Inland Counties Emergency Medical Agency Policy And Protocol Manual PDF

Reference No. 11010 INLAND COUNTIES Effective Date: 05/01/2024 EMERGENCY MEDICAL AGENCY Supersedes: 11/10/2023 POLICY AND PROTOCOL MANUAL...

Reference No. 11010 INLAND COUNTIES Effective Date: 05/01/2024 EMERGENCY MEDICAL AGENCY Supersedes: 11/10/2023 POLICY AND PROTOCOL MANUAL Page 1 of 14 MEDICATION - STANDARD ORDERS Medications listed in this protocol may be used only for the purposes referenced by the associated ICEMA Treatment Protocol. For Nerve Agent Antidote Kit (NAAK) or medications deployed with the ChemPack see Appendix I (Page 12). Acetaminophen (Tylenol) - Adult (ALS) For mild to moderate pain scales of 1-5 or in moderate to severe pain where other medications are contraindicated or deferred. Tylenol, 1 gm IV/IO infusion over fifteen (15) minutes. Single dose only Acetaminophen (Tylenol) – Pediatric (ALS) For mild to moderate pain scales of 1-5 or in moderate to severe pain where other medications are contraindicated or deferred. 2 years to 14 years: Tylenol, 15mg/kg to max of 1000mg or 1 gm IV/IO infusion over fifteen (15) minutes. Single dose only Reference #s 7010, 7020, 14100 Adenosine (Adenocard) - Adult (ALS) Stable narrow-complex SVT or Wide complex tachycardia: Adenosine, 6 mg rapid IVP followed immediately by 20 cc NS bolus, and Adenosine, 12 mg rapid IVP followed immediately by 20 cc NS bolus if patient does not convert. May repeat one (1) time. Reference #s 7010, 7020, 14040 Albuterol (Proventil) Aerosolized Solution - Adult (LALS, ALS) Albuterol, 2.5 mg nebulized, may repeat two (2) times. Reference #s 4060, 7010, 7020, 14010, 14070 Albuterol (Proventil) Metered-Dose Inhaler (MDI) - Adult (BLS, LALS, ALS) Albuterol MDI, four (4) puffs every 10 minutes for continued shortness of breath and wheezing. Reference #s 4060, 4080, 7010, 7020, 14120, 14140, 14190 Albuterol (Proventil) - Pediatric (LALS, ALS) Albuterol, 2.5 mg nebulized, may repeat two (2) times. Reference #s 7010, 7020, 14120, 14140, 14190 MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 2 of 14 Albuterol (Proventil) Metered-Dose Inhaler (MDI) - Pediatric (BLS, LALS, ALS) Albuterol MDI, four (4) puffs every 10 minutes for continued shortness of breath and wheezing. Reference #s 4060, 4080, 7010, 7020, 14120, 14140, 14190 Aspirin, chewable -Adult (LALS, ALS) Aspirin, 325 mg PO chewed (one (1) adult non-enteric coated aspirin) or four (4) chewable 81 mg aspirin. Reference #s 4060, 4080, 5010, 7010, 7020 Atropine (ALS) - Adult Atropine, 1 mg IV/IO. May repeat every five (5) minutes up to a maximum of 3 mg or 0.04 mg/kg. Organophosphate poisoning: Atropine, 2 mg IV/IO, repeat at 2 mg increments every five (5) minutes if patient remains symptomatic. Reference #s 4060, 4080, 7010, 7020, 13010, 14030, 14260 Atropine - Pediatric (ALS) Organophosphate poisoning - Pediatrics less than 14 years of age: Atropine, 0.05 mg/kg IV/IO not to exceed adult dose of 2 mg, repeat at 0.1 mg/kg increments every five (5) minutes if patient remains symptomatic. Reference #s 4060, 4080, 7010, 7020, 13010 Buprenorphine-Naloxone (Suboxone ®)-Adult (ALS): Opioid Withdrawal- Clinical Opioid Withdrawal Scale ≥ 8: Buprenorphine-Naloxone, 16 mg/4mg sublingual, may repeat at 8 mg/2mg sublingual after ten (10) minutes if patient remains symptomatic, to a maximum total dose of 24 mg/6mg. Reference #s 7010, 10050 Calcium