropriate
Suspected Traumatic Injury or
Protocol
medical condition.
Pepper Spray
Minor Laceration Taser
or Abrasions?
Irrigate Eyes and Face
w/ water. Remove Appropriate wound
Taser Barb
contaminated clothing care.
Removal Protocol
Wheezing NO
Coordinate disposition with LEO
and if necessary medical control
YES COPD/Asthma
and the on-duty Supervisor.
Protocol & Transport
 Excited Delirium is a distinct syndrome that is marked by restlessness, combativeness, and

hyperthermia. These patients are at high risk and should be transported by an ALS unit.
 Patients who are in police custody retain their rights to medical care. This should be
coordinated with the law enforcement officer (LEO). If any questions occurs whether the
patient requires transport, contact the on-duty supervisor for guidance.
 Sutures have a 6-8 hour window.
 Advise LEO and patient to obtain a Tetanus shot if the patient has not received one in more
than 10 years.

James Vincent M.D.
If an asthmatic Page 44
pt is exposed to pepper spray and is released to LEO or EMS care is refused
by LEO: all parties should be advised to contact EMS if wheezing or difficulty breathing
occurs.
Medical Protocols
ALLERGIC REACTION
Signs and Symptoms: Differential:
 Stable:  Niacin Overdose

o Rash/ Hives / Urticaria  Angioedema due to ACE Inhibitors
o Stable Vital Signs  Heat rash
 Unstable: Two or more of the following  Pulmonary Embolism
o Dyspnea  Foreign body obstruction
o Wheezing
o Cyanosis
o Excessive Salvation
o Edema to Eyelids, Lips, Hands,
Tongue
Stable Unstable
Epinephrine 1:1000
0.3mg IM
May repeat X1 in 5 min
Benadryl 25-50 mg
SIVP or IM NS Bolus 1000 cc IV
Solumedrol 125mg If Wheezing develops see

IV/IM COPD/Asthma Protocol
 The shorter the time from the patients exposure to the onset of symptoms, the more severe
the reaction.
 Apply cold packs. May be applied to bites and stings in order to reduce the swelling and slow
blood flow from the affected are.
 Famotidine is an antacid with H2 antagonist properties that has been shown to work well for
James Vincent
hives M.D.
and other allergic reactions. Page 45
Medical Protocols
ANXIETY
 Behavioral or  Hyperventilation  Hypoxia

psychiatric disorder  Sensation of panic  Head Trauma
 History of Anxiety  Agitation  Pulmonary Embolism
 Recent trauma or
emotional distress
Verbal Calming
Versed 1-2mg
IN/IM/IV may repeat
once
For pediatric patients < 13 y.o. contact medical control.
 This Protocol is NOT to be implemented for patients who are refusing EMS care and are
legally mentally competent and able to refuse care.
 The majority of patients that present with uncomplicated anxiety will not require
Jamespharmacological
Vincent M.D. management. Verbal calming and empathy is generally effective. Page 46
 Consider midazolam 0.5 mg IV for elderly patients.
Medical Protocols
BEHAVIORAL EMERGENCY
History: Signs and Symptoms: Differential Diagnosis:
 Psychiatric Illness  Anxious, tense, restless,  Excessive Heat or Cold

 Injury to self or fidgeting  Substance Abuse or
threats against others  Hallucinations, or Intoxication
 Substance abuse or delusional thoughts  Head Trauma
Overdose  Labile mood,  Hypoxia
 Diabetes unpredictable, excitable  Hypoglycemia
 Combative or violent  CVA / Brain Tumor
 Expression of suicidal or CNS infection
homicidal ideation
For pediatric patients Universal Treatment Guidelines

< 13 y.o. contact
medical control. Verbal Calming
BGL, Any vital signs that can be

safely obtained.
Physical Restraints (see p.12)
Versed 5mg IN/IM Valium 10mg IM

may repeat X 1 OR One dose
 Suspected Stimulant Overdose should be treated with Valium / Versed until pt is calmed or
systolic blood pressure of 100 is reached.
 Do not restrain in the prone position. Physical restraints without chemical restraint can
increase the risk of Excited Delirium in susceptible patients.
 For agitated or very combative patients do not restrain without adequate sedation to reduce
the risk of excited delirium.
 Patients restrained using handcuffs in police custody must be transported with law
enforcement’s assistance.
legally able to do so.
 If the patient is suspected of excited delirium and cardiac arrest ensues, Sodium Bicarbonate
and fluid bolus should be administered early in the arrest. If available cooled IV fluids should
be used. Consider passive cooling.
 After restraint procedures are used the patient will require continuous monitoring.
Medical Protocols
EXCITED DELIRIUM
 Use of Bath Salts  Agitation  Excessive Heat or Cold

 Use of Synthetic  Aggressive or  Substance Abuse or
Marijuana threatening behavior Intoxication
 Use of LSD  Amazing strength  Head Trauma
 Use of Cocaine  Dilated Pupils  Hypoxia
 Sweating  Hypoglycemia
 Hot to the touch  CVA / Brain Tumor
 Tachypnea CNS infection

For pediatric patients
Cardiac Monitoring, 12 Lead EKG FOR IMMINENT LIFE THREAT
contact medical TO PATIENT OR HARM TO
control. STAFF
Verbal Calming
Versed
CARDIAC ARREST 5 mg IV/IM/IN
Sodium Bicarb Benadryl 25-50 mg

50-100 mEq IV IV/IM Geodon
20 mg IM
GEODON SHALL ONLY

BE GIVEN IM
 If Geodon is given IV, immediacy contact the medical director and notify the Clinical
Coordinator ASAP.
 Do not restrain in the prone position. Physical restraints without chemical restraint can
increase the effects of Excited Delirium and are inhumane.
 Patients restrained using handcuffs in police custody must be transported with law
enforcement’s assistance.
legally able to do so.
 If the patient is suspected of excited delirium and cardiac arrest ensues Sodium Bicarbonate
and fluid bolus should be administered early in the arrest. If available cooled IV fluids should
be used. Consider passive cooling.
Medical Protocols
COPD / ASTHMA
Signs and symptoms: Differential:
 Pursed Lips  Pneumonia

 Audible Wheezing  Congestive Heart Failure
 Decreased Breath Sounds  Anaphylaxis
 Inability to Complete Sentences  Tuberculosis
 Prolonged Expiratory Phase

Cardiac Monitoring, 12 Lead EKG
Respiratory Distress Protocol

Obtain EKG Bronchospasm most likely cause of distress
Albuterol 2.5mg / Atrovent 0.5 mg

may repeat x2
Solumedrol 125mg IV
Consider C-PAP
Apply ETCO2 Device
5cm H20
Albuterol 2.5mg nebs

continuously
Life Threatening Asthma
Magnesium SO4 2G IV over 20 min RSI Protocol
Epinephrine (1:1000) 0.3mg IM

may repeat X1 in 5 min
 Magnesium Sulfate is recommended after 1 hour of treatment or for life-threatening asthma

and should be given over 20 minutes. It should be used infrequently.

Medical Protocols
DIABETIC EMERGENCIES
 Medication use  Thirst, malaise, nausea,  CVA

 Endocrine Disorders vomiting, irritability  ETOH abuse, overdose
 HX of cancer  AMS, Confusion,  Addison’s, Adrenal crisis
 Sepsis and Infection Hallucinations, Bizarre  Pregnancy
behavior
 Focal Impairment and
seizures.
 Unresponsive
BGL <70 Obtain EKG BGL >300
Oral Glucose 15G Fluid Bolus up to 1 liter

NS over 30 min.
Dextrose 50%
25 grams IV / IO Treat associated
symptoms
Thiamine 100 mg
IV/IM for chronically
malnourished pts.
Pt refusals: If a hypoglycemic pt wishes to refuse transport after treatment, and the provider has no
concerns about underlying medical conditions, or the ability of the person or care giver to manage
their disease ensure the following conditions are met:
 Adequate food available, advise pt to eat a meal containing complex carbohydrates

 Functional home glucometer
 Not on Sulfonylurea medications (i.e. Glyburide, Glipizide)
 Document removal of IV site and bandage
 Patients in a Hyperosmotic Nonketotic State (BGL >600) may present with altered mental
status and need for airway management.

Medical Protocols
HYPOTENSION
Signs and Symptoms: Differential Diagnosis:
 SYSTOLIC BP < 90 WITH SYMPTOMS  Shock- Carcinogenic, Septic, Neurogenic,
 Lightheaded, Dizziness Anaphylactic
 Positive Tilt test  Pregnancy
 Altered Mental Status  Ectopic Pregnancy
 Restlessness, Confusion  Dysrhythmias
 Weak, rapid pulse  Pulmonary Embolus
 Pale, cool, clammy skin  Tension Pneumothorax
 Coffee ground emesis, Tarry Stool  Medication Effect / Overdose
 Vasovagal
Cardiac Monitor, 12 Lead EKG
CONSIDER SEPSIS IF ANY TWO ARE MET NON-TRAUMA NON-CARDIAC CARDIAC

1. Temperature >100.9 F or < 96.8 (ex.: dehydration, GI bleed, (ex.: STEMI, CHF,
2. Heart rate > 90 Beats per minute; dysrhythmias,
heat exhaustion, vagal event)
3. Respiratory rate > 20 Breaths per min bradycardia)
4. Acutely altered mental status; or
5. Serum glucose < 120 mg/dL
(The Robson screening tool)
NS Bolus 500cc NS Bolus 500cc X1
repeat x 3
NS Bolus 500cc,
Repeat until
30mL/kg given
Go to
Epinephrine 10 mcg = 1mL appropriate
Q 2-5 minutes protocol once
Norepinephrine OR 5-20 mcg/min IV infusion etiology
determined
2-12 mcg/min IV Titrate to SBP >90
Target MAP 65
EPINEPHRINE FOR HYPOTENSION

Notify receiving hospital of Draw up 9 mL of NS in a 10mL syringe
suspicion of sepsis (“Sepsis Alert”) Add 1 mL of cardiac Epi (1:10,000)
1 mL = 10 mcg = 1:100,000 epinephrine
if hospital has a sepsis program

Medical Protocols
NAUSEA / VOMITING
 Nausea  Infection (viral, food-borne)
 Vomiting  Toxin, overdose, drugs, alcohol
 Dry lips, sunken eyes  Increased intracranial pressure (stroke,
 Tachycardia, hypotension hemorrhage, trauma)
 Acute coronary syndrome
ADULT PEDIATRIC >6

months
Zofran 4mg IV/IM

6 mo to 4 yo:
May repeat X1
Zofran 2 mg IV or IM
>4 yo:
Zofran 4 mg IV or IM
 Patients should be placed in an upright lateral recumbent position.

 Patients experiencing nausea or vomiting should not be allowed to ingest anything
by mouth while in EMS care.
 ALL nausea and vomiting patients should have a Blood Glucose Assessment.

Medical Protocols
Activated Charcoal
OVERDOSE
 Irregular or rapid respirations.  Head trauma
 Shallow respirations or apnea.  Hypoglycemia
 Bradycardia  Hyperglycemia
 Tachycardia  Hypoxia
 Altered mental status.

Calcium Channel Blocker
Cardiac Monitoring , 12 Lead EKG
with symptomatic
hypotension
Consider Activated Suspected

Charcoal 50 Grams Stimulant
Calcium Gluconate 10%
1 -2 grams IV over 10 min
= 10 -20 mL Behavioral Emergency
Known TCA & Wide QRS
Protocol
Suspected Opiate and apneic

Sodium Bicarb
Dystonic Reaction
50 -100 mEq IV
Narcan 0.4 mg IV/IM/IN Benadryl 25-50 mg

May repeat X4 until IV / IM
breathing
Max dose 2mg
 For all medications / drugs contact Poison Control 1-800-764-7661

 Max dose of Narcan 2mg.
 Narcan is NOT to be given to conscious or breathing patients unless a decreasing LOC or decreasing
respiratory drive is noted.
 Narcan is not to be used for diagnostic purposes.
 Narcan is to be administered in 0.4 mg doses titrated to respiratory drive.
 Activated Charcoal can be administered up to 2 hours after ingestion.
 DO NOT administer Activated Charcoal for acids, alkali, or petroleum base products.
 Signs of a Dystonic Reaction include:
o Protruding or pulling sensation of tongue
o Twisted neck, or facial muscle spasm
o Roving or deviated gaze
o Abdominal rigidity and pain
o Spasm of the entire body

Medical Protocols
RESPIRATORY DISTRESS
Sign and Symptoms Differential Diagnosis
 Dyspnea / pursed breathing  Asthma

 Unable to speak full sentences  COPD / Chronic Bronchitis
 Increased respiratory rate and effort  Anaphylaxis
 Wheezing, stridor  Pleural effusion
 Rales, rhonchi  Pneumonia
 Use of accessory muscles  Pulmonary embolus
 Fever, cough  Pneumothorax
 Tachycardia  Cardiac (ACS or CHF)
 Pericardial tamponade
 Anxiety / hyperventilation
Apply Oxygen
12 Lead ECG / Cardiac monitor
Pulse Oximeter and ETCO2
Bronchospasm suggested by: Other Causes: Pulmonary edema suspected:

- History of asthma / COPD - Anxiety - History of CHF
- Use of inhalers chronically - Allergic Reaction - Use of Lasix chronically
- Smoking history - ACS - Cardiac disease history
- wheezing on exam - Pain - Rales and leg edema on
- Pneumothorax exam
- Other
COPD / Asthma Proceed to CHF Protocol

Protocol Appropriate Protocol

Medical Protocols
SEIZURE
 Reported / Witnessed Seizure  Decreased mental status  Head Trauma

activity.  Sleepiness  Tumor
 Previous Seizure History  Incontinence  Metabolic, Hepatic, or Renal
 Medical alert tag Information  Observed seizure activity failure
 History of trauma  Evidence of trauma  Hypoxia
 History of diabetes  Unconscious  Medication non-compliance
 History of pregnancy  Infection / Fever
 Alcohol withdrawal
 Eclampsia
 Stroke
 Hyperthermia
 Hypoglycemia
Status Epilepticus Post-ictal
Blood Glucose BGL < 60

Versed 5 mg
IN / IV / IM Consider ETCO2 Monitoring Diabetic Protocol
May repeat X1
Seizure Reoccurs
OR
Airway Positioning,
Valium 10mg IV RSI Protocol
Nasopharyngeal airway, O2,
BVM Ventilations as needed
 Initial dose of IN Versed 5mg in 1 ml each nostril.

 Status Epilepticus is defined as 2 or more successive seizures without a period of consciousness or recovery. This
is a true emergency requiring rapid airway control, treatment, and transport.
 Grand mal seizures are associated with loss of consciousness, incontinence, and tongue trauma.
 Petit mal seizures effect only a part of the body and are not usually associated with a loss of consciousness.
 Jacksonian seizures are seizures which start as focal seizure and become generalized.
 Be prepared for airway problems and continued seizures. INTUBATION IS USUALLY NOT NEEDED. Attempt airway
positioning and nasopharyngeal airway during immediate post-ictal phase.
 Assess possibility of occult trauma and substance abuse.
 For any seizures in pregnant patient, follow the OB emergency protocols.
 Valium (Diazepam) is not effective when administered IM. It should be given IV or PR only.

Medical Protocols
STROKE / CVA
Sign and Symptoms Differential
 Facial droop on one side  Hypoglycemia

 Slurred Speech / Aphasia  Migraines
 Weakness on effected side  Bell’s palsy
 Hemi paresis  Multiple Sclerosis
 Headache  Inner- ear problems
 Loss of coordination/Ataxia  Vision disturbances
 Dysphasia / vision changes  Brain tumors
12-lead ECG
Consider Labetalol ONLY for BP > 220/120

10-20 mg slow IVP, may repeat X1
CINCINNATI STROKE SCALE

1. Facial Droop
(Have patient show teeth and smile)
Normal: Both side of face move equally
Abnormal: One side of face does not move as well as other
2. Arm Drift
(Have pt close eyes and hold both arms straight out for 10 seconds)
Normal: Both arms move the same or not at all
Abnormal: One arm does not move or one arm drifts down
3. Abnormal Speech
(Have pt say “You can’t teach an old dog new tricks”)
Normal: Patient uses correct words with no slurring.
Abnormal: Pt slurs, uses wrong words, or cannot speak
 Notify receiving Emergency Department of stroke alert as soon as possible.

 Check glucose levels on all suspected CVA patients.
 Ascertaining the exact time of onset of symptoms is key to definitive treatment.
 Hypertension is an expected compensatory response and in general should NOT be treated.

Medical Protocols
SYNCOPE
 Cardiac history,  Loss of consciousness  Orthostatic
Stroke, Seizure with recovery Hypotension
 Occult blood loss (GI,  Lightheadedness,  Psychiatric
Ectopic) dizziness  Stroke
 Fluid Loss: Nausea  Palpations, slow or rapid  Hypoglycemia
Vomiting, Diarrhea pulse  Seizure
 Past medical history.  Pulse irregularity  Shock
 Medications  Hypotension  Heat exhaustion
 Cardiac dysrhythmia
Obtain 12-lead ECG
Proceed to appropriate protocol

as indicated
NS 500 to 1000 cc
Blood Glucose
Orthostatic Vital signs
 Orthostatic vital signs must be assessed.

 Assess for signs and symptoms of trauma if associated or questionable fall with syncope.
 Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of
syncope.
 A tilt test (orthostatic vital signs) is considered positive if the patient becomes dizzy, weak,
altered, pulse increase of 20bpm, or blood pressure decrease 10mm/hg

Medical Protocols
ACUTE CORONARY SYNDROME

 Non-Reproducible chest pain  Trauma vs. Medical
 History of cardiac events  Pulmonary Embolism
 Location (Substernal, Epigastric, Arm,  Asthma / COPD
Neck, Shoulder)  Pneumothorax
 Radiation of pain  Aortic dissection or aneurysm
 Nausea, vomiting, or dizziness  Chest wall injury or pain
 Dyspnea  GE reflux or Hiatal Hernia
 Overdose of Cocaine or
Methamphetamine
12 lead EKG STEMI
NON-STEMI Transmit EKG to receiving hospital
Aspirin 324 mg PO chewed

Keep scene time <15 min.
Nitroglycerin Spray every Consider NS Bolus of 250-500cc

5 min X3 with SBP of >90
for suspected Inferior MI
For continued pain see pain

Establish 2nd IV of at least 18
management protocol
gauge while transporting
Consider Protocols as needed for, Hypotension,

HTN, Nausea / Vomiting, Dysrhythmias
 Notify receiving Emergency Department as soon as possible for suspected STEMI.

