ICEMA MEDS multiple choice

• Medications in the protocol are for use as per the listed ICEMA Treatment Protocol.
• For Nerve Agent Antidote Kit (NAAK) or medications deployed with the ChemPack: Refer to Appendix I.

Acetaminophen (Tylenol) - Adult (ALS)

• Use for mild to moderate pain (1-5) or when other pain meds are not suitable.
• Administer 1 gm IV/IO over 15 minutes, single dose.

Acetaminophen (Tylenol) - Pediatric (ALS)

• Use for mild to moderate pain (1-5) or when other pain meds are not suitable.
• For ages 2-14: 15mg/kg IV/IO (max 1000mg or 1 gm) over 15 minutes, single dose.

Adenosine (Adenocard) - Adult (ALS)

• Use for stable narrow-complex SVT or Wide complex tachycardia.
• Give 6 mg rapid IVP, followed by 20 cc NS bolus. If no conversion, give 12 mg rapid IVP followed by 20 cc NS bolus, may repeat one time.

Albuterol (Proventil) Aerosolized Solution - Adult (LALS, ALS)

• Administer 2.5 mg nebulized, may repeat twice.

Albuterol (Proventil) Metered-Dose Inhaler (MDI) - Adult (BLS, LALS, ALS)

• Administer four puffs every 10 minutes for ongoing shortness of breath and wheezing.

Albuterol (Proventil) - Pediatric (LALS, ALS)

• Administer 2.5 mg nebulized, may repeat twice.

Albuterol (Proventil) Metered-Dose Inhaler (MDI) - Pediatric (BLS, LALS, ALS)

• Administer four puffs every 10 minutes for ongoing shortness of breath and wheezing.

Aspirin, chewable -Adult (LALS, ALS)

• Administer 325 mg PO chewed (one adult non-enteric coated aspirin) or four 81 mg chewable aspirin.

Atropine (ALS) - Adult

• Administer 1 mg IV/IO, repeat every 5 minutes up to 3 mg or 0.04 mg/kg.
• For organophosphate poisoning: 2 mg IV/IO, repeat at 2 mg increments every 5 minutes if symptomatic.

Atropine - Pediatric (ALS)

• For organophosphate poisoning (under 14 years): 0.05 mg/kg IV/IO (max 2 mg), repeat at 0.1 mg/kg increments every 5 minutes if symptomatic.

Buprenorphine-Naloxone (Suboxone ®)-Adult (ALS)

• For Opioid Withdrawal with Clinical Opioid Withdrawal Scale ≥ 8: 16 mg/4mg sublingual.
• May repeat at 8 mg/2mg sublingual after 10 minutes if symptomatic, up to 24 mg/6mg total.

Calcium Chloride - Adult (ALS)

• (Base hospital order only)
• For Calcium Channel Blocker Poisonings: 1 gm (10 ml of a 10% solution) IV/IO.
• For cardiac arrest with suspected hypocalcemia, hyperkalemia, hypermagnesemia or calcium channel blocker poisoning: 1 gm (10 ml of a 10% solution) IV/IO.
• For ESRD patients on dialysis with suspected hyperkalemia and hemodynamic instability with documented sinus bradycardia,3rd degree AV Block, 2nd degree Type II AV Block, slow junctional and ventricular escape rhythms, or slow atrial fibrillation. (Base hospital order only): 1 gm (10 ml of a 10% solution) IV/IO.

Calcium Chloride - Pediatric (ALS)

• (Base hospital order only)
• For Calcium Channel Blocker Poisonings: 20 mg/kg IV/IO over 5 minutes.

Dextrose - Adult (LALS, ALS)

• For Hypoglycemia (Adult with blood glucose less than 80 mg/dL): Dextrose 10% /250 ml (D10W 25 gm) IV/IO Bolus

Dextrose - Pediatric (LALS, ALS)

• For Hypoglycemia in Neonates (0 - 4 weeks) with blood glucose less than 35 mg/dL or pediatric patients (more than 4 weeks) with glucose less than 60 mg/dL: Dextrose 10%/250 ml (D10W 25 gm) 0.5 gm/kg (5 ml/kg) IV/IO

Diazepam – Adult (ALS)

• Only when midazolam is not commercially available.
• For Seizures: 5 mg IV/IO, single dose or 10mg IM, single dose

Diazepam- Pediatric (ALS)

• Only when midazolam is not commercially available.
• Seizures: 0.1mg/kg IV/IO, single dose only, not to exceed adult dose of 5mg or 0.2mg/kg IM, single dose only, not to exceed adult dose of 10mg

Diphenhydramine - Adult (ALS)

• Administer 25 mg IV/IO or 50 mg IM.

