2. Protocol Changes
• Effective October 1st, 2014 the following protocol
modifications will take effect:
– Midazolam dose changes and physician order’s
required for repeat dosing
– Lactated Ringers added for Trauma and Burn patients
– Updated Selective Spinal Immobilization protocol
• Further training will be sent out October 1st (waiting for
clarification from the State)
3. MIDAZOLAM
• Adults:
• OLD protocols included dose ranges from 0.5 mg to 2.5 mg and
option to repeat up to 5 mg on standing orders
• NEW protocols have specific dose of 1 mg, 2 mg, or 4 mg based
on patient’s age and route of administration. After initial
administration, physician orders are REQUIRED for any further
dose.
• Pediatrics:
• OLD protocols included dose range of .01 mg/kg to .02 mg/kg and
repeat on standing orders.
• NEW protocols have specific dose of .02 mg/kg and physician
order’s are REQUIRED for any further dosing.
4. Protocol 2- Airway
• Original: Midazolam 2.5mg
IV/IO, may repeat in 5minutes
if needed.
• CCAAUUTTIIOONN: Use only with
definitive airway in place.
• Update: Midazolam 2 mg
IV/IO/IN. Contact Medical
Control for Additional dosing
5. Protocol 6: Behavioral
• Original Midazolam 1-2.5mg
IV/IO/IN
• 5mg IM, Age =/> 65 0.5mg-
1mg IV/IN 2.5 mg IM, May
repeat Maximum 5mg
• Update: Midazolam 2mg
IV/IO/IN or 4mg IM, Age
=/> 65 1mg IV/IO/IN or 2mg
IM, Contact Medical Control
for additional dosing
6. Protocol 6 Behavioral Con’t
• Original: Midazolam
2.5mg IV/IN 5mg IM,
Age =/> 65 1-2.5mg
IV/IN 2.5mg IM, Repeat
every 2-3 minutes as
needed
• Update: Midazolam
2mg IV/IO/IN or 4mg
IM, Age =/> 1mg
IV/IO/IN or 2mg IM.
Contact Medical
Control for additional
dosing
7. Protocol 12: Bradycardia Pulse
Present
• Original: Midazolam
0.5mg to 2.5mg IV/IO,
may repeat as needed,
Maximum dose 5mg
• Update: Midazolam
2mg IV/IO/IN,
Contact Medical
Control for additional
dosing
8. Protocol 16
Adult Tachycardia; Narrow
Complex
• Original: Midazolam
0-2.5 IV/IO, May
repeat if needed,
Maximum 5mg
• Update: Midazolam
2mg IV/IO/IN Contact
Medical Control for
additional dosing
9. Protocol 17
Adult Tachycardia; Wide Complex
• Original: Midazolam
0-2.5mg IV/IO, may
repeat if needed,
Maximum 5mg
• Update: Midazolam
2mg IV/IO/IN,
Contact Medical
Control for additional
dosing
10. Protocol 19
Post Resuscitation
• Original Versed 2.5mg
IV/IO, May repeat in 5
minutes if needed.
• Update: Midazolam
2mg IV/IO/IN,
Contact Medical
Control for additional
dosing
11. Protocol 32
Seizure
• Original: Midazolam
0.5mg-2.5mg IV/IO, 5mg
IM or 2mg IN if no IV/IO
access, May repeat every
3-5 minutes as needed,
Maximum 10mg
• Update: Midazolam 2mg
IV/IO/IN or 4mg IM if no
IV/IO access. Contact
medical Control for
additional dosing
12. Protocol 39
Obstetrical Emergency
• Original: Midazolam
2.5mg IV/IO, May repeat
every 3-5 minutes as
needed, Midazolam 5mg
IM or 2mg IN, if no IV/IO
access, Maximum 10mg
• Update: Midazolam 2mg
IV/IO/IN or 4mg IM if no
IV/IO access, Contact
Medical Control for
additional dosing
13. Protocol 44
Pediatric Airway
• Original: Midazolam 0.1-
0.2mg/kg IV/IO, May
repeat in 5 minutes if
needed, Use only with
definitive airway in place
• Update: Midazolam
0.2mg/kg IV/IO, Contact
Medical Control for
additional dosing. Use
ONLY with definitive
airway in place.
14. Protocol 52
Pediatric Tachycardia
• Original: Midazolam
0.1-0.2mg/kg IV/IO,
may repeat if needed,
Maximum 5mg,
0.2mg/kg IN maximum
2mg.
