HCEMS Protocol Test Review 2026

Vocabulary flashcards covering key definitions, criteria, mnemonics, and protocols from the Adult Airway protocol AA 1.

Goal Oxygen Saturation

Supplemental oxygen target of oxygen saturation $\ge 92\%$ during airway and breathing management.

Capnography Monitoring Requirements

Mandatory End-tidal ($EtCO_2$) monitoring following placement of an endotracheal tube, and mandatory following placement of a BIAD once available on scene.

Failed Airway

Unable to ventilate and oxygenate $\ge 90\%$ during or after one (1) or more unsuccessful intubation attempts; and/or anatomy inconsistent with continued attempts; and/or three (3) unsuccessful attempts by the most experienced Paramedic/AEMT.

HEAVEN Criteria

Criteria used to identify a potentially difficult or complicated airway, comprising Hypoxemia, Extremes of Size, Anatomic Abnormalities, Vomit/Blood/Fluid, Exsanguination, and Neck Mobility.

Protocol Ventilation Rate

Ventilation rate of $10 - 12$ per minute to maintain an $EtCO_2$ of $35 - 45$ and avoid hyperventilation.

ROMAN Mnemonic

Mnemonic used for predicting Difficult BVM Ventilation: Radiation treatment/Restriction; Obese/Obstruction/OB (2nd and 3rd trimesters)/Obstructive sleep apnea; Mask seal difficulty (hair, secretions, trauma); Age $\ge 55$; No teeth.

LEON Mnemonic

Mnemonic used for predicting Difficult Laryngoscopy: Look externally for anatomical problems; Evaluate 3-3-2; Obese, obstruction, OB (2nd and 3rd trimesters); Neck mobility limited.

Evaluate 3-3-2 Rule

Assessment metric where mouth opening should equal 3 of patient's finger widths, mental area to neck should equal 3 of patient's finger widths, and base of chin to thyroid prominence should equal 2 of patient's finger widths.

RODS Mnemonic

Mnemonic used for predicting Difficulty with BIAD placement: Radiation treatment/Restriction; Obese/Obstruction/OB (2nd and 3rd trimesters)/Obstructive sleep apnea; Distorted or disrupted airway; Short thyromental distance/Small mandible.

SMART Mnemonic

Mnemonic used for predicting Difficulty with Cricothyrotomy / Surgical Airway: Surgery scars; Mass or hematoma, Access or anatomical problems; Radiation treatment to face, neck, or chest; Tumor.

Intubation Attempt Definition

Defined as the laryngoscope blade passing the teeth or the endotracheal tube passed into the nostril.

Secure Airway

A clinical state defined under protocol as when the patient is receiving appropriate oxygenation and ventilation.

Sniffing Position

An optimal airway positioning technique for non-trauma patients where the head is extended upon the neck with the goal of aligning the external ear canal with the suprasternal notch in a straight line.

Surgical Cricothyrotomy (Age Indication)

An invasive surgical airway procedure indicated in failed airway scenarios exclusively for patients $10\text{ years of age and greater}$.

DOPE Mnemonic

A troubleshooting mnemonic used to identify causes of acute deterioration in an intubated patient: Displaced tracheostomy tube/ETT, Obstructed tracheostomy tube/ETT, Pneumothorax, and Equipment failure.

Curare Cleft

A capnography waveform characteristic presenting as a cleft or notch in phase $3$, representing asynchronous ventilation or patient breathing effort, indicating the need to reassess the patient's depth of sedation.

Shark Fin Pattern

A classic capnography waveform featuring an upward-sloping expiratory phase characteristic of bronchospasm or lower airway obstruction, seen in conditions such as asthma or COPD.

Drug Assisted Airway (DAA) Indications

Four specific clinical criteria: Failure to protect the airway, unable to oxygenate, unable to ventilate, and/or impending airway compromise.

DAAM Operational Requirements

On-scene presence of at least two ($2$) HCEMS DAAM-certified paramedics and notification of EMS supervisor before initiating a drug-assisted airway procedure.

