Pharmacology

Adult / Pediatric Dose

Adult Dose
13 years and above: FOUR unit doses of 160 mg/5 mL each for a total of 640 mg/20 mL OR in a form of 325 mg pill or tablet x2 for a total of 650 mg with sips of water as tolerated by the patient.

Pediatric Dose
Less than 2 years of age: Not indicated
2–4 years: Unit dose 160 mg/5 mL
5–12 years: TWO unit doses of 160 mg/5 mL each for a total of 320 mg/10 mL

ACTIVATED CHARCOAL (WITHOUT SORBITOL)

Adult Dose
Administer 1 gram/kg

Pediatric
Administer 1 gram/kg

ADENOSINE (ADENOCARD)

Adult Dose
6 mg rapid IVP bolus followed by a rapid flush
Give 12 mg if no response within 2 minutes.
Give 12 mg more if no response within another 1–2 minutes.

Pediatric Dose
Pediatric: 0.1 mg/kg rapid IVP/IO; maximum initial dose 6 mg.
Second and third doses: 0.2 mg/kg rapid IVP/IO; maximum single additional dose 12 mg.

ALBUTEROL SULFATE (PROVENTIL, VENTOLIN)

Adult Dose
Bronchospasm
- 2.5 mg by nebulized aerosol connected to 6–8 lpm of oxygen; may repeat one time
Hyperkalemia
- 20 mg (if available) by nebulized aerosol connected to 6–8 lpm of oxygen

Pediatric Dose
Bronchospasm
- May repeat one time; connect to 6–8 lpm of oxygen
- Age two or older: 2.5 mg by nebulized aerosol
- Age less than two years: 1.25 mg by nebulized aerosol
Hyperkalemia
- Age two or older: 2.5 mg by nebulized aerosol
- Age less than two years: 1.25 mg by nebulized aerosol

AMIODARONE

Adult Dose
Adult with pulse: 150 mg IV/IO over 10 minutes (mixed in 50 - 100 mL of approved diluent). May repeat once.
Adult without pulse VF/VT/(torsades after magnesium sulfate): 300 mg IV/IO. May repeat one time 150 mg IV/IO

Pediatric Dose
Pediatric with pulse: 5 mg/kg IV/IO over 20 minutes (mixed in 50 - 100 mL of approved diluent)
Pediatric without pulse: 5 mg/kg IV/IO; max single dose 300 mg. May repeat twice to a maximum of 15 mg/kg.

ASPIRIN

Adult Dose
324 mg or 325 mg chewed

Pediatric Dose
Not indicated

ATROPINE SULFATE

Adult Dose
Bradycardia:
- Administer 0.5–1 mg IVP repeated every 3–5 minutes to a total dose of 0.04 mg/kg
Organophosphate poisoning:
- Administer 2–4 mg IVP or IM every 5–10 minutes.
Nerve agent exposure See MARK I / DuoDote Protocol.

Pediatric Dose
Bradycardia:
- Administer 0.02 mg/kg IV/IO; maximum single dose 0.5 mg; ET 0.04–0.06 mg/kg, dilute 5 mL; repeat once
Organophosphate poisoning:
- Administer 0.02 mg/kg IVP/IO or IM every 5–10 minutes.
Nerve agent exposure See MARK I / DuoDote Protocol.

ATROVENT (IPRATROPIUM)

Adult Dose
Single administration ONLY, 500 mcg (2.5 mL) by nebulized aerosol connected to 6–8 lpm of oxygen in combination with albuterol 2.5 mg.

Pediatric Dose
Single administration ONLY. In combination with albuterol, nebulized aerosol is connected to 6–8 lpm of oxygen.
Less than 1 year of age:
- contraindicated
Age 1 year but less than 2 years:
- 250 mcg (1.25 mL) by nebulized aerosol
Age 2 and older:
- 500 mcg (2.5 mL) by nebulized aerosol

CALCIUM CHLORIDE (10% SOLUTION)

Adult Dose
Administer 0.5–1 gram SLOW IVP over 10 minutes. Maximum dose 1 gram
Administer 500 mg SLOW IVP for: hypotension following diltiazem administration. Respiratory depression, decreased reflexes, flaccid paralysis, and apnea following magnesium sulfate administration

Pediatric Dose
Administer 20 mg/kg (0.2 mL/kg) SLOW IVP/IO (50 mg/min) Maximum dose 1 gram

