ELITE RESEARCH REPORT AND
UNIVERSAL TEST BANK: MAINE EMS
PREHOSPITAL PROTOCOLS
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Testing "Hard Deck"
definitions, updated 2026 formulary metrics, and primary protocol algorithms (e.g., Pink 1
BRUE definitions, Blue 5 anxiolysis mandates, and basic OLMC triggers).
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Situation-based
variables focusing on the Red 13 Refractory VF/VT pathway, Yellow 3 TCA Overdose
interventions, and Green 22 Trauma Termination of Resuscitation.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: High-stakes, multi-variable
scenarios requiring algorithmic synthesis, including Maternal Cardiac Arrest (Lavender 3),
Pediatric Post-Resuscitation Care (Red 21), and complex hemodynamic instability.
PART I: THE PRIMER
Mastering this highly calibrated Maine EMS 2026 protocol repository directly translates to
clinical dominance and flawless medical-legal execution in the most unforgiving prehospital
environments. This document forges elite clinical scholars whose academic intuition preempts
catastrophic patient deterioration.
● The 2026 Implementation Mandate: Effective December 1, 2025, all legacy protocols
are structurally void. Algorithmic adherence to the 2026 standards is an absolute,
non-negotiable legal and clinical baseline.
● The Airway Sequence Rule (Blue 5): Under the updated Post-Intubation/BIAD Pain
Control protocol, adequate pain management MUST precede anxiolysis; crucially,
On-Line Medical Consultation (OLMC) is no longer required prior to administering
midazolam or ketamine for anxiolysis.
● The Pediatric Definition Matrix: A "young infant" is strictly defined as less than 60 days
old. In cases of a Brief Resolved Unexplained Event (BRUE) under Pink 1, if a
parent/guardian refuses transport, the clinician MUST immediately contact OLMC.
● The Refractory VF/VT Divergence (Red 13): Persistent Ventricular Fibrillation or
pulseless Ventricular Tachycardia no longer loops indefinitely in the standard arrest
algorithm; it mandates an immediate pivot to the highly specific Red 13 pathway.
● The Toxicologic Hemodynamic Firewall (Yellow 3): For Tricyclic Antidepressant (TCA)
overdoses exhibiting widened QRS complexes unresponsive to maximum Sodium
Bicarbonate, the algorithmic imperative is 2 grams of Magnesium Sulfate infused over 15
minutes via a mechanical pump.
,PART II: THE ELITE TEST BANK
Q1: An adult patient weighing 80 kg presents with systemic anaphylaxis. Based on the
principles of the Maine EMS 2026 Formulary (Gold 1), which IM EPINEPHrine dose and
concentration is the MOST ACCURATE FIRST action? A) 0.15 mg of 1 mg/mL EPINEPHrine IM
B) 0.3 mg of 1 mg/10 mL EPINEPHrine IM C) 0.3 mg of 1 mg/mL EPINEPHrine IM D) 0.5 mg of
1 mg/mL EPINEPHrine IM
● The Answer: C (0.3 mg of 1 mg/mL EPINEPHrine IM)
● Distractor Analysis:
○ A is incorrect: The 0.15 mg dose is explicitly reserved for pediatric patients under
25 kg.
○ B is incorrect: The 1 mg/10 mL concentration is reserved for IV/IO push during
cardiac arrest, lacking the necessary depot absorption profile for intramuscular use.
○ D is incorrect: The 0.5 mg dose exceeds the strict 0.3 mg limit for adult IM
administration in the Maine EMS system.
The Mentor's Analysis: Anaphylaxis requires immediate intramuscular alpha and beta-agonist
stimulation. When facing systemic collapse, the immediate priority is the correct concentration
via the correct route. By utilizing the 1 mg/mL concentration, you bypass the common trap of
administering dilute cardiac arrest formulations into muscle. Professional/Academic Intuition:
Always verify the 1 mg/mL concentration for IM anaphylaxis to ensure rapid systemic
absorption.
Q2: A 30 kg pediatric patient is experiencing severe hypoglycemia. Based on the principles of
the Diabetic Emergencies Protocol (Gold 6), which action is the MOST ACCURATE? A)
Administer 25 grams of D50 IV push. B) Administer 5 mL/kg of D10 IV. C) Administer 250 mL of
D10 IV. D) Administer 1 mg Glucagon IM unconditionally.
