CARROLL COUNTY AMBULANCE

Introduction The purpose of protocols in the out-of-hospital setting is to assure safe and effective intervention during the out-of-hospital phase of patient care. In consideration of the unique resources, needs, population and geography of individual service programs, the physician medical director may choose to enhance or omit portions in accordance with Iowa Code, Chapter 147A. Medical directors are responsible to ensure that EMS personnel use protocols, have the training and skills required, and perform Continuous Quality Improvement (CQI) activities. Use of skills in the out of hospital setting are limited to the EMS provider s scope of practice and EMS service program level of authorization as approved by the physicians medical director. The service program medical director must determine what skills within the level of service authorization and provider scope of practice are to be included or not included for individual EMS services. The Iowa EMS Scope of Practice document, adopted by reference to the administrative rules outlines skills by certification level. It can be found on the Bureau of EMS website or by contacting the Bureau of EMS. Protocols are essential to assure education, training, and standards of care to meet the needs of patients. Ongoing review and update of protocols is necessary to keep pace with interventions known to be effective in out-of-hospital care. The challenge is for all EMS providers, to keep current with the protocols so the EMS continuum of care can effectively reduce suffering, disability, death and costs from life-threatening illness and injury. It is the intent of the Protocol Committee and the Iowa EMS Advisory Council that these protocols will serve as a standard throughout Iowa s EMS system. Approved current protocols shall be available on all authorized service vehicles. According to Iowa Administrative Code 641-132.9(2)(a) individual physician medical directors duties include developing, approving, and updating protocols to be used by service program personnel that meet or exceed the minimum standard protocols developed by the department. Additionally, according to 641-132.8(3)(b) service programs shall utilize department protocols as the standard of care. The service program medical director may make changes to the department protocols provided the changes are within the EMS provider s scope of practice and within acceptable medical practice. A copy of the changes shall be filed with the department. The following authorization page and any changes or revisions made by the EMS service medical director must be on file with the State of EMS Field Coordinator. The complete Iowa Statewide EMS Treatment Protocols, Adult & Pediatric is also available on the Iowa Department of Public Health website https://www.idph.state.ia.us/ems/ 1

PROTOCOLS AUTHORIZATION Authority: According to Iowa Code, Chapter l47a, emergency medical personnel may only deliver emergency medical care under the direction of a physician medical director who is licensed in Iowa. The medical practice of out-of-hospital personnel is an extension of the medical director's license. Protocols shall be approved, signed and dated by the EMS service medical director prior to implementation. Staff training must be documented & on file. Any changes must be on file with your EMS Field Coordinator. Skills must be within the level of service authorization and EMS provider scope of practice. THE SERVICE PHYSICIAN MEDICAL DIRECTOR MUST APPROVE THE PROTOCOL IN ACCORDANCE WITH THE AUTHORIZED LEVEL OF SERVICE CARROLL COUNTY AMBULANCE X Ambulance Non-transport A. Level of Authorization: First Responder/EMR EMT-B/EMT EMT-I AEMT EMT P EMT-PI CCT (attach protocol) PS/Paramedic PS I CCT (attach protocol) B. These protocols are to be considered a standing order. Radio communications are not required prior to performing any protocol action. EMT's/Paramedics should call in for further direction or confirmation of orders whenever the situation warrants. X YES NO C. The emergency medical care provider present with the highest level of certification (on the transporting service) shall determine, based upon patient care needs, the appropriate level of provider to attend the patient during transport. X YES NO D. Approval of Skills and Training Level (Physician Medical Director must approve skills based on providers scope of practice & service authorization level) Esophageal/treacheal Double-lumen airway IV maintenance Glucose Monitor Epinephrine Auto injector Gastric Tube Insertion Needle Thoracostomy NG Tube Insertion Intraosseous Infusion Needle Crichothyrotomy CPAP Nasotracheal Intubation Thrombolytics Assessment-based Spinal Immobilzation _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO _X_ YES NO 2

I understand I am responsible for providing appropriate medical direction and overall supervision or the medical aspects or the service program and I have reviewed this document and the Iowa EMS Scope of Practice which is defined by Iowa Administrative Code 641-132. Physician Medical Director s Name Physician Medical Director s Signature Date (Please Print) 3

Authorized Drug List Basic Oxygen Aspirin Glucose Paste Patient Assisted Inhaler Epi Pen Patient Assisted Nitroglycerin Individual drug protocols are attached to the patient care protocols for additional guidance when choosing an appropriate medication. For situations not covered in the PC Protocols, the drug protocols will be considered valid treatment options. Paramedics may continue IV drip medications initiated in the hospital during an interfacility transfer. The Paramedic should familiarize himself/herself with the drug prior to transport, obtain the appropriate IV drip chart, and have knowledge of the operations of the IV pump being used. The paramedic may take additional medications from the hospital for administration during a transfer provided the paramedic has a written doctor s order for the drug. A stand-alone written doctor s order or a copy of the doctor s order for an inpatient will be accepted. The paramedic should himself/herself with the drug drug prior to transport. For Critical Care Transport, Carroll Co. Ambulance will utilize equipment from the sending hospital, with arrangements made prior to accepting the transport. Advanced Dextrose 5% in water (for drug gtts) Normal Saline Adenosine Amiodarone Albuterol Aspirin Atropine Calcium Gluconate Dextrose Diazepam (Valium) Diphenhydramine (Benadryl) Dopamine Epinephrine Etomidate Fentanyl Flumazenil (Romazicon) Furosemide (Lasix) Glucagon Glucose Haloperidol (Haldol) Ipratopium (Atrovent) Lactated Ringers Lidocaine Magnesium sulfate Metaprolol (Lopressor) Midazolam (Versed) Morphine Sulfate Naloxone (Narcan) Nitroglycerin Odansetron (Zofran) Oxytocin Sodium Bicarbonate Solu-Medrol Succinylcholine Thiamin Vasopressin 4

Drugs Carried on Ambulance: Adenosine Albuterol Amiodarone Aspirin Atropine Dextrose Diphenhydramine (Benadryl) Epinephrine Epinephrine Auto-Injector Fentanyl Glucagon Glucose Paste Haloperidol Lidocaine Midazolam (Versed) Morphine Naloxone (Narcan) Nitroglycerin Odansetron (Zofran) Solu-medrol Vasopressin CARROLL COUNTY AMBULANCE MEDICATION PROTOCOLS 2013 Related Protocols: Medication Assisted Intubation (non-paralytic) Intranasal Drug Administration Rectal Valium/Versed Administration (pediatric) PAIN Protocol Drip Charts Dobutamine Dopamine Heparin Nitro 5

