OCTOBER 2026 OCEMS RELEASE
Drug-guide changes, explained.
Adult and pediatric charts compared. Released contraindications connected to the lessons where they matter. Clinical questions remain visible.
What this comparison changes
Every explicit adult contraindication is captured: 37 checks across 14 indication-specific groups covering 13 medications. Checks are linked to affected medication, treatment and procedure lessons, their Markdown copies and structured data. Learning maps carry an earlier-source notice. The I-20 pediatric chart has no separate contraindication column; its routes, N/A entries, age qualifiers, order markers and footnotes have their own review queue.
A newly printed restriction is not necessarily a new clinical policy. Existing condition-order and product-label exclusions still matter. Blank cells and omitted wording do not waive them. Adult restrictions stay labeled adult/adolescent and are not automatically applied to pediatric care.
EMTs can use these comparisons to recognize eligibility concerns and improve the ALS handoff. Paramedics can follow the indication, route and source questions through medication preparation and reassessment. Learning the change does not expand scope or confirm agency adoption.
Adult contraindications in the released I-15
These are the explicit entries in the chart’s contraindication column, grouped only where repeated route rows match. See the full source and the applicable condition order for the complete clinical context.
Adenosine · Regular narrow-complex tachycardia
- Heart rate below 150 beats/minute.
- Wide-complex rhythm.
- Irregular rhythm.
Clinical review: Confirm the complete rhythm, stability and administration criteria in SO-C-025. A rate of 150 alone does not establish eligibility. These exclusions are newly explicit in the chart, not necessarily new to the standing order.
Updated lessons: Regular narrow-complex tachycardia, Intraosseous infusion — draft; review only, Adenosine
Push-dose epinephrine · Adult push-dose shock / perfusion pathway
- Hemorrhagic shock.
Clinical review: Released PR-230 confirms the adult push-dose indications, preparation and hemorrhagic-shock exclusion. PR-205 separately confirms the pediatric exclusion and mandatory base order. These findings do not create a blanket exclusion for anaphylaxis or arrest epinephrine. Clinical sign-off and agency adoption remain pending.
Updated lessons: Adult cardiac arrest, Base contact: common triggers, Symptomatic bradycardia, Suspected sepsis, Adult shock / hypotension, Epinephrine, Normal saline (0.9% sodium chloride)
Fentanyl · Adult IV, IM and IN analgesia
- Systolic BP below 90 mmHg.
Clinical review: Check the condition order and perfusion before initial and repeat doses. The chart’s below-90 exclusion does not prove eligibility at exactly 90 when a condition order requires BP above 90.
Updated lessons: Adult abdominal / flank pain, Burns & smoke inhalation, Chest pain & suspected ACS, Trauma: bleeding, limb injury & TBI, Fentanyl, Ketamine, Ketorolac (Toradol)
Oral glucose · Oral glucose administration
- Airway reflexes are not intact.
Clinical review: Retain the BLS/ALS pathway’s responsiveness and swallowing requirements; the adult chart does not expand EMT scope or supply pediatric authorization.
Updated lessons: Altered mental status, BLS oral glucose: gel / paste, OCEMS BLS scope of practice, Overdose & poisoning, Seizure / convulsions, Glucagon, Oral glucose
Ketamine · Adult analgesia: IV, IM and IN
- History of psychosis.
- Pregnancy.
- Known ketamine allergy.
- Age below 15 years.
- GCS below 14.
- Concurrent alcohol or drug intoxication is a relative contraindication. The chart allows authorization after base-hospital contact only when intoxication is not significant and the patient is neither lethargic nor otherwise impaired.
Clinical review: Verify the full analgesia procedure and base-hospital exception before use. The relative intoxication exception does not waive the other exclusions or authorize a different ketamine indication.
Updated lessons: Ketamine
Ketorolac · Adult analgesia: IV, IO and IM
- Trauma-center designation.
- Snake envenomation.
- Age above 65 years.
- NSAID hypersensitivity or allergy.
- Active peptic ulcer disease, or GI bleeding or perforation within the preceding 3 months.
- Concurrent NSAIDs and/or anticoagulants.
- Major surgery within the preceding 6 weeks, or scheduled major surgery.
- Renal disease or renal transplant.
- Pregnancy, suspected pregnancy, or breastfeeding.
Clinical review: The earlier PR-075 summary includes an age-below-2 exclusion, suspected cardiac pain and a low-dose-aspirin exception. The released adult chart does not repeat all of that wording. Do not infer that omissions remove exclusions or resolve the aspirin exception; reconcile PR-075 and the product label.
Updated lessons: Trauma: bleeding, limb injury & TBI, Ketorolac (Toradol)
Magnesium sulfate · Obstetric IV / IM rows
- The source prints “Not pregnant or post partem.” in the contraindication column.
