LA County Adult Protocol
Study Guide & Practice Test

Based on the LA County Department of Health Services 1200-Series Treatment Protocols (Rev. 07-01-24 – 07-01-25) — for LA County EMS Agency field providers

39 Treatment Protocols + Ref. 506 Trauma Triage 1200-1244 Series Quick Reference Dosing 79-Question Practice Test

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Overview

How This Manual Is Organized

This guide condenses the LA County DHS 1200-series Treatment Protocols (TP 1200.1 – TP 1244) into categorized study cards, each numbered exactly as the source protocol steps, followed by the protocol's Special Considerations. Every protocol requires Assessment (TP 1201) and defers to General Medical (TP 1202) until a specific Provider Impression is established. Throughout, "MCG" refers to a Medical Control Guideline (e.g., MCG 1302 Airway/Oxygen, MCG 1308 Cardiac Monitoring, 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.

Section 01

Cardiac & Resuscitation

CARDIAC ARREST

Ref. No. 1210
Base Hospital Contact: Required for all cardiac arrest patients who do not meet criteria for
determination of death per Ref. 814; Contact Base prior to transport unless ECPR criteria are met
per MCG 1318 – contact ECPR Base en route.
  1. For patients meeting Ref. 814 Section I criteria for determination of death in the field – document
    • Provider Impression as DOA – Obvious Death
  2. Resuscitate cardiac arrest patients on scene ❶
  3. Initiate chest compressions at a rate of 100-120 per min, depth 2 inches or 5 cm ❷
    • Minimize interruptions in chest compressions
  4. Assess airway and initiate basic and/or advanced airway maneuvers prn ❸❹ (MCG 1302)
    • Supraglottic airway (SGA), e.g., i-gel is the preferred advanced airway ❺
    • Monitor waveform capnography throughout resuscitation ❻
  5. Administer high-flow Oxygen (15L/min) (MCG 1302)
  6. Initiate cardiac monitoring (MCG 1308)
    • Briefly assess rhythm every 2 minutes, minimizing pauses, or continuously via rhythm display
    • technology ❼
V-FIB/PULSELESS V-TACH: ❽
  1. Defibrillate biphasic immediately per manufacturer’s instructions or at 200J
    • Repeat at each 2-minute cycle as indicated
    • If persistent shockable rhythm after three shocks, change the pad position when feasible ❾
  2. Establish vascular access (MCG 1375)
    • Establish IO if any delay in obtaining IV access
  3. Begin Epinephrine after defibrillation x2:
    • Epinephrine (0.1mg/mL) administer 1mg (10mL) IV/IO
    • Repeat every 5 min x2 additional doses; maximum total dose 3mg ❿
  4. Prioritize transport for refractory VF/VT after defibrillation x2 in patients who meet ECPR criteria.
    • Limit scene time to ≤15 minutes. (MCG 1318, Ref 516)
  5. After defibrillation x3 (for refractory or recurrent V-Fib/V-Tach without pulses):
    • Amiodarone 300mg (6mL) IV/IO
    • Repeat Amiodarone 150mg (3mL) IV/IO x1 prn after additional defibrillation x2, maximum total
    • dose 450mg
ASYSTOLE/PEA:
  1. Epinephrine (0.1mg/mL) administer 1mg (10mL) IV/IO
    • Repeat every 5 min x2; administer first dose as early as possible; maximum total dose 3mg ❿
    • CONTACT BASE to discuss additional epinephrine doses in cases where it may be indicated due
    • to refractory PEA or recurrent arrest
  2. Consider and treat potential causes ⓫
  3. Normal Saline 1L IV/IO rapid infusion
    • Repeat x1 for persistent cardiac arrest
    • For suspected hypovolemia, administer both liters simultaneously
  4. For patients with renal failure or other suspected hyperkalemia: ⓬
    • Calcium Chloride 1gm (10mL) IV/IO
    • Sodium Bicarbonate 50mEq (50mL) IV/IO
TERMINATION OF RESUSCITATION:
  1. If resuscitative efforts are unsuccessful and the patient does not meet ALL criteria for Termination
    • of Resuscitation in Ref. 814, Section II.A., CONTACT BASE to consult with Base Physician ❽
RETURN OF SPONTANEOUS CIRCULATION (ROSC):
  1. Initiate post-resuscitation care immediately to stabilize the patient prior to transport ⓭⓮
  2. For SBP < 90 mmHg:
    • Normal Saline 1L IV/IO rapid infusion
    • If no response after Normal Saline 250mL, 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) 1mL IV/IO
    • every 1-5 minutes as needed to maintain SBP > 90mmHg ⓰
  3. Establish advanced airway prn (MCG 1302) ❺
    • 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.
  4. Raise head of stretcher to 30 degrees if blood pressure allows, otherwise maintain supine
  5. Continue low volume ventilations at 10 per minute ⓯
  6. Immediately resume CPR if patient re-arrests
  7. Perform 12-lead ECG and transmit to the SRC ⓱
  8. Check blood glucose
    • For blood glucose < 60mg/dL
    • Dextrose 10% 125mL IV and reassess
    • If glucose remains < 60mg/dL, repeat 125 mL for a total of 250 mL
  9. For suspected narcotic overdose: ⓲
    • Naloxone 2-4mg (2-4mL) IV/IO/IM/IN (For IN, 1mg per nostril or 4mg/0.1mL IN if formulation
    • available)
    • Maximum dose all routes 8 mg
  10. 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). ⓳
Special Considerations
  • Maintaining perfusion with high-quality CPR throughout resuscitation is essential to ensuring good patient outcome. Transporting the patient in cardiac arrest causes interruptions in CPR and reduces CPR quality. Patients who are resuscitated until ROSC on scene have higher neurologically intact survival.
  • Chest compressions are the most important aspect of cardiac arrest resuscitation. Maintaining continuous chest compressions should take priority over any medication administration or transport.
  • Hyperventilation reduces venous return and worsens patient outcomes. Both continuous and interrupted (30:2) compressions/ventilations are acceptable. Regardless of ventilation method used, ventilations should be no more frequent than 10 per minute with appropriate volume, just enough to see chest rise.
  • Bag-mask ventilation (BMV) is the preferred initial method of airway management. Advanced airway placement should be deferred until initial resuscitation priorities are complete unless BMV is inadequate. If a decision is made to transport the patient in refractory cardiac arrest, place an advanced airway prior to transport.
  • Supraglottic airway (SGA), e.g., i-gel is the preferred advanced airway unless specifically contraindicated. In patients who require transport, strongly consider SGA placement to facilitate ventilations during the transport. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality. In general, intubation should be deferred until after return of spontaneous circulation (ROSC) unless ventilation with BMV and SGA is ineffective and/or contraindicated.
  • 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.
  • If you are able to observe the underlying rhythm during compressions via rhythm display technology, do not pause for the rhythm check. In order to minimize pauses in chest compressions, pulse checks should only be performed during rhythm checks when there is an organized rhythm with signs of ROSC, such as normal capnography or sudden rise in capnography.
  • Patients in persistent cardiac arrest with refractory ventricular fibrillation (rVF) or EMS-witnessed arrest of presumed cardiac etiology may have a good outcome despite prolonged resuscitation. Early transport may be initiated using a mechanical compression device when routing a patient to a STEMI Receiving Center (SRC) for initiation of extracorporeal cardiopulmonary resuscitation (ECPR). When ECPR is not available due to transport time or other criteria not met, resuscitation may be continued on scene for up to 40 minutes, as long as resources allow, in order to maximize the chances for field ROSC, which is strongly associated with improved survival with good neurologic outcome.
  • 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.
  • Epinephrine may improve outcomes if given early in non-shockable rhythms, but can worsen outcomes early in shockable rhythms, where defibrillation is the preferred initial treatment. 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.
  • Potential causes that can be treated in the field include hypoxia, hypovolemia, hyperkalemia, hypothermia, toxins, and tension pneumothorax. Massive pulmonary embolism is a rare cause that may be treated with extracorporeal cardiopulmonary resuscitation (ECPR). Hypoglycemia is a very rare cause of cardiac arrest and should not be assessed until after ROSC. If environmental hypothermia is suspected, resuscitation efforts should not be abandoned until the patient is re- warmed, or after consultation with the Base Physician.
  • Treat suspected hyperkalemia with calcium and sodium bicarbonate as soon as possible. The sooner it is administered, the more likely it is to be effective. Flush the line between medication administration.
  • Approximately 40% of patients will re-arrest shortly after ROSC. Early indicators of impending re-arrest include falling EtCO2 and progressive bradycardia. Anticipate this decline as the epinephrine administered during the resuscitation begins to lose effect. Fluid resuscitation, vasopressor support, and avoidance of hyperventilation are recommended to decrease the risk of re-arrest.. These steps take approximately 5 minutes and should be initiated immediately after ROSC to stabilize the patient prior to transport to reduce chances of re-arrest en route.
  • All cardiac arrest patients, with or without ROSC for whom the decision has been made to transport, shall be transported to an SRC if ground transport is 30 minutes or less, as initiation of targeted temperature management and early coronary angiography in a specialty center have been shown to improve outcomes.
  • 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.
  • An ECG with STEMI after ROSC requires notification of ECG findings to the SRC.
  • 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 can cause 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 CHEST PAIN

Ref. No. 1211
Notify the closest STEMI Receiving Center (SRC) as soon as STEMI is identified. Notification shall
be in accordance with MCG 1303 and include immediate ECG transmission initiated prior to
contact.
  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) ❶
    • Assess cardiac rhythm and obtain 12-lead ECG ❷
    • Transmit the ECG to the receiving SRC if STEMI is suspected (MCG 1303)
  4. For patients with dysrhythmias, treat in conjunction with TP 1212, Bradycardia or
    • TP 1213, Tachycardia
  5. Aspirin 325mg chewable tablets PO if alert ❸
  6. For chest pain after 12-lead ECG:
    • Nitroglycerin 0.4mg SL prn ❹❺
    • Repeat every 5 min prn x2, total of 3 doses
    • Hold if SBP < 100mmHg or patient has taken sexually enhancing medication within 48hrs
  7. Establish vascular access (MCG 1375)
  8. For persistent chest pain after, or contraindication to, nitroglycerin: refer to MCG 1345, Pain
    • Management❺
  9. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
  10. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
Special Considerations
  • Patients may have a myocardial infarction (MI) with or without ST elevations on the ECG. You should review and interpret the ECG; the software interpretation is not always accurate. Include your impression of the patient and interpretation of the ECG when discussing destination decision with the base. Patients with ST elevation myocardial infarction (STEMI) require emergent treatment with percutaneous coronary intervention (PCI) in the catheterization lab to improve survival, so they require field routing directly to a STEMI center (SRC). If artifact inhibits your ability to interpret the ECG, the software cannot read it either. ECGs of such poor quality as to inhibit interpretation should not be used to determine destination and should be repeated.
  • Obtain the ECG as soon as possible with initial vital signs. For patients in whom you have a high clinical suspicion for STEMI and the initial ECG does not meet STEMI criteria, you should repeat the ECG prior to transport and at any point that the patient’s clinical status changes. Repeating the ECG increases your chances of detecting an evolving STEMI. Consider repeating the ECG in cases where you have a low clinical suspicion and the initial ECG software interpretation is STEMI, particularly if there is artifact present that may affect the interpretation.
  • Aspirin is the most important medication for patients with acute myocardial infarction to improve outcomes and should be administered as soon as possible. All patients with cardiac chest pain should receive aspirin unless contraindicated due to active gastrointestinal bleeding or allergy, even if they already took aspirin at home or are prescribed anticoagulant medications. While there are other causes of chest pain that can present similarly to an MI, including aortic dissection, these causes are rare and the benefit of aspirin for patients with MI outweighs the risks of administration.
  • Nitroglycerin can cause a severe drop in blood pressure in some patients and, while useful for treatment of pain, it has not been shown to improve survival. Use caution in patients with borderline or relative hypotension (patients with history of hypertension or taking antihypertensive medications and SBP < 110) and/or patients with abnormal heart rate < 50 or > 120. It is acceptable to hold nitroglycerin in these patients. Inferior MI alone is not a contraindication to nitroglycerin.
  • Morphine or fentanyl is preferred for the treatment of cardiac chest pain that does not respond to nitroglycerin or when nitroglycerin is contraindicated; do not administer ketorolac. Morphine or fentanyl is also preferred over nitroglycerin to treat pain in patients with suspected aortic dissection. The classic presentation of acute aortic dissection is acute onset “tearing” chest pain radiating to the back. Other findings that raise concern for aortic dissection are chest pain associated with new focal neurologic abnormalities or with a difference in SBP of 20mmHg or more between arms. The primary treatment goal in the alert patient is to decrease heart rate by alleviating pain and anxiety. These patients are most often hypertensive. Treat hypotension only if SBP is < 90mmHg in both arms or if patient has other signs of poor perfusion.

CARDIAC DYSRHYTHMIA - BRADYCARDIA

Ref. No. 1212
Base Hospital Contact: Required for all patients with symptomatic bradycardia.
  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)
    • Assess cardiac rhythm and obtain 12-lead ECG
  4. If cardiac chest pain/STEMI suspected as cause of bradycardia, treat in conjunction with
    • TP 1211, Cardiac Chest Pain
  5. Maintain supine for patients with signs of poor perfusion, if respiratory status allows
  6. Establish vascular access (MCG 1375)
    • Do not delay transcutaneous pacing (TCP) if indicated for vascular access
  7. For suspected hyperkalemia ❶
    • Calcium Chloride 1gm (10mL) slow IV/IO push, may repeat x1 for persistent symptoms
    • Albuterol 5mg (6mL) via neb, repeat continuously until hospital arrival
    • CONTACT BASE to obtain order for Sodium Bicarbonate 50mEq (50mL) slow IVP ❷
  8. For poor perfusion (MCG 1355):
    • Atropine 1mg (10mL) IV/IO push, repeat every 3-5 min prn, maximum total dose 3mg
    • If IV cannot be rapidly established or if HR ≤ 40bpm in 2nd degree type II or 3rd degree heart
    • block, proceed immediately to transcutaneous pacing ❸
    • If no improvement after initial dose of Atropine, proceed to TCP
  9. TCP for HR ≤ 40 with continued poor perfusion, initiate TCP as per MCG 1365 ❹
    • CONTACT BASE concurrent with initiation of TCP
    • If TCP will be utilized for the awake patient, consider sedation and analgesia
    • For sedation:
    • Midazolam 5mg (1mL) slow IV/IO push or IM/IN
    • May repeat in 5 min prn x1, maximum total dose prior to Base contact 10mg
    • For pain management: refer to MCG 1345, Pain Management
    • CONTACT BASE for additional sedation and/or pain management after maximum dose
    • administered: May repeat as above to a maximum dose of Midazolam 20 mg, and Fentanyl
    • 250mcg or Morphine 20mg
  10. For signs of poor perfusion with HR > 40:
    • CONTACT BASE to discuss appropriateness of TCP
  11. For persistent poor perfusion after initiating TCP:
    • CONTACT BASE to obtain order for Normal Saline 1L IV/IO rapid infusion and/or Push-dose
    • Epinephrine
    • While infusing Normal Saline, reassess after each 250 mL increment for evidence of volume
    • overload (pulmonary edema); stop infusion if pulmonary edema develops
    • 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) 1mL IV/IO
    • every 1-5 min as needed to maintain SBP > 90mmHg ❺
  12. For suspected overdose, treat in conjunction with TP 1241, Overdose/Poisoning/Ingestion ❻
  13. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn ❼
Special Considerations
  • Patients at increased risk for hyperkalemia include those with history or clinical evidence of renal failure, missed dialysis or patients taking potassium-sparing diuretics such as spironolactone. ECG signs of hyperkalemia included peaked T-waves, wide QRS, bradycardia, long PR interval and absent P-waves.
  • Sodium Bicarbonate is another rapid-acting treatment for suspected hyperkalemia. Due to the risk of pulmonary edema, contact Base to discuss administration.
  • In patients with 2nd degree type II or 3rd degree heart block, atropine is unlikely to produce clinical improvement, therefore TCP should not be delayed for atropine administration.
  • Electrical capture can occur without mechanical capture. Assess for electrical capture by reviewing the rhythm strip for a QRS complex and a T wave after each pacer spike. Assess for mechanical capture by palpating a pulse with each QRS complex.
  • Push-dose Epinephrine is appropriate for non-traumatic shock including cardiogenic shock. Additional doses beyond 10mL may need to be prepared for prolonged transports.
  • 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.
  • Nausea and vomiting cause vagal stimulation, which can worsen bradycardia. Ondansetron may be administered to reduce potential for nausea or vomiting.

CARDIAC DYSRHYTHMIA - TACHYCARDIA

Ref. No. 1213
Base Hospital Contact: Required for all patients with wide complex 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)
    • Assess cardiac rhythm and obtain 12-lead ECG
  4. If cardiac chest pain/STEMI suspected, treat in conjunction with TP 1211, Cardiac Chest Pain
  5. Maintain supine for patients with signs of poor perfusion , if respiratory status allows
  6. Establish vascular access prn (MCG 1375)
  7. Advanced airway prn (MCG 1302)
SINUS TACHYCARDIA ❶
  1. Consider possible underlying cause and treat as per applicable protocol ❷
  2. For sinus tachycardia of unclear etiology and suspected hypovolemia or signs of poor perfusion
(MCG 1355):
Normal Saline 1L IV/IO rapid infusion
Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
stop infusion if pulmonary edema develops
For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
Continue to assess for underlying cause ❷
SVT – NARROW COMPLEX ≥ 150bpm ❸
  1. For adequate perfusion:
    • Attempt Valsalva maneuver
    • Adenosine 12mg (4mL) rapid IV push ❹
    • Immediately follow with Normal Saline rapid IV flush
    • Repeat x1 if no conversion
  2. For alert patients with poor perfusion:
    • Adenosine 12mg (4mL) rapid IV push ❹
    • Immediately follow with Normal Saline rapid IV flush, may repeat x1 if persistent SVT
    • CONTACT BASE if no conversion after adenosine or if adenosine contraindicated to discuss
    • order for Synchronized Cardioversion per manufacturer’s guidelines, may repeat x2, or at
120J, 150J, 200J
  1. For poor perfusionwith ALOC: ❺
    • Synchronized Cardioversion per manufacturer’s guidelines, may repeat x2, or at 120J, 150J,
200J
CONTACT BASE concurrent with initial cardioversion
Consider sedation prior to cardioversion:
Midazolam 5mg (1mL) slow IV/IO push or IM/IN
May repeat in 5min prn x1, maximum total dose prior to Base contact 10mg
CONTACT BASE for additional sedation after maximum dose administered
May repeat as above to a maximum total dose of Midazolam 20mg
ATRIAL FIBRILLATION
  1. Consider possible underlying cause and treat as per applicable protocol ❷
  2. For poor perfusion (MCG 1355):
    • CONTACT BASE for treatment guidance ❻
WIDE COMPLEX – REGULAR/MONOMORPHIC
  1. For adequate perfusion:
    • Adenosine 12mg (4mL) rapid IV push ❹ ❼
    • Immediately follow with Normal Saline rapid IV flush
    • If WCT persists:
    • Adenosine 12mg (4mL) rapid IV push ❹ ❼
    • Immediately follow with Normal Saline rapid IV flush
  2. For alert patients with poor perfusion:
    • If vascular access available, Adenosine 12mg (4mL) rapid IV push ❹ ❼
    • Immediately follow with Normal Saline rapid IV flush
    • May repeat x1 for persistent WCT if mental status normal, or proceed directly to cardioversion
    • If no vascular access or no conversion with adenosine:
    • Synchronized Cardioversion per manufacturer’s guidelines, may repeat x2, or at 120J, 150J,
200J
CONTACT BASE concurrent with cardioversion
Consider sedation prior to cardioversion:
Midazolam 5mg (1mL) slow IV/IO push or IM/IN
May repeat in 5min prn x1, maximum total dose prior to Base contact 10mg
CONTACT BASE for additional sedation after maximum dose administered
May repeat as above to a maximum total dose of Midazolam 20mg
  1. For poor perfusion with ALOC: ❺
    • Synchronized Cardioversion per manufacturer’s guidelines, may repeat x2, or at 120J, 150J,
200J
CONTACT BASE concurrent with cardioversion
Consider sedation prior to cardioversion:
Midazolam 5mg (1mL) slow IV/IO push or IM/IN
May repeat in 5min prn x1, maximum total dose prior to Base contact 10mg
CONTACT BASE for additional sedation after maximum dose administered
May repeat as above to a maximum total dose of Midazolam 20mg
WIDE-COMPLEX – IRREGULAR
  1. For adequate perfusion:
    • CONTACT BASE for treatment guidance ❼❽
  2. For poor perfusion:
    • Synchronized Cardioversion per manufacturer’s guidelines, may repeat x2, or at 120J, 150J,
200J
CONTACT BASE concurrent with cardioversion ❼❽
Consider sedation prior to cardioversion:
Midazolam 5mg (1mL) slow IV/IO push or IM/IN
May repeat in 5min prn x1, maximum total dose prior to Base contact 10mg
CONTACT BASE for additional sedation after maximum dose administered
May repeat as above to a maximum total dose of Midazolam 20mg
Special Considerations
  • Treatment of sinus tachycardia should be directed at the underlying cause. Sinus tachycardia due to conditions such as hypovolemia, sepsis, or GI bleed can present as a wide complex tachycardia in patients with left or right bundle branch blocks. P waves should be visible before each QRS and a typical bundle branch block pattern noted on the ECG.
  • Tachycardia is often a response to an underlying illness including but not limited to: sepsis, GI bleeding, respiratory distress, anaphylaxis, hyperthermia, and toxic ingestions. Sinus tachycardia may be a manifestation of pain and/or anxiety, but these should not be considered until other, more dangerous etiologies, are evaluated.
  • Sinus tachycardia can occur at a rate above 150 bpm. Sinus tachycardia does not respond to Adenosine, so it should not be administered, and treatment should be directed at the underlying cause.
  • Adenosine is contraindicated in patients with history of Wolf-Parkinson-White (WPW) Syndrome and atrial fibrillation, Sick Sinus Syndrome, or heart transplant; or if the patient’s medications include carbamazepine (Tegretol) for seizure disorder. In these patients, adenosine may cause degeneration to a fatal dysrhythmia.
  • Altered level of consciousness (ALOC) refers to a decreased or depressed level of consciousness compared to the patient’s baseline (secondary to shock or hypoperfusion).
  • Patients with atrial fibrillation (or flutter) have abnormal impulses generated by the atria. Adenosine is not effective to slow or terminate the rhythm and, in the presence of Wolf-Parkinson-White (WPW) Syndrome, can cause ventricular fibrillation. Further, these rhythms cause abnormal contraction of the atria that can lead to clot formation. Cardioversion increases the risk for stroke as these clots can be forced out of the atria into circulation after cardioversion. Consider and treat underlying causes of rapid atrial fibrillation (e.g. dehydration, sepsis) prior to cardioversion. Cardioversion is appropriate for cases of acute onset (<48 hours) atrial fibrillation with hemodynamic instability and without other apparent cause.
  • Regular monomorphic wide complex tachycardia may be supraventricular rhythm with a bundle branch block or aberrancy. In this case, Adenosine may convert the rhythm to sinus and AHA guidelines recommend its use for regular monomorphic wide complex tachycardia. Adenosine should not be used for irregular wide complex tachycardia, because this may represent atrial fibrillation with WPW and lead to degeneration to a fatal dysrhythmia (see
  • above).
  • Polymorphic ventricular tachycardia (VT), including Torsades de Pointes, refers to a wide-complex tachycardia of ventricular origin with differing configurations of the QRS complex from beat to beat. Polymorphic VT can result from prolonged QT interval, myocardia ischemia, and other causes and can degenerate to ventricular fibrillation. Polymorphic VT cannot be synchronized reliably because of the differing characteristics of each QRS complex. AHA guidelines recommend immediate unsynchronized shock (defibrillation) for adults with sustained polymorphic VT.