 Patients with marginal Blood Pressure and concern for inferior Right sided STEMI, IV access is
preferred before the administration of Nitroglycerin.
 Avoid Nitroglycerin in any patient who has used Viagra or Levitra in the past 24 hours, or
Cialis in the past 36 hours.
 Diabetics, geriatric patients, and females may have atypical pain or only generalized
complaints.
 An IV is not required for administration of Nitroglycerin.
 BP drop is expected after receiving Nitro. Do not hold further doses unless SBP < 90.
Medical Protocols
ACUTE CORONARY SYNDROME

Medical Protocols
SUPRA-VENTRICULAR TACHYCARDIA
 Rapid Regular Pulse >150, palpitations  Ventricular Tachycardia

 Feeling weak, light headed, or dizzy  A-Fib W/ RVR
12 Lead EKG
IV, NS Bolus 250-500 cc
YES STABLE NO
Consider Pain Management

Adenosine 6mg and/or Anxiety Protocols
fast IVP
Synchronized cardioversion
50 joules
Adenosine 12mg
fast IVP, may repeat X1 Synchronized cardioversion
100 joules
Diltiazem 10-20 mg 150 joules
Repeat 25mg X1 in
10 min.
Amiodarone 150 mg
over 10 min
 Unstable is defined by severe hypotension, altered mental status and/or weak or absent
radial pulses.
 Sedation should not be used with hemodynamically unstable pts.
 SVT refractory to Adenosine can be treated with Diltiazem if not contra-indicated.
 Vagal maneuvers are contraindicated if pt has a HX of CVA, carotid surgery or carotid bruits.
 CONTINUOUS PRINT-OUT OF MONITOR TRACING DURING CONVERSION IS VERY HELPFUL
FOR RECEIVING HOSPITAL’S CARDIOLOGIST.

Medical Protocols
A-FIB W/ RVR
 Rapid Irregular Pulse >150  Super Ventricular Tachycardia

 Feeling weak, light headed, or dizzy  Ventricular Tachycardia
 Feelings of Palpations
12 Lead EKG
IV, NS Bolus 250-500 cc
YES STABLE NO

and/or Anxiety Protocols
Diltiazem 10-20 mg
slow IV push
50 joules
Diltiazem 10-20 mg
100 joules
slow IV push
150 joules
 Unstable patients are ones with: severe hypotension, altered mental status and weak or
absent radial pulse.
 Diltiazem requires a systolic blood pressure of at least 80-90 mm/Hg.
 Sedation should be used with extreme caution on hemodynamically unstable patients.
Consider using the minimum dose.

Medical Protocols
VENTRICULAR TACHYCARDIA W/ PULSE

 Runs or sustained Ventricular Tachycardia.  Artifact / Device Failure

 Conscious, rapid pulse  Drugs
 Chest Pain, Shortness of breath  Pulmonary
 Dizziness
 QRS >0.12 sec.
12 Lead EKG
Cardiac
Arrest No Wide, regular rhythm with Narrow
Protocol Pulse SVT
QRS >0.12 sec? Complex
Protocol
STABLE UNSTABLE
YES

Amiodarone 150mg and/or Anxiety Protocols
over 10 min
may repeat x1
Synchronized Cardioversion
150 joules
May repeat as needed
Amiodarone 150mg
over 10 min
may repeat x1
 For witnessed / monitored ventricular tachycardia try having the patient cough.
 Polymorphic V-Tach (Torsade’s de Pointes) consider Magnesium Sulfate 2grams IVP
 Notify receiving Emergency Department as soon as possible of the patient’s condition.
 Brief episodes of ventricular ectopy do not require treatment (Formerly “Ventricular Ectopy”
protocol, which has been removed.)

Medical Protocols
SYMPTOMATIC BRADYCARDIA
Signs and Symptoms Differential Diagnosis
 Heart rate <60  Beta-blocker Overdose

 Chest Pain  Hypothermia
 Hypotension (systolic >90)  Digoxin Toxicity
 Ventricular ectopy  Calcium Channel Overdose
 Dyspnea  Malnutrition
 Altered Mental Status  Increased ICP
 Seizures
12 Lead EKG
ATROPINE 0.5MG-1MG
MAY REPEAT q 3-5 MIN
MAX DOSE 3mg

TRANSCUTANEOUS PACING AT A RATE

OF 60 AT LOWEST MILLIAMP SETTING
THAT OBTAINS CAPTURE.
IF HEART RATE >60 AND BP REMAINS <90 SYSTOLIC

SEE HYPOTENSION PROTOCOL
 USE CAUTION: Atropine should be omitted for second degree Type ll or Third Degree AV
Heart blocks
 DO NOT TREAT BRADYCARDIA IF PT HAS NORMAL BLOOD PRESSURE AND NO SYMPTOMS.

Medical Protocols
ADULT CARDIAC ARREST
EMT B/I to use AED

for rhythm analysis
and shocks
EMT-I may
establish IO when
indicated
EMT-I may use

Epinephrine 1mg
q3-5 min as in
diagram

Medical Protocols
VENTRICULAR TACHYCARDIA W/ PULSE

 Runs or sustained Ventricular Tachycardia.  Artifact / Device Failure

 Conscious, rapid pulse  Drugs
 Chest Pain, Shortness of breath  Pulmonary
 Dizziness
 QRS >0.12 sec.
12 Lead EKG
Cardiac
Arrest No Wide, regular rhythm with Narrow
Protocol Pulse SVT
QRS >0.12 sec? Complex
Protocol
STABLE UNSTABLE
YES

Amiodarone 150mg and/or Anxiety Protocols
over 10 min
may repeat x1
Synchronized Cardioversion
150 joules
May repeat as needed
Amiodarone 150mg
over 10 min
may repeat x1
 For witnessed / monitored ventricular tachycardia try having the patient cough.
 Polymorphic V-Tach (Torsade’s de Pointes) consider Magnesium Sulfate 2grams IVP
 Notify receiving Emergency Department as soon as possible of the patient’s condition.
 Brief episodes of ventricular ectopy do not require treatment (Formerly “Ventricular Ectopy”
protocol, which has been removed.)

Medical Protocols
POST-RESUSCITATION INDUCED HYPOTHERMIA
Criteria Differential:
 Post Cardiac Arrest with ROSC  Continue to address specific differentials

 Patient Comatose associated with the original
dysrhythmia.
 Non-traumatic etiology  Arrests caused by drowning, hanging or
 Transport to a facility that will continue asphyxiation can use this protocol.
procedure
Do not use in Return of Spontaneous

If patients goes
Pediatric patients. Circulation
into cardiac
arrest STOP
Criteria for Induced procedure and
Post Resuscitation NO
Hypothermia and initial resume
Protocol
temp >34c appropriate
protocol
RSI Protocol NO Advanced Airway
Successful 12 Lead EKG ACS Protocol as

needed.
Notify receiving
Expose Patient, Apply Ice Packs
hospital if STEMI
if available to Axilla and groin.
present.
Cold Saline Bolus 1-2 liters

(if available)
>34c and
<33C Reassess Temperature Shivering
Discontinue Cooling Measures Etomidate 20mg IV/IO
 If no advanced airway can be obtained, cooling may only be initiated with online medical
direction.
 Do not delay transport to initiate cooling patient.
 Patients may develop metabolic alkalosis with cooling. Do not hyperventilate.
 Take care to protect patient’s modesty. Undergarments may remain in place during cooling.

Medical Protocols
HYPERTENSION
 Hypertension  Systolic BP >180  Myocardial Infarction

 Stroke OR Diastolic BP >110  Cushing’s Response-
 Medication With one of the following Bradycardia with
Compliance Hypertension
 Headache
 Pregnancy  Pre-eclampsia /
 Nausea / Vomiting Eclampsia
 Chest Pain
 Vertigo
 Nose Bleed
 Shortness of breath
12 Lead EKG
Cardiac (angina, CHF) or Neurologic or Other

labetalol contraindicated (OB, renal, nosebleed)
Nitroglycerin 0.4 mg
spray
Enalapril 1.25 mg Labetalol 10-20mg
may be repeated X2
Slow IV push Slow IV push
May repeat X1 Repeat q10 min X2
Nitro spray q5 min

for continued HTN
 Asymptomatic hypertension does not require treatment regardless of how high the blood
pressure is. Treatment may interfere with compensatory mechanisms and cause harm.
 Target Systolic blood pressure should be two thirds of the initial blood pressure.
 Do not use labetalol if HR < 60
 Labetalol onset 5-10 min with a peak effect of 30 min.
 Never treat Blood pressure based on one set of vitals.
 Avoid Nitroglycerin in pt who has taken erectile dysfunction drugs in the past 48 hrs

Medical Protocols
CONGESTIVE HEART FAILURE

Signs and Symptoms: History: Differential Diagnosis
 Respiratory Distress  Congestive Heart  Myocardial Infarction
 Jugular Vein Distention Failure  Asthma
 Pink, Frothy Sputum  Medications,  Aspiration
 Diaphoresis (Digoxin, Lasix,  COPD
 Hypertension, Viagra)  Pleural Effusion
Hypotension  Cardiac History  Pneumonia
 Chest Pain  Pulmonary Embolus
 Pericardial Tamponade
Oxygen , 12 Lead EKG, ETCO2 Monitor
Respiratory Distress, Alert Respiratory Distress, Lethargic
Consider C-PAP
RSI Protocol
Systolic Blood
Pressure > 140
Expect Hypotension
Nitro spray q3 min Give 250mL Bolus
1 Nitro Spray q 3 min X 5
for SBP >140 and refer to
Hypotension
Protocol
If systolic BP >140
ACS Protocol as
Enalapril 1.25 mg slow IV push
needed
May repeat X1
 DO NOT administer Nitroglycerin to any patient who has used erectile dysfunction medications (Viagra, Cialas,
Levitra, etc.) in the past 48 hours due to possible severe hypotension.
 If patient has taken nitroglycerin without relief, consider potency of the medication.
 Nitroglycerin can be administered to a patient by EMS if the patient has already taken 3 of their own prior to
your arrival. Document it if the patient had any changes in their symptoms or a headache after taking their
own. Document the expiration date of the patients prescribed nitroglycerin.
 Diabetics and geriatric patients often have atypical pain, or only generalized complaints.
 Careful monitoring of LOC, BP, and respiratory status with above interventions is essential.
 Acute pulmonary edema may be a sign of acute cardiac ischemia, which may give rise to cardiovascular
collapse and hypotension as well as malignant atrial and ventricular arrhythmias.
 DO NOT withhold oxygen from hypoxic patients.

Medical Protocols
Taser barb removal Taser barb rem Taser barb removal oval
SELECTIVE SPINAL IMMOBILIZATION
VENTRICULAR ECTOPY
History: Signs and Symptoms:
 Mechanism of injury  Focal neurological deficit
 Fall height  Any spinal tenderness.
 Drugs or alcohol use
 Auto Pedestrian / Bicycle Accident
 Diving incidents
Focal Deficit?
Age <5 or >65?
Yes to any item?

Does the patient have altered
alertness? Patient will require spinal
motion restriction
Suspected or Known
Intoxication?
Distracting injury?
The patient must be able to
look up, touch chin to the
Spinal Exam: any point chest and from side, to side
tenderness to spine or with without spinal process pain.
range of motion?
Dangerous mechanism?
Ex: Fall > 3feet, mod to high speed MVA,
diving accident, ATV crash, auto-ped?
 The decision not to immobilize must be fully documented and include all of the above
historical and exam findings.
 Palpate each spinous process to assess for tenderness. Only if no tenderness was elicited,
perform a range of motion exam.
 Partial Immobilizations:
o At times securing a patient to a rigid spine board may worsen a spinal injury if
present or may otherwise harm the patient. These patients may be transported in
semi-recumbent position with a c-collar.
o Examples of patients who may not tolerate supine positioning: agitated patients and
patients with decompensated CHF or with kyphosis.
Medical Protocols
calcium gluconate 10% 10cc

CRUSH INJURY
Signs and Symptoms: History:
 Pain  Entrapment of extremity or torso for prolonged

 Pallor period of times.
 Pulselessness
 Paralysis
 Skin cool to the touch
Consider RSI Protocol
1-2 L NS

Extremity Trauma or Amputation Protocols as needed
Sodium Bicarb 50-100 mEq IV

to be administered immediately
after removal from entrapment
Calcium Gluconate 10%

1 -2 grams IV over 10 min =
10 -20 mL for arrhythmias
 Observe all crush injuries, even those who look well.

 Administer intravenous fluids before releasing the crushed body part. This step is especially
important in cases of prolonged crush >4 hours.
 Crush syndrome can occur in crush scenarios of <1 hour.
 Sodium Bicarbonate should only be given in instances of entrapment > 2hrs.
 Suspect hyperkalemia if T waves become peaked, QRS>.12seconds, and / or hypotension
develops.
 If cardiac arrest occurs after release of entrapment, give Sodium Bicarbonate 1mEq/kg
immediately and every 10 min during CPR.

Medical Protocols
MAJOR TRAUMA
SIGNS AND SYMPTOMS: DIFFERENTIAL:
 DETERMINE EVENTS LEADING TO  TENSION PNEUMOTHORAX /

TRAUMA AND MECHANISM OF HEMOTHORAX
INJURY  FLAIL CHEST
 PAIN, SWELLING, DEFORMITY,  PERICARDIAL TAMPONADE
BLEEDING, LESIONS  OPEN CHEST WOUND
 ALTERED MENTAL STATUS,  OPEN / CLOSED HEAD INJURY
UNCONSCIOUS  SPINAL INJURY
 HYPOTENSION, SHOCK  PELVIC / HIP FRACTURE
AIRWAY AND BREATHING AND CIRCULATION AND DISABILITY EXPOSURE

CERVICAL SPINE OXYGENATION HEMORRHAGE ASSESSMENT
CONTROL CONTROL
Consider RSI O2 AS NEEDED VITAL SIGNS DETERMINE SPLINT SUSPECTED

Protocol GCS FRACTURES
CONTROL ALL
Consider Needle Consider Pain
MAJOR ASSESS FOR
Decompression Management Protocol
BLEEDING FOCAL NEURO
DEFICITS
BILATERAL IV OR Consider Tourniquet

UNSTABLE IO ACCESS Protocol
PATIENTS MUST
BE TRANSPORTED
IMMEDIATELY. TITRATE BLOOD Consider Antibiotic
PRESSURE TO AT Therapy for open long
Goal Scene Time
LEAST 90 SYSTOLIC bone fractures
< 10 minutes
with small NS
boluses 250mL CONTINUALLY REASSESS
 GERIATIC PT SHOULD BE EVALUATED WITH A HIGH INDEX OF SUSPENSION.

 MECHANISM IS THE BEST INDICATOR OF SERIOUS INJURY.
 SCENE TIMES SHOULD NOT BE DELAYED FOR PROCEDURES; THESE SHOULD BE PERFORMED
DURING TRANSPORT WHEN POSSIBLE.
 ON SCENE TIME OF 10 MIN OR LESS FOR THE UNSTABLE TRAUMA PT IS THE GOAL.
 ALLOW PERMISSIVE HYPOTENSION TO PREVENT FURTHER HEMORRHAGE.

Medical Protocols
EXTREMITY TRAUMA
 Pain
 Swelling
 Deformity
 Altered Sensation / Motor function
 Diminished Pulse / Capillary refill
 Decreased extremity temperature
CONTROL ALL MAJOR BLEEDING
Appropriate wound care.
Open long Splint suspected Fractures

bone fracture as necessary.
Cefazolin Consider Pain

1-2g IV drip Management Protocol
1-2g IV
1 Consider Tourniquet
Protocol
 For patients with an amputation, time is critical. Transport and notify receiving hospital
immediately. (See Extremity Amputation Protocol)
 Hip, knee and elbow fracture/dislocations have a high incidence of vascular compromise.
 Urgently transport any injury with vascular compromise.
 Lacerations must be evaluated for repair within 4 hours from the time of injury.

Medical Protocols
EXTREMITY HEMORRHAGE / AMPUTATION

 Amputation / Partial Amputation  Abrasion

 Pain and Swelling  Amputation
 Deformity  Contusion
 Altered Sensations / Motor Function  Dislocation
 Fracture
 Laceration
Apply direct pressure to control hemorrhaging. Consider Antibiotic

If unable to control with direct pressure, apply Therapy for any open long
indirect pressure using arterial pressure points and bone fractures without
amputation
elevating the affected limb if possible.
If hemorrhage cannot be controlled by direct

pressure and the injury is life threatening consider
tourniquet application

Protocol
Consider Tourniquet
Incomplete Amputation: Splint affected digit / limb in a physiological position.
Amputation:
o All retrievable tissue should be transported. (DO NOT DELAY TRANSPORT for tissue retrieval)
o Rinse amputation with normal saline or sterile water.
o Wrap amputation in sterile gauze that has been moistened with normal saline or sterile water.
o Place in plastic bag or container; place container in separate container filled with ice. (if available)
o DO NOT PLACE AMPUTATED PART IN DIRECT CONTACT WITH ICE.
 Transport amputation victims rapidly, as successful replantation is time-dependent.

 Hip dislocations, knee and elbow fracture / dislocations have a high chance of vascular
compromise.
 Blood loss may be concealed or not apparent with extremity injuries.
 Lacerations must be evaluated for repair within 4 hours.

Medical Protocols
BURNS CHEMICAL / ELECTRICAL

 Burns, pain, swelling  Superficial (1st Degree) Painful and Red
 Dizziness or Loss of consciousness  Partial Thickness (2nd Degree) Blistering
 Hypotension  Full Thickness (3rd Degree) Painless,
 Airway Compromise charred or leathery skin.
 Respiratory Distress / Wheezing  Thermal
 Hypotension / Shock  Chemical
 Signed Facial Hair or Nostril Hair  Electrical
Continuously flush
Eye the affected area
Involvement for 10-15 min.
Remove rings and other constricting items.

Remove clothing and expose affected area.
Apply sterile dressing to entry and exit site

of electrocution injuries.
Cardiac Monitor and

12 lead EKG after electrical injury
Critical Minor
Consider RSI Protocol

>10% TBSA 2nd/3rd Degree Burn <10% TBSA 2nd OR <2% TBSA 3rd
Consider Hypotension Protocol Airway compromise, Not intubated, No Inhalation
Hypotension or GCS<14 Injury, Normotensive. GCS 15
TRANSPORT TO BURN CENTER
Consider Pain Management MAY BE TRANSPORTED TO LOCAL
Protocol HOSPITAL
Chemical: ELECTRICAL:
 Flush the affected area as soon as possible  Do not contact the patient until you are sure
with the cleanest and most readily available the electricity source is disconnected.
saline or tap water using copious amounts of  Attempt to locate contact points, both will
fluid. generally be full thickness burns.
 Utilize industrial decontamination  Anticipate Ventricular, or Atrial irregularity,
equipment/showers and MSDS information V-Tach, V-Fib, Heart Blocks and other
when available. dysrhythmias.

