BLS

 

1. Begin Initial Medical Care.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. Call for an ALS unit if patient has wheezing, stridor, or shows other signs of respiratory distress or nausea/vomiting.

 

5. If patient has a prescribed Epi auto-injector and displays signs of anaphylaxis, assist patient with or administer one dose of the patient’s own Epi auto-injector.

 

6. If patient does not have a prescribed Epi-auto injector and displays signs of anaphylaxis, administer epinephrine 1 mg/mL (1:1000) at the following dose and route:

 

1. Adult (25kg or more) 0.3 mg IM in the anterolateral thigh

 

7. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine, additional IM epinephrine can be repeated every 5-15 minutes at above noted doses.

 

ALS IF suspected anaphylaxis, proceed directly to epinephrine administration

 

1. Establish a saline lock or an IV with 0.9% NaCl or LR. Titrate fluids to a SBP of 90 mmHg.

 

2. Apply cardiac monitor.

 

3. Medicate according to signs/symptoms as below.

 

Isolated Itchy Rash/Hives

 

Administer Diphenyhdramine 25-50 mg IV or IM

 

2 or more body systems involved, such as Rash/Hives & Wheezing

 

1. Administer 0.01 mg/kg Epinephrine 1:1,000 IM (Max 0.3 mg).

 

2. If there is dyspnea or wheezing, administer 2.5 mg nebulized Albuterol at a flow sufficient to produce of mist.

 

3. Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)

 

Stridor &/or Hypotension

 

1. Administer 0.01  mg/kg Epinephrine 1:1,000 IM (Max 0.3 mg) .

 

2. Administer 2.5 mg nebulized Albuterol.

 

3. Administer Diphenhydramine 0.5 mg/kg IV or IM. (Max 50 mg)

 

4. If condition remains unchanged or worsens after 3 minutes, administer additional dose of 0.01 mg/kg Epinephrine 1:1,000 IM.

 

5. 6. If after 3 minutes and second dose of epinephrine condition remains unchanged, mix and infuse epinephrine drip at 0.25mcg/kg/min (max 5mcg/min). Contact medical control if need for titration.

 

Epinephrine drip: Inject 1mL of epinephrine 1:1000 (also known as epinephrine 1 mg/ml for anaphylaxis) into a 1-liter saline or LR bag and mix.

 

This yields a final medication concentration of 1mcg epinephrine / 1mL fluid. You must label the medication “Epi Drip: 1mcg/mL”

 

Use of a 20 gtt drip set is preferred. A 20 gtt drip set allows for: Adult dosing: Drip rate of 100 drops/min yields drug infusion rate of 5 mcg/min. Drip rate can be easily calculated by counting number of drops over 15 seconds then multiply by 4.

 

Weight (Estimated by Broselow tape)	4 kg	6 kg	8 kg	10 kg	12 kg	16 kg	> 20 kg or Adults
Drug Infusion Rate	1 mcg/min	1.5 mcg/min	2 mcg/min	2.5 mcg/min	3 mcg/min	4 mcg/min	5 mcg/min
10 gtt set	10 drops/min	15 drops/min	20 drops/min	25 drops/min	30 drops/min	40 drops/min	50 drops/min
15 gtt set	15 drops/min	23 drops/min	30 drops/min	38 drops/min	45 drops/min	60 drops/min	75 drops/min
20 gtt set	20 drops/min	30 drops/min	40 drops/min	50 drops/min	60 drops/min	80 drops/min	100 drops/min

BLS

 

BRADYCARDIA CRITERIA: Heart rate < 60/minute for children (1-15) and adults; < 80/minute in infants. Bradycardia with hemodynamic compromise is an ominous sign of impending cardiac arrest in infants and children.

 

SYMPTOMATIC CRITERIA: Bradycardia with signs of poor perfusion and altered mentation, chest pain or dyspnea with associated hypotension.

 

1. Begin Initial Medical Care.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. If patient is symptomatic, call for ALS unit. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take the ALS crew to respond to the scene, the BLS crew should emergently transport the patient.

 

ALS

 

1. Apply cardiac monitor and obtain 12-lead EKG

 

2. If patient is symptomatic, establish IV with 0.9% NaCl. (Avoid LR in Pediatric Patients.).  If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

 

3. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.

 

4. Perform CPR if clinically indicated

 

5. Intubate only if BVM ventilations/oxygenation is inadequate

 

6. Administer epinephrine 0.01 mg/kg (1:10,000, 0.1 mL/kg) IV or IO every 3-5 minutes.

 

7. For increased vagal tone or primary AV block administer atropine 0.02 mg/kg (min. dose 0.1 mg, max single dose 0.5 mg) IV or IO; may repeat one time 3-5 minutes after initial dose.

 

8. Continue searching for possible reversible causes of hypoxia

Prior to transport, the patient should first receive on-scene High Quality CPR and include at least 3 rounds of epinephrine or 15 minutes of on-scene care. Movement and transport degrade CPR quality.

 

Oxygenation and ventilation are of utmost importance in pediatric cardiac arrest care! Most pediatric cardiac arrests are secondary to a primary respiratory arrest.

