Item C121t G
CountCounty ���.�� �y,4' ?,"tr, BOARD OF COUNTY COMMISSIONERS
y �a� Mayor Michelle Coldiron, District 2
�1 nff`_ll Mayor Pro Tem David Rice, District 4
-Ile Florida. Keys Craig Cates, District 1
Eddie Martinez, District 3
w Mike Forster, District 5
County Commission Meeting
April 21, 2021
Agenda Item Number: C.12
Agenda Item Summary #8071
BULK ITEM: Yes DEPARTMENT: Emergency Services
TIME APPROXIMATE: STAFF CONTACT: James Callahan (305) 289-6088
NA
AGENDA ITEM WORDING: Issuance (renewal) of a Class A Certificate of Public Convenience
and Necessity (COPCN) to Ocean Reef Volunteer Fire Department, Inc. d/b/a Ocean Reef Public
Safety Department for the operation of an ALS transport ambulance service for the period June 1,
2021 through May 31, 2023.
ITEM BACKGROUND:
On May 22, 2019, a Class A COPCN was issued to Ocean Reef Public Safety Department to
operate an ALS transport ambulance service. This certificate will be expiring on May 31, 2021
In view of the foregoing, Ocean Reef Public Safety Department is applying to renew this Class
A COPCN which would become effective June 1, 2021 and expire May 31, 2023.
PREVIOUS RELEVANT BOCC ACTION:
05/20/15 BOCC approved renewal of Class A COPCN for the period 06/01/15 through 05/31/17.
05/17/17 BOCC approved renewal of Class A COPCN for the period 06/01/17 through 05/31/19.
05/22/19 BOCC approved renewal of Class A COPCN for the period 06/01/19 through 05/31/21.
CONTRACT/AGREEMENT CHANGES:
N/A
STAFF RECOMMENDATION: The Monroe County Code allows the issuance of a COPCN for
the purpose of providing essential emergency medical services to the various geographical areas of
Monroe County. Ocean Reef Public Safety Department complies with the requirements of said
Code and Chapter 401 Florida Statute. In view of the foregoing MCFR staff recommends the
approval of the renewal of a COPCN so they can continue to provide these services to their specific
area of the County.
DOCUMENTATION:
Ocean Reef Application Rec 03.24.202 1 -Redacted
Ocean Reef Class A COPCN Expires 5-31-2023
FINANCIAL IMPACT:
Effective Date: 06/01/21
Expiration Date: 05/31/23
Total Dollar Value of Contract: N/A
Total Cost to County: N/A
Current Year Portion: N/A
Budgeted: N/A
Source of Funds: N/A
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount: N/A
Grant: N/A
County Match: N/A
Insurance Required: Yes
Additional Details: N/A
REVIEWED BY:
Pedro Mercado
Completed
04/06/2021 11:25 AM
James Callahan
Completed
04/06/2021 11:44 AM
Purchasing
Completed
04/06/2021 11:54 AM
Budget and Finance
Completed
04/06/2021 12:57 PM
Maria Slavik
Completed
04/06/2021 2:05 PM
Liz Yongue
Completed
04/06/2021 3:27 PM
Board of County Commissioners
Pending
04/21/2021 9:00 AM
County of Monroe
The Florida
Division of Emergency Services
Fire Rescue Department
490 6314 Street, Ocean
Marathon, FL 33050
Phone: 305-289-6004
Fax: 305-289-6336
Please Attach all of the following documents when submitting your application:
p The name, business mailing address, and telephone number of the service.
The name, age, address and telephone number of each owner of the emergency medical service, or, if
the service is a corporation, the directors of the corporation and of each stockholder of the corporation,
or, if the service is a volunteer organization, the officers of the organization.
The date of incorporation or formation of the business association.
p The level of care to be provided, specifying BLS or ALS, and if ALS, then specifying whether service is to
include transport or nontransport capabilities.
0 The zones that the service desires to serve.
The applicant's present and proposed base station and all substations.
VI The names of all emergency medical technicians, paramedics and drivers to be utilized by the applicant;
the roster will include the state certification number, date of certification expiration, and any other
relevant training of said personnel.
The year, model, type, department of health ambulance permit number, mileage and state vehicle
license number of every ambulance vehicle used by the applicant.
A description of the applicant's communication systems, including its assigned frequency, call numbers,
mobiles, portables, other frequencies in use, and a copy of all FCC licenses held by the applicant.
The names and addresses of three U.S. citizens who will act asreferences for the applicant.
A schedule of rates which the company will charge during the certificate period.
Verification of adequate insurance coverage, during the certificate period.
An affidavit signed by the applicant or an authorized representative stating that all the information
contained in the application, to the best of the applicant's knowledge, is true and correct.
56 A copy of the applicant's contract with a medical director.
A copy of all standing orders as issued by the medical director. IE: Medical Protocols.
Such other pertinent information as the administrator may request.
An initial nonrefundable application fee of $50.00/ $25,00 Renewal
„fi
Ronnie Fell
From: Johnson -Cara <Johnson-Cara@MonroeCounty-FL.Gov>
Sent: Tuesday, March 23, 2021 12:51 PM
To: Ronnie Fell
Cc: Tamborski-Cheri
Subject: Ocean Reef COPCN Class A Renewal
Attachments: COPCN AppiicationClassA (Renewal).pdf, COPCN Class A Check List.pdf
Hi Mr. Fell,
I wanted to reach out about the renewal for the Class A COPCN for Ocean Reef Volunteer Fire Dept., Inc. d/b/a Ocean
Reef Public Safety. I have attached the Class A renewal application to this email along with the check list. If we could
please get the application items and check payment by Monday, March 29, 2021 that would be a huge help to get the
renewal on the April BOCC Agenda on time!
Please let us know if there is anything else we can assist with!
Cara
Cara Johnson
Executive Assistant
Monroe County Fire Rescue
490 63Id Street, Ocean, Suite 140
Marathon, FL 33050
305-289-6004 (Office)
Johnson -Ca
ra@o roepnty- ov
FLORIDAMONROE COUNTY,
APPLICATION FOR CERTIFICATE OF
PUBLIC
• CONVENIENCE r
MEDICAL
0 INITIAL APPLICATION - $50.00 [N RENEWAL APPLICATION - $25.00
IF • PREVIOUS O CERTIFICATE: 1
i'
11
Q
WA-11"TFM Him ip ire TeBartment and/or Ocegn Reef N blic Safe Department
BUSINESS MAILING ADDRESS 110 chor Drive, Key Lar
BUSINESS PHONE
i �.EMERGENCY
PHONE
NUMBER
TYPE OF OWNERSHIP
Sole Proprietor,
I I I Partnership, Corporation,
'. I ! l 1 1 a non- f:Eoflt
BUSINESS5' ;ATE OF INCORPORATION OR FORMATION OF THE
OO
FAST ALL OFFICERS, DIRECTORS, AND SHAREHOLDERS (Use separate sheet if necessary):
�
IF ALS: 131 TRANSPORT or 0 NON TRANSPORT
5. DESCRIBE , • SERVICE DESIRES
IntersectionAil 2000 series fireboxes, generally from the
• : C405 and Card sound Road (C - 905A) north on C -905 to an
Including Ocean Roof and west on Card Sounj Road (C - 905A) to theMade-County line, or as otherwise directed
b—Mon
#, LIST THE ADDRESSM DESCRIBE
separateSTATIONS (Use sheet
BASE STATION 110 ��rehar i3�iv� L�r � �133037
I
Neel of6
Packet;Pg. 350
Eddie Fernandez
Ronnie Fell
John Flynn
110 Anchor Drive, Key Largo FL, 33037
se 26 lane, Homestead, FL 33035
110 Anchor Drive, Key Largo, FL 33037
9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD.
10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD.
11. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR.
12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR.
13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT, MADE PAYABLE TO THE
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS.
I, THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE -NAMED SERVICE, DO HEREBY ATTEST MY SERVICE
MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE
COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN
THIS APPLICATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT.
rr'1 {+'? /Sar,4y
f ,r+ 4 dricee'r
SIG= I`URE OF APPLICANT / AUTHORIZED REPRESENTATIVE
w
Page 2 of
Packet iPg. 35'1
11,
1 i�ii"°
To: whom it may concern
From: Ronnie Fell, Training /Safety Compliance officer, Ocean Reef Public Safety Department/ Volunteer Fire Department
Cc:
Ref: Renewal of COPCN
Message:
Here is the list of our current Board of Directors
Ocean Reef Community Association
Board of Directors- 2020-2021
Gary List, Chairman
Anne Lovett, Vice Chairman
Henry Stout
Nanette Elenbass
Drew Cunningham
Bill Wilson
Brooke Weisleder
Nip Smith
Alex Castellanos
Charlie Johnston
Joe Urbinati
Chip Iglesias, President
Address is 35 Ocean Reef Drive, Suite 220 key largo FL, 33037
Ronnie Fell
Training/Safety Compliance Officer
Ocean Reef Public Safety
305- 676-3351office
Form ORCAPSD 003
FLONCIA AUTCIMOBLE INSURANCE
IDENnFiCAIION CAM
, Pa.
pAw National Union
comfire ins. Co . of Pittsburgh
01-31-2021
-01515 EFFEcyK DXTE
POUr 'yo: VFNUM0002383 BCOILy NJURY —
F1PERSMAL MURY PROTECTION El U*ILITY
BENSqrSIPROPERTY DAMAGE UAWL"
NmED : CEN REEF VOLUNTEEP' E'RE DEPARno'T'
iNSURED•
YEAR: 2 pIifBONE PUMPER LDH
MN#*
FLEET CMVQDF- C3
(11 more *An 25 WdOO Lnsured)
MORE THM DIM WAR FROM EFFECTIVE DATE
worr VALID FOR
FLORIDAMOMOSILE INSURANCE
IDENMRCAIION CARD
COMPAW. National Union Fire Ins. Co. of Pittsburgh, Pa.
POLJCY#: VFNUCM0002383 - 01515 EFFECTIVEDATE 01-31-2021
pq PERSONAL KAIRY PROTECTION M BODILY INJURY
BENEFITSP PROPERTY DAMAGE LIABILITY UABILITY
NAMED
INSURED: OCEAN REEF VOLUNTEER FIRE DEPARTMENT,
YEAR: 2009 MA?CFJMODEL- DODGE AMB ALS
VINN:
FLEET COVERAGE
(11 more Man 25 vehIdes insured)
NCff YALID FOR MORE THAN ONF YEM FROM EFFECTWE DATE
njomm AUTOMOMLE INSURANCE
IDENTIRCATION CARD
COMPANY: National Union Fire ins. Co. of Pittsburgh, Pa.
2021
POLICY#: vFNUCM0002383 - 01515 eFFecTrjE DATE 01 -31-
pq PERSONAL WWRY PROTECTION IS BODILY INJURY
BEHEMSIPROPERTY DAMAGE LIABILITY IJABIUTY
NAMED
INSURED: OCEAN REEF VOLUNTEER FIRE DEPARTMENT,
YEAR: 2 0 16 Lwwmwa- CHEVY AMB ALF
vwk
FLEET COVERAGE
(K mrs Vion 25 vehIC105 Insut6d)
f4OT VALID FOR MORE THAN ONE YEAR FROM EFFECTIVE DANE
FLOIN Aq�FO'400LE INSURAM,;E;
COMPANY* blational I OMFICAWON CARD
Un'011 Fire Ins. Co. of Pittsburgh,
Pa.
POUCY#: VMCM0002383 - o1515
El PERSM& KXJRy PROTSCTIM EFFECT'VEDATF-' 02-31-2021
NAMED 894EFnVpROFERTY DAMAGE LIABILITY El BODILY INjURy
INSURED UABury
OCEAN REEF VOLUMTEER FIRE DEPM7MNT,
YEAR,' 2015
1
VW#:
W 11 -MA'C&MODEL. 1)01)CE AMB ALS
FLEET COVERAGE 0
(F `n0r* then 25 v*hkj&snsur*d)
__NO1r VAUD POR MOM
THAN CWE VFM FRoM EFFECTIVE DATE
FLORIDA ALMMOOLF INSURANCE
IDEIMRCAMoN CARD
COMPANY: National union Firo ins. Co. of Pittsburgh, Pa
eFFECTIVEDATE 01�31-20;1
Vn;UCm0002383 - 01515 BODILY KJURY
prr uURY PROW-071CM El
.RSONAL M LIABILITY
BENEMVPROPERTY DAMAGE LIA&RHY
NAMED
IWSURCD: OCEAN BEEF VoijUNMR FIp.E DEPARTFO",
YEAR: q n M',ajMWEL EONE PUMPER LDH
vw#; 0 FLM R COAAM
tK ffwM m*n 25 vehk!46 Insuied) (ME YEW FROM EFFSCM DATE
MW VA11JD FOR MW T"M__ 011�
FLORIDAMMMOBLE INSURANCE
IDENTIRCA,noN CARD
=MPAW, National Union Fire Ins. Co. of Pittsburgh, Pa.
POUCYO:VFNUCM0002383 .01515 EFFECTIVEDAIE- 01-31-2021
In PERSONAL INJURY PROTECTION El BODILY INJURY
BEN9:=PROPER1Y DAMAGE LLABILITY LIABILITY
NAMED
INSURED OCEAN REEF VOIXWEER FIRE DEPARIWIn,
YEAR: ?nnQ —J—Ri DODGE AKE ALS
ma:
FLEET COMIAGE:
(I nare than 25 vehicles Insured)
NOT VALID FOR UKWE THAN ONE YEAR FROM EFFWTTVE DATE
FWNDAAMMONLEINSURANCE
IDENTIFICAMON CNW
commw National Union Fire Ins. Co. of Pittsburgh, Pa -
POWYN- VFNUCM0002383 - 01515 EFFEcTmDATF- 01-31�2021
PERSONAL *WRY PROrECTION El BODLY NJURY
SENEFIMPROPER(TY DAMAGE LIABILITY LIABILITY
- ONED FIRE DEPARTMENT,
.NSUM: OCEAN REEF VOUWMR
WAR; 2016 MmOMWEL- CHEvy AMB ALS
VINC
FLEEt COVOVAE
(W rmm than 25 vehIcies Insured)
E=11VE
NG`( VAW FOR RWM THAN ONE YEAR FROM EFFMW
-----------
WATILE INBUROWC,,
oM
FICA'nm CAF COMPANY: U"Ion E'j'. Co. f
POWY#' ! 0002383 - 01525 P.07
PER
BINEFIr6 EFFMTP�E OATE� 01"31-2021
SONAL WURY P ROrECTiO
QN
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ED BODXy IWjRy
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INWRED Der
YEAR 201,%
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COMMA., 13
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—Nor VAUD FOR
NORE TNM CNE VIEM
FROM EFFECM2 DATE
N
DIRECTORTHIS MEDICAL AGREEMENTrrreement") Is made and
��ntered into as of the Vt day of August, 2003 (the "Effedlve Date"), by " between
David R. Naternan," d Ocean Reef Community
-:
DistrictWHEREAS, ORCA EMS provides serviQft to the area known as Monroe County
Fire l
FloridaWHEREAS, Physician is a R d physician experienced in thzs
yrovislon of emergency
FloridaWHEREAS, Physician Is the employee of South Florida Emergency Physicians,
professional associati# "P.A.")
777710 ne e5v
T�-� Cl I e- P! 04 "trValkellu"F-MAS re y
IV
agree #
M
glUd-ResponsiblI&I2 -responsibilitiesduties
-1 a) Supervise and accept direct responsibility for the medical performance of
Physician h ii be knoMedgeablef the area of transportation of
patients n ii evaluate each patient In pemon or by written
protocol pdor totransfer for the purpose of determining that the
vehicle, medical crew, and equipment meet the patient's needs.
Physioian, during the tenn hereof, shall be Board certifiedin
emergency`n, with demonstrated experience in - pit. i
Physician shall demonstrate and have availablefor review by BEMS
documentation f acWe participationin a regional or statewide,
physician r p involved in pre -hospital care,
emu,-1w- ",- ,-,-
s K, Is enterAgreement consideration of the
execution, by the parties thereto, and shall be entitled to compensation in the
sum of
0.00
, 4 r monthrigbe rendered hereunder. Payable
the I't day of each month.
third5.2. 2EDGM. * Fe U Sa Bill Physician shall neither bill nor collect
nor retain any amounts for such BervICOS from any patient, patient member,
party payor or any
event , i` Aand Physician
agree In writing, this Agreement may be terminated on the terms and date
specified therein.
(',��i.Omay be terminate
Immediately d'y r notice written by ORCA o,
Agreement,term a„�, '- shall yr' purpose %�
(g) Except as more specifically provided herein above, upon Physician's
material breach of any provision of this Agreement, and failure to cure
such bresoh wfthin ton (10) days after wrftten notice of thereof from
ORSPM
6.2.3. YponA hout Cause. This Agreement may be terTninated
QUavjfflL-
whhout cause by efther party upon ninety (90) days prior written no9ce to the
other.
Noticep. Any nofice required or permitted to be given under thla Agreement
shall be sufficient if in writing and if sent by registered or certified mail, by
overnight express, or by hand delivery to ORCA or Physirlan, at the
addresses set forth below or to any other address of which notice of the
change Is given to the parlies hereto:
To Physiclin: David Nateman M.D.
South Florida Emergency Physicians, P.A.
7700 North Kendall Drive, Suite 145
Miami, Florida 33176
To ORCA: Ocean Reef Community ArmoclaUon
24 Dookside Lane #506
Key Largo, Florida 33037
Attention. David Rft
vvasa-n a eemm�a taws ¢i a t w�x„w.i e
any paramedic, r imedical personnel pmviding emergency
service in connection withthis i r t',
Within 60 days, develop and implement tie t care qualityassurance
system to assess the medical performance of all madical personnel;
Audit the rf f personnel by use of a qualitysour
program r to include r t review of irun reports, direct observaton,
and comparison of performance standards for drugs, equipment,
systems pmtocols and procedures;
PartiOpele€ 1ity assuranoe prograrneto of
Florida Bureau of Emergency Medkcai Services (BEMS),
Maintain i tl n as a medical dilrector with the U.S.Department of
Justice to pruvilledsubstances uc registration
readily pal l r inspecoon upon request,,
Ensure and certify that secuirity proceduresfor w m dlctl nn , fluids rid
contralled substances are In compliance withChapters 490 and 693 of
the Flodda Statutesand Chapter 64F-12 of the Floridadr i i to ti
Code'3
e Within t authorize d ensure adherence to det2lled
w0ften operatingr I all aspects of the handlingf
medications, fluids and controlled substances-,
Notify In writing when the use of telemetry is not necessary;
r Hkar—
rtwriting of ,, by ORCA
medication.
a; Otherwise complyf`
uirements Of Section 401,265 of th-s.
Florida Statutes and Sections 64E-2.004 and 64E-2.005 of the
Administrative ' Florida
q) Participates In candidate selection PrOcOss, as available for review or
r) The Medical `` shall provide "medicald
dutiesministrative duties".
Medical adminlatratIve #'o not
(I) The Providing of or failure to provide on line telecommuni61 ,,,D" toemergency dical personnel; or
medical
Providing or falling to Provide Ptofessionel health care services fif'k
vul ,a &U-'j A- „ -1 1 - - - .. --, , ..
.11
IN WITNESS WHEREOF, this Agreernerd has been executed the parties
the EffeMVe Date. i
PHYSICIAN:
aVid R. No Mag, 5.D.
ORCA'
By:
Name: D
1!1 1 1 1 1111111?p irl 111111 gillill 11
C.12.a
Ocean Reef Community Association"
Department of Public Safety
To: whom it may concern
From: Ronnie Fell, Training/Safety Compliance Officer, Ocean Reef Volunteer Fire Department
Cc:
Ref; Renewal of COPCN
Here is a copy of our fee schedule for Ocean Reef Public Safety as of today 11/05/2020.
Mileage
$12 per mile
ALS Non Emergency
$580
ALS Emergency
$580
BLS Non Emergency
$500
BLS Emergency
$525
ALS2
$825
Treat No Transport
$100
Ronnie Fell
Training/Safety Compliance Officer
Ocean Reef Public Safety
305-367-4357 ext 3351- office
Form ORC"SD 003
Packet;Pg. 365
M
24 DOCKSEDE LANE
PO BOX 505
KEY LARGO, FL 33037
STATION TECBNICAL SPECIFICATIONS
Fixed Location Address or Mobile Area of Operation
File Number
00062666-63
Radio &rvice
3B � Business, 806-821/851-866 MHzyrr,
Conventional
Frequency {ate rdution Number
I.And Mobile Control Station meeting the 6.1 Mrier Rule: FL
Let. 2 Address. ANCHOR DR OCEAN REEF CLUB
City: KEY LARGO County: MONROE State- FL
Lai (NAD83). 25-18-55.4 N Long (NAD93):090-16-46.2 W ASR No.: Ground Elev: 2.0
Loc. 3 Area of Operation
Operating within a 15.0 kin mdius around fixed location 2
Anhumas I
Loc. Ant. Frequencies Sta. No. No. Embislon Output ERP Ant Ant Construct
WHZ) M Units Pagers Designator Power ("afts) HL/Tp AAT Dewifte
(Watts) meters meters Date
I I 000812.83750DOO FXI I 20KOF3E 15.000 20.000
2 1 000857.837500DO FB2 I 20KOF3E 35.000 25.000 3.0 33.0 074)6-200S
3 1 000812.8375OW MO 20 20KOF3E 15.000 20.000 07-0&2005
Control Points
Control Pt. W I
Address: Anchor Drive - Ocean Reef Country Club
city., Key Largo County., MONROE State- FL Telephone Number: (305)367-3067
0
"T4wil i a WIN W61A W10,10=0
I
1,46 AWIN 14- jk"�A MW
U.&C. § 310(d). Thisficense is subject in tenns. to the right of use 1r control conferred by §706 of the Communications Act of
Ocean Reef Community Association
Department of Public Safety
Florida Regional Common EMS Protocols
This memorandum is to confirm the Ocean Reef Community Association Department of Public Safety
adopted from the Florida Regional Common EMS Protocols for Emergency Medical Services.
This practice is documented in the book Common EMS Protocols, Copyright 2010, Jones and Bartlett
Publishers, LLC, and Fire Chiefs Association of Broward County, Inc. Florida
The aforementioned book is utilized in responses, as well as training; further a book is issued to all
personnel who actively perform medical duties for the Ocean Reef Community Association, as well as the
properties assigned for response outside of the Community.
The Common EMS Protocol Booklet has been approved and is supported by the Emergency Medical
Director for Ocean Reef Community Association, Dr. David Nateman.
Should the protocols Change, become adjusted or altered in anyway, the changes will be noted in a
further memorandum to file, with the attached approval of Dr. David Nateman.
David R. Nateman, MD
ORCA Medical Director
Dated: February 17, 2021
y
uan Perez
ORCA VP/ Director of Public Safety
I
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To: whom it may concern
From: Ronnie Fell, Training/safety Compliance Officer, Ocean Reef Volunteer Fire Department
Cc:
Ref: Renewal of COPCN
Message:
Here is the list of our current shift ems personnel
Shift personnel
Wesley Aleman
Enrique Arias
Pedro Castillo
David Cabanzon
Luis Castro
Yusniel Collado
Alex Del Rio
James Faktor
Barbara Fassett
Ronald Fell
Jake Georgiades
Jose Gonzalez
Jonathon Guzman
Kevin Hulse
Christian Loaiza
Pedro Marin
Frank Carlos Morales
Chris Navarro
Jonathon Saldana
Esteban Sanchez
Michael Sierra
Alex Vazquez
Giovanni Quintero
DL #
A455881944180
A620200834030
C234672970180
C151270962600
C236536882450
C430960854011
D460001563330
F236459730200
F230060746060
F400730743798
G623433931040
G524426941700
G255421903290
H420513871500
L200100842500
M650672790640
M642240813080
N160116912050
S435433832050
S522207891030
S600541962280
V220005894170
Q536287960621
Ronnie Fell
Training/ Safety Compliance Officer
Ocean Reef Public Safety
305- 367-4357 ext. 3351 office
Form ORC"SD 003
Packet;Pg. 370
Robert Givens 1 509301 1 12/01/22
O'Neal Hudson 1 88236 1 12/01/22
Albert Alvarez 1 1 547371 1 12/01/22
Jake Georgiades k 1 548385 1 12/01/22
Page 4 of 6
Packet;Pg. 37'1
NAME
First, Middle, Last
MEDICS
PARAMEDIC
SOCUL S
CERT
Wesley Aleman
EXPIRj
P533528
12-1-22
Enrique Arias
P D519089
12-1-22
David Cabanzon
P530817
12-1-22
Luis Castro
P530590
12-1-22
Pedro Castillo
PD532880
12-1-22
Yusniel Collado
P D
12-01-22
Alex Del Rio
PD 10106
12-01-22
James Faktor
P514804
12-01-22
Barbara Fassett
PMD 18382
12-01-22
Ronald Fell
P D510950
12-01-22
Kevin Hulse
P D528298
12-01-22
Pedro Marin
PD518I 11
12-01-22
Frank Carlos Morales
PD530797
12-01-22
Chris Navarro
P 529b98
12-01-22
Jonathon Saldana
P519247
12-01-22
Esteban Sanchez
PD524494
12-0 I -22
Michael Sierra
PMD,53
12-01-22
Alex Vazquez
P524336
12-01-22
Jonathon Guzman
PMD
12-01-22
Jose Gonzalez
PD528179
12-01-22
Christian Loaiza
PD535192
12-01-22
FE
3 nff
Packet iPg. 372
County of Monrole.
The Florida Keys
Monroe County Fire Rescue
490 63"6 Street ocean
Marathon, FL 33050
Phone (305) 289-6088
&EMORANDUM
TO: Nicole Rhodes
SUBJECT: Check for Deposit
I"! A-WR
Mayor Heather Caff uthers, District 3
Mayor Pro Tefn Michelle Coldiron, District 2
Craig Cates, District I
David Rice, District 4
Sylvia J. Murphy, District 5
Attached please find Check dated 02/24/2021, in the amount of $25.00, to be deposited in the
General Fund. This check has been issued for the renewal application of a Class A Certificate of Public
Convenience and Necessity for Ocean Reef Volunteer Fire Department.
Ocean Reef,Volunteer Fire dept.
Operating Account
Dockaide Lane #505
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Florida Regional Common EMS Protocols 4t" Edition Version 2 - Revision & Addition Form
Protocol
Number
Protocol Title
Date
Revision/Addition
New
F
Changed the version to 4.2 Edition effective date March 1, 2015
. Actions authorized for the
paramedic or the EMT (only with specific Medical Director
approval, i.e. establishing an n IV), prior to physician contact.
1.1
Intent of Protocols
Added paragraph on transporting all ALS pts and contacting hospital on
C-
all transports.
1.4
Death in the Field
Removed sentence on leaving/faxing report to Medical Examinar's
office.
Medical
Added - Hospital prenotification of all BLS or ALS (non -
1.7
Communications
interfacility) transported patients is recommended.
0
1.9
MCI
Added three bullets, designating a Triage Aide, designating multiple
U
RTF's and marking doors with victim counts.
C-
Added note (b), If Fentanyl was initially given IN and an IV is
2.1.5
Pain Management
then established, one IV dose (50 mcq) can be given if needed.
2.3.3
Narrow Complex -
Critical
Note b) removed Consider Amiodarone
Added under contraindications atrial fibrillation with Wolf Parkinson
5.4
Amiodarone
Hydrochloride
White (WPW). Changed iodine allergy warning from contraindication
to precaution.
Added - If Fentanyl was initially given IN and an IV is then
5.15
Fentanyl
established, one IV dose (50 mcg) can be given if needed.
Changed BP range from 100 to 90 mm Hg. Removed the sentence Once
the container is opened, nitroglycerin has a shelf life of 3 months.
5.28
Nitroglycerin
Patients should keep all but a few days' supply of the drug in the
n
refrigerator.
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4th Edition, Version 2 3/1/2015 Florida Regional Common EMS Protocols
Florida Regional Common
EMS Protocols
Section 1
General Protocols
4th Edition, Version 2, March 1, 2015
4Ih Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols
General Section Table of Contents
1.1 Intent and Use of Protocols
1.2 Behavioral Emergencies
1.3 Critical Incident Stress Management (CISM)
1.4 Death in the Field
1.5 Emergency Worker Rehabilitation
1.6 Helicopter Safety
1.7 Medical Communications
1.8 Refusal of Care
1.9 Mass Casualty Incidents
1.9.1 MCI Organizational Chart
1.9.2 Active Shooter Organizational Chart
1.10 Crime Scene Management
1.11 Protocol Revision Procedure
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 2
These medical treatment protocols have been developed as a part of the medical direction
program for participating Emergency Medical Services (EMS) agencies. The medical director of
an individual EMS provider may choose to modify certain treatment recommendations. In
addition, some patients may require therapy not specified in these protocols. The treatment
protocols should not be construed as prohibiting such flexibility. The paramedic/EMT must use
his/her judgment in administering treatment in the following manner:
• The paramedic may determine that no specific treatment is needed; or
• The paramedic may consult medical direction before initiating any specific treatment; or
• The paramedic may follow the appropriate treatment protocol and then consult medical
direction.
• The paramedic/EMT may contact medical direction at any time he/ she deems necessary.
When the paramedic/EMT is unable to make contact with other forms of medical direction,
he/she may contact the receiving hospital for consultation with the emergency department
physician. It is recommended that the paramedic/EMT make contact with the physician for
consultation on complicated patients whenever possible. When the paramedic is unable to make
contact with a physician for medical direction, the paramedic may administer BLS treatment
according to his/her judgment. In this instance, the paramedic may administer ALS treatment
only as authorized in the treatment protocols.
The definition of pediatric patients will be described below. It is imperative to understand that the
medical decision making for a pediatric patient should be based on the definitions provided below.
Transport (destination) decisions should be made using the Hospital Capability Form in Section 6.
Pediatric Medical Decision Definitions:
Newborn: A patient who has just been delivered.
Neonate: A patient who is younger than 6 weeks of age.
Infant: A patient who is under 1 year of age.
Child: A patient ranging from 1 year of age to puberty (pubic hair, facial hair, breast development)
Adolescent: A patient who has reached puberty. Treat these patients using adult protocols.
Transport Decision Definitions:
Pediatric: Trauma patient -15 years of age or younger
Medical patients - 17 years of age or younger.
The treatment protocols are divided into adult and pediatric sections, each with three parts:
Supportive Care: Actions authorized for the EMT or paramedic that are supportive in nature.
EMT (BLS) and paramedic (BLS and ALS) actions are specified within each of these protocols.
ALS Level 1: Actions authorized for the paramedic or the EMT (only with specific Medical
Director approval, i.e. establishing an IV), prior to physician contact.
ALS Level 2: Actions authorized only for the paramedic that require a physician consult.
Authorization of procedures prior to physician contact in Level 1 allows the paramedic to initiate
care promptly while getting a better idea of the patient's condition and evaluating his/her
response to initial treatment.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 3
The general protocols outline care for a typical case. As the protocol continues, the assumption is
usually made that previous steps were ineffective. For example, the protocol for ventricular
fibrillation authorizes three unstacked countershocks; however, the second countershock and
third countershock are given only if the previous countershock was unsuccessful and the patient
remains in ventricular fibrillation. If the patient went into asystole/PEA following the first
countershock, the second countershock would not be given. The paramedic would then use the
asystole/PEA protocol to guide further treatment. In this or other situations where a switch is
made to a different protocol during the course of care, the paramedic's judgment must determine
where entry into the new protocol sequence is appropriate.
It would be impractical to write protocols that specify every possible sequence of events. The
order of treatment listed here may not be appropriate for all situations. In fact, not all treatment
options may be indicated in every situation. The paramedic's judgment must be relied upon to
determine which of the authorized treatment procedures are appropriate for a given situation. The
treatment guidelines are given in bulleted list form as a general order of the steps necessary to treat
the patient; however, it is assumed that interventions such as patient assessment, airway
management, establishing medication access, applying AED/heart monitor, and so forth can be
performed simultaneously.
Orders listed in ALS Level 2 may be expected from the physician. They may or may not be the
orders that are actually given, however. The intention in listing ALS Level 2 orders is to allow for
appropriate preparation and to guide the paramedic who wishes to request specific orders. The
physician directing care in the field retains discretion in ordering specific treatment, even if that
treatment conflicts with these protocols. ALS Level 2 orders require consultation with a
physician.
The name of the physician authorizing ALS Level 2 orders must be documented in the patient
care report (PCR). Physicians authorized to approve ALS Level 2 orders include the following
individuals:
I . EMS provider's medical director (a).
2. Receiving hospital emergency department physician (a).
3. Physician present in his/her own office (b).
4. Online medical control physician (a).
5. Bystander physician personally known to the paramedic (c).
6. Bystander physician who presents a valid M.D. or D.O. (c).
7. Poison information center (d).
Note:
(a) Contact for ALS Level 2 orders by the EMS provider's medical director, online medical control
physician, or emergency department physician should be initiated in the following order:
1. Medcom.
2. Telephone.
3. Relay of information via dispatch.
(b) Only verbal or written orders that are signed by the physician that are given directly to the paramedic
by a physician in his/her office are acceptable.
(c) A bystander physician, as described above, must accept full responsibility for patient care and
accompany the patient in the ambulance to the hospital to give Level 2 orders.
(d) The Poison Information Center is authorized to direct all medical care (Supportive Care, ALS Level
1, and ALS Level 2) for the toxicology and hazardous material exposure patient. The Poison
Information Center must be contacted via telephone at 800-222-1222
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 4
This policy is intended to provide emergency departments with sufficient notification of
incoming patients to allow appropriate preparations to be made. Direct contact with the
physician in the emergency department needs be made only when seeking consultation or
authorization for ALS Level 2 orders.
An EMT or paramedic should evaluate all patients on responses to 911 emergencies, as deemed
appropriate by the individual EMS provider's medical director.
The treatment protocols have been designed as clinical guides, not as educational documents.
The therapeutic rationale behind the treatment protocols reflects the general principles of field
care outlined in the following standard EMS references.
Standard List of EMS Resources
Porter R, et al.: Essentials of Paramedic Emergency Care, Brady, Englewood Cliffs, NJ, current
edition
Nancy Caroline's Emergency Care in the Streets current edition
American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, Boston, 2014.
American Heart Association/American Academy of Pediatrics, Textbook of Pediatric Advanced
Life Support, Dallas, 2010.
American Heart Association, "2010 Guidelines for CPR and ECC," Supplement to Circulation
American Heart Association: ACLS Provider Manual, Dallas, TX, 2010.
American Heart Association/American Academy of Pediatrics: Textbook of Pediatric Advanced
Life Support, Dallas, TX, current edition 2012.
Walraven, G: Basic Arrhythmias, 7th edition, Brady, Englewood Cliffs, NJ, 2005.
Garcia, T. Miller, G; Arrhythmia Recognition, Jones and Bartlett, Sudbury Massachusetts.
Trauma NAEMT, Frame, Salomone: Pre -hospital Trauma Life Support, 7th edition, Mosby, St.
Louis, MO, current edition.
Campbell JE: Basic Trauma Life Support, Advanced Pre -hospital Care, 5th edition, Brady,
Englewood Cliffs, NJ.
Pain Control Paris P, Stewart R: Pain Management in Emergency Medicine, Appleton & Lange,
Norwalk, CN, 1988.
McCaffrey M, Pasero C: Pain Clinical Manual, 2nd edition, Mosby, St. Louis, MO, 1999.
Toxicology and Hazardous Materials Exposure, State of Florida Hazardous Material Protocols
Additional educational materials, supplementary to these references, are included in this manual as
Chapter 4 Medical Procedures.
Chapter 5 contains Drug Summaries for each of the drugs authorized in the treatment protocols
These documents are provided to clarify protocol items and issues that might differ from the
preceding references, or in which conflicts between references may occur.
4Ih Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols
GUIDING PRINCIPLES
1. Respect the dignity of the patient.
2. Assure physical safety of the patient and EMS personnel.
3. Diagnose and treat organic causes of behavioral disturbances such as hypoglycemia, hypoxia, or
poisoning.
4. Use reasonable physical restraint only if attempts at verbal control are unsuccessful. Every attempt
should be made to avoid injury to the patient when using physical restraint (Medical Procedure 4.23).
5. Teamwork between EMS personnel and law enforcement will improve patient care.
GENERAL APPROACH
1. Communicate in a calm and nonthreatening manner.
2. Offer your assistance to the patient.
3. Use reasonable physical force via law enforcement if the patient is a threat to themselves or to others.
USE OF RESTRAINTS
1. Physical.
a. Use standard restraining techniques and devices (Medical Procedure 4.23, Physical Restraints).
b. Use sufficient padding on extremity restraints on elderly patients or others with delicate skin.
2. Chemical.
a. Use chemical restraints in conjunction with physical restraints if the latter are unsuccessful in
controlling violent behavior.
b. Agents (Adult Protocol 2.5.2, Violent, Impaired Patient/Excited Delirium Syndrome).
3. Any type of restraints.
a. Constantly monitor and observe the patient to prevent injury. If physical and/or chemical restraints
are used, place the patient on an ECG monitor and pulse oximeter.
b. Carefully document the rationale for the use of restraints.
TREATMENT PROTOCOL
See Adult Protocol 2.5.2, Violent and/or Impaired Patient, for specific treatment protocols.
It may be appropriate for law enforcement to execute an involuntary certificate for psychiatric examination
(Baker Act - FS Chapter 394.463). However, such a certificate shall not be an absolute condition for
hospital transport.
TRANSPORTATION
1. All individuals being transported for psychological evaluation under the premises of the Baker Act
should be accompanied by a police officer. The paramedic in charge shall determine whether the police
officer will ride in the back or follow behind the Rescue Unit.
2. In those situations where a female patient is being transported and a female is not part of the rescue
crew, the paramedic should attempt to have a female police officer accompany the patient to the
hospital. (This is imperative in situations such as possible rape.) Also document the beginning and
ending mileages with dispatch via radio communication.
BAKER ACT
Florida Statute Chapter 394.463 Mental Health relates to the authorization of police, physicians, and the
courts to dictate certain medical care for persons who pose a threat to themselves or to others
INCAPACITATED PERSONS LAW
Florida Statute Chapter 401.445 allows for examination and treatment of incapacitated persons in
emergency situations. (Patients who are not capable of informed consent as provided in FS Chapter
766.103 cannot refuse medical care.) Florida Statutes may be viewed online at www.leg.state.fl.us/statues
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols
PURPOSE
Critical Incident Stress Management (CISM) is a comprehensive, integrated, multicomponent,
systematic program of crisis intervention. Its purpose is to provide education, support,
assessment, and intervention for emergency ser-vice personnel who are often exposed to and/or
affected by critical incidents. CISM was born out of emergency services and has become a world
standard of care for first responders. Formulated and standardized by the International Critical
Incident Stress Foundation (ICISF), CISM has proven to be effective in mitigating many of the
common symptoms of critical incident stress. The goal when applying any of the CISM
components is to assess, educate, and intervene as necessary and return individuals to their work
with the tools and support needed to reduce the effects of a critical incident. The benefits of the
intervention include a reduction in symptoms of post -traumatic stress, quicker return to normal
productive functioning, increased job satisfaction, reduced worker's compensation claims,
reduced absenteeism and presenteeism, reduced errors, enhanced group cohesion, increased
personal confidence and extended longevity.
OVERVIEW
The Broward County CISM Team (Broward Region X CISM) is made up of trained and
credentialed members of law enforcement, fire/rescue, corrections, communications, and others,
as well as trained, credentialed, and licensed mental health professionals, all of whom have
completed at least three (3) of the core ICISF courses. Broward's CISM Team is independent of
any other organization or department in Broward County. The team is designed and organized to
respond to any incident that occurs in any emergency services department or agency in Broward
County on a 24 X 7 X 365 basis, within a maximum of two (2) hours after a critical incident has
occurred and CISM services are requested. The team meets on a periodic basis for additional
training and information.
CONFIDENTIALITY
Florida Statute 401.30(4) (e) protects the discussions held during a CISM intervention as being
"confidential and privileged communication under section 90.503." Therefore, all information
shared during any part of a CISM intervention is held in the strictest of confidence.
CISM SERVICES
The following types of services can be provided by the Broward CISM Team.
A. Pre -event planning and preparation.
1. Educational and informational programs about CISM.
2. Pre -incident planning and education.
B. Strategic planning and assessment.
1. Pre- and post -incident assessment of needs.
2. Development and implementation of a strategic plan for major events.
C. Individual intervention.
1. One-on-one services with a qualified CISM team member.
2. Individual support and follow-up.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 7
D. Small group defusing.
1. Recommended within the first 12 hours after a critical incident occurs.
2. Best delivered as soon as possible after a critical incident.
3. Homogeneous groups.
4. Assessment and education with possible referral and follow-up.
E. Small group debriefing.
1. 12-72 hours post -critical incident.
2. Prior to demobilization from extended deployment or upon return home from extended
deployment.
3. Events of significant personal loss (expanded -phase defusing within first 12 hours).
F. Crisis management briefing.
1. Appropriate for large incidents, incidents with high media involvement, respite/rehab
centers, and demobilizations.
2. Best for large groups or mixed groups.
3. Primary focus on assessment and information.
G. Family crisis intervention.
H. Organizational consultation.
L Assessment of organizational needs.
J. Development and recommendation for coordination and delivery of services.
K. Pastoral/spiritual crisis intervention.
L. Referral and follow-up.
CISM CALL -OUT BASIS
A critical incident is any situation that is either out of the norm or that challenges or would
appear to challenge a person's normal coping mechanisms. Examples include the following
situations:
• Pediatric injury or death
• Multiple youth fatalities
• Events with severe operational challenges
• Line -of -duty death or line -of -duty injury
• Officer involved in a shooting
• Off -duty death, suicide, homicide, or injury
• Events with multiple or mass casualties
• Prolonged events with loss of life
• Events when the victim(s) is (are) known
• Events with excessive media interest
• Any incident that could perceivably cause emotional impact
Emergency responders work under stressful conditions and situations. Training and continuing
education about stress management contribute to the development and maintenance of improved
emotional health, stress resistance, and resilience. Statistics demonstrate significantly higher
instances of drug and alcohol abuse, marital and family strife, intimate -partner and domestic
violence, heart attack, and suicide rates among emergency services personnel compared to the
general population. These facts underscore the need for CISM services in any situation similar to
those in the preceding list. Because one of the positive benefits of a group intervention is
stronger group cohesion, all members of the group are encouraged to be present.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 8
CISM ACTIVATION PROCESS EXAMPLE (BROWARD COUNTY)
A. Requesting agency officer contacts the Communications Captain on duty at the Broward Regionz
Communications Center, requesting a CISM Team response.
B. Communications Center number: 954-765-5100.
C. Requesting agency shall supply the following information:
1. Agency name.
2. Type of incident.
3. Number of members involved.
4. Call-back contact number or pager number.
D. The Communications Captain shall page out the on -call CISM Team Leader.
CISM CALL -OUT PROCEDURE
1. When a critical incident event occurs or when an on/off scene command determines that an
incident may or could have an emotional impact on the responding personnel, department, or
agency, any person authorized to do so shall contact the Broward Regional Communication
Center at 954-765-5100 and requests a CISM response, giving a brief description of the
event, the caller's name, and his/her contact information.
2. The Broward Regional Communication Center shall contact the on -call CISM Team
coordinator and, at the same time, pages and/or sends a text message to all members on the
CISM Team list.
3. The CISM Team Coordinator contacts the CISM Team Clinical Director or designee and
provides the incident contact name and number. The CISM Team Coordinator then begins
assembling peer team members for a response. No team member from the affected
department, agency, or organization will be part of the responding CISM Team.
4. The CISM Clinical Director contacts the site or incident contact person, receives details
about the incident, and advises the contact of the appropriate type and timing of the
response.
5. Once the type, timing, and location of the response are determined, the Clinical Director
contacts the Team Coordinator with the information necessary to conduct the appropriate
intervention. The Clinical Director then contacts mental health members for the intervention
as needed.
6. Upon arrival at the determined site, the CISM Team members assemble for a briefing with
the Team Leader and then meet with the contact person or designee.
7. Personnel are assembled according to type, in a quiet and secure location. All personnel shall
be either off -duty or out of service for the duration of the intervention and related services.
8. In the case of a critical incident stress defusing or debriefing, personnel are assembled
according to rank, involvement in the incident, proximity to the incident, as determined by
the responding Team Leader.
9. No written, audio, or video recording of the intervention shall be permitted.
10. The CISM Team consults with the contact person to provide general recommendations or for
possible follow-up.
11. The CISM Team gathers for a team debriefing.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 9
This protocol is divided into separate sections that cover the different situations involving death
in the field that the paramedic will encounter. All patients found in cardiac arrest will receive
cardiopulmonary resuscitation unless an exception is met as outlined in the following sections:
L Advanced Directives/Do Not Resuscitate Orders (DNRO).
11. Determination of Death.
III. Discontinuance of CPR.
IV. Documentation
ADVANCED DIRECTIVES/DO NOT RESUSCITATE ORDERS (DNRO)
1. Legislative authority. Under Florida Administrative Code (FAC) 64J-2.018. Do Not Resuscitate
Order (DNRO) Form and Patient Identification Device. The Florida DNRO form is the only
form approved in the State of Florida. If there is a DNRO/POLST/MOST/MOLST (see 1.8)
form from another State presented by the patient or family, contact Medical Control as soon as
possible for direction.
2. An EMT or paramedic shall withhold or withdraw cardiopulmonary resuscitation:
a. Upon the presentation of an original or a completed copy of DH Form 1896, Florida Do Not
Resuscitate Order Form, December 2004, which is incorporated by reference and available
from DOH at no cost, or, any previous edition of DH Form 1896; or
b. Upon the presentation or observation, on the patient, of a Do Not Resuscitate Order patient
identification device.
3. The Do Not Resuscitate Order:
a. Form shall be printed on yellow paper and have the words "DO NOT RESUSCITATE
ORDER" printed in black and displayed across the top of the form. DH Form 1896 may be
duplicated, provided that the content of the form is unaltered, the reproduction is of good
quality, and it is duplicated on yellow paper. The shade of yellow does not have to be an
exact duplicate;
b. Patient identification device is a miniature version of DH Form 1896 and is incorporated by
reference as part of the DNRO form. Use of the patient identification device is voluntary and
is intended to provide a convenient and portable DNRO which travels with the patient. The
device is perforated so that it can be separated from the DNRO form. It can also be hole -
punched, attached to a chain in some fashion and visibly displayed on the patient. In order to
protect this device from hazardous conditions, it shall be laminated after completing it.
Failure to laminate the device shall not be grounds for not honoring a patient's DNRO order,
if the device is otherwise properly completed.
4. The DNRO form and patient identification device must be signed by the patient's physician. In
addition, the patient, or, if the patient is incapable of providing informed consent, the patient's
health care surrogate or proxy as defined in Section 765.101, F.S., or court appointed guardian
or person acting pursuant to a durable power of attorney established pursuant to Section 709.08,
F.S., must sign the form and the patient identification device in order for them to be valid. The
form does not need to be nototrized, once signed the form does not expire.
5. An EMT or paramedic shall verify the identity of the patient who is the subject of the DNRO
form or patient identification device. Verification shall be obtained from the patient's driver
license, other photo identification, or from a witness in the presence of the patient. If a witness is
used to identify the patient, this fact shall be documented in the EMS Run Report, which must
include the following information:
a. The full name of the witness.
b. The address and telephone number of the witness.
c. The relationship of the witness to the patient
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 10
6. During each transport, the EMS provider shall ensure that a copy of the DNRO form or the
patient identification device accompanies the live patient. The EMS provider shall provide
comforting, pain -relieving and any other medically indicated care, short of respiratory or
cardiac resuscitation.
7. A DNRO may be revoked at any time by the patient, if signed by the patient, or the patient's
health care surrogate, or proxy or court appointed guardian or person acting pursuant to a
durable power of attorney established pursuant to Section 709.08, F.S. Pursuant to Section
765.104, F.S., the revocation may be in writing, by physical destruction, by failure to present
it, or by orally expressing a contrary intent.
8. Oral orders from nonphysician staff members or telephoned requests from an absent
physician do not adequately assure EMT/paramedics that the proper decision -making process
has been followed and are NOT acceptable.
9. In the near future Florida will be adopting POLST (Physician Orders for Life Sustaining
Treatment Paradigm) The National POLST Paradigm is an approach to end -of -life planning
that emphasizes patients' wishes about the care they receive. The POLST Paradigm is an
approach to end -of -life planning emphasizing: (i) advance care planning conversations
between patients, health care professionals and loved ones; (ii) shared decision -making
between a patient and his/her health care professional about the care the patient would like to
receive at the end of his/her life; and (iii) ensuring patient wishes are honored. As a result of
these conversations, patient wishes may be documented in a POLST form, which translates
the shared decisions into actionable medical orders. The POLST form assures patients that
health care professionals will provide only the care that patients themselves wish to receive,
and decreases the frequency of medical errors. POLST is not for everyone. Only patients
with serious illness or frailty should have a POLST form. For these patients, their current
health status indicates the need for standing medical orders. For healthy patients, an Advance
Directive is an appropriate tool for making future end -of -life care wishes known to loved
ones. Several States use the POLST program and there several other forms used by these
States, Medical Orders for Life Sustaining Treatment (MOLST), Medical Orders for Scope
of Treatment (MOST) and the Physician Orders for Scope of Treatment (POST) form.
Specific Authority 381.0011, 401.45(3) FS. Law Implemented 381.0205, 401.45, 765.401 FS.
History New 11-30-93, Amended 3-19-95, 1-26-97, Formerly IOD-66.325, Amended 2-20-00,
11-3-02, 6-9-05, Formerly 64E-2.031.5.
II. DETERMINATION OF DEATH
The EMT or paramedic may determine that the patient is dead/non-salvageable and decide not to
resuscitate the patient under the following guidelines.
A. The patient may be determined to be dead/non-salvageable and will not be resuscitated or
transported if all four (4) presumptive signs of death and at least one (1) conclusive sign of
death are identified.
1. The four presumptive signs of death that MUST be present are:
a. Unresponsiveness.
b. Apnea.
c. Pulseless.
d. Fixed dilated pupils.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols I I
2. In addition to the four presumptive signs of deaths, at least one (1) of the following
conclusive signs of death MUST be present:
a. Injuries incompatible with life (e.g., decapitation, massive crush injury, incineration).
b. Tissue decomposition.
c. Rigor mortis of any degree with warm air temperature. (Hardening of the muscles of
the body, making the joints rigid).
d. Liver mortis (lividity) of any degree. (Venous pooling of blood in dependent body
parts causing purple discoloration of the skin, which does blanch with pressure).
3. Patients with suspected hypothermia, barbiturate overdose, or electrocution require full
ALS resuscitation unless they have injuries incompatible with life or tissue
decomposition.
4. EMS personnel may contact medical direction for a "determination of death" whenever
support in the field is desired. Clearly state the purpose for the contact as part of the
initial hailing.
5. Children are excluded from this protocol unless EMS personnel make contact with
medical direction for consultation. Only in cases of obvious, prolonged death should CPR
not be started or discontinued on infants, children, or young adults, or in cases in which
an unexpected death has occurred.
B. A trauma victim who does not meet the "Determination of Death" criteria listed above may
be determined to be dead/non-salvageable based on the following criteria:
1. Pulselessness and apnea associated with asystole (confirmed in two leads) and
a. Blunt trauma arrest.
b. Prolonged extrication time (more than 15 minutes) where no resuscitative measures
can be initiated prior to extrication.
1) An additional rhythm assessment is required, followed by at least one
reassessment after 15 minutes.
c. Arrest from primary brain injury or with no brain stem reflexes; arrest from blunt
multiple injuries.
2. If there is any concern regarding leaving the patient at the scene, begin resuscitation and
transport.
3. Consideration should be given for the possibility of organ harvest; however, this should
not be the sole reason for resuscitation.
C. Absence of pulse or spontaneous respiration in a multiple -casualty situation where EMS
resources are required for stabilization of living patients.
The local law enforcement agency that has jurisdiction will be responsible for the body once
death has been determined. The body is to be left at the scene until a disposition has been made
by the Medical Examiner's Office or the local jurisdiction.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 12
III. DISCONTINUANCE OF CPR
A. Resuscitation that is started in the field by EMS personnel cannot be discontinued without an
order from medical direction.
B. EMS personnel are not obligated to continue resuscitation efforts that were started
inappropriately by others at the scene.
C. When there is a delay in presenting a DNRO to EMS personnel, resuscitation must be sta
However, once the DNRO is presented to EMS personnel, the EMT or paramedic with an order i
medical direction may terminate resuscitation.
D. A paramedic with an order from medical direction may terminate resuscitation provided the
following criteria are met:
1. Appropriate BLS and ALS have been attempted without restoration of circulation and
breathing.
2. Advanced airway has been successfully accomplished.
3. Intravenous (IV, IO, ETT) medication and countershocks for ventricular fibrillation have
been administered according to the appropriate treatment protocol(s) (Adult Protocols or
Pediatric Protocols).
4. Persistent asystole or agonal ECG patterns are present and no reversible causes are
identified.
5. Patients with suspected hypothermia, barbiturate overdose, or electrocution require full
ALS resuscitation, unless they have injuries incompatible with life or tissue
decomposition.
E. Provide appropriate grief counseling or support to the patient's immediate family,
bystanders, or others at the scene.
1. Provide family members with appropriate referral information, if available.
F. Patient preparation.
1. Once it has been determined that the patient has died and resuscitation will not
continue, cover the body with a sheet or other suitable item. Do not remove any
property from the body or the scene for any purpose.
2. If the death is a suspected homicide (crime scene), do not cover the body (General
Protocol 1.13).
3. Immediately notify the appropriate law enforcement agency (if not done already), and
remain on scene until their arrival.
4. Complete the EMS Run Report, documenting the previously mentioned criteria.
5. ECG rhythm documentation must be attached to the EMS Run Report.
6. Advanced airway placement may be verified by two paramedics for patients who are
determined to be dead in the field or for whom resuscitation measures have ceased.
The advanced airway should be left in place and its confirmation should be recorded
on the EMS Run Report. Improperly placed advanced airway tubes should be left in
place and reported to the appropriate personnel. (Proper advanced airway tube
placement must be confirmed prior to terminating resuscitation.)
7. Consult the patient's family for "organ donor" information, if appropriate.
IV. DOCUMENTATION
1. All death in the field patients need to have proper documentation on the EMS run report.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 13
MEDICAL EVALUATION OF EMERGENCY WORKERS ON EMERGENCY
INCIDENTS OR TRAINING EVOLUTIONS
A. Purpose: Emergency operations require significant physical activity, but no rescuer will
be required to perform emergency operations beyond safe levels of physical or mental
endurance. This protocol is intended to examine and evaluate the physical and mental
status of emergency workers working on an emergency incident or a training exercise and
determine which treatment, if any, is necessary. Personnel rehabilitation using
appropriate protocols in this area will decrease injury risk and enhance recovery for later
emergency operations.
B. Implementation: A Rehabilitation Area (Rehab Area) will be set up at the discretion of
the Incident Commander. It is recommended that a Rehab Area be utilized at all working
incidents to provide a staging area for on -scene personnel, as well as an immediate source
of personnel for rescue or aid, and an area for recovery and rehabilitation of emergency
workers. When a Rehab Area has been deemed necessary by the Incident Commander
(IC), the first available EMS unit will be responsible for the management and
coordination of the Rehab Area.
C. Location: Establish a Rehab Area away from environmental hazards (e.g., in a shady,
cool place that is, upwind and away from smoke and traffic) that is readily accessible to
rescue personnel for transport and supplies. Air truck and canteen service will be
stationed in this area. Multiple Rehab Areas may be needed on large incidents. If a
specific location has not been designated by the IC, the Rehab Officer shall select an
appropriate location based on the following site characteristics:
I . The Rehab Area should be in a location that will provide physical rest by allowing the
body to recuperate from the demands and hazards of the emergency operation or
training evolution.
2. It should be far enough away from the scene that members may safely remove their
turnout gear and self-contained breathing apparatus (SCBA) and be afforded mental
rest from the stress and pressure of the emergency operation or training evolution.
3. It should provide suitable protection from the prevailing environmental conditions.
During hot weather, it should be in a cool, shaded area. During cold weather, it
should be in a warm, dry area.
4. It should enable members to be free of exhaust fumes from apparatus, vehicles, or
equipment (including those involved in the rehabilitation group operations).
5. It should be easily accessible by EMS units.
6. It should allow prompt reentry back into the emergency operation upon complete
recuperation.
D. Resources: The Rehab Officer shall secure all necessary resources required to adequately
staff and supply the rehabilitation area. The supplies should include the following items:
I. Fluidswater, activity beverages, oral electrolyte solutions, and ice.
2. Food (for extended operations where crews are engaged for 3 hours or more) soup,
broth, or stew in hot/cold cups.
3. Medical equipment —blood pressure cuffs, stethoscopes, oxygen administration
devices, cardiac monitors, intravenous solutions, thermometers, and pulse oximeters
(which include the ability to monitor SpCO).
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4. Other - awnings, "cool zone" misting fans, cooling chairs, heaters (according to
climate), towels, and tarps.
E. Staffing: Assign a minimum of two rescue personnel to monitor and assist fire fighters in
the Rehab Area. An appointed Rehab Officer shall oversee the rehab operations. Their
responsibility is to oversee provision of food, fluids, medical monitoring, establish and
maintain an appropriate environment for rehab and rehabilitation operations in the area.
These personnel will oversee the rehabilitation and availability for work of all emergency
responders placed in this area.
F. Medical evaluations: When the Incident Commander has established a Rehab Area, fire
fighters and other emergency responders shall be evaluated following (a):
I. The use of two SCBA bottles and/or 30 minutes of strenuous activity (e.g., use of
chemical PPE, advancing hose lines, forcible entry, ventilation) (b).
2. SCBA failure.
3. Weakness, dizziness, chest pain, muscle cramps, nausea/vomiting, altered mental
status, difficulty breathing, and other stress -related symptoms (c).
4. At the discretion of the Incident Commander, Rehab Officer, Safety Officer, CISM
Coordinator, and Company Officer.
Note:
(a) A medical evaluation form shall be completed on all personnel entering the Rehab Area and
before they return to emergency work.
(b) This does not preclude an officer from having a team member evaluated if he/she deems it
appropriate. A member may be evaluated any time he/she feels it necessary.
(c) All personnel receiving ALS treatment and transport will have a patient care report
completed for them.
G. Examination: EMS personnel should evaluate persons arriving to the Rehab Area as they
appear. Arriving emergency workers must be questioned regarding any medical
symptoms, be asked about any injury resulting from incident work, and have assessment
of appropriate vital signs. Examination shall occur at I0-minute intervals and will involve
a minimum of:
I. Glasgow Coma Scale (GCS) score.
2. Pupillary response.
3. Vital signs (BP, P, R, CR).
4. ECG (if applicable).
5. Lung sounds.
6. Skin condition.
7. Signs and symptoms.
8. Oral temperature.
9. Pulse oximetry.
a. Arterial oxygen saturation (SPO2).
b. Carboxyhemoglobin saturation (SpCO).
An EMS Run Report and a Casualty Report shall be completed for each fire fighter or
other emergency worker who is not routinely returned to emergency operations.
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H. Guidelines for rehab: The following will occur:
1. Normal presentations: The emergency responder will rehydrate and rest before
reporting to Manpower. Rest shall not be less than 15 minutes.
2. Abnormal presentations:
a. Blood pressure values that are higher or lower than the person's usual level.
b. SpO2 values less than 94%.
c. Values for the pulse rate in an emergency responder will normally be less than
100 beats per minute (BPM) at rest and less than 120 BPM at a working incident.
At no time should the pulse exceed 180 BPM.
d. Values for carbon monoxide (CO) oximetry will normally be 5% for a nonsmoker
and less than 8% for a smoker. A CO oximetry reading of more than 12%
indicates moderate CO inhalation; a reading of more than 25% indicates severe
inhalation of CO.
3. Body temperature greater than 100.6 F
3. Management.
a. The emergency responder will rehydrate and rest. The emergency responder will
report to Manpower when presentations are normal. Presentations should return to
normal within 15 minutes.
b. If a team member's heart rate exceeds 110 BPM, an oral temperature should be
taken. If the oral temperature exceeds 100.6 F, the member should not be
permitted to wear protective equipment and should be treated for heat stress and
monitored for worsening of the heat emergency (i.e., heat exhaustion and heat
stroke).
c. The emergency responder will receive ALS treatment and transport if
presentations are abnormal for more than 15 minutes. Abnormal presentation
includes the following signs and symptoms:
1) SP02 value less than 94%.
2) Persistent heart rate greater than 120 BPM (lasting for 15 minutes or longer).
3) Any emergency worker with a CO oximetry reading of more than 8% but less
than 15% must be given the opportunity to breathe ambient air for 5 minutes.
4) If the CO oximetry reading is still higher than 8%, the emergency worker
should be given oxygen via mask until the value drops below 5%. Any worker
with a CO oximetry reading of more than 25% must be completely evaluated
and removed to a hospital, preferably one that has a hyperbaric chamber. No
emergency worker should leave the Rehab Area until his/her CO level is less
than 8%.
5) Blood pressure above or below the emergency worker's normal level.
6) Symptoms of heat stroke.
7) Oral temperature greater than 100.6 F, lasting longer than 15 minutes (after
oxygen administration).
d. Any emergency responder with chest pain, difficulty breathing, and altered mental
status will receive immediate ALS treatment and transport.
e. Any other abnormal presentation not specified herein, where the examining
paramedic's judgment determines a need for treatment and transport will be
managed accordingly.
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L Treatment: Treatment will consist of one or more of the following measures. Prior to
taking anything orally, the emergency responder will clean his/her hands and face. On -
scene rescue personnel will provide water and a cleaning agent.
1. Remove bunker gear
2. Rest
3. Oral rehydration and nutrition (air truck, canteen service); minimum of 1 to 2 quarts
of fluids over a 15-minute time period (water then full strength electrolyte drink).
Avoid any substance containing caffeine (e.g., sodas, coffee, tea).
a. Members should consume at least 1 quart of water per hour.
b. Members shall rehydrate with at least 8 ounces of fluid while SCBA cylinders are
being changed.
4. Oxygen.
5. Cool environment utilizing "cool zone" fans and/or "cooling chairs" if available (e.g.,
shade, electric fan, air conditioning, showers).
6. For extended operations lasting 3 or more hours, the Rehab Area should provide food
such as soup, broth, or stew; these items are digested much faster than sandwiches
and fast-food products. In addition, foods such as apples, oranges, and bananas
provide supplemental forms of energy replacement. Fatty and/or salty foods should be
avoided.
7. Follow ALS/BLS protocols for further treatment.
J. Return to emergency duties: Members assigned to the rehabilitation group shall enter
and exit the Rehab Area as a crew. The crew designation, number of crew members,
and the times of entry to and exit from the Rehab Area shall be documented by the
Rehab Officer or his/her designee on the check-in/out sheet. Crews shall not leave the
Rehab Area until authorized to do so by the Rehab Officer. Report to Manpower or
Incident Commander when the following criteria have been met:
a) Vital signs within normal limits.
b) Absence of abnormal signs and symptoms.
c) Minimum period of 15 minutes for rest and rehydration.
d) Released by Rehab Officer.
K. Documentation: A Rehab Medical Evaluation Form shall be completed for all personnel
evaluated in the Rehab Area and forwarded to the appropriate Rescue (EMS) Division
following all applicable patient confidentiality guidelines (e.g., HIPAA). A complete
patient care report (PCR) shall be completed for any member who receives
treatment/transport.
See Section 6 or Online Forms for the Emergency Worker Rehabilitation Form
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COMMUNICATION PROCEDURES
The standard dispatch for an Air Rescue assignment should be one (1) engine company and one
(1) rescue. The need for additional units should be dictated by the incident circumstances. It
should be kept in mind that the unit assigned as the hell -spot (HS) group may need all of its
personnel to properly secure the HS site. This may create the need for additional units to address
patient care needs. Dispatchers should not take it upon themselves to modify this assignment, nor
should they suggest modification of the assignment. As with any Fire Department assignment,
the only personnel who can modify the assignment are Uniformed Fire Department Officers.
See General Protocol 1.10, Trauma Transport, Helicopter Transport Protocol.
HELI-SPOT PROCEDURES
Rescue Units, when requesting an Air Rescue assignment, should not concern themselves with
an HS unless they know of one at or very near the incident site. The rescue personnel should
concern themselves with proper and rapid patient packaging. In the event that the unit assigned
as the HS group experiences difficulties in finding an HS, they should wait until Air Rescue
arrives. Air Rescue has a better vantage point in choosing an HS, and its personnel will advise
the HS group.
In the event that the HS is remotely located and appears to be safe for landing, the Pilot in
Command (PIC) may elect to land without the assistance of an HS sector. This does not mean
that the unit assigned to the HS should be canceled. These team members will be utilized for
security, safety, and patient loading once the helicopter is on the ground. The Pilot in Command
(PIC) is both legally and operationally responsible for the safety of the aircraft. There -fore, the
final decision of the suitability of the HS site is that of the PIC.
When setting up an HS, there are several things to keep in mind:
1. The HS should be set up as to facilitate takeoffs and landings into the wind. (Do not rely on
dispatch for correct wind direction; use visual indicators.)
2. If the HS group Officer in Command (OIC) is not sure of the wind direction or the direction
from which the helicopter should approach, then he/she should wait until the helicopter is in
the area and confer with the Air Crew on this decision.
3. The approach and departure ends of the HS should be clear of obstacles (any object more
than 40 feet tall that is within 100 feet of the HS).
4. Debris such as wood, cans, and plastic should be removed from the HS. Flying debris can do
damage to both the helicopter and personnel on the ground.
5. To minimize the hazard of blowing sand and dust, the HS should be hosed down (may be
hosed down as necessary).
6. Once the helicopter has landed, the Marshaller should post a minimum of one tail rotor
guard (two, if available). This person should be someone other than the Marshaller. The
Marshaller shall remain at his/her post until the aircraft departs.
7. No unauthorized personnel shall be permitted to approach the helicopter. This is the general
responsibility of all Fire Department personnel, but it is most definitely the overall combined
responsibility of the PIC and the HS group OIC.
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8. The HS group should assure that the Rescue Unit personnel are supplemented with an
appropriate number of personnel to assist in the safe and efficient loading of patients into the
helicopter.
9. Once the helicopter has landed, the Marshaller should confer with the Air Crew as to the
helicopter's departure.
10. It is not necessary to have a hose line pulled and charged. In the event of a catastrophic event
involving the helicopter, tactics and strategy will be left up to the Incident Commander.
The Marshaller is one of several tools that are at the disposal of the PIC for the accomplishment
of a safe landing and departure. The PIC considers several factors when making an approach or
departure into a confined area. As a consequence, he/she may not always follow the exact
direction of the Marshaller. Note that most approaches will be to the ground, not to a hover. The
PIC, at his/her discretion, may elect to land without the assistance of a Marshaller and may
request that the Marshaller remain clear of the HS until after the helicopter has landed. If the PIC
does not follow the exact direction of the Marshaller, be assured there are reasons for his/her
actions.
REVIEW YOUR MARSHALLING HAND SIGNALS
A. Marshalling.
1. Positioning.
a. The Marshaller will stand at the outer edge of the HS perimeter on the windward
side, with his/her back to the wind.
b. The Apparatus Lieutenant/Captain will have the primary responsibility for the
marshalling duties.
c. An additional fire fighter who is assigned to the Marshaller will maintain constant
radio contact with the helicopter as well as visual and verbal contact with the
Marshaller.
d. Remain in eye contact with the pilot at all times.
e. Do not approach the helicopter; remain vigilant at your post.
2. Equipment.
a. Helmet with chin strap tightly secured.
b. Goggles on or visor down.
c. Gloves.
d. Full bunker gear with collar up.
e. Flash lights with wands for night operations.
3. Safety precautions and procedures.
a. Stay well clear of the tail rotor area.
b. Use caution when traversing uneven terrain.
c. Approach the helicopter in the pilot's field of vision and ONLY after an "All
Clear" signal has been given by a helicopter crewmember.
d. Use low crouch when approaching and departing the helicopter.
e. Do not use road flares. Do not shine spotlights or headlights at the helicopter or
into the HS. The pilot will utilize the "night sun" to light up the HS as needed.
Shining lights or strobes at the HS may cause vertigo, night blindness, or seizures
of the pilot.
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RESCUE UNIT PROCEDURES
The Rescue Unit OIC has the primary responsibility of patient care and should not become
overly concerned with the availability of an appropriate HS. The following points should be kept
in mind when deciding on Air Rescue as the mode of transport for the patient:
1. Make the decision to transport by air early. Have Air Rescue dispatched by the
Incident Commander. Even if you are not sure that a patient meets the established
criteria for air transport, place Air Rescue on standby status. You can always cancel
the standby.
2. It is imperative that the ground Rescue Unit contact the receiving facility prior to
Air Rescue's on -scene arrival. This will preclude any delay in transportation in the
event the receiving facility cannot accept the patient. This early advisory is also
necessary to allow the hospital time to prepare for an Air Rescue arrival. Air Rescue
may monitor the medical channel and receive patient information while it is given
to the receiving facility from the ground Rescue Unit.
3. Relaying information concerning HS location and any hazards is a priority (this
information may be relayed to the Air Rescue team after they are airborne). The
only patient information that the Rescue Unit needs to advise the Incident
Commander about when requesting Air Rescue is the number of patients and the
designated receiving facility. The ground Rescue Unit should not spend time
advising Air Rescue of patient conditions over the incident frequencies. That time
would be better spent communicating with the receiving facility.
4. There is no reason to provide the Air Rescue crew with a completed EMS Run
Report. This may create an undue delay in the transportation of the patient. A "hard
copy" of whatever information you do have should be provided to the Flight Medic.
5. All bandages and dressings shall be affixed securely
6. The patient will be secured to a backboard with a minimum of three (3) straps, unless
contraindicated by his/her medical condition. If the patient is unruly, place an
additional strap above the knees. Having a patient lie on a backboard with the head
immobilized and nothing securing the body is unacceptable. In the event that straps
are not available, another method of securing the patient should be improvised.
7. A minimum of four (4) personnel, one of whom will be a member of the Air Rescue
crew, will carry the stretcher. Each member of this team should have a helmet with
face shield and chin strap in place when loading the patient.
8. If the patient is difficult to carry, a stretcher may be utilized, provided the sheets,
pillow, and mattress are removed.
9. The key to saving a trauma patient who requires surgical intervention is speed. Do not
delay transport for invasive procedures other than those necessary to maintain the
patient's airway. Most invasive procedures can be done while en route to the Trauma
Center.
10. Be aware of the time you are on the scene with the patient. Attempts at certain
procedures may be perceived as progressing at a rapid pace, but in reality they are
taking an extended period of time that can better be used in moving the patient.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 20
11. Advise the Air Rescue Unit if you have any need for additional equipment or
assistance (e.g., for managing patient airway difficulties).
12. Remain at the incident side (or at least 100 feet from the HS) until the helicopter has
landed.
13. Absolutely no personnel should approach the helicopter unless cleared "in" by an Air
Rescue crew member.
a. Do not approach the helicopter with a patient unless escorted by an Air Rescue
crew member.
b. It is the responsibility of all Fire/Rescue/EMS personnel to ensure that any and all
unauthorized persons are prevented from approaching the helicopter. This is
usually accomplished with visual and verbal warnings, but in some instances may
require physical intervention.
14. In the event that the Air Rescue crew requires assistance with patient care, the
ground paramedic in charge of patient care will accompany the patient during air
transport. In this event, the ground paramedic, with Air Crew approval, will bring
any equipment necessary to affect patient care during air transport. Any additional
Fire/Rescue personnel will be determined by the Air Rescue crew and the ground
paramedic in charge of patient care.
References
Broward County Aeromedical Transport Program
Miami -Dade Air Rescue Assignment Procedures
U.S. Coast Guard Helicopter Procedures
The hell -spot shall be a minimum of 100' X 100' (HS size may be increased by local
protocol).
4Ih Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 21
Hospital prenotification of all BLS or ALS (non-interfacility) transported patients is
recommended.
On initial contact by the paramedic with the supervising emergency physician, the following
information should be communicated in this sequence:
1. Priority code and receiving facility
2. Rescue number/paramedic's name
3. Patient's age/sex
4. Patient complaint or major problem/time of onset
5. Assessment: mental status, ROM, pupils, skin, BBS, BP, P, R, ECG, hemodynamic condition
6. Glasgow Coma Scale (GCS) score
7. Mechanism of injury
8. History of illness, medications used, allergies
9. Treatment given
10. Estimated time of arrival
MEDCOM PRIORITIES
Priority I: Critical
Used only for patients who present with an immediately life -threatening illness or critical injury.
As outlined in Trauma Alert Protocol.
Priority II: Serious
Used for those patients who present with an illness or injury requiring immediate medical
intervention and that has the potential for becoming life -threatening if not treated promptly.
Priority III: Stable
Used for those patients who present with an illness or injury not requiring immediate medical
intervention or that is so easily managed that medical direction is not required. Also used for
notification of impending patient arrival to the receiving facility.
Priority IV: Administrative Traffic (Optional)
Used for all transmissions not involving care of a patient, such as radio checks, calibration test,
and administrative traffic.
MEDCOM CLASSIFICATIONS: Adult or Pediatric, Cardiac, Medical, OB, Trauma
TRAUMA PRE -ALERTS
A Trauma Pre -alert is communicated via Fire Dispatch after initial patient contact (a second
contact must be made via Medcom en route to the hospital) and must include the following
information:
1. Rescue number/paramedic's name calling the alert.
2. Name of receiving trauma center.
3. Category (adult, pediatric, or obstetrical).
4. Trauma alert criteria.
5. Patient's sex.
6. Number of patients.
7. Estimated time of arrival to the receiving facility, via ground or air.
See the County Uniform Trauma Telemetry (CUTT) Report located in section 6 and on-line forms
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 22
POLICY
Any and all individuals who are involved as patients or potential patients should receive proper
evaluation, treatment, and transportation to the appropriate medical facility. There may be times
when this policy may not be carried out due to a refusal of care. The refusal of care procedure
should be utilized in situations in which a patient refuses evaluation, treatment, and/or
transportation by prehospital personnel. Persons should be presumed competent to make
decisions affecting their medical care. In cases of minors, attention should be given to signs of
child abuse (Appendix 6.2).
DEFINITIONS
A. Patients able to refuse care.
1. A person can refuse medical care based on the following guidelines:
a. Competent —defined by the ability to understand the nature and consequences of
his/her actions by refusing medical care and/or transportation, and
b. Adult -eighteen (18) years of age or older, except:
1) An emancipated minor.
i. A self-sufficient minor.
ii. A married minor.
iii. A minor in the military.
2) A legal representative for the patient (parent or guardian). (Appendix 6.6, Consent
for the Care of a Minor.)
B. Patients not able to refuse care.
1. A person may be considered incompetent to refuse medical care and/ or transportation if
the severity of his/her medical condition prevents the patient from making an informed,
rational decision regarding medical care. Therefore, the individual may not refuse
medical care and/or transportation based on the following guidelines:
a. Altered level of consciousness (e.g., head injury or under the influence of alcohol
and/or drugs).
b. Suicide (attempt or verbal threat).
c. Severely altered vital signs.
d. Mental retardation and/or deficiency.
e. Not acting as "a reasonable person would do, given the same circumstances."
f. Younger than eighteen (18) years of age (except those persons outlined in A [1] [b]).