Medical Protocols
BURNS - THERMAL
 Burns, pain, swelling  Superficial (1st Degree) Painful and Red
 Dizziness or Loss of consciousness  Partial Thickness (2nd Degree) Blistering
 Hypotension  Full Thickness (3rd Degree) Painless,
 Airway Compromise charred or leathery skin.
 Respiratory Distress / Wheezing  Thermal
 Hypotension / Shock  Chemical
 Signed Facial Hair or Nostril Hair  Electrical
Assess Airway
Critical Minor
Determine TBSA/depth of Burn

>10% TBSA 2nd/3rd Degree Burn <10% TBSA 2nd OR <2% TBSA 3rd
Airway compromise, Not intubated, No Inhalation
Hypotension or GCS<14 Injury, Normotensive. GCS 15
Remove rings, bracelets, and
TRANSPORT TO BURN CENTER
other constricting articles.
MAY BE TRANSPORTED TO LOCAL
Consider RSI Protocol HOSPITAL
Cool the wound with normal saline, cover

burn with dry sterile dressing.
NS infusion < 6 yo 125 mL/hour IV
6-13 yo 250 mL/hour IV
14 + yo 500 mL/hour IV Pain Management Protocol
 Assure whatever caused the burn is

no longer contacting the skin.
 Early intubation is necessary for
patients with significant inhalation
injuries.
 Burn patients are prone to
hypothermia – NEVER cool or apply
ice to the burned area.
 Other burns ideally treated at a
Burn Center:
- Feet, hands, face, genital burns
- Circumferential burns (due to
possible vascular compromise)
- Any 3rd degree burn >2% TBSA
- Burns with associated trauma
- Nontrivial Pediatric burns
- Burns in adults > 50, esp. with
underlying comorbid conditions

Medical Protocols
MARINE LIFE ENVENOMATIONS

 Type of bite or sting  Description of the injury  Snake Bite

 Time, location and size  Rash: local or generalized  Skin Infections
of bite or sting.  Hypotension  Infection risk
 Any prior reaction  Respiratory Distress  Rabies
 Rabies and tetanus  Vomiting  Tetanus
risk & status  Headache  Marine Life
 Immunocompromised  Cellulitis
NOTE: Vinegar
irrigation of jellyfish
wounds is no longer
JELLYFISH recommended, STINGRAY
(except in cases of
Pacific box jellyfish
or Atlantic
Irrigate with copious Portuguese man-of- If able immerse the
amounts of saline over war stings, which are affected site in very hot
the wound. not endemic to water or place hot packs
Galveston.)
to the affected area.
Advise the Pt that if they

Consider Pain Advise pt to allow EMS to
have mild pain after
Management transport PT. for proper
treatment a topical
Protocol wound care and to
antihistamine may help.
ensure no foreign
material remains in the
wound.
 Transport patients with severe systemic response or allergic reaction to jellyfish stings.
 Jellyfish stings in the Galveston area are rarely serious despite the amount of pain. Rarely
toxic varieties can drift into the area and the patient will present in imminent collapse.
 Stingray envenomation require medical attention due to the high risk of infection and risk of
retained barbs or foreign mater in the wound.
 Transport and treat patients with high BSA % of jellyfish stings or patients with stings to the
mucosa due to the risk for infection, severe pain and cosmetic damage.

Medical Protocols
SNAKE BITE
 Type of bite or sting.  Swelling  Animal or Human Bite

 Time location and size  Allergic reaction  Skin Infections
of bite or sting.  Hypotension or Shock  Infection Risk
 Any prior reaction.  Difficulty Breathing  Rabies Risk
 Rabies and tetanus  Signs of Systemic  Tetanus Risk
risk & status. Response  Insect Bite
 Immunocompromised  Marine Life
DO NOT BRING DEAD OR LIVE SNAKES TO THE ER
Immediate transport to a trauma

center.
Consider Anaphylaxis and Consider Pain

Hypotension Protocols Management Protocol
 Keep pt movement to a minimum.

 Remove items that may constrict swelling tissue.
 Document size and time of edema near the injury site.
 When transporting from Moody Gardens bring anti-venin if available with the patient
and all the snake identification card and all records sent by Moody Gardens.
 If the patient is from Moody Gardens then choose the transport destination
requested by Moody Gardens staff based upon their training and knowledge.

Medical Protocols
DROWNING / NEAR-DROWNING
 Submersions in water  Unresponsive  Trauma
regardless of depth  Mental status changes  Pre-existing medical
 Possible trauma to  Decreased or absent problems
c-spine vital signs  Pressure injury
 Temperature of water,  Vomiting (diving)
possibility of  Coughing  Post-immersion
hypothermia  Apnea syndrome
 Stridor, Wheezing, Rales
Immobilize C-spine
Begin CPR if required.
Consider CPAP for

respiratory distress
Consider RSI if CPAP is

ineffective as indicated by
decrease in mental status.
 Have a high index of suspicion for possible spinal injuries. Factors to consider are potential
underwater hazards, height of fall, neurological deficits or length of time missing.
 With cold water drowning – resuscitate all. These patients have an increased chance of survival.
 Some patients may develop delayed respiratory distress due to lung damage and capillary leak.
 All victims should be transported for evaluation due to potential for worsening over the next
several hours.
 Allow appropriately trained and certified rescuers to remove victims from areas of danger.
 With pressure injuries (decompression / barotraumas), consider transport to a hyperbaric
chamber.
 For SCUBA injuries contact Diver Alert Network 1-919-684-9111.

Medical Protocols
ACTIVE LABOR
Signs and Symptoms Differential Diagnosis:
 Evident gravid uterus  Prolapsed cord

 Spasmodic pain  Placenta Previa
 Vaginal discharge or bleeding  Abruptio Placenta
 Crowning or the urge to push  Abnormal Presentation
 Meconium o Buttock
o Hand
o Foot
Left Lateral Position

OB Emergency
Protocol or
Difficult Child Hypotension or Vaginal
YES
Birth Protocol Bleeding;
NO CrowingPresentation
Abnormal
NO
NO Crowning Crowning <36 Weeks, Crowning >36 Weeks

or Multiple Gestation
Child Birth
Procedure
Transport Rapid Transport
 Document all times. (Delivery, Contraction Frequency, and Length)

 If Maternal Seizures occur, refer to OB Emergencies Protocol.
 After delivery, massaging the uterus (lower abdomen) will promote uterine contractions and
help control post-partum bleeding.
 Some perineal bleeding is normal with any child birth, large quintiles of blood or free
bleeding are not.
 Record APGAR at 1 min. and 5 minutes after child birth.

Medical Protocols
OB EMERGENCIES
All of the following are considered priority symptoms and should be
transport to UTMB or CLRMC due to possible need for emergency surgery.
Eclampsia
Magnesium Sulfate 50% 2 gm
in 50 mL NS IV saline wide
open max 4 grams
Eclampsia is described as
seizures in a pregnant woman
that are not related to a
Diazepam 5 mg IV for active
preexisting brain condition.
seizures refractory to
magnesium sulfate
Ectopic Pregnancy
Should be considered as a Normal Saline 500-1000cc NS Bolus
possibility for patients with severe Consider Pain Management Protocol
abdominal/pelvic pain with known
pregnancy
Abrupto Placenta
Should be considered for pregnant High flow O2, position on left side
patients complaining of severe w/ padding;
“ripping” pain with possible NS Bolus 500-1000cc to maintain
hypotension. SBP >100

Medical Protocols
OB EMERGENCIES
Placenta Previa
Should be considered when Treatment for Hypotension: high-flow O2;
the placenta delivers prior Normal Saline 500-1000cc bolus to maintain
to the fetus. systolic BP >100; Position Patient on her left
side with padding under the abdomen.
Shoulder Dystocia
Inform the patient of need to assume

McRobert’s position and assist as
needed. Assert supra-pubic pressure
and tilt head towards posterior of
pelvis to allow for anterior shoulder
to clear pelvis. Then tilt the body
McRoberts Position
upwards towards anterior pelvis to
allow posterior shoulder to clear the
pelvis.

Medical Protocols
NEONATAL RESUSCITATION
Delivery of Newborn
Routine Care
 Term gestation?
 Provide warmth
 Breathing or crying? YES
 Clear airway if needed
 Good muscle tone?
 Dry
 Good color?
 Ongoing evaluation
NO
 Provide warmth
 Position and clear the
airway
 Dry, stimulate, reposition
 Evaluate HR, Respiration,
Color
Apneic, Gasping Breathing, HR >100,

or HR <100 but cyanotic
Observational Care &

O2 By Mask or Blow-by Transport
Persistent
Cyanosis 10-15 rapid
ventilations with Prepare for RSI
BVM will often Protocol if
Ventilate with PPV
stimulate apnea/cyanosis
spontaneous persist
HR<60
breathing
Chest Compressions
Pediatric Cardiac
Arrest Protocol &
Transport

Medical Protocols
PEDIATRIC CARDIAC ARREST
Insert IO
EMT-I Consider
may use advanced
Epinephr airway
ine
ET Tube size
Uncuffed Cuffed
0-1yr 3.5 3.0
1-2yr 4.0 3.5
>2yr 4+(age/4) 3.5+age/4)

Medical Protocols
PEDIATRIC DIABETIC EMERGENCIES

 Medication use  Thirst, malaise, nausea  CVA

 Endocrine Disorders vomiting, irritability  ETOH abuse, overdose
 HX of cancer  AMS, Confusion,  Addison’s, Adrenal crisis
 Sepsis and Infection Hallucinations, Bizarre  Insulin pump malfunction
behavior
 Focal Impairment and
seizures.
 Unresponsive
BGL <60 BGL >300
Oral Glucose 15G

NS 10-20cc/kg
<1mo. AND <45mg/dl 1mo.-12yrs over 30min
D10 D25
5 ml/kg 2 ml/kg
Obtain IO Access rapidly if PIV

unsuccessful with severe
lethargy and hypoglycemia
Dextrose Dilution Procedures

D25 - Waste 25 ml D50W. Use pre-filled syringe (with remaining 25 ml) to withdraw 25 ml of NS from IV bag.
Gently agitate syringe to mix solution.
D10 - Waste 40 ml D50W. Use pre-filled syringe (with remaining 10 ml) to withdraw 40 ml of NS from IV bag.
Gently agitate syringe to mix solution
 EVERY ATTEMPT SHOULD BE MADE TO TRANSPORT THE PEDIATRIC DIABETIC

PATIENT.
 Rapid or excessive fluid administration to children with DKA may increase risk of
cerebral edema and cause neurologic impairment.

Medical Protocols
PEDIATRIC PAIN MANAGEMENT

 Patients that need pain management and are unable to obtain adequate relief with non-
pharmaceutical measures
General Pain
Management
Fentanyl 1 mcg/kg
IV/IN/IM
May repeat X1
OR
Morphine 0.1 mg/kg

IV/IM
max dose of 5mg
 For sickle cell Patients also consider 5cc/kg bolus of Normal saline.
 For hemodynamically unstable patients Fentanyl should be first line treatment.
 Morphine should be administered only with systolic pressure >90 and pt is not presenting
with signs of imminent circulatory collapse.
 Consider administration of Zofran early when administering Morphine.
 Our goal is not complete cessation of pain, aim for 50% reduction of pain.
 Monitor for respiratory depression.

Medical Protocols
PEDIATRIC ALLERGIC REACTION

 Stable:  Niacin Overdose

o Rash/ Hives / Urticaria  Angioedema due to ACE Inhibitors
o Normal Vital Signs  Heat rash
 Unstable: Two or more of the following  Pulmonary Embolism
o Dyspnea or wheezing  Foreign body obstruction
o Cyanosis
o Nausea, vomiting
o Excessive Salvation
o Edema to Eyelids, Lips, Hands,
Tongue
Stable Unstable
NS Bolus 20cc/kg
Max 1000cc Epinepherine 1:1000
0.01 mg/kg IM
Max dose 0.3mg
Solumedrol 2mg/kg IV/IM may repeat 1 in 5 min
Max dose 125mg
Benadryl 1mg/kg IV/ IM

Max dose 25mg
If Wheezing present see

Respiratory Distress Protocol
 The shorter the time from the patients exposure to the onset of symptoms, the more severe
the reaction.
 Apply Cold Packs may be applied to bites and stings, in order to reduce the swelling and slow
blood flow from the affected are.
 Famotidine is an antacid with H2 antagonist properties that has been shown to work well for
hives and other allergic reactions.

Medical Protocols
PEDIATRIC SEIZURE
 Reported / Witnessed Seizure  Decreased mental status  Head Trauma

activity.  Sleepiness  Tumor
 Previous Seizure History  Incontinence  Metabolic, Hepatic, or Renal
 Medical alert tag Information  Observed seizure activity failure
 History of trauma  Evidence of trauma  Hypoxia
 History of diabetes  Unconscious  Drug medication, non-
 History of fever compliance
 Infection / Fever
 Alcohol withdrawal
 Eclampsia
 Stroke
 Hyperthermia
 Hypoglycemia
Status Epilepticus Post-ictal
Blood Glucose BGL < 60
Versed 0.1mg/kg
IN/ IV/IM/buccal Seizure Reoccurs Diabetic Protocol
Max dose 5 mg
May repeat X1
in 5 min
Airway Positioning,
Nasopharyngeal airway, O2, Consider RSI Protocol
OR
BVM Ventilations as needed
Valium 0.2mg/kg
IV Max dose 10mg
 Initial dose of IN Versed should be divided evenly between each nostril.

 Status Epilepticus is defined as 2 or more successive seizures without a period of consciousness or recovery. This
is a true emergency requiring rapid airway control, treatment, and transport.
 Grand mal seizures are associated with loss of consciousness, incontinence, and tongue trauma.
 Petit mal seizures effect only a part of the body and are not usually associated with a loss of consciousness.
 Jacksonian seizures are seizures which start as focal seizure and become generalized.
 Be prepared for airway problems and continued seizures.
 Assess possibility of occult trauma and substance abuse.
 For any seizures in pregnant patient, follow the OB emergency protocols.
 Valium (Diazepam) is not effective when administered IM. It should be given IV or rectally only.

Medical Protocols
PEDIATRIC RESPRITORY DISTRESS

 Spasmodic Coughing  Pneumonia

 Pursed Lips  Croup
 Grunting  Bronchiolitis
 Retractions / Accessory Muscle Usage  Congestive Heart Failure
 Audible Wheezing  Anaphylaxis
 Decreased Breath Sounds  Tuberculosis
 Inability to Complete Sentences
 Prolonged Expiratory Phase
Oxygen by Mask as Needed
ASTHMA
Asthma History, BRONCHIOLITIS CROUP
Normally > 1 yo Infant < 1yo Toddler
Wheezing on exam Wheezing, tight Barky cough,
cough, thick nasal stridor
secretions
Albuterol 2.5mg /
Atrovent 0.5 mg
may repeat x3
Epinephrine 1:1000 Nebulized

0.5 mL diluted with 2.5 ml NS
Solu-medrol 2mg/kg
Repeat X1 in 5 min
IV/IM
Max Dose 125MG
Epinephrine (1:1000) 0.01mg/kg IM

Max dose 0.3mg IM
May repeat X1 in 5 min Consider RSI Protocol
 A careful lung exam will reveal source of respiratory distress and can guide treatment decisions.
 Epinephrine IM is appropriate for use when respiratory failure is imminent, which in children is
signified by a sudden SLOWING in respirations and markedly DEPRESSED MENTAL STATE, (both
indicators of carbon dioxide build-up).

Medical Protocols
NEONATAL RESUSCITATION
Delivery of Newborn
Routine Care
 Term gestation?
 Provide warmth
 Breathing or crying? YES
 Clear airway if needed
 Good muscle tone?
 Dry
 Good color?
 Ongoing evaluation
NO
 Provide warmth
 Position and clear the
airway
 Dry, stimulate, reposition
 Evaluate HR, Respiration,
Color
Apneic, Gasping Breathing, HR >100,

or HR <100 but cyanotic
Observational Care &

O2 By Mask or Blow-by Transport
Persistent
Cyanosis 10-15 rapid
ventilations with Prepare for RSI
BVM will often Protocol if
Ventilate with PPV
stimulate apnea/cyanosis
spontaneous persist
HR<60
breathing
Chest Compressions
Pediatric Cardiac
Arrest Protocol &
Transport

Medical Protocols
PEDIATRIC CARDIAC ARREST
Insert IO
EMT-I Consider
may use advanced
Epinephr airway
ine
ET Tube size
Uncuffed Cuffed
0-1yr 3.5 3.0
1-2yr 4.0 3.5
>2yr 4+(age/4) 3.5+age/4)

Medical Protocols
CAPNOGRAPHY (ETCO2)
Indications:
 Verification of ET tube placement

 Continuous monitoring of ET tube during transport
 Shortness of breath / hyperventilation
 Status epilepticus
 Unconsciousness / poor arousability
 Pre and post treatment for asthma / COPD
 Indicator of Return of Spontaneous Circulation during cardiac arrest
TECHNIQUE
For Verification of ET tube placement:
1. Visualize the ET tube passing through cords with King Vision (when available)
2. Assess for breath sounds high in the axilla, on the anterior chest, and over the
epigastrium
3. Apply the ETCO2 monitor. REQUIRED WITH ALL INTUBATED PATIENTS
4. Note the following ETCO2 information on the ePCR:
a. The initial ETCO2 value and presence or absence of a good waveform
b. A repeat ETCO2 value one minute or so later and quality of waveform
c. Successful intubation is indicated by:
i. ETCO2 of 5 or greater
ii. Good waveform
5. Continuously monitor waveform and ETCO2 value during transport as a sign of tube
dislodgement or loss of pulse.
For assessment of patients who are short of breath:
1. Apply nasal ETCO2 device

2. Document findings on the ePCR
For all patients, consider the following when ETCO2 is outside the normal range (35-45):
1. Tube dislodgement
2. Poor perfusion
3. Hyperventilation / Hypoventilation

Medical Protocols
CAPNOGRAPHY WAVE FORMS

Normal Capnography: A wave form is present; the wave form begins at the base line, raises steeply,
plateaus with a gradual upslope, and quickly returns to the baseline.
End Tidal CO2 normal range: 35-45 mmHg
Hyperventilation
Hypoventilation, Stroke, Seizure, Head Injury, CNS Depression
Asthma, COPD, CHF

ET CO2 monitoring on non-intubated patients - assess severity & effectiveness of treatment.
Bronchospasm will produce a “shark fin” wave form.
CPR with Return of Circulation (ROSC)

Medical Protocols
Apnea, Total Obstruction/Dislodged/Misplaced ET-Tube, Equipment Failure
Partial Tube Obstruction, Blood Loss, Pulmonary Embolism, Hypothermia
Sedation, Hypoventilation, Hypothermia, CNS depression
Hyperthermia, Bicarbonate Infusion

Medical Protocols
CHILD BIRTH
Indications:
 Imminent Child Birth
NORMAL DELIVERY PROCEDURES
1. Attempt to prevent explosive delivery

2. As delivery of head occurs, suction mouth then nose.
3. If membranes are still intact, instruct the mother to stop pushing and
gently tear the membrane and immediately suction mouth, then
nose.
4. Keep newborn warm and dry.
5. Keep newborn at the level of the vagina until the cord is clamped and
cut.
6. Once cord pulsations cease, place one clamp 6 inches from the
newborn and another clamp 9 inches from the newborn. Cut cord
between the clamps.
7. Allow newborn to nurse. If multiple births, do not allow nursing until
all have been delivered.
8. APGAR score at 1st minute and 5th minute after birth.

