Massachusetts EMS protocols,
in your pocket.

• Immediate chest compressions at a rate of 100-120 per minute
• Use AED as soon as possible with minimal interruption of chest compressions
• ✓ Endotracheal intubation to secure a definitive airway
• Place an oral or nasal airway, when appropriate to do so

Protocol 1.1 First Responder Standing Orders include immediate chest compressions at a rate of 100-120 per minute, AED use as soon as possible with minimal interruption of chest compressions, placing an oral or nasal airway when appropriate, and ventilation/oxygenation options as per most recent AHA/ILCOR recommendations. Considering an advanced airway such as endotracheal intubation is listed under Paramedic Standing Orders.

• Administer nebulized albuterol first, then establish vascular access
• ✓ Establish vascular access, administer calcium chloride 1 gram IV over at least 5 minutes, and administer nebulized albuterol up to 20 mg
• Contact Medical Control before administering any medications
• Administer calcium chloride 1 gram IV push as rapidly as possible

Per Paramedic Standing Orders, when clinical factors predisposing to hyperkalemia are present AND the 12-lead ECG is consistent with moderate to severe hyperkalemia, the paramedic must assure vascular access and administer calcium chloride 1 gram IV over AT LEAST 5 minutes along with nebulized albuterol (up to 20 mg max). Medical Control contact is not required before these standing-order interventions, and rapid IV push is not permitted.

• Administer a normal saline bolus titrated to hemodynamic stability.
• ✓ No fluid bolus; assess and treat for pulmonary edema and/or CHF per Protocol 3.6.
• Administer 20 mL/kg normal saline bolus immediately.
• Administer 500 mL boluses up to 30 cc/kg as in the sepsis protocol.

Protocol 2.16A explicitly states 'No fluid bolus' for cardiogenic shock at the Advanced EMT level, and instead directs assessment and treatment for pulmonary edema/CHF per Protocol 3.6. This distinguishes cardiogenic shock from all other shock types, which do allow consideration of normal saline boluses.

• 50 joules
• 100 joules
• ✓ 200 joules
• 360 joules

Protocol 3.2 states that if the systolic blood pressure is unstable (less than 100 mm Hg, with signs of hypoperfusion), in Atrial Flutter synchronized cardioversion begins at 200J, or per manufacturer recommendations based on the specific cardiac monitor you are using. In Atrial Fibrillation the energies are 200J, 300J, and 360J.

• ✓ 3 total doses, including those self-administered prior to arrival
• 3 doses administered by the EMT only, not counting pre-arrival doses
• 5 total doses if symptoms persist
• Unlimited doses as long as SBP remains >120 mm Hg

The EMT standing orders state nitroglycerin 1 tab/spray SL every 5 minutes to a maximum of 3 doses AND that doses self-administered prior to arrival (PTA) must be included in that count. Therefore the total cap is 3 doses combined.

• His core temperature is 35 °C
• He does not respond to commands
• ✓ The arrest was traumatic in origin
• He is intubated with a stable cardiac rhythm

The protocol explicitly lists traumatic arrest as a contraindication to TTM. A core temperature of 35 °C does not meet the hypothermia contraindication threshold (< 32 °C), lack of response to commands is actually part of the indication criteria, and intubation with a stable rhythm are required indications — not contraindications.