• Update: Midazolam
0.2mg/kg IV/IO/IN,
Contact Medical
Control for additional
dosing
15. Protocol 54
Pediatric Post Resuscitation
• Original: Versed 0.1-
0.2mg/kg IV/IO, may
repeat in 3-5 minutes as
needed.
• Update: Midazolam
0.2mg/kg IV/IO,
Contact Medical
Control for additional
dosing
16. Protocol 62
Pediatric Seizure
• Original: Midazolam
0.1-0.2 mg/kg IV/IM/IO
maximum 2mg,
Midazolam 0.2mg/kg
IN maximum 2mg.
• Update: Midazolam
0.2mg/kg IV/IO/IN/IM
Contact Medical
Control for additional
dosing
17. Protocol 78
Bites and Envenomations
• Orignial: Medazolam
0.5-2mg IV/IO over 2-
3 minutes, Midazolam
1 to 2mg IN,
Midazolam 5mg IM,
Maximum 5mg.
• PED: Midazolam 0.1-
0.2mg/kg IV/IO over
2-3 minutes,
Midazolam 0.2mg/kg
IN
18. Protocol 78
Continued
• Update: Midazolam
2mg IV/IO over 2-3
minutes OR 2mg IN
OR 4mg IM. PED:
Midazolam 0.2mg/kg
IV/IO over 2-3
minutes OR
Midazolam 0.2mg/kg
IN. Contact medical
control for additional
dosing
19. Protocol 88
Crush Syndrome Trauma
• Original: Midazolam
0.5-2mg IV/IO, 1-2mg
IN, Maximum 5mg.
Peds: 0.1-0.2mg/kg
IV/IO, 0.2mg/kg IN,
Maximum 2mg.
• Slowly over 2-3
minutes
20. Protocol 88
Crush Syndrome Continued
• Update: Midazolam
2mg IV/IO/IN, Peds
0.2mg/kg IV/IO/IN
• Slowly by over 2-3
minutes as needed.
Contact Medical
Control for additional
dosing
21. Lactated Ringers
• Lactated Ringer’s (LR) will be added to all of the
units October 1st, 2014.
• The exact amount and location will be announced
prior to being placed on the units.
• LR has been added to CCFEMS Protocols ONLY
for Trauma and Burn patients.
22. Lactated Ringers Continued
• Isotonic crystalloid used to treat hypovolemia due
to burns and loss of blood volume.
• Invented in the early 1880s by Sydney Ringer and
is also known as Hartmann's solution. Lactated
Ringers contain 130 mEq of Sodium, 109 mEq of
Chloride, 28 mEq of Lactate, 4 mEq of Potassium,
and 3 mEq of Calcium per liter with a pH of 6.5.
In comparison, Normal Saline contains 154 mEq
of Sodium and 154 mEq of Chloride and has pH
of 5.5.
23. Lactated Ringers Continued
• Lactated Ringers use is contraindicated with a
known hypersensitivity to sodium lactate. It
should be used with caution in patients with
conditions that may predispose them to
hyperkalemia such as renal failure as the
potassium may worsen this condition.
24. Lactated Ringers Continued
• LR is the fluid replacement of choice in the
treatment of significant burns and should be
administered according to protocol using the
percentage of burn and weight based formula in
the protocol (Parkland formula).
• Some studies indicate LR maybe superior to
normal saline for fluid replacement of the trauma
patient. Boluses for the hypotensive patient should
be the same as with normal saline. LR is
compatible with all pre-hospital drugs.
25. Protocol 42
Multiple Trauma
• Original: Normal Saline
Bolus 500mL IV/IO
Repeat to effect SBP
=/> 90, Maximum 2
Liters
• Update: Normal Saline
OR Lactated Ringers
Bolus 500mL IV/IO
Repeated to effect SBP
=/> 90 Maximum 2
Liters
26. Protocol 66
Pediatric Multiple Trauma
• Original: Normal Saline
Bolus 20mL/kg IV/IO,
Repeat to effect age
appropriate SBP =/> 70 +
2x age, Maximum
60mL/kg
• Update: Normal Saline or
Lactated Ringers Bolus
20mL/kg IV/IO, Repeat to
effect age appropriate
SBP =/> 70 + 2x age,
Maximum 60 mL/kg
