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REMSA 4000 Series Treatment Protocol — Comprehensive Paramedic Exam
4100 — Key Policies
30
Intro, UPC, Alt Meds, Skills List, Drug Index, Refusal, DNR, DNAR, On-Scene Physician, APOD, End of Life, Weight Matrix
4200 — General Medical
22
Hypoglycemia, Shock (non-trauma), N/V, Pain Management (adult & peds)
4300 — Trauma
18
Shock due to trauma, Traumatic injuries/arrest, TXA, Blood products, Disposition
4400 — Cardiovascular/Pulmonary
28
ACS, VAD, Tachycardia, Bradycardia, Medical Cardiac Arrest, Respiratory Distress, CPAP
4500 — Neurological
10
Seizures, Suspected Stroke, mLAPSS, disposition
4600 — Toxicological
14
Overdose/Adverse Rx, Behavioral, Toxic Exposure, Nerve Agent/OPP/Carbamate
4700 — Environmental
12
Burns, Heat Illness/Hyperthermia, Frostbite/Hypothermia, Allergy/Anaphylaxis, Snakebite
4800 — Pregnancy/Childbirth
16
Obstetrical emergencies, delivery, eclampsia, neonatal resuscitation, postpartum hemorrhage

Exam Rules & Focus Areas

Total: 150 Questions — Treat This as a Real County Protocol Exam
Protocol Exam
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Answer Key

Rapid Review — High-Yield Protocol Facts

4100 — Key Policies

Pediatric Definition (4101)

  • Age: Appearing or known to be older than 29 days but ≤14 years
  • If age unknown: Weight <36 kg/79.2 lbs AND length within commercially available length-based tape
  • Max peds dose never exceeds max adult single dose
  • IO is PRIMARY vascular access in patients ≤8 years old

Provider Scope Landmarks (4104 Skills List)

  • PSFA: Self-administer EpiPen only (IM); basic airway/CPR; AED; no BHOs
  • EMT: BLS column; may ASSIST with ECG lead placement (cannot interpret); AED; oral glucose; O2; can administer patient's own EpiPen; NO IO access (except assisting AEMT in peds only); LOSOP required for IN naloxone
  • AEMT: EMT + IO (EZ-IO/B.I.G. at distal/proximal tibia in peds only); IV access; some medications
  • EMT-P: Full ALS column; IO any site in any age with BHPO for unusual site; OTI; RSI (HEMS LOSOP); i-gel; cardioversion; pacing
  • NOT PERMITTED in Riverside County: Needle cricothyrotomy, surgical cricothyrotomy, nasal intubation, stomal intubation, joint reduction, nasogastric tube, venous blood sampling, indwelling device access

Refusal of Treatment / Transport (4107)

  • Patient must be a legal adult, alert and oriented ×4 (person, place, time, event)
  • Informed of: provider level, findings, need for treatment, consequences (including death), ability to call 911 again, other options
  • Contact BH for: Non-emancipated minor refusal; patient in custody refusal; refusal of indicated ALS treatment; refusal of transport after ALS initiated; possible STEMI/CTP refusal
  • Law enforcement officer CANNOT sign for a patient in custody

DNAR / Discontinue Resuscitation (4108)

  • Do NOT attempt resuscitation: Rigor mortis/lividity; decapitation; decomposition/incineration; torso transection; evisceration; valid signed DNR/POLST/medallion; MCI apneic after airway maneuvers; neonate <22 weeks WITH no signs of life
  • ALS-only DNAR criteria: Blunt traumatic arrest with persistent asystole/agonal/PEA <40; penetrating traumatic arrest with same PLUS absence of signs of life
  • Discontinue medical arrest after ALL: ≥20 min HP CPR; IV/IO established; airway managed; rhythm-appropriate meds/defibrillations given; persistent asystole/agonal >20 min; NOT refractory VF/VT; NO palpable pulse at any point
  • Discontinuing PEDS/Neonate resuscitation REQUIRES BHPO
  • Do NOT cross county lines when discontinuing during transport — stop in a safe location