 

Use the Broselow® tape (or appropriate equivalent) to obtain approximate weight and determine correct dosing regimen.

 

For EMS witnessed cardiac arrest, quick defibrillation is key – do not delay defibrillation!

 

BLS

 

1. Follow established AHA BLS guidelines for pediatric cardiac arrest

 

2. Attach AED and follow prompts.

 

1. Utilize pediatric pads or pediatric key as appropriate to the AED for children < 8 years old or < 25 kg. The use of an adult AED is acceptable if pediatric supplies are not available


2. Pads should be placed in the anterior-posterior position.


3. If "no shock advised," perform CPR for 2 minutes, then check pulse. Re-analyze rhythm if no pulse is found.

 

3. Initial airway management

 

1. OP/NP - Only if gag reflex absent


2. Provide good bag valve mask ventilation with mask that forms an adequate seal around the mouth.

 

4. Apply waveform capnography to bag-valve-mask if available

 

5. If the patient regains a pulse, follow Peds - Post Cardiac Arrest Care Protocol.

 

ALS

 

1. Establish an IV/IO with 0.9% NaCl or LR

 

2. Apply cardiac monitor and follow appropriate Cardiac Arrest Dysrhythmia protocol

 

3. Defibrillation is the treatment priority when advised by the AED. Bare and dry chest. Place patient on hard surface.

 

1. Defibrillate as described in the appropriate protoco

 

4. Try to minimize interruptions in chest compressions

 

5. Respiratory rate of 1 breath every 2 to 3 seconds (20-30 breaths per minute) is adequate for pediatric patients in cardiac arrest when an advanced airway is in place.


6. Apply waveform capnography in line with the bag.

Consider possible reversible causes of PEA such as hypovolemia, hypoxia, tension pneumothorax, cardiac tamponade, hypothermia, acidosis, drug overdose, hyperkalemia, massive acute MI, or pulmonary embolism

 

Consider possible reversible causes of Asystole such as hypoxia, preexisting acidosis, drug overdose, or hypothermia.

 

ALS

 

1. High quality CPR has priority over any ALS intervention.

 

2. If the rhythm is unclear and possibly ventricular fibrillation, defibrillate as for VF.

 

3. BVM is the preferred method of ventilation. Proceed to advanced airway only if BVM ventilation/oxygenation is inadequate. Use in-line ETCO₂.

 

4. Establish IV (or an IO line, if IV access is not available)

 

5. ASAP administer 0.01 mg/kg epinephrine: (1:10,000, 0.1 mL/Kg) IV or IO every 3-5 minutes (max dose is 1 mg). Goal is to give first dose of epinephrine within 5 minutes of ALS provider arrival.

 

6. Transport patient after providing at least 3 rounds of epinephrine or 15 minutes of on-scene care.

BLS

 

1. Perform chest compressions until defibrillator is attached. Compressions should be performed at a rate of 100-120/minute.

 

2. Refer to Cardiac Arrest General Care guidelines

 

ALS

 

 

Persistent or Recurrent VF/VT

 

1. Defibrillate, if indicated at 2 J/Kg. Subsequent shocks should be at 4 J/Kg.

 

The use of pediatric defibrillation pads is preferred if age < 8 or < 25 kg. If adult pads are used, they should be placed in an anterior-posterior configuration.

 

2. Defibrillate, immediately resume CPR for 2 minutes. Establish an IV or an IO.

 

3. BVM is the preferred method of ventilation. Proceed to advanced airway only if BVM ventilation/oxygenation is inadequate. Use in-line ETCO₂.

 

4. Administer 0.01 mg/Kg (0.1 mL/Kg) 1:10,000 epinephrine IV or IO every 3-5 minutes (max dose is 1mg) Goal is to give first dose within 5 minutes of ALS provider arrival – but defibrillation does have priority over epinephrine administration.

 

5. Check for an organized rhythm at 2-minute intervals. Shock if indicated. Immediately resume CPR.

 

6. If persistent VF/VT after first epinephrine dose and subsequent shock, administer amiodarone 5 mg/Kg IV or IO (max dose is 300 mg).This dose can be repeated up to 3 times as long as the cumulative dose does not exceed a total of 450 mg.

 

7. Resuscitative efforts should rotate on 2 minute cycles. Pattern should be shock, CPR, drug.

 

Once VF/VT has Resolved

 

1. Contact medical control for further instructions.

 

 

If VF/VT has NOT Resolved

 

1. Transport patient if VF/VT does not resolve after 3 shocks and patient has received amiodarone.

 

CRITERIA: If the patient with difficulty breathing is at least 6 months of age and the cause is suspected to be croup (e.g., the patient has stridor at rest with retractions and/or accessory muscle use):

 

BLS

 

1. Begin Initial Medical Care.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration Protocol.

 

4. If the patient is in moderate to severe respiratory distress per the Oxygen Administration Protocol, call for a paramedic unit.