Medical Protocols
CPAP
Clinical indications:
 CPAP is indicated in patients for whom inadequate ventilation is suspected. This could be as
a result of pulmonary edema, pneumonia, COPD, asthma, etc.
1. Ensure adequate oxygen supply to ventilation device.

2. Explain procedure to Pt.
3. Place the delivery mask over the nose and mouth. Oxygen
should be flowing through the device at this point.
4. Secure the mask with the provided straps starting with the
lower straps until minimal air leak occurs.
5. Adjust Positive End Expiratory Pressure (PEEP) on CPAP device
slowly starting at 0cmH2O until desired pressure is reached.
6. Evaluate the response of patient assessing breath sounds,
general appearance and oxygen saturation if possible.
7. Encourage patient to allow forced ventilation to occur.
8. Document time and response on patient care report.
 PATIENT MUST BE BREATHING FOR PROPER USE OF CPAP.

 In asthmatic patients, continuous monitoring is required to reduce the risk of respiratory
depression.

Medical Protocols
EZ-IO INTRAOSSEOUS INFUSION

Indications: Contraindications:
 First-line access for all cardiac arrests  Pt with an available secure IV line adequate for
 Any ALS patient from whom immediate fluid or necessary treatment or in whom an IV line can be
medication treatment is indicated. In addition, placed in a timely fashion.
patients must have at least one of the following  Pt’s that do not require immediate fluid or
1. Altered mental status medication therapy. IO SHALL NOT BE
2. Respiratory compromise PERFORMED FOR PROPHYLAXIS.
3. Hemodynamic instability  Fracture of bone selected for IO infusion.
 Inability to identify landmarks for procedure.
 Known previous orthopedic procedure or
preexisting medical disease (such as tumor of the
bone selected for IO infusion.
 Severe Burn or infection at the site of insertion.
1. Prepare Equipment
2. Select insertion site
a. Adult proximal humerus (PREFERRED SITE)
b. Adult proximal tibia: Measure one finger width distal to tibial tuberosity, along,
along the flat aspect of the medial tibia.
c. Pediatric proximal tibia: One finger width distal to the tibial tuberosity OR if unable
to palpate tibial tuberosity; two fingers below the patella along the flat aspect of
the medial tibia.
d. Adult distal tibia: Two finger widths proximal to the medial malleolus and midline
on the medial shaft.
e. Pediatric distal tibia. One finger width proximal to the medial malleolus along the
flat aspect of the medial distal tibia.
3. Prepare the skin with alcohol and/or betadine.
4. Prepare IO driver and needle set; load needle set onto driver.
5. Hold the IO driver in one hand and stabilize the leg near the insertion site with the opposite
hand.
6. Position the driver at the insertion site with the needle at a 90 Degree angle to the surface of
the bone.
7. Before powering the driver, insert the needle through the skin. When you feel the needle is
hitting resistance from the bone, make sure the 5mm line is still visible above the skin.
Power the driver on while applying minimal pressure. Insert the needle until a change in
resistance is noted. Remove the driver from the needle set and the stylet from the catheter.
Attach the connection tubing.
8. Use syringe to rapidly infuse 10ml of NS. If no infiltration is seen, attach the IV line and infuse
fluids or medications as usual. (For adults the IV bag will need to be under pressure.)
9. Secure the needle by looping the tubing and taping it back to the skin.
 Flow Rate may appear to be slower than those achieved with an IV catheter
 Ensure the administration of appropriate syringe bolus prior to infusion. NO FLUSH =NO FLOW
 Pain control for EZ-IO Insertion should be performed prior to initial syringe flush or infusion. Allow to work for
30-60 seconds prior to Syringe flush
o For adults administer 40mg of Lidocaine = 2ml of 2% lidocaine for cardiac use.
o For pediatric s administer 0.5 MG/KG= 0.05 ml/kg of 2% lidocaine for cardiac use. (20 kg child = 1 mL)
 Be cautious of potential air embolism, subcutaneous infiltration, fracture, or osteomyelitis.

Medical Protocols
EZ-IO INTRAOSSEOUS INFUSION

Medical Protocols
ontact Droplet and Airborne Precautions

INFECTION CONTROL
 Febrile  Warm, flushed, sweaty  Sepsis
 Rash, Discharge or  Rash  Medication Reaction
Potential Exposure  Headache  Hyperthyroid
 Immunocompromised  Abdominal Pain  Heat Stroke
 Generalized vs. focal  Seizure type, duration  Meningitis
seizure (toddlers) (for febrile seizures)  Simple febrile seizure
Suspect Influenza, Mumps or Suspect TB, SARS, or drug

Meningitis resistant pneumonia (MRSA/VRE)
Droplet Precautions Airborne Precautions
PPE + Surgical Mask for PPE + HEPA Mask for Provider;

Provider and Patient Surgical Mask for Patient
For suspected Ebola Virus Disease patient, see dedicated

section under Fundamentals of Care, p 33

Medical Protocols
KENDRICK EXTRICATION DEVICE

INDICATIONS:
 Used to prepare patients with suspected spinal fracture for extrication and / or movement
from a sitting to a supine position.
 When a short spine board could not be used.
Application of patients into KED
1. Open KED and place it between the patient’s buttocks and the seat the
patient is sitting on.
2. Center the KED on the patient and position the KED snugly under the
patient’s armpits.
3. Fasten the chest straps, snug up the bottom and the middle straps.
4. Slide the leg straps under the patient’s legs, and around the tops.
5. Secure the leg straps to the same side of the KED.
Movement of the patient in the KED
1. Both rescuers grasp the side handles on opposite sides of the KED. Place
other arms under the patient’s legs.
2. Locking their arms together under the patient, the rescuers lift the patient
up (keeping the patients legs at a 45 degree angle).
3. Lower the patient onto the long spine board.
4. Undo the leg straps.

Medical Protocols
KING LTS AIRWAY

Indications:
 Two failed attempts at oral tracheal intubation.

 It appears additional attempts at oral tracheal intubation will fail.
 Cardiac Arrest, respiratory arrest.
 No Gag Reflex
 No provider trained in oral tracheal intubation available.
1. Apply a water-based lubricant to the beveled distal tip and posterior aspect of
the tube, taking care to avoid introduction of lubricant in or near the ventilatory
openings.
2. Position the head. (The ideal position for insertion is the “sniffing position”.
3. Hold the KING TUBE at the connector with the dominant hand. Hold the mouth
open with the non-dominant hand.
4. With the king tube rotated laterally 45-90 degrees such that the blue orientation
line is touching the corner of the mouth, introduce the tip into the mouth and
advance behind base of the tongue. NEVER FORCE THE TUBE INTO POSITION.
5. As tube tip passes under the tongue, rotate tube back to midline.
6. Without excessive force, advance KING tube until proximal opening of gastric
access lumen is aligned with the teeth or gums.
7. Inflate the KING tube using the volume of air indicated by the manufacture.
8. Attach BVM to the King Tube, and gently ventilate the patient.
9. Check for chest rise; auscultate the epigastric area for absence of abdominal
sounds, and the lungs bilaterally for breath sounds. (If successful continue to
ventilate patient).
10. Secure the KING-tube using an appropriate method.
If after 2 attempts unable to successfully place KING

Tube see FAILED AIRWAY PROTOCOL.
o Yellow Connector: Height 4-5 feet King size3

o Red Connector: Height 5-6 feet King size 4
o Purple Connector: Height >6 feet King size 5
Contraindications:
 Obvious Signs of death

 Conscious Patients
 Do-Not-Resuscitate order
 Gag Reflex
 Known esophageal disease (Cancer, varices, surgery)
 Known ingestion of caustic substance
 Larygenctomy patient with stoma

Medical Protocols
Apnea, Total Obstruction/Dislodged/Misplaced ET-Tube, Equipment Failure
Partial Tube Obstruction, Blood Loss, Pulmonary Embolism, Hypothermia
Sedation, Hypoventilation, Hypothermia, CNS depression
Hyperthermia, Bicarbonate Infusion

Medical Protocols
OROTRACHEAL INTUBATION
 Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport
distances requiring a more secure airway.
 An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate
respiratory effort.
1. Assemble appropriate equipment (to include):

o BVM
o Oxygen with regulator
o Suction
o Appropriate size ETT and stylet
o ETT securing device
o Gas exchange indicator
o Magill forceps
o 10cc syringe
o Laryngoscope with appropriate size blade
o Cardiac monitor, ETCO2 monitor
2. Properly position the patient in the supine position and ventilate adequately as indicated by the
patient treatment protocol you are following.
3. With suction standing by and proper manpower to provide Slicks maneuver if indicated, take
the laryngoscope in your LEFT hand and insert into the RIGHT side of the patients mouth. In a
forward abducting motion pull the lower jaw up and away from the patient while moving the
laryngoscope blade to the LEFT in an attempt to visualize the glottic opening. When you see the
glottic opening and can identify the landmarks of the glottic opening, insert the ETT through the
glottic opening and into the trachea until you are at approximately at 23-26cm at the lip line.
4. Ventilate the patient while checking for the standard "Earmarks" of a successful intubation,
those being:
o Good waveform on ETCO2 monitor (MOST RELIABLE INDICATOR)
o Condensation in the ETT
o Chest rise and fall
o Good BVM compliance
o Good positive and equal breath sounds
o Good gas exchange as indicated by the color change on the gas indicator
o Negative gastric sounds
5. Advise the receiving ER of an intubated patient and transport A.S.A.P. during protocol.
6.
Secure ET be
Do not Tube
puttooff
the patients
task face, using
by vomitus, in the“tube tamer”,
absence tape, or
of suction string. if you lift a little
sometimes
higher you can see over the top of the vomit into the back of the oropharynx.
 If at all possible the patient should be placed on cardiac monitor at all times, to monitor for
bradycardia and cardiac rhythm.
 Limit attempts to 10sec each.

Medical Protocols
NEEDLE DECOMPRESSION
Indications:
 Tension Pneumothorax
Indications of Tension Pneumothorax
 Hemodynamic Compromise, Systolic BP < 90 with any of the following:

o JVD
o Asymmetrical Chest Movement
o Tracheal Deviation
o Absent/Decreased Breath Sounds
o Increase Resistance with Ventilation
1. Asses Chest and respiratory exertion.

2. Apply O2 per non-rebreather mask or BVM with 100%
supplemental O2.
3. Identify second intercostal space, midclavicular line on the
affected side.
4. Prep the area.
5. Snugly attach a 14 or 16 gauge angiocath to a 10ml syringe or
use arrow kit.
6. Insert the needle into the skin over the rib into the 2nd
intercostal space in mid-clavicular line directly above the 3rd
rib.
7. Puncture the parietal pleura.
8. Aspirate air as necessary to relieve patient’s symptoms.
9. Leave the plastic catheter remaining but remove the needle.
10. Secure the catheter.
11. Connect the catheter to a one way valve.
12. Reassess ventilator status, jugular veins, tracheal position,
pulse, and blood pressure.
13. Document procedure and responses.
Contraindications:
No apparent signs and symptoms of a tension pneumothorax.

Medical Protocols
NEEDLE DECOMPRESSION

Medical Protocols
SPINAL IMMOBILIZATION
INDICATIONS:
 Possible C-Spine FX  Combative patients with high

 Motor Vehicle Collision possibility of traumatic spine injury.
 Fall from greater than patient’s height.  Auto-pedestrian accident
 Fall from standing with pt age >65.  Bicycle accident
 Unconscious patients with high  Traumatic Injury for patients with
possibility of traumatic spine injury. osteoporosis.
1. Place the patient in the appropriately sized c-collar

2. Once the collar is secure a second rescuer should still maintain their
position to ensure stabilization.
3. Log roll the patient to one side, maintain c-spine control.
4. Check the back, legs and back of head for injuries.
5. Place the long spine board under the patient.
6. Roll the patient onto long spine board while still maintaining s-spine
control.
7. Place head blocks next to the patients head.
8. Secure the torso and legs to the long spine board using straps, webbing
or tape.
9. Secure the patients head to the long spine board.
NOTE: for the patients in a vehicle or otherwise unable to be place in the prone
or supine position, place them on a backboard by the safest method available
that maximizes maintenance of in-line spinal stability.
Never force a patient into a non-neutral position to immobilize them. Padding

below the neck may be necessary. The patient may also require alternate
means of neck immobilization, in these cases a “horse collar” made of a towel
may be necessary.
Contraindications:
 Some patients due to size or age will not be able to be immobilized through in-line
stabilization with standard backboards and c-collars.
 See the spinal motion restriction protocol for alternate methods of partial immobilization.

Medical Protocols
TASER BARB REMOVAL

Disposition: Assess and Treat:
 Transport PT if:  Psychosis
1. The barb lodged in a high risk area.  Hypoxia
2. Patient falls under another protocol.  Hypoglycemia
3. Pt meets signs and symptoms of  Overdose
excited delirium and requires  Central Nervous System Infection
chemical restraint.  Trauma or Seizure
1. Stabilize the skin around the barb and use one hard jerk
to pull the barb out of the patient’s skin.
2. Ensure that the barb tips are intact.
3. Return Barbs to LEO. IF LEO does not take custody of the
barbs, dispose of them in a sharps container.
4. Provide proper wound care, clean and cover with a
bandage.
5. Inform patient and LEO that the patient will need to seek
medical attention if signs of infection later develop.
6. The subject will need a tetanus shot if they have not had
one in the last 10 years.
 Remove only one barb at a time.

 DO NOT attempt to remove barbs in the face, genitalia, neck, women’s breast, or any site
that your clinical judgment deems high risk.
 Patients that have been fighting and/or who have taken stimulant medications are at a risk
for excited delirium and may require treatment and transport if symptoms present.
 Ensure that the wires are disconnected from the Taser device.
 Obtain vital signs when safe to do so.

Medical Protocols
INJECTION: SUBCUTANEOUS
INTRAMUSCLAR
 When medication is necessary and the medication is necessary and the medication must be
given via SQ (not auto –injector) or IM route or as an alternative route in selected
medications
1. Receive and confirm medication order, or perform according to

standing order.
2. Prepare equipment and medication, expelling air from the syringe.
3. Explain the procedure to the patient and reconfirm patient
allergies.
4. Expose the selected area and cleanse the injection site with
alcohol.
5. Insert the needle into the skin with a smooth, steady motion.
SQ:45-degree angle skin pinched
IM:90- degree angle skin flat
6. Aspirate for blood.
7. Inject the medication.
8. Withdraw the needle quickly, dispose of needle properly.
9. Apply pressure to the site.
10. Monitor the patient therapeutic effects as well as any possible
side effects.
11. Document the medication, dose, route, and time on/with the
Patient care report.
 The thigh should be used for injections in pediatric patients and injection volume should not
exceed 1cc.
 The most common site for subcutaneous injection is the arm
o Injection volume should not exceed 1cc.
 The possible injection sites for subcutaneous injection include the arm, buttock, and thigh.
o Injection volume should not exceed 1cc for the arm.
o Injection volume should not exceed 2 cc for the thigh or buttock

Medical Protocols
INJECTION: SUBCUTANEOUS
INTRAMUSCLAR

Medical Protocols
KING LTS AIRWAY

Indications:
 Two failed attempts at oral tracheal intubation.

 It appears additional attempts at oral tracheal intubation will fail.
 Cardiac Arrest, respiratory arrest.
 No Gag Reflex
 No provider trained in oral tracheal intubation available.
1. Apply a water-based lubricant to the beveled distal tip and posterior aspect of
the tube, taking care to avoid introduction of lubricant in or near the ventilatory
openings.
2. Position the head. (The ideal position for insertion is the “sniffing position”.
3. Hold the KING TUBE at the connector with the dominant hand. Hold the mouth
open with the non-dominant hand.
4. With the king tube rotated laterally 45-90 degrees such that the blue orientation
line is touching the corner of the mouth, introduce the tip into the mouth and
advance behind base of the tongue. NEVER FORCE THE TUBE INTO POSITION.
5. As tube tip passes under the tongue, rotate tube back to midline.
6. Without excessive force, advance KING tube until proximal opening of gastric
access lumen is aligned with the teeth or gums.
7. Inflate the KING tube using the volume of air indicated by the manufacture.
8. Attach BVM to the King Tube, and gently ventilate the patient.
9. Check for chest rise; auscultate the epigastric area for absence of abdominal
sounds, and the lungs bilaterally for breath sounds. (If successful continue to
ventilate patient).
10. Secure the KING-tube using an appropriate method.
If after 2 attempts unable to successfully place KING

Tube see FAILED AIRWAY PROTOCOL.
o Yellow Connector: Height 4-5 feet King size3

o Red Connector: Height 5-6 feet King size 4
o Purple Connector: Height >6 feet King size 5
Contraindications:
 Obvious Signs of death

 Conscious Patients
 Do-Not-Resuscitate order
 Gag Reflex
 Known esophageal disease (Cancer, varices, surgery)
 Known ingestion of caustic substance
 Larygenctomy patient with stoma

Medical Protocols
NASO/ORO GASTRIC TUBE INSERTION

 To lavage the stomach.  Suspected fractures of the basilar skull.
 To decompress the stomach.  Facial trauma with suspected fractured.
 Evacuation of Stomach contents.  Known or suspected esophageal varices.
 Ingestion of caustic poisons, without
medial direction.
1. Restrain patient as necessary.

2. Position Patient :
a. Conscious Patient: High fowlers with chin on chest.
b. Unconscious Patient: Left lateral recumbent position, with slight
Trendelenburg. Airway must be protected with Intubation prior to NG/OG.
3. Measure length of ng tube from nose to earlobe and then to midway between the
xyphoid process and umbilicus, and mark with tape.
4. If inserting nasally, lubricate tip with water soluble lubricant.
5. Nasal insertion: Direct tube along the floor of nostril to the posterior pharyngeal then
direct the tube downward through the nasopharynx.
Oral Insertion: Direct tube to the back of the tongue and then downward through the
oropharynx.
6. If patient is conscious or old enough to follow instructions direct the patient to
swallow to facilitate the placement of the tube in the stomach.
7. Continue advancing tube until tape is at the nostril and lip.
8. If tube meets resistance or the patient has respiratory distress, remove the tube.
Fogging of the tube accompanied by cough or respiratory distress indicated tracheal
intubation.
9. If patient begins to vomit, suction around tube and leave in place.
10. Confirm placement of tube:
a. Aspirate gastric contents with a syringe.
b. Injecting 5-20cc of air while auscultating over the stomach for a “swoosh” or
“burp” indicates gastric placement.
c. Auscultate lung sounds.
11. Secure tube in place.
If tube is not placed properly remove immediately
DO NOT ATTEMPT PLACEMENT MORE THAN 3 TIMES.
For gastric lavage:
1. Connect to a closed system.
2. Instill 20-150ml boluses of solution to a maximum of 4 liters.
3. Repeat procedure until stomach contents return clear or maximum volume has been
reached.
 NG/OG should only be performed when instructed by medical control or requested by the
patient.
 Infants <6 months are nose breathers and an OG is preferred.
 Nasogastric tubes can be used as orogastric tubes in the pediatric patient.