Documentation Requirements (4101)

  • At least 2 sets of vital signs every patient
  • Stable patients: vitals every 10–15 min; critical: every 5 min
  • 4-Lead or 12-Lead placed → rhythm strip/12-Lead MUST be uploaded/attached to ePCR
  • All interventions and patient responses documented in ePCR Actions Panel
  • Transfer of care: verbal report + completed ePCR (verbal report does NOT replace ePCR)

Alternative Medications Key Rules (4102)

  • Atropine Autoinjector 2 mg/0.7 mL: adults 2 mg IM; weight ≤14 kg NOT PERMITTED; weight ≥15 kg NOT PERMITTED (wrong vial — 2 mg autoinjector peds NOT PERMITTED)
  • Atropine Autoinjector 1 mg/0.7 mL: weight ≤14 kg NOT PERMITTED; weight ≥15 kg 1 mg IM
  • Atropine Autoinjector 0.5 mg/0.7 mL: peds 0.5 mg IM ×2 MAY REPEAT PRN
  • Diazepam Autoinjector 10 mg: adults only (peds NOT PERMITTED)
  • Ketamine IV/IN: adults 0.3 mg/kg IV or 0.5 mg/kg IN; max single dose 30 mg; PEDS NOT PERMITTED
  • DuoDote/Mark I NAAK: adults 1 injection IM, MAY REPEAT TWICE; PEDS NOT PERMITTED

4200 — General Medical

Hypoglycemia Thresholds (4201/4105)

  • Adults: BG <80 mg/dL → treat
  • Pediatrics: BG <70 mg/dL → treat
  • Neonate >48 hr old (<28 days): BG <60 mg/dL → treat
  • Neonate <48 hr old: BG <45 mg/dL → treat
  • Dextrose: Adults 25 gm D10% IV/IO; Peds/Neonates 5 mL/kg D10%
  • If unable to give IV/IO dextrose → Glucagon IM: adults 1 mg; peds ≤21 kg 0.5 mg; ≥22 kg 1 mg
  • Glucagon does NOT work if liver glycogen depleted (malnutrition, adrenal insufficiency, severe hypoglycemia)
  • Contact BH for any patient who refuses transport AFTER initiation of ALS treatment

Pain Management Summary (4204/4105)

  • Pain 1–5 (or 6–10 refusing opioids/Ketamine): Acetaminophen 1 gm IV over 15 min (peds 15 mg/kg; NOT <2 yrs) OR Ketorolac 15 mg IVP / 30 mg IM (peds 0.5 mg/kg; NOT <4 yrs)
  • Pain >5: Fentanyl 50 mcg IVP/IM/IN (SBP ≥90); max 100 mcg standing order; THEN Ketamine 0.3 mg/kg IV or 0.5 mg/kg IN; max 30 mg any route
  • Fentanyl then Ketamine (or vice versa) = standing order; repeating after ALL max doses = BHO
  • Ketamine NOT PERMITTED in pediatric patients (<15 years of age)
  • Ketamine NOT for suspected cardiac pain (ACS)
  • Fentanyl contraindicated: SBP <90 mmHg; sensitivity to opioids
  • Acetaminophen and Ketorolac are both single-dose medications

4300 — Trauma

TXA (Tranexamic Acid) Rules (4105 p.35–36)

  • Indication: Traumatic injury within 3 hrs with hemorrhagic shock: SBP <90 OR HR ≥120 OR uncontrolled bleeding despite tourniquet
  • Dose: Adults 1 gm IV/IO in 50–100 mL NS over 10 min
  • PEDS NOT PERMITTED (<15 years)
  • Contraindications: Shock not from trauma/postpartum/epistaxis; injury >3 hrs; vitals not meeting criteria; bleeding controlled by tourniquet
  • For epistaxis: 250 mg (2.5 mL) IN; may repeat once after 15 min
  • IO infusion only when IV unavailable; IV is preferred route
  • TXA is a single-dose medication for trauma and postpartum hemorrhage
  • If patient allows, apply tourniquet BEFORE TXA if possible

