Protocols

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Randall Wolff MD , Medical Director Revised September 1, 2006 EMS PROTOCOLS

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EMS Protocol Medical Director Signature Form The following EMERGENCY MEDICAL PRTOCOLS (revised 09/06) are the official Advanced Life Support Protocols for the Department and are approved for use by the paramedics of this Agency to care for the sick and injured Approved : Randall Wolff, M.D. September 1, 2006 Randall Wolff, M.D. Medical Director Date Authorization Signature Form Authorization Signature Form

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II. Medical Emergencies: 1-46 III. Trauma: 1-21 V. Environmental: 1-5 IV. Toxic Chemical: 1-10 VI. Obstetrical Emergencies: 1-9 VII. Pediatric Emergencies: 1-16 I. General Information: 1 - 13 VIII. Pharmacology: 1-16 IX. Appendix: 1-58 EMS Protocols Revised September 1, 2006 Randall Wolff, M.D. Medical Director 561-441-9868 561-628-6300 Fax: 561-243-7475 159*93303*1 Nextel Delta97@Comcast.net

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Table of Contents I) General Information Statement Of Purpose: 2 Authorization: 2 Definitions: 3 Guideline for treatment: 4 Transport Policy: 7 System Overview: 8 General Patient Assessment: 9 Airway Maintenance and Oxygen Administration: 12 II) Medical Emergencies Cardiac Arrest – General Guidelines: 1 Guidelines for Field Termination and Resuscitation: 3 Ventricular Fibrillation and Pulseless Tachycardia: 5 Ventricular Tachycardia with Pulses – Unstable: 7 Ventricular Tachycardia with Pulses – Stable: 9 Pulseless Electrical Activity: 11 Asystole: 12 Supraventricular Tachycardia – Stable: 13 Supraventricular Tachycardia – Unstable: 14 Rapid Atrial Fibrillation- Symptomatic: 15 Bradydysrhythmia – Stable: 16 Bradydysrhythmia – Unstable: 17

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Table of Contents II) Medical Emergencies Continued Premature Ventricular Contractions: 19 Chest Pain of Cardiac Origin (IV Nitro available): 20 Chest Pain of Cardiac Origin (IV Nitro not available): 24 Hypotension: 27 Hypertensive Emergencies: 29 Acute Pulmonary Edema (IV Nitro available): 30 Acute Pulmonary Edema (IV Nitro not available): 33 Respiratory Distress: 35 Altered Neurological Status (Stroke, Hypoglycemia, Poisoning): 36 T-PA Contraindications (Exclusion Criteria) and Stroke Scale: 41 Seizure: 42 Extrapyramidal (Dystonic) Reactions: 43 Allergic Reactions: 44 Chemical Restraint for Agitated Patients: 45 Pain Management Protocol: 46 Sickle Cell Anemia: 47 Vomiting: 48 III) Trauma Trauma Patient Management Sequence: 1 Primary Survey: 2 Secondary Survey Examination: 4 Spinal Immobilization: 6 Helmet Removal Protocol: 7 Special Situation Trauma Protocols: 8 Trauma Arrests: 10 Eye Emergencies: 11 Burns: 12 Amputation: 15 Adult Trauma Scorecard: 16 Pediatric Trauma Scorecard: 19 Transport Destination Criteria: 20 Helicopter Activation Criteria: 21

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Table of Contents IV) Toxic Chemical Definition: 1 General Assessment and Treatment: 3 Pesticides: 4 2 PAMCI: 4 Hydrogen Flouride: 9 Hydrogen Sulfide: 9 Classifications: 10 V) Environmental Emergencies Heat emergencies: 1 Cold emergencies: 1 Hazardous marine stings and bites: 2 Snake bites: 3 Drowning/Near Drowning: 4 Decompression Sickness: 5

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Table of Contents VI) Obstetrical Emergencies Normal Delivery: 1 Prolapsed Umbilical Cord: 3 Antepartum/Third Trimester Bleeding: 4 Breech Birth: 5 Toxemia of Pregnancy: 6 Newborn Management: 8 VII. Pediatric Emergencies General Pediatric Rules: 1 Pediatric Vital Signs: 16 Pediatric Bradycardia: 2 Pediatric Pulseless Arrest: 3 Pediatric Ventricular Fibrillation/ Pulseless V-Tach: 4 Pediatric Ventricular Tachycardia w/o pulses and poor perfusion: 6 PVC’s: 7 SVT w/o dehydration or hypovolemia: 8 Hypotension due to dehydration or nontraumatic hypovolemia: 9 Allergic Reaction: 10 Seizures: 11 Altered Neurological Status: 12 Asthma: 14 Croup/Epiglottitis: 15

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Table of Contents VIII) Pharmacology Adult Medication Dosages: 1-3 Dopamine Infusion: 4 Magnesium Sulfate Infusion: 5 Amiodarone Rapid Infusion: 6 Amiodarone Maintenance Infusion: 7 Norepinephrine Infusion: 8 Nitroglycerine Infusion: 9 D50: 10 Pediatric Medication Dosages: 11-12 Pediatric IV Drips: 13-15 Toxicological Antidote Kit: 16 IX) Appendix Glasgow Coma Scale: 1 APGAR: 2-3 Cricothyrotomy: 4-5 Pleural Decompression: 6-7 Transcutaneous Pacemaker: 8-9 Pulse Oximeter: 10 CO2 Detector: 11 Capnography: 12

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Table of Contents IX) Appendix continued Intraosseous Cannulation - Pediatric: 13-14 Intraosseous Cannulation – Adult EZ IO: 15-16 CPAP: 17-21 Nitronox: 22-23 Morgan Therapeutic Lens: 24 DNRO: 25-28 Pediatric Intubation: 29-30 Nasogastric or Orogastric Tube Insertion: 31 ATV: 32-33 RSI: 34-37 Esophageal Intubation Detector: 38 Versed: 39-40 Biosite Triage Meter Plus: 41-43 Taser Protocol: 44 Mark I Autoinjector: 45-46 Top 50 Prescription Drugs of 2005: 48 The “Rave” Drugs: 49 12 Lead EKG Interpretation: 50-51 Cincinnati Pre-Hospital Stroke Scale: 52 Common Medical Abbreviations: 53-54 START Triage: 55-57 H’s & T’s: 58

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I. General Information

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I. General Information Statement Of Purpose The intention of Advanced Life Support Protocols in a pre-hospital health care delivery system is to facilitate the rapid dispersal of adequate measures aimed at stabilizing the sick and injured. The EMS system is founded on the principle of delegated practice. Medical oversight establishes a certain standard of care, which is carried out by pre-hospital providers in the field. These Protocols are written to better define the responsibilities of the Paramedics, to decrease the chance of confusion at an emergency scene and to ensure a coordinated and efficient procedure for treatment and transport to a designated medical facility. These protocols are to be followed as closely as possible on each and every patient encountered by all Paramedics. They are to be used only when the Paramedic is on duty as a representative of the Agency. These protocols have been developed from nationally recognized standards and the latest scientific literature. They are in accordance with currently accepted medical practices advocated by organizations including the American Heart Association (AHA), the American College of Emergency Physicians (ACEP), the National Association of EMT’S (NAEMT), and the National Association of Emergency Medical Services Physicians (NAEMSP). A distinction must be made between a protocol and a standing order. A protocol is a preauthorized course of care for use by prehospital providers in managing patients. Protocols represent the overall steps in patient care management of every patient contact. Protocols may overlap with one another (e.g. a patient in respiratory distress who also has bradycardia). Treatment priorities for these individual patients should be based on good sound clinical judgment by the paramedic in conjunction with medical control as necessary. I. General Information, Page 1

I. General Information : 

I. General Information Standing orders are those components of prehospital care the provider initiates before establishing communications with Medical Control. This is acceptable under the legal concept of delegated practices. Contact with Medical Control is always possible if questions, problems, or unusual cases exist. The rules and guidelines for patient management emphasize those findings with the potential for high risk to the patient. Documentation should be sufficient to reflect the clinical decision making process. These protocols, in general, imply a specific sequence to the care. It is impossible to incorporate all possible situations into this protocol manual. Therefore, the actual order in which items are performed for each patient must be individually determined by the responder for each patient. In addition, because of unusual circumstances encountered in emergency work, the clinical judgment exercised by field paramedics in conjunction with the on-line medical control, may call for variation from the established protocol from time to time. For legal considerations, such as the right to give consent or to refuse treatment, a minor patient is anyone who has not reached their 18th birthday. Authorization These Advanced Life Support Protocols have been developed and circulated for use by Paramedics in the pre-hospital emergency care of the sick and injured, under authority granted Chapter 401 Florida Statutes, and 64E-2 Florida Administrative Code. Changes in these Advanced Life Support Protocols can only be made and promulgated by the Medical Director. All changes will be reflected in amendments to the Advanced Life Support Protocols and will be effective upon publication and receipt of same. Certified Paramedics approved by the Medical Director, are the only personnel authorized to perform ALS procedures called for in these protocols, except as authorized by the Medical Director. I. General Information, Page 2

Definitions : 

Definitions Agency: The responsible, licensed EMS Provider Medical Control: EMS Medical Director Emergency Department Physician Poison Control (for poisoning only) On scene Physician Priority One: Patients in cardiac or respiratory arrest Priority Two: Unstable patients with immediate life-threatening conditions that have been unrelieved by treatment Priority Three: Stable patients with no immediate life-threatening conditions Serious Signs and Symptoms: May include SOB, decreased level of consciousness, systolic blood pressure less than 100 mm Hg, shock, pulmonary congestion, or severe chest pain I. General Information, Page 3

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The following general measures shall be applied to help promote speed and efficiency when rendering emergency medical care to the sick and injured. When applicable, verbal consent should be obtained prior to treatment. Respect the patient’s right to privacy and dignity. Courtesy, concern, and common sense will assure the patient of the best possible care. Generally, non-critical Priority Three patients should be transported to the hospital of their choice, within reason All patients treated with ALS measures should be transported to a hospital. A Paramedic must accompany the patient when: invasive ALS procedures have been initiated OR The patient’s condition appears unstable or is potentially unstable OR The patient has had any known loss of consciousness prior to or while being medically treated. Appropriate therapy must be continued during transport. Vital signs should be monitored and recorded at least every five minutes on all patients during transport. All patients should have at least two sets of vital taken. Bring medication bottles with the patient to the hospital. I. General Information, Page 4 Guidelines for Treatment

Guidelines for Treatment : 

Guidelines for Treatment E All Priority One and Two medical patients must be transported to the nearest most appropriate medical facility with the capability to care for the advanced life support level patients, unless the immediate family insists on the patient being transported to a more distant facility, or unless specifically addressed in individual protocols (e.g., trauma, pediatrics, cardiac alert, strokes, OB). The consequences of this decision must be thoroughly explained to all parties involved. If the patient elects to be transported to a more distant facility and is alert and oriented, the patient must sign a "Refusal of Transport to the Closest Hospital" release form. All details involved in the decision must be recorded. Under no circumstances should a Priority One patient be transported to a hospital that is not the closest qualified facility on the basis of telephone orders from the patient’s private physician. Should the patient’s private physician object to the treatment and/or transport arrangements made by the Paramedic on scene, explain that you are following the protocol and refer the physician to the Medical Director. For the patient’s physician to give orders regarding treatment and/or transport, the physician must be on scene. G) If the family has contacted the private physician, then extreme tact and courtesy must be used. Your primary concern is the patient's health. Treatment and/or transportation should not be delayed or hindered in order to speak with a private physician. If time is critical, have the family inform the private physician to contact the destination hospital. I. General Information, Page 5

Guidelines for Treatment : 

Guidelines for Treatment H) Should a physician, present at an emergency scene, wish to alter the protocols or supervise the care of a patient, he or she must show identification which would convince a reasonable paramedic that the person is a physician; or be known to the paramedic to be a physician; or contacts a hospital or office that confirms that the person is a physician. The physician must be informed that he or she is taking full responsibility for the patient and must sign all medical reports. Contact the Medical Director, if necessary, for further direction. Methods for contacting the Medical Director include: cell phone, Direct Connect, or request Medcom contact Delta97. I) Physicians who call for patients in their office may give orders on their patients, providing those orders DO NOT conflict with these protocols or are otherwise not outside the standard of practice for emergency care. Should a conflict arise over a physician's orders, notify Medical Control for direction. Encodes to the receiving hospital should be made prior to the patient's departure from the scene. Medical communications are to be established via telemetry radio with the appropriate facility or Medical Director. Should an Emergency Department physician give additional orders, the physician's name should be documented in the medical report. Blood specimens will be drawn by all certified Paramedics for blood alcohol analysis upon request of an authorized law enforcement officer. The blood should only be drawn with a kit or tubes provided by the law enforcement officer. In addition, this procedure should be documented in a report, making sure to include the law enforcement officer's name and ID number. Specimens for evidence may also be obtained, if requested. The Medical Director should be notified if the drawing of blood conflicts with patient care. Properly executed Do Not Resuscitate Orders (see Appendix, page 25) will be honored. If CPR has been initiated and a valid DNR order is discovered, resuscitation efforts should be ceased. If necessary, contact Medical Control for assistance. I. General Information, Page 6

General Information : 

General Information Transport Policy Patients that have been evaluated by Department personnel and found to be in need of further medical evaluation at the hospital will be transported by ambulance. Do not suggest that the patient go to the hospital by private vehicle. If the patient, on their own accord, elects to go to the hospital by other means, the appropriate refusal for treatment or transport form will be signed in all instances. Transport Destination Policy 1. Cardiac alert – facilities with ability to perform acute interventional cardiology (i.e. catheterization lab 2. Stroke alert – facilities meeting AHCA and JCAHO criteria designated as primary stroke centers. 3. Obstetrical patient – facilities having designated labor and delivery departments. 4. Pediatric patient – facilities having acute in-patient facilities for pediatric patients with acute serious medical problems. I. General Information, Page 7

General Information : 

General Information System Overview Given the many different agencies involved in the delivery of EMS, it becomes imperative that responsibilities and authorities be clearly defined and known to all agencies within the system. Patient care must remain the most important priority. Team, cooperation and communication are desired and considered essential to our goals. The Agency shall be responsible for primary response of BLS and/or ALS units. Agency personnel shall Assume immediate control and initiate an incident command system as deemed appropriate and as specified in the Agency Manual. If hazardous conditions exist, the Incident Commander shall take immediate steps to control the hazard and protect the patient(s), fire department and non-fire department personnel as deemed appropriate. Agency personnel shall assume control of the patient(s) until all hazards are controlled or the patient(s) has been extricated. EMS Agencies are responsible for providing the timely response and efficient care and transport of patients to a designated medical facility as set forth in their Certificate of Public Convenience and Necessity (COPCN) with Palm Beach County. The non-transport unit's Paramedic shall provide the transport unit with all necessary and available information in a timely manner regarding the patient's condition and treatment given to that point. Upon completion of this interaction, the non-transport unit's crew will give any assistance necessary to the transport unit's crew to assure continuity of care, quick, safe, proper loading and transport to the designated medical facility. I. General Information, Page 8

General Information : 

General Information General Patient Assessment Primary Survey The primary survey is utilized to assess life-threatening situations. The primary survey and appropriate therapy should be completed immediately and efficiently upon reaching the patient. The Paramedic will decide if Advanced Life Support measures are needed. When appropriate, stabilizing therapy (i.e., cervical spine immobilization) should be instituted simultaneously with the survey. The Paramedic Team should complete the primary survey within 60 seconds, checking and/or performing the following: ASSESS AIRWAY Assess patency of the airway; Establish and maintain patent airway. Determine the adequacy and rate of respirations. Follow American Heart Associations BCLS standards; Consider cervical spine injury and apply manual stabilization and cervical immobilization device as soon as possible, if indicated. BREATHING (see Respiratory Emergencies Protocol) Look, listen and feel for movement of air; Support respirations as needed; Check chest for instability, tenderness or crepitation; Record respiratory rate; Auscultate lung sounds. I. General Information, Page 9

General Information : 

General Information ASSESS CIRCULATORY STATUS Assess carotid or femoral pulses; If indicated, perform CPR. Follow American Heart Association BCLS standards; Check for pallor, diaphoresis, capillary refill; Check the neck for deviated trachea; Check the neck for jugular vein distention. HEMORRHAGE Control exsanguinating hemorrhages as appropriate. ASSESS LEVEL OF CONSCIOUSNESS (See Altered Mental Status Protocol) The A.V.P.U. method should be used for initial neurological evaluation. A - Alert V - Responds to verbal stimuli P - Responds to painful stimuli U - Unresponsive EXPOSE AND EXAMINE I. General Information, Page 10

General Information : 

General Information Secondary Survey The secondary survey occurs after the primary survey has been completed and appropriate action has been taken. It is a complete examination designed to check for specific, although not necessarily life-threatening injuries. The secondary survey can be performed in conjunction with the primary survey or when appropriate throughout patient treatment. The Paramedic Team should perform and/or check for the following: Use the pneumonic "SAMPLE" to obtain a patient history: S - Signs-Pulse, respiration, blood pressure, SAO2, temperature A - Allergies M - Medications: Determine what medications the patient takes. Note the dosage and schedule. Whenever possible, bring the medications to the hospital with the patient and document this on the run report. P - Previous illness L - Last meal E - Details of the present complaint and precipitating events Head-to-Toe Survey A thorough hands-on examination as described in the secondary survey guidelines in the Trauma Protocol, as well as the following: - Skin condition, color and temperature - Pupillary reaction - Capillary refill - Distal pulses - Current physician - Age & sex - Weight in Kilograms - approximate if unable to determine - Specialized exams as necessary (e.g., cardiac, neurological) I. General Information, Page 11

General Information : 

General Information Airway Maintenance and Oxygen Administration - General Guidelines Where stated in the specific treatment protocols as "Secure an airway and administer supplemental oxygen as indicated," the following guidelines should be followed: Establish Patency of Airway Airway Management: Clear obstructed airways using the appropriate techniques. If necessary, insert appropriate airway device to maintain the airway, i.e. oropharyngeal, nasopharyngeal, endotracheal tube, Laryngeal Mask Airway (LMA), Combi-tube or cricothyrotomy. Assist Respirations If it is necessary to assist respirations for more than one minute, the patient should be intubated. All intubated patients will have an Emergency Intubation and RSI Report Form filled out and faxed. An Automatic Transport Ventilator (ATV) (see Appendix, page 32) or a Bag-Valve-Mask device with an attached reservoir connected to 100% O2 at 15 L/min flow should be used when assisting respirations. Insert the appropriate airway device as indicated. If approved by the Medical Director and the Department, Paramedics may administer Etomidate to facilitate intubation. CONTACT EMS SUPERVISOR AND ADVISE YOU ARE ADMINISTERING ETOMIDATE. ADMINISTER IF INDICATED: Etomidate 0.3 mg/kg – (Average dose for 70 kg patient is 20 mg IVP; Not to be given to children under 10 years old). Attempt intubation. If necessary to facilitate passage of endotracheal tube through vocal cords, 50 mg Lidocaine 2% may be sprayed onto chords. Any unconscious patient without a gag reflex should be intubated. Perform endotracheal intubation, Confirm ETT position by two methods to include auscultation of bilateral lung sounds, and CO2 levels using capnography, and/or end-tidal CO2 detector. Use Esophageal intubation Detector (EID) if tube placement is in question, (Appendix, page 38) or if the capnograph does not display a reliable reading. The EID is reliable only when used soon after intubation. I. General Information, Page 12

General Information : 

General Information For all intubated patients, secure ETT with commercially available tube holder (not tape) and immobilize neck with cervical collar and backboard to prevent excessive head movement. Nasal intubation should be avoided in the patient with facial trauma or basilar skull fracture. Prior to intubating the head trauma patient, administer Lidocaine 2%, 1 mg/kg with a maximum dose of 100 mg unless Etomidate has been administered. If Etomidate has been administered, then there is no need for Lidocaine. I. General Information, Page 13

General Information : 

General Information Foreign Body Obstruction: a. If BLS measures and the Heimlich maneuver do not clear the airway, perform a direct laryngoscopy and attempt to remove the foreign body with Magill forceps or suction. b. If the obstruction cannot be cleared by any other means perform a Cricothyrotomy Procedure (see Appendix, page 4). The decision to perform this procedure should be made early enough in the patient's course to attempt to prevent hypoxia from causing neurological damage. Airway Maintenance and Oxygen Administration Cricothyrotomy: Surgical, as outlined in Appendix, page 4 Suctioning: As necessary to clear airway Nasogastric Tube: Refer to Appendix, page 31 Administer oxygen: Nasal cannula 4-6 L/min (2 L/min for COPD and stroke patients). Non-rebreather mask (NRM) 10-15 L/min. Pedi/infant simple mask (minimum of 6 L/min must be used). Apply pulse oximeter and document findings on all patients before and after administration of oxygen. Maintain pulse oximetry readings at greater than 90%. Patients with known COPD and CO2 retention should receive low flow oxygen in order to avoid suppressing the ventilatory drive created by chronically low PO2. Higher saturation levels may suppress these patients' oxygen drive. This caution must not, however, prevent the administration of higher levels of oxygen in severe distress. Be prepared for intubation, and continually assess ABC's. I. General Information, Page 14

CARDIAC ARREST – GENERAL GUIDELINES : 

CARDIAC ARREST – GENERAL GUIDELINES Assess responsiveness (AVPU) If unresponsive, attach defibrillator and begin Primary ABCD survey according to AHA standards. Airway: Open the airway Use head tilt-chin lift unless cervical spine injury is suspected. Immobilize C-spine. If c-spine injury is suspected, first use a jaw thrust without head extension Breathing: Check breathing and provide positive pressure ventilations, if indicated (see General Airway Maintenance, Section 1) at a rate of 10 breaths/minute Circulation: Check pulse and perform chest compressions for two minutes, if indicated, at a rate of 100/min Defibrillate: Assess for and shock VF/Pulseless VT, single shock, if indicated. Perform a secondary ABCD survey, when appropriate Airway: Place an adjunct airway device as soon as possible, if not done already. Breathing: Confirm airway device placement by exam plus confirmation devices. Breathing: Secure airway device with commercially available tube holder. Breathing: Confirm effective oxygenation and ventilation. Circulation: Establish IV, if not done already Circulation: Identify rhythm with monitor. Circulation: Administer drugs appropriate for rhythm and condition Circulation: Assess for occult blood flow (pseudo-EMD). Differential Diagnosis: Search for and treat the H's the T's, (see Appendix, page 59) I. General Information Page 1 II. Medical Emergencies, Page 1

CARDIAC ARREST – GENERAL GUIDELINES : 

CARDIAC ARREST – GENERAL GUIDELINES The protocols are written with the intent that the preferred route of administration of ACLS drugs is IV. If the patient is intubated and an IV line is being inserted, and it appears that it will be successfully secured, then ACLS drugs should be given IV. If the IV cannot be established, doses of the appropriate medications may be administered via an intraosseous (IO) device (see Appendix, page 15) or down the ET tube. The IO route is preferred if an IV can not be established. The same dose of medication is given via the IO as is given IV. Use an impedance threshold devise (ITD) in all cases of cardiac arrest. CPR should be performed per AHA guidelines with emphasis on chest compressions. Limit periods of time when chest compressions are not being performed. Do not hyperventilate patients. Ventilate patients with an advanced airway at a rate of 10 breaths/minute. Special Cardiac Arrest Situations: a. Renal Failure Patients: Renal failure patients (some of whom are on dialysis) found in cardiac arrest (except V-fib or V-tach) should be suspected of having hyperkalemia. Typical EKG findings in hyperkalemia include: spiked "T" waves, a sine wave pattern or asystole. Therefore, the initial drug therapy is: Administer CaCl: 1 gm IVP; Flush line with minimum 50 cc NaCl; Administer Sodium Bicarb 1 mEq/kg IV Push; Continue on to the appropriate Cardiac Arrest Protocol. II. Medical Emergencies, Page 2

Guidelines for Field Termination of Resuscitation : 

Guidelines for Field Termination of Resuscitation b. Hypothermia Patients: Treat patients gently to avoid precipitating V-Fib; Do not hyperventilate; Hypothermic patients may be bradycardic. Assess pulses for at least 30-45 seconds to determine presence of pulse. Do not pace the patient unless the patient is in asystole; Limit shocks to a maximum of 3 for V-fib and Pulseless V-Tach until core temperature rises above 30? Centigrade (86? F), then defibrillate as indicated. CPR should be initiated in all cases where the patient is found in cardiopulmonary arrest unless special criteria apply. If at least one of the following conditions is found, CPR may be withheld: Lividity, and/or Rigor mortis, and/or Blunt or penetrating trauma without signs of life, and/or Decomposition, and/or A valid DNRO is discovered, and/or If all of the following are present: known down time greater than thirty minutes, asystole, pupils fixed and dilated, no respirations, and without hypothermic mechanism for arrest. The criteria used to withhold ALS procedures must be properly documented in the medical report. II. Medical Emergencies, Page 3

Guidelines for Field Termination of Resuscitation : 

