Prehospital Care Manual online - Contra Costa Health Services

contra costa county emergency medical services agency 

2013 prehospital 

CARE MANUAL 

For updates throughout the year, visit www.cccems.org

instructions for use 

The Contra Costa Prehospital Care Manual contains both treatment guidelines 

and additional reference materials relevant to EMS care. 

Updates and corrections to this manual will be posted at www.cccems.org. 

• Treatment Guidelines are divided into four main groupings: Adult, General, 

Pediatric and Interfacility Transfer Guidelines. The General Guidelines include 

treatment guidelines that pertain to both adult and pediatric treatments. 

Treatment Guidelines A1 (Adult General Care) and P1 (Pediatric General 

Care) address basic concepts of care that are pertinent to all patients. 

This information is not repeated in other treatment guidelines. 

• More detailed information on performance of specific patient procedures is posted 

at www.cccems.org. 

• Policy summaries reflect critical information for field personnel. For full 

policies, please refer to www.cccems.org.

A1 — Adult Patient Care 

A2 — Chest Pain/Suspected ACS/STEMI 

A3 — Cardiac Arrest-Initial Care and CPR 

A4 — Ventricular Fibrillation/Ventricular Tachycardia 

A5 — PEA/Asystole 

A6 — Symptomatic Bradycardia 

A7 — Ventricular Tachycardia with Pulses 

A8 — Supraventricular Tachycardia 

A9 — Other Dysrhythmias 

A10 — Shock/Hypovolemia 

A11 — Post-Cardiac Arrest Care 

A12 — Public Safety Defibrillation 

Adult 

Treatment 

Guidelines

A1–ADULT ADULT PATIENT CARE 

These basic concepts should be addressed for all adult patients (age 15 and over) 

SCENE SAFETY 

BSI Use universal blood and body fluid precautions at all times 

SYSTEMATIC 

ASSESSMENT 

DETERMINE 

PRIMARY 

IMPRESSION 

BASE 

CONTACT 

TRANSPORT 

MONITORING 

• Assure open and adequate airway. Management of ABCs is a priority. 

• Place patient in position of comfort unless condition mandates other position (e.g. 

shock, coma) 

• Consider spinal immobilization if history or possibility of traumatic injury exists 

• Apply appropriate field treatment guideline(s) 

• Explain procedures to patient and family as appropriate 

• Contact base hospital if any questions arise concerning treatment or if additional 

medication beyond dosages listed in treatment guidelines are considered 

• Use SBAR to communicate with base 

• Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure 

• Transport patient medications or current list of patient medications to the hospital 

• Give report to receiving facility using SBAR 

• At a minimum, vital signs and level of consciousness should be re-assessed every 

15 minutes and should be assessed after every medication administration or 

following any major change in the patient’s condition 

• For critical patients, more frequent vital signs should be obtained when appropriate 

DOCUMENT Document patient assessment and care per policy

A2–ADULT 

CHEST PAIN 

SUSPECTED ACUTE CORONARY SYNDROME / STEMI 

OXYGEN 

CARDIAC MONITOR 

BLS: Low flow unless ALOC / respiratory distress / shock 

ALS: Titrate to sPO of at least 94% 

2 

ASPIRIN 

325 mg po to be chewed by patient – DO NOT administer if patient has allergies to 

aspirin or salicylates or has apparent active gastrointestinal bleeding 

12 – LEAD ECG Repeat ECGs are encouraged 

IV TKO 

If ECG Does Not Indicate Acute MI or STEMI 

NITROGLYCERIN 

CONSIDER 

FLUID BOLUS 

CONSIDER 

MORPHINE SULFATE 

0.4 mg sublingual or spray - May repeat every 5 minutes until pain subsides, 

maximum 3 doses. Contact base hospital if further dosages indicated. IV placement 

prior to NTG recommended for patients who have not taken NTG previously. 

PRECAUTIONS: Do not administer NTG if: 

Blood pressure below 90 systolic; 

Heart rate below 50; 

Patient has recently taken erectile dysfunction (ED) drugs: 

Viagra, Levitra, Staxyn or Stendra within 24 hours, Cialis within 36 hours 

500 ml NS if BP less than 90, lungs clear and unresponsive to supine positioning 

with legs elevated. May repeat X 1. 

2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90 and NTG not 

effective. Consider earlier administration to patients in severe distress from pain. 

Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort.

Acute MI / STEMI Noted by 12-Lead ECG 

Do not administer Nitroglycerin if Acute MI / STEMI noted on 12-lead ECG. 

Exception: Patients with suspected pulmonary edema and STEMI should 

NITROGLYCERIN 

receive nitroglycerin if no other contraindications (e.g. hypotension, bradycardia 

or use of erectile dysfunction drugs) 

Transmit ECG to STEMI Center and contact as soon as possible to notify facility 

STEMI ALERT 

of transport. Enter patient identifiers prior to transmission. 

EARLY TRANSPORT Minimize scene time 

500 ml NS for Inferior MI (elevation in leads II, III, aVF) if lungs clear (regardless 

of blood pressure) 

FLUID BOLUS 

500 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May 

repeat up to X 3. 

2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90. 

CONSIDER 

Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. 

MORPHINE 

SULFATE 

Caution: If Inferior MI suspected, use 1-2 mg increments and observe 

carefully for hypotension 

Key Treatment Considerations 

• Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm, 

nausea, diaphoresis, dyspnea (shortness of breath), anxiety 

• Diabetic, female or elderly patients more frequently present atypically 

• Atypical symptoms can include syncope, weakness or sudden onset fatigue 

• Many STEMI’s evolve during prehospital period and are not noted on initial 12-lead ECG 

• ECG should be obtained prior to treatment for bradycardia if condition permits 

• Transmit all 12-lead ECGs - whether STEMI is detected or not detected

A3–ADULT CARDIAC ARREST – INITIAL CARE AND CPR 

ESTABLISH 

• First agency on scene assumes leadership role 

TEAM LEADER • Leadership role can be transferred as additional personnel arrive 

CONFIRM ARREST • Unresponsive, no breathing or agonal respirations, no pulse 

Begin Compressions: 

• Rate – at least 100/minute 

• Depth - 2 inches in adults – allow full recoil of chest (lift heel of hand) 

• Rotate compressors every 2 minutes if manual compression used 

Minimize interruptions. If necessary to interrupt, limit to 10 seconds or less. 

COMPRESSIONS • Perform CPR during charging of defibrillator 

• Resume CPR immediately after shock (do not stop for pulse or rhythm check) 

Prepare mechanical compression device (if available) 

• Apply with minimal interruption 

• Should be placed following completion of at least one 2-minute manual CPR 

cycle or at end of subsequent cycle 

AED OR MONITOR/ 

DEFIBRILLATOR 

• 

• 

• 

Apply pads while compressions in progress 

Determine rhythm and shock, if indicated 

Follow specific treatment guideline based on rhythm 

• Open airway and provide 2 breaths after every 30 compressions 

BASIC AIRWAY • Avoid excessive ventilation – no more than 8 – 10 ventilations per minute 

MANAGEMENT • Ventilations should be about 1 second each, enough to cause visible chest rise 

AND 

• Use two-person BLS Airway management (one holding mask and one squeezing 

VENTILATION 

bag) 

• If available, use ResQPOD with two-person BLS airway management

IV / IO ACCESS 

ADVANCED AIRWAY 

TREATMENT 

ON SCENE 

• IO access is preferred unless no suitable site is available 

• If IV used (no IO access), antecubital vein is preferred 

• Hand veins and other smaller veins should not be used in cardiac arrest 

• Placement of advanced airway is not a priority during the first 5 minutes of 

resuscitation unless no ventilation is occurring with basic maneuvers 

o Exception: If ResQPOD used, early use of King Airway is appropriate 

• Placement of King Airway or endotracheal tube should not interrupt 

compressions for more than 10 seconds 

• For endotracheal intubation, position and visualize airway prior to cessation 

of CPR for tube passage. Immediately resume compressions after tube 

passage. 

• Confirm tube placement and provide on-going monitoring using end-tidal 

carbon dioxide monitoring 

• Movement of a patient may interrupt CPR or prevent adequate depth and 

rate of compressions, which may be detrimental to patient outcome 

• Provide resuscitative efforts on scene up to 30 minutes to maximize chances 

of return of spontaneous circulation (ROSC) 

• If resuscitation does not attain ROSC, consider cessation of efforts per policy

A4–ADULT 

VENTRICULAR FIBRILLATION 

PULSELESS VENTRICULAR TACHYCARDIA 

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3) 

DEFIBRILLATION 200 joules (low energy 120 joules) 

CPR For 2 minutes or 5 cycles between rhythm check 

VENTILATION/AIRWAY 

• BLS airway is preferred method during first 5 -6 minutes of CPR 

• If no ventilation occurring with basic maneuvers, proceed to advanced airway 

IO OR IV TKO. Should not delay shock or interrupt CPR 


EPINEPHRINE 1:10,000 - 1 mg IV or IO every 3-5 minutes 


AMIODARONE 300 mg IV or IO 

DEFIBRILLATION 360 joules (low energy 200 joules) as indicated after every CPR cycle 


• 

• 

Should not interfere with initial 5-6 minutes of CPR – minimize interruptions 

Do not interrupt compressions more than 10 seconds to obtain airway 

CONSIDER REPEAT 

AMIODARONE 

If rhythm persists, 150 mg IV or IO, 3-5 minutes after initial dose 

TRANSPORT If indicated 

CONSIDER SODIUM 

BICARBONATE 

1 mEq/kg IV or IO for suspected hyperkalemia or pre-existing acidosis 

If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)


• Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance 

takes precedence over advanced airway management and administration of medications. 

• To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock 

administered (no pulse or rhythm check) 

• Rotate compressors every 2 minutes 

• Avoid excessive ventilation. Provide no more than 8-10 ventilations per minute. 

• Ventilations should be about one second each, enough to cause visible chest rise 

• If advanced airway placed, perform CPR continuously without pauses for ventilation 

• If available, ResQPOD impedance threshold device may be used with BLS airway or King / ET tube 

• If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and 

performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR 

after passage. 

• Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide 

measurement. Continuous monitoring with ETCO2 is mandatory – if values less than 10 mm Hg seen, 

assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earliest 

indicator of return of circulation. 

• Prepare drugs before rhythm check and administer during CPR 

• Follow each drug with 20 ml NS flush

A5–ADULT PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE 

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (A3) 

EPINEPHRINE 1:10,000 1 mg IV or IO every 3-5 minutes 

Consider treatable causes – treat if applicable: 

CONSIDER 

FLUID BOLUS 

For hypovolemia: 500-1000 ml NS IV or IO 

VENTILATION For hypoxia: Ensure adequate ventilation (8-10 breaths per minute) 

CONSIDER SODIUM 

BICARBONATE 

CONSIDER CALCIUM 

CHLORIDE 

CONSIDER 

For pre-existing acidosis (e.g. kidney failure), hyperkalemia, or tricyclic 

antidepressant overdose are suspected: 

• 1 mEq/kg IV or IO if indicated 

• Should not be used routinely in cardiac arrest 

For hyperkalemia or calcium channel blocker overdose: 

• 500 mg IV or IO – may repeat in 5-10 minutes 

• Should not be used routinely in cardiac arrest 

WARMING MEASURES 

For hypothermia 

CONSIDER NEEDLE 

THORACOSTOMY 

For tension pneumothorax 

If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11)

CONSIDER 

TERMINATION OF 

RESUSCITATION 

Patients who have all of the following criteria are highly unlikely to survive: 

• Unwitnessed Arrest and 

• No bystander CPR and 

• No shockable rhythm seen and no shocks delivered during resuscitation and 

• No return of spontaneous circulation (ROSC) during resuscitation 

Patients with asystole or PEA whose arrests are witnessed and/or who have 

had bystander CPR administered have a slightly higher likelihood of survival. 

If unresponsive to interventions these patients should be considered for 

termination of resuscitation. 


• Atropine is no longer used in cardiac arrest 

• Pre-existing acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or 

if suspected diabetic ketoacidosis 

• In clear-cut traumatic arrest situations, epinephrine is not indicated in PEA or asystole. If any doubt 

as to cause of arrest, treat as a non-traumatic arrest (e.g. solo motor vehicle accident at low speed in 

older patients).

A6–ADULT SYMPTOMATIC BRADYCARDIA 

Heart rate less than 50 with signs or symptoms of poor perfusion (e.g., acute altered mental status, 

hypotension, other signs of shock). Correction of hypoxia should be addressed prior to other 

treatments. 

OXYGEN 


BLS: High flow initially 


2 

IV 

TKO. If not promptly available, proceed to external cardiac pacing. Consider IO 

ACCESS if patient in extremis and unconscious or not responsive to painful stimuli. 

CONSIDER 

FLUID BOLUS 

250-500 ml NS if clear lung sounds and no respiratory distress 

12-LEAD ECG Consider pre- and post-treatment if condition permits 

TRANSCUTANEOUS Set rate at 80 

PACING 

Start at 10 mA, and increase in 10 mA increments until capture is achieved 

If pacing urgently needed, sedate after pacing initiated 

CONSIDER 

• MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg increments 

SEDATION 

(maximum dose 5 mg), and/or 

• MORPHINE SULFATE 1-5 mg IV or IO in 1 mg increments for pain relief if BP 

90 systolic or greater 

May be used as a temporary measure while awaiting transcutaneous pacing but 

should not delay onset of pacing 

CONSIDER 

• 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective 

ATROPINE 

• Consider repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3 mg 

Use with caution in patients with suspected ongoing cardiac ischemia 

Atropine should not be used in wide-QRS second- and third-degree blocks 

TRANSPORT


• Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor / observe) 

• Fluid bolus may address hypotension and lessen need for pacing or treatment with atropine 

• Sedation prior to starting pacing is not required. Patients with urgent need should be paced first. 

• The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness. 

Patients who are in need of pacing are unstable and sedation should be done with great caution 

• Monitor respiratory status closely and support ventilation as needed 

• Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in 

these patients) 

• Patients with wide-QRS second- and third-degree blocks will not have a response to atropine because 

these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur.

A7–ADULT VENTRICULAR TACHYCARDIA WITH PULSES 

Widened QRS Complex (greater than or equal to 0.12 sec) – generally regular rhythm 

INITIAL THERAPY 


OXYGEN 


2 


12-lead ECG pre-and post-treatment may be useful for comparisons at hospital. 

12-LEAD ECG The computerized rhythm analysis on 12-lead printout should not be used for 

determination of rhythm. 

IV TKO 

STABLE VENTRICULAR TACHYCARDIA 

AMIODARONE 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min) 

CONSIDER REPEAT 

AMIODARONE 

If rhythm persists and patient remains stable, 150 mg IV over 10 minutes 

UNSTABLE VENTRICULAR TACHYCARDIA 

Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF 

CONSIDER 

SEDATION 

SYNCHRONIZED 

CARDIOVERSION 

Prepare for CARDIOVERSION: If awake and aware, sedate with 

MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) 

100 joules (low energy setting – 75 W/S) 




If VT recurs, use lowest energy level previously successful


• Document rhythm during treatment with continuous strip recording 

• Rhythm analysis should be based on recorded strip, not monitor screen 

• Be prepared for previously stable patient to become unstable 

• Give AMIODARONE via Infusion or slow IV push only 

• Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly. 

• AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should 

be considered unstable and should not receive AMIODARONE. 

• If sedation done for cardioversion, monitor respiratory status closely and support ventilations as 

needed

A8–ADULT SUPRAVENTRICULAR TACHYCARDIA 

Heart rate greater than 150 beats per minute – regular rhythm usually with narrow QRS complex 



OXYGEN 


2 


12-lead ECG pre-and post-treatment may be useful for comparisons at hospital. 

12-LEAD ECG The computerized rhythm analysis on 12-lead printout should not be used for 

determination of rhythm. 

IV TKO – Antecubital IV needed for rapid medication administration 

STABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) 

May have mild chest discomfort 

VALSALVA 

CONSIDER 

ADENOSINE 

6 mg rapid IV - followed by 20 ml normal saline flush 

If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml 

normal saline flush

UNSTABLE SVT 

• May need immediate synchronized cardioversion 

• Signs of poor perfusion include moderate to severe chest pain, dyspnea, altered mental status, 

blood pressure less than 90 or CHF 

• If rhythm not regular, SVT unlikely 

• If wide QRS complex, consider ventricular tachycardia 

CONSIDER 

ADENOSINE 

CONSIDER 

SEDATION 

SYNCHRONIZED 

CARDIOVERSION 

6 mg rapid IV - followed by 20 ml normal saline flush 

If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml 

normal saline flush 

Prepare for CARDIOVERSION. If awake and aware, sedate with 







• Document rhythm during treatment with continuous strip recording 

• Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen or 

computerized readout of 12-lead ECG 

• Be prepared for previously stable patient to become unstable 

• Proceed to cardioversion if patient becomes unstable 

• Hypoxemia is a common cause of tachycardia. Focus on determining if oxygenation is adequate. 

• Adenosine should not be administered to patients with acute exacerbation of asthma 

• If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed

A9–ADULT OTHER CARDIAC DYSRHYTHMIAS 

SINUS TACHYCARDIA – Heart rate 100-160, regular 

ATRIAL FIBRILLATION – Heart rate highly variable, irregular 

ATRIAL FLUTTER – Variable rate depending on block. Atrial rate 250-350, “saw-tooth” pattern. 



OXYGEN 


2 


CONSIDER 

12-LEAD ECG 

CONSIDER IV TKO 

12-lead ECG pre-and post-treatment may be useful for comparisons at hospital 

The computerized rhythm analysis on 12-lead printout should not be used for 

determination of rhythm 

UNSTABLE ATRIAL FIBRILLATION OR ATRIAL FLUTTER 

Ventricular rate greater than 150, and: 

BP less than 80, or unconsciousness / obtundation, or severe chest pain or severe dyspnea 

OXYGEN High flow. Be prepared to support ventilation. 

CONSIDER 

Prepare for CARDIOVERSION. If awake and aware, sedate with 

SEDATION 


Atrial Flutter: 

• Initial: 100 joules (low energy setting – 75 joules) 

SYNCHRONIZED • Subsequent: 200, 300, 360 joules (low energy settings 120, 150, 200 joules) 

CARDIOVERSION Atrial Fibrillation 

• Initial: 200 joules (low energy setting – 120 joules) 

• Subsequent: 300, 360 joules (low energy settings 150, 200 joules)


• Sinus tachycardia commonly present because of pain, fever, anemia, or hypovolemia 

• Atrial fibrillation may be well-tolerated with moderately rapid rates (150-170) and often requires no 

specific treatment other than observation (oxygen, monitoring and transport) 

• If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed 

• Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen 

or computerized readout of 12-lead ECG 

• Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI***, 

***Acute MI Suspected*** or ***Meets ST-Elevation MI Criteria*** message encountered, the patient’s 

heart rate is important information to relate to the STEMI center at time of activation.

A10–ADULT SHOCK / HYPOVOLEMIA 

HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with dry lungs, flat neck veins 

May have poor skin turgor, history of GI bleeding, vomiting or diarrhea, altered level of 

consciousness 

May be warm and flushed, febrile, may have respiratory distress 

Sepsis patients may or may not have an associated fever 

CARDIOGENIC SHOCK 

Signs/symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema 

HYPOVOLEMIA WITHOUT SHOCK 

No signs of shock, but history of poor fluid intake or fluid loss (e.g. vomiting, diarrhea). May have 

tachycardia, poor skin turgor. 

OXYGEN BLS/ALS: High flow. Be prepared to support ventilations as needed. 

CONSIDER CPAP If suspected pulmonary edema / cardiogenic shock 

ADDRESS 

Keep patient warm if suspected hypothermia 

HYPOTHERMIA 

CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline 

EARLY TRANSPORT CODE 3 

IV OR IO TKO only if suspected pulmonary edema 

• For hypovolemic or septic shock, 500 ml NS bolus. May repeat once. 

FLUID BOLUS 

• For hypovolemia (poor intake/fluid loss), 250 ml NS bolus. May repeat X 1. 

Do not administer bolus if pulmonary edema or cardiogenic shock suspected

CONSIDER 

12-LEAD ECG 

If cardiac etiology for shock suspected 

Check temperature, use sepsis screening tool and advise hospital of positive 

sepsis screen if indicated 

A positive sepsis screen in adults occurs in the setting of suspected 

SEPSIS SCREEN 

infection when 2 of 3 conditions are met: 

• Heart rate/pulse greater than 100; 

• Respiratory rate greater than 20; 

• Temperature above 100.4 or below 96 

BLOOD GLUCOSE Check and treat if indicated 

Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12)

A11–ADULT POST-CARDIAC ARREST CARE 

Following resuscitation from cardiac arrest in adults 


OXYGEN 


2 

Be prepared to support ventilations as needed. Avoid excessive ventilation. 

END-TIDAL CO2 

MONITORING 

If intubated, monitor and maintain respirations to keep ETCO2 between 35 and 40 

CARDIAC 

MONITOR 

Treat dysrhythmias per specific treatment guideline 

12-LEAD ECG 

Evaluate for possible STEMI. Alert and transport to STEMI center if ECG indicates 

***ACUTE MI*** or equivalent STEMI message 

TRANSPORT CODE 3 

IV OR IO If not previously established 

FLUID BOLUS For BP less than 90 systolic, begin infusion up to 1 liter NS 

BLOOD GLUCOSE Treat if indicated 

CONSIDER 

THERAPEUTIC 

HYPOTHERMIA 

See Indications and contraindications below. 

Expose patient and apply eight (8) ice packs 

• 2 on head, 2 on the neck over the carotid arteries, 1 on each axilla, 1 over each 

femoral artery 

Discontinue ice packs if shivering occurs or increasing level of consciousness 

Advise Emergency Department that hypothermia has been initiated

THERAPEUTIC HYPOTHERMIA – INDICATIONS AND CONTRAINDICATIONS 

All the following must be present: 

• Must be age 18 or greater 

• Return of spontaneous circulation for at least five minutes 

• GCS < 8 

INDICATIONS 

• Unresponsive without purposeful movements. Brainstem reflexes and 

posturing movements may be present 

• Blood pressure 90 systolic or greater 

• Pulse oximetry – 85% or greater 

• Blood glucose – 50 or greater 

• Traumatic cardiac arrest 

• Responsive post-arrest with GCS 8 or greater or rapidly improving GCS 

CONTRAINDICATIONS 

• 

• 

Pregnancy 

DNR or known terminal illness 

• Dialysis patient 

• Uncontrolled bleeding 

Consider and treat other potential causes of altered level of consciousness (e.g. hypoxia or hypoglycemia)

A12–ADULT 

PUBLIC SAFETY DEFIBRILLATION 

BLS / LAW ENFORCEMENT 

SCENE SAFETY / BSI Use universal blood and body fluid precautions at all times 

CONFIRM Unconscious, pulseless patient with no breathing or no normal breathing 

COMPRESSIONS 

AUTOMATED 

EXTERNAL 

DEFIBRILLATOR 

(AED) 

• Begin compressions at a rate of at least 100 per minute 

• Compress chest at least 2 inches and allow full recoil of chest (lift heel of hand) 

• Change compressors every 2 minutes 

• Minimize interruptions in compressions. If necessary to interrupt, limit to 10 seconds 

or less. 