DEXAMETHASONE

Adult Dose
10 mg IV (preferred, if established) or PO

Pediatric Dose
Asthma: 0.5 mg/kg PO (preferred) or IV to a maximum of 10 mg
Croup: 0.5 mg/kg PO/IM/IV to a maximum of 10 mg

DEXTROSE

Adult Dose
If blood glucose is less than 70 mg/dL, administer 10% dextrose in 50 mL (5 grams) boluses, one minute apart, to a maximum of 250 mL OR 25 grams of 50% dextrose IVP, until:
(i) the patient has a return to normal mental status, and
(ii) the patient’s blood glucose is at least 90 mg/dL.
(iii) If, following 250 mL of 10% dextrose or 25 grams of 50% dextrose, patient has persistently altered mental status and blood glucose less than 90 mg/dL, repeat dosing regimen in (a).

DIAZEPAM (VALIUM)

Adult Dose
Administer 2.5–10 mg in 2.5 mg increments SLOW IVP/IM (IM requires all providers to obtain medical consultation.) Maximum total dose 10 mg
Severe nerve agent exposure (providers may administer without consult):
Administer 10 mg IM.

Pediatric Dose
Administer 0.1 mg/kg in 2.5 mg increments SLOW IVP/IO/IM (IM requires all providers to obtain medical consultation.) Maximum total dose 5 mg
Rectal Dose: Administer up to 0.2 mg/kg; maximum total dose 10 mg
Severe nerve agent exposure (providers may administer without consult):
greater than 30 kg: Administer 10 mg via auto-injector or 0.1 mg/kg IM, maximum of 10 mg.

DILTIAZEM (CARDIZEM)

Adult Dose
(a) 0.25 mg/kg (maximum dose 20 mg) by IV bolus administered SLOW IV over 2 minutes; if response is not adequate, repeat in 15 minutes with a dosage of 0.35 mg/kg (maximum dose 25 mg) over 2 minutes.
(b) For patients older than 50 years of age or borderline blood pressure, consider initial bolus 5–10 mg administered IV over 2 minutes.

Pediatric Dose
Contraindicated for patients less than 18 years of age. If needed, consult Pediatric Base Station.

DIPHENHYDRAMINE HYDROCHLORIDE (BENADRYL)

Adult Dose
Administer 25–50 mg SLOW IVP or IM

Pediatric Dose
Administer 1 mg/kg SLOW IV/IO or IM
Medical consultation required for administration in mild allergic reaction.

DOPAMINE HYDROCHLORIDE (INTROPIN)

Adult Dose
For IV infusion use only
In general, the infusion rate is adjusted to blood pressure and clinical response.
Administer 2–20 mcg/kg/min IV drip titrated to BP of 100 systolic or medical consultation selected BP; initial infusion rate 2–5 mcg/kg/min.

Pediatric Dose
For IV infusion use only
In general, the infusion rate is adjusted to blood pressure and clinical response.
Administer 2–20 mcg/kg/min IV drip titrated age specific BP or medical consultation selected BP; initial infusion rate is 2 mcg/kg/min

DROPERIDOL

Adult Dose
- Patient 18–68 years of age: 2.5 mg IM
- Patient 69 years and older: 1.25 mg IM
Medical consultation required for additional dose

Pediatric Dose
- Patient 13–18 years of age: 2.5 mg IM
- Patient less than 13 years of age: contraindicated
Medical consultation required for additional dose

EPINEPHRINE 1:10,000/1:1,000

Adult Dose
Cardiac Arrest
(i) Administer 1 mg (1:10,000) IVP every 3–5 minutes
Bradycardia
not indicated
Allergic Reaction/Anaphylaxis/Asthma
- FOR ANAPHYLAXIS (ADULT ONLY)
For patients who are in extremis with severe hypotension or impending respiratory failure, consider initiating an epinephrine drip after having administered 3 doses of IM epinephrine.
- Mix 1 mg of epinephrine (either 1:1,000 or 1:10,000) in a 1 liter bag of LR IV/IO. Initiate an infusion with a wide open macro drip titrating to a systolic pressure of greater than 90 mmHg. When drip administered, this will be reported as an exceptional call.
Epinephrine: 1:1,000
- not indicated

As replacement for dopamine with the following dosing by indication (NEW ’18)

