2018. pre hospital workbook

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Ambulance Protocol
Workbook
2018.10

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For my friends, chiefs in the wonderful place I had been
And for myself
Nguyen Duc Thanh Liem
2018.10

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Contents
Protocol-Universal.......................................................................................................................................................................... 7
1 Universal Treatment Guideline......................................................................................................8
Question .............................................................................................................................................8
Answer................................................................................................................................................9
2 Rapid Sequence Intubation..........................................................................................................10
Question ...........................................................................................................................................10
Answer..............................................................................................................................................11
3 Failed Airway ...................................................................................................................................12
Question ...........................................................................................................................................12
Answer..............................................................................................................................................13
4 Pain Management ...........................................................................................................................14
Question ...........................................................................................................................................14
Answer..............................................................................................................................................15
5 Police Custody ................................................................................................................................16
Question ...........................................................................................................................................16
Answer..............................................................................................................................................17
Protocol-Internal Medicine.......................................................................................................................................................... 18
1 Allergic Reaction.............................................................................................................................19
Question ...........................................................................................................................................19
Answer..............................................................................................................................................20
2 Anxiety...............................................................................................................................................21
Question ...........................................................................................................................................21
Answer..............................................................................................................................................22
3 Behavioral Emergencies...............................................................................................................23
Question ...........................................................................................................................................23
Answer..............................................................................................................................................24
4 Excited Delirium..............................................................................................................................25
Question ...........................................................................................................................................25
Answer..............................................................................................................................................26
5 COPD/Asthma..................................................................................................................................27
Question ...........................................................................................................................................27
Answer..............................................................................................................................................28
6 Diabetic Emergency.......................................................................................................................29
Question ...........................................................................................................................................29

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Answer..............................................................................................................................................30
7 Hypotension.....................................................................................................................................31
Question ...........................................................................................................................................31
Answer..............................................................................................................................................32
8 Nausea/ Vomiting............................................................................................................................33
Question ...........................................................................................................................................33
Answer..............................................................................................................................................34
9 Overdose...........................................................................................................................................35
Question ...........................................................................................................................................35
Answer..............................................................................................................................................36
10 Respiratory distress ....................................................................................................................37
Question ...........................................................................................................................................37
Answer..............................................................................................................................................38
11 Seizure.............................................................................................................................................39
Question ...........................................................................................................................................39
Answer..............................................................................................................................................40
12 Stroke/ CVA....................................................................................................................................41
Question ...........................................................................................................................................41
Answer..............................................................................................................................................42
13 Syncope ..........................................................................................................................................43
Question ...........................................................................................................................................43
Answer..............................................................................................................................................44
Protocol-Cardiology ..................................................................................................................................................................... 45
1 Acute Coronary Syndrome...........................................................................................................46
Question ...........................................................................................................................................46
Answer..............................................................................................................................................46
2 Supra-Ventricular Tachycardia (SVT)........................................................................................47
Question ...........................................................................................................................................47
Answer..............................................................................................................................................48
3 A-Fib with Repetitive ventricular response (RVR) .................................................................49
Question ...........................................................................................................................................49
Answer..............................................................................................................................................49
4 Ventricular Tachycardia with Pulse...........................................................................................50
Question ...........................................................................................................................................50
Answer..............................................................................................................................................51

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5 Symptomatic Bradycardia............................................................................................................52
Question ...........................................................................................................................................52
Answer..............................................................................................................................................53
6 Adult Cardiac Arrest – 7 Post Resuscitation – 8 Post Resuscitation Induced
Hypothermia........................................................................................................................................54
Question ...........................................................................................................................................54
Answer..............................................................................................................................................55
9 Hypertension (HTN)........................................................................................................................56
Question ...........................................................................................................................................56
Answer..............................................................................................................................................57
10 Congestive Heart Failure............................................................................................................58
Question ...........................................................................................................................................58
Answer..............................................................................................................................................58
Answer..............................................................................................................................................59
11 Ventricular Ectopy........................................................................................................................60
Question ...........................................................................................................................................60
Answer..............................................................................................................................................61
Protocol-Trauma........................................................................................................................................................................... 62
1 Selective spinal immobilization ..................................................................................................63
Question ...........................................................................................................................................63
Answer..............................................................................................................................................64
2 Crush Injury......................................................................................................................................65
Question ...........................................................................................................................................65
Answer..............................................................................................................................................66
3 Major Trauma...................................................................................................................................67
Question ...........................................................................................................................................67
Answer..............................................................................................................................................68
4 Extremity Trauma & 5 Extremity Hemorrhage/ Amputation................................................69
Question ...........................................................................................................................................69
Answer..............................................................................................................................................70
6 Burns- Electrical/ Chemical & 7 Burns- Thermal....................................................................71
Question ...........................................................................................................................................71
Answer..............................................................................................................................................72
8 Marine Life Envenomation (Jellyfish and Stingray)...............................................................73
Question ...........................................................................................................................................73

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Answer..............................................................................................................................................74
9 Snake Bite.........................................................................................................................................75
Question ...........................................................................................................................................75
Answer..............................................................................................................................................76
10 Drowning/ Near Drowning..........................................................................................................77
Question ...........................................................................................................................................77
Answer..............................................................................................................................................78
Protocol-Obstetric ........................................................................................................................................................................ 79
1 Active Labor.....................................................................................................................................80
Question ...........................................................................................................................................80
Answer..............................................................................................................................................81
2 Obstetrics Emergency...................................................................................................................82
Question ...........................................................................................................................................82
Answer..............................................................................................................................................83
Feedback...................................................................................................................................................................................... 85

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Protocol-Universal

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1 Universal Treatment Guideline
Question
1. The three expectations are needed once encounter with every patient?
2. The three things are needed to consider before approaching patient and performing an initial assessment.
3. What need to be done (in Communication) after Secondary Survey with Detailed History was already
performed?
4. What should be done as needed (in Communication) after Secondary Survey with Detailed History was
already performed?
5. How much O2 Sat level is the threshold to consider supplement oxygen?

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Answer
1.
(1) Facility (e.g. Family Medical Practice, or [Name] Hospital) badge displayed
(2) Appropriate dress code
(3) Highest degree of professionalism
2.
(1) Scene safety
(2) Bring all necessary equipment to Scene (patient is there)
(3) Personal protective equipment (PPE) ass needed
3.
(1) Document Patient Case Report
(2) Obtain signature
4.
(1) Notify receiving medical facility (about the patient and her/his condition)
(2) Transmit ECG
(3) Transmit patient information (info.)
(4) Notify Supervisor
5.
• O2 Sat < 92%
Protocol Page 33

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2 Rapid Sequence Intubation
Question
1. What are the clinical indications of Rapid Sequence Intubation (RSI)?
2. Which kind(s) of patient is/are not an indication of RSI?
3. What are the indicators of successful intubation? (see [1]- hear [2,3]- measure [4]- and assess [5])
4. How often the indicators of successful intubation are performed?
5. Medication Dosage in RSI (table in the end)
6. How long the preoxygenated performance via Bag-valve-mask need to done before its next step (of RSI)?
7. How much are SatO2 needed to remain?
8. How many the attempt of intubation is/are indicator of Failed Airway?
9. How many times of intubation the First Medic/ Ambulance Doctor should perform before the Second Medic/
Ambulance Doctor make the last one for intubating patient (based on RSI protocol)?
10. Why Medical Staff (Medic/ Ambulance Doctor) should paralyzing patient with proper sedation?
11. What is the three main points needed to be present in Documentation of RSI procedure?
12. When should use the KING VISION if available?
Medication Pediatric dosage (first dose) Adult dosage (first doses)
Etomidate
Succinylcholine
Midazolam
Vecuronium
Fentanyl

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Answer
1.
• Patients who require the control of airway due to either the airway compromise or the potential of that
condition (airway compromise).
• Patients who require control of the airway due to airway compromise or the potential for airway compromise.
2.
(1) Deeply comatose patient
(2) Patient in cardiac arrest
3.
(1) Visualization of tube going through Vocal Cords
(2) Audible and equal breath sounds bilaterally (lung fields)
(3) Lack of sounds over epigastric region
(4) Positive End-tidal CO2
(5) Improvement in vital signs and color
4.
• Assess the five indicators after EACH ATTEMPT.
5.
Medication Pediatric dosage (first dose) Adult dosage (first doses)
Etomidate 0.3 mg/kg 20mg
Succinylcholine 1 mg/kg 100mg
Midazolam 0.1 mg/kg 5mg
Vecuronium 0.1 mg/kg 10mg
Fentanyl 100mcg
6.
• Preoxygenate patient 100% O2 via Bag-valve-mask for 30-90 seconds
7.
• Monitor pulse oximetry when available. It needs to remain SatO2 ≥ 90% in RSI protocol.
8.
• Three unsuccessful attempts
9.
• Two
• A Second Medic should make the third attempt at intubation if Three attempts are needed.
10.
• Paralyzing a patient without proper sedation is cruel and poor medical practice.
11.
(1) GCS prior the intubation procedure
(2) Indication of intubation
(3) Placement confirmation methods.
12.
(1) Patient with C-spine immobilization
(2) Strongly recommended for all intubations
Protocol Page 34

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3 Failed Airway
Question
1. What are the indications of Failed Airway?
2. A 35-year-old male was found on scene of motorcycle accident. He was not fully alert, shortness of
breathing, palpable pulse (radius), traumatic face with a losing of nose and a deformity of both maxillary
and mandibular. BP 150/90 mmHg. P 110/ min. SpO2 88%. As a paramedics/ ambulance doctor, to support
the breathing you will: (chose one in four following)
A. Ventilation with Bag-valve-mask to maintain SpO2 95-98%
B. Place King Tube
C. Announce over the Radio “Medic Failed Airway Protocol”
D. Ventilation patient at a ≤ 12/ min, keeping SpO2 above 90%

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Answer
1.
(1) Bag-valve-Mask fail to maintain SpO2 > 90% or becomes difficult to ventilate
(2) Three failed total attempts at oral-tracheal intubation
2.
• SpO2 < 90% → Facial trauma (or Swelling) → C Announce over the Radio “Medic Failed Airway
Protocol”→ Surgical Airway or QuickTrach → Ventilation patient at a ≤ 12/ min, keeping SpO2 above 90%
• SpO2 < 90% → NO Facial trauma/ swelling → B Place King Tube
• SpO2 > 90% → A Ventilation with Bag-valve-mask
Protocol Page 35

