1. These medical protocols are intended for use while working under the license of an Ambulance Medical Director for an ambulance service with a Primary Service Area (PSA) in Hennepin County.
2. Remember: courtesy to the patient, the patient's family and other emergency care personnel is of utmost importance.
3. A Patient Care Report (PCR) form must be completed on all patients and a copy left with the patient at the hospital. See www.hennepin.us/ems^(NOTICE) for the Required Documentation Policy. Specific prehospital care information must also be recorded on all patient contacts as part of the MNStar requirements and Hennepin County system Data Collection Program.
4. All equipment appropriate to the nature of the call for assistance, treatment and transport should be taken to the site of the patient at the time of the initial patient contact.
5. In all circumstances, physicians have latitude in the care they give and may deviate from these Medical Protocols if it is felt such deviation is in the best interest of the patient. Nothing in these protocols shall be interpreted as to limit the range of treatment modalities available to meical control physicians to utilize, other than the modalities and the medications used must be consistent with the paramedic's training.
6. The specific conditions listed for treatment in this document, although frequently stated as medical diagnoses, are operational diagnoses to guide the paramedic in initiating appropriate treatment. This document is to be used as consultive material in striving for optimal patient care. It is recognized that specific procedures and/or treatments may be modified depending on the circumstances of a particular case. Also, a medical control physician when consulted will either concur or further evaluate the paramedic's clinical findings and suggest an alternate diagnosis and treatment.

1. Paramedics and other EMS personnel are encouraged to fammiliarize themselves with the causes and contributing factors of critical incident and cumulative stress, and learn to recognize the normal stress reactions that can develop from providing emergency medical services.
2. A "Metro CISM Team" is available to paramedics and other EMS personnel. The program consists of mental health professionals, chaplains and trained peer support personnel who develop stress reduction activities, provide training, conduct debriefings and assist EMS personnel in locating available resources. The team will provide voluntary and confidential assistance to those wanting to discuss conflicts or feelings concerning their work or how their work affects their personal lives.
3. Call 612-207-1130 to contact a Metro CISM Team.
4. See www.metrocism.org^(NOTICE) for further information.

1. If the patient is in cardiac arrest, follow the appropriate cardiac arrest protocol -
1. ADULT -
• 3210 - Cardiac Arrest (Asystole / PEA)
• 3220 - Cardiac Arrest (V-Fib and Pulseless V-Tach)
2. PEDIATRIC -
• 4210 - Cardiac Arrest (Asystole / PEA)
• 4220 - Cardiac Arrest (V_Fib and Pulseless V_Tach)

2. Deactivate an ICD only after consultation with a medical control physician.
3. Establish on ECG that the ICD is inappropriately discharging in the presence of a non-VT/VF rhythm.
4. To deactivate the ICD -
1. Locate the pulse generator on the patient.
2. Place a donut magnet over the generator.
• Depending on the ICD brand, you may or may not hear a high-pitched tone.
3. Secure the magnet in place with adhesive tape.
• The magnet will inhibit further arrhythmia detection and treatment by the ICD.

1. Cardiopulmonary Resuscitation (CPR) will be promptly instituted for all patients found in cardiac arrest unless reliable criteria for the determination of death are present, or if a valid DNR or No CPR order exists.
2. Reliable criteria for the determination of death include:
• Lividity
• Rigor
• Obviously fatal trauma
• Absence of vital signs in a trauma victom upon arrival of EMS personnel despite a patent airway
3. Do Not Resuscitate (DNR, No CPR) orders are issued by a patient's physician to prevent rescuers from initiating resuscitative measures in the event of a cardiopulmonary arrest. Patients with DNR orders may receive vigorous medical support, including all interventions specified in the ALS Medical Protocols, up to the point of cardiopulmonary arrest.
4. In the healthcare facility -
1. A DNR order is valid if it is written in the order section of the patient chart (or on a transfer form) and is signed by a physician, registered nurse practitioner or physician assistant acting under physician authority. Copies of the order are valid.
• See 9110 - Do Not Resuscitate (DNR) Guidelines - section D for examples of healthcare facilities.

5. In a private home -
1. A DNR form (See 9110 - Do Not Resuscitate (DNR) Guidelines - section D for examples for DNR forms you may encounter,) must be signed by the patient or proxy, the physician and a witness in order to be valid. No validation stamp or notarization is necessary and a legible copy is acceptable.
6. If possible, the DNR order or copy should accompany the patient to the hospital. Pertinent documentation should be included on the ambulance report form for the run. In the event of confusion or questions regarding the DNR order, resuscitation should be initiated and a medical control physician should be consulted.
7. Living wills should not be interpreted at the scene, but conveyed to the physicians in the receiving emergency department.
8. Complete DNR guidelines for ambulance services operating within Hennepin County are found in 9110 - Do Not Resuscitate (DNR) Guidelines.

1. A medical control physician should be contacted as specified in these protocols.
2. Whenever possible medical control should be obtained from the destination hospital requested by the patient.
3. If the destination hospital is unable to provide medical control, paramedics may contact their service's default medical control hospital. Default medial control hospitals for each service are:
1. Allina Health EMS - Abbott Northwestern Hospital
2. Edina Fire Department - Fairview Southdale Hosital
3. Hennepin EMS - Hennepin County Medical Center
4. North Memorial Ambulance - North Memorial Medical Center
5. Ridgeveiw Ambulance -
• Ridgeveiw Medical Center - Waconia
• Two Twelve Medical Center - Chaska

4. Except for load-and-go situations with short transport times, any such delay in establishing medical control will be explained in a System Incident Report submitted by the paramedics to their medical director and to the Hennepin County Human Services and Public Health Department. This policy in no way precludes establishment of medical control at any time during the run to obtain physician advice or assistance.
5. In the occurance of communication failure, paramedics may perform those orders outlined in the ALS Medical Protocols under "After Obtaining Verbal Orders" for patients with life-threatening or potentially life-threatening conditions.
6. Initiation and performance of these orders must be in accordance with the paramedic's training and must be carried out as written in these Medical Protocols.
7. Any instance of communications failure where procedures are carried out without a physician's verbal order must be reported in a System Incident Report within 48 hours to the paramedic's medical director and to the Hennepin County Human Services and Public Health Department.

1. In special incidents with potental for multiple casualties, resources for the EMS system may be temporarily overwhelmed or extended to their limits.
2. A system plan for EMS response to Multiple Casualty Incidents (MCIs) establishes a framework for coordinating resources during incidents requiring various ambulance providers, hospitals and public safety agencies to work together to optimize patient care and transportation with the given resources of the community. The goals of the system plan are to:
• Recognize and maintain operations of ambulance providers, hospitals, and other agencies as close to normal as possible.
• Utilize the incident command structures to allow flexibility for effective response to a variety of hazards most likely to occur within the county, including natural disaster, hazardous material exposure, urban fire, air crash, civil unrest or any incident with actual or potential multiple casualties.
• Set system standards to aid individual agencies when developing policies and procedures.
• As rapidly as possible transport patients to appropriate hospital(s).
3. Ambulance services operating a Primary Service Area (PSA) in Hennepin County shall follow the regional Incident Response Plan (IRP) during a major incident or multiple casualty incident. Please see the latest version of the IRP for the definition of a Major Incident or Multiple Casualty Incident (MCI). Contact the Metro Regional System office for copies.

1. Oxygen therapy should be administered when indicated by specific protocol.
2. When an EMS provider believes the patient will improve with oxygen therapy the following guidelines are applicable:
1. For suspected smoke / CO inhalation, pneumothorax or sickle cell crisis, initiate high flow oxygen (≥ 10 lpm) via non-rebreather mask or BVM with appropriate airway management.
   • Titrate to maintain goal SpO₂ of 100%.
2. For critically ill or unconscious patients with suspected hypoxia, initiate high flow oxygen (≥ 10 lpm) via non-rebreather mask or BVM with appropriate airway management.
   • Titrate down to MAXIMUM SpO₂ of 96% (Discontinue for SpO₂ ≥ 97%)
3. For patients with STEMI or CVA DO NOT initiate oxygen therapy if SpO₂ > 92%
4. For patients at risk for hypercapnic respiratory failure (COPD with chronic O₂ use), use minimum flow necessary to achieve target SpO₂ of 90%.
5. For all other patients, use minimum flow necessary to achieve MAXIMUM SpO₂ of 96% (Discontinue for SpO₂ ≥ 97%)
3. For pediatrics, if the patient is agitated use high flow blow-by O₂.

Determination of patient disposition should be based on the following criteria:

1. Patient Preference – Patients should be transported to the hospital of their choice (or family's or physician's choice). Patient preference may be overridden by:
1. The medical expertise of the Ambulance Medical Director,
2. Restriction to specific hospitals.
2. Medical Expertise – This authority may be represented by service specific policy, system policy, the On-Call System Medical Director, a medical control physician, a physician on-scene who has assumed total responsibility for the patient, or the paramedic providing patient care, (see 2160 - Physician Presence at the Emergency Scene.) Medical expertise shall override patient preference in three types of situations:
1. Patient’s preference is unavailable (e.g. closed or unreachable due to weather). See www.hennepin.us/ems ^(NOTICE) for the Hennepin County EMS System Ambulance Diversion Policy.
2. Patient’s preference is inappropriate (e.g. critical trauma patient transported to a facility not capable or equipped for the severity of the patient’s injuries.)
3. Patient’s preference is suboptimal for presenting condition/complaint (the following examples are not inclusive):
• If unable to maintain an airway and ventilate, transport to the closest emergency department.
• Carbon Monoxide patients should be transported per 2090 - Patient Disposition - Carbon Monoxide Poisoning.
• Major burn patients should be transported per 2100 - Patient Disposition - Major Burns.
• Major trauma patients should be transported per 2110 - Patient Disposition - Major Trauma.
• STEMI patients should be transported per 2120 - Patient Disposition - STEMI.

1. For patients with symptoms of severe Carbon Monoxide (CO) poisoning, consider transport to a hospital that has a hyperbaric center.
2. For pregnant patients who are transported with symptoms of CO poisoning, consider transport to a hospital that has a hyperbaric center for possible hyperbaric therapy.
3. Hospitals in the Twin Cities Metro area with a hyperbaric center include:
• Hennepin County Medical Center (HCMC)
4. Signs and symptoms of severe CO exposure include:
• History of loss of consciousness
• Lethargy
• Confusion
• Disorientation
• Seizures
• Focal neurological deficits
• Ischemic chest pain
• New dysrhythmias
• 12 Lead ECG changes
• Hypotension

1. For patients with major burn injuries, consider transport to a hospital that has a burn unit.
2. Hospitals in the Twin Cities Metro area with a burn unit include:
• Hennepin County Medical Center (HCMC)
• Regions Medical Center
3. See the adult burns protocol 3120 - Burns or the the pediatric burns protocol 4120 - Burns.

1. Ground ambulances must immediately transport patients with compromised airways (unable to maintain an airway and ventilate) to the nearest designated trauma hospital.
• If no designated trauma hospital exists within 30 minutes transport time, the patient must be transported to the closest hospital.
2. In cases where a patient does not have a compromised airway, the ground ambulance must transport major trauma patients to a level I or level II trauma hospital within thirty minutes transport time.
• If no level I or level II trauma hospital exists within 30 minutes transport time, the patient must be transported to the closest designated trauma hospital within 30 minutes transport time.
• If no designated trauma hospital exists within 30 minutes transport time, the patient must be transported to the closest hospital.
3. Critical trauma patient indicators for major trauma (as a result of a traumatic injury):
1. Compromised airway.
2. Signs of respiratory distress.
3. Altered Level of Consciousness - less than "A" on the AVPU scale resulting from a traumatic event.
4. Signs of shock or diminished perfusion.
5. Severe burns.
6. Other considerations:
1. Severe multiple injuries (two or more systems) or severe single system injury.
2. Cardiac or major vessel injuries resulting from blunt or penetrating trauma.
3. Injuries with complications (e.g. shock, sepsis, respiratory failure, cardiac failure.)
4. Severe facial injuries.
5. Severe orthopedic injuries.
6. Co-morbid factors (e.g. Age < 5 or > 55 years, cardiac or respiratory disease, insulin-dependent diabetes, morbid obesity.)
7. Evidence of traumatic brain injury and/or spinal cord injury (e.g. new paralysis.)
7. Paramedic provider impression is consistent with major trauma.

