The document summarizes updates made to the 2016 Southwest Ohio Pre Hospital Protocol by the Protocol Subcommittee of the Academy of Medicine of Cincinnati. It includes minor grammatical changes, additions of new protocols for infectious disease and pain management, updates to trauma and cardiac arrest protocols, additions of medications for conditions like asthma and heart failure, and clarification of procedures. It provides direction on renewing the drug license and finalizing approval of the updated protocols.

1. 2016
Southwest Ohio
Pre Hospital Protocol
Update
Academy of Medicine of Cincinnati
Protocol Subcommittee
Hamilton Lempert, MD FACEP CEDC
Chairman

2. Protocol Committee
Hamilton Lempert, MD FACEP CEDC Chairman
Mary Ahlers, RN, CPC, NRP
Justin Benoit, MD
Larry Bennett, Esq
Mike Bilkasley, EMT-P, L.O., L.Ped
Mike Bohanske, MD
Todd Burwinkel EMT-P
Dustin J. Calhoun, MD
Steve Coley NREMT-P
Kenneth Crank, NREMT-P
Dave Derbyshire, NREMT-P
Tom Dietz, NREMT-P
Jeff Durr, EMT-P
Pamela Erpenbeck RN, NREMT-P
Paul Gallo, EMT-P
Ryan Gerecht, MD
Marilyn Goin EMT-P
Nicole Harger, PharmD
Randall Johann, FP-C, EMT-P
Randall Johann, FP-C, EMT-P
Andy Kalb, EMT-P
Dave Kemper EMT-P
Ashley Larrimore, MD
Daniel Mack, NREMT-P
Jason McMullan, MD
Mike Moyer, PhD, MS, EMT-P
Will Mueller, EMT-P
Bob Murray, EMT-P
Mel Otten, MD
Todd Owens, EMT-P
Russ Pollack
Joel Pranikoff, MD
Ros Pwalk
Lauren Riney, DO
Hamilton Schwartz, MD
Emily Sterrett, MD
Mike Steuerwald, MD
Joe Stoffolano, NREMT-P
Ed Von Lehmden, NREMT-P
Scott Williams, NREMT-P

3. Introduction
• A few small grammatical changes
• Magnesium to Magnesium Sulfate
• Added to introduction not to give medications that a
patient is allergic to

4. Administrative
• New Protocol for Infectious Disease – A110
• Approach to patient with
• SARS, MERS, Swine Flu, Ebola, etc….
• Updated A106 to be in agreement to ORC
• Defined valid DNR
• Removed need to call medical control
• A107
• Mercy Fairfield fax number updated

5. Symptom Based
• Trauma Triage Changes
• Physiologic Criteria
• Modified “Needs intubation” to “Need for ventilatory support”
• Respiratory rate less than 20 in infants less than 1 year old
• Added pulse greater than 90 in Geriatric
• Added to signs of shock
• Tachycardia, bradycardia, hypotension
• Anatomic Criteria
• Added Open skull fracture
• Mechanism Changes
• Added Vehicle telemetry data consistent with high risk injury

6. Trauma Triage
• Per the state submersion injuries, strangulation and
asphyxia should go to trauma center
• Burns
• Full thickness or partial thickness greater than ten
percent total body surface area, or other significant
burns involving the face, feet, hands, genitalia, or
airway. 1st degree burns are not calculated in TBSA.
• Mechanism of injury does not make a trauma patient
but needs to be considered

7. Push Dose EPI
• 1 ml of 1:10,000 epi – cardiac epi
• Mix with 9 ml of Normal Saline
• Administer 1 ml every 1-2 minutes as needed
• Takes the place of Dopamine

8. Cardiac
• C308 Traumatic Cardiac Arrest
• Added need to control bleeding per T710

9. Medical
• M400 ACS
• Added some other Erectile Dysfunction meds and
Pulmonary Hypertension drugs
• Added Nitro alternative to M400 ACS and M404 CHF
• 1. Nitroglycerin 0.4 mg sublingual every 3-5 minutes to a
max of 3 doses only if SBP remains greater than 100
• 2. Topical nitroglycerin (Nitropaste) may be used in lieu of
sublingual nitroglycerin. Apply 1 inch of nitropaste to the
anterior chest wall one time.
• Added to remove the nitropaste if the patient become
symptomatic with feeling faint, lightheaded, dizzy or
hypotensive.

