REMS Protocols

ASA-162mg, NTG-.4mg, 3x/20mins, MS 2-5mg increments,⇑ 10 max. BHO: Lidocaine 1-1.5mg/kg for escalating ventricular ectopy, or more than 10mg MS

Atropine- .5mg q 3-5mins up to .04mg/kg, TCP @ 70ppm, ↑ by 20mA intervals, ↓ by 5mA, ↑ by 10ppm to ⇑ 100ppm. Versed – 2mg IV/IO/NT for amnesia prior to TCP. BHO: Adult IO. Consider causes: Poisoning/Overdose.

Unstable: HR>150, ALOC, ↓BP, Versed – 2mg IV/IO/IN for amnesia. Sync @ 50, 100, 150, 200J.
Stable: HR<150 w/ s/s, or >150 w/o s/s – Valsalva, BHO: Adenosine 12mg w/10-20ml NS bolus, 12mg w/10-20ml NS bolus, Verapamil 2.5-5mg over 2-3mins (longer for older Pts) q 15-30mins, repeat @ 2x dose, ⇑ 10mg. (20mg)

Unstable: s/s and HR>150. Versed 2mg IV/IO/IN. Sync @ 100, 120, 150, 200J. Post conversion to RSR, Lidocaine 1-1.5mg/kg.
Stable (borderline): HR<150 w/symptomatic or asymptomatic; 12L EKG & BHC. BHO: Amiodarone 150mg IV over 10mins, Lidocaine 1-1.5mg/kg (may repeat q 5-10mins at ½ initial dose, ⇑ 3mg/kg. Pts refractory to lidocaine = probable SVT. See BHO for adenosine.

CPR (1-2 mins), Defib @ 120, CPR (if hypothermic, no more than 3 shocks) intubate, IV with d-stick, Epi 1mg repeat q 3-5mins, CPR for min of 30 secs, Defib @ 150J, CPR (1-2 mins), Amiodarone 300mg w/CPR for 30 secs, Defib @ 200J, CPR (1-2 mins), Epi 1mg, Defib @ 200J, Amiodarone 150mg w/CPR for 30 secs, Defib @ 200J. BHO: Sodium Bicarbonate 1mEq/kg IV

Check in two leads, CPR, Intubate, IV, consider causes. Epi 1mg q 3-5mins, Atropine 1mg q 3-5mins ⇑ .04mg/kg. BHO: Sodium Bicarbonate 1mEq/kg IV for hyperkalemia/acidosis.

CPR, Intubate, IV (2) Lg bore, consider causes. Epi 1mg q 3-5mins ⇑ .04mg/kg if HR<60, BHO: Sodium Bicarbonate 1mEq/kg IV for hyperkalemia.

Ventilate, Check pulse/pupils, BLS, intubate, treat rhythms as appropriate. NT intubation is contraindicated.

O2, Monitor, Albuterol 2.5-5mg (3-6cc NS) repeat PRN, IV, Ipratropium .5mg w/Albuterol 2.5 BHO: req. for further meds/trx. Repeat of Ipratropium/Albuterol trx. Pts.< 40yo Epi (1:1) .01mg/kg SC, ⇑ .5mg/dose. Use caution w/CAD or HTN.

2 cycles of BLS, direct laryngoscopy, if unsuccessful prepare for needle cricothyrotomy as Pt. is being loaded for trans, IV Lg bore.

Position upright, NTG .4mg SL only if BP >100 q 5mins ⇑ 3x/20mins. BHO: MS 2-5mg increments slow IV if BP >100. Lasix 20-80mg IV over 3-5min if Pt is using diuretic, ½ of usual daily dose.

Stop burning process (chem/tar/thermal), check airway, O2, IV – (kg)(%BSA 2°& 3°)/4 =ml/hr. Burns < 20% BSA use wet dressing, > 20% use dry dressing. MS 2-5mg increments if BP >100, ⇑ 10mg. BHO: for additional amts of MS, compromised airway go to closes fac. ARMC for burns >20% (2°& 3°), at discret.

