Naval Aviation

Medical Treatment Protocols

APRIL 2019

Naval Aviation Medical Treatment Protocols, January 2019 Page 1

 CONTRIBUTORS
Current Edition Contributors
CDR Benjamin Walrath, USN, EMS and ER Physician
CDR Elliot M Ross, USN, EMS and ER Physician
LCDR Paul J Roszko, USN, EMS and ER Physician
LCDR Domenique Selby (Ret), USN, Critical Care Nurse
SMSgt Travis A. Shaw, USAF, NR-P, PJ Program Manager
HMC Wayne Papalski, USN, NR-P/FP-C/TP-C
HMC Brad Reinalda, USN, EMT-P, Independent Duty Corpsman
HM1 Ryan Honnoll, USN NR-P, Enlisted Technical Leader (ETL)
HM1 Michael Chernenko USN, EMT, SAR Model Manager
HM1 Cory Wendland, USN, NR-P
HM1 Matthew Hawkins, USN, EMT, SAR Evaluator
HM2 Austin Shutt, USN, NR-P

Past Contributors
HMCS David Clipson, USN, NR-P
HMCS Matt Bonnett, USN, NR-P
HM2 John Siedler, USN, NR-P FP-C

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INTRODUCTION TO NAVAL AVIATION MEDICAL TREATMENT PROTOCOLS:

This document has been prepared for use by Emergency Room Physicians, Aviation Medical Director’s / Naval
Hospital flight surgeons, and Search and Rescue Medical Technicians (SMT), who are engaged in the conduct of
Search and Rescue with Air Medical Transport (AMT) operations, Aero-Medical Evacuation (MEDEVAC), and
Tactical Evacuations (TACEVAC).

This document is intended to provide a consistent framework of medical treatment guidelines for Naval Aviation
Search and Rescue, as discussed on the following page. The document has been created to reflect current prehospital
medical trends. It has been adapted for use by the Search and Rescue (SAR) Medical Technician (SMT/NEC
L00A), SMT Paramedics, Rescue Swimmers, and EMT-Rescue Swimmers providing medical care. No protocol
template can address every eventuality or medical condition in a universally accepted format. The basic protocols
provided in this document will, however, provide a consistent set of medical treatment standards that can be
delegated from the Medical Director to the infield providers. Protocols provide consistent standards for training and
performance improvement monitoring: they are one of the cornerstones of every EMS system development.

The SMTs possess varying levels of experience from the recently qualified SMT with National Registry of
Emergency Medical Technician (NREMT)-Basic (NREMT) certification up to the SMT with NREMT-Paramedic
certifications. Between the Basic EMT and the Paramedic lies the nebulous EMT intermediate (which has no
consistent skill set from state to state). Each SMT possesses a different skill proficiency level depending on his/her
previous experience and patient care history. Unlike the civilian Paramedic who uses his/her skills on a daily basis,
the SMT may only use his/her skills occasionally for actual patient care in the station SAR environment. All SMTs
have received training and certifications in Intravenous therapy, however it is encouraged and recommended that all
SMTs receive continuing education on ALS classes to include; Advanced Cardiac Life Support (ACLS), Advanced
Pre-Hospital Trauma Life Support (PHTLS), Tactical Combat Casualty Care (TCCC), Pediatric Advanced Life
Support (PALS), Pediatric Education for the Prehospital Provider (PEPP), Neonatal Resuscitation Provider (NRP)
and Operational Emergency Medical Services (OEMS).

The Rescue Swimmers and Rescue Swimmer/EMT possess a base knowledge of first responder/EMT Basic
qualification. Their skill set is a tremendous help in the triage, treatment, and turnover of patients. Each Rescue
Swimmer/EMT medical capabilities is covered in these protocols.

The intent of these protocols is to allow all of the SAR Members to best utilize the skills that they do currently
possess to treat their patients. This is dependent on the validation of any advanced skills (such as endotracheal
intubation, cricothyroidotomy, chest decompression, advanced cardiac life support and pharmacology) at the unit
level by the Petty Officer designated by the Medical Director or Commanding Officer as the Standardization Petty
Officer. SAR Members will perform only those skills with which he/she is proficient. If he/she is not proficient in a
skill that he/she has been taught or if he/she is not confident with his/her ability to correctly perform a procedure,
he/she will consult his/her Standardization Petty Officer for further training. Regular training and practice will be
ongoing, so there should be ample opportunity to become proficient and confident with all of the skills detailed in
these protocols!

In practical terms, this means providing care IAW the guidance above without deviation. If there is a needed
deviation, your medical director is responsible for any directed deviation during on-line Medical Control. If you
provide care outside the scope of your practice during off-line Medical Control, you are personally responsible for
any adverse outcome. DO NOT PROVIDE CARE THAT DEVIATES FROM WHAT YOU ARE TRAINED AND
ALLOWED TO DO.

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TABLE OF CONTENTS

I. INTRODUCTION AND USE

II. ADMINISTRATIVE
1. Medical Director / Flight Surgeon 9
2. Medication Skill Sets 10
3. Principles of Medical Care 13
4. Assessment Checklist 14
5. Refusal of Medical Care and/or Transport 16
6. Triage – S.T.A.R.T Flowchart 17
7. Spinal Immobilization Guidelines 18
8. Altitude Physiology and Patient Transfer 20

III. ADULT PATIENT CARE PROTOCOLS

1. Airway / Oxygenation / Ventilation 24
2. Allergic / Anaphylactic Reaction 29
3. Altered Mental Status / Syncope 31
4. Altitude Medical Emergencies 33
5. Bites and Stings 35
6. Blood Component / Fresh Whole Blood 37
7. Breathing Difficulty 41
8. Burns 43
9. Cerebral Vascular Accident 45
10. Chemical Exposure 49
11. Chest Pain / AMI / ACS 51
12. Combative Patient 55
13. Crush Syndrome 57
14. Dialysis/ Renal Failure 59
15. Diving Medical Disorders 61
16. Drowning / Near Drowning 63
17. Head Injuries / Suspected TBI’s 65
18. Hyper / Hypoglycemia 69
19. Hyperthermia 71
20. Hypothermia 73
21. Nausea / Vomiting 75
22. OB / GYN – Pregnancy / Delivery / Vaginal Bleeding 77
23. OB / GYN – (Pre) Eclampsia 79
24. Pain Management Non-Cardiac 81
25. Post-Operative & CC Interfacility Transfer 83
26. Rapid Sequence Induction 89
27. Seizures 93
28. Shock 95
29. Needle Chest Decompression / Chest Tube 97
30. Toxicological Emergencies (Overdose) 101
31. Trauma / Traumatic Arrest 104
32. Vascular Access 106
33. Ventilator Management 108
34. Determination of Death 113

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IV. ADULT CARDIAC CARE PROTOCOLS
1. Emergency Cardiac Care 117
2. Asystole & Pulseless Electrical Activity 119
3. Bradycardia 121
4. Tachycardia 123
5. ROSC – Return of Spontaneous Circulation 127
6. Termination or Resuscitation 129

V. PEDIATRIC GUIDELINES
1. General Information 133
2. Clinical Reference charts for Pediatric(s) / Neonate(s) 133
3. JUMP START Triage 135
4. APGAR / Glasgow Coma Scale 137
5. Neonate / Pediatric Burn Reference 138
6. Pediatric Cardiac Arrest 139
7. Pediatric Bradycardia 140
8. Pediatric Tachycardia 141

VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

1. Abbreviated TCCC Guidelines 143
2. Care Under Fire Algorithm 148
3. Tactical Field Care Algorithms 149
4. Tactical Evacuation Care Algorithms 160
5. Blood Administration and Protocol 172
6. DD1380 TCCC Card 177
7. Triage Categories 179
8. 9 – Line / MIST Report 180

VII. CANINE PROTOCOL 181

VIII. MEDICATION REFERENCE 192

IX. LABORATORY REFERENCE 204

X. REFERENCES 207

XI. MILITARY ACUTE CONCUSSION EVALUATION (MACE) 2ND EDITION 208

XII. NOTES 219

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II. ADMINISTRATIVE

1. MEDICAL DIRECTOR

The Medical Director should be a licensed physician and Emergency Room physician, or Trauma Surgeon, or EMS
Director. The Medical Director will advise the Unit’s Commanding Officer on all medical components of the Unit’s
operations as required by the CO. The Medical Director will also serve as medical control authority for all patient
care performed by unit SMTs. The Medical Director will be available for consultation, provide retrospective Quality
Assurance/Quality Improvement (QA/QI) review, supervise continuing education (CE) programming, and will serve
as a medical liaison between this unit and other services, facilities, and physicians. The Medical Director may
delegate his or her authority to the senior SAR Medical Technician (typically Standardization PO) as he or she
deems appropriate.

ON-LINE Medical Control: A physician is present at the scene or available through communication.
Although this is the ideal and preferred method it is uncommon in most Rescue operations. Order of precedence for
on-line medical control:

On scene:
Senior Medical Officer (SMO of Ship)
Senior U.S. Military Physician present on scene
Senior Allied Military M.D. (equivalent to US Military Physician)
Civilian M.D. who can prove credentials and assumes responsibility
Senior Military Physician Assistant
Senior SOCM / 18D

Off scene:
U.S. Military Physician in direct contact via audio/visual communication

Off-line Medical Control: Contact with a Physician is impossible or impractical. Care is based on approved
protocols and procedures. This is the most common scenario.

In Off-line control situations,

Note: These sources cover the vast majority of care you will provide. Instances where deviation may occur more
frequently would be in remote situations where certain medications are not available, and the local medical authority
has directed the use of locally available meds, and has provided the adequate in-service education with proper
documentation. Also, certain regions may have diseases and treatments that are endemic and require unique care that
should be added to the protocols in that area of operation.

2. STANDING ORDERS/TREATMENT PROTOCOLS

Designated SMTs will maintain professional certifications, continuing medical education, and military credentials in
accordance with OPNAVINST 3130.6 series, the National Registry of Emergency Medical Technicians, and local
command directives.

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II. ADMINISTRATIVE

A. Skill Sets:

Rescue Swimmer
Skill (RS) RS / EMT SMT EMT-P
Airway
Oral/Nasalpharyngeal Airway x x x
L.M.A or Combi-tube x x
King Airway x x
Magill Forceps Use x x
CPAP/Bipap x x
Cricothyrotomy x x
Chest Decompression x x
Finger Thoracotomy / Chest Tube FP-C / TP-C
Automated Ventilator x x
Bag Valve Mask x x x x
Pocket Mask x x x x
Circulatory Support
Peripheral IV x x
Intraosseous Cannulation x x
External Jugular Cannulation x x
Glucometry x x x
Automatic External Defibulator x x x x
Defibrillation -
Automatic/Manual x x
Synchronized Cardioversion x x
Pacing x x
Vital Signs - Automatic/Manual x x x
Medications
Assisted Medications x x x
Inhaled Medications - Nebulizer x x
IM Medications Limited x
IV Medications Limited x
IO Medications Limited x
PO Medications x x x
SL Medications x x
SQ Medications x x
Transdermal Medications x x
Blood Products x x

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II. ADMINISTRATIVE

A. Skill Sets:

Warning /
Alert for all
providers to
note

All provider levels shall

perform

Only qualified SMT’s

shall perform SMT’s are permitted to perform all skill sets
up. to this level.

Only qualified
Paramedics shall
perform Paramedics’ are permitted to perform all skill
sets up to this level.

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II. ADMINISTRATIVE

B. SMTs who are QUALIFIED and designated are authorized to utilize, at the discretion of the Medical
Director, the following medications:

*** Medications that Highlighted are only for SMT-Paramedic use

++ Controlled Substance ++

1) Administration of the following medications according to treatment protocols:

Acetaminophen (Tylenol) Ipratropium

Activated Charcoal Ketamine ++
Adenosine (Adeonocard) Ketorolac
Albuterol 0.5% Lactated Ringers (LR)
Amiodarone Lidocaine ( Xylocaine )
Aspirin Lorazepam (Ativan) ++
Atropine Sulfate Magnesium Sulfate 10%
Calcium Chloride Meloxicam (Mobic)
Calcium Gluconate Methylprednisolone
Cefazolin Sodium (ANCEF) Midazolam ( Versed ) ++
Ceftraixone (Rocephin) Moxifloxacin (Avelox)
Dextrose 25% / 50% Morphine Sulfate ++
Dexamethasone Naloxone ( Narcan )
Diamox Nitroglycerin SL spray / tablets
Diazepam (Valium) ++ Ondansetron (ZOFRAN)
Diltiazem ++ Oxymetazoline (Afrin)
Diphenhydramine ( Benadryl ) Oxygen
Dopamine Promethazine
Ertapenem (INVANZ) Rocuronium
Erythromycin Ophthalmic Ointment Sodium Bicarbonate
Etomidate Sodium Chloride 0.9% (NS)
Epinephrine Succinylcholine
Fentanyl ++ Vecuronium
Flumazenil (Romazicon) Vasopressin
Furosemide (Lasix) Thiamine
Glucagon / Insta Glucose Terbutaline
Hetastarch Tranexemic Acid (TXA)

2) The following are to be utilized only if the SMT possessed at EMT-P and or FP-C certification. If the SMT
does not possess the certification, the SMT shall have at a minimum a nurse or higher during transport.

Blood Products
Fresh Frozen Plasma (FFP)
Freeze Dried Plasma

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II. ADMINISTRATIVE

3. Principles of Medical Care:

1. MARCH PAWS: A pneumonic device used to cover the vast majority of care required during
medical/tactical field care and medical/tactical Evacuation. It covers the care of any medical/trauma
patient. Other than the “M”, it covers the care for most medical patients since it is just a variation of
the ABC’S. This approach allows for the SAR medical community to treat in an organized manner
ensuring he/she doesn’t neglect any treatment in the event of a break in care.

M – Massive bleeding
A – Airway
R – Respirations
C – Circulation
H – Head and hypothermia
P – Pain
A – Antibiotics
W – Wounds
S – Splinting

The approach/Treatments below include practices & principles from the NREMT, ATLS, TCCC,
PHTLS/ITLS, data from the OCO, Joint Trauma Registry, and past experiences.

2. Principle of the assessment:

a. PPE
b. Scene safety & security
c. Mechanism of injury/illness (MOI)
d. # of patients
e. Call for additional resources as applicable
f. General impression
g. MARCH:
- M – Tourniquet, hemostatic gauze, pressure dressing, pelvic sling/junctional tourniquet,
suture/staple, clamp, direct pressure, junctional hemorrhage device, elevate.
- A – Chin lift/Jaw thrust, recovery position, sit up and lean forward position, NPA, OPA,
supra-glottic device, ET tube, cricothyrotomy.
- R – Chest seal, needle decompression, BVM, SpO2, finger or tube thoracostomy.
- C –Diagnose (Weak or absent radial pulse, decreased mental status) and treat shock.
- H – Head; diagnose increased intracranial pressure (AVPU, pupils, posturing, irregular
respirations, EtCO2). Treatment; Secure the airway, IV/IO. Keep B/P >100, SpO2 >93%,
EtCO2 30-35 mmHg.
- H – Hypothermia; Dry patient, insulate from the ground, casualty blanket, HPMK, hat.
h. Vital Signs – AVPU, HR, BP, RR, SpO2%, EtCO2%, Temp. Blood Sugar, 4 Lead / 12 Lead
(as applicable)
i. Secondary survey (PAWS) – head to toe: DCAP-BTLS, LOBOS, TIC, step in/off
- P – Pain Meds as applicable per protocol.
- A – Antibiotics – PO or IV/IO, for all open combat wounds.
- W – Wounds – clean (remove debris, irrigate) and dress.
- S – Splinting- Perform orthopedic related care, address ortho/PMS; SAM, KTD, spinal
immobilization (per protocol), rigid eye shield.
j. Reassess – every 5 minutes for critical / 15 minutes for non-critical / as needed / feasible.
k. Document – Casualty card, medical report.
l. Package for evacuation / transport.

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II. ADMINISTRATIVE

4. Assessment Checklist:

Scene Size Up

 Scene safety / security

 BSI / PPE
 Determine the mechanism of injury / illness (MOI)
 Determine the # of patients (in case triage is necessary)
 Request additional help if necessary, determine availability of resources
 Verbalize initial impression: “Sick or not Sick

Primary Assessment

 C-Spine as needed unless ruled out

 AVPU
 Massive Hemorrhage – Visualize and feel (sweep) for life threatening hemorrhage:
o All 4 extremities
o Junctional Sites (Neck, Axillae, Groins)
o Torso and back
o Pelvic stability
 Airway - Open and maintainable (LOBOS)
 Respirations – Assess rate, depth, quality, auscultate lung sounds, apply finger pulse oximeter (as needed or
available)
o Look: Chest rise and fall, paradoxical motion, chest wall injuries.
o Listen: if possible with a stethoscope.
o Feel: chest wall: rips, subcutaneous air, holes or defects.
 Circulation – Diagnose shock (Radial / carotid pulse, assess skin color and temp, cap refill).
o Reassess bleeding control interventions
o Check pulses for: Rate, strength, and quality
 Head – Rule out severe intracranial pressure (TBI) by identifying mental status, pupils, posturing or snoring
respirations.
o Glasgow Coma Score (GCS)
o Assess Cranial Nerves
 Hypothermia – Dry and cover patient, use HPMK or blanket/Emergency blanket, insulate from ground.
 Transport decision

Secondary Assessment

 Vital signs - AVPU, HR, BP, RR, SpO2%, EtCO2%, Temp. Blood Sugar, 4 Lead / 12 Lead (as applicable)
 Head to toe examination:
o Head: inspect head and face for DCAP-BTLS, reassess airway (LOBOS), ears for drainage, pupils
(PERRLA), nose for bleeding and stability, jaw for stability.
o Neck: Assess for JVD, Subcutaneous air, hematoma, Tracheal deviation, C-Spine deformity /
tenderness / Step-off/in.
o Shoulders/Clavicles: DCAP-BTLS
o Chest: Expose and inspect, DCAP-BTLS, Reassess the same as primary assessment
o Abdomen: Normal= soft, flat, non-tender. Assess for tenderness, rigidity, distension, and pulsating
masses (TRD-P)
o Pelvis: Check pelvis once (do not rock), document status of genitals if amputations, priapism.
o Extremities: DCAP-BTLS, PMS, strength and ROM.
o Spine: Only log roll if appropriate, DCAP-BTLS, step-off/in.

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  Secure to spine board / rescue litter as required.
 Pain – Pain regimen per protocol
 Antibiotic – Antibiotic per protocol
 Wounds – identify potential life threatening wounds
 Splint – perform orthopedic related care as needed.
 Reassess airway / interventions after move or litter placement
 Do not delay transport for IV/IO, drug therapy, or non-critical interventions
 S.A.M.P.L.E / O.P.Q.R.S.T as available.

Documentation and Verbal Report

 Verbal Report:
o Age
o Time of incident / illness
o MOI
o Signs and symptoms
o Treatment and interventions
 Written Report:
o C – Chief complaint
o H – History
o A – Assessment
o R – Treatment
o T – Transport

Prolonged Field or Extended Field Care

SAR Medical Technicians may be put in a positon for caring for injured/ill patients for periods of up to 24 hours. In
these situations, refer to protocols as a baseline and seek online medical control whenever feasible or available.

 For these situations, the acronym HITMAN should be used:

o H – Hydration, hypothermia, hygiene
 Hydration – PO / IV/ IO / NG Tube (PRN), Urine output should be approx. 1-
1.5ml/kg/HR. Starting maintenance IVF – rate should be approx. 125 ml/hr.
 Hypothermia – Insulate from the ground, keep warm and dry
 Hygiene – Prevent sores / roll and pad the patient, keep patient clean and dry.
o I – Infection: Monitor compartment syndrome, change dressings 12-24hrs, antibiotics as per
protocol.
o T – Tubes: Neat and tight, continue to suction as needed.
o M – Medications: 6 Rights: Patient, med, dose, time, route, documentation.
 Monitoring Vitals: If stable, q2-4 h. At a minimum no less than q 12h.
o A – Analgesic: Document pain scale, Pain regime per protocol.
o N – Nutrition: If able, 1500 calorie a day intake.
 Extremely important for all patients that are alert and oriented and can swallow without
difficulty and for the SMT caring for the patient. (Tubed or altered mental status patients
should not be given food)

If a patient becomes unstable during any extended care, restart back at the MARCH PAWS phase and reassess
history once stability is regained.

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II. ADMINISTRATIVE

5. Refusal of medical care and/or transport:

In general, Active Duty military members may not refuse life-saving medical care. Mentally competent
adult civilians (including dependents, spouses and retired military members) may refuse medical care, even if
refusing medical care endangers their lives. SMT’s should make every effort to ensure that patients refusing medical
care are aware of the possible consequences of their actions. The patient should be urged to seek other medical care
as soon as possible.

• If the patient is unconscious, or unable to make a rational decision (secondary to head injury or
any other cause of altered mental status) the principle of Implied Consent assumes that a normal, rational
person would consent to life-saving medical treatment.

• If the patient is a minor or mentally incompetent adult, permission to treat must be obtained from
a parent or guardian before treatment can be rendered. If a life-threatening condition exists, and the parent
or guardian is unavailable for consent, treatment shall be rendered under the principle of implied consent, as
noted above.

• If an alert, oriented patient with normal mental status refuses medical care, then care cannot be
rendered. Medical control should be contacted (if possible) if such a situation occurs.

• If a patient refuses medical care the following statement must be written on the medical treatment
form and signed by the patient:

“I, THE UNDERSIGNED HAVE BEEN ADVISED THAT MEDICAL ASSISTANCE ON MY BEHALF IS
NECESSARY AND THAT REFUSAL OF SAID ASSISTANCE MAY RESULT IN DEATH, PERMANENT
INJURY OR IMPERIL MY HEALTH. I REFUSE TO ACCEPT TREATMENT, AND ASSUME ALL RISK AND
CONSEQUENCES OF MY DECISION. I RELEASE THE UNITED STATES AIR FORCE AND THE
DEPARTMENT OF DEFENSE FROM ANY LIABILITY ARISING FROM MY REFUSAL TO ACCEPT
MEDICAL CARE.”

 Note: The statement must be signed and dated by the patient, and countersigned by a witness. The medical
record should completely document that the patient is awake, alert, oriented and has normal mental status. If
the patient refuses to sign the form, and still refuses medical care, the patient’s refusal to sign should be
documented and signed by the treating SMT and preferably by at least one other witness.