PULMONARY EDEMA / CHF

Ref. No. 1214
Base Hospital Contact: Required for severe respiratory distress unresponsive or not amenable to
CPAP.
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Maintain patient in position of comfort ❶
  3. Administer Oxygen prn (MCG 1302)
    • High flow Oxygen 15 L/min for patients with impending respiratory failure
  4. CPAP for all alert patients with moderate or severe respiratory distress, SBP ≥ 90mmHg, and no
    • other contraindications (MCG 1315) ❷
  5. Initiate cardiac monitoring (MCG 1308)
  6. For associated chest pain and/or suspected cardiac ischemia ❸
    • Perform 12-lead ECG
    • Aspirin 325mg chewable tablets PO if alert
    • Treat in conjunction with TP 1211, Cardiac Chest Pain
  7. Establish vascular access (MCG 1375)
  8. For SBP > 100 with no sexually enhancing drugs within 48 hours: ❹
    • Nitroglycerin, 0.4mg SL, for SBP ≥ 100mmHg
    • 0.8mg SL, for SBP ≥ 150mmHg
    • 1.2mg SL, for SBP ≥ 200mmHg
    • Repeat every 3-5min prn x2 for persistent dyspnea; assess blood pressure prior to each
    • administration to determine subsequent dose
    • Hold Nitroglycerin if SBP <100mmHg; consider holding further nitroglycerin doses if SBP has
    • dropped by >40mmHg and SBP is <150mmHg
  9. If wheezing despite CPAP
    • Albuterol 5mg (6mL) via neb
    • May be given simultaneously with nitroglycerin based on clinical assessment of patient
    • If patient reports history of COPD or asthma, treat in conjunction with TP 1237, Respiratory
    • Distress
  10. For patients who progress to respiratory failure and/or shock
    • Assist ventilations and CONTACT BASE
    • Treat in conjunction with TP 1207, Shock/Hypotension
Special Considerations
  • Fowler’s or Semi-Fowler’s positioning is likely to be most comfortable for awake patients with pulmonary edema.
  • Early use of CPAP has been shown to decrease hospital length of stay and risk of intubation for patients with pulmonary edema. Unless contraindicated, it should be initiated for all patients in moderate or severe respiratory distress from pulmonary edema regardless of SpO2. Contraindications: refer to MCG 1315
  • Cardiac ischemia should be suspected in patients complaining of chest pain or with new onset pulmonary edema without history of CHF/Heart failure. CHF is a common cause of ECG abnormalities that do not require transport to a SRC.
  • In patients with recent use of sexually enhancing drugs, or systolic murmur and pulmonary edema due to critical aortic stenosis, nitroglycerin may precipitate significant hypotension and cardiovascular collapse. If patient with systolic murmur on exam, consider discussion with Base Physician prior to NTG administration.
  • Sudden significant decreases in blood pressure may cause stroke symptoms in patients with previously uncontrolled hypertension. Target a drop in mean arterial pressure (MAP) of 25%. Concerns include a sudden drop in MAP greater than 25% or patient develops neurologic abnormalities (stroke symptoms or ALOC) after nitroglycerin.
Section 02

Medical / Endocrine / Shock

ASSESSMENT

Ref. No. 1201
  1. Use appropriate PPE precautions – gloves for all patients and additional protective equipment prn
(MCG 1357)
  1. Assess scene for potential hazards and number of adult and pediatric patients
  2. Activate additional resources prn (e.g. EMS personnel, HAZMAT, law enforcement)
  3. Perform patient assessment to determine Provider Impression. Refer to appropriate Treatment
    • Protocol(s) to guide patient management (Ref. 1200, Treatment Protocols Table of Contents)
  4. For pediatric patients, assessment should be performed per MCG 1350 and include
    • determination of the patient’s weight in kg (MCG 1309) ❶
  5. If after complete assessment there is no medical or psychiatric complaint and no signs of trauma
    • or illness – document No Medical Complaint ❷
  6. CONTACT BASE if difficulty in determining Provider Impression or appropriate protocol to use
  7. Continue assessment and treat per TP 1202/1202-P, General Medical until the Provider
    • Impression is established, at which point the appropriate treatment protocol should be used in
    • conjunction with TP 1202/1202-P
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., 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 are 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 Service (DCFS).
  • Parents/caregivers can be concerned about signs and symptoms in children which may not show at the time of paramedic assessment. This does not exclude the possibility that an emergency exists. If there are no physical signs and the complaint does not otherwise have a provider impression associated with it - document No Medical Complaint. If parents/caregivers have ongoing concerns these patients require transport to an EDAP for evaluation.

GENERAL MEDICAL

Ref. No. 1202
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Control external hemorrhage prn (MCG 1370)
  3. Administer Oxygen prn (MCG 1302)
  4. Assess for signs of trauma
    • For traumatic injury, treat in conjunction with TP 1244, Traumatic Injury
  5. Initiate cardiac monitoring prn (MCG 1308)
    • Perform 12-lead ECG if cardiac ischemia suspected and treat per TP 1211, Cardiac Chest Pain
  6. For patients with dysrhythmias, treat per TP 1212, Cardiac Dysrhythmia - Bradycardia or TP
    • 1213, Cardiac Dysrhythmia - Tachycardia
    • If patient with palpitations but normal sinus rhythm on 12-lead ECG – document Provider
    • Impression as Palpitations
  7. Establish vascular access prn (MCG 1375)
  8. 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 ❶
    • If pain in neck or back without trauma – document Body Pain – Non-traumatic
    • If headache and no report or signs of trauma – document Headache – Non-traumatic
  9. For pain management: refer to MCG 1345, Pain Management
  10. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x 1 in 15 min prn and treat in conjunction with TP
    • 1205, GI/GU Emergencies
  11. For patients with complaints of weakness
    • Assess neurologic exam; if focal findings present or stroke suspected treat per
    • TP 1232, Stroke/CVA/TIA
    • If no focal weakness present and complaint of generalized weakness – document Provider
    • Impression as Weakness – General
  12. For patients with complaints of hypertension without other signs or symptoms – document
    • Provider Impression as Hypertension ❷
  13. Consider the following Provider Impressions:
    • If cold/cough symptoms without respiratory distress or wheezing – document Cold/Flu Symptoms
    • If isolated pain or swelling in one or more extremities – document Extremity Pain/Swelling – Non-
    • traumatic ❸
Special Considerations
  • When evaluating a patient for chest pain consider age, previous history of cardiac disease or MI, risk factors, and signs and symptoms to determine if cardiac chest pain suspected. Obtain a 12-lead ECG if age ≥ 35 years and/or patient has risk factors (hypertension, diabetes mellitus, high cholesterol, personal history of cardiac disease, or family history of early cardiac disease – defined as CAD/MI at age < 50 years old).
  • Hypertension in a pregnant or recently post-partum patient is a sign of eclampsia, which requires immediate emergency and obstetric care. Additional signs of eclampsia are edema and seizures. Patients who are ≥ 20 weeks pregnant or ≤ 6 weeks post-partum with hypertension (BP ≥ 140/90mmHg) should be transported to the ED for evaluation.
  • For patients with bilateral swelling of lower extremities, evaluate for signs of congestive heart failure. Careful examination of breath sounds and vital signs, including respiratory rate and pulse oximetry, should be performed. If there are signs or symptoms of pulmonary edema, treat per TP 1214, Pulmonary Edema / CHF.

DIABETIC EMERGENCIES

Ref. No. 1203
  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 prn (MCG 1308)
    • Perform 12-lead ECG if cardiac ischemia suspected
  5. Establish vascular access prn (MCG 1375)
  6. Check blood glucose
  7. For blood glucose < 60 mg/dL:
    • Oral glucose preparation or Glucopaste 15gm PO if patient awake and alert
    • OR
    • Dextrose 10% 125 mL IV/IO and reassess ❶
    • If patient continues to be symptomatic, repeat 125 mL for a total of 250mL
    • Document Provider Impression as Hypoglycemia ❷
    • If unable to obtain venous access, Glucagon 1mg (1mL) IM, may repeat x1 in 20 min prn❸
    • CONTACT BASE for persistent hypoglycemia for repeat dose of Dextrose 10% 250mL IV
  8. For blood glucose > 200 mg/dL:
    • Document Provider Impression as Hyperglycemia
    • For blood glucose >200 mg/dL and <400 mg/dL with suspected related symptoms:❹
    • CONTACT BASE for order for Normal Saline 1L IV rapid infusion
    • For blood glucose > 400 mg/dL or reading “HIGH” ❺ or for poor perfusion (MCG 1355):
    • Normal Saline 1L IV/IO rapid infusion ❶
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  9. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
Special Considerations
  • 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.
  • Patients with hypoglycemia who are successfully treated with oral glucose or Dextrose 10% IV and then wish to decline transport to the hospital should be discouraged to do so if they have abnormal vital signs, fever, are taking long-acting hypoglycemic agents, history of alcohol abuse, 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. Patients at low risk are those with diabetes on short acting hypoglycemic agents who have someone with them and are able to tolerate oral intake. Low risk patients can be assessed, treated and released for follow-up as per Ref. No. 834. If a patient is not transported, he/she should be counseled to eat a high protein meal and to call his/her primary care physician. 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 severe malnutrition, cirrhosis, or adrenal insufficiency may not respond to glucagon.
  • Consider other potential causes of hyperglycemia such as trauma, infection, or myocardial infarction and treat as per associated protocols.
  • Patients with prolonged and/or severe 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.

FEVER / SEPSIS

Ref. No. 1204
  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)
    • Perform 12-lead ECG if cardiac ischemia suspected
  4. Establish vascular access prn (MCG 1375)
  5. If available, consider applying capnography for patients in whom you suspect sepsis (MCG 1305)
    • ❶
  6. For suspected sepsis with any one of the following: tactile fever, tachycardia, or poor perfusion :
    • Normal Saline 1L IV/IO rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • Document Provider Impression of Sepsis ❷
    • For persistent poor perfusion (MCG 1355), treat in conjunction with TP 1207, Shock/Hypotension
  7. Check blood glucose prn;
    • If < 60mg/dL or >400 mg/dL treat in conjunction with TP 1203, Diabetic Emergencies
  8. If fever present without signs of sepsis or poor perfusion:
    • Perform passive cooling measures and cover with thermal blankets if shivering occurs
    • Document Provider Impression of Fever ❸
  9. Obtain a travel history
    • For potential emerging infectious disease, contact the Medical Alert Center to determine if special
    • isolation procedures or transport is required ❹
  10. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM
  11. For pain management: refer to MCG 1345, Pain Management
Special Considerations
  • An end-tidal CO2 (EtCO2) reading ≤ 25mmHG strongly supports the provider impression of sepsis in patients for whom sepsis is suspected.
  • 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 and/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. If fever is present without signs of sepsis (tachypnea, tachycardia, or obvious sign of infection) or septic shock (signs of poor perfusion), document the provider impression as Fever.
  • Certain emerging diseases (e.g., Ebola virus disease) require special isolation procedures and transport. Determination of suspected cases must be made in coordination with the Department of Public Health (DPH). The Medical Alert Center (MAC) will facilitate DPH consultation and deployment of a High-Risk Ambulance (HRA) when indicated. Contact the MAC via phone at (562) 347-1789, ReddiNet, or VMED-28. 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
  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)
    • Perform 12-lead ECG if cardiac ischemia suspected ❶
  4. Establish vascular access prn (MCG 1375)
  5. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250mL increment for evidence of volume overload (pulmonary edema); stop
    • infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, 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, 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: MCG 1345, Pain Management
  8. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
  9. Consider the following Provider Impressions:
    • If nausea or vomiting present in the absence of abdominal pain or diarrhea – document
    • Nausea / Vomiting
    • 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 complaint of diarrhea without hypotension – document Diarrhea
    • If bleeding per rectum – document Lower GI Bleeding ❷
Special Considerations
  • When evaluating a patient with abdominal pain, note that abdominal pain may be a sign of cardiac disease. If age ≥ 35 years, previous history of cardiac disease or MI, or risk factors are present (hypertension, diabetes mellitus), consider obtaining a 12-lead ECG to evaluate for ischemia or STEMI.
  • 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
  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 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  6. Assess and document pain (MCG 1345)
  7. For pain management: refer to MCG 1345, Pain Management
  8. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM
  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, for
    • example:
    • • Insulin Pump: Check blood glucose prn and treat in conjunction with
    • TP 1203, Diabetic Emergencies
    • • Vagal Nerve Stimulation devices: Treat presenting symptoms; for seizure treat per
    • TP 1231, 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.

SHOCK / HYPOTENSION

Ref. No. 1207
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 15 L/min for all patients in shock, regardless of SpO2 ❶
  3. Maintain supine if respiratory status allows ❷
  4. Establish vascular access (MCG 1375)
    • Large bore catheter (18G or 16G) preferred
    • For patients with hypotension and clinical evidence of poor perfusion (MCG 1355), establish IO
    • catheter if unable to obtain peripheral venous access after 2 attempts
    • For IO placement in alert patients administer Lidocaine 2% 40mg (20mg/mL) slow IO push,
    • dose per MCG 1317.23, may repeat once for infusion pain at half initial dose
  5. Initiate cardiac monitoring (MCG 1308)
  6. Apply blanket to keep patient warm ❸
  7. Consider etiology ❹
    • Perform 12-lead ECG if cardiac ischemia suspected
    • For patients with dysrhythmia, treat in conjunction with TP 1212, Cardiac Dysrhythmia-
    • Bradycardia or TP 1213, Cardiac Dysrhythmia-Tachycardia
    • For patients with traumatic injury, treat per TP 1244, Traumatic Injury
    • For concern of overdose or toxic exposure, treat in conjunction with TP 1241, Overdose /
    • Poisoning / Ingestion
    • For patients with suspected sepsis, treat in conjunction with TP 1204, Fever/Sepsis
  8. Normal Saline 1L IV/IO rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
  9. CONTACT BASE for shock despite initial fluid resuscitation, and for order of additional Normal
    • Saline 1L IV/IO
  10. For patients with isolated hypotension without signs of poor perfusion and those who rapidly
    • improve with or without the initial Normal Saline 250mL document Hypotension (HOTN) as
    • provider impression. For patients with hypotension and poor perfusion, as well as patients with
    • poor perfusion who do not respond to an initial Normal Saline 250mL infusion and/or require
    • addition Normal Saline beyond 1L or Push-dose Epinephrine, document as Shock (SHOK).
  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 (0.01mg/mL) 1mL IV/IO
    • every 1-5 minutes as needed to maintain SBP > 90mmHg until hospital arrival ❺
    • 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.
  • 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.
  • 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. Consider Base 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.
Section 03

Behavioral & Psychiatric

BEHAVIORAL / PSYCHIATRIC CRISIS

Ref. No. 1209
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 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 (MCG 1317.32)
  10. For UNCOOPERATIVE PATIENTS who pose a potential safety risk to self and/or EMS
    • personnel:
    • Consider Midazolam 5mg (1mL) IM/IN/IV ❺❼
    • CONTACT BASE concurrent with administration
    • With Base orders may repeat q5 min prn, to a maximum total dose of 20mg
  11. For SEVERE AGITATION WITH ALOC who pose an IMMEDIATE RISK to self and/or EMS
    • personnel:
    • Administer Midazolam 5mg (1mL) IM/IN/IV❺❼, repeat prn x1 in 5 min, or
    • Administer Midazolam 10mg (2mL) IM/IN ❺❽
    • May administer 5mg with repeat prn or 10mg single dose considering size of patient and level of
    • risk, maximum 10mg prior to Base Contact
    • CONTACT BASE for additional sedation
    • With Base orders may repeat up to a maximum total dose of 20mg
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250mL increment for evidence of volume overload (pulmonary edema); stop
    • infusion if pulmonary edema develops
  12. Initiate cardiac monitoring on all patients in restraint and/or post-sedation (MCG 1308) ❺❾
    • 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 50mEq (50mL) IV ❿
  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 ⓫
    • If glucose < 60 mg/dL or > 400 mg/dL treat in conjunction with TP 1203, Diabetic Emergencies
  16. Evaluate for physical trauma; if present treat in conjunction with TP 1244, Traumatic Injury
  17. Evaluate for possible suicide attempt ⓬⓭
    • For potential overdose, obtain patient and bystanders information about ingestions and treat in
    • conjunction with TP 1241, Overdose/Poisoning/Ingestion
  18. If concern for suicidal intent in persons not on a 5150/5585 hold and refusing voluntary treatment
    • or transport, CONTACT BASE (MCG 1306)
  19. Evaluate for acute mental health and/or substance abuse crises ⓭
    • 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 [13]
  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. 526.1 Medical Clearance Criteria Screening Tool for Psychiatric
    • Urgent Care Center, may be transported by Basic Life Support (BLS) or law enforcement (LE) 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. No. 838, Application of Patient 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 (dementia, seizures, parkinsonism, 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 (including capnography when available) 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 larger in size (e.g., ≥100kg) and/or pose a greater risk for harm due to their level of agitation and violence may require the higher dose of midazolam for adequate sedation. Patients in need of sedation who are smaller, frail, elderly or already exhibiting signs of fatigue should preferentially be treated with a 5mg dose, repeating if necessary, to reduce risk of oversedation and potential for apnea.
  • 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, 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
Base Hospital Contact: Required for persistent ALOC of unclear etiology. ❶
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. Administer Oxygen prn (MCG 1302)
  3. Assess level of consciousness per MCG 1320
  4. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-lead ECG if cardiac ischemia suspected and treat in conjunction with
    • TP 1211, Cardiac Chest Pain
  5. Establish vascular access (MCG 1375)
  6. Check blood glucose
    • If < 60mg/dL or > 400mg/dL, treat in conjunction with TP 1203, Diabetic Emergencies
  7. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250mL increment for evidence of volume overload (pulmonary edema); stop
    • infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  8. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244, Traumatic Injury
  9. Perform mLAPSS
    • If stroke is suspected, treat per TP 1232, Stroke/CVA/TIA
  10. For suspected drug overdose or alcohol intoxication, treat in conjunction with
    • TP 1241, Overdose/Poisoning/Ingestion ❷
  11. For suspected carbon monoxide exposure, treat in conjunction with TP 1238, Carbon Monoxide
    • Exposure
  12. CONTACT BASE if the etiology of the ALOC remains unclear
Special Considerations
  • Consider all causes of ALOC using a mnemonic AEIOUTIPS: 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, Stroke Once the cause for ALOC is determined, switch to the more specific protocol.
  • Consider narcotic overdose for patients with hypoventilation (bradypnea), and pinpoint pupils, drug paraphernalia, or strong suspicion of narcotic use.

DIZZINESS / VERTIGO

Ref. No. 1230
  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. For poor perfusion (MCG 1355), treat in conjunction with TP 1207, Shock/Hypotension
  5. Establish vascular access prn (MCG 1375)
  6. Check blood glucose
    • If < 60mg/dL or > 400mg/dL, treat in conjunction with TP 1203, Diabetic Emergencies
  7. For vertigo: ❶
    • Perform and document mLAPSS
    • If mLAPSS positive and/or stroke suspected, treat per TP 1232, Stroke/CVA/TIA ❷❸
  8. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
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.
  • Using a stroke scale, such as mLAPSS, increases the chances of diagnosing a stroke. However, stroke scales do not identify all strokes. Vertigo may be a symptom of a cerebellar stroke. If patient’s coordination or gait is abnormal with complaint of vertigo, strongly consider stroke.
  • Last known well time (LKWT) determines the patient’s eligibility for TPA and/or interventional procedures for clot removal. Document the name and contact information of the family member, caregiver, or witness who can verify the patient’s LKWT and report this information to ED providers. If possible, transport the witness with the patient.