Traumatic Arrest Disposition (4302)

  • Adult blunt traumatic arrest: If meets DNAR criteria OR pulseless/apneic with asystole/agonal/PEA <40 → DO NOT resuscitate or transport
  • Adult penetrating traumatic arrest: Same DNAR criteria + signs of life → transport to closest Level I/II Trauma Center
  • Pediatric traumatic arrest: Signs of life + reasonable transport time → transport to Level I/II; BHPO required to discontinue
  • Epinephrine is NOT indicated in traumatic arrests (if suspected medical cause → 4405)
  • CPR should NOT impede procedural interventions in traumatic arrest
  • Scene time limit: ≤10 minutes for CTP

4400 — Cardiovascular / Pulmonary

Medical Cardiac Arrest — Key Points (4405)

  • Epinephrine 1 mg IVP/IOP every 5 min; max 5 mg (50 mL); additional = BHO
  • Pediatric Epi: 0.01 mg/kg; max 5 administrations
  • Atropine 1 mg IVP/IOP in cardiac arrest (adult only — PEDS/NEONATE NOT PERMITTED)
  • Amiodarone for VF/VT: 300 mg IVP then 150 mg ×1 (max 450 mg); peds 5 mg/kg (max single 150 mg)
  • Lidocaine when Amiodarone unavailable: 1 mg/kg then 0.5 mg/kg 8–10 min later (max 3 mg/kg)
  • Magnesium 2 gm for Torsades/polymorphic VT; peds 50 mg/kg
  • Post-ROSC SBP <90 → Epi infusion (1–10 mcg/min via Dial-a-Flow); IO route CONTRAINDICATED for infusion; NOT for patients ≤14 yrs; NOT for traumatic ROSC
  • OHCA with ROSC → transport to closest STEMI Receiving Center (SRC)
  • iGel NOT PERMITTED in patients ≤14 years of age
  • OG tube MANDATORY after iGel insertion; highly recommended after OTI
  • ETCO2 <10 mmHg → improve CPR quality; target 15–45 during CPR; 30–45 mmHg with ROSC

CPAP Rules (4104/4406)

  • Indications: CHF exacerbation, COPD, asthma, non-fatal drowning — AWAKE patient
  • CPAP NOT PERMITTED in pediatric patients
  • Start at 5 cmH₂O; increase in 2.5–5 cmH₂O increments to max 15 cmH₂O
  • Increasing to 20 cmH₂O requires BHO
  • SBP must be >90 mmHg at onset AND during CPAP; if drops <90 → contact BH
  • Midazolam 1 mg IVP/IM/IN for anxiety related to CPAP (SBP ≥90); peds NOT PERMITTED
  • EMT/AEMT may only ASSIST with CPAP application in presence of EMT-P

Nitroglycerin Rules (4105 p.30)

  • 0.4 mg SL when SBP >90; may repeat ×2 at 3–5 min intervals; additional = BHO
  • 1 gm (1 inch) transdermal paste when SBP >90; wipe away if SBP drops <90
  • Contraindicated: Suspected intracranial bleed; PDE5 inhibitor use within 48 hrs (Viagra/Cialis/Levitra/Stendra) → requires BHPO; VAD patients
  • PEDS NOT PERMITTED
  • VAD patients: NTG may be given for SBP >140 (unlike non-VAD)

Adenosine (4105 p.3–4)

  • Adults: 12 mg rapid IVP + immediate 20 mL NS flush; OR mix 12 mg in 20 mL syringe with 16 mL NS
  • Peds: 0.2 mg/kg rapid IVP + immediate 20 mL NS flush
  • May repeat once; additional = BHO
  • Adenosine will only convert SVT — will NOT convert A-Fib or A-Flutter
  • Use large bore IV in proximal large vein; must push rapidly
  • Caffeine/Theophylline are antagonists; max doses may be required
  • Contraindicated: 2nd/3rd degree AV block; sick sinus syndrome (without pacemaker)

Epinephrine Infusion Criteria (4105 p.13–15)

