Lisbon Fire Department Standard Operating Guidelines and Policies

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX	XX

Blocks the AV node to slow conduction and treat reentry conditions (tachyarrhythmias)

Symptomatic supraventricular tachycardia

Allergy to the drug

Heart block

Drug-induced tachycardias (e.g. from cocaine)

Atrial Flutter and Atrial Fibrillation
SIDE EFFECTS

Headache

Chest pressure

Nausea
SPECIAL NOTES:

Very short duration of action, must enter the circulation and get to the heart within 10-20

seconds

Pregnancy category C

Adult: 6 mg IV bolus followed by 10-20 ml flush; second dose 12 mg IV bolus followed by flush

Pediatric: 0.1 mg/kg IV bolus followed by a 10-20 ml flush, maximum of 6 mg; second dose 0.2

mg/kg followed by flush, maximum 12 mg

Continuous ECG

Attempt to capture conversion on ECG paper

Vital signs before and within 5 minutes after administration.

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	XX	XX	XX	XX

Bronchodilator

Acute bronchospasm (asthma, COPD)

Allergy to the drug

Headache

Hypertension

Monitor patients with cardiovascular disease

Pregnancy category C

USUAL DOSE

Adult and Pediatric: 2.5 mg (O.5 ml) nebulized with 2.5 ml saline (total of 3 ml)

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX - bolus only	XX

Antiarrhythmic

Ventricular tachycardia, ventricular fibrillation {Intermediate and Paramedic}

Wide complex Atrial Fib/Flutter (ie greater than 160 bpm) {Paramedic only – on line medical control}
CONTRAINDICATIONS:

Allergy to the drug

Heart block

Bradycardia

Neonates, infants

Known or suspected drug-induced dysrhythmia (e.g. from cocaine)

Cyclic drug usage
SIDE EFFECTS:

Bradycardia

Hypotension

Congestive heart failure

Heart block
SPECIAL NOTES:

Pregnancy category D

Continuous ECG

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	XX	XX	XX	XX

Anti-inflammatory

Relieves fever

Impedes blood clotting

Given to patients with signs/symptoms of ischemic chest pain (suspected myocardial infarction)

Allergy to the drug

Bleeding disorders

Affirmative answer to any question in the special note section below.

(Note: Should not be given to children with fever associated with acute viral illness – Reye’s Syndrome)
SIDE EFFECTS

Nausea

Rash

Low doses are more effective for anti-clotting effect

Ask patient:

Have you taken any aspirin already today?

Are you allergic to aspirin?

Do you have any bleeding disorder?

Pregnancy category D
USUAL DOSE

162-324 mg chewable tables (2-4 baby aspirin)

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX	XX

Block the effects of the vagus nerve (blocks parasympathetic nerve)

Symptomatic bradycardia, heart blocks, asystole (adults), Pulseless electrical activity with a slow rate

Organophosphate poisoning
CONTRAINDICATIONS

Allergy to the drug

Glaucoma

Heart Blocks with QRS complexes greater than 0.12 mm

Palpitations

Tachycardia

Blurred vision

Dry mouth

Elevated blood pressure

Pregnancy category C

Adults: 0.5-1 mg for cardiac; 2-3 mg for organophosphate poisoning

Pediatric: 0.02 mg/kg (for rhythms associated with activities causing increased vagal tone)

Minimum dose 0.1 mg

Pulse rate before and after administration

Vital signs within 5 minutes after administration

Continuous ECG

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	Oral only	XX	XX	XX

Provides calories for metabolic needs

Hypoglycemia

Increased intracranial pressure

Alcoholic in delirium tremors

SIDE EFFECTS

Will cause tissue sloughing if infiltrated

Must be diluted before administration to children

Especially in children, IM Glucagon should be considered prior to attempting peripheral IV and IV Dextrose.

Consider Thiamine in malnourished or suspected alcoholics

USUAL DOSE:

• 
  In the patient greater than100 pounds with an altered level of consciousness, who is unable to safely take oral glucose and with a blood glucose level less than 60 mg/dL, administer 25 grams Dextrose IV bolus.
  
