Ohio EMS protocols,
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• Administer nitroglycerin 0.4 mg sublingually without concern, since 48 hours have passed
• ✓ Avoid or use nitroglycerin with extreme caution, as erectile dysfunction medication was used within the last 72 hours
• Administer nitroglycerin only after obtaining medical direction, since 48 hours is past the contraindication window
• Skip nitroglycerin and proceed directly to Morphine Sulfate for pain management

The protocol states that any patient who has used erectile dysfunction medication in the last 72 hours should have nitroglycerin avoided or used with extreme caution. Since 48 hours falls within the 72-hour window, nitroglycerin should be avoided or used with extreme caution.

• Administer Morphine Sulfate 2 mg IV since pain is unrelieved
• ✓ Give a fluid bolus of 200 cc 0.9% Normal Saline due to hypotension
• Administer an additional fourth dose of nitroglycerin since the maximum is not yet reached
• Withhold all medications and expedite transport

The protocol instructs that if hypotension occurs, give a fluid bolus of 200 cc 0.9% Normal Saline (may repeat if no signs of pulmonary edema). Additionally, Morphine Sulfate should be stopped if BP falls below 90 mmHg. With a BP of 96/60, hypotension management takes priority. Nitroglycerin is also contraindicated when systolic BP is not above 100 mmHg.

• Maximum of 2.0 mg; proceed to synchronized cardioversion
• ✓ Maximum of 3.0 mg; begin transcutaneous pacing
• Maximum of 1.0 mg; administer Lidocaine drip
• Maximum of 3.0 mg; administer Adenosine 6 mg rapid IV push

The Bradycardia protocol states Atropine Sulfate may be given 0.5–1.0 mg IV and repeated to a total dose of 3.0 mg. If Atropine is ineffective, the protocol directs to begin transcutaneous pacing. Epinephrine or Dopamine drips may also be considered while awaiting or if pacing is ineffective.

• Nitroglycerine 0.4 mg sublingual, since 48 hours have passed since sildenafil use
• ✓ Morphine sulfate 2–5 mg IV for pain and anxiety relief
• Nitroglycerine 0.4 mg sublingual, repeating every 2–5 minutes as BP allows
• Ondansetron 4 mg IV to prevent nausea associated with the cardiac event

Nitroglycerine is contraindicated for two reasons here: the patient's BP is below 90 mmHg (systolic hypotension) AND they used an erectile dysfunction medication within the last 72 hours (48 hours ago), both of which are listed contraindications. Morphine sulfate is indicated for AMI and severe pain, and may be repeated every 5 minutes if systolic BP remains above 90 — though caution is warranted with hypotension; it remains the only protocol-supported analgesic option here. Ondansetron addresses nausea, not chest pain. The protocol contraindicates nitroglycerin in this scenario.

• Administer Morphine Sulfate 2 mg IV, may repeat to a maximum of 10 mg
• ✓ Administer Midazolam (Versed) 2–5 mg slow IV or IO, may repeat to 10 mg while maintaining systolic BP above 100 mmHg
• Administer Midazolam (Versed) 5–10 mg slow IV or IO, may repeat once
• Administer Diazepam 5 mg IV, may repeat to a maximum of 20 mg

The Induced Hypothermia protocol specifies that if the patient is shivering, administer Midazolam (Versed) 2–5 mg slow IV or IO, which may be repeated to a total of 10 mg while maintaining the systolic BP above 100 mmHg. No other anti-shivering agent is listed in this protocol.

• Dopamine drip at 5–20 mcg/kg/min, titrated until BP is greater than 100 mmHg systolic
• ✓ Morphine Sulfate IV in 2 mg increments every 5 minutes, stopping if BP falls below 90 mmHg systolic, the patient becomes obtunded, or a maximum of 10 mg is reached
• Morphine Sulfate IV in 5 mg increments every 10 minutes, stopping when the patient's respiratory rate normalizes
• A second dose of Furosemide (Lasix) 80 mg IV over 8–10 minutes since the first dose was ineffective

Per the Acute Pulmonary Edema/CHF protocol, if pulmonary edema is still not relieved after initial treatment, Morphine Sulfate IV is given in 2 mg increments every 5 minutes. It is stopped when: pulmonary edema is relieved or breathing becomes easier, BP falls below 90 mmHg systolic, BP falls and patient becomes obtunded, or a maximum of 10 mg is reached. Dopamine is only indicated for BP < 80 mmHg systolic, and the higher Furosemide dose is for patients already on a diuretic.