  • Only after ROSC when SBP <90 mmHg
  • Dial-a-Flow REQUIRED; IO route NOT PERMITTED
  • NOT for: patients ≤14 yrs; traumatic ROSC; if unable to obtain SBP; if unable to use Dial-a-Flow; shock due to trauma
  • Start 1 mcg/min (15 mL/hr); increase every 2–3 min; max 10 mcg/min (150 mL/hr)
  • Concentration: 0.4 mg in 100 mL NS OR 0.2 mg in 50 mL NS

4500 — Neurological

Seizures / Stroke (4501/4502)

  • Midazolam for continuous/recurrent tonic-clonic seizures: adults 2.5 mg IVP or 5 mg IM/IN; repeat once; peds 0.1 mg/kg IVP or 0.2 mg/kg IM/IN
  • mLAPSS: 6 criteria — age >17; no prior seizure hx; LKWT within 24 hrs; ambulatory at baseline; BG 60–400; asymmetric exam
  • Stroke: give nothing by mouth; document LKWT, discovery time, symptom onset, blood thinners
  • Stroke scene time: ≤10 min; notify closest stroke center for early team activation
  • Age ≤17 with suspected stroke → transport to closest stroke center

4600 — Toxicological

Naloxone Rules (4105 p.29)

  • Titrate to improvement of RESPIRATORY DEPRESSION only — NOT to resolution of AMS or pupillary constriction
  • Adults: 1 mg IVP/IOP/IM/IN MAY REPEAT PRN
  • Peds: 0.1 mg/kg; max single dose 1 mg; MAY REPEAT PRN
  • PSFA / first-response BLS (absence of ALS, LOSOP required): IN only, may repeat ONCE
  • Agency LOSOP BLS providers: 1 mg IN only, may repeat PRN (adult); 0.1 mg/kg IN peds max 0.5 mg
  • Duration of Narcan < most opioids — watch for re-narcotization

Nerve Agent / OPP Exposure (4604/4605)

  • Stage 300+ feet upwind/uphill/upstream; do NOT enter until IC deems safe
  • Do NOT induce vomiting
  • Atropine is primary treatment; watch for drying of secretions as endpoint (not just HR)
  • ALS (4604): Atropine 1 mg IVP (10 mL prefilled) or 2 mg IM; peds 0.02 mg/kg IV, max 1 mg; or 0.05 mg/kg IM, max 1 mg
  • Mass exposure (4605): IM route preferred; IV/IO requires BHO; Pralidoxime when CDC CHEMPACK deployed
  • Atropine 2 mg autoinjector and 1 mg autoinjector: weight ≤14 kg NOT PERMITTED; weight ≥15 kg: 1 mg autoinjector permitted (1 mg IM)
  • Atropine 0.5 mg autoinjector: peds 0.5 mg IM ×2 MAY REPEAT PRN

Behavioral Emergencies (4602)

  • IM Midazolam preferred for chemical restraint (severe agitation/danger to self or others)
  • Adults: 5 mg IM/IN or 2.5 mg IVP; repeat once; additional = BHO
  • Peds: 0.2 mg/kg IM/IN or 0.1 mg/kg IVP; repeat once; additional = BHO
  • NEVER restrain supine or prone; transport in low-to-high Fowler's position
  • Prevent positional asphyxiation; avoid hog-tie
  • 5150 patient dispatched via 911 → transport to closest ED

4700 — Environmental

Burns Disposition Rules (4701)

  • Transport to burn center requires BHO
  • Airway involvement → closest receiving center (airway priority over burns)
  • Meets CTP criteria → trauma center (trauma priority over burns)
  • Contact BH for destination: 2° burns >30% BSA; 3° burns >10% BSA; burns of face/hands/feet/genitals/major joints/circumferential; high-voltage electrical burns; burns + significant comorbidities
  • Thermal <20% BSA: cool with wet dressings then dry
  • Thermal >20% BSA: dry non-adherent dressings only (no wet)
  • Do NOT remove tar — cool with water; apply petrolatum gauze

Allergy / Anaphylaxis (4704)