HEAVEN Mnemonic

Hypoxia ($\text{SpO}_2 < 94\%$); Extremes of size; Anatomic challenges; Vomit/Blood/Fluid; Exsanguination; Neck mobility limitation.

Adult Definition (DAA Protocol)

The age threshold defining patient eligibility for the Adult Drug Assisted Airway protocol, specified as age $\ge 16\text{ years of age}$.

Succinylcholine (DAA Dosage)

A depolarizing neuromuscular blocking agent administered at $2\,\text{mg/kg}\text{ IV / IO}$ (may repeat $\times 1$) to achieve paralysis during drug-assisted intubation.

Rocuronium (DAA Dosage)

A non-depolarizing neuromuscular blocking agent administered at $1\,\text{mg/kg}\text{ IV / IO}$ (may repeat $\times 1$) use when Succinylcholine is contraindicated.

Etomidate (DAA Dosage)

An induction sedative agent administered at $0.3\,\text{mg/kg}\text{ IV / IO}$ for drug-assisted airway placement.

STEMI (Electrocardiographic Definition)

An acute ST-elevation myocardial infarction identified by $\ge 1\,\text{mm}$ ST-segment elevation in $\ge 2$ contiguous leads, $\ge 2\,\text{mm}$ ST/J-point elevation in V2–V3 for men, $\ge 1.5\,\text{mm}$ ST/J-point elevation in V2–V3 for women, or symptomatic acute MI diagnosed by ECG software.

Modified Sgarbossa Criteria

Criteria used to diagnose STEMI in the presence of LBBB or ventricular paced rhythms: concordant ST elevation $> 1\,\text{mm}$ in any lead, concordant ST depression $> 1\,\text{mm}$ in leads V1–V3, or an excessively discordant ST elevation to S-wave ratio $> 25\%$ ($\text{STE} / \text{S wave} > 0.25$).

Nitroglycerin Paste Protocol

A topical nitrate dosing regimen based on systolic blood pressure: administer $1\text{ in}$ for SBP $> 100\,\text{mm\,Hg}$, $1.5\text{ in}$ for SBP $> 150\,\text{mm\,Hg}$, and $2\text{ in}$ for SBP $> 200\,\text{mm\,Hg}$.

STEMI Scene Time Goal

The operational standard dictating that prehospital on-scene time must be limited to $\le 15\text{ minutes}$ for patients with confirmed STEMI.

Post-ROSC Ventilation Targets

Respiratory parameters after cardiac arrest requiring a ventilation rate of $10\text{ breaths per minute}$, maintenance of $\text{SpO}_2$ between $92 - 98\%$, $\text{EtCO}_2$ between $35 - 45\,\text{mm\,Hg}$, and strict avoidance of hyperventilation.

Post-ROSC Hemodynamic Targets

Blood pressure endpoints requiring titration of fluids and vasopressors to maintain a Systolic BP $> 90\,\text{mm\,Hg}$ ($90 - 100\,\text{mm\,Hg}$) and a Mean Arterial Pressure (MAP) $> 65\,\text{mm\,Hg}$ ($65 - 80\,\text{mm\,Hg}$).

Reversible Causes of Cardiac Arrest (H's and T's)

Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypothermia, Hypo/Hyperkalemia, Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), and Thrombosis (coronary).

Monomorphic QRS

All QRS complexes in a single lead display a uniform and similar shape.

Tikosyn and Sotalol EMS Precautions

Antiarrhythmic agents that prolong the QT interval; when managing wide-complex tachycardia in stable patients taking these medications, lidocaine must be selected instead of amiodarone to avoid adverse QT-prolonging interactions.

Synchronized Cardioversion Energy Dose (AC 7)

Indicated for unstable monomorphic wide-complex tachycardia with serious signs or symptoms, delivered at an initial energy setting of $200\,\text{J}$, with prior sedation considered using midazolam ($2\text{--}2.5\,\text{mg}$) or lorazepam ($0.5\text{--}1\,\text{mg}$).

