Mercy Air

Blood Gases

ANION GAP, serum Na - Cl - HCO3 (normal < 14) CARBON MONOXIDE, ART% Non-smoker: < 1.5, Smoker: 1.5 - 5 CARBON MONOXIDE, VEN% Non-smoker: < 1.5, Smoker: 1.5 - 5 HCO3, ART mmol/L 23 - 29, 20 - 29 HCO3, VEN mmol/L 25 - 30, 23 - 28 O2HB, ART 95 - 97 O2HB, VEN 40 - 70 PCO2, ART (Temperature Corrected) mmHg 36 - 46 PCO2, VEN (Temperature Corrected) mmHg 40 - 52 PH, ART (Temperature Corrected) 7.35 - 7.46 PH, VEN (Temperature Corrected) 7.33 - 7.40 PO2, ART (Temperature Corrected) mmHg 74 - 109 PO2, VEN (Temperature Corrected) mmHg 25 - 44

Pediatric Anaphylaxis

- Consider Diphenhydramine at 1 mg/kg IV/IM. May repeat to a maximum of 50 mg. - Consider administering Ranitidine 1 mg/kg IV up to 50 mg over 5 minutes diluted or Famotidine 0.25 - 0.5 mg/kg up to 20 mg IV. - Administer Dexamethasone 0.6 mg/kg up to a maximum single dose of 10 mg IV or administer Methylprednisolone 2 mg/kg IV up to maximum single dose of 125 mg. - Consider Epinephrine: • Mild to moderate: Epinephrine 1 mg/mL 0.01 mg/kg (0.01 mL/ kg) IM up to a maximum single dose of 0.3 mg, every 3 - 5 min. Anterior thigh is preferred site for IM. • Severe distress: Epinephrine 1 mg/10 mL (0.1 mg/mL) 0.01 mg/ kg (0.1 mL/kg) IV up to a maximum single dose of 1 mg. • May repeat as needed; consider Epinephrine infusion, start at 0.1 mcg/kg/min IV. • For bronchospasm, administer Albuterol 2.5 mg in 3 mL NS via nebulizer repeating as necessary.

Hyperkalemia

- Consider blood draw for lab studies if EKG shows advanced changes such as, loss of P waves, prolonged QRS, peaked T waves and bradycardia. Transport should not be delayed to await lab results. - Calcium is indicated when the EKG shows advanced changes such as loss of P waves and prolonged QRS duration. Calcium is also recommended, regardless of the EKG findings, when the serum potassium exceeds 7.0 mEq/L. Administer: • Calcium Chloride 10% 500 - 1,000 mg over 2 minutes. Repeat every 10 min -OR- • Calcium Gluconate 1 g slow IVP over 5 minutes. Repeat every 10 min. • If the patient is on digitalis, more caution is required as calcium can increase the toxic effects of digitalis. Add the appropriate dose to 100 mL NS and infuse over 20 to 30 minutes. - Consider Sodium Bicarbonate 8.4% 50 mEq IV. - Ensure IV lines are well flushed between medications. - Administer Dextrose 50% 25 g IVP followed by Regular Insulin 10 units IVP to shift potassium into the intracellular space. Check capillary blood glucose every 30 minutes after insulin administration. Treat hypoglycemia (< 60 mg/dL) with an additional Dextrose 50% 25 g IVP. - Albuterol 5 mg in 3 mL of NS via nebulizer, may repeat. - Repeat the above 2 steps for continued signs of hyperkalemia.

Anaphylaxis

- Epinephrine 1 mg/10 mL (0.1 mg/mL) 0.1 - 0.5 mg (1 - 5 mL) IV over 5 minutes if the patient is experiencing a severe life-threatening reaction or shows signs of shock. - If the patient is hypotensive, administer an IV fluid bolus of 250 mL of NS/LR. Repeat as necessary, so long as the patient shows no sign of volume overload. For hypotension that does not respond to fluid resuscitation, treat with an Epinephrine infusion at 2 - 10 mcg/min IV. - Administer Albuterol, Diphenhydramine, Dexamethasone or Methylprednisolone, and Ranitidine or Famotidine per doses above.

Cardiac Arrest

- Epinephrine 1 mg/10 mL (0.1 mg/mL) 1 mg IV push, repeat every 3 - 5 min. - Amiodarone 300 mg IV push for persistent/recurrent V-Fib/pulseless VTach. -OR- - Lidocaine 1.5 mg/kg slow IV push, may repeat in 3 - 5 minutes (maximum dose 3 mg/kg). - Magnesium Sulfate 2 g IV over 2 minutes for Torsades de Pointes, known hypomagnesemic state, or digoxin toxicity. • Consider post-conversion infusions of the antidysrhythmic that proved to be effective in converting rhythm, per sending or receiving physician request: - Amiodarone 60 mg/hr IV x 6 hours then 30 mg/hr IV x 18 hours -OR- - Lidocaine 2 - 4 mg/min IV

Allergic Reaction

- If the patient is experiencing dyspnea (with or without wheezing), administer Albuterol 2.5 mg in 3 mL of NS via nebulizer. May repeat as needed. - Administer Diphenhydramine 1 mg/kg IV or deep IM up to maximum dose 50 mg. - Consider administering Dexamethasone 0.6 mg/kg IV up to maximum dose 10 mg or administer Methylprednisolone 2 mg/kg IV up to maximum dose 125 mg. - Consider administering Ranitidine 1 mg/kg IV over 5 minutes diluted up to maximum dose 50 mg or Famotidine 0.25 - 0.5 mg/kg IV up to maximum dose 20 mg. - For reactions involving mild to moderate airway or hemodynamic compromise: • Consider Epinephrine 1 mg/mL 0.3 - 0.5 mg (0.3 - 0.5 mL) IM every 15 minutes x 3 doses. • If the allergic reaction continues, initiate Epinephrine infusion at 2- 10 mcg/min - When administering Epinephrine to patients with risk of cardiovascular disease, consider beginning at the lower end of the dosage range.

Vent

Acidotic minute ventilation • Consider minute ventilation based on the patient's age range: - 9 L/min for adults - 4 - 5 L/min for pediatrics - 1.5 - 3 L/min for infants. I:E ratio • Initial Setting: 66 - 1:2 for non-air trapping patients - 1:4 - 1:6 for patients with bronchoconstriction, asthma, COPD, and pediatric patients < 15 years old that have reduced ability to exhale inspired gas out of their lungs. Hypotension: --Higher tidal volumes, lower RR - Higher than normal tidal volumes are allowed as long as plateau pressure remains under 30 cmH2O. - Typical initial Vt settings are 8 - 12 mL/kg. • ARDS Approach - An approach that has been designed for ARDS patients focuses on lower volumes and higher rates to achieve an effective minute ventilation. - Target 4 - 6 mL/kg of tidal volume in these patients and then titrate the set respiratory rate to achieve an effective minute ventilation.

Hypomagnesemia

Administer Magnesium Sulfate 2 g IV infusion over 30 minutes to adult patients and Magnesium Sulfate 50 mg/kg IV infusion to maximum 2 g over 30 minutes to pediatric patients.

Hypokalemia

Direct potassium replacement therapy by the symptomatology and the potassium level. Usually, patients who have mild or moderate hypokalemia (potassium of 2.5 - 3.5 mEq/L), are asymptomatic, or have only minor symptoms need only oral potassium replacement therapy. If cardiac dysrhythmias or significant symptoms are present, then more aggressive therapy is warranted. - On the interfacility transfer, if the potassium level is less than 2.5 mEq/L, administer Potassium Chloride 10 - 20 mEq/100 mL IV at rate 10 mEq/hr through peripheral venous access and 20 mEq/hr through central venous access or intraosseous access.

Pediatric Sepsis

Establish an IV with age appropriate rate and solutions. Begin bolus of 20 mL/kg of NS IV, repeat as needed. 60 - 120 mL/kg are often needed. • For continued hypotension, see the PCG "Pediatric Shock - PEDIATRICS." • Obtain blood glucose and treat per the PCG "Hypoglycemia - MEDICAL." • Antibiotics should be initiated, when appropriate, on interhospital transfers prior to transport at the physicians orders. If intravenous access is unobtainable, antibiotics can be given IM or IO in small children. Patient allergies should be considered when determining antibiotic choice. - Consider Ceftriaxone 50 mg/kg up to a maximum dose of 2 g IV. • Meningitis can cause hypoglycemia and hyponatremia. Both can cause seizures and should be treated if identified on interhospital transports. Seizures should be treated under the PCG. • Antipyretics should be considered on interhospital transfers in febrile patients Acetaminophen 15 mg/kg PO/PR up to maximum single dose 1,000 mg and/or Ibuprofen 10 mg/kg PO up to maximum single dose 800 mg. • Inhaled bronchodilators may be considered to optimize ventilation. • Glucocorticoid therapy in children with fluid refractory, catecholamine resistant shock and suspected adrenal insufficiency is indicated. For continued hypotension after multiple IV fluid boluses and vasopressor therapy, administer one time dose of Hydrocortisone 2 mg/kg IV bolus maximum single dose of 100 mg. • If the patient requires intubation, the preferred sedative for children in septic shock is Ketamine. Avoid the use of Etomidate in these patients.

Hypermagnesemia

For symptomatic patients, administer Calcium Chloride 10% 10 mL IV or Calcium Gluconate 10 - 20 mL IV over 3 minutes. If the patient is on Digitalis, more caution is required as calcium can increase the toxic effects of Digitalis.