• Stop compressions for analysis only – resume compressions while AED is charging 

• Resume compressions immediately after any shock 

• If available, place mechanical compression device after first rhythm analysis or after 

subsequent rhythm analysis (LUCAS or Auto-Pulse) 

• Priority of second rescuer is to apply pads while compressions are in progress 

• If less than 8 years of age, attach pediatric electrodes, if available. If not, attach adult 

electrodes with anterior-posterior placement (pads should not touch). 

• (*) Allow AED to analyze heart rhythm 

o If the rhythm is shockable 

Resume compressions until charging of unit is complete 

Clear bystanders and crew (stop compressions) 

Deliver shock 

Resume CPR for 2 minutes, beginning with chest compressions – then return to (*) 

o If the rhythm is NOT shockable (“No Shock Advised”) 

Resume CPR for 2 minutes, beginning with chest compressions – then return to (*)

BASIC AIRWAY 

MANAGEMENT 

AND 

VENTILATION 

CHECK BLOOD 

PRESSURE 

DOCUMENTATION 

Open airway and provide 2 breaths after every 30 compressions 

• AVOID EXCESSIVE VENTILATION – Provide no more than 8 –10 ventilations per 

minute 

• Ventilations should be about one second each, enough to cause visible chest rise. 

Use two-person BLS Airway management (one holding mask and one squeezing 

bag – compressor can squeeze the bag) 

If patient begins to breathe or becomes responsive: 

• Maintain airway 

• Assist ventilations as necessary 

If patient begins to breathe or becomes responsive: 

• Check blood pressure if equipment available 

• Complete AED Use Report 

• Forward report to EMS whenever an AED is used (whether shock administered or 

not)

G1 — Allergy and 

all patients 

G9 — Hypothermia 

Anaphylaxis 

G10 — Pain Management 

G2 — Altered Level of G11 — Poisoning/Overdose 

Consciousness G12 — Respiratory 

G3 — Behavioral 

Repression or Apnea 

Emergency 

G13 — Respiratory Distress 

G4 — Burns 

G14 — Seizure 

G5 — Childbirth 

G15 — Stroke 

G6 — Dystonic Reaction G16 — Trauma 

G7 — Envenomation G17 — Vomiting and Severe 

G8 — Heat Illness/ 

Hyperthermia 

General 

Treatment 

Guidelines 

Nausea

G1–GENERAL ANAPHYLAXIS / ALLERGY 

• Systemic reactions (anaphylaxis) include upper and lower respiratory tracts, gastrointestinal 

or vascular system. Symptoms include dyspnea, stridor, change in voice, wheezing, anxiety, 

tachycardia, tightness in chest, vomiting, diarrhea, abdominal pain, dizziness or hypotension 

• Skin and mucous membrane reactions (swelling of face, lip, tongue, palate), may be seen in either 

uncomplicated allergic reactions or in anaphylaxis 

OXYGEN 


ALS: Titrate to sPO 2 of at least 94% 

EPI-PEN 


May assist with administration of patient’s auto-injector 

If systemic reaction (anaphylaxis): 

EPINEPHRINE 1:1000 

IM 

• Adult – 0.3-0.5 mg IM (use 0.3 mg in elderly, small patients or mild symptoms) 

Pediatric – 0.01 mg/kg IM – maximum dose 0.3 mg 

May repeat in 15 minutes if systemic symptoms persist 

ALBUTEROL Adult and pediatric - 5 mg/6 ml saline via nebulizer – may repeat as needed 

IV TKO 

CONSIDER 

• Adult – wide-open NS if hypotensive. Recheck vitals after every 250 ml 

FLUID BOLUS 

Pediatric - 20 ml/kg NS bolus if hypotensive, may repeat X 2 

If skin or mucous membrane reactions (itching, hives or facial/oral swelling), consider: 

• Adult - 50 mg slow IV or IM 

DIPHENHYDRAMINE 

 

Consider 25 mg dose if patient has taken po diphenhydramine 

Pediatric – 1 mg/kg IV or IM – Maximum dose 50 mg 

Consider 0.5 mg/kg dose if patient has taken po diphenhydramine

If serious progression of symptoms after treatment with IM epinephrine: 

• Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis, 

severe respiratory distress or respiratory arrest 

CONSIDER IO If IV access not immediately available 

FLUID BOLUS 

CONSIDER 

EPINEPHRINE 

1:10,000 IV 

• Adult - wide open NS. Recheck vitals after every 250 ml 

Pediatric - 20 ml/kg NS bolus, may repeat X 2 

If patient not responsive to IM epinephrine treatment in 5-10 minutes: 

• Adult - titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg 

Use extreme caution with patients with cardiac history, angina, hypertension 

Pediatric-titrate in up to 0.1 mg doses slow IV or IO to a maximum of 

0.01 mg/kg 


• Epinephrine IM administered early is the cornerstone of treatment in anaphylaxis 

o Epinephrine is well tolerated in pediatric patients and healthy young adults 

o In patients with prior history of coronary artery disease (angina, MI, stent placement), use of 

epinephrine IM is still indicated if symptoms are moderate to severe. If symptoms mild, careful 

observation is prudent. Consider base contact if any questions 

• Diphenhydramine and albuterol are secondary considerations in anaphylaxis 

• Up to 20% of anaphylaxis patients may present without any skin findings (e.g. hives) 

• Gastrointestinal symptoms may predominate in some patients, especially with serious reactions to 

food 

• In pediatric patients, hypotension is late sign of shock 

Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose.

G2–GENERAL ALTERED LEVEL OF CONSCIOUSNESS 

Glasgow Coma Scale less than 15 – uncertain etiology. Consider AEIOU/TIPPS 

OXYGEN 

BLS: High flow initially. ALS: Titrate to sPO of at least 94%. 

2 

Be prepared to support ventilations as needed. 

Consider if known diabetic, conscious, able to sit upright, able to self-administer 

ORAL GLUCOSE • Adult - 30 g po 


Pediatric – 15-30 g po 

BLOOD GLUCOSE Check level 

EARLY TRANSPORT In patients with ALOC without low blood sugar 

IV TKO NS 

If glucose 60 or less: 

DEXTROSE 10% • Adult – DEXTROSE 10% 100 ml IV 

Pediatric – DEXTROSE 10% 0.5 g/kg IV (5 ml/kg) 

If unable to establish IV (at least 2 attempts or if unable to find suitable site): 

GLUCAGON 

• 

 

Adult – 1 mg IM 

Pediatric – 24 kg or more – 1 mg IM 

Pediatric – Less than 24 kg – 0.5 mg IM 

BLOOD GLUCOSE 

Recheck if symptoms not resolved. If GLUCAGON has been administered, change 

in glucose/mentation may require 15 minutes or more. 

DEXTROSE 10% Repeat additional DEXTROSE 10% 150 ml IV if glucose remains 60 or less. 

DEXTROSE 50% 

Administer DEXTROSE 50% 25 g IV if glucose remains 60 or less after full Dextrose 

10% dose given (250 ml) 

Related guideline: Respiratory Depression or Apnea (G12)


• Naloxone should not be given as treatment for altered level of consciousness in the absence of 

respiratory depression (respiratory depression = rate of less than 12 breaths per minute) 

• After treatment(s) for hypoglycemia, recheck glucose before considering repeat treatment. Mental 

status improvement may lag behind improved glucose levels (especially in elderly patients or 

prolonged hypoglycemia). Further treatment when glucose is 60 or above is not indicated. 

• Oral glucose is the preferred treatment when patient is able to take medication orally 

• Dextrose 10% is the preferred treatment when patient is unable to take oral medication 

• Glucagon should not be administered if patient able to take oral glucose and should be administered 

only if IV starts are unsuccessful or no suitable IV sites found. It may not be effective in patients with 

starvation, poor oral intake, alcoholism or alcohol intoxication. 

• Glucagon may take 10-15 minutes or longer to increase glucose level (peak effects in 45-60 minutes) 

Wait for 10-15 minutes for recheck glucose before considering additional treatment 

• For diabetics with insulin pumps, the amount of insulin administered by the pump is very small and 

should not impede treatment of hypoglycemia. Insulin pumps should not be discontinued because of 

the development of hypoglycemia. 

• The presence of the pump should be identified during patient report at the hospital. 

• Transport is highly recommended in patients with hypoglycemia as a result of oral diabetic 

medications and patients over 65 years of age (higher risk of recurrent hypoglycemia). 

• Transport is also highly recommended for any hypoglycemic patient who is not a diabetic (may occur 

with renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses 

and sulfa drugs or following bariatric surgery). 

• Consider transport earlier in patients with poor vascular access who are not responding to glucagon or 

have reasons listed above for possible impaired response to glucagon 

Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for D10 dose.

G3–GENERAL BEHAVIORAL EMERGENCY 

• A behavioral emergency is defined as combative or irrational behavior not caused by medical 

illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated 

states or other conditions 

• Combative or irrational behavior may be caused by psychiatric or other behavioral disorder 

• History of event and past history are important in patient evaluation 

• Past history of psychiatric condition does not eliminate need to assess for other illnesses 

SCENE SAFETY 

ASSESS PATIENT 

• Many patients merit a weapons search by law enforcement 

• Physical restraints may be needed if patient exhibits behavior that presents a 

danger to him/herself or others 

• Assess for evidence of hypoxia, hypoglycemia, trauma 

• Consider other medical causes for behavioral symptoms 

VITAL SIGNS Obtain vital signs as possible 

CONSIDER OXYGEN 



2 

CARDIAC MONITOR Place as possible / safe 

consider 

BLOOD GLUCOSE 

Obtain as possible / safe

CONSIDER 

CHEMICAL 

RESTRAINT 

MONITOR PATIENT 

BASE ORDER REQUIRED 

Despite verbal de-escalation and physical restraint, if adult patient (15 years or 

older) remains extremely combative and struggling against restraints, consider: 

• MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small 

patients (under 50 kg). 

• MIDAZOLAM 1-5 IV mg in 1 mg increments if IV established and patent 

Monitor closely for respiratory compromise. Assess and document mental status, 

vital signs, and extremity exams (if restrained) at least every 15 minutes. 

Related guidelines: Altered Level of Consciousness (G2), Trauma (G16) 


• Calming measures may be effective and may preclude need for restraint in some circumstances 

• Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if 

possible, but maintain contact with other personnel and ability to exit rapidly. 

• Avoid violating patient’s personal space, making direct eye contact or sudden movements. Frequent 

reassurance and calm demeanor of personnel are important. 

• Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position. 

• Assure adequate resources available to manage patient’s needs. Restraint may require up to five 

persons to safely control patient. 

• Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior 

• In pediatric patients, consider child’s developmental level when providing care 

• Sedation with Midazolam intended for adult patients only (age 15 and over) 

• Not all patients will respond to Midazolam. Repeat dosage is not recommended.

G4–GENERAL BURNS 

• Damage to the skin caused by contact with caustic material, electricity, or fire 

• Second or third degree burns involving 20% of the body surface area, or those associated with 

respiratory involvement are considered major burns 

SCENE SAFETY Move patient to safe area 

STOP BURNING 

PROCESS 

OXYGEN 

• Remove contact with agent, unless adhered to skin 

• Brush off chemical powders 

• Flush with water to stop burning process or to decontaminate 



BURN CARE 

Protect the burned area. Do not break blisters, cover with clean dressings or 

sheets. Remove restrictive clothing/jewelry if possible. 

ASSESS FOR INJURIES Assess for associated injuries if other trauma suspected 

CONSIDER IV OR IO TKO 

CONSIDER 

MORPHINE SULFATE IV 

CONSIDER 

MORPHINE SULFATE IM 

For pain relief in the absence of hypotension (systolic BP less than 90), 

significant other trauma, altered level of consciousness: 

• Adult – 2-20 mg IV or IO, titrated in 2 - 4 mg increments 

Pediatric – 0.05-0.1 mg/kg IV – See Pediatric Drug Chart 

If IV or IO access not available: 

• Adult – 5-20 mg IM 

Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart


• Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or 

edematous mucosa in mouth are clues) 

• Transport to closest receiving facility for advanced airway management if it cannot be done on scene 

in a timely manner. Do not wait for helicopter (air ambulance) if airway patency is a concern and care 

can be provided more rapidly at a receiving facility. 

• Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia. 

• Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section) 


G5–GENERAL CHILDBIRTH – ROUTINE OR COMPLICATED 

IMMINENT DELIVERY - Regular contractions, bloody show, low back pain, feels like bearing down, 

crowning 

PREPARE FOR 

DELIVERY 

Reassure mother, instruct during delivery 

CONSIDER IV TKO if time allows 

• As head is delivered, apply gentle pressure to prevent rapid delivery of the 

infant 

DELIVER INFANT • Gently suction baby’s mouth, then nose, keeping the head dependent 

• If cord is wrapped around neck and can’t be slipped over the infant’s head, 

double-clamp and cut between clamps 

CLAMP/CUT 

CORD 

WARMING 

MEASURES 

PLACENTA 

DELIVERY 

POST-DELIVERY 

OBSERVATION 

Immediately double-clamp cord 6-8 inches from baby and cut between clamps (if not 

done before delivery) 

Dry baby and keep warm, placing baby on mother’s abdomen or breast 

If placenta delivers, save it and bring to the hospital with mother and child 

DO NOT PULL ON UMBILICAL CORD TO DELIVER PLACENTA 

Observe mother and infant frequently for complications. To decrease post-partum 

hemorrhage, perform firm fundal massage, put baby to mother’s breast. 

TRANSPORT Prepare mother and infant for transport. Neonatal care or resuscitation as indicated.

COMPLICATED DELIVERY 

BREECH DELIVERY – Presentation of buttocks or feet 

OXYGEN BLS/ALS: High flow 

DELIVERY 

• Allow delivery to proceed passively until the baby’s waist appears 

• Rotate baby to face-down position (DO NOT PULL) 

• If the head does not readily deliver in 4-6 minutes, insert a gloved hand into the 

vagina to create an air passage for the infant 

TRANSPORT Early transport if available – notify receiving hospital as soon as possible 

PROLAPSED CORD - Cord presents first and is compressed, compromising infant circulation 

OXYGEN BLS/ALS: High flow 

MANAGE CORD 

POSITION 

PATIENT 

• Insert gloved hand into vagina and gently push presenting part off of the cord 

• Do not attempt to reposition the cord 

• Cover cord with saline soaked gauze 

Place mother in trendelenburg position with hips elevated 

TRANSPORT Early transport if available – notify receiving hospital as soon as possible

G6–GENERAL DYSTONIC REACTIONS 

History of ingestion of phenothiazine or related compounds, primarily anti-psychotic and antiemetic 

medications (for nausea/vomiting). Symptoms include restlessness, muscle spasms of the 

neck, jaw, and back, oculogyric crisis. 




IV TKO 


• 

 

Adult – 25-50 mg IV or 50 mg IM if unable to establish IV access 

Pediatric – 1 mg/kg IV or 1 mg/kg IM if unable to establish IV access 


Common drugs implicated in dystonic reactions include many anti-emetics and anti-psychotic medications 

• Prochlorperazine (Compazine) 

• Haloperidol (Haldol) 

• Metoclopromide (Reglan) 

• Phenergan (Promethazine) 

• Fluphenazine (Prolixin) 

• Chlorpromazine (Thorazine) 

• Many other antipsychotic and anti-depressant drugs 

Rarely benzodiazepine drugs have been implicated as a cause of dystonic reaction 


G7–GENERAL ENVENOMATIONS (Bites/Stings) 

SNAKE BITES 

• If the snake is positively identified as non-poisonous, treat with basic wound care 

INSECT STINGS 

• Symptoms of stings usually occur at the site of injury and have no specific treatment 

• Allergic reactions can be severe, and may cause anaphylactic shock 

CALM PATIENT With snake bite, keep patient still and calm 

ASSESS EXTREMITIES Remove rings, bracelets or other constricting items from affected extremity 

WOUND MANAGEMENT 

OXYGEN 

CONSIDER 



Snake bite: Splint extremity and keep at level of heart 

Insect Stings: Flick stinger off – do not squeeze stinger. Apply cold pack. 


ALS: Titrate to sPO 2 of at least 94%. Be prepared to support ventilation. 

Consider if patient potentially unstable 

Related guidelines: Shock/Hypovolemia (A10, P8), Allergy / Anaphylaxis (G1)

G8–GENERAL HEAT ILLNESS / HYPERTHERMIA 

HEAT EXHAUSTION 

• Presentation: Flu-like symptoms, cramps, normal mental status 

HEAT STROKE 

• Presentation: Altered level of consciousness, absence of sweating, tachycardia, and 

hypotension 

OXYGEN 



2 

• Move patient to cool environment 

COOLING MEASURES 

• 

• 

Promote cooling by fanning 

Remove clothing and splash / sponge with water 

• Place cold packs on neck, in axillary and inguinal areas 

IV TKO. Perform if heat stroke or marked symptoms with heat exhaustion 

CONSIDER 

FLUID BOLUS 

CONSIDER 

BLOOD GLUCOSE 

If hypotensive or suspected heat stroke: 

• Adult – 500 ml NS bolus May repeat X 1 

Pediatric – 20 ml/kg NS bolus. May repeat X 1 

Check level if altered level of consciousness, treat as indicated 

Related guidelines: Altered Level of Consciousness (G2), Seizure (G14)


• Seizures may occur with heat stroke – treat as per treatment guideline for seizure 

• Increasing symptoms merit more aggressive cooling measures. With mild symptoms of heat 

exhaustion, movement to cooler environment and fanning may suffice. 

• Conditions that may lead to or worsen hyperthermia include: 

o Psychiatric Disorders 

o Heart Disease 

o Diabetes 

o Alcohol 

o Medications 

o Fever 

o Fatigue 

o Obesity 

o Pre-existent dehydration 

o Extremes of age (Elderly and pediatric) 


G9–GENERAL HYPOTHERMIA 

MODERATE HYPOTHERMIA 

• Conscious and shivering but lethargic, skin pale and cold 

SEVERE HYPOTHERMIA 

• Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations 

• Severe hypothermia patients may appear dead. When in doubt, begin resuscitation. 

BLS: Low flow unless ALOC / respiratory distress / shock. 

OXYGEN 


2 

Use warm humidified oxygen if available 

SPINAL 

PRECAUTIONS 



CONSIDER 

For patients with possible trauma or submersion 

Gently move to sheltered area (warm environment) 

Minimize physical exertion or movement of the patient 

Cut away wet clothing and cover patient with warm, dry sheets or blankets 

EARLY TRANSPORT 

Do not delay transport if patient unconscious 

IV TKO 


CONSIDER 

NALOXONE 

CONSIDER 

If respiratory rate less than 12 and narcotic overdose suspected 

Only if unable to ventilate using BVM 


Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12)


• Avoidance of excess stimuli important in severe hypothermia as the heart is sensitive and 

interventions may induce arrhythmias. Needed interventions should be done as gently as possible. 

o Check for pulselessness for 30-45 seconds to avoid unnecessary chest compressions 

o Defer ACLS medications until patient warmed 

o If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, shock X 1 and defer 

further shocks 

• Patients with prolonged hypoglycemia often become hypothermic – blood glucose check essential 

• Patients with narcotic overdose may develop hypothermia

G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC) 

• Patients of all ages expressing verbal or behavioral indicators of pain shall have an appropriate 

assessment and management of pain 

• Morphine should be given in sufficient amount to manage pain but not necessarily to eliminate it 

CONSIDER 

OXYGEN 



IV TKO 

• Assess and document the intensity of the pain using the visual analog 

ASSESS PAIN 

• 

scale 

Reassess and document the intensity of the pain after any intervention 

that could affect pain intensity 

• Psychological measures and BLS measures, including cold packs, 

repositioning, splinting, elevation, and/or traction splints, are important 

PAIN RELIEF MEASURES considerations for patients with pain 

• If pain cannot be managed using above measures, consider MORPHINE 

SULFATE, especially in patients reporting pain levels of 5 or greater 

CONSIDER 


CONSIDER 


See contraindications and cautions below: 

For pain relief: 

• Adult – 2-20 mg IV, titrated in 2-5 mg increments to pain relief 


If no IV access: 

• Adult - 5-10 mg IM 

Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart

• Closed head injury 

• Altered level of consciousness 

• Headache 

• Respiratory failure or worsening 

respiratory status 

• Childbirth or suspected active 

labor 

Contraindications and Cautions for Morphine Sulfate 

Contraindications for Morphine: 

• Hypotension 

o Adults - Systolic BP less than 90 

o Pediatric - Hypotension or impaired perfusion 

(e.g. capillary refill > 2 seconds) 

Infants 1mo-1yr systolic BP < 60 mmHg 

Toddler 1-4 yrs systolic BP < 75 mmHg 

School age 5-13 yrs systolic BP < 85 

mmHg 

Adolescent >13 yrs systolic BP < 90 mmHg 

Cautions for Morphine: 

• Use with caution in patients with suspected drug or alcohol ingestion or with suspected hypovolemia 

• Older patients may be more sensitive to morphine – consider 1-2 mg increments IV initially 

• Patients with Inferior MI (STEMI with ST elevation in II, III, aVF) may develop hypotension with 

morphine 

o Give 1-2 mg increments IV and administer fluid bolus when indicated 


• Have Naloxone available to reverse respiratory depression should it occur 

• Preferred route of administration for Morphine Sulfate is IV 


G11–GENERAL POISONING - OVERDOSE 

• If possible, determine substance, amount ingested, time of ingestion. Bring in container or label. 

• Be careful not to contaminate yourself and others 

DECONTAMINATION 

OXYGEN 


Remove contaminated clothing, brush off powders, wash off liquids 

Irrigate eyes if affected 


ALS: Titrate to sPO of at least 94%. Be prepared to support ventilation. 

2 

CONSIDER IV TKO if unstable patient or suspected serious ingestion 

Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2), 

Seizures (G14), Shock/Hypovolemia (A10, P8) 

TRICYCLIC ANTIDEPRESSANT OVERDOSE 

Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes 

and associated ventricular arrhythmias are generally signs of a life-threatening ingestion. 