Clinical review: Source question resolved against released O-010 pages 1–2: pregnancy-related disease includes postpartum eclampsia up to 6 weeks after delivery. Do not read the compressed I-15 wording as excluding all postpartum patients. Base contact and the full O-010 criteria apply. Clinical sign-off and adoption remain pending.
Updated lessons: Imminent childbirth & APGAR — draft; review only
Magnesium sulfate · Torsades de pointes with cardiac arrest
- Not for routine ventricular fibrillation, pulseless ventricular tachycardia, or monomorphic ventricular tachycardia.
Clinical review: C-010 page 2 confirms torsades-only use, not routine VF/pulseless VT/monomorphic VT. Keep this separate from the obstetric pathway. Clinical sign-off and adoption remain pending.
Updated lessons: Adult cardiac arrest, Wide-complex tachycardia with a pulse
Midazolam · Adult seizure, pacing, airway and behavioral rows
- Systolic BP below 90 mmHg.
Clinical review: Reconcile indication-specific BP, route, repeat and base-contact requirements. Pacing/airway indications also use BP above 90, so exactly 90 is not automatically eligible. The new chart’s shorter seizure wording does not remove a standing-order base-contact requirement.
Updated lessons: Symptomatic bradycardia, Seizure / convulsions, Transcutaneous pacing — draft; review only, Supraglottic airway placement — draft; review only, Endotracheal intubation & ETCO2 — draft; review only, Midazolam (Versed)
Morphine sulfate · Adult analgesia: all listed preparations and routes
- Systolic BP below 90 mmHg.
Clinical review: Retain the selected condition order’s perfusion criteria and formulation-specific dose. A chart exclusion below 90 is not evidence of eligibility at exactly 90.
Updated lessons: Adult abdominal / flank pain, OCEMS BLS scope of practice, Burns & smoke inhalation, Chest pain & suspected ACS, Trauma: bleeding, limb injury & TBI, Morphine sulfate
Nitroglycerin · Adult sublingual chest-pain / pulmonary-rales pathways
- Systolic BP below 100 mmHg.
Clinical review: Keep SO-C-015 and SO-M-035 boundary wording separate, including the higher-dose pulmonary-edema branch. This is not the PR-225 interfacility infusion stop threshold. Retain the existing drug-interaction and other source exclusions.
Updated lessons: OCEMS BLS scope of practice, Chest pain & suspected ACS, Respiratory distress, Fentanyl, Morphine sulfate, Nitroglycerin
Normal saline · Adult IV / IO fluid-bolus row
- Pulmonary rales.
- Suspected congestive heart failure.
Clinical review: Apply this to the adult fluid-bolus context. It is not a blanket prohibition on medication dilution, line flushes or pediatric nebulized saline. Check the condition-specific resuscitation order and reassess lungs and perfusion.
Updated lessons: Adult abdominal / flank pain, OCEMS BLS scope of practice, Adult hyperglycemia / suspected DKA, Regular narrow-complex tachycardia, Suspected sepsis, Adult shock / hypotension, Intraosseous infusion — draft; review only, Epinephrine, Hydroxocobalamin (Cyanokit), Normal saline (0.9% sodium chloride)
Ondansetron · Adult ODT and IV antiemetic rows
- Known or suspected pregnancy.
Clinical review: This is the local adult chart exclusion, not a universal product-label contraindication. Check the relevant condition order and keep pediatric route/age questions separate.
Updated lessons: Adult abdominal / flank pain, Chest pain & suspected ACS, Nausea, vomiting & dehydration, Stroke & intracerebral hemorrhage, Ondansetron (Zofran)
Tranexamic acid (TXA) · Adult hemorrhagic-shock pathway
- More than 3 hours since traumatic injury.
- More than 3 hours since vaginal delivery.
- Isolated neurogenic shock.
- Isolated extremity injury after bleeding has been controlled.
- Active thromboembolic event within the preceding 24 hours, including stroke, myocardial infarction, pulmonary embolism or DVT.
- History of TXA hypersensitivity or anaphylaxis.
- Traumatic arrest without ROSC.
- Drowning or hanging.
Clinical review: Released PR-080 confirms adult eligibility, exclusions and the premixed infusion. Preserve the separate injury and vaginal-delivery clocks; do not invent a miscarriage clock. Pediatric PR-081 uses a separate base-order pathway, with its age boundaries still flagged. Clinical sign-off and adoption remain pending.
Updated lessons: Adult cardiac arrest, Adult non-fatal drowning, Adult shock / hypotension, Trauma: bleeding, limb injury & TBI, Imminent childbirth & APGAR — draft; review only
18 findings: source answers and clinical decisions
18 findings checked: 9 source-resolved, 5 partly resolved and 4 unresolved. Nine findings still have explicit source or implementation questions; all revised teaching awaits clinical sign-off.