ADENOSINE (ADENOCARD) Classification: Antiarrthymic Mechanism of Action: Adenosine slows conduction through the AV node and may also interrupt re-entry pathways in the AV node. Indications: Symptomatic Paroxysmal Supra-Ventricular Tachycardia Contraindications: Second or Third Degree Heart Blocks Sick Sinus Syndrome Known Hypersensitivity to Adenosine Patient taking Dipyridamole (Persantine) Precautions: Arrthymias, including blocks, are common at the time of conversion. Use with caution in patients with asthma. Dosage: ADULTS: 6 mg given rapid IV bolus over 1-3 seconds followed by 20 cc flush. If after 2 minutes, conversion does not occur, repeat with 12 mg rapid 20cc IV flush. PEDIATRICS: 0.1 mg/kg rapid IV or 10cc bolus (up to 6 mg) over 1-3 seconds. If after 2 minutes, conversion does not occur, repeat with 0.2 mg/kg rapid IV or 10 bolus (up to 12 mg Route: IV should be started with large bore catheter in antecubital vein and administered in medication port closest to IV site with rapid bolus of IV fluid after administration. Side Effects I Complications: Facial Flushing Headache Dizziness Shortness of Breath Nausea I Vomiting Sinus pause of 3-10 seconds is common 6

ALBUTEROL Classification: Sympathomimetic Mechanism of Action: Albuterol is an a2 - adrenergic (pulmonary) agonist. Albuterol causes bronchodilation and stimulates the central nervous system and the heart. Indications: Bronchial Asthma Reversible bronchospasm caused by COPD Pulmonary Edema I CHF if wheezing Contraindications: Known hypersensitivity to Albuterol. Precautions: Vital signs must be monitored, especially in those with history of hypertension. ADULT Dosage: 2.5 mg / 3ml (prepackaged) by nebulizer. PEDIATRIC Dosage: 2.5 mg I 3ml (prepackaged) by nebulizer. Route: Inhalation via nebulizer. Side Effects I Complications: None 7

AMIODARONE Classification: Antiarrthymic Mechanism of Action: Amiodarone prolongs myocardial action potential and effective refractory period and causes noncompetitive a and s adrenergic inhibition. Amiodarone suppresses ventricular ectopy (PSVT, VT, VF,) and slows conduction through the AV node (ventricular rate control; useful in WPW). Amiodarone also causes vasodilation resulting in reduced cardiac work. Indications: Shock refractory ventricular fibrillation and pulseless ventricular tachycardia Ventricular Tachycardia Wide-complex tachycardia of unknown type Contraindications: Cardiogenic shock Marked sinus bradycardia 2nd or 3rd degree heart block Hypersensivity to Amiodarone Precautions: May worsen existing or precipitate new dysrhythmias, including torsades de pointes and VF. Use with beta-blocking agents could increase risk of hypotension and bradycardia. Amiodarone inhibits atrioventricular conduction and decreases myocardial contractility, increasing the risk of AV block with verapamil or diltiazem or of hypotension with any calcium channel blocker Adult Dosage: VF and Pulse less VT: Give 300 mg IV/I0. Give additional 150 mg IV push in 3 to 5 min for refractory or recurrent VF/VT. VT with pulse: Give a rapid infusion of 150 mg over 10 minutes. Dilute 3mg of Amiodarone in a 7ml of saline, for a total of 10 ml. (15mg/cc) Pediatric Dosage: VF and Pulseless VT: Give 5 mg/kg IV/I0. (No subsequent doses) VT with pulse: give an infusion of 5mg/kg over 20 min. Dilute in normal saline according to Pediatric tape. Side Effects I Complications: Dizziness, headache, bradycardia, cardiac conduction abnormalities, CHF, dysrhythmias, hypotension, SA node dysfunction, sinus arrest, dyspnea, pulmonary inflammation 8

ASPIRIN Classification: Anti-Platelet Mechanism of Action: Blocks formation of thromboxane A2, which prevents platelet aggregation and arteriole constriction. Indications: All patients with pain suggestive of an AMI Confirmed AMI by 12 Lead EKG Contraindications: Known hypersensitivity to Aspirin History of active ulcer disease or asthma Use with females in last trimester of pregnancy History of blood coagulation defects or in conjunction with anticoagulation therapy. Precautions: Higher doses can interfere with prostacyclin products and interfere with positive effects. Dosage: 2 81 mg (162 mg) tablets for patients currently on an anti-coagulant/anti-platelet 4 81 mg (324 mg) tablets for patients not currently on an anticoagulant/anti-platelet Route: P.O. Side Effects I Complications: Dyspepsia Heartburn Anorexia Nausea Occult blood loss Epigastic discomfort 9

ATROPINE SULFATE Classification: Antiarrhythmic I Anticholinergic Mechanism of Action: Atropine competes with the neurotransmitter acetylcholine for receptor sites, blocks the parasympathetic fibers, which enhances the sinus node and atrioventricular conduction. Indications: Symptomatic Bradycardia Organophosphate Poisoning Contraindications: None when used in an emergent situation. Precautions: Maximum dosage of 0.04mg/kg should not be exceeded except in organophosphate poisonings. Tachycardia & Hypertension Use with caution in all patients with myocardial ischemia, Type II AV blocks, and third degree heart blocks with wide QRS. Pace if needed. Adult Dosage: Bradycardia: 0.5 mg - every 5 minutes to max dose. Organophosphate Poisoning: 2-5 mg Pediatric Dosage: Bradycardia: 0.02 mg/kg every 5 minutes to max dose. Maximum single dose - Child: 0.5 mg, Adolescent: 1 mg Maximum total dose - Child: 1 mg, Adolescent: 2mg Minimum dose - 0.1 mg IV Route: IV, IM, I0 Side Effects I Complications: Palpitations Tachycardia Headache I Dizziness Anxiety Dry Mouth Pupillary dilation I Blurred Vision Urinary retention 10