Guidelines for Field Termination of Resuscitation Discontinuation of CPR Under the following well-defined circumstances, resuscitative efforts may be discontinued by EMS for patients who do not respond to an adequate trial of resuscitative therapy. Patients for whom resuscitative efforts may be discontinued in the pre-hospital setting include patients who are asystolic, normothermic and fail an adequate trial of resuscitative therapy defined as airway management, CPR, three rounds of medication (1 dose of Vasopressin and 1 mg Epinephrine every 3 minutes, 3 mg Atropine, 1 mEq/kg Sodium Bicarbonate), fluid replacement, and defibrillation when appropriate. EMS must have successfully completed all of the above requirements prior to discontinuing their efforts. The inability to successfully complete any one of these requirements invalidates this protocol. The Paramedic Supervisor or the Medical Director (or designee) must be consulted prior to terminating care. The Paramedic Supervisor and/or the Medical Director must concur with discontinuation of care and this agreement will be properly documented in the patient care record. Any disagreement or the inability to obtain this consultation will prevent the paramedic from using this protocol. II. Medical Emergencies, Page 4

II. Medical Emergencies : 

II. Medical Emergencies Follow Cardiac Arrest General Guidelines Protocol If down time is known or estimated to be five (5) minutes or longer and no CPR was being performed upon arrival, perform CPR for 2 minutes prior to the first defibrillation. If available, use the Autopulse as soon as possible. Defibrillate at 120j Zoll; 200j PhysioControl; 150j Philips. Perform CPR for 2 minutes and Secure airway as specified in General Airway and Oxygen Administration Initiate IV NaCl KVO rate Administer Vasopressin: 40 IU IVP or IO (Vasopressin is not given ETT) Administer Amiodarone 300 mg (6 cc) IVP. Amiodarone may be administered immediately after Vasopressin or Epinephrine (ETT) and before the second defibrillation if it is already drawn up and ready. Otherwise, administer the Amiodarone after the second defibrillation. Until IV or IO can be established, repeat Epinephrine 1:10,000 2 mg ETT every 3 minutes for persistent V-Fib or pulseless V-Tach. (Administer Vasopressin IV or IO as soon as the IV or IO is established, as indicated above). If no change, defibrillate at 150j Zoll; 300j Physio Control; 150j Philips. Perform CPR for 2 minutes and Administer Epinephrine 1:10,000 1 mg IV or IO every 3 minutes after the first Epinephrine or Vasopressin was given. If no change, defibrillate at 200j Zoll; 360j Physio Control; 150j Philips. NOTE: If patient is resuscitated prior to administration of any antidysrhythmic, administer Amiodarone by rapid infusion of 150 mg over 10 minutes (15 mg/min). Mix 150 mg of Amiodarone in 50 ml of D5W (3.0 mg/ml). IV Pump Infusion rate: 300 ml/hour with 50 ml volume to be infused (VTBI). If no IV Pump is available, use 10 gtts/ml IV set at 50 gtts/minute. VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA II. Medical Emergencies, Page 5

VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA : 

VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA If VF or pulseless VT persists 3 minutes after initial dose of Amiodarone, administer Amiodarone 150 mg IV Push. For persistent VF or pulseless VT, administer Amiodarone 150 mg every 3 minutes to a maximum dose of 900 mg. If no change, defibrillate at 200j Zoll; 360j Physio Control; 150j Philips. Perform CPR for 2 minutes For patients with history of diuretic use, or with polymorphic VT (torsades), administer Magnesium Sulfate: 1 gram IV Push. NOTE: The pattern should be DRUG-SHOCK-CPR, DRUG-SHOCK-CPR. Continue secondary ABCD survey, including identifying and treating the H’s and T’s. If resuscitation extends longer than 15 minutes consider the administration of Sodium Bicarbonate: IV Push 1 mEq/kg. May repeat in 10 minutes at 0.5 mEq/kg. If VF or pulseless VT persists, defibrillate at 200j Zoll; 360j Physio Control; 150j, Philips. Continue CPR for up to 2 minutes after a rhythm change to ensure continued circulation. Once a rhythm has been restored, administer Amiodarone maintenance infusion of 1 mg/min. Mix 150 mg of Amiodarone in 50 ml of D5W (3.0 mg/ml). IV Pump infusion rate: 20 ml/hour with 50 ml volume to be infused (VTBI). If no pump is available use a 60 gtts/ml IV set at 20 gtts/minute. II. Medical Emergencies, Page 6

UnstableVentricular Tachycardia : 

UnstableVentricular Tachycardia Ventricular Tachycardia with Pulses - Unstable with Serious Signs and Symptoms (see definitions) related to the Tachycardia. The evaluation of tachycardia is aided by a 12 lead EKG; therefore, all patients with tachycardia will have a 12 lead EKG performed. Wide complex tachycardias are usually ventricular tachycardia. Treat accordingly unless the 12 lead EKG confirms a supraventricular origin to the rhythm. Follow Cardiac Arrest General Guidelines Protocol (Section II, A.). Secure airway as specified in General Airway and Oxygen Administration Monitor rhythm and perform 12 lead EKG as soon as practical. Initiate IV NaCl KVO rate. If patient is awake and alert: Administer Versed (see Versed protocol, Appendix, page 39). Perform synchronized cardioversion. Zoll: 120 joules, 150 joules, 200 joules; Physio Control: 100j, 200j, 300j, and 360j; Philips 150j until rhythm is corrected. NOTE: If the patient is unconscious or loses consciousness, defibrillation should be done immediately to avoid the delay associated with synchronization. If patient is resuscitated prior to administration of any antidysrhythmic, administer Amiodarone by rapid infusion of 150 mg over 10 minutes (15 mg/min). Mix 150 mg of Amiodarone in 50 ml of D5W (3 mg/ml). IV Pump infusion rate: 300 ml/hr with 50 ml volume to be infused (VTBI). If no pump is available, use a 10 gtt/ml IV set at 50 drops/minute. II. Medical Emergencies, Page 7

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If VT persists or recurs, administer Amiodarone 150 mg by rapid infusion over 10 minutes (15 mg/min). Mix 150 mg. of Amiodarone in 50 ml of D5W (3 mg/ml). IV Pump infusion rate: 300 ml/hr with 50 ml volume to be infused (VTBI). If no pump is available, use a 10 gtt/ml IV set at 50 drops/minute. If VT persists or recurs, cardiovert at 200j Zoll; 360j Physio Control; 150j Pjhilips. If V-tach recurs or persists, repeat Amiodarone, 150 mg by rapid infusion over 10 minutes (15 mg/min). Mix 150 mg of Amiodarone in 50 ml of D5W (3 mg/ml). If no pump is available use 10 gtt/ml IV set at 50 drops/minute. If VT persists or recurs, cardiovert at 200j Zoll; 360j Physio Control; 150j Philips. Once a rhythm has been restored, administer Amiodarone maintenance infusion of 1 mg/min. Mix 150 mg of Amiodarone in 50 ml of D5W (3 mg/ml). IV Pump infusion rate: 20 ml/hour with 50 ml volume to be infused (VTBI)). If no pump is available, use a 60 gtt/ml IV set at 20 drops/minute. Contact Medical Control for further orders. UnstableVentricular Tachycardia II. Medical Emergencies, Page 8

StableVentricular Tachycardia : 

The evaluation of tachycardia is aided by a 12 lead EKG; therefore, all patients with tachycardia will have a 12 lead EKG performed. Wide complex tachycardias are usually ventricular tachycardia. Treat accordingly unless the 12 lead EKG confirms a supraventricular origin to the rhythm. Follow Cardiac Arrest General Guidelines Protocol (Section II, A.). Secure airway as specified in General Airway and Oxygen Administration Monitor rhythm and perform 12 lead EKG. Initiate IV NaCl KVO rate. If uncertain whether a rhythm is VT or SVT, assume all wide complex tachycardias are V-Tach and treat accordingly. If still uncertain, then contact Medical Control. Administer Amiodarone 150 mg by rapid infusion over 10 minutes (15 mg/min). Mix 150 mg of Amiodarone in 50 ml of D5W (3 mg/ml). IV Pump infusion rate: 300 ml/hr with 50 ml volume to be infused (VTBI). If no pump is available, use a 10 gtt/ml IV set at 50 drops/minute. NOTE: If the patient becomes unstable during this infusion or anytime while in this protocol, shock the patient at the appropriate energy levels. If rhythm is not corrected after Amiodarone 150 mg is infused, perform synchronized cardioversion : Zoll: 120j, 150j, 200j, or Physio Control: 100j, 200j, 300j, and 360j Philips: 150j If patient is awake and alert: Administer Versed (see Versed protocol, Appendix, page 39). StableVentricular Tachycardia II. Medical Emergencies, Page 9

StableVentricular Tachycardia : 

StableVentricular Tachycardia If V-Tach persists, administer Amiodarone 150 mg by rapid infusion over 10 minutes (15 mg/min). Mix 150 mg of Amiodarone in 50 ml of D5W (3 mg/ml). IV Pump infusion rate: 300 ml/hr with 50 ml volume to be infused (VTBI). If no pump is available, use a 10 gtt/ml IV set 50 drops/minute. NOTE: If the patient becomes unstable any time during this protocol, shock the patient at the appropriate energy levels. If VT persists or recurs, cardiovert at 200j Zoll; 360j Physio Control; 150j Philips. Once rhythm has been restored, administer Amiodarone maintenance infusion of 1 mg/min. Mix 150 mg of Amiodarone in 50 ml of D5W (3 mg/ml). IV Pump Infusion rate: 20 ml/hour with 50 ml volume to be infused (VTBI). If no pump is available, use 60 gtt/ml IV set at 20 drops/minute. Contact Medical Control for further orders. II. Medical Emergencies, Page 10

Pulseless Electrical Activity : 

Pulseless Electrical Activity Includes Idioventricular rhythms and Ventricular escape rhythms Monitor EKG rhythm Follow Cardiac Arrest General Guidelines Protocol (Section II, A.). Secure airway as specified in General Airway and Oxygen Administration Initiate IV NaCl KVO rate Administer Vasopressin: 40 IU IVP or IO. Vasopressin is not given ET. If no IV or IO can be established, administer Epinephrine 1:10,000: 2 mg ET every 3 minutes until an IV or IO can be established. Once the IV or IO is established, give Vasopressin as indicated above. If PEA continues, administer Epinephrine 1:10,000 1 mg IVP or IO every 3 minutes, after the dose of Vasopressin and every 3 minutes thereafter. If rate is bradycardic, administer Atropine: IV Push or IO: 1mg ET: 2mg If bradycardia continues, activate external pacer after first dose of Atropine. May repeat Atropine every 3 minutes until the bradycardia responds or a total dose of 3 mg IV (6 mg ET) is administered. NOTE: A response can be detected by briefly turning the pacer off, or using the 4:1 feature on the monitor and checking the patient's intrinsic rhythm. If an organized rhythm has not been restored, continue pacing. If no mechanical capture is obtained (no pulse) after two courses of drugs (6 minutes), then the pacemaker may be turned off. If resuscitation extends longer than 15 minutes consider the administration of Sodium Bicarbonate: IV Push 1 mEq/kg. May repeat in 10 minutes at 0.5 kg/kg. Perform secondary ABCD survey and assess for the H's and T's and treat accordingly. (see Appendix page 59) Contact Medical Control or further orders. II. Medical Emergencies, Page 11

Asystole : 

Asystole Follow Cardiac Arrest - General Guidelines Protocol. Secure airway as specified in General Airway and Oxygen Administration Initiate IV NaCl KVO rate Monitor rhythm and confirm asystole in 2 or more leads. If there is a possibility that V-Fib exists, follow appropriate protocol. Administer Vasopressin: 40 IU IVP or IO. Vasopressin is not given ET. If no IV or IO can be established, administer Epinephrine 1:10,000: 2 mg ET every 3 minutes until an IV or IO can be established. Once the IV or IO is established, give Vasopressin as indicated above. If asystole continues, administer Epinephrine 1:10,000 1mg, IVP every 3 minutes after the dose of Vasopressin and every 3 minutes thereafter. Initiate a trial of the pacemaker. The pacemaker may be discontinued if mechanical capture is not obtained. NOTE: If complexes are restored at anytime during therapy, follow the appropriate protocol. Administer Atropine: IV Push or IO: 1.0 mg ET: 2.0 mg Repeat Atropine 1 mg IV Push every 3 minutes for additional doses to a total of 3 mg. If resuscitation efforts extend longer than 15 minutes consider the administration of Sodium Bicarbonate: IV Push 1 mEq/kg. May repeat in 10 minutes at 0.5 mEq/kg. If patient remains in asystole, consider implementing field termination guidelines. Contact Medical Control for further orders. II. Medical Emergencies, Page 12

StableSupraventricular Tachycardia : 

StableSupraventricular Tachycardia The evaluation of tachycardia is aided by a 12 lead EKG; therefore, all patients with tachycardia will have a 12 lead EKG performed. Wide complex tachycardias are usually ventricular tachycardia. Treat accordingly unless the 12 lead EKG confirms a supraventricular origin to the rhythm. NOTE: If the rhythm is atrial flutter or atrial fibrillation, do not administer Adenosine. Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm. Initiate IV NaCl KVO rate. Bearing down while breath-holding is an acceptable Vagal Maneuver and may be attempted to control heart rate prior to drug therapy. DO NOT perform carotid massage. Administer Adenosine 6mg rapid IV Push (over 1-3 seconds). Flush IV line. If no change, repeat Adenosine 12mg Rapid IV Push (over 1-3 seconds). Contact Medical Control for further orders. II. Medical Emergencies, Page 13

UnstableSupraventricular Tachycardia : 

UnstableSupraventricular Tachycardia The evaluation of tachycardia is aided by a 12 lead EKG; therefore, all patients with tachycardia will have a 12 lead EKG performed. Wide complex tachycardias are usually ventricular tachycardia. Treat accordingly unless the 12 lead EKG confirms a supraventricular origin to the rhythm. UNSTABLE condition must be related to the tachycardia. Signs and symptoms may include SOB, decreased level of consciousness, systolic blood pressure less than 100 mm/Hg, shock, pulmonary congestion, or chest pain. NOTE: If the patient shows signs of hypovolemia or dehydration, refer to Hypotension Protocols. NOTE: If the rhythm is atrial flutter or atrial fibrillation, do not administer Adenosine and refer to the Atial Fibrillation protocol. Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm Initiate IV NaCl KVO rate. Bearing down while breath-holding is an acceptable Vagal Maneuver and may be attempted to control heart rate prior to drug therapy. DO NOT perform carotid massage. In narrow complex SVT only, if the situation and time permits, administer Adenosine 6mg IV Push prior to cardioversion. If patient is conscious: Administer Versed (see Versed protocol, Appendix, page 39). Perform synchronized cardioversion until rhythm is corrected. Zoll: 120j, 150j, 200j or Physio Control: 100j, 200j, 300j, 360j Philips: 150j Call Medical Control for further orders. II. Medical Emergencies, Page 14

Rapid Atrial Fibrillation or Atrial Flutter - Symptomatic : 

Rapid Atrial Fibrillation or Atrial Flutter - Symptomatic The evaluation of tachycardia is aided by a 12 lead EKG; therefore, all patients with tachycardia will have a 12 lead EKG performed. Wide complex tachycardias are usually ventricular tachycardia. Do not ever administer Cardizem to patients with wide complex tachycardias. For use in patients showing serious signs and symptoms related to the tachycardia. Minimum systolic blood pressure is 110 mm Hg. NOTE: If the patient shows signs of hypovolemia or dehydration, refer to Hypotension Protocols. NOTE: If you are unsure of the rhythm and the patient is tolerating it, do not administer Cardizem. Perform ABCD survey Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm. Initiate IV NaCl KVO rate. If the systolic blood pressure is greater than 110, then administer Cardizem 0.25 mg/kg (Dose range 10-20 mg over 2 minutes depending upon age and blood pressure. Older patients may be more sensitive to the hypotensive effects of the medication. If only 10mg is administered and there is no significant effect on blood pressure or rate, you may repeat the bolus once to achieve a heart rate of 100 bpm.) After administering the bolus, begin a Cardizem drip at 10 mg/hr. Mix 10 mg Cardizem in 50 cc D5W and run at 50 cc/hr. Call Medical Control for further orders. II. Medical Emergencies, Page 15

Slide 43: 

Bradydysrhythmia Stable Bradydysrhythmia - Stable (No signs or symptoms of being hemodynamically impaired) Perform primary ABCD survey. Perform secondary ABCD survey and apply pacer pads, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm. Initiate IV NaCl KVO rate. Monitor patient. Proceed to unstable protocol if patient becomes unstable. II. Medical Emergencies, Page 16

Bradydysrhythmia - Unstable with serious signs and symptoms related to the bradycardia : 

Bradydysrhythmia - Unstable with serious signs and symptoms related to the bradycardia . UNSTABLE condition must be related to the bradycardia. Signs and symptoms may include SOB, decreased level of consciousness, systolic blood pressure less than 100 mm Hg, shock, pulmonary congestion, or chest pain. NOTE: If patient is hypothermic, notify Medical Control prior to giving any medications. NOTE: Rough handling of a hypothermic patient, including rough intubation attempts, may precipitate V-Fib. Perform primary ABCD survey. Perform secondary ABCD survey and apply pacer pads when appropriate. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm. Initiate IV NaCl KVO rate. Administer Atropine: IV Push: 0.5 mg. ET: 1.0 mg. NOTE: Atropine is relatively contraindicated and should be used with care (if at all) with an anterior infarction. Transcutaneous pacing is the preferred method to increase the heart rate. II. Medical Emergencies, Page 17

Slide 45: 

Bradydysrhythmia - Unstable with serious signs and symptoms related to the bradycardia If no response, activate external pacemaker (see Appendix, page 8). If the lowest output causes patient agitation, may administer Versed (see Versed protocol, Appendix, page 39) per patient comfort. Atropine may be repeated every 3 minutes until the Bradycardia responds. Subsequent doses are in 0.5 mg increments to a total dose of 3.0 mg (6.0 mg ET). NOTE: A response can be detected by briefly turning the pacer off or using the 4:1 feature on the monitor and checking the patient's intrinsic rhythm. If no response, continue pacing. For hypotension associated with bradycardia, administer Dopamine at 5 mcg/kg/min. Titrate to systolic B/P greater than or equal to 100 mm/Hg to a maximum dose of 20 mcg/kg/min. Contact Medical Control for further orders. First Degree Block: Constant PRI >.20 Seconds, QRS < .10 Seconds Second Degree Type I- Wenckebach: PRI becomes progressively longer; “Going-Going-Gone” Second Degree Type II- Mobitz II: PRI is constant, some P waves are not followed by a QRS Third Degree Block: P waves show no relationship to the QRS, no relationship between P and R waves AV Blocks II. Medical Emergencies, Page 18

Slide 46: 

Premature Ventricular Contractions Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Search for and treat the H's and T's. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm. Initiate IV NaCl KVO rate. If chest pain is present, follow appropriate protocol. If the ectopy is thought to be from an overdose, follow the appropriate overdose protocol. Drug therapy is not indicated for PVC's. II. Medical Emergencies, Page 19

Slide 47: 

Chest Pain of Cardiac Origin (IV Nitro Available) Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Have patient remain quiet. DO NOT stress the patient. Perform 12 lead EKG and monitor rhythm Obtain a 12 lead EKG on all patients who meet the established criteria: -Chest pain -Dysrhythmia (heart rate greater than 150 or less than 50; frequent PVC's; other abnormal rhythms) -Epigastric pain (unless associated with G.I. bleeding) -Thoracic back pain without trauma -Diaphoresis (unless explained by fever) -Shortness of breath -Congestive heart failure/pulmonary edema -Abnormal appearing lead II EKG rhythm strips NOTE: Patient care is the primary mission. Obtaining the 12 Lead EKG shall not delay transport or treatment. In general however, the 12 Lead EKG should be performed within the first five minutes of patient contact. II. Medical Emergencies, Page 20

Chest Pain of Cardiac Origin (IV Nitro Available) : 

Chest Pain of Cardiac Origin (IV Nitro Available) Cardiac Alert Criteria If the patient has chest pain and or symptoms of an MI and ST segment elevation of greater than one millimeter in two or more related limb leads (II, III, AVF) or precordial leads, or has positive Cardiac Troponin I (Tnl) results if available, the patient meets the criteria for Cardiac Alert. Cardiac Alert patients should have their transport expedited while not compromising patient care. Encode the receiving hospital and advise that this is a "Cardiac Alert" and the estimated time of arrival. Describe the leads with elevation. Repeat 12 Lead EKG. Deliver one copy of the 12 Lead Cardiac Assessment Form and 12 Lead EKG to the receiving hospital medical staff and retain a copy of each to attach to the department's record. Cardiac Transportation Destination Criteria Cardiac Alert Patients should be transported to hospitals capable of performing emergency cardiac catheterization. The three Palm Beach County hospitals with such capability are: Delray Medical Center, JFK Medical Center, and Palm Beach Gardens Medical Center. The catchment areas for these hospitals are: North of Okeechobee Blvd = Palm Beach Gardens Medical Center. Boynton Beach Blvd to Okeechobee Blvd = JFK Medical Center. South Palm Beach County limits to Boynton Beach Blvd = Delray Medical Center II. Medical Emergencies, Page 21

Chest Pain of Cardiac Origin (IV Nitro Available) : 

Chest Pain of Cardiac Origin (IV Nitro Available) As soon as possible,initiate IV M.A.P. or NaCl KVO rate. If enzyme meter is available, draw a purple top blood specimen, prior to flushing the map or flowing the IV. Inoculate the Cardiac and BNP Enzyme test strips and test for enzymes. Attach an Enzyme Marker Form to the patient care record. Use a two port extension set or two separate IV’s for all patients being placed on IV Nitro. Avoid unsuccessful IV attempts. NOTE: IV Nitro tubing should be piggybacked as close to the catheter as possible. Administer Nitroglycerin: Single does spray or 1/150 tablet sublingual (SL). NOTE: Nitro may be administered prior to the establishment of an IV. Repeat Nitro spray or tablet SL every 3 minutes for a total of 3 doses as long as the patient remains symptomatic and the systolic pressure exceeds 100 mm Hg. If chest pain is relieved by SL Nitro, administer 1” Nitro Paste if systolic pressure exceeds 100 mm Hg. NOTE: Nitroglycerin is contraindicated in patients who have used medication to treat erectile dysfunction in the previous 24 hours. For all patients with chest pain of cardiac origin, administer two (2) 81.0 mg chewable aspirins, if not allergic to aspirin and no history of recent GI bleeding. If chest pain does not subside after the third dose of Nitro spray and the systolic pressure is greater than 100 mm Hg, administer Nitroglycerin drip IV. Mix 50 mg of Nitroglycerin in 250 cc D5W (glass bottle) using Nitroglycerin-rated vented tubing. Start drip at 10 mcg/min = 3 cc/hour. Increase IV Nitroglycerin dosage in 3 cc/hour increments every 5 minutes until pain is resolved. Do not exceed dosage of 60 mcg/min. (18 cc/hour). Systolic blood pressure must be greater than 100 mm Hg. If the systolic pressure drops below 100 mm Hg, decrease dose. If the blood pressure does not increase, turn the Nitroglycerin drip off. If the blood pressure remains low and the patient does not show signs of CHF, fluid boluses (100 – 200 cc) of normal saline may be used to increase blood pressure. II. Medical Emergencies, Page 22

Chest Pain of Cardiac Origin (IV Nitro Available) : 

Chest Pain of Cardiac Origin (IV Nitro Available) EKG’s showing ST elevation in leads II, III, and AVF, should be repeated as a right sided EKG (place V3R to the right instead of to the left of the sternum) to detect right ventricular infarcts. In patients with inferior and right ventricular infarcts, maintain systolic blood pressure above 100 mm Hg by administering 250 cc boluses of normal saline. May be repeated up to one liter, if signs of CHF are not present. Titrate to keep SBP above 100 mm Hg). If pain persists after IV Nitro has reached 60 mcg/min. (18 cc/hr.), administer Morphine IV Push in 2 mg increments up to a maximum of 10 mg, as long as systolic blood pressure remains greater than 100 mm Hg. Contact Medical Control for further orders. II. Medical Emergencies, Page 23

Chest Pain of Cardiac Origin (IV Nitro NOT Available) : 

Chest Pain of Cardiac Origin (IV Nitro NOT Available) Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Have patient remain quiet. DO NOT stress the patient. Perform 12 lead EKG and monitor rhythm. Refer to appropriate protocol if indicated. Obtain a 12 lead EKG on all patients who meet the established criteria: Chest pain Dysrhythmia (heart rate greater than 150 or less than 50 frequent PVC’s; other abnormal rhythms) Epigastric pain (unless associated with G.I. bleeding) Thoracic back pain without trauma Diaphoresis (unless explained by fever) Shortness of breath Congestive heart failure/pulmonary edema Abnormal appearing lead II EKG rhythm strips NOTE: Patient care is the primary mission. Obtaining the 12 lead EKG shall not delay transport or treatment. In general, however, the 12 lead EKG should be performed within the first five minutes of patient contact. II. Medical Emergencies, Page 24

