Marion County Protocol

Front 1

Child CRP

Back 1

15:2

Front 2

Max number doses of ipratropium

Back 2

3 x 0.5 mg

Front 3

Pulmonary Edema Tx

Back 3

up to three (3) 0.4 mg doses of nitroglycerin (SL) every 3 minutes

Front 4

Croup Tx

Back 4

(at least 1 year of age)

5 ml of 1:1,000 epinephrine (5 mg) nebulized with 5-6 lpm oxygen

EKG

Continue nebulized EPI with BVM if pt becomes unconscious.

Front 5

Urgent (angina, hypotension and/or CHF) narrow tachycardia Tx

Back 5

IV
Valsalva
6mg Adenosine
12mg Adenosine (if persists)

Front 6

Symptomatic Bradycardia w/ pulse Tx

Back 6

1. IV
2. Atropine q 3-5 min until HR > 60
(max 3 doses)
3. Consider dopamine @ 2-10µg/kg/min - titrate to HR of 60

4. Pace if condition does not change

Front 7

Mild Symptom (CP, dyspnea, decreased LOC) V-tach w/ pulse Tx

Back 7

1. IV
2. if regular monomorphic, 6mg adenosine rapid IV bolus
3. If irregular or VT does not resolve, 150 mg amiodarone IV over 10min (can give additional 150 mg en route if needed)
4. Contact medical control for additional doses.

Front 8

Tx for serious (pulmonary edema, hypotension, or unconscious) V-tach.

Back 8

synchronized cardioversion and 150 mg amiodarone over 10min (x2)

(always re-cardiovert at energy level that was previously successful).

Front 9

Symptomatic bradycardia with children

Back 9

Brady = 80 in infants, 60 in children > 1 yr. (after ventilation, stimulation and O2)

1. EKG
2. CPR (for HR < 60)
3. IV
4. Epi 0.01 mg.kg (1:10,000, 0.1 mL/Kg) IV or IO q 3-5 min.
5. for increased vagal tone or primary AV block....atropine 0.02 mg/kg (minimum 0.1 mg, max 0.5mg) IV or IO......may repeat once after 3-5 min.

Front 10

Fluid challenge for hypovolemic pediatric

Back 10

20 mL/kg
(for infants, be sure to perform gluco-analysis.....if hypoglycemic, 4 mL/Kg of D25)

Front 11

hypoglycemic PEDS dose

Back 11

4 mL/Kg of D25

Front 12

V-fib or pulseless V-tach Tx

Back 12

Shock, CPR, Drug

Epi (1mg 1:10,000 IV or IO) q 3-5 min.

300 mg amiodarone (repeat 1x at half dose: 150mg)

(If no response to amiodarone, consider 2 GRAMS MAG SULFATE IV or IO. May repeat one time in 3-5 mins)

Front 13

Tx after resolution of VF/VT

Back 13

Administer amiodarone if the 300 mg bolus was not given previously:
a. Add 150 mg amiodarone to a 50 mL 5% dextrose IV bag (Infuse over 10 minutes)
2. Begin a Magnesium IV infusion at 33 mg/min (2 g/h) if the 2 g magnesium bolus was used
a. Add 2 g magnesium sulfate to a 50 mL 0.9% saline or 5% dextrose IV bag.

Front 14

end-tidal capnography goal

Back 14

35-50 mm Hg

Front 15

When to consider dopamine post cardiac arrest

Back 15

If the patient’s SBP is less than 90 mm Hg after 500 mL of fluid
begin dopamine and titrate to a SBP >110 and < 140.

Front 16

Therapeutic hypothermia

Back 16

(if not contraindicated.....other conditions present)

infuse up to 2,000 ml iced 0.9% saline with pressure bag.

If shivering develops, administer Midazolam 5 mg IVP (q 5 min)

STOP cooling if dysrythmias develop.

Front 17

LVAD (left ventricular assist device)

Back 17

The most valuable resource for the LVAD patient is their caregiver (transport with pt to hospital)

Determine need for CPR:
1. often no peripheral pulse
2. BP only measurable with doppler
3. Listen.....if whirling sound over heart, NO NEED FOR CPR

Front 18

Other things to know about LVAD patients

Back 18

Not all dysrhythmias need to be treated. (If the patient is warm, pink with good capillary refill is not necessary).

Do not place defibrillator pads over the “pump”

Never disconnect both batteries at the same time.

Always transport patient with Travel Bag containing extra controller, batteries and cables and if stable transport to a VAD center.