For adults only: For life-threatening hemodynamically significant 

SODIUM BICARBONATE 

dysrhythmias, 1 mEq/kg slow IV or IO

ORGANOPHOSPHATE POISONING 

Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness, small/ 

pinpoint pupils, muscle twitching, and/or seizures may occur 

ATROPINE 

CALCIUM CHLORIDE 

CONSIDER 


CONSIDER 


For adults only: 1-2 mg IV 

• Repeat every 3-5 minutes as necessary until relief of symptoms 

• Large doses of Atropine may be required 

HYDROFLUORIC ACID EXPOSURE 

For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10% 

solution) 

For adults only: In the absence of hypotension, significant other trauma or 

altered level of consciousness: 

2-20 mg IV titrated in 2-5 mg increments to pain relief 

For adults only: If no IV access, 5-10 mg IM 


• Few overdoses have specific antidotes. Supportive care is the mainstay of treatment. 

Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients 

• Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium 

Channel Blocker overdose) 

• Poison Control Center can offer information but cannot provide medical direction to EMS

G12–GENERAL RESPIRATORY DEPRESSION OR APNEA 

Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest 

BVM VENTILATION Assist ventilation or provide ventilation if no spontaneous respirations 

OXYGEN 

BLS: High flow initially ALS: Titrate to sPO of at least 94% 

2 

Be prepared to support ventilations as needed 

ETCO2 

MONITORING 


In borderline cases, non-invasive ETCO2 monitoring (when available) may be valuable 

in detection of hypoventilation and can help follow respiratory trend before and after 

treatment. ETCO2 monitoring is not reliable in patients with hypotension or poor perfusion. 

NALOXONE 

INTRANASAL OR IM 

• 

• 

 

Adult not in shock: 2 mg IN (intranasal) if narcotic overdose suspected 

Adult not in shock but unsuitable for IN (copious secretions): 1-2 mg IM 

Pediatric – 0.1 mg/kg IM - maximum dose 2 mg 

CONSIDER IV TKO if intravenous treatment indicated 

If patient in shock, if IN or IM routes ineffective (within 3 minutes), or if IV access already 

NALOXONE IV 

available for another reason: 

• Adult – 1-2 mg IV 

Pediatric – 0.1 mg/kg IV – maximum dose 2 mg 

REPEAT NALOXONE IV or IM if no response and narcotic overdose suspected – maximum dose 10 mg 

CONSIDER TITRATION 

OF DILUTED 

NALOXONE IV 

ADVANCED 

AIRWAY 

Consider for patients with chronic narcotic use for terminal disease or chronic pain: Dilute 

1:10 with normal saline and administer in 0.1 mg (1 ml) increments – titrate to increased 

respiratory rate 

Consider when indicated - only if naloxone ineffective and BVM ventilation not adequate 

Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13)


SAFETY WARNING! 

Naloxone will cause acute withdrawal symptoms 

in patients who are habituated users of narcotics 

(whether prescribed or from abuse) 

• Use of diluted Naloxone IV and titration with small increments may help 

decrease adverse effects of naloxone in patients who have chronic narcotic 

usage for terminal disease or pain relief 

• Naloxone treatment should only be given to patients with respiratory 

depression (rate less than 12) 

• Patients who are maintaining adequate respirations with decreased level of 

consciousness do not generally require Naloxone for management 

• Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small 

number of patients (1-2%) 

• Older patients are at higher risk for cardiovascular complications 

• Be prepared for patient agitation or combativeness after naloxone reversal of narcotic overdose 

In patients without hypotension or poor perfusion, ETCO2 readings below 45 generally do not require 

treatment with naloxone for respiratory depression. ETCO2 should be used to help monitor respiratory 

trend. 


G13–GENERAL RESPIRATORY DISTRESS 

• Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema 

• Rales may be present in pneumonia, pulmonary edema, and many other conditions 



OXYGEN 


2 


If respiratory rate greater than 25, accessory muscle use, pulse ox less than 

CONSIDER CPAP 

94% 

CONSIDER IV TKO. Do not delay transport for vascular access if in extremis. 

ASTHMA 

ALBUTEROL Adult and Pediatric – 5 mg in 6 ml NS via nebulizer. Repeat as needed. 

CONSIDER EPINEPHRINE 

1:1000 SC 

(SUBCUTANEOUSLY) 


IM 

For use in asthma only: Use only if respiratory status deteriorating despite 

repeat treatment with Albuterol and transport time more than 10 minutes 

Do not use in patients with history of coronary artery disease or hypertension 

• Adult - 0.3 mg SC 

Pediatric - 0.01 mg/kg SC - max dose 0.3 mg 

Never give Epinephrine 1:1000 intravenously! 

If respiratory arrest from asthma or bronchospasm: 

• Adult - 0.3 mg IM 

Pediatric - 0.01 mg/kg IM - max dose 0.3 mg 

COPD EXACERBATION 

ALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed.

NITROGLYCERIN 

CONSIDER 

MORPHINE 

SULFATE 

SUSPECTED PULMONARY EDEMA (ADULTS ONLY) 

0.4 mg sublingual if systolic BP between 90 and 149 

0.8 mg sublingual if systolic BP 150 or greater 

Repeat every 5 minutes until symptoms improve 

Maximum dose 4.8 mg (12 - 0.4 mg doses) 

Discontinue if hypotension develops 

Caution: Do not administer if patient has taken erectile dysfunction medications 

Viagra, Levitra, Staxyn or Stendra within prior 24 hours or Cialis within 36 hours 

2-5 mg IV in 1-2 mg increments for relief of anxiety. Do not administer if BP less 

than 90, if patient has altered mental status or decreased respiratory effort. 

Related guidelines – Chest pain / Suspected ACS (A2), Shock (A10) 


• CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of 

respiration will need assistance with BVM. 

• Patients with potential respiratory failure should be transported emergently 

• Patients requiring advanced airway management in these situations are best handled in the hospital 

setting and CPAP may be a valuable “bridge” in care to potentially delay need for emergent intubation 

• IV access should not delay transport 

• For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If 

blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg. 

• Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no other 

contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs) 

• Consider cardiac etiology for diabetic patients with respiratory distress 


G14–GENERAL SEIZURE / STATUS EPILEPTICUS 

• Tonic-clonic movements followed by a period of unconsciousness (post-ictal period) 

• A continuous or recurrent seizure is defined as seizure activity greater than 10 minutes or 

recurrent seizures without patient regaining consciousness 


OXYGEN 


2 

PROTECT PATIENT Do not forcibly restrain but protect from injuring self 




For continuous or recurrent seizures: 

CONSIDER 

• Adult – initial dose 1 mg IV - titrate in 1-2 mg increments – max. dose 5 mg 

MIDAZOLAM IV 

Pediatric – titrate in up to 1 mg IV increments – up to 0.1 mg/kg 

If IV access unavailable: 

CONSIDER 

• Adult – 0.1 mg/kg IM - maximum dose 5 mg 

MIDAZOLAM IM 

Pediatric – 0.1 mg/kg IM - maximum dose 5 mg 

MONITOR PATIENT Carefully observe vital signs, respiratory status – support ventilations as needed 

Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) 

SAFETY WARNING: 

• Use caution when treating with Midazolam in pediatric patients previously 

treated by family or caretaker with rectal diazepam (Valium, Diastat) as a 

higher incidence of respiratory depression may occur 

• Wait five (5) minutes after last rectal dose to determine effect and need for 

further treatment. Consider using reduced dosage of Midazolam.


• Most seizures are self-limiting and do not require prehospital medication 

• Seizures may appear frightening to observers. Provide reassurance to parents/family. 

• Consider spinal immobilization if history of fall or trauma 

• Early administration of midazolam IM is preferable to IV route in smaller children and in other patients 

with potential difficult intravenous access 

• Febrile seizures in children are generally self-limiting 

• For febrile patients, remove or loosen clothing, remove blankets to address cooling measures 


G15–GENERAL STROKE 

• Sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit - may be 

associated with headache 

• Determination of time of onset of symptoms is the most crucial historical information needed 

• If patient awoke with symptoms, time patient last seen normal is the time that should be noted 

OXYGEN 



ALS: Titrate to sPO of at least 94%. Be prepared to support ventilation. 

2 

STROKE SCALE Note findings of stroke scale and time of onset of symptoms 

TRANSPORT Minimize scene time 


IV TKO 

CONSIDER 

FLUID BOLUS 

CONTACT STROKE 

CENTER OR 

RECEIVING HOSPITAL 

ASSURE FAMILY/ 

GUARDIAN 

COMMUNICATION 

250-500 ml if hypotensive or poor perfusion – reassess 

Stroke Alert is indicated only when Cincinnati Stroke Scale (CSS) findings are 

abnormal and onset (time last seen normal) is less than 4 hours from time of patient 

contact. Report time last seen normal (clock time), ETA, physical exam and findings 

of CSS using SBAR format. 

If family member/patient guardian available, assure their availability by either 

transporting them in ambulance, telling them to go immediately to the hospital or 

obtain phone number to allow physician to contact them 

Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12), 

Seizure (G14)

CINCINNATI STROKE SCALE 

If any one of the three tests are abnormal and is a new finding, the Stroke Scale is abnormal and 

may indicate an acute stroke 

Finding Patient Activity Interpretation 

Facial Droop 

Arm 

Weakness 

Speech 

Abnormality 

Ask patient to smile and 

show teeth or grimace 

Ask patient to close both 

eyes and extend both 

arms out straight for 10 

seconds 

Have the patient say the 

words, “The sky is blue in 

Cincinnati” 

Normal: Symmetrical smile or face 

Abnormal: Asymmetry (one side droops or does not move) 

Normal: Both arms move symmetrically or do not move 

Abnormal: One arm drifts down or arms move 

asymmetrically 

Testing with patient holding palms upward is most sensitive 

way to check. Patients with arm weakness will tend to 

pronate (turn from palms up to sideways or palms down). 

Normal: The correct words are used and no slurring of 

words is noted 

Abnormal: If the patient slurs words, uses the wrong 

words, or is unable to speak (aphasia)

G16–GENERAL TRAUMA - GENERAL 

SPINAL 

IMMOBILIZATION 

OXYGEN 

As indicated 



EARLY TRANSPORT Limit scene time to less than 10 minutes when possible. Load and go if high risk. 

WOUND / GENERAL Place splints, cold packs, dressings and pressure on bleeding sites as needed 

CARE 

Keep patient warm – minimize exposure after assessment 


THORACOSTOMY 

Evaluate for and treat tension pneumothorax if indicated 

IV TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS. 

CONSIDER 

FLUID BOLUS 

Fluid resuscitation appropriate in adults if: 

• Head injury and hypotension (BP < 90 or unable to detect peripheral pulses) 

• No head injury but markedly hypotensive and unable to converse due to 

shock 

Administer 250-500 ml NS, recheck vitals. Titrate to presence of peripheral 

pulses. 

In pediatric patients with signs of poor perfusion or shock: 

Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2 

BLOOD GLUCOSE Test if GCS less than 15. See Altered Level of Consciousness (G2). 

CARDIAC MONITOR

INDICATIONS AND 

PRECAUTIONS FOR 

MORPHINE USE 

MORPHINE 

SULFATE IV 

MORPHINE 

SULFATE IM 

Morphine may be used for relief of extremity pain in the absence of head or torso 

trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in 

geriatric patients or in patients with drug or alcohol intoxication. 

See precautions above 

• Adult – 2-20 mg IV in 2-5 mg increments. Titrate to pain relief and systolic 

BP greater than 100. 


See precautions above 

When IV access not available (non-critical patients only): 

• Adult – 5-10 mg IM 

Pediatric – 0.1 mg/kg IM – See Pediatric Drug Chart 

Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) 


• ALS procedures in the field (IV or advanced airway) do not improve outcome in critical trauma patients 

o IV starts should be done en route on these patients 

o Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers 

• Repeated IV attempts in non-critical pediatric patients should be avoided 


G16–GENERAL TRAUMA – HEAD INJURY 

AIRWAY 

CONTROL 

VENTILATION 

CONTROL 

HEMORRHAGE 

TREAT 

HYPOTENSION 

PATIENT 

POSITION 

CONSIDER 

ONDANSETRON 

• Basic airway management is preferred unless unable to manage with BLS maneuvers. 

Utilize jaw thrust technique to open airway. 

• Intubation in head injury patients is best addressed at the hospital or with RSI 

(aeromedical capability) 

• King Airway should be used only in arrest unless no other method to ventilate 

• Avoid hyperventilation if BVM used or patient with advanced airway. 

• Support respiratory rate to 10-12 per minute if slow. 

• Monitor patient with pulse oximetry and end-tidal CO2. Ideal ETCO2 is 35 mm Hg – 

may be unreliable if multiple system trauma or poor perfusion. 

• In patients with a dilated pupil on one side or decerebrate/decorticate posturing 

indicating impending brainstem herniation, modest hyperventilation (increase in rate of 

2-4 per minute) is appropriate (keep ETCO2 30 or above) 

Scalp hemorrhage can be life threatening. Treat with direct pressure and pressure 

dressing. 

In adult patients, in the setting of hypotension (systolic BP 90 or less or absence of 

peripheral pulses), administer NS 250-500 ml. Repeat if necessary. 

In pediatric patients with signs of poor perfusion or shock: 

Pediatric – 20 ml/kg NS. If continued poor perfusion, may repeat X 2. 

Elevate head of backboard 30 degrees unless contraindicated 

Position patient on side if needed for vomiting / airway protection 

• Adults - for vomiting/nausea, 4 mg IV/IM. May repeat every 10 minutes to a total dose 

of 12 mg. 

Pediatric – Limited to patients 4 years of age or older – 4 mg IV/IM. For patients 

40 kg and greater only, may repeat every 10 minutes to a total dose of 12 mg

G16–GENERAL TRAUMA - EXTREMITY 

consider 

TOURNIQUET 

If vigorous hemorrhage not controlled with elevation and direct pressure on wound. 

May be used in pediatric patients. May be appropriate for hemorrhage control in 

multi-casualty situations. 

DISLOCATION If dislocation suspected or noted, splint in position found 

For partial amputations, splint in anatomic location and elevate extremity 

If complete amputation, place amputated part in a dry container or bag. Seal or 

AMPUTATIONS 

tie off bag and place in second container or bag. DO NOT place amputated part 

directly on ice or in water. Elevated extremity and dress with dry gauze. 

PAIN RELIEF Consider Morphine Sulfate as directed in G16 Trauma - General Guideline 

CRUSH INJURY SYNDROME 

• Caused by muscle crush injury and cell death. Most patients have an extensive area of 

involvement such as a large muscle mass in a lower extremity and/or pelvis. 

• May develop after 1 hour in severe crush, but usually requires at least 4 hours of compression 

• Hypovolemia and hyperkalemia may occur, particularly in extended entrapments 

• Hyperkalemia should be suspected if ECG monitor reveals peaked ‘T’ waves, absent ‘P’ waves or 

widened QRS complexes 

FLUID BOLUS 20 ml/kg NS prior to release of compression 

ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer 

IF ECG CHANGES CALCIUM CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after 

SUGGEST 

administration of calcium chloride to avoid precipitation with sodium bicarbonate. 

HYPERKALEMIA: SODIUM BICARBONATE - 1 mEq/kg IV. Additionally, consider 1 mEq/kg added to 

IV 1L NS - use second IV line as other medications may not be compatible

G17–GENERAL VOMITING AND SEVERE NAUSEA 

Vomiting or nausea may be due to viral illness (gastroenteritis) or other medical conditions 

including acute coronary syndrome, stroke, head injury, or toxic ingestion. It may be associated 

with a number of painful abdominal conditions, and may also occur as a result of treatment of pain 

with morphine. 




2 

POSITION PATIENT Position patient to avoid aspiration 

NON-INVASIVE 

MEASURES 


CONSIDER FLUID BOLUS 

Fresh air, oxygen, and removal of noxious odors may lessen nausea 

Consider if patient has prolonged history of vomiting or poor intake, if vital 

signs or exam suggest volume depletion (rapid pulse, low blood pressure, dry 

mucous membranes, poor skin turgor, or capillary refill greater than 2 seconds) 

• Adult – 250-500 ml. Recheck vitals – may repeat X 1 

Pediatric – 20 ml/kg. Recheck vitals – may repeat X 1.

CONSIDER 

ONDANSETRON 

For severe nausea or persistent vomiting: 

• Adult – 4 mg IV, IM, or po (oral disintegrating tablet - ODT). May repeat 

every 10 minutes to a total of 12 mg. 

Pediatric – limited to patients 4 years of age or older – 4 mg IV, IM, or 

po (ODT). For patients 40 kg and greater only, may repeat every 10 

minutes to a total of 12 mg 

NOTE: Administer IV dosage over 1 minute. Ondansetron is contraindicated 

if patient has a history of hypersensitivity to other similar drugs (Dolasetron – 

(Anzemet), granisetron (Kytril), or Palonosetron (Aloxi) 

Related guidelines: Shock/Hypovolemia (A10), Pain Management (Non-Traumatic) (G10) 


Rapid administration of ondansetron has been associated with increased incidence of side effects – most 

notably syncope. Ondansetron must be administered intravenously over 1 minute. 

Rare side effects of ondansetron include headache, dizziness, tachycardia, sedation, hypotension, or 

syncope. Rarely QT prolongation has been seen (with higher doses and rapid administration). 

Ondansetron can be used in pregnancy and with breast-feeding mothers 

May be co-administered with MORPHINE SULFATE when used for pain relief 

Oral disintegrating tablets should be handled with care as moisture may cause premature breakdown of 

tablets before administration 

Oral disintegrating tablets can be placed on tongue and do not need to be chewed. Medication will dissolve 

and be swallowed with saliva. 


P1 — Pediatric Patient Care / ALTE 

P2 — Cardiac Arrest – Initial Care and CPR 

P3 — Neonatal Resuscitation 

P4 — Ventricular Fibrillation / Ventricular Tachycardia 

P5 — PEA / Asystole 

P6 — Symptomatic Bradycardia 

P7 — Tachycardia 

P8 — Shock 

Pediatric 

Treatment 

Guidelines

P1–PEDIATRIC PEDIATRIC PATIENT CARE 

Pediatric patient is defined as age 14 or less. Neonate is 0-1 month. 

These basic treatment concepts should be considered in all pediatric patients 

SCENE SAFETY 

BSI Use universal blood and body fluid precautions at all times 

SYSTEMATIC 

ASSESSMENT 

DETERMINE 

PRIMARY 

IMPRESSION 

BASE CONTACT 

TRANSPORT 

• Management and support of ABCs are a priority 

• Identify pre-arrest states 

• Assure open and adequate airway 

• Place in position of comfort unless condition mandates other position 

• Consider spinal immobilization if history or possibility of traumatic injury exists 

• Assess environment to consider possibility of intentional injury or maltreatment 

• Apply appropriate field treatment guidelines 

• Explain procedures to family and patient as appropriate 

• Provide appropriate family support on scene 

• Contact base hospital if any questions arise concerning treatment or if additional 

medication beyond dosages listed in treatment guidelines is considered 

• Use SBAR to communicate with base 

• Minimize scene time in pre-arrest patient, critical trauma, shock or respiratory failure 

• Transport patient medications or current list of patient medications to the hospital 

• Give report to receiving facility using SBAR 

• At a minimum, vital signs and level of consciousness should be re-assessed every 

15 minutes and should be assessed after every medication administration or 

MONITORING 

following any major change in the patient’s condition 

• For critical patients, more frequent vital signs should be obtained when appropriate 

DOCUMENT Document patient assessment and care per policy

Key Treatment Considerations – Apparent Life-Threatening Event (ALTE) 

An Apparent Life-Threatening Event (ALTE) Is an event that is frightening to the observer (may think 

the infant has died) and involves some combination of apnea, color change, marked change in muscle 

tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with 

symptoms described under 2 years of age may be considered an ALTE. 

Most patients have a normal physical exam when assessed by responding personnel. Approximately half 

of the cases have no known cause, but the remainder of cases have a significant underlying cause such as 

infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS. 

Because of the high incidence of problems and the normal assessment usually seen, there is potential for 

significant problems if the child’s symptoms are not seriously addressed. 

OBTAIN 

DETAILED 

HISTORY 

ASSESSMENT 

Obtain history of event, including duration and severity, whether patient awake or 

asleep at time of episode, and what resuscitative measures were done by the parent or 

caretaker 

Obtain past medical history, including history of chronic diseases, seizure activity, current 

or recent infections, gastroesophageal reflux, recent trauma, medication history 

Obtain history with regard to mixing of formula if applicable 

Perform comprehensive exam, including general appearance, skin color, interaction with 

environment, or evidence of trauma 

TREATMENT Treat identifiable cause if appropriate 

TRANSPORT 

If treatment/transport is refused by parent or guardian, contact base hospital to consult 

prior to leaving patient. Document refusal of care.

P2–PEDIATRIC CARDIAC ARREST – INITIAL CARE AND CPR 

ESTABLISH 

TEAM LEADER 

• First agency on scene assumes leadership role 

• Leadership role can be transferred as additional personnel arrive 

CONFIRM ARREST • Unresponsive, no breathing or agonal respirations, no pulse 

COMPRESSIONS 

AED OR MONITOR/ 

DEFIBRILLATOR 

BASIC AIRWAY 

MANAGEMENT 

AND 

VENTILATION 

• Begin compressions at a rate of at least 100 per minute 

• Compress chest approximately 1/3 of AP diameter of chest: 

o In children (age 1-8) - around 2 inches 

o In infants (under age 1) – around 1 ½ inches 

• Allow full chest recoil (lift heel of hand) 

• Change compressors every 2 minutes 

• Minimize any interruptions in compressions. If necessary to interrupt, limit to 10 

seconds or less. 

• Do not stop compressions while defibrillator is charging 

• Resume compressions immediately after any shock 

• Apply pads while compressions in progress 

• Determine rhythm and shock, if indicated 

• Follow specific treatment guideline based on rhythm 

• Open airway – For 2-person CPR: 

o Provide 2 breaths:30 compressions for children over age 8 

o Provide 2 breaths:15 compressions for infants > 1 month & children to age 8 

• Avoid Excessive Ventilation 

• Ventilations should last one second each, enough to cause visible chest rise 

• Use 2-person BLS Airway management (one holding mask and one squeezing bag)

MEDICATIONS AND 

DEFIBRILLATION 


MANAGEMENT 

AND 

END-TIDAL CO2 

MONITORING 

• Use length-based tape to determine weight 

• If child is obese and length-based tape used to determine weight, use next 

highest color to determine appropriate equipment and drug dosing 

• See Pediatric Drug Chart for medication dose and defibrillation energy levels 

For patients 40 kg or greater only: 

• Placement of advanced airway is not a priority during the first 5 minutes of 

resuscitation unless no ventilation is occurring with basic maneuvers. 

• Placement of endotracheal tube or King Airway should not interrupt 

compressions for a period of more than 10 seconds 

• For endotracheal intubation, position and visualize airway prior to cessation of 

CPR for tube passage. 