Pediatric Shock

If hypotension persists after adequate fluid resuscitation, initiate one of the following agents: - Epinephrine at 0.1 - 1 mcg/kg/min IV, titrate every 5 minutes (first choice) - Dopamine at 5 - 20 mcg/kg/min IV. - Norepinephrine 0.1 - 2 mcg/kg/min IV for "warm shock". • Not first line of treatment in children under 2 years of age. • For patients with hypotension attributed to heart failure, refer to the PCG "Pediatric Cardiogenic Shock - PEDIATRICS." • Hypocalcemia should be corrected: - Administer Calcium Gluconate 50 - 100 mg/kg IV (peripheral line) or Calcium Chloride 10 - 20 mg/kg IV (central line). • For shock refractory to both fluid resuscitation and inotropic/vasopressor agents, consider Hydrocortisone 2 mg/kg IV bolus up to maximum dose 100 mg IV and consider infusion of Hydrocortisone 50 mg/kg/day IV.

Post-Intubation Sedation/Paralysis

May administer bolus doses: Adult • Ketamine 0.5 - 1 mg/kg IV, may repeat every 10 minutes as necessary. • Midazolam 2.5 - 5 mg IV, may repeat in 3 - 5 minutes; consider lower dose in age > 60 or chronically ill. • Lorazepam 1 - 2 mg IV, may repeat in 15 minutes, as necessary. • Diazepam 2 - 10 mg IV/IM, may repeat in 10 minutes, as necessary. • If required to maintain adequate ventilation or to ensure patient/crew safety, administer a non-depolarizing neuromuscular blocking agent: - Rocuronium 0.6 - 1.2 mg/kg IV (usual dose is 1 mg/kg) 5 Pediatric • Ketamine 0.5 - 1 mg/kg IV, may repeat every 10 minutes as necessary. • Midazolam 0.05 - 0.1 mg/kg IV, may repeat in 3 - 5 minutes. Max single dose 5 mg. • Lorazepam 0.05 - 0.1 mg/kg IV, may repeat in 3 - 5 minutes. Max single dose 1 mg (> 5 years old), 0.5 mg (< 5 years old). • Diazepam (> 5 years of age) 0.1 - 0.2 mg/kg IV every 10 minutes. Max single dose 10 mg. • If required to maintain adequate ventilation or to ensure patient/crew safety, administer a non-depolarizing neuromuscular blocking agent: - Rocuronium 0.6 - 1.2 mg/kg IV (usual dose is 1 mg/kg)

LVAD

Normal Operating Conditions - Pump speed: 3,000 - 4,000 RPM. - Pump flow: 4 - 5 LPM. - Rap/LAP: 10 - 15 mmHg. - Activated Clotting Time (ACT): 160 - 180 seconds.

Tocolytics, OB

• A fluid bolus of 500 mL to 1,000 mL IV over 30 - 60 minutes should be administered, followed by maintenance of 125 mL/hr IV. • Administer Magnesium Sulfate: - Verify that Calcium Gluconate is available. - Mix Magnesium Sulfate in D5W or NS to obtain a concentration of 4 g/100 mL. (40 g in 1,000 mL, 20 g in 500 mL, or 10 g in 250 mL) - Infuse 4 g IV bolus over 20 - 30 minutes. - After bolus, administer maintenance infusion of 2 - 4 g/hr IV. • If contractions persist, the Magnesium Sulfate infusion may be increased every 10 - 15 minutes up to a maximum of 4 g/hr IV. • Monitor for magnesium toxicity: If somnolence, muscular paralysis, respiratory depression, or loss of DTRs occurs: - Immediately discontinue Magnesium Sulfate infusion. - Administer Calcium Gluconate 1 g of 10% solution over 1 - 2 minutes. - Calcium Gluconate is the drug of choice, but if this is not available administer Calcium Chloride 500 mg slow IV injection (not to exceed 1mL/min). The usual precautions for IV therapy should be observed. If time permits, the solution should be warmed to body temperature. The injection should be halted if the patient complains of any discomfort; it may be resumed when symptoms disappear. Following injection, the patient should remain recumbent for a short time. - Following administration of calcium, do not restart Magnesium Sulfate infusion until one hour has passed and all signs of magnesium toxicity have resolved, then restart infusion at previous rate. • Administer Terbutaline Sulfate 0.25 mg SQ every 15 - 30 minutes up to a maximum of 1 mg or until Magnesium Sulfate is prepared and ready for administration. - Contraindications to Terbutaline Sulfate: cardiac history, maternal HR >140, maternal BP < 90/60 mmHg, fetal heart rate > 160, signs of maternal pulmonary edema. • Terbutaline or Ritodrine infusions may occasionally be initiated by transferring facilities. If these infusions are encountered, contact the receiving OB physician regarding their management. 44 Terbutaline infusions may be found infusing at 5 ug/min IV to a maximum of 80 ug/min IV. Ritodrine may be found infusing at 50 ug/min IV to a maximum dose of 350 ug/min IV

ACS & STEMI

• Administer Aspirin 162 to 324/325 mg unless contraindicated by a true allergy. Document if aspirin was already received. • If hypotension is present and there is no evidence of pulmonary edema, consider IV fluid challenge and treat hypotension per the PCG "Hypotension -MEDICAL." • Administer Nitroglycerin (NTG) - NTG is contraindicated if the patient has received a dose the erectile dysfunction medication sildenafil within the past 24 hours or a dose of tadalafil or vardenafil within the past 72 hours. - Use with caution in the presence of a Right Sided MI. - NTG 0.4 mg sublingual (SL) every 5 minutes, may continue repeating dose every 5 minutes if relieving pain and maintaining SBP > 90 mmHg. -OR- - Infuse NTG 10 mcg/min IV (25mg/10mL) and titrate for comfort. Do not exceed 200 mcg/min. Monitor VS and maintain SBP > 90 mmHg. Reduce NTG infusion if hypotension occurs and bolus NS/LR IV. • If pain persists, consider administering Fentanyl or Morphine. Maintain SBP > 90 mmHg.

RSI Intubation

• Adult patients: If the patient is not responding to volume resuscitation and has a systolic blood pressure less than 90 mmHg, administer a push dose pressor: - For non-trauma patients administer Phenylephrine 200 mcg IV and repeat every 2 minutes if the SBP is still less than 90 mmHg on repeat vital signs. -OR- - For trauma patients administer Vasopressin 2 units IV, repeat every 2 minutes if the SBP is still less than 90 mmHg on repeat vital signs. • Position the patient with the head of bed elevated 30 - 35 degrees. • Pre-oxygenate the patient: - For an adequately spontaneously breathing patient, apply a nonrebreather mask at 15 L/min oxygen. - Apply nasal cannula oxygen at 10 - 25 L/min for apneic oxygenation. • If unable to maintain oxygen saturation > 93%: - Place an oral and/or nasal airway adjunct. - Suction the mouth and oropharynx to decrease the risk of video laryngoscope view obstruction and ventilator-associated pneumonia (VAP). - Perform 2-person thumbs-up bagging technique with PEEP valve and ETCO2 monitor. - Squeeze bag with one hand in synchrony with patient's intrinsic respiratory effort and apply cricoid pressure with other hand to minimize gastric distension. • Open cervical collar if present. • Assess HEAVEN criteria to help determine appropriate technique for intubation success: - Hypoxemia - Extremes of size - Anatomic disruption/obstruction - Vomit/blood/fluid in airway - Exsanguination - Neck mobility • Once patient physiology, position, and intubating conditions are optimized, proceed with RSI. • Consider Premedication: - Atropine 0.02 mg/kg IV for pediatric patients < 1 year of age who are not markedly tachycardic to prevent vagal bradycardia. Maximum dose 1 mg. • Administer induction agent. - Etomidate 0.3 mg/kg IV (maximum dose 40 mg). • Caution in patients with sepsis and patients at risk for adrenal insufficiency. -OR- - Ketamine 1 - 2 mg/kg IV or 4 mg/kg IM. • Preferred induction agent in patients with reactive airway disease/ bronchospasm, shock/hypotension, sepsis, and pediatrics. • Caution in patients with severe hypertension and conditions where worsening HTN is detrimental (e.g., cerebral hemorrhage, acute myocardial ischemia/infarction, thoracic/abdominal aneurysms). • Administer paralytic agent (Sedation-only intubation comes with an increase in vomiting and potential for aspiration). - Rocuronium 0.6 - 1.2 mg/kg IV (usual dose 1 mg/kg). Use caution in patients with potential difficult airway due to length of paralysis. -OR- - Succinylcholine 1.5 - 2 mg/kg IV • Contraindications to Succinylcholine: - Known or suspected hyperkalemia - Severe crush or traumatic injuries > 2 days old - Spinal cord injuries > 2 days old - Burn injuries > 24 hours old - Renal Failure - Pseudocholinesterase deficiencies - Known history of malignant hyperthermia - Neuromuscular disorders (e.g., muscular dystrophy) -Penetrating eye injuries NOTE Administer Vecuronium 0.1 mg/kg IV only if there is a Rocuronium shortage or Cis-Atracurium 0.2 mg/kg only if there is both a Rocuronium and a Vecuronium shortage