  • BLS: Assist with patient's own EpiPen 0.3 mg IM; record as "self-administered"
  • ALS: Epi 0.3 mg (1 mg/mL) IM; peds 0.01 mg/kg IM; max single dose 0.3 mg; additional = BHO
  • Diphenhydramine: adults 50 mg IVP/IM; peds 1 mg/kg IVP or 2 mg/kg IM; max 50 mg
  • Albuterol 2.5 mg nebulized for bronchospasm; MAY REPEAT PRN
  • For shock: NS boluses + push-dose Epi (SBP goal >90 adults)

4800 — Pregnancy / Childbirth

Obstetrical High-Yield Points (4801)

  • Suspected pre-eclampsia/eclampsia → Magnesium Sulfate 5 gm IV over 10 min (standing order; prophylactic permitted); or 5 gm IM; additional = BHO
  • Eclampsia unresponsive to Mag → Midazolam 2.5 mg IVP or 5 mg IM/IN (requires BHO)
  • Postpartum hemorrhage within 3 hrs with hemorrhagic shock (EBL >500 mL; SBP <90 or HR >120) → TXA 1 gm IV; PEDS NOT PERMITTED
  • Placenta: should deliver within 10–30 min; place in bag, transport with mother
  • Vigorous infant: wait 60 sec then clamp cord at ~3" and ~4"; cut between clamps
  • Non-vigorous infant: clamp and begin resuscitation immediately
  • Do NOT attempt resuscitation: neonate <22 weeks gestation WITH no signs of life
  • Contact single BH for all obstetrical deliveries with any complication or pre-eclampsia/eclampsia
  • Neonatal CPR: compression depth 1/3"–1/2"; rate 120/min; minimize interruptions; avoid hyperventilation
  • Neonate HR <100: O2 + stimulate 30 sec; if no response → PPV at 40–60 breaths/min
  • Neonate HR <60: PPV + chest compressions
  • Neonatal defibrillation: initial 2 j/kg; subsequent 4 j/kg

Critical "NOT PERMITTED" List

PEDIATRICS — NEVER ADMINISTER: Aspirin (any peds) · Nitroglycerin (any peds) · TXA to <15 yrs · Ketamine to <15 yrs · Atropine in cardiac arrest (peds/neonate) · Epi infusion ≤14 yrs · Midazolam post-ROSC anxiety (peds) · Midazolam for CPAP anxiety (peds) · Midazolam for heat shivering (peds) · Fentanyl post-ROSC pain (peds) · Acetaminophen <2 yrs · Ketorolac <4 yrs · Ondansetron ODT <10 kg · Calcium Chloride/Albuterol/Sodium Bicarb for ESRD dysrhythmia (peds) · Nebulized Epi >8 yrs · Blood products (peds) · CPAP (peds) · iGel ≤14 yrs · Albuterol for ESRD dysrhythmia (peds) · Diazepam Autoinjector (peds) in mass exposure
NOT PERMITTED IN RIVERSIDE COUNTY (ANY PROVIDER): Needle cricothyrotomy · Surgical cricothyrotomy · Nasal intubation · Stomal intubation · Joint reduction · Nasogastric tube placement · Venous blood sampling (for law enforcement) · Indwelling device access (ports, shunts, grafts)
SINGLE 5 mL NS PREFILLED SYRINGE: NOT PERMITTED for medication administration. NOT PERMITTED for dilution of Epinephrine. Must combine two 5 mL syringes into empty 10 mL syringe.

Normal Saline — Key Rules (4105 p.31–32)

Dosing & Special Information

  • Adults: 250 mL IV/IO bolus; max 2 L total
  • Pediatrics: 20 mL/kg IV/IO bolus (use volume control chamber)
  • Neonates: 10 mL/kg IV/IO rapid infusion
  • IV fluids = bolus only; NEVER at TKO rate
  • Flush IV line with 10–20 cc NS BEFORE Sodium Bicarbonate and flush BETWEEN Sodium Bicarb and Epi
  • Contraindicated for fluid challenge in patients with rales