Airway Management

Oxygenation: Use nasal cannula (1-6 LPM), NRB mask, or CPAP. Maintain SpO2 ≥ 94%.

• Stable Criteria: Adequate respiratory rate and effort, SpO2 ≥ 94%, no significant distress.
• Unstable Criteria: SpO2 < 90%, altered mental status, cyanosis, significant respiratory distress, or failure.
• CPAP: Start at 10 cm H₂O and adjust for tolerance. Avoid in active vomiting, SBP < 90, or pneumothorax.
• Intubation:
  • Pre-oxygenate with 100% O2 via NRB.
  • Initiate apneic oxygenation (15 LPM via NC).
  • Sedate (Etomidate or Ketamine).
  • Paralyze (Succinylcholine).
  • Confirm placement with ETCO2 and auscultation.
  • Post-intubation: Sedate with Midazolam and consider analgesia (Fentanyl or Dilaudid).
• Challenging Airway: Consider bougie, suctioning, and i-gel® if unable to intubate.

Cardiopulmonary Resuscitation (CPR)

• Scene Safety: Ensure scene safety before approaching the patient.
• Compressions: 100-120/min. Minimize interruptions; ventilate at 10 breaths/min.
• Stable vs. Unstable: Not applicable – cardiac arrest always requires immediate CPR.
• Drugs: Epinephrine for non-shockable rhythms every 4 minutes (max 3 doses).
• Reversible Causes: Treat hypoxia, tension pneumothorax, hypoglycemia, and other H’s/T’s.
• Pediatrics: Compression-to-ventilation ratio: 30:2 (1 rescuer) or 15:2 (2 rescuers).

Ventricular Fibrillation / Pulseless V-Tach (VF/pVT)

• Scene Safety: Ensure scene safety before approaching the patient.
• Stable Criteria: Not applicable – VF/pVT is always considered unstable.
• Unstable Criteria: Absence of pulse, unresponsive, apneic.
• Defibrillation:
  • Immediately defibrillate at 200 J.
  • Perform 2 minutes of CPR, then reassess rhythm and defibrillate at 300 J if VF/pVT persists.
  • Defibrillate at 360 J after subsequent cycles of CPR if no ROSC.
• Drug Administration:
  • Epinephrine: 1 mg IV/IO after the second defibrillation. Repeat every 4 minutes (total 3 doses).
  • Amiodarone:
    • 300 mg IV/IO after the third defibrillation.
    • 150 mg IV/IO after the fifth defibrillation if VF/pVT persists.
  • Esmolol (Refractory VF/pVT):
    • Administer Esmolol 40 mg IV/IO bolus if VF/pVT persists after three doses of epinephrine and defibrillation.
    • Follow with Esmolol infusion: 60 mg IV/IO over 10 minutes (mix in 100 mL NS, administer at 1.5–2 drops/sec on 10-drop set).
    • Monitor for bradycardia or hypotension; discontinue if both occur.
• Pediatric: Follow Handtevy™ guidelines for age-appropriate dosing.
• Special Considerations: Use dual sequential defibrillation for refractory VF/pVT if a second defibrillator is available.

Asystole / Pulseless Electrical Activity (PEA)

• Scene Safety: Ensure scene safety before approaching the patient.
• Stable Criteria: Not applicable – Asystole/PEA is always unstable.
• Unstable Criteria: No pulse, unresponsive.
• CPR: Start immediately; avoid interruptions.
• Drug Administration:
  • Epinephrine: 1 mg IV/IO as soon as possible. Repeat every 4 minutes (maximum of 3 doses).
• Reversible Causes:
  • Hypoxia: Ensure airway and oxygenation.
  • Hypovolemia: Administer fluids (500 mL bolus of NS).
  • Consider other H’s and T’s (e.g., tension pneumothorax, tamponade).
• Pediatric: Compression-to-ventilation ratio: 30:2 (1 rescuer) or 15:2 (2 rescuers). Use Handtevy™ for drug doses.

Symptomatic Bradycardia

• Scene Safety: Ensure scene safety before approaching the patient.
• Stable Criteria: HR ≥ 50 bpm, adequate perfusion, no significant symptoms (e.g., dizziness, hypotension).
• Unstable Criteria: HR < 50 bpm with hypotension, chest pain, altered mental status, or signs of shock.
• Drug Administration:
  • Atropine: 1 mg IV/IO every 4 minutes as needed (maximum dose: 3 mg).
  • Epinephrine (Push-Dose):
    • 1 mL of 1:100,000 every minute (10 mcg/min) for persistent symptoms after atropine or pacing.
    • Maximum dose: 30 mL (300 mcg).
• Unstable Treatment:
  • Initiate pacing for Mobitz II or 3rd-degree block.
  • Sedate with Midazolam 2.5 mg IV/IO as needed for discomfort (maximum: 10 mg).
• Pediatrics: Use Epinephrine or Atropine and initiate pacing if severe compromise persists. Refer to Handtevy™ for doses.

Wide Complex Tachycardia

• Stable Criteria: No chest pain, normal mentation, SBP ≥ 90 mmHg, HR within normal range.
• Unstable Criteria: Altered mental status, hypotension (SBP < 90 mmHg), chest pain, or severe symptoms.
• Drug Administration:
  • Amiodarone: 150 mg IV/IO over 10 minutes for stable patients. May repeat once if needed.
  • Midazolam: 2.5 mg IV/IO as needed for sedation before cardioversion (max 10 mg).
• Unstable Treatment:
  • Synchronized Cardioversion: Start at 100 J, escalate to 200 J, 300 J, and 360 J as needed.
• Pediatric: Refer to Handtevy™ for age-appropriate dosing and energy selection.
• Special Considerations:
  • Consider and rule out hyperkalemia.