Pain management

• Adult: - Fentanyl 1 mcg/kg slow IV, may repeat every 3 - 5 minutes. Max single dose 100 mcg. - Morphine 2 - 5 mg IV, may repeat every 5 - 10 minutes. Maximum single dose 5 mg. - Hydromorphone 0.5 - 1 mg IV may repeat x1 dose (Narcotic Shortage). - Ketamine 0.1 - 0.25 mg/kg IV if opioids are not managing pain, may repeat q10 min • Pediatric: - Fentanyl 1 mcg/kg slow IV, may repeat q3 - 5 min. Max single dose 100 mcg. - Morphine 0.1 mg/kg IV, may repeat every 5 - 10 minutes. Maximum single dose 5 mg. - Ketamine 0.1 - 0.25 mg/kg IV if opioids are not managing pain, may repeat q10 min

Anxiety

• Adult: - Midazolam 2.5 - 5 mg IV/IM/IN, may repeat in 3 - 5 minutes. - If shortage of Midazolam, then administer: • Lorazepam 1 - 2 mg IV, may repeat in 15 minutes, as necessary. -OR- • Diazepam 2 - 10 mg IV/IM, may repeat in 10 minutes, as necessary. • Pediatric: - Midazolam 0.05 - 0.1 mg/kg IV/IM/IN, may repeat in 3 - 5 min. Maximum single dose 5 mg IV/IN or 10 mg IM. - If shortage of Midazolam, then administer: • Lorazepam 0.05 - 0.1 mg/kg IV, may repeat q3 - 5 minutes. Max single dose 2 mg. -OR- • Diazepam (> 5 years of age) 0.1 - 0.2 mg/kg IV/IM every 2 - 4 hours. Max single dose 10 mg.

Cyanide Toxicity

• Apply 100% oxygen • If patient displays signs of inadequate perfusion, begin resuscitation with NS • Assess and treat per the PCG "Burns and Electrical / Lightning Injury -TRAUMA." • If patient meets criteria for cyanide toxicity, administer Hydroxocobalamin: - Adult: 5 g mixed in total of 200 mL normal saline infused over 15 minutes. If a favorable response is seen and a second dose becomes necessary, a second 5 g dose may be considered. - Pediatric: 70 mg/kg IV (maximum single dose 5 g), may repeat once if needed. • Given the high potential for coexisting carbon monoxide toxicity in the smoke inhalation victim, the patient should be transported to a facility with capability for hyperbaric oxygen whenever possible.

Hyponatremia

• Consider Furosemide 1 mg/kg IV usual adult dose 40 mg IV for hypervolemic hyponatremia. • Limit free water intake for patients with euvolemic hyponatremia. • Rehydrate with normal saline at twice maintenance rate for pediatric patients or 125 - 150 mL/hr for adult patients hypovolemic hyponatremia. • If primary adrenal insufficiency, administer Hydrocortisone 1 - 2 mg/kg IV up to a maximum dose of 100 mg. - Seizures, coma, focal neurological deficit attributed to severe hyponatremia • Administer Hypertonic 3% Saline: - Administer 100 mL IV over 10 minutes. - Administer a second 100 mL IV over 50 minutes

Pulmonary Embolism

• Continuous heparin infusions initiated by referring facility needs to be maintained throughout transport. - Suggested Heparin dosing for PE/DVT: • Initial bolus: 80 units/kg IV bolus • Infusion: 18 units/kg/hr IV. - Maximum Dosing Variations: • Maximum Initial Bolus: 4,000 - 7,500 units IV • Maximum Infusion: 1,300 - 1,800 units/hr IV

Pediatric VFib / Pulseless VTach

• Defibrillate at 2 J/kg per the PCG "Defibrillation - PROCEDURE." Immediately resume CPR for 5 cycles, approximately 2 minutes. • Check rhythm, confirm VF/VT. Defibrillate at 4 J/kg. Immediately resume CPR for 5 cycles, approximately 2 minutes. For additional defibrillation increase by 2 J/kg up to a maximum of 10 J/kg (or adult dose) noting the maximum allowable joule settings per manufacturer's guidelines. • Obtain IV/IO access. • Epinephrine 1 mg/10 mL (0.1 mg/mL) 0.01 mg/kg (0.1 mL/kg) IV maximum single dose of 1 mg. Redose every 3 - 5 minutes. - When Epinephrine is repeated, drug administration should always be followed by quality CPR for at least one minute, then attempt defibrillation. • Administer an antidysrhythmic. Consider one of the following: - Amiodarone 5 mg/kg IV maximum single dose 300 mg; may repeat to maximum daily dose of 15 mg/kg. - Lidocaine 1 mg/kg IV, maximum dose 100 mg repeated every 5 minutes as needed at 0.5 mg/kg IV, until the dysrhythmia is suppressed or 3 mg/kg have been given. If the dysrhythmia is suppressed, follow with a 20 - 50 mcg/kg/min IV infusion. • Consider Magnesium Sulfate 50 mg/kg IV push, maximum dose 2 g drug of choice for polymorphic VT. • Out of hospital cessation of resuscitation efforts should not be considered in pediatric patients without contacting medical control

Hemorrhagic Stroke

• Elevate the head of bed (HOB) to 30 degrees (if spinal cord injury is not suspected). • Administer analgesia • If patient has nausea, administer antiemetic • If needed, administer sedation • Hypertension: Treat systolic blood pressures > 160 mmHg using intermittent or continuous IV medications. Administer one of the following antihypertensives: - Nicardipine 2.5 mg/hr IV continuous infusion. Increase by 2.5 mg/hr every 5 - 15 minutes up to a maximum dose of 15 mg/hr IV. Once target BP is achieved, titrate dose down by 2.5 mg/hr to target 3 mg/hr IV infusion. -OR- - Labetalol 10 - 20 mg slow IV (over 2 min). May repeat every 10 minutes with additional doses of 40 mg and then 80 mg until a maximum total dose of 300 mg is administered. • If patient has intracranial pressure monitor in place, maintain CPP between 70 - 100 mmHg. • Treat hypotension aggressively. Maintain systolic blood pressure above 90 mmHg with crystalloid infusion and if inadequate, start a continuous infusion of alpha receptor agonist vasopressor (e.g., Phenylephrine). • If the patient has a reversible coagulopathy, obtain and administer the appropriate reversal agent (e.g., fresh frozen plasma, prothrombin complex concentrate (PCC), cryoprecipitate, specific clotting factors) if these products are available prior to transport and do not delay transport. • Treat per the PCG "Seizures - MEDICAL." if seizures are present. • Treat presumed cerebral herniation. If no hypoxia, hypotension, over-sedation, or other cause, signs of herniation include unilateral dilated pupil, nonreactive pupil, decrease in GCS of 2 or more in a patient with a GCS less than 9, and/or spontaneous posturing. - Hyperventilate to an ETCO2 of 30 - 35 mmHg. - Administer Hypertonic 3% Saline 250 mL IV over 10 minutes for adult patients or 3 mL/kg IV over 10 minutes for pediatric patients. Consider Mannitol 1 g/kg IV over 5 - 10 minutes (filter must be used) only if receiving center prefers Mannitol.

ICP monitoring

• Evaluate the invasive monitor system from referring hospital to ensure that ventricular catheter is functioning correctly and accurately. Verify that a patent transducer system is in place. Use Normal Saline only, do not add Heparin to the system. • Place and secure with tape the transducer level with the foramen of Monro, midway between the outer aspect of the ear canal and the outer canthus of the eye on the same side as the ventriculostomy catheter is inserted on. Connect the transducer to the invasive monitor using the invasive monitoring cable. • Zero the ventriculostomy line. Turn the stopcock closest to the insertion site off to the patient and open to air. Observe the waveform on the monitor flatten. Press the zero button. The monitor will calibrate and "zeroed" will appear on the monitor screen. • Replace the cap and open the stopcock to begin transducing the ICP. Once the ventriculostomy has been "zeroed", observe the monitor for a normal waveform. • If pressure continues to rise, turn stopcock to drain as recommended by referring/ receiving physician.