Cardiogenic (post-ROSC or acute heart failure):
0.05 – 0.3 mcg/kg/min.
Sepsis:
0.05 – 0.3 mcg/kg/min.
Hypovolemic shock (after sufficient volume replacement):
0.05 – 0.3 mcg/kg/min.
Anaphylaxis:
0.5 mcg/kg/min.
Cardiogenic Shock (NEW '20') -hold-

Pediatric Dose
Cardiac Arrest
Administer 0.01 mg/kg (0.1 mL/kg) of 1:10,000 IVP/IO; repeat every 3–5 minutes
ET: 0.1 mg/kg of 1:1,000, diluted with 5 mL of LR; repeat every 3–5 minutes
Neonate:
Administer 0.01 mg/kg (0.1 mL/kg) of 1:10,000 IVP/IO; repeat every 5 minutes
ET: 0.03 mg/kg of 1:10,000, diluted with 1 mL of LR
Bradycardia:
(i) Administer 0.01 mg/kg (0.1 mL/kg) of the 1:10,000 IVP/IO; repeat every 3–5 minutes
(ii) ET: 0.1 mg/kg of 1:1,000, diluted with 5 mL of LR; repeat every 3–5 minutes
Neonate:
(i) Administer 0.01 mg/kg (0.1 mL/kg) of 1:10,000 IVP/IO; repeat every 3–5 minutes
(ii) ET: 0.03 mg/kg of 1:10,000, diluted with 1 mL of LR
Allergic Reaction/Anaphylaxis/Asthma
Epinephrine: 1:1,000
(i) Less than 5 years of age: administer 0.15 mg in 0.15 mL IM
(ii) 5 years and greater: administer 0.5 mg in 0.5 mL IM
Croup
(i) Administer 2.5 mL of epinephrine 1:1,000 via nebulizer.
(ii) If patient does not improve, administer a second dose of 2.5 mL of epinephrine 1:1,000 via nebulizer.
As replacement for dopamine with the following dosing by indication (NEW ’18)

Cardiogenic (post-ROSC or acute heart failure):
0.05 – 0.3 mcg/kg/min.
Sepsis:
0.05 – 0.3 mcg/kg/min.
Hypovolemic shock (after sufficient volume replacement):
0.05 – 0.3 mcg/kg/min.
Anaphylaxis:
0.5 mcg/kg/min.

ESMOLOL

Adult Dose
(age 13 and older): 500 mcg/kg IV/IO over 1-2 minutes. No repeat dosing.

Pediatric Dose
(patients less than age 13 years): Not indicated

FENTANYL

Adult Dose
IV/IO/IN/IM. IN administration max 1 mL per nare
Administer 1 mcg/kg to a maximum initial dose of 200 mcg.
Reassess in 5–10 minutes. If pain remains moderate to severe, then administer a second dose of fentanyl 1 mcg/kg to a maximum dose of 200 mcg. (Divide IN administration of the dose equally between the nares to a maximum of 1 mL per nare.)
Obtain on-line medical direction for additional doses, if required.

Pediatric Dose
IV/IO/IN/IM. IN administration max 1 mL per nare.
Administer 1 mcg/kg to a maximum initial dose of 200 mcg. Administer at a rate of 0.5 mcg/kg/min. (Divide IN administration of the dose equally between the nares to a maximum of 1 mL per nare.)
Reassess in 5–10 minutes. If pain remains moderate to severe, then administer a second dose of fentanyl 1 mcg/kg to a maximum dose of 200 mcg.
Obtain on-line medical direction for additional doses, if required.

GLUCAGON

Adult Dose
For suspected hypoglycemia without IV access:
Administer 1 mg IM/IN (Medical consult for additional dosing to a maximum of 3 mg IM)
For suspected beta blocker overdose:
Administer 1 mg IVP every 5 minutes

Pediatric Dose
For suspected hypoglycemia without IV access:
1 mg IM/IN (5 years of age up to patient's 18th birthday)
(Medical consult for additional dosing to a maximum of 3 mg IM/IN)
0.5 mg IM/IN (28 days–4 years of age)
(Medical consult for additional dosing to a maximum of 3 mg IM/IN)
For suspected beta blocker overdose:
Administer every 5 minutes
1 mg IVP (5 years of age up to patient's 18th birthday) every 5 minutes
0.5 mg IVP (28 days–4 years of age) every 5 minutes

