Fy18 Smog

U.S.
ARMY MEDEVAC
CRITICAL CARE FLIGHT PARAMEDIC
STANDARD MEDICAL OPERATING GUIDELINES
“My duties as an aviation medical aidman are: first to be totally

dedicated to the preservation of life and limb of my fellow Soldier;”
FY18 Version
Published
October 19, 2017
DISTRIBUTION RESTRICTION:
Distribution authorized to U.S. Government Agencies and their Contractors; approved on 19 January 2016. Reproduction of this material is
limited to U.S. Government Agencies and their Contractors.
Other requests for this document shall be referred to: MEDEVAC Proponency, Fort Rucker, AL 36362, (334) 255‐1166 (DSN 558)
FOUO//UNCLASSIFIED//
Summary of Changes
 Added Page numbers
 P. 1, 11, 12- Updated logo and name to reflect change from the formerly titled United
States Army School of Aviation Medicine (USASAM) to the newly titled School of Army
Aviation Medicine (SAAM)
 P. 1- Added Date and version # to SMOG
 P. 2- Added Summery of Changes
 P. 7- Updated AKO link for accessing SMOG
 P. 28- Aligned Fentanyl Dose with Drug Card
 P. 29- Aligned Fentanyl Dose with Drug Card
 P. 46- Clarified Lidocaine dosage for IO flush
 P. 47- Adjusted Norepinephrine doses to align with drug cards
- Added examples of alternative vasopressors
 P. 48- Replaced Dopamine with Epinephrine for alternative vasopressor
 P. 52- Added IV Acetaminophen dose
 P. 53- Corrected spelling error
 P. 58- Adjusted Ketamine Dose
 P. 66- Removed Pre-treatment Atropine (no longer recommended)
- Adjusted Vecuronium dose to align with drug card
- Aligned Rocuronium dosing schedule with drug card
- Adjusted “Continued Sedation” Ketamine dose
 P. 68- Replaced D12.5 (Dextrose 12.5%) with D10 (Dextrose 10%) and adjusted dosing
 P. 69- Aligned Furosemide dose with drug card
- Adjusted “Solu-Medrol” to “Methylprednisolone”
 P. 70- Corrected spelling error
 P. 71- Aligned Vecuronium dose with drug card
- Removed Lidocaine as a pre-treatment medication. Alternative medications have
shown higher efficacy and are listed.
- Added Ketamine as a sedative agent of choice to “Paralysis/Sedation” section
- Added Rocuronium as an alternative RSI paralytic in “Paralysis/Sedation” section
 P. 82- Administrative corrections
 P. 85- Added Onadsetron dose
- Replaced Calcium Gluconate with Calcium Chloride
 P. 86- Added Lidocaine dose if Amiodorone unavailable
 P. 90- Adjusted Glucagon and Ondansetron doses
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 P. 91- Added Lidocaine dose if Amiodorone unavailable
- Replaced Calcium Gluconate with Calcium Chloride
- Added Epinephrine infusion dosage to Pearls
 P. 100- Adjusted weight for Epi-Pen Jr. usage
 P. 101- Adjusted Dexamethasone dosage
 P. 107- Adjusted Activated Charcoal dosing
- Adjusted Glucagon dose for Beta Blocker OD
- Adjusted Atropine dosing schedule for organophosphate exposure
- Adjusted Glucagon dose for Beta Blocker OD and AMS
- Adjusted Atropine dosing schedule for organophosphate exposure
 P. 110- Adjusted Glucagon dose
 P. 117- Adjusted Norepinephrine doses to align with drug cards
 P. 119- Adjusted Promethazine dose
 P. 120- Adjusted Thiamine and Glucagon doses
 P. 150-201
- All drug cards have been adjusted to align with the dosages and indications
within the protocols, refined to remove redundancies and/or conflicting
information, and revised for ease of use.
 P. 202- **NEW**Added new Quick reference pocket drug card. Allows for cargo pocket
size quick reference card while on duty
 P. 203-**NEW** Added Quick reference Drug Dilution chart
 P. 209- Added ISR website address to access DA 4700 Patient Care Report (PCR)
 P. 212-213 Adjusted standing order sheet to be fillable
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Table of Contents
Standard Medical Operating Guidelines (SMOG)
INTRODUCTION
REFERENCES and GUIDELINES
STANDING ORDERS – Air Ambulance, Emergency Medicine Tasks
I. PURPOSE
II. SCOPE OF PRACTICE
III. USAGE INTENT
IV. QUALITY ASSURANCE and QUALITY CONTROL Procedures
V. UPDATE and APPROVAL PROCESS
VI. POINT OF INJURY CARE, TCCC Evacuation Phase Guideline
TREATMENT GUIDELINES AND PROCEDURES
I. THE FLIGHT MEDIC OATH

II. MEDEVAC CLINICAL GUIDELINES and PROCEDURES
III. BLOOD / BLOOD COMPONENT THERAPY
IV. SEXUAL ASSAULT
V. TREATMENT OF MINORS
VI. PATIENT REFUSAL
VII. MEDICATION, DRUG CARDS
VIII. USEFUL CALCULATIONS
IX. COMMON LABORATORY VALUES
X. DOCUMENTATION AND FORMS
a. DD 1380, June 2014 Tactical Combat Casualty Care Card (recommended for POI)
b. DA Form 4700 Overlay (JTS TACEVAC AAR & PCR) CENTCOM use only recommended
c. Standard Order Set for Critical Care Transfers (2016)
d. ECC Guideline: Burn Flow Sheet
e. GTA 08-01-004 May 1997 (MEDEVAC Request Form)
f. Emergency Medication Dosage Table
g. Quick Reference Cargo Pocket Drug Card
h. Blank Page for SOP / Guideline Updates and Changes at Local Level
XI. MEDICAL DIRECTOR / UNIT COMMANDER REVIEW AND APPROVAL PAGE
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INTRODUCTION
This current set of medical guidelines has gone through some significant improvements since
the original release in 2014. They were developed through a collaboration of Emergency
Medicine professionals, experienced Flight Medics, Aeromedical Physician Assistants, Critical
Care Nurses, and Flight Surgeons. Our shared goal is to ensure enroute care is excellent and
standard across all prehospital units. It is our vision that all of these enhancements and
improvements will advance enroute care across the services and Department of Defense.
These medical guidelines are intended to guide Critical Care Flight Paramedics (CCFP) and
prehospital professionals in the response and management of emergency situations and the
care and treatment of patients in a garrison and theater of war environment. Unit medical
providers are not expected to employ these guidelines blindly. In fact, unit medical providers
are expected to manipulate and adjust these guidelines to their unit’s mission and medical air
crew training / experience. Medical directors or designated supervising physicians should
endorse these guidelines as a baseline, appropriately adjust components as needed, and
responsibly manage individual unit medical missions within the scope of practice of their
Critical Care Flight Paramedics, Enroute Critical Care Nurses, and advanced practice
aeromedical providers.
The medication section of this manual is provided for information purposes only. CCFPs may
administer medications only as listed in the guidelines unless their medical director (supervising
physician) orders a deviation. Other medications can be added so long as they are approved by
the unit supervising physician and/or medical director.
This book also serves as a reference for physicians providing medical direction and clinical
oversight to the CCFP. Treatment direction, which is more appropriate to the patient’s
condition than the guideline, should be provided by the physician as long as the CCFP scope of
practice is not exceeded.
Any medical guideline that is out of date or has been found to cause further harm will be
updated or deleted immediately. The Medical Evacuation Proponency Division (MEPD), unless
otherwise directed, will serve as the managing editor of the SMOG, responsible for content
updates, manage the formal review process, and identify review committee members for the
annual review.
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All names have been removed from this documentation for security purposes.
REFERENCES and GUIDELINES
1. FM 4-02.2, 12 August 2014

2. ATP 4-25.13, 15 February 2013
3. TC 3-04.93, 31 August 2009
4. TC 3-04.33, 10 May 2013
5. TC 3-04.21, 4 November 2013
6. TC 3-04.11, 19 November 2009
7. AR 40-8, 16 May 2007
8. STP 8-68W13-SM-TG, 3 May 2013
9. TC 8-800, 15 September 2014
10. Hammesfahr, J.F. Rick. Ranger Medic Handbook. Las Vegas: Cielo Azul Publications, 2012
11. Hammesfahr, J.F. Rick. 160th SOAR (A) Night Stalker Medical Handbook. Las Vegas: Cielo Azul
Publications, 2010
12. Faudree, Kyle. Flight Paramedic Certification, A Comprehensive Study Guide, 2nd Ed. 2011
13. CENTCOM Enroute Critical Care Nurse Guidelines. Version 1.4, May 2012
14. Mosby, Inc. Prehospital Trauma Life Support. 7th Edition. Akron: Michael Ledbetter, 2011
15. American Heart Association. Advanced Cardiovascular Life Support: Provider Manual. USA. 2011
16. American Heart Association. Pediatric Advanced Life Support: Provider Manual. USA. 2011
17. American College of Surgeons. ATLS: Advanced Trauma Life Support for Doctors. 9th Edition, Chicago:
American College of Surgeons. 2012
18. National EMS Scope of Practice Model. February 2007
19. National Emergency Medical Services Education Standards. January 2009
20. Campbell, John. International Trauma Life Support. Saddle River: Pearson Education. 2012
21. American Academy of Pediatrics. Pediatric Education for Prehospital Professionals (PEPP). Sudbury:
Jones and Bartlett Publishers. 2006
22. Hamilton, Richard. Tarascon Pocket Pharmacopoeia. 2012 Classic Shirt Pocket Edition. Philadelphia:
Jones and Bartlett Learning. 2016
23. Marx, John A. Rosen’s Emergency Medicine. Eighth Edition. Elsevier Saunders. 2014
24. Tintinalli, Judith E. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Eight Edition.
McGraw-Hill Education. 2016
25. AR 40-5, 25 May 2007
26. AR 40-3, 23 April 2013
27. AR 40-61, 28 January 2005
28. FM 4-02.1, 8 December 2009
29. AR 190-51, 30 September 1993
30. AR 710-2, 28 March 2008
31. DA Pam 710-2-1, 31 December 1997
32. DOD 4145.19–R–1, 15 September 1979
33. JP 4-02, 26 July 2012
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Standard Medical Operating Guidelines can be found at the following website:
https://www.us.army.mil/suite/files/42540174
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STANDING ORDERS - Air Ambulance, Emergency Medicine Tasks
PURPOSE
The intended purpose of these guidelines is to serve as a baseline for the Aviation Medical
Company’s Aviation Medicine SOP (Standing Orders and Aeromedical Treatment Guidelines).
Practices in Aviation Medicine undergo constant scrutiny and change. As such, this guide should
not be considered an all-inclusive and always up-to-date source of the newest and most relevant
policies, procedures, and practices in Aviation Medicine. It will require continued monitoring for
relevant clinical and operational updates needed to reflect current aviation and clinical practice
standards.
Primarily, this guide should serve as a resource for tactical and non-tactical prehospital, inter-
facility, and post-surgical en-route medical care on an Army aeromedical platform. Initial
patient evacuation and prehospital trauma guidelines are written in a manner to support the
principles of Tactical Combat Casualty Care (TCCC). This principle assumes that a combat
trauma patient will respond to care most effectively when the order of care addresses
circulation (stopping and preventing blood loss) prior to addressing the patient’s airway and
breathing. When these guidelines are adapted for use within US Army civilian missions (non-
combat), unit medical directors should consider the necessity of writing and appending these
guidelines, order of care, and standard operating procedures to address the differences in initial
interventions of the civilian trauma patient verses the battlefield trauma patient.
SCOPE OF PRACTICE
This guide is intended for use by Aviation Medical Personnel to include: Critical Care Flight
Paramedics, Flight Surgeons, Aeromedical Physician Assistants (APAs), Aeromedical Nurse
Practitioners (ANPs), and En Route Critical Care Nurses performing MEDEVAC on an Army
Aviation platform. Preferably, only medical personnel trained in and holding certifications in the
National Registry of Paramedics (NRP), Emergency Medicine, or Critical Care should be eligible
to use all treatment guidelines within this book. However, local training programs may be
adopted that may enable individually trained physicians, Physician Assistants, and Non-NRP
Flight Medics a knowledge base sufficient to satisfy use of these treatment guidelines in an
austere/combat environment. Specific certifications of importance might include: TCMC,
ATLS®, ACLS, PALS, PHTLS, ITLS, and PEPP, among others. Any individual who is not fully trained,
has not demonstrated competency in each of these guidelines, or has not been approved
(credentialed) to use these guidelines by the local Aviation Medicine Medical Director should
not be authorized to perform the respective guideline(s) without direct (on-hand) oversight. All
personnel using these guidelines should adhere to the steps and standards as outlined in each of
the standard medical operating guidelines (SMOG) and procedures. Moreover, all unit medical
personnel providing care aboard US Army Air Ambulances (including Unit Flight Surgeons and
APAs) will, at a minimum, adhere to this standard of care unless superseded by theater and/or
regional clinical practice guidelines under the authorization of an appropriate local command
medical officer/surgeon.
Following the concept set forth in the National Emergency Medical Services (EMS) Scope of
Practice Model, an individual may only perform a skill or role for which that person is:
• educated (has been trained to do the skill or role), AND
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• certified (has demonstrated competence in the skill or role), AND
• licensed [has legal authority issued by the State (Army EMS is the 51st State) to
perform the skill or role], AND
• credentialed (has been authorized by medical director to perform the skill or role).
Depending on the military environment (deployed or austere location), licensing and

credentialing may be satisfied through a local training and standardization policy that
demonstrates an individual medical provider’s capabilities and knowledge of the treatment
guidelines within this handbook. Approval of each individual provider’s usage of these
treatment guidelines must be provided by the unit medical director. This approval should be
documented and maintained in the Soldiers training record. It must be remembered that any
use of these guidelines is prohibited outside of the individual’s military employment.
Furthermore, any civilian based medical care provided by aviation medicine personnel must
satisfy the National EMS Scope of Practice Model noted previously. It must also be realized that
any usage of these guidelines within the civilian environment may be limited to support through
a legitimate local EMS credentialing provider. This would normally be the local Medical
Treatment Facility Emergency Medical Systems credentialing authority. The unit medical
director may not satisfy this requirement in civilian based medicine due to state legal policies
and standards.
USAGE INTENT
This guide contains the specific Treatment Guidelines, Procedures, and Medications that will be
used within Army Aeromedical Evacuation.
The Critical Care Flight Paramedic Standard Medical Operating Guideline will be reviewed at a
minimum semi-annually or upon change of command or medical director. A single copy of the
Review and Approval Page or a substitute document will be distributed to aforementioned
individuals for review and approval signatures.
It is the responsibility of the Unit Commander, the Medical Director, the Training NCO, and the
Standards NCO to ensure that all Flight Paramedics remain current in all required certifications
needed to perform their duties as Flight Paramedics and/or those needed to perform the skills
of a Nationally Registered Paramedic. This should include, at a minimum, certifications in NRP,
ACLS, and BLS. However, it is highly suggested that paramedics maintain certifications in
PALS/PEPP and PHTLS/ITLS. Copies or originals of all current certifications or a memo of training
status/credentials will be maintained in the individual Soldier’s training record.
A medical practitioner’s clinical competence is at least equal in importance to the maintenance

of formal certifications. Competence is the ability to actually perform required interventions
and administer appropriate therapies. Further, a competent practitioner has the knowledge
base and critical-thinking skill required to determine when to perform an intervention and when
it is best NOT to do so. As such, Commanders and Unit Medical Directors/ Flight Surgeons
should ensure that clinical skill competency is maintained, demonstrated, and remediated
(when required) to ensure the maintenance of mandated certifications of medical aircrew
members under their direction. It is recommended that all medical personnel conducting
aeromedical evacuation perform simulated critical care and POI training cases on a monthly
basis in order to develop competency and retain critical care medical proficiency.
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The Flight Paramedic Standard Medical Operating Guideline is not intended to be a
comprehensive patient care manual. Rather, it specifies standard clinical treatment guidelines
for discrete emergency conditions which should be used as a baseline practice standard for
Flight Paramedics and other attached medical aircrew members providing en route emergency
care on a rotary wing platform in the prehospital environment while conducting intratheater,
CONUS, or other tactical/operational contingency.
QUALITY MANAGEMENT PROGRAM Procedures
Physician Medical Direction

Prehospital emergency care constitutes the practice of medicine, either directly by a qualified
physician or indirectly through delegation-of-authority under the physician’s medical direction.
This practice is distinctly different from hospital-based medical, nursing, and paramedical
practice in which practitioners conduct full-spectrum care within their respective scope-of-
practice, executing physician’s orders, or through autonomous practice in the case of Physician
Assistants (PA), Nurse Practitioners (NP), and Clinical Nurse Specialists (CNS).
Medical oversight of Flight Paramedics and other medical aircrew with regard to procedures,
guidelines, medications, documentation (Patient Care Reports), testing, credentials, etc., is the
primary responsibility of the qualified (as defined by AR 40-3) Battalion Flight Surgeon (FS), with
the assistance of the Aeromedical Physician Assistant (APA) and designated company Medical
Training NCO. The Brigade Surgeon, through delegation from the Brigade Commander, has
responsibility for overall medical oversight. In the event that the FS is not qualified to act as an
EMS director or believes themselves underprepared to direct out-of-hospital EMS care
internally, then local implementation and oversight of these policies shall be tasked to a non-
organic board-certified emergency physician. If an emergency physician is not available,
Commanders are advised to nominate a primary care physician or surgeon possessing expertise
in the conduct of prehospital emergency care and in the medical direction of pre-hospital
Emergency Medical Service personnel practicing under their authority. This standard for medical
direction is in common use by most state EMS agencies. In addition, all medical aircrew should
maintain currency on recent literature and equipment pertaining to pre-hospital aeromedical
evacuation and enroute care.
Mid-Level Clinical Oversight

Although they cannot act as a medical director, the role of PAs, NPs and CNSs in the practice of
prehospital emergency care is emerging and holds great promise as a means of extending the
medical director’s capacity to ensure the best quality of care for patients or casualties. While
Federal Regulations and most State Laws pertaining to EMS require physician medical direction
for the prehospital conduct of advanced life support (ALS) scope-of-practice skills, many high-
performance domestic EMS systems have implemented mid-level “clinical director” programs,
employing PAs and advanced practice nurses with emergency or critical care expertise, to
provide initial quality management program (QMP) review, assist with on-line decision support
for pre-hospital practitioners, oversee readiness training and continuing education, and to
augment the medical aircrew when needed on ground and air critical care transport platforms.
PAs, with the approval of the CAB Surgeon, can provide the necessary clinical oversight in the
absence of a unit level Flight Surgeon in order to ensure the CCFPs are trained and proficient for
their deployed mission.
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Quality Assurance
Published Standard Medical Operating Guidelines (SMOG) are written patient care guidance in
algorithm format with discrete basic life support (BLS) and advanced life support (ALS) scopes of
practice, respectively, based on each patient / casualty’s specific medical condition. Once
endorsed by local commanders and unit medical directors, all medical aircrew are expected to
use these guidelines in the care of patients they transport to the next higher level of care.
Periodically, medical aircrew should undergo testing on information and procedures contained
within these guidelines. After each patient that has been aero-medically evacuated to a Role 2
or Role 3 medical treatment facility, each medical aircrew member is responsible for
documenting the care rendered during transport via the appropriate unit, theater, or DA / DD
approved / mandated electronic or written patient care documentation form
Direct Supervision
In addition to the written guidelines, designated unit medical directors are responsible for the
direct supervision of medical aircrew members participating in en route care within the unit,
his/her performance in situations in which the patient’s medical condition(s) does not meet
standard-of-care as defined by these guidelines, or who experience adverse events en route,
merit retrospective review and determination of root cause and corrective action, or
endorsement of their decision, as appropriate.
Quality Management/Process Improvement

After each Aeromedical Evacuation mission, for each patient receiving enroute care, the medical
aircrew team conducts an informal After Action Review (AAR). The initial formal control
measure is the requirement for the FS or APA to review and co-sign each patient care report
(PCR) (e.g., DD 1380, run sheet, Enroute Critical Care Transfer document, DD4700) before it is
submitted as a part of the patient record. After both the lead medical aircrew member and unit
medical director have signed the PCR, a copy will be kept and others will be distributed in
accordance with current Army policy guidelines, local unit policy, and by the medical training
NCO and/or medical director.
Additional quality control measures are encouraged and can foster a rich and open learning
environment between local emergency medicine/trauma facilities and members of the air
ambulance company. One such option might include a monthly aeromedical evacuation
conference chaired by the local MTF Trauma Surgeon in which medical aircrew member’s
present cases to a forum of providers and other medics with emphasis on best practices and
lessons learned.
UPDATE and APPROVAL PROCESS
1. The Critical Care Flight Paramedic Standard Medical Operating Guidelines will be updated
generally on an annual basis, or sooner in response to clinical or operational needs.
2. Based upon the above timeframes, the Dean, School of Army Aviation Medicine (SAAM) or
Director, Critical Care Flight Paramedic (CCFP) Program will initiate an update by sending the
SMOG for inputs from senior aeromedical clinicians (flight surgeons, aeromedical physician
assistants, and aeromedical nurse practitioners), emergency medicine physicians, EMS trained
physicians, and critical care flight paramedic end-users.
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3. Suspense for submitting updates back to an identified editor will be a minimum of 30
calendar days. Extensions may be granted on a case by case basis.
4. The editor will consolidate all inputs and discuss with a designated physician (as identified by
the Dean, SAAM).
5. After all accepted/applicable inputs have been updated; the SMOG will receive final approval
from Dean, SAAM and/or Aeromedical Consultant to TSG.
6. Once final approval is given, the SMOG will undergo OPSEC/PAO review prior to posting on
the MEDEVAC Enterprise portal or JTS website.
POINT OF INJURY CARE, TCCC Evacuation Phase Guideline
INDICATIONS: In combat, the period of care provided at the Point of Injury (POI) is the most
critical period throughout a casualty’s movement across the medical system. Timely,
appropriate, and effective care at the POI will afford a casualty the greatest chance of surviving
preventable causes of death regardless of necessary follow-on surgical interventions and
specialty medical treatment.
GUIDELINE (see TACTICAL EVACUATION, 1st flow chart within Treatment Guidelines and
Procedures). This guideline serves as the starting point for initiation of care for all patients
evacuated from the POI pick-up sight. All subsequent procedural steps of care will be
determined by navigation through continued guideline flow charts. All care will be provided in
accordance with these flow charts.
POLICY NOTE: In the event these guidelines are adapted for use within US Army civilian
missions (non-combat), it is recommended that unit medical directors consider the necessity of
writing and appending these guidelines, order of care, and standard operating procedures to
address the differences in initial interventions of the civilian trauma patient verses the
battlefield trauma patient.
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Table of Contents
a. MOVEMENT POLICY
i. UNIVERSAL GUIDELINES
1. Tactical Evacuation
2. Pre-Transport Checklist (POI and Role 1 Pick-ups, Tail-to-Tail Transfers)
3. Pre-Flight Checklist for Critical Care and Post-surgical Transfers
• Vital Functions: Average Vital Functions
• Glasgow Coma Scale
• Musculoskeletal Injury and Peripheral Nerve Assessment
• Muscle Strength Grading
• Pediatric Advanced Life Support Equipment
• Pediatric (LENGTH BASED RESUSCITATION TAPE) Weight Conversion
• Pediatric (LENGTH BASED RESUSCITATION TAPE ) Fluid Bolus
• Pediatric (LENGTH BASED RESUSCITATION TAPE) Defibrillation,
Energy Selection
4. Intravenous / Intraosseous Guideline
5. Pain Management
 Pediatric Pain Management
6. Universal Patient Care
ii. PROCEDURES
1. Patient Safety
2. Post-Operative and Intra-facility Transfer
3. Altitude Physiology and Patient Transfer
b. TRAUMA
i. MEDICINE GUIDELINES
1. Hemorrhage
2. Hemorrhage Control
3. Tourniquet Application
 Junctional Tourniquet Application
4. Intravenous Vascular Access
5. Intraosseous Vascular Access
6. Hypotension / Shock
 Pediatric Hypotension / Shock
7. Blood Product Therapy / Transfusion
 Transfusion Related Reactions
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8. Multiple Trauma
 Pediatric Multiple Trauma
9. Chest Trauma
10. Extremity Trauma
11. Head Trauma / Injury
12. Eye Trauma / Injury
13. Traumatic Arrest
14. Burns
15. Burn Fluid Resuscitation
16. Spinal Immobilization
c. AIRWAY
1. Adult Airway
2. Pediatric Airway
3. Pearls of Wisdom
4. Difficult / Failed Airway
5. Newborn Care and Distress
6. Respiratory Distress
7. Pediatric Respiratory Distress
8. Rapid Sequence Intubation
9. Airway Confirmation
10. Nasopharyngeal Airway
11. Blind Insertion Airway Device
12. Cricothyroidotomy
13. Needle Cricothyroidotomy
14. Tube thoracostomy placement
15. Needle Thoracostomy
16. Ventilator Management
 Ventilator Capabilities, Terms, Transfer Procedure
d. CARDIAC
1. Bradycardia with Pulse
2. Cardiac Arrest
3. Chest Pain
4. Tachycardia with Pulse
5. Pediatric ALS Indicators and BLS
6. Pediatric Bradycardia with Pulse and poor perfusion
7. Pediatric Cardiac Arrest
8. Pediatric Tachycardia with pulse and adequate perfusion
9. Pediatric Tachycardia with Pulse and poor perfusion
10. Post-Cardiac Arrest Care
11. Withhold Resuscitation
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ii. PROCEDURES, CARDIAC
1. Cardiac Defibrillation
2. External Cardiac Pacing
3. Synchronized Cardioversion
e. ENVIRONMENTAL EMERGENCIES
1. Allergic Reaction
 Pediatric Allergic Reaction
2. Altitude Illness
3. Bites / Envenomation
4. Electrical Injury
5. Hyperthermia
6. Hypothermia
7. Submersion Injury
8. Toxic Ingestions
 Pediatric Toxic Ingestions
f. URGENT CARE
1. Altered Mental Status
 Pediatric Altered Mental Status
2. Suspected Stroke / Transient Ischemic Attack (TIA)
3. Hypertension
4. Seizure
 Pediatric Seizure
5. Syncope
6. Combative Patient
7. Fever / Infection
8. Abdominal Pain
9. Vomiting and Diarrhea
 Pediatric Vomiting and Diarrhea
10. Obstetric Emergency
11. Childbirth
12. Back and Neck Pain
13. Epistaxis
14. Dental Problems
ii. PROCEDURES, URGENT CARE
1. 12-Lead Electrocardiogram
2. Blood Glucose Analysis
3. Urinary Catheter Placement
4. Nasogastric/Orogastric Tube
5. Spinal Evaluation and Immobilization
g. Military Working Dog Guidelines
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i. Clinical Guidelines
ii. Heat Injuries
iii. Cardio Pulmonary Resuscitation
iv. Analgesia and Sedation
v. Gastric Dilation-Volvulus
vi. Emergency Airway Management
vii. Shock Fluid Therapy
III. BLOOD / BLOOD COMPONENT THERAPY
IV. SEXUAL ASSAULT
VI. PATIENT REFUSAL
a. General Use
i. Use as clinically indicated per guideline.
1. Oxygen
2. 0.9% Sodium Chloride (Normal Saline)
3. Ringers, Lactate
4. 3% Hypertonic Saline
5. Dextrose 5% in water, D5W
6. Blood Product (Guideline and Procedures)
b. Medications:
i. If carried, these medications are available for use, within the limitations of these
guidelines and drug cards. These medications may be used during transfer of
critical care patients when provided written orders and guidance from the
transferring physician. These medications are available for use on any patient,
within the limitations of these guidelines, as clinically indicated, and to address
acute life threatening emergencies not accounted for on the transferring
physician’s written orders. The medications listed below do not constitute the
entire available medication list of the CCFP. Medical Directors can add
additional medications as required for mission accomplishment.
1. Acetaminophen
2. Acetazolamide
3. Acetylsalicylic Acid
4. Activated Charcoal
5. Adenosine
6. Albuterol
7. Amiodarone
8. Atropine
9. Calcium Chloride
10. Calcium Gluconate
11. Dexamethasone
12. Dextrose
13. Diazepam
14. Diphenhydramine
15. Dobutamine
16. Dopamine
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17. Epinephrine 1:1,000
18. Epinephrine 1:10,000
19. Etomidate
20. Fentanyl
21. Furosemide
22. Glucagon
23. Heparin
24. Hetastarch
25. Hydromorphone
26. Hydroxocobalamin
27. Ketamine
28. Ketorolac
29. Labetalol
30. Lidocaine
31. Lorazepam
32. Magnesium Sulfate
33. Mannitol
34. Methylprednisolone
35. Midazolam
36. Morphine
37. Naloxone
38. Nifedipine
39. Nitroglycerin
40. Norepinephrine
41. Ondansetron
42. Phenylephrine
43. Pralidoxime Chloride
44. Promethazine
45. Propofol
46. Rocuronium
47. Sodium Bicarbonate
48. Succinylcholine
49. Thiamine
50. Tranexamic Acid
51. Vecuronium
c. Y-site compatibility Chart
X. DOCUMENTATION / FORMS
XI. MEDICAL DIRECTOR / UNIT COMMANDER REVIEW AND APPROVAL PAGE
17
18
TACTICAL EVACUATION
Ground “Pick-Up” Phase “In-Flight” Phase
Attempt to gain info prior to landing: Triage Casualties as required:

• Number of Patients • Assess Responsiveness
• Time & MOI • Conduct Rapid Assessment
• Enemy presence near o Immediately address ANY IMMEDIATE LIFE
helicopter landing zone etc. THREATS WITH APPROPRIATE LIFE
SAVING INTERVENTION(S) (LSI) *See Pearls
Wheels Down
Reassess: If unstable move to:
HEMORRHAGE CONTROL
• HEMORRHAGE CONTROL
Ensure 360 degree scene security YES • Check / Add Tourniquet
Heavy Active
Continuously monitor for threats • Pack and Dress Wound
Bleeding? • EXTREMITY TRAUMA
Identify yourself to the 1st Responder • Pressure Dressing
• Hemostatic Dressing
NO • MULTIPLE TRAUMA
Collect Medical Info from 1st responder: AIRWAY / (Vent Management)

Respiratory Reposition Airway
• Time & MOI YES Reassess: If unstable move to:
Distress? • Nasopharyngeal Airway
• Treatment attempted / Response • Next Level Airway intervention
<8
• Medications: Doses, Routes, Times • RSI (Intubation / King LT) per procedure
>30
• 1st and Last Vital Signs • Cricothyroidotomy
• TCCC card or Available NO CHEST TRAUMA GUIDELINE
Documentation
Chest Injury? YES • Vented Occlusive Dressing Reassess: If unstable move to:
• Name / Unit (Any Available POC INFO)
Impacts • Positive Press Ventilations • Next Level intervention per
Breathing • Needle Thoracostomy procedure
• Chest Tube
Triage & Load Casualties NO
• Quick visual assessment
• Treat ALL untreated or unstable Hypotensive? YES
Hypotension / Shock Guideline
KNOWN preventable causes of S / S of Shock Loss of Circulation at
death as able (*See Pearls) any time:
• PRE-TRANSPORT CHECKLIST NO
Start CPR - 30:2
• Load and Secure casualties per SOP Altered Mental Move to:
Status? YES
(GCS <8 or Head Injury Guideline
TRAUMA ARREST
Wheels Up Unequal / Dilated GUIDELINE
Pupils)
Universal Patient Care Guideline
As Needed: NO
Attempt /
• O2 PAIN Appropriate
Document Contact Continuous
• Monitor / Defibrillator MANAGEMENT URGENT CARE
Patient Care Receiving Monitoring
• IV / IO access (IV Guideline) GUIDELINE prn GUIDELINE prn
Facility
Pearls:
• *If the tactical situation permits, all known preventable causes of death should be
addressed prior to casualty transfer to an air ambulance (e.g., accessible sources of
major hemorrhage, tension pneumothorax, and airway obstruction).
• Goal < 5 minutes time on scene prior to wheels up.
19
PRE-TRANSPORT CHECKLIST
Tactical Situation or Patient Condition
YES Immediate Transport
Requiring Immediate Transport?
NO
MITES CHECK
MEDICATIONS:
 Assure Appropriate Medications Given
 Necessary Medications Available For Transport?
 Note Meds Given (Name / Dosage / Time)
INVASIVE Procedures / IV Access:
 All Patients With At Least One Working Peripheral IV and/or IO Line
 Trauma / Emergent: At Least Two Working Peripheral IV / IO Line
 NG / OG On All Intubated Patients
 Chest Tube / Foley Catheter / etc., As Needed
TUBES & TOURNIQUETS:
 Note Size / Depth of ETT if Present
 Ensure Tubes Appropriately Secured (e.g., ETT, Chest, Foley, Wound)
Universal Patient Care
 Evaluate Tubes for Displacement, Kinking, Clogging
Guideline
 Ensure Heimlich Value or Working Suction To Chest Tube
 Note Location of Tourniquets and Time Placed
 Evaluate for Seepage From Tourniquet Areas and Augment PRN
EVERY VITAL SIGN:
 Document Full Set of Vitals (Including SPO2 and ETCO2, if applicable) and
Monitor En Route En Route Care per
 Recheck As Appropriate Appropriate
SECURE For Transport / Spinal Immobilization: Guideline
 Patient Status Adequate for Transfer?
 Hypothermia Precautions? Tactical
 At Least Two Litter Straps in place? Evacuation Urgent Care
 Equipment Secured to SMEED and SMEED to Litter? Guideline Guideline
 Appropriate Spinal Precautions in Place? (TRAUMA)
PEARLS:
• Any patient with advanced airway and ventilator support should receive sedation and, if indicated, paralytic agent before
flight. These should be available in the aircraft for use by qualified personnel for use if patient becomes conscious,
agitated, combative, etc.
• Spinal immobilization should be ensured in all blunt trauma (e.g., MVA, fall, blast, combination trauma) where spinal
instability may be suspected. The medic should document if spinal injuries are cleared and who cleared them.
• A minimum of two IV / IO sites in patients with emergent or emerging conditions. At least one should be present in all
patients transported by MEDEVAC for any other causes. Rare exceptions may exist (e.g., minor musculoskeletal injury).
• All critical care patients should have continuous cardiac monitoring while in en route. This may also extend to non-
intubated urgent / priority patients under other circumstances (e.g., acute MI, atypical chest pain).
• Tactical situation and emergent care should take priority over all other procedures / monitoring. If unable to
perform checks and/or procedures during flight due to the Tactical / Environmental Conditions (e.g., enemy, weather)
then this must be documented completely in the Patient Care Report and briefed-back to the receiving medical facility.
Continue with monitoring and procedures as soon as situation allows.
20
PRE-FLIGHT CHECKLIST
(for Critical Care and Post-Surgical Transfers)
Once the decision is made to transfer a patient and an accepting physician has been obtained, the following steps will be taken
to prepare the patient for transport:
Initials Evaluation Steps
1. Sending location/physician: ___________________Accepting location/physician:__________________
Flight nurse called: name / time: _____________________
2. Anesthesia called: intubation if indicated. ETT secured/marked
3. Patient meets criteria for en route critical care transport: risk documented by sending physician
(POST-OPERATIVE and CC INTRAFACILITY TRANSFER, Pre-Transfer Patient Status Requirements)
Preparation Steps
Positioning and Proper Monitoring:
1. Patient moved to litter (collapsible handles), positioned, padded, strapped, equipment (with
necessary attachments) added and secured.
2. For head-injured patients, a pre-sedation neurologic examination will be performed. GCS and
neurological exam documented on the en route care form, suggest placing patient sitting at 30°-45⁰. (For
eye injured patients, fox shield in place. For burn patients, JTTS burn sheet initiated.)
3. Ventilator switched to PMI vent at least 20-30 min prior to flight and set with transfer settings ordered
by physician.
4. IV / IO access verified, patent, and secured.
5. Arterial line inserted and secured, if indicated. Transducer accessible.
6. Ventilator tubing checked to be free from obstruction, with ETCO 2 and secondary lines attached.
7. Orogastric or nasogastric tube is inserted (unless contraindicated), placement verified with chest x-ray,
and attached to low-intermittent suction.
8. Chest tubes to water seal/suction (place Heimlich valve for non-atrium chest drainage systems).
9. Wound vacuum disconnected and stowed.
10. Foley catheter secured, urine output measured and documented.
Equipment, Medication, Chart, and Personnel Preparation:
11. Medications needed for flight prepared and organized.
12. Flight equipment bag obtained and checked. Backup pulse oximeter readily available.
13. Complete chart photocopied (including x-ray cd), patient belongings bagged and tagged.
Transfer Document, or other theater / unit approved transfer document, has been initiated.
14. Earplugs and eye protection for patient and flight nurse.
15. If facility sends medical attendant, attendant must have relevant personal protective equipment. In a
combat environment this includes: Uniform, Kevlar, IBA, Weapon, ID Card, and equipment for transport.
Ventilator Management:
16. Blood gas (preferably ABG) obtained, 15 min after initial settings and ventilator changes. All efforts
will be made to have a documented blood gas within 30 minutes prior to flight time.
17. Adjust ventilator settings and check O 2 tank for length of flight. Resuscitator bag under patient’s
head with tubing connected to O 2 source, vent tubing free from obstruction.
Final Verification:
18. Transferring Physician, Flight Paramedic, ECCN (or Flight Provider) verbally agrees to flight care plan.
19. Critical Care Transfer Orders reviewed and signed by transferring physician.
(STANDARD ORDER SET for CRITICAL CARE TRANSFERS)
20. Enroute CC Transfer Document with completed preflight and enroute care data handed over to and
confirmed by receiving provider / facility. (CENTCOM Transfer Document)
21
Vital Functions
Assessment Reference Charts
AVERAGE VITAL FUNCTIONS
Heart
Rate/Min Awake Sleeping Blood
Age Rate Mean Rate Pressure Average Lower Limit
Newborn to 3mo 85-205 140 80-160 1-10y 90+(years old x2)mmHg 70+(years old x2)mmHg
3mo-2y 100-190 130 75-160 > 10y 90mmHg
2-10y 60-140 80 60-90 MAP 55+(years old x1.5)mmHg
>10y 60-100 75 50-90
Respiratory NIBP Systolic Average Urinary Output
Rate/Min Age Rate Age Weight (Lower Limit) (mL/kg/hr)
Infant 30-60 0-12months 0-10kg > 60 2
Toddler 24-40 1-2years 10-14kg >70 1.5
Preschool 22-34 3-5years 14-18kg >75 1
School 18-30 6-12years 18-36kg >80 1
Adolescent 12-16 >13years 36-70kg >90 0.5
Oxygen Normal Range: Normal Range:
Saturation Age Sea Level 5,000 Feet MLS
96-100% or >94% for
SpO 2 (Peripheral O 2 Sat) patient with Normal >92%
All Ages Hemoglobin level
StO 2 (Tissue O 2 Sat) >75-95% <75% = Poor Perfusion
EtCO 2 35-45 mmHg
22
Vital Functions
RESPONSE ADULT SCORE
Eye Opening GLASGOW COMA SCALE
Spontaneous 4
To Speech 3 Modified Pediatric
To Pain 2 Eye Opening Response Same as Adult
None 1 CHILD INFANT
Verbal Response Verbal Response Verbal Response
Oriented 5 Oriented Coos and Babbles
Confused Conversation 4 Confused Conversation Irritable, Cries
Inappropriate Words 3 Inappropriate Words Cries in Response to Pain
Incomprehensible Sounds 2 Incomprehensible Words / Sounds Moans in Response to Pain
None 1 None None
Best Motor Response Best Motor Response Best Motor Response
Obeys Commands 6 Obeys Commands Moves Spontaneously
Localizes Pain 5 Localizes Painful Stimulus Withdraws to Touch
Flexion Withdrawal to Pain 4 Flexion Withdrawal to Pain Withdraws from Painful Stimulus
Abnormal Flexion (Decorticate) 3 Abnormal Flexion (Decorticate) Abnormal Flexion (Decorticate)
Extension (Decerebrate) 2 Extension (Decerebrate) Extension (Decerebrate)
None (Flaccid) 1 None (Flaccid) None (Flaccid)
For Intubated Patient use Verbal “T” (Example: Eyes open to pain, Intubated, and Localizes would be E2,V1,M5, or GCS 8T)
23
Vital Functions
MUSCULOSKELETAL INJURY and PERIPHERAL NERVE ASSESSMENT
UPPER EXTREMITIES
NERVE MOTOR Testing SENSATION Testing INJURY to Consider
Ulnar Index and Little Finger Abduction Little Finger Elbow Injury
Thenar Contraction with
Median Distal Opposition Index Finger Wrist Fracture or Dislocation
Median, Anterior
Interoseous Index Tip Extension None Supracondylar Fracture of Humerus
Musculocutaneous Elbow Flexion Radial Forearm Anterior Shoulder Dislocation
Radial Thumb, Finger group Extension First Dorsal Web Space Distal Humeral Shaft, Anterior Shoulder Dislocation
Anterior Shoulder Dislocation, Proximal Humerus
Axillary Deltoid Lateral Shoulder Fracture
LOWER EXTREMITIES
Femoral Knee Extension Anterior Knee Pubic Rami Fractures
Obturator Hip Adduction Medial Thigh Obturator Ring Fractures
Posterior Tibial Toe Flexion Sole of Foot Knee Dislocation
Superficial Peroneal Ankle Eversion Lateral Dorsum of Foot Fibular Neck Fracture, Knee Dislocation
Dorsal 1st-2nd Web
Deep Peroneal Ankle / Toe Dorsiflexion Space Fibular Neck Fracture, Compartment Syndrome
Sciatic Nerve Plantar Flexion Foot Posterior Hip Dislocation
Superior Gluteal Hip Abduction Upper Buttocks Acetabular Fracture
Inferior Gluteal Hip Extension Lower Buttocks Acetabular Fracture
MUSCLE STRENGTH GRADING

SCORE EXAM RESULT
0 Total Paralysis
1 Palpable or Visible Contraction
2 Full Range of Motion Without Gravity
3 Full Range of Motion Against Gravity
4 Full Range of Motion, but Less than Normal Strength
5 Normal Strength
NT Not Testable
24
Vital Functions
PEDIATRIC ALS EQUIPMENT
(Always use a Broselow® Pediatric Emergency Tape if available)
8-10 yrs 24-
AGE and WEIGHT Premie 3kg 0-6 mos 3.5kg 6-12 Mos 7kg 1-3 yrs 10-12kg 4-7 yrs 16-18kg
30kg
Premie,
O2 MASK Newborn Pediatric Pediatric Pediatric Adult
Newborn
ORAL AIRWAY Infant Infant, Small Small Small Medium Medium, Large
BAG-MASK Infant Infant Pediatric Pediatric Pediatric Pediatric, Adult
Airway and 2 Straight or 2-3 Straight or
LARYNGOSCOPE 0 Straight 1 Straight 1 Straight 1 Straight
Breathing Curved Curved
2.5-3.0 3.0-3.5 3.5-4.0 4.0-4.5 5.0-5.5 5.5-6.5
ET TUBE
uncuffed uncuffed un / cuffed un / cuffed un / cuffed cuffed
STYLET 6 Fr 6 Fr 6 Fr 6 Fr 14 Fr 14 Fr
SUCTION 6-8 Fr 8 Fr 8-10 Fr 10 Fr 14 Fr 14 Fr
Premie, Newborn,
BP CUFF Infant, Child Child Child Child, Adult
Circulation Newborn Infant
IV CATHETER 22-24 ga 22 ga 22 ga 20-22 ga 20 ga 18-20 ga
OG/NG TUBE 8 Fr 10 Fr 12 Fr 12 Fr 12 Fr 14 Fr
CHEST TUBE 10-14 Fr 12-18 Fr 14-20 Fr 14-24 Fr 20-28 Fr 28-38 Fr
Supplemental URINARY 6 Fr or 5-8 Fr
Equipment 5 Fr feeding 8 Fr 10 Fr 10-12 Fr 12 Fr
CATHETER feeding
CERVICAL
Small Small Small Medium
COLLAR
25
Vital Functions
Assessment Reference Charts (Broselow® Pediatric Emergency Tape)
Pediatric Weight Conversion Fluid Bolus
Color Kg Pounds Color Give

Gray 3-5 kg 6-11 lbs Gray (3-5 kg) 80 ml
Pink 6-7 kg 13-15 lbs Pink (6-7 kg) 130 ml
Red 8-9 kg 17-20 lbs Red (8-9 kg) 170 ml
Purple 10-11 kg 22-25 lbs Purple (10-11 kg) 210ml
Yellow 12-14 kg 27-32 lbs Yellow (12-14kg) 260 ml
White 15-18 kg 34-41 lbs White (15-18 kg) 340 ml
Blue 19-23 kg 42-52 lbs Blue (19-23 kg) 420ml
Orange 24-29 kg 54-65 lbs Orange (24-29 kg) 500 ml
Green 30-36 kg 67-80 lbs Green (30-36 kg) 500 ml
40 kg 40 kg 90 lbs 40 kg 500 ml
45 kg 45 kg 101 lbs 45 kg 500ml
ZOLL® Defibrillation Energy Settings for PEDIATRIC Patients
Color First Second Maximum

Gray (3-5kg) 8J 15 J 30 J
Pink (6-7kg) 10 J 20 J 50 J
Red (8-9 kg) 15 J 30 J 75 J
Purple (10-11 kg) 20 J 30 J 100J
Yellow (12-14 kg) 20 J 50 j 120 J
White (15-18 kg) 30 J 50 J 150 J
Blue (19-23 kg) 30 J 75 J 150 J
Orange (24-29 kg) 50 J 100 J 200 J
Green (30-36 kg) 50 J 120 J 200 J
40 kg 75 J 150 J 200 J
45 kg 75 J 150 J 200 J
26
IV / IO PROTOCOL
Assess need for IV

Emergent or potentially emergent medical
or trauma condition
Peripheral IV x 2
Catheter >18ga If patient is deemed a “hard
If unable to obtain peripheral IV stick”, IO should be conducted
access after two attempts, proceed to first.
IO.
Intraosseous Device for

Life / limb-threatening event if unable
to obtain peripheral IV access
Ensure open and functioning

Fluid bolus per specific protocol
At a minimum, maintain a slow “to-
keep-open” (TKO) drip
Pearls:
• Any pre-hospital fluids or medications approved for IV use may be given through an
intraosseous line – including blood products.
• All trauma patients or potentially ill patients should have AT LEAST TWO functioning
IV / IO lines whenever possible.
• Upper extremity IV sites are preferable to lower extremity IV sites.
• Intraosseous confirmed in place by good flush / good flow – may not aspirate blood.
Utilize EZ-IO™, FAST-1™, or unit Medical Director approved IO device.
o Sternal or humeral head sites are preferred over all other sites. Tibia is
preferred for pediatrics. Correct needle size is critical for the EZ-IO; 45mm
for humerus or use of universal/adjustable depth needle.
o BLUF: GAIN VASCULAR ACCESS where available based upon patient.
o Pressure infusion bag is recommended for IO starting at 300mmHg.
• Following IV attempt failure and IO attempt failure, external jugular lines can be
attempted for life-threatening events with no peripheral access.
27
PAIN MANAGEMENT
Signs and Symptoms:
• Tachycardia
• Diaphoresis
• Elevated Blood Pressure
• Vocalizes and/or Signals Pain
Continued From:
Tactical Evacuation Guideline
Patient care according to guideline

based on specific complaint
• Pain >3/10
Consider:
• Vocalizes / Signals Pain
Acetaminophen 1gram PO prn
and requests relief NO
OR every 6-8 hours max 4gm in
Indication for IV / IM medications? 24 hour period
Ketamine
YES
Standard Dose: IV / IO Guideline
0.1-0.2 mg/kg IV/IO
0.5 mg/kg IM/IN Ensure: Return To:
Induction / Dissociative:
SPO2 / Monitors Attached Tactical Evacuation Guideline
1.0-2.5 mg/kg IV OR
Fentanyl 0.5-1mcg/kg IV/IO/IN (max Appropriate Guideline per
TCCC recommended dose: OR
4mcg/kg), PO 800mcg lollipop Complaint
50mg IM/IN q 30min prn
20mg IV/IO q 20min prn
Ondansetron 4-8mg IV / IM
Monitor and Reassess
Contact med control if unable to

maintain adequate pain control
Pearls:
• Document patient’s medications and all allergies prior to administration of medications.
• PO medications should not be used in any patient with altered mental status or anyone in whom
surgery is anticipated, unless directed by transferring provider.
• Narcotic pain medications can be reversed with Naloxone 0.4-2mg IV.
o Use Extreme caution unless the patient has no history of seizures or chronic
benzodiazepine use.
• Start with low dosage of pain medications and titrate upward to desired effect.
• Fentanyl and Morphine will cause a decrease in BP through various drug effects. Fentanyl is
preferred over Morphine for immediate pain control.
• Ketamine is neuro protective and is recommended as first line analgesic agent per TCCC.
• Morphine and/or Ketamine auto-injectors may be used if available; however IV / IO route is preferred.
• Ketamine can cause slight decrease in blood pressure, especially with hypotensive shock patients,
lower doses are recommended in this type of patient.
• Fentanyl lollipop 800mcg may be used if patient is conscious. DO NOT CHEW
28
Pediatric PAIN MANAGEMENT
Vital Functions and Pain Scale
Signs and Symptoms:
• Tachycardia, Diaphoresis, Elevated Blood Pressure, Cry, Grimace, Splinting, Guarding
AVERAGE PEDIATRIC VITAL FUNCTIONS

Heart Rate Awake Sleeping Blood
(per min) Age Rate Mean Rate Pressure Average Lower Limit
Newborn to 3mo 85-205 140 80-160 1-10y 90+(years old x2)mmHg 70+(years old x2)mmHg
3mo-2y 100-190 130 75-160 >10y 90mmHg
2-10y 60-140 80 60-90 MAP 55+(years old x1.5)mmHg
>10y 60-100 75 50-90
Respiratory Urinary Output
Rate/min Age Rate Age Weight NIBP Systolic Average (mL/kg/hr)
Infant 30-60 0-12months 0-10kg >60 2
Toddler 24-40 1-2years 10-14kg >70 1.5
Preschool 22-34 3-5years 14-18kg >75 1
School 18-30 6-12years 18-36kg >80 1
Adolescent 12-16 >13years 36-70kg >90 0.5
Pediatric FLACC Pain Scale

(2 Months – 7 Years or Individuals Unable to Communicate)
Score of 5-10 = Moderate-Severe Pain, Consider Narcotic
Criteria 0 1 2
Occasional grimace Frequent to
No particular
Face or frown, withdrawn, constant quivering
expression or smile
uninterested chin, clenched jaw
Normal position or Uneasy, restless, Kicking or legs
Legs
relaxed tense drawn up
In hemodynamically unstable or Lying quietly, normal
Squirming, shifting, Arched, rigid or
inconsolable child, consider: Activity position, moves
back and forth, tense jerking
easily
Ketamine
(IV / IO Push over 1 min) Crying steadily,
No cry (awake or Moans or whimpers;
• Analgesia: Cry screams or sobs,
asleep) occasional complaint
IM / IN: 0.4 mg/kg frequent complaints
IV / IO: 0.3 mg/kg Reassured by
• Induction / Dissociative: occasional touching, Difficult to console
Consolability Content, relaxed
IV / IO: 1-2 mg/kg hugging or being or comfort
talked to, distractible
FENTANYL 0.5-1mcg/kg SIVP Acetaminophen 10-15mg/kg PO / PR

q 20-30min (Max 4mcg/kg) Follow Procedural steps of:
PAIN MANAGEMENT GUIDELINE
Utilize Appropriate Medication in ONDANSETRON (for Nausea)
MORPHINE 0.1mg/kg IV SIVP/IM Pediatric Dose. • <40kg 0.1mg/kg IV
q 120min (Max 0.4mg/kg) • >40kg 4mg IV
29
UNIVERSAL PATIENT CARE
Scene Safety
(Remain aware and prepared to employ personal weapons in patient and crew self-defense)
Bring all necessary equipment to patient’s side
Demonstrate professionalism and courtesy
Ensure utilizing appropriate PPE

(Including: barrier, aerosol, and IBA - as appropriate)
Initial assessment
BLS Guideline as necessary Cardiac Arrest
Consider Spinal immobilization
Length based resuscitation tape for pediatric Cardiac Arrest
Guideline
Vital signs q15min (sooner if unstable)
(BP, Pulse, Resp, SPO2)
Core temp: assess for hypothermia / heat injury, if appropriate
Blood glucose measurement, if appropriate
Consider Supplemental O2
Airway Guideline as indicated
Continuous Cardiac Monitoring / SPO2