C. Implied consent.
1. If a person is determined to be incompetent, he/she may be treated and transported under
the principle of "implied consent" (what the reasonable individual would consent to
under the same circumstances). Also see General Protocol 1.2, Behavioral Emergencies.
2. If the patient is transported and/or treated on the basis of implied consent, field personnel
should use reasonable measures to ensure safe transport to the closest appropriate facility.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 23
REFUSAL PROCEDURE
A. Single patient.
1. Determine that the individual is involved in the incident.
2. Determine that the individual is refusing to allow the proper evaluation, or necessary
treatment, or necessary transport to the appropriate medical facility.
3. Determine the mental status and extent and history of injury, mechanism, or illness.
a. Ensure that the patient is conscious, alert, and oriented and understands (mental
reasoning) his/her condition (patient GCS = 15).
b. Unless the patient specifically refuses, do a complete physical assessment.
4. Inform the patient and/or responsible parry (parent or guardian) of the potential
consequences of the decision to refuse treatment and/or transport to a definitive -care
facility (loss of life or limb, irreversible sequelae), and ensure that the patient and/or
responsible parry fully understands the explanation.
5. All measures should be taken to convince the patient to consent, including enlisting the
help of family or friends.
6. If the patient continues to refuse, the patient and/or responsible parry may then sign a
"Refusal of Care" form. Ensure that the following information is provided:
a. The release is against medical advice.
b. The release applies to this instance only.
c. EMS should be requested again if necessary or desired.
7. After the "Refusal of Care" form is signed, it must be witnessed (including legibly
printed name, contact information, and signature of witness).
8. If the patient or responsible parry will not sign the release, then document this refusal on
the EMS Run Report. If available, witness signatures should be obtained.
9. Where possible, patients should be left in the care of family, friends, or responsible
parties.
10. Carefully document the assessment and vital signs, including all issues and circumstances
indicated.
B. Multiple patients.
The protocol does not allow for more than one refusal on a single EMS Run Report. However,
individuals who refuse ALL assistance, including proper evaluation, can be combined on a single
report (e.g., all parties deny injury). Once an examination is begun on an individual, a separate
EMS Run Report must be filled out to record the examination. Also, any later refusal of care
requires following the complete protocol outlined previously. The use of multiple refusals of care
is primarily designed for incidents that have numerous participants (potential patients) where it
becomes evident that some participants are not injured at all or refuse to be examined when
approached by EMS personnel.
1. Complete Steps 1 through 10 in section A.
2. Document all names, addresses, and witnesses.
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C. Medical Direction: (The Physician at the destination facility or the agency's Medical
Director).
1. Medical direction should be contacted for consultation under the following circumstances
(high risk refusal):
a. A low -severity patient who is under 18 years of age.
b. A patient whose refusal of care represents a significant risk to the patient or EMS
system/agency.
c. A patient who is not his/her own legal guardian.
d. A patient who refuses transport after administration of any IV medication (also
consider calling the Police Department for assistance).
2. If any questions on the assessment of competency or refusal of care occur, contact
medical direction for further guidance.
D. Refusal of transport or transport destination.
1. Patients who refuse to be transported to the closest appropriate facility and are adamant
about being transported to a different facility should be considered to be refusing
transport. The local department's supervisor should be contacted for further consultation
on the transport destination according to local policy.
2. When a patient refuses to be transported to any facility, medical direction should be
considered for further consultation, when such refusal represents a significant risk to the
patient or the EMS system/agency. Refer to local policy for further direction.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 25
PURPOSE
To efficiently triage, treat, and transport victims of mass/multiple-casualty incidents (MCIs). The
following protocol is applicable to all multiple -victim situations. This protocol is intended for the
everyday MCI when the number of injured exceeds the capabilities of the first -arriving unit as
well as for large-scale MCIs.
PROCEDURE
A. The officer of the first -arriving unit will establish Command and:
1. Perform a size -up, estimating the number of victims.
2. Request a Level 1, 2, 3, 4, or 5 response, and request additional units and/or specialized
equipment as required.
3. Identify a staging area.
4. If it is an active shooter incident or any tactical environment with a MCI establish a
Unified Command (UC) with Law Enforcement (LE). Consider establishing Liaisons for
FD and LE, the Liaisons can interact with each other allowing the transfer of info
between agencies. Law Enforcement will make entry with their contact team and provide
feedback to the UC and the decision may be made to establish a Rescue Task Force (team
of LE officers providing forced protection for rescue personnel). The Rescue Task Force
will initiate triage and provide immediate life saving treatment (i.e hemorrhage control).
5. If the area is deemed safe to enter direct the remaining crew members and any additional
personnel arriving to initiate triage.
6. Triage will be performed in accordance with START or JumpSTART.
Prioritize victims utilizing color -coded ribbons:
Red Immediate care
Yellow Delayed care
Green Ambulatory (minor)
Black Deceased (non -salvageable)
7. Locate and direct the "walking wounded" to one location away from the incident, if
possible. These victims need to be assessed as soon as possible. Assign someone to keep
the walking wounded together.
8. Active shooter incidents considerations: Be on high alert for suspicious individuals,
packages, vehicles or potential IEDs. Integrated active shooter response should include
the critical actions contained in the acronym THREAT
Threat suppression
Hemorrhage control
Rapid Extrication to safety
Assessment by medical providers
Transport to definitive care
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 26
B. As additional units arrive, Command will designate the following officers:
1. Triage (Initially the responsibility of the first -arriving officer).
2. Treatment.
3. Transport.
4. Staging.
C. Additional branches/sections may be required depending on the complexity of the incident.
These officers may include, but are not limited to:
1. Medical Branch.
2. Landing Zone/Hell-spot.
3. Extrication.
4. Hazardous Materials (hazmat).
5. Rehabilitation.
6. Safety.
7. Public Information Officer (PIO).
8. Medical Intelligence - to assist with suspected or known WMD (weapons of mass
destruction) events for decontamination, antidotes, and treatment.
D. MCI: predetermined response plan.
1. Considerations:
a. An MCI shall be classified by different levels depending on the number of victims.
The number of victims will be based on the initial size -up, prior to triage.
b. Levels of response will augment the units already on the scene, and units enroute will
be included in the assignment. The exception would be in conjunction with a Fire
Alarm assignment i.e., a fire with multiple victims may be a Second Alarm with an
MCI Level 3 response; this will be two separate assignments.
c. Command can downgrade or upgrade the assignments at any time.
d. All units will respond to the staging area emergency response unless otherwise
directed by Command.
e. When announcing an MCI, specify the general category (e.g., trauma, hazardous
materials, smoke inhalation).
f. Any victim meeting trauma transport criteria must be reported to a state -approved
trauma center for determination as to transport destination. Trauma transport criteria
will be determined during the secondary triage in the treatment phase. When the
trauma center(s) are overwhelmed they will notify MedCom of the need for units to
transport to other trauma centers or non -trauma centers
g. Consider the use of air transport for patients with special needs, mass -transit
resources for multiple "walking wounded" patients, and private BLS transport units.
h. Consider the use of mobile command vehicles, medical supply trailers, and
communication trailers as needed.
i. Upon notification of an MCI, Medical Control (Medcom/MRCC) will gather
information about each hospital's capability and relay this information to the
Transport Officer or Medical Communication Officer.
j. On a large-scale incident, consider sending a Hospital Coordinator to each hospital to
assist with communications.
k. Request law enforcement to set up a safety parameter.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 27
2. Definitions.
a. Active Shooter: The Department of Homeland Security's (DHS) definition of an active shooter
is an individual actively engaged in killing or attempting to kill people in a confined, populated
area; in most cases, active shooters use firearms and there is no pattern or method to their
selection of victims.
b. Active Shooter Incident: Active shooter situations are unpredictable and evolve quickly; most
are over within 10 to 15 minutes.
c. Casualty Collection Point (CCP): A safe location(s) where fire rescue personnel can receive
victims. Victims may have to be carried or dragged to the CCP. This may be inside a structure
or exterior. This may be the same as the treatment area if located in the cold zone.
d. Concealment: Concealment is a law enforcement term that represents an object that only
provides protection from observation.
e. Contact Team: Contact team is a law enforcement term used to designate the team of law
enforcement officers that make entry with the specific intention of ONLY going after and
neutralizing the perpetrator.
f. Cover: Cover is a law enforcement term that represents an object or location that provides
protection from direct gunfire.
g. Improvised Explosive Device (IED): The Department of Defense (DOD) definition of an IED is
a device placed or fabricated in an improvised manner incorporating destructive, lethal, noxious,
pyrotechnic, or incendiary chemicals and designed to destroy, incapacitate, harass, or distract. It
may incorporate military components, but is normally devised from nonmilitary components.
h. Litter Bearer: A team of personnel assigned to Triage to move victims from the incident site to
the treatment area or Transport Units.
i. Rescue Task Force: Rescue personnel and Law Enforcement personnel formed to make entry
into a structure to triage victims and provide life saving immediate treatment as needed i.e
stopping hemorrhage.
j. Strike Team: Five of the same type of units, including common communications and a leader
(i.e., an ALS Transport Unit Strike Team would consist of five ALS Transport Units with a
leader).
k. Tactical Environment — Any environment that Law Enforcement has a tactical objective due to
a threat assessment (which may require a Fire Rescue/EMS component).
1. Task Force: Five different types of units, including common communications and a leader.
MCI Task Force: May be two ALS Transport Units, two BLS Transport Units, and one
Suppression Unit, including common communications and a leader.
in. THREAT: acronym for Threat suppression, Hemorrhage control, Rapid Extrication,
Assessment by medical providers, and transport to definitive care.
n. Zones in relation to Active Shooter/Mass Casualty Incidents :
1. Hot Zone — Direct Threat Care/Care Under Fire - This zone shall be designated at the area
of the structure that has not been cleared by law enforcement or the area that the perpetrator
is currently in.
2. Warm Zone — Indirect Threat Care/Tactical Field Care - This zone shall be designated at
any area of the active shooter incident that has been declared available for entry by Fire
Rescue/EMS personnel with armed LE coverage to perform immediate life saving
treatment and triage to victims prior to their removal from the initial hazard.
3. Cold Zone — Evacuation Care/Tactical Evacuation Care - This zone extends beyond the
warm zone and is not reachable by the perpetrator. This zone shall encompass positions
such as the command post, staging and other functional groups.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 28
MCI Level 1 (5-10 victims)
• 4 ALS Transport Units
• 2 Suppression Units
• 1 Shift Supervisor
• 1 EMS Supervisor
Note - The two hospitals and trauma center closest to the incident will be notified by Medical
Control (Medcom or local communications center).
MCI Level 2 (11-20 victims) (any active shooter incident until an accurate victim count can be mad,
• 6 ALS Transport Units
• 3 Suppression Units
• 2 Shift Supervisors
• 2 EMS Shift Supervisors
Note - The three hospitals and two trauma centers closest to the incident will be notified by
Medical Control (Medcom or local communications center).
MCI Level 3 (21-100 victims)
• 8 ALS Transport Units
• 4 Suppression Units
• 3 Shift Supervisors
• 3 EMS Shift Supervisors
• Command Vehicle
• MCI Trailer
• Operations Chief
Note — The four hospitals and three trauma centers closest to the incident will be notified by
Medical Control (Medcom or local communications center). The Warning Point will notify the
Emergency Management Agency.
MCI Level 4 (101-1000 victims)
• 5 MCI Task Forces (25 units)
• 2 ALS Transport Strike Teams (10 units)
• 1 Suppression Unit Strike Team (5 units)
• 2 BLS Transport Strike Teams (10 units)
• 2 Mass Transit Buses
• 2 MCI Trailers
• Command Vehicle
• Communications Trailer
• 5 Shift Supervisors
• 3 EMS Shift Supervisors,) EMS Chief
• Operations Chief
Note - The 10 hospitals and 5 trauma centers closest to the incident will be notified by Medical
Control. The Warning Point will notify the Emergency Management Agency.
In an ongoing, long-term MCI, the Metropolitan Medical Response System (MMRS) and the
State Medical Assistance Response Team (SMRT), Medical Reserve Corp (MRC), Florida
Advanced Surgical Team (FAST) Disaster Medical Assistance Team (DMAT) may be notified.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 29
MCI Level 5 (more than 1000 victims)
•
10 MCI Task Forces (50 units)
•
4 ALS Transport Strike Teams (20 units)
•
2 Suppression Unit Strike Teams (10 units)
•
4 BLS Transport Strike Teams (20 units)
•
4 Mass Transit Buses
•
2 Command Vehicles
•
4 Supply Trailers
•
Communications Trailer
•
10 Shift Supervisors
•
6 EMS Shift Supervisors
•
2 EMS Chiefs
•
2 Operations Chiefs
Note -The 20 hospitals and 10 trauma centers closest to the incident will be notified by Medical
Control. The Warning Point will notify the Emergency Management Agency. In an ongoing,
long-term MCI, the MMRS, DMAT, SMRT, MRC, FAST and the International Medical and
Surgical Response Team (IMSURT) may be notified.
Strike Team: Five of the same type of units, including common communications and leader.
Task Force: Five different types of units, including common communications and leader. MCI
Task Force: May be two ALS Transport Units, two BLS Transport Units, and one Suppression
Unit, including common communications and leader.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 30
OFFICER RESPONSIBILITIES - See Online Forms for Field Operating Guides.
A. Command.
1. Established by the first arriving officer. Radio designation "Command."
2. Follow Field Operation Guide (FOG) 41.
3. If active shooter or tactical environment incident get briefing from LE, establish a
Unified Command and co -locate with LE. Consider establishing Liaisons for FD and
LE, the Liaisons can interact with each other allowing the transfer of info between
agencies.
4. Remain in a safe, fixed, and visible location, uphill and upwind of the incident.
5. Determine the MCI Level (1, 2, 3, 4, or 5). If unknown victims in an active
shooter/tactical environment initiate a MCI level 2 until a count can be determined.
6. Designate a staging area.
7. Assign personnel to perform the functions of Triage, Rescue Task Force (if needed),
Treatment, Transport, and Staging.
8. Advise the Communications Center of the number of victims and their categories once
triage is complete.
9. During large-scale or complex MCIs (e.g., a fire with multiple victims/tactical
environment incident), designate a Medical Branch to reduce the span of control.
10. If the incident is due to a known or suspected weapon of mass destruction (WMD event),
refer to WMD FOG 48 and designate a Medical Intelligence Officer to assist with
decontamination, antidotes, and treatment of victims.
11. If active shooter/tactical environment refer to FOG 49
12. Ensure proper security of the incident site, treatment area, and loading area; also provide
for traffic control and access for emergency vehicles, including law enforcement.
B. Medical Branch.
1. Radio designation "Medical." Follow FOG 42.
2. Assure Triage, Treatment, and Transport has been established. If established by
Command, Triage, Rescue Task Force, Treatment, and Transport will now report to the
Medical Branch.
3. Work with Command, and direct and/or supervise on -scene personnel from agencies such
as the Medical Examiner's Office, Red Cross, private ambulance companies, and hospital
volunteers.
4. Ensure notification of Medical Control (Medcom/MRCC).
5. If the incident is due to a known or suspected WMD, refer to WMD FOG 48 and
designate a Medical Intelligence Officer to assist with decontamination, antidotes, and
treatment of victims.
6. If active shooter/ tactical environment refer to FOG 49
7. Ensure proper security of incident site, treatment area, and loading area; also provide for
traffic control and access for emergency vehicles, including law enforcement.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 31
C. Triage Officer.
Reports to Command or the Medical Branch. Supervises the Triage Personnel, Rescue Task
Force (if needed) and Litter bearers. Also directs Medical Examiner personnel locate deceased
victims.
1. Radio designation "Triage", follow FOG 93.
2. Organize the Triage Team to begin initial triaging of victims. Assemble the walking wounded
and uninjured in a safe area. Use bullhorns or a public address (PA) system if necessary.
3. Advise Command (or the Medical Branch, if established) as soon as possible if there is a
need for additional resources.
4. Coordinate with Treatment to ensure that priority victims are treated first.
5. Ensure that all areas around the MCI scene have been checked for potential victims, walking
wounded, ejected victims, and so forth.
6. Maintain security and control of the triage area. Request the assistance of law enforcement.
7. If a RTF is formed designate a Triage Aide to communicate with the RTF.
8. If there is more than one RTF team, designate the teams as RTF 1, RTF 2 etc.
9. Have the RTF mark the doors with the victim count using a grease pencil R=, Y=
G=, B= (greens should have left the area but may stay to assist with care or supervision,
i.e. a teacher).
10. Report to Command/Medical Branch upon completion of duties for further assignments.
D. Treatment Officer.
Reports to Command or the Medical Branch. Supervises the Treatment Managers of the Red,
Yellow, and Green Areas. Coordinates the retriage and tagging of all victims and the on -site
medical care. Directs the movement of victims to the loading area(s).
1. Radio designation "Treatment", follow FOG 94.
2. Consider assigning a Documentation Aide to assist with paperwork.
3. Direct personnel to either begin treatment on the victims where they lay or establish a
centralized treatment area.
4. Considerations for a treatment area:
a. Capable of accommodating the number of victims and equipment.
b. Consider weather, safety, and the possibility of hazardous materials.
c. Designate entrance and exit areas, which are readily accessible (funnel points).
d. On large-scale incidents, divide the treatment area into three distinct areas based on
priority. Designate a Treatment Manager for each area (Red, Yellow, Green). Use
appropriate -color tarps if available.
5. Complete a Treatment Log as victims enter the area.
6. Ensure that all victims are retriaged through a secondary exam and the assessment is
documented on a triage tag (Disaster Management System [DMS] - All Risk Triage tag). The
rescuer filling out the All Risk Triage tag will keep a corner of the tag for future
documentation.
7. All red -tagged victims will be transported immediately as transport units become available.
These victims should not be delayed in the treatment area.
8. Ensure that enough equipment is available to effectively treat all victims.
9. Establish communications with Transport to coordinate proper transport of the appropriate
victims. Direct movement of victims to the ambulance loading areas.
10. Provide periodic status reports to Command/Medical Branch.
Note: Red, Yellow, and Green Treatment Manager: Report to the Treatment Officer and are
responsible for the treatment and continual retriaging of victims. Notify the Treatment Officer of
victim readiness and priority for transportation. Assure that appropriate victim information is
recorded.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 32
E. Transport Officer.
Reports to Command or the Medical Branch. Supervises the Medical Communication
Coordinator and Documentation Aide(s). The Transport Officer is responsible for the
coordination of victims and maintenance of records relating to victim identification, injuries,
mode of transportation, and destination.
1. Radio designation "Transport", follow FOG 45.
2. Assign a Documentation Aide with a radio to assist with paperwork and communications.
3. Assign a Medical Communication Coordinator to establish continuous contact with
Medical Control (Medcom or MRCC).
4. Establish a victim loading area. Advise Staging of the location and direction of travel.
Consider requesting law enforcement assistance for ensuring the security of the loading
area.
5. Arrange for the transport of victims from the treatment area. Maintain a Hospital
Transportation Log 45B. Keep a piece of the triage tag for future documentation.
6. Communicate with the Landing Zone (LZ)/Heli-spot Officer and relay the number of
victims to be transported by air. Air -transported victims should be assigned to distant
hospitals, unless the victims' needs dictate otherwise (e.g., trauma center, burn unit).
F. Medical Communications Coordinator.
Reports to the Transport Officer and is responsible for maintaining communication with Medical
Control to assure proper victim transport information and destination.
1. Radio designation "Communication." Follow FOG 45A.
2. Establish communication with Medical Control (Medcom or MRCC1). Advise Medical
Control of the overall situation (e.g., smoke inhalation, trauma, burns, hazardous
materials exposure) and the number and categories of victims. Medical Control will
survey area hospitals to determine their capabilities and capacities and then relay this
information to the field. Document this information on the Hospital Capability Worksheet
45C and maintain this document for the duration of the incident.
3. When units are prepared to transport, advise Medical Control and supply of the following
information:
a. The unit transporting.
b. The number of victims to be transported.
c. Their priority: Red, Yellow, or Green.
d. Any victims with special needs (e.g., cardiac, burn, trauma).
4. The Medical Communication Coordinator, in conjunction with Medical Control, will
determine the most appropriate facility. Ground -transported victims should be assigned to
hospitals on a rotating basis.
5. Once Medical Control receives the information from the Medical Communication
Coordinator, Medical Control will notify the appropriate hospital. Transporting units will
not contact the individual hospital on their own, unless there is a need for medical
direction/care outside of protocols.
i Medical Resource Coordination Center (MRCC): The MRCC's prime function is to maintain
status information —that is, the number of victims and the hospital readiness status to accept
victims, to coordinate transportation, and to direct patients to the appropriate hospital during a
disaster or other situation characterized by a high demand for medical resources
4Ih Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 33
G. Medical Supply Coordinator.
Reports to the Medical Branch and is responsible for acquiring and maintaining control of all
medical equipment and supplies.
1. Radio designation "Supply", follow FOG 46.
2. Assure necessary equipment is available on the transporting vehicle.
3. Provide an inventory of medical supplies at the staging area for use on scene.
4. Assure support vehicles are requested. (Broward County has four MCI supply trailers and
Region 7 has three large MCI supply trailers available for use during a large-scale MCI.)
H. Staging Officer.
Reports to Command and is responsible for managing all activities within the staging area.
1. Radio designation "Staging", follow FOG 47.
2. Establish the location of a staging area and notify the Communication Center to direct
any incoming units.
3. Maintain a Unit Staging Log 47A.
4. Ensure that all personnel stay with their vehicles unless otherwise directed by Command.
If personnel are directed to assist in another function, ensure that the keys stay with each
vehicle.
5. Coordinate with the Transport Officer the designation of a location for victim loading and
the best route to the area.
6. Maintain a reserve of at least two transport vehicles. When the reserve is depleted,
request additional units through Command.
DOCUMENTATION
A. The Incident Commander will, at the completion of the incident, coordinate the gathering
of all pertinent documentation.
B. A Post -Incident Analysis (PIA) will be completed.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 34
MCI Kits For Responder Vehicles
Each unit should carry an MCI bag. The following items are recommended:
A. Two (2) triage packs recommend to have:
1. Four (4) combine dressings
2. Four (4) 4 X 4's
3. Gloves
4. One (1) pediatric face mask
5. Colored ribbons (Red, Yellow, Green & Black) either rolls or ribbons.
6. Trauma Tourniquets (2)
7. Hemostatic Dressing (2)
8. Chest Decompression Needles(2)
9. Chest Seals (2)
B. Fifty (50) triage tags —Disaster Management Systems (DMS) All Risk Triage tags.
C. Pencils/grease pencils and pens.
D. Additional tourniquets, hemostatic dressing, chest seals & chest decompression needles (10)
E. The following MCI FOGS, logs, and associated paperwork for each officer:
1. Command FOG 91 -White
2. Medical FOG 92 - Blue
3. Triage FOG 93 - Yellow
4. Treatment FOG 94 - Red
5. Treatment Area Log 94A - Red
6. Transport FOG 95 - Green
7. Medical Communication FOG 95A - Green
8. Hospital Transport Log 95B - Green. (10 logs)
9. Hospital Capability Worksheet 95C - Green
10. Medical Supply FOG 96 - Blue
11. Staging FOG 97 - Orange
12. Unit Staging Log 97A - Orange
13. MCI-WMD/Terrorist Event FOG 98 - Beige
MCI SUPERVISOR KIT
A. Complete vest set with the following identification vests:
1. White for Command.
2. Blue for Medical Officer.
3. Yellow for Triage Officer.
4. Red for Treatment Officer.
5. Green for Transport Officer.
6. Green for Medical Communication Coordinator.
7. Blue for Medical Supply Officer.
8. Orange for Staging Officer.
B. Clipboard which contains paperwork for each officer, pens/pencils/grease pencils, and paper
C. EMS Command Board.
D. Tarp set: red, yellow, green, black tarps.
E. Patient tracking device/Scanner (if available)
F Bullhorn (if available)
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 35
START SYSTEM OF TRIAGE
This procedure is based on the Simple Triage and Rapid Treatment (START) process for adult
victims and the JumpSTART adaptation for pediatric victims.
PROCEDURE
A. Initial triage: Using the START or JumpSTART method (described in the following two
sections):
1. Locate and direct all of the walking wounded to one location away from the incident if
possible. Assign someone to keep them together (Fire Rescue Department personnel, Law
Enforcement officer, or capable bystander).
2. Begin assessing all non -ambulatory victims where they are found.
3. Utilize the triage ribbons tied to an upper extremity in a visible location.
4. Independent decisions should be made for each victim. Do not base triage decisions on the
perception of too many reds, not enough greens, and so forth.
5. If borderline decisions are encountered, always triage to the most urgent priority (e.g., for a
Green/Yellow patient, tag as Yellow).
B. Secondary triage.
1. Performed on all victims during the Treatment phase. If a victim is identified in the initial
Triage phase as a Red and transport is available, do not delay transport to perform a
secondary assessment.
2. Utilize a triage tag (Disaster Management System [DMS] All Risk Triage tag) and attempt to
assess for and complete all information required on the tag (time permitting). Affix the tag to
the victim and remove the ribbon.
3. The triage priority determined in the Treatment phase should be the priority used for
transport. If trauma -related, the trauma transport criteria will be applied to trauma victims
during the secondary triage in the Treatment phase.
Remember the mnemonic RPM (Respiration, Perfusion, Mental status). The first assessment that
produces a Red stops further assessment. Only correction of life -threatening problems, such as
airway obstruction or severe hemorrhage, should be managed during the triage phase. Any major
external bleeding should also be controlled at this time. Depending on the victim's injuries (burns,
fractures, bleeding), it may be necessary to prioritize as Yellow
START
Move the Walking Wounded
GREEN
No Respiration after head tilt
LAC
Respirations over 30/min
Perfusion (No radial pulse/cap refill over 2 sec)
Mental Status (unable to follow commands)
Stable RPM/Walking
GREEN
Stable RPM/Non ambulatory
EL
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 36
JUMPSTART TRIAGE
Physiological differences in children necessitate adaptation of the standard START triage
method in children 8 years of age or younger, or in those victims with the anatomical or
physiological features of a child in the age group. The same parameters (RPM) are utilized, with
the adaptations indicated here.
JumpSTART
Move the Walking Wounded (access as soon as possible)
GREE
No Respiration after head tilt No peripheral pulse
BLAC
Respirations over 45/min under 15/min
No resp with pulse give S ventilations
Respirations resume
No spontaneous respirations
BLAC
Perfusion (No radial pulse/cap refill over 2 sec)
on
Mental Status (AVPU) Alert/Verbal
YELLOW—
Pain/Unresponsive
Stable RPM/Walking
GREEN
Stable RPM/Non ambulatory
YELL&
Note -Infants who are developmentally unable to walk should be triaged using the JumpSTART
algorithm either during initial triage or in the Green area if carried out by a nonrescuer. During
triage, if the infant does not fulfill the criteria of a Red victim and has no other outward signs of
significant injury; he/she may be triaged as a Green victim.
Note -The START Triage system was developed by Newport Beach Fire Rescue and Hoag
Hospital. The JumpSTART Triage system was developed by Dr. Lou Romig.
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 37
Above — Complex MCI Command Structure
Below - Active Shooter/Tactical Environment MCI Command Structure
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 38
This protocol will be used when law enforcement personnel advise EMS that they have
responded to a crime scene or EMS determines that a crime scene may exist.
A. Purpose: To ensure the protection of patient welfare as well as to ensure the ability to
conduct an effective and thorough investigation.
B. Response/on-scene situations.
1. Only those units assigned will respond to the call. Over -response tends to cause
confusion at the crime scene and destruction of evidence.
2. When approaching a potential crime scene that is being protected by law enforcement
personnel, the paramedic/EMT may request entry into the area to determine the life
status of the individual.
3. If law enforcement personnel refuse access to the crime scene, do not become
confrontational. Notify the EMS Agency Supervisor and complete an incident report as
required.
4. When personnel are allowed access into the scene, the minimum number of required
EMS personnel should enter to minimize disturbance of the crime scene.
5. Do not attempt resuscitation if the patient has no pulse, has no spontaneous respiration,
and meets criteria outlined in General Protocol 1.4, Death in the Field.
6. If treatment and/or resuscitation are warranted, follow the appropriate protocol.
7. When on scene:
a. Keep your medical equipment close to the victim.
b. Stay close to the body.
c. Keep your hands out of any blood that has pooled.
d. Do not wander around the scene.
e. Minimize destruction of the patient's clothing. If the patient's clothing has a puncture,
do not use the hole in the clothing to start cutting. Begin cutting at another part of the
garment. Removed clothing should be left with the patient or turned over to law
enforcement personnel.
f. Do not go through the victim's personal effects, clean the body, or cover the body
with a sheet or other material (if expired).
g. Do not move, take, or handle any object at the scene or litter the crime scene with
medical equipment, dressings, bandages, or other supplies.
h. If resuscitation efforts are deemed necessary, transfer the victim from the scene to the
vehicle expeditiously and stabilize the victim in the vehicle, when possible.
i. If the patient relates any information relating to the crime while in transit to the
medical facility, inform law enforcement personnel at once
41h Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 39
Any person may submit input for changes to the Common Protocols. The following procedure
will be used to receive and process this input.
PROCEDURE (Electronic)
1. Any member of a participating EMS agency will be permitted to submit queries and
suggestions regarding the Common Protocols via the electronic web based version of the
protocols.
2. The protocols will be located on www.GBEMDA.oEg and a link will be located on the
Broward EMS Council's website www.Broward.or!2/BrowardEMS
3. Simply click on a protocol item and review its contents.
4. At the bottom right hand portion of the screen click on the "Make a Suggestion" link.
5. Fill out the required fields:
a. Department
b. Full Name
c. Telephone Number
d. Email address
e. Protocol number
f. Comments
6. Press Submit
7. Your comment will be sent via email to the Medical Director and EMS Chief for your
particular EMS Agency
8. Medical Directors will meet yearly (or sooner if more emergent) to discuss the submitted
items, reviewing their merit, and bringing substantiated items up for discussion and potential
revision.
9. Once the changes to the Common Protocols have been implemented, the electronic protocols
will be updated on the Broward EMS website and all hospitals will be notified.
10. It is the intent of this procedure that every EMS provider implements all approved changes
to the Common Protocols.
11.The Medical Director of an individual EMS provider reserves the right to change portion of
the protocols, however, if they are unique to that specific department, the information will
be located on a department specific page within the PDF.
4Ih Edition Version 2, 3/1/15 Florida Regional Common EMS Protocols 40
Florida Regional Common
EMS Protocols
Section 2
Adult Protocols
4th Edition, Version 2, March 1, 2015
4Ih Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Adult Section Table of Content
2.1 Adult Initial Assessment and Management
2.1.1 Initial Assessment
2.1.2 Airway Management
2.1.3 Medical Supportive Care
2.1.4 Trauma Supportive Care
2.1.5 Pain Management
2.2 Adult Respiratory Emergencies
2.2.1 Airway Obstruction
2.2.2 Asthma/Bronchospasm
2.2.3 Emphysema and/or Bronchitis
2.2.4 Pulmonary Edema (CHF)
2.2.5 Suspected Pneumonia
2.3 Adult Cardiac Dysrhythmias
2.3.1 Asystole/PEA
2.3.2 Bradycardia
2.3.3 Narrow Complex Tachycardia (Supraventricular Tachycardia)
2.3.4 Premature Ventricular Ectopy (PVC)
2.3.5 Wide Complex Tachycardia with a Pulse (Ventricular Tachycardia)
2.3.6 Wide Complex Tachycardia without a Pulse and Ventricular Fibrillation
2.3.7 Return of Spontaneous Circulation (ROSC)
2.3.8 Therapeutic Hypothermia
2.4 Other Adult Cardiac Emergencies
2.4.1 Cardiogenic Shock
2.4.2 Angina /Suspected AMI
2.4.3 Hypertensive Emergencies
2.5 Adult Neurologic Emergencies
2.5.1 Altered Mental Status Unknown Etiology
2.5.2 Violent, Impaired Patient and/or Excited Delirium (ExDS)
2.5.3 Seizure Disorders
2.5.4 Suspected Stroke (CVA)
2.5.5 Syncopal Episode
2.6 Adult Toxicologic Emergencies
2.6.1 Bites and Stings
2.6.2 CNS Depressant Overdose
2.6.2.1 Benzodiazepines and Sedative Hypnotics
2.6.2.2 Opioid and Narcotic Overdose
2.6.3 CNS Stimulant Overdose
2.6.4 Digitalis Toxicity
2.6.5 Hallucinogen Overdose
2.6.6 Tricyclic Antidepressant Overdose
2.6.7 Unknown Toxicity
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2.7 Adult OB/GYN Emergencies
2.7.1 Complications of Labor and Delivery
2.7.2 Normal Labor and Delivery
2.7.3 Nontraumatic Vaginal Bleeding
2.7.4 Toxemia of Pregnancy
2.8 Other Adult Medical Emergencies
2.8.1
Allergic Reactions/Anaphylaxis
2.8.2
Hypoglycemia/Hyperglycemia
2.8.3
Nausea/Vomiting
2.8.4
Nontraumatic Abdominal Pain
2.8.5
Sickle Cell Anemia
2.8.6
Sepsis
2.9 Adult Environmental Emergencies
2.9.1
Barotrauma/Decompression Illness: Dive Injuries
2.9.2
Cold -Related Emergencies
2.9.3
Heat -Related Emergencies
2.9.4
Drowning
2.9.5
Electrical Emergencies
2.9.6
Electronic Control Devices (TASER)
2.10 Adult Trauma
Emergencies
2.10.1
Head and Spine Injuries
2.10.2
Eye Injuries
2.10.3
Chest Injuries
2.10.4
Traumatic Chest Pain
2.10.5
Abdomino-Pelvic Injuries
2.10.6
Extremity Injuries
2.10.7
Traumatic Arrest
2.10.8
Burn Injuries
2.10.9
Crush/Compartment Syndrome
2.11 Adults with Special Healthcare Needs
2.11.1 Home Mechanical Ventilator
2.11.2 Tracheostomy
2.11.3 Central Venous Lines
2.11.4 Feeding Tubes
2.11.5 LVAD Patients
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Protocols in Section 2.1 are designed to guide the EMT or paramedic in his or her initial
approach to assessment and management of adult patients. Supportive care is specified as being
either EMT and Paramedic (BLS) or Paramedic Only (ALS).
Protocol 2.1.1 should be used on all adult patients for initial assessment. During this assessment,
if the EMT or paramedic determines that there is a need for airway management, Protocol 2.1.2
should be used for the management of the adult airway. These protocols are frequently referred
to by other protocols, which may or may not override them in recommending more specific
therapy.
Protocol 2.1.3 presents the basic components of preparation for transport of medical patients.
Due to the significant differences in priorities and packaging in the prehospital care of trauma
and hypovolemia cases, a separate Trauma Supportive Care protocol has been developed. After
following Protocol 2.1.1, this Medical Supportive Care protocol may be the only protocol used in
medical emergency situations where a specific diagnostic impression and choice of additional
protocols cannot be made. Judgment must be used in determining whether patients require ALS
or BLS level care. This protocol is frequently referred to by other protocols, which may or may
not override it in recommending more specific therapy.
Protocol 2.1.4 presents the basic components of preparation for transport of trauma patients. Due
to the significant differences in priorities and packaging in the prehospital care of medical cases,
a separate Medical Supportive Care protocol has been developed. After following Protocol 2.1.1,
this Trauma Supportive Care protocol may be the only protocol used in trauma or hypovolemia
situations where a specific diagnostic impression and choice of additional protocols cannot be
made. Judgment must be used in determining whether patients require ALS or BLS level care.
This protocol is frequently referred to by other protocols, which may or may not override it in
recommending more specific therapy.
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EMT AND PARAMEDIC
I. Scene Size -up.
A. Review the dispatch information.
B. Assess the need for body substance isolation.
C. Assess for scene safety.
D. Determine mechanism of injury.
E. Determine the nature of the illness.
F. Determine the number and location of patients.
G. Determine the need for additional resources.
H. Consider c-spine immobilization.
11. Initial Assessment.
A. General impression of the patient.
B. Assess mental status; AVPU scale (Alert, Alert to Verbal, Responds to Pain,
Unconscious); maintain spinal immobilization as needed.
C. Assess circulation (rapid evaluation of pulse, major bleeding, skin color, and
temperature). Assess need for defibrillation: VF/VT without pulse.
D. Assess airway.
E. Assess breathing.
F. Assess disability: movement of extremities.
G. Expose and examine the patient's head, neck, chest, abdomen, and pelvis (check
the back when the patient is rolled on his/her side).
H. Identify priority patients.
1. Poor general impression.
2. Unresponsive patients.
3. Responsive but does not or cannot follow commands.
4. Difficulty breathing
5. Hypoperfusion or shock
6. Complicated child birth
7. Chest pain with a systolic BP below 100 mm Hg.
8. Uncontrolled bleeding
9. Severe pain anywhere
10. Multiple injuries
III. Initial Management. (Adult Protocol 2.1.3 or 2.1.4, Medical Supportive Care, or
Trauma Supportive Care).
IV. Secondary Assessment
A. Conduct a head -to -toe survey
B. Conduct a neurological assessment
1. Pupillary response
2. Glasgow Coma Scale (GCS) score
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C. Assess vital signs
1. Respirations
2. Pulse
3. Blood pressure
4. Capillary refill
5. Skin condition
a. Color
b. Temperature
c. Moisture
6. Lung sounds
D. Obtain a medical history. (SAMPLE & OPQRRRST)
1. S - Symptoms: Assessment of chief complaint.
a. 0 - Onset and location
b. P - Provocation
c. Q - Quality
d. R - Radiation
e. R - Referred
f. R - Relief
g. S - Severity
h. T - Time
2. A - Allergies
3. M - Medications
4. P - Past medical history
5. L - Last oral intake
6. E - Events leading to illness or injury
V. Other Assessment Techniques.
1. Cardiac monitoring
2. Pulse oximetry (Medical Procedure 4.22)
3. Glucose determination (Medical Procedure 4.17)
4. Monitor temperature
5. Capnography (EtCO2)
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EMT AND PARAMEDIC
• Initial Assessment Protocol 2.1.1.
If spontaneous breathing is present without compromise:
• Monitor breathing during transport.
• Administer oxygen as needed to maintain 02 saturation of 94% or greater.
• Avoid over oxygenation: Wean oxygen concentration as tolerated.
If spontaneous breathing is present with compromise:
• Maintain airway patency (Medical Procedure 4.1.3).
• Administer oxygen via non-rebreather mask (10-15 L/min).
• If unconscious, insert oropharyngeal, nasopharyngeal as needed (Medical Procedure 4.2).
• If patient accepts oropharyngeal airway, consider the need for a supraglottic device. EMT
may insert the supraglottic device if he/she has been authorized by that department's Medical
Director (Medical Procedure 4.4).
• Assist ventilations with a bag -valve mask (BVM) device attached to supplemental oxygen at
15-25 L/min as needed (Medical Procedure 4.1.5).
• Suction as needed (Medical Procedure 4.3.1, Flexible Suctioning, and Medical Procedure
4.3.2, Rigid Suctioning).
• Apply and monitor pulse oximeter (Medical Procedures 4.22).
• Apply and monitor capnography for wave form (Medical Procedure 4.10.1)
If spontaneous breathing is absent or markedly compromised:
• Maintain airway patency (Medical Procedure 4.1.3).
• Assist ventilation with a BVM device attached to supplemental oxygen at 15-25 L/min as
needed (Medical Procedure 4.1.5). Maintain 02 saturation of 94% or greater. Avoid over
oxygenation: Wean oxygen concentration as tolerated
• If unconscious, insert oropharyngeal, nasopharyngeal as needed (Medical Procedure 4.2).
• If patient accepts oropharyngeal airway, consider the need for a supraglottic device. EMT
may insert the supraglottic device if he/she has been authorized by that department's Medical
Director (Medical Procedure 4.4).
• Suction as needed (Medical Procedure 4.3.1, Flexible Suctioning, and Medical Procedure
4.3.2, Rigid Suctioning).
• Apply and monitor pulse oximeter (Medical Procedures 4.22).
• Apply and monitor capnography for wave form (Medical Procedure 4.10.1)
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PARAMEDIC ONLY
• If patient accepts oropharyngeal airway, consider the need for an advanced airway (see ALS
Level 1, Advanced Airway Management).
ALS Level 1: Advanced Airway Management
Insert an advanced airway and document the following (Medical Procedure 4.4)
1. Confirm an advanced airway placement with an end -tidal COz monitoring device
2. Additional confirmation methods may include the following options:
a. Visualization of the tube passing through the vocal cords.
b. Negative epigastric sounds.
c. Positive bilateral breath sounds.
Secure the advanced airway with a commercially available device.
a. Application of a c-collar may be useful in preventing the advanced airway from
becoming dislodged,
b. For trauma patients or for patients with head/neck injury use full spinal
immobilization
If unable to insert the advanced airway and patient cannot be adequately ventilated by other
means, perform cricothyroidotomy (Medical Procedure 4.5) and transport rapidly to the
nearest appropriate facility.
➢ None
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EMT AND PARAMEDIC
• Initial Assessment Protocol 2.1.1.
• Airway Management Protocol 2.1.2.
• The EMT should apply the AED (Medical Procedure 4.1.1, AED
• Establish hospital contact for notification of an incoming patient.
PARAMEDIC
• Establish IV of normal saline with a regular infusion set (a) (b); unless overridden by the
specific protocol. (Medical Procedure, Medication Delivery 4.18.5)
• In a critical medical patient, an intraosseous (IO) line may be considered (Medical
Procedures 4.18.4)
OR
• Medication may be administered intranasal (IN) via the MAD device. (Medical
Procedure, Medication Delivery 4.18.3)
• Monitor ECG as needed.
➢ The paramedic should obtain consultation for ALS Level 2 orders.
(a) Authorized IV routes include all peripheral venous sites. External jugular veins may be
utilized when other peripheral site attempts have been unsuccessful or would be
inappropriate. A large -bore intracath should be used for unstable patients. Avoid use of
access sites below the diaphragm.
(b) An IV lock or MAP may be used in lieu of an IV bag in some patients, when appropriate
(Medical Procedure 4.18.5).
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EMT AND PARAMEDIC
• Initial Assessment Protocol 2.1.1. Initiate Trauma Alert; if applicable (General Protocol
1.10, Trauma Transport).
• Airway Management Protocol 2.1.2. (Manually stabilize c-spine as needed.)
• Correct any open wound/sucking chest wound (with an occlusive dressing).
• Control hemorrhage.
• Immobilize fractures.
• Determine if the patient is taking any anticoagulant such as warfin (Coumadin) or
antiplatets such as dabigatran (Pradaxa).
• Immobilize c-spine and secure the patient to a backboard as needed (Protocol 2.10.1. and
Medical Procedure 4.24, Spinal Immobilization).
• Expedite transport.
• Correct any massive flail segment that causes respiratory compromise
The following steps should not delay transport.
• Complete bandaging, splinting, and packaging as needed.
• Establish hospital contact for notification of an incoming patient, and obtain consultation
for Level 2 orders.
PARAMEDIC ONLY
• Consider advanced airway to assist with the correction of a massive flail segment that
causes respiratory compromise.
• Correct any tension pneumothorax (Medical Procedure 4.9, Chest Decompression).
M1` PARAMEDIC
• Establish IV of normal saline with a regular infusion set (a) (b), unless overridden by the
specific protocol. (Medical Procedure, Medication Delivery 4.18)
• In a critical trauma patient, an intraosseous (IO) line may be considered (Medical
r Procedure, Medication Delivery 4.18)
• Monitor ECG as needed.
➢ None
(a) Authorized IV routes include all peripheral venous sites. External jugular veins may be
Note utilized when other peripheral site attempts have been unsuccessful or would be
inappropriate. Two IVs using large -bore intracaths should be initiated in unstable patients.
Avoid use of access sites below the diaphragm.
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ISOLATED EXTREMITY FRACTURE
The purpose of this procedure is to manage pain associated with isolated extremity fractures
but not associated with multisystem trauma or hemodynamic instability.
ACUTE BACK STRAIN
This procedure should be used in the isolated back strain where an acute abdominal process
is not suspected (see Appendix 6.1, Abdominal Pain Differential).
RENAL COLIC
This procedure is used for flank pain associated with kidney stones, where an acute
abdominal process can be ruled out (Appendix 6.1, Abdominal Pain Differential).
SOFT -TISSUE INJURIES, BURNS, BITES, AND STINGS
This procedure is used for pain associated with soft -tissue injuries, burns, bites, and stings not
associated with multisystem trauma or hemodynamic instability
For Isolated Extremity Fractures
• Any extremity fracture should be immobilized as described in Adult Protocol 2.10.6,
Extremity Injuries.
• Extremity fractures should be elevated, if possible, and cold applied.
• Distal circulation, sensation, and movement in the injured extremity should be noted and
recorded.
• Patients should be asked to quantify their pain on an analog pain scale (from 0 = least
`'- severe to 10 = most severe). This number should be documented and used to measure the
effectiveness of analgesia.
• Self-administered analgesia with nitrous oxide should be given special consideration for
pain management during this procedure (Medical Procedure 4.20, Nitrous Oxide-Nitronox),
if available.
• If pain persists and systolic BP above 90 mmHg administer,
_ - o Morphine Sulfate may be given via slow IV in 5 mg increments may repeat once, titrated to
--- - =_ _- pain and BP above 90 mm Hg, up to a maximum of 10 mg (b).
OR
= o Fentanyl may be given 100 mcg IN increments every 5-10 minutes to a maximum of 200
mcg IN or 50 mcg slow IV increments every 5-10 minutes up to a maximum of 100 mcg,
titrated to pain and BP remains above 90 mm Hg (a) (b) (Medical Procedure 4.18,
Medication Administration)
➢ None
(a) When administering Morphine Sulfate/Fentanyl, closely monitor the patient's respiratory
status. In the event that the patient's respirations/oxygenation is suppressed (SP02 less
than 94%), utilize basic airway maneuvers (open airway), administer oxygen and if no
improvement consider Narcan.
(b) If Fentanyl was initially given IN and an IV is then established, one IV dose (50 mcq)
can be given if needed.
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Assessment of the adult patient in respiratory distress requires specific attention to the function
of the respiratory system. The EMT's and paramedic's assessment should be more concentrated
in this area, to include the following considerations:
1. Assessment of chest wall movement, including the rate and depth of ventilation as well as the
presence of symmetrical rise and fall.
2. Assessment of accessory muscle use.
3. Auscultation of bilateral lung sounds.
4. Use of pulse oximetry.
5. Use of EtCO2, monitor wave form.
The paramedic must be able to determine the adequacy of ventilation and understand its
relationship to respiration. If signs of hypoxia and respiratory distress are present, immediate
airway and ventilatory management should be initiated. These signs include altered mental
status, tachypnea, use of accessory muscles, nasal flaring, pursed lips, abnormal lung sounds,
tachycardia, and cyanosis. In addition, the general signs of shock may be seen. Other signs of
respiratory insufficiency that should alert the paramedic to the need for immediate airway and
ventilatory management, including placement of an advanced airway, are respiratory rate below
10/min or above 36/min, SP02 below 94%, or EtCO2 outside the normal range of 35-45mmHg.
In patients with chronic respiratory disease, the paramedic must be able to differentiate between
what is chronic and what is acute, as it pertains to the respiratory assessment. Specific questions
about the chief complaint and accompanying symptoms may prove to be invaluable in this
setting. Assessment of lung sounds should be combined with patient history. For example, a
patient with a history of CHF who has wheezing on auscultation of lung sounds should not be
automatically classified as an "asthma patient." The paramedic must remember that patients with
CHF may also present with wheezing. If this patient does not have a history of asthma or allergic
reaction, the more prudent assessment would be that of CHF.
Specific treatments for the different causes of respiratory distress are outlined in the following
protocols. When the paramedic is unsure as to which protocol to follow, he/she should follow the
protocols in Section 2.1 and contact medical control for further direction.
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Causes of upper airway obstruction include the tongue, foreign bodies, swelling of the upper
airway due to angio-neurotic edema (see Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis),
and trauma to the airway. Differentiation of the cause of upper airway obstruction is essential to
determining the proper treatment.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3
• If air exchange is inadequate and there is a reasonable suspicion of foreign body airway
obstruction (FBAO), apply abdominal thrusts until the patient becomes unresponsive
then administer chest compressions (Medical Procedure 4.1.6) (a).
• If unable to relieve FBAO, visualize it with a laryngoscope and extract the foreign body
with magill forceps.
• If the obstruction is due to trauma and/or edema, or if uncontrollable bleeding into the
airway causes life -threatening ventilatory impairment, utilize an advanced airway
(Medical Procedure 4.4, Advanced Airways).
• If unable to insert an advanced airway and the patient cannot be adequately ventilated by
other means, perform a cricothyroidotomy (Medical Procedure 4.5, Needle
Cricothyroidotomy).
• Establish an IV; give normal saline KVO.
➢ None
(a) If air exchange is adequate with a partial airway obstruction, do not interfere; instead,
encourage the patient to cough up the obstruction. Continue to monitor the patient for
adequacy of air exchange. If air exchange becomes inadequate, continue with the protocol.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol is used for patients who are complaining of dyspnea and having wheezing. A
patient with a history of CHF who has wheezing on auscultation of lung sounds should not be
automatically classified as an "asthma patient." If the CHF patient does not have a history of
asthma or allergic reaction, the more prudent assessment would be that of CHF (cardiac asthma)
(Adult Protocol 2.2.4, Pulmonary Edema-CHF).
• Initial Assessment Protocol 2.1.1, Airway Management 2.1.2
• Place the patient in Fowler's position and assist ventilations as needed (Medical Procedure 4.1.5)
• Establish an IV; give normal saline.
• Give Albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Albuterol premixed
with 2.5 mL normal saline (Medical Procedure 4.18.6). This treatment may be repeated twice
as needed.
• If bronchodilators are administered, may add Ipratoprium bromide (Atrovent®) 0.5 mg (0.5 mL)
to Albuterol nebulizer treatment on first nebulizer treatment only.
• Consider the need for advanced airway management (Medical Procedure 4.4).
If patient continues to have severe respiratory distress, consider the following:
• Administer the following steroid
➢ Methylprednisolone sodium succinate (Solu-Medrol) 125mg IV, if IV cannot be established
then administer IM, if available(Medical Procedure, Medication Delivery 4.18)
• Administer Epinephrine (1:1000) 0.3 mg IM (Medical Procedure, Medication Delivery 4.18)(a).
If severe respiratory distress continues, consider the following:
• Administer Magnesium Sulfate 2 g IV (mixed in 50 mL of D5W) given over 5-10 minutes.
• Repeat Epinephrine (1:1000) 0.3 mg IM, if the patient has not responded to the previous
treatments (a) (b) (Medical Procedure, Medication Delivery 4.18)
• Administer CPAP with 2.5- 5 cm H2O PEEP (Medical Procedure 4.12).
➢ Repeat Epinephrine (1:1000) 0.3 mg IM (a).
(a) When administering Epinephrine caution should be used when the patient is older than 40 years
of age or has a history of hypertension or heart disease.
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This protocol is used for patients with a history of emphysema and/or chronic bronchitis
(COPD) who complain of dyspnea. If at any point the patient's respiratory status deteriorates,
consider an advanced airway and administration of Albuterol via the ET tube nebulized, and
transport the patient immediately.
• Initial Assessment Protocol 2.1.1.
• Place the patient in Fowler's position and assist ventilations as needed (Medical Procedure 4.4).
• Establish an IV; give normal saline KVO.
• Give Albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Albuterol premixed
with 2.5 mL normal saline (Medical Procedure 4.18.6). This treatment may be repeated twice as
needed.
• If bronchodilators are administered, may add Ipratoprium Bromide (Atrovent®) 0.5 mg (0.5
mL) to Albuterol treatment on first nebulizer treatment only.
• Administer CPAP with 2.5-5 cm H2O PEEP (Medical Procedure 4.12).
• Consider the need for advanced airway management (Medical Procedure 4.4).
If patient has severe respiratory distress you may administer:
• Methylprednisolone sodium succinate (Solu-Medrol) 125mg, IV push. If IV cannot be
established then administer IM, if available. (Medical Procedure, Medication Delivery 4.18)
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol is used for patients who are exhibiting signs of pulmonary edema-CHF, including
dyspnea with rates and/or wheezing (cardiac asthma). The patient may also have diminished air
exchange. Other treatments for the causes of pulmonary edema-CHF should be considered (e.g.,
supraventricular tachycardia, myocardial infarction, and cardiogenic shock). A patient with a
history of CHF who has wheezing on auscultation of lung sounds should not be automatically
classified as an "asthma patient." The paramedic must remember that patients with CHF may
also present with wheezing. If the CHF patient does not have a history of asthma or allergic
reaction, the more prudent assessment would be that of CHF (cardiac asthma).
• Initial Assessment Protocol 2.1.1.
• Place the patient in Fowler's position and assist ventilations as needed (Medical Procedure
4.1.5).
• If the patient is hypotensive (systolic BP below 90 mm Hg), Adult Protocol 2.4.1,
Cardiogenic Shock.
• If there is no improvement in the patient's pulse oximetry, capnography, and mental status,
consider use of an advanced airway (Medical Procedure 4.4).
• Establish an IV; give normal saline KVO.
• Do not administer nitroglycerin (NTG) if:
o The patient's systolic BP is below 100 mm Hg.
o The patient has taken any of the following erectile dysfunction medications. (Note the
following medications are also marketed under a variety of other trade names).
a. Stendra (Avanafil) — in the past 12 hours
b. Viagra (Sildenafil) — in the past 24 hours
c. Levitra (Vardenafil) or Cialis (Tadalafil) — in the last 48 hours
• If the patient's systolic BP is between 100 and 160 mm Hg, give nitroglycerin (Nitrostae or
Nitrolingual® spray) 0.4mg SL, prior to applying CPAP. May repeat every 3 to 5 minutes
(maximum of two additional doses (0.4mg/each) if the patient is symptomatic and the systolic
pressure is greater than 120 mmHg (b).
• If the patient's systolic BP is above 160 mm Hg, give nitroglycerin (Nitrostae or Nitrolingual®
spray) 0.8mg SL, prior to applying CPAP. May repeat as needed every 3 to 5 minutes
(0.4mg/each) if the patient is symptomatic and the systolic blood pressure is greater than 160
mmHg (b) (c).
• Administer CPAP with 10 cm H2O PEEP (Medical Procedure 4.12) (a).
• Reevaluate the need for advanced airway management. If there is no improvement in the
patient's pulse oximetry, capnography, and mental status, consider use of advanced airway
management (Medical Procedure 4.4, and Medical Procedure 4.10, Capnography).
➢ Give Albuterol (Ventolin): 1 nebulizer treatment containing 2.5 ma of Albuterol
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with 2.5 mL normal saline (Medical Procedure 4.18.6).
➢ If bronchodilators are administered, may add Ipratropium Bromide (Atrovent®) 0.5 mg (0.5
mL) to Albuterol treatment on first nebulizer treatment only.
(a) The CPAP mask must be tight fitting. Some patients may not tolerate CPAP at 10 cm H2O
PEEP initially, in which case you may start with lower pressures (5 — 7.5cm H2O PEEP-
CPAP should not be used if the patient's systolic BP below 100 mm Hg.
(b) Consider withholding if the clinical presentation of the patient indicates signs of
hypovolemia (e.g., poor skin turgor, decreased capillary refill, and elevated temperature).
(c) It is preferred to have an IV in place prior to NTG administration. However, if you are unable
to establish IV access, NTG may be administered with caution.
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Patients complaining of dyspnea should be suspected of having pneumonia when they present
with fever, productive cough, possible pleuritic chest pain, history of being bedridden, known
immunocompromise, diabetes, elderly age, and lung sounds indicative of consolidation (rates
and/or rhonchi with egophony over area of consolidation).
• Initial Assessment Protocol 2.1.1.
• Establish an IV; If lungs sounds are clear administer 250-500cc normal saline
• Give albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Abbuterol premixed
with 2.5 mL normal saline (Medical Procedure 4.18.6). This treatment may be repeated twice
as needed.
• If bronchodilators are administered, may add Ipratropium Bromide (Atrovent®) 0.5 mg (0.5
mL) to albuterol nebulizer treatment on first nebulizer treatment only.
• Avoid the use of diuretics.
➢ None
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Protocols in Section 2.3 follow the ACLS guidelines. The paramedic should use these protocols to
guide him/her through the treatment of cardiac patients with specific dysrhythmias and
accompanying signs and symptoms. After stabilization of the patient, the paramedic may need to
refer to additional protocols for continued treatment (e.g., other cardiac protocols).
In cardiac arrest, a major component of the primary and secondary survey is to consider the
secondary, differential diagnosis and to think carefully about what could be causing the arrest. The
"H's and T's" chart will assist in the recognition of a possible underlying cause.
H's Cause
Treatment
Protocol
Hypovocemia
Fluid challenge NS 500 mL IV/IO
Protocol 2.10
Hypoxia
Airway management
Protocol 2.1.2
Hydrogen ion -acidosis
Airway management, ventilate
consider Sodium Bicarbonate
Protocol 2.1.2
Drug Summary 5.31
Hyperkalemia
Consider Calcium Chloride 1 g
Consider Sodium
Bicarbonatel mEq/kg
Drug Summary 5.9 and
5.31
Hypothermia
Cold -related emergencies
Protocol 2.9.2
Hypoglycemia
If less than 60, consider
D50 or Glucagon
Protocol 2.8.2 Drug
Summary 5.9 and 5.16
Hypogaycemia
Consider Calcium Chloride 1 g
Drug Summary 5.7
T's Cause
Treatment
Protocol
Tablets
Consult poison control
for specific therapy
Protocol 2.6
Tamponade, cardiac
Consider fluid challenge,
Dopamine drip
Protocol 2.4.
Tension pneumothorax
Consider chest decompression
Procedure 4.9
Thrombosis, coronary
Consider AMI, cardiogenic shock
Protocol 2.4.2
Thrombosis, pulmonary
Protocol 2.4.1
Trauma
Protocol 2.10
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• Consider criteria for death/no resuscitation (General Protocol 1.4).
• Initial Assessment Protocol 2.1.1.
• Oxygenate with 15-25 L/min via bag -valve mask (BVM) with an appropriate airway adjunct
device at 8 - 10 BPM (Airway Management Protocol 2.1.2) (a).
• Assess circulation - pulse, major bleeding, skin color and temperature.
• If no pulse, begin immediate chest compressions at a rate of 100 per minute for 2 minutes
while monitor is being attached.
• Do not interrupt CPR to check for a heart rhythm. Continuous uninterrupted compressions
are paramount to patient survival.
• Check the heart rhythm; confirm asystole in two leads.
• Resume 2 minutes of continuous compressions at 100 per minute; check the heart rhythm.
• Consider the H's and T's.
• Confirm airway adjunct placement with electronic EtCO2 and waveform on scene, during
transport, and during transfer at the hospital.
• Establish IV or IO access; give normal saline KVO. Consider infusing saline wide open in
PEA.
• When IV or IO line is established, administer a vasopressor:
o Epinephrine (1:10,000) 1 mg IV/I0; repeat every 3-5 minutes.
o One dose of Vasopressin 40 U IV/IO can replace the first or second dose of Epinephrine.
• Give 2 minutes of chest compressions; check the heart rhythm.
• Search for and treat possible contributing factors; see the H's and T's charts.
• If the patient is taking a calcium -channel blocker or has known renal failure, give Calcium
Chloride 10% 1 g IV or I0.
• As soon as the patient regains spontaneous circulation (Return of Spontaneous Circulation
(ROSC) Protocol 2.3.7 and Therapeutic Hypothermia Protocol 2.3.8).
➢ None
(a) Provide a 30:2 compression to ventilation ratio.
Once an advanced airway is in place, provide 1 breath every 6 seconds.
(b) If EtCO2 less than 1 OmmHg: Attempt to improve CPR (compressions vs. ventilation). If
EtCO2 = 12 - 25mm Hg: Goal during resuscitation.
If EtCO2 = 35 - 45mm Hg: Check for ROSC
(c) If ROSC achieved, wean down oxygen to maintain a SPO2 equal to greater than 94%.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
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41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Patients who present with a heart rate less than 50 and are symptomatic (a).
Consider the potential causes:
Acute myocardial infarction
Head injury
Atrio-ventricular block
Hypoxia
Hypoglycemia
Medications (beta blockers)
Calcium -channel blockers
Clonidine
Digitalis (e)
Toxins
Sick sinus syndrome
Spinal cord lesion
• Initial Assessment Protocol 2.1.1.
• Access the CABS and vital signs.
• Apply a SP02 monitor, and administer oxygen to maintain SP02 greater than or equal to 94%
or assist with bag -valve mask (BVM) ventilations if indicated.
• Consider the H's and T's.
• Establish IV access; give normal saline KVO.
• Perform 12-lead ECG. If inferior wall MI is identified, perform additional 12-lead ECG with
V4R to confirm/rule out concurrent right ventricular MI (b).
Unstable (e.g., acutely altered mental status, ischemic chest pain/discomfort, acute heart failure,
hypotension (systolic BP below 90 mm Hg), dyspnea, heart blocks or ischemia/infarction on
12-lead ECG or other signs of shock that persist despite adequate airway and breathing),
• While preparing to pace administer Atropine 0.5 mg IV/IO; repeat every 3 - 5 minutes, up to
a maximum total dose of 3 mg (a) (b) (c).
• If bradycardia is unresponsive to atropine, establish an IV infusion of a primary 0-adrenergic
agonists (Dopamine) with rate -accelerating effects.
• Bradycardia with hypotension may be due to an inferior wall MI associated with right
ventricular MI (confirmed on 12-lead ECG as a V4R ST elevation). If the patient has an
acute inferior wall MI with hypotension and clear lungs, give normal saline 500 cc fluid
challenge; may repeat once (Adult Protocol 2.4.2, Chest Pain —Suspected AMI).
o When an inferior wall MI is associated with right ventricular MI, avoid the use of nitrates
(Nitroglycerin) and Morphine/Fentanyl.
o If bradycardia and hypotension exist, pacing and IV fluids may improve the patient's
hemodynamic status; consider pacing and IV fluids prior to the use of Atropine. Also
refer to Adult Protocol 2.4.2, Angina/Suspected AML (b)
If the patient has persistent hypotension/cardiogenic shock, give Dopamine 5 - 10
mcg/kg/min (1600 mcg/mL infusion concentration = 15-60 gtts/min). Titrate to maintain a
minimum systolic BP of 90 mm Hg and maximum BP of 120 mm Hg (maximum dose 20
mcg/kg/min)
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
If the patient is conscious and aware of the situation during pacing, administer one of the
following benzodiazepines (d): (Medical Procedure, Medication Delivery 4.18).
o Diazepam (Valium) 5 mg IV, IO, or IN; may repeat once, to a maximum dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg (e).
OR
Lorazepam (Ativan) 2 mg IV, IO, or IN; may repeat once, to a maximum dose of 4 mg.
➢ None
(a) Consider pacing before giving the maximum dose of atropine.
(b) For second-degree AV block type II and third-degree AV block, omit Atropine and use an
external pacer.
(c) Use atropine with caution in the presence of myocardial ischemia.
(d) Administer benzodiazepines slowly, titrate to effect, and be aware of associated hypotension
(e) If suspected digitalis toxicity, Atropine improves AV nodal conduction. Caution should be
used with pacing because it can lower the fibrillatory threshold and induce arrhythmias.
Refer to Protocol 2.6.4 Digitalis Toxicity.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
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4 Ih Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Patients suffering from tachycardia may or may not exhibit symptoms. It is important to note that
narrow complex tachycardia has many origins. The atrial rate may be helpful in the differential
interpretation of these types of tachycardia. The following rates should be considered:
Sinus tachycardia ranges from 100 to 160 beats per minute.
Junctional tachycardia ranges from 100 to 180 beats per minute.
Atrial tachycardia ranges from 150 to 250 beats per minute (atrial rate).
Atrial flutter ranges from 250 to 350 beats per minute (atrial rate).
Atrial fibrillation starts at 350 beats per minute (atrial rate).
In addition, wide complex tachycardia (QRS greater than or equal to 0.12 seconds) should
initially be considered as ventricular in origin, unless proven otherwise (e.g., documented QRS
morphology consistent with preexisting BBB; refer to Adult Medical Protocol 2.3.6, Wide
Complex Tachycardia with a Pulse).
Those patients who present with SVT may have evidence of cardiovascular dysfunction. Those
patients who present with "borderline" symptomatic signs and symptoms may be treated with
medications. Those patients who present with "unstable" signs and symptoms should be
cardioverted immediately.
The following table shows the range from borderline signs and symptoms to unstable signs
and symptoms:
Borderline Symptomatic Stable
Critical Unstable
Alert and oriented
Decreased level of consciousness
SBP equal to greater than 90 mm Hg
SBP below 90 mm Hg (shock)
Mild chest discomfort
Chest pain
Shortness of breath
Shortness of breath
Diaphoresis
Pulmonary edema/CHF
4Ih Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
ALL BORDERLINE SYMPTOMATIC NARROW COMPLEX TACHYCARDIAS
Heart Rate greater than 150 BPM
• Initial Assessment Protocol 2.1.1.
Determine hemodynamic stability and symptoms.
Consider the H's and T's.
STABLE SVT, HEART RATE greater than or equal to 150 BPM
• Apply the ECG monitor, record a rhythm strip, and obtain a 12-lead ECG.
• Establish IV access; give normal saline KVO.
• If the patient is asymptomatic, provide medical supportive care (Protocol 2.1.3) and transport
immediately.
• If necessary, perform vagal maneuvers (Medical Procedure 4.26).
• If not resolved, administer Adenosine Triphosphate (Adenocard®) 6 mg rapid IVP, followed
by rapid 20 mL NS flush (a).
• If not resolved, after 2 minutes Adenosine Triphosphate (Adenocard) 12 mg rapid IVP,
followed by rapid 20 mL NS flush. (a).
➢ If available, administer Diltiazem (Cardizem ) 0.25 mg/kg IV or IO (over 2 minutes) (20 mg
for the average patient) for narrow complex supraventricular tachycardiac (b)
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
BORDERLINE SYMPTOMATIC ATRIAL FIBRILLATION OR ATRIAL FLUTTER
AND HEART RATE greater than or equal to 150 BPM
• Apply the ECG monitor, record a rhythm strip, and obtain a 12-lead ECG.
• Establish IV access; give normal saline KVO.
• If the patient is asymptomatic, provide medical supportive care (Protocol 2.1.3) and
transport immediately.
• If the patient has borderline symptoms with a SBP of 90-100 mm Hg, consider other causes
of hypotension (e.g., hypovolemia or sepsis)
• If available, administer Diltiazem (Cardizem) 0.25 mg/kg IV over 2 minutes (20 mg for the
average patient) (b).
• If the tachyarrhythmia is not resolved in 15 minutes, may repeat Diltiazem (Cardizem) 0.35
mg/kg IV or IO (over 2 minutes) (25 mg for the average patient).
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
ALL CRITICAL/UNSTABLE SYMPTOMATIC NARROW COMPLEX TACHYCARDIAS
This patient group includes individuals who are hypotensive with a systolic BP less than 90 mm
Hg and a heart rate greater than or equal to 150 beats/min and who are symptomatic (clinical
evidence of impending cardiac arrest) as evidenced by any of the following:
Diaphoresis, Shortness of breath, Decreased level of consciousness, Chest pain, Pulmonary edema
• Initial Assessment Protocol 2.1.1.
Determine hemodynamic stability and symptoms.
Consider the H's and T's.
• Provide advanced airway management, if necessary (c).
• Establish IV access; give normal saline KVO.
• Evaluate lung sounds. If they are clear, administer a fluid challenge of normal saline 500 cc
IV or IO.
• If the patient is conscious and aware of the situation, consider sedation with one of the
following benzodiazepines (d): (Medical Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, or IN, maximum dose of 10 mg (e)
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, IO, or IN; may repeat once, up to a max dose of 4 mg (e).
Perform synchronized cardioversion Start at the lower dose and increase to the higher
dose until appropriate clinical effect is obtained.
Narrow regular SVT, atrial flutter: 50-100 joules
Narrow irregular, atrial fibrillation: 120-200 joules (per manufacture recommendation)
Escalate the second and subsequent shock doses as needed.
➢ None
(a) Adenosine Triphosphate should not be given to patients with known atrial flutter or atrial
fibrillation.
(b) Do not give diltiazem (Cardizem®) to patients with a known history of Wolff -Parkinson -
White (WPW) syndrome.
(c) Confirm airway adjunct placement with electronic EtCO2 and waveform on scene,
during transport, and during transfer at hospital.
(d) Administer benzodiazepines slowly, titrate to effect, and be aware of associated hypotension
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Treatment of ventricular arrhythmias after MI has been a controversial topic for two decades.
Similarly, management of ventricular arrhythmias during the acute phase of MI continues to
evolve as treatment strategies are reviewed in the context of new information and changing
epidemiological data during the era of adjunctive medical and reperfusion therapy. At present,
the treatment of asymptomatic premature ventricular ectopy (PVC) is not recommended.
Current ACLS protocols recommend amiodarone for the treatment of hemodynamically stable
VT and prevention of recurrent VF.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3: 100% oxygen via non-rebreather mask at 10-15
L/min.
➢ None
➢ If the patient is symptomatic, contact the physician for further orders
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
BORDERLINE SYMPTOMATIC (STABLE)
• Initial Assessment Protocol 2.1.1.
• Consider the H's and T's.
• Monitor the ECG.
• Establish IV access; give normal saline KVO.
• Give Amiodarone 150 mg in 50 mL of DSW over 10 minutes IV with a lOgtt set at 1
drop a second, if available.
• If the patient has torsades de pointes, administer Magnesium Sulfate 2 g in 50 mL of DSW
infused over 1-2 minutes IV. If the Magnesium Sulfate successfully converts the rhythm,
start Magnesium Sulfate maintenance infusion (1 g in 250 mL of DSW) at 30-60 gtts/min.
with a 60 gtts set.
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
CRITICAL (UNSTABLE)
Heart rate greater than 150 beats/min and systolic blood pressure less than 90 mm Hg with one
of the following signs and symptoms: chest pain, dyspnea, pulmonary edema, diaphoresis, and
altered mental status.
• Initial Assessment Protocol 2.1.1.
• If necessary, oxygenate with 15-25 L/min via bag -valve mask (BVM) with an
appropriate airway adjunct device at 8-10 BPM (Airway Protocol 2.1.2) (a).
• Confirm airway adjunct placement.
• Consider the H's and T's.
• Monitor the ECG.
• Establish IV or IO access; give normal saline KVO.
o If the patient is conscious and aware of the situation, consider sedation with one of the
following benzodiazepines (b): (Medical Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, or IN; maximum dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, IO, or IN; may repeat once, up to a maximum dose of 4 mg
• For unstable monomorphic perform synchronized cardioversion at 100, 200, 300, or 360
joules. If wide irregular/unstable or polymorphic and/or torsades: defibrillate (not
synchronized).
➢ None
(a) Provide one breath every 8 — 10 seconds
Once an advanced airway is in place, provide 1 breath every 6 seconds.
(b) Administer benzodiazepines slowly, titrate to effect, and be aware of associated hypotension.
(c) If an antiarrhythmic medication was not administered prior to cardioversion, administer
Amiodarone 150 mg in 50 mL of DSW over 10 minutes IV if patient's BP is above 100.
Repeat once 10 minutes later as needed.
(d) If suspected digitalis toxicity, consider lowering initial cardioversion dose to 5-20 joules.
Protocol 2.6.4 Digitalis Toxicity
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
• Initial Assessment Protocol 2.1.1.
• Determine the patient's (un)responsiveness and check the CABS.
• Oxygenate with 15-25 L/min via a BVM with an appropriate airway adjunct device at 8-
10 BPM (see Airway Protocol 2.1.2) (a) (e).
• Begin immediate chest compressions at a rate of 100 per minute for 2 minutes while the
monitor is being attached. If the event was witnessed arrest, defibrillate immediately.
• Do not interrupt CPR to check for a heart rhythm. Continuous uninterrupted
compressions are paramount to patient survival.
• Check the heart rhythm. Confirm the rhythm and shock accordingly (b).
• Perform a focused rapid assessment.
• Consider the H's and T's.
• Confirm placement of the airway adjunct with electronic EtCO2 and wave -form while on
scene, during transport, and during transfer at hospital.
• Establish IV or IO access; give normal saline KVO.
• Defibrillate at 200 joules (for a biphasic device based on manufacturer recommendation) (e).
Continue CPR while the defibrillator is charging.
• Immediately resume continuous chest compressions at a rate of 100 per minute for 2 minutes.
• Check the heart rhythm. If it is a shockable rhythm, defibrillate at 300 joules for a biphasic
device based on manufacturer recommendation) (e). Continue CPR while the defibrillator is
charging.
• When an IV or IO line is established, administer a vasopressor:
o Give Epinephrine (1:10,000) 1 mg IV/IO; repeat every 3-5 minutes for the duration of the
arrest.
OR
o One dose of Vasopressin 40 U IV/IO can replace the first or second dose of Epinephrine.
• Immediately resume continuous chest compressions at a rate of 100 per minute for 2 minutes.
• Check the heart rhythm. If it is a shockable rhythm, defibrillate at 360 joules for a biphasic.
Continue CPR while the defibrillator is charging.
• Immediately resume continuous chest compressions at a rate of 100 per minute for 2 minutes.
• Administer Amiodarone 300 mg IV/IO once. If V-Fib/pulseless V-Tach continues after 3-5
minutes administer an additional 150 mg IV/ IO once. Administer during CPR.
• Check the heart rhythm. If it is a shockable rhythm, defibrillate at 360 joules for a biphasic
device based on manufacturer recommendation) (e). Continue CPR while the defibrillator is
charging.
• Immediately resume continuous chest compressions at a rate of 100 per minute for 2 minutes.
• Check the heart rhythm.
• If the patient has torsades de pointes, administer Magnesium Sulfate 2 g in 50 mL of DSW
infused over 1-2 minutes IV/IO (c).
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
• Continue treatment until there is a return of spontaneous circulation (ROSC), a rhythm
change, or termination of efforts.
• If the patient has Return of Spontaneous Circulation (ROSC), (Protocol 2.3.7 and
Therapeutic Hypothermia Protocol 2.3.8).
➢ None
(a) Provide a 30:2 compression to ventilation ratio.
Once an advanced airway is in place, provide 1 breath every 6 seconds.
(b) The EMT should apply the AED. The paramedic should proceed to ALS Level 1
defibrillation.
(c) If Magnesium Sulfate successfully converts the heart rhythm, start Magnesium Sulfate
maintenance infusion (2 g in 500 mL NS) at 30-60 gtts/min.
(d) If EtCO2 is less than 1 OmmHg: Attempt to improve CPR (compressions vs. ventilation).
If EtCO2 = 12-25mm Hg: Goal during resuscitation.
If EtCO2 = 35-45mm Hg: Check for ROSC
(e) For Zoll monitor biphasic device the manufacturer recommends the initial defibrillation at
120 joules and subsequent defibrillations at 150, 200 as the maximum.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
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4 Ih Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Post -resuscitation is an extremely unstable period for the patient, so the patient should be
monitored closely and reassessed frequently. The immediate goals of post -resuscitation care are
as follows:
• Provide cardio-respiratory support to optimize tissue perfusion, especially to the brain.
• Institute antiarrhythmic therapy to prevent recurrence of the arrest.
• Attempt to identify the precipitating cause of the arrest.
• Rapidly transport the patient to the closest appropriate facility.
When responding to a facility that provides therapeutic hypothermia, implement the hypothermia
protocol if the patient has a return of spontaneous circulation (ROSC) and remains unconscious.
• Initial Assessment Protocol 2.1.1.