Patients identified with acute myocardial infarctions, as evidenced by ST elevation (STEMIs), should receive timely transportation to a Level I Cardiac Care Facility per the EMS provider STEMI/Code AMI criteria. EMS Provider/STEMI Code AMI inclusion criteria includes:

1. Patient presents with cardiac symptoms.
2. 12-lead findings which are consistent with ST elevation greater than 1 mm in two or more contiguous leads.
3. QRS complex is narrower than 0.12 seconds (3 small boxes.)
• If wider than 0.12, you are unable to diagnose as STEMI.
4. See www.hennepin.us/ems ^(NOTICE) for the Transport Policy for STEMI Patients.

Patients identified with acute cerebral vascular accident (CVA) per the Adult Stroke (CVA) protocol should receive timely transportation to the most appropriate designated acute stroke ready hospital, primary stroke center, or comprehensive stroke center.

1. Paramedics may find themselves in a situation where a Transport Hold might be necessary to transport a patient to the emergency department.
2. Elements of a Transport Hold (defined Minnesota Statute 253B.05 Emergency Admission Subd. 2):
• A peace or health officer may take a person into custody and transport the person to a licensed physician or treatment facility if the officer has reason to believe, either through direct observation of the person's behavior, or upon reliable information of the person's recent behavior and knowledge of the person's past behavior or psychiatric treatment, that the person is mentally ill or developmentally disabled and in danger of injuring self or others if not immediately detained.
• A peace or health officer or a person working under such officer’s supervision, may take a person who is believed to be chemically dependent or is intoxicated in public into custody and transport the person to a treatment facility. 253B.05 Emergency Admission Subd. 2.
3. If Elements of a Transport Hold are present:
1. Request a Transport Hold from a Peace/Health Officer,
2. If the Peace/Health Officer does not provide a Transport Hold:
1. Contact your service’s designated home medical control hospital and ask the Medical Control Physician to speak with the Peace/Health Officer,
2. If the Peace/Health Officer does not provide a Transport Hold after speaking with the Medical Control Physician:
• Do not transport,
AND
• Leave the patient in the care of the Peace/Health Officer.

4. All patients transported on a Transport Hold should be restrained during transport.
5. For minors, follow statute regarding Health and Welfare Holds 260C.175 subdivision 1.

If the patient has a weapon:

1. Call law enforcement to assist if the crew has a safety concern.
2. Notify the emergency department during your pre-arrival patient care report when transporting a patient known to have a weapon.

1. Personal Physician -
• If the patient's personal physician is present and wishes to assume responsibility for the patient's care:
1. The paramedic should defer to the orders of the personal physician as long as those orders are appropriate and not in conflict with ALS Medical Protocols. Paramedics should establish medical control any time they are uncomfortable carrying out orders from a patient's physician.
2. Orders given by the personal physician should be written on the EMS report form, the physician’s name documented legibly, and signed by the physician, if possible.

2. System Medical Director -
• If a system medical director or associate system medical director is present and wishes to assume responsibility for the patient’s care, the paramedic should defer to the orders of the system medical director or associate system medical director.
3. Medical Control Physician -
• If a medical control physician is present and wishes to assume responsibility for the patient’s care, the paramedic should defer to the orders of the medical control physician as long as those orders are appropriate and not in conflict with ALS Medical Protocols.
4. Other Intervening Physician -
1. If any other intervening physician wishes to assume responsibility for the patient:
1. If medical control exists:
• The intervening physician should be allowed to communicate with the medical control physician prior to the paramedics accepting orders. If there is any disagreement between the two physicians, the paramedics will follow the orders of the medical control physician and allow the physicians to continue their communication.
2. If medical control does not exist:
• The paramedics should relinquish responsibility for patient management if the physician meets the following two criteria:
1. can show appropriate identification (or is known to the paramedics);
2. agrees in advance to accompany the patient to the hospital (exception: majormultiple casualty incident);
• The physician’s name should be documented legibly within the PCR and, if possible, have the physician sign the EMS report form assuming responsibility and verifying orders.

2. In the case of multiple intervening physicians at the scene, the paramedics should request the physicians designate one physician to direct patient care.
5. Any intervening physician not wishing to assume responsibility for care and not accompanying the patient to the hospital may be asked to assist the paramedics and/or act as a medical consultant to them and to the medical control physician.

1. Bag Valve Mask (BVM) – Consider an oropharyngeal or nasopharyngeal airway of appropriate size on all unconscious patients for initial airway maintenance.
2. Endotracheal intubation – After endotracheal intubation, tube position must be confirmed using at least two methods, including continuous end-tidal carbon dioxide (CO₂) detection and a second device or method to confirm tube placement.
3. Alternate Advanced Airway Device – Services may use alternative advanced airway control devices (such as supraglottic airways) as specified by the ambulance service’s medical director. After placement of an alternate advanced airway device, place continuous end-tidal carbon dioxide (CO₂) detection device on the tube.
4. Pulse Oximetry – A pulse oximeter should be used for any patient with suspected hypoxemia, in respiratory distress, or whenever sedating medications are administered.

For all diabetic hypoglycemic patients refusing transport:

1. The following criteria must be documented on your Patient Care Report (PCR) in order to leave a patient (without contacting medical control) experiencing a diabetic hypoglycemic emergency who refuses transport:
1. Identifiable reason why the diabetic emergency happened.
2. Blood sugar over 100 post treatment.
3. Level of consciousness – awake, alert and oriented with a GCS = 15.
4. Food intake – food available and able to eat or has eaten recently.
5. Friend and/or family present and willing to stay with the patient.
6. Discussion with the patient to contact physician for follow-up.
7. Vital signs within normal limits:
• MEDICAL CONTROL CONTACT IS REQUIRED IF:
• Systolic blood pressure is less than 90, or greater than 180.
• Heart rate is less than 50, or greater than 110.

8. Offer of transport made.
2. MEDICAL CONTROL CONTACT IS REQUIRED IF THE PATIENT MEETS ONE OR MORE OF THE FOLLOWING:
• Is on an oral agent
• Has a fever
• Had a recent acute illness
• Has a sign of a possible MI (atypical symptoms, dyspnea, shortness of breath, etc.)
3. If unable to identify or document suspected reason for the diabetic emergency, a medical control physician must be contacted.

1. Establish communication with Incident Command or rehab division officer.
2. Stage ambulance near rehab:
• Consider egress and potential for additional incoming fire apparatus.
3. Perform focused assessment including complete set of vital signs and temperature (if applicable):
1. Consider 12-lead ECG.
2. Consider Blood Glucose check.
3. Consider transcutaneous CO measurement if available -
• Administer high flow O₂ immediately if concern for CO toxicity regardless of level or ability to measure.

4. Immediate transport for:
1. Symptoms of chest pain, severe SOB, altered mental status and syncope.
2. Heart rate greater than 220 (minus patient’s age), systolic blood pressure less than 100, respiratory rate greater than 30, SpO₂ less than 85%.
3. Treatment for immediate transport:
1. IV, O₂, monitor, 12-lead ECG.
2. Consider hydroxocobalamin (Cyanokit) administration if available.

5. Begin active cooling/warming based on weather conditions.
6. Provide oral rehydration 8 - 12 oz/10 minutes.
7. Reassess the following after 10 minutes:
1. Vital signs.
2. Symptoms to assess for include:
• Chest pain, dizziness, shortness of breath, weakness, nausea/vomiting, headache, cramps, change in behavior/speech, unsteady gait.
3. If improving and asymptomatic, monitor until exit criteria met (see H):
• Minimum 20 minute rest/rehydration time.
• Offer transportation, if refused - document per service specific guidelines.
4. If worsening or symptomatic, transport:
• IV, O₂, monitor, 12-lead ECG, blood glucose check.
• Consider hydroxocobalamin (Cyanokit) administration if available.

8. “May return to work” criteria (must meet/document all below):
1. Offer of transport declined.
2. Presence of normal speech/mental status and a steady gait.
3. Normal vital signs:
• Heart rate less than or equal to 110, respiratory rate less than or equal to 20, systolic blood pressure greater than 100, diastolic blood pressure less than 100, SpO₂ greater than 95%, skin temp normal or measured less than 101.5^o F, CO less than 10 (if applicable).
4. Asymptomatic.
5. EMS provider discretion may override and recommend “no return to work” despite meeting criteria.

Not every patient requires an IV. When indicated, intravenous fluid therapy should be administered in accordance with the following guidelines:

1. For most patients requiring IV access, the paramedic has the option of either running fluids through the IV or capping the catheter with a saline lock. However, as specified in these Medical Protocols, IV fluids must always be hung in either situations:
• When the administration of multiple IV medications is anticipated.
• Whenever it is likely the patient will require fluid volume replacement.
2. There should be no delay at the scene for IV attempts on major trauma patients or patients in shock; these IVs should be started during transport.
3. Intraosseous infusion (IO) is a procedure for use in patients who are in critical condition when IV access is unobtainable.
4. Paramedics may access a Peripherally Inserted Central catheter (or PIC line) if the patient has one in place as an alternate IV access point.
5. Paramedics may access a central line if the patient is in cardiac arrest. The cap on the central line must be cleansed with alcohol and then 15-20 ml of fluid and blood must be aspirated from the central line before initiating IV fluids. If unable to aspirate, the central line should not be used.

To provide relief of pain when indicated. This protocol is NOT to be used in cases where the patient:

• Has a systolic BP less than or equal to 90.
• Has pain determined to be cardiac in origin (See 3230 - Ischemic Chest Pain).
• Is in active labor.
• Headache.
• Low back pain (except as described below.)
• Neck pain (except as described below.)
• Any chronic pain (e.g. head, neck or back pain, fibromyalgia, abdominal or pelvic pain.)
• Dental pain.

Indications for use of Pain Management Protocol:

1. Acute severe traumatic pain -
• Neck or back pain from trauma and inability to ambulate from the incident.
• Significant orthopedic injury. (Severe tenderness to palpation with swelling, bruising and/or deformity.)
• Severe traumatic chest or abdominal pain with tenderness (ensure SBP > 90.)
• Major burns (3120 - Burns.)
2. Consider use for acute severe non-traumatic pain (e.g. abdominal or flank) with 2 or more of the following factors which tend to predict need for prompt treatment -
• Less than 2 hours duration.
• Increased heart rate and/or blood pressure.
• Nausea and/or vomiting.
• Writhing.
• Described as severe (or 8 - 10 / 10 on pain scale.)
3. Ischemic Chest pain should only be treated with opioids if there are ischemic changes on ECG and not responding to nitroglycerine. (3230 - Ischemic Chest Pain)
4. Intubated patients with injury, painful condition or evidence of increasing discomfort (e.g. increasing BP or HR.)
5. Active cancer or palliative care.

For patients experiencing pain outside the above listed indications consider:

• Symptomatic relief of nausea/vomiting if needed.
• Advising them of the general concerns in the medical community about opioid use and that doctors are being very careful about which patients receive these addictive medications.
• Inform them that we carry this type of medication for severe trauma such as broken bones and for certain medical situations that require immediate pain control such as heart attacks.
• Acknowledge their pain and try to improve comfort.
• Advise them that a doctor will need to evaluate them prior to administering pain medication.
• Reassure the patient that the receiving facility will be notified of the need for prompt pain management assessment.
• Consult medical control if questions.