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II. ADMINISTRATIVE

6. Triage – S.T.A.R.T Flowchart

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II. ADMINISTRATIVE

7. Spinal Immobilization

Spinal Immobilization is indicated for trauma patients where there is a suspicion of spinal
injury or the patient complains of pain associated with the spinal column. Special
consideration should be given when the patient age is <8 or >70 years of age.
The provider may decide to forgo spinal immobilization if the following criteria are met:

-No significant mechanism of injury (MOI)

-No loss of consciousness (LOC)
-No altered level of consciousness (LOC)
-Patient is able to communicate and is a reliable historian
-No signs of intoxication
-No distracting injuries
-No midline back or neck pain with or without movement
-No midline pain or tenderness or deformity present in back or neck upon palpation
-No pain present through full range of motion

Risk of spinal immobilization versus benefits should be weighed in special circumstances

such as; prolonged extrication from wilderness setting and technical rescue situations. Risks
include; emesis with airway compromise, pressure sores, extreme patient discomfort. Index
of suspicion for injury should be carefully weighed.

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II. ADMINISTRATIVE

8. Altitude Physiology and Patient Transfer

ALTITUDE CONCERNS FOR AEROMEDICAL TRANSFERS:

• Gas expansion occurs as altitude above sea level increases. The volume of a gas
will roughly double at 18,000’ mean sea level (½ sea level atmospheric pressure).
This will typically not affect the operational ceiling for the MH-60S during
Aeromedical Evacuation operations. Certain conditions and precautions to note:

 Air embolism / Decompression illness – This is the only absolute

contraindication to transport of patients at altitude. These patients should be
transferred at sea level or in an A/C capable of cabin pressurization to sea
level.

 Pneumothorax – There is little risk of developing a tension PTX due to gas

expansion from altitude during typical aeromedical evacuation flights in
rotary-wing A/C. However, altitude should be limited when possible to
<5,000’ MSL. If mission requirements mandate higher altitudes, the use of
aeromedical evacuation platforms with pressurized cabins should be
considered as applicable and tactically capable. Prophylactic chest tubes (for
altitude-related concerns) are recommended for any flights above 10,000’
mean sea level.

 Gastric distention – Gas expansion does increase the risk of vomiting and,
therefore, aspiration. Therefore, all patients with decreased LOC should
have an NG / OG tube placed prior to transfer.

 Head injury – As with PTX, there is little concern of altitude related elevation
of elevated ICP in head injured patients although penetrating intracranial or
maxillofacial injuries may set conditions for an entrapped-gas phenomenon
with adverse clinical consequences. Any evidence of elevated ICP should
result in treatment per guideline. Altitude restrictions do not differ from those
listed for PTX. Constant vigilance should be maintained for evidence of
elevation of ICP.

 Eye injury – Penetrating eye injuries or surgeries may introduce air into the
globe. Again, the altitudes obtained for rotary-wing A/C does not pose a risk
of elevating the IOP during normal operations.

 Gas filled equipment – Medical equipment with gas filled bladders also may
suffer from interference at high-altitudes. Primarily, endotracheal tube cuffs
should be evaluated at altitude by testing the pressure of the exterior bladder
or filled with air. If able, utilize manometer to verify tube pressure. Verify with

Naval Aviation Medical Treatment Protocols, April 2019 Page 20

 supervising physician or flight surgeon before filling endotracheal tube with
saline.

• Flow Rates: Decreased atmospheric pressure may interfere with IV flow rates
and/or pump function. These must be monitored continuously.

• Invasive Blood Pressure: Adjust / re-calibrate monitor every 1000’ if required

based upon monitoring device.

• Hypothermia: As altitude increases, the temperature will drop about 3.5° F per
1000 feet. This is further complicated in the H-60 due to rotor-wash, forward air
speed, normal lapse rate. Therefore, patients must be protected from hypothermia
at all times. This includes use of the Hypothermia Prevention and Management
Kit (HPMK), blankets, heaters if available, and closing cabin doors / crew
windows during transport.

• Hypoxia: Patients are at increased risk of hypoxia during transport at altitude. If

transfers are taking place in high-altitude locations, pulse oxygenation should be
monitored at all times and the medic / provider should maintain a low threshold
for the use of supplemental SpO2. At no time should the patient’s SpO2 be allowed
to go below 92 percent (commercial pulse oximeters read up to 3 percent off,
therefore a sat of 91 percent may be seen in a patient who is really at 88 percent.).
Patients who smoke or have underlying cardiopulmonary disease are at
increased risk even at low altitudes.

• Dysbarism: Patients may experience discomfort due to gas expansion in air-

filled body spaces (e.g., ears, sinuses, teeth) during ascent. Conversely, patients
and aircrew may experience "squeeze" resulting from descent from altitude. These
are typically mild during RW transport, however, if severe, altitude should be held
and attempts made to alleviate pain and/or slow rate of ascent / descent.
Document procedure, results, and vital signs.

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III. ADULT PATIENT CARE PROTOCOLS

1. Airway / Oxygenation / Ventilation 24

2. Allergic / Anaphylactic Reaction 29
3. Altered Mental Status / Syncope 31
4. Altitude Medical Emergencies 33
5. Bites and Stings 35
6. Blood Component / Fresh Whole Blood 37
7. Breathing Difficulty 41
8. Burns 43
9. Cerebral Vascular Accident 45
10. Chemical Exposure 49
11. Chest Pain / AMI / ACS 51
12. Combative Patient 55
13. Crush Syndrome 57
14. Dialysis/ Renal Failure 59
15. Diving Medical Disorders 61
16. Drowning / Near Drowning 63
17. Head Injuries / Suspected TBI’s 65
18. Hyper / Hypoglycemia 69
19. Hyperthermia 71
20. Hypothermia 73
21. Nausea / Vomiting 75
22. OB / GYN – Pregnancy / Delivery / Vaginal Bleeding 77
23. OB / GYN – (Pre) Eclampsia 79
24. Pain Management Non-Cardiac 81
25. Post-Operative & CC Interfacility Transfer 83
26. Rapid Sequence Induction 89
27. Seizures 93
28. Shock 95
29. Needle Chest Decompression / Chest Tube 97
30. Toxicological Emergencies (Overdose) 101
31. Trauma / Traumatic Arrest 104
32. Vascular Access 106
33. Ventilator Management 108
34. Determination of Death 112

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III. ADULT PATIENT CARE PROTOCOLS

1. Airway / Oxygenation / Ventilation

A. Objectives:

1) When possible, a room air pulse oximetry reading should be obtained and documented.

2) The goal is to maintain SP02 > 94%, EtCO2 35-45mmHg unless suspected Head Trauma.

3) Establish an airway for all patients who cannot maintain their own.

B. Warnings/Alerts:

1) Failure to use end-tidal C02 monitoring increases the risk of an unrecognized misplaced
tube. EtCO2 Shall be used in all Post Intubation, Cricothyrotomy, or king/supraglottic
airway’s.

2) Failure to confirm tube placement prior to securing or following patient movement may
lead to unrecognized tube displacement.

3) Apnea is an absolute contraindication to nasal intubation.

4) Unable to open or effectively ventilate the patient with the inability to clear, two failed
Supraglottic/ET airway attempts, or intubation is contraindicated shall warrant the
performance of a Cricothyroidotomy.

5) All advanced airway patients shall require at a minimum, a c-collar to prevent

dislodgement of the airway device.

C. Medications:

1) Post-intubation Sedation:

a) 2-5mg Valium IV or 2mg Versed IV

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Naval Aviation Medical Treatment Protocols, April 2019 Page 25
Naval Aviation Medical Treatment Protocols, April 2019 Page 26
 Airway / Oxygenation / Ventilation

Loss of Airway or
Inadequate
Breathing?

NO
YES
NO Airway Patent after Airway Consider Supplemental 02 (if available)
Maneuvers? The GOAL is SP02 > 94% / EtCO2 35-45
mmHg

YES

Consider CON
complete airway Need for breathing support? YES BVM
obstruction. Visualize airway, High 02 (If Available)
remove foreign body if Consider CPAP or Automated Ventilator
necessary.
NO

Complete obstruction? Monitor and Transport

YES

Cricothyrotomy Tension
BVM / CPAP / Ventilator effective? NO
Pneumothorax with
signs of shock?

Advanced Airway YES

Supraglottic device or ET tube

Needle
Decompression

Secure tube placement

Consider post-
intubation sedation

Monitor and transport

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III. ADULT PATIENT CARE PROTOCOLS

2. Allergic / Anaphylactic Reaction

A. Objectives:

1) To assess and appropriately treat patients with allergic reaction and/or anaphylaxis.

2) To differentiate between an allergic reaction and anaphylaxis.

B. General Information:

1) Rapidly progressing signs and symptoms shall be treated as anaphylaxis.

2) RS or RS-EMT’s may use patients EPI-Pen or EPI-Pen from Med Kit.

3) In severe anaphylaxis with hypotension and/or severe airway obstruction, medical control
may order Epinephrine 1: 10,000 IV.

4) Solu-Medrol should not be routinely administered to pediatric patients, however may be

considered by medical control for extended transports.

C. Warnings/Alerts:

1) Epinephrine 1:1000 shall not be given IV.

2) Contact medical control before administering Epinephrine to patients with cardiac HX or

40 years or older.

3) Maximum dose of Epinephrine 1:1000 is 0.5mg.

Naval Aviation Medical Treatment Protocols, April 2019 Page 29

Allergic / Anaphylactic Reaction

Hemodynamically Epinephrine 1:1000

Unstable or 0.01mg/kg
Respiratory Distress? YES IM/SQ – max dose 0.5mg

NO
Albuterol hand-held
Vascular Access Nebulizer 2.5mg

Vascular Access
Consider:
250ml NS bolus.
Diphenhydramine
May repeat up to 1000ml if
(Benadryl) 50mg IV/IM/IO
lungs remain clear

Consider EKG Monitor Diphenhydramine

Contact Medical Control (Benadryl) 50mg IV/IM/IO

Apply EKG monitor

Solu-Medrol 125mg IV

Monitor and transport Contact Medical Control

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III. ADULT PATIENT CARE PROTOCOLS

3. Altered Mental Status / Syncope

A. Objective:

1) To appropriately assess and treat patients with Altered Mental Status / Syncope

B. General Information:

1) Consider alternate causes using AEIOU-TIPS:

- Alcohol / Acidosis
- Epilepsy
- Insulin
- Overdose
- Uremia / Renal Failure
- Trauma
- Infection
- Psychosis
- Seizures

2) Rechecking glucose after all interventions.

3) Assess for signs of trauma in any syncopal event.

4) EKG monitoring should be obtained in all suspected toxin or diabetic ketoacidosis events.

C. Warnings/Alerts:

1) Be aware of AMS as a presentation of environmental exposure, toxins, and hazmat. Use

proper PPE and Decontamination procedures as appropriate.

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 Scene Safety

Altered Mental Status / Syncope

Patient Assessment/History

Treatment per Airway protocol

NO NO
Glucose <70? Vital Signs / ECG Glucose >250?
Blood Glucose 70-250

Evidence of Alcohol Abuse? Exit to hyperglycemia protocol

Consider AEIOU - TIPS
YES

Thiamine 100mg IV/IO/IM

Consider Naloxone 0.4-2mg
IV/IO/IM/IN
Exit to hypoglycemia protocol

Signs of stroke/TIA? Seizure

YES YES
Exit to stroke/CVA protocol Exit to seizure protocol

Continuous monitoring
Vital Signs / ECG

Transport

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III. ADULT PATIENT CARE PROTOCOLS

4. Altitude Medical Emergencies

D. Objective:

1) To appropriately assess and treat patients with Altitude Illness.

2) Descend to safe appropriate altitude and if symptoms do not resolve, begin treatment.

E. General Information:

1) Acute Mountain Sickness (AMS): Usually occurs at altitudes 8,000ft and higher.
Symptoms can occur as quickly as 3 hours after ascent. Signs and symptoms are generally
benign and self-limiting, but can become debilitating. Anorexia, nausea, vomiting,
insomnia, dizziness, lassitude, and or fatigue.
2) High Altitude Pulmonary Edema (HAPE): Caused by hypoxia of altitude. HAPE is the
most common cause of death at altitude. Usually occurs above 8,000ft. Respiratory
distress at altitude is HAPE until proven otherwise. Hallmark sign is dyspnea at rest.
Other symptoms may include cough, crackles upon auscultation, tachypnea, tachycardia,
fever, or low SpO2 sat disproportionate to elevation.
3) High Altitude Cerebral Edema (HACE): Rare below 11,500ft. Headache is common at
altitude and not always associated with HACE. Ataxia and altered mental status at
altitude are HACE until proven otherwise. Symptoms include unsteady, wide unbalanced
gait and AMS.

F. Warnings/Alerts:

1) HAPE and HACE may coexist in the same patient. If suspected, treat both
2) HAPE and HACE should prompt emergent evacuation and descent
3) Individuals with HACE should not be left alone or allowed to descend alone
4) GAMOW Bag treatment is not a substitute for descent.
5) Minimize patient exertion during descent since this will exacerbate symptoms

G. Medications/Treatments:

1) Diamox (Acetazolamide)- FOR AMS- 250 mg PO BID; contraindicated in patients with allergy
to sulfa

2) Dexamethasone (Decadron)- FOR AMS- 4 mg PO q 6 hours (do not ascend until patient
asymptomatic for 24 hours after administration); FOR HAPE/HACE- 10 mg IV/IO/IM STAT, then
4 mg IV/IO/IM q 6 hours

3) GAMOW Bag- One-hour session with bag inflated to 2 PSI above ambient pressure
(approx.100 mmHg); repeat four to five times if tactically feasible

Naval Aviation Medical Treatment Protocols, April 2019 Page 33

 Scene Safety
HA
N/V
Insomnia
Altered Mental
Altitude Medical Emergencies Patient Assessment/History Status
Dyspnea
Cough
Hemoptysis
At altitude any S/S of Fatigue
AMS/HAPE/HACE Unsteady gait
Disorientation
Hallucinations
Cranial nerve
palsy
HALT ASCENT Unconsciousness

Supplemental O2; pulse oximetry & Vitals

YES HIGH ALTITUDE

Altered Mental CEREBRAL EDEMA
status or ataxia? (HACE)

NO

Acute Mountain Sickness NO DYSPNEA AT REST? RR<8 or >30

YES Immediately
descend 3000ft
Descend 1500 ft
HIGH ALTITUDE PULMONARY
EDEMA (HAPE)
Diamox 250 mg PO
Tylenol 1000 mg PO
YES Exit to
Respiratory Airway
failure? Management
Initiate Saline lock as needed Protocol.
PO/IV fluids if dehydrated NO
Descend 1500- Initiate Saline Lock
3000ft. Minimize Administer
exertion Dexamethasone 10 mg
IV/IO/IM
Consider: Then 4 mg q 6 hrs
Dexamethasone 10 mg IM/IV/IO, then 4
mg IM/IV QID x 3 days
Zofran 4 mg ODT/IV/IM for nausea

Monitor
GAMOW Bag- one-hour
Supplemental O2
session at 2 psi above
Document
ambient pressure
Evac- Urgent for HAPE/HACE; Routine
for AMS

Contact Medical Control

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III. ADULT PATIENT CARE PROTOCOLS

5. Bites and Stings

A. Objectives:

1) To appropriately assess and treat patients who receive bites and stings.

2) To identify source of bite and sting.

B. General Information:

1) The use of constriction bands requires an order from Medical Control.

C. Warnings/Alerts:

1) Make no attempt to capture or kill the animal or insect that inflicted the bite or sting.

2) Shall not transport live animals in the Aircraft. Crew should consider extreme caution in
transporting dead animal or consider taking picture of the animal to show Medical
Control.

Naval Aviation Medical Treatment Protocols, April 2019 Page 35

 Scene Safety

Bites and Stings Patient Assessment

Control any Life-

threatening bleeding

YES EXIT to Allergic /

S/S of Anaphylaxis Anaphylactic reaction
protocol

NO

Remove anything on the injured body part that can

be constricting.

Marine Life: Snake Bites: Insect Sting/Bite: Animal/Human/Marine

Bite:
Gently scrape Apply dressing Gently scrape off
material sticking Immobilize stinger Apply dressing
to skin. (Keep site below
heart) Apply dressing If amputated parts:
Apply dressing Cold pack Transport in a dry sterile
dressing in a plastic bag.
Place in a cooled
container, not directly on
ice.

Assess and treat other

injuries as found.
Monitor for shock

Contact Medical Control

Transport

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III. ADULT PATIENT CARE PROTOCOLS

6. Blood Component / Fresh Whole Blood Use:

A. Objectives:

1) Administration of Blood Components and Whole Blood as per JTS CPG’s and DOD
TCCC Protocols.

2) Calcium shall be pushed on all patients in hypovolemic shock, requiring blood products,
or suspected trauma. 1gm Calcium slow IV/IO push via patent line.

Naval Aviation Medical Treatment Protocols, April 2019 Page 37

Blood Component / Fresh Whole Blood Use:

Naval Aviation Medical Treatment Protocols, April 2019 Page 38

Blood Component / Fresh Whole Blood Use:

Naval Aviation Medical Treatment Protocols, April 2019 Page 39

Blood Component / Fresh Whole Blood Use:

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III. ADULT PATIENT CARE PROTOCOLS

7. Breathing Difficulty:

A. Objectives:

1) To assess and treat patients with breathing difficulty.

2) To determine the most likely cause of the patients breathing difficulty.

B. General Information:

1) A patient with a HX of CHF that has wheezing upon auscultation of lung sounds should
not be automatically classified as asthma / COPD patient.

2) Congestive Heart Failure (CHF) is primarily a cardiac event, not a respiratory event.
Treatment should be focused on reducing preload and after load. CPAP or aggressive
BVM treatment is an appropriate first line treatment. Patients in end stage renal failure
should get Medical Control orders before the administration of Lasix.

3) Bronchoconstriction (Asthma, COPD) patients in severe distress may receive Albuterol

2.5mg/ Atrovent 0.5mg duo Nebulizer as first line treatment. Atrovent shall only be used
once.
For severe asthma Medical control may order:
- Epinephrine 1:1,000 0.01mg/kg IM, max dose of 0.5mg

C. Warnings/Alerts:

1) Do not administer Epinephrine 1:1,000 IV/IO

2) Do not administer Nitroglycerin to patients that have taken PDE inhibitors in the past 72
hours.

3) CPAP may worsen existing hypotension.

4) Patients must be conscious with regular respirations for CPAP to be effective.

5) Consider spontaneous pneumothorax vs. tension, monitor closely for s/s of shock.

Naval Aviation Medical Treatment Protocols, April 2019 Page 41

 Patient Assessment

Breathing Difficulty
Treatment per Airway protocol

YES EXIT to Allergic /

YES
S/S of Anaphylaxis Anaphylactic reaction
protocol
NO

YES
NormalYES
respiratory
effort? Transport
Breath sounds clear?

NO

Bilateral Crackles HX of COPD,

present? Asthma, Wheezing
or diminished breath
sounds?

CPAP if available
Monitor
If severe distress Albuterol Contact Medical
Aggressive airway 2.5mg/Atrovent 0.5mg duoNeb. Control
management -----------
Not in severe distress Albuterol
2.5mg Max dose is 2

-EKG / Monitor
- Vascular Access
- If systolic B/P >100 Nitro Vascular Access
0..4 mg SL x 3 every 3-5min

Lasix 40mg IV If no improvement

----------- Solu-Medrol 125mg IV
Albuterol 2.5mg if wheezing And
Magnesium 2g over 5
min in a 100ml NS drip
- M
a
g
n Transport
e
s
i
u
m
Naval Aviation Medical Treatment Protocols, April 2019 Page 42
S
u
l
III. ADULT PATIENT CARE PROTOCOLS

8. Burns

A. Objectives:

1) To assess and appropriately treat patients with burn injuries.

2) To determine the extent and severity of burn injuries.

B. General Information:

1) Stop the burning process.

2) Remove affected clothing, if clothing is stuck to skin cut the clothing instead of pulling it
away.

3) Burned areas shall be covered with dry sterile dressings.

4) Parkland formula for IV Fluid Replacement

2ml X BSAB x weight = total fluid in ml

*Give this amount over first 8 hrs from time of injury, then equal amount over the next 16 hours*

5) Urinary Output is the MOST reliable guide in predicting adequate resuscitation:

Adult: 0.5ml per kg per hour (100ml/hr for Electrical Burns)
Children: <40kg: 1ml/kg/hr

C. Warnings/Alerts:

1) Do not delay transport to start IV’s or perform other non-life saving ALS interventions.

2) In mass casualty situations from Lighting Strikes, reverse triage should be performed (I.E.
those in cardiac arrest should be resuscitated first). Ventricular fibrillation and asystole
are the most common dysrhythmias.

3) Inhalation burns with impending airway compromise should be treated with aggressive
airway management. Burns with >40%, will likely require RSI due to airway edema from
inflammation/fluid resuscitation.

4) Burn patients are prone to hypothermia and shall be protected from the environment.
Avoid using ice to cool “large” affected areas.

5) Never use nitrates for suspected Cyanide toxicity in enclosed space fires, it can worsen
hypoxia. If a suspected cyanide toxicity, consider use of hydroxcobalmin (CYANOKIT)

Naval Aviation Medical Treatment Protocols, April 2019 Page 43

 Patient Assessment

Treatment per Airway protocol Burns

Stop the burning process

Consider aggressive
airway management for
inhalation injury

Estimate body
surface burned

Monitor All Electric burns or possible

Prevent and electrocutions require EKG
Treat for Hypothermia Monitoring.

Vascular Access
2ml X BSAB x weight = total fluid in ml

Pain medications per Pain Transport to burn center or

Protocols Level 1 trauma center as
appropriate.

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III. ADULT PATIENT CARE PROTOCOLS

9. Cerebral Vascular Accident

A. Objectives:

1) To assess and appropriately treat patients with suspected CVA or Stroke.

B) General Information:

1) Obtain specific history:

- Onset of stroke symptoms
- List of signs/symptoms
- Previous CVA?
- New onset dysrhythmias

2) From time of first signs and symptoms to advance level of care, timeline of transport
should be under 90 minutes.