Chloride - Adult (ALS) (base hospital order only): Calcium Channel Blocker Poisonings Calcium Chloride, 1 gm (10 ml of a 10% solution) IV/IO. Reference #s 5010, 7010, 7020, 13010 For cardiac arrest with suspected hypocalcemia, hyperkalemia, hypermagnesemia or calcium channel blocker poisoning Calcium Chloride, 1 gm (10 ml of a 10% solution) IV/IO. Reference #s 7010, 7020, 14050 MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 3 of 14 For End Stage Renal Disease (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). Calcium Chloride, 1 gm (10 ml of a 10% solution) IV/IO Reference #s 5010, 7010, 7020, 14030 Calcium Chloride - Pediatric (ALS) (base hospital order only): Calcium Channel Blocker Poisonings Calcium Chloride, 20 mg/kg IV/IO over five (5) minutes. Reference #s 7010, 7020, 13010 Dextrose - Adult (LALS, ALS) Hypoglycemia - Adult with blood glucose less than 80 mg/dL: Dextrose 10% /250 ml (D10W 25 gm) IV/IO Bolus Reference #s 4060, 4080, 5010, 7010, 7020, 8010, 13020, 13030, 14040, 14060 Dextrose - Pediatric (LALS, ALS) 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: Dextrose 10%/250 ml (D10W 25 gm) 0.5 gm/kg (5 ml/kg) IV/IO Reference #s 5010, 7010, 7020, 13020, 13030, 14150, 14160, 14170 Diazepam – Adult (ALS) only when midazolam is not commercially available. Seizures: Diazepam , 5 mg IV/IO, single dose only Diazepam 10mg IM, single dose only Diazepam- Pediatric (ALS) only when midazolam is not commercially available. Seizures: Diazepam 0.1mg/kg IV/IO, single dose only, not to exceed adult dose of 5mg Diazepam 0.2mg/kg IM, single dose only, not to exceed adult dose of 10mg Reference #s 7010, 7020, 14170 Diphenhydramine - Adult (ALS) Diphenhydramine, 25 mg IV/IO Diphenhydramine, 50 mg IM Reference #s 4060, 4080, 7010, 7020, 13010, 14010 Diphenhydramine - Pediatric (ALS) Allergic reaction: MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 4 of 14 2 years to 14 years Diphenhydramine, 1 mg/kg slow IV/IO, not to exceed adult dose of 25 mg, or Diphenhydramine, 2 mg/kg IM not to exceed adult dose of 50 mg IM. Reference #s 7010, 7020, 14140 Epinephrine (1 mg/ml) - Adult (LALS, ALS) Severe Bronchospasm, Asthma Attack, Pending Respiratory Failure, Severe Allergic Reactions: Epinephrine, 0.3 mg IM. May repeat after 15 minutes one (1) time if symptoms do not improve. Reference # 14010 Epinephrine (0.1 mg/ml) - Adult (ALS) For persistent severe anaphylactic reaction: Epinephrine (0.1 mg/ml), 0.1 mg slow IVP/IO. May repeat every five (5) minutes as needed to total dosage of 0.5 mg. Reference # 14010 Cardiac Arrest, Asystole, PEA: Epinephrine (0.1 mg/ml), 1 mg IV/IO. Reference #s 4060, 4080, 5010, 7010, 7020, 14010, 14050, 14260 Epinephrine (0.3 Auto injector) - Adult (BLS, LALS, ALS) For severe asthma and/or anaphylaxis only Epinephrine 0.3 mg auto-injector, may repeat once after 15 minutes Epinephrine (0.15 Auto injector Jr.) - Pediatric (BLS,LALS, ALS) For anaphylaxis only Epinephrine 0.15 mg auto-injector Epinephrine (0.01 mg/ml) - Adult (ALS) Post resuscitation, persistent profound nontraumatic shock and hypotension, and for persistent shock due to trauma where cardiac arrest is imminent:(Push Dose Epinephrine). Prepare Epinephrine 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 one (1) to five (5) minutes titrated to maintain SBP more than 90 mm Hg. Reference #s 4060, 4080, 5010, 7010, 7020, 11010, 14050, 14090,14230 