 

5. If possible, administer humidified oxygen via the blow-by method.

 

ALS

 

1. Administer one of the following treatments:

 

1. The preferred treatment is 0.5 ml of 2.25% racemic epinephrine (Vaponephrine) diluted with 4.5 ml of 0.9% normal saline (for a total volume of 5 ml) and administered by nebulizer with 5-6 lpm oxygen.

 

2. If racemic epinephrine is unavailable administer 5 ml of 1:1,000 epinephrine by nebulizer with 5-6 lpm oxygen.

 

2. Apply the cardiac monitor.

 

3. If the patient becomes unresponsive or is markedly short of breath, a nebulizer may be connected to a BVM using a "flex connector" to administer racemic epinephrine or epinephrine. Two oxygen connections will be required. The nebulizer will require an oxygen connection at 5-6 lpm in addition to a high flow connector for the BVM.

 

Fever is defined in this protocol as 100.4 degrees F or higher (> 38°C).
Temperatures taken by the patient or family with their own thermometer that documents fever is acceptable.
Do not administer acetaminophen if any acetaminophen product has been given in the previous 4 hours.
This protocol does not apply to environmentally induced cases of fever such as heat stroke.
Acetaminophen does not improve survival in sepsis or serious infection and its administration should not delay transport.


 

Adult Fever

 

If patient is able to take PO, administer 650mg PO acetaminophen.


 

Pediatric Fever

 

If patient is older than 6 months and is able to take PO, administer 10mg/kg PO acetaminophen (max dose 650mg).

Eye Opening	Spontaneous	4
	To Sounds	3
	To Painful Stimuli	2
	None	1
Verbal Response	Appropriate Words or Social Smile	5
	Cries but Consolable	4
	Persistently Irritable	3
	Restless, Agitated	2
	None	1
Verbal Response	Spontaneous Movement	6
	Localizes to Pain	5
	Withdraw to Pain	4
	Flexion to Pain	3
	Extension to Pain	2
	None	1
Total		3 - 15

ALS

 

1. Place the child in the supine position.

 

2. Identify the tibia tuberosity, 1-3 cm below the tuberosity on the medial surface of the tibia, approximately one finger's breath below and just medial to the tuberosity.

 

1. Alternatively, 1 - 2 cm proximal to the medial malleolus on the anteromedial surface of the distal tibia.

 

3. Clean the skin.

 

4. The leg should be supported on a firm surface. Grasp the thigh and knee above and lateral to the insertion site. Do not allow any portion of your hand to rest behind the insertion point.

 

5. With the stylette in place, insert the needle at a 90^o angle to the skin.

 

1. Using gentle pressure that is steady, begin to advance the needle through the skin until you touch the bone, then check needle depth. If at least 5mm of needle remains exposed (the last black line) drill through the bone.

 

2. Stop advancing the needle when a sudden decrease in resistance to forward motion of the needle is felt. Do not pull back or recoil when entering the medullary space. Unscrew the cap and remove the stylet. It may be possible to aspirate bone marrow at this point with a 20 or 30 mL syringe.

 

6. Stabilize the IO.

 

7. If the patient is awake and alert, prime all tubing with lidocaine instead of saline and administer 1 mL 2% lidocaine over 60 seconds, and then allow 30-60 seconds to affect the visceral nerves. Follow with a brisk 10 mL irrigation of saline. A second dose of 0.5 mL 2% lidocaine may be repeated in the same manner

 

8. Check for any signs of increased resistance to injection, increased circumference of the soft tissues of the calf, or increased firmness of the tissue.

 

1. The needle is in the bone marrow when:

 

1. there is a lack of resistance

 

2. the needle passes through the cortex

 

3. the needle stands upright without resistance

 

4. there is no infiltration

 

5. blood and marrow are aspirated (less common)

 

6. fluid flows freely through the needle without evidence of subcutaneous infiltration

 

9. Attach the IV tubing and begin the infusion. A pressure infusion bag or in-line 60 mL syringe may be required to infuse the solution.

 

10. If unsuccessful, remove the needle and move to the other leg.

 

11. Secure tubing and use commercial stabilizer if available or secure with tape.

 

Complications

 

Abscess from prolonged insertion
Leakage around the needle with compartment syndrome
Tibia fractures
Osteomyelitis from prolonged insertion
Potential injury to the bone marrow cavity
Skin necrosis

Jump-START is a modification of the START triage guidelines for pediatric patients and takes into account the normal variation in respiratory rate on the basis of age, and the fact that primary respiratory failure can be corrected easily.

 

An apneic child is more likely to have a primary respiratory problem than an adult. Perfusion may be maintained for a short time and the child may be salvageable.

 

A respiratory rate of 30 may either over-triage or under-triage a child, depending on age.

 

Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment.

 

Obeying commands may not be an appropriate gauge of mental status for younger children.