Chest Pain of Cardiac Origin (IV Nitro NOT Available) : 

Chest Pain of Cardiac Origin (IV Nitro NOT Available) Cardiac Alert Criteria If the patient has chest pain and or symptoms of an MI and ST segment elevation of greater than one millimeter in two or more related limb leads (II, III, AVF) or precordial leads, or has positive Cardiac Troponin I (TnI) results if available, the patient meets the criteria for Cardiac Alert. Cardiac Alert patients should have their transport expedited while not compromising patient care. Encode the receiving hospital and advise that this is a "Cardiac Alert" and the estimated time of arrival. Describe the leads with elevation. Repeat 12 Lead EKG. Deliver one copy of the 12 Lead Cardiac Assessment Form and 12 Lead EKG to the receiving hospital medical staff and retain a copy of each to attach to the department's record. Cardiac Transportation Destination Criteria Cardiac Alert Patients should be transported to hospitals capable of performing emergency cardiac catheterization. The three Palm Beach County hospitals with such capability are: Delray Medical Center, JFK Medical Center, and Palm Beach Gardens Medical Center. The catchment areas for these hospitals are: North of Okeechobee Blvd = Palm Beach Gardens Medical Center. Boynton Beach Blvd to Okeechobee Blvd = JFK Medical Center. South Palm Beach County limits to Boynton Beach Blvd = Delray Medical Center II. Medical Emergencies, Page 25

Chest Pain of Cardiac Origin (IV Nitro NOT Available) : 

Chest Pain of Cardiac Origin (IV Nitro NOT Available) As soon as possible, Initiate IV M.A.P. or NaCl KVO rate. If enzyme device is available, draw a purple top blood specimen, prior to flushing the map or flowing the IV. Inoculate the Enzyme test strips and test for enzymes. Attach an Enzyme Marker Form to the patient care record. Use a two port extension set or two separate IV’s for all patients being placed on IV Nitro. Avoid unsuccessful IV attempts NOTE: Nitro may be administered prior to the establishment of an IV. Repeat nitro spray or tablet SL every 3 minutes for a total of 3 doses as long as the patient remains symptomatic and the systolic pressure exceeds 100 mm Hg. NOTE: Nitroglycerin is contraindicated in patients who have used medication to treat erectile dysfunction in the previous 24 hours. For all patients with chest pain of cardiac origin, administer two (2) 81.0 mg chewable aspirins if not allergic to aspirin and no history of recent GI bleeding. If pain persists, administer 2.0 mg Morphine Sulfate IV Push. May be administered in 2.0 mg increments as needed for pain control to a maximum dose of 10.0 mg. Systolic blood pressure must be greater than 100 mm Hg. Administer 1” of 2% Nitro ointment to the upper arm, if the systolic blood pressure remains greater than 100 mm Hg. In patients with inferior and right ventricular infarcts, maintain systolic blood pressure above 100 mm Hg by administering 250 cc boluses of normal saline. May be repeated up to one liter. (If no pulmonary edema is present. Titrate to keep SBP above 100 mm Hg). Contact Medical Control for further orders. II. Medical Emergencies, Page 26

Hypotension : 

Hypotension Hypotension due to Cardiogenic Shock: Pump failure possibly resulting in chest pain, pulmonary edema associated with hypotension or blood pressure less than 100 mm Hg and symptomatic. Perform primary ABCD survey. Perform secondary ABCD survey when possible. Secure airway as specified in General Airway and Oxygen Administration NOTE: Keep patient in Trendelenburg or supine if tolerated. Establish NaCl IV KVO. Perform 12 lead EKG and monitor rhythm. For patients with systolic B/P less than 70 mm Hg, administer norepinephrine starting at 4 mcg/min (15 cc/hr on IV pump) titrated until systolic B/P is greater than or equal to 100 mm Hg. For patients with systolic B/P greater than 70 but less than 100 mm Hg, administer Dopamine infusion at 5 mcg/kg/min to a maximum dose of 20 mcg/kg. NOTE: If the blood pressure rises to above 100 mm Hg and the patient complains of chest pain, refer to the Chest Pain Protocol. NOTE: Dopamine and norepinephrine should NEVER be given to patients who are hypovolemic, dehydrated or suffering from hypotension due to trauma. Contact Medical Control for further orders. II. Medical Emergencies, Page 27

Hypotension : 

Hypotension Hypotension Due to Dehydration or Non-Traumatic Hypovolemia Indications: Signs of hypotension due to hypovolemia, i.e. prolonged vomiting or diarrhea, poor skin turgor, G.I. or vaginal bleeding, increased pulse rate, low blood pressure, dry mucus membranes, etc. Perform primary ABCD survey. Perform secondary ABCD survey when possible. Secure an airway and administer supplemental oxygen as indicated. Establish an IV Normal Saline with large bore catheter. Administer 250 cc bolus of Normal Saline and repeat as necessary until the systolic blood pressure is greater than 100 mm Hg. NOTE: Reassess vital signs and lung sounds between each bolus, and monitor for onset of pulmonary edema. NOTE: Do not administer Dopamine or Norepinephrine in the setting of hypovolemia. Contact Medical Control for further orders. II. Medical Emergencies, Page 28

Hypertensive Emergencies : 

Hypertensive Emergencies Criteria For Treatment: Blood pressure that exceeds 200 mg Hg systolic and/or 120 mm Hg diastolic on at least 4 successive blood pressures over a period of 15 minutes of times and is associated with an acute onset of symptoms related to acute hypertension, such as epistaxis, headache, and nausea. NOTE: If the patient is pregnant, refer to the Eclampsia portion of the Obstetric Emergencies Protocol. NOTE: If the patient has weakness, or other signs and symptoms of stroke, refer to the CVA Stroke Protocol. NOTE: If the patient is in congestive heart failure, refer to acute Pulmonary Edema Protocol. Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Perform 12 lead EKG and monitor rhythm. Prior to any treatment with anti-hypertensives, you must document at least 4 successive blood pressures over a period of 15 minutes of time. If the blood pressure remains elevated above 200 systolic and/or 120 diastolic. Initiate IV NaCl KVO rate. Administer 20 mg Labetalol (Trandate, Normodyne) at a rate of 10 mg per minute slowly IV. May repeat 10 mg dose every 5 minutes until symptoms relieved or reduced and blood pressure reduced to no less than 160 systolic and/or 90 diastolic. The total dose administered will vary, but is not to exceed the maximum does of 60 mg. Discontinue if pulse rate drops below 60 beats per minute. NOTE: Labetalol is contraindicated in patients with acute or chronic history of congestive heart failure, bronchial asthma, second and third degree heart block, bradycardia, and cardiogenic shock. Contact Medical Control for further orders. II. Medical Emergencies, Page 29

Acute Pulmonary Edema (IV Nitro Available) : 

Acute Pulmonary Edema (IV Nitro Available) Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. If signs and symptoms of cardiogenic shock are present refer to Hypotension Due to Cardiogenic Shock Protocol. Secure an airway and administer supplemental oxygen as indicated. Place patient in a sitting position with legs lower than upper body. NOTE: DO NOT stress the patient. If the patient has a fever greater than 100 degrees Fahrenheit and crackles/rales, the patient may have pneumonia – not CHF. Perform 12 lead EKG and monitor rhythm. Refer to appropriate Arrhythmia Protocol if indicated. As soon as possible, Initiate M.A.P. or IV NaCl KVO rate If enzyme meter is available, draw a purple top blood specimen, prior to flushing the MAP or flowing the IV. Inoculate the Cardiac and BNP Enzyme test strips and test for enzymes. Attach an Enzyme Marker Form to the patient care record. The severity of the symptoms of a patient in acute pulmonary edema will determine the therapy that is administered. There are options available, depending upon the patient’s symptoms. Mild symptoms/CHF: (No accessory muscle use; no respiratory distress). Administer Lasix, 1 mg/kg, IV slowly to a maximum dose of 100 mg. Administer 1” of 2% Nitro Ointment to the upper arm, if the systolic blood pressure remains greater than 100 mm Hg. More Severe Symptoms/Respiratory Distress/Florid PE: More severe symptoms are defined as any of the following: Hypoxia (SaO2 less than or equal to 90) Diaphoresis Tachypnea (respirations greater than 20) Accessory muscle use Paramedic discretion II. Medical Emergencies, Page 30

Acute Pulmonary Edema (IV Nitro Available) : 

Acute Pulmonary Edema (IV Nitro Available) CPAP If the patient’s SaO2 remains less than 90% or the patient shows signs of increased work of breathing despite high flow oxygen at 100% , and systolic blood pressure is 100 or greater, administer CPAP, if available, at 100% FIO2 with 10 cm H2O pressure. Ensure a good seal. Reassess the patient in 3 minutes or sooner, if necessary. If so equipped, and there has been improvement as defined by decreased respiratory rate and/or heart rate, increase in the SaO2, reduced verbal impairment, improvement in mental status or overall patient condition, then continue CPAP and decrease the FIO2 to a level that will sustain an SAO2 greater than 90. If systolic blood pressure drops below 100, discontinue CPAP. If no improvement is noted or the patient’s condition is worsening, then consider intubation. Administer Lasix, 1 mg/kg, IV Push slowly to a maximum dose of 100 mg. If systolic blood pressure is greater than 100 mm Hg, administer Nitroglycerin drip IV. Using Nitroglycerin-rated vented tubing and premixed Nitroglycerin in a glass bottle, start the drip at 10 mcg/min = 3 cc/hr. Reassess every 5 minutes and titrate the dose to effect by increasing the rate in 3 cc/hr increments. The end point is improvement in the respiratory status or the dose has reached 60 mcg/min (18 cc/hr). Systolic blood pressure must be greater than 100 mm Hg. If systolic pressure drops below 100 mm Hg, decrease dose. If the blood pressure does not increase, turn the Nitroglycerin drip off. If the blood pressure remains low, begin a Dopamine drip. Titrate to keep the systolic blood pressure greater than 100 mm Hg. II. Medical Emergencies, Page 31

Acute Pulmonary Edema (IV Nitro Available) : 

Acute Pulmonary Edema (IV Nitro Available) If an IV cannot be established, refer to Mild Symptoms/CHF Protocol, disregard IV medications, and administer Nitroglycerin SL by single dose spray. May repeat Nitro SL twice. If severe shortness of breath persists after IV Nitro has reached 60 mcg/min (18 cc/hr), administer Morphine IV Push in 2 mg increments up to a maximum of 10 mg as long as systolic blood pressure remains greater than 100 mm Hg. II. Medical Emergencies, Page 32

Acute Pulmonary Edema (IV Nitro Not Available) : 

Acute Pulmonary Edema (IV Nitro Not Available) Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. If signs and symptoms of cardiogenic shock are present refer to Hypotension Due to Cardiogenic Shock Protocol. Secure an airway and administer supplemental oxygen as indicated. Place patient in a sitting position with legs lower than the upper body. NOTE: DO NOT stress the patient. If the patient has a fever greater than 100 degrees Fahrenheit, and crackles/rales, the patient may have pneumonia not CHF. Perform 12 lead EKG and monitor rhythm. Refer to appropriate Arrhythmia Protocol if indicated. Initiate M.A.P. or IV NaCl KVO rate. If enzyme meter is available, draw a purple top blood specimen, prior to flushing the MAP or flowing the IV. Inoculate the Cardiac and BNP Enzyme test strips and test for enzymes. Attach an Enzyme Marker Form to the patient care record. The severity of the symptoms will determine the course of therapy. Mild symptoms/CHF: (No accessory muscle use; no respiratory distress.) Administer Lasix, 1 mg/kg, IV slowly to a maximum dose of 100 mg. Administer 1” of 2% Nitro Ointment to the upper arm, if the systolic blood pressure remains greater than 100 mm Hg. More severe symptoms/Respiratory distress/Florid PE: More severe symptoms are defined as any of the following: Hypoxia (SaO2 less than or equal to 90) Diaphoresis Tachypnea (respirations greater than 20) Accessory muscle use Paramedic discretion If the systolic blood pressure is greater than 100 mm Hg: Administer Nitroglycerin SL by single dose spray. May repeat twice. II. Medical Emergencies, Page 33

Acute Pulmonary Edema (IV Nitro Not Available) : 

Acute Pulmonary Edema (IV Nitro Not Available) CPAP If the patient’s SaO2 remains less than 90% or the patient shows signs of increased work of breathing despite high flow oxygen at 100%, and systolic blood pressure is 100 or greater,, administer CPAP, if available, at 100% FIO2 with 10 cm H2O pressure. Ensure a good seal. Reassess the patient in 3 minutes or sooner, if necessary. If so equipped and there has been improvement as defined by decreased respiratory rate and/or heart rate, increase in the SaO2, reduced verbal impairment, improvement in mental status or overall patient condition, then continue CPAP and decrease the FIO2 to a level that will sustain an SAO2 greater than 90. If Systolic blood pressure drops below 100, discontinue CPAP. If no improvement is noted or the patient’s condition is worsening, then consider intubation. Administer MORPHINE IVP in 2 mg increments up to a maximum of 10 mg, as long as systolic B/P remains greater than 100 mm Hg. If IV cannot be established, follow protocol and disregard IV medications. Administer 1” of 2% Nitro Ointment to the upper arm, if the systolic blood pressure remains greater than 100 mm Hg. II. Medical Emergencies, Page 34

Respiratory Distress : 

Respiratory Distress Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Initiate M.A.P. or IV NaCl KVO rate. If enzyme meter is available, draw a purple top blood sample, prior to flushing the MAP or flowing the IV. Inoculate the Cardiac and BNP Enzyme test strips and test for enzymes. Attach an Enzyme Marker Form to the patient care record. Place and transport conscious patient in upright sitting position with high flow oxygen. NOTE: If patient is hypotensive keep patient supine. Perform 12 lead EKG and monitor rhythm. If pulmonary edema is suspected, refer to Acute Pulmonary Edema Protocols. Mild Wheezing: (Minimal distress) Administer Xopenex 0.63 mg (3 cc) via nebulizer. Treatment should not cause a delay in transport. If no response is noted, the Xopenex treatment may be repeated twice (to a total of three). Moderate to Severe Wheezing: (including patients that have their own inhalers; patients with COPD) Mix Xopenex 0.63 mg (3cc) and Atrovent 500 mcg of a 0.02% solution (2.5cc) and administer via nebulizer. If no response is noted, the Xopenex alone may be repeated twice (to a total of three). NOTE: Do not administer more than one dose of Atrovent. Do not administer Atrovent to patients with glaucoma or with allergies to peanuts, soy or lecithin . II. Medical Emergencies, Page 35

Altered Neurological StatusStroke, Hypoglycemia, Poisoning & Overdose : 

Altered Neurological StatusStroke, Hypoglycemia, Poisoning & Overdose Patients with overdose, poisoning, or altered neurological status may have several underlying causes for their medical condition. This protocol is dependent upon obtaining a thorough assessment, including the history of the present illness and past medical history. In addition, physical and neurological exams must be performed. Perform primary ABCD survey. Perform secondary ABCD survey, including neurological exam, when appropriate. Secure an airway and administer supplemental oxygen. If a stroke is suspected, administer oxygen via nasal cannula at 2 l/min. If a stroke is not suspected or the stroke patient is oxygen-compromised, secure an airway and administer oxygen as indicated. Perform 12 lead EKG and monitor rhythm. Establish M.A.P. or NaCl IV KVO. Test blood using glucometer (normal range 60-120 mg/dl), unless delay may cause patient deterioration. If hypoglycemic (less than 60 mg/dl), administer 25 g (50 cc) of D50 IV Push. If an IV can not be established, administer Glucagon 1.0 mg (1 unit) IM/Sub Q or via MAD device, using the supplied diluent. Retest glucose after 10 minutes in all patients with initial readings less than 80 mg/dl. If patient remains hypoglycemic (less than 60 mg/dl), administer another 25 g (50 cc) of D50 IV Push. Glucagon may be repeated in 25 minutes as it may take that long to have an effect. II. Medical Emergencies, Page 36

HYPOGLYCEMIA RELEASE POLICY : 

HYPOGLYCEMIA RELEASE POLICY Diabetic patients who are found to be hypoglycemic and received D50 and are now awake, alert and oriented to person, time and place, with blood sugar greater than 100 mg/dl, and who decline further treatment and transport, may be released without Medical Control authorization if they are with a responsible adult. Paramedics should determine the underlying cause of the hypoglycemia. For example, the patient may have taken too much insulin, the oral medication dose may be too high, or the patient may have missed a meal. The effects of the medication persist for 24 hours and may cause recurring hypoglycemia, and this will be explained to the patient. The patient should be encouraged to go to the hospital. Therefore, in cases where the patient refuses to be transported, the accompanying adult and the patient should be instructed to monitor the blood sugar level and the patient should contact the personal physician regarding the incident. Patient and responsible adult must sign a “Refusal for Treatment or Transport” form. II. Medical Emergencies, Page 37

Altered Neurological StatusStroke, Hypoglycemia, Poisoning & Overdose : 

Altered Neurological StatusStroke, Hypoglycemia, Poisoning & Overdose In patients with an altered mental status, if a narcotic drug overdose is suspected, administer Narcan prior to the D50. Administer Narcan: IV Push or via the MAD device: 2 mg except in narcotic addicts, where an initial dose of 0.4 mg should be given. May be repeated to a total dose of 2 mg. Patients with altered mental status or a stroke should remain NPO. If a stroke is suspected: DO NOT TREAT HYPERTENSION OR ADMINISTER ASPIRIN. Determine to the best of your ability that exact time of stroke onset. This should be determined by asking the patient or a reliable observer, “When was the last time the patient was seen without stroke symptoms?”. The time of onset of the stroke is a critical factor in determining whether a patient is a candidate for thrombolytic therapy. Obtain witness information, including names and phone numbers that will allow the hospital to confirm the time of the stroke. Perform neurological exam including the Prehospital Stroke Scale. Complete the Stroke Alert Check List. If the answers are all “yes” in the four Stroke Alert Criteria then the patient qualifies as a Stroke Alert. (see page 40 for Florida Bureau of EMS Stroke Alert Checklist. II. Medical Emergencies, Page 38

Altered Neurological StatusStroke, Hypoglycemia, Poisoning & Overdose : 

Altered Neurological StatusStroke, Hypoglycemia, Poisoning & Overdose Expedite transport while not compromising patient care or safety. Encode the receiving hospital as early as possible, informing them that this is a “Stroke Alert.” This will allow time to activate their stroke team. Advise the hospital of Stroke Alert Criteria, the time of onset of the stroke and the estimated time of arrival. Refer to the Obstetrical Protocol for patients with suspected Eclampsia. Refer to the Seizure Protocol for treatment of seizures. Refer to the Head Trauma Protocol for treatment of head trauma. Refer to Poisoning/Toxic Substance, Overdoes & Hazardous Materials/Chemical Exposure Protocols for patients in those categories. II. Medical Emergencies, Page 39

Slide 67: 

Stroke Alert Protocol (Checklist) Florida Bureau of EMS Stroke Alert Checklist Date & Times Date: Dispatch Time: Basic Data Patient Name Witness Name Last Time without symptoms Blood Glucose Level History Severe Headache Head Trauma at onset Examination Subarachnoid Hemorrhage Pre-hospital Stroke Scale A. (X) P -137 Level of consciousness (AVPU) Neck stiffness, cannot touch chin to chest “The sun always shines in Florida.” Facial droop (show teeth or smile) Arm drift, close eyes, arms out, palms up STROKE ALERT CRITERIA Time of onset < 5 hours Any abnormal finding on examination? Deficit not likely due to head trauma? Blood glucose >50? If answer is YES to ALL Stroke Alert Criteria, call a STROKE ALERT and transport the patient urgently & safely to the nearest appropriate Stroke Center. BMH – JFK – DMC Destination Stroke Center: Stroke Center Contact: EMS Arrival Time: EMS Departure: ED Arrival: Age M/ F Witness Phone # NO YES Check if Abnormal YES NO Stroke Alert Checklist The Stroke Alert Checklist has been designed to help the paramedic quickly determine the status of the patient presenting with stroke-like S/S. The Stroke Alert Patient should be treated as a load-and-go situation. The Stroke Alert Checklist shall be utilized on every patient with stroke-like S/S. A copy of the checklist shall be left with the receiving Emergency Department. The original shall be attached to the Field Medical Report. II. Medical Emergencies, Page 40

T-PA Contraindications (Exclusion Criteria) For Use in Stroke Alert Patients. : 

T-PA Contraindications (Exclusion Criteria) For Use in Stroke Alert Patients. Stroke more than 3 hours old, if a definitive time of onset can be determined. No definitive time of onset can be determined. Seizure prior to the onset of the stroke symptoms. Patients that have seizures, occurring after a stroke, are not automatically excluded. A prior stroke or serious head injury within preceding three months. Major surgery within preceding 14 days. Known history of intracranial hemorrhage. Gastrointestinal or urinary tract hemorrhage within preceding 21 days. Rapidly improving symptoms. Presently taking Coumadin (anticoagulants). NOTE: If you are unsure of the time of onset or whether the patient meets any of the exclusion criteria, encode the hospital with a “Stroke Alert” and allow the Emergency Department to make a treatment decision. SPEECH have the patient say “you can’t teach an old dog new tricks” Normal – patient uses correct words with no slurring. Abnormal – patient slurs words, uses inappropriate words, or is unable to speak ARM DRIFT both arms move the same or both arms do not move at all; Abnormal – one arm does not move or one arm drifts down compared with the other one FACIAL DROOP Have patient show teeth or smile (Normal – both sides of face move equally well) Abnormal – one side of face does not move as well as the other side Patient closes eyes and holds both arms out II. Medical Emergencies, Page 41

Seizures : 

Seizures Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Monitor EKG. NOTE: If the patient is pregnant, refer to the Eclampsia portion of the Obstetric Emergencies Protocol. Initiate M.A.P. or IV NaCl KVO rate. Test blood using glucometer (normal range 60-120 mg/dl) unless delay may cause patient deterioration. If glucometer reading is less than 60 mg/dl, administer 25 g (50 cc) of D50 IV Push. If patient is actively seizing (Grand Mal or Focal): Administer Versed (see Versed protocol, Appendix, page 39) as needed to control seizures or agitation. Monitor vital signs and airway. Monitor vital signs and airway. Contact medical control for further orders. II. Medical Emergencies, Page 42

Extrapyramidal (Dystonic) Reactions : 

Extrapyramidal (Dystonic) Reactions NOTE: Acute dystonia is a side effect of certain antipsychotic medications and antiemetics, characterized by muscle spasms of the neck, face, tongue and back. Perform primary ABCD assessment. Perform secondary ABCD assessment when appropriate. Secure an airway and administer oxygen as indicated. Initiate M.A.P. or IV NaCL KVO rate. Administer Benadryl, 25 mg IV. May repeat dose if no relief in 15 minutes. If no IV can be established, administer Benadryl 50 mg IM. Contact Medical Control for further II. Medical Emergencies, Page 43

Allergic Reactions : 

Allergic Reactions Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Establish an IV of Normal Saline KVO. Monitor vital signs and cardiac rhythm. Generalized allergic reactions characterized by any of the following: Hypotension (systolic less than 100), respiratory distress, urticarial rash, edema of the tongue. Administer Benadryl, IV or IM 25 mg and Epinephrine 1:1,000 SubQ 0.3 ml. (For patients greater than 50 years old, administer Epinephrine 1:1,000 SubQ 0.15 ml.) In severe anaphylactic shock (all the signs and symptoms of a severe allergic reaction plus cardiovascular collapse) where cardiac arrest appears imminent and blood pressure is unobtainable: Administer Epinephrine 1:10,000 IV in 1 ml increments up to 5 ml and administer Benadryl 50 mg IV Push. Contact Medical Control for further orders. II. Medical Emergencies, Page 44

Chemical Restraint for Agitated Patients : 

Chemical Restraint for Agitated Patients Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Perform 12 lead EKG and monitor rhythm. If patient complains of chest pain refer to Chest Pain Protocols. Initiate IV NaCl KVO rate. For seizures or agitation: Administer Versed (see Versed Protocol, Appendix, page 39) as needed to control seizures or agitation. Monitor vital signs and airway. NOTE: For the extremely combative or violent patients in whom IV access cannot be established: Administer Versed 5 mg IM (see Versed Protocol, Appendix, page 39). Contact Medical Control for further orders. Perform primary ABCD survey. II. Medical Emergencies, Page 45

PAIN MANAGEMENT PROTOCOL : 