● The Answer: B (Administer 5 mL/kg of D10 IV.)
● Distractor Analysis:
○ A is incorrect: D50 is strictly contraindicated for pediatric patients under 40 kg due
to extreme hyperosmolar tissue necrosis risks.
○ C is incorrect: The 250 mL dose is the fixed adult dose, not the required pediatric
weight-based calculation.
○ D is incorrect: Glucagon is a secondary agent utilized only if IV/IO access is entirely
unobtainable.
The Mentor's Analysis: Pediatric vasculature is highly susceptible to hyperosmolar damage.
When facing pediatric hypoglycemia, the immediate priority is controlled, dilute dextrose
administration. By utilizing weight-based D10 (5 mL/kg), you bypass the common trap of
causing severe phlebitis or tissue sloughing associated with D50. Professional/Academic
Intuition: For patients under 40 kg, D10 is the absolute maximum allowable dextrose
concentration.
Q3: A paramedic successfully intubates an adult patient. The patient begins to gag and exhibits
tachycardia. Based on the principles of Post-Intubation/BIAD Pain Control (Blue 5), which
sequence is the MOST ACCURATE? A) IMMEDIATELY contact OLMC to request anxiolysis
with Midazolam. B) Administer Ketamine 0.2 mg/kg IV for pain control BEFORE considering
anxiolysis. C) Administer Midazolam 5 mg IV for anxiolysis, followed by Fentanyl for pain. D)
Extubate the patient to prevent laryngeal trauma.
● The Answer: B (Administer Ketamine 0.2 mg/kg IV for pain control BEFORE considering
, anxiolysis.)
● Distractor Analysis:
○ A is incorrect: The 2026 protocols specifically removed the OLMC requirement for
post-intubation anxiolysis.
○ C is incorrect: The 2026 protocol strongly emphasizes that analgesia MUST be
achieved prior to administering anxiolytics.
○ D is incorrect: Removing a secured airway due to inadequate sedation is a
catastrophic clinical failure.
The Mentor's Analysis: An endotracheal tube is inherently noxious and painful. When facing
post-intubation agitation, the immediate priority is analgesia, not just sedation. By utilizing
Ketamine or Fentanyl first, you bypass the novice error of chemically paralyzing or sedating a
patient who is actively experiencing severe pain. Professional/Academic Intuition: Treat the
pain of the tube before treating the anxiety of the situation.
Q4: An advanced airway attempt fails twice. The paramedic prepares for a third attempt. Based
on the principles of the Failed Intubation Algorithm (Blue 4), which conclusion is the MOST
ACCURATE? A) The paramedic may attempt a fourth intubation if the patient's SpO2 remains
above 90%. B) A maximum of three intubation attempts is allowed before the airway is
definitively deemed "failed." C) The paramedic MUST transition immediately to a surgical
cricothyrotomy. D) The paramedic should contact OLMC to request permission for a fourth
attempt.
● The Answer: B (A maximum of three intubation attempts is allowed before the airway is
definitively deemed "failed.")
● Distractor Analysis:
○ A is incorrect: Three attempts is the absolute hard-deck limit, regardless of transient
oxygenation status.
○ C is incorrect: A BIAD (Blind Insertion Airway Device) or basic BVM management is
the next algorithmic step, not an immediate surgical airway.
○ D is incorrect: OLMC cannot override the physiological trauma limits set by the
3-attempt anatomical rule.
The Mentor's Analysis: Repeated laryngoscopy causes profound oropharyngeal trauma and
airway edema. When facing a difficult airway, the immediate priority is recognizing failure limits.
By utilizing the 3-attempt hard stop, you bypass the trap of fixating on the endotracheal tube
while the patient suffers hypoxic brain injury. Professional/Academic Intuition: Three strikes
and you are out; pivot immediately to an alternative oxygenation strategy.
Q5: A patient experiencing an acute asthma exacerbation is placed on CPAP. Based on the
principles of Respiratory Distress with Bronchospasm (Blue 6-7), what is the MOST ACCURATE
pharmacological intervention? A) Discontinue CPAP to administer nebulized Albuterol via a
standard mask. B) Administer continuous nebulized treatments inline through the active CPAP
circuit. C) Administer an Epinephrine infusion at 0.05 mcg/kg/min immediately. D) Administer
oral Dexamethasone only after the CPAP is permanently removed.
