GTRS — EMS Field Reference

NORMAL VITAL SIGN RANGES

🫀 HEART RATE (HR/BPM)

NORMAL ADULT60–100 bpm

BRADYCARDIA< 60 bpm

TACHYCARDIA> 100 bpm

CRITICAL BRADY< 40 bpm

CRITICAL TACHY> 150 bpm

60–100: Normal sinus rhythm

40–59: Symptomatic bradycardia — monitor, consider Atropine

101–150: Sinus tachycardia — treat cause

>150: SVT/VT/AF with RVR — treat aggressively

🩸 BLOOD PRESSURE (BP)

NORMAL ADULT90–139 / 60–89 mmHg

HYPOTENSIONSBP < 90 mmHg

HYPERTENSION STAGE 1140–159 / 90–99

HYPERTENSION STAGE 2≥ 160 / ≥ 100

HYPERTENSIVE CRISISSBP > 180 / DBP > 120

SHOCK (DECOMPENSATED)SBP < 70 mmHg

MAP goal (perfusion): ≥ 65 mmHg

MAP < 65: Organ hypoperfusion — aggressive resuscitation

Hypertensive emergency: end-organ damage present

🫁 RESPIRATORY RATE (RR)

NORMAL ADULT12–20 breaths/min

BRADYPNEA< 12 /min

TACHYPNEA> 20 /min

CRITICAL LOW< 8 /min — assist ventilation

CRITICAL HIGH> 30 /min — severe distress

12–20: Normal eupnea

8–11 or 21–29: Concerning — identify cause

<8 or >30: Respiratory failure — intervene now

💧 SpO₂ (PULSE OXIMETRY)

NORMAL95–100%

ACCEPTABLE (COPD)88–92%

MILD HYPOXIA91–94%

MODERATE HYPOXIA86–90%

SEVERE HYPOXIA< 85% — immediate O₂

CRITICAL / LIFE THREAT< 80% — BVM / intubate

Note: SpO₂ unreliable with CO poisoning, poor perfusion, nail polish

🌡️ TEMPERATURE

NORMAL CORE36.1–37.2°C (97–99°F)

MILD HYPOTHERMIA32–35°C

MODERATE HYPOTHERMIA28–31°C

SEVERE HYPOTHERMIA< 28°C — cardiac risk

FEVER (PYREXIA)> 38.0°C

HYPERTHERMIA / CRISIS> 40°C — emergency

🍬 BLOOD GLUCOSE (BGL)

NORMAL (FASTING)4.0–6.0 mmol/L

NORMAL (NON-FASTING)< 7.8 mmol/L

HYPOGLYCEMIA< 4.0 mmol/L

SYMPTOMATIC HYPO< 3.0 mmol/L — treat now

HYPERGLYCEMIA> 11.0 mmol/L

DKA CONCERN> 14.0 + ketones + acidosis

📡 EtCO₂ (CAPNOGRAPHY)

NORMAL RANGE35–45 mmHg

HYPOCAPNIA< 35 mmHg (hyperventilation)

HYPERCAPNIA> 45 mmHg (hypoventilation)

SEVERE HYPERCAPNIA> 60 mmHg — resp failure

NEAR-ZERO (ROSC LOSS)< 10 mmHg — check compressions

EtCO₂ rise to >20 during CPR = strong ROSC predictor

📈 GCS — GLASGOW COMA SCALE

NORMAL15/15

MILD IMPAIRMENT13–14

MODERATE9–12

SEVERE TBI≤ 8 — consider airway

EYES (E)4=Spontaneous, 3=Voice, 2=Pain, 1=None

VERBAL (V)5=Oriented, 4=Confused, 3=Words, 2=Sounds, 1=None

MOTOR (M)6=Obeys, 5=Localizes, 4=Withdraws, 3=Flexion, 2=Extension, 1=None

PRIMARY SURVEY — PCP+ PCP+

ACP ASSESSMENT ACP+

12-LEAD ECG ELECTROCARDIOGRAPHY

12-Lead ECG Acquisition

✓ Normal sinus rhythm, no ST changes, QRS <120ms, QTc normal (<440ms men, <460ms women)