Ventilators

• FiO2 = Fraction of inspired oxygen - Pre-hospital providers should start at 100%; room air FiO2 is 21%. - FiO2 of 100% can cause pulmonary fibrosis and/or toxicity over a prolonged period. - Titrate oxygen levels to keep PaO2 60 - 80 mmHg, SpO2 > 93% (94 - 99%) saturation. • Rate = Number of breaths per min - May be a mandatory breath (forced by the ventilator), patient-initiated breath (assisted by the ventilator) or spontaneous breath (independent of the ventilator). - Normally 8 - 16/min, dependent on tidal volumes, PaO2 outcomes and CO2. • I:E = Inspiratory to expiratory ratio - Time it takes to inspire related to the time it takes to expire, normally 1:2. - Expiration time should be at least twice as long as inspiratory time for most pts. - 2/3 of the respiratory cycle is completed during expiration. - Increased inspiratory time may be needed for pts with high airway pressures. • Vt = Tidal volume - The volume of gas inspired (forced into the lungs) during mechanical ventilation. - Use ideal body weight to calculate tidal volume, 6 - 8 mL/kg. • PEEP = Positive end expiratory pressure - Indicated for conditions involving alveolar collapse: pulmonary edema, ARDS, CHF, pneumonia. - PEEP may be applied to recruit alveoli and redistribute pulmonary perfusion. - Normal physiological PEEP exists around 3 - 5 cmH2O; additional PEEP should be added in 2 - 3 cmH2O increments. - If PaO2 is > 60 mmHg on FiO2 of 40% or less, PEEP is unnecessary. - PEEP increases intra-thoracic pressure, decreasing venous return, decreasing stroke volume and cardiac output. Use cautiously in case of hypotension or ↓ cardiac output. - Use PEEP cautiously in patients with already increased intra-thoracic pressure, such as in asthma/COPD, where additional pressure may create a tension pneumothorax. • PIP = Peak inspiratory pressures - Pressures increase with increased inspiratory flow rates (optimally 0.5 -1.5 seconds). The shorter the inspiratory duration, the greater the pressure. Increased airway pressures can cause over-distension of alveoli, air trapping, and pneumothorax. - Limits keep the total set tidal volume from being delivered in the presence of elevated airway pressure (as when a tracheal tube is in the right bronchus) and may safeguard against barotrauma. Maintain PIP <35 cmH2O. ETCO2 is part of the standard of care for any intubated patient and is the primary indicator of tracheal intubation. • Abnormal ETCO2 readings can often be the first sign of: - Ventilator or equipment malfunction - Respiratory complication, such as bronchospasm - Effectiveness of chest compressions during cardiac arrest: Readings of at least 25 mmHg are ideal during resuscitation. Normal readings are not likely. High quality chest compressions are achieved when the ETCO2value is at least 10 - 20 mmHg. - Return of spontaneous circulation during cardiac arrest - Likelihood of survival following cardiac arrest: ETCO2 less than 10 mmHg at 20 minutes into resuscitation has 100% mortality - Hypoventilation or hyperventilation for the mechanically ventilated patient - Determination of acidosis/alkalosis when arterial blood gas results are unavailable: may be used on non-intubated patients, such as patient presenting in DKA - Hypoperfusion and shock: decreased cardiac output = decreased ETCO2 Capnometry is the measurement of FCO2 (fraction of carbon dioxide) in tidal gas at the airway opening and represents the quantity of inhaled/exhaled carbon dioxide. Capnography is the graphic display of measured FCO2 versus time. A capnogram is the graphic display that represents the quality of the patient's ventilation. Colorimetric capnometers detect the presence of carbon dioxide, but are inaccurate monitors of carbon dioxide - SWITCH TO DIGITAL CAPNOGRAPHY WHENEVER POSSIBLE. Normal ETCO2 readings are 35 - 45 mmHg and have a specificity and sensitivity of nearly 100% in detecting tracheal intubation in a patient with a pulse. (However, normal ETCO2 readings may be possible in the case of bronchial and hypopharyngeal intubations.)

Open Fractures

• For open fractures, administer the antibiotic Cefazolin 50 mg/kg up to maximum dose 2 g IV, time permitting

Pediatric Resp

• For total obstruction, a cricothyrotomy should be performed. • Stridor should be treated with either Epinephrine 1 mg/mL 5 mL nebulized or Racemic Epinephrine 2.25% 0.05 mL/kg to a maximum single dose of 0.5 mL nebulized. May repeat in 20 minutes once. • Children with wheezing should be treated with bronchodilators. • Consider steroids for croup only, Dexamethasone 0.6 mg/kg IV/IM/oral to a maximum single dose of 10 mg or Methylprednisolone 2 mg/kg IV to a maximum single dose of 125 mg. • Antipyretics may be given for febrile children prior to transport on interfacility transports, Acetaminophen 15 mg/kg PO/PR up to maximum single dose of 1,000 mg or Ibuprofen 10 mg/kg PO up to a maximum single dose of 800 mg. Consider rectal administration of acetaminophen if child is having difficulty swallowing or severe stridor.

Pediatric Bradycardia

• If correcting hypoxemia / hypovolemia doesn't resolve the bradycardia, administer: - Epinephrine 1 mg/10 mL (0.1 mg/mL) 0.01 mg/kg (0.1 mL/kg) IV maximum dose 1 mg, repeated every 3 - 5 min at the same dose. • Atropine may be given in conjunction with ongoing oxygenation, ventilation, and Epinephrine. The dose is 0.02 mg/kg IV, repeated in 3 - 5 minutes to 0.04 mg/kg total dose. Minimum single dose 0.1 mg, maximum single dose 1 mg. • Transcutaneous pacing (TCP) - When choosing between atropine and TCP, use whichever intervention can be accomplished with the least delay. NOTE Atropine may not be effective unless the bradycardia is due to a primary cardiac etiology or vagal nerve stimulation - For TCP, sedation and/or analgesia are appropriate, if clinically permissible. • If at any time, the bradycardic patient shows signs of cardiovascular collapse with heart rate < 60 bpm, begin chest compressions.

Sepsis

• If febrile, administer Acetaminophen 10 - 15 mg/kg PO/PR up to max single dose 1,000 mg pediatrics and adults. • If intubation is indicated, preferred induction agent is Ketamine over Etomidate. • Monitor VS, hemodynamic status. If PA catheter is available, monitor PA waveform. If CVP is able to be measured, determine this value. • Bolus with NS/LR at 30 mL/kg IV, may repeat as needed to achieve adequate MAP/PCWP/CVP (volume resuscitation is the most important therapeutic step in the management of patients with severe sepsis). - Bolus to achieve MAP > 65 and CVP > 8 (CVP > 12 mmHg in vented patients) • If CVP is adequate or unknown and MAP is low despite fluid resuscitation, continue fluid resuscitation and start vasopressors. - Norepinephrine infusion 2 - 30 mcg/min (0.02 - 1 mcg/kg/min). Usual starting dose 2 - 4 mcg/min (0.02 - 0.04 mcg/kg/min). Titrate to MAP > 65 mmHg. - If blood pressure is not responsive to Norepinephrine, consider: • Epinephrine infusion 2 - 10 mcg/min IV then; • Vasopressin infusion 0.03 Units/min IV. - For hypotension refractory to vasopressors, consider Hydrocortisone 100 mg IV x1 dose. • Broad spectrum antimicrobials should be administered prior to transport or initiated and continued by the transport team. Consult with the sending/receiving physician regarding appropriate antimicrobials. - If no antibiotics have been administered, administer Ceftriaxone 50 mg/ kg up to a maximum dose of 2 g IV. • Review laboratory values, if blood sugar < 60 mg/dL treat per the PCG • If already initiated, Insulin should be continued at rates approaching 0.1 units/kg/hr. Blood glucose levels should be monitored every 30 minutes during transport while the patient is receiving insulin therapy. • For patients intubated and mechanically ventilated, add PEEP to improve SpO2 unless patient is profoundly hypotensive.

TBI

• If mechanically ventilated, maintain ETCO2 35 - 40 mmHg. • For patients with evidence of herniation. - Increase the ventilator rate sufficient to decrease ETCO2 30 - 35 mmHg. - Administer Hypertonic 3% Saline 250 mL IV over 10 minutes for adult patients or 3 mL/kg IV over 10 minutes for pediatric patients. - Consider Mannitol 1 g/kg IV over 5 - 10 minutes (filter must be used) only if receiving center prefers Mannitol to Hypertonic 3% Saline. • PEEP > 5 cmH2O should be avoided unless needed for adequate oxygenation as it may contribute to increased ICP. • Head of bed should be elevated 30 degrees if not contraindicated. • Obtain IV access and infuse normal saline to maintain adequate BP. Treat with fluids in the presence of shock state. Maintain SBP > 90 mmHg for optimal cerebral perfusion. • Consider gastric decompression with NG/OG tube placement if not contraindicated. • Treat pain and anxiety • For seizures, treat per PCG "Seizures - MEDICAL."

Pediatric DKA

• If no signs of volume depletion, start Normal Saline at 1.5 - 2 times the maintenance rate. - Normal maintenance fluids rate: • 4 mL/kg/hr IV for the first 10 kg • 2 mL/kg/hr IV for the second 10 kg • 1 mL/kg/hr IV for each kg of body weight above 20 kg • Insulin therapy: - Begin and/or continue Regular Insulin infusion 0.1 units/kg/hour IV. • Monitor blood glucose every 30 minutes; adjust therapy to decrease serum glucose by no more than 100 mg/dL per hour. - If serum glucose decreases by more than 100 mg/dL per hour, add 5% dextrose to the IV fluids. - If serum glucose falls below 300 mg/dL, IV fluids should be changed to D5NS at the above maintenance rate. • Potassium replacement should be started once urine production is confirmed. - When measured serum potassium < 5, consider potassium supplement KCl IV at 10 mEq per hour (with physician order, only). • Acid / Base status: Patients with acidosis must be adequately ventilated to aid in the correction of acidosis. For intubated patients with suspected or documented acidosis due to DKA, the patient should be hyperventilated with a target range for ETCO2 in the low 20s or guided by the pre-intubation ETCO2 measurement if available. - Sodium Bicarbonate - HAZARDS OUTWEIGH BENEFITS: Rarely needed. • If pH less than 6.9, consider judicious use of sodium bicarbonate (with physician order, only). Administer Sodium Bicarbonate 8.4% 1 mEq/kg IV in 1 liter of NS and infuse at 20 mL/kg/hr IV. If given, should be used only as an infusion; IV bolus should ONLY be used in cases of cardiac arrest. • Monitor for signs of cerebral edema (headache, decreased mental status). - Elevate head of bed 30 degrees. - Consider decreasing fluids and insulin infusion rates. - Consider Mannitol 1 g/kg IV with physician order only

AAA

• If patient displays signs of inadequate perfusion, begin resuscitation with NS . If the patient is being transferred from a facility that has a blood bank, the transport team should consider taking packed RBCs for transfusion in the event of hypotension. FFP and/or platelets should also be considered for patients who are anticoagulated. • If the patient remains tachycardic and hypertensive (SBP > 110 mmHg) after analgesia and anxiolysis, consider short-acting antihypertensives (Esmolol, Nicardipine, Labetalol) per the PCG "Hypertensive Emergency - MEDICAL."