Unless minor / ambulatory patients
Saline Lock*
If not giving fluids, maintain a IV / IO Guideline
slow “to-keep-open” (TKO) drip
12 Lead EKG as indicated
Patient does not fit guideline?
Appropriate Guideline? • Contact and Consult Medical Control
• General Supportive Care
Limit On-Scene Time
Transport to appropriate MTF
Pearls:
• *Fluid boluses given in trauma victims should be done in accordance with
hypotensive resuscitation guidelines – see multiple trauma protocol.
• General supportive measures include: Airway / Respiratory support,
continuous hemodynamic monitoring with SPO2 and EtCO2 as appropriate,
Supplemental O2 PRN, IV Fluid boluses, Pain control PRN.
• All patients should have complete vital signs recorded.
• All patient encounters should be recorded on appropriate care documentation
sheets per theater policies and/or unit SOPs at end of patient encounter.
• Any mishaps / errors should be brought to attention of medical control ASAP.
• Contact medical control for any necessary assistance when feasible.
30
PATIENT SAFETY
Universal Patient Care Protocol
Utilize Broselow® Pediatric Emergency Tape

for all weight-based drug administration.
Verify correct drug and dose prior to
administration.
Prior to flight day, verify presence and

operational condition of all equipment,
medications, and supplies required for
operational readiness.
Following each flight – recheck and verify all

supplies stocked and ready. If unable due
to operation tempo – attempt to call
ahead and have supplies delivered on
arrival.
If class VIII items or patient movement items

are depleted, advise commander and adjust
as necessary to accommodate mission
requirements.
All medication errors, clinical errors, or

adverse outcomes should be reported to the For any patient that does not fit into a
medical director ASAP. guideline (SMOG),
Contact and Consult medical control.
If this is not possible, provide standard
Assume patient’s condition is worse than care within the education, training and
what is presented. Anticipate deterioration scope of the provider, until MTF is
and address aggressively. reached.
Follow appropriate SMOG for patient

treatment. Real-time treatment of the patient
is the responsibility of the flight medic with
the patient.
Pearls:
• Supportive care for all patients includes routine monitoring, IV guideline, O2 / airway support,
and fluid resuscitation (as required) to maintain or approach “normal” vital signs.
• Always check and double-check medications, dosage, condition, indication, potential adverse
reactions, and control measures prior to administration. Record any patient allergies prior to
administration of drugs.
• Check medical supplies and equipment prior to accepting / flying mission. Arrival on scene
without proper equipment will result in inability to provide optimal care, and may result in
adverse outcomes.
• Any medication / clinical errors or other care-associated concerns should be brought to the
attention of the medical officer / director ASAP following the mission or at earliest possible
time.
31
POST-OPERATIVE & CC
INTRAFACILITY TRANSFER
CLINICAL INDICATIONS:
• Patient at outlying MTF requiring transfer to higher role of care for more definitive
surgery/treatment
PRE-TRANSFER Patient Status Requirements:
a. JTS CPG – Intra-theater Transfer and Transport – recommends clinical parameters that
should be met prior to transfer; if parameters are not met, they should be addressed and
en-route mitigation plans formulated BEFORE departure / transfer:
1) Heart rate 50><120 bpm
2) SBP 70-80mmHg, MAP >60mmHg (permissive hypotension)
3) If elevated ICP or CPP, maintain MAP 80><110mmHg, SBP 110><160mmHg
4) Hematocrit >24% (or Hgb >8g/dL)
5) Platelet count >50/mm3
6) INR <2.0
7) pH >7.3
8) Base deficit <5mEq/L
9) Temperature >35.5⁰C or 96⁰F
10) ETCO 2 35><45, SPO 2 >92%, and/or PaCO 2 35><45mmHg
If these criteria are not met, the transferring physician should continue resuscitation or
provide documentation indicating limitations that compel urgent transfer. This can be
documented in the comments section of the Standard Order Set for Critical Care
Transfers document.
b. The four MINIMUM requirements which will be met prior to patient transfer are
hemorrhage control, adequate shock resuscitation (SBP 70-80 mmHg, MAP >60 mmHg,
UOP >0.5 mL/kg/hr, and/or BD <2, Temp >97⁰F and <100⁰F), stabilization of fractures,
and initial post-operative recovery.
c. Attempt to keep patient packaging time at <25 minutes; use of warming devices in
accordance with the JTS Hypothermia Prevention CPG.
d. Movement of Deceased Patients:
1) In general, patients who meet clinical criteria for death are not to be transported
by MEDEVAC, with the exception of extreme extenuating circumstances, such as
emergency exfiltration during CSAR.
2) If vital signs are absent prior to launch, make all reasonable attempts to
resuscitate as clinical and tactical circumstances permit. If unsuccessful,
consider basic cardiac ultrasound (as available) to determine whether any signs
of cardiac activity are present. If absent, mission abort is warranted.
32
3) In such circumstances, contact and consultation with medical control or other
available physician is suggested, in order to facilitate field determination of death
and cessation of resuscitative efforts.
PROCEDURE:
a. Role 2/3 provider responsibilities:
It is the responsibility of the transferring physician to write enroute care orders

appropriate for the transport environment and individualized for each patient in consultation
with the Critical Care Flight Paramedic and/or the ECCN (or attending Flight Provider) prior
to launch. The Flight Paramedic / Provider should be given a Standard Order Set for
Critical Care Transfers or similar document with en route care orders signed by the
transferring physician.
1) Provide a complete report to Flight Paramedic / Provider.
2) Provide all patient-specific related medical records.
3) Assist Flight Paramedic / Provider with packaging patient for transport as
requested.
4) Complete specified areas on the appropriate patient care report
i. Administrative data
ii. Most current laboratory data
iii. Mechanism of Injury (MOI)
iv. Diagnosis
v. Procedures
5) Place patient on ventilator at least 30 minutes prior to flight. Obtain pre-flight
ABG to ensure patient tolerates ventilator settings.
6) It is strongly suggested that the transferring physician make every possible
attempt to contact and discuss the case with the receiving physician or facility
representative. Flight Paramedics and ECCNs should confirm or encourage this
vital "physician-to-physician hand-off" if practicable.
b. FLIGHT PARAMEDIC / PROVIDER responsibilities prior to transfer:

1) Obtain orders for en route care from transferring physician; review orders and
discuss potential en route problems with transferring physician, reconcile
medications (ensure needed medications, specific to patient’s condition, are
obtained and prepared), allergies and patient’s weight, confirm patient’s
identification, and secure personal effects.
2) Perform primary & secondary assessment ensuring an understanding of the
patient’s injuries / illness / procedures performed.
3) Spinal immobilization is indicated during transfer if ordered by transferring
physician.
4) Assess placement and secure all tubes, lines, and drains & ensure proper
functioning.
5) Ensure endotracheal tube is secure; secure pulse oximeter / ETCO 2 monitor.
33
6) Review ABG – ABG should be done within 30 minutes of flight; patient should be
on transport ventilator with vent settings for transport; ABG obtained 15 minutes
after being placed on transport ventilator.
7) Ensure vascular access X 2 - peripheral, central or IO and A-line as needed.
8) Check all bandages, splints, dressing, fixation devices and tourniquets for
placement and ensure no evidence of ongoing hemorrhage.
9) If indicated, insert OG/NG tube for gastric decompression, especially in intubated
patients; cap or place to suction.
10) Empty Foley catheter bag prior to flight; ensure UOP documentation by
transferring facility.
11) For an intubated patient, provide adequate analgesia and sedation PRIOR to
giving additional paralytic medications. Re-dose medications as needed prior to
flight in accordance with transferring physician’s orders.
12) Continue administration of blood products if ordered by transferring physician. If
anticipated administration of blood products enroute, Flight Paramedic/Provider
should request orders for blood products and appropriate blood products from
the transferring physician and use FDA approved fluid warming device as
appropriate for warming fluids.
13) Collect all patient care documentation for transport with patient, i.e. pre-hospital,
transport, labs, x-rays, transferring facility notes, etc.
14) Remove all air from IV fluid bags and place all free flowing bags in pressure
bags.
15) Ensure patient is properly packaged in a warming device unless contraindicated
prior to transfer. Follow directions specific to each warming device ensuring over
heating or thermal burns do not occur. Hypothermia, acidosis and coagulopathy
constitute the “triad of death” in trauma patients.
16) Securely affix all equipment, supplies, loose tubing and lines to NATO litter prior
to moving the patient to the vehicle or aircraft.
17) Once patient is packaged, ensure all lines are leveled and monitors are zeroed.
18) Provide eye and ear protection to patient.
c. Special considerations:
1) Eye Trauma: Fox shields should be placed for any patient with a suspected or
confirmed open globe, possible intraocular foreign body or eye injury. Avoid placing
dressing under the Fox shield and manipulation of the injured eye. Both the injured
and uninjured eye should be covered IOT avoid excessive movement of the injured
eye which may result from involuntary convergence. Also want to avoid
nausea/vomiting in these patients. (JTTS CPG - Initial Care of Ocular & Adnexal
Injuries)
2) Compartment Syndrome: Patients with extremity injuries, abdominal
injuries/surgery, burns, coagulopathy and those who have received massive
transfusion are at risk for compartment syndrome. Ensure proper assessment prior
to flight. If compartment syndrome is suspected during flight, place extremity at the
level of the heart. Pain out of proportion to the injury and paresthesia are symptoms
34
of compartment syndrome, as well as pallor, paralysis, pulselessness, and
poikilothermia. Patients who are sedated, paralyzed or have an epidural or block in
place are at increased risk and require judicious hands on assessment of at risk
abdomen and extremities. (JTTS CPG – Compartment Syndrome and Fasciotomy)
3) Burns: For patients with partial and/or full-thickness burns to > 20% TBSA, use of
the Burn Patient Admission Orders and JTTS Burn Resuscitation Flow Sheet are
REQUIRED and should be continued during transfer to another facility. (JTTS CPG –
Burn)
4) Advanced pain management modalities: For patients with epidurals, continuous
peripheral nerve blocks, PCA infusions, or other pain medicine infusions, a pain note
should be completed prior to transport as it is a vital part of provider communication.
(JTTS CPG – Management of Pain, Anxiety and Delirium in Injured Warfighters)
5) Sedation and pain management must be maintained at appropriate levels throughout
transport. As appropriate and as directed by transferring physician, attempt to
maintain sedation target as follows using the Riker Sedation-Agitation Scale (SAS)
35
Riker Sedation-Agitation Scale (SAS): Used as sedation target goal for Post Surgical / CC
• Non-intubated patients, provide sedation as needed to maintain a goal SAS Score of 3-4.
• Intubated patients, provided sedation as needed to maintain a goal SAS Score of 1-2.
Definition
7 Dangerous Pulling at endotracheal tube, trying to remove catheters, climbing over bedrail,
agitation striking at staff, thrashing from side-to-side
6 Very Does not calm despite frequent verbal reminding of limits, requires physical
agitated restraints, biting endotracheal tube
5 Agitated Anxious or physically agitated, attempting to sit up, calms down on verbal
instructions
4 Calm, Calm, arousals easily, follows commands
cooperative
3 Sedated Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off again,
follows simple commands
2 Very Arouses to physical stimuli but does not communicate or follow commands, may
sedated move spontaneously
1 Unarousable Minimal or no response to noxious stimuli, does not communicate or follow
commands
ECC Nurse Protocols May 2012
d. Patient Care Enroute to the Receiving Hospital

1) Patient vital signs will be monitored continuously enroute and documented at least
every 5 – 15 minutes per transferring physician’s orders.
2) Reassess patient at least every 15 minutes and address events as necessary
following transferring physician’s orders and protocols for the specific illness or
injury.
3) Assess pain control, sedation and need for paralysis. Re-dose medications as
needed in accordance with transferring physician’s orders. Ideally, paralytic
medication should not be administered near the end of the flight. Significant,
adjunctive analgesia may be required to compensate for initial lift, landing and in
flight combat maneuvers, therefore Flight Paramedic/Provider should consider
carrying higher volumes of analgesia that would be normally used in ground
transport or fixed facilities.
4) All events will be addressed with appropriate interventions according to transferring
physician’s orders and protocols. All interventions require reassessment for patient
response to the intervention.
5) All enroute care, including ventilator changes, medications, events, interventions,
and patient’s response will be documented on the appropriate patient care
documentation.
e. Patient Report and Transfer of Care at the Receiving Hospital

1) A verbal and written patient report will be given to the receiving nurse or physician
upon delivery of the patient.
2) Routinely, the responsibility of care will be transferred at the receiving ED. On rare
occasions (i.e. mass casualty incidents, pending emergency flights, etc.), care may
need to be transferred on the helipad rather than at the bedside.
36
3) For Tail-to-Tail transfers, the Flight Paramedic/Provider initiating transport will send
all documentation from the transferring facility and the patient care documentation
from the first leg of the flight with the Flight Paramedic/Provider completing the
second leg of the transfer. The Flight Paramedic/Provider completing the second leg
of the transfer will initiate their own patient care documentation, circling “2nd Leg” at
the top of the form and ensure all documentation is turned over to the MTF upon
arrival and hand off of patient care.
4) The patient care documentation will be completed and left with the patient at the
receiving facility at the time of patient handover. If unable to complete
documentation due to extensive mission requirements, the patient care
documentation will be forwarded to the appropriate medical information receiving
facility/person IAW local / theater policy.
Any in-flight problems should be addressed per appropriate protocol and per written
instruction from transferring physician. Continued problems should prompt contacting
medical control as soon as it is possible.
Document procedure, results, and vital signs.
37
ALTITUDE PHYSIOLOGY AND
PATIENT TRANSFER
ALTITUDE CONCERNS FOR AEROMEDICAL TRANSFERS:
• Gas expansion occurs as altitude above sea level increases. The volume of a gas
will roughly double at 18,000’ mean sea level (½ sea level atmospheric pressure).
This will typically not affect the operational ceiling for the UH-60 Blackhawk during
Aeromedical Evacuation operations. Certain conditions and precautions to note:
 Air embolism / Decompression illness – This is the only absolute
contraindication to transport of patients at altitude. These patients should be
transferred at sea level or in an A/C capable of cabin pressurization to sea
level.
 Pneumothorax – There is little risk of developing a tension PTX due to gas
expansion from altitude during typical aeromedical evacuation flights in
rotary-wing A/C. However, altitude should be limited when possible to
<5,000’ MSL. If mission requirements mandate higher altitudes, the use of
aeromedical evacuation platforms with pressurized cabins should be
considered as applicable and tactically capable. Prophylactic chest tubes (for
altitude-related concerns) are recommended for any flights above 10,000’
mean sea level.
 Gastric distention – Gas expansion does increase the risk of vomiting and,
therefore, aspiration. Therefore, all patients with decreased LOC should
have an NG / OG tube placed prior to transfer.
 Head injury – As with PTX, there is little concern of altitude related elevation
of elevated ICP in head injured patients although penetrating intracranial or
maxillofacial injuries may set conditions for an entrapped-gas phenomenon
with adverse clinical consequences. Any evidence of elevated ICP should
result in treatment per guideline. Altitude restrictions do not differ from those
listed for PTX. Constant vigilance should be maintained for evidence of
elevation of ICP.
 Eye injury – Penetrating eye injuries or surgeries may introduce air into the
globe. Again, the altitudes obtained for rotary-wing A/C does not pose a risk
of elevating the IOP during normal operations.
 Gas filled equipment – Medical equipment with gas filled bladders also may
suffer from interference at high-altitudes. Primarily, endotracheal tube cuffs
should be evaluated at altitude by testing the pressure of the exterior bladder
or filled with air. If able, utilize manometer to verify tube pressure. Verify with
38
supervising physician or flight surgeon before filling endotracheal tube with
saline.
• Flow Rates: Decreased atmospheric pressure may interfere with IV flow rates
and/or pump function. These must be monitored continuously.
• Invasive Blood Pressure: Adjust / re-calibrate monitor every 1000’ if required
based upon monitoring device.
• Hypothermia: As altitude increases, the temperature will drop about 3.5° F per 1000
feet. This is further complicated in the H-60 due to rotor-wash, forward air speed,
normal lapse rate. Therefore, patients must be protected from hypothermia at all
times. This includes use of the Hypothermia Prevention and Management Kit
(HPMK), blankets, heaters if available, and closing cabin doors / crew windows
during transport.
• Hypoxia: Patients are at increased risk of hypoxia during transport at altitude. If
transfers are taking place in high-altitude locations, pulse oxygenation should be
monitored at all times and the medic / provider should maintain a low threshold for
the use of supplemental O 2 . At no time should the patient’s O 2 be allowed to go
below 92 percent (commercial pulse oximeters read up to 3 percent off, therefore a
sat of 91 percent may be seen in a patient who is really at 88 percent.). Patients
who smoke or have underlying cardiopulmonary disease are at increased risk
even at low altitudes.
• Dysbarism: Patients may experience discomfort due to gas expansion in air-filled
body spaces (e.g., ears, sinuses, teeth) during ascent. Conversely, patients and
aircrew may experience "squeeze" resulting from descent from altitude. These are
typically mild during RW transport, however, if severe, altitude should be held and
attempts made to alleviate pain and/or slow rate of ascent / descent.
39
HEMORRHAGE
Signs and Symptoms in a Trauma Patient
• Obvious Arterial Bleeding
• Blood Pooling / Soaked Bandages
• Venous Bleeding from Extensive Penetrating Wounds (Multiple fragments)
• Tachycardia
• Distended / Tender Abdomen
• Shortness of Breath / Difficulty Breathing / Tachypnea
• Decreased LOC
• Signs / Symptoms Shock
• Hypotension
Continued From:
Apply Direct Pressure and

Indirect Pressure as able
Wound Location
Trunk
Extremity Chest / Abdomen / Pelvis Head
EXTREMITY GUIDELINE Penetrating HEAD INJURY GUIDELINE

Chest?
YES NO
CHEST TRAUMA Penetrating
GUIDELINE Abdominal / Pelvic?
• Occlusive Dressing
• Hemostatic
Dressing / Pack • Hemostatic
• Pressure Dressing Dressing / Pack
Needle Thoracostomy Cavities
• NEEDLE
Guideline Thoracostomy • Pressure Dressing
• TUBE • Direct and Indirect
Tube Thoracostomy Thoracostomy Pressure
Guideline • Pos P Ventilations • Abdominal
Dressing
• Pelvic Binder
Consider Possibility of
Intra-abdominal
Bleeding from Hypotension /
Penetrating Shock
Abdominal Injury Guideline
Return to:
Tactical Evacuation
Guideline
40
HEMORRHAGE
CONTROL PROCEDURES
• Hemorrhage
CONTRAINIDICATIONS:
• None
PROCEDURE:
• Rapid bleeding / arterial source recognized (extremities, axial, inguinal) – immediate
application of extremity and/or junctional tourniquets, as appropriately needed, to
stop bleeding.
• All other bleeding:
o Apply combat dressing and apply direct pressure. Must apply adequate force
to compress vessels.
o If size of wound and bleeding are concerning for adequate control, place
hemostatic dressing as close to the bleeding vessel as possible followed by 5
min of direct pressure. If bleeding continues, apply a pressure dressing to
the wound if applicable.
o Maintain pressure on wound at all times – only checking in 10min intervals or
if bandages soaked through.
o In penetrating injuries to the abdomen, after removing blood, hemostatic
dressings should be pushed into the wound and pressure held for five
minutes to encourage clotting. Do not remove bandage after placement.
o If unable to control bleeding in extremity wounds with above, apply
tourniquet. Note: immediate transition to a tourniquet in an extremity wound
hemorrhage is preferred.
o Penetrating abdominal / thoracic injuries require a large amount of pressure
to compress vessels.
o In pelvic wounds – utilize pelvic binding to limit capacity for hemorrhage (tie
pelvis with sheet / commercial binder).
o Administer IVFs as per guideline – use care with internal bleeding so as not
to raise SBP above 80mmHg. MAP should be greater than >60mmHg.
41
***Clear end-points for fluid resuscitation remain unclear. Resuscitation should be
geared towards patient response to therapy.
MAP= Mean Arterial Pressure: (MAP= [(2 x diastolic BP) + systolic BP] / 3)
**A MAP greater than 60mmHg or a systolic BP between 70-80mmHg is a reasonable goal
in trauma patients without a head injury.
**A MAP between 80-110mmHg or systolic pressure between 110-160mmHg is a

recommended goal in patients with a head injury.
Hemorrhage Classification (ATLS)
Class I- EBL up to 15% of blood volume. Minimally elevated HR, minimal

change in BP, pulse pressure, or respiratory rate.
Class II- EBL between 15%-30% blood volume. Tachycardia (100-120),

tachypnea (20-24), decreased pulse pressure; SBP may start to decline
from baseline. Skin may become cool, clammy, and possible delayed
capillary refill.
Class III- EBL between 30%-40% of blood volume. SBP and mental status
decrease. Any decrease in SBP less than 90mmHg or drop in blood
pressure greater than 20-30 percent from baseline is concerning. HR >
120, respiratory rate can be elevated above 24. Urine output will be
diminished. Capillary refill will be delay (> 2 seconds).
Class IV- EBL > 40% of blood volume. SBP will be <90mmHg, pulse
pressure narrowed (< 25mmHg), tachycardia (>120), urine output minimal
or absent. Skin will be cold, pale, and capillary refill is delayed.
42
TOURNIQUET APPLICATION
• Extremity trauma / amputation with continued external hemorrhage.
CONTRAINDICATIONS:
• None
PROCEDURE: All medical personnel should be regularly practiced in deploying and applying all CoTCCC
approved tourniquets. Tourniquets should be pre-set and removed from wrapping (ready for immediate use and
application). Initial HASTY placement as proximal on limb to injury followed by DELIBERATE placement as
needed per the following steps:
• Remove clothing as necessary to visualize bleeding area.
• Place tourniquet (commercial or any 2” wide piece of fabric, leather, etc.) proximal to wound. Tourniquet
should be placed at least 2” above the injury, proximal or distal to joints, as appropriate.
• Tighten tourniquet by twisting included rod (commercial) or piece of 6” rigid material (e.g., stick) until
bleeding stops.
• Secure ends of tension bar to prevent unwinding.
• Document presence of tourniquet and time of placement on patient (forehead). (“T” signifies tourniquet).
Do not cover tourniquet.
• Recheck tourniquet intermittently (q 15min) and after any movements to ensure no new bleeding / loosening
has occurred.
• TC3 recommendation: “Every effort should be made to convert tourniquets in less than two hours if
bleeding can be controlled by other means”.
43
JUNCTIONAL
TOURNIQUET APPLICATION
• High level amputation not amendable to a tourniquet, non-compressible hemorrhage in a transition zone
(inguinal and axilla), and pelvic immobilization.
CONTRAINDICATIONS:
• None
PROCEDURE: All medical personnel should be proficient in deploying and applying all available tourniquets.
Junctional tourniquets (JT) should be pre-set and removed from wrapping (ready for immediate use and
application). Junctional tourniquets should be applied according to manufacturer’s instructions.
• Remove clothing as necessary to visualize area of application if possible. Remove objects from patient’s
pockets or pelvic area. Slide device into place as necessary to proper position.
• Tighten tourniquet by twisting or pumping up balloon / bladder until bleeding stops. (depends on JT used)
• Secure all straps in order to ensure security of device.
• Document presence of tourniquet and time of placement on patient (forehead). (“T” signifies tourniquet).
Do not cover tourniquet.
• Recheck tourniquet intermittently (q 15min) and after any movements to ensure no new bleeding / loosening
has occurred.
• Junctional tourniquets are recommended to be in place for up to four hours.
• ***If using a JT with pump device, additional inflation may be necessary with changes in altitude.
• Do not remove / loosen tourniquet once in place.
44
VASCULAR ACCESS
(INTRAVENOUS)
• Need for intravascular access to provide resuscitative fluids and/or medications.
• Anticipated need for intravenous access in emergency patients.
CONTRAINDICATIONS:
• Injuries proximal to IV site / ipsilateral to IV site (relative).
PROCEDURE:
• Prepare all necessary equipment: PPE, tourniquet, IV catheters, alcohol / betadine
wipe, saline lock or IV tubing, IVFs if administering, and tape / securing device.
• Ensure all IV tubing / saline locks flushed prior to attempting IV.
• Place tourniquet proximal to anticipated IV puncture site.
• Identify vein to be cannulated and cleanse overlying area with alcohol / betadine.
• While holding traction on skin / vessel, cannulate the vessel (use a shallow angle of
attack with the needle). Once flash returned, advance slightly to ensure catheter in
vessel, then advance catheter only fully into vessel (should pass without resistance).
• While holding pressure proximally on vein, remove tourniquet and needle. Attach 20mL
NS flush and flush IV – this fluid should flow easily into the vein – any resistance
suggests missed attempt or “blown” vein. (Note: If blood samples being drawn – they
should be taken prior to removing tourniquet and always prior to flush (after flushing –
may obtain dilute sample which will alter results.)
• Secure catheter using transparent dressing or tape.
• Repeat until 2 IV sites have been established and are functional.
45
VASCULAR ACCESS
(INTRAOSSEOUS)
• Need for intravascular access to provide resuscitative fluids and/or medications with inability to obtain
adequate peripheral intravascular access (2 failed attempts or greater than 90sec).
• Anticipated need for intravenous access in emergency patients.
CONTRAINDICATIONS:
• Only absolute contraindication is fracture at affected site or prior IO attempt in the same bone.
• Cellulitis overlying puncture site (relative contraindication).
• Injury (not fracture) proximal to puncture site (relative – site dependent).
• FAST Tactical™ device contraindicated in pediatric patients less than 18 years old.
PROCEDURE:
• Prepare all necessary equipment: PPE, IO device, betadine scrub, and IV tubing.
• Ensure all IV tubing / saline locks flushed prior to attempting IV.
• Identify appropriate puncture area as follows:
o FAST Tactical™
 Sternum – follow manufacturer instructions or training guidelines.
o EZ IO™
 Proximal humerus – 2cm (2 finger widths) distal to greater tuberosity on lateral
aspect.
 Distal Femur- Proximal to patella (max 1cm) and 1-2cm medial to midline.
 Proximal tibia – 2cm (2 finger widths) distal to tibial tuberosity on medial aspect.
 Distal tibia – 2cm (2 finger widths) proximal to medial malleolus.
o Manual IO
 Proximal tibia and distal tibia – same as EZ IO™ site.
• Cleanse area overlying puncture site well. Failure to appropriately disinfect the area can lead to bone
infections.
• Applying firm pressure, puncture skin at 90 degree angle. Puncture bone (felt as firm resistance followed by
“pop”).
• Attempt to aspirate blood then flush. IO should flush easily – this is confirmation of placement, not
aspiration of blood. (May add 2-3ml’s of 2% lidocaine (without epinephrine) to 5cc NS flush to decrease
pain associated with flushing.) If flushes easily – attach IV line and use as needed.
• Constantly monitor for increased tension in muscular compartments as misplacement into a compartment
with subsequent fluid administration can lead to iatrogenic compartment syndrome.
46
HYPOTENSION / SHOCK
Signs and Symptoms: Differential Diagnosis:
• Restlessness / Confusion • Shock: Hypovolemic, Cardiogenic, Septic,
• Weakness / Dizziness Neurogenic, Anaphylactic
• Tachycardia • Cardiac Arrhythmia
• Pale, Cool, Clammy Skin • Pulmonary Embolus
• Delayed Capillary Refill • Tension Pneumothorax
• Hypotension • Medication Effect / OD
• Coffee-ground Emesis • Vasovagal Episode
• Vaginal Bleeding
• Black, Tarry Stools
• Nausea / Vomiting
Continued From:
Continuous Monitoring AIRWAY GUIDELINE
Loss of Circulation at any time:
Reassess q 5min Start CPR - 30:2
Return to: IV / IO GUIDELINE Move to:
Tactical Evacuation TRAUMA ARREST Guideline
Guideline NO Symptomatic?
Trauma YES Cardiac

Non-trauma & Non-cardiac
Blood Product: 2 units Treat per appropriate
See Blood Component Therapy Guideline Cardiac Guideline:
2L NS/LR Bolus x 2 PRN • BRADYCARDIA w/ Pulse
TXA (with Plasma as available) • CARDIAC ARREST
• TACHYCARDIA w/ Pulse
Optimize Hemostasis: (See Pearls!) No Response / Losing BP Control?
(attempt 250ml aliquots to attain / maintain
PHRG targets noted in Pearls section below) Non-Invasive PPV (BVM) vs.
Consider NOREPINEPHRINE Advanced Airway
8-12mcg/min IV
Maintain SBP 70-80, MAP 60 500mL NS/LR Bolus

Maintain SBP >90, MAP >80
No Response / Losing BP Control? No Response / Losing BP

At Any Point, Once BP Controlled: Control?
• Continuous Monitoring
Consider (as LAST Resort):
Reassess q 5min
Norepinephrine NOREPINEPHRINE
• Return to:
8-12 mcg/min IV drip 8-12mcg/min IV
Or alternate vasopressor (i.e. push-dose or Tactical Evacuation Guideline
infusion Phenylephrine or Epinephrine)
Pearls:
• Optimize Hemostasis: Fluid resuscitation in;
o Hemorrhagic trauma with NO significant head injury should follow permissive hypotensive resuscitation guidelines (PHRG)
maintaining MAP 60, but not raising the BP into the “normal” range, which may increase bleeding. Only give minimal “bolus”
(attempt 250ml increments) of blood product and/or Hextend fluids, to maintain MAP >60, NIBP Systolic BP between 70-80,
palpable FEMORAL pulse, (if NIRS device available, STO2 >70%) and/or change in mental status.
o Hemorrhagic trauma WITH significant head injury should NOT follow permissive hypotension guidelines. Maintain NIBP
Systolic BP 110><160 and MAP 80><110.
• Should treat patient prior to onset of shock if possible. Early signs of impending shock include tachycardia, orthostatic signs, and
narrowing pulse pressure (systolic-diastolic BP).
• Consider all causes of shock and treat per appropriate protocol.
• Avoid Pressors as able (use as LAST RESORT in TRAUMA) – Always continue IVFs: Optimize hemostasis and correct volume loss.
47
Pediatric HYPOTENSION /
SHOCK
• Restlessness / Confusion • Shock: Hypovolemic, Cardiogenic, Septic,
• Weakness / Dizziness Neurogenic, Anaphylactic
• Tachycardia • Cardiac Arrhythmia
• Pale, Cool, Clammy Skin • Pulmonary Embolus
• Delayed Capillary Refill • Tension Pneumothorax
• Hypotension • Medication Effect / OD
• Nausea / Vomiting • Vasovagal Episode
• Responsiveness / Lethargy • Dehydration
• Congenital Heart Disease
Continued from:
Pediatric Systolic Average NIBP Tactical Evacuation Guideline
AGE Lower limit Loss of Circulation at any time: Start CPR
0-12mths >60mmHg Tactical 100 comp/min or 100-120 comp/min
IV / IO GUIDELINE with advanced airway device.
1-2years >70 Evacuation • Supplemental O2 • 1 Rescuer: 30 Compressions to 2 Breaths
3-5y >75 Guideline
6-12y >80 • 2 Rescuer: 15 Compressions to 2 Breaths
>13y >90 NO Symptomatic? Move to: TRAUMA ARREST GUIDELINE
Trauma YES Cardiac
Non-trauma & Non-cardiac Treat per appropriate Cardiac
20mL/kg LR Bolus in <20min x 2 Guideline:
attempts • Pediatric BRADYCARDIA w Pulse
20mL/kg LR Bolus PRN in <20min
and Poor Perfusion
• Pediatric TACHYCARDIA w Pulse
No Response / Losing BP Control? No Response / Losing BP Control?
and Poor Perfusion
• Pediatric CARRDIAC ARREST
Consider NOREPINEPHRINE
0.05-0.1mcg/kg/min IV / IO NO Rales heard on Lung Exam?
10mL/kg pRBC bolus
(Max 2mcg/kg/min) YES
OR Non-Invasive PPV (BVM) vs. Pediatric
Consider Epinephrine Infusion Advanced Airway AIRWAY
No Response / Losing BP Control?
0.1-1mcg/kg/min IV/IO
20mL/kg NS Bolus PRN
Consider (as LAST Resort): At Any Point, Once BP Controlled: No Response / Losing BP
PHENYLEPHRINE • Continuous Monitoring Control?
5-20mcg/kg Reassess q 5min
SLOW IV / IO Push q10-15min • Return to: Consider NOREPINEPHRINE
Or Alternate Pressor Tactical Evacuation Protocol 0.05-0.1mcg/kg/min IV / IO
(Max 2mcg/kg/min)
Pearls: Hypotension in pediatric patients is defined as a SBP less than 70 + [2 x age (yr)].
• Optimize Hemostasis: Fluid resuscitation in:
o Pediatric hemorrhagic trauma with NO significant head injury should NOT follow permissive hypotension resuscitation guidelines
(PHRG). Rapid infusion of crystalloid (20ml/kg of NS or LR), GOAL: Resuscitate as close to normal systolic pressure as possible.
Normal pressure calculated by: 90 + [2 x age (yr)].
o Pediatric Hemorrhagic trauma WITH significant head injury: > 70 + [2 x age (yr)].
• Decreasing heart rate may be a sign of impending collapse in pediatric patients
• Avoid Pressors as able (use as LAST RESORT in TRAUMA) – Always continue IVFs: Optimize hemostasis and correct volume loss.
48
BLOOD COMPONENT / FRESH
WHOLE BLOOD USE
IMMEDIATE CLINICAL INDICATIONS in trauma patients with SERIOUS INJURIES and
evidence of hemorrhage / shock:
• Systolic blood pressure less than 100 mm Hg or absence of radial pulse
• Tachycardia greater than 100 beats per minute (BPM) or higher
• Double, triple, or quadruple amputation
• Uncontrolled hemorrhage or evidence of hemorrhagic shock
o Trauma patients with amputation (complete or partial with distal circulation
compromise)
o Non-compressible penetrating thoracic, abdominal, and transitional zone
injuries (axilla, inguinal, neck)
o Pelvic Fractures in conjunction with traumatic injury (significant mechanism of
injury)
o Clinical signs of coagulopathy
 Tachycardia, tachypnea, fever, altered mentation, hypoxemia
o Severe hypothermia associated with blood loss
CONTRAINIDICATIONS:
• None
PRIOR TO BLOOD PRODUCT TRANSFUSION:
• Maximal hemorrhage control
• Treatment of suspected tension pneumothorax
o Clinical signs may include: hypotension, hypo-perfusion, diminished or
absent breath sounds. Late signs include: tracheal deviation and distended
neck veins.
• Patent airway or airway control
• IV/IO access
• Hypothermia prevented and/or treated
49
PROCEDURE:
• Document all items on the SF 518 (only authorized document for blood products
aboard Army Aeromedical Evacuation platforms.
o Two person verification of patient and blood products given matching SF 518.
• Observe units of blood
o Look for gas, discoloration, clots, and sediment
o Safe-T-Vue must remain white on color indicator. Red coloration indicates
that temperature has been exceeded and is no longer acceptable for use.
• Initiate large bore IV (18G min, 14G preferred) or IO access.
o IO access via sternum or humerus is preferred. Tibia site can be utilized as
secondary, but attempt should be made to gain another access point.
o Lidocaine 2% (2-3 mL) flush in IO sites provides analgesia and increases
compliance.
• All blood and blood products will be administered through a dedicated line of NS
using Y-tubing with filter.
• Transfuse blood through an approved fluid warming device if available.
• Rapid transfusion can be achieved by using an approved pressure infusion device.
o Inflate pressure bag to at least 300 mmHg
o 60 ml syringe or manual pressure can also be utilized in the event a pressure
infuser is not available.
• Slow all other concurrent infusions unless they are TXA or RFVIIa.
• Continue resuscitation until palpable radial pulse, improved mental status or SBP of
70-80 mmHg and MAP >60 mmHg.
• Monitor patient every 5 minutes and document any patient signs and symptoms
consistent with a transfusion reaction. These include: chills, back or chest pain,
rash, fever, hives and/ or wheezing.
Document procedure, results, and vital signs of the SF 518.
CLINICAL PEARLS AND CONSIDERATIONS:
• Febrile Reaction- Temperature increase (1°C or 2°F) from baseline, chills, flushing,
headache and rapid pulse
• Allergic/Anaphylaxis Reaction- itching, chills, flushing, nausea/vomiting, coughing
and/or wheezing, or laryngeal edema
o Treat with Diphenhydramine 50mg IVP or IM. Have epinephrine standing by.
• Acute Hemolytic Reaction- rapid onset of dyspnea, hypotension, hemoglobinuria,
rise in venous pressure, distended neck veins, cough and/or crackles at the bases of
50
the lungs. Treatment is to stop the transfusion, titrate O2 saturations above 94%, and
increase IV fluid hydration to 100-200mL/hr to support a urine output above 100-
200mL/hr.
• Circulatory Overload- onset of shortness of breath, tachycardia, hypertension, jugular
vein distention, pulmonary rates, and hypoxia. This condition may be difficult to
distinguish from a hemolytic reaction.
• If a casualty with an altered mental status due to suspected TBI has a weak or
absent peripheral pulse, resuscitate as necessary to restore and maintain a normal
radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 70
mmHg.
*** Blood component therapy is location specific and is not standard for all missions OCONUS
and CONUS. Whole Blood not FDA approved will not be utilized on MEDEVAC air craft unless
otherwise specified by area policy or Joint/Army Blood Program.
51
BLOOD TRANSFUSION RELATED
REACTIONS
Differential Diagnosis: Signs and Symptoms:
Febrile non-hemolytic transfusion reaction (FNHTR) Fever (>100.4°F) increase of 1°C or 2°F from baseline, chills,
possible dyspnea
Acute hemolytic transfusion reaction (AHTR) Fever (>100.4°F), chills, flank pain, red/brown urine
Anaphylaxis reaction Rapid onset of shock, hypotension (<100mmHg systolic),

angioedema, and respiratory distress
Transfusion-transmitted bacterial infection Fever (>102.2°F or >3.6°F change after transfusion), rigors,
tachycardia (>120 bpm or >40 bpm following transfusion), rise
or fall of systolic blood pressure (>30mmHg)
Mechanical-caused hemolysis Varies with each device. Fever (>100.4°F), chills, possible
dyspnea
Transfusional volume/circulatory overload Dyspnea, orthopnea, tachycardia (>100 bpm), wide pulse
(TACO) pressure, hypertension (>140mmHg systolic), hypoxemia (SPO2
<94%), headache, possible seizure
Transfusion-related acute lung injury Hypoxemia (SPO2 <94%), Fever (>100.4°F), hypotension
(TRALI) (<100mmHg systolic), cyanosis, tachypnea (>24 breaths per
minute), tachycardia (>100 bpm)
Pearls:
• GENERAL RULES:
o Stop the transfusion
o Keep the intravenous line open with saline
o Identify and treat cause of the reaction
o Re-institute the transfusion only if it is deemed to be clinically essential
• Before initiating IVF bolus, ensure IV tubing is new. DO NOT USE existing Y-tubing from blood administration
set.
• The most common transfusion reaction is a febrile, non-hemolytic transfusion reaction. These are mostly
benign with no lasting sequelae. Treatment consists of antipyretics. (Acetaminophen 500mg PO every 4 hours
or 1 Gram IV every 6 hours.)
• TRALI is the leading cause of transfusion-related mortality and commonly occurs is patients who have
undergone recent surgery, massive blood transfusion, or who have an active infection. Goal of treatment is
supportive and aimed at maintaining oxygenation and reducing respiratory distress.
• TACO is essentially pulmonary edema secondary to congestive heart failure usually occurring in elderly, small
children and those with compromised cardiac function. Large volumes of fluid given rapidly are a common
precursor to this reaction. Goal is aimed at mobilizing fluids (diuretics) and treating underlying condition. Both
TACO and TRALI require immediate resuscitation by an advanced level practitioner.
o A unit of packed cells should be given at a rate of 2.5-3.0 mL/kg per hour.
• Mechanical-caused hemolysis is commonly caused by rapid transfusion, poor collection and storage, or heating
the blood above 42°C during transfusion.
52
O₂ (if hypoxic)
IV/ IO Guideline
Cardiac Monitor (ASAP)
TRALI / TACO Allergic Reaction Febrile Transfusion Reaction
STOP TRANSFUSION STOP TRANSFUSION STOP TRANSFUSION
Definitive Airway If concerned for Febrile Non-hemolytic Acute Hemolytic

Established and anaphylaxis: Transfusion Reaction Reaction
SPO₂ >93% Epinephrine 1:1000 (FNHTR) (AHTR)
0.3mg-0.5mg IM
Establish Advanced Airway per

500mL NS MEDICAL Emergency
individual competencies,
if not previously started Draw blood from adjacent limb
contraindications, and/or attempt
failures
Diphenhydramine
1. Endotracheal Intubation 50mg IV/IO/IM/PO
100 - 200mL/ hour NS to support
2. Cricothyroidotomy Methylprednisolone UOP of 100-200mL/ hour
125mg IV/IO
3. Blind Insertion Airway Device
Consider:
4. Non-invasive positive pressure
Acetaminophen
ventilation CPAP or BiPAP Albuterol 90mcg 500mg PO or 1G
2 puffs or 2.5mg nebulized IV
Reassess Patient Reassess Patient

Document on SF 518 Document on SF 518
Notify blood bank of all transfusion

related reactions.
Pearls:
• Blood transfusions conducted during point of injury for casualties suffering from blood loss/massive
hemorrhage may not show any transfusion reaction during the limited transport time.
53
MULTIPLE TRAUMA
Signs and Symptoms: Possible Injuries / Diagnoses: Cont: Possible Injuries / Diagnoses:
• Pain, Swelling, Bleeding • Tension Pneumothorax • Head Injury
• Ecchymosis • Flail Chest • Extremity Fracture /
• Deformity • Pericardial Tamponade Dislocation
• Altered Mental Status • Open Chest Wound • HEENT Injuries
• Respiratory Distress / Failure • Hemothorax • Hypothermia
• Vomiting • Intra-abdominal Injury / Bleeding • Burns
• Hypotension / Shock • Pelvis / Long-bone Fracture
• Cardiac Arrest • Spine / Spinal Cord Injury
Consider early airway
Continued from: Respirations <8 or >30
HEMORRHAGE CONTROL management per
Tactical Evacuation Guideline • Reposition Airway / OPA
• Check / Add Tourniquet Airway and Chest
• Pack and Dress Wound Trauma Guidelines • AIRWAY GUIDELINE
Rapid Assessment with GCS o Nasopharyngeal Airway
• Pressure Dressing
Concentration on C, A, B Spinal o Intubation
Immobilization PRN o Cricothyroidotomy
• Treatment Order by
Minimize On-Scene Time
Severity of Hemorrhage
IV / IO GUIDELINE Chest Injury (Impacts Breathing)
HYPOTENSION / SHOCK GUIDELINE TXA (with Plasma • CHEST TRAUMA GUIDELINE
• Blood (if available): 1-2units (Blood Guideline) as available) if: Vital signs / perfusion? o Needle Thoracostomy
Hextend 500ml X 1, (Keep SBP 70-80) Bolus to Hemorrhage with o Tube Thoracostomy
MINIMUM NEEDED TO ATTAIN PALPABLE PULSE, HR >100 or SBP o Positive Pressure Ventilation
SBP 70-80 and MAP >60. <100 Abnormal Normal
ENSURE Fractures are Stable:

Altered Mental Status
• Reduction / Compression of pelvic fractures
or MOI c/w Head or Head Injury Guideline
• Reduction of long bone (Femur) fractures
Spinal Injury
• Re-assess Control of External Hemorrhage
(Continued Decompensation) Abnormal Vital signs / perfusion Normal
Restart Guideline
Check and Readdress: PAIN MANAGEMENT GUIDELINE
• Hemorrhage control (MOST IMPORTANT) Loss of Circulation at (Hemodynamic & Mental Status Stable)
• Airway: Respiration rate, O₂, SPO₂ any time:
• Breathing: Equal Rise / Fall, Bruising, Tracheal Start CPR - 30:2
shift, Sub-Q Emphysema Move to: Return to:
• IV / IO lines open and running TRAUMA ARREST Tactical Evacuation
• Pelvic / Femur FXs reduced and stable Guideline
Guideline
• Head and/or Spinal Injury
Pearls:
• Severe extremity bleeding should be immediately addressed with a tourniquet.
• Optimize Hemostasis: Fluid resuscitation in:
o Hemorrhagic trauma with NO significant head injury should follow permissive hypotensive resuscitation guidelines
maintaining MAP >60, but not raising the BP into the “normal” range, which may increase bleeding. Only give minimal
“bolus” of blood product, LR, and/or Hextend fluids, to maintain MAP >60, NIBP Systolic BP between 70-80, palpable
FEMORAL pulse, and/or change in mental status.
o Hemorrhagic trauma WITH significant head injury should NOT follow permissive hypotension guidelines. Maintain
NIBP Systolic BP 110><160 and MAP 80><110.
• Narrowed pulse pressure should prompt resuscitation – do not wait for decompensation to ensue.
• Stabilize pelvic fractures with Pelvic Splint or sheet / binder and tie feet together. Up to 4-6L of blood can be hidden in pelvis.
54
Pediatric MULTIPLE TRAUMA
Signs and Symptoms: Possible Injuries / Diagnoses: Cont: Possible Injuries / Diagnoses:
• Pain, Swelling, Bleeding • Tension Pneumothorax • Head Injury
• Ecchymosis • Flail Chest • Extremity Fracture /
• Deformity • Pericardial Tamponade Dislocation
• Altered Mental Status • Open Chest Wound • HEENT Injuries
• Respiratory Distress / Failure • Hemothorax • Hypothermia
• Vomiting • Intra-abdominal Injury / Bleeding • Burns
• Hypotension / Shock • Pelvis / Long-bone Fracture
• Cardiac Arrest • Spine / Spinal Cord Injury
Consider early airway
Continued from: Respirations Abnormal
HEMORRHAGE CONTROL management per
Tactical Evacuation Guideline • Reposition Airway / OPA
• Check / Add Tourniquet Airway and Chest
• Pack and Dress Wound Trauma Guidelines • PEDs AIRWAY GUIDELINE
Rapid Assessment with GCS o Nasopharyngeal Airway
Concentration on C, A, B Spinal o Intubation
Immobilization PRN o Cricothyroidotomy
• Treatment Order by
Minimize On-Scene Time
Severity of Hemorrhage
IV / IO GUIDELINE Chest Injury (Impacts Breathing)
Pediatric HYPOTENSION / SHOCK GUIDELINE TXA (with Plasma • CHEST TRAUMA GUIDELINE
• LR Bolus in <20 min x 2 attempts. as available) if: Vital Signs / Perfusion? o Needle Thoracostomy
• pRBC’s (if available): 10mL/kg (Blood Guideline) Hemorrhage with o Tube Thoracostomy
Bolus ALL FLUIDS following principle of ↑HR or ↓SBP o Positive Pressure Ventilation
PERMISSIVE HYPOTENSION (*See Pearls) Average Abnormal Normal
ENSURE Fractures are Stable: Head Injury Guideline

• Reduction / Compression of pelvic fractures
or MOI c/w Head or
• Reduction of long bone (Femur) fractures
Spinal Injury
• Reassess Control of External Hemorrhage
(Continued Decompensation) Abnormal Vital Signs / Perfusion? Normal
Restart Guideline
Check and Readdress: Pediatric PAIN MANAGEMENT
• Hemorrhage control GUIDELINE
Loss of Circulation at any time: Start CPR (Hemodynamic &
• Airway: Respiration rate, O2, and Sats
100 Comp/Min Mental Status Stable)
• Breathing: Equal Rise / Fall, Bruising,
• 1 Rescuer: 30 Compressions to 2 Breaths
Tracheal shift, Sub-Q Emphysema
• 2 Rescuer: 15 Compressions to 2 Breaths
• IV / IO lines open and running Return to:
Move to: TRAUMA ARREST Guideline
• Pelvic / Femur FXs reduced and stable Tactical Evacuation
• Head and/or Spinal Injury Guideline
Pearls:
• Resuscitation: Maintain, SBP to at least [70 + 2 x age (yr)] or to mental status change.
• Narrowed pulse pressure should prompt resuscitation – do not wait for decompensation to ensue.
• Stabilize pelvic fractures with Pelvic Splint or sheet / binder and tie feet together. Up to 80% of blood volume can be hidden
in pelvis.
• Follow Length Based Resuscitation Tape.
55
CHEST TRAUMA
Signs and Symptoms of Chest Trauma
• Difficulty Breathing: Cyanosis / Pursing of lips / Accessory muscle involvement
• Rapid Respirations with SPO 2 decreasing or <93% (Trauma: In Flight and on O 2 )
• Flail Chest
• Unequal Rise and Fall
• Open Wound / Impalement Over Thorax
• Penetrating Abdominal Wound
• Bruising Across Chest or Base of Neck
• Sub-Q Emphysema or Deviated Trachea
Continued From:
Penetrating Penetrating vs. Blunt Trauma Blunt
Respiratory Distress
OPEN Chest Wound or • SPO2 <93% (On O2 &
Patent Airway) Flail Chest?
IMPALEMENT?
NO • Use of Accessory NO
YES YES
Muscles
• Seal Open Wound (vented • Unequal Rise and Fall PAIN CONTROL
occlusive chest seal) • Cyanosis / Pursed lips Consider:
• Stabilize Impalement • SOB / Can’t speak in Endotracheal
Keep high index of concern for complete sentences Intubation
development of • Wheezing / Rhonchi / Pos P Ventilation
Hemo-pneumothorax Rales / Absent Breath
Sounds
Signs of Signs of
pneumo / YES Needle Thoracostomy YES pneumo /
hemothorax hemothorax
Consider Controlled Descent
Assess response:
• SPO2 >93% NO
NO
• Improved RR
• Equal Rise & Fall
REPEAT NEEDLE Consider finger

THORACOSTOMY as needed! thoracostomy
Maintain High Failing to

Index of Suspicion Improve
for Intra-
Abdominal and Controlled Descent as able
retro-peritoneal Consider:
bleeding in all Finger / Tube Thoracostomy
penetrating Chest (Last resort and OUT of options)
Injuries!
Consider:
SPINAL IMMOBILIZATION Return to:
Tactical Evacuation
Guideline
56
EXTREMITY TRAUMA
• Pain / Swelling • Abrasion
• Deformity • Contusion
• Altered Sensation / Function • Multi-trauma
• Diminished Pulse / Cap • Fracture
Refill • Dislocation
• Decreased Temperature • Laceration
• Bleeding • Sprain / Strain
• Amputation
Continued From:
Multiple Injury Sites YES

Multiple Trauma
HEMORRHAGE CONTROL Guideline
• Check / Add Tourniquet NO
• Pack and Dress Wound YES Heavy Active Bleeding?
• Hemostatic Dressing NO
IV / IO Guideline After Bleeding Controlled:
If Hypotensive or showing signs /
symptoms of hypotension or shock
Pain Control Guideline Move immediately to:
Fluid Resuscitation HYPOTENSION / SHOCK
• Whole Blood (if available) Guideline
• pRBCs and plasma (if Wound Care / Protection
available) • Bandage and Cover Injuries
• Platelets (If authorized) • Immobilize Extremity
• Hextend • Ice (if available) for Edema
• Crystalloid (LR/NS)
Amputation?
• Clean amputated part

• Wrap in sterile dressing damp with Normal Saline
• Place in plastic bag / air tight container
• Place limb in sealed container in ice bath slurry if
available
• Transport with Patient
Pearls:
• In amputations – time is critical.
• Evaluate and document neurovascular status in all fractures /
dislocations.
• Never attempt to reduce an open fracture unless you have a
confirmed loss of pulse.
• Blood loss can be severe and concealed in long bone fractures –
especially the femur.
• Tourniquets should be used without hesitation to control major
bleeding.
57
HEAD INJURY
• Pain, Swelling, Bleeding • Skull Fracture
• Ecchymosis • Brain Injury
• Deformity • Epidural Hematoma
• Altered Mental Status • Subdural Hematoma
• Respiratory Distress / Failure • Subarachnoid Hemorrhage
• Vomiting • Spinal Injury
• Abuse
Continued from:
Pediatric Multiple trauma Tactical Evacuation Guideline
Sedation following Intubation:
Multiple Trauma Guidelines NO Isolated head Trauma? Ketamine: 0.5-1mg/kg q10-20min
YES Fentanyl 1mcg/kg q30-60min
*Propofol 10-50mcg/kg/min IV
KETAMINE (See Pearls): Spinal Immobilization Guideline
Consider use, especially in Paralytic following Intubation:
sedation of head injury *Vecuronium 0.1mg/kg q30-60min
patients with ICP Assess GCS / Responsiveness Rocuronium 1mg/kg q30-45min
Altered Mental Status?
(GCS <8 or Unequal / Blown Pupils)
Pediatric Airway
GCS <8 GCS >8 • Assist with jaw thrust / OPA as able
AIRWAY GUIDELINE • Nasopharyngeal airway
• Return once Stable Airway NO Gag reflex? YES • Supplemental O2
established • Consider: RSI Protocol
Maintain: (ONLY IF treating single Urgent Casualty)
IV/IO Guideline SPO2 >93%
NS Bolus PRN – SBP >110mmHg SBP 110><180 mmHg IV/IO Guideline
ETCO2 at 30-35mmHg LR/NS Bolus PRN – keep SBP >110mmHg
Elevate head of bed to 300 as able

• 3% Hypertonic saline 250ml IV bolus:
Return to: Infusion: 50-100ml/hr or
Tactical Evacuation Continuous Monitoring • MANNITOL 1gram/kg bolus IV followed
Guideline Reassess q5-10min by 0.25g/kg IV push every 4 hours.
(When appropriate) • HYPERVentilation: Goal of ETCO2 of
Seizure develops 30-35 mmHg
Go to: • Pediatric SEIZURE

• SEIZURE GUIDELINE Return here once resolved
Pearls:
Evidence of Elevated ICP and Herniation: Unilateral or Bilateral Fixed / Sluggish and blown pupils, persistent / repetitive vomiting,
decorticate or decerebrate posture, motor abnormalities, Cushing’s Reflex: (Hypertension & Bradycardia +/- Respiratory depression)
• Prevention of hypoxic insult is key! Maintain PO2 and maintain cerebral perfusion pressure by preventing hypotension.
o Target Vital Functions: SBP >110mm Hg, SPO2 >93%, ETCO2 at 35-40mmHg, MAP 80-110.
o It is CRITICALLY IMPORTANT to avoid both hypo-capnea and hyper-capnea. Dedicated and closely managed ventilation
is key to optimal patient outcome.
• With clear signs of herniation, may consider hyperventilation with 100% O2 and capnography: titrate CO2 to 30-35mm Hg.
• Mannitol should be given as boluses – not a constant infusion. Do not use in hypotensive, dehydration, or under-resuscitated patients
• KETAMINE (Dissociative, Analgesic, Induction agent): Preserves respiratory drive, increases HR, contractility, MAP, cerebral blood flow,
and bronchodilation.
o Not an absolute contraindicated in ICP with hypertension and/or spontaneous cerebral hemorrhage.
58
EYE INJURY / PAIN
• Pain, Swelling, Blood • Abrasion / Laceration
• Decreased Visual Acuity / Blindness • Globe Rupture
• Deformity / Contusion • Retinal Detachment
• Foreign Body • Chemical / Thermal Burn
• Excessive Tearing • Infection
• Orbital Fracture
• CNS Event
• Glaucoma
• Retinal Vessel Occlusion
• Iritis
Universal Patient Care Guideline If possible, obtain visual acuity on

all eye patients using pocket size
Snellen chart.
WITHOUT KNOWN INJURY PAIN WITH INJURY
Move to:
Evaluate Pupils ISOLATED and without additional NO Appropriate
and more significant Injuries? Guideline,
YES and Return
Previously unrecognized chemical Assess orbital stability / pupils

exposure? YES
NO
CHEMICAL TRAUMA
Cover both eyes
Copious irrigation with NS for Remove loose debris with

chemical exposure – irrigation. Do not attempt to
30min Minimum! remove impaled objects.
Cover both eyes w/ eye shield
PAIN CONTROL Guideline
Ondansetron 4-8mg IV / IO / IM
Pearls:
• Normal visual acuity can be present even with severely injured eye.
• Covering both eyes prevents further injury / pain from consensual light reflex.
• Use rigid eye shields, not pads, for traumatic injuries. Can use a soft pad on unaffected eye.
• If globe is out of socket – do not attempt to replace. Cover with saline soaked gauze and protect
from further injury.
• Copious irrigation is the cornerstone of treatment for chemical eye injuries. 30 min is the minimum
amount of time to irrigate. Utilize Morgan lens if available.
o The use of a nasal canula across the bridge of the nose attached to 1L of NS will also work.
59
TRAUMA ARREST
• Evidence of Trauma with No • Medical Cause of Arrest
Pulse Preceding Trauma*
• Lack of Response to • Tension Pneumothorax
External Stimuli • Hypovolemia
• Cardiac Tamponade
Continued from:
Tactical Evacuation Guideline In MASCAL situations / multiple victims:
Once passive airway maneuvers have
Do NOT Attempt Injuries obviously incompatible been attempted with no restoration of
Resuscitation YES with life? (*See Pearls) spontaneous breathing, do not attempt
NO further resuscitation until other patients
START CPR have been assessed and triaged. (Triage
using the SALT algorithm)
IV / IO GUIDELINE https://chemm.nlm.nih.gov/salttriage.htm
Place Advanced Airway

