SIERRA-SACRAMENTO VALLEY EMERGENCY MEDICAL SERVICES AGENCY. Memorandum

Transcription

1 SIERRA-SACRAMENTO VALLEY EMERGENCY MEDICAL SERVICES AGENCY Serving Butte, Colusa, Glenn, Nevada, Placer, Shasta, Siskiyou, Sutter, Tehama, & Yuba Counties Memorandum Date: September 26, 2018 To: From: Subject: S-SV EMS System Participants Troy M. Falck, MD EMS Analgesics and Dopamine Medication Updates S-SV EMS has received local optional scope of practice approval from the California EMS Authority to allow S-SV EMS accredited paramedics to utilize the following analgesic medications upon successful training completion: IV Acetaminophen Ketorolac Ketamine The revised S-SV EMS adult and pediatric pain management protocols (M-8 & P-34) were reviewed and approved during the September 18, 2018 S-SV EMS Regional Medical Control Advisory Committee meeting, and will become effective October 1, Please be aware of the following regarding the use of these additional analgesic medications: At this time, the use of these additional medications by ALS provider agencies is optional. However, due to various supply and patient care factors, ALS provider agencies are strongly encouraged to consider the adoption of one or more of these additional analgesic options. The revised S-SV EMS ALS Provider Agency Inventory Requirements Policy (701) incorporating these additional medications will be included in the next policy manual update effective December 1, ALS provider agencies who wish to implement one or more of these additional analgesic medications are responsible for completing the following prior to implementation: o Ensuring that their paramedic personnel who will be administering these medications have successfully completed the S-SV EMS approved training related to the use of these medications. Proof of successful training completion must be maintained by the provider agency and is subject to review by S-SV EMS representatives Pacific Street 2775 Bechelli Lane Rocklin, CA Redding, CA (fax) Page 1 of (fax)

2 SIERRA-SACRAMENTO VALLEY EMERGENCY MEDICAL SERVICES AGENCY o Ensuring that their electronic PCR system is appropriately configured to document/capture the administration of these medications by their paramedic personnel as follows: Medication Name emedications.03 Name RxNorm Export Value IV Acetaminophen Acetaminophen 161 Ketorolac Ketorolac Ketamine Ketamine 6130 o Notifying S-SV EMS of the name and expected implementation date of each medication prior to implementation. o Monitoring the use of these medications through their EMSQIP, and reporting any significant adverse patient reactions related to the use of these medications to S-SV EMS by the end of the next business day following notification/discovery. Please note that S-SV EMS staff will also be conducting a 100% QA/QI audit related to the use of these medications for the foreseeable future. As a result of an ongoing national shortage of dopamine, many ALS provider agencies have been using expired doses of this medication or none at all. In response to this ongoing shortage, S-SV EMS has proposed replacing dopamine with push-dose epinephrine for applicable patients in the prehospital setting. We have recently been notified that limited quantities of specific preparations of dopamine have become available for purchase from some EMS supply vendors. However, based on the likelihood of continued availability issues, current medical literature and current standard practice among many California LEMSA s, we will continue to move forward with phasing out the use of Dopamine by ALS provider agencies in the S-SV EMS region. ALS provider agencies may continue to utilize their current (non-expired) supply of dopamine until it has expired or been used in the provision of patient care. Additional quantities of dopamine should not be purchased by ALS provider agencies from this point forward. Once the current supply of dopamine has been utilized or expired, ALS provider agencies are required to implement the use of push-dose epinephrine for applicable prehospital patients, utilizing the following preparation and administration instructions: Eject 1 ml NS from a 10 ml pre-load NS flush syringe, leaving 9 ml Draw up 1 ml 0.1 mg/ml (1:10,000 IV formulation) and gently mix Administer 1 ml IV/IO push every 1 5 minutes Titrate to maintain SBP > 90 Applicable S-SV EMS protocols (C-5, C-7 and M-1) are currently in the process of being revised to incorporate this treatment language, and will be included in the next policy manual update effective December 1, In the interim, push-dose epinephrine may be utilized as a substitute to dopamine in current S-SV EMS treatment protocols where Page 2 of 3