HALOPERIDOL (HALDOL)

Adult Dose
Patient 18–69 years of age:
5 mg IM or IV
Patient greater than 69 years of age:
2.5 mg IM or IV

Pediatric Dose
Child less than 5 years of age:
Contraindicated
Child 5–12 years of age:
0.05 mg/kg IM or IV, max of 2.5 mg
Patient 13 up to 18th birthday:
2.5–5 mg IM or IV

KETAMINE (KETASET, KETALAR)

Adult Dose
Pain management:
Administer 0.2 mg/kg IV/IO over 1–2 minutes. Maximum single dose 20 mg.
- Reassess in 5–10 minutes. If pain remains moderate to severe, then administer a second dose of ketamine 0.2 mg/kg IV/IO over 1–2 minutes. Maximum single dose 20 mg.
- If IV unavailable, administer 0.5 mg/kg IN/IM (if delivery device is available; divide administration of the dose equally between the nares to a maximum of 1 mL per nare).
- Reassess in 15 minutes. If pain remains moderate to severe, then administer a second dose of ketamine 0.5 mg/kg IN/IM.

Excited Delirium Syndrome:
IV dosing: Administer 1 mg/kg IV/IO. Max. single IV/IO dose 100 mg.
- If severe agitation persists, administer 1 mg/kg IV/IO. Max. single IV/IO dose 100 mg. Max. total IV/IO dose 200 mg.
- If agitation persists after second dose of IV/IO ketamine, consider midazolam 2.5 mg IV/IO.
- IM dosing: 4 mg/kg IM. Max. total IM dose 400 mg.
- If severe agitation persists after IM ketamine dose, administer midazolam 5 mg IM.,/i>
- Additional dose of 4 mg/kg IM ketamine for persistent agitation requires medical consultation.

Severe agitation
Medical consultation is required for the first dose of ketamine for severe agitation in all patients, unless there is immediate or imminent danger to the patient or EMS. Additional doses of ketamine always require medical consultation for all patients.
- IV dosing: Administer 1 mg/kg IV/IO. Maximum single IV/IO dose 100 mg.
- If severe agitation persists, administer 1 mg/kg IV/IO. Maximum single IV/IO dose 100 mg. Maximum total IV/IO dose 200 mg.
- IM dosing: 4 mg/kg IM. Maximum total IM dose 400 mg.
- Additional dose of 4 mg/kg IM ketamine for persistent agitation requires medical consultation.

Ventilatory difficulty secondary to bucking or combativeness in intubated patients
Ketamine may be preferred for patients who have hypotension or possible hypovolemia, or if ventilatory difficulty is thought to be the result of pain response.
- Dose: Administer 2 mg/kg IVP/IO over 60 seconds.
- May repeat 2 additional doses of 1 mg/kg for IVP/IO every 10–15 minutes to a total of 3 doses as needed.
- Additional doses require medical consultation.

CPR-induced awareness
Administer ketamine 1 mg/kg IV/IO.
- Repeat doses with medical consultation.

Pediatric Dose
Pain Management:
Administer 0.2 mg/kg IV/IO over 1–2 minutes. Max. single dose 20 mg.
- Reassess in 5-10 minutes. If pain remains moderate to severe, then administer a second dose of ketamine 0.2 mg/kg IV/IO over 1–2 minutes. Max. single dose 20 mg.
- If IV unavailable, administer 0.5 mg/kg IN/IM (if delivery device is available, divide administration of the dose equally between the nares to a Max. of 1 mL per nare).
- Reassess in 15 minutes. If pain remains moderate to severe, then administer a second dose of ketamine 0.5 mg/kg IN/IM.

Excited Delirium Syndrone:
IV dosing: For children 13 to 18 years of age, administer 1 mg/kg IV/IO. Max. single IV/IO dose 100 mg. Max. total IV/IO dose 200 mg. Patients who have not yet reached their 13th birthday require medical consult: Administer 1 mg/kg IV/IO. Max. single IV dose 100 mg. Max. total IV/IO dose 200 mg.
- If severe agitation persists, administer 1 mg/kg IV/IO. Max. single IV dose 100 mg.
- If agitation persists after second dose of IV ketamine, consider midazolam 0.1 mg/kg in 2.5 mg increments SLOW IVP/IO over 1–2 minutes. Max. single dose of midazolam 2.5 mg.
- IM dosing: Patients aged 13 to 18 years, administer 4 mg/kg IM. Max. IM dose 400 mg.
- Patients who have not yet reached their 13th birthday require medical consult: Administer 4 mg/kg IM. Max. IM dose 400 mg.
- If severe agitation persists, administer midazolam 2.5 mg IM.
- Additional dose of 4 mg/kg IM ketamine for persistent agitation requires medical consultation.