DEXTROSE 50% Classification: Carbohydrate Mechanism of Action: Rapidly elevates blood glucose level. Indications: Hypoglycemic Coma of unknown origin Contraindications: lntracranial hemorrhage. Increased intracranial pressure. Known or suspected CVA in the absence of hypoglycemia. Precautions: Blood glucose level should be checked prior to administration. Make sure IV is patent, extravasation of D50 make cause necrosis in the tissues. If giving with Thiamine, administer Thiamine first. Adult Dosage: 25 grams (50ml) Pediatric Dosage: Up to 8 years old: D25, 2-4 ml/kg (0.5-1.0 g/kg), not to exceed 25 grams If D25 is not available, draw 1-2 ml/kg (0.5-1.0 g/kg) of D50 into syringe and dilute with equal amount of normal saline prior to administration. For infants less than 1 month of age, dilute with four times the amount of normal saline. >8 years old: D50, 2-4 ml/kg (0.5-1.0 g/kg), not to exceed 50 ml (25 grams) Route: Intravenous I/O Rectally Side Effects I Complications: Local venous irritation 11

DIPHENHYDRAMINE (Benadryl) Classification: Antihistamine Mechanism of Action: Competes for H1 receptors on effector cells thus blocking effects of histamine release. Some sedative effects Indications: Anaphylaxis Allergic Reactions Dystonic reactions due to Phenothiazine Contraindications: Acute Asthma Nursing mothers Precautions: Hypotension Adult Dosage: 25-50 mg slow IV 25-50 mg IM Pediatric Dosage: 1-2 mg/kg slow IV, IM, 10 Maximum single dose of 50 mg. Route: Intravenous Deep Intramuscular Intraosseous Side Effects I Complications: Sedation Dries bronchial secretions Blurred Vision Headache Palpitations 12

DOPAMINE Classification: Sympathomimetic Mechanism of Action: Increases cardiac contractility Causes peripheral vasoconstriction Indications: Hemodynamically significant hypotension in the absence of hypovolemia. Contraindications: Hypovolemic shock before fluid resuscitation has been completed. Ventricular Fibrillation I Ventricular Tachycardia Precautions: May be deactivated by alkaline solutions (Furosemide and Sodium Bicarb) Increases myocardial oxygen demand, therefore use with caution in patients in cardiogenic shock or CHF. Should not be administered in the presence of severe tachyarrhythmias. Ventricular irritability Dosage: 5-20 mcg/kg/min Mix 400mg in 250 ml of Normal Saline giving concentration of 1600 mcg/ml. Or use prepackaged drip (1600 mcg/ml). Route: IV drip only Side Effects I Complications: Vasoconstriction Ventricular tachyarrhythmias Hypertension 13

EPINEPHRINE 1:10,000 and 1:1000 Classification: Sympathomimetic Mechanism of Action: Increases cardiac contractility Increases heart rate Causes bronchodilation Indications: Cardiac Arrest Anaphylactic Shock Exacerbation of COPD Bronchial Asthma Contraindications: Underlying cardiovascular disease. Hypertension Pregnancy Tachyarrhythmias None in the cardiac arrest situation. Precautions: Should be protected from light Can be deactivated by alkaline solutions (Furosemide and Sodium Bicarb) Blood Pressure, Pulse, and ECG must be constantly monitored. Adult Dosage: Cardiac Arrest: 1 mg IV (1:10,000) every 3-5 minutes Severe Anaphylaxis: 0.1 mg IV repeat as needed to max dose of 0.5mg (1/10,000) or 0.3-0.5 mg IM (1/1000) Pediatric Dosage: Cardiac Arrest: 0.01 mg/kg of 1:10,000 or 0.1 ml/kg Severe Anaphylaxis: 0.01 mg/kg of 1 :1000 IV or 10, or up to 0.3 mg IM Route: Intravenous Intraosseous Intramuscular Side Effects I Complications: Palpitations Tachyarrhythmias 14

FENTANYL Classification: Synthetic Opiod Agonist Mechanism of Action: Analgesic with short duration of action. Minimal histamine release, so less hemodynamic compromise. Indications: Pain control. Sedation for invasive procedures, premedication for cardioversion. Contraindications: Respiratory depression or insufficiency Uncorrected hypotension Allergy/sensitivity to Fentanyl Side Effects: Respiratory depression, bradycardia, hypotension or hypertension, nausea, vomiting Drug Interactions: Effects may be increased when given with other CNS depressants or skeletal muscle relaxants. Route: IV, I0, IM, IN Dosage: Adults 25-50 mcg slow IV/I0/IM/IN every 5-15 minutes as needed to control pain. Max of 100 mcg Pediatrics 1-2 mcg/kg slow IV/ I0 /IM/ IN every 5-15 minutes as needed to control pain Special considerations: Pregnancy Category C - use only if potential benefits justify the risk Schedule II drug with potential for abuse. Use with caution in elderly patients and those with severe respiratory disorders, seizure disorders, or cardiac disorders. 15

GLUCAGON Classification: Hormone Mechanism of Action: Inhibits glycogen synthesis Causes breakdown of glycogen to glucose Increases blood glucose level Increases cardiac contractile force Increases heart rate Indications: Hypoglycemia Contraindications: Hypersensitivity to Glucagon Precautions: Blood glucose level should be checked prior to administration Only works if pt. has stores of glycogen in liver Use caution in patients with cardiovascular or renal disease Dosage: 1 mg IM Route: Intramuscular injection Side Effects I Complications: Tachycardia Hypertension Nausea and or vomiting 16

GLUCOSE Classification: Carbohydrate Mechanism of Action: Elevates blood glucose level. Indications: Hypoglycemic Contraindications: lntracranial hemorrhage. Increased intracranial pressure. Known or suspected CVA in the absence of hypoglycemia. Unconsciousness and I or pt. unable to maintain own airway Precautions: Blood glucose level should be checked prior to administration. Airway must carefully be maintained. In pt's with blood glucose of <40 mg/dl, IV Dextrose or Glucagon should be first line treatment. Dosage: 1 tube - approximately 25 grams Route: Orally Side Effects I Complications: None, if airway is maintained. 17