GI Bleed

• If patient is hypotensive treat per the PCG "Hypotension - MEDICAL." • A nasogastric tube should be considered in all patients with significant GI bleeding - Over-vigorous suction should be avoided to prevent mucosal trauma. • If balloon tamponade (Minnesota or Blakemore tube) is in place, tracheal intubation should be placed and secured. • Consider administrating Ranitidine 50 mg IV over 5 minutes or Famotidine 20 mg IV. • On the interfacility transport, continue blood products transfusions initiated by the referring physician. • Consider administration of and/or continue treatments already initiated: - Pantoprazole 80 mg IV bolus then 8 mg/hr IV for upper GI bleed - Octreotide 50 mcg IV bolus then 50 mcg/hr IV for esophageal variceal bleeding - Vasopressin 0.2 units/min IV

Afib/flutter

• If patient is symptomatic, consider the following: - Diltiazem 0.25 mg/kg IV push over 2 minutes. If not effective in 15 minutes, a second dose of 0.35 mg/kg IV may be given. If effective, begin Diltiazem infusion at 5 mg/hr IV and titrate to a maximum of 15 mg/hr. -OR- - Metoprolol 5 mg(5mg/5mL) IV push over 2 minutes. May repeat x 2 every 5 minutes until a total of 15 mg. • Avoid with patients in heart failure, with heart block, valvular failure, cocaine use, HR < 50, or SBP < 90 mmHg. - If Diltiazem and Metoprolol are ineffective, may use the following: • Amiodarone 150 mg IV (450mg/9mL, 50mg/1mL) over 10 minutes. • If patient is unstable (e.g., SBP < 90 mmHg, altered level of consciousness, severe chest pain, pulmonary edema): - Perform synchronized cardioversion at increasing energy level. Consider sedation

CHF

• If possible, place patient in high Fowlers position or position of comfort. • Consider either continuous positive pressure ventilation (CPAP) or bi-level positive pressure ventilation (BPAP) • Assist ventilations as needed to reduce work of breathing and be prepared to secure the airway with tracheal intubation. • If patient is intubated, consider PEEP at 5 - 10 cmH2O. Monitor oxygenation and ETCO2. • Administer Nitroglycerin (NTG): - NTG is contraindicated if the patient has received a dose the erectile dysfunction medication sildenafil within the past 24 hours or a dose of tadalafil or vardenafil within the past 72 hours. - NTG 0.4 mg sublingual (SL) every 5 minutes, may continue repeating dose if maintaining SBP > 90 mmHg. -OR- - NTG infusion at 40 mcg/min IV and titrate to relief of symptoms, maintaining SBP > 90 mmHg, maximum dose 200 mcg/min. Reduce NTG drip if hypotension occurs. • If wheezing is present, consider Albuterol • Treat hypotension of a cardiac origin -Consider Norepinephrine, as first line vasopressor. -Consider Dobutamine infusion for inotropic support. Consider inserting an indwelling urinary catheter to monitor urine output. (If available at the sending facility and procedure does not unnecessarily delay transport). • Other considered medications are: 13 - Furosemide (3rd line of therapy): 1 mg/kg IV or the patient's daily PO dose given IV. Maximum dose 80 mg. DO NOT give if patient is hypotensive. - Enalapril 1.25 mg IV. DO NOT administer if inferior wall changes are noted on 12-lead EKG. - Milrinone 0.25 - 0.75 mcg/kg/min IV infusion for cardiogenic shock.

Pediatric Cardiogenic Shock

• If signs of pulmonary vascular congestion are present, withhold fluid bolus and administer Furosemide 1 mg/kg IV to a maximum single dose 20 mg. • If no evidence of pulmonary vascular congestion or fluid overload is present: - Resuscitate with 20 mL/kg warm NS or LR IV bolus over 5 - 10 minutes. - Repeat bolus up to two times for a total of 60 mL/kg if patient remains hypoperfused unless signs of pulmonary vascular congestion or fluid overload develop. - For patients failing fluid boluses, consider initiating inotropic support: • Epinephrine 0.1 - 1 mcg/kg/min IV. OR- • Dopamine 2 - 20 mcg/kg/min IV. -OR- • Norepinephrine 0.1 - 2 mcg/kg/min IV if > 2 years of age. -OR- • Dobutamine 2 - 20 mcg/kg/min IV. • Perform glucose check; if the blood sugar level is less than 60 mg/dL: - Administer Dextrose 25% 0.5 - 1 g/kg IV to pediatric patients and administer Dextrose 10% 0.5 - 1 g/kg IV to neonates. - If unable to obtain IV access, administer Glucagon 1 mg SC/IM/IV to adult patients, Glucagon 0.5 mg SC/IM to pediatric patients, and Glucagon 0.25 mg IM to neonatal patients < 5 kg. • Monitor urine output by indwelling urinary catheter if available. Titrate fluid resuscitation to urine output of 1 mL/kg/hr.

Pediatric VTach with a pulse

• If the dysrhythmia is polymorphic VT (Torsades de Pointes), administer Magnesium Sulfate 50 mg/kg IV as an initial therapy, maximum dose 2 g, then proceed with traditional VT therapies.

Pediatric Seizures

• If the patient is actively seizing, administer a benzodiazepine: - Midazolam 0.05 - 0.2 mg/kg IV/IM/IN repeat as necessary every 2 - 5 minutes, maximum single dose 5 mg IV/IN or 10 mg IM. - If shortage of Midazolam then administer: • Lorazepam 0.1 mg/kg IV, maximum single dose 4 mg, repeat every 2 - 5 minutes as needed. -OR- • Diazepam 0.1 mg/kg IV or 0.5 mg/kg IPR maximum single dose 10 mg, repeat every 5 - 10 minutes as necessary. • If seizure activity continues, administer: - Levetiracetam 20 mg/kg IV over 10 minutes (dilute in 100 mL NS or D5W), maximum dose 1,000 mg.

Bradycardia

• If the patient is symptomatic consider: - Prepare patient for transcutaneous external pacing per the PCG - Consider sedation and analgesia - Atropine 0.5 - 1 mg IV may repeat to maximum dose of 0.04 mg/kg. - Start pacing with a rate typically 10 - 20 bpm above the patient's intrinsic rate or 60 if no rate exists, and increase MA by 10 mA increments until electrical and mechanical capture is obtained. - Vasopressor therapy for hypotension • Epinephrine 2 - 10 mcg/min IV -OR- • Dopamine 2 - 10 mcg/kg/min IV

VTACH with a pulse

• If the patient is unstable (SBP < 90 mmHg, chest pain, pulmonary edema, or shows evidence of clinical deterioration), consider sedation and analgesia and perform synchronized cardioversion • If the patient is symptomatic, initiate antidysrhythmic therapy: - If supraventricular tachycardia (SVT) with aberrancy, consider Adenosine 6 mg IV. - Amiodarone 150 mg IV over 10 min -OR- - Lidocaine 1 - 1.5 mg/kg IV. May repeat every 5 min as needed (maximum dose 3 mg/kg) -OR- - Procainamide 20 mg/min IV. May repeat until dysrhythmia suppressed, symptomatic hypotension, QRS widens by more than 50%, or maximum dose of 17 mg/kg given - Magnesium Sulfate 2 g IV over 2 min for Torsades de Pointes or known hypomagnesemic state. • If VT is resolved, start continuous infusion of antidysrhythmic that resolved the VT. - Amiodarone infusion at 60 mg/hr IV x 6 hrs then 30 mg/hr IV x 18 hrs. -OR- - Lidocaine infusion at 2 - 4 mg/min IV. -OR- - Procainamide infusion at 2 - 4 mg/min IV. • If antidysrhythmic therapy unsuccessful, consider synchronized cardioversion. Consider sedation and analgesia

Hypotension

• If the patient shows no signs of volume overload (edema, JVD, pulmonary edema), administer a 250 mL IV fluid bolus and re-evaluate the blood pressure. Repeat IV boluses, up to 30 mL/kg of NS/LR, as needed in the absence of signs and symptoms of volume overload. • If the patient is actively hemorrhaging, control the bleeding and treat • If the patient remains hypotensive and the cause is likely a condition other than hypovolemia or hemorrhage, consider administering ONE of the following continuous vasopressor infusions to maintain MAP > 65 mmHg: - Norepinephrine infusion 2 - 30 mcg/min (0.02 - 1 mcg/kg/min) to obtain adequate perfusion. First-line for septic shock and cardiogenic shock. - Epinephrine infusion 2 - 10 mcg/min IV for anaphylactic shock and septic shock. - Vasopressin infusion 0.01 - 0.04 units/min IV for septic shock refractory to Norepinephrine. - Dopamine infusion 5 - 20 mcg/kg/min IV for suspected neurogenic shock. - Phenylephrine infusion 100 - 180 mcg/min IV. • Consider administering a second vasopressor when approaching the maximum dose of the first vasopressor. • For inotropic support once adequate BP (SBP > 90 mmHg) is obtained with vasopressor infusion, consider inodilator Dobutamine infusion 2 - 20 mcg/kg/min IV for cardiogenic shock.