One additional naloxone repeat question was found while checking C-010. It is listed separately from the original 18.
Source-resolved means the original question is answered by the cited text. It does not mean clinically approved or adopted by your agency.
Nine original findings still need a decision
- Adult bicarbonate: controlling dose, formulation, indication, timing, repeats and authority.
- Pediatric routes: fentanyl IN; toxic-delirium midazolam; pulsed-VT amiodarone IO; dystonia diphenhydramine IO.
- Pediatric ondansetron: age boundaries, maximum dose, IV/IO routes and use outside trauma.
- Pediatric morphine: correct the black-band 4 mg/mL dose/volume pair and rounding.
- Neonatal IO lidocaine: correct the dose/volume pair and measurement method.
- Pediatric TXA: resolve overlapping eligibility thresholds at exactly 1, 3 and 5 years.
- Pediatric hydroxocobalamin: confirm authorization and the complete regimen.
- Pediatric bicarbonate: confirm indication, dilution, concentration and volume meaning.
- Neonatal albuterol: confirm the dose outside anaphylaxis.
Bicarbonate timing and concentration need reconciliation
Source conflict / gap remains · clinical sign-off pending
The complete released C-010 confirms a source conflict, rather than supplying one consistent replacement regimen. Page 2 and the page 8 flowchart use 50 mL of 7.5% or 8.4% solution and include 10-minute arrest timing; page 3 describes targeted use, 50 mEq and a repeat after 10 minutes; page 6 gives a base-hospital renal-failure/hyperkalemia repeat after 5 minutes if there is a response.
A volume is not automatically the same dose across those formulations. The website does not merge the competing branches into a new bedside regimen.
- Obtain a controlling OCEMS clarification for adult bicarbonate indication, formulation, dose units, initial timing, repeat timing/limit and standing-order versus base-order authority. Reconcile C-010 pages 2, 3, 6 and 8 with I-15 page 10.
Affected guides: Sodium bicarbonate, Adult cardiac arrest
Several pediatric routes changed
Partly resolved · decision needed · clinical sign-off pending
Epinephrine IO is supported in the pediatric arrest and bradycardia orders and explicitly in released PR-205 for push-dose use. PR-205 still requires Base Hospital contact AND an order; an IO route printed in I-20 does not waive that requirement.
P-060 supports IM diphenhydramine for an isolated allergic reaction and IM/IV as an anaphylaxis adjunct after epinephrine. That resolves the allergy-context chart question. It does not settle IO use for dystonia: SO-P-085 lists IM/IV diphenhydramine but also permits all drugs in that order by IO.
Released P-015 still explicitly includes IN fentanyl for trauma, whereas I-20 omits IN. SO-P-070/BH-P-070 use 0.2 mg/kg IM/IN midazolam for toxic delirium, while I-20 prints IV/IO. BH-P-050’s pulsed-VT amiodarone instruction is IV under base authority in a specific AICD scenario; the chart’s IO entry alone does not establish broader pulsed-VT authorization.
- Clarify pediatric fentanyl IN availability despite the I-20 omission; midazolam toxic-delirium route and dose; amiodarone IO and its pulsed-VT indication/authority; and whether diphenhydramine IO remains permitted for the SO-P-085 extrapyramidal-reaction pathway. Keep each indication separate.
P-060 pp. 2, 3 ↗ · P-015 pp. 3 ↗ · SO-P-070 pp. 2 ↗ · BH-P-070 pp. 1 ↗ · BH-P-050 pp. 1 ↗ · SO-P-085 pp. 1 ↗ · SO-P-040 pp. 1 ↗ · SO-P-045 pp. 1 ↗ · PR-205 pp. 1 ↗ · I-20 pp. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ↗
Affected guides: Diphenhydramine (Benadryl), Fentanyl, Amiodarone, Midazolam (Versed), Epinephrine, Pediatric allergic reaction & anaphylaxis, Pediatric overdose / poisoning, Pediatric injury / trauma, Pediatric burns, Pediatric cardiac arrest, Pediatric bradycardia, Pediatric shock / hypotension
Pediatric IV ondansetron added; ODT age wording changed
Partly resolved · decision needed · clinical sign-off pending
P-015 page 3 confirms a parenteral pediatric ondansetron pathway in trauma: 0.1 mg/kg IV/IO once for age >3 months, and 4 mg ODT once for age >4 years with intact airway reflexes. SO-P-090/BH-P-090 still describe 4 mg ODT at age 4 years or greater for general nausea/vomiting.
I-20 includes a 3-month IV row, ODT in the 3–4-year band and a 4 mg upper-band IV entry. The trauma order’s existence does not authorize extrapolating IV/IO treatment to every pediatric vomiting encounter.