3 SIERRA-SACRAMENTO VALLEY EMERGENCY MEDICAL SERVICES AGENCY indicated. ALS provider agencies experiencing a current dopamine shortage or who are utilizing expired dopamine based on previous S-SV EMS direction are required to implement the use of push-dose epinephrine as soon as their paramedic personnel have received the preparation and administration instructions contained in this document. Accordingly, the use of expired dopamine by ALS provider agencies in the S-SV EMS region will no longer be approved. Please feel free to contact S-SV EMS staff with any questions you may have regarding this memorandum. Encl.: EMSA LOSP Approval Letter Dated September 17, 2018 S-SV EMS Adult Pain Management Treatment Protocol (M-8), Effective October 1, 2018 S-SV EMS Pediatric Pain Management Treatment Protocol (P-34), Effective October 1, 2018 S-SV EMS Online Training Presentation Instructions S-SV EMS IV Acetaminophen S-SV EMS Ketorolac Medication Profile S-SV EMS Fentanyl Medication Profile S-SV EMS Morphine Medication Profile S-SV EMS Ketamine Medication Profile S-SV EMS Midazolam Medication Profile Page 3 of 3

4 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY EMERGENCY MEDICAL SERVICES AUTHORITY GOLD CENTER DR., SUITE 400 RANCHO CORDOVA, CA (916) FAX (916) EDMUND G. BROWN JR., Governor ~.a.::r September 17, 2018 Troy Falck, MD, FACEP, FAAEM EMS Medical Director Sierra-Sacramento Valley EMS Agency 5995 Pacific St. Rocklin, CA Dear Dr. Falck: This letter is to inform you that the Sierra-Sacramento Valley EMS Agency's local optional scope of practice request for the following items is approved through September 30, 2021: 1. Ketamine 2. IV Administration of Acetaminophen 3. Ketorolac Your request was reviewed with you and members of the Scope of Practice Committee of the Emergency Medical Services Medical Directors Association of California on September 11, The recommendation from the Scope of Practice Committee,: and concur, was to approve your request. If you have any questions, please contact Sean Trask of my staff at (916) or by at Sincerely, Howard Backer, MD, MPH, FACEP Director cc: Victoria Pinette, Regional Executive Director, Sierra-Sacramento Valley EMS Agency

5 Sierra Sacramento Valley EMS Agency Treatment Protocol M-8 Pain Management Approval: Troy M. Falck, MD Medical Director Effective: 10/01/2018 Approval: Victoria Pinette Executive Director Next Review: 09/2021 Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. Interpretation of pain behaviors and decision-making regarding treatment of pain requires consideration of the context in which the pain behaviors are observed. Not all painful conditions require ALS intervention. BLS pain management methods (splinting, positioning, compression, ice, verbal assurance, etc.) are effective in managing pain and may be sufficient for certain pts. Multiple factors must be considered in determining the most appropriate analgesic(s) to administer for pain management (medication availability & contraindications, clinical impression, pt. history, etc.). IV acetaminophen and/or ketorolac are considered first-line analgesics for pts with mild moderate pain. Opioids or ketamine are considered first-line analgesics for pts with severe pain (pain score typically 7). Continuous cardiac and SpO 2 monitoring are required for all pts receiving analgesics. Medication doses, pt. response and reason for administration shall be adequately documented in the PCR. BLS Assess V/S including SpO 2 O 2 at appropriate rate if hypoxemic (SpO 2 < 94%) Utilize BLS pain management methods as necessary Pain From Acute Injuries Isolated extremity injuries Multi-system trauma Burns Frostbite/bites/envenomations Other Causes of Pain Non-acute injuries Back pain Abdominal pain Sickle cell crisis, cancer, etc. Pain managed effectively with BLS methods? YES Monitor & reassess YES Pain managed effectively with BLS methods? NO NO ALS YES Communication failure? NO IV/IO NS TKO if necessary (may bolus up to 1000 ml) Cardiac monitor Contact base/modified base hospital for pain management consultation See Page 2 for ALS Pain Management Page 1 of 2