 

Criteria (Ages 1 - 8)	Tag
Move the walking wounded	Minor
Apneic or irregular respirations: Open airway
Resume breathing?	Immediate
Still apneic and no peripheral pulse?	Dead / Dying
Still apneic but has a peripheral pulse
Mouth-toMask for 15 seconds (4-5 breaths)
Resume breathing?	Immediate
Still apneic?	Dead / Dying
Respirations <15 or >45	Immediate
Pulse: No peripheral pulse (least injured extremity)	Immediate
Mental status: Unresponsive or responsive to pain only	Immediate
Otherwise	Delayed
Age <1:
If all Jump-START “delayed” criteria are satisfied and there are no significant external injuries, the child may be classified as “ambulatory” and tagged.	Minor

Developed by Lou Romig MD, FAAP, FACEP at Miami Children’s Hospital

Presence of green amniotic fluid or green/black particulate material on face or in upper airway.

 

BLS

 

1. Request ALS if not already en route and initiate transport. Contact receiving facility for further orders if ALS is not on scene.

 

2. Wipe away any collection of meconium in the upper airway with gauze-wrapped finger.

 

ALS

 

1. See Newborn Resuscitation Protocol.

 

2. Perform tracheal suctioning with meconium aspirator for newborns born through meconium only if (1) the newborn is nonvigorous (presenting with apnea or ineffective breathing effort) AND (2) there are signs of airway obstruction during positive pressure ventilation

BLS

 

1. Begin Initial Medical Care.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. If patient is symptomatic, call for ALS

 

ALS

 

1. Apply cardiac monitor and obtain 12-lead EKG

 

2. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. (Avoid LR in Pediatric Patients.)If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

 

3. For pediatric patients with suspected sinus tachycardia or suspected hypovolemia, use 20 mL/kg fluid boluses. For all other cardiac rhythms use 10ml/kg. Avoid LR in pediatric patients.

 

4. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.

 

5. For pediatric patients, refer to Pediatric Emergency weight/length-based tape

 

Urgent: Infants - rate usually > 220/min Children - rate usually > 180/min

 

1. Have patient perform Valsalva maneuver using the REVERT method.

 

  Have patient blow into 10ml syringe to slowly move the plunger (~15 seconds); then quickly position patient supine with legs lifted >45 degrees

 

2. If rhythm has not converted to a sinus rhythm, and in your judgment the rhythm is believed to be SVT, administer:

 

1. Adenosine 0.1 mg/kg (max 6 mg) RIVP, followed with 10 mL fluid flush.

 

2. Second dose of adenosine, 0.2 mg/kg (max 12 mg) RIVP, followed by 10 mL fluid flush.

 

Emergent: Hypotension, acutely altered mentation, signs of shock

 

Perform synchronous cardioversion in an escalating fashion. Start at 0.5-1 Joules/kg then 2 J/kg

If still conscious, consider 0.1mg/kg (max 2.5 mg) IV midazolam or 0.2mg/kg IN (max 2.5mg) before cardioversion. Use capnography if given

Perform the following procedures in a stepwise fashion as indicated. Reassess after each step before proceeding to the next.

 

BLS

 

1. A. If infant is apneic, gasping, or has a HR < 100/min begin Positive Pressure Ventilation (PPV) with a bag-valve-mask (infant preferred) at rate of 40-60 breaths per minute for 30 seconds. (Caution: risk of barotrauma – bag only enough for chest rise and fall.) Positive pressure ventilation and thermoregulation are the most important priorities in newborn resuscitation.
   

 

1. Start oxygen saturation monitoring with pulse oximeter, if available.

 

2. Consider 3-lead EKG monitoring to determine heart rate

 

3. Begin resuscitation with 21% oxygen.

 

2. Reassess after 30 seconds of PPV:

 

1. If HR is < 100/min but > 60/min PPV, ensure good seal and airway position. Continue to perform PPV.

 

2. If HR < 60/min, begining chest compressions with a ratio of 3:1 compressions to breaths (90 compressions and 30 respirations per minute)

 

3. If HR >100/min, transport to closest pediatric facility with continued close monitoring

ALS

 

1. If infant is apneic, gasping, or has a HR < 100 begin Positive Pressure Ventilation (PPV) with a bag-valve-mask (infant preferred) at rate of 40-60 breaths per minute for 30 seconds (Caution: risk of barotrauma – bag only enough for chest rise and fall.) Positive pressure ventilation and thermoregulation are the most important priorities in newborn resuscitation.
   

 

1. Start oxygen saturation and heart rate monitoring with pulse oximeter, if available

 

2. Consider 3-lead monitoring

 

3. If available, begin resuscitation with 21% oxygen.

 

2. Reassess after 30 seconds of PPV:

 

1. If HR is < 100/min but > 60/min, ensure good seal and airway position. Continue to perform PPV.

 

2. If HR < 60/min begin chest compressions with a ratio of 3:1 compressions to breaths (90 compressions and 30 respirations per minute)

 

1. Reassess after additional 30 seconds of PPV and compressions. If HR < 60 BPM, administer epinephrine 0.01mg/kg of 1:10,000 IV/IO and continue compressions and ventilation.

 

2. Reassess after additional 30 seconds. If HR still < 60 bpm, administer 0.9% NS bolus 10ml/kg, slow IV push over 5-10 minutes.