Epinephrine (1 mg/ml) - Pediatric (LALS, ALS) Severe Bronchospasm, Asthma Attack, Pending Respiratory Failure, Severe Allergic Reactions: MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 5 of 14 Epinephrine, 0.01 mg/kg IM not to exceed adult dosage of 0.3 mg. May repeat after 15 minutes one (1) time if symptoms do not improve. Reference #s 4060, 5010, 7010, 7020, 14120, 14140 Epinephrine (0.1 mg/ml) - Pediatric (ALS) Anaphylactic reaction (no palpable radial pulse and depressed level of consciousness): Epinephrine (0.1 mg/ml), 0.01 mg/kg IV/IO, no more than 0.1 mg per dose. May repeat to a maximum of 0.5 mg. Cardiac Arrest: 1 day to 8 years Epinephrine (0.1 mg/ml), 0.01 mg/kg IV/IO (do not exceed adult dosage) 9 to 14 years Epinephrine (0.1 mg/ml), 1.0 mg IV/IO Newborn Care: Epinephrine (0.1 mg/ml), 0.01 mg/kg IV/IO if heart rate is less than 60 after one (1) minute after evaluating airway for hypoxia and assessing body temperature for hypothermia. Epinephrine (0.1 mg/ml), 0.005 mg/kg IV/IO every 10 minutes for persistent hypotension as a base hospital order or in radio communication failure. Reference # 14200 Epinephrine (0.01 mg/ml) - Pediatric (ALS) Post resuscitation, profound shock and hypotension, for persistent shock due to trauma where cardiac arrest is imminent (Push Dose Epinephrine): Prepare Epinephrine 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 one (1) to five (5) minutes. Titrate to maintain a SBP more than 70 mm Hg. Reference #s 5010, 7010, 7020, 11010, 14150, 14180, 14230 Fentanyl - Adult (ALS) Chest Pain (Presumed Ischemic Origin): Fentanyl, 50 mcg slow IV/IO over one (1) minute. May repeat every five (5) minutes titrated to pain, not to exceed 200 mcg. Fentanyl, 100 mcg IM/IN. May repeat 50 mcg every 10 minutes titrated to pain, not to exceed 200 mcg. Acute traumatic injuries, acute abdominal/flank pain, burn injuries, Cancer pain, Sickle Cell Crisis: Fentanyl, 50 mcg slow IV/IO push over one (1) minute. May repeat every five (5) minutes titrated to pain, not to exceed 200 mcg IV/IO, or Fentanyl, 100 mcg IM/IN. May repeat 50 mcg every 10 minutes titrated to pain, not to exceed 200 mcg. Pacing, synchronized cardioversion: Fentanyl, 50 mcg slow IV/IO over one (1) minute. May repeat in five (5) minutes titrated to pain, not to exceed 200 mcg. MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 6 of 14 Fentanyl, 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. Contact base hospital for additional orders and to discuss further treatment options. Reference #s 3050, 4060, 4080, 5010, 7010, 7020, 11020, 13030, 14070, 14090, 14100, 14240 Fentanyl - Pediatric (ALS) Fentanyl, 0.5 mcg/kg slow IV/IO over one (1) minute. May repeat in five (5) minutes titrated to pain, not to exceed 50 mcg for a single dose. Fentanyl, 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 (4) doses or cumulative maximum of 200 mcg. Contact base hospital for additional orders and to discuss further treatment options. Reference #s 3050, 4080, 5010, 7010, 7020, 13030, 14180, 14190, 14240 Glucose - Oral - Adult (BLS, LALS, ALS) Adult with blood glucose less than 80 mg/dL: Glucose - Oral, one (1) tube for patients with an intact gag reflex and hypoglycemia. Reference #s 7010, 7020, 13020, 14060, 14080, 14230 Glucose - Oral - Pediatric (BLS, LALS, ALS) 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: Glucose - Oral, one (1) tube for patients