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4 Pain Management
Question
1. For relieving a suspected right leg fracture in a stable patient, you had put a splint. However, the 45-year-
old male patient (weight: 60kg) still moaned due to shakings during moving of Ambulance. It was just three
minutes, and the estimated Time of Arrival (ETA) was approximately 20 minutes. BP 130/80. P 100. RR
25. SpO2 99% (ambient air). Patient had no allergies. What should you do?
A. Morphine 5 mg IV/IM
B. Morphine 2.5 mg IV/IM
C. Fentanyl 50 mcg IV/IM/IN
D. Fentanyl 25 mcg IV/IM/IN
E. A and C are right
F. B and D are right
2. For relieving a suspected right thigh fracture in a 75-year-old male patient (weight: 60kg) patient, you had
put a splint. However, he still moaned due to shakings on Ambulance. It was just three minutes, and the
estimated Time of Arrival (ETA) was approximately 20 minutes. BP 85/50. P 110. RR 25. SpO2 99%
(ambient air). Patient had no allergies. What should you do?
3. The medical emergency team had approached a 28-year-old female who complained of “camping pain in
lower bowel”. She was 38-week pregnant (weight 55kg). On ambulance, she was distress and irrigated and
teared due to that pain. BP 120/80. P 110. RR 25. SpO2 99% (ambient air). Patient had no allergies. What
should you do?
4. A 29-year old female (weight 50kg) with history of Sickle Cell Disease and Stage 2 Renal Failure
complained of tummy pain, an uncountable diarrhea and vomiting last night. The medical emergency team
had approached patient, during the assessment, she vomited 2 times and moaned of pain in whole body.
Team decided to transfer patient to clinic. On ambulance, the estimated time of arrival (ETA) was
approximately 30 minutes due to heavy traffic. BP 100/70. P 100. SpO2 99% (ambient air). Patient had no
allergies. What should you do? (Chose the applicable answers on this situation)
D. Ondansetron 4mg IV
E. Normal saline 500mL IV
F. Normal saline 1000mL IV
5. For relieving a suspected right leg fracture in a stable patient, you had put a splint. However, the 45-year-
old male patient (weight: 60kg) still moaned due to shakings during moving of Ambulance. It was just three
minutes, and the estimated Time of Arrival (ETA) was approximately 20 minutes. BP 130/80. P 100. RR
25. SpO2 99% (ambient air). Patient had no allergies. You informed him the using pharmaceutical measure
for relieving that pain much more by muscle injection. Patient refused that suggestion due to be afraid of
needle since childhood, then you did not administer that injection. The final decision (did not do anything
else) is right or not-right, based on Pain Management protocol?
A. Right
B. Not-right

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Answer
1.
E A and C are right
Stable patient. BP 130/80 (sBP>90). Patient had no allergies. 45-year-old: not elder.
2.
D Fentanyl 25 mcg IV/IM/IN
Unstable patient. BP 85/50 (sBP<90) → Fentanyl is first line. 75-year-old → half dose
3.
C Fentanyl 50 mcg IV/IM/IN
Patient was 38-week pregnant (weight 55kg) and had “camping pain in lower bowel”. She might be in active child
birth →Morphine should not be used during Active Child Birth. Fentanyl should be used in this case.
4.
F Normal saline 1000mL IV
D Ondansetron 4mg IV
B Morphine 2.5 mg IV/IM
Sickle Cell Disease → Consider (F);
‘during the assessment, she vomited 2 times and moaned of pain in whole body’ or Consider administration of
Ondansetron early when administering Morphine → (D) and Morphine;
Stage 2 Renal Failure →Morphine half dose (2.5mg) for patient 50kg.
5.
A Right
Based on Pain Management Protocol (page 36) ‘This is not the necessary to order of administration, use patient
needs and presentation as a guideline’.
Protocol Page 36

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5 Police Custody
Question
1. In 2018.10.06, a 25-year-old male had just rushed from an occupied place which shot pepper sprays by
force police. He complained of the irritation eyes, face and whole body. What should you do first?
2. Shortly after coming, the patient above felt short of breathing and you heard the wheezing from his
breathing, what protocol should you use at this moment?
3. On examination, you found there was a 3 cm laceration on his back. In which duration should this wound
be closed?
4. Patient reported he had the last shot of Tetanus since 2006, Is the Tetanus shot necessary now?
5. While you were taking care of the 25-year-old male above. The polices came with a 30-year-old male who
was in Police Custody Status and had a 10 cm deep laceration on right shoulder. However, they (police)
came not for asking medical care for this 30-year-old male, and for the 25-year-old. The captain of those
law enforcement officers (LEO) asked for retraining 25-year-old male immediately. What should you do?

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Answer
1.
Irrigate Eyes and Face with plenty of Water.
Remove contaminated clothing.
2.
COPD/ Asthma Protocol
3.
Sutures have a 6-to-8-hour window
4.
Advise A law enforcement officer (LEO) and patient to obtain a Tetanus shot if the patient has not received one in
more than 10 years
5.
Based Police Custody Protocol, page 37.
Patients who are in police custody retain their rights to medical care. This should be coordinated with the LEO. If
any questions are occurred whether patient requires transport, contact the on-duty supervisor for guidance.
Protocol Page 37

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Protocol-Internal Medicine

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1 Allergic Reaction
Question
1. An 18-year-old male patient came to Clinic at midnight with the rash on the whole body. He reported that
the rash appeared right after he took a condom in the first time of his life approximately 15 minutes ago,
and it was very itching. BP 130/80. R 100. RR 16 with no wheezing or short of breath, SpO2 99% (ambient
air). Is he in stable or unstable status?
and it was very itching. Later he breathed with a small wheezing, felt somehow short of breath, and his
eyelids, tongue, both hands and legs became swelling. BP 130/80. R 100. RR 16. SpO2 99% (ambient air)
and he watered very much. Is he in stable or unstable status?
3. The first medication/ fluid is used for allergic patient in Question No.2?
4. The second medication/ fluid is used for allergic patient in Question No.2?
and it was very itching. BP 130/80. R 100. RR 16 with no wheezing or short of breath, SpO2 99% (ambient
air). What medication/ fluid will you first indicate right now?
A. Epipen 0.3mg IM, may repeat x1 in 5 minutes
B. Epinephrine 1:1000. 0.3 mg IM, may repeat x1 in 5 minutes
C. Diphenhydramine 25-50mg SIVP/IM [Slow Intravenous Push, SIVP]
D. Solumedrol 125mg IV/IM
6. For the patient above, what the second medication/ fluid will you administrate secondly?
A. Epipen 0.3mg IM, may repeat x1 in 5 minutes
B. Epinephrine 1:1000. 0.3 mg IM, may repeat x1 in 5 minutes
C. Diphenhydramine 25-50mg SIVP/IM [Slow Intravenous Push, SIVP]
D. Solumedrol 125mg IV/IM
7. For the patient above (in Question 1) (Scenario No.1), if the rash appeared after he wore in the condom
15 minutes (Scenario No.2), which situation is more severe?

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Answer
1.
Stable. The criteria which indicate a stable status are:
(1) Rash/ hives/ urticaria
(2) Stable vital signs
2.
Unstable. The criteria which indicate an unstable status are:
(1) Wheezing, dyspnea, cyanosis
(2) Excessive salvation
(3) Edema to eyelids, lips, tongue, and hands
(4) Unstable vital signs
3.
Epinephrine 1:1000 (1mg/1mL) 0.3 mg IM, may repeat x 1 in 5 minutes
4.
Normal Saline Bolus 1000mL IV
5.
Diphenhydramine 25-50mg SIVP/IM [Slow Intravenous Push, SIVP]
6.
Solumedrol 125mg IV/IM
7.
Scenario No.1, because the signs and symptoms happed earlier than in No.2
Protocol Page 38

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2 Anxiety
Question
1. A 19-year-old male was assessed by the medical team due to his mother complaint of “Very anxiety”. His
mother, reported that he confessed he did go out for girl with no protection by condom, now he was afraid
of HIV/ AIDS. When the team come, BP 120/70, P100, RR 30, SpO2 100% he was very anxious and shortly
after he was agitated and did not allow for anyone touching him. His mother asked for transfer him to clinic
in order to be consulted by Psychiatrics and had some blood tests if needed, following the decision of
medical doctors. What step you need to do first?
2. After 15 minutes the team did the first step with no result, patient became irritated, shouted out, and cried
out, and he repeatedly said “Help me, please, I don’t want to die!” in grief. What should you do at the
moment before transfer him to clinic as request of his mother? (Based on Anxiety Protocol, page 39)
3. If the patient was 12-year-old female who was very anxious because she did not have good IELTS
examination last week, what should you do first?
4. In which situation the Anxiety Protocol is NOT applied? (Vital signs of patient are in stable status)

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Answer
1.
Verbal calming
2.
Midazolam 1-2mg IN/IM/IV, may repeat once
3.
For pediatric patient < 13-year-old, contact medical control.
4.
This Anxiety Protocol is NOT to be implemented for patients who are refused Emergency Medical Service (EMS)
care and are mentally competent and able to refuse care.
Protocol Page 39

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3 Behavioral Emergencies
Question
1. The emergency medical team was called to an apartment which was full of the polices. They were around
a 25-year-old female (weight 50kg) who moaned that “why my face (is) melted like that!”. The police officer
informed that they suspected she was a substance abuse or overdose. After 05 minutes the team and
police had calmed down patient by talking but that did not work, the police decided to do physical restraints
on her, what should you do right after the patient was restrained?
2. The patient above continued violently moving to escape polices after you did (answer of Question 1.), what
(pharmaceutical or non-pharmaceutical measures) should you do at this moment? (Patient had BP 150/90,
P 105, RR 28, SpO2 100% ambient air, Blood glucose level 80mg/dL, combative and violent behavior)
3. Patient was brought into ambulance by polices, faced down on stretcher, what should you do now?
4. You found out that hands of patient were in handcuffs, what should you ask for from Law Enforcement
Officers (LEO)?

