ICEMA Policy & Protocol Exam — Comprehensive Paramedic Exam

Exam Blueprint

ICEMA Policy & Protocol Manual (Effective 11/01/25, Updated 01/01/26) — Comprehensive Paramedic Exam

Standard Orders (11000)

Medication standard orders (all drugs, doses, routes, indications), procedure standard orders (intubation, IO, CPAP, cardioversion, needle thoracostomy, pacing)

General Patient Care (12000)

Patient care guidelines, GCS, BLS/LALS/ALS responsibilities, spinal motion restriction criteria (NSAID)

Environmental Emergencies (13000)

Poisonings, heat, cold, nerve agents/ChemPack, CO/cyanide/smoke inhalation, drowning

Treatment Protocols (14000)

Respiratory, cardiac arrest, bradycardia, tachycardia, ALOC/seizures, burns, stroke, trauma, pain, behavioral, peds protocols, OB, AMI, sepsis, VAD, shock

Destination & Transport (9000)

Trauma triage criteria, STEMI destination, stroke center criteria, continuation of care, APOD, MCI

General & Admin Policies (3000–6000)

Refusal of care, patient restraints, determination of death, DNR/POLST, on-scene physician, controlled substances, organ donor, MICN/Base Hospital roles

Specialty Programs (4000)

STEMI system, stroke system, trauma system, POCUS, opioid withdrawal, leave-behind naloxone, fireline EMT-P

Exam Rules & Focus Areas

160 questions — mix of recall, scenario-based, and compare (adult vs. peds, BLS vs. LALS vs. ALS)
Every answer is cited to a specific ICEMA Reference number from the 11/01/25 manual (01/01/26 drug update)
Pediatric = less than 15 years of age (or less than the length of a pediatric measuring tape)
Adult intubation criteria: taller than the maximum length of a pediatric measuring tape
Base Hospital Order (BHO) = real-time order from MICN or base hospital physician at an ICEMA-authorized base hospital
Supraglottic airway (i-gel) is a backup airway — only after failed BLS airway AND failed ETI
Max 3 intubation attempts and 3 supraglottic attempts before reverting to BLS airway
Capnography is REQUIRED for all cardiac arrest patients and all patients given respiratory-depressant medications
Termination of field resuscitation criteria: ≥20 min HP CPR + ETCO₂ <15 mmHg + no shocks OR arrest not witnessed by EMS OR persistent asystole/agonal/PEA <40 bpm
NSAID mnemonic for spinal motion restriction: Neuro deficit, Spinal tenderness, Altered mental status, Intoxication, Distracting injury
ICEMA covers San Bernardino County, Inyo County, and Mono County — some protocols differ by county

Total: 160 Questions — Treat This as a Real County Protocol Exam

Rapid Review

Medication Doses — Adult ALS

Epinephrine

Cardiac arrest (Asystole/PEA/VF/VT): Epi 1:10,000 — 1 mg IV/IO q5 min
Severe bronchospasm/anaphylaxis (SQ/IM): Epi 1:1,000 — 0.3 mg IM; repeat ×1 after 15 min
Persistent severe anaphylaxis (IV): Epi 1:10,000 — 0.1 mg slow IVP/IO q5 min; max 0.5 mg
Push dose epi (post-ROSC / profound shock): Mix 1 ml Epi 1:10,000 + 9 ml NS → 0.01 mg/ml; give 1 ml q1–5 min titrated to SBP >90
BLS/LALS (auto-injector): 0.3 mg auto-injector IM; repeat ×1 after 15 min (anaphylaxis + severe asthma only)

Fentanyl — Adult

Chest pain (ischemic), trauma, burns, abdominal pain, sickle cell: 50 mcg slow IV/IO q5 min; max 200 mcg IV/IO
IM/IN route: 100 mcg initial; 50 mcg q10 min; max 200 mcg
Cardioversion/pacing pain: same dosing, contact BH for more
When NTG is contraindicated in ACS → use Fentanyl