PAIN MANAGEMENT PROTOCOL This protocol is to be used to alleviate pain in patients that have significant pain in the pre-hospital setting that is unrelieved by other methods. The numeric rating scale will be used to measure pain on all patients. The numeric rating scale ranges from 0 (no pain) to 10 (unbearable pain). Non-pharmaceutical intervention is to be used first. These methods include the technique of therapeutic communications. Careful use of appropriate wording and distraction away from painful stimuli can provide comfort to the patient. This comfort can provide a significant degree of pain relief to patients without the use of pharmacologic agents. Other non-pharmacologic methods include: immobilization of fractures; elevation of extremities; ice packs and padding of spine boards and splints. These non-pharmacologic methods are to be used first and the patient will then be reassessed. If the pain is still significant (3 or greater) and the patient does not have a contraindication (see below), then small doses of pain medication may be given. Vital signs are to be taken before and after the administration of the medication. Appropriate documentation is expected. For patients whose pain is rated at 3 or greater, the pharmacologic pain management techniques include: Nitrous Oxide (if available): self-administered. See protocol in Appendix, page 22. Perform secondary ABCD survey, when appropriate. Morphine Sulfate: Titrated in 2.0 mg increments IV to a maximum total dose of 10 mg. Systolic B/P must be greater than 100 mm Hg. Contraindications: Allergy to the drug Multiple trauma Altered mental status Signs and symptoms of shock Recent ingestion of CNS depressant medication (including alcohol) II. Medical Emergencies, Page 46

Sickle Cell Anemia : 

Sickle Cell Anemia Patients with sickle cell anemia occasionally have a sickle cell crisis characterized by sickling of the abnormal shaped red blood cells. These patients present with severe pain in different parts of their body such as back, legs, joints, etc. Fluids, oxygen, and pain medication should be administered as soon as possible in order to halt the sickling crisis and relieve the pain. Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Initiate IV NaCl at a rate of 150 cc/hr if there is no evidence of volume overload. Administer Morphine Sulfate, if not allergic, in 2mg increments up to a total of 10 mg. Maintain systolic blood pressure greater than 100 mm Hg. Call Medical Control for further orders. II. Medical Emergencies, Page 47

Vomiting : 

Vomiting Inclusion Criteria: Prolonged vomiting, or active vomiting after EMS arrival with no other symptoms or complaints. Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Infuse 250 ml boluses as needed (maximum 1000 ml) to keep systolic blood pressure greater than 100 mm Hg. (Ensure clear lung sounds prior to fluid challenge) For the adult patient, administer one dose of Zofran 4 mg SLOW IVP or IM. II. Medical Emergencies, Page 48

TRAUMA : 

TRAUMA MAJOR TRAUMA PATIENT: Any person who has incurred a single or multi-system physical injury or wound due to external force, violence, or burns, and whose injury severity meets the trauma scorecard methodology criteria and who is in immediate need of trauma services and requirements as specified in 64E-2, F.A.C., and in the Palm Beach County Trauma Ordinance 91-20, Rules and Regulations. Trauma Assessment and Treatment Guidelines The EMS provider upon arrival at the location of a trauma incident shall: Assess the initial management priorities of the trauma patient. Assess the condition of each trauma patient using the trauma scorecard methodology and criteria. Trauma Patient Management Sequence Assess/secure the physical environment. Triage trauma patients at the scene. Perform primary ABCD survey and initiate treatment. Initiate trauma alert for major trauma patients. Transport to definitive care facility: Trauma center Hospital Initiate IV Lactated Ringers if the patient has signs of significant injury. NOTE: Attempts to secure intravenous insertion sites and performance of the secondary survey should not delay transport to the trauma center or hospital. Mechanisms of injury should be relayed to the hospital. Perform secondary survey, when appropriate. Contact Medical Control for further orders. NOTE: Up to 10 mg of Morphine IV or Nitrous Oxide (if available) may be administered for relief of pain in the patient with isolated fractures and dislocations that do not meets Trauma Alert criteria. Systolic blood pressure must be greater than 100 mm Hg, (see Pain Management Protocol). III. General Trauma, page 1

TRAUMA : 

TRAUMA Primary Survey Approach all traumatic injuries in an orderly, organized fashion as guided by BTLS or PHTLS. A primary survey is performed first, correcting problems as you discover them. (Airway with C-spine control, Breathing, Circulation with hemorrhage control, Disability, Exposure). As time permits, perform secondary survey and treat accordingly. A Trauma Alert should be transmitted as soon as possible. Airway: Establish patient airway, immobilize C-spine and maintain in neutral position manually until a cervical immobilization device and backboard is applied. (See Spinal Immobilization Protocol). The modified jaw thrust is the preferred manual methods to open the intact airway. Oral/nasopharyngeal airways can be used to maintain a patient’s airway. NOTE: Altered level of consciousness is the most common cause of upper airway obstruction. Nasopharyngeal airways are contraindicated in patients with suspected facial and basilar skull fractures. Secure an airway and administer supplemental oxygen as indicated. Breathing: Expose the chest and auscultate the rate and depth of respirations. Inspect and palpate the chest wall for unilateral or bilateral movement, and any signs of injury. Administer high flow oxygen. Patients with GCS less than 9 should be intubated or have their airway controlled. Consider paralytics in patients with jaw clench or intact gag reflex. Apply cervical immobilization, if applicable. Perform a cricothyrotomy per protocol (see Appendix, page 4) if airway is compromised and you are unable to intubate. Assess and initiate interventions to alleviate all tension and open pneumothorax injuries (Appendix, page 6). Reassess vital signs to evaluate the effectiveness of interventions. III. General Trauma, page 2

TRAUMA : 

TRAUMA Circulation: Assess the pulse quality, rate, and regularity. Assess the skin color, texture, and capillary refill for signs of shock. Briefly assess the chest, abdomen, and extremities. Initiate two large bore catheters IV’s. Infuse Lactated Ringers using mass infusion sets when large volumes of fluid are indicated. Control bleeding –apply direct pressure dressings to bleeding sites. Monitor EKG and record strip as time permits Disability: Assess the patient’s neurological status: (A.V.P.U.) Level of consciousness (Glasgow Coma Scale) Pupils, size/reaction Expose and Examine: Burns Lacerations Swelling Tenderness Instability Crepitus Pulses distal to injury (capillary refill less than 2 seconds) Motor/movement Sensation III. General Trauma, page 3

TRAUMA : 

TRAUMA Secondary Survey Examination Head/skull: Palpate, inspect the head and skull. Identify all related and significant injuries. Re-evaluate the eyes for pupillary size, hemorrhage and penetrating injuries. Assess visual acuity, if applicable. Assess the nose, ears and mouth. Observe for vomiting and prevent aspiration. Observe for convulsions in head injuries; maintain C-spine immobilization. Maxillofacial: Palpate, inspect for maxillofacial injuries. Treat airway obstruction if present and control hemorrhage. Blunt maxillofacial injury should be presumed to have a cervical spine injury, even in the absence of neurological deficit until ruled out by x-ray diagnosis. Eye injury – inspect eye carefully and document visual acuity. C-spine/neck: Palpate, inspect the C-spine while maintaining immobilization with a cervical device and backboard. Cover the wound with a sterile pressure dressing. Chest: Auscultate, palpate and inspect the chest, ribs, and clavicle for injuries. Evaluate or reassess breath sounds at the apex of the heart for pneumothorax or pulmonary contusion. Auscultate for distant heart sounds and inspect the neck for distended neck veins. Assess and reassess the presence of a narrow pulse pressure for cardiac tamponade. Distended neck veins may be absent in hypovolemia. NOTE: Treat any life-threatening injuries found during the secondary survey. III. General Trauma, page 4

TRAUMA : 

TRAUMA Abdomen: Palpate, auscultate, and inspect the front, back, and sides of the abdomen if MAST garment is not applied. Apply a moist sterile dressing to eviscerated, protruding abdominal wounds or organs. Assess for pelvic fractures. Assess and reassess patients that have neurological injury, altered level or loss of consciousness, and abdominal injuries. Extremities: Inspect upper and lower extremities for deformity, fractures, paralysis and paresis. Palpate the upper and lower extremities for tenderness, crepitus, peripheral pulses, abnormal movement, and reduced range of motion. Visualize extremities, immobilize and splint the injured site before moving. Check distal sensation and circulation before/after splinting or manipulation. Apply traction to any non-resistant, closed, angulated extremity. Check distal sensation/circulation. Splint joint dislocations in the position found above and below the joint. Hip dislocations should be supported with pillows and the uninjured leg in the most comfortable position found. Cover open fractures and amputations with moist sterile dressings. Transport the amputated part in a sealed plastic bag. Do not place the part directly on ice or wrap in moist dressings. Neurologic: Assess the extremities’’ motor and sensory responses. Reassess the Glasgow Coma Scale, level of consciousness, pupils’ size and reaction. Assess and reassess for head injuries. III. General Trauma, page 5

TRAUMA : 

TRAUMA Spinal Immobilization: It is the intent of these Trauma Protocols to fully immobilize any patient who may have any form of spinal injury. All patients presenting with the following should be fully immobilized: Neck or back pain and/or tenderness Head or facial injuries Any deviations in level of consciousness or focal neurological signs. Any patient with penetrating trauma near the spine Any significantly injured multi-trauma patient Any trauma patient with notable decreases in vital signs However, immobilization may be withheld (at the paramedic’s discretion with consideration of the “Mechanism of Injury”) if all of the following conditions are met: There is no neck or back pain or tenderness There has been no loss of consciousness and no neurological deficits There is not a painful distracting injury The patient is not intoxicated from drugs or alcohol The patient has normal vital signs The patient is not too young, too old, or mentally incompetent to reliably report their symptoms NOTE: Patients that experience increased pain or respiratory distress from being immobilized on a backboard should be placed in position of comfort, after they have received appropriate warning regarding potential complications and risks. Documentation of such warnings and patient consent should be included in medical report. III. General Trauma, page 6

TRAUMA : 

TRAUMA Helmet Removal Protocol Football Player Equipment Removal Protocol DO NOT REMOVE THE HELMET AND SHOULDER PADS of a player suspected of having a neck or head injury while still on the football playing field unless “CPR” is necessary or airway is compromised. EMS will accompany the patient to the hospital and assist the emergency department staff in the removal of helmet and pads and the subsequent immobilization of the head and neck area. Motorcycle Helmet Removal Protocol Motorcycle helmets can be removed using BTLS/PHTLS guidelines. See Spinal Immobilization Protocol. III. General Trauma, page 7

TRAUMA : 

TRAUMA Special Situation Trauma Protocols Follow the Trauma Patient Assessment and Treatment Guidelines beginning with the Primary Survey: Chest Trauma Sucking Chest Wound Seal wound with an air tight material and tape the occlusive dressing on 3 sides. Sealing of the wound should be done upon exhalation. Materials used could include: Petroleum gauze, plastic wrap and tape, or a defibrillation pad. Tension Pneumothorax The indication for pleural decompression is the presence of a tension pneumothorax with decompensation. Decompensation is defined as the presence of more than one of the following: (See Appendix, page 6.) Respiratory distress and cyanosis Loss of radial pulse (decompensated shock) Decreasing level of consciousness NOTE: Loss of breath sounds on one side may indicate the presence of a simple pneumothorax. Decompensation must be present to suggest the diagnosis and need for treatment of a tension pneumothorax. If possible, transport the patient on the affected side. Contact Medical Control for further orders. Flail Chest Stabilize flail segments with a multi-trauma dressing. No sandbags. Abdominal Trauma Protruding viscera should be covered with a moistened sterile dressing. III. General Trauma, page 8

TRAUMA : 

TRAUMA Head Trauma Perform airway management with cervical spine immobilization. Secure an airway and administer supplemental oxygen as indicated. Glasgow Coma Score should be determined on all trauma patients with head injuries or that involve a documented loss of consciousness or an altered mental status. The results should be recorded on the appropriate medical reports and should be relayed to the trauma center. NOTE: Trauma patients with head injuries frequently sustain trauma to other body systems. Isolated head injuries do not cause shock. Impaled Objects Impaled objects should not be removed from the major trauma patient unless they threaten the airway. The patient and the impaled object should be immobilized to prevent movement. If the patient is impaled on an object, the object should be cut of at a distance from the skin and stabilized during transport. III. General Trauma, page 9

TRAUMA : 

TRAUMA Trauma Arrests Treatment of patients in cardiorespiratory arrest varies as to the mechanism of injury and whether or not they exhibit any signs of life (pulse, respirations, or reflexes) on initial evaluation. Generally, trauma patients who are found with no signs of life in the field have suffered overwhelming cardiovascular or CNS injuries that are not amenable to surgical treatment under any circumstances. The survival rate on these patients is essentially zero and attempts at resuscitation are futile. Patients suffering cardiorespiratory arrest after treatment has begun should generally be transported to the trauma centers in the usual manner, after immediate life-threatening problems have been ruled out. NOTE: Agonal ECG rhythms without pulses are not considered signs of life in the field. MAST Suit Protocol The MAST suit, if available, should be applied and inflated in trauma patients with suspected pelvic fractures that appear hypovolemic from bleeding associated with the pelvic fracture. The leg sections of the MAST suit may also be applied and inflated in trauma patients with suspected lower extremity fractures with uncontrolled bleeding. Contraindications: Uncontrolled bleeding in the chest or abdomen Head injuries Pregnancy Evisceration Lower extremity fractures with controlled bleeding III. General Trauma, page 10

TRAUMA : 

TRAUMA Eye Emergencies Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Toxic Chemical/Burns Inspect the eye carefully and document visual acuity using the following test: Do you see light? How many fingers do you see? Do you see print? Document the results in the medical report If toxic chemical has entered the eyes, insert the Morgan Therapeutic Lens (Appendix, page 24) and flush with NaCl or Lactated Ringers using IV tubing to direct the stream on the eye. Use care not to allow the run-off to contaminate the other eye. Alkalines: 20 minutes minimum Acids: 10 minutes minimum Morgan Lens is contraindicated in patients with injured globe. If globe is injured, stabilize penetrating objects and apply sterile non-pressure dressings to cover both eyes. Remove contact lens if present. NOTE: Tetracaine (if available) 1-2 gtt may be used to relieve pain and to facilitate irrigation EXCEPT in penetrating injury. Contact Medical Control for further orders. Refer to the Toxic Exposure Protocol for further treatments. III. General Trauma, page 11

TRAUMA : 

TRAUMA Thermal Burns Stop the Burning Process Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Use Normal Saline for irrigation. Do not use refrigerated water or ice. Secure an airway and administer supplemental oxygen as indicated. Patients with respiratory involvement should receive 100% oxygen. Estimate the burn size and body surface area involved. Refer to Pain Management Protocol. Minor Burns Include the following: Third degree burns of less than 2 percent of body surface if critical areas (face, hands, or feet) are not involved. Second degree burns involving less than 15 percent of the body surface First degree burns involving less than 20 percent of the body surface Cover the burned area with a moistened sterile sheet. Contact Medical Control for further orders. III. General Trauma, page 12

TRAUMA : 

TRAUMA Electrical Burns Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Perform airway management with cervical spine immobilization as indicated. Monitor rhythm and perform 12 lead EKG. Initiate IV Lactated Ringers. Contact Medical Control for further orders. NOTE: All high voltage (greater than 600 volts) electrical burns are considered critical burns until proven otherwise and should be treated as high priority and transported to a trauma center. III. General Trauma, page 13

Slide 90: 

III. General Trauma, page 14 Burn Chart Adult Pediatric Layers of the Skin Epidermis Dermis (Nerve Endings) Subcutaneous (Fatty Tissue) First Degree (Red) Second Degree(Blisters) Third Degree Full Thickness (Charring) Characteristics of Burns

Amputation : 

Amputation Patients with isolated amputation of any extremity Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Initiate IV NaCl at a rate of 150 cc/hr if there is no evidence of volume overload. Follow Pain Management Protocol. Care of the amputated part: Remove gross contaminants by rinsing with saline Wrap in moistened saline gauze and place in plastic bag or container Seal the container tightly and place on a solution of ice and water, if available All parts should be brought to the hospital regardless of the condition If the part cannot be located immediately, transport the patient and have other personnel search for and transport the part as soon as possible Call Medical Control for further orders III. General Trauma, page 15

Slide 92: 

III. General Trauma page 16 Palm Beach County Trauma System Adult Trauma Scorecard Methodology This Adult Scorecard is to be utilized for persons age 16 and older (One Red = Trauma Alert) (Two Blues = Trauma Alert) Special Notes 1) Airway assistance beyond administration of 02 2) Major de-gloving injuries, or major flap avulsion( >5” ) 3) Excluding superficial wounds in which the depth of the wound can be determined 4) Long-bone, including Humerus, Radius and Ulna, the Femur, and the Tibia and Fibula. 5) Excluding motorcycle, moped, ATV, bicycle, or open body of a pick-up truck 6) Only applies to the driver

Trauma - Pediatric Trauma Scorecard Methodology : 

Trauma - Pediatric Trauma Scorecard Methodology Primary Survey (Perform at Scene) Airway Establish an airway and immobilize the C-spine. Maintain a neutral position with manual immobilization until a cervical immobilization device and backboard are applied. Assist ventilation if: Level of consciousness is decreased or the patient fails to respond appropriately to voice. Systolic pressure is 20 mm Hg below expected norm. NOTE: To determine normal pressure, use the formula (80 + 2 times the child’s age in years). Severe facial, chest, or neck injuries are present. Pulse Oximeter reading is below 90. Breathing Expose the chest. Auscultate for the rate and depth of respirations. Inspect and palpate for unilateral or bilateral chest movement and any sign of injury. Administer high flow oxygen. Assess for Chest Trauma. Sucking Chest Wound Seal wound with an airtight material and tape the occlusive dressing on 3 sides. Sealing of the wound should be done upon exhalation. Materials used could include: Petroleum gauze, plastic wrap and tape, or a defibrillation pad. Tension Pneumothorax: Perform pleural decompression on the affected side, but not through the wound site. (See Appendix, page 6). If possible, transport the patient on the affected side. Contact Medical Control for further orders. Reassess vital signs to evaluate effectiveness of the intervention. Watch for gastric distention to avoid impairment of respiratory effort and decreased venous return III. General Trauma, page 17

Trauma - Pediatric Trauma Scorecard Methodology : 

Trauma - Pediatric Trauma Scorecard Methodology Circulation Assess the pulse quality, rate, and regularity. Assess the skin color, temperature, and capillary refill for signs of shock. Briefly assess the chest, abdomen, and extremities. Pediatric patients with severe shock/hypovolemia Signs and symptoms: Tachycardia, tachypnea Delayed capillary refill Anxiety/restlessness Hypotension (late, ominous sign) Initiate 2 large bore IV’s Lactated Ringers or Intraosseous infusion NaCl with 20 ml/kg fluid bolus over 10 minutes. May need to repeat dosage to a total of 60 ml/kg. Apply direct pressure dressings to bleeding sites. Disability Assess the patient’s neurological status (A.V.P.U.) Pediatric Trauma Score Pupil size and reaction III. General Trauma, page 18

Slide 95: 

III. General Trauma, page 19 Palm Beach County Trauma System Pediatric Trauma Scorecard Methodology This Pediatric Scorecard is to be utilized for persons age 15 or less (One Red = Trauma Alert) (Two Blues = Trauma Alert) (Green = Follow local Protocols)

Transport Destination Criteria : 

Transport Destination Criteria Determine the transport destination as set forth in Palm Beach County Trauma Ordinance 91-20 and 64E-2 F.A.C. Trauma Centers St. Mary’s Level II Trauma Center and Pediatric Trauma Referral Center Delray Community Level II Trauma Center and Pediatric Trauma Referral Center Minimize on-scene time of the major trauma patient and transport immediately by ground or air, if applicable, after primary survey is performed and patient is fully immobilized with a cervical device and backboard with straps. Treatment must be continued during transport, vital signs and EKG should be monitored and recorded at least every five minutes on major trauma patients. Secondary surveys and IV insertion attempts will be accomplished en route to the trauma center or hospital. Patients should continue to be sent to a single trauma center until that center advises that they are on “BYPASS”. When a trauma center is not able to accept patients meeting the trauma transport criteria, the hospital will notify MEDCOM and field units that they are on BYPASS status. When the trauma center designated above is on BYPASS status, the trauma patient should be transported to the other trauma center. In the even that both trauma centers are on “BYPASS” status, the trauma patient should be transported to the nearest medical facility as defined elsewhere in these ALS Protocols. When a trauma patient is transported via ground unit, a minimum of one Paramedic and one EMT should be in attendance of the patient(s). (This does not include the unit driver). III. General Trauma, page 20

TRAUMA : 

TRAUMA Mass Casualty Incidents In MCI trauma situations, only patients meeting Trauma Alert criteria should be taken to trauma centers. All others should be directed to other appropriate facilities. Helicopter Activation Criteria The guidelines for Trauma Hawk include but are not limited to the following: Trauma patients that meet the trauma scorecard methodology and criteria as set forth in 64E-2 and Palm Beach County Trauma Ordinance 91-20; Scene to trauma center ground transport greater than 20 minutes; Trauma Alert with scene extrication time greater than 15 minutes; Ground response time to the scene greater than 15 minutes; Mass Casualty Incidents evacuations (MCI); To augment or expedite pre-hospital ground transport, transport patient upon request by the provider. When a trauma patient needs to be transferred from a non-trauma center hospital to a trauma center and a private ambulance is not able to provide the service within the allotted time frame (currently 12 minutes), a Fire-Rescue ALS transport unit may be called upon to provide the service. These transports should be regarded as emergencies and should meet the patient attendant requirement addressed above. III. General Trauma, page 21

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure Definition of Toxic Substance Exposure The ingestion, inhalation, injection, dermal or ocular application, intentional or not, of a medication, chemical, or biologically active substance, or the bite/sting of an animal, resulting in immediate or potentially delayed effects. General If a toxic chemical and/or gas exposure incident has occurred, follow the Agency’s Standard Operating Procedures for response to HAZMAT incidents. Personnel should be mindful that such incidents may be the result of a terrorist act and take appropriate actions to maintain safety, possibly including notification of law enforcement to search for secondary devices. When entering an environment where a patient(s) has had a toxic exposure or where one is suspected, precautions for the safety of personnel should be taken prior to entering the environment or as soon as an exposure is realized. Institute appropriate personal protection equipment for all personnel involved in treatment prior to patient contact. When indicated, contact Special Operations and perform a gross decontamination of the patient following your agency’s Standard Operating Procedures. NOTE: All clothing, jewelry, and personal items will be removed from the patient, tagged with patient identification for possible evidence preservation and for return to the owner after decontamination, or disposal by the Special Operations Unit. IV. Toxic Chemical, page 1

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure Identify the type, quantity, route of exposure, and hazard potential of the substance to which the patient(s) is thought to have been exposed as early in the call as possible, preferably concurrent with patient contact. If additional information is necessary for patient assessment and treatment, call Poison Control Center at: 1 (800) 222-1222 Follow the treatment advice given by the Poison Control Center, providing they do not conflict with ALS Protocols. Obtain the Center’s incident number and document it in the patient record. In the event of a conflict, contact the EMS Medical Director. Trauma management should be performed according to Trauma Treatment and Transport Protocols. NOTE: Rapid extrication and transport are not a priority with patients exposed to hazardous materials. Patient decontamination and the safety of personnel and equipment take priority. Contaminated patients, even after gross decontamination, will be transported in a properly prepared ground transport unit to prevent transport unit contamination. Due to safety concerns and possible contamination, no helicopter transports of HAZMAT contaminated patients is permitted. IV. Toxic Chemical, page 2

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure General Assessment and Treatment Protocols for Exposure to Hazardous Materials Prior to initiation of ALS procedures, attempt to obtain information on the chemical and the appropriate treatment and precautions. Oxygen therapy, drug administration, and other ALS treatment modalities will ONLY be utilized per protocol, if either of the following conditions exist: Contact is within a known contaminant, and the treatment is not contraindicated by on-site reference data. Contact is with an unknown contaminant, but symptomology is consistent with the suspected identity of the contaminant. Perform primary ABCD survey. If the patient is unconscious, in respiratory distress, or experiencing other life-threatening symptoms, refer to the appropriate medical treatment protocol. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen. NOTE: If the suspected contaminant is a pesticide, withhold oxygen until the involvement of Dipyridyl herbicide (Paraquat, Diquat) is ruled out. Establish an IV of N.S., if indicated. Monitor vital signs and cardiac rhythm. Information and medical direction can be obtained from the following: On-site written or computer-generated reference data (i.e. Cameo) in conjunction with Medical Director approval, or Medical guidance from Poison Control Center. IV. Toxic Chemical, page 3

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure Pesticides/Nerve Agent: Cholinesterase Inhibitors: 2-PAMCI Protocol You may use the acronym, SLUDGE, to remember the signs and symptoms of organophosphate poisonings: Salivation Lacrimation (tearing) Urination Defecation Gastrointestinal irritation Emesis (nausea/vomiting) 2-PAMCI delivery: The preferred method of administration of 2-PAMCI is by intravenous drip of 1 gram in 20 cc administered through a Buretrol set over 20 minutes (more rapid administration will cause hypertension) dosed in 500 mg increments, depending upon the severity of symptoms. For higher doses in severe reactions, 2 grams (40 cc) may be required in the Buretrol. Autoinjectors containing 600 mg may be available for IM injections. Multiple injectors are required for higher doses in severe reactions. This method may be useful when IV access is unattainable or in multiple patient scenarios that need rapid interventions. Follow steps 1-5 of General Patient Assessment and Treatment for exposures to hazardous materials. IV. Toxic Chemical, page 4