● The Answer: B (Administer continuous nebulized treatments inline through the active
CPAP circuit.)
● Distractor Analysis:
○ A is incorrect: Removing the CPAP mask eliminates the positive end-expiratory
pressure required to keep the lower airways stented open.
○ C is incorrect: IV Epinephrine is reserved for impending respiratory failure or
systemic anaphylaxis, not standard asthma CPAP management.
○ D is incorrect: Dexamethasone is indicated early; waiting for CPAP removal delays
, critical corticosteroid onset.
The Mentor's Analysis: Bronchospasm coupled with positive pressure requires simultaneous
pharmacological delivery. When facing severe asthma on CPAP, the immediate priority is inline
bronchodilation. By utilizing an inline nebulizer, you bypass the trap of sacrificing continuous
positive airway pressure for medication delivery. Professional/Academic Intuition: Never break
the CPAP seal for a nebulizer; integrate them.
Q6: You are managing an adult patient in septic shock. Based on the principles of Medical
Shock (Gold 14), which action mandates IMMEDIATE On-Line Medical Consultation (OLMC)?
A) The administration of a 20 mL/kg isotonic fluid bolus. B) The acquisition of a diagnostic
12-lead ECG. C) The initiation of a Norepinephrine infusion by a Paramedic. D) The
administration of high-flow supplemental oxygen.
● The Answer: C (The initiation of a Norepinephrine infusion by a Paramedic.)
● Distractor Analysis:
○ A is incorrect: Isotonic fluid resuscitation is a primary standing order for
undifferentiated shock.
○ B is incorrect: ECGs are standing diagnostic orders requiring no consultation.
○ D is incorrect: Oxygen therapy is a basic, foundational standard of care.
The Mentor's Analysis: Vasopressors in sepsis drastically alter systemic vascular resistance and
cardiac afterload. When facing refractory septic shock, the immediate priority is fluid
resuscitation followed by pressors under medical guidance. By utilizing OLMC upon
Norepinephrine initiation, you bypass the trap of isolated clinical decision-making during
complex hemodynamic shifts. Professional/Academic Intuition: Initiating Norepinephrine in
sepsis triggers an automatic OLMC consultation.
Q7: A 45-year-old patient presents with a symptomatic heart rate of 38 bpm. Atropine has been
administered without hemodynamic improvement. Based on the Adult Bradycardia Protocol
(Red 29), what is the NEXT required action involving OLMC? A) OLMC must be contacted prior
to initiating transcutaneous pacing. B) OLMC must be contacted immediately after Atropine fails
or an Epinephrine drip is initiated. C) OLMC must be contacted ONLY if the patient loses a
central pulse. D) OLMC is not required for any interventions within the bradycardia algorithm.
● The Answer: B (OLMC must be contacted immediately after Atropine fails or an
Epinephrine drip is initiated.)
● Distractor Analysis:
○ A is incorrect: Transcutaneous pacing can be initiated as a standing order for highly
unstable bradycardia.
○ C is incorrect: Waiting for full cardiac arrest violates the proactive medical direction
mandate.
○ D is incorrect: The 2026 protocols specifically mandate OLMC when Atropine fails
to correct the underlying conduction block.
The Mentor's Analysis: Refractory bradycardia indicates profound conduction system failure
requiring secondary intervention. When facing an Atropine-resistant patient, the immediate
priority is mechanical pacing or chemical chronotropy with oversight. By utilizing early OLMC,
you bypass the trap of unilaterally initiating high-risk vasoactive infusions without physician
consensus. Professional/Academic Intuition: When Atropine fails the rhythm, the radio must
be keyed.
Q8: You are treating a 50-year-old trauma patient with isolated, severe extremity pain. Based on
Universal Pain Management (Green 18), what is the MAXIMUM first dose of IV Fentanyl? A) 50
mcg B) 100 mcg C) 150 mcg D) 200 mcg
● The Answer: B (100 mcg)
UNIVERSAL TEST BANK: MAINE EMS
PREHOSPITAL PROTOCOLS
PART 0: THE NAVIGATOR
● Tier 1 (Questions 1–28) - Foundational Syntax & Application: Testing "Hard Deck"
definitions, updated 2026 formulary metrics, and primary protocol algorithms (e.g., Pink 1
BRUE definitions, Blue 5 anxiolysis mandates, and basic OLMC triggers).