Diphenhydramine - Pediatric (ALS)

• Allergic reaction (ages 2-14): 1 mg/kg slow IV/IO (max 25 mg) or 2 mg/kg IM (max 50 mg IM).

Epinephrine (1 mg/ml) - Adult (LALS, ALS)

• For Severe Bronchospasm, Asthma Attack, Pending Respiratory Failure, Severe Allergic Reactions: 0.3 mg IM, may repeat once after 15 minutes if symptoms do not improve.

Epinephrine (0.1 mg/ml) - Adult (ALS)

• For persistent severe anaphylactic reaction: 0.1 mg slow IVP/IO, may repeat every 5 minutes to 0.5 mg total.
• For Cardiac Arrest, Asystole, PEA: 1 mg IV/IO.

Epinephrine (0.3 Auto injector) - Adult (BLS, LALS, ALS)

• For severe asthma and/or anaphylaxis only, may repeat once after 15 minutes.

Epinephrine (0.15 Auto injector Jr.) - Pediatric (BLS,LALS, ALS)

• For anaphylaxis only

Epinephrine (0.01 mg/ml) - Adult (ALS)

• For Post resuscitation, persistent profound nontraumatic shock and hypotension, and for persistent shock due to trauma where cardiac arrest is imminent:(Push Dose Epinephrine).
• Prepare 0.01 mg/ml solution by mixing 9 ml of normal saline with 1 ml of Epinephrine 0.1 mg/ml in a 10 ml syringe.
• Administer 1 ml every 1-5 minutes, titrate to maintain SBP over 90 mm Hg.

Epinephrine (1 mg/ml) - Pediatric (LALS, ALS)

• For Severe Bronchospasm, Asthma Attack, Pending Respiratory Failure, Severe Allergic Reactions: 0.01 mg/kg IM (max 0.3 mg), may repeat once after 15 minutes if symptoms do not improve.

Epinephrine (0.1 mg/ml) - Pediatric (ALS)

• For Anaphylactic reaction (no radial pulse, depressed consciousness): 0.01 mg/kg IV/IO (max 0.1 mg per dose), may repeat to 0.5 mg max.
• In Cardiac Arrest:
  • For ages 1 day to 8 years: 0.01 mg/kg IV/IO (do not exceed adult dosage)
  • For ages 9 to 14 years: 1.0 mg IV/IO
  • For Newborn Care: 0.01 mg/kg IV/IO if HR less than 60 after 1 minute, after airway/hypoxia evaluation and assessing body temperature for hypothermia.
  • For persistent hypotension as a base hospital order or in radio communication failure: 0.005 mg/kg IV/IO every 10 minutes

Epinephrine (0.01 mg/ml) - Pediatric (ALS)

• For Post resuscitation, profound shock and hypotension, for persistent shock due to trauma where cardiac arrest is imminent (Push Dose Epinephrine):
• Prepare 0.01 mg/ml solution by mixing 9 ml of normal saline with 1 ml of Epinephrine 0.1 mg/ml in a 10 ml syringe.
• Administer 0.1 ml/kg (do not exceed adult dosage), every 1-5 minutes. Titrate to maintain SBP over 70 mm Hg.

Fentanyl - Adult (ALS)

• For Chest Pain (Presumed Ischemic Origin): 50 mcg slow IV/IO over 1 minute, may repeat every 5 minutes titrated to pain, not to exceed 200 mcg, or 100 mcg IM/IN, may repeat 50 mcg every 10 minutes titrated to pain, not to exceed 200 mcg.
• For Acute traumatic injuries, acute abdominal/flank pain, burn injuries, Cancer pain, Sickle Cell Crisis: 50 mcg slow IV/IO push over 1 minute, may repeat every 5 minutes titrated to pain, not to exceed 200 mcg IV/IO, or 100 mcg IM/IN, may repeat 50 mcg every 10 minutes titrated to pain, not to exceed 200 mcg.
• For Pacing, synchronized cardioversion: 50 mcg slow IV/IO over 1 minute, may repeat in 5 minutes titrated to pain, not to exceed 200 mcg, or 100 mcg IN, may repeat 50 mcg every 10 minutes titrated to pain, not to exceed 200 mcg.
• Any combination of IV/IO/IM/IN may be administered, not to exceed 200 mcg.