Start Supplemental O2
Consider SPINAL IMMOBILIZATION*
Blood Products TXA (with Plasma as available)

LR (warm if possible) Bolus Address All Known Points
Hextend 500mL Bolus Hemorrhage
Advanced Procedures to Consider
Bilateral Tube Thoracostomy Bilateral Needle Decompression
VF / pulseless VT?
Consider: CARDIAC
Place on Monitor: Ready Defibrillator ARREST GUIDELINE
(after blood loss
Pulse Return? stopped and fluid
YES Normal Respirations / Rhythm resuscitation
maximized)
NO
• Continue CPR
• Continue Blood and IV Fluids
Consider:
• Reduce Long Bone Fractures
Return to: Bilateral Chest Tube
• Reduce Pelvic Fracture Placement
TACTICAL • Stop Known Blood Loss
EVACUATION Optimize Hemostasis!
or Previous Guideline
YES Pulse Return? NO
Pearls:
• TRAUMA ARREST requires movement to nearest Surgical Facility ASAP!
• Injuries obviously incompatible with life include decapitation, massively deforming head / chest injury, traumatic
hemi-corpectomy or total body disruption, incineration. Also, any evidence of lividity / rigor mortis should result in
withholding of resuscitative efforts.
• If unsure whether arrest due to trauma or medical cause – initiate ACLS guideline for any arrhythmias following
optimization of hemostasis (in trauma patients, volume loss must be corrected 1st).
• *Spinal Immobilization should be considered after hemorrhage control and airway security.
• *Consider severe hypocalcemia if FDP or pRBCs have been recently been transfused due to calcium chelation and
evidence of poor cardiac activity/contractility.
60
BURNS
• Burns, Pain, Swelling • Superficial Burns (1st degree)
• Dizziness • Partial Thickness (2nd degree)
• Loss of Consciousness • Full Thickness (3rd degree)
• Airway Involvement (e.g., singed nasal • Chemical Burns
hair, carbonaceous sputum) • Thermal Burns
• Hoarseness / Wheezing • Electrical Burns
• Loss of Consciousness • Radiation
• Secondary Trauma
All TC3 interventions can be done Universal Patient Care Guideline Burn Depth:
through burnt or charred skin i.e. Superficial / Partial Thickness Burns:
IV, TQ, surgical cricothyroidotomy, • 1st Degree: (limited to epidermis)
needle decompression. Remove rings, bracelets, or other Red, Hypersensitive, and Painful: Not medically
constricting items significant and not calculated in Fluid Therapy
Consider escharotomy if
circumferential burn to chest • 2nd Degree: (epidermis and part of dermis)
Rapid exam for additional Injuries Very Painful, Red and Blistered, Wet, Weepy or
compromising ventilation.
Whiter and Edematous
Full Thickness Burns
>40% TBSA burn, comatose, Position patient supine • 3rdDegree: (destruction throughout dermis)
symptomatic inhalation injury, or deep Immobilize area Non Painful, Whitish / Charred skin often with
facial require large ETT (Sz 8 adult) coagulate vessels (does not blanch to touch)
• 4th Degree: (destruction through fat, fascia,
YES AIRWAY INVOLVEMENT? muscle, and bone)
AIRWAY Guideline
Consider: NO
Early establishment of
Advanced Airway! THERMAL / ELECTRIC (See Pearl) CHEMICAL (See Pearl)
Brush off any dry chemical

Pediatric AIRWAY contamination
Guideline Remove burning / charred clothing
Consider: Cool with sterile saline / gel pad
Early establishment of Cut off contaminated clothing
Advanced Airway! Flush area with saline 10-15min
Return to Cover with Dry sheet / dry sterile If Eye is involved:

dressings Flush with saline x 30min
Pearl: Hydrofluoric Acid- Arterial infusion over

4 hr (40mL of D5W with 10mL of 10% calcium Determine / Start Fluid Replacement
gluconate).
Tear Gas- rinse skin and eyes with NS. Tactical
PAIN CONTROL Evacuation
Alkali Burns to eye- 1-2 L of NS each eye for 30
minutes. Guideline
All symptomatic electric burn patients require an Place Foley Catheter (as able)
ECG regardless of the potential voltage. Monitor Urinary Output
Urinary Output is the MOST Reliable Guide Predicting

Adequate Resuscitation
• Adult: 0.5ml per kg per hour (100mL/hr Electrical Burn)
• Children <40kg: 1ml/kg/hr
61
BURN Fluid Resuscitation
Escharotomy-
Dashed line- preferred
incision lines.
Bold lines- indicate

importance of
extending the incision
over involved major
joints.
Rule of Tens
(TBSA > 20%, may require acute fluid resuscitation in prehospital)
Adults- 10mL/hr x %TBSA(estimate to nearest 10%); patients weighing more than 80kg, add 100
ml/hr to IV fluid rate for each 10 kg > 80 kg. Monitor urine output with goal of target UOP of 30 - 50
mL/hr. Calculation determines initial 24 hours of fluid resuscitation. After first 8 hours, re-evaluate!!!
Pediatrics- 3 x TBSA x body weight (kg) gives the volume for initial 24 hrs. Monitor urine output
with goal of 0.5 to 1 mL/kg/hr in children.
High Voltage Injury: ADULT: 4mL LR x Weight (kg) x % BSA spread over initial 24 hours
(Parkland Formula)
st
Give ½ of total volume over 1 8 hours from time of burn.
nd rd
Example: Adult 70kg patient with 50% TBSA 2 /3 degree (Chemical or Thermal burn)
st
2mL LR x 70(kg) x 50(%TBSA) = 7,000mL LR in 1 24hrs
st
3,500mL (½ of 7,000) is given over 1 8hrs from TOB
st
3,500mL/8hrs = 437mL/hr over 1 8 hrs
Pearls: Both under-resuscitation and over-resuscitation with fluids can precipitate significant adverse clinical events
for the burn patient. Thus, it is both worthwhile and imperative that medical aircrew calculate and administer burn
resuscitation fluids as accurately and fastidiously as possible. Put another way, it is worth your time and effort to
accurately estimate burn surface area, ideal body weight, then calculate and administer appropriate fluids while the
patient is under your care.
• Burns with airway involvement require immediate airway protection with RSI / surgical airway.
• Burns covering >40% TBSA, will likely require RSI due to airway edema from inflammation/fluid resuscitation.
• Infants and Young Children should also receive LR with 5% Dextrose at a maintenance rate and
monitor for hypoglycemia.
• Burn patients are prone to hypothermia – must protect from environment. Also, never use ice to cool large
burn areas.
• All burns require 100% O2 via NRB unless intubated.
• Never use nitrites for suspected cyanide toxicity in enclosed space fires – can worsen hypoxia. Creates
methemoglobinemia. If cyanide toxicity is a tangible threat, consider IV Hydroxycobalmin (CYANOKIT®)
62
SPINAL IMMOBILIZATION
AVPU
YES • ALERT
Altered mental status? • VERBAL: Responds to Verbal Command
• PAIN: Responds to Pain
NO • UNCONSCIOUS: Does NOT Respond to Anything
Significant mechanism of injury? Or YES
Patient >65 or <5 GLASGOW COMA SCALE
• EYE OPENING
NO o Spontaneous 4
o To Voice 3
Any focal neurologic deficit? YES o To Pain 2
o None 1
NO • Verbal Response
o Oriented 5
YES o Confused 4
Intoxication? o Inappropriate Words 3
o Incomprehensible Words 2
NO o None 1
• Motor Response
Distracting injury: Any painful injury o Obeys Commands 6
that might distract the patient from the YES
o Localizes Pain 5
pain of a spinal injury? o Withdraws from Pain 4
NO o Flexion 3
o Extension 2
Spinal Exam: Midline tenderness / o None 1
YES
deformity or painful ROM?
NO Only required once in a tactically

safe environment.
Spinal Immobilization See: Spinal Evaluation (Perform at 1st opportunity when
Not Required & Immobilization indicated and in a safe environment)
Procedure Guideline
Pearls:
• IMMOBILIZE ONLY after addressing life threatening hemorrhage.
• While controlling C-spine, roll patient and palpate spine for tenderness, deformity,
or step-off.
• Range of motion should never be tested in patients with midline tenderness /
deformity. If these are not present – testing requires patient to touch chin to
chest, fully extend, and rotate fully from side to side without pain.
• Do not attempt to quantify patient’s injury as distracting. If it is hurting them
severely regardless of type – it is distracting.
• It is always safer to immobilize if in doubt.
• A cervical collar does not provide adequate C-spine immobilization by itself –
head blocks (commercial or field expedient) should be utilized and the patients
head secured.
63
AIRWAY
Signs and Symptoms of Distress and/or Failure:
• SpO 2 Decreasing or <94% (Room Air) with / without supporting Signs / Symptoms of:
o Tachypnea, Tachycardia, Fever, Cough, Wheezing, Rhonchi, Rales, Shock
• Difficulty Breathing or Excess Work as demonstrated by:
o Pursing of Lips, Accessory Muscle Involvement, Cyanosis, Decreased Ability to
Speak, Diaphoresis
• Airway Obstruction due to Trauma, Edema, Excess Secretions, Foreign Body, or Tongue
• Apnea
• Decreased LOC (GCS <8)
Continued from:
Tactical Evacuation Guideline or Respiratory Distress Guideline
Return to Guideline: Indications of:

TACTICAL EVACUATION Consider:
• Respiratory Distress / Failure
OR Direct Laryngoscopy to
• Patient Unable to Protect Airway (GCS <8)
RESPIRATORY DISTRESS visualize for foreign body
obstruction if Sweep, Suction
Airway Open? YES and Heimlich fail to open
• Continuous • Reassess airway
NO
Monitoring Interventions
• Repeat: • Restart Protocol Reposition Airway
Sedative & • Consider other (jaw-thrust for c-spine injury) Return to Guideline:
Paralytic per Causes Sweep & Suction as needed TACTICAL EVACUATION
dose and time FAILED AIRWAY Heimlich maneuver if indicated OR
guideline GUIDELINE RESPIRATORY DISTRESS
• Start Supplemental O2
YES Indication for Advanced Airway • Place OPA / NPA prn
• Sweep and Suction prn
Definitive Airway NO
YES • NO Gag Reflex
• Recheck q5 minutes
• Not Protecting Airway (GCS <8)
Established and • BVM or assist with respiration prn
SpO2 >93% on O2? • Suspect Deterioration
• Restart Guideline if de-
No compensating (SpO2 <94% on O2)
SpO2 >93?
Establish Advanced Airway per (Room Air) YES
Procedure in the following sequence:
(Move to next procedure per individual NO
competencies, contraindications, and/or • Insert Nasopharyngeal Airway (NPA)
attempt failures) (If NO basal skull fracture suspected)
1. ENDOTRACHEAL INTUBATION • Consider Placing OPA (no gag reflex)
2. CRICOTHYROIDOTOMY • BVM (Assisted Ventilations) as needed Return to Guideline:
TACTICAL EVACUATION
3. BIAD Breathing Impacted by: OR
o Non-RSI. EXCEPTION: cardiac RESPIRATORY DISTRESS
• Penetrating or Blunt CHEST
arrest, when gag-reflex is absent, and
Chest Trauma OR
YES TRAUMA • Recheck q5 minutes
rapid airway placement is critical
• Penetrating Abdominal Protocol • Advanced Airway if de-
Trauma? compensating
Consider: NO
RSI PROCEDURE if: SpO2 >93% on
• Intact Gag Reflex NO Supplemental O2? YES
• Conscious OR
• GCS >8
64
PEDIATRIC AIRWAY
Continued from:
Tactical Evacuation Guideline or Pediatric Respiratory Distress Guideline
Return to Guideline: Indications of:

TACTICAL EVACUATION
• Respiratory Distress / Failure Consider:
OR
• Patient Unable to Protect Airway (GCS <8) Direct Laryngoscopy to
Pediatric RESPIRATORY DISTRESS
visualize foreign body
obstruction. If present Sweep,
Airway Open? YES Suction, and Heimlich fail to
• Continuous • Reassess NO open airway
Monitoring Interventions
Reposition Airway
• Repeat: • Restart Guideline
(Rolled towel under shoulders
Sedative & • Consider other Return to Guideline:
jaw-thrust for c-spine injury)
Paralytic per Causes TACTICAL EVACUATION
Sweep & Suction as needed
dose and time FAILED AIRWAY OR
Heimlich maneuver or Back
guideline Pediatric Guideline Pediatric RESPIRATORY DISTRESS
Slap for Infants as indicated
YES • Place OPA / NPA prn
Need for Advanced Airway? • Sweep and Suction prn
NO
Definitive Airway Indicated • NO Gag Reflex • Recheck every 5 minutes
Established and SpO2 • Not Protecting Airway (GCS <8) • BVM or assist with respiration prn
>93 percent on O2? • Suspect Deterioration • Restart Protocol if de-compensating
(SpO2 <94 percent on O2)
Not Indicated
Establish Advanced Airway per SpO2 >93 percent
(Room Air) YES
Procedure in the following sequence:
(Move to next procedure per individual NO
contraindications and attempt failures) • Insert Nasopharyngeal Airway (NPA)
1. KING-LT™ (Size 2 for 12-25kg, 2.5 for (if NO basal skull fracture suspected)
25-35kg, or 3 for child 4’-5’ tall)
• Consider Placing OPA (no gag reflex)
2. ENDOTRACHEAL INTUBATION Return to Protocol:
3. CRICOTHYROIDOTOMY (Use only TACTICAL EVACUATION
when able to palpate cricothyroid • BVM (Assisted Ventilations) as needed
OR
membrane: typically children >12y/o) Pediatric RESPIRATORY
4. Needle CRICOTHYROIDOTOMY Breathing Impacted by:
DISTRESS
(Unable to palpate chricothyroid • Penetrating or Blunt CHEST
YES • Recheck every 5 minutes
membrane: Children <8-10y/o) Chest Trauma OR TRAUMA
Guideline • Advanced Airway if de-
• Penetrating Abdominal
Trauma? compensating
Consider: NO
RSI PROCEDURE if:
SpO2 >93 percent on
• Intact Gag reflex NO Supplemental O2?
YES
• Conscious OR
• GCS >8
65
AIRWAY Pearls
Signs and Symptoms of Respiratory Distress and/or Failure
• SPO 2 decreasing <90% (Room Air) with / without supporting Signs / Symptoms of:
o Tachypnea, Tachycardia, Fever, Cough, Wheezing, Rhonchi, Rales, Shock
• Difficulty Breathing or Excess Work as demonstrated by:
o Pursing of Lips, Accessory Muscle Involvement, Cyanosis, Decreased Ability to
Speak, Diaphoresis, Tripod Breathing
• Airway Obstruction Due to Trauma, Edema, Excess Secretions, Foreign Body, or Tongue
• Apnea
• Cyanosis, Central and/or Peripheral: Blue/Pale Tinting and Mottling of Skin
• Decreased LOC (GCS <8), Altered Responsiveness, Weak Cry
Pearls:
• PCO2 is affected by respiratory rate and tidal volume (ventilation), while PO2 is affected by PEEP and FiO2 (oxygenation)
• Capnography is mandatory for all intubations. Record results. Capnometer (standalone END TIDAL CO2 detector) is an alternate
if monitor capnography not available. For capnography, normal range is 35-45 mm Hg; adjust vent as needed.
• All intubated patients should receive nasogastric / orogastric tube (time permitting) and continuous pulse oximetry.
• Maternal Medication: Adverse effects can include respiratory insult to newborn.
• Pediatric is defined as anyone <12yo.
• If RSI is impractical or provider is not credentialed to perform, but patient requires an advanced airway with / without
ventilatory support, consider:
1. Pharmacologically-Assisted Sedation using KETAMINE followed by supraglottic airway device placement (do not attempt
BIAD placement without sedation in patients with intact gag reflex)
2. Surgical cricothyroidotomy using approved device. (modified 6.0 ET not ideal)
RSI MEDICATIONS: IV/IO Doses RSI (Abbreviated: see RSI PROCEDURE as needed)
Pretreatment: 1. Preoxygenate (100% FiO2 via mask or PPV as needed)
Fentanyl 3mcg/kg IV Head Injury Pt. 2. Pretreat (Premedicate) as able or mission allows)
Induction Agents: 80kg adult dose: 3. Induce (Primary Sedation / Anesthesia)
Etomidate 0.3mg/kg 24mg 4. Paralyze (Neuromuscular blocking agent)
*Ketamine 1-2mg/kg 80-160mg 5. Wait for Fasciculation, Jaw Relaxation, Absence of Movement
Midazolam 0.1mg/kg 8mg 6. Pass ET Tube or insert BIAD (throughout attempt, ensure good O₂
Paralytics: saturation. If below 94% stop and provide PPV)
Vecuronium 0.1 mg/kg, q30-60min 7. Confirm Placement and Secure Tube
Rocuronium 1mg/kg, q30-45min 8. Continue Sedation and Paralytic as needed per dosing time.
Succinylcholine 1.5mg/kg-Non Trauma
Continued Sedation: Note: Midazolam and Propofol should only be used for continued sedation
Ketamine 0.5-1mg/kg, q10-20min when pain management is NOT a concern (i.e., Non Trauma Patient or
OR 1-2mg/kg/hr continuous infusion Patient is already on adequate narcotic pain control).
Propofol 0.5-1.5mg/kg-NO Pain Control, q5-10m
OR 10-50mcg/kg/min continuous infusion Rescue Breathing Ventilation Rate Without Advanced Airway:
Midazolam 0.1mg/kg-NO Pain Control, q15-30m • NEWBORN = 40-60/min when performed without compressions
Fentanyl 0.5-2mcg/kg, q30-60min • Infant / Child = 1 breath / 3-5 seconds
• Adult = 1 breath / 5-6 seconds
* = Preferred medication for Battlefield Trauma
Patients VENTILATOR SETTINGS:
• Mode: AC or SIMV
• Rate: Varies with age (Typical adult start rate is 12, then adjust PRN)
VOCAL CORD VISUALIZATION MANEUVERS: • Tidal Volume: 8mL/kg initially. Reduce by 1mL/kg every 2 hours to
• Ensure correct alignment- External meet 6mL/kg.
auditory meatus is aligned with sternal notch • I:E Ratio: 1:2-4
and head is in neutral to sniffing position. • PEEP: 5
• BURP = Backward; Upward; Rightward; • FiO2: 90%-100% - adjust as necessary. Try to decrease FiO2 as
Pressure on thyroid cartilage. much as possible while keeping O2 saturation > 93%.
• Goal FiO2 = 50-60% to conserve battery life and O2, while
maintaining patient SpO2 >93%.
66
FAILED AIRWAY
Criteria:
• Unable to open airway
• Two (2) Failed Intubation attempts by most proficient technician on scene
o Assumes at least 1 attempt with King-LT™ / Supraglottic Airway under PAI (unless
contraindicated or appropriate size not available) and 2 attempts with ET Tube
OR
• Intubation contraindicated due to anatomical abnormalities or major upper airway trauma
All Attempted as Appropriate:

• Reposition Airway
(jaw-thrust for c-spine injury)
• Sweep & Suction (as needed)
• Heimlich Maneuver /
Abdominal Thrusts / Back
Slaps (as indicated)
(*See Pearls) Attempt to:
Insert Oral Airway
Able to Ventilate with BVM? NO AND/OR
Nasopharyngeal Airway (NPA)
YES (if NO basal skull fracture suspected)
Continue BVM
Continue BVM
If adequate ventilation with BVM,
continue BVM. If inadequate,
continue with protocol. Respiratory Rate: (breaths/min,
without Advanced Airway and NOT
performing BLS)
CRICOTHYROIDOTOMY open, • Infant: 30-60
percutaneous (>10 y/o) or needle • Toddler: 24-40
• Preschooler: 22-34
• School-age: 18-30
Ventilate Patient • Adolescent: 12-16
(per age respiratory rate)
Pearls:
• Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function.
• Continuous EtCO2 monitoring should be attached when available to monitor adequacy of ventilation.
• If suspicion of head, neck, or facial trauma, maintain cervical spine support (neutral position) and perform the jaw thrust
maneuver.
• Contraindications for Oropharyngeal Airway (OPA): Intact gag reflex, conscious or semiconscious, severe facial trauma.
• Contraindications for Nasopharyngeal Airway (Nasal trumpet): Known esophageal disease, recent ingestion of caustic
substances, severe facial trauma, possible nasal and adjacent fractures.
• Cricothyroidotomy can be performed by all medics once approved by medical director. This should be utilized quickly
with severe airway trauma or inability to intubate.
• Needle Cricothyroidotomy can be performed by all Flight Paramedics once approved by medical director. This should be
utilized quickly with severe airway trauma or inability to intubate.
o Puncture cric. membrane with 14ga IV attached to 3mL syringe at 90 degree angle. Once air aspirated,
change angle to 45 degree and advance CATHETER ONLY. Remove needle / syringe and secure catheter in
place. Remove plunger from syringe and attach adapter from 7-0 ETT. Reattach this to catheter and attach
BVM w/ 100 percent O2. (Note: this procedure requires 50psi O2 and adapter for catheter hub.)
67
NEWBORN CARE & DISTRESS
Continued from: Meconium Staining of Amniotic Fluid? Targeted Preductal
• TACTICAL EVACUATION Guideline, • Suction Mouth then Nose until clear SpO2 After Birth
• CHILDBIRTH Guideline, or • Consider Intubation for deep suctioning
• Pediatric RESPIRATORY DISTRESS Guideline 1 min: 60-65%
2 min: 65-70%
3 min: 70-75%
Maintain: 4 min: 75-80%
Universal Patient Care Guideline Post Resuscitation Care 5 min: 80-85%
(Mother and Newborn) • Clear Airway (bulb syringe mouth / nose) 10 min: 85-95%
• Dry Infant
• Keep Warm (wrap in blanket) Do NOT titrate O2 for
• Airway Open? (Breathing or Crying) o Avoid Hyper / Hypothermia SpO2 >95%
• Good Tone? YES • Determine APGAR Score
• Full Term Delivery? • Treat Hypoglycemia (Glucose <40) Signs of:
• Continuous Monitoring (with SpO2) Dehydration
NO
• Tachycardia, ↓BP
• Clear Airway (Bulb syringe Mouth / Nose) • Sunken Fontanelles
• Dry Infant • HR <100? • No tears
• Stimulate (Foot Tap, Back Rub) • Apnea or Gasping? • Dry mouth, tongue, skin
• Keep Warm (wrap in dry blanket) • Labored Breathing?
NO
• ↓UOP
• SpO2 Monitor (if not already placed) • Persistent Cyanosis? Fluid Overload
• Determine APGAR Score • Shortness of Breath
YES • Ankle / Sacral Edema
Post Resuscitation Care • ↑Jugular venous pressure
• Crackles in Lungs
• Clear Airway
• BVM (PPV): 100% O2 at 40-60/min APGAR SCORE
• SpO2 Monitoring • Determine by end of 1st 60 seconds of care and repeat every 5 min.
• Score of 6 or less? Start Immediate Resuscitation.
(CPR: 90 compressions per 30 ventilations / min - on 100% O2)
HR <100? NO
APGAR
0 POINTS 1 POINT 2POINTS SCORE
YES SCORING
Take Ventilation Corrective Steps HEART RATE ABSENT <100 BPM >100 BPM
(Intubate if NO Chest Rise) RESPIRATORY
ABSENT WEAK CRY STRONG CRY
EFFORT
MUSCLE SOME ACTIVE
NO HR <60? FLACCID
TONE FLEXION MOTION
YES REFLEX NO VIGOROUS
GRIMACE
IRRITABILITY RESPONSE CRY
• Chest Compressions with PPV BODY PINK, BODY PINK,
(120 events/min: 90 compressions BLUE,
COLOR EXTREMITIES EXTREMETIES
interspersed with 30 ventilations) PLAE
BLUE PINK
• Consider Intubation TOTAL
Epinephrine 1:10,000 APGAR:
0.01-0.03mg/kg push q3-5min
NO HR <60? YES (0.1-0.3mL of 1:10,000
10cc Cardiac Epi vial)
1. D10: 5ml/kg IV (Dilute 25ml D50 into Consider:

100ml NS) (Max 25G/Dose) 1. Hypoglycemia (Treat Glucose <40)
2. NS or Blood 10mL/kg IV 2. Shock
3. Intubation 3. Pneumothorax (Intubate)
68
RESPIRATORY DISTRESS
• Shortness of Breath • Asthma
• Pursed Lip Breathing • Anaphylaxis / Allergy
• Decreased Ability to Speak • Aspiration
• Tachypnea / Hyperpnea • COPD
• Wheezing / Rhonchi / Rales • Pleural Effusion
• Use Accessory Muscles • Pneumonia
• Fever / Cough • Congestive Heart Failure / Cardiac
• Tachycardia • Pulmonary Embolus
• Absent Breath Sounds • Pneumothorax
(Emergent) • Pericardial Tamponade
• Hyperventilation
• Toxic Inhalation (e.g., Cyanide, CO)
AIRWAY Guideline
Consider: Indications of: Position to
YES Respiratory Insufficiency NO Monitor O2 Sat
Early establishment of Patient Comfort
(*See Pearls)
Advanced Airway!
Rales / Signs of CHF Wheezes Stridor
PPV (if patient can tolerate) 100% O2 via NRB View for Obstruction:
Otherwise, (jaw-thrust for c-spine injury)
100% O2 via NRB • Sweep & Suction prn
Albuterol 90mcg Inhaler
2puffs or 2.5mg neb 100% O2 via NRB
NTG SL 0.4mg q5min if SBP > 90
Consider Epinephrine 1:1,000
0.3mg IM (EPI PEN) O2 Sat <90% or respiratory
status continues to deteriorate:
IV / IO Guideline Consider:
PEDs AIRWAY Guideline
ALLERGIC
If Failing to Improve, Consider: IV / IO Guideline REACTION
Furosemide 40mg IV (Foley?) • Methylprednisolone Albuterol 90mcg Inhaler
125mg IV 2puffs or 2.5mg neb
Consider: Consider Epinephrine 1:1,000
• Magnesium Sulfate 2gram IV 0.3mg IM (EPI PEN)
over 20min
IV / IO Guideline
Methylprednisolone 125mg IV
Pearls:
• Signs of respiratory insufficiency: Cyanosis, altered mental status / loss of consciousness, fatiguing, inability to speak, or inability
to maintain O2 sat >90% with supplemental O2.
• Albuterol can be administered with spacer or short (6”) section of ventilator tubing to increase delivery if patient unable to perform
action appropriately. No max dose of albuterol, repeat as needed for continued wheezing.
• Lack of abnormal breath sounds does not always signify improvement. As respiratory status worsens, there may be inadequate air
movement to produce these sounds.
69
PEDs RESPIRATORY DISTRESS
• Shortness of Breath • Asthma
• Tri-Pod Position • Anaphylaxis / Allergy
• Pursed Lip Breathing • Aspiration
• Decreased Ability to Speak • Pleural Effusion
• Tachypnea / Hyperpnea • Pneumonia
• Wheezing / Rhonchi / Rales • Pulmonary Embolus
• Use Accessory Muscles • Pneumothorax
• Fever / Cough • Pericardial Tamponade
• Tachycardia • Hyperventilation
• Absent Breath Sounds • Toxic Inhalation (e.g., Cyanide, CO)
AIRWAY Pediatric Indications of:

Consider: Respiratory Insufficiency Position to
YES NO Monitor O2 Sat
Early establishment of Fatigue? Patient Comfort
Advanced Airway! (*See Pearls)
Rales / Signs of CHF Wheezes Stridor
PPV (if patient can tolerate) 100% O2 via NRB View for Obstruction:
Otherwise, (jaw-thrust for c-spine injury)
100% O2 via NRB Albuterol 90mcg Inhaler • Sweep & Suction prn
2 puffs or 2.5mg neb 100% O2 via NRB
NTG SL 0.4mg q5min if SBP > 70
Consider Epinephrine
+ 2 x age Consider:
>30 kg: 1:1,000 0.3mg IM (EPI PEN) O2 Sat <90% or respiratory
15-30 kg: 1:1,000 0.15mg IM (EPI PEN JR) Pediatric
status continues to deteriorate:
IV / IO Protocol OR (for all PEDS) ALLERGIC
PEDs AIRWAY Protocol
1:1,000 0.01mg/kg (max 0.3mg) IM REACTION
If Failing to Improve, Consider:
Furosemide 1mg/kg IV (Foley?) Albuterol 90mcg Inhaler
IV / IO Protocol
2puffs or 2.5mg neb
Consider:
Consider Epinephrine
Methylprednisolone
>30 kg: 1:1,000 0.3mg IM (EPI PEN)
: 1-2mg/kg IV
15-30 kg: 1:1,000 0.15mg IM (EPI PEN JR)
and
OR (for all PEDS)
Magnesium Sulfate 25-75mg/kg 1:1,000 0.01mg/kg (max 0.3mg) IM
IV over 30min (Max 2g)
IV / IO Protocol
Methylprednisone 1-2mg/kg IV
Pearls:
• Signs of respiratory insufficiency: Cyanosis, altered mental status / loss of consciousness, fatiguing, inability to speak, or inability to
maintain O2 sat >94% with supplemental O2.
• Albuterol can be administered with spacer or short (6”) section of ventilator tubing to increase delivery if patient unable to
perform action appropriately. No max dose of albuterol, repeat as needed for continued wheezing.
• Lack of abnormal breath sounds does not always signify improvement. As respiratory status worsens, there may be inadequate air
movement to produce these sounds. In pediatric patients (especially infants), respiratory insufficiency may be the result of cardiac
anatomical anomalies, in addition to standard causes. Peripheral cyanosis is a clue to this condition, and suspicion should be reported to
accepting providers upon arrival.
70
RAPID SEQUENCE INTUBATION
CLINICAL INDICATIONS: RSI MEDICATIONS
Pretreatment:
• Respiratory failure *Fentanyl 3 mcg/kg IV
• Patient who has suffered airway burns or presents with signs of Induction Agents:
Etomidate 0.3-0.5mg/kg IV
allergic reaction / allergy or other disorder which threatens to
Propofol 0.5-1.5mg/kg IV
obstruct airway preventing adequate respirations. Ketamine 1-2mg/kg IV
CONTRAINDICATIONS: Paralytics:
Succinylcholine 1.5mg/kg
• Massive upper airway trauma distorting anatomy Rocuronium 1mg/kg
Vecuronium 0.1-0.15mg/kg
• Penetrating neck trauma Sedatives:
Midazolam 0.1mg/kg
PROCEDURE (6Ps):
Fentanyl 0.5-2mcg/kg
Prepare: Ensure all equipment ready / functional (including rescue Propofol 0.5-1.5mg/kg
airway) and patient positioned / prepared. Ensure patient on monitor,
to include PO 2 .
Pre-oxygenation: Using a NRB, have patient breathe 100% O 2 for several (at least five) minutes prior to
intubation. If this is not possible, have patient take 3-5deep breaths while on 100% O 2 . Breaths can be
delivered / assisted as needed with BVM.
Pre-medication: This can begin during pre-oxygenation and should take place 1-2min prior to intubation.
Pretreatment medications:
- Fentanyl for head injury, cardiac ischemia or aortic dissection. (Drug of choice if pretreatment
medications are used) *** Consider lower dose for trauma patients due to endogenous opiod production
occurring in trauma.
- Atropine in Pediatric Patients (Evidence does not support the routine usage for pre-medication. If
bradycardia is suspected or results from intubation attemps, give atropine as indicated (0.02 mg/kg
Minimum dose is 0.1 mg. Maximum single dose of 0.5 mg. May repeat once in 3-5 minutes. Maximum
total dose is 1 mg (2015 AHA update))
Paralysis / Sedation: Standard paralysis / sedation should consist of Ketamine or etomidate followed in
approx. 1min by succinylcholine or Rocuronium (*Vecuronium can be used, but is not recommended as first-line
due to delayed onset of action and long duration of action.) Sedation should always be performed prior to
paralysis. When using succinylcholine, wait until fasciculations seen and jaw “loose” to attempt visualization. In
patients suffering from acute large burns and crush injuries where hyperkalemia is a concern, Rocuronium is the
preferred agent.
Pass the Tube: Visualization of the cords / arytenoids cartilages should be noted / documented. Tube must be
seen passing these structures. Do not use excessive force as this can damage the cords.
Post-Flight: Once ETT in place, inflate bulb and begin bagging patient – do not let go of tube until secured with
tape or commercial device. Placement should be confirmed with >1 method, capnography preferred. Other
71
methods: capnometer, esophageal detection device, bilateral equal chest rise, PO 2 rise / maintained >95%,
equal bilateral breath sounds.
* Vecuronium is the recommended medication for maintenance of paralysis for prolonged field care and longer
duration flights.
Document procedure, results, and vital signs. Procedure should be documented on intubation record
form and maintained with patient record.
72
AIRWAY CONFIRMATION
• Post endotracheal intubation to confirm proper placement of endotracheal tube.
CONTRAINDICATIONS:
• None
PROCEDURE:
• Primary / First confirmation of proper placement is always good visualization of tube passing through cords.
• Provider or second individual should listen for bilateral breath sounds and absence of gastric sounds. Also
evaluate for equal chest rise.
• CAPNOGRAPHY is gold standard for patient airway monitoring.
• Capnometer: Place onto ETT and bag patient 2-3 breaths. Proper placement will result in color change to
Gold / Yellow. Esophageal placement will result in a purple color. (Gold = good, Barney = bad)
• Esophageal detection device: Squeeze bulb expressing all air out of the EDD. Place this onto end of ETT.
Rapid refilling suggests proper placement (the rigid trachea does not collapse and therefore there is no
obstruction to air return). Poor filling or no filling suggests improper placement (the flaccid esophagus will
collapse around ETT preventing refilling).
• Pulse oxygenation: After a short delay (seconds), the pulse oxygenation should increase to normal range
(this is not reliable in excessively cold patients, methemoglobinemia, or CO poisoning).
At any time, doubt as to correct placement should prompt removal of tube, oxygenate with
BVM, and re-attempt with BIAD before rescue airway!
73
NASOPHARYNGEAL AIRWAY
• Depressed mental status with need for airway augmentation to ensure patency / access.
RELATIVE CONTRAINDICATIONS:
• Patient at high-risk of aspiration and/or unable to protect airway
• Massive facial trauma, burns, or suspicion of basilar skull fracture (e.g., CSF otorrhea, Battle’s sign, raccoon
eyes, mechanism).
PROCEDURE:
• Position patient in the sniffing position.
• Select appropriate sized NP tube and lubricate with water-soluble jelly (can measure tube by placing
exterior (lipped) end next to nare and tip should reach to angle of mandible).
• Select most patent nare and pass tube in a posterior – not superior – direction. If resistance is met,
attempt to corkscrew slightly or remove and attempt in other nare. If unsuccessful, try the next smallest
sized tube.
• Pass tube until lip of NP tube rests against nare.
• Bag patient with BVM / mask as needed.
74
BLIND INSERTION AIRWAY
DEVICE (BIAD)
Patient with inadequate respiratory drive or respiratory failure due to any reason (e.g., altered mental status,
trauma, infection) other than airway burns, anaphylaxis, or other causes of airway swelling / obstruction.
CONTRAINDICATIONS:
• Massive upper airway trauma distorting anatomy
• Penetrating neck trauma
PROCEDURE:
Consider paralytic/analgesia/sedation medications when placing supraglotic airways devices. In any
instance of BIAD placement, caregiver must be prepared for vomiting and aspiration.
• Prepare, position, and pre-oxygenate the patient with 100% O 2 . Ensure patient on monitor if possible.
• Select appropriate size BIAD and ensure proper cuff inflation / deflation.
WARNING: BIADs may not
• Lubricate with water-soluble jelly. prevent or block aspiration of
• Advance tube towards posterior pharynx until seated in correct position. gastric contents.
• Inflate balloon as per package insert and attempt to ventilate with BVM.
• If good airflow / chest rise / PO 2 , secure device in place and ventilate patient with BVM / Vent.
• If unable to ventilate / resistance, leave first BIAD in place, deflate balloon, and pass a second BIAD in
the same manner as the first (this should only be able to enter the esophagus as the first should have
went into the trachea – 5-10%). Once second BAID is in place, remove first and inflate the cuff on the
second device. Attempt to bag as above. If successful, ventilate patient.
75
CRICOTHYROIDOTOMY
• DIFFICULT AIRWAY- Airway can receive one (1) RSI attempt before calling it a failed airway. Two
exceptions exist:
o Inability to maintain proper O saturation above 94% or major trauma or obstruction
• NON-DIFFICULT AIRWAY- Airway can receive two (2) attempts so long as O₂ saturation is >94%.
• Inability to place / ventilate with blind insertion airway device (BIAD) or inability to provide ventilation with
Bag-Valve mask.
• Massive facial trauma or neck trauma precluding the use of orotracheal intubation / BIAD.
CONTRAINDICATIONS:
• Age <12yo, abnormal anatomy.
PROCEDURE:
• Maintain patient in sniffing position or place them into sniffing position. Utilize inline stabilization if indicated.
• Oxygenate the patient with 100% O 2 . Identify and cleanse the cricoid area with betadine / alcohol while
oxygenating if possible.
• Before incising place static non-dominant hand using the middle and thumb to hold either side of the thyroid
cartilage with the palm towards the head leaving and area between the fingers inferiorly to make the
incision. This hand will not move until bougie is confirmed in the trachea.
• Using a scalpel, make an adequate (2-3cm) vertical incision over the cricothyroid membrane. Then, using
hemostats, bluntly dissect until membrane fully visualized.
• Make an adequate horizontal incision through the cricothyroid membrane into the trachea. Spread incision
with either hemostats or scalpel handle.
• At this point the index finger of the hand gripping the thyroid cartilage can be placed within the opening and
the posterior aspect of the trachea can be palpated. The index finger maintains the tract should the airway
be extremely bloody as this procedure is prone to be. The bougie/stylet is then placed along the index finger
ensuring tracheal guidance and not subcutaneous plane dissection or posterior tracheal perforation into the
esophagus.
• Once the bougie/stylet is inserted, pass a cricothyroid tube or 6-0 ETT into the trachea (if ETT used, only
insert until just past the cuff, then inflate the cuff). Secure tube in place and begin to ventilate with BVM /
100% O 2 .
• Confirm placement with capnography, capnometer, bilateral chest rise / breath sounds, good PO 2 , ETCO 2 ,
lack of increasing SQ air (a small amount is normal).
76
• Document procedure, results, and vital signs.
77
NEEDLE CRICOTHYROIDOTOMY
• Child <10yo in whom open cricothyroidotomy is contraindicated with the following:
o Failed intubation attempts x 3 by the most experienced provider present with inability to ventilate
with BVM / high risk to ventilate with BVM.
o Inability to place / ventilate with blind insertion airway device (BIAD).
o Massive facial trauma or neck trauma precluding the use of orotracheal intubation / BIAD.
CONTRAINDICATIONS:
• Ability to ventilate adequately with BVM.
• Prolonged time to definitive care (relative).
NOTE: this technique requires a minimum of 50 psi O 2 or pressurized air flow and a special adapter to connect
the line to the catheter hub; do not attempt otherwise.
PROCEDURE:
• Maintain patient in sniffing position or place them into sniffing position. Utilize inline stabilization if indicated.
• Oxygenate the patient with 100% O 2 . Identify and cleanse the cricoid area with betadine / alcohol while
oxygenating if possible.
• Using a 14Ga IV attached to a 3mL syringe, puncture the cricothyroid membrane at a 90º angle. Do not
advance needle once air returned.
• Change angle to 45º and advance Catheter only. Should advance with no resistance. Remove needle and
syringe.
• Secure catheter in place. Remove needle and plunger from syringe and place an adapter from a 7-0ETT on
end of syringe in place of plunger. Attach this to the catheter.
• Attach a BVM attached to 100% O 2 to the adapter / syringe and ventilate. A large amount of resistance will
be felt due to the small catheter size. Evaluate for chest rise and oxygenation. The provider needs to allow
a 1:3 ratio of inhalation / exhalation.
NOTE: needle cricothyroidotomy only allows for oxygenation, not ventilation. It is meant as a
temporizing measure until definitive care – tracheostomy – can be performed at an MTF.
This airway should be used for only 20-30min maximum if able.
• Start working alternatives immediately after initiation - such as retrograde wire intubation,
surgical cric with needle as an anatomical landmark.
78
TUBE THORACOSTOMY
PLACEMENT
• Pneumothorax + positive pressure ventilation or interfering with oxygenation
• Hemothorax + positive pressure ventilation or interfering with oxygenation
• Chest injury with suspected pneumo / hemothorax as above
• Evidence of tension pneumothorax after needle thoracostomy attempts
CONTRAINIDICATIONS:
• Stable patient oxygenating well, no tension PTX
• Blood clotting abnormalities (relative)
PROCEDURE (STERILE):
• Ensure all equipment prepared / available: Scalpel, 4X4 gauze, petroleum gauze, suture material (0 –
1-0 silk), 36Fr or larger chest tube, Heimlich valve / Water seal, large Kelly clamp x 2, betadine / skin
cleanser, 1-2% lidocaine, 10mL syringe with needle for lidocaine, sterile gloves.
• If possible, position patient supine with shoulder flexed up and hand under his / her head.
• Identify and clean area of insertion with skin cleanser. Area of insertion should be over the 4th or 5th rib
on injured side.
• Anesthetize the area with lidocaine. Take care to anesthetize the rib if possible by passing needle
perpendicular to skin until bone contacted and backing off slightly to inject lidocaine. May also
anesthetize the pleura by advancing needle just until air returned and then injecting area while pulling
back needle.
• Measure depth of tube by holding over patient’s thorax. Approx. depth of insertion is the length from at
the entry site when tip of tube at apex of lung. Clamp the tube with Kelly clamp at this measured
length.
• Make incision in skin / SQ tissue overlying 5th rib. Ensure incision large enough for insertion of tube /
finger.
• Bluntly dissect tissue going over 5th rib with second clamp until pleura is reached. Then puncture the
pleura with the clamps. Holding clamps in hand with index finger on shaft of the instrument will prevent
overly deep insertion and subsequent lung injury. Open clamps as wide as possible and remove them,
enlarging the pleural opening.
• Place finger into opening and palpate for any adhesions.
• Advance tube into opening directing the tip of the tube posteriorly and superiorly towards the lung apex
along the posterior aspect of the chest wall. This method ensures tube will drain both hemo
/pneumothoraces.
• Holding tube in place – Place modified chest seal around the tube ensuring seal of the wound as well
as securing tube in place. If possible, staple chest seal to skin.
• Apply suction to tube / Heimlich valve and remove clamp.
CHEST TUBE TROUBLESHOOTING:
• Ensure tube not clamped / kinked and that suction is working.
• Ensure tube has not become dislodged.
• If evidence of tension PTX – cut attachments from end of chest tube (e.g., suction adapter, Heimlich valves ,
suction devices) to convert to open PTX.
79
NEEDLE THORACOSTOMY
• Suspicion of tension pneumothorax compromising patient’s hemodynamic status.
• Symptoms / signs of tension pneumothorax may include: shortness of breath, chest pain, distended
neck vessels, hypotension, tracheal deviation away from affected side, lack of breath sounds on
affected side, loud percussion on affected side, or cardiac arrest.
CONTRAINDICATIONS:
• None
PROCEDURE: Note: This intervention is a BRIEF stop-gap utilized in order to buy time for a definitive
tube thoracostomy . It is not a solution unto itself.
• Once tension pneumothorax suspected, identify 2nd intercostal space, mid-clavicular line on affected side
(rib palpable just under clavicle is 2nd rib).
• Clean area if possible with betadine / alcohol, but do not delay treatment for this step.
• Using a 14Ga IV, 3.25” (preferable 3.75” or 10cm), puncture skin at 90º angle just over top of 3rd rib
(prevents damage to the neurovascular bundle which runs below each rib) and advance until gush of air is
returned.
• Remove needle and secure catheter in place.
• If unsuccessful / unable to penetrate to pleural space and confident that tension pneumothorax present on
that side, may attempt same procedure in mid-axillary / anterior-axillary line in 4th ICS (ensure that
placement in this area is reported to receiving hospital so that it is not missed).
In cases of cardiac arrest / significant trauma – this may need to be performed bilaterally.
80
VENTILATOR MANAGMENT
• Patient received from transferring facility, intubated, and requires ventilator support.
• Patient requiring intubation in the field and subsequent respiratory support.
CONTRAINDICATIONS:
• Equipment malfunction / failure.
PROCEDURE:
• Turn on ventilator and ensure that machine is functional and battery is charged.
• Attach ventilator tubing and O 2 tubing to machine.
• If patient is a transfer and already on vent, maintain ventilator settings from medical treatment facility.
• If patient “newly” on ventilator, initial settings should include:
o Mode: AC, SIMV, or ASV (if using Hamilton T1)
o Rate: 10-16bpm (or adequate rate for pediatric patient) (typical adult start rate is 12, then adjust PRN)
o FiO₂: 100 percent
o I:E ratio: 1:2 – 1:4
o Tidal Volume: 6-8mL/kg (of ideal body weight)
o PEEP: 5
• Monitor waveform on machine and patient to ensure not “breathe stacking” – if this occurs, a high-pressure alarm may sound.
However, if breath stacking suspected even in absence of alarm – disconnect tubing and allow exhalation. Increase I:E.
• If at any time patient begins to desaturate or develop respiratory problems – check rapidly to ensure that vent did not fail and
O 2 tank not empty. Immediately disconnect ventilator and ventilate patient with BVM and 100% O 2 . If this resolves problem
or vent failed, continue to bag patient. Then titrate FiO 2 down as much as possible while keeping O 2 sat >93% (Goal FiO 2 50-
60%) in order to attempt to conserve oxygen for long flights and conserve battery power.
• If problem does not resolve, ensure tube did not move during transfer. If advanced – pull back to original length and attempt
to bag. If this fails, ensure equal chest rise with breaths and that a tension pneumothorax has not developed (if chest tube in
place, ensure it is functioning). If tension pneumothorax suspected, perform immediate needle thoracostomy.
• If tube has pulled farther out of trachea, DO NOT ATTEMPT TO ADVANCE IT without placement of bougie to verify tracheal
placement. When advancing bougie to verify placement, feel for tracheal rings or carina stop. If in doubt, pull tube and
attempt BVM. If this fixes problem, continue to bag patient.
81
VENTILATOR Capabilities, Terms,
Transfer Procedure, Troubleshooting
Ventilator Capabilities
Impact Model 754 Ventilator Impact Uni-Vent 731 Series EMV+
A/C A/C
SIMV SIMV
CPAP CPAP
Volume Control Volume Control
Pressure Control
Pressure Support
Simplified Automated Ventilator (SAVe) SAVEe II

Single tidal volume and respiratory rate (Vt = 600 mL; BPM 10) Varied tidal volume based on patient height
6 Lpm of supplemental O 2 (MAX FiO 2 = 62%) Accepts supplemental O₂ (FiO₂ 21 – 100%)
AutoVent 3000 Versamed iVent201

CMV A/C
Adult / Child SIMV
Tidal volume CPAP
Inspiratory time Pressure support ventilation (PSV)
BPM
Hamilton T1
CMV, SIMV, PCV, DuoPAP, APRV, ASV
Adult / Child
Terms
Volume-targeted modes (Examples: CMV, A/C, SIMV): Volume constant, inspiration terminates when preset V t
delivered. Peak airway pressure is variable and increases as needed to deliver prescribed V t.
Pressure-targeted modes (Examples: PSV, PCV): Volume variable, terminates when preset pressure reached. Volume
is variable. Peak airway pressure is fixed, determined by set pressure level.
Adaptive Support Ventilation (ASV): Only available on the Hamilton T1. ASV provides intelligent ventilation mode that
continuously adjusts respiratory rate, tidal volume, and inspiratory time depending on the patient’s lung mechanics and
effort.
Tidal volume (V t ): The volume of gas, either inhaled or exhaled, during a breath and commonly expressed in milliliters.
V t is generally set between 6-10ml/kg IBW (ideal body weight), to prevent lung over-distension and barotrauma.
IBW calculation:
Men: [(height in inches – 60) x 2.2] + 50= Kg IBW
Women: [(height in inches – 60) x 2.2] + 45= Kg IBW
82
Minute Ventilation (V E ): The average volume of gas entering, or leaving, the lungs per minute, commonly expressed in
liters per minute. The product of V t and RR (respiratory rate). Normal V E is 5 – 10 L/min.
Inspiratory (I) and Expiratory (E) time and I:E ratio: The speed at which the V t is delivered. Setting a shorter inspiratory
time (I) results in a faster inspiratory flow rate. Average adult I time is 0.7 to 1 second. I:E ratio is usually 1:2 to 1:4
Positive end-expiratory pressure (PEEP): The amount of positive pressure that is maintained at end-expiration. It is
expressed in centimeters of water. The purpose of PEEP is to increase end-expiratory lung volume and reduce air-space
closure at end-expiration. Normal Physiologic PEEP is 5cm/H 2 O.
Peak flow rate or peak inspiratory flow: The highest flow, or speed, that is set to deliver the V t during inspiration,
usually measured in liters per minute. When the flow rate is set higher, the speed of gas delivery is faster and
inspiratory time is shorter.
Peak Airway Pressure (P AW ): Represents the total pressure that is required to deliver the V t and depends upon various
airway resistance, lung compliance, and chest wall factors. It is expressed in centimeters of water (cm H 2 O).
Sensitivity or trigger sensitivity: Effort, or negative pressure, required by the patient to trigger a machine breath,
commonly set so that minimal effort (-1 to -2 cm H 2 O) is required to trigger a breath.
Ventilator Transfer Procedure

1. Ensure endotracheal tube is secure, document size and position of ETT at the teeth.
2. Ventilator settings should be coordinated with the transferring physician, anesthesia provider or respiratory therapist.
Verify settings, review arterial blood gas (ABG) analysis, and current SPO 2 and ETCO 2 readings.
3. ABG should be done within 30 minutes of flight. If time allows, patient should be on transport ventilator for at least
15 minutes prior to transport.
4. The initial tidal volume (V t ) 6 – 10 mL/kg ideal body weight (IBW).
5. Pressure Support: If patient has a spontaneous tidal volume, titrate Pressure Support setting to maintain tidal volume
minimum of 4-5 ml/kg, typically 10 cmH 2 O.
6. Respiratory rate (RR) should be set to administer a minute ventilation (V E ) of 5 –10 L/min. Maintain ETCO 2 between
30-40 mm/Hg. [Current ETCO 2 × Current RR ÷ desired ETCO 2 = new respiratory rate]
7. PEEP 2-10 cm H 2 O
8. I:E Ratio = 1:2 or 1:3
9. FiO 2 : Initiate at 100% and titrate FiO 2 to maintain SpO 2 >94%. Wean patient to the lowest level of FiO 2 and PEEP
while maintaining SpO 2 >94%. Goal is FiO 2 50-60 and SpO 2 >94%.
Troubleshooting: Airway compromise or lost airway in-flight

Remove patient from circuit and perform bag-valve ventilation with 100% O 2 while troubleshooting (check to ensure
patient can fully exhale first in case there was air trapping).
• DOPE: Displaced ETT / Obstructed ETT / Pneumothorax / Equipment failure
83
• Airway: Confirm ETT is in appropriate position: look / feel for symmetric chest wall rise and verify tube
position Check ETCO 2
• Suction ETT if suspected secretion obstruction
• Breathing: Look and feel for chest excursion, check SPO 2 , check patient’s color; Assess for
pneumothorax
• Circulation: check pulse, BP, and cardiac rhythm
• Assess for equipment failure (e.g., battery, depleted oxygen, vent settings)
Note: Remember, PCO 2 is affected by respiratory rate and tidal volume (ventilation), while PO 2 is affected by
PEEP and FiO 2 (oxygenation).
10. High pressure alarms / Peak airway pressure alarms (Peak pressure >35 cm H 2 O): Correct problems causing
increased airway resistance and decreased lung compliance, including pneumothorax or pulmonary edema. Check
ventilator to make sure prescribed tidal volume is being delivered.
11. Air leaks causing low pressure alarms / volume loss: Assess, correct air leaks in endotracheal tube, tracheostomy
cuff, ventilator system; recheck ventilator to make sure prescribed tidal volume is delivered.
12. Ventilator dyssynchrony: Agitation and respiratory distress that develop in a patient on a mechanical ventilator who
has previously appeared comfortable represents an important clinical circumstance that requires a thorough assessment
and an organized approach. The patient should not always be automatically re-sedated, but must instead be evaluated
for several potentially life-threatening developments that can present in this fashion.
13. Lung hyperinflation (air trapping) and auto-PEEP: Dynamic hyperinflation is associated with positive end-expiratory
alveolar pressure, or auto-PEEP. The physiologic effects include decreased cardiac preload because of diminished
venous return into the chest. The reduced cardiac output that results from the reduction in preload can lead to
hypotension and, if severe, to Pulseless Electrical Activity and cardiac arrest. Dynamic hyperinflation can also lead to
local alveolar over-distention and rupture. Prevent, manage lung hyperinflation by decreasing tidal volume, changing
inspiratory and expiratory phase parameters, switching to another mode, and correcting physiological abnormalities
that increase airway resistance.
84
BRADYCARDIA with PULSE
• HR <50bpm • Acute MI
• Chest Pain • Hypoxia
• Respiratory Distress • Hypothermia
• Hypotension / Shock • Sinus Bradycardia
• Altered Mentation • Physiologic Bradycardia (Athletes)
• Syncope • Stroke
• Spinal Cord Lesion
• Toxin / Medications (B-blockers)
• AV Block / Sick Sinus Syndrome
Universal Patient Care Guideline Indicators of Instability:

O2 (if Hypoxemic) • Blood Pressure low (hypotension)
IV / IO Guideline • Altered mental status
Monitor and 12-Lead ECG (ASAP) • Signs/Symptoms of shock
• Ischemic chest pain
• Congestive heart failure (acute)
Place PACER PADS
• Heart block (Mobitz 2 and complete)
YES Patient Stable? NO
Unstable without Block

Observe Unstable with
(or with 1st degree or 2nd
Reassess q 5 minutes 2nd degree type 2 or 3rd degree block
degree type I AVB)
Transcutaneous Pacing Atropine IV / IO