Medical Protocols
TOURNIQUET
 Life threatening extremity hemorrhage that cannot be controlled by other means.

 Tourniquets should be used extremely infrequently
1. Place tourniquet proximal to wound.

2. Tighten per manufacturer instructions until hemorrhage stops
and/or distal pulses in affected extremity disappear.
3. Secure tourniquet per manufacturer instructions.
4. Note Time of tourniquet application and communicate this to
receiving care providers.
5. Dress wounds appropriately.
6. If Delayed or prolonged transport and tourniquet application
time is more than 5 hours contact medical control.
Contraindications:
 Non-extremity hemorrhage
 Proximal extremity location where tourniquet application is not practical.

Medical Protocols
TRACTION SPLINT
 Deformity to the mid-shaft of the femur.

 No pulses in the distal extremity.
 Pale, cyanotic skin distal to the injury in the affected extremity.
1. Place traction splint on the mid-line side of the

patient.
2. Secure the splint to the distal end of the extremity
and the proximal end of the extremity.
3. Expand the traction splint slowly until:
a. Patient fells relief of pain
b. Pulses return to the affected extremity
c. Capillary refill returns to normal in the
presence of pulses.

Protocol
Padding can be placed in the patients groin to add to the patients comfort when possible.
Contraindications:
 Pelvic fracture
 If positioning the traction splint would delay the transport in a trauma patient in imminent
risk of circulatory collapse.

Medical Protocols
OROTRACHEAL INTUBATION
 Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport
distances requiring a more secure airway.
 An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate
respiratory effort.
1. Assemble appropriate equipment (to include):

o BVM
o Oxygen with regulator
o Suction
o Appropriate size ETT and stylet
o ETT securing device
o Gas exchange indicator
o Magill forceps
o 10cc syringe
o Laryngoscope with appropriate size blade
o Cardiac monitor, ETCO2 monitor
2. Properly position the patient in the supine position and ventilate adequately as indicated by the
patient treatment protocol you are following.
3. With suction standing by and proper manpower to provide Slicks maneuver if indicated, take
the laryngoscope in your LEFT hand and insert into the RIGHT side of the patients mouth. In a
forward abducting motion pull the lower jaw up and away from the patient while moving the
laryngoscope blade to the LEFT in an attempt to visualize the glottic opening. When you see the
glottic opening and can identify the landmarks of the glottic opening, insert the ETT through the
glottic opening and into the trachea until you are at approximately at 23-26cm at the lip line.
4. Ventilate the patient while checking for the standard "Earmarks" of a successful intubation,
those being:
o Good waveform on ETCO2 monitor (MOST RELIABLE INDICATOR)
o Condensation in the ETT
o Chest rise and fall
o Good BVM compliance
o Good positive and equal breath sounds
o Good gas exchange as indicated by the color change on the gas indicator
o Negative gastric sounds
5. Advise the receiving ER of an intubated patient and transport A.S.A.P. during protocol.
6.
Secure ET be
Do not Tube
puttooff
the patients
task face, using
by vomitus, in the“tube tamer”,
absence tape, or
of suction string. if you lift a little
sometimes
higher you can see over the top of the vomit into the back of the oropharynx.
 If at all possible the patient should be placed on cardiac monitor at all times, to monitor for
bradycardia and cardiac rhythm.
 Limit attempts to 10sec each.

Medical Protocols
TRANSFERS - TRAUMA

Medical Protocols
TRANSFERS - TRAUMA

Medical Protocols
TRANSFERS - TRAUMA

Medical Protocols
VentiPAC PORTABLE VENTILATOR
1. Connect the ventilator to the oxygen supply

2. Switch the ventilator on/off switch to on (you should hear the ventilator
begin to cycle)
3. Set the breathing parameters to suite the pt (obtain from the facilities
respiratory therapist when available)
4. Set air mix switch to 100% for
A CPR
B Respiratory arrest
C. Contaminated environments
5. Connect tubing to the patient
6. Ensure the settings are adequate for the patient by,
A. Monitoring the patient’s vital signs and physical condition (remember to

treat the patient not the monitor)
B. Confirm airway placement prior to and after each movement, suctioning,

when connecting or discounting the tubing from the patients airway device,
and when checking vital signs
7. If the ventilator fails to work properly at any point during the transport of a
patient, IMMEDIATELY DISCONNECT THE VENTILATOR FORM THE PATIENT
AND SWITCH TO A BVM
Typical Ventilator Settings for an Adult Patient
On/off (On), X100Pa (40)
Inspiratory Time (1.5)
Expiratory Time (3.0)
Air Mix (=50% O2)
Inspiratory Flow L/sec (0.50)

Medical Protocols
APPENDIX A: MEDICATION FORMULARY

Medication Quick Reference Dosage Page
Acetylsalicylic Acid 324 mg PO 121
Activated Charcoal 50 grams PO 122
Adenosine (Adenocard) 6/12/12 mg 123

Pedi 0.1/0.2/0.2 mg/kg
Albuterol 2.5 mg per neb 125
Amiodarone 300 then 150 mg for arrest 126

150 mg over 10 min for dysrhythmias
Pedi 5 mg/kg
Anectine (Succinylcholine) 100 mg IV/IO 127
3-4 mg/kg IM, (Max 150 mg)
Pedi 1 mg/kg IV/IO, (Max 100 mg)
Atropine 0.5 to 1 mg 128
Calcium gluconate 1 gram IV = 10ml 129
Cefazolin (Ancef) 1-2 gram(s) IV infusion in 50-250 mL 130
Diltiazem (Cardizem) 10-20 mg, then 25mg 131
Diphenhydramine (Benadryl) 25-50 mg IV/IM 132

Pedi 1 mg/kg IV, (Max 25mg)
Dextrose 50% 25 grams = “1 amp” 133

Pedi D10 5mL/kg, D25 2 mL/kg
Diazepam (Valium) 5-10 mg IV 134

Pedi 0.2 mg/kg
Enalaprilat (Vasotec) 1.25 mg IV 135

Medical Protocols
Epinephrine 1 mg IV for arrest 136

10mcg q2-5 min or 5-20 mcg/min
For hypotension
0.3 mg IM for allergy, asthma
Pedi 0.01 mg/kg, (Max 0.3 mg)
Epinephrine 1:1000 Nebulized 0.5 mL = 0.5 mg with 2.5 mL saline neb 138
Etomidate 20 mg IV 139
Pedi 0.3 mg/kg
Fentanyl 50-100 mcg IV/IM/IN 140

Pedi 1 mcg/kg
Geodon 20 mg IM for Excited Delirium 141
Ipratropium (Atrovent) 0.5 mg nebulized 142
Labetalol 10-20 mg IV 143
Lidocaine 100 mg IV 144

40mg IO = 2mL of 2% (for IO pain)
Pedi: 0.5 mg/kg = 0.05 mL/kg
Magnesium 2 grams in 50 mL NS 145
Methylprednisolone (Solu-Medrol) 125 mg IV/IM* 146

Pedi 2 mg/kg/IM*
*IM only for allergic reaction & dystonia
Midazolam (Versed) 1-2 mg IV/IM/IN for anxiety 147

5 mg IV/IM/IN for RSI, Seizure, Behav.
10 mg IV/IM for excited delirium
Pedi 0.1 mg/kg (Max 5mg)
Morphine 2-5 mg IV, Max 10mg 148

Pedi 0.1 mg/kg (Max 5mg)
Naloxone (Narcan) 0.4 mg IV/IM/IN, Max 2mg 149

Medical Protocols
Nitroglycerin 0.4 mg SL q5 min for ACS or HTN 150

0.4 mg SL q3 min for CHF
Norepinephrine (Levophed) 2-12 mcg/minute IV for hypotension 151

Pedi: not indicated
Ondansetron (Zofran) 4 mg IV/IM 152

Pedi 6mo to 4yr 2mg, >4 yr 4 mg
Oral Glucose 15 grams PO 153
Oxygen NC: 1-4 L, Neb: 8 L, Mask 10-15L/min 154
Rocuronium 50 mg IV 155
Pedi 1 mg/kg
Sodium Bicarbonate 50-100 mEq IV 156
Thiamine 100 mg IV/IM 157
Vecuronium 10 mg IV 158
Pedi 0.1 mg/kg

Medical Protocols
ACETYLSALICYLIC ACID (ASPRIN, ASA)

Class
 Platelet inhibitor, anti-inflammatory agent
Mechanism of Action
 Prostaglandin inhibition, prevents platelet aggregation
Indications
 Chest pain suggestive of acute myocardial infarction
 Protocol: Acute Coronary Syndrome
Contraindications
 Hypersensitivity to ASA or nonsteroidal anti-inflammatory drugs (NSAIDS)
 Gastrointestinal bleeding
Adverse Reactions
 Heartburn
 Gastrointestinal bleeding
 Nausea, vomiting
 Wheezing in allergic patients
 Prolonged bleeding
Dosage and Administrations
 Adult :
324mg PO
 Pediatric: not recommended in pediatric population
Duration of Action
 Onset: 30-45 minutes
 Duration: life of platelet (7-10 day)
Special Considerations/Drug Interactions
 Pregnancy safety: category D

Medical Protocols
ACTIVATED CHARCOAL (ACTIDOSE-AQUA)

Class
 Poison antidote
Mechanism of Action
 Binds and absorbs ingested toxins and inhibits the absorption of poisons
Indications
 Many oral poisonings, medication overdoses
 Protocol: Overdose
Contraindications
 Ingestion of: turpentine, corrosives (lye and strong acids), caustics, or
petroleum distillates (kerosene, gasoline, paint thinner, cleaning fluid,
furniture polish)
Adverse Reactions
 May indirectly induce nausea and vomiting
 May cause constipation
 Adult:
50 grams PO or NGT
Duration of Action
 Onset: Immediate
 Duration: Continual while in GI tract
 Is relatively insoluble in water
 May blacken feces
 Does not adsorb all drugs and toxic substances (for example, cyanide, lithium,
iron, lead and arsenic)
 Overdoses such as Phenobarbital, Carbamazepine, Theophylline, Phonation
and Digitalis, multiple doses of charcoal may be required to be effective
 Syrup of Ipecac is adsorbed by activated charcoal

Medical Protocols
ADENOSINE (ADENOCARD)
Class
 Antiarrhythmic
Mechanism of Action
 An endogenous purine nucleotide that slows conduction through the AV node,
interrupts the reentry pathways to the AV node and can restore normal sinus
rhythm in PSVT via modulation of K+ currents and blunting of catecholamine
response
Indications
 Conversion to sinus rhythm of Paroxysmal Supraventricular Tachycardia
(PSVT), including that associated (Wolff-Parkinson-White syndrome)
 To aid in the diagnosis of broad or narrow complex supraventricular
tachycardia
 Protocol: Supraventricular Tachycardia
Contraindications
 Hypersensitivity to the medication
 2nd or 3rd degree AV block (except in patients with a functioning artificial
pacemaker)
 Sick Sinus Syndrome where you see the accessory pathway conduct the atrial
impulses at rates > 220)
Adverse Reactions
 Non-cardiac: facial flushing, chest pain, dyspnea, headache, lightheadedness
 Cardiac: 1st, 2nd or 3rd degree heart block; transient asystole; varied atrial
and ventricular arrhythmias
 1/2 life is 10 seconds. A brief period of asystole (up to 15 seconds) following
conversion, followed by resumption of NSR is common after rapid
administration
 Adverse reactions are generally transient, resolve within 1 minute of
drug administration, and do not require intervention, nor are they an
indication to not attempt a subsequent administration of a higher dose of
the same medication.
 Adult:
6mg FIVP with 10cc NS flush, wait 1-2 min if no conversion 12mg FIVP with
10cc NS flush , wait 1-2 minutes if no conversion 12mg FIVP with 10cc NS
flush (Max of 30mg)
 Pediatric:
0.1 mg/kg (to a max of 6 mg) IV/IO with 10cc NS flush, wait 1-2 minutes.
If no conversion, 0.2 mg/kg (to a maximum of 12 mg) with a NS 10 ml flush.
Wait 1-2 minutes; if no conversion, 0.2 mg/kg (to a max of 12 mg) with a 10cc NS flush
(Total Max of 30mg)

Medical Protocols
SURGICAL AIRWAY: CRICOTHYROTOMY

 Unable to ventilate.  Inability to identify landmarks.
 Unable to intubate.  Not trained in this procedure.
 Unable to ventilate with rescue airway.  Able to ventilate with less invasive
 Severe Facial or nasal injuries that techniques
prevent successful ventilation or airway  Able to intubate
placement.
 Severe mid-tracheal injuries or anatomy
that prevents intubation / ventilation.
 Sever uncontrolled angioedema,
anaphylaxis and certain types of
inhalation injures.
1. Assemble equipment
a. Betadine prep swabs
b. Scalpel
c. Large curved hemostat, Bougie Tube, or Extra scalpel handle
d. Tracheostomy or endotracheal tube
e. Tape
2. Expose the neck.
3. Identify the thyroid cartilage. The space between the cricothyroid notch and the
thyroid cartilage is the location of the cricothyroid membrane.
4. Prep the area.
5. Stabilize the trachea by holding the thyroid cartilage between the thumb and
fingers.
6. Make a horizontal incision approximately ½ inch through the skin and cricothyroid
membrane.
7. Insert hemostat to dilate the incision. (Never remove scalpel or hemostat without
something in the incision space; the small incision will close.)
8. Turn the hemostat or scalpel handle until the opening is sufficient to allow the
passing of a small endotracheal tube. (6.0-7.0 mm
9. Pass the endotracheal tube about 1 – 1.5 inches into the trachea.
10. Inflate the cuff if using a cuffed tube and ventilate the pt with high flow oxygen.
11. Check breath sounds bilaterally and secure with tape.
12. Monitor patient condition and reassess frequently.
13. Control any bleeding and dress the wound.
 Notify the receiving Emergency Department of procedure as soon as possible during

protocol.
 If bleeding occurs, use suction and proceed. Insertion and inflation of endotracheal tube
through the cricothyotomy site will protect the patient from blood entering the airway.
 If using an endotracheal tube only advance 2 - 2.5cm to avoid right main stem intubation.

Medical Protocols
SURGICAL AIRWAY: QUICK TRACH

 Surgical Airway as indicated by the failed airway protocol.
1. Pre-oxygenate patient when possible.

2. Assemble all available equipment.
3. Locate cricothyroid membrane at the inferior portion of the thyroid cartilage
(with the head in the neutral position, membrane is approx. 3 finger widths
above the sterna notch).
4. Have assistant hold skin taunt over membrane and locate midline.
5. Prepare the area with betadine if possible.
6. Hold the needle bevel up at a 90 degree angle, aimed inferiorly as you
approach the skin.
7. Puncture the skin with the needle and continue with firm steady pressure
while aspirating for air with a syringe.
8. As soon as air is aspirated freely stop advancing the needle airway assembly.
9. Modify the angle to 60 degrees from the head and advance to level of the
stopper.
10. Remove the stopper while holding the needle /airway assembly firmly in
place. Do not advance the needle further. (NOTE: if the patient is obese and
no air can be aspirated with the stopper in place you may remove the stopper
and continue advancing until air is aspirated. Be aware that without the
stopper, risk of perforating the posterior aspect of the trachea is greatly
increased).
11. Hold the needle and syringe firmly and slide only the plastic cannula along the
needle into the trachea until the flange rests on the neck. Carefully remove
the needle and syringe.
12. Secure the cannula with the neck strap.
13. Apply the EtCO2 detector and to the tube and the bvm.
14. Confirm placement with the use of breath sounds, pulse ox, and Color-metric
change.
15. Ensure 100% supplemental Oxygen via BVM.
 Notify the receiving Emergency Department of procedure as soon as possible during

protocol.

Medical Protocols
TOURNIQUET
 Life threatening extremity hemorrhage that cannot be controlled by other means.

 Tourniquets should be used extremely infrequently
1. Place tourniquet proximal to wound.

2. Tighten per manufacturer instructions until hemorrhage stops
and/or distal pulses in affected extremity disappear.
3. Secure tourniquet per manufacturer instructions.
4. Note Time of tourniquet application and communicate this to
receiving care providers.
5. Dress wounds appropriately.
6. If Delayed or prolonged transport and tourniquet application
time is more than 5 hours contact medical control.
Contraindications:
 Non-extremity hemorrhage
 Proximal extremity location where tourniquet application is not practical.

Medical Protocols
TRACTION SPLINT
 Deformity to the mid-shaft of the femur.

 No pulses in the distal extremity.
 Pale, cyanotic skin distal to the injury in the affected extremity.
1. Place traction splint on the mid-line side of the

patient.
2. Secure the splint to the distal end of the extremity
and the proximal end of the extremity.
3. Expand the traction splint slowly until:
a. Patient fells relief of pain
b. Pulses return to the affected extremity
c. Capillary refill returns to normal in the
presence of pulses.

Protocol
Padding can be placed in the patients groin to add to the patients comfort when possible.
Contraindications:
 Pelvic fracture
 If positioning the traction splint would delay the transport in a trauma patient in imminent
risk of circulatory collapse.

