LA County Pediatric Protocol
Study Guide & Practice Test

Based on the LA County Department of Health Services 1200-P Series Pediatric Treatment Protocols (Rev. 07-01-20 – 01-01-26) — for LA County EMS Agency field providers

39 Pediatric Treatment Protocols 1202-P – 1244-P Series Broselow / Weight-Based Dosing 57-Question Practice Test

Quick Navigation

1. Cardiac & Resuscitation2. Medical / Endocrine / Shock3. Behavioral & Psychiatric4. Neurologic Emergencies5. OB / Newborn / Infant6. Allergy / Airway / ENT / Eye7. Respiratory & Inhalation8. Environmental & Toxicology9. Trauma10. Quick Reference & Key Numbers11. Practice Test (57 Questions)12. Answer Key & Explanations
Overview

How This Manual Is Organized

This guide condenses the LA County DHS 1200-P series Pediatric Treatment Protocols (TP 1202-P – TP 1244-P) into categorized study cards, numbered exactly as the source protocol steps, followed by each protocol's Special Considerations. Pediatric protocols carry the "-P" suffix and apply to patients who meet the LA County pediatric age/size criteria (generally patients who fit the length-based resuscitation tape, e.g. Broselow Tape, or per local base/agency policy up to a defined age cutoff). Throughout, "MCG" refers to a Medical Control Guideline (e.g., MCG 1302 Airway/Oxygen, MCG 1308 Cardiac Monitoring, MCG 1309 Pediatric Drug Dosing Reference, MCG 1355 Poor Perfusion, MCG 1375 Vascular Access, MCG 1345 Pain Management) — these are referenced constantly across protocols but are procedural guidelines rather than standalone treatment algorithms. "CONTACT BASE" denotes a required Base Hospital physician or MICN contact before proceeding, as opposed to a standing order a paramedic can carry out independently. Most drug doses in this manual are weight-based (mg/kg) and should be cross-referenced against MCG 1309 or a length-based resuscitation tape in the field.

Section 01

Cardiac & Resuscitation

CARDIAC ARREST

Ref. No. 1210-P
Base Hospital Contact Required.
  1. For patients meeting Ref. 814 Section I criteria for determination of death in the field – document
    • DOA – Obvious Death ❶
  2. Resuscitate cardiac arrest patients on scene ❷
  3. Assess airway and initiate bag-mask ventilation; escalate to advanced airway prn (MCG 1302; 1309) ❸❹
    • Supraglottic airway (SGA), e.g., i-gel is the preferred advanced airway ❸
    • Monitor waveform capnography throughout resuscitation
  4. Assist respirations with bag-mask-ventilations (BMV), using high-flow Oxygen 15L/min;
    • squeeze bag just until chest rise and then release - state “squeeze, release, release” to avoid hyperventilation ❹
  5. For suspected foreign body (no chest rise with BMV): ❺
    • Perform direct laryngoscopy and use pediatric Magill forceps to remove visible obstruction(s)
  6. Initiate chest compressions at a rate of 100-120 compressions per minute with a compression to
    • ventilation rate of 15:2 ❻
  7. Initiate cardiac monitoring (MCG 1308)
    • Briefly assess rhythm every 2 minutes, minimizing pauses, or continuously via rhythm display technology ❼❽
  8. Establish vascular access (MCG 1375) ❾
  9. CONTACT BASE concurrent with ongoing management
ASYSTOLE/PEA
  1. Epinephrine (0.1mg/mL) 0.01mg/kg IV/IO, dose per MCG 1309
    • May repeat every 5 min x2, maximum single dose 1mg ❿
    • CONTACT BASE for additional epinephrine doses
  2. Consider and treat potential causes ⓫
  3. Normal Saline 20mL/kg IV/IO per MCG 1309
    • May repeat x2
V-FIB/PULSELESS V-TACH
  1. Defibrillate at 2J/kg, dose per MCG 1309
    • Repeat at 4J/kg at each 2-minute cycle as indicated
    • If persistent shockable rhythm after three shocks, change the pad position when feasible and without pads touching ⓬
  2. Epinephrine (0.1mg/mL) 0.01mg/kg IV/IO, dose per MCG 1309
    • Begin after second defibrillation
    • May repeat every 5 min x2, maximum single dose 1mg ❿
    • CONTACT BASE for additional epinephrine doses
  3. For persistent or recurrent V-Fib/V-Tach without pulses:
    • Amiodarone (50mg/mL) 5 mg/kg IV/IO, dose per MCG 1309
RETURN OF SPONTANEOUS CIRCULATION
  1. Initiate post-resuscitation care on scene to stabilize the patient prior to transport ⓭⓮
  2. For hypotension per MCG 1309:
    • Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • Repeat x1 for persistent poor perfusion
    • If no response after Normal Saline 20mL/kg, or worsening hypotension and/or bradycardia:
    • Push-dose Epinephrine – mix 9mL Normal Saline with 1mL Epinephrine (0.1mg/mL) IV formulation in a 10mL syringe; administer Push-dose Epinephrine (0.01mg/mL) per MCG 1309 every 1-5 minutes as needed to maintain normal SBP per MCG 1309 ⓯
  3. Continue ventilation at 20 breaths per minute or every 2-3 seconds
  4. Establish advanced airway prn (MCG 1302; 1309) ⓰
    • For agitation post-advanced airway in patients who require ongoing ventilation support, refer to
    • MCG 1302 for sedation and analgesia; dose per applicable MCG drug reference.
  5. Raise head of stretcher to 30 degrees if blood pressure allows, otherwise maintain supine
  6. Check blood glucose
    • For blood glucose < 60mg/dL
    • Dextrose 10% 5mL/kg IV/IO
    • ≤24kg: Dextrose 10%, 5mL/kg IV/IO per MCG 1309. Administer slow IVP. Recheck glucose prn
    • >24 kg: Dextrose 10%, administer 125mL IV/IO and reassess, continue infusion as needed with maximum dose of 5mL/kg
    • CONTACT BASE for persistent hypoglycemia for repeat dose of Dextrose 10% 5mL/kg IV, maximum total dose 10mL/kg, not to exceed 250mL
  7. For suspected narcotic overdose: ⓱
    • Naloxone (1mg/mL) 0.1mg/kg IM/IN/IO/IV, dose per MCG 1309
  8. Contact Public Health 213-989-7140 for all submersion incidents involving pools or spas after
    • transfer of patient care in the emergency department or upon termination of resuscitation in the field (this requirement is effective 10/1/21). ⓲
Special Considerations
  • EMS Personnel are mandated reporters of child abuse and neglect, and a report should be made when suspected as per Ref. 822. Communicate suspicion for child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkept home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to the Department of Children and Family Services (DCFS).
  • Maintaining perfusion with high-quality CPR throughout resuscitation is essential to ensuring good patient outcome. Chest compressions are the most important aspect of cardiac arrest resuscitation. Maintaining chest compressions should take priority over any medication administration or transport. Transporting the patient in cardiac arrest causes interruptions in CPR and reduces CPR quality. Similar to adults in OHCA, pediatric patients who are resuscitated on scene have higher neurologically intact survival. Transport may be initiated sooner if scene safety concerns.
  • Supraglottic airway (SGA), e.g., i-gel is the preferred advanced airway unless specifically contraindicated. Sizing of the SGA per MCG 1309.
  • Hyperventilation reduces venous return and worsens patient outcomes. Both continuous and interrupted (15:2) compressions/ventilations are acceptable. Regardless of ventilation method used, ventilations should be no more frequent than 10 per minute with a volume just enough to see chest rise and then release the bag to allow for exhalation (“squeeze, release, release”). Once ROSC is achieved ventilation rates can increase to 20 per minute.
  • Children < 3 years of age are at high risk for foreign body aspiration. Foreign body aspiration should be suspected if there is a history of possible aspiration or when there is no chest rise with BMV after repositioning of the airway.
  • EMS personnel should remain on scene up to 20 minutes to establish chest compressions, vascular access and epinephrine administration for nonshockable rhythms or until return of spontaneous circulation (ROSC) is achieved; for shockable rhythms, remain on scene until 3 defibrillations or until ROSC is achieved. The best results occur when resuscitation is initiated and maintained on scene, and post ROSC care is initiated.
  • If you are able to observe the underlying rhythm during compressions via rhythm display technology, do not pause for the rhythm check.
  • ETCO2 should be > 10 with a “box-shaped” waveform during effective CPR. A flat or wavy waveform or ETCO2 < 10 may indicate ineffective compressions or airway obstruction. A sudden increase in ETCO2 is suggestive of ROSC. The waveform can also be used to confirm ventilation rate if an advanced airway or asynchronous ventilation with continuous compressions is used.
  • Peripheral venous access may be difficult to obtain in infants and small children. Consider IO placement as primary vascular access in patients for whom venous access is unlikely to be achieved rapidly. For older children, make two attempts at venous access and, if unsuccessful, place and IO for vascular access.
  • Epinephrine may improve outcomes if given early in nonshockable rhythms and should be given within 5 minutes of the resuscitation. For shockable rhythms, where defibrillation is the preferred initial treatment, epinephrine should be given after the second defibrillation. Epinephrine is most likely to be effective if it is given early and after chest compressions have begun. The likelihood of meaningful survival declines after three (3) doses of epinephrine. Resuscitation should continue focused on quality CPR, defibrillation, and identifying reversible causes. Additional doses of epinephrine should only be administered with Base order if indicated, based on the individual patient.
  • Potential causes that can be treated in the field include hypoxia, hypovolemia, hyperkalemia, hypothermia, toxins, and tension pneumothorax. Hypoxia and Hypovolemia are common causes of PEA arrest in children. Hypoglycemia is a very rare cause of cardiac arrest and should not be assessed until after ROSC.
  • Changing the pad position, called vector change, from anterior-lateral to anterior-posterior or vice versa in patients who do not respond to initial defibrillation attempts, increases the chances of converting to a perfusing rhythm.
  • Re-arrest shortly after ROSC is common. Early indicators of impending re-arrest include falling EtCO2 and progressive bradycardia. Initiate post-resuscitation care prior to transport, if the scene allows, in order to reduce chances of re-arrest en route. Fluid resuscitation, vasopressor support, and avoidance of hyperventilation are recommended to decrease the risk of re-arrest. Transport considerations include suspected cause of arrest and anticipated transport time to a Pediatric Medical Center. Pediatric patients with ROSC should be transported to a Pediatric Medical Center if within 30 minutes.
  • ETCO2 can help guide your ventilation rate; target ETCO2 35-45 mmHg. Just after ROSC, the ETCO2 may be transiently elevated. This will decrease appropriately with ventilation and does not require hyperventilation to normalize. Persistently elevated ETCO2 and/or “sharkfin” waveform may indicate respiratory failure as cause of the cardiac arrest. Falsely low ETCO2 measurements can occur if there is a leak with BMV or shock.
  • Push-dose Epinephrine is appropriate for non-traumatic shock including cardiogenic shock. Additional doses beyond 10mL may need to be prepared for prolonged transports. For patients < 10kg, transfer the diluted Push-dose Epinephrine to a smaller (1mL or 3mL) syringe in order to administer the dose accurately.
  • Consider SGA placement to facilitate effective ventilations during transport. In patients longer than the length-based resuscitation tape or >12 years old, for whom intubation is also in scope of practice, SGAs are the preferred advanced airway unless specifically contraindicated. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality for pediatric patients in whom multiple modalities are authorized.
  • Narcotic overdose should be suspected in cases where there is drug paraphernalia on scene or there is a witness report. Pinpoint pupils may be present, but hypoxia during cardiac arrest more often causes mydriasis (dilated pupils) instead.
  • EMS is assisting the Department of Public Health (DPH) in promptly investigating fatal or nonfatal drownings at public pools or spas in order to ensure safety can be verified before reopening. Contacting the on-call DPH officer will allow timely investigation of these incidents and prevent future incidents.

CARDIAC DYSRHYTHMIA - BRADYCARDIA

Ref. No. 1212-P
Base Hospital Contact: Required for all patients with symptomatic bradycardia
  1. Assess patient’s airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. If foreign body suspected, perform direct laryngoscopy for foreign body removal and treat in
    • conjunction with TP 1234-P, Airway Obstruction
  3. Administer Oxygen prn (MCG 1302)
    • High-flow Oxygen 15L/min for poor perfusion❶
  4. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-lead ECG if dysrhythmia suspected prn
  5. For poor perfusion (MCG 1355):
    • Begin bag-mask-ventilation (BMV) ❶
  6. Establish vascular access prn (MCG 1375)
  7. Administer Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
  8. For persistent poor perfusion: ❷
    • Begin chest compressions if severe ALOC
    • Epinephrine (0.1mg/1mL) 0.01mg/kg slow IV/IO push, dose per MCG 1309
    • Repeat every 3-5 min
    • CONTACT BASE for Physician Consultation concurrent with above treatment
  9. If suspected AV Block or patient unresponsive to epinephrine: ❸
    • Atropine (0.1mg/mL) 0.02 mg/kg IV/IO push, dose per MCG 1309
    • May repeat x1 in 5 min
  10. Consider Transcutaneous Pacing (TCP) for HR ≤ 40 with continued poor perfusion (MCG 1365)
    • For infants and young children place pacing pads anterior and posterior chest; for older children place as per adult patients ❹
    • Recommended initial settings: rate 70 bpm (100 bpm if < 12 months old), initial current 40 mA and slowly increase mAs until capture is achieved
    • CONTACT BASE concurrent with initiation of TCP
    • If TCP will be utilized for the awake patient, consider sedation and analgesia
    • For sedation:
    • Midazolam (5mg/mL) 0.1mg/kg IV/IO or 0.2mg IM/IN, dose per MCG 1309
    • May repeat in 5 min prn x1 with Base order, maximum single dose 5mg
    • For pain management: refer to MCG 1345, Pain Management, dose per MCG 1309
  11. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
  12. For suspected overdose, treat in conjunction with TP 1241-P, Overdose/Poisoning/Ingestion ❺
Special Considerations
  • Management of oxygenation and ventilation is the most important aspect of treatment of bradycardia in children. Squeeze the bag mask device just until chest rise is initiated and then release; state “Squeeze, Release, Release” to prevent hyperventilation. Young athletes, typically adolescents may have normal resting heart rates < 60 bpm, treat only if signs of poor perfusion.
  • For pediatric patients with bradycardia (HR <60 bpm) unresponsive to bag-mask ventilation and continued poor perfusion who remain responsive, support perfusion with fluid resuscitation and epinephrine administration. For patients with persistent poor perfusion and severe ALOC, begin chest compressions, administer epinephrine and assess need for TCP. If you have concerns about initiating these therapies contact Base Physician for further guidance.
  • Potential causes of unresponsiveness to epinephrine in children include increased intracranial pressure, beta blocker/calcium channel overdose, hypothyroidism, infection, congenital heart disease, and sleep apnea where administration of atropine could be of theoretical benefit.
  • There is minimal data on the use of TCP in infants and children in the out-of-hospital setting. Patients unresponsive to BMV and epinephrine may be candidates. Base Physician consultation is recommended in these patients.
  • Consider calcium channel blocker and beta blocker overdose in patients with bradycardia and hypotension. Ask about potential exposures including medications in the home. Hyperglycemia is a common finding with calcium channel blocker overdose.

CARDIAC DYSRHYTHMIA - TACHYCARDIA

Ref. No. 1213-P
Base Hospital Contact: Required for all patients with cardiac dysrhythmias (excludes sinus
tachycardia)
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring (MCG 1308)
    • Document cardiac rhythm and obtain12-lead ECG if dysrhythmia suspected
  4. Maintain supine for patients with signs of poor perfusion if respiratory status allows
  5. Establish vascular access prn (MCG 1375)
SINUS TACHYCARDIA (Infants: heart rate < 220bpm, Children: heart rate < 180bpm) ❶
  1. For adequate perfusion:
    • Monitor closely for potential deterioration, rapid transport
  2. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
SVT - NARROW COMPLEX (Infants: heart rate ≥ 220bpm, Children: heart rate ≥ 180bpm)
  1. For adequate perfusion:
    • Attempt Valsalva maneuver when age appropriate
  2. Adenosine (3mg/mL) 0.1mg/kg rapid IV push, dose per MCG 1309, maximum 6mg ❷
    • Immediately follow with 10mL Normal Saline rapid IV flush
    • If SVT persists:
    • Adenosine (3mg/mL) 0.2mg/kg rapid IV push, dose per MCG 1309, maximum 12mg
    • CONTACT BASE concurrent with adenosine treatment
  3. For persistent poor perfusion after adenosine
    • CONTACT BASE to discuss order for Synchronized Cardioversion
    • Synchronized cardioversion 1 J/kg, dose per MCG 1309 ❸
    • May repeat x2 at 2J/kg, dose per MCG1309
    • Consider sedation prior to cardioversion:
    • Midazolam (5mg/mL) 0.1mg/kg slow IV/IO push or 0.2 mg/kg IM/IN, dose per MCG 1309
    • May repeat in 5 min prn x1 with Base order, maximum single dose 5mg
WIDE COMPLEX (WCT) – REGULAR/MONOMORPHIC
  1. For adequate perfusion:
    • Adenosine (3mg/mL) 0.1mg/kg rapid IV push, dose per MCG 1309, maximum 6mg ❷❹
    • Immediately follow with 10mL Normal Saline rapid IV flush
    • If WCT persists:
    • Adenosine (3mg/mL) 0.2mg/kg rapid IV push, dose per MCG 1309, maximum 12mg ❹
    • CONTACT BASE concurrent with adenosine treatment
  2. For poor perfusion (MCG 1355):
    • CONTACT BASE to discuss order for:
    • Adenosine (3mg/mL) 0.2mg/kg rapid IV push, dose per MCG 1309, maximum 12mg and/or
    • Synchronized cardioversion 1.0J/kg, dose per MCG 1309 ❸ ❹
    • May repeat x2 at 2J/kg, dose per MCG1309
    • Consider sedation prior to cardioversion:
    • Midazolam (5mg/mL) 0.1mg/kg slow IV/IO push or 0.2 mg/kg IM/IN, dose per MCG 1309
    • May repeat in 5 min prn x1 with Base order, maximum single dose 5mg
WIDE-COMPLEX – IRREGULAR
  1. For adequate perfusion:
    • CONTACT BASE and monitor closely for potential deterioration
  2. For poor perfusion (MCG 1355):
    • CONTACT BASE to discuss order for synchronized cardioversion 1.0J/kg, dose per MCG 1309 ❸
    • May repeat x2 at 2J/kg, dose per MCG1309
    • Consider sedation prior to cardioversion:
    • Midazolam (5mg/mL) 0.1mg/kg slow IV/IO push or 0.2 mg/kg IM/IN, dose per MCG 1309
    • May repeat in 5 min prn x1 with Base order, maximum single dose 5mg
Special Considerations
  • Sinus tachycardia is common and SVT is rare. Consider sinus tachycardia in patients with history of fever, volume loss (e.g., vomiting or diarrhea), or congenital heart disease. An indication of sinus tachycardia is narrow complex and beat-to-beat variability seen on the ECG. Vital signs vary by age and normal ranges can be found in MCG 1309. Any pediatric patient with vital signs outside the normal range for age should be considered potentially ill and transported to an EDAP or PMC if criteria are met.
  • Contraindications: 2nd and 3rd Degree Heart Blocks; history of Sick Sinus Syndrome
  • For failure to convert or transient conversion to normal sinus rhythm, consider expedited transport.
  • Regular monomorphic wide complex tachycardia may be a supraventricular rhythm with a bundle branch or aberrancy. In this case, Adenosine may convert the rhythm to sinus and American Heart Association guidelines recommend its use for regular monomorphic wide complex tachycardia.
Section 02

Medical / Endocrine / Shock

GENERAL MEDICAL

Ref. No. 1202-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Control external hemorrhage/bleeding prn (MCG 1370)
  3. Administer Oxygen prn (MCG 1302)
  4. Assess for signs of trauma
    • For traumatic injury, treat in conjunction with TP 1244-P, Traumatic Injury
  5. Initiate cardiac monitoring prn (MCG 1308)
    • For suspected cardiac ischemia or dysrhythmia, perform 12-lead ECG and CONTACT BASE ❶
    • For patients with dysrhythmias, treat per TP 1212-P, Cardiac Dysrhythmia - Bradycardia or
    • TP 1213-P, Cardiac Dysrhythmia - Tachycardia
    • If patient with palpitations but normal sinus rhythm on 12-lead ECG – document Provider
    • Impression as Palpitations
  6. Establish vascular access prn (MCG 1375)
  7. Assess and document pain (MCG 1345)
    • Consider the following Provider Impressions:
    • If chest pain present without suspicion of cardiac cause – document Chest Pain – Not Cardiac
    • If pain in neck or back without trauma – document Body Pain – Non-traumatic
    • If headache and no report or signs of trauma and normal physical assessment – document
    • Headache – Non-traumatic
  8. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  9. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT and treat in conjunction with TP 1205-P, GI/GU Emergencies
  10. For patients with complaints of weakness
    • Assess neurologic exam; if focal findings present or stroke suspected, treat in conjunction with
    • TP 1232-P, Stroke/ CVA/ TIA. CONTACT BASE and transport to a PMC ❷
    • If no focal weakness present and complaint of generalized weakness – document
    • Weakness – General
  11. Consider the following Provider Impressions:
    • If cold/cough symptoms without respiratory distress or wheezing – document Cold/Flu Symptoms
    • If isolated pain or swelling in extremity – document Extremity Pain/Swelling – Non-traumatic
Special Considerations
  • Chest pain in pediatrics is rarely due to cardiac ischemia. Children at risk are those with history of Kawasaki’s Disease or with congenital heart conditions. Young athletes often show slow heart rates and ST-elevation which is normal and not a result of ischemia. If there is a concern for cardiac ischemia contact the Base and consider transport to a PMC or to a PMC that is also an SRC - document Chest Pain-Suspected Cardiac
  • Children with focal neurologic signs may have a stroke mimic or a stroke. These are specialized problem often requiring subspecialists at PMCs. Contact the Base hospital for transport of these patients to a PMC.