Heat Cramps/Exhaustion: Cooling measures, IV (fluid bolus of 250cc, if BP <90
Heat Stroke: Cooling measures, IV (fluid bolus of 250cc, if BP <90). Trx ALOC, Seizures – Versed 2mg slow IV/IO, 1mg increments, ⇑ 5mg, or 2mg IN (appropriate conc.?), 5mg IM. BHO: for additional amounts Versed.

Warming measures, O2, Intubate only if apneic (spontaneous ventilations at 4-6 per min are a sufficient), ECG observe for 1 min (only defib 3x until warm), Supine, move gently, warm IV fluids. Frostbite – warm with blankets but do not rub affected areas, do not allow to refreeze. BHO: MS 2-5mg increments, ⇑ 10mg.

Mild-Moderate: (rash/wheezing) – remove allergen (may apply cold pack to site), O2, Albuterol 2.5mg in 3cc, Benadryl 25-50mg IV-IM, Epi .01mg/kg (1:1) SC, ⇑ .5mg. Severe (low BP, oral swelling, dyspnea, ALOC, chest pain): remove allergen, O2, monitor, Epi .01mg/kg (1:1) SC, ⇑ .5mg. 2 Lg bore IV. Benadryl 25-50mg IV-IM, Albuterol 2.5mg in 3cc. BHO: Epi .1mg (1:10) IV if BP < 80 & dyspnea. May repeat q 1-2 min and no relief. Dopamine 5-20 mcg/kg/min IVPB.

Hypoglycemia - O2, monitor, IV w/d-stick, if BS < 80mg/dL dive DW50 - 25Gms, may repeat once. Or Glucagon 1mg IM/SC.
DKA – Fluid challenge 250cc, reassess, cautious of BP.

Supine/Trendelenberg (if pregnant > 6 months = L-lateral , O2, Monitor, IV, assess lungs and give fluid bolus 250cc, ⇑ 2L. BHO: Dopamine 5-20mcg/kg/min IVPB for cardiogenic or anaphylactic shock.

O2, IV (fluid bolus of 250cc, if BP <90), DW50 – 25Gms IV, or Glucagon 1mg IM/SC. Narcan 1-2mg IV/IO/IN/IM? 2-4mg ET (total down tube?), may repeat in 2mg increments, IV/IO ⇑ 10mg.

If BS < 80mg/dL give DW50 – 25Gms, may repeat once. Or Glucagon 1mg IM/SC.

Versed 2mg slow IV/IO, 1mg increments, ⇑ 5mg. If BS < 80mg/dL give DW50 – 25Gms, may repeat once. Or Glucagon 1mg IM/SC. Narcan 1-2mg IV/IO/IN/IM 2-4mg ET, may repeat in 2mg increments, IV/IO ⇑ 10mg.

HTN and edema cause ES. If actively seizing or multiple seizure activity contact BH. Position L/lateral. BHO: Magnesium Sulfate 4Gm in 50cc, infuse over 5min.

Wrapped cord- if around baby neck, try to unwrap cord over baby head. If not possible, double clamp cord and cut cord. Once cord has stopped pulsating, cut 6-8 inches from newborn.
Breech presentation – If buttock is delivered first use hand to prevent explosive delivery, When legs and buttock are delivered the head can be assisted out. If head does not deliver in 4-6mins, insert sterile glove and create space.
Prolapsed cord – Use knee cheat post, and insert gloved hand and push presenting part off cord, cover exposed cord w/gauze.

β-blocker: If BP < 90 or HR < 60 w/ s/s. Atropine .5mg IV/IO q 3-5min ⇑ .04mg/kg. Albuterol 2.5mg. Versed 2mg IV/IO/IN, 1mg increments, ⇑ 5mg, 5mg IM. BHO: Charcoal 25-50Gms PO, Glucagon 1mg IV/IO/IM/SC.
Ca 2+ channel blocker: If BP < 90 or HR < 60 w/ s/s. Atropine .5mg IV/IO q 3-5min ⇑ .04mg/kg
BHO: Charcoal 25-50Gms PO, Glucagon 1mg IV/IO/IM/SC.