Fentanyl - Pediatric (ALS)

• Administer 0.5 mcg/kg slow IV/IO over 1 minute, may repeat in 5 minutes titrated to pain, not to exceed 50 mcg for a single dose.
• Administer 1 mcg/kg IM/IN, may repeat every 10 minutes titrated to pain not to exceed 100 mcg for a single dose.
• Any combination of IV/IO/IM/IN may be administered, not to exceed four doses or cumulative maximum of 200 mcg.

Glucose - Oral - Adult (BLS, LALS, ALS)

• For Adult with blood glucose less than 80 mg/dL: one tube for patients with an intact gag reflex and hypoglycemia.

Glucose - Oral - Pediatric (BLS, LALS, ALS)

• For Hypoglycemia - Neonates (0 - 4 weeks) with blood glucose less than 35 mg/dL or pediatric patients (more than 4 weeks) with glucose less than 60 mg/dL: one tube for patients with an intact gag reflex and hypoglycemia.

Glucagon - Adult (LALS, ALS)

• Administer 1 mg IM/SC/IN, if unable to establish IV, may administer one time only.
• For Beta blocker Poisoning (base hospital order only): 1 mg IV/IO.

Glucagon - Pediatric (LALS, ALS)

• For Hypoglycemia, if unable to establish IV: 0.03 mg/kg IM/IN, if unable to start an IV, may be repeated one time after 20 minutes for a combined maximum dose of 1 mg.
• For Beta blocker poisoning (base hospital order only:) 0.03 mg/kg IV/IO

Ipratropium Bromide (Atrovent) Inhalation Solution use with Albuterol Adult (ALS)

• Administer 0.5 mg nebulized, one dose only.

Ipratropium Bromide (Atrovent) Metered-Dose Inhaler (MDI) use with Albuterol Adult (ALS)

• When used in combination with Albuterol MDI use Albuterol MDI dosing.

Ipratropium Bromide (Atrovent) Inhalation Solution use with Albuterol - Pediatric (ALS)

• For ages 1 day to 12 months: 0.25 mg nebulized, one dose only.
• For ages 1 year to 14 years: 0.5 mg nebulized, one dose only.

Ipratropium Bromide (Atrovent) Metered-Dose Inhaler (MDI) use with Albuterol - Pediatric (ALS)

• When used in combination with Albuterol MDI use Albuterol MDI dosing.

Ketamine - Adult (ALS)

• For Acute traumatic injury, acute abdominal/flank pain, burn injuries, cancer related pain and sickle cell crisis: 0.3 mg/kg (max 30 mg) in 50-100 ml NS IV over 5 minutes, may repeat once after 15 minutes if pain remains at 5 or higher.
• Do not administer IVP, IO, IM, or IN.

Lidocaine - Adult (ALS)

• For VT (pulseless)/VF:
  • Initial Dose: 1.5 mg/kg IV/IO
  • For refractory VT (pulseless)/VF, may administer an additional 0.75 mg/kg IV/IO, repeat one time in 5-10 minutes; maximum total dose of 3 mg/kg.
• For V-Tach, Wide Complex Tachycardia - with Pulses: 1.5 mg/kg slow IV/IO, may administer an additional 0.75 mg/kg slow IV/IO; maximum total dose of 3 mg/kg.

Lidocaine - Pediatric (ALS)

• For Cardiac Arrest:
  • For ages 1 day to 8 years: 1.0 mg/kg IV/IO
  • For ages 9 to 14 years: 1.0 mg/kg IV/IO
  • May repeat Lidocaine at 0.5 mg/kg after 5 minutes; maximum total dose of 3 mg/kg.

Lidocaine 2% (Intravenous Solution) - Pediatric and Adult (ALS)

• For Pain with IO infusion: 0.5 mg/kg slow IO push over 2 minutes, not to exceed 40 mg total.

Magnesium Sulfate-Adult (ALS)

• For Polymorphic Ventricular Tachycardia: 2 gm IV/IO bolus over 5 minutes for polymorphic VT if prolonged QT is observed during sinus rhythm post-cardioversion.
• For Eclampsia (Seizure/Tonic/Clonic Activity): 4 gm IV/IO slow IV push over 3-4 minutes, followed by 10 mg/min IV/IO drip to prevent continued seizures.
• For Severe Asthma/Respiratory Distress (ALS) (base hospital order only): 2 gm slow IV drip over 20 minutes, do not repeat.

Magnesium Sulfate - Pediatric (ALS)

• For Severe Asthma/Respiratory Distress (base hospital order only): 50 mg/kg slow IV drip over 20 minutes, not to exceed 2 gm total, do not repeat.