DIABETIC EMERGENCIES

Ref. No. 1203-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring prn (MCG 1308)
  4. Establish vascular access prn (MCG 1375)
  5. Check blood glucose
  6. For blood glucose < 60 mg/dL: ❶ ❷
    • Oral glucose preparation or Glucopaste 15gm PO (4 years or older) if patient awake and alert
    • OR
    • Dextrose 10%, 5mL/kg IV/IO ❸
    • ≤24kg: Dextrose 10%, 5mL/kg IV/IO in 1mL/kg increments dose per MCG 1309, reassess for clinical improvement after every 1mL/kg. Administer slow IVP. Recheck glucose prn after 3mL/kg infused
    • >24 kg: Dextrose 10%, administer 125mL IV/IO and reassess, continue infusion as needed with maximum dose of 5mL/kg
    • CONTACT BASE for persistent hypoglycemia for repeat dose of Dextrose 10% 5mL/kg IV in 1mL/kg increments, maximum total dose 10mL/kg, not to exceed 250mL
    • Document Provider Impression as Hypoglycemia ❹
    • If unable to obtain venous access, Glucagon (1mg/mL) IM per MCG 1309 ❺
    • <1 year of age: Glucagon 0.5mL IM, may repeat x1 in 20 min prn
    • ≥1 year of age: Glucagon 1.0mL IM, may repeat x1 in 20 min prn
  7. For blood glucose > 200 mg/dL:
    • Document Provider Impression as Hyperglycemia
    • For blood glucose >250mg/dL❻
    • Normal Saline 10mL/kg IV rapid infusion per MCG 1309
  8. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • For persistent poor perfusion (MCG 1355), treat in conjunction with TP 1207-P,
    • Shock/Hypotension
  9. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
Special Considerations
  • In pediatric patients with hypoglycemia consider causes such as medication error or medication given without appropriate oral intake, infection, or toxins. Survey scene and ask family for types of medications in the home including those in various forms (e.g., pill, patch, drops, salves, inhaled or herbal). Caretakers of pediatric patients should always be encouraged to have patient be transported to the hospital for evaluation as hypoglycemia in this population is rare as compared to adults and is often caused by serious disease or poisonings.
  • Use judgment based on the clinical status of the patient to determine whether IO placement for dextrose and/or fluid administration prior to hospital arrival is warranted. For altered patients who show signs of shock/poor perfusion and/or extremis with severe HYPERglycemia or HYPOglycemia and an IV cannot be obtained, an IO may be placed for fluid resuscitation or treatment with dextrose. Refer to MCG 1375.
  • Normal glucose for the newly born is ≥40mg/dl; consider treatment in newly born patient only if symptomatic with glucose <40mg/dl.
  • Pediatric patients with hypoglycemia who are successfully treated with oral glucose or Dextrose 10% IV and then their parent wishes to decline transport to the hospital should be discouraged to do so, especially if they have abnormal vital signs, fever, are taking long acting hypoglycemic agents possible ingestion or poisoning, or if they DO NOT have a history of diabetes mellitus as these patients are at high risk for recurrent hypoglycemic episodes. Long Acting hypoglycemic agents • Sulfonylureas: gliclazide, glimepiride, glipizide, gliquidone, glyburide, glyclopyramide, • Thiazolidinediones (TZDs): pioglitazone (Actos), rosiglitazone (Avandia), troglitazone (Rezulin) • Alpha-glucosidase inhibitors: acarbose, miglitol, voglibose • Meglitinides – nateglinide, repaglinide • Combination drugs: glipizide and metformin (Metaglip), glyburide and metformin (Glucovance), pioglitazone and glimepiride (Duetact), pioglitazone and metformin (ACTOplus • Met), rosiglitazone and metformin (Avandamet), rosiglitazone and glimepiride (Avandaryl)
  • Glucagon is effective only if there are sufficient glycogen stores in the liver. Patients with low glycogen stores such as young infant, severe malnutrition, cirrhosis, or adrenal insufficiency may not respond to glucagon.
  • Patients with hyperglycemia are at risk for significant volume losses leading to dehydration and electrolyte abnormalities. Fluid resuscitation with Normal Saline is recommended until their glucose can be lowered with medications. Hyperglycemia can also be associated with trauma, infection, or other serious illness. For patients with elevated glucose requiring fluids IV Normal Saline should be given – only those patients who show signs of poor perfusion and an IV cannot be obtained would have an IO placed for fluid resuscitation.

FEVER / SEPSIS

Ref. No. 1204-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring prn (MCG 1308)
  4. Establish vascular access prn (MCG 1375)
  5. For suspected sepsis: ❶
    • Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • CONTACT BASE to obtain order for additional Normal Saline 20mL/kg IV/IO per MCG 1309
    • Document Provider Impression of Sepsis
    • For persistent poor perfusion (MCG 1355), treat in conjunction with TP 1207-P,
    • Shock/Hypotension
  6. Check blood glucose prn;
    • < 60mg/dL or >250mg/dL treat in conjunction with TP 1203-P, Diabetic Emergencies
  7. If fever present without signs of sepsis or poor perfusion:
    • Perform passive cooling measures and cover with blankets if shivering occurs.
    • Document Provider Impression of Fever ❷❸❹
  8. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
  9. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
Special Considerations
  • Sepsis is defined as the body’s response to infection and may include fever, tachycardia or bradycardia, tachypnea, and signs of poor perfusion. Other signs of infection may be present such as cough (e.g., pneumonia), painful urination (e.g., urinary tract infection), abdominal pain (e.g., appendicitis), headache (e.g., meningitis), or a red swollen extremity (e.g., cellulitis, or necrotizing fasciitis). Septic shock is a continuum of signs and symptoms, which includes the presence of hypotension or evidence of poor perfusion. If infection is present and sepsis with or without shock is present document provider impression as Sepsis.
  • Fever is a natural response of the body to fight infection and may be present without signs of sepsis. Often children with a fever have tachycardia, however if tachycardia is greater than that explained by the fever (>180 in infants and >140 in children) consider sepsis. If fever is present without signs of sepsis (skin hot to touch and tachycardia) or septic shock (signs of poor perfusion), document the provider impression as Fever.
  • For patients presenting with fever, obtain travel history, and if travel history positive contact the Medical Alert Center to determine risk for infectious disease requiring special isolation procedures or transport.
  • Infants and small children are at high risk for hypothermia due to their large surface area to body mass ratio, reduced ability to shiver, and limited body fat. Infants with sepsis may present with fever or hypothermia. For Ebola Virus Disease: Patient Assessment and Transportation Guidelines can be accessed at the EMS Agency website or the following link https://file.lacounty.gov/SDSInter/dhs/1040046_LACoEbola911FlowChart-CongoDRC20180524FINAL.pdf

GI / GU EMERGENCIES

Ref. No. 1205-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring prn (MCG 1308)
  4. Establish vascular access prn (MCG 1375)
  5. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  6. Assess and document pain (MCG 1345)
    • If abdominal or pelvic pain during pregnancy, or vaginal bleeding with known or suspected pregnancy treat per TP 1217-P, Pregnancy Complications
    • Consider the following Provider Impressions:
    • If abdominal or pelvic pain – document Abdominal Pain/Problems
    • If pain in penis, scrotum or testes in a male or complaints of vaginal symptoms in a female, or if for sexual assault – document Genitourinary Disorder
  7. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  8. For nausea or vomiting in patients ≥ 4years old:
    • Ondansetron 4mg ODT
  9. Consider the following Provider Impressions:
    • If nausea or vomiting present in the absence of abdominal pain or diarrhea – document
    • Nausea / Vomiting ❶
    • If vomiting blood or coffee ground material and/or tarry/black stools – document
    • Upper GI Bleeding ❷
    • If vaginal bleeding without known pregnancy – document Vaginal Bleeding
    • If diarrhea without hypotension – document Diarrhea
    • If bleeding per rectum – document Lower GI Bleeding ❷
Special Considerations
  • When evaluating an infant or child with vomiting, the presence of bile (green vomitus) in the vomit is a surgical emergency and must be taken as a sign of a life-threatening condition. These patients need rapid transport to the closest EDAP.
  • For both upper and lower GI bleeding, if abdominal pain is also present, document GI bleeding as primary provider impression and abdominal pain as secondary provider impression.

MEDICAL DEVICE MALFUNCTION

Ref. No. 1206-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Establish type of medical device inserted ❶
  4. Establish vascular access prn (MCG 1375)
  5. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  6. Assess and document pain (MCG 1345)
  7. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  8. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
  9. Document Medical Device Malfunction as the Provider Impression if the patient’s presentation
    • suggests malfunction of the medical device, otherwise treat as per applicable protocol.
    • Insulin Pump: Check blood glucose prn and treat in conjunction with TP 1203-P, Diabetic
    • Emergencies
    • Vagal Nerve Stimulation devices: Treat presenting symptoms; for seizure treat per
    • TP 1231-P, Seizure – Active
    • Ventricular Assist Device: CONTACT BASE and refer to MCG 1325
    • Ventriculoperitoneal (VP) Shunt: Treat presenting symptoms ❷
    • Pacemaker or Automated Internal Defibrillator: Treat presenting symptoms and obtain 12-lead ECG prn (MCG 1308)
Special Considerations
  • Most patients with an inserted medical device have medical complaints that are not related to the device itself and should be treated as per standard protocols based on presenting signs and symptoms. It is important to obtain a history of when the medical device was inserted as different complications occur depending on time since insertion.
  • Patients with ventriculoperitoneal shunts can have breakage of the shunt connections, obstruction, or infection of the shunt, which may present as ALOC, headache, nausea and vomiting, or fever. History should include last shunt revision date as shunt infections are most likely if a shunt revision is recent.

SHOCK/HYPOTENSION

Ref. No. 1207-P
Base Hospital Contact Required.
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
    • Continually assess patient’s airway and ventilation status
  2. Administer Oxygen prn (MCG 1302)
    • High-flow Oxygen 15L/min for all patients in shock, regardless of SpO2 ❶
  3. Maintain supine if respiratory status allows ❷
  4. Establish vascular access (MCG 1375)
    • For patients with hypotension or clinical evidence of poor perfusion (MCG 1355), establish IO catheter if unable to obtain peripheral venous access after 2 attempts ❸
    • For IO placement in alert patients administer Lidocaine 2% 0.5mg/kg (20mg/mL) slow IO push, dose per MCG 1309, may repeat once for infusion pain at half initial dose
  5. Initiate cardiac monitoring (MCG 1308)
  6. Apply blanket to keep patient warm ❹
  7. Consider etiology ❺
    • For neonates, treat in conjunction with TP 1216-P, Newborn/Neonatal Resuscitation
    • For patients with dysrhythmia, treat in conjunction with TP 1212-P, Cardiac Dysrhythmia –
    • Bradycardia or TP 1213-P, Cardiac Dysrhythmia – Tachycardia
    • For patients with traumatic injury, treat per TP 1244-P, Traumatic Injury
    • For concern of overdose or toxic exposure, treat in conjunction with TP 1241-P, Overdose /
    • Poisoning / Ingestion
    • For patients with suspected sepsis, treat in conjunction with TP 1204-P, Fever/Sepsis
  8. Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
  9. For patients with isolated hypotension without signs of poor perfusion and those who rapidly
    • respond without intervention or to < 20mL/kg Normal Saline document Hypotension (HOTN) as
    • Provider Impression. For patients with hypotension with poor perfusion that require addition normal saline or push-dose epinephrine document as Shock (SHOK)
  10. CONTACT BASE for shock and for additional Normal Saline 20mL/kg IV/IO per MCG1309
  11. If clinical evidence of poor perfusion persists despite fluid infusion or pulmonary edema develops
    • requiring cessation of fluid administration:
    • Push-dose Epinephrine – mix 9mL Normal Saline with 1mL Epinephrine (0.1mg/mL) IV formulation in a 10mL syringe; administer Push-dose Epinephrine (0.01 mg/mL), dose per
    • MCG 1309 every 1-5 minutes as needed to maintain normal SBP per MCG 1309 until hospital arrival ❻
    • CONTACT BASE concurrent with initial dose of Push-dose Epinephrine
Special Considerations
  • Shock is inadequate tissue perfusion, equivalent to poor perfusion for the purposes of this protocol. Consider Base Hospital Contact if hypotension/shock of unclear etiology. Use caution if the patient has known cyanotic congenital heart disease. Newborns requiring positive-pressure ventilation should receive 90 seconds of room air, and then start oxygen 15L/min if heart rate remains < 100 beats per minute and/or persistent shock.
  • Maintaining a patient supine improves perfusion to vital organs; raising the lower limbs does not provide additional benefit. However, not all patients will tolerate a supine position, which can further compromise respiratory function and airway patency.
  • Peripheral venous access may be difficult to obtain in infants and small children. Consider IO placement as primary vascular access in extremis patients for whom venous access is unlikely to be achieved rapidly. For older children, make two attempts at venous access and, if unsuccessful, place an IO for vascular access.
  • Exposure to cold increases the likelihood of bleeding complications.
  • There are many etiologies of shock. The treatment protocols referenced here contain guidance on specific interventions beyond what is contained in this treatment protocol. The level of systolic blood pressure varies by age and thresholds for hypotension are found in MCG 1309 and can be used in decisions for fluid resuscitation. Hypotension is a late finding in pediatric shock; fluid resuscitation should be guided by clinical evidence of poor perfusion (MCG 1355). Consider Base Hospital Contact if hypotension/shock of unclear etiology.
  • Push-dose Epinephrine is appropriate for non-traumatic shock including cardiogenic shock. Additional doses beyond 10mL may need to be prepared for prolonged transports. For patients < 10kg, transfer the diluted Push-dose Epinephrine to a smaller (1mL or 3mL) syringe in order to administer the dose accurately.
Section 03

Behavioral & Psychiatric

BEHAVIORAL / PSYCHIATRIC CRISIS

Ref. No. 1209-P
Base Hospital Contact: Required for all patients with agitation requiring midazolam.
  1. Perform initial assessment of scene and patient situation for safety ❶
  2. Attain law enforcement (LE) assistance prior to approaching a patient if a weapon is visualized or
    • the patient threatens violence or for potential assistance with application of an involuntary psychiatric hold ❶❷
  3. Approach patient with caution, assess for agitation and use of verbal de-escalation as needed
    • (MCG 1307, Care of the Psychiatric Patient with Agitation) ❸
  4. Evaluate for medical conditions, including those that may present with psychiatric features ❹
  5. Initiate basic and/or advanced airway maneuvers prn
    • Prepare in advance to support ventilations prn for any patient who receives midazolam sedation❺
  6. Administer Oxygen prn (MCG 1302)
  7. Pre-plan approach to physical restraint; apply restraints when indicated (Ref. No. 838, Application of Patient Restraints) ❻
  8. Manage ongoing agitation based on patient’s condition
  9. For COOPERATIVE PATIENTS:
    • Olanzapine 10mg Oral Disintegrating Tablet (ODT); given once for pediatric patients longer than the length-based resuscitation tape per MCG 1309 (MCG 1317.32)
  10. For UNCOOPERATIVE PATIENTS who pose a potential safety risk to self and/or EMS
    • personnel:
    • CONTACT BASE
    • Consider Midazolam (5mg/mL) 0.2 mg/kg IM/IN, dose per MCG 1309
    • Or Midazolam (5mg/mL) 0.1 mg/kg IV, for pre-existing vascular access only
    • Repeat every 5 min prn; maximum single dose 5mg
    • With Base orders may repeat as above to a total maximum dose of 15mg ❺❼
  11. For SEVERE AGITATION WITH ALOC who pose an IMMEDIATE RISK to self and/or EMS
    • personnel:
    • Administer Midazolam (5mg/mL) 0.2 mg/kg IM/IN, dose per MCG 1309❺❼
    • Or Midazolam (5mg/mL) 0.1 mg/kg IV, for pre-existing vascular access only
    • Repeat x1 in 5 min prn, maximum single dose 5mg, maximum total 10mg prior to Base Contact
    • CONTACT BASE for additional sedation
    • With Base orders may repeat as above up to a maximum total dose of 15mg
    • Normal Saline 20mg/kg IV rapid infusion per MCG 1309
  12. Initiate cardiac monitoring on all patients in restraint and/or post-sedation (MCG 1308) ❺❽
    • Pre-position monitor prior to sedation; continuously monitor airway and breathing peri- and post- sedation
    • Assess for dysrhythmia or interval widening
  13. CONTACT BASE for QRS > 0.12 sec or heart rate < 50 to discuss need to administer Sodium
    • Bicarbonate 1 meq/kg per MCG 1309❾
  14. If patient’s skin is hot to touch or has a measured fever with suspected hyperthermia (i.e.,
    • measured temperature greater than 39C or 102F), initiate cooling measures
  15. Establish vascular access prn (MCG 1375)
    • Check blood glucose prn ❿
    • If glucose < 60 mg/dL or > 250 mg/dL treat in conjunction with TP 1203-P, Diabetic Emergencies
  16. Evaluate for physical trauma; if present treat in conjunction with TP-1244-P, Traumatic Injury
  17. Evaluate for a possible suicide attempt ⓫
    • For potential overdose, obtain patient and bystanders information about ingestions and treat in conjunction with TP 1241-P, Overdose/Poisoning/Ingestion
  18. If concern for suicidal intent in persons not on a 5585 hold and refusing voluntary treatment or
    • transport, CONTACT BASE (MCG 1306)
  19. Evaluate for acute mental health and/or substance abuse crises
    • Obtain relevant clinical history regarding patient’s current psychiatric diagnoses, psychiatric and other medications, and any recent alcohol or recreational drug ingestions
    • Obtain and document relevant third party or collateral data ⓬
  20. Patients who respond to verbal de-escalation or are treated only with olanzapine for agitation,
    • and are now cooperative, and who meet criteria in Ref. No. 526, Behavioral/Psychiatric Crisis
    • Patient Destination and Ref. No. 526.1 Medical Clearance Criteria Screening Tool for Psychiatric
    • Urgent Care Center, may be transported by Basic Life Support (BLS) or law enforcement to the
    • MAR or to a Psychiatric Urgent Care Center.
  21. Patients, evaluated by EMS personnel not yet approved for alternate destination transport, who
    • receive olanzapine for agitation and are otherwise stable, and do not have an emergency medical condition, may be transported by BLS or law enforcement to the MAR only.
Special Considerations
  • Scene safety includes the assessment for the presence of firearms or weapons, including observations and direct inquiry with the patient and any available/relevant third parties (e.g., family, caregivers, or witnesses). If a weapon is found on the scene, EMS personnel should notify all members on the scene, and contact law enforcement (LE) immediately.
  • Psychiatric, including mental health and substance abuse, emergencies are medical emergencies, and as such are best treated by EMS personnel. Those patients with psychiatric emergencies presenting with agitation, violence, threats of harm to self or others, or criminal activity are best managed by an EMS and LE co-response.
  • Always attempt verbal de-escalation first and avoid applying restraints to patients who do not present a threat to self or EMS personnel (Ref. 838, Application of Patients Restraints)
  • Many medical causes of psychiatric symptoms exist: Agitation (see MCG 1307) Acute pain Head trauma Infection Encephalitis or Encephalopathy Exposure to environmental toxins Metabolic derangement Hypoxia Thyroid disease or other hormone irregularity Neurological disease Toxic levels of medications Alcohol or recreational drugs: intoxication or withdrawal Exacerbation of a primary psychiatric illness Autism Spectrum Disorder Psychosis Delirium Chronic neurological disease (seizures, brain tumor) Steroid use, other medication reactions Alcohol or recreational drugs: intoxication or withdrawal Mania Delirium Thyrotoxicosis Alcohol or recreational drugs: intoxication or withdrawal Anxiety Respiratory disease Cardiac disease Thyroid disease Toxic levels of medications Alcohol or recreational drugs: intoxication or withdrawal Depression Reaction to medication Chronic disease or chronic pain Hormonal variations Subclinical / clinical hypothyroidism Alcohol or recreational drugs: intoxication or withdrawal
  • Medications used for pharmacologic management of agitation may cause respiratory depression; administer only when necessary for the safety of the patients and/or EMS personnel. Apnea can occur suddenly and with little warning. Resuscitation equipment (oxygen and bag-mask ventilator) should be positioned near the patient and readily available prior to sedation. Every individual who receives restraint and/or midazolam pharmacologic management should be continuously monitored and transported for additional clinical assessment and treatment.
  • Use of restraints in severely agitated patients is associated with an increased risk of sudden death. Avoid using restraints in patients who do not present a threat to self or to EMS personnel. Monitor patients closely when restraints are applied. Never secure or transport a patient in restraints in prone position.
  • The IM or IN route is preferred unless an IV has been previously established.
  • Patients who are agitated while in physical restraint and have the potential for injury due to the degree of agitation, should receive medication by EMS personnel to reduce agitation with continued monitoring for respiratory depression, in accordance with Ref 838, Application of Patient Restraints.
  • Several drugs that may cause agitation and present similarly to a psychiatric crisis may also cause life threatening cardiac arrhythmias after intentional or accidental overdose. These arrhythmias are often preceded by prolonged QRS intervals (> 0.12 sec) or bradycardia. Cocaine intoxication is strongly associated with severe agitation and may also produce cardiac effects similar to Tricyclic antidepressant (TCA) overdose (widened QRS progressing to malignant arrhythmia). These patients may require a large dose of sodium bicarbonate to prevent sudden cardiac death. Consult Base Physician immediately to discussion administration of Sodium Bicarbonate; may repeat x1 if QRS remains > 0.12 sec after initial sodium bicarbonate. Treat in conjunction with TP 1241-P, Overdose / Poisoning / Ingestion
  • Agitation may be present after a seizure, or in the setting of hypo/hyperglycemia. Consider checking glucose early if the patient is a known diabetic or demonstrates clinical evidence of hypoglycemia, but only if safe to do so.
  • It is important to assess for any evidence of suicide attempt. If there is concern for overdose, ask the patient or bystanders to provide information on agents used (specifically what, when, and how much). Collect and transport any medication vials, or additional pills). This will assist in determining necessary antidote treatment and monitoring at the hospital. This information is often lost, if not obtained immediately on scene.
  • Patients with acute mental health or substance abuse crises may not be capable or willing to provide reliable information, therefore, it is important to obtain third party collateral information about the patient’s condition (e.g., from family, caregivers, witnesses), including names and contact information for persons knowledgeable about the patient’s illness, treatment and medications.
Section 04

Neurologic Emergencies

ALTERED LEVEL OF CONSCIOUSNESS (ALOC)

Ref. No. 1229-P
Base Hospital Contact: Required for persistent ALOC of unclear etiology ❶ ❷
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-lead ECG if cardiac dysrhythmia detected and treat in conjunction with TP 1212-P,
    • Cardiac Dysrhythmia - Bradycardia or TP 1213-P, Cardiac Dysrhythmia - Tachycardia
  4. Establish vascular access (MCG 1375)
  5. Check blood glucose
    • If < 60mg/dL or > 250mg/dL, treat in conjunction with TP 1203-P, Diabetic Emergencies
  6. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • For patients with persistent poor perfusion, treat in conjunction with TP 1207-P,
    • Shock/Hypotension
  7. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  8. Perform neurological exam
    • If stroke or stroke mimic suspected CONTACT BASE and transport to PMC
  9. For suspected drug overdose or alcohol intoxication, treat in conjunction with
    • TP 1241-P, Overdose/Poisoning/Ingestion ❸
  10. For suspected carbon monoxide exposure, treat in conjunction with
    • TP 1238-P, Carbon Monoxide Exposure
  11. CONTACT BASE if the etiology of the ALOC remains unclear
Special Considerations
  • Once the cause for ALOC is determined, switch to the more specific protocol. Consider the following differential using the mnemonic AEIOU-TIPS: A – Alcohol, abuse, atypical migraine E – Epilepsy, electrolytes I – Insulin (hypoglycemia) O – Oxygen, overdose U – Uremia (kidney failure) T – Trauma, tumor I – Infection P – Psych, poisoning S – Seizure, Subarachnoid hemorrhage, Sepsis
  • EMS Personnel are mandated reporters of child abuse and neglect, and a report should be made when suspected as per Ref. 822. Communicate suspicion for child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkempt home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to the Department of Children and Family Services (DCFS).
  • Consider narcotic overdose for patients with hypoventilation (bradypnea), and pinpoint pupils, drug paraphernalia, or strong suspicion of narcotic use.