10. Medical
• M404 CHF – Nitro use more complex
• 1. For patients with mild symptoms (eg. HR < 100, SBP 100-150, RR <25, no
accessory muscle use, retractions, fatigue or O2 sats >94%) Administer LOW DOSE
nitroglycerin 0.4 mg sublingual every 3-5 minutes to a max of 3 doses
• 2. For patients with moderate to severe symptoms (eg. HR >100, SBP >150mmHg,
RR >25, accessory muscle use, retractions, fatigue, O2 sats <94%) consider HIGH
DOSE nitroglycerin 0.8 mg SL (2 tablets or 2 sprays of 0.4mg nitroglycerin) q 3-5
minutes for max 3 doses. Don’t remove CPAP to provide additional doses of
nitroglycerine.
• 3. Topical nitroglycerin (nitropaste) may be used in lieu of sublingual nitroglycerin.
Apply the nitropaste to the anterior chest wall one time. Dosing is 1" for SBP 100-150,
1.5" for 150-200, and 2" for SBP>200.
• 4. Blood pressure must be reassessed after each dose of nitroglycerin is given.
Repeat doses should not be given if SBP is less than 100mmHg. The goal is for a 20%
reduction in patient’s blood pressure
• 5. In addition to blood pressure, carefully monitor level of consciousness and
respiratory status. Do not administer NTG tablets if decreased respiratory rate, level of
consciousness or other concerns for aspiration exist based on patient’s clinical status
• 6. If inferior MI evident on EKG contact medical control prior to administering
nitroglycerin

11. Medical
• M403 Asthma – COPD
• Clarified that epi is for asthma patients if needed
• M409 Allergic Reaction – Anaphylaxis
• Clarified for Epi Anterolateral thigh is the preferred IM administration
site for 1:1000 epi. Other sites may be used if preferred site would
cause unneeded delay. Absorption is fastest with IM injection in the
thigh.
• M411 Toxicological Emergencies
• Added some other named medications to the list of Beta Blockers
and Calcium Channel Blockers
• Added suggested premedication with Zofran if giving glucagon

12. Medical
• M411 Toxicological Emergencies
• Changed that Cyanokit can turn the skin red

13. Surgical
• S505 Pain management and P612
• Removed requirement for specific painful conditions in order
to give patients pain meds
• S506 TXA Administration
• Added that it should not be given in isolated closed head
injury
• Reminder that it is not yet for pediatrics
• There has been some questions about how to administer
TXA over 10 minutes. This is an approximate time. Infusing
100 ml over approximately 10 minutes can be done by a
variety of methods including but not limited to: counting
drops of a macro or mico drip set; on a pump; or just
estimating. The range of infusion should be between 5 and
15 minutes.

14. Surgical
Tranexamic acid (TXA) Checklist
Administration of TXA is indicated if all of the following criteria are present
1) Age  16
2) Evidence of significant blunt or penetrating traumatic injury
(MVC with ejection, rollover MVC, fall > 20 ft, pedestrian struck, penetrating injury to head,
neck, torso, etc.)
3) Evidence of or concern for severe internal or external hemorrhage
(bleeding requiring a tourniquet, unstable pelvic fracture, two or more proximal long-bone
fractures,
flail chest etc.)
4) Sustained Systolic BP < 90mmHg (or < 100mmHg if older than 55 yo)
5) Sustained heart rate > 110 bpm
6) Time since the initial injury is known to be < 3 hours
To administer TXA: Mix 1g of TXA in 100ml of 0.9% Normal Saline or Lactated Ringers & infuse over 10
minutes IV or IO. (If given as an IV push, may cause hypotension) Use dedicated IV/IO line if possible and Do NOT
administer in the same IV or IO line as blood products, factor VIIa, or Penicillin

15. Pediatric
• Added Steroids to P607 Pediatric Respiratory Distress
(Wheezing or Asthma)
• Prednisolone 3mg/ml liquid
• Age 3-7 years: 30mg (10ml)
• Age 8-16 years: 60mg (20ml)
• Prednisone 20mg tablets
• Age 3-7 years: 30mg (1.5 tabs)
• Age 8-16 years: 60mg (3 tabs)
• Solumedrol IV solution to be administered PO (125mg/2ml)
• Age 3-7 years: 30mg (0.5ml)
• Age 8-16 years: 60mg (1ml)