(consider sedation: 0.5mg bolus
midazolam 2-5mg IV / IO) Repeat q 3-5 minutes
(MAX 3mg)
No improvement
Transcutaneous Pacing
Continuous Monitoring (consider sedation:
midazolam 2-5mg IV / IO)
OR
“OVERDOSE” treatable causes:
Dopamine IV / IO
• B-blocker (atenolol, metoprolol, labetalol): 2-10 mcg/kg/min
o Glucagon 0.05mg/kg (3-10mg) IV – pretreat with
ondansetron 4-8mg for nausea if possible OR
• Calcium channel blocker (diltiazem, verapamil, nifedipine):
o Calcium Chloride 10% 1000mg (1amp) slow IV Epinephrine IV / IO
push (1-1.5 mL per minute; not exceeding 2-10 mcg/min
200mg/min) (profound bradycardia or
hypotension)
Pearls:
• Decompensation at any time (e.g., altered MS, hypotension) should prompt treatment as unstable patient.
• All bradycardic patients should have pacer pads in place after initial evaluation.
• Epinephrine infusion for refractory bradycardia: 2-10 mcg/min or 0.1-0.5 mcg/kg/minute (7 to 35 mcg/min in
a 70 kg patient)
o 1mg 1:10,000 in 250mL D5W / NS = 4 mcg/mL concentration
• Evaluate for treatable causes of bradycardia (B-blockade, Ca Channel blockade).
85
CARDIAC ARREST
Signs and Symptoms: START CPR (100/min, Breath 30:2) Signs and Symptoms:
• Pulseless
• Unresponsive, apneic, Universal Patient Care Guideline
pulseless • Apneic
O2
• Ventricular fibrillation or • No electrical activity in at
Monitor / Defibrillator
ventricular tachycardia on least two ECG leads
EKG VF / pulselessVT Asystole / PEA (asystole)
• Electrical activity on monitor
Rhythm shockable? without pulses (PEA)
YES Confirm in two leads NO • No heart tones
Shock
200J biphasic, 360 monophasic
CPR 2 min CPR 2 min

IV / IO access (IV Guideline) IV / IO access (IV Guideline)
Epinephrine (every 3-5 min)
Return of Spontaneous NO
Rhythm shockable? NO IV / IO: 1:10,000 1mg (amp)
Circulation (ROSC)?
Consider advanced airway,
YES capnography: 6-10 breaths/min
Shock
YES (Airway Guideline)
CPR 2 min ROSC at any time: Rhythm shockable? YES

go to:
Epinephrine (every 3-5 min)
Post-Cardiac Arrest Care NO
IV / IO: 1:10,000 1mg (amp)
Guideline
Consider advanced airway, CPR 2 min
capnography: 8-10 breaths/min
(Airway Guideline) Treat Reversible Causes
Reversible Causes:
• Hypovolemia
Rhythm shockable? NO NO Rhythm shockable? YES
• Hypoxia
YES • Hypothermia
Shock • Hypoglycemia
• Tension pneumothorax Move to
• Tablets/toxin VF / pulseless VT side of guideline
CPR 2 min • Tamponade, cardiac
• Hydrogen ion (acidosis)
Amiodarone IV / IO • Hypo-hyperkalemia
1st Dose: 300mg bolus • Thrombus – cardiac
2nd Dose: 150mg • Thrombus – pulmonary
Treat Reversible Causes
Pearls:
• Reversible causes should be addressed as soon as possible.
• Consider discontinuation of efforts if:
o Asystole following trauma – especially blunt.
o Prolonged downtimes - > 15min.
o Prolonged code with no response - >3 rounds of medications, 30min of resuscitation.
o All patients should get a glucose check, at least 1L fluid bolus, and ultimately bilateral
needle decompression (especially in Trauma) before discontinuation of efforts.
o Should take at least 1min to check for pulse in hypothermic patients.
•
nd
Lidocaine can be used if Amiodorone is unavailable. 1-1.5mg/kg Initial dose. 2 dose 0.5-0.75mg/kg
86
CHEST PAIN
Signs and Symptoms: Differential Diagnosis: Differential Diagnosis:
• Chest Pain • Angina • Aortic Dissection /
• Radiation of Pain • Acute MI Aneurysm
• Location of Pain • Pericarditis • GERD
• Pale / Diaphoretic / Lightheaded • Pulmonary Embolism • Esophageal Spasm
• Nausea / Vomiting • Asthma / COPD • Chest Wall Injury / Pain
• Shortness of Breath • Pneumothorax
O2
IV / IO access (IV Protocol)
Aspirin 324mg PO chewed (if no

significant aspirin allergy - *See Pearls)
Dysrhythmia? / Pulse? • ST Elevation MI or LBBB
Move to appropriate protocol below 12 Lead ECG • ST Depression or Flipped T -Wave
**NTG 0.4mg SL q5min (hold if
pain free, SBP <100, or taken
Viagra, Cialis, Levitra in last 48 hrs) Transport to nearest MTF ASAP
Bradycardia with Pulse • Do not delay reperfusion: *See Pearls
Normal Sinus Rhythm
BP >100 Hypotension /
Shock? STEMI or LBBB
Tachycardia with Pulse Continuous • Do not delay reperfusion: *See Pearls.
Monitoring: • Move to appropriate Cardiac Protocol
Move to (opposite side of page) based on
appropriate 500 ml bolus NS/LR changes in Pulse and ECG.
Protocol
Cardiac Arrest based
(VF / Pulseless VT or changes in
Asystole / PEA) ECG and Consider Treatable
Pulse Causes: 5Hs / 5Ts
For continued pain after NTG and if

NOT Hypotensive:
Morphine 2-5mg IV or
Fentanyl 25-50mcg IV
Pearls:
• Aspirin should be held only for patients with known significant allergy: if rash alone give DIPHENHYDRAMINE
then aspirin. If stomach ache, give H2 blocker (RANITIDINE) then aspirin.
• Patients with suspected AMI should be transferred to the nearest MTF for further treatment / thrombolytics.
• **With right sided MI (ST Elevations in leads II, III, AvF), NTG may cause hypotension so use with caution. Add
small fluid boluses for low BP.
• Ensure that you have IV access before giving SL NTG.
• Hold Morphine or Fentanyl for SBP <90.
• Max dose Morphine 20mg, Fentanyl 200mcg for non-traumatic chest pain (higher doses may be required for
trauma, see Pain Control algorithm).
87
TACHYCARDIA w/PULSE
Signs and Symptoms: Differential Diagnosis (Wide Complex Differential Diagnosis (Narrow QRS):
• Ventricular Tachycardia on EKG QRS >.12sec): • Wolf-Parkinson-White Syndrome
(rate typically >150/min) • Artifact / Device Failure • Valvular Heart Disease
• Conscious, Rapid Pulse • Cardiac • Sick Sinus Syndrome
• Chest Pain / Shortness of Breath • Endocrine / Metabolic • Myocardial Infarction
• Palpitations • Hyperkalemia • Electrolyte Imbalance
• Dizziness • Drugs • Sinus Tachycardia / Atrial Flutter
• Anxiety • Pulmonary • Hypoxia
• Drug Overdose / Toxin
• Hyperthyroidism
Universal Patient Care Guideline METOPROLOL DILTIAZEM ADENOSINE
O2 (if Hypoxemic) 5mg IV q5min X 3 20mg (0.25mg/kg) IV over • 1st Dose: 6mg rapid IV
IV / IO Guideline Hold if SBP <100, P <60 2min. If no hypotension, push: followed by NS
Monitor and 12-lead ECG (ASAP) after 15 min repeat at Flush
25mg (0.35mg/kg) • 2nd Dose: 12mg
Chest Pain / SOB / YES NO
Dizziness?
“Sinus Tach” STABLE UNSTABLE: Signs / Symptoms of:
• BP Low (hypotension)
YES NO *Synchronized
• Altered mental status Cardioversion:
Chest Pain QRS Width? • Signs/symptoms of shock • Narrow Irregular, A-Fib
NO Guideline No unstable signs / • Ischemic chest pain • Narrow Regular, SVT,
symptoms, No • Congestive heart failure (acute) Atrial Flutter
“Sinus Tach”
Observe • Wide Regular, Stable
Reassess q 5 minutes Monomorphic VT
Consider Sedation:
• Vagal Maneuvers: Regular Narrow QRS? Wide QRS? Regular Midazolam 2-5mg IV / IO
Blow through 18ga IV <0.12 Second >0.12 Second
catheter, carotid massage, Consider:
bear down. Irregular AMIODARONE
• ADENOSINE: use for AMIODARONE
Regular Rhythm ONLY! • DILTIAZEM Stable Wide-QRS Tachy
Consider:
• DILTIAZEM • METOPROLOL • 1st Dose: 150mg IV
• **Torsades
• METOPROLOL If refractory or over 10min
• A-Fib with/or Wolff- becomes unstable • Repeat prn if VT recurs
Parkinson-White (look at any time!
*Synchronized for a delta wave) • Maintenance infusion:
Cardioversion: -Arrhythmia suppression, 1mg/min for 1st 6 hrs
• Narrow Irregular, A-Fib -Hypotension,
• Narrow Regular, SVT, -QRS widens by >50%, or All Pathways End with Continuous Monitoring
Atrial Flutter
Consider Sedation:
Midazolam 2-5mg IV / IO *Synchronized Cardioversion
(Increase Js per manufacture’s recommendation)
Pearls: Narrow Irregular, Atrial Fibrillation:
• **Torsades de Pointes may Benefit from early use of • 50-100 J biphasic
Magnesium: 1-2 grams IV over 60 min (Mix in 50ml Narrow Regular, Other SVT, Atrial Flutter:
D5W) Start drip of 0.5-1 gram/hr and titrate to effect. • 50-100 J, increase in stepwise fashion
Wide Regular, Stable Monomorphic VT:
• If hyperkalemia suspected (end-stage renal disease,
• 100 J, increase in stepwise fashion
dialysis) – administer Ca Chloride through central Wide Irregular:
access or Ca Gluconate through peripheral IV. • Defibrillate (NOT Synchronized)
• All patients should be warned of discomfort / feeling of • Go to: Cardiac Arrest Guideline
heart stopping prior to adenosine administration.
88
PEDIATRIC ALS INDICATORS
and BLS
Indicators of Potential Need for Cardiopulmonary Support
• Breathing
o Irregular Respirations or >60 breaths/min
o Labored Breathing (Retractions, Nasal Flaring, Grunting, Pursing of Lips, Tripod Positioning, ↓Ability to
Speak)
• Heart Rate Rages (especially if associated with poor perfusion)
o <2 Years Old: <80/min or >180/min
o >2 Years Old: <60/min or >160/min
• Poor Perfusion with Weak or Absent Distal Pulses
o Cyanosis
o ↓O 2 Sat
• Altered Mental Status
o GCS <8, Weak Cry, Unusual Irritability, Altered Responsiveness, Lethargy, or Failure to Respond to Painful
Stimulus
• Seizures, Fever with Petechiae, Trauma, and/or Burns >10% Body Surface Area
IOT Prevent Cardiac Arrest You Must Detect and Treat:

Respiratory Failure
Respiratory Arrest
Shock
Pediatric Cardiac Arrest Results from Deterioration in Respiratory or Cardiac Function!
Heart Awake Sleeping Blood

Rate/Min Age Rate Mean Rate Pressure Average Lower Limit
Newborn to
3mo 85-205 140 80-160 1-10y 90+(years old x 2)mmHg 70+(years old x 2)mmHg
3mo - 2y 100-190 130 75-160 >10y 90mmHg
2 - 10y 60-140 80 60-90 MAP 55+(years old x 1.5)mmHg
>10y 60-100 75 50-90 Rescue Breathing Ventilation Rate Without Advanced Airway:
Respiratory Universal Patient Care • NEWBORN = 40-60/min when performed without compressions
Rate/Min Age Rate O2 (100% FiO2) • Infant / Child = 1 breath / 3 to 5 seconds
Infant 30-60 Monitor / Defibrillator • Adult = 1 breath / 5 to 6 seconds
IV / IO access (IV Protocol) CPR Rate of 100 Compressions / Min at:
Toddler 24-40
• One Rescuer = 30 Compressions and 2 Breaths
Preschool 22-34 Unresponsive, Not • Two Rescuer = 15 Compressions and 2 Breaths
School 18-30 Breathing or ALS
Adolescent 12-16 Indicators Check Pulse (up to 10 sec)
DEFINITE Pulse Rapid Pulse with Rapid Pulse with poor Pulse <60/min with No Pulse?
good perfusion? perfusion despite O2 poor perfusion despite
and ventilation? O2 and ventilation?
• GIVE: 1 Breath every 3-5 seconds PEDs Tachycardia Begin CPR and move to
• Ensure adequate oxygenation & with Pulse & appropriate protocol
ventilations Adequate Perfusion
• Recheck Pulse every 2 minutes
o Add compressions if pulse <60/min PEDs Tachycardia PEDs Bradycardia
Pediatric
despite O2 and Ventilation with Pulse & Poor with Pulse & Poor
Cardiac Arrest
o Move to appropriate Guideline Perfusion Perfusion
89
PEDIATRIC BRADYCARDIA with
Pulse and Poor Perfusion
Typical HR/min Indicators of CARDIOPULMONARY COMPROMISE
• Newborn 85 - 205 • Hypotension
• 3mth - 2y/o 100 - 190 o 1-10 y/o lower limit = 70+(years old x 2)mmHg
• 2y/o - 10y/o 60 -140 o >10 y/o lower limit = 90mmHg
• >10 y/o 60 - 100 • Acutely Altered Mental Status
Typical Sinus Tachycardia Rates o GCS <8, Weak Cry, Unusual Irritability, Altered
• Infants <220/min Responsiveness, Lethargy, or Failure to Respond to
Painful Stimulus
• Children <180/min
• Signs of Shock
Identify and Treat Underlying Cause! Rescue Breathing Ventilation Rate Without Advanced Airway:
Continue: • NEWBORN = 40-60/min when performed without compressions
Universal Patient Care Guideline • Infant / Child = 1 breath / 3 to 5 seconds
• Maintain Airway / Assisted Breathing • Adult = 1 breath / 5 to 6 seconds
• O2 (100% FiO2)
• IV / IO access (IV Guideline) CPR Rate of 100 Compressions / Min at:
• Monitor and 12-Lead ECG (ASAP) • One Rescuer = 30 Compressions and 2 Breaths
• Check Glucose • Two Rescuer = 15 Compressions and 2 Breaths
CPR
Cardiopulmonary
if HR <60/min
Compromise YES with Poor Perfusion
Continues? Check Pulse every 2
despite O2 and Ventilation
NO minutes during CPR
• Support ABCs
• Continue O2 Bradycardia
• Continuous Monitoring
NO Persists? If Pulse is lost, GO TO:
• Consider Consultation PEDIATRIC
CARDIAC ARREST
Treatable causes: YES
• Check & Treat compromise in ABCs
• Hypoglycemia Consider:
o D25 2mL/kg slow IV (max 25mL) Epinephrine 1:10,000 Transcutaneous Pacing
o Glucagon 0.025mg/kg IM (max 1mg) 0.01mg/kg IV/IO q3-5min (Consider sedation:
• Tension Pneumothorax Midazolam 0.05-0.1mg/kg IV / IO)
“OVERDOSE (Mothers Milk)”: Atropine
• B-blocker (atenolol, metoprolol, labetalol): 0.02mg/kg IV / IO
o Glucagon 30-150mcg/kg IV – pretreat with ondansetron Treat Underlying Causes
(Increased Vagal Tone or
(0.1mg/kg – max 2mg) for nausea if possible Primary AV Block)
• Calcium channel blocker (dilitiazem, verapamil, nifedipine) • Support ABCs
May Repeat Once
o Calcium chloride 10% 0.2ml/kg slow IV push • Continue O2
(Minimum dose 0.1mg
• Narcotic • Continuous Monitoring
Max Single dose 0.5mg)
o Naloxone 0.1mg/kg IV / IM (max 2mg) • Consider Consultation
Pearls:
• Decompensation at any time (e.g., altered MS, hypotension) should prompt treatment as unstable patient.
• All bradycardic patients should have pacer pads in place after initial evaluation.
• Evaluate for treatable causes of bradycardia (B-blockade, Ca channel blockade).
• The majority of pediatric cardiac problems are actually airway problems.
• In young, breast fed patients – evaluate for mother’s medications as they can cause toxicity in the infant.
• Pediatric pacer pads should be used if available. If only adult pads are obtainable – they should be placed in
the anterior-posterior position.
90
PEDIATRIC CARDIAC ARREST
Signs and Symptoms: START CPR Signs and Symptoms:
• Pulseless
• Unresponsive, apneic, Universal Patient Care Guideline
pulseless • Apneic
O2
• Ventricular fibrillation or • No electrical activity in at
ventricular tachycardia on least two ECG leads
EKG VF / pulseless VT Asystole / PEA (asystole)
• Electrical activity on monitor
Rhythm shockable? without pulses (PEA)
YES Confirm in two leads NO • No heart tones
Shock
1st Shock 2 J/kg,
2nd Shock 4 J/kg,
Then >4 J/kg up to 10 J/kg
CPR 2 min
CPR 2 min
IV / IO access (IV Guideline)
IV / IO access (IV Guideline)
Epinephrine (q 3-5 min)
Return of Spontaneous 0.01mg/kg (0.1mL/kg of
Rhythm Shockable? NO NO 1:10,000) IV / IO
Circulation (ROSC)?
YES capnography: 8-10 breaths/min
Shock 4 J/kg YES (Airway Guideline)
CPR 2 min
ROSC at any time: Rhythm Shockable? YES
Epinephrine (q3-5 min) go to:
0.01mg/kg (0.1mL/kg of Post-Cardiac Arrest Care NO
1:10,000) IV / IO Guideline
CPR 2 min
capnography: 8-10 breaths/min Treat Reversible Causes
(Airway Guideline) Reversible Causes:
• Hypovolemia
Rhythm Shockable? NO • Hypoxia NO Rhythm Shockable? YES
• Hypothermia
YES • Hypoglycemia
Shock >4 J/kg up to Move to
10J/kg or Adult • Tension pneumothorax VF / pulseless VT side of guideline
• Tablets / toxin
CPR 2 min • Tamponade, cardiac
• Hydrogen ion (acidosis) CPR Rate of 100 Compressions/Min
Amiodarone IV / IO • Hypo-/hyperkalemia >1/3 of anterior-posterior diameter of
5mg/kg bolus • Thrombus – cardiac chest with complete chest recoil
May Repeat X 2 • Thrombus – pulmonary • One Rescuer = 30 to 2 Breaths
Treat Reversible Causes • Two Rescuer = 15 to 2 Breaths
Pearls:
• Reversible causes should be addressed as soon as possible.
• Epinephrine Endotracheal Dose: 0.1 mg/kg (0.1mL/kg of 1:1,000 vial)
• Consider discontinuation of efforts if:
o Asystole following trauma – especially blunt
o Prolonged downtimes - > 15min
o Prolonged code with no response - >3 rounds of medications, 30min of resuscitation
o All patients should get a glucose check, at least 20ml/kg fluid bolus of NS, and ultimately
bilateral needle decompression (especially in Trauma) before discontinuation of efforts
o Should take at least 1min to check for pulse in hypothermic patients
• Lidocaine can be used if Amiodarone is unavailable. 1mg/kg Initial dose. May repeat twice
91
PEDIATRIC TACHYCARDIA with
Pulse and Adequate Perfusion
• 3mth – 2y/o 100 - 190 o 1-10 y/o lower limit = 70+(years old x 2)mmHg
• 2y/o to 10y/o 60 -140 o >10 y/o lower limit = 90mmHg
• >10y/o 60 - 100 • Acutely Altered Mental Status
• Infants <220/min Responsiveness, Lethargy, or Failure to Respond to
Painful Stimulus
• Signs of Shock
Identify and Treat Underlying Cause!

Continue: Wide QRS?
Universal Patient Care Guideline QRS Width? Uniform QRS?
>0.09 Second
• Maintain Airway / Assisted Breathing
• O2 (100% FiO2) YES NO
• IV / IO access (IV Guideline) Narrow QRS? Possible
• Monitor and 12-Lead ECG (ASAP) <0.09 Second Supraventricular
• Check Glucose Probable
Tachycardia
Ventricular
Tachycardia
• Heart Rate?:
o Infants: Typically >220/min
Probable Sinus Tachycardia o Child: Typically >180/min • Expert Consultation ASAP
• Search for and Treat NO o Constant Rate w/o variability on 6 second strip • Search for and Treat
Underlying Causes o Abrupt Rate changes between tachy and normal Underlying Causes
• P waves absent or abnormal? • 12-Lead ECG
• Vague history inconsistent with known cause
Treatable causes: YES

Consider Chemical Conversion:
• Check & Treat Compromise in ABCs Amiodarone 5mg/kg over
• Hypoglycemia Probable
Supraventricular Tachycardia 20-60 minutes IV / IO
o D25 2mL/kg slow IV (max 25mL)
o Glucagon 0.025mg/kg IM (max 1mg) • Consider Vagal Maneuvers
• Tension Pneumothorax with NO delay to next step
OVERDOSE : If NOT Already Administered:
• B-blocker (atenolol, metoprolol, labetalol): Adenosine IV / IO Rapid Push *Adenosine IV / IO Rapid Push
o Glucagon 30-150mcg/kg IV – pretreat with 1st 0.1mg/kg (max 6mg) 1st 0.1mg/kg (max 6mg)
ondansetron (0.1mg/kg – max 2mg) for nausea if 2nd 0.2mg/kg (max12mg) 2nd 0.2mg/kg (max12mg)
possible. Consider:
• Calcium Channel Blocker (dilitiazem, verapamil, Fails to Convert
Synchronized Cardioversion
nifedipine) 1st 0.5-1J/kg, if fails then 2J/kg
o Calcium Chloride 10% 0.2ml/kg slow IV push. (Sedation before Cardioversion:
• Narcotic Midazolam 0.05-0.1mg/kg IV / IO)
o Naloxone 0.1mg/kg IV/IM (max 2mg)
Pearls:
• Vagal maneuvers: blow through 18ga IV catheter, ice water immersion (facial), carotid massage (unilateral
only – listen for bruits prior to performing), or having patient blow against closed glottis (“bear down”).
• *Adenosine should be given with the “2 syringe technique” – one with adenosine and the other with the
saline flush. These should be attached to a 2 port IV adapter and flush should immediately follow drug.
• *Adenosine should be utilized in monomorphic and regular R-R interval type presentation.
• All patients should be warned of discomfort / feeling of heart stopping prior to adenosine administration.
92
PEDIATRIC TACHYCARDIA with
Pulse and Poor Perfusion
• 3mth – 2y/o 100 - 190 o 1-10 y/o lower limit = 70+(years old X 2)mmHg
• 2y/o to 10y/o 60 -140 o > 10 y/o lower limit = 90mmHg
• >10 y/o 60 - 100 • Acutely Altered Mental Status
• Infants < 220/min Responsiveness, Lethargy, or Failure to respond to
painful stimulus
• Signs of Shock
Identify and Treat Underlying Cause!

Continue: Wide QRS? Possible
Universal Patient Care Guideline QRS Width?
>0.09 Second Ventricular Tachycardia
• Maintain Airway / Assisted Breathing
• O2 (100% FiO2)
• IV / IO access (IV Guideline) Narrow QRS?
• Monitor and 12-Lead ECG (ASAP) <0.09 Second Cardiopulmonary
• Check Glucose YES Compromise?
• Heart Rate?: NO
o Infants: Typically >220/min
Probable Sinus Tachycardia o Child: Typically >180/min If Regular Rhythm (R-R) and
• Search for and Treat NO o Constant Rate w/o variability on 6 second strip QRS Monomorphic:
Underlying Causes o Abrupt Rate changes between tachy and normal Adenosine IV / IO Rapid Push
• P waves absent or abnormal? 1st 0.1mg/kg (max 6mg)
• Vague history inconsistent with known cause 2nd 0.2mg/kg (max12mg)
YES
Treatable causes: Probable Amiodarone 5mg/kg over 20-
• Check & Treat compromise in ABCs Supraventricular Tachycardia 60 minutes IV / IO
• Hypoglycemia • Consider Vagal Maneuvers
o D25 2mL/kg slow IV (max 25mL) with NO delay to next step
OR
o Glucagon 0.025mg/kg IM (max 1mg) * Procainamide 15mg/kg over
• Tension Pneumothorax 30-60 minutes
Adenosine IV / IO Rapid Push
“OVERDOSE (Mothers Milk)”: 1st 0.1mg/kg (max 6mg)
• B-blocker (atenolol, metoprolol, labetalol): 2nd 0.2mg/kg (max12mg)
o Glucagon 30-150mcg/kg IV – pretreat with ondansetron
(0.1mg/kg – max 2mg) for nausea if possible If no IV / IO access or adenosine fails
• Calcium channel blocker (dilitiazem, verapamil, nifedipine) Synchronized Cardioversion
o Calcium chloride 10% 0.2ml/kg slow IV push 1st 0.5-1J/kg, if fails then 2J/kg
• Narcotic (Sedation w/o delay to Cardioversion:
o Naloxone 0.1mg/kg IV/IM (max 2mg) Midazolam 0.05-0.1mg/kg IV / IO)
Pearls:
• Vagal maneuvers: blow through 18ga IV catheter, ice water immersion (facial), carotid massage (unilateral
only – listen for bruits prior to performing), or having patient blow against closed glottis (“bear down”).
• Adenosine should be given with the “2 syringe technique” – one with adenosine and the other with the
saline flush. These should be attached to a 2 port IV adapter and flush should immediately follow drug.
o All patients should be warned of discomfort / feeling of heart stopping prior to adenosine administration.
* If available
93
POST-CARDIAC ARREST CARE
• Return of Spontaneous • Continually Address
Circulation Primary Pathology
• Pulse Associated with Arrest
• Respirations
Continuous Monitoring and Maintain: Consider as appropriate:

Hypotension • Circulation: Palpable Pulses and BP Post-Resuscitation Induced
(SBP <90 mm Hg) • O2: Sat 94%-99% (may need advanced Hypothermia Guideline
airway)
• ECG / Defibrillator: Normal Sinus Rhythm
• IV / IO access (IV Guideline)
Fluid bolus *See pearls Loss of Pulses, or onset of VF /
Reperfusion and Trauma pulseless VT, asystole / PEA:
Patients Changes in Pulses or Move to Cardiac Arrest
Guideline
Significant Ectopy
Symptomatic Bradycardia move to

For Refractory Hypotension Bradycardia with Pulse
Consider: Guideline
Norepinephrine Reversible Causes:
0.1-0.5 mcg/kg/min
• Hypovolemia
• Hypoxia Symptomatic Tachycardia,
• Hypothermia Pulse >150/min move to
• Hypoglycemia Tachycardia with Pulse
Consider Treatable Causes
• Tension pneumothorax Guideline
• Tablets/toxin
• Tamponade, cardiac
• Hydrogen ion (acidosis)
Move to appropriate Cardiac
• Hypo-/hyperkalemia
guideline (opposite side of page)
• Thrombus – cardiac
based on changes in Pulse and
• Thrombus – pulmonary
ECG.
Pearls:
• Hyperventilation may cause hypotension and/or recurrence of cardiac arrest in the post-
resuscitation phase and must be avoided.
• Most patients will require ventilatory assistance in the post-resuscitative phase.
• In non-airway controlled patients, it is important to prevent aspiration following resuscitation. For
this reason, patients should be rotated onto their side (non-spinal immobilization) or be closely
monitored in case vomiting occurs.
• *Reperfusion: 1-2 L NS / LR and consider use of a pressor IV / IO Drip – EPINEPHRINE 2-
10mcg/min titrated or NOREPINEPHRINE 0.1-0.5 mcg/kg/min.
o Dopamine should be started at a low dose (5mcg/kg/min) and titrated up to maintain
a SBP >90. The same applies norepinephrine.
• *Trauma patients post-resuscitation should have fluid resuscitation consistent with hypotensive
resuscitation guidelines. Consider Hextend 500ml bolus 1-2 if patient has not received Hextend.
94
WITHHOLD RESUSCITATION
• Unresponsive • Medical vs. Traumatic Arrest
• Apneic • Dysrhythmia
• Pulseless
Evaluate for Criteria for

Death / No Resuscitation
YES NO
Withhold Resuscitation Attach Monitor / Defibrillator

Begin BLS / CPR
Criteria for Death / No Resuscitation:

Assess Rhythm
• Presence of decay / lividity / rigor mortis
• Decapitation
• Incineration TRAUMA ARREST
• Massively deforming head / chest trauma
• Downtime >15min with no CPR
Appropriate ACLS guideline
CARDIAC ARREST BRADYCARDIA with PULSE TACHCARDIA with PULSE
Pearls:
• As with all ACLS protocols – concentrate on adequate compressions.
• Minimize interruptions in compressions, including if/when placing advanced airway.
• Early defibrillation associated with greatest success in early cardiac arrest.
• Survival rate for traumatic arrest approaches zero.
• Cardiac arrest in MASCAL situations requires frequent re-triage to apply care where it will be
most effective.
• Lack of response alone does not equal death – always check for pulse / cardiac activity.
o If available, cardiac US can be helpful in determining if continued efforts will be helpful. If
there are no signs of cardiac movement on US and there is no other known reversible
cause, the likelihood of ROSC and recovery with continued resuscitative efforts in the out-
of-hospital setting is incredibly unlikely.
95
CARDIAC DEFIBRILLATION
• Patient who is in pulseless cardiac arrest with either ventricular fibrillation or ventricular tachycardia seen on
monitor.
CONTRAINDICATIONS:
• None
PROCEDURE:
• Ensure patient attached to monitor / defibrillator. If paddles used, ensure that they are several centimeters
away from monitor leads to prevent arcing. Use pediatric paddles as indicated – if unavailable and pads
used, should place in anterior / posterior position for pediatric patients.
• Set energy level to appropriate level. Start 200J adult (biphasic) or 360J adult (monophasic), or 2J/kg
pediatric.
• Press “charge” button 30 seconds prior to end of compressions. This maneuver minimizes time between
compressions and defibrillation. Compressions should continue until end of cycle.
• Ensure all personnel clear of patient and pilots aware of cardioversion.
• Press and hold “shock” button until energy delivered.
• If rhythm converts – treat as per post resuscitation protocol.
• Following shock delivery, immediately begin / return to CPR for 2 minutes before checking for pulse.
• If pediatric patient fails to convert – repeat steps 2-7 above using escalating energy levels.
• Document procedure, results, and vital signs on run sheet following mission.
AUTOMATED EXTERNAL DEFIBRILLATOR (AED):

• Turn on power to machine and follow prompts to attach pads to patient and machine.
• Ensure no one touching / moving patient and press the “Analyze” or equivalent button. (If not present, the
machine will automatically check the rhythm at dedicated time intervals. A vocal warning will tell you when
this is occurring).
• If shock advised, press button to deliver shock and return to CPR for 2 minutes.
• After analysis, if subsequent shocks advised, repeat steps 2-3 up to 3 shocks, until further care arrives, or
until no further shock advised. If no shock advised at any time, CHECK PULSE. Continue CPR if no
pulse. If pulse present, place patient in recovery position and transport.
96
EXTERNAL
CARDIAC PACING
• Patients with pulse rate <60 (or appropriate for age) and signs of inadequate cerebral or end-organ
perfusion.
CONTRAINDICATIONS:
• None
PROCEDURE:
• Ensure patient attached to monitor and defibrillator with external cardiac pacing capabilities.
• Time-permitting, ensure adequate IV / IO access prior to pacing. Also, may administer sedative agent
(midazolam) prior to beginning pacing.
• Turn selector switch to “Pace.”
• Set rate to twice the patients intrinsic rate (often 70-80 for adult, 100 for pediatric).
• Set energy level to lowest setting and gradually increase until capture is obtained (each pacer spike
followed by QRS).
• Once capture obtained, ensure pulse and vital signs correspond with pacing. Evaluate patient for
improvement. Monitor and continue sedation as needed.
• If fails to capture at maximal setting, discontinue pacer.
• At any time, if patient degenerates and needs CPR – begin compressions immediately. Pacer pads are
insulated and it is okay to perform compressions with pacer running.
97
SYNCHRONIZED
CARDIOVERSION
• Unstable patient with tachycardia-dysrhythmia noted on monitor / EKG.
• Patient who has failed conservative and/or chemical cardioversion.
• Patient not pulseless.
CONTRAINDICATIONS:
• None
PROCEDURE:
• Ensure patient attached to monitor / defibrillator with synchronized cardioversion capability.
• Time-permitting, ensure adequate IV / IO access present. Ensure that unsynchronized cardioversion /
defibrillation capabilities present in case patient degenerates into other dysrhythmia.
• Consider use of sedating medication (e.g., midazolam 0.1mg/kg (5mg max / dose)) prior to delivery of
shock. Note: This step is not mandatory and should not delay appropriate management of emergent
condition.
• Set energy level to appropriate level. Usually starting at 50J / 100J in adults or 0.5J/kg / 1J/kg in children for
atrial / ventricular arrhythmias, respectively.
• Select Synchronized Cardioversion option. This should result in machine displaying “SYNC” as well as
tracking electrical activity (arrow or highlighted segment of EKG).
• Ensure all personnel clear of patient and pilots aware of cardioversion.
• Press and hold “Shock” button until energy delivered. (This may take several seconds for machine to
synchronize with cardiac cycle. Shock is not immediately delivered as in defibrillation.)
• If rhythm converts – monitor and treat as appropriate.
• If fails to convert – repeat steps 4-7 above using escalating energy levels. If patient degenerates, treat as
per appropriate protocol / CPR. Note: most machines require pushing the “SYNC” after each shock if
synchronized cardioversion to be repeated, failure to do so will result in delivery of an
unsynchronized shock.
98
ALLERGIC REACTION
• Itching or Hives • Urticaria (rash only)
• Cough / Wheeze / Resp. Distress • Shock (other than anaphylactic)
• Chest / Throat Tightness • Angioedema
• Difficulty Swallowing • Aspiration / Airway Obstruction
• Hypotension or Shock • Asthma or COPD
• Edema • Pulmonary Edema / CHF

Continued from: O2 (if Hypoxemic) 1) Skin changes with resp.
Tactical Evacuation Guideline IV / IO Guideline sx’s or bp reduction.
Cardiac Monitor (ASAP) 2) Any 2 of following: skin
Hives / Rash Only changes, resp. sx’s, bp
Without: Resp. reduction, or GI sx’s.
depression or ASSESSMENT
3) shock or reduced bp
reduced BP
Epinephrine-Pen
Diphenhydramine
Or
25-50mg IV / IO / IM / PO
Epinephrine 1:1000
Epinephrine IV 0.3-0.5mg IM
Methylprednisolone See “pearls” prior to use!
125mg IV / IO (IV Push: 1-2cc every 2 min
until status improving) 500mL NS / LR if not
Reassess q 5 minutes previously started
If unable to mix epinephrine,
may consider repeat:
Albuterol 90mcg 2 puffs
Epinephrine-Pen OR
or 2.5mg via nebulizer
Epinephrine 1:1000
0.3-0.5mg IM Diphenhydramine
Worse 50mg IV / IO / IM / PO
Bradycardia with Pulse Guideline or
Unstable Methylprednisolone
125mg IV / IO
Cardiac Arrest Guideline Contact Medical Control
Reassess Patient
Tachycardia with Pulse Guideline Arrhythmia?
Improved
YES
Continuous Monitoring
NO
Hypotension Guideline Resp. Distress Guideline
Pearls:
• Contact medical control prior to giving epinephrine IV, or to patients >50yo, pregnant, have a history of cardiac
disease, or have HR >150. Epinephrine can precipitate dysrhythmias / ischemia – all patients should be on
monitors and have 12-lead ECG.
• Epinephrine:
o IM: 0.3-0.5mg (0.3-0.5 mL 1:1000) or EpiPen®
o IV Bolus: 100 mcg over 5-10 min; mix 0.1mg (0.1 mL of 1:1000 in 10mL NS and infuse over 5-10 min
o IV Infusion: Start at 1 mcg/min; mix 1mg (1 mL of 1:1000 in 500 mL NS and infuse at 0.5 mL/min; titrate
as needed
• The shorter the interval from contact to symptoms, the more severe the reaction.
99
Pediatric ALLERGIC REACTION
• Itching or Hives • Urticaria (rash only)
• Cough / Wheeze / Resp. Distress • Anaphylaxis (2 or more systems)
• Chest/Throat tightness • Shock (other than anaphylactic)
• Difficulty Swallowing • Angioedema
• Hypotension or Shock • Aspiration / Airway Obstruction
• Edema • Asthma or COPD
• Nausea / Vomiting • Pulmonary Edema / CHF

Continued from: O2 (if Hypoxemic) Shock / Unresponsive
Tactical Evacuation Guideline IV / IO Guideline or
Cardiac Monitor (ASAP) Respiratory Distress / Failure
Hives / Rash Only

No Resp. Complaint ASSESSMENT Emergency Airway
YES Intervention Needed?
Pediatric NO
Diphenhydramine Airway Epinephrine-Pen (Jr for
1mg/kg IV / IO / IM / PO <30kg) OR
Epinephrine 1:1,000
Methylprednisolone
0.01mg/kg IM (max 0.3mg)
2mg/kg IV / IO
Epinephrine
250-500mL NS / LR if not
Reassess q 5 minutes IM: 0.01 mg/kg (0.01mL/kg
of 1:1000) or EpiPen Jr.® previously started
Pediatric Bradycardia with Pulse IV Infusion: 0.1-0.3 Albuterol 90mcg 2 puffs

and Poor Perfusion mcg/kg/min or 2.5 mg via nebulizer
Diphenhydramine
Worse 1mg/kg IV / IO / IM / PO
Pediatric Cardiac Arrest
or
Unstable Methylprednisolone
Pediatric Tachycardia with Pulse 2mg/kg IV
Contact Medical Control
and Poor Perfusion
Reassess Patient
Pediatric Tachycardia with Pulse Improved
YES Arrhythmia?
and Adequate Perfusion Continuous Monitoring
NO
Pediatric Hypotension Pediatric Resp. Distress
Pearls:
• Epinephrine can precipitate dysrhythmias / ischemia – all patients should be on monitors and have
12-lead ECG.
• The shorter the interval from contact to symptoms, the more severe the reaction.
100
ALTITUDE ILLNESS
Differential Diagnosis: Acute Mountain Sickness High Altitude Cerebral High Altitude
• Head Trauma (AMS) Edema (HACE) Pulmonary Edema
• Stroke • Headache • AMS Symptoms (HAPE)
• CNS Tumor / Mass / Bleed / • Nausea / Vomiting • Unstable Gait • Cough
Infection • Lethargy • Drowsiness • Dyspnea
• Endocrine Disorder • Dizziness • Confusion • Pink Frothy Sputum
• Toxic Ingestion • Coma • Cyanosis
• Pneumonia / PE • Hyperthermia
• Cephalgia
Universal Patient Care Guideline Immediate / 1st Line Care for any
Continued from: O2 (ASAP) form of Altitude Illness:
Tactical Evacuation Guideline IV / IO Guideline • Rapid Descent (as mission able)
Cardiac Monitor (ASAP) • O2
• Gamow Bag (when descent is
Hypothermia Precautions not possible)
Hypothermia Guideline
Pulmonary Symptoms
Headache Symptoms (HAPE)
YES (HACE)
Altered Mental Status Rapid Descent Rapid Descent
Ataxia? Consider: Consider:
NO (AMS) Gamow Bag (*See Pearls) Gamow Bag (*See Pearls)
Prevent Further Ascent
O2 O2
(If not previously started) (If not previously started)
O2
(If not previously started)
Nifedipine
Dexamethasone: Initial 10mg PO q4-6hr
Descend 500-1000m if able Loading dose 8mg PO/IV/IO
(4mg if 4mg already provided)
(then 4mg IV / IO / PO q6hr) Consider:
Acetazolamide 125-250mg PO
Assisted Ventilation (PPV)
Dexamethasone 4mg IV / IO / Ondansetron 4-8mg IV / IO

PO q6hr YES Altered Mental Status
YES Ataxia?
NO
Consider:
• Acetaminophen 650-1000mg PO When appropriate, return to:
NO Tactical Evacuation Guideline
• Ibuprofen 600-800mg PO
Pearls:
• The treatment of choice for all altitude-related illnesses is supplemental O2 and descent – at least 500-1000m. If unable to
descend, a hyperbaric bag (Gamow bag) can be utilized if available.
o If unable to descend immediately - as soon as HACE or HAPE are suspected, the crew must begin engaging actively with
the PIC or other tactical commander to work the issue of descent ASAP.
• Acetazolamide should not be given to those patients with Sulfa allergies or known Sickle Cell Anemia.
• High-altitude pulmonary edema often occurs along with high-altitude cerebral edema. These patients may have crackles / fever /
hypoxia.
• *Descent should be done with the least amount of patient exertion possible to prevent worsening of the condition.
• ANY altered mental status / confusion / abnormal gait should be presumed to have cerebral edema and descent should be
undertaken immediately.
101
BITES / ENVENOMATIONS
• Rash, Skin Break, Wound, Retained • Bite / Envenomation
Stinger • Other Allergic Reaction
• Pain, Swelling, Erythema • Anaphylaxis
• Bleeding / Discharge • Rabies / Tetanus Risk
• Shortness of Breath / Wheezing / Throat
Tightness
• Hypotension or Shock

• Place wounded extremity (if applicable)
Continued from: O2 (if Hypoxemic)
in a dependent position (lower than
Tactical Evacuation Guideline IV / IO Guideline
trunk / heart)
Cardiac Monitor (prn)
• Immobilization / splint / loose bandage
• Follow local / surgeon policy / CPG for
treatment of envenomation, as able
Position patient supine
Immobilize area
Consider:
Pressure Immobilization
Allergic Reaction Guideline YES Allergic Reaction?
NO Pressure Immobilization
Consider: • Only used for species with little to no
Midazolam 2-5mg local tissue damage
IV / IO • Avoid excessive movement of the
(for black widow spider or affected limb
scorpion) • Ensure bandage is firm and has similar
tightness as for wrapping an ankle
• DONOT remove bandage until reaching
Pain Management Guideline medical treatment facility
• MES options: IV tourniquets, IV tubing,
When appropriate, return to: surgical gloves, BP Cuff deflated to
Tactical Evacuation Guideline return of distal pulse.
Pearls:
• Never attempt to capture / transport a live animal / insect.
• Amount of envenomation from snake bites can be variable – assume all are lethal.
• For snake envenomation – do not use ice / tourniquets as these can worsen the effects of toxins – a
pressure bandage can be utilized over the bite wound and proximal to the injured area.
• Black Widow spider bites tend to be minimally painful, but then develop into severe pain in muscles /
abdomen with muscular spasm over hours. The abdominal pain may mimic surgical abdomen.
• Brown recluse spider bites may be painless or result in burning sensation. A blister may form over
hours – which later can turn into tissue necrosis. Abnormal vital signs in association with a brown
recluse bite may symbolize systemic toxicity (loxoscelism) – which requires emergent treatment.
• Outside of the U.S. – there are few reliable types of anti-venom for poisonous snakes / insects.
• Scorpions are found throughout the U.S. and overseas, one species in the U.S. is capable of causing
systemic toxicity. The black scorpion is located throughout Arizona, New Mexico, and parts of
Texas. Review country environmental concerns before deployment or visitation.
• All animals should be considered rabid outside the U.S. until proven otherwise. This excludes
rodents, which do not carry rabies.
• Anaphylactic reactions should be treated as soon as recognized.
102
ELECTRICAL INJURY
• Burns • Cardiac Arrest
• Pain • Environmental Exposure
• Arrhythmia • Seizure
• Loss of Consciousness • Burns
• Entry / Exit Wounds • Multiple Trauma
• Shock / Hypotension
• Cardiac Arrest

Continued from:
Ensure: O2 (if Hypoxemic)
Tactical Evacuation
Scene Safety IV / IO Guideline
Guideline
Lightning Strike?
Spinal Immobilization Guideline (or other source of massive
direct current)
Bradycardia with Pulse Guideline 12-Lead EKG

Reverse Patient Triage
(*See Pearls)
Cardiac Arrest Guideline Arrythmia?
Tachycardia with Pulse Guideline NS Bolus PRN

BURN Guideline
Full Evaluation for Injuries
HEAD INJURY Guideline
Treat / Dress Wounds
(per appropriate Guideline) MULTIPLE TRAUMA Guideline
Pain Management Guideline HYPOTENSION / SHOCK Guideline
Pearls:
• Ventricular fibrillation (AC) and asystole (DC) are the most common dysrhythmias seen with electrical
shock.
• Damage is often hidden as current follows conductive structures (e.g., blood vessels, nerves, muscle).
• In mass casualty situations where lightning is involved – reverse triage should be performed. Those
victims in full arrest should be resuscitated first. The reason for this is the respiratory center of the
brain takes longer to recover from the shock than the heart and respiratory support during this
period can lead to survival.
o Specifically, if there are no spontaneous respirations after airway maneuver, but no other signs of
non-survivable injury, administer ventilatory support aggressively as personnel resources allow.
• Do not overlook secondary trauma.
• Electrical shock victims do not “store” electricity.
• Many electrical injury patients will also have significant burn injuries – do not overlook fluid resuscitation.
103
HYPERTHERMIA
• Altered Mental Status • Infection
• Loss of Consciousness • Dehydration
• Hot / Dry or Sweaty Skin • Thyroid Storm
• Hypotension or Shock • Medications / Toxin
• Seizure • Delirium Tremens
• Nausea / Vomiting • Heat Cramps
• Heat Exhaustion
• Heat Stroke
• CNS Lesions or Tumors

Altered Mental Status and Altered Mental Status

Remove from Heat Source with
Temperature >40ºC / 104ºF
Loosen / Remove Clothing Temperature <40ºC / 104ºF
Consider Intubation: Assessment: Consider Intubation:
AIRWAY Guideline AIRWAY Guideline
• Mental Status
• Rectal Temperature
Aggressive cooling: • Glucose (treat per AMS Guideline) 1L NS Bolus / PO fluids
• Tepid water to skin with fanning
• Ice packs to groin / axillae / neck Tepid Water or Room Temp
• Consider open doors (as mission Temperature <40ºC Saline to Skin
permits)
D/C once temp ≤40ºC / 104ºF!!! Altered Mental Status
1L NS Bolus or PO fluids Guideline
(prevents rebound hypothermia)
Be prepared for and consider:
Consider benzodiazepines to • PO fluids as able
Seizure Guideline
block/stop shivering of rebound Consider:
Hypothermia: • Tepid Water or Room Monitor EKG for Arrhythmia
Midazolam 0.1mg/kg Temp Saline to Skin (treat per appropriate guideline)
Monitor EKG for Arrhythmia
(treat per appropriate guideline) Continuous Monitoring / Arrhythmia?
Reassess
Be prepared for and consider:
Seizure Guideline NO Bradycardia Tachycardia
When appropriate, return to: with Pulse with Pulse
1L NS Bolus / PO fluids
Cardiac Arrest
Altered Mental Status (VF / Pulseless VT or
Altered Mental Status? YES Asystole / PEA)
Guideline
Pearls:
• Groups at elevated risk for heat emergencies: elderly, very young, highly active.
• Use of alcohol, cyclic antidepressants, phenothiazines, and anticholinergic medications increase risk.
• Cocaine, ecstasy, amphetamines, and aspirin toxicity can all raise body temperature.
• Sweating does not exclude heat stroke / heat illness.
• In conscious patients that can protect their airway, encourage intake of PO fluids and electrolytes.
• If infection is suspected consider use of acetaminophen 1 gram.
104
HYPOTHERMIA
• Cold, Clammy • Sepsis
• Shivering / Lack of Shivering • Environmental Exposure
• Mental Status Changes • Hypoglycemia
• Extremity Pain / Numbness • CNS Dysfunction
• Bradycardia / Arrhythmia • Toxic Ingestion
• Hypotension or Shock

FROSTBITE
Tactical Evacuation Guideline IV / IO Guideline • Extremity or body part with
Cardiac Monitor (ASAP) suspected frostbite must be
protected to prevent further
injury (wrapped and covered
Remove Wet Clothing with a dry blanket).
Assessment:
Core Temperature <95ºF / 35ºC • Mental Status Core Temp <95º / 35ºC with
Patient is Alert, w/o Arrhythmia, and • Rectal Temperature AMS, Arrhythmia, or Absence of
is Actively Shivering • Glucose (treat per AMS Guideline Shivering
while re-warming)
WARMED IV FLUIDS
• Dry Blankets Handle Very Gently
(Thermal Angel)
• Hypothermia Blanket • HPMK Kit / Hypothermia
1L NS/LR Bolus
• Warm PO fluids (if available) Blankets
• Dry Clothing
Target re-warming
• Hot Packs to Groin, Axilla,
(D/C warmed IV Fluids)
Abdomen (avoid contact burn)
12-lead EKG
Arrhythmia? YES
Submersion Injury Guideline Bradycardia with Pulse Guideline
NO
Treat per Appropriate
Airway Guideline Cardiac Arrest Guideline
Guideline
Transport to ECMO team or
When appropriate, return to: Tachycardia with Pulse Guideline
nearest hospital
Pearls:
• “No patient is dead until they are warm and dead.”
• Hypothermia defined as core temperature <95ºF (35ºC).
• With temperatures <31ºC (88ºF) ventricular fibrillation is common. Cardiac muscle becomes very irritable as
temperature drops and rough handling may induce a cardiac dysrhythmia.
• With temperatures below 30ºC (86ºF) shivering ceases – removing an important heat production source.
• Pulse may be very slow in hypothermic patients – should wait at least one minute to feel pulse.
• Arrhythmias at temperature >30ºC (86ºF) treated similar to normo-thermic patients with the addition of active
re-warming. At temperatures <30ºC (86ºF) one defibrillation can be attempted, but further attempts / meds
withheld until temp >30ºC (86ºF).
105
SUBMERSION INJURY
• Unresponsive • Trauma (esp. C-spine)
• Mental Status Changes • Dysbarism
• Hypoxia • Pressure Injury as in Self-
• Cyanosis contained under water
• Hypothermia breathing apparatus
• Vomiting (SCUBA)
• Coughing

Continued from: O2 (100% FiO2 for all injuries) Always Record
Tactical Evacuation Guidelines IV / IO Guideline • Dive Depth
Cardiac Monitor (ASAP) • Duration of decent
Spinal Immobilization Protocol
Hypothermic? YES Hypothermia Guideline

NO
Multiple Trauma Guideline YES Trauma?
Patients with SCUBA or decompression
NO injuries involving the CNS or respiratory
system (stroke symptoms, pulmonary
embolism symptoms) should be treated
Reassess Airway, with 100% O2 and delivered
Check for Arrhythmias EXPEDITIOUSLY to a facility with a
Consider as appropriate: Address per appropriate protocol hyperbaric chamber.
Post-Resuscitation Induced
Hypothermia Guideline
Pain Management Guideline
Airway Guideline Tachycardia with Pulse
When appropriate, Return To:
Tactical Evacuation Guideline Cardiac Arrest Guideline Bradycardia with Pulse
Pearls:
• If Decompression Illness or arterial gas embolism is suspected and neurological deficits (including altered mental status) are present,
consider high-flow oxygen, lidocaine 1.5 mg/kg IV / IO, and aspirin 325mg. While these interventions remain unproven, the risk / benefit
ratio makes them acceptable options, particularly if time to hyperbaric chamber is anticipated to be prolonged.
• Rapid hypothermia from cold water immersion in children has resulted in survival despite prolonged downtime – resuscitate per
appropriate protocols and rapidly transport. This has not been seen in adults.
• All near-drowning victims should be transported for evaluation due to potential for worsening respiratory status over next several hours.
• Drowning is the leading cause of death among would-be rescuers.
• Head-first diving injuries often associated with unstable Jefferson fracture (burst fracture of C1) due to axial load. Patients found with
suspicion of this type of injury should have early and careful C-spine immobilization.
• Altitude should be restricted in patients suffering from decompression illnesses to prevent worsening. Should remain <1000 ft. AGL /
10,000 ft. MSL whenever possible.
o Aggressive pre-planning for access to hyperbaric treatment facilities is encouraged if mission requirements warrant it.
106
TOXIC INGESTIONS
• Mental Status Changes • Cyclic Antidepressants
• Hypo / Hypertension • Acetaminophen
• Respiratory Depression • Depressants
• Tachycardia / Arrhythmias • Stimulants
• Seizure • Anticholinergic
• Cardiac Medications
• Solvents / Cleaners
• Organophosphate / Carbamate
• Medical Cause (hyperthyroidism)
Universal Patient Care Guideline If possible,

Continued from: O2 (if Hypoxemic) Contact Poison Control Center or Medical
Tactical Evacuation Guideline IV / IO Guideline Control if toxin known or for treatment advice
Cardiac Monitor (ASAP) In US: 1-800-222-1222
Altered Mental Status Guideline Supportive care is keystone in management
(50% Dextrose 25g in 500mL NS IV or YES Blood Sugar <60? of toxic ingestions:
Glucagon 1mg IM if no IV) • Continuous monitoring, supplemental O2 /
NO
IV Bolus PRN airway support, IVF resuscitation
Beta Blocker Overdose:

TriCyclic Overdose: Activated Charcoal 50grams PO AV Block (especially, 1st Degree),
QRS >100 = Predictive of seizures (If alert / protecting airway and Bradycardia, and Hypotension:
QRS >160 = Predictive of VT time of ingestion <1hr) Consider giving: Glucagon 3-10mg IV
Opiates TriCyclic Antidepressant Organophosphate / Carbamate Other

(Respiratory
Depression) 12 Lead EKG Atropine 2mg IV / IO q3-5min 12-lead EKG
(No max dose: double each
dose given until ↓ secretions)
Naloxone 0.4-2mg QRS >100ms or Hypotensive?
2-PAM 600mg IV / IM Hypotension, Seizures,
IV / IO Ventricular Dysrhythmias,
(Atropine + 2-PAM = Mark 1 Kit)
Sodium Bicarbonate 1mEq/kg Altered Mental Status, Chest
May repeat to maintain QRS <100 Pain
Airway Guideline Start Maintenance Infusion: If in Seizure give:
100-150mEq (2-3 amps) in 1 L D5 / NS
@ 100-200 mL/hr IV Midazolam 2.5-5mg IV/IM x 2 Appropriate Guideline
Seizure Guideline
Continuous Monitoring, reassess q5 min
Pearls:
• Anticholinergic: Altered mental status (mad as a hatter), Hyperthermia (hot as a hare), mydriasis (blind as a bat), Flushing (red as a
beet), anhidrosis (dry as a bone), Full Bladder (full as a flask).
o Treat as with Tricyclic overdose pathway (including EKG and Sodium Bicarb for prolonged QRS and/or arrhythmias)
o LORAZEPAM for agitation and seizures and Hyperthermia Guideline if hyperthermic
• Beta Blocker: HypOglycemia.
• Calcium Channel Blocker: HypERglycemia.
• Cyclic Antidepressant: Hypotension, depressed mental status, respiratory depression, cardiac arrhythmias.
• Opioid: Depressed mental status, pinpoint pupils, N/V, respiratory depression, hypotension possible.
• Organophosphate / Carbamate (Cholinergic): Salivation, lacrimation, urination, diarrhea, emesis, altered mental status.
• Sympathomimetic / Stimulant (Methamphetamine / Cocaine): Altered mental status, tachycardia, diaphoresis, mydriasis, and
hyperthermia. Treat with Benzodiazepine (LORAZEPAM) and PRN cooling or Hyperthermia Guideline.
107
Pediatric TOXIC INGESTIONS
• Mental Status Changes • Cyclic Antidepressants
• Hypo / Hypertension • Acetaminophen
• Respiratory Depression • Depressants
• Tachycardia / Arrhythmias • Stimulants
• Seizure • Anticholinergic
• Cardiac Medications
• Solvents / Cleaners
• Organophosphates / Carbamate
• Medical Cause (hyperthyroidism)

Blood Glucose:
Less than1 Month Old <40?
More than 1 Month Old <65?
Beta Blocker Overdose: NO YES
AV Block (especially, 1st Degree), Altered Mental Status Guideline
Bradycardia, and Hypotension: NS 20mL/kg IV Bolus PRN (25% Dextrose 2mL/kg IV OR
Consider: Glucagon 30-150mcg IV/IM Glucagon 20-30 mcg/kg IM if no IV,
Activated Charcoal 1 gram/kg PO Max 1mg)
Tricyclic Overdose: (if alert / protecting airway and
QRS > 100 = Predictive of seizures time of ingestion <1hr)
QRS > 160 = Predictive of VT (via NG OK if airway protected)
Opiates Tricyclic Antidepressant Organophosphate / Carbamate Other

(Respiratory
Depression) 12-lead EKG Atropine 0.05-0.1mg IV / IO 12-lead EKG
q3-5min (No max: double each
dose given until ↓ secretions)
QRS >100ms or Hypotensive?
Naloxone 0.1mg/kg IV 2-PAM 25mg/kg IV/IM Hypotension, Seizures,
(Max 1mg) (Atropine + 2-PAM = Mark 1 Kit) Ventricular Dysrhythmias,
Sodium Bicarbonate 1mEq/kg Altered Mental Status, Chest
May repeat to maintain QRS <100 Pain.
Start Maintenance Infusion: If in Seizure give:
Pediatric Airway 100-150mEq (2-3 amps) in 1 L D5/NS Lorazepam 0.1mg/kg IV
Guideline Appropriate Guideline
@ 100-200 mL/hr IV
Pediatric Seizure Guideline
Continuous Monitoring, reassess q5 min
Pearls:
• Supportive care is keystone in management of toxic ingestions: Continuous monitoring, supplemental O2 / airway support, IVF
resuscitation.
• Anticholinergic: Altered mental status (mad as a hatter), hyperthermia (hot as a hare), mydriasis (blind as a bat), Flushing (red as a
beet), anhidrosis (dry as a bone), Full Bladder (full as a flask).
o Treat as with Tricyclic overdose pathway (including EKG and Sodium Bicarb for prolonged QRS and/or arrhythmias)
o LORAZEPAM for agitation and seizures and Hyperthermia Guideline if hyperthermic.
• Beta Blocker: HypOglycemia.
• Calcium Channel Blocker: HypERglycemia.
• Cyclic Antidepressant: Hypotension, depressed mental status, respiratory depression, cardiac arrhythmias.
• Opioid: Depressed mental status, pinpoint pupils, N/V, respiratory depression, hypotension possible.
• Organophosphate / Carbamate (cholinergic): Salivation, lacrimation, urination, diarrhea, emesis, altered mental status.
• Sympathomimetic / Stimulant (Methamphetamine / Cocaine): Altered mental status, tachycardia, diaphoresis, mydriasis, and
hyperthermia. Treat with Benzodiazepine (LORAZEPAM) and PRN cooling or Hyperthermia Guideline.
108
ALTERED MENTAL STATUS
• Decreased Mental Status / Coma • Head Trauma
• Bizarre Behavior • Stroke
• Somnolence • CNS Tumor / Mass / Bleed / Infection
• Diaphoresis / Dry, Red Skin • Thyroid Dysfunction
• Polyuria / Polydipsia • Hyperglycemia / Hypoglycemia
• Sweet / Fruity Breath • Diabetic Ketoacidosis
• Altered Respirations • Toxic Ingestion
• Signs of Trauma • Environment (Hyperthermia / Hypothermia)
• Fever • Hypoxia
• Psychiatric Disorders
• Seizure Disorder
• Sepsis
Universal Patient Care Guideline Glucose >250?