DIZZINESS / VERTIGO

Ref. No. 1230-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring prn (MCG 1308)
  4. Establish vascular access prn (MCG 1375)
  5. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  6. Check blood glucose
    • If < 60mg/dL or > 250mg/dL, treat in conjunction with TP 1203-P, Diabetic Emergencies
  7. For vertigo: ❶
    • CONTACT BASE if focal neurologic findings present and transport to PMC
  8. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
Special Considerations
  • Dizziness is often used to describe two different feelings; vertigo and lightheadedness. Vertigo is the sensation of a person or their surroundings moving when no actual movement is occurring. People often describe the feeling of spinning, falling, tilting, or being off balance. This is often associated with nausea/vomiting. Lightheadedness can lead to feeling faint or syncope, and the patient often reports improvement with supine position. Vertigo is an unusual complaint for children and should be taken as a possible sign of serious disease.

SEIZURE

Ref. No. 1231-P
Base Hospital Contact: Required for status epilepticus or pregnant patients
  1. Assess airway and initiate basic and/or airway maneuvers prn (MCG 1302) ❶
  2. Administer Oxygen prn (MCG 1302)
  3. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  4. Initiate cardiac monitoring prn (MCG 1308)
  5. If seizure stops spontaneously prior to EMS arrival and no seizure witnessed by EMS:
    • Document Provider Impression – Seizure - Post
  6. For active seizure witnessed by EMS: ❷❸
    • 0-11 months (Gray, Pink)
    • Midazolam (5mg/mL) 0.2mg/kg IM/IN, dose per MCG 1309
    • Repeat x1 in 2 min prn, up to 2 doses prior to Base contact 12-16 months (Red if age unknown)
    • Midazolam (5mg/mL) 1.25 mg or 0.25mL IM/IN
    • Repeat x1 in 2 min prn, up to 2 doses prior to Base contact 17 months – 5 years (Purple, Yellow, White if age unknown)
    • Midazolam (5mg/mL) 2.5 mg or 0.5mL IM/IN
    • Repeat x1 in 2 min prn, up to 2 doses prior to Base contact 6-11 Years (Blue, Orange, Green if age unknown)
    • Midazolam (5mg/mL) 5mg or 1mL IM/IN
    • Repeat x1 in 2 min prn, up to 2 doses prior to Base contact
    • ≥12 years (Longer than the length-based tape if age unknown)
    • Midazolam (5mg/mL) 10 mg or 2mL IM/IN
    • Single dose prior to Base contact
    • For patients with severe growth restriction (e.g., genetic disorder, severe malnutrition), administer weight-based dose per color code.❹
    • CONTACT BASE for persistent seizure and for additional medication orders: ❺
    • May repeat Midazolam as above, maximum total of 3 doses or 20 milligrams, whichever is less.
    • Document Provider Impression – Seizure – Active, even if seizure spontaneously resolves
  7. Establish vascular access prn (MCG 1375)
  8. For persistent seizure or persistent ALOC:
    • Check blood glucose
    • If < 60mg/dL or > 250mg/dL, treat in conjunction with TP 1203-P, Diabetic Emergencies
  9. Complete Paramedic Self Report, https://redcap.link/lacpedi-dose
Special Considerations
  • Children with seizure may develop apnea; therefore, monitor oxygenation and ventilation including continuous pulse oximetry during seizure and after treatment with midazolam. Be prepared to initiate BMV.
  • Active seizures, including febrile seizures, may include tonic and/or clonic activity or focal seizure with altered level of consciousness. Eye deviation, clenched jaw, lip smacking or focal twitching may be subtle signs of seizure.
  • Seizures may occur as a result of underlying medical problems or toxic ingestions. Please make every effort to obtain a medical history and determine all medications/drugs that the patient may have taken.
  • Severe growth restriction is determined on clinical assessment when a patient is much smaller in size than expected for age due to an underlying medical condition (e.g., genetic disorder, severe malnutrition). A child that is simply small for their age would not be considered to have severe growth restriction.
  • Vital signs vary by age and normal ranges can be found in MCG 1309. Any pediatric patient with vital signs outside the normal range for age should be considered potentially ill and transported to an EDAP or PMC if criteria are met. Pediatric patients who continue to seize after administration of midazolam should be transported to a PMC.

STROKE / CVA / TIA

Ref. No. 1232-P
Base Hospital Contact: Required prior to transport for all patients with suspected Stroke or TIA
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Advanced airway prn (MCG 1302)
  4. Initiate cardiac monitoring (MCG 1308)
Perform 12-lead ECG if dysrhythmia suspected prn
  1. Establish vascular access prn (MCG 1375)
  2. Check blood glucose
If < 60mg/dL or > 250mg/dL, treat in conjunction with TP 1203-P, Diabetic Emergencies
  1. Assess for signs of trauma ❶
If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  1. Document focal neurologic deficits, and date and time of Last Known Well Time (LKWT) ❷
  2. CONTACT BASE and transport to PMC
Special Considerations
  • EMS Personnel are mandated reporters of child abuse and neglect. Communicate concerns about child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkempt home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to the Department of Children and Family Services (DCFS).
  • Stroke is rare in children as compared to adults. Children with focal neurologic deficits could have a stroke (rare) or a stroke mimic such as, atypical migraine or petit mal seizures. LKWT for children determines time course of the disease and may have an impact on treatment. PMC is the best destination for these patients as subspecialty consultation will assist in establishing the diagnosis.

SYNCOPE / NEAR SYNCOPE

Ref. No. 1233-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Establish vascular access prn (MCG 1375)
  4. For symptomatic orthostasis (in older children), signs of dehydration or fluid losses, or for poor
    • perfusion: ❶ ❷
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  5. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-Lead ECG if dysrhythmia suspected
    • If cardiac dysrhythmia is present, treat per TP 1212-P, Cardiac Dysrhythmia-Bradycardia or
    • TP 1213-P, Cardiac-Dysrhythmia-Tachycardia
  6. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  7. For persistent ALOC, treat in conjunction with TP 1229-P, ALOC ❸
Special Considerations
  • Patients who are lightheaded and/or tachycardic when sitting and/or standing compared to lying down, referred to as orthostatic, are likely dehydrated and in need for fluid resuscitation. Orthostatic vitals provide little information and may result in harm so should not be performed. Syncope can result from a lack of adequate perfusion to the brain, and in the setting of suspected dehydration or fluid losses, this can be a sign of poor perfusion. Therefore, for patients who present with syncope with orthostasis and/or dehydration, fluid resuscitation is appropriate unless contraindicated.
  • In females of child-bearing age with syncope, ask about possible pregnancy and any history of vaginal bleeding. One cause of syncope in females is a ruptured ectopic pregnancy. This can be life threatening and may present with poor perfusion and require fluid resuscitation with Normal Saline. Contact Base if patient known to be pregnant.
  • Syncope in children is most often a result of vasovagal syncope and transport to an EDAP is appropriate. However, syncope associated with a dysrhythmia or ALOC indicates a serious underlying disease and patients should be transported to a PMC.

DYSTONIC REACTION

Ref. No. 1239-P
Base Hospital Contact Required.
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Establish vascular access prn (MCG 1375)
  3. Assess for medication exposure as the potential cause of the dystonic reaction ❶ ❷
  4. CONTACT BASE to confirm Provider Impression of Dystonic Reaction
  5. Diphenhydramine (50mg/mL) 1mg/kg slow IV push, dose per MCG 1309
    • If unable to obtain venous access, Diphenhydramine (50mg/mL) 1mg/kg deep IM, dose per
    • MCG 1309
Special Considerations
  • The table below shows common medications that can cause an acute dystonic reaction. Generic Name Trade Name General Use Prochlorperazine Compazine Antiemetic, migraine headache Hydroxyzine Vistaril, Atarax Antiemetic, antipruritic Promethazine Phenergan Antiemetic, antipsychotic Haloperidol Haldol Antipsychotic, Tourette’s syndrome Thioridazine Mellaril Antipsychotic Alprazolam Xanax Antianxiety Metoclopramide Reglan Antiemetic Droperidol Inapsine Antiemetic, antipsychotic Fluphenazine Prolixin Neuralgia, antipsychotic
  • Signs and symptoms of a dystonic reaction include anxiety, agitation and associated involuntary muscle spasms of the head, neck, face, eyes or trunk. This often results in an inability to retract the tongue into the mouth, forced jaw opening, facial grimacing, and/or eye deviation.
Section 05

OB / Newborn / Infant

CHILDBIRTH MOTHER

Ref. No. 1215-P
Base Hospital Contact Required ❶
  1. Assess the mother’s airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Establish vascular access prn (MCG 1375)
    • Vascular access should not take precedence over controlled delivery or emergency transport
  4. Place mother in Semi-Fowler’s or Lateral Sims position
  5. If mother has the urge to push or crowning is evident, prepare for delivery
    • Prepare OB kit
  6. If crown is showing with amniotic sac intact, pinch sac and twist the membrane to rupture
  7. If maternal hypertension, breech presentation, shoulder dystocia, or prolapsed or nuchal cord
    • treat in conjunction with TP 1217-P, Pregnancy Complication
  8. Once delivered, dry newborn with a towel, clamp and cut the cord ❷
    • Treat newborn per TP 1216-P, Newborn/Neonate Resuscitation
  9. For management of the placenta:
    • The placenta may deliver spontaneously; do not pull on cord but allow placenta to separate naturally
    • Place placenta in plastic bag from the OB kit and bring to the hospital with the mother
  10. Massage the mother’s lower abdomen (fundus) after the placenta delivers
    • For post-partum hemorrhage, treat in conjunction with TP 1217-P, Pregnancy Complication ❸
  11. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 20mL/kg IV per MCG 1309
  12. If delivery occurs in the field, determine destination based on stated or estimated gestational age
    • and CONTACT BASE: ❶
    • Transport both patients to a Perinatal Center with an EDAP if newborn > 34 weeks gestation
    • Transport both patients to a Perinatal Center with an EDAP and a NICU if ≤ 34 weeks gestation
Special Considerations
  • Any delivery after the first trimester (12 weeks) should be considered childbirth for the purposes of this treatment protocol and paramedics should contact Base to discuss the management and transport. In general, delivery prior to 20 weeks gestation is nonviable and does not require resuscitation. However, dates can be incorrectly estimated, therefore, Base Contact is strongly encouraged. Any potentially viable birth should be resuscitated in the field and transported to a perinatal center that is also an EDAP (with a NICU if <34 weeks gestation). Births prior to 20 weeks do not necessarily require specialty center care and can be transported to the MAR.
  • Delay in clamping and cutting the cord for up 30 to 60 seconds is recommended unless newborn needs immediate resuscitation.
  • Some bleeding is normal during delivery, typically up to 500mL. Bleeding is reduced with fundal massage after placental delivery, which promotes contraction of the uterus. Post-partum hemorrhage is defined as blood loss with signs of poor perfusion and/or cumulative blood loss ≥1000mL.

NEWBORN / NEONATAL RESUSCITATION

Ref. No. 1216-P
Base Hospital Contact required for all newborn deliveries
  1. Assist delivery; if amniotic sac intact and crown is presenting part, pinch sac and twist
    • membrane to rupture and continue with delivery. Treat mother per TP 1215-P, Childbirth
    • (mother)
  2. Dry, warm and stimulate newborn by drying with towel ❶
  3. Assess airway and initiate basic airway management (MCG 1302; 1309)
    • Monitor pulse oximetry on right hand of newborn ❷
    • For airway obstruction suction prn; mouth first then nostrils ❸
  4. Clamp and cut cord ❹
  5. If newborn is vigorous, after drying and warming with a towel place on mother’s chest skin-to-
    • skin to ensure heat transfer to the newborn; cover mother and newborn with a blanket
  6. Transport newborn and mother to same facility (EDAP and Perinatal Center)
  7. Reassess every 30 sec the need for assisted ventilation or CPR intervention
  8. Check pulse at the precordium (auscultation), the base of the umbilical cord or at the brachial
    • artery
  9. If further resuscitation required, initiate resuscitation on scene prior to transport
IF PULSE < 100bpm OR poor respiratory rate, effort, or persistent central cyanosis ❺
  1. Perform BMV with room air for 90 secs, squeeze the bag just enough to see chest rise then
    • release; state “squeeze, release” to avoid hyperventilation
  2. Recheck pulse every 30 secs
    • For persistent poor respiratory rate, effort or central cyanosis, add high flow Oxygen 15L/min to BMV
    • Assess the need for chest compressions
  3. Establish vascular access (MCG 1375)
    • If unable to obtain peripheral vascular access, place IO; should not take precedence over emergency transport ❻ ❼
IF PULSE < 60bpm ❽
  1. Begin BMV with high flow oxygen and chest compressions at a rate of 120/min, maintain 3:1
    • compression to ventilation ratio (90 compressions to 30 ventilations per minute); continue for 2 minutes before pulse check.
    • Consider supraglottic airway in infants 3 kg or greater, if BMV ineffective or cardiac arrest despite BMV, size per MCG 1309
  2. Epinephrine (0.1mg/1mL) 0.01 mg/kg IV/IO push dose per MCG 1309
    • May repeat every 5 min
  3. Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • CONTACT BASE for persistent poor perfusion (MCG 1355) to obtain order for additional
    • Normal Saline 20mL/kg IV/IO per MCG 1309
  4. Once pulse is > 60bpm, chest compressions should be discontinued
  5. Transport newborn and mother to the same facility which is an EDAP or PMC and Perinatal
    • Center with a NICU ❾
Special Considerations
  • This protocol is be used for the newly born only; infants otherwise within the first month of life use TP 1210-P Pediatric Cardiac Arrest. The most important intervention for a resuscitation of the newly born in the field is to “Dry, Warm and Stimulate” – this allows for reversal of apnea after delivery.
  • “Dry, Warm, and Stimulate then you have to Ventilate” – If respiratory effort poor or HR <100bpm then Ventilate using BMV. The most important signs to monitor are respiratory effort, pulse oximetry and heart rate. Measuring the pulse oximetry on the right hand provides the most accurate oxygen saturation in infants that are transitioning from fetal to normal circulation. At 60 seconds, 60% is the target with an increase of 5% every minute until 5 minutes of life when pulse oximetry is 80-85%. Projected Increase in Time Since Birth Pulse Oximeter Over Time 1 minute 60-65% 2 minutes 65-70% 3 minutes 70-75% 4 minutes 75-80% 5 minutes 80-85% 10 minutes 85-90% Assessments that are used to initiate BMV and chest compressions. Respiratory Central Cyanosis Heart Rate (bpm) Intervention Distress/Apnea Present > 100 No Yes Blow-by Oxygen --- Yes Yes/No BMV 60-100 - - BMV <60 - - BMV; Chest compressions
  • Suction prior to delivery is no longer recommended for presence of meconium (thick or thin). Suctioning should occur only if there is airway obstruction present and mouth should be suctioned first followed by the nose.
  • Delay clamping and cutting the cord for 60 seconds unless the newborn needs immediate resuscitation.
  • Assessing pulse at the base of the umbilical cord is preferred, pulse rate < 100bpm is a sign of newborn distress and requires BMV.
  • In obtaining vascular access, place an IO in a newborn use light pressure as the bone cortices are soft and the needle can easily penetrate both cortices of the bone.
  • It is not necessary to check glucose in a vigorous newborn. Normal glucose is ≥40mg/dl. If glucose is measured during neonatal resuscitation, consider treatment only for symptomatic patients with glucose <40mg/dl per 1203-P.
  • Chest compression should be initiated in newborns with a pulse < 60bpm and continued until the pulse increases > 60bpm.
  • Newborns requiring field resuscitation are at high risk for complications and will require critical care by neonatologists; consider stability of both patients for destination decisions (Mother and Newborn).

PREGNANCY COMPLICATION

Ref. No. 1217-P
Base Hospital Contact: Required for vaginal bleeding at > 20 weeks pregnancy and newborn
delivery ❶ ❷ ❸ ❹
  1. Do not delay transport for treatment if suspected eclampsia; Manage delivery en route
  2. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  3. Administer Oxygen prn (MCG 1302)
  4. Establish vascular access (MCG 1375)
    • Vascular access should not take precedence over controlled delivery or emergency transport
  5. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 20mL/kg IV/IO per MCG 1309
  6. If crown is showing with amniotic sac intact, pinch sac and twist the membrane to rupture
BREECH DELIVERY
  1. Support presenting part and allow newborn to deliver
  2. If head does not deliver, place gloved hand inside mother and form “V” formed with fingers by
    • baby’s face to provide an opening for the airway
PROLAPSED CORD
  1. Manually elevate presenting fetal part off the umbilical cord; maintain elevation of the presenting
    • part until transfer of care ❺
  2. Wrap cord with moist gauze
NUCHAL CORD
  1. If nuchal cord is loose attempt slipping the cord over the head prior to delivery
  2. If the cord is too tight to easily slip over the head, clamp the cord in two places 1 inch apart and
    • cut the cord with scissors
SHOULDER DYSTOCIA
  1. Perform McRobert’s maneuver with suprapubic pressure in order to deliver the anterior shoulder
    • ❻
MATERNAL HYPERTENSION (SBP ≥140mmHg and/or DBP ≥90mmHg) / ECLAMPSIA ❼
  1. Place mother in left lateral decubitus position
  2. For seizure, treat in conjunction with TP 1231-P, Seizure
POST-PARTUM HEMORRHAGE ❽
  1. Massage the mother’s lower abdomen (fundal massage)
  2. Establish 2 IVs, large bore catheter (16g or 18g) preferred
  3. Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 20mL/kg IV/IO per MCG 1309
Special Considerations
  • Pediatric patients who are pregnant must be evaluated for child maltreatment and are at high risk for complications during delivery for the mother and the newborn.
  • This protocol was intended for complications of pregnancy at the time of delivery; if patient is known to be pregnant and has complaints not associated with labor or delivery treat per TP 1202-P, General Medical or most applicable protocol.
  • If the patient has vaginal bleeding associated with known pregnancy >20 weeks, Contact Base and communicate signs and symptoms so that the receiving hospital can pre-notify OB consultants as needed.
  • Any delivery after the first trimester (12 weeks) should be considered childbirth for the purposes of this treatment protocol and paramedics should contact Base to discuss the management and transport. In general, delivery prior to 20 weeks gestation is nonviable and does not require resuscitation. However, dates can be incorrectly estimated, therefore, Base Contact is strongly encouraged. Any potentially viable birth should be resuscitated in the field and transported to a perinatal center that is also an EDAP (with a NICU if ≤34 weeks gestation). Births prior to 20 weeks do not necessarily require specialty center care and can be transported to the MAR.
  • In addition to manually elevating the presenting part from the umbilical cord, placing the patient in Trendelenburg position during transport can help to elevate the presenting part off the cord to maintain blood flow to the fetus. Do not attempt to push a prolapsed cord back in.
  • Shoulder dystocia is inability to deliver the anterior shoulder, which usually occurs in large newborns. If delivery fails to progress after head delivers, hyperflex mother’s hips tightly in knee to chest position and apply firm suprapubic pressure in attempt to dislodge anterior shoulder (McRobert’s maneuver).
  • Consider preeclampsia and eclampsia when evaluating patients at or beyond 20 weeks gestation and post-partum up to 6 weeks after delivery. Preeclampsia and eclampsia require immediate emergency and obstetric care. Patients in this group with SBP ≥140mmHg or DBP ≥90mmHg, or with new-onset seizure (with or without elevated blood pressure) should be transported to a Perinatal Center for evaluation.
  • Some bleeding is normal during delivery, typically up to 500mL. Bleeding is reduced with fundal massage, which promotes contraction of the uterus.

PREGNANCY / LABOR

Ref. No. 1218-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Establish vascular access prn (MCG 1375)
  4. Monitor frequency and duration of contractions ❶
  5. If delivery is imminent ❷, treat per TP 1215-P, Childbirth (Mother)
  6. If breech presentation, shoulder dystocia, nuchal cord or prolapsed cord treat per
    • TP 1215-P, Childbirth (Mother) in conjunction with TP 1217-P, Pregnancy Complication
  7. Opiate or Ketoralac analgesia is contraindicated (MCG 1345)
Special Considerations
  • The more frequent the contractions, the closer the patient is to delivery; if the contractions are < 2 minutes apart or last > 60 seconds prepare for delivery. Women who have had prior vaginal deliveries can progress through labor very rapidly.
  • Crowning, urge to push, or presentation of a presenting part indicate imminent delivery.