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure Exposure to nerve agents may present in the following manner: VAPOR EXPOSURE – MILD Eyes…………………Miosis (constricted pupils) Dim vision Headache Nose…………………Rhinorrhea (running nose) Mouth………………..Salivation Lungs………………...Dyspnea (tightness in the chest) Time of onset………...Seconds to minutes after exposure NOTE: Miosis alone is not an indication for 2-PAMCI Protocol. For patients with miosis and severe rhinorrhea that is troublesome, administer 2-PAMCI 500 mg IV drip over 20 minutes (600 mg IM autoinject, if available). VAPOR EXPOSURE – SEVERE All the above, plus: Severe dyspnea or respiratory arrest Generalized muscle twitching, weakness, or paralysis Convulsion Loss of consciousness Loss of bladder/bowel control Time of onset: Seconds to minutes after exposure Administer Atropine 2 mg IV Push, repeat dose every 5 minutes titrated to a reduction of secretions and to reduction of ventilatory resistance. Pediatric dose: 0.015 to 0.05 mg/kg IV Push. Repeat same as adult. Administer 2-PAMCI, 1,500 mg IV drip over 20 minutes (1,800 mg IM autoinject, if available). Do not give in Carbamate Poisoning. Do not administer Lasix or Morphine in Cholinesterase inhibitor poisoning patients. IV. Toxic Chemical, page 5

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure LIQUID ON SKIN – MILD/MODERATE Muscle twitching at site of exposure Sweating at site of exposure Nausea, vomiting Feeling of weakness Time of onset: 10 minutes to 18 hours after exposure Administer Atropine 2 mg IV Push at 3-5 minute intervals and should be titrated to a reduction of secretions and to reduction of ventilatory resistance. Administer 2-PAMCI 500 mg (mild) or 1,000 mg (moderate) over 20 minutes (600-1,200 mg IM autoinject) depending on the severity of the symptoms. LIQUID ON SKIN – SEVERE All the above, plus: Severe dyspnea or respiratory arrest Generalized muscular twitching, weakness, or paralysis Convulsions Loss of consciousness Loss of bladder and bowel control Time of onset: Minutes to an hour after exposure IV. Toxic Chemical, page 6

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure Administer Atropine 2 mg IV Push at 3-5 minute intervals and should be titrated to a reduction of secretions and to reduction of ventilatory resistance, and Administer 2-PAMCI 1,500 mg IV drip over 20 minutes (1,800 mg IM autoinject, if available). NOTE: In a severe patient, Atropine should be pushed at frequent intervals until secretions are dry (or nearly dry) and until ventilation can be accomplished with ease. The need for ventilation may continue for 0.5 to 3 hours. For seizures see Seizure Protocols. IV. Toxic Chemical, page 7

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure Exposure to Hazardous Materials Specific Exposure Treatment Guidelines Eye Irrigation: Remove contact lens, if present Administer: Tetracaine (1-2 gtt) in each eye NOTE: Except in penetrating injuries – Insert Morgan Therapeutic Lens in the affected eye(s). Irrigate the eyes with a minimum of 2,000 cc of Normal Saline or Lactated Ringers. Nitrate-Induced Methemoglobinemia Follow steps 1-5 of General Patient Assessment and Treatment. If patient is symptomatic, (i.e., altered LOC, dizziness, lethargy, confusion): Administer Methylene Blue, 1 mg/kg IV over 5-10 minutes. May repeat once if symptoms persist. Adult and pediatric doses are the same. Contact Poison Control for further orders. Cyanide Compounds Follow steps 1-5 of General Patient Assessment and Treatment. If IV is already established, skip #2 and proceed to #3. If patient is symptomatic, administer Amyl Nitrite, 0.3 ml inhalant for 15 seconds, then discontinue for 15 seconds. Repeat until IV is established and first dose of Sodium Nitrite is given. Administer Sodium Nitrite, 300 mg (10 ml) slow IV over 2-3 minutes. Administer Sodium Thiosulfate 12.5 g (50 ml) IV Push over 1-2 minutes. Pediatric dose: 1.2 ml/kg, maximum dose of 12.5 g. Repeat steps (iii) and (iv) if symptomatic after 5-10 minutes. Contact Poison Control for further orders IV. Toxic Chemical, page 8

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure : 

Poisoning/Toxic Substance, Overdose, and Hazardous Materials/Chemical Exposure Hydrogen Fluoride Follow steps 1-5 of General Patient Assessment and Treatment. Apply Calcium Gluconate gel: Mix 3.6 g 10% solution with 6 ounces of water soluble lubricant. Massage into burn area. Contact Poison Control for further orders. Hydrogen Sulfide Follow steps 1-5 of General Patient Assessment and Treatment. Administer Amyl Nitrite, 0.3 ml inhalant for 15 seconds. Discontinue for 15 seconds. Repeat cycle until administration of Sodium Nitrite. Administer Sodium Nitrite, 300 mg (10 ml) slow IV over 2-3 minutes. DO NOT ADMINISTER SODIUM THIOSULFATE!! Contact supervising physician (Poison Control or ER physician) for further orders. IV. Toxic Chemical, page 9

Slide 108: 

IV. Toxic Chemical, page 10 Hazardous Materials Classification System Classifications: Class 1: Explosives Class 2: Gases Class 3: Flammable liquids and combustible liquids Class 4: Flammable solids Class 5: Oxidizers and Organic peroxides Class 6: Toxic materials and Infectious substances Class 7: Radioactive Class 8: Corrosives Class 9: Miscellaneous dangerous goods

Environmental Emergencies : 

Environmental Emergencies Heat Emergencies Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Move the patient to a cool environment and remove clothing as indicated. Establish an IV Normal Saline KVO. If patient appears dehydrated, give a fluid challenge of 250 cc and reassess. Repeat fluid bolus as needed. Monitor vital signs. Perform 12 lead EKG and monitor rhythm. Cool the patient down with cool water and fanning. Prevent shivering, which raises body temperature. Cold Emergencies Hypothermia: Patients with core or rectal temperature of less than 95 degrees. Perform ABCD primary survey. If no palpable pulses after 30-45 second assessment, refer to Cardiac Arrest Special Situation Protocols. Perform secondary ABCD survey, including obtaining a rectal temperature. Secure an airway and administer supplemental oxygen as indicated. Do not hyperventilate. NOTE: Rough handling of a hypothermic patient, including rough intubation attempts, may precipitate V-fib. Perform 12 lead EKG and monitor rhythm. Initiate M.A.P. or IV Lactated Ringers KVO rate. NOTE: Treat patient gently. Overly aggressive treatment of bradycardia and hyperventilation may also cause V-fib. Hypothermic patients may be bradycardic. Assess pulses for at least 30-45 seconds to determine presence of pulse. Do not pace the patient unless the patient is in asystole. V. Environmental Emergencies, page 1

Hazardous Marine Stingsand Bites : 

Hazardous Marine Stingsand Bites Hazardous Marine Stings and Bites Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Remove tentacles or residue by flushing the area with seawater or normal saline. Wear gloves to protect yourself. Place adhesive tape over the affected area alternately between application and removal to help remove the neumatocysts. Secure an airway and administer oxygen as indicated. DO NOT USE FRESH WATER ON THE AFFECTED AREA To neutralize the poison, pour white vinegar or ammonia (if available), or alcohol on the affected area for up to 30 minutes. Do not rub or massage the skin. If transport is needed, this procedure should not delay transport. NOTE: You may give the patient a basin with the solution for continued application. If signs of an allergic reaction occur, refer to Allergic Reaction Protocol. Inform the patient that other symptoms, such as dizziness, drop in blood pressure, or allergic reactions, may occur and need immediate medial attention. After the 30-minute application of the solution, the application and removal of tape or shaving the affected area may remove any residue. V. Environmental Emergencies, page 2

Snake Bite : 

Snake Bite Snake Bite Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. NOTE: Survey should include a history of sensitivity, allergies, and time of bite. Secure an airway and administer supplemental oxygen as indicated. Establish a large bore IV Lactated Ringers KVO in the uninvolved extremity. Monitor vital signs, cardiac rhythm, and record a lead II strip to submit to the hospital with the patient. Place patient supine and immobilize the affected extremity in neutral position. Check for signs of respiratory distress, fang marks, edema, and ecchymosis. Remove any constrictive jewelry or clothing and mark the area of edema, if present, with a pen. NOTE: Measure the circumference of the affected extremity. Do not apply ice!!!!! Check for distal pulses and neurological function of the involved extremity. Attempt to identify or bring the dead snake with you. Remember: Handle the dead snake with extreme care. Contact Medical Control for further orders. Transport patient ASAP. V. Environmental Emergencies, page 3

Drowning/Near Drowning : 

Drowning/Near Drowning Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen as indicated. Consider C-spine injury and take appropriate precautions. Initiate IV Lactated Ringers KVO rate. If hypotensive, (usually due to large fluid shifts in near drowning patients) give fluid bolus of 250 cc. May repeat as indicated. If patient remains hypotensive, Dopamine may be indicated. See Hypotension Protocol. If patient is in cardiac arrest, refer to appropriate protocol. NOTE: The early use of Sodium Bicarbonate should be given special consideration in the drowning victim as a significant metabolic acidosis may exist. NOTE: No drowning victim is to be pronounced dead at the scene if, in the Paramedic’s judgment, the possibility of hypothermia exists. NOTE: All near drowning victims must be transported by ambulance to the nearest appropriate emergency department. The patient may not sign a release. Notify the Medical Director if any problems arise for possible involvement of local law enforcement and Baker Act, if necessary. NOTE: Consider Mechanism of Injury to determine if patient meets Trauma Alert criteria. V. Environmental Emergencies, page 4

Decompression Sickness : 

Decompression Sickness Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Place patient in supine position. NOTE: There is no support for left lateral decubitus position or Trendelenburg as may have been previously recommended. Trendelenburg has been shown to be harmful except possibly in the first 20 minutes after surfacing. Secure an airway and administer high flow oxygen by non-rebreather mask. Monitor EKG and treat arrhythmias per appropriate protocol. Initiate IV Lactated Ringers. Give 500 cc fluid bolus (unless patient is in respiratory distress; then decrease the rate to 250 cc/hr). If patient is not breathing or obtunded, assist respirations, then intubate. If patient is breathing but with respiratory symptoms or decreased breath sounds (short of breath, hemoptysis, etc.) decrease IV fluids to “KVO”. Rule out tension pneumothorax, a life-threatening condition seen frequently in divers requiring immediate attention. Transport the patient as rapidly as possible by the most expedient means available to the nearest Hyperbaric Chamber capable of handling a diving emergency. (In Palm Beach County, St. Mary’s Hospital is the only hospital capable of handling a diving emergency). Divers in cardiac arrest should be transported to the nearest hospital facility with a chamber, prior to ending CPR. Case reports of divers with up to one hour of CPR have been successfully resuscitated under hyperbaric pressure. Any patient that has used SCUBA gear or compressed air within a 24-hour period preceding a medical complaint and has any signs of decompression sickness should be considered a diving emergency unless the patient is clearly a victim of unrelated trauma. V. Environmental Emergencies, page 5

Slide 115: 

VI. Obstetrical Emergencies

Obstetrical Emergencies : 

Obstetrical Emergencies Patients with greater than twenty (20) weeks gestation necessitating transport shall be taken to an OB facility, except for very minor complaints unrelated to the pregnancy, in which case they should be transported to the closest appropriate facility. Normal Delivery Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. This will include definitive evaluation of the mother. History should include: Number of previous pregnancies Number of previous births Document if multiple births are expected Expected date of delivery Show of blood. Document time Gush of water. Document time Examination: Assess vital signs Evaluate stage of labor Secure an airway and administer supplemental oxygen Assist in delivery by controlling the expulsion of the presenting parts Place mother in comfortable position (head up or left lateral) on the stretcher. Discourage mother from “pushing down”. Do not apply manual pressure to the uterine fundus. Do not pull or push the fetus and do not allow sudden hyperextension of the infant’s head. VI. Obstetrical Emergencies, page 1

Obstetrical Emergencies : 

Obstetrical Emergencies If the cord is wrapped tightly around the infant’s neck, slip it over the shoulder. If this cannot be performed, clamp the cord in two places and cut between the clamps. Establish IV Lactated Ringers on patients in active labor, or if the mother is experiencing excessive bleeding. Upon delivery of the infant, follow Newborn Management Protocol. Document delivery time. Apply firm, continuous pressure manually, massaging the uterine fundus until the placenta delivers. DO NOT push in the direction of the cord. DO NOT delay transportation for the delivery of the placenta. Preserve the placenta in a plastic bag for the hospital. Contact Medical Control for further orders. VI. Obstetrical Emergencies, page 2

Obstetrical Emergencies : 

Obstetrical Emergencies Prolapsed Umbilical Cord Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen. Place the mother in a knee-chest position with hips elevated on a pillow. Verify a pulse in the umbilical cord. If no pulse is present, with a gloved hand push the baby up into the uterus and away from the vagina and the compressed cord until a pulse returns in the cord. Wrap the exposed cord in a moist sterile dressing. Contact Medical Control for further orders. VI. Obstetrical Emergencies, page 3

Obstetrical Emergencies : 

Obstetrical Emergencies Antepartum/Third Trimester Bleeding Includes: Abruptio placenta Placenta previa Uterine rupture Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer 100% oxygen. Initiate large bore IV Lactated Ringers at appropriate rate. Contact Medical Control for further orders. NEVER ATTEMPT TO EXAMINE PATIENT INTERNALLY VI. Obstetrical Emergencies, page 4

Obstetrical Emergencies : 

Obstetrical Emergencies Breech Birth Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer 100% oxygen. If the infants head is not delivered within 3 minutes of the body: Elevate the mother’s hips. With gloved fingers form a “V” and attempt to push the vaginal wall away from the infant’s mouth and nose and administer 100% oxygen at the earliest possible time. NEVER ATTEMPT TO PULL THE BABY OUT! Transport ASAP to the hospital with the mother’s hips elevated and baby’s airway maintained while en route. Notify the hospital en route. Contact Medical Control for further orders. VI. Obstetrical Emergencies, page 5

Obstetrical Emergencies : 

Obstetrical Emergencies Toxemia of Pregnancy – Eclampsia and Pre-Eclampsia Pre-Eclampsia – A syndrome characterized by hypertension (greater than 140/90), generalized edema, and usually in the last trimester of pregnancy. Headache and altered mental status are seen later as the process worsens. Eclampsia – All of the above plus seizures and possible coma. Remember: Eclampsia is not the same as epilepsy. Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure an airway and administer supplemental oxygen. Initiate IV Lactated Ringers. In patients with Eclampsia or severe pre-eclampsia: Administer Magnesium Sulfate IV bolus 4 g over 20 minutes. Mix the bolus by adding 4 g (8 ml of the 50% magnesium sulfate) in a 50 cc “adds unit” with a macro drip and administer at 2.5 cc/min (about 38 drops per minute). NOTE: VERSED IS CONTRAINDICATED IN SEIZURES DUE TO ECALMPSIA Transport patient to facilities with obstetrical service capability. Contact Medical Control for further orders. VI. Obstetrical Emergencies, page 6

: 

Newborn = first hours after birth Neonate = up to 28 days Infant = up to age 1 year Child = 1-8 years of age Upon delivery of the newborn, bulb suction the mouth and each nostril. NOTE: If meconium staining is present, suction the mouth and nose after the delivery of the head, but BEFORE delivery of the infant’s body. Perform primary ABCD survey. Perform Basic Life Support if the following situations exist: If the heart rate falls below 100 beats per minute, or at delivery is between 60-100 beats per minute and is not rapidly increasing, 100% supplemental oxygen should be delivered for 30 seconds via bag-valve mask (resuscitation efforts should be guided by the chart below). Time should not be taken to stimulate the infant more than twice. Use this chart for the sequence of resuscitation efforts. Newborn Management VI. Obstetrical Emergencies, page 7

Slide 123: 

VI. Obstetrical Emergencies, page 8 Drying-Warming-Positioning Suctioning and Tactile Stimulation Oxygen BVM if HR < 100 BPM Chest Compressions If HR < 60 BPM Intubation Medications Always Needed Infrequently Needed Infant Resuscitation Chart

Obstetrical Emergencies : 

Obstetrical Emergencies If oxygen therapy does not cause an increase in heart rate, or if the heart rate falls to or remains below 60 beats per minute, perform chest compressions and ventilations at a rate of 120 events/minute (90 compressions and 30 ventilations/minute). Chest compressions should be discontinued when a spontaneous heart rate of 60 beats per minute or greater is reached. If heart rate remains below 60 beats per minute despite positive pressure ventilations and chest compressions, administer Epinephrine (1:10,000) at 0.1 cc/kg IVP. If the respiratory rate falls below 40 breaths per minute, ventilatory efforts should be supported via bag-valve positive pressure, using 100% oxygen, at a rate of 30-60 breaths per minute. Dry the infant and wrap it in a silver swaddler blanket. Record APGAR score at one and five minutes after birth (See Appendix, page 2). After the umbilical cord stops pulsating, apply two clamps, one 3 inches and one 4 inches from the infant. Cut the cord between the clamps. VI. Obstetrical Emergencies, page 9

Slide 125: 

VII. Pediatric Medical Emergencies

General Pediatric Rules : 

General Pediatric Rules Pediatric cardiac dysrhythmias are usually caused by extra cardiac factors such as hypoxia, hypercarbia, acidosis or shock. Treat for underlying cause. Infants and children under the age of 18 with serious or life-threatening medical problems should be transported to hospitals with pediatricians on staff and a pediatric in-patient service. The Broselow Pediatric Resuscitation Tape should be used in appropriate situations, as rapidly as possible, for accurate treatment of pediatric patients. Pulse oximeters should be used on all pediatric patients in distress. Blood sugar testing should be done on all pediatric patients in distress. Results should be treated per the appropriate protocol. Use an appropriate CO2 monitor. VII. Pediatric Medical Emergencies, page 1

Pediatric Bradycardia (includes CHB) : 

Pediatric Bradycardia (includes CHB) Perform primary ABCD survey and secondary ABCD survey, when appropriate. Perform 12 lead EKG and monitor rhythm. Secure airway as specified in General Airway and Oxygen Administration NOTE: Bradycardia is most commonly seen secondary to hypoxia. Therefore, evaluation of oxygenation and ventilation should be made prior to any drug therapy. If after oxygenation and ventilation the heart rate is less than 60 for an infant or a child with poor systemic circulation perform chest compressions. Initiate IV/IO NaCl Buretrol KVO. Administer Epinephrine: IV/IO 0.01 mg/kg (1:10,000) or 0.1 cc/kg ET: 0.1 mg/kg (1:1,000) or 0.1 cc/kg Repeat Epinephrine every 3 minutes as long as indicated. For patients greater than 5 kg: Administer Atropine: IV or IO 0.02 mg/kg ET: 0.02 mg/kg May be repeated once in 5 minutes Minimum dose = 0.1 mg Maximum dose = 1 mg for children (1-8 years of age) Maximum dose = 2 mg for adolescents (8-18 yrs of age) If no response and patient remains symptomatic, begin external cardiac pacing. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 2

Pediatric Pulseless Arrest (PEA and Asystole) : 

Pediatric Pulseless Arrest (PEA and Asystole) Perform primary ABCD survey. Follow cardiac arrest general guideline protocol (Section II, A). Perform secondary ABCD survey, when appropriate. Check and record EKG rhythm in at least two leads. If there is a possibility that V-fib exists, follow appropriate protocol. Secure airway as specified in General Airway and Oxygen Administration Initiate IV/IO NaCl Buretrol KVO rate. Administer Epinephrine: IV/IO: 0.01 mg/kg (1:10,000) or 0.1 cc/kg ET: 0.1 mg/kg (1:1,000) or 0.1 cc/kg Repeat Epinephrine every 3 minutes Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 3

Pediatric Ventricular Fibrillation and Pulseless Ventricular Tachycardia : 

Pediatric Ventricular Fibrillation and Pulseless Ventricular Tachycardia VII. Pediatric Medical Emergencies, page 4 Follow Cardiac Arrest General Guidelines Protocol (Section II, A.). If down time is known or estimated to be five (5) minutes or longer and no CPR was being performed upon arrival, perform CPR for 2 minutes prior to the first defibrillation. Defibrillate at 2 joules/kg. Perform CPR for 2 minutes and Secure airway as specified in General Airway and Oxygen Administration Initiate IV/IO NaCl Buretrol KVO and Administer Administer Epinephrine: IV/IO: 0.01 mg/kg (1:10,000) or 0.1 cc/kg ET: 0.1 mg/kg (1:1,000) or 0.1 cc/kg Repeat Epinephrine every 3 minutes Administer Amiodarone 5 mg/kg IVP bolus up to 150 mg. Amiodarone may be administered immediately after Epinephrine (ETT) and before the second defibrillation if it is already drawn up and ready. Otherwise, administer the Epinephrine after the second defibrillation. If no change, defibrillate at 4 joules/kg. Perform CPR for 2 minutes and Administer Epinephrine at the dose listed above every 3 minutes. If no change, defibrillate at 4 joules/kg. NOTE: If patient is resuscitated prior to administration of Amiodarone, administer Amiodarone by rapid infusion of 5 mg/kg up to 150 mg. over 10 minutes. Mix Amiodarone in 50 ml of D5W IV Pump. Infusion rate: 300 ml/hour with 50 ml volume to be infused (VTBI). If no IV Pump is available, use 10 gtts/ml IV set at 50 gtts/minute.

Pediatric Ventricular Fibrillation and Pulseless Ventricular Tachycardia : 

Pediatric Ventricular Fibrillation and Pulseless Ventricular Tachycardia VII. Pediatric Medical Emergencies, page 5 If VF or pulseless VT persists 3 minutes after initial dose of Amiodarone, administer Amiodarone 5mg/kg IV Push. For persistent VF or pulseless VT, administer Amiodarone 5mg/kg every 3 minutes to a maximum dose of 900 mg. If no change, defibrillate at 4joules/kg. Perform CPR for 2 minutes NOTE: The pattern should be DRUG-SHOCK-CPR, DRUG-SHOCK-CPR. Continue secondary ABCD survey, including identifying and treating the H’s and T’s. If resuscitation extends longer than 15 minutes consider the administration of Sodium Bicarbonate: IV Push 1 mEq/kg. May repeat in 10 minutes at 0.5 mEq/kg. If VF or pulseless VT persists, defibrillate at 4joules/kg Continue CPR for up to 2 minutes after a rhythm change to ensure continued circulation.

