Charleston County Clinical Operating Guidelines: Adult & Pediatric

Charleston County
Clinical Operating Guidelines

Adult & Pediatric
As Effective:
June 1, 2021
Medical Directors’ Preface to Clinical Operating Guidelines
EMS operates on the basis of enabling legislation called the “Emergency Services Act of
South Carolina”. The South Carolina Department of Health and Environmental Control (DHEC)
administers the Act under Regulation 61-7. These contain stipulations regarding Medical
Control and Standing Orders which have the force of law. An EMS agency, its Medical Control
Physicians and its EMTs cannot deviate from these binding regulations.
Section 200.V: Medical Control

Medical control is usually provided by a licensed agency’s physician who is
responsible for the care of the patient by the provider’s medical attendants.
Actual medical control may be direct by two-way voice communication (on-line)
or indirect by standing orders or protocols (off-line) control.
Section 200.V.1: Off-Line Medical Control Physician

A provider’s medical control physician who actually takes responsibility for
treatment of patients in the prehospital setting, by standing orders, protocols, or
patient care guidelines.
Section 200.V.2: On-Line Medical Control Physician

The physician who directly communicates with EMTs regarding appropriate
patient care procedures en-route or on-scene. An on-line Medical Control
Physician must be available for all EMTs performing procedures designated by
the Department.
Section 1100.B: “Misconduct” constituting grounds for revocation or suspension or

other restriction of a certificate means while holding a certificate, the holder:
6. Disregarded an appropriate order by a physician concerning emergency
treatment and transportation.
It is clear that both South Carolina law and DHEC regulations place great responsibility on the
Medical Control Physicians who provide orders and on the EMTs who execute their
instructions.
The primary source of Medical Control is direct on-line communication between the EMT and a
physician while care of a patient is actually being provided. Standing Orders are to be used
when the patient needs immediate treatment and cannot tolerate the delay required to obtain
on-line medical control. In these cases, direct on-line medical control will be obtained as soon
as possible. Standing Orders are not a substitute for direct on-line medical control.
Your Medical Directors have devoted great effort to ensure that these Standing Orders are
based on authoritative information and the consensus of both local and national authorities on
prehospital care. Some variation between EMS systems based on local customs and
perspectives should be expected.
It is not possible to write protocols that address every clinical situation. Every patient
encounter is unique. Patients seldom present in textbook fashion. A patient’s condition is not
static and may change from moment to moment. The environment in which the medic renders
care is highly variable and may change abruptly and without warning. Protocols must
sometimes be adapted to the demands of unusual situations. In situations where standard
operating procedure does not seem adequate or appropriate, contact one of the Medical
Directors or the receiving hospital for on-line medical control.
Under most circumstances, these protocols should be followed as written and in order. In
some cases, performing steps simultaneously or in a different order may be justified.
Sometimes protocols must be adapted in unusual circumstances before on-line medical
control can be obtained. If these protocols cannot be followed as written, then documentation
must explain in a defensible way why it was necessary to deviate from the protocols.
We want to help you any time 24-7 that you need us. With rare exceptions, one of us is
immediately available to you by phone. Whenever special cases cause uncertainty or
concern, please contact one of us for help.
Guideline Format
It is increasingly common for multiple responders to participate in the emergency care of a
single patient. These responders may have various levels of certification. They may come
from different agencies. They may arrive on the scene at different times.
Smooth, seamless, and efficient care is best achieved when there is a common action plan
shared by all responders. Best outcomes for the patient are achieved when cooperation,
professionalism and teamwork prevail.
Your Medical Directors are working with the Medical Directors of other agencies to develop
common protocols so that the same action plan will take effect no matter who arrives at a
scene first and everyone will know in advance how to make a meaningful contribution to
achieving the desired objectives in an orderly fashion.
These Standing Orders have been formatted so that caregivers at each level of certification
can immediately identify the components of the Standing Order which are appropriate to them.
In this way, first arriving responders can contribute to the timely execution of the order in an
organized and efficient manner.
Authorized Agencies
These guidelines are designed to be utilized by Charleston County EMS, Charleston County
Fire Departments, and other DHEC EMS licensed agencies within Charleston County. The
following agencies are authorized to utilize these standing orders to their appropriate agency
and provider level of service:
Charleston County EMS - ALS/Paramedic

Mount Pleasant Fire Department - ALS/Paramedic
James Island Fire Department - BLS/EMT

North Charleston Fire Department - BLS/EMT
Saint Andrews Fire Department - BLS/EMT
Version 06.01.2021
General
Adult
Pediatric
Pandemic
Procedures
Medication Formulary
Reference Sheets
General Guidelines
General Universal Patient Care 9/1/2017
General Assessment 9/1/2019
General Field Trauma Triage 5/1/2020
General Vascular Access 9/1/2017
General Cardiac Arrest: BLS 11/25/2020
General Fire Rehab 4/1/2021

Adult
Adult Only Guidelines (≥12 years OR longer than length-based tape)
Airway Universal Airway 11/24/2020
Airway Drug Assisted Intubation 11/24/2020
Airway Post Airway Management 11/24/2020
Airway Failed Airway 11/24/2020
Airway Respiratory Distress 9/1/2018
Cardiac Bradycardia 10/1/2018
Cardiac Tachycardia (Narrow Complex) 10/1/2018
Cardiac Tachycardia (Wide Complex) 10/1/2018
Cardiac Cardiac Arrest: Team Approach 11/1/2017
Cardiac Cardiac Arrest: ALS Rhythms 11/1/2017
Cardiac Post Resuscitation 11/1/2017
Cardiac Chest Pain: Cardiac and STEMI 10/1/2018
Cardiac CHF/Pulmonary Edema 10/1/2018
Cardiac LVAD 11/24/2020

Adult Continued
Adult Only Guidelines (≥12 years OR longer than length-based tape)
Medical Allergic Reaction 11/24/2020
Medical Altered Mental Status 11/24/2020
Medical Behavioral Emergencies 4/28/2021
Medical Fever/Infection/Suspected Sepsis 11/24/2020
Medical Nausea/Vomiting 11/24/2020
Medical Overdose/Toxic Ingestion 3/1/2019
Medical Pain Control 3/1/2019
Medical Psychiatric Evaluation 9/1/2018
Medical Seizure or Post Ictal State 11/24/2020
Medical Suspected Stroke 3/1/2019
Medical Symptomatic Hypotension 11/24/2020
Trauma Burns 11/24/2020
Trauma Open Fracture Antibiotic: Cefazolin 2/1/2020
Trauma Traumatic Cardiac Arrest 11/1/2017
Trauma Trauma Patients with Life Threatening Injuries 11/26/2020
Environmental Carbon Monoxide 10/1/2018
Environmental Hydroflouric Acid Exposure 11/24/2020

Pediatric
Pediatric Only Guidelines (<12 years OR fits on length-based tape)
Airway Universal Airway 11/25/2020
Airway Post Airway Management 11/25/2020
Airway Failed Airway 11/25/2020
Airway Respiratory Distress 9/1/2018
Medical Allergic Reaction 11/25/2020
Medical Altered Mental Status 11/25/2020
Medical Fever/Infection/Suspected Sepsis 11/25/2020
Medical Nausea/Vomiting 11/25/2020
Medical Overdose/Toxic Ingestion 11/25/2020
Medical Pain Control 11/25/2020
Medical Seizure of Post Ictal State 11/25/2020
Medical Symptomatic Hypotension 11/25/2020
Cardiac Bradycardia 11/25/2020
Cardiac Tachycardia 11/25/2020
Cardiac Cardiac Arrest: Team Approach 11/1/2017
Cardiac Cardiac Arrest: ALS Rhythms 11/1/2017
Cardiac LVAD 11/25/2020
Trauma Burns 11/25/2020
Trauma Open Fracture Antibiotic: Cefazolin 2/1/2020
Trauma Trauma Patients with Life Threatening Injuries 11/27/2020
Environmental Carbon Monoxide/Cyanide 11/24/2020

Pandemic
Pandemic Patient Care 3/1/2020
Pandemic Adult Respiratory 3/1/2020
Pandemic Pediatric Respiratory 4/1/2020
Pandemic Cardiac Arrest 4/1/2020
Pandemic Opioid Overdose 4/1/2020
Pandemic Telehealth 3/1/2020

Procedures
Skills
Airway CPAP 11/1/2017
Behavioral Physical Restraint 2/1/2020
Cardiac Cardiac: 12-Lead 10/1/2018
Cardiac Cardiac: EMS Code STEMI - Cath Lab Activation 10/1/2018
Cardiac Cardiac: External Pacing 10/1/2018
Cardiac Cardiac: Synchronized Cardioversion 4/1/2020
Cardiac Mechanical CPR: Lucas 3 3/1/2020
Trauma Pelvic: T-Pod 2/1/2020
Trauma Patella Dislocation Reduction 11/25/2020
Trauma Taser Barb Removal 11/25/2020
Trauma Spinal Motion Restriction, Adult 11/25/2020
Trauma Spinal Motion Restriction, Pediatric 11/25/2020
Venous Access Venous Access: Existing Catheters 9/1/2017
Venous Access Venous Access: External Jugular 9/1/2017
Venous Access Venous Access: Extremity 9/1/2017
Venous Access Venous Access: Intraosseous 9/1/2017

Procedures
Medical Operations Procedures
Cardiac Criteria for Death/Withholding Resuscitation 9/1/2017
Cardiac Death Communication with Family 9/1/2017
Cardiac Discontinuation of Prehospital Resuscitation 9/1/2017
Cardiac DNR, POST, and Advance Directives 9/1/2017
Cardiac Resuscitation Discontinuation Checklist 2018-10
Cardiac Resuscitation Time / Intervention Log 2018-10
Procedures
Standard Procedures
Documentation Patient Categories 11/25/2020
Documentation Dispostions 11/25/2020
Legal Duty to Act 11/25/2020

Acetaminophen
Adenosine
Albuterol Sulfate
Amiodarone
Aspirin
Atropine Sulfate
Calcium Gluconate
Cefazolin
10% Dextrose
Diltiazem
Diphenhydramine
Epinephrine
Etomidate
Fentanyl
Glucagon
Hydroxocobalamin
Ipatropium Bromide
Ibuprofen
Ketamine
Magnesium Sulfate
Methylprednisolone
Midazolam
Morphine
Naloxone
Nitroglycerin
Ondansetron
Oral Glucose
Proparacaine
Rocuronium
Sodium Bicarbonate
Succinylcholine
Vecuronium
Reference Pages
Hospital Capabilities
Phone List
APGAR
Glasgow Coma Score
Lab Values
General Guidelines
Universal Patient Care
Scene Safety Minimum Equipment

Bring all necessary equipment to patient’s side  Combo / “First In” Bag
Demonstrate Professionalism and Courtesy  Cardiac Monitor or AED
 Oxygen / Airway Bag
PPE (Consider Airborne or Droplet if indicated)
PEDIATRIC: < 12 years old

Initial Assessment AND
Perform Age Appropriate Assessment Procedure [a] < 55 Kg -or- [b] Fits on
Consider Spinal Motion Restriction [as indicated] Pediatric Length Based Tape
Airway Protocol
(Age Appropriate)
See appropriate protocol

based on assessment
Foundation
Obtain appropriate vital signs:
 BP, Heart Rate, Respiratory Rate, GC Consider Supplemental
 Pulse Oximetry (if indicated) Oxygen
 Minimum two sets
Consider F.A.S.T / R. A. C. E. Assessment

Go To Glucose
Consider Blood Glucose Analysis Management
Protocol
Consider
Cardiac Monitor / ECG Acquisition
Consider
P P
Cardiac Monitor / ECG Interpretation
Unstable Patient Does Not

Exit To
M Fit a Protocol: M
Appropriate Protocol/Guideline
Contact Medical Control
Go to Refusal /
Non-Transport NO Transport? YES M Notify Receiving Facility M
Procedure
Charleston County
Clinical Guidelines 2020-08
A patient is defined as any person who meets ANY of the following criteria:
Receives basic or advanced medical or trauma treatment
Is physically examined
Has visible signs of injury or illness or has a medical complaint
Requires EMS specific assistance to change locations and/or position
Identified by any party as a possible patient because of some known or reasonably suspected illness/injury
Has a personal medical device evaluated or manipulated by EMS
Requests EMS assistance with the administration of personal medications or treatments
Completion of an EHR (ePCR) is required for any and all patient encounters in accordance
with DHEC regulations.
Pearls
 Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status Foundation
 with GCS, and location of injury or complaint.
 Required vital signs on every patient include blood pressure, pulse, respirations, pain / severity.
 Pulse oximetry, temperature, and glucose documentation is dependent on the specific complaint.
 Every patient should have at least one full set of vital signs taken manually.
 There should be at least one set of vitals for every 15 minutes of patient contact time; every 5 minutes for
 unstable patients.
 Capnography is:
 Required for ALL Intubated and Cricothyroidotomy Patients *
 Recommended for utilization of any Airway Device (BIAD) – required if available on scene.
 [* Attachment of the Capnograph may be delayed until the scene is safe / non-threatening]
 Timing of transport should be based on patient's clinical condition and the transport policy / destination
Charleston County
Assessment
Universal Patient Care and

Appropriate Guideline Based on
Condition/Complaint
Patient age < 1 years YES

Transport SHALL
NO NOT be delayed for
Patient age > 65 years critical patients.
with acute medical YES
complaint
NO
Assess Vital Signs:

HR, RR, BP, SpO2
If Indicated: Assess BGL
ADULT
Pulse < 50 or > 120
RR < 8 or > 30
Universal
SBP <85 or >180, or DBP >120 YES ALS on Scene?
SpO2 < 94%
BGL < 60 or > 500
GCS <14
Pediatrics = Refer to
Handtevy NO YES
NO
ALS Intervention or
Monitoring Required by YES Provide Appropriate
Initiate BLS Transport
Other Guideline Level of Care and
with ALS Intercept
Transport as
Remaining enroute
NO Neccessary.
Indications for IV/IM YES

Pain Medication
NO
Significant Airway,
Breathing, or Circulation YES
Condition (see pearls)
NO
BLS Transport/Refusal
Notify Destination or
M M
Charleston County
Assessment
Examples of when an ALS assessment should be requested:
 Any patient with chest pain consistent with being cardiac in nature.
 Any patient in cardiac arrest.
 Any patient with significant respiratory complaint and patient history with obvious signs of distress.
 Any significant trauma.
 Altered mental status.
 Any patient with new-onset hypertension.
 Any trauma that results in a significant amount of blood loss, or presents with a change in mental status.
 Any patient with loss of consciousness, acute mental status changes or sudden onset of unilateral numbness.
 Any acute neurological change (i.e. stroke/TIA).
Universal
Pearls
 Recommended exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro
 This guideline applies to ALL responders and resources covered by the Charleston County Joint Clinical
Guidelines.
 Age appropriate vital signs, as defined in the Charleston County Handtevy Guide, may be utilized for the BLS Vital
Signs Assessment for SBP, HR, and RR in pediatric patients.
 Elderly patients (age > 65 years) with an acute medical complaint or suspected medical cause of fall should be
considered potential cardiac patients and evaluated by a Paramedic whenever possible. Acute medical complaints
involving the skin or extremities may be treated by the BLS provider.
 Significant Airway Conditions include, but are not limited to, patients needing ventilatory support, advanced
airway placement, relief of airway obstruction, or those with uncontrollable emesis.
 Significant Breathing Conditions include, but are not limited to, patients with exacerbation of asthma, COPD,
CHF, or those with SpO2 < 94%.
 Significant Circulation Conditions include, but are not limited to, uncontrollable blood loss or need for CPR.
 Patients meeting any trauma criteria, including trauma with history of anticoagulants/blood-thinners, should be
transported by Paramedics where possible. Do NOT delay transport of critical trauma patients.
 An ALS unit may always be requested for additional assessment and treatment. Request ALS as soon as it is
known that ALS will be needed.
 A BLS provider can write a refusal only if a Paramedic assessment is not indicated.
 When ALS assistance is requested, and a Paramedic makes patient contact, their ALS level assessment must be
documented and included in the ePCR.
 Whenever the Paramedic who performed the ALS assessment is not on the transporting unit, an Assist, Unit must
be completed.
 Transport SHALL NOT be delayed. Initiate transport as soon as patient is ready and keep ALS enroute.
 ALS Intercept may be utilized for any patient at the discretion of the provider.
Charleston County
Field Trauma Triage
Assessment of Serious Signs / Symptoms
ABC and LOC Adult Trauma Centers
Level 1: MUSC
Level 2: Trident
Measure Vital Signs and Level of Consciousness Pediatric Trauma Centers
Level 1: MUSC
 Glasgow Coma Scale < 13
 Systolic Blood Pressure < 90 mmHg Pediatric: Less than 16 years
 Respiratory Rate < 10 or > 29 Breaths / min
 Need for Ventilatory Support
 Rate < 20 in infant age < 1 Year NO
YES
Transport to closest Level 1 Assess anatomy of injury:

or Level 2 trauma center • Amputation proximal to wrist or ankle
unless patient requires • Penetrating injuries to head, neck, torso or
• Pelvic fracture
YES extremity above elbow or knee
emergent stabilization at a • Chest wall instability/deformity
• Paralysis
• Open or depressed skull fracture
closer facility (failed airway, • Crush, de-gloved, mangled or pulseless
• Two or more proximal long bone fractures
impending arrest, etc). extremity
NO
GENERAL GUIDELINE
Assess mechanism of injury:
Falls: High Risk Auto Crash:

• > 20 ft. in adult (one story = 10 feet) • Intrusion including roof: > 12 inches
• > 10 ft. or 2-3 times the height of a child occupant side or > 18 inches any site
YES • Ejection (partial or complete) from
Pedestrian or bicyclist struck by
automobile
vehicle, thrown, run over, or with
• Death in same passenger compartment
impact > 20 MPH
• Vehicle telemetry data consistent with a
Motorcycle crash > 20 MPH high risk of injury
NO
Transport to closest
appropriate trauma center. Assess special patient or system considerations:
Anticoagulants / bleeding disorders:
A lower level Trauma Center Older Adults: • Notify destination facility. If concern for
• Presenting with new altered mental status
should not be bypassed to internal bleeding transport to trauma center.
YES (GCS<15) and evidence of head trauma.
transport to a higher level Burns:
Pregnancy > 20 weeks • If no other trauma: triage to burn facility as
Trauma Center. • Presenting with vaginal bleeding and/or appropriate
abdominal pain following trauma
EMS provider judgment
Air Transport from incident
scene is rarely appropriate
NO
Transport according to usual

Transport Guidelines
Pearls
 Geriatric patients should be evaluated with a high index of suspicion. Occult injuries are often more difficult to
recognize, and patients can decompensate unexpectedly with little warning.
 In prolonged extrications or serious trauma, consider air transportation for transport times and advanced care.
 Scene times should not be delayed for procedures. These should be performed en route when possible. Rapid
transport of the unstable trauma patient is the goal.
 Patient transportation via ground ambulance will not be delayed to wait for helicopter transportation. If
the patient is packaged/ready for transport and the helicopter is not in view, transport will be initiated by
ground ambulance.
Charleston County
Vascular Access
Universal Patient Care Protocol Maximum IV Attempts

Not to Exceed:
 2 by Non-transport
 3 by CCEMS
Assess need for Vascular Access
Emergent or Potentially emergent medical
Total attempts shall not
or trauma condition OR indicated by
exceed 4 without OLMC.
another protocol
Life-Threatening
YES NO
Event?
A Peripheral IV Procedure A
Unstable* with
NO
Central Catheter
Foundation
A Peripheral IV Procedure A
YES If peripheral IV is unavailable or will

cause a delay, consider:
Unsuccessful
Utilize Already Accessed/Flushed
A A A External Jugular IV A
Central Venous Catheter
Access/Flush
P P A Intraosseous Access A
Central Venous Catheter
Successful
Unsuccessful
A Monitor Non-Medicated Infusion A
P Monitor Medicated Infusion P M M
Pearls
 *In patients who are NOT hemodynamically unstable, contact medical control prior to accessing or using central
venous catheters.
 In the setting of cardiac arrest, any preexisting dialysis shunt or external central venous catheter may be used.
 Intraosseous access: Proximal tibia is the preferred site in pediatrics.
 Any prehospital fluids or medications approved for IV use may be given through an intraosseous line.
 All IV rates should be at KVO (minimal rate to keep vein open) unless administering fluid bolus.
 Upper extremity IV sites are preferable to lower extremity sites.
 Lower extremity IV sites are discouraged in patients with vascular disease or diabetes.
Charleston County
Clinical Guidelines
2020-08
Cardiac Arrest: BLS
Cardiac Arrest: Team Approach

 Push Hard (≥ 2 inches) Push Fast (~110 / min)
 Change Compressors every 2 minutes
(Limit changes / pulse checks < 5 seconds)
2 minutes of CPR
Attach Cardiac Monitor / AED
Shock Advised AED Rhythm No Shock Advised

Interpretation
Defibrillate x 1 BLS Airway Guidelines

2 minutes of CPR
BLS Airway Guidelines Continue steps until Assess Rhythm – Shock
2 minutes of CPR ROSC has been Advised?
Assess Rhythm – Shock Achieved
NO
Advised? OR
BLS CARDIAC
>25 Minutes of Team 2 minutes of CPR
YES
Approach CPR has Assess Rhythm – Shockable?
been Reached
Defibrillate x 1
2 minutes of CPR
Assess Rhythm – Shockable?
> 25 Minutes Team Approach

CPR
YES
Is ALS On-Scene
NO Or YES
Is ALS Reasonably Close
Await For
Consider Notify Destination or ALS Arrival/
M Contact Medical Control
M
Transport Initiate
Transport
Charleston County
Cardiac Arrest: BLS
History Signs and Symptoms Differential
 Estimated down time  Unresponsive, apneic/agonal  Cardiac
 Past medical history respirations, pulseless  Endocrine / Metabolic
 Medications  Drugs
 Events leading to arrest  Pulmonary
 Renal failure / dialysis
 DNR or living will
BLS CARDIAC
Pearls
 Recommended Exam: Mental Status
 Treatment priorities are: uninterrupted chest compressions, defibrillation, then airway control.
 Apply AED immediately if patient has received two minutes of high quality chest compressions prior to AED arrival.
 Continue compressions while AED is charging after “shock advised.” Continue CPR immediately after each
defibrillation. Check for pulses if next rhythm analysis is "no shock."
 Effective CPR and prompt defibrillation are the keys to successful resuscitation.
 After 25 minutes of HPCPR, consider transport if ALS has a prolonged ETA and hospital is within close proximity to
the scene.
 If scene becomes unsafe, consider transport and attempt to coordinate ALS intercept.
 If ROSC is achieved, notify supervisor and begin moving towards ambulance. If ALS has a prolonged ETA,
initiate transport and attempt to coordinate ALS intercept.
 Transport to a PCI capable facility is preferred.
 If issues are encountered with ABCs, transport to the closest facility.
 Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control. Notify
supervisor, prepare for transport, and attempt to coordinate ALS intercept.
 Remember that good communication is the key to success!
 Shockable Rhythms - If AED continues to advise “shock” after 4 defibrillation sequences, consider changing pad
vector.
Charleston County
Clinical Guidelines
2020-07
Scene Rehabilitation: General
Remove: Initial Process
PPE 1. Patients logged into General Rehabilitation Documentation
Body Armor 2. VS Assessed / Recorded (If HR > 110 then obtain Temp)
Chemical Suits 3. Patients assessed for signs / symptoms
SCBA
Turnout Gear
Other equipment as
Indicated
Continue: Exit to
Significant Injury
Heat and Cold Stress Appropriate
Cardiac Complaint: Signs / Symptoms
treatment techniques YES guideline and
Respiratory Complaint: Serious Signs / Symptoms
consider
Symptomatic Hypotension
transport
Injury / Illness /
Complaint should be
treated using appropriate
guideline beyond the
need for oral or IV
hydration.
Heat
Or
NFPA Age-Predicted 85%
Cold stress
Maximum Heart Rate (PMHR)
YES
AGE Heart Rate
Initiate active warming or cooling
20 - 25 170 NO measures. Reference pearls for
further guidance.
26 - 30 165
General
31 - 35 160
Rehydration Techniques
12–32 oz Oral Fluid over 20 minutes
36 - 40 155 Oral Rehydration may occur along with
Active Warming or cooling Measures
41 - 45 152
45 - 50 148
Reassess individual after 20 Minutes
51 - 55 140 in General Rehabilitation Section
Reassess Vital Signs
56 - 60 136
61 - 65 132
HR <110
SBP <180 YES Return to Work
DBP <120
SpO2 >90 %
NO
Symptoms
YES Medical Rehabilitation
HR >85% NFPA PMHR
NO
Greater than 40 minutes

of general rehabilitation YES
NO
Additional general
rehabilitation for 20
minutes
Charleston County
Clinical Guidelines
2021-04
Scene Rehabilitation: General
General
Pearls
Active Cooling Measures - Forearm immersion, cool shirts, cool mist fans etc. for 10 – 20 Minutes
Active Warming Measures - Dry patient, place in warm area Hot packs to axilla and / or groin
Pearls
This protocol should be utilized for evaluating patrons of certain special events that may or may not
otherwise meet the definition of a patient.
Paramedic on-scene has full authority in deciding when individuals meet the definition of a patient and/or
require further treatment or transport.
Personnel that don’t require transport but are unable to return to full duty status after extended rehab:
 Refer to fire department rehabilitation manager for decision.
 If EMS is assigned the role of rehabilitation manager, report to IC for further guidance.
Regarding documentation under this protocol, individuals who are evaluated only at the rehabilitation
center require a narrative-based patient log entry under one PCR for all of these individuals. If a patient
receives ALS care more than one over-the-counter medications and/or is transported to an emergency
department, the patient requires a separate run number and full PCR like any other patient.
People taking anti-histamines, blood pressure medication, diuretics or stimulants are at increased risk for
cold and heat stress.
Establish rehab location such that it provides shelter, privacy and freedom from smoke or other hazards.
Ideally, water or fluid replacement supplement being utilized should be ambient temperature.
Blood Pressure may be prone to inaccuracy on scenes, interpret in context. Elevated blood pressure may
be due to physical exertion and is not typically pathologic. Individuals with Systolic BP >160 or Diastolic
>100 may need extended rehabilitation. However this does not necessarily prevent them from returning to
the event.
Charleston County
Scene Rehabilitation: Medical
Initial Process
1. Personnel logged into Responder Rehabilitation Section
2. VS Assessed and Recorded / Orthostatic Vital Signs
3. Cardiac monitoring
4. Pulse oximetry and SPCO (if available)
Injury / Illness / 5. Personnel assessed for signs / symptoms
Complaint should be 6. Consider obtaining 12-lead ECG
treated using appropriate 7. Consider BGL assessment
guideline beyond the
need for oral or IV
hydration. 20 Minute Rest Period
Firefighters should consume at least 8 ounces of
fluid between SCBA change-out
Normal Saline IV Bolus

NFPA Age Predicted Pulse Rate greater than Up to 2 L
Maximum Heart Rate NFPA Age Predicted YES Until Pulse Rate is 100 or less
Maximum And
Blood pressure has normalized
AGE Heart Rate NO
Systolic BP ≥ 180
20 - 25 170 Or YES
Diastolic BP ≥ 120
26 - 30 165 NO
No improvement
after 30 minutes
31 - 35 160 of additional
Respirations < 8 or > 40 YES
rehabilitation;
General
consider
36 - 40 155 NO Transport
Pulse oximetry < 90 %

41 - 45 152 YES
SPCO > 10 %
45 - 50 148 NO
51 - 55 140 Temperature ≥ 100.6 YES Mandatory Rest Period

Rehydration is Most
Important
NO
Re-evaluate in 10 minutes
56 - 60 136
Discharge Responder
61 - 65 132 from Medical
Rehabilitation Section
M M
Charleston County
Scene Rehabilitation: Medical
General
Pearls
Active Cooling Measures - Forearm immersion, cool shirts, cool mist fans etc. for 10 – 20 Minutes
Active Warming Measures - Dry patient, place in warm area Hot packs to axilla and / or groin
Pearls
This protocol should be utilized for evaluating patrons of certain special events that may or may not
otherwise meet the definition of a patient.
Paramedic on-scene has full authority in deciding when individuals meet the definition of a patient and/or
require further treatment or transport.
Personnel that don’t require transport but are unable to return to full duty status after extended rehab:
 Refer to fire department rehabilitation manager for a decision.
 If EMS is assigned the role of rehabilitation manager, report to IC for further guidance.
Regarding documentation under this protocol, individuals who are evaluated only at the rehabilitation
center require a narrative-based patient log entry under one PCR for all of these individuals. If a patient
receives ALS care more than one over-the-counter medications and/or is transported to an emergency
department, the patient requires a separate run number and full PCR like any other patient.
People taking anti-histamines, blood pressure medication, diuretics or stimulants are at increased risk for
cold and heat stress.
Establish rehab location such that it provides shelter, privacy and freedom from smoke or other hazards.
Ideally, water or fluid replacement supplement being utilized should be ambient temperature.
Blood Pressure may be prone to inaccuracy on scenes, interpret in context. Elevated blood pressure may
be due to physical exertion and is not typically pathologic. Individuals with Systolic BP >160 or Diastolic
>100 may need extended rehabilitation. However this does not necessarily prevent them from returning to
the event.
Charleston County
Adult
Adult Universal Airway
Assess Airway and Breathing Adequate
Inadequate
Supplemental Oxygen
Basic Maneuvers First
Goal saturation 90%-99%
 Position Airway
 Consider OPA/NPA
Exit to Appropriate Guideline
Consider Suction and/or Foreign

NO Airway Patent?
Body Obstruction Procedures
YES
Ventilatory Monitor / Reassess

Support NO Supplemental Oxygen &
Needed?
ADULT AIRWAY
YES
Supplemental Oxygen BVM
Consider CPAP Procedure
Unable to Ventilate and

Oxygenate adequately
during or after:
BVM / CPAP Notify Destination or
 One (1) or more YES M M
Effective? Contact Medical Control
unsuccessful
intubation attempts
AND NO
Anatomy inconsistent
with continued
BIAD Procedure
attempts OR
BIAD or Intubation
 Three (3) total P
as Appropriate
unsuccessful
Consider Drug Assisted
attempts
Intubation Guideline
SUCCESSFUL
Exit to Follow Airway Confirmation

Adult Failed Airway Procedure and Post Airway
Guideline Management Guideline
Charleston County
Clinical Guidelines
2020-11
Adult Universal Airway
Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital endotracheal intubations
are to be considered high risk. If ventilation / oxygenation is adequate, transport may be the best option. The most important airway
device, and the most difficult to use correctly and effectively, is the Bag Valve Mask (not the laryngoscope).
Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques.
Difficult BVM Ventilations-MOANS: Difficult Mask seal due to facial hair, anatomy, blood or secretions / trauma; Obese or late
pregnancy; Age > 55; No teeth (roll gauze and place between gums and cheeks to improve seal); Stiff or increased airway pressures
(Asthma, COPD, Obese, Pregnant).
Difficult Laryngoscopy: Difficult laryngoscopy is difficult to predict. In the prehospital environment anticipate that all intubations will
be difficult and prepare appropriately. Consider Video Laryngoscope and Bougie, and have Plans A, B, and C ready.
Difficult BIAD-RODS: Restricted mouth opening; Obstruction / Obese or late pregnancy; Distorted or disrupted airway; Stiff or
increased airway pressures (Asthma, COPD, Obese, Pregnant).
Difficult Cricothyrotomy / Surgical Airway-SHORT: Surgery or distortion of airway; Hematoma overlying neck; Obese or late
pregnant; Radiation treatment skin changes; Tumor overlying neck.
Trauma: Utilize in-line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD placement, the cervical
collar front should be opened or removed to facilitate translation of the mandible / mouth opening.
ADULT AIRWAY
Pearls
 Capnometry (Color) or capnography is mandatory with all methods of intubation/BIAD. Document results.
 Continuous capnography (EtCO2) is mandatory for the monitoring of all patients with an ET tube and required, once
available, for all patients with a BIAD.
 If an effective airway is being maintained by BVM with continuous pulse oximetry values of >90%, it is acceptable to
continue with basic airway measures instead of using a BIAD or Intubation.
 Use the least invasive method necessary to maintain an adequate airway – especially in pediatric patients.
 For the purposes of this guideline, an adequate airway is when the patient is receiving appropriate oxygenation and ventilation
– and not at an undue risk of aspiration or deterioration.
 An Intubation Attempt is defined as passing the laryngoscope blade or tube past the teeth.
 Ventilatory rate should be 30 for neonates, 25 for toddlers, 20 for school age, and 10 for adolescents and adults. Maintain an
EtCO2 of 35-45. Avoid hyperventilation.
 Hyperventilation in deteriorating head trauma should only be done to maintain an EtCO2 of 30-35.
 Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful.
 Maintain c-spine motion restriction for patients with suspected spinal injury.
 Obese adults (greater than 120 kg) desaturate to 0% in less than 3 minutes. Proceed with DAI/RSI cautiously.
 Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
 Gastric tube should be placed in all BIAD patients (if available) and considered in all intubated patients.
 It is important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement – especially during
patient movement.
Charleston County
HEAVEN Criteria
Emergency Difficult Airway Predictor
Criteria Definitions
Hypoxemia O2 ≤93% at time of initial laryngoscopy
Extremes of Size Pediatric patient ≤8 years of age or clinical obesity
Anatomic Trauma, mass, swelling, foreign body, or other structural

Challenge abnormality limiting laryngoscopic view.
Fluid present in the pharynx/hypopharynx at the time of

Vomit/Blood/Fluid laryngoscopy.
Suspected anemia potentially accelerating desaturation during RSI

Exsanguination associated apnea.
Neck Limited cervical range of motion due to immobilization or arthritis.

Adult Airway – Drug Assisted Intubation
This guideline is only for use in patients: Age ≥ 12 or patients longer than the pediatric tape.
Procedure will remove patient’s

Indications for RSI / DAI Universal Airway Guideline protective airway reflexes and
Failure to protect the airway ability to ventilate.
Unable to oxygenate
Preoxygenate 100% O2
Unable to ventilate You must be sure of your ability
to intubate before beginning
Impending airway compromise
this procedure.
Vascular Access Guideline
Assemble:
Airway Equipment
P P
Suction Equipment
Alternative Airway Device
NO Dangerously Combative ? YES
Apneic Oxygenation
P Ketamine 4 mg/kg IM
ADULT AIRWAY
Ketamine 2 mg/kg
IV / IO
P or
Etomidate 0.3 mg/kg IV / IO
Induction Only Administer Paralytic

Difficult to
YES Ventilate / NO
Oxygenate?
Succinylcholine 1.5 mg / kg IV/ IO

Intubate or BIAD as appropriate or
P Placement verified
P Rocuronium 0.6 mg / kg
IV / IO
Consider:
 Change Provider
Successful  Attempt BIAD
YES
Attempt?
NO  Administer Paralytic
(if not already given)
More than 3 Attempts
Follow Airway Confirmation

Procedure and Post Airway Exit to Adult Failed Airway
Management Guideline Guideline as indicated
Charleston County
Clinical Guidelines
2018-09
Adult Airway – Drug Assisted Intubation
Minimum Qualifications for RSI / DAI Credential
 Current SC Paramedic with at least 2 years’ experience
 Attend an approved RSI course
 Successfully complete medical director’s check-off
DAI/RSI Credentials must be renewed annually for each organization in which the Paramedic is authorized.
Authorization at one agency is not transferrable to another.
ADULT AIRWAY
Pearls
 This procedure requires at MINIMUM of one RSI Credentialed Paramedic and one EMT. Two Paramedics are
always preferred. Divide the workload – ventilate, suction, drugs, intubation.
 Utilize RSI / DAI Check Sheet and Dosing Guide
 Patients with hypoxia and/or hypotension are at risk of cardiac arrest when a sedative and paralytic
medication are administered. Hypoxia and hypotension require resuscitation and correction prior to use of
these combined agents. Consider mixing push-dose pressor prior to RSI / DAI.
 This guideline is only for use in patients with an Age ≥ 12 or patients longer than the pediatric tape.
 Before administering any paralytic drug, screen for contraindications with a thorough neurologic exam.
 Capnography is:
 Required for ALL Intubated Patients and Cricothyroidotomy Patients*
 Recommended / Encouraged for utilization of any Airway Device (e.g. BIAD) – required if
available.
 [* Attachment of the Capnograph may be delayed until the scene is safe / non-threatening]
 If First intubation attempt fails, make an adjustment and try again:
 Different laryngoscope blade or ETT size
 Change head positioning - Align external auditory canal with sternal notch / proper positioning.
 Consider applying BURP maneuver (Back [posterior], Up, and to patient’s Right)
 Treat pain & administer medications to maintain sedation after successful intubation – See Post Airway
Management.
 RSI / DAI not recommended in urban setting (short transport) when able to maintain oxygen saturation ≥ 90 %.
 Consider orogastric tube placement in all intubated patients to limit aspiration and decompress stomach if needed.
Charleston County
Clinical Guidelines
2018-09
DAI Check Sheet
Preparation
 CCEMS monitoring equipment ON and in place
EtCO2 zeroed
 Consider fluid resuscitation and tension
pneumothorax
 NRB and Passive O2 (NC greater than 10 LPM)
 Consider OPA/NPA placement
 Head of bed elevated 30-35 degrees
 SPO2 less than 93%?