HALOPERIDOL (HALDOL) Classification: antipsychotic Mechanism of Action: Blocks the dopamine receptors in the brain associated with mood and behavior. It has strong antiemetic effects and it impairs central thermoregulation. It produces weak central anticholinergic effects and transient orthostatic hypotension. Indications: Acute psychotic disorder. Contraindications: Parkinson's disease Seizure disorders Coma Alcoholism Severe mental depression CNS depression Thyrotoxicosis Precautions: Pregnancy Category C Do not give if other sedatives have been given. Use with caution in elderly or debilitated patients. Use with caution in patients with urinary retention, glaucoma, and cardiovascular disorders. Use with caution in patients receiving anticonvulsant, anticoagulant, or lithium therapy. Dosage: Adults: 2-5 mg IM or IV, titrated to effect. Max of 10 mg Use low dose if patient is on lithium Route: Intramuscular injection Side Effects I Complications: Dystonia, akathisia Lethargy, fatigue, weakness Tremor Headache, confusion, vertigo Tachycardia, hypotension, ECG changes Laryngospasm, bronchospasm, increased depth of respirations 18

MIDAZOLAM (Versed) Classification: Benzodiazepine I Sedative I Hypnotic Mechanism of Action: Short acting CNS depressant 3-4 times more potent than Valium Produces sleepiness and relief of apprehension Diminished patient recall very effectively Indications: To produce sedation in conscious patients or high anxiety patients To impair memory of therapeutic procedures To provide muscle relaxation in patients with long bone fracture, used in conjunction with pain control medication To control seizure activity Contraindications: Acute narrow angle glaucoma Hypersensitivity to Versed Pregnancy Lactation Acute alcohol intoxication with depressed vital signs Precautions: Use with caution in elderly and patients with chronic diseases Increased risk of apnea Be alert for developing hypotension Adult Dosage: 1-2.5 mg IV every 3-5 minutes, titrated to effect OR 2 mg IN every 2-5 minutes, titrated to effect, delivered via mucosa! atomizer device, with limit of 1 ml per nostril per dose. Pediatric dosage: 0.2 mg/kg IV, I0, IM, or IN delivered via mucosal atomizer device Route: Intravenous, lntraosseous, Intranasal, Intramuscular Side Effects I Complications: Apnea Airway obstructions Blurred vision Bradycardia Hypotension Nausea I vomiting Coma Arrhythmias Patient Wtg Intranasal (IN) Midazolam age (yr) (kg) volume in ml (assuming 5mg/ml concentration) and maximum dosage Neonate 3 0.12 ml 0.6mg <1 6 0.24ml 1.2 mg 1 10 0.40ml 2.0mg 2 14 0.56ml 2.8mg 3 16 0.64ml 3.2mg 4 18 0.72ml 3.6mg 5 20 0.80ml 4.0mg 6 22 0.88ml 4.4mg 7 24 0.96ml 4.8mg 8 26 1.04 ml 5.2mg 9 28 1.12 ml 5.6 mg 10 30 1.20 ml 6.0mg 11 32 1.28 ml 6.4mg 12 34 1.36 ml 6.8mg Small teenager 40 1.60 ml 8.0mg Adult or full grown teenager 50 or more 2.00ml 10.0 mg 19

MORPHINE Classification: Narcotic Mechanism of Action: CNS Depressant Peripheral vasodilator Decreases sensitivity to pain Indications: Severe Pain Pulmonary Edema Contraindications: Head Injury Volume depletion Patients with undiagnosed abdominal pain Patients with hypersensitivity to Morphine Precautions: Hypotension Respiratory depression Nausea I vomiting Adult Dosage: IV: 2-5 mg every 5 minutes until relief of pain, respiratory depression occurs, or until 10 mg is reached. IM: 2-5 mg based on patient's weight. Call med control to exceed 10 mg. Non STEMI MI 1-5 mg one time only Pediatric Dosage: IV: 0.1-0.2 mg/kg every 5 minutes until relief of pain, respiratory depression occurs, or until 10 mg is reached. IM: 0.1-0.2 mg/kg Route: Intravenous Intraosseous Intramuscular Side Effects I Complications: Respiratory depression Dizziness Hypotension Altered level of consciousness 20

NALOXONE (NARCAN) Classification: Narcotic Antagonist Mechanism of Action: Reverses effects of opiate narcotics Indications: Narcotic overdoses including the following: Codeine, Demerol, Dilaudid, Fentanyl, Heroin, Lortabs, Methadone, Morphine, Paregoric, Percodan, Tylox, Vicodin, and synthetic analgesics. Overdoses including the following: Darvon, Nubain, Stadol, Talwin, alcoholic coma To rule out narcotics in coma of unknown origin. Contraindications: Patients with hypersensitivity to Narcan Precautions: Use with caution in patients with narcotic dependence as this may cause withdrawal symptoms. Short-acting, should be augmented every 5 minutes Adult Dosage: 1-2 mg IV, given in increments to effect OR 2 mg IN, limit of 1 ml per nostril, administered via mucosal atomizer device Pediatric Dosage: <20 kg- 0.1 mg/kg, titrated to effect > 20 kg - 2 mg, titrated to effect Route: Intravenous Intraosseous Intramuscular Side Effects I Complications: None 21

NITROGLYCERIN Classification: Antianginal Mechanism of Action: Smooth muscle relaxant Decreases cardiac work load Dilates systemic and coronary arteries and veins Indications: Angina Pectoris Cardiac related chest pain Hypertensive crisis Contraindications: Children under 12 years of age Patients with Viagra or similar drug use in last 24 hours Hypotension Precautions: Constantly monitor blood pressure Protect from light Syncope Tablets will expire in 30 days once bottle is opened Dosage: 1 tablet (0.4 mg) every 3-5 minutes up to 3 times Up to 3 doses can be administered if blood pressure is above 90 Systolic Route: Sublingual Side Effects I Complications: Hypotension Headache Dizziness 22

ODANSETRON (ZOFRAN) Classification: Anti-Emetic Mechanism of Action: Selectively antagonizes serotonin 5-HT3 receptors. Indications: Nausea and vomiting Contraindications: Hypersensitivity to drug I class Impaired liver functions Precautions: Use with caution in patients with HTN, Diabetes, Seizure Disorder, and hypothyroidism. Use with caution in patients with Arrhythmias and Cardiovascular Disease. Adult Dosage: 4 mg slow IV push Pediatric Dosage: 0.1 mg/kg slow IV push Max dose 4mg Route: IV, IM Side Effects I Complications: Headache Fatigue Anaphylaxis Vertigo I Dizziness Diarrhea Seizure 23