6 Sierra Sacramento Valley EMS Agency Treatment Protocol Pain Management M-8 ALS Pain Management Any Pain Severity Not Effectively Managed With BLS Methods May administer one or both of the following Acetaminophen 1 gram IV/IO infusion over 15 minutes (single dose only) Ketorolac mg IV/IO or IM (single dose only) i Acetaminophen and/or ketorolac may be administered in addition to opioids or ketamine for pts with severe pain (ketorolac is preferred for pts with suspected kidney stones or chronic back pain) i Do not administer acetaminophen to pts with severe hepatic impairment or active liver disease i Do not administer ketorolac to pts 65 yo, or who have any of the following contraindications: - Multi-system trauma - Active bleeding - Current anticoagulation therapy - Pregnancy - Current steroid use - Hx of GI bleeding or ulcers - Hx of asthma - NSAID allergy - Hx of renal disease/insufficiency/transplant Severe Pain, Pain Not Effectively Managed With Acetaminophen/Ketorolac, Acetaminophen/Ketorolac Contraindicated, or Acetaminophen/Ketorolac not available Fentanyl (opioid) mcg slow IV/IO (over 1 minute) or IM/IN May repeat every 5 minutes (maximum cumulative dose = 200 mcg) Morphine Sulfate (opioid) 2 5 mg slow IV/IO (over 1 minute) or IM May repeat every 5 minutes (maximum cumulative dose = 20 mg) Ketamine (non-opioid) 0.3 mg/kg slow IV/IO (over 1 minute, maximum = 30 mg) or 0.5 mg/kg IM/IN (maximum = 50 mg) May repeat every 10 minutes (maximum cumulative dose = 100 mg) i Do not administer opioids to pts with any of the following contraindications: - Systolic BP < Hypoxia or RR < 12 - ALOC or evidence of traumatic brain injury i Do not administer ketamine to pts with any of the following contraindications: - Pregnancy - ALOC - Multi-system trauma or active bleeding i Do not administer opioids and ketamine to the same pt. i If administering fentanyl and morphine to the same pt., maximum cumulative dose = 100 mcg fentanyl and 10 mg morphine i Use lower doses of opioids/ketamine when co-administered with acetaminophen and/or ketorolac Severe Pain From Acute Isolated Extremity Injuries (including hip and shoulder injuries) Midazolam (if pain not effectively managed with opioids/ketamine/acetaminophen/ketorolac) 1 mg slow IV/IO May repeat x 1 in 5 minutes (max = 2 mg) i Do not administer midazolam to pts with any of the following contraindications : - Systolic BP < Hypoxia or RR < 12 - ALOC or evidence of traumatic brain injury i Use caution when administering opioids or ketamine and midazolam to the same pt. Page 2 of 2

7 Sierra Sacramento Valley EMS Agency Treatment Protocol P-34 Pediatric Pain Management Approval: Troy M. Falck, MD Medical Director Effective: 10/01/2018 Approval: Victoria Pinette Executive Director Next Review: 09/2021 Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. Interpretation of pain behaviors and decision-making regarding treatment of pain requires consideration of the context in which the pain behaviors are observed. Not all painful conditions require ALS intervention. BLS pain management methods (splinting, positioning, compression, ice, verbal assurance, etc.) are effective in managing pain and may be sufficient for certain pts. Multiple factors must be considered in determining the most appropriate analgesic(s) to administer for pain management (medication availability & contraindications, clinical impression, pt. history, etc.). IV acetaminophen and/or ketorolac are considered first-line analgesics for pts with mild moderate pain. Opioids or ketamine are considered first-line analgesics for pts with severe pain (pain score typically 7). Continuous cardiac and SpO 2 monitoring are required for all pts receiving analgesics. Medication doses, pt. response and reason for administration shall be adequately documented in the PCR. BLS Assess V/S including SpO 2 O 2 at appropriate rate if hypoxemic (SpO 2 < 94%) Utilize BLS pain management methods as necessary Pain From Acute Injuries Isolated extremity injuries Multi-system trauma Burns Frostbite/bites/envenomations Other Causes of Pain Non-acute injuries Back pain Abdominal pain Sickle cell crisis, cancer, etc. Pain managed effectively with BLS methods? YES Monitor & reassess YES Pain managed effectively with BLS methods? NO NO Age 4 years old? NO Contact base/modified base hospital for pain management consultation YES ALS IV/IO NS TKO if necessary (may bolus up to 20 ml/kg) Cardiac monitor See Page 2 for ALS Pain Management Page 1 of 2