If in eyes, flush for 20mins. BHO: Water or milk PO if orally ingested and Pt is awake w/gag. Fluid resuscitation for burns.

Hyperventilate. If seizure activity - Versed 2mg IV/IO/IN, 1mg increments, ⇑ 5mg, 5mg IM. Give fluid w/caution. BHO: Sodium Bicarbonate 1mEq/kg for dysrhythmia, ALOC, or QRS widens, repeat PRN ⇑ 2mEq/kg. Charcoal 50-100Gms PO, early administration. Caution with NS boluses due to Pul-Edema because of overdose.

Narcan 1-2mg IV/IO/IN/IM 2-4mg ET, may repeat in 2mg increments, IV/IO ⇑ 10mg.
BHO: Charcoal 25-50Gms PO if ingested orally.

Atropine 2-5mg slow IV or 2mg IM or 4mg ET, repeat q 3mins PRN. Versed 2mg IV/IO/IN, 1mg increments, ⇑ 5mg, 5mg IM. BHO: Charcoal 25-50Gms PO if ingested orally.

Benadryl 25-50mg IV/IM titrated to s/s relief.

CPR, Monitor, Secure airway, 2 Lg bore IV – NS ⇑ 2L under pressure, May initiate Adult IO. Blunt trauma goes to nearest. Penetrating = trauma center if ETA is < 10mins. Needle thoracostomy if indicated.

Secure airway, C-spine, 2 Lg bore IV (fluid bolus of 250cc, if BP < 90) ⇑ 2L. Needle thoracostomy if indicated.

Secure airway, C-spine, 2 Lg bore IV (fluid bolus of 250cc, if BP < 90) ⇑ 2L. Impaled = immobilize, Eviscerating/Genital = sterile dressings on organs. BHO: MS 2-5mg increments, ⇑ 10mg, if BP >100.

Secure airway, C-spine, 2 Lg bore IV (fluid bolus of 250cc, if BP < 90) ⇑ 2L. Impaled, Flail, Open, Cardiac Tamp, Cardiac Contusion. BHO: MS 2-5mg increments, ⇑ 10mg, if BP > 100

Secure airway, C-spine, Dress & splint. Isolated, non-multi-system. MS 2-5mg increments, ⇑ 10mg, if BP > 100.

Secure airway, C-spine, 2 Lg bore IV (fluid bolus of 250cc, if BP <90) ⇑ 2L BHO: MS 2-5mg increments, ⇑ 10mg, if BP > 100.

CPR if HR< 80 for infant, HR< 60 for 1yo or older (NS bolus of 20ml/kg), Epi .01mg/kg (1:10) IV/IO OR .1mg/kg (1:1) ET q 3-5mins. BHO: Atropine .02mg/kg OR .04mg/kg ET, ⇓.1mg, ⇑ .5mg.

ST - Fluid bolus @ 20ml/kg.
SVT – BHO: Valsalva (ice H20 to face), Adenosine .1mg/kg, ⇑ 6mg, may repeat in 3mins @ .2mg/kg ⇑ 12mg. Sync @ .5, 1, 1J/kg for children < 10kg.

BHO: Lidocaine – 1mg/kg or 2mg/kg ET, ⇑ 3mg/kg IV, or 6mg/kg ET. Sync @ .5, 1, 1J/kg for children < 10kg

CPR, defib @ 2J/kg, intubate (Pts age)+(16)/4 = ET size. Transport. Epi .01mg/kg (1:10) IV/IO or .1mg/kg (1:1) ET, defib @ 4J/kg, Lidocaine 1mg/kg IV/IO or 2mg/kg ET, defib @ 4J/kg. Repeat Epi and Lido rounds.

CPR, intubate (Pts age)+(16)/4 = ET size, transport, Epi .01mg/kg (1:10) or .1mg/kg (1:1) ET, BHO: Atropine .02mg/kg or .04mg/kg ET, min of .1mg, ⇑ .5mg. Declaration of death q 10mins of intubation & 2 rounds of ACLS meds & no reversible causes identified.

CPR, intubate (Pts age)+(16)/4 = ET size, transport, Epi .01mg/kg (1:10) or .1mg/kg (1:1) ET, fluid bolus @ 20ml/kg, consider causes.

