EMS Protocol Library

Airway Management

BLS · airway-rsi

Patient unable to protect or maintain airway, or with impending respiratory failure.

Assessment and recognition

• Level of consciousness: GCS ≤ 8 typically indicates need for definitive airway
• Gag reflex, ability to follow commands
• LEMON assessment: Look, Evaluate (3-3-2 rule), Mallampati, Obstruction, Neck mobility
• SpO₂ trend, respiratory rate and effort, ETCO₂

BLS steps

1. Head-tilt chin-lift (or jaw thrust if spinal precautions)
2. Suction — Yankauer for secretions/vomit
3. OPA in unconscious patient with no gag reflex
4. NPA in conscious/semi-conscious or suspected gag reflex
5. BVM with PEEP valve if available; 2-person BVM preferred for better seal
6. Supraglottic airway (iGel, King LT, LMA) if BVM inadequate or prolonged

ALS steps

1. Endotracheal intubation: blade selection (Mac 3/4 or Miller 2/3), ETT size (7.0–8.5 cuffed adult)
2. Pre-oxygenate for 3 min via BVM or high-flow NRB before intubation attempt
3. Maximum 2 attempts at direct laryngoscopy — then move to surgical/supraglottic
4. Video laryngoscopy (Glidescope/C-MAC) for anticipated difficult airway
5. Confirm with: direct visualization, ETCO₂ waveform, bilateral breath sounds, absence of epigastric sounds, chest rise
6. Secure ETT and document depth at teeth/gum

Clinical pearls: Failed airway algorithm: attempt 1 (direct laryngoscopy) → attempt 2 (video laryngoscopy or different blade) → supraglottic rescue (iGel/King LT) → surgical airway (cricothyrotomy). Never attempt > 2 laryngoscopic attempts without repositioning or alternative device.

Altered Mental Status (AMS)

BLS · neurological

Altered level of consciousness with unknown or unclear etiology.

Assessment and recognition

• AVPU or Glasgow Coma Scale; AEIOU-TIPS mnemonic for differential
• Blood glucose (hypoglycemia most common reversible cause)
• Temperature (hypothermia/hyperthermia), O₂ saturation, BP, HR
• Pupils (narcotics = miotic; stimulants = mydriatic; herniation = blown)
• Signs of trauma, alcohol, drug paraphernalia

BLS steps

1. Airway management — position, suction, OPA/NPA as appropriate
2. O₂ to maintain SpO₂ ≥ 94%
3. Blood glucose — treat hypoglycemia immediately
4. IV access; protect patient from injury
5. Vital signs, 12-lead ECG

ALS steps

1. BG < 60: D10 250 mL IV or Dextrose 50% 25 g IV; recheck in 5 min
2. Thiamine 100 mg IV before dextrose if suspected alcohol abuse/malnutrition
3. Suspected opioid: Naloxone 0.4–2 mg IV/IM/IN; titrate to adequate breathing
4. Suspected alcohol: supportive care, airway protection, glucose management
5. If unresponsive to treatment: treat for traumatic cause, consider stroke/meningitis

Key doses

• Dextrose 50%: 25 g IV (1 amp); or D10 250 mL IV
• Thiamine: 100 mg IV (give before dextrose if malnourished)
• Naloxone: 0.4–2 mg IV/IM/IN (titrate)

Clinical pearls: AEIOU-TIPS: Alcohol, Epilepsy/Electrolytes, Insulin (hypoglycemia), Overdose, Uremia, Trauma, Infection, Psychiatric, Stroke/Structural. Never assume intoxication without ruling out hypoglycemia, hypoxia, head injury, and stroke.

Anaphylaxis / Allergic Reaction

BLS · toxicology

Severe systemic allergic reaction with airway compromise, hemodynamic instability, or multi-system involvement.

Assessment and recognition

• Airway: stridor, hoarseness, angioedema (upper airway threat)
• Breathing: bronchospasm, wheeze, decreased air movement
• Circulation: hypotension, tachycardia, distributive shock
• Skin: urticaria, flushing, angioedema
• Time of exposure, known allergens, prior anaphylaxis history

BLS steps

1. Epinephrine auto-injector (EpiPen) 0.3 mg IM anterolateral thigh — first intervention
2. Assist with patient's own EpiPen if available
3. Lay flat with legs elevated if hypotensive (not if airway compromise — sit up)
4. O₂ high-flow
5. Remove trigger if possible (bee stinger — scrape don't squeeze)
6. Rapid transport; second EpiPen in 5–15 min if no improvement

ALS steps

1. Epinephrine 0.3–0.5 mg IM (1:1000) — anterolateral thigh; repeat q5–15 min
2. If severe hypotension/cardiac arrest: Epinephrine 0.1 mg IV (1:10,000) slow push
3. IV/IO access — NS bolus 1–2 L for anaphylactic shock
4. Diphenhydramine 25–50 mg IV (adjunct, not first-line — does not reverse airway edema or shock)
5. Methylprednisolone 125 mg IV or Dexamethasone 10 mg IV (delayed onset)
6. Albuterol 2.5 mg nebulized for bronchospasm
7. Intubate early if upper airway edema progressing — delay makes intubation impossible

Key doses

• Epinephrine IM: 0.3–0.5 mg IM (1:1000); repeat q5–15 min
• Epinephrine IV: 0.1 mg slow IV push (cardiac arrest/profound shock)
• Diphenhydramine: 25–50 mg IV (adjunct only)

Clinical pearls: Epinephrine is the only definitive treatment for anaphylaxis. Antihistamines and steroids are adjuncts that do not reverse life-threatening airway edema or distributive shock. Biphasic reactions occur in 5–20% — all anaphylaxis patients should be transported even after resolution.