BVM 2 thumbs up w/ PEEP & EtCO2
 Open C-Collar if present
 Any HEAVEN Criteria?
Equipment
 Suction on and accessible
 AirTraq on and warmed-up
 Induction and paralytic drawn up and doses

confirmed
 ETT, Bougie, and alternate airways out and
accessible
Induction/Intubation
 Induction agent administered
 Paralytic administered
 Suction prior to intubation
 Intubate
 ETT placement – Direct visualization/EtCO2/lung
sounds
 Secure tube and place OG tube
 CONTINUED SEDATION/PAIN MANAGEMENT
Charleston County
Clinical Guidelines
Drug Assisted Intubation
Ketamine (100 mg / 1 ml)
Induction
IV/IO IM
Ketamine Ketamine
IV/IO Induction IM Induction
Dosing 2 mg / kg Dosing 4 mg / kg
Concentration 100 mg / 1 ml Concentration 100 mg / 1 ml
Weight MG / ML Weight MG / ML
90 lbs 40 kg 80 mg / 0.8 ml 90 lbs 40 kg 160 mg / 1.6 ml
110 lbs 50 kg 100 mg / 1 ml 110 lbs 50 kg 200 mg / 2 ml
220 lbs 100 kg 200 mg / 2 ml 220 lbs 100 kg 400 mg / 4 ml
285 lbs 130 kg 260 mg / 2.6 ml 285 lbs 130 kg 500 mg / 5 ml

Succinylcholine
Paralysis
IV/IO
Succinylcholine
IV/IO
Dosing 1.5 mg / kg
Concentration 20 mg / 1 ml
Weight MG / ML
90 lbs 40 kg 60 mg / 3 ml
110 lbs 50 kg 80 mg / 4 ml
130 lbs 60 kg 90 mg / 4.5 ml
155 lbs 70 kg 100 mg / 5 ml
175 lbs 80 kg 120 mg / 6 ml
200 lbs 90 kg 140 mg / 7 ml
220 lbs 100 kg 150 mg / 7.5 ml
240 lbs 110 kg 160 mg / 8 ml
265 lbs 120 kg 180 mg / 9 ml
285 lbs 130 kg 200 mg / 10 ml

Vecuronium
Continued Paralysis
IV/IO
Vecuronium
IV/IO
Dosing 0.1 mg / kg
Weight MG / ML
90 lbs 40 kg 4 mg / 4 ml
OLMC ONLY 110 lbs 50 kg 5 mg / 5 ml
130 lbs 60 kg 6 mg / 6 ml
155 lbs 70 kg 7 mg / 7ml
175 lbs 80 kg 8 mg / 8 ml
200 lbs 90 kg 9 mg / 9 ml
220 lbs 100 kg 10 mg / 10 ml
240 lbs 110 kg 11 mg / 11 ml
265 lbs 120 kg 12 mg / 12 ml
285 lbs 130 kg 12 mg / 12 ml
Charleston County
Clinical Guidelines
Adult Post Airway Management
ETT or BIAD Airway Device Placed
Verify tube placement through:

 Auscultation and Chest Rise
 Continuous capnography
 Pulse oximetry
Administer 3 Ventilations
EtCO2
NO > 10 and Good YES
Waveform
Direct look to confirm
P ETT Placement
Dislodged? NO Secure Tube
Consider Restraints
ADULT AIRWAY
YES [Physical] Procedure
Reposition ETT or remove and Consider Gastric Tube

P Insertion Procedure
Ventilate with BVM
Yes
Consider Etiology and NO

At Risk of
Exit to Appropriate Guideline Awakening / Moving After Intubation?
YES
Consider Symptomatic
NO Systolic BP > 90
Hypotension Guideline
Yes
Fentanyl 1 mcg/kg IV/IO
Max Dose 100mcg
May repeat half dose Q 5 minutes.
Max Total Dose = 200 mcg
P and
Midazolam 0.1 mg/kg IV/IO up to
5 mg
Repeat 0.05 mg/kg up to 2.5 mg
Q 5 minutes PRN (Max 10mg or
Clinically significant drop in BP)
OR
Ketamine 2.0 Mg/Kg IV/IO
Notify Destination or Repeat Q 10 PRN (Q5 if pt is
M M P
Contact Medical Control showing signs of inadequate
sedation)
Consider Long Acting Paralytic
P Vecuronium (Norcuron) 0.1 mg/kg
Charleston County
Clinical Guidelines
2020-11
Adult Post Airway Management
ADULT AIRWAY
Pearls
 Etiology of hypotension post intubation: Tension pneumothorax, Hyperventilation, Hypovolemia, or
shock.
 Ketamine should be used for sedation in the presence of hypotension.
 Monitor closely for S&S of inadequate sedation---Tachycardia, Tearing, Hyper/Hypotension, ect
 Continuous Waveform Capnography is:
 Recommended / Encouraged for utilization of any Airway Device (e.g. BIAD) – required if available.
 Waveform capnography and pulse oximetry should be continued throughout transport and until turnover at the
emergency department.
 Bradycardia after tube placement is a strong predictor of a misplaced endotracheal tube (ETT).
 Reassess the patient continuously. Sedation and pain relief should be administered to all hemodynamically
stable DAI patients.
 Administer push dose epinephrine and fluid boluses to hemodynamically unstable DAI patients.
 It’s important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement –
especially during patient movement.
 Confirm airway placement by ED staff prior to moving the patient from EMS stretcher.
 Long acting paralytic (Vecuronium) to be administered only with on-line medical control orders. The need for re-
paralization is rarely indicated if proper sedation/pain management achieved.
Charleston County
Clinical Guidelines
2020-11
Post Intubation
Sedation and Pain Control
Fentanyl Ketamine
Long Acting Sedation
Dosing 1 mcg / kg Dosing 2 mg / kg
Concentration 50 mcg / 1 ml Concentration 100 mg / 1 ml
Weight MG / ML Weight MG / ML
90 lbs 40 kg 40 mcg / 0.8 ml 90 lbs 40 kg 80 mg / 0.8 ml
110 lbs 50 kg 50 mcg / 1 ml 110 lbs 50 kg 100 mg / 1 ml
220 lbs 100 kg 100 mcg / 2 ml 220 lbs 100 kg 200 mg / 2 ml
240 lbs 110 kg 100 mcg / 2 ml 240 lbs 110 kg 220 mg / 2.2 ml
Midazolam
Midazolam 0.1 mg/kg IV/IO up to 5 mg
Repeat 0.05 mg/kg up to 2.5 mg Q 5

minutes PRN (Max 10mg or Clinically
significant drop in BP)
Charleston County
Clinical Guidelines
Richmond Agitation-Sedation Scale
Scale Label Description
+4 Combative Violent, immediate danger to staff
Pulls or removes tube(s) or catheter(s);

+3 Very agitated
aggressive
Frequent non-purposeful movement, fights

+2 Agitated
ventilations
+1 Restless Anxious but movements not aggressive, vigorous
0 Alert and calm Spontaneously pays attention to care giver
Not fully alert, but has sustained awakening

-1 Drowsy
(eye-opening/eye contact) to voice (>10 seconds)
Briefly awakens with eye contact to voice (<10

-2 Light sedation
seconds)
Movement or eye opening to voice (but no eye

-3 Moderate
contact)
No response to voice, but movement or eye

-4 Deep sedation
opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Pearls
 Any patient that requires sedation must have vital signs monitored every 5 minutes with EtCO2 attached and monitoring.
Richmond Agitation Sedation Scale (RASS)

The Richmond Agitation and Sedation Scale (RASS) is a validated and reliable method to assess patient’s level of sedation.
It can be used in all patients to describe their level of alertness or agitation. As opposed to the Glasgow Coma Scale
(GCS), the RASS is not limited to patients with intracranial processes. It is mostly used in mechanically ventilated patients
in order to avoid over and under-sedation.
A RASS of -2 to 0 has been advocated in this patient population in order to minimize over-sedation.
Patients with a RASS of -3 or less should have their sedation decreased or modified in order to achieve a RASS of -2 to 0.
Patients with a RASS of 2 to 4 are not sedated enough and should be assessed for pain, anxiety, or delirium.
Underlying etiology of the agitation should be investigated and appropriately treated to achieve a RASS of -2 to 0.
NOTE: The RASS score does not apply to patients who have received a paralyzing medication. Any patient who was
administered a paralytic shall receive post intubation sedation as outlined in the Clinical Guideline. Under NO
CIRCUMSTANCES will ANY patient be paralyzed before receiving adequate sedation.
Adult Failed Airway
Unable to Ventilate and Oxygenate Call for additional resources

adequately during or after: if available
 One (1) or more unsuccessful Consider Emergent Transport to

intubation attempts AND Nearest Resource
Anatomy inconsistent with
continued attempts OR
 Three (3) total unsuccessful
attempts BVM and Adjunctive Airway(s)
Consider Bilateral NPAs
Each attempt should include change
in approach or equipment. Consider Apneic Oxygenation
with BVM
NO MORE THAN THREE (3)
ATTEMPTS TOTAL
Continue BVM &

Surgical Airway Indications SpO2 ≥ 90% Supplemental Oxygen
ADULT Patient with: or acceptable based YES
Significant Facial on condition Exit to Appropriate
Guideline
Trauma / Swelling / Distortion
With Inability to Manage
via Other Means NO
ADULT AIRWAY
Airway BIAD Procedure
Continue Ventilation /
BIAD Oxygenation
YES
Successful?
Maintain SpO2 90-99%
NO
Surgical
P
Percutaneous Cricothyrotomy
YES Indications &
Procedure
Credentialed?
Continue Ventilation / Oxygenation

NO
BVM w/ OPA, Bilateral NPA &

Apneic Oxygenation
Emergent Transport to
CLOSEST RESOURCE
M M
Charleston County
Clinical Guidelines
2020-11
Adult Failed Airway
A failed airway occurs when a provider begins a course of airway management by endotracheal intubation and
identifies that intubation by that method will not succeed.
Conditions which define a Failed Airway:

1. Failure to maintain adequate oxygen saturation after 2 or more failed intubation attempts, OR
2. Three (3) failed attempts at intubation by the most experienced prehospital provider on scene in a patient who
requires an advanced airway to prevent death, OR
3. Unable to maintain adequate oxygen saturation with BVM techniques and insufficient time to attempt alternative
maneuvers.
It should be noted that a patient with a “failed airway” is one who is near death or dying, not stable or improving.
Patients who cannot be intubated or who do not have an oxygen saturation greater than 90% do not necessarily have a
failed airway. Many patients who cannot be intubated easily may be sustained by basic airway techniques and BVM,
with stable if not optimal oxygen saturation, i.e. stable (not dropping) SpO2 values as expected based on
pathophysiologic condition with otherwise reassuring vital signs (e.g. consistent pulse oximetry of 85% with otherwise
normal or near-normal vitals in a post-drowning patient).
The most important way to avoid a failed airway is to identify patient with expected difficult airway, difficult BVM
ventilation, difficult BIAD, difficult laryngoscopy and / or difficult cricothyrotomy. Please refer to the Universal Airway
Guideline for information on how to identify the patient with potential difficult airway.
Position of the patient: In the field, improper position of the patient and rescuer are responsible for many failed and
difficult intubations. Often this is dictated by uncontrolled conditions present at the scene and we must adapt. However,
many times the rescuer does not optimize the patient and rescue position. The sniffing position or the head simply
ADULT AIRWAY
extended upon the neck are probably the best positions. The goal is to align the ear canal with the suprasternal notch
in a straight line.
In the obese or late pregnant patient, elevating the torso by placing blankets, pillows, or towels will optimize the
position. This can be facilitated by raising the head of the cot.
Use of cot in optimal patient / rescuer position: The cot can be elevated and lowered to facilitate intubation. With the
patient on the cot raise until the patients nose is at the level of your umbilicus which will place you at the optimal
position.
Cricothyrotomy / Surgical Airway Procedure: Use in patients 12 years of age and greater only. Relative
contraindications include: Pre-existing laryngeal or tracheal tumors, or infections or abscess overlying the cricoid area
or hematoma or anatomical landmark destruction / injury.
Pearls
 Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function.
 Continuous EtCO2 should be utilized in all patients with respiratory failure and in all patients with advanced
airways.
 Notify Medical Control AS EARLY AS POSSIBLE about the patient’s difficult / failed airway.
 If an effective airway is being maintained by BVM and/or basic airway adjuncts (e.g. nasopharyngeal airway) with
continuous pulse oximetry values of ≥ 90% or stable values as expected based on pathophysiologic condition with
otherwise reassuring vital signs (e.g. consistent pulse oximetry of 85% with otherwise normal vitals in a post-
drowning patient), it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation, or
proceeding to Surgical Airway. Consider CPAP as indicated by protocol and patient condition. If scene resources
allow, do not hesitate to contact On-Line Medical Control regarding decision-making for patients with a difficult/
failed airway.
 Consider 2-person BVM technique.
 Consider apneic oxygenation with bilateral nasopharyngeal airways.
 When transporting to closest resource, consider free-standing EDs or intercept. In outlying areas, consider meeting
helicopter while en-route to ED for additional assistance.
Charleston County
Clinical Guidelines
2020-11
Adult Respiratory Distress
CDC Flagged or High
Pandemic Adult Respiratory Yes
Suspicion of COVID-19
No
Universal Patient Care Guideline

Respiratory / Ventilatory Insufficiency?
If available measure EtCO2 Universal Airway Guideline
Consider Airway Compromise or Foreign Body
Rales or
Pulmonary Edema Guideline Signs of
CHF?
No
Consider Anaphylaxis Guideline
Assess Airway
Assess Lung
Nebulized Albuterol 5mg Wheezing Stridor Consider Foreign Body Obstruction
ADULT AIRWAY
Sounds Procedure
P Consider Ipratropium 0.5 mg
Nebulized Normal Saline (3mL)
If No Improvement or Severe
P Epinephrine Nebulized 1mg
(1mg/mL) in 2 mL of NS
Repeat Albuterol
Improving? No A
as Needed
Consider CPAP Procedure
Consider Magnesium Sulfate
P 2g IV/IO Over ~20 minutes
Methylprednisolone
P No Improving?
125mg IV/IO
Yes Consider Epinephrine
A
(1mg/mL) 0.3 mg IM
Consider
Universal Airway Guideline or Yes
M M
Pearls
 Pulse oximetry should be monitored continuously if initial saturation ≤ 94%, or there is a decline in patients status
despite normal pulse oximetry readings. Consider Nasal EtCO2 with signifiant distress or no response to initial
albuterol treatment.
 Contact Medical Control prior to administering epinephrine in patients who are > 50 years of age, have a history
of cardiac disease, or if the patient’s heart rate is > 150. Epinephrine may precipitate cardiac ischemia. A 12-lead
ECG should be performed on these patients.
 A silent chest in respiratory distress is a pre-respiratory arrest sign.
Charleston County
Clinical Guidelines
2020-06
Adult Bradycardia
Heart Rate < 60 / minute,
Hypotensive, and Symptomatic:
Universal Patient
Acute AMS, Chest Pain, Acute CHF,
Care Guideline Seizures, Syncope, or Shock secondary
to bradycardia
YES
Dyspnea / Increased
Also Utilize Universal
Work of Breathing, YES
Airway Guideline
especially with hypoxia
NO
Cardiac Monitor /
Consider 12 Lead ECG Acquisition
Cardiac Monitor /
P
EKG Interpretation
ADULT CARDIAC
Atropine 1 mg IV / IO
P Repeat every 3-5 minutes PRN
Maximum 3 mg
NO Improving ? YES
Transcutaneous Pacing
P (Should be considered first line

therapy for severe symptoms and
early in 2nd or 3rd degree AVB)
Consider Sedation
Midazolam 2.5 mg IV / IO / IM / IN Notify Destination or
P M M
May repeat once after 5 minutes
Pearls
 Recommended exam: Mental Status, Skin, Neck, Heart, Lungs, Neuro
 Bradycardia causing symptoms is typically < 50/minute. Rhythm should be interpreted in the context of
symptoms, and pharmacological treatment given only when symptomatic, otherwise monitor and reassess.
 Pacing can be considered first for critical patients in the presence of 2nd or 3rd degree heart block. Atropine
is ineffective in cardiac transplantation.
 If bradycardic patient is also a STEMI patient, follow the STEMI guidelines
 Consider Glucagon 2 mg IV/IO if patient is still bradycardic and on beta blockers.
 Consider Calcium Gluconate 10 mL IV/IO if patient is still bradycardic and on calcium channel blockers.
 Consider Calcium Gluconate 10 mL IV/IO for suspected hyperkalemia (wide complex slow rhythm with bizarre
appearance).
 Hypoxemia is a common cause of bradycardia. Be sure to oxygenate the patient and support respiratory effort.
 Remember: The use of Atropine for PVC’s in the presence of an MI may worsen heart damage.
Charleston County
Adult Tachycardia
Narrow Complex (< 0.12 sec)
Unstable / peri-arrest
NO (no radial pulse) YES
HR Typically > 150
Cardiac Monitor / Synchronized Cardioversion

12 Lead ECG Acquisition 120 Joules
P
Cardiac Monitor / May repeat at 150J, and then 200J
P for all subsequent PRN
EKG Interpretation
Vascular Access Guideline Consider Sedation pre-shock

P Midazolam 2.5 mg IV / IO / IM / IN
Rhythm Regular ? NO
If Rhythm Changes
YES
P Attempt Vagal Maneuvers
ADULT CARDIAC
Adenosine 12 mg IV / IO
Rapid Push
P
May repeat 12 mg x1 dose
if needed
Persistent Consider Diltiazem 20 mg IV / IO

YES P
Tachydysrhythmia ? Over 2 minutes if SBP ≥ 100*
NO Repeat 12 Lead ECG Acquisition
M M
Pearls
 Recommended exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro
 If at any point the patient becomes unstable, move to the unstable arm in the algorithm.
 For ASYMPTOMATIC PATIENTS (or those with only minimal symptoms, such as palpitations) or any
tachycardia with rate < 150 and a normal BP, consider CLOSE OBSERVATION and/or fluid bolus rather
than immediate treatment with anti-arrhythmic medication.
 Serious Signs / Symptoms include: Hypotension. Acutely altered mental status. Signs of shock / poor perfusion.
Chest pain with evidence of ischemia (STEMI, T wave inversions, or depressions). Acute CHF.
 Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, dehydration, substance use, etc.
 If patient has history, or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium
Channel Blocker (e.g. Diltiazem). Use caution with Adenosine and give only with defibrillator available.
 Adenosine may not be effective in atrial fibrillation / flutter, yet is not harmful and may help identify rhythm.
 Calcium Channel Blocker (Diltiazem) is to be administered for rate control, ONLY with acute onset Narrow Complex
Tachydysrhythmia. Dose may be titrated down if rate effect is achieved.
 *Monitor for hypotension after administration of Calcium Channel Blockers. If patient is age ≥ 60 or BP is borderline
low, administer Diltiazem as two 10 mg doses 10 minutes apart.
 Continuous pulse oximetry is required for all SVT patients.
 Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Charleston County
Adult Tachycardia
Wide Complex (≥ 0.12 sec)
Unstable / peri-arrest
NO (no radial pulse) YES
HR Typically > 150
Cardiac Monitor / Synchronized Cardioversion

12 Lead ECG Acquisition 120 Joules
P
Cardiac Monitor / May repeat at 150J, and then 200J
P for all subsequent PRN
EKG Interpretation
Vascular Access Guideline Consider Sedation pre-shock

P Midazolam 2.5 mg IV / IO / IM / IN
Amiodarone 150 mg IV / IO
P Over 10 minutes
May repeat x1 if no response
Consider Amiodarone 150 mg IV /
YES IO if Shock Refractory,
P
or for recurrent dysrhythmia
ADULT CARDIAC
after conversion.
If Unsuccessful – Rapid Transport with
Early Destination Notification
Becomes Unstable ?
NO Repeat 12 Lead ECG Acquisition
M M
Pearls
 For ASYMPTOMATIC PATIENTS (or those with only minimal symptoms, such as palpitations) or any
tachycardia with rate < 150 and a normal BP, consider CLOSE OBSERVATION and/or fluid bolus rather
than immediate treatment with anti-arrhythmic medication.
 Serious Signs / Symptoms include: Hypotension. Acutely altered mental status. Signs of shock / poor perfusion.
Chest pain with evidence of ischemia (STEMI, T wave inversions, or depressions). Acute CHF.
 Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc.
 If patient has history, or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium
Channel Blocker (e.g. Diltiazem). Cardioversion or Amiodarone are the treatments of choice.
 For witnessed / monitored ventricular tachycardia, try having patient cough.
 Polymorphic V-Tach (Torsades de Pointes) is usually unstable and immediate cardioversion is warranted.
Magnesium Sulfate 2 g IV / IO may be administered over 2-3 minutes for more stable patients.
 If presumed hyperkalemia (end-stage renal disease, dialysis, etc.), administer Calcium Gluconate 10 mL IV/IO.
 Adenosine should NOT be given for unstable, irregular, or polymorphic wide-complex tachycardias as it may cause
degeneration of the arrhythmia to Ventricular Fibrillation.
 Continuous pulse oximetry is required for all Wide Complex Tachycardia patients.
 Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Charleston County
Adult Cardiac Arrest: Team Approach
Go to Discontinuation /
Death Procedure
Yes Criteria for Death / No Resuscitation
Contact / Notify EMS
Exit to
Supervisor and Coroner Traumatic Arrest
Yes Traumatic Arrest
(Blunt/Penetrating Trauma) Guideline
No
Begin Continuous CPR Compressions

Push Hard (≥ 2 inches) Push Fast (~110 / min)
Change Compressors every 2 minutes AT ANY TIME
(Limit changes / pulse checks < 5 seconds) Return of Spontaneous
First Arriving BLS / ALS Responder
Circulation
Initiate Compressions Only CPR
Initiate Defibrillation (Automated) Procedure
if available
Call for additional resources
Second Arriving BLS / ALS Responder
ADULT CARDIAC
Assume Compressions or Go to Post
Initiate Defibrillation (Automated/Manual) Resuscitation
Intermittent Compressions with Ventilations Guideline
30:2 Adult
Consider BIAD
10 Ventilations/min with Continuous Compressions
Third Arriving Responder

BLS ALS
BLS or ALS
Establish Incident Command Establish Team Leader / Code Commander

Fire Department Officer Responsible for patient care
Team Leader until ALS arrival Ensure high-quality compressions
Manages Scene / Bystanders Ensure frequent compressor change
Responsible for briefing/counseling family
Rotate Compressors Every 2 Minutes
To prevent fatigue and effect high quality Initiate Defibrillation (Manual) Procedure
compressions. Continuous Cardiac Monitoring
Take direction from Team Leader P Establish Vascular Access P
Fourth / Subsequent Arriving Responders Administer Appropriate Medications
Take direction from Team Leader Establish Airway if not in place
Go To Age Appropriate
Interrupt Compressions Only as Cardiac Arrest: ALS Rhythms
per AED Procedure. Guideline
Do NOT hyperventilate. Continue Team Approach CPR
Charleston County
Adult Cardiac Arrest: Team Approach
AIRWAY
DEFIB
CPR MEDS
ADULT CARDIAC
TEAM
TIMER
LEADER
Pearls
Efforts should be directed at high quality and continuous compressions with limited interruptions and early
defibrillation when indicated (After 2 minutes of CPR if not witnessed by EMS and no bystander CPR).
DO NOT HYPERVENTILATE: Ventilate at approximately 10 breaths per minute when BIAD present.
The use of feedback devices and/or metronome are MANDATORY if available at the scene.
DO NOT interrupt compressions to place advanced airway. Use BIAD for first attempt unless contraindicated. Leave in
place unless airway compromise necessitates tube exchange.
Mechanical CPR should be considered for transport or limited personnel only. Minimize interruptions/application.
Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control and rapid
transport.
Success is based on proper planning and execution and a team-based approach. Procedures require space and
patient access. Make room to work.
Consider possible CAUSES of arrest early: Consider traditional ACLS “Hs and Ts” for PEA: Hypovolemia, Hypoxia,
Hydrogen ions (acidosis), Hyperkalemia, Hypothermia, Tablets/Toxins/Tricyclics, Tamponade, Tension pneumothorax,
Thrombosis (MI), Thromboembolism (Pulmonary Embolism)
When considering CAUSES, consider utilizing relevant protocols in conjunction: airway, all cardiac protocols, allergic
reaction, diabetic, dialysis/renal failure, overdose/ingestion, suspected stroke, environmental protocols, etc.
Charleston County
Adult Cardiac Arrest: ALS Rhythms
Cardiac Arrest: Team Approach AT ANY TIME

 Push Hard (≥ 2 inches) Push Fast (~110 / min) Return of
 Change Compressors every 2 minutes Spontaneous
(Limit changes / pulse checks < 5 seconds) Circulation
5 cycles (2 minutes) of CPR
1 Attach Cardiac Monitor / AED

Go to Post
Resuscitation
Guideline
Rhythm Not Shockable

Shockable
Interpretation
P Defibrillate x 1 – 120J
Airway Guidelines Airway Guidelines

5 cycles of CPR 5 cycles of CPR
2 Assess Rhythm – Shockable?
NO YES
Assess Rhythm – Shockable?
YES NO
ADULT CARDIAC
P Defibrillate x 1 – 150J AT ANY TIME Vascular Access Guideline
Rhythm Changes to Normal Saline 500ml Bolus
Vascular Access Guideline Shockable/ A Repeat once if still pulseless
Nonshockable Rhythm
Epinephrine 1mg IV/IO Epinephrine 1mg IV/IO
P P
(Repeat Q 5 minutes x4) (Repeat Q 5 minutes x4)
3 Assess Rhythm – Shockable? Switch Columns - Assess Rhythm – Shockable?
YES Go to appropriate
treatment bundle /
P Defibrillate x1 – 200J energy level Consider and Treat
Reversible Causes (H’s and T’s)
Amiodarone 300mg IV/IO Do NOT administer Consider Calcium
P P
Repeat once at 150mg more than 5 doses Gluconate 1g IV/IO
5 cycles of CPR (5 mg) Epinephrine Consider Sodium
4 Assess Rhythm – Shockable? during cardiac P
Bicarbonate 50meq IV/IO
arrest.
YES 5 cycles of CPR
Continue other Assess Rhythm – Shockable?
P Defibrillate x1 – 200J treatments until NO NO
ROSC or Criteria for
5 cycles of CPR Termination are met.
5+ Assess Rhythm – Shockable?
> 25 Minutes Team Approach
CPR and ETCO2 < 10
YES YES
Exit to Cardiac Arrest

M
M Discontinuation Guideline
Charleston County
Adult Cardiac Arrest: ALS Rhythms
 Estimated down time  Unresponsive, apneic/agonal  Asystole
 Past medical history respirations, pulseless  Artifact / Device failure
 Medications  Ventricular fibrillation or ventricular  Cardiac
 Events leading to arrest tachycardia on ECG  Endocrine / Metabolic
 Renal failure / dialysis  Drugs
 DNR or living will  Pulmonary
Pearls
 High dose Epinephrine is associated with poor neurological outcome. Do NOT administer more than 5mg
Epinephrine.
 Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of
care.
 Treatment priorities are: uninterrupted chest compressions, defibrillation, then airway control and IV access.
 Do not stop CPR to check for placement of ET tube (use ETCO2) or to give medicines.
If arrest not witnessed by EMS then give 5 cycles of CPR prior to 1st defibrillation.
ADULT CARDIAC

 If BVM is ventilating the patient successfully, intubation should be deferred until rhythm has changed or 4 or 5
defibrillation sequences have been completed.
Pearls – Shockable Rhythms

 Recurrent ventricular fibrillation/tachycardia is defined as SUCCESSFULLY CONVERTED by standard defibrillation
techniques (i.e. 200 J), but subsequently returns. It is managed by treatment of correctable causes and use of anti-
arrythmic medications in addition to standard defibrillation. Consider change in pad vector after 4 defibrillation
sequences.
 Refractory ventricular fibrillation/tachycardia is defined as NOT CONVERTED by standard defibrillation. If standard
defibrillation and antiarrhythmic medications fail to produce a response, change the pad placement/vector with a new
set of pads.
 Polymorphic V-Tach (Torsades de Pointes) may benefit from administration of 2g magnesium sulfate IV/IO, if
available.
Pearls – Asystole / PEA / Reversible Causes

 Potential association of PEA with hypoxia - placing definitive airway with oxygenation early may provide benefit.
 PEA caused by sepsis or severe volume loss may benefit from higher volume of normal saline administration.
 Calcium Gluconate 1 gm IV/IO and Sodium Bicarbonate 50 meq IV/IO if hyperkalemia is suspected (renal failure,
dialysis).
 Administer via separate lines or administer 100cc normal saline between medications.
 Consider Calcium Gluconate for Calcium Channel Blocker overdose.
 Consider Sodium Bicarbonate for tricyclic antidepressant overdose.
 Glucagon 2-4mg IV/IO for suspected beta blocker overdose, if available.
 Chest decompression for suspected pneumothorax.
 Dextrose for known hypoglycemia. Glucometer readings may be inaccurate in presence of
cardiac arrest.
 Naloxone is not a treatment priority in confirmed cardiac arrest, regardless of cause. Consider
after all other treatment priorities or with ROSC (in absence of advanced airway).
Charleston County
Medical Protocols 2017-11
Adult Post Resuscitation
Repeat Primary Assessment
Finger On Pulse
Do NOT Move for 5-10 Minutes
Continue ventilatory support
 O2 Sats 94‐99 %
 EtCO2 ideally 35 – 45
DO NOT HYPERVENTILATE
Airway Guidelines
Cardiac Monitor / 12 Lead ECG Acquisition
Vital Signs
Chest Pain &
STEMI P Cardiac Monitor / 12 Lead ECG Interpretaion P
Guidelines
ADULT CARDIAC
Hypotension Bradycardia / Tachycardia
Ectopy / Ventricular Arrhythmia
Consider Amiodarone 150 mg Treat with

Hypotension
P if ventricular rhythm terminated with Appropriate
Guideline
defib or antiarrhythmic Guideline
If arrest reoccurs, revert to appropriate

protocol and/or initial successful treatment
Divert to closest Emergency Department
Transport to Facility Capable of PCI
M Notify Destination or Contact Medical Control M
Pearls
 Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase
and must be avoided at all costs.
 Most patients immediately post resuscitation will require ventilatory assistance.
 The condition of post-resuscitation patients fluctuates rapidly and continuously, and they require close monitoring.
Appropriate post-resuscitation management may best be planned in consultation with medical control.
 Common causes of post-resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and
medication reaction to ALS drugs.
 Titrate Pressor Agent to maintain a systolic blood pressure > 90 mmHg. Ensure adequate fluid resuscitation is
ongoing.
 Induction of hypothermia is no longer indicated in the field. However, temperature should be assessed and
hyperthermia should be avoided.
Charleston County
Adult Chest Pain: Cardiac and STEMI
Chest Pain
Dyspnea / Atypical Exit to
Signs / Symptoms
NO Symptoms NO Appropriate
consistent with cardiac
Suspect Cardiac Etiology Guideline
etiology ?
YES
Cardiac Monitor /
YES
12 Lead ECG Acquisition
Cardiac Monitor /
P P
EKG Interpretation Charleston County PCI Facilities:
Aspirin 81 mg x 4 PO (chewed)  Medical University of SC (CPC)
 Ralph. H. Johnson VA
 Roper St. Francis (Downtown)
 Trident Medical Center
ADULT CARDIAC
Transport to PCI Facility
Acute MI / STEMI ?
Immediate Notification of Facility
(STEMI = 1 mm ST Segment YES Immediate Transmission of ECG
Elevation ≥ 2 Contiguous Leads) if capable
Minimize Scene Time
NO
Lung Exam:
Systolic BP ≥ 100 NO
CHF / Pulmonary Edema
NO
YES
Normal Saline Bolus 250 mL

YES
A Repeat as needed
Nitroglycerin 0.4 mg SL Maximum 500 mL
A
Repeat every 5 minutes PRN
If pain not improved with Nitro,

consider Fentanyl: Notify Destination or
P M M
Fentanyl 1 mcg/kg IV / IO Contact Medical Control
May repeat half dose Q 5.
Charleston County
Adult Chest Pain: Cardiac and STEMI
STEMI/Culprit Vessel Localization Aid:
Pearls
ADULT CARDIAC
 Items in Red Text are key performance indicators.
 Avoid Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or
Cialis (tadalafil) in the past 36 hours due to potential severe hypotension.
 If ischemia is noted in the inferior leads (II, III, aVF), consider right sided ECG. If ST elevation noted in V3R or V4R,
Nitroglycerin and / or opioids may cause hypotension requiring fluid boluses.
 Isolated ST elevation in aVR, with ST depression EVERYWHERE ELSE is concerning for a possible proximal LAD
or Left Main lesion. Not STEMI criteria, but ECG should be sent for consult and ED notified early.
 Diabetics, geriatric, and female patients often have atypical pain, or only generalized complaints. Have a low
threshold to perform 12 lead ECG in these patients.
 Document the time of the 12-lead ECG in the EHR as a procedure along with the interpretation (EMT-P).
 If ASA 324 or 325mg given PTA, do not repeat. Document ASA administration in the EHR.
 EMT may administer Nitroglycerine to patients already prescribed medication.
Charleston County
Adult CHF / Pulmonary Edema
Signs / Symptoms Airway Patent Universal Airway

consistent with CHF / YES Ventilations adequate NO Guideline(s)
Pulmonary Edema Oxygenation adequate Consider CPAP Procedure
YES
Chest Pain and STEMI

Cardiac Monitor /
Guideline
if indicated
Cardiac Monitor /
P P
EKG Interpretation
Assess Symptom Severity
MILD MODERATE / SEVERE CARDIOGENIC SHOCK
ADULT CARDIAC
Mild Dyspnea OR Respiratory Distress AND Bradycardia
SBP < 180 mmHg SBP > 180 mmHg Hypotension
Nitroglycerin 0.4 mg SL Nitroglycerin 1.2 mg SL Remove CPAP, but only while

A A
Repeat every 5 minutes (3 Sprays Consecutively) hypotensive (SBP < 90)
Consider Airway CPAP Procedure Airway CPAP Procedure Symptomatic Hypotension