• Confirm tube placement and provide ongoing monitoring using end-tidal 

carbon dioxide monitoring 

BLOOD GLUCOSE Treat if indicated. Glucose may be rapidly depleted in pediatric arrest. 

PREVENT 

HYPOTHERMIA 

Move to warm environment and avoid unnecessary exposure 

• Pediatric arrest victims are at risk for hypothermia due to their increased 

body surface area, exposure and can be exacerbated by rapid administration 

of IV/IO fluids 

TRANSPORT Consider rapid transport to definitive care

P3–PEDIATRIC NEONATAL CARE AND RESUSCITATION 

WARM PATIENT Provide warmth – move to warm environment immediately 

CLEAR AIRWAY If needed, position airway or suction. Rapidly suction secretions from mouth or nares. 

DRY AND 

STIMULATE 

EVALUATE 

RESPIRATIONS, 

HEART RATE 

AND COLOR 

REASSESS / 

BEGIN CPR 

IF INDICATED 

Dry child thoroughly, stimulate, reposition if needed, place hat on infant 

• If breathing, heart rate above 100 and pink, observational care only 

• If breathing, heart rate above 100 and central cyanosis – OXYGEN 100% by mask 

– reassess in 30 seconds 

o If cyanosis resolves (skin pink) – observational care only 

o If persistent central cyanosis after oxygen, initiate bag mask ventilation at 

rate of 40-60/minute 

• If apneic, gasping, or heart rate below 100 – initiate bag mask ventilation at a rate 

of 40-60/minute with OXYGEN 100% – reassess in 30 seconds 

o If heart rate increases to above 100 and patient ventilating adequately, 

discontinue bag mask ventilation and continue close observation 

o If heart rate persists below 100 continue bag mask ventilation 

If heart rate less than 60 despite ventilation with oxygen for 30 seconds, begin CPR 

(3:1 ratio – 90 compressions and 30 ventilations/minute). Reassess in 30 seconds.

If heart rate remains less than 60 despite adequate ventilation and chest compressions: 

IV/IO 

TKO. 100-500 ml NS bag (use care to avoid inadvertent fluid administration). Do not 

delay transport for IV or IO access. 

EPINEPHRINE 

1:10,000, 0.01 mg/kg IV or IO. Repeat every 3-5 minutes if heart rate remains below 

60. 

CONSIDER FLUID 

BOLUS 

10 ml/kg NS IV or IO. May repeat once if needed. 

CONSIDER 

NALOXONE 

0.1 mg/kg IV or IO if depressed respiratory status despite efforts. Avoid use if longterm 

use of opioids during pregnancy known or suspected. 


• For uncomplicated deliveries, treatment priorities are to warm, dry, and stimulate the infant 

• Anticipate complex resuscitation if not term gestation, amniotic fluid not clear, if newborn is not 

breathing or crying or if newborn does not have good muscle tone 


P4–PEDIATRIC 

VENTRICULAR FIBRILLATION 

PULSELESS VENTRICULAR TACHYCARDIA 

INITIAL CARE See Cardiac Arrest - Initial Care and CPR (P3) 


2-4 joules/kg 

• AED can be used if patient over 1 year and pediatric electrodes available 

(age 1-8) or if adult electrodes can be applied without touching each other 

• Use infant paddles and manual defibrillator up to 1 year of age or 10 kg 

CPR For 2 minutes or 5 cycles between rhythm check 

BVM VENTILATION 

For patients 40 kg and over, defer advanced airway unless BLS airway 

inadequate 

IO or IV TKO. Should not delay defibrillation or interrupt CPR. 

DEFIBRILLATION 4 joules/kg 

EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes - See Pediatric Drug Chart 


4 joules/kg. Higher energy levels may be considered – not to exceed 10 joules/kg 

or the adult maximum. 

AMIODARONE 

TRANSPORT 

5 mg/kg IV or IO (see Pediatric Drug Chart for dosage) 

If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated


• Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their 

performance takes precedence over advanced airway management and administration of medications. 

• To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after 

shock administered (no pulse or rhythm check) 

• Avoid excessive ventilation with BLS airway management, which may cause gastric distention and 

limit chest expansion. Provide breaths over 1 second, with movement of chest wall as guide for 

volume needed. 

• If advanced airway placed (40 kg and over), perform CPR continuously without pauses for ventilation 

• Confirm placement of advanced airway with end-tidal carbon dioxide measurement. Continuous 

monitoring with ETCO2 is mandatory – if values less than 10 mm Hg seen, assess quality of 

compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earlist indicator of return 

of circulation. 


• Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) 

• Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in 

adolescents). 

Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for medication 

dose and defibrillation energy levels.

P5–PEDIATRIC PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE 

INITIAL CARE See Cardiac Arrest – Initial Care and CPR (P3) 

BVM VENTILATION 

IV OR IO TKO 

Defer advanced airway (for patients 40 kg and over) unless BLS airway 

inadequate 

EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO every 3-5 minutes 

Consider treatable causes – treat if applicable: 

CONSIDER 

FLUID BOLUS 

20 ml/kg NS – may repeat X 2 for hypovolemia 

VENTILATION Ensure adequate ventilation (8-10 breaths per minute) for hypoxia 

CONSIDER 



THORACOSTOMY 

BASE CONTACT 

For hypothermia 

For tension pneumothorax 

To determine treatment for other identified potentially treatable causes - 

Hydrogen Ion (Acidosis), Hyperkalemia, Toxins 

Safety Warning: Unlike adult resuscitation, atropine is not used 

in treatment of asystole or PEA in the pediatric patient 

If Return of Spontaneous Circulation – see guidelines for Shock (P8) if treatment indicated


• Uninterrupted CPR is key to successful resuscitation. This takes precedence over advanced airway 

management and administration of medications. 

• If advanced airway placed in patients 40 kg and over, perform CPR continuously without pauses for 

ventilation 

• Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one 

second. 


• Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in 

adolescents). 


P6–PEDIATRIC SYMPTOMATIC BRADYCARDIA 

• 90% of pediatric bradycardias are related to respiratory depression and respond to support of 

ventilation 

• Only unstable, severe bradycardia causing cardiorespiratory compromise will require further treatment 

• Signs of severe cardiorespiratory compromise are poor perfusion, delayed capillary refill, hypotension, 

respiratory difficulty, altered level of consciousness 

OXYGEN 

CARDIAC 

MONITOR 



2 

IV OR IO TKO. Use IO only if patient unstable and requires medication. Use 100-500 ml NS bag. 

CONSIDER CPR 

If heart rate remains less than 60 with poor perfusion despite oxygenation and ventilation, 

perform CPR 

EPINEPHRINE 1:10,000 - 0.01 mg/kg IV or IO. Repeat every 3-5 minutes. 

CONSIDER 

ATROPINE 

SAFETY WARNING: 

Atropine should be considered only 

after adequate oxygenation/ventilation has been assured 

0.02 mg/kg IV, IO (0.1 mg minimum dose) 

Maximum single dose 0.5 mg 

If continued heart rate less than 60, repeat 0.02 mg/kg IV or IO 


P7–PEDIATRIC TACHYCARDIA 

Sinus tachycardia is by far the most common pediatric rhythm disturbance 

UNSTABLE SINUS TACHYCARDIA (narrow QRS less than or equal to 0.09) 

• ‘P’ waves present/normal, variable R-R interval with constant P-R interval 

• Unstable sinus tachycardia is usually associated with shock and may be pre-arrest 

UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less or equal to 0.09) 

• ‘P’ waves absent/abnormal, heart rate not variable 

• History generally vague, non-specific and/or history of abrupt heart rate changes 

• Infants’ rate usually greater than 220 bpm, Children (ages 1 – 8) rate usually greater than 180 

bpm 

UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA - Wide QRS (greater than 0.09 sec) 

• In some cases, wide QRS can represent supraventricular rhythm 

INITIAL THERAPY – ALL TACHYCARDIA RHYTHMS 

OXYGEN 

BLS: Low flow unless ALOC / respiratory distress / shock. 

ALS: Titrate to sPO of at least 94% Be prepared to support ventilation. 

2 

Determine stability: 

CHECK PULSE 

AND PERFUSION 

• 

• 

Stable - Normal perfusion: Palpable pulses, normal LOC, normal capillary 

refill, and normal BP for age 

Unstable - Poor perfusion: ALOC, abnormal pulses, delayed cap. refill, 

difficult/unable to palpate BP. If unstable, transport early and treat as below. 

CARDIAC MONITOR Run strip to evaluate QRS Duration 

IV OR IO TKO. Use 100-500 ml bag NS 

FLUID BOLUS 20 ml/kg NS if hypovolemia suspected. May repeat X 1

UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (narrow QRS less or equal to 0.09) 

VAGAL MANEUVERS Consider if will not result in treatment delays. ICE PACK to face of infant/child. 

BASE CONTACT For all treatments listed below: 

0.1 mg/kg rapid IV push followed by 10-20 ml NS flush (maximum dose 6 mg) 

ADENOSINE 

If not converted, 0.2 mg/kg rapid IV push followed by 10-20 ml NS flush 

(maximum dose 12 mg) 

SYNCHRONIZED 

CARDIOVERSION 

CONSIDER SEDATION 

If unable to obtain IV access, prepare for Synchronized Cardioversion. Do NOT 

delay cardioversion to obtain IV or IO access or sedation. 

Consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum 

increments (maximum dose 5 mg) 

SYNCHRONIZED 

CARDIOVERSION 

0.5-1 joule/kg. If not effective, repeat at 2 joules/kg. 

UNSTABLE – POSSIBLE VENTRICULAR TACHYCARDIA ( Wide QRS greater than 0.09 sec) 

BASE CONTACT For all treatments listed below: 

SYNCHRONIZED Prepare for CARDIOVERSION while attempting IV/IO access, but do not 

CARDIOVERION unduly delay care for IV access or medications 

CONSIDER 

If IV/IO access has been obtained, consider MIDAZOLAM 0.1 mg/kg IV or IO, 

SEDATION 

titrated in 1 mg maximum increments (maximum dose 5 mg) 

SYNCHRONIZED 

CARDIOVERSION 

0.5-1 joule/kg. If not effective, repeat at 2 joules/kg. 

• Early transport appropriate in unstable patients. 


P8–PEDIATRIC SHOCK 

• Altered level of consciousness; cool, clammy, mottled skin; capillary refill greater than 2 

seconds; tachycardia; blood pressure less than 70 systolic 

• Listless infant or child with poor skin turgor, dry mucous membranes, history of fever may 

indicate sepsis, meningitis 

OXYGEN BLS/ALS: High flow. Be prepared to support ventilations as needed. 

PREVENT 

HYPOTHERMIA 

Move to warm environment. Avoid unnecessary exposure. 


EARLY TRANSPORT CODE 3 

IV OR IO 

FLUID BOLUS 20 ml/kg NS – may repeat X 2 


Related guidelines: Altered level of consciousness (G2), Tachycardia (P7)


Successful pediatric resuscitation relies on early identification of the pre-arrest state 

• Normal blood pressure, delayed capillary refill, diminished peripheral pulses and tachycardia indicates 

compensated shock in children 

• Hypotension and delayed capillary refill > 4 seconds indicates impending circulatory failure 

• Systolic blood pressure in children may not drop until the patient is 25-30% volume depleted. This may 

occur through dehydration, blood loss or an increase in vascular capacity (e.g. anaphylaxis). 

• Decompensated shock (Hypotension with > 5 seconds capillary refill) may present as PEA in children 

• Sinus tachycardia is the most common cardiac rhythm encountered 

• Supraventricular tachycardia should be suspected if heart rate greater than 180 in children (ages 1-8) 

or greater than 220 in infants 

• Hypoglycemia may be found in pediatric shock, especially in infants 

• Pediatric shock victims are at risk for hypothermia due to their increased body surface area, exposure 

and rapid administration of IV/IO fluids 


IFT1 — Interfacility Transfer of STEMI Patients 

IFT2 — Interfacility Transfer of Intubated Patients 

IFT3 — Interfacility Transfer of Stroke Patients 

Interfacility 

Transfer 

Guidelines

IFT 1–TRANSFER INTERFACILITY TRANSFER OF STEMI PATIENTS 

Patients with ST-elevation Myocardial Infarction (STEMI) needing interventional cardiac care require 

timely transfer. A scene time of 10 minutes or less at the sending facility is ideal. 


OXYGEN 


2 

MONITOR IV Maintain TKO or other existing flow rate 

PROMPT TRANSPORT Transfer for definitive care is the priority in STEMI patients 

CONSIDER 

MORPHINE SULFATE 

2-20 mg in 2-4 mg increments for pain relief if BP greater than 90. Patients with 

STEMI often do not get complete relief with morphine treatment. 

Do not administer Morphine Sulfate if Right Ventricular MI is suspected 


Treatment during interfacility transfer varies from field approach to chest pain/ACS: 

• Confirmatory ECG for STEMI has been done by hospital and does not need repeat prior to transfer or 

en route to accepting facility 

• Nitroglycerin treatment is not required and generally ineffective in patients with confirmed STEMI 

• Aspirin or other anti-platelet treatment if indicated should be administered by sending hospital prior to 

patient departure 

Patients generally will be directed directly to catheterization laboratory 

Outcome in STEMI patients directly related to timeliness of intervention to relieve coronary artery 

blockage. Minimizing time delay in transfer is essential.

IFT 2–TRANSFER 

INTERFACILITY TRANSFER OF 

INTUBATED PATIENTS 

Patients requiring specialty care (most commonly trauma or neurosurgical care) may be transferred 

with an established endotracheal tube. Sedation may be required if patient agitation present because 

of risk of inadvertent extubation. NOTE: This treatment guideline pertains to sedation of intubated 

patients during interfacility transport only (not for patients with field response who are intubated). 

OXYGEN 100% 

VENTILATION As needed if patient with apnea or inadequate respiratory rate or effort 


END-TIDAL CO 2 

MONITORING 

PULSE OXIMETRY 

CONSIDER 

MIDAZOLAM 

MONITOR PATIENT 

Continuous monitoring with waveform capnography is required and must be 

established prior to departure from sending facility. Maintain end-tidal CO 2 between 

35 and 45. ETCO 2 may not be reliable in patients with shock or significant lung injury. 

Maintain at least a minimum respiratory rate of 8-10 breaths per minute. 

For sedation in agitated or uncooperative patient: 2-5 mg IV in up to 2 mg 

increments. Repeat dosing with base contact only. 

Follow vital signs and ETCO closely. If Midazolam administered, anticipate potential 

2 

respiratory depression. 


• Some patients may need paralysis and require additional nursing or physician staff to administer these 

medications 

• If inadvertent extubation occurs, manage with basic airway maneuvers unless ventilation cannot be 

adequately maintained

IFT 3–TRANSFER INTERFACILITY TRANSFER OF STROKE PATIENTS 

Patients with acute stroke that may not qualify for thrombolytic therapy or that may not respond to thrombolytic 

therapy, necessitating transfer for potential interventional care 


OXYGEN 


2 


MONITOR VITAL 

SIGNS 

Monitor blood pressure and Glasgow coma scale at least every 15 minutes. Use pulse oximetry - 

consider non-invasive end-tidal carbon dioxide monitoring if any respiratory difficulty. 

MONITOR IV Maintain TKO or other existing flow rate 

PROMPT 

Transfer for definitive care is the priority in stroke patients. Minimizing time delay is essential. 

TRANSPORT 


• Stroke patients who are transferred may have already received thrombolytic therapy or may not have qualified for 

thrombolysis based on length of time from stroke onset or other medical contraindications 

• Ongoing administration of thrombolytic therapy requires additional qualified staff (nurse or physician) for transport 

• Thrombolytic therapy in stroke patients is associated with around a 6% incidence of symptomatic intracerebral hemorrhage, 

and around a 1% of serious hemorrhage elsewhere 

Close monitoring is important. Significant changes in patient vital signs/GCS during transport should be reported immediately to 

receiving facility staff as it may affect immediate treatment: 

• Hypotension may occur because of external or internal hemorrhage 

• Hypertension may be related to acute intracranial process or underlying disease 

• Respiratory depression or airway compromise may occur due to stroke or intracerebral hemorrhage 

• Decreasing level of consciousness may occur due to stroke or intracerebral hemorrhage 

Cardiac dysrhythmias may occur in stroke patients (bradycardia or tachyarrhythmia) 

Observe for external hemorrhage in patients with prior administration of thrombolytics. Place direct pressure if hemorrhage noted. 

Related guidelines: Shock/Hypovolemia (A10), Altered level of consciousness (G2), Respiratory Depression or apnea (G12)

Policy 9 — Destination Determination 

Policy 9 — Destination – 5150 and Obstetric 

Policy 9 — Burn Patient Destination 

Policy 10 — Declining Medical Care or Transport (AMA) 

Policy 13 — Trauma Base Call-In Criteria 

Policy 13 — Trauma Triage Criteria 

Policy 19 — Determination of Death 

Policy 20 — DNR and POLST Orders 

Policy 23 — Reporting Requirements - Abuse 

Policy 30 — Restraints 

Policy 33C — Helicopter Transport Criteria 

Policy 35 — Safely Surrendered Baby 

Policy 36 — Hazardous Materials – Exposure Management Principles 

Policy 39 — 911 Activation for Non-Emergency Transport Providers 

note: These are summaries of policies – full policies are available at the EMS website at: http://cchealth.org/ems/policies.php 

Policy 

Summaries

DESTINATION DETERMINATION – BASIC PROCEDURE 

• Field personnel shall assess a patient to determine if the patient is unstable or stable 

• Patient stability must be considered along with a number of additional factors in making 

destination and transport code decisions 

FACTORS TO 

CONSIDER 

UNSTABLE 

PATIENTS 

STABLE 

PATIENTS 

• Patient or family’s choice of receiving hospital and ETA to that facility 

• Recommendations from a physician familiar with the patient’s current condition 

• Patient’s regular source of hospitalization or health care 

• Ability of field personnel to provide field stabilization or emergency intervention 

• ETA to the closest basic emergency department 

• Traffic conditions 

• Hospitals with special resources 

• Hospital diversion status 

• Usually transported to the closest appropriate acute care hospital emergency 

department or specialized care centers if indicated 

• If the patient or family requests, or if other factors exist which indicate that another 

facility be considered, field personnel are to contact the base hospital and present 

their findings, including ETAs to both facilities. Base personnel will assess the 

benefits of each destination and may direct field personnel to a facility other than 

the closest. 

• Stable patients are transported to appropriate acute care hospitals within 

reasonable transport times based on patient’s/family preference 

• If a patient does not express a preference, the hospital where the patient normally 

receives health care or the closest ED is to be considered

PATIENTS ON 

5150 HOLDS 

OBSTETRIC 

PATIENTS 

DESTINATION DETERMINATION – 5150 / OBSTETRIC PATIENTS 

A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical 

emergency. Based upon the history and physical examination of the patient, field personnel 

shall determine whether the patient is stable or unstable. 

Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center 

Unstable patients on 5150 holds shall be transported to the closest acute care hospital: 

• A patient with a current history of overdose of medications is to be considered unstable 

• A patient with history of ingestion of alcohol / illicit street drugs is considered unstable if: 

o Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or 

o Significantly abnormal vital signs; or 

o Any other history or physical findings that suggest instability (e.g. chest pain, shortness 

of breath, hypotension, diaphoresis) 

A patient is considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or 

more. Obstetric patients should be transported to hospitals with in-patient OB services in the 

following circumstances: 

• Patients in labor 

• Patients whose chief complaint appears to be related to the pregnancy, or who potentially 

have complications related to the pregnancy 

• Injured patients who do not meet trauma criteria or guidelines 

Obstetric patients with impending delivery or unstable conditions where imminent treatment 

appears necessary to preserve the mother’s life should be transported to the nearest basic 

emergency department 

Stable obstetric patients should be transported to the emergency department of choice if their 

complaints are clearly unrelated to pregnancy

GENERAL 

DESTINATION 

PRINCIPLES 

PATIENT 

SELECTION FOR 

INITIAL TRANSPORT 

TO BURN CENTER 

PROCEDURE FOR 

BURN CENTER 

DESTINATION 

BURN PATIENT DESTINATION 

• Burned patients with unmanageable airways should be transported to the 

closest basic ED 

• Patients with minor burns and moderate burns can be cared for at any acute 

care hospital 

• Adult and pediatric patients with burns and significant trauma should be 

transported to the closest appropriate trauma center 

The following patients may be appropriate for initial transport to a Burn Center: 

• Partial thickness (2nd degree) greater than 20% TBSA 

• Full thickness (3rd degree) greater than 10% 

• Chemical or high voltage electrical burns 

• Smoke inhalation with external burns 

• Contact Burn Center prior to transport to confirm bed availability 

• Consult base hospital if any questions regarding destination decision

DECLINING MEDICAL CARE OR TRANSPORT (AMA) 

All qualified persons are permitted to make decisions affecting care, including the ability to decline care 

Patient 

Competency 

Qualified 

Person 

Base Contact 

Requirements 

Any person encountered by EMS personnel who demonstrates any known or suspected illness or 

injury OR is involved in an event with significant mechanism that could cause illness or injury OR who 

requests care or evaluation 

The ability to understand and to demonstrate an understanding of the nature of the illness/injury and 

the consequence of declining medical care 

A competent person making decision for him/herself or another qualified by: 

• An adult patient defined as a person who is at least 18 years old; 

• A minor (under 18 years old) who qualifies based on one of the following conditions: 

o A legally married minor; 

o A minor on active duty with the armed forces; 

o A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault; 

o A minor, 12 years of age or older, seeking treatment of contact with an infectious, 

contagious or communicable disease or sexually transmitted disease; 

o A self-sufficient minor at least 15 years of age, living apart from parents and managing his/ 

her own financial affairs; 

o An emancipated minor (must show proof); OR 

• The parent of a minor child or a legal representative of the patient (of any age). Spouses or 

relatives cannot consent to or decline care for the patient unless they are legally designated 

representatives. 

• When, in the field personnel’s opinion, patient’s decision to decline care poses a threat to his/her 

well being 

• If the patient’s competency status is unclear (neither competent nor clearly incompetent) and 

treatment or transport is felt to be appropriate 

• Any other situation in which, in the field personnel’s opinion, that base contact would be 

beneficial in resolving treatment or transport issues

BASE HOSPITAL 

DESTINATION 

DECISION 

REQUIRED PRIOR 

TO TRANSPORT 

PRECAUTION WITH 

ELDERLY PATIENTS 

ADDITIONAL 

CONSIDERATIONS: 

TRAUMA – BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA) 

• Evidence of high-energy dissipation or rapid deceleration which may 

include: 

o vehicle rollover with unrestrained occupant 

o intrusion of passenger space by 1 foot or greater 

o impact of 40 mph or greater (restrained) 

o persons requiring disentanglement from a vehicle 

• Patient struck by a vehicle with impact 20 mph or less 

• Persons ejected from a moving object (motorcycle, horse, etc.) 