PROCEDURE

1. Assess the patient’s pain on a 0-10 scale or other acceptable method for patients with difficulty communicating.
2. Inform the patient that pain is an important diagnostic parameter and the goal of this protocol is to relieve suffering and not to totally eliminate pain.
3. Administer one of the following medications:
1. Morphine Sulfate IV -
1. 2 mg up to 10 mg per dose IV/IO/IM/SQ.
• Usual effective initial dose 0.1 mg/kg.
• If using IV/IO route titrate in increments to patient response.
2. If necessary administer additional dose(s) up to 5 mg IV/IO/IM/SQ every 5 to 10 minutes.
• If using IV/IO route titrate in increments to patient response.
3. No maximum total dose of Morphine Sulfate for adults.
2. fentanyl -
1. 50 - 100mcg IV/IO/IM/IN
• Intranasal administration should not exceed 1 ml per nostril, (2 ml total fluid volume IN.)
2. If necessary administer additional dose(s) of 50 mcg per dose every 10 minutes.
3. Not to exceed total maximum cumulative dose of 200mcg.
3. ketamine hydrochloride (Ketalar) -
1. Pain must be -
• Of a traumatic origin (non-cardiac),
• Is moderate to severe,
• Not responding to initial 10 mg Morphine Sufate or 100 mcg fentanyl administration,

OR

• If the patient has a morphine allergy,
2. 0.1 mg/kg (not to exceed total dose of 10 mg) IV/IO/IM.
3. May repeat x 1 after 10 minutes for persistent pain.

4. Monitor the patient’s vital signs (including O₂ saturation.) If respiratory depression or hypotension occurs after administration of Morphine Sulfate -
1. Ventilate the patient as necessary.
2. Administer naloxone hydrochloride (Narcan) -
• 0.4 mg up to 2 mg IV/IO.

5. Contact medical control physician for orders if:
• The patient has a systolic BP less than or equal to 90.
6. AFTER OBTAINING VERBAL ORDERS
1. Consider initial or additional pain medication including benzodiazepines as appropriate:
• midazolam hydrochloride (Versed) 2 mg up to 5 mg IV/IO/IM (if using IV/IO route, titrate to patient response.)
2. Monitor for respiratory depression when administering narcotics and benzodiazepines together.

1. If the patient is ET intubated and becomes agitated from increased consciousness -
1. Consider midazolam hydrochloride (Versed) -
• 2 mg to 5 mg IV/IO/IM titrated.
• Maintain a systolic BP of 100 or greater.
2. Consider treatment of pain per 3050 - Pain Management.
3. Consider additional Midazolam HCL (Versed) -
• 2 mg to 5 mg IV/IO/IM titrated.
• Maintain a systolic BP of 100 or greater.

2. If the systolic BP is less than 100 -
1. Consider ketamine hydrochloride (Ketalar) -
• 1 mg/kg up to 2 mg/kg IV/IO.

OR

• 4 mg/kg up to 5 mg/kg IM.
2. Ketamine is preferred in patients with low blood pressure.
3. Should not be used for patients with penetrating eye injury.

1. Patient:
1. Control hemorrhage and cover stump with sterile dressing saturated with saline.
2. Treat per 3140 - General Trauma / Traumatic Shock.
3. Do not spend excessive time looking for the amputated part if the patient is unstable.
2. Amputated Part:
1. Wrap the amputated part in sterile gauze.
2. Moisten with saline.
3. Place in plastic bag.
4. Place on top of ice, if available, or cold packs (do not freeze).

1. Consider direct transport to a burn center for major burns ( 2100 - Patient Disposition - Major Burns).
2. Major burn criteria includes:
• Partial-thickness burns greater than 10% of total body surface area.
• Partial-thickness or third degree burns that involve the face, hands, feet, genitalia, perineum, or major joint.
• Third degree burns in any age group.
• Lightning injury and other electrical burns.
• Chemical burns.
• Inhalation injury.
• Burn in any patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
3. For any significant burn:
1. Begin oxygen therapy. Use positive pressure ventilatory assist as needed.
2. Obtain IV access.
4. If less than 20% of the body surface is burned:
1. Apply sterile dressings and saturate with cool water (leave Gel-pack(s) in place if applied by first responders).
2. Do not allow any burn patient to become chilled and begin shivering.
5. If more than 20% of the body surface is burned:
1. Remove any non-adherent burned clothing and cover the patient with a sterile sheet.
2. Consider NS bolus:
• 500 ml for patients 18 to 65.
• 250 ml for patients greater than 65 or history of CHF.
3. Do not cool down with water (exception: presence of smoldering clothes, articles or material adhering to skin that would continue the burning process, e.g., hot tar, etc.).
4. Begin rapid transport.
5. Consider direct transport to a burn center for major burns.
6. Consider pain management - 3050 - Pain Management.
6. Monitor the patient’s ECG after any electrical burn including a lightning strike.

1. Confirm prolonged entrapment (greater than one hour) of one or more full extremities by a crushing object (e.g. vehicle, building rubble, hanging in harness, self).
2. If a distal extremity is accessible, assess sensation, motor function, skin color and distal pulses.
3. For entrapments with potential extended scene times (>30min), contact your service for notification/activation of your service’s medical director(s).
4. Pre-Extrication, if possible:
1. Administer oxygen via mask if the situation allows.
2. Obtain venous access with two large bore IV/IOs when possible and hang two 1000 ml Normal Saline bags.
• Administer up to two liters of NS bolus followed by 500 ml/hr.
3. Control pain per protocol - 3050 - Pain Management.
4. Monitor the patient’s cardiac rhythm when situation allows.
5. Immediately prior to extrication, consider Sodium Bicarbonate -
• 2 mEq/Kg IV/IO up to 100 mEq.
6. Extricate.
5. Post-Extrication:
1. Suspect hyperkalemia if T waves become peaked, QRS becomes prolonged (greater than 0.12 sec) or hypotension develops.
2. Consider calcium chloride 10% -
• 1 Gm IV/IO over 5 minutes for ventricular dysrhythmias.
3. Consider additional Sodium Bicarbonate.
4. Contact a medical control physician for persistent hyperkalemia or dysrhythmias.
5. Post-extrication cardiac arrest – administer:
1. calcium chloride 10% -
• 2 Gm IV/IO push
2. Sodium Bicarbonate -
• 100mEq (2 amps) IV push
3. Contact medical control for additional orders.

6. NOTES:
• Risk of crush syndrome is directly proportional to the amount of muscle tissue trapped - a single arm = low risk, both legs = high risk.
• Crush is different than trapped – if the patient can feel and/or move the distal extremity easily the risk for crush syndrome is very low.

1. Begin oxygen therapy.
2. Spinal immobilization as appropriate.
3. If the patient is intubated and begins to develop strong evidence of tension pneumothorax (i.e. increased airway resistance, hypotension and/or jugular vein distention) consider needle thoracostomy.
• Perform needle thoracostomy at the second intercostal space, midclavicular line of affected side.
• May be done without verbal orders if the patient is already intubated.
• If the patient is NOT INTUBATED, consult a medical control physician immediately if a tension pneumothorax is suspected.

4. Transport.
5. Start an IV Normal Saline while en route on any patient with severe trauma. If systolic BP is less than 90, run the IV wide open until systolic BP reaches 90, then TKO.
   • Consider Tranexamic Acid (TXA)

6. AFTER OBTAINING VERBAL ORDERS
1. Consider needle thoracostomy if strong evidence of tension pneumothorax is present.

1. Control major hemorrhaging -
• Consider application of a Tourniquet for Severe Hemorrhage.
• Consider Tranexamic Acid (TXA).
2. Manage the airway -
• Begin oxygen therapy as early as possible in all major traumatic emergencies.
• Ventilate as necessary - DO NOT OVER VENTILATE.
3. Consider Spinal Immobilization/Precautions - 3160 - Spinal Precautions Algorithm.
4. Consider pain management - 3050 - Pain Management.
5. Expedite transport -
• IV/IO access should be started in route to the hospital.
• The only exception is when there is an unavoidable delay moving the patient from the scene (e.g., trapped in auto, etc.) in which case IV/IO access should be started on scene.
6. For disposition considerations - 2110 - Patient Disposition - Major Trauma.

1. Complete a rapid scene survey observing for any indications or evidence that resuscitation should not be attempted (e.g., DNR orders or conditions incompatable with life.)
2. If cardiac arrest occures in presence of the ambulance crew, assess the patient's cardiac rhythm and continue with the appropriate protocol.
3. If the patient is in cardiac arrest upon arrival of the ambulance crew, institute or continue Basic Life Support:
1. CPR: compressions 100/min, breaths 8 - 10/min. DO NOT OVER VENTILATE
2. Impedance Threshold Device (ITD): Attach ITD to BVM and apply to patient within 30 seconds. You must maintain a tight, continuous, 2-handed face mask seal for the ITD to fuction properly. Use of ITD is service dependent.
3. Reassess the patient's rhythm after every 5 cycles (2 minutes) of CPR. Limit interruptions in CPR during pulse/rhythm checks to less than 10 seconds for airway insertion and/or administration of medications
4. Assess and confirm the patient's cardiac rhythm (check second lead to verify asystole,) immediately resume CPR.
5. Review the most frequent causes for PEA, treat according to protocols if present:
1. Hypovolemia - IV Fluids:
• 500 ml for patients 18 to 65.
• 250 ml for patients greater than 65 or history of CHF.
2. Hypoxia - Ventilation and oxygenation.
3. Hypothermia - Re-warming. See the 3510 - Hypothermia protocol.
4. CONSIDER OBTAINING VERBAL ORDERS FOR:
1. Acidosis - Sodium Bicarbonate.
2. Hyperkalemia - calcium chloride 10% AND Sodium Bicarbonate.
3. Tension pneumothorax - Needle chest decompression.
4. Drug overdose - Intubation and specific antidote.
5. Coronary thrombosis - 12-lead ECG.
5. NO SPECIFIC PREHOSPITAL TREATEMENT FOR:
1. Hypokalemia
2. Cardiac tamponade
3. Pulmonary embolism

6. Secure the patient's airway during the pulse check. Continue CPR immediately then confirm tube placement by exam and confirmation device.
• Once intubated with an advanced airway (ETT, i-gel, etc.) switch to continuous compressions with 10 breaths/min.
7. Obtain IV access while providing two minutes of continuous CPR.
8. During CPR, administer the following medication:
1. epinephrine 1:10,000 -
• 1 mg IV/IO every 3 - 5 minutes.

9. Provide continuous CPR and reassess pulse and rhythm every two minutes.
10. Continue CPR and contact medical control physician for further orders.
11. AFTER OBTAINING VERBAL ORDERS
1. If the cause of PEA is hypovolemia, consider requesting additional fluid orders.
2. If there is no response, consider termination of resuscitative efforts.

1. If cardiac arrest occurs in the presence of the ambulance crew -
1. Assess the patient’s cardiac rhythm and defibrillate x 1 if necessary.
2. If the patient is in cardiac arrest on arrival of the ambulance crew, institute or continue Basic Life Support (BLS):
1. CPR: Continuous compressions 100/min, breaths 8-10/min. DO NOT OVER VENTILATE.
2. Impedance Threshold Device (ITD): Attach ITD to BVM and apply to patient within 30 seconds. You must maintain a tight, continuous, 2-handed face mask seal for the ITD to function properly. Use of ITD is service dependent.
3. Reassess the patient’s rhythm after every 5 cycles (2 minutes) of CPR.
• Limit interruptions in CPR during pulse/rhythm checks to less than 10 seconds for airway insertion and/or administration of medications.

3. Assess and confirm Pulseless Ventricular Tachycardia/Ventricular Fibrillation then defibrillate x 1 if necessary using the following guidelines:
1. Continue CPR while the defibrillator charges.
2. Defibrillate at an intitial dose of 120 joules.
3. Immediately resume CPR.
4. Reassess the patient’s cardiac rhythm after 5 cycles (2 minutes) of CPR. If a shockable rhythm is present -
1. Continue CPR while the defibrillator charges.
2. Defibrillate at an escalated dose of 150 joules.
3. Immediately resume CPR.
5. Secure the patient’s airway during the pulse check. Confirm tube placement by exam and confirmation device. Monitor continuous End-Tidal (ETCO2).
• Once intubated with an advanced airway (ETT, i-gel, etc.) switch to continuous compressions with 10 breaths per minute.
6. Obtain IV access while providing two minutes of continuous CPR.
7. The following pressor is to be given during CPR:
• epinephrine 1:10,000 -
• 1 mg IV/IO every 3-5 min.