Signs Favoring Ventricular Tachycardia (ECG Criteria)

Diagnostic criteria differentiating VT from SVT with aberrancy, including extreme axis deviation ("northwest axis"), Brugada's sign (onset of QRS to nadir of S-wave $> 100\,\text{ms}$), Josephson's sign (notching near nadir of S-wave), precordial concordance, AV dissociation, and fusion or capture beats.

PDE-5 Inhibitor Nitroglycerin Contraindication

A strict contraindication requiring avoidance of nitroglycerin in any patient who has taken Viagra (sildenafil) or Levitra (vardenafil) within the previous $24\,\text{hours}$, or Cialis (tadalafil) within the previous $36\,\text{hours}$, due to the risk of profound and intractable hypotension.

Nitroglycerin Paste Dosing (AC 5)

Transdermal nitroglycerin dosing stratified by systolic blood pressure: $1\,\text{in}$ for $\text{SBP} > 100\,\text{mmHg}$, $1.5\,\text{in}$ for $\text{SBP} > 150\,\text{mmHg}$, and $2\,\text{in}$ for $\text{SBP} > 200\,\text{mmHg}$.

Enalaprilat Administration Criteria (AC 5)

ACE inhibitor indicated at $1.25\,\text{mg}$ IV/IO for moderate-to-severe CHF/pulmonary edema, restricted exclusively to patients with an $\text{SBP} > 120\,\text{mmHg}$.

Preeclampsia

A hypertensive pregnancy disorder presenting after $20\,\text{weeks}$ gestation up to $6\,\text{weeks}$ postpartum, defined by proteinuria and hypertension ($\text{BP} > 140\,\text{mmHg}$ systolic or $> 90\,\text{mmHg}$ diastolic, or a relative increase of $30\,\text{mmHg}$ systolic and $20\,\text{mmHg}$ diastolic from baseline), commonly presenting with headache, visual disturbances, and epigastric or RUQ pain.

Magnesium Sulfate Intramuscular Dosing (AO 3 / UP 13)

An emergency loading dose administered when IV or IO access cannot be established in a seizing pregnant or postpartum eclamptic patient, consisting of $10\,\text{g}$ IM divided as $5\,\text{g}$ injected into each buttock.

Labetalol Protocol in Gestational Hypertension (AO 3)

An antihypertensive administered at $20\,\text{mg}$ IV/IO over $2\,\text{minutes}$ for severe gestational hypertension ($\text{SBP} \ge 160\,\text{mmHg}$ or $\text{DBP} \ge 110\,\text{mmHg}$); may repeat once at $20\,\text{mg}$ after $10\,\text{minutes}$ if blood pressure remains severely elevated; contraindicated in severe asthma or bradycardia.

McRoberts Maneuver

An obstetrical maneuver utilized to relieve shoulder dystocia during delivery, performed by hyperflexing the mother's legs back onto her abdomen to facilitate disimpaction of the anterior fetal shoulder.

Gaskin Maneuver

An emergency technique used to resolve shoulder dystocia in which the laboring mother is moved onto an all-fours (hands-and-knees) position.

APGAR Scoring System

A standardized clinical evaluation conducted at $1\,\text{minute}$ and $5\,\text{minutes}$ after birth, assigning values from $0$ to $2$ points across five signs: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration.

Delayed Preterm Umbilical Cord Clamping

The clinical practice of deferring cord clamping for at least $60\,\text{seconds}$ following delivery in preterm neonates born at $< 37\,\text{weeks}$ gestation who do not require immediate resuscitation.

Shock Index (SI)

$\text{Shock Index} = \frac{\text{HR}}{\text{SBP}}$, where a value of $\ge 1.2$ is defined as clinically significant shock.

Mean Arterial Pressure (MAP)

The average arterial pressure across the cardiac cycle, calculated as $\text{MAP} = \frac{(\text{DBP} \times 2) + \text{SBP}}{3}$, with a clinical goal of $> 65\,\text{mmHg}$ required to maintain vital organ perfusion.