• Significant blunt force to the head. Symptoms may include loss of 

consciousness, repetitive questioning, abnormal or combative behavior, 

vomiting, headache, or new onset of confusion 

• Significant blunt force to the neck, thorax (chest/back), abdomen or pelvis 

• Penetrating injury to extremities (above knee or elbow) without apparent fracture 

• Patients 60 years of age and older may sustain significant injuries 

with less forceful mechanisms, and may merit call-in for less significant 

mechanisms (e.g. ground level fall with new alteration of mental status) 

• Base contact should be made if a patient meets call-in criteria and it is 

believed trauma center services may be needed, even in the event that the 

trauma has occurred several hours prior to EMS response 

• If no significant symptoms or physical findings noted despite above 

mechanism(s), call-in not required and patient may be transported to 

hospital of choice or to closest facility

HIGH-RISK TRAUMA CRITERIA (Direct Trauma Center Transport) 

The following meet high-risk criteria and merit direct transport to the trauma center: 

PHYSIOLOGIC • BP < 90 in adults 

CRITERIA 

• GCS 13 or below if not pre-existing 

• Penetrating injury to head, neck, torso, groin, pelvis or buttocks 

• Fracture of femur 

ANATOMIC 

CRITERIA 

• 

• 

• 

Fracture of long bone(s) resulting from penetrating trauma 

Traumatic Paralysis 

Amputation above wrist or ankle 

• Major burns associated with trauma 

• Crushed, mangled, or degloved extremity 

• Motor vehicle crash with: 

o Extrication > 20 minutes 

o Fatalities in the same vehicle 

Note: In the absence of 

o Ejection 

significant symptoms or 

MECHANISM • Unrestrained motor vehicle crash with: 

physical findings with these 

CRITERIA 

o Head on mechanism > 40 mph 

mechanisms, 

o Extrication required 

call base hospital for 

• Fall 15 feet or greater 

destination determination 

• Auto vs. pedestrian/bicyclist thrown, 

run over, or struck with significant impact (>20 mph) 

COMBINED 

CRITERIA 

(COMBINED 

MECHANISM 

AND PHYSICAL 

FINDINGS) 

• 

• 

Motorcycle crash with: 

o Abdominal or chest tenderness 

o Observed loss of consciousness 

Unrestrained motor vehicle crash with abdominal tenderness 

Note: Patients with unmanageable airways or trauma arrest not meeting field determination criteria should be transported 

to the closest receiving facility.

OBVIOUS 

DEATH 

MEDICAL 

ARREST 

TRAUMATIC 

ARREST 

DETERMINATION OF DEATH 

Pulseless, non-breathing patients with any of the following: 

• Decapitation, Total incineration, Decomposition 

• Total destruction of the heart, lungs, or brain, or separation of these organs from the 

body 

• Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or 

poisoning. In patients with rigor mortis or post-mortem lividity: 

o Attempt to open airway, assess for breathing for at least 30 seconds; assess 

pulse for 15 seconds 

o Rigor, if present, should be noted in jaw and/or upper extremities 

o If any doubt exists, place cardiac monitor to document asystole in 2 leads for 1 

minute 

• Mass casualty situations 

Definition: 

Cardiac arrest with total absence of observers Aor 

witness information; or cardiac arrest in 

which witness information states arrest occurred greater than 15 minutes prior to arrival of 

prehospital personnel and no resuscitative measures have been done 

Procedure: 

• BLS personnel – Follow Public Safety defibrillation guideline 

• ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no 

heart tones/no carotid or femoral pulses), document asystole in 2 leads for 1 minute 

Definition: Blunt or penetrating traumatic arrest 

Procedure: 

• BLS personnel – Follow Public Safety defibrillation guideline 

• ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness 

(no heart tones/no carotid or femoral pulses), document asystole or wide-complex 

pulseless electrical activity (PEA) at rate of 40 or less

VALID DNR 

ORDERS 

COMPLYING WITH 

AN HONORED 

DNR ORDER 

COMPLYING WITH 

A POLST ORDER 

(NOT IN ARREST) 

NO VALID DNR 

ORDER PRESENT 

AND REQUEST 

MADE FOR NO 

RESUSCITATION 

DNR and POLST ORDERS 

• A California EMSA/CMA Prehospital DNR Form 

• A California/EMSA POLST form in which Section A (Do Not Attempt Resuscitation/ 

DNR) has been chosen 

• An Advanced Health Care Directive (includes living will or Durable Power of 

Attorney for Health Care) presented by an agent of the patient empowered to 

make health care decisions for the patient 

• An EMS-approved standard DNR medallion/bracelet e.g. Medi-Alert 

• A DNR order in the medical record of a licensed healthcare facility (e.g. acute care 

hospital, skilled nursing facility, hospice or intermediate care facility) signed by a 

physician. Electronic physician orders are considered signed and will be honored. 

• A verbal DNR order given by the patient’s physician who is present at the scene 

• Verify identity of patient 

• Perform no life-saving measures 

• Cancel the responding ambulance 

• Verify identity of patient. Review section B. 

o If “Full Treatment” marked, patient receives full care 

o If “Limited Additional Interventions” or “Comfort Measures Only” is marked, no 

advanced airway should be done 

If the patient presents with advanced or terminal disease and incomplete forms or 

no forms are presented and an immediate family member, agent, or conservator 

requests no resuscitation, resuscitative measures may be withheld if there is complete 

agreement of family and providers on scene. Immediate family members include 

spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient No base 

contact is required. If any question of circumstances or disagreement of family or 

providers, proceed with resuscitation.

ABUSE REPORTING RESPONSIBILITIES 

EMS personnel are mandated reporters. Report when there is reason to suspect abuse, which may 

be of a physical, sexual, or financial nature, or may involve neglect or domestic violence toward a 

child, elder, or dependent adult. 

BASIC 

ACTIONS 

CHILD ABUSE 

REPORTING 

ELDER ABUSE 

REPORTING 

(LONG-TERM 

CARE FACILITY) 

Notify the appropriate law enforcement agency immediately if the scene is 

unsafe or it is suspected that a crime has been committed 

Make reasonable efforts to transport the patient to a receiving hospital for 

evaluation, and advise the receiving hospital staff of abuse/neglect suspicions 

Document observations and findings on the patient care report 

• Contact the appropriate reporting agency by telephoning immediately or as soon 

as reasonably possible to provide a verbal report 

• Call Children & Family Services Screening Unit: (all numbers are 24 hours/day) 

at 1-877-881-1116 

• Complete a Suspected Child Abuse Report Form within 2 working days (SS 

8572) (available online at http://www.ag.ca.gov/childabuse/pdf/ss_8572.pdf ) 

If the alleged abuse has occurred in a long-term care facility: 

• Call Ombudsman Services of Contra Costa (925) 685-2070 to make a verbal 

report 

• 24-Hour Crisis Line: 1-800-231-4024 

• Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working 

days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/entres/ 

forms/English/SOC341.pdf

ELDER ABUSE 

REPORTING – 

(ALL OTHER 

SITES) 

SEXUAL 

ASSAULT 

DOMESTIC 

VIOLENCE 

ABUSE REPORTING RESPONSIBILITIES (Continued) 

If the alleged abuse has occurred anywhere else (not at a long-term care 

facility): 

• Call Adult Protective Services (925) 646-2854 or 1-877-839-4347 to make a 

verbal report 

• Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working 

days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/entres/ 

forms/English/SOC341.pdf 

Sexual assault shall be reported as above in situations involving elder, dependent 

adult, child, or domestic violence. 

It is recommended to transport patients who have been sexually assaulted to 

Contra Costa Regional Medical Center for evaluation and evidentiary exam; 

however, the patient may be transported to the receiving hospital of choice or if 

medically unstable to the most appropriate facility for medical care 

Discourage any activity that would compromise evidence collection prior to 

transport such as bathing, brushing teeth, brushing hair, urinating, defecating or 

changing clothes 

• Reporting responsibilities are fulfilled by notifying the local law enforcement 

agency, and by reporting suspicions and patient findings to receiving hospital 

staff (if transported)

RESTRAINT TYPES 

RESTRAINT 

ISSUES 

LAW 

ENFORCEMENT 

ROLE 

TRANSPORT 

ISSUES 

RESTRAINTS 

• Leather or soft restraints may be used during transport 

• Handcuffs may only be used during transport if law enforcement accompanies the 

patient in the ambulance. Patients may not be handcuffed to the gurney. 

• Chemical restraint requires a base hospital order 

• Patients shall be placed in Fowler’s or Semi-Fowler’s position 

• Patients shall not be restrained in hogtied or prone position 

• Method of restraint should allow for monitoring of vital signs and respiratory effort 

and should not restrict the patient or rescuer’s ability to protect the airway should 

vomiting occur 

• Restrained extremities should be monitored for circulation, motor and sensory 

function every 15 minutes 

• Law enforcement agencies are responsible for capture and/or restraint of 

assaultive or potentially assaultive patients 

• Law enforcement agencies retain responsibility for safe transport of patients under 

arrest or on 5150 holds 

• Patients under arrest or 5150 hold should undergo a weapons search by law 

enforcement personnel 

• Patients under arrest must be accompanied by law enforcement personnel 

• If an unrestrained patient becomes assaultive during transport, ambulance 

personnel shall request law enforcement assistance, and make reasonable efforts 

to calm and reassure the patient 

• If the crew believes their personal safety is at risk, they should not inhibit a patient’s 

attempt to leave the ambulance. Every effort should be made to release the patient 

into a safe environment. Ambulance personnel are to remain on scene until law 

enforcement arrives to take control of the situation.

TIME CRITERIA 

CLINICAL 

CRITERIA 

USE AND 

CANCELLATION 

HELICOPTER TRANSPORT CRITERIA 

USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET 

• Helicopter transport generally should be used only when it provides a time advantage. 

Helicopter field care and transport time (which includes on-scene time, flight time, and 

transport from helipad to the emergency department) is optimally 20-25 minutes in most 

cases. 

• Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter 

arrival 

• Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, 

trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when 

time criteria not met 

• Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except 

for: 

o Stable patients with isolated extremity trauma 

o Patients with mechanism but no significant physical exam findings 

• Trauma patients who do not meet high-risk criteria but by evaluation of mechanism 

and physical exam findings, appear to have potential significant injuries that merit rapid 

transport 

• Patients with specialized needs available only at a remote facility such as burn victims/ 

critical pediatric 

• Critically ill or injured patients whose conditions may be aggravated or endangered by 

ground transport (e.g. limited access via ground ambulance or unsafe roadway) 

The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not 

met, helicopter should be cancelled. Considerations for IC: 

• Patient need 

• Estimated ground transport time versus air response and transport 

• Proximity of a helispot or need for a helicopter/ambulance rendezvous site 

• ETA of the helicopter

BACKGROUND 

SITE 

REQUIREMENTS 

PROCEDURE 

SAFELY SURRENDERED BABY PROGRAM 

• California Law permits parents to voluntarily safely surrender their infant up to 72 hours 

old at fire stations (hospitals and many medical clinics are also authorized) 

• The law was created in an effort to reduce baby abandonments which lead to death in 

some circumstances 

• Parents have a 14-day “cooling off” period to reclaim the surrendered infant. The person 

surrendering the child has immunity from criminal liability for child endangerment if there 

is no abuse or neglect involved. 

• Self-training is available for personnel who potentially may manage a surrendered infant 

at cchealth.org/baby-safe 

• Each Safely Surrender Site (Fire Station) should have 2 Newborn Safe Surrender Kits 

on hand at all times. Replacement kits are available from Contra Costa County Public 

Health – Maternal and Child Health – (925) 313-6254. 

• Accept infant – even if more than 72 hours old 

• By law, the parent is under no obligation to provide information – no questions should be 

asked although parents may voluntarily provide information 

• Assess for medical needs and treat as indicated 

• Open Newborn Safely Surrender Kit, follow directions and complete documentation 

• Place confidential coded ankle bracelet on infant and record code on face of kit 

• Parent is handed two inner envelopes in kit which has matching code, survey forms, and 

information about their rights. Parent may leave at this point. 

• Notify dispatch and request code 2 ambulance to transport to nearest emergency 

department 

• The “Notes” section on face of Kit must be completed and the envelope must 

accompany the patient to the emergency department 

• PCR documentation must include bracelet code in narrative 

• If suspected abuse or neglect, contact law enforcement

HAZMAT 

RECOGNITION 

WHILE 

RESPONDING 

HAZMAT 

RECOGNITION 

WHILE ON 

SCENE 

HAZARDOUS MATERIALS – EXPOSURE MANAGEMENT PRINCIPLES 

If alerted to a known or suspected hazmat exposure prior to scene arrival: 

• Request from dispatch the location and safe route to staging area or IC 

• If no staging area, determine location and safe route to report to IC 

• Do not enter contaminated areas or approach contaminated patients until 

cleared to do so by Incident Commander or designee 

• Decontaminate patient - Appropriately trained personnel shall perform 

decontamination in a designated area 

• Obtain clearance from IC prior to transport 

• Obtain MSDS for chemical if available 

• After patient decontamination, provide care as indicated per treatment 

guidelines 

• Provide early alert to hospital – repeat decontamination may be needed 

If EMS personnel become aware that a patient in their care may have been 

contaminated by a unknown or suspected hazardous material: 

• EMS personnel should consider themselves contaminated 

• Minimize exposure by evacuating to an uphill/upwind safe location 

• If in cloud, travel crosswind until out of cloud 

• Notify fire/medical dispatch and IC of exposure 

• Request Hazardous Materials response team through Sheriff’s Dispatch 

• Request backup Fire / Transport as needed for affected EMS personnel and 

patients

HAZMAT 

RECOGNITION 

WHILE ON 

SCENE 

(CONTINUED) 

HAZMAT 

RECOGNITION 

WHILE 

TRANSPORTING 

GENERAL 

GUIDELINES 

FOR ALL 

SITUATIONS 

• Remain in safe area until Incident Commander arrives and provides further 

instructions 

• Prepare to be decontaminated 

• Decontaminate EMS personnel and patient(s) - Appropriately trained 

personnel shall perform decontamination in a designated area. 

If EMS personnel become aware while transporting that a patient may have been 

contaminated by a known or suspected hazardous material: 

• EMS personnel should consider themselves contaminated 

• Determine if safe to drive (e.g. rescuers with or without symptoms) 

• If not safe to drive, immediate decontamination is needed. Stop transport, 

notify Fire/Medical Dispatch and request CCHS HazMat response. Request 

Fire/Transport backup as needed. Protect from further exposure and prepare 

to be decontaminated. 

• If safe to drive (decontamination is not immediately indicated), proceed to 

hospital decontamination staging area. Alert hospital early of the HazMat 

situation. Request staging site if not known. Prepare to be decontaminated. 

• Provide prehospital medical care as soon as it is safe 

• All precautions should be taken to prevent contamination of hospital 

emergency department and personnel

9-1-1 ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS 

Criteria for upgrade to advanced life support (ALS) for non-emergency transport providers 

DEFINITIONS 

UNSTABLE 

PATIENTS 

• Unstable: A patient who has life- or limb-threatening condition requiring immediate and 

definitive care. An unstable patient may have respiratory distress, airway compromise, 

neurological changes from baseline, signs of actual or impending shock or may meet criteria 

for transport directly to a trauma center. 

• Non-emergency ambulance provider: An ambulance provider holding a valid Contra Costa 

non-emergency ambulance permit 

• 9-1-1 ambulance provider: An ambulance provider holding a valid Contra Costa emergency 

ambulance permit and/or contracting with the County to provide advanced life support 

ambulance response to 9-1-1 requests 

• Code 3: Responding to a location and/or transporting to a receiving facility using red lights 

and sirens 

• A patient, determined to be unstable and/or needing Code 3 transportation to a hospital shall 

be transported by a 9-1-1 provider, whenever possible. 

• Non-emergency ambulance providers may transport an unstable patient to the closest/ 

appropriate facility, if they can do so safely and the time from arrival on scene to arrival at the 

hospital is less than 10 minutes. In all other cases the non-emergency ambulance crew shall 

activate the 9-1-1 system and request an ALS response. 

• Any non-emergency ambulance provider transporting a patient that becomes unstable during 

transport should divert to the closest/appropriate ED per the Patient Destination Determination 

Policy (Policy #9). Receiving facilities should receive notification as soon as possible of the 

need for diversion, patient status and the ETA to that facility. 

• All transports by non-emergency ambulance providers of unstable patients, and/or transports 

requiring Code 3 transportation are considered an unusual occurrence. For each such 

occurrence an EMS Event report must be completed and submitted to the EMS Agency within 

24 hours of the call.

ON-VIEWS 

• In the event that a non-emergency ambulance provider arrives on the scene of a 

collision, illness or injury by coincidence, the crew shall provide appropriate care and 

immediately activate the 9-1-1 system

12-Lead ECG, STEMI, and Transmission 

BLS Airway Management 

Key Procedures 

Non-Invasive ETCO2 Monitoring 

Oxygen Therapy 

Oxygen Titration and Pulse Oximetry 

Pain Assessment and Management 

Pain Assessment Tools 

Pediatric Assessment 

Pediatric Vital Signs and GCS Scoring 

Pediatric Medication Administration 

Rule of 9s – Burn Surface Area 

Sepsis Screening 

Spinal Immobilization 

Vascular Access 

Ventricular Assist Devices (VAD) 

Procedures and 

Patient Care 

Reference

12-LEAD ACQUISITION AND LEAD PLACEMENT 

Sternal 

angle 

Limb Lead Placement: 

Place limb leads on distal extremities if possible 

Confirm correct lead placement for each limb 

May be moved to proximal if needed (if motion artifact) 

Chest Lead Placement: 

To begin placement of chest leads, locate sternal angle 

(2nd ribs are adjacent) then count down to 4th interspace 

(below 4th rib) 

V1 – 4th intercostal space at the right sternal border 

V2 – 4th intercostal space at the left sternal border 

V4 – 5th intercostal space at left midclavicular line 

Note: Place V4 lead first to aid in correct placement of 

V3 

V3 – Directly between V2 and V4 

V5 – Level of V4 at left anterior axillary line 

V6 – Level of V4 at left mid-axillary line 

Note: Careful skin preparation prior to lead placement 

(rub with gauze or abrasive, clean skin oils with alcohol) 

is critical to obtaining a high-quality ECG

LOCALIZING SITE OF INFARCT 

• Localization of an infarct pattern adds to the accuracy of ECG interpretation 

• A STEMI will have 1 mm or more ST-segment elevation in 2 or more contiguous leads (which means 

findings noted in the same anatomical location of the infarct) 

o Contiguous leads for inferior infarction include II, III, and aVF 

o Contiguous leads for anterior infarction include V1-V4 (V1-V2 elevation also called septal infarction) 

o Contiguous leads for lateral myocardial infarction include Leads I, aVL, V5, and V6 

o Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or 

inferolateral) 

I – LATERAL aVR 

II - INFERIOR aVL – LATERAL 

V1 – SEPTAL 

or ANTERIOR 

V2 – SEPTAL 

or ANTERIOR 

V4 – ANTERIOR 

(V4R – RVMI) 

V5 – LATERAL 

III – INFERIOR aVF - INFERIOR V3 – ANTERIOR V6 – LATERAL

STEMI 

RECOGNITION 

STEMI 

REPORT 

DESTINATION 

POLICY 

STEMI RECOGNITION AND DESTINATION 

• Patients who have ECGs of acceptable quality with the following messages are 

candidates for transport to STEMI Receiving Centers: 

o ***Acute MI*** (Zoll) 

o ***Acute MI Suspected*** (LIFEPAK 12) 

o ***Meets ST-Elevation MI Criteria*** (LIFEPAK15) 

• The 12-lead ECG should be inspected prior to initiation of a STEMI Alert – a steady 

baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation 

• Causes of artifact include patient motion or tremor, poor lead contact, or electrical 

interference 

• Good skin preparation is essential for optimal lead contact and clear 12-lead tracings 

• If artifact is noted the ECG should be repeated 

• Paced rhythms may cause false readings – the pacemaker spike is not always detected 

by the computer algorithm. Inform facility if patient has a pacemaker during report. 

If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon 

as possible following completion of the ECG 

Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC) 

• Patients shall be transported to the closest SRC unless they request another facility 

• A SRC that is not the closest facility is an acceptable destination if estimated additional 

transport time does not exceed 15 minutes 

• Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after 

arrest shall be transported to the closest SRC 

• Patients with unmanageable airway en route shall be transported to the closest available 

emergency department

STEMI REPORT 

• A patient with a computer interpretation of ***Acute MI*** (Zoll) or ***Acute MI Suspected*** (LP-12) or 

***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center 

• Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have 

significant baseline artifact or other deficit before initiating a STEMI Alert 

SITUATION 

BACKGROUND 

ASSESSMENT 

RX – RECAP 

• Identify the call as a “STEMI Alert” 

• Estimated time of arrival (ETA) in minutes 

• Patient age and gender 

• Report ECG computer interpretation has a STEMI message (as listed above) 

• Report if subsequent ECG findings are variable or if ECG quality not optimal (e.g., if no 

***Acute MI*** findings noted in tracings without significant artifact) 

• Verify that 12-lead ECG Transmission has been completed and received 

• Presenting chief complaint and symptoms 

• Pertinent past cardiac history 

• History of pacemaker (important – paced rhythms may give false ECG interpretations) 

• General assessment 

• Pertinent vitals (especially heart rate and BP) and physical exam 

• Cardiac rhythm 

• Pain level 

• Prehospital treatments given 

• Patient response to prehospital treatments

TRANSMISSION OF MONITOR DATA 

• 12-Lead ECG transmission is an enhancement to the STEMI system that allows facilities to interpret 12-lead data prior to 

patient arrival, appropriately prepare, and appropriately activate resources when indicated 

• Transmission of cardiac arrest monitor data and data related to treatment of dysrhythmias and patient intubations allows 

appropriate documentation and review of care provided in those situations 

12-Lead ECG Transmission 

12-LEAD 

TRANSMISSION 

IDENTIFIERS 

HOSPITAL 

NOTIFICATION 

REVIEW 

INDICATIONS 

FOR 

TRANSMISSION 

• All 12-Lead ECGs are to be transmitted 

• Any 12-Lead that indicates that the patient is having an STEMI should be transmitted to the STEMI receiving 

center where the patient is being transported 

• All other 12-Leads should be transmitted to the destination hospital site listed on the monitor 

At a minimum, 12-Lead ECG labeling should include initials of the first and last name of the patient Provider 

agencies may require additional labeling 

Once a STEMI 12-Lead has been transmitted to a STEMI receiving facility, that facility should be notified as soon as 

possible following the transmission of the ECG to verify receipt and to complete STEMI alert 

Not all hospitals have ability to review transmitted ECGs and some may filter out normal or non-acute appearing 

ECGs. Hard copies of ECGs also must be left at all receiving facilities. 