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Answer
1.
Any vital signs, blood glucose level that can be safely obtained
2.
Midazolam 5mg IN/IM may repeat x1, OR
Diazepam 10mg IM (One dose)
3.
“Do not restrain in the prone position (face down). Physical restraints without chemical restraint can increase the risk
of Excited Delirium in susceptible patients” (Note of Behavioral Emergencies Protocol, page 40)
You should change position from prone (laying on one’s front) to supine (laying flat on one’s back)
4.
“Patients restrained using handcuffs in police custody must be transported with law enforcement’s assistance”. (Note
of Behavioral Emergencies Protocol, page 40).
You should ask for assistance (at least one police) from LEO during transporting patient to clinics.
Protocol Page 40

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4 Excited Delirium
Question
1. The emergency medical team was called to an apartment by mother of patient. She reported that patient,
a 19-year-old male with past history of using of Cocaine several times, used Cocaine again. At the moment
team come, he was agitated with rock rhythms, hold the glass of beer, sweating. After taking to calm down
the patient, he allowed team to access vital signs. BP 150/90. P 110. RR 30. SpO2 100% ambient air.
Temperature 39.0 degree of Celsius. Suddenly, he aggressively pulled the cuff of monitor, pushed the
medical staff out. What medication/ fluid, based on Excited Delirium Protocol (page 41), should you
administrate at this moment?
2. After the medication/fluid (Answer from Question No.1) administrated, patient calmed down. While the team
prepared to bring him onto stretcher, he suddenly caught the glass on table nearby, boke it by hitting it to
the edge of table, then waved, and shouted “Mom, I should be died right now, sorry mum, for everything!”.
What medication/ fluid, based on Excited Delirium Protocol (page 41), should you administrate at this
moment?
3. Patient was brought into ambulance and be restrained to avoid further harm to himself and others, what
should we do continuously during the transfer?
4. During transfer, patient suddenly had a cardiac arrest, what medication/ fluid, based on Excited Delirium
Protocol (page 41), except Epinephrine, Amiodarone, Electric Shock, should be administered early in the
arrest?

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Answer
1.
Diphenhydramine 25-50 mg IV/IM
2.
Midazolam 10mg IN/IM may repeat x1
3.
“After restraint procedures used, the patient should be continuously monitored” (Modified Notes from Excited
Delirium Protocol (page 41): “After restraint procedures are used, the patient will require continuous monitoring”)
4.
“If the patient is suspected of excited delirium and cardiac arrest ensues Sodium Bicarbonate and Fluid Bolus should
be administrated early in the arrest. If available cooled IV fluids should be used. Consider passive cooling”. (Notes,
Excited Delirium Protocol (page 41))
Protocol Page 41

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5 COPD/Asthma
Question
1. Ambulance was dispatched for a patient with “Hard to breath”. On approach, a 72-year-old man with history
“used to smoking very much”, Hypertension, Diabetes mellitus 2, breathed with pursed lips, small wheezing,
and using neck muscle each breathing. On auscultation, there was bilaterally decreased breath sounds,
bilateral crackles. Radial pulse was palpable, regular. Hands and fingers were pink, warm and dry. BP
160/90. P 99. RR 24. SpO2 91%. Temperature 37.5 degree of Celsius. What protocol should you recall first
after the COPD/ ASTHMA protocol?
2. What the medication/ Fluids should you administrate in this moment? (based on COPD/ ASTHMA protocol)
3. The medication list showed by wife of patient includes: Salbutamol puff, Pulmicort puff, Amiodarone 5mg,
and Metformin (Glucophage) 500mg. Patient’s wife reported that they had been stolen sack which
contained Pulmicort two week ago. Patient had been administrated medication/ fluids (which is answer of
Question No.2), at this moment, what the medication/ Fluids should you administrate much more (based
on COPD/ ASTHMA protocol)?
4. Which non-invasive ventilation measure should be thought of for this patient, (based on COPD/ ASTHMA
protocol)?
5. After treated by answer of Question No.1 and 2, approximately 15 minutes, patient became better, easier
to breath, calmed, what the investigation should be performed on ambulance? (based on COPD/ ASTHMA
protocol)

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Answer
1.
Respiratory Distress Protocol
“Bronchospasm most likely cause of distress” (based on COPD/ ASTHMA protocol, page 42)
2.
Albuterol 2.5mg/ Ipratropium bromure (Atrovent) 0.5mg, may repeat x2.
3.
Solumedrol 125mg IV
“Solumedrol SHOULD NOT BE given to patients who are on HIGH DOSE corticosteroids”. COPD/ ASTHMA
protocol, page 42
4.
“Consider C-PAP 5cm H2O” (based on COPD/ ASTHMA protocol, page42)
5.
ECG
Protocol Page 42

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6 Diabetic Emergency
Question
1. The emergency medical team accessed a 45-year-old man, who had past history “drunk all the time”, was
skinny man and recently confused and mal-responsive with command from team thought BP 100/70. P 75.
RR 18. SpO2 98%. The ECG was sinus rhythm 73/min. Quick blood glucose test was 60 mg/dL. What
medication/ fluid should you administrate at the moment?
2. If the team could not open vein in patient above, what kind of medication/ fluids should be administrated?
3. After the team performed the answers of Question No.1, patient became fully alert, and reported that he
did not eat anything from yesterday afternoon, now he felt good. He refused transport to clinic, his wife
agreed with his decision. What should you introduce to them?
4. The emergency medical team accessed a 45-year-old man, who complained of fatigue and malaise
although he was regularly on diabetes treatment. BP 100/70. P 75. RR 18. SpO2 98%. The ECG was sinus
rhythm 73/min. Quick blood glucose test was 333 mg/dL. What medication/ fluid should you administrate
at the moment?

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Answer
1.
Due to altered mental status, Oral glucose 15g should not be used.
The team should administrate:
• Dextrose 50% 25gm IV.
• Thiamine 100mg IV/IM (skinny man+ “Drunk all the time”: chronically mal-nourished patient)
2.
Glucagon 1mg IM
3.
If a hypoglycemic patient wishes to refuse transport after treatment, and the provider has no concerns about
underlying medical conditions, or the ability of person or care giver to manage their disease, ensure the following
conditions are met:
• Adequate food available, advise patient to eat a meal containing complex carbohydrates
• Functional home glucometer
• Not on Sulfonylurea medications, e.g. Glyburide, Glypizide.
• Document removal of IV site and bandage
4.
Fluid bolus up to 1 Liter (Normal Saline over 30 minutes)
Protocol Page 43

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7 Hypotension
Question
1. Ambulance was dispatched for a patient with “confused behavior”. On approach, a 72-year-old man with
history “used to smoking very much”, Hypertension (in usual, around 150/90 mmHg), Diabetes mellitus 2,
breathed with pursed lips, small wheezing, and with no using neck muscle each breathing. On auscultation,
there was bilaterally decreased breath sounds, bilateral crackles. There was a radial thready-pulse. Hands
and fingers were pale, cold and dry. Capillary refill time (CRT) 3 seconds. BP 100/50. P 105. RR 25. SpO2
93% (ambient air). Temperature 38.5 degree of Celsius. ECG was sinus rhythm 107 bpm. The remainder
of examination was not remarkable. What un-invasive investigation should you perform now?
2. What medication/ fluid should you administrate right after the answer of Question No.1?
3. The emergency medical team accessed a 35-year-old man with unclear heart disease complaining of
fatigue and malaise due to plenty of diarrhea. He was not fully alert, breathed normally, radial weak pulse,
hands and fingers were cold and dry (patient was African America). Capillary refill time (CRT) 2 seconds.
BP 85/50. P 100. RR 20. SpO2 95% (ambient air). Temperature 36.8 degree of Celsius. ECG was sinus
rhythm 105 bpm, no ST-T elevation. The remainder of examination was not remarkable. What medication/
fluid should you administrate at this moment?
4. A 50-year-old business man with no remarkedly past medical history was accessed by the emergency
medical team due to “tummy pain, very bad”. He was fully alert but restless, breathed hardly and irregularly,
rapidly palpable radius, hands and fingers were cool, clammy. BP 89/50. P 105. SpO2 95% (ambient air).
Temperature 36.8 degree of Celsius. ECG was not clear by artifacts. He did take stomach medication 6
hours ago (Esomeprazole, Buscopan). Patient at first informed that “Just take me a shot of stomach pain
killer, I am going to have an important meeting tomorrow morning”, but later the team had convinced
successfully patient using medication/ fluid, and be transferred to clinic to rule out life-threatening causes
of pain. What fluid should you administrate at this moment, and how much should you prescribe?
5. Patient (of Question No.3) had been given 1,500 mL Normal Saline, the ambulance was sticking in the
highway due to heavy traffics. The estimated time of arrival was 35 minutes much more. He was fully alert,
breathed normally, vital signs were BP 87/49. P 97. RR 20. SpO2. SpO2 95% (ambient air). Temperature
36.8 degree of Celsius. ECG was sinus rhythm 100 bpm, no ST-T elevation. Based on Hypotension
Protocol, page 44, what medication/ fluid should you administrated?

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Answer
1.
Cardiac monitor, 12 lead-ECG
2.
Potential SEPSIS
Consider when patient is febrile with possible infection source and has tachycardia, altered mental status, delay
capillary refill or signs of the other end-organ dysfunction.
Normal Saline bolus 500mL, repeat until 30mL/kg given.
Notes: Sepsis goals: 30mL/kg crystalloid for hypotension. MAP > 65 if pressor needed.
The patient above: Febrile: 38.5 degree of Celsius. Possible infection source is lungs. P 105 tachycardia, “confused
behavior” is altered mental status, CRT 3 seconds (> 2 seconds, meaning delay CRT).
Although based Notes of Hypotension protocol, page 44:
“Hypotension can be defined as symptomatic systolic blood pressure < 90”, this patient has usual blood-pressure
150/90 and now it is just 100/50 (differentiated > 30 mmHg). It should be considered hypotension as well.
3.
Potential Non-trauma, Non-cardia hypotension. E.g. Dehydration, GI Bleeding, Heat exhaustion, Vagal event.
Normal Saline bolus 500mL, repeat x3
4.
Potential Myocardial Infraction, Hypotension.
Normal Saline bolus 500mL, x1
5.
Epinephrine 10mcg =1mL q2-5 minutes for hypotension refectory to fluid bolus. Titrate to sBP > 90 mmHg.
Epinephrine 10mcg
• Draw up 09mL of Normal Saline in 10 mL syringe.
• Add 01 mL of Cardiac Epinephrine 1:10,000 (equally, 0.1 mL Adrenalin [epinephrine] 1mg/1mL
(1:1000))
Therefore, 1mL=10mcg = 1:100,000 epinephrine.
Protocol Page 44