Asthma / Bronchospasm

BLS · respiratory

Acute bronchospasm with expiratory wheeze, dyspnea, and decreased air movement.

Assessment and recognition

• Lung sounds: expiratory wheeze; silent chest = severe/life-threatening
• SpO₂, respiratory rate, accessory muscle use
• Peak expiratory flow rate (PEFR) if available: < 50% predicted = severe
• History of intubation or ICU admits indicates high-risk patient
• Triggers: allergen, infection, exercise, cold air

BLS steps

1. Upright positioning, O₂ to maintain SpO₂ ≥ 94%
2. Assist with patient's own MDI (albuterol): 2–4 puffs via spacer
3. Calm reassurance; reduce anxiety to decrease O₂ demand
4. Transport; note improvement or deterioration trend

ALS steps

1. Albuterol 2.5 mg nebulized (can run continuously for severe cases)
2. Ipratropium 0.5 mg nebulized combined with albuterol (first treatment)
3. Magnesium sulfate 2 g IV over 10–20 min for severe/refractory bronchospasm
4. Methylprednisolone 125 mg IV or Dexamethasone 10 mg IV
5. Epinephrine 0.3 mg IM for severe refractory bronchospasm or impending arrest
6. Intubate as last resort — PPV extremely difficult in severe asthma; consider CPAP first

Key doses

• Albuterol: 2.5 mg nebulized q20 min
• Ipratropium: 0.5 mg nebulized (combined with albuterol)
• Magnesium sulfate: 2 g IV over 10–20 min
• Epinephrine: 0.3 mg IM (1:1000)

Clinical pearls: Silent chest in a severe asthmatic means air movement is so poor that wheeze cannot be generated — this is impending respiratory arrest. Move to RSI plan. Helium-oxygen (heliox) reduces turbulent flow and work of breathing when available.

Behavioral Emergency / Excited Delirium

ALS · behavioral

Acute behavioral crisis with agitation, combativeness, or excited delirium syndrome.

Assessment and recognition

• Ensure scene safety first — law enforcement presence if needed
• Rule out organic causes: blood glucose, SpO₂, temperature, signs of stimulant use
• Excited delirium signs: superhuman strength, hyperthermia, tachycardia, diaphoresis, unexpected calm
• Risk of sudden cardiac death in excited delirium — treat aggressively
• AVPU, skin signs, vital signs when able

BLS steps

1. Ensure law enforcement on scene and scene safety
2. De-escalation techniques: calm tone, personal space, avoid direct confrontation
3. Do not restrain in prone position — positional asphyxia risk
4. Oxygen if SpO₂ < 94%
5. Expedite transport with continuous monitoring

ALS steps

1. Chemical sedation — call medical direction if in doubt:
2. Midazolam 5 mg IM (preferred — rapid onset, reliable absorption) or 2.5 mg IV
3. Ketamine 4 mg/kg IM (excited delirium with violence) — most rapid onset
4. Haloperidol 5–10 mg IM for less acute agitation
5. Monitor O₂ and airway closely after sedation
6. 12-lead ECG after sedation — prolonged QT risk

Key doses

• Midazolam: 5 mg IM or 2.5 mg IV
• Ketamine: 4 mg/kg IM (excited delirium)
• Haloperidol: 5–10 mg IM

Clinical pearls: Excited delirium is a medical emergency, not a behavioral one. Hyperthermia + cardiovascular collapse can follow rapidly. Cool patient, support airway, monitor continuously. Document vital signs frequently and all sedation given with time.

Bradycardia (Symptomatic)

ALS · cardiac

HR < 60 bpm with signs of hemodynamic compromise (hypotension, AMS, chest pain, heart failure).

Assessment and recognition

• HR < 60 with symptoms: hypotension, AMS, chest pain, dyspnea, syncope
• 12-lead ECG: sinus brady, 2nd degree type II, complete heart block, junctional
• BP, SpO₂, ETCO₂, skin signs
• Medication history (beta-blockers, calcium channel blockers, digoxin)

BLS steps

1. Position supine or semi-recumbent based on BP
2. O₂ if SpO₂ < 94%; cardiac monitoring
3. IV access; prepare for rapid transport
4. Be prepared to initiate CPR if patient deteriorates

ALS steps

1. Atropine 0.5 mg IV q3–5 min; max 3 mg total
2. If atropine ineffective: transcutaneous pacing at rate 60–80 bpm, starting at minimum mA and increasing until capture
3. Dopamine infusion 2–20 mcg/kg/min OR Epinephrine infusion 2–10 mcg/min if pacing unavailable
4. Identify underlying cause (hyperkalemia, hypothermia, drug toxicity, ischemia)
5. 12-lead for ischemic changes — coordinate cath lab if ACS-related

Key doses

• Atropine: 0.5 mg IV q3–5 min (max 3 mg)
• Dopamine infusion: 2–20 mcg/kg/min IV
• Epinephrine infusion: 2–10 mcg/min IV

Clinical pearls: Transcutaneous pacing: apply pads (anterior-posterior preferred), set rate 60–80, increase mA until electrical capture confirmed on monitor, then confirm mechanical capture by palpating femoral or carotid pulse. Sedate before pacing if patient is conscious (Midazolam 1–2 mg IV).

Burns

BLS · trauma

Thermal, chemical, electrical, or radiation burns with significant BSA involvement or critical locations.

