2017 RI Statewide EMS Protocols Education Module - Section 2

Rhode Island Emergency Medical Services Statewide EMS ProtocolsOctober 2016Rhode Island Department of Health

Medical ProtocolsSection 2

Medical Protocol

General Changes and Additions• This is a new section in the EMS protocols• This section has 24 protocols• Pediatric Protocols are separate• New Section PEARLS serves as an

educational guideline for changes in protocols but MAY contain care direction.

Medical ProtocolNew Protocol Previous Protocol

Previous Protocol Section

2.01 Acute Neurologic Event with Evidence of Increased ICP NEW – not in previous version

2.02 Abdominal Pain 4.1 Abdominal Pain Medical Emergencies

2.03 Adrenal Insufficiency NEW – not in previous version

02.04A Allergic Reaction/anaphylaxis - Adult 4.3 Anaphylaxis and Severe Bee Sting Medical Emergencies02.04P Allergic Reaction/anaphylaxis - Pediatric 4.3 Anaphylaxis and Severe Bee Sting

02.05A Altered Mental Status - Adult4.7 Impaired Consciousness/Altered Mental Status Medical Emergencies

02.05P Altered Mental Status - Pediatric 4.7 Impaired Consciousness/Altered Mental Status Medical Emergencies

02.06P Brief Resolved Unexplained Event NEW – not in previous version

02.07A Patient Comfort - Adult 8.4 Patient Comfort Clinical Procedures

02.07P Patient Comfort - Pediatric 8.4 Patient Comfort Clinical Procedures02.08A Respiratory Distress (Asthma/COPD/RAD) - Adult 4.4 Asthma COPD Medical Emergencies02.08P Respiratory Distress (Asthma/RAD/Croup) - Ped 4.4 Asthma COPD Medical Emergencies

2.09 Behavioral Emergencies NEW – not in previous version



02.10A Diabetic Emergencies - Adult NEW – not in previous version

02.10P Diabetic Emergencies - Pediatric NEW – not in previous version 2.11 Dialysis Emergencies and Renal Failure NEW – not in previous version

2.12 Ischemic Stroke 4.13 Stroke (CVA) Medical Emergencies

2.13 IV t-PA for Acute Ischemic Stroke NEW – not in previous version

2.14 Epistaxis NEW – not in previous version

02.15A Fever - Adult NEW – not in previous version

02.15P Fever - Pediatric NEW – not in previous version

2.16 Neonatal Resuscitation 4.9 Newborn Resuscitation Medical Emergencies

2.17 Obstetrical-Delivery-Labor 4.8 Obstetrical Assistance Medical Emergencies

2.18 Obstetrical Complications NEW – not in previous version

02.19A Seizures - Adult 4.10 Seizures / Postictal State Medical Emergencies

02.19P Seizures - Pediatric 4.11 Seizures / Postictal State



02.20A General Shock and Hypotension - Adult 4.12 Shock Medical Emergencies02.20P General Shock and Hypotension - Ped 4.12 Shock Medical Emergencies

02.21A Hemorrhagic Shock - Adult 4.12 Shock Medical Emergencies

02.21P Hemorrhagic Shock - Pediatric 4.12 Shock Medical Emergencies

02.22A Septic Shock - Adult 4.12 Shock Medical Emergencies

02.22P Septic Shock - Pediatric 4.12 Shock Medical Emergencies

2.23 Sickle Cell Crisis NEW – not in previous version

2.24 Syncope NEW – not in previous version

2.25 Excited Delirium NEW – not in previous version

2.01 Acute Neurologic Event with Evidence of Increased ICP Protocol Summary

• New protocol for all levels of care.

• This protocol recognizes and provides standing orders for patients with altered mental status, abnormal posturing, unilateral or bilateral dilation of pupils, +/- bradycardia and/or hypertension.

• Possible etiologies include traumatic brain injury, epidural hematoma, subdural hematoma, subarachnoid hemorrhage, tumor or encephalopathy.

• EMTs avoid obstruction to venous drainage.

