Rhode Island EMS protocols,
in your pocket.

• 1 mg IV/IO every 3 minutes to a maximum of 3 doses
• ✓ 1 mg IV/IO every 5 minutes to a maximum of 5 doses
• 0.5 mg IV/IO every 5 minutes to a maximum of 5 doses
• 1 mg IV/IO every 5 minutes with no maximum dose limit

The protocol states that for non-shockable rhythms, epinephrine (1 mg/10 ml) 1 mg IV/IO should be administered every 5 minutes to a maximum of 5 doses. An infusion of 0.5 mcg/kg/minute may be considered in place of IV bolus, but the bolus dose and interval are 1 mg every 5 minutes.

• Adenosine 12 mg rapid IV push
• Normal saline 500-1000 ml IV/IO bolus
• ✓ Calcium chloride 1 gm slow IV/IO
• Amiodarone 150 mg IV over 10 minutes

The protocol states to consider Calcium Chloride 1 gm SLOW IV/IO prior to administering Diltiazem if the BP is tenuous (SBP ~100). With an SBP of 98 mmHg, this patient meets the threshold and calcium chloride should be considered before diltiazem to help protect against further hemodynamic compromise.

• SBP ≥ 80 mmHg
• ✓ SBP ≥ 90 mmHg
• SBP ≥ 100 mmHg
• SBP ≥ 110 mmHg

The protocol states that for patients with respiratory distress, crackles on lung auscultation, or SpO₂ less than 92%, CPAP up to 10 cmH₂O should be provided if the SBP ≥ 90. This is an EMT-level (E) intervention listed under the green band.

• Administer Lactated Ringer's 500 ml IV and repeat up to 2L to achieve SBP ≥100
• Do not administer IV fluids due to evidence of pulmonary edema; proceed directly to vasopressors
• Administer Lactated Ringer's 250 ml IV and do not repeat, as fluid is contraindicated with signs of pulmonary edema/CHF
• ✓ Administer Lactated Ringer's 250 ml IV; repeat once only if needed to achieve SBP ≥100 or MAP ≥65, but withhold if shortness of breath or pulmonary edema/CHF is present

Per Protocol 2.20 Adult (Paramedic level), for cardiogenic shock: administer Lactated Ringer's 250 ml IV and repeat x1 if needed to achieve SBP ≥100 or MAP ≥65. However, the protocol explicitly states 'do not administer IVF if there is shortness of breath or evidence of pulmonary edema/CHF.' Since this patient has bilateral crackles and JVD indicating pulmonary edema, IVF should not be administered, and vasopressors (Norepinephrine preferred, or Dopamine) should be used instead.

• Immediately proceed with shock delivery regardless of marker display
• Switch to unsynchronized (defibrillation) mode and deliver the shock
• ✓ Select another lead or reposition the ECG electrodes; increasing gain to increase QRS amplitude may also help
• Abort the procedure and transport the patient without cardioversion

Per Protocol 7.23, Step 6: 'If the R wave markers do not appear, or appear elsewhere on the ECG, select another lead or reposition the ECG electrodes. Increasing the gain to increase QRS amplitude may also be helpful.' Proceeding without confirmed R wave markers risks shock delivery during the relative refractory period, potentially inducing ventricular fibrillation.

• A 40-year-old male with a complaint of heartburn and a history of diabetes
• A 30-year-old female with weakness, dizziness, and nausea
• A 38-year-old male with non-traumatic chest pain
• ✓ A 25-year-old male with palpitations and no significant medical history

Protocol 7.18 requires a 12-lead ECG for any patient ≥35 years old with palpitations, OR any patient of any age with symptoms AND a history of diabetes, cardiac disease, obesity, recent cocaine use, or family history of premature cardiac disease. A 25-year-old with palpitations and no significant medical history does not meet the age threshold (≥35) and lacks any qualifying comorbidity, so he does not automatically meet criteria. The 40-year-old with heartburn AND diabetes meets the 'any age with symptoms + comorbidity' criterion; the 30-year-old female with weakness/dizziness/nausea meets the adult female criterion; and the 38-year-old male with chest pain meets the ≥35 criterion.