O2 (if Hypoxemic)
Continued from:
IV / IO Guideline 1000mL NS IV
Cardiac Monitor
Check Blood Glucose
12-lead ECG
Consider Spinal Immobilization
Glucose <70? Guideline NO Arrhythmia?
Evidence of Alcohol Abuse? NO YES

NO Blood Glucose 70-250?
YES Bradycardia Tachycardia
NO with Pulse with Pulse
Thiamine 100mg IV / IM Consider Alternate Causes:
(AEIOU-TIP)
Oral Glucose (*See Pearls) Cardiac Arrest
(VF / Pulseless VT or
OR
Asystole / PEA)
50% Dextrose 25g IV
OR
Consider: Naloxone 0.4-2mg IV
Glucagon 1mg IV / IM Consider Alternate Causes:
IV 1000mL NS IV • Alcohol / Acidosis
Return to Baseline? NO • Epilepsy
Improved Unimproved • Insulin
and
Glucose 70-250? Continuous Monitoring • Overdose
YES Recheck Glucose: Give additional Fluid Bolus if • Uremia / Renal Failure
Glucose >250. Be alert for signs of fluid overload. • Trauma
• Infection
When appropriate, return to: • Psychosis
Pearls:
• Be aware of AMS as a presentation of environmental exposure / toxins / hazmat – use personal
protection accordingly / decontamination.
• Recheck blood glucose after each intervention.
• *Oral glucose okay if patient alert, protecting airway, and solution available. Proteins + complex
carbs (e.g., sandwich, granola) are better, longer lasting glucose source than simple sugars.
• EKG should be obtained in all suspected toxin or diabetic ketoacidosis cases – evaluate for tall,
peaked T-waves (hyperkalemia) or QRS widening >100ms (toxins).
• Restrain patient as necessary for their safety and crewmembers safety during flight.
• Glucagon may cause nausea / vomiting – should have anti-emetic prepared.
109
Pediatric AMS
• Decreased Mental Status / Coma • Head Trauma
• Bizarre Behavior • Stroke
• Somnolence • CNS Tumor / Mass / Bleed / Infection
• Diaphoresis / Dry, Red Skin • Thyroid Dysfunction
• Polyuria / Polydipsia • Hyperglycemia / Hypoglycemia
• Sweet / Fruity Breath • Diabetic Ketoacidosis
• Altered Respirations • Toxic Ingestion
• Signs of Trauma • Environment (Hyperthermia / Hypothermia)
• Fever • Hypoxia
• Seizure Disorder
• Sepsis
Universal Patient Care Guideline Glucose >250?

O2 (if Hypoxemic)
Continued from:
IV / IO Guideline NS 20mL/kg IV
Cardiac Monitor
Check Blood Glucose
12-lead ECG
Glucose?
Less than Month Old <40? Consider Spinal Immobilization
More than 1 Month Old <65? Guideline NO Arrhythmia?
Evidence of Malnourishment? YES

NO Normal Blood Glucose? NO
Bradycardia Tachycardia
NO YES Less than Month Old: 40-99
with Pulse with Pulse
Thiamine 25mg IV / IM More than 1 Month Old: 65-99
and Poor and Poor
Unimproved YES Perfusion Perfusion
Oral Glucose (*See Pearls) nd
After 2 dose Consider Alternate Causes:
OR (AEIOU-TIP) Pediatric Cardiac
25% Dextrose 2mL/kg Arrest
OR Consider:
Glucagon 20-30mcg/kg IM Naloxone 0.1mg/kg IV/IM Consider Alternate Causes:
(If no IV Access) • Alcohol / Acidosis
NS 20mL/kg IV • Epilepsy
NO • Insulin
Return to Baseline? Improved Unimproved
and • Overdose
Continuous Monitoring: 12-lead ECG • Uremia / Renal Failure
Glucose Normalized?
Recheck Glucose: Give additional Fluid Bolus if • Trauma
Less than Month Old: 40-99
Glucose >250. Be alert for signs of fluid overload. • Infection
More than 1 Month Old: 65-99
• Psychosis
When appropriate, return to:
YES Tactical Evacuation Guideline
Pearls:
• Be aware of Altered Mental Status (AMS) as a presentation of environmental exposure / toxins /
hazmat – use personal protection accordingly / decontamination.
• Recheck blood glucose after each intervention.
• *Oral glucose okay if patient alert, protecting airway, and solution available. Proteins + complex
carbs (e.g., sandwich, granola) are better, longer lasting glucose source than simple sugars.
• EKG should be obtained in all suspected toxin or diabetic ketoacidosis cases – evaluate for tall,
peaked T-waves (hyperkalemia) or QRS widening >100ms (toxins).
• Glucagon may cause nausea / vomiting – should have anti-emetic prepared.
110
SUSPECTED STROKE / TIA
• Altered Mental Status • Transient Ischemic Attack
• Weakness / Paralysis • Stroke
• Blindness or Other Sensory Loss • Seizure
• Aphasia / Dysarthria • Hypoglycemia
• Syncope • CNS Infection / Mass
• Vertigo / Dizziness • Trauma
• Vomiting • Metabolic
• Headache
• Seizures

Tactical Evacuation Guideline IV / IO Guideline 50% Dextrose 25g IV
Cardiac Monitor
OR
Glucagon 1mg IV/IM
Blood Glucose <70? YES
NO
Prehospital Stroke Scale: any 1 abnormal finding = Quick Neurologic Status:
72% chance of stroke GCS >8? AIRWAY Guideline
Facial Droop (show teeth and smile) Can protect airway? NO (maintain stable airway)
• Abnormal when one side of face does not move Can move all extremities?
equally with opposite side.
Arm Drift (close eyes and extend both arms) YES NO Intubated?
• Abnormal when one arm drifts down compared to Perform pre-hospital Stroke
opposite arm (arms move separately). Scale as able. YES
Abnormal Speech (say, “you can’t teach an old dog
new tricks”) Tachycardia
12-lead ECG
• Abnormal with slurred words, using wrong words, with Pulse
or unable to speak. (A-Fib)
Arrhythmia? YES
NO Bradycardia Cardiac Arrest
Consider Alternate Guidelines with Pulse (VF / Pulseless VT,
Asystole / PEA)
ALTERED MENTAL
HYPERTENSION SEIZURE
STATUS
Pearls:
• Duration of symptoms should be determined as accurately as possible. Family members / colleagues can be helpful. If pt awaken with
symptoms – onset time est. from last time patient was seen “normal.”
• Be alert for airway problem / risk of aspiration. If concerned, request intubation before departure.
• Hypoglycemia can mimic stroke / TIA. May present with focal neurologic deficit, especially in the elderly.
• EKG should be obtained in all patients to evaluate for arrhythmia – especially atrial fibrillation.
• All TIAs should be transferred for evaluation, even if symptoms abated – these patients have 10% risk of stroke within 30 days.
• Aspirin should not be given to patients for suspected stroke. Aspirin use is a contraindication to the use of thrombolytics for stroke.
• All strokes/TIAs are not associated with motor findings. Although uncommon, pure sensory strokes can occur. More frequently, very
subtle motor abnormalities are present that the patient may not note.
• Systolic >220 or Diastolic 121-140: Labetalol 10-20 mg IV for 1-2 mins. May repeat or double q10 mins for a maximum dose of
300mg. Aim for no more than a 20% reduction in MAP. MAP = [(2 x Diastolic) + Systolic] / 3
• Systolic 180-220 or Diastolic 105-120: Labetalol 10 mg IV for 1-2 minutes. May repeat or double q10 mins to max dose of 300mg.
For additional info see: ACLS Acute Coronary Syndromes and Stroke.
111
HYPERTENSION
Signs and Symptoms of Hypertensive Crisis w/ end Differential Diagnosis:
organ damage. • Primary CNS injury
One of These: (Cushing’s Reflex)
• Systolic BP 200 or Higher • Myocardial Infarction
• Diastolic BP 120 or Higher • Aortic Dissection
Plus One of These: • Pre-Eclampsia / Eclampsia
• Altered Mental Status • Toxin / Medication
• Blurred Vision
• Dizziness / Stroke Symptoms
• Chest Pain

Continued from: O2 (if Hypoxemic) MAP
= [(2 x Diastolic) + Systolic] / 3
Cardiac Monitor
Appropriate Size Cuff

• Check BP in Both Upper
Extremities (manual if able)
12 Lead EKG
STEMI, LBBB, Flipped Ts, ST

YES CHEST PAIN Guideline
Depression, or Dysrhythmia?
NO
If Symptomatic, consider: When appropriate, return to:
LABETALOL 20mg IV Tactical Evacuation Guideline
Do Not Lower MAP >20%

Hold for Pulse <60
Pearls:
• Do not treat elevated blood pressure based on one set of vital signs.
• Improper cuff size and equipment malfunction are common reasons for abnormally high readings.
• If patient has none of the above symptoms of hypertensive emergencies – they do not require treatment of their blood pressure.
• In setting of stroke – do not treat blood pressure unless SBP >220 and/or DBP >120 or signs of end-organ involvement. Elevated
BP is required to maintain perfusion during a stroke.
• Only lower MAP approximately 20% with slow, titrated doses – hypertensive patients often need elevated BP to maintain organ /
CNS perfusion. MAP = [(2 x Diastolic) + Systolic] / 3
• Labetalol is contraindicated in patients with severe asthma / COPD. In these patients, NTG can be given to lower BP if
absolutely necessary. Labetalol doses above are for symptomatic hypertension patients, not necessarily hypertensive
emergency patients.
• Metoprolol is contraindicated for CHF, Acute PE, bronchospasms, bradycardia, hypotension, hx of asthma, and
thyrotoxicosis.
112
SEIZURE
• Decreased Mental Status • CNS Trauma
• Seizure Activity • Tumor / Mass / Infection
• Somnolence • Metabolic
• Incontinence • Hypoxia
• Evidence of Trauma • Electrolyte Abnormality
• Loss of Consciousness • Drugs / Toxins
• Oral Injuries (e.g., Tongue, • Alcohol / Benzodiazepine Withdrawal
Buccal) • Stroke
• Eclampsia
• Hyperthermia
• Hypoglycemia

O2 (if Hypoxemic) LORAZEPAM
Continued from: 1-2mg IV / IM
IV / IO Guideline
Cardiac Monitor
MIDAZOLAM
Patient Safety (ensure secured to litter)
2.5-5mg IV / IM
YES Consider:
Evidence of Alcohol Abuse? Having Active Seizure? Magnesium Sulfate
OR 1-2g IV
NO, Postictal Over 30min
NO YES
Monitor for Hypotension
Thiamine 100mg IV / IM YES Blood Glucose <70?
Wait 60 seconds
NO Seizure Stopped? NO
50% Dextrose 25g IV NO Evidence of Significant Trauma?
YES
OR YES
SPINAL IMMOBILIZATION Consider: AIRWAY Guideline
Glucagon 1mg IV / IM
GUIDELINE
NO Glucose 70-250?
May Repeat Anticonvulsants Twice
YES Consider: HEAD INJURY Guideline (Must Have Definitive Airway Control)
Recurrence of Seizure? NO AIRWAY Guideline for RSI
YES Monitor and Reassess every Consider:
Restart Guideline at: 15min Pregnancy (Obstetric Emergency)
Having Active Seizure? • Mag Sulfate 4g IV Over 15min
When appropriate, return to: Elevated ICP
Tactical Evacuation Guideline • HEAD INJURY Guideline
Pearls:
• Status epilepticus defined as seizure >15min or two or more successive seizures without a period of
consciousness / recovery. This is a true emergency requiring rapid airway control, treatment, and transport to
nearest suitable medical treatment facility.
• Paralysis for airway control does not stop seizure activity – only hides it. Seizure is a CNS electrical
phenomenon and damage is still being done even when no muscular activity seen due to paralysis.
• Anticipate further seizure activity / recurrence and monitor continually.
• Assess probability of toxin, occult trauma, abuse, or substance use.
• Be prepared to assist with ventilations with the use of midazolam. If airway controlled and ventilating well – may
give total of 4 doses of Midazolam.
• In pregnant patients, Magnesium should be attempted first line to abort seizures. Midazolam should only
be used if this fails (pregnancy class D).
• Adult Alcohol Withdrawal or Malnutrition (Thiamine 100mg IV).
AD
113
Pediatric SEIZURE
Signs and Symptoms: Differential Diagnosis by Age:
• Decreased Mental Status Less Than 3 Years Old:
• Seizure Activity • Trauma
• Somnolence • Fever
• Incontinence • Infection
• Evidence of Trauma • Birth Injury
• Loss of Consciousness • Drug / Toxin
• Oral Injuries (e.g., Tongue, • Metabolic: Hypoglycemia / Electrolyte Abnormality
Buccal) More Than 3 Years Old:
• Trauma, Infection, Brain Degenerative Disease

O2 (if Hypoxemic)
Continued from: IV / IO Guideline
Tactical Evacuation Guideline Cardiac Monitor
Blood Glucose LORAZEPAM 0.05-0.1mg/kg IV
Patient Safety (ensure secured to litter) Max 4mg, (preferred medication)
OR
MIDAZOLAM 0.2mg/kg IM
Evidence of Malnourishment? Having Active Seizure? YES (if NO IV access)
NO YES NO, Postictal Wait 60 seconds
Thiamine 25mg IV/IM Blood Glucose: Seizure Stopped? NO
YES Less than Month Old <40?
More than 1 Month Old <65? YES
25% Dextrose 2mL/kg IV Consider: Pediatric AIRWAY
NO
OR NO Evidence of Significant Trauma?
Glucagon 20-30mcg/kg
(If NO IV Access) YES
SPINAL IMMOBILIZATION May Repeat Anticonvulsants Twice
PROCEDURE (then must establish Definitive Airway
NO Glucose: Control prior to subsequent doses)
0-1 Month Old >40? AIRWAY Guideline for RSI
1 Month Old and Up >65?
Consider: Pediatric HEAD INJURY
TRAUMA
YES
NO • Pediatric HEAD INJURY
Recurrence of Seizure? FEBRILE SEIZURE and Infection
Continuously Monitor and
YES Reassess ever 5min • Cooling Measures
Restart guideline at: (anticipate recurrence) • Tylenol 15mg/kg PO as able
Having Active Seizure? • Consider: Ceftriaxone 100mg/kg IV
When appropriate, return to: up to 2gm if evacuation >60mins
Tactical Evacuation Guideline (Note: interferes with blood cultures,
seek medical director guidance)
Pearls:
• Status epilepticus defined as seizure >5min or two or more successive seizures without a period of
consciousness / recovery. This is a true emergency requiring rapid airway control, treatment, and transport to
nearest suitable medical treatment facility.
• Paralysis for airway control does not stop seizure activity – only hides it. Seizure is a CNS electrical
phenomenon and damage is still being done even when no muscular activity seen due to paralysis.
• Be prepared to assist with ventilations with the use of Lorazepam / Midazolam. If airway controlled and
ventilating well – may give total of 4 doses of Lorazepam.
• MAX DOSES:
o LORAZEPAM = 4mg/dose, D25 = 25mL/dose, GLUCAGON = 1mg/dose
114
SYNCOPE
• Loss of Consciousness With Recovery • Vasovagal Episode
• Lightheadedness / Dizziness • Orthostatic Hypotension
• Nausea / Vomiting • Cardiac Etiology
• Palpitations / Chest Pain • Psychiatric
• Shortness of Breath • Stroke
• Decreased Pulse Pressure • Hypoglycemia
• Seizure
• Shock
• Toxicologic / Medication
Universal Patient Care Guideline GO To:

Continued from: O2 (if Hypoxemic) AMS Guideline
Tactical Evacuation Guideline IV / IO Guideline If patient unresponsive or mental status is altered
Cardiac Monitor upon arrival of MEDEVAC to patient pick-up site.
Consider Spinal Immobilization True Syncope is a brief self-resolving event.

Guideline If the patient is still altered upon your arrival it’s
NOT Syncope!
O2 Sat <94%?
Evidence of Alcohol Abuse? AIRWAY Guideline
GCS <8? YES (maintain stable airway)
NO YES Unable to protect Airway?
Thiamine 100mg IV / IM NO
Tachycardia / Hypotension? YES 1000mL NS IV
50% Dextrose 25g IV
NO
OR Blood Glucose <70?
YES If no improvement after
Glucagon 1mg IV / IM 1000mL Bolus:
NO
Hypotension / Shock
12-lead ECG Guideline
NO Glucose 70-250? YES
OR
Move to Appropriate Protocol as needed
Stroke / TIA Guideline Seizure Guideline
Altered Mental Status Guideline Hypotension Guideline

Cardiac Arrest
Bradycardia Tachycardia
(VF / Pulseless VT or
with Pulse with Pulse
Asystole / PEA)
Pearls:
• Assess every patient for signs of trauma if suspected with syncopal event.
• Consider occult bleeding in all cases of syncope: GI bleeding, ruptured ectopic pregnancy, and seizure.
• Prodromal symptoms (e.g., flushing, lightheadedness, diaphoresis, tunnel vision) are often associated
with more innocent etiologies, especially if temporally related to standing / rising. Absence of prodrome
should raise concern for cardiac / CNS (emergent) etiologies.
• It is uncommon for stroke to cause syncopal episode.
• Patients who sustain trauma to the temporal region of the skull and are now lucid may experience a
precipitous loss of consciousness / degeneration due to epidural hematoma.
115
COMBATIVE PATIENT
• Bizarre Behavior • Head Trauma
• Violent Activities • Thyroid Dysfunction
• Head Injuries / AMS • Hyperglycemia / Hypoglycemia
• Anxiety • Diabetic Ketoacidosis
• Tachycardia / Elevated BP • Toxic Ingestion
• Environment (Hyper / Hypothermia)
• Hypoxia
Continued from: Universal Patient Care Guideline

Tactical Evacuation Guideline O2 (if Hypoxemic)
IV / IO Guideline (prn)
1. HEAD INJURY Guideline
(Spinal Immobilization once sedated 1. Significant Head Injury?
with Advanced Airway) 2. Inability to Protect Airway (GCS <8)?
YES 3. Violent Behavior
4. Altered Mental Status
2. AIRWAY Guideline
(Establish Advanced Airway) NO Consider Need / Use Of:
EPW or Potential Hostile? YES • Security Escort
• Hard Restraints (*See Pearls)
3. Consider: RSI PROCEDURE
NO
(Must Maintain and Manage Airway) Attempt to Calm / Reassure
Physical Restraints as Needed

4. When safe: obtain blood
glucose: If Still Combative, Consider:
• If <70 or >250 switch to: Ketamine RSI PROCEDURE
(ALTERED MENTAL STATUS 0.5 mg/kg IM/IN / 0.3 mg/kg (Must Maintain and Manage Airway)
Guideline) IV/IO
Glucose 70-250? YES

• LORAZEPAM 1-2mg IV / IM
(can be used alone) When appropriate, return to:
MIDAZOLAM 2.5-5mg IV / IM
q3-5 minutes prn
(Large Patient may require 10mg
if using IM)
Pearls:
• Combative patients present a very real threat to the safety of themselves, the medic, and the aircrew during flight.
For this reason, any patient with altered mental status and the potential for combativeness that would threaten
aircrew safety or themselves should be prophylactically sedated / paralyzed and intubated for the flight.
• *Physical restraints such as tying down patient hands to prevent pulling lines, etc., should be limited to the least
amount necessary to accomplish treatments / prevent injuries. (Kerlex gauze can be a useful restraint)
o Do not jeopardize the patient’s airway! – Avoid hog tying, lying prone in restraints, sandwiching
between spine boards, etc.
o Check Vitals, SpO2, Pulse and Cap Refill every 5 minutes.
• Use of sedative medications adds risk of decreasing respiratory drive and should be used with caution. However,
medications should be titrated to adequate dosage to control patient. Be prepared for airway interventions /
vomiting if used.
116
FEVER / INFECTION
• Warm • Infection / Sepsis
• Flushed • Cancer / Tumor / Lymphoma
• Diaphoretic • Medication / Drug Reaction
• Chills • Connective Tissue Diseases
Associated Symptoms: • Hyperthyroidism
• Myalgias, Cough, Chest • Heat Stroke
Pain, Headache, Dysuria, • Meningitis
Abdominal Pain, Mental
Status Change, Rash, Stiff
Neck

Tactical Evacuation Guidelines IV / IO Guideline (prn)
Consider Droplet, Airborne, or

Contact Precautions
(*See Pearls)
Consider:
Hyperthermia Guideline
1000mL NS IV prn
YES Orthostatic BP / Tachycardia?
(repeat as needed) Toxic Ingestion Guideline
NO
2L IVF and still Hypotensive? Encourage PO Intake if
Consider: Protecting Airway
Norepinephrine Acetaminophen 1gram PO
8-12mcg/min IV (if not provided in last 6 hours)
>38ºC (100.4ºF)
Temperature?
<38ºC (100.4ºF)
Return to:
Or Appropriate Guideline by Complaint
Pearls:
• Fever may not be present in immunocompromised, elderly, or those on immunosuppressive drugs.
• All fever is not due to infection – evaluate for environmental / thyroid / toxic etiology.
• *Appropriate precautions should be used for personal protection when transporting patients with
contagious disease:
o Airborne: standard PPE plus N-95 mask and NRB or surgical mask on patient. Used for
tuberculosis, measles, varicella, or other infections spread by droplets.
o Droplet: standard surgical mask for provider and patient. Use with: influenza, meningitis,
mumps, streptococcal pharyngitis.
o Contact: standard PPE with strict hand-washing. Use with: MRSA, scabies, varicella-zoster.
• It is better to use more PPE than is necessary.
• Acetaminophen may also be given PR if suppository form available and patient not tolerant of PO
medications.
117
ABDOMINAL
PAIN
Signs and Symptoms:
• Pain (RUQ, RLQ, LUQ, LLQ) (Location /
Migration / Radiation)
• Tenderness
• Diarrhea (Bloody?)
• Dysuria
• Constipation
• Vaginal Bleeding / Discharge
• Distention
• Guarding / Rigidity
Associated symptoms:
• Fever, Headache, Weakness, Malaise /
Fatigue, Myalgias, Cough, Mental
Status Changes, Rash
Universal Patient Care Guideline Consider use of BLOOD PRODUCT for:

O2 (if Hypoxemic) • Persistent or Worsening Signs of Hypovolemic Shock
Continued from:
IV / IO Guideline (Tachycardia, Hypotension, ↓Pulse Pressure)
Cardiac Monitor • Rigid Distended Abdomen and/or Known: AAA, GI
12 Lead ECG (>40yo) Bleed, or Ruptured Ectopic / Abruption
500mL NS / LR Bolus
(Repeat as Needed) YES Tachycardia / Hypotension / Orthostatic BP? Pain Management Guideline
IV / IO Guideline
NO Consider
Significant or Disabling Pain? Chest Pain Guideline
YES
NO
Nausea and/or Vomiting? YES 500mL NS / LR Bolus
NO Promethazine 12.5-25mg IV
OR
Reassess every 5 minutes Ondansetron 4-8mg IV
Pearls:
• Maintain a high index of suspicion for ectopic pregnancy as a cause of abdominal pain in females of
childbearing age.
• Antacids should be avoided in patients with renal disease.
• Patients older than 50 are at increased risk for life-threatening diagnoses (e.g., AAA).
• Appendicitis presents with vague, periumbilical pain that migrates to the RLQ. This classic
presentation may not be present in some patients.
• Repeat VS after each intervention. In non-traumatized patients, may repeat fluid bolus PRN
depending on patient condition and VS. In trauma patients, fluid boluses should be used in
accordance with hypotensive resuscitation guidelines (see Multiple Trauma Guideline).
• Choose the lower promethazine dosage for patients likely to experience sedative effects (e.g.,
elderly).
• Promethazine contraindicated in any patient less than 2yo (see Pediatric Guidelines).
• Pain management can be used PRN.
118
VOMITING & DIARRHEA
• Pain • CNS Injury / Mass / Infection
• Abdominal Distention • Myocardial Infarction
• Constipation • Drugs / Toxins
• Diarrhea • Bowel Obstruction
• Anorexia • Diabetic Ketoacidosis
• Pregnancy
Associated Symptoms: • Infections
Fever, Headache, Weakness, Malaise, • Gastroenteritis
Myalgias, Cough, Dysuria, Mental • Food Borne / Toxic
Status Changes, Rash • Psychologic
• Appendicitis

Cardiac Monitor If no improvement after
1000mL Bolus:
Evidence of Alcohol Abuse? Hypotension / Shock
NO YES Guideline
YES Blood Glucose <70?
Thiamine 100mg IV / IM
NO
Tachycardia / Hypotension? YES 1000mL NS IV
50% Dextrose 25g IV
OR NO
Glucagon 1mg IV / IM
Nausea and/or Vomiting? YES Promethazine 12.5-25 mg IV
NO Glucose 70-250? YES NO OR
YES Abdominal Pain? Ondansetron 4-8mg IV
NO
Reassess q5 minutes

Abdominal Pain Guideline
Consider
Pain Management Guideline
Consider
Chest Pain Guideline
Pearls:
• Suspicion of other underlying condition should prompt immediate referral to appropriate protocol.
• In pregnant patients with nausea / vomiting – can substitute D5 1/2NS or D5NS in place of NS.
• Fluid of choice for vomiting is NS. Fluid of choice for diarrhea is LR.
• Continually monitor for any decompensation.
119
Pediatric VOMITING &
DIARRHEA
• Pain • CNS Injury / Mass / Infection
• Abdominal Distention • Myocardial Infarction
• Constipation • Drugs / Toxins
• Diarrhea • Bowel Obstruction
• Anorexia • Diabetic Ketoacidosis
• Pregnancy
Associated Symptoms: • Infections
Fever, Headache, Weakness, Malaise, • Gastroenteritis
Myalgias, Cough, Dysuria, Mental • Food Borne / Toxic
Status Changes, Rash • Psychologic
• Appendicitis

Cardiac Monitor
Evidence of Malnourishment? Blood Glucose:

YES 0-1 Month Old <40?
NO YES 1 Month Old and Up <65?
Thiamine 25mg IV / IM
NO
Tachycardia / Hypotension? YES NS 20mL/kg PRN
25% Dextrose 2mL/kg IV
NO
OR
Glucagon 20-30mcg/kg Promethazine (If >2 years old)
IM Nausea and/or Vomiting? YES 0.25mg/kg/dose IV
(up to 12.5 mg/dose)
YES NO
OR
NO Glucose:
0-1 Month Old >40? Ondansetron
1 Month Old and Up >65? YES Abdominal Pain? • <40kg: 0.1mg/kg IV
• >40kg: 4mg IV
NO
Abdominal Pain Guideline
Reassess every 5 minutes
Consider When appropriate, return to:

HR HR Pediatric Pain Management Tactical Evacuation Guideline
Age Awake Sleeping
Newborn
to 3mo 85-205 80-160
3mo - 2y 100-190 75-160 BP Average Lower Limit
2 - 10y 60-140 60-90 1-10y 90+(years old x 2)mmHg 70+(years old x 2)mmHg
>10y 60-100 50-90 >10y 90mmHg
Pearls:
• Suspicion of other underlying condition should prompt immediate referral to appropriate guideline.
• Continually monitor for any decompensation.
120
OBSTETRIC EMERGENCY
• Vaginal Bleeding • Pre-Eclampsia / Eclampsia
• Abdominal Pain • Placenta Previa
• Seizure • Abruptio Placentae
• Hypertension • Spontaneous Abortion
• Headache
• Visual Disturbance

Cardiac Monitor ABDOMINAL PAIN
Guideline
Place in Left Lateral Decubitus

Abdominal Pain (alone)?
or with Pad Under Right Hip
Magnesium Sulfate 4g IV
Over 15min Seizure? Hypertension with Headache Vaginal Bleeding?
(or 5g IM each buttocks) and/or Vision Complaints?
Glucose <70 or >250? Magnesium Sulfate 4g IV

Tachycardia / Orthostatic?
If in Status Epilepticus, Over 15min
Move to: YES NO
YES NO
SEIZURE Guideline
ALTERED MENTAL MIDAZOLAM Blood Product
STATUS Guideline 2.5-5mg IV / IM (as available) OR
Monitor,
OR
Reassess, 1000mL NS IV bolus
LORAZEPAM
Address:
1-2mg IV / IM
• BP?
Wait 60 seconds
• Seizure? NO S/Sx, Complaint of Labor?
Seizure Stopped? NO • Glucose
• Vision YES
Failed to resolve YES Changes /
after 2nd dose CHILDBIRTH
Headache
Guideline
Throughout transport to MTF,
any Complaint of Labor, move to:
Pearls:
• Seizure / headache / vision complaints: can give Midazolam 0.1mg/kg IV every 15-30 or 1mg IV every2-
3min up to 5mg while waiting for magnesium to take effect.
• Seizure activity in an OB patient signifies eclampsia.
• The best life support for the fetus is to resuscitate the mother.
• All pregnant / suspected pregnant patients should be kept in the left lateral decubitus position or have
padding placed below the right hip to keep pressure off of the inferior vena cava.
• Use caution when using magnesium – it can lead to cardiorespiratory collapse with hypotension and
decreased respiratory drive.
• Treat all hypertensive patients as if they are pre-eclamptic despite any prior history of hypertension.
121
CHILDBIRTH
Signs and Symptoms: Possible Complications:
• Spasmodic Pain • Preterm Labor
• Vaginal Fluid / Bleeding • Spontaneous Vaginal Delivery
• Crowning / Urge to Push • Placenta Previa
• Meconium • Prolapsed Cord
• Abnormal Presentation (e.g., breech)

O2 (if Hypoxemic)
Continued from:
IV / IO Guideline
Cardiac Monitor
Check Blood Glucose
Left Lateral Position or

Place Pad / Lift Under Right
Hip
OBSTETRIC EMERGENCY Hyper / Hypotension?

Guideline YES Abnormal Bleeding?
Crowning? Assist With Childbirth

(Visually Inspect - NO Digital Exam) YES (*See Pearls)
NO
NEWBORN CARE AND DISTRESS
Monitor and Reassess
Guideline

Rapid Transfer to Nearest MTF
Pearls:
• Document all times – delivery, contraction frequency / length.
• Assist with birth:
o Position mother as necessary.
o Prepare 2 sets of hemostats and scissors / scalpel, umbilical cord clamp if available, bulb suction.
o If umbilical cord palpable around neck– attempt to reduce manually prior to delivery of head
(should feel rope-like structure around neck). As last resort, and if unable to keep pressure off of
the cord, clamp and cut cord when unable to manually reduce.
o If prolapsed cord seen (overlying fetal head) – use upward pressure on fetal presenting part to
delay delivery. Place saline soaked (moist / wet) dressing over prolapsed cord.
o Suctioning of nose and mouth with bulb aspirate recommended if obvious obstruction from
secretions.
o Use slight downward pressure to deliver superior shoulder, then slight upward pressure to deliver
lower shoulder.
o Clamp cord after 1-3 minutes with 2 hemostats and cut between clamps.
o Immediately wrap infant and give to mother – assistant to aid in monitoring child.
o Deliver placenta – should feel lengthening / giving way of cord and gush of blood – keep placenta
for pathology evaluation. (This process may take up to 30min. Never pull on the umbilical cord in
attempts to speed delivery.)
o “Externally” massage uterus to encourage contraction and limit bleeding.
122
BACK and NECK PAIN
• Pain • Muscle Spasm / Strain
• Swelling • Degenerative Disc Disease
• Pain with Motion • Fracture
• Weakness / Numbness • Kidney Stone / Infection
• Bowel / Bladder Dysfunction • Abdominal Aortic Aneurysm
• Pneumonia / PE
• Cauda Equina Syndrome
• Tumor / Mass / Infection
• Thoracic Pain: Thoracic or abdominal aortic aneurysm
Universal Patient Care Guideline BACK OR NECK PAIN ASSOCIATED

Continued from: O2 (if Hypoxemic) WITH A NEUROLOGIC OR
Tactical Evacuation Guideline IV / IO Guideline (prn) VASCULAR DEFICIT IS AN
Cardiac Monitor (prn) EMERENCY!
Mechanisms that increase suspicion

YES Injury / Trauma? of possible Spinal Cord Injury:
• Blunt trauma to head or neck
NO • Injury associated with high energy
SPINAL IMMOBILIZATION
Guideline Extremity BP difference? / transfer (e.g., blast, motor vehicle)
Suspicion of AAA? • Fall from >3 feet
NO
• Fall directly onto head / neck
HEAD INJURY Guideline YES • History of back / neck arthritis plus
1000mL NS IV any trauma
OR Consider:
MULTIPLE TRAUMA Guideline Blood Product for AAA
Bradycardia with
Pulse
Arrhythmia?
NO Tachycardia with
YES Pulse
Suspicion of ACS?
CHEST PAIN YES Chest Pain?
Cardiac Arrest
NO (VF / Pulseless VT or
PAIN MANAGEMENT Guideline Asystole / PEA)

Pearls:
• Examine: mental status, HEENT, neck, chest, lungs, abdomen, back, extremities,
neurologic.
• Abdominal aortic aneurysm is a concern in hypertensive / diabetic / >50yo populations
– feel for pulsatile abdominal mass. Symptoms may mimic kidney stones.
• Patients with trauma / midline tenderness should be immobilized.
• Any bowel / bladder incontinence is significant and may represent true surgical
emergency (Cauda Equina Syndrome).
123
DENTAL PROBLEMS
• Bleeding • Dental Caries
• Pain • Infection
• Fever • Fracture
• Swelling • Avulsion
• Missing / Fractured Tooth • Abscess / Cellulitis
• Gingivitis

Tactical Evacuation Guideline IV / IO Guideline (prn)
Control Bleeding
If less than 1hr – attempt to

PAIN MANAGEMENT Guideline NO Tooth Avulsion? YES replace tooth in socket
(*See Pearls)
Place tooth in NS
(milk if available)

PAIN MANAGEMENT Guideline
Pearls:
• Significant soft tissue swelling to face / mouth can represent cellulitis or an abscess.
• Avulsion (Complete Avulsion Only)
o Gently rinse (do not scrub) tooth with NS and attempt to re-implant with firm
pressure into the socket. Never perform this in children with primary teeth.
o As able and without obstructing airway, place bulky dressing over tooth and use
as a soft bite block to stabilize tooth. Instruct to bite down gently, do not move
jaw.
• Subluxation (tooth displaced in socket)
o Treatment not always required.
o For obviously loose or displaced tooth consider placing bulky dressing over tooth
and use as a soft bite block to stabilize tooth. Instruct to bite down gently, do not
move jaw.
• Occasionally, cardiac chest pain can radiate to the jaw.
124
EPISTAXIS
• Bleeding From One or Both • Trauma
Nares • Infection
• Pain • Allergic / Chemical Rhinitis
• Nausea / Vomiting • Nose Picking
• Nasal Deformity • Lesions (Polyp, Ulcer)
• Hypertension
• Anticoagulant Therapy
• Thrombocytopenia (ITP)

Tactical Evacuation Guideline IV / IO Guideline (prn)
Have Patient Blow Nose to

Evacuate Clots
Afrin Nasal Spray (*see Pearls)
Compression (Pinch) and Tilt

Head Forward x 10min
Hypotension?
Assess BP and Pulse Hypertension?
Tachycardia?
Normotensive
Blood Product Consider:

(as available) OR Ondansetron 4-8mg IV HYPERTENSION Guideline
(nausea from swallowed blood)
500mL NS IV prn

Pearls:
• *Avoid Afrin in patients who have a diastolic blood pressure >110 or known coronary
artery disease.
• It is better to overestimate the amount of blood lost with epistaxis.
• Anticoagulants including aspirin, ibuprofen, and even herbals (ginseng) can lead to
increased bleeding.
• Firm pressure should be applied for compression. Pressure should not be applied over the
bridge of the nose, but instead under the bony portion to effectively compress vessels. Do
not release pressure prior to the 10 minutes mark to check bleeding.
• Hypertensive patients will often not stop bleeding until BP is controlled.
• Re-bleeding is common with epistaxis.
125
12-LEAD ELECTROCARDIOGRAM
• Suspicion of arrhythmia.
• Chest pain believed to be of cardiac origin.
• Toxic ingestion with cardiac side effects.
CONTRAINDICATIONS:
• None
PROCEDURE:
• Ensure patient lying flat on bed and place leads as per diagram.
• If patient is unstable, address any emergent issues prior to attempting the 12-lead EKG.
• Once leads are in place, instruct the patient to remain still and limit any movements around the patient (as
possible).
• Press button to obtain 12-lead EKG.
• If questions exist, maintain supportive care and contact medical control if able.
126
BLOOD GLUCOSE ANALYSIS
• Suspicion of blood glucose abnormalities – hyperglycemia / hypoglycemia.
CONTRAINDICATIONS:
• None
PROCEDURE:
• Gather and prepare equipment.
• Obtain blood samples for analysis as per manufacturer’s recommendations.
• Place blood sample onto reagent strip and place into machine for analysis as per manufacturer
recommendations.
• Record result and treat any glucose abnormalities per appropriate guideline.
• Perform quality assurance on glucometers weekly, if any suspicious recordings are noted, and/or per
manufacturer’s recommendations.
127
FOLEY CATHETER PLACEMENT
• Bladder distention in an unconscious person, or for blockage / inability to urinate in conscious
person.
• Allows for accurate monitoring of output for fluid management.
CONTRAINDICATIONS:
• Known or suspected urethral disruption resulting from pelvic trauma.
• Combative or uncooperative patient.
PROCEDURE:
• Choose appropriate catheter (16-18 for adults) and ready equipment.
• Position patient. Females in supine position with legs abducted. Cleanse urethra and surrounding
area with antiseptic solution. Isolate area with drapes provided.
• Insert xylocaine jelly provided into urethra with the syringe provided.
• Insert catheter into urethra. For females advance the catheter approx. 3 inches. For males, pass
catheter into the bladder the full length to the junction of the catheter and inflation port for
balloon. Once urine is obtained, inflate balloon with 5cc NS, then pull catheter outward until
balloon against bladder neck.
• Secure catheter to leg with tape to prevent trauma to urethra. Document procedure.
128
NASO / OROGASTRIC TUBE
• Enabling gastric decompression, decreasing risk of vomiting and aspiration, obtain sample of gastric
contents.
• Allows for gastric lavage in drug overdose or poisoning.
CONTRAINDICATIONS:
• Nasogastric tubes contraindicated in the presence of massive facial trauma, burns, or suspicion of
basilar skull fracture (CSF otorrhea, Battle’s sign, raccoon eyes, mechanism). May insert orogastric
tube instead.
PROCEDURE:
• If possible, sit patient upright for optimal neck and stomach alignment.
• Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the
sternum and the navel. Mark measured tube with marker.
• Select most patent nare and pass lubricated tube in a posterior – NOT SUPERIOR – direction. If
resistance is met, attempt to corkscrew slightly or remove and attempt in other nare.
• Withdraw tube immediately if changes occur in patient’s respiratory status, if tube coils in mouth, if
the patient begins to cough, or becomes cyanotic.
• Advance tube until mark is reached.
• Verify tube placement by listening over stomach while air is passed or examining aspirate when
applied to suction. Secure tube. Watch vital sign for changes.
129
SPINAL EVALUATION &
IMMOBILIZATION
CLINICAL INDICATIONS: (Cervical collar)
• Trauma resulting in the following: loss of consciousness, questionable loss of consciousness, temporary
amnesia.
• Pt. involved in the following: major blast/explosion, direct blunt force/penetrating trauma to head, neck,
torso or pelvis, sudden acceleration/deceleration or lateral bending forces on the neck/torso, fall from height,
ejection or fall from any motorized vehicle, or vehicle roll over.
CONTRAINDICATIONS:
• Patients with isolated penetrating cervical injury who are conscious and have no neurologic signs should not
have a cervical collar placed in the pre-hospital environment.
PROCEDURE:
• Evaluation should take place after the primary survey and all emergent procedures completed. However,
during the primary survey, the spine should be protected by manual inline stabilization / limited movement
prior to completion of spinal examination. This does not apply to situations in which imminent danger exists
and immediate movement is necessary.
• Maintaining spinal stability, log-roll the patient onto their side and palpate the spinal column for any step-off,
deformity, or tenderness to palpation. If any of this exists, patient should be rolled back onto a spinal board,
if available.
• After palpation, test upper and lower gross motor function by having patient move arms and legs slightly.
• Conduct an abbreviated combat neurologic exam:
o Muscle strength- test bilateral upper and lower extremities for variations. If limited to pain or injury
note in patient care report.
o Sensory- test light touch and pin-prick sensation at major dermatomes.
o Digital Rectal Exam- test for anal contraction/tone. Look for anal wink.
o DOCUMENT all findings and time the test was conducted. This information will serve as a
baseline.
• Place patient into a rigid C-collar and then apply head blocks with tape to the spinal board. A C-collar itself
does not provide adequate stabilization if unstable injuries exist.
• In pregnant patients, place blocks / padding under the right hip to elevate it. This relieves pressure on the
inferior vena cava and improves venous return to the heart.
• On the battlefield, safety of patient and medical personnel are paramount. In hostile situations,
evacuation to a more secure area takes precedence over spine immobilization.
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Normal Clinical Parameters
Vital Signs
• Temperature (rectal)- 99.0° to 102.5° F
• Heart Rate/ Pulse- 60 to 80 bpm
• Respiratory Rate- 16 to 30 bpm
• Blood Pressure- Systolic 120 mmHg, Diastolic
80 mmHg, Mean 90 to 100 mmHg
Clinical Pearls for MWDs-

• Average MWD weighs 25-40 kg (German shepherd dogs, Belgian Malinois, Labrador retrievers). All
drug dosages should be calculated based on measured or estimated body weight.
• IV catheterization access points are:
• Cephalic vein on the cranial (superior) aspect of the forearm (figures 1 & 2)
• Lateral saphenous vein on the lateral aspect of the hind limb at the distal tibial area (figure 3)
• External jugular vein in either jugular furrow of the neck
• IO catheterization access points are:
• Greater trochanter of the humerus (figure 4 & 5)
• Medial tibia just distal to tuberosity (figure 6 & 7)
• Arterial Pulse is palpated at the femoral artery on the medial aspect of the proximal thigh in the
inguinal area or at the dorsal metatarsal artery on the dorsal aspect of the proximal hind paw. (figure
8)
• Heart sounds are best auscultated over the lower lateral thoracic wall between the 4th and 5th
intercostal space. (figure 9)
• 3-lead electrocardiograms are sufficient for MWDs. Adhesive electrodes should be taped to the pads
of the paws of the left forelimb (black lead), right forelimb (white lead), and left hind limb (red lead).
(figure 10)
• Pulse oximetry probes can be utilized on conscious dogs using the ear pinna, lip fold, or flank skin;
while not optimal for oximetry, these alternative sites are acceptable and generally yield reliable
results.
Figure 2- Vein occlusion superior to

elbow joint while elbow is in extension.
Figure 1- Vein Figure 3- lateral saphenous

best punctured vein on the hind limb of a MWD
toward the elbow.
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Figure 4 - Musculoskeletal
view of greater trochanter of
the humerus for IO catheter
Figure 5 - Shoulder IO catheter location
Figure 7 - medial tibia IO catheter location just distal to tuberosity
Figure 6 - Musculoskeletal
view of medial tibia location
for IO catheter just distal to
tuberosity
132
Figure 8 - location for palpation of
Figure 9 - optimal location for auscultation of the
the femoral arterial pulse
heart sounds and palpation of the heart beat
Figure 10 - placement of adhesive ECG

electrode pads on the footpads
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Heat Injury Treatment
MILD heat injury MODERATE heat injury SEVERE heat injury
(heat stress) - excessive thirst, (heat exhaustion) - heat stress (heat stroke) – heat exhaustion
discomfort associated with present, as well as weakness, are present, coupled with
physical activity, mild anxiety, and uncontrolled varying degrees of CNS
dehydration, but with controlled panting (i.e., the patient cannot abnormalities (changes in
panting (i.e., the patient can reduce panting when exposed mentation and level of
control or reduce panting when to a noxious inhalant), but consciousness, seizures,
exposed to a noxious inhalant central nervous system (CNS) abnormal pupil size, blindness,
such as alcohol). abnormalities are not present. head tremors, and ataxia.
-Remove patient from source of -Same as MILD but more -Triage-

heat, discontinue exercise, cool aggressive cooling required • Establish airway
by fans or air condition, give Remove patient from all heat • Provide oxygen
cold water to drink. and stop all activity. • Establish IV for shock
treatment
-Cool by fans or air condition.