• All levels manage and perform glucose analysis.

• Advanced EMT Cardiac and Paramedic providers manage as per General Shock and Hypotension Protocol.

• Paramedics may administer 3% hypertonic saline.

2.02 Abdominal Pain Protocol Summary

• Previously protocol 4.1 Abdominal Pain in Medical Emergencies.

• This protocol recognizes and delineates care for patients with a complaint of abdominal pain, discomfort or cramping.

• Multi-lead ECG in all patients ≥35 YO.

• If cardiac etiology, all levels manage as per Chest Pain – Acute Coronary Syndrome – STEMI protocol.

• If signs of shock, manage as per appropriate shock protocols.

• Advanced EMT Cardiac and Paramedic providers should provide analgesia and antiemetic therapy per the Patient Comfort Protocol.

2.03 Adrenal InsufficiencyProtocol Summary • New protocol for all levels of

care.• This protocol recognizes and

delineates care for patients suspected AI.

EMT• Maintain and promote

normothermia.• Perform glucose analysis and

treat.• Transport patient.Advanced EMT Cardiac and Paramedic• All of the above and treat with

steroids.• If indicated, manage per

Shock Protocol.

2.04Adult – Allergic Reaction - Anaphylaxis

Protocol Summary • Previously protocol 4.3 in Medical Emergencies Section.• This protocol recognizes and delineates care for patients

with history of exposure to an antigen and itching, urticaria, angioedema, wheezing, respiratory distress, chest or throat tightness, difficulty swallowing, GI symptoms, or hypotension.

• Patient is now classified as mild, moderate and severe.No changes made.

• Routine Patient Care.• Initial dose for mild severity of

Diphenhydramine has changed to starting dose of 50 mg PO/IV/IO/IM.

• For patients with moderate severity, Albuterol 2.5-5 mg (+/- IPRATROPIUM) for continued wheezing.

• Consider Glucagon 1-4 mg IV/IO in patients with severe symptoms that are taking beta agonists.

• DOPAMINE removed.

• Routine Patient Care.• Initial dose for mild

severity of Diphenhydramine has changed to starting dose of 50 mg PO/IV/IO/IM.

• Consider FAMOTIDINE 20-40 mg PO/IV/IO.

• For patients with hypotension refractory to IM EPINEPHRINE, EPINEPHRINE 1-4 mcg/min by IV infusion.

• DOPAMINE removed.

READ PEARLS

2.04Pediatric – Allergic Reaction - Anaphylaxis

Protocol Summary • Previously protocol 4.3 in Medical Emergencies Section.• Recognition: Same as Adult.• Patient is now classified as mild, moderate and severe.

• Pediatric dosing weight has changed from > 20kg (50lbs) to >30 kg (66lbs).

• Contact Medical Control for additional doses after max of 3 doses.

• Routine Patient Care.• For patients with moderate severity, Albuterol 2.5-5

mg (+/- IPRATROPIUM) for continued wheezing.• For patients with moderate severity,

HYDROCORTISONE dose changed from 1-2mg/kg IV to 2 mg/kg IV/IO (max dose of 100 mg).

• Consider Methylprednisolone 2 mg/Kg IV/IO (60 ml/kg max dose).

• Dopamine removed.

• Routine Patient Care.• Maximum dose for mild

severity of Diphenhydramine is 50 mg.

• Consider FAMOTIDINE 1 mg/kg IV/IO (max 40 mg).

• For patients in peri-arrest anaphylaxis EPINEPHRINE (1:10,000) 0.01mg/kg diluted in 10 ml 0.9% Saline IV/IO.

• Dopamine removed.

READ PEARLS

2.05Adult – Altered Mental Status

Protocol Summary • Previously protocol 4.7 Impaired

Consciousness/Altered Mental Status.• This protocol recognizes and delineates

care for adult patients with change in mental status from baseline.

• This protocol applies to all levels of care.• Routine Patient Care.• Blood glucose > 60 or < 250mg

manage as per Diabetic Emergencies Protocol.