Assessment and recognition

• Estimate %BSA using Rule of Nines or Lund-Browder chart
• Burn depth: superficial (redness), partial thickness (blisters), full thickness (leathery/painless)
• Critical locations: face, hands, feet, genitalia, circumferential burns
• Airway signs: singed nasal hair, eyebrows, hoarseness, stridor, carbonaceous sputum
• Chemical: identify agent; electrical: entry and exit wounds, cardiac monitoring

BLS steps

1. Stop the burning process — remove clothing/jewelry (not embedded)
2. Cool burns with room-temperature water (not ice) for 10–20 min if < 1 h old
3. Cover with dry/clean dressings or burn sheets (moist only for < 10% BSA)
4. O₂ high-flow; monitor for inhalation injury signs
5. Prevent hypothermia — burns cause massive heat loss
6. Transport to burn center if criteria met (> 10% partial thickness, full thickness, critical locations, chemical/electrical)

ALS steps

1. Intubate early if airway burn suspected — delay can make intubation impossible
2. IV access × 2 (avoid burned tissue); Parkland formula: 4 mL × weight (kg) × %BSA; give first half in 8 h
3. Morphine 2–4 mg IV or Fentanyl 1 mcg/kg IV for pain
4. For chemical burns: copious water irrigation for 15–30 min (do not neutralize)
5. For electrical: cardiac monitoring, 12-lead; watch for dysrhythmias and rhabdomyolysis

Key doses

• Morphine: 2–4 mg IV q5–10 min
• Fentanyl: 1 mcg/kg IV
• Parkland fluid: 4 mL × kg × %BSA (first half in 8 h)

Clinical pearls: Chemical burns to the eye: irrigate with water or NS for minimum 20 min en route. Electrical burns: assume cardiac monitoring mandatory — dysrhythmias can be delayed. Treat any lightning strike patient aggressively (reverse triage — those who appear dead may be survivable).

Cardiac Arrest — Adult (CPR / ACLS)

BLS · cardiac

Unresponsive patient with absent or agonal breathing and no palpable pulse.

Assessment and recognition

• Confirm unresponsiveness, absent/agonal breathing, no pulse (< 10 sec)
• CPR quality: rate 100–120/min, depth 2–2.4 inches, full recoil
• Initial rhythm: shockable (VF/pVT) vs. non-shockable (PEA/Asystole)
• Identify and treat reversible causes: 5 Hs & 5 Ts
• ETCO₂ target ≥ 10 mmHg; > 35–40 suggests ROSC

BLS steps

1. Begin high-quality CPR immediately — minimize interruptions
2. AED/defibrillator as soon as available — analyze and shock if advised
3. Ventilate 30:2 (BLS) or 10 breaths/min asynchronous once advanced airway placed
4. Rotate compressors every 2 min to avoid fatigue
5. Avoid hyperventilation — do not stop compressions to ventilate beyond 10/min

ALS steps

1. Establish IV/IO access — do not interrupt CPR for access
2. Epinephrine 1 mg IV/IO q3–5 min for all rhythms
3. VF/pVT: defibrillate 200 J (biphasic); resume CPR immediately after shock
4. Amiodarone 300 mg IV/IO first dose after 3rd shock for refractory VF/pVT; 150 mg second dose
5. Lidocaine alternative: 1–1.5 mg/kg IV/IO first dose
6. Advanced airway (supraglottic or ETT): confirm placement with ETCO₂ + waveform capnography
7. Sodium bicarbonate 1 mEq/kg if suspected hyperkalemia, TCA overdose, or prolonged arrest
8. Consider ROSC if ETCO₂ suddenly > 40 mmHg

Key doses

• Epinephrine: 1 mg IV/IO q3–5 min
• Amiodarone: 300 mg IV/IO (then 150 mg)
• Lidocaine: 1–1.5 mg/kg IV/IO

Clinical pearls: 5 Hs: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia. 5 Ts: Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE), Thrombosis (MI). After ROSC: avoid hypoxia (SpO₂ 92–98%), hypotension (SBP > 90), hyperthermia. Target TTM 32–36 °C if comatose.

Chest Pain / Acute Coronary Syndrome

BLS · cardiac

Chest pain, pressure, or discomfort possibly representing ACS, unstable angina, or STEMI.

Assessment and recognition

• Onset, provocation, quality, radiation, severity (OPQRST)
• Diaphoresis, pallor, nausea/vomiting, dyspnea
• BP both arms, peripheral pulses, lung sounds
• 12-lead ECG — identify STEMI, LBBB, or ischemic changes
• Blood glucose, SpO₂, ETCO₂ if intubated

BLS steps

1. Position of comfort — seated or semi-recumbent
2. High-flow O₂ if SpO₂ < 94% or respiratory distress; titrate to ≥ 94%
3. Aspirin 324 mg PO (chewed) if no allergy and not already taken
4. 12-lead ECG — transmit to hospital if STEMI alert protocol active
5. IV access, cardiac monitoring
6. Reassess vital signs every 5 min; note any rhythm changes
7. Expedite transport; activate cath lab if STEMI criteria met

ALS steps

1. IV/IO access — 18 g or larger antecubital
2. Nitroglycerin SL 0.4 mg q5 min × 3 if SBP > 90 (withhold if RV infarct suspected — ST elevation in II, III, aVF with hypotension)
3. Morphine 2–4 mg IV q5 min or Fentanyl 1 mcg/kg IV for refractory pain per medical direction
4. Repeat 12-lead post-treatment; document time of first medical contact
5. Heparin per STEMI protocol if ordered by medical direction
6. Initiate STEMI alert and direct transport to PCI-capable facility

Key doses

• Aspirin: 324 mg PO (chewed)
• Nitroglycerin: 0.4 mg SL q5 min × 3
• Morphine: 2–4 mg IV q5 min
• Fentanyl: 1 mcg/kg IV

Clinical pearls: STEMI criteria: ≥ 1 mm ST elevation in ≥ 2 contiguous limb leads or ≥ 2 mm in ≥ 2 contiguous precordial leads, or new LBBB. Door-to-balloon time < 90 min is the goal — early notification saves lives.