with an intact gag reflex and hypoglycemia. Reference #s 7010, 7020, 14170, 14160 Glucagon - Adult (LALS, ALS) Glucagon, 1 mg IM/SC/IN, if unable to establish IV. May administer one (1) time only. Beta blocker Poisoning (base hospital order only): Glucagon, 1 mg IV/IO Reference #s 4060, 4080, 7010, 7020, 13010, 13030, 14060 Glucagon - Pediatric (LALS, ALS) Hypoglycemia, if unable to establish IV: Glucagon, 0.03 mg/kg IM/IN, if unable to start an IV. May be repeated one (1) time after 20 minutes for a combined maximum dose of 1 mg. Reference #s 7010, 7020, 13030, 14160, 14170 MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 7 of 14 Beta blocker poisoning (base hospital order only): Glucagon, 0.03 mg/kg IV/IO Reference #’s 4060, 4080, 7010, 7020, 13010 Ipratropium Bromide (Atrovent) Inhalation Solution use with Albuterol Adult (ALS) Atrovent, 0.5 mg nebulized. Administer one (1) dose only. Reference #s 7010, 7020, 14010, 14070 Ipratropium Bromide (Atrovent) Metered-Dose Inhaler (MDI) use with Albuterol Adult (ALS) When used in combination with Albuterol MDI use Albuterol MDI dosing. Reference #s 4060, 4080, 7010, 7020, 14010, 14070 Ipratropium Bromide (Atrovent) Inhalation Solution use with Albuterol - Pediatric (ALS) 1 day to 12 months Atrovent, 0.25 mg nebulized. Administer one (1) dose only. 1 year to 14 years Atrovent, 0.5 mg nebulized. Administer one (1) dose only. Reference #s 7010, 7020, 14120, 14140, 14190 Ipratropium Bromide (Atrovent) Metered-Dose Inhaler (MDI) use with Albuterol - Pediatric (ALS) When used in combination with Albuterol MDI use Albuterol MDI dosing. Reference #s 4060, 4080, 7010, 7020, 14120, 14140, 14190 Ketamine - Adult (ALS) Acute traumatic injury, acute abdominal/flank pain, burn injuries, cancer related pain and sickle cell crisis: Ketamine, 0.3 mg/kg to a max of 30 mg in a 50 - 100 ml of NS via IV over five (5) minutes. May repeat one (1) time, after 15 minutes, if pain score remains at five (5) or higher. Do not administer IVP, IO, IM, or IN. Reference #s 7010, 7020, 14100 Lidocaine - Adult (ALS) VT (pulseless)/VF: Initial Dose: Lidocaine, 1.5 mg/kg IV/IO For refractory VT (pulseless)/VF, may administer an additional 0.75 mg/kg IV/IO, repeat one (1) time in five (5) to 10 minutes; maximum total dose of 3 mg/kg. V-Tach, Wide Complex Tachycardia - with Pulses: Lidocaine, 1.5 mg/kg slow IV/IO MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 8 of 14 May administer an additional 0.75 mg/kg slow IV/IO; maximum total dose of 3 mg/kg. Reference #s 4060, 5010, 7010, 7020, 8010, 11020, 14040, 14050, 14090 Lidocaine - Pediatric (ALS) Cardiac Arrest: 1 day to 8 years Lidocaine, 1.0 mg/kg IV/IO 9 to 14 years Lidocaine, 1.0 mg/kg IV/IO May repeat Lidocaine at 0.5 mg/kg after five (5) minutes; maximum total dose of 3 mg/kg. Reference #s 5010, 7010, 7020, 14150 Lidocaine 2% (Intravenous Solution) - Pediatric and Adult (ALS) Pain associated with IO infusion: Lidocaine, 0.5 mg/kg slow IO push over two (2) minutes, not to exceed 40 mg total. Reference #s 5010, 7010, 7020, 11020 Magnesium Sulfate-Adult (ALS) Polymorphic Ventricular Tachycardia: Magnesium Sulfate, 2 gm IV/IO bolus over five (5) minutes for polymorphic VT if prolonged QT is observed during sinus rhythm post-cardioversion. Eclampsia (Seizure/Tonic/Clonic Activity): Magnesium Sulfate, 4 gm IV/IO slow IV push over three (3) to four (4) minutes. Magnesium