• Table was added to manage patient using the appropriate protocol based on suggestive findings.

2.05Pediatric – Altered Mental Status

Protocol Summary • Previously protocol 4.7 Impaired

Consciousness/Altered Mental Status.• This protocol recognizes and delineates

care for pediatric patients with change in mental status from baseline.

• This protocol is for all levels of care.• Routine Patient Care.• Blood glucose > 60 or < 250mg

manage as per Diabetic Emergencies Protocol.

• Table was added to manage patient using the age-appropriate protocol based on suggestive findings.

2.06 Brief Resolved Unexplained Event

Protocol Summary • This is a new protocol. • This protocol recognizes and

delineates care for an event occurring in an infant < 1 yo when the observer reports a sudden, brief (< 1 min), and now resolved episode of ≥ 1 of the following: (1) cyanosis or pallor (2) absent, decreased or irregular breathing (3) a marked change in tone (hyper/hypotonia) (4) an altered level of responsiveness.

• This protocol is for all levels of care.• Routine Patient Care.• Measure blood glucose and treat.• Obtain history. • Transport patient.

2.07Adult – Patient ComfortProtocol Summary • Previously protocol 8.4 Patient Comfort.• This protocol recognizes and delineates care for adult patients with

pain or nausea or vomiting. • This protocol is divided into different levels of care.• Assess pain severity. • EMTs can administer IBUPROPHEN 10mg/kg (400- 800 mg) PO or

ACETAMINOPHEN 15 mg/kg (500-1000 mg) PO or ASPIRIN 324-650 mg PO for mild to moderate pain.

• For severe pain, if available, inhaled NITRONOX (50/50 nitrous oxide and oxygen blend. • Advanced EMT Cardiacs may administer FENTANYL 0.5-1 mcg/kg IV/IM/IN (max single dose 100 mcg).

• Patients with nausea or vomiting, ONDANSETRON 4 mg PO/IV/IM/IO/ODT.

• Patients requiring electrical therapy, MIDAZOLAM 2.5-5 mg.• DOCUMENT.• Paramedics may administer

KETOROLAC 15 mg IV or 30 mg IM for mild to moderate pain.

• Fentanyl doses changed to 0.5-1 mcg/kg.

• If patient has traumatic pain or burns, KETAMINE 0.2-0.5 mg/kg IV/IO or 0.5- 1.0 mg/kg IM/IN .

• Patients who do not respond to ONDANSETRON, consider PROMETHAZINE 6.25-12.5 mg IV/IO/IM

• For Electrical therapy MIDAZOLAM 2.5- 5 mg IV/IO/IM/IN or DIAZEPAM 2.5-5 mg IV/IO/IM or if IV access is unavailable in patient requiring cardioversion, KETAMINE 2mg/kg IM.

• For advanced airway IN PLACE:• MIDAZOLAM dose changed: 2.5 mg IV every 5-10 min as needed.• LORAZEPAM dose changed: 1- 2 mg IV every 15 min as needed (max

10 mg).• ROCURONIUM 1 mg/kg IV/IO.

• MUST HAVE CONTINUOUS QUANTITATIVE WAVEFORM CAPNOGRAPHY.

2.07Pediatric – Patient Comfort

Protocol Summary • Previously integrated in Protocol 8.4 Patient Comfort.• This protocol recognizes and delineates care for pediatric

patients with pain, nausea or vomiting. • Assess pain severity. • EMTs can administer IBUPROPHEN

10mg/kg PO or ACETAMINOPHEN 15 mg/kg PO for mild to moderate pain.

• For severe pain, if available, inhaled NITRONOX (50/50 nitrous oxide and oxygen blend).

• DOCUMENT.• Advanced EMT Cardiac may administer

FENTANYL 0.5-1 mcg/kg IV/IM/IN (max single dose 75 mcg).

• Patients with nausea or vomiting, ONDANSETRON 0.2 mg/kg (max dose 4 mg) PO/IV/IO/ODT. DO NOT use in patients <3 mo. of age.