Guideline
Repeat Nitroglycerin
A
0.4 mg SL every 5 minutes
M M
Pearls
 Items in Red Text are key performance indicators.
 Avoid Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or
Cialis (tadalafil) in the past 36 hours due to potential severe hypotension.
 If ischemia is noted in the inferior leads (II, III, aVF), consider right sided ECG. If ST elevation noted in V3R or V4R,
Nitroglycerin and / or opioids may cause hypotension requiring fluid boluses.
 Consider myocardial infarction in all of these patients: Diabetics, geriatric, and female patients often have atypical
pain, or only generalized complaints.
 Allow the patient to be in a position of comfort to maximize their breathing effort.
 Document CPAP application using CPAP procedure in the EHR. Document the time of the 12-lead ECG in the
EHR as a procedure along with the interpretation (EMT-P).
 EMT may administer Nitroglycerine to patients already prescribed medication.
 Consider Midazolam 1-2mg IV to assist with CPAP compliance. Benzodiazepines may precipitate respiratory
depression or may actually worsen compliance with CPAP in patients who are already tired, already with altered
mental status, or who have recent history of alcohol or drug ingestion. All efforts at verbal coaching should be
utilized prior to giving benzodiazepines for patients in respiratory distress.
Charleston County
Adult Left Ventricular Assist Device
Is patient unconscious and
apneic with no signs of YES
Guideline
perfusion?
NO
Evidence to suggest
NO possible device malfunction
or failure?
YES
 Determine Type of Device

 Assess any Alarms
 Contact LVAD Coordinator
 Discuss plan with family.
Consider: changing device batteries,
reconnecting cables
Cardiac Monitor /
ADULT CARDIAC
P
EKG Interpretation
Cardiac Monitor /
Consider 12 Lead EKG Acquisition
Assess for other treatable

YES Exit to appropriate guideline
causes.
Transport to
MUSC
M M
Pearls
 ALWAYS talk to family / caregivers as they have specific knowledge and skills. CALL THE VAD
COORDINATOR EARLY as per patient / family instructions or as listed on the device. They are available 24 / 7
and should be an integral part of the treatment plan.
 QUESTIONS TO ASK: DOES THE PATIENT HAVE A DNR? Can the patient be cardioverted or defibrillated if
needed? Can CHEST COMPRESSIONS be performed in case of pump failure?
 Deciding when to initiate chest compressions can be difficult. Consider that chest compressions may cause
death by exsanguination if the device becomes dislodged. However, if the pump has stopped the heart will
not be able to maintain perfusion and the patient will likely die. Ideally, plan the decision in advance with a
responsive patient and the VAD coordinator. If a VAD patient is unresponsive and pulseless with a non-
functioning pump and has previously indicated a desire for resuscitative efforts, begin compressions.
Contact the VAD coordinator and medical control.
 Common complications in LVAD patients include Stroke and TIA (incidence up to 25%), bleeding, dysrhythmia, and
infection
 The Cardiac Monitor and 12 lead EKG are not affected by the VAD and will provide important information.
 LVAD patients are preload dependent. Consider that a FLUID BOLUS can often reverse hypoperfusion.
 Transport patients with ALL device equipment including any instructions, hand pumps, backup batteries, primary and
secondary controllers, as well as any knowledgeable family members or caregivers.
Charleston County
Adult Allergic Reaction / Anaphylaxis
Guideline
Moderate to Severe
Mild Allergic Reaction (Anaphylaxis) Allergic
Reaction
Diphenhydramine Epinephrine IM
1 mg/kg, max 50 mg PO
0.15 or 0.3 mg Auto-Injector
Diphenhydramine OR
P 1 mg/kg, Max 50 mg IV/IM
Epinephrine 1:1000
A 0.01 mg / kg IM
Maximum 0.3 mg
Monitor and Reassess
Monitor for Worsening Repeat in 5 min if no improvement
Signs and Symptoms
If Symptoms Progress
Exit to
ADULT MEDICAL
Move to Other Column Difficulty Oxygenating,
Appropriate YES Ventilating, or Impending
Airway Guideline Airway Compromise
Cardiac Monitor /
The EMT may substitute a SC DHEC
approved Anaphylaxis Epinephrine
Kit for an Auto-Injector in this Cardiac Monitor /
P P
guideline. EKG Interpretation
Adult Patients
0.3 mg Epinephrine 1:1000 or EpiPen
If Wheezing, Administer
Nebulized Albuterol 5 mg
Repeat Albuterol
A
When indicated, give Epinephrine IM as Needed
in the Lateral Thigh; this site provides
the best absorption.
Symptomatic
Refractory/peri-arrest
Hypotension YES
Anaphylaxis
Guideline
Diphenhydramine
Methyl-prednisolone
P
2 mg/kg IV/IO, max 125 mg
M M
Charleston County
Clinical Guidelines
2020-11
Adult Allergic Reaction / Anaphylaxis
SC DHEC Approved Anaphylaxis Epinephrine Kit Contents:
1 – Tuberculin Syringe – 1 mL
2 – 20-22 gauge 1"-1 ½” Needles
2 – Alcohol Prep Pads
1 – Epinephrine Ampule or Vial (1:1,000 = 1 mg / 1 mL)
Pearls
 Recommended exam: Mental Status, Skin, Lung, Heart
 Anaphylaxis is an acute and potentially lethal multisystem allergic reaction.
 Epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. IM
Epinephrine should be administered in priority before or during attempts at IV or IO access.
 Symptom Severity Classification:
 Mild Symptoms (Allergic Reaction):
Flushing, hives, itching, and/or erythema; with normal blood pressure and perfusion.
ADULT MEDICAL

 Allergic reactions may occur with only respiratory and gastrointestinal symptoms and have no
rash / skin involvement.
 Moderate Symptoms (Anaphylaxis):
 Flushing, hives, itching, and/or erythema; plus respiratory (wheezing, dyspnea, hypoxia) or
gastrointestinal symptoms (nausea, vomiting, abdominal pain) with normal blood pressure and
perfusion.
 If symptoms are rapidly progressing, administer early Epinephrine 1:1000 IM.
 Severe Symptom (Anaphylaxis):
 Skin symptoms may or may not be present, depending on perfusion. Possible itching, erythema,
plus respiratory (wheezing, dyspnea, hypoxia) or gastrointestinal symptoms (nausea, vomiting,
abdominal pain) with hypotension and poor perfusion (possible altered LOC).
 Ace inhibitors can cause isolated angioedema (i.e., lip swelling without airway involvement). Methylprednisolone
125 mg IV can be administered to isolated angioedema caused by ACE Inhibitors.
 Common ACE-inhibitor blood pressure medications include Zestril (Lisinopril), Tritace (Ramipril), Renitec
(Enalapril), Vasostad (Captopril), and Cibacen (Benazepril).
 Dystonic Reactions should be treated with diphenhydramine at the same dose given for a mild allergic reaction.
Common medication groups that cause dystonic reactions include
 Antipsychotics: Zyprexa (Olanzapine), Haloperidol (Haldol), Alprazolam (Xanax), Fluphenazine (Prolixin),
Thorazine (Chlorpromazine), Ziprasidone (Geodon) and
 Antiemetics: Compazine (Prochlorperazine), Promethazine (Phenergan), Hydroxyzine (Vistaril), and
Metoclopramide (Reglan).
 Epinephrine may precipitate cardiac ischemia. Use caution with Epinephrine if:
 Patient has a history of coronary artery disease, MI, stents, CHF, cardiac surgery OR
 Patient takes Beta-Blockers or Digoxin OR
 A patient 50 years or older that has a heart rate > 150 bpm
 Adult patients who receive Epinephrine should receive a 12-Lead ECG at some point in their care, but this should
NOT delay administration of epinephrine.
 EMT may administer diphenhydramine by oral route only and may administer from EMS supply. Consider the
patient’s ability to swallow pills well and avoid PO meds with respiratory distress.
Charleston County
Clinical Guidelines
2020-11
Adult AMS / Diabetic Emergencies
Dyspnea / Increased
Airway Guideline
hypoxia or apnea
Consider Cardiac Monitor /

12 Lead EKG Acquisition
Cardiac Monitor /
P P
EKG Interpretation
Assess Blood Glucose
Glucose >250 mg/dL

Glucose <70 mg/dL Glucose > 70 mg/dL
ADULT MEDICAL
With Signs of Poor Perfusion
With Signs of Hypoglycemia With Altered Mental Status
and/or Dehydration
Consider Oral Glucose If not already done,

1-2 tubes if awake and Obtain 12-Lead EKG
no risk for aspiration
Consider Normal Saline
A
20 mL/kg; Max 1 Liter
10% Dextrose (D10) IV
Titrate to Effect
A
up to 2-4 mL/kg, max 250 mL
May Repeat Once PRN
If no IV access, administer:
A Glucagon IM
0.1 mg/kg; max 1 mg.
Assess for and Treat
Other Causes of AMS:
 Overdose/Toxic
Ingestion
Improvement? NO  Seizure
 Stroke
 Trauma
 Cardiac Dysrhythmia
 Cardiac Arrest
 Infection/Sepsis
YES
M M
Charleston County
Adult AMS / Diabetic Emergencies
Pearls
 Recommended exam: Mental Status, Skin, Respirations and Effort, Neuro
 Pay careful attention to the head exam for signs of bruising or other injury. Assess pupils.
 Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia and may have
unrecognized injuries.
 Be aware of altered mental status as a presenting sign of an environmental toxin or HazMat exposure and protect
ADULT MEDICAL
personal safety.
 Patients with prolonged hypoglycemia or malnourishment may not respond to Glucagon.
 Response to Glucagon can take 15-20 minutes. Consider the entire clinical picture when treating hypoglycemia,
including a patient’s overall clinical condition and vital signs. It may be safe to wait for Glucagon to work, instead of
pursuing the more aggressive course of performing IO access to give faster acting IO Dextrose solution. Diabetics
may have poor wound healing, and IO access may present a greater risk for infection or poor wound healing in
diabetic patients. On the other hand, consider giving IO Dextrose early in patients who are critically ill or peri-arrest
and hypoglycemic.
 Do not administer oral glucose to patients that are not able to swallow or protect the airway.
 AEMT may administer both D10 and Glucagon, however, the Paramedic should be the primary attendant unless all
symptoms in the Adult Patient are resolved after Dextrose administration, and there are no indications of other
causes of AMS.
 Use caution when allowing a patient taking oral agents or long-acting insulin agents to refuse, especially when BGL
is < 80 mg/dL. Encourage family member or other responsible party to remain with patient and recall EMS if
needed.
 Patients Refusing Transport After Treatment and Taking Oral Agents:
 Patients taking oral diabetic medications should be strongly encouraged to allow transportation to a
medical facility. They are at risk of recurrent hypoglycemia that can be delayed for hours and require close
monitoring even after normal blood glucose is established. Patients who meet criteria to refuse care should
be instructed to contact their physician immediately and consume a meal with complex carbohydrates and
protein. Consider consultation with On-Line Medical Control.
 Patients Refusing Transport After Treatment and Taking Insulin Agents:
 Many forms of insulin now exist. Longer acting insulin places the patient at risk of recurrent hypoglycemia
even after a normal blood glucose is established. Patients who meet criteria to refuse care should be
instructed to contact their physician immediately and consume a meal with complex carbohydrates and
protein.
 EMS Personnel are not permitted to administer, or assist with administration of, insulin. In the unresponsive
hypoglycemic patient with an insulin pump, consider suspending or disconnecting device. Elicit family assistance if
unfamiliar with the device.
Charleston County
Adult Behavioral
Exit to Appropriate Guideline If Indicated

Remove patient from
Altered Mental Status Guideline stressful environment
Scene
YES Overdose/Toxic Ingestion Guideline and use verbal calming
Safe?
techniques, when
Assume patient has Medical cause of
appropriate.
behavioral change
NO
Call for help / additional

resources. Diabetic Guideline
Blood Glucose Analysis Procedure
Stage until scene safe. If indicated
Paranoia, disorientation, extremely

aggressive or violent, hallucinations,
tachycardia, increased strength,
hyperthermia.
Clearly a danger to self or others. YES
NO
Ketamine 4 mg/kg IM
P
ADULT MEDICAL
Maximum dose 500 mg
Aggressive or Agitated,
possible psychosis.
Consider Restraint Physical Procedure
Possibly a danger to
self or others Monitor per restraint procedure
YES

Consider Restraint Physical Procedure Cardiac Monitor /
Monitor per restraint procedure Consider 12 Lead EKG Acquisition
Cardiac Monitor /
P P
EKG Interpretation
Midazolam 2.5 mg IV NO For Possible Excited/Agitated Delirium:

OR
Normal Saline 1L Bolus
P If unable to initiate IV, May repeat 500 mL bolus x2 as
Midazolam 5 mg IM/IN A
indicated
Repeat x1 after 5 min, if needed Maximum 2 Liters
Consider External Cooling Measures
Cardiac Monitor /
Consider 12 Lead EKG Acquisition Consider Midazolam 2.5 mg IV
Cardiac Monitor / P for Emergence Reaction.
P P Repeat x1 after 5 min, if needed
EKG Interpretation
M M
Charleston County
Adult Behavioral
When appropriate, attempt less restrictive means of managing patient:
 Remove patient from stressful environment
 Use verbal calming techniques (calm, reassure, establish rapport)
Pearls
 Recommended exam: Mental Status, Skin, Lung, Heart, Neuro
 Crew / responder safety is the main priority. SEE PHYSICAL RESTRAINT PROCEDURE.
 Any patient who is handcuffed or restrained by Law Enforcement and transported by EMS must be
accompanied by law enforcement.
ADULT MEDICAL
 All patients who receive restraint must be continuously monitored. Refer to restraint procedure.
 Midazolam (Versed) should not be administered to patients with a systolic blood pressure (SBP) of less
than 100 mmHg. Use caution in patients with age >65 years, and administer medication at 1 mg IV or 2 mg
IM/IN if indicated in guideline above.
 Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse,
hypoxia, head injury, etc.)
 Consider sedation and pain control early in combative patients with head injury.
 Do not irritate the patient with a prolonged exam.
 Do not overlook the possibility of associated domestic violence or child abuse.
 Do not position or transport any restrained patient in a way that negatively affects the patient’s respiratory or
circulatory status.
 Excited Delirium Syndrome:
 Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances,
disorientation, violent / bizarre behavior, insensitivity to pain, hyperthermia and increased strength.
 Life-threatening and associated with use of physical control measures, including physical restraints and
Tasers. Most commonly seen in male subjects with a history of serious mental illness and/or drug abuse,
particularly stimulant drugs such as cocaine, crack cocaine, methamphetamine, amphetamines or similar
agents.
 Cardiac Dysrhythmia: If patient is in a wide complex tachycardia, administer Sodium Bicarbonate 50
meq IV. Repeat sodium bicarbonate twice, or until QRS narrows. Consider contacting on-line medical
control.
 If patient suspected of excited delirium suffers cardiac arrest, consider fluid bolus and Sodium Bicarbonate
early.
 Emergence Agitation / Reaction:
 Emergence reaction is a condition in which emergence from sedation with Ketamine (or other medications)
is accompanied by psychomotor agitation. Patients may experience hallucinations and increased motor
activity.
 Emergence reaction may be treated with Midazolam 2.5 mg IV or 5 mg IM/IN. Dose may be repeated
after 5 minutes if needed and systolic blood pressure is >100 mmHg.
Charleston County
Adult Fever / Infection / Suspected Sepsis
Consider Appropriate PPE and/or

indicated infection control measures
Consider Ibuprofen PO
Pediatric: 10 mg/kg
Temperature > 100.4° F
YES OR
(38° C)
Acetaminophen PO
Pediatric: 15 mg/kg
Obvious or suspected
infection
AND NO Exit to Appropriate Guideline
Patient meets criteria for
Sepsis / Severe Sepsis
Possible Sepsis (Any 2 SIRS): YES
 Temp: ≥ 100.4° F (38° C) OR

 Temp: < 96.8° F (36° C) Consider Cardiac Monitor /
 Respirations > age appropriate 12 Lead ECG Acquisition
range
Cardiac Monitor /
P P
EKG Interpretation
ADULT MEDICAL
Severe Sepsis/Shock
 Sepsis (2 SIRS) AND
 Age Appropriate hypotension OR
 ETCO2: < 26 mmHg Vascular Access Guideline
Normal Saline 500 mL bolus

then reassess SIRS criteria and
re-examine.
A Repeat 500cc bolus to Max 2
Liters as long as SIRS criteria
present, unless concern for fluid
overload.
Consider Hypotension Guideline and

use of push-dose vasopressors if
patient remains hypotensive
Possible Sepsis Severe Sepsis/Shock

Notify Receiving Hospital of Suspicion of Declare Sepsis ALERT to Receiving
Sepsis. Do NOT provide alert. Hospital
M M
Charleston County
Adult Fever / Infection / Suspected Sepsis
Pearls
 Recommended exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
 Febrile seizures are more likely in children with a history of febrile seizures and with rapid elevation in temperature.
Febrile seizures are uncommon in children > 6 years old.
 UTILIZE STANDARD UNIVERSAL PRECAUTIONS FOR ALL PATIENTS WITH SUSPECTED INFECTION.
 Droplet precautions include standard PPE plus a standard surgical mask for providers who accompany patients in
the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be
utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle
droplets are suspected. A patient with a potentially infectious rash should be treated with droplet precautions.
ADULT MEDICAL
 Contact precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact,
and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g.
MRSA), scabies, or zoster (shingles), or other illnesses spread by contact are suspected.
 All-hazards precautions include standard PPE plus airborne precautions plus contact precautions. This level of
precaution is utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when
the causative agent is found to be highly contagious (e.g. SARS).
 Ibuprofen should not be used in patients who are pregnant, with known renal disease or renal transplant, in
patients who have known drug allergies to NSAID’s (non-steroidal anti-inflammatory medications), or with active or
suspected bleeding (intracranial, GI, etc).
 Do not administer Ibuprofen to patients < 6 months of age.
 Do not administer Acetaminophen to patients with a history of liver disease or liver transplant.
 Consider whether elevated temperature is due to “fever” (and suspected infection), or a possible environmental
heat emergency. NSAIDs should not be used in the setting of environmental heat emergencies.
 If patient has been administered Ibuprofen or Acetaminophen within the past 4 hours do not administer the same
medication.
 Suspected Sepsis / Septic Shock
 Early recognition of Sepsis allows for attentive care and early antibiotics. Patient must have an obvious or
suspected infection, PLUS at least two Systemic Inflammatory Response Syndrome (SIRS) criteria.
 If pediatric patient has suspected sepsis, relay suspicion to receiving hospital and treat with pediatric fluid/
hypotension guidelines as indicated.
 Aggressive IV fluid therapy is the most important prehospital treatment for sepsis. Suspected septic patients
should receive repeated fluid boluses (to a max of 2 liters) while being checked for signs of pulmonary edema,
especially patients with known history of CHF or ESRD on dialysis. STOP fluid infusion in the setting of
pulmonary edema.
 Attempt to identify source of infection (skin, respiratory, etc) and relay previous treatments and related history
to ED physician.
 Elevated serum lactate levels are a useful marker of hypoperfusion in sepsis and often become elevated prior
to the onset of hypotension. End Tidal CO2 levels are correlated with lactate levels.
 Measure ETCO2 with any patient with suspected sepsis. Two values less than 26 mmHg on consecutive
measurements 5 minutes apart can be used to help identify severe sepsis.
 Document amount and rate of fluid administration in the EHR. Expected rate is 500mL / 10 minutes.
Charleston County
Adult Nausea / Vomiting

Diabetic Guideline
If indicated
Serious Signs /
Symptoms
NO YES
Hypotension, poor
perfusion, shock
ADULT MEDICAL
Symptomatic Hypotension Guideline
Consider Ondansetron 4 mg IV/

IO/IM
Administer Over 2 Minutes
P
May Repeat After 5 Minutes
May Substitute ODT, if Available
May Consider Diphenhydramine

P 1 mg/kg, Max 50 mg IV/IM if
Ondansetron is Ineffective
M M
Pearls
 Consider and treat underlying cause of nausea/vomiting. Cardiac monitoring is indicated in elderly patients and
those with significant history.
 Use ODT (orally disintegrating tablets) with caution in adult patients complaining of abdominal pain.
 For ODT, place one tablet on top of patient’s tongue.
 Heart Rate: One of the first clinical signs of dehydration is increased heart rate. Tachycardia increases as
dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal.
 Beware of vomiting only in children. Pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or
increased CSF pressures) all often present with vomiting.
Charleston County
Adult Overdose / Toxic Ingestion
Pandemic Patient Care and

Scene
YES Pandemic Airway Guideline
Safe?
As indicated
If Needed,
Cardiac Monitor /
Palmetto Poison Control
NO Consider 12 Lead EKG Acquisition
1-800-222-1222
Cardiac Monitor /
P P
EKG Interpretation
resources. Vascular Access Guideline
Stage until scene safe.
Adequate Respirations / Utilize Appropriate Airway

NO
Oxygenation / Ventilation Guideline
AMS / Diabetic Guideline YES Altered Mental Status
ADULT MEDICAL
Naloxone 0.5 - 1 mg IN
Symptomatic Hypotension Naloxone 0.5 – 1 mg IV/IM/

YES Age Specific Hypotension
Guideline IN
Titrate to adequate
A ventilation and oxygenation;
NOT GIVEN TO RESTORE
CONSCIOUSNESS
Consider Potential Cause
Repeat As Needed*
NO Patient has serious Signs /
Symptoms with suspected:
Tricyclic
Beta Blocker OR Organophosphate Exposure
Antidepressant OD
Calcium Channel Blocker OD
Hypotension and Tachycardia,
Hypotension, Tachycardia,
Hypotension and Bradycardia S.L.U.D.G.E.
and QRS ≥ 0.12 sec
YES YES YES
Utilize Cardiac External Sodium Bicarbonate IV/IO Atropine IV/IO

P Pacing Procedure Early for 1 mEq/kg, up to 50 mEq 0.1 mg/kg, up to 2 mg
Severe Cases P P
Repeat Every 5 Min May Repeat Every 5 Min
Calcium Gluconate IV/IO Until QRS Narrows Maximum 10 mg
P 100 mg/kg, up to 1 g
May Repeat Every 10 Min
Glucagon 2 mg IV/IO
P
May Repeat if Symptomatic
M M
Charleston County
Adult Overdose / Toxic Ingestion
Isolated Heroin Overdose Refusal Guidelines
EMS crews should attempt to convince any patient treated for a possible opioid overdose to allow transport to the ED of
their choice for additional evaluation and monitoring. However, multiple observational studies have indicated that no
short-term deaths were found in the subsets of opioid overdose patients who received naloxone treatment in the field
and refusal may be permissible in some circumstances. Patient’s wishing to refuse must meet the following guidelines:
 The patient must be age 18 or older and be suffering from an isolated IV opioid overdose, i.e. with depressed
mental status or respiratory distress/arrest from an opioid overdose. Patients are treated as per page 1 of this
guideline.
 The patient must not have overdosed on any transdermal or oral narcotics such as oxycontin, methadone, etc.
 The patient must never have been in cardiac arrest during this incident, nor received CPR.
 The patient must regain a normal mental and respiratory status after naloxone administration of up to 2mg.
 Once “awake” the patient must be fully oriented to person, place, time and events. EMS crew should monitor
patient for up to 30 minutes to ensure no recurrence of altered mentation.
The treating EMS crew must document all attempts to convince the patient of transport, the total observation time, and
refusal plan (who is going to observe them, if possible). If patient does not meet these criteria and still wishes to refuse,
consult with On-Line Medical Control for guidance and disposition.
ADULT MEDICAL
Pearls
 Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not
carrying other medications or has any weapons.
 Bring pill bottles, contents, emesis to the emergency department.
 S.L.U.D.G.E: Salivation, Lacrimation, Urination, Defecation, GI Distress, Emesis
 D.U.M.B.B.E.L.S.: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Salivation
 Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid
progression from alert mental status to death.
 Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure.
 Aspirin: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later.
Renal dysfunction, liver failure, and or cerebral edema among other things can take place later.
 Depressants: decreased HR, decreased BP, decreased temp., decreased respirations, non-specific pupils
 Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures
 Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes
 Cardiac Medications: dysrhythmias and mental status changes.
 Solvents: nausea, coughing, vomiting, and mental status changes
 Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils
 Consider restraints if necessary for patient’s and/or personnel’s protection per the Restraint Procedure.
 Naloxone*:
 Repeat dosing as needed (no maximum) if high suspicion for significant opioid overdose not responsive to
initial dosing.
 EMT may administer naloxone by IN route only. May administer from EMS supply.
 IV administration of Glucagon may precipitate nausea and vomiting. Consider Ondansetron administration.
 When appropriate, contact the Palmetto Poison Control Center (1-800-222-1222) for guidance.
Charleston County
Adult Pain Control
Patient care according to Clinical

Guideline based on Specific Complaint
Maximize non-pharmaceutical means
of pain management:
 Splinting
 Icing
 Elevating the Injury
 Utilizing Positions of Comfort
Pediatric: 10 mg/kg
Pain Severity >6 out of 10 Adult: 400-800 mg
OR NO OR
Indication for IV / IM Medication Acetaminophen PO
Pediatric: 15 mg/kg
YES Adult: 1000 mg
Obtain baseline SPO2 and
ADULT MEDICAL
Monitor Continuously.
Consider ETCO2 Monitoring.
Fentanyl 1 mcg/kg IV/IO/IM/IN Morphine and Fentanyl Doses listed

up to 100 mcg. in this guideline may not be exceeded
P
May repeat half dose Q 5 without On-Line Medical Control
minutes. Max Dose = 200 mcg
OR
Morphine 0.1 mg/kg IV/IO/IM
up to 5 mg.
P
May repeat half dose Q 5
minutes. Max Dose = 10 mg
Consider Nausea/Vomiting Guideline
Consider Ketamine
SEVERE Pain Refractory to Max 0.2 mg/kg IV/IO

Fentanyl or Morphine Dose OR
YES P
OR 0.4 mg/kg IM/IN
Significant Burns
Repeat Q 5-10 minutes,
NO as needed
Must reassess patient at least every

10 minutes after sedative medication
M M
Charleston County
Adult Pain Control
Relative Contraindications Relative Contraindications
for IV Pain Control: for Non-Steroidal Agents:
 Severe Head Injury  Active Bleeding
 End-Stage Lung Disease  Possible Surgery
 Untreated Hypotension  Renal Disease
Pearls
 Recommended exam: Mental Status, Area of Pain, Neuro
 Pain severity (0-10) is a vital sign to be recorded pre and post medication delivery and at disposition.
 Vital signs should be obtained pre, 10 minutes post, and at disposition with all pain medications.
 IV / IM Medications (Fentanyl, Morphine, Ketamine)
 Relative Contraindications to the use of a narcotic include hypotension, head injury, respiratory distress or
severe lung disease. Treat hypotension prior to administration of Fentanyl or Morphine.
 Weight-based dosing may provide a standard means for dose calculation, but does NOT predict patient
response. It may be appropriate to start with LESS THAN the weight-based dose. For example, minimal
doses of opioids may be effective for pain management and/or cause respiratory depression in the elderly,
opiate naïve, and possibly intoxicated patients.
 All patients who receive IM or IV medications must be observed 15 minutes for drug reaction.
 Monitor all patients receiving narcotic or sedative medications with continuous Pulse Oximetry. Consider
nasal ETCO2 for any patient with decreased LOC or at risk for respiratory depression.
 Rapid administration of IV/IO Ketamine has been associated with increased incidence of Emergence
Reaction/Agitation. Ketamine should be diluted in 10-20 mL of NS and administered over 2 minutes.
 PO Medications (Ibuprofen, Acetaminophen)
 Do not administer any PO medications for patients who may need surgical intervention such as open
fractures or fracture deformities, headaches, or abdominal pain.
 Ibuprofen should not be used in patients who are pregnant, with known renal disease or renal transplant,
in patients who have known drug allergies to NSAID’s (non-steroidal anti-inflammatory medications), or
with active or suspected bleeding (intracranial, GI, etc).
 Ocular Anesthesia
 Instill one or two drops of Proparacaine into the effected eye every five to ten minutes to relieve eye pain,
up to five doses.
 Instill two drops of Proparacaine into the eye prior to irrigating the eye.
 Protected the eye from foreign bodies and abrasion during the period of anesthesia. Warn the patient not
to touch the eye until the anesthesia has worn off.
 Burn patients may require higher than usual opioid doses to effect adequate pain control. IF AN ADULT PATIENT
HAS SUFFERED BURNS THAT REQUIRE TRANSPORT TO THE BURN CENTER, consider the use of
Ketamine after the initial dose of Fentanyl. Do not hesitate to contact medical control regarding the pain
management strategy for patients in severe pain despite medications or with significant burns.
Charleston County
Charleston County
Adult Psychiatric Evaluation
Does the patient meet ANY of the

following criteria?:
 Acute medical or trauma complaint
 Pediatric Patient (<12 years)
 Non-ambulatory (or requires assist)
 Suspicion of overdose
NO Refer to Appropriate Guideline

and Transport
Evaluate vital signs:
 Pulse <50 or >110
 RR <8 or >24
 SBP <85 or >180, or DBP >120
 SpO2 <94% on Room Air
 BGL <60 or >300
 GCS <14
NO
Teleconference with
P P
Mobile Crisis
Involuntary Hospital Voluntary Hospital Mental Health Follow-up

Admission Admission Center (Immediate) appointment
Therapeutic Transport Family/friend, self,

(CCSO) takes patient to community partner transport
destination to destination
Treated, Transported by Law Treated, Transported by

Enforcement Other Means
Pearls
• Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro
• Patients with medical/trauma complaints or those who are combative/uncooperative are not candidates for
teleheath consult.
• BGL should be assessed in known or suspected diabetics and any patient with altered mental status
• Teleconference with mobile crisis: Ambulance leaves and SUV stays. PD to remain if needed.
• Mobile Crisis will make destination determination and will coordinate arrangements for transport. EMS will transport
to ED if requested by Mobile Crisis.
Charleston County
Adult Seizure
Protect patient from

physical harm Respiratory/Ventilatory Insufficiency
If available measure EtC02 Universal Airway Guideline
Consider Airway Compromise
If patient is actively seizing consider:

P Midazolam 0.2 mg/kg IM/IN up to 10 P
mg
Cardiac Monitor /
Cardiac Monitor /
P P
EKG Interpretation
Consider Spinal
YES Evidence of Trauma
Motion Restriction
ADULT MEDICAL
Still Actively Seizing?
NO Recurrence of Seizure Activity?
Combative Postictal State?
YES
Midazolam (Versed) 0.1 mg/kg slow IV

push up to 5 mg
P May repeat Midazolam 0.05 mg/kg up to 2.5
mg X2 Q 5 minutes, if needed
Max Total IV Dose = 10 mg
OR
Midazolam (Versed) 0.1 mg/kg IM up to

5 mg
P May repeat Midazolam 0.1 mg/kg up to 5 mg
X2 Q 5 minutes, if needed
Max Total IM Dose = 20 mg
Monitor and Transport
M M
Charleston County
Adult Seizure
ADULT MEDICAL
Pearls
 Recommended Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro
 Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This
is a true emergency requiring rapid airway control, treatment, and transport.
 Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma.
 Focal seizures (petit mal) affect only a part of the body and are not usually associated with a loss of consciousness
 Jacksonian seizures are seizures which start as a focal seizure and become generalized.
 Be prepared for airway problems and continued seizures. Be prepared to assist ventilations.
 Assess possibility of occult trauma and substance abuse.
 For actively seizing patients on EMS arrival, (i.e. no IV) administer IM VERSED prior to establishing IV access.
 Todd's paralysis is a neurological condition experienced by individuals with epilepsy, in which a seizure is followed by
a brief period of temporary paralysis. The paralysis may be partial or complete but usually occurs on just one side of
the body.
 If a pregnant patient is actively seizing or postictal, administer magnesium sulfate 2 gm slow IVP. If a pregnant
patient gives a history of a recent seizure but is not actively seizing and is not postictal, contact Medical Control
before administering magnesium sulfate.
Charleston County
Adult Suspected Stroke

Cardiac Monitor /
P P
EKG Interpretation
Diabetic Guideline
If Indicated
Prehospital Stroke Screen

Negative Exit to Appropriate Guideline
Tool (FAST/Cincinnati)
Positive
RACE Stroke Score
ADULT MEDICAL
Transport to Closest Stroke Center
<4
≥4 with STROKE ALERT if onset <7 hours
NO Minimize Scene Time
Last Known Normal
Time is < 24 Hours
YES
Transport to Closest
Comprehensive or Thrombectomy
Capable Stroke Center
with STROKE ALERT
Minimize Scene Time
Charleston County Stroke Facilities Consider Other Guidelines as Indicated

 Altered Mental Status
Comprehensive Stroke Center:  Seizure
MUSC  Hypotension
 Overdose / Toxic Ingestion
Thrombectomy Capable Center
Trident Vascular Access Guideline
Primary Stroke Center:
Roper Downtown
Saint Francis Notify Destination or
East Cooper M M
Charleston County
Adult Suspected Stroke
Absent (symmetrical movement) 0
Assess Facial Palsy
Mild (slight asymmetrical) 1
Cincinnati Stroke Assessment
Ask patient to show their teeth (smile) 2

Moderate to Severe (completely asymmetrical)
Assess Arm Motor Function Normal to Mild (limb upheld >10 seconds) 0
Extending the arm of the patient Moderate (limb upheld <10 seconds) 1
to 90 (sitting) or 45 (supine) Severe (unable to raise arm against gravity) 2
Slurred Speech Consider

Positive – Inability to repeat words correctly and intelligibly Transport to
Ask the patient to repeat a simple sentence No points awarded for RACE; raises index of suspicion Primary Stroke
such as “The sky is blue in Cincinnati” Center*
Absent (limb upheld >5 seconds) 0

Assess Leg Motor Function
Mild (limb upheld less than 5 seconds) 1
Extending the leg of the patient 30 (in supine) 2
Moderate to Severe (unable to raise leg)
Absent (eye movement to both sides possible

Assess Head & Gaze Deviation 0
and no head deviation was observed)
Observe eyes and head deviation to one side 1
Present (eyes and head deviation to one side)
ADULT MEDICAL
LEFT Deficit Any Deficits? RIGHT Deficit
Aphasia Assessment
Agnosia Assessment
Difficulty understanding spoken or written words. Ask
Inability to recognize familiar objects. Ask patient:
patient to follow two simple commands:
1) “Whose arm is this?” (while showing affected arm)
1) “Close your eyes.”
2) “Can you move your arm?”
NO 2) “Make a fist.”
Normal (recognizes arm and attempts to move it) 0 Normal (performs both tasks correctly) 0
Moderate (doesn’t recognize arm or is unaware of it) 1 Moderate (performs only 1 of 2 tasks correctly) 1
Severe (doesn’t recognize arm and is unaware of it) 2 Severe (Cannot perform either task correctly) 2
Transport to ADD all points Transport to