SOLU-MEDROL Classification: Corticosteriod, anti-inflammatory Mechanism of Action: Used in management of allergic reactions and occasionally as an adjunctive agent in the management of shock Used for spinal cord injury in both Emergency Departments and pre-hospital settings Indications: Spinal cord injury Anaphylaxis Asthma Exacerbation of COPD Contraindications: None in the emergency setting Adult Dosage: Initial bolus of 30 mg/kg is administered IVP over a fifteen minute period, 45 minutes later follow with maintenance infusion of 5.4 mg/kg/hour Asthma/COPD/Allergic reactions 80 to 125 mg IVP or IM Pediatric Dosage: 2 mg/kg IV to a max of 125 mg Route: IV/IO IM Side Effects I Complications: Fluid retention CHF Hypertension Abdominal distention Vertigo Headache Nausea Malaise Hiccups Special Considerations: Single dose is all that should be given in the prehospital setting. Long term steroid therapy can cause GI bleeding, prolonged wound healing, and suppression of adrenocortical steriods 24

VASOPRESSIN Classification: Hormone Mechanism of Action: Potent peripheral vasoconstrictor Indications: May be used once in pulseless arrest patients in lieu of 2nd dose of epinephrine Contraindications: None when used in above emergency situation Dosage: 40 units IVP. May not be repeated Route: Intravenous Side Effects I Complications: None Special Considerations: Standard Epinephrine therapy may begin ten minutes after Vasopressin dose 25

MEDICATION ASSISTED INTUBATION INDICATIONS: A qualified EMS provider* may use this skill for the following: Uncontrolled, obstructed or inadequate airway secondary to trauma or overdose when further sedation is needed Decreased level of consciousness, combativeness or severe agitation secondary to trauma or suspected CV A Combative or uncontrollable head trauma patient that presents potential for injury to self or others CHF, COPD, or Asthma patient with hypoxia and/or respiratory exhaustion who cannot be nasotracheally intubated or easily orally intubated Burn patient with potential or existing respiratory compromise CONTRAINDICATIONS: Hypersensitivity to medications that would be used PROCEDURE: 1. Ensure all equipment is set up for intubation. 2. Ensure adequate spinal precautions are taken. 3. Pre-oxygenate with high flow oxygen by mask. Excessive manual ventilation may result in gastric distention with vomiting and aspiration. Be prepared to suction as needed. 4. If needed, sedate the patient with Valium/Versed 2.0-5.0 mg IV (adult) or Valium/Versed 0.05-0.2 mg/kg IV diluted 1: 1 in NS (peds), Wait for 1-2 minutes for sedative effect. May use repeat doses of 2.0 mg every 2-3 minutes as needed to titrate for effect. Maximum dose not to exceed 10 mg. 5. Once intubation is completed, confirm tube placement and secure the tube. 6. If bradycardia occurs associated with intubation, temporarily halt attempt and hyperventilate the patient with the BVM and 100o/o oxygen. If the patient remains bradycardic, consider Atropine 0.5 mg IV (adult) or Atropine 0.01 mg/kg IV (peds). 7. Consider use of Narcan 1-2 mg IV over 1-2 min for reversal of sedative effects. (May repeat in one minute. Max dose of 1.0 mg) *Qualified EMS provider: A certified EMT-P/PS who has the skills necessary to competently perform this procedure and the approval of the medical director. RECTAL VALIUM/VERSED ADMINISTRATION Administration of rectal Valium may be considered for pediatric seizure emergencies after the usual procedures to stabilize the patient are completed (ABC's management). 26

Procedure/Treatment: Draw up 0.4 mg/kg of Valium/Versed into syringe and remove needle. Lubricate end of feeding tube and insert approximately 2 inches into the rectum. Attach syringe to end of tube and push appropriate dose of Valium/Versed into tube. Clamp the tube and remove syringe. Pull back 2 cc's of air in syringe and reattach to tube. Unclamp the tube and push air into feeding tube, being sure the Valium/Versed is placed into the rectum. Repeat 4, 5 and 6 until Valium/Versed is fully into rectum. Remove the tube from rectum and hold buttocks together. 27

INTRANASAL MEDICATION ADMINISTRATION Indications Unable to initiate IV access. Administration of Midazolam for control for seizures or for sedation OR Administration of Fentanyl for pain control OR Administration of Naloxone for proven or probable narcotic overdose Procedure Inspect nostrils for significant amounts of blood or mucous discharge. Presence of these fluids will limit medication absorption. Suctioning the nasal passage prior to administration of the medication should be considered. Draw into a syringe the proper dose of medication per the drug protocol. Remove the needle from the syringe and attach the atomizer tip. Hold the forehead stable, place the tip of the atomizer 1.5 cm into the nostril aiming slightly up and outward. Briskly compress the syringe to administer half of the medication into the nostril. Remove and repeat into the other nostril until all the medication has been administered. NOTE: For the adult, volume should be limited to 1 ml per nostril. For children under 30 kg in weight, limit volume to 0.5 ml per nostril. 28