8. Reassess and confirm Pulseless Ventricular Tachycardia/Ventricular Fibrillation then defibrillate x 1 if necessary using the following guidelines:
1. Continue CPR while the defibrillator charges.
2. Defibrillate at an escalated dose of 200 joules.
3. Immediately resume CPR.
9. The following antiarrhythmic is to be given during CPR:
1. amiodarone hydrochloride (Cordarone) -
• Initial dose of 300 mg IV/IO.
• Repeat dose of 150 mg IV/IO once after four minutes of continuous CPR.

OR

2. lidocaine hydrochloride IV -
• 1.0 to 1.5 mg/kg IV/IO first dose.
• Repeat at 0.5 to 0.75 mg/kg IV/IO.
• Maximum of 3 doses or 3 mg/kg.

10. Reassess rhythm after 2 minutes of CPR; if shockable rhythm, continue CPR while defibrillator charges then defibrillate x 1 if necessary using the following guidelines:
1. Continue CPR while the defibrillator charges.
2. Defibrillate at a dose of 200 joules.
3. Immediately resume CPR.
11. Consider Magnesium Sulfate IV -
• Loading dose 1 - 2 Gm IV/IO for Torsades de Pointes.
12. Continue CPR and contact medical control physician for further orders.
13. For patients who have received 2 unsuccessful defibrillation attempts (including AED prior to your arrival) - Transport to an ECMO capable facility (U of MN East Bank, Fairview Southdale, Abbott Northwestern or HCMC)
    1. Inclusion Criteria:
       1. Transport time to destination is approximately < 30 min OR total CPR time < 60 min
       2. Age 18 to 75,
       3. Independently living,
       4. V-fib/V-tach as initial rhythm (or AED shock)
       5. Presumed arrest is of cardiac etiology.
       6. Mechanical CPR device

    2. Continue usual Cardiac arrest management including
       1. Adequate airway management (prefer King or ETT)
       2. Vascular access (IV or IO.)
       3. First dose of antiarrhythmic (Amiodarone or Magnesium Sulfate.)
       4. Ensure First Responder help (two) and extra batteries for transport

    3. Provide EARLY communication:
       1. contact W-MRCC and notify you have a "Refractory V-fib Patient"
       2. Provide usual info (age, gender, pertinent clinical findings/medical history, ETA)

    4. Changes in condition (e.g. ROSC, PEA, asystole) should not change destination
    5. Limit epinephrine to TOTAL of 3mg IV/IO
    6. Administer 1 amp (50mEq) Sodium Bicarbonate IV while enroute
    7. If Inclusion Criteria are NOT met, provide usual Cardiac arrest care per protocol

14. AFTER OBTAINING VERBAL ORDERS
1. Consider additional doses of initial antiarrhythmic.
2. Consider Sodium Bicarbonate for metabolic acidosis, tricyclic anti-depressant overdose or hyperkalemia.
3. If there is no response to treatment consider termination of resuscitative efforts.

1. Obtain 12-Lead ECG.
2. Administer:
1. aspirin (ASA) -
• 325 mg PO if the patient has no history of allergy to Aspirin (even in absence of chest pain.)
2. nitroglycerin lingual spray -
• 0.4 mg metered dose spray if the patient's systolic BP is greater than or equal to 100.
• Consult with medical control physician if systolic BP is less than 100.
• Check the BP immediately prior to and after administration of nitro.

3. Establish IV access:
1. If the patient has been loaded in the ambulance without IV access begin transport promptly.
2. Establish IV access en route.
4. Consider repeat/serial ECGs.
5. If there is no pain relief and the patient’s systolic BP remains 100 or greater:
1. Repeat nitro every five minutes.
2. Recheck the patient’s BP before and after administration.
3. If pain -
• Persists after 3 nitro,
• Systolic BP is greater than or equal to 100,
• There are ischemic changes on ECG -
1. May use Morphine Sulfate IV -
• 2 to 10 mg titrated to obtain pain relief.
• Continuing to administer nitro every 5 minutes.
2. If the patient is allergic to Morphine Sulfate, may administer fentanyl -
• 1 mcg/kg (up to 100 mcg per single dose) IV/IO.

6. If the patient meets the inclusion criteria as an ST Elevation Myocardial Infarction (STEMI) patient as defined in the Metro Region STEMI Protocol the patient should be transported to a designated Level I Cardiac Center except as allowed in the protocol. The receiving facility should be notified as soon as possible that the patient is a STEMI patient by stating in your radio/phone report “STEMI ALERT.”

1. Do not delay nitro to establish IV access.
2. Keep the patient’s head elevated at all times.
3. Begin oxygen therapy:
1. If the patient’s respiratory distress is severe -
1. Consider positive pressure ventilatory assistance if the patient is able to tolerate.
2. Consider ET intubation if when -
1. The patient's breathing is ineffective,

OR

2. The Glasgow Coma Score is less than 8.

4. Monitor the ECG closely for dysrhythmias secondary to hypoxia.
5. Give nitroglycerin lingual spray -
1. 0.4 mg metered dose spray SL x 2 if the patient’s systolic BP is 140 or greater.
2. Two minutes after the initial nitro dose, repeat nitroglycerin 0.4 mg metered dose spray SL x 1 if the patient still has signs of pulmonary edema AND the systolic BP remains 140 or greater.
3. Five minutes after the second dose, repeat nitroglycerin 0.4 mg metered dose spray SL x 1 if the patient still has signs of pulmonary edema and the systolic BP is 140 or greater.
6. Give aspirin (ASA) -
1. 160 - 325 mg by mouth if the patient has no history of allergy.
7. If the patient has no relief and their systolic BP remains 140 or greater:
1. Repeat nitroglycerin every three to five minutes as necessary. Recheck the patient’s BP before and after administration
8. Consider CPAP if two or more of the following are present:
• Retractions or accessory muscle use.
• Pulmonary edema.
• Respiratory rate greater than 25/min.
• SpO₂ less than 92%.
1. Administer CPAP (CPAP MODE) to achieve 11 - 12 cm H₂O (15 LPM).
2. Assess the patient’s response. If the patient’s condition worsens, (e.g. the patient becomes hypotensive, decreased SpO₂) discontinue CPAP.
3. If CPAP is initiated, continue to treat with medications as normal.

For post-cardiac arrest Return of Spontaneous Circulation (ROSC):

1. Initiate cardiac cooling measures if possible and if time allows.
2. Patient must meet the following criteria:
• Patient must be 18 years of age or older.
• Initial arrest appears to be a primary cardiac arrest (non-traumatic in origin.)
• Patient had ROSC in the field.
• Patient is unconscious.
• Patient has a BP greater than or equal to 90 systolic.
3. Place standard chemical ice packs in the following locations:
• One on the neck covering both carotid arteries.
• One in each of the axillae.
• One over each of the femoral vasculature in the groin.
• Consider other cooling measures -
• Turn on the ambulance AC in the patient compartment and direct air flow over the patient.
• Removal of the patient’s clothes.

4. Glucose check if possible and if time allows.
5. Obtain a 12-lead ECG if possible and time allows.
6. If an Impedance Threshold Device has been applied, remove with ROSC.
7. Advise the emergency department personnel upon arrival that you have initiated the cooling process.

1. Prepare for Transcutaneous Pacing.
• Consider sedation.
• Use without delay for high degree block (type II second-degree block or third-degree AV block.)
2. Consider atropine sulfate IV -
• 1.0 mg IV/IO while waiting for pacer.
• May repeat atropine sulfate IV as necessary,
• Not to exceed total maximum cumultive dose of 3 mg.
• If atropine sulfate IV is ineffective begin pacing.
3. Treat contributing causes.

1. Administer BiLevel CPAP to achieve 11 - 12 cm H₂O IPAP (16 LPM) with EPAP set to lowest possible pressure. If oxygenation status doesn't improve, increase EPAP to achieve desired SpO₂.

If the patient has a history of COPD and is symptomatic (presence of wheezing alone does not indicate COPD), en route to hospital, the following may be administered:

1. Use a nasal cannula at 2 – 3 liters per minute initially. Oxygen may need to be increased if the patient’s oxygenation status worsens.
• When a patient is already on oxygen, EMS oxygen therapy flow rate should not start at a lower rate than the patient’s current rate.
2. Oxygen flow should be titrated to a target SpO₂ of 90%.
• Does not apply to patients on CPAP.
3. May give nebulized treatment of:

• Medications need to be mixed together:
1. albuterol sulfate Inhalation Solution, 0.083% 2.5 mg
2. ipratropium inhalation (Atrovent) 0.5 mg.
• May repeat nebulized medications x 1.

4. Consider CPAP if two or more of the following are present:
• Retractions or accessory muscle use.
• Pulmonary edema.
• Respiratory rate greater than 25/min.
• SpO₂ less than 92%.
1. Administer BiLevel CPAP to achieve 11 - 12 cm H₂O IPAP (16 LPM) with EPAP set to lowest possible pressure. If oxygenation status doesn't improve, increase EPAP to achieve desired SpO₂.
2. Assess the patient’s response. If the patient’s condition worsens, (e.g. the patient becomes hypotensive, decreased SpO₂) discontinue CPAP.
3. If CPAP is initiated, continue to treat with medications as normal.

5. AFTER OBTAINING VERBAL ORDERS
1. Treatment based on patient history and physical exam findings.

To be used for patients with known or suspected transmittable respiratory illnesses in the presence of a known outbreak. This would include patients who have a febrile illness with cough. Examples include -

• Severe Acute Respiratory Syndrome (SARS),
• Tuberculosis,
• Epidemic influenza,
• Others not listed here,

1. Protect yourself and crew with gowns, gloves and N95 mask/Powered Air Purifying Respirators (PAPR) and eye protection.
2. Begin oxygen therapy by mask. If oxygen is not needed then place a surgical mask on the patient.
3. For wheezing -
1. albuterol sulfate Inhalation Solution, 0.083%
• Metered dose inhaler (MDI) 2 puffs,

OR

• Breath actuated nebulizer.
2. May repeat selected dose method x 1.
3. Additional treatment(s) may be given every 15 minutes thereafter as needed.
4. Consider CPAP if two or more of the following are present:
• Retractions or accessory muscle use.
• Pulmonary edema.
• Respiratory rate greater than 25/min.
• SpO₂ less than 92%.
1. Administer CPAP (CPAP MODE) to achieve 11 - 12 cm H₂O (15 LPM).
2. Assess the patient’s response. If the patient’s condition worsens, (e.g. the patient becomes hypotensive, decreased SpO₂) discontinue CPAP.
3. Contact receiving hospital for isolation room preparations.

5. For patients in moderate to severe respiratory distress, may administer on-site:
1. terbutaline sulfate
• 0.25 mg SC.

OR

2. epinephrine (1:1,000)
• 0.5 mL IM.

6. AFTER OBTAINING VERBAL ORDERS
1. If not already given, consider terbutaline sulfate -
• 0.25 mg SC.
2. May repeat albuterol sulfate Inhalation Solution, 0.083% immediately for moderate to severe distress.

To be used for patients with known or suspected transmittable respiratory illnesses in the presence of a known outbreak. This would include patients who have a febrile illness with cough. Examples include -

• Severe Acute Respiratory Syndrome (SARS),
• Tuberculosis,
• Epidemic influenza,
• Others not listed here,

1. Protect yourself and crew with gowns, gloves and N95 mask/Powered Air Purifying Respirators (PAPR) and eye protection.
2. Insert oral airway and begin positive pressure ventilation.
3. Insert ET tube or other airway control device as authorized, as soon as possible. Use face shield (or Powered Air Purifying Respirator if wearing one) for your eye protection during intubation.
4. May administer:
1. terbutaline sulfate
• 0.25 mg SC.

OR

2. epinephrine (1:1,000)
• 0.5 mL IM.

5. See the EMSRB website www.emsrb.state.mn.us ^(NOTICE) for the “EMS Exposure/Special Pathogen Situation Response Guide” for further information.