Push-Dose Epinephrine Preparation ($1:100,000$)

A temporizing vasopressor mixture prepared by injecting $1\,\text{mg}$ of epinephrine $1:1,000$ into a $100\,\text{mL}$ bag of normal saline (yielding a $10\,\text{mcg/mL}$ concentration) and administering $10\text{--}20\,\text{mcg}$ ($1\text{--}2\,\text{mL}$) every $5\,\text{minutes}$ as needed.

Anaphylaxis Hemodynamic Cascade

The pathophysiological chain of events following severe allergen exposure: systemic vasodilation and increased vascular permeability cause reduced venous return and decreased cardiac output, resulting in profound hypotension, inadequate tissue oxygenation, anaerobic metabolism, and metabolic acidosis.

Severe Anaphylaxis Classification

An acute allergic presentation involving two or more organ systems combined with hypotension/poor perfusion, or isolated hypotension following suspected allergen exposure.

Should you transfer from DuoNeb treatments to albuterol alone after 3 subsequent DuoNeb treatments?

Yes! After 3 DuoNeb treatments it is preferred to switch to Albuterol alone as there is no proven benefit to continued ipratropium administration.

Epinephrine Nebulizer (PA 3)

Administered for croup/stridor or in bronchiolitis for patients $< 18\,\text{months}$ unresponsive to beta-agonists, dosed at $1\,\text{mg}$ ($1:1,000$) mixed in $2\,\text{mL}$ normal saline via nebulizer (may repeat once).

Pediatric Epinephrine Intramuscular Dosing (PM 1)

Weight-based dosing of epinephrine $1:1,000$ IM for pediatric anaphylaxis: $0.3\text{--}0.5\,\text{mg}$ for patients $\ge 30\,\text{kg}$, and $0.15\,\text{mg}$ for patients $< 30\,\text{kg}$, repeated every $5\,\text{minutes}$ if unimproved.

Trauma Triad of Death

metabolic acidosis, coagulopathy, and hypothermia

True or False: Epinephrine is not routinely indicated in traumatic arrests.

True

Tranexamic Acid (TXA) Multiple Trauma Criteria (TB 6)

An antifibrinolytic indicated in adult patients ($> 12\,\text{years}$ of age) within $< 3\,\text{hours}$ of injury displaying hemorrhagic shock with two or more criteria: $\text{SBP} < 90\,\text{mmHg}$, $\text{MAP} < 65\,\text{mmHg}$, $\text{HR} > 120$, $\text{Shock Index} > 1.2$, altered mental status, delayed capillary refill, or $\text{EtCO}_2 < 25\,\text{mmHg}$; dosed at $2\,\text{g}$ IV/IO over $10\,\text{minutes}$.

Traumatic Brain Injury (TBI) Blood Pressure Targets

Specific minimum systolic blood pressure targets designed to prevent secondary brain injury during multiple trauma resuscitation: $\text{SBP} \ge 100\,\text{mmHg}$ in adults, and $\text{SBP} \ge 70 + (2 \times \text{Age})\,\text{mmHg}$ in pediatric patients.

Pediatric Hypotension Thresholds (PM 3)

Age-stratified systolic blood pressure cutoffs defining hypotension: age $0\text{--}28\,\text{days}$ is $\text{SBP} < 60\,\text{mmHg}$; age $\ge 1\,\text{month}$ is $\text{SBP} < 70\,\text{mmHg}$; age $1\text{--}9\,\text{years}$ is $\text{SBP} < 70 + (2 \times \text{Age})\,\text{mmHg}$; age $10\text{--}64\,\text{years}$ is $\text{SBP} < 90\,\text{mmHg}$; and age $\ge 65\,\text{years}$ is $\text{SBP} < 110\,\text{mmHg}$.

Pediatric Cardiogenic Shock Fluid Bolus

A restricted fluid volume challenge consisting of normal saline at $5\text{--}10\,\text{mL/kg}$ IV/IO (maximum $10\,\text{mL/kg}$), titrated cautiously to age-appropriate blood pressure rather than the standard $20\,\text{mL/kg}$ bolus used in hypovolemia.