Sulfate, 10 mg/min IV/IO drip to prevent continued seizures. Reference #s 5010, 7010, 7020, 8010, 14210 Severe Asthma/Respiratory Distress (ALS) (base hospital order only): Magnesium Sulfate, 2 gm slow IV drip over 20 minutes. Do not repeat. Reference# 14010 Magnesium Sulfate - Pediatric (ALS) Severe Asthma/Respiratory Distress (base hospital order only): Magnesium Sulfate, 50 mg/kg slow IV drip over 20 minutes. Do not exceed the adult dosage of 2 gm total. Do not repeat. Reference # 14120 Midazolam (Versed) - Adult (ALS) Behavioral Emergencies, if patient meets criteria for potentially fatal and dangerous agitation: Midazolam, 2.5 mg IV/IO. May repeat in five (5) minutes, or Midazolam, 5 mg IM/IN. May repeat in 10 minutes. Maximum of three (3) doses using any combination of IV/IO/IM/IN may be administered. Contact base hospital for additional orders and to discuss further treatment options. MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 9 of 14 Reference # 14110 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. Midazolam, 2.5 mg IV/IO or Midazolam 5 mg IM/IN Patient must have advanced airway (endotracheal tube or i-gel.) Repeat dose requires base hospital contact. Reference # 14050 Seizure: Midazolam, 2.5 mg IV/IO. May repeat in five (5) minutes for continued seizure activity, or Midazolam, 5 mg IM/IN. May repeat in 10 minutes for continued seizure activity. Assess patient for medication related reduced respiratory rate or hypotension. Maximum of three (3) doses using any combination of IV/IO/IM/IN may be administered for continued seizure activity. Contact base hospital for additional orders and to discuss further treatment options. Pacing, synchronized cardioversion: Midazolam, 2.5 mg slow IV/IO. May repeat in five (5) minutes. Midazolam, 5 mg IM/IN. May repeat in ten (10) minutes. Maximum of three (3) doses using any combination of IV/IO/IM/IN may be administered. Contact base hospital for additional orders and to discuss further treatment options. CPAP: Midazolam, 1 mg IV/IO/IM/IN may be administered one (1) time for anxiety related to application of CPAP. Contact base hospital for additional orders. Reference #s 4060, 4080, 7010, 7020, 11020, 13020, 14060, 14210 Midazolam (Versed) - Pediatric (ALS) Seizures: Midazolam, 0.1 mg/kg IV/IO with maximum dose 2.5 mg. May repeat Midazolam in five (5) minutes, or Midazolam, 0.2 mg/kg IM/IN with maximum dose of 5 mg. May repeat Midazolam in 10 minutes for continued seizure. Assess patient for medication related reduced respiratory rate or hypotension. Maximum of three (3) doses using any combination of IV/IO/IM/IN may be administered for continued seizure activity. Contact base hospital for additional orders and to discuss further treatment options. MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 10 of 14 Behavioral Emergencies, if patient meets criteria for potentially fatal and dangerous agitation (base hospital order): Midazolam, 0.1 mg/kg IV/IO. May repeat in five (5) minutes, or Midazolam, 0.2 mg/kg IM/IN. May repeat in 10 minutes. Assess patient for medication related reduced respiratory rate or hypotension. Maximum of three (3) doses using any combination of IV/IO/IM/IN may be administered. Not to exceed adult dose. Contact base hospital for additional orders and to discuss further treatment options. Reference #s 7010, 7020, 14170, 14110 Naloxone (Narcan) - Adult (BLS) For