• Reassess the CABS and vital signs.
• Maintain an open airway with an appropriate airway adjunct device, administer 100% 02 to
maintain SPO2 greater than or equal to 94%, and monitor with electronic EtCO2
capnography/waveform. Ventilate at 8-10 BPM; avoid hyperventilation (d).
• Determine the patient's hemodynamic stability. If systolic blood pressure below 90 mm Hg:
o If the patient's lungs are clear, administer IV NS 500 mL; may repeat once to maintain
systolic blood pressure above 90 mm Hg (a).
If systolic BP remains below 90 mm Hg:
- o Give a Dopamine infusion at 5 -10 mcg/kg/min; titrate to maintain BP at greater than or
_ equal to 90 mm Hg.
• Manage dysrhythmias according to the specific protocol.
• If the cardiac arrest was the result of VF or VT, manage the patient as follows:
o If an antiarrhythmic medication was not used to convert the heart rhythm, administer
Amiodarone 150 mg in 50 mL of DSW over 10 minutes IV/IO (b).
- o If Amiodarone was administered during resuscitation, do not administer additional
Amiodarone.
- - - o If the patient is having frequent PVC or runs of VT, or if the transport time will exceed
30 minutes, start an Amiodarone drip (150 mg in 50 mL of DSW = 3:1 concentration).
. = Using a 60 gtt/mL set, initiate the flow at 1 gtt every 3 seconds.
o Proceed to Therapeutic Hypothermia Protocol 2.3.8.
• Transport the patient to the closest interventional cardiac/ice facility (c).
➢ None
(a) If rates or crackles are auscultated in the lungs or the patient's systolic blood pressure
remains less than 90 mm Hg despite fluid therapy, proceed directly to dopamine
administration.
(b) Do not use Amiodarone if the patient has a heart rate less than 60, second-degree type II AV
block, third-degree AV block or if patient is hypotensive
(c) If the patient's airway is compromised or crews are unable to manage the patient, transport
the patient to the nearest facility.
(d) If EtCO2 is less than OmmHg: Attempt to improve CPR (compressions vs. ventilation).
If EtCO2 = 12-25mm Hg: Goal during resuscitation.
If EtCO2 = 35-45mm Hg: Check for ROSC
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Cardiac arrest outside of the hospital is a common occurrence and typically results in a poor
outcome for the patient. Those patients who do have a return of spontaneous circulation (ROSC)
will often have a poor neurological out -come as a result of cerebral reperfusion injury. The
American Heart Association (AHA) has recognized this fact and offers the following
recommendation: "Unconscious adult patients with ROSC after out -of -hospital cardiac arrest
should be cooled to 320C to 340C (89.6°F to 93.2°F) for 12 to 24 hours when the initial rhythm was
ventricular fibrillation/pulseless ventricular tachycardia (Class IIa)." (b)
Inclusion Criteria
Exclusion Criteria
All patients with ROSC post non -traumatic
cardiac arrest (defined as compressions or
defibrillation performed)
Pregnant
Advanced Airway, EtCO2 greater than 20 mm
Hg and patient remains comatose
Traumatic cardiac arrest
Systolic BP (SBP) greater than 90mmHg - If
initial SBP less than 90 but responds to
fluids/vasopressors and becomes greater than 90
then protocol may be executed
Significant head trauma
Age older than or equal to 16 years old
Actual or suspected significant hemorrhage
Initial temperature less than 34 C/93.2 F
Obvious pulmonary edema
SBP less than 90mmHg
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Reassess the CABS and vital sign
• Confirm therapeutic hypothermia inclusion/exclusion criteria.
• Transport the patient to the nearest hospital providing therapeutic hypothermia resuscitation
and cardiac catheterization.
• Contact receiving facility; prepare them to resume care and cooling
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
• The patient must have an advanced airway and have an EtCO2 greater than 20 mm Hg
prior to proceeding with therapeutic hypothermia treatment.
• Maintain SP02 above 94% and attempt to maintain an EtCO2 of 35-45 mm Hg. Avoid
hyperventilation.
• Conduct a neurological assessment. Document and reassess:
o Pupils (size, reactivity, equality).
o Motor response to pain.
• Remove the patient's clothing.
• Attempt to place an IV line of NS, if not already in place. (Do not delay transport)
The following steps are intended for those agencies establishing therapeutic hypothermia in
the field:
• Apply cold packs to the patient's head, axillae, and groin.
• Prevent shivering. Sedate the patient with one of the following benzodiazepines (a):
(Medical Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, I0, or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, I0, or IN, up to a maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, I0, or IN; may repeat once, up to a max dose of 4 mg.
• For persistent shivering or if allergic to benzodiazepines, may consider;
o Morphine 5 mg IVP may repeat once in 5 - 10 min (maximum 10 mg)
OR
o Fentanyl may be given 100 mcg IN increments every 5-10 minutes to a maximum of 200
mcg IN or 50 mcg SLOW IV increments every 5-10 minutes up to a maximum of 100
mcg, titrated to pain and BP remains above 90 mm Hg.
• Start a cold IV/IO saline bolus at 30 mL/kg, up to a maximum of 2 L, if available. Label
the saline bag "Hypothermia".
• If systolic blood pressure drops to less than 90 mm Hg, start a Dopamine drip at 10
mcg/kg/min. Maintain systolic blood pressure above 110 mm Hg to ensure adequate
perfusion.
• Continually monitor and reassess the patient.
If at any time the patient has a loss of spontaneous circulation, discontinue cooling and refer to
appropriate protocol.
➢ None
(a) Short transport times may preclude initiation of prehospital hypothermia
(b) Confirm asystole rhythm is not a fine fibrillation
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
The paramedic should use these protocols to guide him/her through the treatment of patients with
other cardiac -related emergencies who are exhibiting signs and symptoms. In addition to these
protocols, the paramedic may need to refer to additional protocols for continued treatment (e.g.,
adult cardiac dysrhythmias protocols).
4Ih Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol is used for the patient who is hypotensive (systolic BP less than 90 mm Hg) with
signs and/or symptoms that are cardiac in origin (Adult Protocol 2.2.4, Pulmonary Edema-CHF;
Adult Protocol 2.3, Adult Cardiac Dysrhythmias; and Adult Protocol 2.4.2, Angina/Suspected
AMI).
• Initial Assessment Protocol 2.1.1.
• Administer oxygen via non-rebreather mask (10-15 L/min). If the patient's airway is
compromised, assist ventilations by using the appropriate airway adjunct.
• Consider possible causes (e.g., the H's and T's).
• Monitor the ECG.
• Perform a 12-lead ECG, and initiate a Cardiac Alert if AMI is present.
• Start IV/IO normal saline. If time permits, establish a second IV/IO line if possible.
• If the patient is not experiencing pulmonary edema, administer a fluid challenge of 500 mL
normal saline. If this measure does not improve the patient's systolic blood pressure, the fluid
challenge may be repeated once (a).
• If the fluid challenge does not improve blood pressure, or if the patient is experiencing rates
(or pulmonary edema), administer a Dopamine infusion at 5-20 mcg/kg/min (b).
• Titrate Dopamine to maintain a minimum systolic SBP of 90 mm Hg and a maximum
systolic BP of 120 mm Hg.
• If the heart rate is slow, less than 60/min, Adult Protocol 2.3.2, Bradycardia.
• If the heart rate is fast, greater than 150/min, Adult Protocol 2.3.3, Narrow Complex
Tachycardia, or Adult Protocol 2.3.6, Wide Complex Tachycardia with a Pulse, as
appropriate.
➢ None
(a) Avoid giving fluids if an anterior wall MI is suspected (evidenced by ST elevations in leads
I, AVL, V1 through V6).
(b) Dopamine 1600 mcg/mL infusion concentration = 15-60 gtts/min with a 60-gtt set. The
maximum dose is 20 mcg/kg/min.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol is used for the patient who is experiencing chest pain or discomfort due to angina
pectoris or suspected AML Other signs and/or symptoms associated with acute coronary
syndrome include dyspnea, diaphoresis, nausea/vomiting, and weakness/ fatigue. If these
additional signs and symptoms are present in the absence of chest pain or discomfort, AMI may
still be present.
If nontraumatic chest pain other than angina/AMI is suspected consider other potential causes;
dissecting aortic aneurysm, pericarditis, spontaneous pneumothorax, pulmonary embolism,
pneumonia, pleurisy, costochondritis, hiatal hernia, esophageal spasm, peptic ulcer, cholecystitis,
pancreatitis, and cervical disk problem These conditions should not be treated under this
brotocol. refer to sbecific brotocol and utilize ADDendix 6.5_ Chest Pain Differential.
m •
Initial Assessment Protocol 2.1.1.
•
Consider oxygen if the SPO2 is less than 94% and/or the patient is in respiratory distress.
Maintain SpO2 of 94% (nasal cannula recommended).
•
EMTs should:
o Assist the patient in self -administration of previously prescribed Aspirin.
o Assist the patient in self -administration of previously prescribed Nitroglycerin. The total
dose should not exceed three doses (tablets or spray), including doses that the patient may
have taken prior to your arrival. Do NOT administer Nitroglycerin if the SBP less than
100 99 mm Hg or The patient has taken erectile dysfunction medications within the last
24 hours (Viagra) or within the last 48 hours (Levitra or Cialis) The patient has taken any
of the following erectile dysfunction medications. (Note the following medications are
also marketed under a variety of other trade names).
a. Stendra (Avanafil) — in the past 12 hours
b. Viagra (Sildenafil) — in the past 24 hours
c. Levitra (Vardenafil) or Cialis (Tadalafil) — in the last 48 hours
•
Monitor the ECG.
•
If AMI is probable (c), initiate a Cardiac Alert and transport the patient to the appropriate
cardiac interventional facility.
•
Limit cardiac alert on scene time. (d)
•
Establish IV access; give normal saline KVO.
- •
Give aspirin 162 mg, up to 324 mg PO (chewable), unless contraindicated (a).
•
Perform a 12-lead ECG and transmit the results to the destination hospital, as soon as
possible.
•
If an inferior wall MI is identified, perform an additional 12-lead ECG with WR to
-
confirm/rule out concurrent right ventricular MI (b). (Medical Procedure 4.14)
•
If the patient is hypotensive (SBP less than 90 mm Hg), see Adult Protocol 2.4.1,
Cardiogenic Shock.
•
If the patient is experiencing chest pain or discomfort and systolic BP above 100 mm Hg,
_
administer Nitroglycerin (Nitrostat® or Nitrolingual® Spray) 0.4 mg SL; repeat every 3-5
minutes (maximum dose is 1.2 mg or 3 doses).
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
• Do NOT administer Nitroglycerin if:
o SBP less than 100 mm Hg.
o The patient has taken any of the following erectile dysfunction medications. (Note the
following medications are also marketed under a variety of other trade names).
a. Stendra (Avanafil) — in the past 12 hours
b. Viagra (Sildenafil) — in the past 24 hours
c. Levitra (Vardenafil) or Cialis (Tadalafil) — in the last 48 hours
• If pain continues and the patient is normotensive (systolic BP greater than 90 mm Hg),
administer
o Morphine 5 mg IVP may repeat once in 5 - 10 min (maximum 10 mg) Titrated to pain and
BP greater than or equal to 90 mm Hg, up to a maximum of 10 mg. Can also be given IM
(Medical Procedure, Medication Delivery 4.18)
OR
o Fentanyl may be given 100 mcg IN increments every 5-10 minutes to a maximum of 200
mcg IN or 50 mcg SLOW IV increments every 5-10 minutes up to a maximum of 100 mcg,
titrated to pain and BP remains above 90 mm Hg. (Medical Procedure, Medication Delivery
4.18)
• Treat dysrhythmia per specific protocol.
➢ None
(a) Allergies to ASA should be suspected in patients with anaphylaxis signs and symptoms (e.g.,
flushed itchy skin, increased heart rate, dyspnea, or urticaria).
(b) Bradycardia with hypotension may be due to an inferior wall MI associated with right
ventricular MI (confirmed on 12-lead ECG by ST elevation in lead V4R); (Adult Protocol
2.3.2, Bradycardia). When an inferior wall MI is associated with right ventricular MI, avoid
the use of nitrates (Nitroglycerin). If bradycardia and hypotension exist, pacing and IV fluids
may improve the patient's hemodynamic status.
(c) AMI is probable when there is:
1. A minimum of lmm ST elevation in two or more related leads on the 12-lead ECG with a
history suggestive of AMI, signs and symptoms regardless of onset time.
2. A "new onset" left bundle branch block (LBBB) on the ECG with signs/symptoms and
history suggestive of AMI.
3. Patients meeting the above criteria should be transported to the nearest cardiac center and
pre -alert the hospital of a Cardiac Alert
(d) Minimize the Cardiac Alert on -scene time to 10 minutes or less.
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Hypertensive emergencies are commonly defined as accelerated blood pressures (systolic greater
than 180 mm Hg, diastolic greater than 110 mm Hg) with signs and symptoms of end organ
failure. Neurologic end -organ damage due to uncontrolled BP may include hypertensive
encephalopathy and cerebral vascular accident. Cardiovascular end -organ damage may include
myocardial ischemia/infarction, acute left ventricular dysfunction, acute pulmonary edema, and
aortic dissection. Other organ systems may also be affected by uncontrolled hypertension, which
may lead to acute renal failure, and eclampsia.
Hypertension is rarely treated in the prehospital setting. Treatment should focus on the patient's
presentation and not the blood pressure by itself. Blood pressures that should not be treated in
the prehospital setting include:
• Transient hypertension secondary to pain, anxiety, hypoxia, or drug intoxication. (treatment
should be directed at the underlying causes, not antihypertensives)
• Chronic hypertension. (rapid reduction of blood pressure in asymptomatic patients may cause
more harm than benefit)
• Thrombotic stroke. (elevated blood pressure is a normal physiologic response to brain
ischemia, excessively lowering of blood pressure in these patients may extend the area of
injury)
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3: Administer oxygen via nasal cannula at 4 L/min
(use a non-rebreather mask at 15 L/min if SP02 less than 94%). If the patient is
asymptomatic, contact medical control.
Symptomatic patients with accelerated blood pressures should be treated by the appropriate
_ protocol based on their symptoms.
_ • Chest pain consistent with myocardial ischemia or infarction, (Angina/AMI Protocol 2.4.2)
• Shortness of breath with signs and symptoms of acute pulmonary edema, (CHF Protocol 2.2.4'
• Patients in the 2nd or 3rd trimester of pregnancy (over 20 weeks) or up to 6 weeks postpartum
with accelerated hypertension and or seizures (Toxemia of Pregnancy Protocol 2.7.4)
➢ None
Note
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The paramedic should use these protocols to guide him/her through the treatment of atraumatic
patients with signs and symptoms that are suggestive of neurological impairment or when the
cause of the patient's altered mental status is unknown. In addition to these protocols, the
paramedic may need to refer to other protocols for continued treatment (e.g., adult cardiac
dysrhythmias protocols).
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This protocol is used for patients with altered mental status where the etiology is unknown
(e.g., patients with a history of diabetes; Adult Protocol 2.8.2).
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3: Consider the need for cervical spine
immobilization.
• Contact the Poison Information Center (1-800-222-1222).
• Obtain 02 Sat above 94% and EtCO2
• Consider the need for an advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick (Medical Procedure 4.17).
• If blood glucose below 60 mg/dL, refer to Hypoglycemia/Hyperglycemia Protocol 2.8.2.
• Administer Naloxone (Narcan) 0.4 mg IV/IO, IM every minute and titrate to effect to a maximum
dose of 10 mg. If no response after 10 mg, then condition is probably not due to narcotic.
• If administering Naloxone (Narcan) via IN, must use concentration 2 mg/2 mL and administer
2 mg, repeat 3-5 minutes to a maximum dose of 10 mg. (Medical Procedure, Medication
Delivery 4.18)
• If administering Naloxone (Narcan) via nebulization must use concentration 2 mg/2 mL (add 2
mg of Narcan to 3 mL of saline) and titrate to effect.
• Reevaluate the need for an advanced airway (Medical Procedure 4.4).
➢ None
(a) Use appropriate discretion regarding immediate placement of an advanced airway in patients
who may quickly regain consciousness, such as hypoglycemics after administration of D50 or
opiate overdose cases after administration of Narcan.
(b) To avoid infiltration and resultant tissue necrosis, Dextrose 50% should be given via slow IV
with intermittent aspiration of the IV line to confirm IV patency, followed by saline flush.
(c) If the patient is conscious with control of the airway, oral glucose may be given.
(d) Administration of Narcan to patients with chronic use of narcotics may induce withdrawal
and/or violent behavior. In these instances, the therapeutic goal is to restore adequate
ventilatory effort and/or improve mental status. Consider restraining the patient (Medical
Procedure 4.23, Physical Restraints).
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This treatment protocol is used in conjunction with General Protocol 1.2, Behavioral
Emergencies. There are many reasons for patient to be impaired or violent like psychiatric, drug
overdose, CVA, ETOH, hypoxia, hypoglycemia.
• If patient is violent and an immediate threat to the patient, EMS crew or bystander safety exists,
chemical and/or physical restraint should be used to prevent patient from harming him / herself or
others.
• If patient is not violent, be observant for possibility of violence and avoid provoking patient.
• Particular caution should be exercised when evaluating and treating any patient that was subdued
by a "non -lethal" law enforcement device with pepper spray or taser.
• Typical findings for any violent and/or impaired patient:
o P — Psychological issues
o R — Recent drug / alcohol use
o I — Incoherent thought process
o O — Off (clothes) and sweating
o R — Resistant to presence / dialogue
o I — Inanimate objects / shiny / glass — violent
o T — Tough, unstoppable, superhuman strength
o Y — Yelling
• Excited delirium syndrome is a state in which a person is in a psychotic and extremely agitated
state. Mentally the patient is unable to focus and process any rational thought. The condition is
brought on by overdose on stimulant or hallucinogenic drugs, drug withdrawal, or psychiatric
patient not taking medication for significant amount of time.
• Typical signs and symptoms to suspect excited delirium are elevated temperature, nudity,
profuse sweating, and change from aggressive behavior to "instant tranquility." These patients
should be closely observed for cardiac and respiratory changes.
• Initial Assessment Protocol 2.1.1. Monitor the patient's glucose.
• Follow Medical Supportive Care Protocol 2.1.3
• Consult with Law Enforcement about placing patient under Baker Act or
Impaired/Incapacitated Persons Act, and refer to the Impaired/Incapacitated Persons Act (see
General Protocol 1.2).
• Rule out non -psychiatric causes (e.g., drug overdose, CVA, ETOH, hypoxia, hypoglycemia).
• Apply Sp02 and administer oxygen to maintain Sp02 greater than or equal to 94%.
• Perform glucose test with finger stick.
• Obtain body temperature.
• If appropriate, consider physically restraining patient. (Medical Procedure 4.23, Physical
Restraints).
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If patient has elevated temperature above 100 degrees, consider cooling patient using cold
packs to patient's head, axilla and groin; if surface is ineffective consider cold fluid
challenges of 500mL normal saline in increments, to a maximum of 30mL/kg to a maximum
of 2 liters (goal temperature less than 100 degrees F).
Administer one of the following benzodiazepines: (Medical Procedure, Medication Delivery
4.18)
o Diazepam (Valium®) 5 mg IV, IM or IN; may repeat to a max of 20 mg (a) (b).
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN, up to a maximum dose of 10 mg (a)
OR
o Lorazepam (Ativan®) 2 mg IV, IM, or IN; may repeat once (maximum dose of 4 mg)(a)
• Administer Diphenhydramine HCl (Benadryl®) 50 mg IM or SLOW IV (a).
• Consider Ketamine 250 mg EV, or 2mg/kg IN (concentration 100mg/mL) if the patient does
not respond to benzodiazepine if available.
OR
• Administer Haloperidol (Haldol®) 5 mg IM or IV (a) (c).if available
• Initiate cardiac monitoring.
• Once patient has been sedated establish an IV; give normal saline wide open.
• Treat dysrhythmias per specific protocol (see Adult Protocol 2.3).
• Expedite transport — Transport Code 3 to closest appropriate facility.
➢ Repeat Haloperidol (Haldol®) 5 mg IM or IV (a) (f).
(a) In some instances, IV administration may present a safety concern; in this case, IM or IN
administration of sedatives may be the more desirable route.
(b) Haloperidol (Haldol®) may result in a dystonic reaction if it is administered alone. This effect
can be avoided or reversed with Benadryl. Haloperidol should be used with caution in cases
of suspected overdose, especially cocaine, and its use should be preceded by benzodiazepine
administration.
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This protocol should be used when the patient has witnessed, continuous convulsions
(generalized tonic-clonic seizure or grand mal) or repeating episodes without regaining
consciousness or sufficient respiratory decompensation. Consider the underlying etiology, such
as hypoglycemia, drug overdose, head injury, or fever. Other types of seizures include absence
(petit mal), simple partial (focal motor and Jacksonian), complex partial (psychomotor or
temporal lobe), atonic (drop attacks), and myoclonic. When the patient is continuously showing
signs of these other types of seizures, Medical Supportive Care Protocol 2.1.3 should be initiated
and the paramedic should contact medical control for further direction.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3.
If the patient is an eclamptic female, administer Magnesium Sulfate 4 g IV (mixed in 50
mL of DSW given over 5-10 minutes). (Toxemia of Pregnancy Protocol 2.7.4) (a).
Administer one of the following benzodiazepines: (Medical Procedure 4.18, Medication
Administration)
o Diazepam (Valium®) 5 mg IV, IO, IM or IN; may repeat once, up to a max dose of 10 mg.(b)
OR
o Midazolam (Versed®) 2 mg increments IV, IO, or IN, (IN concentration 10mg/2ml)
maximum dose of 10 mg. (b)
0
OR
o Lorazepam (Ativan®) 2 mg IV, IO, IM, or IN; may repeat once as needed, up to a maximum
dose of 4 mg. (b)
Perform a glucose test with a finger stick (Medical Procedure 4.17). If glucose is less
than 60 mg/dL, refer to Hypoglycemia/Hyperglycemia 2.8.2.
➢ For additional benzodiazepine contact Medical Control
(a) Females in their second or third of pregnancy (over 20 weeks gestation) who are seizing
should be assumed to have eclampsia. It should also be noted that eclampsia can occur
postpartum (up to 6 weeks postpartum).
(b) For IN administration, administer lml per nare, give half the volume in one nostril and
the other half of the volume in the other nare.
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This protocol is used for those patients exhibiting signs consistent with acute stroke/cerebrovascular
accident (CVA)/"brain attack," such as altered mental status, slurred speech, loss of function of any
body part, hemiplegia, loss of vision, weakness of facial muscles, loss of sensation, and drooling.
Other causes should be ruled out (e.g., hypoglycemia, drug overdose, hypoxia).
History
Signs and Symptoms
Differential Diagnosis
Previous stroke/TIA
Impaired understanding of speech
TIA
Previous neurological deficit
Aphasia/dysarthria
Weakness/hemi aresis
Seizure
Hypoglycemia
Hypertension
Facial droop
Drug ingestion
Heart disease
Poor coordination/balance
Tumor
Diabetes
Loss of peripheral vision
Trauma
Anticoagulant medications
Syncope, dizziness/vertigo
Stroke:
Family history
Headache, vomiting, stiff
neck seizures
• Ischemic
Smoking
• Hemorrhagic
STROKE ALERT CRITERIA
• Utilize the Advanced Stroke Triage Form. (Appendix 6.20 or online forms).
• Time last seen normal is less than 12 hours.
• Deficit not likely due to head trauma, TIA or stroke mimic.
• Blood glucose is greater than 60 OR symptoms don't resolve after correction of BGL.
• Initial Assessment Protocol 2.1.1.
• Determine and document the time of onset of stroke symptoms, defined as "the last time
the patient was seen without symptoms." (c)
• If stroke is suspected, complete the Advanced Stroke Triage Form (Appendix 6.20 or
online forms) to determine if the patient meets criteria for Stroke Alert (page 1). (a)(b)
• If the patient is a "Stroke Alert" complete page 2 of the "Advanced Stroke Triage"
checklist to determine transport destination (Appendix 6.20 or online forms).
• Limit Stroke Alert on scene time and transport the patient to the closest appropriate stroke
center based on the Advanced Stroke Triage Form page 2 Destination Determination Page
(Appendix 6.20 or online forms)
• Position the patient supine, with head elevation of 30 degrees, unless the patient cannot
tolerate this position.
• Administer oxygen according to following criteria:
o SPO2 94% or above do not administer 02.
o SPO2 less than 94% administer 02 by nasal cannula at 2 L/min.
o If SPO2 cannot be maintained at 94% with nasal cannula at 2 L/min and/or the patient is
in respiratory distress, administer high -flow 02 and assist ventilations with a bag -valve
mask if indicated.
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• If the patient has a decreased level of consciousness and does not have an intact gag reflex,
insert an advanced airway (Medical Procedure 4.4), confirm tube placement and
oxygenation, and monitor ventilations with EtCOz.
• Establish IV access; give normal saline KVO.
• Perform a glucose test with a finger stick (Medical Procedure 4.17). If glucose is less than 60
mg/dL, refer to Hypoglycemia/Hyperglycemia 2.8.2.
• If drug overdose is suspected, refer to Adult Protocol 2.6, Adult Toxicologic Emergencies.
• Perform a neurological exam, including assessment of the patient's level of consciousness,
Glasgow Coma Scale (GCS) score, and Cincinnati Prehospital Stroke Scale (CPSS) score.
• Contact the stroke center, and advise its personnel of the time of symptom onset, baseline
neurological examination findings, and any changes found in reassessment. (c)
• Complete the top section of the Stroke Data Form (Appendix 6.20 or online forms) and
provide to the stroke center.
➢ Elevated blood pressure is commonly present with stroke. Severely elevated blood pressure
may be lowered with a physician order.
(a) Minimize the Stroke Alert on -scene time to 10 minutes or less.
(b) If your findings do not indicate the patient has experienced an ischemic or hemorrhagic
stroke, see the appropriate protocol.
(c) Continually reassess the patient to determine if his/her symptoms are worsening or
improving, and advise the stroke center of any changes.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol should be used for patients with a chief complaint of syncopal episode. Consider
the patient's history and the possibility of medication side effects, glucose imbalance, inner ear
disorders, CVA, TIA, and MI.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3 (refer to other protocols as appropriate): Treat the
underlying cause, if it can be determined.
• All patients with a known syncopal episode, or a syncopal episode that was witnessed by
a reliable source, should be transported to the hospital via ambulance.
• Perform a 12-lead ECG. If an inferior wall MI is identified, perform an additional 12-
lead ECG with V4R to confirm/rule out concurrent right ventricular MI. Transmit the
12-lead ECG results to the destination hospital, if possible (a). If acute coronary
syndrome is suspected, see Adult Protocol 2.4.2.
➢ None
(a) Bradycardia with hypotension may be due to inferior wall MI associated with right
ventricular MI (confirmed on the 12-lead ECG by ST elevation in lead V4R); see Adult
Protocol 2.3.2, Bradycardia. When an inferior wall MI is associated with right ventricular
MI, avoid the use of nitrates (Nitroglycerin). If bradycardia and hypotension exist, pacing
and IV fluid may improve the patient's hemodynamic status.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol is to be used for those patients suspected of exposure to toxic substances via any
route of exposure (e.g., drug overdose, snake bite). The protocols give specific considerations for
each type of exposure as well as general treatment guidelines. Additional assistance may be
necessary in certain cases (e.g., hazardous materials team for toxic exposure or police for scene
control, including management of a violent and/or impaired patient; see Adult Protocol 2.5.2). If
the toxic substance is unknown or cannot be readily determined, see Adult Protocol 2.6.7
Unknown Toxicity
A history of the events leading to the illness or injury should be obtained from the patient and
bystanders:
1. To which drugs, poisons, or other substances was the patient exposed? Consider
exposure to multiple substances, especially on overdoses.
2. What was the route of exposure?
3. When did the exposure occur, and how much exposure was there?
4. What is the duration of symptoms?
5. Is the patient depressed or suicidal? Does he/she have a history of previous overdose (if
applicable)?
6. Was the exposure accidental? What was the nature of the accident?
7. What was the duration of exposure (if applicable)?
Collect all pill bottles, empty or full, and check for "suicide notes" (if applicable). Transport
any/all information or items that may assist in the treatment of the patient to the emergency
department.
Contact the Poison Information Center (1-800-222-1222) for consultation regarding specific
therapy.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol includes the treatment for snake bites, dog and cat bites, insect stings, and marine
animal envenomations and stings. All bite victims should be transported to the hospital. Contact the
Poison Information Center (1-800-222-1222) for treatment and transport decision and consultation
in all cases involving bites and stings.
• Initial Assessment 2.1.1
• Trauma Supportive Care Protocol 2.1.4.
• Contact the Poison Information Center (1-800-222-1222).
• See General Protocol 1.12, Infectious Disease Exposure and 1.10.1 Exposure Reference
Sheet if needed
SNAKE BITES
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis.
• Splint the affected area.
• Place the patient supine, with extremities kept at a neutral level.
• Keep patient quiet.
• Remove and secure all jewelry.
• Wash the area of the bite with copious amounts of water.
• Attempt to identify the snake, if it is safe to do so.
• Check the patient's temperature and pulse distal to the bite on an extremity, and mark the
level of swelling and time with pen every 15 minutes.
DOG, CAT, AND WILD ANIMAL BITES
• Wound care: BLS (do not use hydrogen peroxide on deep puncture wounds or wounds
exposing fat). Clean the wound area with soap and water.
• Advise dispatch to contact animal control and the police department for identification and
quarantine of the animal.
INSECT STINGS (INCLUDING CENTIPEDES, SCORPIONS, AND SPIDERS)
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis.
• Remove the stinger by scraping the patient's skin with the edge of a flat surface (e.g., a credit
card). Do not attempt to pull the stinger out, as this action may release more venom.
• Clean the wound area with soap and water.
MARINE ANIMAL ENVENOMATIONS: STINGRAY, SCORPIONFISH (LIONFISH,
ZEBRAFISH, STONEFISH), CATFISH, WEEVERFISH, STARFISH, SEA URCHIN
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis.
• Immerse the punctures in nonscalding hot water to tolerance (110-113°F) to achieve pain
relief (30-90 minutes). Transport should not be delayed for this measure; immersion in
nonscalding hot water may be continued during transport.
Remove any visible pieces of the spine(s) or sheath. Gently wash the wound with soap and
water, and then irrigate it vigorously with fresh water (avoid scrubbing).
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MARINE ANIMAL STINGS: JELLYFISH, MAN-OF-WAR, SEA NETTLE,
IRUKANDJI, ANEMONE, HYDROID, FIRE CORAL
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis.
• Rinse the skin with sea water. (Do not use fresh water; do not apply ice; do not rub the skin.)
• Apply soaks of acetic acid 5% (vinegar) until the pain is relieved. If vinegar is not available,
use a paste of baking soda or unseasoned meat tenderizer.
• Remove large tentacle fragments using forceps (use gloves to avoid contact with your bare
hands).
• Apply a lather of shaving cream or a paste of baking soda, and shave the affected area with
the edge of a flat surface (e.g., a credit card).
HUMAN BITES
• Wound care: BLS (do not use hydrogen peroxide on deep puncture wounds or wounds
exposing fat). Clean the wound area with soap and water.
• Consider contacting the police department for investigation
• Refer to Adult Protocol 2.1.5 for pain management guidelines.
➢ None
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2.6.2.1 Benzodiazepines and Sedative Hypnotics
Benzodiazepines are used for anxiety, seizures, insomnia, agitation, muscle spasms, and alcohol
withdraw. Sedative hypnotics are used for inducing sleep. Signs and symptoms of overdose include:
• Altered mental status
• Slurred speech
• Hypotension
• Coma
• Dilated pupils (benzodiazepines)
The following is a partial list of Benzodiazepines:
alprazolam
flurazepam
quazepam
Ativan
halazepam
Restoril
Centrax
Halcion
Rohypnol
chlordiazepoxide
Klonopin
Serax
clonazepam
Librium
temazepam
clorazepate
loazepam
Tranxene
Dalmane
midazolam
triazolam
diazepam
oxazepam
Valium
Doral
Paxipam
Versed
flunitrazepam
prazepam
Xanax
The following is a partial list of sedative hypnotics
Compoz
estazolam
propofol
Ambien
ethchlorvynol
Prosom
Amidate
etomidate
Sleep-Eze
Diprivan
Placidyl
Sominex
zolpidem tartrate
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3 (refer to other protocols as appropriate): Treat the
underlying cause, if it can be determined.
• Contact Poison Information Center (1-800-222-1222) for consultation.
• Obtain Pulse oximetry reading and administer oxygen as needed. SpO2 readings less than or
equal to 94% require oxygenation, or if indicated, assist with BVM ventilations.
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2.6.2.1 Benzodiazepines and Sedative Hypnotics
• Consider the need for an advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick (Medical Procedure 4.17).
• If glucose is less than 60 mg/dL, refer to Adult Protocol 2.8.2 Hypoglycemia/Hyperglycemia.
• If the patient is seizing, administer one of the following benzodiazepines: (Medical
Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, IO, or IN; may repeat once, up to a max dose of 4 mg.
• If the patient is hypotensive (systolic BP less than 90 mm Hg), administer a fluid challenge of
500mL.
• If the patient is combative, consider the need for physical and chemical restraints (Adult
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical
Restraints).
➢ None
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2.6.2.2 Opioid and Narcotic Overdose
Signs and symptoms of opioid and narcotic overdose include:
• Altered mental status
• Respiratory depression
• Constricted pupils
• Hypotension
• Bradycardia
• Coma
Alfenta
alfentanil HCl
alfentanyl
alphaprodine
Anexsia
aspirin & codeine
phosphate
Astramorph/PF
B & O Supprettes
belladonna and opium
Buprenex
butalbital, aspirin,
caffeine, codeine
phosphate
butorphanol
codeine
diacetylmorphine
Darvocet-N
Darvon-N
Demerol
dextromethorphan
DHCplus
difenoxin HCl with
atropine sulfate
dihydrocodeme
bitartrate,
acetaminophen, caffeine
Dilaudid
diphenoxylate HCI, atropine
sulfate
Dolophine
Duragesic
Duramorph
Empirin with Codeine 43
and 44
fentanyl citrate
fentanyl citrate & droperidol
fentanyl transdermal
Fiorinol or Fioricet with
Codeine
Heroin
Hycodan
Hydrocet
hydrocodone bitartrate
hydrocodone bitartrate &
acetaminophen
hydromorphone
hydromorphone HCl
Hydrostat
Imodium, Imodium A-D
Infumorph 200
Infumorph 500
Innovar
Levo-Dromoran
levorphanol tartrate
Lomotil
loperamide HCl
Loracet
Loratab
Mepergan
meperidine HCl
meperidine HCl &
promethazine HCl
methodone HCl
morphine sulfate
Motofin
MS Contin
MSIR
nalbuphine HCl
napsylate
Nisenti
Nubain
Numorphan
Oramorph
oxycodone
oxymorphone HCl
pentazocine HCl
Percocet
Percodan
propoxyphene HCl
propoxyphene HCl &
acetaminophen
Rescudose
Roxanol
Roxicodone
Stadol
Sublimaze
Sufenta
sufentanil
Talacen
Talwin
Tylenol 43, Tylenol 44
Tylox
Vicodin
Wygesic
4Ih Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
2.6.2.2 Opioid and Narcotic Overdose (continued)
• Initial Assessment Protocol 2.1.1.
Medical Supportive Care 2.1.3
Contact Poison Information Center (1-800-222-1222) for consultation.
Obtain Pulse oximetry reading and administer oxygen as needed. Sp02 readings less than or
equal to 94% require oxygenation, or if indicated, assist with BVM ventilations.
• Consider the need for an advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick (Medical Procedure 4.17).
• If glucose is less than 60 mg/dL, Adult Protocol 2.8.2, Hypoglycemia/Hyperglycemia.
• Administer Narcan 0.4 mg IV/IO, IM, IN per minute titrated to effect to a maximum dose of 10
mg. If no response after 10 mg, then condition is probably not due to narcotic. Fentanyl may
require large doses of Naloxone to reverse Fentanyl's effects. Narcan can also be administered
via nebulization (add 2 mg of Narcan to 3 mL of saline) and titrated to effect. (Medical
Procedure, Medication Delivery 4.18).
• If the patient is experiencing chest pain, Adult Protocol 2.4.2, Angina/Suspected AMI.
• If the patient is seizing, administer one of the following benzodiazepines: (Medical
Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, I0, or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, I0, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, I0, or IN; may repeat once, up to a max dose of 4 mg.
• If the patient is hypotensive (systolic BP less than 90 mm Hg), administer a fluid challenge of
500mL.
• If the patient is combative, consider the need for physical and chemical restraints (Adult
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical
Restraints).
➢ None
(a) Use appropriate discretion regarding immediate intubation of patients who may quickly regain
consciousness following treatment.
(b) If patient is a suspected opioid addict, the administration of Narcan should be titrated to increase
respirations to normal levels without fully awakening patient to prevent hostile and
confrontational episodes. Consider restraining patient. Narcan may need to be repeated in 20-30
minutes to maintain effect.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Signs and symptoms of CNS stimulant overdose include dilated pupils, agitation, paranoia,
bizarre behavior, PVC, tachycardia, hypertension, hyperthermia, and seizures. The following is a
partial list of CNS stimulants.
COCAINE - Cocaine, crack (a)
AMPHETAMINES -Amphetamine variants (DMA, PMA, STP, MDA, MMDA, TMA, DOM, DOB)
DESIGNER DRUGS - Ecstasy
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3.
• Contact the Poison Information Center (1-800-222-1222).
• If the patient is experiencing chest pain, see Adult Protocol 2.4.2, Chest Pain/Suspected AMI.
• Establish IV access; give normal saline.
• If the patient is seizing, administer one of the following benzodiazepines: (Medical
Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, or IN; maximum dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
o Lorazepam (Ativan) 2 mg IV, IO, or IN; may repeat once, up to a max dose of 4 mg.
If the patient is hyperthermic (hot to the touch), aggressively cool the patient.
If the patient is combative, consider the need for physical and chemical restraints (see
Adult Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23,
Physical Restraints).
➢ Treat tachydysrhythmias as per physician order.
(a) Beta blockers are contraindicated in cocaine overdose.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Digitalis toxicity should be suspected in patients who are taking digitalis and have signs and
symptoms associated with digitalis toxicity - for example, bradycardia, AV blocks with rapid
ventricular response, supraventricular tachycardias, ventricular ectopy, and other ECG changes:
wide PR interval greater than 0.20, short QT interval (rate dependent), spoon -shaped ST
segment, peaked T wave. Contact with the oleander tree can also cause a digitalis -type toxicity,
which will cause the same type of dysrhythmias and requires the same treatment.
DIGITALIS: GENERIC NAME (TRADE NAME)
digoxin (Lanoxicaps, Lanoxin, Digoxin) digitoxin (Crystodigin)
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3.
• Contact the Poison Information Center (1-800-222-1222).
°i.�` • Treat tachydysrhythmias with medication per specific protocol (Adult Protocol 2.3).
-_ - -, Avoid the use of Calcium Chloride.
-_ _ -_ • If unstable tachycardia (heart rate greater than 150 beats/min), synchronize and
- - _ cardiovert. Energy settings for synchronized cardioversion should be in the range of 5-20
joules.
• If the patient has unstable bradycardia with wide QRS (greater than 0.12 seconds)
administer Sodium Bicarbonate 1 mEq/kg IV.
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol includes the hallucinogenic drugs: LSD (acid, microdot), mescaline and peyote
(mesc, buttons, cactus), and similar agents (e.g., DET, EMT, psilocybin). Signs and symptoms of
hallucinogen overdose include illusions and hallucinations, poor perception of time and distance,
possible paranoia, anxiety, panic, unpredictable behavior, emotional instability, possible
flashbacks, dilated pupils, and rambling speech.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3: "Talk down" the patient.
• Contact the Poison Information Center (1-800-222-1222).
• Consider the need for ventilation assistance and advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick. If glucose is less than 60 mg/dL, see Adult
Protocol 2.8.2, Hypoglycemia/Hyperglycemia.
• If respiration is depressed, Administer Narcan 0.4 mg IV/IO, IM, IN per minute titrated to
effect to a maximum dose of 10 mg. If no response after 10 mg, then condition is probably not
due to narcotic. Narcan can also be administered via nebulization (add 2 mg of Narcan to 3 mL
of saline) and titrated to effect. (Medical Procedure, Medication Delivery 4.18)
• If the patient is experiencing chest pain, see Adult Protocol 2.4.2, Angina/Suspected AMI.
• If the patient is seizing, administer one of the following benzodiazepines: (Medical
Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, IO, or IN; may repeat once, up to a max dose of 4 mg.
• If the patient is combative, consider the need for physical and chemical restraints (Adult
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical
Restraints).
➢ Treat tachydysrhythmias as per physician order.
➢ Additional benzodiazepine
(a) Use appropriate discretion regarding immediate placement of an advanced airway in patients
who may quickly regain consciousness, such as hypoglycemics after D50 administration or
opiate overdose patients after Narcan administration.
(b) If the patient is a suspected opioid addict, the administration of Narcan should be titrated to
increase respiration to normal levels without fully awakening the patient, so as to prevent
hostile and confrontational episodes. Consider restraining the patient (Medical Procedure
4.23, Physical Restraints).
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Universally found EKG cases in all three classifications include:
Wide QRS complex greater than 0.12 seconds R waves in lead aVR
ST and T wave changes S waves in lead aVL and lead I
Barbiturates are used as sleep aids, antianxiety medications, and anticonvuls ants. Signs and
symptoms of overdose include:
Lethargy Hypotension
Altered mental status Coma
Respiratory depression
Tricyclic antidepressants are used as antidepressants. Signs and symptoms of overdose include
CNS depression Slurred speech
Tachycardia
Dilated pupils
Respiratory depression
Twitching and jerking
Seizures
Hypotension /hypertension
Selective Serotonin Reuptake Inhibitors (SSRI) is used as antidepressants, antianxiety
medications, and personality disorders. Signs and symptoms of overdose include:
Agitation Hypotension/hypertension
Nausea and vomiting Seizures
Muscluar rigidity
Teeth chattering
Dilated pupils
Tachycardia
Hallucinations
Hyperthermia
The following is a partial list of tricyclic antidepressants, barbiturates and selective serotonin
reuptake inhibitors:
Tricyclic Antidepressants:
Adapin
doxepin HCl
Pamelor
perphenazine &
amitriptyline HCl
Elavil
amitriptyline HCl
amoxapine
Endep
protriptyline HCl
Anafranil
Etrafon
Sinequan
Asendin
imipramine pamoate
Surmontil
chlordiazepoxide & amitriptyline
HCl
Limbitrol
Tofranil
clomipramin HCl
Norpramin
Triavil
trimipramine
desipramine HCl
nortriptyline HCl
maleate
Vivactil
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
Barbiturates:
butabarbital sodium
Butisol Sodium
Mebaral
mephobarbital
Nembutal Sodium
Selective Serotonin Reuptake Inhibitors (SSRI):
Celexa
citalopram
fluoxetine
fluvoxamine
Luvox
pentobarbital sodium
Phenobarbital
secobarbital sodium
Seconal Sodium
paroxetine
Paxil
Prozac
sertraline
Zoloft
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3: "Talk down" the patient.
• Contact the Poison Information Center (1-800-222-1222).
• Obtain pulse oximetry reading and administer oxygen as needed. Sp02 readings less than or
equal to 94% require oxygenation, or if indicated, assist with BVM ventilations.
• Consider the need for ventilation assistance and advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick. If glucose is less than 60 mg/dL, see Adult
Protocol 2.8.2, Hypoglycemia/Hyperglycemia.
• Perform 12 lead, if QRS is greater than 0.12 seconds, Sodium Bicarbonate 1 mEq/kg IV.
• If the patient is seizing, administer one of the following benzodiazepines: (Medical
Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, I0, or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, I0, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, I0, or IN; may repeat once, up to a max dose of 4 mg.
• If the patient is combative, consider the need for physical and chemical restraints (Adult
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical
Restraints).
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol is to be used for those patients suspected of exposure to toxic substances via any
route of exposure, where the toxic substance is unknown or cannot be readily determined.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3. If the patient has an altered mental status,
dyspnea, or SP02 is less than 94%, administer oxygen to maintain Sp02 at or above 94%.
• If the patient has an altered mental status, see Adult Protocol 2.5.1.
• If bronchospasm is present, administer Albuterol (Ventolin®): one nebulizer treatment
containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline (Medical Procedure
4.18.6). This treatment may be repeated twice as needed (a).
• If Albuterol is administered, may add Ipratropium Bromide (Atrovent®) 0.5 mg (0.5 mL) to
the Albuterol nebulizer treatment for the first nebulizer treatment only (a)
• Treat dysrhythmias with medication per specific protocol (Adult Protocol 2.3).
• If the patient has unstable bradycardia with wide QRS (greater than 0.12 second), administer
Sodium Bicarbonate 1 mEq/kg IV (Adult Protocol 2.6.6).
• If the patient is hypotensive and not in pulmonary edema, administer a fluid challenge of
normal saline 500 mL IV (Adult Protocol 2.4.1).
• If the patient is seizing, administer one of the following benzodiazepines: (Medical
Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, I0, or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, I0, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, I0, or IN; may repeat once, up to a max dose of 4 mg.
➢ None
(a) If the patient's heart rate above 140, contact medical control for bronchodilator orders
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
The paramedic should use these protocols to guide him/her through the treatment of patients who
are pregnant. These protocols cover complications of pregnancy and normal and abnormal labor
delivery. In addition to these protocols, the paramedic may need to refer to other protocols (e.g.,
protocols for seizures). The assessment of these patients should follow the normal approach to
patient assessment as well as ask specific questions related to the history of the pregnancy.
Questions for pregnancy history include:
1. Number of previous pregnancies (gravida).
a. Miscarriages.
2. Number of previous live births (para).
3. Expected date of delivery or due date.
4. When did contractions begin?
5. Any history of labor complications?
a. Premature births?
b. C-section?
c. Multiple births?
6. What are the duration and frequency of contractions?
a. Duration is timed from when the contraction starts to when the contraction stops
(e.g., 45 seconds, 1 minute).
b. Frequency is timed from the beginning of one contraction to the beginning of the
next contraction (e.g., 2 minutes apart, 4 minutes apart).
7. Evidence of blood show or spotting?
8. Did the water break?
a. When?
b. What was the color (e.g., clear, greenish, brownish)?
c. Did it have an unusual odor?
9. Does the patient have an urge to push?
10. Does the patient feel like she has to move her bowels? If the patient complains of uterine
contractions, an external visual examination for crowning should be done to determine if the
delivery is imminent.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4. Notify the nearest appropriate OB-capable hospital
early and prepare for transport to an OB-capable hospital.
PROLAPSED CORD
• Place the mother in a knee -chest position or supine position with pillows under the buttocks.
• Do not attempt to push the cord back. Wrap the cord in a warm, sterile -saline -soaked
dressing.
• With a gloved hand, palpate the cord for a pulse.
• If a pulse is absent in the umbilical cord, and positioning of the mother does not restore the
pulse, insert a gloved hand into the vagina and lift the fetal head, or other presenting part, off
of the umbilical cord while gently pushing the fetus into the uterus. With the other hand,
press on the lower abdomen in an upward or cephalic direction. Push the fetus back only far
enough to regain a pulse in the umbilical cord.
• Transport immediately, while maintaining fetal position so as to maintain umbilical
pulse.
BREECH BIRTH
• Do not pull on the newborn. Allow the delivery to proceed normally, supporting the
newborn with the palm of your hand and arm, and allowing the head to deliver.
• If the head does not deliver within 3 minutes, place a gloved hand in the vagina with
your palm toward the newborn's face. Form a "V" with your index and middle fingers
on either side of the newborn's nose, and push the vaginal wall away from the newborn's
face to create an airspace for the newborn until delivery of the head. Suction may be
provided as needed.
• Transport immediately, while maintaining the airspace for the newborn.
LIMB PRESENTATION
• Place the mother in either a knee -chest position or a supine position with pillows under
the buttocks.
• Transport immediately.
SHOULDER DYSTOCIA
• Determine the presence of shoulder dystocia as follows: The newborn's head will deliver
normally, and then it will retract back into the perineum because the shoulders are
trapped between the symphysis pubis and the sacrum (the "turtle sign").
• If this occurs, do not pull on the newborn's head.
• Have the mother drop her buttocks off the end of the bed and flex her thighs upward to
facilitate delivery.
• Apply firm pressure with an open hand immediately above the symphysis pubis.
• If delivery does not occur, transport immediately.
• None
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol should be used when the paramedic encounters an imminent delivery prior to
arrival at the hospital_ Imminent delivery is evidenced by crowning at the vaginal opening.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4. Notify the nearest appropriate OB-capable hospital
early and prepare for transport.
• Place the mother in a comfortable, supine position.
• Prepare the OB kit. (Also have a pediatric kit on standby.)
• Gently and carefully assist expulsion of the newborn from the birth canal in its natural
descent. Do not pull or push the newborn.
• Upon complete presentation of newborn's head:
o Instruct the mother to stop pushing.
o Clear the airway by gentle suction of the newborn's mouth, and then nose, with a bulb
syringe.
o Inspect and palpate the newborn's neck for the umbilical cord. If it is present, carefully
unwrap the cord from the neck. If unable to remove the cord, apply two umbilical clamps
and cut between the clamps to release the cord.
o Once the newborn's airway is clear and the cord is free from around its neck, instruct the
mother to push on her next contraction to complete delivery.
• Upon complete delivery of the newborn:
o Keep the newborn at the level of the vagina to prevent over- or under -transfusion of
blood from the cord.
o Never "milk" the cord. Apply two umbilical cord clamps (2 inches apart and at least 8
inches from the navel), and then cut the cord between the clamps.
o Avoid holding the newborn by the legs, allowing the head to hang below the body, as this
may cause cerebral hemorrhage to occur.
o Gently suction the newborn's mouth and nose with the bulb syringe.
o If meconium is noted in the airway, see Pediatric Protocol 3.4.1, Newborn Resuscitation.
o Dry and wrap the newborn in a blanket to preserve body heat. Be sure to cover the
newborn's head, as this is a major area of heat loss.
Evaluate the newborn:
o If the newborn is not breathing, see Pediatric Protocol 3.4.1, Newborn Resuscitation.
o Evaluate the APGAR scores at 1 and 5 minutes (Appendix 6.3).
o If APGAR score is less than 7, see Pediatric Protocol 3.4.1, Newborn Resuscitation.
Following delivery of the newborn, the mother's vagina should continue to ooze blood. Do
not pull on the umbilical cord.
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
If active hemorrhage is noted from the vagina, apply firm continuous massage manually
to the uterine fundus. If the mother wants to breastfeed, encourage her to do so; this will
aid in the contraction of the uterus, which will help stop the bleeding and facilitate
delivery of the placenta. (Do not attempt to examine the patient internally. Never pack
the vagina to stop bleeding.) Apply a sanitary napkin to the vaginal opening.
If the placenta does deliver, preserve it in a plastic bag and transport it with the mother.
It is not necessary to delay transport to wait for the placenta to deliver.
After delivery of the placenta, clean the perineal area and remove soiled drop sheets
from under the mother's buttocks. Visually inspect the perineal area for tears. If active
bleeding is present, apply direct pressure with sterile gauze. Apply a sanitary napkin to
vaginal opening.
None
➢ Administer Nitronox for pain control during a normal, uncomplicated delivery (Medical
Procedure 4.20).
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol should be used for female patients who may or may not be pregnant and who
present with nontraumatic vaginal bleeding. Examples of causes include antepartum hemorrhage
(abruption placenta, placenta previa, and uterine rupture), postpartum hemorrhage, ruptured
ectopic pregnancy, ruptured ovarian cyst, and spontaneous abortion.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Place all products of delivery (e.g., undeveloped fetus, placenta) in a plastic bag and
transport with the patient to the hospital.
• If the patient is hypotensive (systolic BP less than 90 mm Hg), administer a fluid
challenge of 250-500 mL.
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol should be used for the patient in her second or third trimester of pregnancy (above
20 weeks gestation) who is exhibiting signs of pre-eclampsia or eclampsia. The signs of toxemia
include proteinuria (dark -colored urine), excessive weight gain, and hypertension. The presence
of two of these signs constitutes pre-eclampsia; the presence of all three constitutes eclampsia.
The seizing patient in her second or third trimester of pregnancy should be assumed to be
eclamptic and treated as specified below. However, consideration of another underlying etiology,
such as hypoglycemia, drug overdose, head injury, or fever, should also be considered.
Eclamptic seizures can also occur postpartum (< 6 week after giving birth). Witnessed
continuous convulsions (generalized tonic-clonic seizure or grand mal) or repeating episodes
without regaining consciousness or sufficient respiratory decompensation demonstrate a need for
immediate treatment.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care 2.1.4.
• If the patient is seizing, administer Magnesium Sulfate 4 g IV (mixed in 50 mL of DSW
given over 5-10 minutes). May repeat once at 2 g IV (mixed in 50 mL of DSW given
over 5-10 minutes) as needed.
• If the patient continues to seize, administer one of the following benzodiazepines:
(Medical Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, or IN; maximum dose of 10 mg.
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, IO, or IN; may repeat once, up to a max dose of 4 mg.
• Perform a glucose test with a finger stick (Medical Procedure 4.17) if glucose is less than
60 mg/dL refer to Hypoglycemia/Hyperglycemia Protocol 2.8.2.
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
The paramedic should use these protocols to guide him/her through the treatment of patients
with other medical emergencies who are exhibiting signs and symptoms. In addition to these
protocols, the paramedic may need to refer to other protocols for continued treatment.
4Ih Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
This protocol should be used for patients exhibiting signs and symptoms consistent with allergic
reaction, as follows:
• Skin: flushing, itching, hives, swelling, cyanosis.
• Respiratory: dyspnea, sneezing, coughing, wheezing, stridor, laryngeal edema,
laryngospasm, bronchospasm.
• Cardiovascular: vasodilation, increased heart rate, decreased blood pressure.
• Gastrointestinal: nausea/vomiting, abdominal cramping, diarrhea.
• CNS: dizziness, headache, convulsions, tearing.
Treatment is outlined here according to the severity of the allergic reaction (mild, moderate, and
severe or anaphylaxis).
MILD REACTIONS
These reactions consist of redness and/or itching, stable vital signs with a systolic BP greater
than 110 mm Hg without dyspnea.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Diphenhydramine HCl (Benadryl®) 50 mg IM or SLOW IV (Medical Procedure,
Medication Delivery 4.18).
➢ None
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
MODERATE REACTIONS
These reactions are evidenced by edema, hives, dyspnea, wheezing, "lump in throat" feeling,
difficulty swallowing, facial swelling, and stable vital signs with a systolic BP greater than 90
mm Hg.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Remove offending agent, if possible
• Epinephrine (1:1000) 0.3 mg IM (Medical Procedure, Medication Delivery 4.18) (a) (b).
• Diphenhydramine HCl (Benadryl®) 50 mg IM or SLOW IV (Medical Procedure,
Medication Delivery 4.18).
• If bronchospasm is present, administer Albuterol (Ventolin®): one nebulizer treatment
containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline (Medical Procedure
4.18.6). May be repeated twice as needed.
• If Albuterol is administered, may add Ipratropium Bromide (Atrovent®) 0.5 mg (0.5 mL) to
the Albuterol nebulizer treatment for the first nebulizer treatment only.
• May repeat Epinephrine (1:1000) 0.3 mg IM (Medical Procedure, Medication Delivery 4.18) (a
(b).
➢ None.
(a) Caution should be used with administration of Epinephrine when the patient has a
history of hypertension or heart disease.
(b) The EpiPen® may be used if other means of Epinephrine administration are not available
(Medical Procedure 4.18.1).
41h Edition Version 2, 3/01/15 Florida Regional Common EMS Protocols
SEVERE REACTIONS
Signs and symptoms include edema, hives, severe dyspnea and wheezing, unstable vital signs
with a systolic BP less than 100 mm Hg, and possibly cyanosis and laryngeal edema
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Remove the offending agent if possible
• Epinephrine (1:1,000) 0.3 mg IM (Medical Procedure, Medication Delivery 4.18) (a) (b).
• Diphenhydramine HCl (Benadryl®) 50 mg IM or SLOW IV (Medical Procedure, Medication
Delivery 4.18)
• If the patient remains in respiratory distress, administer Albuterol (Ventolin ): one nebulizer
treatment containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline (Medical
Procedure 4.18.6). May be repeated twice as needed.
• If Albuterol is administered, may add Ipratropium Bromide (Atrovent®) 0.5 mg (0.5 mL) to
the Albuterol nebulizer treatment for the first nebulizer treatment only.
• Consider the need for an advanced airway (Medical Procedure 4.4).
• May repeat Epinephrine (1:1,000) 0.3 mg IM to a max of 3 doses (Medical Procedure,
Medication Delivery 4.18) (a) (b).
Administer Epinephrine 1:100,000 (0.1 mg/10 mL) IV diluted;
To dilute Epinephrine from 1:10,000 to 1:100,000;
o Remove 9 ml of Epi 1:10,000 from the 10 ml prefilled syringe
o Fill the syringe backup with 9 mLs of normal saline, You now have Epi 1:100,000
o Administer the 10 mL Epinephrine (1:100,000) solution IV slowly over 5-10 minutes, titrate to
clinical effect and systolic BP greater than 90.
Close hemodynamic monitoring is required when providing Epinephrine 1:100,000 IV
(a) Caution should be used with administration of Epinephrine when the patient has a history of
hypertension or heart disease.
(b) The EpiPeri may be used if other means of Epinephrine administration are not available
(Medical Procedure 4.18.1).
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This protocol is to be used for those patients whose blood glucose is less than 60 mg/dL or
more than 300 mg/dL
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
Perform a glucose test with a finger stick (Medical Procedure 4.17).
If glucose is less than 60 mg/dL:
o If the patient is conscious and has an intact gag reflex, -administer oral glucose 15g (1
tube), if possible.
o If the patient is stuporous or unconscious, administer DSo 50 mL via slow IV (a).
o If unable to start an IV/IO access, provide Glucagon 1 mg IM. This can be repeated
once in 20 minutes. (Medical Procedure, Medication Delivery 4.18)
o Perform a second glucose test with a finger stick. If glucose remains less than 60
mg/dL, administer D50 50 mL IV (a).
If blood glucose greater than 300 mg/dL:
o Administer normal saline 500 mL IV, unless contraindicated.
➢ None
(a) To avoid infiltration and resultant tissue necrosis, DSo should be given via slow IV with
intermittent aspiration of the IV line to confirm IV patency, followed by saline flush.
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To enhance patient comfort and safety, the treatment of nausea and vomiting may be
appropriately accomplished in the field. The symptoms of nausea and vomiting may occur as a
result of acute illness or as a medication side effect.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• Administer Zofran® (Ondansetron hydrochloride)
• Oral 4 mg PO oral disintegrating tablet (ODT) placed under the tongue. May
repeat at 10-15 minutes with maximum dose is 8 mg
• Injection 4 mg slow IV push over 2-3 minutes OR IM lateral thigh. May be
repeated once if no improvement within 10-15 minutes. Do not exceed 8 mg total
dosage
➢ None
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This protocol should be used for patients who complain of abdominal pain without a history of
trauma. Assessment should include specific questions pertaining to the GFGU systems.
Abdominal physical assessment:
Ask the patient to point to the area of pain (palpate this area last).
Gently palpate for tenderness, rebound tenderness, distention, rigidity, guarding, and
pulsatile masses. Also palpate the flank for CVA tenderness.
Abdominal history:
o History of pain (OPQRRRST)
o History of nausea/vomiting (color, bloody, coffee grounds)
o History of bowel movement (last BM, diarrhea, bloody, tarry)
o History of urine output (painful, dark, bloody)
o History of abdominal surgery
o History of acute onset of back pain
o SAMPLE history (attention to last meal)
Additional questions should be asked of the female patient regarding OB/GYN history (Adult
Protocol 2.7, Adult OB/GYN Emergencies).
All female patients of childbearing age who complain of abdominal pain should be considered to
have an ectopic pregnancy (even if vaginal bleeding is absent) until proven otherwise.
An acute abdomen can be caused by appendicitis, cholecystitis, duodenal ulcer perforation,
diverticulitis, abdominal aortic aneurysm, kidney infection, urinary tract infection (UTI), kidney
stone, pelvic inflammatory disease (PID female), or pancreatitis (Appendix 6.1, Abdominal Pain
Differential).
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
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Sickle cell anemia is a chronic hemolytic anemia occurring almost exclusively in African
Americans; it is characterized by the presence of sickle -shaped red blood cells. Sickle cell crisis
results from the occlusion of a blood vessel by masses of these misshapen blood cells. Pain is the
principal manifestation and represents the most common type of crisis. Typical pain occurs in the
joints and back. Hepatic, pulmonary, or central nervous system involvement can occur, with each
type being associated with its own group of symptoms. Keep in mind that patients with sickle
cell disorder have a high incidence of life threatening disorders at a very young age.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3. Administer 100% oxygen via non-rebreather
mask at 15 L/min.
• Provide emotional support.
• Fluid challenge of normal saline 500 mL may repeat once to a maximum of 1000 mL IV.
• If pain persists and systolic BP is greater than 90 mm Hg, Administer
o Morphine Sulfate may be given via slow IV in 5 mg may repeat once in 5-10 minutes,
titrated to pain and BP above 90 mm Hg, up to a maximum of 10 mg (a)
OR
o Fentanyl maybe given 100 mcg IN increments every 5-10 minutes to a maximum of 200
mcg IN or 50 mcg SLOW IV increments every 5-10 minutes up to a maximum of 100
mcg, titrated to pain and BP remains above 90 mm Hg. (Medical Procedure, Medication
Delivery 4.18).
➢ None
(a) Extreme caution should be used with administering narcotic analgesics to a patient with
a SP02 less than 94%.
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Sepsis is a rapidly progressing, life threatening condition due to systemic infection. Sepsis must
be recognized early and treated aggressively to prevent progression to shock and death.
Appendix 6.19 Sepsis Alert form.
Definitions SEPSIS ALERT = Patient Meets the Definition of Sepsis (#2) Below
1. Systemic Inflammatory Response Syndrome (SIRS)
• Temperature greater than 38' C (100.4' F) OR less than 36' C (96.8° F)
• Respiratory Rate greater than 20 breaths/min
• Heart Rate greater than 90 beats/min
2. Sepsis
• SIRS + Documented OR Suspected Infection
o Documented infections include but are not limited to pneumonia, UTI, wounds, skin
and decubitus ulcers.
o Suspected infection may be determined via the presence of high risk criteria such as a)
nursing home resident b) recent surgery c) immunosuppression or d) indwelling device.
o Symptoms such as cough, increased work of breathing, stiff neck, ALOC, urinary pain
or frequency, abdominal pain -distension -firmness, or inflamed joint may determine
suspicion of infection.
3. Severe Sepsis
• Sepsis + Sepsis -induced organ dysfunction or tissue hypoperfusion
• Organ dysfunction or tissue hypoperfusion defined as either
o Hypotension (Mean Arterial Pressure (MAP) less than 65 mmHg)(a)
o Lactate > 4 mg/dL (if available)
o Altered Mental Status
o Modified Shock Index (MSI) of < 0.7 or > 1.3) MSI HR/MAP
Note - Severe sepsis may cause decreased ETCO2 levels (measured by capnography) due to
inadequate organ perfusion and the resultin4 metabolic acidosis
• Initial Assessment Protocol 2.1.1.
• Apply cardiac monitor: Document rhythm
• Administer oxygen according to following criteria:
o SPO2 94% or above do not administer 02.
o SPO2 less than 94% administer 02 by nasal cannula at 2 L/min.
• Utilize the Broward Sepsis Alert Form Section 6.19 or on-line forms.
• Notify hospital of incoming Sepsis Alert (Meets definition of Sepsis).
• Place one large bore IV (18g or larger).
FOR SEVERE SEPSIS ONLY
Administer Normal Saline 30 mL/kg, may repeat to a maximum of 2 Liters (a)
o Titrate fluid volume to MAP of at least 70 mmHg.
Consider use of vasopressors after 1 Liter NS has been infused
o Dopamine infusion at 5-20 mcg/kg/min titrated to maintain a MAP of at least 70 mmHg.
Place a second large bore IV (18g or larger) if time permits.
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➢ None
(a) Mean Arterial Pressure is located on your monitor can be determined using the grid below.
• Alternatively it can be calculated using the following formula
• MAP = [(2 x diastolic)+systolic] / 3
(b) Monitor for pulmonary edema by clinical status and physical exam (auscultation) especially
in the elderly.
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The following protocols cover a range of problems attributable to the environment, including
trauma due to changes in atmospheric pressure, exposure to heat and cold extremes, water
submersion, and exposure to electricity. Initial efforts should focus on removing the patient from
the harmful environment.
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Barotrauma and decompression illness are caused by changes in the surrounding atmospheric
pressure beyond the body's capacity to compensate for excess gas load. These injuries are most
commonly associated with the use of SCUBA (Self -Contained Underwater Breathing
Apparatus). SCUBA diving emergencies can occur at any depth, with the most serious injuries
manifesting symptoms after a dive. If a patient took a breath underwater, from any source of
compressed gas (e.g., submerged vehicle, SCUBA) while greater than three (3) feet in depth, the
patient may be a victim of barotrauma. Barotrauma may cause several injuries to occur,
including arterial gas embolism (AGE), pneumothorax, pneumomediastinum, subcutaneous
emphysema, and the "squeeze." Decompression illnesses may also include decompression
sickness ("bends").
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4. Administer 100% oxygen via non-rebreather
mask at 15 L /min.
• Place the patient in a supine position.
• Complete the Dive Accident Signs and Symptoms checklist (Appendix 6.7).
• Obtain a Dive History Profile, if possible (the patient's dive buddy may be helpful in
answering many of these questions).
• Whenever possible, have the legal authority in charge (e.g., police, Florida Marine
Patrol, U.S. Coast Guard) secure all of the victim's dive gear and maintain the proper
chain of custody for testing, analysis, and other measures.
• Manage the patient according to the appropriate protocol(s).
• Transport the patient to the closest emergency department or trauma center with a
helipad (air transport of diving accident victims must remain at an altitude of less than
1000 feet).
• Contact the Diver's Alert Network (DAN) at Duke University Medical Center, by calling
919-684-4326, for further assistance (a).
• Bring the dive computer to the hospital if available.
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Factors that predispose and/or cause a patient to develop hypothermia include geriatric and
pediatric age, poor nutrition, diabetes, hypothyroidism, brain tumors or head trauma, sepsis, use
of alcohol and certain drugs, and prolonged exposure to water or low atmospheric temperature.
Patients can be classified into three categories based on their degree of hypothermia: mild
(temperature = 94-97 17), moderate (temperature = 86-94°F), and severe (temperature below
86°F). Most oral thermometers will not register below 96°F. However, some tympanic
thermometers (Braun ThermoscanTM Pro-1 and Pro 3000) will register in the range of 68-108°F.
Mild to moderate hypothermia patients will generally present with shivering, lethargy, and stiff,
uncoordinated muscles.
Severe hypothermia patients may be disoriented and confused to the point of stupor and coma.
Shivering will usually stop and physical activity will be uncoordinated. In addition, severe
hypothermia will frequently produce an Osborn wave or J wave on the ECG, as well as
dysrhythmias (bradycardia, ventricular fibrillation).
• Initial Assessment Protocol 2.1.1.
• Airway Management 2.1.2
• Trauma Supportive Care Protocol 2.1.4 (a).
• Remove all wet clothes and dry the patient.
• Protect the patient from heat loss and wind chill.
• Maintain the patient in a horizontal position.
• Avoid rough movement and excess activity.
• Monitor the patient's temperature.
• Add heat to the patient's head, neck, chest, and groin.
• For severe hypothermia, warm IV fluids.
• For severe hypothermic cardiac arrest: Start CPR.
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Hyperthermia occurs when the patient is exposed to increased environmental temperature and
can manifest as heat cramps, heat exhaustion, or heat stroke. Certain drugs may cause an increase
in temperature (e.g., cocaine, Ecstasy)
Some tympanic thermometers (Braun ThermoscanTM Pro-1 and Pro 3000) will register in the
range of 68-108°F.
• Heat cramps: Signs and symptoms include muscle cramps of the fingers, arms, legs, or
abdomen; hot, sweaty skin; weakness; dizziness; tachycardia; normal BP; and normal
temperature.
• Heat exhaustion: Signs and symptoms include cold and clammy skin, profuse sweating,
nausea/vomiting, diarrhea, tachycardia, weakness, dizziness, transient syncope, muscle
cramps, headache, positive orthostatic vital signs, and normal or slightly elevated
temperature.
• Heat stroke: Signs and symptoms include hot dry skin (sweating may be present), confusion
and disorientation, rapid bounding pulse followed by slow weak pulse, hypotension with low
or absent diastolic reading, rapid and shallow respirations (which may later slow), seizures,
coma. and elevated temperature greater than 105°F.
HEAT CRAMPS AND HEAT EXHAUSTION
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Remove the patient from the warm environment; cool the patient.
• Monitor the patient's temperature.
• For mild to moderate heat cramps and heat exhaustion, if the patient is conscious and alert,
encourage the patient to drink salt -containing fluids (e.g., half -strength Gatorade®).
HEATSTROKE
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Remove the patient from the warm environment; aggressively cool the patient. Remove the
patient's clothing, and wet the patient directly with ice water. Also, turn air-conditioning
units and fans on high, and apply ice packs to the patient's head, neck, chest, and groin.
• Monitor the patient's temperature. Cool the patient to 102°F, then dry the patient, remove
any ice packs, and turn off fans (avoid lowering the patient's temperature too much).
HEAT CRAMPS AND HEAT EXHAUSTION
• If heat cramps are severe or if the patient's level of consciousness is diminished, administer a
fluid challenge of normal saline 500 mL IV.
HEATSTROKE
• Treat hypotension (systolic BP less than 90 mm Hg) with IV fluids. Avoid using
vasopressors and anticholinergic drugs; they may potentiate heat stroke by inhibiting
sweating. Administer a fluid challenge of normal saline 500 mL IV.
➢ None
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Drowning is a process resulting in primary respiratory impairment from submersion in a liquid
medium. Implicit to this definition, is that a liquid -air interface is present at the entrance to the
victim's airway, which prevents the individual from breathing oxygen. Outcome may include
delayed morbidity or death, death, or life without morbidity. The terms wet drowning, dry
drowning, active or passive drowning, near -drowning, secondary drowning, and silent drowning
should be discarded. The proper terms should be drowning, fatal or drowning, non -fatal.
Persons who have been submerged in fresh or salt water may or may not be conscious. If the
patient is still in the water upon arrival of EMS, a Dive Rescue Team should be used to remove
the patient from the water whenever possible. Additional protocols may be needed for treatment
decisions (e.g., Adult Protocol 2.9.1, Barotrauma/Decompression Illness: Dive Injuries).
Drownings are NOT Trauma Alerts, unless there is a specific traumatic component associated
with the event.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (protect the c-spine).
• Determine any pertinent history (e.g., duration of submersion, depth, water temperature,
possible seizure, drug and/or alcohol use).
• Maintain the patient's body temperature; dry and warm the patient.
• All non -fatal drowning patients should be transported to the hospital, regardless of how well
they may seem to have recovered. Delayed death or complications due to pulmonary edema
or aspiration pneumonia are not uncommon.
• Consider contacting the police department for investigation.
• Treat dysrhythmias per specific protocol (Adult Protocol 2.3).
➢ None
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A wide range of injuries can be caused by a lightning strike or contact with electricity. Electrical
injury can occur from direct contact, an arc, or a flash of the electricity, and from a direct hit or a
splash from lightning. The movement of electrical current through the body can cause violent
muscle contractions that can lead to fractures; as a consequence, the patient's c-spine should be
protected. The thermal energy can cause external burns, but in many cases the majority of
thermal damage is internal, with few external signs of injury. Dysrhythmias are also common
(e.g., ventricular fibrillation). The rescuer should be sure that the patient is no longer in contact
with the electrical current before initiating treatment.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (protect the c-spine) (a).
• Treat burns per Adult Protocol 2.10.8.
• Try to determine the amps, volts, and duration of contact with the electricity, if possible
(500 volts or more should be categorized as high voltage).
• Consider the need to transport the patient to a trauma center (General Protocol 1.10).
• Treat dysrhythmias per specific protocol (Adult Protocol 2.3).
➢ None
(a) Asystole is a common presentation with lightning strikes. These patients should be
aggressively resuscitated unless their injuries are incompatible with life.
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This protocol outlines and defines the steps that EMS personnel should carry out when they
encounter a patient who has been subdued with any type of an electronic control device.
Typically it is not the electronic control device event itself that leads to the need for transport to
the hospital, but rather the events that led to the individual having an electronic control device
used on them, such as excited delirium syndrome (ExDS) or the events following the electronic
control device event, such as a sudden fall to the ground.
The following is a systematic, seven -step approach to responding to and evaluating patients who
have been subdued with an electronic control device:
1. Find out what happened before the patient had a electronic control device used on them; this
history will provide you with information regarding the patient's mental status prior to
having electronic control device deployed and suggest the potential for future
decompensation. Consider any report of extreme behavior prior to the electronic control
device event as significant, regardless of the patient's current presentation.
2. Approach the patient with caution. The electronic control device event can dramatically
change a patient's outward presentation. Assume that any patient who has had an electronic
control device used was violent and dangerous.
3. Complete a thorough physical exam and history. The exam should include a basic
neurological exam, skin signs, pupil assessment, a complete set of vital signs, and a close
look for traumatic injuries. All patients that have had an electronic control device deployed
are considered to have experienced a fall until proven otherwise. It is not uncommon to find
minor first -degree burns located between the electronic control device probe sites on the
patient's body. Anything that looks worse than minor sunburn should be considered
abnormal_ Incontinence should be considered abnormal. Chest pain, shortness of breath,
vomiting, and headaches should all be treated according to the appropriate medical treatment
protocol.
4. Consider the potential for sudden unexpected death syndrome. The vast majority of patients
who have died following an electronic control device event have shown signs of ExDS
(Adult Protocol 2.5.2).
5. During transport, be very conscientious of patients whom exhibit one or more of the
following signs and symptoms:
a. Evidence of ExDS prior to being having an electronic control device deployed
b. Persistent abnormal vital signs
c. History or physical findings consistent with amphetamine or hallucinogenic drug use
d. Cardiac history
e. Altered level of consciousness or aggressive, violent behavior, including resistance to
evaluation
f. Evidence of hyperthermia
g. Abnormal subjective complaints, including chest pain, shortness of breath, nausea, or
headaches
6. Removal of the probes will not be performed by EMS personnel. To transport the patient, the
wires to the probes will likely need to be removed. This can be done by simply cutting the
wires with a pair of trauma sheers.
In the event that the probes are removed by the police officer, the probes should be treated as a
contaminated sharp. The probes can be stored in the electronic control device cartridge in the
absence of a sharps container.
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All EMS personnel will treat and transport any patient who has had an electronic control device
used and requests treatment and transport. This treatment will be guided by the signs and
symptoms that the patient is exhibiting, as well as possible occult injuries that may have occurred
while the individual was being subdued. At minimum, all electronic control device -event patients
will receive the supportive and ALS Level 1 care outlined below.
In the event that a patient resists the delivery of care, these actions will be carried out with the
safety of the crew in mind. If a patient is violent, a police officer will be required to accompany
the patient in the rescue unit during transport and appropriate chemical restraints will be utilized
according to Adult Protocol 2.5.2, Violent and/or Impaired Patient and Excited Delirium.