● Tier 2 (Questions 29–58) - Complex Application & Simulation: Situation-based
variables focusing on the Red 13 Refractory VF/VT pathway, Yellow 3 TCA Overdose
interventions, and Green 22 Trauma Termination of Resuscitation.
● Tier 3 (Questions 59–88) - Grandmaster Synthesis: High-stakes, multi-variable
scenarios requiring algorithmic synthesis, including Maternal Cardiac Arrest (Lavender 3),
Pediatric Post-Resuscitation Care (Red 21), and complex hemodynamic instability.
PART I: THE PRIMER
Mastering this highly calibrated Maine EMS 2026 protocol repository directly translates to
clinical dominance and flawless medical-legal execution in the most unforgiving prehospital
environments. This document forges elite clinical scholars whose academic intuition preempts
catastrophic patient deterioration.
● The 2026 Implementation Mandate: Effective December 1, 2025, all legacy protocols
are structurally void. Algorithmic adherence to the 2026 standards is an absolute,
non-negotiable legal and clinical baseline.
● The Airway Sequence Rule (Blue 5): Under the updated Post-Intubation/BIAD Pain
Control protocol, adequate pain management MUST precede anxiolysis; crucially,
On-Line Medical Consultation (OLMC) is no longer required prior to administering
midazolam or ketamine for anxiolysis.
● The Pediatric Definition Matrix: A "young infant" is strictly defined as less than 60 days
old. In cases of a Brief Resolved Unexplained Event (BRUE) under Pink 1, if a
parent/guardian refuses transport, the clinician MUST immediately contact OLMC.
● The Refractory VF/VT Divergence (Red 13): Persistent Ventricular Fibrillation or
pulseless Ventricular Tachycardia no longer loops indefinitely in the standard arrest
algorithm; it mandates an immediate pivot to the highly specific Red 13 pathway.
● The Toxicologic Hemodynamic Firewall (Yellow 3): For Tricyclic Antidepressant (TCA)
overdoses exhibiting widened QRS complexes unresponsive to maximum Sodium
Bicarbonate, the algorithmic imperative is 2 grams of Magnesium Sulfate infused over 15
minutes via a mechanical pump.
,PART II: THE ELITE TEST BANK
Q1: An adult patient weighing 80 kg presents with systemic anaphylaxis. Based on the
principles of the Maine EMS 2026 Formulary (Gold 1), which IM EPINEPHrine dose and
concentration is the MOST ACCURATE FIRST action? A) 0.15 mg of 1 mg/mL EPINEPHrine IM
B) 0.3 mg of 1 mg/10 mL EPINEPHrine IM C) 0.3 mg of 1 mg/mL EPINEPHrine IM D) 0.5 mg of
1 mg/mL EPINEPHrine IM
● The Answer: C (0.3 mg of 1 mg/mL EPINEPHrine IM)
● Distractor Analysis:
○ A is incorrect: The 0.15 mg dose is explicitly reserved for pediatric patients under
25 kg.
○ B is incorrect: The 1 mg/10 mL concentration is reserved for IV/IO push during
cardiac arrest, lacking the necessary depot absorption profile for intramuscular use.
○ D is incorrect: The 0.5 mg dose exceeds the strict 0.3 mg limit for adult IM
administration in the Maine EMS system.
The Mentor's Analysis: Anaphylaxis requires immediate intramuscular alpha and beta-agonist
stimulation. When facing systemic collapse, the immediate priority is the correct concentration
via the correct route. By utilizing the 1 mg/mL concentration, you bypass the common trap of
administering dilute cardiac arrest formulations into muscle. Professional/Academic Intuition:
Always verify the 1 mg/mL concentration for IM anaphylaxis to ensure rapid systemic
absorption.