- Clarify eligibility at exactly 3 months and exactly 4 years, ODT below age 4, the parenteral maximum dose (including the chart’s 4 mg upper band), IV versus IO, and whether parenteral dosing applies outside trauma.
P-015 pp. 3 ↗ · SO-P-090 pp. 1 ↗ · BH-P-090 pp. 1 ↗ · I-20 pp. 3, 6, 10 ↗
Affected guides: Ondansetron (Zofran), Pediatric nausea / vomiting, Nausea, vomiting & dehydration, Pediatric injury / trauma
Black-band morphine dose and volume disagree
Source conflict / gap remains · clinical sign-off pending
The released I-20 black-band 4 mg/mL morphine cell pairs 4.5 mg with 1 mL. Those values are not equivalent. P-015’s 0.1 mg/kg explains 4.5 mg at the representative 45 kg weight, but does not establish that 1 mL is an approved rounding choice.
Arithmetic check only: 4.5 mg divided by 4 mg/mL is 1.125 mL. This calculation is evidence of the discrepancy, not an authorized replacement volume.
- Obtain the corrected black-band morphine dose/volume pair for the 4 mg/mL presentation and the approved rounding/measuring instruction.
Affected guides: Morphine sulfate, Pediatric injury / trauma, Pediatric burns
Neonatal IO lidocaine dose/volume question persists
Source conflict / gap remains · clinical sign-off pending
PR-115 confirms pediatric IO analgesia with 2% lidocaine 0.5 mg/kg, maximum 40 mg, slowly IO with a 60-second dwell. I-20’s gray-band cell pairs 2 mg with 0.15 mL.
Arithmetic check only: 2% is 20 mg/mL, so 2 mg corresponds to 0.10 mL and 0.15 mL contains 3 mg. The full procedure confirms the weight-based dose but does not resolve the chart cell or authorize a rounding rule.
- Obtain a corrected gray-band lidocaine dose/volume pair and a clinically approved small-volume rounding and measurement method.
Affected guides: Lidocaine, Intraosseous infusion (draft)
Pediatric TXA added in every band
Partly resolved · decision needed · clinical sign-off pending
PR-081 resolves the preparation question: pediatric TXA is Base Hospital order only, 15 mg/kg IV/IO over 10 minutes, maximum 1 g. The stock vial is 100 mg/mL. Draw the calculated stock volume, then add saline to a TOTAL syringe volume of 10 mL; give that entire syringe evenly over 10 minutes (1 mL/min). Do not confuse stock withdrawal volume with final administration volume.
The source’s 20 kg example is 300 mg: 3 mL stock plus 7 mL saline, final volume 10 mL. The procedure calls for a line flush, blood-pressure monitoring, documentation and communication to base and the trauma center.
PR-081 requires traumatic hemorrhagic shock and ongoing bleeding despite basic control. Its printed age intervals overlap at 1, 3 and 5 years. Those boundaries need clarification; the separate normal-vital-sign table is not authority to silently rewrite TXA eligibility.
- Clarify which TXA SBP/shock-index threshold applies at exactly 1, 3 and 5 years. Confirm the implementation teaching follows the explicit 10 mL final-syringe steps, rather than reading the page 3 footer as administration of undiluted stock volume.
PR-081 pp. 1, 2, 3 ↗ · P-015 pp. 5 ↗ · I-20 pp. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ↗
Affected guides: Pediatric injury / trauma, Pediatric shock / hypotension, Base contact: common triggers
Hydroxocobalamin rows omitted
Source conflict / gap remains · clinical sign-off pending
Hydroxocobalamin is omitted from the released I-20. Released PR-130 is labeled Adult/Adolescent and supplies an adult/adolescent 5 g preparation under Base Hospital order; it does not establish a pediatric weight-based replacement.
The current pediatric poisoning standing order supplies supportive measures for suspected cyanide exposure but does not provide a pediatric hydroxocobalamin regimen. An adult procedure cannot fill that pediatric authorization gap.
- Obtain explicit OCEMS clarification of pediatric hydroxocobalamin availability/authorization, indication, dose, dilution, infusion instructions and base-order requirements. Do not infer either withdrawal or continued pediatric authorization from the omission alone.
PR-130 pp. 1, 2 ↗ · SO-P-085 pp. 1 ↗ · I-20 pp. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ↗
Affected guides: Hydroxocobalamin (Cyanokit), Pediatric overdose / poisoning, Pediatric burns, Burns & smoke inhalation, HazMat response (draft)
Preparation labels and dilution notes changed
Partly resolved · decision needed · clinical sign-off pending
PR-205 explicitly preserves push-dose epinephrine at 10 mcg/mL: 0.1 mL/kg IV/IO, maximum 1 mL per dose, with repeat dosing every 3 minutes to its age-based SBP targets. Base Hospital contact and order are required before administration. The abbreviated chart’s missing preparation label does not change the concentration.