8 Sierra Sacramento Valley EMS Agency Treatment Protocol Pediatric Pain Management P-34 ALS Pain Management Any Pain Severity Not Effectively Managed With BLS Methods May administer one or both of the following: Acetaminophen 15 mg/kg IV/IO infusion over 15 minutes (maximum = 1000 mg) single dose only Ketorolac 0.5 mg/kg IV/IO or IM (maximum = 15 mg) single dose only i Acetaminophen and/or ketorolac may be administered in addition to opioids or ketamine for pts with severe pain i Do not administer acetaminophen to pts with severe hepatic impairment or active liver disease i Do not administer ketorolac to pts who have any of the following contraindications : - Multi-system trauma - Active bleeding - Current anticoagulation therapy - Pregnancy - Current steroid use - Hx of GI bleeding or ulcers - Hx of asthma - NSAID allergy - Hx of renal disease/insufficiency/transplant Severe Pain, Pain Not Effectively Managed With Acetaminophen/Ketorolac, Acetaminophen/Ketorolac Contraindicated, or Acetaminophen/Ketorolac not available Fentanyl (opioid) 1 mcg/kg slow IV/IO (over 1 minute) or IM/IN (maximum = 50 mcg) May repeat every 5 minutes (maximum = 4 doses) Morphine Sulfate (opioid) 0.1 mg/kg slow IV/IO (over 1 minute) or IM (maximum = 5 mg) May repeat every 5 minutes (maximum = 4 doses) Ketamine (non-opioid) 0.3 mg/kg slow IV/IO (over 1 minute) or IM/IN (maximum = 15 mg) May repeat every 10 minutes (maximum = 4 doses) i Do not administer opioids to pts with any of the following contraindications: - Systolic BP < Hypoxia or RR < 12 - ALOC or evidence of traumatic brain injury i Do not administer ketamine to pts with any of the following contraindications: - Pregnancy - ALOC - Multi-system trauma or active bleeding i Do not administer opioids and ketamine to the same pt. i If administering fentanyl and morphine to the same pt., maximum cumulative dose = 4 total doses combined i Use lower doses of opioids/ketamine when co-administered with acetaminophen and/or ketorolac i Use caution when administering opioids or ketamine and midazolam to the same pt. Page 2 of 2

9 S-SV EMS Online Training Presentation Instructions Links to S-SV EMS online training presentations are located on the Education/Training page of the S-SV EMS website ( o Note: internet access is required for the duration of the presentation training presentations are hosted by a different service and may take a few seconds to load You will need to utilize either Apple Safari or Google Chrome internet browsers to ensure that the training presentation functions properly Training Presentation Navigation: Numbers indicate current and total slides Click the arrows < or > to advance to the next slide or go back to the previous slide the forward and back keyboard arrows can also be used to navigate the presentation Click to play embedded presentation videos if they do not play automatically Click for gallery of all slides Click to view in full screen mode

10 IV Acetaminophen (Ofirmev) Medication Profile Classification: Non-opioid analgesic Mechanism of Action: The precise mechanism of action is not established, but is thought to primarily involve central actions Indications: Mild to moderate pain Adjunct to other analgesics for severe pain Contraindications: Hypersensitivity/allergy to acetaminophen Severe hepatic impairment or active liver disease Adverse Reactions/Side Effects: Adverse reactions may include hepatic injury, serious skin reactions, allergy, and hypersensitivity Side effects include nausea, vomiting, headache, and insomnia in adult patients and nausea, vomiting, constipation, and pruritus in pediatric patients Administration: Adult Patients: 1 gram IV/IO infusion over 15 minutes Pediatric Patients: 15 mg/kg IV/IO infusion over 15 minutes (max = 1,000mg) Onset of Action: minutes from the start of infusion Peak Effect: 1 hour Duration of Action: 4 6 hours Special Instructions/Precautions: o No minimum SBP required for administration o May be administered in addition to opioids/ketamine for patients in severe pain o Continuous cardiac and SpO 2 monitoring required with administration o Administer one dose only o Should be administered within 6 hours of opening package Storage: Should ideally be stored between 68 0 F and 77 0 F S-SV EMS (Updated 09/2018)

11 Ketorolac (Toradol) Medication Profile Classification: Nonsteroidal anti-inflammatory drug (NSAID) Mechanism of Action: Inhibits the bodily synthesis of prostaglandins Indications: Mild to moderate pain Adjunct to other analgesics for severe pain Contraindications: NSAID hypersensitivity/allergy Multi-system trauma Active bleeding Current anticoagulation therapy Hx of renal disease/insufficiency/transplant Current steroid use Hx of asthma Hx of GI bleeding or ulcers Pregnancy Adverse Reactions/Side Effects: Risk of bleeding is increased with ketorolac administration Side effects include burning or pain at injection site, edema, nausea, hypertension, rash/itching, GI distress, drowsiness Administration: Adult Patients (< 65 years old): mg IV/IO or IM Pediatric Patients: 0.5 mg/kg IV/IO or IM (max = 15 mg) Onset of Action: minutes Peak Effect: 1 2 hours Duration of Action: 4 6 hours Special Instructions/Precautions: o Do not administer to patients 65 years old o No minimum SBP required for administration o May be administered in addition to opioids/ketamine for patients in severe pain o Continuous cardiac and SpO 2 monitoring required with administration o Administer one dose only Storage: Should ideally be stored between 59 0 F and 86 0 F, protect from light S-SV EMS (Updated )