Medical Protocols
TRANSFERS – AIR MEDICAL

Medical Protocols
CALCIUM GLUCONATE 10%

Class
 Minerals and electrolytes
Mechanism of Action
 Calcium is a positive inotrope
 Variable effect on systemic vascular resistance
 When used to prevent or treat negative calcium balance (e.g., osteoporosis), the
calcium in calcium salts moderates nerve and muscle performance and allows
normal cardiac function
Indications
 Suspected Hyperkalemia in adult PEA/Asystole associated with renal patients
 Antidote for calcium channel blocker overdose and magnesium sulfate toxicity
 Hyperkalemia associated with adult crush injury
 Protocol: Overdose, crush injury
Contraindications
 Patients with digitalis toxicity
 Caution should be used with dehydrated patients
Adverse Reactions
 When given too rapidly or to someone on digitalis, can cause sudden death from
ventricular fibrillation
 Adult:
1 gram (= 10mL) over 10 minutes. May repeat X1
Duration of Action
 Duration: 30 minute to 2 hours
 Incompatible with Sodium Bicarbonate- IV line must be flushed with copious
amounts of saline
 Calcium may decrease the bioavailability of tetracycline’s, fluoroquinolones, iron
salts and salicylates, Atenolol, and sodium polystyrene sulfonate
 I.V. calcium may antagonize the effects of Verapamil; large intakes of dietary fiber
may decrease calcium absorption due to a decreased GI transit time and the
formation of fiber-calcium complexes
 Increased effect: I.V. calcium may increase the effects of Quinidine and digitalis

Medical Protocols
Cefazolin (Ancef)
Class
 Antibiotic - cephalosporin
Mechanism of Action
 Bactericidal agent that acts by inhibition of bacterial cell wall synthesis
Indications
 Open Skeletal fracture
 A break in the skin over a fracture site
Contraindications
 History of anaphylaxis (not a simple rash) to penicillin
 Known allergy to the cephalosporin group of antibiotics
 <1 year of age
Adverse Reactions
 Diarrhea
 Anaphylaxis
 Itching
 Skin rash
Dosage and Administration
 Adult:
1-2 gram IV infusion over 10-30 minutes
 Can administer 1 gram for patient <70kg
 Can administer 2grams for patients >70kg
 After reconstituting medication, mix into a 50ml, 100ml or 250ml bag of Normal
Saline
 Preferred mixing dose is 50ml Normal saline for each 1mg of
antibiotic
Duration of Action
 Duration unknown
 Be alert for hypersensitivity reaction
 Pregnancy Category B
 Renal Impairment may require reduced dosage
 IV incompatible with Amiodarone
 Parenteral drug products should be shaken well when reconstituted and inspected
for particulate matter prior to administration
 Note that reconstituted solutions may range in color from pale yellow to yellow
without a change in potency.

Medical Protocols
DILTIAZEM (CARDIZEM)
Class
 Benzothiazepine, Calcium Channel Blocker, Cardiovascular agent
Mechanism of Action
 A slow calcium channel blocker that blocks calcium ion influx during depolarization
of cardiac and vascular smooth muscle. It decreases peripheral vascular resistance
and caused relaxation of the vascular smooth muscle resulting in a decrease of both
systolic and diastolic blood pressure
Indications
 Atrial arrhythmia
 Protocol: Atrial Fibrillation
Contraindications
 Administration of intravenous beta-blockers within a few hours of intravenous
Diltiazem
 Atrial fibrillation or flutter associated with an accessory bypass tract (Wolff-
Parkinson- White or short PR syndromes)
 Hypotension
 Sick sinus syndrome without a pacemaker
Adverse Reactions
 Bradyarrhythmia
 Peripheral edema
 CHF
 Heart block
 Myocardial infarction
 Adult:
10-20mg SIVP over 2 min
May repeat with a dose of 25mg SIVP over 2 min
Duration of Action
 Renal impairment can cause an increased risk of toxicity
 Ventricular function, impaired
 Hepatic or renal impairment, heart failure

Medical Protocols
DIPHENHYDRAMINE (BENADRYL)
Class
 Antihistamine
Mechanism of Action
 Antihistamines prevent histamines from reaching H1- and H2-receptor sites.
Antihistamine is specific for conditions in which histamine excess is present (for
example, acute urticaria) but is adjunctive therapy in the treatment of anaphylactic
shock because epinephrine is more effective.
Indications
 Allergic reactions
 Anaphylaxis
 Acute dystonic reactions
 Protocol: Overdose, anaphylaxis, excited delirium
Contraindications
 Lower respiratory diseases such as asthma attacks
 Patients taking MAOIs
 Hypersensitivity
 Narrow-angle glaucoma
Adverse Reactions
 Dose-related drowsiness
 Disrupted coordination
 Hypotension
 Palpitations
 Tachycardia, bradycardia
 Thickening of bronchial secretions
 Adult:
25-50 mg SIVP/ IM
 Pediatric:
1mg/kg SIVP/IM Max 25mg
Duration of Action - Diphenhydramine
 Peak: 1-3 hours
 Duration:6-12 hours
 CNS depressants may increase depressant effects.
 MAOIs may prolong and intensify Anticholinergic effects of antihistamines.

Medical Protocols
DEXTROSE 50%
Class
 Carbohydrate , hypertonic solution
Mechanism of Action
 The term dextrose is used to describe the six-carbon sugar d-glucose, the principal
form of carbohydrate used by the body. D50 is used in emergency care to treat
hypoglycemia and to manage coma of unknown origin.
Indications
 Hypoglycemia
 Protocol: Diabetic emergencies
Contraindications
 There are no significant contraindications for IV administration of 50% dextrose in
emergency care.
Adverse Reactions
 Warmth
 Pain and burning from medication infusion
 Thrombophlebitis
 Rhabdomyolysis
Adult:
25 g slow IV
Pediatric:
<1 mo AND < 45mg/dL D10 5mL/kg
1mo-12yr D25 2mL/kg
Duration of Action
 Onset: < 1 minute
 Extravasations may cause tissue necrosis; use a large vein and aspirate occasionally
to ensure route patency.
 D50 sometimes precipitates severe neurological symptoms (Wernicke's
encephalopathy) in thiamine-deficient patients such as alcoholics. (This can be
prevented by administering 100 mg of thiamine, IV.)

Medical Protocols
TRANSFERS - TRAUMA

Medical Protocols
ENALAPRILAT (VASOTEC)
Class
 Enalaprilat is an angiotensin converting enzyme (ACE) inhibitor.
Mechanism of Action
 Inhibition of ACE results in decreased plasma angiotensin II, which leads to
decreased vasopressor activity and to decrease aldosterone secretion.
Indications
 Hypertension associated with Congestive Heart Failure (CHF)
 Protocol: Congestive Heart Failure
Contraindications
 Patients with a history of angioedema related to previous treatment with an
angiotensin converting enzyme inhibitor and in patients with hereditary or
idiopathic angioedema.
Adverse Reactions
 Angioedema (severe swelling of tongue, face, lips, throat)
 Headache
 Hypotension
 Nausea
 Adult: 1.25mg SIVP over 5 minutes, may repeat X1
Duration of Action
 Onset: 15 minutes
 Peak:1-4 hrs
 Duration:4-6 hrs
 Use caution when administering to renal patients
 May cause hyperkalemia
 Enalaprilat may potentiate the effect of diuretics causing a significant decrease in
blood pressure
 Lithium toxicity has been reported in patients receiving lithium concomitantly with
drugs which cause elimination of sodium, including ACE inhibitors

Medical Protocols
EPINEPHRINE (ADRENALINE)
Class
 Sympathomimetic
Mechanism of Action
 Epinephrine stimulates alpha-, beta1-, and beta2-adrenergic receptors in dose-
related fashion. It is the initial drug of choice for treating bronchoconstriction and
hypotension resulting from anaphylaxis as well as all forms of cardiac arrest. Rapid
injection produces a rapid increase in systolic pressure, ventricular contractility,
and heart rate. In addition, epinephrine causes vasoconstriction in the arterioles of
the skin, mucosa, and splanchnic areas and antagonizes the effects of histamine.
Indications
 Bronchial asthma
 Acute allergic reaction
 Cardiac arrest
 Anaphylaxis
 Protocol: V-Fib/Pulseless V-Tach, Asystole/PEA, Anaphylaxis, COPD/Asthma,
Bradycardia
Contraindications
 Hypovolemic shock
 Coronary insufficiency
 Hypertension
Adverse Reactions
 Headache, nausea, restlessness, weakness, dysrhythmias, hypertension
Adult:
V-Fib/Pulseless V-Tach, Asystole/PEA – 1mg (1:10,000) IV/IO every 3-5 minutes
Anaphylaxis – 0.3mg (1:1,000) IM every 5 minutes. May repeat x 1
COPD/Asthma - 0.3mg (1:1,000) IM. May repeat x 1 in 5 minutes.
Hypotension – 10 mcg q 3 minutes, or 5-20 mcg/min (calculated from normal
Dosage of 0.1-0.4 mcg/kg/min
Pediatric:
V-Fib/Pulseless V-Tach, Asystole/PEA – 0.01mg/kg (1:10,000) IV/IO every 3-5
minutes
Anaphylaxis – 0.01mg/kg (1:1,000) IM every 5 minutes, Max dose 0.3 mg. May
repeat x 2
Asthma - 0.01mg/kg (1:1,000) IM every 5 minutes. May repeat x 1
Bradycardia - 0.01mg/kg (1:10,000) IV/IO every 3-5 minutes
Duration of Action
 Onset:
(SQ) 5-10 min (IV) 1-2 min
 Duration: 5-10 min

Medical Protocols
TRANSFERS - TRAUMA

Medical Protocols
EPINEPHRINE NEBULIZED
Class
 Sympathomimetic
Mechanism of Action
 Acts as a bronchodilator that stimulates beta2 receptors in the lungs, resulting in
relaxation of bronchial smooth muscle. It alleviates bronchospasm, increases vital
capacity, and reduces airway resistance. It inhibits the release of histamine and is
useful in treating laryngeal edema.
Indications
 Prevention of bronchospasm
 Croup (laryngotracheobronchitis)
 Laryngeal edema
 Protocol: Pediatric Respiratory Distress : Brochiolitis and Croup
Contraindications
 Hypertension
 Cardiovascular disease
 Epiglottitis
Adverse Reactions
 Tachycardia
 Dysrhythmia
 Pediatric:
Dilute 0.5ml of Epinephrine (1:1000) in 2.5ml of saline. Administer by
aerosolization
May repeat x 1 in 5 minutes.
Duration of Action
 Onset : within 5 minutes
 Duration : 1-3 hours
Special Considerations/Drug Interactions - Epinephrine

 May produce tachycardia and other dysrhythmias
 Monitor vital signs closely
 Excessive use may cause bronchospasm
 MAOI’s and Bretylium may potentiate the effect of Epinephrine.
 Beta-adrenergic antagonists may blunt inotropic response.
 Sympathomimetics and phosphodiesterase inhibitors may exacerbate dysrhythmia
response.

Medical Protocols
ETOMIDATE (AMIDATE)
Class
 Etomidate is a hypnotic drug without analgesic activity
Mechanism of Action
 Etomidate is a hypnotic drug without analgesic activity
Etomidate is a short-acting hypnotic, which appears to have gamma-aminobutyric
acid (GABA)–like effects. Unlike the barbiturates, etomidate reduces subcortical
inhibition at the onset of hypnosis while inducing neocortical sleep. Studies in
animals suggest that a part of the action of etomidate consists of a depression of the
activity and reactivity of the brain stem reticular formation.
Indications
 Induction of general anesthesia
 Protocol: Rapid sequence intubation, and post resuscitation induced hypothermia
Contraindications
 Patients who have known hypersensitivity
Adverse Reactions
 Etomidate may induce cardiac depression in elderly patients, particularly those with
hypertension
 Transient venous pain on injection and transient skeletal muscle movements,
including myoclonus
 Hyperventilation, hypoventilation, apnea of short duration (5 to 90 seconds with
spontaneous recovery), laryngospasm, hiccup and snoring. These conditions were
managed by conventional countermeasures.
 Hypertension, hypotension, tachycardia, bradycardia and other arrhythmias have
occasionally been observed
 Adult:
20 mg IV/IO
 Pediatric:
0.3 mg/kg IV/IO, Max dose 20mg
Duration of Action - Etomidate

 Onset: within 1 minute
 Duration: 3 to 5 minutes
 Risk benefit should be considered with Immunosuppression, sepsis or
Transplantation (potential effects on adrenal function)
 Etomidate can block the adrenal gland's production of cortisol and other steroid
hormones, possibly resulting in temporary adrenal gland failure. This may cause
abnormal salt and water balance, lowered blood pressure, and, ultimately, shock.

Medical Protocols
FENTANYL
Class
 Synthetic narcotic
Mechanism of Action
 A potent, short-acting, rapid-onset opioid agonist that relieves pain by stimulating
opioid receptors in CNS; also causes respiratory depression and peripheral
vasodilation; inhibits intestinal peristalsis and sphincter of Oddi spasm; stimulates
chemoreceptors that cause vomiting; increases bladder tone.
Indications
 Traumatic and Cardiac pain management, rapid sequence intubation
 Protocol: rapid sequence intubation, pain management,
Contraindications
Adverse Reactions
 Bradycardia, more rapid and significant ventilation impairment in patients with
COPD and prolonged clinical effects in patients with hepatic or renal impairment.
 Severe muscular rigidity develops in patients if administered rapidly.
 Adult:
50-100mcg SIVP over 1-2 minutes; Max dose of 200mcg, May repeat X1
May be administered via IV/IM/IN
 Pediatric:
1 mcg/kg SIVP over 1-2 minutes May repeat 1 mcg/kg X1
Duration of Action
 Onset: Immediately (IV); 7 to 8 min (IM).
 Duration: 30 to 60 min (IV); 1 to 2 h (IM).
 Amiodarone: Profound bradycardia, sinus arrest, and hypotension may occur.
 Barbiturate anesthetics (e.g., thiopental) May have additive effects. Reduce
dosage of one or both agents.
 CNS depressants (e.g., alcohol, benzodiazepines [e.g., diazepam], general
anesthetics, hypnotics, other opioid, phenothiazines, sedating antihistamines,
sedatives, skeletal muscle relaxants, tranquilizers) Concomitant use may
produce increased depressant effects (e.g., hypotension, profound sedation,
respiratory depression).
 MAOIs (e.g., phenelzine) Fentanyl is not recommended for use in patients who
have received MAOIs within 14 days.

Medical Protocols
Geodon
Class
 Antipsychotropic
Mechanism of Action
 It has been proposed that Geodon’s beneficial effects are achieved by blocking
dopamine and serotonin receptors. Geodon also inhibits reuptake of serotonin and
epinephrine in the brain.
Indications
 Psychosis where Excited Delirium is suspected.
Contraindications
 Hypersensitivity to Geodon
Adverse Reactions
 Prolonged Q-T Interval
 Adult:
Excited Delirium: 10-20mg IM
Duration of Action
 Onset: Within 1 min
 Should not be given to patients with recent acute myocardial infarction, or known
history of QT prolongation.
 Geodon should never be given intravenously.

Medical Protocols
IPRATROPIUM (ATROVENT)
Class
 Anticholinergic (parasympatholytic) agent
Mechanism of Action
 Atrovent inhibits interaction of acetylcholine at receptor sites on the bronchial
smooth muscle, resulting in bronchodilation
Indications
 Patients with bronchospasm (asthma and COPD) may benefit from this medication.
Patients will typically present with wheezing or persistent cough. Remember with
severe bronchospasm, the patient may not be moving enough air to have lung
sounds auscultated
 Protocol: COPD/Asthma
Contraindications
 The solution that is used for nebulization can be safely used in patients with a soy
product allergy, but not if there is a known hypersensitivity to Ipratropium or
atropine.
Adverse Reactions
 Palpitations
 Dizziness
 Anxiety
 Tremors
 Headache
 Nervousness
 Dry mouth
 Adult:
0.5mg mixed with Albuterol via aerosolization x 3
 Pediatric:
0.5mg mixed with Albuterol via aerosolization x 3
Duration of Action
 Onset:5-15 minutes
 Duration: 2-8 hrs
 Can cause a paradoxical bronchospasm increasing the patient's respiratory
difficulties.
 Nebulizers can be attached to the ET tube and ventilated into patient with BVM.

Medical Protocols
LABETALOL
Class
 Alpha- and beta-adrenergic blocker
Mechanism of Action
 Labetalol is a competitive alpha1-receptor blocker as well as a nonselective beta-
receptor blocker used to lower blood pressure in a hypertensive crisis. Because of
alpha- and beta-blocking properties, blood pressure is reduced without reflex
tachycardia, and total peripheral resistance is decreased without a significant
alteration in cardiac output.
Indications
 Hypertension
 Protocol: Hypertension
Contraindications
 Congestive heart failure
 Second- and third-degree heart block
 Bradycardia
 Cardiogenic shock
Adverse Reactions
 Headache and facial flushing
 Ventricular dysrhythmias
 Hypotension and dizziness
 Dyspnea
 Diaphoresis
 Adult:
10-20 mg SIVP over 2 min. Repeat X2 q 10 min
Duration of Action
 Duration: 3-6 hr
 Bronchodilator effects of beta-adrenergic agonists may be blunted by Labetalol.
Nitroglycerin may augment hypotensive effects.
 Observe for signs of congestive heart failure, bradycardia, and bronchospasm.
Labetalol should only be administered with the patient in a supine position.

Medical Protocols
LIDOCAINE (XYLOCAINE)
Class
 Antidysrhtythmic
Mechanism of Action
 Lidocaine decreases phase-4 diastolic depolarization and suppresses premature
ventricular contractions. In addition, it is used to treat ventricular tachycardia and
some cases of ventricular fibrillation. Lidocaine also raises the ventricular
fibrillation threshold
Indications
 Protocol: IO pain management
Contraindications
 Stokes-Adams syndrome
 Second- or third-degree heart block in the absence of an artificial pacemaker
Adverse Reactions
 Lightheadedness, hypotension, confusion, blurred vision, cardiovascular collapse,
bradycardia
 CNS depression (altered level of consciousness, irritability, muscle twitching,
seizures) with high doses
 Adult:
Intraosseous pain: 40 mg IV = 2 mL of 2% cardiac lidocaine
 Pediatric:
Intraosseous pain: 0.5 mg/kg of 2% cardiac lidocaine
= 0.05 mL/kg,
10 kg = 0.5 mL, 20 kg = 1 mL, 30 kg = 1.5mL
Duration of Action
 Onset: 30-90 sec
 Since Lidocaine is metabolized in the liver, elderly patients, patients with hepatic
diseases, shock or congestive heart failure will not break down the drug rapidly.
Consider one-half dose for boluses and drip rate in these patients.
 Apnea induced with succinylcholine may be prolonged with large doses of
Lidocaine.
 If bradycardia occurs in conjunction with PVCs, always treat the bradycardia first
with atropine or TCP. Exceedingly high doses of Lidocaine can result in coma or
death.

Medical Protocols
MAGNESIUM SULFATE
Class
 CNS depressant
Mechanism of Action
 Magnesium sulfate reduces striated muscle contractions and blocks peripheral
neuromuscular transmission by reducing acetylcholine release at the myoneural
junction.
Indications
 Seizures of eclampsia (toxemia of pregnancy)
 Torsade’s de pointes
 Severe asthma
 Protocol: Asthma, Eclamptic pregnancy
Contraindications
 Heart block
Adverse Reactions
 Diaphoresis
 Facial flushing
 Hypotension
 Depressed reflexes
 Hypothermia
 Reduced heart rate
 Circulatory collapse
 Respiratory depression
 Adult:
2 grams in 50 cc of NS over 10 minutes
Duration of Action
 CNS depressant effects may be enhanced if the patient is taking other CNS
depressants.
Serious changes in cardiac function may occur with cardiac glycosides.
 IV calcium gluconate or calcium chloride should be available as an antagonist to
magnesium if needed.
 Magnesium must be used with caution in patients with renal failure, since it is
cleared by the kidneys and can reach toxic levels easily in those patients.