• Patients requiring electrical therapy, MIDAZOLAM 0.1 mg/kg [2.5 mg max] IV/IO/IM/IN or FENTANYL 2 mcg/kg [75 mcg max].

• DOCUMENT.• Paramedics may administer KETOROLAC 0.5 mg/kg IV/IO/IM (max 30 mg). • For Electrical therapy MIDAZOLAM 0.1 mg/kg [2.5 mg max] IV/IO/IM/IN or

FENTANYL 2 mcg/kg [75 mcg max] or if IV access is unavailable, KETAMINE 2mg/kg IM.

• For advanced airway IN PLACE, FENTANYL 1.5 – 3 mcg/kg IV/IO.

2.08Adult – Respiratory Distress (Asthma/COPD/RAD)

Protocol Summary• Previously protocol 4.4 Asthma (COPD).• This protocol recognizes and delineates care for

adult patients with shortness of breath, pursed lip breathing, wheezing/rhonchi, prolonged expiratory phase, use of accessory muscles, increased respiratory rate and effort, fever, cough.

• This protocol is divided into different levels of care.• EMT may administer Albuterol 2.5 mg (+/-

IPRATROPIUM BROMIDE 500 mcg) via SVN. CONTACT MEDICAL CONTROL for additional doses.

• This level will no longer administer EPINEPHRINE. • For patients not responding to initial therapy, consider

continuous positive airway pressure (CPAP) at 5-10 cmH2O.

• METHYLPREDNISOLONE 125 mg IV/IO or HYDROCORTISONE 100 mg IV/IO.

• In a patient with a diagnosis of asthma who is in extremis, contact MEDICAL CONTROL for EPINEPHRINE (1:1000) 0.3 mg IM (lateral thigh [auto injector preferred) or TERBUTALINE 0.25 mg SC.

• Consider LEVALBUTEROL 1.25 mg via SVN or MDI. • Patients with Asthma, consider MAGNESIUM SULFATE 2

gm IV/IO• Asthma in extremis EPINEPHRINE (1:1000) 0.3 mg IM

(lateral thigh [auto injector preferred) or TERBUTALINE 0.25 mg SC.

2.08Pediatric – Respiratory Distress (Asthma/RAD/Croup)Protocol Summary

• Previously integrated in Protocol 4.4 Asthma (COPD).• This protocol is divided into different levels of care.• This protocol recognizes and delineates care for pediatric patients with

respiratory distress. • Note the recognition is divided into respiratory distress, bronchiolitis,

croup, asthma and epiglottitis. • For patients with suspected epiglottitis manage a per the airway

management protocols.• Routine Patient Care.• New management of pediatric

patient based on recognition.• Contact MEDICAL CONTROL for

authorization to administer-EPINEPHRINE (1:1000) 0.15-0.3 mg IM (lateral thigh) [auto injector preferred) for continued respiratory distress.

• Routine Patient Care.• New management of pediatric

patient based on recognition.• Respiratory distress with

suspected croup, DEXAMETHASONE 0.6 mg/kg PO/IM/IV/IO (PO preferred) (max 10 mg).

• For patients with significant respiratory distress or stridor at rest, consider EPINEPHRINE (2.25% sol) 0.5 ml/3 ml NS via SVN (may repeat X1).

• For patients ≥ 2 yo with reactive airway disease (RAD)/asthma follow routine medications or METHYLPREDNISOLONE 2 mg/kg IV/IO (max 60 mg ) or HYDROCORTISONE 2 mg/kg IV/IO (100 mg max) or PREDNISONE/PREDNISOLONE (Orapred) 2 mg/kg PO (60 mg max).

• Consider MAGNESUM SULFATE 40 mg/KG IV/IO over 10 min.• For continued respiratory distress, EPINEPHRINE (1:1:000) 0.15-0.3

mg IM (lateral thigh) [auto-injector preferred].