Transmission of Cardiac Arrest and Other Monitor Data 

• Cardiac arrests 

• Any calls that involve the treatment of a cardiac dysrhythmia (medication, cardioversion or pacing) 

• Any call involving monitoring of intubated patients 

• Any other call in which the paramedic believes data review may add to PCR documentation of events 

TRANSMISSION • Transmit these calls to the Arrest/Rhythm site listed on the monitor 

REVIEW 

• This data is transmitted to the provider agency and to EMS for review but does not go to hospitals for 

immediate access. Code summaries should be printed and left at receiving facilities. 

Note: Optimally, a single monitor should be used to gather data, particularly with regard to cardiac arrest or continuous monitoring of 

intubated patients

GOALS 

VENTILATION 

RATES AND 

DELIVERY 

PREFERRED 

MANEUVERS 

BLS AIRWAY MANAGEMENT 

The goal of airway management is to ensure adequate ventilation and oxygenation. 

Initial airway management should always begin with BLS Maneuvers 

Avoid excessive ventilation. In non-arrest patients, ventilation rates: 

Adults – 10 / minute 

Children – 20 / minute 

Infants – 30 / minute 

Deliver ventilations over one second to produce visible chest rise and to avoid 

distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary 

based on patient size. 

Two-person technique is the preferred method to ventilate patients using bag-valve 

mask device 

Maneuvers – Use “JAWS” 

J—Jaw thrust maneuvers to open airway 

A—Airway - Use oral or nasal airway 

W—Work together - Ventilation using a bag-valve mask should include two 

rescuers – one to hold mask and other to deliver ventilations 

S—Slow and small ventilations to produce visible chest rise

AIRWAY 

POSITIONING 

Position the patient to optimize airway opening and facilitate ventilations (see below) 

• Use the sniffing position with head extended (A) and neck flexed forward (B) 

unless suspected spinal injury 

• Position with head/shoulders elevated – anterior ear should be at the same 

horizontal level as the sternal notch (C). This is especially advantageous in 

larger or morbidly obese patients. 

A 

C

KEY PROCEDURES 

Skill Indication / Comment Contraindication 

12-LEAD ECG 

Autopulse 

(SRVFPD) 

Blood 

Glucose 

Testing 

• Chest pain or suspected Acute Coronary 

Syndrome (ACS) 

• Atypical ACS or anginal equivalents: 

o Symptoms include shortness of breath, 

diaphoresis, syncope, dizziness, weakness, 

and altered level of consciousness 

o Elderly patients, females and diabetics are 

more likely to present atypically 

• Arrhythmias (both pre- and post-conversion) 

• Suspected cardiogenic shock 

• Cardiac arrest after return of spontaneous 

circulation 

• Cardiac Arrest in Adults 


• Patients with signs and symptoms of 

hypoglycemia (may include diaphoresis, 

weakness, hunger, shakiness, anxiety) 

• Uncooperative patient 

• Any condition in which 

delay to obtain ECG would 

compromise immediately 

needed care (e.g. arrhythmia 

requiring immediate shock) 

• Pediatric patients 

• Trauma patients 

• Patients too small or large for 

the compression band 

• Patients not meeting any 

indication



Continuous 

Positive 

Airway 

Pressure 

(CPAP) 

Endotracheal 

Intubation 

Endotracheal 

Tube 

Introducer 

(Bougie) 

Patient has 2 or more findings: 

• RR >25 

• Pulse ox

External 

Cardiac 

Pacing 

Helmet 

Removal 



Impedance 

Threshold 

Device (ITD) - 

ResQPOD 

(SRVFPD) 

Symptomatic bradycardia 

Note: Use careful titration with midazolam or 

morphine if required for relief of discomfort 

Helmet should be removed if: 

• Interferes with airway management or spinal 

immobilization 

• Improper fit, allowing head to move within helmet 

• Patient in cardiac arrest 

Face mask of sports helmets can be removed to 

facilitate easy airway access. If helmet removed, 

shoulder pads (if worn) must also be removed to 

maintain neutral spinal alignment. 

• Patients ≥ 9 years of age in cardiac arrest 

o Remove if patient resumes spontaneous 

breathing or regains perfusing pulse 

Note: If secretions encountered, clear device by 

removing and shaking 

• Cardiac arrest 

• Hypothermia 

• Pediatric Patients 

• Patient airway and spinal 

immobilization can be addressed 

without helmet removal 

• Age below 9 years 

• Perfusing pulse or spontaneously 

breathing 

• History of traumatic cardiac arrest 

due to blunt chest trauma 

• Flail chest



Intranasal 

Naloxone 

King Airway 

LUCAS Chest 

Compression 

System 

• Patient with altered mental status, 

respiratory rate less than 12 and 

suspected opiate overdose 

Note: May be less effective in patients with 

prior nasal mucosal damage 


• Inability to ventilate non-arrest patient 

(with BLS airway maneuvers) in a setting 

in which endotracheal intubation is not 

successful or unable to be done 

Patients with medical cardiac arrest who 

properly fit device. 

• Shock 

• Copious nasal secretions or bleeding 

• Patients with established vascular access 

• Presence of gag reflex 

• Caustic ingestion 

• Known esophageal disease (e.g. cancer, varices, 

stricture) 

• Laryngectomy with stoma (place ET tube in stoma) 

• Height less than 4 feet 

• Traumatic arrest 

• Pregnant Patients 

• Improper fit of device 

o Too small – suction cup pad does not touch 

chest when lowered as far as possible 

o Too large – support legs of LUCAS cannot be 

locked to back plate without compressing patient



Needle 

Thoracostomy 

Oral Glucose 

Stomal 

Intubation 

Signs and symptoms of tension pneumothorax: 


• Decreased BP 

• Increased pulse and respirations 

• Absent breath sounds, hyperresonance to 

percussion on affected side 

• Jugular venous distention 

• Difficulty ventilating 

• Tracheal shift 

• Altered level of consciousness with known 

history of diabetes. Patient is conscious and 

should be able to sit in an upright position. 

• Administer up to 30 grams in the patient’s 

mouth. Optimally the patient will self-administer. 

Patients requiring intubation who have 

mature stoma and do not have a replacement 

tracheostomy tube available 

Note: Pass tube until cuff is just past stoma. If 

inserted further, mainstem bronchus intubation may 

occur as carina is only around 10 cm from stoma. 

Any condition without signs and symptoms of 

tension pneumothorax 

• Unconscious patient or unable to sit 

upright 

• If patient has difficulty swallowing, 

discontinue procedure and assure open 

airway 

Patients without mature stoma



Tourniquet 

(Combat 

Application 

Tourniquet) 

Tracheostomy 

Tube 

Replacement 

• External hemorrhage from extremity that cannot 

be controlled with application of dressings with 

direct pressure 

• May be appropriate for use for hemorrhage 

control in multi-casualty settings 

• Dislodged tracheostomy tube (decannulation) 

• Tracheostomy tube obstruction not resolved by 

suction 

• Hemorrhage that can be controlled with 

pressure or dressings 

• Recent tracheostomy surgery (less than 

1 month) 

• Inadequately sized tract or stoma for 

insertion of new tube (use endotracheal 

tube instead)

Non-Invasive 

ETCO2 

Monitoring 

Indications 

For ETCO2 

Monitoring 

ETCO2 

Findings 

NON-INVASIVE MONITORING OF END-TIDAL CO2 

• In patients without shock (normal perfusion), use of non-invasive end-tidal carbon dioxide measurement 

(ETCO 2 ) can be valuable in monitoring respiratory rate and ventilation 

• ETCO 2 measurements are an earlier indicator of respiratory depression than pulse oximetry 

• Patients at risk for inadequate ventilation may include: 

o Patients with borderline respiratory rates (8-12) from overdose or other cause (may help 

determine if naloxone appropriate) 

o Patients who have received medications such as morphine or midazolam that may depress 

respiratory rate. 

o Patients with chronic lung disease and chronic hypoxia - many patients have elevated 

ETCO 2 levels to begin with and rapidly increasing levels may indicate that a patient has 

decreased respirations due to oxygen therapy (loss of hypoxic drive) 

• ETCO 2 readings may be unreliable if there is shock or poor perfusion 

• Normal ETCO 2 levels range from 32-36, but this may vary based on the patient’s underlying 

respiratory and metabolic status 

• ETCO 2 levels that rise from a normal baseline to above 40 generally indicate hypoventilation is 

occurring 

• Patient stimulation, use of BVM, or use of naloxone may be appropriate based on the situation

Oxygen Safety 

Initial 

Indications for 

Oxygen 

BLS Oxygen 

Administration 

Oxygen 

Delivery 

OXYGEN THERAPY 

• Oxygen has the potential to be harmful to patients – the general goal is to have normal oxygen levels (normoxemia) 

– high levels are not better than normal levels. When pulse oximetry can be used, an sPO 2 of 94% 

is considered adequate. 

• Conditions in which high levels may be dangerous include stroke, patients who have return of circulation 

following cardiac arrest, and patients with severe chronic lung disease 

Supplemental oxygen is indicated in the following conditions: 

• Altered Level of Consciousness (e.g. overdose, seizure, stroke) 

• Cardiac Arrest 

• Chest Pain or other suspected cardiac problem (rapid or irregular pulse) 

• Obstetric complication (e.g. breech, prolapsed cord, bleeding or pain) 

• Respiratory Distress / Respiratory Depression or Apnea 

• Shock 

• Smoke or other chemical Inhalation 

• Suspected carbon monoxide exposure 

• Trauma (major) 

Follow specific treatment guidelines where applicable 

In general, patients in distress should receive high-flow oxygen initially 

• Chest pain and stroke patients without respiratory distress or shock should receive low-flow oxygen 

Low flow – Use nasal cannula with 4 L/min initial flow 

High-flow – Non-rebreather mask with 15 L/min flow 

Supplement with BVM if patient is apneic or has shallow respirations

Pulse 

Oximetry 

Pulse 

Oximetry 

Pitfalls 

ALS Oxygen 

Titration 

OXYGEN TITRATION AND PULSE OXIMETRY MONITORING 

• Utilize pulse oximetry in all patients with oxygen therapy or suspected hypoxia 

• Pulse oximetry is a tool to measure oxygenation, but must be combined with other assessments 

and skills to determine best patient care 

• Pulse oximetry readings can be misleading with poor perfusion (shock) or cold extremities, 

hypothermia, anemia or in carbon monoxide poisoning. 

• Readings may be difficult to obtain or unreliable during with excessive patient movement 

(e.g.seizures) or if nail polish is present. 

• High flow oxygen should be maintained in patients with shock and in those with severe respiratory 

distress or profound hypoxia 

• In most conditions, titration of oxygen should occur to assure an sPO 2 of at least 94% 

• Titration may involve decreasing the oxygen flow for either nasal cannula or non-rebreather 

masks, or switching from high to low flow devices 

• Stable patients without distress who have sPO 2 readings of 94% or greater without therapy do 

not need supplemental oxygen 

• Some patients with chronic lung problems will not be able to attain an sPO 2 of 94% and in fact 

may be at baseline with readings of 90% or less 

o The patient’s level of distress is an important finding in these cases –patients may be without 

distress at lower baseline levels and do not require high-flow oxygen

PAIN ASSESSMENT AND MANAGEMENT 

Relief of pain and suffering is an important component of quality EMS field care. Pain assessment is the 

5 th vital sign and should be performed on each patient using an age appropriate pain scale. Pain 

is a subjective experience for the patient and should be treated following the appropriate pain treatment 

guideline. 

Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts 

should be made to alleviate pain using both pharmacologic (e.g, Morphine, Nitroglycerin for cardiac cases) 

and non-pharmacologic (e.g., splinting, immobilization) measures. 

Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5 

minutes after every medication administration 

Assess pain using the same pain scale before and after pain administration and document 

Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved. 

Administer medication cautiously and monitor patient. 

Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can 

alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional 

narcotic administration.

FACES Pain 

Rating Scale 

(Ages 3 to adult) 

0-10 Numeric 

Pain Rating Scale 

(Ages > 9 yo) 

Pain Assessment 

in the Very Young, 

Non-Verbal Infant 

and Child 

PAIN ASSESSMENT TOOLS 

See pain scale and English/Spanish chart on back cover of field manual 

• Point to each face using the words to describe the pain intensity 

• Ask the patient to choose the face that best describes how they are feeling. A 

person does not have to be crying to have the worst pain. 

Explain scale (0 means no pain and 10 is the most severe pain they have ever 

had). Ask patients what number on a scale of 0-10 they would give as the level of 

pain currently. 

Pain assessment in infants, non-verbal young children or developmentally 

delayed children is more complex and presents special challenges. Despite 

this, pain medication should be considered in cases where the infant or child is 

in severe pain. This includes evidence of painful mechanisms such as burns, 

limb fractures or other events. Using pain medication in these children requires 

judgment and caution. Signs and symptoms of pain in non-verbal young or 

developmentally delayed children include: 

Inconsolable crying, screaming that cannot be distracted from by a caregiver 

High pitched crying 

Any pain face expression that is continual, such as grimace or quivering chin 

Constant tense/stiff body tone and/or guarding 

“Whatever is painful to adults, is painful to children until proven otherwise”

PEDIATRIC ASSESSMENT 

Begin interventions immediately and transport promptly if life-threatening conditions are identified 

in general visual assessment or primary assessment 

PEDIATRIC ASSESSMENT TRIANGLE - GENERAL VISUAL ASSESSMENT 

Assessment Abnormal 

Assess TICLS: Tone, Interactiveness, 

Appearance Any abnormality 

Consolability, Look/Gaze, Speech/Cry 

Work of 

Breathing 

Assess effort 

Increased or decreased effort or abnormal 

sounds 

Circulation Assess for skin color Abnormal skin color or external bleeding 

PREHOSPITAL PRIMARY ASSESSMENT 

Assessment Signs of Life-Threatening Condition 

Airway Assess patency Complete or severe airway obstruction 

Breathing 

Assess respiratory rate and effort, 

air movement, airway and breath 

sounds, pulse oximetry 

Apnea, slow respiratory rate, very fast respiratory 

rate or significant work of breathing 

Assess heart rate, pulses, capillary Tachycardia, bradycardia, absence of detectable 

Circulation refill, skin color and temperature, pulses, poor blood flow (increased capillary refill, 

blood pressure 

pallor, mottling, or cyanosis), hypotension 

Disability 

Assess AVPU response, pupil size 

and reaction to light, blood glucose 

Decreased response or abnormal motor response 

(posturing) to pain, unresponsiveness 

Hypothermia, rash (petichiae/purpura) consistent 

Exposure Assess skin for rash or trauma with septic shock, significant bleeding, abdominal 

distention

PEDIATRIC VITAL SIGNS / GLASGOW COMA SCALE 

Age Normal RR Normal HR Hypotension by systolic blood pressure 

Term Neonate 30-60 100-205 

Infant (

PEDIATRIC MEDICATION ADMINISTRATION 

Patient safety in medication administration is paramount. Accurate administration of 

pediatric medications requires multiple steps. Follow each of these steps in every case. 

Remember the 6 Rights – Right patient, right drug (and indication), right dose, right 

Assess Patient 

route of administration, right timing and frequency, right documentation 

Obtain Weight 

Estimate In Kg 

Determine Volume 

On Drug Chart 

Draw Up 

Medication 

Double Check To 

Confirm Volume 

Administer 

Medication 

Documentation 

• Use Broselow tape in every child of appropriate height to determine color range of 

weight 

o Broselow applies to patients less than 147 cm tall (4 feet 10 inches) 

• If taller than Broselow tape, estimate weight by patient/parent history or paramedic 

estimate and ALWAYS convert to kg using conversion table 

• Consult drug chart based on medication name to determine volume in ml 

• If 50 kg or greater, utilize adult dosages 

• Verify drug being administered 

• Utilize smallest syringe for volume (e.g. 1 ml or less, use tuberculin syringe) 

• When giving IM or intranasal medication, load syringe only with amount to be 

administered 

• Double-check volume and dose with drug chart in hand –verbalize name of 

medication, volume, dosage and route to another paramedic or EMT on scene 

• Administer by appropriate route 

• Observe patient for any signs of adverse reaction 

• Always document drug dosages in chart by mg (if dextrose, in grams) 

• Document response to medication and any observed adverse reaction

RULE OF NINES – BURN SURFACE AREA

SEPSIS SCREENING 

• Sepsis is a life-threatening condition that can occur when a systemic reaction known as Systemic Inflammatory 

Response Syndrome (SIRS) develops and is related to an infection 

• The inflammatory response may be the result of exposure to infectious agents in the blood, urine, lungs, skin, or 

other organs 

RISK 

FACTORS 

INDICATIONS 

FOR 

SCREENING 

ASSESSMENT 

CRITERIA 

FOR POSITIVE 

SCREEN 

HOSPITAL 

REPORTING 

Common risk factors for sepsis include elderly age, diabetes, and immunocompromised states. Other risk 

factors include cancer, renal disease, alcoholism, injection drug use, malnutrition, hypothermia, or recent 

surgery or invasive procedure. 

Sepsis screening should be done in adults when a patient is suspected of an infection. Examples include 

patients with the following: 

• Fever; 

• Respiratory symptoms such as tachypnea, shortness of breath, cough, sputum production; 

• Abdominal symptoms such as vomiting, diarrhea, or abdominal pain; 

• Urinary symptoms such as flank pain or painful / frequent urination; 

• Skin infections (cellulitis or abscess); 

• General weakness, altered level of consciousness or lethargy, especially in the elderly 

Sepsis screening includes assessment of pulse rate, respiratory rate and temperature. 

It is important to note that an elevated temperature may not be seen in sepsis, particularly in elderly 

patients or advanced stages. 

A positive sepsis screen in adults occurs in the setting of suspected infection when 2 of 3 conditions are 

met: 

• Heart rate/pulse greater than 90; 

• Respiratory rate greater than 20; 

• Temperature above 100.4 or below 96. 

If a positive sepsis screen is encountered, the receiving facility should be notified as part of the report from the 

field. Report the finding as a “positive sepsis screen.” Not all patients with a positive screen will have sepsis but 

alerting the facility may assist in calling attention to time-sensitive steps in evaluation and care that are needed 

to be taken upon hospital arrival.

Penetrating Injury 

(Trauma to head, 

neck or torso) 

Blunt Injury 

(Regardless of 

mechanism) 

Blunt Injury 

(When mechanism of 

injury is concerning) 

INDICATIONS FOR SPINAL IMMOBILIZATION 

• Presence of neurologic complaint or deficit – paralysis, weakness, 

numbness, tingling, priapism or neurogenic shock, loss of consciousness 

• Anatomic deformity of spine 

• Altered level of consciousness (GCS < 15) 

• Presence of spinal pain or tenderness 

• Anatomic deformity of spine 

• Presence of neurologic complaint or deficit – paralysis, weakness, 

numbness, tingling, priapism or neurogenic shock 

• Presence of alcohol or drugs or acute stress reaction / anxiety 

• Distracting injury (e.g. long bone fracture, large laceration, crush or 

degloving injury, large burns) 

• Inability to communicate (e.g. speech or hearing impaired, language gap, 

small children, developmental or psychiatric conditions) 

Concerning mechanisms of injury include but are not limited to: 

• Violent impact to head, neck, torso, or pelvis (e.g. assault, entrapment in structural collapse) 

• Sudden acceleration, deceleration or lateral bending forces to neck or torso (e.g., moderate- to highspeed 

MVC, pedestrian struck, explosion) 

• Falls (especially in elderly patients) 

• Ejection from motorized or other transportation device (e.g. scooter, skateboard, bicycle, motor 

vehicle, motorcycle, recreational vehicle, or horse) 

• Victims of shallow-water diving incident 

*** USE CLINICAL JUDGMENT – IF IN DOUBT, IMMOBILIZE ***

VASCULAR ACCESS 


Saline Lock 

Arm IV 

Antecubital IV 

Intraosseous 

Access (IO) 

External 

Jugular IV 

When medication alone is being given or a 

potential for medication is anticipated 

When fluids or medications needed and 

patient not in shock or arrest. Antecubital site 

not ideal unless no other vein available. 

• Shock 

• Adenosine (rapid IV bolus) 

• Cardiac arrest if IO cannot be obtained 

• Other peripheral sites not available and 

medications or fluids indicated 


• Profound shock or unstable dysrhythmia 

when rapid IV access or suitable vein 

cannot be rapidly located 

o Use lidocaine for pain control in nonarrest 

patients PRIOR to IO flush, fluid 

or medication (Infusion is painful!) 

Unstable patient needs emergent IV 

medication or fluids AND no peripheral site 

is available AND IO not appropriate (e.g. 

very alert patient) 

No anticipated need for prehospital 

medication or fluid 





• If no medication or fluid is being 

administered (do not use for 

prophylactic vascular access) 

• If patient stable 

• When other routes for medications 

available (IM, IN) 

• Contraindicated in cardiac arrest 

unless IO and antecubital IV cannot 

be started (interrupts CPR) 

• When other routes for medications 

available (IM, IN) – e.g. naloxone or 

use of glucagon instead of dextrose

BACKGROUND 

INFORMATION 

ASSESSMENT 

VENTRICULAR ASSIST DEVICES (VAD) 

• A Ventricular Assist Device (VAD) is an implanted device used to partially or 

completely replace the pumping function of a failing heart. VADs are used 

both as a bridge device while patients are awaiting heart transplant, and now 

increasingly are used permanently in patients who are not transplant candidates 

(referred to as destination therapy). 

• VAD patients and their families/caretakers have been given training for their 

devices and they should be capable of basic troubleshooting of the device. 

Hospitals that implant VADs have 24-hour on-call coverage (VAD Coordinators) 

for families or responders to contact in case of any issues. The contact phone 

number should be present on the patient’s equipment and this person may be 

able to help the family or responding personnel in assessing the device. 

• Depending on the type of VAD, a patient may or may not present with a palpable 

pulse, and blood pressure may not be detected, particularly with automatic 

measurements. Most newer VADs work without generating a pulse. The pulse, 

if present, may not correspond to the patient’s heart rate on the monitor. 

• In the absence the ability to detect pulse and blood pressure, patient evaluation 

of skin signs, level of consciousness, oxygen saturation, non-invasive end-tidal 

carbon-dioxide, and general appearance may give the best clues as to the 

patient’s clinical status.

TREATMENT 

DESTINATION 

AND 

DISPOSITION 

• Patients may be cardioverted or defibrillated if symptomatic, but asymptomatic 

dysrhythmias do not require treatment 

• VAD devices may become dislodged with chest compressions and this may lead 

to massive hemorrhage. Do not perform chest compressions on patients with 

VADs, even if the patient is unconscious. 