CHF / Pulmonary Edema

ALS · respiratory

Acute heart failure with pulmonary congestion causing dyspnea, orthopnea, and diffuse crackles.

Assessment and recognition

• Bilateral crackles (often diffuse), frothy pink sputum
• JVD, peripheral edema, S3 gallop
• SpO₂, BP, HR — note hypertensive (flash pulmonary edema) vs. hypotensive (cardiogenic shock)
• Orthopnea, paroxysmal nocturnal dyspnea history
• Medication compliance (diuretics, ACE inhibitors, beta-blockers)

BLS steps

1. High-Fowler's position (legs dependent)
2. O₂ — CPAP preferred; NRB if CPAP unavailable
3. IV access; expedite transport
4. Reduce patient anxiety and exertion

ALS steps

1. CPAP 5–10 cmH₂O — reduces preload and improves oxygenation
2. Nitroglycerin 0.4 mg SL q5 min if SBP > 90 (repeat up to 3 doses; venodilator reduces preload rapidly)
3. Furosemide 40–80 mg IV (existing diuretic users may need higher dose)
4. If hypotensive/in shock: Dopamine 5–10 mcg/kg/min; avoid diuretics
5. Intubate with RSI if CPAP fails, patient exhausted, or GCS declining

Key doses

• Nitroglycerin: 0.4 mg SL q5 min (SBP > 90)
• Furosemide: 40–80 mg IV
• CPAP: 5–10 cmH₂O

Clinical pearls: CPAP is the single most effective prehospital intervention for flash pulmonary edema — it can prevent intubation in most cases. Distinguish from ARDS and pneumonia, which will not respond to the same treatment approach.

Hemorrhagic Shock

ALS · trauma

Life-threatening blood loss causing hemodynamic instability (Class III/IV hemorrhagic shock).

Assessment and recognition

• Class III/IV: SBP < 90, HR > 120, altered mental status, cool/pale/diaphoretic
• Identify source: external (visible), internal (abdomen, pelvis, femur, chest)
• Mechanism and injury pattern
• Skin signs, capillary refill, peripheral pulses

BLS steps

1. Aggressive hemorrhage control: direct pressure, tourniquet (junctional wound packing with hemostatic dressing)
2. Tourniquet: apply 2–3 inches proximal to wound, tighten until bleeding stops, note time
3. Supine position unless airway compromise; keep patient warm (hypothermia worsens coagulopathy)
4. Oxygen high-flow; rapid transport

ALS steps

1. Large-bore IV × 2 or IO; draw blood samples en route
2. Permissive hypotension: target SBP 80–90 mmHg (penetrating torso) or 90–100 (TBI)
3. Warm crystalloid 250–500 mL bolus; reassess — do not exceed 1–2 L
4. TXA 1 g IV over 10 min within 3 h of injury
5. Pelvic binding for suspected pelvic fracture
6. Needle decompression for tension pneumothorax if concurrent

Key doses

• TXA: 1 g IV over 10 min (within 3 h)
• NS bolus: 250–500 mL; reassess; permissive hypotension

Clinical pearls: Do not remove a tourniquet in the field once applied for arterial bleeding. Mark time of application on patient's forehead or tourniquet. Junctional bleeding (groin, axilla, neck) requires wound packing with hemostatic gauze (Combat Gauze, XStat) and firm direct pressure.

Hypoglycemia / Diabetic Emergency

BLS · toxicology

Blood glucose < 60 mg/dL with symptoms, or clinical presentation consistent with hypoglycemia.

Assessment and recognition

• Blood glucose reading (always check in AMS, seizure, syncope)
• Sympathomimetic signs: diaphoresis, tremors, tachycardia, anxiety
• Neuroglycopenic signs: confusion, focal deficits, seizure, coma
• Insulin type and dose, last meal, alcohol, exercise

BLS steps

1. If conscious and able to swallow: oral glucose 15–25 g (glucose gel, OJ, 4 glucose tablets)
2. Recheck glucose in 15 min; repeat if < 60
3. IV access; transport

ALS steps

1. Dextrose 50% 25 g IV (1 amp 50 mL) if altered or unable to swallow
2. D10 250 mL IV at 250 mL/h — gentler option, preferred for elderly/renal patients
3. Thiamine 100 mg IV before dextrose if alcoholic or malnourished
4. Glucagon 1 mg IM if no IV access (less reliable in patients with depleted glycogen stores)
5. Recheck glucose q15 min; target > 80 mg/dL

Key doses

• Dextrose 50%: 25 g IV (one amp)
• D10W: 250 mL IV
• Glucagon: 1 mg IM (no IV access)
• Thiamine: 100 mg IV before dextrose (if malnourished)

Clinical pearls: Treat empirically if unable to obtain glucose reading with clinical picture consistent with hypoglycemia. Hyperglycemic emergencies (DKA/HHS) in the field: IV hydration, transport. DKA = anion gap acidosis, HHS = profound dehydration without acidosis. Do not administer insulin in the field.

Hypotension / Shock

ALS · general

SBP < 90 mmHg or signs of inadequate perfusion (altered mental status, mottling, weak pulses).