Most patients are on sidenifil (Viagra®, Revatio®) and nitrates should not be administered.

Front 19

Pediatric Defibrilation setting

Back 19

2 J/kg.......then......4 J/kg

Front 20

If adult pads are used on Ped.....

Back 20

Place anterior/psoterior

Front 21

Amiodarone dose for VF/VT pediatric

Back 21

Administer amiodarone 5 mg/Kg IV or IO.

Front 22

What age to use defibrillation?

Back 22

everyone (including infants)

Front 23

Allergic Reaction Tx: Urticaria (itchy rash) only (adult dose)

Back 23

25-50 mg diphenhydramine IVP (or deep IM if no IV)

Front 24

Allergic Reaction Tx: Urticaria (itchy rash) only (peds dose)

Back 24

0.5mg/Kg diphenhydramine IVP (or deep IM if no IV) up to a maximum of 50 mg.

Front 25

Allergic Reaction Tx: Wheezing

Back 25

1. Albuterol, 2.5 mg
2. EKG
3. IV, 25-50 mg diphenhydramine IVP (or deep IM if no IV)
(peds: 0.5 mg/Kg up to maximum of 50 mg)

4. If condition remains unchanged or worsens, administer 0.01 mg/Kg 1:1,000 epinephrine IM (up to a maximum of 0.3 mg).

Front 26

Allergic Reaction Tx: Stridor or Hypotension

Back 26

1. If available, assist pt with or administer 1 dose of epinephrine auto-injector

2. EKG, IV

3. Administer 0.01 mg/Kg 1:1,000 epinephrine
IM (up to a maximum of 0.3 mg).

4. Albuterol 2.5mg for wheezing

5. Administer 25-50 mg diphenhydramine IV
push (or deep IM if no IV). Pediatric dose is
0.5 mg/Kg up to maximum of 50 mg.

7. If the condition worsens, contact Medical Control. You may be asked to administer 10 mL epinephrine 1:100,000 slow IV push and repeat every 5 minutes so long as the
patient remains hypotensive.

Front 27

To make epi 1:100,000 (for stridor/hypotension allergic reaction)

Back 27

(MUST CONTACT MED CONTROL)

10 ml prefilled syringe of 1:10,000 epinephrine

Expel 9 ml of the solution. Then pull 9 ml of NS from an IV bag back into the pre-filled syringe.)


Slow IV push and repeat every 5 minutes so long as the patient remains hypotensive.

Front 28

Hypoglycemia

Back 28

blood glucose < 70 mg/dL

Front 29

Hypoglycemia Tx

Back 29

50% dextrose -
4 mL IVP for every 10 mg/dL under 100 mg/dL.:

Glucose 50% Dextrose
60-69 16 mL
50-59 20 mL
40-49 24 mL
30-39 28 mL
20-29 32 mL
10-19 36 mL

Front 30

If unable to get IV after 2 attempts on hypoglycemic pt

Back 30

Glucagon 1 mg IM or intra-nasal.

Front 31

Suspected opiate overdose with respiratory depression Tx

Back 31

0.4 mg of naloxone IVP or intra-nasal

(repeat after 5 min if respiratory depression persists)
- Alternate nostrils
- MAX 2mg !!!!!

Front 32

Max naloxone Tx

Back 32

2mg

Front 33

Tx for awake and confused hypoglycemic pediatric

Back 33

oral glucose

Front 34

Tx for severe hypoglycemic pediatric

Back 34

EKG
4 mL/Kg of 25% dextrose IV push for infants (<10 Kg)
or
2 mL/Kg of 50% dextrose (or 4 mL/Kg of 25% dextrose) for older/heavier children..

Front 35

Unable to establish IV on hypoglycemic pediatric

Back 35

glucagon 0.5 mg IM or intra-nasal forchildren < 20 Kg,

1 mg IM or intra-nasal for children ≥ 20Kg.

Front 36

Resp depression with suspected opiate overdose - Pediatric Tx

Back 36

0.01 mg/Kg (up to 0.4 mg) of naloxone IV push or intra-nasal

May repeat after 5min - TOTAL OF 2mg

Front 37

Time critical stroke patients

Back 37

< 4.5 hours

Front 38

Cincinnati Prehospital Stroke Scale

Back 38

Facial Droop (have patient show teeth or smile):
Arm Drift (have patient close eyes and hold both arms out, palms up):
Speech (have the patient say “you can’t teach an old dog new tricks”):

Front 39

Post-ictal pts requesting not to be transported

Back 39

consult with the hospital for authorization not to transport.