-Monitor patient for -Thoroughly soak the hair coat -Aggressively cool patient until
• Body Temp to the skin (room-temp) in order rectal temp is less than 105°F.
• Mentation / LOC to reduce core body • Use only room
• Weakness / collapse temperature. temperature fluids.
• Anxiety/ restlessness
• Shock
-Monitor patient for -Monitor patient for

• Body Temp • Vitals, Blood Glucose
• Mentation / LOC • ECG
• Weakness / collapse • Mentation / LOC
• Anxiety/ restlessness • Gait
• Shock • Vision
• Seizure
Clinical Pearls:
• PANTING is the only significant cooling mechanism for dogs.
• NO specific body temperature defines heat stroke in MWD’s. Normal rectal temperature is 99.0° to
102.5° F in the MWD. Temperatures as low as 105.8°F have been associated with pathology. Most
commonly, heat stroke is seen in MWDs with rectal temperatures greater than 107°F.
• DO NOT use of cold intravenous fluids, ice packs, or ice-water baths for cooling.
• Once the MWD’s body temperature is <103° CEASE all cooling efforts and monitor for rebound
hypothermia.
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CPR Management
Cardiopulmonary Arrest Confirmed
BEGIN BASIC LIFE SUPPORT- SUSTAIN CPR for 2-3 minute cycles
- Circulation- Chest compressions, FAST and HARD, 100 compressions per minute
- Airway- Clear airway and intubate; perform tracheostomy if obstructed airway
- Breathing- Manually ventilate with 100% O₂ at 8-10 breaths per minute
BEGIN ADVANCED LIFE SUPPORT

ECG (determine arrest rhythm)
IV / IO access for drug delivery
VF or VT ASYSTOLE/ BRADYCARDIA/ PEA

- Defibrillate- 2-5 J/kg - Drug therapy:
- Resume chest compressions x 1 cycle • Atropine 0.04 mg/kg IV/IO
- Defibrillate twice more, with 1 compression and
cycle between each counter-shock, if refractory • Epinephrine 0.01 mg/kg IV/IO
- Drug therapy if counter-shock no successful: or
• Epinephrine 0.01 mg/kg IV/IO • Vasopressin 0.8 U/kg IV/IO once
or
Vasopressin 0.8 U/kg IV/IO once
and
• Lidocaine 2 mg/kg IV/IO
or
• Amiodarone 5-10 mg/kg IV/IO
- Repeat counter-shock (2 x initial energy) if
refractory
CPR EMERGENCY DRUG CACLUATION (Quick Reference)

Caution: you m ust first validate the drug concentrations on the Weight (Pounds) 50 60 70 80 90 100
bottle is the sam e as on this quick reference chart. Weight (Kg) 22.7 27.3 32 36.3 41 45.5
DRUG/ACTION [CONC] DOSE ROUTE ml ml ml ml ml ml
Vasopressin 20 units/ml 0.80 U/kg IV / IO 0.91 1.09 1.28 1.45 1.64 1.82
Epinephrine (1:1,000) 1 mg/ml 0.01 mg/kg IV / IO 0.23 0.27 0.32 0.36 0.41 0.46
Epinephrine (1:10,000) 0.1 mg/ml 0.01 mg/kg IV / IO 2.27 2.73 3.20 3.63 4.10 4.55
Atropine 0.4 mg/ml 0.04 mg/kg IV / IO 2.27 2.73 3.20 3.63 4.10 4.55
Lidocane (1%) 10 mg/ml 2.00 mg/kg IV / IO 4.54 5.46 6.40 7.26 8.20 0.91
Amiodarone 50 mg/ml 5.00 mg/kg IV / IO 2.27 2.73 3.20 3.63 4.10 4.55
Magnesium Sulfate (0.5 g/ml) 500 mg/ml 30.00 mg/kg IV 1.36 1.64 1.92 2.18 2.46 2.73
Sodium Bicarbonate (8.4%) 1 mEq/ml 1.00 mEq/kg IV 22.70 27.30 32.00 3.63 41.00 45.50
Defibrillate 2-5 J/kg 2.00 J/kg External 45.40 54.60 64.00 72.60 82.00 91.00
135
Analgesia and Sedation
If MWD is suspected of having PAIN or PAIN is
anticipated, please provide analgesia
Intermittent IV or IM supplementation CRI supplementation
Or Or Or
Hydromorphone Morphine Sulfate Fentanyl Morphine Hydromorphone
0.1-0.2 mg/kg 0.2-0.5 mg/kg 2-10 0.1-0.25 mg/kg/ 0.02-0.05
q 2-4 hours q 4-6 hours mcg/kg/hour hour mg/kg/hour
Mild Sedation Fractious Patient Sedation

allow exam; relax MWD; reduce anxiety; use for MWDs that are too fraction to handle safely in order
no painful procedure anticipated to allow further care to allow catheterization
- IV catheter (discretional) - Place IV catheter once the MWD is controlled

- Give Midazolam 0.3 mg/kg IM & - Give Midazolam 0.3 mg/kg IM & Ketamine 2 mg/kg IM &
Hydromorphone 0.2 mg/kg IM Hydromorphone 0.1 mg/kg IM
24h - Can also use Propofol in 1 mg/kg boluses IV as needed
to allow catheterization or intubation
Clinical Pearls:
- Assessment of pain in dogs is difficult. Health Care Providers should err on side of providing
analgesia. Properly performed, it is safe and effective, and analgesia is critically important for safe
handling and alleviation of pain.
- Note that all protocols have analgesia incorporated into them. Additional analgesia can
be provided by the IV/IM or PO route, as necessary.
- CAUTION: Do NOT use acetaminophen or ibuprofen in MWDs, as these drugs can

cause liver toxicity. AVOID use of NSAIDs such as naproxen and aspirin in
emergently ill or injured MWDs.
- OPIOID REVERSAL: At appropriate doses, dogs appear less susceptible to opioid-induced
respiratory depression and excessive sedation. However, opioid side effects can be reversed
in the dog using NALOXONE 0.01-0.02 mg/kg slow IV to effect if needed. Note that this
will reverse analgesia as well as sedation!
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Gastric Dilation-Volvulus
GDV is a rapidly life-threatening condition common in MWDs. In GDV, the stomach rapidly dilates (gastric
dilation) with fluid, food, and air, and then rotates along the long axis (volvulus) and causes shock by
interfering with venous return from the abdomen and pelvic limbs.
Clinical Signs:
-Non-productive retching, attempted vomiting without result; signs of pain (grunting when
palpating stomach); signs of anxiety; inability to lay comfortably; and signs of
compensatory shock (tachycardia, tachypnea)
Initiate Monitoring:
ECG, NIBP, SpO₂, ETCO₂, Evaluate for dysrhythmias,
hypotension, hypoxemia, hypo- or hypercapnia
Treat Shock
- Give supplemental O₂
- Place at least 2 IV or IO catheters
- Give IV or IO crystalloid therapy utilizing the 10-20-10-10 fluid guideline
- Give hydroxyethyl starch (HES) boluses (10-20 mL/kg) IV or IO as
needed to maintain normal blood pressure. Repeat this bolus if no
response to therapy.
- Give hypertonic saline (HTS) IV bolus of 4 mL/kg over 5 minutes (if 7-
7.5% HTS is available) for MWDs that fail to respond to two or three
quarter-shock boluses of crystalloids and/or one or two boluses of HES.
Decompress the Tympanic Stomach

- Position self on left side, or lay dog on left side
- Locate Insertion point: Palpate last rib, move hand two inches caudal to the last rib, midway between the
spine and the ventral border of the abdomen on the right side, auscultate the lateral abdominal wall at most
distended area while percussing the wall with finger. Loudest “ping” is the site of insertion.
- Clip hair over a 6-inch area over the area.
- Prepare area with surgical scrub.
- Forcefully insert 14-18 gauge IV over-the-needle catheter through skin, abdominal wall, and stomach wall.
- Note gas or air escaping through the trocar/needle from the stomach to signify a successful trocarization.
(DO NOT ATTEMPT SECOND INSERTION if first is unsuccessful)
- Apply gentle external pressure to abdominal wall to assist exiting air.
- Remove trocar/catheter once air is evacuated.
Provide analgesia utilizing analgesia guideline
Clinical Pearls:
Goal is to treat for shock, decompress stomach, and transport for surgical
intervention.
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Emergency Airway Management
RESPIRATORY DISTRESS PRESENT
- Tachypnea
- Tachycardia
- Abnormal breathing pattern, as below
o Head and neck extended
o Resists restraint and handling
o Forelimbs abducted
o Open-mouth breathing
o (+/-) cyanosis
OBSTRUCTIVE BREATHING RESTRICTIVE BREATHING PARENCHYMAL BREATHING

- Labored inspiration - Rapid, shallow breathing - Labored inspiration and
- Abnormal upper airway noise - Muffled/absent lung or Heart Expiration
(stertor/stridor) sounds - Absence of abnormal upper
airway noise
DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS

- Upper airway obstruction - Pneumothorax - Pulmonary contusions
- Laryngeal paralysis - Hemothorax - Pulmonary edema
- Diaphragmatic hernia - Pneumonia
- Pleural effusion
- Pyothorax
100% Oxygen Supplementation Examples
Conscious or fractious muzzled dogs (10-15 L/min) Orotracheal intubation or Tracheostomy (2 L/min)
Clinical Pearls:
- Unconscious MWDs: Use tracheal insufflation, orotracheal intubation, or tracheostomy. If there
is an obstruction then bypass the obstruction until the patient is more stable.
- NOTE: intubation of the MWD is most easily performed with the dog in sternal or prone position
and the head and neck extended.
- Assisted ventilation via an Ambu-bag® at a rate of 8-10 breaths per minute.
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Shock Fluid Therapy
The “10-20-10-20 Rule
Shock Fluid Therapy Protocol of MWDs

- Place multiple large-bore intravenous catheters, perform venous cut-down, and/or place intra-
osseous (IO) catheters.
- Give IV or IO crystalloid therapy utilizing the 10-20-10-10 fluid guideline:
1. Calculate total fluid “shock” volume (90 mL/kg) that might be required.
2. Collect baseline physiologic and clinical data (mentation, NIBP, HCT, TP, HR, pulse quality,
CRT, mucous membrane color).
3. Give one quarter of the calculated “shock” volume over the first 10 minutes.
4. Reassess the patient‘s pulse quality, CRT, mucous membrane color, heart rate, NIBP, etc.
5. Give another one quarter of the calculated “shock” volume over the next 10-20 minutes, if
necessary.
6. Reassess baseline data.
7. If HCT > 20% and TP not below 50% of starting value, and further fluid therapy is
required, then give another one quarter of the calculated “shock” volume over 10 minutes.
8. Reassess baseline data.
9. If fluid therapy is still required, give the final one quarter of the calculated “shock”
volume over 10-20 minutes.
- Give a hydroxyethyl starch (HES) IV or IO bolus of 10-20 mL/kg over 5-10 minutes if clinical signs of
shock do not abate after the first 30 minutes (first 2 quarter-shock IV challenges) of crystalloid fluids, or
response to crystalloid challenges is not sustained. Repeat this bolus if no response to therapy.
- Give a hypertonic saline (HTS) IV bolus of 4 mL/kg over 5 minutes (if 7-7.5% HTS is available) for
MWDs that fail to respond to two or three quarter-shock boluses of crystalloids and/or one or two boluses
of HES.
Clinical Pearls:
- CAUTION: Human blood products and albumin, or other animal blood products,
must never be given to dogs, given the high risk of anaphylactic reactions.
- Blood product transfusions for MWDs are ONLY available from Veterinary Service Support units
and their administration is only authorized under the direct supervision of a Veterinarian.
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III. BLOOD / BLOOD PRODUCTS
***See Blood Component Therapy Guideline***
PURPOSE:
To ensure the safe delivery of blood products to those patients meeting criteria for transfusion by US
ARMY Aeromedical Evacuation medical personnel.
Prior to use and/or transport of blood products, maintenance and handling of blood products must be
sustained IAW Theater / relevant Command Surgeon SOP. If maintenance and handling cannot be
sustained IAW Theater SOP all blood products must be considered non-usable.
INDICATIONS:
• Patients requiring aggressive intravascular blood replacement and resuscitation due to acute,
ongoing, major hemorrhage associated with pending or frank shock, and/or acute traumatic
coagulopathy
o Any patient whose clinical course may be improved by increased intravascular oxygen-
carrying capacity and/or plasma coagulation factors
o Usage of blood products requires specific demonstration of proficiency.
 Certification memorandum maintained in medical aircrew member’s folder and
guideline binder or consistent with provider delineated clinical privileges.
 Complete annual refresher course utilizing concepts of theater blood guideline
SOP and approved and validated by unit medical director and trainer.
Adult Inclusion Criteria:
• Injured patients assumed age of 18 years or older
• Patients with two or more positive ABC Scoring System variables (see table)
• ABC Scoring System. 2 or more points = positive prediction for Massive Trauma
Heart rate > 120 bpm 1 Point

Systolic BP less than 90mmHg 1 Point
Penetrating Trauma 1 Point
Positive FAST if available 1 Point
CONTRAINDICATIONS:
- None in pre-hospital combat trauma setting when clinically indicated
o See PATIENT REFUSAL guideline as needed
EQUIPMENT:
- Blood refrigerator (located at FRST/CSH), which will have a temperature monitoring system
(digital, graphic and bottled thermometers) that meets standard guidelines for Blood Bank
Refrigerators
- A Temperature Log for the Blood Refrigerator that meets standard guidelines for monitoring
blood refrigerators
- Large bore IV or IO access, two sites preferred
- Blood-Y tubing
- Fluid warming equipment
- Safe-T-Vue
- Patient temperature monitoring equipment
- Monitor for possible transfusion reactions
140
- I-Stat Monitoring Device with CG8 Cartridges (Flight Surgeon Kit)
- Pressure Bags
TRANSFUSION REACTION:
See Blood Component Therapy Transfusion Related Reaction Guideline
Document procedure, results, and vital signs on run sheet following mission.
Post-Surgical, Transfer Patients: (adopted from: CENTCOM ECC Nurse Guidelines, 2012)
a. Patients may require initiation or continuation of blood products during transport. Proper
identification and documentation of patient’s blood type is necessary prior to transport and physician’s
orders are required.
b. Blood product compatibility.

1) Whole blood does not have a universal donor and requires type specific blood. Low-titer O negative
whole blood that is FDA cleared is second choice to type specific whole blood.
2) The universal donor for packed or deglycerolized red blood cells is type O Negative. Male recipients
may receive O Positive packed red blood cells.
3) Female recipients of child-bearing age (age 10-50) should receive type O Negative. If type O Negative
is not available, type O Positive pRBC may be administered provided the accepting MTF is notified so
that Rhogam therapy can be provided.
4) The universal donor for plasma is AB positive.
c. Ensure verification of blood products with a second medical person prior to leaving medical facility
with blood products.
d. If initiating blood product administration, obtain and record pre-transfusion vital signs. If the
operational situation does not allow for a temperature, it should be measured and documented at the
first opportunity.
e. Prior to transfusion, the price unit will be assessed for gas, discoloration or sediment. Thawed Plasma
units will be assessed to ensure there is no cracking of the plastic bag that has led to a leak,
contaminating the unit. Thawed Plasma will be assessed to ensure that there are no clumps or
discoloration.
f. All blood products will be administered through a dedicated line of Normal Saline (NS) using blood
tubing (inline filter standard in blood tubing). Flush the entire IV line with NS prior to starting the
infusion. Minimum caliber IV gauge shall be 18, preferably 14, in adults.
g. DO NOT add any other medications or IV fluids, except NS, to the line or unit of blood.
h. If initiating transfusion and patient is not in extremis, start the transfusion slow and infuse
approximately 50 mL over 15 minutes.
141
i. Continually monitor patient during the first 15 minutes. Check and record vital signs. Increase rate to
200 mL/hr after 15 minutes. If patient is in extremis, initiate infusion immediately with high flow rate
and pressure bag.
j. Documentation:
1) 1st and 2nd verifiers sign the SF 518
2) Pre-transfusion vital signs to include temperature documented on SF 518 and ECC Record.
3) Date and time transfusion started on SF 518 and ECC Record.
4) Type of blood product transfused and serial number or may place sticker on the ECC Record.
5) Post transfusion, record the amount given and the time the transfusion was completed or
interrupted, along with vital signs on the SF 518 and ECC Record. If applicable, also document
information regarding transfusion reaction, see “i.” below.
k. Observe patient for signs and symptoms of transfusion reaction to include: chills, back or chest pain,
hives, rash, fever, and/or wheezing.
1) If signs or symptoms of transfusion reaction occur, STOP TRANSFUSION IMMEDIATELY.
2) Disconnect and change the IV tubing KVO with NS.
3) Obtain a complete set of vital signs including a temperature. Continue to record VS every 15
minutes.
4) For febrile reaction (temperature increase of > 2⁰F from baseline), administer acetaminophen 650 mg
PO if possible.
5) For allergic or anaphylactic reaction (itching, chills, flushing, nausea/vomiting, coughing, wheezing, or
laryngeal edema) administer diphenhydramine 50 mg IVP once. Prepare to administer epinephrine.
6) For acute hemolytic reaction (rapid onset of itching, chills, flushing, nausea/vomiting, coughing,
wheezing, laryngeal edema, dyspnea, hypotension hemoglobinuria, rise in venous pressure, distended
neck veins, crackles at base of lungs), administer epinephrine (1:1000) 0.5 mL IM in the thigh
(preferred) or deltoid every 5 to 15 minutes. Repeat up to 3 times for moderate bronchospasm, facial
and laryngeal edema. *If thigh and deltoid are unavailable, may administer subcutaneously.
Also, administer diphenhydramine 50 mg IVP once.
7) Document reaction on SF 518 and on ECC Record, type and time of symptom onset, time blood was
stopped, vital signs, O2 saturation, blood draw, interventions, and physician to whom you reported and
time of report.
8) Save the blood bag and tubing. Blood will be drawn from the patient upon arrival to MTF.
9) Notify receiving physician of transfusion reaction.
EXAMPLE VAMPIRE PROGRAM
*CENTCOM Clinical Operating Protocol CCOP-01: URGENT RESUSCITATION USING BLOOD PRODUCTS
DURING TACTICAL EVACUATION FROM POINT OF INJURY
To provide essential instructions on urgent/life-saving resuscitation procedures using blood products

during tactical evacuation (refers to both casualty evacuation and medical evacuation) from the point of
injury (POI) for casualties suffering major blood loss/massive hemorrhage. Referred to as, Vampire
Program. All USCENTCOM clinical operating protocols (CCOPs) are posted to the CCSG SharePoint site at
https://intelshare.intelink.gov/sites/ccsg/SitePages/CCSG-CLINOPS.aspx or can be found on the Joint
Trauma System page at http://www.usaisr.amedd.army.mil/10_jts.html
142
2.APPLICABILITY
This CCOP applies to all USCENTCOM Service Components, Combined and other Joint Task Forces
(CJTFs), and all U.S. military forces operating under Title 10 within the geographic area of responsibility
(AOR) assigned or allocated to Commander, USCENTCOM by approved Global Force Management (GFM)
processes (e.g., Command Plan) and Department of Defense (DoD) civilian medical employees deploying
with U.S. Forces (hereafter referred to as “DoD personnel”) consistent with DoD and Service specific
guidance.
a.Medical and non-medical personnel (e.g., flight medic, crew chief, registered nurse, enlisted medical
personnel, physician, nurse practitioner, or physician assistant), assigned/attached or allocated to
perform tactical evacuation (CASEVAC and MEDEVAC) duties that involve direct or indirect patient care.
b.All operational units participating in the USCENTCOM Vampire Program will comply withquality
assurance and patient safety reporting requirements IAW USCENTCOM Regulation (CCR) 40-1.
***This only applies to the CENTCOM AOR unless adopted by other Geographic Comabatant
Commands.
143
IV. SEXUAL ASSAULT
INDICATIONS:
1. Reported and/or suspected assault on any person regardless of age or gender.

2. Trauma and/or bleeding to the vagina, rectum or buttocks that can not be identified as
being the result of any other cause.
REMARKS:
1. Focus shall be placed on the victim and on doing what is necessary and appropriate to
support victim recovery and also, if a Service member, to support that Service member to be
fully mission capable and engaged.
2. Medical personnel should be gender-responsive, culturally competent, and recovery-
oriented.
a. Medical providers giving care to sexual assault victims shall recognize the high
prevalence of pre-existing trauma (prior to present sexual assault incident) and the
concept of trauma-informed care.
b. If the attending flight medic is not appropriately trained to conduct a Sexual Assault
Forensic Evidence (SAFE) Kit, information will be forwarded to the Medical Treatment
Facility in order to make the necessary arrangements to complete the SAFE Kit as soon
as possible.
3. Flight Paramedics shall abide by the Sexual Assault Prevention and Response (SAPR)
Program and coordinate with the Sexual Assault Response Coordinator (SARC) and Sexual
Assault Prevention and Response Victim Advocate (SAPR VA).
a. The SARCs shall serve as the single point of contact for coordinating care to ensure that
sexual assault victims receive appropriate and responsive care.
4. Sexual assault victims shall be given priority and treated as emergency cases. Emergency
care shall consist of emergency medical care and the offer of a SAFE Kit.
PATIENT MANAGEMENT PROCEDURE:
1. In the management of sexual assault patients, the DoD first priority for victims is to protect,
treat with dignity and respect, and to provide the medical treatment, care, and counseling
that patients deserve. Under the DoD Confidentiality Policy, sexual assault victims have two
reporting options: Restricted and Unrestricted. It is mandatory that all DoD health care
providers (including 68Ws) adhere to the parameters of confidentiality and notification
pursuant to each form of reporting.
a. Restricted Reporting: Reporting option that allows assault victims to confidentially
disclose the assault to specified individuals (e.g., SARC, SAPR VA, healthcare
personnel) and receives medical treatment (including emergency care), counseling,
and assignment of a SARC and SAPR VA; without triggering an investigation. The
victim’s report provided to healthcare personnel (including the information acquired
from a SAFE Kit), SARCs, or SAPR VAs will NOT be reported to law enforcement or to
144
the command to initiate the official investigative process unless the victim consents
or an established EXCEPTION applies.
i. Restricted reporting applies to Service members and their military
dependents 18 years of age and older. Additional persons who may be
entitled to Restricted Reporting are NG and Reserve Component members.
ii. Only a SARC, SAPR VA, or healthcare personnel may receive a Restricted
Report.
b. Unrestricted Reporting: A process that an individual covered by this policy uses to
disclose, without requesting confidentiality or Restricted Reporting, that he or she is
the victim of a sexual assault. Under these circumstances, the victim’s report
provided to healthcare personnel, the SARC, a SAPR VA, command authorities, or
other persons is reported to law enforcement and may be used to initiate the
official investigative process.
2. Priority treatment as emergency cases includes activities relating to access to healthcare,
coding, and medical transfer of evacuation and complete physical assessment, examination,
and treatment of injuries including immediate emergency interventions.
3. DO NOT attempt to examine the patient without informed consent except to treat
immediate life, limb, or eyesight threats. SARC notification must not delay emergency
medical care treatment of a victim.
a. Limit cleaning of wounds to only determine severity.
b. Check for associated or additional injury and/or other illness. Refer to appropriate
medical treatment guidelines as appropriate.
4. In situations where installations do not have a SAFE capability, the installation commander
will require that the eligible victim, who wishes to have a SAFE, be transported to a MTF or
local off-base, non-military facility that has a SAFE capability. A local sexual assault nurse
examiner or other healthcare providers who are trained and credentialed to perform a SAFE
may also be contacted to report to the MTF to conduct the examination.
5. Preserve all evidence:
a. Bag all personal items (e.g., blood stained items, clothes). Paper bags are
recommended if available, in order to prevent excess moisture accumulation and
subsequent evidence degradation.
b. Ensure all items are signed for before handing off.
c. Ensure all interactions, statements made by the patient, and all treatment given is
medically documented in patient care record while maintaining patient
confidentiality.
INDICATIONS: Responding to treat a minor patient without parent or legal guardian

representative available. For the purpose of these guidelines, all patients under age 18 years
will be considered minors. Medical aircrew and medical directors should consult unit rules of
engagement and applicable laws and adjust accordingly.
1. Treatment and transport of any minor requiring immediate care to save life or prevent
severe injury will be performed following the principle of implied consent for emergency
145
care. (Assume any minor who needs treatment to save life, limb, eyesight, or to prevent
severe injury has provided consent to treatment.)
2. ALWAYS act in the patient’s best interest. ALWAYS maintain complete and careful
documentation.
3. If the parent or guardian is present, follow these guidelines:
a. Allow one (1) parent to accompany the child during transport after approval of
the pilot in command (PIC) and if it does not interfere with patient care or flight
safety.
b. In event of major trauma and/or cardiac arrest, judgment should be exercised in
allowing parents to accompany the child. Recent evidence supports this
practice in emergency departments and some EMS settings, but care should be
exercised to maintain crew safety and mission accomplishment.
c. Allow the parent to hold or touch the child, if possible, while assuring optimal
transport restraints to assure safety.
d. Remember to be open and honest to both parent and child about the child's
condition and any treatment given. DO NOT diagnose, DO NOT deceive, and DO
try to comfort the child or parent.
VI. PATIENT REFUSAL
INDICATIONS: If a patient (or person[s] responsible for a minor) refuses treatment or transport,
after pre-hospital providers have arrived on scene, the following procedures should be carried
out:
1. A Primary Assessment (to include vital signs) should be completed, if possible. Pay
particular attention to the patient's mental status.
2. Any injuries or illnesses found to immediately threaten life, limb, or eyesight (or can be
assumed will deteriorate enroute) should be addressed and treated immediately while
enroute, to the greatest extent possible while assuring safety. Patients that prevent
treatment of these injuries should be treated in accordance with the COMBATIVE
PATIENT GUIDELINE and appropriate supporting guidelines.
3. Injuries or illnesses that do not represent imminent threats to life, limb, or eyesight (or
considered unlikely to deteriorate enroute) may be addressed in accordance with the
following:
 Determine the patient's (parent's) decision making capacity to make sound/valid
judgments concerning the patient's condition. If there are any doubts from the
provider's aspect, consider treating in accordance with the ALTERED MENTAL
STATUS GUIDELINE or COMBATIVE PATIENT GUIDELINE.
 Ensure that you clearly and repeatedly explain to the patient or responsible parties
of the concerns and possible risks involved in refusing medical care.
 Clearly document all findings during the patient assessment and any discussions
with the patient regarding his/her condition as well as all persons involved with the
patient. Document all statements made pertaining to the risks associated with
refusing treatment and transportation and obtain a signature from a witness (crew
member) and the patient or parties responsible for the patient as to refusal of care.
146
Clearly explain to Military Personnel why the treatment is needed. Notify them
that refusal of treatment may bring judicial or administrative adverse action upon
them under UCMJ.

a. General Use
i. Use as clinically indicated per guideline.
Oxygen
Class: Atmospheric gas.
Mechanism of Action: Essential substrate for cellular respiration.
Duration of action: Onset: immediate. Peak effect: not applicable. Duration: less than 2 minutes.
Indications: All causes of decreased tissue oxygenation and/or decreased level of consciousness.
(Confirmed or expected hypoxemia, ischemic chest pain, respiratory, insufficiency, prophylactically
during air transport, confirmed or suspected carbon monoxide poisoning). Also provides mechanical
work for gas-powered ventilators, if supply and flow rate is sufficient (OBOGS will not work).
Contraindications: Coincidental paraquat inhalation (rare); COPD patients may become hypopneic with
high O2 flow rates due to “oxygen baroreceptor respiratory drive (relative contraindication).
Adverse Reactions: Retinopathy of prematurity (prolonged use); potential oxygen toxicity in hyperbaric
environments; cerebral vasoconstriction
Drug Interactions: None
How Supplied: Oxygen cylinders (usually green and white) of 100% compressed oxygen gas.
Dosage and Administration:
• Assure adequate ventilation (spontaneous or supported) coincidental to supplemental oxygen
therapy, ideally by end-tidal CO2 measurement (Goal EtCO2 35-45).
• All critically ill and injured transport patients will receive supplemental oxygen to maintain
oxygen saturation of > 93%.
• Administer oxygen 2-6 LPM via nasal cannula.
o If O2 Saturation remains < 95%, apply non-rebreather face mask with oxygen at 15 LPM.
o If O2 Saturation remains < 90%, refer to Airway guideline.
• Patient on Ventilator:
o Adjust ventilator settings based on ventilatory goals for patient: ETCO2, peak pressures,
SpO2, and patient clinical condition.
o Adjust FiO2 to maintain pulse oxygen saturations > 93% / tissue oxygen saturation
(STO2) > 70%, if applicable.
• When planning for available O2 during non-pressurized, aeromedical transfer, ensure adequate
resources to provide 1.5 to 2 times the ground transport volume of O2 to compensate for
increased consumption associated with altitude related physiological impact.
147
0.9% Sodium Chloride (Normal Saline)
Class: Isotonic crystalloid solution.
Mechanism of Action: Replaces water and electrolytes.
Indications: Hypovolemia, Shock, Heat-related injuries, diabetic ketoacidosis, TKO IV, diluent of choice
for blood product transfusion.
Contraindications: Avoid for intravascular volume replacement for hemorrhagic shock due to
hemodilution and hyperchloremic metabolic acidosis. Use with caution in patients with known
congestive heart failure.
Adverse Reactions: Rare
Drug Interactions: Few in the pre-hospital emergency setting.
How Supplied: 250mL, 500mL, and 1,000mL bags.
Dosage and Administration: The specific situation being treated will dictate the rate in which normal
saline will be administered. Hypovolemic shock requires rapid bolus (see relevant guidelines). In other
cases, it is advisable to administer the fluid at a moderate rate (for example, 100 mL/h).
Lactated Ringer’s (Hartman’s Solution)

Class: Isotonic crystalloid solution.
Mechanism of Action: Replaces water and electrolytes.
Indications: Hypovolemic shock; keep open IV.
Contraindications: Should not be used in same line with blood components. Use with caution for
intravascular volume replacement for hemorrhagic shock due to hemodilution and exacerbation of
coagulopathy. Use with caution in patients with known congestive heart failure and kidney disease. Can
cause lactic acidosis.
How Supplied: 250mL, 500mL, and 1,000mL bags. IV infusion.
Dosage and Administration: Hypovolemic shock; titrate according to patient’s physiologic response.
(See appropriate Guidelines)
Normal Saline Hypertonic 3%

Class: Hypertonic crystalloid solution.
Mechanism of Action: Replaces water and electrolytes, increases intravascular sodium concentration,
may induce diuresis
Indications: Refractory elevated intracranial pressure (ICP) due to various etiologies (eg, subarachnoid
hemorrhage, neoplasm); traumatic brain injury with elevated ICP: (Can be used in place of mannitol).
Contraindications: Do not use in same line as Blood Products – cause crenation and lysis of RBC.
Caution or avoid use in patients with known congestive heart failure and kidney disease.
How Supplied: 250mL, 500mL, bags.
Dosage and Administration:
• Dosing (Adult):
o Bolus: 250-500 cc IV Bolus over 15 min
o Infusion: 40 cc/hr
• Dosing (Pediatrics):
o Bolus: 5 cc/kg IV Bolus over 15 min.
o Infusion: 0.5 cc/kg/hr
148
Dextrose 5% in Water (D5W)
Class: Hypotonic dextrose-containing solution.
Mechanism of Action: D5W provides nutrients in the form of dextrose as well as free water.
Indications: IV diluent for certain emergency drugs; for dilution of concentrated drugs for intravenous
infusion.
Contraindications: Not for use as fluid replacement for hypovolemic states.
Drug Interactions: Phenytoin (Dilantin)
How Supplied: Supplied in 50mL, 100mL, 150mL, 250mL, 500mL, and 1,000mL bags.
Dosage and Administration: Normally administered through a mini-drip (60 gtt/mL) set at a rate of “to
keep open” (TKO).
b. Medications, all:
i. If carried, these medications are available for use, within the limitations of these
guidelines, drug cards, and supervising medical director / physician. These
medications may be used during transfer of critical care patients or during point of
injury. These medications are available for use on any patient, within the limitations
of these guidelines, as clinically indicated, to address acute life threatening
emergencies not accounted for on the transferring physician’s written orders. Some
medications utilized during critical care transfer requires written orders and
guidance from transferring physician or as directed by unit medical director /
supervising physician.
149
ACETAMINOPHEN Lactation Yes(Caution) Trade Name: Tylenol
Class / Mechanism of Action
Analgesic
Blocks cyclooxygenase (COX 1 and 2) enzymes, resulting in reduced formation of prostaglandin
precursors. Blocks formation of prostaglandin derivative, thromboxane A2, resulting in inhibited platelet
aggregation. Has antipyretic, analgesic, and anti-inflammatory properties.
Indications
Labeled Indications: Treatment of mild to moderate pain and fever, Treatment of moderate to severe
pain when provided via IV with opioid analgesia
Contraindications
• Hypersensitivity to acetaminophen or any component of the formulation
• Hepatic impairment or liver disease
Adverse Reactions / Precautions
• Use IV form cautiously in volume depleted patients
• Avoid use in patient suffering alcohol toxicity, known alcohol abuse, or renal impairment
• IV form can cause nausea and vomiting (especially in adults), headache
Dose and Administration: ADULT PEDIATRIC Always Reference BROSELOW Tape
Pain or fever: (Limit total daily dose to <4 g/day Pain or fever: Children ≥12 years & Adolescents:
PO: Refer to adult dosing
• Regular release: 325-650 mg every 4-6 hours PO:
or 1000 mg 3-4 times daily (maximum: 4 g • Infants and Children <12 years: 10-15
daily) mg/kg/dose every 4-6 hours as needed; do
not exceed 5 doses (2.6 g) in 24 hours
RECTAL:
• 325-650 mg every 4-6 hours or 1000 mg 3-4 RECTAL:
times daily (maximum: 4 g daily) • Infants and Children <12 years: 10-20
mg/kg/dose every 4-6 hours as needed; do
IV: not exceed 5 doses (2.6 g) in 24 hours.
• <50 kg: 15 mg/kg every 6 hours
o Max single dose: 15 mg/kg/dose (750 IV:
mg/dose) • Children 2-12 years: 15 mg/kg every 6 hours
o Max daily dose: 75 mg/kg/day (≤3.75 g or 12.5 mg/kg every 4 hours
daily) o Max single dose: 15 mg/kg/dose (≤750
• ≥50 kg: 1000 mg every 6 hours; mg/dose)
o Max single dose: 1000 mg/dose o Max daily dose: 75 mg/kg/day (≤3.75 g
daily)
150
ACETAZOLAMIDE Lactation Yes(Caution) Trade Name: Diamox
Diuretic, Carbonic Anhydrase Inhibitor; Anticonvulsant
Inhibits carbonic anhydrase causing a decrease in hydrogen ion renal secretion with increased renal
secretion of sodium, potassium, bicarbonate, and water. Onset of action PO: 2 hours, IV 5-10 minutes
Indications
Labeled Indications:
• Prevention or treatment of symptoms of acute mountain sickness
• Edema due to congestive heart failure
Contraindications
• Hypersensitivity to acetazolamide, sulfonamides, or any component of the formulation
• Confirmed low sodium / potassium levels otherwise none in emergency setting
• May worsen respiratory acidosis
• Drowsiness, deceased alertness, impairment of coordination, nausea, headache
• Flushing of skin, allergic skin reaction, skin photosensitivity
Dose and Administration: ADULT PEDIATRIC Always Reference LB tape
Altitude illness (Acute Mountain Sickness): Altitude illness (Acute Mountain Sickness):
PO: PO: (IM not recommended due to alkaline pH)
• 125-250 mg twice daily. • 2.5 mg/kg/dose every 8-12 hours
o MAX dose 250mg/dose.
Note: For high altitude cerebral edema (HACE),
dexamethasone is the primary treatment; however, Note: For high altitude cerebral edema (HACE),
acetazolamide can be used (together with dexamethasone is the primary treatment; however,
dexamethasone) at the AMS dose. acetazolamide can be used (together with
dexamethasone) at the AMS dose.
Edema (Only with referring doctor or medical
director instruction):
PO, IV:
• 250-375 mg once daily
151
ACETYLSALICYLIC ACID Lactation Yes (Short Term Trade Name: Aspirin
or Low Dose OK)
Systemic Corticosteroid
Blocks cyclooxygenase (COX 1 and 2) enzymes, resulting in reduced formation of prostaglandin
precursors. Blocks formation of prostaglandin derivative, thromboxane A2, resulting in inhibited platelet
aggregation. Has an antipyretic, analgesic, and anti-inflammatory property.
Indications
Labeled Indications: Treatment of acute coronary syndromes (ST-elevation MI, non-ST-elevation MI,
unstable angina), acute ischemic stroke, and transient ischemic episodes.
Contraindications
• Hypersensitivity to salicylates, other NSAIDs, or any component of the formulation
• Asthma, Rhinitis
• Inherited or acquired bleeding disorders (including factor VII and factor IX deficiency)
• Do not use in children less than 16 years old (Reye's syndrome)
• Not for use on trauma patients in the combat environment.
• Risk of bleeding: Avoid use in patients with known or suspected, Bleeding disorders, GI Bleed, GI
Ulcers, patients taking Coumadin, or within 24hrs of taking Alteplase (tPA) for suspected stroke
Acute coronary syndrome (ST-segment N/A:

elevation myocardial infarction [STEMI], No Appropriate need on evacuation platform
unstable angina (UA)/non-ST-segment elevation
myocardial infarction [NSTEMI]): (Not for use in
trauma patients ):
PO:
• 324 mg (chew nonenteric-coated aspirin as a
single 325 mg tablet or 4 X 81 mg tablets)
152
ACTIVATED CHARCOAL Safe Lactation Safe Trade Name: Actidose
Antidote
Non-absorbable agent that absorbs toxins within the GI tract inhibiting GI absorption.
Indications
Labeled Indications: Management of suspected or known poisonings when gastrointestinal
decontamination is an option.
• Decontamination within 1 hour of ingestion of toxic substance
Contraindications
• No absolute contraindications in severe poisoning
• If patient unconscious, must establish airway control and must utilized NG/OG tube.
• Be prepared for possible emesis. Consider use of antiemetic.
• Avoid use in patients at risk of GI hemorrhage or perforation
Acute Poisoning: Acute Poisoning: Children >12 years: Refer to

PO,NG/OG: adult dosing.
• Single dose: 50 grams PO,NG/OG:
• Multidose: Initial dose: 50 grams initially • Single dose: 1 gram/kg
followed by 25 grams every 2 hours • Multidose: Initial dose: 1Gram/kg initially,
followed by multiple doses of 0.5 Gram/kg
Note: Some products may contain sorbitol. Co- every 2 hours
administration of a cathartic, including sorbitol, is
no longer recommended. Note: Some products may contain sorbitol.
Coadministration of a cathartic, including sorbitol, is
Note: Activated Charcoal has limited efficacy if not no longer recommended.
utilized within 1 hour of toxin ingestion.
Note: Activated Charcoal has limited efficacy if not
Note: Multidose charcoal is indicated if patient utilized within 1 hour of toxin ingestion.
ingested life-threatening amount of drug
(carbamazepine, dapsone, phenobarbital, guanine,
or theophylline)
153
ADENOSINE Lactation? Trade Name: Adenocard®
Antiarrhythmic Agent
Slows conduction time through the AV node, inhibits re-entry pathways through the AV node, restoring
normal sinus rhythm. Half-life of less than 10 seconds allows for rapid repeat dosing.
Indications
Labeled Indications: Paroxysmal supraventricular tachycardia (PSVT) when clinically advisable, vagal
maneuvers should be attempted first; not effective for conversion of atrial fibrillation, atrial flutter, or
ventricular tachycardia.
Unlabeled: ACLS/PALS Guidelines (2015): Stable, narrow-complex regular tachycardias; unstable
narrow-complex regular tachycardias while preparations are made for synchronized direct-current
cardioversion; stable regular monomorphic, wide-complex tachycardia as a therapeutic (if SVT) and
diagnostic maneuver.
Contraindications
• Hypersensitivity to adenosine or any component of the formulation
• Second- or third-degree AV block, sick sinus syndrome, or symptomatic bradycardia (except in
patients with a functioning artificial pacemaker)
• Use in patients with atrial fibrillation/flutter with underlying Wolff-Parkinson-White (WPW) syndrome
(Fuster, 2006); asthma (ACLS, 2015)
• Known or suspected bronchoconstrictive (Asthma) or bronchospastic lung disease.
• May cause transient asystole and new arrhythmia after cardioversion (PACs, AF, PVCs) chest
discomfort
• Headache, Dizziness, Flushing, GI upset
• Dyspnea, Bronchospasm in asthmatics
Paroxysmal supraventricular tachycardia: Paroxysmal supraventricular tachycardia:
I.V. (rapid push, over 1-2 seconds, via proximal IV/IO (rapid push, over 1-2 seconds, via peripheral
peripheral line (forearm or above, large bore). line; see Note): Follow each dose with 10-20 mL
• Initial: 6 mg; if not effective within 1-2 minutes, normal saline flush..
12 mg may be given if needed (maximum
single dose: 12 mg). • Initial: 0.1 mg/kg (maximum initial dose: 6 mg);
if not effective within 1-2 minutes, administer
0.2 mg/kg (maximum single dose: 12 mg).
Notes): Follow each dose with 20 mL normal Follow each dose with 5-10 mL normal saline
saline flush. flush.
Note: Initial dose of adenosine should be reduced

to 3 mg if patient is currently receiving
carbamazepine or dipyridamole, has a transplanted
heart or if adenosine is administered via central line
(ACLS, 2015).
Note: Adenosine effects are antagonized by

caffeine and theophylline, and patients may require
higher doses.
154
ALBUTEROL Lactation? Trade Name: Proventil / Ventolin
Beta 2 Agonist (Bronchodilator)
Synthetic sympathomimetic that relaxes bronchial smooth muscle, causing bronchodilation, with little
cardiac impact. Onset of action is 2-15 minutes
Indications
Labeled Indications: Treatment or prevention of bronchospasm in patients with reversible obstructive
airway disease; prevention of exercise-induced bronchospasm
• Asthma
• Reactive Airway / Bronchospasm
• COPD
Contraindications
• Hypersensitivity to albuterol or any component of the formulation
• Symptomatic tachycardia
• Risk of abortion during 1 or 2 trimester
st nd
• Headache, Dizziness, Flushing, Diaphoresis, Tremor, Weakness

• Angina, A-Fib, Arrhythmia, Chest Pain, Palpitations
• Dyspnea, Bronchospasm in asthmatics
Bronchospasm: Bronchospasm:
Metered-dose inhaler (90 mcg/puff): Metered-dose inhaler (90 mcg/puff):
• 2 puffs every 4-6 hours as needed • 2 puffs every 4-6 hours as needed
Solution for nebulization: Solution for nebulization:

• 2.5 mg 3-4 times daily as needed • Children ≤4 years: 0.63-2.5 mg every 4-6 hours
as needed
Exacerbation of asthma (acute, severe): • Children ≥5 years: 1.25-5 mg every 4-8 hours
Metered-dose inhaler: as needed
• 4-8 puffs every 20 minutes for up to 4 hours, • Children ≥12 years: Refer to adult dosing.
then every 1-4 hours as needed
Solution for nebulization: Exacerbation of asthma (acute, severe):
• 2.5-5 mg every 20 minutes for 3 doses, then Metered-dose inhaler (90 mcg/puff):
2.5-10 mg every 1-4 hours as needed. • Children <12 years: 4-8 puffs every 20 minutes
for 3 doses, then every 1-4 hours as needed
• Children ≥12 years: Refer to adult dosing.
Solution for nebulization:

• Children <12 years: 0.15 mg/kg (minimum: 2.5
mg) every 20 minutes for 3 doses, then 0.15-
0.3 mg/kg (maximum: 10 mg) every 1-4 hours
as needed
• Children ≥12 years: Refer to adult dosing.
155
AMIODARONE Lactation: Yes, Not Recommended
Antiarrhythmic Agent, Class III
Inhibits adrenergic stimulation (alpha and beta blocking), prolongs action potential and refractory period
(prolongs PR and QT intervals); decreases AV conduction and sinus node function (decreases sinus rate)
Indications
Labeled Indications: Management of life-threatening recurrent ventricular fibrillation (VF) or
hemodynamically unstable ventricular tachycardia (VT) refractory to other antiarrhythmic agents
Unlabeled:
• Recurrent, hemodynamically unstable VT. (after other drugs have failed)
• Ventricular tachyarrhythmias (ACLS/PALS 2015): VF/VT Cardiac arrest unresponsive to CPR, Shock,
and Vasopressor.
Contraindications
• Hypersensitivity to amiodarone, iodine, or any component of the formulation
• Severe sinus-node dysfunction
• 2 and 3 degree heart block (except in patients with a functioning artificial pacemaker)
nd rd
• Bradycardia causing syncope (except in patients with a functioning artificial pacemaker)

• Cardiogenic shock
• Complex drug with multiple complex drug reactions! (Do not administer with procainamide)
• Hypotension
• Dizziness, fatigue, Headache, Poor coordination, Neuropathy
• Nausea, Vomiting
• Dysrhythmias, Asystole, AF, Bradycardia, AV block, Conduction abnormalities, SA node dysfunction
Pulseless VT or VF (ACLS, 2015): Pulseless VT or VF (PALS, 2015):

IV/IO push IV/IO push
• 300 mg rapid bolus; should be diluted in 30 mL • 5mg/kg IV bolus during cardiac arrest, May
of NS or D5W; if pulseless VT or VF continues repeat twice for refractory VF/pulseless VT.
after subsequent defibrillation attempt or • Max single dose: 300mg
recurs, administer supplemental dose of 150
mg. Tachycardia with Pulse and poor perfusion, or
symptomatic with adequate perfusion (PALS,
Recurrent, Hemodynamically unstable VT 2015):
(ACLS, 2015): IV/IO push
Initial Dose: • Loading dose: 5mg/kg over 20 to 60 minutes
IV/IO slow push • Can repeat two times (max dose: 15 mg/kg in
• 150mg IV over 1 10 minutes (15mg per
st
24 hrs)
minute) dilute in 20-30 mL of NS or D5W. • Max single dose: 300mg
• May repeat 150 mg every 10 minutes PRN if
VT recurs
Maintenance Infusion following initial dosing:
• 360 mg over 6 hours (1 mg/ min)
156
ATROPINE Sulfate Lactation: Yes, Use Caution Trade Name: AtroPen
Anticholinergic, Antidysrhythmic, Antidote for Carbamate Anticholinesterase poisoning
Blocks acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS;
increases cardiac output, and dries secretions. Atropine reverses the muscarinic effects of cholinergic
poisoning. Reverses bronchorrhea and bronchoconstriction, but has no effect on the nicotinic receptors
responsible for muscle weakness, fasciculations, and paralysis.
Indications
Labeled Indications: Treatment of
• Symptomatic Sinus Bradycardia, AV block (nodal level)
• Antidote for anticholinesterase poisoning (carbamate insecticides, nerve agents, organophosphate
insecticides)
• Note: No longer recommended for use in asystole or pulseless electrical activity (ACLS, 2015).
Contraindications
• Hypersensitivity to atropine or any component of the formulation
• Narrow-angle glaucoma; adhesions between the iris and lens (ophthalmic product)
• Pyloric stenosis
• Prostatic hypertrophy
• Note: NO contraindications should prevent use of atropine in setting of life threatening
organophosphate, carbamate, or nerve agent poisoning
• Tachycardia and arrhythmia (VTach, VFib), Hypotension, Palpitations
• Dilated Pupils, Angle-closure glaucoma
• Headache, Dry Mouth, constipation, urinary retention, flushing
• Paradoxical Bradycardia noted with doses less than 0.1mg
Symptomatic Bradycardia Symptomatic Bradycardia

IV/IO
IV/IO
• 0.5 mg every 3-5 minutes, not to exceed a total
• 0.02 mg/kg (Minimum dose is 0.1 mg.
of 3 mg or 0.04 mg/kg (ACLS, 2015)
Maximum single dose of 0.5 mg. May repeat
once in 3-5 minutes. Maximum total dose is 1
Organophosphate or carbamate insecticide or
mg (PALS, 2015)
nerve agent poisoning:
IV/IM: (Used with 2-Pam Chloride auto injector)
Organophosphate or carbamate insecticide or
• Initial: 1-6 mg; repeat every 3-5 minutes as
nerve agent poisoning:
needed, doubling the dose if previous dose did
• IV/IO: Initial: 0.05-0.1 mg/kg; repeat every 5-10
not induce atropinization. Maintain with repeat
minutes as needed, double dose if previous
doses as needed for ≥ 2-12 hours based on
dose does not induce atropinization. Maintain
recurrence of symptoms.
with repeat doses as needed for ≥2-12 hours
IM (AtroPen®): anterolateral aspect of thigh and
based on recurrence of symptoms.
hold in place for 10 seconds. Follow with 2-Pam
Chloride auto injector.
• Mild symptoms (≥2 mild symptoms): 2 mg once
an exposure is known or strongly suspected.
• Severe symptoms (≥1 severe symptoms):
Three 2 mg doses in rapid succession.
Mild and Severe Symptoms are noted on product
labeling and Pralidoxime Chloride drug card.
157
CALCIUM Chloride 10% Safe, Lactation Safe
Calcium Salt, Electrolyte Supplement
Moderates nerve and muscle contractility via action potential excitation threshold regulation
Indications
Labeled Indications: Treatment of hypocalcemia and conditions secondary to hypocalcemia (eg, tetany,
seizures, arrhythmias); emergent treatment of severe hypermagnesemia,
Unlabeled: Calcium channel blocker overdose; beta-blocker overdose (refractory to glucagon and high-
dose vasopressors); severe hyperkalemia (K+ >6.5 mEq/L with toxic ECG changes) [ACLS guidelines];
malignant arrhythmias (including cardiac arrest) associated with hypermagnesemia [ACLS guidelines]
Contraindications
• Known or suspected digoxin toxicity
• Not recommended as routine treatment in cardiac arrest (includes asystole, ventricular fibrillation,
pulseless ventricular tachycardia, or pulseless electrical activity)
• Hypercalcemia
• Hypokalemia: Use with caution in patients with severe hypokalemia. Acute rises in calcium can cause
life-threatening arrhythmias
• Rapid push can cause: Arrhythmia, bradycardia, cardiac arrest, hypotension, syncope, vasodilation
• Use small IV / Large Vein, flush prior and after, AVOID Extravasation (will cause tissue necrosis)
o In general, IV Calcium Gluconate is preferred over I.V. calcium chloride in nonemergency
settings due to the potential for extravasation with calcium chloride
• Do not infuse calcium chloride in the same I.V. line as phosphate-containing solutions.
• Precipitates with NaHCO 3 in IV Bag/Tubing
Cardiac arrest or cardiotoxicity in the presence Cardiac arrest or cardiotoxicity in the presence
of hyperkalemia, hypocalcemia, or of hyperkalemia, hypocalcemia, or
hypermagnesemia: hypermagnesemia:
IV/IO, SLOW IV/IO, SLOW
• 500-1000 mg over 2-5 minutes; may repeat as • 20 mg/kg (maximum: 2000 mg/dose); may
necessary repeat as necessary
Beta-blocker overdose, refractory to glucagon Calcium channel blocker overdose (unlabeled

and high-dose vasopressors (unlabeled use):
use): IV/IO IV/IO
• 20 mg/kg over 5-10 minutes followed by an • Initial: 20 mg/kg (0.2ml/kg) (maximum: 1000
infusion of 20 mg/kg/hour titrated to adequate mg/dose) over 10-15 minutes; may repeat
hemodynamic response every 10-15 minutes
Calcium channel blocker overdose (unlabeled Note: Adult and Pediatric dosages are expressed
use) (CaCl preferred over Calcium Gluconate for in terms of the calcium chloride salt based on a
this use): solution concentration of 100 mg/mL (10%)
IV/IO containing 1.4 mEq (27 mg)/mL elemental calcium.
• Initial: 1000mg over 5 minutes; may repeat (1gram = 10cc of a 10% solution)
every 10-20 minutes with 3-4 additional doses;
or a continuous infusion of 2-6 grams/hour may Note: Calcium Chloride is 3X more potent than
be initiated Calcium Gluconate and therefore lower doses of
Calcium Chloride must be used to reach similar
therapeutic doses
158
CALCIUM Gluconate Safe, Lactation Safe
Calcium Salt, Electrolyte Supplement
Moderates nerve and muscle contractility via action potential excitation threshold regulation
Indications
Labeled Indications: Treatment of hypocalcemia and conditions secondary to hypocalcemia (eg, tetany,
seizures, arrhythmias); cardiac disturbances secondary to hyperkalemia; magnesium sulfate overdose;
Unlabeled: Calcium channel blocker overdose; treatment of hydrofluoric acid exposure
Contraindications
• Ventricular fibrillation
• Hypercalcemia
• Concomitant use of IV calcium gluconate and ceftriaxone in neonates (risk of precipitation of calcium-
ceftriaxone)
• Hypokalemia: Use with caution in patients with severe hypokalemia. Acute rises in calcium can cause
life-threatening arrhythmias
• Rapid push can cause: Arrhythmia, bradycardia, cardiac arrest, hypotension, syncope, vasodilation
o Do not exceed 200mg/min except in emergency situations
• Caution in patients receiving digoxin therapy, may cause arrhythmias
• Use small IV / Large Vien, flush prior and after, AVOID extravasation (will cause tissue necrosis)
o In general, IV Calcium Gluconate is preferred over I.V. calcium chloride in nonemergency
settings due to the potential for extravasation with calcium chloride
• Do not infuse calcium chloride in the same I.V. line as phosphate-containing solutions.
• Precipitates with NaHCO 3 in IV Bag/Tubing
Cardiac arrest or cardiotoxicity in the presence Cardiac arrest or cardiotoxicity in the presence
of hyperkalemia, hypocalcemia, or of hyperkalemia, hypocalcemia, or
hypermagnesemia: hypermagnesemia:
IV/IO, SLOW IV/IO, SLOW
• 1500-3000mg over 2-5 minutes • 60-100 mg/kg/dose (maximum: 3000
mg/dose)
Calcium channel blocker overdose (unlabeled
use): Hypotension/conduction disturbances: Calcium channel blocker overdose (unlabeled
IV/IO use): Hypotension/conduction disturbances:
• 3 Grams (3000mg) over 5 minutes; may repeat IV/IO
every 10-20 minutes with 3-4 additional doses. • 45 mg/kg (maximum 3000mg/dose) over 10-15
minutes; may repeat every 10-15 minutes
Note: Adult and Pediatric Dosages are expressed
in terms of the calcium gluconate salt based on a Note: Calcium chloride may provide a more rapid
solution concentration of 100 mg/mL (10%) increase of ionized calcium in critically-ill children.
containing 0.465 mEq (9.3 mg)/mL elemental
calcium.
(1gram = 10cc of a 10% solution)
Note: Calcium Chloride is 3X more potent than

Calcium Gluconate and therefore higher doses of
Calcium Gluconate must be used to reach similar
therapeutic doses.
159
DEXAMETHASONE Lactation ?(Not Recommended) Trade Name: Decadron
Anti-inflammatory, Immunosuppressant Onset of action, IV: Prompt; Duration IV: 72 hours
Indications
• Anti-inflammatory or immunosuppressant in treatment of a variety of diseases: allergic, dermatologic,
endocrine, hematologic, inflammatory, neoplastic, renal, respiratory, rheumatic, and autoimmune
• Management if cerebral edema
Unlabeled:
• Treatment of acute mountain sickness (AMS) and high altitude cerebral edema.
Contraindications
• Hypersensitivity to dexamethasone or any component of the formulation
• Systemic fungal infection, cerebral malaria
• Not for use in treatment of head injury; increased mortality has occurred in head injury patients
treated with high dose IV methylprednisolone. Corticosteroids should not be used in head injuries.
Acute mountain sickness (AMS)/high altitude Acute mountain sickness (AMS)/high altitude
cerebral edema (HACE) (unlabeled use): cerebral edema (HACE) (unlabeled use):
PO, IM, IV: PO, IM, IV:
• AMS: 4 mg every 6 hours • 0.15 mg/kg/dose every 6 hours
• HACE: 8 mg as a single dose; followed with: 4 o consider use in high altitude pulmonary
mg every 6 hours until symptoms resolve edema because of associated HACE
with pulmonary edema
160
DEXTROSE 50% Lactation? Trade Name: Glutose / B-D Glucose
Antidote, Hypoglycemia
Basic source of calories (fuel) for the body and brain, regulated by insulin. Rapidly increases blood
glucose, decreases protein and nitrogen loss, preventing ketosis, and promotes glycogen deposition in
liver.
Onset of action: Treatment of hypoglycemia Oral dose: 10 minutes
Maximum effect: Treatment of Hyperkalemia IV: 30 minutes
Indications
Labeled Indications: Treatment of:
• Hypoglycemia: Doses may be repeated in severe cases
• Hyperkalemia: (Must be used in combination WITH Insulin)
Contraindications
• Known Hyperglycemia, otherwise None in Pre-hospital setting
Most adverse effects associated with excessive dose or infusion rate
• If evidence of malnutrition or alcohol abuse, thiamine should be given 1
st
• Tissue Necrosis if Extravasation occurs; immediately D/C and change IV site

• Hyperglycemia
• Hypokalemia
• Hyponatremia
Hypoglycemia: Hypoglycemia:
Oral: Oral:
• 4-20 g as a single dose; may repeat if • 4-20 g as a single dose; may repeat if
necessary necessary
IV: IV:
• 10-25 g (40-100 mL of 25% solution or 20-50 • Newborns: 5ml/kg D10 (Max 25 G/dose)
mL of 50% solution) • Infants and Children: 2ml/kg D25 (Max 25
G/dose)
Note: Society of Critical Care Medicine • Adolescents: Refer to adult dosing
recommends: Treat blood glucose <70 mg/dL
(<100 mg/dL in patients with neurologic injury) Note:
immediately by stopping insulin therapy (if • D25= 25ml NS + 25ml D50 (12.5g in 50ml's
receiving) and administering 10-20 g (20-40 mL of solution)
50% solution) IV; repeat blood glucose • D10= 100ml NS + 25ml D50 (12.5g in 125ml's
measurement in 15 minutes with repeat dextrose solution)
as needed; avoiding overcorrection. or
40ml NS + 10ml D50 (5g in 50ml's solution)
161
DIAZEPAM Lactation Yes (Unsafe) Trade Name: Valium
Benzodiazepine;
Acts as an Anxiolytic/Hypnotic, anticonvulsant and sedative – Long Half Life (25-100hrs)
Onset of action: IV, Almost Immediate
Duration: IV, 20-30 minutes
Indications
• Anxiety Disorders
• Convulsive Disorders and Alcohol Withdrawal Symptoms
• Skeletal Muscle Relaxant
• Induce Sedation and Amnesia (Midazolam is primary medication)
Contraindications
• Hypersensitivity to diazepam or any component of the formulation or other benzodiazepines
• Acute narrow angle glaucoma , Acute Alcohol Intoxication
• Respiratory Insufficiency/Depression (Overdose Reversal: FLUMAZENIL can be used, however it
carries elevated risk. Respiratory support until the medication is metabolized is traditionally the best
care in Benzodiazepine overdose)
• Neurologic Depression (Head Trauma)
• No Analgesic properties (Narcotic pain control is needed for RSI’d / Intubated trauma patients)
• May Cause Respiratory depression: Do not give without stable IV line and BVM (airway control) ready
• Hypotension, vasodilation
• Amnesia, confusion, drowsiness, slurred speech (Paradoxical Reactions possible: aggressiveness,
agitation, anxiety, inappropriate behavior)
Anxiety: Sedation / Muscle relaxation / Anxiety :