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8 Nausea/ Vomiting
Question
1. The emergency medical team accessed a 47-year-old female with no remarked past history, who had been
well until 15 minutes previously, complained of vertigo, nausea and vomiting. The symptoms were worse
once she opened eyes or moved her head. She was fully alert, breathed fast, clammy and closed eyes
tight. BP 140/90. P 100. RR 25. SpO2 99% (ambient air). Patient prayed for relieving that nausea, by “doing
anything, please!”. What medication/ fluid should you administrate, based on Nausea/Vomiting Protocol,
page 45?
2. What the quick investigation should you perform immediately in this patient, based on Nausea/Vomiting
Protocol, page 45?
3. On ambulance, husband of patient asked you: “May I give her some water”. Is it okay?
4. What the best position should you place the patient in stretcher?
5. Fill the blanks (A and B) following (doses of medication), based on Nausea/Vomiting Protocol, page 45:
Pediatrics > 6 months Zofran
6mo—4yro A
>4yro B

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Answer
1.
Ondansetron 4mg IV/IM, may repeat x1.
2.
Blood Glucose Assessment
“All nausea and vomiting patients should have a Blood Glucose Assessment.”
3.
“Patient experiencing nausea or vomiting SHOULD NOT be allowed to ingest anything by mouth while in Emergency
Medical Service (EMS) care”.
4.
Upright lateral recumbent position
“Patients should be placed in an upright lateral recumbent position.”
Pediatrics > 6 months Zofran (Ondansetron)
6mo—4yro A 2mg IV/IM
>4yro B 4mg IV/IM
Protocol Page 45

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9 Overdose
Question
1. Fill the blank of Antidote with the right answers based on protocol
Conditions Antidote
Beta-blocker with symptomatic HYPOTENSION
Calcium Channel Blocker with symptomatic
HYPOTENSION
Dystonic Reaction
Suspected Stimulant
Suspected Opiate and apneic
Known Tricyclic Anti-depressants (TCAs) and
Widen QRS
All above
2. What are the common symptoms and signs of Dystonic Reaction?
• (Neck and Face?)
• (Eyes?)
• (Tongue?)
• (Abdomen?)
• (Body?)
3. A 25-year-old female was evaluated by the emergency medical team. Her mother revealed that she used
morphine again after finishing the course from Morphine Addiction Treatment Facility. Patient was recently
alert, breathed normally. BP 120/90. P 95. RR 16. SpO2 95%. Temperature 37.0 degree of Celsius. Your
junior member decided using Naloxone 1mg to finger out was the morphine used in this patient. Is this idea
right (or wrong), why?
4. While the junior member was preparing Naloxone and you was going to guide your member what should
be done, the patient became confused, was not fully alert with slow breathing rate than a couple minutes
ago, her pupils were constricted about 2 mm, her hands were clammy and cold. What the medication/ fluid
you should do at the moment?
5. What the maximum dose (for medication/ fluid in Answer of Question No.4) you can use?
6. How much milligram Naloxone are there in 01 Responder Bag until 2018.10.10?
7. The mother (of patient above) said her daughter had eaten some kind of morphine about 1.5 hours ago,
she had tried to avoid but she was failed to patient. Now she prayed you do something to clear out the
drugs in her daughter’s stomach. If possible, what medication/ fluid should you use?

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Answer
1.
Conditions Antidote
Beta-blocker with symptomatic HYPOTENSION Glucagon 2mg IV x1
Calcium Channel Blocker with symptomatic
HYPOTENSION
Calcium Gluconate 10% 1—2 gm IV over 10min (=
10-20mL)
Dystonic Reaction Diphenhydramine 25-50 mg IV/IM
• Protruding or pulling sensation of tongue
• Twisted neck or facial muscle spasm
• Roving or deviated gaze
• Abdominal rigidity and pain
• Spasm of the entire body
Suspected Stimulant Behavioral Emergency Protocol
Suspected Opiate and apneic Naloxone 1mg IV/IM/IN, may repeat x1
Max: 2mg; Naloxone 0.4mg (02 Amp)
Known Tricyclic Anti-depressants (TCAs) and
Widen QRS
Sodium Bicarbonate 50—100 mEq IV
All above Consider Activated Charcoal 50gm
2.
• Twisted neck or facial muscle spasm
• Roving or deviated gaze
• Protruding or pulling sensation of tongue
• Abdominal rigidity and pain
• Spasm of the entire body
3.
“Naloxone is NOT to begiven to conscious or breathing patients unless a decreasing level of
consciousness or decreasing respiratory drive is noted; is NOT to be used for diagnostic purposes; is
administrated in 0.4 mg doses titrated to respiratory drive; Max dose: 2mg”.
Therefore, in the patient with fully alertness, normal breathing, no need to use Naloxone.
The idea of member is not right.
4.
Patient was in altered mental status, a respiratory drive, should administrate Naloxone 0.4 mg (or as Protocol, 1mg,
IV/IM/IN).
5.
2mg
6.
Tow ampule, 0.4 mg/ 1 amp. Total 0.8 mg Naloxone in 01 Responder Bag.
7.
Activated Charcoal can be administrated up to 02 hours after ingestion; DO NOT administrate Activated
Charcoal for acids, alkali, or petroleum base products.
Protocol Page 46

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10 Respiratory distress
Question
1. A 74-year-old male was evaluated by the emergency medical team complained of shortness of breathing.
He was fully alert but irritated, pursed breathing, and unable to speak full sentences with wheezing stridor.
The accessory muscle was used, auscultation revealed crackles on the base of bilateral lung sides, edema
was on both legs, his hands was cold and clammy. BP 190/100. P 110. RR 30. SpO2 87% (ambient air).
He had history of cardiac and pulmonary disease (at this moment, this information was not clear) and
smoking. How many causes may be presented on this patient?

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Answer
03 including of (1) Respiratory with bronchospasms; (2) Cardiac with suspected pulmonary edema and (3)
others e.g. Acute coronary syndrome; Allergic Reaction; Anxiety; Pneumothorax and others.
Bronchospasm suggested by: Pulmonary edema suspected:
• History of asthma/ COPD
• Use of inhalers chronically
• Smoking history
• Wheezing on exam
• History of Congestive heart failures
• Cardiac disease history
• Use of Furosemide (Laxis) chronically
• Crackles and leg edema on exam
Protocol Page 47

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11 Seizure
Question
1. A 30-year-old female was evaluated by the emergency medical team due to convulsion. The witness
reported a couple minutes ago while she was sleeping, she was suddenly “shaking the whole body with
eyes looked up”. Patient now looked like in sleeping, in left side recumbence. BP 140/90, P 100. RR 20.
SpO2 95%. Which test should you perform now? (based on Seizure protocol, page 48)
2. Past history was gathered from her co-workers, you knew patient had several times of Status Epilepticus,
the last time happened 6 months ago. During prepared transfer patient to clinic, patient had an episode of
“shaking whole body” anew, which medication/ fluid should you use?
3. Since the emergency medical team approach patient to the second seizure, patient was not conscious.
Vital signs were in normal range. Based on information of Question No.1, 2, and 3, is this a Status
Epilepticus, and why if it is?
4. What kind of the seizure above:
A. Grand Mal Seizures
B. Petit Mal Seizures
C. Jacksonian Seizures
5. How to perform Recovery Position?
6. If needed, what maneuver and airway device should you use to protect patient’s airway in the moment of
the end of Question No.1?
7. What other cause should you assess in this patient accompanied with Occult Trauma?
8. What other protocol should you think of in case the Patient of Question No.1 pregnant?

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Answer
1. She was in Post-ictal, then Blood glucose test should be performed.
2. Patient had Seizure Recurs, then Midazolam 5mg IV/IM/IN or Diazepam 10mg IV.
3. Yes, it is a status epilepticus. Because “Status Epilepticus is defined as 2 or more successive seizure
without a period of consciousness or recovery. This is a true emergency requiring rapid airway control,
treatment, and transport.
4. A Grand Mal Seizure.
A. Grand Mal Seizures are associated with loss of consciousness, incontinence, and tongue trauma.
B. Petit Mal Seizures effect only a part of the body and are not usually associated with a loss of consciousness.
C. Jacksonian Seizures are seizures which start as focal seizure and become generalized.
5. Performing the Recovery Position
6.
Airway Position
Nasopharyngeal airway
Based on Protocol Page 48, “Be prepared for airway problems and continued seizure. INTUBATION USUALLY IS
NOT NEEDED. Attempt Airway Positioning and Nasopharyngeal airway during immediate POST-ICTAL phase”.
7. Substance abuse
8. Obstetrics Emergency Protocol
Protocol Page 48

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12 Stroke/ CVA1
Question
1. A 55-year-old male was evaluated by the emergency medical team due to “he suddenly cannot speak
normally”. On examination, his face was drooped, drifted his right arm, and could speak but not clear. BP
190/110. P 100. RR 20. SpO2 98% (ambient air). IV was opened in 02 minutes. On ambulance, which
quick tests should you perform?
2. On the way to hospital, the vital signs in minutes No. 5 was BP 222/122. P 105. RR 22. SpO2 98%. What
medication/ fluid should you use at this moment?
3. What the most important moment should you ask for from his wife?
4. Which hospital (in Question No.2) should you transfer patient to, in your location/ city/ province? (Write
them out, please)
5. Tell about Cincinnati Stroke Scale?
1 Cerebrovascular accident (CVA)