⚠ STEMI: ST elevation ≥1mm in ≥2 contiguous leads | New LBBB | AF | VT | AV Block

▶ HOW TO APPLY AND INTERPRET

EtCO₂ CAPNOGRAPHY WAVEFORM CAPNOMETRY

EtCO₂ Monitoring

✓ 35–45 mmHg, consistent square waveform

⚠ <35 = hyperventilation | >45 = hypoventilation | <10 during CPR = poor perfusion

▶ HOW TO APPLY AND INTERPRET

JUMP TO:

⚠ STEMI EQUALS TIME-CRITICAL — Every minute = ~2 million cardiomyocytes lost. Door-to-balloon target: <90 minutes.

❤️ CARDIAC CHEST PAIN / ACS PROTOCOL

SCENE / INITIAL

Scene safety, BSI/PPE, note MOI/NOI
General impression — position of comfort? Diaphoretic? Clutching chest?
Introduce yourself — obtain consent — begin primary survey (ABCDE)
Position patient: Semi-Fowler's (45°) — do NOT let them walk
High-flow O₂ if SpO₂ < 94% (do NOT hyperoxia in STEMI — target 94–98%)
Establish IV access × 2 (large bore, AC or EJ if peripheral poor)
Apply cardiac monitor — 12-lead ECG ASAP (<10 min of contact)
Obtain OPQRST + SAMPLE history

OPQRST FOR CHEST PAIN

Onset: "When did it start? What were you doing?"
Provocation/Palliation: "Does anything make it better or worse?"
Quality: "Describe the pain — crushing, pressure, tearing, burning?"
Radiation: "Does it go anywhere? Arm, jaw, back, shoulder?"
Severity: "1–10 scale right now?"
Time: "Has this happened before? How long now?"

MEDICATION SEQUENCE (PCP)

Aspirin 324mg PO — chew, not swallow — if no allergy and not already taken today
Nitroglycerin 0.4mg SL — if SBP > 100 and no right-sided/inferior MI — repeat q5min × 3
Nitrous Oxide (Entonox) — for pain relief while establishing IV
Reassess vitals after each NTG dose — watch for hypotension

MEDICATION SEQUENCE (ACP+)

Morphine 2–4mg IV — titrated for pain (use caution — may mask symptoms)
Fentanyl 1mcg/kg IV — preferred analgesia if hemodynamically unstable
Clopidogrel 300mg PO — if STEMI confirmed and PCI-capable hospital available
Heparin — per medical direction for confirmed STEMI
Amiodarone — if VT/VF complicates presentation
Atropine 0.5–1mg IV — if symptomatic bradycardia
Adenosine 6mg rapid IV — if SVT (narrow complex tachycardia)

ECG INTERPRETATION QUICK GUIDE

STEMI ST elevation ≥1mm in ≥2 contiguous leads. V1–V4=anterior. II/III/aVF=inferior. I/aVL=lateral.

NSTEMI/UA ST depression, T-wave inversion, or dynamic changes with troponin rise.

VT (Pulseless) Wide complex (QRS >120ms), rate >100 — defibrillate immediately.

SVT Narrow complex tachycardia >150bpm — vagal first, then Adenosine.

AF Irregularly irregular rhythm, no distinct P waves — rate control vs rhythm control.

VF Chaotic waveform — no organized rhythm — immediate CPR + defibrillation.

ROLEPLAY SCRIPT — CARDIAC

"Sir/Ma'am, your ECG is showing some concerning changes in your heart rhythm that suggest your heart isn't getting enough blood flow. I'm going to give you some Aspirin — I need you to chew it, not swallow. I'm also going to put a nitroglycerin tablet under your tongue — it'll help open up the blood vessels around your heart. You might feel a headache or your BP drop a bit — that's normal. I need to get you to hospital as quickly as possible. Can you tell me if you've taken any Viagra, Cialis, or similar medications in the last 24–48 hours before I give you the NTG?"

🔴 GSW = HIGH-ACUITY TRAUMA — Scoop and go. Load and run. Haemorrhage control is your only on-scene priority.