Severe agitation
Medical consultation is required for the first dose of ketamine for severe agitation in all patients, unless there is immediate or imminent danger to the patient or EMS. Additional doses of ketamine always require medical consultation for all patients.
- For patients who have not yet reached their 18th birthday, IV dosing: Administer 1 mg/kg IV/IO. Maximum single IV/IO dose 100 mg.
- If severe agitation persists, administer 1 mg/kg IV/IO. Maximum single IV/IO dose 100 mg.
- IM dosing: Patients who have not yet reached their 18th birthday, Administer 4 mg/kg IM. Maximum total IM dose 400 mg.
- Additional dose of 4 mg/kg IM ketamine for persistent agitation requires medical consultation.

CPR-induced awareness
- Obtain medical consultation from a Pediatric Base Station.

KETOROLAC (TORADOL®)

Adult Dose
Administer single dose of 15 mg IV only. No repeat doses.
If IV is unavailable: Administer single dose of 30 mg IM. No repeat doses.

Pediatric Dose
(1) Newly born to 2 years of age: Contraindicated
(2) Age 2 to patients who have not reached their 18th birthday: Administer 0.5 mg/ kg IV only to a maximum total dose of 15 mg. No repeat doses.
If IV is unavailable: Administer 1 mg/kg IM to a maximum total dose of 30 mg. No repeat doses.

LACTATED RINGER’S

Adult Dose
Maximum dose 2,000 mL without medical consultation
Initiate IV LR fluid therapy (20 mL/kg bolus).
Titrate to a systolic pressure of 100 mmHg.

Pediatric Dose
Maximum dose 2,000 mL without medical consultation
If age-related vital signs and patient’s condition indicate hypoperfusion, administer initial fluid bolus of 20 mL/kg LR IV/IO. Fluid boluses for neonates and volume-sensitive children are 10 mL/kg.
If patient’s condition does not improve, administer the second uid bolus of 20 mL/kg LR IV/IO.
Third and subsequent uid boluses at 20 mL/kg LR IV/IO

LIDOCAINE (XYLOCAINE)

Adult Dose
Adult/Adolescent with an IO infusion:
To prevent or treat pain during an IO infusion in patients greater than or equal to 13 years of age, administer 20–40 mg (1–2 mL) of 2% (preservative free) lidocaine IO.
IO infusion in patients less than 13 years of age:
To prevent or treat pain during an IO infusion for patients under 13 years of age, consult a Pediatric Base Station.
Nasal Pharyngeal Anesthesia (age 13 years and greater) (NEW ’17) Draw up 4 mL of lidocaine 4% (40 mg/mL) and using mucosal atomization device, administer 2 mL per nare. The patient IV, gel, and intranasal dosing should not exceed 3 mg/kg.

Pediatric Dose
See Adult Dose.

MAGNESIUM SULFATE

Adult Dose
Seizure activity associated with pregnancy: 4 grams IV/IO over 10 minutes (mixed in 50–100 mL of approved diluent)
Refractory VT/VF: 1–2 grams IV/IO over 2 minutes
Moderate to severe asthma/bronchospasm exacerbation: 1–2 grams IV/IO over 10–20 minutes (mixed in 50–100 mL of approved diluent)
Torsades de pointes: 1–2 grams IV/IO over 2 minutes

Pediatric Dose (under 18 years old)
Seizure activity associated with pregnancy: 4 grams IV/IO over 10 minutes (mixed in 50–100 mL of approved diluent)
Moderate to severe asthma/bronchospasm exacerbation: consider magnesium sulfate 50 mg/kg IV/IO (mixed in 50 - 100 mL of approved diluent) to max of 2 grams given over 10–20 minutes
MAGNESIUM ADMINISTRATION OFTEN CAUSES HYPOTENSION IN CHILDREN. CONSIDER ADMINISTERING BOLUS 20 ML/KG OF LACTATED RINGER’S WITH THE ADMINISTRATION OF MAGNESIUM.
Torsades de pointes: 25 mg/kg to a max of 2 grams IV/IO over 2 minutes