2.09 Behavioral Emergencies

Protocol Summary • This is a new protocol.• This protocol recognizes and provides standing orders for patients

exhibiting any one or a combination of the following: anxiety, agitation, affect change, hallucinations, delusional thoughts, bizarre behavior, combative or violent behavior, expression of suicidal/homicidal thoughts.

• This protocol is divided into different levels of care.• Consider safety of EMS providers first.• Utilize SAFER model:

• Follow E guidelines.• If agitated behavior without

suspected acute substance abuse, consider chemical restraint with MIDAZOLAM 2.5-5 mg IV/IO or 5 mg IM/IN.

• If suspected acute substance abuse (alcohol), consider chemical restraint with HALOPERIDOL 5 mg IV/IM or DROPERIDOL 5 mg IV/IM (2.5 mg if age ≥ 65), (cumulative dose of 10 mg).

Stabilize the situation by lowering stimuli, including voice.Assess and acknowledge crisis by validating the patient’s feelings and not minimizing them.Facilitate identification and activation of resources (clergy, family, friends, and police).Encourage patient to use resources and take action in the patient’s best interest.Recovery/referral – transport patient to Hospital Emergency Facility. If the patient is not transported, be sure the patient is in the care of a responsible individual or professional.

2.10Adult – Diabetic Emergencies

Protocol Summary• This is a new protocol.• This protocol recognizes and provides

standing orders for adult patients with hypoglycemia or possible diabetic ketoacidosis.

• This protocol is divided into different levels of care.

• Routine Patient Care.• Perform Glucose Analysis.• Treat as recommended in the table.

2.10Pediatric – Diabetic Emergencies


standing orders for pediatric patients with hypoglycemia or possible diabetic ketoacidosis.


• Routine Patient Care.• Perform Glucose Analysis.• Treat as recommended in the Table.

2.11 Dialysis Emergencies and Renal Failure


standing orders for treatment of volume overload and hyperkalemia.


2.12 Ischemic StrokeProtocol Summary• Previously 4.13 Stroke in Medical Emergencies.• This protocol is divided into two levels of care. Advanced EMT Cardiac

level providers follow E standing orders.• This protocol recognizes and provides standing orders for new onset

(<24hrs) of unilateral motor weakness or paralysis (including facial droop), unilateral numbness, speech/language disturbance, visual disturbance, or abrupt gait disturbance.• Routine patient care.• For patients with a LAMS score

of ≥ 4 and the transport time is less than 30 minutes to a Comprehensive Stroke Center (CSC), transport the patient to the nearest CSC, otherwise transport the patient to the nearest stroke center.

• On scene time should be limited to ≤ 10 minutes.

https://docs.google.com/presentation/d/1EBMJC35sI42Vm09g56Oe5VkboMxTjn1HLxVtm2BOBX4/edit#slide=id.p4b

• Paramedics may transport patients receiving fibrinolytic agents (tPA) via IV infusion and may maintain and titrate (following parameters set by the sending MD) infusions of NICARDIPINE or LABETALOL that have been initiated by the sending facility for blood pressure management.



2.13 IV t-PA for Acute Ischemic Stroke

Protocol Summary• New Protocol • This protocol is for Paramedic Level

2.14 EpistaxisProtocol Summary• This is a new protocol.• This protocol recognizes and

provides standing orders for Anterior and Posterior epistaxis.


2.15Adult – Fever Protocol Summary• This is a new protocol.• This protocol recognizes and

provides standing orders for body temperatures ≥ 100.4 in Adult Patients.

• This protocol is for all level providers.

2.15Pediatric – Fever Protocol Summary• This is a new protocol.• This protocol recognizes and

provides standing orders for body temperatures ≥ 100.4 in pediatric patients.

• This protocol is for all level providers.

2.16Pediatric – Neonatal Resuscitation

Protocol Summary• Previously 4.9 Newborn

Resuscitation in Medical Emergencies.

• This protocol recognizes and provides standing orders for a newly born infant that is less than term gestation (<37 weeks), or not crying/breathing, or has a HR <100, or has poor muscle tone, or has labored breathing/gasping, or persistent (>5-10 min) central cyanosis.