SEIZURE

Ref. No. 1231
Base Hospital Contact: Required for status epilepticus or pregnant patients.
  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, Traumatic Injury
  4. Initiate cardiac monitoring prn (MCG 1308)
  5. For suspected eclampsia,
    • CONTACT BASE, do not delay transport ❶
  6. If seizure stops spontaneously prior to EMS arrival or no witnessed seizure by EMS:
    • Document Provider Impression – Seizure - Post
  7. For active seizure witnessed by EMS:
    • Midazolam 10mg (2mL) IM/IN, or
    • Midazolam 5 mg (1mL) IV/IO, if existing vascular access, repeat x1 in 2 min prn
    • Maximum total dose prior to Base contact 10mg all routes
    • Document Provider Impression – Seizure – Active, even if seizure spontaneously resolves ❷❸
    • CONTACT BASE for persistent seizure and additional medication orders
    • May repeat as above up to a maximum total dose of 20mg
  8. Establish vascular access prn (MCG 1375)
  9. For persistent seizure or persistent ALOC:
    • Check blood glucose
    • If < 60mg/dL or > 400mg/dL, treat in conjunction with TP 1203, Diabetic Emergencies
Special Considerations
  • Preeclampsia and eclampsia may develop anytime between 20 weeks gestation and 6 weeks after delivery (postpartum). Signs/symptoms of preeclampsia include systolic blood pressure > 140, edema, changes in vision, headache and/or right upper quadrant pain. Treat seizures from eclampsia with Midazolam.
  • Active 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. Make every effort to obtain a medical history and determine all medications/drugs that the patient may have taken.

STROKE / CVA / TIA

Ref. No. 1232
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. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-lead ECG if concern for cardiac ischemia or dysrhythmia
  4. Establish vascular access prn (MCG 1375) ❶
    • Establish IV in all patients with LAMS 4 or 5, large bore catheter (16g or 18g) preferred
  5. Check blood glucose
    • If < 60mg/dL or > 400mg/dL, treat in conjunction with TP 1203, Diabetic Emergencies
  6. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244, Traumatic Injury
  7. Perform Modified Los Angeles Prehospital Stroke Screen (mLAPSS) on all patients exhibiting local
    • neurologic signs. ❷❸
    • The mLAPSS is positive if all of the following criteria are met:
    • i. No history of seizures or epilepsy
    • ii. Age 40 years or older
    • iii. At baseline, patient is not wheelchair bound or bedridden
    • iv. Blood glucose between 60 and 400 mg/dL
    • v. Obvious asymmetry-unilateral weakness with any of the following motor exams:
    • a. Facial Smile/Grimace
    • b. Arm Strength
    • c. Grip Strength
  8. If mLAPSS is positive, or your provider impression remains stroke despite negative mLAPSS ❷❸,
    • calculate Los Angeles Motor Score (LAMS) from the mLAPSS motor items:
    • i. Facial Droop
    • a. Absent = 0
    • b. Present = 1
    • ii. Arm Drift
    • a. Absent = 0
    • b. Drifts down = 1
    • c. Falls rapidly = 2
    • iii. Grip Strength
    • a. Normal = 0
    • b. Weak grip = 1
    • c. No grip = 2
  9. Verify and document date and time of Last Known Well Time (LKWT) ❹
  10. Determine patient destination based on mLAPSS, LAMS and LKWT: ❹
    • mLAPSS positive, LAMS 4-5, LKWT ≤24 hours → Transport to Comprehensive Stroke Center (CSC)
    • if within 30 min
    • mLAPSS positive, LAMS ≤ 3, LKWT ≤24 hours → Transport to closest Stroke Center
    • mLAPSS negative but acute stroke suspected → CONTACT BASE for destination
  11. Transport with head of bed elevated 30-45 degrees ❺
Special Considerations
  • If LAMS is 4 or greater, place 18 gauge IV if possible to facilitate advanced imaging studies at CSC.
  • The Modified LAPSS (mLAPSS) is a validated tool that helps to identify stroke mimics and excludes patients that will not benefit from stroke care. Using a stroke scale, such as mLAPSS, increases the chances of diagnosing strokes. However, stroke scales do not catch all strokes, including presentations such as aphasia, ataxia and vertigo. For patients in whom you suspect stroke but are mLAPSS negative, calculate the LAMS and contact the Base to discuss the destination decision. History of prior stroke does not exclude the need to evaluate for possible new deficits. New findings in a patient with prior stroke should be managed similarly to first-time strokes and such patients should be routed to the closest appropriate approved stroke center per Ref. 521.
  • In patients with suspected stroke, the LAMS is performed by verbally requesting movement of face, arm, and grip or, if the patient is aphasic, by non-verbally encouraging such movement via pantomime and/or by gentle placement of limbs (painful stimulation is avoided). In patients with suspected stroke with ALOC (e.g., GCS <9) attempt neurologic assessment as noted above; alternatively, for patients unable to perform movements, compare tone and strength through passive movement of the limbs.
  • LKWT determines the patient’s eligibility for TPA and/or interventional procedures for clot removal. Document the name and contact information of the family member, caregiver, or witness who can verify the patient’s LKWT and report this information to ED providers. If possible, transport the witness with the patient.
  • Whenever possible transport patients with suspected stroke with head of bed elevated 30-45 degrees. This reduces risk of aspiration and also reduces elevation in intracranial pressure.
Section 05

OB / Childbirth

CHILDBIRTH (MOTHER)

Ref. No. 1215
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, 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, Pregnancy Complication ❸
  11. For signs of poor perfusion (MCG 1355) in mother:
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 1L IV
  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.

PREGNANCY COMPLICATION

Ref. No. 1217
Base Hospital Contact: Required for vaginal bleeding at > 20 weeks pregnancy or newborn
delivery. ❶❷❸
  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 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
  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 care❹
  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 McRoberts maneuver with suprapubic pressure in order to deliver the anterior shoulder
    • ❺
    • MATERNAL HYPERTENSION (SBP ≥140mmHg or DBP ≥90mmHg) / ECLAMPSIA ❻
  2. Place mother in left lateral decubitus position
  3. For seizure, treat in conjunction with TP 1231, Seizure
POST-PARTUM HEMORRHAGE ❼
  1. Massage the mother’s lower abdomen (fundal massage)
  2. Establish 2 IVs, large bore catheter (16g or 18g) preferred
  3. Administer Normal Saline 1L IV rapid infusion
    • Repeat x1 for ongoing hemorrhage and/or poor perfusion
    • Reassess after each 250mL increment for evidence of volume overload (pulmonary edema); stop
    • infusion if pulmonary edema develops
  4. For patients within 3 hours post delivery with ongoing bleeding and one or more of the following:
    • Systolic blood pressure (SBP) <90 mmHg, OR
    • Heart rate > SBP, OR
    • Estimated blood loss >500mL
    • Tranexamic Acid (TXA) 1 gram in 50 or 100mL Normal Saline IV/IO, infuse over 10 minutes
Special Considerations
  • 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, 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 (McRoberts maneuver) and apply firm suprapubic pressure in attempt to dislodge anterior shoulder.
  • 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. For post-partum hemorrhage, initiate TXA and fluids concurrently.

PREGNANCY LABOR

Ref. No. 1218
  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, Childbirth (Mother)
  6. If breech presentation, shoulder dystocia, nuchal cord or prolapsed cord treat per
    • TP 1215, Childbirth (Mother) in conjunction with TP 1217, Pregnancy Complication
  7. Opiate and Ketorolac 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.
Section 06

Allergy / Airway / ENT / Eye

ALLERGY

Ref. No. 1219
Base Hospital Contact: Required for anaphylaxis.
  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 15 L/min for anaphylaxis with poor perfusion or airway compromise
  3. Initiate cardiac monitoring prn (MCG 1308)
  4. For anaphylaxis:
    • Epinephrine (1mg/mL) administer 0.5mg (0.5mL) IM in the lateral thigh ❶
    • CONTACT BASE: Repeat as above every 10 min x2 prn persistent symptoms, maximum total 3
    • doses
  5. Establish vascular access prn (MCG 1375)
    • Vascular access for all patients with anaphylaxis
  6. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops.
  7. For persistent poor perfusion after initial 250 mL Normal Saline (anaphylactic shock):
    • Continue Normal Saline 1L 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) 1mL IV/IO
    • every 1-5 minutes as needed to maintain SBP > 90mmHg until hospital arrival
    • CONTACT BASE concurrent with initial dose of Push-dose Epinephrine
    • Treat in conjunction with TP 1207, Shock/Hypotension
  8. If wheezing: ❷
    • Albuterol 5mg (6mL) via neb or 4 puffs via MDI
    • Repeat x2 prn, maximum total prior to Base contact 3 doses
  9. For itching/hives:
    • Diphenhydramine 50mg (1mL) slow IV push one time ❸
    • If unable to obtain venous access, Diphenhydramine 50mg (1mL) deep IM
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.
  • 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.
  • 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
  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, 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 forward ❷
    • 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
  10. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
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
  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, 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, Burns
  8. For eye pain: refer to MCG 1345, Pain Management
  9. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
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
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 15 L/min for all patients with impending respiratory arrest due to severe
    • airway obstruction
  3. For physical obstruction from foreign body:
    • If patient unable to speak but is conscious, perform 5 back blows, then 5 abdominal thrusts
    • alternating; if patient becomes unconscious lower to ground and begin chest compressions
    • If patient is unconscious, initiate CPR X 2 minutes
    • 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 MAR and CONTACT BASE en route
  5. Initiate cardiac monitoring (MCG 1308)
  6. If patient is conscious and spontaneous ventilation is adequate:
    • Monitor in position of comfort
  7. Consider specific presentation:
    • For suspected anaphylaxis treat per TP 1219, Allergy
    • For stridor:
    • Epinephrine (1mg/mL solution) administer 5mg (5mL) via neb
    • Repeat x1 in 10 min prn
    • Prepare to manage airway if patient’s condition deteriorates
    • For visible airway/tongue swelling:
    • Epinephrine (1mg/mL) administer 0.5mg (0.5mL) IM
    • Repeat every 10 min prn x2, maximum total 3 doses
    • For patients with a tracheostomy and suspected obstruction: ❷
    • Attempt suctioning
    • Remove and clean inner cannula with saline if present; replace if positive-pressure ventilation
    • required ❸
    • If the obstruction is not relieved, remove entire tracheostomy tube and replace with a new
    • tracheostomy or 6.0mm endotracheal tube ❹
    • If a new tube cannot be placed, cover stoma and attempt BMV first via the mouth. If no chest rise
    • attempt BMV over stoma with a small mask
  8. Establish vascular access prn (MCG 1375)
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.
  • 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 only used during insertion. The inner cannula allows for connection to a ventilator or bag mask for positive pressure ventilation. There are both cuffed and uncuffed tracheostomy tubes. If the tracheostomy does not have a cuff (balloon inflated in the trachea indicated by a side port), 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 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 relieved.
  • 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.

DYSTONIC REACTION

Ref. No. 1239
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 (1mL) slow IV push
    • If unable to obtain venous access, Diphenhydramine 50mg (1mL) deep IM
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 07

Respiratory

RESPIRATORY DISTRESS

Ref. No. 1237
Base Hospital Contact: Required for respiratory failure, severe respiratory distress unresponsive
or not amenable to CPAP.
  1. Use appropriate PPE ❶
  2. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302) ❷ ❸
  3. Maintain patient in position of comfort ❹
  4. Administer Oxygen prn (MCG 1302)
    • High flow Oxygen 15 L/min for all patients with impending respiratory failure, suspected
    • pneumothorax, inhalation injury, or carbon monoxide exposure
  5. If patient with stridor, obstruction or tracheostomy concerns, treat per TP 1234, Airway Obstruction
  6. If pulmonary edema/CHF exacerbation suspected, treat per TP 1214, Pulmonary Edema/CHF
  7. If anaphylaxis suspected, treat in conjunction with TP 1219, Allergy
  8. Initiate CPAP for alert patients with moderate or severe respiratory distress. ❺
    • Hold CPAP for patients with hypotension, suspected pneumothorax, upper airway
    • edema/obstruction or other contraindications (MCG 1315)
  9. Capnography is encouraged for patients with moderate or severe respiratory distress (MCG1305)
    • ❻
  10. Initiate cardiac monitoring prn (MCG 1308)
    • Perform 12-lead ECG if cardiac ischemia suspected and treat in conjunction with
    • TP 1211, Cardiac Chest Pain
  11. Consider the following etiologies of respiratory distress without pulmonary edema:
    • Bronchospasm (asthma or COPD) – document Provider Impression as Respiratory Distress /
    • Bronchospasm
    • Pneumonia – document Provider Impression as Respiratory Distress / Other
    • Pulmonary embolism – document Provider Impression as Respiratory Distress / Other
    • Spontaneous pneumothorax – document Provider Impression as Respiratory Distress / Other
  12. For bronchospasm, COPD or asthma exacerbation:
    • Albuterol 5mg (6mL) via neb or 4 puffs via MDI ❼❽
    • May repeat x2 prn wheezing
    • May be administered in-line with CPAP for patients with moderate or severe respiratory distress
    • Document Provider Impression as Respiratory Distress / Bronchospasm
    • For deteriorating respiratory status despite albuterol:
    • Epinephrine (1mg/mL) administer 0.5mg (0.5mL) IM
    • Consider early in asthma exacerbation with poor perfusion or severe respiratory distress ❾
    • Unlikely to benefit patients with COPD exacerbation
  13. Establish vascular access prn (MCG 1375)
  14. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250mL increment for evidence of volume overload (pulmonary edema); stop
    • infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  15. If sepsis suspected, treat in conjunction with TP 1204, Fever/Sepsis
  16. If overdose is suspected, treat in conjunction with TP 1241, Overdose/Poisoning/Ingestion
  17. If inhalation injury suspected, treat in conjunction with TP 1236, Inhalation Injury
  18. Perform needle thoracostomy for suspected tension pneumothorax (MCG 1335)
  19. 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.
  • Initiate BMV to assess patient response. Effective BMV may improve the patient’s respiratory status enough to restore adequate spontaneous respirations. Place advanced airway if BMV is ineffective and consider placement once assessment for rapidly reversible causes is complete. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality.
  • 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.
  • Early use of CPAP has been shown to decrease ICU length of stay and risk of intubation for patients with severe respiratory distress. It should be strongly considered for patients in moderate-to-severe respiratory distress, based on assessment of work of breathing, regardless of SpO2. CPAP is appropriate for undifferentiated respiratory distress. It is the treatment of choice for patients with COPD exacerbation and may be used in conjunction with albuterol or if patient does not improve after initial albuterol.
  • Persistently high or increasing end-tidal CO2 (EtCO2) readings above normal with low respiratory rate indicate respiratory failure (bradypneic hypoventilation); low EtCO2 readings with a low respiratory rate also may represent respiratory failure due to low tidal volumes (hypopneic hypoventilation); consider the need for assisted ventilations in these cases. In a patient with respiratory distress of unclear etiology, a “shark-fin” capnography waveform indicates likely Bronchospasm/COPD exacerbation. Gradually elevating EtCO2 waveforms (“stacking”) in a patient with BMV indicates excessive ventilation by the provider, resulting in inadequate exhalation; in this case, decrease ventilation rate significantly to avoid progression to cardiopulmonary arrest.
  • Wheezing may also be caused by pulmonary edema; reassess breath sounds frequently for patients without history of asthma or with other concerns for volume overload (edema, etc.), because as air entry improves with treatment, rales may be more easily heard. If pulmonary edema/CHF exacerbation suspected, treat per TP 1214, Pulmonary Edema/CHF.
  • 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.

INHALATION INJURY

Ref. No. 1236
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 patient 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 15 L/min for all patients with smoke inhalation, carbon monoxide exposure, or
    • severe respiratory distress due to airway injury, regardless of SpO2 ❶
  7. If patient has an Unmanageable Airway (MCG 1302)
    • Initiate immediate transport to the MAR and CONTACT BASE en route
  8. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244, Traumatic Injury
  9. For airway burns, treat in conjunction with TP 1220, Burns
  10. For suspected carbon monoxide exposure, treat in conjunction with TP 1238, Carbon Monoxide
    • Poisoning
  11. For suspected exposure to hazardous materials including cyanide toxicity, treat in conjunction with
TP 1240, HAZMAT
  1. For airway edema and/or stridor:
    • Epinephrine (1mg/mL solution) administer 5mg (5mL) via neb
    • Repeat x1 in 10 min prn
  2. For wheezing/bronchospasm (consider also for cough):
    • Albuterol 5mg (6mL) via neb or 4 puffs via MDI
    • Repeat x2 prn, maximum total dose prior to Base contact 15mg
  3. Initiate CPAP for alert patients with moderate or severe respiratory distress
    • Hold CPAP for patients with hypotension, suspected pneumothorax, upper airway
    • edema/obstruction, or other contraindications (MCG 1315) ❷
  4. Initiate cardiac monitoring prn (MCG 1308)
  5. Perform 12-lead ECG if cardiac ischemia suspected (MCG 1308)
  6. Establish vascular access prn (MCG 1375)
  7. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250mL increment for evidence of volume overload (pulmonary edema); stop
    • infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
Special Considerations
  • Suspect smoke inhalation and carbon monoxide exposure in setting of closed-space fires, carbonaceous sputum in mouth/nose, elevated carbon monoxide levels (if point of care testing available), and facial burns. For patients with ALOC or seizure after industrial or closed space fire, also consider cyanide toxicity; contact Base and ensure notification of the receiving hospital.
  • CPAP is appropriate for undifferentiated respiratory distress and may be used if patient does not improve after initial albuterol.
Section 08

Environmental & Toxicology

BURNS

Ref. No. 1220
nd rd
Base Hospital Contact: Required for burns meeting Trauma Center criteria, 2 or 3 degree
burns ≥ 20% 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, 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, Carbon Monoxide Poisoning ❶
  3. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244, Traumatic Injury
  4. Remove jewelry and clothing from involved area
  5. Apply blanket to keep patient warm
  6. For ELECTRICAL burns:
    • Cover with dry dressing or sheet, treat in conjunction with TP 1221, Electrocution
  7. For THERMAL burns:
    • 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 ❷
    • 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, HAZMAT
  9. Establish vascular access prn (MCG 1375)
    • For IO placement in alert patients administer, Lidocaine 2% 40mg (20mg/mL) slow IO push,
    • 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 1L IV/IO rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 1L
IV/IO
  1. Elevate burned extremities as able for comfort
  2. For pain management: refer to MCG 1345, Pain Management
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, Carbon Monoxide Poisoning)
  • Observe for hypothermia; cooling large surface area burns (greater than 10% body surface area) may result in hypothermia.

ELECTROCUTION

Ref. No. 1221
  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 Cardiac Arrest ❷
  4. Administer Oxygen prn (MCG 1302)
  5. Initiate cardiac monitoring (MCG 1308)
    • Perform 12-Lead ECG prn
    • If cardiac dysrhythmia present, treat in conjunction with TP 1212, Bradycardia or TP 1213,
    • Tachycardia ❸
  6. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244, Traumatic Injury
  7. Remove jewelry and clothing from involved areas
  8. Establish vascular access prn (MCG 1375)
  9. For burns, treat in conjunction with TP 1220, Burns
    • Cover affected areas with dry dressing or sheet ❹
  10. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  11. For pain management: refer to MCG 1345, Pain Management
  12. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
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.
  • For young, healthy patients, especially in lightning injuries, 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
  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, Bradycardia or
    • TP 1213, Tachycardia
  4. Initiate temperature monitoring if available
  5. Establish vascular access prn (MCG 1375)
  6. Initiate cooling measures ❶
    • For altered patients perform on-scene cooling with ice bath immersion if possible, monitor for
    • mental status improvement, immersion not to exceed 15 minutes ❷
  7. For patients with fever due to presumed infection/sepsis, treat per TP 1204, Fever/Sepsis ❸
  8. For patients with seizure, treat in conjunction with TP 1231, Seizure
  9. For altered level of consciousness, also consider other causes per TP 1229, ALOC
  10. For adequate perfusion and normal mental status, encourage oral hydration
  11. For poor perfusion (MCG 1355) or if unable to take fluids orally:
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
Special Considerations
  • Cooling measures for patients with normal level of consciousness should include moving patient to a cooler environment (e.g. ambulance with air conditioner), removing clothing, applying wet towels, applying ice packs to cheeks/palms/soles, and fanning/blowing cool air from air conditioning vents.
  • 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. 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
  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, Bradycardia or
    • TP 1213, Tachycardia
  4. Provide warming measures ❶
  5. For frostbite:
    • Handle affected area gently, remove jewelry, cover and protect the area ❷
  6. Establish vascular access prn (MCG 1375)
  7. For altered level of consciousness, treat in conjunction with TP 1229, ALOC
  8. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion; use warm saline if available
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  9. For cardiac arrest, treat in conjunction with TP 1210, Cardiac Arrest
    • Initiate rewarming while resuscitation is ongoing ❸
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.
  • 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
  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, Allergy
    • For poor perfusion (MCG 1355), treat in conjunction with TP 1207, 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 envenomation (e.g., jelly fish, stingrays and scorpion fish):
    • Remove barb when applicable
    • Soak area in hot water if available ❷
  7. Establish vascular access prn (MCG 1375)
  8. For continued pain after specific measures above: refer to MCG 1345, Pain Management
  9. For nausea or vomiting:
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
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
Base Hospital Contact: Required for ALOC and decompression emergencies (Ref. 518). If
decompression emergency suspected, Base Hospital shall contact the Medical Alert Center (Ref.
518).
  1. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302)
  2. For cardiac arrest, treat per TP 1210, Cardiac Arrest ❶
  3. Administer Oxygen prn (MCG 1302)
    • For suspected decompression illness ❷, provide high flow Oxygen 15 L/min and CONTACT
BASE
  1. Maintain supine if suspected decompression illness
  2. Advanced airway prn (MCG 1302)
  3. Initiate cardiac monitoring (MCG 1308)
  4. Provide warming measures ❸
  5. Establish vascular access prn (MCG 1375)
  6. For altered level of consciousness, treat in conjunction with TP 1229, Altered Level of
    • Consciousness (ALOC)
  7. For respiratory distress, treat in conjunction with TP 1237, Respiratory Distress ❹
  8. For poor perfusion (MCG 1355) or for suspected decompression illness:
    • Normal Saline 1L IV rapid infusion; use warm saline if available
    • Reassess after each 250 mL increment for evidence of worsening respiratory distress and if
    • noted CONTACT BASE to discuss need to continue or hold Normal Saline based on patient
    • condition ❹
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  9. 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. ❺
Special Considerations
  • Cardiac arrest from drowning should be treated per TP 1210, 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.
  • 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) 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.