Pediatric AMS

• If volume depletion is suspected, begin fluid resuscitation with 20 mL/kg NS IV bolus. Refer to the PCG "Pediatric Shock - PEDIATRICS." • Perform glucose check; if the blood sugar level is less than 60 mg/dL: - Administer Dextrose 25% 0.5 - 1 g/kg IV to pediatric patients and administer Dextrose 10% 0.5 - 1 g/kg IV to neonates. - If unable to obtain IV access, administer Glucagon 1 mg SC/IM/IV to adult patients, Glucagon 0.5 mg SC/IM to pediatric patients, and Glucagon 0.25 mg IM to neonatal patients < 5 kg. • If an opioid drug overdose is suspected, administer Naloxone 0.1 mg/kg IV/IN to maximum single dose 2 mg. Pediatrics < 20 kg: 0.01 - 0.1 mg/kg IV/IN maximum single dose 2 mg. If no improvement in level of consciousness, evaluate need for airway protection with tracheal intubation.

Subarachnoid, non-traumatic

• Maintain head of bed elevated to 30 degrees if spinal cord injury is not suspected. • Administer pain control, antiemetics, and sedation as needed • Treat hypotension aggressively. Maintain systolic blood pressure above 90 mmHg. If crystalloid fluid infusion is inadequate, start a continuous intravenous infusion of an alpha receptor agonist vasopressors (e.g., Phenylephrine). • Treat hypertension: Reduce systolic blood pressures to < 140 mmHg using intermittent or continuous IV medications. - Nicardipine 2.5 mg/hr IV continuous infusion. Increase by 2.5 mg/hr IV every 5 - 15 minutes up to a maximum dose of 15 mg/hr IV. Once target BP is achieved, titrate dose down by 2.5 mg/hr IV to target 3 mg/hr IV infusion. -OR- - Labetalol 10 - 20 mg slow IVP (over 2 minutes). May repeat every 10 minutes with additional doses of 40 mg and then 80 mg until a maximum of 300 mg is administered. • If patient has intracranial pressure monitor in place, maintain CPP between 70 -100 mmHg. • Treat seizures if seizures are present. Consider administering a loading dose of an anticonvulsant for seizure prophylaxis. • If the patient has a reversible coagulopathy, obtain and administer the appropriate reversal agent (e.g., fresh frozen plasma, prothrombin complex concentrate (PCC), cryoprecipitate, specific clotting factors) if these products are available prior to transport and do not delay transport. • Treat presumed cerebral herniation. If no hypoxia, hypotension, over-sedation, or other cause, signs of herniation include unilateral dilated pupil, nonreactive pupil, decrease in GCS of 2 or more in a patient with a GCS less than 9, and/or spontaneous posturing. Maintain ETCO2 30 - 35 mmHg. - Administer Hypertonic 3% Saline 250 mL IV over 10 minutes for adult patients or 3 mL/kg IV over 10 minutes for pediatric patients. -OR- - Consider Mannitol 1 g/kg IV over 5 - 10 minutes (filter must be used) only if receiving center prefers Mannitol to Hypertonic 3% Saline.

TXA

• Inclusion criteria: - Consider TXA if the patient is being transported to a trauma center that supports administration of TXA. - Blunt or penetrating trauma. - Age > 15 years (or local trauma definition of the age of an adult trauma patient). - Duration since the time of initial injury is less than 180 minutes (3 hours), prefer < 60 minutes. - Blunt of penetrating trauma with evidence of injury consistent with noncompressible hemorrhage (e.g., penetrating thoracoabdominal trauma, unstable pelvic fracture). - Signs and symptoms consistent with severe hemorrhage (internal or external) are: • SBP < 90 mmHg after a minimum 10 mL/kg NS or LR bolus • Pulse rate > 110 bpm after a minimum 10 mL/kg NS or LR bolus and adequate analgesia • Exclusion criteria: - Time from initial traumatic insult > 180 minutes or unknown time of injury. - Patients who have contraindication to antifibrinolytic therapy agents. - Medical Control discretion • Treat any life-threatening injuries. • Treat compressible external hemorrhage with direct pressure, pressure dressings, hemostatic agents, or tourniquets • Review inclusion and exclusion criteria and if the patient remains hemodynamically unstable with evidence of noncompressible hemorrhage, administer Tranexamic Acid. - Loading dose 1 g/100 mL NS over 10 minutes IV bolus. - Maintenance dose 1 g/500 mL NS infusing at 60 mL/hr IV for total infusion of 8 hours. • Consider consulting Medical Control for those patients who may benefit from this medication including impending hemodynamic instability • During initial report to receiving facility and at transition of care, report of time of injury, time of TXA loading dose, and time of maintenance infusion started will be given.

Burn

• Infuse crystalloid IV fluids sufficient to maintain systolic BP of > 90 mmHg (adult patients) and adequate urine output (1 - 2 mL/kg/hour). Use the consensus fluid resuscitation formula to estimate fluid requirements for partial/full thickness burns > 20% TBSA. - 2 mL x (% TBSA) x (weight in kg) over first 24 hours. Give the first half over the first 8 hours from time of burn and the second half over the remaining 16 hours. - For pediatric patients, maintenance fluids with dextrose must be calculated and administered in addition to consensus formula fluids.

Crush Injury

• Initiate and ensure adequate vascular access. Infuse NS/LR wide open rate for 1L, then KVO. Take care to limit total fluid administration to 1.5 liters. • Alkalinization (if patient meets the diagnostic criteria for crush syndrome as detailed above). - PRIOR TO EXTRICATION: • Sodium Bicarbonate: - 1 amp Sodium Bicarbonate 8.4% (50 mEq) IV x 1. - FOLLOWING EXTRICATION: • Sodium Bicarbonate: - 1 amp Sodium Bicarbonate 8.4% (50 mEq) into 1 L NS at hr 500 mL/hr. • If hyperkalemia is suspected (onset of PVCs, QRS > 0.12, or peaked T-waves), administer Calcium Gluconate

DKA

• Initiate fluid replacement immediately. Aggressive fluid replacement is one of the most important initial steps in the treatment of DKA. Fluid replacement should start immediately. Patients with DKA have an average of 5 - 7 L of fluid deficit. - Initially, adult patients should receive a 1,000 mL 0.9% NS IV bolus over 1 hour followed by 500 mL of 0.9% NS IV infusion per hour for the next 3 - 4 hours. For continued hypotension, administer additional NS fluid boluses. • Evaluate the need for Potassium replacement therapy prior to departing the referring facility. A normal Potassium level in an acidotic patient will require Potassium replacement as the acidosis is corrected. Potassium replacement should start once urine output is established. • Following initiation of fluid resuscitation, Regular Insulin should be administered. - The patient should receive a Regular Insulin infusion of 100 units/100 mL NS at 0.1 units/kg/hr IV as ordered. - Blood glucose levels should be monitored every 30 minutes during transport while the patient is receiving insulin therapy. - The Insulin drip is continued until ketonemia and acidosis have been corrected; however, the insulin dose should be decreased if the blood glucose level falls by more than 100 mg/dL each hour (more than 50 mg/dL each half-hour). - When blood glucose level falls to 300 mg/dL, glucose should be added to IVF (D5NS at 100 mL/hr).

Excited Delirium

• Ketamine 0.5 - 1 mg/kg IV may repeat x 1 or 4 mg/kg IM x 1 dose. • Etomidate 10 mg IV x 1 dose (40mg/20mL, 2mg/1mL) - Prepare to provide airway management and ventilator support, as necessary. - Follow-up sedation with Midazolam as above is highly recommended.

Pediatrics

• Kidney perfusion can be assessed by urine output (in the absence of renal disease). Adequate urinary output in an infant is 1 - 2 mL/kg/hr and in an older child and adolescent is 0.5 - 1 mL/kg/hr. Normal laboratory values that reflect adequate renal function are: BUN 5 - 20 and creatinine 0.3 - 1.5. - Maintenance fluid: • 4 mL/kg/hr IV for the first 10 kg • 2 mL/kg/hr IV for the second 10 kg • 1 mL/kg/hr IV for each kg of body weight above 20 kg NOTE Maintenance IV fluids should be calculated and administered on every pediatric patient, even in the absence of hemodynamic instability, and should contain dextrose if no evidence of traumatic brain injury.

Ischemic Stroke

• Maintain head inline and place patient supine, if not otherwise contraindicated. • Perform a bedside glucose check and treat per the PCG "Hypoglycemia -MEDICAL." • Do not treat hypertension in prehospital patients presenting as possible stroke/TIA. Transport the patient to the nearest stroke center. • For interfacility transports with a confirmed diagnosis of ischemic stroke, do not treat blood pressure unless over 220/120 mmHg. • For those patients that have received intravenous thrombolysis, maintain blood pressure below 180/105 mmHg. • Treat seizure activity • Consider notification of receiving facility as soon as possible to determine and alert stroke team activation based on facilities stroke activation guidelines. Do not delay transport. • Perform frequent thorough neurologic checks especially if patients have received thrombolytic therapy (looking for signs of hemorrhage). • If the patient is receiving thrombolytic therapy and has a deterioration in neurological status, contact Medical Control to discuss continuing or discontinuing the thrombolytic infusion.