Midazolam — Adult

Seizures: 2.5 mg IV/IO q5 min; 5 mg IM/IN q10 min; max 3 doses any combo
Behavioral emergencies (potentially fatal/dangerous agitation): 2.5 mg IV/IO; 5 mg IM/IN; max 3 doses; contact BH for more
Cardioversion/pacing (sedation): 2.5 mg IV/IO; 5 mg IM/IN; max 3 doses
CPAP anxiety: 1 mg IV/IO/IM/IN × 1; contact BH for more
Post-intubation agitation (BHO only): 2.5 mg IV/IO or 5 mg IM/IN; repeat requires BH contact

Naloxone (Narcan) — Adult

BLS — respiratory depression from opioids: 0.5 mg IM/IN q2–3 min; max 10 mg total
LALS/ALS: 0.5 mg IV/IO/IM/IN q2–3 min; max 10 mg total
Suspected fentanyl OD: Consider 4 mg IN loading dose; may repeat ×1; then 0.5 mg q2–3 min if no improvement

Lidocaine — Adult

VF/pulseless VT (after 2 cycles CPR): 1.5 mg/kg IV/IO; may repeat 0.75 mg/kg ×1 in 5–10 min; max 3 mg/kg
V-Tach with pulses / wide complex tach: 1.5 mg/kg slow IV/IO; may repeat 0.75 mg/kg; max 3 mg/kg
IO infusion pain: Lido 2% — 0.5 mg/kg slow IO over 2 min; max 40 mg

Adenosine, NTG, Aspirin, Atropine

Adenosine SVT: 6 mg rapid IVP + 20 cc NS flush; 12 mg if no conversion (×2)
NTG: 0.4 mg SL/transmucosal q3 min; Nitro paste 1 inch × 1; CONTRAINDICATED in shock, RVI, phosphodiesterase inhibitors (48 hr)
Aspirin ACS: 325 mg chewed (1 adult) or 4 × 81 mg chewable
Atropine bradycardia: 1 mg IV/IO q5 min; max 3 mg or 0.04 mg/kg
Atropine organophosphate: 2 mg IV/IO q5 min while symptomatic

Dextrose, Glucagon, Ondansetron, Magnesium

D10W (adult hypoglycemia, BG <80): 25 gm (250 ml D10W) IV/IO bolus
Glucagon (adult, no IV): 1 mg IM/SC/IN × 1
Ondansetron (N/V, ≥9 yo): 4 mg IV/IO/ODT; repeat ×2 at 10 min intervals; max 12 mg
Magnesium (eclampsia seizure): 4 gm IV/IO slow push over 3–4 min; then 10 mg/min drip
Magnesium (polymorphic VT with long QT): 2 gm IV/IO bolus over 5 min
Magnesium (severe asthma, BHO only): 2 gm IV over 20 min; do not repeat

TXA, Ketamine, Acetaminophen, Sodium Bicarb, Calcium Chloride

TXA (hemorrhagic shock, ≥15 yo): 2 gm slow IV/IO over 1 min OR 1 gm IM (2×5 ml injections)
Ketamine (moderate–severe pain, trauma/burns/abdominal/cancer/sickle cell): 0.3 mg/kg (max 30 mg) in 50–100 ml NS IV over 5 min; repeat ×1 after 15 min if pain ≥5; NO IVP/IO/IM/IN
Acetaminophen (mild–moderate pain): 1 gm IV/IO infusion over 15 min; single dose only
Sodium Bicarb (cardiac arrest w/ suspected metabolic acidosis/hyperkalemia/TCA, BHO): 50 mEq IV/IO; TCA poisoning: 1 mEq/kg IV/IO
Calcium Chloride (CCB OD, BHO; hyperkalemia crush BHO; ESRD hyperkalemia BHO): 1 gm (10 ml of 10% solution) IV/IO

Medication Doses — Pediatric ALS (<15 years)