BRIEF RESOLVED UNEXPLAINED EVENT (BRUE)

Ref. No. 1235-P
Base Hospital Contact: Required prior to transport for all patients with BRUE ❶ ❷ ❸
  1. Assess patient’s airway and initiate basic and/or advanced airway management prn (MCG 1302)
    • ❹
  2. Administer Oxygen prn (MCG 1302)
  3. For suspected foreign body aspiration treat per TP 1234-P, Airway Obstruction
  4. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-lead ECG if dysrhythmia suspected
    • For bradycardia treat per TP 1212-P, Cardiac Dysrhythmia - Bradycardia
  5. Establish vascular access prn (MCG 1375)
  6. For poor perfusion (MCG 1355)
    • Normal Saline 20mL/kg IV/IO rapid infusion (MCG 1309) ❺
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  7. For persistent ALOC – treat per TP 1229-P, ALOC
Special Considerations
  • Obtain thorough history or physical examination that one or more of the following occurred and is resolved: cyanosis or pallor, absent, decreased, or irregular breathing, marked change in tone (hyper- or hypotonia), or altered level of responsiveness – document Provider Impression BRUE
  • Patients with a brief resolved unexplained event or a BRUE require Base Contact and transport to a PMC. For patients with ongoing signs of serious illness Base Contact should be made for discussion on appropriate destination. Vital signs vary by age and normal ranges can be found in MCG 1309. Any pediatric patient with vital signs outside the normal range for age should be considered potentially ill and transported to an EDAP or PMC if criteria are met.
  • EMS Personnel are mandated reporters of child abuse and neglect, and a report should be made when suspected as per Ref. 822. Communicate suspicion for child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkempt home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to the Department of Children and Family Services (DCFS).
  • Support respiration prn with BMV using “squeeze-release-release” technique; hyperventilation has negative effects on coronary and cerebral perfusion and should be avoided.
  • In infants < 1 month of age with increasing respiratory distress after fluid resuscitation, stop infusion as it may be a result of volume overload and contact Base for medical direction.
Section 06

Allergy / Airway / ENT / Eye

ALLERGY

Ref. No. 1219-P
Base Hospital Contact: Required for anaphylaxis.
  1. Assess airway and initiate basic airway maneuvers (MCG 1302)
    • Continually assess patient’s airway and ventilation status
  2. Administer Oxygen prn (MCG 1302)
    • High-flow Oxygen 15L/min for anaphylaxis with poor perfusion or airway compromise
  3. Advanced airway prn (MCG 1302)
  4. Initiate cardiac monitoring prn (MCG 1308)
  5. For anaphylaxis:
    • Epinephrine (1mg/mL) 0.01mg/kg IM, dose per MCG 1309, in the lateral thigh ❶
    • CONTACT BASE: Repeat Epinephrine (1mg/mL) 0.01mg/kg IM every 10 min x2 prn persistent symptoms, maximum total 3 doses
  6. Establish vascular access prn (MCG 1375)
    • Vascular access for all patients with anaphylaxis
  7. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
  8. For persistent poor perfusion after initial 5mL/kg Normal Saline (anaphylactic shock):
    • Continue Normal Saline 20mL/kg IV rapid infusion
    • Push-dose Epinephrine – mix 9mL Normal Saline with 1mL Epinephrine (0.1mg/mL) IV formulation in a 10mL syringe; administer Push-dose Epinephrine (0.01mg/mL), dose per MCG 1309 every 1-5 minutes as needed to maintain normal SBP per MCG 1309 until hospital arrival
    • CONTACT BASE concurrent with initial dose of Push-dose Epinephrine
    • Treat in conjunction with TP 1207-P, Shock/Hypotension
  9. If wheezing: ❷
    • < 4 year of age: Albuterol 2.5mg (3mL) via neb or 2 puffs via MDI per MCG 1309 ❸
    • ≥ 4 year of age: Albuterol 5mg (6mL) via neb or 4 puffs via MDI per MCG 1309 ❸
    • Repeat x2 prn, maximum 3 total doses prior to Base contact
  10. For itching/hives:
    • Diphenhydramine (50mg/mL) 1mg/kg slow IV push one time, dose per MCG 1309 ❹
    • If unable to obtain venous access, Diphenhydramine (50mg/mL) 1mg/kg deep IM, dose per
    • MCG 1309
Special Considerations
  • Epinephrine is the drug of choice for allergic reactions with any one of the following: angioedema, respiratory compromise or poor perfusion. It should be given IM into a large muscle group, lateral thigh preferred or alternatively the lateral gluteus. Vital signs vary by age and normal ranges can be found in MCG 1309. Any pediatric patient with vital signs outside the normal range for age should be considered potentially ill and transported to an EDAP or PMC if criteria are met.
  • Patients with wheezing due to allergic reaction should be treated with Epinephrine IM. Albuterol may be administered in addition to Epinephrine IM if wheezing persists.
  • Consider blow-by to avoid agitation in pediatric patients if a mask cannot be tolerated (e.g., infants and toddlers).
  • Diphenhydramine does not treat anaphylaxis. For patients in anaphylaxis, Epinephrine administration is the first priority. Diphenhydramine may be considered once other treatments are complete or in stable patients with discomfort for isolated hives.

ENT / DENTAL EMERGENCIES

Ref. No. 1226-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  4. Control bleeding with direct pressure ❶
  5. For epistaxis:
    • Control bleeding by pinching nose just distal to nasal bone with head in neutral position and patient sitting forward❷
    • Document Provider Impression – Epistaxis
  6. For tooth avulsion:
    • Handle it by the enamel (crown) and do not touch the root
    • Place in container with Normal Saline
  7. For complaints of throat irritation and/or foreign body sensation:
    • Assess for airway obstruction, if present treat per TP 1234, Airway Obstruction
    • For throat complaints without airway obstruction, document Provider Impression – ENT/Dental
    • Emergencies
  8. Establish vascular access prn (MCG 1375)
  9. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  10. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
Special Considerations
  • If unable to sit upright due to poor perfusion or concerns for trauma with possible thoracic or lumbar spinal injury, consider log rolling on side to prevent airway compromise.
  • To prevent aspiration and for patient comfort, sit patient in high Fowler’s position leaning forward and suction prn.

EYE PROBLEM

Ref. No. 1228-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Assess for additional signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  3. If penetrating globe injury present/suspected, shield the eye and position patient at 45 degrees ❶
    • Do not put any pressure on the eye
  4. Do not remove any impaled foreign bodies from eye; secure them in place
  5. If contacts lenses are present and the patient is unable to remove them, leave in place
  6. Establish vascular access prn (MCG 1375)
  7. Burns to eye:
    • Chemical Burn – Irrigate with Normal Saline 1L
    • Thermal Burn – Cover with dry dressing
    • Treat in conjunction with TP 1220-P, Burns
  8. For eye pain: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  9. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
Special Considerations
  • Consider a penetrating globe injury with any eye trauma, especially penetrating trauma, large subconjunctival hemorrhage, abnormal shaped pupil or iris, or the appearance of fluid or tissue coming from the eye.

AIRWAY OBSTRUCTION

Ref. No. 1234-P
Base Hospital Contact: Required for patients with severe respiratory distress and/or respiratory
arrest.
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302) ❶
  2. Administer Oxygen prn (MCG 1302)
    • High flow Oxygen 15L/min for all patients with impending respiratory arrest/failure ❷
  3. For airway obstruction due to foreign body:
    • If patient unable to speak but is conscious, perform 5 back blows, then 5 abdominal thrusts (chest thrusts for <1 year) alternating;
    • If patient becomes unconscious lower to ground and begin chest compressions
    • If patient is unconscious, initiate CPR x 2 min
    • Perform direct laryngoscopy to visualize potential obstruction when indicated
    • Remove visible foreign body with Magill forceps
  4. If patient has an Unmanageable Airway (MCG 1302):
    • Initiate immediate transport to EDAP and CONTACT BASE en route
  5. Advanced airway prn for patients of appropriate age and size (MCG 1302)
  6. Initiate cardiac monitoring (MCG 1308)
  7. If patient is conscious and spontaneous ventilation is adequate:
    • Monitor in position of comfort
  8. Consider specific presentation:
    • For suspected anaphylaxis treat per TP 1219-P, Allergy
    • For stridor concerning for croup or tracheitis:
    • <1 year old: Epinephrine (1mg/mL) 2.5mL via neb, dose per MCG 1309 ❷
    • ≥ 1 year of age: Epinephrine (1mg/mL) 5mL via neb, dose per MCG 1309 ❷
    • Repeat x1 in 10 min prn, maximum 2 total doses prior to Base contact
    • Prepare to manage airway if patient’s condition deteriorates
    • For visible airway/tongue swelling:
    • Epinephrine (1mg/mL) 0.01mg/kg IM dose per MCG 1309
    • Repeat every 10 min prn x2, maximum 3 total doses prior to Base contact
    • For patients with a tracheostomy and suspected obstruction: ❸
    • Attempt suctioning
    • Remove and clean inner cannula with saline; replace if positive-pressure ventilation required ❹
    • If obstruction is not relieved by above maneuvers:
    • For children ≥ 7 years of age consider placing a 6.0mm endotracheal tube in the stoma and attempt BMV ❺
    • For children < 7 years of age remove entire tracheostomy tube and cover stoma and attempt
    • BMV first via the mouth. If no chest rise attempt BMV over stoma with a small mask.
Special Considerations
  • In evaluation of patient with suspected airway obstruction, assessment of the airway should include the tongue and posterior oropharynx, including uvula and tonsillar pillars.
  • Consider blow-by to avoid agitation in pediatric patients if a mask cannot be tolerated (e.g., infants and toddlers).
  • Common tracheostomy emergencies include obstruction of the tracheostomy tube and bleeding. There are different types of tracheostomy tubes, some with an inner cannula and/or obturator. The obturator obstructs airflow and is usually only used during insertion. The inner cannula allows for connection to a ventilator or bag mask for positive pressure ventilation. Tracheostomy tubes may be cuffed (balloon inflated in the trachea as indicated by a side port) or uncuffed. If the tracheostomy does not have a cuff, the airway is not protected against aspiration and air can leak out through the mouth during positive-pressure ventilation. If respiratory failure occurs in a patient with an uncuffed tracheostomy tube, it should be replaced with a cuffed endotracheal tube (if the appropriate size is available) if feasible in order to facilitate positive-pressure ventilation. For bleeding, direct pressure should be applied and suctioning as needed to reduce aspiration of blood.
  • The inner cannula is required to attach a ventilator or bag mask to a tracheostomy for positive- pressure ventilation. It may become obstructed with secretions; remove, clean with saline, and replace once obstruction is relieved. If it cannot be replaced, cover the stoma with gauze and begin BMV via the mouth. If no chest rise, place a small mask over the stoma and begin stoma-mask ventilation.
  • Removal and reinsertion of the tracheostomy tube is contraindicated if the tracheostomy is < 1 week old because the stoma has not fully formed and a false tract may be created. Once the stoma has matured, a tracheostomy can be safely removed and replaced when necessary. If a flexible intubation guide (e.g., Bougie) can be inserted, it may be used to guide the removal and reinsertion of the tracheostomy or endotracheal tube.
Section 07

Respiratory & Inhalation

INHALATION INJURY

Ref. No. 1236-P
Base Hospital Contact: Required for severe respiratory distress unresponsive or not amenable to
CPAP
  1. Assess scene for safety
  2. Use appropriate PPE
  3. Remove from environment if potential for ongoing exposure
  4. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  5. If patient awake and alert, place in position of comfort
  6. Administer Oxygen prn (MCG 1302)
    • High-flow Oxygen 15L/min for all patients with smoke inhalation, carbon monoxide exposure, or severe respiratory distress due to airway injury, regardless of SpO2 ❶
  7. Advanced airway prn (MCG 1302)
  8. If patient has an Unmanageable Airway (MCG 1302)
    • Initiate immediate transport to the EDAP and CONTACT BASE
  9. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  10. For airway burns, treat in conjunction with TP 1220-P, Burns
  11. For suspected carbon monoxide exposure, treat in conjunction with TP 1238-P, Carbon Monoxide
    • Poisoning
  12. For suspected exposure to hazardous materials including cyanide toxicity, treat in conjunction
    • with TP 1240-P, HAZMAT
  13. For airway edema and/or stridor:
    • < 1 year old: Epinephrine (1mg/mL) 2.5mL via neb per MCG 1309 ❶
    • ≥ 1 year of age: Epinephrine (1mg/mL) 5mL via neb per MCG 1309 ❶
    • Repeat x1 in 10 min prn
  14. For wheezing/bronchospasm (consider also for cough):
    • < 4 year of age: Albuterol 2.5mg (3mL) via neb per MCG 1309 ❶
    • ≥ 4 year of age: Albuterol 5mg (6mL) via neb per MCG 1309 ❶
    • Repeat x2 prn
    • CONTACT BASE for additional Albuterol after maximum dose administered
  15. Initiate CPAP for alert patients with moderate or severe respiratory distress, size longer than the
    • length-based resuscitation tape (e.g., Broselow Tape),
    • Hold CPAP for patients with hypotension, suspected pneumothorax, upper airway edema/obstruction, or other contraindications (MCG 1315) ❷
  16. Initiate cardiac monitoring prn (MCG 1308)
  17. Establish vascular access prn (MCG 1375)
  18. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
Special Considerations
  • Consider blow-by to avoid agitation in pediatric patients if a mask cannot be tolerated (e.g., infants and toddlers).
  • While CPAP may be used in pediatric patients, current ALS equipment does not support use of CPAP in pediatric patients who are not longer than the Broselow Tape™.

RESPIRATORY DISTRESS

Ref. No. 1237-P
Base Hospital Contact: Required for respiratory failure, severe respiratory distress or hypoxia
and for patients < 1 year old with moderate respiratory distress
  1. Use appropriate PPE ❶
  2. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302; 1309) ❷❸
    • ❹
  3. Maintain patient in position of comfort❺
  4. Administer Oxygen prn (MCG 1302) ❷
    • High flow Oxygen 15 L/min for all patients with impending respiratory failure, suspected pneumothorax, inhalation injury, or carbon monoxide exposure
    • Use Oxygen with caution in patients with known congenital heart disease
  5. If patient with stridor, obstruction or tracheostomy concerns, treat per TP 1234-P, Airway
    • Obstruction
  6. If anaphylaxis suspected, treat in conjunction with TP 1219-P, Allergy
  7. Initiate cardiac monitoring prn (MCG 1308)
    • For suspected dysrhythmia, perform 12-lead ECG and CONTACT BASE
    • For patients with dysrhythmias, treat per TP 1212-P, Cardiac Dysrhythmia - Bradycardia or
    • TP 1213-P, Cardiac Dysrhythmia - Tachycardia ❻
  8. For bronchospasm, wheezing or asthma exacerbation:
    • < 4 years of age: Albuterol 2.5mg (3mL) via neb or 2 puffs via MDI per MCG 1309 ❼
    • ≥ 4 years of age: Albuterol 5mg (6mL) via neb or 4 puffs via MDI per MCG 1309 ❼❽
    • May repeat x2 prn wheezing
    • Document Provider Impression – Respiratory Distress / Bronchospasm
  9. For deteriorating respiratory status despite albuterol:
    • Epinephrine (1mg/mL) 0.01mg/kg IM, dose per MCG 1309
    • Consider giving initially if wheezing with poor perfusion or severe respiratory distress ❾
    • CONTACT BASE concurrent with Epinephrine
  10. Establish vascular access prn (MCG 1375)
  11. Initiate CPAP for alert patients with moderate or severe respiratory distress with length greater
    • than the length-based resuscitation tape (e.g., Broselow Tape)
    • Hold CPAP for patients with hypotension, suspected pneumothorax, upper airway edema/obstruction, or other contraindications (MCG 1315) ❿
  12. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For patients with persistent poor perfusion, treat in conjunction with
    • TP 1207-P, Shock/Hypotension
  13. Consider etiology ⓫
    • For bronchospasm, wheezing, bronchiolitis, or asthma exacerbation document Provider
    • Impression – Respiratory Distress / Bronchospasm
    • For other and unknown causes of respiratory distress document Provider Impression –
    • Respiratory Distress / Other
  14. If sepsis suspected, treat in conjunction with TP 1204-P, Fever/Sepsis
  15. If accidental or intentional overdose or toxic exposure is suspected, treat in conjunction with
    • TP 1241-P, Overdose/Poisoning/Ingestion
  16. If inhalation injury suspected, treat in conjunction with TP 1236-P, Inhalation Injury
  17. Perform needle thoracostomy for suspected tension pneumothorax (MCG 1335)
  18. For agitation post-advanced airway in patients who require ongoing ventilation support,
    • administer sedation and analgesia prn, dose per MCG drug reference.
Special Considerations
  • Consider wearing surgical mask when caring for patients with respiratory distress of unclear etiology, which may be infectious.
  • Patients with cyanotic congenital heart disease may be expected to have a measured SpO2 of 75- 85%. Parents/caretakers may also know the patient’s “normal” SpO2 range. It is important to ask caretakers and consider this possibility, as administration of Oxygen in these patients will worsen respiratory status.
  • Initiate BMV to assess patient response. Effective BMV may improve the patient’s respiratory status enough to restore adequate spontaneous respirations. Place advanced airway placement if BMV is ineffective and consider placement once assessment for rapidly reversible causes is complete as authorized per MCG 1302; supraglottic airway (sizing per MCG 1309) is preferred unless contraindicated. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality for pediatric patients in whom multiple modalities are authorized.
  • If positive pressure ventilation is performed at any time, document Provider Impression as Respiratory Arrest / Respiratory Failure.
  • Fowler’s or Semi-Fowler’s positioning is likely to be most comfortable for awake patients with respiratory distress. Avoid agitating children with suspected partial foreign body obstruction and/or impending airway failure. Allow parents/caretakers to handle/facilitate patient if safe to do so.
  • In pediatric patients with respiratory distress, bradycardia is likely to represent a pre-terminal event, ensure that oxygenation and ventilation is adequate; bradycardic dysrhythmia is persistent despite adequate oxygenation and ventilation before moving to TP 1212-P, Cardiac Dysrhythmia – Bradycardia. Respiratory rates vary by age and normal ranges can be found in MCG 1309.
  • Consider blow-by to avoid agitation in pediatric patients if a mask cannot be tolerated (e.g., infants and toddlers).
  • Administration of albuterol via a metered-dose inhaler (MDI) with spacer is considered equivalent to nebulized albuterol; a spacer is typically required for this route to be effective in novice users. MDIs are single use and should be left with the hospital staff upon handoff of the patient.
  • Epinephrine may be administered prior to albuterol as initial drug therapy in patients with Respiratory Failure due to bronchospasm.
  • While CPAP may be used in pediatric patients, current ALS equipment does not support use of CPAP in pediatric patients who are not longer than the length-based resuscitation tape (e.g., Broselow Tape).
  • Etiologies of respiratory distress in pediatrics are varied; etiologies may include the following: • Bronchospasm due to asthma, bronchiolitis, reactive airway disease or viral illness – document Provider Impression as Respiratory Distress / Bronchospasm • Pneumonia or Upper Respiratory Illness – document Provider Impression as Respiratory Distress / Other • Croup or Bacterial Tracheitis – document Provider Impression as Airway Obstruction • Spontaneous pneumothorax – document Provider Impression as Respiratory Distress / Other • Acute Chest Syndrome in patients with Sickle Cell Disease – document Provider Impression as Chest Pain – Not Cardiac. For patients with history of Sickle Cell Disease presenting with chest pain, respiratory distress, and hypoxia, treat in conjunction with TP 1202-P, General Medical.

CARBON MONOXIDE EXPOSURE

Ref. No. 1238-P
  1. Assess scene for potential hazards and number of patients
  2. Remove patient from the source of carbon monoxide ❶
  3. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  4. Administer high-flow Oxygen 15 L/min (MCG 1302)
  5. Initiate cardiac monitoring prn (MCG 1308)
  6. If carbon monoxide monitor available, consider measuring CO level ❷
    • Report and document results
  7. Establish vascular access prn (MCG 1375)
  8. For altered level of consciousness, treat in conjunction with TP 1229-P, ALOC
  9. Assess for signs of trauma
    • For traumatic injury, treat in conjunction with TP 1244-P, Traumatic Injury
  10. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  11. For suspected exposure to hazardous materials including cyanide toxicity, treat in conjunction
    • with TP 1240-P, HAZMAT ❸
Special Considerations
  • Symptoms of carbon monoxide poisoning include headache, altered level of consciousness, malaise, nausea, dizziness and unresponsiveness. Consider carbon monoxide when multiple persons in same location present with any of these symptoms.
  • The measured carbon monoxide level should not impact the transport decision. It will be helpful for hospital treatment of the exposure.
  • Exposures to certain chemicals can be associated with carbon monoxide poisoning. For example, methylene chloride (dichloromethane) is an industrial solvent and a component of paint remover. It is metabolized to carbon monoxide by the liver and may cause carbon monoxide toxicity if inhaled or ingested.
Section 08

Environmental & Toxicology

BURNS

Ref. No. 1220-P
Base Hospital Contact: Required for burns meeting Trauma Center criteria, 2nd or 3rd degree
burns ≥ 10% TBSA.
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
    • If evidence of inhalation injury, treat in conjunction with TP 1236-P, Inhalation Injury
  2. Administer Oxygen prn (MCG 1302)
    • If carbon monoxide exposure suspected, provide high-flow Oxygen 15 L/min and treat in conjunction with TP 1238-P, Carbon Monoxide Poisoning ❶
  3. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  4. Remove jewelry and clothing from involved area
  5. Apply blanket to keep patient warm ❷
  6. For ELECTRICAL burns
    • Cover with dry dressing or sheet, treat in conjunction with TP 1221-P, Electrocution
  7. For THERMAL burns ❸
    • Cover with dry dressing or sheet
    • Consider cooling with water for burns isolated to less than 5% BSA
  8. For CHEMICAL burns
    • If dry, brush and flush with copious amounts of water
    • If liquid, flush with large amounts of water ❹
    • If eye involvement, irrigate eye with Normal Saline 1L during transport; allow patient to remove contact lenses if possible, treat in conjunction with TP 1240-P, HAZMAT
  9. Establish vascular access prn (MCG 1375)
    • For IO placement in alert patients administer Lidocaine 2% 0.5mg/kg (20mg/mL) slow IO push, dose per MCG 1309, may repeat once for infusion pain at half initial dose
  10. For partial/full thickness burn >10% body surface area or poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 20mL/kg IV/IO
  11. Elevate burned extremities as able for comfort
  12. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
Special Considerations
  • Consider potential for carbon monoxide and/or cyanide toxicity in closed space fires. Pulse oximetry is not accurate in carbon monoxide poisoning. (TP 1238-P, Carbon Monoxide Poisoning)
  • Infants and small children are at high risk for hypothermia due to their large surface area to body mass ratio, reduced ability to shiver, and limited body fat.
  • EMS Personnel are mandated reporters of child abuse and neglect, and a report should be made when suspected as per Ref. 822. Communicate suspicion for child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkept home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to the Department of Children and Family Services (DCFS).
  • Observe for hypothermia; cooling large surface area burns (>10% body surface area) may result in hypothermia.

ELECTROCUTION

Ref. No. 1221-P
  1. Ensure source of electricity is turned off ❶
  2. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  3. For cardiac arrest, treat per TP 1210-P Cardiac Arrest ❷
  4. Administer Oxygen prn (MCG 1302)
  5. Advanced airway prn (MCG 1302)
  6. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-Lead ECG prn
    • If cardiac dysrhythmia present, treat in conjunction with TP 1212-P, Cardiac Dysrhythmia-
    • Bradycardia or TP 1213-P, Cardiac Dysrhythmia-Tachycardia ❸
  7. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  8. Remove jewelry and clothing from involved areas
  9. Establish vascular access prn (MCG 1375)
  10. For burns, treat in conjunction with TP 1220-P, Burns
    • Cover affected areas with dry dressing or sheet ❹
  11. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  12. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  13. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
Special Considerations
  • Do not touch the patient unless you have removed the source of the electricity. An electrical current can be conducted through water and skin. Ensure that area surrounding the patient is dry before approaching him/her.
  • Consider prolonged cardio-pulmonary resuscitation.
  • Electrocution may result in ventricular tachycardia, ventricular fibrillation, asystole or other dysrhythmias. However, if the patient is in a regular rhythm on evaluation, they are unlikely to develop a dysrhythmia.
  • Superficial skin findings do not correlate with the severity of an electrical burn. As the electrical current passes through tissue, it can cause more damage than is superficially present.