Assessment and recognition

• Identify shock type: hypovolemic, distributive (septic/anaphylactic/neurogenic), cardiogenic, obstructive
• Skin signs: cool/clammy (hypovolemic/cardiogenic) vs warm/flushed (distributive/neurogenic)
• History: fever, bleeding, cardiac history, trauma, allergy exposure
• Lung sounds (crackles = cardiogenic), JVD (tension pneumo, cardiac tamponade, cardiogenic)
• 12-lead ECG — exclude STEMI, PE pattern

BLS steps

1. Supine position; legs elevated for non-cardiogenic shock
2. O₂ high-flow
3. Bleeding control if external hemorrhage
4. IV access; maintain warmth

ALS steps

1. Hypovolemic/distributive: NS bolus 500 mL IV; reassess BP — repeat to SBP > 90
2. Cardiogenic: avoid aggressive fluids — careful 250 mL bolus; vasopressors if no fluid response
3. Septic: fluid resuscitation 30 mL/kg (1–2 L over 30 min); Norepinephrine if fluid-refractory
4. Anaphylactic: epinephrine 0.3–0.5 mg IM; see anaphylaxis protocol
5. Neurogenic (spinal injury): fluids + vasopressors; bradycardia + hypotension classic
6. Pericardial tamponade: fluid challenge, expedite transport (pericardiocentesis hospital-only)

Key doses

• NS bolus: 500 mL IV; reassess; repeat to SBP > 90
• Epinephrine IM: 0.3–0.5 mg IM (anaphylactic)
• Norepinephrine: 0.1–0.5 mcg/kg/min IV infusion (septic)

Clinical pearls: Shock is inadequate oxygen delivery to tissues, not just low blood pressure. Shock index (HR / SBP) > 1.0 indicates significant hemorrhage. Early identification of shock type guides treatment. Vasopressors require continuous monitoring — peripheral IV vasopressors acceptable briefly in prehospital setting.

OB Emergency / Imminent Delivery

BLS · ob-peds

Active labor with imminent or precipitous delivery in the prehospital setting.

Assessment and recognition

• Gestational age, due date, parity (G#P#), prenatal care
• Contractions: frequency, duration, intensity; urge to push
• Crowning on inspection — do not delay for more history
• Rupture of membranes (time, color of fluid); meconium = high-risk
• Vital signs, bleeding (> 500 mL = hemorrhage)

BLS steps

1. Transport if time allows — do not delay for delivery if crowning
2. Left lateral decubitus position (30–40°) unless delivery imminent
3. OB delivery kit: gloves, drape, clamps × 2, scissors, bulb syringe
4. Control head: gentle counterpressure — do not force or retract
5. Check for nuchal cord — gently slip over head or clamp/cut
6. Deliver shoulders: gentle downward for anterior, upward for posterior
7. Clamp cord × 2, cut between clamps; 1 cm from infant for first clamp
8. Dry and stimulate newborn; assess APGAR at 1 and 5 min
9. Newborn: position, suction mouth then nose, warm and dry
10. Placenta usually delivers within 15–30 min — do not pull cord
11. Oxytocin 10 units IM post-delivery to reduce hemorrhage (if available and placenta delivered)

ALS steps

1. IV access large-bore × 2; fluid resuscitation for hemorrhage
2. Oxytocin 10–20 units in 1 L NS IV infusion for postpartum hemorrhage
3. Newborn: PPV with BVM at 40–60 breaths/min if apneic or HR < 100
4. For eclampsia: Magnesium sulfate 4–6 g IV over 15–20 min
5. Breech presentation: do not pull — support torso and legs; call medical direction

Key doses

• Oxytocin: 10 units IM or 10–20 units in NS IV drip
• Magnesium sulfate: 4–6 g IV over 15–20 min (eclampsia)

Clinical pearls: APGAR: Appearance, Pulse, Grimace, Activity, Respirations (0–2 each, max 10). 7–10 = normal, 4–6 = moderate distress, 0–3 = severe distress. Meconium-stained fluid: intubate and suction below cords only if infant non-vigorous. Umbilical cord prolapse is an obstetric emergency — elevate presenting part manually and expedite transport.

Opioid Overdose / Naloxone

BLS · toxicology

Suspected opioid overdose with respiratory depression (RR < 12 or shallow), pinpoint pupils, decreased LOC.

Assessment and recognition

• Opioid triad: CNS depression, respiratory depression, miosis (pinpoint pupils)
• RR, SpO₂, depth of breathing
• Evidence: drug paraphernalia, Rx bottles, fentanyl patches, bystander report
• Concomitant stimulants (meth + opioid = stimulant signs may mask opioid signs)
• SpO₂ may be falsely normal until arrest — watch RR and clinical appearance

BLS steps

1. Stimulate and assess — responsive patient may not require naloxone
2. Airway positioning; BVM ventilation if respirations inadequate
3. O₂ high-flow
4. Naloxone 2–4 mg IN (via MAD device) if available at BLS
5. Transport; monitor for re-narcotization (naloxone wears off before opioids)

ALS steps

1. Naloxone 0.4–2 mg IV/IO/IM/IN; titrate to adequate spontaneous respirations (not full reversal)
2. For fentanyl analogs or high-potency synthetics: higher doses may be needed (4 mg+)
3. Repeat q2–3 min as needed; duration of naloxone (30–90 min) shorter than most opioids
4. For respiratory arrest: BVM first, then naloxone
5. Consider infusion 2/3 effective dose/hr IV if long transport

Key doses

• Naloxone: 0.4–4 mg IV/IM/IO/IN; titrate to RR > 12 and SpO₂

Clinical pearls: Goal of naloxone is restoration of adequate breathing, not full reversal. Full reversal causes acute withdrawal — patient may become combative and remove IV. Titrate to RR > 12 and adequate SpO₂. Transport all naloxone patients due to re-narcotization risk.