Key Peds Dosing

Epi 1:1,000 IM (bronchospasm/anaphylaxis): 0.01 mg/kg IM; max 0.3 mg; repeat ×1 after 15 min
Epi 1:10,000 cardiac arrest (1 day–8 yr): 0.01 mg/kg IV/IO
Epi 1:10,000 cardiac arrest (9–14 yr): 1.0 mg IV/IO
Fentanyl: 0.5 mcg/kg IV/IO q5 min; max 50 mcg/dose; 1 mcg/kg IM/IN q10 min; max 100 mcg/dose; cumulative max 200 mcg
Midazolam seizure: 0.1 mg/kg IV/IO (max 2.5 mg); 0.2 mg/kg IM/IN (max 5 mg); max 3 doses
Naloxone (1 day–8 yr): 0.1 mg/kg IM/IN; max 0.5 mg/dose; (9–14 yr) 0.5 mg; max 10 mg total
D10W hypoglycemia (BG <60; neonate BG <35): 0.5 gm/kg (5 ml/kg) IV/IO
Glucagon hypoglycemia (no IV): 0.03 mg/kg IM/IN; repeat ×1 after 20 min; max cumulative 1 mg
Diphenhydramine allergic rx: 1 mg/kg IV/IO (max 25 mg) or 2 mg/kg IM (max 50 mg)
Lidocaine cardiac arrest (1 day–8 yr): 1.0 mg/kg IV/IO; repeat 0.5 mg/kg after 5 min; max 3 mg/kg
Atropine peds (organophosphate): 0.05 mg/kg IV/IO; max adult dose 2 mg; repeat 0.1 mg/kg q5 min
Albuterol neb: 2.5 mg; repeat ×2 (same as adult)
Acetaminophen (2–14 yr): 15 mg/kg; max 1 gm IV/IO over 15 min × 1

Key Protocol Thresholds & Criteria

Stroke: mLAPSS + LAMS

mLAPSS positive: ALL of criteria 1–5 (age >17, no prior seizure, new sx <24h, ambulatory at baseline, BG 60–400) AND unilateral weakness (facial droop/grip/arm weakness)
LAMS ≥4 = suspect Large Vessel Occlusion (LVO) → transport to comprehensive stroke center
Last seen normal + transport <24 hr (or wake-up stroke) → Stroke Receiving Center
Last seen normal + transport >24 hr → closest receiving hospital
mLAPSS negative but stroke still suspected → contact base hospital for destination

Cardiac Arrest — Termination of Efforts

ETCO₂ <15 mmHg after 20 min of HP CPR with ALS, AND one of:
No shocks delivered, OR
Arrest NOT witnessed by EMS, OR
Persistent asystole, agonal rhythm, or PEA <40 bpm
If ETCO₂ trending up or PEA ≥40 bpm → consider transport to STEMI Center
No BH contact required to terminate if criteria met

STEMI & AMI Pearls

ST elevation in ≥2 contiguous leads → early STEMI notification to STEMI Receiving Center
Inferior wall infarct → get right-sided 12-lead (V4R)
RVI suspected + hypotension → NS 300 ml bolus; NTG CONTRAINDICATED
Post-ROSC → transport to closest STEMI Receiving Center regardless of 12-lead findings
ETCO₂ target post-ROSC: 35–45 mmHg

Trauma

Spinal motion restriction: NSAID (Neuro deficit, Spinal tenderness, Altered MS, Intoxication, Distracting injury)
Penetrating trauma WITHOUT NSAID indicators → NO spinal motion restriction
Long backboard is an EXTRICATION TOOL only — remove as soon as safe and practical
Needle thoracostomy preferred site: midaxillary line, 5th ICS
Indications: SBP <90 + shock signs + JVD OR tracheal deviation OR absent breath sounds OR increased ventilation resistance
Consider bilateral if no improvement OR traumatic cardiac arrest
TXA inclusion criteria: hemorrhagic shock signs in trauma patients ≥15 years
Crush injury with hyperkalemia: Albuterol + Calcium Chloride + Sodium Bicarb (all BHO)