 

3. If HR does not improve despite performance of good PPV, intubate or use supraglottic airway. Use meconium aspirator to suction thick secretions only if there is evidence of meconium airway obstruction.

 

4. If continued HR <100/min then intubate or place a Supraglottic Airway

 

5. If HR >100/min, transport to closest pediatric facility with continued close monitoring. Newborns are very prone to hypothermia even in summer months. Use warmed blankets and newborn cap.

Targeted Preductal SpO2 After Birth
1 min	60% - 65%
2 min	65% - 70%
3 min	70% - 75%
4 min	75% - 80%
5 min	80% - 85%
10 min	85% - 95%

BLS

 

1. Begin Initial Medical Care.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.

 

5. If evidence of trauma or hemorrhage present see Initial Trauma Care Protocol

 

6. Consider other causes of shock

 

ALS

 

1. Administer 20 mL/kg IV or IO NaCl solution as rapidly as possible.

 

2. Reassess vital signs and peripheral perfusion; reassess for signs of pulmonary edema.

 

3. If no improvement in vital signs, peripheral perfusion, and no indication of pulmonary edema is present, repeat NaCl bolus of 20 mL/kg

 

4. In cases of hypotension involving infants, perform glucose analysis. If blood glucose suggest hypoglycemia administer 4 mL/kg D₂₅
   If hypoglycemic, see hypoglycemia in ALOC protocol.

BLS

 

1. Determine complete airway obstruction.

 

2. Deliver cycles of alternating chest thrusts and back slaps until the obstruction is relieved or the patient becomes unconscious.

 

3. Do not perform blind finger sweeps.

 

4. If patient becomes unconscious, see Obstructed Airway - Unconscious.

BLS

 

1. Determine complete airway obstruction.

 

2. Deliver abdominal thrusts until the obstruction is relieved or the patient becomes unconscious (Chest thrusts can be substituted in obese or pregnant patients.)

 

3. If patient becomes unconscious, see Obstructed Airway - Unconscious.

BLS

 

1. Begin Initial Medical Care and call for ALS.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. Investigate for possible causes (medical history, medications, medic alert tag, recent trauma).

 

5. Perform Blood Glucose analysis if available. If hypoglycemic, administer oral glucose if patient can tolerate oral medication
   

 

6. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate BVM ventilation first, then administer intranasal naloxone. Wait 2 minutes before providing another dose of naloxone – ensure adequate BVM ventilation is being provided during this time.

 

ALS

 

1. Establish a saline lock or an IV with 0.9% NaCl. Avoid LR in Pediatric Patients.

 

2. Apply cardiac monitor. Obtain a 12-lead electrocardiograph (ECG).

 

3. If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

 

4. Perform blood glucose analysis.

    

   1. If the patient has respiratory depression and a history suggestive of possible opiate overdose, initiate ventilation using BVM and administer 0.1 mg/kg (up to 2mg) Naloxone IVP or 0.1 mg/kg (up to 2mg) intra-nasally.

    

   2. If respiratory depression persists after 2 minutes, contact medical control for recommendations for any further dosing.

 

 

Pediatric Naloxone Dosages

PEDs - IV / IO /IN

Respiratory Depression

Conc: 1 mg in 1 ml

Dose: 0.1 mg/kg

 

lbs	Kg	Dose	Volume		lbs	Kg	Dose	Volume
	3	0.3 mg	0.3 ml			20	2 mg	2 ml
	4	0.4 mg	0.4 ml			22	2 mg	2 ml
	5	0.5 mg	0.5 ml			24	2 mg	2 ml
	6	0.6 mg	0.6 ml			26	2 mg	2 ml
	7	0.7 mg	0.7 ml			28	2 mg	2 ml
	8	0.8 mg	0.8 ml			30	2 mg	2 ml
	9	0.9 mg	0.9 ml			32	2 mg	2 ml
	10	1 mg	1 ml			34	2 mg	2 ml
	11	1.1 mg	1.1 ml			36	2 mg	2 ml
	12	1.2 mg	1.2 ml		84	38	2 mg	2 ml
	13	1.3 mg	1.3 ml		88	40	2 mg	2 ml
	14	1.4 mg	1.4 ml		97	44	2 mg	2 ml
	15	1.5 mg	1.5 ml		106	48	2 mg	2 ml
	16	1.6 mg	1.6 ml		114	52	2 mg	2 ml
	17	1.7 mg	1.7 ml		123	56	2 mg	2 ml
	18	1.8 mg	1.8 ml		132	60	2 mg	2 ml
	19	1.9 mg	1.9 ml		Use adult dosing if > 60 kg

 

Indianapolis EMS Open ResourcesConistent with 2020 Indianapolis Metro Area EMS Protocols