Open airway, ventilate, check pulse/pupils, watch monitor, Intubate, Narcan .1mg/kg IV/IO/IN, ⇑ 2mg (.5mg ⇑ per nostril). If caregiver states Pt. stopped breathing w/hx of apparent respiratory disease/infection. Pt had “ALTE”, and should be transported for further evaluation.

Epiglottis – Keep Pt calm, do not attempt to visualize airway, position Pt upright, if complete/near complete = ventilate, and intubate. Pts 3-6yrs, shallow breathing, inspiratory stridor, drooling, tripod positioning, high fever, sore throat/swallowing.
Asthma/Croup/Bronchiolitis: Asthma: hx of, wheezes, unproductive cough. Bronchiolitis: Pts < 1yr, prominent expiratory wheezes. Croup: Fall & Winter, hx of mild cough/infection, Pts 6months – 4yrs, harsh barking, inspiratory stridor. Albuterol 2.5mg in 3cc NS, Neb. Saline for Croup. BHO: Asthma – Epi .01mg/kg of (1:1) SC for Pts >1yo, ⇑ .5mg, may repeat once. Ipratropium .5mg in 2.5cc w/ albuterol 5mg in 6cc. Reasses need to contine after 1/2 dose given.

Combitube if >16yrs & 4.5 ft tall. If complete obstruction & > 8yrs old, prepare for needle cricothyrotomy.

Stop burning Pt, O2, Intubate, (kg)(%BSA 2°& 3°)/4 =cc/hr. Dress thermal burns w/dry dressings after cooled. MS .1mg/kg for pain.

Active cooling measures, O2, 20ml/kg NS bolus, Versed .1mg/kg IV/IO/IN (Do not exceed max per nostril) for Sz >10mins (increase in 1mg increments ⇑5mg). .2mg/kg IM ⇑ of 5mg.

Warming measures, O2, Intubate only if Pt apneic (4-6 ventilations/min). Only defib 3x if necessary. Warm IV fluid. Frostbite – warm w/blankets, no not rub affected area. BHO: MS .1mg/kg.

Remove allergen, apply ice indirectly to site, O2, Monitor
Mild-Moderate – Albuterol 2.5mg in 3cc NS, Epi .01mg/kg of (1:1) SC, ⇑ .3mg, repeat q 20mins. Benadryl 1mg/kg IV/IM, ⇑ 50mg. Severe – Epi .01mg/kg of (1:1) SC, ⇑ .3mg, repeat q 20mins. Benadryl 1mg/kg IV/IM, ⇑ 50mg. Albuterol 2.5mg in 3cc NS. BHO: .01mg/kg (1:10) IV/IO, ⇑ .1mg q 5min. If ET only .1mg/kg (1:1).

Secure airway, O2, Monitor, Two lg bore IV – 20ml/kg NS bolus. Consider causes (Cardio, Hypoxia, Hypovol, Anaphax, OD) BHO: Dopamine 2-20mcg/kg/min

Hypoglycemia – O2, Monitor, IV w/d-stick, if BS <80mg/dL give DW50 – 1ml/kg if Pt >2yo. If Pt < 2yo give DW25 – 2ml/kg, or Glucagon .03mg/kg to a max of 1mg IM/SC
DKA – Fluid bolus 20ml/kg

AEIOUTIPS, trx  hypoglycemia - DW50  1ml/kg for Pts > 2yrs if BS < 60mg/dL. DW25  2ml/kg for Pts < 2 yrs is BS < 60mg/dL. Shock – 20ml/kg NS fluid bolus, OD –Narcan .1mg/kg IV/IN/IO , or ET, w/⇑ 2mg (1mg IN, can not repeat does IN) Sz - Versed.

Cooling measures, Trx hypoglycemia (see above), Versed - .1mg/kg IV/IO/IN for Sz > 10min (increase in 1mg increments, ⇑ 5mg), .2mg/kg IM w/⇑ of 5mg.