3) Cincinnati Prehospital Stroke Scale is preferred method of prehospital determination. In

the event that the assessment of the patient is done in the aircraft, the Los Angeles Pre-
Hospital Stroke Screen (LAPSS) should be done.

4) Using the Cincinnati Scale, if any of the screening questions are answered yes and the
exam is positive for any one Stroke signs and symptoms then the patient should be treated
as a Cerebral Vascular Accident. Information shall be relayed to the appropriate next
level of care to relay the Cincinnati Stroke Scale results.

C. Warnings/Alerts:

1) Do not delay transport to start IV’s or perform other non-life-saving ALS interventions.

2) Patients with stroke symptoms are at high risk for airway compromise.

3) Hypoxemia will worsen stroke outcomes.

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III. ADULT PATIENT CARE PROTOCOLS

10. Chemical Exposure

A. Objectives:

1) To assess and treat patients who have been poisoned by various substances.

B. General Information:

1) If the scene is unsafe, do not put your aircraft in an unsafe environment.

2) Dry chemicals shall be brushed off before flushing the skin or eyes with water.

3) Chemical exposure to eyes can be flushed with IV saline.

4) Removed all contaminated clothing.

5) Asphyxiants:
- Examples – Carbon monoxide, cyanide, hydrogen sulfide
- Pulse oximetry may be unreliable due to effect on red blood cells
Cholinergic:
- Examples – Organophosphates, carbamates, military nerve agents
SLUDGE – Salvation, Lacrimation, Urination, Defecation, Gastro cramping, Emesis
Corrosives:
- Examples – Acids and Bases
Do not induce vomiting. Consider aggressive airway management because of mucous
membrane swelling.
Hydrocarbons:
- Examples – Gasoline, methane, toluene
Do not induce vomiting.
Irritant Gas:
- Examples – Chlorine, ammonia, phosgene
Aggressive airway management per protocol.

C. Warnings/Alerts:

1) Do not bring any hazardous material in the aircraft.

2) Do not use diuretics or nitroglycerin for patients with non-cardiogenic pulmonary edema.

3) PPE for the crew/providers is paramount when treating any suspected chemical exposure.

Naval Aviation Medical Treatment Protocols, April 2019 Page 49

 DECON

Chemical Exposure

Patient Assessment

Treatment per Airway protocol

Notify next level of

care of HAZMAT
incident.

Vascular access

EKG Monitor

NO
Cholinergic?

YES

WMD Kits:
Atropine 2mg every 3-5
minutes until drying of
secretions

For seizures: Transport

Ativan 2mg (or approved Notify next level of care
Benzodiazepine)

Naval Aviation Medical Treatment Protocols, April 2019 Page 50

III. ADULT PATIENT CARE PROTOCOLS

11. Chest Pain / AMI / ACS

A. Objectives:

1) To assess and appropriately treat patients with chest pain or suspected AMI.

2) To eliminate patient’s chest pain.

B. General Information:

1) Do not administer Aspirin in the following cases:

- HX of GI bleeding or bleeding disorders.
- HX of recent surgery
- Already taken max dose of Aspirin (324mg)
- Sensitivity / Allergy to aspirin

2) Nitroglycerin should be given to patients without IV/IO access only if blood pressure is >
100 mmHg.

3) Morphine may be administered concurrently with nitroglycerin.

4) If the patient has cocaine-induced chest pain, Valium 5mg IV/IM may be given at
discretion of Medical Control.

5) Do not delay patient treatment to obtain 12 Lead EKG.

C. Warnings/Alerts:

1) Do not administer nitroglycerin to patients that have taken PDE inhibitors in the past 72
hours.

2) Do not administer more than three nitroglycerin doses in a 15-minute time period.

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III. ADULT PATIENT CARE PROTOCOLS

12. Combative Patient

A. Objectives:

1) To assess and appropriately treat a patient who is combative.

2) To ensure patient safety and safety for Aircrew.

B. General Information:

1) All patients shall be disarmed by ground medics before transport to aircraft.

2) Physical Restraint Guidelines:

- Soft restraints may be sufficient
- If Law enforcement is available, use their restraints under their supervision
- Do not endanger yourself, crew, or aircraft
- Flex cuffs, zip ties, or tie downs are authorized for in-flight environment restraints

3) Avoid placing restraints in such a way as to preclude evaluation of the patient or will
cause further harm.

4) Chemical Restraint Guidelines:

- Sedative agents may be used to provide safe, humane method of restraining the
violently combative patient. Ativan 2mg IM or Ketamine 2-4mg/kg
- Consider 50mg IV/IM diphenhydramine (Benadryl) if patient exhibits signs of dystonic
reaction.

C. Warnings/Alerts:

1) All patients who receive chemical restraints shall be physically restrained.

2) Consider closed head injury/brain bleed in cases of combative patients. Complete

neurologic assessment shall be completed and documented.

3) Providers shall avoid using any other restraints other than the once listed.

Naval Aviation Medical Treatment Protocols, April 2019 Page 55

 Combative Patient

Is patient 14 NO Contact
years old or Next Level of
older? care

YES

De-Escalation

Consider Sedation
Can patient be Ativan 2mg IM
Allows NO NO or
safely
assessment? Ketamine 2-4mg/kg
restrained?
IM

YES YES
Restrain per
Vital Signs Restrain per Guidelines
Monitor Guidelines
Treat injuries as
found
Implement other
protocols as needed Vital Signs
Vital Signs Monitor
Monitor Treat injuries as
Treat injuries as found
found Implement other
Implement other protocols as needed
protocols as needed

Consider Sedation if
the patient remains
combative.
Ativan 2mg IM
or
Ketamine 2-4mg/kg
IM

Transport
Notify Next level of care

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III. ADULT PATIENT CARE PROTOCOLS

13. Crush Syndrome

A. Objectives:

1) To assess and appropriately treat patients with suspected crush injuries/syndrome.

B. General Information:

1) Entrapped patients under heavy loads greater than 30 minutes shall be treated as
suspected crush syndrome.

2) Serious signs and symptoms are:

- Hypotension
- Hypothermia
- Abnormal ECG findings
- Pain
- Anxiety

C. Warnings/Alerts:

1) Scene safety is of paramount importance as typical scenes pose hazards to rescuers. Call
for appropriate resources.

2) Avoid Ringers Lactate IV solution due to potential worsening of hyperkalemia.

3) Hyperkalemia from crush syndrome can produce ECG changes described in protocol, but
may also be a bizarre wide complex rhythm. Wide complex rhythms should also be
treated using VF/Pulseless VT Protocol with the focus on hyperkalemia.

4) Patients may become hypothermic even in warm environments.

Naval Aviation Medical Treatment Protocols, April 2019 Page 57

 Scene safety

Crush Syndrome
Patient assessment and monitoring

IV/IO per protocol

NORMAL SALINE BOLUS

1 Liter then 500mL/hr IV/IO
Repeat to effect SBP >90
Maximum 2 Liters

Peaked T waves
QRS > 0.12 sec Abnormal ECG
YES YES Asystole / PEA
QT > 0.46 sec and or
VF / VT
Loss of P wave Hemodynamically
unstable?

NO
YES YES
Consider tourniquet placement
SODIUM BICARBONATE and CALCIUM CHLORIDE SODIUM BICARBONATE
50 mEq IV/IO 1gram IV/IO 50 mEq IV/IO
And Over 3 minutes And
CALCIUM CHLORIDE CALCIUM CHLORIDE
1gram IV/IO Immediately prior to 1gram IV/IO
Over 3 minutes Extrication Over 3 minutes
SODIUM BICARBONATE
50 mEq IV/IO

MORPHINE4mg IV/IO
Maximum 10mg Treatment per ACLS protocols
Repeat 2mg every 5 minutes as
needed
Or
FENTANYL 50-75mcg IV/IO
Repeat 25mcg every 20 minutes
as needed
Maximum 200mcg

Midazolam 0.5-2mg IV/IO for

max dose of 5mg

Transport
Monitor and reassess for fluid
Notify next level of care
overload

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III. ADULT PATIENT CARE PROTOCOLS

14. Dialysis/ Renal Failure

A. Objectives:

1) To assess and appropriately treat patients who receive dialysis.

B. General Information:

1) Dialysis patients are very susceptible to electrolyte imbalances and hypoglycemia.

2) Serious signs and symptoms of electrolyte imbalances are:

- Weakness
- Chest pain / pressure
- Peaked T waves on an EKG
- Hypo/Hypertension
- Pulmonary Edema
- Headaches
- Dizziness

3) Blood pressure and IV’s shall not be taken or given on extremities with shunts.

4) Bleeding from shunts can be difficult to control, do not apply tourniquet directly on top of
shunt. If possible, apply tourniquet above the affected area.

5) For cardiac arrest in dialysis patients, calcium chloride 1g IV/IO followed by 40ml flush
and sodium bicarbonate 1 meq/kg IV/IO should be administered as first line medications.

C. Warnings/Alerts:

1) Do not use tourniquets directly on shunt or fistula.

2) Do not give magnesium sulfate to renal failure patients.

3) Flush IV lines thoroughly between sodium bicarbonate and calcium chloride

administration.

Naval Aviation Medical Treatment Protocols, April 2019 Page 59

 Treatment per Airway protocol

Dialysis/ Renal Failure

Shunt or Apply fingertip / or if

fistula YES uncontrolled apply
bleeding? tourniquet

YES NO NO
Cardiac Serious S/S?
Arrest?

YES

Treat hypoglycemia
If necessary

Calcium Chloride 1g
IV/IO over 3
minutes
If systolic pressure less YES Dialyzed
than 80 give 250ml NS within past 4
bolus, may repeat up to hours?
Sodium Bicarbonate 1000ml NS if lungs
1mEq/kg IV/IO remain clear
NO

Apply EKG

Treat per appropriate

protocol

Peaked T waves NO
with wide QRS?

YES
Calcium Chloride 0.5-1g in
100ml NS over 10 min
-----------

Sodium Bicarbonate
1mEq/kg IV/IO

Transport
Notify next level of care

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III. ADULT PATIENT CARE PROTOCOLS

15. Diving Medical Disorders / Flight Physiology Events

A. Objectives:

1) To assess and appropriately treat patients who are experiencing a diving medical disorder

B. General Information:

1) Altitude precautions shall be considered in transporting these patients.

2) 100% O2 via non rebreather if patient is conscious shall be applied, to flush out all N2
from the blood stream.

3) The patients diving gear shall be transported with the patient. (I.E tanks, depth gauge,
dive watch, rebreathing apparatus, etc…)

4) Maintain Carboxyhemoglobin levels via RAD57 Device at 1-5%. Any reading over 5%
after a Flight Physiology event shall be placed on 100% O2 via NRB until levels are less
than 5%.

C. Warnings/Alerts:

1) Transport patients in supine position.

2) Only transport to facilities with hyperbaric chambers in local area.

Diving Alert Network (Duke University): 919-684-9111
For information on closest chamber: http://www.diversalertnetwork.org/

3) Increasing altitude for these patients can severely increase signs and symptoms or cause
fatal harm.

D. Notes:

1) Dive Medical HX:

a. Type of dive performed, depth, duration.
b. Number of dives in the last 24hrs.
c. When were the symptoms noticed: Before, during, or after the dive.
d. Was it during descending, the bottom or ascending?
e. Has the symptom/s increased, decreased, or stayed the same.
f. Have you ever had DCS or AGE before, when?

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Diving Medical Disorders

Treatment per Airway protocol

YES
Arrest? Exit to cardiac arrest
protocol

NO

HX of breathing
NO
underwater, altitude Not barotrauma
NO
chamber, sudden Exit to drowning/near drowning
depressurization?

YES

Serious NO High concentration

S/S? SpO2 and lay supine

YES
High concentration O2
appropriate airway
management

Vascular access / treat for

shock

Transport
Notify next level of care

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III. ADULT PATIENT CARE PROTOCOLS

16. Drowning / Near Drowning

A. Objectives:

1) To assess and appropriately treat patients who have experienced a submersion injury.

B. Warnings/Alerts:

1) All patients with submersion incidents shall be transported for evaluation. Patients are in
high risk of developing life-threatening pulmonary edema within 72 hours of incident.

2) Do not insert an NG tube without securing the airway with an ET tube.

3) Patients shall be considered for C-spine precautions, as diving injuries are associated with
spinal injury.

4) Drowning is the leading cause of death among would-be rescuers.

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Drowning / Near Drowning Rescue patient as
Victim in
applicable and per
water? YES NTTP 3-50.1

NO
Rescue breathing
Treatment per airway protocol & CPR ASAP

YES
Exit to cardiac arrest
Arrest?
protocol
NO

Complete patient assessment

and initiate appropriate protocol

Monitor / EKG
Vascular access

Transport
Notify next level of care

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III. ADULT PATIENT CARE PROTOCOLS

17. Head Injury / Suspected TBI

A. Objectives:

1) To appropriately assess, treat, and manage patients with head injuries / suspected
traumatic brain injuries.

2) To maintain adequate airway and oxygenation, maintain EtCO2 35-40 mmHg.

3) Establish and maintain adequate perfusion to vital organs or to sustain life until further
care.

4) Appropriately administer the Military Acute Concussion Evaluation (MACE).

B. General Information:

1) Little that can be done to correct the primary injury in the prehospital environment. The
primary goal is to prevent secondary injuries associated with hypoxia, hypotension,
anemia, and both hyper/hypothermia.

2) The hallmark sign is altered level of consciousness. The optimal assessment includes
AVPU, neurological evaluation, and MACE 2 exam.

3) The use of low altitude flight shall be considered in transportation of these patients.

C. Warnings/Alerts:

1) Do not elevate the feet to treat for shock.

2) Administer fluids to maintain MAP of 85mmHg.

3) There are many medications with contradictions associated with ICP, with most of them
being Analgesics. Be cautious in the medication given and consult OMD or the
medication reference in the back of these protocols for further guidance.

4) Hyperventilation is NOT recommended in treatment of these patients.

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 Head Injury / Suspected TBI

AVPU, neurological exam and

Patient Assessment
MACE2

Treatment per Airway protocol

C-Spine immobilization if indicated

YES
Hemorrhage? Stop / Control
Bleeding

YES Refer to Seizures

Seizing?
Protocol

NO

NO
GCS GCS
3-8? 9-15?

YES
Advanced Airway Management Airway management
Pain management based on
other injuries
Reassess and control Bleeding
Elevate Head >30 degrees

IV/IO access
Fluid management IAW with Transport in Low Level
Shock Protocol Flight
Monitor Patient Notify next level of care

Naval Aviation Medical Treatment Protocols, April 2019 Page 66

 Head Injury / Suspected TBI

Refer to XI. MILITARY ACUTE

CONCUSSION EVALUATION

(MACE) 2ND EDITION on page 206, for all

suspected Head Injury

and Traumatic Brain Injury patients that ARE

DOD entities.

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III. ADULT PATIENT CARE PROTOCOLS

18. Hyper / Hypoglycemia

A. Objectives:

1) To assess and appropriately treat patients with Hyper / Hypoglycemia.

B. General Information:

1) Dextrose 50% may be administered rectally.

2) Dextrose administration requires a patent IV line, not a saline lock.

3) Malnourished patients or suffering from severe dehydration may need Thiamine to

properly metabolize dextrose.

C. Warnings/Alerts:

1) Do not administer oral glucose to patients that are not able to swallow or protect their
own airway.

2) If the IV line infiltrates while administering Dextrose, stop dextrose administration

immediately.

3) Patients shall have their weapons removed for patient safety.

Naval Aviation Medical Treatment Protocols, April 2019 Page 69

 Hyper / Hypoglycemia

Patient Assessment

NO NO
Glucometry Glucometry Treatment per appropriate
less than 60? greater than 500? protocol

YES YES

Only if patient can Administer 250ml NS

swallow, administer 1 bolus, may repeat up to
tube of oral glucose 1000ml NS if lungs
clear

Vascular access
Thiamine 100mg IV
Dextrose 50% 25g IV
Or Glucagon 1mg IM

Monitor

Monitor
Recheck
Glucometry

Transport
Notify next level of care

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III. ADULT PATIENT CARE PROTOCOLS

19. Hyperthermia

A. Objectives:

1) To assess and appropriately treat patients who are hyperthermic.

B. General Information:

1) Administer oral fluids if patient can swallow – water and half-strength electrolyte solution

2) Active cooling measures:

- Air moving across wet skin
- Ice packs at axilla, groin, neck
- Doors and windows of aircraft should be open based on environment to help cooling

C. Warnings/Alerts:

1) Heat stroke is a life-threatening emergency, do not delay transport.

2) Patients shall have their weapons removed for patient safety.

3) Do not exceed 2000ml of IV fluids unless directed to by Medical Control.

4) Cease active cooling when core temperature has been lowered to102 degrees F and
continue to monitor.

5) Cocaine, ecstasy, amphetamines, and aspirin toxicity can all raise body temperatures.

Naval Aviation Medical Treatment Protocols, April 2019 Page 71

Hyperthermia

Patient Assessment

Remove to a cool
environment

YES
Nausea/Vomiting
Altered Mental Status Initiate transport
Hypoperfusion?

NO Glucometry
Vascular Access
250ml bolus, may
Rehydrate
repeat as lung
Monitor
remain clear
active cooling
Monitor / EKG

Transport
Notify next level of care

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III. ADULT PATIENT CARE PROTOCOLS

20. Hypothermia

A. Objectives

1) To assess and appropriately treat patients who are hypothermic.

B. General Information:

1) Remove all of the patient’s wet clothing.

2) Cover the patient with blankets or Hypothermia Kits.

3) Hypothermia is defined as a core temperature <95F (35C)

- With temperatures <31C (88F) ventricular fibrillation is common. Cardiac muscle is
very irritable and rough handling of patients at these temperatures can result in cardiac
dysrhythmias.
- Core temperatures below 30C (86F) ceases shivering.

C. Warnings/Alerts:

1) 1) Handle hypothermic patients gently to avoid spontaneous conversion into ventricular

fibrillation. Avoid aggressive rewarming, sudden movements, and/or rough handling in severe
hypothermia patients.

2) Severe hypothermic patients can present with Rigor Mortis. Providers should attempt
resuscitation unless clear evidence of irreversible death.

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 Hypothermia

Treatment per Airway protocol

YES NO Implement
Cardiac V-Fib or
appropriate
Arrest? V-Tach?
cardiac protocol

NO YES
Implement
NO
Altered appropriate
Mental? cardiac protocol

YES

Implement
appropriate
protocol

Epinephrine 1mg IV
Defibrillate @ max setting
Amiodarone 300mg IV
Defibrillate @ max setting

Transport
Notify Next level of care

Naval Aviation Medical Treatment Protocols, April 2019 Page 74

III. ADULT PATIENT CARE PROTOCOLS

21. Nausea / Vomiting

A. Objectives

1) To assess and appropriately treat patients who are profoundly nauseous and vomiting.

B. General Information:

1) Nausea and Vomiting generally are not life-threatening conditions.

2) Suction should be readily available.

3) Zofran (Ondansetron) or Phenergan (Promethazine) may be administered to patients with

vomiting. Medication is highly recommended for in-flight transport.

4) Zofran – 4mg slow IV push or IM if IV not available

Phenergan – 25mg IV push or IM if IV not available

C. Warnings/Alerts:

1) Ventilating an unconscious vomiting patient will produce aspiration and airway

obstruction, suctioning and advanced airway management is essential.

Naval Aviation Medical Treatment Protocols, April 2019 Page 75

Nausea / Vomiting

Treatment per Airway protocol

Actively vomiting or NO
profoundly nauseous?

YES

Vascular access
250ml bolus up to 1000ml with
clear lungs

Administer Zofran 4mg IV over

2-5 minutes
Or
Administer Phenergran 25mg IV
over 2-5 minutes

May repeat
drug
treatments 20
minutes after
first dose.

Transport
Notify Next level of care

Naval Aviation Medical Treatment Protocols, April 2019 Page 76

III. ADULT PATIENT CARE PROTOCOLS

22. OB / GYN – Pregnancy / Delivery / Vaginal Bleeding

A. Objectives

1) To appropriately access and manage out-of-hospital births.

2) To appropriately access and manage patients with vaginal bleeding.

B. General information:

1) Obtain functional HX:

- Premature?
- Multiple births?
- Meconium?
- Prenatal care?
- Narcotic use?

2) Transport patients in left lateral recumbent position.

3) Vaginal bleeding is considered moderate to severe if the patient has lost more than 500ml
of blood or if she is using 1 heavy pad/hour or more.

4) With severe vaginal bleeding post birth, consider uterine massage for placental delivery.

C. Warnings/Alerts:

1) Do not assume that vaginal bleeding is due to normal menstruation.

2) Third-trimester bleeding is never normal and can be life-threatening to the mother and
fetus.

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OB / GYN – Pregnancy / Delivery / Vaginal Bleeding

Treatment per Airway protocol

Vascular access
Hypoperfusion or Administer 250ml NS
YES
Excessive vaginal bolus, may repeat up to
bleeding? 1000ml NS if lungs clear

NO

NO
Birth imminent
Crowning?

Prepare for
delivery

Delivery

Implement
the care of
Newly Born
protocol

Moderate to NO
severe bleeding?

YES
Vascular access
Administer 250ml NS Transport
bolus, may repeat up to Notify Next level of care
1000ml NS if lungs clear

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III. ADULT PATIENT CARE PROTOCOLS

23. OB / GYN – (Pre) Eclampsia

A. Objectives

1) To appropriately access and treat patients with pre-eclampsia or eclampsia.

B. General Information:

1) Pre-eclampsia may occur for up to 18weeks pre-birth - 8weeks post-partum.

2) Ativan (lorazapam) is preferred drug for seizures

- Dose is 2mg slow IV push, dilute in NS

Valium (Diazepam) is first line treatment for seizing patients

- Dose is 5mg slow IV push over 2 minutes

Magnesium Sulfate is treatment to control eclampsia

- Dose is 2g in 100ml over 5 minutes

3) Transport patient in left lateral recumbent position.

C. Warnings/Alerts:

1) Use caution in administering magnesium sulfate to patients in renal failure.

2) Valium has the potential to cause respiratory depression and bradycardia, patients shall be
monitored. After Valium administration, flush IV lines thoroughly.

3) Monitor closely for elevated blood pressure based on the patient’s normal baseline.