• Initial Assessment Protocol 2.1.1.
• Establish that the scene has been secured and determine which events led up to the individual
being subdued with an electronic control device.
• Determine whether the patient wants to be treated. If the patient refuses treatment, (General
Protocol 1.8) (a).
• Provide general supportive care, including:
o C-spine precautions, unless a cervical spine injury can be definitively ruled out.
o Oxygen as needed.
Determine how many 5-second cycles of energy the individual was exposed to, and document
this information in the Patient Care Report
• Initiate cardiac monitoring, Treat dysrhythmias per specific protocol (Adult Protocol 2.3).
,i • Monitor the patient's glucose.
A
• Establish an IV; give normal saline KVO. If patient is exhibiting signs of excited delirium
and is hyperthermic, use "cool" normal saline and/or apply ice packs to groin and axilla.
(Adult Protocol 2.5.2)
➢ None
(a) Determine whether the patient will consent to be medically evaluated by Fire/Rescue personnel
and/or transported to a medical facility (per General Protocol 1.1). In the event that the patient
refuses treatment/transport, refer to General Protocol 1.8.
(b) Keep in mind that it is the patient's right to accept or refuse treatment. Exceptions include:
o Patient who is a minor or a patient who has an altered mental status, in which case implied
consent would be initiated
o Patient under arrest
o Patient who refuses treatment/transport in an attempt to cause harm to self, in which case
invocation of the Incapacitated Persons Law 401.445 would be appropriate.
(c) At no time should Fire/Rescue or Police Department personnel advise a patient that he/she does not
need to be transported to a hospital. That decision is at the sole discretion of the patient based on
the information that EMS personnel provide the patient during the physical exam.
In the majority of electronic control device incidents, it will not be possible for EMS personnel to
determine the extent of injuries that the patient has sustained. While it is unlikely that the electronic
control device itself will have caused an injury, there is a high likelihood of an occult injury secondary
to the event. Examples would include fall injuries as a result of the incapacitation, pathological
fractures secondary to muscle contraction, and impending demise secondary to a state of ExDS.
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These protocols cover specific types of injuries and their treatment. The initial assessment of the
trauma patient should include determination of trauma alert criteria (see General Protocol 1.10,
Trauma Transport). When the situation demands it (e.g., when Trauma Alert criteria are met),
scene time should be limited as much as possible (e.g., 10 minutes) and the patient should be
expeditiously transported to a trauma center. Do not delay transport to establish vascular access
or bandage and splint every injury. Priority should be given to airway management and rapid
preparation for transport (e.g., full immobilization on a backboard) and control of gross
hemorrhage.
If a vascular access is obtained and hypovolemia is suspected (e.g., the patient shows signs and
symptoms of shock, such as systolic BP less than 90 mm Hg), a fluid challenge of 1-2 L (20
mL/kg) may be administered until a systolic BP of 90 mm Hg is maintained. If the patient is still
in shock after receiving 2 L of fluid, an additional 1 L of fluid may be administered (maximum
total fluid administration = 3 L). However, administration of large volumes of IV fluids has been
found to be deleterious to the survival of patients with uncontrolled hemorrhage, internally or
externally. Studies (NEJM, 1994) have shown that maximal fluid resuscitation may increase the
bleeding, thereby preventing the formation of a protective thrombus or dislodging it once the
intraluminal pressure exceeds the tamponading pressure of the thrombus. For this reason, consult
with the physician should be made prior to the administration of large volumes of IV fluids when
the transport time is relatively short (e.g., less than 20 minutes).
A female in her second or third trimester (greater than 20 weeks) of pregnancy should be placed
on her left side for transport. If the injuries require the use of a backboard, following full
immobilization to the backboard, the backboard should be tilted to the left. Failure to follow this
practice may cause hypotension due to decreased venous return.
If history, symptoms, or signs of head or spinal injuries are present, manually immobilize the
patient's head and neck while maintaining a patent airway using a modified jaw -thrust method.
Immobilization of the entire spine is indicated following initial stabilization. Cases involving
hangings that do not meet Trauma Alert criteria are not considered Trauma Alert patients (e.g., a
"suffocation type" patient without c-spine deformity).
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• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (Procedure Spinal Immobilization 4.24).
• If the patient is not hypotensive (systolic BP greater than 90 mm Hg), elevate the head of the
backboard to 30 degrees (12-18 inches).
If signs of brain stem herniation exist (e.g., pupillary dilation, asymmetric pupillary
reactivity, or motor posturing), consider placement of an advanced airway and hyperventilate
the patient to achieve an optimal EtCO2 of 30-40 mm Hg (Medical Procedure 4.4 and
Medical Procedure 4.10).
If the patient is seizing, refer to Adult Protocol 2.5.3; avoid administration of glucose -
containing solutions and medications.
Apply a hemostatic gauze on severe wounds to the head, neck, face, or axilla that cannot be
controlled by other means (direct pressure) Medical Procedure Hemostatic Gauze 4.27.1
➢ None
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This protocol covers a variety of injuries to the eye. If other injuries to the body exist,
priority of care should be given as appropriate.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (establish an IV as needed).
• Remove, or ask to the patient to remove, contact lenses, if still in the affected eye(s).
• For a penetrating object, stabilize the object and cover the affected eye with an ocular shield
or similar rigid device. Cover both eyes to minimize eye movement. Avoid direct pressure on
either the eye or the penetrating object.
• If the eyeball has been forced out of the socket, cover the entire eye area with a rigid
container, such as a disposable drinking cup. Avoid contact with the exposed globe. If
bleeding is present, control it by administering direct pressure with a sterile dry dressing.
• If there are signs and symptoms or suspicion of ocular exposure to chemicals or foreign
body, without obvious or suspected penetrating injury or laceration of the cornea or globe,
irrigate the eye with a normal saline IV solution (Medical Procedure 4.19, Morgan Lens).
• If the patient is experiencing eye pain, administer Tetracaine, 1 drop in each affected eye.
Tetracaine may NOT be given in penetrating eye injuries or in patients with allergies to
Lidocaine.
➢ None
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This protocol covers both blunt and penetrating chest trauma and should be part of initial
resuscitation if the patient's breathing is compromised.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Penetrating injuries to the chest or upper back should be covered immediately with an
occlusive dressing (e.g., Vaseline gauze). Secure the occlusive dressing on 3 sides and
monitor for signs of tension pneumothorax. If needed "burp" the dressing to prevent/relieve a
tension pneumothorax.
• Do not attempt to remove an impaled object; instead, stabilize it with a bulky dressing or
other means. If the impaled object is very large or unwieldy, attempt to cut object to no less
than 6 inches from the chest.
• For tension pneumothorax, decompress the chest on the affected side (Medical Procedure
-, 4.9).
• For massive flail chest with severe respiratory compromise, insert an advanced airway and
- - - assist ventilations (Medical Procedures 4.1.5 and 4.4). If flail chest does not cause severe
respiratory compromise, stabilize the chest externally by placing the patient's ipsilateral arm
_ . in a sling and swathe.
• For traumatic asphyxia refer to Crush Protocol 2.10.9
➢ None
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Chest pain due to blunt trauma may be an indication of underlying injury. Blunt injuries such as
pulmonary contusion and cardiac contusion may cause respiratory insufficiency and/or
myocardial infarction.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Treat dysrhythmias per specific protocol (Adult Protocol 2.3).
• Consider the need for other protocols (Adult Protocol 2.4.2).
➢ None
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This protocol covers blunt and penetrating abdomino-pelvic trauma. Penetrating injuries may
also include the chest (Adult Protocol 2.10.3, Chest Injuries).
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• For penetrating injuries, apply an occlusive dressing (e.g., Vaseline gauze).
• For evisceration, cover the organs with a saline -soaked sterile dressing and then cover it with
an occlusive dressing (e.g., foil). Do not attempt to put the organs back into the abdomen.
• Do not log -roll any patient with a suspected pelvic fracture (may use scoop stretcher).
• If a pelvic fracture is suspected, stabilize the patient with a "sheet sling" or a commercial
available pelvic splint.
• None
➢ None
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This protocol covers open and closed injuries to the extremities, including amputation.
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (establish an IV as needed).
• Any fracture or suspected fracture should be splinted appropriately, with ice being applied to
the affected area. Remove and secure all jewelry. Check pulse sensation and movement
before and after splinting.
• Closed angulated fractures should be aligned using proximal and distal traction during
splinting, except in fractures that involve joints, which should be splinted in the position in
which they are found.
• Traction splints should be used in cases of closed femur fractures, unless a pelvic fracture is
suspected.
• Amputations should be dressed with bulky dressings. The amputated part should be placed in
a plastic bag and then the bag placed on ice for transportation to the hospital.
• Apply direct pressure for hemorrhage control. If direct pressure does not stop the hemorrhage
apply a trauma tourniquet (Procedure Wound Care Trauma Tourniquet 4.27.2).
• Apply a hemostatic gauze on severe wounds to the head, neck, face, axilla, buttocks that
cannot be controlled by other means (direct pressure/tourniquet) Medical Procedure
Hemostatic Gauze Procedure 4.27.1.
• See Adult Protocol 2.1.5 for pain management guidelines
➢ None
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The decision to attempt resuscitation of a traumatic arrest should be based on the paramedic's
judgment as to the possibility of survival and/or the possibility of organ harvest. There are
instances where resuscitation of a traumatic arrest is not warranted (General Protocol 1.4, Death
in the Field).
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Rapidly prepare the patient for transport and then expeditiously transport the patient to the
trauma center.
• If IV(s) can be established, infuse to a maximum of 3 L of fluid.
• Avoid use of vasopressors in cases of suspected hypovolemia.
➢ None
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Burns can be caused by thermal, chemical, and electrical sources. If an electrical burn is
suspected, also see Adult Protocol 2.9.5, Electrical Emergencies. Remember that burn patients
are volume depleted. However, burns do not bleed, so you should look for other sources of
bleeding. Many burn injuries are associated with inhalation injury. The signs and symptoms of
inhalation injury include nasal and oropharyngeal burns, charring of the tongue or teeth, sooty
(blackened) sputum, singed nasal and facial hair, abnormal breath sounds (e.g., stridor, rhonchi,
wheezing), and respiratory distress.
In cases of inhalation injury, attention should be given to the patency of the airway. Acute
swelling can cause an airway obstruction. The paramedic should consider the need for early
intubation to avoid a complete airway obstruction that requires a cricothyroidotomy
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Stop the burning process:
o Thermal turns: Lavage the burned area with tepid water (sterile, if possible) to cool the
skin. Do not attempt to wipe off semisolids (e.g., grease, tar, wax).
o Dry chemical burns: Brush off dry powder, then lavage with copious amounts of tepid
water (sterile, if possible) for 15 minutes.
o Liquid chemical burns: Lavage the burned area with copious amounts of tepid water
(sterile, if possible) for 15 minutes. (When phenol has caused the burn, also see
Hazardous Material Exposure Section Phenol 7.1.20.)
• Remove clothing from around the burned area, but do not remove/peel off skin or tissue.
• Remove and secure all jewelry and tight -fitting clothing.
• Assess the extent of the burn using the Rule of Nines and the degree of burn severity
(Appendix 6.4, Burn Severity Categorization, and Rule of Nines).
• Apply a dressing to the burned area as follows:
o If there is greater than or equal to 20% second-degree burns or 5% third-degree burns,
cover the burned area with dry sterile dressings or Water GeITM wraps.
o If there is less than 20% second-degree burns or 5% third-degree burns, apply wet sterile
dressings to the burned areas for 15 minutes to aid in pain control. Alternatively, Burn
FreeTM gel pads or Water GeITM wraps may be applied continuously to aid in pain
control.
• Prevent hypothermia by keeping the patient warm and ensuring that all outer layers of
dressings are dry.
• Pain Management Protocol (Adult Protocol 2.1.5).
➢ None
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Crush injuries are rarely seen in pre -hospital medicine but are common in times of disaster, both
natural and manmade. Early and aggressive treatment of victims suspected of having a crush
injury is paramount. Without aggressive pre -hospital treatment, the victim may die during
extrication or weeks later from complications of the injury.
In the crush injury syndrome, the initial injury is at the site of the muscle crushed by the
mechanical force of an object. The muscle cells die as the result of the following. First, the force
of the crushing object ruptures muscle cells. Second, the direct pressure of the object on the limb
causes muscle cells to become ischemic. The combination of mechanical force and ischemia can
cause muscle death within an hour. Third, the force of the crush injury compresses large vessels,
resulting in the loss of blood supply to muscle tissue. Muscles can normally survive circulatory
ischemia for up to four hours before the cell death. After four hours, the cells begin to die as a
result of the circulatory compromise.
The damaged muscle tissue produces and releases many toxins that can have detrimental effects
on the body. The longer the victim is trapped, the longer the toxins are given to build up distal to
the crush site. The crushing force acts as a dam that prevents these toxins from being released
into the rest of the body. Once the force is removed, the toxins are allowed to run freely
throughout the body, causing a myriad of problems. Along with the release of toxins after
extrication, the victim can become severely hypovolemic from the third spacing of fluid, and the
rapid swelling of the injured area can cause acute compartment syndrome
Toxins Released bV Dama ed
Muscle Tissue
Toxin
Effect
Histamine
Vasodilitation and Bronchoconstriction
Lactic Acid
Acidosis and dysrhythmias
Nitric Oxide
Vasodilitation
Potassium
Hyperkalemia
Thromboplastin
DIC
TREATMENT
GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Spinal immobilization
• Apply cardiac monitor: Document rhythm
• Administer oxygen according to following criteria:
o SP02 94% or above do not administer 02.
o SP02 less than 94% administer 02 by nasal cannula at 2 L/min.
• Rapidly prepare the patient for transport and then expeditiously transport the patient to the
trauma center.
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CRUSH INJURY or COMPARTMENT SYNDROME
• Establish IV access; give Normal Saline 1 Liter.
• Pain management: If patient is normotensive (systolic BP greater than 90 mm Hg),
administer
o Morphine Sulfate 5 mg via slow IV may be repeated once in 5-10 minutes, titrated to
pain and BP greater than or equal to 90 mm Hg, up to a maximum of 10 mg.
OR
o Fentanyl maybe given 100 mcg IN increments every 5-10 minutes to a maximum of 200
mcg IN or 50 mcg SLOW IV increments every 5-10 minutes up to a maximum of 100
mcg, titrated to pain and BP remains above 90 mm Hg. (For IN administration refer to
4.18.3).
• For crush injury release compression and extricate patient
CRUSH SYNDROME
If unable to release compression and situation progresses to CRUSH SYNDROME
• Entrapment with compression lasting longer than 4 hours OR on the thorax for 20
minutes.
• Suspicion of hyperkalemia (Peaked T-waves, absent P waves or widened QRS).
• Establish IV access, 2 large bore IVs recommended in order to separate CaCL and Bicarb;
• Pain management: If patient is normotensive (systolic BP greater than 90 mm Hg),
administer
o Morphine Sulfate 5 mg via SLOW IV may be repeated once in 5-10 minutes, titrated to
pain and BP greater than or equal to 90 mm Hg, up to a maximum of 10 mg.
OR
o Fentanyl may be given 100 mcg IN increments every 5-10 minutes to a maximum of 200
mcg IN or 50 mcg SLOW IV increments every 5-10 minutes up to a maximum of 100
mcg, titrated to pain and BP remains above 90 mm Hg. (For IN administration refer to
4.18.3).
• Calcium Chloride 1 g into 50 mL bag of normal saline and administer SLOW IV over 10
minutes (follow with minimum of 20 mL flush).
• Sodium Bicarbonate and Normal Saline — Add 50 mEq to 1 L or 25 mEq to 500 mL Normal
Saline and run IV wide open just prior to extrication, administer 1 Liter. Recommended in
second line.
• Continue IV fluids at 500 mL/hr
• Administer Albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Albuterol
premixed with 2.5 mL normal saline (Medical Procedure 4.18.6).
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• Consider sedation, administer one of the following benzodiazepines: (see Medication
Delivery Procedure 4.18)
o Diazepam (Valium®) 5 mg IV, IM or IN; may repeat once.
OR
o Midazolam (Versed) 2 mg increments IV, IO, or IN, (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan®) 2 mg IV, IM, or IN; may repeat once as needed, up to a maximum
dose of 4 mg.
➢ None
• Ideally Calcium and Sodium Bicarb should not be administered through the same IV line due
to crystallization within the tubing therefore 2 large bore IVs are recommended. If 2 IVs are
not possible administer 20 mL flush in between Calcium and Sodium Bicarb.
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These protocols cover specific types of special healthcare needs in adult patients. Adults with
special healthcare needs are those who have or are at risk for chronic physical, developmental,
behavioral, and emotional conditions that necessitate use of health and related services of a type
or amount not usually required by typical adults.
The general approach to adults with special healthcare needs includes the following:
1. Priority is given to the CABS.
2. Do not be overwhelmed by the machines.
3. Listen to the caregiver.
4. If a nurse is present, rely on his/her judgment.
5. Remember that the patient's cognitive level of function may be altered.
6. Assume that the patient can understand exactly what you say.
7. Bring all medications and equipment to the hospital.
Obtaining a history includes asking the parent/caregiver about the following issues:
1. The patient's normal vital signs.
2. The patient's actual weight.
3. Developmental level of the patient.
4. The patient's allergies, including to latex.
5. Pertinent medications/therapies.
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Home mechanical ventilators may be indicated for chronically ill adults with abnormal
respiratory drive, severe chronic lung disease, or severe neuromuscular weakness. Some patients
require continuous mechanical ventilations, whereas others require only intermittent support
during sleep or acute illness. Home ventilators may either be volume limited or pressure limited.
All are equipped with alarms.
TYPES OF VENTILATOR ALARMS
• Low pressure or apnea - may be caused by a loose or disconnected circuit or an air leak in the
circuit or at the tracheostomy, resulting in inadequate ventilation.
• Low power - caused by a depleted battery.
• High pressure - can be caused by a plugged or obstructed airway or circuit tubing, by
coughing, or by bronchospasm.
• Setting error - caused by ventilator settings outside the capacity of the equipment.
• Power switchover - occurs when the unit switches from alternating- current power to the
battery.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• If a ventilator -dependent patient is in respiratory distress and the cause is not easily
ascertained and corrected, remove the ventilator and provide assisted manual ventilations
with a BVM. Suction as needed.
• Consider the need for other protocols (e.g., Adult Protocol 2.2, Adult Respiratory
Emergencies).
• None
➢ None
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Tracheostomies are indicated for long-term ventilatory support to bypass an upper airway
obstruction and to aid in the removal of secretions. Tracheostomies come in a variety of sizes
and can either be single lumen or double lumen. Special attachments include a tracheostomy
nose (filtration device), tracheostomy collar (for oxygen or humidification), and Passy-Muir
valve (speaker valve).
SIGNS OF TRACHEOSTOMY OBSTRUCTION
■ Excess secretions
■ No chest wall movement
■ Cyanosis
■ Accessory muscle use
■ No chest wall rise with bag -valve ventilations
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• If an obstruction is present, inject 1-3 mL of normal saline into the tracheostomy tube
and suction as needed.
• If unable to clear the obstruction by suctioning, remove the tracheostomy tube and insert
a new tube (either of the same size or one size smaller). Do not force the tube.
• If unable to insert a new tracheostomy tube, or if one is unavailable, insert an
endotracheal tube of similar size into the stoma and ventilate with a BVM as needed.
• If unable to insert an endotracheal tube, ventilate with a bag -valve mask over the stoma
or over the patient's mouth while covering the stoma as needed.
• Consider the need for other protocols (e.g., Adult Protocol 2.2, Adult Respiratory
Emergencies).
• None
➢ None
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Central venous lines are indicated for administration of medications, delivery of chemotherapy,
nutritional support, infusion of blood products, and blood draws. Types of central venous lines
include Broviac/Hickman, Port-a-Cath/ Med-a-Port, and percutaneous intravenous catheters
(PIC). Central venous line emergencies include the catheter coming completely out, bleeding at
the site, the catheter broken in half, blood embolus, thrombus, air embolus, and internal bleeding.
Use of SQ ports requires special training; these ports should not be used for IV access.
Signs of blood embolus, thrombus, air embolus, and internal bleeding are as follows:
• Chest pain
• Cyanosis
• Dyspnea
• Shock
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3. CVP and PIC lines may be used for emergency
IV access under sterile conditions.
• If the catheter has come completely out, apply direct pressure to the site.
• If there is bleeding at the site, apply direct pressure.
• If the catheter is broken in half, clamp the end of the remaining tube.
• If blood embolus, thrombus, or internal bleeding is suspected, clamp the line.
• If air embolus is suspected, clamp the line and place the patient on his/her left side.
• Consider the need for other protocols (e.g., Adult Protocol 2.2, Adult Respiratory
Emergencies).
• None
➢ None
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Feeding tubes are indicated for administration of nutritional supplements and in patients who
have an inability to swallow. Types of feeding tubes include nasogastric tubes (temporary) and
gastrostomy tubes (G tube). Types of G tubes include those that are surgically placed,
percutaneous endoscopic gastrostomy tubes (PEG tubes), and jejunal tubes (J tube). Potential
complications include leaks, bleeding around the site, and displacement of the tube.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• If the catheter has come completely out, cover the site with Vasoline gauze and apply
direct pressure to the site.
• If there is bleeding at the site, apply direct pressure.
• None
➢ None
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Left Ventricular -Assist devices (LVADs) also known as heart pumps are surgically implanted
circulatory support devices designed to assist the pumping action of the heart. Caring for these
patients is complicated, and every effort should be made to contact the patient's primary
caretaker (spouse, guardian etc.) and the LVAD coordinator during your evaluation. Patients
with a properly functioning LVADs may NOT have a detectable pulse, normal blood
pressure or oxygen saturation.
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• Treat non-LVAD associated conditions in accordance with the appropriate protocol.
• Determine the type of device, access alarms, auscultate for pump sounds, if needed assist
patient (caretaker) in replacing the device's batteries or cables.
• Contact the LVAD coordinator phone number will be on the device and the equipment
carrying bag.
• If there is bleeding at the site, apply direct pressure.
• Monitor capnography to access ventilation and perfusion
• Perform a blood glucose level if any weakness, altered mental status or history of diabetes
(Medical Procedure 4.17). If blood glucose is less than 60 mg/dl, refer to
Hypoglycemia/Hyperglycemia protocol 2.8.2.
• If signs of hypoperfusion administer 500 mL bolus of normal saline
• Evaluate unresponsive patients carefully for reversible causes
• CPR risks rupturing of the ventricular wall leading to fatal hemorrhage. Only perform
CPR when the patient's LVAD has no hand pump and no other option exists.
• Transport to the closest appropriate facility based on the patient's chief complaint. If a
cardiac issue or LVAD mechanical issue is identified (alarm sounds) then transport to
the most appropriate Broward County LVAD receiving center, if possible (see hospital
capabilities).
➢ None
• Take all equipment associated with the LVAD system to the ED
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Florida Regional Common
EMS Protocols
Section 3
Pediatric Protocols
4th Edition, Version 2, March 1, 2015
4Ih Edition 3/1/2015 Florida Regional Common EMS Protocols
Pediatric Section Table of Contents
3.1 Pediatric Initial Assessment and Management
3.1.1
Pediatric Assessment
3.1.2
Airway Management
3.1.3
Medical Supportive Care
3.1.4
Trauma Supportive Care
3.1.5
Pain Management
3.2 Pediatric Respiratory Emergencies
3.2.1 Airway Obstruction
3.2.2 Upper Airway (Stridor-Croup/Epiglottitis)
3.2.3 Lower Airway (Wheezing-Asthma/Bronchiolitis)
3.3 Pediatric Cardiac Dysrhythmias
3.3.1 Asystole/Pulseless Electrical Activity (PEA)
3.3.2 Bradycardia
3.3.3 Narrow Complex Tachycardia
3.3.4 Wide Complex Tachycardia with a Pulse (Ventricular Tachycardia)
3.3.5 Wide Complex Tachycardia without a Pulse and Ventricular Fibrillation
3.4 Newborn/Infant Cardiopulmonary Arrest
3.4.1 Newborn Resuscitation
3.4.2 Sudden Unexpected Infant Death (SUID)
3.5 Pediatric Neurologic Emergencies
3.5.1 Altered Level of Consciousness (Altered Mental Status)
3.5.2 Seizure Disorders
3.5.3 Violent and/or Impaired Patient
3.6 Pediatric Toxicologic Emergencies
3.6.1 Pediatric Ingestion (Overdose)
3.6.2 Bites and Stings
3.7 Other Pediatric Medical Emergencies
3.7.1
Allergic Reactions/Anaphylaxis
3.7.2
Hypoglycemia/Hyperglycemia
3.7.3
Nausea/Vomiting
3.7.4
Nontraumatic Abdominal Pain
3.7.5
Nontraumatic Chest Pain - Undifferentiated
3.7.6
Suspected Child Abuse
3.7.7
Sickle Cell Anemia
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3.8 Pediatric Environmental Emergencies
3.8.1 Drowning
3.8.2 Heat -Related Emergencies
3.8.3 Cold -Related Emergencies
3.8.4 Barotrauma/Decompression Illness: Dive Injuries
3.8.5 Electrical Emergencies
3.9 Pediatric Trauma Emergencies
3.9.1
Head and Spine Injuries
3.9.2
Eye Injuries
3.9.3
Chest Injuries
3.9.4
Abdomino-Pelvic Injuries
3.9.5
Extremity Injuries
3.9.6
Traumatic Arrest
3.9.7
Burn Injuries
3.10 Children with Special Healthcare Needs
3.10.1 Home Mechanical Ventilator
3.10.2 Tracheostomy
3.10.3 Central Venous Lines
3.10.4 Feeding Tubes
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 3
The protocols in Section 3.1 are designed to guide the EMT or paramedic in his or her initial
approach to assessment and management of pediatric patients. The Level 1 care is specified as
either EMT and Paramedic (BLS) or Paramedic Only (ALS).
Protocol 3.1.1 should be used on all pediatric patients for initial assessment. During this
assessment, if the paramedic determines that there is a need for airway management, Protocol
3.1.2 should be used for the management of the pediatric airway. These protocols are frequently
referred to by other protocols, which may or may not override them in recommending more
specific therapy.
Protocol 3.1.3 presents the basic components of preparation for transport of medical patients.
Due to the significant differences in priorities and packaging in the prehospital care of trauma
and hypovolemia cases, a separate Trauma Supportive Care protocol has been developed. After
following Protocol 3.1.1, this Medical Supportive Care protocol may be the only protocol used
in medical emergency situations where a specific diagnostic impression and choice of
additional protocol(s) cannot be made. Judgment must be used in determining whether patients
require ALS or BLS level care. Protocol 3.1.3 is frequently referred to by other protocols,
which may or may not override it in recommending more specific therapy.
Protocol 3.1.4 presents the basic components of preparation for transport of trauma patients.
Due to the significant differences in priorities and packaging in the prehospital care of medical
cases, a separate Medical Supportive Care protocol has been developed. After following
Protocol 3.1.1, this Trauma Supportive Care protocol may be the only protocol used in trauma
or hypovolemia situations where a specific diagnostic impression and choice of additional
protocol(s) cannot be made. Judgment must be used in determining whether patients require
ALS or BLS level care. This protocol is frequently referred to by other protocols, which may or
may not override it in recommending more specific therapy.
Paramedics only should use Protocol 3.1.5 for pain management.
When transporting a pediatric patient consider all pediatric restraints necessary for a safe
transport to the medical/trauma facility. In general a parent should not hold a pediatric patient
on the stretcher. If available, utilize the infant's/child's car seat, or the on board child restraint
system built into the seat, or a pediatric immobilization device (Procedure 4.24) or Pedi-MateTM
(Procedure 4.23.1) or similar restraining device. The goal is to provide the pediatric patient
with a safe transport to the medical/trauma facility.
References:
American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, Boston,
2010.
American Heart Association/American Academy of Pediatrics, Textbook of Pediatric Advanced
Life Support, Dallas, 2010.
American Heart Association, "2010 Guidelines for CPR and ECC," Supplement to Circulation.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 4
The initial assessment of the pediatric patient will vary with the age of the patient.
Nevertheless, some initial components of assessment remain consistent for all patients,
regardless of their age. The paramedic or EMT should follow the appropriate approach to
patient assessment with respect to the patient's age. In addition to addressing the patient, the
responder may need to interview the parents or caregiver to gain information needed for a
complete assessment of the patient.
A five -step, systematic approach should be used when assessing the child:
1. Scene size -up
2. General assessment (pediatric assessment triangle [PAT].
a. Appearance
b. Work of breathing
c. Circulation
3. Primary assessment
a. ABCDE
b. Cardiopulmonary function
c. Neurological function
d. Vital signs
4. Secondary assessment
a. SAMPLE
b. Head -to -toe survey
5. Ongoing assessment
EMT AND PARAMEDIC
I. Scene Size -up.
A. Review the dispatch information.
B. Assess the need for body substance isolation.
C. Assess scene safety.
D. Determine the mechanism of injury.
E. Determine the number and location of patients.
F. Determine the need for additional resources.
G. Observe the environment of the pediatric patient.
IL Pediatric Assessment Triangle: Rapid Cardiopulmonary Assessment.
The PAT has three major components: appearance, work of breathing, and circulation to the skin.
A. Appearance. The appearance is assessed by considering the following clinical signs: tone,
interactiveness, consolability, look or gaze, and speech or cry (Table 3-1). This particular
component is influenced by developmental issues and must be applied with knowledge of
normal childhood development.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 5
Table 3-1 Characteristic of Appearance: The "Tickles" (TICLS) Mnemonic
Characteristic
Features to Look For
Tone
Is the infant/child moving or resisting examination
vigorously? (Normal)
Does the infant/child have good muscle tone? (Normal)
Or is the infant/child limp, listless, or flaccid?
(Abnormal)
Interactiveness:
How alert is the infant/child? (Alert is normal)
How readily does a person, object, or sound
distract/draw the infant/child's attention? (Distract or
draw attention is normal) Will the infant/child reach for,
grasp, and play with a toy or exam instrument, such as a
penlight or tongue blade? (Reaching is normal)
Or is the infant/child uninterested in playing or
interacting with the caregiver or prehospital
professional? (Abnormal)
Consolability:
Can the infant/child be consoled or comforted by the
caregiver or by the prehospital professional? (Normal)
Or is the infant/child's crying or agitation unrelieved by
gentle reassurance? (Abnormal)
Look/gaze
Does the infant/child make eye contact with you?
(Normal) Or is there a "nobody home," glassy -eyed
stare? (Abnormal)
Speech/cry
Is the infant/child's cry strong and spontaneous?
(Normal)
Or is the cry weak or high-pitched? (Abnormal)
Is the content of speech age appropriate? (Normal)
Or is the content confused or garbled? (Abnormal)
B. Work of Breathing. The work of breathing reflects a child's respiratory status -
specifically, the degree of respiratory effort needed to oxygenate and ventilate the
child's body. As work of breathing increases, physical signs appear to alert the
prehospital provider to an underlying illness or injury. Table 3-2 outlines the clinical
signs associated with increased work of breathing. The presence of any of these
features indicates abnormal work of breathing; the presence of specific signs may
further delineate the category of disease process as upper or lower airway obstruction,
disease of the lungs, or disorders of breathing.
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Table 3-2 Characteristics of Work of Breathing
Characteristic
Abnormal Features to Look For
Abnormal airway
sounds
Snoring, muffled or hoarse speech, stridor,
grunting, wheezing
Abnormal positioning
Sniffing position, tripoding, refusing to lie down
Retractions
Supraclavicular, intercostal, or substernal
retractions of the chest wall; head bobbing in
infants
Flaring
Flaring of the nares on inspiration
C. Circulation to Skin. Circulation to the skin is assessed by looking at the overall skin color
and color pattern. A child's appearance will reflect inadequacies in brain perfusion, but
altered appearance may be caused by a number of other conditions, including
overdose/intoxication, metabolic disease, primary injury, and hypoxia. As a consequence,
the addition of skin and mucous membrane color/perfusion changes to the PAT adds to the
evaluation of core perfusion (Table 3-3). When faced with fluid or blood loss or changes in
venous capacitance, the body will preserve perfusion to vital organs (heart and brain)
through increased systemic vascular resistance (decreasing skin perfusion) and increases in
heart rate; thus changes in skin color and skin perfusion are important early signs of shock
in children.
Table 3-3 Characteristics of Circulation to Skin
Characteristic
Abnormal Features to Look For
Pallor
White or pale skin or mucous membrane
coloration from inadequate blood flow
Mottling
Patchy skin discoloration due to
vasoconstriction/vasodilation
Cyanosis
Bluish discoloration of skin and mucous
membranes
D. Each component of the PAT is evaluated separately, utilizing specific predefined physical
findings as outlined in Tables 3-1, 3-2, and 3-3. If an abnormal physical finding is noted,
the corresponding component is, by definition, abnormal. Abnormalities in the three
components can then be combined to form a general impression (Table 3-4).
Table 3-4 Components of the PAT and the General Impression
Component
Stable
Respiratory
Respiratory
Shock
CNS/
Cardiopulmonar.
Distress
Failure
Metabolic
Failure
Appearance
Normal
Normal
Abnormal
Normal/
Abnormal
Abnormal
Abnormal
Work of
Normal
Abnormal
Abnormal
Normal
Normal
Abnormal
Breathing
Circulation to
Normal
Normal
Normal/
Abnormal
Normal
Abnormal
the skin
Abnormal
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III. Primary Assessment.
A. Assess airway, c-spine, and initial level of consciousness (AVPU: Alert, responds to
Verbal stimuli, responds to Pain, Unresponsive).
B. Assess breathing.
C. Assess circulation and presence of hemorrhage.
D. Assess disability - movement of extremities.
E. Expose and examine the patient's head, neck, chest, abdomen, and pelvis (check the
back when the patient is rolled on his/her side).
F. Identify priority patients.
G. Assess the vital signs:
1. Blood pressure
2. ECG
3. SPO2
IV. Initial Management. (Pediatric Protocol 3.1.3, Medical Supportive Care, or Pediatric
Protocol 3.1.4, Trauma Supportive Care.)
A. Life -threatening (urgent)
B. Non -life -threatening (not urgent)
V. Secondary Assessment.
A. Conduct a toe -to -head survey.
B. Neurological assessment.
1. Pupillary response.
2. Pediatric Glasgow Coma Scale (GCS) score. (Appendix 6.9.2)
C. Repeat -PAT and rapid cardiopulmonary assessment.
D. Obtain a medical history.
1. S - Symptoms; assessment of chief complaint.
2. A - Allergies.
3. M - Medications.
4. P - Past medical history.
5. L - Last oral intake.
6. E - Events leading to illness or injury.
VI. Ongoing Assessment. Reassess the patient every fifteen (15) minutes, or for critical
patients every five (5) minutes.
A. Continually monitor:
1. Respiratory effort
2. Skin color
3. Mental status
4. Temperature
5. Pulse oximetry (Medical Procedure 4.22)
B. Reevaluate vital signs and compare with baseline vital signs.
VII. Other Assessment Techniques.
A. Glucose determination (Medical Procedure 4.17).
B. Capnography (Medical 4.10).
Dealing with the autistic patient (Medical Procedure 4.6).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 8
EMT AND PARAMEDIC
• Initial Assessment Protocol 3.1.1.
If spontaneous breathing is present without compromise:
• Monitor breathing during transport.
• Administer oxygen as needed to maintain 02 saturation of 94% or greater (a). Avoid over
oxygenation; Wean oxygen concentration as tolerated.
o Infants via infant mask at 2-4 L/min.
o Small child (1-8 years) via pediatric mask at 6-8 L/min.
o Older child (9-15 years) via non-rebreather mask at 10-15 L/min.
o If the mask is not tolerated, administer oxygen via blow -by method.
If spontaneous breathing is present with compromise:
• Maintain the patient's airway (e.g., modified jaw -thrust procedure) (Medical Procedure
4.1.4).
• Suction as needed (Medical Procedure 4.3.1, Flexible Suctioning, and Medical Procedure
4.3.2, Rigid Suctioning).
• Administer oxygen as needed to maintain 02 saturation of 94% or greater (a). Avoid over
oxygenation; Wean oxygen concentration as tolerated.
o Infants via infant mask at 2-4 L/min.
o Small child (1-8 years) via pediatric mask at 6-8 L/min.
o Older child (9-15 years) via non-rebreather mask at 10-15 L/min.
o If the mask is not tolerated, administer oxygen via blow -by method.
• If unable to maintain the patient's airway, insert an oropharyngeal, nasopharyngeal, or
supraglottic airway (e.g., King tube, i-gel or LMA) as needed (Medical Procedure 4.4
Advanced Airways).
o Attach an end -tidal CO2 monitoring device.
o Confirm placement via auscultation and capnography.
o Secure the tube with tape or a tube stabilizing device.
o Monitor SpO2 with the pulse oximeter.
• Assist ventilations with bag valve mask (BVM) as needed (see Medical Procedure 4.1.5,
Rescue Breathing).
• Apply and monitor a pulse oximeter and capnography monitoring device, as soon as
possible (Medical Procedures 4.10 and 4.22).
If spontaneous breathing is absent or markedly compromised:
• Maintain the patient's airway (e.g., modified jaw -thrust procedure) (Medical Procedure
4.1.3, 4.1.4).
• Suction as needed (Medical Procedure 4.3.1, Flexible Suctioning, and Medical Procedure
4.3.2, Rigid Suctioning).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 9
_ - • If unable to maintain the patient's airway, insert an oropharyngeal, nasopharyngeal, or
- -- - supraglottic airway (e.g., i-gel, King tube or LMA) as needed (Medical Procedure 4.4,
-¢ Advanced Airways).
x o Attach an end -tidal CO2 monitoring device.
o Secure the tube with tape or a tube stabilizing device.
o Monitor SpO2 with the pulse oximeter.
o Confirm placement via auscultation and capnography
• Ventilate with a BVM (Medical Procedure 4.1.5, Rescue Breathing)
• Perform endotracheal intubation as a procedure of last resort if previous advanced
airway/BVM support is ineffective (a) (b) (c) (see Medical Procedure 4.4, Advanced
- Airways).
o Attach an end -tidal CO2 monitoring device.
�- - o Confirm ETT placement via auscultation and capnography.
o Secure the ETT with tape or an ETT-stabilizing device.
- - _ o Monitor SpO2 with the pulse oximeter.
• If unable to intubate and the patient cannot be adequately ventilated by other means
J
perform a needle cricothyroidotomy (Medical Procedure 4.5.1, Needle Cricothyroidotomy
for Pediatrics) and transport the patient rapidly to the Nearest hospital.
➢ None
(a) Ineffective ventilations may be evident by poor chest rise, poor lung sounds, and
capnography readings failing to improve with ventilations.
(b) The BVM should be initially used for ventilatory support. Endotracheal intubation should
be used only when the BVM is ineffective or prolonged ventilatory support is necessary.
(c) Follow the Universal Airway Algorithm on all advanced airways
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 10
EMT AND PARAMEDIC
• Initial Assessment Protocol 3.1.1.
• Airway Management Protocol 3.1.2.
• Attempt to maintain or restore normal body temperature.
• Establish hospital contact for notification of an incoming patient and advise of the
patient's length/weight-based color category.
• The EMT should apply the AED (Medical Procedure 4.1.1, AED).
PARAMEDIC
• Establish an IV/IO; give normal saline with a regular infusion set as needed (a), unless
overridden by other specific protocols. Medical Procedure, Medication Delivery 4.18
OR
• Medication may be administered via intranasal (IN) via the MAD device. (Medical
Procedure, Medication Delivery 4.18)
• Monitor the ECG as needed.
• If the patient is hypotensive administer 20mL/kg normal saline bolus, may be repeated to a
total of 3 times (60ml/kg) over a minimum of 30 minutes.
• If the patient remains hypotensive consider Dopamine infusion 5-15mcg/kg/min
➢ The paramedic should obtain consultation for ALS Level 2 orders.
(a) Authorized IV routes include all peripheral venous sites. External jugular veins may be
utilized when other peripheral site attempts have been unsuccessful or would be
inappropriate. A large -bore intracath should be used for unstable patients; avoid
establishing access sites below the diaphragm.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 11
EMT AND PARAMEDIC
• Initial Assessment Protocol 3.1.1.
• Initiate a Trauma Alert, if applicable (General Protocol 1.10, Trauma Transport).
• Airway Management Protocol 3.1.2. Manually stabilize the patient's c-spine as needed.
• Correct any open wound/sucking chest wound (occlusive dressing).
• Control any hemorrhage.
• Immobilize the c-spine and secure the patient to a backboard or pediatric immobilizer as
needed (Protocol 2.10.1. and Medical Procedure 4.24, Spinal Immobilization) (a).
• Keep the patient warm.
PARAMEDIC ONLY
• Correct any massive flail segment that causes respiratory compromise with positive
pressure ventilation (advanced airway as needed).
• Correct any tension pneumothorax (Medical Procedure 4.9, Chest Decompression).
• Expedite transport.
The following steps should not delay transport:
• Complete bandaging, splinting, and packaging as needed.
• Contact online medical control for notification of an incoming patient and obtain
consultation for ALS Level 2 orders.
(a) Infants and small children in car seats may be immobilized without removing them from the
car seat, as long as it will not interfere with patient assessment and other needed procedures
and the car seat is intact. If the patient is not in a car seat on your arrival, do not put the
patient back into the car seat to immobilize him/her; use a backboard or pediatric
immobilizer instead.
(b) Authorized IV routes include all peripheral venous sites. The external jugular vein may be
utilized when other peripheral site attempts have been unsuccessful or would be
inappropriate. Two IVs, using large -bore intracaths, should be used for unstable patients;
avoid establishing access sites below the diaphragm. Rapid transport should not be delayed
to establish an IV.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 12
PARAMEDIC ONLY
This entire protocol is ALS/Paramedic Only.
ISOLATED EXTREMITY FRACTURE
The purpose of this procedure is to manage pain associated with isolated extremity fractures
that are not associated with multisystem trauma or hemodynamic instability.
ACUTE BACK STRAIN
This procedure should be used in the isolated back strain where an acute abdominal process is
not suspected (see Appendix 6.1, Abdominal Pain Differential).
SOFT -TISSUE INJURIES, BURNS, BITES, AND STINGS
This procedure is used for pain associated with soft -tissue injuries, burns, bites, and stings that
are not associated with multisystem trauma or hemodynamic instability.
• Initial Assessment Protocol 3.1.
For Isolated Extremity Fractures
• Any extremity fracture should be immobilized as described in Adult Protocol 2.10.6,
Extremity Injuries.
• Extremity fractures should be elevated, if possible, and cold applied.
• Distal circulation, sensation, and movement in the injured extremity should be noted and
recorded.
• Patients should be asked to quantify their pain on an analog pain scale (from 0 = least
severe to 10 = most severe) or Wong -Baker Faces Scale; for infants, an infant behavior
score may be used. This score should be documented used to measure the effectiveness of
analgesia.
• The extremity should be immobilized as described in Pediatric Protocol 3.9.5, Extremity
Injuries. Self-administered analgesia with Nitrous Oxide should be given special
consideration for pain management during this procedure (Medical Procedure 4.20, Nitrous
Oxide-Nitronox), if available.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 13
• If pain persists and systolic BP is adequate (Appendix 6.16, Pediatric Vital Signs),
Administer (Medical Procedure, Medication Delivery 4.18)
o Morphine Sulfate - may be given IV titrated to pain, pediatric dose: 0.1 mg/kg; infant
dose: 0.05 mg/kg. Maximum single dose of 4 mg. If pain persists and systolic BP is
adequate, may repeat dose x 1 in 3-5 minutes, (repeat single dose maximum of 4 mg).
Administer at a rate not to exceed 1 mg/min(a). (Appendix 6.16, Pediatric Vital Signs).
OR
o Fentanyl 0.5 mcg/kg (maximum 25 mcg) SLOW IV; repeat once after 5 minutes as
needed (max 50 mcg total dose) OR IN 1.5 mcg/kg (max 100 mcg)
➢ None
(a) Extreme caution should be used with administering narcotic analgesics to a patient with a
SP02 less than 94%.
(b) When administering Morphine Sulfate/Fentanyl, closely monitor the patient's respiratory
status. In the event that the patient's respirations/oxygenation is suppressed (SP02 less than
94%), utilize basic airway maneuvers (open airway), administer oxygen and if no
improvement consider Narcan.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 14
Pain Scale
0 2 4 6 8 10
ASSESSMENT OF SCORE
0 Relaxed: infant comfortable, not distressed.
1-2 Some transitory distress caused: returns immediately to "relaxed."
3-4 Transitory distress; likely to respond to consolation.
5 Infant experiences pain; if no response to consolation, may require analgesia.
6 "Anguished" and "exaggerated": infant experiencing acute pain; is unlikely to
respond to consolation, will probably benefit from analgesia.
7-8 "Inert": no response to traumatic procedure; infant is habituated to pain; will not
respond to consolation; systematic pain control by analgesia should be considered.
FACIAL EXPRESSION
0 Relaxed - Smooth muscled; relaxed expression; either in deep sleep or quietly
alert.
1 Anxious - Anxious expression; frown; REM behind closed lids; wandering gaze;
eyes narrowed; lips parted; pursed lips as if "oo" is pronounced.
2 Anguished - Anguished expression/crumpled face; brow bulge; eye squeeze;
nasolabial furrow pronounced; square -stretched mouth; cupped tongue; "silent
cry.
3 Inert - No response to trauma; no crying; rigidity; gaze avoidance; fixed/staring
gaze; apathy; diminished alertness (only during or immediately after traumatic
procedure).
BODY MOVEMENT
0 Relaxed - Relaxed trunk and limbs; body in tucked position; hands in cupped
position or willing to grasp a finger.
1 Restless - Moro reflex; startles; jerky or uncoordinated movement of limbs;
flexion/extension of limbs; attempt to withdraw limb from site of injury.
2 Exaggerated - Abnormal position of limbs; limb/neck extension; splaying of
fingers and/or toes; flailing or thrashing of limbs; arching of back; side
swiping/guarding site of injury.
3 Inert - No response to trauma; inertia; limpness/ rigidity; immobility (only during
or immediately after traumatic procedure).
COLOR
0 Normal skin color.
1 Redness; congestion.
2 Pallor; mottling; gray.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 15
Most children requiring urgent intervention have primary respiratory problems. Approximately
80-90% of all pediatric cardiac arrests originate in the respiratory system. When the child who
ies is in respiratory distress can no longer compensate, respiratory failure will be followed by
cardiac failure. It is crucial to recognize respiratory distress and dysfunction early, so that
cardiopulmonary failure may be prevented. Note that the respiratory system also attempts to
compensate for the hypoxia and acidosis found in primary circulatory failure. Assessment of
the pediatric respiratory system should focus on clinical status, as reflected by general
appearance (adequacy of cerebral oxygenation and ventilation) and work of breathing.
COMPONENTS OF APPEARANCE
1. Alertness - How responsive and interactive is the child with a stranger or other changes in
the environment? Is the patient restless, agitated or lethargic?
2. Distractibility - How readily does a person, object, or sound draw the child's interest or
attention? Will the patient play with a toy or new object?
3. Consolability - Can the patient be comforted by the caregiver or by the paramedic?
4. Eye contact - Does the child maintain eye contact with objects or people? Will the patient
fix his/her gaze on a face?
5. Speech/cry - Is the speech/cry strong and spontaneous? Weak and muffled? Hoarse?
6. Spontaneous Motor Activity - Is the patient moving and resisting vigorously and
spontaneously? Is there good muscle tone and responsiveness?
7. Color - Is the patient pink? Or is the patient pale, ashen, blue, or mottled? Does the skin
coloring of the trunk differ from that of the extremities?
SIGNS OF WORK OF BREATHING
1. Use of accessory muscles - Pediatric patients will use accessory muscles early to
compensate for deficiencies in perfusion. Intercostal and supraclavicular retractions, as well
as diaphragmatic breathing (see -saw), may be very apparent.
2. Respiratory rate - Significant finding if above 60/min (for a premature baby to a 1 year old)
or less than 20/min for an infant (less than one year old) and less than 10/min for children.
3. Tidal volume - Inspection of chest wall movement may not be adequate for assessment of
tidal volume. It is imperative to auscultate bilateral lung sounds to determine the adequacy
of tidal volume.
4. Nasal flaring - Flaring of the external nares indicates respiratory distress.
5. Grunting - Grunting is an ominous sign associated with severe distress. It is caused by a
premature closure of the glottis on exhalation due to atelectasis. The patient is attempting to
maintain a positive end -expiratory pressure (PEEP) to allow for better lung inflation.
6. Cyanosis - Cyanosis is usually a late finding and will initially be visible around the mouth
and gums (perioral) and nail beds.
7. Pulse oximeter - SP02 less than 94% is suggestive of respiratory insufficiency.
8. Capnography - Use EtCO2, monitor wave form.
9. Lung sounds - Auscultation of bilateral lung sounds not only assesses tidal volume, but may
also uncover abnormal sounds (e.g., wheezing, stridor, rates).
Specific treatments for the different causes of respiratory distress are outlined in the following
protocols. When the paramedic is unsure as to which protocol to follow, he/she should follow the
protocols in Section 3.1 and contact medical control for further direction.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 16
Causes of upper airway obstruction include the tongue, foreign bodies, swelling of the upper
airway due to angio-neurotic edema (Pediatric Protocol 3.7.1, Allergic Reactions/Anaphylaxis),
trauma to the airway, and infections (Pediatric Protocol 3.2.2, Upper Airway [Stridor-
Croup/Epiglottitis]). Differentiation of the cause of upper airway obstruction is essential to
determine the proper treatment.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• If air exchange is inadequate and there is a reasonable suspicion of foreign body airway
obstruction (FBAO), apply abdominal thrusts until the patient becomes unresponsive then
administer chest compressions (a). For an infant apply chest compressions and back blows
(Medical Procedure 4.1.6, Suspected Foreign Body Airway Obstruction) (a).
If unable to relieve the FBAO, visualize it with a laryngoscope and extract the foreign body
with magill forceps.
If the obstruction is due to trauma and/or edema, or if uncontrollable bleeding into the
airway causes life -threatening ventilatory impairment, proceed directly to an advanced
airway (Medical Procedure 4.4, Advanced Airways).
If unable to intubate and the patient cannot be adequately ventilated by other means, perform a
needle cricothyroidotomy (Medical Procedure 4.5.1, Needle Cricothyroidotomy for Pediatrics).
➢ None
(a) If air exchange is adequate with a partial airway obstruction, do not interfere, but rather
encourage the patient to cough up the obstruction. Continue to monitor for adequacy of air
exchange. If air exchange becomes inadequate, continue with the protocol.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 17
Stridor is a high-pitched "crowing" sound caused by restriction of the upper airway (usually
heard on inspiration). In addition to FBAO (see Pediatric Protocol 3.2.1), stridor can be caused
by croup and epiglottitis.
Croup (laryngotracheobronchitis) is a viral infection of the upper airway, which causes
edema/inflammation below the larynx and glottis with a resultant narrowing of the lumen of the
airway. Croup most often occurs in children 6 months to 4 years of age. The child with croup
will have stridor, a distinctive barking cough, and cold symptoms (low-grade fever [100-
101°F]), with a gradual onset of respiratory distress.
Epi2lottitis is an acute infection and inflammation of the epiglottis that potentially is life -
threatening. Since the Haemophilus influenza, type B (Hib) vaccine became available, the
incidence of epiglottitis has markedly decreased, yet it may still occur from other bacterial
pathogens. Epiglottitis usually occurs in children 4 years of age and older. The child with
epiglottitis will present with stridor, acute respiratory distress, sore throat, pain upon
swallowing that causes the distinctive drooling, and high-grade fever (102-104°F). The patient
may assume the classic tripod position.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3, including use of a pulse oximeter (Medical
Procedure 4.22, Pulse Oximeter). Avoid IVs in these patients (a).
• Avoid agitating the child with suspected epiglottitis. Keep the patient in a position of comfort
(he/she may be held by a parent to avoid agitation). Never examine the epiglottis (a).
• Administer humidified oxygen. If humidified oxygen is unavailable, use nebulized saline. Do
not force an oxygen mask on a pediatric patient; use the blow -by technique if necessary (a).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 18
Wheezing is a whistling -type breath sound associated with narrowing or spasm of the smaller
ies airways (usually heard on expiration, but may also be heard on inspiration). Wheezing in the child
younger than 1 year of age is usually the result of bronchiolitis, a viral infection of the bronchioles
that causes prominent expiratory wheezing, clinically resembling asthma.
Asthma is a chronic inflammatory disease that is triggered by many different factors (e.g.,
environmental allergens, cold air, exercise, foods, irritants, certain medications). Asthma is
characterized by a two-phase response. The first phase is associated with a histamine release, which
causes bronchoconstriction and bronchial edema. Early treatment with bronchodilators may reverse
the bronchospasm. The second phase consists of inflammation of the bronchioles and additional
edema. The second phase will usually not respond to bronchodilators; instead, an anti-inflammatory
medication (e.g., a corticosteroid) is typically required.
Assessment of the asthma patient usually includes a history of asthma with associated medications.
The patient will be tachypneic and may have an unproductive cough. Use of accessory muscles is
evident and wheezing may be heard, most commonly on expiration. In a severe asthma attack, the
patient may not wheeze at all due to a lack of air flow.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3, including use of a pulse oximeter (Medical Procedure
4.22, Pulse Oximeter).
Administer the following bronchodilator:
• Albuterol (Ventolin®): one nebulizer treatment. (Medical Procedure 4.18.6, Nebulizer). May
repeat twice as needed.
o If patient less than 1 year or less than 10 kg, 1.25 mg/1.5 mL (0.083%);
o If patient greater than 1 year or greater than 10 kg, 2.5 mg/3 mL (0.083%)
• If a bronchodilator is administered, add Ipratropium Bromide (Atrovent ®) to Albuterol nebulizer
treatment. (See Medical Procedure 4.18.6, Nebulizer).
o If patient less than 8 year, 0.25mg/1.25mL
o If patient greater than 8 year, 0.5mg/2.5mL
• Consider the need for assisted ventilation and advanced airway (Medical Procedure 4.4,
Advanced Airways).
If respiratory distress is severe:
• Administer Epinephrine (1:1000) 0.01 mg/kg IM (up to a maximum dose of 0.3 mg) may be
repeated every 3-5 minutes to a maximum of 3 doses (Medical Procedure 4.18, Medication
Administration)
• Methylprednisolone sodium succinate (Solu-Medrol) 2mg/kg not to exceed 60 mg IV or IM if an
IV cannot be established; if available. (Medical Procedure, Medication Delivery 4.18)
• For severe dyspnea, administer Magnesium Sulfate 40 mg/kg (maximum dose of 2 g) IV (mixed
in 50 mL of D5W given over 30 minutes), as needed
-�O- None
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 19
General
Guidelines_
Cardiac dysrhythmias in pediatric patients are uncommon and are usually due to noncardiac
problems, unless the patient is known to have congenital or acquired cardiac disease. Cardiac arrest
is usually the end result of hypoxemia and acidosis resulting from respiratory insufficiency or
shock. Therefore, attention should be given initially to support of the respiratory system. Pediatric
dysrhythmias can be classified into three categories: slow rhythms, fast rhythms, or no rhythm. The
most common dysrhythmia is bradycardia, which is the result of hypoxia or acidosis. Tachycardia
can be a compensatory mechanism or a result of a reentry mechanism. Ventricular fibrillation,
although rare in pediatric patients, is usually the result of hypoxia. Asystole is a terminal event,
following prolonged, untreated bradycardia.
Automated external defibrillators (AEDs) may be used for children 1 to 8 years of age who have n
signs of circulation. Ideally the device should deliver a pediatric dose. The arrhythmia detection
algorithm used in the device should demonstrate high specificity for pediatric shockable rhythms; i.e
it will not recommend delivery of a shock for non -shockable rhythms (Class IIb).
The protocols in Section 3.3 follow the AHA/PALS guidelines. The paramedic should use these protocols t
guide him/her through the treatment of cardiac patients with specific dysrhythmias and accompanying sign
and symptoms. After stabilization of the patient, the paramedic may need to refer to additional protocols fc
continued treatment (e.g., other cardiac protocols).
In cardiac arrest, a major component of the primary and secondary survey is to consider the secondar
differential diagnosis and to think carefully about what could be causing the arrest. The "H's and Us" chaff
will assist in the recognition of a possible underlvinR cause.
H's
Cause
Treatment
Protocol
Hypovolemia
Fluid challenge with normal saline 20ml/kg
or 10ml/kg for neonates (infants less than
1 month) IV/IO
Shock Protocol
Hypoxia
Airway management
Protocol 3.1.2
Hydrogen ion-
acidosis
Airway management, ventilate consider
Sodium Bicarbonate
Protocol 3.1.2 Drug
Summary 5.31
Hyperkalemia
Consider Calcium Chloride Consider Sodium
Bicarbonate I mEq/kg
Drug Summary 5.7 Drug
Summary 5.31
Hypothermia
Cold -related emergencies
Protocol 3.8.3
Hypoglycemia
If glucose is less than 60 mg/dl, consider
Dextrose or Glucagon
Protocol 3.7.2 Drug
Summary 5.11 and 5.18
Hypogaycemia
Consider Calcium Chloride
Drug Summary 5.7
T's
Cause
Treatment
Protocol
Tablets
Protocol 3.6
Tamponade,
cardiac
Consider fluid challenge, Dopamine drip
Protocol 3.4.1
Tension
pneumothorax
Consider chest decompression
Procedure 4.9
Thrombosis,
coronary
Consider AMI, cardiogenic shock
Protocol 3.4
Thrombosis,
pulmonary
Protocol 3.4
Trauma
Protocol 3.9
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 20
This protocol is used for asystole, electromechanical dissociation (EMD), pseudo-EMD,
idioventricular rhythms, bradyasystolic rhythms, and post -defibrillation idioventricular
rhvthms.
• Consider criteria for death/no resuscitation (General Protocol 1.4).
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Determine the patient's (un)responsiveness and check the CABS.
• Oxygenate with 15-25 L/min via bag -valve mask with an appropriate airway adjunct device
at 8-10 BPM (Airway Protocol 3.1.2) (a).
• Begin immediate chest compressions at a rate of 100/min for 2 minutes while the monitor is
being attached.(a)
• Do not interrupt CPR to check the heart rhythm. Continuous uninterrupted compressions
are paramount to patient survival.(b)
• Consider the H's and T's.
•
Confirm airway adjunct placement with electronic EtCO2 and waveform on scene,
during transport, and during transfer at the hospital.(a)
w - •
Establish IV or IO access; give normal saline wide open for fluid challenge at 20ml/kg or
-_
10ml/kg for neonates (infants less than 1 month).
•
When IV or IO line is established, administer a vasopressor:
-'
o Epinephrine (1:10,000) 0.01 mg/kg IV/IO (max single dose ling); repeat every 3-5
minutes for the duration of pulselessness.
•
Give 2 minutes of chest compressions; check the heart rhythm.
•
Search for and treat possible contributing factors; see the H's and T's charts.
•
If the patient is taking calcium channel blockers or if there is a high suspicion for
-
hyperkalemia, administer Calcium Chloride 20 mg/kg IV/IO slowly.
� - .
Perform a glucose test with a finger stick. If glucose is less than 60 mg/dL, refer to
Hypoglycemia/Hyperglycemia Protocol 3.7.2
•
Perform ten cycles of CPR and then reevaluate the heart rhythm.
- •
If a pulse is present, begin post -resuscitative care.
•
Administer Narcan 0.1 mg/kg, IVP may repeat once.
➢ None
(a) Provide a 15:2 compression to ventilation ratio.
Once an advanced airway is in place, provide 1 breath every 6 seconds.
(b) If EtCO2 is less than 10mmHg: Attempt to improve CPR (compressions vs. ventilation).
If EtCO2=12 - 25mm Hg: Goal during resuscitation.
If EtCO2=35 - 45mm Hg: Check for ROSC
(c) If ROSC achieved, wean down oxygen to maintain a SP02 at greater than or equal to 94%
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 21
Causes of symptomatic bradycardia include hypoxemia, hypothermia, head injury, heart block,
heart transplant (special situation), and toxin/poison/drug overdose.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Assure adequate ventilation and oxygenation.
• If heart rate is less than 60/min in an infant or child associated with poor systemic
perfusion, start chest compressions (Medical Procedure 4.1.2, Cardiopulmonary
Resuscitation).
• Consider the H's and T's.
• Start IV/IO administer a fluid challenge of normal saline 20 mVkg IV or 10 mVkg for neonates
(infants less than 1 month).
• Administer Epinephrine (1:10,000) 0.01 mg/kg IV or IO (maximum dose 1 mg IV/IO). (a).
• Administer Atropine 0.02 mg/kg IV or IO (minimum single dose 0.1 mg) (b). May repeat
Atropine once, maximum single dose for a child is 0.5 mg, maximum single dose for an
adolescent is 1 mg(a)
• If the patient remains hypotensive and bradycardic and is conscious and aware of the
situation, consider sedation with one of the following benzodiazepines, Midazolam
(Versed®) is the preferred benzodiazepine: (Medical Procedure, Medication Delivery 4.18)
o Midazolam (Versed®) O.lmg/kg, maximum single dose 4 mg IV, IO, IM. For IN
administration use 0.2 mg/kg/dose (use 10 mg/2mL concentration), maximum single dose
5 mg; may repeat once if necessary. Maximum total dose of 10 mg.
OR
o Diazepam (Valium) 0.2mg/kg (maximum single dose 5 mg) IV, IO or IN; may repeat
once, to a maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 0.05 mg/kg IV, IO, or IN; may repeat once, to a maximum dose of 4
Mg.
• Use an external pacemaker (Medical Procedure 4.14.2, External Pacemaker).
➢ None
(a) Administer Atropine before Epinephrine for bradycardia due to suspected increased vagal
tone or primary AV block.
(b) Small doses of Atropine less than 0.1 mg may produce paradoxical bradycardia.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 22
Pediatric patients suffering from tachycardia may or may not exhibit symptoms. Narrow
complex tachycardia (QRS less than or equal to 0.08 second) may be either sinus tachycardia or
supraventricular tachycardia. The following rates should be considered:
• Sinus tachycardia is a greater than normal rate (see Appendix 6.16, Pediatric Vital Signs),
usually greater than 180/min for a child and greater than 220/min for an infant (less than
one year old). The rate may vary with sinus tachycardia.
• Supraventricular tachycardia is usually a rate above 220/min for infants. If the patient is
greater than 2 years of age, SVT may be slower (e.g., 180-220/min). The rate will not vary
with SVT.
Wide complex SVTs are rare in children and, therefore, should initially be considered as
ventricular in origin, unless proven otherwise (e.g., documented QRS morphology consistent
with preexisting BBB or Wolff -Parkinson -White (WPW) syndrome).
UNSTABLE SINUS TACHYCARDIA (DIMINISHED PERFUSION)
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Determine the patient's hemodynamic stability and symptoms.
• Apply SpO2 monitor and administer oxygen to maintain SpO2 at greater than or equal to
94%.
• Consider the H's and T's.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 23
STABLE SVT (NORMAL PERFUSION)
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Determine the patient's hemodynamic stability and symptoms.
• Apply Sp02 monitor and administer oxygen to maintain Sp02 greater than or equal to
94%.
• Consider the H's and T's
• Apply an ECG; record a rhythm strip and obtain a 12-lead ECG.
• Establish IV access; give normal saline wide open for fluid challenge at 20ml/kg or
l0ml/kg for neonates (infants less than 1 month).
• If the patient is asymptomatic, provide Medical Supportive Care Protocol 3.1.3 and
transport.
• Attempt vagal maneuvers; begin with ice water (Medical Procedure 4.26, Vagal
Maneuvers) (a).
• Administer Adenosine Triphosphate (Adenocard ®) 0.1 mg/kg (6 mg is the maximum first
dose) via rapid IVP/I0, followed by 6 mL normal saline flush (a).
• If not resolved after 2 minutes repeat Adenosine 0.2 mg/kg (12 mg is the maximum second
dose) via rapid IVP/I0, followed by 6 mL normal saline flush (a).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 24
UNSTABLE SVT (DIMINISHED PERFUSION)
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Determine the patient's hemodynamic stability and symptoms.
• Apply Sp02 monitor and administer oxygen to maintain Sp02 greater than or equal to
94%.
• Consider the H's and T's.
• Consider sinus tachycardia as the underlying rhythm, not SVT.
• Apply an ECG; record a rhythm strip and obtain a 12-lead ECG.
• Establish IV/IO access; give normal saline wide open.
• If the patient is responsive, administer Adenosine Triphosphate (Adenocard ®) 0.1 mg/kg
(maximum dose 6 mg) via rapid IVP/I0, followed by 6 mL normal saline flush (a).
• If unresolved after 2 minutes, repeat Adenosine 0.2 mg/kg (maximum dose 12 mg) via
rapid IVP/I0, followed by 6 mL normal saline flush. (a).
• If the patient is conscious and aware of the situation, consider sedation with one of the
following benzodiazepines with Midazolam (Versed®) being the preferred benzodiazepine:
(Medical Procedure, Medication Delivery 4.18)
o Midazolam (Versed®) O.lmg/kg, maximum single dose 4 mg IV, I0, IM. For IN
administration use 0.2 mg/kg/dose (use 10 mg/2mL concentration), maximum single dose
5 mg; may repeat once if necessary. Maximum total dose of 10 mg (c).
OR
o Diazepam (Valium) 0.2mg/kg (maximum single dose 5 mg) IV, IO or IN; may repeat
once, to a maximum dose of 10 mg (c).
OR
o Lorazepam (Ativan) 0.05 mg/kg IV, I0, or IN; may repeat once, to a max dose of 4 mg (c).
• If the patient is poorly responsive, apply synchronized cardioversion at 0.5 joule/kg. (b).
• If the patient remains poorly responsive, apply synchronized cardioversion at 1 joule/kg (b).
• If the patient is still poorly responsive, apply synchronized cardioversion at 2 joule/kg (b).
➢ None
(a) Record the patient's heart rhythm while attempting to convert the rhythm so as to capture
conversion data.
(b) Do not delay synchronized cardioversion to establish an IV for sedation purposes.
(c) Administer Benzodiazepines slowly, titrate to effect, and be aware of associated
hypotension.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 25
This protocol is used in wide complex tachycardia (QRS greater than 0.12 second).
STABLE (NORMAL PERFUSION) and UNSTABLE (DIMINISHED PERFUSION)
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Determine the patient's (un)responsiveness and check the CABS.
• Consider the H's and T's
STABLE (NORMAL PERFUSION)
Administer Amiodarone 5 mg/kg IV over 20-60 minutes.
UNSTABLE (DIMINISHED PERFUSION)
• If the patient is conscious and aware of the situation, consider sedation with one of the
following benzodiazepines with Midazolam (Versed®) being the preferred benzodiazepine:
(a) (Medical Procedure 4.18, Medication Administration)
o Midazolam (Versed®) O.lmg/kg, maximum single dose 4 mg IV, IO, IM. For IN
administration use 0.2 mg/kg/dose (use 10 mg/2mL concentration), maximum single dose
5 mg; may repeat once if necessary. Maximum total dose of 10 mg (b).
OR
o Diazepam (Valium) 0.2mg/kg (maximum dose 5 mg) IV, IO or IN; may repeat once, to a
maximum dose of 10 mg (b).
o Lorazepam (Ativan) 0.05 mg/kg IV, IO, or IN; may repeat once, to a maximum dose of 4
mg (b).
If the patient is poorly responsive, apply synchronized cardioversion at 0.5 joule/kg. (a).
If the patient remains poorly responsive, apply synchronized cardioversion at 1 joule/kg
(a).
If the patient is still poorly responsive, apply synchronized cardioversion at 2 joule/kg (a).
➢ If the patient converts to a sinus rhythm after cardioversion and the patient is normotensive,
consult medical control for Amiodarone 5mg/kg over 20-60 minutes.
(a) Do not delay synchronized cardioversion to establish an IV for sedation purposes.
(a) Administer Benzodiazepines slowly, titrate to effect, and be aware of associated
hypotension.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 26
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Determine the patient's (un)responsiveness and check the CABS.
• Oxygenate with 15-25 L/min via bag -valve mask with an appropriate airway adjunct device
at 8-10 BPM (Airway Protocol 3.1.2).
• Begin immediate chest compressions at a rate of 100/min for 2 minutes while the monitor is
being attached.
• Perform chest compressions at 15:2 ratio unless an advanced airway has been established
(supraglottic or ETT)
• Do not interrupt CPR to check the heart rhythm. Continuous uninterrupted compressions
are paramount to patient survival.
• Consider the H's and T's.
• Defibrillate at an initial dose of 2 J/kg.
• Resume CPR immediately. Administer ten cycles of CPR.
• Check the heart rhythm. Treat according to the applicable protocol.
• For refractory VF, increase the dose to 4 J/kg; continue CPR while the defibrillator is
charging.
• Resume CPR immediately.
• Administer Epinephrine (1:10,000) 0.01 mg/kg IV or IO (maximum dose 1 mg). Repeat
every 3-5 minutes for the duration of pulselessness.
• Reevaluate the heart rhythm after ten cycles of CPR.
• Subsequent energy levels should be at least 4 J/kg, and higher energy levels may be
considered, not to exceed 10 J/kg or the adult maximum dose (AHA Class Ilb, LOE C).
CPR while the defibrillator is charging.
• Resume CPR immediately.
• Administer one of the following anti arrhythmi cs:
o Amiodarone 5 mg/kg IV or IO.
OR
o If the patient has torsades de pointes, Magnesium Sulfate 25-50 mg/kg IV/IO, up to a
maximum dose of 2 g over 2 minutes.
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 27
Infant and newborn cardiopulmonary arrest is usually a result of prolonged poor oxygenation
and/or severe circulatory collapse. Newborn/neonates (infants less than 1 month) should be
resuscitated using Pediatric Protocol 3.4.1. Unless there are obvious signs of death (General
Protocol 1.4, Death in the Field), the infant in cardiopulmonary arrest should be resuscitated
using the protocols in Pediatric Protocol 3.3. While some infants may not be salvageable, the
paramedic may determine a resuscitation attempt is warranted for psychological reasons (e.g.,
the parent's peace of mind). Consideration should also be given to Sudden Unexpected Infant
Death (SUIDs) (Pediatric Protocol 3.4.2).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 28
This protocol is to be used for newborns that are in need of resuscitation immediately following
deliverv.
• Initial Assessment Protocol 3.1.1
• Dry and keep the newborn warm (cover with a thermal blanket or dry towel, and cover the
scalp with a stocking cap).
• Position the patient so as to open the airway (a).
• Clear the airway; suction the mouth and nose with a bulb syringe as needed.
• Paramedic Only: If the newborn has signs of thick meconium after suctioning with a bulb
syringe and if the newborn is not vigorous and crying, incubate and suction the trachea
using the meconium aspirator (see Medical Procedure 4.3.1, Flexible Suctioning, Medical
Procedure 4.3.2, Rigid Suctioning) (b). (From PALS 2010: In the absence of randomized,
controlled trials, there is insufficient evidence to recommend a change in the current
practice of performing endotracheal suctioning of nonvigorous babies with meconium-
stained amniotic fluid (Class Ilb, LOE C). However, if attempted intubation is prolonged
and unsuccessful, BVM should be considered, particularly if there is persistent
bradycardia.)
• Stimulate the newborn (rub the newborn's back).
• Clamp and cut the cord, if not already done. Apply two umbilical clamps, 2 inches apart
and at least 8 inches from the navel, and cut between clamps.
• Assess skin color, respirations, and heart rate.
• Administer 100% oxygen via blow -by method to newborns that are breathing but have
central cyanosis or have no improvement in respiratory, circulatory, or neurological status
within 90 seconds of initial assessment.
• Ventilate at 40-60 breath/min with 100% oxygen under the following conditions:
o Apnea.
o Heart rate less than 100 beat/min.
o Persistent central cyanosis after high -flow oxygen.
• Paramedic Only: Place an advanced airway only under the following conditions (Medical
Procedure 4.4):
o Bag valve mask (BVM) ventilation is ineffective after 2 minutes.
o Tracheal suctioning is required, especially for thick meconium, and the newborn is not
vigorous and crying (b).
o Prolonged positive -pressure ventilation is needed.
• Newborns who require CPR in the prehospital setting, should receive CPR according to
infant guidelines: 2 rescuers provide continuous chest compressions with asynchronous
ventilations if an advanced airway is in place and a 15:2 ventilation -to -compression ratio if
no advanced airway is in place (Class Ilb, LOE C). Perform chest compressions at 120/min
using two thumbs placed side by side (or superimposed one on top of the other) over the
mid -sternum, just below the nipple line, with the fingers encircling the chest and supporting
the back, under the following conditions:
o Heart rate is less than 100 beat/min and not rapidly increasing despite adequate
ventilation with 100% oxygen for approximately 30 seconds.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 29
• Administer Epinephrine (1:10,000) O.Olmg/kg IV/IO under the following conditions:
o Asystole.
o Heart rate is less than 60 beat/min despite adequate ventilation with 100% oxygen and
30 seconds of chest compressions.
• Repeat every 3-5 minutes as needed.
• Administer a fluid challenge of normal saline IOmL/kg IV under the following conditions:
o Pallor that persists after adequate oxygenation.
o Faint pulses with a good heart rate.
o Poor response to resuscitation with adequate ventilations.
• Check the blood glucose level for all resuscitated newborns who do not respond to initial
therapy. Use a heel stick (see Medical Procedure 4.17, Glucometer).
o If blood glucose less than 40 mg/dL, administer Dio 5 mL/kg IV/IO (dilute D50 1:4 with
normal saline to make Dio).
• Perform Pediatric Assessment Triangle: Rapid Cardiopulmonary Assessment (Pediatric
Protocol 3.1.1, Initial Assessment) frequently.
• If the newborn is unresponsive with depressed respirations, consider Naloxone (Narcari )
0.1 mg/kg (1 mg/mL concentration) IV/IO/IN/IM (c) (Medical Procedure, Medication
Delivery 4.18)
(a) The newborn should be placed on his/her back or side with the neck in a neutral position.
To help maintain correct position, a rolled blanket or towel may be placed under the back
and shoulders of the supine newborn to elevate the torso 0.75 or 1 inch off the mattress to
extend the neck slightly. If copious secretions are present, the newborn should be placed on
his/her side with the neck slightly extended to allow secretions to collect in the mouth rather
than in the posterior pharynx.
(b) Tracheal suctioning for thick meconium should be done via an endotracheal tube using a
meconium aspirator attached to the 15-mm adaptor of the ETT. The suction unit is then
attached and placed on low pressure (no more than 100 mm Hg). Suctioning should be
performed until the ETT is clear (maximum 5 seconds). It may be necessary to repeat the
incubation and continue suctioning until clear (maximum three times).
(c) Avoid the use of Naloxone if the mother has a history of drug use/abuse, as Naloxone may
precipitate seizures in the newborn due to acute withdrawal.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 30
Sudden unexpected infant deaths (SUID) are defined as deaths in infants less than 1 year of age
that occur suddenly and unexpectedly, and whose cause of death are not immediately obvious prior
to investigation. Each year in the United States, about 4,000 infants die suddenly of no
immediately obvious cause. About half of these SUIDs are due to Sudden Infant Death Syndrome
(SIDS), the leading cause of SUID and of all deaths among infants aged 1-12 months. The three
most frequently reported causes are SIDS, cause unknown, and accidental suffocation and
strangulation in bed. Additional information and training material is available at
www.cdc.gov/SIDS/
Expanding Safe Infant Sleep Outreach - The U.S. national campaign to reduce the risk of SIDS has
entered a new phase and will now include all sleep -related SUIDs. The campaign, which has been
known as the Back to Sleep Campaign, has been renamed the Safe to Sleep Campaign.