• This protocol is divided into two levels of care. Advanced EMT Cardiac level providers follow E standing orders.

Paramedics• Advanced airway management

as indicated.• IV/IO/UVC access as indicated.• EPINEPHRINE (1:10,000) 0.01-

0.03 mg/kg IV/IO or EPINEPHRINE (1:10,000) 0.05-0.10/kg via ETT (IV/IO administration if preferred) if IV access is not yet established.

• NORMAL SALINE 10 ml/kg over 5-10 minutes (may repeat X1) if suspected hypovolemia.

• All critically ill neonates should have their bG determined.

• Perform needle thoracostomy for suspected tension pneumothorax..

All level providers• No changes made.

2.17 Obstetrical DeliveryProtocol Summary• Previously 4.8 Obstetrical Assistance. • This protocol recognizes and provides standing orders for

obstetrical delivery.• This protocol is for all levels of care.• Routine Patient Care.• ALS will no longer start routine IV access. Follow the

Obstetrical Complications protocol or the Neonatal resuscitation protocol.

Obstetrical ComplicationsProtocol Summary• This is a new protocol.• This protocol is for all levels of provider.• This protocol recognizes and provides

standing orders for obstetrical complications such as:

o Prolapsed umbilical cordo Shoulder dystociao Malpresentation (Breecho 3rd trimester bleedingo Postpartum hemorrhageo Preterm labor

2.19Adult - SeizuresProtocol Summary• Previously 4.10 Seizures/Postictal State.• This protocol recognizes and provides standing orders for adult patients

with generalized or grand mal seizures, petit mal seizures and focal or partial seizures.

• This protocol is divided into different levels of care.• Routine patient care.• Perform blood glucose analysis and follow Diabetic Emergencies

Protocol.• EMTs can assist the family or caregiver with the

administration of prescribed DIAZEPAM rectal gel or MIDAZOLAM (IN or via auto-injector).

• EMTs can assist the family or caregiver with the use of VAGAL NERVE STIMULATOR (VNS) if needed. • Advanced EMT Cardiac and Paramedic notice the change in initial medication management:

• NO IV Access and Generalized or focal seizures: MIDAZOLAM 10 mg IM or 2 mg IN.

• IV access and/or patient with seizure activity refractory to MIDAZOLAM o LORAZEPAM 4 mg IV/IO (repeat 2 mg every 3-5 min to a

max of 10 mg) or o MIDAZOLAM 2.5 mg IV/IO [5 mg IM or 2 mg IN] (repeat 2

mg every 3-5 min to a max of 20 mg) oro DIAZEPAM 5 mg IV/IO (repeat every 3-5 min to a max of

20 mg).

2.19 Pediatric - SeizuresProtocol Summary• Previously 4.11 Seizures (Pediatric).• This protocol recognizes and provides standing orders for pediatric

patients with generalized or grand mal seizures, petit mal seizures and focal or partial seizures.

• This protocol is divided into different levels of care.• Routine patient care.• Perform blood glucose and follow Diabetic Emergencies Protocol.• EMTs can assist the family or caregiver with the administration of

prescribed DIAZEPAM rectal gel or MIDAZOLAM (IN or via auto-injector).

• EMTs can assist the family or caregiver with the use of VAGAL NERVE STIMULATOR (VNS) if needed.

• Suspected febrile seizure, eliminate other causes, obtain body temperature, use passive cooling measures ACETAMINOPHEN 15 mg/kg suppository PR if temperature above 100.4

• CONSIDER ALS Intercept if seizures last more than 5 minutes and require anti-seizure medications.

• Advanced EMT Cardiac notice the change in initial medication management:o MIDAZOLAM 0.2 mg/kg IM/IN or 0.1 mg/kg IV/IO [4 mg

max single dose via any route)] (may repeat every 5 min to a max of 1 mg/kg) or

o LORAZEPAM 0.1 mg/kg IV/IO [4 mg max single dose] (may repeat every 5 min to a max of 0.5 mg/kg) or

o DIAZEPAM 0.1 mg/kg IV [5 mg max single dose] or 0.5 mg/kg PR [20 mg max single dose] (may repeat every five min to a max of 1 mg/kg).