Naval Aviation Medical Treatment Protocols, April 2019 Page 79

OB / GYN – (Pre) Eclampsia

Treatment per Airway protocol

Signs and Symptoms Exit to

NO appropriate
of Pre-Eclampsia?
protocol

YES

Vascular access

NO
Seizure?

YES

Ativan: 2mg IV
or
Valium: up to 5mg IV push over 2
minutes
And
Magnesium Sulfate: 2g in 100ml
NS IV over 5 minutes

Transport
Notify Next level of care

Naval Aviation Medical Treatment Protocols, April 2019 Page 80

III. ADULT PATIENT CARE PROTOCOLS

24. Pain Management Non-Cardiac

A. Objectives

1) To assess and appropriately treat non-cardiac pain.

B. General Information:

1) Pain is an important indicator of disease or injury, but generally under treated in the
prehospital environment. Pain management is associated with a reduction in PTSD
symptoms after traumatic injury.

2) Pain management medications:

- Morphine: 2mg IV or IM with a maximum total dose 10mg
- Should be administered via slow IV push

- Fentanyl: 1mcg/kg, for a max dose of 100mcg.

- Shall be slow IV push
- May be used IM or IN.

- Ketamine: 20mg IV/IO over 1 minute

50mg IM
50mg Intranasal / Atomizer every 30-60min as needed for severe pain

3) Implement Nausea / vomiting protocol as needed.

C. Warnings/Alerts:

1) Patients who receive pain medications shall receive cardiac and SpO2 monitoring.

2) Naloxone shall be on hand with the administration of opioid medications to counter-act

respiratory depression.
- Naloxone: 0.4-2mg titrated to effect, or respiratory depression improves.

3) The mixing the of analgesics should be avoided in pain management. In the event mixing
of analgesics, documentation of why needs to be completed on the DA4700.

Naval Aviation Medical Treatment Protocols, April 2019 Page 81

 Treatment per Airway protocol
Pain Management Non-Cardiac

Assess pain
and severity

Mild/Moderate Severe pain

pain 1-5? 6-10?

Vascular access Vascular access

Fentanyl 1mcg/kg IV/IO, for Fentanyl 1mcg/kg IV/IO, for a

a max dose of 100mcg max dose of 100mcg
fix
Or

Ketamine 20mg IV/IO

50mg IM/IN

Nausea / Vomiting
protocol as needed

Transport
Notify Next level of care

Naval Aviation Medical Treatment Protocols, April 2019 Page 82

III. ADULT PATIENT CARE PROTOCOLS

25. Post-Operative & CC Interfacility Transfer

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Post-Operative & CC Interfacility Transfer

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Post-Operative & CC Interfacility Transfer

Naval Aviation Medical Treatment Protocols, April 2019 Page 85

Post-Operative & CC Interfacility Transfer

Naval Aviation Medical Treatment Protocols, April 2019 Page 86

Post-Operative & CC Interfacility Transfer

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Post-Operative & CC Interfacility Transfer

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III. ADULT PATIENT CARE PROTOCOLS

26. Rapid Sequence Induction-RSI

A. Objectives:

1) To facilitate airway management through the use of sedatives and paralytics.

B. General Information:

1) Patients presenting or have the potential for severe airway compromise require sedatives
and paralytics to secure the airway.

2) Patients with the following should be considered for RSI:

- Burns to the face with suspected inhalation injury
- Severe trauma to the face that may occlude airway
- Patients who must have prolonged ventilator assistance
- GCS less than 8, with associated TBI or Head injury

C. Warnings/Alerts:

1) This procedure shall be done with at least 2 providers. Divide the work load- ventilate,
suction, cricoid pressure, drugs, and intubation

2) Shall use end-tidal CO2 monitors and SpO2 monitoring. Suspected TBI/Head trauma
patients end-tidal CO2 shall be kept between 35-40 mmHg.

3) Protect the patient from self-extubation.

4) Do not administer Succinylcholine to patients with a HX of Malignant Hyperthermia.

5) Administration of analgesics is required on patients requiring advanced airway

procedures.

6)

Naval Aviation Medical Treatment Protocols, April 2019 Page 89

 Indication
NO Treatment per Airway and
for RSI?
applicable protocol Rapid Sequence Induction-RSI

Transport
YES Notify Next level of care

Head YES Administer Lidocaine 1mg/kg

Injury? up to 100mg’s IV/IO if time
allows.

Administer Atropine IV/IO

YES Infant/Child – 0.02 mg/kg
Bradycardia
or under 14? Minimum dose 0.1mg
Adult – 1.0 mg if time allows.

NO

SEDATION
in order of preference
KETAMINE 2mg/kg IV/IO
or
MIDAZOLAM 0.1-0.3 mg/kg
IV/IO. Max 10mg
or
FENTANYL 2-5mcg/kg IV/IO

Administer Paralytic based on

medications on hand:

Succinylcholine: 1-1.5 mg/kg

for a max dose of 150mg

Vecuronium: 0.1-0.2 mg/kg

Rocuronium: 0.6-1.2 mg/kg

Jaw relaxes
Orally intubate the
patient

Successful NO Insert secondary airway or Transport

intubation? consider Notify Next level of care
Cricothyroidotomy

Naval Aviation Medical Treatment Protocols, April 2019 Page 90

 Successful Insert secondary airway or Transport
intubation? consider Notify Next level of care
NO
Cricothyroidotomy

YES

Is the patient YES

paralyzed?
Rapid Sequence Induction-RSI

NO

Is the patient YES Monitor / EKG

Sedated? Immobilize

NO

Sedate patient with:

2-5mg Midazolam slow IV/IO

May be repeated after 6-10
minutes.
OR
KETAMINE 2mg/kg IV/IO

Insert OG/NG
tube

Reassess every 5 Transport

minutes during Notify Next level of care
transport

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III. ADULT PATIENT CARE PROTOCOLS

27. Seizures

A. Objectives:

1) To assess and treat patients with seizures.

2) To protect the airway of a seizing patient.

B. General Information:

1) Medications shall only be given to patients having active seizure lasting greater than 2
minutes.

2) All patients who receive Ativan, Valium, and Versed shall have cardiac and SpO2
monitoring.

3) - Ativan (Lorazepam) is the preferred drug for seizures.

Dilute in equal amount of NS before administration IV/IO
2mg slow push
Can be given IM/IN if no vascular access, do not dilute

- Versed (Midazolam)
2mg slow IV/IO push
Can be given IM/IN if no vascular access

- Valium (Diazepam)
Up to 5mg slow IV push IV/IO
Can be given IM/IN if no vascular access

C. Warnings/Alerts:

1) Ativan, Valium, and Versed all have the potential to cause respiratory depression and
bradycardia. Patients shall have continuous cardiac and SpO2 monitoring.

2) Flush IV lines thoroughly after Valium administration. Valium is incompatible with most
other medications.

3) After two attempts of controlling a seizure, seizure activity continuing, implement RSI
protocol.

Naval Aviation Medical Treatment Protocols, April 2019 Page 93

 Treatment per Airway protocol

Seizures

Protect patient
from injury

Glucometer YES Implement Hypo/Hyperglycemia

<60 or >500? protocol

NO

YES
Seizing activity greater Vascular access
than two minutes? Monitor / EKG

NO

Vascular access Lorazepam 2mg

Monitor / EKG IV/IO/IM/IN
Or

Midazolam 2mg
IV/IO/IM/IN
Or

Diazepam 5mg
IV/IO/IM/IN

Repeat seizure control as

needed for repeated seizure
activity.

Transport
Notify Next level of care

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III. ADULT PATIENT CARE PROTOCOLS

28. Shock

A. Objectives:

1) To assess and treat patients with tissue perfusion.

B. General Information:

1) Types of shock:
- Hypovolemic: Hemorrhage / Fluid loss
- Cardiogenic (Pump failure)
- Distributive (Sepsis)
- Obstructive (Tension Pneumo)

2) All patients being treated for shock shall be given a blanket or hypothermia prevention
kit.

3) Optimize Hemostasis: Fluid resuscitation in;

- Hemorrhagic trauma with NO significant head injury should follow permissive

hypotensive resuscitation guidelines (PHRG) maintaining MAP 60, but not raising the BP
into the “normal” range, which may increase bleeding. Only give minimal “bolus”
appropriate resultative fluid per JTS CPG to maintain MAP >60, NIBP Systolic BP
>90 , palpable Radial pulse (Femoral pulse preferred), (if NIRS device available,
STO2 >70%) and/or change in mental status.

- Hemorrhagic trauma WITH significant head injury should NOT follow permissive
hypotension guidelines. Maintain NIBP Systolic BP 110><160 and MAP 80><110.

- Calcium shall be administered on all trauma patients with suspected internal bleeding or
hypovolemic shock, as is directly helps with clotting factors. This may be given in
conjunction with TXA and blood products, however if only one IV/IO access is present
do not delay the administration of blood products.

C. Warnings/Alerts:

1) Avoid Pressors as able (use as LAST RESORT in TRAUMA) – Always continue IVFs:
Optimize hemostasis and correct volume loss.

D. Notes:

1) The goal of hypovolemic shock management is to prevent the lethal triad of hypothermia,
acidosis, and coagulopathy.

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 Treatment per Airway protocol
Shock

Trendelenburg
position unless
contraindicated

Vascular access
Monitor / EKG

Hypovolemic / Trauma Distributive Cardiogenic

Stop all life threatening 250 ml bolus, may be 250 ml bolus, may be
bleeding if external repeated up to 1000ml if repeated up to 1000ml if
lungs remain clear lungs remain clear

Blood products
Follow Protocol / TCCC
Guidelines Epinephrine Implement Chest pain and
Mix 2mg in 250mls of breathing difficulty protocol
NS/D5W (8mcg/ml) and as needed
Infuse at 0.1mcg/kg/min
TXA as applicable to maintain systolic BP
od 90 mmHg as needed
Epinephrine
1gm Calcium slow push Mix 2mg in 250mls of
IV/IO NS/D5W (8mcg/ml) and
Epinephrine Push Dose
Infuse at 0.1mcg/kg/min
1/100,000
to maintain systolic BP
Draw 1 ml of Epi 1/10,000
od 90 mmHg as needed
20ml/kg or 250 ml into 9 mL NS 10 mcg/mL
bolus, may be repeated Loading dose: 20 mcg/2mL
up to 1000ml if lungs Continuous Dosing:
remain clear 10mcg/1mL/min
To maintain SBP of >90
mmHg

Transport
Notify Next level of care

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III. ADULT PATIENT CARE PROTOCOLS

29. Needle Chest Decompression/Thoracostomy-finger or tube

A. Objectives:

1) To provide guidance for how and when providers should perform needle decompression.

2) Insertion of a chest tube is an advanced level practice to be performed only by those

providers certified as FP-C, TP-C, or RN and above.

B. General Information:

1) Management of Tension Pneumothorax and or Massive Hemothorax requires chest

decompression.

2) Needle decompression is the primary relief of a Tension Pneumothorax pre-hospital.

- Midclavicular – 2nd intercostal space
- Anterior axillary – 5th intercostal space

3) After needle decompression a chest seal or occlusive dressing shall be placed over site to
prevent sucking chest wound.

4) If needle decompression is ineffective, prolonged transport time or distance expected, or

in the presence of massive barotrauma, a chest tube or finger thoracostomy may be the
most effective for maintaining chest decompression.
- Incision site: Affected side, anterior axillary- 5th intercostal space

5) Consider pain management/sedation prior to procedure. Do not delay treatment for

sedation.

C. Warnings/Alerts:

1) Larger patients may require multiple needle decompressions or alternate anterior axillary
site.

2) Do not insert any needle/tube/finger medial to the Anterior axillary line as there is risk to
damage the great vessels and impact the myocardium.

3) Avoid Needle decompression in patients that are hemodynamically stable.

Naval Aviation Medical Treatment Protocols, April 2019 Page 97

Needle Chest Decompression
Treatment per Airway protocol

Tension NO Implement other

pneumothorax or protocols as
Hemothorax? needed

YES Transport
Notify Next level of care

Needle
decompression

Relief of
S/S? YES

Monitor for progression

NO or re-occurrence
Transport
Notify Next level of care
Alternate site for needle
decompression

YES
Relief of
S/S?

NO

Implement other
protocols as
needed

Transport
Notify Next level of care

Naval Aviation Medical Treatment Protocols, April 2019 Page 98

 Chest Tube Insertion/Finger Thoracostomy

Treatment per Airway protocol

Implement other
NO protocols as
Tension PTX or HTX
needed
unrelieved by NCD?

TO BE YES Transport
PERFORMED Cleanse site with iodine Notify Next level of care
ONLY BY solution
PROVIDERS
WITH PROPER
CERTIFICATION
AND TRAINING Anesthetize the incision
site and surrounding area

If performing finger
Make 2-3cm horizontal incision and puncture
thoracostomy- allow
through the subcutaneous tissue with scalpel
drainage to occur; place
over the 6th rib anterior auxiliary site
occlusive dressing over
site; continuously
reassess and vent site if
Puncture parietal pleura with the tip S/S PTX or HTX
WARNING: progress
IF MASSIVE BLOOD of clamp and spread tissue
EVACUATION
OCCURS FROM
TUBE (> 1500mL) With the index finger of the non-dominant
CLAMP TUBE AND hand, trace the clamp into the incision to
DO NOT ALLOW avoid injury to organs and clear any
FURTHER adhesions or clots
DRAINAGE.

Leave finger in place; clamp distal end of

chest tube; insert into cavity to desired If Pleur-evac drainage
depth; look for fogging in tube on unavailable, field
expiration expedient version
accomplished by
securing free end of tube
Connect end of tube to Heimlich valve in a container of water
lower than the level of
the insertion site.
Secure tube in place with sutures,
staples or center cut chest seal

Wrap 4x4 gauze sponge around tube; Apply negative pressure

tape tube to chest suction if possible

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III. ADULT PATIENT CARE PROTOCOLS

30. Toxicological Emergencies (Overdose)

A. Objectives:

1) To assess and treat patients who have a toxicological medical emergency.

B. General Information:

1) CNS depressants (Symptoms may include: respiratory depression, pinpoint pupils,

bradycardia, and hypotension)
- Examples: Opiates, Benzodiazepines, Ethyl Alcohol

2) Hallucinogens (Symptoms may include: Hallucinations, Hypertension, and Tachycardia)

- Examples: LSD, Cannabis, PCP, Mushrooms, Ecstasy, Jimson Weed, Spice, Nutmeg

3) CNS stimulants (Symptoms may include: Hypertension, tachycardia, dysrhythmias)

- Examples: Cocaine, amphetamines, methamphetamines, Dexedrine, caffeine, ephedrine

4) Tricyclic Antidepressants (Symptoms may include: Altered mental status, seizure,

depressed respirations, and coma)
- Examples: Amitrptyline (Elavil), Amoxapine (Asendin), Flexeril (Cyclobenzaprine),
Imipramine (Trofanil), etc…

C. Warnings/Alerts:

1) Narcan can precipitate seizures in patients with seizure HX or in long term narcotic
addicts.

2) The goal of Narcan is to establish adequate respiratory rate and drive, not to return the
patient to full consciousness.

3) Narcan has a short half-life and may need to be repeatedly dosed until transfer of care is
complete.

4) If at all possible, documentation or collection of medications suspected to be used by the

patient should be transported.

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Toxicological Emergencies ( Overdose )

Treatment per Airway protocol

Respiratory NO Wide QRS? NO

depression?

YES YES

NO
Suspect
Tricyclic?

YES

Narcan Sodium Bicarbonate 50 mEq

0.4-2 mg IV or IV over 2 minutes
IM
Repeat as needed Magnesium Sulfate 2g IV
over 5 minutes of
VT/Torsades

Implement other
protocols as
needed

Transport
Notify Next level of care

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Naval Aviation Medical Treatment Protocols, April 2019 Page 103
III. ADULT PATIENT CARE PROTOCOLS

31. Trauma / Traumatic Arrest

A. Objectives:

1) To appropriately assess and treat patients who have traumatic injuries.

B. General Information:

1) Control all life-threatening bleeding

- Direct pressure / wound packing
- If direct pressure does not work, Tourniquet if appropriate

2) Lifesaving interventions that may be performed pre-transport:

- Control of all Arterial or massive bleeding
- Emergency Cricothyroidotomy of an Obstructed Airway
- Needle decompression or Chest tube relief of a Tension Pneumothorax or
massive Hemothorax. Chest tubes are indicated for long transports or no relief from
needle decompressions.
- Stabilization of Pelvic injury with use of Pelvic sling device
- Management of a Flail Chest- positive pressure support or if indicated, Intubate and
assist in ventilations as needed.

3) The goal of IV fluid administration is to maintain a systolic BP of >90 mmHg. Should be

practiced with caution in cases of abdominal injuries.

4) For patients with head injuries and a GCS < 8, the goal of IV fluid administration is to
maintain a systolic BP of >110 mmHg and establish a secure airway.

5) Trauma resuscitation Criteria:

- Should be discontinued if injuries are incompatible with life (rigor mortis, lividity, etc.)
- Mass casualty situation, patients with no breathing and pulse shall follow START
algorithm.

6) All treatments to Trauma patients shall be in accordance with International Trauma Life
Support guidelines (ITLS), Pre-Hospital Trauma Life Support (PHTLS), Tactical Combat
Casualty Care Guidelines (TCCC), and/or Clinical Practice Guidelines (CPG’s).

C. Warnings/Alerts:

1) Do not delay transport to perform NON-lifesaving interventions on scene.

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Trauma / Traumatic Arrest

Treatment per Airway protocol

Treat all life

threatening
Cardiac NO injuries
Arrest?
Package and
transport
YES
Terminate
Meets CPR Vascular access
NO Monitor / EKG
resuscitation Treat other
criteria? patients as
needed
Fluid
YES management to
maintain
Treat all life-threatening Injuries required blood
pressure

Implement appropriate protocols

Implement Pain
management protocols
Blood product as per protocol

Monitor every 15 minutes if

Fluid management if no blood stable or every 5 minutes if
products. unstable
Treat all non-life threatening
injuries once patient is
Chest tube as per protocol
stabilized during transport

Bilateral needle decompression

Implement other
protocols as
needed

YES
Return of
pulse?

NO

Continue CPR, Fluid

management, apply pelvic Transport
binder Notify Next level of care

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III. ADULT PATIENT CARE PROTOCOLS

32. Vascular Access

A. Objectives

1) To provide guidance for how and when providers should obtain vascular access.

B. General Information:

1) Fluid management standing orders for hyperprofusion:

- Adults: 250mL bolus with reassessment up to 1000mL

2) All bolus medications shall be followed by an appropriate flush, 20-30ml.

3) Site selection for peripheral access shall start distally in the extremities.

4) Indications for Intraosseous access:

- Cardiac arrest
- Profound hypovolemia
- Patients’s with immediate need for medications or fluids.

5) IO’s shall be flushed prior to administering any fluid/medications into the site.

6) IO approved sites:
- Sternal (F.A.S.T 1 Device only)
- Proximal Tibia – 1-2 finger width medial to the tuberosity
- Proximal Humerus – Directly in the greater tubercle (Lateral, upper aspect of the
humerus)

C. Warnings/Alerts:

1) Do not use a 14g or above needle for IV use.

2) Failure to properly flush after administration of an IO will result in poor or occluded flow.

3) Caution in placement of External Jugular (EJ) due to increased improper placement.

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 Vascular Access

Need for
NO
administration of
medication or
fluid?

All Trauma patients

will have 2 forms of
access. YES
Consider
Peripheral IV External
*2 attempts Jugular (EJ)

YES
Successful?

NO

Intraosseous
IO

Implement other
protocols as
needed

Transport
Notify Next level of care

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III. ADULT PATIENT CARE PROTOCOLS

33. Ventilator Management

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Ventilator Management

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Ventilator Management

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Ventilator Management

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Naval Aviation Medical Treatment Protocols, April 2019 Page 112
III. ADULT PATIENT CARE PROTOCOLS

34. Determination of Death

1. GENERAL PROVISIONS:

A. Purpose: The purpose of this policy is to assist SMTs in the determination of death in the field (i.e.
pre-hospital setting). This policy is intended to provide SMTs with parameters to be used
when determining whether or not to withhold resuscitative efforts and to provide
guidelines for the Flight Surgeon for discontinuing resuscitative efforts.

B. Principles:

1) Resuscitative efforts are of no benefit to patients whose physical condition precludes any
possibility of successful resuscitation.

2) Shall determine death based on specific criteria set forth in this policy.

3) Cold water drowning, hypothermia and barbiturate ingestion all prolong brain life and therefore
treatment and transport should be considered on these patients.

4) The Unit’s Flight Surgeon recognizes that SAR Medical Technicians have the discretion to initiate
resuscitation in cases where the patient is obviously dead but a concern for unit morale exists.
However, the SMT may decide to cease CPR once en route and or out of sight of concerned unit.
Note: Given this situation, the SMT may perform CPR so long as:

a) The patient is not decapitated

b) No obvious decomposition (i.e. rigor) is present
c) Doing so does not put the provider and aircrew in danger

2. DEFINITIONS:

A. Obvious Death Criteria: A patient may be determined obviously dead by SAR Medical Technicians if, IN
ADDITION to the absence of respiration, cardiac activity, and neurological reflexes, one or more of the
following physical or circumstantial conditions exists:

1) Decapitation
2) Massive crush injury to the head, neck, or trunk
3) Penetrating or blunt injury with evisceration of the heart, lung or brain
4) Decomposition
5) Incineration
6) Rigor Mortis
7) Post-Mortem Lividity
8) Absence of vital signs (breathing, clear pulse, organized cardiac activity on a monitor)
9) Pupils fixed and dilated; absence of corneal reflex

B. Traumatic Cardiac Arrest: No pulse, no spontaneous respirations, no response to aggressive stimulation and
pupils are fixed.

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 Determination of Death Cont’d.

A. Assessment: The Patient Assessment shall, at minimum, include the following items which must be
documented on the patient’s Patient Care Record (PCR):

1) Assure the patient has a patent airway;

2) Look, listen and feel for respirations; and
3) Check for a pulse for a minimum of 60 seconds.
4) Place patient on cardiac monitor (minimum of 3 leads)

B. Procedure:

1) Perform a Primary Assessment:

a. If patient meets obvious death criteria, do not proceed with resuscitation.

b. If a patient has been confirmed pulseless and apneic for at least 10 minutes (CPR having
not been performed in that 10 minutes), do not proceed with resuscitation.