Sudden Infant Death Syndrome (SIDS) is defined as the sudden death of an infant less than 1 year
of age that cannot be explained after a thorough investigation is conducted, including a complete
autopsy, examination of the death scene, and review of the clinical history.
SIDS almost always occurs when the infant is asleep or is thought to be asleep. Although there
may be obvious signs of death the paramedic may attempt resuscitation of the infant for
psychological reasons (e.g., the parent's peace of mind). There may also be some infants in
whom the Paramedic determines that a resuscitation attempt is not warranted (General Protocol
1.4, Death in the Field). In either event, the Paramedic should be prepared for a myriad of grief
reactions from the parents and/or caregiver. The Paramedic should document the location the
infant was found and the appearance of the infant.
Some SIDS deaths are mistaken for child abuse. If there are possible signs of abuse (Appendix
6.2.2, Signs of Child Abuse), the paramedic should continue as if it were a SIDS death, to avoid
any unnecessary grief on the part of the parents and/or caregiver. The paramedic should not
attempt to determine whether child abuse has taken place. The scene should be treated as any
other death scene, with attention to preservation of potential evidence.
• Initial Assessment Protocol 3.1.1
• In most instances, resuscitation should be attempted (see the appropriate Pediatric
Protocols).
• Assign a crew member to assist the parents and/or caregiver and to explain the procedures.
• If time permits, elicit a brief history and perform an environmental check. Document all
findings on the EMS Run Report.
• Once resuscitation is started, do not stop until directed to do so in the hospital by a
physician.
• None
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 31
This section covers the most common pediatric neurologic emergencies, altered mental status,
and seizures. It is important for the paramedic to understand appropriate behavior for the
child/infant's age to properly assess level of consciousness (Appendix 6.9.2, Glasgow Coma
Scale Score, for pediatric patients). Attention should be given to how the child interacts with
parents and the environment and whether the patient can make good eye contact. Parents may
be invaluable for a baseline comparison of level of consciousness. The parents may simply state
that the patient is not acting right. Causes of pediatric altered mental status may include
hypoxia, head trauma, ingestion/ poisoning, infection, and hypoglycemia.
Approximately 4-6% of all children will have at least one seizure. Seizures may be due to an
underlying disease (e.g., epilepsy) or may simply be a result of fever. Other potential causes of
pediatric seizures include trauma, hypoxia, infection of brain and spinal cord (e.g., meningitis),
hypoglycemia, and ingestion/poisoning.
4Ih Edition 3/1/2015 Florida Regional Common EMS Protocols 32
Common signs of altered mental status in pediatric patients include combative behavior,
decreased responsiveness, lethargy, weak cry, moaning, hypotonia, ataxia, and changes in
personality. The initial management approach should be based on the assumption that the
patient is suffering from infection, hypoxia, ischemia, hypoglycemia, or dehydration.
Secondary considerations should include medications, illicit drugs/alcohol, plants, trauma, and
other factors.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3; consider the need for spinal immobilization
(Medical Procedure 4.24, Spinal Immobilization).
• Consider the need for ventilatory assistance.
• If the child remains unresponsive and prolonged ventilatory assistance is needed, consider
use of an appropriate airway adjunct device (a).
-_ • Perform a glucose test with a finger stick. If glucose less than 60 mg/dL, refer to
Hypoglycemia/Hyperglycemia protocol 3.7.2
• If the patient's mental status is depressed and signs of dehydration exist, administer a fluid
challenge of normal saline 20 mL/kg IV or 10 mgkg for neonates (infants less than 1
month).
• If the patient's mental status and respiratory effort are depressed, administer naloxone
(Narcan®) 0.1 mg/kg (maximum dose 2 mg) IV/IO/IM/IN. May repeat every 5 minutes as
needed. (Medical Procedure 4.18, Medication Administration)
�- • If toxicology (poisoning) is suspected, contact the Poison Information Center (1-800-222-
-= 1222)
- r
➢ None
(a) Use appropriate discretion regarding the immediate use of airway adjuncts in pediatric
patients, as they may quickly regain consciousness.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 33
This protocol should be used when the patient has shown continuous convulsions or repeating
episodes without regaining consciousness or sufficient respiratory compensation. Consider an
underlying etiology such as fever, hypoxia, head trauma, infection (e.g., meningitis),
hypoglycemia, electrolyte imbalance, and ingestion/poisoning.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3. Apply gentle support to the patient's head to avoid
trauma, and loosen tight -fitting clothing. (a)
• Perform a glucose test with a finger stick. If glucose is less than 60 mg/dL, refer to
Hypoglycemia/Hyperglycemia Protocol 3.7.2
• If the seizure continues, administer: (Medical Procedure, Medication Delivery 4.18).
o Diazepam (Valium) 0.2mg/kg (maximum dose 5 mg) IV, IO or IN; may repeat once, to
a maximum dose of 10 mg(b)
OR
o Midazolam (Versed®) 0.1 mg/kg, maximum single dose of 4 mg IV/IO. For IN or IM
administration use 0.2mg/kg/dose (use 10mg/2mL concentration), maximum single dose
5 mg; may repeat once if necessary. Maximum total dose 10mg (b)
OR
o Lorazepam (Ativan ®) O.lmg/kg IV or IN, max 2 mg per dose, if no effect after 5
minutes may be repeated once to a maximum total dose of 4 mg (b)
➢ Call for orders for additional benzodiazepine
(a) Providers should not withhold obtaining IV access for fear of not wanting to agitate the
patient.
(b) Administer Benzodiazepines slowly, titrate to effect, and be aware of associated
hypotension.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 34
This treatment protocol is used in conjunction with General Protocol 1.2, Behavioral
Emergencies. There are many reasons for a patient to be impaired or violent such as, psychiatric,
drug overdose, CVA, ETOH, hypoxia and hypoglycemia.
• If the patient is violent and an immediate threat to the patient, EMS crew or bystander safety
exists, chemical and/or physical restraint should be used to prevent patient from harming him /
herself or others.
• If patient is not violent, be observant for possibility of violence and avoid provoking the patient.
• Particular caution should be exercised when evaluating and treating any patient that was subdued
by a "non -lethal" law enforcement device such as pepper spray or taser.
• Typical findings for any violent and/or impaired patient:
o P — Psychological issues
o R — Recent drug / alcohol use
o I — Incoherent thought process
o O — Off (clothes) and sweating
o R — Resistant to presence / dialogue
o I — Inanimate objects / shiny / glass — violent
o T — Tough, unstoppable, superhuman strength
o Y — Yelling
• Excited delirium syndrome is a state in which a person is in a psychotic and extremely agitated
state. Mentally the patient is unable to focus and process any rational thought. The condition i�
brought on by overdose on stimulant or hallucinogenic drugs, drug withdrawal, or psychiatric
patient not taking medication for significant amount of time.
• Typical signs and symptoms to suspect excited delirium are elevated temperature, nudity,
profuse sweating, and change from aggressive behavior to "instant tranquility." These patients
should be closely observed for cardiac and respiratory changes.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care 3.1.3.
• Consult with Law Enforcement about placing the patient under the Baker Act provisions
when appropriate and refer to the Impaired/Incapacitated Persons Act (General Protocol
1.2, Behavioral Emergencies).
• Rule out causes other than psychiatric (e.g., drug overdose, ETOH, head trauma, hypoxia,
hypoglycemia).
• If appropriate, consider physically restraining patient (Medical Procedure 4.23, Restraints).
• Apply Sp02 and administer oxygen to maintain Sp02 greater than or equal to 94%.
• Perform glucose test with finger stick (Medical Procedure 4.17, Glucometer).
• Obtain body temperature.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 35
• If patient has elevated temperature above 100 degrees, consider cooling patient using cold
packs to patient's head, axilla and groin (goal temperature less than 100 degrees).
• Administer benzodiazepines as rapidly and as safely as possible (a) (b). (Medical Procedure
4.18, Medication Administration)
o Diazepam (Valium) 0.2mg/kg (maximum single dose 5 mg) IV, IO or IN; may repeat
once, to a maximum dose of 10 mg (a) (b).
OR
o Midazolam (Versed®) O.lmg/kg, maximum single dose 4 mg IV, IO, IM. For IN
administration use 0.2 mg/kg/dose (use 10 mg/2mL concentration), maximum single
dose 5 mg; may repeat once if necessary. Maximum total dose of 10 mg (a)(b).
OR
o Lorazepam (Ativan ®) O.lmg/kg IV or IN, max 2 mg per dose if not effect after 5
minutes may be repeated once to a maximum total dose of 4 mg (a)(b) .
• Diphenhydramine HCl (Benadryl®) 1 mg/kg (maximum dose 50 mg) IM or SLOW IV. If
administering Benadryl IV dilute in 9mL of normal saline (Medical Procedure 4.18,
Medication Administration).
• Consider Ketamine 4 mg/kg IM, 2mg/kg IN if available if the patient does not respond to
_ benzodiazepine (Medical Procedure 4.18, Medication Administration).
-, - OR
• Administer Haloperidol (Haldol®) 0.1mg/kg IM maximum of 5 mg, if available (a) (c).
• Initiate cardiac monitoring.
• Treat dysrhythmias per specific protocol (Pediatric Protocol 3.3).
• Expedite transport — Transport Code 3 to closest appropriate facility.
➢ None
(a) In some instances, IV administration may present a safety concern; in this case, IM or IN
administration of sedatives may be the more desirable route.
(b) Administer Benzodiazepines slowly, titrate to effect, and be aware of associated hypotension.
(c) Haloperidol (Haldol®) may result in a dystonic reaction if it is administered alone. This effect
can be avoided or reversed with Benadryl. Haloperidol should be used with caution in cases
of suspected overdose, especially cocaine, and its use should be preceded by benzodiazepine
administration.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 36
This protocol is to be used for those patients suspected of exposure to toxic substances via any
route of exposure (e.g., drug overdose, snake bite). Each of the subprotocols gives specific
considerations for each type of exposure as well as general treatment guidelines. Additional
assistance may be necessary in certain cases (e.g., hazardous materials team for toxic exposure;
police for scene control, including the presence of violent and/or impaired patient - see
Pediatric Protocol 3.7.5). Also refer to the Chemical Treatment Guidelines (found in Chapter 7)
as needed.
A history of the events leading to the illness or injury should be obtained from the patient and
bystanders, to include the following information:
1. To which drugs, poisons, or other substances was the patient exposed? Consider
multiple substances, especially on overdoses. Also consider plants and herbal remedies.
2. When did the exposure occur, and how much exposure was there?
3. What is the duration of symptoms?
4. Is the patient depressed or suicidal? Does he/she have a history of previous over -dose?
(if applicable)
5. Was the exposure accidental? What was the nature of the accident?
6. What was the duration of exposure? (if applicable)
Collect all pill bottles - empty or full - and check for a "suicide note" (if applicable). Transport
any/all information or items that may assist in the treatment of the patient to the emergency
department.
Contact the Poison Information Center (1-800-222-1222) for consultation regarding specific
therapy.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 37
This protocol should be used on most types of ingestion /poisoning (e.g., acetaminophen,
benzodiazepines, narcotics, tricyclic antidepressants, vitamins with iron). See Adult Protocol
2.6 for lists of different types of medications. Symptoms vary with the substance involved. Also
refer to the Pediatric Chemical Treatment Guidelines (found in Chapter 7) as needed.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Consider the need for ventilatory support (Medical Procedure 4.1).
• Contact the Poison Information Center (1-800-222-1222).
• Consider the need for use of an airway adjunct device. If an endotracheal tube is used,
attempt to utilize a "cuffed tube" to prevent aspiration.
• Perform a glucose test with a finger stick. If glucose less than 60 mg/dL, refer to
Hypoglycemia/Hyperglycemia Protocol 3.7.2
• If narcotic overdose is suspected in a non -neonate, administer naloxone (Narcan®)
0.1 mg/kg (maximum dose of 2 mg) IV/IO/IM/IN. May repeat every 5 minutes as needed. .
(Medical Procedure, Medication Delivery 4.18)
• If tricyclic antidepressant overdose is suspected, administer Sodium Bicarbonate 1 mEq/kg
IV/IO
➢ None
If the patient is seizing, also see Pediatric Protocol 3.5.2.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 38
This protocol includes the treatment for snake and spider bites, dog and cat bites, insect stings,
and marine animal envenomations and stings. All bite patients should be transported to the
hospital.
• Contact the Poison Information Center (1-800-222-1222).
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
SNAKE BITES
• Consider the need for Pediatric Protocol 3.7.1, Allergic Reactions/Anaphylaxis.
• Splint the affected area. Place the patient in a supine position with the extremities at a
neutral level. Keep the patient quiet. Remove and secure all jewelry.
• Wash the area of the bite with copious amounts of water.
• Attempt to identify the snake, if it is safe to do so.
• Check the temperature and pulse distal to a bite on an extremity, and mark level of swelling
and time with pen every 15 minutes.
DOG, CAT, AND WILD ANIMAL BITES
• Wound care: BLS. Do not use hydrogen peroxide on deep puncture wounds or wounds
exposing fat.
• Advise dispatch to contact animal control and the police department for identification and
quarantine of the animal.
INSECT STINGS (INCLUDING CENTIPEDES, SCORPIONS, AND SPIDERS)
• Consider the need for Pediatric Protocol 3.7.1, Allergic Reactions/Anaphylaxis.
• Remove the stinger by scraping the skin with the edge of a flat surface (e.g., a credit card).
Do not attempt to pull the stinger out, as this may release more venom.
Clean the wound area with soap and water.
HUMAN BITES
• General Protocol 1.12, Personal Exposure to Infectious Diseases.
Wound care: BLS. Do not use hydrogen peroxide on deep puncture wounds or wounds
exposing fat. Clean the wound area with soap and water.
Advise dispatch to contact the police department for possible domestic disturbance.
MARINE ANIMAL ENVENOMATIONS: STINGRAY, SCORPIONFISH (LIONFISH,
ZEBRAFISH, STONEFISH), CATFISH, WEEVERFISH, STARFISH, AND SEA URCHIN
• Consider the need for Pediatric Protocol 3.7.1, Allergic Reactions/Anaphylaxis.
• Immerse the punctures in nonscalding hot water to tolerance (110-113°F) to achieve pain
relief (30-90 minutes). Transport should not be delayed for this purpose; immersion in
nonscalding hot water may be continued during transport.
• Remove any visible pieces of the spine(s) or sheath. Gently wash the wound with soap and
water, and then irrigate it vigorously with fresh water (avoid scrubbing).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 39
MARINE ANIMAL STINGS: JELLYFISH, MAN-OF-WAR, SEA NETTLE,
IRUKANDJI, ANEMONE, HYDROID, AND FIRE CORAL
• Consider the need for Pediatric Protocol 3.7.1, Allergic Reactions/Anaphylaxis.
Rinse the skin with sea water. Do not use fresh water, do not apply ice, and do not rub the
skin.
• Remove any large tentacle fragments using forceps. Use gloves to avoid contact with your
bare hands.
• Refer to Pediatric Protocol 3.1.5 for pain management guidelines.
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 40
The paramedic should use these protocols to guide him/her through the treatment of patients
with other medical emergencies who are exhibiting signs and symptoms. In addition to these
protocols, the paramedic may need to refer to other protocols for continued treatment
4Ih Edition 3/1/2015 Florida Regional Common EMS Protocols 41
This protocol should be used for patients who are exhibiting signs and symptoms consistent
with allergic reaction:
• Skin: flushing, itching, hives, swelling, cyanosis.
• Respiratory: dyspnea, sneezing, coughing, wheezing, stridor, laryngeal edema,
laryngospasm, bronchospasm.
• Cardiovascular: vasodilatation, increased heart rate, decreased blood pressure.
• Gastrointestinal: nausea/vomiting, abdominal cramping, diarrhea.
• CNS: dizziness, headache, convulsions, tearing.
Treatment is outlined according to the severity of the allergic reaction (mild, moderate,
and severe or ananhvlaxisl.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
MILD REACTIONS
Mild reactions consist of redness and/or itching, but normal perfusion without dyspnea.
• For severe itching, administer Diphenhydramine (Benadryl®) 1 mg/kg IM or SLOW IV
(maximum dose 50 mg). If administering Benadryl IV dilute amount in 9mL of normal
saline (Medical Procedure 4.18, Medication Administration).
MODERATE REACTIONS
Moderate reactions are characterized by edema, hives, dyspnea, wheezing, and normal
perfusion (Medical Procedure 4.18, Medication Administration).
• Epinephrine (1:1000) 0.01 mg/kg IM lateral thigh (maximum dose of 0.3 mg) (a).
• Diphenhydramine (Benadryl®) 1 mg/kg IlVI lateral thigh or SLOW IV (maximum dose of
50 mg). If administering Benadryl IV dilute amount in 9 mL of normal saline.
• Albuterol (Ventolin ): If the patient remains in respiratory distress, administer one
nebulizer treatment.
o If less than 1 year or less than 10 kg: 1.25 mg/1.5 mL (0.083%).
o If greater than 1 year or greater than 10 kg: 2.5 mg/3 mL (0.083%).
SEVERE REACTIONS
Severe reactions are characterized by edema, hives, severe dyspnea and wheezing, poor
perfusion, and possible cyanosis and laryngeal edema. Consider the need for immediate
incubation. (Medical Procedure 4.18, Medication Administration).
• Epinephrine (1:1000) 0.01 mg/kg IM lateral thigh (maximum dose of 0.3 mg) (a).
• Diphenhydramine (Benadryl®) 1 mg/kg IM lateral thigh or SLOW IV (maximum dose of
50 mg). If administering Benadryl IV dilute amount in 9 mL of normal saline.
• Albuterol (Ventolin®): If patient remains in respiratory distress, administer 1 nebulizer
treatment.
o If less than 1 year or less than 10 kg: 1.25 mg/1.5 mL (0.083%).
o If greater than 1 year or greater than 10 kg: 2.5 mg/3 mL (0.083%).
• If bronchodilators are administered, may add Ipratropium Bromide (Atrovent®) 0.5 mg (2.5
mL) to either Albuterol nebulizer treatment for the first nebulizer treatment only.
• May repeat Epinephrine (1:1000) 0.01 mg/kg IM lateral thigh.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 42
MILD REACTIONS: Epinephrine (1:1000) 0.01 mg/kg IM lateral thigh (max dose 0.3 mg)
MODERATE REACTIONS: None
SEVERE REACTIONS: Consult Medical Direction for further orders.
(a) The EpiPeri (greater than 8 yrs) or EpiPen Jr (1-8 yrs) may be used if other means of
Epinephrine administration are not available.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 43
This protocol is to be used for those patients whose blood glucose is less than 60 mg/dL (see
Pediatric Protocol 3.4.1 for newborn guidelines). Consider medication errors, overdoses,
accidental ingestions, and other factors related to etiology. Look for pill bottles.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Perform a glucose test with a finger stick.
• If the child is above 3 years of age and the patient is conscious with an intact gag reflex,
administer oral glucose 15 g (1 tube), if possible.
• For neonates (infants less than 1 month) with blood glucose of less than 40 mg/dL
administer D10 5 mL/kg IV/IO (b).
• If glucose less than 60 mg/dL, administer:
o If 1 month-1 year: Dio 5 mL/kg IV/IO (b).
o If 1- 8 years: D25 2 mL/kg IV/IO (a).
o If greater than 8 years: D50 1 mL/kg IV/IO (Medical Procedure 4.17, Glucometer) (a).
o If unable to obtain IV/IO access provide Glucagon IM as follows: (Medical Procedure
4.18, Medication Administration)
IJ Patient less than or equal to 20 kg: 0.5 mg IM
IJ Patients greater than 20 kg: 1 mg IM
• Repeat a glucose test with a finger stick. If glucose less than 60 mg/dL, administer dextrose
dosing above.
➢ None
(a) To avoid infiltration and resultant tissue necrosis, dextrose 25% and 50% should be given
via slow IV with intermittent aspiration of the IV line to confirm IV patency, followed by
saline flush.
(b) Dilute D501:4 with normal saline to make Dio.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 44
To enhance patient comfort and safety, the treatment of nausea and vomiting may be
appropriately accomplished in the field. The symptoms of nausea and vomiting may occur as a
result of acute illness or as a medication side effect
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
Administer Zofran® (Ondansetron hydrochloride) (Drug Summary 5.37)
Oral
Less than 20 kg: Do NOT administer
20 kg - 39 kg (5-11 year): 4 mg oral disintegrating tablet (ODT) placed under the tongue.
Dose may not be repeated
40 kg or more (12 year or older): 4 mg oral disintegrating tablet (ODT) placed under the
tongue. May repeat at 10-15 minutes with maximum dose of 8 mg
Injection
Less than 40 kg: 0.1 mg/kg SLOW IV push over 2-3 minutes or IM (Medical Procedure
4.18, Medication Administration). Do not repeat.
40 kg or more: 4 mg SLOW IV push over 2-3 minutes or IM (Medical Procedure 4.18,
Medication Administration). May be repeated once if no improvement within 30 minutes. Do
not exceed 8 mg total dosage.
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 45
This protocol should be used for patients who complain of abdominal pain without a history of
trauma (refer to Appendix 6.2.2 Signs of Child Abuse). Assessment should include specific
questions pertaining to the GFGU systems.
Abdominal physical assessment:
• Ask patient to point to the area of pain (palpate this area last).
• Gently palpate for tenderness, rebound tenderness, distention, rigidity, guarding, and
pulsatile masses. Also palpate the flank for CVAT (costovertebral angle tenderness).
• Abdominal history:
• History of pain (OPQRRRST).
• History of nausea/vomiting (color, bloody, coffee grounds, dark bilious).
• History of bowel movement (last BM, diarrhea, bloody, tarry).
• History of urine output (painful, dark, bloody).
• History of abdominal surgery.
• History of medication ingestions.
• SAMPLE history (pay attention to last meal).
Additional questions should be asked of the female adolescent patient regarding OB/GYN
history (Adult Protocol 2.7, Adult OB/GYN Emergencies).
An acute abdomen can be caused by appendicitis, diabetic ketoacidosis, incarcerated hernia,
intussuception, cholecystitis, cystitis-UTI (bladder inflammation), duodenal ulcer, diverticulitis,
abdominal aortic aneurysm, kidney infection, urinary tract infection (UTI), kidney stone, pelvic
inflammatory disease (PID; female), or pancreatitis (Appendix 6.1, Abdominal Pain
Differential).
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 46
Most chest pains in children are non -cardiac related. Causes of nontraumatic chest pain in the
pediatric patient include wheezing -associated illness, spontaneous pneumothorax, pleurisy,
costochondritis, pulmonary embolism, pneumonia, peptic ulcer, drug usage (e.g., stimulants
cocaine), dissecting aortic aneurysm, pericarditis, hiatal hernia, esophageal spasm,
cholecystitis, pancreatitis, cervical disk problem, and, rarely, cardiac problems (see Appendix
6.5, Chest Pain Differential). Also refer to Appendix 6.2.2, Signs of Child Abuse.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Consider the need for other protocols (e.g., Pediatric Protocol 3.2, Pediatric Respiratory
Emergencies).
➢ None
• Consider pain control management (Pediatric Protocol 3.1.5 for pain scale and medication
dosage —same as isolated extremity fracture pain control).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 47
This protocol should be used when the paramedic suspects that child abuse may have occurred.
See Appendix 6.2.2, Signs of Child Abuse, and Appendix 6.2.1, Report of Abuse. Child abuse
is when a person intentionally inflicts, or allows to be inflicted, physical or psychological injury
to a child, which causes or results in risk of death, disfigurement, or distress. Child neglect is
when a child's physical, mental, or emotional condition is impaired or endangered because of
failure of the legal guardian to supply basic necessities, including adequate food, clothing,
shelter, education, or medical care.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
• Advise police that child abuse is suspected.
• Protect the child from further abuse.
• Obtain information in a nonjudgmental manner.
• Do not confront the caregiver and/or parent.
• Transport the patient to the hospital for evaluation and possible treatment (a).
• Report suspected child abuse —Florida Child Abuse Hotline: 1-800 -96 ABUSE
(1-800-962-2873)(b) (Appendix 6.2.1 Report of Abuse and Appendix 6.2.2 Signs of Abuse)
• None
➢ None
(a) If the parent refuses to have the pediatric patient transported to a hospital, request police
assistance.
(b) Reporting of suspected child abuse is required by law.
Multiple bruises or injuries that are in different stages of healing are concerns for abuse
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 48
Sickle cell anemia is a chronic hemolytic anemia occurring frequently in African Americans
and Hispanics; it is characterized by sickle -shaped red blood cells. Sickle cell crisis results from
the occlusion of a blood vessel by masses of sickle -shaped red blood cells. Pain is the principal
manifestation— it represents the most common type of crisis. This pain typically occurs in the
patient's joints and back. Hepatic pulmonary or central nervous system involvement can occur,
with each manifestation having its own group of symptoms. Patients with sickle cell disorder
have a high incidence of life threatening disorders at a very young age.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Provide emotional support.
Administer a fluid challenge of normal saline 20mL/kg or 10 mL/kg for neonates (infants
less than 1 month) IV.
If pain persists and systolic BP is adequate (Appendix 6.16, Pediatric Vital Signs): (Medical
Procedure, Medication Delivery 4.18)
o Morphine Sulfate -maybe given IV titrated to pain, pediatric dose: 0.1 mg/kg; infant dose:
0.05 mg/kg. Maximum single dose of 4 mg. If pain persists and systolic BP is adequate,
may repeat dose x 1 in 3-5 minutes, (repeat single dose maximum of 4 mg). Administer at a
rate not to exceed 1 mg/min (a). (Appendix 6.16, Pediatric Vital Signs).
OR
o Fentanyl 0.5 mcg/kg (maximum 25 mcg) SLOW IV; repeat once after 5 minutes as
needed (max 50 mcg total dose) OR IN 1.5 mcg/kg (max 100 mcg)
➢ None
(a) Extreme caution should be used with administering narcotic analgesics to a patient with a
SP02 less than 94%.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 49
The following protocols cover a range of problems related to the environment, including
trauma due to changes in atmospheric pressure, exposure to heat and cold extremes, water
submersion, and exposure to electricity. Initial management efforts should focus on removing
the patient from the harmful environment.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 50
Drowning is a process resulting in primary respiratory impairment from submersion in a liquid
medium. Implicit to this definition, is that a liquid -air interface is present at the entrance to the
victim's airway, which prevents the individual from breathing oxygen. Outcome may include
delayed morbidity or death, or life without morbidity. The terms wet drowning, dry drowning,
active or passive drowning, near -drowning, secondary drowning and silent drowning should be
discarded. The proper terms should be fatal drowning, or non -fatal drowning.
If the patient is still in open water upon arrival of EMS crew members, a Dive Rescue Team
should be used to remove the patient from the water whenever possible. Additional protocols
may be needed for treatment decisions (e.g., Pediatric Protocol 3.8.4, Barotrauma/
Decompression Illness: Dive Injuries). Drownings are not Trauma Alerts, unless there is specific
traumatic component associated with the event.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4: protect the c-spine (a).
• Determine any pertinent history (duration of submersion, depth, water temperature, possible
seizure, drug and/or alcohol use, possible trauma).
• Maintain the patient's body temperature; dry and warm the patient.
• All non -fatal drowning patients should be transported to the hospital, regardless of how
well they may seem to have recovered. Delayed death or complications due to pulmonary
edema or aspiration pneumonia are not uncommon. The most devastating injury is the result
of asphyxia.
• Treat dysrhythmias per specific protocol (Pediatric Protocol 3.3).
➢ None
(a) The routine use of chest thrusts for a drowning, non -fatal patient is not recommended. This
maneuver should be used only in cases of FBAO.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 51
Hyperthermia occurs when the patient is exposed to increased environmental temperature. It
can manifest as heat cramps, heat exhaustion, or heat stroke. Certain drugs may also cause an
increase in body temperature (e.g., cocaine, ecstasy).
Some tympanic thermometers (e.g., Braun ThermoscanTM Pro-1 and Pro 3000) will register
temperatures in the range of 68-108°F. Tympanic thermometers should not be used in infants
less than 1 year.
• Heat cramps: Signs and symptoms include muscle cramps of the fingers, arms, legs, or
abdomen; hot, sweaty skin; weakness; dizziness; tachycardia; normal BP; and normal
temperature.
• Heat exhaustion: Signs and symptoms include cold and clammy skin, profuse sweating,
nausea/vomiting, diarrhea, tachycardia, weakness, dizziness, transient syncope, muscle
cramps, headache, positive orthostatic vital signs, and normal or slightly elevated
temperature.
• Heat stroke: Signs and symptoms include hot dry skin (sweating may be present), confusion
and disorientation, rapid bounding pulse followed by slow weak pulse, hypotension with
low or absent diastolic reading, rapid and shallow respirations (which may later slow),
seizures, coma, and elevated temperature (greater than 105°F).
HEAT CRAMPS AND HEAT EXHAUSTION
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Remove the patient from the warm environment; cool the patient.
• Monitor the patient's temperature.
For mild to moderate heat cramps and heat exhaustion, if the patient is conscious, encourage
the patient to drink salt -containing fluids.
HEATSTROKE
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• Remove the patient from the warm environment; aggressively cool the patient. Remove the
patient's clothing, and cover the patient with sheets soaked in ice water. Also, turn air-
conditioning units and fans on high, and apply ice packs to the patient's head, neck, chest,
and groin.
• Monitor the patient's temperature. Cool the patient to 102 °F, then remove wet sheets and
ice packs, and turn off fans (avoid lowering the patient's temperature too much).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 52
HEAT CRAMPS AND HEAT EXHAUSTION
If heat cramps are severe or if the patient's level of consciousness is diminished, administer
a fluid challenge of normal saline 20 mL/kg IV or 10 mVkg for neonates (infants less than 1
month) IV or IO. (Medical Procedure 4.18, Medication Administration).
HEATSTROKE
• Treat hypotension with IV fluids. Avoid using vasopressors and anticholinergic drugs, as
they may potentiate heat stroke by inhibiting sweating. Administer a fluid challenge of
normal saline 20 mL/kg IV or 10 mVkg for neonates (infants less than 1 month) IV or IO.
(Medical Procedure 4.18, Medication Administration).
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 53
Factors that predispose and/or cause a patient to develop hypothermia include geriatric and
pediatric age, poor nutrition, diabetes, hypothyroidism, brain tumors or head trauma, sepsis, use
of alcohol and certain drugs, and prolonged exposure to water or low atmospheric temperature.
Hypothermia patients can be classified into three categories:
• Mild hypothermia: temperature 94-97 17.
• Moderate hypothermia: temperature 86-94°F.
• Severe hypothermia: temperature less than 86°F.
Most oral thermometers will not register temperatures of less than 96°F. However, some
tympanic thermometers (e.g., Braun ThermoscanTM Pro-1 and Pro 3000) will register
temperatures in the range of 68-108°F. Tympanic thermometers should not be used in infants
less than 1 year.
Patients with mild to moderate hypothermia will generally present with shivering, lethargy, and
stiff, uncoordinated muscles. Patients with severe hypothermia may have altered mental status,
ranging from confusion to lethargy or coma. Shivering will usually stop and physical activity
will be uncoordinated. In addition, severe hypothermia will frequently produce an Osborn wave
or J wave on the ECG, as well as dvsrhvthmias (bradvcardia, ventricular fibrillation).
•
Initial Assessment Protocol 3.1.1
a •
Medical Supportive Care Protocol 3.1.3 (a).
•
Remove all wet clothes; dry the patient.
•
Protect the patient from heat loss and wind chill.
•
Maintain the patient in a horizontal position.
•
Avoid rough movement and excess activity.
•
Monitor the patient's temperature.
•
Add heat to the patient's head, neck, chest, and groin.
•
In cases of severe hypothermia, warm IV fluids, if possible.
•
For severe hypothermic cardiac arrest: - Start CPR.
•
For VF or pulseless VT, see Pediatric Cardiac Dysrhythmia Protocol 3.3.6.
•
Insert an advanced airway and ventilate the patient with warm humidified oxygen, if
possible. (Procedure Section 4.4)
•
Establish IV access; give warm normal saline.
•
If temperature is greater than 86°F: follow the appropriate dysrhythmia treatment (Pediatric
Protocol 3.3).
•
If temperature is less than 86°F: continue CPR and transport the patient immediately. Do
not treat dysrhythmias in patients with severe hypothermia; warm the patient prior to
treatment.
➢
None
Note (a)
Areas of frostbite should be bandaged with dry sterile dressings. Patients with frostbite
should be transported without attempting rewarming in the prehospital setting.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 54
Barotrauma and decompression illness are caused by changes in the surrounding atmospheric
pressure beyond the body's capacity to compensate for the excess gas load. These injuries are
most commonly associated with the use of SCUBA (Self -Contained Underwater Breathing
Apparatus). SCUBA diving emergencies can occur at any depth, with the most serious injuries
manifesting symptoms after a dive. If a patient took a breath underwater from any source of
compressed gas (e.g., submerged vehicle, SCUBA), while at a depth greater than 3 feet, the
patient may be a victim of barotrauma. Barotrauma may cause several injuries to occur,
including arterial gas embolism (AGE), pneumothorax, pneumomediastinum, subcutaneous
emphysema, and the "squeeze." Decompression illnesses may also include decompression
sickness ("bends").
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4: Give high -flow 02.
• Place the patient in a supine position.
• Complete the Dive Accident Signs and Symptoms checklist (Appendix 6.7).
• Start a Dive History Profile, if possible (the patient's dive buddy may be helpful in
answering many of these questions).
• Whenever possible, have the legal authority in charge (e.g., police, Florida Marine Patrol,
U.S. Coast Guard) secure all of the victim's dive gear, following the proper chain of
custody for testing, analysis, and other purposes.
• Manage the patient according to the appropriate protocol(s).
• Transport the patient to the closest emergency department or trauma center with a helipad.
Air transport of a diving accident victim must remain below an altitude of 1000 feet.
• Contact the Diver's Alert Network (DAN) at Duke University Medical Center for further
assistance; call DAN collect at 919-684-4326 (a).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 55
A wide range of injuries can be caused by a lightning strike or contact with electricity.
Electrical injury can occur from direct contact, an arc, or a flash of electricity, and by a direct
hit or a splash from lightning. The movement of electrical current through the body can cause
violent muscle contractions that can lead to fractures; for this reason, the c-spine of a patient
who has experienced an electrical emergency should be protected. The thermal energy can
cause external burns, but in many cases the majority of thermal damage is internal, with few
external signs of injury. Dysrhythmias are also common (e.g., ventricular fibrillation). The
rescuer should be sure that the patient is no longer in contact with the electrical current before
initiating treatment.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4: Protect the c-spine.
• Treat burns per Pediatric Protocol 3.9.7.
• Consider the need to transport the patient to a trauma center (General Protocol 1.10).
• Try to determine the amps, volts, and duration of contact with the electricity, if possible.
(500 volts or more should be categorized as high voltage).
• Treat dysrhythmias per specific protocol (Pediatric Protocol 3.3).
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 56
These protocols cover specific types of injuries and their treatment. The initial assessment of
the trauma patient should include determination of Trauma Alert criteria (General Protocol
1.10, Trauma Transport). When the situation demands it (e.g., when Trauma Alert criteria are
met), scene time should be limited as much as possible (e.g., 10 minutes), and the patient
should be expeditiously transported to a trauma center. Do not delay transport to establish
vascular access or to bandage and splint every injury. Priority should be given to airway
management, rapid preparation for transport (e.g., full immobilization on a backboard), and
control of gross hemorrhage.
If a vascular access is obtained and hypovolemia is suspected (e.g., the patient shows signs and
symptoms of shock), a fluid challenge of 20 mL/kg or 10 ml/kg for neonates (infants less than 1
month) should be administered. If the patient is still in shock, repeat the fluid challenge at 20
mL/kg until a maximum of 60 mL/kg of fluid is administered.
Be aware that administration of large volumes of IV fluids has been found to be deleterious to
the survival of patients with uncontrolled hemorrhage, internally or externally. Studies (NEJM,
1994) have shown that maximal fluid resuscitation may increase bleeding, thereby preventing
the formation of a protective thrombus or dislodging it once the intraluminal pressure exceeds
the tamponading pressure of the thrombus. Therefore, consultation with the physician should be
made prior to the administration of large volumes of IV fluids when the transport time is
relatively short (e.g., less than 20 minutes).
Avoid the use of vasopressor agents (e.g., dopamine) in trauma patients who are hypotensive
(Appendix 6.16, Pediatric Vital Signs). The adolescent female in her second or third trimester
of pregnancy should be placed on her left side for transport. If the injuries require the use of a
backboard, following full immobilization to the backboard, the backboard should be tilted to
the left. Failure to follow this practice may cause hypotension due to decreased venous return.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 57
If history, symptoms, or signs of head or spinal injuries are present, manually immobilize the
patient's head and neck while maintaining a patent airway using a modified jaw -thrust method.
Immobilization of the entire spine is indicated following initial stabilization.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
• If the patient is not hypotensive (Appendix 6.16, Pediatric Vital Signs), elevate the head of
the backboard 30 degrees (12-18 inches).
• Apply a hemostatic gauze on severe wounds to the head, neck, face, axilla, or buttocks that
cannot be controlled by other means (direct pressure) Medical Procedure Hemostatic Gauze
4.27.1
• If signs of brain stem herniation exist (e.g., pupillary dilation, asymmetric pupillary
reactivity, or motor posturing), consider advanced airway and ventilate at 20 breaths/min
for a child and 30 breaths/min for an infant (Medical Procedure 4.4, Advanced Airways,
and Medical Procedure 4.1.5, Rescue Breathing).
• If the patient is seizing, see Pediatric Protocol 3.5.2. Avoid administration of glucose -
containing solutions and medications.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 58
This protocol covers a variety of injuries to the eye. If other injuries to the body exist, priority
of care should be determined as appropriate.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4:
• Establish IV access as needed.
• Remove, or ask the patient to remove, contact lenses, if still in the affected eye(s).
• For a penetrating object, stabilize the object and cover the affected eye with an ocular shield
or similar rigid device. Cover both eyes to minimize eye movement. Avoid placing direct
pressure on the eye or penetrating object.
• If the eyeball has been forced out of the socket, cover the entire eye area with a rigid
container, such as a disposable drinking cup. Avoid contact with the exposed globe. If
bleeding is present, control it by applying direct pressure with a sterile dry dressing.
• If there are signs and symptoms or suspicion of ocular exposure to chemicals or foreign
body, without obvious or suspected penetrating injury or laceration of the cornea or globe,
irrigate with a normal saline IV solution (Medical Procedure 4.19, Morgan Lens).
• If the patient is experiencing eye pain, administer tetracaine 1 drop in each affected eye.
Tetracaine is contraindicated in penetrating eye injuries or patients with allergies to
lidocaine.
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 59
This protocol covers both blunt and penetrating chest trauma and should be part of the initia
resuscitation effort if the patient's breathing is compromised.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
• Penetrating injuries to the chest or upper back should be covered immediately with an
occlusive dressing (e.g., Vaseline gauze).
Do not attempt to remove an impaled object; instead, stabilize it with bulky dressing or other means
If the impaled object is very large or unwieldy, attempt to cut the object to no less than 6 inches
from chest.
• For tension pneumothorax with evidence of respiratory and circulatory compromise,
decompress the chest on the affected side (Medical Procedure 4.8, Chest Decompression).
• For massive flail chest with severe respiratory compromise, ventilate at 20 breaths/min for a
child and 30 breaths/min for an infant consider advanced airway. If the flail chest does not
cause severe respiratory compromise, stabilize the chest externally by placing the ipsilateral
-- arm in a sling and swathe.
-' • For crush/compartment injury, refer to Protocol 3.9.8, Crush/Compartment Syndrome.
- r
is
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 60
This protocol covers blunt and penetrating abdomino-pelvic trauma. Penetrating injuries may
General also affect the chest (Pediatric Protocol 3.9.3, Chest Injuries, also refer to Appendix 6.2.2,
Guidelines Signs of Child Abuse).
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
• For penetrating injuries, cover the wound with an occlusive dressing (e.g., Vaseline gauze).
• For evisceration, cover the organs with a saline -soaked sterile dressing, and then cover it
with an occlusive dressing (e.g., foil). Do not attempt to put the organs back into the
abdomen.
• Do not log -roll any patient with suspected pelvic fracture; you may use a scoop stretcher if
it is appropriate given the patient's size.
• None
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 61
This protocol covers open and closed injuries to the extremities, including amputation.
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
• Any fracture or suspected fracture should be splinted appropriately, with ice being applied
to the affected area. Remove and secure all jewelry. Check the pulse, motor and sensation,
in the extremity before and after splinting.
• Angulated fractures should be aligned using proximal and distal traction during splinting,
except in fractures that involve a joint, which should be splinted in the position in which
they are found.
• Traction splints should be used in cases of femur fractures, unless a pelvic fracture is
suspected.
• Amputations should be dressed with bulky dressings. The amputated part should be
wrapped in moistened sterile gauze and placed in a plastic bag; this bag should then be
placed on ice for transportation to the hospital.
• Apply direct pressure for hemorrhage control. If direct pressure does not stop the hemorrhage
apply a trauma tourniquet (Medical Procedure Wound Care Trauma Tourniquet 4.27.2).
• Apply a hemostatic gauze on severe wounds(head, neck, face, axilla or buttocks) that cannot
be controlled by other means (direct pressure/tourniquet) Medical Procedure Hemostatic
Gauze 4.27.1
`_ • If pain persists and systolic BP is adequate (Appendix 6.16, Pediatric Vital Signs): (Medical
procedure 4.18.3, 4.18.5)
o Morphine Sulfate - may be given IV titrated to pain, pediatric dose: 0.1 mg/kg; infant
- dose: 0.05 mg/kg. Maximum single dose of 4 mg. If pain persists and systolic BP is
_.: adequate, may repeat dose x 1 in 3-5 minutes, (repeat single dose maximum of 4 mg).
_ Administer at a rate not to exceed 1 mg/min (a). (Appendix 6.16, Pediatric Vital Signs).
OR
o Fentanyl 0.5 mcg/kg (maximum 25 mcg) SLOW IV; repeat once after 5 minutes as
needed (max 50 mcg total dose) OR IN 1.5 mcg/kg (max 100 mcg).
(a) Extreme caution should be used with administering narcotic analgesics to a patient with a
SP02 less than 94%.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 62
The decision to attempt resuscitation of a patient in traumatic arrest should be based on the
paramedic's judgment as to the possibility of survival and/or the possibility of organ harvest. In
some instances, attempted resuscitation of a traumatic arrest is not warranted (General Protocol
1.4, Death in the Field).
• Initial Assessment Protocol 3.1.1
• Trauma Supportive Care Protocol 3.1.4.
• Rapidly prepare the patient for transport and then expeditiously transport the patient to the
trauma center.
• If IV access can be established, infuse normal saline 20 mL/kg, (newborn IOmL/kg) up to a
maximum of 60 mL/kg IV.
Avoid use of vasopressors in cases of suspected hypovolemia
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 63
Burns can be caused by thermal, chemical, and electrical sources. If an electrical burn is suspected,
also see Pediatric Protocol 3.8.5, Electrical Emergencies. Remember that burn patients are volume
depleted. Burns do not bleed, however, so look for other sources if bleeding is present. Assume that
any patient with compromised perfusion has other injuries and treat him/her accordingly.
Many burn injuries are associated with inhalation injury. Signs and symptoms of inhalation injury
include nasal and oropharyngeal burns, charring of the tongue or teeth, sooty (blackened) sputum,
singed nasal and facial hair, abnormal breath sounds (e.g., stridor, rhonchi, wheezing), and
respiratory distress. In cases of inhalation injury, attention should be given to the patency of the
airway. Acute swelling can cause an airway obstruction. The paramedic should consider the need
for early intubation to avoid a complete airwav obstruction that requires a cricothvroidotomv.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 64
Crush injuries are rarely seen in pre -hospital medicine but are common in times of disaster, both
natural and manmade. Early and aggressive treatment of victims suspected of having a crush
injury is paramount. Without aggressive pre -hospital treatment, the victim may die during
extrication or weeks later from complications of the injury.
In the crush injury syndrome, the initial injury is at the site of the muscle crushed by the
mechanical force of an object. The muscle cells die as the result of the following. First, the force
of the crushing object ruptures muscle cells. Second, the direct pressure of the object on the limb
causes muscle cells to become ischemic. The combination of mechanical force and ischemia can
cause muscle death within an hour. Third, the force of the crush injury compresses large vessels,
resulting in the loss of blood supply to muscle tissue. Muscles can normally survive circulatory
ischemia for up to four hours before the cell death. After four hours, the cells begin to die as a
result of the circulatory compromise.
The damaged muscle tissue produces and releases many toxins that can have detrimental effects
on the body. The longer the victim is trapped, the longer the toxins are given to build up distal
to the crush site. The crushing force acts as a dam that prevents these toxins from being released
into the rest of the body. Once the force is removed, the toxins are allowed to run freely
throughout the body, causing a myriad of problems. Along with the release of toxins after
extrication, the victim can become severely hypovolemic from the third spacing of fluid, and the
rapid swelling of the injured area can cause acute compartment syndrome
Toxins Released by Damage
Muscle Tissue
Toxin
Effect
Histamine
Vasodilitation and Bronchoconstriction
Lactic Acid
Acidosis and dysrhythmias
Nitric Oxide
Vasodilitation
Potassium
Hyperkalemia
Thromboplastin DIC
TPXATMENT GUIDELINES
Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Spinal immobilization
• Apply cardiac monitor: Document rhythm
• Administer oxygen according to following criteria:
o SPO2 94% or above do not administer 02.
o SP02 less than 94% administer Oz by nasal cannula at 2 L/min.
• Rapidly prepare the patient for transport and then expeditiously transport the patient to the
trauma center.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 65
E
CRUSH INJURY or COMPARTMENT SYNDROME
• Establish IV access; give Normal Saline 1 Liter.
• Pain management: If patient is normotensive (systolic BP greater than 90 mm Hg),
administer
o Morphine Sulfate - may be given intravenously in increments every 3-5 minutes, titrated
to pain, to a maximum dose of 4 mg. Administer at a rate not to exceed 1 mg/min.
Pediatric dose: 0.1 mg/kg IV. Infant dose: 0.05 mg/kg IV (a).
OR
o Fentanyl 0.5 mcg/kg (maximum 25 mcg) SLOW IV; repeat once after 5 minutes as
needed (max 50 mcg total dose) OR IN 1.5 mcg/kg (max 100 mcg)
• For crush injury release compression and extricate patient
CRUSH SYNDROME
If unable to release compression and situation progresses to CRUSH SYNDROME
• Entrapment with compression lasting longer than 4 hours OR on the thorax for 20
minutes.
• Suspicion of hyperkalemia (Peaked T-waves, absent P waves or widened QRS).
• Establish IV access, 2 large bore IVs recommended in order to separate CaCL and Bicarb;
• Pain management: If patient is normotensive (systolic BP greater than 90 mm Hg),
administer
o Morphine Sulfate - may be given IV titrated to pain, pediatric dose: 0.1 mg/kg; infant
dose: 0.05 mg/kg. Maximum single dose of 4 mg. If pain persists and systolic BP is
adequate, may repeat dose x 1 in 3-5 minutes, (repeat single dose maximum of 4 mg).
Administer at a rate not to exceed 1 mg/min.
OR
o Fentanyl 0.5 mcg/kg (maximum 25 mcg) SLOW IV; repeat once after 5 minutes as
needed (max 50 mcg total dose) OR IN 1.5 mcg/kg (max 100 mcg)
• Calcium Chloride 20mg/kginto 50 mL bag of normal saline and administer SLOW IV over
10 minutes (follow with minimum of 20 mL flush).
• Sodium Bicarbonate and Normal Saline —Add Sodium Bicarbonate 50 mEq to 1 L of Normal
Saline (or alternatively sodium bicarbonate 25 mEq added into 500 ML of normal saline).
Infuse via IV wide-open just prior to extrication. May repeat x 1 for prolonged extrication.
Recommended in second line.
• Continue IV fluids at 500 mL/hr
• Administer Albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Albuterol
premixed with 2.5 mL normal saline (Medical Procedure 4.18.6).
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 66
These protocols cover specific types of special healthcare needs in pediatric patients. Children
with special health care needs are those who have or are at risk for chronic physical,
developmental, behavioral, and emotional conditions that necessitate use of health and related
services of a type or amount not usually required by typically developing young children.
The general approach to children with special healthcare needs includes the following
measures:
1. Priority is given to the CABS.
2. Do not be overwhelmed by the machines.
3. Listen to the caregiver.
4. If a nurse is present, rely on his/her judgment.
5. Remember that the child's cognitive level of function may be altered.
6. Assume that the child can understand exactly what you say.
7. Bring all medications and equipment to the hospital.
Obtaining a history includes asking the patient/caregiver about the following issues:
1. The child's normal vital signs.
2. The child's actual weight.
3. The child's developmental level.
4. The child's allergies, including to latex.
5. Pertinent medications/therapies.
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 67
Home mechanical ventilators may be indicated for chronically ill children with abnormal
respiratory drive, severe chronic lung disease, or severe neuromuscular weakness. Some
children require continuous mechanical ventilation, whereas others require only intermittent
support during sleep or acute illness. Home ventilators may either be limited or pressure
limited. All are equipped with alarms.
TYPES OF VENTILATOR ALARMS
• Low pressure or apnea: may be caused by a loose or disconnected circuit or an air leak in
the circuit or at the tracheostomy, resulting in inadequate ventilation.
• Low power: caused by a depleted battery.
• High pressure: may be caused by a plugged or obstructed airway or circuit tubing, by
coughing, or by bronchospasm.
• Setting error: caused by ventilator settings that exceeds the capacity of the equipment.
• Power switchover: occurs when the unit switches from alternating -current power to the
internal battery.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• If a ventilator -dependent child is in respiratory distress and the cause is not easily
ascertained and corrected, remove the ventilator and provide assisted manual ventilations
with a bag -valve device. Suction as needed.
• Consider the need for other protocols (e.g., Pediatric Respiratory Emergencies Protocol
3.2).
• None
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 68
Tracheostomies are indicated for long-term ventilatory support, to bypass an upper airway
obstruction, and to aid in the removal of secretions. Tracheostomies come in neonatal,
pediatric, and adult sizes and can include either a single lumen or a double lumen. Special
attachments include a tracheostomy nose (filtration device), tracheostomy collar (for oxygen or
humidification), and Passy-Muir valve (speaker valve).
SIGNS OF TRACHEOSTOMY TUBE OBSTRUCTION
• Excess secretions.
• No chest wall movement.
• Cyanosis.
• Accessory muscle use.
• No chest wall rise with bag -valve ventilations.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• If an obstruction is present, inject 1-3 mL of normal saline into the tracheostomy tube and
suction as needed (set the suction pressure at 100 mm Hg or less).
• If unable to clear the obstruction by suctioning, remove the tracheostomy tube and insert a
new tube (the same size or one size smaller). Do not force the tube.
• If unable to insert a new tracheostomy tube or if one is unavailable, insert an endotracheal
tube of similar size into the stoma and ventilate with a bag -valve mask as needed.
• If unable to insert an endotracheal tube, ventilate with a bag -valve mask over the stoma or
over the patient's mouth while covering the stoma as needed.
• Consider the need for other protocols (e.g Pediatric Respiratory Emergencies Protocol 3.2).
• None
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 69
Central venous lines are indicated for administration of medications, delivery of chemotherapy,
nutritional support, infusion of blood products, and blood draws. Types of central venous lines
(CVL) include Broviac/Hickman, Port-a-Cath/ Med-a-Port, and percutaneous intravenous
catheters (PIC). Central venous line emergencies include the catheter coming completely out,
bleeding at the site, the catheter broken in half, blood embolus, thrombus, air embolus, and
internal bleeding. Use of SQ ports requires special training; these ports should not be used for
IV access.
SIGNS OF BLOOD EMBOLUS, THROMBUS, AIR EMBOLUS, AND INTERNAL
BLEEDING
• Chest pain.
• Cyanosis.
• Dyspnea.
• Shock.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3. CVL and PIC lines may be used for emergency IV
access under sterile conditions.
• If the catheter has come completely out, apply direct pressure to the site.
• If there is bleeding at the site, apply direct pressure.
• If the catheter is broken in half, clamp the end of the remaining tube.
• If a blood embolus, thrombus, or internal bleeding is suspected, clamp the line.
• If an air embolism is suspected, clamp the line and place the patient on his/ her left side.
• Consider the need for other protocols (e.g., Pediatric Protocol 3.2, Pediatric Respiratory
Emergencies).
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 70
Feeding tubes are indicated for administration of nutritional supplements and in patients who
have an inability to swallow. Types of feeding tubes include nasogastric tubes (temporary) and
gastrostomy tubes (G tube). Types of G tubes include those that are surgically placed,
percutaneous endoscopic gastrostomy tubes (PEG tubes), and jejunal tubes (J tubes). Potential
complications include leaks, bleeding around the site, and the displacement of the tube.
• Initial Assessment Protocol 3.1.1
• Medical Supportive Care Protocol 3.1.3.
• If the catheter has come completely out, cover the site with Vaseline gauze and apply direct
pressure to the site.
• If there is bleeding at the site, apply direct pressure.
• None
➢ None
41h Edition 3/1/2015 Florida Regional Common EMS Protocols 71
Florida Regional Common
EMS Protocols
Section 4
Procedure Section
4th Edition, Version 2, March 1, 2015
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols
Procedure Section Table of Contents
4.1 Basic Life Support
4.1.1 Automated External Defibrillator (AED)
4.1.2 Cardiopulmonary Resuscitation (CPR)
4.1.3 Head Tilt -Chin Lift
4.1.4 Jaw Thrust
4.1.5 Rescue Breathing
4.1.6 Suspected Foreign Body Airway Obstruction (FBAO)
4.2 Airway Adjuncts
4.2.1 Nasopharyngeal Insertion (NPA)
4.2.2 Oropharyngeal Insertion (OPA)
4.3 Airway Suctioning
4.3.1 Flexible Suctioning
4.3.2 Rigid Suctioning
4.4 Advanced Airways
4.4.1 Laryngeal Mask Airway (LMA)
4.4.2 KingLT Supraglottic Airway
4.4.3 i-gel Airway
4.4.4 Orotracheal Intubation by Direct Laryngoscopic Visualization
4.5 Surgical and Nonsurgical Airways
4.5.1 Needle Cricothyroidotomy for Pediatrics
4.5.2 Surgical Airway (Cricothyroidotomy)
4.6 The Autistic Patient
4.7 Blood Alcohol Sampling
4.8 Chest Compression Devices
4.8.1 Auto -Pulse
4.8.2 Lucas Chest Compression System
4.9 Chest Decompression
4.10 CO2 Monitoring Devices
4.10.1 Electronic Waveform CO2 Detection
4.10.2 Color Metric End -Tidal CO2 Detector
4.11 CO Monitoring (Rad-57) Carboxyhemoglobin
4.12 CPAP
4.12.1 Whisper Flow Fixed -Flow Oz Generator
4.12.2 FlowSafe
4.13 Cyanokit (Hydroxocobalamin for Injection)
4.14 ECG Monitoring/Treatment
4.14.1 12-Lead Application
4.14.2 External Pacemaker
4.15 Eye Washing for Chemical and Small Foreign Body
4.16 Helmet/Face Mask Removal
4.16.1 Football Helmet Face Mask Removal
4.16.2 Full Face Mask Helmet Removal
4.16.3 Football Helmet Removal
4.16.4 Other Helmets
4.17 Glucometer
41h Edition 3/1/15 Florida Regional Common EMS Protocols 2
4.18 Medication Administration
4.18.1 Auto-Inj ector
4.18.1.1 AtrOPen
4.18.1.2 Auto -Injector EpiPen®
4.18.1.3 Auto -Injector DuoDote®
4.18.2 Intramuscular Injection (IM)
4.18.3 Intranasal (IN) Mucosal Atomization Device (MAD)
4.18.4 Intraossous
4.18.4.1 Intraosseous - Bone Injection Gun (BIG)
4.18.4.2 Intraosseous - Cook IO
4.18.4.3 Intraosseous - EZ-IO (Adult and Pediatric)
4.18.5 Intravenous Cannulation (IV)
4.18.6 Nebulizer
4.19 Morgan Lens
4.20 Nitrous Oxide - Nitronox
4.21 Pediatric Weight -Based Emergency Tape: Broselow and Handtevy
4.22 Pulse Oximeter
4.23 Restraints
4.23.1 Pediatric Restraint Device — Pedi-Mate TM
4.23.2 Physical Restraints
4.24 Spinal Immobilization
4.24.1 Spinal Immobilization - Blunt
4.24.2 Spinal Immobilization - Penetrating
4.24.3 Horizontal Spinal Immobilization
4.24.4 Pediatric Spinal Immobilization
4.24.5 Standing Spinal Immobilization
4.24.6 Vest -Type Extrication Device (KED)
4.25 Splinting
4.25.1 Air Splint
4.25.2 Rigid Splint
4.25.3 Hare Traction Splint
4.25.4 Sager Traction Splint
4.25.5 Vacuum Splint
4.26 Vagal Maneuvers
4.26.1 Ice Water Immersion of the Face (Vagal Maneuvers)
4.26.2 Valsalva Maneuver (Vagal Maneuvers)
4.27 Wound Care
4.27.1 Hemostatic Gauze
4.27.2 Trauma Tourniquet
41h Edition 3/1/15 Florida Regional Common EMS Protocols 3
4.1.1 Automated External Defibrillator (AED)
Automated external defibrillators are to be used by the first responder and EMT, when Advanced
Life Support providers (e.g., paramedics with monitors/defibrillators) are not available, for
treatment of the patient in nontraumatic cardiac arrest. Two types of AEDs are distinguished:
fully automatic and semiautomatic.
1. Perform continuous CPR until the AED is applied.
2. Apply the AED pads to the patient according to the manufacturer's recommendation.
3. Activate the unit and follow the AED prompts.
4. If the AED advises to "shock," clear everyone from touching the patient.
5. Push the "shock" button to defibrillate the patient.
6. Immediately resume chest compressions.
7. Analyze per AED prompt after 2 minutes of uninterrupted compressions
41h Edition 3/1/15 Florida Regional Common EMS Protocols
4.1.2 Cardiopulmonary Resuscitation (CPR)
Adult
1. Establish unresponsiveness (call for backup as needed).
2. C: Assess circulation via carotid pulse (5-10 seconds). If a pulse is absent, start chest
compressions (push hard, push fast). Administer compressions at a rate of 100 per minute
(place the heel of hand on the sternum between the nipples and compress to a depth of 2
inches).
3. A: Open the airway using an appropriate method.
4. B: Assess breathing (5-10 seconds). If breathing is absent, give two breaths.
5. Administer 30 compressions and then 2 ventilations
6. If an advanced airway is in place and there are two rescuers, administer continuous
compressions and unsynchronized ventilations at a rate of 1 breath every 6 seconds or 1
breath every 10 compressions.
7. Continue compressions and ventilations until the return of a pulse is noted. Intermittently
check for the return of a spontaneous pulse.
Child
1. Establish unresponsiveness (call for backup as needed).
2. C: Assess circulation via carotid pulse (5-10 seconds). If a pulse is absent, start chest
compressions. Administer compressions at a rate of 100 per minute (place the heel of one
hand or two hands on the mid sternum and compress at a depth of two inches).
3. A: Open the airway using an appropriate method.
4. B: Assess breathing (5-10 seconds). If breathing is absent, give two breaths to make the
chest rise.
5. For one rescuer, administer 30 compressions and then 2 ventilations; for two rescuers,
administer 15 compressions and then 2 ventilations.
6. If an advanced airway is in place and there are two rescuers, administer continuous
compressions and unsynchronized ventilations at a rate of 1 breath every 6 seconds or 1
breath every 10 compressions.
7. Continue compressions and ventilations until the return of a pulse is noted. Intermittently
check for the return of a spontaneous pulse.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 5
4.1.2 Cardiopulmonary Resuscitation (CPR) (continued)
Infant
1. Establish unresponsiveness (call for backup as needed).
2. C: Assess circulation via brachial pulse (5-10 seconds).
• For one rescuer, use two fingers on the sternum, one finger width below the nipple
line; administer at least 100 compressions per minute, at one-half the depth of the
chest.
• For two rescuers, use two thumbs side by side at the center of breast bone just below
the nipple line. Squeeze the infant's posterior chest with the encircled fingers, and
administer at least 100 compressions per minute at a depth of 1 1/z inches of the chest.
3. A: Open the airway using an appropriate method.
4. B: Assess breathing (5-10 seconds). If breathing is absent, give two breaths to make the chest
rise.
5. For one rescuer, administer 30 compressions and then 2 ventilations, for two rescuers;
administer 15 compressions and then 2 ventilations.
6. If an advanced airway is in place and there are two rescuers, administer continuous
compressions and unsynchronized ventilations at a rate of 1 breath every 6 seconds or 1
breath every 10 compressions.
7. Continue compressions and ventilations until the return of a pulse is noted. Intermittently
check for the return of a spontaneous pulse.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 6
4.1.3 Head Tilt — Chin Lift
1. Place one hand on the patient's forehead and push with your palm to tilt the head back.
2. Place the fingers of the other hand under the bony part of the patient's lower jaw near the
chin. Do not press deeply into the soft tissue under the chin because it might obstruct the
airway.
3. Lift the jaw to bring the chin forward.
4.1.4 Jaw Thrust
1. Place a hand on each side of the patient's face.
2. Grasp the angles of the patient's mandible and lift upward.
3. If there are not enough responders to maintain the jaw thrust or if the jaw thrust is not
successful in opening the airway, proceed to the head tilt -chin lift maneuver (Medical
Procedure 4.1.3).
41h Edition 3/1/15 Florida Regional Common EMS Protocols 7
4.1.5 Rescue Breathing
One Person
1. Position yourself directly above the patient's head.
2. Place the mask on the patient's face, using the bridge of the nose as a guide for correct
positioning.
3. Use the E-C clamp technique to hold the mask in place while you lift the patient's jaw to hold
the airway open.
Perform a head tilt.
• Use the thumb and index finger of one hand to make a "C," pressing the edges of the
mask to the face.
• Use the remaining fingers to lift the angles of the jaw (three fingers form an "E") and
open the airway.
4. Squeeze the bag to achieve chest rise. The delivery of breaths is the same whether you do or
do not use supplementary oxygen.
For perfusing rhythm:
Adult: 10-12 breaths/min.
• Pediatric: 12-20 breaths/min.
When CPR is being performed or if an advanced airway is in place:
Adult and pediatric: 8-10 breaths/min.
Insert an oral or nasal airway.
Two Persons
1. Rescuer one:
Take a position directly above the patient's head.
• Place the mask on the patient's face, using the bridge of the nose as a guide for correct
positioning.
• Use the E-C clamp technique to hold the mask in place with both hands.
• Use the thumb and index finger of one hand to make a "C," pressing the edges of the
mask to the face.
• Use the remaining three fingers to form an "E" to lift the angles of the jaw.
2. Rescuer two:
• Squeeze the bag for 1 second, while watching for chest rise.
• Apply continuous cricoid pressure.
3. Squeeze the bag to achieve chest rise. The delivery of breaths is the same whether you do or
do not use supplementary oxygen.
For perfusing rhythm:
• Adult: 10-12 breaths/min.
Pediatric: 12-20 breaths/min.
When CPR is being performed or if an advanced airway is in place:
Adult and pediatric: 8-10 breaths/min.
4. Insert an oral or nasal airway
41h Edition 3/1/15 Florida Regional Common EMS Protocols
4.1.6 Suspected Foreign Body Airway Obstruction (FBAO)
Adult
1. If the patient is conscious, ask, "Are you choking?"
2. If the patient is unable to speak and/or nods his/her head "yes," give abdominal thrusts, or
chest thrusts if the patient is pregnant or obese.
3. Repeat the abdominal thrusts until they are effective or the patient becomes unconscious.
If the patient becomes unconscious, continue with the following steps:
4. Open the airway. If able to visualize the obstruction, perform a finger sweep to remove the
obj ect.
5. Attempt to ventilate; if the airway is still obstructed, reposition the airway and try to ventilate
again.
6. Give 30 chest compressions.
7. Repeat Steps 4 through 6 until the FBAO is relieved.
Child
1. If the patient is conscious, ask, "Are you choking?"
2. If the patient is unable to speak and/or nods his/her head "yes," give abdominal thrusts.
3. Repeat the abdominal thrusts until they are effective or the patient becomes unconscious
If the patient becomes unconscious, continue with the following steps:
1. Open the airway. If able to visualize the obstruction, perform a finger sweep to remove the
obj ect.
2. Attempt to ventilate; if the airway is still obstructed, reposition the airway and try to ventilate
again.
3. Give 30 chest compressions.
4. Repeat Steps 4 through 6 until the FBAO is relieved.
Infant
1. If the patient is conscious, determine airway patency.
2. If the patient is unable to move air or has poor air exchange, give 5 back slaps between the
shoulder blades and then 5 chest thrusts with the patient in a head -dependent position.
3. Repeat the back slaps and chest thrusts until they are effective or the patient becomes
unconscious.
If the patient becomes unconscious, continue with the following steps:
1. Open the airway. If able to visualize the obstruction, perform a finger sweep to remove the
obj ect.
2. Attempt to ventilate; if the airway is still obstructed, reposition the airway and try to ventilate
again.
3. Give 30 chest compressions.
4. Repeat Steps 4 through 6 until the FBAO is relieved.
41h Edition 3/1/15 Florida Regional Common EMS Protocols
4.2.1 Nasopharyngeal Airway Insertion (NPA)
This procedure should not be performed in the presence of frontal head or midfacial trauma where
the cribriform plate may be fractured.
1. Determine the proper size of tube (measure from the nostril to the earlobe).
2. Lubricate with a water-soluble lubricant (optional lidocaine gel).
3. Position the patient's head in a neutral position, inspect the nose, and select the larger nostril.
(Optional: Spray Neo-Synephrine into nasopharynx.)
4. Insert the nasopharyngeal tube with the bevel facing the nasal septum.
5. Gently insert the tube until the flange rests against the nostril.
• If resistance is met, insert with a twisting motion.
• If there continues to be resistance, attempt insertion in the other nostril.
6. Ventilation with a bag -valve device.
4.2.2 Oropharyngeal Airway Insertion (OPA)
1. Determine the proper size of tube (measure from the corner of the mouth to the earlobe).
2. Open the patient's mouth by tongue/jaw-lift maneuver.
3. Insert the oropharyngeal tube with the tip toward the side of the mouth.
• Prior to complete insertion; start to rotate the tube 90 degrees so that the flange rests on
the lips.
• If the patient has an intact gag reflex, perform a nasopharyngeal insertion.
4. Ventilate with a bag -valve device.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 10
4.3.1 Flexible Suctioning
1. Wear protective eyewear, gloves, and face mask.
2. Preoxygenate the patient.
3. Turn on the suction unit.
4. Insert the catheter to an appropriate depth, place your thumb over the suction control orifice,
and rotate the catheter between your fingertips while withdrawing catheter. (Caution: Do not
suction for more than 10 seconds.)
5. Monitor the patient's heart rate, pulse, oxygen saturation, and clinical appearance during
suctioning. If bradycardia occurs or the clinical appearance deteriorates, administer high -flow
oxygen until the rate and clinical appearance return to normal.
6. Maintain ventilatory support with 100% oxygen
4.3.2 Rigid Suctioning
1. Wear protective eyewear, gloves, and face mask.
2. Preoxygenate the patient.
3. Turn on the suction unit.
4. Measure the depth of catheter insertion from the patient's earlobe to the corner of the mouth.
5. Insert the catheter to an appropriate depth, place your thumb over the suction control orifice,
and suction the oropharynx. (Caution: Do not suction for more than 10 seconds.)
6. Monitor the patient's heart rate, pulse, oxygen saturation, and clinical appearance during
suctioning. If bradycardia occurs or the clinical appearance deteriorates, administer high -
flow oxygen until the rate and clinical appearance return to normal.
7. Maintain ventilatory support with 100% oxygen.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 11
For all advanced airways/supraglottics airway devices (SGA)
• Assure a patent airway and ventilate with 100% 02 before attempting placement of the any
advanced airway. Do not hyperventilate the patient
• Monitor SPO2 with a pulse oximeter and provide 100% 02 via a BVM
• Select the proper size tube
• Assemble and check the necessary equipment
• Confirm the SGA placement with an end -tidal CO2 monitoring device and additional
confirmation methods such as negative epigastric sounds and positive bilateral breath sounds.
• Secure the SGA with tape or a commercially available device.
• Continually monitor the pulse oximeter and the end -tidal CO2 levels. Provide ventilations at a
rate to keep the ETCO2 between 35-45.
4.4.1 Laryngeal Mask Airway (LMA)
1. .Tightly deflate the cuff so that it forms a smooth "spoon shape." Lubricate the posterior
surface of the mask with a water-soluble lubricant.
2. Hyperextend the patient's neck (unless cervical spine injury is suspected).
3. Carefully flatten the laryngeal mask tip against the hard palate.
4. Advance the mask until definite resistance is felt at the base of the hypopharynx.
5. Without holding the tube, inflate the cuff to the recommended volume of air for the tube size.
4.4.2 KingLT Airway
1. Lubricate the tip of the tube with a water-soluble gel.
2. Place the patient's head in a neutral position.
3. Apply the tongue/jaw-lift maneuver with one hand while passing the tube with the other
hand. Insert the device at a 45- to 90-degree angle, and rotate it to midline as it passes the
tongue.
4. Without exerting excessive force, advance the tube until the base of the connector
gastric access lumen is aligned with the patient's teeth or gums.
5. Inflate the pharyngeal cuff with the recommended volume of air for the tube size.
6. Ventilate the tube with a BVM while slowly withdrawing the tube in the airway.
Initially, little or no air movement will occur
• Once the tube is withdrawn into the proper space, air will readily pass, and good
compliance will be felt. Stop withdrawing at this point.
• Assess for chest rise, breath sounds and negative epigastric sounds
4.4.3 i-gel Airway
1. Lubricate the back, sides and front of the cuff with a thin layer of water-soluble lubricant (do
not use silicone based lubricants).
2. Grasp the i-gel firmly along the integral bite block. Position the device so that the i—gel cuff outle
is facing towards the chin of the patient.
3. The patient should be in the sniffing position with head extended and neck flexed. The chin shout
be gently pressed down before pro ceding to insert the i-gel.
4. Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate.
5. Glide the tube downwards and backwards along the hard palate with a continuous but gentle pust
until a definitive resistance is felt.
6. At this point the tip of the airway should be located into the upper esophageal opening and the
cuff should be located against the laryngeal framework.
7. The incisors should be resting on the integral bite -block.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 12
4.4.4 Orotracheal Intubation by Direct Laryngoscopic Visualization
Adult
1. Assure a patent airway and ventilate with 100% Oz before attempting placement
of the airway device. Do not hyperventilate the patient.
2. Assemble and check the necessary equipment.
3. Hyperextend the patient's neck (unless cervical spine injury is suspected).
4. Perform laryngoscopy in less than 30 seconds:
Hold the handle in your left hand.
• Insert the blade from the right side of the patient's mouth.
• Displace the tongue to the left.
• Lift the laryngoscope forward to view the glottic opening.
Do not use the patient's teeth or lips as a fulcrum.
5. Advance the tube through the glottic opening until the proximal end of the cuff disappears past th
vocal cords.
6. If the patient is having difficulty tolerating the intubation attempt, sedate with Versed 0.02
mg/kg IV.
7. Remove the stylet, inflate the cuff with 10 cc of air, and remove the syringe.
8. Hold the tube firmly in place, attach a BVM, and confirm its placement.
9. Auscultate:
Negative epigastric sounds.
• Positive bilateral breath sounds.
10. Attach an end -tidal COz monitoring device.
11. Monitor SP02 with a pulse oximeter.
12. After positive confirmation of tube placement, secure it with a commercial
device or tape applied to the maxillary region of the face.
Child
1. Assure a patent airway and ventilate with 100% Oz before attempting placement of the
airway device. Do not hyperventilate the patient.
2. Assemble and check the necessary equipment.
The endotracheal tube can be sized by several methods, including a weight -based tape or
size of the nares or pinky finger.
3. Hyperextend the patient's neck (unless cervical spine injury is suspected).
4. Perform laryngoscopy in less than 30 seconds:
• Hold the handle in your left hand.
Insert the blade from the right side of the patient's mouth.
• Displace the tongue to the left.
Lift the laryngoscope forward to view the glottic opening.
• Do not use the patient's teeth or lips as a fulcrum.
5. Advance the tube through the glottic opening until the proximal end of the tube disappears
past the vocal cords.
6. If the patient is having difficulty tolerating the intubation attempt, sedate with Versed 0.02
mg/kg IV.
7. Remove the stylet.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 13
4.4.4 Orotracheal Intubation by Direct Laryngoscopic Visualization (continued)
8. Hold the tube firmly in place, attach a bag -valve device, and confirm its placement.
9. Auscultate:
• Negative epigastric sounds.
• Positive bilateral breath sounds.
10. Attach an end -tidal COz monitoring device.
11. Monitor SP02 with a pulse oximeter.
12. After positive confirmation of tube placement, secure it with a commercial device or
tape applied to the maxillary region of the face.
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 14
4.5.1 Needle Cricothyroidotomy for Pediatrics
1. Hyperextend the patient's neck (unless cervical spine injury is suspected).
2. Locate the cricothyroid membrane between the cricoid and thyroid cartilages by palpating the
depression caudal (toward the feet) to the midline Adam's apple.
3. Clean the area well with a Betadine solution or povidone-iodine swabstick.
4. Prepare the necessary equipment:
• 14-gauge, over -the -catheter needle
10-cc syringe
• 15-mm adaptor from 3.0 or 3.5 intubation tube
5. Insert the IV catheter through the skin and cricothyroid membrane into the trachea. Direct the
needle at a 45-degree angle caudally (toward the feet). When the needle penetrates the
trachea, a "pop" will be felt.
6. Aspirate with the syringe. If air is returned easily, the needle is in the trachea.
7. Withdraw the stylet while gently advancing the catheter downward into the position.
8. Attach the 15-mm adaptor to the needle hub.
9. Ventilate the patient with a bag -valve device using the 15-mm adaptor; provide high -flow
oxygen.
10. Confirm placement:
• Negative epigastric sounds.
Positive bilateral breath sounds.
11. Attach an end -tidal COz monitoring device.
12. Monitor SP02 with a pulse oximeter.
13. Provide 100% Oz with positive -pressure oxygen or a bag -valve device.
14. Monitor for changes in breathing or airway status.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 15
4.5.2 Surgical Airway (Cricothyroidotomy)
1. If the patient less than 12 years of age, refer to the needle cricothyroidotomy protocol
(Medical Procedure 4.5.1).
2. Hyperextend the patient's neck (unless cervical spine injury is suspected).
3. Locate the cricothyroid membrane between the cricoid and thyroid cartilages by palpating the
depression caudal (toward the feet) to the midline Adam's apple.
4. Clean the area well with a Betadine solution or povidone-iodine swabstick.
5. Using a scalpel, make a vertical incision through the skin and then a horizontal incision
through the cricothyroid membrane.
6. 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. Do not aim the knife
cephalad (toward the head), because injury to the vocal cords may occur.
It is recommended to use a safety scalpel.
or
A trach hook may also be used.