• Paramedic notice the change in initial medication management:o MIDAZOLAM 0.2 mg/kg IM/IN or 0.1 mg/kg

IV/IO [4 mg max single dose via any route)] (may repeat every 5 min to a max of 1 mg/kg) or

o LORAZEPAM 0.1 mg/kg IV/IO [4 mg max single dose] (may repeat every 5 min to a max of 0.5 mg/kg) or

o DIAZEPAM 0.1 mg/kg IV [5 mg max single dose] or 0.5 mg/kg PR [20 mg max single dose] (may repeat every five min to a max of 1 mg/kg).

• Phenobarbital dose remains unchanged.

DO NOT DELAY MEDICATION ADMINISTRATION TO OBTAIN VASCULAR ACCESS.

2.20Adult – General Shock and Hypotension

Protocol Summary• Previously 4.12 Shock.• This protocol recognizes and provides standing orders for adult

patients with undifferentiated, hypovolemic, obstructive, cardiogenic, and neurogenic shock.

• This protocol is divided into different levels of care.• Although a previous protocol existed, this protocol is completely new.

READ THOROUGHLY AND CAREFULLY.

2.20 Pediatric – General Shock and Hypotension

Protocol Summary• Previously integrated 4.12 Shock.• This protocol recognizes and provides standing orders for pediatric

patients with undifferentiated, hypovolemic, obstructive, cardiogenic, and neurogenic shock.

• This protocol is divided into different levels of care.• Although a previous protocol existed, this protocol is completely new.

READ THOROUGHLY AND CAREFULLY.

2.21Adult – Hemorrhagic Shock

Protocol Summary• Previously integrated 4.12 Shock.• This protocol recognizes and provides standing orders for adult

patients compensated and uncompensated hemorrhagic shock, and external hemorrhage.

• This protocol is divided into different levels of care.• Although a previous protocol existed, this protocol has new

medication management. READ THOROUGHLY AND CAREFULLY.

2.21Pediatric – Hemorrhagic Shock

Protocol Summary• Previously integrated 4.12 Shock.• This protocol recognizes and provides standing orders for pediatric

patients with compensated and uncompensated hemorrhagic shock, and external hemorrhage.



2.22Adult – Septic ShockProtocol Summary• Previously integrated 4.12 Shock.• This protocol recognizes and provides standing orders for

adult patients with sepsis and septic shock.• This protocol is divided into different levels of care.• Although a previous protocol existed, this protocol has

new medication management. READ THOROUGHLY AND CAREFULLY.

2.22Pediatric Septic ShockProtocol Summary• Previously integrated 4.12 Shock.• This protocol recognizes and provides standing orders for pediatric

patients with suspected or known infectious process and temperature abnormality (- >38.5°C or <36.0°C ), a heart rate greater than normal for age and one of the following: Mental status abnormality, perfusion abnormality, high risk condition, EtCO2 <25 mmHg and/or finger stick lactate level >4 mmol/L.



2.23 Sickle Cell CrisisProtocol Summary• This is a new protocol.• This protocol recognizes and provides

standing orders for sickle cell crisis in patients with sickle cell disease.

• This protocol is for all levels of provider.

2.24 SyncopeProtocol Summary• This is a new protocol.• This protocol is for all levels of provider.• This protocol recognizes and provides

standing orders for transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery.

2.25 Excited Delirium Syndrome (ExDS)

Protocol Summary• This is a new protocol.• This protocol

recognizes and provides standing orders for individuals exhibiting bizarre and aggressive behavior including agitation and ≥6 of the following; increased tolerance to pain, tachypnea, diaphoresis, agitation, warm/hot skin to touch, non-compliance to police presence/commands, absence of fatigue, unusual strength, naked or dressed inappropriately for conditions, unusual attraction to glass or mirrors, or keening (unintelligible animal like noises).


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