MIDAZOLAM (VERSED)
(paramedic and CRT-(I) may perform without consult for patients with active seizures.)
All indications except for Bucking Endotracheal Intubated patient, Chemical Restraint, and Excited Delirium Syndrome (NEW ’17)

Adult Dose
REDUCE THE BELOW IV/IO/IN/IM BY 50% FOR PATIENTS 69 YEARS OR OLDER.
0.1 mg/kg in 2 mg increments SLOW IVP over 1–2 minutes per increment with maximum single dose 5 mg.
If IV unavailable, 5 mg IN/IM may be administered. IN administration max 1 mL per nare
Additional doses up to a maximum total dose 10 mg require medical consultation for all providers. For seizures lasting greater than 10 minutes (status), consider IO administration of midazolam.
If suspected severe nerve agent exposure, providers may administer midazolam 5 mg IM without medical consultation.
Chemical Restraint
Patient 15–69 years: midazolam 5 mg IM/IV
Patient greater than 69 years: midazolam 2.5 mg IM/IV Repeat doses may be given with medical direction
Bucking Endotracheal Intubated patient (NEW ’17)
Administer 0.05 mg/kg SLOW IVP over 1–2 minutes, while maintaining systolic BP greater than 90 mmHg. STOP ONCE BUCKING HAS RESOLVED AND VENTILATION IS RELAXED. Maximum single dose is 5 mg.
Additional doses require medical consultation.
ADMINISTER UP TO 0.05 MG/KG IV WHEN TREATING ENDOTRACHEAL TUBE BUCKING, STOPPING ONCE BUCKING HAS RESOLVED AND VENTILATION IS RELAXED.
Excited Delirium Syndrome (ExDS)
Administer midazolam in 2 mg increments (SLOW IV/IO push over 1–2 minutes).
May be repeated twice to a maximum total IV dose of 6 mg prior to consult.
Reduce by 50% for patients 69 years or older.
If IV/IO unavailable or unsafe to obtain, administer 2 mg increments IN (1 mL per nare)
If IV/IO/IN administration routes are not possible, administer 5 mg IM.
Multiple doses may be required to achieve therapeutic effect.
Additional doses require medical consultation.

Pediatric Dose
0.1 mg/kg in 2 mg increments. SLOW IVP over 1–2 minutes per increment to a maximum single dose of 5 mg.
If IV unavailable, 0.2 mg/kg IN/IM IN administration max 1 mL per nare Maximum total dose 5 mg
Additional doses up to a maximum total dose 5 mg require medical consultation for all providers.
For life-threatening conditions, consider IO administration of midazolam.
If suspected severe nerve agent exposure, providers may administer midazolam as above without medical consultation.
Chemical Restraint
Not indicated
Bucking Endotracheal Intubated patient (NEW ’17)
Administer 0.05 mg/kg SLOW IVP over 1–2 minutes, while maintaining systolic BP greater than 60 in neonates, 70 in infants, [70 + (2 x years) = systolic BP] for patients greater than 1 year of age. Maximum total dose 5 mg.
ADMINISTER UP TO 0.05 MG/KG IV WHEN TREATING ENDOTRACHEAL TUBE BUCKING, STOPPING ONCE BUCKING HAS RESOLVED AND VENTILATION IS RELAXED.
Excited Delirium Syndrome (ExDS)
Administer midazolam 0.1 mg/kg in 2 mg increments (SLOW IV/IO push over 1–2 minutes) with a maximal single dose of 2 mg.
If IV/IO unavailable or unsafe to obtain, administer 2 mg increments IN (1 ml per nare)
If IV/IO/IN administration routes are not possible, administer 2 mg IM.
Multiple doses may be required to achieve therapeutic effect with a maximum total dose of 5 mg. Additional doses require medical consultation via a medical consult center.

MORPHINE SULFATE

Adult Dose
IV/IM
Administer 0.1 mg/kg to a maximum initial dose of 20 mg.
Reassess in 5–10 minutes. If pain remains moderate to severe, then administer a second dose of morphine 0.05 mg/kg to a maximum additional dose of 10 mg.
Obtain on-line medical direction for additional doses, if required.