Meconium – use ETT to suction airway, mouth then nose, If HR 60-100  O2 via mask, q 30sec HR< 100, BVM @ 40-60 vent/min. If HR< 60, BVM @ 40-60 vent/min, if no change CPR 3:1 @120bpm, Intubate, Epi .01mg/kg (1:10) IV or .03mg/kg (1:10) ET if HR< 80.

Trx Sz (usually short lived w/cyclic OD, give fluid cautiously). Versed - .1mg/kg IV/IO/IN for Sz > 10min (increase in 1mg increments, ⇑ 5mg), .2mg/kg IM w/⇑ 5mg. BHO: Sodium Bicarbonate 1mEq/kg slow IV/IO for ST & ALOC, ⇑ 2mEq/kg. Charcoal 1Gm/kg if Pt has gag, ⇑ 50Gms.

Narcan .1mg/kg IV/IO/IN, ⇑ single dose 2mg, ⇑ 1mg IN, can not repeat dose IN. Repeat q 5mins. BHO: Charcoal 1Gm/kg if Pt has gag, ⇑ 50Gms.

Atropine - .05mg/kg IV/IO/IM ⇓ of .1mg. Versed - .1mg/kg IV/IO/IN for Sz > 10min (increase in 1mg increments, ⇑ 5mg), .2mg/kg IM w/⇑ 5mg. BHO: Charcoal 1Gm/kg if Pt has gag, ⇑ 50Gms.

Benadryl 1mg/kg IV or IM, ⇑ 50mg titrate to s/s.

CPR, Monitor, Secure Airway, C-spine, transport, Blunt = closes facility, Penetrating = trauma if ETA under 10mins, if not then go to closest. O2, IV/IO (20ml/kg), Needle thoracostomy. BHO: Declaration of Death if criteria is meet.

Secure airway, C-spine, Control bleeding, Transport, IV/IO (20ml/kg), trx possible ALOC, Needle thoracostomy.

Secure airway, C-spine, O2, IV/IO, Consideration: Impaled, Eviscerating, Genital, confirm BS level. BHO: MS .1mg/kg slow.

Secure airway, C-spine, O2, Transport, Consider: Impaled, Flail, Open Chest wound, Cardiac Tamponade, Cardiac contusion. Confirm BS level, Needle thoracostomy. BHO: MS .1mg/kg slow.

Secure airway, C-spine, O2, Dress & splint, IV/IO, Confirm BS level, MS .1mg/kg slow.

Secure airway, C-spine, O2, Position (if brain injured, reverse trendelenburg 15-20°, if Pt exhibits no signs of shock) Considerations: Avulsed tooth, Eye injury, Impaled object. BHO: MS .1mg/kg

5ml per nostril for Pts < 10yrs, 1ml per nostril for adults. (Versed 5mg/ml, Narcan 1mg/ml)

Indications: Unconcious peds, adult full arrest, adult MLA w/2 failed IV attempts, (No/extreme caution on neonates, frx of target site/infection), only 1 attempt can be made on ped w/o then contacting BH. Proximal tibia preferred, BH for distal tibia, and distal femur 90 w/twisting, after LOR advance 1-2mm, attach syringe with 5-10ml of saline. QA form.

At least 16yo & 4.5ft, after 2 missed ET attempt.

< 14yrs (15yrs), > 30kg (= 31kg), only one attempt per nostril, no longer than 1 min during attempt.

Indications: Unconcious & unresponsive, > 8yrs, & complete upper airway obstruction (no movement of air) (FBAO, isolated trauma to neck or face, edema due to anaphylactic/inflammation, tumor). 10g curved needle, cricothyroid membrane then distal 3cm (1-1.25incehs), 45°, aspirate for free air return (if resistance, esophagus b/c soft muscle is collapsing upon suction of needle). After ventilating, assist exhalation by taking BVM off and squeezing ribs. QA form

tension pneumothorax, can be performed prior to contact on both adult & pediatric, Becks triad (tracheal deviation away from affected sides, distant lung sounds, ), QA form.

> 12yo, 70ppm, increase by 20mA, decrease by 5mA, increase by 5mA. If low BP & ALOC you can increase by 10ppm to ⇑ 100ppm