12 Fentanyl (Sublimaze) Medication Profile Classification: Synthetic opioid analgesic Mechanism of Action: Binds to opiate receptors, producing analgesia and euphoria Indications: Severe pain, pain not effectively managed with acetaminophen/ketorolac, acetaminophen/ketorolac contraindicated, or acetaminophen/ketorolac not available Pain/discomfort of cardiac origin Sedation for cardioversion or transcutaneous pacing (TCP) Contraindications: Hypersensitivity/allergy to fentanyl Hypoxia or RR < 12* SBP < 100* ALOC or evidence of traumatic brain injury* *Relative contraindication if administering to patients for pre-cardioversion/tcp sedation Adverse Reactions/Side Effects: Adverse reactions may include bradycardia, restlessness, circulatory depression, respiratory depression, altered mental status Common side effects include rash, nausea, vomiting, drowsiness, dry mouth, dizziness, difficulty urinating, constipation (prolonged use), constricted pupils Uncommon side effects include rigid chest wall, decreased breathing, confusion, hives, itching, slowing or elevated HR, abdominal pain, increased ICP, flushing Administration: Adult Patients: o Pain Management (non-cardiac): mcg slow IV/IO (over 1 minute) or IM/IN, may repeat every 5 minutes (max cumulative dose = 200 mcg) o Chest Pain/Discomfort of Cardiac Origin: 25 mcg slow IV/IO (over 1 minute), may repeat every 5 minutes (max cumulative dose = 200 mcg) o Pre-cardioversion or TCP sedation: mcg IV/IO Pediatric Patients: o Pain Management: 1 mcg/kg slow IV/IO (over 1 minute) or IM/IN (max = 50 mcg), may repeat every 5 minutes (max cumulative = 4 doses) o All Other Indications: Contact base/modified base hospital for orders Onset of Action: 1 2 minutes IV/IO/IN, 7 15 minutes IM Duration of Action: minutes Special Instructions/Precautions: o CNS depression can be enhanced when administered with antihistamines, antiemetics, sedatives, hypnotics, barbiturates, and alcohol o Use lower doses when co-administered with acetaminophen and/or ketorolac o Continuous cardiac and SpO 2 monitoring required with administration, monitor respiratory status carefully, naloxone should be available as an antagonist Storage: Should ideally be stored between 68 0 F and 77 0 F S-SV EMS (Updated 09/2018)

13 Morphine Medication Profile Classification: Opioid analgesic Mechanism of Action: Acts on opiate receptors in the brain providing analgesia and sedation, increases peripheral venous capacitance and decreases venous return, decreases myocardial oxygen demand Indications: Severe pain, pain not effectively managed with acetaminophen/ketorolac, acetaminophen/ketorolac contraindicated, or acetaminophen/ketorolac not available Pain/discomfort of cardiac origin Pre-cardioversion or transcutaneous pacing (TCP) sedation Contraindications: Hypersensitivity/allergy to morphine Hypoxia or RR < 12* SBP < 100* ALOC or evidence of traumatic brain injury* *Relative contraindications if administering to patients for pre-cardioversion/tcp sedation Adverse Reactions/Side Effects: Adverse reactions may include bradycardia, restlessness, circulatory depression, respiratory depression, altered mental status Common side effects include nausea, vomiting, abdominal cramps, blurred vision, constricted pupils, headache Administration: Adult Patients: o Pain Management (non-cardiac): 2 5 mg slow IV/IO (over 1 minute) or IM, may repeat every 5 minutes (max cumulative dose = 20 mg) o Chest Pain/Discomfort of Cardiac Origin: 2 mg slow IV/IO (over 1 minute), may repeat every 5 minutes (max cumulative dose = 20 mg) o Pre-cardioversion or TCP sedation: 2 5 mg IV/IO Pediatric Patients: o Pain Management: 0.1 mg/kg slow IV/IO (over 1 minute) or IM/IN (max = 5 mg), may repeat every 5 minutes (max cumulative = 4 doses) o All Other Indications: Contact base/modified base hospital for orders Onset of Action: < 5 minutes IV/IO/IM Duration: 2 4 hours Special Instructions/Precautions: o CNS depression can be enhanced when administered with antihistamines, antiemetics, sedatives, hypnotics, barbiturates, and alcohol o Use lower doses when co-administered with acetaminophen and/or ketorolac o Continuous cardiac and SpO 2 monitoring required with administration, monitor respiratory status carefully, naloxone should be available as an antagonist Storage: Should ideally be stored between 68 0 F and 77 0 F S-SV EMS (Updated 09/2018)