• 
  In the patient less than100 pounds but at least 2 years old, Glucagon IM should be considered prior to attempting an IV and giving Dextrose. If Dextrose is indicated, administer 500 mg/kg (0.5 grams/kg) Dextrose diluted 1:1 with NS. Draw up the dose calculated into a large syringe and dilute (draw into the same syringe) with an equal volume of NS. For patients younger than 2 years, contact medical control for appropriate dose and dilution of dextrose (deleted reference to ml/kg).
  
• 
  In the patient who can safely eat or drink, oral glucose (Glutose) replacement is preferred.
  

• 
  Instruct patient that the gel must be swallowed
  
• 
  Allow patient to self-administer gel incrementally or assist with squeezing gel into patient’s mouth incrementally.
  
• 
  Repeat as necessary until you arrive at the hospital or mental status is normal and blood sugar is equal to or greater than 80 mg/dL.
  
• 
  If the patient is not responding to oral glucose and blood sugar continues to be low, consider IV dextrose administration.
  

• 
  For patients in whom an IV cannot be established:
  

• 
  For patients who weigh more than 44 pounds, administer 1 mg Glucagon IM (see drug profile # 011).
  
• For pediatric patients (less than 44 pounds) administer 0.5 mg Glucagon IM (See drug profile # 011)

Changes in level of consciousness

Blood sugar before and after treatment

Vital signs within 5 minutes after administration

Watch carefully for infiltration

END

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX – For Seizures only	XX

Central nervous system depressant

Muscle relaxant

INDICATIONS FOR USE

Continuous or recurrent seizures, status epilepticus

Sedation for procedures
CONTRAINDICATIONS

Allergy to the drug

Hypotension

Altered level of consciousness

Intoxication
SIDE EFFECTS

Hypotension

Rash

Respiratory depression

Controlled substance (federal regulations), addictive

Pregnancy category D
USUAL DOSE

Adult: 2-5 mg IV, (rectally if unable to establish an IV line)

Pediatric: 0.05-0.1 mg/kg IV, maximum of 8 mg.

Vital signs and respiratory assessment within 5 minutes after administration

Altered level of consciousness

Seizure activity

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Antihistamine, blocks histamine’s effect on smooth muscle in the respiratory, circulatory and gastrointestinal systems. Histamine causes bronchoconstriction, vasodilation and GI spasms

Allergic reactions

Allergy to drug

Glaucoma

Newborns
SIDE EFFECTS

Drowsiness, confusion

Seizures

Blurred vision

Nausea, vomiting
SPECIAL NOTES:

12 and older: 25-50 mg IV or PO

Younger than 12 years old: 1.25 mg/kg, maximum of 25 mg IV or PO
MONITOR, REPORT, DOCUMENT

Vital signs within 5 minutes after administration

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	XX (IM 1:1,000) for anaphylaxis*	XX (IM 1:1000) for anaphylaxis	XX	XX

Increases heart rate and force

Vasoconstriction

Bronchodilation

Asthma (1:1000 IM) (EMT-Intermediate and Paramedic only)

Anaphylaxis (1:1000 IM)

Patients in cardiopulmonary arrest while CPR is in progress (IV bolus 1:10,000) (Intermediate and Paramedic only)

Glaucoma

Headache

Hypertension

Tachycardia
SPECIAL NOTES:

Don’t mix with alkaline solutions (sodium bicarbonate)

Epi-Pen = 0.3 mg

Epi-Pen Jr. = 0.15 mg (less than 60 pounds)

Pregnancy category C
USUAL DOSE

IM dose (1:1,000) (1 mg in 1 ml)

0.1-0.3mg 1:1000 for anaphylaxis. For asthma (Intermediate and Paramedic use only),

May repeat in 5 minutes if no improvement or worsening of condition with medical control

approval

IV/IO dose (1:10,000) (1 mg in 10 ml) Cardiopulmonary arrest

Adult: 1 mg IV/IO, 2 mg ET

Pediatrics less than 60 pounds:

0.01 mg/kg dose, 0.1 mg/kg ET dose

MONITOR, REPORT, DOCUMENT

Breath sounds, vital signs within 5 minutes after administration

Effect on heart rate

Continuous ECG monitoring

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX	XX

Diuretic
INDICATIONS FOR USE

Not recommended for routine pre-hospital treatment of acute congestive heart failure/pulmonary edema unless diagnosis of CHF/pulmonary edema confirmed
CONTRAINDICATIONS

Allergy to the drug

Anuria (no urine output, e.g. dialysis patient)

Hypotension (Systolic BP less than 90 mmHg)

Hypotension

Rash
SPECIAL NOTES:

Long term use can result in electrolyte imbalance and dehydration

Use with caution in patients with allergy to sulfa drugs

Pregnancy category C

40 mg IV bolus

Daily maintenance dose

Vital signs, respiratory assessment within 5 minutes after administration

Any urinary output

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	XX **optional**	XX	XX	XX

Raises blood glucose by stimulating liver to release stored glycogen (sugar) and converting fats and proteins to glucose

Hypoglycemia

Allergy to the drug

History of pheochromocytoma (tumor which secretes epinephrine)
SIDE EFFECTS

Hypotension

Nausea, vomiting

Respiratory distress

May be repeated in 20 minutes if no response. IV glucose must be given if patient doesn’t respond to glucagon.

Drug is supplied in a powdered form and must be reconstituted in the solution supplied with the powder.

Patient needs to eat carbohydrates as soon as awake and able to swallow safely.

In the pediatric patient, IM Glucagon should be administered prior to attempting peripheral IV and IV Dextrose.

Pregnancy category B

In the patient who can safely eat or drink, oral glucose replacement is preferred.

Instruct patient that the gel must be swallowed

Allow patient to self-administer gel incrementally or assist with squeezing gel into patient’s mouth incrementally.

Repeat as necessary until tube content has been consumed.
For patients in whom an IV cannot be established:

For patients who weigh more than 44 pounds, administer 1 mg Glucagon IM.

Vital signs within 5 minutes after administration

DRUG PROFILE

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX-bolus only	XX

Antiarrhythmic (ventricular)

Ventricular arrhythmias (PVCs, ventricular tachycardia, ventricular fibrillation)

Local and bone marrow anesthetic for placement of IO line
CONTRAINDICATIONS

Allergy to this or other “caine” drug

Heart blocks
SIDE EFFECTS

Seizures

Bradycardia

If allergic to other local anesthetics (e.g. Novocain), contact medical control prior to administration

Pregnancy category B
USUAL DOSE

1-1.5 mg/kg IV, maximum dose 3 mg/kg

2-4 mg/min maintenance dose

For IO placement:

0.5-1 ml 2% solution infiltrated subcutaneously at IO site

Adult: 20-40 mg (1-2 ml) of 2% Lidocaine IO bolus over one minute

Pediatric: 0.5 mg/kg of 2% Lidocaine IO bolus

Note: 2% Lidocaine = 20 mg/ml
MONITOR, REPORT, DOCUMENT

Continuous ECG

Vital signs within 5 minutes after administration
END
DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX	XX

Long acting narcotic analgesic (pain relief)

Central nervous system depressant
INDICATIONS FOR USE

Chest pain of cardiac origin

Burns (moderate to severe pain)

Extremity trauma (moderate to severe pain)

Contact medical control prior to any other use
CONTRAINDICATIONS

Allergy to the drug

Hypotension

Head, chest, abdominal trauma

Respiratory depression
SIDE EFFECTS

Decreased level of consciousness

Bradycardia

Hypotension

Nausea, vomiting

Respiratory depression

Addictive, federal regulations apply

Can be reversed with naloxone (see drug profile 014)

Pregnancy category C (D in long-term use or high dose)

2-5 mg slow IV bolus over 2-3 minutes, may be repeated for severe pain (adult)

0.05 mg/kg (pediatric)
MONITOR, REPORT, DOCUMENT

Vital signs within 5 minutes after administration

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
		XX	XX	XX

Reverses narcotic-induced respiratory depression and altered level of consciousness

Suspected narcotic overdose in patients with altered level of consciousness

Allergy to the drug

Tremors

May induce narcotic withdrawal in addicts (Nausea, vomiting, diaphoresis, tachycardia, hypertension)

Duration of action of naloxone may be shorter than the narcotic and the patient may relapse

Consider contact of Poison Control (1-800-222-1222).