2) When not to initiate CPR:

a. Primary assessment reveals a pulseless, non-breathing patient who has signs of prolonged
lifelessness in accordance with obvious death criteria.
b. A patient with an approved “Do-Not-Resuscitate” (DNR) document in accordance with
Department policy.

C. Termination of CPR by SAR Medical Technicians:

1) Providers may discontinue resuscitative efforts as outlined below:

a. Any case in which information becomes available that would have prevented initiation of
CPR had that information been available before CPR was initiated, CPR should be
terminated.
b. If patient does not meet above criteria, initiate CPR. After 30 minutes of failure to
respond to appropriate advanced life support treatment, defined as:

1) Establishment of airway
2) Sustained ventricular fibrillation or ventricular tachycardia with no pulse, despite
attempts to defibrillate
3) Adequate medication therapy consistent with the patient’s condition and rhythm
4) Successful thoracic needle decompression for trauma victims if indicated

c. If the treatment of one deteriorating patient would apparently lead to the further
deterioration or loss of life of the other patient

2) Disposition of the decedent: If a determination of death has occurred and the decedent has not
been moved from the original place of death:

a. The decedent shall remain at scene and not be transported:

b. Any treatment items, such as endotracheal tubes, intravenous catheters, ECG or
defibrillation electrodes, shall be left in place;
c. Resuscitation equipment, such as bag-valve-mask devices ECG monitoring equipment,
etc., may be removed from the deceased.

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IV. ADULT CARDIAC CARE PROTOCOLS

1. Emergency Cardiac Care 116

2. Asystole & Pulseless Electrical Activity 118
3. Bradycardia 120
4. Tachycardia 122
5. ROSC – Return of Spontaneous Circulation 126
6. Termination or Resuscitation 128

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IV. ADULT CARDIAC CARE PROTOCOLS

1. Adult Cardiac Arrest

A. Objectives

1) Early recognition and appropriate intervention of pulseless / apneic adult patients.

B. General Information

 Cardiopulmonary Resuscitation (CPR)

a) CPR shall be given IAW 2015 American Heart Association Basic Life Support
Guidelines
b) Push hard and fast (at least 2 inches and at a rate of 100-120/Min)
c) Ensure full chest recoil
d) Minimize interruptions in compressions
e) One cycle of CPR: 30 compressions then 2 breaths; 5 cycles-2min (If no Advanced
Airway)
f) Rotate compressors every 2 min if possible
g) Check Rhythm every 2 min
h) After advanced airway is placed, rescuers no longer deliver “cycles” of CPR
1) Give continuous chest compressions without pauses for breaths
2) Give 10 breaths/min
 Monitor / Defibrillator Use
a) Follow appropriate protocol algorithm based on your rhythm analysis.
b) Contraindications to defibrillation
1) Rigor / Liver Mortis
2) No Code / DNR situations
c) If Patient successfully regains a pulse, maintain airway and ventilations as necessary
and continue to monitor a pulse.

*If Patient becomes pulseless during transport, start CPR, and analyze rhythm.

C. Warnings / Alerts
 CPR may still be required in the presence of an organized cardiac rhythm.
 It is the responsibility of the provider delivering the shock to ensure that no one is
touching the patient prior to shock delivery.
 Ensure that the patient is dried off and not laying in water prior to defibrillation.
 Ensure that transdermal medications are taken off and wiped clean prior to defibrillation.

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Naval Aviation Medical Treatment Protocols, April 2019 Page 118
IV. ADULT CARDIAC CARE PROTOCOLS

2. Adult Asystole and Pulseless Electrical Activity

A) Objectives:

1) Early recognition and appropriate intervention of pulseless / apneic adult patients.

2) Early appropriated recognition of lethal rhythms.

B) General Information:

 CPR shall be given IAW 2015 American Heart Association Basic Life Support
Guidelines.
 Endotracheal administration of medications should be used ONLY when IV/IO access is
not available.
 Search for and treat possible contributing factors using appropriate protocol for:
a) Hypovolemia
b) Hypoxia
c) Hypokalemia / Hyperkalemia
d) Hypoglycemia
e) Hypothermia / Hyperthermia
f) Hydrogen ion- (Acidosis)
g) Tension Pneumothorax
h) Toxins
i) Trauma
j) Tamponade Cardiac
k) Thrombosis (coronary or pulmonary)
 For cardiac arrest in renal patients administer Calcium Chloride 1 gm IV/IO push
followed by 40 ml flush, Sodium Bicarbonate 1 Meq/kg and repeat in 10.

C) Warnings / Alerts

 CPR may still be required in the presence of an organized cardiac rhythm.

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Naval Aviation Medical Treatment Protocols, April 2019 Page 120
IV. ADULT CARDIAC CARE PROTOCOLS

3. Adult Bradycardia

A) Objectives:

1) Early appropriate recognition and management of bradycardic rhythms.

2) Recognition of poor perfusion attributed to a bradycardic rhythm.

B) General Information:
 Signs and symptoms of poor perfusion include:
a) New onset of altered mental status
b) Ongoing chest pain
c) Hypotension Systolic B/P less than 90. with associated signs and symptoms.
 If patient is stable, Atropine is first line medication.
 External Pacing
a) Consider pain control and/or sedation
b) Do not delay pacing for administration of medication
 Dopamine Drip
a) Premixed Drip is preferred
i) If not available then add 400 mg of Dopamine to 250 ml NS for concentration of 1600
mcg/ml
b) Dose 2-10 mcg/kg/min
 Epinephrine Drip
a) Add 0.4 mg of Epinephrine 1:1000 to 100 ml NS for a concentration of 4mcg/ml
i) Dose 2-10 mcg/min
b) Epinephrine Push Dose 1/100,000
(i) Draw 1 ml of Epi 1/10,000 into 9 mL NS 10 mcg/mL
Loading dose: 20 mcg/2mL
Continuous Dosing: 10mcg/1mL/min
To maintain SBP of >100 mmHg

C) Warnings/Alerts

 Patient may deteriorate due to unnecessary delay in pacing.

 Failure to recognize electrical and mechanical capture may lead to patient deterioration.
 Assessment of a carotid pulse may be inaccurate due to muscle jerking which may mimic a carotid
pulse.
 Patients that are hypothermic should not be paced.
 Consider analgesia or sedation for pacing.

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Naval Aviation Medical Treatment Protocols, April 2019 Page 122
IV. ADULT CARDIAC CARE PROTOCOLS

4 Cont. Adult Tachycardia- Narrow

A) Objectives:

1) Early appropriate recognition and management of narrow complex tachycardia rhythms.

2) Recognition of poor perfusion attributed to a narrow complex tachycardia rhythm.

B) General Information:
 Signs and symptoms of a hemodynamically unstable patient include:
a) Altered mental status
b) Ongoing chest discomfort
c) Shortness of breath
d) Hypotension
e) Shock
 Heart rate of 150/minute is one factor to distinguish SVT from sinus tach. Younger adult patients
may experience sinus tach at rates greater than 150/minute and older patients may have SVT at rates
lower than 150/minute. Other considerations should include presence/absence of P waves, beat to
beat variability and patient history; if unsure of treatment contact medical control.
 If the patient has cocaine-induced SVT, administer Valium 5 mg IV/IO.

C) Warnings/Alerts
 Avoid low energy unsynchronized defibrillations. Low energy unsynchronized defibrillations are
likely to induce ventricular fibrillation.
 If unable to obtain synchronization, deliver unsynchronized shock at defibrillation energy
(manufacturer recommendations) not to delay cardioversion for administration of sedation to the
unstable patient.
 It is the responsibility of the provider delivering the shock to ensure that no one is touching the
patient prior to shock delivery.
 The following conditions need to be addressed prior to cardioversion:
a) Patients in standing water
b) Patients with transdermal medications
 Adenosine is contra-indicated in patients with a history of WPW.

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Naval Aviation Medical Treatment Protocols, April 2019 Page 124
IV. ADULT CARDIAC CARE PROTOCOLS

4 Cont. Adult Tachycardia - Wide

A) Objectives

1) Early appropriate recognition and management of tachycardia rhythms.

2) Recognition of poor perfusion attributed to a tachycardia rhythm
Adult Tachycardia – Wide Complex.
B) General Information
 Signs and Symptoms of a hemodynamically unstable patient include:
a) Altered mental status
b) Ongoing chest discomfort
c) Shortness of breath
d) Hypotension
e) Shock
 Although not common, V-Tach can occur at rates less than 150; if unsure of
treatment contact medical control

C) Warnings/Alerts

 Polymorphic VT can deteriorate quickly to VF – defibrillate ASAP.

 Avoid low energy unsynchronized defibrillations. Low energy unsynchronized
defibrillations are likely to induce ventricular fibrillation.
 If unable to obtain synchronization, deliver unsynchronized shock at
defibrillation energy (manufacturer recommendations).
 Do not delay cardioversion for administration of sedation to the unstable patient.
 It is the responsibility of the provider delivering the shock to ensure that no one.
Is touching the patient prior to shock delivery
 The following conditions need to be addressed prior to cardioversion
a) Patients in standing water
b) Patients with transdermal medications
 Other conditions may mimic wide complex tachycardia
a) Internal pacemakers
b) Aberrancy

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Naval Aviation Medical Treatment Protocols, April 2019 Page 126
IV. ADULT CARDIAC CARE PROTOCOLS

5. Return of Spontaneous Circulation (ROSC)

A) Objectives

1) To appropriately treat patients who have return of spontaneous circulation.

2) To ensure adequate perfusion.

B) General Information
 Amiodarone:
a) 150 mg in 100 ml over 10 minutes
b) Do not use in the same IV line with furosemide, heparin or sodium bicarbonate
 Dopamine:
a) Starting dose 2 mcg/kg/min
b) Max dose of 20 mcg/kg/min
c) Titrate to systolic blood pressure of 90-100 mm/Hg
d) Mix 400 mg in 250 ml NS for a concentration of 1600 mcg/ml; see reference chart for drip rate

C) Warnings/ Alerts
 Amiodarone is contraindicated in the following conditions:
a) Bradycardia
b) Heart block
c) Hypotension
d) Pulmonary edema
e) Cardiogenic shock

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Naval Aviation Medical Treatment Protocols, April 2019 Page 128
IV. ADULT CARDIAC CARE PROTOCOLS

6. Termination of resuscitation

A) Objectives
1) To provide criteria for field terminating resuscitation.

B) General Information
 Contraindications to using the protocol include patients who are exhibiting neurological activity,
patients under 18 years old, or patients with suspected hypothermia.
 Inappropriate initiation of CPR includes patients with dependent lividity, rigor mortis, injuries
incompatible with life or a valid DNR.
 Resuscitation must continue while you are evaluating the patient.
 Patients in cardiac arrest from environmental causes may warrant resuscitation efforts greater than
20 minutes (ie hypothermia, submersion injuries etc.).
 Once resuscitation has been discontinued
a) Distribute bereavement booklet to family members, if available
b) Leave all expendable ALS supplies in place

C) Warnings / Alerts

 This protocol is not to be used during transport (transport is defined as moving the patient
into the aircraft)
 Recent studies have shown that resuscitation outcomes for witnessed arrest have had
ROSC at times greater than 20 minutes while maintaining a refractory Ventricular
Fibrillation rhythm in these patients. Sound judgment and all aspects of the patient
situation should be held into consideration prior to any termination of efforts in these
patients.

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 Termination of resuscitation

Inappropriate initiation
of CPR without ALS Discontinue
Yes
procedures? resuscitation

No

18 years or No
older?

Yes

Cumulative BLS &

ALS resuscitation for No
at least 20 minutes?

Yes

Completed
ACLS No
rule-outs?

Yes

Any ROSC Continue resuscitation

during the Yes and implement
resuscitation? appropriate protocol

No

Discontinue resuscitation

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V. PEDIATRIC GUIDELINES

1. General Information 132

2. Clinical Reference charts for Pediatric(s) / Neonate(s) 133
3. JUMP START Triage 134
4. APGAR / Glasgow Coma Scale 136
5. Neonate / Pediatric Burn Reference 137
6. Pediatric Cardiac Arrest 138
7. Pediatric Bradycardia 139
8. Pediatric Tachycardia 140

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 V. PEDIATRIC GUIDELINES

1. General information:

Pediatric and Neonatal patients are not typically in the SAR Medical Technicians Scope of
Practice, but have the potential to become patients under our care. The following charts are tools to help the SAR
Medical Technician in treatment of Pediatric and Neonatal patients.

References to ALS EMS Field Guide (AHA2015), AHA ACLS/PALS Handbook, or BRASLOW
Child Reference Tape shall be done anytime treatment is being conducted on a Pediatric or Neonatal patient. Next
level of care shall be notified while transporting Pediatric and Neonatal patients.

2. Important reminders for providers treating Pediatric and Neonatal patients:

- Up until the age of 8, a child’s head is proportionally large and contains 25% of total body
weight.
- A Child’s Airway is narrower and less stable at all levels than those of adults.
- Small amounts of blood loss in children can cause shock.
- Children can compensate in shock for long periods of time, during this time it is vital to perform
lifesaving and shock treatment. When children start to decompensate in shock it tends to be
irreversible. Aggressive stabilization of Pediatric and Neonate patients is key to managing these
patients.

3. Clinical Reference charts for Pediatric(s) / Neonate(s):

6
Age Preterm Term Months 1YR 3YR 6YR 8YR 10YR 11YR 12YR 14YR
Weight lbs. 3 7.5 15 22 33 44 55 66 77 88 99
Weight kg 1.5 3.5 7 10 15 20 15 30 35 40 45
Length in. 16 21 26 31 39 46 50 54 57 60 64
Length cm 41 53 66 79 99 117 127 137 145 152 163
Heart Rate 140 125 120 120 110 100 90 90 85 85 80
Respirations 40-60 40-60 24-36 22-30 20-26 20-24 18-22 18-22 16-22 16-22 14-22
65-
Systolic B/P 50-60 60-70 60-120 125 100 100 105 110 110 115 115
ET Tube (mm) 2.5,3.0 3.5 3.5 4 4.5 5.5 6 6.5 6.5 7 7
Suction Cath 5-6 Fr 8 Fr 8 Fr 8 Fr 8 Fr 10 fr 10 Fr 10 fr 10 Fr 10 Fr 10 Fr
Defibrillation:
2 J/kg ( Initial ) 3J 7J 14J 20J 30J 40J 50J 60J 70J 80J 90J
4 J/kg ( Repeat ) 6J 14J 28J 40J 60J 80J 100J 120J 140J 160J 180J
8 J/kg ( Repeat ) 12J 28J 56J 80J 120J 160J 200J 240J 280J 320J 360J
10 J/kg (Repeat ) 15J 35J 70J 100J 150J 200J 250J 300J 350J 360J 360J
Cardioversion:
0.5-2J/kg 1-3J 2-7J 4-14J 5-20J 8-30J 10-40J 13-50J 15-60J 18-70J 20-80J 23-90J
Fluid Challenge:
20ml/kg IV/IO 15ml 35ml 140ml 200ml 300ml 400ml 500ml 600ml 700ml 800ml 900ml
Neonates:
10ml/kg 10ml/kg 10ml/kg

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 V. PEDIATRIC GUIDELINES

2. Clinical Reference charts for Pediatric(s) / Neonate(s):

6
Age Preterm Term Months 1YR 3YR 6YR 8YR 10YR 11YR 12YR 14YR
Weight kg 1.5 3.5 7 10 15 20 15 30 35 40 45
Amiodarone (50mg/ml) 0.15ml 0.35ml 0.7ml 1ml 1.5ml 2ml 2.5ml 3ml 3.5ml 4ml 4.5ml
5mg/kg IV/IO
Atropine (0.1mg/ml) 1ml 1ml 1.4ml 2ml 3ml 4ml 5ml 6ml 7ml 8ml 9ml
0.02 mh/kg IV/IO
Dextrose (D50%w) 3ml 7ml 14ml 20ml 15ml 20ml 25ml 30ml 35ml 40ml 45ml
0.5gm/kg IV/IO D25% D25% D25% D25%
{use D25%W for infant}
Diazepam (5mg/ml) 0.03- 0.07- 0.14- 0.2- 0.3- 0.4- 0.5- 0.6- 0.7- 0.8- 0.9-
0.1-0.3 mg/kg IV/IO 0.09ml 0.21ml 0.42ml 0.6ml 0.9ml 1.2ml 1.5ml 1.8ml 2.1ml 2.4ml 2.7ml
EPI 1:10,000 (o.1mg/ml) 0.15ml 0.35ml 0.7ml 1ml 1.5ml 2ml 2.5ml 3ml 3.5ml 4ml 4.5ml
0.01 mg/kg IV/IO
ET EPI 1:1,000 0.15ml 0.35ml 0.7ml 1ml 1.5ml 2ml 2.5ml 3ml 3.5ml 4ml 4.5ml
(1mg/ml) 0.1 mg/kg ET
Etomidate (2mg/ml) 0.2ml 0.5ml 1ml 1.5ml 2.3ml 3ml 3.8ml 4.5ml 5.3ml 6ml 6.8ml
0.3mg/kg IV/IO
Morphine (1mg/ml) 0.15ml 0.35ml 0.7ml 1ml 1.5ml 2ml 2.5ml 3ml 3.5ml 4ml 4.5ml
0.1mg/kg IV/IO/IM
Naloxone (0.4 mg/ml) 0.4ml 0.9ml 1.8ml 2.5ml 3.8ml 5ml 5ml 5ml 5ml 5ml 5ml
0.1 mg/kg IV/IO/IM/SQ
Succinylcholine (20mg/ml) 0.15ml 0.35ml 0.7ml 1ml 0.75ml 1ml 1.25ml 1.5ml 1.75ml 2ml 2.3ml
1mg/kg IV/IO 2mk/kg 2mg/kg 2mg/kg 2mg/kg
{infant: 2mg/kg}

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V. PEDIATRIC GUIDELINES

3. Jump START Triage

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JumpStart Triage

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V. PEDIATRIC GUIDELINES

4. APGAR / Glasgow Coma Scale

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V. PEDIATRIC GUIDELINES

5. Neonate / Pediatric Burn Reference

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V. PEDIATRIC GUIDELINES

6. Pediatric Cardiac Arrest

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V. PEDIATRIC GUIDELINES

7. Pediatric Bradycardia

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V. PEDIATRIC GUIDELINES

8. Pediatric Tachycardia

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

1. Abbreviated TCCC Guidelines 142

2. Care Under Fire Algorithm 147
3. Tactical Field Care Algorithms 148
4. Tactical Evacuation Care Algorithms 159
5. Blood Administration and Protocol 171
6. DD1380 TCCC Card 176
7. Triage Categories 178
8. 9 – Line / MIST Report 179

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

1. Abbreviated TCCC Guidelines

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

2. Care Under Fire Algorithm

VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

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3. Tactical Field Care Algorithm

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

4. Tactical Evacuation Care Algorithm

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

5. Blood/Fresh Frozen Plasma(FFP) Administration and Protocol

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

6. DD1380 TCCC Card

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

7. DD1380 TCCC Card

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

8. Triage Categories

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VI. TACTICAL COMBAT CASUALTY CARE (TCCC)

9. 9 – Line / MIST Report

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VII. CANINE PROTOCOL(Military & DOD working Dogs)

K-9 Trauma Management Protocol

SIGNS AND SYMPTOMS for Shock:

1. Pale color in gums, capillary refill time greater than 2 seconds
2. Dry lips and gums, dehydration
3. Excessive drooling in some poisoning cases
4. Weak femoral pulse
5. Rapid heart rate of 150-200 beats per minute
6. Cool extremities
7. Hyperventilation, rapid breathing generally over 25 breaths per minute (panting may or may not be normal)
8. Confusion, restless, anxiousness
9. General weakness

Advanced stages of shock:

1. Continued depression and weakness to the point of not being able to move or becoming unresponsive or
unconscious
2. Dilated pupils
3. Capillary refill time greater than 4 seconds
4. White mucous membranes
5. Rectal temperature below 98° F.