PAIN MANAGEMENT PROTOCOL INTRODUCTION: Pain is the most frequent symptom experienced by patients. The management of pain should be a priority. The purpose of this protocol is not to totally alleviate pain, but to safely decrease the intensity of the pain without causing physiologic compromise, delaying transport to definitive care or interfering with the patient's diagnostic workup following arrival at the emergency department. Indications: Acute myocardial infarction I Chest Pain Burns Isolated musculoskeletal injuries Other trauma with stable blood pressure (natural or with fluid bolus) Pain consistent with kidney stones Cancer pain Palliative care for DNR patients Non-traumatic back pain with history Contraindications: Head injury with suspected intracranial pressure Hypotension (SBP < 90 mmhg) Sensitivity or allergy to pain medication being used Altered level of consciousness due to overdose Pregnancy (Contact Medical Control) Respiratory depression DRUG OVERVIEW: DRUG Adult dose and routes Pediatric dose and routes Special considerations Fentanyl Morphine Midazolam 25-50 mcg slow IV I IO I IM I IN every 5-15 minutes as needed to control pain Maximum dose 100 mcg IV I IO: 2-5 mg every 5 minutes until relief of pain, respiratory depression occurs. IM: 2-5 mg based on patient s weight Maximum dose 10 mg 1-5 mg IV or 10 every 1-2 minutes, titrated to effect OR 2 mg IN every 2-5 minutes, titrated to effect, delivered via mucosal atomizer device, with limit of l ml per nostril per dose. Maximum dose 10 mg 2-4 mcg/kg slow IV /IO/IM/IN every 5-15 minutes as needed to control pain IV I IO: 0.1-0.2 mg/kg every 5 minutes until relief of pain, respiratory depression occurs, or until 10 mg is reached. IM: 0.1-0.2 mg/kg 0.2 mg/kg IV, IO, IM, or IN delivered via mucosal atomizer device 29 May be given intranasally Drug of choice for abdominal pain, headache, and mutli-system trauma. See: Elderly Patients, Hypotensive Patients, Musculoskeletal injuries (for use of benzodiazepine with Fentanyl) Naloxone can be used to reverse effects of FentanvI if needed. DO NOT give intranasally. DO NOT give for abdominal pain or headache. See: Musculoskeletal injuries (for use of benzodiazepine with Fentanyl) Naloxone can be used to reverse effects of fentanvi if needed. May be given intranasally. May be beneficial in suspected long bone fractures for muscle spasm relief. Flumazenil can be used to reverse effects of Midazolam if needed.

Procedure: Obtain pain scale rating from patient using a 1-10 scale for adults and older children, and "faces" scale for young children. Except for chest pain, treatment of pain pharmacologically should be limited to pain rated at moderate or severe, or 4 or higher on a 1- l0 scale. If the patient can't rate the pain, the use of pain medication should be based on patient presentation. o Chest pain should be treated per "Acute Coronary Syndromes" protocol with a goal of complete relief of pain, within the limitations of the vital signs of the patient Verify and document any drug allergies the patient may have Document pain level prior to and after administration of analgesia Be sure to maintain adequate ventilation, oxygenation, and monitor cardiac rhythm I VS frequently. Consider premedicating patient with Odansetron 4 mg IVP to prevent nausea. Basic Pain Control Interventions: Splint, Elevate, Apply Cold Pak as appropriate Provide emotional support and I or distraction from pain Allow patient to remain in position of comfort unless contraindicated Paramedic Level Pain Control Interventions: Abdominal Pain o Fentanyl is the drug of choice for abdominal pain Limit total dose to no more than 100 mcg Contact Medical Control before administering to pediatric patient o Goal is to reduce pain level to tolerable, not to eliminate it o Be prepared to administer Zofran for nausea o Assess for referred pain, such as right shoulder pain indicative of cholecystitis o In patients over age 50, suspect and assess for possibility of AAA and do not administer pain medication if AAA is suspected. o Pain control for abdominal trauma is contraindicated o For epigastric pain, consider possibility of cardiac origin and treat accordingly Back pain (non-traumatic) o Fentanyl or Morphine may be used o Adding a benzodiazepine such as Midazolam or Diazepam may be considered for muscle relaxation effects o Assess amount and type of pain medication the patient is already taking. If the patient has been on long-term pain medications the dose may need to be increased. If short term and recent use, dose administered should be given onehalf dose at a time until effects are known. o If vital signs are stable and patient's pain is more severe with movement, consider pain control prior to moving patient o If pain is mid-thoracic or higher, consider possibility of cardiac or cardiovascular origin and treat accordingly. 30

Burns o o o o Fentanyl or Morphine may be used. Fentanyl has less hemodynamic effect, while Morphine may provide longer relief Large doses may be required; monitor VS every 5 minutes Be sure to provide oxygen as indicated Keep the patient warm Do not delay transport to initiate pain medication Chronic pain o For an increase in chronic pain to a severe state, in patients with chronic health conditions such as cancer, prior back injuries, and other conditions, use Fentanyl or Morphine o For analgesia during transport of hospice (or similar) patients with moderate to severe pain use Fentanyl or Morphine o Do not delay transport to initiate pain medication Headache o If acute onset without history, contact Medical Control. Musculoskeletal injuries o Fentanyl or Morphine may be used. Fentanyl is preferred for pediatric patients. o Consider Midazolam in conjunction with analgesia for relief of spasms of muscles when long bones are affected, especially femur fractures o If pain is severe, and splinting and/or moving will exert more pain on the patient, and the patient's VS are stable, analgesia may be considered prior to moving I transporting the patient Severe pain (other) o Follow drug protocols, contacting Medical Control for patients with questionable types of pain Multi-system trauma o Fentanyl is the drug of choice for pain. A combative patient cannot be safely secured, assessed or transported. Airway management is a priority.. o Monitor patient's blood pressure, administer fluid boluses as necessary. Considerations: Elderly patients (age 70 or older) o Administer pain medications in smaller increments and increase time between doses until the patient's reaction to the medication is displayed Fentanyl 0.5 mcg/kg for no more than single dose of 25 mcg Pediatric patients o Use drug protocols for pediatric doses o Consider intranasal administration o Consider initiation of IV after IN medication administration in case additional medications are needed, or to provide hemodynamic support in the event of hypotension developing 31

Hypotensive patients Analgesia medications should be provided in smaller increments when the patient's systolic blood pressure is between 100 and 120 mmhg Fentanyl 0.5 mcg/kg to be given cautiously to patients with borderline hypotension, to max single dose of 25 mcg IV fluids should be administered if blood pressure drops below I 00 mmhg after administration of analgesia in adults 200-500 ml Normal Saline for adult patients Pediatric patients who show signs of hypoperfusion: 20 ml/kg Normal Saline Refusal of transport o If patients receive analgesia a refusal of transport should not be accepted Patients must be monitored for at least 15-30 minutes after medication administration to observe for possible allergic reactions. o Administering analgesia en route will alleviate this problem 32