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Answer
1.
12-lead ECG
Blood Glucose Test: “Check glucose levels on ALL SUSPECTED CVA patients” Stroke/CVA Protocol, page49
2.
BP > 220/120. Labetalol 10—20 mg IV over 20 minutes x 1.
3.
Exact time of onset (signs and symptoms)
“Notify receiving Emergency Department of Stroke Alert As soon as possible (ASPS)” Stroke/CVA Protocol, page49
4.
People 115 Hospital
(Nhân dân 115)
527 Sư Vạn Hạnh, Phường 12, Quận 10, Hồ Chí Minh 028 3865 4249
People Gia-dinh
Hospital
01 Đường Nơ Trang Long, Phường 7, Bình Thạnh, Hồ Chí Minh 028 3841 2692
Nguyen Tri Phuong
Hospital
468 Nguyễn Trãi, Phường 8, Quận 5, Hồ Chí Minh 028 3923 4349
University of Medicine
and Pharmacy
Hospital
215 Hồng Bàng, Phường 11, Quận 5, Hồ Chí Minh 028 3855 4269
Trung Vuong Hospital 266 Lý Thường Kiệt, Phường 14, Quận 10, Hồ Chí Minh 028 3865 6744
Xuyen A Hospital Quốc lộ 22 028 7300 9115
An-Binh
(Peacefulness)
Hospital
146 An Bình, Phường 7, Quận 5, Hồ Chí Minh 028 3923 4260
Military 175 Hospital 786 Nguyễn Kiệm, Phường 3, Gò Vấp, Hồ Chí Minh 096 983 10 10
Cho Ray Hospital 201B Nguyễn Chí Thanh, phường 12, quận 5, Thành phố Hồ Chí
Minh, Việt Nam
028 3855 4137
Thu Duc Province
Hospital
29 Phú Châu, Tam Phú, Thủ Đức, Hồ Chí Minh 028 3729 5503
5. Cincinnati Stroke Scale
Normal Abnormal
Facial Droop
Have patient show teeth and
smile
Both side of face move equally One side face does not move as
well as other
Arm Drift
Have patient close eyes and
hold both arms straight out for
10 seconds
Both arms move the same or
not at all
One arms does not move or one
arm drifts down
Abnormal Speech
Have patient say “You can’t
teach an old dog new tricks”
Patient uses correct words with
no slurring
Patient slurs, uses wrong words,
or cannot speak
Protocol Page 49

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13 Syncope
Question
1. In the sunny days, in Quảng-Nam Province, a province in the South Central Coast region of Vietnam,
bordered by Thừa-Thiên–Huế Province to the north, the nation of Laos to the west, Kon-Tum Province to
the southwest, Quảng-Ngãi Province to the southeast, the East Sea to the east, and the city of Da Nang to
the northeast, in Habitat Project, there was a 45-year-old male patient who was brought to the Medical
Station due to short time of Loss of Consciousness. He suddenly fell down and lost consciousness shortly
then awaked. On medical station, BP 95/60. P 90. RR 18. SpO2 98% (ambient air). His girl-friend reported
that last night he had gotten to toilet and bowel movement with a lot of a watery feces. Emergency Medical
Technician thought that patient was in Syncope. What non-invasive investigation should be performed
now? (based on Syncope Protocol, page 50)
2. What the medication/ fluid should be administrated at this moment?
3. What the first invasive investigation should be performed in Medical Station?
4. The result of invasive investigation done (by answer of Question No.3) was in normal range. What
maneuver should be performed at this moment to get a kind of special vital signs?
5. What do criteria indicate the maneuver (answer of Question No.4) positive?

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Answer
1. ECG
2. Normal Saline 500 –1.000 mL
3. Blood glucose test
4. Orthostatic maneuver to figure out vital signs
5. A tilt test orthostatic vital signs is considered Positive if the patient becomes dizzy, weak, alert, pulse
increase of 20 bpm, or blood pressure decrease 10 mmHg.
Protocol Page 50

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Protocol-Cardiology

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1 Acute Coronary Syndrome
Question
1. A 50-year-old patient was evaluated by the emergency medical team complained of pain in the center of
chest. Within 10 minutes approaching patient, 12 lead ECG was performed (see below, in all leads), BP
130/90. P 120 bpm. RR 30. SpO2 98% (ambient air). What the first medication/ fluid should be
administrated at this moment?
2. After taking the first medication/ fluid, the patient still complained painful on the chest, BP 130/90. P 125
bpm. RR 30. SpO2 98% (ambient air). What medication/ fluid should be administrated at this moment?
3. After taking the maximal dose of the medication/ fluid (answer of Question No.2), patient was still painful,
what protocol should be recalled?
4. Before administrating medication/ fluid which is answer of question No.2, what information should be
achieved?
5. How long should you keep patient in the scene?
6. You suspected an Inferior MI happened, what medication/ fluid should be administrated?
Answer
1. Sinus tachycardia → NON-STEMI, then Aspirin 324mg PO Chewed
2. Nitroglycerin Spray every 5 minutes x3 with s-BP > 90 mmHg.
Notes
• Patient with marginal Blood Pressure and concern for Inferior Right Sided STEMI, IV access is preferred
before the administration of Nitroglycerin.
• An IV is not required for administration of Nitroglycerin
• BP drop is expected after receiving Nitroglycerin. DO NOT hold further doses unless s-BP < 90.
3. Pain Management Protocol
4. Avoid Nitroglycerin in any patient who has used Viagra, Levitra in the past 24 hours, or Cialis in the past
36 hours.
5. Keep scene time < 15 minutes
6. Normal Saline 250—500 mL, and establish 2nd
IV of at least 18 Gauge while transporting.
Protocol Page 51

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2 Supra-Ventricular Tachycardia (SVT)
Question
1. A 50-year-old patient was evaluated by the emergency medical team complained of palpitation. Within 10
minutes approaching patient, 12 lead ECG was performed (see below, in all leads), he was fully alert,
palpable radius. BP 130/90. P 180 bpm. RR 30. SpO2 98% (ambient air). IV was performed and Normal
Saline 500cc was in bolus. What the first medication/ fluid/ maneuver should be considered at this
moment?
2. After performed the first medication/ fluid/ maneuver, patient was fully alert, palpable radius. BP 140/90.
P 170 bpm. RR 25. SpO2 99% (ambient air). What the second medication/ fluid/ maneuver should be
administrated at this moment? 12 lead ECG was performed (see above, in all leads)
3. After performed the second medication/ fluid/ maneuver, patient was fully alert, palpable radius. BP
135/90. P 180 bpm. RR 27. SpO2 99% (ambient air). What the 3rd
medication/ fluid/ maneuver should be
administrated at this moment? 12 lead ECG was performed (see above, in all leads)
4. After performed the 3rd
medication/ fluid/ maneuver, patient was fully alert, palpable radius. BP 135/90. P
180 bpm. RR 27. SpO2 99% (ambient air). What the 4th
medication/ fluid/ maneuver should be
administrated at this moment? (based on medical equipment and protocol of your recent Facility) 12 lead
ECG was performed (see above, in all leads)
5. After performed the 3rd
medication/ fluid/ maneuver, patient was not fully alert, he felt lightheaded, then
dizzy and weak, radius was weak. BP 90/60. P 183 bpm. RR 16. SpO2 95% (ambient air). What the
medications/ fluid/ maneuver should be administrated at this moment? 12 lead ECG was performed (see
above, in all leads)
6. What the medication/ fluid/ maneuver if the maximal dose of answer of Question No.5 had been
administrated? 12 lead ECG was performed (see above, in all leads)

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Answer
1. Patient was in stable status.
ECG: supra-ventricular tachycardia.
Consider Vagal Maneuver
“Vagal maneuvers are contraindicated if patient has history of Cerebrovascular accident (CVA), carotid
surgery or carotid bruits”.
2. Patient was in stable status. Adenosine 6 mg fast IVP
3. Patient was in stable status. Adenosine 12 mg fast IVP
4. Patient was in stable status. Diltiazem 10—20 mg, Repeat 25mg x 1 in 10 minutes.
There are 3 ampule of Adenosine 6mg in Responder Bag, then in lieu of using Adenosine 12mg fast IVP for
second time, it needs to turn to Diltiazem 10mg. And in Responder Bag, there are 2 ampules of diltiazem 10mg.
“SVT refractory to Adenosine can be treated with Diltiazem if not contra-indicated”.
“Diltiazem requires a systolic Blood pressure (s-BP) of at least 80—90mmHg”.
5. Patient was in unstable status. Consider Pain Management and/ or Anxiety Protocol (Fentanyl, and
Midazolam 1-2mg). Synchronized cardioversion 50 joules. Then 100 joules and 150 joules.
“Sedation should not be used with hemodynamically unstable patients”.
6. Amiodarone 150 mg over 10 minutes.
Continuous Print-out of Monitor tracing during conversion is very helpful for Receiving hospital’s
Cardiologist.
Protocol Page 53

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3 A-Fib with Repetitive ventricular response (RVR)
Question
1. A 50-year-old patient was evaluated by the emergency medical team complained of palpitation. Within 10
minutes approaching patient, 12 lead ECG was performed (see below, in all leads), he was fully alert,
palpable radius. BP 130/90. RR 30. SpO2 98% (ambient air). IV was performed and Normal Saline 500cc
was in bolus. What the first medication/ fluid/ maneuver should be considered at this moment?
2. After performed the answer of Question No.1, patient was not fully alert, he felt lightheaded, then dizzy
and weak, radius was weak. BP 90/60. RR 16. SpO2 95% (ambient air). What the medications/ fluid/
maneuver should be administrated at this moment? 12 lead ECG was performed (see above, in all leads)
Answer
ECG: Atrial fibrillation.
Diltiazem 10—20 mg IVP over 2 minutes.
The second time of using Diltiazem is: Diltiazem 25 mg IVP over 2 minutes.
Notes:
In Responder Bag, there are 2 ampules of diltiazem 10mg.
Midazolam 1-2mg). Synchronized cardioversion 50 joules. Then 100 joules and 150 joules.
“Sedation should not be used with hemodynamically unstable patients”.
“Sedation should be used extreme caution on hemodynamically unstable patients. Consider using the minimum
dose”.
Protocol Page 54

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4 Ventricular Tachycardia with Pulse
Question
1. A 50-year-old patient was evaluated by the emergency medical team complained of palpitation, chest pain
and shortness of breath. Within 10 minutes approaching patient, 12 lead ECG was performed (see below,
in all leads), he was fully alert, palpable radius. BP 130/90. RR 30. SpO2 98% (ambient air). IV was
performed. What the first medication/ fluid/ maneuver should be considered at this moment?
2. After performed the answer of Question No.1, patient was not fully alert, he felt lightheaded, then dizzy
and weak, radius was weak. BP 90/60. RR 16. SpO2 95% (ambient air). What the medications/ fluid/
maneuver should be administrated at this moment? 12 lead ECG was performed (see above, in all leads)
3. After performed the answer of Question No.2, patient was dizzy, radius was weak. BP 90/60. RR 16. SpO2
95% (ambient air). ECG was performed anew (below). What the medications/ fluid/ maneuver should be
4. A 50-year-old patient was evaluated by the emergency medical team complained of palpitation, chest pain
and shortness of breath. Within 10 minutes approaching patient, 12 lead ECG was performed (see below,
in all leads), he was fully alert, palpable radius. BP 130/90. RR 30. SpO2 98% (ambient air). IV was
performed. Right after IV was opened, on monitoring you see ECG below, what the first medication/
fluid/ maneuver should be considered at this moment?