Pediatric Ventricular Tachycardia with Pulses and Poor Perfusion : 

Pediatric Ventricular Tachycardia with Pulses and Poor Perfusion Poor perfusion is defined as: Altered level of consciousness Chest pain Hypotension Dyspnea or tachypnea Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Perform 12 lead EKG and monitor rhythm. Secure airway as specified in General Airway and Oxygen Administration Initiate IV NaCl IV Pump or Buretrol or IO NaCl KVO. Sedate as needed with Versed up to 0.1 mg/kg titrated to effect up to a maximum dose of 5 mg. Cardiovert at 1 joule/kg If no change, administer Adenosine 0.1 mg/kg IVP, to a maximum of 6 mg If no change, cardiovert at 2 joules/kg If recurrent or unsuccessful in cardioversion, administer Amiodarone 5 mg/kg over 10 minutes up to 150 mg. Mix 150 mg Amiodarone in 50 ml D5W, calculate the total to be infused (VTBI), refer to the Amiodarone Infusion table and infuse that volume. May repeat doses to maximum of 300 mg or 15 mg/kg, which ever is less. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 6

Pediatric Premature Ventricular Contractions (PVC) : 

Pediatric Premature Ventricular Contractions (PVC) Criteria for Treatment Multi-focal Three or more in a six second strip ‘R on T’ Phenomena Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration NOTE: PVC’s in pediatric patients are usually associated with hypoxia and acidosis. Ensure that the patient has an adequate airway and administer oxygen. Perform 12 lead EKG and monitor rhythm. Initiate IV NaCl IV Pump or Buretrol or IO NaCl KVO. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 7

Pediatric Supraventricular Tachycardia without Dehydration or Hypovolemia : 

Pediatric Supraventricular Tachycardia without Dehydration or Hypovolemia SVT in a pediatric patient has a rate above 220 beats per minute. Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm. Treat underlying cause(s). H’s and T’s: see Appendix, page 59 If the patient appears to be hemodynamically compromised with decrease perfusion, altered mental status, etc. and an IV line has been established, Administer Adenosine 0.1 mg/kg rapid IV Push (over 1-3 seconds), 6 mg maximum. If no response, repeat Adenosine at 0.2 mg/kg to a maximum of 12 mg. NOTE: Do Not Administer Adenosine if rhythm is atrial fibrillation or atrial flutter. If an IV line cannot be rapidly established or patient is unresponsive to Adenosine, sedate with Versed (see Versed protocol, Appendix, page 39), cardiovert at 1 joule/kg. Repeat cardioversion as necessary at 2 joules/kg. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 8

Hypotension Due to Dehydration or Non-Traumatic Hypovolemia : 

Hypotension Due to Dehydration or Non-Traumatic Hypovolemia Indications: Signs of hypotension due to hypovolemia, ie., prolonged vomiting or diarrhea, poor skin turgor, G.I. or vaginal bleeding, increased pulse rate, low blood pressure, dry mucus membranes, etc. Perform primary ABCD survey. Perform secondary ABCD survey when possible. Secure airway as specified in General Airway and Oxygen Administration Perform 12 lead EKG and monitor rhythm. Establish an IV Normal Saline. Administer 20 cc/kg bolus of NS and repeat as necessary up to 60 mg/kg until the systolic blood pressure is greater than 100 mm Hg. NOTE: May repeat bolus until adequate systolic blood pressure is attained. Reassess vital signs and lung sounds between each bolus, and monitor for onset of pulmonary edema. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 9

Pediatric Allergic Reaction : 

Pediatric Allergic Reaction Perform primary ABCD survey. Perform secondary ABCD survey. Secure airway as specified in General Airway and Oxygen Administration NOTE: If child is resistant to use of O2 equipment, mask may be held close by face rather than secured to child. Perform 12 lead EKG and monitor rhythm. Administer Epinephrine (1:1,000): SQ 0.01 mg/kg, (0.01 ml/kg) Maximum dose: 0.3 mg. Administer Benadryl: 1.5 mg/kg IM to a maximum of 50 mg Initiate IV/IO NaCl Buretrol for severe reactions. Contact Medical Control for further orders. NOTE: The patient with an anaphylactic reaction must be watched closely for signs of airway obstruction. NOTE: If patient goes into cardiopulmonary arrest, refer to appropriate arrest protocol. VII. Pediatric Medical Emergencies, page 10

Pediatric Seizures : 

Pediatric Seizures Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Febrile Seizures (usually only up to age 3): Actively try to cool patient’s body temperature. Cool patient by sponging with cool water. DO NOT cover patient with wet towel, apply ice or give cold liquids to drink. Actively Seizing Patients (including Febrile Seizures): Initiate IV/IO NaCl Buretrol KVO. Test blood using glucometer (normal range 80-120 mg/dl). If hypoglycemic: Administer Dextrose, slow IV Push: 5-10 cc/kg D10W; Infants & children: 0.5-1 g/kg = 2-4 ml/kg of D25W or 1-2 ml/kg D50W. Administer Versed (see Versed Protocol). Monitor Vital signs and airway. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 11

Pediatric Altered Neurological Status : 

Pediatric Altered Neurological Status Hypoglycemia, Overdose & Poisonings Patients with overdose, poisoning, or altered neurological status may have several underlying causes for their medical condition. This protocol is dependent upon obtaining a thorough assessment, including the history of the present illness and past medical history. In addition, physical and neurological exam must be performed. Perform primary ABCD survey. Perform secondary ABCD survey, including neurological exam, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Identify the type, quantity and route of administration of the substance that the patient is thought to have taken. This should be done as early in the call as possible, preferably concurrent with patient care. If additional information is necessary for patient assessment and treatment, call Poison Control Center at: 1 (800) 222-1222 If a phone is available, follow the advice given by Poison Control, providing they do not conflict with ALS Protocols. Obtain the Center’s incident number and document it in the patient record. In the event of a conflict, contact the EMS Medical Director. Document orders received from Poison Control in the patient record narrative, including documentation of patient/guardian consent to follow directives from the Poison Control Center. Perform 12 lead EKG and monitor rhythm. Establish M.A.P. or NaCl by Buretrol IV or IO, KVO. Test blood using glucometer (normal range 80-120 mg/dl), unless delay may cause patient deterioration. VII. Pediatric Medical Emergencies, page 12

Pediatric Altered Neurological Status : 

Pediatric Altered Neurological Status If hypoglycemic (less than 80 mg/dl): Administer Dextrose, Neonates slow IV Push: 5-10 cc/kg D10W; Infants & children: 0.5-1 g/kg = 2-4 ml/kg of D25W or 1-2 ml/kg D50W. If an IV can not be established, administer Glucagon IM/Sub Q or via MAD device, using the supplied diluent. Dose: Greater than 20 Kg – 1.0 mg Less than 20 Kg – 0.5 mg Retest glucose after 10 minutes in all patients with initial readings less than 80 mg/dl. If patient remains hypoglycemic (less than 80 mg/dl), repeat previously administered dose. Glucagon may be repeated in 25 minutes as it may take that long to have an effect. In patient with an altered mental status, if a drug overdose is suspected: Administer Narcan prior to the D10W. Narcan is administered differently for newborns of mothers suspected to be addicted to narcotics. The main concern is precipitating narcotic withdrawal symptoms in the addicted newborn. For suspected accidental overdose: Administer Narcan IV Push: Birth to 5 years of age (up to 20 KG): 0.1 mg/kg IV. 5 years of age or greater than 20 KG: 2.0 mg IV. For newborns of mothers suspected to be addicted to narcotics: Administer Narcan IV Push: 0.01mg/kg IV Repeated doses are 0.01mg/kg up to a total of 2 mg. If an IV cannot be established, administer Narcan via the MAD device. VII. Pediatric Medical Emergencies, page 13

Pediatric Asthma : 

Pediatric Asthma Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Secure airway as specified in General Airway and Oxygen Administration Administer Xopenex 0.63 mg via nebulizer, (0.31 mg for children less than 3 years of age). Treatment should not cause a delay in transport. If no response is noted, the Xopenex treatment may be repeated twice (for a total of three) Initiate IV NaCl Buretrol KVO rate, if indicated. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 14

Croup/Epiglottitis : 

Croup/Epiglottitis Perform primary ABCD survey. Perform secondary ABCD survey, when appropriate. Transport patient in position of comfort. Allow parent to hold patient to reduce patient stress. Secures an airway and administer supplemental oxygen as indicated Administer oxygen only if patient will tolerate it. If child is resistant to use of O2, mask may be held close to the face rather than secured to child. If the patient is cyanotic or has altered mental status, ventilatory effort may need to be assisted. Do not introduce oral airways, tongue blades or any other device in the patient’s mouth, as this may precipitate complete airway obstruction. Contact Medical Control for further orders. VII. Pediatric Medical Emergencies, page 15

Slide 141: 

VII. Pediatric Medical Emergencies, page 16 Pediatric Vital Signs Age Newborn 1- 6 weeks 6 - months 1-year 3-years 6-years 10-years Respirations 30 – 60 30 – 60 25 – 40 20 – 30 20 – 30 18 – 25 15 - 20 Heart Rate 100 – 160 100 – 160 90 – 120 90 – 120 80 – 120 70 – 110 60 - 90 Systolic BP 50 – 70 70 – 95 80 – 100 80 – 100 80 – 110 80 – 100 90 - 120 This chart shows expected normal pediatric Vital Signs for the ages indicated.

Slide 142: 

VIII. Pharmacology ATROPINE SULFATE Injection, USP 1 mg (0.1mg/mL) Lifeshield® EPINEPHRINE Injection, USP 10 mL 1: 10,000 1mg (0.1mg/mL) Glass ABBOJECT® Unit of use Syringe With male luer lock Adapter and 20-Gauge Protected needle R ONLY PROTECT FROM LIGHT Adenocard 6mg/2mL For Rapid Bolus Intravenous Use 2mL (fill volume) 8.4% SODIUM 50mL BICARBONATE Injection, USP 50mEq (1 mEq/mL) 100mg/10mL FUROSEMIDE Injection,USP 10mL FOR IV or IM

Slide 143: 

Listed Alphabetically VIII. Pharmacology, page 1 Adult Medication Dosages

Slide 144: 

Adult Medication Dosages VIII. Pharmacology, page 2

Slide 145: 

Adult Medication Dosages VIII. Pharmacology, page 3

Slide 146: 

VIII. Pharmacology, page 4 Dopamine Infusion Dopamine HCI Caution Must be Diluted 400mg 40mg/mL 250mL Yields 1600mcg/mL 1600 60 400 15 800 30 1200 45 Mix 400mg into a 250mL D5W, which yields 1600mcg/mL. The dose is 5mcg/kg/minute Dopamine is a Vasopressor that increases Blood Pressure by acting on both the a and B1 receptors. 400mg Dopamine @ 5mcg/kg /minute mcg/min gtts/min 5% DEXTROSE Injection, USP

Slide 147: 

Magnesium Sulfate Infusion Magnesium Sulfate Injection 1 Grams/2mL VIII. Pharmacology, page 5 Magnesium Sulfate @ 4 Grams 4 Grams Magnesium Sulfate is Classified as an Anticonvulsant, Electrolyte (Magnesium), and Laxative (Saline) Magnesium Sulfate is basically Epsom Salt 50 mL D5W Injection, usp Mix 4 Grams into a 50 mL D5W, which yields 80mg/mL, administered over 20 minutes. The rate of IV infusion should generally not exceed 200mg/minute. 38gtts/minute utilizing the 15 drops/mL administration set, 200mg/minute

Slide 148: 

VIII. Pharmacology, page 6 Amiodarone Infusion – Rapid Infusion Yields 3.0 mg/mL Infuse 15mg/Minute Mix 150mg into a 50 ml bag of D5W, Administer over 10-minutes. 15mg/minute AMIODARONE HCI 150mg (50mg/mL) Amiodarone is a Class III Antiarrhythmic used for life-threatening ventricular rhythms. It acts to slow the sinus rate. Amiodarone is diluted into an infusion to help reduce the risk of Hypotension. Amiodarone @ 150mg 15mg/Minute Always label the bag when administering any medication 50 ml D5W INJECTION, USP 50 gtts/minute utilizing the 10 drops/mL administration set

Slide 149: 

VIII. Pharmacology, page 7 Amiodarone Infusion – Maintenance Infusion Yields 3.0 mg/mL Infuse 1mg/Minute Mix 150mg into a 50 ml bag of D5W, administer at 1mg/minute AMIODARONE HCI 150mg (50mg/mL) Amiodarone is a Class III Antiarrhythmic used for life-threatening ventricular rhythms. It acts to slow the sinus rate. Amiodarone is diluted into an infusion to help reduce the risk of Hypotension. Amiodarone @ 150mg 1mg/Minute Always label the bag when administering any medication 50 ml D5W INJECTION, USP 20 gtts/minute utilizing the 60 drops/mL administration set

Norepinephrine Infusion : 

Norepinephrine Infusion Only to be used with IV pump! Standard drip mix is 4 mg (1 amp) in 250 ml D5W (avoid Saline-only solutions) for a concentration of 16 mcg/ml. Starting dose is 4 mcg/min, titrated up to 12 mcg/min 4 mcg/min = 15 ml/hr 6 mcg/min = 23 ml/hr 8 mcg/min = 30 ml/hr 10 mcg/min = 38 ml/hr 12 mcg/min = 45 ml/hr VIII. Pharmacology, page 8

Nitroglycerin Infusion : 

Nitroglycerin Infusion Dosage: 10 mcg/min = 3ml/hr Mix 50 mg into 250 cc D5W VIII. Pharmacology, page 9

Slide 152: 

VIII. Pharmacology, page 10 50% Dextrose (D50) 50% DEXTROSE 50 mL 25 grams (0.5g/mL) LifeShied® Glass ABBOJECT® Unit of Use Syringe Open with male luer lock adapter and 18-Gauge protected needle R only “D50” Inside the numbers. 1) D50 = 25 grams of Dextrose diluted into 50mL’s of solution. 2) D25 = 12.5 grams of Dextrose diluted into 50mL’s of solution. 3) D12.5 = 6.25 grams of Dextrose diluted into 50mL’s of solution 4) D10 can be made by expelling 40mL’s of solution from the D50 syringe and then simply drawing up 40mL’s of 0.9% NaCl. Which yields 10% Dextrose. Reference the Pediatric Altered Mental Status Protocol, P-93 Diabetes overview: Diabetes Insipidus: Is the inadequate secretion or resistance of the kidney to the action of the antidiueretic hormone (ADH). Major S/S are polydipsia (thirst) and polyuria (frequent urination). Diabetes Mellitus Type I: Insulin-dependent. Usually occurs before the age of 30. The patient may need insulin injections and dietary modifications to control blood sugar levels. Cells in the pancreas that produce insulin are damaged – so they may produce little or no insulin. Diabetes Mellitus Type II: Non insulin-dependent. Usually occurs in obese adults over the age of 40. The cells in the pancreas are able to produce insulin, just not enough. Hyperglycemia is caused by insulin deficiency Hypoglycemia is caused by an excess of insulin or medication

Slide 153: 

Pediatric Medication Dosages VIII. Pharmacology, page 11

Slide 154: 

Pediatric Medication Dosages VIII. Pharmacology, page 12

Pediatric IV Drips : 

Pediatric IV Drips Dopamine: Dosage is 5-20 mcg/kg/min. Mix 100 mg in 250 ml D5W = 400 mcg/cc 100 mcg = 15 ugtts/min 200 mcg = 30 ugtts/min 300 mcg = 45 ugtts/min 400 mcg = 60 ugtts/min VIII. Pharmacology, page 13

Pediatric IV Drips : 

Pediatric IV Drips Pediatric Amiodarone Infusion Weight in kg Weight in lbs. mg VTBI (ml) ml/hr 3.0 6.6 15 5 30 6.0 13.2 30 10 60 9.0 19.8 45 15 90 12.0 26.4 60 20 120 15.0 33.0 75 25 150 18.0 39.6 90 30 180 21.0 46.2 105 35 210 24.0 52.8 120 40 240 27.0 59.4 135 45 270 30 and up 66.0 and up 150 50 300 VIII. Pharmacology, page 14

Pediatric IV Drips : 

Pediatric IV Drips D10 and D25 Mix Instructions Mix D10W and/or D25 solutions by injecting 30 cc of D50 into a 250 cc bag of D5W. Mix and withdraw 30 cc of the 250 cc bag back into D50 syringe, yielding D25 in syringe and D10W in bag. VIII. Pharmacology, page 15

Toxicological Antidote Kit Contents : 

Toxicological Antidote Kit Contents VIII. Pharmacology, page 16

Slide 159: 

IX. Appendix, page 1 Glascow Coma Score A score of 13 correlates with a Mild Brain Injury. 9-12 is Moderate. 8 or less is Severe. 3 usually equates to Death. Response Value

APGAR Scoring Table : 

APGAR Scoring Table The APGAR scoring system is widely used as an indicator of the need for resuscitation of the newborn. Five objective signs (Appearance/color, Pulse, Grimace/reflex, Activity/muscle tone, Respirations) are evaluated and the total score is noted at 1 minute and at 5 minutes after the complete birth of the infant. If the 5-minute APGAR score is less than 7, additional scores are obtained every 5 minutes for a total of 20 minutes. The heart rate of the newborn is determined by listening to the chest with a stethoscope or by feeling the cord stump for arterial pulsations. Respiratory activity is judged by the newborn’s breathing efforts and rate. Muscular tone is best seen in the extremities in response to stimulation. Reflex activity is best evaluated during suctioning of the naso- and oropharynx or when handling of the infant. Most newborns score only 1 for color both at one and five minutes of age, as there is always some degree of peripheral cyanosis (acrocyanosis). The need for immediate resuscitation can be more rapidly assessed by evaluating the heart rate, respiratory activity and color, than by the total APGAR score. Since even a short delay in initiating resuscitation may result in a long delay in establishing spontaneous and regular respirations, resuscitation should be started immediately when indicated by inadequate respirations and/or heart rate. It should not be delayed while obtaining the one- minute score. IX. Appendix, page 2

APGAR Scoring Table : 

APGAR Scoring Table IX. Appendix, page 3

Cricothyrotomy – Shiley tube and scalpel (Adults) : 

Cricothyrotomy – Shiley tube and scalpel (Adults) NOTE: Surgical cricothyrotomy is contraindicated in children less than 12 years of age. Cricothyrotomy is an emergency lifesaving procedure. It is an invasive technique that allows rapid entrance into the airway for temporary ventilation and oxygenation in those patients in whom airway control is not possible by other methods. It is indicated to relieve partial or complete upper airway obstruction when all other manual maneuvers for improving the airway have been used without success. Direct visualization with a laryngoscope should be attempted to improve the airway by using Magill forceps to remove the foreign body if indicated. When the diagnosis of a severe upper airway obstruction is made and the decision is made to do a cricothyrotomy, the following procedures should be followed: Hyperextend the patient’s neck (unless cervical spine injury is suspected). This position brings the larynx and cricothyroid membrane into the extreme anterior position. Locate the cricothyroid membrane between the cricoid and thyroid cartilages by palpating the depression caudal (towards the feet) to the midline Adam's Apple. Clean the area well with Betadine solution. Using a scalpel, make a vertical incision just large enough to accommodate a Shiley tube through the cricothyroid membrane. Once the scalpel has passed into the membrane, insert the handle into the opening and twist the handle to open a space between the cricoid and thyroid cartilages. It is important not to aim the knife cephalad (toward the head), since injury to the vocal cords may occur. Insert a Shiley tube caudally through the incision. Ventilate the patient with a bag-valve unit or ventilator at the highest available oxygen concentration. Auscultate lung sounds for proper tube placement. If present, inflate the cuff with 10 cc of air and secure the tube. IX. Appendix, page 4

Cricothyrotomy – Melker Style (less than 12 years of age) : 

Cricothyrotomy – Melker Style (less than 12 years of age) This procedure may be used to relieve an upper airway obstruction after unsuccessful attempts at establishing an airway. Pre-procedure Recommendation Patients with airway injuries may have significant spinal injuries. The C-spine should be immobilized before beginning the procedure in trauma patients. Care should always be exercised to avoid additional spinal injuries. Whenever possible and appropriate, utilize aseptic technique and local anesthetic for the procedure. The Melker emergency transcricothyrotomy catheter is stocked for pediatrics. The pediatric Melker emergency transcricothyrotomy catheter set should not be used on a child unless the landmarks (the cricothyroid membrane between the cricoid and thyroid cartilage) can be felt (usually not before a child is between 6 and 8 years old). Identify the cricothyroid membrane between the cricoid and thyroid cartilages. If the structures cannot be identified, DO NOT perform this procedure. Carefully palpate the cricothyroid membrane and, while stabilizing the cartilage, make a vertical incision in the midline using the #15 short handle Scalpel blade. An adequate incision eases introduction of the dilator and airway. Advance the handled dilator, tapered end first, into the connector end of the airway catheter until the handle stops against the connector. Use of lubrication on the surface of the dilator may enhance fit and placement of the emergency airway catheter. Fix the emergency airway catheter in place with the cloth tracheostomy tape in a standard fashion. Connect the emergency airway catheter, using its standard 15-22 adapter to an appropriate ventilatory device. If the Melker Device is not available, use a catheter over needle device as an alternative. IX. Appendix, page 5

Pleural Decompression : 

Pleural Decompression A suspected tension pneumothorax may not necessarily require field treatment. The conservative management of a tension pneumothorax is oxygen, ventilatory assistance and rapid transport. The indication for performing emergency chest decompression is the presence of a tension pneumothorax with decompensation. Decompensation is defined as the presence of more than one of the following: Respiratory distress and cyanosis. Loss of radial pulse (decompensated shock.) Decreasing level of consciousness. The patient with a tension pneumothorax may exhibit any or all of the following signs and symptoms: Shortness of breath Chest pain Cyanosis Deviation of the trachea (may not always be present) Tympany (hyperresonance) on the side of the pneumothorax Wide changes in the blood pressure with respirations Diminished or absent breath sounds on the side of the suspected tension pneumothorax Loss of breath sounds on one side does not necessarily indicate a tension pneumothorax Reduced blood pressure Neck vein distention (may not be present if there is associated severe hemorrhage) Shock If the patient’s condition is markedly deteriorating, vital signs are poor, respirations inadequate, and it appears that a life or death situation exists, pleural decompression should be performed according to the following procedures: Administer high flow oxygen and ventilatory assistance, if indicated. IX. Appendix, page 6

Pleural Decompression : 

Pleural Decompression Identify the 2nd and 3rd intercostal space in the mid clavicular line on the same side as the pneumothorax. Prep the area with Betadine solution. Insert a 2 ¼”, 14 or 16 gauge, catheter with a syringe attached into the skin at the mid clavicular line between the 2nd and 3rd intercostal space, and direct it just over the top of the rib (superior border) into the intercostal space. Insert the catheter through the parietal pleura until air escapes. It should exit under pressure. Remove the needle and syringe, leaving the plastic catheter in place. Connect a HEIMLICH CHEST DRAIN VALVE, if available, or a section of IV tubing to the catheter and create an under water seal with the distal end of the tubing. Leave in place until it is replaced by a chest tube at the hospital. IX. Appendix, page 7

Transcutaneous Pacemaker : 

Transcutaneous Pacemaker Monitor the patient EKG via chest lead cables. Attach the pacer electrodes to the patient. Follow manufacturer guidelines of your particular machine to establish pacing. SET the PACE RATE control to the rate of 80 beats per minute. Bradycardic Conscious Patients SET the OUTPUT amplitude control to zero (0) milliamps. Turn the mode control to the DEMAND mode. The PACE light should flash with each issued pace pulse. Slowly increase the setting of the OUTPUT amplitude control until capture is achieved. Capture should be verified by palpating the carotid or femoral pulses. Once capture has been determined, the amplitude is increased by approximately 5-10 percent. May give Versed (see Versed Protocol, Appendix, page 39), for patient comfort if the lowest output causes patient agitation, up to 10 mg titrate to effect. Bradycardic Unconscious Patients SET the OUTPUT amplitude control to maximum milliamps. Turn the mode control to the DEMAND mode. The PACE light should flash with each issued pace pulse. Determine if pulses are present. If pulses have been verified, decrease the amplitude output to the lowest energy needed to sustain capture. Once the lowest energy is determined, increase the amplitude output by 5-10% If the patient regains consciousness, turn the OUTPUT milliamps down to the lowest level while still maintaining capture. IX. Appendix, page 8

Transcutaneous Pacemaker : 

Transcutaneous Pacemaker Symptomatic Bradycardia and some cases of Asystole SET the OUTPUT amplitude control. Turn the mode control to the FIXED mode. Determine if pulses are present. If pulses have been verified, decrease the amplitude output to the lowest energy level needed to sustain capture. Once the lowest energy is determined, increase the amplitude output by 5-10% CPR should be continued if pulses are not detected with the pacer. Continue Asystole Protocol. NOTE: Regarding Electrical Safety Considerations Linens that have become wet during emergency resuscitation should be changed as soon as possible to prevent the possibility of conducting an electric current from the pacemaker. The pacemaker should only be used in dry situations. IX. Appendix, page 9

Pulse Oximeters : 

Pulse Oximeters Definition: Pulse oximeters are used for the detection of hypoxemia in arterial oxyhemoglobin. Indications: Patients complaining of history of: Respiratory distress or disease Cardiac conditions Neurological problems To monitor distal oxygenation of extremity fractures and dislocations. Patients treated and/or transported with oxygen. Precautions Patients with carbon monoxide inhalation may yield slightly higher oxygen saturation readings than actual blood oxygen saturation. Patients wearing false fingernails may affect the accuracy of the reading when the finger probe is used. Low flow states, such as severe hypotension, cardiac arrest, etc. will cause the pulse oximeter to not register. Procedure Attach appropriate sensor to patient. Turn unit on. A valid reading is indicated by a continuous accurate reading of pulse rate and consistent steady percent saturation reading. Print the saturation reading. Oxygen therapy should be guided by the pulse oximeter percent SAO2 reading and the ALS Protocols. Remember that, in general, a 90% SAO2 corresponds to a PO2 of 60, a minimum acceptable level. Apply appropriate amount of oxygen according to ALS Protocols. Contact supervising physician for further guidance. Document the saturation and give the reading in the encode. Type of sensor used and sensor placement should be documented on the rescue report. Save strip for documentation purposes. IX. Appendix, page 10

CO2 Detector : 

CO2 Detector Definition: The End-Tidal CO2 Detector attaches to the endotracheal ET tube and a breathing device (or may be made into the BVM or ATV circuit) (e.g. BVM/Demand Valve) to detect approximate ranges of End-Tidal CO2 by color comparison for up to two hours. Indications: To assist verification of endotracheal tube placement after intubation and during transport. To detect approximate ranges of End-Tidal CO2 when clinically significant. Cautions: Interpreting results before administering six breaths can yield false results {initial detector color may yield a false positive (yellow)}. Results are not conclusive, the endotracheal tube should be immediately removed unless correct anatomic placement can be confirmed with certainty by other means. This device should not be used in conjunction with a heated humidifier or nebulizer. Excessive humidity will affect accuracy. In cardiac standstill, re-establishment of cardiac output and pulmonary perfusion by adequate cardiopulmonary resuscitation is necessary to increase End-Tidal CO2 levels detectable by the CO2 Detector. The chemical indicator may become mottled or irreversible yellow after Epinephrine is instilled into the ET tube and/or after any liquid (gastric contents, pulmonary edema) passes through the barrier. Remove the device and replace with a new device if this occurs. This device cannot be used to detect oropharyngeal tube placement. Standard clinical assessment should be used. Use an appropriate CO2 indicator based on patient weight. For patients weighing less than 30 lbs. Use a pediatric size. Document the CO2 color change. IX. Appendix, page 11