HYPERTHERMIA (ENVIRONMENTAL)

Ref. No. 1222-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring (MCG 1308)
    • For patients with dysrhythmias, treat in conjunction with TP 1212-P, Cardiac Dysrhythmia-
    • Bradycardia or TP 1213-P, Cardiac Dysrhythmia-Tachycardia
  4. Initiate cooling measures ❶ ❷
    • For altered patients perform on-scene cooling with ice bath immersion when age-appropriate, if possible, monitor for mental status improvement, immersion not to exceed 15 minutes ❸
  5. For patients with fever due to presumed infection/sepsis, treat per TP 1204-P, Fever/Sepsis ❹
  6. For patients with seizure, treat in conjunction with TP 1231-P, Seizure
  7. Establish vascular access prn (MCG 1375)
  8. For altered level of consciousness, also consider other causes per TP 1229-P, ALOC
  9. For adequate perfusion and normal mental status, encourage oral hydration
  10. For poor perfusion (MCG 1355) or if unable to take fluids orally:
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
Special Considerations
  • Cooling measures should include moving patient to a cooler environment (e.g. ambulance with air conditioner), removing clothing, applying wet towels, and fanning/blowing cool air from air conditioning vents. If shivering occurs, stop and cover with a dry blanket.
  • Children left in vehicles are at significant risk of hyperthermia even with normal external ambient temperatures, because of the greenhouse effect. Entrapped children should be immediately extricated; this may require breaking the window.
  • Altered level of consciousness, including confusion, lethargy, unresponsiveness and seizures, in patients with suspected heat emergency should be treated as heatstroke, a time-critical emergency, with a goal of decreasing body temperature by at least 3°C within the first 30 minutes of care to decrease the risk of cardiovascular collapse. The most efficient method for performing this is to initiate immersion in cold or ice water for up to 15 minutes. When age-appropriate, this should be initiated on-scene or during transport if equipment is available.
  • This protocol is intended for hyperthermia due to environmental exposures and toxic ingestions.

HYPOTHERMIA / COLD INJURY

Ref. No. 1223-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Initiate cardiac monitoring (MCG 1308)
    • For patients with dysrhythmias, treat in conjunction with TP 1212-P, Cardiac Dysrhythmia-
    • Bradycardia or TP 1213-P, Cardiac Dysrhythmia-Tachycardia
  4. Provide warming measures ❶ ❷
  5. For frostbite:
    • Handle affected area gently, remove jewelry, cover and protect the area ❸
  6. Establish vascular access prn (MCG 1375)
  7. For altered level of consciousness, treat in conjunction with TP 1229-P, ALOC
  8. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309; use warm saline if available
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  9. For cardiac arrest, treat in conjunction with TP 1210-P, Cardiac Arrest
    • Initiate rewarming while resuscitation is ongoing ❹
Special Considerations
  • Warming measures should include moving the patient to a warm environment as quickly as possible, removing wet clothing/items, covering with an emergency/rescue blanket or blanket/sheets, and using warm normal saline if available.
  • Infants and small children are at high risk for hypothermia due to their large surface area to body mass ratio, reduced ability to shiver, and limited body fat.
  • Do not allow an area of frostbite to thaw and then refreeze as this causes more tissue damage.
  • Follow usual protocols for resuscitation of patients with hypothermic cardiac arrest while rewarming. Patients with hypothermia may have good neurologic outcome despite prolonged resuscitation; resuscitative efforts should continue until the patient is rewarmed. Consultation with the Base Physician is required before consideration of termination of resuscitation.

STINGS / VENOMOUS BITES

Ref. No. 1224-P
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Prioritize treatment of systemic symptoms
    • For signs or symptoms of allergic reaction, treat in conjunction with TP 1219-P, Allergy
    • For poor perfusion (MCG 1355), treat in conjunction with TP 1207-P, Shock/Hypotension
  3. Keep patient calm and limit activity
    • Position affected extremity at or below level of the heart
  4. For SNAKE BITES:
    • Splint the affected area
    • Elevate the extremity to the level of the heart
  5. For INSECT (bee, wasp, ant), SPIDER and SCORPION STINGS:
    • Remove stinger if visualized ❶
    • Apply cold pack
  6. For MARINE ENVENOMATIONS (e.g., jelly fish, stingrays and scorpion fish):
    • Remove barb when applicable
    • Soak area in hot water ❷
  7. Establish vascular access prn (MCG 1375)
  8. For continued pain after specific measures above: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  9. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
Special Considerations
  • Remove stinger by scraping patient's skin with the edge of a flat surface (credit card or similar). Do not attempt to pull the stinger out with fingernails or tweezers, as this may cause release of additional venom.
  • Do not use vinegar given the type of jellyfish endemic to California.

SUBMERSION

Ref. No. 1225-P
Base Hospital Contact: Required for ALOC and decompression emergencies (Ref. 518).
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. For cardiac arrest, treat per TP 1210-P, Cardiac Arrest ❶
  3. Administer Oxygen prn (MCG 1302)
    • For suspected decompression illness ❷, provide high-flow Oxygen 15L/min and CONTACT
    • BASE
  4. Maintain supine if suspected decompression illness
  5. Advanced airway prn (MCG 1302)
  6. Initiate cardiac monitoring (MCG 1308)
  7. Provide warming measures ❸ ❹
  8. Establish vascular access prn (MCG 1375)
  9. For altered level of consciousness, treat in conjunction with TP 1229-P, Altered Level of
    • Consciousness (ALOC)
  10. For respiratory distress, treat in conjunction with TP 1237-P, Respiratory Distress ❺
  11. For poor perfusion (MCG 1355) or for suspected decompression illness:
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309; use warm saline if available ❺
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  12. Contact Public Health 213-989-7140 for all submersion incidents involving pools or spas after
    • transfer of patient care in the emergency department or upon termination of resuscitation in the field. ❻
Special Considerations
  • Cardiac arrest from drowning should be treated per TP 1210-P, Cardiac Arrest. Ventilation is particularly important as the cardiac arrest is almost always due to respiratory failure. In cases of cold water drowning follow usual protocols for resuscitation while simultaneously rewarming the patient. Patients with hypothermia due to cold water drowning, may have good neurologic outcome despite prolonged resuscitation; resuscitative efforts should continue until the patient is rewarmed. Consultation with the Base Physician is required before consideration of termination of resuscitation in patients with suspected hypothermia.
  • Decompression illness includes arterial gas embolism from barotrauma and decompression sickness (aka “the bends”) due to dissolved nitrogen in the blood coming out of solution. Decompression illness most frequently occurs in scuba divers after breathing compressed air at depth. While arterial gas embolism presents almost immediately after ascent, decompression sickness is often delayed and should be considered in any patient with symptoms (e.g. respiratory distress, ALOC, chest or body pain) within 24 hours of completing a dive. All patients with possible decompression illness need immediate evaluation for possible hyperbaric treatment. Per Ref. 518, contact Base immediately to discuss.
  • Warming measures should include moving the patient to a warm environment as quickly as possible, removing wet clothing/items, covering with an emergency/rescue blanket or other blankets/sheets, and using warm Normal Saline if available.
  • Infants and small children are at high risk for hypothermia due to their large surface area to body mass ratio, reduced ability to shiver, and limited body fat.
  • Rales may be present in patients after submersion/drowning due to direct lung injury and/or aspiration of water. This is not an indication of cardiogenic pulmonary edema (such as from congestive heart failure), which is extremely rare in children, and does not prohibit administration of IV fluids. IV fluids should be initiated and continued unless respiratory status worsens during administration.
  • EMS is assisting the Department of Public Health (DPH) in promptly investigating fatal or nonfatal drownings at public pools or spas in order to ensure safety can be verified before reopening. Contacting the on-call DPH officer will allow timely investigation of these incidents and prevent future incidents.

HAZMAT

Ref. No. 1240-P
Contact Medical Alert Center (MAC) for all MCIs prior to transport otherwise notify the receiving
hospital ❶
1. Secure area, establish incident site, and don protective equipment/gear appropriate for
hazardous material exposure according to the provider agency protocol
2. If MCI, begin triage (Ref. 519.2 and Ref. 519.5)
Provide MAC with the following incident information: properties of contaminant, type of
decontamination performed, signs/symptoms, and smells
3. Remove patient from source if safe to do so, and move to decontamination area prn
4. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
5. Administer Oxygen prn (MCG 1302)
6. Remove patient’s clothing
7. Flush skin, eyes and mucous membranes with copious amounts of water
For eye involvement, irrigate with Normal Saline 1L during transport; allow patient to remove
contact lenses if possible
8. Initiate cardiac monitoring (MCG 1308)
Perform 12-lead ECG prn
For patients with dysrhythmias, treat in conjunction with TP 1212-P, Cardiac Dysrhythmia -
Bradycardia or TP 1213-P, Cardiac Dysrhythmia - Tachycardia
9. Establish vascular access prn (MCG 1375)
10. Assess for signs of trauma
If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
11. For poor perfusion (MCG 1355):
Normal Saline 20mL/kg IV rapid infusion per MCG 1309
For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
12. Consider contacting the Poison Control Center in conjunction with the Base Hospital for
assistance with management of toxins (Ref. 805)
NERVE AGENT EXPOSURE
13. If multiple symptomatic patients with > 50 victims involved, request EMS CHEMPACK from the
MAC (Ref. 1108)
14. Pediatric patients longer than the length-based resuscitation tape (Broselow™) should be
treated according to adult doses which are listed below and found in TP 1240, HAZMAT ❷
Mild Exposure: 1 DuoDote IM
Moderate Exposure: 2 DuoDotes IM, one after the other
Severe Exposure: 3 DuoDotes IM, one after the other
  1. Pediatric patients between 3 – 36 kilograms body weight based on measurement using the
    • length-based resuscitation tape (Broselow™) should be treated as follows: ❷
    • Mild Exposure: Atropine (0.1mg/mL) 0.02mg/kg IV/IM, dose as per MCG 1309
    • Moderate Exposure: 1 DuoDote IM
    • Severe Exposure: 1 or 2 DuoDote(s) IM, one after the other when applicable, based on the table below:
    • Avg Wt (KG) Color Initial Emergency Dose 4 Grey 6.5 Pink 8.5 Red 1 DuoDote 10.5 Purple 13 Yellow 16.5 White 20.5 Blue 26 Orange 2 DuoDotes 33 Green
    • *Duodote (2.1mg Atropine/600 mg 2PAM Chloride)
  2. For seizure, treat in conjunction with TP 1231-P, Seizure
  3. For EMS CHEMPACK Deployment:
    • EMS CHEMPACK may be used for repeat dosing as necessary
    • Avg Wt Color Repeat Atropine 2PAM Chloride* Diazepam** Multi-dose
    • (KG) Dose Multi-dose Multi-dose vial vial (5mg/mL) 0.1 – vial (0.4mg/mL) (50mg/mL) 50 0.2mg/kg IV or IM 0.1mg/kg IV or IM mg/kg IM or IV prn seizure 4 Grey 0.4mg, 1mL 200mg, 4mL 0.5 mg, 0.1mL 6.5 Pink 0.7mg, 1.75mL 325mg, 6.5mL 1mg, 0.2mL 8.5 Red 0.9mg, 2.25mL 425mg, 8.5mL 1.5mg, 0.3mL 10.5 Purple 1mg, 2.5mL 525mg, 10.5mL 2mg, 0.4mL 13 Yellow 1.3mg, 3.25mL 650mg, 13mL 2.5mg, 0.5mL 16.5 White 1.6mg, 4mL 825mg, 16.5mL 3mg, 0.6mL 20.5 Blue 2mg, 5mL 1000mg, 20mL 4mg, 0.8mL 26 Orange 2.6mg, 6.5mL 1000mg, 20mL 5mg, 1mL 33 Green 3.3mg, 8.25mL 1000mg, 20mL 6mg, 1.2mL
    • Repeat Atropine dose prn 5 minutes after initial emergency DuoDote. Multi-dose vials can provide closer to ideal dosages, if available.
    • *Repeat Pralidoxime dose 60 minutes after Initial Emergency DuoDote.
    • ** For seizure, if utilizing the CHEMPACK, prioritize midazolam to treat pediatric seizure per TP- 1231-P, Seizure since the diazepam autoinjector will be too large a dose for pediatric patients.
    • If midazolam supply is limited, multi-dose vial diazepam may be available and can be administered as per above table.
    • Dosing is rounded to the nearest tenth.
    • IV preferred route for Diazepam but can administer IM if not IV available
    • May repeat diazepam dose x1 in 5 min
    • If the child is too tall for the pediatric resuscitation tape and adult size, treat per adult protocol
    • TP 1240, HAZMAT
ORGANOPHOSPHATE EXPOSURE
  1. For heart rate < 60bpm, hypotension, respiratory depression and/or extreme salivation
    • Atropine (0.1mg/mL) 0.05mg/kg IV/IO
    • May be repeated every 5 min, maximum total dose 5mg
    • For seizure, treat in conjunction with TP 1231-P, Seizure
RADIOLOGIC EXPOSURE
  1. If radiation contamination is suspected, confirm by using appropriate detection devices
    • available through Department of Public Health (DPH), Radiation Management at (213) 989- 7140
  2. If radiation contamination present, identify the cause of the contamination ❸
    • Internal Radiation is exposure through open wound, ingestion or inhalation of radioactive materials
    • External Radiation is exposure through a Radiological Dispersal Device (RDD), Radiological
    • Material Release (RMR) or Radiological Exposure Device (RED)
  3. For External Radiation:
    • If a RDD is used and in the absence of any other information, evacuate 1,650 feet in all directions from the detonation site and then contact the MAC ❸
    • Notify DPH Radiation Management at (213) 989-7140 if departmental HAZMAT team is not available and prolonged exposures are expected ❹
  4. For patients with a life-threatening condition:
    • Treat using appropriate treatment protocol based on complaints in conjunction with decontamination
    • Remove the outer clothing and utilize containment mitigation techniques before transport
  5. For patients without a life-threatening condition:
    • Decontaminate using departmental protocols
    • Treat using appropriate treatment protocol based on signs and symptoms
  6. Asymptomatic and minimal exposure suspected:
    • Decontaminate and release patient if appropriate ❺
CYANIDE EXPOSURE
  1. For patients with cardiovascular, neurologic, and/or respiratory compromise due to suspected or
    • known cyanide exposure:
    • Hydroxocobalamin 70mg/kg IV/IO, dose per MCG 1309
    • Reconstitute 5 grams in 200mL of Normal Saline (25mg/ml) and infuse over 15 minutes
    • May repeat x1 in 15 min
Special Considerations
  • If MCI, MAC should be contacted for 5 or more patients and coordinate all destination decisions otherwise the Base Hospital should be notified as specified in this protocol, and if no Base Hospital required then the receiving hospital will be notified.
  • Nerve agent exposure symptom severity: SEVERE: severe respiratory distress, respiratory arrest, cyanosis, extreme SLUDGE (salivation, lacrimation, urination, defecation, gastrointestinal distress and emesis) seizures, unconsciousness MODERATE: miosis, rhinorrhea, shortness of breath, vomiting, diarrhea MILD: miosis, rhinorrhea and increased salivation
  • Radiation Exposure Safety: Exposure to victims with internal radiation poses low-to-no risk to EMS personnel Exposure to victims with external radiation exposure poses low-to-moderate risk to EMS personnel Remember the following principles: Time: limit time with the victim to a minimum Distance: the further away from the source, the smaller the dose received. Shielding: “Turnouts” will protect from alpha and beta emitters, wear respiratory protection if particulate matter (i.e., dust or powder) present
  • The HAZMAT team, MAC, or Department of Public Health Radiation Management will be able to redefine boundaries, establish radiation dose guidelines, assist with monitoring and decontamination procedures, and provide support to on-scene responders. These resources may also refer to Emergency Response Guidebook for other recommended scene precautions.
  • If number of patients exceeds available resources, asymptomatic patients with minimal exposure may be released for home decontamination.

OVERDOSE / POISONING / INGESTION

Ref. No. 1241-P
1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
2. Administer Oxygen prn (MCG 1302)
3. Establish vascular access prn (MCG 1375) ❶
4. For suspected opioid overdose with altered mental status and hypoventilation/apnea:
Naloxone (1mg/mL) 0.1mg/kg IM/IN/IV, dose per MCG 1309 ❶ or
Naloxone 2-4 mg IN if using pre-packaged nasal spray (1mg per nostril or 4mg/0.1 mL IN
depending on formulation available); excludes newborns ❷
Maximum dose all routes 8 mg
Titrate to adequate respiratory rate and tidal volume
5. If partial response to Naloxone and strong suspicion for opioid overdose:
CONTACT BASE for additional doses of Naloxone
6. For respiratory distress, treat in conjunction with TP 1237-P, Respiratory Distress
7. Initiate cardiac monitoring prn (MCG 1308)
For suspected cardiac ischemia or dysrhythmia, perform 12-lead ECG and CONTACT BASE
For patients with dysrhythmias, treat in conjunction with TP 1212-P, Cardiac Dysrhythmia -
Bradycardia or TP 1213-P, Cardiac Dysrhythmia - Tachycardia
8. Evaluate for other causes of altered level of consciousness (MCG 1320)
9. Assess for signs of trauma
If traumatic injury suspected, treat in conjunction with TP 1244-P, Traumatic Injury
  1. Check blood glucose
    • If < 60mg/dL or > 250mg/dL, treat in conjunction with TP 1203-P, Diabetic Emergencies
  2. For alcohol intoxication, document Provider Impression – Alcohol Intoxication
    • For other intoxications, including overdose or ill affects of prescription medications and illicit substances, document Provider Impression – Overdose/Poisoning/Ingestion
  3. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • For persistent poor perfusion, treat in conjunction with TP 1207-P, Shock/Hypotension
  4. CONTACT BASE to discuss antidote administration
    • Calcium channel and/or beta blocker overdose: Calcium chloride (100mg/mL) 20mg/kg slow
    • IV push, dose per MCG 1309 ❸
    • Tricyclic antidepressant overdose: Sodium bicarbonate (1mEq/mL) 1mEq/kg slow IV push, dose per MCG 1309 ❹
  5. Assess for co-ingestion of other substances
  6. Consider contacting the Poison Control Center (1-800-222-1222) in conjunction with Base for
    • assistance with identification and management of unknown medications/toxins (Ref. 805)
  7. Bring containers of ingested substances to the emergency department with patient
  8. If patient refuses treatment or transport, CONTACT BASE
    • Patient/parent must demonstrate decision-making capacity (Ref. 834)
    • If EMS personnel or Base Hospital determines it is necessary to transport the patient against their will and/or the will of the parent, contact law enforcement for assistance❺
Special Considerations
  • The first priority for apneic patients after narcotic overdose is to begin positive pressure ventilation. Once ventilations are established, naloxone should be administered with the goal of restoring spontaneous ventilations. Vascular access should not take priority over initial treatment with Naloxone (IN or IM) for patients with suspected opiate overdose. Patients who are awake and alert with normal respirations after naloxone therapy may not require IV access or additional doses of naloxone.
  • Higher dose pre-packaged nasal spray should not be used in the newborn/neonate due to potential risk to precipitate withdrawal.
  • Signs of calcium channel overdose include bradycardia along with hypotension and hyperglycemia. Signs of beta blocker overdose include bradycardia along with hypotension and hypoglycemia. Consider when the patient is taking or has access to a calcium channel and/or beta blocker medication. Ask about potential exposures including medications in the home.
  • ECG findings consistent with tricyclic overdose include wide QRS (>0.12mm) and terminal R in aVR. Consider when the patient is taking or has access to a tricyclic medication. Ask about potential exposures including medications in the home.
  • EMS Personnel are mandated reporters of child abuse and neglect. Communicate concerns about child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkempt home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to Department of Children and Family Services.
Section 09

Trauma

CRUSH INJURY/SYNDROME

Ref. No. 1242-P
Base Hospital Contact: Required for patients at risk for crush syndrome ❶ or prolonged
entrapment > 30 minutes. ❷
  1. For multi-system trauma, treat in conjunction with TP 1244-P, Traumatic Injury
  2. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  3. Provide spinal motion restriction (SMR) if indicated (MCG 1360)
    • For alert patients, logroll patient off backboard (if used during extrication) and onto gurney prior to transport ❸
  4. Administer Oxygen prn (MCG 1302)
  5. For anticipated prolonged extrication (> 30 minutes)
    • Consider activating the Hospital Emergency Response Team (HERT), Ref. 817
  6. Establish vascular access immediately (MCG 1375) ❹
  7. Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309 as soon as possible and prior to
    • release of compressive force
    • Repeat x1 for a total of 40mL/kg IV/IO, maximum prior to Base contact 2L
    • CONTACT BASE to obtain order for additional Normal Saline 20 mL/kg IV/IO if persistent entrapment ❹
  8. Initiate cardiac monitoring (MCG 1308)
    • Assess for signs of hyperkalemia
  9. Apply blanket to keep patient warm ❺
  10. If evidence of hyperkalemia (peaked T-waves in multiple leads, absent p-waves, and/or widened QRS complex) administer: ❻
    • Calcium Chloride (100mg/mL) 20mg/kg slow IV/IO push, dose per MCG 1309
    • Repeat x1 for persistent ECG abnormalities
    • Sodium Bicarbonate (1mEq/mL) 1 mEq/kg slow IV/IO push, dose per MCG 1309
    • Repeat x1 for persistent ECG abnormalities
    • Albuterol 5mg (6mL) via neb, repeat continuously until hospital arrival ❼
    • CONTACT BASE for persistent ECG abnormalities to obtain order for additional medications ❽
  11. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  12. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT
  13. For CRUSH INJURY without risk of crush syndrome
    • Release compression and extricate patient
    • Monitor cardiac rhythm for signs of hyperkalemia
  14. Consider pre-positioning a tourniquet prior to extrication in order to prevent hemorrhage upon
    • release of compression
  15. For patients at risk for CRUSH SYNDROME ❶, administer the following medications 5 minutes
    • prior to extrication: ❹ ❻ ❽ ❾
    • Calcium Chloride (100mg/mL) 20mg/kg slow IV/IO push, dose per MCG 1309
    • Sodium Bicarbonate (1mEq/mL) 1 mEq/kg slow IV/IO push, dose per MCG 1309
    • Albuterol 5mg (6mL) via neb, repeat immediately x1
    • If unable to establish vascular access while entrapped
    • Place tourniquet PRIOR to extrication ❿
Special Considerations
  • Crush syndrome is a systemic illness characterized by dysrhythmias and shock. It results from toxins released from crushed muscle tissue into the blood stream. Patients are at risk for crush syndrome if they have all of the following: 1) circumferential compression causing crush injury; AND 2) involvement of a large muscle group (lower extremity including the thigh(s) and/or pelvic girdle or upper extremity including the pectoral girdle); AND 3) entrapment for at least 1 hour. The risk of crush syndrome increases with the amount of muscle involved and the duration of the entrapment.
  • For patients requiring transport to a Pediatric Trauma Center per Ref. 506, which is also a Base Hospital, contact receiving Pediatric Trauma Center for Base Medical Direction and notification. If the Base Hospital is contacted and the Base redirects transport to a Pediatric Trauma Center, Base personnel will notify the Pediatric Trauma Center.
  • A backboard is not required for spinal motion restriction (SMR) and may cause harm as well as increased pain. Patients should not be transported on a backboard for the purpose of SMR. If a backboard is used for extrication, patients who are alert should then be logrolled onto the gurney prior to transport. The backboard may be used during patient transport for splinting of multiple simultaneous extremity fractures or to assist with maneuvering the unconscious patient. In all cases, the backboard should be removed immediately if causing respiratory compromise.
  • Patients with significant crush injury at risk for crush syndrome require large volumes of fluid resuscitation. Patients with prolonged entrapment will require maintenance fluids. IO access should be considered when attempts at IV access are not successful if: 1) prolonged entrapment is likely (> 30 minutes) and/or 2) there are signs of hyperkalemia and/or 3) there is risk of crush syndrome requiring medication administration.
  • Infants and small children are at high risk for hypothermia due to their large surface area to body mass ratio, reduced ability to shiver, and limited body fat.
  • Flush the IV line with normal saline after each medication. Administration of Calcium and Bicarbonate together will cause precipitation of the medication.
  • Dosing differs from MCG 1309; higher doses of albuterol are required to treat hyperkalemia. Consider blow-by to avoid agitation in pediatric patients if a mask cannot be tolerated (e.g., infants and toddlers).
  • The duration of action of the medications is approximately 30 minutes. Contact Base to discuss re- dosing the medications if persistent signs of hyperkalemia or if the patient will not arrive at the hospital within 30 minutes.
  • These medications should be administered prior to release of the compressive force to prevent complications from the cellular toxins that enter the circulation upon extrication of the patient. Calcium stabilizes the cardiac muscle and should be administered first.
  • Tourniquet placement PRIOR to extrication is a last resort for patients who are at risk for crush syndrome in whom vascular access cannot be established or when transport time is anticipated to be > 30 minutes. The tourniquet must completely occlude venous and arterial flow in order to protect the patient from crush syndrome. Establish vascular access and cardiac monitoring immediately after extrication and be prepared to treat symptoms of crush syndrome.