Oxygen Targets

Standard: Titrate to SPO₂ ≥94%; do NOT give supplemental O₂ if SPO₂ >95%
COPD: Titrate to SPO₂ ≥90%; do NOT give supplemental O₂ if SPO₂ >91%
ALOC suspected CO poisoning: 100% O₂ via NRB mask
Post-ROSC ventilation: ETCO₂ 35–45 mmHg

CPAP Parameters

Start at lowest setting, increase slowly to max 15 cm H₂O
CPAP anxiety: Midazolam 1 mg IV/IO/IM/IN × 1 (if SBP >90)
Indications: COPD, asthma, CHF/pulmonary edema, respiratory distress

Airway Hierarchy

1. BLS airway (BVM) — preferred during active CPR
2. Oral ETI (adult only = taller than peds measuring tape) — 3 attempts max
3. Supraglottic (i-gel) — backup ONLY, after failed BLS + failed ETI — 3 attempts max
Failed all 3 → needle cricothyrotomy (absolute CI: distal tracheal transection)
ETI: verify with auscultation + visualization + continuous capnography

IO Access Rules

≤8 years: LALS and ALS; proximal tibia only
≥9 years (ALS only): Proximal tibia, distal tibia, humeral head; anterior distal femur = BHO only
Lido 2% for IO infusion pain: 0.5 mg/kg slow IO over 2 min; max 40 mg
External jugular: NOT for patients ≤8 years old

Determination of Death — Do NOT Resuscitate Field Criteria

Obvious death: decapitation, rigor mortis, dependent lividity, decomposition, or injuries incompatible with life
Valid DNR/POLST signed by licensed physician or ARNP
POLST form: must have "DNR/Allow Natural Death" checked with physician signature
Do NOT start resuscitation if valid DNR/POLST present AND patient in cardiac arrest

Behavioral Emergencies — Agitation Criteria

Criteria for "potentially fatal and dangerous agitation": one of — hyperthermia, extreme diaphoresis, superhuman strength, unresponsive to verbal redirection, family states marked behavior change
Midazolam: 2.5 mg IV/IO OR 5 mg IM/IN; max 3 doses
Capnography required after Midazolam for behavioral emergencies
Contact BH after 3 doses for additional orders

Sepsis — Adult (14280)

Suspected sepsis: altered mental status + fever or hypothermia + tachycardia + tachypnea + suspected infection
ALS: Obtain 12-lead, establish IV/IO, NS 300 ml bolus (may repeat); contact BH early
Identify source if possible; note last known well time