Pain Management

BLS · general

Moderate to severe acute pain (scale ≥ 4/10) requiring pharmacological management.

Assessment and recognition

• Pain scale 0–10, character, location, onset, radiation, associated symptoms
• Vital signs (hypotension may contraindicate some analgesics)
• Allergies and prior analgesic use
• Mechanism if traumatic; rule out acute abdomen, AAA

BLS steps

1. Position of comfort
2. Non-pharmacological: ice pack (trauma), positioning, splinting
3. IV access; reassess pain q10–15 min
4. Assist with patient's own analgesics per protocol

ALS steps

1. Morphine 2–4 mg IV/IO slow push q10–15 min (max 10–20 mg per protocol)
2. Fentanyl 1 mcg/kg IV/IO q15 min — preferred in hemodynamic instability or allergy
3. Ketorolac 30 mg IV (musculoskeletal, renal colic) — avoid in renal failure, GI bleed, pediatrics
4. Ketamine low dose (0.1–0.3 mg/kg IV) for dissociative analgesia when standard analgesics contraindicated

Key doses

• Morphine: 2–4 mg IV q10–15 min
• Fentanyl: 1 mcg/kg IV q15 min
• Ketorolac: 30 mg IV (one-time dose, adult)
• Ketamine sub-dissociative: 0.1–0.3 mg/kg IV

Clinical pearls: Prehospital analgesia is underutilized. Adequate pain control does not mask diagnosis. Document pain scale before and after administration. Respiratory monitoring mandatory after opioid administration — naloxone at hand.

Pediatric Cardiac Arrest

BLS · ob-peds

Pediatric patient (< 8 years) in cardiac arrest — respiratory cause most common.

Assessment and recognition

• Confirm pulselessness (brachial or femoral pulse in infants; carotid in child)
• Respiratory arrest most common cause — prioritize ventilation
• Rhythm: VF/pVT (uncommon), PEA/asystole (most common in peds)
• Identify reversible causes: 5 Hs and 5 Ts

BLS steps

1. Infant CPR: 2 fingers on sternum (1 finger below nipple line); depth 1.5 inches
2. Child CPR: 1 or 2 hands; depth 2 inches (1/3 AP diameter)
3. Rate 100–120/min; 30:2 single rescuer; 15:2 two rescuers
4. Ventilate with BVM — small tidal volumes; just visible chest rise
5. AED > 1 year (use pediatric pads/mode if available); defibrillate if shockable
6. Minimize interruptions to compressions

ALS steps

1. IO access preferred if IV not quickly established (EZ-IO 15 mm for standard weight; 25 mm for > 40 kg)
2. Epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL dilution) q3–5 min
3. Amiodarone 5 mg/kg IV/IO for VF/pVT; max 300 mg
4. Advanced airway: uncuffed ETT for infants < 1 year; cuffed for > 1 year
5. Ventilate asynchronously at 20–30 breaths/min with advanced airway

Key doses

• Epinephrine: 0.01 mg/kg IV/IO q3–5 min
• Amiodarone: 5 mg/kg IV/IO (VF/pVT)

Clinical pearls: Pediatric cardiac arrest is respiratory until proven otherwise. Provide high-quality CPR and oxygenation immediately. Weight-based dosing is critical — use Broselow tape or peds quick card. Post-ROSC: avoid hypoxia and hypotension; targeted temperature management per protocol.

Rapid Sequence Intubation (RSI)

ALS · airway-rsi

Emergent need for definitive airway in a patient with intact gag reflex or high aspiration risk.

Assessment and recognition

• LEMON difficult airway assessment
• SpO₂, ETCO₂, respiratory status, GCS
• Contraindications to succinylcholine: crush injury > 72h, burns > 72h, denervation, hyperkalemia
• Ensure backup airway plan and all equipment ready before drug administration

BLS steps

1. RSI is an ALS-only procedure. BLS: maximize preoxygenation, position patient, prepare suction

ALS steps

1. PREPARATION: suction on, BVM ready, ETT sizes (one above/below predicted), backup supraglottic device
2. PREOXYGENATION: BVM or NRB 100% O₂ × 3 min; apneic oxygenation with NC 15 LPM during attempt
3. PRE-TREATMENT (optional): Fentanyl 3 mcg/kg IV to blunt sympathomimetic response
4. INDUCTION: Etomidate 0.3 mg/kg IV (hemodynamically neutral) OR Ketamine 2 mg/kg IV (bronchospasm/hypotension)
5. PARALYTIC: Succinylcholine 1.5 mg/kg IV (max 200 mg) OR Rocuronium 1.2 mg/kg IV (succs contraindicated)
6. INTUBATE: pass ETT; confirm with waveform ETCO₂; secure at 21–23 cm at teeth
7. POST-INTUBATION: Sedation (Midazolam 0.05 mg/kg IV) + analgesia (Fentanyl 2 mcg/kg IV)

Key doses

• Etomidate: 0.3 mg/kg IV
• Ketamine: 2 mg/kg IV
• Succinylcholine: 1.5 mg/kg IV (max 200 mg)
• Rocuronium: 1.2 mg/kg IV (reversal: sugammadex 16 mg/kg)

Clinical pearls: Rocuronium 1.2 mg/kg has equivalent onset to succinylcholine at high dose. Must have sugammadex available if rocuronium used for RSI (immediate reversal). Do not ventilate during intubation attempt — maintain ETCO₂-guided ventilation post-intubation.