TRAUMATIC ARREST

Ref. No. 1243-P
Base Hospital Contact: Contact the Trauma Center for patients not meeting criteria for
determination of death per Ref 814. ❶
  1. Prioritize rapid transport for patients who do not meet Ref. 814 ❷
  2. Immediately control major bleeding (MCG 1370)
    • Apply tourniquet prn
  3. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302; 1309) ❸
    • Ventilate with high flow Oxygen 15L/min
  4. Begin chest compressions
  5. Perform bilateral needle thoracostomy for suspected tension pneumothorax (MCG 1335)
  6. Initiate cardiac monitoring (MCG 1308)
    • Assess cardiac rhythm
  7. If shockable rhythm (V-Fib/V-Tach) identified:
    • Defibrillate V-Fib/V-Tach, dose per MCG 1309
    • For penetrating trauma: ❹
    • Defibrillate while prioritizing immediate transport
    • For blunt trauma: ❺
    • Initiate resuscitation on scene
    • If organized rhythm is not restored after defibrillation x3 or patient converts to nonshockable rhythm
    • CONTACT BASE for guidance on continued resuscitation or transport
  8. Provide spinal motion restriction (SMR) if indicated (MCG 1360)
    • Do not delay transport for SMR ❻
  9. Establish vascular access en route (MCG 1375)
    • Establish IO if unable to establish IV access
  10. Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309 x2, maximum 2L
    • Administer through two sites simultaneously if possible
  11. Hanging/asphyxia should be transported to the nearest Pediatric Medical Center (PMC) if
    • transport is <30 mins or Emergency Department Approved for Pediatrics (EDAP) if > 30 minutes, not trauma center, unless other evidence of trauma
Special Considerations
  • EMS Personnel are mandated reporters of child abuse and neglect, and a report should be made when suspected as per Ref. 822. Communicate suspicion for child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkept home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to the Department of Children and Family Services (DCFS).
  • Rapid transport after hemorrhage control is the priority for all patients with severe trauma. With the exception of hemorrhage control, needle thoracostomy, and initiation of CPR, all other procedures may be deferred for immediate ambulance loading of patient and performed en route.
  • Bag-mask ventilation (BMV) is the preferred initial method of airway management. An advanced airway may be placed as authorized per MCG 1302 once initial resuscitation priorities are complete, and preferably during transport, unless BMV is ineffective; supraglottic airway (sizing per MCG 1309) is preferred unless contraindicated. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality for pediatric patients in whom multiple modalities are authorized.
  • Patients with penetrating trauma should receive defibrillation while still prioritizing early transport.
  • Sudden cardiac death can result from blunt cardiac injury (commotio cordis) triggering V-fib/V-tach. Patients in cardiac arrest due to commotio cordis typically have minimal external trauma and should be treated as a medical cardiac arrest, with immediate defibrillation on scene. If the patient with suspected commotio cordis remains in V-fib/V-tach after two defibrillations, contact Base to discuss transport versus continued on-scene resuscitation. Patients with multisystem blunt trauma in persistent cardiac arrest and without organized rhythm are generally not transported.
  • For patients in traumatic arrest, spinal motion restriction (SMR) using a backboard causes harmful delays in care. However, a backboard may be helpful to assist in patient movement and to support chest compressions.

TRAUMATIC INJURY

Ref. No. 1244-P
Base Hospital Contact: Required for patients who meet Trauma Center criteria or guidelines. ❶❷
Notify the receiving Pediatric Trauma Center as soon as possible for all patient transports.
  1. Immediately control major bleeding (MCG 1370)
    • Apply tourniquet prn
  2. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302; 1309) ❸
  3. For traumatic arrest, treat per TP 1243-P, Traumatic Arrest
  4. Provide spinal motion restriction (SMR) if indicated (MCG 1360)
    • For alert patients, logroll patient off the backboard (if used during extrication) and onto gurney prior to transport ❹
  5. Administer Oxygen prn (MCG 1302)
    • High flow Oxygen 15L/min for all patients with shock or with suspected traumatic brain injury
  6. If patient has an Unmanageable Airway: (MCG 1302)
    • Initiate immediate transport to EDAP and CONTACT BASE en route
  7. For anticipated prolonged extrication (> 30 minutes)
    • Consider activating the Hospital Emergency Response Team (HERT), Ref. 817
  8. For crush injury, treat in conjunction with TP 1242, Crush Injury/Syndrome
  9. Initiate cardiac monitoring prn (MCG 1308)
  10. Establish vascular access prn (MCG 1375)
  11. Apply blanket to keep patient warm ❺
  12. Consider medical condition preceding accident and refer to appropriate treatment protocol prn ❻
MULTI-SYSTEM TRAUMA
  1. Perform needle thoracostomy for suspected tension pneumothorax (MCG 1335)
  2. For an open or sucking chest wound, cover with a commercially available vented chest seal or
    • vented (3-sided) occlusive dressing ❼
  3. For poor perfusion (MCG 1355) with hypotension per MCG 1309:
    • Normal Saline 20mL/kg IV/IO rapid infusion per MCG 1309 ❽
    • CONTACT BASE to discuss further fluid resuscitation
  4. Cover eviscerated organs with a moist non-adhering dressing
  5. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  6. For nausea or vomiting in patients ≥ 4 years old:
    • Ondansetron 4mg ODT ❾
ISOLATED HEAD INJURY
  1. Administer high flow Oxygen 15L/min ❿
    • Continually assess patient’s airway and ventilation status, assist prn ⓫
  2. For poor perfusion (MCG 1355) or hypotension per MCG 1309:
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309 to maintain normal SBP per MCG 1309 ⓬
    • CONTACT BASE for persistent poor perfusion (MCG 1355) to obtain order for additional Normal
    • Saline 20mL/kg IV
  3. For nausea or vomiting in patients ≥ 4 years old: ❾
    • Ondansetron 4mg ODT
  4. Transport with head of gurney elevated to 30 degrees when possible ⓭
  5. If patient develops seizure activity, treat in conjunction with TP 1231-P, Seizure
  6. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
ISOLATED EXTREMITY INJURY
  1. For pain management: refer to MCG 1345, Pain Management
    • Dose per MCG 1309
  2. For poor perfusion (MCG 1355):
    • Normal Saline 20mL/kg IV rapid infusion per MCG 1309
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 20mL/kg IV
  3. Splint and dress injuries prn
    • For distal extremity fractures with poor neurovascular status distal to injury – realign and stabilize extremity
    • Mid-shaft femur – apply traction splint per manufacturer guidelines ⓮
    • All other fractures/dislocations – splint in position of comfort
    • For amputations – rinse off debris (do not manually debride), wrap with saline-moistened sterile gauze and ace wrap, then apply a splint for potential underlying fracture
Special Considerations
  • EMS Personnel are mandated reporters of child abuse and neglect, and a report should be made when suspected as per Ref. 822. Communicate suspicion for child abuse and/or neglect to accepting ED staff when home suggests children could be at risk for harm (e.g., unkept home, evidence of drug or alcohol abuse, unsafe living conditions, known or suspected domestic violence), when the history does not match with the severity of physical findings (e.g., child posturing after a roll off the couch), when patterned injury or burns or noted (e.g., circular burns as from a cigarette, whip marks on the skin, burns of both hands or feet), or when child reports physical or sexual abuse. Children < 3 years of age and those with developmental delay are at increased risk of abuse. This must also be accompanied by notification to the Department of children and Family Services (DCFS).
  • For patients requiring transport to a Pediatric Trauma Center per Ref. 506, which is also a Base Hospital, contact receiving Pediatric Trauma Center for Base Medical Direction and notification. If the Base Hospital is contacted and the Base redirects transport to a Pediatric Trauma Center, Base personnel will notify the Pediatric Trauma Center.
  • Transport should be prioritized over advanced airway placement unless BMV is ineffective. Advanced airway may be placed during transport as authorized per MCG 1302; supraglottic airway (sizing per MCG 1309) is preferred unless contraindicated. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality for pediatric patients in whom multiple modalities are authorized.
  • A backboard is not required for spinal motion restriction (SMR) and may cause harm as well as increased pain. Patients should not be transported on a backboard for the purpose of SMR. If a backboard is used for extrication, patients who are alert should then be logrolled onto the gurney prior to transport. The backboard may be used during patient transport for splinting of multiple simultaneous extremity fractures or to assist with maneuvering the unconscious patient. In all cases, the backboard should be removed immediately if causing respiratory compromise.
  • Infants and small children are at high risk for hypothermia due to their large surface area to body mass ratio, reduced ability to shiver, and limited body fat.
  • Traumatic events may be due to a medical emergency, e.g. seizure.
  • Placement of a vented dressing can prevent conversion of an open pneumothorax to a tension pneumothorax. However, tension pneumothorax may still develop in the presence of a vented dressing and should be treated with needle thoracostomy. Furthermore, needle thoracostomy in a patient with evidence of tension pneumothorax should not be delayed for placement of dressing.
  • Fluid resuscitation increases vascular pressure and dilutes clotting factors, which may increase internal bleeding. For patients at risk of internal hemorrhage, fluids should only be administered for hypotension and other signs of poor perfusion, titrated to maintain SBP within normal range for age. In patients with penetrating trauma, permissive hypotension (withholding fluids if patient has normal mental status) is preferred to reduce ongoing blood loss. Patients with ALOC or hypotension should receive fluids until their mental status and SBP improve. Permissive hypotension is contraindicated in patients with possible traumatic brain injury.
  • Vomiting should be prevented and/or immediately treated in patients with head injury, since it increases intra-cranial pressure and can compromise the patient’s airway.
  • Any hypoxic episode, even brief, is associated with worse patient outcome for patients with traumatic brain injury.
  • Hyperventilation reduces blood flow to the brain by reducing CO2 and is associated with worse outcomes in severe head injuries. Ventilate to maintain an ETCO2 in the range 35-45mmHg.
  • Any hypotension increases mortality in patients with traumatic brain injury. Normal Saline should be initiated to maintain SBP within normal range for age at all times but can be withheld if the blood pressure is elevated. The level of systolic blood pressure varies by age. Those thresholds are found in MCG 1309 and should be used in decisions for fluid resuscitation.
  • A head-elevated position at about 30 degrees reduces intra-cranial pressure and improves respiratory status. Reverse Trendelenburg is an option for patients that cannot be seated. Patients who are hypotensive should be maintained supine unless airway compromise requires repositioning.
  • Open femur fracture is not a contraindication to apply the traction splint. If the bone is protruding and there is gross contamination, wash with saline prior to applying the splint.
Section 10

Quick Reference & Key Numbers

How to use this section
These are the numbers, thresholds, and weight-based doses that show up most often on exams and in the field. Every value below traces back to a specific Pediatric Treatment Protocol (TP-P) above — use the Ref. No. to jump back for full context. Always cross-check exact volumes against MCG 1309 or your agency's length-based resuscitation tape.

Universal Fluid & Poor Perfusion Rule (MCG 1355)

SituationAction
Poor perfusion, most medical protocolsNormal Saline 20mL/kg IV/IO rapid infusion per MCG 1309
Persistent poor perfusion after fluidsTreat in conjunction with TP 1207-P, Shock/Hypotension → Push-dose Epinephrine if refractory
Push-dose Epinephrine prep9mL NS + 1mL Epinephrine 0.1mg/mL (IV formulation) in a 10mL syringe = 0.01mg/mL; give per MCG 1309 q1-5min. For patients <10kg, transfer to a smaller 1-3mL syringe for dosing accuracy

Cardiac Arrest Epinephrine & Antiarrhythmic Timing (TP 1210-P)

RhythmEpinephrineAntiarrhythmic
V-Fib/pulseless V-Tach0.01mg/kg IV/IO (0.1mg/mL), begin AFTER 2nd defibrillation, repeat q5min x2 (max single dose 1mg)Amiodarone 5mg/kg IV/IO for persistent/recurrent V-Fib/V-Tach
Asystole/PEA0.01mg/kg IV/IO as early as possible, repeat q5min x2 (max single dose 1mg)N/A — consider/treat reversible causes (hypoxia, hypovolemia, hyperkalemia, hypothermia, toxins, tension pneumo)
Defibrillation energy2J/kg initial, 4J/kg for subsequent shocks each 2-min cycle
Compression:ventilation15:2 at 100-120 compressions/min (newborn: 3:1 at 120/min total)

Broselow / Weight-Based Seizure Midazolam Dosing (TP 1231-P)

Age / ColorMidazolam Dose (5mg/mL) IM/IN
0-11 months (Gray, Pink)0.2mg/kg
12-16 months (Red)1.25mg (0.25mL)
17 months-5 years (Purple, Yellow, White)2.5mg (0.5mL)
6-11 years (Blue, Orange, Green)5mg (1mL)
≥12 years (longer than tape)10mg (2mL), single dose prior to Base contact

May repeat x1 in 2 min prn, up to 2 doses prior to Base contact. Base-ordered max: 3 total doses OR 20mg, whichever is less.

Key Doses That Are Frequently Tested

Drug / SituationDoseNotes
Naloxone (any route)0.1mg/kg IM/IN/IV/IOMax ALL routes combined = 8mg (TP 1241-P/1210-P)
Epinephrine, anaphylaxis0.01mg/kg (1mg/mL) IM lateral thighRepeat q10min x2 with Base contact, max 3 total doses (TP 1219-P)
Epinephrine, stridor/croup<1yr: 2.5mL; ≥1yr: 5mL (1mg/mL) via nebMay repeat x1 in 10 min, max 2 doses prior to Base contact (TP 1234-P)
Epinephrine, angioedema0.01mg/kg IMRepeat q10min x2, max 3 total doses prior to Base contact (TP 1234-P)
Adenosine, SVT/regular WCT0.1mg/kg (max 6mg), then 0.2mg/kg (max 12mg)Weight-based, NOT fixed adult 12mg/12mg (TP 1213-P)
Atropine, bradycardia0.02mg/kg IV/IOReserved for AV block or epi-unresponsive; may repeat x1 in 5 min (TP 1212-P)
Atropine, organophosphate0.05mg/kg IV/IORepeat q5min, max total dose 5mg (TP 1240-P)
Dextrose, hypoglycemia≤24kg: D10 5mL/kg in 1mL/kg increments; >24kg: D10 125mLGlucagon 0.5mL (<1yr) or 1.0mL (≥1yr) IM if no access (TP 1203-P)
Calcium Chloride, hyperkalemia/crush20mg/kg (100mg/mL) slow IV/IOFlush line before/after — precipitates with bicarb (TP 1212-P/1242-P)
Sodium Bicarbonate, crush/TCA OD1mEq/kg (1mEq/mL) slow IV/IOBase order for TCA OD; standing order pre-extrication for crush syndrome (TP 1241-P/1242-P)
Hydroxocobalamin, cyanide70mg/kg IV/IO (5g/200mL NS = 25mg/mL) over 15 minMay repeat x1 in 15 min (TP 1240-P)
DuoDote, nerve agent (<Broselow max)Mild: Atropine 0.02mg/kg; Moderate: 1 DuoDote; Severe: 1-2 DuoDotes by color code≥length of tape treated with adult dosing (TP 1240-P)
Diphenhydramine, dystonic reaction/hives1mg/kg slow IV push or deep IMDoes NOT treat anaphylaxis itself (TP 1219-P/1239-P)

Standing Order vs. Base Hospital Contact — Common Gray Areas

SituationStanding Order?
Epinephrine IM for anaphylaxis (1st dose)Standing order (TP 1219-P); repeat doses require Base contact
Midazolam for uncooperative/agitated patientBase contact required CONCURRENT with administration (TP 1209-P)
Calcium Chloride / Bicarb pre-extrication for crush syndromeStanding order (TP 1242-P)
Calcium channel/beta blocker or TCA overdose antidotesBase order required (TP 1241-P)
Additional epinephrine doses beyond 3 in arrestBase order required (TP 1210-P)
Dystonic reaction DiphenhydramineBase contact required to confirm impression before treating (TP 1239-P)
Sedation for TCP or cardioversionMidazolam standing order up to max single dose, additional doses need Base order (TP 1212-P/1213-P)

Destination Decision Quick Hits

PresentationDestination
Suspected stroke/TIA, BRUE, focal neuro deficitsPMC (Base contact required prior to transport)
Newborn delivery/resuscitationPerinatal Center with EDAP (add NICU if ≤34wk gestation)
Pediatric ROSC after cardiac arrestPMC if within 30 minutes transport
Major/critical burn (2nd/3rd degree ≥10% TBSA, age ≤14)Trauma/Burn Center per Ref. 506 criteria
Hanging/asphyxia traumatic arrestNearest PMC if <30min, else EDAP — NOT trauma center, absent other trauma
Section 11