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Answer
ECG: Monomorphic Ventricular Tachycardia.
Amiodarone 150mg over 10 minutes, may repeat x1 OR
Lidocaine 100mg over 5 minutes, may repeat x1.
Notes:
In Responder Bag, there are 07 ampules of Amiodarone 150mg.
Midazolam 1-2mg). Synchronized cardioversion 150 joules, may repeat as needed, then Amiodarone
150mg over 10 minutes, may repeat x1
3. Consider Magnesium Sulfate 2gm IVP
4. Patient was in stable status. There was a witnessed/ monitored ventricular tachycardia.
“For witnessed/ monitored ventricular tachycardia, try having the patient cough”
Protocol Page 55

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5 Symptomatic Bradycardia
Question
1. A 50-year-old patient was evaluated by the emergency medical team complained of diarrhea and pain on
epigastric area. Within 10 minutes approaching patient, 12 lead ECG was performed (see below, in all
leads), he was fully alert, palpable radius. BP 130/90. P 55. RR 30. SpO2 98% (ambient air). IV was
performed. What the medication/ fluid/ maneuver should be considered at this moment?
2. A 50-year-old patient was evaluated by the emergency medical team complained of chest pain, dyspnea.
Within 10 minutes approaching patient, 12 lead ECG was performed (see below, in all leads), he was fully
alert, radius was weak. BP 85/50. P 55. RR 30. SpO2 98% (ambient air). IV was performed. What
medication/ fluid/ maneuver should be considered at this moment?
1. Shortly later, patient (in Question No.1) was not fully alert. BP 87/53. P 55 RR 25. SpO2 98% (ambient
air). Second ECG was as below. What medication/ fluid/ maneuver should be considered at this moment?

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Answer
1. Patient was in a stable status.
ECG: Second-degree AV block type I.
Observe and ask for Specialist consultation.
2. Patient was in an unstable status.
ECG: Second-degree AV block type I
Atropine 0.5mg – 1.0 mg (Atropine 0.25mg/1 Ampule), may repeat q3—5 minutes, Max Dose 3.0 mg
3. Patient was in an unstable status.
ECG: Second-degree AV block type II.
Transcutaneous pacing at a rate of 60 at lowest milli-amp setting that obtains capture.
“Atropine should be omitted for the second-degree AV type II or third-degree AV”.
Protocol Page 56

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6 Adult Cardiac Arrest – 7 Post Resuscitation – 8 Post Resuscitation Induced Hypothermia
Question
1. A middle-age man (unknown name) was found by the police with no breath and pulse, he was taken CPR
by police right after found and the emergency medical team assessed patient approximately 3 minutes
later. He was unconscious with no spontaneous breathing and pulse. The team performed basic life
support and advanced life support. 03 ampules Amiodarone, 8 adrenaline, 05 Normal Saline 500mL were
used. Intubation tube 8.0 was used. IV line was opened after approaching 3 minutes. 04 electrical shocks
were performed with no effect. How long was patient rescued excepted time of first-aid?
A. Approximately 20 minutes
B. Approximately 30 minutes
C. Approximately 40 minutes
D. Approximately 50 minutes
E. Approximately 60 minutes
2. Please write the pre-hospital medical document for the case above.

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Answer
1. (B) Approximately 30 minutes (31 minutes)
2. Prehospital Document, example:
A middle-age man (unknown name) was assessed by the emergency medical team after he was found and
supported First-Aid (CPR) approximately 03 minutes by the police.
At the same time, the following activities were performed.
• The Basic Life Support (BLS) and Advanced Cardiovascular Life Supported (ACLS) protocols were
applied.
• Chest compress and Bag-valve-mask breathing with ratio 30:2, and bag-valve-intubation 01 breath every
06 seconds once advanced airway control achieved with an intubation.
• Firstly, Bag-Valve-Mask with Oxygen 15 L/min and later intubation tube size 8.0 was successfully inserted
into tracheal, trailered/ immobilized in the cm 22.0 at the mouth (curve of teeth), with no complications.
• Epinephrine (Adrenalin) 1mg/1mL x 01 ampoule immediately right after IV opened.
• Based on AED advices, 04 time of electrical shocks was delivered, Amiodarone 300mg (02 ampoules)
was administrated after No.3rd
shock, and Amiodarone 150mg (01 ampoule) after No.4th
shock.
• Epinephrine (Adrenalin) 1mg/1mL x 01 ampoule, repeated every 04 minutes (total 08 ampoules)
• Carotid/femoral pulses were checked every 02 minutes (not more than 10 seconds).
+3min Min 0-1 2 3 4 5 6 7 8 9
Adre 1st
2nd
3rd
Amio 300mg 150mg
Shock 1st
2nd
3rd
4th
No10 11 12 13 14 15 16 17 18
Adre 4th
5th
Amio
No19 20 21 22 23 24 25 26 27
Adre 6th
7th
No28 - - - - - - - -
Adre 8th
- - - - - - - -
• After approximately 30 minutes resuscitation, patient was unconscious, had no spontaneous breathing,
no pulse, large fixed dilated pupils, negatively reacted to light, Doll’s eye movement and no corneal reflex.
The resuscitation was terminated.
• The patient was sent to FV Hospital as request of police.
Protocol Page 57, 58, 59

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9 Hypertension (HTN)
Question
1. A 50-year-old patient was evaluated by the emergency medical team complained of headache and chest
pain (center of chest) and shortness of breath. Within 10 minutes approaching patient, 12 lead ECG was
regularly sinus rhythm 55 beats per minute, BP 185/115. P 55 bpm. RR 22. SpO2 98% (ambient air). What
should you ask to have important information at this moment in order to have a good decision of treatment?
2. If the answer is “Not at All” for the answer of Question No.1. What the first medication/ fluid should be
3. A 50-year-old patient was evaluated by the emergency medical team complained of headache, vertigo
and nausea with one time of vomiting and nosebleed. Within 10 minutes approaching patient, 12 lead
ECG was regularly sinus rhythm 75 beats per minute, BP 185/115. P 75 bpm. RR 22. SpO2 98% (ambient
air). What the first medication/ fluid should be administrated at this moment?
4. A 50-year-old patient was evaluated by the emergency medical team complained of laceration in the
middle eyebrows due to falling down a couple minutes ago. The bleeding was stopped, and clean. Within
10 minutes approaching patient, 12 lead ECG was regularly sinus rhythm 75 beats per minute, BP
185/115. P 75 bpm. RR 22. SpO2 98% (ambient air). What the first medication/ fluid should be

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Answer
1. “Did you take erectile dysfunction drugs, e.g. Viagra, Levitra in the past 24 hours or Cialis in the past 36
hours?”
“Avoid Nitroglycerin in patient who has taken ERECTILE DYSFUNCTION DRUGS in the past 48
HOURS”
2. Patient was in cardiac angina (the others are Congestive Heart Failure [CHF, CHF Protocol, page 61]),
and Labetalol contra-indication. And Blood pressures were s-BP >180; d-BP>110
Nitroglycerin 0.4 mg, may be repeated x2. Then Nitroglycerin spray q5 min for prolonged
transports or continued hypertension (HTN) OR
Enalapril 1.25mg over 5 minutes, may repeat x1.
In Responder Bag, there is no Enalapril.
3. Patient was in neurologic and nosebleed (“Neurologic or other OB, renal, nosebleed”, based on
Hypertension Protocol, page 60) and with no Labetalol contra-indication (“DO NOT use Labetalol if HR <
60”; “Labetalol onset 5—10 minutes with a peak effect of 30 minutes”).
Labetalol 10—20 mg over 02 minutes, repeat q 10 minutes x2
In Responder Bag, Labetalol 25mg/5mL (5mg/1mL) x 01 ampoule
4. “Never treat Blood pressure based on set of Vital signs”.
“Asymptomatic hypertension DOES NOT REQUIRE TREATMENT regardless of how high the blood
pressure is. Treatment may interfere with compensatory mechanism and cause harm”.
Protocol Page 60

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10 Congestive Heart Failure
Question
1. A 73-year-old patient was evaluated by the emergency medical team complained of shortness of breath.
Within 10 minutes approaching patient, 12 lead ECG was regularly sinus rhythm 105 beats per minute,
BP 145/90. P 105 bpm. RR 22. SpO2 98%. He was fully alert, diaphoresis, and complain of chest pain.
His jugular vein was in distend and his neck muscle was moved in waves with breathing. IV line was
opened, Oxygen mask was performed with 10 L/min. What should you ask to have important information
at this moment in order to have a good decision of treatment?
2. What the first medication/ fluid should be administrated at this moment?
3. Right after patient was transferred to Emergency Room from Ambulance, he became not fully alert, and
the clinic signs and symptoms seemed not to be changed, what the protocols should be recalled at this
moment?
4. What the important details should you note in the Pre-hospital Document (Past History, Provisional
Diagnosis, Treatment, Examination and Follow-up) for this case?
Answer
Protocol Page 61