7. Insert a size 6.0 endotracheal tube or tracheostomy tube through the incision.
8. Inflate the cuff with the recommended amount of air.
9. Ventilate the patient with a bag -valve device using the 15-mm adaptor; provide high -flow
oxygen.
10. Confirm placement:
Negative epigastric sounds.
• Positive bilateral breath sounds.
11. Attach an end -tidal COz monitoring device.
12. Monitor SP02 with a pulse oximeter.
13. Provide 100% Oz with positive -pressure oxygen or a bag -valve device.
14. Monitor for changes in breathing or airway status.
15. If necessary, cut several 4 X 4 gauze pads down the middle to the center of the pads. Wrap
the pads at the base of the tube and secure them to assist in bleeding control and/or to reduce
air escape.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 16
4.5.3 Rapid Sequence Intubation (RSI)
• Evaluate the patient for the need to use paralytics.
• Contraindications:
o Penetrating eye injuries.
o Renal failure (dialysis patients).
o Patients with distorted midface/neck anatomy
o History of malignant hyperthermia
o Inability to ventilate with a bag -valve -mask (BVM)
1. Prepare the necessary equipment:
a. BVM connected to a functioning 02 delivery system.
b. Working suction with yankauer suction tip attached.
c. Endotracheal tube(s) with stylet in place; tube shaped and lubricated, and cuff intact.
d. Laryngoscope handle with straight and curved blades.
e. Cricothyroidotomy kit.
2. Verify the patient has a functioning, secure IV line in place.
3. Ensure ECG monitoring and observe for dysrhythmia during induction.
4. Palpate the cricothyroid space and mark it with an ink pen.
5. Premedicate the patient as appropriate:
• Versed 0.02mg/kg via IV push, for sedation
OR
• Amidate (Etomidate) 20mg (0.2mg/kg) or 0.2-0.6mg/kg via IV push for sedation
• Atropine 0.02mg/kg (minimum dose 0.1mg; maximum dose 0.5mg) via IV push, for
pediatric patients.
6. Administer succinylcholine chloride (Anectine) 1 mg/kg via IV push.
7. Apply cricoid pressure to occlude the esophagus until incubation is successfully completed and
the endotracheal tube cuff is inflated. Elevate the patient's head 15 degrees when possible.
a. After fasciculations stop (if they occur), demonstrate adequate relaxation by ventilating
the patient four to five times with the BVM (hyperventilate to blow off CO2).
b. Jaw relaxation and decreased resistance to BVM ventilation indicate that the cords are
paralyzed and that it is time to proceed with intubation (approximately 45 seconds to 1
minute).
8. Perform endotracheal incubation.
a. If unable to intubate during the first 20-second attempt, stop and ventilate with the BVM
for 30-60 seconds.
b. If inadequate relaxation is present, give a second dose of succinylcholine chloride (1.0-1.5
times the initial dose). Observe for severe bronchospasm in pediatric patients.
c. If repeated incubation attempts fail, ventilate the patient via BVM until spontaneous
ventilations return (usually 3-5 minutes).
9. If unable to intubate after the administration of succinylcholine chloride, ventilate the patient
with a BVM. If unable to appropriately ventilate the patient with a BVM, consider
performing surgical cricothyroidotomy.
10. Treat bradycardia occurring during incubation by temporarily halting incubation attempts and
continue ventilation of the patient via BVM with 100% 02. If bradycardia does not resolve
with oxygenation and ventilation, administer atropine 0.5-1.0 mg via IV push.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 17
4.6 Autistic Patient
This protocol is intended to assist emergency personnel in dealing with the special challenges
that they face when encountering an autistic patient.
Signs of Autism
Many parents are in denial or do not realize the possibility that their child is autistic. It is for this
reason that careful consideration should be made before inquiring whether a child is autistic.
Doing so may prompt the parent to "shut down" or become defensive, which could hamper the
process of acquiring patient information. Signs of autism that the emergency care provider may
recognize include these:
• Has not "babbled" or "cooed" by the age of 1 year.
• Has not gestured, pointed, or waved by 1 year.
Has not spoken a single word by 16 months.
Has not spoken a two -word phrase by 2 years.
Special Considerations
When dealing with an autistic patient, special accommodations must be made during the
encounter to achieve a positive outcome. Conditions that may affect the encounter include these:
Autistic patients may respond aggressively to an unwanted touch.
• Autistic patients may appear to have a hearing impairment.
o This may affect your assessment of the patient's level of consciousness and the Glasgow
Coma Scale score.
o It may also prevent the patient from coming to you if called, such as in motor vehicle
accidents, fires, and evacuations (a).
During stressful times, autistic persons may "bolt" or run away from the
situation even if they are hurt. These patients will not respond to someone
calling their name to stop! This behavior may result in the person running into
traffic or other hazardous areas (b).
Autistic patients cannot tell or describe what is hurt or what they want (c).
• Autistic patients will likely not follow any directions. This will present a great challenge
during the patient assessment (c).
Autistic children do not play with toys appropriately.
Autistic patients have poor eye contact, which may affect the evaluation of pupils.
o The autistic patient usually directs his/her eyes up, down, or away. This
factor should be considered when head injuries are suspected.
• Autistic patients appear to be in their own world. This could pose a concern if a patient is in
danger and is not aware of it (d).
• Autistic patients have odd movement patterns.
o These movements may include hand flapping, hand washing motions, spinning motions;
head slapping, and covering of the ears or eyes
Autistic patients exhibit an unusual attachment to toys or other objects.
o To gain the trust of an autistic patient, provide him/her with a favorite object, which
may not necessarily be a toy. Ask the parent/caregiver to assist you.
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 18
• Autistic patients often demonstrate repetitive behaviors.
o Autistic persons feel compelled to complete certain tasks, such as lining up their
toys.
o Before allowing an intrusion, such as emergency workers examining them, autistic
patients may feel compelled to complete a certain task such as lining up toys,
opening a door, or going through a certain routine.
• Autistic patients do not adjust well to a change in their surroundings or routines.
o These patients are usually set in a certain routine and are extremely comfortable in
their known surroundings. Any changes could result in an aggressive response.
Autistic patients may walk on "tippy toes."
• Autistic patients may have an increased level of pain tolerance.
o This may be a major consideration during the physical exam. A thorough physical
exam is required, especially with suspected abdominal pain, fractures/sprains, and
head/neck injuries.
• Autistic patients have an extreme sensitivity to touches and textures (i.e., smooth, rough,
sticky, hot/cold, wet/dry).
o Consideration should be given to this factor when applying dressings and bandages.
The simplest of procedures, such as applying a Band-Aid or irrigating a wound,
could result in a "meltdown."
Autistic patients are extremely sensitive to having things on their heads or around their necks.
o This factor should be considered when applying dressings to head injuries, as well
as when utilizing a sling to secure an extremity.
"Meltdowns and Refocus Periods"
Children with autism can have frequent "meltdowns" (tantrums) due to any one of the factors
mentioned in the "Special Considerations" section of this protocol. These meltdowns may also
occur for no apparent reason and may result in aggressive behavior.
After a meltdown, autistic children will likely go through what is known as a "refocus" period.
They will suddenly become quiet; they may crouch down and cover their ears or eyes. Typically
they will look for a quiet, darkened, "sheltered" area. During this period, patients are trying to
"refocus" their world; this is their time. The refocus period can last a few minutes to possibly 30
minutes or longer. If there is an attempt to rush this period, another meltdown may occur, to be
followed by another refocus period; this process could become a vicious cycle.
If you encounter a parent/caregiver who is aware of the autism, ask him/her for advice on how to
handle the patient. Parents of autistic children are usually very actively involved with their
children and understand their "quirks." Their help should enhance your treatment and be a major
factor in lessening the stress level in an already stressful situation.
Note:
(a) Clues that may indicate that you are dealing with an autistic patient may include car magnet
"puzzle piece" ribbons on vehicles involved in motor vehicle accidents as well as window
stickers on homes indicating the presence of a special needs person.
(b) Autistic patients are not aware of any present dangers. To safely secure the patient, reduce the ris
of danger before encountering the patient.
(c) Ask the parent/caregiver to assist you during your interview.
(d) If possible, ask the parent/caregiver to assist with "refocusing" the patient. If such a person is
not available, try clapping your hands to get the patient's attention if the situation is urgent.
Be aware of a possibly aggressive response to an unwanted touch.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 19
4.7 Blood Alcohol Sampling
Drawing a blood alcohol sample should not delay treatment or transport of the critical patient.
1. The EMS Run Report should contain the following information:
a. A blood alcohol kit was used.
b. A Betadine (povidone-iodine) solution (or hydrogen peroxide/acetone if the patient is
allergic to iodine) was used for the skin preparation.
c. Name of the law enforcement officer requesting blood sample.
d. Time of draw.
e. If the paramedic drawing sample is different from the one signing the report, that
paramedic will sign under the above information.
2. All blood samples taken must be surrendered to the requesting law enforcement officer.
3. The paramedic:
May be required to obtain multiple samples.
• Must follow all blood sampling kit guidelines.
Must obtain blood alcohol samples only at the request of a law enforcement officer,
either in the field or upon arrival in the emergency department.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 20
4.8.1 Auto -Pulse Chest Compression System
A load -distributing band device is designed to deliver consistent uninterrupted chest
compressions during cardiac arrest.
1. Initiate CPR.
2. Maintain high -quality compressions.
3. Power up the Auto -Pulse by pressing the ON/OFF button at the top of the device.
4. Remove the clothing on the patient's torso:
• Sit the patient up and perform a single cut down the back of the patient's clothing. Then
slide the Auto -Pulse platform into position behind the sitting patient, and have the
patient lie down on the platform.
or
• Log -roll the patient to one side and perform a single cut down the back of the patient's
clothing. Then log -roll the patient onto the Auto -Pulse platform.
5. Align the patient on the platform. The patient's armpit should be positioned on the "yellow"
indicator line on the Auto -Pulse platform.
6. Close the LifeBand over the patient's chest.
• Therapy electrodes or defibrillation pads should be in place before applying the
LifeBand.
• Make sure the LifeBand is not twisted.
The LifeBand is secure when the mating slot is placed over the alignment tab and the
bands are pressed together to engage the Velcro.
• Center the LifeBand on the patient's chest.
7. Begin compressions by pressing the green Start/Continue button once. The Auto -Pulse device
will automatically adjust the bands on the chest.
8. The Auto -Pulse unit will pause for 3 seconds to allow for a check of proper alignment.
• If patient is not aligned correctly, push the orange Stop/Cancel button.
• Realign the LifeBand and press the green Start/Continue button.
9. Select the desired mode of compressions by pushing the gray Menu/Mode button.
30:2 mode: 30 compressions and a pause for 2 ventilations.
or
• Continuous mode: uninterrupted compressions.
10. Complete the process of securing the patient for transport.
• Clip the straps for the shoulder restraint to the Auto -Pulse platform and tighten them.
• Secure the patient's head to the Auto -Pulse platform with the manufacturer's head
immobilizer or tape applied across the patient's forehead.
11. After successful resuscitation or termination of activities, press the orange Stop/Cancel
button.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 21
4.8.2 LUCAS Chest Compression System
1. Initiate CPR, Maintain high -quality compressions.
2. Open the LUCAS carrying bag to expose the unit.
3. Make certain the On/Off knob is in the "adjust" position.
4. Connect the high-pressure air line to the regulator on the air source.
5. Take the back plate out of the bag. With one rescuer on each side of patient, grab the
patient's arm to lift the upper body. One person should lift the patient and support the head,
and the other person should lift the patient and slide the back plate below the armpits.
6. Continue manual compressions.
7. Take the upper part of the LUCAS unit out of the bag. Hold the LUCAS device by the
handles on the support legs and make sure the support legs have reached their outer position.
8. Pull up once on the release rings to check that the claw locks are open.
9. Interrupt manual chest compressions and place the upper part of the LUCAS unit over the
patient's chest. The claw locks at the end of each support leg should be aligned with the back
plate to lock the components together.
10. Check by pulling upward that both support legs are locked into the back plate.
11. Lower the suction cup with the height adjustment handles until the pressure pad inside the
suction cup touches the patient's chest without compressing the chest.
12. Turn the ON/OFF knob to activate the chest compressions.
13. Attach the neck pad by raising the patient's head slightly. Clip the pad into each buckle
attached to the support arms. Pull the excess slack out of each strap by pulling gently and
simultaneously until the pad positions itself into place.
14. Attach the wrist straps to each of the patient's wrists to assist with securing the arms during
movement/transportation. Use caution to determine that the intravenous site is not
compromised due to a slight bend that will occur in the patient's arm. If this does occur,
release the arm and secure the unit by other means.
15. After successful resuscitation or termination of activities, turn the ON/OFF knob to the "Off'
position.
LUCAS 2 Chest Compression System
1. Initiate CPR, Maintain high -quality compressions.
2. Pull red handle on bag to open
3. To activate, push ON/OFF button for one second to start self -test and power up
4. The green LED adjacent to ADJUST illuminates
5. Take the back plate out of the bag. Pause manual CPR. With one rescuer on each side of
patient, grab the patient's arm to lift the upper body. One person should lift the patient and
support the head, and the other person should lift the patient and slide the back plate below
the armpits.
6. Continue manual compressions.
7. Take the upper part of the LUCAS 2 unit out of the bag. Hold the LUCAS 2 device by the
handles on the support legs and make sure the support legs have reached their outer position.
8. Check that the release rings on claw locks are open.
9. Interrupt manual chest compressions and place the upper part of the LUCAS 2 unit over the
patient's chest. The claw locks at the end of each support leg should be aligned with the back
plate to lock the components together. Listen for the CLICK when attached.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 22
4.8.3 LUCAS Chest Compression System
10. Check by pulling upward that both support legs are locked into the back plate.
11. Center the suction cup over the chest with the lower edge of the suction cup placed
immediately above the end of the sternum
12. Push the suction cup down using two fingers, making sure you are in the ADJUST MODE
and the green led is lit
13. The pressure pad should touch the patient's chest. If pad does not touch or Lucas 2 does not
fit properly, remove and continue manual compressions
14. Press PAUSE to lock the start position then remove your fingers from the suction cup
15. Check for proper position and press ACTIVE (continuous) or ACTIVE (30:2)
16. Attach stabilization strap by fully extending the buckles and placing cushion under patient's
neck
17. Fasten cushion to Lucas 2 device and tighten the straps
18. Delay the application of the stabilization strap when it might prevent or delay treatment
19. Attach the wrist straps to each of the patient's wrists to assist with securing the arms during
movement/transportation. Use caution to determine that the intravenous site is not
compromised due to a slight bend that will occur in the patient's arm. If this does occur,
release the arm and secure the unit by other means.
20. Press PAUSE to stop compressions during ECG analysis
21. Keep interruptions to a minimum
22. After successful resuscitation or termination of activities, Press and hold the ON/OFF button
for one second.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 23
4.9 Chest Decompression
1. Assess the patient to make sure that his/her condition is due to a tension pneumothorax:
• Mechanism of injury
• Absent or decreased breath sounds on the affected side.
• Poor ventilation despite an open airway.
Tracheal deviation away from the side of the injury (may not always be present).
• Neck vein distention (may not be present if there is associated severe hemorrhage).
Tympany (hyperresonance) to percussion on the affected side.
• Shock.
• Decreased SpO2/end-tidal CO2.
2. Provide the patient with high -flow oxygen and ventilatory assistance.
3. Identify the second or third intercostal space (i.e., the space between the second and third
ribs or between the third and fourth ribs) in the midclavicular line on the same side as the
tension pneumothorax. If the mid -clavicular site cannot be accessed due to any reason
(ballistic vest or patient trapped) utilize the mid-axillary site (the space between the 5th and
6th ribs) in the mid-axillary line.
4. Quickly prepare the area with povidone-iodine.
5a. Utilize a 14-gauge, 3- to 31/z-inch needle IV catheter.
OR
5b. Use a commercial decompression device.
6. If there is an extended transport time consider making a one way valve by inserting the IV
catheter through the finger of a sterile glove that has been moistened with sterile water or
(optional) attach the IV catheter to a syringe half-filled with saline to aid in visualizing air
release
7. Insert the catheter into the intercostal space.
8. Insert the catheter through the parietal pleura until air escapes. It should exit under pressure.
9. Remove the needle and/or syringe. Leave the plastic catheter in place until it is replaced by a
chest tube at the hospital.
10. Monitor the patient, as the initial catheter may clog or kink, requiring reinsertion of another
needle.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 24
4.10.1 Electronic Waveform CO2 Detection
Intubated/Supraglottic Device
1. Follow the manufacturer's recommendation for inserting the airway device.
2. Verify placement of the airway device.
3. Attach the CO2 detection tubing to the airway device.
4. Monitor the electronic readings.
Non-intubated Device
1. Select the appropriate size of detection tubing.
2. Place the detection tubing on the patient.
3. Attach the detection tubing to the CO2 detection device.
4. Monitor the electronic readings.
40
C.apnogram of Patent
Normal CapnogrBM with Br ohiosp.as,r
40
E E:
ahrk:-fin"'
Time(sec) Time (see)
Capno raphy Wayeform.
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 25
4.10.2 Color Metric End -Tidal COz Detector
1. Remove the detector from the package and match the initial color of the indicator to the
purple color labeled "CHECK" on the product dome.
• The color should be the same or darker.
If the color is lighter, do not use the unit.
• Use an appropriate CO2 indicator based on the patient's weight.
2. After the tube is inserted, firmly attach the EASY CAP detector between the tube and the
breathing device.
3. Ventilate the patient with 6 breaths of moderate tidal volume. Interpreting results with fewer
than 6 breaths can yield false results.
4. Compare the color of the indicator on full end -expiration to the color chart on the product
dome. (The chemical indicator may become irreversibly yellow after contact with any
liquid.)
• If the color indicator is "yellow," the ETT is in the trachea.
If the color indicator is "tan," ventilate six more times and recheck.
• If the color indicator is "purple," recheck ETT placement with direct laryngoscopy to
confirm placement.
If the results are not conclusive, the tube should be immediately removed unless correct
anatomic placement can be confirmed with certainty by other means.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 26
4.10
2
0
6
7
9.
10
11
12
CO Monitoring (Rad-57) Carboxyhemoglobin
Press the green power button to activate the unit.
Place the sensor on the patient's finger (observe the top and bottom of the sensor). Do not
place the sensor on the thumb or fifth digit (pinky). If available, utilized the pediatric sensor
as instructed by the manufacturer.
Four green LED lights below the power button indicate the battery level.
The sensor is calibrated to penetrate the mid -nail area, not the cuticle area. Do not force the
patient's finger in too far.
RAD-57 will calibrate on the patient in 5-8 seconds.
Displays will come up in pulse oximeter (SP02) mode.
The PI graph will display perfusion strength.
The display will show "SEN OFF" until the sensor is on the finger.
Press the orange "SpCO" button.
The display will show the SpCO level from 1% to 99%.
Record the level(s) on the patient report.
Press and hold the green power button to turn the unit off.
CO Level: Signs and Symptoms
Level:
Signs and Symptoms:
0-4
Minor headache
5-9
Headache
10-19
Dyspnea, headache
20-29
Headache, nausea, dizziness
30-39
Severe headache, vomiting, altered LOC
40-49
Confusion, syncope, tachycardia
50-59
Seizures, shock, apnea, coma
60-Up
Coma, death
41h Edition 3/1/15 Florida Regional Common EMS Protocols 27
CPAP Overview
Continuous Positive Airway Pressure (CPAP) is a non-invasive mechanically assisted delivery
system designed to administer oxygenation of several respirational pathologies. CPAP is not a
replacement for any medication or procedure, but a tool which can provide a high level of
ventilatory support without the need for RSI or intubation. CPAP is approved for patients 18
years of age and older, with moderate to severe respiratory distress.
Indications
Respiratory distress secondary to suspected congestive heart failure, acute cardiogenic
pulmonary edema, and chronic obstructive pulmonary disease (asthma, bronchitis, emphysema).
Contraindications
• Severely Impaired Consciousness.
• Uncooperative Patient or Inability to Follow Instructions (GCS<14)
• Respiratory or Cardiac Arrest
• Suspected Pneumothorax
• Inadequate Respiratory Drive
• Shock/Hypotension (BP <90)
• Facial, Head or Chest Trauma
• Chest Wall Trauma
• Persistent Nausea/Vomiting and or High Risk of Aspiration
• Has Active Upper GI Bleeding or History of Recent Gastric/Esophageal Surgery.
• Upper Airway Obstructions
4.12.1 CPAP (Whisper Flow Fixed -Flow Oz Generator)
1. Place the patient in an upright or high Fowler's position.
2. Assess vital signs.
3. Attach a cardiac monitor, pulse oximeter, and capnography.
4. Select a sealing face mask and ensure that the mask fits comfortably. The mask should form a
seal with the bridge of the patient's nose and fully cover the nose and mouth.
5. Connect the generator to a 50-psi oxygen outlet.
6. Hold the mask or have the patient hold the mask to his/her face. If the patient seems anxious,
it is acceptable to turn the generator "on" and have the gas flowing before placing the mask
on the patient's face. When the patient is comfortable, use the head strap to hold the mask in
place. Ensure it is not too tight. Some air leakage is acceptable, unless it is in the eye area.
7. Choose the appropriate PEEP valve 5-10 cm H20.
8. Treatment should be given continuously throughout transport.
9. Evaluate vital signs every 5 minutes.
10. In case of a life -threatening complication, stop treatment and consider the need for intubation.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 28
4.12.2 CPAP (F1owSafe II)
Procedure
1. Position patient in fowlers or semi -fowlers.
2. Connect CPAP unit to suitable 02 supply.
3. Place delivery device over mouth and nose. (leave ETCO2 nasal cannula in place)
4. Patient may require substantial coaching in order to receive compliance with mask seal,
but a leak -less mask seal is essential.
5. Titrate CPAP pressure to patient's tolerance until improvement in patient's SpO2 and
symptoms.
6. Max 5 cm/H2O for Bronchospasm
7. Max 10 cm/H2O for CHF, Pulmonary Edema, and Pneumonia.
8. Max 5 cm/H2O for pediatrics
9. If respiratory drive or level of consciousness deteriorates, discontinue use and prepare to
support airway and ventilations.
10. Monitor patient every 5 minutes and advise receiving hospital as soon as possible of CPAP
use, so they can prepare to continue treatment.
11. In case of a life -threatening complication, stop treatment and consider the need for
intubation.
Considerations
Continue CPAP at receiving hospital until facility is ready to take over treatment.
Monitor for gastric distension
CPAP is not a replacement for current parenteral medication treatments, but is to be used
in conjunction with these treatments.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 29
4.13 Cyanokit (Hydroxocobalamin for Injection)
This kit is for intravenous use. The hydroxocobalamin is to be reconstituted with 100 mL per
vial of 0.9% sodium chloride injection. The starting dose is 5 g. (may be packaged in one or two
vials).
1. Start a dedicated IV line
2. Reconstitution: Add 100 mL of 0.9% sodium chloride injection to the vial using a
transfer spike. Fill to the line (with the vial in an upright position).
3. Mix: Rock or rotate the vial for 30 seconds to mix the solution. Do not shake.
4. If one vial infuse the 5 g vial: Use vented IV tubing to hang the bag and infuse over 15
minutes.
5. If two vials infuse the first vial: Use vented IV tubing to hang the bag and infuse over 7.5
minutes and then infuse the second vial: Repeat Steps 2 and 3 before the second infusion. Use
vented IV tubing to hang the bag and infuse over 7.5 minutes.
See Drug Summary 5.18, Hydroxocobalamin.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 30
4.14.1 12-Lead ECG Application
12-Lead ECG Electrode Placement.
1.
RA:
right arm, upper arm, or upper chest near the shoulder.
2.
LA:
left arm, upper arm, or upper chest near the shoulder.
3.
RL:
right leg or lower abdominal quadrant near the hip.
4.
LL:
upper leg or lower abdominal quadrant near the hip.
5.
V1:
fourth intercostal space, immediately to the right of the sternum.
6.
V2:
fourth intercostal space, immediately to the left of the sternum.
7.
V4:
fifth intercostal space in the midclavicular line. (Note: V4 must be placed prior to V3.)
8.
V3:
placed between V2 and V4.
9.
V5:
fifth intercostal space in the anterior axillary line.
10.
V6:
fifth intercostal space in the midaxillary line.
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 31
4.14.2 External Pacemaker
Several different external pacers are available. While their control panels may look different, all
of them have several features in common.
1. Turn on the device.
2. Attach an ECG monitor and therapy electrodes and cables.
• Place electrodes over the heart on the anterior and posterior locations.
or
• Place one electrode in the upper right torso (lateral to the sternum and below the
clavicle). Place the other electrode in the left upper midaxillary area (lateral to patient's
left nipple).
3. Evaluate the patient:
• Medication patches: Remove the patches.
Patient located on wet surface: Relocate the patient to a dry area.
• Patient with fluid on chest or back area: Dry with a towel.
4. Record a strip of the patient's rhythm prior to initiating pacing.
5. Consider sedation for conscious patients.
6. Set the unit to pacer mode.
7. Set the heart rate at 70 or 80 beats per minute. (Pediatrics 100-120 beats per minute)
8. Increase the energy setting until electrical capture is achieved (evidenced by a pacer spike
followed by a wide QRS complex).
9. Evaluate pacing effectiveness and perform one of the following options:
• Electrical capture is achieved: Check pulse and blood pressure (right carotid, right
femoral, or either brachial pulse due to muscle twitching).
or
• Electrical capture is achieved but no pulse: Treat with the Asystole/PEA protocol.
or
• No electrical capture: Increase pacer to maximum energy setting and recheck all settings,
cables, battery charge, electrode placement, and patient's own rhythm.
10. ECG rhythm strips should be recorded and retained for documentation.
11. Continue all other supportive measures. (There is no risk of electrical shock from touching
the patient or from performing other procedures during pacing.)
Pediatric Pacing Indications
• bradycardias from surgically acquired AV blocks
• congenital AV block
• viral myocarditis
• newborn complete heart block due to maternal lupus
• heart block secondary to toxin or drug overdose
• Permanent pacemaker generator failure in the pediatric patient with an implanted
pacemaker.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 32
4.15 Eye Washing for Chemical and Small Foreign body
l . Remove the patient from the contaminated area.
2. Attempt to identify the chemical and notify the receiving facility.
3. Remove the patient's clothing (if necessary) and decontaminate with copious amounts of
water.
4. Remove contact lenses (if present) to ensure that chemicals are not trapped under the lenses.
5. To ensure adequate rinsing behind the eyelid, hold the lid with your thumb and index finger,
as it is normal for the eye to close when splashed.
6. Flush the eye away from the nose to avoid contamination of the other eye for a minimum of
20 minutes. Do not delay transport to complete the irrigation process.
7. Use any of these methods:
• Flush using a faucet spray from a sink or shower.
Flush using a bottle of normal saline or sterile water.
• Flush using a basin filled with water.
Flush using nasal cannula tubing.
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 33
4.16 Helmet/Face Mask Removal
4.16.1 Football Helmet Face Mask Removal
1. Apply manual in -line stabilization.
2. Employ any of these face mask removal methods:
Use a cordless screwdriver to remove the screws attaching the face mask to the helmet.
or
• Use a face mask extractor or other cutting device to cut the face mask straps.
3. Secure the patient to a long spine board.
4. Perform cervical immobilization.
Apply towel rolls on each side of the helmet and tape the helmet to the long spine board.
or
• Use a commercial cervical immobilization device.
4.16.2 Full Face Mask Helmet Removal
1. Apply manual in -line stabilization by placing your hands on each side of the helmet, with
your fingers on the patient's mandible.
2. Cut or disconnect the chin straps.
3. Transfer manual in -line stabilization to the second rescuer by placing one hand on the
patient's mandible (thumb on one side and fingers on the other side) and the other hand
under the patient's head at the occipital area.
4. Inspect the patient for glasses; remove them, if present.
5. Laterally move the helmet to clear the patient's ears.
6. Tilt the helmet backward to raise over the patient's nose and remove it.
7. Apply a cervical collar.
8. Secure the patient to a long spine board.
4.16.3 Football Helmet Removal
1. Apply manual in -line stabilization.
2. Consider completely removing the helmet in the following circumstances:
• The face mask cannot be removed after a reasonable period of time to access the
patient's airway.
• The helmet chin strap does not hold the patient's head securely.
The helmet prevents immobilization during transport.
3. Cut or disconnect the chin straps.
4. Transfer manual in -line stabilization to the second rescuer by placing one hand on the
patient's mandible (thumb on one side and fingers on the other side) and the other hand under
the patient's head at the occipital area.
5. Laterally move the helmet to clear the patient's ears.
6. Tilt the helmet backward to raise it over the patient's nose and remove it.
7. Apply a cervical collar.
8. If the patient has a chest pad on, it is important to apply padding under the head so the
cervical spine is maintained in a neutral position on the spinal board.
9. Secure the patient to a long spine board.
10. Perform cervical immobilization with a commercial cervical immobilization device.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 34
4.16 Helmet/Face Mask Removal
4.16.4 Other Helmets
In the absence of off -setting padding such as football shoulder pads, all other helmets should be
removed. Failure to do so will result in compromising the neutral alignment of the spine.
Helmets that should be removed include:
1. Motorcycle helmets
2. Bicycle helmets
3. Skateboard/Ski helmets
4. Roller blading helmets
Steps for Helmet Removal
1. Stabilize the helmet in the neutral in -line position and have a second individual remove the
chin strap.
2. The individual that removed the chin strap will then support the occiput and mandible while
the helmet is gently slipped up and forward.
3. Once the helmet is removed, standard c-spine control will take place and an appropriate
sized cervical collar applied.
Note: If the helmet is too snug or you encounter significant resistance during the removal
attempt, then leave the helmet in place and pad the body. Make sure you can access the airway.
Always check the helmet for damage to help assess mechanism of injury. Transport the helmet
with the patient if possible.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 35
4.17 Glucometer
The glucometer is designed to be used to test capillary blood for the level of glucose. Several
types of glucometers are available. The paramedic should refer to the user's manual for his/her
specific type for further information.
l . Select a sample site on the patient's finger and clean the area with an alcohol swab. Allow the
alcohol to dry before sticking the finger for a sample.
2. Tear off a single test strip packet. Note the expiration date on the packet. Open the packet and
fold back the foil ends to expose the meter end of the test strip.
3. Hold the test end of the test strip between the foil_ Insert the test strip fully into the test slot
located on the side of the meter; continue the insertion until a confirmation tone is heard.
4. Stick the patient's finger with a lancing device and press the finger to form a small drop of
blood. If blood does not readily form on the surface of the patient's skin, have the patient
lower his/her hand below the level of the heart to aid in this process.
5. Apply the drop of blood to the test strip.
6. Dispose of the sharp in a biohazard puncture -resistant container.
7. Following a brief delay, the blood glucose result appears in the display.
8. Remove and dispose of the test strip in biohazard garbage bag.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 36
4.18.1 Auto -injectors
4.18.1.1 Auto -Injector AtroPen
Mild symptoms of nerve agent (nerve gas) or insecticide exposure appear in situations where
exposure is known or suspected: blurred vision, miosis, excessive unexplained teary eyes,
excessive unexplained runny nose, increased salivation such as sudden unexplained excessive
drooling, chest tightness or difficulty breathing, tremors throughout the body or muscular
twitching, nausea and/or vomiting, unexplained wheezing or coughing, acute onset of stomach
cramps, tachycardia, or bradycardia. One AtroPen®is recommended if 2 or more of the above are
identified.
Severe symptoms include: strange or confused behavior, severe difficulty breathing or severe
secretions from the lungs/airway, severe muscular twitching and general weakness, involuntary
urination and defecation (feces), convulsions, or unconsciousness. If a victim is encountered who
is unconscious or has any of the severe symptoms, immediately administer 3 AtroPen injections
into the victim's midlateral thigh in rapid succession using the appropriate weight -based AtroPen
dose.
1. Check the expiration date.
2. Remove the auto -injector's safety cap.
3. Grasp the unit like a pen and position the tip of the AtroPen on the outer thigh mid -way
between waist and knee.
4. Push the auto -injector firmly against the site until the injector is activated.
5. Hold the auto -injector in place until the medication is fully injected (minimum of 10 seconds).
6. Record the time.
7. Dispose of the auto -injector in a biohazard puncture -resistant container.
8. Reassess the patient.
4.18.1.2 Auto -Injector EpiPen®
The EMT (or Paramedic) may administer prescribed epinephrine via an auto -injector for patients
who are exhibiting signs of respiratory distress associated with allergic reaction. These signs
may include dyspnea, hives, flushing of the skin, wheezing, edema, and possibly unstable vital
signs.
1. Assure the auto -injector is prescribed for the patient: EpiPen for adult patient and EpiPen
Jr.® for pediatric patient.
2. Check the expiration date.
3. Remove the auto -injector's safety cap.
4. Grasp the unit like a pen and position the tip of the EpiPen® on the outer thigh mid -way
between waist and knee.
5. Push the auto -injector firmly against the site until the injector is activated.
6. Hold the auto -injector in place until the medication is fully injected (minimum of 10 seconds).
7. Record the time.
8. Dispose of the auto -injector in a biohazard puncture -resistant container.
9. Reassess the patient.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 37
4.18.1.3 Auto -Injector DuoDote (source DuoDote.com)
The DuoDote® contains 2.1mg of atropine and 600 mg of Pralidoxime Chloride for use in nerve
agent & insecticide poisoning.
Before injecting
1. Tear open the plastic pouch at any of the notches. Remove the DuoDote auto -injector from
its protective pouch.
2. Place the DuoDote® in your dominant hand. Firmly grasp the center of the DuoDote with
the green tip (needle end) pointing down.
3. With your other hand, remove the gray safety release. The DuoDote® auto -injector is now
ready to be administered.
Select Site & Inject
4. The injection site is the mid -outer thigh area. The DuoDote® can inject through clothing.
However, make sure pockets at the injection site are empty.
5. Swing and firmly push the green tip against the mid -outer thigh; it should be at a 90 degree
angle to the thigh. Continue to firmly push until you feel the DuoDote trigger and begin
injecting the antidote. IMPORTANT: After the auto -injector triggers, hold the DuoDote in
place against the injection site for approximately 10 seconds.
After Injecting
6. Remove the DuoDote from the thigh and look at the green tip. If the needle is visible, the
drug has been administered. If the needle is not visible, check to be sure the grey safety
release has been removed and repeat the previous steps beginning with Step 4, but push
harder in Step 5.
7. After the drug has been administered, dispose of the unit in a biohazard puncture -resistant
container. If biohazard container is not available push the needle against a hard surface to
bend the needle back against the auto -injector.
8. Reassess the patient, immediately move yourself and the patient away from the contaminated arf
and seek definitive care for the patient.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 38
4.18.2 Intramuscular Injection (IM)
1. Prepare the equipment. The needle size should be 21-23 gauge and 1-1.5 inches long.
2. Check for proper medication, expiration date, vial integrity, and color and clarity. Draw the
medication into the syringe.
3. Preferred site is mid -lateral thigh, if the patient is obese use the distal portion of the thigh.
The deltoid can also be used but has a longer absorption rate.
4. Cleanse the injection site with alcohol or Betadine in an expanding circular pattern using a
firm pressure.
5. With one hand, pull the skin taut and insert the needle at a 90-degree angle into the muscle.
6. Aspirate to ensure that a blood vessel has not been entered. If blood is aspirated, remove the
needle and repeat the procedure at a different site.
7. Administer the appropriate dose.
8. Remove the needle from the injection site and dispose of it in a secure sharps container.
9. Monitor the patient.
4.18.3 Intranasal Medication Administration (IN) Mucosal Atomization Device (MAD)
Damaged nasal mucosa may inhibit absorption of the medication. For this reason,
contraindications for a MAD include the following conditions:
Facial trauma.
Epistaxis (nose bleed).
Nasal congestion or discharge.
Any recognized nasal mucosal abnormality.
1. Prepare the equipment.
2. Check the medication for proper name, expiration date, vial integrity, and color and clarity.
3. Draw the medication into the syringe.
Maximum adult and pediatric administration is 1 mL per nostril. The medication should
be split with 1/z of the dose given in one nostril and the other 1/z given in the other nostril.
4. Expel all of the air from the syringe.
5. Securely attach the mucosal atomizer to the syringe.
6. The patient should be in a recumbent or supine position. If the patient is sitting, compress
the nares after administration.
7. Briskly compress the syringe plunger to properly atomize the medication.
8. Monitor the patient.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 39
4.18.4 Intraosseous (IO)
4.18.4.1 BIG (Bone Injection Gun)
Adult
1. Find and mark a penetration site located 2 cm medially and 1 cm proximally to the tibial
tuberosity.
2. Clean the area with a povidone-iodine swab.
3. Position the BIG device with one hand to the site and pull out the safety latch with the other
hand.
4. Trigger the BIG at a 90-degree angle to the surface.
5. Remove the BIG handle.
6. Pull out the stylet trocar.
7. Fix the cannula with the safety latch.
8. Attach a 10-cc syringe filled with 1/z normal saline.
• Aspirate for bone marrow, and then flush with fluid.
• Observe for any signs of infiltration.
9. If the route is patent, connect it to the drip set tubing.
10. Attach a pressure infuser.
11. Secure the site.
Child
1. Find and mark a penetration site located 1 cm medially and 1 cm proximally to the tibial
tuberosity.
2. Clean the area with a povidone-iodine swab.
3. Position the BIG device with one hand to the site and pull out the safety latch with the other
hand.
4. Trigger the BIG at a 90-degree angle to the surface.
5. Remove the BIG handle.
6. Pull out the stylet trocar.
7. Fix the cannula with the safety latch.
8. Attach a 10-cc syringe filled with 1/z normal saline.
Aspirate for bone marrow, and then flush with fluid.
• Observe for any signs of infiltration.
9. If the route is patent, connect it to the drip set tubing.
10. Attach a pressure infuser.
11. Secure the site.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 40
Intraosseous (IO)
4.18.4.2 Cook Pediatric IO
1. Locate the site of cannulation. Palpate the tibial tuberosity, and move 1-3 cm below the
tuberosity on the medial surface of the tibia, approximately one finger's width below the
tuberosity.
2. Prep the area with antiseptic solution (e.g., povidone-iodine).
3. Grasp the patient's thigh and knee above and lateral to the insertion site with the palm of your
nondominant hand. Wrap your fingers and thumb around the knee to stabilize the proximal
tibia. Do not let any portion of your hand rest behind the insertion site.
4. Palpate the landmarks again to confirm the insertion site.
5. Insert the needle through the skin, over the flat anteromedial surface of the tibia.
6. Advance the needle through the bony cortex of the proximal tibia, directing the needle
perpendicular (90 degrees) to the long axis of the bone or slightly caudad (toward the toes) to
avoid the epiphysial plate, using a gentle back -and -forth twisting or drilling motion.
7. Stop advancing the needle when a sudden decrease in resistance to forward motion of the
needle is felt.
8. Unscrew the cap and remove the stylet from the needle.
9. Stabilize the needle and attach a 10-mL syringe filled with normal saline.
10. Aspirate for bone marrow, and then flush the needle with normal saline. Check for any signs
of increased resistance to injection or swelling of the surrounding tissue.
11. If the test injection is successful, remove syringe and connect the IV tubing.
12. Attach a pressure infuser.
13. Secure the site.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 41
Intraosseous (IO)
4.18.4.3 EZ IO
Locate an insertion site:
• Proximal Tibia
The proximal tibia insertion site is approximately 2 cm below the patella and
approximately 2 cm medial to the tibial tuberosity (depending on patient anatomy).
• Proximal Humerus — permitted in pediatrics when landmarks are clearly identified
The proximal humerus insertion site is located directly on the most prominent aspect of
the greater tubercle. Ensure that the patient's hand is resting on the abdomen and that the
elbow is adducted (close to the body). Slide thumb up the anterior shaft of the humerus
until you feel the greater tubercle, this is the surgical neck. Approximately 1 cm
(depending on patient anatomy) above the surgical neck is the insertion site. This is the
preferred site for patients who are responsive to pain. Once the insertion is completed
secure the arm in place to prevent movement and accidental dislodgement of the IO
catheter.
• Distal Tibia - The distal tibia insertion site is located approximately 3 cm proximal to
the most prominent aspect of the medial malleolus (depending on patient anatomy).
Place one finger directly over the medial malleolus; move approximately 3 cm proximal
and palpate the anterior and posterior borders of the tibia to assure that your insertion site
is on the flat center aspect of the bone.
2. Clean the area with a povidone-iodine swab.
3. Select the appropriate needle.
• Small (pink) 15mm needle: weight = 3-39 kg
• Medium (blue) 25mm needle: weight > 40 kg
Large (yellow) 45mm needle: weight > 40 kg and patients with excessive tissue over insertio
sites
4. Remove the needle from the case. Push the needle onto the power driver, and make sure that it i<
securely seated.
5. Remove and discard the needle set safety cap from the needle.
6. Insert the EZ-IO needle into the tibial site at a 90-degree angle to the bone surface.
7. Gently power the needle set until it touches bone, and then apply steady downward pressure.
8. Release the driver's trigger until:
• There is a sudden "give" or "pop.',
or
The needle reaches the desired depth at 5 mm, which is indicated on the needle by the black
line.
9. Remove the power driver and needle stylet.
10. Confirm that the catheter is stable.
11. Take the syringe containing 10 mL of normal saline and attach the EZ-IO catheter luer lock.
12. Use 5 mL of normal saline to flush the EZ-IO catheter luer lock; attach the luer lock
to the needle.
13. Pull back on the syringe to aspirate blood, and then flush with 5 mL of normal saline.
14. If the route is patent, connect it to the drip set tubing.
15. Attach a pressure infuser.
16. Secure the site and attach the wrist label to the patient's hand.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 42
4.18.5 Intravenous Cannulation
1. Locate a suitable venipuncture site. The back of the hand, forearm, and antecubital fossa are
preferred sites. The external jugular vein is acceptable if no other suitable site can be found.
2. Place a constricting band to halt venous return without obstructing arterial flow. Leave one
end of the slip knot exposed to assure rapid release when the procedure is complete.
3. Inspect the catheter to be sure that the catheter hub and primary push -off tab are fully seated
to the needle housing assembly.
4. Locate a suitable vein. Palpate one that is well fixed (not rolling) and that does not have
valves (firm nubs of tissue) proximal to the intended site of entry.
5. Cleanse the venipuncture site. Employ alcohol or Betadine in an expanding circular pattern,
using a firm pressure.
6. Anchor the vein with gentle skin traction.
7. Hold the needle bevel up and insert catheter at a 30- to 45-degree angle until you feel the
needle pop into the vein. Flashback of blood should be observed in the catheter/chamber.
8. At this point, the metal stylet is in the vein, but the catheter is not. Advance the cannula
approximately 0.5 cm farther. Holding the metal stylet stationary, slide the catheter over the
needle into the vein. Place a finger over the vein at the catheter tip and tamponade the vein
to prevent blood from flowing out of the catheter.
9. Remove the tourniquet. Do not reinsert the needle into the catheter at any time.
10. Secure a luer device to the catheter by following the manufacturer's instructions for that
device.
11. Secure the catheter with tape or a commercial device.
12. Dispose of the needle in a secure sharps container.
Troubleshooting a Nonflowing IV
• Has the constricting band been removed? This is the most common cause.
Is there swelling at the cannulation site? This indicates infiltration into the tissues.
• Are the tubing control valves open?
Does the cannula need to be repositioned because it is up against a valve or wall of the
vein? You may have to remove the securing device to check for this condition.
Is the IV bag hung high enough?
• Is the drip bag completely filled with solution? If it is, turn bag upside down and squeeze
the drip chamber to return some of the fluid to the bag.
• Lower the bag below the level of the insertion site. If blood return is seen in the IV site,
the site is patent.
If problems persist, remove the IV and reestablish it at another site.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 43
4.18.6 Nebulizer
1. Prepare the equipment for appropriate application:
Mask application: mask, mist chamber, oxygen supply tubing, and cylinder.
• Self -administration application: mouthpiece, mist chamber, oxygen supply tubing, and
cylinder.
2. Add medication to the nebulizer mist chamber. Make sure the nebulizer mist chamber cap is
tightly secured.
3. Gently swirl the nebulizer to mix the contents.
4. Attach the mouthpiece or mask.
5. Connect the nebulizer to the oxygen tubing and oxygen cylinder.
6. Set the flow:
Adult: 6-8 L/min
Pediatric: 6 L/min
7. The patient should breathe as calmly, deeply, and evenly as possible until no more
mist is formed in the nebulizer chamber (5-15 minutes).
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 44
4.19 Morgan Lens
Morgan Lens Insertion
1. Remove the patient's contact lenses, if present.
2. Instill topical local anesthetic (tetracaine HO 0.5% eye drops) to the affected eye(s)
3. Attach the Morgan lens to IV tubing or Morgan lens delivery set.
4. Prime the tubing and lens with irrigation solution.
5. Have the patient look down; insert the Morgan lens under the upper lid.
6. Have the patient look up; retract the lower lid to drop the lens in place.
7. Release the lower lid over the lens.
8. Adjust the flow to the desired rate.
9. Tape the tubing to the patient's forehead to prevent accidental lens removal.
10. Absorb any outflow with towels.
Removal of Morgan Lens
1. Have the patient look up; retract the lower lid behind the interior border of the lens.
2. Hold this position.
3. Have the patient look down; retract the upper lid and slide the lens out.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 45
4.20 Nitrous Oxide- Nitronox
l . Prepare the equipment. Nitronox units consist of a nitrous oxide cylinder, a blending
regulator, an oxygen cylinder, and a mask.
2. Contraindications: altered state of consciousness, COPD, acute pulmonary edema,
pneumothorax, decompression sickness, air embolus, pregnancy (except during delivery),
abdominal pain with distention or suspicion of obstruction, and inability to self-administer
the medication.
3. Turn the oxygen and nitrous oxide cylinder valves to the "on" position. Make sure the
device shows appropriate blending of the gases.
4. Attach a mask to the Nitronox unit regulator and provide it to the patient for self -
administration. The patient must be able to self-administer the medication; if he/she cannot,
Nitronox cannot be used.
5. Monitor the patient's vital signs and pulse oximeter. If the patient's vital signs become
unstable or the patient becomes symptomatic from the side effects, discontinue Nitronox.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 46
4.21 Pediatric Length -Based Emergency Tape: Broselow or Handtevy
The pediatric length -based emergency tape is designed to be used as a quick reference for drug
dosages and equipment sizing for pediatric patients. The tape is calibrated in different zones
according to different lengths. The zone that corresponds to the patient's length is used. If the
pediatric length -based emergency bag/box is also used, the zone on the tape can be matched
with the zone on the pouch that contains the appropriately sized equipment.
1. Place the patient in a supine position.
2. Remove the tape and unfold it.
3. Place the tape next to the patient, ensuring that the multicolored side faces up.
4. Place the red end of the tape even with the top of the patient's head.
5. Place the edge of one hand on the red end of the tape.
6. Starting from the patient's head, run the edge of your free hand down the tape.
7. Stop your hand even with the heel of the patient's foot. If the patient is larger than the tape,
stop here and use the appropriate adult technique.
8. Verbalize the zone on the tape (color and/or age) where your free hand has stopped. If the
patient falls on the line, go to the next higher section.
9. Use the medication doses which correspond to the zone selected.
10. Use the corresponding zone (color and/or age) to determine appropriate equipment sizes.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 47
4.22 Pulse Oximeter
Pulse oximeters are used for the detection of hypoxemia in arterial oxyhemoglobin. Peripheral
oxygen is obtained by placing a sensor probe on the peripheral capillary bed.
1. Attach the appropriate sensor to the patient's finger or toe. Remove any nail polish.
2. Turn on the pulse oximeter unit.
3. Evaluate the results:
• Normal range: oxygen saturation of 92-100%
Mild distress: oxygen saturation of 90-92%
• Moderate distress: oxygen saturation of 80-89%
• Severe distress: oxygen saturation of less than 80%
4. Oxygenate the patient with the appropriate delivery device based on the reading and the
patient's condition.
5. Evaluate the patient for possibly false high readings:
• Carbon monoxide poisoning: Elevated carboxyhemoglobin can falsely elevate saturation
readings because carboxyhemoglobin modulates light similar to oxyhemoglobin as it
passes through the tissue.
• Trauma: Despite a normal saturation level, severe hemorrhage can cause the patient to not
have enough blood to perfuse the organs, so that the patient is hypoxic.
6. Evaluate the patient for possibly false low readings:
Deeply pigmented patients: may diminish light transmission.
• Nail polish or fake nails: may diminish light transmission.
Patient movement: may cause the pulse oximeter to not register.
• Low blood flow states: may cause the pulse oximeter to not register.
7. Continuously monitor and document readings.
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 48
4.23.1 Pediatric Restraint System— Pedi-Mate®
Description - The Pedi-Mate® is designed to secure infants and toddlers from 10 to 40 lbs (4.5
to 18.1 kg) on a stretcher.
The Pedi-Mate® is designed for use only in an emergency setting and only by suitably trained
personnel. Where child restraint is needed outside of this setting, the transport applicable local
standards and regulations, including but not limited to, the United States Federal Motor Vehicle
Safety Standards and Regulations. The Pedi-Mate® is not designed as an immobilization device
and should not be used to immobilize the patient, or as part of an immobilization system.
Positioning the Pedi-Mate®
1. Remove any restraints attached to the cot.
2. Raise the cot backrest and lock in place at an angle between 15 and 45 degrees. This will
keep the patient's shoulders higher than the pelvis and maintain the proper center of gravity.
3. Unroll the Pedi-Mate® mattress with all straps extended.
4. Center the blanket left to right on the mattress.
5. Position the blanket with the black backrest strap at the point where you expect the patient's
shoulders to rest.
6. Using the Pedi-Mate®
7. Run the ends of the backrest strap around the cot backrest until they meet in the back, then
fasten the buckle. Leave some slack in the strap for
Securing the Pedi-Mate® to the stretcher
1. Place the patient on the Pedi-Mate®. If the black backrest strap is not at the patient's
shoulder level, adjust the blanket position.
2. With the blanket properly positioned, tighten the strap until the mattress is compressed.
3. Fasten a main frame strap by threading the free end downward between the cot main frame
and the mattress next to the head --end sidearm casting.
4. Wrap the strap up around the cot main frame and fasten the buckle. Leave a little slack in the
strap for final adjustment
5. Repeat with the other main --frame strap.
6. Tighten each main frame strap by holding onto the buckle with one hand and pulling firmly
on the free end of the strap.
Note: To loosen a main- frame strap, unfasten it, then grasp the buckle tang, and pull outward.
Refasten the buckle.
Securing the Pedi-Mate® to the stretcher
1. Place the patient on the Pedi-Mate®. If the black backrest strap is not at the patient's
shoulder level, adjust the blanket position.
2. With the blanket properly positioned, tighten the strap until the mattress is compressed.
3. Fasten a main frame strap by threading the free end downward between the cot main frame
and the mattress next to the head --end sidearm casting.
4. Wrap the strap up around the cot main frame and fasten the buckle. Leave a little slack in the
strap for final adjustment
5. Repeat with the other main --frame strap.
6. Tighten each main frame strap by holding onto the buckle with one hand and pulling firmly
on the free end of the
41h Edition 3/1/15 Florida Regional Common EMS Protocols 49
4.23.1 Pediatric Restraint System— Pedi-Mate
Securing the Patient
l . Pull the crotch strap buckle up between the patient's legs and lay the strap on the patient's
abdomen.
2. Lift a shoulder strap over one shoulder of the patient. Place patient's arm through the strap,
then lock the buckle half into the central buckle.
3. Repeat with the other shoulder strap.
4. Thread the shoulder strap on the patient's left side through the chest clip and slide the chest
clip to armpit level.
5. To snug the shoulder/torso straps, refer to Figure 6 and use the following procedure:
• Snug the shoulder strap against the shoulder and chest by pulling the end of the strap of
the strap with one hand while steadying the central buckle with the other hand.
• Repeat with the other shoulder strap.
• Snug the torso strap by pulling on the end of the strap with one hand while steadying
the central buckle with the other hand.
• Repeat with the other torso strap.
6. Snug the crotch strap by pulling on the free end.
Disinfecting the Pedi-Mate®
Wipe or spray disinfectant on all Pedi-Mate® and surfaces and straps. Follow the disinfectant
manufacturer's directions for application and contact time.
Cleaning the Pedi-Mate®
Hand wash the Pedi-Mate® blanket and straps with warm, soapy water and a clean cloth or soft
brush. Rinse with clear water. Dry the blanket with a towel and allow the straps to air dry.
Do not immerse the buckles in water.
straps
for Cot
Backs
strap
Adaustra
Tab
Buckle a
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Maim Fra
Shoulder chest
aps
Cat
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ustment
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Tab
4th Edition 3/1/15 Florida Regional Common EMS Protocols 50
4.23.2 Physical Restraints
A restraint is defined as any mechanism that physically restricts a person's freedom of
movement, physical activity, or normal access to his/her body. Restraints should be used only as
a last resort because they have the potential to produce serious consequences, such as physical
and psychological harm, loss of dignity, violation of the individual's rights, and even death.
Justification for the restraints must be noted in the EMS Run Report.
Restraints should be used only when attempts at pharmacological, verbal, and family
intervention have been deemed ineffective and when the patient is:
• Attempting to inflict intentional harm on self or others.
• Attempting to inflict bodily harm on EMS personnel.
Only a commercial soft restraint system should be used.
1. The patient should be placed supine on a long spine board (or backboard). Never place a
patient in the prone position.
• Use of a long spine board provides the flexibility to easily move the patient should he/she
vomit.
• It also provides a safe means of transfer from the stretcher to the bed.
2. Wrap the cuff pad around each limb.
• Do not cinch the strap tight. You should be able to insert one finger between the limb and
the device.
• Ensure that the device is properly applied per the manufacturer's instructions, as some
products can constrict circulation when improperly installed.
3. Secure one of the patient's arms on the upper part of the long spine board and the other arm
on the lower part of the long spine board.
4. Secure the patient's ankles to the lower portion of the long spine board.
5. Secure the strap to the long spine board with a quick -release tie.
6. Check for and correct any circulatory, respiratory, or neurological compromise caused by the
restraint.
7. Document the time when the restraint is applied.
8. Utilize the strapping mechanisms of the long spine board to provide additional security and
support for the patient with moving.
9. Continuously monitor the patient for the following issues:
Tightening of the strap around the limb.
• Changes in mental status.
• Changes in vital signs.
• Changes in pulse oximetry.
ECG changes.
• Changes in respiratory effort (positional asphyxia).
• Vomiting.
• Signs of circulatory and/or neurological compromise at the site of the restraint.
10. Immediately address any changes in patient status.
11. Document the duration of the restraint.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 51
4.24.1 Spinal Immobilization — Blunt Trauma
Determining the need for spinal immobilization requires a careful assessment of the patient's:
• Mechanism of Injury
• Mental status and ability to recognize the presence of spinal injury symptoms
• Physical complaints and overall condition
The following algorithm (Blunt Trauma) can be used to assist paramedics in making the most
appropriate decision about the need for spinal immobilization.
Blunt Trauma with Concerning Mechanism of Injury
Concerning Mechanism of Injury is defined as:
• Any mechanism that produces a violent impact on the head, neck, torso or pelvis
• Incidents that produce sudden acceleration or deceleration, including lateral bending forces
• Any fall, especially in the elderly
• Ejection or fall from a moving mode of transportation
Immobilize if any of the following exist:
Altered level of consciousness or inability to communicate:
• Abnormal GCS
• Evidence of significant intoxication
• Dementia
• Speech or hearing impairment
• Age (young children)
• Language barrier
Complaints suggestive of spinal injury:
• Spinal pain or tenderness, including paraspinal musculature
• Neurologic deficit or complaint, including parasthesia, paralysis or weakness
• Anatomical deformity of the spine
Distracting Injuries:
• Long bone fractures
• Joint dislocations
• Abdominal or thoracic pain, or obvious visceral injury
• Large lacerations, degloving injuries or crush injuries
• Serious burns
• Any injury producing acute functional impairment
IF IN DOUBT, IMMOBILIZE
41h Edition 3/1/15 Florida Regional Common EMS Protocols 52
4.24.2 Spinal Immobilization — Penetrating Trauma
Determining the need for spinal immobilization requires a careful assessment of the patient's:
• Mechanism of Injury
• Mental status and ability to recognize the presence of spinal injury symptoms
• Physical complaints and overall condition
The following algorithm (Penetrating Trauma) can be used to assist paramedics in making the most
appropriate decision about the need for spinal Immobilization
Penetrating Trauma
Immobilize if any of the following exist:
• Altered level of consciousness
Any neurological deficits* or complaints
o Test motor function in both upper and lower extremities (entire extremity)
o Test sensation in both upper and lower extremities (start proximal and work towards
hands and feet)
o Ask about numbness or tingling in extremities
* Examples are numbness, focal weakness, focal sensory deficit, parasthesias. Identifying the
presence of neurological signs and symptoms requires careful assessment and history taking.
IF IN DOUBT, IMMOBILIZE
Spinal precautions can be maintained by application of a cervical collar and securing patient
firmly to the stretcher without a long backboard if all 4 of these criteria are met:
1. Patient is ambulatory at the scene
2. Patient does not demonstrate an altered level of consciousness or inability to communicate
3. Patient does not have complaints suggestive of spinal injury
4. Patient does not have distracting injuries
Immobilize all patients with the following conditions:
• High voltage electrical injuries (does not include Taser use)
• Shallow water drowning or diving injuries
If spinal immobilization is indicated but refused by the patient:
• Advise the patient of the indication for immobilization, and the risks of refusing the interventio
• If the patient allows, apply the cervical collar even if backboard is refused
• Maintain spinal alignment as best as can be achieved during transport
• Clearly document refusal of immobilization
If spinal immobilization is indicated but the patient cannot tolerate supine position:
• Apply all elements of spinal immobilization that the patient will tolerate
• Maintain spinal alignment as best as can be achieved during transport
• Clearly document the clinical condition that interfered with full immobilization
41h Edition 3/1/15 Florida Regional Common EMS Protocols 53
4.24.3 Horizontal Spinal Immobilization
1. Manually immobilize the head in a neutral, in -line position. Manual immobilization should
be provided without interruption until complete patient immobilization is accomplished.
2. Contraindications to placement in an in -line position:
• Neck muscle spasm that prohibits neutral alignment.
• Increased pain.
• Onset of or increase of a neurological deficit such as numbness, tingling, or loss of motor
ability.
• Compromise of the airway or ventilation.
• If the patient's injuries are so severe that the head presents with such misalignment that it
no longer appears to extend from the midline of the shoulders.
3. Size and apply a cervical collar according to the manufacturer's recommendations.
4. While maintaining manual stabilization with a cervical collar in place:
• Log -roll the patient.
Position the backboard next to the patient so that the head of the backboard is
approximately 1-2 feet above the patient's head.
Roll the patient onto the backboard in a supine position.
• Reposition the patient to center him/her on the backboard, by sliding patient in an
upward motion (axial) on the board. Do not slide the patient in a direct lateral position,
as this may manipulate the spine.
5. Secure the patient's body to the board with straps.
• Immobilize the upper torso to prevent upward sliding of patient's body during movement
and transportation. This is accomplished by bringing the straps over the shoulders and
across the chest to make an X.
• Additional straps must be placed to prevent side -to -side movement of the body on the
board. This can be accomplished by placing the straps across the iliac crests and mid -to -
distal thigh or at the pelvis with groin loops.
• Arms should be placed at the patient's side to prevent movement of the shoulder girdle.
6. Secure the patient's head with a cervical immobilization device:
• Commercially available cervical immobilization device: Follow the manufacturer's
recommendation.
or
• Towel rolls applied to each side of the head: Secure the towels by placing 1- or 2-inch
tape directly across the patient's forehead to the underpart of the backboard. Also secure
the towels with tape across the surface of the semi -rigid cervical collar to the underpart
of the backboard. Do not apply tape directly under the patient's chin, as this may create
an airway obstruction.
7. Pad the space, as needed, between the back of the patient's head and the back -board to
prevent hyperextension of the cervical vertebrae.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 54
4.24.4 Pediatric Spinal Immobilization
1. Manually immobilize the patient's head in a neutral, in -line position. Manual immobilization
should be provided without interruption until complete patient immobilization is
accomplished.
2. Contraindications to placement in an in -line position:
• Neck muscle spasm that prohibits neutral alignment.
Increased pain.
• Onset of or increase of a neurological deficit such as numbness, tingling, or loss of motor
ability.
• Compromise of the airway or ventilation.
• If the patient's injuries are so severe that the head presents with such misalignment that it
no longer appears to extend from the midline of the shoulders.
3. Size and apply a cervical collar according to the manufacturer's recommendations.
4. While maintaining manual stabilization with a cervical collar in place:
Log -roll the patient.
• Position the pediatric immobilizer next to the patient so that the head of the immobilizer
is approximately 6-12 inches above the patient's head.
• Roll the patient onto the backboard in a supine position.
Reposition the patient to center him/her on the immobilizer, by sliding the patient in an
upward motion (axial) on the immobilizer.
Do not slide the patient in a direct lateral position, as this may manipulate the spine.
5. Secure the patient's body to the board with straps.
Pediatric immobilizers with integrated strapping design: Secure them according to the
manufacturer's recommendation.
or
• Immobilize the upper torso to prevent upward sliding of the patient's body during
movement and transportation. This is accomplished by bringing the straps over the
shoulders and across the chest to make an X.
• Additional straps must be placed to prevent side -to -side movement of the body on the
board. This can be accomplished by placing the straps across the iliac crests and mid -to -
distal thigh or at the pelvis with groin loops.
6. If the patient is so small that there is a space left between straps and sides of patient, take up
space with pads (e.g., blanket, towel).
7. The patient's arms should be placed at his/her side to prevent movement of the shoulder
girdle.
8. Secure the patient's head with a cervical immobilization device.
• Commercially available cervical immobilization device: Follow the manufacturer's
recommendation.
or
• Towel rolls applied to each side of the head: Secure the towels by placing 1- or 2-inch
tape directly across the patient's forehead to the underpart of the backboard. Also secure
the towels with tape across the surface of the semi -rigid cervical collar to the underpart
of the backboard. Do not apply tape directly under the patient's chin, as this may create
an airway obstruction.
9. Pad the space, as needed, between the back of the patient's head and the backboard to prevent
hyperextension of the cervical vertebrae.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 55
4.24.5 Standing Spinal Immobilization
1. Manually immobilize the patient's head in a neutral, in -line position from the front to
eliminate lateral movements. Manual immobilization should be provided without
interruption until complete patient immobilization is accomplished.
2. Contraindications to placement in an in -line position:
• Neck muscle spasm that prohibits neutral alignment.
Increased pain.
• Onset of or increase of a neurological deficit such as numbness, tingling, or loss of motor
ability.
Compromise of the airway or ventilation.
• If the patient's injuries are so severe that the head presents with such misalignment that it
no longer appears to extend from the midline of the shoulders.
3. Size and apply a cervical collar according to the manufacturer's recommendations.
4. Position the backboard behind the standing patient.
5. Have the rescuer performing manual stabilization of the head from the front of the patient
pass off the stabilization to a second rescuer who will perform manual stabilization of the
head from behind the patient, with arms on either side of the standing backboard. The third
rescuer can hold the backboard in place during this switch.
6. Have two rescuers on either side of the patient grasp the backboard with one hand and the
patient's armpit with the other hand.
7. With one rescuer at each side of the backboard and the third rescuer holding the patient's
head, slowly lay the board down. A stop approximately halfway down will be needed to
allow the rescuer holding the head to reposition his/her hands.
8. Reposition the patient to center him/her on the backboard, by sliding the patient in an
upward motion (axial) on the board. Do not slide the patient in a direct lateral position, as
this may manipulate the spine.
9. Secure the patient's body to the board with straps.
• Immobilize the upper torso to prevent upward sliding of patient's body during movement
and transportation. This is accomplished by bringing the straps over the shoulders and
across the chest to make an X.
• Additional straps must be placed to prevent side -to -side movement of the patient's body
on the board. This can be accomplished by placing the straps across the iliac crests and
mid -to -distal thigh or at the pelvis with groin loops.
• The patient's arms should be placed at his/her side to prevent movement of the shoulder
girdle.
10. Secure the patient's head with a cervical immobilization device:
• Commercially available cervical immobilization device: Follow the manufacturer's
recommendation.
or
• Towel rolls applied to each side of the head: Secure the towels by applying 1- or 2-inch
tape directly across the patient's forehead to the underpart of the backboard. Also secure
the towels with tape across the surface of the semi -rigid cervical collar to the underpart
of the backboard. Do not apply tape directly under the patient's chin, as this may create
an airway obstruction.
11. Pad the space, as needed, between the back of the patient's head and the back -board to
prevent hyperextension of the cervical vertebrae.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 56
4.24.6 Vest -Type Extrication Device (KED)
l . Manually immobilize the patient's head in a neutral, in -line position. Manual
immobilization should be provided without interruption until complete patient
immobilization is accomplished.
2. Contraindications to placement in an in -line position:
• Neck muscle spasm that prohibits neutral alignment.
Increased pain.
• Onset of or increase of a neurological deficit such as numbness, tingling, or loss of motor
ability.
• Compromise of the airway or ventilation.
• If the patient's injuries are so severe that the head presents with such misalignment that it
no longer appears to extend from the midline of the shoulders.
3. Size and apply a cervical collar according to the manufacturer's recommendations.
4. Insert the device behind the patient. Try to limit the patient's movement while you are
positioning the device.
5. Position the device so that it fits securely under the axilla of the patient. Open the side flaps
and place them around the patient's torso. Make sure the device is centered on the patient.
6. Position, connect, and adjust the torso straps. Leave the uppermost strap loose until the
patient's head is immobilized.
7. Position and fasten each groin loop. Adjust one side at a time to prevent excess movement
of the patient.
8. Place the pad behind the patient's head, filling the void to prevent hyperextension.
9. Position the head flaps. Fasten the forehead strap and apply the chin strap over the cervical
collar.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 57
4.25.1 Air Splint
1. Expose the injured area.
2. Evaluate the patient's distal pulse, motor function, and sensory function.
3. Align the extremity, stabilize it, and support the extremity.
Do not align a joint injury if resistance is met. Use another device instead.
4. Place your arm through the splint and grasp the patient's hand or foot.
5. Apply gentle traction while sliding the splint into position.
6. Inflate the splint to a point that a slight dent can be made into the plastic when pressed with a
finger.
7. Reevaluate the patient's distal pulse, motor function, and sensory function.
4.25.2 Hare Traction Splint
1. Expose the injured area.
2. Apply manual traction of the affected leg.
3. Check the patient's distal pulse, motor function, and sensory function.
4. Place the splint next to the uninjured leg. Adjust it to the proper length, from the top of the
patient's pelvis to a few inches past the ankle.
5. Attach the ankle hitch about the foot and ankle.
6. Manually apply gentle in -line traction to the ankle hitch.
7. Slide the splint into position under the injured leg.
8. Place the ischial pad against the iliac crest.
9. Fasten the ischial strap.
10. Connect the loops of the ankle hitch to the end of the splint.
11. Tighten the ratchet and release the manual traction. Continue to pull until the patient has
relief of pain and muscle spasms.
12. Secure the splint with straps.
13. Reevaluate the patient's distal pulse, motor function, and sensory function
4.25.3 Rigid Splinting
1. Expose the injured area.
2. Evaluate the patient's distal pulse, motor function, and sensory function.
3. Align the extremity, stabilize it, and support the extremity. Do not align a joint injury if
resistance is met.
4. Acquire the appropriate -length wood planks. Provide padding to ensure even contact with the
splint.
5. Place the wood on each side of the injury.
6. Secure the extremity to the rigid splint with tape, cling, or Ace wraps.
• Long bone injury: Immobilize the joint above and joint below the injury.
• Joint injury: Immobilize the bone above and bone below the injury.
7. Reevaluate the patient's distal pulse, motor function, and sensory function.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 58
4.25.4 Sager Traction Splint
1. Expose the injured area.
2. Apply manual traction to the affected leg.
3. Check the patient's distal pulse, motor function, and sensory function.
4. Position the Sager traction splint between the patient's legs.
5. Adjust the splint to a distance slightly past the patient's ankle.
6. Apply the abductor bridle (thigh strap) around the upper thigh of the fractured limb.
7. Push the ischial perineal cushion gently down while pulling the thigh strap snugly.
8. Apply the Malleolar Harness (ankle harness) and attach it to the traction handle.
9. Place one hand on the padded shaft and the other hand on the traction handle while gently
extending splint.
10. Pull the traction handle and release the manual traction. Continue to pull until one of the followin
conditions is met:
• Maximum of 7 kg (15 lb) for one femur fracture.
Maximum of 14 kg for bilateral femur fractures.
• Patient has relief of pain and muscle spasms.
11. Secure the splint with large elastic leg cravats.
12. Reevaluate the patient's distal pulse, motor function, and sensory function.
4.25.5 Vacuum Splint
1. Expose the injured area.
2. Evaluate the patient's distal pulse, motor function, and sensory function.
3. Align the extremity, stabilize it, and support the extremity. Do not align a joint injury if resistancf
is met.
4. Wrap and secure the vacuum splint around the extremity.
5. Draw the air out of the splint.
6. Reevaluate the patient's distal pulse, motor function, and sensory function
4Ih Edition 3/1/15 Florida Regional Common EMS Protocols 59
The degree of stimulation of the vagus nerve affects the heart rate. The greater the degree of
vagal stimulation, the more the vagus nerve will slow the heart rate, thereby inhibiting the SA
node.
4.26.1 Ice Water Immersion of the Face (Vagal Maneuvers)
1. Attach the patient to an ECG for continuous monitoring.
1. Establish intravenous access.
2. Determine that patient is conscious and cooperative.
3. Note that this procedure is contraindicated for patients with history of acute coronary
syndrome, hypertension, and heart transplant.
4. Document the ECG and any dysrhythmia.
5. Describe the procedure to the patient.
Fill a large basin or sink with ice water. It must be very cold.
• Ask the patient to hold his/her breath and put the entire face into the water for several
seconds.
OR
Fill a large latex exam glove with ice water.
• Place the glove on the patient's face for several seconds.
6. Continue to monitor the heart rhythm during the procedure. Stop the procedure if:
• The patient becomes confused.
The heart rate drops below 100 BPM.
• Asystole occurs.
4.26.2 Valsalva Maneuver (Vagal Maneuvers)
1. Attach the patient to an ECG for continuous monitoring.
2. Establish intravenous access.
3. Determine that the patient is conscious and cooperative.
4. Document the ECG and any dysrhythmia.
5. Describe the procedure to the patient.
• Have the patient inhale and hold his/her breath.
Bear down as if to have a bowel movement.
• Hold for 20-30 seconds.
Try to turn the face red.
OR
Have the patient blow forcefully through a straw or IV catheter for as long as possible.
6. Continue to monitor the heart rhythm during the procedure. Stop the procedure if:
The patient becomes confused.
• The heart rate drops below 100 BPM.
Asystole occurs.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 60
4.27.1 Wound Care — Hemostatic Dressing
Indications
Wounds involving the scalp, face, neck, axilla, groin or buttocks.
Severe wounds that cannot be controlled by other means (direct pressure/tourniquet).
Junctional hemorrhage
Contraindications
• Avoid contact with eye injuries
• Vaginal bleeding
• Internal bleeding
• Open abdominal or chest wounds
Procedure
1. Provide supportive care.
2. Apply direct pressure to wound or proximal pressure point (axillary junction or medical
groin).
3. If extremity wound and a trauma tourniquet is indicated, apply tourniquet.
4. If direct pressure is insufficient, apply hemostatic dressing; maintain direct pressure when
using hemostatic dressing.
5. Open the hemostatic dressing package and remove dressing.
6. Remove clothing around wound. Remove excess pooled blood from wound with gauze.
a. Preserve any clots already in the wound to aid in the clotting process.
b. When the source of the bleeding is located, pack the wound tightly and directly onto the
wound with the hemostatic dressing.
c. Use as much of the dressing as needed to stop the blood flow. The remainder of the
dressing can be used to cover the top of the wound.
7. Quickly apply pressure until the bleeding stops. Estimated time 3-5 minutes of continuous
pressure.
8. Leave the hemostatic dressing in place and wrap the area with kling or ace bandage to
secure wound and dressing.
9. Do NOT remove the bandage or hemostatic dressing, elevate the injury if needed.
10. Reassess the wound and patient for any changes and document.
11. Transport the patient to the appropriate trauma center.
Note
Hemostatic dressings are NOT appropriate for minor bleeding, bleeding that can be controlled by
direct pressure, or bleeding that can be controlled by the application of a trauma tourniquet.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 61
4.27.2 Wound Care — Trauma Tourniquet (Combat -Application TourniquetO C-A-T)
Indications for tourniquet use: to stop bleeding when;
• Life -threatening extremity hemorrhage that is not controlled by direct pressure or
immediately obvious that direct pressure alone will not provide control.
• Traumatic amputation has occurred
• Serious or life threatening extremity hemorrhage and tactical considerations prevent the
use of standard hemorrhage control techniques.
Contraindications
Non -extremity hemorrhage
Proximal extremity location where tourniquet application is not practical.
Procedure — Upper extremities/arms
1. Provide supportive care.
2. Apply direct pressure (with hand or knee) to wound or proximal pressure point (axillary
junction)
3. Expose the extremity by removing clothing in proximity to the wound
4. Place tourniquet over the extremity proximal to the wound over exposed skin.
5. Route the self -adhering band around the extremity.
6. Pass the band through the outside slit of the buckle
7. Pull the self -adhering band tight and secure the band back on itself with the velcro adhesive
strap.
8. Twist the windless rod until the bleeding has stopped.
9. Lock the rod in place with the windlass clip.
10. Secure the rod with the strap by pulling it tight and adhering it to the opposite hook on the
windlass hook
11. Record the date/time of application on the tourniquet.
12. Reassess the wound and patient for any changes and document.
13. When time and the tactical situation permit, a distal pulse check should be accomplished. If
a distal pulse is still present, consider additional tightening of the tourniquet or the use of a
second tourniquet, side by side and proximal to the first, to eliminate the distal pulse.
14. Transport the patient to the appropriate trauma center.
Procedure- Lower Extremities — Legs
1. Provide supportive care.
2. Apply direct pressure (with hand or knee) to wound or proximal pressure point (medial groin)
3. Expose the extremity by removing clothing in proximity to the wound
4. Place tourniquet over the extremity proximal to the wound high in the groin/thigh over
exposed skin.
5. Route the self -adhering band around the extremity. Pass the band through the inside/double
friction bracket slit of the buckle. Double friction bracket use must be used for lower
extremities.
6. Pull the self -adhering band tight and secure the band back on itself with the velcro adhesive
strap.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 62
7. Twist the windless rod until the bleeding has stopped.
8. Lock the rod in place with the windlass clip.
9. Secure the rod with the strap by pulling it tight and adhering it to the opposite hook on
the windlass hook
10. Record the date/time of application on the tourniquet.
11. Reassess the wound and patient for any changes and document.
12. When time and the tactical situation permit, a distal pulse check should be accomplished. If a
distal pulse is still present, consider additional tightening of the tourniquet or the use of a
second tourniquet, side by side and proximal to the first, to eliminate the distal pulse.
13. Transport the patient to the appropriate trauma center.
Note
If one tourniquet correctly applied does not completely control hemorrhage, in addition to direct
pressure, an additional tourniquet may be applied just proximal to the first tourniquet.
Once bleeding has been controlled by a tourniquet, leave the tourniquet in place throughout the
remainder of scene care and transport.