Practice Test — 57 Questions

Instructions
Tap an answer to check it instantly, then tap Show Answer & Explanation for the full rationale and protocol reference. Your running score is tracked at the bottom of the screen.
Question 1 Cardiac
You are resuscitating a 4-year-old in V-Fib/pulseless V-Tach. What is the correct initial defibrillation energy and epinephrine timing per LA County pediatric protocol?
  • 4J/kg initial, then Epinephrine before the first shock
  • 2J/kg initial (repeat at 4J/kg each cycle), Epinephrine 0.01mg/kg IV/IO beginning after the second defibrillation
  • 200J fixed dose regardless of weight, Epinephrine with every shock
  • 2J/kg initial, Epinephrine only after Amiodarone has been given
Question 2 CardiacPharmacology
A pediatric patient remains in refractory V-Fib after appropriate defibrillation and epinephrine. What antiarrhythmic and dose is indicated?
  • Lidocaine 1mg/kg IV/IO
  • Amiodarone 5mg/kg IV/IO
  • Magnesium Sulfate 2g IV/IO
  • Adenosine 0.1mg/kg rapid IV push
Question 3 Cardiac
During pediatric cardiac arrest, what compression-to-ventilation ratio and rate does LA County protocol specify?
  • 30:2 at a rate of 100-120/min
  • 15:2 at a rate of 100-120/min
  • 3:1 at 90 compressions per minute
  • Continuous compressions with 1 breath every 6 seconds only
Question 4 CardiacPharmacology
A 2-year-old has a heart rate of 35 with poor perfusion despite adequate BMV. What is the correct medication sequence?
  • Atropine first, then epinephrine if no response
  • Epinephrine (0.1mg/1mL) 0.01mg/kg IV/IO first (repeat q3-5min); Atropine 0.02mg/kg IV/IO reserved for suspected AV block or if unresponsive to epinephrine
  • Synchronized cardioversion is the first-line treatment for bradycardia
  • Transcutaneous pacing before any medications, regardless of age
Question 5 CardiacPharmacology
An infant is in SVT with a heart rate of 240 and adequate perfusion. Vagal maneuvers fail. What is the correct Adenosine dosing sequence?
  • 6mg rapid IV push, then 12mg fixed dose if it persists (adult dosing)
  • 0.1mg/kg rapid IV push (max 6mg) followed by NS flush; if SVT persists, 0.2mg/kg rapid IV push (max 12mg)
  • 0.05mg/kg IV push with no maximum
  • Synchronized cardioversion should be attempted before any Adenosine in infants
Question 6 Cardiac
How does LA County pediatric protocol define the sinus tachycardia vs. SVT cutoff for infants vs. older children?
  • Infants: HR ≥220bpm is SVT; Children: HR ≥180bpm is SVT (below these, sinus tachycardia)
  • Any HR >150bpm is SVT regardless of age
  • SVT is defined only by QRS width, not rate
  • Infants: HR ≥180bpm is SVT; Children: HR ≥220bpm is SVT
Question 7 Medical
A 10-year-old with a history of Kawasaki Disease reports chest pain. What is the correct approach per General Medical protocol?
  • Chest pain in children is essentially never cardiac and can be documented as non-cardiac without further workup
  • Recognize that Kawasaki Disease and congenital heart conditions are risk factors for pediatric cardiac ischemia; contact Base and consider a PMC/SRC destination
  • Treat exactly as an adult STEMI protocol with aspirin and nitroglycerin as standing orders
  • No special consideration is needed since the patient is asymptomatic on the monitor
Question 8 MedicalPharmacology
A 30kg child (>24kg) has a blood glucose of 42 mg/dL and is obtunded with an IV in place. What is the correct Dextrose dosing?
  • Dextrose 10% administer 125mL IV/IO and reassess, continuing infusion as needed up to a maximum of 5mL/kg
  • Dextrose 50% 25mL IV push, single dose only
  • Dextrose 10% 5mL/kg given as one rapid IV push regardless of weight bracket
  • Skip dextrose and go straight to Glucagon since the patient is obtunded
Question 9 MedicalPharmacology
A hypoglycemic infant has no IV/IO access. What is the correct Glucagon dose for a child <1 year of age?
  • Glucagon 1.0mL IM, may repeat x1 in 20 min prn
  • Glucagon 0.5mL IM, may repeat x1 in 20 min prn
  • Glucagon is contraindicated under 1 year of age
  • Glucagon 2.0mL IM as a single dose only
Question 10 Medical
An infant has a fever with a heart rate of 195. At what point does tachycardia raise concern for sepsis rather than simple fever?
  • Any tachycardia with fever should be documented as sepsis
  • Tachycardia greater than what is explained by the fever alone (>180bpm in infants, >140bpm in children) should raise concern for sepsis
  • Heart rate is not a useful data point in pediatric fever assessment
  • Only bradycardia is concerning in febrile children
Question 11 Medical
A 6-month-old is vomiting bright green material. What is the significance and correct action?
  • Green (bilious) vomiting is a normal finding in infants and requires no special urgency
  • Bile-stained (green) vomitus in an infant/child is a surgical emergency requiring rapid transport to the closest EDAP
  • Green vomitus indicates a viral gastroenteritis and should be treated with Ondansetron only
  • Green vomitus should prompt treatment per the Overdose/Poisoning protocol
Question 12 Medical
A child with a ventriculoperitoneal (VP) shunt presents with headache, vomiting, and altered mental status. What should you suspect and how should you treat?
  • Automatically document Medical Device Malfunction without further assessment and transport routinely
  • Consider shunt malfunction, breakage, obstruction, or infection as the cause; treat presenting symptoms and obtain history of last shunt revision
  • VP shunts cannot malfunction and symptoms are unrelated
  • Immediately attempt to access/tap the shunt in the field
Question 13 MedicalPharmacology
A child in shock has failed peripheral IV attempts and continues to show poor perfusion despite fluids. What is the correct Push-dose Epinephrine preparation and pediatric-specific note?
  • Mix 9mL NS with 1mL Epinephrine 0.1mg/mL in a 10mL syringe (0.01mg/mL); for patients <10kg, transfer the diluted dose into a smaller 1-3mL syringe for dosing accuracy
  • Give undiluted 1mg/mL Epinephrine directly IV push
  • Push-dose Epinephrine is not authorized in the pediatric shock protocol
  • Mix 1mL NS with 9mL Epinephrine for a more concentrated push-dose
Question 14 Medical
Per pediatric shock protocol, when should IO access be considered the primary vascular access route rather than a backup?
  • IO is never appropriate in pediatric patients
  • In extremis patients for whom peripheral IV access is unlikely to be achieved rapidly; for older children, 2 failed IV attempts before IO
  • Only after 4 failed peripheral IV attempts in any pediatric patient
  • IO should always be the first attempt in every pediatric patient regardless of condition
Question 15 Neuro
What mnemonic does LA County pediatric protocol use for the differential diagnosis of ALOC?
  • FAST-ED
  • AEIOU-TIPS
  • SAMPLE
  • OPQRST
Question 16 Neuro
Why is a complaint of true vertigo in a pediatric patient treated with more concern than in an adult?
  • It never occurs in children and should be presumed factitious
  • Vertigo is an unusual complaint in children and should be taken as a possible sign of serious disease
  • Vertigo in children is always due to inner ear infection and requires no further workup
  • It is treated identically to lightheadedness with no distinction needed
Question 17 NeuroPharmacology
A 4-year-old (Purple/Yellow/White on the Broselow tape) is actively seizing. What is the correct initial Midazolam dose and route?
  • Midazolam 2.5mg or 0.5mL IM/IN, may repeat x1 in 2 min prn (up to 2 doses prior to Base contact)
  • Midazolam 10mg IV push regardless of size
  • Midazolam 1.25mg IM/IN only, with no repeat allowed
  • Diazepam 5mg PR is first-line in this age group
Question 18 NeuroPharmacology
What is the maximum total Midazolam dose for pediatric seizure per LA County protocol, inclusive of Base-ordered doses?
  • 20mg total, unlimited doses
  • Maximum total of 3 doses OR 20 milligrams, whichever is less
  • No maximum — titrate until seizure stops
  • 10mg total maximum regardless of age
Question 19 NeuroDestination
How does the pediatric stroke protocol differ in approach from the adult LAPSS/LAMS-based stroke protocol?
  • It uses the identical mLAPSS/LAMS scoring tool as the adult protocol
  • It does not use a numeric stroke scale; instead it documents focal deficits and Last Known Well Time, with mandatory Base contact and transport to a PMC given that stroke is rare and mimics are common in children
  • Pediatric stroke patients are never transported to a specialty center
  • Only hemorrhagic strokes are relevant in pediatrics
Question 20 Neuro
A 15-year-old female has an episode of syncope. What pediatric-specific history point should be asked given the differential for syncope?
  • Ask about possible pregnancy and any vaginal bleeding, since ruptured ectopic pregnancy is a life-threatening cause of syncope in females of child-bearing age
  • Pregnancy history is not relevant to syncope evaluation
  • Only cardiac history needs to be asked
  • Syncope in teenage females is always vasovagal and needs no further questioning
Question 21 NeuroPharmacology
A child recently given Metoclopramide (Reglan) for nausea develops involuntary neck twisting and forced eye deviation. What is the correct treatment?
  • Diphenhydramine (50mg/mL) 1mg/kg slow IV push (or deep IM if no IV access), after confirming the impression with Base
  • Midazolam 0.2mg/kg IM as first-line treatment
  • Epinephrine IM as for anaphylaxis
  • No treatment is needed; symptoms will resolve spontaneously within seconds
Question 22 OB
Immediately after a field delivery, when should the umbilical cord be clamped and cut?
  • Immediately upon delivery, with no delay
  • Delay clamping and cutting for up to 30-60 seconds unless the newborn needs immediate resuscitation
  • Only after the placenta has fully delivered
  • Cord clamping should be delayed a minimum of 10 minutes in all cases
Question 23 OBPeds
A newly delivered infant has a pulse of 45bpm despite 30 seconds of effective BMV with high-flow oxygen. What is the correct next action?
  • Continue BMV alone for another 2 minutes before considering compressions
  • Begin chest compressions with high-flow oxygen and BMV at 120/min, maintaining a 3:1 compression-to-ventilation ratio (90 compressions:30 ventilations/min)
  • Give Epinephrine before starting compressions
  • Immediately place an advanced airway before any compressions
Question 24 OBPeds
Where is pulse oximetry preferentially monitored in a newborn resuscitation, and why?
  • Left foot, because it best reflects lower body perfusion
  • Right hand, because it provides the most accurate saturation during the fetal-to-normal circulation transition
  • Either ear lobe
  • Location does not matter for newborns
Question 25 OB
A pregnant adolescent patient has a shoulder dystocia during delivery. What maneuver does the protocol specify?
  • McRobert's maneuver with suprapubic pressure to deliver the anterior shoulder
  • Immediate fundal pressure only
  • Push the baby's head back into the birth canal
  • Wait passively without intervention until spontaneous delivery
Question 26 OB
What SBP/DBP threshold defines maternal hypertension warranting concern for preeclampsia/eclampsia in the pregnancy complication protocol?
  • SBP ≥140mmHg and/or DBP ≥90mmHg
  • SBP ≥180mmHg only
  • Any BP above the patient's baseline
  • DBP ≥110mmHg only
Question 27 OB
What analgesic classes are specifically contraindicated in the pediatric Pregnancy/Labor protocol?
  • Opiate and Ketorolac analgesia are contraindicated
  • Acetaminophen is contraindicated
  • No analgesics are restricted in pregnancy
  • Only NSAIDs other than Ketorolac are restricted
Question 28 Peds
An infant's caregiver reports a brief episode of cyanosis, irregular breathing, and altered responsiveness that has now fully resolved. What is the correct Provider Impression and disposition?
  • Document BRUE and disregard, since the infant now appears normal
  • Document Provider Impression BRUE; Base Hospital Contact is required prior to transport and destination is a PMC
  • This does not qualify for any specific protocol since symptoms resolved
  • Treat only if the event recurs during EMS contact
Question 29 AllergyPharmacology
A 15kg child with facial angioedema and stridor after a bee sting needs Epinephrine. What is the correct dose, concentration, and route?
  • Epinephrine (1mg/mL) 0.01mg/kg IM in the lateral thigh, repeatable with Base contact every 10 min x2 (max 3 total doses)
  • Epinephrine (0.1mg/mL) 0.01mg/kg IV push as first-line
  • Epinephrine 0.3mg fixed adult auto-injector dose regardless of weight
  • Diphenhydramine IM is first-line, with Epinephrine reserved for cardiac arrest only
Question 30 ENT
A child has an avulsed permanent tooth. What is the correct field handling?
  • Scrub the root clean before transport
  • Handle the tooth by the crown (enamel), avoid touching the root, and place it in a container with Normal Saline
  • Place the tooth in ice with no fluid
  • Attempt to reimplant the tooth in the field regardless of provider training
Question 31 Eye
A child has a suspected penetrating globe injury after being struck by a toy dart. What is the correct field management?
  • Apply firm direct pressure to control bleeding from the eye
  • Shield the eye (do not apply pressure), position the patient at 45 degrees, and do not remove any impaled object — secure it in place
  • Irrigate the eye vigorously with Normal Saline before shielding
  • Patch both eyes tightly to prevent movement
Question 32 AirwayPharmacology
A 6-month-old has barky cough and inspiratory stridor concerning for croup. What is the correct nebulized Epinephrine dose?
  • Epinephrine (1mg/mL) 2.5mL via neb, repeatable x1 in 10 min prn (max 2 total doses prior to Base contact)
  • Epinephrine (1mg/mL) 5mL via neb regardless of age
  • Racemic epinephrine is not authorized in this protocol
  • Epinephrine 0.01mg/kg IM is the only route authorized for stridor
Question 33 Airway
A 5-year-old with a tracheostomy has an obstructed tube that cannot be cleared by suctioning or inner cannula replacement. What is the correct next step given the child's age?
  • For children <7 years, remove the entire tracheostomy tube, cover the stoma, and attempt BMV via the mouth first; if no chest rise, attempt stoma-mask BMV
  • For children <7 years, immediately place a 6.0mm ETT into the stoma
  • Never remove a tracheostomy tube in the field regardless of age
  • Perform a surgical cricothyrotomy immediately
Question 34 RespiratoryPharmacology
A 3-year-old with wheezing and poor perfusion from a severe asthma exacerbation is deteriorating despite albuterol. What treatment should be considered, and when may it be given even before albuterol?
  • Epinephrine (1mg/mL) 0.01mg/kg IM; it may be given initially, before albuterol, if wheezing presents with poor perfusion or severe respiratory distress
  • IM Epinephrine is never used for asthma, only for anaphylaxis
  • Give IV Epinephrine (0.1mg/mL) 1mg as for cardiac arrest
  • Terbutaline is first-line for severe pediatric asthma per this protocol
Question 35 Respiratory
What size restriction applies to CPAP use in the pediatric respiratory distress and inhalation injury protocols?
  • CPAP has no size restriction and can be used on any pediatric patient
  • Current ALS equipment does not support CPAP use in patients who are not longer than the length-based resuscitation tape (Broselow Tape)
  • CPAP is restricted to patients over 18kg only
  • CPAP may only be used with an advanced airway already in place
Question 36 Respiratory
What condition should be strongly suspected concurrently in a pediatric patient with smoke inhalation from a closed-space fire?
  • Cyanide toxicity and carbon monoxide exposure should both be considered and treated per TP 1240-P and TP 1238-P respectively
  • Only thermal airway burns need to be considered
  • Inhalation injury never causes systemic toxicity
  • Pulse oximetry reliably rules out carbon monoxide poisoning
Question 37 Toxicology
Multiple family members from the same household present with headache, dizziness, and nausea. What should be strongly suspected, and what is the correct initial oxygen therapy?
  • Suspect carbon monoxide exposure; administer high-flow Oxygen 15L/min
  • This pattern is coincidental and does not warrant suspicion of a common cause
  • Give low-flow oxygen only to avoid oxygen toxicity
  • Oxygen is contraindicated until CO levels are measured
Question 38 TraumaEnvironmental
What is the correct fluid resuscitation trigger for a pediatric burn patient per LA County protocol?
  • Fluids are given only for burns >50% TBSA
  • Normal Saline 20mL/kg IV/IO rapid infusion for partial/full thickness burns >10% BSA or for poor perfusion
  • All burn patients automatically receive 1L NS regardless of size
  • IV fluids are contraindicated in pediatric burns
Question 39 Trauma
What child-abuse red flags does the pediatric Burns protocol specifically instruct providers to watch for?
  • Patterned injury or burns (e.g., circular cigarette burns, whip marks, burns of both hands/feet), or a history inconsistent with the severity of findings
  • Any burn on an extremity automatically indicates abuse
  • Only burns in children over age 10 require abuse screening
  • Abuse screening is not part of EMS scope of practice
Question 40 Environmental
Why can superficial skin findings be misleading in an electrical burn?
  • They are always proportional to the internal tissue damage
  • Superficial findings do not correlate with severity — current passing through tissue can cause far more internal damage than what's visible on the skin
  • Electrical burns never cause internal injury
  • Skin findings are the only reliable indicator and internal exams are unnecessary
Question 41 Environmental
An altered, hyperthermic 3-year-old is found in a hot car. What cooling method and time limit does the protocol specify?
  • Ice bath immersion (when age-appropriate) not to exceed 15 minutes, with the goal of decreasing body temperature by ≥3°C within the first 30 minutes
  • Antipyretic medication is the primary treatment
  • No active cooling is recommended in the field
  • Immersion should continue indefinitely until temperature normalizes
Question 42 Environmental
A hypothermic pediatric patient is found in cardiac arrest after cold-water exposure. What is the correct resuscitation approach?
  • Withhold resuscitation since hypothermic arrest has universally poor outcomes
  • Follow usual cardiac arrest protocols while simultaneously rewarming; hypothermic patients may have good neurologic outcome despite prolonged resuscitation, and Base consultation is required before considering termination
  • Only rewarm the patient; do not begin CPR until normothermic
  • Terminate resuscitation immediately per standard field criteria without Base contact
Question 43 Environmental
A child was stung by a jellyfish at a Southern California beach. What treatment does the protocol specify, and what should be avoided?
  • Remove the barb when applicable and soak the area in hot water; do NOT use vinegar given the jellyfish species endemic to California
  • Apply vinegar liberally as first-line treatment
  • Apply an ice pack and avoid any water exposure
  • Cut an X over the sting site and suction the venom
Question 44 Environmental
A child who was rescued from a swimming pool has crackles (rales) on lung exam but normal mental status and vital signs. Should IV fluids be withheld due to concern for pulmonary edema?
  • Yes, rales after submersion always indicate cardiogenic pulmonary edema and fluids should be withheld
  • No — rales after submersion are usually from direct lung injury/aspiration, not cardiogenic edema (which is rare in children); IV fluids should be initiated and continued unless respiratory status worsens
  • Fluids are never indicated after a submersion event
  • Rales in this context always indicate need for immediate intubation
Question 45 BehavioralPharmacology
A severely agitated adolescent poses an immediate risk to self and EMS personnel. What is the correct initial Midazolam dosing and maximum prior to Base contact?
  • Midazolam 0.2mg/kg IM/IN (or 0.1mg/kg IV if access already established), repeat x1 in 5 min prn, max single dose 5mg, max total 10mg prior to Base contact
  • Midazolam 10mg IV push as a single dose with no weight-based calculation
  • Olanzapine ODT is used for severely agitated patients with ALOC
  • Physical restraint alone is sufficient and medication is never indicated
Question 46 Behavioral
A cooperative pediatric patient with agitation who is longer than the length-based resuscitation tape can receive which standing-order medication?
  • Olanzapine 10mg Oral Disintegrating Tablet (ODT), given once
  • Midazolam 5mg IM as first-line
  • Haloperidol IM
  • No medication is authorized for cooperative patients
Question 47 ToxicologyPharmacology
A 20kg child is found apneic with pinpoint pupils and drug paraphernalia nearby. What is the correct Naloxone dose and priority of care?
  • Begin positive-pressure ventilation first, then give Naloxone (1mg/mL) 0.1mg/kg IM/IN/IV, dose per MCG 1309, max 8mg all routes combined; vascular access should not delay initial IM/IN dosing
  • Naloxone should be given before any ventilation support
  • A fixed 2mg IV dose regardless of weight is correct for all pediatric patients
  • Naloxone is contraindicated in patients under 25kg
Question 48 ToxicologyPharmacology
A child has taken an unknown quantity of a calcium channel blocker and now has bradycardia, hypotension, and hyperglycemia. What antidote requires Base contact, and at what dose?
  • Calcium Chloride (100mg/mL) 20mg/kg slow IV push, dose per MCG 1309, with Base contact required to discuss antidote administration
  • Sodium Bicarbonate 1mEq/kg is the antidote of choice for calcium channel blocker overdose
  • No specific antidote exists and only supportive care is given
  • Glucagon 5mg IV is standing order for CCB overdose in this protocol
Question 49 ToxicologyHAZMAT
A child weighing approximately 13kg (Yellow on the Broselow tape) has moderate nerve agent exposure. What is the correct treatment per the weight-based dosing table?
  • 1 DuoDote IM
  • 3 DuoDotes IM given one after another
  • Atropine 2mg IV only, no DuoDote
  • No treatment is authorized below 20kg
Question 50 ToxicologyHAZMAT
A patient has suspected cyanide toxicity with respiratory and neurologic compromise following a structure fire. What is the correct Hydroxocobalamin dose and administration?
  • 70mg/kg IV/IO, reconstituted 5g in 200mL NS (25mg/mL) infused over 15 minutes, may repeat x1 in 15 min
  • 70mg/kg IV push over 30 seconds
  • A fixed 5g dose regardless of weight given as a slow IV push
  • Hydroxocobalamin is not authorized for pediatric patients
Question 51 TraumaPharmacology
A child has been entrapped under debris for 45 minutes with a large muscle group involved. What medications should be given approximately 5 minutes prior to extrication to prevent crush syndrome complications, and in what order?
  • Calcium Chloride 20mg/kg slow IV/IO push FIRST (stabilizes cardiac muscle), then Sodium Bicarbonate 1mEq/kg slow IV/IO push, then Albuterol 5mg neb — flushing the line between Calcium and Bicarbonate
  • Sodium Bicarbonate first, then Calcium Chloride, no flush needed between them
  • Albuterol alone is sufficient prophylaxis for crush syndrome
  • No pre-extrication medications are recommended; treat only after release
Question 52 Trauma
What three criteria together define a patient 'at risk for crush syndrome' per this protocol?
  • 1) Circumferential compression causing crush injury; 2) involvement of a large muscle group (thigh/pelvic girdle or upper arm/pectoral girdle); 3) entrapment for at least 1 hour
  • Any crush injury regardless of duration or muscle group involved
  • Only injuries involving the hand or foot
  • Entrapment for any duration with any muscle group
Question 53 Trauma
A child in traumatic arrest from blunt trauma is found in V-Fib. What is the correct sequence of care?
  • Initiate resuscitation on scene with defibrillation; if a shockable rhythm persists after 3 defibrillations or converts to nonshockable, Contact Base for guidance on continued resuscitation versus transport
  • Always transport immediately without defibrillating on scene for blunt trauma
  • Defibrillation is contraindicated in traumatic arrest
  • Transport takes priority over defibrillation regardless of mechanism
Question 54 Trauma
For penetrating trauma in traumatic arrest, how does the defibrillation approach differ from blunt trauma?
  • Defibrillation is given while still prioritizing immediate transport, rather than remaining on scene
  • Defibrillation is withheld entirely for penetrating trauma
  • The same on-scene resuscitation approach as blunt trauma is used
  • Penetrating trauma patients are never defibrillated in the field
Question 55 TraumaPharmacology
A child with penetrating abdominal trauma has a normal mental status and a palpable radial pulse. What fluid strategy is correct?
  • Permissive hypotension — withhold fluids since mental status is normal, to avoid diluting clotting factors and increasing blood loss
  • Aggressively bolus 60mL/kg NS regardless of mental status
  • Fluids should always be given to maximize blood pressure regardless of trauma type
  • IV fluids are contraindicated entirely in penetrating trauma
Question 56 Trauma
What ETCO2 target should be maintained in a pediatric patient with suspected traumatic brain injury requiring ventilation?
  • 35-45mmHg, avoiding hyperventilation which reduces cerebral blood flow and worsens outcomes
  • 15-20mmHg to minimize intracranial pressure as much as possible
  • There is no target; ventilate as fast as tolerated
  • 60mmHg or greater is the target to maximize cerebral oxygenation
Question 57 Trauma
How should a mid-shaft femur fracture be splinted per pediatric traumatic injury protocol, and what about an open femur fracture with visible bone?
  • Apply a traction splint per manufacturer guidelines; an open/protruding fracture is NOT a contraindication to traction splinting
  • Traction splints are contraindicated in pediatric patients entirely
  • Only rigid board splinting is authorized for femur fractures
  • Open fractures should never be splinted, only covered
Section 12