Midazolam (Versed) - Adult (ALS)

• For Behavioral Emergencies with potentially fatal and dangerous agitation: 2.5 mg IV/IO, may repeat in 5 minutes, or 5 mg IM/IN, may repeat in 10 minutes, maximum of three doses using any combination of IV/IO/IM/IN.
• For Post ROSC Agitation (base hospital order only): Agitation following ROSC that hinders patient’s care, i.e. biting or attempting to remove ET tube/lines, Not to be used for sedation during intubation of any patients 2.5 mg IV/IO or 5 mg IM/IN Patient must have advanced airway (endotracheal tube or i-gel.) Repeat dose requires base hospital contact.
• For Seizure: 2.5 mg IV/IO, may repeat in 5 minutes for continued seizure activity, or 5 mg IM/IN, may repeat in 10 minutes for continued seizure activity, maximum of three doses using any combination of IV/IO/IM/IN for continued seizure activity.
• For Pacing, synchronized cardioversion: 2.5 mg slow IV/IO, may repeat in 5 minutes, or 5 mg IM/IN, may repeat in 10 minutes, maximum of three doses using any combination of IV/IO/IM/IN.
• For CPAP: 1 mg IV/IO/IM/IN may be administered one time for anxiety, contact base hospital for additional orders.

Midazolam (Versed) - Pediatric (ALS)

• For Seizures: 0.1 mg/kg IV/IO (max 2.5 mg), may repeat in 5 minutes, or 0.2 mg/kg IM/IN (max 5 mg), may repeat in 10 minutes for continued seizure, maximum of three doses using any combination of IV/IO/IM/IN for continued seizure activity.
• For Behavioral Emergencies with potentially fatal and dangerous agitation (base hospital order): 0.1 mg/kg IV/IO, may repeat in 5 minutes, or 0.2 mg/kg IM/IN, may repeat in 10 minutes, maximum of three doses using any combination of IV/IO/IM/IN, not to exceed adult dose.

Naloxone (Narcan) - Adult (BLS)

• For resolution of respiratory depression related to suspected opiate overdose: 0.5 mg IM/IN, may repeat every 2-3 minutes if needed to improve respiratory effort.
• For suspected Fentanyl overdose with respiratory depression: Consider a loading dose of 4 mg IN Naloxone. If no signs of respiratory improvement, consider 0.5 mg IM/IN every 2-3 minutes if needed. Do not exceed 10 mg total regardless of route.

Naloxone (Narcan) - Adult (LALS, ALS)

• For resolution of respiratory depression related to suspected opiate overdose: 0.5 mg IV/IO/IM/IN, may repeat every 2-3 minutes if needed to improve respiratory effort.
• For suspected Fentanyl overdose with respiratory depression: Consider a loading dose of 4 mg IN Naloxone, may repeat one time. If no signs of respiratory improvement, consider 0.5 mg IV/IO/IM/IN every 2-3 minutes if needed. Do not exceed 10 mg total regardless of route.

Naloxone (Narcan) - Pediatric (BLS)

• For resolution of respiratory depression related to suspected opiate overdose:
  • For ages 1 day to 8 years: 0.1 mg/kg IM/IN (do not exceed the adult dose of 0.5 mg per administration)
  • For ages 9 to 14 years: 0.5 mg IM/IN
• May repeat every 2-3 minutes if needed, do not exceed 10 mg total IM/IN.

Naloxone (Narcan) - Pediatric (LALS, ALS)

• For resolution of respiratory depression related to suspected opiate overdose:
  • For ages 1 day to 8 years: 0.1 mg/kg IV/IO/IM/IN (do not exceed the adult dose of 0.5 mg per administration)
  • For ages 9 to 14 years: 0.5 mg IV/IO/IM/IN
• May repeat every 2-3 minutes if needed, do not exceed 10 mg total IV/IO/IM/IN.

Nitroglycerin (NTG) -Adult (LALS, ALS)

• Administer 0.4 mg sublingual/transmucosal every 3 minutes as needed, may be repeated as long as patient has adequate tissue perfusion.
• If Right Ventricular Infarction is suspected, base hospital contact is required
• Nitroglycerin Paste, 1 inch (1 gm) transdermal, may not repeat.
• Nitroglycerin sublingual is the preferred route of administration for ACS. Nitro Paste is a one time dose and intended for when sublingual cannot be easily administered (i.e., CPAP).
• Nitroglycerin is contraindicated if signs of inadequate tissue perfusion are present or if sexual enhancement medications have been utilized within the past 48 hours.