Respiratory Distress

BLS · respiratory

Patient presenting with dyspnea, increased work of breathing, or hypoxia of any cause.

Assessment and recognition

• SpO₂, respiratory rate, depth, and effort
• Lung sounds: wheezing, crackles, absent sounds
• Position of comfort — tripod, orthopnea suggest severe distress
• Accessory muscle use, retractions, nasal flaring, cyanosis
• Medical history: COPD, asthma, CHF, PE risk factors

BLS steps

1. Position of comfort — high-Fowler's (sitting upright) preferred
2. O₂ to maintain SpO₂ ≥ 94% (≥ 88% for known COPD); titrate up as needed
3. Assist ventilations with BVM if inadequate respirations
4. Loosen restrictive clothing
5. Assist patient with their own prescribed inhaler (per protocol)
6. Rapid transport if severe

ALS steps

1. CPAP/BiPAP if respiratory failure with adequate spontaneous respirations (SpO₂ < 90%, ETCO₂ elevated, severe dyspnea)
2. Intubate if GCS ≤ 8, exhaustion, or pending respiratory arrest
3. For bronchospasm: albuterol 2.5 mg via nebulizer, repeat × 3 prn
4. For CHF/pulmonary edema: CPAP + Furosemide 40–80 mg IV + Nitroglycerin SL if SBP > 90
5. For anaphylaxis: epinephrine 0.3–0.5 mg IM (see anaphylaxis protocol)

Key doses

• Albuterol: 2.5 mg nebulized, q20 min × 3
• CPAP: 5–10 cmH₂O; titrate to SpO₂ and distress
• Furosemide: 40–80 mg IV (pulmonary edema)

Clinical pearls: Do not assume all respiratory distress is the same. Differentiate: COPD (prolonged expiratory phase, barrel chest), CHF (crackles, JVD, orthopnea), asthma (diffuse wheeze, peak flow < 50%), PE (pleuritic chest pain, tachycardia, risk factors).

Seizure

BLS · neurological

Active or post-ictal seizure activity.

Assessment and recognition

• Active or post-ictal phase; seizure type (tonic-clonic, absence, focal)
• Duration of seizure — > 5 min = status epilepticus
• History of epilepsy, compliance with medications
• Blood glucose, fever, alcohol/drug use, head trauma
• SpO₂, respiratory status, bite marks on tongue, incontinence

BLS steps

1. Protect patient from injury — clear area, pad surfaces, do not restrain
2. Do NOT place anything in patient's mouth
3. Position laterally to prevent aspiration when seizure ends
4. O₂ via NRB after seizure subsides; suction if needed
5. IV access; blood glucose check
6. Reassess for repeat seizure activity

ALS steps

1. If actively seizing (> 5 min or repeated): Midazolam 5–10 mg IM (preferred) or 5 mg IV
2. Alternative: Diazepam 5–10 mg IV or Lorazepam 4 mg IV
3. Blood glucose < 60: administer dextrose (see hypoglycemia protocol)
4. Febrile seizure in peds: acetaminophen 15 mg/kg PR if available and febrile
5. Post-ictal: manage airway, monitor for recurrence, assess for injury

Key doses

• Midazolam: 5–10 mg IM (preferred) or 5 mg IV
• Diazepam: 5–10 mg IV or 10–20 mg PR
• Lorazepam: 4 mg IV q5–10 min

Clinical pearls: Status epilepticus: seizure > 5 min or 2 consecutive seizures without recovery. Treat aggressively — each minute of status increases mortality and neurological injury. Eclampsia in pregnant patients: Magnesium 4–6 g IV over 15–20 min is first-line (not benzodiazepines).

Stroke / CVA

BLS · neurological

Sudden-onset neurological deficit consistent with acute ischemic or hemorrhagic stroke.

Assessment and recognition

• Cincinnati Prehospital Stroke Scale: facial droop, arm drift, speech abnormality
• LAMS (Los Angeles Motor Scale): facial weakness, grip, arm weakness — LAMS ≥ 4 suggests LVO
• Time of last known well (LKW) — critical for thrombolysis eligibility (< 4.5 h)
• Blood glucose — hypoglycemia mimics stroke
• BP, SpO₂, 12-lead (Afib?), pupils

BLS steps

1. Time is brain — activate stroke alert early; notify receiving hospital
2. O₂ if SpO₂ < 94%
3. IV access — do not delay transport
4. Blood glucose — if < 60 mg/dL, treat hypoglycemia (may resolve deficits)
5. Position: head of bed 0° for ischemic; 30° HOB for hemorrhagic (if known)
6. Nothing by mouth — aspiration risk with dysphagia

ALS steps

1. Blood glucose check mandatory — do not withhold D10 or D50 if hypoglycemic
2. Do NOT lower BP in the field (hypertension is compensatory in ischemic stroke)
3. Treat seizures with Diazepam 5–10 mg IV or Midazolam 5 mg IM if they occur
4. LAMS ≥ 4: prenotify stroke center with LVO capabilities (thrombectomy facility)

Key doses

• D10W: 250 mL IV if glucose < 60 mg/dL
• Dextrose 50%: 25 g IV (1 amp) if glucose < 60 mg/dL

Clinical pearls: Stroke mimics: hypoglycemia, Todd's paralysis post-seizure, complex migraine, hypertensive encephalopathy, brain tumor. LKW is the key time marker — not when symptoms were discovered. If patient was last seen normal at midnight and woke with deficits, LKW = midnight.