16. Pediatrics
• P607 Pediatric Respiratory Distress (Wheezing or
Asthma)
• Steroids work by reducing airway inflammation,
mucous plugging, and secretions, which can be seen
within 1-2 hours after administration. Oral
corticosteroids have been proven to reduce rates of
hospital admission and length of ED stay if given early
for children presenting to the ED with asthma
exacerbations.
• For patients who vomit their oral steroids, please
document the episode and make sure it is part of
handoff to the receiving institution, but do not re-dose
the medication.

17. Pediatrics
• P613 Pediatric Head or Spinal Trauma
• Clarified Hyperventilation
• If altered mental status, assure good oxygenation and
ventilation of the patient and maintain control of the C-spine.
• ONLY if the patient has obvious asymmetric pupils with
altered mental status, hyperventilate to 30 breaths/minute or
a goal end-tidal CO2 of 30mmHg. STOP if pupils normalize
• Added Hypertonic Saline to Medics
• ONLY if the patient has obvious asymmetric pupils with
altered mental status, administer 3% saline solution if
available.
• PEDIATRIC DOSE: 8 mL/kg IV/IO ONCE; max 500mL.

18. Pediatric
• Updated P616 Pediatric Immersion Injury to better
define where patients should go and why
• Pediatric Level 1 Trauma Center capable of
• Extracorporeal membrane oxygenation (ECMO)
• Many small grammatical updates
• Added that if there is ice in the area of moving water,
but not seen in the water

19. Procedures
• T711 IO access
• Added dose of lidocaine (1-2 ml for adults)

20. Quick Sheets
• Updated both Adult and Pediatric
• Each one now 2 pages
• Re-organized

21. Medications
• Added
• Nitropaste
• Prelone

22. Additional Resources
• Added Listing of all drugs used in protocol
• Listing by drug
• Listing by protocol
• Explanatory page for each drug

23. Drug Listings
Class Antidysrhythmic
Mechanism of
Action
Slows AV node conduction
Indications Symptomatic PSVT
Contraindications -Second- or third-degree heart block
-Sick-sinus syndrome
Precautions -Arrythmias, including blocks, are common at the time of
cardioversion
-Use with caution in patients with bronchospam
Adverse Effects Facial flushing, headache, shortness of breath, dizziness,
nausea, lightheadedness, chest pressure, discomfort of neck,
throat or jaw, AV block
Adult Dose Adenosine 6mg given as rapid IVP over 1-2 seconds. If
cardioversion does not occur after 1-2 minutes, may repeat with
adenosine 12mg rapid IVP over 1-2 seconds up to 2 times.
Pediatric Dose ≥ 50 kg: Use adult dose. Think fluids in young children and
infants.
Route/Administra
tion
Rapid IVP over 1-2 seconds. Should be administered directly
into a vein or into the medication administration port closest to
the patient and followed immediately by a flush of the line with
IV fluid
Monitoring Vitals, cardiac monitoring
Special
Considerations
-6 second half-life – must get into the patient as quickly as
possible
-Feeling of “impending doom”
-Brief asystole possible
-Profound dyspnea possible
-Pregnancy Class C – ACLS guidelines suggest use is safe and
effective in pregnancy
ADENOSINE (Adenocard)

24. Drug License
• New drug license renewal scheduled to renew in March 2016
• May want to wait until at least January for final edits
• Go to State Pharmacy Board website to renew
• Upload 2016 protocols, drug list, personnel list
• Protocol and drug list must be notarized
• Instructions on State website and will get letter from state by
snail mail
• Call Todd Owens of Reading with any questions
• 733-5537

25. Final Approval
• 2016 Protocols posted on Academy of Medicine
Website on October 1st. academyofmedicine.org
• Open for comments until December 1st
• Please find all of our typo’s and mistakes
• Send your comments to Dr. Lempert
hlempert9@gmail.com
• Updated Protocols will be posted on Academy of
Medicine website the last week of December for
implementation January 1st, 2016