Released P-065 and P-075 confirm 10% dextrose, 5 mL/kg IV/IO, maximum 250 mL, within their hypoglycemia pathways. D10 is 100 mg/mL; the earlier 0.1 mg/mL chart label was not a usable concentration. The patient’s condition, glucose criterion and route remain part of the order.
The indexed pediatric arrest standing and base orders do not supply the missing bicarbonate preparation pathway. The omission of old dilution notes from I-20 is not a new preparation instruction.
- Confirm pediatric bicarbonate indication and authority, stock and final concentrations, whether dilution is required, and whether each I-20 volume means stock withdrawal or final administered solution. Do not infer a universal dilution rule or its removal.
PR-205 pp. 1 ↗ · P-065 pp. 1 ↗ · P-075 pp. 2 ↗ · SO-P-040 pp. 1, 2 ↗ · BH-P-040 pp. 1, 2, 3, 4 ↗ · I-20 pp. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ↗
Affected guides: Epinephrine, Sodium bicarbonate, Dextrose 10% (D10), Pediatric cardiac arrest, Pediatric shock / hypotension, Pediatric altered mental status, Pediatric seizure / convulsions
Neonatal albuterol discrepancy remains unresolved
Partly resolved · decision needed · clinical sign-off pending
Released P-060 explicitly gives 2.5 mg/3 mL for neonates 0–30 days and 5 mg/6 mL at 31 days or older in anaphylaxis-associated wheezing. Epinephrine remains first-line. This supports the new I-20 neonatal entry in that specific pathway.
The indexed SO-P-035/BH-P-035 wheezing/suspected-asthma pathway still prints 5 mg/6 mL without that neonatal split. Do not silently apply the anaphylaxis-specific change to every neonatal respiratory presentation.
- Clarify whether 2.5 mg is the intended neonatal albuterol dose outside anaphylaxis and reconcile the general respiratory standing/base orders with I-20.
P-060 pp. 2 ↗ · SO-P-035 pp. 1 ↗ · BH-P-035 pp. 1 ↗ · I-20 pp. 1, 2 ↗
Affected guides: Albuterol, Pediatric respiratory distress, Pediatric allergic reaction & anaphylaxis
Additional source question: adult arrest naloxone repeat
C-010 page 3 prints 2 mg IV/IO or 4 mg IN, permits one repeat and gives a 6 mg maximum. Repeating the full 4 mg IN dose would exceed that maximum. The permitted repeat amount/route after an initial IN dose is not explicit.
Decision needed: Clarify the allowed naloxone repeat amount and route within the printed 6 mg maximum. Keep CPR priority and do not publish an inferred repeat schedule.
C-010 page 3 ↗Nine original source questions answered
IO lidocaine dose and dwell time changed
Source question resolved · clinical sign-off pending
PR-115 page 2 confirms 2% lidocaine 40 mg slowly IO for adults when IO is used outside cardiopulmonary arrest. Allow a 60-second dwell before the saline flush. The purpose is to address infusion pain before other medications or fluids enter the IO.
If pain occurs with medication administration or flushing after the initial dose, PR-115 permits half the initial dose. I-15 specifies a 20 mg repeat after 3 minutes. Keep the pain trigger, dwell time and chart timing attached to the instruction.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
Affected guides: Lidocaine, Intraosseous infusion (draft)
Poisoning atropine repeat interval is now explicit
Source question resolved · clinical sign-off pending
The released I-15 poisoning row specifies atropine 2 mg IV or IM with one repeat after 5 minutes. The currently indexed SO-M-050 and BH-M-050 permit one repeat but do not give an interval in that row. This is a newly explicit chart interval, not permission for unlimited repeat doses.
Use the organophosphate pathway for the exposure and presentation. Do not carry its dose or repeat timing into the separate bradycardia indication.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
Affected guides: Atropine, Overdose & poisoning, HazMat response (draft)
Epinephrine indication wording changed
Source question resolved · clinical sign-off pending
PR-230 confirms the released adult push-dose pathway: ROSC, shock unresponsive to the initial fluid bolus, bradycardia refractory to atropine and pacing, or deterioration with unknown shock etiology. Hemorrhagic shock is contraindicated. Its preparation is 10 mcg/mL, with 1 mL (10 mcg) IV/IO every 3 minutes, titrated to SBP >90. Condition-specific base-contact requirements still apply.