Capnography : 

Capnography Capnography is the comprehensive, quantitative measurement and display of carbon dioxide, including end-tidal, inspired, and the real-time CO2 waveform. Capnography is used to: Validate end-tidal CO2 values; assess airway patency; assessment of ventilator, breathing circuit and gas sampling integrity; and verification of proper endotracheal tube placement. Indications To assist verification of endotracheal tube placement after intubation and during transport. To quantitatively detect ranges of End-Tidal CO2 when clinically significant. Normal Pa CO2 is 35-45 mm Hg. Document the end tidal CO2 level and the wave form. IX. Appendix, page 12

Intraosseous Cannulation - Pediatric : 

Intraosseous Cannulation - Pediatric Intraosseous infusion uses the rich vascular network of the long bones to transport fluids and drugs from the medullary cavity to the circulation. The medullary cavity is composed of a spongy network of venous sinusoids that drain into a venous canal. Fluids or drugs injected into the medullary space rarely diffuse more than a few centimeters before entering the venous circulation. Indications The procedure for intraosseous cannulation should be limited to those occasions when intravenous access cannot be obtained or in which the time to establish IV access may significantly alter the chances of survival. Cardiac arrest is the most common indication; others include shock, extensive burns, major trauma, and situations where IV access is deemed essential. Clinical Applications Intraosseous infusion is useful for emergency administration of medications. Drugs should be given in the same dose as with the intravenous route; fluids are given at the same rate. Although it is not the best course of action, intraosseous infusion may be used for volume replacement. Intraosseous infusion should be used only until venous access is obtained. NOTE: After drug administration, a 10 cc bolus of NaCl should be infused to enhance absorption. Complications Though a relatively safe procedure, the following are possible complications that may be experienced: The needle may become obstructed with bone or marrow. The needle is accidentally forced through the opposite side of the bone. Extravasation of fluid around the puncture site (usually minor). Extravasation of fluid from fractures or previous attempts. Potential for osteomyelitis. IX. Appendix, page 13

Intraosseous Cannulation - Pediatric : 

Intraosseous Cannulation - Pediatric Intraosseous Cannulation Procedure The EX-IO product system is approved for patients weighing 40 kg and greater using the EZ-IO AD and for patients weighing between 3 and 39 kg using the EZ IO PD. Locate the anterior medial surface of the proximal tibia. Palpate the tibial tuberosity with the index finger, and grasp the medial aspect of the tibia with the thumb. Halfway between these two points is the optimal point for needle insertion (1 to 2 cm distal to the tibial tuberosity). The needle (using sterile technique) should be inserted perpendicularly or slightly inferiorly to avoid the epiphyseal plate. Using the drill to insert the needle with the bevel pointing away from the joint space until a slight decrease in resistance is noted, indicating that the cortex of the bone has been punctured. The IO solution is Normal Saline only. IX. Appendix, page 14

EZ IO Adult Intraosseous Cannulation : 

EZ IO Adult Intraosseous Cannulation PURPOSE: To obtain rapid circulatory access in order to administer emergency fluids and medications where attempts at IV access have been unsuccessful INDICATIONS: It should be considered for use in any seriously ill or injured patient in whom rapid IV access cannot be established. Any fluids or medications that can be given intravenously can be given via the intraosseous route. The EZ IO product system is approved for patients weighing 40 kg and greater using the EZ-IO AD and for patients weighing between 3 and 39 kg using the EZ-IO PD. The needle can safely remain in place for up to 24 hours post-insertion Prior to IO flush on alert adult patients, SLOWLY administer 40mg (or 2mLs) 2% IV Lidocaine through the EZ-IOTM hub. CONTRAINDICATIONS: Fracture of the tibia or humerus Previous orthopedic procedures Infection at the insertion site Inability to locate landmarks Excessive tissue over the insertion site IX. Appendix, page 15

EZ IO Intraosseous Cannulation : 

EZ IO Intraosseous Cannulation PROCEDURE: Locate the anatomical site and cleanse the insertion site 3 times with Betadine using a circular motion beginning at the insertion site and circling outward. If the patient is awake and aware of pain, infiltrate the site (just below the dermis) with 1-2 cc’s of 2% Lidocaine. Load the needle onto the driver Firmly stabilize the entire insertion site Firmly press the needle against the site at a 90 degree angle and operate the driver. Use firm, gentle pressure As the needle reaches the bone, stop and be sure that the 5mm marking on the needle is visible; if it is, continue to operate the driver When a sudden decrease in resistance is felt and the flange of the needle rests against the skin, remove the driver and remove the stylet from the catheter. Do not attempt to aspirate bone marrow (may clog needle and tubing) Use a syringe to infuse Normal Saline to ensure patency of the system If there is no evidence of infiltration, attach the IV line and infuse fluids and medications as indicated. IV fluids will need to be infused under pressure either with a pump or pressure device around the bag of fluids. Secure the needle and dress the site If requested to assist in the removal of the device, the following procedure is to be used: Firmly grasp the needle flange, or attach a luer lock syringe to use as a handle Pull the catheter straight out at a 90 degree angle to the skin Clean and dress the site IX. Appendix, page 16

CPAP : 

CPAP Continuous Positive Airway Pressure (CPAP) is used to increase airway pressure. The increased pressure opens alveoli that have collapsed due to increased surface tension in the alveoli. The re-expanded alveoli provide increased useable alveolar surface area to improved gas exchange across the alveolar-capillary membrane. Indications: CPAP is indicated for the treatment of moderate to severe Pulmonary Edema/CHF as evidenced by: Hypoxia: SaO2 less than 90% after treatment with 100% O2 Diaphoresis (the classic symptom) Tachypnea (Respirations greater than 20/minute) Accessory muscle use and increased use of breathing   Note: Crackles (rales) in the lungs may or may not be heard and are often unreliable. Fever greater than 100 may indicate pneumonia -- not PE Dry mucosal membranes indicate dehydration and/or sepsis – not PE.  Mild symptoms/CHF: (No accessory muscle use; no respiratory distress) may not require CPAP. Follow Acute Pulmonary Edema protocol  More Severe Symptoms/Respiratory Distress/Florid PE usually requires CPAP. Follow Acute Pulmonary Edema protocol.     Contraindications: CPAP with fixed PEEP of 10 cmH2O is contraindicated in COPD or asthma. .   CPAP is contraindicated in hypotension (BP systolic <100 mm Hg). CPAP causes an increase in intrathoracic pressure, which in turn reduces venous return to the right atrium.   Patients with an altered mental status, inability to protect their airway, and patients remaining hypoxic require intubation, not CPAP IX. Appendix, page 17

CPAP : 

CPAP Contraindications: CPAP with fixed PEEP of 10 cmH2O is contraindicated in COPD or asthma. CPAP is contraindicated in hypotension (BP systolic <100 mm Hg). CPAP causes an increase in intrathoracic pressure, which in turn reduces venous return to the right atrium.   Patients with an altered mental status, inability to protect their airway, and patients remaining hypoxic require intubation, not CPAP  Procedure: Ensure the patient meets criteria for use. Prepare equipment (including installation of air filter) and have a full, spare O2 tank with regulator and quick disconnect at patient’s side. Attach CPAP to an oxygen source. Open oxygen; and place mask on patient with circuit in place. Patient is now receiving 100% FiO2. Gradually increase the PEEP to 5 cm of H2O and then titrate to patient relief, not to exceed 10 cm of H2O. Some patients may require the full 10 PEEP, while others may require less pressure to attain relief. After fitting, and oxygen is flowing, install PEEP valve. Reassess for proper seal by adjusting the straps and/or inflating the mask. Nitroglycerine spray may be administered prior to CPAP application. Removing CPAP defeats the alveolar “splinting” effect. Follow Acute Pulmonary Edema Protocol for appropriate medications. Decreased severity of symptoms usually occurs within 2-3 minutes of CPAP administration. Do not discontinue CPAP unless patient does not improve. If no improvement is noted, patient may need to be intubated. Once the patient is turned over to the care of the medical center, reset the CPAP’s PEEP back to zero for use by the next patient. IX. Appendix, page 18

CPAP : 

CPAP Contraindications: CPAP with fixed PEEP of 10 cmH2O is contraindicated in COPD or asthma. CPAP is contraindicated in hypotension (BP systolic <100 mm Hg). CPAP causes an increase in intrathoracic pressure, which in turn reduces venous return to the right atrium.   Patients with an altered mental status, inability to protect their airway, and patients remaining hypoxic require intubation, not CPAP  Procedure: Ensure the patient meets criteria for use. Prepare equipment (including installation of air filter) and have a full, spare O2 tank with regulator and quick disconnect at patient’s side. Attach CPAP to an oxygen source. Open oxygen; and place mask on patient with circuit in place. Patient is now receiving 100% FiO2. Gradually increase the PEEP to 5 cm of H2O and then titrate to patient relief, not to exceed 10 cm of H2O. Some patients may require the full 10 PEEP, while others may require less pressure to attain relief. After fitting, and oxygen is flowing, install PEEP valve. Reassess for proper seal by adjusting the straps and/or inflating the mask. Nitroglycerine spray may be administered prior to CPAP application. Removing CPAP defeats the alveolar “splinting” effect. Follow Acute Pulmonary Edema Protocol for appropriate medications. Decreased severity of symptoms usually occurs within 2-3 minutes of CPAP administration. Do not discontinue CPAP unless patient does not improve. If no improvement is noted, patient may need to be intubated. Once the patient is turned over to the care of the medical center, reset the CPAP’s PEEP back to zero for use by the next patient. IX. Appendix, page 19

CPAP : 

CPAP If so equipped and there has been improvement, as defined by decreased respiratory rate and /or heart rate, increase in the SaO2, reduced verbal impairment, improvement in mental status or overall patient condition, then continue CPAP and decrease the FiO2 to a level that will sustain an SaO2 greater than 90. Even if the FiO2 is set to its lowest setting, the Down’s flow generator is still delivering 33% FiO2.) Prepare the ER early on in the treatment sequence by advising the receiving hospital that you are requesting a “CPAP machine and respiratory therapist” in the ER to receive the patient. Keep the Ohio and Chemetron wall adapters with quick connect fittings on hand to facilitate patient transfer. Early notification gives the RT time to assemble the CPAP / BIPAP and arrive at the ER in time to accept your patient. The wall adapters are provided for continual use of CPAP until the ED is prepared to transfer the patient onto their CPAP/BIPAP device. Certain CPAP kits contain: Down’s flow generator Particle air filter for intake Green high pressure O2 hose Corrugated O2 tubing with attached CPAP mask Head strap 10cm/H2O PEEP valve 30cc syringe, Ohio and Chemetron adapters for hospitals IX. Appendix, page 20

Slide 179: 

Continuous Positive Air Pressure CPAP Flow Generator TIZ04 and CRHI63 Connections Connective Flex Tubing Face Mask 10cm ACCU-PEEP threshold resistance attachment Low-pressure Hose Filter OXYGEN IX. Appendix, page 21

Nitronox Protocols : 

Nitronox Protocols Nitronox is a mixture of 50% nitrous oxide and 50% oxygen. Indication Pre-hospital relief of pain, particularly for musculoskeletal injuries, fractures, and burns. Contraindications Any altered level of consciousness, i.e., alcohol intoxication or drug overdose. Head injury. Hypotension or shock. Minors (under the age of 18). COPD. Acute P.E. Chest trauma, especially pneumothorax. Nausea and vomiting. Pregnancy Elderly patients with hip fractures. Patients unable to understand instructions for Nitronox use. Severe abdominal pain and distention suspicious of bowel obstruction. After the above conditions have been excluded, nitrous oxide may only be self-administered by the patient. All vital signs are to be monitored frequently and documented. Document duration of nitrous oxide administration in the medical report. If the patient’s vital signs become unstable or the patient becomes symptomatic from the side effects, discontinue nitrous oxide administration. Whenever nitrous oxide is administered to a patient, the patient will be transported by the ALS unit administering the drug. Patients will not be released to a BLS unit for transport. IX. Appendix, page 22

Nitronox Protocols : 

Nitronox Protocols An IV of Lactated Ringers should be started in patients who are candidates for Nitronox use. Nitronox should be considered a drug and as with any drug, complications may develop. Proper precautions should always be taken. Operational concerns: Prior to opening the nitrous bottle, invert the bottle several times. All exhaust fans in the truck’s patient compartment must be on during nitrous oxide use to prevent nitrous oxide accumulation in the truck. IX. Appendix, page 23

Morgan Therapeutic Lens Insertion : 

Morgan Therapeutic Lens Insertion Instill topical local anesthetic to the affected eye. Irrigate the eyes with a minimum of 2,000 cc of Normal Saline or Lactated Ringers. Have the patient look down, insert edge of the lens under the upper lid. Have the patient look up, retract the lower lid. Release lower lid over the lens and continue flow. Tape tube and adapter to patient’s forehead to prevent accidental lens removal. Absorb outflow with towels. Removal Have patient look up. Retract lower lid behind interior border of the lens. Hold position. Have patient look down, retract upper lid and slide lens out. Contraindication The Morgan Lens is contraindicated in patients with injured globe. IX. Appendix, page 24

Do Not Resuscitate Orders : 

Do Not Resuscitate Orders Do No Resuscitate Orders, Initiation & Discontinuance of CPR, Living Wills Do Not Resuscitate Orders: Properly executed Do Not Resuscitate Orders (DNRO) in accordance with Chapter 401, Florida Statutes, will be honored provided the following conditions are met: Is presented on a valid pre-hospital DNRO – Florida HRS Form 1896, or a Florida DNRO bracelet (worn by the patient, must contain the patient’s Name, Social Security Number, attending physician’s name and phone number, and effective date of the order); OR Is presented a DNRO document from a facility licensed pursuant to Chapter 393, 395, or 400 Florida Statues; OR The DNRO-Florida HRS Form 1896 also comes in a wallet-sized card complete with identical information to the long form To be considered valid, the DNR must meet the following criteria: The form states that it is a DNRO and specifies that the patient is not to be resuscitated. Original is signed and dated by the patient’s physician. Photocopies are acceptable. The form has been signed and dated by the patient or the patient’s surrogate or proxy, if applicable. The DNR order is not withdrawn by the patient, the patient’s attending physician, or the patient’s healthcare surrogate or proxy. Identity is verified by the driver’s license, other photo identification, or from a witness in the presence of the patient. If a witness is used, this shall be documented in the run report to include: Full name of the witness, address, telephone number, and relationship to the patient. DNRO must accompany patients transported to hospitals. IX. Appendix, page 25

Do Not Resuscitate Orders : 

Do Not Resuscitate Orders Initiation of CPR CPR should be initiated in all cases where the patient is found in cardiopulmonary arrest, unless special criteria apply. If at least one of the following conditions are found, CPR may be withheld: Lividity Rigor mortis Blunt or penetrating trauma found without signs of life Decomposition A valid DNRO is discovered Known down time greater than twenty minutes; asystole; pupils fixed and dilated; no respirations; and without hypothermic mechanism for arrest. Document the time and the applicable clinical criteria or DNRO. Special Situations Triage Situations – When there are multiple critical trauma casualties and insufficient resources, choices will have to be made in resource allocations. Physician in attendance – The patient’s physician is in attendance and requests that the patient be given limited or no resuscitative effort. Document the name of the physician and the time the order was given. This order, verbal or in writing, must be given by a Florida licensed MD or DO to be legal. If a special situation arises where the patient remains asystolic (confirmed in two (2) leads) despite appropriate resuscitative efforts, and other causes of refectory asystole have been excluded (i.e. hypothermia), the paramedic may refer to Guideline for Field Termination of Resuscitation. IX. Appendix, page 26

Do Not Resuscitate Orders : 

Do Not Resuscitate Orders Discontinuing CPR If CPR had been initiated and a valid DNRO is discovered, resuscitation efforts should cease. If necessary, contact Medical Director for assistance. When EMS withholds CPR because of a DNRO, a copy of the DNRO itself should be made and attached to the trip report. The presentation of a valid DNRO does not relieve EMS of the responsibility to provide interventions in the non-arrested patient, short of intubation and defibrillation. Other medically indicated and comforting care and therapy should be initiated. Pain relieving measures may be particularly appropriate in such cases. Living Wills Do not confuse DNRO with living wills, which serve an entirely different purpose and may not influence the acute application of resuscitation. In general, a living will is made prior to a terminal condition while a patient is in good physical and mental health. While this prior declaration may assist a physician in charting a course of treatment for a critically ill patient, EMS personnel cannot substitute it for a DNRO. A living will is not the same as a physician’s DNRO, and can be respected only when accompanied by a DNRO. The paramedic is legally obligated to provide the level of care commensurate with the situation, based on their knowledge that the patent is in need of such care. IX. Appendix, page 27

Do Not Resuscitate Form : 

Do Not Resuscitate Form

Pediatric Intubation : 

Pediatric Intubation The pediatric patient is very reliant on oxygen with hypoxemia the major cause of cardiopulmonary arrest in the age group. Delivery of oxygen in the highest tolerable concentration is indicated with endotracheal intubation the most definitive delivery method. Use of the LMA or BVM is an acceptable alternative airway device in Pediatrics. The following rules are to be followed when intubating the pediatric patient: The endotracheal tube can be sized by several methods to include the Broselow Tape, size of the nares or pinky finger. Remember to ready not only the indicated size, but also a tube, which is 0.5 mm in the next larger and smaller size. (This is especially important in smaller children when the uncuffed tube is utilized relying on an anatomical seal.) The anatomy of the airway is different than the adult patient and very apparent vocal cords may not be anticipated. Due to the over-abundance of tissue in the posterior pharynx in infants, the tracheal opening may simply present as the anterior opening found in the sub-glottic region. Anytime the pediatric patient is intubated, or prolonged bag-valve-mask ventilation (more than 3 minutes) occurs, a nasogastric or orogastric tube will be inserted (see Appendix, page 31). (This procedure will insure that gastric distention is relieved and maximum ventilatory support is achieved.) The endotracheal tube (ET) will be secured with ETT holder as soon as correct placement is assured by auscultation of lung sounds. Do not let go of the ET during this process! The most experienced crew members should be charged with airway control and great care should be exercised when moving the patient from one surface to another in order to assure that accidental extubation does not occur. IX. Appendix, page 29

Pediatric Intubation : 

Pediatric Intubation When assessing the child for intubation complications (bradycardia, cyanosis, etc.) remember to assess in order of the following causes: Equipment failure (O2 supply, BVM reservoir, etc.) Blocked ET (kinked, secretions in the tube, etc.) Displaced ET (right mainstream, esophagus, etc.) Pneumothorax (spontaneous, trauma, etc.) IX. Appendix, page 30

Nasogastric or Orogastric Tube Insertion : 

Nasogastric or Orogastric Tube Insertion Nasogastric or Orogastric Tube insertion is indicated to relieve gastric distention in the ventilated patient who meets the following criteria: The adult patient with noticeable gastric distention that interferes with ventilatory support. Any pediatric patient that is intubated or receives long-term (greater than 3 minutes) ventilation by bag-valve-mask. NOTE: This procedure should not be performed in cases of ingestion of caustic substances or history of esophageal varices. In the presence of frontal head trauma or where the cribiform plate may be fractured, place the tube through the mouth. The procedure will be performed as follows: Ready the proper size tube, 60 cc syringe, water soluble lubricant and tape. Adult: 16 french Pediatric: 6-16 french as indicated by Broselow Tape Measure the tube by placing over the stomach region and extend to the ear and then to the nose. (Note tube mark at this time.) Lubricate the end of the tube and insert into the largest nares, advancing until the tube mark noted above is at the nares opening. Verify placement by auscultating epigastric sounds while inserting 20-30 cc of air. Tape in place and note depth of tube on the run report. IX. Appendix, page 31

Ventilator (ATV) : 

Ventilator (ATV) ATV’s are indicated for use when a patient requires administration of 100% oxygen in situations such as: Cardiac arrest Near drowning Respiratory arrest Smoke inhalation Periods of acute cardiopulmonary instability Toxic gas inhalation Carbon monoxide poisoning Shock While it is preferred to have patient intubated in such situations, the ATV does not require intubation. It can be operated with a well-sealed face mask and airway adjuncts, i.e., Combi-tubes. Operating Instructions Connect supply hose to oxygen regulator. SET Breaths Per Minute (BPM) and Tidal Volume appropriate for patient: ADULT: Normal resuscitation rate = 10 BPM Head injured rate = 12 BPM CHILD: Normal resuscitation rate = 20 BPM Adult and Child Tidal Volume Tidal Volume (TV) = 7 ml/kg NOT TO EXCEED 1 LITER In patients that are significantly overweight, the standard 7 ml/kg calculation will give an artificially high TV. Therefore, Tidal Volume (TV) to be delivered should be based upon “Lean Body Mass”. To correct this calculation in overweight patients, use the following formula based upon average lean body weights (see table); base standard height of 5 feet = 50 kg + 3 kg for each inch of height greater than 5’. Example: Pt. Is 5’6” = 50 kg + 18 kg (wherein 18 kg is obtained by 6” x 3 kg/in) = 68 kg x 7 ml/kg = 476 ml. Round off to the nearest 50 ml setting on the ventilator = 500 ml. Connect ATV Patient Valve to oxygen respirator circuit. IX. Appendix, page 32

Ventilator (ATV) : 

Ventilator (ATV) Open oxygen cylinder valve. Connect circuit to airway device, i.e., ETT, Combitube, or face mask. Observe patient for equal chest rise. Ensure rate and volume are properly set; time number of ventilations/minute; and adjust as appropriate. Monitor patient at ALL times. If audible alarm sounds or other problems occur, take appropriate corrective action by manually ventilating patient with BVM until problem is identified and resolved. Table of Tidal Volume based on height and average lean body weight 5’0” – 5’1” 400 ml 5’2” – 5’3” 450 ml 5’4” – 5’5” 500 ml 5’6” – 5’7” 500 ml 5’8” – 5’9” 600 ml 5’10-5’11” 650 ml 6’0” – 6’1” 700 ml 6’2” – 6’3” 700 ml >6’3” 750 ml IX. Appendix, page 33

Rapid Sequence Intubation – Succinylcholine Emergency Intubation with Induced Paralysis : 

Rapid Sequence Intubation – Succinylcholine Emergency Intubation with Induced Paralysis WARNING: ONLY PARAMEDICS HAVING RECEIVED PRIOR APPROVAL AND TRAINING BY THE MEDICAL DIRECTOR ARE ALLOWED TO PROCEED WITH THIS PROTOCOL. Indication To facilitate endotracheal intubation when other methods to secure an airway have failed due to factors such as clenched teeth, gag reflex, etc. Contraindications When intubation is predicted to be difficult or impossible due to anatomic factors Patients that cannot be ventilated by bag-valve-mask Penetrating eye injuries Victims of trauma or burns greater than five days old Patients with a known or family history of malignant hyperthermia Skeletal muscle disease Organophosphate poisoning Known hypersensitivity to the drug Extensive injury or disease of muscle or nerves Severe hyperkalemia Glaucoma Dose – Adults 1 mg/kg rapid IV Push Dose - Children Less than 13 years: 1.5 mg/kg IV Push Pre-medicate children between 1 and 5 years of age with Atropine (to prevent bradycardia) Atropine Dose: 0.02 mg/kg IV Push (max. dose 1 mg) IX. Appendix, page 34

Rapid Sequence Intubation – Succinylcholine Emergency Intubation with Induced Paralysis : 

Rapid Sequence Intubation – Succinylcholine Emergency Intubation with Induced Paralysis Rapid Sequence Intubation Procedure Prepare Suction, Intubation, Combitube, and Cricothyrotomy equipment. Monitor EKG, respiratory rate and dept, and oxygen saturation using pulse oximetry. Oxygenate the patient with 100% Non-Rebreather Mask or, if necessary, a Bag-Valve-Mask (BVM may cause over distension of the stomach and increase the risk of subsequent aspiration) for two minutes (if practical). ADMINISTER: Etomidate 0.3 mg/kg – (Average dose for 70 kg patient is 20 mg IVP; Not to be given to children under 10 years old). Attempt intubation. If intubation is successful after administering Etomidate, do not give Succinylcholine. ADMINISTER: Adults: 1 mg/kg Succinylcholine IV Push. Children less than 13 years old: 1.5 mg/kg IV Push. Premedicate children less than 5 years with Atropine 0.02 mg/kg IV Push. (Maximum Atropine Dose 1.0 mg). Apply Cricoid Pressure (SELLICK’S MANUEVER) to prevent reflux of gastric contents until the intubation has been successful and the cuff is inflated. The cervical collar on a trauma patient may have to be temporarily removed to provide access to the neck. If the patient does vomit, Cricoid Pressure should be released and the airway actively suctioned. Intubate and inflate the cuff as soon as practical. The medication takes effect in 45-60 seconds. Ventilate the patient with 100% oxygen. Confirm ET Tube placement by auscultation, chest rise, and CO2 detector. IX. Appendix, page 35

Rapid Sequence Intubation – Succinylcholine Emergency Intubation with Induced Paralysis : 