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Answer
1. “Did you take erectile dysfunction drugs, e.g. Viagra, Levitra in the past 24 hours or Cialis in the past 36
hours?”
“Avoid Nitroglycerin in patient who has taken ERECTILE DYSFUNCTION DRUGS in the past 48
HOURS”
“DO NOT administrate Nitroglycerin to any patient who has used Erectile dysfunction medications
Viagra, Levitra, Cialis) in the past 48 hours du to POSSIBLE SEVERE HYPOTENSION.
2. The patient was in Respiratory Distress but ALERT. Therefore:
Consider C-PAP (Continuous positive airway pressure)
Because the systolic blood pressure was 145/90 (>140 mmHg), Nitroglycerin spray q 3 minutes x5.
And then (1) Nitroglycerin spray q3 minutes for s-BP >140) OR (2) Enalapril 1.25 mg OVER 5 minutes,
may repeat x1 for s-BP> 140).
In Responder Bag, there is no Enalapril.
3. The patient was in Respiratory Distress but LETHARGIC. Therefore:
RSI Protocol → Expect Hypotension, give 250mL Bolus and Refer to Hypotension protocol → ACS
Protocol as needed.
4. Some things must be noted
(1) Past history:
• Diabetics and geriatric patients often have ATYPICAL PAIN, or ONLY GENERALIZED Complaints.
(2) Provisional diagnosis:
• Acute pulmonary edema may be a sign of acute cardiac ischemia, which may give rise to cardiovascular
collapse and hypotension as well as malignant atrial and ventricular arrhythmias.
(3) Actions on scene (Treatment):
• Nitroglycerin can be administrated to a patient by Emergency Medical Staff (EMS) if the patient HAS
ALREADY taken 03 of their own prior to your arrival.
• If patient has taken nitroglycerin without relief, consider POTENCY of the medication, that is why:
a. Document it if the patient has any changes in their symptoms or headache after taking their own.
b. Document the expiration date of the patients prescribed nitroglycerin.
(4) Examination and Follow-up
• Careful monitoring of Level of Consciousness, Blood Pressure, and Respiratory Status with above
interventions is essential.
• Do Not withhold oxygen form hypoxic patients
• Monitor and document vital signs every 05 minutes (if patient is unstable; and every 15 minutes if patient
is stable, on ambulance)
Protocol Page 61

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11 Ventricular Ectopy
Question
1. A 50-year-old patient was evaluated by the emergency medical team complained of chest pain and
dyspnea. Within 10 minutes approaching patient, 12 lead ECG was as below, BP 175/105. P 100 bpm.
RR 22. SpO2 98% (ambient air). IV was opened, oxygen mask 10L/min. What the first medication/ fluid
should be administrated at this moment?
2. What should you need to prepare for the side effect of the answer from Question No.1, based on its
protocol?
3. A 50-year-old patient was evaluated by the emergency medical team complained of malaise. Within 10
minutes approaching patient, 12 lead ECG was as below, BP 175/105. P 100 bpm. RR 22. SpO2 98%. IV
was opened, oxygen mask 10L/min. What the first medication/ fluid/ actions should be administrated at
this moment?

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Answer
1. Patient had signs and symptoms of Ventricular Ectopy (chest pain, dyspnea and hypertension among
Chest pain, dyspnea syncope, hypo/hyper-tension, altered level of consciousness, pulmonary
edema) and the criteria which must be met for treatment of Ventricular Ectopy (symptomatic trigeminy
among multi-focal PVC, Runs of Ventricular Tachycardia, R on T Phenomenon), therefore:
Lidocaine 100mg IV, may repeat x1, then Amiodarone 150 mg in 50 cc Normal Saline Over 10 minutes,
may repeat x1 in 10 minutes.
In Responder Bag, there are 02 ampoules of Lidocaine 200mg/10mL.
Multifocal Premature Ventricular Complex (PVCs) Runs of ventricular tachycardia
R on T: Occur on the peak of the T wave of the
preceding beat.
R on T Phenomenon
Ventricular Bigeminy
2. Be prepared for patient to vomit following administration of antiarrhythmics
“DO NOT administrate antiarrhythmics to patient with BRADYCARDIA. Refer to Bradycardia Protocol,
page 56.
3. Patient was Asymptomatic Ventricular Trigeminy.
No need to do anything but following up and transfer patient to clinic; monitor and document vitals every
5 minutes.
“Pre-hospital treatment of PVCs or Ventricular Ectopy is seldom warranted. Treatment should be based
on re-oxygenation of the heart and quality cardiac output”.
“If a patient has PVCs that are generating a pulse and the underlying rhythm is bradycardic, use caution
when suppressing the ectopy”.
Protocol Page 62

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1 Selective spinal immobilization
Question
1. What the items should you perform spinal immobilization?
2. When should you perform a partial spinal immobilization?

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Answer
1. Items, if YES in ANY ITEM, patient need to be in spinal motion restriction.
• Age < 5 or >65
• Dangerous mechanism: Fall > 3 feet (0.91 meters), mod to high speed motor vehicle accident (MVA),
diving accident, an all-terrain vehicle (ATV), auto-pedestrian, distracting injury
• Suspected/ Known intoxication
• Altered alertness
• Spinal exam: any point tenderness to spine or with range of motion
• Focal neurological deficit
“The decision NOT TO immobilize must be fully documented and include all of the above historical and exam
finding”.
“Palpate each spinous process to assess for tenderness. Only if no tenderness was elicited, perform a range of
motion exam”.
Spinal Immobilization2
2. Partial immobilization
• A times securing a patient to a rigid spinal board may worsen a spinal injury if present or may otherwise
harm the patient. These patients may be transported in semi-recumbent position with a C-collar.
• Examples of patients who may not tolerate supine position: agitated patients and patients with
decompensated Congestive Heart Failure with kyphosis.
Protocol Page 63
2 Links: http://keywordsuggest.org/gallery/249287.html; https://nl.wikipedia.org/wiki/Wervelplank; http://keywordsuggest.org/gallery/249287.html

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2 Crush Injury
Question
1. A 30-year-old male was assessed by the emergency medical team due to terrain vehicle accident. He was
alert after almost 2.5 hours trapped under car. Both legs couldn’t move and seemed to be crushed. IV line
was opened in both right and left arms. BP 140/90. HR 100. RR 25. SpO2 95%. Fentanyl 50mcg/1 mL was
administrated to reduce his pain and 1 mg Midazolam, IM to calm down patient’s anxiety. What medication/
fluid should be administrated right now?
2. The emergency medical team intended to remove patient from entrapment, what medication/ fluid
should be administrated right after the removal was done?
3. During the removal, patient suddenly was in cardiac arrest. The team turned to Cardiac Arrest Protocol
with electric shock, epinephrine, amiodarone. What the other medication/ fluid should be added in this
duration (CPR time)?
4. After 03 circles of CPR, patient had pulse with ECG (below). BP 100/60. P 100. He was partial alert
(GCS E3V5M6= 14/15). What medication/ fluid should be administrated?3
3 Link pictures: https://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/; https://acadoodle.com/articles/5-ecg-changes-of-hyperkalemia-you-need-to-know;
https://www.researchgate.net/figure/Electrocardiographic-findings-in-hyperkalemia-The-profiles-are-schematized-the_fig5_273377800;

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Answer
1. Normal Saline 1—2 L
As protocol, Universal Treatment Guideline → Consider RSI Protocol → 1—2 L Normal Saline → Consider Pain
Management and/or Anxiety Protocol.
RSI Protocol is no need in this case. Pain management and Anxiety Protocol were applied.
“Administrate intravenous fluids before releasing the crushed body part. This step is especially important in case of
prolonged crush > 4.0 hours”
“Crush syndrome can occur in crush scenarios of < 01 hours”.
2. Sodium Bicarbonate 50—100mEq IV immediately after removal from entrapment.
“Sodium Bicarbonate should only be given in instances of entrapment > 2.0 hours”
3. Sodium Bicarbonate 1 mEq/kg every 10 minutes during CPR
“If Cardiac arrest occurs after release of entrapment, give Sodium Bicarbonate 1mEq/kg immediately and every 10
minutes during CPR”.
4. ECG: Hyperkalemia, with normal P waves.
Calcium Gluconate 10% 1—2 gm IV over 10 minutes =10—20 mL for arrhythmias
“Suspect hyperkalemia if T waves become peaked, QRS >0.12 seconds and/or hypotension develops”.
Protocol Page 64

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3 Major Trauma
Question
A 19-year-old man was assessed by the emergency medical team due to motor vehicle accident. The
witness reported that patient drove motor to the loop and lost control, went straight to the barrier, hit head
then immobilized. On examination, there was a laceration on chin and head, bleeding a bit. A huge
laceration on right thigh, bleeding a lot. He complained painful on neck and repeated continuously “Help
me! Help me, please” The C-cervical was performed. His airway was patent, breathing normally, carotid
and radius pulses were palpable. He had no tenderness with palpation and stress on chest, abdomen,
pubic joint, closing pelvises, lower extremities, left upper extremity, and the rest of spinal bone. BP 90/60
mmHg, P 110. RR 25. SpO2 99% (ambient air). The right upper extremity was deformed. Oxygen mask
15 L/minutes applied. Bleeding on right thigh was controlled by compressed bandage. How long you
should stay on scene?

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Answer
Lower 10 minutes
• Airway and cervical spine control
Airway was patent and cervical spine control was done. It is no need to consider RSI Protocol.
• Breathing and oxygenation.
Oxygen was applied, aimed to SpO2 > 95% (Especially, head trauma). He had no signs of tension
pneumothorax, then no need to consider Needle Decompression.
• Circulation and Hemorrhage control.
Vital signs were in acceptable ranges, there was a major bleeding in right thigh which was controlled by
compressed bandage. Bilateral IV or IO access should be performed on ambulance in order not to delay
the Scene time. Blood pressure will be titrated to at least 90 mmHg (systolic-BP) with small Normal Saline
boluses 250mL.
• Disability assessment
Glasgow coma scale was 15/15. The assessment for focal neuro deficits should be carry on later, on
ambulance and in emergency room, not on scene.
• Exposure
The right upper extremity was deformed, which indicated there was a fracture, the immobilization should
be performed on ambulance. “splint suspected fracture”. Consider Pain management protocol. Consider
tourniquet protocol. These two protocols should be performed on ambulance as needed.
• The re-assessment should be performed continually.
The patient was wounded on head and bleeding, BP 90/60 mmHg (border line of Hypotension, and P 110 which
indicated that patient may be in compensatively traumatic shock. Then, he was in unstable status.
“Unstable patients must be transported immediately. Goal Scene Time < 10 minutes”.
“On scene time of 10 minutes or less for the unstable trauma patient is goal”.
“Scene times should not be delayed for procedures; these should be performed during transport when possible”.
“19-year-old man”
“Geriatric patient should be evaluated with a high index of suspension”.
“motor vehicle accident”
“Mechanism is the best indicator of serious injury”.
“BP 90/60 mmHg”
“Allow permissive hypotension to prevent further hemorrhage”.
Protocol Page 65

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4 Extremity Trauma & 5 Extremity Hemorrhage/ Amputation
Question
1. A 27-year-old male who was a senior in 18G gang, was evaluated by the emergency medical team due to
multiple lacerations, and left wrist incomplete amputation. The bleeding on affected left upper extremity
was stopped by applied multiple bandages and point-compressed and this extremity was cared correctly
following the Extremity Hemorrhage/ Amputation Protocol. The other shallow laceration had been cared
appropriately. His vital signs were in stable range. The Pain Management protocol was applied. How was
this incomplete amputation cared, supposedly the bleeding was correctly stopped?
2. A 27-year-old male who was a senior in 18G gang, was evaluated by the emergency medical team due to
multiple lacerations, and left wrist amputation. The bleeding on affected left upper extremity was stopped
by applied multiple bandages and point-compressed. The amputated body part (left hand) was collected
and stored correctly. The other shallow laceration had been cared appropriately. His vital signs were in
stable range. The Pain Management protocol was applied. How was this amputation cared, supposedly
the bleeding was correctly stopped?
3. For both situations, what is the most importance for the successful replantation ‘in the light of prehospital
care’?
4. What should the duration for evaluating and repairing the other lacerations be within?
5. A 5-year-old male who had been made a right leg-foot plaster cast due to closed 1/3-middle right tibia
fracture from falling down but unclear mechanism (you cannot imagine how the boy fell down), was
evaluated by emergency doctor. The falling down happened one hour before they were present in clinic.
The x-ray in affected part was performed and results of reduction and casting was well. In conversation,
you revealed that he, father of little boy, brought his son to your clinic because he had a negative argument
with the emergency staffs in the Government hospital, where the boy had been performed a plaster cast.
Vital signs of patient were in normal range, he was alert and did not complain of pain. What do you need
to be careful in this case?