Drug Reference Quick Table

Drug	Adult Dose	Peds Dose	Route	Key Notes
Epinephrine 1:1,000	0.3 mg IM ×2	0.01 mg/kg IM; max 0.3 mg ×2	IM / auto-inj	Anaphylaxis, severe asthma
Epinephrine 1:10,000	1 mg IV/IO q5 min (arrest)	0.01 mg/kg IV/IO (1–8 yr); 1 mg (9–14 yr)	IV/IO	Arrest, persistent anaphylaxis
Push Dose Epi 0.01 mg/ml	1 ml q1–5 min	0.1 ml/kg q1–5 min	IV/IO	Mix: 1 ml Epi 1:10,000 + 9 ml NS
Fentanyl	50 mcg IV/IO q5 min; max 200	0.5 mcg/kg IV/IO; max 50 mcg/dose	IV/IO/IM/IN	Pain, cardiac chest pain, pacing/cardioversion
Midazolam	2.5 mg IV/IO; 5 mg IM/IN	0.1 mg/kg IV/IO (max 2.5); 0.2 mg/kg IM/IN (max 5)	IV/IO/IM/IN	Seizures, agitation, sedation for procedures
Naloxone	0.5 mg q2–3 min; max 10 mg; fentanyl OD: 4 mg IN load	<8 yr: 0.1 mg/kg (max 0.5 mg); 9–14 yr: 0.5 mg	IV/IO/IM/IN	Suspected opioid OD with respiratory depression
D10W	25 gm (250 ml) IV/IO bolus (BG <80)	0.5 gm/kg (5 ml/kg) (neonate BG <35; peds BG <60)	IV/IO	LALS + ALS only
Adenosine	6 mg → 12 mg → 12 mg IVP + 20 cc NS flush	N/A (adult protocol applies)	IV only	SVT, wide complex tach
Atropine	1 mg IV/IO q5 min; max 3 mg or 0.04 mg/kg	OPP: 0.05 mg/kg; max 2 mg; repeat 0.1 mg/kg q5 min	IV/IO	Bradycardia, organophosphate poisoning
Lidocaine (cardiac)	1.5 mg/kg; repeat 0.75 mg/kg; max 3 mg/kg	1.0 mg/kg; repeat 0.5 mg/kg after 5 min; max 3 mg/kg	IV/IO	VF/VT (pulseless and with pulses)
NTG	0.4 mg SL q3 min; paste 1 inch ×1	N/A	SL/transmucosal/transdermal	CI: shock, RVI, phosphodiesterase inhibitors (48 hr)
Aspirin	325 mg chewed	N/A	PO	ACS; LALS + ALS
Magnesium Sulfate	Eclampsia: 4 gm IVP over 3–4 min; Polymorphic VT: 2 gm IV over 5 min	Severe asthma (BHO): 50 mg/kg; max 2 gm over 20 min	IV/IO	BHO for asthma; drip 10 mg/min post-eclampsia seizure
TXA	2 gm slow IV/IO over 1 min OR 1 gm IM (2×5 ml)	N/A (≥15 yr)	IV/IO/IM	Hemorrhagic shock; postpartum (BHO)
Ketamine	0.3 mg/kg (max 30 mg) in 50–100 ml NS over 5 min; repeat ×1 after 15 min if pain ≥5	N/A (adult only in ICEMA)	IV drip ONLY	Do NOT give IVP/IO/IM/IN; trauma/burns/abd/cancer/sickle cell
Ondansetron	4 mg; repeat ×2 at 10 min; max 12 mg (≥9 yr)	4–8 yr: max 4 mg total before BH contact	IV/IO/ODT	Nausea/vomiting; prophylactic with narcotics
Diphenhydramine	25 mg IV/IO; 50 mg IM	1 mg/kg IV (max 25 mg); 2 mg/kg IM (max 50 mg)	IV/IO/IM	Allergic reaction
Calcium Chloride	1 gm (10 ml of 10% solution) IV/IO	CCB OD (BHO): 20 mg/kg IV/IO over 5 min	IV/IO	BHO: CCB OD, cardiac arrest hypocalcemia/hyperkalemia, crush injury, ESRD hyperkalemia
Sodium Bicarb	50 mEq IV/IO (cardiac arrest); 1 mEq/kg (TCA poisoning)	Same	IV/IO	BHO for cardiac arrest; TCA poisoning; crush hyperkalemia (no BHO needed)
Buprenorphine-Naloxone	16 mg/4 mg SL; repeat 8 mg/2 mg after 10 min; max 24 mg/6 mg	N/A (≥16 yr)	SL	Opioid withdrawal (COWS ≥8); ALS only
Glucagon	1 mg IM/SC/IN × 1	0.03 mg/kg IM/IN; repeat ×1 after 20 min; max 1 mg total	IM/SC/IN (or IV if BHO)	Hypoglycemia (no IV); beta-blocker poisoning (IV, BHO)
Albuterol	2.5 mg neb ×3; MDI 4 puffs q10 min	Same	Neb/MDI	BLS/LALS (MDI); LALS/ALS (neb); crush hyperkalemia: continuous 7.5 mg neb