V1.08

Behavior	Scoring
	0	1	2	3
Facial	Neutral/smiling	Frowning/grimacing	Clenched teeth	Full cry expression
Body Movement	Calm, relaxed	Restless/fidgeting	Moderate agitation or moderate mobility	Thrashing, flailing, incessant agitation or strong voluntary immobility
Sleep	Sleeping quietly with easy respirations	Restless while asleep	Sleeps intermittently (sleep/awake)	Sleeping for prolonged periods of time interrupted by jerky movements or unable to sleep
Verbal/Vocal	No cry	Whimpering, complaining	Pain crying	Screaming, high pitched cry
Consolability	Neutral	Easy to console	Not easy to console	Inconsolable
Response to Movement/Touch	Moves easily	Winces when touched/moved	Cries out when moved/touched	High-pitched cry or scream when touched or moved

0 No hurt
2 Hurts little bit
4 Hurts little more
6 Hurts even more
8 Hurts whole lot
10 Hurts worst

Pit crew CPR is a high performance model of CPR that maximizes compressions and minimizes interruptions by pre-assigning provider roles based on order of arrival to the patient. Below is a description of the positions that are to be assumed by those arriving on scene to a cardiac arrest.

 

NOTE: The positions for Pediatric Pit Crew CPR are slightly different to emphasize the importance of Oxygenation and Ventilation

1. Pit Crew CPR applies to all cardiac arrest patients (VT, VF, PEA and asystole)

 

2. Positions:

 

1. Position #1: (Patient’s right hand side)

 

1. Check pulses and initiate first 2 minutes of compressions
2. Alternate compressions with Position #4 on 2 minute interval
3. Compressions should be continuous until BVM is set up then switch to ratio of 15 compressions:2 breaths

 

2. Position #2: (Patient’s head)

 

1. Initiate BVM with 100% Oxygen
2. Focus on achieving and maintaining an excellent seal with 2 handed technique
3. Apply waveform capnography to bag-valve-mask if available

 

3. Position #3: (Patient’s head right/left)

 

1. Assist Position #2 with BVM and airway management
2. Maintain quality CPR with 15:2 ratio until an advanced airway is placed.
3. Alternate with Position #2 holding the mask in case of fatigue

 

4. Position #4: (Patient’s left hand side)

 

1. Attach AED and follow prompts
2. Alternate compressions with Position #1 on 2 minute intervals

 

5. Position #5: First arriving EMT-P after Positions 1-4 are filled.

 

1. Obtain IV/IO access and administer medications as per current Indianapolis Metropolitan Area EMS Protocols. The administration of epinephrine should ideally be given within 5 minutes of paramedic arrival.
2. Directs PALS interventions based on rhythm, EtCO₂ and pulse
3. Temporarily slide to position #3 if advanced airway required

 

6. Position #6: “Quality Assurance”

 

1. Utilizes checklist (see appendix) to verify positions are appropriately filled and performing required interventions
2. Records rhythm and if shock delivered every 2 minutes
3. Records time of administration of PALS medications
4. IF ROSC OBTAINED – Utilizes Checklist to verify all tasks have been completed.

 

7. Position #7: “Liaison” (if available)

 

1. Liaisons with family, bystanders and maintains scene safety.

1. Applies to pediatric patients resuscitated from cardio-respiratory arrest who have a perfusing rhythm and pulse, and who remain unresponsive.

 

2. Continue to support respirations with BVM, attempting to time support with the patients own respirations

 

3. ETCO₂ should be used in line with bag during BVM. If the patient is breathing and BVM is not necessary then nasal cannula ETCO₂ should be placed on the patient.

 

4. Maintain normal ventilation and oxygenation. Respiratory rate of 1 breath every 2 to 3 seconds (20-30 breaths per minute) is adequate for pediatric patients in cardiac arrest when an advanced airway is in place or if the patient is only in respiratory arrest. Target a pulse oximetry value of 94 to 99%.

 

5. Stabilize dysrhythmias:

 

1. Stable tachycardia or bradycardia – treat per protocols

 

2. If initial arrest rhythm was v-fib or v-tach, give Amiodarone 5 mg/kg (max 300 mg) IV/IO over 10 minutes if not already given during resuscitation. If significant ventricular ectopy persists, repeat amiodarone per protocol

 

6. Support blood pressure

 

1. Administer 20 mL/kg boluses of NS to maintain adequate blood pressure for age (70 + 2xPatient Age) if post arrest rhythm is sinus tachycardia, otherwise for other cardiac rhythms use 10ml/kg NS


2. b. If the patient’s SBP is less than lower limit based on the above equation after first bolus of fluid, call medical control for further instructions

 

7. Obtain a 12-lead EKG.

 

8. Check glucose and treat per protocol

 

9. Seizure activity – monitor for seizure activity and treat per protocol.

 

10. Monitor for fever.

1. Administer high flow oxygen. (See Oxygen Administration)

 

2. Apply end-tidal capnography

 

3. Protect patient from injury while patient is seizing. DO NOT RESTRAIN PATIENT. DO NOT FORCE A BITE STICK INTO THE PATIENT'S MOUTH. Determine the duration of the seizure. Observe the type of seizure activity and what part(s) of the body it affects.

 

Not in Status Seizures

 

1. Initiate transport.

 

1. Adult patients who are no longer post-ictal may request not to be transported. You should consult with the hospital for authorization not to transport. (See Non-Transported Patient Protocol)

 

Status Seizures

 

Criteria: Continuous seizure activity for longer than 3 minutes or two or more consecutive seizures without regaining consciousness.