• Treatment should otherwise follow appropriate treatment guidelines. Medical 

direction is provided by the base hospital (VAD coordinators cannot provide 

medical direction). 

• In most circumstances, when transport is indicated the appropriate destination 

for the patient is the hospital where the VAD was implanted and the patient is 

managed. 

• For very minor conditions (e.g. small laceration repair) local transport may be 

appropriate. 

• Contact the base hospital if there are questions concerning destination. 

• If possible, the patient’s family member or caregiver should accompany the patient 

in the ambulance, and all related VAD equipment (e.g. spare batteries) should also 

be transported with the patient. 

• In arrest situations, determine if DNR/POLST or advance directives are available. 

Many VAD patients have made end-of-life care decisions.

Multicasualty Incident Tiers and Examples 

Radio Communications 

SBAR Reporting 

EMT Scope of Practice 

Paramedic Scope of Practice 

Paramedic Local Optional Scope of Practice 

Base Hospital and Receiving Centers 

Burn Centers 

Out-of-County Specialty Centers 

Operational and 

Regulatory 

References

TIER 

ZERO 

TIER 

ONE 

TIER 

TWO 

TIER 

THREE 

MULTICASUALTY INCIDENTS (MCI) – TIER DEFINITIONS and EXAMPLES 

• Official notification of an incident that has the potential to result in activation of the MCI plan at a 

higher tier, even when the number of known victims is zero 

• Activation at this tier is required for a Community Warning System Level II or Level III incident or any 

receiving hospital Emergency Department closure or evacuation (not diversion or trauma bypass) 

• Other examples of this might include active shooter where number of victims unknown or cannot be 

confirmed, emergency landing at airport, actual or potential significant hazmat incident, including 

transportation incidents 

• An incident involving 6-10 patients when the scene is contained and the number of patients is not 

expected to rise significantly 

• Examples include a multi-vehicle traffic collision, multiple known shooting victims and no ongoing 

active shooter threat 

• An incident involving more than 10 patients OR an incident involving less than 10 patients when 

there is a substantial chance that the number of patients may rise 

• EMS Transportation Resource Ordering will be processed by EMS Operational Area 

Communications Center (Sheriff’s Dispatch) 

• Examples include a petrochemical incident with a dispersal cloud moving over a populated area, 

passenger train derailment, or an active shooter with an uncontained scene 

• Any incident involving more than 50 patients, mass casualties, or a reasonable expectation of mass 

casualties 

• EMS Transportation Resource Ordering will be processed by EMS Operational Area 

Communications Center (Sheriff’s Dispatch) 

• Examples include a significant explosion around occupied commercial or multi-resident structure, or 

in a heavily populated area, or a large-scale evacuation of a hospital or skilled nursing facility

RADIO COMMUNICATIONS 

Four radio channels are designated for communications with hospitals in Contra Costa County. Receiving 

hospital communications are done via XCC EMS 2, whereas paramedic base hospital communications may occur 

via XCC EMS 2 or XCC EMS 3, depending on location 

XCC EMS 1 T: 491.4375 

Use for Sheriff’s Dispatch-to-ambulance communication 

(formerly L9) R: 488.4375 

XCC EMS 2 

(formerly L19) 

XCC EMS 3 

XCC EMS 4 

T: 491.9125 

R: 488.9125 

T: 491.6125 

R: 488.6125 

T: 491.6625 

R: 488.6625 

Primary channel for base contact for West County paramedic units. Also used 

county-wide for BLS and helicopter radio traffic 

Primary channel for base contact for paramedic units operating south of Ygnacio 

Valley Road and west of I-680 along Highway 24 

Primary channel for base contact for paramedic units operating in East County and 

Central County north of Ygnacio Valley Road 

Whenever possible, paramedic personnel should use the XCC EMS channel assigned to the area in which they are 

responding, for ambulance-to-base hospital communications. XCC EMS 2 is the county-wide backup ALS channel and 

should be used if XCC EMS 3 or XCC EMS 4 is not available. Ambulance and helicopter personnel are to contact Sheriff’s 

Dispatch on XCC EMS 1 to request the use of XCC EMS 2 prior to utilizing the channel. The dispatcher shall be given unit 

identification and a description of current traffic (Code 2, Code 3 or trauma destination decision). 

No request for use is necessary for XCC EMS 3 or XCC EMS 4. However, each unit must monitor the channel prior to use 

to ensure that other units are not already using the channel. Radio identification procedures must be strictly followed, as 

more than one call may be occurring at the same time. If traffic is in progress on a XCC EMS channel, other ambulance 

personnel may either wait until current traffic is finished or find an alternate means of contacting the desired hospital. 

Any unit may, in cases such as trauma destination decisions, request that Sheriff’s Dispatch break into current traffic 

on XCC EMS 2 to request temporary use of the channel. Units using XCC EMS 3 or XCC EMS 4 may request use 

of the channel from a unit that is currently on that channel. When making base contact for trauma destination only, 

the initial transmission should make the purpose of the call clear. Cellular phones may also be used as a means of 

communication.

SBAR REPORTING 

SBAR is a tool that is recommended to assure timely, effective communication during all patientrelated 

communications between all health care providers. SBAR assures that urgent issues and 

immediate needs get addressed up front. SBAR is compatible with the trauma MIVT reporting. 

Routine use during base contact and patient handoff supports safe and effective patient care. 

Key Information SBAR Report Example 

SITUATION 

BACKGROUND 

ASSESSMENT 

RX RECAP 

• Identify yourself 

• What is the situation? 

• State urgent issues and immediate 

needs up front! 

• What has happened up to this point? 

• What past history would be important 

to know for further patient treatment? 

(e.g. high risk medications, past 

medical history) 

• How is the patient now? 

• Improved or worse since on scene? 

• Patient stable or unstable? 

• What field care given? 

• Was it effective? 

• Concerns? 

This is Unit 123 with a STEMI alert 

Patient is a 45 yo male with 12 lead 

positive for ST elevation 

Patient started having chest pain 

off and on the last 2 hours. Family 

called 911. Patient has no history of 

heart problems and takes Lipitor and 

metformin. 

RR 28 labored B/P 160/98 Diaphoretic, 

Pain 9 out 10, 12 lead ***Acute MI*** no 

significant artifact seen. No significant 

change with treatment. Airway stable. 

ASA, Nitro X 2 and 100% rebreather 

STEMI alert

S 

B 

A 

R 

TRAUMA BASE CALL EXAMPLE (Destination Decision Report) 

This is paramedic unit 123 with a trauma call, requesting destination decision. We have a 66-yearold 

male with a fall and altered level of consciousness, and we think the patient needs trauma center 

activation. Our ETA is 20 minutes. 

The patient was working on his roof and fell approximately 10 feet, landing on his head on a cement 

path. He sustained an injury to the right parietal area and there is significant swelling in that area. He 

has a GCS of 14. He is apparently generally healthy although he does take aspirin daily. 

BP 180/110, pulse 52, RR 10. SpO2 95%. His airway is stable. The patient is awake and 

cooperative, but is confused has repetitive questioning. He is vomiting and complains of a severe 

headache. He also has right chest wall tenderness but no flail chest, and has deformity of his right 

forearm with intact CMSTP. 

We have him on 100% oxygen, in spinal precautions. We are going to be splinting his right forearm 

and will start an IV en route. We believe he needs trauma activation. 

TRAUMA HAND-OFF EXAMPLE (Report at Trauma Center) 

S MECHANISM This is unit 123 with a 66-year-old male who fell from a roof onto a cement path 

B INJURIES 

Swelling and deformity in the right parietal area. He is confused, with repetitive 

questioning, vomiting, and complaining of a severe headache. He also has pain 

in the right chest and deformity of the right forearm which we splinted. 

A VITAL SIGNS BP 180/110, pulse 52, RR 10. SpO2 95%. GCS is 14 

R TREATMENT 100% oxygen non-rebreather, IV placed and infusing NS

EMT SCOPE OF PRACTICE (STATE REGULATION) 

“Emergency Medical Technician” or “EMT” means a person who has successfully completed an EMT course 

which meets the requirements of this Chapter, has passed all required tests, and who has been certified by 

the EMT certifying authority 

100063. Scope of Practice of Emergency Medical Technician (EMT) 

a) During training, while at the scene of an emergency, during transport of the sick or injured, or during 

interfacility transfer, a supervised EMT student or certified EMT is authorized to do any of the following: 

1) Evaluate the ill and injured. 

2) Render basic life support, rescue and emergency medical care to patients. 

3) Obtain diagnostic signs to include, but not be limited to the assessment of temperature, blood 

pressure, pulse and respiration rates, level of consciousness, and pupil status. 

4) Perform cardiopulmonary resuscitation (CPR), including the use of mechanical adjuncts to basic 

cardiopulmonary resuscitation. 

5) Use the following adjunctive airway breathing aids: 

A) oropharyngeal airway; 

B) nasopharyngeal airway; 

C) suction devices; 

D) basic oxygen delivery devices; and 

E) manual and mechanical ventilating devices designed for prehospital use. 

6) Use various types of stretchers and body immobilization devices. 

7) Provide initial prehospital emergency care of trauma. 

8) Administer oral glucose or sugar solutions. 

9) Extricate entrapped persons. 

10) Perform field triage.

11) Transport patients. 

EMT SCOPE OF PRACTICE (STATE REGULATION) 

12) Set up for ALS procedures, under the direction of an Advanced EMT or Paramedic. 

13) Perform automated external defibrillation when authorized by an EMT AED service provider. 

14) Assist patients with the administration of physician prescribed devices, including but 

not limited to, patient operated medication pumps, sublingual nitroglycerin, and selfadministered 

emergency medications, including epinephrine devices. 

15) In addition to the activities authorized by subdivision (a) of this section, the medical director 

of the local EMS agency may also establish policies and procedures to allow a certified 

EMT or a supervised EMT student in the prehospital setting and/or during interfacility 

transport to: 

A) Monitor intravenous lines delivering glucose solutions or isotonic balanced salt solutions 

including Ringer’s lactate for volume replacement; 

B) Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow and turn 

off the flow of intravenous fluid; and 

C) Transfer a patient who is deemed appropriate for transfer by the transferring physician, 

and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, 

tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines; 

D) Monitor preexisting vascular access devices and peripheral lines delivering intravenous 

fluids with additional medications pre-approved by the Director of the EMS Authority (not 

currently allowed in Contra Costa County).

PARAMEDIC SCOPE OF PRACTICE 

California Code of Regulations, Title 22, Division 9, Chapter 4: 

100145. Scope of Practice of Paramedic. 

a) A paramedic may perform any activity identified in the scope of practice of an EMT in Chapter 2 of the Division, or 

any activity identified in the scope of practice of an Advanced EMT in Chapter 3 of this Division. 

b) A paramedic shall be affiliated with an approved paramedic service provider in order to perform the scope of 

practice specified in this Chapter. 

c) A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a 

hospital as part of his/her training or continuing education under the direct supervision of a physician, registered 

nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during 

interfacility transfer, or while working in a small and rural hospital pursuant to section 1797.195 of the Health 

and Safety Code, may perform the following procedures or administer the following medications when such are 

approved by the medical director of the local EMS agency and are included in the written policies and procedures 

of the local EMS agency. 

1) Basic Scope of Practice: 

A) Perform defibrillation and synchronized cardioversion. 

B) Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps. 

C) Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway, stomal 

intubation, and adult endotracheal intubation. 

D) Institute intravenous (IV) catheters, saline locks, needles, or other cannulae (IV lines), in peripheral veins; 

and monitor and administer medications through pre-existing vascular access. 

E) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer’s lactate 

solution. 

F) Obtain venous blood samples. 

G) Use glucose measuring device. 

H) Utilize Valsalva maneuver. 

I) Perform needle cricothyroidotomy. (not currently used in Contra Costa County) 

J) Perform needle thoracostomy. 

K) Monitor thoracostomy tubes

PARAMEDIC SCOPE OF PRACTICE 

L) Monitor and adjust IV solutions containing potassium, equal to or less than 20 mEq/L. 

M) Administer approved medications by the following routes: intravenous, intramuscular, subcutaneous, 

inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or topical. 

N) Administer, using prepackaged products when available, the following medications: 

(1) 25% and 50% dextrose; 

(2) activated charcoal; (not currently used in Contra Costa County) 

(3) adenosine; 

(4) aerosolized or nebulized beta-2 specific bronchodilators; 

(5) aspirin; 

(6) atropine sulfate; 

(7) pralidoxime chloride; 

(8) calcium chloride; 

(9) diazepam; (not currently used in Contra Costa County) 

(10) diphenhydramine hydrochloride; 

(11) dopamine hydrochloride; (not currently used in Contra Costa County) 

(12) epinephrine; 

(13) furosemide; (not currently used in Contra Costa County) 

(14) glucagon; 

(15) midazolam 

(16) lidocaine hydrochloride; 

(17) morphine sulfate; 

(18) naloxone hydrochloride; 

(19) nitroglycerin preparations, except intravenous, unless permitted under (c)(2)(A) of this section; 

(20) sodium bicarbonate

PARAMEDIC SCOPE OF PRACTICE (continued) – LOCAL OPTIONAL SCOPE 

Paramedic Regulations (continued) 

2) Local Optional Scope of Practice: 

A) Perform or monitor other procedure(s) or administer any other medication(s) determined to be 

appropriate for paramedic use, in the professional judgment of the medical director of the local EMS 

agency, that have been approved by the Director of the Emergency Medical Services Authority 

when the paramedic has been trained and tested to demonstrate competence in performing the 

additional procedures and administering the additional medications. 

CONTRA COSTA LOCAL OPTIONAL SCOPE 

• Amiodarone 

• Esophageal Airway (King LTS-D) 

• External Cardiac Pacing 

• Impedance Threshold Device (ResQPOD) 

• Intraosseous Infusion 

• Pediatric Endotracheal Intubation (limited to patients > 40 kg) 

CONTRA COSTA LOCAL OPTIONAL SCOPE ITEMS 

ITEMS LIMITED TO CRITICAL CARE TRANSPORT PARAMEDICS ONLY 

• Blood/Blood Product Infusion 

• Glycoprotein IIb/IIIa Receptor Inhibitor Infusion 

• Heparin Infusion 

• Ipratropium 

• KCL Infusion 

• Lidocaine Infusion 

• Midazolam Infusion 

• Morphine Sulfate Infusion 

• Nitroglycerin Infusion 

• Sodium Bicarbonate Infusion 

• Total Parenteral Nutrition (TPN) Infusion

Hospital 

Contra Costa County Base Hospital 

Base Phone ED Phone 

John Muir Health - Walnut Creek Campus 

1601 Ygnacio Valley Road 

Taped: 

(925) 939-5804 

Receiving Facility 

Notification: 

(925) 947-3379 

Walnut Creek CA 94598 

ED: (925) 939-5800 

Contra Costa County Hospitals (Receiving Facilities) 

Hospital Services ED Phone 

Contra Costa Regional Medical Center 

2500 Alhambra Avenue 

Martinez CA 94553 

Doctors Medical Center – San Pablo 

2000 Vale Road 

San Pablo CA 94806 

John Muir Health - Concord Campus 

2540 East Street 

Concord CA 94520 

John Muir Health - Walnut Creek Campus 

1601 Ygnacio Valley Road 


Basic ED 

OB/Neonatal 

Basic ED 

STEMI Center 

Stroke Center 

Basic ED 

STEMI Center 

Stroke Center 

Basic ED 

OB/Neonatal 

Trauma Center 

STEMI Center 

Stroke Center 

XCC EMS 2 

Alert Code 

14524 

XCC EMS 2 

Alert Code 

(925) 370-5971 14574 

(510) 234-6010 13613 

(925) 689-0553 14214 

Receiving Facility 

Notification: 

(925) 947-3379 

ED: (925) 939-5800 

14524

Kaiser Medical Center – Antioch 

5001 Deer Valley Road 

Antioch CA 94531 

Kaiser Medical Center – Richmond 

901 Nevin Avenue 

Richmond CA 94504 

Kaiser Medical Center – Walnut Creek 

1425 South Main Street 


San Ramon Regional Medical Center 

6001 Norris Canyon Road 

San Ramon CA 94583 

Sutter/Delta Medical Center 

3901 Lone Tree Way 

Antioch CA 94509 

Basic ED 

OB/Neonatal 

Stroke Center 

Basic ED 

Stroke Center 

Basic ED 

OB/Neonatal 

STEMI Center 

Stroke Center 

Basic ED 

OB/Neonatal 

STEMI Center 

Stroke Center 

Basic ED 

OB/Neonatal 

STEMI Center 

(925) 813-6099 14564 

(510) 307-1758 13653 

(925) 939-1788 14284 

(925) 275-8338 13623 

(925) 779-7273 14294

BURN CENTERS 

Hospital Services Phone 

Santa Clara Valley Medical Center 

751 S. Bascom Avenue 

San Jose CA 

UC Davis Medical Center 

Regional Burn Center 

2315 Stockton Blvd. 

Sacramento CA 

St. Francis Burn Center 

900 Hyde Street 

San Francisco CA 

Adult and Pediatric Burn Center 408-885-6666 

Adult and Pediatric Burn Center 916-734-3636 

Adult and Pediatric Burn Center 

(No Helipad available) 

415-353-6255

OUT-OF-COUNTY SPECIALTY CENTERS 

Hospital Type ED Phone 

Alameda County Medical Center – Oakland (Highland) Trauma 510-535-6000 

Alta Bates Medical Center – Berkeley Stroke 510-204-2500 

Children’s Hospital – Oakland Trauma 510-428-3240 

Eden Medical Center – Castro Valley 

Trauma 

Stroke 

510-889-5015 

Kaiser Oakland Stroke 510-752-7667 

Kaiser South Sacramento Trauma 916-688-6964 

Marin General Hospital Trauma 415-925-7203 

San Francisco General Hospital Trauma 415-647-4747 

Summit Campus – Alta Bates Medical Center - Oakland 

STEMI 

Stroke 

UC Davis Medical Center - Sacramento Trauma 

510-869-8797 

916-734-3892 

916-734-5669 

Valley Care – Pleasanton STEMI 925-416-6518

Adult Drug Reference 

Pediatric Drug Reference 

Pediatric Drug Dosage Charts 

Drug 

References

ADULT DRUG REFERENCE 

Drug Indication Adult Dosage Precautions / Comments 

ADENOSINE Paroxysmal SVT 

ALBUTEROL 

AMIODARONE 

Bronchospasm 

Crush Injury – 

Hyperkalemia 

Ventricular 

Fibrillation or 

Pulseless VT 

Stable Ventricular 

Tachycardia 

1 st Dose – 6 mg rapid IV 

2 nd Dose – 12 mg rapid 

IV push 

Follow each dose with 

rapid bolus of 20 ml NS 

5 mg in 6 ml NS 

nebulized 

5 mg in 6 ml NS 

nebulized continuously 

300 mg IV or IO bolus, 

repeat 150 mg bolus if 

rhythm persists 

150 mg IV infusion or 

slow IV push over 10 

minutes (15 mg/minute) 

May cause transient heart block 

or asystole. Side effects include 

chest pressure/pain, palpitations, 

hypotension, dyspnea, or 

feeling of impending doom. Use 

caution when patient is taking 

carmbamazepine, dipyramidole, 

or methylxanthines. Do not 

administer if acute asthma 

exacerbation. 

Repeat as needed for 

bronchospasm 

Use with caution in patients taking 

MAO inhibitors (antidepressants 

Nardil and Parnate) 

In patient with pulses, may cause 

hypotension. Do not administer 

if patient hypotensive. When 

creating infusion, careful mixing 

needed to avoid foaming of 

medication (do not use filter 

needle).

ASPIRIN 

ATROPINE 

CALCIUM 

CHLORIDE 



Chest Pain – 

Suspected ACS 

Symptomatic 

Bradycardia 

Organophosphate 

poisoning 

Hyperkalemia – 

Arrest 

Hyperkalemia – 

Crush Injury 

Hydrofluoric Acid 

Toxicity 

DEXTROSE 10% Hypoglycemia 

4 – 81 mg tabs – chewed 

0.5 mg IV or IO every 3-5 

minutes up to max. 3 mg 

1-2 mg IV or IO – repeat 

every 3-5 min. as needed 

to decrease symptoms 

500 mg IV or IO slowly May 

repeat in 5-10 minutes 

1 gm IV or IO slowly over 

60 seconds 

500 mg IV or IO slowly 

10 g initially (100 ml). If 

glucose remains 60 or 

below, give additional 15 g 

(150 ml) 

Contraindicated in aspirin or salicylate 

allergy. Coumadin or Plavix use is not 

a contraindication. 

Atropine can dilate pupils, aggravate 

glaucoma, cause urinary retention, 

confusion, and dysrhythmias, including 

V-tach and Vfib. Doses less than 0.5 

mg can cause paradoxical bradycardia. 

Increases myocardial oxygen 

consumption. 

Remove clothing of victim of 

organophosphate poisonings, and flush 

skin to remove traces of poison 

Use cautiously or not at all in patients 

on digitalis. Avoid 

extravasation 

Rapid administration can cause 

dysrhythmias or arrest 

Recheck glucose after administration



DEXTROSE 50% Hypoglycemia 25 g IV 

Use D10 initially – use D50 if 

repeat dosage needed 


EPINEPHRINE 

1:10,000 

EPINEPHRINE 

1:1000 

Allergy – Hives / 

Itching 

Dystonic Reaction 

Cardiac Arrest 

Anaphylactic 

Shock 

Allergy/ 

Anaphylactic 

Shock 

Asthma 

25-50 mg IV or IM 

1 mg IV or IO every 3-5 

minutes 

0.1 mg increments IV or IO 

up to 0.5 mg IV total dose 

Use only if IM treatment 

ineffective 

0.3-0.5 mg IM 

Use lower dose in smaller, 

older patients 

0.3 mg subcutaneously 

0.3 mg IM if respiratory 

arrest from asthma or 

bronchospasm 

For allergy, consider lower 

dose if patient has already 

taken po dose in past two 

hours for symptoms 

Alpha & beta 

sympathomimetic. 

May cause serious 

dysrhythmias and exacerbate 

angina. 

Never administer 

intravenously! 

Do not use in asthma patients 

with a history of hypertension 

or coronary artery disease. 

May cause serious 

dysrhythmias and exacerbate 

angina.