Oral, IV, IM: (Oral and IV doses more reliable) IV, IM (IV doses more reliable)
• 2-10 mg 2-4 times/day if needed • Children: 0.04-0.3 mg/kg/dose every 2-4 hours
Status Epilepticus: to a maximum of 0.6 mg/kg within an 8-hour
IV: (SLOW) period if needed
• 5-10 mg every 5-10 minutes given over 3
minutes (maximum dose: 30 mg) Status Epilepticus:
Sedation in ICU patient: IV:
IV: • Infants >30 days and Children <5 years: 0.2-
• Loading dose: 5-10 mg; Maintenance dose: 0.5 mg given slowly every 2-5 minutes
0.03-0.1 mg/kg every 30 minutes to 6 hours (maximum total dose: 5 mg); repeat in 2-4
Muscle Spasm: hours if needed
IV: • Children ≥5 years: 1 mg given slowly every 2-5
• Initial: 5-10 mg; then 5-10 mg in 3-4 hours, if minutes (maximum total dose: 10 mg); repeat
necessary. Larger doses may be required if in 2-4 hours if needed
associated with tetanus.
Nerve Agent Exposure (CBRNE) Muscle spasm associated with tetanus:
IM: IV, IM
• 10mg for seizures associated with Nerve Agent • Infants >30 days and Children <5 years: 1-2
exposure; or if 3 MARK 1 kits were used on a mg/dose every 3-4 hours as needed
casualty • Children ≥5 years: 5-10 mg/dose every 3-4
hours as needed
162
DIPHENHYDRAMINE Lactation Yes (Unsafe) Trade Name: Benadryl
Histamine H 1 Antagonist;
Competes with histamine for H1-receptor sites within the gastrointestinal tract, blood vessels, and
respiratory tract; Also produces anticholinergic and sedative effects
Indications
• Anaphylaxis and allergy disorders
• Motion Sickness
• Antitussive
Contraindications
• Hypersensitivity to diphenhydramine or any component of the formulation
• Acute Asthma
• Use on Neonates, premature infants, Nursing mothers
• Normally causes sedation, but may cause paradoxical excitation in children
• May have increased sedative effects when used with other sedatives or alcohol
• May cause hypotension (use with caution in patient with cardiovascular disease)
• Dry mouth
Anaphylaxis/Allergic Reactions and Motion Anaphylaxis/Allergic Reactions and Motion

Sickness: Sickness:
Oral: Oral, IM, IV:
• 25-50mg every 6-8 hours • 1 mg/kg every 6 hours
IV Push:
• 50mg once, prepare to administer epinephrine
Max Doses:
Acute Hemolytic reaction (rapid onset of itching, 2 to <6 years:
chills, flushing, nausea/vomiting, coughing, • 6.25mg every 4-6hrs; max of 37.5mg/day
wheezing, laryngeal edema, dyspnea, hypotension
hemoglobinuria, rise in venous pressure, distended 6 to <12 years:
neck veins, crackles in lung bases): • 12.5-25mg every 4-6hrs; max of 150mg/day
IV:
• 50mg once, after administration of epinephrine >12 years:
0.5mL in lateral thigh • See Adult dosing
163
DOBUTAMINE B Lactation? (Caution) Trade Name: Dobutrex
Adrenergic Agonist
Positive Inotropic agent. Stimulates beta1 adrenergic receptors: Increases HR and contraction force
while sparing beta2 and alpha receptors. Onset IV: 1-2 minutes
Indications
Labeled Indications: Short term management of cardiac decompensation.
Contraindications
• Hypersensitivity to dobutamine or sulfites (some contain sodium metabisulfate), or any component of
the formulation
• Idiopathic hypertrophic subaortic stenosis (IHSS)
• Always attempt to correct Hypovolemia 1 when using vasopressors and/or inotropes
st
o May be combined with Dopamine or Norepinephrine for hypotension not responding to

fluid administration
o No applicable use in hemorrhagic shock until fluid replacement therapy maximized!
• Increase in BP is common, but does have a rare incidence of causing hypotension
• Increases HR
• May exaggerate ventricular ectopy
Cardiac Decompensation: Cardiac Decompensation:

IV: IV
Dobutamine may be combined with dopamine or • Refer to adult dose
norepinephrine for hypotension not responsive to
fluid therapy.
• 2-20 mcg/kg/min, start low and titrate to
targeted MAP > 60 mmHg
• Preparation: Mix 250mg Dobutamine in

250mL D5W or NS for a concentration of
1000mcg/mL
Infusion Rates for Dobutamine at 1000mcg/mL

Desired Delivery Rate Infusion Rate
(mcg/kg/min) (mL/kg hour)
2.5 0.15
5 0.3
7.5 0.45
10 0.6
12.5 0.75
15 0.9
20 1.2
164
DOPAMINE Lactation? (Use Caution) Trade Name: Intropin

Adrenergic Agonist; Vasopressor
Stimulates adrenergic and dopaminergic receptors. High doses stimulate dopaminergic and beta1
adrenergic receptors, producing cardiac stimulation and renal vasodilation. Very large doses stimulate
alpha adrenergic receptors.
Indications
Treatment of non-hemorrhagic shock (eg, neurogenic, renal failure, cardiac decompensation) persisting
after adequate fluid volume replacement
Unlabeled: Symptomatic bradycardia or heart block unresponsive to atropine or pacing
Contraindications
• Hypersensitivity to sulfites
• Ventricular Fibrillation
• No applicable use in hemorrhagic shock unless fluid replacement therapy maximized!
Maximize use of Blood products / Crystalloids before considering use in hemorrhagic shock.
• Tachycardia and/or Arrhythmias: May increase HR and worsen arrhythmias
• Vesicant: Avoid extravasation, will cause tissue damage/necrosis
• Assure adequate circulatory volume to minimize need for vasoconstrictors. Monitor BP closely, avoid
hypertension and adjust infusion rate as needed.
Hemodynamic Support: Hemodynamic Support:

IV(Use microdrip chamber only): IV:
• 2-20mcg/kg/min; titrate to desired response. • "Use adult dosing"
Infusion may be increased by 1-
4mcg/kg/minute at 10 to 30 minute intervals
until optimal response is obtained Note: Dopamine is a second line medication for
hemodynamic support in Pediatric patients behind
Dopamine Dosage Efficacy: Epinephrine and Norepinephrine
• 1-5 mcg/kg/min= Dopaminergic effects:
increased urine output, increased renal blood
flow
• 5-10 mcg/kg/min= Beta1 effects: Increased
CO, HR, and contractility
• >10 mcg/kg/min= Alpha1 effects: Increased
BP, vasoconstriction
Note: Doses >20 mcg/kg/minute likely do not have

a beneficial effect on blood pressure and may
increase risk of tachyarrhythmias
Add additional vasopressor if Dopamine doses of
20 mcg/kg/min are inadequate.
(phenylephrine, norepinephrine, epinephrine.
165
DOPAMINE Drip Rates, Dosing Chart:
Mix 400mg dopamine in 250mL D5W or NS (or 800mg dopamine in 500mL
D5W or NS); Concentration = 1600mcg/mL
PT DESIRED DOSE (mL/hr):
WEIGHT Drops per minute based on microdrip tube (60gtt/ml)
Lbs Kg 5mcg/kg/min 10mcg/kg/min 15mcg/kg/min 20mcg/kg/min
88 40 8 15 23 30
100 45 8 17 25 34
110 50 9 19 28 38
120 55 10 21 31 41
132 60 11 23 34 45
143 65 12 24 37 49
154 70 13 26 39 53
165 75 14 28 42 56
176 80 15 30 45 60
187 85 16 32 48 64
198 90 17 34 51 68
209 95 18 36 53 71
220 100 19 38 56 75
231 105 20 39 59 79
242 110 21 42 62 83
253 115 22 43 65 86
264 120 23 45 68 90
275 125 23 47 70 94
Drip Rate Formula: (1600mcg/mL) / (60gtt/mL) = 26.66mcg/gtt
(mcg x Kg/min) / 26.66 = drops/min
Example: (5mcg x 40Kg/min) divided by 26.66mcg/gtt = 7.5 (or 8gtt/min)
166
EPINEPHRINE 1:1000 Lactation? (Caution)
Trade Name: EpiPen / EpiPen Jr
(1mg/ml)
Alpha & Beta Agonist
Sympathomimetic, stimulates both alpha and beta adrenergic receptors, causing relaxation of the
bronchial tree, cardiac stimulation (increasing myocardial oxygen consumption), and dilation of skeletal
muscle blood vessels
Indications
• Allergic Reactions, Anaphylaxis
• Asthma (Bronchoconstriction)
Contraindications
• Not for IV use, must first dilute into 10mL NS syringe for Cardiac / IV use
• Chest Pain, Tachycardia, Arrhythmias, Palpitations, Sudden death
• Anxiety, Cerebral Hemorrhage, Headache
• Use with caution in patients taking tricyclic antidepressants; effects of epinephrine may be increased
Bronchodilator: Bronchodilator:
SubQ, IM: 1:1000 SubQ: Infants and Children 1:1000
• 0.3-0.5 mg every 20 minutes for 3 doses • 0.01 mg/kg (0.01 mL/kg) (maximum single
Nebulization: dose: 0.5 mg) every 20 minutes for 3 doses
• Add 0.5 mL to nebulizer and dilute with 3 mL of Nebulization:
NS; administer over 15 minutes • Children <4 years: Croup: 0.05 mL/kg
(maximum dose: 0.5 mL); dilute in 3 mL of NS.
Anaphylaxis / Hypersensitivity reaction Administer over 15 minutes; do not administer
(ACLS,2015): more frequently than every 2 hours
IM: 1:1000 • Children ≥4 years: Adult dosing
• 0.3-0.5 mg every 5-15 minutes until clinical
improvement Anaphylaxis / Hypersensitivity reaction
(PALS,2015): Infants and Children
IV: Dilute 1 ml 1:1000 w/9ml NS to make 1:10,000 IM:
or use 0.1mg/mL Pre-filled 10cc (Cardiac) Syringe • 0.01 mg/kg (0.01 mL/kg of 1:1000 [1 mg/mL]
• 0.1 mg (1ml) over 5 minutes; solution) (maximum single dose: 0.3 mg) every
Or 5-15 minutes
IV Infusion: EpiPen Jr, Children 15-29 kg:
• Initiate with an infusion at 5-15 mcg/minute • 0.15 mg; if anaphylactic symptoms persist,
(with crystalloid) dose may be repeated in 5-15 minutes using
an additional EpiPen Jr
Acute Hemolytic reaction EpiPen, Children ≥30 kg:
IM: 1:1000 • 0.3 mg; if anaphylactic symptoms persist, dose
• 0.5mg IM in lateral thigh may be repeated in 5-15 minutes using an
o Repeat every 5-15min for moderate additional EpiPen
bronchospasm or facial/laryngeal
edema.
• Follow with Diphenhydramine 50mg IV Push
167
EPINEPHRINE 1:10,000 Lactation? (Caution) Trade Name: Adrenalin
Alpha & Beta Agonist
Sympathomimetic, stimulates both alpha and beta adrenergic receptors, causing relaxation of the
bronchial tree, cardiac stimulation, and dilation of skeletal muscle blood vessels
Indications
• Cardiac Arrest (VF, pulseless VT, asystole, PEA)
• Symptomatic Bradycardia unresponsive to atropine or pacing
• Anaphylaxis and severe allergic reaction
• Hypotension (Shock) unresponsive to volume resuscitation, hypotension with bradycardia
Contraindications
• Uncontrolled hypertension is a relative contraindication, otherwise none
• Chest Pain, Tachycardia, Arrhythmias, Palpitations, Sudden death
• Anxiety, Cerebral Hemorrhage, Headache
• Use with caution in patients taking tricyclic antidepressants; effects of epinephrine may be increased
Asystole/pulseless arrest, pulseless VT/VF Asystole/pulseless arrest, pulseless VT/VF after

(ACLS, 2015): failed DEFIB (PALS, 2015)
IV: 1:10,000 (0.1mg/mL) Pre-filled 10cc Syringe and
• 1 mg (10cc of 0.1mg/mL) every 3-5 minutes to Bradycardia (symptomatic; unresponsive to
ROSC, Follow each with 20mL flush atropine or pacing) Infant and children
Endotracheal:
• 2-2.5 mg every 3-5 minutes until IV/IO access IV: 1:10,000 – 0.1mg/mL Pre-filled 10cc Syringe
or ROSC; dilute in 5-10 mL NS or sterile water. • 0.01 mg/kg (0.1 mL/kg of 1:10,000 [0.1
mg/mL]) (maximum single dose: 1 mg) every 3-
Bradycardia (symptomatic; unresponsive to 5 minutes as needed or until ROSC
atropine or pacing) (ACLS,2015): •
IV Continuous Infusion: Severe Hypotension/shock and fluid resistant
• 2-10 mcg/minute titrate to desired effect (unlabeled use):
IV: Continuous Infusion
Anaphylaxis / severe Hypersensitivity reaction • 0.1 - 1 mcg/kg/minute titrated to desired effect
(ACLS,2015):
IV: 1:10,000 (0.1mg/mL) Pre-filled 10cc Syringe
• 0.1 mg (1ml) over 5 minutes;
IV Continuous Infusion:
• Initiate with an infusion at 5-15 mcg/minute
(with crystalloid)
Severe Hypotension/shock, fluid resistant
and/or dopamine dose >20mcg/kg/min
• 2-10 mcg/minute; titrate to desired effect
Infusion Preparation (standard):

1mg epinephrine (1:10,000) in 250mL D5W or NS=
4mcg/ml concentration
1mg epinephrine (1:10,000) in 500ml D5W or NS=
2mcg/ml concentration.
168
ETOMIDATE Lactation? (Caution) Trade Name: Amidate
General Anesthetic
Very short acting non-barbiturate sedative/hypnotic used for induction of anesthesia with little
cardiovascular effects. Onset of action: 30-60 seconds, Duration 5-10 minutes
Indications
• Induction and maintenance of general anesthesia
Contraindications
• Hypersensitivity to etomidate or any component of the formulation
• NO Analgesic properties!
• Safety in children less than 10 years has not been established
• Inhibits adrenal steroid production; may increase mortality if repeat dosing is required
RSI: RSI:
IV: IV:
• 0.3-0.5 mg/kg over 30-60 seconds for Children <10
induction of anesthesia; • Despite dosing on Broselow tape, not the
preferred induction agent for this group due to
Note: Limit to single dose for anesthesia/induction. limited safety information
Repeat dosing and continuous infusion Children >10:
(maintenance dosing) may increase patient • 0.2-0.4 mg/kg over 30-60 seconds will produce
mortality due to adrenal suppression and inability to rapid sedation lasting 10-15 minutes.
respond to stress. o Max dose: 20 mg
Note: Limit to single dose for anesthesia/induction.

Repeat dosing and continuous infusion
(maintenance dosing) may increase patient
mortality due to adrenal suppression and inability to
respond to stress.
169
FENTANYL Lactation Yes (Not recommended) Trade Name: Sublimaze
Opioid Analgesic; General Anesthetic
Binds to opioid receptors within the CNS increasing pain threshold and altering pain reception; inhibits
ascending pain pathways (blocking painful stimulus); produces CNS depression
Onset: IV almost immediate, Duration: IV 0.5-1 hour
Indications
• Pain relief
• Adjunct to general or regional anesthesia
Contraindications
• Hypersensitivity to fentanyl or any component of the formulation
• When using only as pain med and not adjunct to general anesthesia, ensure Slow IV Push (3-5 min).
Rapid infusion may result in chest wall rigidity, impaired ventilation, or respiratory distress/arrest Always
be prepared for use of paralytic and intubation (positive control of airway).
• Head trauma: Use with extreme caution in head injury, or suspected increased ICP; exaggerated
increase in ICP may occur.
• May worsen Bradycardia
• May cause life-threatening hypoventilation and Reparatory depression
• CNS depression: Impairs physical and mental abilities
Pain Management: Pain Management:
IV: Slow (Unlabeled) IV: Slow (Unlabeled)
• 0.5-1mcg/kg PRN for breakout pain q 30-60 min • 0.5-1mcg/kg PRN for breakout pain q 30-60 min
(Max 4mcg/kg) (Max 4mcg/kg)
Note: Patients with prior opioid exposure may have
increased tolerance and require higher dosing Sedation during mechanical ventilation:
IV:
Sedation during mechanical ventilation: • Initial Bolus: 1-2mcg/kg
IV: • Continued Sedation: 0.5-2mcg/kg q 30-60min or
• Initial Bolus: 1-2mcg/kg 0.5-1mcg/kg/hr infusion
• Continued Sedation: 0.5-2mcg/kg q 30-60min or (Combine with 0.05-0.1mg/kg Midazolam for best
0.5-1mcg/kg/hr infusion effect)
(Combine with 0.05-0.1mg/kg Midazolam for best
effect)
Pretreatment for RSI:

3-5 min prior to RSI in pt's with Increased ICP or
Cardiac Ischemia (if situation allows):
• 3mcg/kg slow IV push
Non-Traumatic Chest Pain (Cardiac)
• 25-50mcg IV (Max 200mcg)
Note: Titrate doses and intervals to pain

relief/prevention. Monitor vital signs.
• Single IV doses last 0.5-1 hour
170
FUROSEMIDE Lactation Yes (Caution) Trade Name: Lasix
Loop Diuretic
Inhibits reabsorption of sodium and chloride in the kidney, causing increased loss of water, sodium,
chloride, magnesium, and calcium within urine. When given IV it also causes rapid venous dilation.
Symptomatic improvement of acute pulmonary edema approximately 15-20 minutes
Indications
Labeled Indications: Management of edema associated with heart failure and hepatic or renal disease;
• Acute Pulmonary Edema
• Hypertension (alone or in combination with other antihypertensives)
Contraindications
• Hypersensitivity to furosemide or any component of the formulation
• Anuria (No pre-hospital utility in hypovolemic shock)
• Can cause profound diuresis with resulting shock and electrolyte depletion. Monitor closely
o May cause: Hypovolemia, Hypotension, hyponatremia, hypokalemia
• May potentiate effect of additional antihypertensives
Acute pulmonary edema:
IV Edema, heart failure: Infants and Children
• 40 mg over 1-2 minutes. If response not IV, IM:
adequate within 1 hour, may increase dose to • Initial: 1 mg/kg/dose; if response not
80 mg adequate, may increase dose in increments of
1 mg/kg/dose and administer not sooner than 2
Edema, heart failure: hours after previous dose, until a satisfactory
IV, IM: response is achieved; may administer
• Initial: 20-40 mg/dose; if response is not maintenance dose at intervals of every 6-12
adequate, may repeat the same dose or hours; maximum dose: 6 mg/kg/dose
increase dose in increments of 20 mg/dose and
administer 1-2 hours after previous dose
(maximum dose: 200 mg/dose).
Continuous IV Infusion:
• Initial: IV bolus dose 20-40 mg over 1-2
minutes, followed by continuous IV infusion
doses of 10-40 mg/hour. If urine output is <1
mL/kg/hour, double as necessary to a
maximum of 80-160 mg/hour.
171
GLUCAGON B Lactation? (Caution)
Antidote, Hypoglycemia Antidote, Diagnostic agent
Raises blood glucose levels by stimulating increased production of cyclic AMP, promoting hepatic
glycogenolysis and gluconeogenesis
Indications
Labeled Indications: Management of hypoglycemia (Glucose <70 in adults or <60 in children)
Unlabeled:
• Beta-blocker or calcium channel blocker induced myocardial depression (with or without hypotension)
unresponsive to standard measures
• Hypoglycemia secondary to insulin or sulfonylurea overdose (as adjunct to dextrose)
Contraindications
• Hypersensitivity to glucagon or any component of the formulation
• Insulinoma / Pheochromocytoma
• Should NOT be used as 1 line medication for hypoglycemia or Altered mental status
st
o Hypoglycemia patients should receive dextrose. If IV access cannot be established or if

dextrose is not available, glucagon may be used as alternate until dextrose can be given.
• Thiamine should precede use in patient with suspected alcoholism or malnutrition
Hypoglycemia: Hypoglycemia:
IV, IM, SubQ: IV, IM, SubQ:
• 1 mg; may repeat in 20 minutes as needed • Children <20 kg: 0.5 mg or 20-30
mcg/kg/dose; repeated in 20 prn.
Note: IV dextrose should be given ASAP; if patient • Children ≥20 kg: Adult dosing.
fails to respond to glucagon, IV dextrose must be
given Note: IV dextrose should be given ASAP; if patient
fails to respond to glucagon, IV dextrose must be
Beta-blocker / Calcium channel blocker given
overdose (myocardial depression) unresponsive
to standard measures (unlabeled use): Beta-blocker / Calcium channel blocker
IV: (ACLS, 2015) overdose (myocardial depression) unresponsive
• 3-10 mg (or 0.05-0.15 mg/kg) bolus followed to standard measures (unlabeled use):
by an infusion of 3-5 mg/hour (or 0.05-0.1 IV:
mg/kg/hour); titrate infusion rate to achieve • 30-150mcg/kg bolus. Can be repeated if no
adequate hemodynamic response response in 15 min. Follow with an infusion of
20-70mcg/kg/hr; titrate infusion rate to achieve
adequate hemodynamic response
172
HEPARIN Lactation No Trade Name:
Anticoagulant
Inactivates thrombin and activated coagulation factors (IX, X, XI, XII, and plasmin) and prevents
conversion of fibrinogen to fibrin.
Indications
Labeled Indications: Treatment of thromboembolic disorders
Unlabeled: ST elevation MI (STEMI) as an adjunct to thrombolysis; unstable angina/non-STEMI
Contraindications
• Hypersensitivity to heparin or any component of the formulation
• Active Bleeding (Trauma Patient)
• Continuously monitor for bleeding: Stop immediately if any bleeding occurs
• Urticarial reactions and anaphylaxis can occur
Acute coronary syndromes: STEMI/Unstable Treatment of venous thromboembolism:

Angina as an adjunct to fibrinolysis (full-dose IV: (unlabeled dosing)
alteplase: >1 year
IV: • DVT/PE: 75 units/kg IV push followed by
• Initial bolus of 60 units/kg (MAX: 4000 units) continuous infusion of 20 units/kg/hour
o Maintenance: 12 units/kg/hour (MAX:
1000 units/hour) as continuous
infusion.
Treatment of venous thromboembolism:

IV: (unlabeled dosing)
• DVT/PE: 80 units/kg (or alternatively 5000
units) IV push followed by continuous infusion
of 18 units/kg/hour
Note: Heparin is ONLY for use only under written

direction of referring provider or direct consultation
with medical director.
173
HETASTARCH Lactation Yes (Caution) Trade Name: Hextend
Plasma Volume Expander, Colloid
Colloidal starch producing plasma volume expansion. Onset of Action: approximately 30 minutes
Indications
Labeled Indications: Volume expander used in treatment of hypovolemic / hemorrhagic shock
Contraindications
• Hypersensitivity to hydroxyethyl starch or any component of the formulation
• Renal failure with oliguria and anuria (not related to Hypovolemia)
• Fluid overload conditions, (pulmonary edema, congestive heart failure
• Pre-existing bleeding or coagulation disorders (eg, von Willebrand’s disease): Use caution in bleeding
disorders; may increase risk of more bleeding
• Anaphylactoid reactions (allergies to corn)
Plasma volume expansion:

IV
• 250-500ml Bolus. May repeat PRN (up to 1500
mL/day). Titrate to individual hemodynamic
needs (Sys BP >90).
Notes:
• May be administered via infusion pump or
pressure infusion.
• Do not administer with blood through the same
line / tubing
• Change tubing or flush extensively with NS
before administering blood through the same
line.
174
HYDROMORPHONE Lactation Yes(Not Recommended) Trade Name: Dilaudid
Opioid Analgesic
Onset: IV 10-20 minutes. Duration 2-4 hours
Indications
Labeled Indications: Moderate to severe pain.
Contraindications
• Hypersensitivity to hydromorphone or any component of the formulation
• Severe respiratory depression (in absence of resuscitative equipment or ventilator support)
• Acute or severe asthma
• Paralytic ileus
• Always be prepared for use of paralytic and intubation (maintain positive control of airway).
• Head trauma: Use with extreme caution in head injury, or suspected increased ICP;
exaggerated increase in ICP may occur.
• May cause Hypotension, Use with caution in hypovolemic patients.
• May cause life-threatening Reparatory depression
Acute pain (moderate-to-severe): Acute pain (moderate-to-severe):

IV: (Slow) IV: (Slow)
• 0.2-1 mg every 2-3 hours as needed; patients • Children: 0.015mg/kg IV q 4-6 PRN
with prior opioid exposure may require higher • Adolescents >50kg: Refer to adult dosing
initial doses.
• Critically ill patients (unlabeled dosing): 0.2-0.6
mg every 1-2 hours as needed or 0.5 mg every
3 hours as needed
• Continuous infusion: Usual dosage range: 0.5-
3 mg/hour
175
HYDROXOCOBALAMIN Lactation? (Caution) Trade Name: Cyanokit®
Antidote; Vitamin
Precursor to Vitamin B 12 (cyanocobalamin). Binds cyanide ion to form cyanocobalamin which is excreted
within urine
Indications
• IM: Treatment of pernicious anemia and B12 deficiencies
• IV: (Cyanokit®) Treatment of known or suspected cyanide poisoning
Contraindications
• No contraindications when treating for suspected or known cyanide poisoning
• May cause transient hypertension (>180mmHG systolic, >110mmHG diastolic)
• Will cause red colored urine and skin
Cyanide Poisonings: Cyanide Poisonings:

IV IV: (Unlabeled Use)
• Initial: 5 grams as single infusion given over 15 • Initial: 70mg/kg (max 5 grams) as single
min infusion given over 15 min
o Repeat a second 5 gram dose based o Repeat a second dose of 35mg/kg
on severity and clinical response. based on severity and clinical
o Maximum cumulative dose: 10 grams response.
Smoke Inhalation / Fire victims: (Closed space Smoke Inhalation / Fire victims: (Closed space
exposure with evidence of airway injury: soot in exposure with evidence of airway injury: soot in
mouth / nose / sputum) mouth / nose / sputum)
• May present with both cyanide and carbon • May present with both cyanide and carbon
monoxide poisoning. Hydroxocobalamin is the monoxide poisoning. Hydroxocobalamin is the
agent of choice for treating cyanide toxicity in agent of choice for treating cyanide toxicity in
this setting. this setting.
Preparation:
Cyanokit®: Reconstitute each vial with 200 mL of
NS (LR and D5W also OK).
• Do not shake vial (gently mix)
• Do not use if solution is not dark red
176
KETAMINE ?, Lactation?
General Anesthetic
Dissociative anesthetic; produces a cataleptic like state acting directly on the cortex and limbic system.
Onset of action IV: 30-60 seconds; Duration is dose dependent averaging 10-20 minutes
Indications
Labeled Indications: Induction and maintenance of general anesthesia
Unlabeled: Analgesia and sedation
Contraindications
• Hypersensitivity to ketamine or any component of the formulation
• Conditions that cannot tolerate increases in blood pressure
o Ex. Hypertensive Head Injury patient with suspected or known elevated ICP and/or
spontaneous cerebral hemorrhage
o Cushing’s Reflex: Hypertension & Bradycardia +/- Respiratory depression
• Rapid IV dose or overdose may cause respiratory depression, always be prepared to manage airway
• May increase BP. Use with caution in patients with cardiovascular disease (CAD, Catecholamine
depletion, Hypertension, and Tachycardia). Continuously monitor cardiac function.
• Preferred general anesthetic / sedative for hypo/normotensive head injury patient without
increased cerebral pressure.
o May increase cerebrospinal fluid pressure. Use with caution in patients with suspected
elevated CSF pressure.
Analgesia (unlabeled use): Analgesia (unlabeled use):

IV/IO Push (over 1 min) IM:
• 0.1 - 0.2 mg/kg, repeat q 10-30 prn • 0.4 mg/kg, repeat q 10-30 prn
IM/IN Push (over 1 min) IV:
• 0.5 mg/kg, repeat q 10-30 prn • 0.3 mg/kg, repeat q 10-30 prn
CoTCCC recommendations for analgesia:
• 20 mg IV/IO, repeat q 20 min prn Induction of anesthesia (unlabeled dosing):
• 50 mg IM/IN, repeat q 30 min prn IV:
• 1-2 mg/kg
RSI / Induction of anesthesia:
IV Push Maintenance of anesthesia:
• 1-2 mg/kg IV Bolus:
IM • ½ to Full induction dose every 20-30 minutes
• 4-10 mg/kg IV Continuous Infusion:
• 1-2 mg/kg/hr. Titrate levels by 0.25mg/kg/hr
Maintenance of anesthesia: PRN to achieve appropriate sedation.
IV Bolus:
• ½ to Full induction dose every 10-20 minutes
IV Continuous Infusion Children >15 years: Adult dosing
• 1-2 mg/kg/hr. Titrate levels by 0.25mg/kg/hr
PRN to achieve appropriate sedation.
Note: May be used in combination with

anticholinergic agents to decrease hyper salivation.
***Avoid sub-dissociative doses to prevent

emergence phenomenon.
177
KETOROLAC Lactation Yes(Caution) Trade Name: Toradol
Nonsteroidal Anti-inflammatory Drug (NSAID)
Inhibits cyclooxygenase (COX 1 & 2) enzymes, which decreases production of prostaglandin precursors.
Provides antipyretic, analgesic, and anti-inflammatory action.
Indications
Labeled Indications: Short term management of moderate to severe acute pain as an opioid alternative.
Contraindications
• Hypersensitivity to ketorolac, aspirin, other NSAIDs, or any component of the formulation.
• High risk of bleeding, recent history of GI bleeding or perforation, known history of peptic ulcer
disease.
o Not for use as pain management for battlefield trauma patient!
• Suspected cerebrovascular bleeding Dizziness, Flushing, Diaphoresis, Tremor, Weakness
• Risk of renal failure secondary to volume depletion
• Concurrent use with other NSAIDs
• Inhibits platelet function
• Associated with an increased risk of adverse cardiovascular thrombotic events, including MI and
stroke
• May increase risk of GI irritation, inflammation, ulceration, bleeding, and perforation.
• May cause severe bronchospasm in patients with asthma
• May cause new onset hypertension or worsening of existing hypertension.
Pain management (acute; moderately severe): Pain management (acute; moderately severe):
Patients ≥50 kg Adolescents >17 years only:
IM: • Refer to adult dose
• 30-60 mg as a single dose or 15-30 mg every
6 hours (maximum daily dose: 120 mg)
IV:
• 10-15 mg as a single dose or 15 mg every 6
hours (maximum daily dose: 120 mg)
Adults >65 years and/or adults <50 kg

IM:
• 30 mg as a single dose or 15 mg every 6 hours
(maximum daily dose: 60 mg)
IV:
• 15 mg as a single dose or 15 mg every 6 hours
(maximum daily dose: 60 mg)
178
LABETALOL C Lactation Yes (Caution) Trade Name: Trandate
Beta Blocker with alpha blocking activity
Blocks alpha and beta1/beta2 adrenergic receptor sites. Onset IV: 2-5 minutes
Indications
Labeled Indications: Treatment of hypertension.
• IV: Treatment of severe hypertension and hypertensive emergencies
Unlabeled:
• Pre-eclampsia and severe hypertension in pregnancy, hypertension during acute ischemic stroke,
and Pediatric hypertension
Contraindications
• Hypersensitivity to labetalol or any component of the formulation
• Severe Bradycardia, heart block >1 degree
st
• Uncompensated heart failure, Cardiogenic shock

• Asthma
• Symptomatic hypotension with or without syncope, Monitor EKG closely
• Use with extreme caution in patients with compensated heart failure
• Patient with bronchospastic diseases (reactive airway) should not use Beta blockers
Acute Hypertension (hypertensive Hypertension emergencies:

emergency/urgency: IV Continuous Infusion
Hypertensive Crisis Urgency • 0.4-1 mg/kg/hour with a maximum of 3
(Sys: 180-220/Dia: 105-120) mg/kg/hour have been used; administration
• 10 mg IV for 1-2 minutes. May repeat or requires the use of an infusion pump.
double q 10 min to max dose of 300mg • Intermittent bolus doses of 0.3-1 mg/kg/dose
have been reported
Hypertensive Crisis Emergency
(Sys: >220/Dia: 121-140)
• 10-20 mg IV for 1-2 min; May repeat or double
q 10 min to max dose of 300mg.
Continuous Infusion:
• If continued medication required, 2mg/min;
titrate to desired response up to max 300mg
dose.
Note: Goal to lower MAP by no more than 20%

within minutes to one hour.
179
LIDOCAINE B Lactation Yes (Caution) Trade Name: Xylocaine(Cardiac)
Antiarrhythmic
Suppresses automaticity of cardiac conduction tissue.
Indications
Labeled Indications: Acute treatment of ventricular arrhythmias from myocardial infarction (alternate to
amiodarone when amiodarone not available)
Unlabeled: (ACLS, 2015)
• Hemodynamically stable monomorphic VT and polymorphic VT
• Pulseless VT / VF (unresponsive to defibrillation, CPR, and vasopressor administration)
• Monomorphic VT secondary to drug, when amiodarone is not available
Contraindications
• Hypersensitivity to lidocaine or any component of the formulation
• Prophylactic use in AMI
• Bradycardia, severe degrees of SA, AV, or intraventricular heart block
• Wolff-Parkinson-White syndrome, Adam-Stokes syndrome
• Continuous EKG monitoring is necessary
• Increased ventricular rate may be seen when given to a patient in AFib
• At high doses, monitor closely for CNS toxicity, seizure, depression, and respiratory depression.
o D/C immediately if toxicity develops
• The elderly may have increased chance of CNS and cardiovascular side effects.
Cardiac Arrest from VF/VT, (if Amiodarone is not VF/Pulseless VT, Wide Complex Tachycardia
available): (ACLS, 2015): (with pulses): (PALS, 2015)
IV, IO: IV, IO:
• Initial dose: 1 to 1.5mg/kg • Initial dose: 1mg/kg
• For refractory VF may give additional 0.5 to
0.75mg/kg IV push, repeat in 5 to 10 minutes
o Maximum of 3 doses or total of 3mg/kg
Perfusing Arrhythmia (if amiodarone is not

available): Stable VT, wide complex tachycardia, 2015 AHA ACLS guidelines state:
significant ectopy: "There is inadequate evidence to support the
IV, IO routine use of lidocaine after cardiac arrest.
• Doses ranging from 0.5 to 0.75mg/kg and up However, the initiation or continuation of lidocaine
to 1 to 1.5mg/kg. Repeat 0.5 to 0.75mg/kg may be considered immediately after ROSC
every 5 to 10 minutes from cardiac arrest due to VF/pVT"
o Maximum cumulative dose 3mg/kg
Maintenance Infusion (Adults and Peds):
Flush after initiation of IO: IV, IO: Continuous Infusion
• May add 2-3 ml Lidocaine 2% (without • 1-3 mg/hour (or 20-50 mcg/kg/minute).
epinephrine) to 5ml NS flush
Local Anesthesia during Tube/Finger
Thoracostomy
• Draw 10ml 2% Lidocaine and locally
anesthetize incision area.
Decompression Illness/ Arterial Gas Embolism:
• 1.5mg/kg IV/IO
180
LORAZEPAM D Lactation Yes (not recommended) Trade Name: Ativan
Benzodiazepine
Acts as an Anxiolytic/Hypnotic, anticonvulsant and sedative.
Onset of action: IV Sedation 2-3 minutes; IM hypnotic, 15-30 minutes. Duration: IV, 8-12 hours.
Indications
Labeled Indications: Anesthesia premedication, Status epilepticus
Unlabeled:
• Rapid tranquilization of the combative / agitated patient
• Alcohol withdrawal delirium / syndrome
• Seizures
• Induce Sedation and Amnesia (Midazolam is primary medication)
Contraindications
• Hypersensitivity to Lorazepam or any component of the formulation or other benzodiazepines
• Acute narrow angle glaucoma, Acute Alcohol Intoxication, Sleep apnea
• Respiratory Insufficiency/Depression (except during mechanical ventilation)
o (Overdose Reversal: FLUMAZENIL can be used, however it carries elevated risk.
Respiratory support until the medication is metabolized is traditionally the best care in
Benzodiazepine overdose)
• Neurologic Depression (Head Trauma) (unless having active seizure)
Acute Seizures: Acute Seizures / Status epilepticus (unlabeled

IV: use):
• 1-2mg over 2-5min. May repeat in 10-15min. IV:
Max dose 8mg in 12hr period. • 0.05-0.1 mg/kg; repeat doses every 10-15
minutes for clinical effect. Max 4mg
Agitation:
Rapid tranquilization of agitated / combative
• 0.05 mg/kg/dose q 20-30 min PRN
patient (unlabeled use):
IV, IM:
• 1-2mg every 30-60 minutes; may be used
alone or administered with an antipsychotic
(i.e. haloperidol)
181
MAGNESIUM SULFATE Lactation Yes(Caution)
Anticonvulsant, Electrolyte Supplement
IV magnesium decreases acetylcholine in motor nerve terminals and slows rate of SA node impulse
formation and prolongs conduction time. Magnesium functions to facilitate the movement of calcium,
sodium, and potassium in and out of cells.
Indications
• Prevention and treatment of seizures in pregnancies with severe pre-eclampsia or eclampsia
• Torsades de Pointes: Cardiac arrhythmias (VT/VF) cause by low serum magnesium
Contraindications
• Hypersensitivity any component of the formulation
• Myocardial damage and heart blocks
• Use for pre-eclampsia / eclampsia during 2 hour period before delivery
• Possible cardiovascular arrest, respiratory depression, and hypotension in large doses
• Hypomagnesaemia is often joined by hypokalemia and requires correction in order to normalize
potassium.
Torsades de pointes or VF/pulseless VT
associated with torsades de pointes (unlabeled Torsades de pointes: (PALS, 2015)
use): IV, IO:
IV, IO: • 25-50 mg/kg/dose over several minutes
• 1-2 g over 15 minutes (ACLS, 2015) o maximum single dose: 2000 mg
Wheezing in Respiratory Distress (3rd line drug): Respiratory Distress:

IV: IV:
• 2 Grams over 20min • 25-75 mg/kg over 30 min (max 2 grams)
Seizure (Refractory to Benzodiazepines):

IV:
• 1-2 Grams over 30 min
Magnesium Sulfate should be diluted
Eclampsia/pre-eclampsia, severe (unlabeled): into 50-100ml NS or D5W for all Adult
IV: and Pediatric infusions
• 4-6 g over 15-20 minutes followed by 2 g/hour
continuous infusion
182
MANNITOL 20% Lactation? (Caution)
Osmotic Diuretic
Increases osmotic pressure of glomerular filtrate. This reduces kidney reabsorption of water and
electrolytes and increases urinary output. Decreases cerebral blood volume and intracranial pressure
(ICP) while increasing cerebral blood flow and O2 transport. Onset of action is 15-30 minutes
Indications
• Reduction of increased ICP secondary to cerebral edema
• Reduction of elevated intraocular pressure
• Urinary excretion of toxic substances
Contraindications
• Hypersensitivity to mannitol or any component of the formulation
• Active intracranial bleeding
• Pulmonary congestion and edema
• Severe renal disease, or renal dysfunction after mannitol use
• Severe dehydration: (Do NOT use in under-resuscitated or hypotensive casualties)
• Chest pain, CHF, tachycardia, circulatory overload (with rapid administration), peripheral edema
• Headache, seizure
• Fluid and electrolyte imbalance, dehydration and hypovolemia
Moderate to severe head injury, Patient Increased intracranial pressure (unlabeled

continuing to deteriorate or showing signs of dosing):
herniation despite adjustment to ventilation and IV:
starting hypertonic saline. • 0.25-1 g/kg/dose;
IV • Maintenance dose of 0.25-0.5 g/kg IV q 4-6hrs
• 1 g/kg IV bolus over <20 minutes. prn to maintain serum osmolality <300-320
• Follow with 0.25 g/kg IVP every 4 hours mOsm/kg
Vital Functions Goal in Head Injury (Prevention

of secondary brain injury):
• Keep SBP >90mmHg, MAP >60mmHg, and
SaO2 >93%. [(CPP = MAP – ICP) Minimal goal
CPP >60mmHg]
Note: Always have urinary catheter in place and

monitor output.
183
METHYLPREDNISOLONE Lactation Yes(Caution) Trade Name: SoluMedrol
Anti-inflammatory, Immunosuppressant, shock
Indications
Labeled Indications: Treatment of a variety of diseases: allergic, inflammatory, hematologic, neoplastic,
and autoimmune;
Unlabeled:
None identified unless added by medical direction.
Contraindications
• Hypersensitivity to methylprednisolone or any component of the formulation
• No other in emergency setting
• Not for use in treatment of head injury; increased mortality has occurred in head injury patients
treated with high dose IV methylprednisolone.
• No immediate effect will be observed while treating in the pre-hospital environment. Onset of action
may take several hours
Asthma exacerbations, including status Asthma exacerbations, including status

asthmaticus asthmaticus
IV: IV:
• 125mg x 1 dose • Children <12 years: 1-2 mg/kg initial dose;
followed by 0.5-1 mg/kg q 6 hrs. (maximum: 60
Allergic Reaction: mg/day)
IV:
• 125mg x 1 dose Allergic Reaction
IV
• 2 mg/kg x 1 dose
Note: Only methylprednisolone sodium succinate

can be used for IV doses. Note: Only methylprednisolone sodium succinate
can be used for IV doses.
184
MIDAZOLAM Lactation Yes(Caution) Trade Name: Versed
Benzodiazepine
Acts as an Anxiolytic/Hypnotic, anticonvulsant and sedative.
Onset of action: Sedation; IV: 1-5 minutes, IM: 15 minutes, Intranasal: 4-8 minutes
Duration: IV, less than 2 hours. (20-30 Minutes per ECCN Nurse Protocols, May 2012)
Indications
Labeled Indications: Preoperative sedation, induction and maintenance of general anesthesia
Unlabeled: Anxiety, status epilepticus, conscious sedation (intranasal)
Contraindications
• Hypersensitivity to midazolam or any component of the formulation or other benzodiazepines
• Acute narrow angle glaucoma, Acute Alcohol Intoxication
• Respiratory Insufficiency/Depression (except during mechanical ventilation)
• (Overdose Reversal: FLUMAZENIL can be used, however it carries elevated risk.
Respiratory support until the medication is metabolized is traditionally the best care in
Benzodiazepine overdose)
• Should not be used in shock
• Neurologic Depression (Head Trauma) (unless having active seizure)
Induction for RSI; Continued sedation; Procedural sedation; Transcutaneous Pacing;

Hyperthermia: Cardioversion:
IV: IV:
• 0.1mg/kg IV/IO q 15-30 min PRN • 0.05-0.1mg/kg q 15-30 PRN
Intranasal (unlabeled route):
Sedation for Transcutaneous Pacing; • 0.2-0.5 mg/kg (maximum total dose: 10 mg or
Cardioversion; Bites/envenomation’s; Seizures 5 mg per nare
(all causes); Combative Pt’s:
IV Induction/RSI (Not preferred drug)
• 2.5-5mg q 15-30 PRN IV:
• 0.1-0.3 mg/kg
Status epilepticus, prehospital treatment
(unlabeled use): Seizure
IV: IV, IM:
• 10 mg once for seizures >15min or two or • 0.2 mg/kg Q 15-30 PRN
more successive seizures without a period of
consciousness / recovery. Status epilepticus, prehospital treatment
(unlabeled use):
IV:
• 13-40 kg: 5 mg once
• >40 kg: Refer to adult dosing
185
MORPHINE Lactation Yes(Caution) Trade Name:
Opioid Analgesic
Onset: IV variable but rapid, Duration variable, patient dependent.
Indications
Labeled Indications: Moderate to severe acute and chronic pain; pain of myocardial infarction;
preanesthetic medication
Contraindications
• Hypersensitivity to morphine sulphate or any component of the formulation
• Severe respiratory depression
• Acute or severe asthma (in an unmonitored setting or without resuscitative equipment)
• Paralytic ileus
• Always be prepared for use of paralytic and intubation (maintain positive control of airway).
• Head trauma: Use with extreme caution in head injury, or suspected increased ICP;
exaggerated increase in ICP may occur. Some formulations are specifically contraindicated.
• May cause Hypotension, Use with caution in hypovolemic patients.
• May worsen Bradycardia
• May cause life-threatening hypoventilation and Reparatory depression
Chest Pain/AMI: Acute pain (moderate-to-severe):

IV: IM, SubQ:
• 2-5 mg q 5-15 min PRN • 0.1-0.2 mg/kg.
Acute pain (moderate-to-severe): IV: (Slow)

IM, SubQ: • 0.1-0.2 mg/kg q 120 min PRN, not to exceed
• 5-10 mg every 4 hours as needed; usual 10 mg per dose
dosage range: 5-15 mg every 4 hours as
needed. Patients with prior opioid exposure Continuous infusion:
may require higher initial doses. • 10-30 mcg/kg/hour; titrate PRN for pain
IV: (Slow)
• 2-3 mg every 5 minutes until pain relief or if
associated sedation, oxygen saturation <95%
186
NALOXONE Lactation ?(Caution) Trade Name: Narcan
Antidote, Opioid Antagonist
Competes and displaces opioids at opioid receptor sites, reversing narcotic effects.
Indications
Labeled Indications: Reversal of opioid drug effects, including respiratory depression
Contraindications
• Hypersensitivity to naloxone or any component of the formulation
• When correcting for respiratory depression in a postoperative (intubated patient), carefully titrate the
dose to reverse hypoventilation; do not fully awaken patient or reverse analgesic effect.
• Recurrence of respiratory depression is possible continue to watch for respiratory depression until
patient hand-off.
• May cause narcotic withdrawal effects
Opioid overdose (with standard ACLS protocols): Opioid overdose (with standard PALS protocols):
IV, IM, SubQ: IV, IM, SubQ:
• 0.4-2 mg; may dose every 2-3 minutes if • <5 years or ≤20 kg (unlabeled dose): 0.1
needed; mg/kg/dose (maximum dose: 2 mg); repeat
o If no response after 10 mg total, look every 2-3 minutes PRN
for other cause of respiratory • ≥5 years or >20 kg: Adult Dosing
depression.
o Following reversal, may need to Reversal of respiratory depression with
readminister after 20-60 minutes. therapeutic opioid doses:
IV, IM, SubQ:
Reversal of respiratory depression with • 0.001-0.015 mg/kg/dose; repeat as
therapeutic opioid doses: needed.
IV, IM, SubQ:
• 0.1-0.4 mg titrated to adequate respiratory
rate. If not improved after 0.8 mg total, look for
other cause of respiratory depression.
187
NIFEDIPINE Lactation Yes(Not Recommended) Trade Name: Procardia
Antianginal Agent, Calcium Channel Blocker
Inhibits movement of calcium ion across cell membranes of smooth muscle and myocardium resulting in
relaxation of coronary vascular smooth muscle and vasodilation as well as reduced peripheral vascular
resistance (reducing blood pressure).
Indications
Labeled Indications: Chronic stable or vasospastic angina
Unlabeled: Prevention and treatment of high altitude pulmonary edema
Contraindications
• Hypersensitivity to nifedipine or any component of the formulation
• Cardiogenic Shock
• Acute MI
• Symptomatic hypotension:
• Bradycardia, nausea
High altitude pulmonary edema (unlabeled use): High altitude pulmonary edema (Not FDA
PO: approved for use in children) (unlabeled use):
• 10 mg every 4-6 hours PO:
• Immediate release: 0.5 mg/kg/dose
Pulmonary hypertension (unlabeled use) (maximum: 20 mg/dose) every 8 hours
PO:
• 30 mg (Extended Release) twice daily; may Note: Treatment is needed only necessary if
increase cautiously to 120-240 mg/day response to oxygen and/or descent is poor.
Note: Do not use for acute anginal episodes; may

precipitate myocardial infarction
188
NITROGLYCERIN Lactation ?(Caution) Trade Name: NitroMist/Nitrostat
Antianginal agent, Vasodialator
Induces smooth muscle relaxation and vasodilation of peripheral veins and arteries and coronary arteries
thus improving collateral blood flow to ischemic regions of the myocardium. Reduces cardiac oxygen
demand by decreasing preload. Onset of action: Sublingual tablet and spray, 1-3 minutes. Duration: 25
minutes
Indications
Labeled Indications: Treatment or prevention of angina pectoris
Contraindications
• Hypersensitivity to nitrates or any component of the formulation
• Use with phosphodiesterase-5 inhibitors (Sildenafil, Levitra, Cialis) in previous 48hrs
• Increased intracranial pressure
• Hypotension (SBP <90mmHg or >30mmHg below baseline), Bradycardia <50bpm, Tachycardia
without heart failure (>100bpm), and Right ventricular infarction.
• IV/IO access should be placed and SBP should be > 110.
o Use cautiously in cases of chest pain unless inferior wall / right-ventricular MI can be
ruled-out by ECG prior to administration
• Can cause severe hypotension with associated paradoxical bradycardia and increased angina
• Use with caution in volume depleted patients
• Do not use for inferior wall MI and suspected right ventricular involvement
Angina/coronary artery disease: CHF related Respiratory Distress:

PO: PO:
• Sublingual: 0.4 mg every 5 minutes for • 0.4mg q 5min if SBP > 70 + 2 x Age
maximum of 3 doses in 15 minutes
• Translingual: 1 spray (0.4mg per spray) onto CHF or Cardiogenic Shock:
or under tongue every 3-5 minutes for IV Drip:
maximum of 3 doses in 15 minutes • Children: 0.25 - 0.5 mcg/kg/min; titrate by 1
mcg/kg/min q 15-20 min as tolerated (Typical
CHF related Respiratory Distress: dose=1-5mcg/kg/min)(Max 10mcg/kg/min)
PO:
• Sublingual: 0.4 mg every 5 minutes for • Adolescents: 5-10 mcg/min (not per kg) (max
maximum of 3 doses in 15 minutes as long as 200 mcg/min)
SBP>90
IV Drip: (Only used at written direction of referring

provider or consultation with medical director)
• Start at 10 mcg/min, titrate up or down to:
o 10% reduction in MAP if normotensive
o 30% reduction in MAP if hypertensive.
o Max dose: 400mcg/minute)
189
NOREPINEPHRINE Lactation ?(Caution) Trade Name: Levophed
Alpha and Beta Agonist
Stimulates beta 1 and alpha adrenergic receptors: increases contractility, heart rate, and vasoconstriction.
Increases systemic blood pressure and coronary blood flow. Effects on vasoconstriction (alpha
receptors) are greater than inotropic (beta receptors). Onset of action: IV very rapid. Duration: 1-2
minutes
Indications
Labeled Indications: Treatment of shock persisting after adequate fluid volume replacement; severe
hypotension.
ACLS Guidelines 2010: Severe cardiogenic shock and hemodynamically significant hypotension (SBP
<70mmHg) with low total peripheral resistance. Agent of last resort for management of ischemic heart
disease and shock.
Contraindications
• Hypersensitivity to norepinephrine, bisulfites or any component of the formulation
• Hypotension from hypovolemia except as an emergency measure to maintain coronary and cerebral
perfusion until volume can be replaced
• Strong Vesicant; ensure proper catheter placement and avoid extravasation, use a large vein
(preferably a central line) and avoid leg veins.
Dose and Administration: ADULT PEDIATRIC
Hypotension/shock: Hypotension/shock:
IV: Administer as continuous infusion with infusion pump. Do not use in IV: Continuous infusion
same line as sodium bicarbonate. It will inactivate norepinephrine. • Initial: 0.05-0.1
• Initial: 8-12 mcg/minute; titrate to effect. mcg/kg/minute; titrate
o Maintenance: 2-4 mcg/minute to effect
o Max dose: 2
Post ROSC Hypotension: mcg/kg/minute
• Initial: 0.1-0.5 mcg/kg/minute titrate to effect.
If unable to maintain MAP >60mmHg, add Epinephrine infusion.
Use in Burn Patient:

For Burn patients, norepinephrine is only used when target MAP (>55) and
UOP (>30mL/hr) fail to be reached with fluid resuscitation alone. Its
sequence of use follows administration of Vasopressin.
Mixing Norepinephrine Solution:

• Mix 4 mg norepinephrine in 500mL D5W for a concentration of
8mcg/mL
OR
• 4mg norepinephrine in 250mL D5W to make 16mcg/mL.
To titrate, ↑ rate by 0.5mcg/min every >2 minutes.
190
ONDANSETRON B Lactation?(Caution) Trade Name: Zofran
Antiemetic
Blocks serotonin, peripherally on vagus nerve terminals and centrally. Onset of action is 5-30 minutes
dependent on route.
Indications
Labeled Indications: Prevention of postoperative nausea and vomiting
Unlabeled: Hyperemesis gravidarum (severe or refractory)
Contraindications
• Hypersensitivity to ondansetron or any component of the formulation
• Dose dependent QT interval prolongation occurs and IV doses >16mg are not recommended.
o In most patients, QT changes are not clinically relevant; however, if used with other
medications that prolong QT intervals (antiarrhythmics) or in those at risk for QT prolongation,
arrhythmia can occur. Torsades de points has been reported.
Nausea and Vomiting (Children 1 month to 12

Nausea and Vomiting: years):
IV/IO/IM/PO
• 4-8 mg IV:
• ≤40 kg: 0.1 mg/kg as a single dose over 2-5
Treatment of severe or refractory hyperemesis minutes
gravidum (unlabeled use): • >40 kg: 4 mg as a single dose over 2-5
IV: Minutes
• 8 mg administered over 15 minutes every 12
hours
191
PHENYLEPHRINE C Lactation?(Caution) Trade Name: Neosynephrine
Alpha Adrenergic Agonist
Potent, direct acting alpha adrenergic agonist with virtually no beta adrenergic activity; causes systemic
arterial vasoconstriction.
Onset of action IV: Immediate, Duration: approximately 15-20 minutes.
Indications
Labeled Indications: Treatment of hypotension, vascular failure in shock
Contraindications
• Hypersensitivity to phenylephrine or any component of the formulation
• Ventricular Tachycardia and Hypertension
• Not recommended for routine use in the treatment of septic shock
• Vesicant: Avoid extravasation, will cause tissue damage/necrosis, ensure proper needle placement
Hypotension / Shock: Hypotension / Shock:

IV Push: IV Push:
• 100-500 mcg/dose every 10-15 minutes as • 5-20 mcg/kg/dose every 10-15 minutes as
needed needed
o initial dose should not exceed 500 IV Infusion:
mcg • 0.1-0.5 mcg/kg/minute
o Start with lower doses and adjust
higher based on length of desired
hemodynamic effect
IV Infusion:
• 100 mcg/min; titrate to MAP > 60 mm Hg.
o To titrate, increase rate by 10 mcg/min
every 2 minutes.
o Maximum dose is 200 mcg/min.
Maintenance infusion:
• Rate of 40-60 mcg/min after BP stabilizes.
Mixing Norepinephrine Solution