Bougie (Endotracheal Introducer) CONTRAINDICATIONS to use of Bougie Do not use on endotracheal tubes smaller than 6.0. Do not use for nasotracheal intubation. PROCEDURE 1. Holding the Bougie in your right hand and the angled tip pointing upward, gently advance the bougie anteriorly (under the epiglottis or over the posterior notch) to the glottic opening (cords). 2. Gently advance the device until resistance is encountered at the carina. 3. If no resistance is encountered and the entire length of the bougie is inserted, the device is in the esophagus. 4. The bougie is correctly placed when you see the device going through the cords, when you feel the washboard effect of the tip on the trachea, and/or when you meet resistance while advancing the bougie (bougie is at the carina). 5. Once positioned, withdraw the bougie until the black line mark is aligned with the lip and advance the lubricated ETT over the bougie and into the trachea. This indicates that the tip is well beyond the cords and the proximal end has enough length to slide the ETT over. 6. If resistance is encountered - caused by the ETT catching on the arytenoids or aryepiglottic folds - withdraw the ETT slightly, rotate 90 degrees and reattempt. If this is unsuccessful, use a smaller tube. 7. At no time should the ETT be forced as this may cause, or be caused by laryngospasm. 8. Once ETT is in position, while holding the tube, remove the bougie through the ETT. 33

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IOWA EMS TREATMENT PROTOCOLS Adult Treatment Initial Patient Care Protocol... 36 Abdominal Pain... 37 Acute Coronory Syndrome... 38 Airway... 39 Allergic Reaction... 40 Altered Mental Status... 41 Amputated Part... 42 Apparent Death... 43 Asthma... 44 Behavioral Emergencies... 45 Burns... 46 Cardiac Arrest... 48 Childbirth... 49 Congestive Heart Failure... 50 Frostbite... 51 Heat Illness... 52 Hypothermia... 53 Nausea & Vomiting... 54 Pain Control... 55 Poisoning... 56 Seizure... 57 Sexual Assault... 58 Stroke... 59 Trauma... 60 35

Initial Patient Care Protocol 1. Scene Size Up a) Review the dispatch information b) As you approach the scene consider safety for yourself and your patient. c) Observe universal precautions d) After determining the number and location of patients, consider the need for additional resources d) Determine mechanism of injury and/or nature of illness e) Reassess the situation often 2. Primary Survey a) Obtain general impression of patient, chief complaint, and priority problems b) Determine responsiveness c) Assess airway d) Assess breathing e) Assess circulation 3. Initial Interventions a) Treat airway/breathing problems b) Treat circulation problems c) Establish IV/IO access if indicated d) Apply cardiac monitor if indicated e) Apply pulse oximetry or EtC02 monitor if available and indicated f) Treat pain or nausea if present 4. Secondary Survey a) Perform secondary assessment after initial interventions are completed b) Address problems identified in the secondary survey utilizing the appropriate protocol(s) c) Obtain vital signs, including blood glucose if available and indicated 5. Ongoing Assessment a) Repeated evaluation of patient Vitals every 5 minutes or as appropriate for unstable patients Vitals every 15 minutes or as appropriate for stable patients b) Assess effect of interventions 6. Transport/Contact Medical Control a) Patients should be transported as soon as feasible to an appropriate medical facility. Immediate transport with treatment en route is recommended for patients with significant trauma or unstable airways b) Tier with an appropriate service if level of care indicates or assistance is needed and can be accomplished in a timely manner c) Contact medical direction as soon as feasible in accordance with local protocol for further orders d) For seriously injured or critically ill patients, give a brief initial report from the scene when possible, with a more detailed report given to medical direction while en route 36

Abdominal Pain (non-traumatic) Follow Initial Care Protocol for all Patients a) Give nothing by mouth BASIC CARE GUIDELINES ADVANCED CARE GUIDELINES b) Consider a fluid bolus if indicated. c) Evaluate the need for pain and nausea control. d) Follow pain protocol 37

Acute Coronory Syndrome 1. Follow Initial Care Protocol for all Patients a. Place patient in position of comfort, loosen tight clothing and provide reassurance. If patient is complaining of shortness of breath, has signs of respiratory distress, or pulse oximetry of less than 94% then titrate oxygen to maintain a saturation of 94% or higher. b. If capability exists, obtain a 12-lead EKG and transmit to the receiving facility and/or medical control for interpretation as soon as possible c. If patient is alert and oriented and expresses no allergy to aspirin have patient chew (4) 81 mg non-enteric aspirin. d. An initial management goal should be to identify STEMI and transport the patient with cardiac symptoms to the facility most appropriate for their needs e. Contact medical direction for orders f. If the patient has been prescribed nitroglycerin (patient's nitro only) and systolic blood pressure is 90 mmhg or above, give one dose. If patient is taking erectile dysfunction drugs such as Viagra, contact medical direction prior to giving nitroglycerin g. Repeat one dose of nitroglycerin every 3-5 minutes if pain continues, systolic blood pressure is 90 mmhg or above and authorized by medical direction, up to a maximum of three doses h. If systolic blood pressure less than 90 mmhg or patient does not have prescribed nitroglycerin, transport promptly continuing assessment and supportive measures i. Further assess the patient and evaluate the nature of pain (unless other treatment priorities exist). j. If capability exists, obtain a 12-Lead EKG and transmit to the receiving facility and/or medical control for interpretation as soon as possible k. Establish IV access at TKO rate unless otherwise ordered or indicated l. Monitor EKG and treat dysrhythmias following appropriate protocols approved by the medical director, referencing AHA guidelines m. Administer nitroglycerin (tab or spray) 0.4 mg sublingually if systolic blood pressure 90 mmhg or above for symptoms of chest pain or atypical cardiac pain. Repeat every 3~ 5 minutes if pain continues and systolic blood pressure is greater than 90 mmhg or above. Morphine sulfate can be administered after 2 doses of nitro if no change in pain n. If pain continues after administration of nitroglycerin and systolic blood pressure remains above 90 mmhg administer morphine sulfate following the AHA ST Elevated Myocardial Infarction (STEMI) guidelines: BASIC CARE GUIDELINES ADVANCED CARE GUIDELINES STEMI - Morphine 2-4 mg IV may repeat 2-8 mg IV every 5 minutes titrated to pain relief and vitals remain stable OR NONSTEMI - Morphine 1-5 mg IV given once 38