1. Begin appropriate oxygen therapy. ET intubate for severe distress and/or ineffective breathing.
2. Consult with a medical control physician immediately if a tension pneumothorax is suspected.
3. AFTER OBTAINING VERBAL ORDERS
1. Consider needle thoracostomy if there is strong evidence of a tension pneumothorax (i.e. increased respiratory distress, weak rapid pulse, cyanosis, hypotension, uneven chest wall movement and decreased lung sounds on affected side).
• Perform a needle thoracostomy at the second intercostal space, midclavicular line of affected side.
2. Treatment based on patient history and physical exam findings.

1. For signs and symptoms consistent with anaphylaxis:
1. Administer epinephrine 1:1000 -
• 0.3 mg up to 0.5 mg IM.

OR

• One adult EpiPen IM.
• May repeat either as needed every five to ten minutes.
2. Manage airway as appropriate.
3. Obtain vascular access.
4. Administer diphenhydramine HCL (Benadryl) IV -
• 50 mg IV/IO/IM.
5. Consider NS bolus:
• 500 ml for patients 18 to 65.
• 250 ml for patients greater than 65 or history of CHF.
6. If bronchospasm and/or wheezing exists after administration of epinephrine consider:
1. Nebulized medications (mixed together):
1. albuterol sulfate Inhalation Solution, 0.083% 2.5 mg
2. ipratropium inhalation (Atrovent) 0.5 mg
2. If there is no improvement, may nebulize continuously with -
1. albuterol sulfate Inhalation Solution, 0.083% 2.5 mg

2. For signs and symptoms consistent with a mild allergic reaction -
1. diphenhydramine HCL (Benadryl) IV -
• 50 mg IV/IO/IM.

1. Assess the severity of the patient’s agitation.
2. Consider additional personnel to adequately and safely restrain the patient.
3. SEVERE AGITATION
1. If the patient is severely agitated and poses an immediate threat to himself/herself or others, consider giving one or both medications (may be mixed together in one syringe):
1. midazolam hydrochloride (Versed) -
• 5 mg IV/IO/IM

AND/OR

2. haloperidol (Haldol) -
• 5 mg up to 10 mg, IV/IO/IM (dosage based on the patient’s age and/or weight).

2. For continued agitation, consider contacting a medical control physician for further orders.
3. AFTER OBTAINING VERBAL ORDERS
1. Consider additional midazolam hydrochloride (Versed) -
• 1 mg up to 5 mg IV/IO/IM.

4. PROFOUND AGITATION
1. If the patient is profoundly agitated with active physical violence to himself/herself or others evident, and usual chemical or physical restraints (section C) may not be appropriate or safely used, consider:

• 5 mg/kg IM.
• If IV already established, give 2 mg/kg IV/IO.
1. DO NOT attempt to place an IV in a severely combative patient.
2. If ketamine hydrochloride (Ketalar) is administered, rapidly move the patient to the ambulance and be prepared to provide:
1. Respiratory support including suctioning, oxygen, and intubation.
2. Monitoring of the airway for laryngospasm (presents as stridor, abrupt cyanosis/hypoxia early in sedation period). If laryngospasm occurs perform the following in sequence until the patient is ventilating, then support as needed:
• Provide jaw thrust and oxygen.
• Attempt Bag Valve Mask (BVM) ventilation.
3. If hypersecretion is present -
1. Consider atropine sulfate IV -
• 0.1 mg up to 0.3 mg IV/IO.
• 0.5 mg IM.

4. If emergence of hallucinations/agitation after administration of Ketamine:
• Consider midazolam hydrochloride (Versed) -
• 2 mg up to 5 mg IV/IO/IM.

3. Consider IV access once sedation occurs (if no IV access previously established and Ketamine given IM) then administer Normal Saline wide open up to 1 liters.
4. Consider Sodium Bicarbonate -
• 1 amp IV/IO push.
5. Rapid transport at earliest opportunity.

1. Begin high-flow oxygen therapy.
2. Monitor the ECG.
3. See 2090 - Patient Disposition - Carbon Monoxide Poisoning for transport decisions.
4. AFTER OBTAINING VERBAL ORDERS
1. Consider transport directly to Hennepin County Medical Center for hyperbaric oxygen therapy.

1. Assess ABCs and vital signs.
2. Provide oxygen via nasal cannula ONLY if SpO2 < 92% and establish IV access.
3. Check blood glucose level and treat if indicated.
4. If B.E.F.A.S.T Stroke Scale (includes: Balance, Eyes/vision, Facial droop, Arm drift, Speech and Severe Headache) is positive (abnormal findings on the Scale), and:
1. Symptom onset time < 8 hours:
• Expedite transport,
• Use “Stroke Alert” in radio report, and
• Give time of symptom onset in clock time (e.g. 2:30 pm.)
2. Symptom onset time > 8 hours:
• State time of symptom onset (e.g. 2:30 pm) in your radio report.
• DO NOT use “Stroke Alert” in radio report.
3. Symptom onset time unknown (e.g. “wake up” stroke or patient is unable to communicate):
• Expedite transport,
• Use “Stroke Alert” in radio report,
• State "unknown symptom onset time,” and
• Document last known well time on your PCR
4. Consider diversion if the difference in transport times to the requested hospital versus the closest hospital is greater than 30 minutes.
5. Obtain ECG - 12 lead preferred.

1. Attempt to remove the patient’s contact lenses, if present.
2. Instill ophthalmic anesthetic (for example, tetracaine hydrochloride 0.5% (Altacaine).)
• 1 to 2 drops into the affected eye(s).
• May be repeated only once.
3. Immediately and continuously flush the affected eye(s).
4. Paramedics may insert Morgan lenses for irrigation if authorized.

Hennepin County EMS Units are equipped with Duodote (Atropine 2.1mg/Pralidoxime 600mg) kits primarily for treatment of responders. Chempack assets for mass casualty events can be activated via MRCC. Each Chempack treats up to 1000 patients using Mark 1 kits (same as Duodote but separate injectors for atropine and pralidoxime), Atropens (atropine for pediatric dosing), and diazepam auto- injectors for seizures.

• Note – Chempack may contain Duodotes in the future and pediatric atro-pens may be eliminated.

Common cholinergic agents include: Carbamates (carbofuran (Fursban), etc.), Nerve gas agents (sarin, tabun, VX, etc.), and Organophosphates (parathion, diazinon, malathion, chlorpyrifos (Dursban), etc.).

1. Recognize a toxidrome: Miosis (small pupils) present in ALL significant exposures in association with at least two of the following:
• Fasciculations
• Respiratory distress
• Increased secretions
• Vomiting/diarrheas/incontinence
• Seizure
• Cardiovascular collapse
2. Request CHEMPACK activation from MRCC if mass casualty incident.
3. Wear appropriate personal protective equipment; DO NOT enter the hot zone.
4. Assure appropriate patient decontamination measures if liquid or vapor exposures have occurred (in concert with fire department/HazMat).
5. Assess the patient’s ABCs and begin oxygen therapy (when possible); intubate if needed (may have high airway resistance).
6. Treat seizures with midazolam (or CHEMPACK – 10 mg diazepam auto-injectors).
7. In cases of known organophosphate overdose/exposure or in a setting of a multiple casualty incident (MCI) with patients exhibiting this toxidrome:
1. Administer atropine sulfate IV -
• 2 mg up to 5 mg IV/IO/IM.
• Repeat as necessary to control bronchial secretions.

OR

• CHEMPACK - Atropine IM 2 mg auto-injectors.
2. For patients with seizures, severe shortness of breath, and cardiovascular collapse administer:
• 2 Duodote auto-injector kits (600 mg Pralidoxime, 2.1 mg Atropine) or 2 Mark 1 kits (CHEMPACK).
3. Paramedics may administer one additional Duodote or Mark 1 kit after ten minutes if the patient continues to exhibit severe symptoms and no IV access has been established.
4. Consider aggressive management of cardiac arrest if resources allow.

1. Determine blood glucose level.
2. HYPERGLYCEMIA - If the patient’s blood glucose level is greater than 400 mg/dL and the patient is symptomatic:
1. Obtain IV access.
2. Give NS bolus -
• 500 ml for patients age 18 to 65.
• 250 ml for patients age who are greater than 65 or history of CHF.
3. Transport
3. HYPOGLYCEMIA - If blood glucose level is less than 60 mg/dL and the patient is symptomatic:
1. If the patient is conscious give sugar:
1. Dextrose IV -
• 50 ml PO.

OR

2. oral glucose (Glutose) -
• 80 Gm PO.

2. If the patient is unable to take oral fluids due to an altered level of consciousness:
1. Obtain IV access.
2. Administer either:
1. Dextrose IV -
• 50 ml IV/IO.

OR

2. Glucagon -
• 1 mg IM / IN if IV access is difficult or impossible to establish.
• NOTE: For all IN doses that are ≤ 0.9 mL, add 0.1 mL to ensure full dose of medication is given.

3. For adult patients who have experienced a hypoglycemic event and refuse medical transportation, see 3020 - Diabetic Hypoglycemic Patient Refusal of Transport.
4. AFTER OBTAINING VERBAL ORDERS
1. Consider transport of all patients on oral hypoglycemic agents or long-acting insulin.

1. Begin oxygen therapy.
2. Tricyclic overdoses requiring respiratory support should be ventilated with high flow O₂ via bag-valve-mask device.
3. For any patient with a respiratory rate less than eight, or a patient history of or physical findings consistent with opioid overdose -
1. Assist the patient’s ventilation.
2. Consider naloxone hydrochloride (Narcan) -
• 0.4 mg up to 2 mg IV/IO/IM/IN.
• NOTE: For all IN doses that are ≤ 0.9 mL, add 0.1 mL to ensure full dose of medication is given.
• Due to the relatively short half-life of naloxone hydrochloride (Narcan), patients that respond favorably to naloxone (Narcan) administration should still be considered under the influence and transported on a peace/health officer hold (aka transport hold) regardless of their mental status and/or refusal of care.

4. For all suspected tricyclic overdoses, monitor ECG.
5. AFTER OBTAINING VERBAL ORDERS
1. Consider additional naloxone hydrochloride (Narcan) -
• Not to exceed total maximum cumulative dose of 10 mg IV/IO/IM.
2. Consider Sodium Bicarbonate -
• 50 mEq IV/IO for tricyclic ingestion.
3. Consider Glucagon -
• 1 mg IV/IO/IM/IN for known beta blocker overdose.
• NOTE: For all IN doses that are ≤ 0.9 mL, add 0.1 mL to ensure full dose of medication is given.
4. Consider calcium chloride 10% -
• 1 Gm for known calcium channel blocker overdose with hypotension or bradycardia.

1. Begin cooling measures.
2. If the patient is confused or unconscious, start a Normal Saline IV.
3. Give NS bolus -
• 500 ml for patients age 18 to 65.
• 250 ml for patients age who are greater than 65 or history of CHF.
4. Transport lights and siren.
5. Monitor ECG -
• DO NOT delay transport to obtain ECG.

1. For patients with:
1. Signs of hyperkalemia based on known EKG findings;
2. Hemodynamic instability due to known or suspected hyperkalemia;
3. Cardiac arrhythmia or instability due to known or suspected hyperkalemia;
4. Patients at risk for hyperkalemia (renal failure, dialysis, or diabetic ketoacidosis); or
5. Laboratory confirmed hyperkalemia.
2. Begin oxygen therapy.
3. Monitor the patient’s ECG rhythm for wide QRS complex.
4. Administer continuous nebulized albuterol sulfate Inhalation Solution, 0.083%.
5. Obtain IV/IO access.
6. Contact a medical control physician.
7. AFTER OBTAINING VERBAL ORDERS
1. Consider calcium chloride 10% 10 ml (1 Gm) IV/IO or more if indicated, over 5 minutes.
2. Consider Sodium Bicarbonate 50 mEq IV/IO.
3. Other treatments based on the patient history and physical exam findings.