M-015 makes epinephrine first-line for anaphylaxis; diphenhydramine and albuterol are adjuncts. Its initial dose is 0.5 mg IM using 1 mg/mL; do not duplicate that initial dose when epinephrine was self-administered before arrival. After 5 minutes, persistent hypotension, respiratory distress or impending airway obstruction leads to 0.5 mg IM OR 0.3 mg IV/IO using 0.1 mg/mL. Base Hospital contact is required for anaphylaxis.
The indication tells you which preparation belongs in the syringe. Push-dose, anaphylaxis and arrest epinephrine are separate pathways; their concentrations and doses are not interchangeable.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
Affected guides: Epinephrine, Allergic reaction & anaphylaxis, Adult shock / hypotension, Suspected sepsis, Symptomatic bradycardia, Adult cardiac arrest, Base contact: common triggers
Calcium, magnesium and TXA need complete guide coverage
Source question resolved · clinical sign-off pending
C-010 supplies the missing context for calcium gluconate and magnesium. Calcium gluconate 10% 3 g IV/IO is a targeted adjunct for the listed causes (hyperkalemia, hypocalcemia, calcium-channel-blocker overdose or hypermagnesemia), not a routine medication for every arrest. Confirm secure access and do not mix calcium and bicarbonate in the same line.
The C-010 magnesium pathway is torsades-specific: 25 mg/kg IV/IO, maximum 2 g, over 2 minutes; may repeat once. It does not establish routine use in VF, pulseless VT or monomorphic VT.
O-010 explicitly includes postpartum eclampsia up to 6 weeks after delivery. The compressed I-15 obstetric wording must not be read as excluding all postpartum patients. Magnesium is first-line for eclamptic seizures; the source gives 4 g in 100 mL saline IV over 15–20 minutes OR 10 g IM split between the gluteal muscles. Base contact is required; do not place an IO solely for magnesium. Watch for respiratory depression with rapid infusion and stop the infusion/support the patient/contact base if toxicity occurs.
PR-080 ties adult TXA to traumatic or miscarriage/postpartum hemorrhagic shock, SBP <90 or shock index >1, and significant ongoing bleeding despite basic control measures. It specifies 1 g in a 100 mL premixed bag IV/IO over 10 minutes, with IV preferred. Check the full contraindications, continue bleeding control and transport, and communicate administration to base and the trauma center.
These source questions are resolved in the existing arrest, obstetric and trauma lessons. Dedicated medication guides for calcium, magnesium and TXA are still a coverage gap; source reconciliation does not imply that new standalone guides were created.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
C-010 pp. 2, 3 ↗ · O-010 pp. 1, 2 ↗ · PR-080 pp. 1 ↗ · SO-ALS pp. 1, 2, 3 ↗ · I-15 pp. 2, 6, 10 ↗
Affected guides: Adult cardiac arrest, Wide-complex tachycardia with a pulse, Imminent childbirth & APGAR (draft), Trauma: bleeding, limb injury & TBI, Adult shock / hypotension
Shorter repeat and route text needs the full order
Source question resolved · clinical sign-off pending
Short chart rows do not replace treatment sequence. SO-C-025 retains adenosine after attempted Valsalva in the regular narrow-complex pathway, with one repeat after 3 minutes. SO-C-040 places antiarrhythmic repeats within the unsuccessful-cardioversion sequence for unstable pulsed wide-complex tachycardia.
C-010 permits one half-dose lidocaine repeat after approximately 3–5 minutes in arrest; the I-15 3-minute wording falls within that interval. It does not authorize repeated half-doses without a limit.
SO-M-040 retains 10 mg IM midazolam once as the preferred seizure route, before starting IV/IO. Its alternate 5 mg IV/IN/IO pathway applies if IM cannot be delivered or access is already present, with one repeat after approximately 3 minutes. Base contact is required if seizure continues 5 minutes after the first IM or second alternate-route dose (10 mg total). Keep that escalation instruction even though the chart is shorter.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
SO-C-025 pp. 1, 2 ↗ · SO-C-040 pp. 1 ↗ · SO-M-040 pp. 1 ↗ · C-010 pp. 2 ↗ · I-15 pp. 1, 5, 6, 7 ↗
Affected guides: Adenosine, Lidocaine, Midazolam (Versed), Seizure / convulsions, Regular narrow-complex tachycardia, Wide-complex tachycardia with a pulse, Base contact: common triggers
Oxygen indication list is shorter
Source question resolved · clinical sign-off pending
E-010 is explicitly the decompression sickness / air embolism guideline and retains early 100% oxygen by mask in its BLS interventions, with Base Hospital contact required. The omission of air embolism from the short drug-chart row is not removal of that indication.