41h Edition 3/1/15 Florida Regional Common EMS Protocols 63
4.27.2 Wound Care — Trauma Tourniquet (Combat -Application TourniquetO C-A-T)
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4 Ih Edition 3/1/15 Florida Regional Common EMS Protocols 64
Florida Regional Common
EMS Protocols
Section 5
Drug Section
4th Edition Version 2, March 1, 2015
4Ih Edition Version 2, 111115 Florida Regional Common EMS Protocols 1
Packet Pg. 657
Drug Summary Section Table of Contents
5.1 Activated Charcoal (Actidose )
5.2 Adenosine Triphosphate (Adenocard®)
5.3 Albuterol (Proventil®, Ventoliri )
5.4 Amiodarone Hydrochloride (Cordarone®)
5.5 Aspirin
5.6 Atropine
5.6.1 Atropine Sulfate as Cardiac Agent
5.6.2 Atropine Sulfate as Antidote for Poisonings
5.7 Calcium Chloride 10%
5.8 Calcium Gluconate
5.9 Dextrose (Glucose)
5.10 Diazepam Hydrochloride (Valium®)
5.11 Diltiazem Hydrochloride (Cardizem )
5.12 Diphenhydramine Hydrochloride (Benadryl®)
5.13 Dopamine Hydrochloride (Intropin®)
5.14 Epinephrine
5.14.1 Epinephrine 1:1000
5.14.2 Epinephrine 1:10,000
5.15 Fentanyl
5.16 Glucagon
5.17 Haloperidol (Haldol®)
5.18 Hydroxocobalamin (Cyanokit®)
5.19 Ipratropium Bromide (Atrovene)
5.20 Ketamine hydrochloride
5.21 Lorazepam (Ativan®)
5.22 Magnesium Sulfate
5.23 Methylene Blue
5.24 Methylprednisolone Sodium Succinate (Solu-Medrol ®)
5.25 Midazolam (Versed®)
5.26 Morphine Sulfate (MS)
5.27 Naloxone Hydrochloride (Narcan®)
5.28 Nitroglycerin (Nitrostae, Nitrolingual® Spray)
5.29 Nitrous Oxide 50% Blended in Oxygen (Nitronox®)
5.30 Pralidoxime (2-PAM® Protopam Chloride®)
5.31 Sodium Bicarbonate 8.4% and 4.2%
5.32 Sodium Thiosulfate
5.33 Succinylcholine Chloride (Anectine®)
5.34 Tetracaine Hydrochloride 0.5% Eye Drops
5.35 Vasopressin
5.36 Vecuronium Bromide (Norcuron®)
5.37 Zofran (Ondansetron Hydrochloride)
4Ih Edition Version 2, 111115 Florida Regional Common EMS Protocols 2
Packet Pg. 658
ACTIONS
Activated charcoal binds and absorbs ingested toxins present in the gastrointestinal tract. Once
bound to the activated charcoal, the combined complex is excreted from the body.
INDICATIONS
Ingested poisons and medication overdoses after the stomach has been emptied or when
vomiting must not occur, but absorption therapy is indicated.
CONTRAINDICATIONS
Activated charcoal should not be administered to the patient who has, or has the potential for, an
altered level of consciousness unless it is administered by nasogastric tube and the patient's
airway is protected by an endotracheal tube. Avoid use in cyanide, methanol, organophosphate
toxicity, and/or caustic ingestion.
PRECAUTIONS
If emesis is to be induced with ipecac, it is often best to wait until the patient has vomited to
administer activated charcoal. Activated charcoal given with ipecac will inactivate the ipecac.
Contact the Poison Control Center or online medical control prior to administering activated
charcoal.
ADVERSE REACTIONS AND SIDE EFFECTS
Nausea, vomiting, abdominal cramping/bloating, and constipation (with black stools).
DOSAGE
Adult: 1 g/kg (average 50-75 g) PO of activated charcoal mixed with a glass of water to form a
slurry.
Pediatric: 1 g/kg PO of activated charcoal mixed with a glass of water to form a slurry
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Packet Pg. 659
ACTIONS
Adenosine exerts its effects by decreasing conduction through the AV mode. The half-life of
Adenocard (adenosine) is less than 10 seconds. Thus its effects - both desired and undesired - are
self -limited.
INDICATIONS
Adenocard is indicated for supraventricular tachycardia (SVT), including that associated with
accessory bypass tracts (Wolff -Parkinson -White syndrome). When clinically advisable,
appropriate vagal maneuvers should be attempted prior to Adenocard administration.
CONTRAINDICATIONS
Adenocard is contraindicated in second- or third-degree AV block and sick sinus syndrome
(except in patients with a functioning artificial pacemaker), and known hypersensitivity to
adenosine.
PRECAUTIONS
The effects of adenosine are antagonized by methylxanthines such as caffeine and theophylline.
Thus larger doses may be required for adenosine to be effective in patients who have taken
methylxanthines.
Adenosine effects are potentiated by dipyridamole (PersantineTM). Thus smaller doses of
adenosine may be effective in those who have taken this drug. Adenosine may produce
bronchoconstriction in patients with asthma.
ADVERSE REACTIONS AND SIDE EFFECTS
Cardiovascular: Facial flushing, headache, and rarely: sweating, palpitations, chest pain, and
hypotension.
Respiratory: Shortness of breath, chest pressure, and rarely: hyperventilating metallic taste,
tightness in throat, and head pressure.
CNS: Light headedness and rarely: dizziness, blurred vision, tingling and numbness in
extremities, apprehension.
WARNINGS
Adenocard may produce a short -lasting first-, second-, or third-degree heart block. In extreme
cases, transient asystole may result. At the time of conversion to normal sinus rhythm, a variety of
new rhythms may appear (PVCs, PACs sinus bradycardia, sinus tachycardia, skipped beats, and
varying degrees of AV block), though they generally last only a few seconds without
intervention.
DOSAGE
Adult: 6 mg rapid IVP immediately followed by 20 mL NS flush.
If not resolved repeat in 2 minutes at 12 mg IVP, followed by 20 mL NS flush PRN.
Pediatric: 0.1 mg/kg (maximum dose 6 mg) rapid IVP, immediately followed by 6 mL NS flush.
Repeat in 2 minutes, at 0.2 mg/kg (maximum dose 12 mg) rapid IVP, followed by 6 mL NS flush
PRN.
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ACTIONS
Albuterol is primarily a beta2 sympathomimetic and, as such, produces bronchodilation. Because
of its greater specificity for beta2-adrenergic receptors, it produces fewer cardiovascular side
effects and more prolonged bronchodilation than isoproterenol. Onset of action is within 15
minutes; peak action occurs in 60-90 minutes. Therapeutic effects may be active up to 5 hours.
INDICATIONS
The albuterol inhaler is indicated for relief of bronchospasm in patients with reversible
obstructive airway disease, including asthma.
CONTRAINDICATIONS
Albuterol is contraindicated in patients with a history of hypersensitivity.
ADVERSE REACTIONS AND SIDE EFFECTS
• Cardiovascular: Tachycardia, hypertension, and angina.
• CNS: Nervousness, tremor, headache, dizziness, and insomnia.
• GI: Drying of oropharynx, nausea, and vomiting, unusual taste.
WARNINGS
Use cautiously in patients with coronary
diabetes. Administer cautiously to patients
blockers and albuterol will inhibit each other
DOSAGE
artery disease, hypertension, hyperthyroidism, and
on MAO inhibitors or tricyclic antidepressants. Beta
If greater than 1 year or greater than 10 kg: Add 2.5 mg of albuterol already mixed in 3 mL of NS
(0.083%) to the nebulizer and flow oxygen at 6-8 L/min
If less than 1 year or less than 10 kg: Add 1.25 mg of albuterol already mixed in 1.5 mL of NS
(0.083%) to the nebulizer and flow oxygen at 3 L/min.
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ACTIONS
Amiodarone blocks sodium channels at rapid pacing frequencies and exerts a noncompetitive
antisympathetic action. One of its main effects, with prolonged administration, is to lengthen the
cardiac action potential_ In addition, it produces a negative chronotropic effect in nodal tissues.
Amiodarone blocks potassium channels, which contributes to slowing of conduction and
prolongation of refractoriness. Its vasodilatory action can decrease cardiac workload and
consequently myocardial oxygen consumption.
INDICATIONS
Amiodarone is indicated for initiation of treatment and prophylaxis of frequently recurring
ventricular fibrillation and hemodynamically unstable ventricular tachycardia in patients
refractory to other therapy. It may also be used to treat supraventricular tachycardia.
CONTRAINDICATIONS
Amiodarone is contraindicated in patients with known hypersensitivity to amiodarone, or in
patients with cardiogenic shock, marked sinus bradycardia, atrial fibrillation with Wolf Parkinson
White (WPW) and second or third degree AV block. Also tise withe„tier witIi patients a"ergie to
Vie -
PRECAUTIONS
Amiodarone may worsen existing or precipitate new dysrhythmias, including torsades de pointes
and VF. Use with beta -blocking agents could increase the patient's risk of hypotension and
bradycardia. Amiodarone inhibits atrioventricular conduction and decreases myocardial
contractility, increasing the risk of AV block with verapamil or diltiazem, or of hypotension with
any calcium -channel blocker. Use with caution in pregnant patients and nursing mothers. Also use
with caution with patients allergic to iodine.
ADVERSE REACTIONS AND SIDE EFFECTS
Adverse reactions include fever, bradycardia, CHF, cardiac arrest, hypotension, ventricular
tachycardia, nausea, and abnormal liver function.
DOSAGE
Adult: VT with pulse and SVT: 150 mg IV in 50 mL DSW over 10 minutes. May repeat every 10
minutes PRN.
VF and pulseless VT: 300 mg IV push, if unresolved consider repeat 150 mg IVP
Pediatric: VT with a pulse and SVT: 5 mg/kg in 50 mL DSW IV/IO over 20 minutes.
VF and pulseless VT: 5 mg/kg IV/IO push.
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ACTIONS
Aspirin is an analgesic, anti-inflammatory, and antipyretic agent, which also appears to inhibit
the synthesis and release of prostaglandins. Aspirin also blocks formation of thromboxane Az
(thromboxane Az causes platelets to aggregate and arteries to constrict). Use of aspirin can
reduce the overall mortality from acute myocardial infarction.
INDICATIONS
Aspirin is indicated in the acute myocardial infarction (AMI) setting to prevent further clotting.
CONTRAINDICATIONS
Known allergy to aspirin (e.g., asthma), active GI ulceration or bleeding, hemophilia or other
bleeding disorders, during pregnancy, children younger than 2 years of age.
ADVERSE REACTIONS AND SIDE EFFECTS
• GI: Nausea, vomiting, heartburn, and stomach pain.
• Otic: Tinnitus.
• Hypersensitivity: Bronchospasm, tightness in chest, angioedema, urticaria, and anaphylaxis.
DOSAGE
Adult: 162 mg chewable (2 tablets), up to 324 PO for AML (High doses may interfere with the
benefits of aspirin.)
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ACTIONS
Atropine is a potent anticholinergic (parasympathetic blocker, parasympatholytic) agent that
reduces vagal tone, thereby increasing automatically the SA node and increasing AV conduction.
INDICATIONS
Sinus bradycardia accompanied by hemodynamic com promise (e.g., hypotension; confusion;
frequent PVCs; pale, cold, clammy skin). In infants (< 6 months), bradycardia of less than 80
beats/min should be treated even if BP is normal.
CONTRAINDICATIONS
None in emergency situations.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, and
headache.
• Cardiovascular: Increased heart rate, may worsen ischemia or increase area of infarction,
ventricular fibrillation, ventricular tachycardia, angina, flushing of skin.
• GI: Dry mouth, difficulty swallowing.
• Other: Urinary retention; may worsen preexisting glaucoma.
WARNINGS
If a too -small dose (< 0.5 mg) is given or if atropine is pushed too slowly, it may initially cause
the heart rate to decrease. Antihistamines and antidepressants potentiate the effects of atropine. A
maximum dose of 0.04 mg/kg should not be exceeded. For second-degree AV block type II and
third-degree AV block, omit atropine and use an external pacer instead.
DOSAGE
Adult: Bradycardia: 0.5-1 mg IV, or 1-2 mg ET; may repeat every 3-5 minutes until improved or
total of 0.04 mg/kg or 3 mg is reached.
Pediatric: 0.02 mg/kg IV or ET (minimum dose = 0.1 mg; maximum single dose = 0.5 mg for a
child and 1 mg for an adolescent).
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ACTIONS - Atropine is a potent parasympatholytic agent that binds to acetyl choline receptors,
thereby diminishing the actions of acetylcholine.
INDICATIONS - Anti cholinesterase syndrome poisoning, such as with organophosphates (e.g.,
Parathion, Malathion, Rid -a -Bug) and carbamate (Baygon, Sevin, and many common roach and
ant sprays). Signs of organophosphate poisoning are Salivation, Lacrimation, Urination,
Defecation, GI distress, Emesis, Miosis — SLUDGEM - plus pinpoint pupils, bradycardia, and
excessive sweating.
CONTRAINDICATIONS - None when used in the management of severe organophosphate poisonin€
ADVERSE REACTIONS AND SIDE EFFECTS - Victims of organophosphate poisoning can
tolerate large doses (1000 mg) of atropine. Signs of atropinization are the endpoint of treatment:
flushing, pupil dilation, dry mouth, and tachycardia.
WARNINGS - It is important that the patient be adequately oxygenated and ventilated prior to
using atropine, as atropine may precipitate ventricular fibrillation in a poorly oxygenated patient.
Even after atropine is administered, the patient may require incubation and aggressive ventilatory
support.
DOSAGE
Adult: 0.03 mg/kg IV, repeat q 5-10 minutes until atropinization occurs.
Pediatric: 0.05 mg/kg (max dose 3 mg) IV, repeat q 5-10 minutes until atropinization occurs.
Atropen
Adults : FDA -approved uses: Poisoning, Anticholinesterase poisoning: At least 2 to 3 mg
parenterally; repeat until signs of atropine intoxication appear. AtroPen 2 mg is typically used for
adults and patients weighing more than 90 lbs.
The AtroPen auto -injector should be administered as soon as symptoms of organophosphorus or
carbamate poisoning appear (eg, usually tearing, excessive oral secretions, wheezing, muscle
fasciculations).More than 1 AtroPen may be required until atropinization is achieved (flushing,
mydriasis, tachycardia, dryness of the mouth and nose). No more than 3 AtroPen injections should
be used unless the /Patient is under the supervision of a trained medical provider. Different dose
strengths of the AtroPen are available depending on the recipient's age and weight.
Mild symptoms - One AtroPen is recommended if 2 or more of the following mild symptoms of
nerve agent (nerve gas) or insecticide exposure appear in situations where exposure is known or
suspected: blurred vision, miosis, excessive unexplained teary eyes, excessive unexplained runny
nose, increased salivation such as sudden unexplained excessive drooling, chest tightness or
difficulty breathing, tremors throughout the body or muscular twitching , nausea and/or vomiting,
unexplained wheezing or coughing, acute onset of stomach cramps , tachycardia, or bradycardia.
Severe symptoms - Two additional AtroPen injections given in rapid succession are recommended
10 minutes after receiving the first AtroPen injection if the victim develops any of the following
severe symptoms. If possible, a person other than the victim should administer the second and third
injections. If a victim is encountered who is unconscious or has any of the severe symptoms,
immediately administer 3 AtroPen injections into the victim's midlateral thigh in rapid succession
using the appropriate weight -based AtroPen dose. Symptoms include: strange or confused
behavior, severe difficulty breathing or severe secretions from the lungs/airway, severe muscular
twitching and general weakness, involuntary urination and defecation (feces), convulsions, or
unconsciousness.
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ACTIONS
Calcium chloride increases the force of myocardial contraction; it may either increase or
decrease systemic vascular resistance. In normal hearts, calcium's positive inotropic and
vasoconstricting effects produce a predictable rise in systemic arterial pressure.
INDICATIONS
Calcium chloride is indicated during resuscitation for the treatment of hypocalcemia and calcium -
channel blocker toxicity (e.g., Verapamil or Cardizem overdose) and magnesium sulfate
overdose. It also protects the heart from hyperkalemia, which may occur in patients with end -
stage renal disease.
CONTRAINDICATIONS
Cardiopulmonary arrest not associated with calcium -channel blocker toxicity, hypocalcemia, or
hyperkalemia.
ADVERSE REACTIONS AND SIDE EFFECTS
If the heart is beating, rapid administration of calcium can produce slowing of the cardiac rate.
WARNINGS
Calcium chloride should not be administered in the same infusion with sodium bicarbonate,
because calcium will combine with sodium bicarbonate to form an insoluble precipitate (calcium
carbonate). Calcium chloride should be given with extreme caution, and in reduced dosage, to
persons taking digitalis because it increases ventricular irritability and may precipitate digitalis
toxicity.
DOSAGE
Adult: For hypotension following administration of calcium -channel blockers (e.g., Cardizem,
Verapamil): 4 mg/kg IV, slowly. If the patient is taking digitalis, 2 mg/kg IV, slowly. Repeat every
10 minutes PRN.
For calcium -channel blocker overdose and hyperkalemia: 8-16 mg/kg IV, slowly.
Pediatric: 5 mg/kg or 0.2 mL/kg IV, slowly, every 10 minutes PRN.
For calcium -channel blocker overdose and hyperkalemia: 20 mg/kg IV, slowly.
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Packet Pg. 666
ACTIONS
Calcium is a basic element that is essential for growth and maintenance of nerve, muscle, and
bone tissue. It is necessary for transmission of nerve impulses; contraction of cardiac, smooth,
and skeletal muscles; renal function; respirations; and blood clotting. Calcium also plays an
important role in the regulation of neurotransmitters, hormones, and amino acid metabolism. Its
IV administration improves vascular tone and myocardial contractility in patients in hypocalcemic
states. Cardiac output and blood pressure usually increase. In cases of hydrofluoric acid toxicity,
calcium binds with fluoride ions, producing calcium fluoride.
INDICATIONS
Used in the treatment of hydrofluoric acid burns and magnesium sulfate overdose. Also indicated
in the management of black widow spider bites to relieve muscle spasms.
CONTRAINDICATIONS
• Absence of hydrofluoric acid burns or magnesium sulfate overdose
• Digitalis toxicity
ADVERSE REACTIONS AND SIDE EFFECTS
der IM administration can cause severe tissue necrosis and tissue sloughing. Calcium gluconate
can also induce serious cardiac dysrhythmias.
DOSAGE
Adult: Burns to eyes: Mix Calcium Gluconate (10%) 50 mL in normal saline 500 mL and wash the
eyes with the solution using a Morgan lens.
Burns to skin: Mix Calcium Gluconate (10%) 10 mL into a 2-oz tube of sterile water -based gel
lubricant (KY Jelly). Apply the gel to the burned skin area.
Inhalation: Administer Calcium Gluconate (10%) 1 mL mixed with normal saline 3 mL via
nebulizer. For severe exposure, administer calcium gluconate (10%) 1-2 g via slow IV over 5
minutes.
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols I 1
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ACTIONS
Glucose is a monosaccharide that provides calories for metabolic needs, thereby sparing body
proteins and preventing loss of electrolytes. It is readily excreted by the kidneys, producing
diuresis. Dextrose is a hypertonic solution.
INDICATIONS
Hypoglycemia; coma of unknown origin.
CONTRAINDICATIONS
• Intracranial or intraspinal hemorrhage
• DTs with dehydration
• Blood glucose level > 60 mg/dL
ADVERSE REACTIONS AND SIDE EFFECTS
• Cardiovascular: Thrombosis, sclerosing —if given in a peripheral vein.
• Local: Tissue irritation —if infiltration occurs.
• Other: Acidosis, alkalosis, hyperglycemia, and hypokalemia.
WARNINGS
May cause Wernicke-Korsakoff syndrome in acute alcohol intoxication; usually this outcome is
prevented by prior administration of thiamine 100 mg IM or IV, Thiamine can be given within
24 hours to treat Wernicke-Korsakoff . Perform a glucose test prior to administering dextrose.
DOSAGE
Adult: (above 8 years of age) 50 cc of a 50% solution; (25 g) IV.
If conscious, glucose paste/gel may be given orally (15g tube)
Pediatric: (8 years of age and under) 2 mL/kg slow IV of a 25% solution.
If conscious, and above 3 years of age glucose paste/gel may be given orally (15g tube).
Newborn: 5 mL/kg IV of a 10% solution (dilute Dso 4:1 with NS).
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 12
Packet Pg. 668
ACTIONS
A member of the benzodiazepine family, diazepam depresses the limbic system, thalamus, and
hypothalamus, resulting in calming effects. Diazepam produces an amnesic effect and is also a
muscle relaxant.
INDICATIONS
• Status epilepticus
• Premedication prior to cardioversion
• Agitation due to acute alcohol withdrawal
• Short-term relief of acute anxiety
• Cocaine intoxication
• Severe muscle spasm due to acute back strain
CONTRAINDICATIONS
• Acute alcohol intoxication
Pregnancy (except for control of seizures associated with status epilepticus or eclampsia)
Neonates
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Confusion, muscular weakness, blurred vision, drowsiness, respiratory depression,
respiratory arrest, slurred speech.
• Cardiovascular: Bradycardia, hypotension, and cardiovascular collapse.
• GI: Nausea, vomiting, abdominal discomfort, hiccups.
• Other: Potentiates MAOs, barbiturates, tricyclic antidepressants, and phenothiazines; potentiated
by cimetidine, ETOH, and other CNS depressants.
WARNINGS
Do not mix diazepam with any other drug, as it precipitates with almost all medications. When
injecting the drug via IV, administer it slowly through the IV tubing, as close as possible to the
vein insertion. Do not administer diazepam into small veins such as those on dorsum of the hand,
as this causes local irritation and possibly venous thrombosis in small veins.
DOSAGE
Adult: 5-20 mg IV. The IV route should be administered slowly no faster than 5 mg/min or 10 mg
PR.
Pediatric: For status epilepticus, 0.1-0.2 mg/kg (maximum dose 10 mg) IV slowly or 0.5 mg/kg
(maximum dose 10 mg) PR.
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Packet Pg. 669
ACTIONS
Diltiazem inhibits the influx of calcium ions during membrane depolarization of cardiac and
vascular smooth muscle. The therapeutic benefits of diltiazem in supraventricular tachycardias
are related to its ability to slow AV nodal conduction time and prolong AV nodal refractoriness.
Diltiazem slows ventricular rates and interrupts the reentry circuit in AV nodal reentrant
tachycardiac and reciprocating tachycardiac (e.g., Wolff -Parkinson -White syndrome). It also
prolongs the sinus cycle length and decreases peripheral vascular resistance.
INDICATIONS
• Atrial fibrillation or atrial flutter with rapid ventricular response.
• Paroxysmal supraventricular tachycardia. Unless contraindicated, vagal maneuvers should be
attempted prior to administration of diltiazem.
CONTRAINDICATIONS
• Sick sinus syndrome, except in the presence of a functioning ventricular pacemaker.
• Second- or third-degree AV block, except in the presence of a functioning ventricular
pacemaker.
• Severe hypotension or cardiogenic shock.
• Demonstrated hypersensitivity to diltiazem.
• Intravenous diltiazem and intravenous beta blockers should not be administered together or in
close proximity (within a few hours).
• Wolff -Parkinson -White syndrome or short PR syndrome.
• Ventricular tachycardia.
PRECAUTIONS
Diltiazem should be used with caution in patients with impaired liver or renal function.
Intravenous diltiazem administered to a patient who is taking oral beta blockers may cause
bradycardia, AV block, and/or depression of contractility. Caution should be used when
administering diltiazem and anesthetics. Caution should also be used in pregnant females and
mothers who are nursing. Use with caution if administered in the presence of CHF.
ADVERSE REACTIONS AND SIDE EFFECTS
Hypotension, itching or burning at the injection site, flushing of skin, or junctional rhythm. Other
side effects are less frequently encountered (e.g., AV blocks, atrial flutter, chest pain).
DOSAGE
Adult: 0.25 mg/kg IV over 2 minutes. If the tachyarrhythmia is not resolved in 15 minutes, may
repeat Diltiazem (Cardizem) 0.35 mg/kg IV or IO (over 2 minutes) (25 mg for the average
patient).
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ACTIONS
Diphenhydramine is an antihistamine with anticholinergic (drying) and sedative side effects.
Antihistamines appear to compete with histamine for cell receptor sites on effector cells.
Diphenhydramine prevents, but does not reverse, histamine -mediated responses particularly
histamine effects on the smooth muscle of the bronchial airways, gastrointestinal tract, uterus,
and blood vessels.
INDICATIONS
• Allergy symptoms, anaphylaxis (as an adjunct to epinephrine)
• Sedation of a violent patient
• Dystonic reactions from phenothiazine overdose (e.g., Haldol, Compazine, Thorazine, and
Stelazine)
• Rhinitis
• Anti-Parkinsonism syndrome
• Nighttime sedation
• Motion sickness
CONTRAINDICATIONS
Diphenhydramine is not to be used in newborn or premature infants or in nursing mothers. It is
also not to be used in patients with lower respiratory tract symptoms, including asthma.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Drowsiness, confusion, insomnia, headache, vertigo (all especially in the elderly)
• Cardiovascular: Palpitations, tachycardia, PVCs and hypotension.
• Respiratory: Thickening of bronchial secretions, tightness of the chest, wheezing, nasal
stuffiness.
• GI: Nausea, vomiting, diarrhea, dry mouth, and constipation.
• GU: Dysuria, urinary retention.
WARNINGS
• In infants and children especially, antihistamines in overdose may cause hallucinations,
convulsions, or death.
• As in adults, antihistamines may diminish mental alertness in children. In young children, they
may produce excitation.
• Diphenhydramine has additive effects with alcohol and other CNS depressants (e.g., hypnotics,
sedatives, tranquilizers).
• Antihistamines are more likely to cause dizziness, sedation, and hypotension in elderly patients
(60 years or older).
DOSAGE
Adult: 50 mg IV or 50 mg deep IM lateral thigh. The patient may require as much as 100 mg.
Pediatric: 1 mg/kg (maximum dose 50 mg). I1V1 or IV if administering IV dilute with 9 mL NS to
equal 50 mg/10 mL.
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ACTIONS
Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic receptors of the
sympathetic nervous system. It exerts an inotropic effect on the myocardium, resulting in an
increased cardiac output. Dopamine produces less increase in myocardial oxygen consumption
than does isoproterenol, and its use is rarely associated with tachyarrhythmia. Dopamine dilates
renal and mesenteric blood vessels at low doses that may not increase heart rate or blood pressure.
Therapeutic doses have predominant beta-adrenergic receptor -stimulating actions that result in
increases in cardiac output without marked increases in pulmonary occlusive pressure. At high
doses, dopamine has alpha -receptor stimulating actions that result in peripheral vasoconstriction
and marked increases in pulmonary occlusive pres sure.
INDICATIONS
To treat shock and correct hemodynamic imbalances, improve perfusion to vital organs, and
increase cardiac output.
CONTRAINDICATIONS
Dopamine should not be used in patients with pheochromocytoma or hypovolemic shock.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Headache.
• Cardiovascular: Ectopic beats, tachycardia, anginal pain, palpitations, hypotension.
• GI: Nausea, vomiting.
• Local: Necrosis and tissue sloughing with extravasation.
• Other: Piloerection, dyspnea.
WARNINGS
Do not administer dopamine in the presence of uncorrected tachydysrhythmias or ventricular
fibrillation. Do not add dopamine to any alkaline diluent solution, because the drug is inactivated
in alkaline solution.
Patients who have been treated with monoamine oxidase (MAO) inhibitors will require
substantially reduced dosage. MAO inhibitors include the following agents:
• Furazolidone (Furoxone)
• Isocarboxazid (Marplan)
• Pargyline hydrochloride (Eutonyl)
• Pargyline hydrochloride with methyclothiazide (Eutron)
• Phenelzine sulfate (Nardil)
• Procarbazine hydrochloride (Matulane)
• Tranylcypromine sulfate (Parnate)
DOSAGE
Adult: Mix dopamine in DSW or Normal Saline to yield a concentration of 800 or 1600 mcg/mL.
Begin the infusion at 5 mcg/kg/min and titrate to effect (maximum dose 20 mcg/kg/min).
Pediatric: Dopamine (1600 mcg/mL) Mix 400 mg in 250 mL of DSW, Concentration = 1600
mcg/mL, Dosage: 5-15 mcg/kg/min. Use a microdrip (60 gtt/mL) and refer to the Handtevy
Medication Guide for drip rate based on patient weight or age.
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ACTIONS
Epinephrine is a sympathomimetic agent that stimulates both alpha- and beta-adrenergic
receptors, causing immediate bronchodilation, increase in heart rate, and increase in the force of
cardiac contraction.
INDICATIONS
• Asthma
• Anaphylaxis
• Angioneurotic edema
CONTRAINDICATIONS
Hyperthyroidism, hypertension, cerebral arteriosclerosis in asthma. Epinephrine should not be
administered in elderly or debilitated patients with underlying cardiovascular disease. In the
setting of anaphylaxis, however, there are no contraindications.
ADVERSE REACTIONS AND SIDE EFFECTS
Same as for epinephrine 1:10,000 (Drug Summary 5.14.2).
WARNINGS
Same as for epinephrine 1:10,000 (Drug Summary 5.14.2). Epinephrine 1:1000 also causes
hyperglycemia. With the exception of cardiac arrest cases, Epinephrine 1:1000 should not be
given intravenously; it should be diluted first (1 mg in 9 mL of NS = 1:10,000 or 1 mg/10 mL).
DOSAGE
Adult: 0.3 mg (0.3-0.5 cc) IM preferred site lateral thigh; may be repeated every 15 minutes
maximum of 3 doses.
Pediatric: 0.01 mg/kg, up to 0.3 mg IM preferred site lateral thigh for asthma and anaphylaxis
may be repeated every 15 minutes maximum of 3 doses.
ET dose of Epinephrine (1:1000) can be given in a dosage of 0.1 mg/kg as a cardiac agent, max
dose 2.5mg mix with 5 cc of normal saline
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ACTIONS
Epinephrine is a sympathomimetic agent that stimulates both alpha- and beta-adrenergic
receptors. As a result of its effects, myocardial and cerebral blood flows are increased during
ventilation and chest compression. Epinephrine increases systemic vascular resistance and,
therefore, may enhance defibrillation.
INDICATIONS
Asystole, ventricular fibrillation unresponsive to defibrillation, PEA. Other pediatric indications:
hypotension in patients with circulatory instability, symptomatic bradycardia (before use of
Atropine).
CONTRAINDICATIONS
None in the cardiac arrest situation.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Anxiety, headache, cerebral hemorrhage.
• Cardiovascular: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations.
• GI: Nausea and vomiting.
WARNINGS
Epinephrine is inactivated by alkaline solutions - never mix it with sodium bicarbonate. Do not
mix isoproterenol and epinephrine, as this combination results in exaggerated response. The
action of catecholamines is depressed by acidosis; attention to ventilation and circulation is
essential. Antidepressants potentiate the effects of epinephrine.
DOSAGE
Adult: IV push (1:10,000): 1 mg (10 mL) IV; repeat every 3-5 minutes.
Pressor infusion: 1 mg/250 mL DSW; start at 1 mcg/min and titrate to effect.
For severe anaphylaxis ALS level 2
Epinephrine (1:100,000) 0.1 mg via slow IV over 5 minutes, Administration instructions
1. Remove 9 mL of Epi 1:10,000 from the 10 ml prefilled syringe
2. Fill the syringe backup with 9 mLs of normal saline, You now have Epi 1:100,000
3. Administer this solution IV (Epi 1:100,000) slowly over 10 minutes, titrate to clinical effect an,
systolic BP greater than 90.
Close hemodynamic monitoring is required when providing Epinephrine 1:100,000 IV
Pediatric: 0.01 mg/kg (0.1 mL/kg IV or IO); repeat every 3-5 minutes.
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ACTIONS
Fentanyl is similar to morphine and meperidine in its respiratory effects, except that respiration
of healthy individuals returns to normal more quickly after fentanyl. This agent exhibits little
hypnotic activity and histamine release rarely occurs.
Preferentially use intranasal delivery (IN) via MAD for those where IV access may be difficult to
obtain in a timely fashion (extremity burns/injuries) or not indicated for chief complaint (stable dento
or back pain) After each drug dosage administration, (divide dose equally between nostrils)
• Reassess the patient's pain
• Note adequacy of ventilation and perfusion
• Assess vital signs
• Monitor oxygen saturation & end -tidal CO2
INDICATIONS
For relief of moderate to severe pain.
Pain from acute myocardial infarction
Pain associated with isolated extremity fracture, renal colic, or burns
CONTRAINDICATIONS
• Contraindicated if systolic blood pressure less than 90 mmHg
• Pain due to trauma or acute abdomen (except isolated extremity trauma or burns)
• Volume depletion or hypotension
• Head trauma
• Acute alcoholism
• Depressed ventilatory function (e.g., COPD, cor pulmonale, emphysema and acute asthma
• Patients with known hypersensitivity to hydromorphone
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Sedation, drowsiness, mental clouding, lethargy, impairment of mental and physical
performance, anxiety, fear, dysphoria, dizziness, psychic dependence, and mood changes.
• Cardiovascular: Circulatory depression, peripheral circulatory collapse, and cardiac arrest have
occurred following rapid administration.
• Orthostatic hypotension and fainting may occur if the patient stands up following injection.
• GI: Nausea and vomiting, constipation, urinary retention
• Respiratory: Respiratory depression, bronchoconstriction, decreased cough reflex
WARNINGS
The concomitant use of other CNS depressantsincluding other opioids, sedatives or hypnotics,
general anesthetics, phenolthiazines, tranquilizers, skeletal muscle relaxants, sedating
antihistamines, potent inhibitors of P450 (e.g., erythromycin, ketoconazole, and certain protease
inhibitors), and alcoholic beverages may produce increased depressant effects. Hypoventilation,
hypotension, and profound sedation may occur.
DOSAGE
Adult - Fentanyl may be given 100 mcg IN increments every 5-10 minutes to a maximum of 200 me
IN or 50 mcg SLOW IV increments every 5-10 minutes up to a maximum of 100 mcg, titrated to pair
and BP remains above 90 mm Hg. If Fentanyl was initially given IN and an IV is then established,
one IV dose (50 mcg) can be given if needed.
Pediatric - 0.5 mcg/kg (maximum 25 mcg) SLOW IV; repeat once after 5 minutes as needed (max 5
mcg total dose) OR IN 1.5 mcg/kg (max 100 mcg)
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ACTIONS
Glucagon, which is produced naturally in the pancreas by the alpha cells of the islets of
Langerhans, causes an increase in blood glucose concentrations. It is effective in small doses,
and no evidence of toxicity has been reported with its use. Glucagon acts only on liver glycogen,
converting it to glucose if the patient has adequate glycogen reserves. Also, glucagon possesses
positive inotropic and chronotropic properties.
INDICATIONS
Glucagon is indicated for the treatment of hypoglycemia when an IV cannot be established and
oral glucose is contraindicated. It may also be effective in symptomatic beta-blocker overdose.
CONTRAINDICATIONS
Because glucagon is a protein, hypersensitivity is a possibility.
ADVERSE REACTIONS AND SIDE EFFECTS
Occasional nausea and vomiting.
WARNINGS
Glucagon should be administered with caution in patients with a history of insulinoma and/or
pheochromocytoma.
DOSAGE
Adult: 1.0 unit 1.0 mg) of Glucagon IM. This can be repeated once in 20 minutes.
Pediatric:
Patient less than or equal to 20 kg: 0.5 mg IM.
Patient greater than 20 kg: 1 mg IM
Not as effective in children as in adults
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ACTIONS
Haloperidol is a potent, long -acting butyrophenone derivative. It has pharmacologic actions
similar to those of piperazine phenothiazines, but is associated with higher incidence of
extrapyramidal effects, less hypotension, and relatively low sedative activity. It exerts a strong
antiemetic effect; it also impairs central ther moregulation. Haloperidol produces weak central
anticholinergic effects and transient orthostatic hypotension. Its actions are thought to be due to
blockade of dopamine activity.
INDICATIONS
Used for management of manifestations of psychotic disorders and for the treatment of agitated
states in acute and chronic psychoses.
CONTRAINDICATIONS
Hypersensitivity to haloperidol, Parkinson's disease, seizure disorders, coma, alcoholism, severe
mental depression, CNS depression, thyrotoxicosis, and cocaine overdose.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Parkinson -like symptoms, restlessness, lethargy, headache, exacerbation of psychotic
symptoms.
• Cardiovascular: Tachycardia, hypotension, hypertension (with overdose).
• GI: Nausea, vomiting.
• Other: Bronchospasm, laryngospasm, respiratory depression, dry mouth, hypersalivation
("drooling").
WARNINGS
Use with caution in patients with severe cardiovascular disorders (may cause transient
hypotension and/or precipitation of anginal pain), receiving anticonvulsant medication (may
lower the convulsive threshold), or with a history of allergic reactions to drugs.
DOSAGE
Adult: 5-10 mg IM
Pediatric: 0.lmg/kg IM (maximum 5 mg).
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ACTIONS
The action of hydroxocobalamin in the treatment of cyanide poisoning is based on its ability to
bind to cyanide ions. Each hydroxocobalamin molecule can bind one cyanide ion by substituting
it for the hydroxo ligand linked to the trivalent cobalt ion, thereby forming cyanocobalamin,
which is then excreted in urine.
INDICATIONS
Hydroxocobalamin is indicated for known or suspected cyanide poisoning. Cyanide poisoning
may result from inhalation, ingestion, or dermal exposure to various cyanide -containing
compounds, including smoke from closed -space fires. Sources of cyanide poisoning include
hydrogen cyanide and its salts, cyanogenic plants, aliphatic nitrites, and prolonged exposure to
sodium nitro-prusside.
The presence and extent of cyanide poisonings are often initially unknown. There is no widely
available, rapid confirmatory cyanide blood test. Treatment decisions must be made on the basis
of clinical history and signs and symptoms of cyanide intoxication. If clinical suspicion of
cyanide poisoning is high, hydroxocobalamin should be administered without delay.
Common Signs and Symptoms of Cyanide Poisoning
Symptoms
Signs
Headache
Altered mental status (e.g., confusion, disorientation)
Confusion
Seizures or coma
Dyspnea
Mydriasis
Chest tightness
Tachypnea/hyperpnea (early)
Nausea
Bradypnea/apnea (late)
Hypertension (early) / hypotension (late)
Cardiovascular collapse
Vomiting
Plasma lactate concentration 3 8 mmol/L
CONTRAINDICATIONS None.
ADVERSE REACTIONS AND SIDE EFFECTS
Serious adverse reactions include allergic reactions and increased blood pressure. Other side
effects include:
Red -colored urine
Red -colored skin and mucous membranes, acne -like rash
Nausea, vomiting, diarrhea, bloody stools, trouble swallowing, stomach pain
Throat tightness, dry throat
Headache, dizziness, memory problems, restlessness
Infusion site reaction
Eye swelling, irritation, or redness
Swelling of feet and ankles
Irregular heartbeat, increased heart rate
Fluid in lungs
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WARNINGS
In addition to hydroxocobalamin, treatment of cyanide poisoning must include immediate
attention to airway patency, adequacy of oxygenation and hydration, cardiovascular support, and
management of any seizure activity. Consideration should be given to decontamination measures
based on the route of exposure.
Many patients with cyanide poisoning will be hypotensive; however, elevations in blood
pressure have also been observed in known or suspected cyanide poisoning victims.
DOSAGE
Adult: 5 g packaged as a single 5 g vial or in two 2.5 g vials administered as an IV infusion over 15
minutes (approximately 15 mL/min)—if using the two vials 7.5 minutes per vial. Depending on
the severity of the poisoning and the clinical response, a second dose of 5 g may be administered by
IV infusion for a total dose of 10 g. The rate of infusion for the second dose may range from 15
minutes (for patients in extremis) to 2 hours, as clinically indicated.
Pediatric: 70 mg/kg 10 gtt/min over 15 minutes has been used to treat pediatric patients.
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ACTIONS
Ipratropium bromide is an anticholinergic (parasympatholytic) agent, which causes localized
bronchodilation.
INDICATIONS
Ipratropium bromide is indicated for relief of bronchospasms associated with asthma and chronic
obstructive pulmonary disease, including chronic bronchitis and emphysema that is unresponsive
to treatment with albuterol alone.
CONTRAINDICATIONS
Hypersensitivity to atropine or its derivatives.
ADVERSE REACTIONS AND SIDE EFFECTS
• Respiratory: Cough, exacerbation of symptoms.
• CNS: Nervousness, dizziness, headache.
• Cardiovascular: Palpitations.
• GI: Nausea, vomiting, GI distress.
• Other: Tremor, dry mouth, blurred vision.
WARNINGS
Ipratropium bromide is not indicated for the initial treatment of acute episodes of bronchospasms
where rapid response is required.
DOSAGE
Adult: Add 0.5 mg (0.5 mL) of Atrovent to the nebulizer (in addition to the standard dose of
albuterol) and flow oxygen at 6-8 L/min.
Pediatric: Add Ipratropium Bromide (Atrovent ®) to Abbuterol nebulizer treatment and flow
oxygen at 6-8 L/min
o If patient less than 8 year, 0.25mg/1.25mL
o If patient greater than 8 year, 0.5mg/2.5mL
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ACTIONS Nonbarbiturate anesthetic
INDICATIONS
• Violent Agitated Patient
• Failure to "talk patient down"
• Suspected "Excited Delirium" ( confusion, agitation, drug abuse)
• Resisting restraints putting self or crew in danger
CONTRAINDICATIONS
• Significant Head Trauma
• Increased intracranial pressure
WARNINGS/PRECAUTIONS
Respiratory depression/apnea may occur with overdosage or too rapid rate of use; employ
supportive ventilation and respiration. Caution with chronic alcoholics and acutely alcohol -
intoxicated and in elderly patients. Use in pregnancy is not recommended.
ADVERSE REACTIONS
• Hypertension and tachycardia, generally self limited
• Laryngospasm: may produce mild stridor, oxygen and BVM prn
• Hypersalivation
• Nausea and vomiting
• Tonic and clonic muscle movements
• Transient respiratory depression occasionally occurs
• Roving eye movements and nystagmus
PSYCHOLOGICAL ADVERSE REACTIONS
• Visual Hallucinations
• Emergence Delirium
• Sensation of detachment from the body
Adult Dosage IM or IN is the preferred route
4 mg/kg IM (max dose 400 mg) to the lateral thigh or deltoid
2 mg/kg IN
1 mg/kg IV
If safe to do so consider temporarily releasing the patient after injection till sedation occurs (2
or 3 minutes)
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ACTIONS
Lorazepam is a benzodiazepine, so it depresses the central nervous system. It produces sedation,
relieves anxiety, causes lack of recall, and provides for relief of skeletal muscle spasms.
INDICATIONS
Adjunct to seizure control
Control of violent patients
CONTRAINDICATIONS
Known sensitivity to benzodiazepines; narrow -angle glaucoma.
PRECAUTIONS
May cause respiratory depression.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Excessive CNS depression.
• Cardiovascular: Rarely hypotension/hypertension.
• Respiratory: Hypoventilation, partial airway obstruction.
• Local: Pain, burning, and redness at injection site.
• General: Nausea/vomiting and skin rash.
DOSAGE
Adult: 1-2 mg IV, IM or IN may be repeated once as needed, up to maximum of 4 mg.
Pediatric: 0.lmg/kg IV, IM or IN, maximum single dose 2 mg, if no effect after 5 minutes may be
repeated once to maximum of 4 mg.
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ACTIONS
Magnesium is an important cofactor for enzymatic reactions and plays an important role in
neurochemical transmission and muscular excitability. Magnesium prevents or controls
convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine
liberated at the end -plate by the motor nerve impulse. It is said to have a depressant effect on the
central nervous system, but it does not affect the mother, fetus, or neonate when used as directed
in eclampsia and pre-eclampsia. Magnesium acts peripherally to produce vasodilatation.
INDICATIONS
• Parenteral anticonvulsant for the prevention and control of seizures in severe toxemia of
pregnancy.
• Torsades de pointes.
• Severe asthma
• Suspected hypomagnesemic state (e.g., chronic alcoholism and chronic use of diuretics).
• Refractory ventricular fibrillation.
PRECAUTIONS - Because magnesium is removed from the body solely by the kidneys, this drug
should be used with caution in patients with renal impairment. Monitoring magnesium serum
levels and the patient's clinical status is essential to avoid the consequences of overdose and
toxemia. Clinical indications that it is safe to give magnesium to the patient include the presence
of a patellar reflex (knee jerk) and the absence of respiratory depression (approximately 16
breaths or more per minute). Calcium chloride should be immediately available to counteract the
potential hazards of magnesium intoxication in eclampsia.
ADVERSE REACTIONS AND SIDE EFFECTS - Adverse effects of magnesium sulfate IV
are usually the result of magnesium intoxication. Signs of hypermagnesemia include flushing,
sweating, hypotension, depression of reflexes, flaccid paralysis, hypothermia, circulatory
collapse, depression of cardiac function, and central nervous system depression. These symptoms
can precede fatal paralysis.
WARNINGS - Magnesium sulfate should not be given intravenously to mothers with toxemia of
pregnancy during the 2 hours immediately preceding delivery. Magnesium sulfate injection USP,
50%, must be diluted to a concentration of 20% or less prior to IV infusion.
DOSAGE
Adult:
For severe asthma — 2 g IV mixed in 50 mL D5W given over 30 minutes. Monitor the blood
pressure and if it decreases slow down or stop the infusion.
For eclampsic seizures 4 gm IV (mixed in 50 mL of D5W and administered over 5-10 minutes).
May repeat once at 2 g IV (mixed in 50 mL of D5W and administered over 5-10 minutes).
For torsades de pointes and refractory VF: 1-2 g IV (mixed in 50 mL of D5W and administered
over 1-2 minutes), followed by a maintenance infusion (1 g in 250 mL of D5W administered at 30-
60 gtts/min).
Pediatric:
For severe asthma— 40mg/kg (max 2 g) IV mixed in 50 mL D5W given over 30 minutes. Monitor
the blood pressure and if it decreases slow down or stop the infusion
For torsades de pointes (without a pulse) and refractory VF: 40mg/kg IV (mixed in 50 mL of D5W
and administered over 1-2 minutes if in arrest and over 10 min if torsades with pulse, followed by a
maintenance infusion (1 �4 in 250 mL of DSW administered at 30-60 ats/min).
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ACTIONS
Low concentrations of methylene blue will convert methemoglobin to hemoglobin
(methemoglobin is toxic and gives the blood a chocolate -brown color; it does not carry oxygen).
High concentrations convert ferrous iron of hemoglobin to ferric iron, thereby forming
methemoglobin.
INDICATIONS
Initial treatment of methemoglobinemia.
CONTRAINDICATIONS
Renal insufficiency (excreted in urine and bile).
ADVERSE REACTIONS AND SIDE EFFECTS
Cyanosis, profuse sweating, dizziness, headache, nausea, vomiting, diarrhea (turns urine and
stool blue-green). May induce hemolysis in patients deficient in glucose-6-phosphate
dehydrogenase.
DOSAGE Methylene blue (10 mg/mL)
Adult: 1 mg/kg of a 1% solution. Very slow IV push of 1 mL (10 mg) every 5 minutes.
Pediatric:I mg/kg IV over 5 minutes, See Handtevy Medication Guide (WMD page) for dosing
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ACTIONS
Methylprednisolone sodium succinate is a potent anti-inflammatory synthetic steroid.
INDICATIONS
Control of severe allergic reactions, asthmatic attacks, and bronchospasm associated with
COPD that do not respond to other treatments.
CONTRAINDICATIONS
Known hypersensitivity, neonates, and patients with systemic fungal infections.
ADVERSE REACTIONS AND SIDE EFFECTS
• Cardiovascular: Fluid retention, hypertension/hypotension, dysrhythmias, CHF, electrolyte
imbalance.
• CNS: Seizures, vertigo, headache.
• GI: Nausea/vomiting, GI bleeding, abdominal distention.
• General: Urticaria, anaphylactic reaction.
DOSAGE
Adult: Bronchospasm associated with asthma, COPD, or severe allergic reactions: 125 mg IV
Pediatric: Bronchospasm associated with asthma or severe allergic reaction: 2 mg/kg IV
(maximum dose 60 mg).
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ACTIONS
Midazolam is a short -acting benzodiazepine (a central nervous system depressant) that produces
sedation and lack of recall.
INDICATIONS
• Status epilepticus
• Premedication prior to cardioversion
• Agitation due to acute alcohol withdrawal
• Short-term relief of acute anxiety
• Cocaine intoxication
• Severe muscle spasm due to acute back strain
CONTRAINDICATIONS
• Acute alcohol intoxication
Pregnancy (except for control of seizures associated with status epilepticus or eclampsia)
Neonates
PRECAUTIONS
Midazolam does not protect against the increase in intracranial pressure and bradycardia
associated with multiple intubation attempts.
ADVERSE REACTIONS AND SIDE EFFECTS
• Respiratory: Respiratory depression, laryngospasm, bronchospasm, dyspnea.
• Cardiovascular: PVCs, bradycardia, tachycardia, nodal rhythms, hypotension.
• CNS: Retrograde amnesia, altered mental status, dizziness, prolonged emergence from
anesthesia.
• GI: Nausea/vomiting, hiccoughs, coughing.
• Local: Pain, redness, swelling, burning at injection site.
DOSAGE
Adult: Sedation and seizures: 2 -5 mg increments IV, IO, IM, or IN. Maximum total dose of
10 mg.
Pediatric: 0.1mg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once if
necessary. Maximum total dose of 10 mg.
For IN administration, administer lml per nare, give half the volume in one nostril and the other
half of the volume in the other nare.
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ACTIONS
Morphine is a narcotic analgesic. It depresses the central nervous system and decreases
sensitivity to pain. It increases venous capacitance, decreases venous return, and produces mild
peripheral vasodilatation. Morphine also decreases myocardial oxygen demand.
INDICATIONS
• Pain from acute myocardial infarction
• Pain associated with isolated extremity fracture, renal colic, or burns
CONTRAINDICATIONS
• Pain due to trauma or acute abdomen (except isolated extremity trauma or bums)
• Volume depletion or hypotension
• Head trauma
• Acute alcoholism
• Acute asthma
• Known hypersensitivity to MS
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Euphoria, drowsiness, pupillary constriction, respiratory arrest.
• Cardiovascular: Bradycardia, hypotension.
• GI: Decreased gastric motility, nausea and vomiting.
• GU: Urinary retention.
• Respiratory: Bronchoconstriction, decreased cough reflex
WARNINGS
Morphine is detoxified by the liver. It is potentiated by alcohol, antihistamines, barbiturates,
sedatives, and beta blockers.
DOSAGE
Adult: 5 mg -SLOW IV may repeat once in 5 - 10 minutes until desired response is achieved
(maximum dose 10 mg). Can also be given IM
Pediatric: 0.1-0.2 mg/kg IV slowly.(maximum single dose 4 mg)
Infant: 0.05 mg/kg IV slowly
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ACTIONS
The mechanism of action for naloxone hydrochloride is not fully understood. It does appear that
this agent antagonizes the effects of opiates by competing at the same receptor sites. When given
IV, the action is apparent within 2 minutes. Effects appear slightly more slowly with IM.
INDICATIONS
Naloxone is indicated for the complete or partial reversal of opiate narcotic depression and
respiratory depression secondary to opiate narcotics or related drugs: Naloxone can also be used
for suspected acute opiate overdosage.
Codeine
Methadone
Fentanyl (Sublimaze;
known on the street as
"white china"
Morphine
Heroin
Pentazocine (Talwin)
H dromo hone (Dilaudid)
Percodan
Lomotil
Propoxyphene (Darvon)
Meperidine (Demerol)
CONTRAINDICATIONS
Naloxone is contraindicated in patients known to be hypersensitive to it.
Nebulized Narcan with EtCO2 greater than 45 and Sp02 less than 94% or inadequate ventilatory
effort.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear production,
sweating, seizures secondary to withdrawal.
• Cardiovascular: Hypertension, hypotension, ventricular tachycardia, pulmonary edema, ventricular
fibrillation.
• GI: Nausea, vomiting
WARNINGS
Naloxone should be administered cautiously to persons (including newborns of mothers) who are
known or suspected to be physically dependent on opiates; it may precipitate an acute abstinence
syndrome in these individuals. Naloxone administration may need to be repeated in this scenario
because the duration of action of some narcotics may exceed that of naloxone. Naloxone is not
effective against a respiratory depression caused by non -opiate drugs. Use caution during its
administration because patients may become violent as their level of consciousness increases.
DOSAGE
Adult:
• Administer Naloxone (Narcan) 0.4 mg IV, I0, IM every minute and titrate to effect to a maximum
dose of 10 mg. If no response after 10 mg, then condition is probably not due to narcotic.
• If administering Naloxone (Narcan) via IN, must use concentration 2 mg/2 mL and administer 2
mg, repeat 3-5 minutes to a maximum dose of 10 mg. (For IN administration refer to 4.18.5)
• If administering Naloxone (Narcan) via nebulization must use concentration 2 mg/2 mL (add 2 mg
of Narcan to 3 mL of saline) and titrate to effect.
Pediatric:O.I mg/kg IV, IM, I0, IN may repeat with 0.1 mg/kg if no improvement is noted
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 32
Packet Pg. 688
ACTIONS
Nitroglycerin is a direct vasodilator that acts principally on the venous system, although it also
produces direct coronary artery vasodilation. Its use decreases venous return, which in turn
decreases the workload on the heart, and thereby decreases myocardial oxygen demand.
Sublingual nitroglycerin is readily absorbed. Pain relief occurs within 1-2 minutes and
therapeutic effects can last as long as 30 minutes.
INDICATIONS
• Chest pain or discomfort associated with suspected AMI or angina pectoris
• Pulmonary edema with hypertension
CONTRAINDICATIONS
Patients with increased intracranial pressure, systolic blood pressure less than 489 90 mm Hg,
children younger than 12 years.
PRECAUTIONS
Tolerance to nitrates easily develops, which necessitates increasing the dosage. Nitroglycerin
tablets are inactivated by light, heat, air, and moisture, so they must be kept in amber glass
containers with tight -fitting lids. Do not leave cotton in the container. wee toe eefft iffe - is
opened, nitfeglyeer-in has a shelf life of 3 ment4s. P4ients shetild keep all btA a few days' s"pl
Do not shake Nitrolingual spray. Alcohol will accentuate the
vasodilating and hypotensive effects of nitroglycerin.
The patient has taken any of the following erectile dysfunction medications. (Note the following
medications are also marketed under a variety of other trade names).
a. Stendra (Avanafil) — in the past 12 hours
b. Viagra (Sildenafil) — in the past 24 hours
c. Levitra (Vardenafil) or Cialis (Tadalafil) — in the last 48 hours
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Headache, dizziness, flushing, nausea and vomiting.
• Cardiovascular: Hypotension, reflex tachycardia.
DOSAGE
Adult: 0.4 mg (1 tablet or 1 spray sublingual); may repeat in 3-5 minutes (maximum dose of 1.2
mg or 3 doses).
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 33
Packet Pg. 689
ACTIONS
Nitrous oxide is a colorless gas that acts on the central nervous system. When mixed with 50%
oxygen and inhaled, it produces an effect similar to a mild intoxicant. The patient laughs and
talks but does not go to sleep. When inhaled, nitrous oxide has potent analgesic effects, which
dissipate within 2-5 minutes after stopping its administration.
INDICATIONS
Moderate to severe pain, as in trauma, burns, renal colic, and labor.
CONTRAINDICATIONS
Nitrous oxide is contraindicated in any altered state of consciousness (e.g., head injury, alcohol
ingestion, drug overdose). It is also contraindicated in patients with COPD, acute pulmonary
edema, pneumothorax, decompression sickness, air embolus, abdominal pain with distention or
suspicion of obstruction, and pregnancy (except during delivery), and in patients who are unable
to self-administer Nitronox.
ADVERSE REACTIONS AND SIDE EFFECTS
Light-headedness, confusion, drowsiness, nausea and vomiting.
WARNINGS
Because nitrous oxide is heavier than air, it may accumulate on floor of ambulance. During
transits lasting more than 15 minutes, nitrous oxide may affect ambulance personnel.
DOSAGE
Blended mixture of 50% nitrous oxide and 50% oxygen, which is self administered through
inhalation. Also apply 02 cannula at 4-6 L to maintain 02 therapy when nitrous oxide is not
being ad ministered.
Note: Also see Medical Procedure 4.21, Nitrous Oxide-Nitronox
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 34
Packet Pg. 690
ACTIONS
Pralidoxime reactivates cholinesterase that has been deactivated by organophosphorous
pesticides and related products. It inactivates acetylcholine at both muscarinic and nicotinic sites
in the periphery.
INDICATIONS
Organophosphorous toxicity; used as an adjunct to systemic atropine administration.
CONTRAINDICATIONS
• Poisoning with Sevin (a carbamate insecticide); Sevin increases the drug's toxicity.
• Use with extreme caution in patients with a history of asthma, renal insufficiency, and peptic
ulcers.
ADVERSE REACTIONS AND SIDE EFFECTS
• CNS: Dizziness, headache, drowsiness, excitement.
• Cardiovascular: Tachycardia.
• EENT: Blurred vision, diplopia, impaired accommodation, laryngospasm.
• GI: Nausea.
• Other: Muscular weakness or rigidity, hyperventilation.
• Rapid injection of 2-PAM can cause tachycardia, laryngeal spasm, muscle rigidity, and transient
neuromuscular blockage.
DOSAGE Pralidoxime (2-PAM) (1 g dry powder: Mix with 20 cc sterile water (50 mg/mL)
Adult: IV infusion 1-2 g in 100 mL of saline over 30 minutes.
If pulmonary edema is present, give IVP over 5 minutes.
Pediatric: 25 mg/kg IV See Handtevy Medication Guide (WMD page) for dosing, Dilute
recommended dose with NS and infuse over 10 minutes, then can provided continuous infusion
at 5-10 mg/kg/hr.
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 35
Packet Pg. 691
ACTIONS
This alkalizing agent is used to buffer acids present in the body during and after severe hypoxia.
Bicarbonate combines with excess acids (usually lactic acid) present in the body to form a weak,
volatile acid. This acid is broken down into CO2 and H2O. Sodium bicarbonate is effective only
when administered in patients who have adequate ventilation and oxygenation.
INDICATIONS
Metabolic acidosis due to the following causes:
• Salicylate (aspirin) overdose
• Barbiturate overdose
• Tricyclic antidepressant overdose
• Hyperkalemia
• Severe ketoacidosis
• Cardiac arrest
• Shock
• Physostigmine toxicity
• Methanol toxicity
• Ethylene glycol toxicity
CONTRAINDICATIONS
Congestive heart failure; alkalosic states.
ADVERSE REACTIONS AND SIDE EFFECTS
Metabolic alkalosis; hypernatremia; cerebral acidosis; sodium and H2O retention, which can cause
CHF.
WARNINGS
Excessive bicarbonate therapy inhibits the release of oxygen. Bicarbonate does not improve the
ability to defibrillate. Administration of sodium bicarbonate may inactivate simultaneously
administered catecholamines; it will create an insoluble precipitate if mixed with calcium
chloride. Administration should be guided by arterial blood gases and pH data, when available.
DOSAGE
Adult: 1 mEq/kg IV (8.4%). Repeat with 0.5 mEq/kg q 10 minutes.
Pediatric: 1 mEq/kg IV (8.4%). Repeat with 0.5 mEq/kg q 10 minutes.
Infant: 1 mEq/kg IV (4.2%) slowly; may repeat in 10 minutes.
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 36
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ACTIONS
Sodium thiosulfate converts cyanide to the less toxic thiocyanate. The thiocyanate is then excreted
in the urine.
INDICATIONS
Used in acute cyanide toxicity; not useful in hydrogen sulfide toxicity.
CONTRAINDICATIONS
None in acute cyanide toxicity.
DOSAGE Sodium Thiosulfate (25%
Adult: 12.5 g (50 mL of 25% solution) given by slow IV over 10 minutes.
Pediatric:1.2 mL/kg IV over 10-20 minutes, See Handtevy Medication Guide (WMD page) for
dosing
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 37
Packet Pg. 693
ACTIONS
Succinylcholine chloride is a short -acting skeletal muscle paralytic. Onset of action occurs in 1-2
minutes, with recovery happening in 5-10 minutes. This agent works by depolarizing the
receptors on skeletal muscle. It then blocks the action of acetylcholine, which causes enhanced
cholinergic activity, with the face and neck muscles being affected first. These effects are
followed by paralysis of the chest, diaphragm, and other skeletal muscles. Use of succinylcholine
may trigger histamine release.
INDICATIONS
Facilitation of endotracheal incubation.
CONTRAINDICATIONS
• Known sensitivity to succinylcholine or other anesthetics
• Preexisting neuromuscular disease (myasthenia gravis)
• Organophosphate or anti cholinesterase toxicity
• Severe burns or eye injuries
• Tetanus
ADVERSE REACTIONS AND SIDE EFFECTS
• Prolonged respiratory depression
• Bradycardia (rare tachycardia or hypertension)
• Hypersalivation and bronchospasm
DOSAGE Succinylcholine (20mg/mL)
Adult: 1 mg/kg IV over 30-60 seconds
Pediatric:
1 year and below: 2 mg/kg IV/IM
2 years and above: 1 mg/kg IV/IM
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 38
Packet Pg. 694
ACTIONS
Tetracaine is an ophthalmic solution that anesthetizes the eyes. The onset of anesthesia usually
begins within 20 seconds and lasts as long as 15 minutes.
INDICATIONS
Tetracaine is intended for use in the patient who is unable to cooperate with the provider in
adequately flushing the eye(s) due to discomfort or pain. If flushing can be accomplished easily,
tetracaine may not be needed.
CONTRAINDICATIONS
Allergy to any topical anesthetic.
PRECAUTIONS
Do not use the solution if it contains crystals, or if it is cloudy or discolored. Tetracaine eye
drops are for topical ophthalmic use only - not for injection. The patient should be advised not to
touch or rub the eye(s) until the effect of the anesthesia has worn off.
DOSAGE Adult and Pediatric
1 drop in the eye.
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 39
Packet Pg. 695
ACTIONS
Vasopressin is a naturally occurring antidiuretic hormone. In unnaturally high doses —much
higher than those needed to produce antidiuretic hormone effects vasopressin acts as a non-
adrenergic peripheral vasoconstrictor. It directly stimulates smooth muscle V1 receptors. In
recent studies, after a short duration of ventricular fibrillation, vasopressin during CPR increased
coronary perfusion pressure, vital organ blood flow, ventricular fibrillation median frequency, and
cerebral oxygen delivery.
INDICATIONS
Vasopressin is indicated for patients with shock -refractory VF and VT without a pulse.
CONTRAINDICATIONS
None in cardiac arrest.
PRECAUTIONS
None in cardiac arrest.
ADVERSE REACTIONS AND SIDE EFFECTS
None in cardiac arrest.
DOSAGE
Adult: 40 units IV push
41h Edition Version 2, 111115 Florida Regional Common EMS Protocols 40 An
Packet Pg. 696
ACTIONS
Vecuronium bromide is a short -acting, nondepolarizing skeletal muscle relaxant. Its binding with
cholinergic receptor sites inhibits transmission of nerve impulses, antagonizing the action of
acetylcholine. Vecuronium bromide has no analgesic properties, and the patient may be
conscious but unable to communicate by any means. The first muscles affected are those of the
eyes, face, and neck, followed by the limbs, abdomen, and chest; the diaphragm is affected last.
Recovery usually occurs in the reverse order and may take longer than 60 minutes. With IV
administration, the onset of action is in 30-60 seconds; peak action occurs in 3-5 minutes and the
effects last for 30-60 minutes.
INDICATIONS
An authorized paramedic may induce general anesthesia to facilitate intubation.
PRECAUTIONS
Vecuronium bromide causes respiratory paralysis —supportive airway control must be continuous
and under direct observation at all times. Myasthenia gravis and other neuromuscular diseases
increase sensitivity to the drug.
ADVERSE REACTIONS AND SIDE EFFECTS
Hypersensitivity reactions are possible.
DOSAGE
Adult and Pediatric (over 10 years): 0.08-0.1 mg/kg; slow administration over 30-60 seconds IV
Dose is usually 5-7 mg for an average -size adult.
Pediatric (1-9 years of age): May require a higher dose.
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Packet Pg. 697
ACTIONS
Ondansetron hydrochloride (Zofran) blocks serotonin receptors (5HT3) found in the neurons of
the gastrointestinal system and in the area of the brain that controls nausea and vomiting.
INDICATIONS
Ondansetron is useful in the prevention and treatment of nausea and vomiting
PRECAUTIONS
Ondansetron can be associated with a prolongation of the QT interval. Therefore, do not use
Ondansetron in patients with a known long QT interval or who are taking medications that are
known to prolong the QT interval. Arrhythmias believed to be caused by prolongation of the QT
interval should be treated immediately with IV Magnesium Sulfate (Protocol 2.3.6). Zofran ODT
contains Phenylalanine which is aspartame artificial sweetener found in Equal. May cause an
allergic reaction to patients allergic to aspartame.
ADVERSE REACTIONS AND SIDE EFFECTS
Hypersensitivity reactions are possible.
Common side effects of Ondansetron include abdominal pain, anxiety, diarrhea, fever, dizziness,
drowsiness, constipation and headache.
Uncommon side effects of Ondansetron include chest pain, decrease in blood pressure, itch, rash,
tremor and uncontrolled muscle movements.
DOSAGE
Adult
Oral 4 mg PO disintegrating tablet (ODT) placed under the tongue. May repeat at 10-15
minutes with maximum dose of 8 mg
Injection 4 mg slow IV push over 2-3 minutes OR 11\4 lateral thigh. May be repeated once if
no improvement within 10-15 minutes. Do not exceed 8 mg total dosage
Pediatric
Oral
Less than 20 kg : Do NOT administer
20 kg - 39 kg (5-11 year): 4 mg oral disintegrating tablet (ODT) placed under the tongue. Dose may
not be repeated
40 kg or more (12 year or older): 4 mg oral disintegrating tablet (ODT) placed under the tongue
May repeat at 10-15 minutes with maximum dose of 8 mg
Injection
Less than 40 kg: 0.1 mg/kg SLOW IV over 2-3 minutes or 11\4 (preferably in the lateral thigh). Do nc
repeat.
40 kg or more: 4 mg. SLOW IV push over 2-3 minutes or 11\4 (preferably in the lateral thigh)
May be repeated once if no improvement within 30 minutes. Do not exceed 8 mg total dosage
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Florida Regional Common
EMS Protocols
Section 6
Appendix
4th Edition, Version 2, March 1, 2015
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols
Appendix Section Table of Contents
6.1 Abdominal Pain Differential
6.2 Abuse
6.2.1 Report of Abuse
6.2.2 Signs of Child Abuse
6.2.3 Signs of Elderly Abuse
6.3 APGAR Score
6.4 Burns
6.4.1 Bums Severity Categorization
6.4.2 Burns Rule of Nines
6.5 Chest Pain Differential
6.6 Consent for the Care of a Minor
6.7 Dive Accident Checklists
6.7.1 Dive History Profile
6.7.2 Dive Accident Signs and Symptoms
6.7.3 Dive Accident Rapid Field Neurological Exam Record
6.8 Emergency Worker Rehabilitation Form
6.9 Glasgow Coma Scale Score
6.9.1 Adult Glasgow Coma Scale Score
6.9.2 Pediatric Glasgow Coma Scale
6.10 Types of EMS Information
6.10.1 Types of Care
6.10.2 Types of EMS Providers
6.10.3 Types of EMS Units
6.10.4 Types of Patients
6.11 Hospital Information
6.11.1 Hospital Capabilities
6.11.2 Hospital Capabilities Worksheet (see on-line form)
6.11.3 Hospital List
6.12 Infectious Disease Exposure
6.12.1 Exposure Form
6.13 IV Drip Calculations
6.14 Medical Abbreviations
6.15 Medical Terminology
6.16 Pediatric Vital Signs
6.17 Phone Numbers
6.18 Safe Haven for Newborns
6.18.1 Birth Mother Questionnaire
6.19 Sepsis Alert Form
6.20 Stroke Forms
6.21 Trauma Transport Protocol
6.21.1 County Unified Trauma Telemetry — CUTT form
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Upper GI Bleed
Lower GI Bleed
Gynecological
History of peptic ulcer
May be occult or bright
Think ectopic! if the patient is
disease; can cause massive
red; a common cause of
still having menses; diagnosis
hemorrhage
orthostatic hypotension and
includes:
undetected anemia
1. Lower abdominal pain
2. Hypotension
3. Shoulder pain
4. Vaginal bleeding +/-
5. Syncope
Common Causes Associated with the Difference T es of Presenting Pain
Upper GI Bleed
Lower GI Bleed
Gynecological
Esophageal varices (history
Diverticulitis
Ectopic pregnancy
of cirrhosis, hepatitis
Peptic ulcer disease
Hemorrhoids
Pelvic inflammatory
disease/STDs
Aspirin, NSAIDS
Cancer
Ovarian cyst
Alcohol
Inflammatory bowel
Kidney/urinary infection
disease
Ingestion of caustic
Chronic diarrhea, overuse
Endometriosis
substances
of laxatives
Back Pain
Colicky Pain
Peritoneal Pain
Vomiting
Every pain
Spasmodic—
Rigid, board -like
Nonspecific
presenting with
usually results from
abdomen,
syndrome, can be
new onset back
smooth muscle
resulting from
caused by a wide
pain (> 60 years)
contracting against
infection or long-
variety of
should have an
obstruction of
standing rupture
underlying
abdominal exam
hollow organ
problems, some of
R/O AAA
I
I
I which are serious
Common Causes Associated with the Different Types of Presen ng Pain
Back Pain
Colicky Pain
Peritoneal Pain
Vomiting
Abdominal aortic
Bowel obstruction
Ruptured
Infection of GI
aneurysm
appendix
tract
Cholelithiasis
Renal
Ruptured ovarian
Ulcers
obstruction/"kidney
cyst
stones"
Pancreatitis
Gallbladder
Pelvic
Toxic ingestions
obstruction
inflammatory
disease (PID)
Perforated ulcer
Ulcerative colitis
Perforated ulcer
Bowel obstruction
Crohn's disease
Peritonitis,
Stones of the
advanced
gallbladder or
kidney
Reference Bosker G, MD; Sequeira M, MD, FACED; Weins D, MD, FACEP: The 60-Second EMT: Rapid BLS/ALS
Assessment, Diagnosis, and Triage, 2nd edition, Mosby, St. Louis, MO, 1996
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols
415.504 Mandatory reports of child abuse or neglect; mandatory reports of death; central abuse
hotline.
(1) Any person, who knows, or has reasonable cause to suspect, that a child is an abused,
abandoned, or neglected child shall report such knowledge or suspicion to the department.
415.511 Immunity from liability in cases of child abuse or neglect.
(1) (a) Any person, official, or institution participating in good faith in any act authorized or
required by FS 415.502-415.514, or reporting in good faith any instance of child abuse to any
law enforcement officer shall be immune from any civil or criminal liability which might
otherwise result by reason of such action.
415.513 Penalties relating to abuse reporting.
(1) A person who is required by FS 415.504 to report known or suspected child abuse or neglect;
and who knowingly and willfully fails to do so, or who knowingly or willfully prevents another
person from doing so, is guilty of a misdemeanor of the second degree.
Report Elder Abuse or Neglect
The Florida Department of Elder Affairs is committed to ensuring the safety and well-being of
the elders in Florida. The Department works in conjunction with the Department of Children and
Families (DCF) Adult Protective Services (APS) and the Aging Network to protect disabled
adults or elderly persons from further occurrences of abuse, neglect or exploitation. Services
provided may include protective supervision, placement and in -home and community -based
services.
How To Report Child, Elder Abuse, Neglect and Exploitation
By Phone: Call Florida Abuse Hotline at 1-800-96-ABUSE (1-800-962-2873). Press 1 to report
suspected abuse, neglect or exploitation of the elderly or a vulnerable adult, press 2 to report
abuse, neglect or abandonment of a child. This toll free number is available 24/7. TDD
(Telephone Device for the Deaf): 1-800-453-5145
By Fax: To make a report via fax, please send a detailed written report with your name and
contact telephone to 1-800-914-0004.
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6.2.2 Signs of Child Abuse
PHYSICAL ASSESSMENT SUGGESTIVE OF CHILD ABUSE
1. Fractures in children younger than 2 years of age.
2. Injuries in various stages of healing.
3. Frequent injuries.
4. Bruises or bums in patterns (e.g., iron or cigarette burns, cord marks, bite or pinch marks, and
bruises to head, neck, back, or buttocks).
5. Widespread injuries over the body.
6. Obvious physical neglect (malnutrition, lack of cleanliness).
7. Inappropriate dress (e.g., very little clothes in winter).
HISTORY SUGGESTIVE OF CHILD ABUSE
1. The history does not match with the nature or severity of the injury.
2. The parents' and/or caregivers' account is vague or changes.
3. The "accident" is beyond the capabilities of the child (e.g., a 12-month-old who burns
himself/herself by turning on the hot water in the bathtub).
4. There is a delay in seeking help.
5. The parent and/or caregiver may be inappropriately unconcerned about the child's injury
CHARACTERISTICS OF THE ABUSED CHILD
1. If younger than 5 years old, is likely to be passive.
2. If older than 5 years of age, is likely to be aggressive.
3. Does not look to the parent (the abuser) for support, comfort, or reassurance.
4. May cry without any expectation of receiving help.
5. May be quiet and withdrawn.
6. May be fearful of the parent (the abuser).
CHARACTERISTICS OF THE ABUSER
1. Crosses all religious, ethnic, occupational, educational, and socioeconomic boundaries.
2. May resent or reject the child.
3. May have feelings of worthlessness about self or about the child.
4. May have unrealistic expectations of what the child is capable of doing.
5. May be very critical of the child.
6. Oftentimes is repeating what the abuser learned as a child (the abuser was more than likely
abused as a child).
7. May be overly defensive rather than concerned.
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6.2.3 Signs of Elderly Abuse (information from the Florida Department of Elder Affairs)
The Power to Prevent Elder Abuse
Physical signs may include cuts, puncture wounds, burns, bruises, welts, dehydration or
malnutrition, poor coloration, sunken eyes or cheeks, soiled clothing or bed, or lack of
necessities such as food, water or utilities.
Behavioral Signs of Abuse:
Behavioral signs may include fear, anxiety, agitation, anger, isolation, withdrawal, depression,
non -responsiveness, resignation, ambivalence, contradictory statements, implausible stories,
hesitation to talk openly, confusion or disorientation.
What Is Abuse?
Physical Abuse Pushing, striking, slapping, kicking, pinching, restraining, shaking, beating,
burning, hitting, shoving or other acts that can cause harm to an elder.
Emotional or Psychological Abuse: verbal berating, harassment, intimidation, threats of
punishment or deprivation, criticism, demeaning comments, coercive behavior or isolation from
family and friends.
Financial or Material Exploitation: Improper use of an elder's funds, property, or assets; cashing
checks without permission; forging signatures; forcing or deceiving an older person into signing
a document; using an ATM/debit card without permission.
Sexual Abuse: Nonconsensual sexual contact of any kind including assault or battery, rape,
sodomy, coerced nudity or sexually explicit photographing.
Self -neglect: When individuals fail to provide themselves with whatever is necessary to prevent
physical or emotional harm or pain.
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The APGAR score should be used in newborns at 1 and 5 minutes after birth. If the patient is not
immediately improving after birth, see Pediatric Protocol 3.4.1, Newborn Resuscitation.