CARBON MONOXIDE EXPOSURE

Ref. No. 1238
  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)
    • Perform 12-lead ECG to assess for cardiac ischemia ❷
  6. If carbon monoxide monitor available, consider measuring CO level ❸
    • Report and document results
  7. Establish vascular access prn (MCG 1375)
  8. For altered level of consciousness, treat in conjunction with TP 1229, ALOC
  9. Assess for signs of trauma
    • For traumatic injury, treat in conjunction with TP 1244, Traumatic Injury
  10. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250mL increment for evidence of volume overload (pulmonary edema); stop
    • infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  11. For suspected exposure to hazardous materials including cyanide toxicity, treat in conjunction
    • with TP 1240, HAZMAT ❹
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.
  • Patients with carbon monoxide poisoning have impaired oxygen delivery and are at high risk for cardiac ischemia.
  • The measured CO 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.

HAZMAT

Ref. No. 1240
Contact Medical Alert Center (MAC) for all MCIs prior to transport otherwise notify the receiving
hospital.
  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, Cardiac Dysrhythmia-
    • Bradycardia or TP 1213, 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, Traumatic Injury
  11. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, 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
  1. If multiple symptomatic patients with > 50 victims involved, request EMS Chempack from the
    • MAC (Ref. 1108)
  2. For SEVERE EXPOSURE: ❶
    • Begin treatment immediately (concurrent with decontamination) and transport after
    • decontamination procedures are completed
    • DuoDote (Atropine 2.1mg and Pralidoxime Chloride 600mg) IM x3, one after another
    • For seizure, treat in conjunction with TP 1231, Seizure
  3. For MODERATE EXPOSURE: ❶
    • Ensure decontamination procedures are completed before treatment or transport to facility
    • DuoDote IM x2, one after another
  4. For MILD EXPOSURE: ❶
    • Ensure decontamination procedures are completed before treatment or transport to facility
    • DuoDote IM x1
  5. If symptoms in MILD or MODERATE exposures progress after initial evaluation, administer
    • additional DuoDote IM for a total of 3 doses
  6. For EMS CHEMPACK Deployment:
    • EMS CHEMPACK may be used for repeat dosing as necessary
    • Repeat Atropine dose prn 5 minutes after initial emergency DuoDote
    • Repeat Pralidoxime dose prn 60 minutes after initial emergency DuoDote
    • For seizure, treat in conjunction with TP 1231, Seizure, or Diazepam 10mg/mL autoinjector
    • IM x 1
ORGANOPHOSPHATE EXPOSURE
  1. For heart rate < 60bpm, hypotension, respiratory depression and/or extreme salivation
    • Atropine 2mg (20mL) IV/IO ❷
    • May be repeated every 5 min until patient is asymptomatic
    • For seizure, treat in conjunction with TP 1231, 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 complaints
  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 5 grams in 200mL of Normal Saline IV/IO (25mg/ml) infused over 15
    • minutes
    • May repeat x1 in 15 min
Special Considerations
  • 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
  • High cumulative doses may be required, maximum single dose 2mg.
  • 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 DPH 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
  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 2-4 mg IN (1mg per nostril or 4mg/0.1 mL IN depending on formulation available) or
    • Naloxone 2mg IM or
    • Naloxone 0.8-2mg IV push, maximum dose all routes 8 mg
    • Titrate to adequate respiratory rate and tidal volume ❶
  5. For patients whose medical condition improves after naloxone and who demonstrate decision-
    • making capacity, offer “Leave Behind Naloxone” (MCG 1337)
  6. If partial response to Naloxone and strong suspicion for opioid overdose:
    • CONTACT BASE for additional doses of Naloxone
  7. If available, consider capnography to monitor ventilations (MCG 1305) ❷
  8. For respiratory distress, treat in conjunction with TP 1237, Respiratory Distress
  9. Initiate cardiac monitoring prn (MCG 1308)
    • For suspected cardiac ischemia, treat in conjunction with TP 1211, Cardiac Chest Pain
    • For patients with dysrhythmias, treat in conjunction with TP 1212, Cardiac Dysrhythmia -
    • Bradycardia or TP 1213, Cardiac Dysrhythmia - Tachycardia
  10. Evaluate for other causes of altered level of consciousness (MCG 1320)
  11. Assess for signs of trauma
    • If traumatic injury suspected, treat in conjunction with TP 1244, Traumatic Injury
  12. Check blood glucose
    • If < 60mg/dL or > 200mg/dL, treat in conjunction with TP 1203, Diabetic Emergencies
  13. For alcohol intoxication, document Provider Impression – Alcohol Intoxication
    • For other intoxications, including overdose or ill effects of prescription medications and illicit
    • substances, document Provider Impression – Overdose/Poisoning/Ingestion
  14. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • For persistent poor perfusion, treat in conjunction with TP 1207, Shock/Hypotension
  15. CONTACT BASE to discuss antidote administration
    • Calcium channel and/or beta blocker overdose: Calcium chloride 1g (10mL) IV push over 60
    • seconds❸
    • Tricyclic overdose: Sodium bicarbonate 50mEq (50mL) IV push over 60 seconds ❹
  16. Assess for co-ingestion of other substances
  17. 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)
  18. Bring containers of ingested substances to the Emergency Department with patient
  19. If patient refuses recommended treatment or transport, CONTACT BASE
    • Patient must demonstrate decision making capacity (Ref. 834)
    • If EMS personnel or Base Hospital determines it is necessary to transport the patient against
    • their will, contact law enforcement for assistance
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.
  • Persistently high or increasing end-tidal CO2 (EtCO2) readings above normal with low respiratory rate indicate respiratory failure (bradypneic hypoventilation); whereas low EtCO2 readings with a low respiratory rate may also represent respiratory failure due to low tidal volumes (hypopneic hypoventilation); consider the need for assisted ventilation in these cases.
  • 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.
Section 09

Trauma

CRUSH INJURY / SYNDROME

Ref. No. 1242
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, 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 1L IV/IO rapid infusion as soon as possible and prior to release of compressive
    • force
    • Repeat x1 for a total of 2 liters
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • CONTACT BASE to obtain order for additional Normal Saline if persistent entrapment ❹
  8. Initiate cardiac monitoring (MCG 1308)
    • Assess for signs of hyperkalemia
  9. Apply blanket to keep patient warm
  10. If evidence of hyperkalemia (peaked T-waves in multiple leads, absent p-waves, and/or widened
    • QRS complex) administer: ❺
    • Calcium Chloride 1gm (10mL) slow IV/IO push, repeat x1 for persistent ECG abnormalities
    • Sodium Bicarbonate 50mEq (50mL) slow IV/IO push, repeat x1 for persistent ECG
    • abnormalities
    • Albuterol 5mg (6mL) via neb, repeat continuously until hospital arrival
    • CONTACT BASE for persistent ECG abnormalities to obtain order for additional medications ❻
  11. For pain management: refer to MCG 1345, Pain Management
  12. For CRUSH INJURY without risk of crush syndrome
    • Release compression and extricate patient
    • Monitor cardiac rhythm for signs of hyperkalemia
  13. Consider pre-positioning a tourniquet prior to extrication in order to prevent hemorrhage upon
    • release of compression
  14. For patients at risk for CRUSH SYNDROME ❶, administer the following medications 5 minutes
    • prior to extrication: ❹❺ ❻ ❼
    • Calcium Chloride 1gm (10mL) slow IV/IO push
    • Sodium Bicarbonate 50mEq (50mL) slow IV/IO push
    • Albuterol 5mg (6mL) via mask nebulization x2 for a total dose of 10mg
    • If unable to establish vascular access while entrapped
    • Place tourniquet PRIOR to extrication ❽
  15. For patients within 3 hours of injury with uncontrolled extremity hemorrhage despite pressure and
    • tourniquets (MCG 1370)
    • Tranexamic Acid (TXA) 1 gram in 50-100mL Normal Saline IV/IO, infuse over 10 minutes ❾
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 Trauma Center per Ref. 506, contact the receiving Trauma Center for Base Medical Direction and notification. If the Base Hospital is contacted and the Base redirects transport to a Trauma Center, Base personnel will notify the 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.
  • Flush the IV line with normal saline after each medication. Administration of Calcium and Bicarbonate together will cause precipitation of the medication.
  • 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.
  • In patients meeting an indication for TXA, administer fluid resuscitation with Normal Saline and TXA concurrently.

TRAUMATIC ARREST

Ref. No. 1243
Base Hospital Contact: Contact the Trauma Center for patients not meeting criteria for
determination of death per Ref 814.
  1. Prioritize rapid transport for patients who do not meet Ref. 814 ❶
  2. Immediately control major bleeding (MCG 1370)
    • Apply tourniquet prn
  3. Assess airway and initiate basic and/or advanced airway maneuvers prn (MCG 1302) ❷
    • Ventilate with high flow Oxygen 15 L/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 at 200J or per manufacturer’s instructions
    • For penetrating trauma: ❸
    • Defibrillate while prioritizing immediate transport
    • For blunt trauma: ❹❺
    • Initiate resuscitation on scene
    • If organized rhythm is not restored after defibrillation x3 or patient converts to
    • nonshockable rhythm, refer to Ref. No. 814 for determination of death
    • CONTACT BASE if needed 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)
    • Two large bore IV catheters (16 or 18 gauge) preferred
    • Establish IO if unable to establish IV access
  10. Normal Saline 2L IV/IO rapid infusion
    • Administer through two sites simultaneously if possible
Special Considerations
  • 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 once initial resuscitation priorities are complete, and preferably during transport, unless BMV is ineffective. Supraglottic airway is preferred unless contraindicated. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality.
  • Patients with penetrating trauma should receive defibrillation while still prioritizing early transport.
  • Patients in cardiac arrest with hanging or submersion mechanisms are asphyxial in the large majority of cases and should be considered a medical cardiac arrest, and therefore managed in accordance with TP-1210-Cardiac Arrest with transport destination per Ref. No. 516. Trauma center destination in cases with ROSC should only be considered if there is strong evidence of cervical spine injury.
  • 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, consider transport to an ECPR center if criteria are met, or 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
Base Hospital Contact: Required for patients who meet Trauma Center criteria or guidelines. ❶
Notify the receiving 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) ❷
  3. For traumatic arrest, treat per TP 1243, Traumatic Arrest
  4. Provide spinal motion restriction (SMR) if indicated (MCG 1360)
    • For alert patients, logroll off the backboard (if used during extrication) and onto gurney prior to
    • transport ❸
  5. Administer Oxygen prn (MCG 1302)
    • High flow Oxygen 15 L/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 MAR 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
  12. Consider medical condition preceding accident and refer to appropriate treatment protocol prn ❹
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 ❺
  3. For poor perfusion (MCG 1355) with hypotension:
    • Normal Saline 250mL IV/IO rapid infusion ❻
    • CONTACT BASE to discuss further fluid resuscitation
  4. For patients within 3 hours of injury and one or more of the following:
    • Systolic blood pressure (SBP) <90 mmHg, OR
    • Heart Rate > SBP, OR
    • Uncontrolled external hemorrhage (MCG 1370)
    • Tranexamic Acid (TXA) 1 gram in 50-100mL Normal Saline IV/IO, infuse over 10 minutes ❼
  5. Cover eviscerated organs with a moist non-adhering dressing
  6. For pain management prn (MCG 1345)
    • Fentanyl 50mcg (1mL) slow IV/IO push or IM/IN
    • Morphine 4mg (1mL) slow IV/IO push or IM
    • Ketorolac is contraindicated for multi-system trauma
    • CONTACT BASE for additional pain management:
    • May repeat as above up to maximum total dose Fentanyl 250mcg or Morphine 20mg
  7. For nausea or vomiting: ❽
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
ISOLATED HEAD INJURY
  1. Administer high flow Oxygen 15 L/min for all patients with suspected traumatic brain injury ❾
    • Continually assess patient’s airway and ventilation status, assist prn ❿
  2. For SBP ≤ 90mmHg:
    • Normal Saline 1L IV/IO rapid infusion⓫
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • CONTACT BASE for persistent poor perfusion (MCG 1355) after Normal Saline 1L
  3. For nausea or vomiting: ❼
    • Ondansetron 4mg ODT/IV/IM, may repeat x1 in 15 min prn
  4. Transport with head of gurney elevated to 30 degrees when possible⓬
  5. If patient develops seizure activity, treat in conjunction with TP 1231, Seizure
  6. For pain management prn (MCG 1345)
    • For an alert and oriented patient with GCS 15:
    • Fentanyl 50mcg (1mL) slow IV/IO push or IM/IN
    • Morphine 4mg (1mL) slow IV/IO push or IM
    • Ketorolac is contraindicated for head injury
    • CONTACT BASE for additional pain management or for initial orders if patient not alert and
    • oriented with GCS 15
    • May provide or repeat as above up to maximum total dose Fentanyl 250mcg or Morphine 20mg
ISOLATED EXTREMITY INJURY
  1. For pain management prn (MCG 1345)
  2. For poor perfusion (MCG 1355):
    • Normal Saline 1L IV/IO rapid infusion
    • Reassess after each 250 mL increment for evidence of volume overload (pulmonary edema);
    • stop infusion if pulmonary edema develops
    • CONTACT BASE for persistent poor perfusion to obtain order for additional Normal Saline 1L
IV/IO
  1. For patients within 3 hours of injury with uncontrolled extremity hemorrhage despite pressure and
    • tourniquets (MCG 1370)
    • Tranexamic Acid (TXA) 1 gram in 50-100mL Normal Saline IV/IO, infuse over 10 minutes ❼
  2. 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 guidelines⓭
    • 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 fracture⓮
Special Considerations
  • For patients requiring transport to a Trauma Center per Ref. 506, contact the receiving Trauma Center for Base Medical Direction and notification. If the Base Hospital is contacted and the Base redirects transport to a Trauma Center, Base personnel will notify the Trauma Center.
  • Transport should be prioritized over advanced airway placement unless BMV is ineffective. Advanced airway may be placed during transport; supraglottic airway is preferred unless contraindicated. Paramedics should use judgment based on patient characteristics, circumstances, and skill level when selecting the advanced airway modality.
  • 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 in maneuvering the unconscious patient. In all cases, the backboard should be removed immediately if causing respiratory compromise.
  • Traumatic events may be due to a medical emergency, particularly single-vehicle accidents and unexplained falls.
  • 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.
  • Aggressive fluid resuscitation increases vascular pressure and dilutes clotting factors, which may increase internal bleeding. • In patients with blunt trauma and poor perfusion: administer fluids to target SBP ≥ 90mmHg. • In patients with penetrating trauma and poor perfusion: administer fluids to target SBP ≥ 70mmHg if patient has normal mental status (permissive hypotension). Patients with ALOC or SBP < 70mmHg should receive fluids until their mental status and SBP improve. • In patients with possible traumatic brain injury: permissive hypotension is contraindicated and SBP should be maintained ≥ 90mmHg.
  • In patients meeting an indication for TXA, administer fluid resuscitation with normal saline and TXA concurrently.
  • 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.
  • Traumatic brain injury presents with altered mental status after head injury. 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 ≥ 90mmHg at all times but can be withheld if the blood pressure is elevated.
  • A head-elevated position at about 30 degrees reduces intra-cranial pressure and improves respiratory status. Patients in a cervical collar may have their head elevated if there is no concern for thoracic or lumbar spine injury. Reverse Trendelenburg is another 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.
  • If the amputated part is available, similar care should be taken to rinse off any gross debris, wrap the part with saline-moistened sterile gauze, seal in plastic and place indirectly on ice after wrapping; do not submerge in water or place directly on ice. Transport the amputated part with the patient and leave it with hospital staff.

TRAUMA TRIAGE — Destination Criteria

Ref. No. 506
Establishes criteria/standards ensuring patients requiring trauma center care are appropriately triaged and transported. Paramedics shall make base hospital contact with the receiving trauma center on all patients meeting trauma triage criteria and/or guidelines, without delaying transport. Do not delay transport of hypotensive patients with penetrating torso trauma to apply spinal motion restriction.
I. TRAUMA CRITERIA — Immediate transport to a designated trauma center if transport time does not exceed 30 minutes
  1. Systolic blood pressure less than 90 mmHg, or less than 70 mmHg in infants age less than one year
  2. Respiratory rate greater than 29 breaths/min (sustained), less than 10 breaths/min, less than 20 breaths/min in infants age less than one year, or requiring ventilatory support
  3. Cardiopulmonary arrest with penetrating torso trauma, unless the paramedic's thorough assessment finds the patient apneic, pulseless, asystolic, and without pupillary reflexes upon EMS arrival
  4. All penetrating injuries to head, neck, torso, and extremities proximal to the elbow or knee
  5. Blunt head injury associated with a suspected skull fracture, altered level of consciousness (GCS ≤14), seizures, unequal pupils, or focal neurological deficit
  6. Injury to the spinal column associated with acute sensory or motor deficit
  7. Blunt injury to chest with unstable chest wall (flail chest)
  8. Diffuse abdominal tenderness
  9. Suspected pelvic fracture (excluding isolated hip fracture from a ground level fall)
  10. Extremity with:
    • Neurological/vascular compromise and/or crushed, degloved, or mangled extremity
    • Amputation proximal to the wrist or ankle
    • Fractures of two or more proximal (humerus/femur) long-bones
    • Bleeding not controlled by direct pressure requiring a hemorrhage control tourniquet or hemostatic agent (approved provider agencies only)
  11. Fall from height > 10 feet (all patients)
  12. Passenger space intrusion of greater than 12 inches into an occupied passenger space
  13. Ejected from vehicle (partial or complete)
  14. Auto versus pedestrian/bicyclist/motorcyclist thrown, run over, or with significant (>20 mph) impact
  15. Unenclosed transport crash with significant (>20 mph) impact
  16. Major/Critical Burn (excluding when the MAR is a recognized Burn Center):
    • Age ≥15 years with 2nd/3rd degree burns ≥20% TBSA
    • Age ≤14 years with 2nd/3rd degree burns ≥10% TBSA
II. TRAUMA GUIDELINES — At Base discretion, transport to a trauma center is advisable
  1. Passenger space intrusion of greater than 18 inches into any unoccupied passenger space
  2. Automobile versus pedestrian/bicyclist/motorcyclist (impact ≤20 mph)
  3. Injured victims of vehicular crashes in which a fatality occurred in the same vehicle
  4. Patients requiring extrication
  5. Vehicle telemetry data consistent with high risk of injury
  6. Injured patients (excluding isolated minor extremity injuries):
    • On anticoagulation or antiplatelet therapy, other than aspirin-only
    • With bleeding disorders
III. SPECIAL CONSIDERATIONS — Consider trauma center transport
  1. Patients in blunt traumatic full arrest who, based on paramedic assessment, were NOT found apneic, pulseless, and without organized ECG activity (narrow complex SVT rhythm) upon EMS arrival
  2. Systolic blood pressure less than 110 mmHg may represent shock after age 65 years
  3. Heart rate greater than systolic blood pressure for age ≥14 years
  4. Child (0-9 years) unrestrained or in an unsecured child safety seat
  5. Pregnancy greater than 20 weeks gestation
  6. Prehospital judgment
IV. EXTREMIS PATIENTS — Immediate transport to the MAR
  1. Patients with an obstructed airway, or concern for imminent airway obstruction due to inhalation injury
  2. Patients, as determined by base hospital personnel, whose lives would be jeopardized by transportation to any destination but the MAR
Key Principles & Re-Triage
  • When base hospital contact cannot be made, the destination decision for injured patients is made by paramedics using the criteria above.
  • EMT personnel may immediately transport hypotensive patients with life-threatening penetrating torso injuries to the closest trauma center (not the MAR) when transport time is less than the estimated time of paramedic arrival, making every effort to contact the receiving trauma center.
  • When pediatric and adult trauma patients are transported together in one aircraft, the receiving trauma center must be both a trauma center and a pediatric trauma center.
  • 9-1-1 Trauma Re-Triage (Section VI) applies to injured ED patients at non-trauma centers initially under-triaged by EMS, or walk-in patients later found by the ED physician to require immediate trauma center care. Re-triage criteria: persistent signs of poor perfusion; need for immediate blood replacement therapy; intubation required; GCS <9; GCS deteriorating by ≥2 points during observation; penetrating injuries to head, neck, or torso; extremity injury with neurovascular compromise or loss of pulses; or physician judgment of high likelihood of needing emergent life/limb-saving intervention within 2 hours.
  • For re-triage, contact the designated receiving (or pediatric) trauma center if transport does not exceed 30 minutes, and do not delay transfer for diagnostic procedures without direct impact on immediate resuscitation, or for records that can be sent later. Paramedic scope of practice does not include paralyzing agents, but paramedics can monitor blood product infusions already started by the transferring hospital.
Section 10

Quick Reference & Key Numbers

How to use this section
These are the numbers, thresholds, and "standing order vs. Base contact" distinctions that show up most often on exams and in the field. Every value below traces back to a specific Treatment Protocol (TP) above — use the Ref. No. to jump back for full context.