Adult Sepsis Screening Criteria (UP 15)

Screening parameters defined by an obvious or suspected source of infection with a temperature $\ge 100.4^\circ\text{F}\,(38^\circ\text{C})$ or $\le 96.8^\circ\text{F}\,(36^\circ\text{C})$, plus any one of: $\text{SBP} \le 100\,\text{mmHg}$, sustained $\text{EtCO}_2 < 25\,\text{mmHg}$, or acute altered mental status.

Ceftriaxone (Rocephin) Sepsis Dosing (UP 15)

A prehospital cephalosporin antibiotic administered at $1\,\text{g}$ IV/IO infused over $10\,\text{minutes}$ for adult sepsis patients with $\text{SBP} < 90\,\text{mmHg}$ or $\text{MAP} < 65\,\text{mmHg}$, ideally collected after drawing two sets of blood cultures.

Status Epilepticus

A life-threatening neurologic emergency defined by continuous seizure activity lasting longer than $5\,\text{minutes}$, or multiple recurrent seizures occurring without a return to baseline neurological status between episodes.

Adult Midazolam Route Priority in Seizures (UP 13)

A treatment guideline establishing midazolam $10\,\text{mg}$ IM as the preferred route of administration when IV access is not established, explicitly stating that IM administration should not be delayed to attempt difficult IV or IO access and that IM is preferred over IO.

Ketamine for Refractory Seizures (UP 13)

A dissociative NMDA-receptor antagonist administered at $2\,\text{mg/kg}$ IV/IO/IN/IM as a second-line antiepileptic agent when active seizure activity continues and is refractory to multiple benzodiazepine doses.

Adult Blood Administration Criteria (USP 7)

The prehospital transfusion standard requiring adult patients to meet two or more criteria resulting directly from hemorrhagic shock: $\text{SBP} < 90\,\text{mmHg}$, $\text{MAP} < 65\,\text{mmHg}$, $\text{HR} > 120$, $\text{Shock Index} > 1.2$, $\text{EtCO}_2 < 25\,\text{mmHg}$, altered mental status (without TBI), traumatic cardiac arrest, or delayed capillary refill; dosed at $1\text{--}2\,\text{units}$ of PRBCs or whole blood.

Topical Tranexamic Acid Protocol for Epistaxis (UP 9)

A local hemostatic technique consisting of saturating a gauze pad with $10\,\text{mL}$ of a $1\,\text{g}/10\,\text{mL}$ ($100\,\text{mg/mL}$) tranexamic acid solution, inserting it into the affected nasal cavity, and allowing it to remain in place for $20\,\text{minutes}$.

Oxymetazoline in Epistaxis (UP 9)

A topical alpha-agonist vasoconstrictor administered as $2\,\text{sprays}$ to the bleeding nasal passage, followed immediately by continuous direct nostril compression with the head tilted forward.

Hyperactive Delirium with Severe Agitation

A medical emergency characterized by delirium, severe psychomotor agitation, hyperthermia, disorientation, diaphoresis, insensitivity to pain, and exceptional physical strength, commonly associated with stimulant intoxication or psychiatric illness.

Ketamine Sedation Age Restriction (UP 19)

A safety restriction specifying that ketamine may not be administered to pediatric patients, with pediatrics defined in this protocol as any patient $\le 15\,\text{years of age}$.

Therapeutic Take Down Restraint Team (USP 6 / UP 19)

A standardized team-based physical control technique requiring six providers: one provider assigned to control each individual limb (four providers), one provider at the head to maintain airway and control the head, and one provider to administer sedating medications.

Behavioral Activity Rating Scale (BARS) Score 6 Management

The clinical management of an agitated and disruptive (but non-violent) patient: attempted verbal de-escalation followed, if sedation is indicated, by haloperidol ($2\text{--}5\,\text{mg}$ IM) and/or midazolam ($5\,\text{mg}$ IM or $2.5\,\text{mg}$ IV/IO/IN), or lorazepam ($1\text{--}2\,\text{mg}$).