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Answer
1. “Splint affected digit/ limb in a physiological position”.
2. For amputation:
• All retrievable tissue should be transported. DO NOT DELAY TRANSPORT for tissue retrieval.
• Rinse amputation with Normal Saline or Sterile Water.
• Wrap amputation in sterile gauze that has been moistened with Normal Saline or Sterile Water.
• Place in plastic bag or container; place container in separated container filled with ice if available.
• DO NOT PLACE AMPUTATED PART(S) IN DIRECT CONTACT WITH ICE.
(illustration below4
)
3. “For patients with an amputation, time is critical. Transport and notify receiving hospital immediately”
(Extremity Trauma Protocol, page 66).
“Urgently transport any injury with vascular compromise” (Extremity Trauma Protocol, page 66).
“Transport amputation victims rapidly, as successful replantation is time-dependent” (Extremity
Hemorrhage/ Amputation Protocol, page 67).
4. “Lacerations must be evaluated for repair within 04 hours” (Extremity Hemorrhage/ Amputation Protocol,
page 67).
5. Find other injuries until having clear proof that there is none. This story is based on the real case. Let’s
see the rest.
The father and son come back the second clinic in the next 01 weeks for following-up, with normal re-x-ray, which
was evaluated a plaster cast and fracture site. Then 03 weeks later they came again to remove a plaster cast. After
removal, emergency doctor revealed both legs were not equal, and the right leg was dropped laterally. He ordered
a pelvic x-ray and the result was a right hip dislocation… and it happened for 04 weeks! He explained to the father
of patient that he missed the joint dislocation and transferred them to the Pediatric Hospital.
Therefore, please remember: “Hip dislocations, knee and elbow fracture/ dislocations have a high chance of
vascular compromise”. (Extremity Hemorrhage/ Amputation Protocol, page 67). Try not to say ‘apology’ by
‘hunting’ concealed injuries.
As the same, “Blood loss may be concealed or not apparent with extremity injuries” (Extremity Hemorrhage/
Amputation Protocol, page 67).
Protocol Page 66
4
Guidelines for Management of Amputated Parts- American College of Surgeons Committee on Trauma 1996

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6 Burns- Electrical/ Chemical & 7 Burns- Thermal
Question
1. A 22-year-old-married female was evaluated by the emergency medical team 15 minutes after was
rescued from Carina apartment building, block A, 9th
floor. She was confused and opened eyes by pain
stimulants, responded with comprehensive answers accompanied with wheezing and followed correctly
the instructor’s command. There were signs of heating on her head and nostril hairs. BP 150/90. P 110.
RR 30. SpO2 99% (oxygen mask 15 L/minute). The remainders were not abnormally remarked. Where
should patient be transferred to?
2. What accompanied with “whatever caused burn” should especially be removed from this patient inside
ambulance on the transferring?
3. On ambulance you found patient had eyes involvement from fire, what should be performed now?
4. On ambulance, when all clothing of patient was removed, you saw several blister on her left leg, and the
burn in 1/3 middle part of left arm was not painful as the left leg was. How much percentage of body
surface area (%BSA) was affected?
5. In case patient was burned from electrical source in the left arm, what should be also performed on
ambulance to monitor continuously patient?
6. In case patient was burned from electrical source in the left arm, what should be also noted on ambulance
for the electrical injury?
7. IV line was opened and patient was administered 500 mL Normal Saline. Based on protocol, how much
Normal saline she should be at least added to reach the amount of Normal Saline which should be infused
over first 8 hours after initial burn time? (her weight: 50 kg)
Protocol Page 68

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Answer
1. Transport to BURN CENTER due to: (1) GCS (E2V5M6) = 13/15; (2) Breathing with wheezing.
Criteria of Critical Patient Criteria of Minor
→ Transport to BURN CENTER → May be transported to LOCAL HOSPITAL
• Equal to more than 15% Total Body Surface
Area (TBSA) 2nd
degree burn OR Equal to
more than 2% 3rd
degree burn
• Airway compromise (therefore “Early
intubation is necessary for patients with
significant inhalation injuries”)
• Hypotension
• GCS < 14
• Fewer than 15% TBSA 2nd
OR Fewer than
2% TBSA 3rd
• Not intubated
• No inhalation injury
• Normotensive
• GCS15
AND
• Face, hands, genital, hands burns
• Circumferential burns (due to possible
vascular compromise)
• Any 3rd
degree burn > 2% TBSA
• Burns with associated trauma
• Non-trivial Pediatric burns
• Burns in adults > 50, esp. with underlaying
co-morbid conditions.
Burns Chemical/ Electrical/ Thermal Protocol, page 68, 69.
2. Remove rings and other constricting items.
Remove clothing and expose affected area.
“Assure whatever caused the burn is no longer contacting the skin”.
3. “Eye involvement → Continuously flushed the affected area for 10—15 minutes”.
4. 18% 2nd
degree burn on left leg; approximately 3% 3rd
degree burn on left arm.
5. “Cardiac Monitor and 12 lead ECG after electrical injury”
“Anticipate Ventricular, or Atrial irregularity V-Tach, V-Fib, Heart blocks and other dysrhythmias.
6. “Attempt to locate contact point, both will generally be full thickness burns”
“Burn patients are prone to hypothermia, NEVER cool or apply ice to the burned area”
7. 3,700mL
“IV Normal Saline Bolus: 04 cc x weight (kg) x %TBSA of burns. Over first 8 hours after initial burn time”
IV Normal Saline = 04 x 50 x 21 = 4,200 mL; 4,200- 500 = 3,700 mL.
Chemical Burns
• Flush the affected area as soon as possible with the cleanest and most readily available Saline or Tap
water using copious amounts of fluid
• Utilize industrial decontamination equipment/ showers and Material Safety Data Sheets (MSDS's)
information when available.
Burns Chemical/ Electrical/ Thermal Protocol, page 68, 69.

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8 Marine Life Envenomation (Jellyfish and Stingray)
Question
1. Which one is stingray? (right, left or middle)
2. First-aid could be performed on wound/ affected sites from the creature on the middle?
3. First-aid could be performed on wound/ affected sites from the creature on the left?
4. What the protocol should be recalled, based on Marine Life Envenomation Protocol?

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Answer
1. Left
Middle: Jellyfish
Right: Sea snake
2. “Irrigate with copious amounts of vinegar over the wound”.
• “Advise the patient that if they have mild pain after treatment a topical anti-histamine may help”.
• “Transport patients with severe systemic response or allergic reaction to jellyfish stings”.
• “Transport and treat patients with high BSA% of jellyfish stings or patients with stings to the mucosa due
to the risk for infection, severe pain and cosmetic damage”.
• “Jellyfish stings in the Galveston area are rarely serious despite the amount pain. Rarely toxic varieties
can drift into the area and the patient will present in imminent collapse”.
3. “If able immerse the affected site in very hot water or place hot packs to the affected area”.
• “Advise patient to allow EMS to transport patient to proper wound care and to ensure no foreign material
remains in the wound”.
• “Stingray envenomation require medical attention due to the high risk of infection and risk of retained barbs
or foreign mater in the wound”.
4. “Consider Pain management Protocol”. And Allergic Reaction, Anaphylaxis Protocols.
Protocol Page 70

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9 Snake Bite
Question
1. A 25-year-old man was assessed by medical team due to complained of snake bite a couple minutes ago.
His big toe was swelling with teeth marks (02 holds separated each other about 1 cm, non-bleeding). With
a raw, he head-opened the snake, and crushed its head. The snake was green on body and red in tail. He
was alert with vital signs in normal ranges. Where should the patient be transferred to?
2. What the protocols should be recalled in this situation?
3. On Ambulance, what the most important things linked to wound should be done?

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Answer
1. “Immediate transport to a Trauma Center”.
In Saigon city, it will be Chợ-Rẫy Hospital.
2. Anaphylaxis, Hypotension and Pain Management Protocols.
3. These following things, at least, should be done before arriving to Trauma Center
• Keep patient (bite site) movement to a minimum.
• Remove items that may constrict swelling tissues.
• Document size and time of edema near the injury site.
“DO NOT BRING LIVE SNAKES TO EMERGENCY ROOM”
Protocol Page 71

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10 Drowning/ Near Drowning
Question
1. In the freezing winter, a 5-year-old baby sunk into pool of hotel in about 3 minutes due to falling down from
01 floor above. The rescuer team of 7-stars Hotel had put cervical collar and brought him on the spinal
scoop which specialized for water rescue activity. The little boy was performed CPR due to cardiac arrest
by the rescuer team of Hotel and the effort was successful, patient was alert and in respiratory distress.
The emergency medical team came and brought patient to the International Hospital of Family Medical
Practice. On ambulance, patient was warmed up by special blanket. What the value items (information)
in the scenario, make a list, please?
2. What the non-invasive technique should be performed, in case you had every essential medical
equipment?
3. In Emergency Room, patient was gradually not alert, confused and in respiratory distress still. What should
be performed now?

2018. pre hospital workbook

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