Score 1-3 Score 4-9
Primary Stroke Center for total score Comprehensive Stroke Center
Pearls
 Recommended exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro
 Items in Red Text are key performance measures used in the EMS Acute Stroke Care Toolkit.
 RACE is based on Acute Non-Traumatic Symptoms ONLY.
 ALL RACE SCORES > 0 are indicative of stroke.
 RACE SCORE ≥ 4 is INDICATIVE of Large Vessel Occlusion (LVO) Stroke that may benefit from
interventional procedures.
 With suspected acute stroke, limit scene time and provide early hospital notification
 Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke
symptoms would be defined as an onset time of the previous night when patient was symptom free).
 The differential listed on the Altered Mental Status Guideline should also be considered.
 Be alert for airway problems (swallowing difficulty, vomiting/aspiration).
 Hypoglycemia can present as a localized neurologic deficit.
 Document the Stroke Screen results in the PCR.
 Document the STROKE ALERT and 12 Lead ECG as a procedures in the PCR.
 For Suspected Stroke, elevate head of stretcher to approximately 30 degrees.
Charleston County
Adult Hypotension (Symptomatic)
Vascular Access Protocol
Suspected
Etiology?
Trauma Cardiac
Non-Cardiac / Non-Trauma
Treatment per Consider Anaphylaxis or Treatment per

appropriate Sepsis Protocol appropriate
Trauma Protocol Cardiac Protocol
ADULT MEDICAL
Normal Saline 500mL Bolus
A Maintain SBP > 80 mmHG
Normal Saline 500mL Bolus Maximum 2 L No rales present
A Maintain SBP > 80 mmHG A Normal Saline 250mL Bolus
Maximum 2 L Maximum 500 mL
Consider
P Push-Dose Epinephrine
10-20 mcg q 2-5 minutes
Consider Consider
Push-Dose Epinephrine Notify Destination or Push-Dose Epinephrine
P M M P
10-20 mcg q 2-5 minutes Contact Medical Control 10-20 mcg q 2-5 minutes
for Neurogenic Shock
Pearls
 Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro.
 Hypotension can be defined as a systolic blood pressure of less than 90. This is not always reliable and should be
interpreted in context and with patient s history and typical BP if known.
 Repeat Vital Signs AFTER each Bolus or Change in Pharmacologic Therapy (Change in Dose or Agent).
 STOP fluid administration if signs of pulmonary edema develop.
 Shock may be present with a normal blood pressure initially.
 Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only
manifestation.
 Consider all possible causes of shock and treat per appropriate protocol.
 Push-dose vasopressors should be considered only after administration of fluid, and never for hypovolemic/
hemorrhagic
 shock.
Acute Adrenal Insufficiency:
 State where body cannot produce enough steroids (glucocorticoids/mineralocorticoids). May have primary adrenal
disease or more commonly have stopped a steroid like prednisone. Usually hypotensive with nausea, vomiting,
dehydration and/orabdominal pain. If suspected, Paramedic should give Methylprednisolone 125 mg IV / IO.
Charleston County
Adult Burn
Ensure that Scene is Safe
Thermal Burn Chemical Burn

Cool down the wound with Remove clothing or expose area;
Isotonic Crystalloid or Sterile brush off any dry chemicals
Water. After cooling cover burn or powder; then flush area with
with a Dry sheet or dressings. large amount of water or Isotonic
Take Proper Measures to Crystalloid
Prevent Hypothermia after Take Proper Measures to
Cooling Prevent Hypothermia after
Cooling
Burn Center Criteria

 Partial thickness burns greater
than 10% total body surface area Identify total body surface area
(TBSA). (BSA) affected by burns
 Burns that involve the face, Exit to Appropriate
(2nd and 3rd Degree) NO
hands, feet, genitalia, perineum, Guideline
Does patient meets burn center
or major joints.
 Third degree burns in any age
criteria or require ALS intervention?
group.
 Electrical burns, including YES
lightning injury.
 Chemical burns. Cardiac Monitor /
 Inhalation injury. Consider 12 Lead EKG Acquisition
 Burn injury in patients with
preexisting medical disorders that Cardiac Monitor /
could complicate management, P P
EKG Interpretation
TRAUMA
prolong recovery, or affect
mortality.
 Any patient with burns and Vascular Access Guideline
concomitant trauma (such as
fractures) in which the burn injury Obtain baseline SPO2 and
poses the greatest risk of Monitor Continuously.
morbidity or mortality.
Exit to Appropriate Airway Difficulty Oxygenating, Ventilating,

YES
Guideline or Impending Airway Compromise
Exit to Carbon Monoxide/ Suspected Carbon Monoxide/

YES
Cyanide Guideline Cyanide Exposure
Exit to Pain Management

YES Severe Pain
Guideline
Normal Saline
≥14 years = 500 ml/hr
Burn Centers <14 years = 250 ml/hr
 Medical University of South

Carolina (Adult and Pediatric)
M M
Charleston County
Clinical Guidelines
2020-11
Adult Burn
TRAUMA
Pearls
 Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro.
 Classification of Burns:
First Degree (Partial Thickness) Superficial, red, sometimes painful.
Second Degree (Partial Thickness) Skin may be red, blistered, swollen. Very painful.
Third Degree (Full Thickness) Whitish, charred or translucent, no pin prick sensation in burned area.
 Critical or Serious burns should be transported directly to a Burn Center if possible (MUSC). Consider whether a
patient meets trauma criteria as per Field Trauma Triage. Transport to a Trauma Center or the CLOSEST
EMERGENCY DEPARTMENT as necessary in the event of any airway management complication in a burn patient.
Consider remaining at the ED if possible in order to resume transport to burn center once airway secured, if patient
condition permits.
 Early intubation is indicated if the patient has sustained significant inhalation injuries.
 Burn patients are trauma patients, evaluate for multisystem trauma.
 Assure whatever has caused the burn is no longer contacting the injury. STOP THE BURNING PROCESS!
 Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue
swelling.
 Burn patients are prone to hypothermia - never apply ice to cool the burn, must maintain normal body temperature.
 Evaluate the possibility of geriatric abuse with burn injuries in the elderly.
Charleston County
Open Fracture Antibiotic: Cefazolin

• Exposed bone
• Open joint fractures and dislocations
• Amputations of any extremity or part
(excluding tips of fingers or toes)
• Grossly contaminated large soft tissue
defects
Trauma
Reported allergy to Penicillins or Do not administer
Yes
Cephalosporins Cefazolin
No
Cefazolin IV
Reconstitute in 5-10mL of Sterile
P Water
2 grams
M M
Pearls
• Recommended exam: Mental Status, Neuro, areas of injury
• Administration of Cefazolin should not precede any other needed interventions or assessments.
• Be cognizant of lacerations above areas of crepitus where the fractured bone may have pierced the skin and not
remained visible.
• Examples of grossly contaminated large soft tissue defects include: animal bites or open wounds containing an
excessive amount of foreign matter.
• Be alert for signs and symptoms of anaphylaxis during antibiotic administration.
• Scene time should not be delayed for administration of Cefazolin.
Charleston County
Adult Traumatic Cardiac Arrest

AT ANY TIME
While On Scene
Rhythm deteriorates to
Asystole or PEA < 30
Injuries Incompatible with Life
or
YES
Place patient on the monitor. Is there
Asystole or PEA with rate < 30?
NO Discontinue
Resuscitation
Notify Coroner
Attempt Resuscitation. Continue CPR
Bilateral Chest throughout and Transport rapidly to the
P P YES
Decompression nearest hospital.
Known or Suspected Chest Injury?
NO
Possible medical cause of arrest

Go to Cardiac
(in presence of trauma) or YES
Arrest Guidelines
suspected drowning/aspyxia?
ADULT TRAUMA
NO
Transport to
Airway Guidelines Nearest Hospital –
after CPR and
Airway Control
Vascular Access
with Fluid Bolus
Go to Appropriate
Return of Pulse? YES
Guideline
NO
Transport to
Continue Fluid Bolus
Level 1 or 2
Transport to Nearest Hospital
Trauma Center
Pearls
 Injuries obviously incompatible with life include: decapitation, massively deforming head or chest injuries,
dependent lividity, rigor mortis, extended downtime with cold skin.
 In general, resuscitation should be attempted for traumatic cardiac arrest patients with “signs of life” for any
professional responders, especially in cases with short transport times to the trauma center (< 15 minutes).
 Resuscitation should be attempted in the case of maternal traumatic arrest where the patient is visibly pregnant or
is known to be ≥ 24 weeks gestation.
 “Signs of Life” include any pulse or blood pressure, any spontaneous respirations or movement, reactive pupils.
 Take only immediately life-saving equipment and transport device to patient side.
 As with all major trauma patients, transport should not be delayed and scene times should be minimal.
 Where the use of spinal immobilization interferes with performance of quality CPR, make reasonable efforts to
manually limit patient movement.
Charleston County
Trauma Patients With Life Threatening Injuries –
Adult
Consider whether helicopter evacuation is appropriate. E EMT
A Advanced EMT
Assure adequate airway and ventilation.
See SPINAL MOTION RESTRICTION protocol. P Paramedic
 Support oxygenation with high flow oxygen.
 Assist ventilation with bag-valve-mask if needed.
 Suction as needed
Reference airway guidelines for further guidance.
Control major external hemorrhage. Apply tourniquet(s) early if needed.
Perform pleural decompression if:

1. The patient is hemodynamically unstable, AND
2. There is strong evidence of tension pneumothorax.
Transfer to stretcher, stabilizing extremity injuries manually.
EVACUATE TO UNIT AND TRANSPORT!
Monitor BP, pulse rate, oxygen saturation, and level of consciousness.
Initiate vascular access with normal saline.

1. If BP and perfusion are adequate, run fluid at KVO rate.
2. If BP or perfusion are compromised, rapidly infuse fluid IV or IO
a. Until a systolic blood pressure of 80 mm Hg is attained, OR
b. Until evidence of adequate perfusion is achieved, OR
c. Until a maximum of two liters have been infused.
3. Establish a second point of vascular access if possible.
If time permits
1. Complete secondary survey.
2. Dress wounds.
3. Splint fractures.
Charleston County
Carbon Monoxide / Cyanide
Immediately Remove from Exposure

and administer High Flow Oxygen
Blood Glucose Analysis Diabetic Guideline
Age appropriate Multiple Trauma Spinal Motion Restriction Guideline

Guideline if indicated If indicated
Cardiac Monitor /
Cardiac Monitor /
ADULT ENVIRONMENTAL/OTHER
P P
EKG Interpretation
EtCO2 Monitoring
Consider CO Monitoring
Difficulty Breathing OR Monitor & Reassess

NO
Altered Sensorium ? Continue High Flow Oxygen
YES
Age appropriate Airway Guideline

if indicated
Hydroxocobalamin
Strong Suspicion 70 mg/kg IV / IO
YES P
of Cyanide ? Maximum 5 g IV / IO
infused over 15 minutes
NO
Adult SBP <90 or

Age Specific VS Consider Symptomatic
YES
(SBP < 70 + 2 x Age) Hypotension Guideline
Poor Perfusion / Shock
NO
Monitor & Reassess Notify Destination or

M M
Continue High Flow Oxygen Contact Medical Control
Pearls
 Recommended exam: Neuro, Skin, Heart, Lungs, Abdomen, Extremities
 Scene safety is priority.
 Consider CO and Cyanide with any product of combustion, especially burning wools, silk, plastics, and furniture.
 Follow medical Cardiac Arrest algorithm for patients in cardiac arrest, with prioritization of airway management and
oxygenation, and consider early transport. Hydroxocobalamin may be administered after achieving ROSC.
 Normal environmental CO level does not exclude CO poisoning.
 Symptoms present with lower CO levels in pregnancy, children and the elderly.
 Continue high flow oxygen regardless of pulse ox readings.
 Do NOT delay treatment or transport of the sick/unstable patient to obtain 12 Lead ECG.
 Pulse Oximetry Readings may read FALSELY HIGH with Carbon Monoxide Poisoning
Charleston County
Hydrofluoric Acid Exposure
Use PPE to Prevent

Exposure to Acid
Rapidly decontaminate patient to prevent
further absorption:
 Remove Contaminated Garments
 Copiously irrigate exposed tissues with water.
Inhalation Route of Exposure ? Eye
Skin
ADULT ENVIRONMENTAL/OTHER
Nebulize Calcium Gluconate Immediately flush exposed area with Immediately flush eyes with
solution large amounts of water. large amounts of water.
P
(Mix 3 mL of 10% solution Apply Calcium Gluconate Instill Proparacaine eye
with 6 mL Normal Saline) P
Gel to burned area. drops to the affected eye(s).
P
(Mix 10mL of 10% solution
with approx 30 ml of KY jelly) Continuously irrigate the eye(s).
Leave gel in place.

Reapply as needed to Control Pain.
Cardiac Monitor /
Cardiac Monitor /
P
EKG Interpretation
For signs of system involvement:
10% Calcium Gluconate

P
10 mL IV / IO.
M M
Pearls
 Responder safety is priority. Utilize PPE and proper decontamination procedures.
 Injury is twofold – compound causes corrosive burning of the skin and deep underlying tissue, and also binds with
calcium and magnesium from the nerve pathways, bone, and blood stream.
 Symptoms of systemic involvement: Cardiac dysrhythmias, conduction disturbances, ST Segment
abnormalities, tetany, and/or seizures. Systemic involvement may deteriorate to cardiac arrest.
 Pain is managed through administration of calcium, not analgesic. General Pain Control Guidelines may be
considered AFTER all treatment steps above.
Charleston County
Pediatric
Pediatric Universal Airway
Assess Airway and Breathing Adequate
Inadequate
Supplemental Oxygen
Basic Maneuvers First
Goal saturation 90%-99%
 Position Airway
 Consider OPA/NPA
Consider Suction and/or Foreign

NO Airway Patent?
Body Obstruction Procedures
YES
Ventilatory Monitor / Reassess

Support Supplemental Oxygen &
PEDIATRIC AIRWAY
NO
Needed? Exit to Appropriate Guideline
YES
Supplemental Oxygen BVM
Unable to Ventilate and

Oxygenate adequately
during or after:
 One (1) or more BVM Effective? YES M M
unsuccessful
intubation attempts
AND NO
Anatomy inconsistent
with continued
BIAD Procedure
attempts OR
BIAD or Intubation
 Three (3) total P P
as Appropriate
unsuccessful
attempts
SUCCESSFUL
Exit to Follow Airway Confirmation

Adult Failed Airway Procedure and Post Airway
Guideline Management Guideline
Charleston County
Clinical Guidelines
2020-08
Pediatric Universal Airway
Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital endotracheal
intubations are to be considered high risk. If ventilation / oxygenation is adequate, transport may be the best option. The
most important airway device, and the most difficult to use correctly and effectively, is the Bag Valve Mask (not the
laryngoscope).
Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques.
Difficult BVM Ventilations: Difficult mask seal due to anatomy, blood or secretions / trauma, obesity, and stiff or
increased airway pressures.
Difficult Laryngoscopy: Difficult laryngoscopy is hard to predict. In the prehospital environment anticipate that all
intubations will be difficult and prepare appropriately. Consider Video Laryngoscope and Bougie, and have Plans A, B,
and C ready.
Difficult BIAD-RODS: Restricted mouth opening; Obstruction / Obesity; Distorted or disrupted airway; Stiff or increased
airway pressures.
Trauma: Utilize in-line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD placement,
the cervical collar front should be opened or removed to facilitate translation of the mandible / mouth opening.
PEDIATRIC AIRWAY
Pearls
 Capnometry (Color) or capnography is mandatory with all methods of intubation/BIAD. Document results.
 Continuous capnography (EtCO2) is mandatory for the monitoring of all patients with an ET tube and
required, once available, for all patients with a BIAD.
 If an effective airway is being maintained by BVM with continuous pulse oximetry values of >90%, it is
acceptable to continue with basic airway measures instead of using a BIAD or Intubation.
 Use the least invasive method necessary to maintain an adequate airway – especially in pediatric patients.
 For the purposes of this guideline, an adequate airway is when the patient is receiving appropriate oxygenation
and ventilation – and not at an undue risk of aspiration or deterioration.
 An Intubation attempt is defined as passing the laryngoscope blade or tube past the teeth.
 The head of a pediatric patient is larger relative to body size. The larger occiput combined with a shorter neck
makes laryngoscopy more difficult by providing obstacles to the alignment of the oral, laryngeal, and tracheal
axes. Proper positioning is one of the keys to success. Consider padding under the shoulders prior to intubation.
 Ventilatory rate should be 30 for neonates, 25 for toddlers, 20 for school age, and 10 for adolescents. Maintain an
EtCO2 of 35-45. Avoid hyperventilation.
 Hyperventilation in deteriorating head trauma should only be done to maintain an EtCO2 of 30-35.
 Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful.
 Maintain c-spine motion restriction for patients with suspected spinal injury.
 Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
 It is important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement –
Charleston County
HEAVEN Criteria
Emergency Difficult Airway Predictor
Criteria Definitions
Hypoxemia O2 ≤93% at time of initial laryngoscopy
Extremes of Size Pediatric patient ≤8 years of age or clinical obesity
Anatomic Trauma, mass, swelling, foreign body, or other structural

Challenge abnormality limiting laryngoscopic view.
Fluid present in the pharynx/hypopharynx at the time of

Vomit/Blood/Fluid laryngoscopy.
Suspected anemia potentially accelerating desaturation during RSI

Exsanguination associated apnea.
Neck Limited cervical range of motion due to immobilization or arthritis.

Pediatric Post Airway Management
ETT or BIAD Airway Device Placed
Verify tube placement through:

 Auscultation and Chest Rise
 Continuous capnography
 Pulse oximetry
Administer 3 Ventilations
EtCO2
NO > 10 and Good YES
Waveform
Direct look to confirm
P ETT Placement
Confirmed? YES Secure Tube
PEDIATRIC AIRWAY
NO
Consider Restraints
[Physical] Procedure
Reposition ETT or remove and
Ventilate with BVM
Consider Etiology and At Risk of

NO
Exit to Appropriate Guideline Awakening/Moving After Intubation?
Is patient hypotensive?
YES (Reference Handtevy for age
appropriate blood pressure values)
YES
Fentanyl 1 mcg/kg IV/IO

Morphine and Fentanyl Doses listed Max Dose 100mcg
in this guideline may not be May repeat half dose Q 5 minutes. Max
exceeded without On-Line Medical Total Dose = 200 mcg
Control
P and
Midazolam 0.1 mg/kg IV/IO up to 5
Do NOT Administer IV/IM/IN Pain mg
Medications to Patients < 5 years of Repeat 0.05 mg/kg up to 2.5 mg Q 5
age without On-Line Medical Control minutes PRN (Max 10mg or Clinically
significant drop in BP)
OR
Long Acting Sedation

P Ketamine 2 mg/kg IV/IO
M M
Charleston County
Clinical Guidelines
2020-08
Pediatric Post Airway Management
PEDIATRIC AIRWAY
Pearls
 Etiology of hypotension post intubation: Tension pneumothorax, Hyperventilation, Hypovolemia, or shock.
 Continuous Waveform Capnography is:
 Recommended / Encouraged for utilization of any Airway Device (e.g. BIAD) – required if available.
 Waveform capnography and pulse oximetry should be continued throughout transport and until turnover at the
emergency department.
 Bradycardia after tube placement is a strong predictor of a misplaced endotracheal tube (ETT).
 Reassess the patient continuously.
 It’s important to secure the endotracheal tube well and consider c-collar to better maintain ETT placement –
 Confirm airway placement by ED staff prior to moving the patient from EMS stretcher.
Charleston County
Clinical Guidelines
2020-08
Richmond Agitation-Sedation Scale
Scale Label Description
+4 Combative Violent, immediate danger to staff
Pulls or removes tube(s) or catheter(s);

+3 Very agitated
aggressive
Frequent non-purposeful movement, fights

+2 Agitated
ventilations
+1 Restless Anxious but movements not aggressive, vigorous
0 Alert and calm Spontaneously pays attention to care giver
Not fully alert, but has sustained awakening

-1 Drowsy
(eye-opening/eye contact) to voice (>10 seconds)
Briefly awakens with eye contact to voice (<10

-2 Light sedation
seconds)
Movement or eye opening to voice (but no eye

-3 Moderate
contact)
No response to voice, but movement or eye

-4 Deep sedation
opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Pearls
 Any patient that requires sedation must have vital signs monitored every 5 minutes with EtCO2 attached and monitoring.
Richmond Agitation Sedation Scale (RASS)

The Richmond Agitation and Sedation Scale (RASS) is a validated and reliable method to assess patient’s level of sedation.
It can be used in all patients to describe their level of alertness or agitation. As opposed to the Glasgow Coma Scale
(GCS), the RASS is not limited to patients with intracranial processes. It is mostly used in mechanically ventilated patients
in order to avoid over and under-sedation.
A RASS of -2 to 0 has been advocated in this patient population in order to minimize over-sedation.
Patients with a RASS of -3 or less should have their sedation decreased or modified in order to achieve a RASS of -2 to 0.
Patients with a RASS of 2 to 4 are not sedated enough and should be assessed for pain, anxiety, or delirium.
Underlying etiology of the agitation should be investigated and appropriately treated to achieve a RASS of -2 to 0.
Pediatric Failed Airway
Unable to Ventilate and Call for additional resources

Oxygenate adequately during or if available
after:
Consider Emergent Transport to
 One (1) or more unsuccessful
Nearest Resource
intubation attempts AND
Anatomy inconsistent with
continued attempts OR
 Three (3) total unsuccessful
BVM and Adjunctive Airway(s)
attempts
Consider Bilateral NPAs
Each attempt should include
Consider Apneic Oxygenation
change in approach or equipment.
with BVM
NO MORE THAN THREE (3)
ATTEMPTS TOTAL
Continue BVM &

SpO2 ≥ 90% Supplemental Oxygen
or acceptable based YES
on condition Exit to Appropriate
Guideline
PEDIATRIC AIRWAY
NO
Airway BIAD Procedure
Continue Ventilation /
BIAD Oxygenation
YES
Successful?
NO
BVM w/ OPA, Bilateral NPA &

Apneic Oxygenation
Emergent Transport to
CLOSEST RESOURCE
M M
Charleston County
Clinical Guidelines
2018-09
Pediatric Failed Airway
A failed airway occurs when a provider begins a course of airway management by endotracheal intubation and
identifies that intubation by that method will not succeed.
Conditions which define a Failed Airway:

1. Failure to maintain adequate oxygen saturation after 2 or more failed intubation attempts, OR
2. Three (3) failed attempts at intubation by the most experienced prehospital provider on scene in a patient who
requires an advanced airway to prevent death, OR
3. Unable to maintain adequate oxygen saturation with BVM techniques and insufficient time to attempt alternative
maneuvers.
It should be noted that a patient with a “failed airway” is one who is near death or dying, not stable or improving.
Patients who cannot be intubated or who do not have an oxygen saturation greater than 90% do not necessarily have a
failed airway. Many patients who cannot be intubated easily may be sustained by basic airway techniques and BVM,
with stable if not optimal oxygen saturation, i.e. stable (not dropping) SpO2 values as expected based on
pathophysiologic condition with otherwise reassuring vital signs (e.g. consistent pulse oximetry of 85% with otherwise
normal or near-normal vitals in a post-drowning patient).
The most important way to avoid a failed airway is to identify patient with expected difficult airway, difficult BVM
ventilation, difficult BIAD, and difficult laryngoscopy. Please refer to the Universal Airway Guideline for information on
how to identify the patient with potential difficult airway.
Position of the patient: In the field, improper position of the patient and rescuer are responsible for many failed and
difficult intubations. Often this is dictated by uncontrolled conditions present at the scene and we must adapt. However,
PEDIATRIC AIRWAY
many times the rescuer does not optimize the patient and rescue position. The sniffing position or the head simply
extended upon the neck are probably the best positions. The goal is to align the ear canal with the suprasternal notch
in a straight line.
In the obese patients elevating the torso by placing blankets, pillows, or towels will optimize the position. This can be
facilitated by raising the head of the cot.
Use of cot in optimal patient / rescuer position: The cot can be elevated and lowered to facilitate intubation. With the
patient on the cot raise until the patients nose is at the level of your umbilicus which will place you at the optimal
position.
Pearls
 Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function.
 Continuous EtCO2 should be utilized in all patients with respiratory failure and in all patients with advanced
airways.
 Notify Medical Control AS EARLY AS POSSIBLE about the patient’s difficult / failed airway.
 If an effective airway is being maintained by BVM and/or basic airway adjuncts (e.g. nasopharyngeal airway) with
continuous pulse oximetry values of ≥ 90% or stable values as expected based on pathophysiologic condition with
otherwise reassuring vital signs (e.g. consistent pulse oximetry of 85% with otherwise normal vitals in a post-
drowning patient), it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation, or
proceeding to Surgical Airway. Consider CPAP as indicated by protocol and patient condition. If scene resources
allow, do not hesitate to contact On-Line Medical Control regarding decision-making for patients with a difficult/
failed airway.
 Consider 2-person BVM technique.
 Consider apneic oxygenation with bilateral nasopharyngeal airways.
 When transporting to closest resource, consider free-standing EDs or intercept. In outlying areas, consider meeting
helicopter while en-route to ED for additional assistance.
Charleston County
Clinical Guidelines
2020-08
Pediatric Respiratory Distress
Pandemic Pediatric YES
CDC Flagged or High
Respiratory Suspicion of COVID-19
NO

Respiratory / Ventilatory Insufficiency?
If available measure EtCO2 Universal Airway Guideline
Consider Airway Compromise or Foreign Body
NO
Consider Anaphylaxis Guideline
Assess Airway
Assess Lung
Nebulized Albuterol 5mg Wheezing
Sounds
Stridor Consider Foreign Body Obstruction
Procedure
P Consider Ipratropium 0.5 mg
Nebulized Normal Saline (3mL)
PEDIATRIC AIRWAY
If No Improvement or Severe
Repeat Albuterol P Epinephrine Nebulized 1mg
Improving? NO A (1mg/mL) in 2 mL of NS
as Needed
Methylprednisolone
P NO Improving?
2 mg/kg IV/IO
Consider Epinephrine
A (1mg/mL) 0.01 mg/kg up to
0.3 mg IM
YES
Consider YES
Universal Airway Guideline
M M
Pearls
 Do not force a child into a position. They will protect their airway by their body position.
 Bronchiolitis is a viral infection typically affecting infants which results in wheezing which may not respond to beta-
agonists.
 Consider Epinephrine if patient < 18 months and not responding to initial beta-agonist treatment.
 Croup typically affects children < 2 years of age. It is viral, possible fever, gradual onset, no drooling is noted.
 Epiglottitis typically affects children > 2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patient
wants to sit up to keep airway open, drooling is common. Airway manipulation may worsen condition.
 Avoid direct laryngoscopy unless intubation is imminent.
 Ipratopium is indicated for patients with a history of asthma. Not indicated for patients age < 1 year.
Charleston County
Clinical Guidelines
2020-06
Pediatric Allergic Reaction / Anaphylaxis
Guideline
Moderate to Severe
Mild Allergic Reaction (Anaphylaxis) Allergic
Reaction
Diphenhydramine
1 mg/kg, max 50 mg PO
Epinephrine IM
OR 0.15 or 0.3 mg Auto-Injector
Diphenhydramine OR
Epinephrine 1:1000
A 0.01 mg / kg IM
Maximum 0.3 mg
Monitor for Worsening Repeat in 5 min if no improvement
Signs and Symptoms
If Symptoms Progress
Move to Other Column
Exit to Difficulty Oxygenating,
Appropriate YES Ventilating, or Impending
PEDIATRIC MEDICAL
Airway Guideline Airway Compromise
The EMT may substitute a SC

DHEC approved Anaphylaxis Cardiac Monitor /
Epinephrine Kit for an Auto-Injector Consider 12 Lead EKG Acquisition
in this guideline. Cardiac Monitor /
P P
<8 years EKG Interpretation
0.15 mg Epinephrine 1:1000
>8 years
0.3 mg Epinephrine 1:1000 or EpiPen If Wheezing, Administer
Nebulized Albuterol 5 mg
Repeat Albuterol
A
When indicated, give Epinephrine IM as Needed
in the Lateral Thigh; this site provides
the best absorption.
Symptomatic
Refractory/peri-arrest
Hypotension YES
Anaphylaxis
Guideline
Diphenhydramine
Methyl-prednisolone
P
2 mg/kg IV/IO, max 125 mg
M M
Charleston County
Clinical Guidelines
2020-11
Pediatric Allergic Reaction / Anaphylaxis
SC DHEC Approved Anaphylaxis Epinephrine Kit Contents:
1 – Tuberculin Syringe – 1 mL
2 – 20-22 gauge 1"-1 ½” Needles
2 – Alcohol Prep Pads
1 – Epinephrine Ampule or Vial (1:1,000 = 1 mg / 1 mL)
PEDIATRIC MEDICAL
Pearls
 Recommended exam: Mental Status, Skin, Lung, Heart
 Anaphylaxis is an acute and potentially lethal multisystem allergic reaction.
 Epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. IM
Epinephrine should be administered in priority before or during attempts at IV or IO access.
 Symptom Severity Classification:
 Mild Symptoms (Allergic Reaction):
 Flushing, hives, itching, and/or erythema; with normal blood pressure and perfusion.
 Allergic reactions may occur with only respiratory and gastrointestinal symptoms and have no
rash / skin involvement.
 Moderate Symptoms (Anaphylaxis):
 Flushing, hives, itching, and/or erythema; plus respiratory (wheezing, dyspnea, hypoxia) or
gastrointestinal symptoms (nausea, vomiting, abdominal pain) with normal blood pressure and
perfusion.
 If symptoms are rapidly progressing, administer early Epinephrine 1:1000 IM.
 Severe Symptom (Anaphylaxis):
 Skin symptoms may or may not be present, depending on perfusion. Possible itching, erythema,
plus respiratory (wheezing, dyspnea, hypoxia) or gastrointestinal symptoms (nausea, vomiting,
abdominal pain) with hypotension and poor perfusion (possible altered LOC).
 Dystonic Reactions should be treated with diphenhydramine at the same dose given for a mild allergic reaction.
Common medication groups that cause dystonic reactions include
 Antipsychotics: Zyprexa (Olanzapine), Haloperidol (Haldol), Alprazolam (Xanax), Fluphenazine (Prolixin),
Thorazine (Chlorpromazine), Ziprasidone (Geodon) and
 Antiemetics: Compazine (Prochlorperazine), Promethazine (Phenergan), Hydroxyzine (Vistaril), and
Metoclopramide (Reglan).
 EMT may administer diphenhydramine by oral route only and may administer from EMS supply. Consider the
patient’s ability to swallow pills well and avoid PO meds with respiratory distress.
Charleston County
Pediatric AMS / Diabetic Emergencies
Dyspnea / Increased
Airway Guideline
hypoxia or apnea

12 Lead EKG Acquisition
Cardiac Monitor /
P P
EKG Interpretation
PEDIATRIC MEDICAL
Glucose <70 mg/dL Glucose >250 mg/dL
Glucose > 70 mg/dL
OR Newborn < 40 mg/dL
With Signs of Poor Perfusion
With Altered Mental Status
With Signs of Hypoglycemia and/or Dehydration
Consider Oral Glucose If not already done,

1-2 tubes if awake and Obtain 12-Lead EKG
no risk for aspiration
Consider Normal Saline
A
20 mL/kg; Max 1 Liter
10% Dextrose (D10) IV
Titrate to Effect
A
up to 4 mL/kg, max 250 mL
May Repeat Once PRN
If no IV access, administer:
A Glucagon IM
0.1 mg/kg; max 1 mg.
Assess for and Treat
Other Causes of AMS:
 Overdose/Toxic
Ingestion
Improvement? NO  Seizure
 Stroke
 Trauma
 Cardiac Dysrhythmia
 Infection/Sepsis
YES
M M
Charleston County
Pediatric AMS / Diabetic Emergencies
Pearls
 Recommended exam: Mental Status, Skin, Respirations and Effort, Neuro
 Pay careful attention to the head exam for signs of bruising or other injury. Assess pupils.
 Be aware of altered mental status as presenting sign of an environmental toxin or HazMat exposure and protect
PEDIATRIC MEDICAL
personal safety.
 Patients with prolonged hypoglycemia or malnourishment may not respond to Glucagon.
 Response to Glucagon can take 15-20 minutes. Consider the entire clinical picture when treating hypoglycemia,
including a patient’s overall clinical condition and vital signs. It may be safe to wait for some time for Glucagon to
work, instead of pursuing the more aggressive course of performing IO access to give faster acting IV/IO Dextrose
solution. Diabetics may have poor wound healing, and IO access may present a greater risk for infection or poor
wound healing in diabetic patients. On the other hand, consider IO access to give Dextrose early in patients who
are critically ill or peri-arrest and hypoglycemic.
 Do not administer oral glucose to patients that are not able to swallow or protect the airway.
 AEMT may administer both D10 and Glucagon, however, the Paramedic should be the primary attendant.
 Use caution when allowing a patient taking oral agents or long-acting insulin agents to refuse, especially when BGL
is < 80 mg/dL. Encourage family member or other responsible party to remain with patient and recall EMS if
needed.
 Legal Guardian Refusing Transport of Child After Treatment and Child is Taking Oral Agents:
 If the child is taking oral diabetic medications the legal guardian should be strongly encouraged to allow
transportation to a medical facility. They are at risk of recurrent hypoglycemia that can be delayed for hours
and require close monitoring even after normal blood glucose is established. If refusal criteria is met, the
legal guardian should be instructed to contact the patient’s physician immediately. Instruct the guardian to
feed the child a meal with complex carbohydrates and protein. Consider consultation with On-Line Medical
Control.
 Legal Guardian Refusing Transport of Child After Treatment and Child is Taking Insulin Agents:
 Many forms of insulin now exist. Longer acting insulin places the patient at risk of recurrent hypoglycemia
even after a normal blood glucose is established. If refusal criteria is met, the legal guardian should be
instructed to contact the patient’s physician immediately. Instruct the guardian to feed the child a meal with
complex carbohydrates and protein. Consider consultation with On-Line Medical Control.
 EMS Personnel are not permitted to administer, or assist with administration of, insulin. In the unresponsive
hypoglycemic patient with an insulin pump, consider suspending or disconnecting device. Elicit family assistance if
unfamiliar with the device.
Charleston County
Pediatric Fever / Infection / Suspected Sepsis

Pediatric: 10 mg/kg
Temperature > 100.4° F
YES OR
(38° C)
Acetaminophen PO
Pediatric: 15 mg/kg
Obvious or suspected
infection
AND NO Exit to Appropriate Guideline
Patient meets criteria for
Sepsis / Severe Sepsis
YES
Possible Sepsis (Any 2 SIRS):
 Temp: ≥ 100.4° F (38° C) OR Consider Cardiac Monitor /
 Temp: < 96.8° F (36° C) 12 Lead ECG Acquisition
 Respirations > age appropriate
range Cardiac Monitor /
P P
EKG Interpretation
PEDIATRIC MEDICAL
Heart Rate
 1 month – 1 year >180
 2 – 5 years >140 Vascular Access Guideline
 6 – 12 years >130
Severe Sepsis/Shock
 Sepsis (2 SIRS) AND Consider Normal Saline bolus
 Age Appropriate hypotension OR 20 mL/kg up to 500 mL, if
 ETCO2: < 26 mmHg appropriate for patient condition.
10mL/kg for neonates
A
If SIRS criteria present, repeat
initial bolus up to 3 times as
needed. Monitor for signs of
volume overload and cease fluids
if present.
Consider Hypotension Guideline and

use of push-dose vasopressors if
patient remains hypotensive
Possible Sepsis Severe Sepsis/Shock