Mix 10 mg phenylephrine in 250 mL D5W/NS for a
concentration of 40 mcg/mL or Mix 10 mg
phenylephrine in 100 mL NS for a concentration of
100 mcg/mL if using push-dose.
If unable to maintain MAP >60mmHg,

add Epinephrine infusion.
192
PRALIDOXIME CHLORIDE C Lactation?(Caution) Trade: 2-Pam Chloride
Antidote for organophosphate anticholinesterase poisoning
Peak plasma concentration following IM dose is reached in approximately 30 minutes
Indications
• Organophosphate Pesticide Poisoning: Used with Atropine to reverse muscle paralysis
• Chemical Warfare Agent Poisoning: Used with Atropine for treatment of nerve agent (e.g., sarin,
soman, tabun, VX [methylphosphonothioic acid])
Contraindications
• None in emergency setting
• Not effective in exposure to phosphorus, inorganic phosphates, or organophosphates that do not
possess anticholinesterase activity.
• Consider cautions and adverse reactions of Atropine when using together
• Monitor BP and cardiac rhythm
Pesticide Poisoning: Chemical Warfare Agent Poisoning:

Mild symptoms: miosis or blurred vision, tearing, Organophosphate Anticholinesterase Nerve
runny nose, hypersalivation or drooling, wheezing, Agents:
muscle fasciculations, nausea/vomiting. IM:
Severe symptoms: behavioral changes, severe • Children 0–10 years of age and adolescents
breathing difficulty, severe respiratory secretions, >10 years of age who present with
severe muscle twitching, involuntary defecation or mild/moderate symptoms: 15 mg/kg.
urination, seizures, unconsciousness. • Children 0–10 years of age and adolescents
>10 years of age who present with severe
Chemical Warfare Agent Poisoning: symptoms: 25 mg/kg.
Mild to moderate symptoms: localized sweating,
muscle fasciculations, nausea, vomiting, weakness,
and/or dyspnea
Severe symptoms: apnea, flaccid paralysis,
seizures, and/or unconsciousness
DOSING:
Auto-injector: IM into anterolateral aspect of thigh
and hold in place for 10 seconds.
• Pralidoxime chloride auto-injector single dose
600mg: (administer after Atropine). Repeat
injections if symptoms remain after 15min.
nd
Repeat again if not resolved after 2 15min.
• DuoDote®, ATNAA: For ≥2 mild symptoms,
inject single dose. If severe symptoms develop,
inject 2 additional doses in rapid succession.
• DuoDote®, ATNAA: For severe symptoms,
utilize 3 auto-injectors (total dose: atropine 6.3
mg and pralidoxime chloride 1800 mg) in rapid
succession.
Note: DuoDote® and ATNAA auto-syringe provides
a sequential single IM dose of atropine 2.1 mg and
pralidoxime chloride 600 mg through one needle.
193
PROMETHAZINE Lactation?(Not Recommended) Trade Name: Phenergan
Phenothiazine derivative Antiemetic, Histamine H 1 Antagonist, Sedative
Blocks postsynaptic dopaminergic receptors in the brain; strong alpha adrenergic blocking effect and
depresses release of hypothalamic and hypophyseal hormones; reduces stimuli to the reticular system
Onset of action IV: 5 minutes, Duration 4-6 hours
Indications
Labeled Indications: Symptomatic treatment for allergic conditions; antiemetic; motion sickness;
sedative; adjunct to postoperative analgesia and anesthesia
Unlabeled: Treatment of nausea and vomiting of pregnancy
Contraindications
• Hypersensitivity to promethazine, phenothiazine allergy, or any component of the formulation
• Coma
• Children <2 years old
• Intra-arterial and SubQ administration
• May cause Bradycardia, hyper-/hypotension, nonspecific QT changes, orthostatic hypotension,
tachycardia: Life threatening arrhythmias have occurred with normal dosage
• May cause extrapyramidal symptoms (pseudoparkinsonism, acute dystonic reactions, akathisia, etc.)
• Avoid use in severe respiratory disease (asthma, COPD), and in patients using other sedatives or
depressants: may lead to respiratory depression
• Vesicant: can cause severe tissue injury regardless of route of delivery
o Deep IM injection; or IV in line. Slow IVP over 1 minute
o For IV, ensure proper needle/catheter venous placement; avoid extravasation
Antiemetic: Antiemetic:
IV push over >1 minute IM, IV:
• 12.5 mg, not to exceed 25 mg • Children ≥2 years: 0.25 mg/kg 4-6 times/day
o May repeat 12.5mg once after 10 as needed (maximum: 12.5 mg/dose)
minutes if first dose ineffective
o Subsequent dose of 25mg may be Preoperative analgesia/hypnotic adjunct:
given every 4 hours IM, IV:
o Can dilute with 10-20mL of NS • Children ≥2 years: 1.1 mg/kg in combination
with an analgesic or hypnotic (at reduced
Sedation, analgesia/hypnotic adjunct: dosage) and with an atropine like agent (at
IM, IV: appropriate dosage).
• 25-50 mg in combination with analgesic or
hypnotic (at reduced dosage) Note: Promethazine dosage should not exceed
half of suggested adult dosage.
Allergic conditions (including allergic reactions to
blood or plasma):
IM, IV:
• 25 mg, may repeat in 2 hours when necessary
194
PROPOFOL B Lactation Yes(Not Recommended) Trade Name: Diprivan
General Anesthetic
Lipophilic intravenous general anesthetic.
Onset of action IV bolus: 9-51 seconds (average 30 seconds), Duration is dose and rate dependent: 3-10
minutes, prolonged with continued doses
Indications
Labeled Indications: Induction of anesthesia in patients ≥3 years of age; maintenance of anesthesia in
patients >2 months of age; sedation in intubated, mechanically-ventilated ICU patients
Contraindications
• Hypersensitivity to propofol or any component of the formulation
• Allergy to eggs, egg products, soybeans, soy products, and peanuts.
• May cause Hypotension especially in hypovolemic patients or if bolus dosing is used.
o Hypotension may result in reduction of MAP exceeding 30%
 Head Injury patients or those with suspected / known increased intracranial pressure
are at increased risk of decreased cerebral perfusion pressure.
• Do not use in pre-hospital trauma environment or in transfer patients unless directed by medical
director or provided written orders by referring provider.
• No Analgesic properties. Must supplement with analgesic agents.
Sedation/ RSI: (For use in intubated patients only) Sedation/ RSI: (For use in intubated patients only)
IV Push: IV Push:
• 0.5-1.5 mg/kg every 5-10min PRN. • 3 mg/kg every 5-10min PRN.
Maintenance of general anesthesia: Maintenance of general anesthesia,

IV Infusion: IV Infusion:
• 10-50 mcg/kg/min via infusion pump or Dial-a- Healthy children 2 months to 16 years:
Drip. Titrate to minimum effective dose. • 125-300 mcg/kg/minute (or 7.5-18
o MAX DOSE: 100 mcg/kg/min. mg/kg/hour)
CAUTION: Administration of a Propofol drip during

rotary wing operations can be problematic; Alaris III
is unreliable in the UH-60 (especially with Propofol)
and dosages often need to be increased secondary
to increased patient stimulation with resultant
negative hemodynamic effects (hypotension).
• Use of Dial-a-Drip tubing in the absence of an
infusion pump will increase accuracy of
infusion dosage.
Note: Wait 3-5 minutes between dosage changes

to clinically assess drug effects. Smaller doses are
required when used with opioids.
195
ROCURONIUM C Lactation?(Caution) Trade Name: Zemuron
Nondepolarizing Neuromuscular Blocking Agent (Paralytic)
Blocks acetylcholine from binding to motor neuron receptors inhibiting depolarization.
Onset of action IV: 1-2 minutes, Duration: approximately 30 minutes (increases with higher doses)
Indications
Labeled Indications: Rapid sequence and routine endotracheal intubation, facilitates mechanical
ventilation in ICU patients
Contraindications
• Hypersensitivity (eg, anaphylaxis) to rocuronium, other neuromuscular-blocking agents, or any
component of the formulation
• Resistance may occur in burn patients (>30% of body) for period of 5-70 days after injury
• High potential for interactions: Numerous drugs either antagonize (eg, acetylcholinesterase inhibitors)
or potentiate (eg, calcium channel blockers, certain antimicrobials, inhalation anesthetics, lithium,
magnesium salts, procainamide, and quinidine) the effects of neuromuscular blockade; use with
caution in patients receiving these agents.
• Provides NO analgesia or sedation!
o Must provide appropriate sedation and analgesia prior to paralytic use and throughout
maintenance.
Rapid sequence intubation (RSI): Rapid sequence intubation (unlabeled use):

IV Push: IV:
• 1mg/kg • 1mg/kg
(Dosing ranges from 0.6-1.2 mg/kg) (Dosing ranges from 0.9 mg/kg or 1.2 mg/kg.)
Note: In adult patients with morbid obesity (BMI
>40 kg/m2), use dose of 1.2 mg/kg using ideal Army Rotary wing RSI and maintenance bolus
body weight (IBW) dosing: (unlabeled and unreferenced dose)
IV Push:
Army Rotary wing RSI and maintenance bolus • 1mg/kg every 30-45 minutes
dosing: (unlabeled and unreferenced dose)
IV Push: Maintenance for continued surgical relaxation:
• 1mg/kg every 30-45 minutes IV:
• Bolus: 0.075-0.15 mg/kg
ICU paralysis (eg, facilitate mechanical o Redosing interval is guided by
ventilation): monitoring with a peripheral nerve
IV: stimulator or
• Initial bolus dose: 0.6-1 mg/kg, • Continuous infusion: 7-12 mcg/kg/minute
• Maintenance: continuous infusion of 8-12 (0.42-0.72 mg/kg/hour)
mcg/kg/minute o Use lower end of the continuous
Note: Loading dose of 50 mg followed by 25 mg infusion dosing range for neonates and
given when peripheral nerve stimulation returns infants up to age 28 days and the
has been described. upper end for children >2 to ≤11 years
of age
Note: Paralytic use and management: If available,
utilize the train of four stimulation device with either
the temple or radial/ulnar nerve placement.
Maintain paralysis at a level of 2/4 twitches with
TOF stimulation.
196
SODIUM BICARBONATE Lactation Yes Trade Name:
Alkalinizing Agent; Antacid
Provides bicarbonate ion to neutralize hydrogen ion concentration and raise blood and urinary pH
Onset of action IV: 15 minutes, Duration 1-2 hours
Indications
Labeled Indications: Management of metabolic acidosis, hyperkalemia, overdose of certain drugs
(including tricyclic antidepressants and aspirin), and gastric hyperacidity.
Contraindications
• Alkalosis, hypernatremia, hypocalcemia
• severe pulmonary edema
• Unknown abdominal pain
• Use should be reserved for documented metabolic acidosis and for hyperkalemia induced cardiac
arrest. Routine use in cardiac arrest is not recommended.
• Avoid extravasation, tissue necrosis can occur.
• Can cause Hypernatremia, hypocalcemia, hypokalemia, intracranial acidosis, metabolic alkalosis
TriCyclic Antidepressant OD • Follow Adult Dosing

IV:
• 1mEq/kg; May repeat to maintain QRS <100
• Start Maintenance Infusion: 100-150mEq (2-3
amps) in 1 L D5 / NS @ 100-200 mL/hr IV
Cardiac arrest (ACLS Guidelines, 2015):

IV:
• 1 mEq/kg/dose; repeat doses should be
guided by arterial blood gases
Note: Routine use in cardiac arrest is not

recommended. Use may be considered in cases of
prolonged cardiac arrest once adequate alveolar
ventilation and effective cardiac compressions
have been established. In some cardiac arrest
situations (eg, metabolic acidosis, hyperkalemia, or
tricyclic antidepressant overdose), sodium
bicarbonate may be beneficial.
Hyperkalemia (ACLS Guidelines, 2015)

IV:
• 50 mEq over 5 minutes
Metabolic acidosis:
If acid-base status is not available: 2-5 mEq/kg
infusion over 4-8 hours
197
SUCCINYLCHOLINE Lactation?(Caution) Trade Name: Anectine
Depolarizing Neuromuscular Blocking Agent (Paralytic)
Acts like acetylcholine, produces myoneural depolarization causing sustained flaccid skeletal muscle
paralysis. Onset of action IV: 45-60 seconds, Duration 5-9 minutes with single dose
Indications
Labeled Indications: Rapid sequence and routine endotracheal intubation
Contraindications
• Hypersensitivity to succinylcholine or any component of the formulation
• Acute phase of injury following major burns, multiple trauma (greater than 5 days after injury)
• Myopathies associated with elevated serum creatine phosphokinase and myasthenia gravis
• DO NOT USE IN PATIENTS WITH BURNS, CRUSH INJURIES, OR HYPERKALEMIA
• Re-Dosing is not advised due to increased risk of Hyperkalemia
• May cause Bradycardia, Malignant hyperthermia, and increased intraocular pressure
• Severe hyperkalemia can develop in cases of chronic abdominal infection, burn injury, children with
skeletal muscle myopathy, subarachnoid hemorrhage, or conditions which cause degeneration of the
nervous system commonly greater than 5 days old. Potassium increase of 0.5 mEq/L is expected
with use.
maintenance.
RSI / Neuromuscular blockade: RSI / Neuromuscular blockade:

IV: IV:
• 1-1.5 mg/kg • <10kg:
o Initial: 1.5-2 mg/kg/dose
Note: Pretreatment with 10% dosage of non- • >10kg:
depolarizing agents prior to neuromuscular- o Initial: 1-1.5 mg/kg/dose
blockade with Succinylcholine is NO LONGER
ADVISED Note: Pretreatment with 10% dosage of non-
depolarizing agents prior to neuromuscular-
blockade with Succinylcholine is NO LONGER
ADVISED
198
THIAMINE A LactationYes(Caution) Trade Name: Vitamin B1
Vitamin, water soluable
Essential coenzyme in carbohydrate metabolism. Onset of action IV/IM: Rapid
Indications
Labeled Indications: Treatment of thiamine deficiency including beriberi, Wernicke's encephalopathy,
Korsakoff’s syndrome, neuritis associated with pregnancy, or in alcoholic patients
Contraindications
• Hypersensitivity to thiamine or any component of the formulation
• Administration of dextrose may worsen acute symptoms of thiamine deficiency; use caution when low
thiamine is suspect
AMS; Seizure; Syncope; Malnutrition; Vomiting AMS or Seizure w/ signs of Malnutrition:

and Diarrhea; w/ Hx of ETOH abuse: IM/IV:
IM/IV: • 25mg/day
• 100mg/day
199
TRANEXAMIC ACID B Lactation: Yes(Caution) Trade Name: TXA
Antifibrinolytic Agent, Hemostatic Agent
Displaces plasminogen from fibrin resulting in inhibition of fibrinolysis and inhibits the proteolytic activity of
plasmin
Indications
Unlabeled: Trauma-associated hemorrhage
Contraindications
• Hypersensitivity to tranexamic
• Subarachnoid hemorrhage
• Thromboembolic disease (Cerebral Thrombosis, DVT, PE)
• TXA is contraindicated in trauma if initial dose is not given within first 3 hours following
Traumatic event (Ideal dosing time-frame is within 1 hour of trauma)
• Disseminated intravascular coagulation (DIC): Use with extreme caution in patients with DIC requiring
antifibrinolytic therapy; patients should be under strict supervision of a physician experienced in
treating this disorder. TXA should be used in Pt.'s with trauma related DIC however.
Trauma-associated hemorrhage (unlabeled

use):
IV:
• Initial Dose: 1 gram of TXA in 100 cc NS or LR
ASAP, but NOT later than 3 hours after injury
• Follow-up dose: 1 gram of TXA over the next 8
hours following blood, Hextend, or other fluid
treatment to attain hemodynamic stability.
TCCC Guidelines, September 2012:

If a casualty is anticipated to need significant blood
transfusion (for example: presents with
hemorrhagic shock, one or more major
amputations, penetrating torso trauma, or evidence
of severe bleeding):
• Administer 1 gram of tranexamic acid in 100 cc
Normal Saline or Lactated Ringers as soon as
possible but NOT later than 3 hours after injury.
• Begin second infusion of 1 gram TXA after
Hextend or other fluid treatment.
200
VECURONIUM C Lactation?(Caution) Trade Name: Norcuron
Nondepolarizing Neuromuscular Blocking Agent (Paralytic)
Blocks acetylcholine from binding to motor neuron receptors inhibiting depolarization.
Onset of action IV: 1.5-3 minutes, Duration: approximately 25-40 minutes
Indications
Labeled Indications: Endotracheal intubation, facilitates mechanical ventilation in ICU patients
Contraindications
• Hypersensitivity to vecuronium or any component of the formulation
• Resistance may occur in burn patients (>30% of body) for period of 5-70 days after injury
• High potential for interactions: Numerous drugs either antagonize (eg, acetylcholinesterase inhibitors)
or potentiate (eg, calcium channel blockers, certain antimicrobials, inhalation anesthetics, lithium,
magnesium salts, procainamide, and quinidine) the effects of neuromuscular blockade; use with
caution in patients receiving these agents.
maintenance.
Rapid sequence intubation (RSI) and Rapid sequence intubation (RSI) and
maintenance of paralysis: maintenance of paralysis:
IV Push: IV Push:
• Induction: 0.1 mg/kg • Induction: 0.1-0.15 mg/kg
• Maintenance: 0.1 mg/kg every 30-60 minutes • Intermittent bolus dosing: 0.1 mg/kg every 30-
PRN 60 minutes PRN
IV Continuous infusion: IV Continuous infusion:
• 1 mcg/kg/min and titrate to 2:4 train of four • 1-2.5 mcg/kg/minute
(TOF) if stimulation devise is available.
Note: Paralytic use and management: If available,

utilize the train of four stimulation device with either
the temple or radial/ulnar nerve placement.
Maintain paralysis at a level of 2/4 twitches with
TOF stimulation.
Note: Vecuronium is only recommended for use in

RSI in the absence of available Succinylcholine or
Rocuronium, as they are the preferred induction
agents.
201
SMALL ADULT ADULT LARGE ADULT RESTRICTIONS/
DRUG STANDARD DOSING INDICATIONS DURATION REPEATABILITY/ MAX DOSE
(60KG)132LBS (80KG)176LBS (100KG)220LBS WARNINGS
ANTI‐FIBRINOLYTIC
Tranexamic Acid (TXA) 1000 mg IV/IO over 10 min 1 Gram diluted in 100cc NS over 10min Int/Ext Hemorrhage Give <3 hrs from injury UNK additional 1000 mg over 8 hours
ANALGESIA
Ketamine ** LOW‐DOSE 0.1‐0.2 mg/kg IV/IO >1 min 20mg IV/IO; 50mg IM/IN Analgesia HTN, Emergence 20‐30 min Q 20‐30 min PRN for pain
Fentanyl (Sublimaze) ** 0.5‐1 mcg/kg IV/IO >3‐5 min 60mcg 80mcg 100mcg Analgesia, Sedation, AMI Resp depression 30‐60 min Q 30‐60 min PRN; MAX 4mcg/kg
Ketorolac (Toradol) 10‐15mg IV 10‐15mg IV Musculoskeletal Pain Not for Battlefield Trama 4‐6hrs 15mg Q 6 hrs; MAX 120mg/day
Morphine ** 0.5‐0.1 mg/kg IV/IO/IM >3 min 5‐10mg IM q 20‐30 min; 2‐5mg IV q 5‐15 PRN Pain, Anxiolytic, AMI Resp/BP drop; Head Tx Variable PRN for sedation if BP/Resp stable
SEDATION ** = Controlled Substance
Dissociative Sedation/ HTN, emergence, avoid 1/2 to Full dose Q 10‐20 PRN for
Ketamine ** HIGH DOSE 1‐2 mg/kg IV/IO >2 min 60‐120mg 80‐160mg 100‐200mg 10‐20 min
RSI sub‐dissociative doses sedation or 1‐2 mg/kg/hr infusion
0.5‐1.5 mg/kg bolus IV/IO, RSI/General Anesthesia Hypotension (up to 30%
Propofol (Bolus) 30‐90mg 40‐120mg 50‐150mg 3‐10 min Titrate to effect
q 5‐10min PRN (Non‐analgesic) of MAP)
600‐3000 800‐4000 1000‐5000 General Anesthesia Hypotension (up to 30%
Propofol (Constant Infusion) 10‐50 mcg/kg/min IV/IO Infusion Titrate to effect
mcg/min mcg/min mcg/min Maint. (Non‐analgesic) of MAP)
Sedation, RSI (Non‐ Repeat doses can cause
Etomidate 0.3‐0.5mg/kg IV/IO push 24mg 32mg 40mg 5‐10 min NO REPEAT
analgesic) adrenal suppresion
Midazolam (Versed)** 0.05‐0.1mg/kg IV/IO >1 min Sedation/Seizures=2.5‐5 mg; Status Epilep=10mg Sedation, Seizures BP/Resp drop 10‐30 min PRN q 15‐30min if BP/Resp stable
PARALYTICS
Rocuronium (Zemuron) 0.6‐1.2 mg/kg IV/IO push 60mg 80mg 100mg RSI/ Maint of paralysis Must maintain PT airway 30+min PRN q 30‐45min for paralysis
Succinylcholine 1‐1.5 mg/kg IV/IO push 75mg 100mg 125mg RSI RSI Only 5‐9 min NO REPEAT
0.1 mg/kg IV/IO push To Use this Card:
Vecuronium 6mg 8mg 10mg Maint of paralysis Must maintain PT airway 25‐40 min PRN q 30‐60 min for paralysis
Reconstitute w/ 10 ml NS 1)Print
PRESSERS 2)Cut off all white
1mg/250ml NS= 4mcg/ml or Must be diluted/ Max edges to include
Epinephrine 1:10,000 2‐10mcg/min IV/IO infusion Hypotension Infusion Start low; Titrate to desired response
1mg/500ml NS= 2mcg/ml resuscitation w/blood 1st this text Box
4mg/500 ml D5W= 8 mcg/ml or Start 8‐12mcg/min infusion initally. (adjust for BP) Mix only with D5W/ Max Consistent 3)Fold in half
Norepinephrine (Levophed) Hypotension Titrate to desired response
4mg/250 ml D5W= 16mcg/ml Once BP is appropriate, 2‐4mcg/min resus w/ blood 1st Infusion 4)Laminate
10mg/100ml NS= 100mcg/ml or Must be diluted/ Max PRN to maintain SYS BP; start w/ low **This card is
Phenylephrine(NEO) 100‐500mcg (1‐5 ml) q 10‐15 min IVP/IO >1min Hypotension 10‐15 min
10mg/250ml NS= 40mcg/ml resus w/ blood 1st doses and titrate PRN designed to fit
OD/Tox Ingestions (See also Sodium Bicarbonate, Calcium Chloride) inside the cargo
Glucagon Kit 3‐10mg IV/IO/IM 3‐10mg bolus; follow w/ 3‐5mg/hr infusion Beta/Ca‐ch blocker OD Dosage is higher than kits UNK Titrate infusion for hemodynamics pocket of the A2CU
Naloxone (Narcan) 0.4‐2mg IV/IO/IM 0.4‐2mg titrated to appropriate ventilation Opioid OD Use minimum needed 20‐60 min Q 2‐3 min PRN (Max 10mg) and ideally should
ANTI‐EMETICS be carried while on
Zofran(Ondansetron) 4‐8mg IV/IO/IM/PO 4‐8mg >30 sec Antiemetic Can cause QT prolongation 4‐6hrs Max 8mg q 6 hrs MEDEVAC duty and
Promethazine (Phenergan ) 12.5‐25mg IV/IO/IM 12.5‐25mg Antiemetic/Sedation Altered LOC/ Vesicant 4‐6hrs Max 25mg q 4 hrs referenced PRN
ANAPHYLAXIS during medication
Epi‐Pen/ Epinephrine 1:1000 0.3‐0.5mg IM; 0.1mg IV/IO 1 Auto‐Injector or 0.3mg IM; 0.1mg IV/IO Anaphylaxis Hold for 10 sec 5‐15m Add doses Q 5‐15 min until improve administration
Diphenhydramine (Benadryl) 25‐50mg 25‐50mg PO; 50mg IV/IO Antihistamine Minor sedation 4‐8hrs Max 50mg
Methylprednisolone/Solu‐ 125mg IV/IO 125mg Anaphylaxis/Asthma Do not use for head Tx 4hrs NO REPEAT
RESPIRATORY (See also: Methylprednisolone)
Albuterol(Nebulizer) 2.5‐5mg 2.5‐5mg q 20 min prn (mixed in 3ml NS) Bronchodilator Cardiac arrhythmia 1‐4hrs Max 3 initial doses; q 1‐4hrs PRN
Albuterol(MDI) 4‐8 Puffs 4‐8 Puffs Q 1‐4 hrs Bronchodilator Cardiac arrhythmia 1‐4hrs PRN q 1‐4 hours
Epinephrine 1:1000 0.3‐0.5mg SQ/IM or 0.5ml Neb 0.3‐0.5mg SQ/IM q20min PRN or 0.5ml w/ 3ml NS Bronchodilator No IV use 5‐15m Neb over 15 min/ Max 3x for SQ/IM
HYPOGLYCEMIA
D50 10‐25 Grams IV/IO 20‐50ml >5min Hypoglycemia Intracranial hemorrhage UNK Titrate; avoid over‐correction
Glucagon Kit 1mg 1 Kit (1mg) IV/IM Hypoglycemia Only if D50 not available UNK Give D50 ASAP following use
CARDIAC (See also Morphine or Fentanyl for AMI pain)
Aspirin, Chewable, 81mg 324mg PO 4 X 81mg Tablets (Chewed) Angina/ AMI Must be chewed 4‐6hrs NO REPEAT
Nitroglycerin Tablet/Spray 0.4mg SL 1 Tab/Spray SL Q 3‐5 min‐‐‐MAX 3 Angina/ AMI Maintain SYS BP>90 20‐30 min May repeat up to max of 3 Doses
Epinephrine 1:10,000 1mg 1mg (1 amp) IV/IO Q 3‐5 min for Arrest Pulseless Arrest Profusing Tachycardia's 3‐5 min Repeat Q 3‐5min w/ CPR‐No Max
300mg 1st Dose/ 150 mg 2nd 300mg IV/IO bolus. If no change in 3‐5min give 150 Refractory Pulseless Sinus Bradycardia,
Amiodarone (Cardiac Arrest) 3‐5 min Max 2 doses
Dose (Follow w/20ml NS flush) mg IV/IO. V‐Fib/V‐Tach 2nd/3rd Deg Block
150mg over 10‐15min, followed 150mg infusion over 10‐15min; followed by 360mg Hemodynamically Sinus Bradycardia, Maintain May repeat 150mg infusion q 10 PRN.
Amiodarone (Infusion)
by 1mg/min for 6hrs (1mg/min) infusion over 6hrs unstable V‐Tach/SVT 2nd/3rd Deg Block drip Do not exceed 15mg/min
6mg 1st dose/12mg 2nd dose‐‐‐‐Fast push w/ rapid, Stable, narrow complex May cause transient Give 2nd dose if no rhythm change in
Adenosine 6mg/ 12mg IV/IO Rapid Push 1‐2 min
large (>20cc) flush tach/PSVT Asystole following push 1‐2 min
Symptomatic
Atropine 0.5mg IV/IO 0.5mg q 3‐5 min Glaucoma 5‐15min MAX 3mg (6 doses)
Bradycardia
Symptomatic Use if refractive to
Epinephrine 1:10,000 0.05‐0.5mcg/kg/min 2‐10mcg/minute infusion titrated to desired effect 5‐15min MAX 3mg (6 doses)
Bradycardia Atropine/Pacing
1‐2 Gram diluted in 50ml D5W over 15 Torsades De Pointes Infusion of 1‐2 Grams per hr needed
Magnesium Sulfate 1‐2 Gram IV/IO AV Blocks 30 min
min(Torsades w/ pulse/VF/V‐Tach) (with or without pulse) following loading dose
SMALL ADULT ADULT LARGE ADULT RESTRICTIONS/

DRUG STANDARD DOSING INDICATIONS DURATION MAX DOSE/ REPEATABILITY
(60KG)132LBS (80KG)176LBS (100KG)220LBS WARNINGS
CARDIAC‐continued
TCA OD; Prolonged Do not mix with other Maint Infusion of 100‐150mEq in 1L
Sodium Bicarbonate 1mEq/kg IV/IO 60mEq 80mEq 100mEq 1‐2hrs
Cardiac Arrest meds/ Flush line after D5W @ 100‐200ml/hr for TCA OD
Labetalol 10‐20mg IV/IO over 1‐2min Urgency=10mg; Emergency=10‐20mg HTN Urgency/Emergency Lower MAP by <20% 15‐60 min Repeat/double q 10min; Max 300mg
Ca Gluconate can alternatively be 500‐1000mg over 2‐5 min for Hyper K issues; Hyperkalemia/ 20mcg/kg/hr infusion for Beta OD;
Calcium Chloride (100mg/ml) used @ 3x doses listed here 20mg/kg >5‐10min for Beta Blocker OD; 1000mg Beta&Calcium Channel Central Line use preferred 30min‐4 hrs 1000mg Q 10‐20 x 3 doses PRN for Ca
(except for Beta Blocker OD) >5min for Ca Channel Blocker OD Blocker OD Chan Blocker OD
CBRNE
0.05‐0.1mg/kg IV/IO q 5‐10 min Organophosphate/ Requires large amounts of Double dose if previous dose does
Atropine 3mg 4mg 5mg 5‐15min
PRN Nerve Agent Atropine (5‐20 boxes) not relieve secretions(atropinization)
Inject 1‐3 injectors (based on sverity of symptoms) Use Atropine 1st if only If symptoms remain after 15 min, re‐
Pralidoxime Chloride (2‐Pam) Organophosphate/
1‐3 Auto‐Injectors (600mg ea) IM. DuoDote/ATNAA Injector contains both using single dose 2‐Pam 15min inject subsequent doses (Max
(DuoDote ATNAA) Nerve Agent
Atropine (2.1mg) and 2‐Pam(600mg) (Mark 1/NAAK Kit) 1800mg 2‐Pam)
Multi‐Use/ Seizures/ Other
Anxiety: 2‐10mg IV/IM q 6hrs///Seizures: 5‐10mg q 3‐4hrs///Seizures following Nerve Anxiety/ Seizures/
Diazepam Respiratory Depression 20‐30min Max dose 30mg for seizures
agent Exposure: 10mg IM for seizures or if 3x Mark 1 Kits used Nerve Agent Seizures
Seizures = 1‐2mg q 10‐15 prn; Agitated/Combative Seizures/ Agitated or
Lorazepam 1‐2mg IV/IO Respiratory Depression 30‐120min Max 8mg in 12hrs for seizures
Patient = 1‐2mg q 30‐60 Combative Patient
Seizures = 1‐2mg over 30 min; Wheezing/ Seizures/ Wheezing in
Dilute into 50‐100ml NS 2 Grams/hr infusion needed
Magnesium Sulfate 1‐2 Gram IV/IO Respiratory Distress (3rd line) = 2mg over 20 min; Resp Distress/ 30 min
or D5W following loading dose for Eclampsia
(Pre)Eclampsia = 4‐6G over 15‐20min (Pre)Eclampsia
Mannitol (20%) 1 Gram/kg IV over <20 min 60G 80G 100G Mod to severe head Tx Avoid in HoTN Pt's 3‐8hrs Follow with 0.25 Gram/kg IVP q 4hrs
FLUIDS
Resuscitation (Crystaloid) ≤20ml/kg 250‐500 ml Bolus to achieve systolic BP >90 Hypo‐tension/volemia Blood is 1st fluid choice PRN Titrate to maintain SBP >90
Maintenance 1‐2 ml/kg 75ml/hr(TKO) 105ml/hr(TKO 150ml/hr(TKO) IV access/Homeostasis Do not over hydrate PRN Titrate to effect
10ml * %
LR 10ml * %TBSA (Based on 40‐ 10ml * % BSA 10ml * % BSA >20% TBSA partial or Track start time and Add 100ml/hr for each 10kg over
Burns >20% TBSA BSA+200ML Per N/A
80kg adult) Per Hour Per Hour full‐thickness burns amount infused 80kg
Hour
Hypertonic Saline (3%) 0.1‐1 ml/kg/hr 250ml bolus followed by 50‐100ml/hr ICP Reduction Use only in Head Injuries N/A MAX 250ml
HetaStarch/Hextend (HTS) 250‐500 ml 250‐500ml to achieve sys BP >90 Int/Ext Hemorrhage Equates to 1.5 L NS 2+ weeks PRN up to 1500ml/day
Blood Products and Management (See also Epinephrine and Benadryl for Hemolytic Reactions)
1‐2 units PRN to achieve Sys BP ~90 (Shelf Int/Ext Hemorrhage/ Monitor for Anaphylaxis/ Repeat PRN to maintain SYS BP >90/
PRBC (1u=250ml) 10ml/kg PRN
Life =42 days) O‐Neg Uni Donor Hyperthermia/HyperK MAP >60/hemostasis
1‐2 units PRN to achieve 1:1 ratio w/ PRBC's Int/Ext Hemorrhage/ Monitor for Anaphylaxis/ Ideal ratio of FFP:PRBC:Platelets is
FFP (1u=200‐250ml) 10ml/kg PRN
(Shelf Life(thawed) =5 days) AB+ Uni Donor Hyperthermia 1:1:1
Acetaminophen 500mg PO or 1G IV 500mg PO or 1Gram IV infusion Febrile Reaction Infuse slowly 6hrs Use only for Non‐Hemolytic react
HEMATOLOGY CHEMISTRIES Initial Vent Settings and Goals

Vent Parameter Vent setting
MODE AC
FIO2 100%
TIDAL VOLUME 6‐8ml/kg ideal body weight
BLOOD GAS RESPIRATORY RATE 12 bpm
I:E RATIO 1:2‐4
PEEP 5 cm H2O
MILITARY WORKING DOG

VITALS Normal Excited MISCELLANEOUS VALUES
Temperature 99‐102.5 ºF 103 ºF FLUID MANAGEMENT
Respirations 16‐30/MIN Panting Maintenance 50 ml/hr NS
Blood Pressure Systolic 100‐180 mm Hg; MAP 90‐120 Bolus Add "0" to wt in lbs (i.e. 40kg=400cc NS)
Heart Rate 60‐80 Intubate w/ 6.0 ET tube and 4 Miller blade
EtCO2 35‐45 mmHg Defib 2‐5 Joules/Kg
202
mcg/ml
mg/ml Fluid volume for Dilution
5cc 10cc 20cc 50cc 100cc 250cc 500cc 1000cc
1mcg 0.20mcg/ml 0.1mcg/ml 0.05mcg/ml 0.02mcg/ml 0.01mcg/ml 0.004mcg/ml 0.002mcg/ml 0.001mcg/ml
5mcg 1mcg/ml 0.5mcg/ml 0.25mcg/ml 0.1mcg/ml 0.05mcg/ml 0.02mcg/ml 0.01mcg/ml 0.005mcg/ml
10mcg 2mcg/ml 1mcg/ml 0.5mcg/ml 0.2mcg/ml 0.1mcg/ml 0.04mcg/ml 0.02mcg/ml 0.01mcg/ml
D 25mcg
50mcg
5mcg/ml
10mcg/ml
2.5mcg/ml 1.25mcg/ml 0.5mcg/ml 0.25mcg/ml 0.1mcg/ml 0.05mcg/ml 0.025mcg/ml
5mcg/ml 2.5mcg/ml 1mcg/ml 0.5mcg/ml 0.2mcg/ml 0.1mcg/ml 0.05mcg/ml
100mcg 20mcg/ml 10mcg/ml 5mcg/ml 2mcg/ml 1mcg/ml 0.4mcg/ml 0.2mcg/ml 0.1mcg/ml
R 250mcg 50mcg/ml 25mcg/ml 12.5mcg/ml 5mcg/ml 2.5mcg/ml 1mcg/ml 0.5mcg/ml 0.25mcg/ml
500mcg 0.1mg/ml 50mcg/ml 25mcg/ml 10mcg/ml 5mcg/ml 2mcg/min 1mcg/ml 0.5mcg/ml
U 1mg
2mg
0.2mg/ml
0.4mg/ml
0.1mg/ml
0.2mg/ml
50mcg/ml 20mcg/ml 10mcg/ml 4mcg/ml
0.1mg/ml 40mcg/ml 20mcg/ml 8mcg/ml
2mcg/ml
4mcg/ml
1mcg/ml
2mcg/ml
G 3mg
4mg
0.6mg/ml
0.8mg/ml
0.3mg/ml
0.4mg/ml
0.15mg/ml 60mcg/ml 30mcg/ml 12mcg/ml 6mcg/ml
0.2mg/ml 80mcg/ml 40mcg/ml 16mcg/ml 8mcg/ml
3mcg/ml
4mcg/ml
5mg 1mg/ml 0.5mg/ml 0.25mg/ml 0.1mg/ml 50mcg/ml 20mcg/ml 10mcg/ml 5mcg/ml
6mg 1.2mg/ml 0.6mg/ml 0.3mg/ml 0.12mg/ml 60mcg/ml 24mcg/ml 12mcg/ml 6mcg/ml
D 8mg 1.6mg/ml 0.8mg/ml 0.4mg/ml 0.16mg/ml 80mcg/ml 32mcg/ml 16mcg/ml 8mcg/ml
O 10mg
15mg
2mg/ml
3mg/ml
1mg/ml
1.5mg/ml
0.5mg/ml 0.2mg/ml
0.75mg/ml 0.3mg/ml
0.1mg/ml 40mcg/ml 20mcg/ml
0.15mg/ml 60mcg/ml 30mcg/ml
10mcg/ml
15mcg/ml
S 25mg
50mg
5mg/ml
10mg/ml
2.5mg/ml
5mg/ml
1.25mg/ml 0.5mg/ml
2.5mg/ml 1mg/ml
0.25mg/ml 0.1mg/ml
0.5mg/ml 0.2mg/ml
50mcg/ml
0.1mg/ml
25mcg/ml
50mcg/ml
E 75mg
100mg
15mg/ml
20mg/ml
7.5mg/ml
10mg/ml
3.75mg/ml 1.5mg/ml
5mg/ml 2mg/ml
0.75mg/ml 0.3mg/ml
1mg/ml 0.4mg/ml
0.15mg/ml 75mcg/ml
0.2mg/ml 0.1mg/ml
250mg 50mg/ml 25mg/ml 12.5mg/ml 5mg/ml 2.5mg/ml 1mg/ml 0.5mg/ml 0.25mg/ml
500mg 100mg/ml 50mg/ml 25mg/ml 10mg/ml 5mg/ml 2mg/ml 1mg/ml 0.5mg/ml
750mg 150mg/ml 75mg/ml 37.5mg/ml 15mg/ml 7.5mg/ml 3mg/ml 1.5mg/ml 0.75mg/ml
1Gram 200mg/ml 100mg/ml 50mg/ml 20mg/ml 10mg/ml 4mg/ml 2mg/ml 1mg/ml
Value equals amount of fluid in each ml of dilution
Each ml of medication diluted into your chosen fluid still counts towards total solution volume (i.e. 1ml of drug + 4ml fluid = 5ml
solution; 1ml drug + 9ml fluid = 10ml solution). Small volume medications (1-2ml) are inconsequential above dilutions >50ml
1mg=1000mcg 0.1mg=100mcg 0.01mg=10mcg
203
Amiodarone Epinephrine Etomidate Fentanyl Hydromorphone Ketamine Lorazepam Midazolam Morphine Norepinephrine Phenylephrine Propofol Rocuronium Sodium bicarb Succinylchloline Vecuronium
Amiodarone C C C C C C C I C C
Epinephrine C C C C C C C C C I C C
Etomidate C C C C C C I
Fentanyl C C C C C C C C C C C C C C
Hydromorphone C C C C C C C C C C C I C C
Ketamine C C C C C C C I
Lorazepam C C C C C C C C C C I C C C
Midazolam C C C C C C C C C C-syringe C I C C
Morphine C C C C C C C C C C C-Y; I-admixture C C
Norepinephrine C C C C C C C C I C C
Phenylephrine C C C C C C C C C C C C C
Propofol C C C C C C C-admixture
Rocuronium C C C C I C C C
Sodium bicarb I I C I I C I C I C C C I C
Succinylchloline C C C C C C C C C C I C
Vecuronium C C I C C C C C C C C C
D50W
Hetastarch C-Y C-Y C-Y C-Y C-Y C-Y C-Y C-Y C-Y C-Y I-Y C-Y C-Y
LR C-Y; solutn C-Y C-solutn C-Y C-Y, solutn C-Y, solutn C-Y, solutn C-solutn C-solutn C-Y C-Y, solutn C-solutn
NS C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn
NaCl 3%
D5W C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn C-solutn
C=compatible
I=Incompatible
Y=Y-site
204
PEDIATRIC FORMULAS:
• ETT Size = (Age/4)+4 (Age divided by 4 plus 4)

• ETT Depth = 3 x ETT Size (Endotracheal)
• Weight in kg (>1 year) = (Age (years) x 2) + 8
• Systolic Blood Pressure minimum = 70 + [2 x Age (years)]
MEDICATION FORMULAS:
• Mcg/kg/min (micrograms/kilogram/minute) = [16.7 X Drug Concentration (mg/ml) x infusion

rate (ml/h)] Weight (kg).
• INFUSION RATE (ml/h) = [Desired mcg/kg/min x Weight (kg) x 60]/Drug concentration (mcg/mL)
HEMODYNAMIC FORMULAS:
• MAP: Mean Arterial Pressure = [(2 x DBP) + SBP]/3.

• SBP = (Systolic Blood Pressure)
• DBP = (Diastolic Blood pressure)
• / = (Divided by)
• PULSE PRESSURE: SBP – DBP or (Systolic Blood Pressure minus Diastolic Blood pressure).
• Cerebral Profusion Pressure(CPP): MAP-ICP=CPP
• ICP= (Intracranial Pressure)
• Ideal CPP=>65 While ICP cannot often be measured during flights; an assumption that patients
with TBI have an ICP of 15-20 will allow hemodynamic optimization in these patients to ensure
adequate CPP.
Common Conversions:
• lbs. = kg x 2.2 or kg = lbs. x 0.45

• Fahrenheit = (Celsius x 1.8) + 32 or Celsius = (Fahrenheit -32) x 5/9
• 1 tsp. = 5 ml
• 1 tbsp. = 15 ml
• 1 oz. = 30 ml
• 1g = 1,000 mg
• 1mg = 1,000 mcg
• 1 g = 10,000 mcg
205
Length of Use for Compressed O2 Cylinders: Approx. Guide
Cylinder D E G H
Liters 356 622 5260 6900
Flow (LPM) Length of Length of Length of Length of

use (min) use (min) use (min) use (min)
2 178 311 2630 3450
4 89 155 1315 1725
6 59 104 876 1150
8 44 78 658 862
10 35 62 526 690
12 30 52 438 575
15 23 41 350 460
NOTE: Current MEDEVAC Oxygen Cylinder is “D” type.
To estimate duration of use for Oxygen Cylinders:
• Duration of Flow = Contents of cylinder / Flow rate.
Cylinder Factors for Calculation of Duration of Oxygen Flow:
• Cylinder Size D E G H and K

Factor 0.16 0.28 2.41 3.14
Once you have the cylinder factor and the amount of pressure remaining in the cylinder, the duration of
flow can be calculated with the following equation.
Duration of flow (min) = Pressure (psig) x Cylinder Factor/Flow (L/min)
206
Laboratory Conventional SI Units

Anion Gap 8-16 mEq/L 8-16 mmol/L
BUN 8-25 mg/100mL 2.9-8/9 mmol/L
Calcium 8.5-10.5 mg/100mL 2.1-2.6 mmol/L
Carbon Dioxide 24-30 mEq/L 24-30 mmol/L
Male: 0.2-0.5 mg/dL
Creatine Female: 0.3-0.9
mg/dL
Male: 17-40 U/L
Creatine Kinase
Female: 10-79 U/L
Creatinine 0.6-1.5 mg/100L 53-133
Glucose 70-110 mg/100mL 3.9-5.6 mmol/L
Sodium 135-145 mEq/L
Potassium 3.5-5.0 mEq/L 3.5-5.0 mmol/L
140,000-
Platelets
450,000/ml
INR 0.8-1.2 Treatment/prophylaxis
2.0-3.0 DVT
HEMATOLOGY
Male: 13-18 g/100
Hemoglobin
mL
Female: 12-16 g/
100mL
Hematocrit Male: 45-52%
Female: 37-48%
CARDIAC MARKERS
*Troponin I Onset: 4-6 hrs.
Peak: 12-24 hrs.
*Troponin T Onset: 3-4 hrs.
Peak: 10-24 hrs.
Myoglobin M: 10-95 ng/ml Onset: 1-3 hrs.
F: 10-65 ng/ml Peak: 6-10 hrs.
NORMAL BLOOD
GASES
pH 7.35-7.45
Pco2 35-45 mm Hg
HCO3 22-26 mmol/L
Base excess (-2)-(+2) mEq/L
CO2 19-24 mEq/L
SaO2 96-100%
*Troponin assays are becoming more analytically sensitive. Each device has different reference ranges
associated. Correlate cTn with reference lab. Point of care readers are less sensitive.
207
X. DOCUMENTATION AND FORMS
DD 1380 (Tactical Combat Casualty Care (TCCC) Card
208
***All medical providers should indicate their level of training after their name (e.g., CCFP, RN,
APA/ANP, MD/DO)
209
EXAMPLE: DA FORM 4700, FEB 2003 JTS TACEVAC AAR & PCR OP 05 (MCMR-SRJ) NOV 2014
210
211
212
EXAMPLE Standing Order Sheet for Critical Care Patient Transfers 2016
PAGE 1
PATIENT IDENTIFICATION
(Last, First, Middle Initial; SSN/Identification Number; grade; DOB; treatment facility)
Date:
Sending Facility:
Sending Physician:
Receiving Facility:
Diagnosis:
Condition:
Patient Category:
Allergies:
Height:
Weight (kg):
Fluids: [ ] LR____mL/hr [ ] NS____ mL/hr [ ] 3% Saline____mL/hr [ ] D5W____ml/hr

[ ] Other__________________ [ ] PRBC [ ] FWB [ ] Plasma [ ] LTOWB
Monitoring: Vital Signs [ ] Every 5 min; Vital Signs [ ] Every 15 min; Vital Signs [ ] Every 30
min
[ ] Continuous cardiac monitoring, document rhythm strips pre-flight and with any rhythm
changes
[ ] ICP/CPP [ ] CVP [ ] GCS [ ] ETCO2 [ ] UO_____mL hourly
Activity: [ ] Bed rest

[ ] Spine precautions: C-Collar/C-Spine TLS Spine
Nursing: [ ] Wound VAC dressing to ______mm Hg suction

[ ] NGT to low continuous suction OR [ ] Clamp NGT
[ ] OGT to low continuous suction OR [ ] Clamp OGT
[ ] Chest tube 1 to: water seal (circle: R L Both) OR ______cm H2O Suction (circle: R L Both)
[ ] Keep HOB elevated _______ degrees [ ] Keep HOB flat
Respiratory: [ ] Keep O2Sat >______ %
Oxygen: [ ] Nasal Cannula at ______LPM [ ] Non-rebreather at _____ LPM
Ventilator Settings: Mode: [ ] SIMV [ ] AC [ ] CPAP [ ] BiPAP

Rate: ______breaths per minute I:E ratio:_________
Tidal Volume: ______ mL FiO2:______ % PEEP: ______cm H2O PIP: _____
213
PAGE 2
PATIENT IDENTIFICATION
(Last, First, Middle Initial; SSN/Identification Number; grade; DOB; treatment facility)
Vasoactive Medications:
[ ] Dopamine ___mg/___mL at____mcg/kg/min IV; titrate to MAP > ______mm Hg
[ ] Norepinephrine 4mg/___mL at____mcg/min IV; titrate to MAP >______ mm Hg
[ ] Phenylephrine 10mg/____mL at____mcg/min IV; titrate to MAP >______ mm Hg
[ ] Epinephrine __mg (1:10,000)/___mL at____mcg/min IV; titrate to MAP >______ mm Hg
[ ] Other________________________________
Sedation and Analgesics:

[ ] Ketamine __mg/kg Q___minutes IVP PRN sedation to Riker Sedation-Agitation Scale of 1-2
[ ] Midazolam ___mg Q___minutes IVP PRN sedation to Riker Sedation-Agitation Scale of 1-2
[ ] Haloperidol ___mg Q___minutes IVP PRN sedation to Riker 1-2
[ ] Lorazepam ___mg Q___minutes IVP PRN sedation to Riker 1-2
[ ] Fentanyl ____mcg Q___minutes IVP PRN pain
[ ] Morphine ___mg Q___minutes IVP PRN pain
[ ] Other__________________________________
Paralytics:
[ ] Rocuronium ______mg IVP Q____minutes PRN
[ ] Vecuronium ______mg IVP Q____minutes PRN
Intracranial Hypertension:
[ ] 3% Hypertonic Saline 250 cc bolus for any signs of herniation
[ ] Mannitol Infusion Rate: _______
Labs:
[ ] ABG 15 minutes prior to departing sending facility
[ ] Other:
Additional critical information:
Physician Signature:
214
Burn Care CPG ID: 12
JTS BURN RESUSCITATION FLOW SHEET (1 of 3)
Date Initial Treatment Facility

Name SSN Pre-burn %TBSA Calculate Rule Calculate max 24hr
estimated (Do not include of Tens (if volume (250ml x kg)
st
weight (kg) superficial 1 >40<80kg, Avoid over-
degree burn) %TBSA x 10 = resuscitation, use
starting rate adjuncts if necessary
for LR
Date &Time of Injury BAMC/ISR Burn Team DSN 312-429-2876: Yes No
Pressors
Crystalloid* UOP MAP (Vasopressin 0.04
HR
Tx Site/ Base Deficit/ Heart (>55) / u/min)
from Local Time (LR) Total (Target 30-
Team Lactate Rate CVP (6-8
burn 50ml/hr) Bladder Pressure
Colloid mmHg)
(Q4)
st
1
nd
2
rd
3
th
4
th
5
th
6
th
7
th
8
th
9
th
10
th
11
th
12
th
13
th
14
th
15
th
16
th
17
th
18
th
19
th
20
st
21
nd
22
rd
23
th
24
Total Fluids:
Guideline Only/Not a Substitute for Clinical Judgment 29
215
216
Addendum Page for Unit Level Flight Surgeon/ Aeromedical Physician Assistant
217
XI. MEDICAL DIRECTOR / UNIT COMMANDER
REVIEW AND APPROVAL PAGE
It is the responsibility of the Unit Commander, the Medical Director, the Training NCO, and the Standards
NCO to ensure that all Flight Paramedics remain current in all required certifications needed to perform
their duties as Flight Paramedics and/or those needed to perform the skills of a Nationally Registered
Paramedic. This includes at a minimum certifications in NRP, ACLS, and BLS. Copies or originals of all
current certifications will be placed maintained in the individual Soldiers training record. It is
recommended that all CCFP level providers maintain PALS certifications and Flight Paramedic- Certified
(FP-C) certifications.
The Critical Care Flight Paramedic Standard Medical Operating Guideline is not intended to be a
comprehensive patient care manual. Rather, it specifies standard medical treatment guidelines to be used
by all Flight Paramedics and Medical Providers performing medical care while serving in this unit in an
austere, deployed, or garrison environment.
This document has been reviewed by the below noted individuals for correctness, and mission applicability.
Unit Standards Officer/NCO Signature________________________________ Date________________
Approval/Review Date______________ Initials_____________________
Unit Training NCO Signature________________________________________ Date________________
The Flight Paramedic Standard Medical Operating Guideline has been reviewed and approved for use by
the undersigned.
Medical Director or designated physician

Signature of Approval______________________________ Date________________
Unit Commander Signature of Approval______________________________ Date________________
Approval/Review Date______________ Medical Director's Initials_____________________
Additional Medical Director comments and addendums can be attached and should
contain counter signature of unit commander for validity.
218

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U.S.

“My duties as an aviation medical aidman are: first to be totally

REFERENCES and GUIDELINES

STANDING ORDERS – Air Ambulance, Emergency Medicine Tasks

TREATMENT GUIDELINES AND PROCEDURES

I. THE FLIGHT MEDIC OATH

REFERENCES and GUIDELINES

1. FM 4-02.2, 12 August 2014

Depending on the military environment (deployed or austere location), licensing and

A medical practitioner’s clinical competence is at least equal in importance to the maintenance

QUALITY MANAGEMENT PROGRAM Procedures

Physician Medical Direction

Mid-Level Clinical Oversight

Quality Management/Process Improvement

UPDATE and APPROVAL PROCESS

POINT OF INJURY CARE, TCCC Evacuation Phase Guideline

II. MEDEVAC CLINICAL GUIDELINES and PROCEDURES

Attempt to gain info prior to landing: Triage Casualties as required:

Collect Medical Info from 1st responder: AIRWAY / (Vent Management)

MUSCLE STRENGTH GRADING

Pediatric Weight Conversion Fluid Bolus

Color Kg Pounds Color Give

ZOLL® Defibrillation Energy Settings for PEDIATRIC Patients

Color First Second Maximum

Universal Patient Care Guideline

Assess need for IV

Intraosseous Device for

Ensure open and functioning

Patient care according to guideline

Monitor and Reassess

Contact med control if unable to

AVERAGE PEDIATRIC VITAL FUNCTIONS

Pediatric FLACC Pain Scale

FENTANYL 0.5-1mcg/kg SIVP Acetaminophen 10-15mg/kg PO / PR

Ensure utilizing appropriate PPE

Continuous Cardiac Monitoring / SPO2

Utilize Broselow® Pediatric Emergency Tape

Prior to flight day, verify presence and

Following each flight – recheck and verify all

If class VIII items or patient movement items

All medication errors, clinical errors, or

Follow appropriate SMOG for patient

It is the responsibility of the transferring physician to write enroute care orders

b. FLIGHT PARAMEDIC / PROVIDER responsibilities prior to transfer:

d. Patient Care Enroute to the Receiving Hospital

e. Patient Report and Transfer of Care at the Receiving Hospital

Apply Direct Pressure and

EXTREMITY GUIDELINE Penetrating HEAD INJURY GUIDELINE

**A MAP between 80-110mmHg or systolic pressure between 110-160mmHg is a

Hemorrhage Classification (ATLS)

Class I- EBL up to 15% of blood volume. Minimally elevated HR, minimal

Class II- EBL between 15%-30% blood volume. Tachycardia (100-120),

Trauma YES Cardiac

Maintain SBP 70-80, MAP 60 500mL NS/LR Bolus

No Response / Losing BP Control? No Response / Losing BP

CLINICAL PEARLS AND CONSIDERATIONS:

Anaphylaxis reaction Rapid onset of shock, hypotension (<100mmHg systolic),

TRALI / TACO Allergic Reaction Febrile Transfusion Reaction

STOP TRANSFUSION STOP TRANSFUSION STOP TRANSFUSION