Universal Fluid & Poor Perfusion Rule (MCG 1355)

SituationAction
Poor perfusion, most medical protocolsNormal Saline 1L IV rapid infusion; reassess after each 250mL for volume overload; stop if pulmonary edema develops
Persistent poor perfusion after fluidsTreat in conjunction with TP 1207, 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 1mL IV/IO q1-5min, titrate SBP >90 (peds target >70)

Cardiac Arrest Epinephrine & Amiodarone Timing (TP 1210)

RhythmEpinephrineAntiarrhythmic
VF/pulseless VT1mg IV/IO AFTER defibrillation x2, repeat q5min x2 (max 3mg)Amiodarone 300mg after defib x3; repeat 150mg x1 after 2 more defibs (max 450mg)
Asystole/PEA1mg IV/IO as early as possible, repeat q5min x2 (max 3mg)N/A — consider/treat reversible causes
Renal failure / hyperkalemia arrestCalcium Chloride 1gm IV/IO + Sodium Bicarbonate 50mEq IV/IO

Key Doses That Are Frequently Tested

Drug / SituationDoseNotes
Naloxone (any route)2-4mg IN, 2mg IM, or 0.8-2mg IV titratedMax ALL routes combined = 8mg (TP 1241); cardiac arrest max also 8mg (TP 1210)
Epinephrine, anaphylaxis0.5mg (1mg/mL) IM lateral thighRepeat q10min x2 with Base contact, max 3 total doses (TP 1219)
Epinephrine, stridor5mg (1mg/mL) via nebMay repeat x1 in 10 min (TP 1234)
Midazolam, active seizure10mg IM/IN or 5mg IV/IOMax 10mg prior to Base contact; may go to 20mg w/ orders (TP 1231)
Midazolam, behavioral crisis5mg IM/IN/IVBase contact concurrent with administration; max 20mg w/ orders (TP 1209)
Adenosine, SVT/regular WCT12mg rapid IVP + flushBoth doses are 12mg in LA County (not 6mg then 12mg) (TP 1213)
Atropine, bradycardia1mg IV/IO q3-5minMax 3mg (TP 1212)
Atropine, organophosphate2mg IV/IO q5minNo stated maximum — titrate to symptoms (TP 1240)
Dextrose, adult hypoglycemiaD10W 125mL IV, repeat once (250mL total)Glucagon 1mg IM if no IV/IO access (TP 1203)
TXA1g in 50-100mL NS IV/IO over 10 minTrauma = standing order; PPH = Base order; give concurrently with fluids (TP 1244/1217/1242)
Calcium Chloride, hyperkalemia/crush1gm (10mL) slow IV/IOFlush line before/after — precipitates with bicarb (TP 1212/1242)
Hydroxocobalamin, cyanide5g in 200mL NS over 15 minMay repeat x1 in 15 min (TP 1240)
DuoDote, nerve agentx1 mild / x2 moderate / x3 severeSevere = treat concurrent with decon; mild/moderate = decon first (TP 1240)

Standing Order vs. Base Hospital Contact — Common Gray Areas

SituationStanding Order?
Midazolam for uncooperative/agitated patientBase contact required CONCURRENT with (not before) administration (TP 1209)
TXA for trauma hemorrhageStanding order (TP 1244)
TXA for postpartum hemorrhageStanding order if criteria met (TP 1217) — same criteria structure as trauma
Calcium Chloride / Bicarb for crush syndromeStanding order pre-extrication (TP 1242)
Sodium Bicarb for bradycardia 2/2 hyperkalemiaBase order required (TP 1212)
CCB/TCA overdose antidotes (CaCl2 / NaHCO3)Base order required (TP 1241)
Additional epinephrine doses beyond 3 in arrestBase order required (TP 1210)
Shifting between analgesics mid-treatmentNot addressed in this manual's pain protocol excerpt — always reasonable to contact Base with any uncertainty

Stroke Destination Decision (TP 1232)

mLAPSSLAMSLKWTDestination
Positive4-5≤24hComprehensive Stroke Center (CSC) if within 30 min
Positive≤3≤24hClosest Stroke Center
Negative but stroke suspected——CONTACT BASE for destination

Transport all suspected stroke patients with head of bed elevated 30-45°. Vertigo with abnormal gait/coordination should raise suspicion for cerebellar stroke even with a negative mLAPSS.

Fluid Targets by Trauma Type (TP 1244)

Trauma TypeTarget
Blunt trauma, poor perfusionFluids to SBP ≥ 90mmHg
Penetrating trauma, poor perfusion, normal mental statusPermissive hypotension — fluids to SBP ≥ 70mmHg
Penetrating trauma, ALOC or SBP <70Fluids until mental status/SBP improve
Suspected traumatic brain injuryPermissive hypotension CONTRAINDICATED — maintain SBP ≥ 90mmHg
Section 11