1. Standing orders for all hypothermic patients:
1. Remove wet garments.
2. Protect against further heat loss and wind chill (use blankets and insulating equipment).
3. Maintain the patient in a horizontal position.
4. Avoid rough movement and excess activity.
5. Monitor the patient’s cardiac rhythm.
6. Assess responsiveness, breathing and pulse.
7. Do a pulse check for 30 to 45 seconds (clinical signs of death may be misleading).
2. Pulse and breathing present:
1. Begin oxygen therapy.
2. Begin transport immediately.
3. Obtain IV access in route.
4. Monitor ECG.
5. Rewarming:
• Mild hypothermia (temperature greater than or equal to 92^o F or if the patient is shivering) - Passive rewarming, active external rewarming.
• Moderate hypothermia (temperature greater than or equal to 86^o F to less than 92^o F, or if patient is shivering) - Passive rewarming, active external rewarming to truncal areas only (neck, armpits, groin).
• Severe hypothermia (temperature less than 86^o F) - Transport for active internal rewarming.

3. Pulse and breathing not present - Generally, CPR should not be initiated if the patient:
1. Is known to have been submerged (head under water) in cold water for more than 90 minutes.
2. Has obvious signs of death (e.g. decapitation, slippage of skin, animal predation).
3. Is frozen (e.g. ice formation in the airway).
4. Has a chest wall that is so stiff that compressions are impossible.
4. For pulseless patients with or without an organized ECG rhythm who do not meet criteria in part C and resuscitation efforts are initiated:
1. Begin CPR.
2. For VF/Pulseless VT, defibrillate once as prescribed by current AHA ACLS guidelines. See 3220 - Cardiac Arrest (V_Fib and Pulseless V_Tach).
• Withhold medication treatments and further shocks and transport immediately.
3. Obtain IV/IO access.
4. Warm packs should not be used.
5. AFTER OBTAINING VERBAL ORDERS
1. Paramedics may consider cardiac arrest drugs and defibrillation but they are usually not effective until hypothermia is corrected.

1. If imminent delivery is not present, transport the patient in the position of comfort, usually on the patient’s left side.
2. If in question of imminent delivery, observe briefly, then transport unless delivery is in progress.
• Be prepared to stop the ambulance if delivery occurs en route.
3. If delivery is in progress:
1. Assist delivery using clean technique.
2. Suction the infant only if needed to clear obvious obstructions.
3. Protect from heat loss.
4. If no need for immediate resuscitation, wait 30-60 seconds then double clamp and cut the umbilical cord approximately 8-10 inches from the infant.
5. Term infants (> 37weeks) who are crying (good respiratory effort) and have good muscle tone can be given to the mother to nurse with continued warming efforts and re- assessment.
1. For all others see 4480 - Newborn Emergencies.
6. Transport; do not wait for nor attempt delivery of the placenta.
7. Closely observe the infant for signs and symptoms of distress and monitor the mother for excessive postpartum bleeding.
8. If complication(s) arise, see 4480 - Newborn Emergencies.

1. Begin oxygen therapy and administer high flow O₂ by mask for any complications.
2. Immediate transport for:
• Prepartum or postpartum hemorrhage (moderate to heavy).
• Limb presentation.
• Prolapsed umbilical cord.
• Known multiple fetuses.
• Previous cesarean section.
3. Start an IV Normal Saline in route.
4. If the patient is hypotensive, position on the left side and/or push the uterus to the patient’s left side.
5. For postpartum hemorrhage:
1. Massage the uterus gently.
6. For prolapsed umbilical cord:
1. Place the mother in a position to minimize pressure on the cord (e.g. the knee-chest position or Trendelenburg).
2. Insert a gloved finger into the vagina and hold the presenting part off of the umbilical cord.
3. Do not touch or attempt to replace the umbilical cord.
7. Suspected eclampsia (20 weeks gestation with hypertension, or up to 7 days postpartum) –
1. If patient is seizing with no known history of epilepsy/seizure disorder, administer 4 Gm Magnesium Sulfate IV/IO over 10 minutes.
   
   • NOTE: Dilute Magnesium Sulfate so total fluid volume is 20 ml.
8. For infant distress, see 4480 - Newborn Emergencies.
9. Contact a medical control physician for further orders for any complication(s).

1. Consider sepsis if you suspect the patient has an infection plus two of the following:
1. Systolic blood pressure less or equal to 100

OR

2. Respiratory rate greater than or equal to 22

OR

3. Altered mental status (e.g. GCS less than or equal to 14)
2. If the patient meets sepsis criteria in A:
1. Administer NS bolus -
1. 500 ml for patients age 18 to 65.
2. 250 ml for patients age who are greater than 65 or history of CHF.
3. May repeat up to 30 ml/kg to treat hypotension.
2. If positive for suspected sepsis -
1. Notify the receiving facility as soon as possible.
2. State clearly in your radio/phone report - “SEPSIS ALERT.”

If the patient has severe nausea and/or vomiting:

1. Obtain IV access.
2. If over age 12, administer ondansetron (Zofran) -
1. 4 mg slow IV/IO (over 1 - 2 minutes.)
• OR 4 mg IM (if unable to start an IV.)
2. May repeat ondansetron (Zofran) dose once.
3. Consider administration of:
1. Give NS bolus -
1. 500 ml for patients age 18 to 65.
2. 250 ml for patients age who are greater than 65 or history of CHF.

1. Begin oxygen therapy.
2. Begin transport immediately.
3. Start a Normal Saline IV en route to hospital.
4. Give NS bolus -
• 500 ml for patients age 18 to 65.
• 250 ml for patients age who are greater than 65 or history of CHF.
• Goal should be BP of 90-100 systolic or improvement of clinical indicators.
5. AFTER OBTAINING VERBAL ORDERS
1. Consider requesting additional fluid orders for volume loading for hypotension.

1. Position the patient to maintain an open airway.
2. Begin oxygen therapy.
3. If the seizure is ongoing greater than 5 minutes:
1. Administer midazolam hydrochloride (Versed) -
• 5 mg IV/IO/IN.
• NOTE: For all IN doses that are ≤ 0.9 mL, add 0.1 mL to ensure full dose of medication is given.
• 10 mg IM (if unable to start an IV.)
• May repeat midazolam hydrochloride (Versed) dose x 1 after 3 minutes for persistent seizure.

4. Be prepared to support respirations.
5. Determine the patient’s blood glucose level -
• If blood glucose low - 3470 - Diabetic Emergencies.
6. If seizure activity is suspected from eclampsia (20 weeks gestation with hypertension, or up to 7 days postpartum) -
• 3530 - Obstetric Complications - section G.

Age limits for pediatric patients must be flexible. For patients less than 13 years of age, pediatric orders should always apply. Between the ages of 13 and 18 judgment should be used, although the pediatric orders will usually apply. It is recognized that the exact age of a patient is not always known.

1. Parents should be allowed to stay with children during the evaluation and transport, if appropriate. The parent's lap is usually the best place for the examination of a stable patient.
2. Paramedics may follow dosage and equipment recommendations listed on the Broselow Tape.
3. See 9150 - Pediatric Reference Chart.

1. Bag Valve Mask (BVM) – Consider an oropharyngeal or nasopharyngeal airway of appropriate size on all unconscious patients for initial airway maintenance.
2. Endotracheal intubation – After endotracheal intubation, tube position must be confirmed using at least two methods, including continuous end-tidal carbon dioxide (CO₂) detection and a second device or method to confirm tube placement.
3. Alternate Advanced Airway Device – Services may use alternative advanced airway control devices (such as supraglottic airways) as specified by the ambulance service’s medical director. After placement of an alternate advanced airway device, place continuous end-tidal carbon dioxide (CO₂) detection device on the tube.
4. Pulse Oximetry – A pulse oximeter should be used for any patient with suspected hypoxemia, in respiratory distress, or whenever sedating medications are administered.

Not every patient requires an IV. When indicated, intravenous fluid therapy should be administered in accordance with the following guidelines:

1. For most patients requiring IV access, the paramedic has the option of either running fluids through the IV or capping the catheter with a saline lock. However, as specified in these Medical Protocols, IV fluids must always be hung in either situations:
• When the administration of multiple IV medications is anticipated.
• Whenever it is likely the patient will require fluid volume replacement.
2. There should be no delay at the scene for IV attempts on major trauma patients or patients in shock; these IVs should be started during transport.
3. Intraosseous infusion (IO) is a procedure for use in patients who are in critical condition when IV access is unobtainable.
4. Paramedics may access a Peripherally Inserted Central catheter (or PIC line) if the patient has one in place as an alternate IV access point.
5. Paramedics may access a central line if the patient is in cardiac arrest. The cap on the central line must be cleansed with alcohol and then 15-20 ml of fluid and blood must be aspirated from the central line before initiating IV fluids. If unable to aspirate, the central line should not be used.

This protocol is to be used to provide relief of pain when indicated for pediatric patients. This protocol is NOT to be used in cases where the patient meets any of the following:

• Is hypotensive (i.e. clinical signs of poor perfusion, capillary refill greater than two seconds.)
• Complains of abdominal pain.
• Has sustained a head injury.
• Has pain determined to be cardiac in origin.
• Is in active labor.
• Headache
• Low Back pain (except as described below.)
• Neck pain (except as described below.)
• Any chronic pain (e.g. head, neck or back pain, fibromyalgia, abdominal or pelvic pain.)
• Dental pain.

Indications for use of Pain Management Protocol:

1. Acute severe traumatic pain -
• Neck or back pain from trauma and inability to ambulate from the incident.
• Significant orthopedic injury.(Severe tenderness to palpation with swelling, bruising and/or deformity)
• Severe traumatic chest or abdominal pain with tenderness (ensure SBP > 90.)
• Major burns (4120 - Burns).
2. Consider use for acute severe non-traumatic pain (e.g. Kidney stone) with 2 or more of the following factors which tend to predict need for prompt treatment -
• Less than 2 hours duration.
• Increased heart rate and/or blood pressure.
• Nausea and/or vomiting.
• Writhing.
• Described as severe (or 8 - 10 / 10 on pain scale.)
3. Intubated patients with injury, painful condition or evidence of increasing discomfort (e.g. increasing BP or HR.)
4. Active cancer or palliative care.

For patients experiencing pain outside the above listed indications consider:

• Symptomatic relief of nausea/vomiting if needed.
• Advising them of the general concerns in the medical community about opioid use and that doctors are being very careful bout which patients receive these addictive medications.
• Inform them that we carry this type of medication for severe trauma such as broken bones and for certain medical situations that require immediate pain control such as heart attacks.
• Acknowledge their pain and try to improve comfort.
• Advise them that a doctor will need to evaluate them prior to administering pain medication.
• Reassure the patient that the receiving facility will be notified of the need for prompt pain management assessment.
• Consult medical control if questions.

PROCEDURE

1. Assess the patient’s pain on 0 - 10 scale if possible or use other scale if necessary. See also 9100 - Pain Scales.
2. Inform the patient and/or guardians that pain is an important diagnostic parameter and the goal of this protocol is to relieve suffering, not totally eliminate pain.
3. Administer one of the following medications:
1. Morphine Sulfate IV -
1. 0.1 mg/kg IV/IM/SQ (Maximum dose of 5 mg.)
2. fentanyl -
1. 1 mcg/kg IV/IO/IM/IN (Maximum dose of 50 mcg.)
• Intranasal administration should not exceed 1 ml per nostril, (2 ml total fluid volume IN.)
• NOTE: For all IN doses that are ≤ 0.9 mL, add 0.1 mL to ensure full dose of medication is given.

3. ketamine hydrochloride (Ketalar) -
1. Pain must be -
• Of a traumatic origin (non-cardiac),
• Is moderate to severe,
• Not responding to initial dose of Morphine Sulfate or fentanyl,

OR

• If the patient has a Morphine Sulfate allergy,
2. 0.1 mg/kg (maximum dose 10 mg) IV/IO/IM.
3. May repeat x 1 after 10 minutes for persistent pain.
4. NOTE: Refer to pediatric reference (e.g., Broselow Tape) if assistance is needed with pediatric vital signs or drug dosage calculations.
4. Monitor the patient’s vital signs (including O₂ saturation.) If respiratory depression or hypotension occurs after administration of Morphine Sulfate -
1. Ventilate the patient as necessary.
2. Administer naloxone hydrochloride (Narcan) -
• 0.01 mg/kg IV (Maximum dose of 0.4 mg.)