Hypoglycemia

• Measure blood glucose. If blood glucose < 60 mg/dL, and the patient has symptoms consistent with hypoglycemia, administer Dextrose: - Adults: 25 g IV - Pediatrics: • > 2 years old: 0.2 - 0.5 g/kg IV • < 2 years old: 0.5 - 1 g/kg IV over 5 - 10 minutes. Do not use D50. - Neonates: Dextrose 10% 0.5 - 1 g/kg IV • For neonates, an IV bolus of 10 mL/kg of D5 will provide 0.5 g/kg of glucose. • Patients who are unresponsive and suspected to be hypoglycemic should receive Dextrose therapy prior to ascertaining blood glucose level if glucose measurement is not immediately available. • If unable to obtain IV access, administer Glucagon: - Adults: 1 mg SQ/IM/IN - Pediatrics: 0.5 mg IM/IN - Neonates < 5 kg: 0.25 mg IM • Glucagon should be followed by administration of Dextrose

Thoracic Aortic Dissection

• Monitor VS: non-invasive blood pressure every 5 minutes or if A-line is available, monitor continuously. • If the patient has pain and/or anxiety, treat as per the PCGs. Use narcotics cautiously in hypotensive patients. • Goal is adequate end-organ perfusion with vital signs of HR < 60 and SBP < 120mmHg: - Administer a Beta Blocker. • Esmolol loading dose 500 mcg/kg IV over 1 minute, then begin infusion at 50 mcg/kg/min IV. If no response: consider repeating IV bolus and increase infusion by 50 mcg/kg/min IV increments every 5 - 15 minutes up to total dose of 300 mcg/kg/min IV. -OR- • Labetalol 10 - 20 mg slow IV push (over 2 minutes). May repeat every 10 minutes with additional doses of 40 mg and then 80 mg until a SBP of 100 mmHg or a maximum total dose of 300 mg is administered. -OR- • Metoprolol 5 mg IV every 5 minutes x 3 doses. - If SBP remains > 120 mmHg after β-blockers, initiate: • Nicardipine 2.5 mg/hr IV continuous infusion. Increase by 2.5 mg/hr IV every 5 - 15 minutes up to a maximum dose of 15 mg/hr IV. Once target BP is achieved, titrate dose down by 2.5 mg/hr IV to target 3 mg/hr IV infusion. • Patients with Hypotension with signs of end-organ hypoperfusion (Change in mental status, oliguria, etc.) - Discontinue all vasodilator / β-blocker infusions. - Administer IV fluids as per the PCG. consider administering blood if available. - Consider contacting thoracic surgeon for treatment guidelines for hypotension and use of vasopressors. • Patients with associated MI confirmed by EKG - Proceed as above with β-blockade. - Initiate Nitroglycerin as per the PCG, and avoid thrombolytics, heparin, and aspirin.

Overdose

• Narcotics Overdose: Administer Naloxone if the patient has respiratory depression, pinpoint pupils or other signs of narcotic abuse: - Naloxone • Adult: 0.4 - 2 mg IV/IN • Peds > 20 kg: Same as adult • Peds < 20 kg: 0.01 - 0.1 mg/kg IV/IN maximum single dose 2 mg • May repeat every 3 - 4 minutes as needed; be prepared for resedation. • Cocaine or Methamphetamine overdose: The appropriate treatment is large doses of benzodiazepines with appropriate ventilatory and circulatory support. Beta blockers are contraindicated for severe hypertension nitrates are preferred. Treat per the PCG • Benzodiazepine overdose: Flumazenil is generally contraindicated for any benzodiazepine overdose due to risk of precipitating seizures, unless overdose is due to procedural sedation. Supportive care includes appropriate ventilatory and circulatory support. • Digoxin overdose: Digibind® is the antidote; obtain from hospital. Watch patient closely for hyperkalemia. Note that Calcium Chloride is contraindicated for treatment of hyperkalemia in patients who are digoxin-toxic. • Calcium channel blocker or Magnesium Sulfate overdose: Administer Calcium Chloride IV. - Calcium Chloride 10% • Adult: 500 - 1,000 mg IV over 5 - 10 min • Peds: 0.5 - 1 mg/kg IV over 2 - 5 minutes maximum single dose 1,000 mg • May repeat in 5 - 10 min • Beta blocker overdose: Glucagon may be effective for severely symptomatic patients. - Glucagon • Adult: 3 - 10 mg IV/IN • Peds: 0.1 mg/kg, maximum dose 10 mg IV/IN • Tricyclic antidepressant overdose: May result in cardiovascular deterioration (dysrhythmias, hypotension) and rapid CNS deterioration (seizures, coma). - Sodium Bicarbonate 8.4% 1 mEq/kg up to 50 mEq (1 amp) IV or 3 amps in 1,000 mL 35 of D5W continuous IV infusion at 250 mL/hr if patient is experiencing a prolonged QT interval, widened QRS, ventricular dysrhythmias, or hypotension. - Hypotension: 500 - 1,000 mL IV bolus with NS or LR. Pediatric dose 20 mL/kg. May repeat x 2. - Contact Medical Control for orders for Epinephrine IV infusion or Norepinephrine IV infusion if IV fluid boluses are inadequate. - Seizures: Treat per the PCG • Magnesium sulfate - Indicated for Torsades de Pointes - Adult: 1 - 2 g IV over 1 - 2 minutes; may be repeated in 5 -15 minutes if not eradicated. - Peds: 25 - 50 mg/kg maximum dose 2 g • Organophosphate/cholinergic poisoning: Administer Atropine IV repeated doses every minute until reversal of symptoms. - Atropine • Adult: 2 mg IV repeated until symptoms reversed • Peds: 0.05 mg/kg IV repeated until symptoms reversed - If available, administer Pralidoxime (2-PAM) 600 mg IV (or 1 autoinjector IM) as soon as possible. May repeat x 2 for persistent symptoms (decreased level of consciousness, respiratory compromise, and/or cardiovascular compromise) to total of 1,800 mg. Pralidoxime is not indicated for patients < 12 years of age. Organophosphates induce cholinergic excess resulting in muscarinic, nicotinic, and CNS effects. - Muscarinic effects - Bradycardia, bronchorrhea, respiratory distress,visual disturbance, and the SLUDGE syndrome (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal, and Emesis). - Nicotinic effects - Tachycardia, hypertension, and muscle fasciculations with weakness or paralysis. - CNS effects - Headache, altered mental status, ranging from anxiety to lethargy and coma. 36 • Carbon monoxide poisoning: Administer 100% O2 per NRB or intubate patient if unconscious. SpO2 readings are inaccurate due to carboxyhemoglobin poisoning. Consider transporting the patient to a facility with hyperbaric oxygen available. • Inhaled poisons: Remove patient from exposure and administer 100% oxygen.

SVT

• Narrow Complex, Stable Patient: If patient is stable: - Administer Adenosine 6 mg rapid IV push followed by a 20 mL IV bolus of NS. - If the SVT persists, administer Adenosine 12 mg rapid IV push followed by a 20 mL IV bolus of NS. May repeat a second Adenosine 12 mg IV dose. - If adenosine is not effective, to rate control, administer Diltiazem 0.25 mg/kg IV bolus over 2 minutes. May repeat Diltiazem 0.35 mg/kg IV bolus if needed in 15 minutes. - If effective in rate control, begin Diltiazem infusion at 5 mg/hr IV and titrate to maximum 15 mg/hr IV; target heart rate 100 bpm. • Wide Complex, Stable Patient: - If rhythm regular and monomorphic, consider Adenosine per above dosing guideline. - If Adenosine ineffective, administer Amiodarone 150 mg IV infusion over 10 minutes and if effective, followed by maintenance infusion of Amiodarone 60 mg/hr IV x 6 hours then 30 mg/hr IV x 18 hours. If SVT recurs, may repeat load of Amiodarone 150 mg IV infusion over 10 minutes one time. • If patient is unstable, prepare for synchronized cardioversion. Consider sedation and analgesia • Perform synchronized cardioversion per device manufacturer recommendations • Contact Medical Control if none of the above interventions are successful in converting the dysrhythmia.

Nausea Medications- Adult

• Ondansetron 4 mg IV/IM/SL, may repeat after 10 minutes, as needed. • Promethazine 12.5 mg - 25 mg dilute dose in 50 mL of NS and give IV over 10 minutes. - If a patient complains of pain during intended intravenous injection, stop the injection immediately. Subcutaneous or intraarterial injection is contraindicated as these routes of administration may cause tissue necrosis and gangrene of the affected extremity, respectively. • Metoclopramide 10 mg slow IV. - For patients demonstrating or complaining of dystonia, dysphorias, or dyskinesia after receiving Promethazine or Metoclopramide, administer Diphenhydramine 25 - 50 mg IV.

Nausea Medications- Pediatric

• Ondansetron: 0.1 mg/kg IV, maximum single dose 4 mg or oral dissolving tablet (2 mg) SL. • Metoclopramide (> 2 years of age) 0.1 - 0.2 mg/kg IV maximum single dose 10 mg IV. - For patients demonstrating or complaining of dystonia, dysphorias, or dyskinesia after receiving Promethazine or Metoclopramide, administer Diphenhydramine 1 mg/kg IV, maximum single dose 50 mg.