Airway 1. Follow Initial Care Protocol for all Patients BASIC CARE GUIDELINES Breathing spontaneous on initial assessment and adequate ventilation present a) Maintain oxygenation with a cannula or mask if oxygen saturations are below 94% titrate to 94% or higher. Breathing spontaneous on initial assessment without adequate ventilation present a) Check airway for obstruction and clear if needed b) After airway is clear, assist ventilation with an appropriate adjunct and oxygen c) If adequate ventilation is not maintained, and no gag reflex present, proceed to an advanced airway Not breathing, pulse present on initial assessment a) Open airway with head tilt chin lift. If successful, assist ventilations at an adequate rate and depth then reassess b) If head tilt chin lift is not successful, check airway for obstruction and clear if needed c) After airway is clear, assist ventilation d) If adequate ventilation is not maintained, proceed to an advanced airway e) Assess for presence of pulse frequently and follow cardiac arrest protocol if needed ADVANCED CARE GUIDELINES a) Place advanced airway as needed to maintain patent airway. b) If airway is obstructed in an unresponsive or apneic patient, visualize with laryngoscope and use Magill forceps to remove obstruction if possible. c) If unable to clear the airway, perform needle cricothyrotomy as appropriate. 39

1) Follow Initial Patient Care Protocol Allergic Reaction BASIC CARE GUIDELINES a) Use Auto-Inject 0.3 mg Epinephrine pen and administer it if signs of anaphylaxis are present. ADVANCED CARE GUIDELINES b) Administer epinephrine 1:1,000 concentration 0.01 mg/kg IM, up to a maximum dose of 0.3 to 0.5 mg c) Administer diphenhydramine 25-50 mg IV/IM d) Administer albuterol 2.5mg by nebulizer if respiratory distress, repeat as needed. e) For cases of severe anaphylaxis consider administration of 0.3-0.5 mg (3-5 ml) epinephrine 1:10,000 slow IV/IO. f) Evaluate need for early intubation if severe anaphylaxis g) Contact medical control to repeat dose of Epi 40

1. Follow Initial Patient Care Protocol Altered Mental Status BASIC CARE GUIDELINES a) Obtain blood glucose b) If conscious & able to swallow, administer 1 tube glucose, up to 15 grams by mouth ADVANCED CARE GUIDELINES c) If blood sugar less than 60 mg/dl, and patient is not alert or able to swallow, administer D50 12.5-25 gm IV d) If blood sugar is less than 60 mg/dl, patient is not alert or able to swallow, and no vascular access, administer glucagon 1 mg IM e) Evaluate the need for naloxone 1 mg IV. If no response may repeat in 3 minutes. f) Evaluate the need for intubation 41

Amputated Part 1. Follow Initial Patient Care Protocol 2. Follow Trauma Protocol if indicated BASIC CARE GUIDELINES a) Locate amputated part if possible b) Wrap amputated part in saline moistened gauze c) Place wrapped amputated part in empty plastic bag d) Place the plastic bag with the amputated part in a water and ice mixture e) Do not use ice alone or dry ice f) Make sure the part is transported with the patient, if possible ADVANCED CARE GUIDELINES g) Follow pain protocol. 42

Apparent Death 1. Follow Initial Patient Care Protocol Apparent death indications are as follows: Signs of trauma are conclusively incompatible with life Physical decomposition of the body Rigor mortis and/or dependent lividity If apparent death is confirmed, continue as follows: BASIC AND ADVANCED CARE GUIDELINES a) The county Medical Examiner and law enforcement shall be contacted b) At least one EMS provider should remain at the scene until the appropriate authority is present c) Provide psychological support for grieving survivors d) Document the reason(s) no resuscitation was initiated e) Preserve the crime scene if present f) In all other circumstances (except where "NO CPR/DNR" protocol applies; full resuscitation must be initiated 43

Asthma 1. Follow Initial Patient Care Protocol BASIC CARE GUIDELINES a) If patient has a physician prescribed hand-held metered dose inhaler: 1. Assist patient in administering a single dose if they have not done so already 2. Reassess patient and assist with second dose if necessary per medical direction ADVANCED CARE GUIDELINES b) Administer albuterol 2.5 mg via nebulizer, repeat as needed. c) Evaluate the need for epinephrine 1:1,000 concentration 0.3-0.5 mg IM. d) Evaluate the need for CPAP, if available e) Evaluate the need for intubation f) Contact medical control to repeat dose of Epi 44

1. Follow Initial Patient Care Protocol Behavioral Emergencies a) If there is evidence of immediate danger, protect yourself and others by summoning law enforcement to help ensure safety BASIC CARE GUIDELINES b) Consider medical or traumatic causes of behavior problems c) Keep environment calm ADVANCED CARE GUIDELINES d) For severe anxiety, consider VERSED 2.5 mg IV or IM or 2.5mg to 5mg IM max of 10mg e) For excited delirium, consider administering haloperidol 1-5 mg IM/IV max of 10mg. 45

Burns 1. Follow Initial Patient Care Protocol Thermal Burns BASIC CARE GUIDELINES a) Initially stop the burning process with water or saline b) Perform primary survey with attention to airway and ventilation c) Estimate percent of body surface area injured and depth of injury d) If wound is less than 10 % Body Surface Area, cool down burn with Normal Saline e) Remove smoldering clothing and jewelry and expose area f) Continually monitor the airway for evidence of obstruction g) Cover the burned area with plastic wrap or a dry sterile dressing h) Do not break blisters i) Do not use any type of ointment, lotion, or antiseptic j) Keep patient warm ADVANCED CARE GUIDELINES k) Establish an IV of NS. Using the Parkland Burn Formula: 1. 4 ml x total body surface area sustaining 2nd/3rd/4th degree burns x person's weight in kilograms. 2. Infuse half of this volume over the first 8 hours from the time of the burn, with the remainder infused over the following 16 hrs. 3. Quick Calculation for the first hour: Patient's weight in kilograms x 20 ml= volume for the first hours. The total volume can be calculated when there is time l) Follow Pain Control protocol m) Transport to the most appropriate medical facility Chemical Burns BASIC CARE GUIDELINES a) Brush off powders prior to flushing. Lint roller may also be used to remove powders prior to flushing b) Immediately begin to flush with large amounts of water c) Continue flushing the contaminated area when en route to the receiving facility d) Do not contaminate uninjured areas while flushing e) Attempt to identify contaminant f) Transport to the most appropriate medical facility g) Estimate percent of body surface area injured and estimate the depth of burn as superficial, partial thickness or full thickness 46