 

Focal seizure activity meeting the above criteria should also be considered status epilepticus

 

BLS

 

1. Assist ventilations and apply end-tidal capnography if available. (See Airway Management Protocol)

 

2. Contact receiving facility for further orders if ALS is not on scene. Request advanced life support.

 

3. Perform Blood Glucose analysis if available. If hypoglycemic, follow hypoglycemia BLS protocol in “Altered Level of Consciousness”.

 

ALS

 

1. Apply the cardiac monitor and pulse oximeter

 

2. Administer midazolam using IM/IN route FIRST:

 

1. If patient ≥ 50 kg, administer 10 mg IM/IN
2. If patient < 50 kg give 0.2mg/kg of midazolam (up to a maximum of 5mg) IM/IN If IN, divide the dose so that each nares receives half

 

3. Perform blood glucose analysis. If blood glucose <60 mg/dL (Newborns <40 mg/dL), refer to hypoglycemia protocol in “Altered Level of Consciousness”.

 

4. If seizure continues for 5 minutes after initial administration of midazolam and the total dose has not yet exceeded 10 mg, then administer midazolam IM, IN, IO or IV

 

1. 0.2mg/kg of midazolam (up to a maximum of 5 mg) IM/IN. If IN, divide the dose so that each nares receives half

 

2. 0.1mg/kg of midazolam (up to a maximum of 2.5 mg) IV/IO

 

5. The EMS Administered maximum cumulative dose should not exceed 15mg total via all routes. Contact the receiving facility for further instructions or additional dosing if needed.

 

Note: Patient must be placed on nasal waveform capnography.

 

Pediatric Status Epilepticus

 

BLS

 

1. Assess for and manage trauma or burns per the appropriate protocol.

 

2. Carbon monoxide and cyanide toxicity should be considered for any patient who experiences smoke inhalation in an enclosed space. See Carbon Monoxide Poisoning Protocol.

 

3. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient. (Pulse oximetry monitors may give false readings in patients exposed to carbon monoxide.)

 

1. Provide high flow O₂

 

2. Request ALS if not already en route

ALS

 

No evidence of significant cyanide toxicity

 

1. Provide high flow O₂ by NRB mask

Soot in airway and 1) altered level of consciousness or 2) hypotension

 

1. Ensure an airway and provide high flow O₂

 

2. For wheezing or stridor, treat with 2.5-5 mg nebulized albuterol as needed.

 

3. Establish an IV

 

4. Draw blood samples

 

5. If available, mix one or both Cyanokit^® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer 70 mg/Kg over 15 minutes.

 

6. If hypotensive, consider fluid challenge(s)

 

7. Transport emergently to closest appropriate hospital

BLS

 

1. Assess for and manage trauma or burns per the appropriate protocol.

 

2. Carbon monoxide and cyanide toxicity should be considered for any patient who experiences smoke inhalation in an enclosed space. See Carbon Monoxide Poisoning Protocol.

 

3. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient. (Pulse oximetry monitors may give false readings in patients exposed to carbon monoxide.)

 

1. Establish airway with OP, NP or non-visualized airway

 

2. Provide high flow O₂ by NRB mask or BVM

 

3. Request ALS if not already en route

 

4. If BLS can transport the patient before ALS can arrive at the scene, do so.

ALS

 

1. Ensure an airway and provide high flow O₂

 

2. For wheezing or stridor, treat with 2.5-5 mg nebulized albuterol as needed.

 

3. Establish an IV; if patient is in cardiac arrest, establish 2 IVs

 

4. Draw blood samples

 

5. If available, mix one or both Cyanokit^® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer 70 mg/Kg over 15 minutes.

 

6. If hypotensive, consider fluid challenge(s)

 

7. Transport emergently to closest appropriate hospital

 

If a patient is in significant respiratory distress, is not breathing or is in cardiac arrest with a tracheostomy, replacement of the tracheostomy tube may be lifesaving. BLS providers should immediately direct trained caregivers to replace trach tube. ALS providers should locate emergency replacement trach tubes that are usually kept near the patient and attempt tube replacement.

 

BLS

 

1. Existing Tracheostomy Care

 

Suctioning

 

1. Utilize appropriate PPE.

 

2. Suction tracheostomy as needed using appropriate sized soft suction catheter.

 

1. Sterile technique is preferred when suctioning. Clean technique may also be utilized if sterile technique cannot be performed

 

2. Pre-oxygenate if at all possible.

 

3. Suction no more than 4-6” or until resistance is felt. For pediatric patients, refer to safe suction card for appropriate suction depth. If a “safe suction card” is not available suction the tracheostomy approximately the estimated length of the tube. Providers may measure the suction catheter on a spare tracheostomy tube or obturator. If an obturator is used to measure length add approximately 1-1/2 cm

 

4. Apply suction only after insertion and upon withdrawing the catheter.

 

5. Suction for no more than 10 seconds at a time.


 

Ventilation

 

1. Most adult tracheostomy tubes require an inner cannula to adapt to a standard BVM. Pediatric tracheostomy tubes naturally attach to a standard BVM. The use of omni-flex/accordion tubing can make attaching easier and give better flexibility

 

2. Utilize capnography when ventilating a patient using an existing tracheostomy.

 

Displaced Tracheostomy Tube

 

1. In the event of tracheostomy tube dislodgement ALS intervention is preferred.

    

2. BLS providers may place a gloved finger or palm over the stoma area and provide BVM ventilations via nose and mouth until ALS arrives or if the patient is breathing adequately provide supportive care.