Practice Test — 79 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 arrive to find a 61-year-old male in cardiac arrest. Your monitor shows V-Fib. After the first defibrillation at 200J, CPR is resumed. What is the correct epinephrine strategy per LA County protocol?
  • Give Epinephrine 1mg IV/IO immediately, before any defibrillation
  • Withhold Epinephrine until after the second defibrillation, then give 1mg IV/IO, repeating q5min x2 for a max of 3mg
  • Give Epinephrine 1mg IV/IO after every defibrillation attempt
  • Epinephrine is not indicated for shockable rhythms
Question 2 Cardiac
During a resuscitation for refractory V-Fib, the patient has now been defibrillated three times without conversion. Per protocol, what should you do next regarding pad placement, and what antiarrhythmic is indicated?
  • Continue anterior-lateral pads only; give Lidocaine 1.5mg/kg
  • Change pad position (vector change) when feasible; give Amiodarone 300mg IV/IO
  • Change pad position; give Amiodarone 450mg IV/IO as a single dose
  • Pads should never be repositioned mid-arrest; give Magnesium 2gm IV
Question 3 Cardiac
A patient achieves ROSC after a resuscitation. Their EtCO2 is 52 mmHg. What is the correct post-ROSC ventilation target and action?
  • Hyperventilate to bring EtCO2 below 30 mmHg quickly
  • No action needed — any EtCO2 above 40 is acceptable post-ROSC
  • Adjust ventilation rate to bring EtCO2 into the 35-45 mmHg target range
  • Stop ventilating and allow apnea until EtCO2 normalizes
Question 4 CardiacDestination
A 54-year-old is resuscitated to ROSC after a witnessed cardiac arrest of presumed cardiac etiology. Ground transport time to the closest STEMI Receiving Center (SRC) is 25 minutes. What is the correct destination decision?
  • Transport to the closest hospital of any type, since ROSC patients don't need a specialty center
  • Transport to the SRC because ground transport is 30 minutes or less
  • Contact Base before deciding on any destination for ROSC patients
  • Transport only to a Comprehensive Stroke Center for post-arrest care
Question 5 CardiacPharmacology
A patient with an inferior STEMI (ST elevation in II, III, aVF) has a BP of 78/48. What is the correct next step before considering Nitroglycerin?
  • Give NTG 0.4mg SL immediately since chest pain relief is the priority
  • Obtain a right-sided 12-lead (V4R) to assess for right ventricular infarction and give fluids instead of NTG
  • Give Fentanyl first, then NTG once pain is controlled
  • Withhold all treatment and transport emergently with no interventions
Question 6 CardiacPharmacology
A patient with cardiac chest pain has taken sildenafil (Viagra) 36 hours prior to your arrival. Can you administer Nitroglycerin?
  • Yes, 36 hours exceeds the commonly-taught 24 hour rule
  • No — NTG is held if a sexually enhancing medication was taken within 48 hours
  • Yes, but only at half the normal dose
  • No — NTG is permanently contraindicated after any use of sildenafil
Question 7 Cardiac
A 70-year-old presents with a heart rate of 38, 2nd degree AV block Type II, and a BP of 82/50 with altered mental status. IV access is proving difficult. What is the correct sequence of action?
  • Continue attempting IV access for several more minutes before considering any other intervention
  • Give Atropine 1mg IV and wait 5 minutes before considering pacing
  • Do not delay transcutaneous pacing for vascular access; proceed immediately to TCP given the type II block and HR ≤ 40
  • Give a Normal Saline bolus first, then reassess in 10 minutes
Question 8 CardiacPharmacology
A hemodynamically unstable bradycardic patient has ECG findings of peaked T-waves and a widened QRS. History includes missed dialysis. What treatment(s) are indicated per standing order versus base contact?
  • Calcium Chloride 1gm IV/IO and continuous nebulized Albuterol are standing orders; Sodium Bicarbonate requires Base order
  • All three (Calcium Chloride, Albuterol, Sodium Bicarbonate) are standing orders
  • Only Albuterol is indicated; calcium is contraindicated in renal failure
  • Sodium Bicarbonate is a standing order; Calcium Chloride requires Base contact
Question 9 CardiacPharmacology
A patient in SVT at 180 bpm with adequate perfusion does not convert after Valsalva. You give Adenosine 12mg rapid IVP with a saline flush and there is no conversion. What is the correct next action?
  • Immediately proceed to synchronized cardioversion
  • Repeat Adenosine 12mg rapid IVP x1 with immediate NS flush
  • Give Adenosine 6mg as a smaller repeat dose
  • Give Amiodarone 150mg IV over 10 minutes
Question 10 CardiacPharmacology
A patient has a regular, monomorphic wide-complex tachycardia with adequate perfusion. Per LA County protocol, what is appropriate?
  • Adenosine is contraindicated in any wide-complex tachycardia
  • Adenosine 12mg rapid IV push with immediate NS flush; may repeat if WCT persists
  • Immediate synchronized cardioversion regardless of perfusion status
  • Amiodarone 300mg IV push over 1 minute
Question 11 Cardiac
A patient presents with an irregular wide-complex tachycardia and poor perfusion. What is the correct treatment approach?
  • Adenosine 12mg rapid IVP is first-line
  • Synchronized cardioversion with concurrent Base contact; sedate with Midazolam if time allows
  • Amiodarone 300mg IV/IO push
  • Observe only — irregular WCT with poor perfusion does not require treatment
Question 12 CardiacPharmacology
A patient in pulmonary edema has an SBP of 210 mmHg with severe respiratory distress. Sexual enhancement drug use is denied. What is the correct Nitroglycerin dose?
  • 0.4mg SL
  • 0.8mg SL
  • 1.2mg SL
  • NTG is contraindicated above SBP 200
Question 13 Cardiac
A patient in respiratory distress from suspected pulmonary edema is alert, SBP 130, with wheezing that does not improve after CPAP. What additional treatment is appropriate?
  • Withhold Albuterol entirely — wheezing in CHF is never treated with bronchodilators
  • Albuterol 5mg via neb may be given simultaneously with NTG based on clinical assessment
  • Immediately treat as COPD exacerbation using TP 1237 only
  • Administer high-dose Epinephrine IM
Question 14 MedicalPharmacology
A known diabetic is found unresponsive with a blood glucose of 42 mg/dL. IV access cannot be obtained after two attempts. What is the correct treatment?
  • Continue attempting IV access; Glucagon is not part of this protocol
  • Glucagon 1mg IM, may repeat x1 in 20 minutes prn
  • Oral glucose paste, even though the patient is unresponsive
  • Withhold treatment until arrival at the hospital
Question 15 Medical
A 68-year-old with a history of cirrhosis and malnutrition is hypoglycemic with an altered mental status, and IV access cannot be established. You administer Glucagon 1mg IM without clinical improvement. What is the most likely explanation?
  • Glucagon was underdosed
  • Patients with poor glycogen stores (malnutrition, cirrhosis, adrenal insufficiency) may not respond to Glucagon
  • Glucagon should have been given IV instead
  • Glucagon does not work in any patient with altered mental status
Question 16 Medical
A patient with suspected sepsis has an EtCO2 reading of 22 mmHg on capnography. How does this finding factor into your assessment?
  • It has no clinical significance in sepsis
  • An EtCO2 ≤25 mmHg strongly supports a provider impression of sepsis in a patient where sepsis is suspected
  • It indicates the patient is hyperventilating from anxiety and sepsis is unlikely
  • It confirms the patient needs immediate intubation
Question 17 Medical
A patient has a tactile fever with no tachycardia, tachypnea, or signs of poor perfusion. What is the correct Provider Impression and treatment approach?
  • Document 'Sepsis' and begin an aggressive 1L fluid bolus
  • Document 'Fever'; provide passive cooling measures and thermal blankets if shivering occurs
  • Document 'Sepsis' but withhold all treatment
  • No documentation is required for isolated fever
Question 18 Medical
Which of the following best distinguishes a Provider Impression of 'Hypotension (HOTN)' from 'Shock (SHOK)' per TP 1207?
  • HOTN requires a heart rate above 100; SHOK does not
  • Isolated hypotension without poor perfusion signs that rapidly improves is HOTN; hypotension WITH poor perfusion, or that fails to respond to initial fluids/requires Push-dose Epi, is SHOK
  • There is no meaningful distinction — both terms are interchangeable
  • SHOK is used only for traumatic causes of hypotension
Question 19 MedicalPharmacology
A patient in shock from a non-traumatic cause has received 1L of Normal Saline with persistent poor perfusion. Base has been contacted. What medication is indicated, and how is it prepared?
  • Dopamine infusion at 5 mcg/kg/min
  • Push-dose Epinephrine: mix 9mL NS with 1mL Epinephrine 0.1mg/mL, giving 1mL IV/IO every 1-5 min titrated to SBP >90
  • Norepinephrine infusion titrated to MAP >65
  • A second 1L bolus given as rapidly as possible with no further intervention
Question 20 Medical
A patient has an insulin pump alarming and reports feeling unwell. What is the most appropriate initial approach per TP 1206?
  • Assume malfunction and disconnect the pump immediately without further assessment
  • Check blood glucose and treat per TP 1203, Diabetic Emergencies if abnormal, rather than automatically documenting device malfunction
  • Contact Base before any assessment can occur
  • Insulin pumps are outside EMS scope and require no protocol
Question 21 Medical
A patient with a Ventricular Assist Device (VAD) presents with a medical complaint. Per protocol, what is required?
  • Treat per standard shock protocol without any special consideration
  • CONTACT BASE and refer to MCG 1325 for VAD-specific guidance
  • VAD alarms should be silenced and ignored during transport
  • No base contact needed unless cardiac arrest occurs
Question 22 Medical
A patient reports abdominal pain with vomiting blood that appears like coffee grounds. What is the correct Provider Impression?
  • Abdominal Pain/Problems
  • Upper GI Bleeding
  • Lower GI Bleeding
  • Nausea/Vomiting
Question 23 Medical
A patient describes vague generalized weakness with no focal neurologic deficits on exam and no stroke concern. What is the appropriate approach?
  • Automatically treat per TP 1232, Stroke/CVA/TIA regardless of exam findings
  • Perform a neurologic exam; if no focal weakness is found, document Provider Impression as Weakness — General
  • No documentation is needed for nonspecific weakness
  • Weakness always requires Base contact regardless of findings
Question 24 BehavioralPharmacology
An uncooperative, agitated patient poses a safety risk to EMS personnel. What is the correct standing-order Midazolam approach before Base contact?
  • Midazolam 5mg IM/IN/IV, with Base contact required concurrent with administration
  • Midazolam 20mg IM as a single maximum dose without Base contact
  • Midazolam is never given without prior Base authorization in LA County
  • Only Olanzapine can be used for uncooperative patients
Question 25 Behavioral
A severely agitated patient with ALOC poses an immediate risk to self/EMS. Sizing up the patient, they appear to weigh approximately 110 kg with high-risk violent behavior. What Midazolam dosing consideration applies?
  • Larger patients (≥100kg) and/or higher violence risk may require the higher 10mg IM/IN dose for adequate sedation
  • Weight has no bearing on Midazolam dosing in this protocol
  • Larger patients should receive a reduced dose to avoid respiratory depression
  • Only the 5mg dose is ever appropriate regardless of size
Question 26 Behavioral
After sedating an agitated patient with Midazolam, cardiac monitoring reveals a QRS duration of 0.14 sec and a heart rate of 44. What should you do?
  • This is an expected effect of Midazolam and requires no action
  • CONTACT BASE to discuss administration of Sodium Bicarbonate 50mEq IV, since this may indicate sodium-channel blocking toxicity (e.g. cocaine-related)
  • Immediately defibrillate the patient
  • Give a second dose of Midazolam to correct the rhythm
Question 27 Behavioral
A cooperative patient with agitation is treated with oral Olanzapine only, becomes cooperative, and meets criteria in Ref. 526/526.1 for psychiatric urgent care screening. What transport option is available?
  • ALS transport to the closest Trauma Center only
  • May be transported by BLS or law enforcement to the MAR (Medical Alert Receiving) or to a Psychiatric Urgent Care Center
  • The patient must always be transported ALS regardless of clinical status
  • No transport is needed if Olanzapine was given
Question 28 Neuro
Using the AEIOUTIPS mnemonic for ALOC, which of the following pairs is correctly matched?
  • T = Trauma, tumor
  • U = Unresponsiveness
  • P = Pulmonary embolism
  • S = Syncope only
Question 29 Neuro
A patient complains of dizziness described as a spinning sensation with associated nausea, worse with head movement. Their gait is notably abnormal/ataxic. What should you consider?
  • This is classic benign positional vertigo and requires no further workup
  • Abnormal coordination or gait with vertigo should raise strong suspicion for a cerebellar stroke
  • This presentation rules out any neurologic cause
  • Vertigo with nausea is always cardiac in origin
Question 30 NeuroPharmacology
A pregnant patient at 32 weeks gestation has an actively witnessed seizure. What is the correct action?
  • Withhold Midazolam because she is pregnant
  • CONTACT BASE, do not delay transport, and treat with Midazolam per the active-seizure standing order
  • Delay transport until the seizure fully resolves before treating
  • Only oxygen is indicated; medications are contraindicated in pregnancy
Question 31 NeuroPharmacology
A patient has an actively witnessed tonic-clonic seizure. You have IV access already established. What is the correct Midazolam dose and route?
  • Midazolam 10mg IM/IN only — IV route is never used for seizures
  • Midazolam 5mg IV/IO, repeat x1 in 2 minutes PRN, max 10mg prior to Base contact
  • Midazolam 2mg IV push one time only
  • Midazolam 20mg IV push as an initial dose
Question 32 Neuro
A 68-year-old with unilateral facial droop and arm drift has a blood glucose of 110 mg/dL, no seizure history, and is not wheelchair-bound at baseline. What does a positive mLAPSS require?
  • Only unilateral weakness — the other criteria are optional
  • No seizure history, age ≥40, not baseline wheelchair-bound/bedridden, glucose 60-400, AND obvious unilateral weakness on facial/arm/grip exam — ALL must be present
  • Positive mLAPSS only requires an abnormal glucose
  • mLAPSS is positive whenever the patient is over 65
Question 33 NeuroDestination
A patient has a positive mLAPSS, a LAMS of 5, and a Last Known Well Time of 6 hours. The Comprehensive Stroke Center (CSC) is 25 minutes away. What is the destination?
  • Closest Stroke Center regardless of LAMS
  • Comprehensive Stroke Center (CSC), since mLAPSS+, LAMS 4-5, LKWT ≤24h, and CSC is within 30 minutes
  • CONTACT BASE because LKWT exceeds 4.5 hours
  • Any hospital, since LAMS does not affect destination
Question 34 Neuro
During transport of a suspected stroke patient, what positioning is recommended and why?
  • Trendelenburg position to improve cerebral perfusion
  • Head of bed elevated 30-45 degrees to reduce aspiration risk and intracranial pressure
  • Fully supine and flat at all times
  • Prone positioning
Question 35 OB
During delivery, the umbilical cord is wrapped tightly around the newborn's neck and cannot be easily slipped over the head. What is the correct action?
  • Leave the cord in place and deliver anyway, regardless of tightness
  • Clamp the cord in two places 1 inch apart and cut it with scissors
  • Attempt to forcibly stretch the cord over the head
  • Immediately transport without attempting delivery
Question 36 OB
A newborn delivers in a breech presentation and the head does not deliver spontaneously. What is the correct maneuver?
  • Pull firmly on the newborn's legs to complete delivery
  • Place a gloved hand inside the mother and form a 'V' with fingers around the baby's face to create an airway opening
  • Immediately cut the umbilical cord to separate the baby
  • Apply firm suprapubic pressure only, with no vaginal maneuver
Question 37 OBPharmacology
A patient is 45 minutes postpartum with ongoing vaginal bleeding, SBP of 84, and heart rate of 118. What treatment is indicated?
  • Fundal massage only — medication is never indicated for PPH in the field
  • Fundal massage, two large-bore IVs, Normal Saline, AND Tranexamic Acid (TXA) 1 gram IV over 10 minutes since she is within 3 hours postpartum with SBP <90
  • TXA is contraindicated in postpartum hemorrhage
  • Immediate blood transfusion in the field
Question 38 OB
A woman in active labor reports contractions occurring every 90 seconds, each lasting about 70 seconds. What does this suggest?
  • Labor is not yet progressing and transport can proceed without urgency
  • Contractions this frequent and prolonged suggest the patient is close to delivery; prepare accordingly
  • This pattern indicates false labor
  • This is a normal, early first-stage labor pattern requiring no special preparation
Question 39 OBPharmacology
A patient in active labor with significant pain requests pain medication. What analgesics are permitted per TP 1218?
  • Fentanyl and Morphine are both standing orders for labor pain
  • Opiate and Ketorolac analgesia are contraindicated during active labor
  • Ketamine is the preferred analgesic in labor
  • Any analgesic may be given at paramedic discretion
Question 40 AllergyPharmacology
A patient with a known bee sting develops facial angioedema and wheezing. What is the correct first-line medication, route, and site?
  • Diphenhydramine 50mg IV first
  • Epinephrine 0.5mg (1mg/mL) IM in the lateral thigh
  • Albuterol nebulizer alone, with Epinephrine only if that fails
  • Epinephrine 0.5mg IV push
Question 41 Allergy
A patient in anaphylactic shock has received Epinephrine IM and initial fluids without improvement in perfusion. What is the next standing-order step?
  • Repeat Epinephrine IM immediately without fluid consideration
  • Continue Normal Saline 1L rapid infusion and begin Push-dose Epinephrine, with concurrent Base contact
  • Give Diphenhydramine IV as the priority next step
  • Nothing further can be done until Base authorizes any additional treatment
Question 42 Airway
A patient with a tracheostomy has an obstructed airway. Suctioning does not relieve the obstruction, and the inner cannula (if present) has been removed and cleaned without success. What is the next step?
  • Immediately perform a surgical cricothyrotomy
  • Remove the entire tracheostomy tube and replace with a new tracheostomy tube or a 6.0mm endotracheal tube
  • Abandon airway management and transport without further intervention
  • Insert a nasopharyngeal airway through the stoma
Question 43 AirwayPharmacology
A patient presents with inspiratory stridor from suspected upper airway swelling, without visible tongue/facial angioedema. What is the correct nebulized treatment?
  • Albuterol 5mg via neb only
  • Epinephrine (1mg/mL solution) 5mg via nebulizer, may repeat x1 in 10 minutes PRN
  • Racemic epinephrine is not available and no nebulized treatment exists in this protocol
  • Ipratropium 0.5mg via neb
Question 44 Airway
A conscious adult is choking, unable to speak, but still conscious. What is the correct BLS sequence?
  • 5 abdominal thrusts only
  • 5 back blows, then 5 abdominal thrusts, alternating
  • Immediate chest compressions while still conscious
  • Encourage forceful coughing only, no manual maneuvers
Question 45 ENT
A patient has an avulsed permanent tooth from facial trauma. How should the tooth be handled and transported?
  • Scrub the root vigorously to remove debris before transport
  • Handle by the enamel (crown), avoid touching the root, and place it in a container with Normal Saline
  • Place the tooth in a dry container without any liquid
  • Discard the tooth and focus only on bleeding control
Question 46 Eye
A patient has a suspected penetrating globe injury with an impaled foreign body visible in the eye. What is the correct management?
  • Carefully remove the foreign body and apply firm pressure to control bleeding
  • Do not remove the impaled object; secure it in place, shield the eye, and avoid pressure on the eye
  • Irrigate the eye vigorously with Normal Saline regardless of the impalement
  • Patch both eyes tightly to immobilize
Question 47 AllergyPharmacology
A patient recently received Haloperidol at a psychiatric facility and now presents with forced jaw opening, facial grimacing, and eye deviation, but no airway compromise. What is the treatment?
  • Epinephrine IM as for anaphylaxis
  • Diphenhydramine 50mg slow IV push (or deep IM if no IV access), after confirming Provider Impression with Base
  • Midazolam as for a seizure
  • No treatment is available for this presentation
Question 48 Enviro
A patient sustains partial-thickness thermal burns to 12% of their body surface area with normal vital signs. What fluid management is indicated?
  • No IV fluids are indicated for burns under 20% TBSA
  • Normal Saline 1L IV/IO rapid infusion is indicated because the burn exceeds 10% BSA, even with normal perfusion
  • Only oral hydration is appropriate for burns
  • A 2L bolus is mandatory regardless of burn size
Question 49 Enviro
A patient has sustained thermal burns covering 35% of their body surface area. What consideration applies to cooling the burns with water?
  • Cool with water regardless of burn size, as long as water is available
  • Cooling with water is only considered for burns isolated to less than 5% BSA; larger burns risk hypothermia from cooling
  • Ice should always be applied directly to large burns
  • Cooling measures are contraindicated for all burns
Question 50 Enviro
You arrive at a scene where a patient is still in contact with a downed power line. What is the very first priority action?
  • Immediately begin assessing the patient's airway
  • Do not touch the patient until the source of electricity is confirmed turned off, since current can conduct through water and skin
  • Apply gloves and approach immediately, since gloves provide adequate protection from electrocution
  • Begin CPR immediately if the patient appears unresponsive
Question 51 Enviro
A young, healthy patient is found in cardiac arrest after a lightning strike. How does this affect your resuscitation approach?
  • Resuscitation should be terminated quickly since lightning injuries are universally fatal
  • Consider prolonged CPR, especially given the patient's young age and health, per Special Consideration ❷
  • Lightning strike arrest should never be resuscitated in the field
  • Standard cardiac arrest protocol duration limits apply with no modification
Question 52 Enviro
An altered patient is found outdoors on a 105°F day, confused and hot to the touch. What is the priority intervention and its time target?
  • Passive cooling only — active cooling is contraindicated in altered patients
  • On-scene ice bath immersion (not to exceed 15 minutes) with a goal of decreasing body temperature by at least 3°C within the first 30 minutes
  • Cooling is deferred until hospital arrival
  • Only oral fluids should be given, with no active cooling
Question 53 Enviro
A patient in cardiac arrest is found to be significantly hypothermic after prolonged cold water submersion. When should resuscitation efforts be terminated?
  • After the standard 20-minute cardiac arrest algorithm, same as normothermic arrest
  • Resuscitative efforts should continue until the patient is rewarmed; Base Physician consultation is required before considering termination
  • Immediately, since hypothermic arrest has a universally poor prognosis
  • Hypothermic patients should never receive CPR
Question 54 Enviro
A patient has frostbite to the fingers with partial thawing evident. What is a key management principle?
  • Actively rewarm and then allow to refreeze if needed during transport
  • Handle the affected area gently, remove jewelry, cover and protect it — never allow a thawed area to refreeze
  • Vigorously massage the area to restore circulation
  • Apply direct ice to the affected digits
Question 55 Enviro
A patient was stung by what appears to be a jellyfish while swimming in California waters. A bystander offers vinegar to treat the sting. What is correct?
  • Apply vinegar immediately as first-line treatment
  • Do not use vinegar, given the type of jellyfish endemic to California; soak the area in hot water if available
  • Apply ice only, never hot water
  • No treatment is indicated for marine envenomation
Question 56 Enviro
A patient with a suspected bee sting has a visible stinger still embedded in the skin. What is the correct removal technique?
  • Pull the stinger out with fingernails as quickly as possible
  • Scrape the stinger out using the edge of a flat surface such as a credit card
  • Use tweezers to grasp and pull the stinger
  • Leave the stinger in place indefinitely and do not attempt removal
Question 57 Enviro
A scuba diver surfaces after a deep dive and develops respiratory distress and altered mental status within an hour. What condition should you suspect, and what is required?
  • This is unrelated to diving; treat as routine ALOC
  • Suspected decompression illness; provide high-flow O2, maintain supine, and CONTACT BASE, who will contact the Medical Alert Center
  • No special protocol exists for diving-related emergencies
  • Immediately place the patient in a seated, upright position for comfort
Question 58 Enviro
A patient rescued from a pool is found in cardiac arrest, with cold water submersion suspected. What documentation/reporting requirement applies after care is transferred?
  • No special reporting is required for pool/spa submersions
  • Contact Public Health at 213-989-7140 for all submersion incidents involving pools or spas after transfer of care or termination of resuscitation
  • Only law enforcement needs to be notified
  • Reporting is only required if the patient survives
Question 59 Enviro
A patient is exposed to smoke in a closed-space structure fire and has carbonaceous sputum with facial burns. Their pulse oximeter reads 98%. How should you interpret this?
  • The normal SpO2 rules out significant carbon monoxide exposure
  • Pulse oximetry is unreliable in CO poisoning since carboxyhemoglobin reads similarly to oxyhemoglobin; treat with 100% O2 regardless of the SpO2 reading
  • A 98% reading means no oxygen therapy is needed
  • SpO2 accurately reflects oxygenation status in all toxic inhalation scenarios
Question 60 EnviroPharmacology
Multiple patients present with severe respiratory distress, seizures, extreme salivation/lacrimation/urination, and unconsciousness after a suspected nerve agent exposure. What is the DuoDote dosing for SEVERE exposure?
  • DuoDote IM x1
  • DuoDote IM x2
  • DuoDote (Atropine 2.1mg / Pralidoxime 600mg) IM x3, one after another, begun concurrently with decontamination
  • No DuoDote until decontamination is fully complete
Question 61 EnviroPharmacology
A HAZMAT patient has known cyanide exposure with respiratory and neurologic compromise. What is the antidote, dose, and administration method?
  • Hydroxocobalamin 5 grams in 200mL NS IV/IO infused over 15 minutes, may repeat x1 in 15 minutes
  • Sodium thiosulfate IV push as a single dose
  • Naloxone 2mg IV
  • No specific antidote exists for prehospital cyanide exposure
Question 62 EnviroPharmacology
A patient has bradycardia (HR 45), hypotension, and extreme salivation after suspected organophosphate exposure (not a nerve agent/MCI scenario). What is the correct Atropine approach?
  • Atropine 2mg IV/IO, repeated every 5 minutes until asymptomatic, with a hard maximum of 3mg
  • Atropine 2mg IV/IO, may repeat every 5 min until asymptomatic — no stated maximum, unlike the bradycardia-specific 3mg cap
  • Atropine is contraindicated in organophosphate poisoning
  • A single dose of Atropine 1mg only
Question 63 ToxicologyPharmacology
A patient with suspected opioid overdose is apneic. What is the correct sequence of priorities?
  • Establish IV access first, then give Naloxone
  • Begin positive pressure ventilation first; Naloxone should not delay or take priority over establishing effective ventilation, and vascular access should not delay IN/IM Naloxone
  • Naloxone IV push is the only acceptable route
  • Wait for spontaneous respirations to return before intervening
Question 64 ToxicologyPharmacology
A patient is bradycardic and hypotensive, and is found to have hyperglycemia. Empty pill bottles of a calcium channel blocker are found at the scene. What antidote requires Base contact?
  • Calcium chloride 1g IV push over 60 seconds, with Base contact required for antidote discussion
  • Naloxone is the correct antidote
  • Sodium bicarbonate is the antidote of choice for CCB overdose
  • No antidote is available for CCB overdose
Question 65 Toxicology
ECG findings show a wide QRS (>0.12 sec) with a terminal R wave in aVR in a patient found unresponsive with empty medication bottles nearby. What toxicity is suggested, and what is the Base-order antidote?
  • Opioid overdose; Naloxone
  • Tricyclic antidepressant (TCA) overdose; Sodium Bicarbonate 50mEq IV push over 60 seconds via Base order
  • Beta blocker overdose; Glucagon
  • Acetaminophen overdose; N-acetylcysteine
Question 66 TraumaPharmacology
A patient has been entrapped under a collapsed structure for 90 minutes, with a large lower extremity crush injury. Vascular access is finally obtained. What medications should be given 5 minutes PRIOR to extrication, and in what order?
  • Sodium Bicarbonate first, then Calcium Chloride, then Albuterol
  • Calcium Chloride 1gm IV/IO first (to stabilize cardiac membrane), then Sodium Bicarbonate 50mEq IV/IO, then Albuterol 5mg neb x2 (10mg total) — flushing the line between medications
  • Only Albuterol is needed prior to extrication
  • No pre-extrication medications are indicated; treat only after release
Question 67 Trauma
A patient is entrapped with a large-muscle-group crush injury, and vascular access cannot be established while the patient remains entrapped. Extrication is expected to take longer than 30 minutes. What is the correct action?
  • Extricate immediately without any intervention
  • Place a tourniquet PRIOR to extrication as a last resort to protect against crush syndrome, since it must completely occlude both venous and arterial flow
  • Wait indefinitely for IV access before doing anything else
  • A tourniquet should never be placed before extrication
Question 68 Trauma
A patient in traumatic cardiac arrest from a penetrating gunshot wound has a shockable rhythm (V-Fib). What is the correct approach to defibrillation and transport?
  • Defibrillate on scene and delay transport until multiple defibrillation attempts are complete
  • Defibrillate while prioritizing immediate transport — do not delay transport for penetrating trauma arrest
  • Do not defibrillate penetrating trauma patients under any circumstance
  • Transport without any defibrillation attempt
Question 69 Trauma
A patient in traumatic arrest from a blunt mechanism (vehicle collision) is found in V-Fib. Defibrillation is attempted 3 times without organized rhythm return, and the rhythm remains non-shockable. What is the correct next action?
  • Continue defibrillating indefinitely on scene
  • Refer to Ref. No. 814 for determination of death, or CONTACT BASE for guidance on continued resuscitation or transport
  • Immediately transport with ongoing CPR regardless of rhythm
  • Terminate efforts without any Base contact or determination-of-death criteria
Question 70 TraumaPharmacology
A blunt trauma patient has an SBP of 82 with signs of poor perfusion, no head injury suspected. What is the correct fluid target?
  • Permissive hypotension targeting SBP ≥70 mmHg, same as penetrating trauma
  • Administer fluids to target SBP ≥90 mmHg
  • No fluids should be given regardless of BP in blunt trauma
  • Fluids should be given to achieve SBP of 120 mmHg or higher
Question 71 TraumaPharmacology
A trauma patient with suspected traumatic brain injury has an SBP of 78. How does permissive hypotension apply here?
  • Permissive hypotension is appropriate and preferred in suspected TBI
  • Permissive hypotension is contraindicated in suspected TBI — SBP should be maintained ≥90mmHg because any hypotension increases mortality in TBI
  • No fluids are given in suspected head injury regardless of BP
  • TBI patients should be kept normotensive to exactly 120/80
Question 72 TraumaPharmacology
A trauma patient meets criteria for TXA administration (SBP <90, within 3 hours of injury). What is the correct dose, diluent, and infusion time?
  • TXA 2 grams IV push over 1 minute
  • TXA 1 gram in 50-100mL Normal Saline IV/IO, infused over 10 minutes, given concurrently with fluid resuscitation
  • TXA 500mg IM injection
  • TXA is not part of the LA County trauma formulary
Question 73 TraumaPharmacology
A patient has a mid-shaft femur fracture with good distal neurovascular status. What splinting technique is indicated, and what is a key exception to be aware of?
  • Apply a traction splint per manufacturer guidelines; an open femur fracture with protruding bone is NOT a contraindication (wash with saline first if grossly contaminated)
  • Traction splints are contraindicated for all femur fractures
  • Splint only in position of comfort — traction splints are never used for femur fractures
  • No splinting is required if neurovascular status is intact
Question 74 Trauma
A patient has a traumatic amputation of several fingers. The amputated parts are recovered at the scene. How should they be prepared for transport?
  • Submerge the amputated parts directly in ice water
  • Rinse off gross debris (no manual debridement), wrap in saline-moistened sterile gauze, seal in plastic, and place indirectly on ice — never submerge in water or place directly on ice
  • Place the parts directly on ice with no wrapping
  • Amputated parts should be left at the scene and not transported
Question 75 TraumaDestination
A 30-year-old has a stab wound to the left flank. Vitals are stable. Transport time to the designated trauma center is 22 minutes. Does this patient meet Ref. 506 Trauma Criteria for immediate trauma center transport?
  • No, penetrating trauma only qualifies if the patient is hypotensive
  • Yes — all penetrating injuries to the head, neck, torso, and extremities proximal to the elbow/knee are a Trauma Criterion, and transport time is within 30 minutes
  • No, only gunshot wounds qualify as penetrating trauma criteria
  • This only qualifies as a Trauma Guideline, not a Trauma Criterion
Question 76 TraumaDestination
A 70-year-old fell and has an isolated hip fracture with no other injuries, normal vital signs. Does this meet Ref. 506 Trauma Criteria?
  • Yes, all pelvic/hip fractures are automatic trauma criteria
  • No — isolated hip fracture from a ground-level fall is specifically EXCLUDED from the suspected pelvic fracture criterion
  • Yes, because the patient is over 65
  • No, hip fractures are never trauma center criteria regardless of mechanism
Question 77 TraumaDestination
A 45-year-old was in a car crash with 15 inches of passenger space intrusion into the seat next to them (unoccupied). What triage category does this fall under?
  • Trauma Criterion, requiring immediate trauma center transport
  • Trauma Guideline — advisable for trauma center transport at Base discretion, since intrusion into an UNOCCUPIED space qualifies at >18 inches, not >12
  • This does not meet any trauma triage category
  • Automatic Extremis classification
Question 78 TraumaDestination
A 68-year-old blunt trauma patient has a systolic blood pressure of 105 mmHg with tachycardia. She does not meet any Trauma Criteria. What Special Consideration applies?
  • None — SBP 105 is normal and no special consideration applies at any age
  • SBP less than 110 mmHg may represent shock after age 65, so trauma center transport should be considered
  • This automatically qualifies as extremis
  • Age alone never factors into trauma destination decisions
Question 79 TraumaDestination
A patient has an obstructed airway from severe facial trauma that your team cannot manage in the field, and the closest trauma center is 25 minutes away while the MAR (Most Accessible Receiving hospital) is 6 minutes away. What is the correct destination?
  • The trauma center, because all severe trauma must go to a trauma center
  • The MAR — this patient meets Extremis criteria (obstructed airway) requiring immediate transport to the closest appropriately capable facility
  • Contact Base and wait on scene until a decision is reached
  • Whichever facility the patient's family requests
Section 12