Front 40

Status seizures (def)

Back 40

Continuous seizure activity for longer than 3 min or two or more consecutive seizures without
regaining consciousness

Front 41

Status seizure Tx

Back 41

Administer midazolam IV, IM, or intra-nasal:
a. If patient ≥ 50 kg, administer 5 mg
b. If patient < 50 kg, administer 2.5 mg

(may repeat in 5min)

Front 42

Pregnant pt with status seizures

Back 42

(if 3rd trimester)

2g magnesium IVP over 2 min

Front 43

Pediatric status seizure Tx

Back 43

midazolam IV, IM, or intra-nasal

0.1mg/kg of midazolam (max of
2.5 mg)

(may repeat 1x in 5 min)
Contact receiving facility for further dosese

Front 44

Cyclic antidepressant overdose Tx

Back 44

Wide QRS, hypotension or seizures

Sodium Bicarbonate 1mEq/Kg IVP

Front 45

Calcium channel blocker overdose Tx

Back 45

With bradycardia AND hypotension:

Calcium chloride 1g slow IVP

Front 46

Beta-blocker overdose Tx

Back 46

With hypotension:

Glucagon 3mg IVP

Front 47

If venous or arterial air embolus is suspected....

Back 47

(esp wiht dialysis pt)

Trendelenburg position on the left side

Front 48

Dialysis pt, missed Tx,
with wide QRS, hypotension or refectory V-fib........Tx

Back 48

1. Calcium Chloride 1g slow IVP
2. Albuterol 5mg back-to-back continuous
3. Sodium Bicarb, 100 mEq IVP (IF LUNG SOUNDS CLEAR)

Front 49

Chemical restraint Tx

Back 49

Midazolam IV, IM, or intra-nasal

> 50kg = 10mg
< 50kg = 5mg

Front 50

Hypothermic Pt ........PEA, organized rhythm

Back 50

No not use CPR

(CPR if asystole or Vfib)
Intubate if no spontaneous breathing

Front 51

Rapid correction of acidosis can....

Back 51

induce V-fib

Front 52

If hyperthermic pt shivers.....

Back 52

remove cooling packs......do not allow pt to shiver during cooling

Front 53

All near drownings.....

Back 53

Should be transported to hospital.....pulmonary edema may be delayed!!!fa

Front 54

When to clamp cord after newborn birth

Back 54

wait at least 1 min after birth

Front 55

Newborn scoring chart

Back 55

APGAR (0 -2 on each......0-10)
limp - somewhat - good
absent - <100 - >100
absent - some - good
blue - pink torso/blue extremities - pink
absent - weak cry - strong cry

Front 56

Newborn resuscitation at time of delivery

Back 56

RR <30
HR <100
Central cyanosis

Then.....

1. tactile stimulation
2. blow-by O2
3. (suction if obstruction seen or BVM needed)
4. BVM (40-60/min)
5. if HR <60, CPR (90 compressions and 30 breaths/min)......continue until HR >60

Front 57

If muconium staining after birth

Back 57

Suction! Mouth and nose.

Only in nonvigorous infant.....use muconium aspirator (or suction through ET tube)

Front 58

In eclamptic seizures

Back 58

midazolam before mag

(no lights, no sirens)

Front 59

Uncontrollable maternal bleeding posture

Back 59

transport LLR (also if >20 weeks gestation)

Front 60

Prolapsed cord Tx

Back 60

O2
LLR position
elevate presenting part of cord with gloved hand in vagina
Contact receiving facility.

Front 61

Postpartum hemorrhage =

Back 61

any patient who has an estimated blood loss exceeding 500 ml
following childbirth

Front 62

Postpartum hemorrhage Tx

Back 62

O2
Massage fundus until firm (chech ever 5 min and repeat if necessary)

Front 63

Pain management

Back 63

MILD PAIN - ASA
(conta = allergy, liver dysfunction, active vomiting, ASA used in last 4hrs)

MODERATE PAIN - ketorolac
(Toradol®)
(For patients > 14 and < 65 years old and > 50 kg: 30 mg IV or 60 mg IM once.
For patients > 65 years old or < 50 kg: 15 mg IV or 30 mg IM once.)
(contra = allergy to it or ASA or NSAID, Hx renal dysfunction, Hx GI bleed, active bleeding or suspicion, NSAID within las 6hrs, or pregnant)

Front 64

Vomiting Tx

Back 64

Ondansetron 4-8mg IVP or oral tablet (for >50kg)

(0.1mg/kg IVP or appropriate portion of tablet for <50kg)