⚠ SCENE SAFETY FIRST — Do NOT enter until law enforcement declares scene clear. Cover and concealment. Watch for secondary threats.

🔴 GUNSHOT WOUND (PENETRATING TRAUMA) PROTOCOL

SCENE / C-ABCDE APPROACH

C — CATASTROPHIC HAEMORRHAGE: Identify and control life-threatening bleeding first. Tourniquet, wound packing, junctional pressure.
A — Airway: Open and maintain — jaw thrust if trauma, BVM if inadequate breathing
B — Breathing: Inspect chest — open wounds = seal with vented chest seal. Tension PTX = needle decompression
C — Circulation: IV access × 2, blood products if CCP, permissive hypotension target SBP 80–90 in penetrating torso trauma
D — Disability: GCS, pupils, BGL — document baseline neuro
E — Expose: Full TRIAGE — front AND back. Log roll with C-spine if indicated. Count entry/exit wounds.

HAEMORRHAGE CONTROL

Direct pressure — first line for any compressible wound
Tourniquet (extremity) — high and tight, 5–8cm proximal to wound. Note time of application.
Wound packing with haemostatic gauze (Combat Gauze/QuikClot) — junctional wounds
Chest seals (vented) — all penetrating chest wounds — anterior and posterior if through-and-through
TXA (Tranexamic Acid) — within 3 hours of injury if significant haemorrhage suspected

MEDICATIONS (ACP+)

Tranexamic Acid (TXA) 1g IV over 10 min — antifibrinolytic — give early
Fentanyl 1mcg/kg IV — analgesia if hemodynamically stable (SBP > 90)
Ketamine 0.1–0.3mg/kg IV — dissociative analgesia — preferred if hemodynamically compromised
Normal Saline / LR — fluid resuscitation — permissive hypotension in penetrating torso trauma (SBP 80–90)
Morphine — pain management once haemorrhage controlled and BP stable

MEDICATIONS (CCP+)

Packed Red Blood Cells (pRBC) — O-negative if type unknown — restore O₂ carrying capacity
Fresh Frozen Plasma (FFP) — replace clotting factors — 1:1 ratio with pRBC
Platelets — if massive haemorrhage
Cryoprecipitate — fibrinogen replacement — DIC or massive transfusion
Whole Blood — ideal massive transfusion product when available
Calcium Chloride — after multiple blood products — citrate toxicity prevention
Norepinephrine — vasopressor if haemorrhage controlled but persistent hypotension

INDICATIONS FOR RSI (CCP)

GCS ≤ 8 with loss of airway protective reflexes
Expanding neck haematoma / tracheal deviation
Severe maxillofacial trauma compromising airway
Anticipated airway deterioration en route

ANATOMICAL ZONES — PENETRATING NECK TRAUMA

Zone I Clavicle to cricoid. Vascular injuries to great vessels — high morbidity.

Zone II Cricoid to angle of mandible. Most common, most accessible — surgical priority.

Zone III Angle of mandible to skull base. Difficult surgical access — angiography often required.

ROLEPLAY SCRIPT — GSW

"You've been shot — I'm with paramedics, I'm going to help you. Stay as still as you can. I'm applying pressure to the wound right now — I know it's painful but I need to keep this here. [If tourniquet:] I'm putting a tourniquet on your arm — it's going to be tight and uncomfortable but it's going to stop the bleeding. I need you to count with me — stay with me. [On scene:] We're going to get you on the stretcher and into the ambulance — I'm going to keep working on you while we move, okay?"

TENSION PNEUMOTHORAX — NEEDLE DECOMPRESSION

Signs: Tracheal deviation AWAY from affected side, absent breath sounds, hypotension, JVD, cyanosis, respiratory distress

Identify: 2nd intercostal space, midclavicular line (or 4th/5th ICS anterior axillary line)
Insert 14g angiocath over superior border of rib (avoid neurovascular bundle inferiorly)
Listen for rush of air — positive decompression
Leave catheter in — secure — monitor for reaccumulation
Formal chest tube at hospital — this is temporizing only

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