Answer Key & Explanations

✓ Correct Answer: B
TP 1210 specifies Epinephrine begins <strong>after defibrillation x2</strong> for VF/pulseless VT — 1mg (10mL of 0.1mg/mL) IV/IO, repeated every 5 minutes for 2 additional doses, maximum total 3mg.
Special Consideration ❿ explains why: epinephrine can worsen outcomes if given early in a shockable rhythm, where defibrillation is the priority initial treatment. It is more useful once compressions/defibrillation have already been prioritized.
Option A is wrong because it jumps the priority order (compressions/defibrillation come first). Option C over-doses beyond the every-5-minute schedule. Option D is wrong — epinephrine IS used in refractory shockable arrest, just delayed.
Protocol: TP 1210 Cardiac Arrest, steps 7-9
✓ Correct Answer: B
Special Consideration ❾ instructs providers to change the pad position (vector change, e.g. anterior-lateral to anterior-posterior) after three shocks without conversion, which increases the chance of converting to a perfusing rhythm.
Step 11 gives Amiodarone 300mg (6mL) IV/IO after defibrillation x3, with a repeat dose of 150mg after 2 more defibrillations, to a maximum total dose of 450mg — so the initial dose is 300mg, not the full 450mg at once.
Lidocaine is not the first-line antiarrhythmic in the LA County arrest algorithm for refractory VF/VT (Amiodarone is); Magnesium is not indicated here.
Protocol: TP 1210 Cardiac Arrest, step 11 & Special Consideration ❾
✓ Correct Answer: C
Special Consideration ⓯ states ETCO2 should be used to guide ventilation rate with a target of 35-45 mmHg after ROSC.
Hyperventilation reduces cerebral blood flow and is explicitly discouraged — a transient elevation is expected right after ROSC and should not be treated with hyperventilation.
Continuing to ventilate at an appropriate, unhurried rate (approximately 10/min) while monitoring EtCO2 is the correct approach; stopping ventilations entirely is never appropriate.
Protocol: TP 1210 Cardiac Arrest, step 21 & Special Consideration ⓯
✓ Correct Answer: B
Special Consideration ⓮ states all cardiac arrest patients, with or without ROSC, being transported should go to an SRC if ground transport is 30 minutes or less, since targeted temperature management and early coronary angiography improve outcomes.
At 25 minutes, this patient falls within that window, so transport should proceed directly to the SRC.
Stroke centers are irrelevant here; this is a cardiac, not neurologic, presentation.
Protocol: TP 1210 Cardiac Arrest, Special Consideration ⓮
✓ Correct Answer: B
Inferior STEMI with hypotension raises concern for right ventricular infarction (RVI); NTG is contraindicated in hypotensive patients (SBP <100) and can cause profound, sometimes fatal, hypotension by dropping RV preload.
TP 1211 directs holding NTG when SBP is below 100 and treating poor perfusion per TP 1207 with fluids; assessing for RVI with a right-sided ECG helps confirm the diagnosis before further cardiac medications.
Fentanyl does not address the underlying hemodynamic problem and NTG remains contraindicated regardless.
Protocol: TP 1211 Cardiac Chest Pain, Special Consideration ❹ / TP 1207
✓ Correct Answer: B
TP 1211 step 6 explicitly holds NTG if the patient has taken a sexually enhancing medication within 48 hours. Combining NTG with PDE-5 inhibitors like sildenafil can cause severe, refractory hypotension.
36 hours is within that 48-hour window, so NTG must be held even though the patient is otherwise a candidate for it.
This is not a permanent contraindication — once 48 hours have passed, NTG can be considered.
Protocol: TP 1211 Cardiac Chest Pain, step 6
✓ Correct Answer: C
TP 1212 step 6 states not to delay TCP for vascular access if indicated. Step 8 specifies that if IV cannot be rapidly established, or if HR is ≤40 in 2nd degree type II or 3rd degree block, proceed immediately to TCP.
Special Consideration ❸ notes atropine is unlikely to help in type II or third-degree block, so TCP should not be delayed waiting on atropine to work.
Delaying for repeated IV attempts or watching-and-waiting risks further hemodynamic deterioration in an unstable, high-grade block.
Protocol: TP 1212 Cardiac Dysrhythmia-Bradycardia, steps 6-9
✓ Correct Answer: A
TP 1212 step 7 lists Calcium Chloride 1gm slow IV/IO push (may repeat x1) and continuous nebulized Albuterol 5mg as standing orders for suspected hyperkalemia causing bradycardia.
Sodium Bicarbonate 50mEq requires the paramedic to CONTACT BASE to obtain the order, per the same step — it is not a standing order in this protocol.
Renal failure/missed dialysis is a classic hyperkalemia risk factor per Special Consideration ❶, and calcium is specifically indicated (not contraindicated) to stabilize the cardiac membrane.
Protocol: TP 1212 Cardiac Dysrhythmia-Bradycardia, step 7
✓ Correct Answer: B
TP 1213 step 10 specifies Adenosine 12mg (4mL) rapid IV push immediately followed by a rapid NS flush, which 'may repeat x1 if no conversion' — note that in this LA County protocol the dose is 12mg for both the first and repeat doses (unlike some other systems' 6mg/12mg stepped dosing).
Cardioversion is reserved for patients with poor perfusion/ALOC, or after adenosine fails/is contraindicated and Base is contacted — it isn't the immediate next step for an adequately perfusing patient after just one adenosine dose.
Amiodarone is not part of the SVT algorithm in this protocol.
Protocol: TP 1213 Cardiac Dysrhythmia-Tachycardia, step 10
✓ Correct Answer: B
TP 1213 step 15 allows Adenosine 12mg rapid IVP with immediate flush for regular/monomorphic wide-complex tachycardia with adequate perfusion, and it may be repeated if the WCT persists.
Special Consideration ❼ explains that a regular monomorphic WCT may represent SVT with aberrancy/bundle branch block, and AHA guidelines support adenosine's use here to potentially convert to sinus rhythm.
Adenosine is contraindicated specifically for irregular wide-complex tachycardia (possible A-fib with WPW), not regular monomorphic WCT — so option A is too broad. Cardioversion/amiodarone are not the first steps for a perfusing patient.
Protocol: TP 1213 Cardiac Dysrhythmia-Tachycardia, step 15 & Special Consideration ❼
✓ Correct Answer: B
TP 1213 step 19 directs synchronized cardioversion for irregular WCT with poor perfusion, with concurrent Base contact, and consideration of Midazolam sedation prior to cardioversion if feasible.
Adenosine should NOT be used for irregular wide-complex tachycardia, since this may represent atrial fibrillation with WPW, which can degenerate to a fatal dysrhythmia with adenosine (Special Consideration ❹).
Amiodarone is not part of this algorithm, and untreated poor perfusion in an unstable dysrhythmia is never appropriate.
Protocol: TP 1213 Cardiac Dysrhythmia-Tachycardia, step 19 & Special Consideration ❹
✓ Correct Answer: C
TP 1214 step 8 uses a tiered NTG dosing scheme based on SBP: 0.4mg SL for SBP ≥100, 0.8mg SL for SBP ≥150, and 1.2mg SL for SBP ≥200 mmHg.
This patient's SBP of 210 meets the ≥200 threshold, so the highest dose (1.2mg) is indicated, reassessing BP before each subsequent dose (may repeat q3-5min x2).
High SBP is not a contraindication to NTG in pulmonary edema — in fact, it drives more aggressive dosing to reduce afterload.
Protocol: TP 1214 Pulmonary Edema/CHF, step 8
✓ Correct Answer: B
TP 1214 step 9 allows Albuterol 5mg via nebulizer for wheezing that persists despite CPAP, and it may be given simultaneously with nitroglycerin based on clinical assessment.
If the patient reports a history of COPD or asthma, treatment is done in conjunction with TP 1237, Respiratory Distress — but this doesn't preclude Albuterol use in CHF-associated wheeze.
Epinephrine IM is not indicated for cardiogenic wheezing in this scenario.
Protocol: TP 1214 Pulmonary Edema/CHF, step 9
✓ Correct Answer: B
TP 1203 step 7 specifies that if unable to obtain venous access, Glucagon 1mg (1mL) IM may be given, and may repeat once in 20 minutes if needed.
Oral glucose is only appropriate for a patient who is awake and alert enough to protect their airway — this patient is unresponsive, so oral glucose is unsafe (aspiration risk).
Delaying treatment for hypoglycemia risks ongoing neurologic injury; IM Glucagon is the standing-order alternative when IV/IO access fails.
Protocol: TP 1203 Diabetic Emergencies, step 7
✓ Correct Answer: B
Special Consideration ❸ in TP 1203 explains that Glucagon works by releasing stored glycogen from the liver — it is only effective if there are sufficient glycogen stores.
Patients with severe malnutrition, cirrhosis, or adrenal insufficiency often have depleted glycogen stores and may not respond adequately to Glucagon.
In this scenario, continued attempts at IV/IO access for Dextrose, along with Base contact, would be the next appropriate steps rather than assuming dosing error.
Protocol: TP 1203 Diabetic Emergencies, Special Consideration ❸
✓ Correct Answer: B
TP 1204 Special Consideration ❶ states that an EtCO2 reading ≤25 mmHg strongly supports the provider impression of sepsis in patients where sepsis is suspected — low EtCO2 reflects the compensatory tachypnea and metabolic acidosis of sepsis.
This is a documentation/impression aid, not by itself an indication for intubation.
Low EtCO2 in this clinical context should raise suspicion for sepsis rather than be dismissed as simple anxiety.
Protocol: TP 1204 Fever/Sepsis, Special Consideration ❶
✓ Correct Answer: B
TP 1204 step 8 and Special Consideration ❸ direct documenting Provider Impression as 'Fever' (not Sepsis) when fever is present without tachycardia, tachypnea, or other signs of infection/poor perfusion.
Management for isolated fever is passive cooling and thermal blankets if shivering occurs — not an aggressive fluid bolus, which is reserved for suspected sepsis with tachycardia, tactile fever, or poor perfusion (step 6).
Sepsis is a distinct clinical impression requiring specific criteria; fever alone does not meet that threshold.
Protocol: TP 1204 Fever/Sepsis, step 8 & Special Consideration ❸
✓ Correct Answer: B
TP 1207 step 10 draws this distinction explicitly: isolated hypotension without poor perfusion that improves with or without an initial 250mL NS bolus is documented as HOTN.
Hypotension WITH poor perfusion, or hypotension that doesn't respond to an initial 250mL bolus and requires additional fluid beyond 1L or Push-dose Epinephrine, is documented as SHOK.
This distinction matters for documentation accuracy and downstream hospital communication about severity.
Protocol: TP 1207 Shock/Hypotension, step 10
✓ Correct Answer: B
TP 1207 step 11 specifies Push-dose Epinephrine preparation: 9mL Normal Saline mixed with 1mL Epinephrine (0.1mg/mL) IV formulation in a 10mL syringe, yielding a 0.01mg/mL concentration, given 1mL IV/IO every 1-5 minutes titrated to maintain SBP >90mmHg.
CONTACT BASE is required concurrent with the initial dose of Push-dose Epinephrine.
Dopamine and Norepinephrine infusions are not part of the LA County field formulary for this indication; vasopressor support here is via push-dose epi only.
Protocol: TP 1207 Shock/Hypotension, step 11
✓ Correct Answer: B
TP 1206 step 9 specifies that for an insulin pump, you should check blood glucose PRN and treat in conjunction with TP 1203, Diabetic Emergencies — the underlying glucose abnormality is what should be addressed clinically.
'Medical Device Malfunction' as a Provider Impression is reserved for when the presentation truly suggests the device itself is malfunctioning; otherwise, treat the presenting problem per the applicable protocol.
Most patients with an implanted/worn medical device have complaints unrelated to the device and should be assessed and treated per standard protocols based on signs and symptoms (Special Consideration ❶).
Protocol: TP 1206 Medical Device Malfunction, step 9
✓ Correct Answer: B
TP 1206 step 9 specifically states that for a Ventricular Assist Device, providers should CONTACT BASE and refer to MCG 1325 — VADs alter normal hemodynamic assessment (e.g., may not have a palpable pulse or standard BP) and require specialized guidance.
This differs from other device categories (e.g., VP shunt or pacemaker), where symptoms are simply treated per presenting complaint — VAD patients specifically require Base involvement given the complexity and risk.
Alarms should never be ignored; they may indicate a life-threatening device malfunction.
Protocol: TP 1206 Medical Device Malfunction, step 9
✓ Correct Answer: B
TP 1205 step 9 specifies documenting 'Upper GI Bleeding' when the patient is vomiting blood or coffee-ground material, and/or has tarry/black stools (melena), both of which reflect blood that has been partially digested in the upper GI tract.
'Lower GI Bleeding' is reserved for bleeding per rectum (typically bright red), which is a distinct impression.
While abdominal pain and nausea/vomiting are relevant symptoms, the specific finding of coffee-ground emesis has its own dedicated Provider Impression that should be used when present.
Protocol: TP 1205 GI/GU Emergencies, step 9
✓ Correct Answer: B
TP 1202 step 11 directs assessing a neurologic exam for complaints of weakness; if focal findings are present or stroke is suspected, treat per TP 1232, Stroke/CVA/TIA.
If no focal weakness is present and the complaint is generalized, document Provider Impression as 'Weakness – General' rather than defaulting to a stroke workup.
This distinction matters for appropriate triage and hospital routing — not every weakness complaint requires stroke-center transport.
Protocol: TP 1202 General Medical, step 11
✓ Correct Answer: A
TP 1209 step 10 specifies Midazolam 5mg (1mL) IM/IN/IV for uncooperative patients posing a safety risk, with CONTACT BASE required concurrently with administration — this is a standing order given simultaneously with, not delayed by, base contact.
With Base orders, dosing may repeat every 5 minutes PRN to a maximum total dose of 20mg — 20mg is not a single initial dose.
Olanzapine (step 9) is reserved for cooperative patients; it is a different medication for a different clinical scenario (agitation management in a cooperative patient).
Protocol: TP 1209 Behavioral/Psychiatric Crisis, step 10
✓ Correct Answer: A
TP 1209 Special Consideration ❽ states that larger patients (≥100kg) and/or those posing greater risk of harm due to agitation/violence may require the higher dose of Midazolam (10mg IM/IN single dose) for adequate sedation.
Conversely, smaller, frail, elderly, or already-fatigued patients should preferentially receive the lower 5mg dose (with repeat PRN) to reduce oversedation and apnea risk.
Step 11 allows either 5mg with a repeat in 5 minutes, OR a single 10mg dose, based on this clinical judgment — maximum 10mg prior to Base contact either way.
Protocol: TP 1209 Behavioral/Psychiatric Crisis, step 11 & Special Consideration ❽
✓ Correct Answer: B
TP 1209 step 13 directs CONTACT BASE for a QRS >0.12 sec or heart rate <50 to discuss administering Sodium Bicarbonate 50mEq IV.
Special Consideration ❿ explains that several agitation-causing drugs (notably cocaine, which produces TCA-like sodium channel blockade) can cause widened QRS progressing to malignant arrhythmia, and large-dose sodium bicarbonate may be needed to prevent sudden cardiac death.
This is treated in conjunction with TP 1241, Overdose/Poisoning/Ingestion — it is not a benign, expected finding, and Midazolam does not treat it.
Protocol: TP 1209 Behavioral/Psychiatric Crisis, step 13 & Special Consideration ❿
✓ Correct Answer: B
TP 1209 step 20 allows patients who respond to verbal de-escalation or receive only Olanzapine, and who are now cooperative and meet the Ref. 526/526.1 medical clearance screening criteria, to be transported by BLS or law enforcement to the MAR or a Psychiatric Urgent Care Center.
This reflects the goal of routing low-acuity, medically-cleared psychiatric patients to an appropriate alternate destination rather than requiring an ALS unit and ED bed.
This option is specific to patients who only received Olanzapine or de-escalation — patients requiring Midazolam sedation have a different, more monitored transport pathway.
Protocol: TP 1209 Behavioral/Psychiatric Crisis, step 20
✓ Correct Answer: A
TP 1229 Special Consideration ❶ lists the AEIOUTIPS mnemonic: A-Alcohol/abuse/atypical migraine, E-Epilepsy/electrolytes, I-Insulin (hypoglycemia), O-Oxygen/overdose, U-Uremia, T-Trauma/tumor, I-Infection, P-Psych/poisoning, S-Seizure/Subarachnoid hemorrhage/Sepsis/Stroke.
T correctly corresponds to Trauma and tumor. U stands for Uremia (kidney failure), not unresponsiveness — that's a symptom, not a cause category. P stands for Psych and poisoning, not pulmonary embolism. S covers Seizure, Subarachnoid hemorrhage, Sepsis, and Stroke — not syncope alone.
Protocol: TP 1229 ALOC, Special Consideration ❶
✓ Correct Answer: B
TP 1230 Special Consideration ❷ specifically warns that vertigo may be a symptom of a cerebellar stroke, and if a patient's coordination or gait is abnormal with a complaint of vertigo, providers should strongly consider stroke.
Stroke scales like mLAPSS do not catch every stroke presentation — vertigo/ataxia is a known blind spot, which is why this special consideration exists to prompt heightened suspicion despite a possibly negative mLAPSS.
This is treated per TP 1232, Stroke/CVA/TIA when stroke is suspected, rather than dismissed as routine vertigo.
Protocol: TP 1230 Dizziness/Vertigo, Special Consideration ❷
✓ Correct Answer: B
TP 1231 requires Base Hospital Contact for pregnant patients or status epilepticus. Step 5 specifically states for suspected eclampsia, CONTACT BASE and do not delay transport.
Active seizure in a pregnant patient (possible eclampsia) is still treated with the standard Midazolam regimen (10mg IM/IN, or 5mg IV/IO with repeat x1 in 2 min prn, max 10mg prior to Base contact) — pregnancy does not contraindicate seizure treatment.
Delaying transport for a pregnant seizure patient is explicitly discouraged given the risk of eclampsia progression.
Protocol: TP 1231 Seizure, step 5 & Base Hospital Contact line
✓ Correct Answer: B
TP 1231 step 7 gives two dosing options for active seizure: Midazolam 10mg IM/IN, OR (if existing vascular access) Midazolam 5mg IV/IO, repeat x1 in 2 minutes PRN — maximum total dose 10mg via any route prior to Base contact.
With Base contact and orders, dosing may continue up to a maximum total of 20mg.
The IV dose (5mg) is intentionally lower than the IM/IN dose (10mg) because IV onset is faster and more predictable.
Protocol: TP 1231 Seizure, step 7
✓ Correct Answer: B
TP 1232 step 7 specifies mLAPSS is positive only if ALL listed criteria are met together: no seizure/epilepsy history, age ≥40, not baseline wheelchair-bound/bedridden, glucose between 60-400 mg/dL, AND obvious asymmetric unilateral weakness (facial, arm, or grip).
This patient meets all five criteria (age 68, no seizure history, ambulatory at baseline, glucose 110, unilateral facial/arm findings), so the mLAPSS would be positive.
It's a conjunctive (AND) test, not just a single criterion — missing even one excludes a positive result, which is why option A and C are incorrect.
Protocol: TP 1232 Stroke/CVA/TIA, step 7
✓ Correct Answer: B
TP 1232 step 10 gives destination criteria: mLAPSS positive + LAMS 4-5 + LKWT ≤24 hours → transport to a Comprehensive Stroke Center (CSC) if within 30 minutes.
This patient meets all three criteria and the CSC is within the 30-minute window (25 min), so CSC is the correct destination — LAMS 4-5 indicates a higher likelihood of large vessel occlusion, which benefits from CSC-level intervention capability.
A LAMS of ≤3 (not 4-5) with mLAPSS positive would instead go to the closest Stroke Center rather than the CSC.
Protocol: TP 1232 Stroke/CVA/TIA, step 10
✓ Correct Answer: B
TP 1232 step 11 and Special Consideration ❺ direct transporting suspected stroke patients with the head of bed elevated 30-45 degrees.
This reduces aspiration risk (relevant given possible dysphagia/impaired swallow with stroke) and reduces elevation in intracranial pressure.
Trendelenburg would worsen ICP and is not indicated; fully flat/supine or prone positioning are not the protocol recommendation for suspected stroke.
Protocol: TP 1232 Stroke/CVA/TIA, step 11 & Special Consideration ❺
✓ Correct Answer: B
TP 1217 step 12 (Nuchal Cord section) specifies: 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.
Step 11 covers the alternative: if the nuchal cord is loose, first attempt slipping it over the head before delivery — cutting is reserved for when the cord is too tight to slip over.
Forcing a tight cord over the head risks cord avulsion and hemorrhage; cutting when appropriately indicated is the safer, protocol-directed action.
Protocol: TP 1217 Pregnancy Complication, Nuchal Cord section, step 12
✓ Correct Answer: B
TP 1217 step 8 (Breech Delivery section) directs: if the head does not deliver, place a gloved hand inside the mother and form a 'V' with fingers around the baby's face to provide an airway opening.
Cutting the cord before the head delivers would be catastrophic, cutting off the fetal blood/oxygen supply while the head remains undelivered and unable to breathe independently.
Suprapubic pressure with the McRoberts maneuver is the technique for shoulder dystocia, a different complication (step 13), not for a retained breech head.
Protocol: TP 1217 Pregnancy Complication, Breech Delivery section, step 8
✓ Correct Answer: B
TP 1217 Postpartum Hemorrhage section (steps 18-21) directs fundal massage, establishing 2 large-bore IVs, Normal Saline 1L (repeat x1 for ongoing hemorrhage/poor perfusion), and TXA 1 gram in 50-100mL NS over 10 minutes for patients within 3 hours postpartum with ongoing bleeding AND SBP <90, OR HR>SBP, OR estimated blood loss >500mL.
This patient meets criteria (SBP 84 <90, within 3 hours, HR 118 > SBP 84) — so TXA and fluids should be initiated concurrently per Special Consideration ❼.
Blood products are not part of the field EMS formulary in this protocol; TXA is the indicated antifibrinolytic intervention.
Protocol: TP 1217 Pregnancy Complication, Postpartum Hemorrhage section
✓ Correct Answer: B
TP 1218 Special Consideration ❶ states that contractions less than 2 minutes apart or lasting more than 60 seconds indicate the patient is close to delivery, and providers should prepare accordingly.
This patient's contractions are every 90 seconds (< 2 min apart) and lasting 70 seconds (> 60 sec), meeting both criteria for impending delivery.
The protocol also notes that women who have had prior vaginal deliveries can progress through labor very rapidly, reinforcing the need to prepare for field delivery rather than assume there's time for extended transport.
Protocol: TP 1218 Pregnancy Labor, Special Consideration ❶
✓ Correct Answer: B
TP 1218 step 7 explicitly states: 'Opiate and Ketorolac analgesia is contraindicated (MCG 1345).'
This reflects concern for neonatal respiratory depression from opioids crossing the placenta close to delivery, and bleeding/renal risk from NSAIDs like Ketorolac in a peripartum patient.
This is a notable protocol-specific restriction that differs from general pain management guidance in other contexts and is a common point of confusion/testing.
Protocol: TP 1218 Pregnancy Labor, step 7
✓ Correct Answer: B
TP 1219 step 4 and Special Consideration ❶ establish Epinephrine (1mg/mL) 0.5mg (0.5mL) IM in the lateral thigh (preferred site) as the drug of choice for anaphylaxis presenting with angioedema, respiratory compromise, or poor perfusion.
Diphenhydramine does NOT treat anaphylaxis (Special Consideration ❸) — it may be used afterward for isolated hives/itching once definitive treatment with Epinephrine has been given.
Albuterol may be added if wheezing persists after Epinephrine, but Epinephrine IM is always first for true anaphylaxis with respiratory or angioedema findings — not held until Albuterol fails.
Protocol: TP 1219 Allergy, step 4 & Special Considerations ❶❸
✓ Correct Answer: B
TP 1219 step 7 addresses anaphylactic shock (persistent poor perfusion after initial 250mL NS): continue Normal Saline 1L rapid infusion AND begin Push-dose Epinephrine (0.01mg/mL, 1mL IV/IO q1-5min titrated to SBP >90), with CONTACT BASE concurrent with the initial Push-dose Epi dose.
This is then treated in conjunction with TP 1207, Shock/Hypotension.
IM Epinephrine may still be repeated per step 4 (q10min x2, max 3 total doses) with Base contact, but the shock-specific next step for persistent poor perfusion after fluids is Push-dose Epi, not simply repeating IM epi in isolation.
Protocol: TP 1219 Allergy, step 7
✓ Correct Answer: B
TP 1234 step 7 (tracheostomy section) directs that if suctioning and inner cannula cleaning don't relieve obstruction, remove the entire tracheostomy tube and replace it with a new tracheostomy tube OR a 6.0mm endotracheal tube.