Notify Receiving Hospital of Suspicion of Declare Sepsis ALERT to Receiving
Sepsis. Do NOT provide alert. Hospital
M M
Charleston County
Pediatric Fever / Infection / Suspected Sepsis
Pearls
 Febrile seizures are more likely in children with a history of febrile seizures and with rapid elevation in temperature.
Febrile seizures are uncommon in children > 6 years old.
 UTILIZE STANDARD UNIVERSAL PRECAUTIONS FOR ALL PATIENTS WITH SUSPECTED INFECTION.
 Droplet precautions include standard PPE plus a standard surgical mask for providers who accompany patients in
the back of the ambulance and a surgical mask for the patient. This level of precaution should be utilized when
influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplets are
suspected. A patient with a potentially infectious rash should be treated with droplet precautions.
 Contact precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact,
PEDIATRIC MEDICAL
and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g.
MRSA), scabies, or zoster (shingles), or other illnesses spread by contact are suspected.
 All-hazards precautions include standard PPE plus airborne precautions plus contact precautions. This level of
precaution is utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when
the causative agent is found to be highly contagious (e.g. SARS).
 Ibuprofen should not be used in patients who are pregnant, with known renal disease or renal transplant, in
patients who have known drug allergies to NSAID’s (non-steroidal anti-inflammatory medications), or with active or
suspected bleeding (intracranial, GI, etc).
 Consider whether elevated temperature is due to “fever” (and suspected infection), or a possible environmental
heat emergency. NSAIDs should not be used in the setting of environmental heat emergencies.
 If patient has been administered Ibuprofen or Acetaminophen within the past 4 hours do not administer the same
medication.
 Suspected Sepsis / Septic Shock
 Early recognition of Sepsis allows for attentive care and early antibiotics. Patient must have an obvious or
suspected infection, PLUS at least two Systemic Inflammatory Response Syndrome (SIRS) criteria.
 If pediatric patient has suspected sepsis, relay suspicion to receiving hospital and treat with pediatric fluid/
hypotension guidelines as indicated.
 Aggressive IV fluid therapy is the most important prehospital treatment for sepsis. Suspected septic patients
should receive repeated fluid boluses (to a max of 2 liters) while being checked for signs of pulmonary edema,
especially patients with known history of CHF or ESRD on dialysis. STOP fluid infusion in the setting of
pulmonary edema.
 Attempt to identify source of infection (skin, respiratory, etc) and relay previous treatments and related history
to ED physician.
 Elevated serum lactate levels are a useful marker of hypoperfusion in sepsis and often become elevated prior
to the onset of hypotension. End Tidal CO2 levels are correlated with lactate levels.
 Measure ETCO2 with any patient with suspected sepsis. Two values less than 26 mmHg on consecutive
measurements 5 minutes apart can be used to help identify severe sepsis.
 Document amount and rate of fluid administration in the EHR. Expected rate is 500mL / 10 minutes.
Charleston County
Pediatric Nausea / Vomiting

Diabetic Guideline
If indicated
Serious Signs /
Symptoms
NO YES
Hypotension, poor
perfusion, shock
PEDIATRIC MEDICAL
Symptomatic Hypotension Guideline
Consider Ondansetron IV/IO/IM

Administer Over 2 Minutes
> 15 kg Patient: 4 mg
P May Repeat After 10 Minutes
May Substitute ODT, if Available
8-15 kg Patient: 2mg
M M
Pearls
 Consider and treat underlying cause of nausea/vomiting. Cardiac monitoring is indicated in those with significant
history.
 For ODT, place one tablet on top of patient’s tongue.
 Heart Rate: One of the first clinical signs of dehydration is increased heart rate. Tachycardia increases as
dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal.
 Beware of vomiting only in children. Pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or
increased CSF pressures) all often present with vomiting.
Charleston County
Pediatric Overdose / Toxic Ingestion
Universal Patient Care and

Scene
YES Universal Airway Guideline
Safe?
As indicated
If Needed,
Cardiac Monitor /
Palmetto Poison Control
NO Consider 12 Lead EKG Acquisition
1-800-222-1222
Cardiac Monitor /
P P
EKG Interpretation
resources. Vascular Access Guideline
Stage until scene safe.
Adequate Respirations / Utilize Appropriate Airway

NO
Oxygenation / Ventilation Guideline
AMS / Diabetic Guideline YES Altered Mental Status
Naloxone 0.1 mg/kg IN up to

0.5 mg
PEDIATRIC MEDICAL
Symptomatic Hypotension Naloxone 0.1 mg/kg IV/IM/IN
YES Age Specific Hypotension up to 0.5 mg
Guideline
Titrate to adequate
CONSCIOUSNESS
Consider Potential Cause Repeat As Needed*
NO Patient has serious Signs /
Symptoms with suspected:
Tricyclic
Beta Blocker OR Organophosphate Exposure
Antidepressant OD
Calcium Channel Blocker OD
Hypotension and Tachycardia,
Hypotension, Tachycardia,
Hypotension and Bradycardia S.L.U.D.G.E.
and QRS ≥ 0.12 sec
YES YES YES
Utilize Cardiac External Sodium Bicarbonate IV/IO Atropine IV/IO

P Pacing Procedure Early for 1 mEq/kg, up to 50 mEq 0.1 mg/kg, up to 2 mg
Severe Cases P P
Repeat Every 5 Min May Repeat Every 5 Min
Calcium Gluconate IV/IO Until QRS Narrows Maximum 10 mg
P 100 mg/kg, up to 1 g
May Repeat Every 10 Min
Glucagon 0.1 mg/kg IV/IO
up to a max of 2 mg
P
May Repeat Once if Patient
Remains Symptomatic
M M
Charleston County
Pediatric Overdose / Toxic Ingestion
PEDIATRIC MEDICAL
Pearls
 S.L.U.D.G.E: Salivation, Lacrimation, Urination, Defecation, GI Distress, Emesis
 D.U.M.B.B.E.L.S.: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Salivation
 Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid
progression from alert mental status to death.
 Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure.
 Aspirin: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later.
Renal dysfunction, liver failure, and or cerebral edema among other things can take place later.
 Depressants: decreased HR, decreased BP, decreased temp., decreased respirations, non-specific pupils
 Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures
 Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes
 Cardiac Medications: dysrhythmias and mental status changes.
 Solvents: nausea, coughing, vomiting, and mental status changes
 Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils
 Naloxone*:
initial dosing.
 IV administration of Glucagon may precipitate nausea and vomiting. Consider Ondansetron administration.
Charleston County
Pediatric Pain Control

Maximize non-pharmaceutical means

of pain management:
 Splinting
 Icing
 Elevating the Injury
 Utilizing Positions of Comfort
Pediatric: 10 mg/kg
Pain Severity >6 out of 10 Adult: 400-800 mg
OR NO OR
Indication for IV / IM Medication Acetaminophen PO
Pediatric: 15 mg/kg
YES Adult: 1000 mg
PEDIATRIC MEDICAL
Obtain baseline SPO2 and
Monitor Continuously.
≥ 5 Years Old
Fentanyl 1 mcg/kg IV/IO/IM/IN Morphine and Fentanyl Doses listed

up to 100 mcg. in this guideline may not be
P
May repeat half dose Q 5 exceeded without On-Line Medical
minutes. Max Dose = 200 mcg Control
OR
Do NOT Administer IV/IM/IN Pain
Morphine 0.1 mg/kg IV/IO/IM
Medications to Patients < 5 years of
up to 5 mg.
P age without On-Line Medical Control
May repeat half dose Q 5
minutes. Max Dose = 10 mg
Consider Nausea/Vomiting Guideline
Must reassess patient at least every

10 minutes
M M
Charleston County
Pediatric Pain Control
Relative Contraindications Relative Contraindications
for IV Pain Control: for Non-Steroidal Agents:
 Severe Head Injury  Active Bleeding
 End-Stage Lung Disease  Possible Surgery
 Untreated Hypotension  Renal Disease
Pearls
 Recommended exam: Mental Status, Area of Pain, Neuro
PEDIATRIC MEDICAL
 Pain severity (0-10) is a vital sign to be recorded pre and post medication delivery and at disposition.
 For children, use Wong-Baker faces scale (4-16 yrs) or the FLACC score (0-7 yrs).
 Vital signs should be obtained pre, 10 minutes post, and at disposition with all pain medications.
 IV / IM Medications (Fentanyl, Morphine)
 Relative Contraindications to the use of a narcotic include hypotension, head injury, respiratory distress or
severe lung disease. Treat hypotension prior to administration of Fentanyl or Morphine.
 Weight-based dosing may provide a standard means for dose calculation, but does NOT predict patient
response. It may be appropriate to start with LESS THAN the weight-based dose. For example, minimal
doses of opioids may be effective for pain management and/or cause respiratory depression in the elderly,
opiate naïve, and possibly intoxicated patients.
 All patients who receive IM or IV medications must be observed 15 minutes for drug reaction.
 Monitor all patients receiving narcotic or sedative medications with continuous Pulse Oximetry. Consider
nasal ETCO2 for any patient with decreased LOC or at risk for respiratory depression.
 PO Medications (Ibuprofen, Acetaminophen)

 Do not administer any PO medications for patients who may need surgical intervention such as open
fractures or fracture deformities, headaches, or abdominal pain.
 Ibuprofen should not be used in patients who are pregnant, with known renal disease or renal transplant,
in patients who have known drug allergies to NSAIDs (non-steroidal anti-inflammatory medications), or with
active or suspected bleeding (intracranial, GI, etc).
 Ocular Anesthesia
 Instill one or two drops of Proparacaine into the effected eye every five to ten minutes to relieve eye pain,
up to five doses.
 Instill two drops of Proparacaine into the eye prior to irrigating the eye.
 Protected the eye from foreign bodies and abrasion during the period of anesthesia. Warn the patient not to
touch the eye until the anesthesia has worn off.
 Burn patients may require higher than usual opioid doses to effect adequate pain control. Do not hesitate to
contact medical control regarding the pain management strategy for patients in severe pain despite medications or
with significant burns.
Charleston County
Pediatric Seizure
Respiratory/Ventilatory Insufficiency
If available measure EtC02 Universal Airway Guideline
Protect patient from
physical harm Consider Airway Compromise
If patient is actively seizing consider:

P Midazolam 0.2 mg/kg IM/IN up to P
10 mg
Cardiac Monitor /
Cardiac Monitor /
P P
EKG Interpretation
Fever/Sepsis Guideline YES Febrile
Consider Spinal Motion
PEDIATRIC MEDICAL
YES Evidence of Trauma
Restriction
Still Actively Seizing?

NO Recurrence of Seizure Activity?
Combative Postictal State?
YES
Midazolam (Versed) 0.1 mg/kg slow IV

push up to 5 mg
P May repeat Midazolam 0.05 mg/kg up to 2.5
mg X2 Q 5 minutes, if needed
Max Total IV Dose = 10 mg
OR
Midazolam (Versed) 0.1 mg/kg IM up to
5 mg
May repeat Midazolam 0.1 mg/kg up to 5 mg
P
X2 Q 5 minutes, if needed
Max Total IM Dose = 20 mg
Monitor and Transport
M M
Charleston County
Pediatric Seizure
PEDIATRIC MEDICAL
Pearls
 Recommended Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro
 Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This
is a true emergency requiring rapid airway control, treatment, and transport.
 Febrile seizures are the most common type of seizure in children.
 Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and trauma.
 Focal seizures (petit mal) affect only a part of the body and are not usually associated with a loss of consciousness
 Jacksonian seizures are seizures which start as a focal seizure and become generalized.
 Be prepared for airway problems and continued seizures. Be prepared to assist ventilations.
 Assess possibility of occult trauma and substance abuse.
 For actively seizing patients on EMS arrival, (i.e. no IV) administer IM/IN VERSED prior to establishing IV access.
Charleston County
Clinical Guidelines 2020/07
Pediatric Hypotension (Symptomatic)
Reference Handtevy
application for blood
pressure ranges associated Vascular Access Protocol
with age
Suspected
Etiology?
Trauma Non-Cardiac / Non-Trauma Cardiac
Consider Anaphylaxis or
Treatment per Sepsis Protocol Treatment per
appropriate appropriate
Trauma Protocol Cardiac Protocol
PEDIATRIC MEDICAL
Normal Saline bolus 20 mL/
kg up to 250 mL, if
A appropriate for patient
Normal Saline bolus 20 mL/ condition. Consider repeating
No rales present
kg up to 250 mL, if X1.
Normal Saline bolus 10 mL/
appropriate for patient 10mL/kg for Neonates
kg up to 125 mL, if
A condition. Consider repeating A appropriate for patient
X1. condition.
10mL/kg for Neonates Maximum 250 mL
Consider
Push-Dose Epinephrine
Newborn to <1 year = 5 mcg
P
q 2-5 minutes
≥1 Year = 5-10 mcg q 2-5
Consider minutes
Consider
Newborn to <1 year = 5 mcg
Notify Destination or Newborn to <1 year = 5 mcg
P q 2-5 minutes M M P
Contact Medical Control q 2-5 minutes
≥1 Year = 5-10 mcg q 2-5
≥1 Year = 5-10 mcg q 2-5
minutes
minutes
for Neurogenic Shock
Pearls:
 Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro.
 Reference Handtevy application for blood pressure ranges associated with age.
 If patient’s condition warrants Push-Dose Epinephrine:
Newborns through all age groups less than 1 year = 5 mcg/0.5 mL q 2-5 minutes.

Patient’s that are greater than or equal to 1 year = 10 mcg/1 mL q 2-5 minutes.

 Repeat Vital Signs AFTER each Bolus or Change in Pharmacologic Therapy (Change in Dose or Agent).
 STOP fluid administration if signs of pulmonary edema develop.
 Shock may be present with a normal blood pressure initially.
 Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only
manifestation.
 Consider all possible causes of shock and treat per appropriate protocol.
 Push-dose vasopressors should be considered only after administration of fluid, and never for hypovolemic/
hemorrhagic shock.
Charleston County
Clinical Guidelines
2020-11
Pediatric Bradycardia
Universal Patient
Care Guideline
Bradycardia Causing Hypotension /

AMS Poor Perfusion / Shock YES
Guideline
Typically Less than 60
NO
Dyspnea / Increased
Universal Airway
Guideline
especially with Hypoxia
NO
Cardiac Monitor /
Cardiac Monitor /
P
EKG Interpretation
Consider Fluid Bolus
PEDIATRIC CARDIAC
A < 1 month = 10ml/kg
> 1 month = 20ml/kg
YES Improving ?
NO
Epinephrine 0.01 mg/kg up to

0.5 mg
P Repeat Q 5 minutes as long as
patient remains symptomatic
YES Improving ?
NO
Transcutaneous Pacing
(Should be considered first line
P
therapy for severe symptoms and
early in 2nd or 3rd degree AVB)
Consider Sedation
Midazolam 0.05 mg/kg IV / IO/
P IM / IN
(Max 2.5mg)
M M
Charleston County
Pediatric Bradycardia
PEDIATRIC CARDIAC
Pearls
 Recommended exam: Mental Status, Skin, Neck, Heart, Lungs, Neuro
 Bradycardia is defined as a heart rate less than the lower limit of normal for a child’s age. Rhythm should
be interpreted in the context of symptoms, and pharmacological treatment given only when symptomatic,
otherwise monitor and reassess.
 HYPOXIA is the most common cause of bradycardia in children <8. Be sure to oxygenate the patient and
support respiratory effort.
 Most children with structural heart disease will present with signs of heart failure. Assess for signs of heart
failure prior to administering fluid. Continuously reassess lung sounds for developing pulmonary edema.
 If <7 y/o, set pacer to a rate of 100. If ≥7 y/o, set pacer to a rate of 70. Monitor for improvement. Ensure that
electrical/mechanical capture has been achieved and is maintained.
 Arrhythmias due to a primary cardiac issue are rare in children.
 The key to appropriate management is gathering a thorough history and attempting to identify and treat
underlying causes.
 Transport to a pediatric capable facility. Divert to closest facility if patient experiences cardiac arrest or
difficulties are encountered with managing the ABCs.
Charleston County
Pediatric Tachycardia
Consider other causes
Universal Airway first.
YES Difficulty Oxygenating/Ventilating?
Guideline
Consider age
appropriate fluid
Cardiac Monitor / boluses as dehydration
P
EKG Interpretation is one of the most
Cardiac Monitor / common causes of
Consider 12 Lead ECG Acquisition tachycardia in
pediatrics.
Fever/Sepsis Guideline YES Febrile?
Exit to Appropriate Guideline YES Treatable Cause?
Unstable / Peri-Arrest
(Signs of
Hypoperfusion)
PEDIATRIC CARDIAC
NO YES
HR Typically
Infants > 220
Children > 180
Vascular Access Consider Vascular Access

Adenosine 0.2 mg/kg IV / IO
(Max 12mg) Synchronized Cardioversion
Only if Rhythm is Regular/QRS 0.5 J/kg
P P May repeat at 1 J/kg for all
Monomorophic
May Repeat 0.2 mg/kg x1 if subsequent PRN
needed
Consider Sedation pre-shock
Midazolam 0.05 mg/kg IV / IO /
No Response to P IM / IN
Adenosine (Max 2.5mg)
If Rhythm Changes
Is Patient Still
NO
Stable?
YES
Consider
Amiodarone 5 mg/kg IV / IO Repeat 12 Lead ECG Acquisition
(Max 150mg)
P
Over 20 minutes Notify Destination or
If QRS is >0.09 and rhythm is M M
regular and monomorphic
Charleston County
Pediatric Tachycardia
PEDIATRIC CARDIAC
Pearls
 Contact medical control early for guidance in patient management.
 Proper diagnosis is based on history. Patients will often have a history consistent with a known cause that
requires compensation. Find and treat the underlying cause. For example, in dehydration replace fluid.
 Common causes of tachycardia include hypovolemia, sepsis, fever, pain, hypoxia, and anemia. SINUS
TACHYCARDIA SECONDARY TO DEHYDRATION IS MUCH MORE COMMON THAN SVT.
 For ASYMPTOMATIC PATIENTS (or those with only minimal symptoms) or any tachycardia with a normal
BP, consider CLOSE OBSERVATION and/or fluid bolus rather than immediate treatment with medication or
cardioversion.
 When considering CAUSES, consider utilizing relevant protocols in conjunction: all cardiac protocols,
allergic reaction, diabetic, dialysis/renal failure, overdose/ingestion, suspected stroke, environmental
protocols.
 If patient is experiencing polymorphic v-tach (Torsades de Pointes) administer 25-50mg/kg of magnesium
sulfate IV/IO.
 Adenosine should NOT be given for unstable, irregular, or polymorphic wide-complex tachycardias as it
may cause degeneration of the arrhythmia to Ventricular Fibrillation.
 Continuous pulse oximetry is required.
 Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic
intervention.
 Ensure that all medications are dosed appropriately. Remember the RIGHTS OF MEDICATION
ADMINISTRATION.
Charleston County
Pediatric Cardiac Arrest: Team Approach
Traumatic Arrest
Go to Discontinuation / (Blunt/Penetrating Trauma)
Death Guideline
Supervisor and Coroner
No

Push Hard (1/3 Diameter) Push Fast (~110 / min)
Change Compressors every 2 minutes

Initiate Compressions Only CPR
if available
Call for additional resources
PEDIATRIC CARDIAC
Second Arriving BLS / ALS Responder
Assume Compressions or
Initiate Defibrillation (Automated/Manual)
Intermittent Compressions with Ventilations

15:2 Pediatric (30:2 after puberty)
Consider BIAD
15 Ventilations/min (20 Ventilations/min Infant)
with Continuous Compressions
Third Arriving Responder

BLS ALS
BLS or ALS

Manages Scene / Bystanders Ensure frequent compressor change
Fourth / Subsequent Arriving Responders Administer Appropriate Medications
Take direction from Team Leader Establish Airway if not in place
Interrupt Compressions Only as

Go To Age Appropriate Protocol:
per AED Procedure.
Pediatric Cardiac Arrest: ALS
Do NOT hyperventilate.
Rhythms Protocol
Charleston County
Pediatric Cardiac Arrest: Team Approach
AIRWAY
DEFIB
CPR MEDS
PEDIATRIC CARDIAC
TEAM
TIMER
LEADER
Pearls
defibrillation when indicated (After 2 minutes of CPR if not witnessed by EMS and no bystander CPR).
DO NOT HYPERVENTILATE: Ventilate at approximately 15-20 breaths per minute when BIAD present.
In order to be successful in pediatric arrests, a cause must be identified and corrected.
Airway is the most important intervention. This should be accomplished immediately. Patient survival is often
dependent on airway management success.
DO NOT interrupt compressions to place advanced airway. Use BIAD for first attempt unless contraindicated. Leave in
place unless airway compromise necessitates tube exchange.
Consider possible CAUSES of arrest early: Consider traditional PALS “Hs and Ts” for PEA: Hypovolemia, Hypoxia,
Hydrogen ions (acidosis), Hyperkalemia, Hypothermia, Hypoglycemia, Tablets/Toxins/Tricyclics, Tamponade, Tension
pneumothorax, Thrombosis (MI), Thromboembolism (Pulmonary Embolism)
Charleston County
Pediatric Cardiac Arrest: ALS Rhythms
Cardiac Arrest: Team Approach

 Push Hard (1/3 Diameter) Push Fast (~110 / min)
 Change Compressors every 2 minutes
1 5 cycles (2 minutes) of CPR
Attach Cardiac Monitor / AED
Consider and Treat Correctable Causes Early
Rhythm Not Shockable

Shockable
Interpretation
P Defibrillate x 1 – 2 J/kg
Airway Guidelines Airway Guidelines

2 NO YES
PEDIATRIC CARDIAC
Assess Rhythm – Shockable? Assess Rhythm – Shockable?
YES NO
P Defibrillate x 1 – 4 J/kg AT ANY TIME Vascular Access Guideline

Rhythm Changes to Normal Saline 20ml/kg
Vascular Access Guideline Shockable/ A Repeat once if still pulseless
Nonshockable Rhythm
Epinephrine 0.01 mg/kg Epinephrine 0.01 mg/kg
P P
(Repeat Q 5 minutes x4) (Repeat Q 5 minutes x4)
3 Assess Rhythm – Shockable? Switch Columns - Assess Rhythm – Shockable?
YES Go to appropriate
treatment bundle /
P Defibrillate x1 – 4 J/kg energy level Consider and Treat
Correctable Causes (H’s and T’s)
Amiodarone 5 mg/kg Consider Calcium
P Do NOT administer P
(max 150mg) Repeat twice Gluconate 50 mg/kg
more than 5 doses
5 cycles of CPR Consider Sodium
4 Assess Rhythm – Shockable?
Epinephrine during P
cardiac arrest. Bicarbonate 1 mEq/kg
YES 5 cycles of CPR
Continue other Assess Rhythm – Shockable?
treatments until
P Defibrillate x1 – 4 J/kg ROSC or Criteria for NO NO
Termination are met.
5 cycles of CPR
5+ Assess Rhythm – Shockable?
> 25 Minutes High Performance
CPR and ETCO2 < 10
YES
YES
Notify Destination or Notify Destination or
M Contact Medical Control
M M Contact Medical Control
M
Charleston County
Pediatric Cardiac Arrest: ALS Rhythms
 Estimated down time  Unresponsive, apneic, pulseless  Asystole
 Past medical history  Ventricular fibrillation or ventricular  Artifact / Device failure
 Medications tachycardia on ECG  Cardiac
 Events leading to arrest  Endocrine / Metabolic
 Renal failure / dialysis  Drugs
 DNR or living will  Pulmonary
Pearls
 High dose Epinephrine is associated with poor neurological outcome. Do NOT administer more than 5 doses
Epinephrine.
 Reassess and document ETT/BIAD placement and EtCO2 frequently, after every move, and at transfer of care.
PEDIATRIC CARDIAC
 Treatment priorities are: uninterrupted chest compressions, defibrillation, then airway control and IV
access.
 Do not stop CPR to check for placement of ET tube or to give medicines.
 If arrest not witnessed by EMS then 5 cycles of CPR prior to 1st defibrillation.
 If BVM is ventilating the patient successfully, intubation should be deferred until rhythm has changed or 4 or 5
defibrillation sequences have been completed.
Pearls – Shockable Rhythms

 Recurrent ventricular fibrillation/tachycardia is defined as SUCCESSFULLY CONVERTED by standard defibrillation
techniques (i.e. 4 J/kg), but subsequently returns. It is managed by treatment of correctable causes and use of anti-
arrythmic medications in addition to standard defibrillation. Consider change in pad vector after 4 defibrillation
sequences.
 Refractory ventricular fibrillation/tachycardia is defined as NOT CONVERTED by standard defibrillation. If standard
defibrillation and antiarrhythmic medications fail to produce a response, change the pad placement/vector with a new
set of pads.
 Polymorphic V-Tach (Torsades de Pointes) may benefit from administration of magnesium sulfate 25-50mg/kg IV/
IO.
Pearls – Asystole / PEA / Reversible Causes
 Potential association of PEA with hypoxia - placing definitive airway with oxygenation early may provide benefit.
 PEA caused by sepsis or severe volume loss may benefit from higher volume of normal saline administration.
 Calcium Gluconate 50 mg/kg (up to 1 gm) IV/IO and Sodium Bicarbonate 1 meq/kg (up to 50 meq) IV/IO if
hyperkalemia is suspected (renal failure, dialysis).
 Administer via separate lines or administer 100cc normal saline between medications.
 Consider Calcium Gluconate for Calcium Channel Blocker overdose.
 Consider Sodium Bicarbonate for tricyclic antidepressant overdose.
 Glucagon 1-2mg IV/IO for suspected beta blocker overdose, if available.
 Chest decompression for suspected pneumothorax.
 Dextrose for known hypoglycemia. Glucometer readings may be inaccurate in presence of
cardiac arrest.
 Naloxone is not indicated in presence of confirmed cardiac arrest, regardless of cause.
Charleston County
Pediatric Left Ventricular Assist Device
Is patient unconscious and
apneic with no signs of YES
Guideline
perfusion?
NO
Evidence to suggest
NO possible device malfunction
or failure?
YES
 Determine Type of Device

 Assess any Alarms
 Contact LVAD Coordinator
 Discuss plan with family.
Consider: changing device batteries,
reconnecting cables
Cardiac Monitor /
P
PEDIATRIC CARDIAC
EKG Interpretation
Cardiac Monitor /
Assess for other treatable

YES Exit to appropriate guideline
causes.
Transport to
MUSC Notify Destination or
M M
Pearls
 ALWAYS talk to family / caregivers as they have specific knowledge and skills. CALL THE VAD
COORDINATOR EARLY as per patient / family instructions or as listed on the device. They are available 24 / 7
and should be an integral part of the treatment plan.
 QUESTIONS TO ASK: Can the patient be cardioverted or defibrillated if needed? Can CHEST
COMPRESSIONS be performed in case of pump failure?
 Deciding when to initiate chest compressions can be difficult. Consider that chest compressions may cause
death by exsanguination if the device becomes dislodged. However, if the pump has stopped the heart will
not be able to maintain perfusion and the patient will likely die. Ideally, plan the decision in advance with a
responsive patient and the VAD coordinator. If a VAD patient is unresponsive and pulseless with a non-
functioning pump and has previously indicated a desire for resuscitative efforts, begin compressions.
Contact the VAD coordinator and medical control.
 Common complications in LVAD patients include Stroke and TIA (incidence up to 25%), bleeding, dysrhythmia,
and infection
 The Cardiac Monitor and 12 lead EKG are not affected by the VAD and will provide important information.
 LVAD patients are preload dependent. Consider that a FLUID BOLUS can often reverse hypoperfusion.
 Transport patients with ALL device equipment including any instructions, hand pumps, backup batteries, primary and
secondary controllers, as well as any knowledgeable family members or caregivers.
Charleston County
Pediatric Burn
Ensure that Scene is Safe
Thermal Burn Chemical Burn

Cool down the wound with Remove clothing or expose area;
Isotonic Crystalloid or Sterile brush off any dry chemicals
Water. After cooling cover burn or powder; then flush area with
with a Dry sheet or dressings. large amount of water or Isotonic
Take Proper Measures to Crystalloid
Prevent Hypothermia after Take Proper Measures to
Cooling Prevent Hypothermia after
Cooling
Burn Center Criteria

 Partial thickness burns greater
than 10% total body surface area Identify total body surface area
(TBSA). (BSA) affected by burns
 Burns that involve the face, Exit to Appropriate
(2nd and 3rd Degree) NO
hands, feet, genitalia, perineum, Guideline
Does patient meets burn center
or major joints.
 Third degree burns in any age
criteria or require ALS intervention?
group.
 Electrical burns, including YES
lightning injury.
 Chemical burns. Cardiac Monitor /
 Inhalation injury. Consider 12 Lead EKG Acquisition
PEDIATRIC TRAUMA
 Burn injury in patients with
preexisting medical disorders that Cardiac Monitor /
could complicate management, P P
EKG Interpretation
prolong recovery, or affect
mortality.
 Any patient with burns and Vascular Access Guideline
concomitant trauma (such as
fractures) in which the burn injury Obtain baseline SPO2 and
poses the greatest risk of Monitor Continuously.
morbidity or mortality.
Exit to Appropriate Airway Difficulty Oxygenating, Ventilating,

YES
Guideline or Impending Airway Compromise
Exit to Carbon Monoxide/ Suspected Carbon Monoxide/

YES
Cyanide Guideline Cyanide Exposure
Exit to Pain Management

YES Severe Pain
Guideline
Normal Saline
6-12 years = 250 ml/hr
≤ 5 = 125 ml/hr
Burn Centers
 Medical University of South
Carolina (Adult and Pediatric)
M M
Charleston County
Clinical Guidelines
2020-11
Pediatric Burn
INFANT CHILD ADOLESCENT
PEDIATRIC TRAUMA
Pearls
 Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, and Neuro.
 Classification of Burns:
First Degree (Partial Thickness) Superficial, red, sometimes painful.
Second Degree (Partial Thickness) Skin may be red, blistered, swollen. Very painful.
Third Degree (Full Thickness) Whitish, charred or translucent, no pin prick sensation in burned area.
 Critical or Serious burns should be transported directly to a Burn Center if possible (MUSC). Consider whether a
patient meets trauma criteria as per Field Trauma Triage. Transport to a Trauma Center or the CLOSEST
EMERGENCY DEPARTMENT as necessary in the event of any airway management complication in a burn patient.
Consider remaining at the ED if possible in order to resume transport to burn center once airway secured, if patient
condition permits.
 Early intubation is indicated if the patient has sustained significant inhalation injuries.
 Burn patients are trauma patients, evaluate for multisystem trauma.
 Assure whatever has caused the burn is no longer contacting the injury. STOP THE BURNING PROCESS!
 Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue
swelling.
 Burn patients are prone to hypothermia - never apply ice to cool the burn, must maintain normal body temperature.
 Evaluate the possibility of geriatric abuse with burn injuries in the elderly.
Charleston County
Open Fracture Antibiotic: Cefazolin

• Exposed bone
• Open joint fractures and dislocations
• Amputations of any extremity or part
(excluding tips of fingers or toes)
• Grossly contaminated large soft tissue
defects
Trauma
Reported allergy to Penicillins or Do not administer
Yes
Cephalosporins Cefazolin
No
Cefazolin IV
Reconstitute in 5-10mL of Sterile
Water
P <15kg Patient: 250mg
15-39kg Patient: 500mg
≥40kg Patient: 2g
M M
Pearls
• Recommended exam: Mental Status, Neuro, areas of injury
• Administration of Cefazolin should not precede any other needed interventions or assessments.
• Be cognizant of lacerations above areas of crepitus where the fractured bone may have pierced the skin and not
remained visible.
• Examples of grossly contaminated large soft tissue defects include: animal bites or open wounds containing
excessive amounts of foreign matter.
• Be alert for signs and symptoms of anaphylaxis during antibiotic administration.
• Scene time should not be delayed for administration of Cefazolin.
Charleston County
Trauma Patients With Life Threatening Injuries -
Pediatric
Consider whether helicopter evacuation is appropriate. E EMT
A Advanced EMT
Assure adequate airway and ventilation.
See SPINAL MOTION RESTRICTION protocol. P Paramedic
1. Support oxygenation with high flow oxygen.
2. Assist ventilation with bag-valve-mask if needed.
3. Suction as needed P See AIRWAY, ADVANCED protocol.
Control major external hemorrhage. Apply tourniquet(s) early if needed.
Perform pleural decompression if:

1. The patient is hemodynamically unstable, AND
2. There is strong evidence of tension pneumothorax.
Transfer to stretcher, stabilizing extremity injuries manually.
EVACUATE TO UNIT AND TRANSPORT!
Monitor BP, pulse rate, oxygen saturation, and level of consciousness.
Initiate vascular access with normal saline.