Answer Key & Explanations

✓ Correct Answer: B
TP 1210-P defibrillates at 2J/kg initially, repeating at 4J/kg each 2-minute cycle as indicated.
Epinephrine 0.01mg/kg (0.1mg/mL concentration) IV/IO begins after the second defibrillation, repeated every 5 minutes x2, maximum single dose 1mg.
Protocol: TP 1210-P Cardiac Arrest, V-Fib/Pulseless V-Tach, steps 13-14
✓ Correct Answer: B
For persistent or recurrent V-Fib/V-Tach without pulses, TP 1210-P calls for Amiodarone (50mg/mL) 5mg/kg IV/IO, dosed per MCG 1309.
This is a single weight-based dose, not a fixed adult 300mg dose as used in the adult protocol.
Protocol: TP 1210-P Cardiac Arrest, step 15
✓ Correct Answer: B
TP 1210-P specifies chest compressions at 100-120/min with a compression-to-ventilation ratio of 15:2 (not the adult 30:2).
This 15:2 ratio is specific to pediatric two-rescuer CPR and reflects the greater relative importance of ventilation in pediatric arrest, which is more often respiratory in origin.
Protocol: TP 1210-P Cardiac Arrest, step 6
✓ Correct Answer: B
TP 1212-P treats persistent poor perfusion with Epinephrine 0.01mg/kg slow IV/IO push, repeated every 3-5 minutes, as the primary drug therapy for pediatric symptomatic bradycardia.
Atropine 0.02mg/kg IV/IO is reserved for suspected AV block or patients unresponsive to epinephrine — this differs from adult bradycardia, where atropine is first-line.
Protocol: TP 1212-P Cardiac Dysrhythmia - Bradycardia, steps 8-9
✓ Correct Answer: B
TP 1213-P doses the first Adenosine as 0.1mg/kg rapid IV push (max 6mg) immediately followed by a rapid NS flush.
If SVT persists, the second dose is 0.2mg/kg rapid IV push (max 12mg) — weight-based, not the adult fixed 12mg/12mg regimen.
Protocol: TP 1213-P Cardiac Dysrhythmia - Tachycardia, SVT-Narrow Complex, step 9
✓ Correct Answer: A
TP 1213-P defines sinus tachycardia as infants HR <220bpm and children HR <180bpm; SVT-narrow complex is infants HR ≥220bpm and children HR ≥180bpm.
This age-based cutoff (rather than a single universal number) is unique to the pediatric tachycardia algorithm.
Protocol: TP 1213-P Cardiac Dysrhythmia - Tachycardia, headers
✓ Correct Answer: B
Special Consideration ❶ of TP 1202-P notes chest pain is rarely cardiac in pediatrics, but flags Kawasaki Disease history or congenital heart conditions as risk factors warranting Base contact and consideration of a PMC or SRC-capable PMC.
Young athletes commonly show benign slow rates and ST-elevation that is not ischemic — this is a normal variant, not a red flag by itself.
Protocol: TP 1202-P General Medical, Special Consideration ❶
✓ Correct Answer: A
TP 1203-P splits dosing by weight: patients >24kg receive Dextrose 10% 125mL IV/IO, reassessed and continued as needed to a maximum of 5mL/kg.
Patients ≤24kg instead receive Dextrose 10% 5mL/kg IV/IO given in 1mL/kg increments with reassessment after every 1mL/kg — a much more titrated approach for smaller patients.
Protocol: TP 1203-P Diabetic Emergencies, step 6
✓ Correct Answer: B
TP 1203-P specifies Glucagon (1mg/mL) 0.5mL IM for patients <1 year of age, versus 1.0mL IM for patients ≥1 year, each repeatable once in 20 minutes if needed.
Glucagon is only effective if there are adequate glycogen stores in the liver, so it may not work in patients with severe malnutrition or low glycogen reserves.
Protocol: TP 1203-P Diabetic Emergencies, step 6
✓ Correct Answer: B
Special Consideration ❷ notes that fever alone often causes tachycardia, but tachycardia beyond what fever explains — >180bpm in infants or >140bpm in children — should raise suspicion for sepsis.
If sepsis is suspected (fever plus signs of poor perfusion or greater-than-expected tachycardia), document Provider Impression of Sepsis and give Normal Saline 20mL/kg IV/IO rapid infusion.
Protocol: TP 1204-P Fever/Sepsis, Special Consideration ❷
✓ Correct Answer: B
Special Consideration ❶ of TP 1205-P specifically flags bile (green) vomitus as a surgical emergency (e.g., possible malrotation with volvulus) requiring rapid transport to the closest EDAP.
This is a distinct, high-yield pediatric-specific red flag not present in the adult GI/GU protocol.
Protocol: TP 1205-P GI/GU Emergencies, step 9 and Special Consideration ❶
✓ Correct Answer: B
Special Consideration ❷ notes VP shunt complications (breakage, obstruction, infection) can present as ALOC, headache, nausea/vomiting, or fever.
The protocol directs providers to treat presenting symptoms and to obtain a history of when the shunt was last revised, since infection risk is highest soon after a revision.
Protocol: TP 1206-P Medical Device Malfunction, step 9 and Special Consideration ❷
✓ Correct Answer: A
TP 1207-P Special Consideration ❻ specifies the standard push-dose prep (9mL NS + 1mL Epi 0.1mg/mL = 0.01mg/mL) but adds a pediatric-specific note: for patients <10kg, transfer the diluted solution into a smaller 1mL or 3mL syringe to dose accurately.
This is given every 1-5 minutes as needed to maintain a normal SBP for age per MCG 1309, with concurrent Base contact.
Protocol: TP 1207-P Shock/Hypotension, step 11 and Special Consideration ❻
✓ Correct Answer: B
Special Consideration ❸ states peripheral venous access can be difficult in infants and small children, so IO may be considered as primary access in extremis patients when IV access is unlikely to be achieved rapidly.
For older children, the protocol calls for two attempts at venous access before placing an IO if unsuccessful.
Protocol: TP 1207-P Shock/Hypotension, Special Consideration ❸
✓ Correct Answer: B
Special Consideration ❶ of TP 1229-P lists AEIOU-TIPS (Alcohol/abuse/atypical migraine, Epilepsy/electrolytes, Insulin, Oxygen/overdose, Uremia, Trauma/tumor, Infection, Psych/poisoning, Seizure/subarachnoid/sepsis) as the differential framework for ALOC.
Once a specific cause is identified, the protocol directs switching to the more specific applicable protocol (e.g., TP 1203-P for hypoglycemia, TP 1241-P for overdose).
Protocol: TP 1229-P ALOC, Special Consideration ❶
✓ Correct Answer: B
Special Consideration ❶ explicitly states vertigo is an unusual complaint for children and should be taken as a possible sign of serious disease, distinct from lightheadedness (which is more often benign/orthostatic).
If focal neurologic findings are present with vertigo, contact Base and transport to a PMC.
Protocol: TP 1230-P Dizziness/Vertigo, Special Consideration ❶
✓ Correct Answer: A
TP 1231-P uses Broselow color-code-based dosing for active seizure: the 17 months-5 years bracket (Purple, Yellow, White) receives Midazolam 2.5mg (0.5mL) IM/IN, repeatable once in 2 minutes, up to 2 total doses before Base contact.
IM/IN is preferred for rapid seizure termination without requiring vascular access, which can be difficult in an actively seizing child.
Protocol: TP 1231-P Seizure, step 6
✓ Correct Answer: B
TP 1231-P caps additional Base-ordered Midazolam doses at a maximum total of 3 doses or 20mg, whichever limit is reached first.
Patients who continue to seize after Midazolam should be transported to a PMC given the risk of an underlying serious process.
Protocol: TP 1231-P Seizure, step 6
✓ Correct Answer: B
TP 1232-P does not use the mLAPSS/LAMS scoring system found in the adult protocol. It simply requires documenting focal neurologic deficits and LKWT, with Base contact required prior to transport for all suspected stroke/TIA, and routing to a PMC.
Special Consideration ❷ notes stroke is rare in children compared to adults, and stroke mimics (e.g., atypical migraine, petit mal seizure) are common — PMC transport allows subspecialty consultation to sort this out.
Protocol: TP 1232-P Stroke/CVA/TIA, steps 8-9 and Special Consideration ❷
✓ Correct Answer: A
Special Consideration ❷ specifically instructs asking females of child-bearing age about possible pregnancy and vaginal bleeding, since ruptured ectopic pregnancy can present with syncope and poor perfusion requiring fluid resuscitation and Base contact.
Most pediatric syncope is vasovagal (EDAP-appropriate), but syncope with dysrhythmia or ALOC suggests serious underlying disease warranting PMC transport.
Protocol: TP 1233-P Syncope/Near Syncope, Special Consideration ❷
✓ Correct Answer: A
TP 1239-P treats confirmed dystonic reaction (associated with medications such as metoclopramide, prochlorperazine, promethazine, haloperidol) with Diphenhydramine 1mg/kg slow IV push, or deep IM if venous access is unavailable.
Base contact is required to confirm the Provider Impression of Dystonic Reaction before treating, since the presentation can mimic other neurologic emergencies.
Protocol: TP 1239-P Dystonic Reaction, steps 4-5
✓ Correct Answer: B
Special Consideration ❷ of TP 1215-P recommends delaying cord clamping/cutting for up to 30-60 seconds (delayed cord clamping improves newborn outcomes) unless the newborn requires immediate resuscitation.
TP 1216-P similarly recommends delaying up to 60 seconds unless immediate resuscitation is needed.
Protocol: TP 1215-P Childbirth Mother, Special Consideration ❷
✓ Correct Answer: B
TP 1216-P initiates chest compressions once the pulse is <60bpm, using a 3:1 compression-to-ventilation ratio at a combined rate of 120/min (90 compressions + 30 ventilations per minute), continued for 2 minutes before the next pulse check.
This 3:1 ratio is specific to the newly born and differs from the 15:2 ratio used in TP 1210-P for infants/children beyond the immediate newborn period.
Protocol: TP 1216-P Newborn/Neonatal Resuscitation, step 13
✓ Correct Answer: B
TP 1216-P Special Consideration ❷ specifies monitoring pulse oximetry on the right hand, which provides the most accurate oxygen saturation reading as the newborn transitions from fetal to normal circulation (pre-ductal saturation).
Target saturations rise progressively: ~60-65% at 1 minute up to 80-85% by 5 minutes of life.
Protocol: TP 1216-P Newborn/Neonatal Resuscitation, Special Consideration ❷
✓ Correct Answer: A
TP 1217-P specifies McRobert's maneuver (hyperflexing the mother's hips into knee-to-chest position) with firm suprapubic pressure to attempt to dislodge the anterior shoulder in shoulder dystocia.
Fundal pressure is not indicated and can worsen impaction; the goal is disimpaction via pelvic repositioning plus suprapubic pressure.
Protocol: TP 1217-P Pregnancy Complication, step 13 and Special Consideration ❻
✓ Correct Answer: A
TP 1217-P defines Maternal Hypertension/Eclampsia as SBP ≥140mmHg and/or DBP ≥90mmHg, and instructs placing the mother in left lateral decubitus position.
Preeclampsia/eclampsia should be considered from 20 weeks gestation through 6 weeks postpartum, including in patients with new-onset seizure with or without elevated BP.
Protocol: TP 1217-P Pregnancy Complication, step and Special Consideration ❼
✓ Correct Answer: A
TP 1218-P explicitly states Opiate or Ketorolac analgesia is contraindicated during labor (per MCG 1345), reflecting fetal/neonatal respiratory depression and bleeding risk concerns.
Contraction frequency and duration should be monitored — contractions <2 minutes apart or lasting >60 seconds signal imminent delivery and should prompt preparation per TP 1215-P.
Protocol: TP 1218-P Pregnancy/Labor, step 7
✓ Correct Answer: B
TP 1235-P defines BRUE as a resolved event involving cyanosis/pallor, absent/decreased/irregular breathing, marked tone change, or altered responsiveness in an infant.
Base Hospital Contact is required prior to transport for all BRUE patients, with transport to a PMC, since BRUE can be a marker of underlying serious illness despite resolution.
Protocol: TP 1235-P BRUE, Special Considerations ❶❷
✓ Correct Answer: A
TP 1219-P treats anaphylaxis with Epinephrine (1mg/mL concentration) 0.01mg/kg IM in the lateral thigh as first-line, standing-order treatment.
Repeat doses require Base contact, every 10 minutes as needed for persistent symptoms, to a maximum of 3 total doses. Diphenhydramine does NOT treat anaphylaxis itself and is reserved for isolated hives/itching once epinephrine has been given.
Protocol: TP 1219-P Allergy, steps 5, 10 and Special Consideration ❹
✓ Correct Answer: B
TP 1226-P instructs handling an avulsed tooth by the crown/enamel only (never the root, to preserve periodontal ligament cells) and transporting it in a container with Normal Saline.
This maximizes the chance of successful reimplantation at the receiving facility.
Protocol: TP 1226-P ENT/Dental Emergencies, step 6
✓ Correct Answer: B
TP 1228-P specifies shielding a suspected penetrating globe injury without applying any pressure to the eye, positioning the patient at 45 degrees, and never removing an impaled foreign body — it should be secured in place instead.
Signs raising suspicion for penetrating globe injury include large subconjunctival hemorrhage, abnormally shaped pupil/iris, or fluid/tissue appearing to come from the eye.
Protocol: TP 1228-P Eye Problem, step 3-4 and Special Consideration ❶
✓ Correct Answer: A
TP 1234-P doses nebulized Epinephrine for stridor/croup by age: <1 year old receives 2.5mL of the 1mg/mL concentration via neb; ≥1 year receives 5mL, each repeatable once in 10 minutes, max 2 total doses before Base contact.
This is distinct from the IM Epinephrine dosing (0.01mg/kg) used for visible airway/tongue swelling (angioedema) in the same protocol.
Protocol: TP 1234-P Airway Obstruction, step 8
✓ Correct Answer: A
TP 1234-P differentiates management by age: children <7 years get the tracheostomy tube fully removed, stoma covered, and BMV attempted via the mouth first, escalating to stoma-mask BMV if no chest rise.
Children ≥7 years may instead have a 6.0mm endotracheal tube placed directly into the stoma and BMV attempted through it — reflecting stoma maturity and airway anatomy differences by age.
Protocol: TP 1234-P Airway Obstruction, step 8 (tracheostomy section)
✓ Correct Answer: A
TP 1237-P authorizes IM Epinephrine 0.01mg/kg for deteriorating respiratory status despite albuterol, and Special Consideration ❾ notes it may be given initially — even before albuterol — when wheezing presents with poor perfusion or severe respiratory distress (i.e., approaching respiratory failure).
Base contact is required concurrent with Epinephrine administration in this protocol.
Protocol: TP 1237-P Respiratory Distress, step 9 and Special Consideration ❾
✓ Correct Answer: B
Both TP 1237-P and TP 1236-P note that current ALS equipment does not support CPAP use in pediatric patients who are not longer than the Broselow Tape — CPAP is only initiated for alert patients with moderate/severe distress who meet that size threshold.
CPAP is also held for hypotension, suspected pneumothorax, upper airway edema/obstruction, or other MCG 1315 contraindications.
Protocol: TP 1237-P Respiratory Distress, step 11 / TP 1236-P Inhalation Injury, step 15
✓ Correct Answer: A
TP 1236-P directs consideration of both carbon monoxide exposure (treat per TP 1238-P) and hazardous material/cyanide exposure (treat per TP 1240-P) in patients with smoke inhalation, since combustion of synthetic materials commonly produces both toxins.
Pulse oximetry is NOT reliable for detecting carbon monoxide poisoning, since it cannot distinguish carboxyhemoglobin from oxyhemoglobin.
Protocol: TP 1236-P Inhalation Injury, steps 11-12
✓ Correct Answer: A
TP 1238-P specifically flags multiple persons at the same location with headache, ALOC, malaise, nausea, dizziness, or unresponsiveness as a signal to consider carbon monoxide poisoning.
Standing-order treatment is high-flow Oxygen 15L/min, which helps displace carbon monoxide from hemoglobin regardless of the measured CO level.
Protocol: TP 1238-P Carbon Monoxide Exposure, step 4 and Special Consideration ❶
✓ Correct Answer: B
TP 1220-P gives Normal Saline 20mL/kg IV/IO rapid infusion for partial/full thickness burns exceeding 10% body surface area, or for signs of poor perfusion regardless of burn size, with Base contact for additional fluid.
Base Hospital Contact is specifically required for burns meeting Trauma Center criteria or 2nd/3rd degree burns ≥10% TBSA in the pediatric population (a lower threshold than the adult 20%/10% split by age).
Protocol: TP 1220-P Burns, step 10
✓ Correct Answer: A
Special Consideration ❸ instructs EMS (as mandated reporters) to notify accepting ED staff when findings suggest abuse — patterned burns, a history that doesn't match injury severity, or an unsafe home environment — and children <3 years or with developmental delay are at increased risk.
This must be accompanied by a notification to the Department of Children and Family Services (DCFS).
Protocol: TP 1220-P Burns, Special Consideration ❸
✓ Correct Answer: B
Special Consideration ❹ of TP 1221-P specifically warns that superficial skin findings do not correlate with the severity of an electrical burn, since current traveling through tissue can cause much more extensive internal damage than external appearance suggests.
The first action in any electrocution call is ensuring the electrical source is off before approaching, since current can be conducted through water and skin.
Protocol: TP 1221-P Electrocution, step 1 and Special Consideration ❹
✓ Correct Answer: A
Special Consideration ❸ of TP 1222-P treats ALOC/seizures in suspected heat emergency as heatstroke, a time-critical emergency, targeting a ≥3°C temperature drop within 30 minutes, primarily via ice/cold water immersion for up to 15 minutes when age-appropriate.
Special Consideration ❷ also flags that children in hot cars are at high risk even at normal ambient temperatures due to the vehicle greenhouse effect, and should be extricated immediately, breaking a window if necessary.
Protocol: TP 1222-P Hyperthermia, step 4 and Special Consideration ❸
✓ Correct Answer: B
Special Consideration ❹ of TP 1223-P instructs following standard resuscitation protocols while rewarming, noting hypothermic patients may have good neurologic outcomes despite prolonged efforts.
Base Physician consultation is specifically required before considering termination of resuscitation in these patients — this is a notable exception to standard termination criteria.
Protocol: TP 1223-P Hypothermia/Cold Injury, step 9 and Special Consideration ❹
✓ Correct Answer: A
TP 1224-P specifically instructs soaking marine envenomations (jellyfish, stingray, scorpion fish) in hot water, and Special Consideration ❷ explicitly states not to use vinegar, since it is not effective for the jellyfish species found in California waters (unlike some other regions' species).
For insect/spider/scorpion stings, the stinger should be removed by scraping (e.g., with a credit card edge), not with tweezers or fingernails, to avoid squeezing more venom into the wound.
Protocol: TP 1224-P Stings/Venomous Bites, steps 5-6 and Special Considerations ❶❷
✓ Correct Answer: B
Special Consideration ❺ of TP 1225-P explains rales after submersion typically reflect direct lung injury or aspirated water rather than cardiogenic pulmonary edema (which is extremely rare in children), and instructs continuing IV fluids unless respiratory status worsens.
Any submersion incident at a pool or spa also requires a Public Health notification (213-989-7140) after ED handoff or termination of resuscitation.
Protocol: TP 1225-P Submersion, step 11 and Special Consideration ❺
✓ Correct Answer: A
TP 1209-P doses severe agitation with ALOC/immediate risk using Midazolam 0.2mg/kg IM/IN (or 0.1mg/kg IV only if vascular access is already established), repeatable once in 5 minutes, max single dose 5mg, max total 10mg before Base contact — additional doses up to 15mg total require Base orders.
Continuous cardiac monitoring is required peri- and post-sedation, watching for QRS widening or bradycardia, since agitation medications and co-ingestants (e.g., cocaine, TCAs) can cause dangerous arrhythmias.
Protocol: TP 1209-P Behavioral/Psychiatric Crisis, step 11
✓ Correct Answer: A
TP 1209-P authorizes Olanzapine 10mg ODT as a standing order for cooperative pediatric patients longer than the length-based resuscitation tape, per MCG 1317.32.
Midazolam is reserved for uncooperative patients who pose a safety risk, or severe agitation with ALOC — it requires Base contact in both scenarios.
Protocol: TP 1209-P Behavioral/Psychiatric Crisis, step 9
✓ Correct Answer: A
Special Consideration ❶ of TP 1241-P states the first priority for apneic patients after narcotic overdose is positive-pressure ventilation; Naloxone (0.1mg/kg IM/IN/IV, max 8mg all routes) is then given to restore spontaneous ventilation, and vascular access should not delay the initial IM/IN dose.
Higher-dose pre-packaged nasal Naloxone spray should specifically be avoided in newborns/neonates due to the risk of precipitating withdrawal.
Protocol: TP 1241-P Overdose/Poisoning/Ingestion, step 4 and Special Considerations ❶❷
✓ Correct Answer: A
TP 1241-P treats suspected calcium channel/beta blocker overdose with Calcium Chloride 20mg/kg slow IV push, requiring Base contact to discuss antidote administration.
Special Consideration ❸ notes CCB overdose classically causes bradycardia, hypotension, AND hyperglycemia (distinguishing it from beta blocker overdose, which instead causes hypoglycemia).
Protocol: TP 1241-P Overdose/Poisoning/Ingestion, step 13 and Special Consideration ❸
✓ Correct Answer: A
TP 1240-P specifies that pediatric patients 3-36kg (measured by the Broselow tape) with moderate nerve agent exposure receive 1 DuoDote IM, while mild exposure receives weight-based Atropine 0.02mg/kg IV/IM, and severe exposure receives 1-2 DuoDotes IM based on the color-coded weight table.
Children longer than the tape (i.e., adult-sized) are instead treated with adult dosing — Mild: 1 DuoDote, Moderate: 2 DuoDotes, Severe: 3 DuoDotes.
Protocol: TP 1240-P HAZMAT, steps 14-15
✓ Correct Answer: A
TP 1240-P doses Hydroxocobalamin at 70mg/kg IV/IO for suspected cyanide exposure with cardiovascular, neurologic, or respiratory compromise, reconstituted as 5g in 200mL Normal Saline (25mg/mL) and infused over 15 minutes, repeatable once in 15 minutes.
This is a weight-based dose calculated from the same 25mg/mL reconstituted concentration used in the adult protocol, rather than a fixed 5g dose.
Protocol: TP 1240-P HAZMAT, step 25
✓ Correct Answer: A
TP 1242-P gives Calcium Chloride 20mg/kg, Sodium Bicarbonate 1mEq/kg, and Albuterol 5mg neb about 5 minutes prior to extrication for patients at risk of crush syndrome, per Special Consideration ❾.
Special Consideration ❻ specifies flushing the IV line between Calcium and Bicarbonate, since administering them together causes precipitation — Calcium is given first because it stabilizes cardiac muscle membrane.
Protocol: TP 1242-P Crush Injury/Syndrome, step 15 and Special Considerations ❻❾
✓ Correct Answer: A
Special Consideration ❶ of TP 1242-P defines crush syndrome risk as requiring all three: circumferential compression, involvement of a large muscle group, AND entrapment of at least 1 hour — risk increases with more muscle involved and longer entrapment.
This distinguishes 'crush injury without risk of crush syndrome' (simply release and monitor) from true at-risk patients (who need pre-extrication medications).
Protocol: TP 1242-P Crush Injury/Syndrome, Special Consideration ❶
✓ Correct Answer: A
TP 1243-P differentiates by mechanism: for blunt trauma with a shockable rhythm, initiate resuscitation on scene; if not converted after 3 defibrillations, or if it becomes nonshockable, Contact Base to discuss further resuscitation versus transport.
Special Consideration ❺ notes commotio cordis (sudden blunt cardiac injury triggering V-Fib/V-Tach with minimal external trauma) should actually be treated as a medical arrest with immediate on-scene defibrillation, since outcomes can be favorable.
Protocol: TP 1243-P Traumatic Arrest, step 7 and Special Consideration ❺
✓ Correct Answer: A
TP 1243-P Special Consideration ❹ specifies that for penetrating trauma, defibrillation of a shockable rhythm should be performed while still prioritizing immediate transport (rather than remaining on scene as with blunt trauma), since penetrating trauma survival is closely tied to definitive surgical hemorrhage control.
Rapid transport after hemorrhage control remains the overall priority for all traumatic arrest patients — nearly every other intervention can be deferred to en route.
Protocol: TP 1243-P Traumatic Arrest, step 7 and Special Consideration ❹
✓ Correct Answer: A
Special Consideration ❽ of TP 1244-P describes permissive hypotension for penetrating trauma with normal mental status — withholding fluids reduces the dilutional and hypertensive effects that can worsen ongoing internal bleeding.
Patients with ALOC or hypotension despite this approach should still receive fluids until mental status/SBP improve; permissive hypotension is explicitly contraindicated if traumatic brain injury is suspected, where normal SBP must be maintained.
Protocol: TP 1244-P Traumatic Injury, step 15 and Special Consideration ❽
✓ Correct Answer: A
Special Consideration ⓫ of TP 1244-P targets an ETCO2 of 35-45mmHg for patients with traumatic brain injury, explicitly warning that hyperventilation reduces cerebral blood flow and is associated with worse outcomes in severe head injury.
The head of the gurney should also be elevated to about 30 degrees when possible to reduce intracranial pressure, unless the patient is hypotensive (maintain supine) or airway compromise requires repositioning.
Protocol: TP 1244-P Traumatic Injury, step 19-22 and Special Consideration ⓫
✓ Correct Answer: A
TP 1244-P calls for a traction splint per manufacturer guidelines for mid-shaft femur fractures, and Special Consideration ⓮ clarifies that an open femur fracture with protruding bone is not itself a contraindication to applying the traction splint.
All other fractures/dislocations are splinted in position of comfort, and amputated parts are rinsed of debris (not manually debrided), wrapped in saline-moistened gauze, and the limb splinted for a potential underlying fracture.
Protocol: TP 1244-P Traumatic Injury, step 27 and Special Consideration ⓮

Ball Knowledge Medics — LA County Pediatric Protocol Study Guide

Based on LA County DHS Prehospital Care Pediatric Treatment Protocols · For educational use only · Always follow current agency protocols and your local Base Hospital direction

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