Allergic Reactions

Refer to Handtevy™ for pediatric dosing.

• Mild Symptoms (skin only):
  • Administer Diphenhydramine 50 mg IV/IM over 2 minutes.
• Moderate/Severe Symptoms (2 or more body systems, airway involvement, hypotension):
  • Administer Epinephrine 1:1,000 0.3 mL IM in the mid anterolateral thigh. May repeat once in 5 minutes PRN.
  • Administer Diphenhydramine 50 mg IV/IO/IM over 2 minutes.
  • Administer Methylprednisolone 40 mg IV/IO/IM.
  • Administer Albuterol 5 mg nebulized. Repeat at 2.5 mg up to 3 times as needed.
• Refractory Anaphylaxis (refractory to above or for peri-arrest state):
  • Administer push-dose Epinephrine 1:100,000 1 mL IV/IO every minute (10 mcg/min), max dose 30 mL.

Diabetic Emergencies

Refer to Handtevy™ for pediatric dosing.

• Hypoglycemia (blood glucose < 70 mg/dL):
  • Administer D10W 100 mL IV bolus. Recheck blood glucose and repeat up to 3 boluses at 50 mL increments (total 250 mL).
  • If IV access unobtainable, administer Glucagon 1 mg IM/IN.
• Hyperglycemia (blood glucose > 300 mg/dL with dehydration, vomiting, abdominal pain, DKA):
  • Administer NS 500 mL bolus. May repeat once.

Suspected Opiate Toxicity

Refer to Handtevy™ for pediatric dosing.

• Treatment:
  • Administer Naloxone 0.5 mg IV/IM/IO/IN. Repeat every 2 minutes to achieve desired effect (max dose 6 mg).
• Desired Effect:
  • Patent airway with spontaneous RR ≥ 10 bpm.
  • SpO2 ≥ 94% (with or without supplemental O2).
  • ETCO2 < 45 mmHg.
• Special Considerations:
  • Document if law enforcement or other entities administered Naloxone prior to EMS arrival.
  • Contact EMS Operations Captain for OLMC if patient refuses transport after receiving Naloxone.

Naloxone Leave-Behind

• Consider Leave-Behind Kit:
  • If patient refuses transport after suspected opiate overdose reversal.
  • If responsible family member/friend is present who agrees to call 911 in overdose emergency.
• Distribution:
  • Educate individual receiving the kit on its contents.
  • Document distribution in ePCR under medications.

Hyperkalemia

Refer to Handtevy™ for pediatric dosing.

• Suspect Hyperkalemia:
  • History of acute or chronic renal failure and/or on dialysis.
  • EKG abnormalities: peaked T-waves, new onset heart blocks, wide QRS, sine wave, regular really-wide complex tachycardia.
• Treatment:
  • Administer Calcium Chloride 1 g IV/IO. Flush line thoroughly after administration.
  • Administer Albuterol 2.5 mg via nebulizer. Continuous treatment for total dose of 15 mg.

Seizures

Refer to Handtevy™ for pediatric dosing.

• Protect Patient: Prevent injury during seizure activity.
• Witnessed Seizure Onset:
  • Administer Midazolam 2.5 mg IV/IM/IN bolus. Repeat every 5 minutes until seizure resolves (max 4 doses).
• Unwitnessed Seizure Onset (still seizing on arrival) OR Repeated Convulsive Seizures w/o Regaining Consciousness:
  • Administer Midazolam 10 mg IM once.
  • Contact EMS Operations Captain for OLMC if seizure activity persists.
• Additional Care:
  • Initiate cooling measures if febrile.
  • Measure blood glucose in all patients with seizure or altered LOC.

Drowning

Refer to Handtevy™ for pediatric dosing.

• Initial Assessment:
  • Remove patient from water.
  • Apply spinal motion restriction if indicated.
  • Consider hypothermia. Remove wet clothing and keep warm with blankets.
• Treatment:
  • For cardiac arrest, proceed to appropriate protocol in Section 2.
  • Insert nasogastric tube for abdominal distention.
  • If wheezing/bronchospasm, treat per Respiratory Distress Protocol 4.6.
  • If pulmonary edema or rales are present and SpO2 < 94%, use CPAP per Airway Management Protocol 1.4.
  • Contact EMS Operations Captain for OLMC for patients refusing treatment/transport with symptoms beyond a cough (e.g., rales, hypoxia, foam in airway, hypotension).
• Transport:
  • Patients > 15 years with ROSC: Transport to local Resource Hospital.
  • Patients ≤ 15 years with ROSC: Transport to ACH or TGH by helicopter if possible, or ground transport to closest Resource Hospital.