 

1. If ventilation via the nose and mouth does not work use a small BVM mask and ventilate over the stoma.

 

2. In some cases it may be necessary to occlude the nose and mouth to obtain chest rise.


 

ALS

 

1. 1. If the patient is breathing inadequately determine if a spare tracheostomy tube is available on the scene - (if no spare tracheostomy present go to Step 4)
   

 

2. Insert the new tracheostomy tube using the same size of the existing trach tube into the existing stoma carefully and secure into place. If tube does not fit, skip to step 3
   

 

1. For adults, a soft suction catheter may be inserted thru the new tracheostomy tube and used as a guide (see photo)

 

2. If patient is still in distress, attempt suctioning to appropriate depth

 

3. If patient does not respond to suctioning after an appropriate amount of time or suction catheter does not reach correct depth go to Step 3

 

4. Confirm the placement utilizing waveform capnography

 



 

3. Same sized Trach Tube does not fit: Utilize the smaller/emergency trach tube

 

1. Insert the new tracheostomy tube using the existing stoma carefully and secure into place (if smaller size tracheostomy tube does not go in, skip to Step 4

 

2. If patient is still in distress, attempt suctioning to appropriate depth

 

3. c. If patient does not respond to suctioning after an appropriate amount of time or suction catheter does not reach correct depth go to Step 4

 

4. If the same size and smaller size tracheostomy tube does not insert into the stoma, does not allow appropriate suction depth to be achieved or relieve distress with good suctioning, or the tracheostomy tubes are not available, use an ET tube. For most adults, first attempt using a 6.0 ET tube. For pediatric patients, use an ET tube the same size diameter as the patient’s tracheostomy tube.

 

1. Advance the ET tube so that the balloon advances into the stoma and inflate the balloon, DO NOT force the ET tube

 

2. Utilize waveform capnography to confirm placement

 

3. Secure the ET tube in place and monitor for leaks

 

5. If these procedures fail consider intubation or ventilation via BVM covering the stoma

 

Ventilator Patients

 

1. Many tracheostomy patients will be on portable ventilator systems.

 

2. If the patient is NOT in cardiorespiratory arrest and the ventilator is determined to be functioning appropriately it may be in the best interest of the patient to be transported on their own ventilator.

 

1. Family members typically are well trained in the operation of portable ventilators and should be transported with the patient to operate the ventilator.

 

2. If a family member is not available to operate the ventilator and the EMS provider is not familiar with the ventilator the patient should be transported using BVM ventilation via their existing tracheostomy.

 

3. If there is a question regarding the appropriate functioning of the ventilator then patient should be removed from the ventilator and ventilated using BVM attached to the existing tracheostomy.

 

3. If a patient is removed from a portable ventilator the portable ventilator should be transported with the patient if at all possible.

 

4. Settings for the portable ventilator should be noted and relayed to the receiving hospital.

 

5. In-line capnography should be utilized if available and documented.

BLS

 

1. Begin Initial Medical Care.

 

2. Follow Airway Management protocol.

 

3. Follow Oxygen Administration protocol.

 

4. If patient is symptomatic, call for ALS

 

ALS

 

1. Apply cardiac monitor and obtain 12-lead EKG

 

2. If patient is symptomatic, establish a saline lock or IV with 0.9% NaCl. (Avoid LR in Pediatric Patients.)If an IV cannot be established and an urgent need for vascular access exists, establish IO access.

 

3. For pediatric patients with suspected sinus tachycardia or suspected hypovolemia, use 20 mL/kg fluid boluses. For all other cardiac rhythms use 10ml/kg. Avoid LR in pediatric patients.

 

4. If patient remains symptomatic, perform the following in a step-wise fashion. Reassess after each step and proceed to the next step if there is no improvement.

 

5. For pediatric patients, refer to Pediatric Emergency weight/length-based tape

 

Asymptomatic

 

1. Establish IV access and contact medical control for further instructions

 

Mild Symptoms Chest pain or dyspnea

 

1. Contact medical control for further instructions

 

Serious Symptoms Hypotension, acutely altered mentation, signs of shock

 

1. Perform synchronous cardioversion beginning with 0.5-1 j/kg; if not effective, increase to 2 j/kg
   If still conscious, consider 0.1mg/kg (max 2.5 mg) IV midazolam or 0.2mg/kg IN (max 2.5mg) before cardioversion. Use capnography if given.

 

2. Contact medical control for further instructions

 

Unconscious without Pulses

 

Treat as Cardiac Arrest, VF/VT