MANAGEMENT:
1. MARCHE Protocol
2. Muzzle, Massive hemorrhage: Control bleeding per TCCC standards, Morphine
A. Muzzle
B. Massive hemorrhage: Control bleeding with direct pressure and pressure dressings. Tourniquets
are not as effective in dogs due to anatomical differences. All hemostatic agents used in humans
are safe for use in dogs.
C. Morphine: 10-30mg IM. May cause vomiting and respiratory depression. Use Naloxone
(0.02mg/kg) for reversal if necessary.
3. Airway
A. An injured dog or an animal in shock may not recognize you. The dog may bite you out of pain
or fear. If the dog is having trouble breathing or panting heavily, DO NOT apply a muzzle. If a

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 muzzle is placed on the dog it must be monitored at all times and removed at the first sign of
overheating or vomiting because they can easily aspirate. Get help if possible from someone who
can help hold the dog, so you can do an examination and/or treat the dog.
1) Carefully pull the tongue out of the animal's mouth.
2) Even an unresponsive dog may bite by instinct!!
3) Make sure that the neck is reasonably straight; try to bring the head in-line with the
neck.
4) Do not hyperextend in cases where neck trauma exists
B. Intubation or tracheostomy if necessary to assure airway
1) Do not attempt to intubate a conscious animal, personnel must have prior training. ET
tube size can range from 7-10.
C. If intubation is not possible, then attempt tracheostomy.
D. After achieving a patent airway, one must determine whether the animal is breathing, and
whether this breathing is effective.
E. AIRWAY CONSIDERATIONS:
1) Size 7mm to 10mm cuffed endotracheal tube, secure with gauze or IV tubing. Tie over
nose.
2) Flow by oxygen – secure airline to muzzle.
3) Field expedient O2 masks.
4) Nasal trumpets are ineffective in canines

4. Respirations
A. Look, Listen, and Feel
B. If not breathing, ventilate the animal by closing the mouth, and performing mouth-to-nose
ventilations. If patient is intubated or has tracheostomy, ventilate the animal using an Ambu-bag.
C. Ventilate at 20 breaths per minute.
D. If available, use supplemental oxygen
E. Needle thoracentesis: Place the dog in the lateral recumbency, go midway between sternum and
spine between the 7th and 9th ribs. Use a 14G 3.25in needle. Perform needle decompression on
both sides.
5. Circulation
A. Be sure that there are no major (pooling/spurting blood) points of bleeding. Control as
necessary.
B. Hemorrhagic Shock Fluid Resuscitation (Administration Routes):
1) Primary route is IV
2) Secondary route is IO (Tibia or Humerus) on a sedate or unconscious dog only.
C. Incorporate crystalloids and colloids as needed
1) Bolus of crystalloid, 10-20ml/kg, reassess and repeat a maximum of 2 times
2) Bolus of colloid, 5-10ml/kg given once over 20-30 minutes.
D. The targeted endpoint for resuscitation should be to achieve and maintain permissive
hypotension.
E. Blood transfusion (dog-to-dog), if available.
1) For the first transfusion in a trauma/field situation it is generally safe to give any type
of blood without typing or cross-matching.
2) Collect no more than 20% blood volume (collect 1 unit/450ml from typical size
working dog). Perform a sterile prep and use the jugular vein for collection.
3) In a trauma/field situation you will usually administer the whole unit. Human blood
transfusion guidelines apply for rate and monitoring requirements.
6. Hypothermia: Prevent loss of body heat. Dry the fur. Use a hypothermia blanket. Watch for overheating.
7. Evacuation and Everything Else
A. TXA – Administer 10-15ml/kg IM or slowly IV
B. Analgesia
1) Morphine: Administer 0.5-1mg/kg IM or IV, may cause vomiting

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 2) Hydromorphone/Dilaudid: Administer 0.1-0.2mg/kg IM or IV, may cause vomiting
3) Fentanyl: Administer 3-4mcg/kg IV; Can also use a fentanyl lollipop inserted in the
rectum secured with tape to the tail base
4) Naloxone: Opiod reversal , administer at 0.02-0.04mg/kg IV, IM, or SQ
C. Antibiotic Therapy for Penetrating Wounds
1) Ceftriaxone (Rocephin) 1gm IV / IM daily
2) Ertapenem (Invanz) 500mg IV / IM two times a day

Monitoring:

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IV/IM Sites

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Hydration Status

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 VIII. MEDICATION REFERENCES

1. Mosby Paramedic (VOL. 8/2015 AHA updates)

2. AHA ACLS provider manual
3. AHA PALS provider manual
4. TCCC Guidelines
5. Clinical Practice Guidelines (CPG’s)
6. Advanced Tactical Paramedic (ATP) Guidelines 10th Edition
7. Tactical Medical Emergency Protocols (TMEPS) 10th Edition

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XIII. MEDICATION REFERENCE

ACTIVATED CHARCOAL
Class Absorbent, Antidote
Indications Oral poisoning and medication overdose.
Contraindications GI obstruction, GI bleed or perforation, patients with an unprotected airway
1 to 12 years: 25 to 50 grams
>12 years and adults: 25 to 100 grams
Dose & Route
Given PO or via NG or OG tube. Agitate contained thoroughly and mix with water to
make a slurry prior to administration.
Side Effects May induce nausea, vomiting, constipation or diarrhea.

ADENOSINE
Class Antidysrhythmic
PSVT refractory to vagal maneuvers, including dysrhythmias associated with bypass
Indications
tracts as WPW syndrome.
2 or 3 AVB's, Sick Sinus Syndrome, A-fib/flutter and VT usually not converted with
Contraindications
Adenosine.
Adult: 6mg rapid IV push followed by a 20cc flush.
2nd dose at 12mg may be administered in 1-2 minutes
3mg IV initially for patients taking carbamazepine or dipyridamole, heart
Dose & Route
transplant, or if adenosine is being administer through a central line.
Peds: 0.1mg/kg rapid IV push (Max= 6mg), double the 2nd and 3rd doses (Max=
12mg).
Transient periods of new arrhythmia after cardioversion, chest pressure/discomfort,
Side Effects SOB, Nausea, chest pain, Diaphoresis, Flushing, HA, Palpitations, Paresthesia’s, neck
discomfort

ALBUTEROL
Class Sympathomimetic, Bronchodilator, Beta-2 selective
Indications Asthma, bronchospasm, exercise-induced bronchospasm, hyperkalemia
Contraindications Hypersensitivity. Symptomatic tachycardia dysrhythmias.
Bronchospasm: 2.5 to 5mg diluted in 3ml of NS administered by nebulizer Q 20min x3
Dose & Route doses or 10 to 15mg/hour as continuous nebulization
Hyperkalemia: 10 to 20mg nebulized over 10 minutes
Anxiety, tremor, chest pain, diaphoresis, dizziness, HA, nausea, palpitations,
Side Effects
restlessness, tachycardia.

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AMIODARONE
Class Antiarrhythmic Class III
Indications Initial treatment and prophylaxis of recurring VF and hemodynamically unstable VT.
Contraindications Cardiogenic shock, iodine hypersensitivity, bradycardia, 2° and 3° AVB
VF/VT Cardiac arrest:
Adult: 300mg IV/IO push, second dose of 150mg IV/IO push if needed
Peds: 5mg/kg (Max 300mg) IV/IO push, may repeat twice (Max total
dose=15mg/kg)
Life-Threatening arrhythmias WITH pulse:
Dose & Route
Adult: 150mg IV over 10 min, may repeat if necessary
Peds: 5 mg/kg IV (Max 300mg) over 20-60 min, may repeat twice up (Max
total=15mg/kg)
Maintenance Infusion after return of spontaneous resuscitation:
360mg over 6°, then 540mg over 18°
Bradycardia, flushing, HA, hypotension (rapid infusions), Vertigo, N/V, QT
Side Effects
prolongation, epithelial keratopathy, pulmonary toxicity

ASPIRIN
Class Analgesic, anti-inflammatory, anti-pyretic, anti-platelet
Mild to moderate pain or fever. Chest pain (suspected angina or AMI) Prevention of
Indications
AMI or reinfarction.
Contraindications Children with flu-like symptoms, Hypersensitivity to NSAIDS.
STEMI/NSTEMI:
Dose & Route PO: (4) 81mg chewable tablets (324mg) Or adult 325mg non-enteric coated
Rectal: 600mg suppository for those who can’t take PO
Anaphylaxis, pulmonary edema, GI bleeding, Heartburn, coma, confusion, dizziness,
Side Effects
tinnitus.

ATROPINE
Class Parasympatholytic (anticholinergic) agent
Symptomatic sinus bradycardias
Indications
Organophosphate or nerve gas poisoning
Contraindications There are no contraindications listed in the manufacturer’s labeling
Bradycardia:
Adult: 0.5 mg IV/IO repeat Q 3-5min (Max total dose=3mg)
Peds: 0.02mg/kg IV/IO Q 3-5 min (Minimum dose=0.1mg, Max SINGLE
dose=0.5mg, Max TOTAL dose=1mg)
Dose & Route Organophosphate and nerve gas poisoning:
Adult: 1 to 6 mg IV/IM/ET Q3-5 minutes prn, double the dose if no response from
previous dose.
Peds: 0.05 to 0.1mg/kg IV/IM/ET Q 5-10 minutes prn, double the dose if no
response from previous dose
Anticholinergic effects (dry mouth, blurred vision, photophobia, urinary retention, and
constipation). Dizziness, Dysrhythmias, Flushing, HA, Hot, dry skin, Nausea/vomiting.
Side Effects Palpatations. Tachycardia. Paradoxical bradycardia if pushed too slowly or in dose
<0.5mg in adults or <0.1mg in peds.

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CALCIUM CHLORIDE 10%
Class Electrolyte
Acute hyperkalemia, acute hypocalcemia, calcium channel and beta blocker OD,
Indications abdominal spasms associated with spider bites and portugese man-o-war stings.
Magnesium sulfate OD.
Contraindications Known or suspected digoxin toxicity
Cardiac arrest or cardiotoxicity d/t hyperkalemia, hypocalcemia, or hypermagnesemia
Adult: 500 to 1000mg IV over 3-5minutes, may repeat prn
Peds: 20mg/kg IV/IO Max= 2000mg/dose, may repeat prn

Beta-blocker OD (Refractory to first line treatments)

Adult: 10% solution: 20mg/kg over 5-10min, followed by 20 to 50mg/kg/hr

Dose & Route Ca channel blocker OD:

Adult: 10% solution: 1 to 2 grams over 5 min Q10-20min, then 20 to
50mg/kg/hr
Peds: 10 to 20mg/kg over 10-15min (Max=2000mg/dose) Q10-15min prn,
followed by 20-50 mg/kg/hr

Hypovolemic shock:
Infused via a 10% solution, 1 gram over 10 minutes.
ADE due to rapid IV injections: bradycardia, cardiac arrest, hypotension, syncope,
Side Effects
feeling abnormal, tingling sensation, hot flash

DEXTROSE 50% / 25%

Class Carbohydrate, Hypertonic solution
Altered LOC, Coma of unknown origin, Hypoglycemia (usually FSBS <70). Seizures of
Indications
unknown origin.
Increased intracranial pressure or hemorrhage. Known or suspected CVA in absence of
Contraindications
hypoglycemia. Hypersensitivity to corn
Adult: 10 to 25G slow IVP, repeat if necessary.
Dose & Route Peds: 0.5-1.0g/kg slow IVP. If D25 not available, dilute D50 1:1 with sterile water or
saline for 25% concentration May repeat of necessary.
Side Effects Irritation, burning, and pain at the injection site.

DIAZEPAM (Valium)
Class Benzodiazepine
Acute alcohol. Acute anxiety state. Pre-medication prior to counter shock or TCP.
Indications
Seizure activity. Skeletal muscle relaxation.
Coma (except seizures or rigidity.) Respiratory depression. Acute narrow-angle
Contraindications
glaucoma. Untreated open-angle glaucoma.
Seizures (adult and peds):
IV: 0.15mg/kg over 2 minutes (Max=10mg/dose). May repeat Q 5min prn
Dose & Route
Anxiety:
Adult: 2 to 10 mg IV/IM; may repeat in 3-4 hours prn
Confusion. Drowsiness. Hypotension. N/V. Psychomotor impairment. Reflex
Side Effects
tachycardia. Respiratory depression or arrest.

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DILTIAZEM (Cardizem)
Class Nondihydropyridine Calcium Channel Blocker
Indications Atrial fibrillation, flutter, and tachycardia with rapid ventricular response rate. PSVT.
2nd or 3rd degree AVB. AMI. Cardiogenic shock. Hypersensitivity. Hypotension.
Within a few hours of IV Beta blocker use. Sick sinus syndrome. Short PR syndrome.
Contraindications
Ventricular tachycardia. WPW syndrome. Wide complex tachycardia of unknown
origin.
Adult: 0.25mg/kg IV over 2 min. Repeat in 15 minutes if needed at 0.35mg/kg.
Dose & Route
Peds: Same as adult, but rarely used.
1st degree AVB. Bradycardia. Chest pain. CHF. Diaphoresis. Dizziness. Dyspnea.
Side Effects
Headache. Hypotension. Nausea/vomiting. Peripheral edema

DIPHENHYDRAMINE (Benadryl)
Class Antihistamine
Acute extrapyramidal reactions. Dystonic reactions to phenothiazines. Moderate to
Indications
severe anaphylaxis after epinepherine. Allergic symptoms.
Contraindications Hypersensitivity. Nursing mothers.
Adult: 25-50mg IM/IV
Dose & Route
Peds: 1 to 2mg/kg IM/IV (Max 50mg/dose)
Bradycardia. Disturbed coordination. Drowsiness. Dry mouth and throat. Paradoxical
Side Effects
excitement in children. Sedation. Tachycardia. Thickening of bronchial secretions.

DOPAMINE (Intropin)
Class Sympathomimetic (Inotrope)
Adjunct treatment of Hypotension in the absence of Hypovolemia. Second line for
Indications
symptomatic bradycardia (after atropine)
Hypovolemic shock without fluid resuscitation. Patients with Pheochromocytoma.
Contraindications
Tachydysrhythmias. Ventricular Fibrillation.
Adult and Peds: (Concentrations of 1600mcg/ml or 800mcg/ml)
400mg in 250ml=1600mcg/ml,
400mg in 500ml=800mcg/ml
800mg in 500ml=1600mcg/ml,
Dose & Route
800mg in 1000ml=800mcg/ml
Renal Dose: 1-5mcg/kg/min
Cardiac Dose: 5-10mcg/kg/min
Vasopressor dose: >10mcg/kg/min
Dose related tachycardia's, Hypertension, Increased myocardial O2 demands (may
Side Effects
increase ischemia), Palpitations, Excessive vasoconstriction

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ETOMIDATE
Class Nonbarbituate hypnotic, anesthetic
Indications Premedication for tracheal intubation or cardioversion.
Contraindications Hypersensitivity

Dose & Route Adult and Peds: 0.2-0.6mg/kg IV/IO over 30 seconds (usually 0.3mg/kg)
Adrenal Suppression, Apnea, Hiccups, Hypo/Hyperventilation, Pain at injection site,
Side Effects Bradycardia, HTN, Involuntary muscle movements, Tachycardia, Dysrhythmias,
Hypotension, N/V

EPINEPHRINE
Class Sympathomimetic
1:1000: Anaphylaxis. Severe allergic reactions. Bronchial asthma. Exacerbation of COPD.
Indications Used in adult and pediatric cardiac arrest after 1:10,000.
1:10000: Anaphylactic Shock, Cardiac Arrest, Profound symptomatic bradycardia
Contraindications There are no contraindications
1:1000: (1 mg in 1 ml vial; See EPI 1:10,000 for cardiac arrest dosing regimens)
Hypersensitive Reactions (Intramuscular is preferred over SQ)
Adult: 0.2-0.5mg IM/SQ Q 5-15min
Peds: 0.01mg/kg up to 0.3mg IM/SQ Q 5-15min

1:10000: (1mg in 10ml syringe)

Cardiac Arrest:
Adult: 1MG IVP every 3-5 Minutes (ETT 2-2.5 x IV dose)
Peds: 0.1mg/kg (1:10,000) initial dose IV
(0.1mg/kg of 1:1,000 ETT)
Subsequent doses 0.1mg/kg of 1:1,000 IV/ET/IO

Anaphylactic reaction or bronchoconstriction:

Dose & Route
Adult: 0.1mg over 5 minutes
Peds: 0.1mcg/kg/min IV infusion (Refractory to IM dose; Max=10mcg/min)
Infusions for cardiac arrest or symptomatic Bradycardia:
Adult: Mix 2mg in 250mls of NS/D5W (8mcg/ml) and
Infuse at 0.1mcg/kg/min for desired response.
Peds: Mix 2mg in 250mls of NS/D5W (8mcg/ml), begin at
0.1mcg/kg/min, titrate up to 1mcg/kg/min

Epinephrine Push Dose:

1/100,000
Draw 1ml of Epi 1/10,000 into 9 mL of a NS saline flush: 10mcg/ml
Loading dose: 20 mcg/2ml
Continuous Dosing: 10mcg/1ml/min to maintain SBP of >90 mmHg
Anxiousness, Chest Pain, Headache, Nausea, Palpitations, Restlessness, Tachycardia,
Side Effects
Tremors. Tachyarrhythmia. Injection site tissue necrosis.

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FENTANYL (Sublimaze)
Class Narcotic Analgesic
Indications Adjunct to aesthesia for procedures, Severe pain

Contraindications Hypersensitivity

Adult: 25-100 mcg IV over 1 min Q30-60 minutes (May also give IM)
Dose & Route
Peds: 1-2 mcg/kg IV over 1 min Q30-60 minutes (May also give IM)
Altered LOC, Abnormal dreams, Arrhythmias, Confusion, Dizziness, Headaches,
Side Effects
Hypotension, N/V, Respiratory depression

FUROSEMIDE
Class Loop diuretic
Indications Pulmonary edema associated with CHF, hepatic or renal disease.
Anuria. Hypersensitivity. Hypersensitivity to sulfonamides. Hypovolemia/Dehydration.
Contraindications
Uncorrected states of electrolyte depletion
Adult: 20 to 40mg IV, may repeat in 1-2hours as same dose or increase by 20mg/dose
Dose & Route
Peds: 1mg/kg IV, May repeat in 2 hours or increase by 1mg/kg/dose (max 6mg/kg/dose)
Dry Mouth, ECG changes with electrolyte imbalances, Hypercalcemia, Hyperuricemia,
Side Effects Hypochloremia, Hyponatremia, Hypokalemia, Hypotension, Transient deafness, Tinnitus

GLUCAGON
Class Pancreatic Hormone, insulin antagonist.
Hypoglycemia (if D50 unavailable). Unconscious, combative, seizuring patients that an IV
Indications cannot be started and glucose is needed. Beta Blocker and Calcium Channel Blocker
Overdose.
Contraindications Hypersensitivity; pheochromocytoma, insulinoma
Hypoglycemia:
Adult: 1mg reconstituted IM/IV/SQ Q 15 min prn
Peds: <20kg = 0.5mg, >20kg = 1mg IM/IV/SQ Q 15min prn
Dose & Route
Beta Blocker and Calcium Channel Blocker Overdose
Adult: 3 to 10 mg IV bolus followed by an infusion of 3-5 mg/hr
Peds: 0.15mg/kg IV bolus followed by an infusion of 0.07mg/kg/hr (Max 5mg/hr)
Side Effects Hypotension, N/V, Tachycardia, Uticaria

IPATROPIUM (Atrovent)
Class Anticholinergic, Bronchodilator
Indications Persistent bronchospasm associated with asthma and COPD.
Contraindications Hypersensitivity to ipatropium, atropine, alkaloid, soybean products, or peanuts.

Adult: 500mcg (0.5mg) in nebulizer typically with a beta adrenergic (Albuterol) Pediatrics:
Dose & Route
N/A
Anxiety. Blurred vision. Coughing. Dry mouth. Headache. Nausea/vomiting.
Side Effects
Palpatations. Tachycardia.

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KETOROLAC (Toradol)
Class NSAID
Indications Short-term management of moderate to severe pain
Hypersensitivities to aspirin/NSAIDS, Active peptic ulcer disease, History of GI bleeding,
Contraindications
Angioedema, Asthma, Renal Failure
Dose & Route Adult: 30-60mg IM or 15-30 MG IVP Peds: Not recommended
Side Effects Anaphylaxis, Bleeding disorders, Edema, Headache, Nausea, Sedation.

KETAMINE
Class Analgesic
Indications Moderate to Severe acute and chronic pain, adjunct to aesthesia for procedures, or RSI
Contraindications <3 months old, known or suspected schizophrenia (even if stable on current meds)
Pain:
Adult:
IM: 2-4 mg/kg (repeat dose every 30 minutes to 1 hour as necessary to control severe
pain or casualty develops nystagmus/rhythmic eye movement back and forth)
IN: 0.5 to 1mg/kg (using nasal atomizer device) Q10min with 0.25-0.5mg/kg prn
Dose & Route IV: 0.3mg/kg infused over 5 minutes

Sedation:
Adult and Peds:
IM: 4-5 mg/kg, may repeat Q5-10 minutes prn
IV: 1-2mg/kg over 1 min, may repeat 0.5-1mg/kg Q5-15 minutes prn
Delirium, confusion, dreamlike state, hallucinations, vivid imagery, Bradycardia,
Side Effects sialorrhea, nausea/vomiting, tachycardia, nystagmus, hypertension, hypertonia

LIDOCAINE 2%
Class Antidyrshythmic, local anesthetic
Significant ventricular ectopy in the setting of myocardial ischemia or infarction.
Indications Ventricular fibrillation. Ventricular Tachycardia.
2nd or 3rd degree heart block in absence of artificial pacemaker. Adams-stokes syndrome.
Contraindications
WPW syndrome. PVC's in conjunction with bradycardia. Allergy to corn
Cardiac Arrest (V-fib, Pulseless V-Tach):
Adult: 1-1.5mg/kg IV/IO, repeat Q 5-10 minutes with 0.5-0.75mg/kg to a max of 3mg/kg
May give 2-3.75mg/kg ET diluted in 5-10 ml NS or SWFI
Peds: 1mg/kg IV/IO follow with infusion of 20- 50mcg/kg, May give 2-3 mg/kg/dose ET
Dose & Route
flushed with 5ml NS and 5 assisted manual ventilations
Maintenance infusion after conversion of rhythm:
Adult: Mix 2 grams in 500ml (4mg/ml) and infuse at 2-4mg/min.
Peds: Dilute 120mg in 100ml and infuse at 20-50mcg/kg/min (1-2.5mg/kg/Hour)
Bradycardia, Blurred Vision, Cardiovascular collapse, CNS depression with high doses.
Side Effects
Confusion. Hypotension. Lightheadedness.

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LORAZEPAM (Ativan)
Class Benzodiazepine
Acute anxiety episodes, Combative patients, Difficult intubations, Muscle relaxant, Status
Indications
epilepticus, Pre-medication for cardioversion or TCP.
Contraindications Hypersensitivity. Respiratory depression. Acute narrow-angle glaucoma
Adult: 2-4mg IV/IM Q5-10min (Max=4mg/dose)
Dose & Route
Pediatrics: 0.1 mg/kg IV/IM Q5-10min (Max=4mg/dose)
Side Effects Decreased LOC. Hypotension. Respiratory depression.

MAGNESIUM SULFATE 10%

Class Electrolyte, Anti-Convulsant
Hypomagnesium, Pre-term labor, Seizures of ecclampsia, Torsades de Points, Refractory
Indications
ventricular fibrillation.
Heart Block. Hypersensitivity. Hypocalacemia. Myocardial damage. Shock. Severe
Contraindications
persistent hypertension
Seizure activity associated with pregnancy/pre-term labor:
4-6 grams IV infused over 20 min, followed by 1-2grams/hour (Max=40g/24 hours)

Torsade/Refreactory VF,VT:
Dose & Route
Adult: 1-2 grams IV/IO in 10 ML NS or D5W bolus if pulseless and over 15 Minutes
with a pulse.
Peds: 25-50mg/kg/dose IV/IO bolus if pulseless or over 20 minutes with pulse
(Max=2grams/dose)
Bradycardia. Circulatory collapse. CNS Depression. Depressed reflex. Diaphoresis.
Side Effects
Diarrhea. Flushing. Hypotension. Hypothermia. Respiratory depression

METHYLPREDNISOLONE (Solu-medrol)
Class Glucocorticoid (synthetic steroid)
Acute spinal cord injury. Anaphylaxis. Bronchodilator-unresponsive. Asthma. Shock (
Indications
controversial)
Contraindications None In emergency. Use in caution in GI bleeding, diabetes, and severe infection.
Adult: 40-125mg IVP except for spinal injury which is 30mg/kg IV over 15 minutes
followed by 5.4mg/kg/hour infusion.
Peds:
Dose & Route
Spinal cord injury: same dose as adult
Asthma Exacerbation: <12 years old; 1-2 mg/kg/day, Max=60mg/day
>12 years old; Same as adult
Alkalosis, GI bleeding. Headache, Hypertension. Hypokalemia. Prolonged wound
Side Effects
healing. Sodium and water retention.