Q2: A 30 kg pediatric patient is experiencing severe hypoglycemia. Based on the principles of
the Diabetic Emergencies Protocol (Gold 6), which action is the MOST ACCURATE? A)
Administer 25 grams of D50 IV push. B) Administer 5 mL/kg of D10 IV. C) Administer 250 mL of
D10 IV. D) Administer 1 mg Glucagon IM unconditionally.
● The Answer: B (Administer 5 mL/kg of D10 IV.)
● Distractor Analysis:
○ A is incorrect: D50 is strictly contraindicated for pediatric patients under 40 kg due
to extreme hyperosmolar tissue necrosis risks.
○ C is incorrect: The 250 mL dose is the fixed adult dose, not the required pediatric
weight-based calculation.
○ D is incorrect: Glucagon is a secondary agent utilized only if IV/IO access is entirely
unobtainable.
The Mentor's Analysis: Pediatric vasculature is highly susceptible to hyperosmolar damage.
When facing pediatric hypoglycemia, the immediate priority is controlled, dilute dextrose
administration. By utilizing weight-based D10 (5 mL/kg), you bypass the common trap of
causing severe phlebitis or tissue sloughing associated with D50. Professional/Academic
Intuition: For patients under 40 kg, D10 is the absolute maximum allowable dextrose
concentration.
Q3: A paramedic successfully intubates an adult patient. The patient begins to gag and exhibits
tachycardia. Based on the principles of Post-Intubation/BIAD Pain Control (Blue 5), which
sequence is the MOST ACCURATE? A) IMMEDIATELY contact OLMC to request anxiolysis
with Midazolam. B) Administer Ketamine 0.2 mg/kg IV for pain control BEFORE considering
anxiolysis. C) Administer Midazolam 5 mg IV for anxiolysis, followed by Fentanyl for pain. D)
Extubate the patient to prevent laryngeal trauma.
● The Answer: B (Administer Ketamine 0.2 mg/kg IV for pain control BEFORE considering
, anxiolysis.)
● Distractor Analysis:
○ A is incorrect: The 2026 protocols specifically removed the OLMC requirement for
post-intubation anxiolysis.
○ C is incorrect: The 2026 protocol strongly emphasizes that analgesia MUST be
achieved prior to administering anxiolytics.
○ D is incorrect: Removing a secured airway due to inadequate sedation is a
catastrophic clinical failure.
The Mentor's Analysis: An endotracheal tube is inherently noxious and painful. When facing
post-intubation agitation, the immediate priority is analgesia, not just sedation. By utilizing
Ketamine or Fentanyl first, you bypass the novice error of chemically paralyzing or sedating a
patient who is actively experiencing severe pain. Professional/Academic Intuition: Treat the
pain of the tube before treating the anxiety of the situation.
Q4: An advanced airway attempt fails twice. The paramedic prepares for a third attempt. Based
on the principles of the Failed Intubation Algorithm (Blue 4), which conclusion is the MOST
ACCURATE? A) The paramedic may attempt a fourth intubation if the patient's SpO2 remains
above 90%. B) A maximum of three intubation attempts is allowed before the airway is
definitively deemed "failed." C) The paramedic MUST transition immediately to a surgical
cricothyrotomy. D) The paramedic should contact OLMC to request permission for a fourth
attempt.
● The Answer: B (A maximum of three intubation attempts is allowed before the airway is
definitively deemed "failed.")
● Distractor Analysis:
○ A is incorrect: Three attempts is the absolute hard-deck limit, regardless of transient
oxygenation status.
○ C is incorrect: A BIAD (Blind Insertion Airway Device) or basic BVM management is
the next algorithmic step, not an immediate surgical airway.
○ D is incorrect: OLMC cannot override the physiological trauma limits set by the
3-attempt anatomical rule.
The Mentor's Analysis: Repeated laryngoscopy causes profound oropharyngeal trauma and
airway edema. When facing a difficult airway, the immediate priority is recognizing failure limits.
By utilizing the 3-attempt hard stop, you bypass the trap of fixating on the endotracheal tube
while the patient suffers hypoxic brain injury. Professional/Academic Intuition: Three strikes
and you are out; pivot immediately to an alternative oxygenation strategy.