resolution of respiratory depression related to suspected opiate overdose: Naloxone, 0.5 mg IM/IN, may repeat Naloxone 0.5 mg IM/IN every two (2) to three (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 Naloxone 0.5 mg IM/IN every two (2) to three (3) minutes if needed. Do not exceed 10 mg of Naloxone total regardless of route administered. Reference #s 7010, 7020, 8030, 14060 Naloxone (Narcan) - Adult (LALS, ALS) For resolution of respiratory depression related to suspected opiate overdose: Naloxone, 0.5 mg IV/IO/IM/IN, may repeat Naloxone 0.5 mg IV/IO/IM/IN every two (2) to three (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 (1) time. If no signs of respiratory improvement, consider Naloxone 0.5 mg IV/IO/IM/IN every two (2) to three (3) minutes if needed. Do not exceed 10 mg of Naloxone total regardless of route administered. Reference #s 4080, 7010, 7020, 14060 Naloxone (Narcan) - Pediatric (BLS) For resolution of respiratory depression related to suspected opiate overdose: 1 day to 8 years Naloxone, 0.1 mg/kg IM/IN (do not exceed the adult dose of 0.5 mg per administration) 9 to 14 years Naloxone, 0.5 mg IM/IN May repeat every two (2) to three (3) minutes if needed. Do not exceed the adult dosage of 10 mg total IM/IN. Reference #s 7010, 7020, 8030, 14150, 14160 Naloxone (Narcan) - Pediatric (LALS, ALS) MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 11 of 14 For resolution of respiratory depression related to suspected opiate overdose: 1 day to 8 years Naloxone, 0.1 mg/kg IV/IO/IM/IN (do not exceed the adult dose of 0.5 mg per administration) 9 to 14 years Naloxone, 0.5 mg IV/IO/IM/IN May repeat every two (2) to three (3) minutes if needed. Do not exceed the adult dosage of 10 mg total IV/IO/IM/IN. Reference #s 7010, 7020, 14150, 14160 Nitroglycerin (NTG) -Adult (LALS, ALS) Nitroglycerin, 0.4 mg sublingual/transmucosal. One (1) every three (3) minutes as needed. May be repeated as long as patient continues to have signs of adequate tissue perfusion. If a Right Ventricular Infarction is suspected, the use of nitrates requires base hospital contact. 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 (1) time dose and intended for when sublingual cannot be easily administered (i.e., CPAP). Nitroglycerin is contraindicated if there are signs of inadequate tissue perfusion or if sexual enhancement medications have been utilized within the past 48 hours. Reference #s 4060, 4080, 7010, 7020, 14010, 14240 Ondansetron (Zofran) - Patients four (4) years old to Adult (ALS) Nausea/Vomiting: Ondansetron, 4 mg slow IV/IO/ODT All patients four (4) to eight (8) years old: May administer a total of 4 mgs of Ondansetron prior to base hospital contact. All patients nine (9) and older: May administer Ondansetron 4 mg; may repeat two (2) 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. Reference #s 4080, 7010, 7020, 14090, 14180, 14220 Oxygen - Pediatric and Adult (BLS, LALS. ALS) (non-intubated patient per appropriate delivery device) General Administration (Hypoxia): Titrate Oxygen at lowest rate required to maintain SPO 2 at 94%. Do not administer supplemental oxygen for SPO 2 more than 95%. Chronic Obstructive Pulmonary Disease (COPD): Titrate Oxygen at lowest rate required to maintain SPO 2 at 90%. Do not administer supplemental oxygen for SPO 2 more than 91%. MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 12 of 14 