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MIDAZOLAM (Versed)
Class Benzodiazepine sedative/hypnotic
Indications Premedication for cardioversion, RSI, Acute anxiety, status epilepticus.
Contraindications Hypersensitivity. Acute narrow angle glaucoma.
Sedation/anxiolysis
Adult:
IV: 2.5-5mg over 2 minutes, Q2-3min prn
IM: 0.08 mg/kg
IN: 0.1mg/kg
Peds:
IV:
<6 months: Not recommended
6months-5 years: 0.05-0.1mg/kg (Max total dose= 6mg)
6-12 years old: 0.05mg/kg (Max total dose=10mg)
Dose & Route >12 years old: Refer to Adult dosing (Max total dose=10mg)
IM: 0.1-0.5mg/kg, Max total dose=10mg
IN: 0.2-0.5mg/kg, Max total dose=10mg

Status Epilepticus
Adult:
IV: 0.2mg/kg
IM: 10mg once or 0.2mg/kg (Max 10mg/dose)
Peds:
IV: 0.2mg/kg
IM: 0.2mg/kg (Max=10mg/dose)
AMS. Amnesia. Blurred Vision. Bradycardia. Cough. Drowsiness. Fluctuations in
Side Effects respiratory arrest. Respiratory depression. Tachycardia.

MORPHINE
Class Opioid analgesic
Chest Pain associated with MI. Moderate to Severe acute and chronic pain. Pulmonary
Indications
edema with or without pain.
GI obstruction. Hypersensitivity. Hypotension. Hypovolemia. Patient having taken MAO
Contraindications inhibitors in last 14 days. Severe respiratory depression.

Adult: Start 2-10mg SIVP (2mg/min) titrate to effect.

Peds: 0.1-0.2mg/kg/dose SIVP
Dose & Route
Max dose: <1 year old= 2mg/dose, 1-6 years=4mg/dose, 7-12 years=8mg/dose, >12
years=10mg/dose
Allergic reaction, Altered mental status, Bradycardia, Bronchospasm, Dry Mouth,
Side Effects Euphoria, Flushing, Hypotension, Palpitations, Respiratory depression, Syncope,
Tachycardia.

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NALOXONE (Narcan)
Class Opioid antagonist
Indications Coma of unknown origin, Decreased LOC, Known or suspected opioid overdose.
Contraindications Hypersensitivity
Adult: 0.4-2mg IV (preferred), IM, SC, and ET (2-2.5 times IV dose). Q 2 minutes
Dose & Route (Max=10mg total)
Peds: 0.1mg/kg IV (preferred), IM, SC, ET, or IO. (Max=2mg/dose) Q2 minutes
Blurred Vision, Diaphoresis, Dysrhythmias, Hypertension, N/V, Tachycardia, Withdrawal
Side Effects
symptoms.

NITROGLYCERINE
Class Vasodilator, Antianginal agent, Extravasation antidote
AMI, CHF with pulmonary edema, Hypertensive emergencies, Ischemic chest pain,
Indications
Pulmonary Hypertension.
Children under 12. Head injury with/without hemorrhage. Hypersensitivity to nitrates.
Contraindications
Hypotension. Concurrent use with PDE-5 inhibitors. Corn allergy
Adult: 0.3 or 0.6mg tablet or spray SL every 5 minutes to a total of 3 doses.

IV Infusion: Mix 100-200mcg/ml drip and infuse at a rate of 5-20mcg/min to start.

Dose & Route Increase at 5-10mcg/min every 5 minutes until desired effect is achieved or hypotension
occurs. (Max=400mcg/min)

Peds: N/A
Diaphoresis, Dizziness, Headache, Hypotension, N/V, Reflex tachycardia, syncope.
Side Effects

ONDANSETRON (ZOFRAN)
Class Antiemetic
Indications Nausea & Vomiting

Contraindications Hypersensitivity to dolasetron, granisetron. May precipitate with bicarb.

Adult: 4-8mg IV/IO Slowly or IM. 8mg PO.
Dose & Route
Ped: 0.1mg/kg Slow IV/IO or IM. Max dose 4mg.
Side Effects H/A, diarrhea, Fever, dizziness, pain, seizure, EPS, QT prolongation.

PROMETHAZINE (Phenegran)
Class Phenothiazine, Antihistamine, Antiemetic
Allergic Reactions, Motion Sickness, N/V, Pre/Post-Operative and obstetric sedation,
Indications
potentiate analgesic effects
CNS depression from alcohol, barbiturates or narcotics. Comatose states, Hypersensitivity,
Contraindications
Signs of Reye's Syndrome. Children <2 years old
Dose & Route Adult: 12.5-25mg IVP/IM Peds: 0.5mg/kg IV/IM(Max=25mg/dose)
Tissue injury, Dizziness, Dysrhythmias, Dystonias, Hyperexcitability, Impairment of
Side Effects mental and physical ability, N/V, Sedation, Tachycardia / Bradycardia. Use in children
may cause hallucinations, convulsions, and sudden death.

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RACEMIC EPINEPHERINE
Class Sympathomimetic
Indications Croup, laryngeal edema
Contraindications Oral inhalation. Concurrent use or within 2 weeks of MAO inhibitors
Adult: 0.5ml in 3-5ml saline nebulized
Dose & Route
Peds: 0.05-0.1 ML/kg in 3-5 salin nebulized (Max=0.5ml/dose)
Side Effects Anxiety, HA, palpitations

ROCURONIUM
Class Neuromuscular blocker (non-depolarizing)
Adjunct to general anesthesia. Facilitation of endotracheal intubation. Maintenance of
Indications
paralysis after intubation to assist ventilations.
Contraindications Hypersensitivity
Dose & Route Adult and Peds: 0.6-1.2 mg/kg IV
Side Effects Apnea, Bradycardia, Hypo/Hypertension, Prolonged paralysis.

SODIUM BICARBONATE
Class Buffer, Alkalinizing agent, electrolyte supplement.
Alkalinization for treatment of specific intoxication’s, Intubated patients with long arrest
interval, PEA, Known or pre-existing bicarb responsive acidosis, Management of
Indications metabolic acidosis, Return circulation after long arrest interval, Tricyclic antidepressant
OD. Hyperkalemia.

Contraindications Abdominal pain of unknown origin, Hypocalcemia, Hypernatrenua, Alkalosis

Adult:
Cardiac Arrest: 1mEq/kg SIVP, repeat doses should be guided by arterial blood gases
Hyperkalemia: 50meq IV over 5 minutes
Peds:
Cardiac Arrest/Hyperkalemia: (> two years of age) Same as Adult
Dose & Route Infants: (< two years of age) 4.2% solution is recommended for IV administration Slow
administration rates and the 4.2% solution are recommended in neonates, to guard against
the possibility of producing hypernatremia, decreasing cerebrospinal fluid pressure, and
inducing intracranial hemorrhage.
Tricyclic Antidepressant Overdose: 1-2 mEq/kg IV boluses Q5-10min followed by an
continuous infusion of 150meq/L solution to maintain alkalosis
Electrolyte Imbalance. Hypoxia, Metabolic alkalosis. Rise in intracellular PcO 2 and
Side Effects
increased tissue acidosis. Seizures. Tissue sloughing at injection site.

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SODIUM CHLORIDE
Class Isotonic IV fluid
Dehydration / Hypovolemia, Diabetic Ketoacidosis, Heat related emergency, Hypotension,
Indications
Medication route.
Contraindications CHF. Pulmonary edema. Severe electrolyte imbalance
Adult: KVO for maintenance of drug route. 250-500 ml bolus for fluid resuscitation.
Dose & Route Repeat as needed.
Peds: 20ml/kg bolus repeat as needed.
Side Effects Electrolyte imbalance. Pulmonary edema from overload.

SUCCINYLCHOLINE
Class Neuromuscular blocker (depolarizing)
Indications Muscle relaxation. Terminate laryngospasm, facilitate intubation
Acute injuries, Acute rhabdomyolsis, Hypersensitivity, Inability to control airway or
Contraindications ventilate patient, Personal or family Hx of malignant hyperthermia, Skeletal muscle
myopathies.
Adult: 1-1.5mg/kg IVP over 10-30 seconds or 3 to 4 mg/kg IM
Dose & Route
Peds: Same as adult
Allergic Reaction, Bradycardia, Dysrhythmias, Excessive salivation, Hypotension, Initial
Side Effects muscle fasciculations, Malignant hyperthermia, May exacerbate hyperkalemia in trauma
patients, Respiratory depression

THIAMINE
Class Vitamin B1
Indications Beriberi. Delirium tremors. Wernicke's Encephalopathy.
Contraindications None
Adult: 100-250mg SIVP over 30 min for doses >100mg
Dose & Route
Peds: Rarely indicated
Allergic reactions (rare). Anxiety. Diaphoresis. Hypotension from rapid injection or large
Side Effects
dose. N/V

VECURONIUM
Class Neuromuscular blocker (non-depolarizing)
Adjunct to anesthesia. Facilitation of endotracheal intubation. Maintenance of paralysis
Indications
after intubation to assist ventilations.
Contraindications Hypersensitivity to the drug or bromides.
Adult and Peds: 0.1-0.2mg/kg IVP bolus
Dose & Route

Side Effects Apnea, Bradycardia, Hypotension, Prolonged paralysis.

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IX. LABORATORY REFERENCE
(Mosby Paramedic (VOL. 7/2010 AHA updates) )

HEMATOLOGY VALUES

*HCT (HEMATOCRIT) - Measures relative volume of cells and plasma in blood. Low values suggest hemorrhage
or anemia. High values suggest polycythemia or dehydration.
Normal Adult Male Range 40 - 54%
Normal Adult Female Range: 37 - 47%
Normal Newborn Range: 50 - 62%

*HGB (HEMOGLOBIN) - Measures Oxygen carrying capacity of blood. Low values suggest Hemorrhage or
anemia, high values suggest polycythemia.
Normal Adult Male Range: 14 - 18 g/dl
Normal Adult Female Range: 12 - 16 g/dl
Normal Newborn Range: 14 - 20 g/dl

*RBC (RED BLOOD CELL COUNT) - Measures the number of red blood cells. RBCs transport hemoglobin,
which carries oxygen. The amount of oxygen body tissues receive depends on the amount and function of RBCs and
hemoglobin. RBCs normally survive about 120 days in the blood. They are then removed by specialized "clean-up"
cells in the spleen and liver.
Normal Adult Male Range: 4.2 - 5.6 mill/mcl
Normal Adult Female Range: 3.9 - 5.2 mill/mcl
Lower ranges are found in Children, newborns and infants

*WBC (WHITE BLOOD CELL COUNT) - Measures defense against inflammatory agents. Low values suggest
aplastic anemia, drug toxicity, specific infections. High values suggest inflammation, trauma, toxicity, leukemia.
Normal Adult Range: 3.8 - 10.8 thous/mcl
Higher ranges are found in children, newborns and infants.

*PLATELET COUNT - A platelet count is often ordered as a standard part of a complete blood count and is almost
always ordered when a patient has unexplained bruises or takes what appears to be an unusually long time to stop
bleeding from a small cut or wound.
Normal Adult Range: 150 - 450 thous/mcl
Higher ranges are found in children, newborns and infants

ELECTROLYTE VALUES

*SODIUM - Sodium is the most abundant cation in the blood and it's chief base. It functions in the body to
maintain osmotic pressure, acid-base balance and to transmit nerve impulses.
Normal Adult Range: 135-146 mEq/L

*POTASSIUM - Potassium is the major intracellular cation.

Normal Range: 3.5 - 5.5 mEq/L

*SODIUM/POTASSIUM
Normal Adult Range: 26 - 38 (calculated)

*CO2 (CARBON DIOXIDE) - The CO2 level is related to the respiratory exchange of carbon dioxide in the lungs
and is part of the buffer system. Generally when used with the other electrolytes, it is a good indicator of acidosis
and alkalinity.
Normal Adult Range: 22-32 mEq/L
Normal Childrens Range - 20 - 28 mEq/L

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IX. LABORATORY REFERENCE

*ANION GAP (SODIUM + POTASSIUM – CO2 + CHLORIDE) - An increased measurement is associated with
metabolic acidosis due to the overproduction of acids. Decreased levels may indicate metabolic alkalosis due to the
overproduction of alkaloids. Normal Adult Range: 4 - 14 (calculated)

PROTEIN

*PROTEIN, TOTAL - Decreased levels may be due to poor nutrition, liver disease, malabsorption, diarrhea, or
severe burns. Increased levels are seen in lupus, liver disease, chronic infections, alcoholism, leukemia, tuberculosis
amongst many others.
Normal Adult Range: 6.0 -8.5 g/dl

*ALBUMIN - Major constituent of serum protein (usually over 50%). High levels are seen in liver disease (rarely),
shock, dehydration, or multiple myeloma. Lower levels are seen in poor diets, diarrhea, fever, infection, liver
disease, inadequate iron intake, third-degree burns and edemas or hypocalcemia
Normal Adult Range: 3.2 - 5.0 g/dl

HEPATIC ENZYMES

AST (SERUM GLUTAMIC-OXALOCETIC TRANSAMINASE - SGOT ) - Found primarily in the liver, heart,
kidney, pancreas, and muscles. Seen in tissue damage - especially damage to the heart and liver.
Normal Adult Range: 0 - 42 U/L

ALT (SERUM GLUTAMIC-PYRUVIC TRANSAMINASE - SGPT) - Decreased SGPT in combination with

increased cholesterol levels is seen in cases of a congested liver. Increased levels seen in mononucleosis,
alcoholism, liver damage, kidney infection, chemical pollutants or myocardial infarction
Normal Adult Range: 0 - 48 U/L

ALKALINE PHOSPHATASE - Used as a tumor marker elevated levels seen in bone injuries, pregnancy, or
skeletal growth. Low levels are sometimes found in hypoadrenia, protein and vitamin deficiency, and malnutrition.
Normal Adult Range: 20 - 125 U/L
Normal Children's Range: 40 - 400 U/L

GGT (GAMMA-GLUTAMYL TRANSPEPTIDASE) - Elevated levels seen with liver disease, alcoholism, bile-duct
obstruction, cholangitis, drug abuse, and hypermagnesemia. Decreased levels can be found in hypothyroidism,
hypothalamic malfunction and hypomagnesemia.
Normal Adult Male Range: 0 - 65 U/L
Normal Adult Female Range: 0 - 45 U/L

LDH (LACTIC ACID DEHYDROGENASE) - Increases are usually found in cellular death and/or leakage from
the cell or in some cases it can be useful in confirming myocardial or pulmonary infarction (in conjunction with
other tests). Decreased levels of the enzyme may indicate malnutrition, hypoglycemia, adrenal exhaustion or low
tissue or organ activity.
Normal Adult Range: 0 - 250 U/L

*BILIRUBIN, TOTAL - Elevated in liver disease, mononucleosis, hemolytic anemia, low levels of exposure to the
sun, and toxic effects to some drugs, decreased levels are seen in people with an inefficient liver, excessive fat
digestion, and possibly a diet low in nitrogen bearing foods
Normal Adult Range 0 - 1.3 mg/dl

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IX. LABORATORY REFERENCE

RENAL RELATED

*B.U.N. (BLOOD UREA NITROGEN) - Increases can be caused by excessive protein intake, kidney damage,
certain drugs, low fluid intake, intestinal bleeding, and exercise or heart failure. Decreased levels may be due to a
poor diet, malabsorption, liver damage or low nitrogen intake.
Normal Adult Range: 7 - 25 mg/dl

*CREATININE - Low levels are sometimes seen in kidney damage, protein starvation, liver disease or pregnancy.
Elevated levels are sometimes seen in kidney disease due to the kidneys job of excreting creatinine, muscle
degeneration, and some drugs involved in impairment of kidney function.
Normal Adult Range: .7 - 1.4 mg/dl

*URIC ACID - High levels are noted in gout, infections, kidney disease, alcoholism, high protein diets, and with
toxemia in pregnancy. Low levels may indicate kidney disease, malabsorption, liver damage or an acidic kidney.
Normal Adult Male Range: 3.5 - 7.5 mg/dl
Normal Adult Female Range: 2.5 - 7.5 mg/dl

*BUN/CREATININE - This calculation is a good measurement of kidney and liver function.

Normal Adult Range: 6 -25 (calculated)

CARDIAC

*CREATINE PHOSPHOKINASE (CK) - Levels rise 4 to 8 hours after an acute MI, peaking at 16 to 30 hours and
returning to baseline within 4 days
25-200 U/L
32-150 U/L

*CK-MB CK ISOENZYME - It begins to increase 6 to 10 hours after an acute MI, peaks in 24 hours, and remains
elevated for up to 72 hours.
< 12 IU/L if total CK is <400 IU/L
<3.5% of total CK if total CK is >400 IU/L

*(LDH) LACTATE DEHYDROGENASE - Total LDH will begin to rise 2 to 5 days after an MI; the elevation can
last 10 days.
140-280 U/L

LDH-1 and LDH-2 (LDH ISOENZYMES) - Compare LDH 1 and LDH 2 levels. Normally, the LDH-1 value will be
less than the LDH-2. In the acute MI, however, the LDH 2 remains constant, while LDH 1 rises. When the LDH 1 is
higher than LDH 2, the LDH is said to be flipped, which is highly suggestive of an MI. A flipped pattern appears 12-
24 hours post MI and persists for 48 hours.
LDH-1 18%-33%
LDH-2 28%-40%

*MYOGLOBIN - Early and sensitive diagnosis of myocardial infarction in the emergency department This small
heme protein becomes abnormal within 1 to 2 hours of necrosis, peaks in 4-8 hours, and drops to normal in about
12 hours.
<1

*TROPONIN COMPLEX - Peaks in 10-24 hours, begins to fall off after 1-2 weeks.
< 0.4

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X. REFRENCES

The following materials have been used to provide information in this Medical Handbook:

1. Mosby Paramedic (VOL. 8/2015 AHA updates)

2. AHA ACLS 2015

3. AHA PALS 2015

4 CoTCCC Guidelines

5. Special Operations Advanced Tactical Paramedics Protocols (ATP 10th edition)

6. Tidewater Emergency Services Protocols Guide (TEMS 2017)

7. Lehne Pharmacology for Nurses

8. INFORMED ALS Field Guide (2016)

9. Dublin Rapid Interpretation of EKG’s (Published 2016)

10. Advanced Trauma Life Support (ATLS)

11. Pre-hospital Trauma Life Support – Military Edition (PHTLS - Vol. 9)

12. Brady Tactical Emergency Medical Care (Published 2015)

13. Critical Care Emergency Medicine Guide

14. Emergency War Surgery Guide 4th Edition

15. COMNAVAIRFORINST 6000.2

16. BUMED Sick Call Screeners Guide and Lesson Plan

17. Pararescue Medical Operations Handbook

18. CoERCCC / Clinical Practice Guidelines

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XI. Military Acute Concussion Evaluation (MACE) 2nd Edition

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Naval Aviation Medical Treatment Protocols, April 2019 Page 209
Naval Aviation Medical Treatment Protocols, April 2019 Page 210
Naval Aviation Medical Treatment Protocols, April 2019 Page 211
Naval Aviation Medical Treatment Protocols, April 2019 Page 212
Naval Aviation Medical Treatment Protocols, April 2019 Page 213
Naval Aviation Medical Treatment Protocols, April 2019 Page 214
Naval Aviation Medical Treatment Protocols, April 2019 Page 215
Naval Aviation Medical Treatment Protocols, April 2019 Page 216
Naval Aviation Medical Treatment Protocols, April 2019 Page 217
Naval Aviation Medical Treatment Protocols, April 2019 Page 218
XII. NOTES

QUICK CONVERSIONS

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Naval Aviation Medical Treatment Protocols, April 2019 Page 222
Naval Aviation Medical Treatment Protocols, April 2019 Page 223
 Critical Care Quick Resource Sheet

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 Critical Care Quick Resource Sheet

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 EtCO2 Quick Reference

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 EtCO2 Quick Reference

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 EtCO2 Quick Reference

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 Useful Mnemonics
Dive Related Accidents
Causes of Coma/Decreased Level of Consciousness V - Visual (Tunnel vision or blurred vision)
A - Alcohol (and other drugs), Acidosis E - Ear symptoms (Tinnitus)
(hyperglycemic coma/DKA) N - Nausea and/or vomiting
E - Electrolyte abnormality, Endocrine problem, T - Twitching (Generally involves facial muscles, but
Epilepsy can involve arms/legs)
I - Insulin (diabetes/hypoglycemic shock) L - Irritability (Change in diver's mental status)
O - Oxygen (Hypoxia), Overdose (or poisoning) D - Disability (Sudden neurological deficit)
U - Uremia (renal failure/insufficiency) Patient Care
T - Trauma; Temperature (hypothermia, heat stroke) V - Vitals
I - Infection (e.g., meningitis, encephalitis, sepsis) O – Oxygen
P - Psychogenic ("hysterical coma") M – Monitor / Medications
S - Stroke or Space-occupying lesions in the cranium; I – IV/IO
Seizure; Shock T - Transport

Coma Assessment
D - Depth of coma (responds to verbal or painful
stimulus, unresponsive)
E - Eyes (PERRLA)
R - Respiration (rate and rhythm)
M - Motor (posturing; loss of movement/sensation)

Level of Consciousness
A - Alert
V - Responds to Verbal stimuli
P - Responds to Painful stimuli
U – Unresponsive

Patient History / Pain Assessment

A - Allergies
M - Medications
P - Past medical history (illness, injury)
P - Pain (PPQRST)
L - Last intake (food, fluid)
E - Ever happen before?
P - Pain (sharp or dull)
P - Palliative &/or Precipitating (exacerbating)
measures related to the pain
Q - Quality (diffuse, pinpoint, or localized)
R - Radiating
S - Severity (scale of 1-10)
T - Timing: Time of onset; frequency; duration

Pupil Reaction
P - Pupils
E - Equal
R - Round
R - Reactive to
L - Light
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XII. MEDICATIONS AND THEIR USES

Trade names start with an uppercase letter and appear in blue.