Medical Protocols
METHYLPREDNISOLONE (SOLU-MEDROL)
Class
 Glucocorticoid
Mechanism of Action
 Methylprednisolone is a synthetic steroid that suppresses acute and chronic
inflammation. In addition, it potentiates vascular smooth muscle relaxation by beta-
adrenergic agonists and may alter airway hyperactivity. A newer usage is for
reduction of posttraumatic spinal cord edema
Indications
 Anaphylaxis
 Bronchodilator for unresponsive asthma
 Shock (controversial)
 Acute spinal cord injury
 Protocol: COPD/Asthma, Anaphylaxis
Contraindications
 Use with caution in patients with, immuno-suppressed systems, GI bleeding and
diabetes mellitus.
Adverse Reactions
 Headache
 Hypertension
 Sodium and water retention
 Hypokalemia
 Alkalosis
 Adult:
125mg IV/IM
 Pediatric:
2mg/kg IV/IM Max dose of 125 mg
Duration of Action
 Onset: 1-2 hrs
 Crosses the placenta and may cause fetal harm.
 Ensure that the patient is not currently ill (pneumonia) or is currently taking
steroids.

Medical Protocols
MIDAZOLAM (VERSED)
Class
 Short-acting benzodiazepine CNS depressant
Mechanism of Action
 Midazolam HCl is a water-soluble benzodiazepine that may be administered for
conscious sedation to relieve apprehension or impair memory before endotracheal
or nasotracheal intubation.
Indications
 Premedication for tracheal intubation
 Seizures
 Protocols: Rapid sequence intubation, seizures, anxiety, behavioral, sedation prior
to cardioversion
Contraindications
 Hypersensitivity to Midazolam
 Glaucoma
 Shock
 Depressed vital signs
 Concomitant use of barbiturates, alcohol, narcotics, or other CNS depressants
Adverse Reactions
 Cough and/or hiccups
 Over-sedation
 Nausea and vomiting
 Headache and/or blurred vision
 Fluctuations in vital signs including hypotension
 Respiratory depression and/ or arrest
 Adult:
Anxiety: 1-2 mg IV/IM/IN
RSI: 5mg IV/IM/IN, May Repeat X 1
Seizures, behavioral: 5mg IN/IV/IM, May repeat x 1
Excited Delirium: 10 mg/IV/IM
 Pediatric:
Seizures: 0.1 mg/kg IN/IV/IM Max 5mg
Sedation: 0.1mg/kg Max 2mg
Duration of Action
 Onset: 1-3 min (IV); dose dependent
 Duration: 2-6 hr; dose dependent
 Sedative effect of midazolam may be accentuated by concomitant use of
barbiturates, alcohol, or narcotics (it should therefore not be used in patients who
have taken CNS depressants).
 Administer immediately before the intubation procedure.

Medical Protocols
MORPHINE SULFATE
Class
 Opioid analgesic
Mechanism of Action
 Morphine sulfate is a natural opium alkaloid that increases peripheral venous
capacitance and decreases venous return ("chemical phlebotomy"). It promotes
analgesia, euphoria, and respiratory and physical depression. Secondary
pharmacological effects of morphine include depressed responsiveness of alpha-
adrenergic receptors (producing peripheral vasodilation) and baroreceptor
inhibition. In addition, because morphine decreases both preload and afterload, it
may decrease myocardial oxygen demand.
Indications
 Moderate to severe acute and chronic pain
Should be used with caution with pulmonary edema
 Protocol: pain management
Contraindications
 Hypersensitivity to narcotics
 Diarrhea caused by poisoning
 Hypovolemia
 Hypotension
Adverse Reactions
 Hypotension, tachycardia, bradycardia, palpitations, syncope, facial flushing,
respiratory depression, euphoria, bronchospasm, dry mouth
 Adult:
2-5 mg every 5 minutes Max 10 mg
 Pediatric
0.1 mg/kg Max 5mg
Duration of Action
 CNS depressants may potentiate effects of morphine (respiratory depression,
hypotension, sedation).
 MAOl’s may cause paradoxical excitation.
 Narcotics rapidly cross the placenta. Use with caution in older adults, those with
asthma, and those susceptible to CNS depression. May worsen bradycardia or heart
block in inferior myocardial infarction (vagotonic effect). Naloxone should be
readily available.

Medical Protocols
NALOXONE (NARCAN)
Class
 Synthetic opioid antagonist
Mechanism of Action
 Naloxone is a competitive narcotic antagonist used in the management and reversal
of overdoses caused by narcotics and synthetic narcotic agents. Unlike other
narcotic antagonists, which do not completely inhibit the analgesic properties of
opiates, naloxone antagonizes all actions of morphine.
Indications
 Decreased level of consciousness
 Coma of unknown origin
 For the complete or partial reversal of CNS and respiratory depression induced by
opioids: Narcotic agonist : Morphine sulfate, Heroin, Hydromorphone (Dilaudid),
Methadone , Meperidine (Demerol) , Paregoric, Fentanyl citrate (Sublimaze),
Oxycodone (Percodan), Codeine, Propoxyphene (Darvon)
 Narcotic agonist and antagonist: Butorphanol tartrate (Stadol), Pentazocine
(Talwin), Nalbuphine (Nubain)
 Protocol: Overdose
Contraindications
Adverse Reactions
 Tachycardia and/or dysrhythmias
 Hypertension
 Diaphoresis
 Adult:
0.4mg IV/IM/IN, Max of 2 mg
Duration of Action
 Seizures have been reported (no causal relationship established).
 May not reverse hypotension. Caution should be exercised when administering
naloxone to narcotic addicts (may precipitate withdrawal with hypertension,
tachycardia, and violent behavior).

Medical Protocols
NITROGLYCERIN
Class
 Vasodilator
Mechanism of Action
 It is now believed that atherosclerosis limits coronary dilation and that the benefits
of nitrates and nitrites result from dilation of arterioles and veins in the periphery.
The resulting reduction in preload and to a lesser extent in afterload decreases the
work load of the heart and lowers myocardial oxygen demand. Nitroglycerin is very
lipid soluble and is thought to enter the body from the GI tract through the
lymphatics rather than the portal blood.
Indications
 Ischemic chest pain
 Congestive heart failure(CHF)
 Protocol: Acute coronary syndrome(ACS) , CHF
Contraindications
 Hypotension
 Do not administer NTG to male patients who have taken medication for erectile
dysfunction in the previous 48 hours. The combination of these meds with NTG may
produce profound hypotension or cardiac arrest.
Adverse Reactions
 Transient headache
 Postural syncope
 Reflex tachycardia
 Hypotension
 Muscle twitching
 Diaphoresis
 Adult:
ACS: 0.4 mg metered dose every 5 minutes until systolic BP of > 90
CHF: 0.4mg every 3 minutes x 5
Hypertension: 0.4mg X3
Duration of Action
 Onset:1-3 min
 Duration:20-30 min
 Nitroglycerin decomposes when exposed to light or heat.

Medical Protocols
NOREPINEPHRINE (LEVOPHED)
Class
 Sympathomimetic
Mechanism of Action
 Norepinephrine alpha- and beta1-adrenergic receptors in dose-related fashion. It is
the initial drug of choice for treating hypotension refractory to IV fluids in the
setting of sepsis. Continuous IV infusion results in increased contractility and heart
rate as well as vasoconstriction, thereby increasing systemic blood pressure and
coronary blood flow. Clinically, alpha effects (vasoconstriction) are greater than
beta effects (inotropic and chronotropic effects).
Indications
 Hypotension refractory to 2L of IV fluids in the setting of sepsis
 Protocol: Hypotension
Contraindications
 Hypertension
Adverse Reactions
 Headache, nausea, restlessness, weakness, dysrhythmias, hypertension
 Adult: Hypotension – 2-12 mcg/min
 NOTE: NOT WEIGHT BASED INFUSION
 Pediatric: Not used in prehospital setting due to need for extremely low
weight-based dose (0.05-0.1 mcg/kg/min)
 Now considered first line vasoactive agent for septic shock, as dopamine was found
in a large clinical trial to have an unacceptably high occurrence of dysrhythmias
 Large doses have been described in clinical trials 0.01-3 mcg/kg/minute
(0.7 to 200 mcg/min)

Medical Protocols
ONDANSETRON (ZOFRAN)
Class
 Antiemetic, Serotonin Receptor Antagonist, 5-HT3
Mechanism of Action
 Antiemetic - The mechanism by which ondansetron works to control nausea and
vomiting is not fully understood; it is believed that the antiemetic properties occur as a
result of serotonin receptor antagonism.
Indications
 Nausea and vomiting due to chemotherapy.
 Prophylactic use prior to administration of pain management medication.
 Nausea and vomiting with moderate to severe dehydration or electrolyte imbalance.
 Protocol: nausea including nausea in a CVA patient
Contraindications
 History of allergic reaction to ondansetron or to any medicine similar to ondansetron,
including dolasetron (Anzemet), granisetron (Kytril), or palonosetron (Aloxi).
Adverse Reactions
 Constipation, diarrhea, dry mouth
 Headache, dizziness, drowsiness/sedation
 Anaphylaxis (rare)
 Fatigue, malaise, chills
 Cardiac dysrhythmia (rare), hypotension
 Bronchospasm
 Muscle pain
 Adult:
4mg IV/IM, may repeat X1
 Pediatric:
6 months to 4 years: 2 mg IV/IM
Greater than 4 years: 4 mg IV/IM
Duration of Action
 Duration 4-6 hours
 Patients with a history, or family history, of Long QT syndrome; transient EKG changes
have been seen with IV administration including QT interval prolongation.

Medical Protocols
ORAL GLUCOSE
Class
 Monosaccharide Carbohydrate
Mechanism of Action
 After absorption of glucose in the GI tract, glucose is distributed in the tissues and
provides a prompt increase in circulating blood sugar
Indications
 Hypoglycemic conscious pt w/ altered mental status
Contraindications
 Unconscious
 Patient hasn't taken insulin for days
Adverse Reactions
 Nausea
 Adult and Pediatric:
15 grams PO
SL Preferred method of administration is between the cheek and gums
Duration of Action
 Onset: 15 minutes
 Assure patient has the capabilities of swallowing and maintaining an airway
 Ensure that a BGL is checked prior to administration of Glucose in all patients,
especially ones that may have a suspected head injury
 Reassess BGL after administration of Glucose

Medical Protocols
OXYGEN
Class
 Naturally occurring atmospheric gas
Mechanism of Action
 Oxygen is odorless, tasteless, colorless gas that is present in room air at a
concentration of about 21%. It helps oxidize glucose to produce ATP (Adenosine
triphosphate).
Indications
 Confirmed or suspected hypoxia
 Ischemic chest pain
 Respiratory insufficiency
 Prophylatically during air transport
 Confirmed or suspected carbon monoxide poisoning and other causes of decreased
tissue oxygenation
 Protocol: Universal treatment guidelines
Contraindications
 Oxygen should not be withheld from any patients, even those with COPD.
Adverse Reactions
 High flow oxygen may cause decreased LOC and respiratory depression in patients
with COPD
 Adult and Pediatric:
High concentration: 10-15 lpm via nonrebreather mask
Low concentration: 1-4 lpm via nasal cannula
Nebulizer: 8 lpm
Duration of Action
 Duration: less than 2 minutes
 Oxygen vigorously supports combustion

Medical Protocols
ROCURONIUM
Class
 Non depolarizing neuromuscular blocker
Mechanism of Action
 Rocuronium bromide is a non-depolarizing skeletal muscle relaxant. Binding with
cholinergic receptor sites inhibits transmission of nerve impulses, antagonizing the
action of acetylcholine. Has no analgesic properties and the patient maybe conscious,
but unable to communicate by any means.
Indications
 To maintain complete muscle relaxation with an intubated patient
 Protocol: rapid sequence intubation
Contraindications
Adverse Reactions
 Causes respiratory paralysis; supportive airway control must be continuous and under
direct observation at all times.
 Adult:
50mg IV
 Pediatric:
1mg/kg (max 50mg)
Duration of Action
 Peak: 4 minutes
 Duration: 30 minutes
 Myasthenia gravis and other neuromuscular diseases increase sensitivity to the drug.

Medical Protocols
SODIUM BICARBONATE
Class
 Buffer
Mechanism of Action
 Sodium bicarbonate reacts with hydrogen ions to form water and carbon dioxide
and thereby can act to buffer metabolic acidosis. Increasing the plasma
concentration of bicarbonate causes blood pH to rise.
Indications
 Tricyclic antidepressant (TCA) overdose
 Alkalinization for treatment of specific intoxications
 Protocol: Hyperkalemia, Crush injury
Contraindications
 In patients with chloride loss from vomiting and Gl suction
 Metabolic and respiratory alkalosis
 Hypocalcemia
 Hypokalemia
Adverse Reactions
 Metabolic alkalosis
 Hypoxia
 Rise in intracellular Pco2 and increased tissue acidosis
 Electrolyte imbalance (tetany)
 Seizures
 Tissue sloughing at injection site
 Adult:
Hyperkalemia/Crush injury: 50- 100mEq
TCA: 50-100 mEq
Duration of Action
 Onset: 2-10 min
 May precipitate in calcium solutions.
 Vasopressors may be deactivated.
 Bicarbonate administration produces carbon dioxide, which crosses cell membranes
more rapidly than bicarbonate, potentially worsening intracellular acidosis.
 May increase edematous or sodium-retaining states.
 May worsen congestive heart failure.

Medical Protocols
THIAMINE
Class
 Vitamin (B1)
Mechanism of Action
 Thiamine combines with ATP to form thiamine pyrophosphate coenzyme, a
necessary component for carbohydrate metabolism. Most vitamins required by the
body are obtained through diet, but certain states, such as alcoholism and
malnourishment, may affect the intake, absorption, and use of thiamine. The brain is
extremely sensitive to thiamine deficiency.
Indications
 Coma of unknown origin (before the administration of dextrose 50%, or Naloxone)
 Delirium tremens
 Beriberi (rare) / Wernicke's encephalopathy
Contraindications
 There are no significant drug interactions with other emergency medications
Adverse Reactions
 Hypotension (from rapid injection or large dose)
 Anxiety
 Diaphoresis
 Allergic reaction (usually from IV injection; very rare)
 Adult: 100mg IV/IM
Duration of Action
 Onset: Rapid
 Duration: variable
 Large IV doses may cause respiratory difficulties.
 Anaphylactic reactions have been reported.

Medical Protocols
VECURONIUM
Class
 Non depolarizing neuromuscular blocker
Mechanism of Action
 Vecuronium bromide is a non-depolarizing skeletal muscle relaxant. Binding with
cholinergic receptor sites inhibits transmission of nerve impulses, antagonizing the
action of acetylcholine. Has no analgesic properties and the patient maybe conscious,
but unable to communicate by any means. First muscles affected include eyes, face,
neck; followed by limbs, abdomen, chest; diaphragm affected last. Recovery usually
occurs in the reverse order and may take longer than 60 minutes.
Indications
 To maintain general anesthesia with an intubated patient
 Protocol: rapid sequence intubation
Contraindications
Adverse Reactions
 Causes respiratory paralysis; supportive airway control must be continuous and under
direct observation at all times.
 Adult:
10mg IV
 Pediatric:
0.1mg/kg (max 10mg)
Duration of Action
 Onset: 30-60 seconds
 Peak: 3-5 minutes
 Duration: 30-60 minutes
 Myasthenia gravis and other neuromuscular diseases increase sensitivity to the drug.

GAAA DAILY AMBULANCE CHECK LIST
911 ( ) Laryngoscope Handle – 1 ( ) Paper tape 1” - 1