Pregnancy category C

USUAL DOSE

Intranasal dose same as IV/IM dosing

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	XX (Patient assisted) *	XX	XX	XX

Vasodilator

Decreases venous return
INDICATIONS FOR USE

Hypotension (systolic pressure less than 100 mm/Hg)

Use of sildenafil (Viagra) within the past 24 hours

Use of tadalafil (Cialis) or vardenafil (Levitra) within past 48 hours

Headache

Tachycardia

Adults: 0.4 mg sublingually, may repeat every 3-5 minutes for 15 minutes. Check with medical control for additional doses.

Vital signs and pain assessment within 5 minutes after administration

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Antiarrhythmic

Ventricular tachycardia, ventricular fibrillation, PVCs

Allergy to the drug

Heart block

Torsades des pointes

Hypotension

Bradycardia

Heart block

Nausea, vomiting

Rash
SPECIAL NOTES:

Monitor the width of the QRS and the blood pressure

Pregnancy category C

Adult: 50-100 mg IV bolus over 5 minute period until:

QRS is 50% wider than at start of medication administration

Maximum dose of 17 mg/kg has been given

Effect on dysrhythmia achieved

Special pediatric considerations: 15 mg/kg over 30-60 minutes only for ventricular tachycardia

with pulses
MONITOR, REPORT, DOCUMENT

QRS duration

ECG changes

Vital signs before and within 5 minutes after administration

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Neutralizes acids

Treat metabolic acidosis associated with cardiopulmonary arrest

Ventricular dysrhythmias secondary to cyclic antidepressants
CONTRAINDICATIONS

Alkalosis

Alkalosis

Must be diluted for neonates

Pregnancy category C
USUAL DOSE

1 mEq/kg

Vital signs within 5 minutes after administration

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	XX	XX	XX	XX

Olfactory stimulant, reflex respiratory stimulant, elevates blood pressure

Patient who presents with an altered level of consciousness after other physical causes have been ruled out.

Patient is alert and oriented

Medical cause for the altered level of consciousness has been established
SIDE EFFECTS

Rule out all medical and traumatic causes for altered level of consciousness before using ammonia inhalants

DO NOT insert ammonia inhalants into any orifice or place under oxygen mask

May irritate patient

One capsule, broken and waved under the patient’s nose during inhalation

Change in level of consciousness

Vital signs within 5 minutes after administration
END

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
	XX **	XX	XX	XX

Bronchodilator

Maintenance therapy in patients with Chronic Obstructive Pulmonary Disease (COPD)

Allergy to the drug, soybeans, peanuts

Glaucoma
SIDE EFFECTS

Dry mouth

Headache

Nausea, vomiting, cramping

Tachycardia
SPECIAL NOTES:

Most often used in combination with or immediately following albuterol

Not recommended to be used alone in acute respiratory distress

May use pre-mixed combination with Albuterol for first adult treatment (ie “Duo-Neb”)

Pregnancy category B
USUAL DOSE

0.5 mg nebulized with 2.5 ml saline (total of 3 ml)

0.25 mg nebulized for children less than 12 years of age

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
			XX	XX

Peripheral vasoconstriction

Cardiac arrest patients in ventricular fibrillation, pulseless ventricular tachycardia, asystole or pulseless electrical activity (as an option in place of initial or second dose of epinephrine)

Conscious patients with coronary artery disease

Allergy
SIDE EFFECTS

Pallor

Uterine contraction

Vasopressin may be given in place of the 1^st or 2^nd dose of epinephrine (see drug profile #009) in the cardiac resuscitation protocol

Pregnancy category C
USUAL DOSE

Adults: 40 Units IV or IO, one dose only

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Cardiac stimulant, increases force of contraction