Pediatric Dose
IV/IM
Administer 0.1 mg/kg to a maximum initial dose of 20 mg.
Reassess in 5–10 minutes. If pain remains moderate to severe, then administer a second dose of morphine 0.05 mg/kg to a maximum additional dose of 10 mg.
Obtain on-line medical direction for additional doses, if required.

NALOXONE (NARCAN)

Adult Dose
Administer 0.4–2 mg IVP/IO (titrated)/IM/IN (if delivery device is available, divide administration of the dose equally between the nares to a maximum of 1 mL per nare); repeat as necessary to maintain respiratory activity.

Pediatric Dose
Administer 0.1 mg/kg IVP/IO (titrated)IM/IN (if delivery device is available, divide administration of the dose equally between the nares to a maximum of 1 mL per nare), up to maximum initial dose of 2 mg; may be repeated as necessary to maintain respiratory activity. ET dose: 0.2–0.25 mg/kg

NITROGLYCERIN

Adult Dose
Chest pain If patient has a prescription or previous history of nitroglycerin use, administer nitroglycerin: 0.4 mg SL (may repeat dose 2 times at 3–5 minute intervals) May be repeated if symptoms persist, BP is greater than 90 mmHg, and pulse is greater than 60 bpm, to a maximum dose of 1.2 mg
If patient does not have a prescription or previous history of nitroglycerin use, establish IV prior to the administration of nitroglycerin, then adminis- ter nitroglycerin as above.
Additional doses may be administered with medical consultation.
Pulmonary Edema/Congestive Heart Failure
Low dose - Administer 0.4 mg SL at 3–5 minute intervals to a maximum dose of 1.2 mg.
High dose - (until CPAP is applied or if CPAP is not tolerated)
Administer 1 dose of 0.4 mg SL and apply 1 inch of NTG paste.
Administer 1 dose of 0.8 mg SL.
Continue 0.8 mg NTG dosing to achieve a 20% reduction in systolic blood pressure.

Pediatric Dose
Requires medical consultation from Pediatric Base Station.

NITROGLYCERIN PASTE

Adult Dose
1 inch of the NTG paste is applied. Measuring applicators are supplied.

Pediatric Dose
Requires medical consultation from Pediatric Base Station.

ONDANSETRON (ZOFRAN)

Adult Dose
8 mg SLOW IV over 2–5 minutes OR 4-8 mg IM OR 8 mg orally disintegrating tablet (ODT)
May repeat once without medical consultation.
For third repeat dose to a patient with maximum total dose of 24 mg.

Pediatric Dose
Patients 28 days to 12 years old: 0.1 mg/kg SLOW IV over 2–5 minutes
Patients who are 13 to 18 years old: 8 mg ODT OR 8 mg SLOW IV over 2–5 minutes
OR
If no IV: 0.1 mg/kg IM (with max single dose of 8 mg); May repeat once without medical consultation.
For third repeat dose to a patient with maximum total dose of 0.3 mg/kg or 24 mg, whichever is lower.

OXYGEN

Adult Dose
Administer 12–15 lpm via NRB mask or 2–6 lpm via nasal cannula, as needed. CO exposure: Administer 100% oxygen via NRB mask. Maintain SpO2 at 100%

Pediatric Dose
Administer 12–15 lpm via NRB mask or 2-6 lpm via nasal cannula, as needed. CO exposure: Administer 100% oxygen via NRB mask. Maintain SpO2 at 100%

SODIUM BICARBONATE

Adult Dose
Should only be given after airway has been secured and ventilations achieved
Administer 1 mEq/kg IVP bolus initially with 0.5 mEq/kg at 10-minute intervals.
Hyperkalemia (Reserve for patients with suspected CRUSH SYNDROME or patients with functional kidneys by history.)
FLUSH IV WITH 5 ML OF LR BETWEEN CALCIUM AND BICARBONATE ADMINISTRATION.
Consider sodium bicarbonate 50 mEq SLOW over 5 minutes and then initiate drip of sodium bicarbonate 100 mEq in 1,000 mL LR to run over 30–60 minutes.
IV drip for diuresis prior to receiving IV contrast dye: Continue the sodium bicarbonate drip at the rate ordered by the sending physician. Document the base solution and the amount of sodium bicarbon- ate that was added to the solution and the total volume infused.