Date __________________________ ( ) Mac Blades-(1, 2, 3, 4) - 1ea ( ) Alcohol Preps – 5
Truck # ________________________ ( ) Miller Blades-(0, 1, 2, 3, 4) -1ea ( ) Beta Dine Preps - 2
Medic # ________________________ ( ) ET Tubes-(2.5, 3, 3.5, 4, 5, 6, 6. 5, 9) - ( ) Non sterile 4x4 - 10
Personnel Printed Name 1 ea ( ) Saline Locks – 5
_______________________________ ( ) ET Tubes (7.0, 7.5, 8.0) – 2 ea ( ) Saline 10cc vial/syringe – 5
Personnel Printed Name ( ) Stylet – (6fr, 10fr, 14fr) -1 ea ( ) Saline Bags (250 & 500 or 1000cc) –
_______________________________ ( ) ET Tube Holder / Ties – 1 1ea
Supervisor _____________________ ( ) Capnography ETT (Adult & Pedi) – 1ea ( ) Select 3 Drip Sets – 1
Tough Book # __________________ ( ) OPA’s (5 sizes) – 1 set ( ) Glucometer – 1
( ) Engine Oil Level ( ) Adult Magill Forceps – 1 ( ) Strips and Lancets – 6 ea
( ) Radiator Level ( ) Pediatric Magill Forceps – 1
( ) Transmission Fluid ( ) Bougie ETT Introducer – 1 Unit Equipment
( ) Tires ( ) ETT Tamer/Ties (Adult and Pedi) – Main O2 Cylinder ____________psi
Safety Sticker Expiration ________ 1 ea Stretcher # _____________________
Insurance Card Expiration________ ( ) Surgilube - 1 Stair chair # ____________________
DHSH Cert. Expiration __________ ( ) Syringe 10cc – 1 Combi-Board or Scoop #-____________
( ) GAAA Protocols - 1 ( ) Syringe 30cc – 1 ( ) KED
( ) Emergency Response Guide - 1 ( ) C Batteries – 2 ( ) Sager Splint
( ) Triage Tags - 25 ( ) Air Splint(Sm, Med, Lg, & Torso)
( ) Mounted Fire Extinguisher - 1 ( ) Airway Bag ( ) Air Splint Pump - 1
( ) Key Map Book – 1 Oxygen Cylinder _____________psi ( ) Portable O2 - 3
( ) Flashlight - 1 ( ) CPAP Quick Connect – 1 ( ) Traffic Safety Vest – 3
( ) BVM (Adult, Child, Infant) - 1 ea ( ) Reflector Kit - 1
EKG Monitor#__________ (MICU) ( ) ET Roll – 1 ( ) Child seat (optional) – 1
( ) Data Cable – (E-series) - 1 ( ) King Tube (Sizes 3, 4, 5) – 1ea ( ) Back boards – 2
( ) USB thumb drive – (X-series) - 1 ( ) Quick Tach – 1 ( ) Backboard webbing - 1
( ) V-Leads - 1 ( ) Needle Decompression Kit - 1 ( ) C-Collars Adult – 6
( ) Limb Leads - 1 ( ) NRB Adult – 2 ( ) C-Collars (Pedi & Infant) – 4 ea
( ) Electrodes - 1 pack ( ) NRB Pediatric - 1 ( ) Head Rolls – 6
( ) Multi-function Pads Adult - 1 ( ) Nasal Cannula – 2 ( ) 2inch backboard tape – 1
( ) Multi-function Pads Pedi – 1 ( ) Nebulizer - 1 ( ) BP Cuff (Thigh, Lg. Adult, Reg.
( ) Capnography NC (Adult and Pedi ) – ( ) Hemostat – 1 Adult, Child, Infant) – 1ea
1ea ( ) BP Cuff (Lg & Reg Adult, Child) 1ea ( ) Stethoscope – 1
Capnography ETT (Adult & Pedi) – 1ea King Vision # ___________________ ( ) ET Roll – 1
( ) Additional Battery - 1 ( ) King Vision Blade - 1 ( ) AAA Batteries – 3
( ) Stethoscope – 1 ( ) King Vision Blade - 1
NarcKit – MICU’s / M10 ( ) Pen Light - 1 ( ) ETT holder/Tie – 1
[ ] Diazepam 20mg x 1 ( ) Trauma Shears – 1 ( ) ETCO2 detector ET tube -1
[ ] Fentanyl 100mcg x 2 ( ) Kerlix Roll – 2 ( ) ETCO2 detector ET tube -1
[ ] Versed 5 mg x 4 ( ) Ace Wrap - 1 ( ) Capnography NC Adult – 4
[ ] Morphine 10mg x 1 ( ) Occlusive Dressing – 2 ( ) BVM (Adult, Child, Infant) - 1 ea
[ ] Geodon 20mg x 1 ( ) 4 x 4 sterile – 4 ( ) NRB- Adult –5
( ) Carpujet - 1 ( ) Triangular Bandage - 2 ( ) NRB – Pedi & Infant – 2 ea
( ) MADD Nasal Atomizer – 1 ( ) Sam Splint - 1 ( ) NC – 5
( ) Knocks box key-1 (M-1,2,3,4 only) ( ) N95 Mask – 3 ( ) Nebulizer – 5
( ) Yankuer/Suction Tubing - 3
( ) CPAP # _____________________ ( ) Medication Kit ( ) Suction Canister – 1 wall & 1 extra
( ) CPAP Circuit - 1 EZ IO Drill #___________________ ( ) NGT- 18fr – 2
( ) IO Needles (15, 25, 45mm) - 1ea ( ) Suction catheters (14fr & 6fr) 2ea
( ) Portable Suction # ____________ ( ) Broselow Tape - 1 ( ) EKG Electrodes - 1 pk
( ) Disposable Canister - 1 ( ) IV Caths (16, 18, 20,22,24ga) 2ea ( ) Multi-function Pads Adult - 1
( ) Suction Tubing – 1 ( ) Needles (20ga) - 2 ( ) Multi-function Pads Pedi - 1
( ) Yankuer – 1 ( ) Syringe 1cc – 1 ( ) ECG Paper - 1
( ) Suction Cath (6fr & 14fr) – 1ea ( ) Syringe 3cc – 3 ( ) OB Kit – 2
( ) Syringe 10cc –3
( ) ET Roll ( ) Tape 1” – 2

( ) odor neutralizer x1 [ ] x 2 Sodium Bicarb 50mEq [ ] x 2

911 Unit Equipment Continued…
( ) Foil Blanket - 1
( ) Burn Sheet - 2 MEDICATIONS
( ) Trauma Dressing – 2 MEDICATIONS
( ) Abdominal Pads - 2 KIT UNIT
( ) Alcohol Preps – 1 bx KIT UNIT
( ) Iodine Preps – 3 Activated Charcoal 50g [ ] x 1
( ) Band Aids – 1 bx [ ] x 1 Solu-Medrol 125mg []x1
( ) Bacitracin – 5 pk [ ] x 5 Adenosine 6mg [ ]x5
( ) Tape – 1” – 4 [ ] x 1 Succinylcholine 200mg [ ] x 1
( ) Paper Tape - 1 [ ] x 3 Albuterol 2.5mg [ ]x6 (Keep in cooler if available)________
( ) Sterile Water - 2
( ) Rubbing Alcohol - 1 [ ] x 2 Amiodarone 150mg [ ]x4 [ ] x 1 Thiamine 200mg []x1
( ) Triangular Bandages - 4
( ) Kerlix – 4 Ancef (Cefazolin) 1g [ ]x2 [ ] x 1 Vecuronium 10mg or [ ]x1
( ) Ace Wrap – 2 Rocuronium 100mcg [ ] x1
( ) Commercial Tourniquet - 1 [ ] x 1 Aspirin 81mg - 1 btl [ ]x1 (Keep In cooler if available_________)
( ) Occlusive Dressing - 4
( ) 4x4 Sterile – 1 bx [ ] x 3 Atropine 1mg [ ]x3
( ) 4x4 Non sterile – 1 pk
( ) Cold packs- 5 [ ] x 1 Dextrose 50% 25g [ ]x1
( ) Hot Packs – 5
( ) Trauma Shears – 1 [ ] x 1 Diltiazem 25mg [ ]x2
( ) Ring Cutter - 1 (Keep in cooler if available)________
( ) Glucometer Strips – 10
( ) Lancets – 6 [ ] x 1 Diphenhydramine 50mg [ ] x 1
( ) Ammonia Inhalants – 5
( ) Select 3 – 6 [ ] x 1 Calcium Gluc. 10ml [ ]x1
( ) Buretrol set – 1
( ) Dial-a-flow-1 [ ] x 1 Enalaprilat 2.5mg [ ]x1
( ) Saline 10cc vial/syringe – 10
( ) Saline 50cc bag – 2 [ ] x 1 Epinephrine (1:1) 1mg [ ] x 1
( ) Saline 250cc bag – 2
( ) Saline 500 or 1000cc bag – 6 [ ] x 6 Epinephrine (1:10) 1mg [ ] x 6
( ) IV catheter (16, 18, 20) -6 ea
( ) IV catheter (22, 24) – 2 ea [ ] x 1 Etomidate 20mg [ ]x1
( ) Needle 20ga – 5
( ) IO 15ga – 1 [ ] x 1 Glucose Oral 15g [ ]x1
( ) Syringe 1cc- 2
( ) Syringe 3 cc – 5 [ ] x 2 Ipratropium 0.5 mg [ ]x3
( ) Syringe 10cc – 10
( ) Syringe 30cc – 2 [ ] x 1 Labetalol 40mg [ ]x1
( ) Sharps Container Lg – 1
( ) Sharps Container Sm – 1 [ ] x 1 Lidocaine 2% 100mg [ ]x1
( ) Biohazard Bags – 2
( ) Trash Bags – 2 [ ] x 2 Magnesium Sulfate 1g [ ]x2
( ) N95 Mask – 4
( ) Gowns- 4 [ ] x 1 Narcan 2mg [ ]x1
( ) Safety Glasses- 3
( ) Gloves (Sm, Med, Lg, X-Lg) -1bx [ ] x 1 Nitroglycerin Spray Btl [ ] x 1
( ) Hand Sanitizer – 1
( ) Cavicide Wipes/Spray- 1 [ ] Norepinephrine 4mg [ ] x2
( ) Thermometer
( ) Peroxide-1 btl [ ] x 1 Ondansetron 4mg [ ]x2
( ) stuffed animal x2

NET ( ) ET Tubes (7.0, 7.5, 8.0) – 2 ea

Date __________________________ ( ) Stylet – (6fr, 10fr, 14fr) -1 ea Unit Equipment
Truck # ________________________ ( ) ET Tube Holder / Ties – 1 Main O2 Cylinder ____________psi
Medic # ________________________ ( ) CO2 detector (Adult & Pedi) – 1ea Unit Equipment Continued…
Personnel Printed Name ( ) OPA’s (5 sizes) – 1 set Stretcher # _______________________
_______________________________ ( ) Adult Magill Forceps – 1 Stair chair # _______________________
Personnel Printed Name ( ) Pediatric Magill Forceps – 1 Combi-Board or Scoop #____________
_______________________________ ( ) Bougie ETT Introducer - 1 ( ) KED
Supervisor _____________________ ( ) Surgilube - 1 ( ) Sager Splint
( ) Tough Book # ________________ ( ) Syringe 10cc – 1 ( ) Air Splint(Sm, Med, Lg, & Torso)
( ) Engine Oil Level ( ) Syringe 30cc – 1 ( ) Air Splint Pump - 1
( ) Radiator Level ( ) C Batteries – 2 ( ) Portable O2 - 2
( ) Transmission Fluid ( ) Traffic Safety Vest – 3
( ) Tires ( ) Airway Bag ( ) Reflector Kit - 1
Safety Sticker Expiration ________ Oxygen Cylinder _____________psi ( ) Child seat (optional) – 1
Insurance Card Expiration________ ( ) CPAP Quick Connect – 1 ( ) Back boards – 1
DHSH Cert. Expiration __________ ( ) BVM (Adult, Child, Infant) - 1 ea ( ) Backboard webbing - 1
( ) GAAA Protocols -1 ( ) ET Roll – 1 ( ) C-Collars Adult – 4
( ) Emergency Response Guide - 1 ( ) King Tube (Sizes 3, 4, 5) -1 ( ) C-Collars (Pedi and Infant) – 2 ea
( ) Triage Tags - 25 ( ) Quick Trach - 1 ( ) Head Rolls – 4
( ) Mounted Fire Extinguisher -1 ( ) Needle Decompression Kit - 1 ( ) 2inch backboard tape – 1
( ) Key Map Book – 1 ( ) NRB Adult – 1 ( ) BP Cuff (Thigh, Lg. Adult, Reg. Adult,
( ) Flashlight - 1 ( ) NRB Pediatric - 1 Child, Infant) – 1ea
( ) Nasal Cannula – 2 ( ) Stethoscope – 1
EKG Monitor/AED#_____________ ( ) Nebulizer - 1 ( ) BVM (Adult, Child, Infant) - 1 ea
( ) Data Cable - 1 ( ) BP Cuff (Lg & Reg. Adult) 1ea ( ) NRB- Adult – 3
( ) V-Leads - 1 ( ) Stethoscope – 1 ( ) NRB – Pedi & Infant – 2 ea
( ) Limb Leads - 1 ( ) Pen Light - 1 ( ) NC –3
( ) Electrodes - 1 pack ( ) Trauma Shears – 1 ( ) Nebulizer – 2
( ) Multi-function Pads Adult - 1 ( ) Kerlix Roll – 1 ( ) Yankuer/Suction Tubing - 1
( ) Multi-function Pads Pedi - 1 ( ) Occlusive Dressing – 2 ( ) Suction Canister – 1 wall
( ) Additional Battery - 1 ( ) 4 x 4 sterile – 2 ( ) NGT- 18fr – 1
( ) Triangular Bandage -2 ( ) Suction catheters (14fr & 6fr) 1ea
NarcKit – MICU’s / M10 ( ) Sam Splint - 1 ( ) EKG Electrodes - 1 pk
[ ] Diazepam 10mg x 1 ( ) N95 Mask – 3 ( ) Multi-function Pads Adult - 1
[ ] Fentanyl 100mcg x 2 ( ) Multi-function Pads Pedi - 1
[ ] Versed 5 mg x 4 ( ) Medication Kit ( ) ECG Paper - 1
[ ] Morphine 10mg x 1 EZ IO Drill #_________________ ( ) OB Kit – 1
[ ] Geodon 20mg x 1 ( ) IO Needles (15, 25, 45mm) - 1ea ( ) Foil Blanket - 1
( ) Carpujet - 1 ( ) Broselow Tape - 1 ( ) Burn Sheet - 1
( ) MADD Nasal Atomizer – 1 ( ) IV Caths (16, 18, 20, 22,24ga) 2ea ( ) Trauma Dressing – 1
( ) Knoks box key1 (medic 10 only) ( ) Needles (20ga) – 2 ea ( ) Abdominal Pads - 2
( ) Syringe 1cc – 1 ( ) Alcohol Preps – 1 bx
( ) CPAP # _____________________ ( ) Syringe 3cc – 2 ( ) Iodine Preps – 3
( ) CPAP Circuit - 1 ( ) Syringe 10cc – 2 ( ) Band Aids – 1 bx
( ) Portable Suction # ____________ ( ) Tape 1” – 2 ( ) Bacitracin – 5 pk
( ) Disposable Canister - 1 ( ) Paper Tape 1” - 1 ( ) Tape – 1” – 2
( ) Suction Tubing – 1 ( ) Alcohol Preps – 5 ( ) Paper Tape - 1
( ) Yankuer – 1 ( ) Beta Dine Preps - 2 ( ) Sterile Water - 1
( ) Suction Cath (6fr & 14fr) – 1ea ( ) Non sterile 4x4 - 5 ( ) Rubbing Alcohol - 1
( ) Saline Locks – 2 ( ) Triangular Bandages - 2
( ) ET Roll ( ) Saline 10cc vial/syringe – 2 ( ) Kerlix –2
( ) Laryngoscope Handle – 1 ( ) Saline Bags (250cc & 500 or 1000cc) ( ) Ace Wrap – 1
( ) Mac Blades-(1, 2, 3, 4) - 1ea 1ea ( ) Commercial Tourniquet - 1
( ) Miller Blades-(0, 1, 2, 3, 4) -1ea ( ) Select 3 Drip Sets – 1 ( ) Occlusive Dressing - 2
( ) ET Tubes-(2.5, 3, 3.5, 4, 5, 6, 6.5, 9) - 1 ( ) Glucometer – 1 ( ) 4x4 Sterile – 1 bx
ea ( ) Strips and Lancets – 4 ea

NET Unit Equipment Continued… [ ] Succinylcholine 200mg x 1

MEDICATIONS- KIT ONLY (Keep In cooler if available)
( ) 4x4 Non sterile – 1 pk
( ) Cold packs- 5 [ ] Activated Charcoal 50g x 1 [ ] Thiamine 200mg x 1
( ) Hot Packs – 5
( ) Trauma Shears – 1 [ ] Adenosine 6mg x 6 [ ] Vecuronium 10mg x 1
( ) Ring Cutter - 1
( ) Thermometer -1 [ ] Albuterol 2.5mg x 6
( ) Glucometer Strips – 5
( ) Lancets – 5 [ ] Amiodarone 150mg x 4
( ) Ammonia Inhalants – 2
( ) Select 3 – 2 [ ] Ancef (Cefazolin) 1g x 2
( ) Buretrol set – 1
( ) Dial a Flow-1 [ ] Aspirin 81mg - 1 bottle
( ) Saline 10cc vial/syringe – 5
( ) Saline 50cc bag –1 [ ] Atropine 1mg x 3
( ) Saline 250cc bag – 1
( ) Saline – 500 or 1000cc bag –2 [ ] Dextrose 50% 25g x 2
( ) IV cath (16, 18, 20, 22, 24) -2 ea
( ) Needle 20ga –2 [ ] Diltiazem 25mg x 2
( ) IO 15ga – 1 (Keep in cooler if available)
( ) Syringe 1cc- 1
( ) Syringe 3 cc – 1 [ ] Diphenhydramine 50mg x 1
( ) Syringe 10cc – 5
( ) Syringe 30cc –1 [ ] Calcium Gluconate 10ml x 2
( ) Sharps Container Lg – 1 MEDICATIONS - KIT ONLY
( ) Sharps Container Sm – 1
( ) Biohazard Bags – 2 [ ] Enalaprilat 2.5mg x 1
( ) Trash Bags – 2
( ) N95 Mask – 4 [ ] Epinephrine (1:1) 1mg x 1
( ) Gowns- 4
( ) Safety Glasses- 3 [ ] Epinephrine (1:10) 1mg x 6
( ) Gloves (Sm, Med, Lg, X-Lg) -1bx
( ) Hand Sanitizer – 1 [ ] Etomidate 20mg x 2
( ) Cavicide Wipes/Spray- 1
( ) SLIPP [ ] Glucagon 1mg – 10 x 2
( ) Peroxide-1 btl
( ) Stuffed animal x2 [ ] Glucose Oral 15g x2
( ) odor neutralizer x1
[ ] Ipratropium 0.5 mg x 3
[ ] Labetalol 40mg x 1
[ ] Lidocaine 2% 100mg x 1
[ ] Magnesium Sulfate 1g x 4
[ ] Narcan 2mg x 1
[ ] Nitroglycerin Spray Btl x 1
[ ] Ondansetron 4mg x 2
[ ] Sodium Bicarb 50mEq x 2
[ ] Solu-Medrol 125mg x 1

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Galveston Area Ambulance Authority

James Stephen Vincent M.D.

James Vincent M.D. Page 1

GAAA Field Staff:

1. Do not give IV fluids indiscriminately or “reflexively” for any patient.

Medical Director, GAAA

James Stephen Vincent M.D.

James Vincent M.D. Page 2

General System Guidelines 13

Air Medical Activation Guidelines 15

On-Scene Medical Providers 18

Selected Age Definitions, Competency 19

Restraint / Transport against Patient Will 22

Out of Hospital DNR 26

Expired Medications and Medication Shortages 34

Universal Treatment Guidelines 40

Rapid Sequence Induction 41

James Vincent M.D. Page 3

Acute Coronary Syndrome 58

A-Fib with RVR 61

Ventricular Tachycardia with a Pulse 62

Adult Cardiac Arrest 64

Post Resuscitation Induced Hypothermia 66

James Vincent M.D. Page 4

Congestive Heart Failure 68

Selective Spinal Immobilization 69

Extremity Hemorrhage or Amputation 73

Burns – Electrical / Chemical 74

Marine Life Envenomation 76

Drowning / Near Drowning 78

Pediatric Cardiac Arrest 83

Pediatric Diabetic Emergencies 84

Pediatric Pain Management 85

Pediatric Allergic Reaction 86

Pediatric Respiratory Distress 88

Pediatric Supra-Ventricular Tachycardia 90

James Vincent M.D. Page 5

EZ-IO Intraosseous Infusion 96

Kendrick Extrication Device 99

King LTS Airway 100

Nasogastric / Orogastric Tube Insertion 101

Oral Tracheal Intubation 102

Needle Decompression 103

Spinal Immobilization 105

Taser Barb Removal 106

Injection: Subcutaneous / Intramuscular 107

Surgical Airway: Cricothyrotomy 109

Surgical Airway: Quick Trach 110

Traction Splint 112

Transfers – Air Medical 113

Transfers – Trauma 114

Appendix A – Medication Formulary 118

Appendix B – Equipment List 159

James Vincent M.D. Page 6

EMT Basic Procedure-

EMT Basic Drug Administration-

EMT Intermediate Procedure-

EMT Intermediate Drug Administration-

Paramedic Drug Administration-

Important Note Regarding Protocol-

Pediatric Protocol Note-

James Vincent M.D. Page 7

1. Reassure the patient and keep him/her informed about treatment.