Hypertensive Emergency

• Otherwise, for BP > 220/120 mmHg with signs of end-organ damage, consider one of the following antihypertensives until: - Symptoms are alleviated; -OR- - 20% reduction of MAP is achieved. - Labetalol 10 - 20 mg slow IV push (over 2 minutes). May repeat every 10 minutes with additional doses of 40 mg and then 80 mg until to a maximum total dose of 300 mg is administered. -OR- - Hydralazine 10 mg slow IV push. May repeat in 20 minutes up to max dose of 40 mg. -OR- - Nicardipine 2.5 mg/hr IV continuous infusion. Increase by 2.5 mg/hr IV every 5 - 15 minutes up to a maximum dose of 15 mg/hr IV. Once target BP is achieved, titrate dose down by 2.5 mg/hr IV to target 3 mg/hr IV infusion. - Esmolol loading dose 500 mcg/kg IV over 1 minute. Begin infusion at 50 mcg/kg/min IV. If no response, consider repeating load dose and increase infusion by 50 mcg/kg/min IV every 5 - 15 min up to 300 mcg/kg/min IV. • Certain medical conditions call for specific treatment guidelines. Hypertensive states associated with sympathomimetic drug use (e.g.,cocaine methamphetamines, bath salts, ecstasy, etc.) - treat with benzodiazepines and AVOID beta-blockers. - Midazolam 2.5 - 5 mg IV. May repeat in 3 - 5 minutes. - If shortage of Midazolam, then admininster: • Lorazepam 1 - 4 mg IV. May repeat in 15 min, as necessary. -OR- • Diazepam 2 - 10 mg IV/IM. May repeat in 10 minutes as necessary

Bronchospasm (Asthma/COPD)

• Place the patient in a position of comfort, usually in a high Fowler's position. • If the patient presents with acute dyspnea (with or without wheezing), administer Albuterol 2.5 mg in 3 mL of NS via nebulizer. Repeat as necessary. • Administer Ipratropium bromide 0.02% 0.5 mg (2.5 mL) nebulized; may be repeated x3 doses during the initial management of the patient with severe distress. • If the patient presents with stridor, administer Racemic Epinephrine 2.25% 0.05 mL/kg to a maximum single dose of 0.5 mL. May repeat every 20 minutes prn. • Administer Dexamethasone 10 mg IV or Methylprednisolone 2 mg/kg IV maximum dose 125 mg. • Administer Magnesium Sulfate 2 g IV over 20 minutes in the patient with severe bronchospasm. • Consider administering the following: - Terbutaline 0.25 mg SQ/IM - Continuous nebulizer of Albuterol 5 - 10 mg/hr - Epinephrine 1 mg/mL 0.3 mg (0.3 mL) IM if the patient experiencing a severe life threatening reaction not improving with the above therapy or shows signs of shock. • Use with caution in patients with risk factors for or known cardiovascular disease. In these patients, administer Epinephrine only in cases of severe bronchospasm and when imminent threat to life exists. - Consider trial of CPAP or BPAP and be prepared for advanced airway management. - If intubation is indicated, the preferred induction agent is Ketamine over Etomidate.

Seizures

• Prepare a safe environment for the patient. • If the patient requires intubation and requires neuromuscular blockade in order to safely complete the procedure, short acting neuromuscular blockers should be used. Long acting neuromuscular blockade will only mask physical evidence of seizures. • Perform a bedside glucose check and if glucose is < 60 mg/dL, administer Dextrose 50% 25 g IV or if unable to establish IV access, Glucagon 1 mg IM/IN. Repeat blood glucose check in 15 minutes and repeat dose of Dextrose or Glucagon if glucose remains < 60 mg/dL • In the intubated or obtunded patient, consider placement of NGT/OGT to decrease risk of aspiration. • If the patient is actively seizing, administer a benzodiazepine. Consider administering a single dose to a the patient who has had more than one witnessed seizure, even in the absence of ongoing seizure activity: - Midazolam 5 mg IV/IN or 10 mg IM; repeat as necessary every 2 - 5 minutes. - If shortage of Midazolam, administer: • Lorazepam 4 mg IV; repeat as necessary every 2 - 5 minutes. Or Diazepam 5 - 10 mg IV/PR; repeat as necessary every 10 - 15 minutes. • If the patient has repeated seizures and has required multiple doses of benzodiazepines, administer: - Levetiracetam 1,000 mg IV over 10 minutes (dilute 5 mL vial in 100 mL NS or D5W).

Hemodynamic values

• Pulmonary artery pressure (PAP): Systolic 15 - 30 mmHg and Diastolic 4 - 12 mmHg • Pulmonary artery mean (MPAP): 10 - 18 mmHg • Pulmonary capillary wedge pressure (PCWP): 6 - 12 mmHg • Central venous pressure (CVP): 2 - 8 mmHg or 3 - 12 cmH2O • Left ventricular end diastolic pressure (LVEDP): 5 - 12 mmHg • Systemic vascular resistance (SVR): 80x (MAP - CVP)/CO • Cardiac output (CO): 4 - 6 L/min • Ejection fraction (EF): 60 - 70% • Intracranial pressure (ICP): < 20 mmHg • Cerebral perfusion pressure (CPP = MAP-ICP): > 70 mmHg

Hypernatremia

• Rehydrate with normal saline at twice maintenance rate for pediatric patients or 150 - 200 mL/hr for adult patients. • Monitor vital signs and urine output if able.

Pre-eclampsia/Eclampsia

• Seizure prevention should be accomplished through administration of Magnesium Sulfate. - 4 grams IV bolus over 20 min. - Continuous infusion of 2 - 4 g/hr IV. • Patients receiving Magnesium Sulfate infusion must be closely monitored for signs and symptoms of toxicity (somnolence, decreased respiratory rate, and decreased DTRs). • Monitor for magnesium toxicity. If somnolence, muscular paralysis, respiratory depression, or loss of DTRs occurs: - Immediately discontinue Magnesium Sulfate infusion. - Administer Calcium Gluconate 1 g of 10% solution over 1 - 2 minutes. - Calcium Gluconate is the drug of choice, but if this is not available administer Calcium Chloride 500 mg slow IV injection (not to exceed 1 mL/min). The injection should be halted if the patient complains of any discomfort; it may be resumed when symptoms disappear. Following injection, the patient should remain recumbent for a short time. - Following administration of calcium, do not restart Magnesium Sulfate infusion until one hour has passed and all signs of magnesium toxicity have resolved, then restart infusion at previous rate. • If SBP > 160 mmHg or DBP is > 110 mmHg, administer: - Labetalol 20 mg slow IV push (over 2 min). May repeat every 10 minutes with additional doses of 40 mg and then 80 mg, and then may repeat the 80 mg x 2 for the maximum total dose of 300 mg until DBP <100. - If BP is not responsive to Labetalol then administer Hydralazine 5 mg IV repeated as needed every 20 minutes at a dose of 5 - 10 mg IV to a total dose of 40 mg. • Monitor patient for sudden decreases in blood pressure. To avoid sudden reduction in perfusion to the placenta, diastolic blood pressure should not be reduced to < 100 mmHg. • Pulmonary edema should not be treated only with diuretics. Utilize the following treatments: - Elevate head of bed. - Positive pressure ventilation as indicated. • Seizure activity should be treated with: - Supportive care first (maintain airway, administer supplemental oxygen as needed to 42 maintain SpO2 > 93%, prevent injury). - Administer Magnesium Sulfate 4 g IV bolus, then a continuous infusion of 2 g/hour IV. - If magnesium is not effective, administer Levetericetam 1000 mg IV. - For seizure lasting greater than 2 minutes, administer a benzodiazepine: • Midazolam 5 mg IV/IN or 10 mg IM; repeat as necessary every 2- 5 minutes. • If shortage of Midazolam then administer: • Lorazepam 2 - 4 mg IV; repeat as necessary every 2 - 5 minutes. -OR- • Diazepam 5 - 10 mg IV/PR; repeat as necessary every 10 - 15 minutes. • Cerebral edema may be minimized by mild hyperventilation if the patient is intubated. • Consider group B strep prophylaxis; discuss with the receiving physician and/or physician medical director (conferencing an obstetrical specialty physician medical director as needed) per the PCG "Medical Control / Consultation - GENERAL CARE." to determine appropriate treatment. • Consider steroid administration with Betamethasone 12 mg IM for lung maturity for gestational age < 37 weeks; discuss with the receiving physician and/or physician medical director (conferencing an obstetrical specialty physician medical director as needed) per the PCG "Medical Control / Consultation - GENERAL CARE." to determine appropriate treatment.

Blood Transfusion

• Subject to modification by local/regional receiving center preference, the preferred order of transfusion is: - Plasma - PRBCs - Platelets if available - Repeat in this order 1:1:1 as indicated. • Document the time transfusion begins. • Plasma administration: - Pediatric: transfuse 10 - 20 mL/kg, maximum rate 0.5 mL/kg/min. - Adult: transfuse an entire unit. • PRBC administration: - Infant (1 month - 1 year): transfuse 15 mL/kg. - Pediatric (> 1 to < 18 years or local/regional adult trauma definition): transfuse 10 mL/kg up to a single unit. - Adult: transfuse a single unit. • Start transfusion slowly and assess vital signs every 10 minutes. • Monitor and document any complication. If a transfusion reaction occurs: - Stop transfusion immediately. - Remove blood product bag and tubing and set aside to be given to receiving facility. • Consider administration of TXA per the PCG "Tranexamic Acid (TXA) -TRAUMA." • When transfusion is complete: - Flush IV with NS flush. - Record time of completion on tag. - Continue to monitor for transfusion reaction. • Once the patient has been transfused 2 units of PRBC total from sending facility or during transport, administer calcium: - Adult: Calcium chloride 1 g IV over 5 minutes or Calcium gluconate 2 g IV over 5 minutes each. - Pediatric: Calcium chloride 10 - 20 mg/kg (maximum 1 g) IV over 5 minutes or Calcium gluconate 50 - 100 mg/kg (maximum 2 g) IV over 5 minutes (per g).