Generic names start with a lowercase letter and appear in red.
The primary type of medical problem for which the medication is used is listed, and the type of medication is shown
in parentheses, when indicated.

Abilify Bipolar disorder, schizophrenia

Accolate Asthma
Accupril High blood pressure, congestive heart failure
acetaminophen with codeine Pain
Aciphex Gastric problems (antiulcer)
Actiq Pain (narcotic analgesic)
Actonel Osteoporosis
Actos Diabetes (oral antidiabetic)
acyclovir Viral infections (antiviral)
Adderall Attention deficit/hyperactivity disorder
Adipex Weight loss
Advair Breathing problems
albuterol Breathing problems (bronchodilator)
Aldactazide High blood pressure (diuretic/water pill)
Aldactone Congestive heart failure (diuretic/water pill)
Aldomet High blood pressure
alendronate Osteoporosis
Alesse 28 Birth control pills
Allegra Allergies (antihistamine)
Alli Weight loss
allopurinol Gout, kidney stones
alprazolam Anxiety, depression (sedative/antianxiety)
Altace High blood pressure (ACE inhibitor)
Alupent Asthma, breathing problems (bronchodilator)
Amaryl Diabetes (oral antidiabetic)
Ambien Insomnia (hypnotic)
Amitiza Gastrointestinal problems
amitriptyline Depression (antidepressant)
amlodipine High blood pressure, angina
amoxicillin Infection (antibiotic)
Amoxil Infection (antibiotic)
Anaprox Arthritis (anti-inflammatory)
Ansaid Arthritis (anti-inflammatory)
Antivert Dizziness, motion sickness (antivertigo)
Apresoline High blood pressure (antihypertensive)
Aricept Alzheimer’s disease
Artane Parkinson’s disease (anti-Parkinson)
Arthrotec Arthritis (anti-inflammatory)
Asacol Ulcerative colitis (antibacterial)
Asmanex Asthma (anti-inflammatory)
Aspirin Analgesic
Atarax Anxiety, behavioral disorders (sedative)
atenolol High blood pressure, heart problems, angina (beta blocker)
Ativan Anxiety (sedative/antianxiety)
Atrovent Breathing problems (bronchodilator)
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Augmentin Infection (antibiotic)

Avandamet Diabetes
Avandia Diabetes (oral antidiabetic)
Avapro High blood pressure
Avodart Prostate enlargement
Axid Ulcers (antiulcer)
azithromycin Infection (antibiotic)
Azulfidine Ulcerative colitis (antibacterial)
Bactrim Infection (antibiotic)
Bactroban Impetigo (antibiotic)
Benadryl Allergies (antihistamine)
benazepril High blood pressure, congestive heart failure
Benicar High blood pressure
Bentyl Irritable bowel syndrome (anticholinergic)
benzonatate Cough (antitussive)
Biaxin Infection (antibiotic)
bisoprolol High blood pressure (diuretic)
Boniva Osteoporosis
Brethine Asthma, breathing problems (bronchodilator)
Bumex Edema, congestive heart failure (diuretic)
bupropion Depression, smoking cessation
BuSpar Anxiety (antianxiety)
buspirone Anxiety (antianxiety)
Byetta Diabetes
Caduet High blood pressure
Calan Angina, high blood pressure, rapid heart rate
Capoten High blood pressure, congestive heart failure
captopril High blood pressure, congestive heart failure
Carafate Ulcers (antiulcer)
carbamazepine Seizure disorder (anticonvulsant)
Cardizem Heart problems, angina (coronary vasodilator)
Cardura High blood pressure (alpha blocker)
carisoprodol Muscle spasms (muscle relaxant)
Cartia Angina, heart problems (calcium-channel blocker)
carvedilol High blood pressure
Catapres High blood pressure (antihypertensive)
Ceclor Infection (antibiotic)
cefaclor Infection (antibiotic)
cefdinir Infection (antibiotic)
cefixime Infection (antibiotic)
cefprozil Infection (antibiotic)
Ceftin Infection (antibiotic)
cefuroxime Infection (antibiotic)
Cefzil Infection (antibiotic)
Celebrex Arthritis (anti-inflammatory)
Celexa Depression (antidepressant)
cephalexin Infection (antibiotic)
cetirizine Antihistamine
Chantix Smoking cessation
Cialis Male impotence
Ciloxin Infection (antibiotic)
cimetidine Ulcers, gastric problems (antiulcer)

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Cipro Infection (antibiotic)
citalopram Depression

Clarinex Allergies (antihistamine)

Claritin Allergies (antihistamine)
clarithromycin Infection (antibiotic)
clindamycin Infection (antibiotic)
Clinoril Arthritis pain (anti-inflammatory)
clonazepam Seizure disorder (anticonvulsant)
clonidine High blood pressure (antihypertensive)
clopidogrel Antiplatelet
clotrimazole Fungal infection (antifungal)
Colestid High cholesterol (cholesterol-lowering agent)
Combivent Breathing problems (bronchodilator)
Compazine Nausea (antiemetic)
Concerta Attention deficit/hyperactivity disorder
Coreg High blood pressure, heart problems
Corgard Heart problems, angina (beta blocker)
Cotrim Infection (anti-infective)
Coumadin Blood clots (blood thinner)
Cozaar High blood pressure
Crestor High cholesterol
cyclobenzaprine Muscle spasms (muscle relaxant)
Cymbalta Depression
Darvocet-N Pain management (narcotic analgesic)
Daypro Arthritis (anti-inflammatory)
Deltasone Severe inflammation (anti-inflammatory)
Demadex Edema, congestive heart failure (diuretic)
Demerol Pain (narcotic analgesic)
Depakote Seizure disorder (anticonvulsant)
Desyrel Depression (antidepressant)
Detrol Overactive bladder
Dexedrine Narcolepsy, attention-deficit disorder
dexmethylphenidate Attention deficit/hyperactivity disorder
DiaBeta Diabetes (oral antidiabetic)
Diabinese Diabetes (oral antidiabetic)
diazepam Anxiety (antianxiety)
diclofenac Inflammation (anti-inflammatory)
Diflucan Fungal infection (antifungal)
Digitek Heart problems
digoxin Heart problems
Dilantin Seizure disorder (anticonvulsant)
diltiazem Heart problems, angina (coronary vasodilator)
Diovan High blood pressure (antihypertensive)
Dipentum Ulcerative colitis
diphenhydramine Allergies (antihistamine)
dipyridamole Thromboembolism
Ditropan Bladder problems (antispasmodic)
Donnatal Irritable bowel syndrome (anticholinergic)
doxazosin Hypertension, prostate problems
doxycycline Infection (antibiotic)
Duricef Infection (antibiotic)
Dyazide High blood pressure, edema (diuretic)

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DynaCirc High blood pressure
E.E.S. Infection (antibiotic)
Effexor Depression (antidepressant)
Elavil Depression (antidepressant)
Eldepryl Parkinson’s disease (anti-Parkinson)
Elocon Dermatologic problems
Emend Nausea (antiemetic)
enalapril High blood pressure, heart failure
Enbrel Rheumatoid arthritis
E-Mycin Infection (antibiotic)
Entex Cough and congestion (expectorant)
epinephrine Cardiac arrest, allergic reactions
Epivir Antiretroviral
Ery-Tab Infection (antibiotic)
erythromycin Infection (antibiotic)
escitalopram Depression
Esidrix High blood pressure (diuretic/water pill)
Eskalith Behavioral disorders (antimanic)
Estrace Estrogen therapy
Estraderm Estrogen therapy
estradiol Menopause, gynecologic problems
etodolac Arthritis, pain (anti-inflammatory)
Evista Osteoporosis
famotidine Ulcers, gastric problems (antiulcer)
Feldene Arthritis (anti-inflammatory)
fentanyl Pain management (narcotic analgesic)
finasteride Prostate enlargement
Fiorinal Pain management (non-narcotic analgesic)
Flagyl Infections (antibacterial)
Flexeril Muscle spasms (muscle relaxant)
flexofenadine Antihistamine
Flomax Enlarged prostate (alpha blocker)
Flonase Allergies
Flovent Breathing problems
Floxin Infection (antibiotic)
fluconazole Fungal infection
fluoxetine Depression (antidepressant)
flurbiprofen Inflammation (anti-inflammatory)
folic acid Anemia
Fosamax Osteoporosis
fosinopril Osteoporosis
furosemide Congestive heart failure (diuretic/water pill)
gabapentin Seizures
Gabitril Seizure disorder (antiseizure)
Gantrisin Infection (antibiotic)
gemfibrozil High cholesterol (cholesterol-lowering agent)
Geodon Antipsychotic
glimepiride Diabetes (hyperglycemia)
glipizide Diabetes (oral antidiabetic)
Glucophage Diabetes (oral antidiabetic)
Glucotrol Diabetes (oral antidiabetic)
Glucovance Diabetes (oral antidiabetic)
glyburide Diabetes (oral hypoglycemic)

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Glycolax Constipation
granisetron Nausea
guaifenesin Cough and congestion (expectorant)
Halcion Insomnia (hypnotic/sedative)
Haldol Psychotic disorders (antipsychotic)
HCTZ High blood pressure (diuretic/water pill)
Humira Rheumatoid arthritis
Humulin Diabetes (insulin)
hydrochlorothiazide High blood pressure (diuretic)
hydrocodone Cough, pain (narcotic)
HydroDiuril High blood pressure (diuretic/water pill)
hydroxyzine Anxiety, behavioral disorders (sedative)
Hygroton High blood pressure (diuretic/water pill)
Hytrin High blood pressure (alpha blocker)
Hyzaar High blood pressure (antihypertensive)
ibuprofen Inflammation, pain, fever (anti-inflammatory)
Imdur Heart problems, angina (coronary vasodilator)
Imitrex Migraine headaches (antimigraine)
Inderal High blood pressure, heart problems, angina (beta blocker)
Indocin Osteoarthritis, pain (anti-inflammatory)
indomethacin Arthritis (anti-inflammatory)
Intal Asthma (mast cell stabilizer)
Iophen Cough (antitussive)
Isoptin Angina, high blood pressure, rapid heart rate
Isordil Heart problems, angina (coronary vasodilator)
isosorbide dinitrate Heart problems, angina (coronary vasodilator)
K-Dur Potassium replacement, taken with diuretics
K-Tab Potassium replacement, taken with diuretics
Keflex Infection (antibiotic)
Keppra Seizure disorder (anticonvulsant)
ketoconazole Fungal infection (antifungal)
ketorolac Pain management (anti-inflammatory)
Klonopin Seizure disorder (anticonvulsant)
labetalol High blood pressure (beta blocker)
Lamictal Seizure disorder (anti-epileptic)
Lamisil Antifungal
Lanoxin Heart problems
Lasix Congestive heart failure (diuretic/water pill)
Lescol High cholesterol (cholesterol-lowering agent)
Levaquin Infection (antibiotic)
Levitra Male impotence
Levothroid Thyroid disease (thyroid hormone)
levothyroxine Thyroid problems (thyroid hormone)
Levoxyl Thyroid disease (thyroid hormone)
Lexapro Depression
Librax Peptic ulcer (anticholinergic)
Lipitor High cholesterol (cholesterol-lowering agent)
lisinopril High blood pressure
lithium carbonate Behavioral disorders (antipsychotic)
Lodine Arthritis, pain (anti-inflammatory)
Loestrin Fe Birth control pills
Lomotil Diarrhea (antidiarrheal)
Lopid High cholesterol (cholesterol-lowering agent)

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Lopressor High blood pressure (beta blocker)
Lorabid Infection (antibiotic)
loracarbef Infection (antibiotic)
loratadine Allergies (antihistamine)
lorazepam Anxiety (sedative/antianxiety)
Lorcet Pain (narcotic analgesic)
Lortab Pain (narcotic analgesic)
Lotensin High blood pressure (ACE inhibitor)
Lotrel Hypertension
Lotrimin Fungal infection (antifungal cream and ointment)
Lotrisone Fungal infection (antifungal cream)
lovastatin High cholesterol (cholesterol-lowering agent)
Lozol Congestive heart failure, high blood pressure
Lunesta Sleep aid
Luvox Parkinson’s disease (anti-Parkinson)
Lyrica Nerve pain
Macrobid Urinary tract infection (antibiotic)
Macrodantin Urinary tract infection (antibiotic)
marijuana Comfort management
Maxzide High blood pressure (diuretic/water pill)
meclizine Dizziness, vertigo, motion sickness (antiemetic)
medroxyprogesterone Gynecologic problems
meloxicam Inflammation, pain
metformin Diabetes
methadone Pain (narcotic analgesic), opiate withdrawal
methylphenidate Attention deficit disorder, narcolepsy
methylprednisolone Anti-inflammatory
metoclopromide Gastric problems (antiemetic)
metoprolol tartrate High blood pressure, heart problems (beta blocker)
metronidazole Infection (anti-infective)
Mevacor High cholesterol (cholesterol-lowering agent)
Micro-K Potassium replacement, taken with diuretics
Micronase Diabetes (oral antidiabetic)
Minipress High blood pressure (antihypertensive)
Minocin Infection (antibiotic)
minocycline Infection (antibiotic)
Miralax Constipation
Mirapex Parkinson’s disease (anti-Parkinson)
Mircette Birth control pills
mirtazapine Anxiety, depression
Mobic Inflammation, pain
moexipril High blood pressure
Monopril High blood pressure
morphine Pain management (narcotic analgesic)
Motrin Inflammation, pain, fever (anti-inflammatory)
nabumetone Inflammation, pain (anti-inflammatory)
Namenda Alzheimer’s disease
Naprosyn Inflammation, pain (anti-inflammatory)
naproxen Inflammation, pain (anti-inflammatory)
Nasacort Asthma, breathing problems (anti-inflammatory)
Nasonex Allergies (anti-inflammatory)
Necon Birth control pills
Neurontin Seizure disorders (anticonvulsant)

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Nexium Gastric problems
Niaspan High cholesterol
nifedipine Heart problems, angina (coronary vasodilator)
Nitro-Dur Heart problems, angina (coronary vasodilator)
nitrofurantoin Urinary tract infection
nitroglycerin Heart problems, angina (coronary vasodilator)
Nitrostat Heart problems, angina (coronary vasodilator)
nizatidine Ulcers (antiulcer)
Nizoral Fungal infection (antifungal)
Norco Pain (narcotic analgesic)
Normodyne High blood pressure
nortriptyline Depression (antidepressant)
Norvasc High blood pressure (calcium-channel blocker)
nystatin Fungal infection (antifungal)
omeprazole Ulcers, gastric problems (antiulcer)
Omnicef Infections (antibiotic)
Omnipen Infections (antibiotic)
ondansetron Nausea
Ortho-Cept Birth control pills
Ortho-Cyclen Birth control pills
Ortho-Novum Birth control pills
Ortho Tri-Cyclen Birth control pills
Oruvail Arthritis pain (anti-inflammatory)
oseltamivir Antiviral
oxaprozin Inflammation, pain, fever (anti-inflammatory)
oxcarbazepine Seizures
oxybutynin Bladder problems (antispasmodic)
oxycodone Pain (narcotic analgesic)
Oxy-Contin Pain (narcotic analgesic)
Pamelor Depression (antidepressant)
pantoprazole Gastric problems, ulcers
paroxetine Depression (antidepressant)
Pataday Allergies (antihistamine)
Patanol Allergies (antihistamine)
Paxil Depression (antidepressant)
Pediazole Infection (antibiotic)
penicillin Infection (antibiotic)
pentoxifylline Vascular disease (blood thinner)
Pepcid Ulcers, gastric problems (antiulcer)
Percocet Pain (narcotic analgesic)
Percodan Pain (narcotic analgesic)
Persantine Thromboembolism
phenazopyridine Urinary tract irritation, infection
Phenergan Nausea (antiemetic)
phenobarbital Seizure disorder (anticonvulsant)
phentermine Weight loss
phenytoin Seizure disorder (anticonvulsant)
Plavix Thromboembolism (antiplatelet)
Plendil High blood pressure (calcium-channel blocker)
potassium chloride Potassium replacement, taken with diuretics
Prandin Diabetes (oral antidiabetic)
Pravachol High cholesterol (cholesterol-lowering agent)
prednisone Severe inflammation (anti-inflammatory)

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Premarin Menopause, gynecologic problems (estrogen)
Prempro Menopause, gynecological problems
Prevacid Ulcers, gastric problems (antiulcer)
Prilosec Ulcers, gastric problems (antiulcer)
Prinivil High blood pressure (ACE inhibitor)
Pro-Banthine Peptic ulcer (anticholinergic)
Procan Rapid heart rate, tachycardia (antiarrhythmic)
Procardia Heart problems, angina (coronary vasodilator)
Proloprim Infection, mainly urinary tract (antibiotic)
promethazine Nausea (antiemetic)
Propacet Pain management (narcotic analgesic)
Propecia Hair loss
propoxyphene Pain management (narcotic analgesic)
propranolol High blood pressure, heart problems, angina (beta blocker)
Proscar Prostate enlargement
Protonix Gastric problems
Proventil Breathing problems (bronchodilator)
Provera Gynecologic problems (progestogen)
Provigil Narcolepsy
Prozac Depression (antidepressant)
Pulmicort Asthma
Pyridium Urinary tract infections, pain
Quinaglute Ventricular arrhythmias (antiarrhythmic)
quinapril High blood pressure (ACE inhibitor)
Qvar Asthma, breathing problems (anti-inflammatory)
ramipril High blood pressure (ACE inhibitor)
ranitidine Ulcers, gastric problems (antiulcer)
Reglan Nausea (antiemetic)
Relafen Inflammation, pain (anti-inflammatory)
Remeron Anxiety, depression (sedative)
Restoril Sleep disorders (hypnotic)
Retrovir Antiretroviral
Risperdal Psychological disorders (antipsychotic)
Ritalin Attention deficit disorder, narcolepsy
Robaxin Muscle spasms (muscle relaxant)
Roxicet Pain management (narcotic analgesic)
Rythmol Heart problems, ventricular tachycardia
Sectral High blood pressure (beta blocker)
Septra Infection (antibiotic)
Serevent Asthma, breathing problems (bronchodilators)
Seroquel Psychological disorders (antipsychotic)
sertraline Depression (antidepressant)
Serzone Depression (antidepressant)
simvastatin High cholesterol
Sinemet Parkinson’s disease (anti-Parkinson)
Sinequan Anxiety, depression (antidepressant)
Singulair Asthma
Skelaxin Muscle relaxant
Slo-Bid Breathing problems, asthma (bronchodilator)
Slow-K Potassium replacement, taken with diuretics
Soma Muscle spasms (muscle relaxant)
Spiriva Breathing problems
spironolactone High blood pressure, heart failure (diuretic)

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Suboxone Treatment of opioid dependence
sucralfate Ulcers (antiulcer)
Sular High blood pressure
sulfamethoxazole Infection (antibiotic)
sulfasalazine Ulcerative colitis (antibacterial)
sulfisoxazole Infection (antibiotic)
Sumycin Infection (antibiotic)
Suprax Infection (antibiotic)
Sustiva Antiretroviral
Symbicort Asthma
Synthroid Thyroid disease (thyroid hormone)
Tagamet Ulcers, gastric problems (antiulcer)
Tamiflu Antiviral
tamoxifen Cancer (antineoplastic)
Tavist Allergies (antihistamine)
TegretoI Seizure disorder (anticonvulsant)
temazepam Insomnia (sedative)
Tenex High blood pressure (alpha blocker)
Tenormin High blood pressure, heart problems, angina (beta blocker)
Tequin Infection (anti-infective)
terazosin High blood pressure (alpha blocker)
tetracycline Infection (antibiotic)
Theo-Dur Breathing problems (bronchodilator)
theophylline Breathing problems (bronchodilator)
Tiazac High blood pressure
Ticlid Stroke (antiplatelet)
Tigan Nausea and vomiting (antiemetic)
Tofranil Depression (antidepressant)
Tolinase Diabetes (oral antidiabetic)
Topamax Seizures
Toprol High blood pressure (beta blocker)
Toradol Short-term pain
tramadol Pain (analgesic)
trazodone Depression (antidepressant)
Trental Vascular disease (blood thinner)
triamterene High blood pressure (diuretic)
Triavil Anxiety, depression (antidepressant)
Tricor High triglycerides (antilipemic)
trimethoprim Infection, mainly urinary tract (antibiotic)
Trimox Infection (antibiotic)
Triphasil Birth control pill
Trivora-28 Birth control pills
Tussionex Cough (antitussive)
Tylenol with codeine (Tylenol #3) Pain
Ultram Pain (analgesic)
valacyclovir Herpes (antiviral)
Valium Anxiety (antianxiety)
valproic acid Seizure disorder (anticonvulsant)
Valtrex Herpes (antiviral)
Vantin Infections (antibiotic)
Vasotec High blood pressure, heart failure
Veetids Infection (antibiotic)
venlafaxine Depression (antidepressant)

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Ventolin Breathing problems (bronchodilator)
verapamil Angina, high blood pressure, rapid heart rate
Viagra Male impotence
Vibramycin Infection (antibiotic)
Vicodin Pain (narcotic)
Vicoprofen Pain (narcotic analgesic)
Viramune Antiretroviral
Viread Antiretroviral
Voltaren Arthritis (anti-inflammatory)
Vytorin High cholesterol
warfarin sodium Blood clots (blood thinner)
Wellbutrin Depression (antidepressant)
Xalatan Glaucoma
Xanax Anxiety, depression (sedative)
Xenical Weight loss
Xopenex Breathing problems
Yasmin Birth control
YAZ Birth control
Zantac Ulcers, gastric problems (antiulcer)
Zerit Antiretroviral
Zestoretic High blood pressure
Zestril High blood pressure (ACE inhibitor)
Zetia High cholesterol
Ziac High blood pressure (beta blocker, diuretic)
Zithromax Infection (antibiotic)
Zocor High cholesterol (cholesterol-lowering agent)
Zofran Nausea
Zoloft Depression (antidepressant)
zolpidem Sleep aid
Zomig Migraine headaches
zonisamide Seizures
Zovirax Herpes, shingles, chicken pox (antiviral)
Zyflo Asthma
Zyloprim Gout
Zyprexa Psychological disorders (antipsychotic)
Zyrtec Allergies (antihistamine)

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