14 Ketamine (Ketalar) Medication Profile Classification: Dissociative anesthetic Mechanism of Action: N-methyl-D-aspartate (NMDA) receptor antagonist with a potent anesthetic effect Indications: Severe pain, pain not effectively managed with acetaminophen/ketorolac, acetaminophen/ketorolac contraindicated, or acetaminophen/ketorolac not available Contraindications: Hypersensitivity/allergy to ketamine Multi-system trauma or active bleeding ALOC Pregnancy Adverse Reactions/Side Effects: CNS: Possible seizure like activity Cardiovascular: Hypertension, arrhythmias Administration: Adult Patients: 0.3 mg/kg slow IV/IO (over 1 minute, max = 30 mg) or 0.5 mg/kg IM/IN (max = 50 mg), may repeat every 10 minutes (max cumulative dose = 100 mg) Pediatric Patients ( 4 years old): 0.3 mg/kg slow IV/IO (over 1 minute) or IM/IN (max = 15 mg), may repeat every 10 minutes (max cumulative = 4 doses) Onset of Action: 1 2 minutes Duration of Action: 15 minutes Special Instructions/Precautions: o No minimum SBP required for administration o Fast IV/IO administration of ketamine can result in transient apnea, MUST administer slowly (over 1 minute) o Do not administer ketamine and opioids to the same patient o Use lower doses of ketamine when co-administered with acetaminophen and/or ketorolac o Continuous cardiac and SpO 2 monitoring required with administration, monitor respiratory status carefully Storage: Should ideally be stored between 59 0 F and 86 0 F, protect from light S-SV EMS (Updated )

15 Midazolam (Versed) Medication Profile Classification: Benzodiazepine Mechanism of Action: Reversibly interacts with gamma-amino butyric acid (GABA) receptors in the central nervous system causing sedative, anxiolytic, amnesic, and hypnotic effects Indications: Status epilepticus Chemical restraint Sedation for cardioversion, transcutaneous pacing (TCP) or following advanced airway placement (if necessary due to patient regaining consciousness after airway placement) Severe pain from acute isolated extremity injuries (including hip and shoulder injuries) if pain not effectively managed with opioids/ketamine/acetaminophen/ketorolac Contraindications: Contraindication (for all patients): Hypersensitivity/allergy to midazolam Contraindications (for isolated extremity injury pain management patients), or use with caution (all other types of patients where midazolam is indicated): o SBP < 100 o Hypoxia or RR < 12 o ALOC or evidence of traumatic brain injury Adverse Reactions/Side Effects: Laryngospasm, bronchospasm, dyspnea, respiratory depression/arrest, drowsiness, altered mental status, amnesia, bradycardia, tachycardia, PVCs, retching Administration: Adult Patients: o Status Epilepticus: 5 mg IV/IO or 10 mg IM/IN, may repeat same dose x 1 after 5 minutes of continued seizure activity o Pre-cardioversion/TCP: 2 5 mg IV/IO o Advanced Airway Sedation or Chemical Restraint: 5 mg IV/IO or 10 mg IM/IN o Severe Pain From Isolated Extremity Injuries (not effectively managed with opioids/ketamine/acetaminophen/ketorolac: 1 mg slow IV/IO, may repeat x 1 in 5 minutes (max = 2 mg) Pediatric Patients: o Status Epilepticus: 0.1 mg/kg (max = 5 mg) IV/IO or 0.2 mg/kg (max = 10 mg) IM/IN, may repeat same dose x 1 after 5 minutes of continued seizure activity o All Other Indications: Contact base/modified base hospital for orders Onset of Action: 2 minutes Duration of Action: 2 hours Special Instructions/Precautions: o Use caution when administering with opioids or ketamine o Continuous cardiac and SpO 2 monitoring required with administration, monitor respiratory status carefully Storage: Should ideally be stored between 68 0 F and 77 0 F S-SV EMS (Updated 09/2018)