Obstetrical

• Obtain Obstetrical History:
  • Number of pregnancies and deliveries.
  • Miscarriages.
  • Duration of current pregnancy.
  • Ruptured membranes, contractions.
  • Known complications of pregnancy.
• Management of Normal Delivery:
  • Support baby’s head over perineum with gentle pressure.
  • Tear amniotic sac if covering head after it emerges.
  • Guide head down to allow delivery of anterior shoulder.
  • Deliver other shoulder by gentle upward traction.
  • Deliver remainder of infant slowly.
  • Clamp cord after 1-3 minutes, 6 inches from infant’s abdomen.
  • Cut cord between clamps.
  • Record APGAR scores at 1 and 5 minutes.
  • Suction only if airway obstruction or positive pressure ventilation required.
  • Dry and warm infant, wrap in towel, place on maternal chest.
  • Allow placenta to deliver spontaneously.
  • Keep infant warm and transport per Policy 004 – Hospital Destination.
• Umbilical Cord Around Neck:
  • Unwrap or slip cord from neck if possible.
  • If unable to free cord, clamp with two clamps and cut between them.
• Shoulder Dystocia:
  • Hyperflex mother’s hips to severe supine knee-chest position.
  • Apply firm suprapubic pressure to dislodge shoulder.
  • Apply high-flow oxygen to mother.
  • Contact receiving hospital.
  • Transport ASAP.
  • Contact EMS Operations Captain for OLMC as needed.
• Prolapsed Umbilical Cord:
  • Gently lift head/body off cord. Assess for pulsations in cord.
  • Place mother in knee-chest position.
  • Apply high-flow oxygen to mother.
  • Contact receiving hospital.
  • Transport ASAP.
• Breech Birth:
  • Allow buttocks and trunk to deliver spontaneously, then support body while head is delivered.
  • If head fails to deliver, create open airway with gloved hand.
  • Apply high-flow oxygen to mother.
  • Transport immediately if arm or leg presents through vagina.
  • Contact receiving hospital.
  • Assess for prolapsed cord.
• Excessive Bleeding:
  • Treat for shock: NS 1 L IV/IO to maintain SBP > 90 mmHg (repeat once, max 2 L).
  • Contact EMS Operations Captain for OLMC if hypotension persists.
  • Loosely place trauma pads over vagina to stop flow. DO NOT pack the vagina.
  • Contact receiving hospital.
  • Transport ASAP.

Hyperactive Delirium with Severe Agitation

Refer to Handtevy™ for pediatric dosing.

• Safety: Ensure physical safety of patient, others, and EMS crew.
• Inclusion Criteria:
  • Danger to self or others.
  • Lack of decisional capacity and uncooperative, agitated, violent.
• Assessment:
  • Ensure behavior is not due to underlying metabolic disorder (hypoglycemia, hypoxia).
• Treatment:
  • Administer Midazolam 5 mg IM/IN or 2.5 mg IV AND Haloperidol 5 mg IM.
  • If additional sedation is required, contact EMS Operations Captain for OLMC.
• Special Considerations:
  • Continuous EKG, SpO2, and ETCO2 monitoring for patients with physical or chemical restraints.
  • Never restrain or transport patient in prone position.
  • Remove restraints when safe.
  • Request law enforcement assistance as needed.
  • If symptoms believed to be anxiety only, contact EMS Operations Captain for OLMC.

Pain Management

Refer to Handtevy™ for pediatric dosing.

• Monitoring:
  • Continuous SpO2 and ETCO2 monitoring.
  • Document at least 3 sets of vitals and pain level.
• Moderate/Severe Pain:
  • Hydromorphone: 1 mg IV/IM/IO every 10 minutes as needed (max 3 doses). Contact EMS Operations Captain for OLMC if more pain control required.
  • OR Fentanyl:
    • Large frame: 100 mcg IV/IO/IM.
    • Medium frame: 75 mcg IV/IO/IM.
    • Small frame: 50 mcg IV/IO/IM
  • Repeat every 10 minutes as needed, titrating to pain relief (max 3 doses). Contact EMS Operations Captain for OLMC if more pain control required.
• Alternative
• If IV/IO not feasible, administer Hydromorphone 2 mg IM/IN every 10 minutes as needed (max 3 doses). Contact EMS Operations Captain for OLMC if more pain control required.
• Avoid Hydromorphone or Fentanyl in patients with respiratory
• If patient is unresponsive or cannot follow commands, contact EMS Operations Captain for OLMC before pain medications.

Sepsis

• Criteria: Infection + ≥2:
  • Temp >100.4°F – <96.8°F,
  • RR >20
  • HR >90
  • SBP <90
  • ETCO2 <25.
• Treatment:
  • NS 500 mL bolus; repeat as needed.
  • Push-dose epinephrine for refractory hypotension.