Do not administer IVP medications through the same IV line as the bicarbonate drip unless compatibility has been established. Flush the line well before and after giving any IVP medication.

Pediatric Dose
Should only be given after airway has been secured and ventilations achieved
Administer 1 mEq/kg IVP/IO; for patients less than 1 year of age, must be diluted (1:1) with LR.
Hyperkalemia (Reserve for patients with suspected CRUSH SYNDROME or patients with functional kidneys by history.)
FLUSH IV WITH 5 ML OF LR BETWEEN CALCIUM AND BICARBONATE ADMINISTRATION.
Consider sodium bicarbonate 1 mEq/kg IV over 5 minutes. For patients less than 1 year of age, must be diluted 1:1 with LR.
IV drip for diuresis prior to receiving IV contrast dye: Continue the sodium bicarbonate drip at the rate ordered by the sending physician. Document the base solution and the amount of sodium bicarbon- ate that was added to the solution and the total volume infused.

Do not administer IVP medications through the same IV line as the bicarbon- ate drip unless compatibility has been established. Flush the line well before and after giving any IVP medication.

TRANEXAMIC ACID (TXA)

Adult/Pediatric Dose
For patients 15 years of age and older: Administer 1 gram in 100 mL approved diluent (normal saline/Lactated Ringer’s/D5W) IV/IO over 10 minutes

TERBUTALINE

Adult Dose
Patients 12 years of age and older:
Administer 0.25 mg IM. May repeat one time after 15 minutes if there is not adequate improvement. Maximum total dose 0.5 mg IM.

Pediatric Dose
Patients less than 12 years of age: Not indicated

VERAPAMIL (ISOPTIN®)

Adult Dose
2.5–10 mg slow IV over 2 minutes;
if response is not adequate, repeat in 15 minutes with a dosage of 2.5–10 mg slow IV over 2 minutes with medical consultation.

Pediatric Dose
Contraindicated for patients less than 18 years of age.

-- Pilot Protocol --

Adult / Pediatric Dose

** Pilot Protocol – LOW TITER O+ WHOLE BLOOD (LTO+ WB) TRANSFUSION

Age-defined
Evidence of significant physiologic compromise: Age-defined hypotension* PLUS at least one of the following:
• Age-defined tachycardia**
• ETCO2 less than 25
• Positive eFAST exam (if available)
• Lactate greater than 4 (if available)
• Capillary reperfusion greater than 3 sec
• Altered sensorium thought not secondary to intoxication or head trauma
• Witnessed PEA cardiac arrest less than 5 min duration
Pilot Protocol: Low Titer O+ Whole Blood (LTO+ WB) Transfusion 14.6

*Age-Defined Hypotension **Age-Defined Tachycardia
Ages less than 10 Yrs: systolic BP less than [70 + 2 x years)]
Age 1 year: greater than 190
Ages 10-65: systolic BP less than 90 Ages 2-4 yrs: greater than 140
Ages greater than 65: systolic BP less than 100 Ages 5-12 yrs: greater than 140
Any age: absent radial pulses Ages greater than 12 years: 120

On-line medical direction required for patients under 1 year of age.

Pediatric Dose
On-line medical direction required for patients under 1 year of age.

** Pilot Protocol – INTRAVENOUS NITROGLYCERIN FOR SEVERE CHF (Paramedic Only)

Adult
a) While IV nitroglycerin may be started by paramedics without medical direction, online medical consultation must be obtained for any patient treated using this protocol at the earliest possible opportunity.

b) IV Bolus
(1) Use a 25mg/250ml vial (100 mcg/mL), OR a high dose vial which has been diluted to 100 mcg/mL in D5W or normal saline
(2) Administer 400 mcg (.8 ml [25mg/250ml]) SLOW IV every 5 minutes, titrated to achieve a 20% reduction in SBP
(3) Medical consultation required for further administration beyond 2 separate dosages of IV bolus nitroglycerin

c) IV Infusion pump
(1) Only for use in EMSOPs approved for IV infusion pump OSP
(2) Start at 40 mcg/min, increase rate by 5 mcg/min every 5 minutes, to achieve a 20% reduction in SBP; maximum rate of 80 mcg/min.
(3) If SBP decreases by more than 20%, reduce infusion rate by 5 mcg/min every 5 minutes until goal SBP is attained.

Pediatric Dose
Contraindicated for patients less than 18 years of age