1. If BP and perfusion are adequate establish INT only.
2. If BP or perfusion are compromised, rapidly infuse fluid IV or IO.
3. Administer NS 20 mL/kg bolus via Pull-Push method. Reassess.
4. Administer a second bolus of NS 20 mL/kg via Pull-Push method if necessary.
5. Establish a second point of vascular access if possible. B CONTACT MEDICAL CONTROL with brief
report and ETA.
If time permits
1. Complete secondary survey.
2. Dress wounds.
3. Splint fractures.
Charleston County
Pediatric Carbon Monoxide / Cyanide
Immediately Remove from Exposure

and administer High Flow Oxygen
Blood Glucose Analysis Diabetic Guideline
Age appropriate Multiple Trauma Spinal Motion Restriction Guideline

Guideline if indicated If indicated
Cardiac Monitor /
Cardiac Monitor /
P P
EKG Interpretation
EtCO2 Monitoring
PEDIATRIC ENVIRONMENTAL / OTHER

Consider CO Monitoring
Difficulty Breathing OR Monitor & Reassess

NO
Altered Sensorium ? Continue High Flow Oxygen
YES
Age appropriate Airway Guideline

if indicated
Hydroxocobalamin
Strong Suspicion 70 mg/kg IV / IO
YES P
of Cyanide ? Maximum 5 g IV / IO
infused over 15 minutes
NO
Age Specific VS
(SBP < 70 + 2 x Age) YES
Poor Perfusion / Shock Hypotension Guideline
NO
Monitor & Reassess Notify Destination or

M M
Continue High Flow Oxygen Contact Medical Control
Pearls
 Scene safety is priority.
 Consider CO and Cyanide with any product of combustion, especially burning wools, silk, plastics, and furniture.
 Follow medical Cardiac Arrest algorithm for patients in cardiac arrest, with prioritization of airway management and
oxygenation, and consider early transport. Hydroxocobalamin may be administered after achieving ROSC.
 Normal environmental CO level does not exclude CO poisoning.
 Symptoms present with lower CO levels in pregnancy, children and the elderly.
 Continue high flow oxygen regardless of pulse ox readings.
 Do NOT delay treatment or transport of the sick/unstable patient to obtain 12 Lead ECG.
 Pulse Oximetry Readings may read FALSELY HIGH with Carbon Monoxide Poisoning
Charleston County
Pandemic
Pandemic Patient Care
Scene Safety PEDIATRIC: < 12 years old

Demonstrate Professionalism and Courtesy AND
[a] < 55 Kg -or- [b] Fits on
Pediatric Length Based Tape
PPE (Droplet Precautions)
Initial Assessment at a Distance (6' back)

Perform Age Appropriate Assessment Procedure
Consider Spinal Motion Restriction [as indicated]
Pandemic Respiratory Guideline
See appropriate protocol
FOUNDATION
based on assessment
Obtain appropriate vital signs:
 BP, Heart Rate, Respiratory Rate, GCS
 Pulse Oximetry (if indicated)
 Minimum two sets
Consider F.A.S.T / R. A. C. E. Assessment
Go To Glucose
Consider Blood Glucose Analysis Management
Protocol
Consider
Cardiac Monitor / ECG Acquisition
Consider
P P
Cardiac Monitor / ECG Interpretation
Unstable Patient Does Not

Exit To
M Fit a Protocol: M
Appropriate Protocol/Guideline
Go to Telehealth/
Notify Receiving Facility
Non-Transport NO Transport? YES M M
Guideline
Early
Charleston County
Pandemic Patient Care
A patient is defined as any person who meets ANY of the following criteria:
 Receives basic or advanced medical or trauma treatment
 Is physically examined
 Has visible signs of injury or illness or has a medical complaint
 Requires EMS specific assistance to change locations and/or position
 Identified by any party as a possible patient because of some known or reasonably suspected illness/injury
 Has a personal medical device evaluated or manipulated by EMS
 Requests EMS assistance with the administration of personal medications or treatments
Completion of an EHR (ePCR) is required for any and all patient encounters.
FOUNDATION
Pearls
 Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status with
GCS, and location of injury or complaint.
 Safety is priority. Ensure proper use of needed PPE (gowns, gloves, eye protection, mask).
 Contact should be limited with COVID-19 patients. When able, contact and initial assessment should be
made from a safe distance (>6 feet) and by 1 provider.
 Required vital signs on every patient include blood pressure, pulse, respirations, pain / severity.
 Pulse oximetry, temperature, and glucose documentation is dependent on the specific complaint.
 Every patient should have at least one full set of vital signs taken manually.
 If hypoxia is present and patient has adequate respiratory drive, oxygen should be administered with a nasal cannula
and a procedure mask on patient.
 There should be at least one set of vitals for every 15 minutes of patient contact time; every 5 minutes for unstable
patients.
 Timing of transport should be based on patient's clinical condition and the transport policy / destination.
Charleston County
Adult Pandemic Respiratory
Oxygen administration
should be performed with CDC Flagged or High
Nasal Cannula and Suspicion of COVID-19
Procedure mask placed
on patient.
Pandemic Patient Care Guideline
Non-Rebreathers and Bag

Valve Masks should be
avoided.
Is patient a candidate for
Yes
telehealth/non-transport?
Exit to appropriate guideline

No maintaining PPE.
SPO2 able to be
maintained >90% with NC
Adult Airway
No
If SPO2 >85%,
Assemble MDI with
continue with O2 via
Spacer (see PEARLs)
NC
Administer 8 “puffs” SPO2 <90% with
Wheezing Rales P <85%, utilize CPAP
of MDI albuterol. Oxygen
mask w/BVM for
May repeat once in 5
Positive Pressure
minutes.
*see Pearls*
Improving? Yes M M
If respiratory status continues

No to decline, focus on BLS airway
management to reduce risk of
respiratory droplets. BIAD
A preferred and Humid-Vent
(1mg/mL) 0.3mg IM
Filter must be utilized in
conjunction. DL should be
avoided, VL with bougie if ETT
needed.
Charleston County
Adult Pandemic Respiratory
Adult Airway
Pearls
 Recommended exam: Mental status, skin, HEENT, heart, lungs, and neuro.
 Safety is priority. Ensure proper use of needed PPE.
made from a distance (>6 feet) and by 1 provider.
 Common signs and symptoms of COVID-19: Fever, cough, sore throat, body aches, fatigue, shortness of breath.
Rhinorrhea (runny/stuff nose) is uncommon for COVID-19, but may be present or usually found with other viral or
bacterial upper respiratory infections.
 When providing oxygen via nasal cannula at a high rate, ensure that airway is maintained open with needed
maneuvers or basic adjuncts.
 There are no obvious indications that this patient is experiencing an isolated exacerbation of a chronic illness, such
as COPD, CHF, asthma, etc. utilize Adult Respiratory Distress guideline.
 If a patient has an albuterol MDI and/or spacer, this may be utilized.
 MDI with spacer. The MDI with spacer will be used instead of nebulized medication to help prevent the
transmission of the virus by aerosolization. IM epinephrine is indicated for its beta2 agonist effects.
 COVID-19 is considered as a droplet-precaution viral disease. However, droplets may be aerosolized by coughing,
sneezing, or nebulized medication use and remains in the air for several hours. Use the recommended mask on
yourself when making patient contact. If the patient is transported, apply a surgical mask to the patient to limit
contamination and protect others. Do NOT use an N95 on these patients.
 Contact Medical Control prior to administering epinephrine in patients who are > 50 years of age, have a history
of cardiac disease, or if the patient’s heart rate is > 150. Epinephrine may precipitate cardiac ischemia. A 12-lead
ECG should be performed on these patients.
 CPAP should not be utilized with possible COVID-19 patients.
 Closed System BVM/CPAP: HighFlow NC on patient, CPAP Mask, Humid-Vent Filter, ETCO2, and BVM w/PEEP.
With the PEEP Valve, the patient will get positive pressure without squeezing the BVM.
 If patient’s pulse ox cannot be maintained above 85% with Oxygen therapy, consider repositioning the
patient into left lateral recumbent. If after 10min in a lateral position they remain hypoxic, consider placing
patient prone. When repositioning patient, be sure to continually monitor patency of patient’s airway. For
obese patients or those with CHF, repositioning may be contraindicated. If in distress, consider DAI.
Charleston County
Pediatric Pandemic Respiratory
CDC Flagged or High

Suspicion of COVID-19
Oxygen administration
should be performed with
Nasal Cannula and
Procedure mask placed
on patient.
Is patient a candidate for
Yes
telehealth/non-transport?
Non-Rebreathers and Bag
Valve Masks should be
Exit to appropriate guideline
ENVIRONMENTAL / OTHER
avoided.
maintaining PPE.
No
SPO2 able to be
Yes
maintained >90% with NC
No
Assemble MDI with

Spacer (see PEARLs)
SPO2 <90% with Oxygen
Administer 4 “puffs” of
Yes and wheezing or limited
MDI albuterol.
air movement from
May repeat once in 5
bronchospasm?
minutes.
Improving? Yes M M
No
A (1mg/mL) 0.01 mg/kg IM
Maximum 0.3 mg
If respiratory status continues to decline,
focus on BLS airway management to
reduce risk of respiratory droplets. BIAD
preferred and Humid-Vent Filter must be
utilized in conjunction. DL should be
avoided, VL with bougie if ETT needed.
Charleston County
Pediatric Pandemic Respiratory
ENVIRONMENTAL / OTHER
Pearls
 Recommended exam: Mental status, skin, HEENT, heart, lungs, and neuro.
 Safety is priority. Ensure proper use of needed PPE (gloves, eye protection, mask, and gowns).
 Common signs and symptoms of COVID-19: Fever, cough, sore throat, body aches, fatigue, shortness of breath.
Rhinorrhea (runny/stuff nose) is uncommon for COVID-19, but may be present or usually found with other viral or
bacterial upper respiratory infections.
 There are no obvious indications that this patient is experiencing an isolated exacerbation of a chronic illness, such
as COPD, CHF, asthma, etc utilize Pediatric Respiratory Distress guideline.
 If a patient has an albuterol MDI and/or spacer, this may be utilized.
 MDI with spacer. The MDI with spacer will be used instead of nebulized medication to help prevent the
transmission of the virus by aerosolization. IM epinephrine is indicated for its beta2 agonist effects.
sneezing, or nebulized medication use and remains in the air for several hours. Use the recommended mask on
Charleston County
Pandemic Cardiac Arrest
Go to Discontinuation /
Death Procedure
Exit to
Supervisor and Coroner Traumatic Arrest
Yes Traumatic Arrest
(Blunt/Penetrating Trauma) Guideline
No

When LUCAS Device Push Hard (≥ 2 inches) Push Fast (~110 / min)
arrives on scene, place Change Compressors every 2 minutes AT ANY TIME
(Limit changes / pulse checks < 5 seconds) Return of Spontaneous
patient to limit needed Circulation
resources. Initiate Compressions Only CPR
Place patient on Nasal Cannula 10-15 lpm with
Surgical Mask / Place BIAD
3 Fire Personnel if available
with PPE + Call for additional resources
Go to Post
Adult Cardiac
2 CCEMS with PPE First Arriving Ambulance Resuscitation
Additional Personnel Assume Compressions or Guideline
outside of Hot Zone ready to Initiate Defibrillation (Automated/Manual)
deploy in PPE Place BIAD if needed
10 Ventilations/min with Continuous Compressions
BLS Additional Responders Stage ALS

Inside Outside Inside

Manages Scene / Bystanders Ensure only needed resources present
Administer Appropriate Medications
Establish Airway if not in place
Go To Age Appropriate
Interrupt Compressions Only as Cardiac Arrest: ALS Rhythms
per AED Procedure. Guideline
Do NOT hyperventilate. Continue Team Approach CPR
Charleston County
Pandemic Cardiac Arrest
AIRWAY
DEFIB
CPR MEDS
Adult Cardiac
TEAM
TIMER
LEADER
Pearls
defibrillation when indicated.
DO NOT HYPERVENTILATE: Ventilate at approximately 10 breaths per minute when BIAD present.
Safety is priority. Only needed resources allowed in hot zone. Stage unneeded outside.
To minimize responder contamination/resources needed, place LUCAS device as soon as available.
DO NOT interrupt compressions to place advanced airway. Use BIAD to minimize contamination. Do not
ventilate without airway placed. No BIAD=high flow nasal cannula (10-15 lpm) with surgical mask on patient.
If ETT must be utilized it should be done with video laryngoscopy and bougie.
In line suctioning should be done with closed circuit suctioning.
Follow current PPE policies.
When providing oxygen via nasal cannula at a high rate, ensure that airway is maintained open with needed
Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control and rapid
transport.
Consider possible CAUSES of arrest early: Consider traditional ACLS “Hs and Ts” for PEA: Hypovolemia, Hypoxia,
Hydrogen ions (acidosis), Hyperkalemia, Hypothermia, Tablets/Toxins/Tricyclics, Tamponade, Tension pneumothorax,
Thrombosis (MI), Thromboembolism (Pulmonary Embolism)
Charleston County
Pandemic Opioid Overdose
Scene
YES Pandemic Patient Care
Safe?
NO

resources. Evidence of Opioid Exit to appropriate guideline
No
Stage until scene safe. Overdose? maintaining PPE.
Yes
Adequate Respirations /
Oxygenation / Ventilation
No
High Flow Nasal Cannula (10-
Yes 15lpm) with Procedure Mask
Do not Ventilate with BVM
Enviornmental/Other
No
SPO2 >90%
Naloxone 0.5 -1 mg IN
Naloxone 0.1 mg/kg IV/IM/

IN up to 0.5 mg
Titrate to adequate
Yes CONSCIOUSNESS
Repeat As Needed*
Improved?
Yes
Cardiac Monitor /
No
Cardiac Monitor / Pandemic Airway Guideline

P P
EKG Interpretation
M M
Charleston County
Pandemic Opioid Overdose
Isolated Heroin Overdose Refusal Guidelines
EMS crews should attempt to convince any patient treated for a possible opioid overdose to allow transport to the ED of
their choice for additional evaluation and monitoring. However, multiple observational studies have indicated that no
short-term deaths were found in the subsets of opioid overdose patients who received naloxone treatment in the field
and refusal may be permissible in some circumstances. Patient’s wishing to refuse must meet the following guidelines:
 The patient must be age 18 or older and be suffering from an isolated IV opioid overdose, i.e. with depressed
mental status or respiratory distress/arrest from an opioid overdose. Patients are treated as per page 1 of this
guideline.
 The patient must not have overdosed on any transdermal or oral narcotics such as oxycontin, methadone, etc.
 The patient must never have been in cardiac arrest during this incident, nor received CPR.
 The patient must regain a normal mental and respiratory status after naloxone administration of up to 2mg.
 Once “awake” the patient must be fully oriented to person, place, time and events. EMS crew should monitor
patient for up to 30 minutes to ensure no recurrence of altered mentation.
The treating EMS crew must document all attempts to convince the patient of transport, the total observation time, and
refusal plan (who is going to observe them, if possible). If patient does not meet these criteria and still wishes to refuse,
consult with On-Line Medical Control for guidance and disposition.
MEDICAL
Pearls
 Recommended exam: Mental Status, Skin, HEENT, Heart, Lungs, Extremities, Neuro
 Safety is a priority. Ensure proper use of needed PPE.
 Naloxone*:
initial dosing.
sneezing, or ventilating with BVM use and remains in the air for several hours. Use the recommended mask on
Charleston County
Pandemic Telehealth
Patient age <1 years or >65

Yes
years
No
Assess Vital Signs:

HR, RR, BP, SpO2
If Indicated: Assess BGL
Pulse <50 or >110

RR <8 or >24
SBP <85 or >180, or DBP >120
SpO2 <94% on Room Air Refer to Appropriate Guideline
Yes
BGL <60 or >300 Maintaining PPE.
GCS <15
Temperature: >100.4
Peds-See Handtevy
No
Does the patient have any of the

following complaints?:
 Minor Allergic Reactions No
 Superficial Animal/Insect Bites
 Nontraumatic Back/Joint Pain
 Mild Asthma Exacerbations
 Minor Burns No
 Pink Eye
 Minor Lacerations
 Elevated Blood Pressure (SBP
<180, DBP <120)
 Upper Respiratory Complaints/Flu/  Patient has a support
COVID system.
 Earache  Patient is competent
 Sore Throat  Patient consents to not
 Dental Pain being transported.
 STDs Yes
 Patient provided with
 Rashes resources (local public
 Diarrhea or Constipation health authorities,
 Female Urinary Complaints telehealth number,
 Provider Discretion etc.)
Telehealth
Charleston County
Pandemic Telehealth
Pearls
 Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro
 Proper PPE should be taken with possible infectious patients (gloves, eye protection, mask, and gowns).
 Age appropriate vital signs, as defined in the Charleston County Handtevy Guide, should be utilized for the vital
signs assessments of SBP, HR, and RR in pediatric patients.
 Patients with serious medical/trauma complaints or those who are combative/uncooperative are not candidates for
telehealth consult.
 BGL should be assessed in known or suspected diabetics and any patient with altered mental status.
 Telehealth will make non-ED destination determination and patient will coordinate transport
 Roper Telehealth: https://www.rsfh.com/virtualcare/
 Roper St Francis Virtual Care app loaded onto truck smart phones.
 Patient needs to have an email address in order to utilize this service.
 Assist patient with registration process.
 Unit must remain on scene with patient until end of telehealth consult to ensure transport will not be needed.
 Telehealth cannot be initiated until proper patient assessment has occurred.
 Dispositions will be “Patient Evaluated: No treatment/transport required”
Charleston County
Procedures
Standard Procedure (Skill)
Airway: CPAP
Clinical Indications:
E EMT
 CPAP is indicated in all patients whom inadequate ventilation is suspected and who
have adequate mental status and respiratory drive to allow CPAP to function. This A Advanced EMT
could be as a result of pulmonary edema, pneumonia, asthma, COPD, etc. Paramedic
P
Contraindications:
 Patients <12 years of age.
 Systolic blood pressure < 90 mmHg
 Facial features or deformities that prevent an adequate mask seal.
 Excessive respiratory secretions, vomiting, or active upper GI bleeding.
 Respiratory distress due to trauma and/or suspected pneumothorax.
 Tracheostomy.
 Use caution with impaired mental status or poor cooperation.
Procedure:
1. Ensure adequate oxygen supply (100%) to ventilation device.
2. Explain the procedure to the patient.
3. Apply continuous pulse oximetry, and consider placement of a nasal capnography.
4. Place the delivery mask over the mouth and nose. Oxygen should be flowing through the device.
a. Allow patient to hold mask in place as they adjust to treatment.
5. Secure the mask with provided straps, adjust starting with the lower straps, until minimal air leak occurs.
6. If the Positive End Expiratory Pressure (PEEP) is adjustable on the CPAP device, adjust the PEEP beginning at 5
cmH2O of pressure and slowly titrate to achieve a positive pressure as follows:
a. 5 – 15 cmH2O for Pulmonary Edema, Near Drowning, possible aspiration or pneumonia
b. 5 cmH2O for COPD
7. Evaluate the response of the patient assessing breath sounds, oxygen saturation, and general appearance.
8. Actively coach patient to improve tolerance to therapy.
9. Continuously monitor patient’s blood pressure. Decrease or discontinue CPAP for systolic BP less than 90 mmHg.
10. CPAP therapy needs to be continuous. Do not discontinue CPAP unless the patient cannot tolerate the mask or
experiences continued or worsening respiratory failure.
a. Therapy may be briefly interrupted for medication administration, suctioning, etc.
b. Do not remove CPAP until hospital therapy is ready to be placed on patient.
11. If respiratory status deteriorates, remove CPAP and consider bag valve mask ventilation or advanced airway use.
12. Document time and response on electronic health record (EHR).
Certification Requirements:
 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure.
Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom
demonstrations, skills stations, or other mechanisms as deemed appropriate by the Charleston County EMS
system.
Charleston County
Physical Restraint
E EMT
 Behavior or threats that create or imply a danger to the patient or others A Advanced EMT
 Safe and controlled access for medical procedures Paramedic
P
 Change in behavior that results from improvement or deterioration of patient
condition, i.e. hypoglycemia, overdose, intubation
 Involuntary evaluation or treatment of combative patients
Precautions:
 Be aware of items at the scene or medical equipment that may become a weapon
 Assure that the scene is safe as possible before approaching the patient
 Patients that are actively seizing should never be restrained
 The patient should never be restrained in a prone or fully supine position. This position may interfere with the
patient’s ability to breathe
 Restraining a patient’s hands and feet together behind the patient (hog-tying) is not allowed. The only exception is a
prisoner or suspect in the custody of law enforcement or prison guard
Procedure:
 Attempt first to control the patient with verbal counseling

 Make every attempt not to aggravate or worsen pre-existing injuries or medical conditions
 The least restrictive means of control should be employed
 Only "reasonable force" may be used when applying physical control. This is generally defined as the use of force
equal to, or minimally greater than, the amount of force being exerted by the resisting patient.
 Restraints should not interfere with the assessment or treatment of the patient’s ABCs
 The decision to restrain a patient should usually be made prior to transport
 Do not remove restraints once applied unless the patient seizes or has a life endangering emergency
 If circulation becomes compromised, the benefit of removing the restraints must be weighed against crew safety.
 EMS does not apply handcuffs or hard plastic ties (flex cuffs), but if already in place and circulation is adequate,
may be left on
 If transporting with handcuffs a key must be readily available in case of a medical emergency
 Restraints should be individualized and afford as much dignity to the patient as the situation allows. Attempt to
accommodate patient comfort or special needs whenever possible
 Ensure that enough help is available to insure patient and provider safety during the restraint process
 Optimally, five people should be available to apply full body restraint (one for each limb and one for restraint
application). Communicate the restraint plan to all personnel
 Assure that the patient’s clothing and personal belongings have been searched for weapons prior to transport.
 In the combative or potentially combative patient all four limbs must be secured
 HOB should be elevated to at least 30 degrees
 Continuous SpO2 monitoring required and attached to report (EtCo2, recommended for ALS crews)
 CMS (distal to the restraints) checks every 5 minutes
 Consider ALS (Sedation, Monitoring)
Charleston County
Physical Restraint
ALS Care E EMT
 Consider addition of sedation for those patients that remain combative A Advanced EMT
(If administered refer to chemical restraint guideline) P Paramedic
 Consider cardiac and EtCo2 monitoring, must document reason if not applied
Special Population considerations

 Always attempt to involve parents when restraining children
 Pregnant women should be restrained in a semi-reclining or left lateral recumbent position
 Always attempt to involve family or supervisory facility staff prior to restraining elderly
Documentation Requirements:
 An emergency existed
 The need for treatment was explained to the patient (regardless of competence)
 The patient refused treatment or was unable to consent to treatment
 Evidence of the patient’s incompetence to refuse treatment
 Failures of less restrictive methods of control (such as verbal counsel)
 The restraints were used for the safety of the patient or others
 The reasons for restraint were explained to the patient (regardless of competence)
 The type/method of restraint used, and which limbs were restrained
 Injuries that occurred, if any, during the restraint procedure (patient and/or provider)
 Which agency placed the restraints
 CMS checks and the patient’s ability to breathe
Special Notes:
 The use of SpO2 monitoring may be useful in assessing distal circulation but does not take the place of CMS
checks
Charleston County
Cardiac: 12 Lead
E EMT
 Suspected cardiac patient or Suspected Stroke Patient
 Suspected tricyclic overdoses A Advanced EMT
 Electrical injuries Paramedic
P
 Syncope
 Dyspnea / Atypical Symptoms
 Any patient age 35 or over with chest pain
Procedure:
1. Assess patient and monitor cardiac status.
2. Administer oxygen as patient condition warrants (SPO2 94-99%).
3. If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after treatment, perform 12
Lead ECG.
4. Prepare ECG monitor and connect patient cable with electrodes.
5. Enter the required patient information (patient name, age, etc.) into the 12 Lead ECG device.
6. Expose chest and prep skin by abrading gently with gauze or towel. Shave as necessary. Modesty of the patient
should be respected.
7. Apply chest leads and extremity leads using the following landmarks:
 RA, LA, RL, LL applied to appropriate extremities
 V1 – 4th intercostal space at right sternal border
 V2 – 4th intercostal space at left sternal border
 V3 – Directly between V2 and V4
 V4 – 5th intercostal space at midclavicular line
 V5 – Level with V4 at left anterior axillary line
 V6 – Level with V5 at left midaxillary line
8. Instruct patient to remain still.
9. Press the appropriate button to acquire the 12 Lead ECG.
10. If an inferior infarct is suspected, obtain a right-sided EKG.
 V3 – V6 are moved to same location on right side
 Obtain ECG as instructed above
 Label as V3R through V6R on ECG printout – DO NOT TRANSMIT.
10. Once acquired, transmit the ECG data to the appropriate hospital.
11. Contact the receiving hospital to notify them that a 12 Lead ECG has been sent.
12. Monitor the patient while continuing with the treatment guideline.
13. Download data as per guidelines and attach a copy of the 12 lead to the EHR.
15. Document the procedure, time, and results on the electronic health record (EHR).
16. Go to the next page for procedures regarding suspected STEMI.
system.
Charleston County
Cardiac: EMS CODE STEMI – Cath Lab Activation
P Paramedic
 Suspected ST-Elevation MI (STEMI), based on patient condition and ECG
Procedure:
1. Enter the first 5 letters of the patient’s last name in the “patient last name” field, and transmit diagnostic 12-lead
ECG; transmit multiple ECGs as necessary.
2. Obtain the following information before your radio call in:
a. Patient age and gender
b. Patient cardiologist and preferred STEMI hospital (if present)
c. Clinical presentation, history, symptoms that suggest this is an acute cardiac event
d. What are the 2 or more anatomically contiguous leads with 1+ mm ST elevation (SEE STEMI Localization Tool)
e. Is there a LBBB that is possibly new?
f. Absence or presence of LVH
g. Absence or presence of profound tachycardia (heart rate > 129)
h. Absence or presence of pacemaker activity
i. Was the patient resuscitated from cardiac arrest but does not have obvious STEMI?
3. If patient has 1+ mm of ST elevation in two anatomically contiguous leads and none of the characteristics in red
above, call a CODE STEMI to the hospital. If any of the characteristics in red are present, do NOT call “Code STEMI.”
Instead, transmit the 12-lead for physician consultation; be sure to communicate the need for physician consult due to
concern for possible STEMI.
 Isolated ST elevation in aVR, with ST depression EVERYWHERE ELSE is concerning for a possible proximal LAD
or Left Main lesion. Not STEMI criteria, but ECG should be sent for consult and ED notified early.
4. Give your standard radio call-in including the following information:
 This is EMS [Unit #] en route with a CODE STEMI patient, ETA [x] minutes
 The 12-lead [has been / could not be] transmitted.
 Clinical presentation suggesting acute event: Chest Pain, Shortness of Breath, diaphoresis, etc.
 [x] mm of ST segment elevation are present in leads [X, Y…], with reciprocal depression in [X, Y…]
 There is no LVH noted
 The patient has no pacemaker (or no pacer spikes are present)
 [He/She] is a patient of Dr. [x] (or has no cardiologist)
 Provide patient’s name and DOB if requested (Not a HIPAA issue)
system.
Charleston County
Cardiac: External Pacing
P Paramedic
 Patients with symptomatic bradycardia (less than 60 per minute) with signs
and symptoms of inadequate cerebral or cardiac perfusion such as:
 Chest Pain
 Hypotension
 Pulmonary Edema
 Altered Mental Status, Confusion, etc.
 Ventricular Ectopy
Procedure:
1. Attach standard four-lead monitor.
2. Apply defibrillation/pacing pads to chest and back:
 One pad to left mid chest next to sternum
 One pad to mid left posterior chest next to spine
3. Select pacing option on monitor unit. Utilize “Demand” pacing.
4. Adjust heart rate to 70 BPM for an adult patient.
5. Note pacer spikes on ECG screen.
6. Set pacer current level at 50 mA to start, and increase until capture is obtained and pulse is palpable. Typical mechanical
capture thresholds are 50-90 mA but may vary widely.
 NOTE: For critically ill patients (e.g. hypotension, peri-arrest, unconscious), start pacing attempts at 100 mA.
7. If unable to capture while at maximum current output, stop pacing immediately.
8. If electrical capture is observed on monitor, continuously check for corresponding pulse and assess vital signs (e.g. blood
pressure) to ensure ONGOING mechanical capture. Pulse oximetry waveform (pleth) is a use tool for secondary
confirmation.
9. Consider the use of sedation or analgesia if patient is uncomfortable.
10. Once successful capture is obtained, do not disconnect pacer or four-lead monitor. Ensure therapy is continued until
receiving hospital is prepared to transition to their equipment.
11. Document the dysrhythmia and the response to external pacing with ECG strips in the EHR.
system.
Charleston County
Cardiac: Synchronized Cardioversion
P Paramedic
 Unstable patient with a tachydysrhythmia (rapid atrial fibrillation, supraventricular
tachycardia, ventricular tachycardia)
 Patient is not pulseless (the pulseless patient requires unsynchronized cardioversion, i.e., defibrillation)
Procedure:
1. Attach standard four-lead monitor.
2. Apply defibrillation/pacing pads. Either Anterior-Posterior (AP) or Anterior-Lateral (AL) placement may be used.
AP placement is preferred if possible without delay:
 One pad to left mid chest next to sternum
 One pad to mid left posterior chest next to spine
3. Consider the use of pain or sedating medications.
4. Set energy selection to the appropriate setting.
5. Set monitor/defibrillator to SYNCHRONIZED cardioversion mode.
6. Press and hold the shock button to cardiovert. Stay clear of the patient until the energy has been delivered.
 NOTE: It may take the monitor/defibrillator several cardiac cycles to “synchronize”, so there may be a delay between
activating the cardioversion and the actual delivery of energy.
7. Note patient response and perform immediate unsynchronized cardioversion (defibrillation) if the patient’s rhythm has
deteriorated into pulseless ventricular tachycardia/ventricular fibrillation, following the procedure for Defibrillation.
8. If the patient’s condition is unchanged, repeat steps 2 to 7 above, using escalating energy settings.
9. Repeat until maximum settings or until efforts succeed. Consider discussion with medical control if cardioversion is
unsuccessful after 2 attempts.
10. Note procedure, response, and time in the electronic health record (EHR).
system.
Charleston County
Mechanical CPR: LUCAS 3
E EMT
 To perform external cardiac compressions on adult patients who have acute circulatory
arrest, where performance of high quality CPR via manual compressions is not possible: A Advanced EMT
 When moving the patient from the scene to the ambulance. Paramedic
P
 When transporting the patient in a moving ambulance.
 Rescuer fatigue during prolonged arrest.
 Mechanical CPR should be applied after high performance manual CPR, and only when enough personnel are
available to minimize any interruptions to compressions.
Contraindications:
 Patients <12 years of age.
 Patients who do not fit within the device:
 Patients who are too large and with whom you cannot press the pressure pad down 2 inches.
 Patients who are too small and with whom you cannot pull the pressure pad down to touch the sternum.
Procedure:
1. Treat with manual CPR first – minimize all interruptions in compressions.
2. Power on LUCAS device by pressing ON/OFF. This starts self-test and places device in ADJUST mode.
3. Place the back plate under the patient, immediately below the armpits. Continue CPR for ≥ 100 compressions.
4. Pull the RELEASE RINGS once to open the CLAW LOCKS. Then let go of the rings.
5. Stop manual CPR briefly while attaching the UPPER PART to the BACK PLATE. Listen for “CLICK” and pull up once.
6. Push down the SUCTION CUP and adjust if necessary.
a. The lower edge of SUCTION CUP should be immediately above the end of the sternum.
7. Push PAUSE to lock START POSITION.
8. Push ACTIVE (continuous) to start compressions.
9. Attach stabilization strap and secure arms.
Additional Pearls:
1. PAUSE for manual ECG interpretation. Continue compressions during defibrillation.
2. Do NOT pause for intubation or BIAD placement.
3. LUCAS 3 is NOT contraindicated in pregnant patients – consider manual left uterine displacement.
4. LUCAS 3 is NOT contraindicated in trauma patients unless specific findings preclude its use.
5. Consider sedation for patient who remains in cardiac arrest but “wakes up” due to increased blood flow to brain/heart.
Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills
stations, or other mechanisms as deemed appropriate by the Charleston County EMS system.
Charleston County
Pelvic Splinting: T-Pod
E EMT
 Unconscious with multisystem trauma
 Unstable pelvic injuries. A Advanced EMT
 Pelvic pain with indicative mechanism of injury.
P Paramedic
Procedure:
1. Initiate SMR if indicated.
2. Slide belt under patient smoothly with minimal patient movement and into correct position under the pelvis. The top edge
of the belt should be level with the iliac crest.
3. Trim the belt, leaving a 6-8" gap over the center of the pelvis.
4. Apply velcro backed pulley system on each side of the trimmed belt.
5. Draw the pull tab, creating simultaneous circumferential compression.
6. Loop excess string around clips and secure the pull tab to the belt.
7. Record the date and time of application on belt.
8. Treat pain and any other injuries.
Additional Pearls:
1. Does not replace other SMR.
2. Do not forget to treat other life threats prior to application.
3. Do not forget pain management.
Charleston County
Patella Dislocation Reduction
P Paramedic
Isolated, clinically obvious, medial or lateral dislocation
of the patella (usually described as “knee went out”). Usually involves
planting and turning of the foot as found in people doing athletic events. Rarely will occur with a
direct blow to the knee or significant traumatic events such as an MVC. Sometimes occurs with only
minimal trauma to people with a slightly flexed knee.
CONTRAINDICATIONS:
 Intraarticular and superior dislocations (knee, hip).
 Provider is unsure or if body habitus (e.g. large body build or obesity) precludes accurate
assessment.
 Life threatening conditions, serious injuries or hemorrhage.
Clinical Procedure:
1. Don appropriate PPE and ensure scene safety.
2. Provide appropriate initial treatment as per Clinical Guidelines.
3. Address any hemorrhage or other more serious injuries first – DO NOT PROCEED WITH
PROCEDURE! If no hemorrhage or serious injuries, proceed to the next step.
4. Assess affected extremity for pulse, motor function and sensory.
5. Identify obvious medial or more commonly lateral patella dislocation. If patient’s body
habitus precludes adequate assessment, STOP THE PROCEDURE and immobilize in position
found.
6. Flex the hip then gradually and SLOWLY extend the knee, at the same time, a second provider
applies pressure on the patella towards the midline of the knee. NOTE: Some increased pain
may occur during reduction. If there is severe increased pain or resistance, STOP and splint in
the position found. Patients usually feel significantly better after reduction, but they still need
transport to a hospital for further evaluation and treatment.
7. When straight, immobilize the knee joint per Splinting procedures.
8. Reassess affected extremity for pulse, motor function and sensory.
9. Cold packs may be applied to affected area (avoid direct contact to skin).
10. Transport, as necessary, to the nearest appropriate Emergency Department.
11. Document the time, type of device, and patient condition response in the patient care report
(PCR).
Charleston County
Standard Procedure
Taser Barb Removal
Clinical Indications: E EMT

 Patient with uncomplicated conducted electrical weapon A Advanced EMT
probes embedded subcutaneously in non-sensitive
P Paramedic
areas of skin.
 Taser probes are barbed metal projectiles that may embed
themselves up to 13 mm into the skin.
Contraindications:
Patients with conducted electrical weapon probe penetration in vulnerable areas of
body as mentioned below should be transported for further evaluation and probe
removal.
Probes embedded in skin in area of genitalia, female breasts, or above clavicles.
Suspicion that probe might be embedded in bone, blood vessel, or other sensitive
structure.
Procedure:
Ensure wires are disconnected from weapon.
Stabilize skin around probe using non-dominant hand.
Grasp probe by metal body with dominant hand. Use caution to prevent puncture
wounds to EMS personnel.
Remove probe in single quick motion.
Wipe wound with antiseptic wipe and apply dressing.
Requirements:
Contact Medical Control for further guidance if needed.
Maintain knowledge of the indications, contraindications, technique, and

possible complications of the procedure.
Charleston County
Standard Procedure
Spinal Motion Restriction, Adult
Spinal motion restriction is generally indicated in patients with known or probable
traumatic injury of the spine, however: E EMT
Spinal motion restriction need not be applied when ALL of the following conditions A Advanced EMT
are met:
1. No complaint of midline spinal pain or tenderness with palpation P Paramedic
2. No neurological deficit or paresthesia (numbness or tingling)
3. No evidence of intoxication or altered sensorium.
4. No significant distracting injury (to self or others).
5. No insurmountable communication barrier (e.g. deafness, language, etc.)
6. Age less than 65 years or age greater than 65 years with minor mechanism.
Spinal motion restriction with a long spine board should not be routinely used in
cases of penetrating trauma unless there is one or more of the following:
• Obvious neurologic deficit to the extremities
• Significant secondary blunt mechanism (e.g. – significant fall after being shot)
• Priapism
• Neurogenic shock
• Anatomic deformity to the spine secondary to injury
If spinal motion restriction is indicated, perform SPINAL MOTION RESTRICTION

PROCEDURE
Procedure:
Apply an appropriately sized cervical collar.
For patients requiring extrication from a vehicle or other environment (residence, etc.)
• Self-extrication by patient is allowable if patient is capable
• Minimize spinal movement during the assessment and extrication
• A long backboard or other appropriate full-length extrication device may be
used for extrication if needed. Do not routinely use short board or KED
device during extrication.
For ambulatory patients:

• Allow the patient to sit on the stretcher and then lie flat.
• The “standing take-down” is eliminated.
Lay the patient flat on the stretcher, secure firmly with all straps, and leave the
cervical collar in place. Elevate the back of the stretcher only if necessary to
support respiratory function, patient compliance or other significant treatment
priority.
Instruct the patient to avoid moving their head or neck as much as possible.
Charleston County
Standard Procedure
Spinal Motion Restriction, Pediatric
E EMT
A Advanced EMT
P Paramedic
 Spinal MOTION RESTRICTION is indicated in pediatric patients where mechanism

of injury suggests the possibility of spinal trauma.
 Patients twelve years old or older OR weighing more than 55 kg are treated under
the SPINAL MOTION RESTRICTION - ADULT protocol, which permits certain
exclusions.
 If uncertainty exists, stabilize
Charleston County
Venous Access: Existing Catheters
P Paramedic
 Inability to obtain adequate peripheral access in hemodynamically unstable patients.
 Central venous access in a patient in cardiac arrest.
Procedure:
1. Clean the port of the catheter with alcohol wipe.
2. Using sterile technique, withdraw 5-10 mL of blood and discard syringe in sharps container.
3. Using 5 mL of Normal Saline, access the port with sterile technique and gently attempt to flush the saline.
4. If there is no resistance, no evidence of infiltration (e.g. no subcutaneous collection of fluid), and no pain
experienced by the patient proceed to step 5. If there is resistance, evidence of infiltration, pain experienced by the
patient, or any concern that the catheter may be clotted or dislodged, do not use the catheter.
5. Begin administration of medications or IV fluids slowly and observe for any signs of infiltration. If difficulties are
encountered, stop the infusion and reassess.
6. Record procedure, any complications, and fluid/medications administered in the patient care report (PCR).
The Broviac® catheter and the Hickman® catheter are temporary IV lines placed into a vein in the chest. The Broviac® is
smaller than the Hickman® and therefore used for pediatric patients. These catheters are soft and come in double and
triple lumens (as shown above).
The Groshong® catheter is similar to the Hickman® but includes a valve at the tip of the catheter which reduces the
amount of Heparin needed in the line. Used mainly for pediatric patients.
Peripherally inserted central catheter (PICC) is a 20-24 inch soft IV line which is inserted in the patients arm and
threaded into the heart. These Catheters come in single or double lumen.
system.
Charleston County
Venous Access: External Jugular
Clinical Indications: A Advanced EMT
 External jugular (EJ) vein cannulation is indicated in a critically ill patient greater P Paramedic
than 2 years of age who requires intravenous (IV) access for fluid or medication
administration, and in whom an extremity vein is not obtainable.
 Consider intraosseous (IO) access in addition to, or instead of, an EJ attempt.
 EJ cannulation may be attempted initially in life threatening events where no obvious peripheral site is noted.
Procedure:
1. Place the patient in a supine head down position. This helps distend the vein and prevents air embolism.
2. Turn the patient’s head toward the opposite side if no risk of cervical injury exists.
3. Prepare the skin with an antiseptic solution.
4. Align the catheter with the vein and aim toward the same side shoulder.
5. Compressing the vein lightly with one finger above the clavicle, puncture the vein midway between the angle of the
jaw and the clavicle and cannulate the vein in the usual method.
6. Attach the IV and secure the catheter avoiding circumferential dressing or tape.
7. Document the procedure, time, and result (success) on/with the patient care report (PCR).
system.
Charleston County
Venous Access: Extremity
A Advanced EMT
 Any patient where intravenous (IV) access is indicated (significant trauma or mechanism,
P Paramedic
emergent or potentially emergent medical condition).
Procedure:
1. Saline locks may be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the ALS
professional.
2. May use intraosseous (IO), external jugular (EJ), or preexisting venous catheter where threat to life exists and no obvious
peripheral site is noted. Actual attempt is NOT required.
3. Use the largest catheter bore necessary based upon the patient’s condition and size of the vein.
a. Use of 16ga is sufficient for rapid fluid infusion; 14ga is not indicated for routine use.
4. Fluid and setup choice is preferably:
a. Normal Saline with macro drip (10 gtt/mL) for medical and trauma conditions, and
b. Normal Saline with micro drip (60 gtt/mL) for medication infusions.
5. Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles.
6. Connect IV tubing to the solution in a sterile manner. Fill the drip chamber half full and then flush the tubing bleeding all
air bubbles from the line.
7. Place a constricting band around the patient’s extremity to restrict venous flow only.
8. Upper extremity IV sites are preferable to lower extremity sites.
9. Lower extremity IV sites are discouraged in patients with vascular disease or diabetes.
10. In post-mastectomy patients, avoid IV, blood draw, injection, or blood pressure in arm on affected side.
11. Select a vein and an appropriate gauge catheter for the vein and the patient’s condition.
12. Prep the skin with an antiseptic solution.
13. Insert the needle with the bevel up into the skin in a steady, deliberate motion until the bloody flashback is visualized in
the catheter.
14. Advance the catheter into the vein. Never reinsert the needle through the catheter. Dispose of the needle into the proper
container without recapping.
15. Remove the constricting band and connect the IV tubing or saline lock.
16. Open the IV to assure free flow of the fluid and then adjust the flow rate as per protocol or as clinically indicated.
17. All IV rates should be at KVO (minimal rate to keep vein open) unless administering fluid bolus.
a. Adult KVO: 60 mL/hr (1 gtt/6 sec for a macro drip set)
b. Pediatric KVO: 30 mL/hr (1 gtt/12 sec for a macro drip set)
18. Consider a second IV line if indicated by patient condition.
19. Pediatric: Use push-pull method for fluid administration.
20. Cover the site with a sterile dressing and secure the IV and tubing.
Charleston County
Venous Access: Intraosseous (EZ-IO)
A Advanced EMT
 Where rapid, regular intravenous (IV) access is unavailable with any of the following:
 Cardiac Arrest (may be used as a first line vascular access). P Paramedic
 Multisystem trauma with hypovolemia.
 Severe dehydration with vascular collapse and/or loss of consciousness.
 Require live-saving medications that cannot be administered intramuscular (IM).
Contraindications:
 Fracture in bone, or joint replacement of intraosseous (IO) site.
 Previous IO insertion at proposed site within 48 hours.
 Inability to find landmarks (e.g., proximal humerus on small pediatrics).
Sites:
1. Proximal humerus (preferred site, >12 years of age) (Yellow needle >40 kg)
a. Place the patient’s palm on the umbilicus and elbow on the ground/stretcher, or place the patient’s arm flat on the
ground or stretcher with the palm facing downward.
b. Place your palm on patient’s shoulder anteriorly, the area that feels like a “ball” is the general target area.
c. Place ulnar aspect of your hand vertically over the axilla and ulnar aspect of other hand on midline of lateral arm.
d. Place your thumbs together over the arm to locate the vertical line of insertion.
e. Palpate deeply up the humerus to the surgical neck (where “golf ball” and “tee” meet)
f. The insertion site is 1 to 2 cm above the surgical neck, on the most prominent aspect of the greater tubercle.
2. Proximal tibia (Blue needle >3 kg)
a. Identify the tibial tuberosity located 2 finger-breadths below the base of the patella.
b. The insertion site is 1-2 cm medial from this boney prominence, on the superior portion of the flat aspect of the
proximal tibia. Rotating the leg laterally can aid in positioning the site anterior.
Procedure:
1. Cleanse site using antiseptic agent and allow to air dry thoroughly.
2. Connect appropriate needle set to driver and stabilize site.
3. Remove needle cap and position the driver at the insertion site with the needle at 90° angle to the bone surface.
4. Gently pierce the skin with the needle tip until the tip touches the bone.
5. The 5 mm mark must be visible above the skin for confirmation of adequate needle length.
6. Gently drill into the bone 2 cm or until the hub reaches the skin in an adult (humerus).
a. Stop when you feel the “pop” or “give” in infants/children (tibia)
7. Hold the hub in place and pull the driver straight off. Continue to hold the hub while twisting the stylet off the hub.
a. The needle should feel firmly seated in the bone (1st confirmation of placement).
8. Place the stylet in a sharps container and secure site with EZ stabilizer and connect primed EZ-connect extension
set to the hub, firmly secure by twisting clockwise.
9. Flush the catheter with 10 mL Normal Saline (2-3 mL pediatric); look for infiltration (2nd confirmation of placement).
a. If the patient is responsive to pain, administer 0.5 mg/kg up to 40 mg (2 mL) 2% Lidocaine, slow
push over 120 seconds for anesthetic effect prior to the saline flush. May repeat at half initial dose.
10. Begin infusion utilizing a pressure delivery system and continue to monitor extremity for complications.
11. Any prehospital fluids or medications approved for intravenous (IV) use may be given IO.
Charleston County
Standards Policy
Criteria for Death / Withholding Resuscitation
Policy:
 CPR and ALS treatment are to be withheld only if the patient is obviously dead per criteria below, or a valid South
Carolina POST and/or Do Not Resuscitate form is present.
Purpose:
 To honor those who have obviously expired prior to EMS arrival.
Assessment:
 If a patient is in cardiopulmonary arrest (clinically dead) and meets one or more of the criteria below, CPR and ALS
therapy need not be initiated:
o Body decomposition
o Rigor mortis
o Dependent lividity
o Traumatic arrest in asystole or PEA <30
o Injury not compatible with life (i.e., decapitation, burned beyond recognition, massive open or penetrating
trauma to the head or chest with obvious organ destruction).
Procedure:
1. If a bystander or first responder has initiated CPR or automated defibrillation prior to EMS Paramedic’s arrival and
any of the above criteria (signs of obvious death) are present, the Paramedic may discontinue CPR and ALS
therapy. All other EMS personnel levels must communicate with Medical Control prior to discontinuation of the
resuscitative efforts.
2. If doubt exists, start resuscitation immediately. Once resuscitation is initiated, continue resuscitation efforts until
either:
a) Resuscitation efforts meet the criteria for implementing the Discontinuation of Prehospital Resuscitation
Policy.
b) Patient care responsibilities are transferred to the destination hospital staff.
c) Orders to terminate resuscitation are received by Medical Control.
Charleston County
Standards Policy
Death Communication with Family
Policy:
 To aid in the notification and grieving process for family and friends after the immediate death of a loved one.
Purpose:
1. Death notification can be very complex and will have lasting impact on family and friends. Understanding the basics
of human emotion and the normal reactions to traumatic events can help guide a proper notification.
2. Everyone reacts differently to death notifications; some will appear catatonic with little to no outward emotion while
others will become angry and irrational.
3. The five basic stages of grief are:
1. Denial and isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance
4. In the pre-hospital environment, it is likely that family will express all five stages of grief rapidly and while EMS is on-
scene.
5. Each individual processes a death notification in their own unique manner. Be patient and courteous and allow the
family member to find peace in his or her own way.
Procedure:
1. Delivery matters:
a. Introduce yourself by name and get on eye level with the family member.
b. Confirm the identity and relationship of the family member.
c. Use a very simple one line sentence to break the news, “I am very sorry to tell you but (use the victim’s
name) has died. Do not use “passed”, “expired”, or “moved on”. Also, refrain from referring to the body as a
victim, patient, son, etc.
d. Immediately inform the family member that they will be helped through the entire process.
e. Pause and allow the family member time to process the information and ask questions.
f. Demonstrate empathy and understanding.
g. Ask if other family members or friends should be notified.
2. Statements to avoid:
a. I know how you feel.
b. You need to be strong.
c. Calm down.
d. God must have needed him/her more than you.
e. Now that you know, I need to know what funeral home you would like.
f. It could have been worse.
3. Helpful statements:
a. I am sorry.
b. This is harder than most people think.
c. Is there anyone I can contact for you?
d. I wish I could give you an answer that could help, but I just cannot.
e. I can only imagine how you must feel
4. Listen; allow the family to speak and grieve. Many times they just want to be heard.
Charleston County
Standards Policy
Discontinuation of Prehospital Resuscitation
Policy:
 Unsuccessful resuscitative efforts may be discontinued prior to transport or arrival at the hospital when this policy is
followed.
Purpose:
 To allow for discontinuation of prehospital resuscitation after the delivery of appropriate ALS resuscitative efforts.
Procedure:
1. Discontinuation of CPR and ALS intervention for a medical cardiac arrest patient may be implemented prior to
contact with Medical Control if ALL of the following criteria have been met:
a. Patient is 18 years of age or older.
b. At least 25 minutes of high performance (team approach) CPR has been administered.
c. Airway has been successfully managed with verification of placement by bilateral lung sounds, absence of
epigastric sounds, and capnography. Acceptable management techniques include oral tracheal intubation
or blind insertion airway device such as the KING LTS.
d. IV or IO access has been achieved.
e. Rhythm appropriate medications and defibrillation have been administered according to protocol.
f. Persistent asystole or agonal rhythm is present and no untreated reversible causes are identified.
g. EtCO2 less than or equal to 10 after 25 minutes of resuscitation.
h. Failure to establish sustained palpable pulses or refractory/recurrent ventricular fibrillation/tachycardia, and
lack of any continued neurological activity such as eye opening or motor responses.
k. All EMS Paramedic personnel involved in the patient’s care agree that discontinuation of the resuscitation
is appropriate.
l. The patient is in a residence (non-public place) and the scene is safe to do so.
2. If all of the above criteria are not met and discontinuation of prehospital resuscitation is deemed appropriate,
contact Medical Control.
3. If the patient is in a public place or the scene is deemed unsafe to terminate resuscitation; work the arrest until the
patient can be transferred to the ambulance. Continue resuscitation efforts, transport to the closest appropriate
emergency room, and contact Medical Control for possible termination orders.
4. Traumatic arrests can be terminated on-scene without contacting Medical Control if at any point the patient
presents with asystole or a wide complex PEA less than 30.
5. Document all patient care and interactions with the patient’s family, personal physician, Medical Control, Coroner,
and law enforcement in the electronic health record (EHR).
6. Involve the family early in the resuscitation process:
a. Provide reassurance that everything possible is being done.
b. Ease the family into the decision to terminate resuscitation.
c. Provide emotional support.
8. If a possible Coroner case, do not allow family to disturb the patient or the surroundings.
9. If the Coroner’s office releases the body, make the patient presentable by removing IV’s and airway devices and
covering the patient. Do not remove any devices prior to contacting the Coroner’s office.
10. Whenever possible, terminate resuscitation prior to transport and follow the same procedures as if the patient was
found dead on-scene.
Charleston County
Standards Policy
DNR, POST, and Advanced Directives
Policy:
 Any patient presenting to any component of the EMS system with a completed South Carolina Do Not Resuscitate
(DNR) form shall have the form honored. Treatment will be limited as documented on the DNR form. A living will or
other legal document that identifies the patient’s desire to withhold CPR or other medical care may be honored with
approval of Medical Control. This should be done when possible in consultation with the patient’s family and personal
physician.
Purpose:
 To honor the terminal wishes of the patient and to prevent the initiation of unwanted resuscitation.
Procedure:
1. When confronted with a cardiac arrest patient, the following conditions must be present in order to honor the DNR
request and withhold CPR and ALS therapy:
a. The form must be a South Carolina DNR form – or – DNR box is checked in section A of the POST form.
b. The effective date (and expiration date if applicable) must be completed and current.
c. The DNR form must be signed by a physician, physician's assistant, or nurse practitioner.
2. A valid DNR form may be overridden by the request of the patient, the guardian of the patient, or an on-scene MD.
3. If the patient or anyone associated with the patient requests that a SC DNR form not be honored, EMS personnel
should contact Medical Control to obtain assistance and direction.
4. When confronted with a seriously ill patient who is not in cardiac arrest and has a POST form, the POST form
Section B shall be utilized as follows:
a. Full Scope of Treatment box is checked: Use all appropriate measures included in Charleston County EMS
system protocols to stabilize/resuscitate the patient.
b. Limited Scope of Treatment box is checked: The maximum airway intervention is oxygen mask and airway
suctioning. All appropriate IV medications may be utilized. No electrical therapies are to be provided.
c. Comfort Measures box is checked: The maximum airway intervention is oxygen mask and airway
suctioning. IV pain medications may be administered. Medical Control may be contacted regarding
appropriate treatment.
5. If patient has an obvious life-limiting illness (terminal cancer, advanced neurological disease, etc.) and family
members are present and ask that resuscitative efforts be withheld in the absence of an approved SC DNR or SC
POST, determine their relationship to the patient and the patient’s history. Paramedics may withdraw or withhold
resuscitative efforts without contacting Medical Control.
6. If the patient does not have an obvious life-limiting illness or family members are not present, living wills or other
documents indicating the patient’s desire to withhold resuscitative efforts may be honored only in consultation with
Medical Control.
7. When in doubt – start resuscitation and contact Medical Control immediately.
Resuscitative Measures to be withheld in Approved procedures in presence of DNR:

presence of DNR:  Suction
 CPR  Basic cardiac monitoring
 Advanced airway (ETT, King)  Oxygen and basic airway (OPA, NPA)
 Artificial ventilations (BVM)  CPAP
 Defibrillation / Pacing  Control Bleeding
 Cardiac arrest resuscitation medications  Comfort Care
 Non-cardiac arrest resuscitation medications
 Pain Management
Charleston County
Supplemental / Forms
Resuscitation Discontinuation Checklist
Initial Assessment
☐ Valid South Carolina POST and/or Do Not Resuscitate Form or Bracelet is present
☐ Body decomposition
☐ Rigor mortis
☐ Dependent lividity
☐ Traumatic arrest in asystole or PEA <30
☐ Injury not compatible with life (i.e., decapitation, burned beyond recognition, massive open or
penetrating trauma to the head or chest with obvious organ destruction).
If one of the above criteria are met, you may withhold prehospital resuscitation.
ALL of the below criteria must be met to discontinue resuscitation on standing order.
If all are not met and discontinuation is deemed appropriate; contact On‐line Medical Control.
Medical Cardiac Arrest
☐ 18 years of age or older
☐ >25 minutes of high performance (team approach) CPR has been administered
☐ Airway has been successfully managed
☐ Endotracheal Intubation OR King LTS
☐ Bilateral lung sounds AND absence of epigastric sounds
☐ Capnography waveform
☐ ETCO2 now ≤ 10 (after 25 minutes HPCPR)
☐ IV or IO access achieved
☐ Rhythm appropriate medications and defibrillation have been administered according to protocol
☐ Persistent asystole or agonal rhythm is present and no untreated reversible causes are identified
☐ Failure to establish sustained palpable pulses or refractory/recurrent ventricular fibrillation/tachycardia
☐ Lack of any continued neurological activity such as eye opening or motor responses
☐ All EMS Paramedic personnel involved in the patient’s care agree that discontinuation of the
resuscitation is appropriate
☐ The patient is in a residence (non‐public place) and the scene is safe to do so
OR
Traumatic Arrest
☐ Any point while still on scene the patient presents with asystole or a wide complex PEA less than 30
10‐79 Time:_____________________
Coroner Name: ___________________ Coroner Phone #: ______________________ Time: ___________
If a possible Coroner case, do not allow family to disturb the patient or the surroundings.
Do not remove any devices prior to contacting the Coroner s office.
Charleston County
Supplemental / Forms
Resuscitation Time / Intervention Log
Time keeper: monitor times and assist in reminders for the items below:
 Every 2 minutes – Pulse Check/Rhythm + Switch Compressors
 Every 5 minutes –EPInephrine due
Charleston County
Standard Procedure
Category Definition
E EMT
 Guidance on category selection for patients.
A Advanced EMT
P Paramedic
Procedure:
 Category 1: (Life Threatening)
Patients Presentations:
Cardiac Arrest
Failed Airway
Transport:
Use of lights and sirens permitted. Consider diverting to the closest ED.
 Category 2: (Potentially Life or Limb Threatening)
Patient Presentations:
Unstable Vital Signs.
Time Dependent Emergencies:
STEMI
Evidence of Large Vessel Occlusion (refer to guideline)
Significant Trauma
Other potentially life or limb threatening conditions.
Transport:
Use of lights and sirens permitted.
 Category 3: (Non-Life Threatening)
Patient Presentations:
Anyone who is not Category 1 or 2.
Transport:
Non-emergent/no lights and sirens.
Charleston County
Standard Procedure
ESO Dispositions
E EMT
 Explanation of ESO Dispositions and indications for use
A Advanced EMT
Procedure: P Paramedic
Cancelled on Scene / No Patient Found
• Fire Department or Police Department cancel CCEMS as unit arrives on scene.

• Medical Alarms where subject does not require medical attention (i.e. accidental
activation).
• Incidents where subject(s) do not meet the DHEC definition of a patient.
Patient Evaluated, No Treatment/Transport Required

 Patient accepts assessment but declines major treatment and transport
 Any significant treatment (diabetic glucose, splinting, etc) does not fall under this outcome.
 This outcome is NOT billed to the patient
o Billing signature and insurance information are NOT required.
Patient Treated, Released (AMA)
 Patient accepts assessment and treatment but declines transport
 This outcome is billed to the patient at a non-transport rate
o Billing signature and insurance information are required.
Patient Treated, Transferred Care to Another EMS Professional
 CCEMS initiates assessment and/or care and subsequently transfers care to:
o A flight service
o Another ground EMS agency
 Required regardless of assessment and care level (i.e. includes BLS)
 This outcome is billed to the patient at a non-transport rate
o Billing signature and insurance information are required.
Assist, Unit
 CCEMS initiates ALS care or performs a paramedic assessment and transfers to another
CCEMS resource.
o IV, IO, medications, electrical therapy, advanced airway (including King)
 BLS care or assessment only (12-lead) does not require a Unit Assist report unless the
transferring or receiving crew deems it necessary due to unique circumstances at the scene.
o BLS care should be verbally relayed to receiving crew and documented in their report.
 Never to be used when transferring to an outside agency
Charleston County
Standard Procedure
ESO Dispositions
Telepsych and Telehealth ONLY Outcomes
 Patient Treated, Released (per protocol)
 Patient Treated, Transported by Law Enforcement
 Patient Treated, Transported by Private Vehicle
Standby-No Service or Support Required

 Standby at a special event, fire scene, hazmat scene, etc with no patients
 Document a narrative describing any actions performed. All patients should be documented
in separate reports.
 For designated special events standbys only (Cooper River Bridge Run, 5ks, etc)
o Persons approaching EMS for assistance but not meeting transport criteria may be
documented in the flow chart of the standby report as follows:
General Comments: Enter time/date of contact and comment similar to “FirstName
LastName (DOB) approached EMS and requested [bandaid, ice, etc]. Provided as
required. Party denies all other complaints and/or need for EMS transport. Advised
party too….”
o Any person meeting CCEMS transport criteria must be documented in a separate report
with appropriate outcome as described above.
Resuscitation Outcomes
 Patient Dead on Scene – No Resuscitation Attempted (Without Transport)
 Patient Dead on Scene – Resuscitation Attempted (Without Transport)
Transport Outcomes
 Transported No Lights/Sirens
 Transported Lights/Sirens
 Transported No Lights/Sirens, Upgraded
 Transported Lights/Sirens, Downgraded
**Any treatments that are declined (i.e. immobilization), a refusal form denoting the
treatment is required. Document in the narrative the declination and reasonable risks
patient was advised of.**
Charleston County
Standard Procedure
Duty to Act
E EMT
 Personnel who are on duty have a duty to act unless extenuating circumstances exist.
 This procedure is pursuant to a written directive from SC DHEC. A Advanced EMT
P Paramedic
Procedure:
A. DUTY TO ACT WHEN ALREADY EN ROUTE TO A CALL FOR SERVICE:
1. When personnel are already en route to a call for service, they are not required to stop, assess, or render aid to
potentially ill or injured person(s) randomly encountered along the way. Notify dispatch of the incident.
2. There may be circumstances where the lead or officer in charge can choose to stop, assess, or render aid
i. If the potentially ill or injured person(s) appear to be unstable
ii. If dispatched incident is a lower acuity call than the encountered incident appears to be.
iii. If there are other units on scene of the dispatched incident.
B. RANDOM ENCOUNTERS WITH POTENTIALLY ILL OR INJURED PERSONS:
1. When a potentially ill or injured person(s) is encountered by personnel who are on duty, but not responding to a
call for service, notify dispatch of a potential patient and assess, treat, and transport in accordance with all
Charleston County guidelines, policies, and procedures.
C. DUTY TO ACT WITH MULTIPLE PATIENTS:
1. Incidents may occur that involve multiple patients and more than one CCEMS resources to adequately treat/
transport all patients. In these situations, it is preferable that once CCEMS has made contact, all potential patients
be in the care of CCEMS personnel until said person(s) have been dispositioned per Charleston County guidelines,
policies, and procedures.
2. There may be circumstances where, in the best interest of patient care, the first arriving CCEMS crew may need to
transport a potentially critically ill or injured patient(s) prior to the arrival of additional CCEMS resources. This will
be at the medic crews’ recommendation to the IC if the following requirements are met:
i. Dispatch has been notified of other potentially ill or injured person(s) on scene.
ii. An agency operating under Charleston County guidelines is on scene with adequate resources to care for
the additional person(s), can operate at the same level of care they have already received, and has
adequate knowledge of those person(s).
iii. CCEMS personnel will not leave person(s) on scene in the care of non‐CCEMS EMTB/A or EMR responders
if ALS interventions have been performed except for Grey/Black tags or persons that have been declared
dead.
D. SCENE SAFETY:
1. There are times when scene safety will be in question. Personnel are not required to act immediately in cases
where the scene is clearly unsafe or in cases where a reasonable person would question scene safety. If there is
any question about a scene being safe or not, personnel shall withdraw from the immediate vicinity, contact
dispatch, contact their supervisor, and act as directed by the supervisor. Withdrawing to a safe location does not
automatically relieve personnel of their duty to act. Action will likely be required when the scene has been
declared safe.
Charleston County
Medication
Formulary
Acetaminophen
Tylenol
Fever (greater than 100.4 degrees Fahrenheit)
Indications Pain
Allergy
Contraindications Hypersensitivity
Use caution with known thrombocytopenia and/or
Precautions Liver Disease.
Pregnancy category B.
Nausea/Vomiting
Adverse/Side Effects Abdominal Pain
Hepatotoxicity
Class Analgesic, Antipyretic
Equivalent to aspirin in both analgesic and
antipyretic effects. Unlike aspirin, acetaminophen
has little effect on platelet function and is not
known to produce gastric bleeding.
Mechanism of Action: Acetaminophen is not an NSAID, as it has no anti‐
inflammatory properties. Absorption is rapid, peak
1‐2h, duration 3‐4h, ½life 1‐3h. APAP is processed
in the Liver.
Adult Dosage 1000 mg PO
Pediatric Dosage 15 mg/kg PO
Charleston County
Clinical Guidelines
Adenosine
Adenocard
Indications Supraventricular Tachycardia (SVT)
Known Sick sinus syndrome

Contraindications Known History of Long QT Syndrome
Irregular Wide-complex tachycardia
Advising patient of the side effects of

adenosine prior to administering can help
minimize patient anxiety. Administration of
Precautions adenosine will cause a period of asystole, be
patient, most will transiently resolve.
Pregnancy Category C
Flushing Numbness
Dizziness Headache
Adverse/Side Effects Chest Pain Nausea/Vomiting
Lightheadedness Diaphoresis
Dyspnea Palpitations
Class Supraventricular Antiarrhythmic, Nucleoside
Slows tachycardias associated with the AV

node via modulation of the autonomic nervous
system without causing negative inotropic
effects. It acts directly on sinus pacemaker
Mechanism of Action cells and vagal nerve terminals to decrease
chronotropic & dromotropic activity. Slows
conduction through the AV node, blocks
reentry pathways through the AV node, can
transiently slow conduction in the SA node.
Initial dose: 12 mg rapid IV/IO push
Adult Dosage Second dose: 12 mg rapid IV/IO push
Initial dose: 0.2 mg/kg rapid IV/IO push (Max 12
mg)
Pediatric Dosage Second dose of 0.2 mg/kg rapid IV/IO (Max 12
mg)
Charleston County
Clinical Guidelines
Albuterol Sulfate
Ventolin/Proventil
Beta‐agonist used for the treatment of respiratory
Indications distress with bronchospasm
Contraindications None in the emergency setting
Precautions Pregnancy Category C
Palpitations Tremor
Tachycardia HTN
Adverse/Side Effects Anxiety Dysrhythmias
Nervousness Chest Pain
Dizziness
Class Beta2 Agonist, Sympathomimetic
Acts selectively on Beta2 receptor sites in the
lungs, relaxing bronchial smooth muscle,
decreasing airway resistance, relief of
Mechanism of Action bronchospasm. Although Albuterol is beta
selective, it will cause some CNS stimulation,
cardiac stimulation, increased diuresis, & gastric
acid secretion
5 mg nebulized (may repeat 3 times)
Adult Dosage 8 “puffs” of MDI albuterol
5 mg nebulized (may repeat 3 times)
Pediatric Dosage 4 “puffs” of MDI albuterol
Charleston County
Clinical Guidelines
Amiodarone
Cordarone
Regular Wide Complex Tachycardia W/ pulse that
Indications is shock refractory or recurrent after conversion.
Bradycardia
Second/third degree block
Contraindications Hyperkalemia
**No contraindications in cardiac arrest**
Precautions Pregnancy Category D
Hypotension Asystole
Adverse/Side Effects Bradycardia PEA
AV block Hepatoxicity
Class Class III Antiarrrhythmic
Prolongs the duration of the action potential and
refractory period of all Cardiac fibers. Depresses
the Phase 0 slope by causing a sodium blockade.
Causes a Beta block as well as a weak calcium
channel blockade. Primarily a Potassium‐channel
blocker (Class III antiarrhythmic) blocks the
potassium channels that are responsible for phase
Mechanism of Action 3 repolarization. Blocking these channels slows
(delays) repolarization, which leads to an increase
in action potential duration and an increase in the
effective refractory period (ERP). Relaxes vascular
smooth muscle, decreases peripheral vascular
resistance, and increases coronary contractility.
Drug has a rapid onset, serum concentrations
drop to 10% w/in 30‐45 minutes.
Pulseless VT/VF: 300 mg IV/IO push. May repeat
once at 150 mg IV/IO
Adult Dosage Stable VT: 150 mg IV/IO (over 10 minutes; may
repeat 1 time if no response)
Pulseless VT/VF: 5 mg/kg IV/IO push (max 150
mg) (may repeat twice)
Pediatric Dosage Stable VT: 5 mg/kg IV/IO (max 150 mg) over 20
minutes if QRS is >0.09 and rhythm is regular and
monomorphic
Charleston County
Clinical Guidelines
Aspirin
Indications Suspected ACS, STEMI
Contraindications Ulcer, Allergy, GI bleeding
Other blood thinners

Precautions Pregnancy Category D
Nausea/vomiting, diarrhea, heartburn, GI

Adverse/Side Effects bleeding
Analgesic, Antipyretic, NSAID, platelet

Class inhibitor
In Inhibits the formation of prostaglandins

associated with pain, fever, and inflammation.
Inhibits platelet aggregation by acetylating
cyclooxygenase permanently disabling it so
Mechanism of Action that it cannot synthesize prostaglandins and
Thromboxanes. Since Thromboxane A2 is
important in clotting its absence does not
allow blood to clot effectively.
Adult Dosage: 81 mg x 4 PO (chewed)
Pediatric Dosage: N/A
Charleston County
Clinical Guidelines
Atropine Sulfate
Atropen
Symptomatic bradycardia
Indications Organophosphate exposure
Contraindications: A‐Fib, A‐Flutter
Slow administration of atropine can cause
Precautions paradoxical bradycardia
Tachycardia
V‐Tach
Adverse/Side Effects V‐Fib
Pupil dilation
Dry Mouth
Class Parasympatholytic

Competitive antagonist that selectively
blocks all muscarinic responses to
acetylcholine. Blocks vagal impulses,
thereby increasing SA node discharge,
thereby enhancing AV conduction and
cardiac output. Potent anti‐secretory
Mechanism of Action
effects caused by the blocking of
acetylcholine at the muscarinic site.
Atropine is also useful in the treatment of
the symptoms associated with nerve agent
poisoning. Rapid onset, peak in 2‐4m IV,
half‐life 2‐3h.
 Bradycardia: 1 mg IV/IO (repeat every 3‐5
minutes PRN) Maximum 3 mg
Adult Dosage  Organophosphate Exposure: 0.1 mg/kg IV/IO,
up to 2 mg (may repeat every 5 minutes)
Maximum 10 mg
Organophosphate Exposure: 0.1 mg/kg, up to 2
Pediatric Dosage mg (may repeat every 5 minutes) Maximum 10 mg
Charleston County
Clinical Guidelines
Calcium Gluconate
Hydrofluoric acid burns and exposure
Indications Beta Blocker OR Calcium Channel Blocker OD
Hyperkalemia
Contraindications Hypercalcemia
Nausea/vomiting Increased thirst
Constipation Increased urination
Side Effects Bradycardia Hypotension
Cardiac Arrest
Class Antidotes, Calcium Salts
Replaces elemental calcium, which is
essential for regulating excitation threshold of
nerves and muscles. Calcium is also essential
Mechanism of Action for blood clotting mechanisms, maintenance
of renal function, and bone tissues. Calcium
increases myocardial contractile force and
ventricular automaticity.
Hydroflouric Acid Exposure
Inhalation: Nebulize 3 mL of 10% solution with 6 mL
normal saline
Skin: Mix 10 mL of 10% solution with approx. 30 mL of
KY jelly and apply gel to burned area.
Signs of system involvement: 10 mL of a 10% solution
IV/IO.
Adult Dosage:
Beta Blocker or Calcium Channel Blocker OD:
100 mg/kg IV/IO up to 1 gram (may repeat every 10
minutes)
Hyperkalemia Suspect (cardiac arrest):
 1 gram IV/IO
Beta Blocker or Calcium Channel Blocker OD:
100 mg/kg IV/IO up to 1 gram (may repeat every 10
Pediatric Dosage: minutes)
Hyperkalemia Suspect (cardiac arrest): 50 mg/kg (up
to 1 gram) IV/IO
Charleston County
Clinical Guidelines
Cefazolin
Ancef
Obvious or perceived fracture with bone

Indications visualization or bone visualization with
associated crepitus.
Reported allergy to penicillins or

Contraindications cephalosporins
Precautions Pregnancy Category B
Nausea
Vomiting
Diarrhea
Adverse/Side effects Weakness
Drowsiness
Hypotension
Class Cephalosporin antibiotics
Cefazolin inhibits cell wall biosynthesis by

binding Penicillin binding proteins which stops
peptidoglycan synthesis. Penicillin binding
Mechanism of Action proteins are bacterial proteins that help to
catalyze the last stages of peptidoglycan
synthesis, which is needed to maintain the cell
wall.
Adult Dosage 2 grams
<15 kg patient: 250 mg