Tachycardia (Unstable / Stable SVT)

ALS · cardiac

HR > 150 bpm with or without hemodynamic compromise.

Assessment and recognition

• Is patient stable or unstable? (hypotension, AMS, chest pain, heart failure = unstable)
• 12-lead: wide vs narrow QRS, regular vs irregular
• Narrow regular → likely SVT; Narrow irregular → likely Afib; Wide regular → likely VT
• BP, SpO₂, ETCO₂, level of consciousness

BLS steps

1. High-flow O₂ if SpO₂ < 94%
2. Cardiac monitoring, IV access
3. If unstable: prepare for cardioversion; call for ALS if not on scene
4. Position of comfort; continuous vitals

ALS steps

1. UNSTABLE (signs of shock): synchronized cardioversion at 50–100 J (narrow) or 100–200 J (wide); increase energy if unsuccessful
2. Sedate before cardioversion if conscious: Midazolam 1–2 mg IV or Diazepam 5–10 mg IV
3. STABLE narrow regular (SVT): vagal maneuvers first (Valsalva, carotid sinus massage)
4. Adenosine 6 mg rapid IV push + 20 mL flush; if no conversion, 12 mg × 2
5. Stable Afib with rapid ventricular rate: rate control per medical direction
6. Stable wide regular (VT): Amiodarone 150 mg IV over 10 min; consider cardioversion

Key doses

• Adenosine: 6 mg rapid IVP, then 12 mg × 2
• Amiodarone: 150 mg IV over 10 min (stable VT)
• Cardioversion: 50–100 J narrow / 100–200 J wide

Clinical pearls: Synchronized cardioversion: press SYNC button before each shock to avoid delivering unsynchronized shock during T-wave (can precipitate VF). Always sedate if patient is conscious. WPW + Afib is a life-threatening combination — avoid AV nodal blockers.

Trauma — General

BLS · trauma

Significant mechanism of injury with potential for multi-system trauma.

Assessment and recognition

• Primary survey: ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
• Mechanism: high-speed MVC, fall > 20 ft, penetrating torso injury, blast
• Glasgow Coma Scale, AVPU
• External hemorrhage, deformity, signs of internal bleeding
• Vital signs trend — hypotension + tachycardia = hemorrhagic shock until proven otherwise

BLS steps

1. Spinal motion restriction if mechanism and assessment warrant
2. Control life-threatening hemorrhage: direct pressure, wound packing, tourniquet for extremity bleeding
3. Airway management: jaw thrust (maintain spinal precautions), OPA/NPA
4. O₂ high-flow; assist ventilations if inadequate
5. Full body exposure for assessment — prevent hypothermia (blankets)
6. Load and go — do not stay on scene > 10 min for critical trauma

ALS steps

1. Large-bore IV × 2 (18 g minimum); IO if no IV access
2. Permissive hypotension: target SBP 80–90 in penetrating torso trauma; 90–100 in TBI
3. Warm isotonic fluids — no more than 1–2 L before definitive hemorrhage control
4. Needle decompression for suspected tension pneumothorax (tracheal deviation, absent breath sounds, hypotension)
5. Chest seal for open chest wounds (commercial vented preferred)
6. Tranexamic acid (TXA) 1 g IV over 10 min if within 3 h of injury and hemorrhagic shock suspected

Key doses

• TXA: 1 g IV over 10 min (within 3 h of injury)
• Normal saline: 250 mL bolus — reassess; permissive hypotension

Clinical pearls: Platinum 10 minutes — keep scene time < 10 min for critical trauma patients. The OR is the only definitive treatment for hemorrhagic shock. Hypothermia + acidosis + coagulopathy = lethal triad; prevent by minimizing crystalloid and keeping patient warm.

Traumatic Brain Injury (TBI)

ALS · trauma

Head trauma with altered mental status, focal deficits, or signs of herniation.

Assessment and recognition

• Glasgow Coma Scale — document and trend
• Pupils: unequal, unreactive, blown (herniation sign)
• Cushings triad: hypertension + bradycardia + irregular respirations = herniation
• Battle's sign, raccoon eyes, hemotympanum (basilar skull fracture)
• Signs of C-spine injury; combativeness suggests hypoxia or herniation

BLS steps

1. Maintain airway — jaw thrust; suction immediately
2. O₂ to maintain SpO₂ ≥ 94%; avoid hypoxia (single episode worsens outcome)
3. Spinal motion restriction — evidence of mechanism or symptoms
4. Rapid transport to trauma center (neurosurgical capability preferred)
5. Avoid hypotension: keep SBP ≥ 90–100 mmHg

ALS steps

1. Intubate early if GCS ≤ 8 — RSI preferred (avoid succinylcholine if > 72 h post-injury)
2. Ventilate to ETCO₂ 35–40 mmHg — hyperventilation only for herniation (ETCO₂ 30–35) as a bridge
3. Avoid hypotension: normal saline or hypertonic saline 3% 250 mL for herniation per medical direction
4. Mannitol 1 g/kg IV if signs of herniation and adequate BP
5. Keep head midline, 30° head of bed if no spinal injury

Key doses

• 3% Normal saline: 250 mL IV for herniation
• Mannitol: 1 g/kg IV (herniation only)

Clinical pearls: ETCO₂ monitoring is mandatory during TBI airway management. Normal ventilation target: ETCO₂ 35–40. Herniation bridge only: ETCO₂ 30–35 temporarily. Hypoxia and hypotension are the two most preventable causes of secondary brain injury.