5. AFTER OBTAINING VERBAL ORDERS
1. Consider initial or additional pain medication as appropriate.

1. Patient:
1. Control hemorrhage and cover stump with sterile dressing saturated with saline.
2. Treat as per protocol - 4500 - Shock.
3. Do not spend excessive time looking for the amputated part if the patient is unstable.
2. Amputated Part:
1. Wrap the amputated part in sterile gauze.
2. Moisten with saline.
3. Place in plastic bag.
4. Place on top of ice, if available, or cold packs (do not freeze).

1. Consider direct transport to a burn center for major burns ( 2100 - Patient Disposition - Major Burns.)
2. Major burn criteria includes:
• Partial-thickness burns greater than 10% of total body surface area.
• Partial-thickness or third degree burns that involve the face, hands, feet, genitalia, perineum, or major joint.
• Third degree burns in any age group.
• Lightning injury and other electrical burns.
• Chemical burns.
• Inhalation injury.
• Burn in any patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
3. For any significant burn:
1. Begin oxygen therapy. Use positive pressure ventilatory assistance as needed.
2. Obtain IV access.
4. If less than 20% of the body surface is burned:
1. Apply sterile dressings and saturate with cool water (leave Gel-pack(s) in place if applied by first responders).
2. Do not allow any burn patient to become chilled and begin shivering.
5. If more than 20% of the body surface is burned:
1. Remove any non-adherent burned clothing and cover the patient with a sterile sheet.
2. Give 20 mL/kg NS bolus.
3. Do not cool down with water (exception: presence of smoldering clothes, articles or material adhering to skin that would continue the burning process, e.g., hot tar, etc.).
4. Begin rapid transport and contact a medical control physician for further orders and destination decision.
5. Consider direct transport to a burn center for major burns.
6. Consider pain management per protocol ( 4030 - Pain Management.)
7. Monitor the patient’s ECG after any electrical burn including a lightning strike.

1. Complete a rapid scene survey observing for any indications or any evidence that resuscitation should not be attempted (e.g., DNR orders or conditions incompatible with life).
2. If cardiac arrest occurs in the presence of the ambulance crew, assess the patient’s cardiac rhythm and continue with the appropriate protocol.
3. If the patient is in cardiac arrest on arrival of the ambulance crew:
1. Institute or continue BLS.
2. CPR: compressions 100/min, breaths 8-10/min. DO NOT OVER VENTILATE
3. Reassess the patient’s rhythm after every 5 cycles (2 minutes) of CPR. Limit interruptions in CPR during pulse/rhythm checks to less than 10 seconds for airway insertion and/or administration of medications.
4. Assess and confirm the patient’s cardiac rhythm, immediately resume CPR.
5. Review the most frequent causes for PEA, treat according to protocols if present:
1. Hypovolemia – fluids.
2. Hypoxia – ventilation and oxygenation
3. Hypothermia – re-warming, treat per 4470 - Environmental Hypothermia.
4. Hypoglycemia – if blood sugar < 60, treat per 4460 - Hypoglycemia.
5. CONSIDER OBTAINING VERBAL ORDERS FOR:
1. Acidosis - Sodium Bicarbonate.
2. Hyperkalemia - calcium chloride 10% & Sodium Bicarbonate.
3. Tension pneumothorax - Needle chest decompression.
4. Drug overdose - Intubation and specific antidote.
5. Coronary thrombosis - 12-lead ECG.
6. NO SPECIFIC PREHOSPITAL TREATEMENT FOR:
1. Hypokalemia
2. Cardiac tamponade
3. Pulmonary embolism

6. Secure the patient’s airway during the pulse check. Continue CPR immediately then confirm tube placement by exam and confirmation device.
7. Obtain IV access while providing two minutes of continuous CPR.
8. During CPR, administer the following medication:
1. epinephrine 1:10,000 -
• 0.01 mg/kg IV/IO every 3 - 5 min. (0.1 mL/kg)

9. Provide continuous CPR and reassess, checking the patient’s pulse/rhythm every two minutes.
10. Contact medical control physician for further orders.
11. AFTER OBTAINING VERBAL ORDERS
1. If no response consider termination of resuscitative efforts.

1. If cardiac arrest occurs in the presence of the ambulance crew -
1. Assess the patient’s rhythm
2. Defibrillate x 1 if necessary (energy rates as prescribed by current AHA ACLS guidelines; e.g., 2 J/kg.).
2. If the patient is in cardiac arrest on arrival of the ambulance crew, institute or continue BLS:
1. CPR: compressions 100/min, breaths 8-10/min. DO NOT OVER VENTILATE.
2. Reassess the patient’s rhythm after every 5 cycles (2 minutes) of CPR.
• Limit interruptions in CPR during pulse/rhythm checks to less than 10 seconds for airway insertion and/or administration of medications.

3. Assess and confirm the patient’s cardiac rhythm, if a shockable rhythm is present then defibrillate x 1 using the following guidelines:
1. Continue CPR while the defibrillator charges.
2. Defibrillate x 1 (energy rates as prescribed by current AHA ACLS guidelines; e.g., 2 J/kg.).
3. Immediately resume CPR.
4. Secure the patient’s airway during the pulse check, then confirm tube placement by exam and confirmation device.
5. Obtain IV access while providing two minutes of continuous CPR. Transport early if no readily accessible IV/IO access.
6. The following pressor is to be given during CPR:
• epinephrine 1:10,000 -
• 0.01 mg/kg (0.1 mL/kg) every 3-5 min.

• NOTE: Refer to pediatric reference (e.g., Broselow Tape) if assistance is needed with drug dosage calculations for pediatric patients.
7. Reassess the patient’s cardiac rhythm after 5 cycles (2 minutes) of CPR, if a shockable rhythm is present then defibrillate x 1 using the following guidelines:
1. Continue CPR while the defibrillator charges.
2. Defibrillate x 1 (energy rates as prescribed by current AHA ACLS guidelines; e.g., 2 J/kg.).
3. Immediately resume CPR.
8. Consider:
1. amiodarone hydrochloride (Cordarone) -
• 5 mg/kg bolus IV/IO

OR

2. lidocaine hydrochloride IV -
• 1 mg/kg bolus IV/IO.

OR

3. Magnesium Sulfate IV
• 25 mg/kg up to 50 mg/kg IV (for Torsades de Pointes or hypomagnesemia.)
• Maximum of 2 grams.

9. If no response to treatment, consider termination of resuscitative efforts.

1. Oxygenate and ventilate.
2. If cardiorespiratory compromise is present and heart rate is less than 60 beats per minute:
1. Begin chest compressions.
2. If despite oxygenation and ventilation symptomatic bradycardia persists:
1. epinephrine 1:10,000 -
• 0.01 mg/kg IV/IO.
• May repeat every 3 to 5 minutes at same dose.
2. For heart block or vagel etiologies atropine sulfate IV -
• 0.02 mg/kg (minimum dose 0.1 mg) IV/IO.
• May repeat once.
• Maximum total combined dose for the patient not to exceed 1 mg.
3. Consider cardiac pacing.
3. If pulseless arrest develops see 4210 - Cardiac Arrest (Asystole / PEA).
3. Review the most frequent causes and treat according to protocols if present:
1. Hypovolemia – fluids.
2. Hypoxia – ventilation and oxygenation.
3. Hypothermia – re-warming, treat per 4470 - Environmental Hypothermia.
4. Hypoglycemia – if blood sugar < 60, treat per 4460 - Hypoglycemia.

Includes:

• Probable sinus tachycardia.
• Probable ventricular tachycardia.
• Probable supraventricular tachycardia.

Assess and support the patient’s ABCs, provide oxygen and ventilation, and attach the cardiac monitor/defibrillator.

1. PROBABLE SINUS TACHYCARDIA

Probable sinus tachycardia is defined as a QRS duration normal for the patient’s age (approximately less than or equal to 0.08 sec). An infant’s heart rate is usually less than 220 bpm; a child’s heart rate is usually less than 180 bpm. If hemodynamically unstable:

1. Continue to assess and support ABCs, monitor, and provide oxygen and ventilation as necessary.
2. Search for and treat underlying cause.
• Consider Normal Saline bolus 20 mL/kg IV/IO.

2. PROBABLE VENTRICULAR TACHYCARDIA

Probable ventricular tachycardia is defined as a QRS duration wide for the patient’s age (approximately greater than 0.08 sec). If hemodynamically unstable:

1. Perform synchronized cardioversion:
1. Energy rates as prescribed by current AHA ACLS guidelines:
• 0.5-1.0 J/kg; if not effective, increase to 2 J/kg
2. Use sedation if possible but do not delay cardioversion.
• midazolam hydrochloride (Versed) -
• 0.1 mg/kg IV/IM.
• Maximum of 4 mg.

2. May attempt adenosine IV -
1. 0.1 mg/kg IV (Maximum first dose 6 mg) - if it does not delay electrical cardioversion.
2. May double first dose and repeat once (Maximum second dose 12 mg).
3. Use rapid bolus technique.
3. AFTER OBTAINING VERBAL ORDERS
1. Consider amiodarone hydrochloride (Cordarone) -
• 5 mg/kg IV over 20-60 minutes.

3. PROBABLE SUPRAVENTRICULAR TACHYCARDIA

Probable supraventricular tachycardia is defined as a QRS duration normal for the patient’s age (approximately less than or equal to than 0.08 sec). An infant’s heart rate is usually greater than or equal to 220 bmp; a child’s heart rate is usually greater than or equal to 180 bpm. If hemodynamically unstable:

1. Consider vagal maneuvers (no delays).
2. If IV access is readily available give adenosine IV -
1. 0.1 mg/kg IV (Maximum first dose 6 mg).
2. May double first dose and repeat once (Maximum second dose 12 mg).
3. Use rapid bolus technique.
3. If IV access is not readily available perform synchronized cardioversion:
1. Energy rates as prescribed by current AHA ACLS guidelines:
• 0.5-1.0 J/kg; if not effective, increase to 2 J/kg
2. Use sedation if possible but do not delay cardioversion.
• midazolam hydrochloride (Versed)
• 0.1 mg/kg IV/IM
• Maximum 4 mg.

4. AFTER OBTAINING VERBAL ORDERS
1. Consider amiodarone hydrochloride (Cordarone) -
• 5 mg/kg IV over 20-60 minutes.

1. Begin oxygen therapy.
2. Move the patient to the ambulance and begin transport.
• Asthma patients should always be transported to a hospital for monitoring and further treatment.
3. Give nebulized medications:
1. Medications need to be mixed together -
• albuterol sulfate Inhalation Solution, 0.083% 2.5 mg
• ipratropium inhalation (Atrovent) 0.5 mg
2. May repeat as needed.
4. Contact a MEDICAL CONTROL physician for patients with continued moderate-to-severe respiratory distress after two nebs.
1. If no improvement after 2 nebs consider:
1. terbutaline sulfate -
• 0.01 mg/kg SC.
• MAXIMUM DOSE - 0.25 mg.

OR

2. epinephrine 1:1,000 -
• 0.01 mg/kg (0.01 ml/kg) SC.
• MAXIMUM DOSE - 0.3 ml.

To be used in the field only if the patient’s condition is severe.

AND

3. Magnesium Sulfate IV -
• 25 mg/kg IV/IO over 3 to 5 minutes. Dilute (any dose) to 10 ml, total volume and given over 10 min.
• MAXIMUM DOSE - 2 Gm
• If hypotensive response to magnesium sulfate -
• Administer 20 mL/kg normal saline bolus.

5. If the patient is unresponsive to other treatments and impending respiratory failure is evident consider advanced airway.