Calcium as an element is required for many physiological activities
INDICATIONS FOR USE

Calcium channel blocker overdose

Elevated potassium (hyperkalemia)

Low calcium (hypocalcemia)

Patient taking digitalis (Use with caution)

Ventricular tachycardia

Ventricular fibrillation

Bradycardia

Arrhythmias

Syncope

Flush line before administering sodium bicarbonate (causes precipitation)

Be sure the IV is not infiltrated, causes tissue sloughing

Pregnancy category C

Adult: 100-500 mg IV bolus

Pediatric: 20 mg/kg, maximum dose 500 mg
MONITOR, REPORT, DOCUMENT

Continuous ECG

Vital signs before and within 5 minutes after administration
END

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Allows breakdown of Glucose

Alcoholic patients and those who are malnourished

Allergy to the drug

Helpful prior to administration of glucose in alcoholic or those malnourished

Pregnancy category A
USUAL DOSE:

100 mg IVP

Vital signs before and within 5 minutes after administration

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Central nervous system depressant

Sedation for patients prior to intubation and cardioversion

Seizure management
CONTRAINDICATIONS:

Allergy to the drug

hypotension
SIDE EFFECTS:

Hypotension, respiratory depression, bradycardia, disinhibition resulting in agitation

Always have advanced airway equipment ready prior to use. Always preoxygenate prior to use. Can reverse with Romazicon (see drug profile 025)

Pregnancy category D
USUAL DOSE:

Adults – 2-5 mg

Maximum RSI dose 10 mg.

Seizures: 2-5 mg IV/IM (may repeat in 5 minutes) (Titrate IV bolus dose to effect)

Pediatrics – 0.05 mg/kg (not to exceed adult dose)

Seizures: 0.05 mg/kg-0.1 mg/kg IV/IM (may repeat in 5 minutes)(Titrate IV bolus

dose to effect)

Rectal Dose 0.1 mg/kg; maximum total dose 5 mg

Continuous ECG and Oxygen Saturation monitoring.

Vital signs before and within 5 minutes after administration.
END

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Vasoconstriction

Low doses cause renal and mesenteric vasodilation

Increases force of contraction of heart to increase cardiac output

Hypotension not associated with hypovolemia

Allergy to the drug

Tachydysrhythmia

Ventricular fibrillation

Hypovolemia
SIDE EFFECTS:

Hypertension, tachydysrhythmia (dose related), increased myocardial oxygen demand

If hypotension related to hypovolemia, tachydysrhythmia are very common.

MAO’s may potentiate the effect of Dopamine

Pregnancy category C

Mix 400 mg in 250 cc of normal saline and titrate for effect

Typical range 5-10 mcg/kg/min

Titrate dose to BP systolic of 100 mmHg

Continuous ECG

Vital signs before and within 5 minutes after administration.
END

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Reversal of sedative effects of benzodiazepines

Known pure benzodiazepine overdose, Versed reversal

To be used only with the approval of on-line medical control
CONTRAINDICATIONS:

Allergy to the drug

Cyclic antidepressant overdose, mixed overdose, dysrhythmias, wide QRS, chronic benzodiazepine use
SIDE EFFECTS:

Headache, dizziness, dysrhythmias, seizures, vomiting

Used in patients with respiratory failure secondary to pure benzodiazepine overdose.

Not to be used as part of routine unresponsive patient care. Contact medical control before administration

Pregnancy category C

Initial dose 0.2 mg IVP. Repeat dose to max of 1 mg if needed

Continuous ECG

Vital signs before and within 5 minutes after administration.
END

DRUG PROFILE

The following is the basic information and guideline for use of:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	Paramedic
				XX

Central nervous system depressant, anticonvulsant, antiarrhythmic, bronchial smooth muscle relaxant

Obstetrical: Eclampsia

Cardiovascular: Refractory ventricular fibrillation or pulseless ventricular tachycardia, torsades

de pointes

Respiratory: Status asthmaticus
CONTRAINDICATIONS