Teach the condition-specific oxygen objective and delivery method. A general chart flow entry does not replace E-010’s 100% oxygen instruction.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
Affected guides: Oxygen
Defibrillation sequences are now printed explicitly
Source question resolved · clinical sign-off pending
For the initial VF/pulseless-VT branch, SO-P-040 supports the I-20 first/second/third defibrillation sequence of 2, 4 and 4 J/kg, while retaining the source’s manufacturer/programmed-setting option. Follow the actual arrest branch and device guidance; a color-band entry is not a substitute for the complete sequence.
PR-095 explicitly requires Base Hospital contact AND an order for pediatric synchronized cardioversion. BH-P-050/BH-P-055 provide the condition-specific base pathways. The missing chart-header marker does not remove that authority requirement.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
SO-P-040 pp. 1 ↗ · PR-095 pp. 1 ↗ · BH-P-050 pp. 1 ↗ · BH-P-055 pp. 1 ↗ · I-20 pp. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ↗
Affected guides: Pediatric cardiac arrest, Synchronized cardioversion (draft), Base contact: common triggers
Vital-sign references require a separate cross-check
Source question resolved · clinical sign-off pending
B-003 and PR-006 supply explicit age boundaries for the new reference ranges: 0–30 days, 31 days to <1 year, 1 to <3 years, 3 to <5 years, 5 to <10 years, and ≥10 years. Their SBP reference values are >60, >60, >70, >75, >80 and >90 respectively.
In the same age order, B-003/PR-006 list pulse ranges of 100–180, 100–160, 90–150, 80–140, 70–120 and 60–100, and respiratory rates of 30–60, 30–60, 24–40, 22–34, 18–30 and 12–16. Keep the exact age interval attached to each range.
Released PR-205 explicitly points to that age-based table for push-dose epinephrine titration. Use those targets when working from the adopted released PR-205, rather than combining its preparation with an older target formula.
These are source-specific reference ranges and PR-205 targets. They do not automatically replace every condition’s hypotension criteria; the overlapping age intervals in PR-081 remain a separate TXA review question.
The original source question is answered. A qualified reviewer still needs to approve the teaching and record agency adoption.
B-003 pp. 1 ↗ · PR-006 pp. 1 ↗ · PR-205 pp. 1 ↗ · I-20 pp. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ↗
Affected guides: Pediatric assessment triangle, Pediatric shock / hypotension, Pediatric bradycardia
Additional pediatric safety checks from the full procedures
Ten explicit checks across three indication-specific groups supplement the 37 adult I-15 checks. This focused review is not an exhaustive contraindication audit of every protocol.
Push-dose epinephrine · Pediatric · PR-205 push-dose pathway
- Hemorrhagic shock is contraindicated.
Base Hospital contact AND an order are required before administration. In cardiogenic shock with pulmonary edema, the procedure directs contact without the fluid bolus.
Released source; clinical sign-off pending. PR-205 p. 1 ↗
Tranexamic acid · Pediatric · PR-081 traumatic hemorrhagic shock
- Traumatic injury more than 3 hours earlier.
- Isolated neurogenic shock.
- Isolated extremity injury when bleeding has been controlled.
- Active thromboembolic event within the last 24 hours (stroke, myocardial infarction, pulmonary embolism or DVT).
- History of hypersensitivity or anaphylactic reaction to TXA.
- Traumatic arrest without ROSC.
- Drowning or hanging.
Base Hospital order only. These pediatric exclusions come from PR-081; do not import the adult obstetric timing criterion. Exact age-boundary eligibility still needs clarification.
Released source; clinical sign-off pending. PR-081 p. 1 ↗
Ketorolac · Pediatric · P-015 trauma analgesia
- Age younger than 2 years.
- Designated trauma patients.
P-015 explicitly lists these exclusions in its ketorolac row. Trauma analgesia eligibility is not established by a drug-chart dose alone.
Released source; clinical sign-off pending. P-015 p. 3 ↗
Clinical sign-off still required
- Qualified clinical reviewer name, role and review date.
- Controlling source versions and written decisions/corrections for the nine original findings with remaining questions, plus the additional naloxone repeat question.
- Agency adoption date, scope, stocked formulations, preparation/rounding methods and base-contact workflow.
- Approval of the revised teaching and affected native/reference content; retain unresolved flags until decisions are documented.
No clinical reviewer, approval date or agency adoption has been recorded. Document-level migration remains separate from this focused cross-check.
Download the structured findings and evidence · Read the reviewer checklist as Markdown
Complete medication-row coverage
Adult: 25 medications in the release, compared with 22 in the earlier chart. Pediatric: 19 medications in the union of the two charts; TXA is added and hydroxocobalamin is omitted. A retained chart row does not mean every related standing order has been reconciled.