Drug Indication 


Adult Dosage Precautions / Comments 

GLUCAGON Hypoglycemia 1 mg IM Effect may be delayed 5–20 min 

LIDOCAINE IO Anesthesia 

40 mg IO 

Repeat dose 20 mg 

Administer slowly over 1 minute 

Not needed in arrest situations 

MIDAZOLAM 

MORPHINE 

Seizure 

Sedation for pacing 

or cardioversion 

Sedation – transfer 

of intubated patient 

Behavioral 

Emergency 

Pain Control 

Trauma, Burn or 

Non-Traumatic Pain 

Sedation – Pacing 

Pulmonary Edema 

Titrate 1-5 mg IV in 1-2 

mg increments 

0.1 mg/kg IM 

(max. dose 5 mg IM) 

Titrate 1-5 mg IV in 1-2 

mg increments 

Titrate 2-5 mg IV in up to 

2 mg increments 

5 mg IM 

1-5 mg IV in 1 mg 

increments if IV available 

2-20 mg IV 

(2-5 mg increments) 

5-20 mg IM 

(max single dose 10 mg) 

1-5 mg IV in 1 mg 

increments 

2-5 mg IV in 1-2 mg 

increments 

With IV dosing, begin with 

1 mg dose. IV increments should not 

exceed 2 mg. 

Observe respiratory status 

Use with caution in patients over age 60 

Base order required for behavioral 

emergency indication 

Can cause hypotension and respiratory 

depression. Recheck VS between each 

dose. Hypotension more common in 

patients with low cardiac output or volume 

depletion. Nausea is a frequent side 

effect. Respiratory depression reversible 

with naloxone.

NALOXONE 



NITROGLYCERIN 

ONDANSETRON 

SODIUM 

BICARBONATE 

Respiratory 

Depression or 

Apnea 

(Respiratory rate 

less than 12) 

Chest Pain – 

Suspected ACS 

Pulmonary Edema 

Vomiting and 

Severe Nausea 

2 mg intranasally (IN) 

1-2 mg IV or IM 

For careful titration in 

chronic pain or terminal 

patients, dilute 1:10 and 

give 0.1 mg increments 

0.4 mg sl or spray 

up to 3 doses 


if systolic BP 90-149 


if systolic BP 150 or over 

Max.dose 4.8 mg 

4 mg IV, IM or po (ODT) 

May repeat q 10 min X 2 

Cardiac arrest 1 mEq/kg IV or IO 

Tricyclic 

Antidepressant OD 

Crush injury 

For crush injury, consider 

additional 1 mEq/kg added 

to 1L NS using second 

IV line 

Intranasal administration preferred 

unless patient in shock or has copious 

secretion/blood in nares. 

Shorter duration of action than that 

of most narcotics. Abrupt withdrawal 

symptoms and combative behavior 

may occur. 

Can cause hypotension and 

headache. Do not give if BP less 

than 90 systolic or heart rate below 

50. Perform 12-lead ECG before 

administration. Do not give if STEMI 

detected. Do not give if Viagra, 

Levitra, Staxyn or Stendra taken 

within 24 hours or if Cialis taken 

within 36 hours. 

Give IV over 1 minute – may cause 

syncope if administered too rapidly 

Assure adequate ventilation. Can 

precipitate or inactivate other drugs. 

In cardiac arrest, indicated for 

treatment of suspected hyperkalemia 

(history of renal failure or diabetes).

ADENOSINE 

PEDIATRIC DRUG REFERENCE 

Drug Indication Pediatric Dosage Precautions / Comments 

Paroxysmal 

SVT 

1st Dose – 0.1 mg/kg rapid IV 

(max. 6 mg) 

2nd Dose – 0.2 mg/kg rapid 

IV (max 12 mg) 

Follow each dose with rapid 

10-20 ml NS bolus 

Base Order Required: 

May cause transient heart block 

or asystole. Side effects include 

chest pressure/pain, palpitations, 

hypotension, dyspnea, or feeling 

of impending doom. Do not 

administer if acute exacerbation 

of asthma. 

ALBUTEROL Bronchospasm 5 mg in 6 ml NS nebulized Repeat as needed 

AMIODARONE 

ATROPINE 

Ventricular 

Fibrillation or 

Pulseless VT 

Symptomatic 

Bradycardia 

5 mg/kg IV or IO bolus 

Maximum dose 300 mg 

0.02 mg/kg IV or IO 

Minimum dose 0.1 mg 

Maximum dose 0.5 mg 

Bradycardia in pediatric patients 

primarily related to respiratory 

issue – assure adequate 

ventilation first



DEXTROSE 10% Hypoglycemia 


EPINEPHRINE 1:10,000 


Allergy - Hives / 

Itching 

Cardiac Arrest 

Anaphylactic 

Shock 

Allergy/ 

Anaphylactic 

Shock 

Asthma 

GLUCAGON Hypoglycemia 

0.5 g/kg IV (5 ml/kg) 

Maximum 250 ml 

1 mg/kg IV or IM 


0.01 mg/kg IV or IO 

every 3-5 minutes Max. 

dose 1 mg 

Titrate in up to 0.1 mg 

increments slow IV or IO 

to a max. of 0.01 mg/kg 

0.01 mg/kg IM Max 

single dose 0.3 mg 

0.01 mg/kg 

subcutaneously 

Maximum dose 0.3 mg 

Weight less than 24 kg: 

0.5 mg IM 

Weight 24 kg or more: 

1 mg IM 

Recheck glucose after 

administration 

Consider lower dose (0.5 mg/kg) if 

patient has already taken po dose 

in the past two hours for symptoms 

In anaphylactic shock, IM 

epinephrine 1:1000 should be 

administered first and epinephrine 

1:10,000 IV should only be used if 

IM is ineffective 

Never administer intravenously! 

If respiratory arrest from asthma or 

bronchospasm, administer IM 

Effect may be delayed 5–20 

minutes - if patient responds, give 

po sugar



LIDOCAINE IO Pain 

MIDAZOLAM 

Seizure 

Sedation for 

Cardioversion 

MORPHINE Pain Control 

NALOXONE 

ONDANSETRON 

Respiratory 

Depression or 

Apnea 

Vomiting and 

Severe Nausea 

0.5 mg/kg IO. 


Titrate in up to 1 mg 

increments IV up to 0.1 mg/kg 

Maximum total IV dose 5 mg 

0.1 mg/kg IM Maximum dose 

5 mg IM 

0.1 mg/kg IV or IO titrated in 

1 mg increments 


See pain management drug 

chart for dosage. Use IV 

increments of up to 2 mg 

0.1 mg/kg IM 

0.1 mg/kg IM or IV 


May repeat as needed 

4 mg IV, IM, or po (ODT) 

In patients 40 kg and over, 

may repeat q 10 min X 2 

Give slowly over one minute. 

Not needed in arrest situations 

Observe respiratory status carefully 

Sedation and cardioversion only with base hospital 

order 

Can cause hypotension and respiratory 

depression. Hypotension is more common in 

patients with volume depletion. Nausea is a 

frequent side effect. 

Use IM route initially unless shock present. Shorter 

duration of action than that of most narcotics. 

For use in patients 4 years and up. 

Administer IV over 1 minute. Rapid administration 

may cause syncope.

Yellow (12-14 kg) 

2.7 mg 2nd - 0.9 ml 

1.7 mg 1 

White (15-18 kg) 

st - 0.6 ml 

3.4 mg 2nd - 1.2 ml 

2.1 mg 1 

Blue (19-23 kg) 

st - 0.7 ml 

4.2 mg 2nd - 1.4 ml 

2.7 mg 1 

Orange (24-29 kg) 

st - 0.9 ml 

5.4 mg 2nd - 1.8 ml 

3.3 mg 1 

Green (30-36 kg) 

st - 1.1 ml 

6.6 mg 2nd - 2.2 ml 

4 mg 1 

40 kg 

st - 1.3 ml 

8 mg 2nd - 2.7 ml 

4.5 mg 1 

45 kg 

st - 1.5 ml 

9 mg 2nd - 3 ml 

Note: Follow with rapid bolus 10-20 ml NS 

DOSES 

GIVE (ml) 

(mg) 

0.45 mg 1st - 0.15 ml 

0.9 mg 2nd - 0.3 ml 

0.66 mg 1st - 0.22 ml 

1.35 mg 2nd - 0.45 ml 

0.9 mg 1st - 0.3 ml 

1.8 mg 2nd - 0.6 ml 

1 mg 1st - 0.33 ml 

2 mg 2nd - 0.67 ml 

1.35 mg 1st - 0.45 ml 

Purple (10-11 kg) 

Red (8-9 kg) 

Pink (6-7 kg) 

Gray (3-5 kg) 

COLOR 

Concentration = 3 mg/ml 

1st Dose = 0.1 mg/kg IV 2nd Dose = 0.2 mg/kg IV 

Base Order Only 

ADENOSINE 

INDICATION: SUPRAVENTRICULAR TACHYCARDIA

40 kg 200 mg 4 ml 

45 kg 225 mg 4.5 ml 

Orange (24-29 kg) 130 mg 2.6 ml 

Green (30-36 kg) 170 mg 3.4 ml 

White (15-18 kg) 80 mg 1.6 ml 

Blue (19-23 kg) 100 mg 2 ml 

Purple (10-11 kg) 50 mg 1 ml 

Yellow (12-14 kg) 65 mg 1.3 ml 

Pink (6-7 kg) 35 mg 0.7 ml 

Red (8-9 kg) 45 mg 0.9 ml 

COLOR DOSE (mg) GIVE (ml) 

Gray (3-5 kg) Not given 


Dose = 5 mg/kg IV 

AMIODARONE 

INDICATION – VENTRICULAR FIBRILLATION

Assure adequate ventilation before considering atropine 

Not indicated for asystole 

40 kg 0.5 mg 5 ml 

45 kg 0.5 mg 5 ml 

Orange (24-29 kg) 0.5 mg 5 ml 

Green (30-36 kg) 0.5 mg 5 ml 

White (15-18 kg) 0.35 mg 3.5 ml 

Blue (19-23 kg) 0.42 mg 4.2 ml 

Purple (10-11 kg) 0.2 mg 2 ml 

Yellow (12-14 kg) 0.25 mg 2.5 ml 

Pink (6-7 kg) 0.13 mg 1.3 ml 

Red (8-9 kg) 0.17 mg 1.7 ml 


Gray (3-5 kg) 0.1 mg 1 ml 

Concentration = 0.1 mg/ml 

Dose = 0.02 mg/kg IV 

Minimum Dose – 0.1 mg IV 

Maximum Dose – 0.5 mg IV 

ATROPINE 

INDICATION – SYMPTOMATIC BRADYCARDIA

Note: Cardioversion energy dosages are equal to 

first and second energy levels. Cardioversion in 

pediatric patients requires base hospital direction. 

40 kg 70 J 150 J 360 J 

45 kg 100 J 175 J 360 J 

Orange (24-29 kg) 50 J 100 J 250 J 

Green (30-36 kg) 70 J 125 J 300 J 

White (15-18 kg) 30 J 70 J 175 J 

Blue (19-23 kg) 30 J 70 J 200 J 

Purple (10-11 kg) 20 J 30 J 100 J 

Yellow (12-14 kg) 30 J 50 J 125 J 

Pink (6-7 kg) 15 J 30 J 50 J 

Red (8-9 kg) 15 J 30 J 70 J 

COLOR First Second Maximum 

Gray (3-5 kg) 8 J 15 J 30 J 


PHYSIO-CONTROL 

Energy Selection 

(LP-12 and LP-15)

Note: Cardioversion energy dosages are equal to 

first and second energy levels. Cardioversion in 

pediatric patients requires base hospital direction. 

45 kg 75 J 150 J 200 J 

Green (30-36 kg) 50 J 120 J 200 J 

40 kg 75 J 150 J 200 J 

Blue (19-23 kg) 30 J 75 J 150 J 

Orange (24-29 kg) 50 J 100 J 200 J 

Yellow (12-14 kg) 20 J 50 J 120 J 

White (15-18 kg) 30 J 50J 150 J 

Red (8-9 kg) 15 J 30 J 75 J 

Purple (10-11 kg) 20 J 30 J 100 J 

Gray (3-5 kg) 8 J 15 J 30 J 

Pink (6-7 kg) 10 J 20 J 50 J 

COLOR First Second Maximum 


ZOLL Energy Selection

45 kg 22.5 g 225 ml 

Green (30-36 kg) 17 g 170 ml 

40 kg 20 g 200 ml 

Blue (19-23 kg) 11 g 110 ml 

Orange (24-29 kg) 14 g 140 ml 

Yellow (12-14 kg) 6.5 g 65 ml 

White (15-18 kg) 8.5 g 85 ml 

Red (8-9 kg) 4.5 g 45 ml 

Purple (10-11 kg) 5.5 g 55 ml 

Gray (3-5 kg) 2 g 20 ml 

Pink (6-7 kg) 3.5 g 35 ml 

COLOR DOSE (g) GIVE (ml) 

Concentration = 0.1 g/ml 

Dose = 0.5 g/kg IV 

DEXTROSE 10% 

INDICATION – HYPOGLYCEMIA

Consider giving one-half dosage diphenhydramine if patient 

has taken/been given full dose within 1 hour 

Utilize epinephrine 1:1000 IM first if serious systemic reaction 

(anaphylaxis) 

40 kg 40 mg 0.8 ml 

45 kg 45 mg 0.9 ml 

Orange (24-29 kg) 25 mg 0.5 ml 

Green (30-36 kg) 35 mg 0.7 ml 

White (15-18 kg) 17.5 mg 0.35 ml 

Blue (19-23 kg) 20 mg 0.4 ml 

Purple (10-11 kg) 10 mg 0.2 ml 

Yellow (12-14 kg) 12.5 mg 0.25 ml 

Pink (6-7 kg) 6.5 mg 0.13 ml 

Red (8-9 kg) 8.5 mg 0.17 ml 


Gray (3-5 kg) 5 mg 0.1 ml 


Dose = 1 mg/kg – Give IV or IM 


INDICATION: ALLERGIC REACTION 

(URTICARIAL RASH or ITCHING)

** In anaphylactic shock: 

• Patients under 10 kg receive smaller increments (same as 

single dose for cardiac arrest) 

• For patients 10 kg and up, give 0.1 mg increments (1 ml) 

Epinephrine 1:10,000 IV is also used in anaphylactic shock if 

IM treatment ineffective 

40 kg 0.4 mg 4 ml 

45 kg 0.45 mg 4.5 ml 

Orange (24-29 kg) 0.27 mg 2.7 ml 

Green (30-36 kg) 0.33 mg 3.3 ml 

White (15-18 kg) 0.17 mg 1.7 ml 

Blue (19-23 kg) 0.21 mg 2.1 ml 

Purple (10-11 kg) 0.1 mg 1 ml 

Yellow (12-14 kg) 0.13 mg 1.3 ml 

Pink (6-7 kg) 0.06 mg 0.6 ml ** 

Red (8-9 kg) 0.08 mg 0.8 ml ** 


Gray (3-5 kg) 0.04 mg 0.4 ml ** 

FOR CARDIAC ARREST 

Concentration = 0.1 mg/ml 

Dose = 0.01 mg/kg IV 

EPINEPHRINE 1:10,000

45 kg 0.3 mg 0.3 ml IM / SC 

40 kg 0.3 mg 0.3 ml IM / SC 

Green (30-36 kg) 0.3 mg 0.3 ml IM / SC 

Orange (24-29 kg) 0.27 mg 0.27 ml IM / SC 

Blue (19-23 kg) 0.21 mg 0.21 ml IM / SC 

White (15-18 kg) 0.17 mg 0.17 ml IM / SC 

Yellow (12-14 kg) 0.13 mg 0.13 ml IM / SC 

Purple (10-11 kg) 0.1 mg 0.1 ml IM / SC 

Red (8-9 kg) 0.08 mg 0.08 ml IM / SC 

Pink (6-7 kg) 0.06 mg 0.06 ml IM / SC 

Gray (3-5 kg) 0.04 mg 0.04 ml IM / SC 



Dose = 0.01 mg/kg IM or SC 

Maximum Dose 0.3 mg IM / SC 


Anaphylaxis – use IM Route 

Asthma – use Subcutaneous (SC) Route 

NEVER GIVE EPINEPHRINE 1:1000 VIA IV ROUTE

45 kg 500 ml 

Green (30-36 kg) 500 ml 

40 kg 500 ml 

Blue (19-23 kg) 420 ml 

Orange (24-29 kg) 500 ml 

Yellow (12-14 kg) 260 ml 

White (15-18 kg) 340 ml 

Red (8-9 kg) 170 ml 

Purple (10-11 kg) 210 ml 

Gray (3-5 kg) 80 ml 

Pink (6-7 kg) 130 ml 

COLOR GIVE (ml) 

NORMAL SALINE BOLUS = 20 ml/kg IV 

Maximum single bolus = 500 ml 

INDICATION – SHOCK / HYPOTENSION 

FLUID BOLUS

45 kg 1 mg 1 ml 

Green (30-36 kg) 1 mg 1 ml 

40 kg 1 mg 1 ml 

Blue (19-23 kg) 0.5 mg 0.5 ml 

Orange (24-29 kg) 1 mg 1 ml 

Yellow (12-14 kg) 0.5 mg 0.5 ml 

White (15-18 kg) 0.5 mg 0.5 ml 

Red (8-9 kg) 0.5 mg 0.5 ml 

Purple (10-11 kg) 0.5 mg 0.5 ml 

Gray (3-5 kg) 0.5 mg 0.5 ml 

Pink (6-7 kg) 0.5 mg 0.5 ml 



Dose = 0.5 – 1 mg/ml IM 

GLUCAGON 

INDICATION – HYPOGLYCEMIA

45 kg 20 mg 1 ml 

40 kg 20 mg 1 ml 

Green (30-36 kg) 16 mg 0.8 ml 

Orange (24-29 kg) 14 mg 0.7 ml 

Yellow (12-14 kg) 7 mg 0.35 ml 

White (15-18 kg) 9 mg 0.45 ml 

Blue (19-23 kg) 10 mg 0.5 ml 

Purple (10-11 kg) 5 mg 0.25 ml 

DOSE 

COLOR 

GIVE (ml) 

(mg) 


Pink (6-7 kg) 3 mg 0.15 ml 

Red (8-9 kg) 4 mg 0.2 ml 

Concentration = 2% (100 mg / 5 ml) 

Dose = 0.5 mg/kg IO – 20 mg max 

LIDOCAINE 

INDICATION – PAIN MANAGEMENT FOR IO 

(PATIENTS NOT IN ARREST)

40 kg 4 mg 0.8 ml 

45 kg 4.5 mg 0.9 ml 

Orange (24-29 kg) 2.75 mg 0.55 ml 

Green (30-36 kg) 3.25 mg 0.65 ml 

White (15-18 kg) 1.75 mg 0.35 ml 

Blue (19-23 kg) 2 mg 0.4 ml 

Purple (10-11 kg) 1 mg 0.2 ml 

Yellow (12-14 kg) 1.25 mg 0.25 ml 

Pink (6-7 kg) 0.75 mg 0.15 ml 

Red (8-9 kg) 0.85 mg 0.17 ml 


Gray (3-5 kg) 0.5 mg 0.1 ml 

IM administration - single dose only 

Titrate IV dosage in 0.5-1 mg (0.1-0.2 ml) 

increments to desired effect (seizure cessation) 

or maximum dose listed 


Dose = 0.1 mg/kg IV or IM 

MIDAZOLAM 

INDICATION – SEIZURE

40 kg 4 mg 0.4 ml 

45 kg 4.5 mg 0.45 ml 

Orange (24-29 kg) 2.7 mg 0.27 ml 

Green (30-36 kg) 3.3 mg 0.33 ml 

White (15-18 kg) 1.7 mg 0.17 ml 

Blue (19-23 kg) 2 mg 0.2 ml 

Purple (10-11 kg) 1 mg 0.1 ml 

Yellow (12-14 kg) 1.3 mg 0.13 ml 

Pink (6-7 kg) 0.6 mg 0.06 ml 

Red (8-9 kg) 0.8 mg 0.08 ml 



IM dosing is single dose only 

Base contact required for repeat doses 


Dose = 0.1 mg/kg IM 

MORPHINE IM 

INDICATION – PAIN MANAGEMENT

For patients 19 kg and above may titrate in 1-2 mg 

increments up to 10 mg maximum (1 ml) . 

For patients 18 kg and below, dose can be repeated 

once. Additional doses require base approval. 

40-45 kg 1 - 2 mg 0.1 - 0.2 ml 

Green (30-36 kg) 1 - 2 mg 0.1 - 0.2 ml 

Orange (24-29 kg) 1 - 2 mg 0.1 - 0.2 ml 

Yellow (12-14 kg) 0.7 mg 0.07 ml 

White (15-18 kg) 0.8 mg 0.08 ml 

Blue (19-23 kg) 1 mg 1.1 ml 

Purple (10-11 kg) 0.5 mg 0.05 ml 

Red (8-9 kg) 0.4 mg 0.04 ml 


Pink (6-7 kg) 0.3 mg 0.03 ml 

(mg) 

COLOR 

INITIAL 

DOSE 

GIVE (ml) 

MORPHINE IV 

INDICATION – PAIN MANAGEMENT 

Concentration = 10 mg/ml

45 kg 2 mg 2 ml 

Green (30-36 kg) 2 mg 2 ml 

40 kg 2 mg 2 ml 

Blue (19-23 kg) 2 mg 2 ml 

Orange (24-29 kg) 2 mg 2 ml 

Yellow (12-14 kg) 1.3 mg 1.3 ml 

White (15-18 kg) 1.7 mg 1.7 ml 

Red (8-9 kg) 0.9 mg 0.9 ml 

Purple (10-11 kg) 1 mg 1 ml 

Gray (3-5 kg) 0.4 mg 0.4 ml 

Pink (6-7 kg) 0.7 mg 0.7 ml 


Naloxone is available in other concentrations 

This chart is correct for 1 mg/ml concentration 


Dose = 0.1 mg/kg IV or IM 

Maximum single dose = 2 mg (may be repeated) 

NALOXONE 

INDICATION – RESPIRATORY DEPRESSION

45 kg 45 kg 101 lbs 

Green 30-36 kg 67-80 lbs 

40 kg 40 kg 90 lbs 

Blue 19-23 kg 42-52 lbs 

Orange 24-29 kg 54-65 lbs 

Yellow 12-14 kg 27-32 lbs 

White 15-18 kg 34-41 lbs 

Red 8-9 kg 17-20 lbs 

Purple 10-11 kg 22-25 lbs 

Gray 3-5 kg 6-11 lbs 

Pink 6-7 kg 13-15 lbs 

COLOR Kg Pounds 

Always Document Weight in kg 

WEIGHT 

CONVERSION

contra costa county 

emergency medical services agency 

1340 arnold drive, ste. 126 

martinez ca 94553 

925-646-4690 phone 

925-646-4379 fax 

www.cccems.org

0 

0 

1–2 

MILD 

1–2 

LEVE 

PAIN RATING SCALE 

3–4 5–6 

MODERATE 

ESCALA DE VALORACIÓN DE DOLOR 

3–4 5–6 

MODERADO 

7–8 9–10 

SEVERE 

7–8 9–10 

SEVERO

Prehospital Care Manual online - Contra Costa Health Services

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