Q5: A patient experiencing an acute asthma exacerbation is placed on CPAP. Based on the
principles of Respiratory Distress with Bronchospasm (Blue 6-7), what is the MOST ACCURATE
pharmacological intervention? A) Discontinue CPAP to administer nebulized Albuterol via a
standard mask. B) Administer continuous nebulized treatments inline through the active CPAP
circuit. C) Administer an Epinephrine infusion at 0.05 mcg/kg/min immediately. D) Administer
oral Dexamethasone only after the CPAP is permanently removed.
● The Answer: B (Administer continuous nebulized treatments inline through the active
CPAP circuit.)
● Distractor Analysis:
○ A is incorrect: Removing the CPAP mask eliminates the positive end-expiratory
pressure required to keep the lower airways stented open.
○ C is incorrect: IV Epinephrine is reserved for impending respiratory failure or
systemic anaphylaxis, not standard asthma CPAP management.
○ D is incorrect: Dexamethasone is indicated early; waiting for CPAP removal delays
, critical corticosteroid onset.
The Mentor's Analysis: Bronchospasm coupled with positive pressure requires simultaneous
pharmacological delivery. When facing severe asthma on CPAP, the immediate priority is inline
bronchodilation. By utilizing an inline nebulizer, you bypass the trap of sacrificing continuous
positive airway pressure for medication delivery. Professional/Academic Intuition: Never break
the CPAP seal for a nebulizer; integrate them.
Q6: You are managing an adult patient in septic shock. Based on the principles of Medical
Shock (Gold 14), which action mandates IMMEDIATE On-Line Medical Consultation (OLMC)?
A) The administration of a 20 mL/kg isotonic fluid bolus. B) The acquisition of a diagnostic
12-lead ECG. C) The initiation of a Norepinephrine infusion by a Paramedic. D) The
administration of high-flow supplemental oxygen.
● The Answer: C (The initiation of a Norepinephrine infusion by a Paramedic.)
● Distractor Analysis:
○ A is incorrect: Isotonic fluid resuscitation is a primary standing order for
undifferentiated shock.
○ B is incorrect: ECGs are standing diagnostic orders requiring no consultation.
○ D is incorrect: Oxygen therapy is a basic, foundational standard of care.
The Mentor's Analysis: Vasopressors in sepsis drastically alter systemic vascular resistance and
cardiac afterload. When facing refractory septic shock, the immediate priority is fluid
resuscitation followed by pressors under medical guidance. By utilizing OLMC upon
Norepinephrine initiation, you bypass the trap of isolated clinical decision-making during
complex hemodynamic shifts. Professional/Academic Intuition: Initiating Norepinephrine in
sepsis triggers an automatic OLMC consultation.
Q7: A 45-year-old patient presents with a symptomatic heart rate of 38 bpm. Atropine has been
administered without hemodynamic improvement. Based on the Adult Bradycardia Protocol
(Red 29), what is the NEXT required action involving OLMC? A) OLMC must be contacted prior
to initiating transcutaneous pacing. B) OLMC must be contacted immediately after Atropine fails
or an Epinephrine drip is initiated. C) OLMC must be contacted ONLY if the patient loses a
central pulse. D) OLMC is not required for any interventions within the bradycardia algorithm.
● The Answer: B (OLMC must be contacted immediately after Atropine fails or an
Epinephrine drip is initiated.)
● Distractor Analysis:
○ A is incorrect: Transcutaneous pacing can be initiated as a standing order for highly
unstable bradycardia.
○ C is incorrect: Waiting for full cardiac arrest violates the proactive medical direction
mandate.
○ D is incorrect: The 2026 protocols specifically mandate OLMC when Atropine fails
to correct the underlying conduction block.
The Mentor's Analysis: Refractory bradycardia indicates profound conduction system failure
requiring secondary intervention. When facing an Atropine-resistant patient, the immediate
priority is mechanical pacing or chemical chronotropy with oversight. By utilizing early OLMC,
you bypass the trap of unilaterally initiating high-risk vasoactive infusions without physician
consensus. Professional/Academic Intuition: When Atropine fails the rhythm, the radio must
be keyed.
Q8: You are treating a 50-year-old trauma patient with isolated, severe extremity pain. Based on
Universal Pain Management (Green 18), what is the MAXIMUM first dose of IV Fentanyl? A) 50
mcg B) 100 mcg C) 150 mcg D) 200 mcg
● The Answer: B (100 mcg)