1. Insert an oral or nasal airway and begin positive pressure ventilation. Ventilate with a short inspiration: long expiration ratio at a rate of 8 - 10/min.
2. Insert advanced airway.
3. Administer -
1. epinephrine 1:1,000 -
• 0.01 mg/kg (1 mg/mL) IM.
• MAXIMUM DOSE - 0.5 mg.
2. Continuous in-line nebulizer:
1. Medications need to mixed together -
• albuterol sulfate Inhalation Solution, 0.083% - 2.5 mg
• ipratropium inhalation (Atrovent) - 0.5 mg

4. Perform manual exhalation.
5. Start an IV/IO.
6. Administer -
1. Magnesium Sulfate IV -
• 25 mg/kg IV/IO over 3 to 5 minutes. Dilute (any dose) to 10 ml, total volume and given over 10 min.
• MAXIMUM DOSE - 2 Gm
• If hypotensive response to magnesium sulfate -
• Administer 20 mL/kg normal saline bolus.

1. Keep the patient upright at all times when conscious.
2. Begin oxygen therapy.
• Remove the O₂ mask if it is not well tolerated by the patient,
• Or if O₂ sats indicate no oxygen is needed.
3. If the child is unconscious, position supine and begin ventilation.
4. Place ECG leads.
5. Transport early.
6. For suspected croup consider -
1. Nebulized epinephrine 1:1,000 -
• Dosage - 5 mg (5 ml.)

OR if unable to administer via neb -

2. IM epinephrine 1:1,000 -
• Dosage - 0.01 mg/kg (0.01 ml/kg) IM.

1. If the patient is making efforts to clear their airway without success, you may assist with careful back blows (slaps) and chest thrusts for infants (less than one year old), and abdominal thrusts for children (greater than or equal to one year old) per BCLS guidelines.
• Synchronize with the patient's cough.
• Avoid abdominal compressions in infants less than one year old.
2. If the patient has lost consciousness, attempt to open the airway (use moderate extension and jaw-lift) and ventilate the patient with a bag-valve-mask (BVM). Reposition and attempt ventilation again if the initial attempt was unsuccessful. If ventilations are unsuccessful, perform standard obstructed airway maneuvers for an infant or child as appropriate.
• Position an infant with the head dependent during back blows and chest compressions.
3. Consider direct laryngoscopy and foreign body removal with Magill forceps.
4. Attempt endotracheal intubation.
5. Transport early.

1. For signs and symptoms consistent with anaphylaxis:
1. Administer -
1. epinephrine 1:1,000 -
• Dosage - 0.01 mg/kg (0.01 ml/kg) IM up to 0.5 mg.
• May repeat as needed every five to ten minutes.

2. Manage airway as appropriate.
3. Obtain vascular access.
4. Administer -
1. diphenhydramine HCL (Benadryl) IV -
• Dosage - 1 mg/kg IV/IM.
• MAXIMUM dose - 50 mg.

5. Transport early.
6. If the patient remains hypotensive consider -
• Fluid bolus 20 mL/kg (up to 500 mL.)
7. If bronchospasm and/or wheezing exists after administration of epinephrine consider:
1. Nebulized medications (mixed together):
1. albuterol sulfate Inhalation Solution, 0.083% 2.5 mg
2. ipratropium inhalation (Atrovent) 0.5 mg
2. If there is no improvement, may nebulize continuously with -
1. albuterol sulfate Inhalation Solution, 0.083% 2.5 mg

2. For signs and symptoms consistent with a mild allergic reaction -
1. diphenhydramine HCL (Benadryl) IV -
• 1 mg/kg IV/IO/IM.
• MAXIMUM dose - 50 mg.

1. Assess the severity of the patient’s agitation.
2. Consider additional personnel to adequately and safely restrain the patient.
3. If the patient is agitated and not amenable to reassurance, verbal de-escalation, or physical restraints, and poses an immediate threat to himself/herself or others -
1. ketamine hydrochloride (Ketalar)
• 3 - 5 mg/kg IM.

4. Once sedation occurs establish IV access -
1. Consider Normal Saline 20 ml/kg.
5. For continued agitation, consider contacting a medical control physician for further orders.

Hennepin County EMS Units are equipped with Duodote (Atropine 2.1mg/Pralidoxime 600mg) kits primarily for treatment of responders. Chempack assets for mass casualty events can be activated via MRCC. Each Chempack treats up to 1000 patients using Mark 1 kits (same as Duodote but separate injectors for atropine and pralidoxime), Atropens (atropine for pediatric dosing), and diazepam auto-injectors for seizures.

• Note – Chempack may contain Duodotes in the future and pediatric atro-pens may be eliminated.

Common cholinergic agents include: Carbamates (carbofuran (Fursban), etc.), Nerve gas agents (sarin, tabun, VX, etc.), and Organophosphates (parathion, diazinon, malathion, chlorpyrifos (Dursban), etc.).

1. Recognize a toxidrome: Miosis (small pupils) present in ALL significant exposures, in association with at least two of the following:
• Fasciculations
• Respiratory distress
• Increased secretions
• Vomiting/diarrheas/incontinence
• Seizure
• Cardiovascular collapse
2. Request CHEMPACK activation from MRCC if mass casualty incident.
3. Wear appropriate personal protective equipment; DO NOT enter the hot zone.
4. Assure appropriate patient decontamination measures if liquid or vapor exposures have occurred (in concert with fire department/HazMat.)
5. Assess the patient’s ABCs and begin oxygen therapy if possible; intubate if needed (may have high airway resistance.)
6. Treat seizure per protocol with midazolam (or CHEMPACK – Diazepam 10 mg auto injector IM only if > 25 kg.)
7. In cases of known organophosphate overdose/exposure or in a setting of multiple casualty incident (MCI) with patients exhibiting this toxidrome:
1. Administer atropine sulfate IV 0.1 mg/kg IV/IO/IM (up to 2 - 5 mg/dose); repeat as necessary to control bronchial secretions
• CHEMPACK – may contain auto injectors appropriate for:
• Infant < 6 months = 0.5 mg infant (blue)
• Todler < 2years = 1mg (red)
• > 2 years old = 2 mg (standard Duodote or Mark 1 kit)

2. For patients with seizures, severe shortness of breath, and cardiovascular collapse administer Duodote auto-injector if available (or Mark 1 kit from CHEMPACK):
• 2 - 10 years of age – 1 Duodote/Mark 1
• > 10 years of age – 2 Duodote/Mark 1 kits per adult protocol
3. Paramedics may administer one additional Duodote (or Mark 1) kit after ten minutes if the patient continues to exhibit severe symptoms and no IV access has been established. IV atropine is preferred in pediatric patients.
8. Consider aggressive management of cardiac arrest if resources allow.

1. For any patient with -
1. Respiratory rate less than eight,

OR

2. Has a history of opioid overdose,

OR

3. Has physical findings consistent with opioid overdose,
1. Administer naloxone hydrochloride (Narcan) -
• 0.1 mg/kg IV/IO/IM up to 2 mg.
2. Due to the relatively short half-life of naloxone hydrochloride (Narcan), patients that respond favorably to naloxone hydrochloride (Narcan) administration should still be considered under the influence and transported on a peace/health officer hold (aka transport hold) regardless of their mental status and/or refusal of care.
4. For all suspected tricyclic overdoses, monitor ECG.
2. AFTER OBTAINING VERBAL ORDERS
1. Consider additional naloxone hydrochloride (Narcan) -
• 0.1 mg/kg IM/IV up to 2 mg.
2. Consider Sodium Bicarbonate -
• 1 mEq/kg IV/IO for tricyclic ingestions.
3. Consider Glucagon -
• 0.1 mg/kg IV/IO/IM/IN for known beta blocker overdose.
• NOTE: For all IN doses that are ≤ 0.9 mL, add 0.1 mL to ensure full dose of medication is given.
4. Consider calcium chloride 10% -
• 20 mg/kg (0.2 mL/kg) for known calcium channel blocker overdose with hypotension or bradycardia.

1. Begin cooling measures:
1. Apply cool packs to head and truncal areas.
2. Suspend cooling measures if shivering occurs.
2. If the patient is confused or unconscious:
1. Start a Normal Saline IV.
2. Give a bolus of 20 mL/kg.
3. Monitor ECG.
3. Transport lights and siren.

1. Determine blood glucose level.
2. If blood glucose < 60 mg/dL and the patient is symptomatic:
1. If the patient is conscious, cooperative, and able to swallow effectively, give oral glucose therapy.
2. If the patient is unable to take oral fluids due to an altered level of consciousness:
1. Obtain IV access.
2. Give dextrose:
• For patients 4 or older - Dextrose IV - D50W
• 1 ml/kg IV up to 50 ml.
• For patients 3 or younger - Dextrose IV - D25W
• 2 ml/kg.

3. May give Glucagon 1 mg IM / IN if IV access is difficult or impossible to obtain.
• NOTE: For all IN doses that are ≤ 0.9 mL, add 0.1 mL to ensure full dose of medication is given.

3. A medical control physician must be contacted in any case where the patient experienced a hypoglycemic event and the parent or guardian refused medical transportation.

1. Standing orders for all hypothermic patients:
1. Remove wet garments.
2. Protect against further heat loss and wind chill (use blankets and insulating equipment.)
3. Maintain the patient in a horizontal position.
4. Avoid rough movement and excess activity.
5. Monitor the patient’s cardiac rhythm.
6. Assess responsiveness, breathing and pulse.
7. Do a pulse check for 30-45 seconds (clinical signs of death may be misleading.)
2. Pulse and breathing present:
1. Begin oxygen therapy.
2. Begin transport immediately.
3. Obtain IV access en route.
4. Monitor ECG.
5. Rewarming:
• Mild hypothermia (temperature greater than or equal to 92^o F or if the patient is shivering) - Passive rewarming, active external rewarming.
• Moderate hypothermia (temperature greater than or equal to 86^o F to less than 92^o F, or if patient is shivering) - Passive rewarming, active external rewarming to truncal areas only (neck, armpits, groin).
• Severe hypothermia (temperature less than 86^o F) - Transport for active internal rewarming.

3. Pulse and breathing not present - Generally, CPR should not be initiated if the patient:
1. Is known to have been submerged (head under water) in cold water for more than 90 minutes,
2. Has obvious signs of death (e.g. decapitation, slippage of skin, animal predation),
3. Is frozen (e.g. ice formation in the airway) or,
4. Has a chest wall that is so stiff that compressions are impossible.
4. For pulseless patients with or without an organized ECG rhythm who do not meet criteria in part C and resuscitation efforts are initiated:
1. Begin CPR.
2. For VF/Pulseless VT defibrillate once as prescribed by current AHA ACLS guidelines. 4220 - Cardiac Arrest (V_Fib and Pulseless V_Tach). Withhold medication treatments and further shocks and transport immediately.
3. Obtain IV access and contact medical control physician en route.
4. Warm packs SHOULD NOT be used.
5. AFTER OBTAINING VERBAL ORDERS
1. Paramedics may consider cardiac arrest drugs and defibrillation but they are usually not effective until hypothermia is corrected.

1. In all situations, minimize the newborn’s heat loss:
1. Dry the newborn well.
2. Increase environmental temperature.
2. Suction the newborn only if needed to clear secretions or an obstruction:
1. During or after delivery, suction the mouth and oropharynx first, then the nose.
2. If meconium is present at birth, and the infant has poor muscle tone and inadequate respiratory effort, keep warm and provide ventilatory assistance and oxygenation as needed, including intubation and suction if the airway is obstructed.
3. During the first minute warm the infant, position airway, clear secretions if needed, and dry and stimulate.
4. Assess for apnea, gasping, or heart rate less then 100:
1. If apneic, gasping, or heart rate less than 100, initiate positive pressure ventilation, monitor SpO₂, and consider ECG monitoring.
2. If labored breathing or persistent cyanosis, reposition airway and administer oxygen (less then 30% FiO₂).
5. Reassess heart rate:
1. If less than 100: correct ventilation of increase oxygen.
2. If less than 60: start chest compressions, increase oxygen to 100%, and intubate.
3. Continue to reassess heart rate.
6. If heart rate remains less then 60, administer epinephrine 1:10,000 (0.01 mg/kg) IV/IO.
7. Transport early. Attempt to maintain body temperature and assure optimal ventilation and oxygenation.