EMT Standing Order:

• Routine patient Care.
• Assist inadequate ventilations with BVM (bag-valve-mask) ventilation.
• If the patient is in cardiac arrest, begin immediate chest compressions (See Cardiac Arrest Protocol - Adult).
• For suspected opioid overdose with severe respiratory depression, administer:
• For suspected CO toxicity or isolated cyanide poisoning, apply 100% oxygen via a non-rebreather. And See Smoke Inhalation Protocol - Adult.
• For decontamination/hazardous materials exposure, see Hazardous Materials Exposure
• For hypoglycemia, see Diabetic Emergencies (Hypoglycemia) Protocol Adult.
• For seizures, see Seizure Protocol - Adult.
• Acquire and transmit 12-lead ECG if available.
• Consider contacting Poison Control as soon as practical for consultation.
• Call for AEMT/Paramedic intercept, if available & assist them in patient care.

AEMT/Paramedic Standing Order

• For severe respiratory depression, administer naloxone 0.4 - 2 mg IV/IM/IO/ SQ/intranasal.
• Establish IV access.
  • Consider restraint. See Restraint Procedure.
• Titrate to response.
  • If there is no response, may repeat the initial dose every 3 - 5 minutes to a total of 12 mg.
• If Ingested Poison:
  • Contact Medical Direction.

Suggested Treatments :

• Dystonic Reaction:
  • Diphenhydramine 25 - 50 mg IV/IM
• Organophosphates, see Nerve Agent/Organophosphate Protocol - Adult (22 Medical).
• For severe agitation, seizures or hyperthermia:
  • Midazolam 2.5 mg IV/intranasal, may repeat once in 5 minutes OR 5 mg IM, may repeat once in 10 minutes; OR
  • Diazepam 2 mg IV, may repeat once in 5 minutes,
    • Tricyclic with symptomatic dysrhythmias, (e.g., tachycardia and wide QRS > 110 Beta Blocker and Ca Channel Blocker, see Bradycardia Protocol - Adult
      o Sodium bicarbonate 1 to 2 mEq/kg IV/IO

Signs & Symptoms

• Acetaminophen: Initially normal or nausea/vomiting. If not detected and treated, may cause irreversible liver failure.
• Anticholinergic:Tachycardia, fever, dilated pupils, mental status changes.
• Aspirin:Abdominal pain, vomiting, pulmonary edema, tachypnea, fever, tinnitus and/ or altered mental status. Renal dysfunction, liver failure, and/or cerebral edema among other things can take place later. Consider in elderly with altered mental status.
• Cardiac Medications:Dysrhythmias, altered mental status, hypotension, hypoglycemia.
• Carbon Monoxide (CO) Poisoning: A colorless, oderless gas causing headache, dizziness, weakness, nausea, mental changes, seizure, coma, death.
• Sedatives/Depressants: Bradycardia, hypotension, decreased temperature, decreased respirations, pinpoint or non-specific pupils (miosis).
• Dystonic Reaction: Neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. This may be induced byantipsychotics, such as haloperidol, or anti-emetics such as prochlorperazine or metoclopramide.
• Akathisia: May consist of feelings of anxiety, agitation, and jitteriness, as well as inability to sit still / pacing. This may be induced by antipsychotics, such as haloperidol, or anti-emetics such as prochlorperazine or metoclopramide.
• Opioids: Respiratory arrest or hypoventilation, evidence of opiate use (bystander report, drug paraphernalia, opioid prescription bottles, “track marks”), depressed mental status, miosis (constricted or “pinpoint” pupils).
• Organophosphates: Bradycardia, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils, SLUDGEM, BBB.
• Solvents: Nausea, coughing, vomiting, and mental status change.
• Sympathomimetic/Stimulants:Tachycardia, hypertension, increased temperature, dilated pupils, anxiety, paranoia, diaphoresis. Examples are bath salts, cocaine, caffeine, methamphetamine, ecstasy, ADHD drugs, thyroid meds (rarely), albuterol.

Tricyclic (Cyclic): Seizures, dysrhythmias, hypotension, decreased mental status or coma.