Pediatric Dosage 15 – 39 kg patient: 500 mg
≥40kg patient: 2 grams
Charleston County
Clinical Guidelines
10% Dextrose
Indications Hypoglycemia
None with symptomatic hypoglycemia. Use with
Contraindications caution in patients with suspected increased ICP.
Patients may complain of warmth, pain, or burning
at the injection site. Extravasation causes necrosis.
Precautions/Side Effects Infusing through larger vessels decreases the risk
of necrosis.
Class Carbohydrate
Charleston
County Principal form of glucose used by the body.
Clinical Dextrose (aka. glucose) is one of the basic building
blocks of all sugars. Glucose
Guidelines
is a monomer and is therefore readily processed
in the blood. Through glycolysis glucose is turned
Mechanism of Action into pyruvate giving off a small amount of
chemical energy (ATP). Pyruvate is further
processed through the Citric Acid Cycle (Kreb’s
Cycle) yielding even more energy (GTP, FADH2
and NADH) and CO2.
IV/IO titrate to effect (up to 2‐4 mL/kg, max 250
Adult Dosage mL. May repeat once PRN)
IV/IO titrate to effect (up to 2‐4 mL/kg, max 250
Pediatric Dosage mL. May repeat once PRN)
Charleston County
Clinical Guidelines
Diltiazem
Cardizem
Atrial fibrillation
Atrial Flutter
Indications Multifocal atrial tachycardias
SVT/PSVT refractory to Adenosine
History of (or 12‐lead ECG reveals) Wolfe‐
Parkinson White DO NOT Administer!
Hypotension
Contraindications  Patients with second‐ or third‐degree AV block
except in the presence of a functioning ventricular
pacemaker.
Hypersensitivity
Cardiac Conduction: Diltiazem prolongs AV node
refractory periods without significantly prolonging
sinus node recovery time, except in patients with
Precautions sick sinus syndrome. Concomitant use of diltiazem
with beta‐blockers or digitalis may result in
additive effects on cardiac conduction
Hypotension Flushing
Headache Edema
Constipation Drowsiness
Side Effects Rash Dizziness
Nausea
Charleston
County
Clinical Calcium ion cellular influx inhibitor (slow channel
Class blocker or calcium antagonist).
Guidelines
Nondihydropyridine calcium‐channel blocker:
Inhibits extracellular calcium ion influx across
membranes of myocardial cells and vascular
smooth muscle cells, resulting in inhibition of
cardiac and vascular smooth muscle contraction
and thereby dilating main coronary and systemic
Mechanism of Action arteries; no effect on serum calcium
concentrations; substantial inhibitory effects on
cardiac conduction system, acting principally on
the AV node, with some effects on the sinus node.
Diltiazem hydrochloride is extensively
metabolized by the liver and excreted by the
kidneys and in bile.
Charleston County
Clinical Guidelines Continued on Next Page
Diltiazem Continued
20 mg IV/IO over 2 minutes if SBP > 100 mmHg
If patient is age ≥ 60 or BP is borderline low,
Adult Dosage administer Diltiazem as two 10 mg doses IV/
IO 10 minutes apart
Pediatric Dosage N/A
Charleston County
Clinical Guidelines
Diphenhydramine
Benadryl
Indications Allergic Reaction/Anaphylaxis
Contraindications Known Allergy
Antihistamine Toxicity:
Remember: "red as a beet, dry as a bone, hot

as a hare, blind as a bat, mad as a hatter, and
full as a flask."
Precautions Brugada-like ECG patterns are seen with
anticholinergic toxicity.
Elimination mechanism concerns
Potent anticholinergic agent
Pregnancy Category B
Drowsiness
Mydriasis
Adverse/Side Effects Dizziness
Tachycardia
Photophobia
Charleston County
Clinical Guidelines
Class Antihistamine, Ethanolamine, Anticholinergic
Charleston County
Clinical Guidelines
Diphenhydramine blocks the effects of
Histamine (H1 histamine) on the H1 receptor
site through a competitive competition for the
peripheral H1 site. When diphenhydramine is
Mechanism of Action bound the H1 site cannot be stimulated
preventing the effects of histamines (swelling,
etc…). As an antihistamine, diphenhydramine
one of the most effective antihistamines.
Onset of 15m IV, peak 1-4h, ½ life 2-10h.
Adult Dosage: 1 mg/kg IV/IM/IO (maximum 50 mg)
Pediatric Dosage: 1 mg/kg IV/IM/IO (maximum 50 mg)
Charleston County
Clinical Guidelines
Epinephrine
Adrenalin
Cardiac Arrest
Allergic Reaction/Anaphylaxis
Indications Respiratory Distress (Stridor/Wheezing)
Hypotension (Symptomatic)
Bradycardia
Contraindications Known Allergy
Palpitations Dizziness
Hypertension Nausea
Side Effects Dysrhythmias Vomiting
Anxiety Increased myocardial O2
Tremors demand
Sympathetic Agonist. Epinephrine is a

naturally occurring catecholamine. It is a
Class
potent alpha- and beta-adrenergic stimulant
with more profound beta effects.
Epinephrine works directly on alpha- and

beta-adrenergic receptors with effects of
increased heart rate, cardiac contractile force,
increased electrical activity in the
Mechanism of Action myocardium, increased systemic vascular
resistance, increased blood pressure, and
increased automaticity. It also causes
bronchodilation.
Cardiac Arrest:
1 mg IV/IO (Repeat every 5 minutes x 4)
Allergic Reaction/Anaphylaxis:
0.15 or 0.3 mg IM auto‐injector
OR
1:1000 0.01 mg/kg IM (maximum 0.3 mg)
(Repeat in 5 minutes if no improvement)
Adult Dosage Stridor:
Nebulized 1 mg (1 mg/mL) in 2 mL of NS
Then 0.3 mg IM (if not improving)
Wheezing:
0.3 mg IM (if not improving w/other treatments)
Hypotension (Symptomatic)
10‐20 mcg every 2‐5 minutes IV/IO
Charleston County
Clinical Guidelines Continued on Next Page
Epinephrine Continued
Cardiac Arrest:
0.01 mg/kg IV/IO (Repeat every 5 minutes x 4)
Allergic Reaction/Anaphylaxis:
0.15 or 0.3 IM auto‐injector
OR
1:1000 0.01 mg/kg IM (maximum 0.3 mg)
(repeat in 5 minutes if no improvement)
Stridor:
Nebulized 1 mg (1 mg/mL) in 2 mL of NS
Pediatric Dosage Then (1 mg/mL) 0.01 mg/kg up to 0.3 mg IM
 Wheezing:
(1 mg/mL) 0.01 mg/kg up to 0.3 mg IM
 Hypotension (Symptomatic)
Newborn to <1 year = 5 mcg every 2‐5 minutes
>1 year = 10 mcg every 2‐5 minutes
 Bradycardia
0.01 mg/kg up to 0.5 mg IV/IO (repeat every
5 minutes as long as patient remains symptomatic)
Charleston County
Clinical Guidelines
Etomidate
Amidate
Indications Sedative used in Drug Assisted Intubation
Hypotension
Hypertension
Side Effects Dysrhythmias
Nausea/vomiting
Cortisol suppression
Class Sedative‐Hypnotic
Etomidate binds at a distinct binding site
associated with a Cl‐ ionopore at the GABAA
Charleston receptor, increasing the duration of time for which
Mechanism of Action
County the Cl‐ ionopore is open. The post‐synaptic
Clinical inhibitory effect of GABA in the thalamus is,
therefore, prolonged.
Guidelines
Adult Dosage 0.3 mg/kg IV/IO
Pediatric Dosage N/A
Charleston County
Clinical Guidelines
Fentanyl
Moderate to severe pain
Indications Sedation following advanced airway placement
Chest Pain
Hypotension
Relative Contraindications Respiratory depression
Charleston
County Narcan should be available
Clinical Precautions Lower doses should be considered in elderly and
frail patients
Guidelines Pregnancy Category C
Muscle Rigidity Dizziness
Respiratory Depression Blurred vision
Apnea Nausea
Adverse/Side Effects Bradycardia Vomiting
Hypotension Laryngospasm
Class Opioid, Schedule II controlled substance
Competitive agonist that binds to opioid receptors
which are found principally in the central and
Mechanism of Action peripheral nervous
system.
Pain: 1 mcg/kg IV/IO/IM/IN up to 100 mcg (may
repeat half dose every 5 minutes. Max dose = 200
mcg)
Adult Dosage Sedation (after airway placement): 1 mcg/kg IV
(maximum dose 100 mcg)
Chest Pain: 50 mcg IV/IO (repeat 50 mcg after 5
minutes)
Pain: 1 mcg/kg IV/IO/IM/IN up to 100 mcg (may
repeat half dose every 5 minutes. Max dose = 200
mcg)
Pediatric Dosage Sedation (after airway placement): 1 mcg/kg IV/
IO (max dose 100 mcg. May repeat half dose
every 5 minutes. Max dose = 200 mcg)
Charleston County
Clinical Guidelines
Glucagon
Hypoglycemia
Indications Beta blocker overdose
Contraindications None in the Emergency setting
Glucagon for Hypoglycemia is only effective if
Precautions there are sufficient stores of glycogen in the liver.
Dizziness
Headache
Side Effects Hypotension
Nausea/vomiting
Hormone secreted by the alpha cells of the
Class pancreas.
Glucagon causes a breakdown of stored glycogen
to glucose, and inhibits the synthesis of glycogen
Mechanism of Action from glucose. Glucagon exerts a positive inotropic
action on the heart and decreases renal vascular
resistance
Hypoglycemia: 0.1 mg/kg IM (max 1 mg)
Beta blocker overdose: 2 mg IV/IO. May repeat once if
Adult Dosage patient remains symptomatic.
Calcium channel blocker overdose: 2 mg IV/IO. May
repeat once if patient remains symptomatic.
Hypoglycemia: 0.1 mg/kg IM (max 1 mg)
Beta blocker overdose: 0.1 mg/kg IV/IO up to a max of
Pediatric Dosage 2 mg. May repeat once if patient remains symptomatic.
Calcium channel blocker overdose: 2 mg IV/IO. May
repeat once if patient remains symptomatic.
Charleston County
Clinical Guidelines
Hydroxocobalamin
Cyanokit
Indications Cyanide Toxicity
Known anaphylactic reactions to Hydroxocobalamin or
Contraindications cyanocobalamin
Anaphylaxis Rash
Chest Tightness Hypertension
Adverse/Side Effects Edema
Urticaria
Charleston Pruritus
County
Clinical Class Cobalamin derivative
Guidelines
Hydroxocobalamin binds with Cyanide to form
Mechanism of Action nontoxic cyanocobalamin, which is then excreted
in the urine.
70 mg/kg IV/IO (Maximum 5 g IV/IO infused over
Adult Dosage 15 minutes)
70 mg/kg IV/IO (Maximum 5 g IV/IO infused over
Pediatric Dosage 15 minutes)
Charleston County
Clinical Guidelines
Ipratropium Bromide
Atrovent
Persistent bronchospasms
Indications COPD
Asthma
Use caution when administering this drug to
elderly patients and those with cardiovascular
Precautions disease or hypertension.
Palpitations Tremor
Anxiety Hypertension
Adverse/Side Effects Dizziness Arrythmias
Headache Nausea/vomiting
Nervousness
Class Anticholinergic
Ipratropium is a parasympatholytic used in the
treatment of respiratory emergencies. It causes
Mechanism of Action bronchodilation and dries respiratory tract
secretions. Ipratropium acts by blocking
acetylcholine
Adult Dosage 0.5 mg nebulized
Pediatric Dosage 0.5 mg nebulized (0.25 mg if age 1‐5 years)
Charleston County
Clinical Guidelines
Ibuprofen
Motrin
Fever (greater than 100.4 degrees Fahrenheit)
Relative Contraindications Hypersensitivity
Pregnancy (especially third trimester), aspirin‐
sensitive asthma, coagulation disorders or
Precautions/Side Effects patients receiving anticoagulants should be
carefully monitored.
Class Non‐Steroidal Anti‐Inflammatory Drug (NSAID)
Ibuprofen possesses analgesic and antipyretic
activities. Its mode of action, like that of other
NSAIDs, is not completely understood, but may be
Mechanism of Action related to prostaglandin synthetized inhibition, by
blocking the enzyme in your body that makes
prostaglandins. Decreasing prostaglandins helps
Charleston to reduce pain, swelling, and fever.
County
Clinical Adult Dosage 400‐800 mg PO
Guidelines
Pediatric Dosage 10 mg/kg PO
Charleston County
Clinical Guidelines
Ketamine
Ketalar
Pain
Severe agitation
Indications Severe bronchospasm
Sedation
Head Injury
Relative Contraindications Hypersensitivity
Severe hypertension
Laryngospasms and other forms of airway
obstruction have occurred. Use with caution in
patients with history of Schizophrenia. Be aware
Precautions that in lower dosing some patients may
experience partial disassociation.
Pregnancy Category not assigned
Respiratory depression Nausea
Laryngospasms Vomiting
Hypertension
Side Effects Emergence reactions
Dizziness
Rapid‐acting dissociative anesthetic. Schedule III
Class controlled substance.
The anesthetic state produced by ketamine
hydrochloride has been termed "dissociative
anesthesia" in that it appears to selectively
interrupt association pathways of the brain
before producing somatesthetic sensory
Mechanism of Action blockade. It may selectively depress the
thalamoneocortical system before significantly
obtunding the more ancient cerebral centers and
pathways (reticular‐activating and limbic
systems).
Post airway management (long acting sedation):
2 mg/kg IV
Pain Control:
0.2 mg/kg IV/IO OR 0.4 mg/kg IM/IN (Repeat
every 5‐10 minutes, as needed
Adult Dosage Drug Assisted Intubation:
Not dangerously combative: 2 mg/kg IV/IO
Dangerously combative: 4 mg/kg IM
Severe agitation (danger to self or others):
4 mg/kg IM (maximum dose 500 mg)
Charleston County
Clinical Guidelines
Magnesium Sulfate
Torsades de Pointes
Indications Respiratory distress or failure
Eclampsia
Hypotension
Contraindications Hypocalcemia
Heart block
Magnesium Sulfate should be administered

slowly to minimize side effects. Use with
caution in patients with known renal
Precautions insufficiency. In hypermagnesemia Calcium
Chloride should be available as an antidote if
serious side effects occur
Pregnancy Category D
Bradycardia Drowsiness
Side Effects Hypotension Respiratory depression
Diaphoresis Decreased reflexes
Class Antiarrhythmic (Class V), Electrolyte
Magnesium Sulfate is a salt that dissociates

into the Magnesium cation and the sulfate
anion. Magnesium is an essential element in
numerous biochemical reactions that occur
within the body. Magnesium Sulfate acts as a
calcium channel blocker and blocks
Mechanism of Action neuromuscular transmission.
Hypomagnesemia can cause refractory
ventricular fibrillation. Magnesium Sulfate is
also a central nervous system depressant
used for seizures associated with eclampsia
and it is also a bronchodilator.
Respiratory distress: 2 grams IV/IO over
approximately 20 minutes
Adult Dosage: Torsades de Pointes: 2 grams IV/IO
Seizure or postictal (gravid patient): 2 grams IV/
IO
Pediatric Dosage: Torsades de Pointes: 25‐50 mg/kg IV/IO
Charleston County
Clinical Guidelines
Methylprednisolone
Solu‐Medrol
Allergic reaction/anaphylaxis
Respiratory distress presumed bronchospasm
Indications Adrenal insufficiency
Isolated angioedema caused by ACE inhibitors
Contradictions None in the emergency setting
Hypertension
Hyperglycemia
Adverse/Side Effects Vertigo
Headache
Nausea
Class Glucocorticoids steroid
Methylprednisolone is a synthetic steroid with
potent anti-inflammatory properties. Effective
as anti-inflammatory agents, they are used in
the management of allergic reactions, asthma,
Therapeutic Effects and anaphylaxis. Methylprednisolone alters
the body’s immune response. Swelling is
reduced because it prevents the white blood
cells traveling to the area.
Allergic reaction/anaphylaxis: 2 mg/kg IV/IO, max 125
mg
Adult Dosage ACE inhibitor angioedema: 125 mg IV/IO
Respiratory distress: 125 mg IV/IO
Allergic reaction/anaphylaxis: 2 mg/kg IV/IO, max 125
Pediatric Dosage mg
Respiratory distress: 2 mg/kg IV
Charleston County
Clinical Guidelines
Midazolam
Versed
Sedation following advanced airway placement
Seizure control
Sedation for combative/aggressive patients
Indications Emergence reaction
Pre‐medication prior to cardioversion or
Transcutaneous pacing
Anxiety reduction during CPAP
Allergy
Contraindications Hypotension/shock
Premedication with an opiate may potentiate

Precautions midazolam and lead to apnea.
Pregnancy Category D
Hypotension
Adverse/Side Effects Respiratory depression or arrest
CNS depression
Short-acting benzodiazepine central nervous
Class system (CNS) depressant. Schedule IV
Controlled Substance
Acts at the level of the limbic, thalamic, and
hypothalamic regions of the CNS through
potentiation of GABA (inhibitory
neurotransmitter). Decreases neural cell
activity in all regions of CNS. Anxiety is
decreased by inhibiting cortical and limbic
arousal. Promotes relaxation through
Mechanism of Action inhibition of spinal motor reflex pathway, also
depresses muscle & motor nerve function
directly. As an anticonvulsant, augments
presynaptic inhibitions of neurons, limiting the
spread of electrical activity. However, it does
not alter the electrical activity of the seizure’s
focus. It is short acting and roughly 3-4 times
more powerful than diazepam.
Charleston County
Clinical Guidelines
Continued on Next Page
Midazolam Continued
Post airway management: 2.5 mg IV (repeat every 5
minutes to max 10 mg or drop in BP)
Anxiety reduction during CPAP: 1‐2 mg IV (use extreme
caution)
Sedation for combative/aggressive patients:
2.5 mg IV OR 5 mg IM/IN (repeat x 1 after 5 minutes, if
needed)
Emergence reaction: 2.5 mg IV (repeat x 1 after 5
minutes, if needed)
Adult Dosage Seizure: 0.1 mg/kg slow IV push up to 5 mg (May
repeat 0.05 mg/kg up to 2.5 mg x 2 every 5 minutes if
needed (max total IV dose = 10 mg))
OR
0.1 mg/kg IM up to 5 mg (May repeat 0.1 mg/kg up to
5 mg x 1 every 5 minutes if needed (max total IM dose =
20 mg))
Pre‐medication prior to cardioversion/pacing: 2.5 mg
IV/IO/IM/IN (may repeat once after 5 minutes)
Post airway management:
0.1 mg/kg IV/IO up to 5 mg (Repeat 0.05 mg/kg up to
2.5 mg every 5 minutes PRN (max 10 mg or clinically
significant drop in BP)).
Charleston County Seizure:

Clinical Guidelines 0.1 mg/kg slow IV push up to 5 mg (May repeat 0.05
mg/kg up to 2.5 mg x 2 every 5 minutes if needed (max
Pediatric Dosage total IV dose = 10 mg))
OR
0.1 mg/kg IM up to 5 mg (May repeat 0.1 mg/kg up to
5 mg x 1 every 5 minutes if needed (max total IM dose
= 20 mg))
Pre‐medication prior to cardioversion/pacing:
0.05 mg/kg IV/IO/IM/IN (max 2.5 mg) May repeat once
after 5 minutes
Charleston County
Clinical Guidelines
Morphine
Hypersensitivity Hypovolemia
CNS depression Head Injury
Contraindications Respiratory depression Increased ICP
Hypotension
Hypotension
CNS depression
Side Effects Tachycardia
Respiratory depression
Class Opioid, Schedule II controlled substance
This drug produces the majority of its
analgesic effects by binding to the mu‐
opioid receptor within the central nervous
system (CNS) and the peripheral nervous
system (PNS).[6] The net effect of
Mechanism of Action morphine is the activation of descending
inhibitory pathways of the CNS as well as
inhibition of the nociceptive afferent
neurons of the PNS, which leads to an
overall reduction of the nociceptive
transmission.
0.1 mg/kg IV/IO/IM up to 5 mg (May repeat half
Adult Dosage dose every 5 minutes. Max dose = 10 mg)
0.1 mg/kg IV/IO/IM up to 5 mg (May repeat half
Pediatric Dosage dose every 5 minutes. Max dose = 10 mg)
Charleston County
Clinical Guidelines
Naloxone
Narcan
Reversal of respiratory depression caused by
Indications opiates or synthetic narcotics
Known allergy, known hypersensitivity, neonates
Contraindications with narcotic use by mother
Vomiting/hypotension with rapid administration
Nausea
Adverse/Side Effects SCAPE
Dysrhythmias
Tachycardia
Class Opioid antagonist
Naloxone hydrochloride is an opioid antagonist
that antagonizes opioid effects by competing for
the same receptor sites. Naloxone hydrochloride
Mechanism of Action reverses the effects of opioids, including
respiratory depression, sedation, and
hypotension.
0.4‐2 mg IV/IM/IN (titrate to adequate ventilation and
Adult Dosage oxygenation; NOT GIVEN TO RESTORE
CONSCIOUSNESS; repeat as needed)
0.1 mg/kg IV/IM/IN (titrate to adequate ventilation and
Pediatric Dosage oxygenation; NOT GIVEN TO RESTORE
CONSCIOUSNESS; repeat as needed)
Charleston County
Clinical Guidelines
Nitroglycerin
Chest pain consistent with acute coronary
Indications syndromes
Pulmonary edema
Hypotension
Hypovolemia
Bradycardia
Contraindications Tachycardia
Use of erectile dysfunction drugs within the
past 24 hours.
Headache
Dizziness
Adverse/Side Effects Hypotension
Syncope
Class Nitrate
Potent vasodilator with antianginal, anti-

ischemic, and antihypertensive effects.
Relaxes vascular smooth muscle by
an unknown mechanism. Decreases
Mechanism of Action peripheral vascular resistance, preload, and
afterload. Onset 1-3m SL, 30m transdermal.
Peak 5-10m SL. Duration is 20-30m SL, 3-6h
transdermal
Chest Pain:
0.4 mg SL (repeat every 5 minutes PRN)
CHF/Pulmonary Edema (Mild)
Adult Dosage 0.4 mg SL (repeat every 5 minutes)
CHF/Pulmonary Edema (Moderate/Severe):
1.2 mg SL (3 sprays consecutively)
Charleston County
Clinical Guidelines
Ondansetron
Zofran
Indications Nausea/Vomiting
Known Allergy
QT prolongation
Arrhythmias (including ventricular and

supraventricular tachycardia, premature
ventricular contractions, and atrial fibrillation),
Adverse/Side Effects bradycardia, electrocardiographic alterations
Charleston County
Clinical Guidelines (including second-degree heart block, QT/QTc
interval prolongation, and ST segment
depression), palpitations, and syncope.
Anti-emetic, Selective Serotonin (5HT3)
Class Receptor Antagonist
Ondansetron reduces the activity of the vagus

nerve, which activates the vomiting center in
the medulla oblongata and also
Mechanism of Action blocks serotonin receptors in the
chemoreceptor trigger zone. It has little effect
on vomiting caused by motion sickness.
Safely tolerated at high dose ranges.
Administer over 2 minutes
>15 kg Patient: 4 mg (may repeat after 10 minutes,
Adult Dosage may substitute ODT, if available)
 8‐15 kg Patient: 2 mg
Administer over 2 minutes
>15 kg Patient: 4 mg (may repeat after 10 minutes,
Pediatric Dosage may substitute ODT, if available)
 8‐15 kg Patient: 2 mg
Charleston County
Clinical Guidelines
Oral Glucose
Hypoglycemia with patients who can protect their
Indications airway.
Known allergy, patients who are unable to protect
Contraindications their airway
Side Effects Nausea
Class Monosaccharide, Carbohydrate
After absorption from GI tract, glucose is
Mechanism of Action distributed in the tissues and provides a prompt
increase in circulating blood sugar.
15‐30 grams PO (if awake and no risk for
Adult Dosage aspiration)
15‐30 grams PO (if awake and no risk for
Pediatric Dosage aspiration)
Charleston County
Clinical Guidelines
Charleston County
Clinical Guidelines
Proparacaine
Flucaine
Indications Eye Pain
Corneal injury due to insensitivity
Transient stinging or burning
Side Effects Conjunctival redness
Ocular discomfort
Charleston Class Ophthalmic anesthetics
County
Proparacaine blocks sodium ion channels required
Clinical
for the initiation and conduction of neuronal
Guidelines impulses thereby affecting corneal local
Mechanism of Action anesthesia. Maximal corneal anesthesia is
achieved within 20 seconds of installation, with
anesthetic effects lasting 15‐20 minutes.
1‐2 drops into affected eye every 5‐10 minutes, up
Adult Dosage to 5 doses
1‐2 drops into affected eye every 5‐10 minutes, up
Pediatric Dosage to 5 doses
Charleston County
Clinical Guidelines
Rocuronium
Zemuron
Indications Facilitate endotracheal intubation
Charleston
Adverse Effects Allergic reaction
County
Clinical Class Neuromuscular Blockers, Nondepolarizing
Guidelines
Competes with acetylcholine for binding at
nicotinic receptors at the neuromuscular junction
Mechanism of Action preventing depolarization of the muscle cell
membrane and inhibiting muscular contraction.
Rocuronium has no sedating or analgesic
properties and therefore, sedation and analgesia
must be administered at the same time it is. Pay
close attention to signs of unintentional
Special Notes awareness (patient is awake, but under paralysis)
or pain requiring additional sedation/analgesia.
Signs may include tachycardia, hypertension,
ocular tearing.
Charleston County
Clinical Guidelines
Sodium Bicarbonate
Severe metabolic acidosis
Hyperkalemia
Indications Tricyclic Antidepressant OD (hypotension,
tachycardia and QRS > 0.12 seconds)
Hypokalemia
Suspected metabolic and respiratory alkalosis
Contraindications Hypernatremia
Severe pulmonary edema
Metabolic alkalosis
Seizures
Side Effects Electrolyte disturbance
Decreased fibrillation threshold
Hyperirritability
Class Alkalinizing Agent
In the presence of hydrogen ions, sodium
bicarbonate dissociates to sodium and carbonic
acid, the carbonic acid
picks up a hydrogen ion changing to bicarbonate
and then dissociates into water and CO2,
Mechanism of Action functioning as an effective
buffer and alkalinizing the blood. In summary,
increases plasma bicarbonate, which can buffer
metabolic acids and
move TCAs and phenobarbital off receptor sites
and back into circulation.
Hyperkalemia: 50 mEq IV/IO
Tricyclic Antidepressant OD: 1 mEq/kg, up to 50
Adult Dosage mEq IV/IO (repeat every 5 minutes until QRS
narrows)
Hyperkalemia: 50 mEq IV/IO
Tricyclic Antidepressant OD: 1 mEq/kg, up to 50
Pediatric Dosage mEq IV/IO (repeat every 5 minutes until QRS
narrows)
Charleston County
Clinical Guidelines
Succinylcholine
Anectine
Indications Facilitate endotracheal intubation
Hypersensitivity
Malignant hyperthermia
Contraindication Lack of ventilatory support
Acute phase of injury following major burns
Fasciculations Tachycardia

Hypotension Malignant hyperthermia
Side Effects Hypertension Hyperkalemia
Bradycardia
Class  Neuromuscular Blockers, Depolarizing
Prevents neuromuscular transmission by blocking
Mechanism of Action the effect of acetylcholine at the myoneural
junction.
 Succinylcholine has no sedating or analgesic
properties and therefore, sedation and
analgesia must be administered at the same
time. Pay close attention to signs of
Special Notes unintentional awareness (patient is awake, but
under paralysis) or pain requiring additional
sedation/analgesia.
Charleston County
Clinical Guidelines
Vecuronium
Norcuron
Airway Management for post intubation after
Indications sedation
No confirmed advanced airway

Contraindications
Known Allergy
Prior administration of succinylcholine may

enhance the neuromuscular blocking effect of
Precautions vecuronium and its duration of action
Skeletal muscle weakness, profound and

prolonged skeletal muscle paralysis resulting
Adverse/Side effects in respiration insufficiency or
apnea. Prolonged paralysis.
Non-depolarizing neuromuscular blocking

Class agent of intermediate duration
Vecuronium is a nondepolarizing
neuromuscular blocking agent possessing all
of the characteristic pharmacological
actions of this class of drugs (curariform). It
acts by competing for cholinergic receptors at
the motor end-plate. The
Mechanism of Action antagonism to acetylcholine is inhibited and
neuromuscular block is reversed by
acetylcholinesterase inhibitors
such as neostigmine, edrophonium, and
pyridostigmine. Onset 3 minutes, Duration 45
minutes
 Vecuronium has no sedating or analgesic
properties and therefore, sedation and
analgesia must be administered at the same
time. Pay close attention to signs of
Special Notes unintentional awareness (patient is awake, but
under paralysis) or pain requiring additional
sedation/analgesia.
Charleston County
Clinical Guidelines
Reference Pages
East Cooper Medical Center

Door Code: 911*
 Adult Emergency Department ED Report: (843) 416-6100
 Primary Stroke Center Main Phone: (843) 881-0100
 Orthopedic Services
 OB services
Medical University of South Carolina

 Level I Adult Trauma Center
 Adult Emergency Department Door Code: 00911
 Adult Burn Center ED Report: (843) 792-3826
 Comprehensive Stroke Center Main Phone: (843) 792-2300
 PCI Center
 Hemodialysis
 Psychiatric Services
MUSC Shawn Jenkins

 Level I Pediatric Trauma Center Door Code: 00911
 Pediatric Emergency Department ED Report: (843) 792-1269
 Pediatric Burn Center Main Phone: (843) 792-2300
 Full ICU/NICU/PICU Services
 OB services
Ralph H. Johnson VA Medical Center

 PCI Center
 Hemodialysis
Charleston County
Clinical Guidelines
Roper St. Francis ED – Moncks Corner

Free-standing ED with limited resources and no
admitting capabilities.
 Minor injuries Door Code: 730*
 Minor illnesses ED Report: (843) 719-5577
 Cardiac Arrest Main Phone: (843) 899-7700
 Unmanageable Airway
 Uncontrolled Bleeding
Roper St. Francis ED – Northwoods

admitting capabilities. Door Code: 8733
 Minor injuries ED Report: (843) 746-2411
 Minor illnesses Main Phone: (843) 746-2400
Roper St. Francis – Berkeley

Door Code: FOB
 Orthopedic Services Main Phone: (654) 529-3100
 OB Services
Roper St. Francis – Downtown

 Adult Emergency Department Door Code: 911*
 Primary Stroke Center ED Report: (843) 724-2010
 PCI Center Main Phone: (843) 724-2000
 Hemodialysis
 Hyperbaric Chamber (Call for availability)
 Orthopedic services
Charleston County
Clinical Guidelines
Roper St. Francis – Mount Pleasant

Door Code: 91111
ED Report: (843) 606-7683
 Adult Emergency Department Main Phone: (843) 606-7000
Roper Saint Francis – West Ashley
 Adult Emergency Department Door Code: FOB

 Primary Stroke Center ED Report: (843) 402-1037
 NICU Services Main Phone: (843) 402-1000
 OB Services
Georgetown Memorial Hospital

 OB Services
Trident Medical Center (MAIN)

 Level II Trauma Center
Door Code: FOB
 Thrombectomy Capable Stroke Center
ED Report: (843) 847-4854
 PCI Center
Main Phone: (843) 832-5000
 Hemodialysis
Charleston County
Clinical Guidelines
Trident Brighton Park Emergency

Door Code: FOB
Trident Centre Pointe Emergency

Door Code: 911#
Summerville Medical Center
 Adult Emergency Department Door Code: FOB

 Pediatric Emergency Department ED Report: (843) 832-5376
 NICU/PICU Services Main Phone: (843) 832-5000
 OB Services
Charleston County
Clinical Guidelines
Phone List
Name Phone Number
Dr. Matt Blue 843-870-3649
Dr. Dustin LeBlanc 228-218-0425
Dr. Will Rivers 843-708-7337
County Dispatch 843-743-7200
County Coroner’s Office 843-746-4030
Centre Pointe 843-746-2400
East Cooper Hospital 843-416-6100
Georgetown Hospital ER 843-527-7476
Mt. Pleasant Hospital (Roper) ER 843-606-7683
MUSC Hospital ER 843-792-3826
MUSC Shawn Jenkins ER 843-792-1269
Roper Hospital Downtown ER 843-724-2010
Roper Northwoods ER 843-842-8734
St Francis Hospital ER 843-402-1037
Summerville Medical Center ER 843-832-5160
Trident Regional Hospital ER 843-797-8866
VA – Ralph Johnson 843-789-6012
Delta 1 843-693-4231
Delta 2 843-696-3662
Delta 3 843-696-4303
Delta 4 843-696-3664
Sierra 1 843-696-4307
Sierra 2 843-991-5795
Sierra 4 843-696-3659
Sierra 5 843-693-4894
Charleston County
Clinical Guidelines
APGAR
Score of 0 Score of 1 Score of 2 Acronym
Skin Color Blue all over Blue at extremities Normal Appearance
Heart Rate Absent <100 >100 Pulse
Sneeze/cough
No response Grimace/feeble cry
Reflex Irritability pulls away Grimace
to stimulation when stimulated
when stimulated
Muscle Tone None Some flexion Active movement Activity
Respiration Absent Weak or irregular Strong Respiration
Pearls
The test is performed twice: once at 1 minute after birth, and again at 5 minutes after birth
A normal Apgar score is 7 to 10 and means a newborn is in good to excellent condition, usually
only requiring routine post-delivery care.
Those with an Apgar score under 4 are in poor condition and need immediate medical attention.
Charleston County
Clinical Guidelines
Glasgow Coma Score
Eye Opening (E) Verbal (V) Motor (M)
4 = Spontaneous 5 = Normal conversation 6 = Normal
4 = Disoriented
3 = To voice 5 = Localizes to pain
conversation
3 = Words, but not

2 = To pain 4 = Withdrawals to pain
coherent
2 = No words, only
1 = None 3 = Decorticate posture
sounds
1 = None 2 = Decerebrate posture
1 = None
Total = E + V + M
Mild: GCS 13 - 15
Moderate: GCS 9 - 12
Severe: GCS 8 or less
Charleston County
Clinical Guidelines
Labs
Basic Metabolic Panel
Sodium 135 – 145 mEq/L
Potassium 3.5 – 5.0 mEq/L
Chloride 96 – 106 mEq/L
Bicarbonate/Total CO2 22 – 26 mEq/L
BUN 8 – 23 mEq/L
Creatinine 0.7 – 1.4 mg/dL
Glucose 70 – 110 mg/dL
Complete Blood Count (CBC)
RBC 5 million/uL
Hemoglobin 15 g/dL
Hematocrit 45%
Platelet 150K – 400K/uL
WBC 4,500 – 11,000/uL
Arterial Blood Gas
pH 7.35 – 7.45
PCO2 35 – 45 mmHg
HC03 22-26 mmol/L
PO2 80-100 mmHg
SaO2 94-99%
BE -2 – 2 mEq/L
Labs
Comprehensive Metabolic Panel
Sodium 135 – 145 mEq/L
Potassium 3.5 – 5.0 mEq/L
Chloride 96 – 106 mEq/L
Bicarbonate/Total CO2 22 – 26 mEq/L
BUN 8 – 23 mEq/L
Creatinine 0.7 – 1.4 mg/dL
Glucose 70 – 110 mg/dL
Calcium 8.5 – 10.2 mg/dL
Ionized Calcium 4.4 – 5.4 mg/dL
Albumin 3.5 – 5.5 g/dL
Total Protein 6.0 – 8.0 g/dL
ALP 45 – 115 U/L
ALT 7 – 55 U/L
AST 8 – 48 U/L
Bilirubin 0.1 – 1.2 mg/dL
Cardiac Enzyme Panel
Troponin I <0.04 ng/mL
Troponin T <0.01 ng/mL
CK 20 – 200 U/L
CK-MB 0 – 3 ng/mL
Myoglobin 5 – 70 ng/mL
Labs
Gastrointestinal Function Panel
Albumin 3.5 – 5.5 g/dL
Total protein 6.0 – 8.0 g/dL
ALP 45 – 115 U/L
ALT 7 – 55 U/L
AST 8 – 48 U/L
Bilirubin 0.1 – 1.2 mg/dL
Amylase 25 – 125 U/L
Lipase 5 – 60 U/L
Coagulation Panel
PT 10 – 13 sec
PTT 25 – 40 sec
INR 0.9 – 1.3

Charleston County Clinical Operating Guidelines: Adult & Pediatric

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Charleston County Clinical Operating Guidelines: Adult & Pediatric

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Charleston County

Clinical Operating Guidelines

Section 200.V: Medical Control

Section 200.V.1: Off-Line Medical Control Physician

Section 200.V.2: On-Line Medical Control Physician

Section 1100.B: “Misconduct” constituting grounds for revocation or suspension or

Charleston County EMS - ALS/Paramedic

James Island Fire Department - BLS/EMT

General Universal Patient Care 9/1/2017

General Assessment 9/1/2019

General Field Trauma Triage 5/1/2020

General Vascular Access 9/1/2017

General Cardiac Arrest: BLS 11/25/2020

General Fire Rehab 4/1/2021

Airway Drug Assisted Intubation 11/24/2020

Airway Post Airway Management 11/24/2020

Airway Failed Airway 11/24/2020

Airway Respiratory Distress 9/1/2018

Cardiac Bradycardia 10/1/2018

Cardiac Tachycardia (Narrow Complex) 10/1/2018

Cardiac Tachycardia (Wide Complex) 10/1/2018

Cardiac Cardiac Arrest: Team Approach 11/1/2017

Cardiac Cardiac Arrest: ALS Rhythms 11/1/2017

Cardiac Post Resuscitation 11/1/2017

Cardiac Chest Pain: Cardiac and STEMI 10/1/2018

Cardiac CHF/Pulmonary Edema 10/1/2018

Cardiac LVAD 11/24/2020

Medical Altered Mental Status 11/24/2020

Medical Behavioral Emergencies 4/28/2021

Medical Fever/Infection/Suspected Sepsis 11/24/2020

Medical Nausea/Vomiting 11/24/2020

Medical Overdose/Toxic Ingestion 3/1/2019

Medical Pain Control 3/1/2019

Medical Psychiatric Evaluation 9/1/2018

Medical Seizure or Post Ictal State 11/24/2020

Medical Suspected Stroke 3/1/2019

Medical Symptomatic Hypotension 11/24/2020

Trauma Burns 11/24/2020

Trauma Open Fracture Antibiotic: Cefazolin 2/1/2020

Trauma Traumatic Cardiac Arrest 11/1/2017

Trauma Trauma Patients with Life Threatening Injuries 11/26/2020

Environmental Carbon Monoxide 10/1/2018

Environmental Hydroflouric Acid Exposure 11/24/2020

Airway Post Airway Management 11/25/2020

Airway Failed Airway 11/25/2020

Airway Respiratory Distress 9/1/2018

Medical Allergic Reaction 11/25/2020

Medical Altered Mental Status 11/25/2020

Medical Fever/Infection/Suspected Sepsis 11/25/2020

Medical Nausea/Vomiting 11/25/2020

Medical Overdose/Toxic Ingestion 11/25/2020

Medical Pain Control 11/25/2020

Medical Seizure of Post Ictal State 11/25/2020

Medical Symptomatic Hypotension 11/25/2020

Cardiac Bradycardia 11/25/2020

Cardiac Tachycardia 11/25/2020

Cardiac Cardiac Arrest: Team Approach 11/1/2017

Cardiac Cardiac Arrest: ALS Rhythms 11/1/2017

Cardiac LVAD 11/25/2020

Trauma Burns 11/25/2020

Trauma Open Fracture Antibiotic: Cefazolin 2/1/2020

Trauma Trauma Patients with Life Threatening Injuries 11/27/2020

Environmental Carbon Monoxide/Cyanide 11/24/2020