Paroxysmal Supraventricular Tachycardia (PSVT)

• Stable Criteria: HR ≤ 150 bpm, normal mentation, no significant symptoms, SBP ≥ 90 mmHg.
• Unstable Criteria: HR > 150 bpm with hypotension (SBP < 90 mmHg), chest pain, altered mental status, or shock.
• Drug Administration:
  • Adenosine: 6 mg rapid IV push, followed by 12 mg rapid IV push if needed.
  • Midazolam: 2.5 mg IV/IO as needed for sedation before cardioversion (max 10 mg).
• Stable Treatment:
  • Modified Valsalva Maneuver: Perform twice unless conversion to SR or development of instability.
• Unstable Treatment:
  • Synchronized Cardioversion: Start at 100 J, escalate to 200 J, 300 J, and 360 J as needed.
• Pediatric: Refer to Handtevy™ for age-appropriate dosing and energy selection.

Atrial Fibrillation / Atrial Flutter

• Scene Safety: Ensure scene safety before approaching the patient.
• Stable Criteria: HR < 150 bpm, no chest pain, SBP ≥ 90 mmHg, normal mentation.
• Unstable Criteria: HR ≥ 150 bpm with hypotension, altered mental status, chest pain, or signs of shock.
• Drug Administration:
  • Diltiazem:
    • 0.25 mg/kg IV over 2 minutes for stable patients with HR > 150 bpm.
    • If no improvement after 10 minutes, repeat at 0.35 mg/kg IV over 2 minutes.
• Unstable Treatment:
  • Fluids: 0.9% NS 500 mL bolus as needed.
  • Synchronized Cardioversion: Start at 100 J, escalate to 200 J, 300 J, and 360 J.
  • Sedation: Midazolam 2.5 mg IV/IO as needed for discomfort.

Acute Coronary Syndrome (ACS)

• Scene Safety: Ensure scene safety before approaching the patient.
• Stable Criteria: SBP ≥ 90 mmHg, no significant chest pain, adequate perfusion.
• Unstable Criteria: Chest pain, diaphoresis, dyspnea, hypotension, or altered mentation.
• Drug Administration:
  • Aspirin: 324 mg PO (chewed).
  • Nitroglycerin:
    • 0.4 mg SL every 5 minutes if SBP ≥ 90 mmHg.
    • Hold nitroglycerin if SBP < 90 mmHg or recent use of ED drugs (Viagra/Levitra within 24 hours, Cialis within 48 hours).
  • Fentanyl: 50-100 mcg IV/IO for pain unrelieved by nitroglycerin. Repeat every 10 minutes as needed, titrating to pain relief and SBP ≥ 90 mmHg.
• Special Considerations:
  • Obtain a 12-lead EKG as soon as possible (within 5 minutes).
  • Issue a STEMI Alert for confirmed ST elevation in ≥2 contiguous leads.
  • Rapid transport to a STEMI center; transmit EKG en route if equipped.

Congestive Heart Failure (Pulmonary Edema)

• Scene Safety: Ensure scene safety before approaching the patient.
• Stable Criteria: Mild respiratory distress, SBP ≥ 90 mmHg, adequate oxygenation (SpO2 ≥ 94%).
• Unstable Criteria: Severe respiratory distress, altered mental status, hypotension, or cyanosis.
• Drug Administration:
  • Nitroglycerin:
    • SBP 90-160 mmHg: 0.4 mg SL every 5 minutes.
    • SBP > 160 mmHg: 0.8 mg SL every 5 minutes.
  • Furosemide: 20-40 mg IV/IO for severe pulmonary edema and volume overload (per OLMC if needed).
• Treatment:
  • Apply CPAP for moderate-to-severe respiratory distress per Airway Protocol.
  • Monitor for hypotension after nitroglycerin and adjust as needed.
• Special Considerations: Avoid nitroglycerin if SBP < 90 mmHg or recent ED drug use.

Stroke

• Scene Safety: Ensure scene safety before approaching the patient.
• Stable Criteria: Mild or resolving symptoms, SBP ≥ 90 mmHg, SpO2 ≥ 94%.
• Unstable Criteria: Severe deficits (e.g., unilateral paralysis), altered mental status, airway compromise.
• Drug Administration:
  • Dextrose: Administer if BG < 70 mg/dL (D10W or D50W IV push).
• Treatment:
  • Use CPSS (Cincinnati Prehospital Stroke Scale) and RACE if CPSS is positive.
  • Document “Last Seen Normal” (LSN) time and place Stroke Alert Sticker.
  • Transport to an appropriate stroke center:
    • RACE ≥ 5: Comprehensive Stroke Center.
    • CPSS negative: Follow local transport policy.
• Special Considerations: Do not delay transport for postictal patients; do not issue Stroke Alert for postictal state.

Suspected Intracranial Hemorrhage (ICH) Alert

• Scene Safety: Ensure scene safety before approaching the patient.
• Criteria for ICH Alert:
  • Recent anticoagulant use (e.g., Coumadin, Eliquis, Xarelto).
  • New neurological symptoms (e.g., severe headache, vertigo, ataxia, or unresponsiveness).
• Stable Criteria: Alert and oriented, SBP ≥ 90 mmHg, mild symptoms.
• Unstable Criteria: Altered mental status, severe neurological symptoms, or signs of herniation (e.g., unilateral pupillary dilation).
• Treatment:
  • Elevate head of bed ≥ 45° unless contraindicated.
  • Manage BP per OLMC to prevent further hemorrhage.
  • Transport to an ICH Alert facility (e.g., Sarasota Memorial Main/Venice Campus).
  • Notify receiving facility via radio and document findings on the Stroke Alert Sticker.