Rapid Sequence Intubation – Succinylcholine Emergency Intubation with Induced Paralysis If intubation attempts are unsuccessful and you are unable to adequately ventilate and oxygenate the patient with the bag-valve-mask, consider securing a definitive airway by other means, i.e., Combitube, Cricothyrotomy, and Lighted Stylet with ETT. Treat bradycardia during intubation by temporarily stopping the attempt. Hyperventilate the patient with BVM and 100% oxygen. If the patient remains bradycardic, consider Atropine 0.5 mg IV. If sedation is necessary, administer Versed (see Versed protocol, Appendix, page 39). When longer term paralysis is necessary after successful intubation with RSI, for the safety of the patient or crew, the patient my be paralyzed with Vecuronium (Norcuron). Ensure that the ET tube is in proper postion and secured. Administer Vecuronium 0.05mg/kg IV. This will provide an additional 30 minutes of paralysis. This may be repeated once. When vecuronium is administered after succinylcholine, the administration of vecuronium should be delayed until the patient starts recovering from succinylcholine-induced neuromuscular blockade. For each incident where RSI including Etomidate only and/or Succinylcholine and/or Vecuronium is used, complete an RSI form and fax a copy to the Medical Director. Attach the original copy to the medical report. IX. Appendix, page 36

Emergency Intubation & Rapid Sequence Intubation Report Form : 

Emergency Intubation & Rapid Sequence Intubation Report Form Department: Case #: Date: Time: Indication for Procedure: [ ] Jaw Clenched [ ] Gag Reflex [ ] Combative Patient Needing Intubation [ ] Other (specify)________________________ Call Type: [ ] Trauma [ ] Medical [ ] Head Injury [ ] Pediatric Patient Information: Age: Weight: kg Dosage Administered: _____ mg of Succinylcholine;____ mg of Etomidate; _____ mg of Vecuronium;_____mg of Versed Additional Medications Used: [ ]Lidocaine [ ] Atropine Intubation: [ ]Successful [ ]Unsuccessful If Unsuccessful, Reason:____________________________________________________ If Unsuccessful, Adjunct Used: [ ]Cricothyrotomy [ ]BVM Only [ ]LMA Additional Comments:____________________________________________________ Administering Paramedic Name: ID#: Signature: Date: ***FAX TO DR. WOLFF (561) 243-7475*** IX. Appendix, page 37

Esophageal Intubation Detector : 

Esophageal Intubation Detector Indication To assist verification of placement of the endotracheal tube in the trachea. The device is to be used in conjunction with a CO2 detector, capnographer, auscultation of bilateral breath sounds, and clinical judgement. The esophageal intubation detection device must be used in all cases of difficult intubation where tube position is in question. Procedure Perform leak test. Place a gloved finger over the end of the device and attempt to move air through. Discard if an air leak is detected. Immediately after intubation, and before ventilating the patient with a bag-valve-mask, retract the plunger. Caution: Ventilating the patient with a B.V.M. prior to using this device may cause the esophagus to fill with air and therefore give unreliable results. If air returns and fills the syringe completely: The endotracheal tube is likely in the trachea. If air does not fill the syringe immediately, gastric contents return or resistance to retraction occurs: The endotracheal tube is likely in the esophagus. Extubate the patient and ventilate with a bag-valve-mask prior to intubating. Contraindications Children less than five years old or less than 44 pounds. IX. Appendix, page 38

Versed Protocol (Midazolam) : 

Versed Protocol (Midazolam) Indications: Conscious sedation for procedures such as cardioversion, sedation or control of seizures. Contraindications: Hypersensitivity to Midazolam or other benzodiazepines. Adverse reactions: Cardiovascular: Slight reduction in blood pressure and cardiac output. Precaution: Pulmonary disease: May cause prolonged respiratory depression. Open angle glaucoma: Use only if patient is receiving appropriate glaucoma therapy. Skin: Avoid extravasation. Drug Interaction: In patients receiving Dilantin or Tegretol, larger doses of Midazolam may be required. Potency: Midazolam is 4-5 times more potent per milligram than Valium. How Supplied: 1 mg/cc Guidelines: The dose of Midazolam, a short-acting Benzodiazepine, should be slowly titrated to achieve the desired effect. Do not administer by rapid IV bolus – especially in neonates. It takes time for the drug to permeate the brain. Onset after IV administered is usually 1-1.5 minutes. An additional 2 minute period should be used to fully evaluate the sedative effect. Further titration should be done in 1 mg increments, waiting at least 2 minutes between increments to fully evaluate sedation before repeating a dose. A total dose greater than 5 mg is usually not necessary. Warning: Patients older than 55 have an increased sensitivity to Midazolam. IX. Appendix, page 39

Versed Protocol (Midazolam) : 

Versed Protocol (Midazolam) Adult Dose: For adult conscious sedation, sedation and seizures, administer 2.0 mg IV slowly over 20-30 seconds or via MAD device. Wait 2 minutes. If seizures continue, administer in 1 mg increments. Wait 2 minutes for effect. Maximum dose is 10 mg. Pediatric Dose: Administer 0.1 mg/kg IV slowly over 20-30 seconds or via MAD device. May repeat in 2 minutes to maximum total dose of 5 mg. Do not administer by rapid IV bolus – especially in neonates as it may cause hypotension and seizures. Monitor vital signs and airway. IX. Appendix, page 40

Biosite Triage Meter Plus, Enzyme Detector : 

Biosite Triage Meter Plus, Enzyme Detector Enzymes should be tested for all patients with chest pain suspected to be of cardiac origin, difficulty breathing and/or pulmonary edema. This meter is considered by the federal regulations (Clinical Improvement Act) to be a “moderately complex” device which requires frequent quality control tests to ensure a safe and accurate sample. The following is the process to use the meters, including mandatory quality controls (QC). QUALITY CONTROL: Daily: Each morning, as soon as practical, a QC Simulator assessment is to be made. Once 24 hours has elapsed in the meter's internal clock, the meter will not perform a patient sample test until that QC test is performed. This step cannot be overlooked or patient care will be adversely impacted. Monthly: As indicated by the meter, the units will be taken to the EMS office for monthly QC assessment using a QC Control SET sample. As this process uses actual human plasma that is frozen until use, having this QC completed at one time with all the machines is the most practical method. All the machines will be tested at the same time, saving sample and device costs as well as ensuring compliance. If this test is not run within 30 days of the previous test, the meter will not perform a patient sample test until that QC is performed. A QC Control SET test must be run on every testing device lot number available in order to have the meters recognize that lot number as a valid test device. Failure to test each lot will result in the meter not reading test devices with that lot number. Additionally, during this time, all the code chips for all devices in stock will be loaded into each machine so that multiple device lots can be used. Up to 20 reagent code chips can be stored in these machines. A print-out of the month’s tests and Q/C results will be performed and held in the meter Q/C book for compliance monitoring. Then that history will be erased to make room for another month’s data collection. IX. Appendix, page 41

Biosite Triage Meter Plus, Enzyme Detector : 

Biosite Triage Meter Plus, Enzyme Detector Semiannually: Twice yearly, the meters must be assessed with Calibration Verification Controls. PATIENT TESTING: Test Devices: Multiple devices are issued to each station. In these kits are extra bulb syringes, paper and code chips. These devices must be refrigerated when not in use. One test device is to be kept in the Rescue medication box for up to 14 days without refrigeration. Write the date on the test device package when removed from refrigeration and keep in a plastic bag along with all the blood draw supplies for immediate inoculation of the test device at the patient’s side. Non-transport units will have the blood draw supplies, but not the test devices, so that blood can be drawn prior to arrival of a Rescue truck and before flushing the extension line. Upon assessment of the patient and finding the patient to be a candidate for testing, draw blood. Do not flush the extension set until the blood has been drawn. Once blood has been drawn, then flush the extension set and secure as usual. If the extension set was flushed and a blood sample was not taken, draw blood from the opposite arm. Inoculate the test device and note the time of inoculation. You have 30 minutes before the device expires to perform the test. Send the device to the meter for analysis while further patient assessment and treatment is being performed. It takes approximately 15 minutes from the time of inoculation for the device to be read by the meter. For stable patients, transport decisions can be delayed to await the outcome of the tests. It is better patient care to take the patient to the correct facility the first time, than to have the patient transferred hours later and delay definitive care. Print out the results of the tests and submit them to the hospital for their records. IX. Appendix, page 42

Biosite Triage Meter Plus, Enzyme Detector : 

Biosite Triage Meter Plus, Enzyme Detector Follow the manufacturer’s directions for testing the patient sample. Abnormal findings will be highlighted in black with white letters. Record the findings in the patient care record (PCR) and complete the Enzyme Marker Survey tool to attach to the patient care record. ENZYME MARKER SURVEY TOOL: Every time a test is performed (positive or negative findings) and Enzyme Marker Survey Tool will be completed and submitted with the patient care record (PCR). The EMS Supervisor will remove the form when performing the Q/A review and enclose the form in the 3-ring binder in the office. The report reviewer will contact the receiving hospital and obtain the following data: Results of the three sequential sets of cardiac enzymes Discharge diagnosis (or if the patient is still in the hospital) Procedures performed, i.e. cardiac catheterization, stents, etc.) This data will be entered on the form for further data compilation as part of the ongoing Q/A on this process as well as meeting grant requirements. IX. Appendix, page 43

Taser Protocol : 

Taser Protocol The Advanced Taser is used by law enforcement to control subjects without the use of deadly force. The probes deliver a five second, pulsed, 2 joule, .004 amps, electrical shock that causes incapacitation by involuntary skeletal muscle contraction. The probes are straightened fish hooks. They penetrate the skin a maximum of ¼ to ½ inch depending upon the type of cartridge fired. The officer is knowledgeable as to which probes were deployed. Taser causes a momentary loss of muscle control and a small superficial skin wound. Falling, as a result of this loss of muscle control may result in injury. Patients may be under the influence of drugs or alcohol or may have other medical problems that may be difficult to access. Therefore, all patients who have received an electrical shock from a conducted energy weapon will be transported to the most appropriate facility for medical evaluation. This treatment protocol will apply to all brands of conducted energy weapons. PROCEDURE FOR TREATMENT: Assess the patient’s Airway, Breathing and Circulation. Refer to the appropriate medical or trauma treatment protocols. If the only medical or traumatic condition is the presence of the probes, then stabilize the probes and cut the wires one inch from the probes. Transport all patients to the most appropriate facility. IX. Appendix, page 44 M-26 Taser Facts: The darts are attached to two bare wires approximately 21-feet in length and travel at speeds of 160 feet per second. When deployed, the gun sends 50,000 volts of energy into the victim’s body.

Mark I Autoinjector Kit : 

Mark I Autoinjector Kit Procedure When a first responder arrives on a scene potentially contaminated with nerve agents, she/he must don a protective mask. If symptoms of nerve agent exposure manifest: 1. Remove Mark I kit from protective pouch. 2. Hold unit by plastic clip. (See graphic A) 3. Remove AtroPen from slot number 1 of the plastic clip. The yellow safety cap will remain in the clip and the AtroPen will now be armed. DO NOT hold unit by green tip. The needle ejects from the green tip. (See graphics B & C) 4. Grasp the unit and position the green tip of the AtroPen on victim’s outer thigh. 5. Push firmly until auto-injector fires. 6. Hold in place for 10 seconds to ensure Atropine has been properly delivered. 7. Remove 2-PAM CI ComboPen from slot number 2 of the plastic clip. The gray safety cap will remain in the clip and the ComboPen will now be armed. DO NOT hold the unit by the black tip. The needle ejects from the black tip. 8. Grasp the unit and position the black tip of the ComboPen on victim’s outer thigh. (See graphic D) 9. Push firmly until auto-injector fires. 10. Hold in place for 10 seconds to ensure Pralidoxime Chloride has been properly delivered. 11. If nerve agent symptoms are still present after 10 minutes, repeat injections. If symptoms still exist after 10 minutes, repeat injections for a third time (if available). If after the third set of injections, symptoms remain, do not give any more antidotes but seek medical help. IX. Appendix, page 45

Mark I Autoinjector Kit : 

Mark I Autoinjector Kit Adult Chemical Treatment Guide CARBAMATE - INSECTICIDE POISONING ORGANOPHOSPHATE - INSECTICIDE POISONING AND NERVE AGENTS (GA, GB, GD, GE, VX) Signs and Symptoms The muscarinic effects are described as the Classic SLUDGE syndrome (excessive Salivation, Lacrimation, Urination, Diarrhea, Gastrointestinal distress, and Emesis). Additional muscarinic effects include: bronchorrhea, bronchospasm, and bradycardia. The patient will have constricted pupils (miosis, which may last up to two months - despite appropriate treatment) with inhalation or skin exposure. Ingestion may or may not cause miosis. However, stimulation of nicotinic receptors will produce tachycardia, muscle paralysis (apnea), muscle twitching/fasciculation, and seizures. Remove patient from hazardous area. Avoid exposure to patient’s sweat, vomit, stool and vapor emitting from soaked clothes. Administer high-flow O2. If patient was exposed externally, remove clothing and decontaminate as appropriate (place clothes in sealed bag). Contact Poison Information Center (1-800-222-1222). IX. Appendix, page 46

Mark I Autoinjector Kit : 

Mark I Autoinjector Kit If treating patient or self-exposure (with PINPOINT PUPILS): Administer Mark I kit(s)(two autoinjectors containing Atropine 2mg in one and Pralidoxime 600mg in the other) as follows: a. For early symptoms (severe rhinorrhea or mild to moderate dyspnea) administer one (1) Mark I autoinjector kit. If no improvement in patient’s status in 10 minutes, administer another Mark I autoinjector kit. b. For severe respiratory distress, coma, or seizures, administer (3) Mark I autoinjectors and (1) CANA autoinjector (Diazepam 10mg IM) For all patients meeting above criteria: Alert emergency department to prepare for contaminated patient. Do not induce vomiting or give Furosemide (Lasix) or Morphine. NOTE: Risk of exposure from fumes is high, call HAZMAT team, (usually Level A) with SCBA must be worn in hazardous area. PPE with minimum of Level C protection must be worn for treatment outside of the hazardous areas, don SCBA first. If advised by Poison Information Center, every other dose of Atropine can be increased to 0.06mg/kg IV. End point for treatment is manifested by patient improvement with clear lung sounds. IX. Appendix, page 47

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Top 50 Prescriptions in 2005 1) Lipitor: Is utilized to lower cholesterol 2) HYCD/APAP: Used to treat pain 3) Norvasc: CCB utilized to manage HTN 4) Toprol: Beta Blocker used to manage HTN/Angina 5) Zoloft: Antidepressant 6) Synthroid: Treatment of Hypothyroidism 7) HYCD/APAP: Used to treat pain 8) Amoxicillin: Anti-infective 9) Lexapro: Antidepressant 10) Albuterol: Bronchodilator 11) Zocor: Is utilized to manage cholesterol 12) Nexium: Proton Pump Inhibitor (PPI) heartburn 13) Levothyroxine: Hormone (thyroid) 14) Ambien: Is utilized as a sleeping aid. 15) Singulair: Asthma 16) Prevacid: Antiulcer agent 17) Plavix: Inhibits platelet aggregation 18) Zithromax: Anti-infective 19) Fosamax: Treatment of Osteoporosis 20) Zyrtec: Antihistamine 21) Advair: Anti-Asthma 22) Protonix: Ulcers 23) Furosemide: Diuretic 24) Atenolol: Beta Blocker used to manage HTN/Angina 25) Effexor XRE: Antidepressant 26) Warfarin SO: Anticoagulant 27) Cephalexin: Antibiotic for bacterial infections 28) Flonase: Corticosteroid for nasal congestion 29) Oxycodone: Pain 30) Levaquin: Used to treat bacterial infections 31) Diovan: HTN 32) Hydrochlorothiazide: Diuretic 33) Premarin: Hormone(estrogen 34) Lisinopril: Blood Pressure 35) Atenolol: Angina and Blood Pressure 36) Lotrel: Blood Pressure 37) Allegra: Allergies 39) Levoxyl: Thyroid 40) Altace: HTN Other Medications on the Top 200 List; 56) Diflucan: Treatment of vaginal yeast infections 92) Lanoxin: Digitalis, regulates HR 102) Depakote: Migraine headaches 114) Verapamil: CCB Class IV antiarrhythmic 138) Diazepam: Sedative 158) Dilantin: Antiepileptic 167) Augmentin: Treatment of bacteria infections 175) Lorazepam: used to treat anxiety 200) Biaxin: Bacteria infections of the respiratory tract ) Reference: Pharmacy Times Magazine, May 2006 Top 200 Prescriptions in the USA in 2005. Data by IMS Health IX. Appendix, page 48

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The “Rave” Drugs Cocaine: Is a Stimulant/Anesthetic. AKA – coke, crack, flake, snow (Common S/S: HA, NV, CP, tachycardia, AMI, HTN, seizure, dilated pupils). Reference the Cocaine Protocol, P-41. Ecstasy (MDMA): Is a Stimulant/Hallucinogen. AKA – XTC, X, love drug, MDMA, empathy. (Common S/S: euphoria, hallucinations, agitation, nausea, teeth grinding, HTN, tachycardia, heart and renal failure, dilated pupils, CVA) GHB (Gamma Hydroxy Buterate): Is a Depressant. AKA – G, easy lay, liquid X, cherry meth (Common S/S: euphoria, sedation, dizziness, myoclonic jerking, NV, HA, bradycardia, apnea) Hallucinogens: Alter perception. AKA – LSD, psilocybin mushrooms (Common S/S: anxiety, panic, NV, disorientation, hallucinations) Ketamine (KETALAR®): Is a Dissociative Anesthetic. AKA – Special K, Vitamin K, horse tranquilizer (Common S/S: sedation, babbling, tachycardia, hallucinations, paranoia, coma, seizure, NV, respiratory depression, egocentrism, nystagmus) Nystagmus is involuntary eye movement, which can result in some degree of vision loss. PCP (Phencyclidine): Tranquilizer. AKA – peace pills, angel dust, horse tranquilizer (Common S/S: nystagmus, disorientation, HTN, hallucinations, catatonia, sedation, paralysis, stupor, mania, tachycardia, dilated pupils, status epilepticus) Rohypnol (Flunitrazepam): Benzodiazepine. AKA – roofies, Mexican Valium, row-shay (Common S/S: anterograde amnesia, hypotension, sedation, dizziness, confusion, coma) Oxycontin: Narcotic. (Common S/S include; pinpoint pupils, respiratory and CNS depression, confusion, drowsiness, mood changes, N/V, apathy, LOC, coma and reduced vision) to name a few. Reference the Overdose Protocol, P-40. IX. Appendix, page 49

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IX. Appendix, page 50 12-Lead Interpretation 1) Check QRS for width (V1 is a good lead for this) .12 seconds is too wide. 2) Look @ V1. Upward defection with a QRS > .12 (3 Boxes) indicates a RBBB. A Downward deflection with a QRS of > .12 is an indication of a LBBB. 3) Leads I and aVL = High Lateral 4) Leads II, III, and aVF = Inferior 5) VI – V6 = Anterior 6) V2 = Septal 7) V5 – V6 = Low Lateral Scan The EKG for ST Elevation. ST Elevation is measured @ the “J” Point. ST Elevation/ Depression is a sign of Acute Infarct. T-wave Inversion is a sign of Ischemia and may be associated with acute MI. Pathological Q-wave is ¼ of the height of the entire QRS, it indicates an old injury. Definitions ST Elevation/Depression: The ST segment rises 0.05mV above/below the Isoelectric Line from the “ J ” point, an indication of MI. T-wave inversion: Of more than 0.1mV is also a good indication of MI. “J” point: The point where the QRS complex ends and the ST segment begins. Ischemia: A deficit between blood supply and demand. Injury: Damage to the cardiac tissue caused by Ischemia. Necrosis: Death of tissue that cannot be reversed. Seen on the EKG as a Pathological Q-wave.

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IX. Appendix, page 51 12-Lead Placement 1) V1 is placed at the 4th intercostal space, just right of the sternum. 2) V2 is placed at the 4th intercostal space just left of the sternum. 3) V4 is placed on the mid clavicular line and 5th intercostal space. 4) V6 is placed on the mid axillary line, horizontal with V4 5) V5 is simply placed between V4 and V6 6) V3 is placed between V2 and V4 V1 V2 4th Intercostal Sternum V4 5TH Intercostal V3 Mid Clavicular V6 V5 Mid Axillary Line

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IX. Appendix, page 52 Cincinnati Pre-Hospital Stroke Scale

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IX. Appendix, page 53 Common Medical Abbreviations a = before aa = of each AED = automated external defibrillator AOX4 = alert, and oriented to person, place, time and self abd. = abdomen Ab. = abortion a.c. = before meals aq = water AF = atrial fibrillation ARDS = Adult Respiratory Distress Syndrome AT = atrial tachycardia AV = atrioventricular b.i.d. = twice a day BSA = body surface area BS = blood sugar and/or breath sounds c = with CC or C/C = chief complaint CHF = congestive heart failure CNS = central nervous system c/o = complains of CO = carbon monoxide CO² = carbon dioxide D/C = discontinue DM = diabetes mellitus DOE = dyspnea on exertion DPT = diphtheria, pertussis and tetanus vaccine DT’s = delirium tremens DVT = deep venous thrombosis Dx = diagnosis ECG – EKG = electrocardiogram EDC = estimated date of confinement e.g. = for example ENT = ear, nose and throat ETOH = alcohol by definition is any chemical compound containing the Hydroxl group OH. ETOH is the abbreviation of Ethanol (grain alcohol) fl = fluid fx = fracture GB = gall bladder Gm – g = gram gr. = grain GSW = gun shot wound gtt. = drop GU = genitourinary GYN = gynecologic h, hr. = hour H/A = headache H. (H) = hypodermic Hb. – Hgb = hemoglobin Hg = mercury H & P = history and physical hs = at bedtime Hx = history IC = intracardiac ICP = intracranial pressure

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IX. Appendix, page 54 Common Medical Abbreviations JVD = jugular venous distention KVO = keep vein open LAC = laceration LBP = lower back pain LBBB = left bundle branch block MAEW = moves all extremities well NaCl = sodium chloride NAD = no apparent distress NPO = nothing by mouth NKA = no known allergies OD = overdose O.D. = right eye O.S. = left eye PERL = pupils equal and reactive to light PID = pelvic inflammatory disease p.o. = by mouth 1° = primary, first degree PTA = prior to admission pt. = patient PT = physical therapy q = every q.h. = every hour q.i.d. = four times a day RBBB = right bundle branch block RHD = rheumatic heart disease R/O = rule out ROM = range of motion Rx = take, treatment s = without S/S = signs and symptoms ss = half TIA = transient ischemic attack t.i.d. = three times a day TPR = temperature, pulse, respirations V.S. = vital signs y.o. = years old Medical Terminology (commonly misspelled words) Alzheimer’s Anaphylaxis Aneurysm Apnea Catecholamine Contrecoup Cor pulmonale Decerebrate Decorticate Dyspnea Ecchymosis Emphysema Meniere’s Mesothelioma

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IX. Appendix, page 55 START Triage/MCI Operations (Cheat Sheet) The goal of the START program is to provide the “greatest good for the greatest number of patients”. Definitions: MCI = Mass Casualty Incident (Any incident where first responders capabilities are exceeded) Level I = 5-10 patients Level II = 11-20 patients Level III = > 20 patients Level IV = 100-1000 patients Level V = > 1000 patients Groups needed: Command – Triage – Treatment – Transport – Staging – Extrication – Haz-Mat – Landing Zone – Re-hab The patient assessment process is based on the following; R- respirations - <10 and/or > 30 P- perfusion/pulse – capillary refill > 2-seconds M- mental status – follow commands Immediate Delayed Walking wounded Deceased Contaminated New Statewide Triage Tag (Front) The colors of Triage

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IX. Appendix, page 56 Triage Flow-Chart Deceased Immediate <10 or >30 Immediate Immediate Delayed Immediate Walking wounded Contaminated Respirations Mental Status Perfusion NO YES POSITION AIRWAY YES <30/MINUTE RADIAL PULSE PRESENT/CAP-REFILL < 2-SECONDS RADIAL PULSE ABSENT/CAP-REFILL >2-SECONDS Follows Commands Cannot Follow Commands

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IX. Appendix, page 57 Pediatric “Jump” START Able To Walk? Breathing Respiratory Rate Palpable Pulse? AVPU Minor Secondary Triage Position upper airway Palpable pulse? 5-Rescue breaths Immediate Immediate Deceased Deceased Immediate Immediate Immediate Delayed YES NO NO Breathing NO APNEIC YES <15 OR >45 NO 15-45 “P” Inappropriate posturing or “U” A – V – P ( Appropriate) Evaluate infants first in secondary triage using the Jump Start Algorithm

H’s and T’s : 

H’s and T’s Hypovolemia Tablets: Drugs, OD Hypoxia Tamponade, cardiac Hydrogen ion – acidosis Tension pneumothorax Hyper/hypokalemia, other metabolic problems Thrombosis, coronary Hypothermia Thrombosis, pulmonary embolism IX. Appendix, page 58