I-15 · Adult / adolescent
| Medication | Released pages | Comparison |
|---|---|---|
| Adenosine | 1 | Same 12 mg dose and one repeat; new 6 mg/2 mL stock option is a preparation, not a new 6 mg dose. |
| Albuterol | 1 | Nebulized and MDI numerical regimens retained. |
| Amiodarone | 1 | Pulsed and arrest numerical regimens retained; preparation presentation revised. |
| Aspirin | 1 | 324/325 mg single-dose options retained; blank contraindication cell does not remove SO-C-015 exclusions. |
| Atropine | 1, 2 | Bradycardia regimen retained; poisoning repeat now states 5 minutes. |
| Calcium gluconate | 2 | Added chart entry; standalone guide coverage pending. |
| Dextrose | 2 | D10 amount and route conditions retained. |
| Diphenhydramine | 2 | 50 mg and established-IO condition retained; once now explicit. |
| Epinephrine | 2 | Chart regimens retained; full PR-230/M-015 indication and preparation questions source-resolved; clinical sign-off pending. |
| Fentanyl | 3 | Numerical adult regimens retained; explicit BP exclusion. |
| Glucagon | 3 | 1 mg IM once and glucose/access criteria retained. |
| Oral glucose | 3 | Oral use with intact airway reflexes retained; explicit exclusion column. |
| Ketamine | 3, 4 | Analgesia regimens retained; full contraindication column added. |
| Ketorolac | 5 | 15 mg IV/IO/IM once retained; full contraindication column added. |
| Lidocaine | 5 | IO initial dose/dwell changed; antiarrhythmic repeat wording changed. |
| Magnesium sulfate | 6 | Added chart entry; obstetric and arrest restrictions differ. |
| Midazolam | 6, 7 | Principal numerical regimens retained; explicit BP exclusion and shorter route/base wording. |
| Morphine | 7, 8 | Formulation-specific adult regimens retained; explicit BP exclusion. |
| Naloxone | 8 | Adult formulation/route options and respiratory-response repeats retained. |
| Nitroglycerin | 8, 9 | SL regimens retained; BP wording still needs condition-specific boundaries. |
| Normal saline | 9 | 250 mL bolus / 1 L chart pattern retained; explicit rales/CHF exclusions. |
| Ondansetron | 9 | Adult ODT/IV regimens and pregnancy exclusion retained. |
| Oxygen | 9 | Delivery flows retained; indication list shortened. |
| Sodium bicarbonate | 10 | 50 mL retained; concentration options explicit and arrest timing omitted. |
| Tranexamic acid | 10 | Added chart entry; eight explicit exclusions captured. |
I-20 · Pediatric
| Medication | Released pages | Comparison |
|---|---|---|
| Adenosine | 1–10 | Dose/volume, rapid-IV route and base-order markers retained. |
| Albuterol | 1–10 | Numerical rows retained; neonatal cross-source discrepancy remains. |
| Amiodarone | 1–10 | Pulsed-VT route adds IO; dose/volume retained. |
| Atropine | 1–10 | Numerical doses, preparations and routes retained. |
| Dextrose | 1–10 | Dose volumes retained; black-band concentration label corrected to 10%. |
| Diphenhydramine | 1–10 | IO omitted from released routes; dose/volume retained. |
| Epinephrine | 1–10 | IO pathways and push-dose preparation confirmed against the full orders; clinical sign-off pending. |
| Fentanyl | 1–10 | IN omission remains a source conflict; trauma base-order age criterion confirmed as younger than 2 years. |
| Glucagon | 1–10 | 0.5 mg IM in all bands retained. |
| Hydroxocobalamin | Omitted | Omitted from release; do not infer withdrawal. |
| Ketorolac | 1–10 | Numerical values and N/A bands retained; generic name replaces Toradol. |
| Lidocaine | 1–10 | Numerical entries retained; neonatal dose/volume question persists. |
| Midazolam | 1–10 | Toxic-delirium route changed; other listed route families and numerical amounts retained. |
| Morphine | 1–10 | Black-band dose/volume mismatch remains; trauma base-order age criterion confirmed as younger than 2 years. |
| Naloxone | 1–10 | Numerical rows retained; preloaded spray dose now explicitly 4 mg / one spray. |
| Normal saline | 1–10 | Numerical volumes retained; hypotension/croup indications labeled. |
| Ondansetron | 1–10 | IV entries added; white-band ODT age qualifier omitted. |
| Sodium bicarbonate | 1–10 | Numerical entries retained; concentration and small-child dilution notes omitted. |
| Tranexamic acid | 1–10 | PR-081 confirms base order and dilution to a total 10 mL; exact age-boundary eligibility still needs clarification. |
Compared official documents
- I-15 · Earlier April 2026 chart · 5 pages ↗
- I-15 · October 2026 release · 10 pages ↗
- I-20 · Earlier April 2026 chart · 10 pages ↗
- I-20 · October 2026 release · 10 pages ↗
Structured source comparison, contraindications and coverage register