If a new tube cannot be placed, the next step is to cover the stoma and attempt BMV first via the mouth; if no chest rise, attempt BMV over the stoma with a small mask.
Special Consideration ❹ notes removal/reinsertion is contraindicated if the tracheostomy is <1 week old (immature stoma, false tract risk) — but for a mature stoma, this stepwise approach applies.
Protocol: TP 1234 Airway Obstruction, tracheostomy section, step 7
✓ Correct Answer: B
TP 1234 step 7 (stridor section) specifies Epinephrine (1mg/mL solution) 5mg (5mL) via nebulizer for stridor, which may repeat x1 in 10 minutes PRN, while preparing to manage the airway if the patient's condition deteriorates.
This nebulized (racemic-style) epinephrine dose for stridor is distinct from the IM Epinephrine 0.5mg dose used for visible airway/tongue swelling (angioedema) in the same protocol step.
Albuterol is a bronchodilator for lower airway bronchospasm, not the primary treatment for upper airway stridor/swelling.
Protocol: TP 1234 Airway Obstruction, stridor section
✓ Correct Answer: B
TP 1234 step 3 specifies for a conscious patient unable to speak due to physical obstruction: perform 5 back blows, then 5 abdominal thrusts, alternating between the two.
If the patient becomes unconscious during this process, you lower them to the ground and begin chest compressions, then initiate CPR x2 minutes with direct laryngoscopy to visualize and remove the obstruction with Magill forceps if indicated.
Chest compressions are reserved for the unconscious/pulseless choking patient, not as an initial maneuver while the patient is still conscious.
Protocol: TP 1234 Airway Obstruction, step 3
✓ Correct Answer: B
TP 1226 step 6 (tooth avulsion) directs handling the tooth by the enamel/crown, not touching the root (which contains the periodontal ligament cells needed for potential reimplantation), and placing it in a container with Normal Saline.
Scrubbing or drying the root damages the delicate periodontal ligament cells and reduces the chance of successful reimplantation at the hospital or by a dentist.
The tooth should be preserved and transported with the patient, not discarded.
Protocol: TP 1226 ENT/Dental Emergencies, step 6
✓ Correct Answer: B
TP 1228 steps 3-4 direct shielding the eye and positioning the patient at 45 degrees for suspected penetrating globe injury, with no pressure placed on the eye, and NOT removing any impaled foreign bodies — instead securing them in place.
Removing an impaled object or applying pressure risks extruding intraocular contents and causing permanent vision loss.
Vigorous irrigation is reserved for chemical burns (step 7), not for a penetrating injury with an impaled object, which requires careful stabilization instead.
Protocol: TP 1228 Eye Problem, steps 3-4
✓ Correct Answer: B
This presentation (involuntary muscle spasms of the face/neck/eyes, forced jaw opening, facial grimacing, eye deviation) after a dopamine-blocking medication like Haloperidol is a classic acute dystonic reaction, covered by TP 1239.
TP 1239 requires CONTACT BASE to confirm the Provider Impression, then Diphenhydramine 50mg slow IV push, or deep IM if venous access is unavailable.
Special Consideration ❶ lists Haloperidol among the common causative medications (along with Compazine, Reglan, Phenergan, and others) — recognizing the medication list helps confirm the diagnosis.
Protocol: TP 1239 Dystonic Reaction, steps 4-5 & Special Consideration ❶
✓ Correct Answer: B
TP 1220 step 10 specifies Normal Saline 1L IV/IO rapid infusion for partial/full-thickness burns >10% body surface area OR for poor perfusion — this patient's 12% TBSA burn meets the >10% threshold independent of perfusion status.
Reassess after each 250mL increment for volume overload; CONTACT BASE for persistent poor perfusion to obtain an order for additional Normal Saline.
A full 2L is not specified as a mandatory starting dose; fluid is titrated with reassessment.
Protocol: TP 1220 Burns, step 10
✓ Correct Answer: B
TP 1220 step 7 specifies considering cooling with water only for thermal burns isolated to less than 5% BSA.
Special Consideration ❷ explicitly warns that cooling large surface area burns (greater than 10% BSA) may result in hypothermia — a significant risk given this patient's 35% TBSA burn.
For larger burns, the priority shifts to covering with a dry dressing/sheet and keeping the patient warm with a blanket, rather than active cooling.
Protocol: TP 1220 Burns, step 7 & Special Consideration ❷
✓ Correct Answer: B
TP 1221 step 1 and Special Consideration ❶ make scene safety the absolute first priority: ensure the source of electricity is turned off before approaching, since electrical current can be conducted through water and skin, and standard gloves do not protect against high-voltage current.
Approaching a live electrical hazard risks the rescuer becoming a second victim — this must be resolved before any patient contact, including airway assessment or CPR.
Only after the source is confirmed off and the surrounding area is dry should providers approach and begin assessment/treatment.
Protocol: TP 1221 Electrocution, step 1 & Special Consideration ❶
✓ Correct Answer: B
TP 1221 Special Consideration ❷ states that for young, healthy patients, especially in lightning injuries, providers should consider prolonged cardiopulmonary resuscitation.
Lightning/electrical arrest often causes a primary respiratory arrest with cardiac standstill that can have a favorable prognosis with aggressive, prolonged resuscitation, unlike many other arrest etiologies.
This is a specific exception encouraging extended effort, not termination, especially in young and otherwise healthy patients.
Protocol: TP 1221 Electrocution, Special Consideration ❷
✓ Correct Answer: B
TP 1222 step 6 and Special Consideration ❷ direct on-scene cooling with ice bath immersion for altered patients (not exceeding 15 minutes of immersion), monitoring for mental status improvement.
The goal is to decrease body temperature by at least 3°C within the first 30 minutes of care, since ALOC with suspected heat emergency is treated as heatstroke — a time-critical emergency with risk of cardiovascular collapse.
Oral fluids are reserved for patients with adequate perfusion and normal mental status (step 10) — not appropriate for an altered patient who cannot safely protect their airway.
Protocol: TP 1222 Hyperthermia, step 6 & Special Consideration ❷
✓ Correct Answer: B
TP 1223 Special Consideration ❸ (and echoed in TP 1225 Special Consideration ❶ for cold-water drowning) states that patients with hypothermia may have good neurologic outcome despite prolonged resuscitation, and resuscitative efforts should continue until the patient is rewarmed.
Consultation with the Base Physician is required before considering termination of resuscitation in these patients — this differs from standard normothermic termination-of-resuscitation criteria.
'The cold and dead aren't dead until warm and dead' reflects the physiologic protective effect hypothermia can have on organs including the brain during a low-flow state.
Protocol: TP 1223 Hypothermia/Cold Injury, step 9 & Special Consideration ❸
✓ Correct Answer: B
TP 1223 step 5 and Special Consideration ❷ direct handling frostbite gently, removing jewelry, and covering/protecting the area.
Critically, Special Consideration ❷ warns not to allow an area of frostbite to thaw and then refreeze, as a freeze-thaw-refreeze cycle causes significantly more tissue damage than either freezing or thawing alone.
Vigorous massage and direct ice application would cause additional mechanical tissue trauma to already-injured, fragile frostbitten tissue and are contraindicated.
Protocol: TP 1223 Hypothermia/Cold Injury, step 5 & Special Consideration ❷
✓ Correct Answer: B
TP 1224 step 6 and Special Consideration ❷ specifically instruct NOT to use vinegar for marine envenomation, given the species of jellyfish found in California waters (vinegar can actually worsen nematocyst discharge for certain species found locally, unlike box jellyfish elsewhere where vinegar is recommended).
Instead, the protocol directs soaking the area in hot water if available, and removing any visible barb.
This is a California-specific protocol nuance that differs from generic marine sting teaching in other regions, making it a notable point for the exam.
Protocol: TP 1224 Stings/Venomous Bites, step 6 & Special Consideration ❷
✓ Correct Answer: B
TP 1224 Special Consideration ❶ specifies removing a stinger by scraping the skin with the edge of a flat surface (like a credit card), rather than pulling it out with fingernails or tweezers.
Pulling/pinching the stinger with fingernails or tweezers can compress the venom sac still attached to the stinger, injecting additional venom into the patient.
A scraping motion lifts the stinger out without compressing the venom sac further.
Protocol: TP 1224 Stings/Venomous Bites, Special Consideration ❶
✓ Correct Answer: B
TP 1225 requires Base Hospital Contact for ALOC and decompression emergencies; if decompression emergency is suspected, Base Hospital contacts the Medical Alert Center per Ref. 518.
Step 3 directs high-flow Oxygen 15L/min and CONTACT BASE for suspected decompression illness; step 4 directs maintaining the patient supine.
Special Consideration ❷ explains decompression sickness ('the bends') can be delayed and should be considered in any patient with symptoms within 24 hours of a dive — all such patients need evaluation for possible hyperbaric treatment, so upright positioning for 'comfort' is not appropriate here.
Protocol: TP 1225 Submersion, steps 3-4 & Special Consideration ❷
✓ Correct Answer: B
Both TP 1210 (step 26) and TP 1225 (step 12) require contacting Public Health at 213-989-7140 for all submersion incidents involving pools or spas, after transfer of patient care in the ED or upon termination of resuscitation in the field.
Special Consideration ❺/❳ explains this supports the Department of Public Health in promptly investigating fatal or nonfatal drownings at public pools/spas, to verify safety before the facility can reopen.
This requirement applies regardless of patient outcome (survival or death) — it's about facility investigation, not just fatality reporting.
Protocol: TP 1225 Submersion, step 12
✓ Correct Answer: B
TP 1236/1238 and Special Consideration ❶ in the Burns protocol all emphasize that pulse oximetry is not accurate in carbon monoxide poisoning — standard pulse oximeters cannot distinguish carboxyhemoglobin from oxyhemoglobin, giving a falsely reassuring normal reading.
Given the classic exposure history (closed-space fire, carbonaceous sputum, facial burns), high-flow Oxygen 15L/min should be administered regardless of the SpO2 reading.
This is a frequently tested LA County-specific clinical pearl given how counterintuitive a 'normal' SpO2 can be in true CO toxicity.
Protocol: TP 1238 Carbon Monoxide Exposure, step 4 & TP 1220 Special Consideration ❶
✓ Correct Answer: C
TP 1240 step 14 specifies for SEVERE nerve agent exposure: begin treatment immediately, concurrent with decontamination, with DuoDote IM x3 given one after another.
This contrasts with MODERATE exposure (DuoDote IM x2, step 15) and MILD exposure (DuoDote IM x1, step 16) — both of which require decontamination to be completed BEFORE treatment/transport, unlike severe exposure where treatment starts immediately.
Special Consideration ❶ defines severity tiers: severe includes respiratory arrest, cyanosis, extreme SLUDGE, seizures, and unconsciousness — matching this scenario.
Protocol: TP 1240 HAZMAT, step 14 & Special Consideration ❶
✓ Correct Answer: A
TP 1240 step 26 (Cyanide Exposure section) specifies Hydroxocobalamin 5 grams in 200mL Normal Saline IV/IO (25mg/mL), infused over 15 minutes, which may repeat x1 in 15 minutes for patients with cardiovascular, neurologic, and/or respiratory compromise due to suspected or known cyanide exposure.
This is the field-available cyanide antidote in the LA County formulary — sodium thiosulfate/nitrite kits are not the LA County field standard here.
Cyanide toxicity should also be considered in industrial fires or closed-space fires with ALOC/seizure, per cross-references in the Burns and Inhalation Injury protocols.
Protocol: TP 1240 HAZMAT, step 26
✓ Correct Answer: B
TP 1240 step 19 (Organophosphate Exposure section) specifies Atropine 2mg (20mL) IV/IO, which may be repeated every 5 minutes until the patient is asymptomatic — this dose is notably higher than the cardiac bradycardia dose (1mg).
Unlike TP 1212's bradycardia Atropine, which caps at a maximum total of 3mg, the organophosphate exposure indication has no stated maximum — high cumulative doses may be needed to overcome the toxin's cholinergic excess.
For seizures in this setting, treatment is given in conjunction with TP 1231, Seizure.
Protocol: TP 1240 HAZMAT, step 19
✓ Correct Answer: B
TP 1241 Special Consideration ❶ makes clear the first priority for an apneic overdose patient is beginning positive pressure ventilation; Naloxone is then given (IN or IM preferred initially) with the goal of restoring spontaneous ventilation.
Vascular access should NOT take priority over initial treatment with Naloxone via the IN or IM route — you don't need an IV to give the first dose.
Patients who become awake and alert with normal respirations after naloxone may not need IV access or additional doses at all.
Protocol: TP 1241 Overdose/Poisoning/Ingestion, step 4 & Special Consideration ❶
✓ Correct Answer: A
TP 1241 step 15 requires CONTACT BASE to discuss antidote administration, including Calcium Chloride 1g (10mL) IV push over 60 seconds for suspected calcium channel and/or beta blocker overdose.
Special Consideration ❸ notes CCB overdose classically presents with bradycardia, hypotension, AND hyperglycemia (distinguishing it from beta blocker overdose, which causes hypoglycemia) — matching this scenario.
Sodium bicarbonate is the antidote used for tricyclic antidepressant overdose (wide QRS), not CCB overdose — a common point of confusion.
Protocol: TP 1241 Overdose/Poisoning/Ingestion, step 15 & Special Consideration ❸
✓ Correct Answer: B
TP 1241 Special Consideration ❹ identifies wide QRS (>0.12mm/sec) with a terminal R wave in aVR as classic ECG findings for tricyclic antidepressant overdose.
Step 15 requires CONTACT BASE to discuss antidote administration — for TCA overdose, this is Sodium Bicarbonate 50mEq (50mL) IV push over 60 seconds, which works by alkalinizing the blood to reduce TCA binding to cardiac sodium channels.
Naloxone and Glucagon are not appropriate here; N-acetylcysteine (for acetaminophen toxicity) is not part of the prehospital formulary and doesn't address the acute cardiotoxicity shown on this ECG.
Protocol: TP 1241 Overdose/Poisoning/Ingestion, step 15 & Special Consideration ❹
✓ Correct Answer: B
TP 1242 step 14 specifies giving Calcium Chloride 1gm IV/IO, Sodium Bicarbonate 50mEq IV/IO, and Albuterol 5mg via nebulizer x2 (10mg total) approximately 5 minutes PRIOR to extrication for patients at risk for crush syndrome.
Special Consideration ❼ explains these should be given before release of compressive force to counteract the surge of cellular toxins (especially potassium) that enters circulation upon extrication.
Special Consideration ❺ specifically notes Calcium should be given first and the line flushed between medications, since Calcium and Bicarbonate will precipitate if mixed together in the same line.
Protocol: TP 1242 Crush Injury/Syndrome, step 14 & Special Considerations ❺❼
✓ Correct Answer: B
TP 1242 step 14 and Special Consideration ❽ specify that if unable to establish vascular access while entrapped, a tourniquet should be placed PRIOR to extrication as a last resort — but only when vascular access cannot be established or transport is anticipated to exceed 30 minutes.
The tourniquet must completely occlude both venous and arterial flow to effectively protect the patient from the systemic release of crush syndrome toxins upon release of the compressive force.
Once extricated, vascular access and cardiac monitoring must be established immediately, and providers should be prepared to treat crush syndrome symptoms.
Protocol: TP 1242 Crush Injury/Syndrome, Special Consideration ❽
✓ Correct Answer: B
TP 1243 step 7 and Special Consideration ❸ direct that for penetrating trauma with a shockable rhythm, providers should defibrillate WHILE prioritizing immediate transport — this differs from the blunt trauma approach, which initiates on-scene resuscitation.
Rapid transport after hemorrhage control is the overall priority for severe trauma (Special Consideration ❶); with the exception of hemorrhage control, needle thoracostomy, and initiating CPR, other procedures should be deferred for immediate loading and performed en route.
This reflects that penetrating trauma arrest often has a surgically correctable cause (hemorrhage) that can only be fixed at a trauma center, unlike many blunt trauma arrests.
Protocol: TP 1243 Traumatic Arrest, step 7 & Special Consideration ❸
✓ Correct Answer: B
TP 1243 step 7 (blunt trauma subsection) directs that if organized rhythm is not restored after defibrillation x3, or the patient converts to a nonshockable rhythm, providers should refer to Ref. No. 814 for determination of death, and CONTACT BASE if needed for guidance on continued resuscitation or transport.
This differs from penetrating trauma arrest, where transport is prioritized regardless of rhythm outcome; blunt traumatic arrest without a shockable rhythm after adequate defibrillation attempts has a very poor prognosis and specific field termination criteria may apply.
This is never done unilaterally without either meeting Ref. 814 criteria or Base guidance — it isn't an option to simply stop without following one of these pathways.
Protocol: TP 1243 Traumatic Arrest, step 7 (blunt trauma) & Special Consideration ❹
✓ Correct Answer: B
TP 1244 Special Consideration ❻ specifies that for blunt trauma with poor perfusion, fluids should be administered to target SBP ≥90mmHg — a higher target than the permissive hypotension approach used for penetrating trauma.
Penetrating trauma with poor perfusion and normal mental status targets a lower SBP ≥70mmHg (permissive hypotension) to avoid disrupting clot formation, but this specifically does NOT apply to blunt trauma.
Aggressive over-resuscitation beyond target (e.g., pushing to 120) increases vascular pressure and dilutes clotting factors, potentially worsening internal bleeding — so fluids are titrated to the specific target, not maximized.
Protocol: TP 1244 Traumatic Injury, Special Consideration ❻
✓ Correct Answer: B
TP 1244 Special Consideration ❻ explicitly states that in patients with possible traumatic brain injury, permissive hypotension is contraindicated, and SBP should be maintained ≥90mmHg.
Special Consideration ⓫ reinforces this: any hypotension increases mortality in TBI patients, so Normal Saline should be initiated to maintain SBP ≥90mmHg at all times (though it can be withheld if BP is already elevated).
This is a critical distinction from penetrating/blunt torso trauma without head injury, where permissive hypotension (lower targets) may apply — TBI physiology (cerebral perfusion pressure) demands a higher floor.
Protocol: TP 1244 Traumatic Injury, Isolated Head Injury section, Special Considerations ❻⓫
✓ Correct Answer: B
TP 1244 step 16 (and mirrored in TP 1217 for PPH and TP 1242 for crush injury) specifies TXA 1 gram in 50-100mL Normal Saline IV/IO, infused over 10 minutes, for patients within 3 hours of injury with SBP <90, HR>SBP, or uncontrolled hemorrhage.
Special Consideration ❼ notes that in patients meeting TXA indications, fluid resuscitation with Normal Saline and TXA should be administered concurrently, not sequentially.
This is a slow infusion (10 minutes), not an IV push or IM injection.
Protocol: TP 1244 Traumatic Injury, step 16 & Special Consideration ❼
✓ Correct Answer: A
TP 1244 step 29 directs applying a traction splint per manufacturer guidelines for mid-shaft femur fractures.
Special Consideration ⓭ clarifies that an open femur fracture (with protruding bone) is NOT a contraindication to applying the traction splint — if the bone is protruding with gross contamination, wash it with saline before applying the splint.
All other fractures/dislocations are splinted in position of comfort rather than with a traction splint, which is specific to femur shaft fractures.
Protocol: TP 1244 Traumatic Injury, step 29 & Special Consideration ⓭
✓ Correct Answer: B
TP 1244 step 29 and Special Consideration ⓮ direct rinsing off gross debris (without manual debridement) from an amputated part, wrapping it in saline-moistened sterile gauze, sealing it in plastic, and placing it indirectly on ice (i.e., the sealed bag sits on/near ice, not touching it directly).
It should never be submerged in water or placed directly on ice, both of which can cause additional tissue damage (maceration or frostbite injury to the part).
The amputated part should be transported with the patient and given to hospital staff, not left behind at the scene.
Protocol: TP 1244 Traumatic Injury, step 29 & Special Consideration ⓮
✓ Correct Answer: B
Ref. 506, Section I.D lists 'All penetrating injuries to head, neck, torso, and extremities proximal to the elbow or knee' as a Trauma Criterion requiring immediate transport to a designated trauma center, with no requirement for abnormal vital signs.
Trauma Criteria apply as long as transport time does not exceed 30 minutes, which this patient's 22-minute transport time satisfies.
Vital sign abnormality (Criterion A/B) is a separate, independent criterion — penetrating torso trauma qualifies on its own regardless of hemodynamic status.
Protocol: Ref. No. 506 Trauma Triage, Section I.D
✓ Correct Answer: B
Ref. 506, Section I.I lists 'Suspected pelvic fracture' as a Trauma Criterion, but explicitly EXCLUDES 'isolated hip fracture from a ground level fall.'
This carve-out exists because isolated ground-level-fall hip fractures in older adults are extremely common and are usually appropriately managed at a non-trauma-center orthopedic service rather than requiring full trauma team activation.
Age over 65 alone is a Special Consideration for possible occult shock at a higher SBP threshold (Section III.B), not by itself a Trauma Criterion — and it doesn't override the pelvic fracture exclusion here.
Protocol: Ref. No. 506 Trauma Triage, Section I.I
✓ Correct Answer: B
Ref. 506 distinguishes intrusion into an OCCUPIED passenger space (>12 inches = Trauma Criterion, Section I.L) from intrusion into an UNOCCUPIED passenger space (>18 inches = Trauma Guideline, Section II.A).
This patient had intrusion into an unoccupied space, and at 15 inches, does not reach the 18-inch Guideline threshold either — but Guidelines are broader and 'at the discretion of the base hospital,' so it's still reasonable to discuss with Base given the significant mechanism, even without meeting a hard numeric criterion.
The key testable distinction is 12 inches (occupied/Criterion) vs. 18 inches (unoccupied/Guideline) — a common point of confusion.
Protocol: Ref. No. 506 Trauma Triage, Sections I.L & II.A
✓ Correct Answer: B
Ref. 506, Section III.B (Special Considerations) states that a systolic blood pressure less than 110 mmHg may represent shock after age 65 years — this patient's SBP of 105 falls below that age-adjusted threshold.
Special Considerations are not hard Trauma Criteria requiring mandatory transport, but they are factors that should prompt consideration of trauma center transport, especially combined with tachycardia (HR > SBP is also a Special Consideration for age ≥14, Section III.C).
Elderly patients often don't manifest hypotension by traditional thresholds (SBP <90) despite significant blood loss, due to age-related physiologic changes and common use of antihypertensive medications — hence the adjusted 110 mmHg threshold.
Protocol: Ref. No. 506 Trauma Triage, Section III.B
✓ Correct Answer: B
Ref. 506, Section IV.A lists patients with an obstructed airway, or concern for imminent airway obstruction due to inhalation injury, as Extremis patients requiring immediate transport to the MAR (Most Accessible Receiving hospital) — not the more distant trauma center.
The rationale is that an unmanageable airway is immediately life-threatening; the patient will not survive a longer transport to a trauma center without an airway secured, so the closest facility capable of emergent airway management takes priority over trauma center capability.
This mirrors the 'Unmanageable Airway' language used throughout the treatment protocols (e.g., TP 1234, TP 1236, TP 1244) directing immediate transport to the MAR with Base contact en route.
Protocol: Ref. No. 506 Trauma Triage, Section IV.A

Ball Knowledge Medics — LA County Adult Protocol Study Guide

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

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