Reference #s 12010, 13010, 13020, 13030, 13050, 14010, 14020, 14030, 14040, 14060, 14070, 14090, 14120, 1 4 1 3 0 , 14140, 14160, 14170, 14180, 14190, 14200, 14210, 14220, 14230, 14240 Sodium Bicarbonate - Adult (ALS) Tricyclic Poisoning (base hospital order only): Sodium Bicarbonate, 1 mEq/kg IV/IO Reference #s 5010, 7010, 7020, 13010 For cardiac arrest with suspected metabolic acidosis, hyperkalemia or tricyclic poisoning (base hospital order only): Sodium Bicarbonate, 50 mEq IV/IO/ 50cc preload or 50cc single-dose vial Reference #’s 7010, 7020, 14050 Sodium Bicarbonate - Pediatric (ALS) Tricyclic Poisoning (base hospital order only): Sodium Bicarbonate, 1 mEq/kg IV/IO Reference #’s 7010, 7020, 13010 Tranexamic Acid (TXA) - Patients 15 years of age and older (ALS) Signs of hemorrhagic shock meeting inclusion criteria: Administer TXA 1 gm in 50 - 100 ml of NS via IV/IO over 10 minutes. Do not administer IVP as this will cause hypotension. Signs of postpartum hemorrhagic shock (base hospital order only) Administer TXA 1 gm in 50 - 100 ml of NS via IV/IO over 10 minutes. Do not administer IVP as this will cause hypotension. Reference #s 7010, 7020, 14090, 14210, 14230, MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 13 of 14 APPENDIX I Medications for self-administration or with deployment of the ChemPack. Medications listed below may be used only for the purposes referenced by the associated ICEMA Treatment Protocol. Any other use, route or dose other than those listed, must be ordered in consultation with the Base Hospital physician. Atropine - Pediatric (BLS, AEMT-Auto-injector only with training, ALS) Known nerve agent/organophosphate poisoning with deployment of the ChemPack using: Two (2) or more mild symptoms: Administer the weight-based dose listed below as soon as an exposure is known or strongly suspected. If severe symptoms develop after the first dose, two (2) additional doses should be repeated in rapid succession 10 minutes after the first dose; do not administer more than three (3) doses. If profound anticholinergic effects occur in the absence of excessive bronchial secretions, further doses of atropine should be withheld. One (1) or more severe symptoms: Immediately administer (3) three weight-based doses listed below 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, as provided by manufacturer in the AtroPen product labeling, to guide therapy: 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. Reference #s 11010, 13010, 13040 Diazepam (Valium) - Adult (ALS) For seizures associated with nerve agent/organophosphate exposure ONLY with the deployment of the ChemPack: Diazepam 10 mg (5 mg/ml) auto-injector IM (if IV is unavailable), or Diazepam 2.5 mg IV Reference # 13040 MEDICATION - STANDARD ORDERS Reference No. 11010 Effective Date: 05/01/24 Supersedes: 11/10/23 Page 14 of 14 Diazepam (Valium) - Pediatric (ALS) For seizures associated with nerve agent/organophosphate exposure ONLY with the deployment of the ChemPack: Diazepam 0.05 mg/kg IV Reference # 13040 Nerve Agent Antidote Kit (NAAK)/Mark I or DuoDote (containing Atropine/Pralidoxime Chloride for self-administration or with deployment of the ChemPack) - Adult Nerve agent exposure with associated symptoms: One (1) NAAK auto-injector IM into outer thigh. May repeat up to two (2) times every 10 to 15 minutes if symptoms persist. Reference #s 7010, 7020, 13010, 13040