Episode 12 - "The Leftovers" Part 2 - More drugs in the Box 

Episode 12 - More drugs in the Box


October 2023 - 5th Monday BONUS Material


John Hill

Scott Wildenheim

Caleb Ferroni

Ray Pace

Episode Video and Audio

October Extra Monday Episode

Show Notes

Leftovers from the previous extras episodes


Used locally in our EMS protocol for field heparinization of patients with confirmed STEMI (along with Ticagrelor).

Concentration is 5000U / 1ml dose is 60u/kg UP TO 4000 units. Max volume to draw is 0.8ml to achieve the 4000U

There are other indications in medicine (not necessarily in EMS) that may use more heparin, thus there are concentration differences from the max we may give.

Harrington Heart and Vascular Institute (HHVI) is UH's cardiovascular specialty that developed and promotes the out of hospital use of these agents

If patient inadvertently given 5000u, there is unlikely to be harm (they are going to get a lot more if they go to the cath lab). This is still a medication error and must be reported.

 There may be (in longer transport times) prehospital benefit. EKG's may improve. Regardless the prehospital use may soften clots for expedient more resolution in the lab

If patient is already anti-coagulated, withhold

Drawing Medications

Providers need to take some time and understand what graduations are on each size of syringe... Not all syringes have the same graduations. Smaller volumes difficult to properly draw and dose in larger syringes. Choose according to need  / use.

May make a good drill for training, practice drawing various medications .

CertaDose is only geared for 3 medications. You still have many medications that you will still need to draw on your own accord.

Refer to the medication reference charts in the protocol. Indicates both the volume AND dose.

Racemic Epinephrine

More alpha potent preparation of epinephrine tuned for use in upper airway problems. Upper airway is very vascular, need an alpha potent agent. Racemic is this agent. Essentially upper airway problems are vascular problems, lower airway problems are smooth muscle problems.

Racemic is concentrated, normal preparation is 0.5ml - this will not run long in a nebulizer. You need to dilute it to make it run longer.

Old myth that sodium in normal saline is broncho reactive, this is not the case. Can dilute with normal saline. Use 3 ml to get the total volume up so it runs longer, rather than a puff. 

Can use regular epinephrine 1mg/ml in lieu of racemic epinephrine, but does not need diluted.

Epinephrine Drips

Epinephrine drips are permitted in the protocol if there is extended transport time or the provider  / medical director prefers. 

If a patient requires frequent push doses of epi, this may be a more coinvent way to deliver the agent. Making an coinvent  concentration makes it easy to drip

Recall 1mg = 1000mcg

Put 1000mcg of epinephrine in 100ml D5 or NS - Yield of 10 mcg/ml

The choice to spike this mix with a 10 drop set makes life even easier. Every 10 drops that fall = 1ml (every ml = 10 mcg of epinephrine) Thus every drop = 1mcg

Topical TXA

Can be used for epistaxis - soak gauze product in TXA - no specific dose or amount, just soak it

Blow out clots and suction 

Put in offending nostril(s)

Vitals with sign-offs

100/100 rule - if the HR is over 100 and/or the BP is less than 100, its requires explanation and investigation

Document why and what was done

Highest risk call - hardest to defend inaction. Push assessment and create good documentation

EMS Protocol Beta Blockers

We carry 2 beta blockers



Although both are in the same class, they have different functions. Using for the wrong indication may actually cause harm. 

Labetalol for hypertension (mixed alpha and beta blocker) - Protocol use in eclampsia

Metoprolol (selective agent for beta1 - heart rate blocker) - Protocol use in refractory narrow complex tachycardia

Antibiotics for open fracture

There is a pilot program in UH for the use of ceftraxone (ancef) for open extremity fracture 

Required by trauma service anyway, but there are gaps. If EMS can get this onboard, the patient can go to surgey sooner. 

The Protocols

Episode Shorts

From The Episode

Ray discusses prehospital heparinization principals

Scott explains protocol medication refrence

Caleb explains why patients can't refuse the  respiration vital sign

Dr. Hill reviews a real-time EKG with his crew while on the air