Ondansetron (Zofran) - Patients four years old to Adult (ALS)

• For Nausea/Vomiting: 4 mg slow IV/IO/ODT
  • For all patients four to eight years old: May administer up to 4 mgs of Ondansetron prior to base hospital contact.
  • For all patients nine and older: May administer 4 mg; may repeat two times, at 10 minute intervals, for a total of 12 mgs prior to base hospital contact.
• May be used as prophylactic treatment of nausea and vomiting associated with narcotic administration.

Oxygen - Pediatric and Adult (BLS, LALS. ALS)

• Administer (non-intubated patient per appropriate delivery device)
• For General Administration (Hypoxia): Titrate Oxygen at lowest rate required to maintain SPO2 at 94%. Do not administer supplemental oxygen for SPO2 above 95%.
• For Chronic Obstructive Pulmonary Disease (COPD): Titrate Oxygen at lowest rate required to maintain SPO2 at 90%. Do not administer supplemental oxygen for SPO2 above 91%.

Sodium Bicarbonate - Adult (ALS)

• For Tricyclic Poisoning (base hospital order only): 1 mEq/kg IV/IO
• For cardiac arrest with suspected metabolic acidosis, hyperkalemia or tricyclic poisoning (base hospital order only): 50 mEq IV/IO/ 50cc preload or 50cc single-dose vial

Sodium Bicarbonate - Pediatric (ALS)

• For Tricyclic Poisoning (base hospital order only): 1 mEq/kg IV/IO

Tranexamic Acid (TXA) - Patients 15 years of age and older (ALS)

• For Signs of hemorrhagic shock meeting inclusion criteria: Administer 1 gm in 50-100 ml NS via IV/IO over 10 minutes.
• Do not administer IVP as this will cause hypotension.
• For Signs of postpartum hemorrhagic shock (base hospital order only): Administer 1 gm in 50-100 ml NS via IV/IO over 10 minutes. Do not administer IVP as this will cause hypotension.

APPENDIX I: Medications for self-administration or with deployment of the ChemPack.

Atropine - Pediatric (BLS, AEMT-Auto-injector, ALS)

• For Known nerve agent/organophosphate poisoning with deployment of the ChemPack:
  • For Two or more mild symptoms: Administer the weight-based dose as soon as exposure is known or strongly suspected. If severe symptoms develop after the first dose, two additional doses should be repeated in rapid succession 10 minutes after the first dose; do not administer more than three doses.
  • If profound anticholinergic effects occur in the absence of excessive bronchial secretions, further doses of atropine should be withheld.
  • For One or more severe symptoms: Immediately administer three weight-based doses in rapid succession.
• Weight-based dosing:
  • Less than 6.8 kg (less than 15 lbs): 0.25 mg, IM using multi-dose vial
  • 6.8 to 18 kg (15 to 40 lbs): 0.5 mg, IM using AtroPen auto-injector
  • 18 to 41 kg (40 to 90 lbs): 1 mg, IM using AtroPen auto-injector
  • More than 41 kg (more than 90 lbs): 2 mg, IM using multi-dose vial
• Symptoms of insecticide or nerve agent poisoning:
  • Mild symptoms: Blurred vision, bradycardia, breathing difficulties, chest tightness, coughing, drooling, miosis, muscular twitching, nausea, runny nose, salivation increased, stomach cramps, tachycardia, teary eyes, tremor, vomiting, or wheezing.
  • Severe symptoms: Breathing difficulties (severe), confused/strange behavior, defecation (involuntary), muscular twitching/generalized weakness (severe), respiratory secretions (severe), seizure, unconsciousness, urination (involuntary).
• NOTE: Infants may become drowsy or unconscious with muscle floppiness as opposed to muscle twitching.

Diazepam (Valium) - Adult (ALS)

• For seizures associated with nerve agent/organophosphate exposure ONLY with ChemPack deployment: 10 mg (5 mg/ml) auto-injector IM (if IV unavailable), or 2.5 mg IV.

Diazepam (Valium) - Pediatric (ALS)

• For seizures associated with nerve agent/organophosphate exposure ONLY with ChemPack deployment: 0.05 mg/kg IV

Nerve Agent Antidote Kit (NAAK)/Mark I or DuoDote (containing Atropine/Pralidoxime Chloride) - Adult

• For Nerve agent exposure with associated symptoms: One NAAK auto-injector IM into outer thigh, may repeat up to two times every 10-15 minutes if symptoms persist.