The APGAR score occurs right after the baby's birth. The test is designed to quickly evaluate a
newborn's physical condition after delivery and to determine any immediate need for extra medical
or emergency care.
The acronym stands for: Activity, Pulse, Grimace, Appearance, and Respiration.
The APGAR test is preformed at 1 minute after birth, and again at 5 minutes after birth.
Five factors are used to evaluate the baby's condition and each factor is scored on a scale of 0 to 2
• appearance (skin coloration)
• pulse rate (heart)
• grimace response (medically known as "reflex irritability")
• activity and muscle tone
• breathing (rate and effort)
These five factors together to calculate the APGAR score. Scores obtainable are between 10 and 0,
with 10 being the highest possible score.
APGAR Scoring 2 1 0
Appearance Normal color all over Body pink, hands and Bluish -gray or pale all
(skin color) (hands and feet are pink) feet bluish over
Pulse Rate Normal (above 100 beats Less than 100 beats
(heart rate) per minute) per minute
Grimace (irritability Vigorous cry Some motion,
response to flick on Pulls away, sneezes, or Weak cry
sole") coughs with stimulation
Activity Active, spontaneous Some flexion of
(muscle tone) movement extremities
Respiratory Normal rate and effort Slow or irregular
(rate and effort) breathing
Absent (no pulse)
Absent (no response to
stimulation)
Flaccid, limp
Absent (no breathing)
A baby who scores a 7 or above on the test at 1 minute after birth is generally considered in good health
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6.4.1 Burn Classification
Burn Classification
Characteristics
Minor burn injury
First -degree (P) burn Second- degree (2°)
burn < 15% BSA in adults
Second-degree (2°) burn < 5% BSA in
children/elderly Third-degree (Y) burn < 2%
BSA
Moderate burn injury
Second-degree (2°) burn 16-25% BSA in
adults Second-degree (2°) burn 5-20% BSA
in children/elderly Third- degree (Y) burn 2-
10% BSA
Major burn injury
Second-degree (2°) burn > 25% BSA in
adults
Second-degree (2°) burn > 20% BSA in
children/elderly
Third-degree (Y) burn > 10% BSA
Burns involving the hands, face, eyes, ears,
feet, or perineum
Most patients with inhalation injury, electrical
injury, concomitant major trauma, or
significant preexisting diseases
6.4.2 Rules of Nine
is
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Myocardial
Angina
Dissecting
Pericarditis
Peptic
Infarction
Pectoris
Aneurysm
Ulcer
Onset
Usually
Exertional/
Acute
Subacute
Acute/
sudden
emotional
subacute
Quality
Crushing
Discomfort,
Deep tearing,
Sharp
Burning
heaviness, dull
choking,
shearing,
pressure, band
pressing
"knife -like"
like,
squeezing,
constricting
strangling
squeezing,
constricting,
burning,
bursting,
bursting
burning
Location
Substemal,
Substemal
Substemal
Substemal,
Epigastric
may vary
more left-
substemal
sided
Radiation
Across mid-
Same as MI
Back lumbar
Usually none
back
Occasionally
region
occasionally
thorax,
tip of
anterior
shoulder,
arms,
neck, flank
shoulder,
neck, jaw,
teeth, fingers
Duration
Usually >
5-15
Hours
Hours
Hours
30minutes
minutes
Provocation
Usually
Exercise,
None
Worsened:
Alcohol, lack of
none, see
excitement,
lying down,
food, acidic
comments
stress, cold,
breathing,
foods
meals
swallowing,
coughing,
twisting
Alleviation
None
Rest, NTG
None
Tripod
Antacids
position,
food
Shallow
respirations
Comments
After heavy
May be
Sudden onset,
May be with
ASA, NSAIDs
meals, severe
nocturnal
may subside
URI, flu,
(e.g., Voltaren
emotional stress
spontaneously or
Prone- styl,
Feldene,
S/S: SOB, N&V,
be associated with
hydralazine,
Naprosyn
pallor,
paralysis
lupus; may be
Motrin, Advil)
diaphoresis,
febrile
may trigger
impending
doom, elderly -
atypical
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols
Pancreatitis
Esophageal
Pulmonary
Esophageal
Rupture
Embolism
Spasm
Costochondritis
Onset
Acute/
Acute
Sudden or
Subacute
Sudden or
subacute
gradual
gradual
Quality
Severe or dull
Severe
Sharp or
Dull,
Sharp
dull
pressure
superficial,
colicky
Location
Epigastric
Retrosternal
Multiple
Substernal,
Anterior/
epigastric
Lateral
costochondral
junction
Radiation
Back
Lateral
None
Jaw, either
None
arm
Duration
Hours
Hours
Variable
5-60
Variable
minutes
Provocation
Alcohol,
Swallowing
Respiration
Spontaneous,
Movement,
trauma,
s, cough
cold liquids,
palpation,
gallbladder
recumbency
cough
disease
respirations
Alleviation
Time
None
None
Antacids
Time, heat,
occasion
analgesia
ally
NTG
Comments
May be viral
Alcoholics
May have
Mimics
Signs and
(e.g., mumps)
with forceful
hemoptysis
angina, may
symptoms:
vomiting;
, signs of
occur after
fever, cough,
associated
peripheral
meals, at
URI
with pleural
phlebitis,
night with
effusion,
cough, and
an acid
shock, and
fever
taste,
hydro-
sensation—
pneumothorax
linear
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 10
EMANCIPATION: FLORIDA STATUTE 326
Freedom of a child from legal subjection to parents/guardians and having the right to labor for
himself/herself and collect and control the person's own wages is called "emancipation."
• Emancipation of a child may be in writing.
• Emancipation of a child may be by parol (word of mouth).
• Emancipation of a child may be expressed or implied from the parents' conduct, which makes
further obedience of the child difficult.
• Emancipation cannot result merely from a minor child giving birth and becoming a parent.
Emancipation becomes a matter of law when a minor leaves home permanently, secures his/her
own living quarters, and becomes completely self supporting, with the parents paying none of
his/her bills. Once emancipation is established, the parent is no longer liable for the child's debts,
including those for "necessities" such as medical treatment.
REMOVAL OF DISABILITIES OF NON -AGE (COURT -ORDERED EMANCIPATION):
FLORIDA STATUTE 743.075
The court may determine that the removal of disability of non -age (minor) at least 16 years of age,
is in the child's best interest and shall enter an order to that effect. This order shall give a minor
the status of an adult for purposes of all criminal and civil laws of the state. The judgment is
recorded in the county where the minor resides, and a certified copy shall be issued as proof.
MARRIED MINORS
Any minor who is married, even if divorced or widowed, may give consent.
UNWED PREGNANT MINOR OR MINOR MOTHER - CONSENT TO MEDICAL CARE:
FLORIDA STATUTE 743.065
• An unwed pregnant minor may consent to care relating to her pregnancy.
• An unwed minor mother may consent to care for her child.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 11
DIVE HISTORY/PROFILE Complete as much as possible.
1. Type of Dive: Rescue Commercial
2. Type of Gas Used: Compressed Air
3. Water Type: Contaminated Fresh
4. Water Temperature:
5. Number of Dives in the Past Several Days
List Each Dive with:
Maximum Depth Bottom Time
6. Time of Last Ascent:
Recreational
Nitrox Heliox Other
Salt
Surface Interval
7. Did Diver: Panic? Emergency Ascend? Run Out of Air?
Hold Breath Upon Ascent? Miss a Decompression Stop(s)? _
8. Problems During Dive (e.g., Buoyancy, Clearing Ears, Equipment):
9. Possible Contact with Dangerous Marine Life:
10. Fly After Diving: How Long After:
11. Alcohol Ingestion: When: Quantity:
12. Dive Workload (e.g., Currents, Hard Work, Over -weighted):
13. Any Post -dive Physical Activity:
14. Dive Buddy: Is He/She Present? Name and Phone Number:
15. Other Witnesses (Names and Phone Numbers):
16. Statements and Other Information:
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 12
Dive Accident: Signs and Symptoms Enter "Y" (yes) or "N" (no). Explain where needed.
1 a. Joint Pain lb. Location
2a. Head Pain 2b. Location
3a. Chest Pain 3b. Location
3c. Increase with Inspiration or Cough
3e. Location
4a. Abdominal Pain
5a. Unconsciousness
6a. Difficulty Breathing
7. Convulsions
8. Confused/Disoriented
9. Extremity Edema
3d. Radiates
4b. Encircling Pain
5b. When
6b. Rapid Respirations
10a. Rash IOb. Blotching
11. Shock
12. Weakness/Fatigue
13a. Numbness 13b. Tingling
13d.Location
10c. Itching
13c. Decreased Sensation
14a. Faintness 14b. Dizziness
15a. Difficulty Urinating
15b. Difficulty Moving Bowels
16a. Difficulty Hearing 16b. Which Ear?
17a. Difficulty Speaking 17b. Facial Droop 17c. Which Side?
18a. Staggering 18b. Paralysis 18c. Location
19. Visual Disturbances
20a. Apnea 20b. Bloody Froth from Mouth
21a. Cyanosis 21b. Location
22a.Feeling of Blow to Chest During Dive
20c. Cough
22b. When?
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 13
Dive Accident Rapid Field Neurological Exam Record Answer yes or no.
Mental Status: Does He/She Know
Ia. His/her name? lb. Where he/she is? lc. Time of day?
1 d. Most recent activity? le. Speech is clear, correct?
Sight
2a. Correctly counts fingers?
Eye Movement
3a. Move all four directions?
2b. Vision clear?
3b. Nystagmus absent?
Facial Movements
4a. Teeth clench okay? 4b. Able to wrinkle forehead?
4c. Tongue moves all directions? 4d. Smile symmetrical?
Head/Shoulder Movements
5a. Adam's apple moves? 5b. Shoulder shrug normal, equal?
5c. Head movements normal, equal?
Hearing
6a. Normal for that diver? 6b. Equal in both ears?
Sensations: Present, Normal, and Symmetrical Across
7a. Face? 7b. Chest? 7c. Abdomen? 7d. Arms (front)?
7e. Hands? 7f. Legs (front)? 7g. Feet? 7h. Back?
7i. Arms (back)? 7j. Buttocks? 7k. Legs (back)?
Muscle Tone: Present, Normal, and Symmetrical for
8a. Arms? 8b. Legs? 8c. Hand grips? 8d. Feet?
Balance and Coordination
9a. Romberg okay? 9b. If supine, heel -shin slide okay?
9c. Alternating hand movements okay?
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 14
Florida Regional Common EMS Protocols
Strenuous Activi y - MedicaFEvaluation
I noid ent 4:
Name:
Looaton:
Unit
Dale:
Last
Time of Evaluation:
Pulse Rate
Sp02
SPCO
BP
8
InjurieviUness?
Y N
Y N
Y N
Y N
CL LU
Ora f Temperature
Other
All Workers
Hydrated Wilth'16oz
Water or Electrolyte,
Solubon
Time of Evaluation:
Pulse Rate
Sp02
SPCO
0
BP
W
U3 M >
InjurieviUness?
Y N
Y N
Y N
Y N
LLJ
Oral Temperature
Other
M Z'
Vomiting, Dla-rhea, Heat Wheezirjj or,rongested . SPCO >8% after Oxygen
Exhaustion in the 'last 72 hours Lungs w Oral Tern i). > 1 GO.r3r-7 or <901P
Larne open skinwourds frash - w
Respirations <8 or >40 Systolic BP � 1160 or < 100 mmHg
Insulin -using diabetio has not . Pulse ewer 120,oT irregular w Dizziness
eaten to the past 4 hours . Sp02 <94% w Need fio- 7ran sport (see below)
Time of Evaluation:
Pulse Rate
Sp02
0
SPCO
BP
E
>
InjurieviUness?
Y N
Y N
Y N
Y N
LLJ
Oral Temperature
Other
Consider Transport of Emergency
Worker to HGspiital if syriaptorns are
present for Jan gerthan 20 minutes.
Transport Emergency
bellow are present:�
Worker to 1111105,pitail immediately if anyof the signs
• Respirations <e, or >40
• Pulse ratepve120 BPPA
• SpO2 ss9L
• SpCO >896 after oxygen
• Oral Temperature >1 01 F or <-QGF
• Systolic B P '�1 0 or < I GD rnrnHg
Preautar Pulse tacute onset) . Shortness of Breath
Altered %Mental Status Che sit Patin
r. Symptoms of Heat Stroke . Severe Headache
Significant inju ry . SpCO 25%
Heat Index::
I Comments:
RED22514
Return Completed form to EMS Division
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 15
6.9.1 Adult Glasgow Coma Scale Score (GCS)
EYE OPENING
4 Spontaneous: At this point, with no further stimulation, the patient has eyes open.
3 To Voice: If the patient's eyes are unopened, a request to "open your eyes" should be
spoken, and if necessary, should be shouted.
2 To Pain: If verbal stimulation is unsuccessful in eliciting eye opening, the standard painful
stimulus is applied. NOTE: Document if eyes are closed due to swelling, facial injuries, or
other causes.
1 None: No eye opening.
BEST VERBAL RESPONSE
5. Oriented: After the patient is aroused, he/she is asked who he/she is, where he/she is, and
what the year and month are. If accurate answers are obtained, this is recorded as oriented.
4. Confused: Although the patient is unable to give correct answers to previous questions,
he/she is capable of producing complete phrases, sentences, and even conversational
exchange.
3. Inappropriate Words: The patient speaks or exclaims only a word or two. Such a response is
usually obtained only by physical stimulation rather than a verbal stimulus, although
occasionally a patient will shout obscenities or call relatives names for no apparent reasons.
2. Incomprehensible Words: The patient's response consists of groans, moans, or indistinct
mumbling and does not contain any intelligible words.
1 No Verbal Response: Prolonged and, if necessary, repeated stimulation does not produce
any phonation.
BEST MOTOR RESPONSE
6. Obeys Command: This requires an ability to comprehend instructions, usually given in
some form of verbal commands but sometimes by gestures and writing. The patient is
required to perform the specific movements requested. The command is given to hold up two
fingers (if physically feasible); the patient should respond appropriately.
5. Localizes Pain: If the patient does not obey commands, a painful stimulus may be applied as
firm pressure to the sternum or nail bed for 5 seconds. The patient should reach to and/or try
to remove source of pain
4. Withdrawals: After painful stimulus:
Elbow flexes, Rapid movement, No muscle stiffness, Arm is drawn away from the torso
3. Flexion Response: After painful stimulation:
Slow movement, Accompanied by stiffness, Forearm and head held against the body, Limbs
assume hemiplegic position
2. Extension Response: After painful stimulation:
Legs and arms extend, Accompanied by stiffness, Internal rotation of shoulder and forearm
None: No motor response.
Note: The Glasgow Coma Scale measures cognitive ability. Therefore, if injury (chronic or acute)
has caused paraplegia or quadriplegia, alternate methods of assessing motor response must be used
(e.g., ability to blink eyes = obeys commands).
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 16
6.9.1 Adult Glasgow Coma Scale Score (GCS)
Glasgow Coma Score
Eye Opening (E) Verbal Response (V)
4=Spontaneous 5=Normal conversation
3=To voice 4=Disoriented conversation
2=To pain 3=Words, but not coherent
I=None 2=No words...... only sounds
1=None
6.8.2 Pediatric Glasgow Coma Scale
Motor Response (M)
6=Normal
5=Localizes to pain
4=Withdraws to pain
3=Decorticate posture
2=Decerebrate
1=None
Total = E+V+M
> 1 Year
< 1 Year
Eye Opening
4
Spontaneously
Spontaneously
3
To verbal command
To verbal command
2
To pain
To pain
1
No response
No response
> 1 Year
< 1 Year
Best Motor Response
6
Obeys
Localizes pain
5
Localizes pain
Flexion normal
4
Flexion —withdrawal
Flexion —abnormal (decorticate
rigidity)
3
Flexion—
abnormal(decorticate
rigidity)
Extension(decerebrate rigidity)
2
Extension(decerebrate
rigidity)
No response
1
No response
Best Verbal Response
> 5 Years
< 2-5 Years
0-23 Months
5
Oriented and converses
Appropriate
words and
phrases
Smiles, coos,
cries
appropriately
4
Disoriented and
converses
Inappropriate
words
Cries
3
Inappropriate words
Cries and/or
screams
Inappropriate
crying and/or
screaming
2
Incomprehensible
Grunts
I Grunts
1
No response
No response
I No response
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 17
6.10.1 Types of Care
Basic Life Support: All medical care that is classified as BLS by the State of Florida and outlined in
these protocols.
Advanced Life Support: All medical care, in addition to BLS care, that is classified as ALS by the
State of Florida and outlined in these protocols.
6.10.2 Types of EMS Providers
Paramedic: Being certified by the State of Florida as a Paramedic enables the provider to administer
Basic and Advanced Life Support as outlined in these protocols.
EMT: Being certified by the State of Florida as an EMT enables the provider to administer Basic
Life Support as outlined in these protocols.
Emergency First Responder: A provider (e.g., firefighter, lifeguard, police officer) who is not
certified as a Paramedic or EMT.
6.10.3 Types of EMS Units
Advanced Life Support Transport - An ambulance (e.g., freightliner rescue) that is licensed by the
State of Florida to carry ALS equipment and transport patients in an ALS capacity.
Advanced Life Support Non -transport - An emergency vehicle (e.g., fire engine) that is licensed
by the State of Florida to carry ALS equipment, but does not transport patients.
Advanced Life Support Helicopter - An air ambulance (rescue helicopter) that is licensed by the
State of Florida to carry ALS equipment and transport patients in an ALS capacity.
6.10.4 Types of Patients
Adult: For trauma a patient who is 16 years of age or older, medical patients 18 years of age or
older.
The definition of pediatric patients will be described below. It is imperative to understand that the
medical decision making for a pediatric patient should be based on the definitions provided below.
Transport (destination) decisions should be made using the Hospital Capability Form.
Pediatric Medical Decision Definitions:
Newborn: A patient who has just been delivered.
Neonate: A patient who is younger than 6 weeks of age.
Infant: A patient who is under 1 year of age.
Child: A patient ranging from 1 year of age to puberty (pubic hair, facial hair, breast development)
Adolescent: A patient who has reached puberty. Treat these patients using adult protocols.
Transport Decision Definitions:
Pediatric: Trauma patient -15 years of age or younger
Medical patients - 17 years of age or younger.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 18
6.11.1 Hospital Capabilities
All hospitals licensed under Chapter 395, Florida Statutes, are required to accept patients via
their emergency departments in accordance with Chapter 395.1041, Florida Statutes, and other
state and federal laws. However, some patients may require specialized treatment not available at
every hospital. It is these specialized care capabilities that should be considered when
determining a transport destination. In most cases, patients with medical needs that do not
require specialized care would be transported to the closest hospital emergency room. For those
patients who require specialized care, the following hospital capabilities should be considered.
TRAUMA CENTER
These hospitals are able to provide specialized trauma care and have been designated as a Trauma
Center as defined in Chapter 395.4001, Florida Statutes. Adult trauma patients who meet Adult
Trauma Alert Criteria must be transported to a Level 1 or Level 2 Trauma Center, if available
(General Protocol 1.10).
Pediatric patients who meet Pediatric Trauma Alert Criteria must be transported to a Pediatric
Trauma Referral Center, if available (General Protocol 1.10).
MATERNITY (OB) HOSPITAL
These hospitals are able to provide specialized obstetric care, including labor and delivery
services in accordance with the guidelines established by the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) and Agency for Health Care Administration (AHCA).
PRIMARY STROKE CENTER
These hospitals are able to provide specialized care to stroke patients in accordance with the
standards outlined by the American Stroke Association (ASA) or JCAHO and AHCA, and have
been designated by the State of Florida as Stroke Centers.
COMPREHENSIVE STROKE CENTER (CSC)
Hospitals shall ensure that stroke centers establish specific procedures for screening patients that
recognize that numerous conditions, including cardiac disorders, often mimic stroke in children.
Stroke centers should ensure that transfer to an appropriate facility for specialized care is
provided to children and young adults with known childhood diagnoses. A hospital's program
may be designated as a Comprehensive Stroke Center on the basis of that hospital providing to
the Agency for Health Care Administration an affidavit signed by the Chief Executive Officer of
the hospital that the program has received initial Primary Stroke Center designation as provided
in paragraph 59A-3.2085(15)(a), F.A.C:
PSYCHIATRIC TREATMENT CENTER
These hospitals are able to provide specialized care to psychiatric patients in accordance with
Chapter 394, Florida Statute. All patients who have been "Baker Acted" (General Protocol 1.2)
should be transported to the closest hospital, as defined in Chapter 395, Florida Statutes, for
medical clearance prior to transport to a mental health facility that does not meet the requirement
for a hospital in Chapter 395, Florida Statutes.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 19
6.11.1 Hospital Capabilities (continued)
INTERVENTIONAL CARDIOVASCULAR CENTER
These hospitals are able to provide specialized cardiac care and have been designated as
Interventional Cardiac Centers by JCAHO or AHCA. These hospitals will be able to provide the
following services:
1. An Emergency Department with dedicated chest pain triage, treatment, interventional beds, and
staffing. Must have immediate 12-lead ECG capabilities available in the ED.
2. 24 hour/day, 7 day/week committed receiving station (fax machine and/or electronic receiving
station) in the ED for transmission of prehospital ECGs.
3. 24 hour/day, 7 day/week interventional cardiology catheterization lab availability within 30
minutes of prehospital field notification and ED confirmation via 12-lead ECG transmission.
a. Documented track record of at least 20 acute coronary non -elective (from ED to cath lab)
interventions per year.
b. 24 hour/day emergency cardiac surgery availability, which does not have to be "in-house."
c. 24 hour/day left ventricular (LV) assist capabilities, including intra-aortic balloon pump
(IABP) insertion and maintenance.
d. One on -call interventional team per participating interventional facility that will respond
upon ED notification.
4. An interventional cardiologist on call, 24 hour/day, 7 day/week. Must have a track record that
meets all ACC guidelines, with optimal outcomes and acceptable complication rates, and must
be signed off by the Cath Medical Director.
5. Documented volume of at least 200 acute MI patients admitted to the hospital per year.
6. Dedicated coronary care unit with sufficient beds and staff to accommodate acute MI and
sudden death patients with ROSC.
7. Identification of a research coordinator/administrator to track and release treatment and patient
outcomes of patients transported to the facility by Fire Rescue personnel.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 20
6.11.2 Hospital Categorization available on - www.gbemda.org under forms
6.11.3 Broward County Hospital List also available on - www.�bemda.org under forms
Broward County Hospital List
Revised March 2014
Broward Healtlx Coral Sjxrux
Meinoi al Regiowd - Traxuwa Center
3000.
Axlxdt. & PE-&itaic II4061
ER # 954-344-3108 Fax#954-344-3389 (secure)
ER location — Northwest side
350.1. od
ER # 954-265-3401 Fax# 954-985-1493 (mase's s-uR )
Jae DiA AWD Fax #
ER location — West side between parking garage
Broward Healtlx Ixrgxex~ral Ponxt
Meinox~ral Hosfxxtal NN°est.410616
64Q.1.N.,.F.e ral.Hwy, Ft. Lauderdale
703.N:.Flawinp.R'Qad,FerabrokQYines.
ER # 954-776-8610 Fax# 954-776-8521 (secure)
ER # 954-438-1103 Fax# 954-430-4619 (secure)
ER location — Northwest side
ER location — West side, faces F.laxxxiAgo..PQ.Qd
Broward Healtlx Medical Center i40601
Nortlxwest Medical Center
2801 N. State Rd 7, Margate
Traxuma Center Adult & Petluatfic
1600 S. Andrews Ave. Ft. Laud
ER# 954-978-4100 Fax## 954-978-4146 (=e,s gaaim)
ER # 954-355-5760 Fax ##954-355-5113 (secure)
ER location — East side
PED fax 954-712-7948
Broward Health Nortlx
Plantation Gei*ral Hostxital gl06'_1
Traxuma Center .Adult. 0xxl}
401 NW 42 Ave, Plantation
201 E. Sample Road, Pompano Beach
ER #954-786-2179 Fax# 954-786-7340 (se cure)
ER # 954-513-6470 Fax# 954-513-6677 (mase's m im)
ER location — West side
ER location - North side
Cleveland Cluxic i40618
Uuix=ersity Hostxit.al
1825 N Corporate l s..BK Weston
7 Q.1.N:.Ux rs�ty.Dx„ artlaxa
ER # 954-659-5132 Fax 4954-689-5687 (secure)
ER 4954-724-6225 Fax#954-724-6433 (msse's station)
ER location -North side
ER location — West side
Floii&i Medical Center
Westside Regiowd kle(hcal Center a1O631
5000 W. Oakland Park Blvd, Lauderhill
8Q.1.,.&.zwaxd.l.lvd,,.Plar4tatn
ER # 954-730-2895 Fa)# 954-730-2829 (secure)
ER # 954-476-3900 #1 Fax# 954-236-0247
ER location — South side
ER location — West side
Holy Cross Hosfxital
wixtu a Njedical Center — (Dade County)
4725 N. Federal Hwy, Ft. Lauderdale
20900 Biscayne Blvd. Miami
ER # 954-492-1842 Fax# 954-351-5920 (secure)
ER 305-682-7290 #1 Fax# 305-937-3909 (rnsse geim)
ER location — West side;
ER location — West side
Memor al Hoq)ital Soudi
Boca Ratan Regional Hospital — (Pain Bear-h Crnm2,1
B00.Meadews.Rd.5oQa.RatQ.n
ER# Fax# (=e staum)
bQQ.V askux�gtaz .S.t,.HallywQad
ER # 954-985-6300 Fax # 954-985-6382 (secure)
ER location — North side
ER location — West side
Memoilal Hosfxital 14luanuar
NN'est. Boca Xleflical Center -(PahnBeach Cmty)
1901 SW 172 Ave, Miramar
21644 Florida 7, Boca Raton,
ER # 954-538-5101 Fax# 954-538-5107 (secure)
Adult (561) 488-8200 press 1 Peds. (561) 488-8297
ER location — Northwest side
Fax (561) 488-8374
ER Location SE Corner
Memoilal Hosfxital Peinbroke -406l21
7�QQ. Sku�ridax� St,.Per.z�ke_F�es.
ER # 954-964-0231 Fax# 954-883-8467 (=e's a dim)
ER location — West side
TBD .i nursed 2l2&M
x
Version 4 Version 2, 3/l/15 Florida Regional Common EMS Protocols 21
RECOMMENDED GUIDELINES (Version 4.5 2/2014)
PREVENTION AND P*B IUNIZATION PRACTICES
Purpose Each employer shall identify "at risk" workers based on job descriptions. (OSHA CFR
1910.1030)
Risk Levels:
At -risk Workers. Emergency medical and public safety workers are at risk for exposure to
blood, body fluids, feces and/or respiratory secretions.
Low -risk Workers. These workers are identified through job descriptions as having job tasks
that are low or not "At -risk" to exposure to blood, body fluids, feces and/or respiratory
secretions. For these workers timely postexposure prophylaxis rather than preexposure
vaccination may be considered.
Special Risk Workers. Periodic evaluation of job description may be done as indicated to
evaluate certain tasks that may be considered at a higher level.
History of Immunity. Workers who are "at risk" for exposure to and possible transmission of
vaccine preventable diseases should have on record of employment all immunizations currently
recommended by the US Public Health Service. A medical evaluation that includes childhood
immunity or immunization history for Measles, Mumps, Rubella, Tetanus, Diphtheria, Polio,
Pertussis (Whooping cough) and Varicella zoster (chicken pox) should be obtained and recorded
for these workers. This program should be completed at the time of hire or as part of a catch-up
program. (CDC MMWR November 25, 2011/60(RR07); 1-45). (NFPA 1581; 2010ed., 4.5.2.1).
INFECTION CONTROL PROGRAMS.
Infection Control Officer. Employers shall identify a Designated Infection Control Officer.
Education. Workers shall have Bloodborne/Airborne Pathogen Training.
Immunization Programs. Employers with vaccination programs shall offer vaccine product
information and declination statements as determined by CDC and OSHA regulation. Employers
shall make vaccines available to workers who initially decline and later decides to accept the
vaccines within 10 days.
Medical Records and Test Maintenance. All workers' medical records, immunization records
and baseline testing shall be maintained according to applicable laws governing medical
confidentiality. (29 CFR 1910.1030(h)).
Needle -Stick Prevention Programs. Employers shall provide needleless systems (where
applicable). Needleless systems means a device that does not use needles for: (1) The collection
of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established;
(2) The administration of medication or fluids; or (3) Any other procedure involving the potential
for occupational exposure to bloodborne pathogens due to percutaneous injuries from
contaminated sharps. (OSHA 29 CFR 1910.1030(e) (2)).
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 22
Hepatitis Vaccination Programs. All "At -Risk" workers shall have made available to them at
employment (within 10 days) of initial assignment the Hepatitis vaccine and education, unless
the worker has documentation of the following: completed vaccination series, record of
immunity (positive titer), or medical contraindications. (29 CFR 1910.1030(f) (2)). Hepatitis A
vaccination is strongly recommended and may be offered if specific local conditions dictate.
(NFPA 1581; 2010 ed., 4.5.2.1).
Influenza Vaccination Programs. "At -Risk" Workers are considered to be at significant risk
for acquiring or transmitting influenza (the common Flu). Influenza vaccine should be made
available to workers from October through February annually. (CDC MMWR November 25,
2011/60(RR07);1-45) (NFPA 1581).
Tdap Vaccination Programs. "At -Risk" Workers are considered to be at significant risk for
acquiring or transmitting tetanus toxoid, diphtheria toxoid and acellular pertussis. Tdap vaccines
should be made available to workers from October through February annually.. (CDC MMWR
November 25, 2011/60(RR07);1-45).
Periodic Titer Screening for Immunizations. Routine periodic post vaccination screening is
not recommended after initial titer level has been determined. Booster doses are not currently
recommended. If the US Public Health Service recommends a routine booster dose(s) at a future
date, such booster dose(s) shall be made available. (29 CFR 1910.1030(f) (1) (ii).
BASELINE AND ANNUAL SCREENING
Baseline Screening. Baseline screening for TB, Hepatitis A, B and C is indicated for
presumptive laws requirements. Meningitis is also covered in the presumptive law but does not
require a baseline screening. (FS 112.181 6(a) (b)). (Florida Pension Statue for police and
firefighters only)
TB Screening. A tuberculin skin test (PPD) or Quantiferon-TB (CPT 84480) Test shall be
performed for all "at -risk" annually. Workers who have previously tested negative and now test
positive shall have a baseline chest x-ray and one follow-up a year later. All new positive TB test
results shall have prophylactic treatment offered. (CDC MMWR 1994:43(RR13) or for
Quantiferon MMWR 2003: January 31 (RR02; 15-18).
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 23
POSTEXPOSURE MANAGEMENT
• Provide personal first aid.
• Remove contaminated clothing
• Secure area to prevent further contamination.
• Wash the area well with soap and water or personal protective solution.
• Notify Supervisor
• Assess the level of exposure (Significant or non -significant)
Notification and Relief of Duty. The worker's supervisor should be notified if a worker
experiences an occupational exposure involving potentially infectious material. The supervisor
should determine if the worker needs to be relieved of duty.
Assess the level of Exposure. An Occupational exposure is the "exposure to another person's
body fluids or airborne fluids. There are two types of occupational exposures, non significant and
significant.
Non -Significant Exposure. Non -Significant exposures are occupational exposures that have
little to no risk of transmission of diseases known at this time. All Non -Significant exposures
need to be documented on the "Infectious Disease Exposure Report Form", so at a later date
should said occupation exposure be reported by the CDC as having an increased risk, the
exposure was documented.
Significant Exposure. Significant Exposures have increased risk of transmission and acquiring
of disease(s). All Significant exposures need documentation and medical follow-up.
Assessing Exposures to Blood or Body Fluids. A significant bloodborne or body fluid exposure
Body Fluids:
• Blood, Serum, and all fluids visibly contaminated with blood
• Pleural, amniotic, peritoneal, synovial, and cerebrospinal fluids
• Uterine/vaginal secretions, semen, feces and urine
• Saliva
Action or Injury:
• Percutaneous (through the skin injuries such as, needlestick, laceration, abrasion, bites, ect.)
• Mucous membranes (e.g. eyes, nose, mouth)
• Nonintact skin (e.g. cut, chapped or abraded skin). Consider the larger the area and/or the
longer the material is in contact, the more difficult it is to verify that all relevant skin area
is intact. Also, an increased risk if within 2 hours of shaving skin and scabs <24 hours, if
skin is still open.
Assess the Exposure to droplets or airborne exposure. A significant airborne exposure is
considered a combination of a source exhibiting signs/symptoms of suspected airborne illness
and an incident that would place the worker at risk of droplet or airborne exposure.
Source: Any aerosolized exhalations containing droplets, sputum, lung secretions or saliva either
by the source coughing, spitting, breathing or by any airway management action by the worker
such as suctioning or incubating AND the worker was not wearing appropriate respiratory
protection (HEPA mask, eye protection).
Actions by worker that have increased risk of airborne disease spread include; unprotected
mouth-to-mouth CPR, and airway management.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 24
REPORTING MEDICALATTENTION,CONSENTANDTESTING
Report the Exposure. The worker or supervisor should begin filling out an Infectious Disease
Exposure Form" and submit it to the Designated Infection Control Officer
Transport. A Significantly exposed worker should be transported to a designated facility within 2
hours for evaluation, testing and treatment options (preferably a facility that offers rapid HIV testing if
the material was blood or body fluids). The worker and the source patient should be transported to the
same medical facility.
Triage. The worker should be rapidly triaged as soon as possible. The worker should present to the
medical facility an Infectious Disease Exposure reporting Form and an Employer Information Sheet
that contains specific information about the employer, the employees Designated Infection Control
Officer, the employers worker compensation policy, and employers medical providers information for
follow-up care.
Consent and Counseling.
Counseling shall be provided to and consent obtained from both source of the exposure and the
exposed worker (29 CFR 1910.1030(f) (3)). The Worker's Compensation carrier will incur cost of
testing for source and worker.
Informed Consent. Source and exposed worker consent to physician authorizing testing. The source
will not incur any cost of said testing.
No Consent. (e.g. source is unconscious or denies consent) If consent cannot be obtained from the
source of the exposure and blood sample is available, the facility can conduct testing without consent
and the attending physician documents the need in the medical record of the worker.
Note: Florida's Omnibus AIDS Act provides for a court order for the source to comply and have
testing completed. In this case, prophylaxis treatment may not be completed in a timely manner,
medical protocol provides for an "unknown source" category.
Postexposure Testing for Blood and Body Fluids. The facility should perform an Acute Hepatitis
Panel (CPT 80074), Rapid HIV and RPR (Syphilis) tests. Testing maybe added as per attending
physician request.
Postexposure Testing for droplets or airborne exposure. Focus on airborne droplet exposure is
focused on alerting the medical facility that a significant exposure has occurred. Testing is
administered by the facility targeting a myriad of airborne diseases. If TB exposure is suspected a
tuberculin skin test (PPD) or Quantiferon (CPT 84480) following the exposure should be performed on
source and exposed worker. Do not perform tuberculin skin test (PPD) on an exposed worker who has
been tested within the previous 12 weeks, or has a history of positive skin test reaction.
Hospital Notification. If no exposure was reported to the medical facility, and the medical facility
determined through testing that an increased risk of disease transmission may have occurred, shall
notify the agency of such event within 48 hours after determination. (F.S. Ryan White Act)
Discharge. The Infectious Disease Exposure Reporting form should be complete with a discharge
summery that includes a description of all diagnostic tests performed on the worker. A copy of the
form is routed to the Designated Infection Control Officer and a copy is provided to the worker.
Postexposure Medical Follow -Up. The employer is responsible to provide or make available
postexposure monitoring as directed by the medical provider. Follow-up testing from blood and body
fluid exposures will be performed after the initial, at week six, week twelve and week twenty-six after
the exposure. Testing after one year maybe indicated for high -risk significant exposures.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 25
C.12.a
6.12 Personal Exposure to Infectious Diseases (continued)
INFECTIOUS EXPOSURE REFERENCE SHEET 2014
AIRBORNE
DROPLET
Transmission
Prevention
Post Exposure
Follow U
Tuberculosis
Droplets:
Annual PPD
Source=PPD, or Quantiferon
PPD at week 12 post
(TB)
coughing,
or
Employee= PPD unless PPD tested
exposure. If new positive: 2
sneezing,
Quantiferon.
within prior 12 weeks or
CRX and Rx with Isoniazid
intubation,
Wear HEPA
previously PPD reactive or
(INH) for 9 months.
suctioning, mouth
/ N-95
Quantiferon.
to mouth
masks.
resuscitation.
�
Meningitis
Droplets:
Wear HEPA
Antibiotics: Cipro, Rocephin,
Seek medical care if
bacterial/viral
coughing,
mask.
Rifampin.
symptoms of meningitis
sneezing,
develop: fever, stiff neck,
intubation,
severe headaches. U
suctioning.
Influenza
Close contact,
Annual Flu
Treatment: analgesics,
As determined by medical U
droplets: coughing,
Vaccine.
Rimantadine,Tamiflu, Relenza.
professional. <
sneezing,
Hepa mask
y
intubation,
suctioning.
Varicella Zoster
Close contact,
Vaccine=l
Treatment: Varicella Zoster
As determined by medical
(Chicken Pox)
droplets: coughing,
shot
Immune Globulin (VZIG) within
professional.
sneezing,
(Varivax).
96 hours of exposure.
6
intubation,
HEPA mask.
suctioning. Also
BSI
direct contact with
vesicle fluid.
BLOODBORNE
Transmission
Prevention
Post Exposure
Follow U y
HIV
Percutaneous,
OSHA BBP,
See PEP Flow Chart.
Periodic screening: 6, 12, 2E A
Mucous
BSI. No
weeks after exposure.
Membranes, and
Vaccine.
Non Intact Skin,
Syphilis
Percutaneous,
OSHA BBP,
Source=RPR, Employee=RPR.
Repeat test at 3 and 6
Mucous
BSI No
RX Penicillin.
months, if positive refer for
Membranes, and
Vaccine.
FTA
Non Intact Skin,
ry
HBV
Percutaneous,
Vaccine=3
Source=Acute Hep panel.
If unvaccinated, periodic N
Mucous
shot series.
Employee=Acute Hep panel. If
screening: 6, 12, 26 weeks
Membranes, and
Titer and
source positive, employee not
after exposure. If positive U
Non Intact Skin,
reimmunize
immune: administer immune
titer no further TX is
if necessary.
globulin and consider vaccine
needed.
OSHA BBP,
series at this time.
BSI
HCV
Percutaneous,
No Vaccine.
Source=Acute Hep Panel.
Periodic screening: 6, 12 0.
Mucous
OSHA BBP,
Employee=Acute Hep Panel.
and 26 weeks after
Membranes, and
BSI
exposure. If source
Non Intact Skin,
positive, consider employee
qualitative HCV RNA &
ALT testing 6 weeks post
exposure. If employee
becomes HCV RNA
positive, treat as determined m
by medical professional.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 26
INFECTIOUS EXPOSURE REFERENCE SHEET 2014
OTHER
Transmission
Prevention
Post Exposure
Follow U
HAV
Fecal/Oral. Also, has
Vaccine = 2
Source Acute Hep
Periodic screening:
blood to blood
shot series.
Panel.
12 weeks after
precautions.
OSHA BBP,
Employee=Acute Hep
exposure or if
BSI. Caution of
Panel. If source
symptoms occur. If
food /water
positive, employee not-
positive titer no
cleanliness.
immune: administer
further TX is
immune globulin and
needed.
consider HAV vaccine.
Tetanus
Soiled object causing
Vaccine good
If no vaccine,
Seek medical care
open wound.
for 10 years.
administer at this time.
if symptoms of
tetanus develop:
lockjaw, rigid
muscles.
Lyme Disease
Tick -borne: tick attached
Avoid tick
Antibiotics:
As determined by
24 hours.
infested areas.
Amoxicillin,
medical
Vaccine=3 shot
Doxycycline
professional.
series for prone
areas.
Methicillin-
Direct contact: Skin, open
BSI
Clean, disinfect.
As determined by
Resistant
sores, vesicles, mucous
Alcohol based
medical
Staphylococcus
membranes,
antibacterial hand
professional.
Aureaus
bedding/clothing, nursing
cleaners. If illness
(MRSA)
homes
presents seek medical
attention.
Scabies
Direct contact: mite
Avoid infested
Lindane or Kwell
Close supervision
infested areas,
areas.
applied to the whole
of treatment
bedding/clothing, nursing
body overnight.
including bathing.
homes
Rabies
Virus laden saliva of
Avoid animal
Wash affected areas.
Continue to treat
infected animal: animal
bites.
Administer rabies anti-
employee with
bites.
serum injection and
vaccine series.
first dose of rabies
vaccine. Contact animal
control, monitor animal
for presence of
infection.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 27
HEPA masks A personal protective device worn on the face to remove particles equal
to and greater than 0.3 microns (which essentially includes all bacteria,
spores and viruses).
PPD A method of assessing whether someone has become infected with M.
tuberculosis complex. The test involves measurement of a subject's
immune response to an injection of tuberculin purified protein
derivative (PPD) manufactured from killed Mycobacterium
tuberculosis bacilli. Also referred to as tuberculin skin tests or PPD
tests.
Vesicle fluid The serum from the blister formed during a varicella zoster infection.
VZIG Varicella Zoster Immune Globulin.
Qualitative Blood test to detect the presence of Hepatitis C virus.
HCV-RNA.
ALT Blood test to measure a liver -specific enzyme which indicates liver cell
death or inflammation.
OSHA BBP Occupational Safety and Health Adm. Blood Borne Pathogen
Precautions.
BSI Body Substance Isolation
Standard
Precautions Precautions that should be utilized on all patient contact
QuantiFERON- Is a highly -specific controlled blood test for use as an aid to the
TB Gold In- diagnosis of infection with bacteria responsible for TB and provides
Tube test (QFT) results showing an individual's T-cell response to highly specific
antigens from the TB bacterium.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 28
Also available on-line www.gbemda.com under forms
FECTIOLJS DISEASE EXPOSURE FORM slcl-eckore� sigriftantE] rion-S ig nff ica ryt Ej
,L
germ, Na nier: Case.,,la rni, Pun o r Pa po rt -F: Ex-posuip Date: Exposure Tin-p:
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L Las -P
a s t Na n
F first [Ja We:
address:
Cit,'Stat. 7ip:
contact Phone :F:
-!,,ork Phone :F:
E rnploe r Na n-p:
Mte of Birth:
E nriplo, nrie rit Ca tnor; ic I-ec k orie i ELLS Lj F i Ki/N-5c Lie Lj La,,,,., E r4orce nrie rit Lj otl-ie rLj ;spec if.; s:
4 n.; PPPV bus E-:pOs UR!.S _' riD Lj VeS Lj E; p.X um! Date tteatwie nt p urp.xes;
SOU[Ce History Kheckall that appkt: HPI.Iaim Li Hepatitis- 4 Li BLJ c Li rr,ieningococcal InfectiDn[] TBLJ
a rice Ila sc hic ke n po)�� shi
I o -ngless[_] fl-kerF-Isspecif,r:
source Last [,Iarrr-.
First Nare.
1�1 kid le Initial:
Horre,add ipss:
C it,,, - state lip:
contact Phone :F:
-!,,ork Phone :F:
occupation: Date of Birth: Ge =er F.1a Fenn
77,riattlula 77 ra -.,ou Incontact %,vith-1 ichieckallthatappLm: Blood.sSeruniLj 4n.-., fluidvisibk, contarninat-d vvith blood Lj
Pie ura I [:] a rnnbti F lu id E] Pe ritonea I E] °�ornit[:] Svrrj,,-iaIE] Ce ip b rc-6 pi na I F lu ids E] ute rirP.,-.,ag ina I sec re, tio ns El
Senrien[_] FeCeS[—] U tire [—] SalKa[—] �,ouglispra,.,sputurnE] ot 1-k-rFlU ids Ejidesc r1et:
hat vvw t- wd of contact ;c I-e : k a 11 t hat a pp [v Need lest ic as 5 harils Lj Lacs ration lbrasionL] Bit-Lj SplasF[T i re nett V Conta rni na-b--d o b)--c t E:];s pec if.; s: othp rE] s's pec if.; s:
List a 11 bod -., a mas eq)osed: E ;eS [:] rose[:] r,.Iouth [:] othie r. [:]!S: pec it.; 4:
Wni rytact S kin K ut- c ha pped ora b raded s kini: [:] we ie tha n 24- his o Id E] less t ha n 2-4- h is old
List a M, pe isona I protect K,e eq uipne nt Use d at time of e:,.pos uie: L_j G Lj E,,,e protection L—J alas
OtVe rF_1 is pe c if.;
hat inin-P _d iata action ta ke n in res pwise to fl-ke e xpos u ip to re rnrj,e the c onn rni na nt' -c Vie c k a 11 t hat a pp t: Ned area
E-1e1,nxe1,n-outhfIush[:] 0tl-o-rF_jsspecif.,s:
Did ,,ou see k me d ica I attention' No L_j (es " Of ;es - rie�,t section must be corp le ted
FaCilit.Nan-re: attending Plv.,skian:
Date (yf a rit-a 1: Tire of a rrt,.,a 1: appro.:.. time elapsed since ex-pos urp:
Testing ;c Iec ka I I tha t a ppkr s: PP D�, Qua ntife ron Lj Cl-estx, Pa,,, Lj 4c Lrb-- HE P Panel ;H,4�..W,' FK°,; LJ HPI LJ PPP LJ
othe rF_j s's pe c if; is
tteatrrie rit piv,° ided -1 ijo Lj re5 L] - is Nc if.� s:
n)F --d icatio n, presc ription g K'e n' 1,30 L] Yes L] - �s pe c it;
Folksy', - up-'
Ernpb,ee Signature: late:
I rifectinn contro I office r, Des ig me S ig MtU le Mt.-:
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 29
Amiodarone
SVT/VT with a Pulse OR if the patient converts out of VF or Pulseless VT using electricity:
Adult
Mix 150 mg in 50 mL of D5W
Dosage: 150 mg over 8-10 min Using a macrodrip (10 gtt/mL): Run at 60-75 gtt/min
Pediatric:
Mix 5 mg/kg in 50 mL of D5W
Dosage: 5 mg/kg over 8-10 minutes, using a macrodrip (1 Ogtt/mL): Run at 60-75 gtt/min.
Dopamine
Mix 400 mg in 250 mL of D5W, Concentration = 1600 mcg/mL, Dosage: 5-15 mcg/kg/min
Using a macrodrip (60 gtt/mL):
15 gtt/min = 400 mcg/min
30 gtt/min = 800 mcg/min
45 gtt/min = 1200 mcg/min
60 gtt/min = 1600 mcg/min
Alternative: Mix 400 mg in 500 mL of D5W Concentration = 800 mcg/mL
Using a macrodrip (60 gtt/mL):
30 gtt/min = 400 mcg/min
60 gtt/min = 800 mcg/min
90 gtt/min = 1200 mcg/min
120 gtt/min = 1600 mcg/min
Quick Calculation:
Take the patient's weight in pounds, drop the last number, and then subtract 2. This will give you
the starting drip rate at 5 mcg/kg/min. For every change in micrograms, add or subtract 3 drops.
Example:
Patient weighs 175 lb; Drop last number (5) from 175 = 17, 17 - 2 = 15
5 mcg/kg/min = 15 gtt/min
6 mcg/kg/min = 15 + 3 = 18 gtt/min
(This quick calculation gives a very close approximate dose.)
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 30
Epinephrine
Mix 1 mg of 1:10,000 in 250 mL DSW Concentration = 4 mcg/mL Dosage: 2-10 mcg/min
Using a microdrip (60 gtt/mL): 15 gtt/min = 1 mcg/min
30 gtt/min = 2 mcg/min
45 gtt/min = 3 mcg/min
60 gtt/min = 4 mcg/min
75 gtt/min = 5 mcg/min
90 gtt/min = 6 mcg/min
105 gtt/min = 7 mcg/min
120 gtt/min = 8 mcg/min
135 gtt/min = 9 mcg/min
150 gtt/min = 10 mcg/min
Magnesium Sulfate
Eclamptic Seizures: Mix 4 g in 50 mL of DSW, Concentration = 80 mg/mL, Dosage: 4 g over 5-10
min, Using a macrodrip (10 gtt/min): Run at 58-116 gtt/min
Torsades de Pointes and VF: Mix 1-2 g in 50 mL of DSW, Concentration = 20-40 mg/mL, Dosage
1-2 g over 1-2 min, Using a macrodrip (10 gtt/min): Run at 270 gtt/min
Maintenance:
Mix 1 g in 250 mL of DSW, Concentration = 4 mg/mL, Dosage: 2-4 mg/min
Using a microdrip (60 gtt/mL):
30 gtt/min = 2 mg/min
45 gtt/min = 3 mg/min
60 gtt/min = 4 mg/min
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 31
Abd
abdominal
ABG
arterial blood gas
A/C
Antecubital fossa
ACLS
Advanced Cardiac Life Support
ADL
Activities of daily living
AF
Arterial fibrillation
AICD
Automatic implantable cardiac defibrillator
AIDS
Acquired immunodeficiency syndrome
ALS
Advanced Life Support
AK
Above the knee
a.m.
Morning
a.m.a
Against medical advise
AMI
Acute myocardial infarction
amp
ampule; amputation
A.P.
Anteriorposterior
ARC
AIDS — related complex
ARDS
Acute respiratory distress syndrome
ATV
All -terrain vehicle
BLS
Basic Life Support
BK
Below the knee
BM
Bowel movement
BP
Blood pressure
bpm
Beats per minute
BSA
Body surface area (burns)
BSI
Body substance isolation
BVM
Bag -valve mask
C
Calorie; Celsius
CAB
Circulation Airway, breathing
CABG
Coronary artery bypass graft
CBC
Complete blood count
CCU
Coronary care unit
CDC
Centers for disease control and prevention
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 32
CHF Congestive heart failure
cm Centimeter
CNS Central nervous system
CO Carbon monoxide; cardiac output
CO2 Carbon dioxide
COPD Chronic obstructive pulmonary disease
CP Cerebral palsy
CPAP Continuous positive airway pressure
CPR Cardiopulmonary resuscitation
CS Cesarean section
CSF Cerebrospinal fluid
C-spine Cervical spine
CVA Cerebrovascular accident
CVL Central Venous Line
D5W 5% dextrose in water
D25 Dextrose 25%
D50 Dextrose 50%
DCAP-BLS Deformity, contusions, abrasions, penetrations, burns, lacerations, and swelling
DIC disseminated intravascular coagulation
DKA Diabetic ketoacidosis
DM Diabetes mellitus
DNA deoxyribonucleic acid
DNR Do not resuscitate
DNRO Do not resuscitate order
DOA Dead on arrival
DOB Date of birth
DT Delirium tremens
Dx Diagnosis
ECG or EKG Electrocardiogram
EDD Estimated date of delivery
EEG Electroencephalogram
EENT eye, ear, nose, throat
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 33
e.g.
For example
EMS
Emergency medical services
EMT
Emergency medical technician
ENT
Ears, nose, and throat
ER
Emergency room
ETA
Estimated time of arrival
ET tube
Endotracheal tube
F
Fahrenheit
f
Female
FBAO
Foreign body airway obstruction
GCS
Glasgow Coma Scale
g, gm
Gram
GERD
gastroesophageal reflux disease
GI
Gastrointestinal
GSW
Gunshot wound
Gtt, gtt
drops
GU
Genitourinary
GYN
Gynecology
HAV
Hepatitis A virus
HBV
Hepatitis B virus
HBP
High blood pressure
HCV
Hepatitis C virus
HEENT
Head, ears, eyes, nose, and throat
Hgb
Hemoglobin
HIV
Human immunodeficiency virus
h/o
History of
H2O
Water
H2O2
Hydrogen peroxide
HR
Heart rate
HTN
Hypertension
Hx, hx
History
HTN
Hypertension
ICP
Intracranial pressure
ICU
Intensive care unit
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 34
IDDM
Insulin dependant diabetic mellitus
ICU
Intensive care unit
IM
Intramuscular
IUD
Intrauterine device
IV
Intravenous
IVP
Intravenous push
J
Joule
JVD
Jugular vein distention
kg
Kilogram
KVO
Keep vein open
L
Liter
lb
Pound
L&D
Labor and delivery
LDL
Lethal dose
LLE
Left lower extremity
LLL
Lower left lobe
LLQ
Lower left quadrant
Imp
Last menstrual period
LOC
Level/loss of consciousness
LUE
Left upper extremity
LUL
Left upper lobe
LUQ
Left upper quadrant
m
Male
MAP
Mean arterial pressure
mcg
Microgram
MCI
Mass -casualty incident
MD
Muscular dystrophy; Medical doctor
MDI
Meter dose inhaler
mEq
Milliequivalent
mg
Milligram
min
Minute
mL
Milliliter
mm
Millimeter
MS
mitral stenosis; multiple sclerosis, morphine sulfate
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 35
MVA
Motor vehicle accident
MVC
Motor vehicle collision
N/A
Not applicable
NAD
No acute distress
NG
Nasogastric
NKA
No known allergies
NIDDM
Noninsulin dependant diabetes mellitus
NPO
Nothing by mouth
NS
Normal saline
NSR
Normal sinus rhythm
N&V, N/V
Nausea and vomiting
O
Oxygen
OB
Obstetrics
OR
Operating room
os
Mouth
OTC
Over the counter
oz
ounce
PaCO2
Partial pressure of CO2 in arterial blood
Pa02
Partial pressure of 02 in arterial blood
PALS
Pediatric advanced life support
PDR
Physician's Desk Reference
per
By
PERRLA
Pupils equal, regular, react to light and accommodation
pH
hydrogen ion concentration
PIC
Percutaneous Intravenous Catheter
p.m.
Evening
PMD
Private medical doctor
PVC
Premature ventricular contraction
RBC
Red blood cell
RDS
Respiratory distress syndrome
RLE
Right lower extremity
RLL
Right lower lobe
RLQ
Right lower quadrant
R/O
Rule out
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 36
ROM Range of motion
RR Respiratory rate
RUE Right upper extremity
RUL Right upper lobe
RUQ Right upper quadrant
SIDS Sudden infant death syndrome
SOB Shortness of breath
SUIDS Sudden unexpected infant death syndrome
sq subcutaneous
SP02 Percentage of oxygen in the blood as measured via pulse oximeter (equal to Sa02 )
SV Stroke volume
T Temperature
TB Tuberculosis, tuberculin
TIA Transient ischemic attack
THREAT Threat suppression, Hemorrhage control, Rapid Extrication to safety, Assessment
by medical providers, Transport to definitive care
TMJ Temporomandibular joint
Tx Treatment
URI
Upper respiratory infection
UTI
Urinary tract infection
WBC
White blood cell
WFBF
White female/black female
WMBM
White male/black male
WNL
Within normal limits
yo
year old
MISCELLANEOUS
- Negative
+ Plus/positive
# Number
% Percent
@ At
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 37
Active Shooter: The Department of Homeland Security's (DHS) definition of an active shooter is
an individual actively engaged in killing or attempting to kill people in a confined, populated area;
in most cases, active shooters use firearms and there is no pattern or method to their selection of
victims.
Active Shooter Incident: Active shooter situations are unpredictable and evolve quickly; most are
over within 10 to 15 minutes.
Aerosolized: In the form of ultramicroscopic solid or liquid particles dispersed or suspended in air
or gas
Adult Patient: For trauma a patient who is 16 years of age or older, medical patients 18 years of
age or older.
Amniotic Fluid: The serous liquid in which the embryo is suspended in the uterus.
Antibody: A protein substance produced in the blood or tissues in response to a specific antigen,
such as a virus. Antibodies destroy or weaken bacteria and neutralize organic poisons, thereby
forming the basis of immunity.
Asthma: Chronic inflammatory disease that can be acutely triggered by many irritants.
Ataxia: Staggered/unsteady gait that may be indicative of neurological impairment.
Baker Act: Florida Statutes, Chapter 394, which relate to the authorization of police, physicians, and
the courts to dictate certain medical care for persons who pose a threat to themselves or to others.
Blood: Human blood, human blood components, and products made from human blood.
Bloodbome Pathogens: Pathogenic microorganisms that are present in human blood and can cause
disease in humans. These pathogens include, but are not limited to, hepatitis B, hepatitis C, human
immunodeficiency virus (HIV), and syphilis.
BSI: Body Substance Isolation
Casualty Collection Point (CCP): A safe location(s) where fire rescue personnel can receive
victims. Victims may have to be carried or dragged to the CCP. This may be inside a structure or
exterior. This may be the same as the treatment area if located in the cold zone.
Cerebrospinal Fluid: The serum -like liquid that circulates through the ventricles of the brain and the
cavity of the spinal cord.
Child Abuse: When persons intentionally inflict, or allow to be inflicted, physical or psychological
injury to a child, which causes or results in risk of death, disfigurement, or distress.
Child Neglect: When an endangered child's physical, mental, or emotional condition is impaired or
because of failure of the legal guardian to supply basic necessities, including adequate food,
clothing, shelter, education, or medical care
CISM: Critical incident stress management. Support and professional intervention provided after a
significant traumatic event where personal coping mechanisms may become overwhelmed.
Competent: When individuals are able to understand the nature and consequences of their actions by
refusing medical care and/or transportation.
Concealment: Concealment is a law enforcement term that represents an object that only provides
protection from observation.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 38
Contact Team: Contact team is a law enforcement term used to designate the team of law
enforcement officers that make entry with the specific intention of ONLY to go after and to
neutralize the perpetrator
Cover: Cover is a law enforcement term that represents an object or location that provides
protection from direct gunfire
Contraindication: A factor that renders the administration of a drug or the carrying out of a medical
procedure inadvisable.
Croup: A viral infection of the upper airway that causes edema/inflammation below the larynx and
glottis, with a resultant narrowing of the lumen of the airway.
Decompression Sickness: A disorder resulting from a reduction of ("Bends"): surrounding
pressure, such as during an ascent from a dive, and attributed to the formation of bubbles from
dissolved gas in the body tissues. It is usually characterized by symptoms of pain and neurological
dysfunction, which may range from subtle to very acute in nature.
DNRO: Do not resuscitate order; Florida HRS form 1896, provider notification of a patient's/legal
guardian's wishes not to be resuscitated.
Drowning: Submersion in either fresh or saltwater, such that the person may or may not be
conscious — fatal or non -fatal.
Epiglottitis: An acute infection and inflammation of the epiglottis that is potentially life -threatening
HEPA Mask: A high -efficiency particulate air filter that is used as a personal protective device. It is
worn over the nose and mouth to filter/ remove bacteria, spores, and viruses whose size is equal to
and greater than 0.3 micron. OSHA's standard for respiratory protection requires that employees be
trained in the use of respirators and that the mask be fit tested.
Hemiplegia: Weakness on a unilateral side of the body.
Improvised Explosive Device (IED): The Department of Defense (DOD) definition of an IED is a
device placed or fabricated in an improvised manner incorporating destructive, lethal, noxious,
pyrotechnic, or incendiary chemicals and designed to destroy, incapacitate, harass, or distract. It
may incorporate military components, but is normally devised from nonmilitary components.
Influenza: An acute contagious viral infection characterized by inflammation of the respiratory tract
and by fever, chills, and muscular pain.
Intubation: To insert a tube into a hollow organ or body passage.
Level 1: Actions authorized prior to physician contact.
Level 2: Actions expected or to be requested with physician contact
Litter Bearer: A team of personnel assigned to Triage to move victims from the incident site to
the treatment area or Transport Units
Mantoux Test (PPD): A method of assessing whether someone has become infected with
Mycobacterium tuberculosis complex. The test involves measurement of a subject's immune
response to an injection of tuberculin purified protein derivative (PPD) manufactured from killed M.
tuberculosis bacilli. Also referred to as a tuberculin skin test or PPD test.
Mass Casualty Incident (MCI): The number of injured exceeds the capabilities of the first -arriving
unit as well as for large-scale MCIs_
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 39
Medical Direction: The action of a licensed physician granting authority and accepting
responsibility for the care provided by EMS; it includes participation in all aspects of EMS to ensure
maintenance of accepted standards of medical practice.
Medication Access Point (MAP): Intermittent vascular access site (i.e., saline or heparin lock)
Miosis: Constricted pupils
Morgan Lens: Ocular irrigation device that is placed on the global surface
Nasopharyngeal AirwaX: The part of the pharynx above the soft palate that is continuous with the
nasal passages.
Newborn: A patient who has just been delivered.
Neonate: A patient who is younger than 6 weeks of age.
Online Medical Control: The moment -to -moment contemporaneous medical supervision of EMS
personnel caring for patients in the field by a licensed physician. It occurs via radio, telephone, or
on -scene physicians.
OSHA BBP: Occupational Safety and Health Adm. Blood Borne Pathogen Precautions
Percutaneous: Passed, done, or effected through the skin.
Pericardial Fluid: The liquid suspended in the sac surrounding the heart.
Peritoneal Fluid: The liquid suspended in the body cavity that contains most of the abdominal and
pelvic organs.
Plasma: The clear yellowish fluid portion of blood, lymph, or intramuscular fluid in which cells are
suspended.
Pleural Fluid: The liquid matter contained in and around the body cavity that contains the lungs.
PPD: A method of assessing whether someone has become infected with M. tuberculosis
complex. The test involves measurement of a subject's immune response to an injection of
tuberculin purified protein derivative (PPD) manufactured from killed Mycobacterium
tuberculosis bacilli. Also referred to as tuberculin skin tests or PPD tests.
Post -exposure Prophylaxis (PEP, chemoprophylaxis): Prophylaxis means disease prevention. Post -
exposure prophylaxis (PEP) means taking antiviral medications as soon as possible after exposure
to a pathogen so that the exposure will not result in an infection.
PRN: As needed
QuantiFERON-TB Gold In -Tube test (QFT) - Is a highly -specific controlled blood test for use an
aid to the diagnosis of infection with bacteria responsible for TB and provides results showing an
individual's T-cell response to highly specific antigens from the TB bacterium.
Qualitative HCV-RNA.: Blood test to detect the presence of Hepatitis C virus.
Rapid HIV Testing: A laboratory method called Single -Use Diagnostic System (SUDS® HIV-1
Test) that detects and reports HIV antibody test results in the same day.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 40
Rescue Task Force: Rescue personnel and Law Enforcement personnel formed to make entry
into a structure to triage victims and provide life saving immediate treatment as needed i.e
stopping hemorrhage.
SUIDS: Sudden Unexpected infant Death which includes SIDS and sleep related deaths.
START: Simple Triage And Rapid Treatment; A protocol that allows for assessing a large number
of victims rapidly and can be used effectively by personnel with limited medical training
Seroconversion: Development of antibodies in blood serum as a result of infection or immunization.
Serum: The clear yellowish fluid obtained by separating whole blood into its solid and liquid
components.
Sputum: Matter that is coughed up and usually ejected from the mouth, including saliva, foreign
material, and substances such as mucus or phlegm from the respiratory tract.
Strike Team: Five of the same type of units, including common communications and leader (i.e.,
an ALS Transport Unit Strike Team would consist of five ALS Transport Units with a leader).
Synovial Fluid: The liquid that lubricates joints and nourishes cartilage.
Task Force: Five different types of units, including common communications and leader. MCI
Task Force: May be two ALS Transport Units, two BLS Transport Units, and one Suppression
Unit, including common communications and leader
Titer: A level of concentration of antibodies in a blood sample that shows whether exposure and
subsequent immunity to an infectious disease are present.
Triage: The process for sorting and prioritizing injured people into groups based on their need for or
likely benefit from immediate medical treatment in a medical setting
Vesicle fluid: The serum from the blister formed during a varicella zoster infection
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 41
Age
Weight (kg)
Minimum Systolic
BP
Normal Heart Rate
Normal
Respiratory Rate
Premature
< 2.5
40
120-170
40-60
Term
3.5
60
100-170
40-60
3 months
6
60
100-170
30-50
6 months
8
60
100-170
30-50
1 year
10
72
100-170
30-40
2 years
13
74
100-160
20-30
4 years
15
78
80-130
20
6 years
20
82
70-115
16
8 years
25
86
70-110
16
10 years
30
90
60-105
16
12 years
40
94
60-100
16
Typical blood pressure in children 1 to 10 years of age: 80 mm Hg + (child's age in years X 2)
Lower limits of systolic blood pressure in children 1 to 10 years of age: 70 mm Hg + (child's age in
years X 2)
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 42
OTHER RESOURCE NUMBERS
Agency for Toxic Substance and Disease Registry (ATSDR) (800) 232-4636
Chemtrec (800) 424-9300
Diver's Alert Network (DAN) (Duke University) (800) 446-2671 or 1-919-684-9111
Domestic Abuse Hotline
Environmental Protection Agency (EPA)
Florida Abuse Hotline (800) 96 ABUSE
Florida Department of Health - Bureau of EMS
Poison Information Center
Runaway Hotline
(800) 500-1119
(404)562-8700 or(800)424-8802
(800) 962-2873
(850)245-4440
(800)222-1222
(800) 786-2929
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 43
Gioria 11. Wwylo Fbimdafion 501 (c) 3 - "A SqA,
,qfi)r)?ei4,bi.,,v-nsxor?7 - E.ductaiw2ID-ainirig proptam,,
A Safe Haven f or Newborns
Fire/EMS Quick Reference Guide Is
"A
T)�g &tana A. aj�no FOU'dwim, 501(c)3 W
www' aaafehay- fwwbm5,a m
1-977-767-BABY
V2229)
,; Recognize that a "Safe. Haven Newborn" event is occurring and
epi I
assure parent(s) remain anonyllious by not making personal
information available to an-y organization public or private.
Notification of Law Enforcement, Department of Chikirell and
Failiflies or any other agency is not required by law unless chikI,
abuse is suspected
sit-3' Provide. cinergency inedical care to the newborn infant.
6 U Y�, J Surrender period is approximately 7 days ok]. or younger -
Physician to make final determination.
R,, Offer the inother emergency iliedical care' hile allowing her to 14,
rent in anonymous in person and list the mother oil the
medical report as"SAFE HAVEN MOTHEW under naine category.
Arrange for ininiediate transportation of the newborn infant to
the appropriate hospital.
ST.: Ie � I ji 6j Coiliplete agency run report and list newborn infant as ""Safe
Haven Baby" un&r natne category.
SNo0 tify y ur agency public ifif orniation office]- to handle inedia
inquiries.
te, Important: Notify'A Safe Haven for Newborns" immediately by
calling 1-877-767-2229.
Note: For othei- qtiestions/issties refer to the complete updated version of the "Safe Haven"
procedures, which can be downloaded
Pas,,.; code: 120799FE or call "Safe haven" at 148 7 7 - 767- 22 2 9.
Oi,der Training/Education mateiiaLs, public awareness materials, signs, etc., at
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 44
SAFE HAVEN MEDICAL QUESTIONNAIRE
Bear Birth toother::
rv'icu have taken the first step in assuring that your chit d voill be safe and well taken care of. wE know
this has been a vewant to assure you that voe -wil7. grye your child
r� dAcuit decision for you, andwe w
the best possib!"e, care.
We are asking for your help by previding some hea fth information that may be important for Your
child to know in his or her future. 7111i's information is important for ' �-our chi Id's, care, and viAl be(222115 most helpfu I for the adoptive family, The i�nformation will be used oWy for this purpose- it wHI not
be used to identifa vou or find vou. You may n of kricyow a 11 of the ansvrers - P',ease provide as much information as you do knove.
0oviriat is the bab-y's birth date?
became praZnant? ___
%vas the baby premature? 4 yes., vehen %%,as the approximate date -you
Were there an-, problems withi the T egna ncle or delivery? if -yes, please cleschbe:
Did you smoke, use alcohol, drugs or a nV medication during the pregnancy? if yes, p6ease list them:
Do you have an-,, medi ca I conditions such as
• Diabetes
c: Arthritis
• Asthma
c: Eye, problems
• Allergies
c: Hearing, lmpairment
• SeiZures
c other (expi4n�
• Cancer
• Heart DiSee Sa,
• High Blood Pressure
• Nienta i I liness
what is your:
AF:__
Pace:
Does tha be bys Father have
• Bibetes
• Asthma
z Allalgies
• Seizures
• Cancer
Heart Disease
High Blood Pressure
%liental IFness
what it is the,
Age:__
father's
� medical conditions such as::
Race:
Arthritis
E, , -e problems
Hearing im pa irment
other (explain)
Height: _ weight: I fletht:_ waight:
To your knowledge, are there arvyL hereditary conditions that rum in your fami'-,v, orthe father's farridy?
Please feel free to inci ude a note to your baby,, or to the people 'e.-ho will adopt your child.. You can use the back of this foam..
You have given your baby a spe64,Ejft by provi&ngthis medical information. you hava taken good care of your baby; nove
please, takE care of yourself, it is nove important that Vou personalh,, get a me& cal check. -up — -.qou wid remain a nonyrrous, iust
as the isive ai lovis. we can assist -.qou.
Gic,ria M, Si1verLo For iadabom —"A Safe Have. for Newbom"
6SCil �4177t Ave. Stuta 404
Ifisim" FL. 33; 166
'O."Cbske Elm Issfali'mem"o." fl:Safehavenfbr.ni2,wb = cozi
Phone:3054,192-1304 ex!103 Fi%305-&N-0017
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 45
Also available on-line www.gbemda.com under forms
a] hatelyff.Al hal GRIAMERIBRIM
Date: Unit #: Age,:__ Sex: E Male E] Female,
Patient's Name: Incident dumber,
Pre -Hospital Treatment Determination (Severe Sepsis Only
Does the patient meet one or more of the following criteria?
Cardiovascular: MAP < 65 (see display on monitor)
ID YES
El NO
Neurological: Acute Change in Mental Status
Metabolic: Lactate > 4 (if availlable)
ETCO2 < .15 ;correlates to, lactate of > 4)
If the box above is "YES" administer Normal Saline 30 cc/kg bolus
71trate Fluids to Goal MAP, > 70. Consider pressors after IL NS infused Max of 2 L NS
EMS Script: This is Rescue- coming in with a Sepsis Alert. The patient is a _y1ear old
(male/female) with suspected sepsis. The patient is positive for SIRS criteria and a suspected
infection. Vital signs are as follows (state VS), with a MAP of'--. The patientldoesldoes not)
qualify for a 30 cc/kg bolus based on criteria for severe sepsis. We (a re/are not) requesting
further orders. ETA is minutes.
Sepsis
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 46
Also available on-line www.gbemda.com under forms
GBEMDA
Aw1mr-9mull n1e,17-W-CU N1ek_AL'FkQq&11r.1FLA_
BROWARD ADVANCED STROKE, TWAGE
Stroke!'Stroke Alert Deterinin,;ition Page
El IF (Face) Facial Droop
Have patient smile or show teethe_ (Look for asymmetry)
Normal:
Both sides, of Ulte face move equallty or not at all
Abnormal:
One side of the patients face diroops
El A (Arm) Motor Weakness: Arm drift (close eyes, extend arms, palms up)
Normal:
Arms remain extanded equally, drift equally, or do not miove atall
Abnormal-
One ar m drifts, down when comparedwith, the other
El S (S,peech) Speaking:
"You can't teach an old dog new tricks.' (Repeat Phrase)
Normal:
P1hrase is repeated clearly and correctly
Abnormal:
Words are slurred (dysarthria), abnormal (aphasia), or none
E] T (Time) TIME LAST
SEEN NORMAL:
iIf any box is checked above, thin a. possible S I R 0 K E ALE P l'. M ove on to section 1
Section 1: Check all] appropriate lbox(.es)
F1 Time last seen normal greater than 12 hours
El Resolution of stroke symptoms prior to, arrival in the ED (TIA)
Ej Glucose less, than 50 and symptoms, improve wiM administration of 050
Are army items in Section, I checked?
Y ES: Patient tS NO T a. Stroke Alert.. TRANSPORT TO NEAREST STRO KE CENTER
NO: PROCEED TO SECTION 2, THIS A CTROKE ALERT
Browafd A&anced Stroke Triage, Form -Version 1 (212013)
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 47
Also available on-line www.gbemda.com under forms
Section 2:
4 Destimaticon Deter- inination Paige
Is the patient permanently bed or wheelchair confined, do they require constant care OR
is assiIstaince essentiall for activifies of daily living prior to today's. ew.nt?
YES: TRANSPORT TO NEAREST STROKE CENTER
NO- PROCIEED TO SECTION 3
Section 3: Check the appropriate boI
Los Angeles Motor Scale
,(LAMS)
symptom
Score
Fa6al Droop
---------
El -0
-----------------
El - I
Arm Drift
---------
El -0
Drifts
El - I
Falls Rapidly ..........
E] -2
Grip Strength
Weak Drip_....._ .......
El - I
No Gnip__.. ......................
Ej -2
Total
❑ Score 4-5 - TRANSPORT"IR-I COMPREHENSWE S, FROKE CEN(TER.
El Score 3 - Proceed to Section 4
R Score 0 -2 - TRANSPORT TO NEAREST STROKE CENTER
Section 4: Check, the appropriate boxfes)
F1 Estimated arrirval at Emergency Department is, greater than 3-5, hours since last seen normiall
E] Seizure (at onsetr)
F1 Patient ison any of the following blood thihners- Cournadin ()uarlarin), Pradaxa (dabiga.tran),
Brilinta (tilcagrelor), Xarefto ifivaroxaban), Lovenox (enoxaparin). or Fragrnih (dailtepanin)
F1 Recent (within 14 days) or current bleeding, traunia, surgery, or invasive. procedure
E] Bleeding I Clotting disorders. (history of Gil GU bleeding within last 21 clays)
El Pregnancy or Completion I Termination of pregnancy less Umn 30 days
El lintracraniall pathology {Tumor, Aneurysm, AxterioVenous, MaHournation lAVM), Inbacranial hemcwrhage)z
El Sudden onset of worst headache ever
Are any ii-terns, in Section 4 checked?
YES: TPANSPOR'f TO A COMPREHENSIVE ST'17;0KE CENTER (Cail a Sg..roke Aiert)
NO: TRANSPORT TO NEAREST STROKE CENTER: {Callll a Strafe Alert)
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 48
I.
BROWARD COUNTY UNIFORM TRAUMA TRANSPORT PROTOCOL
(revised December 2011)
COMMUNICATION (DISPATCH) CENTER PROCEDURE
A. All EMS systems utilize the 911-phone system in conjunction with either manual or
Computer Aided Dispatch (CAD) programs. The call taker confirms all emergency
information, including address and callback data prior to the end of the telephone
conversation. Emergency information is immediately transmitted to the Fire-Rescue/EMS
Dispatcher who selects the nearest available unit(s) for response; dispatches the call and
provides all unit(s) with all available information concerning the incident.
B. Call taker personnel/dispatchers shall make every attempt to obtain the following
information from the 911 caller:
1. Nature of the emergency;
2. Location of the incident;
3. Call back number;
4. Number of patients;
5. Severity of the illness/injury;
6. Name of the caller.
Should on scene personnel recognize a need for other emergency agencies (e.g. law
enforcement, fire, EMS, Coast Guard) they shall notify Dispatch immediately. On scene
personnel must identify the agencies needed and the specific amount of personnel, equipment,
etc. required. The communications center shall make contact with the appropriate services
(mutual aid/automatic aid). A contact list of all available emergency services is maintained and
available through the Broward County Warning Point (Broward Sheriff's Office
Communications Center).
II. ON SCENE PROCEDURE - Ground
A. Upon arrival at the scene, EMS personnel shall conduct a size up of the scene, to include,
but not limited to, Trauma Alert Criteria (Section IV), safe entry, severity, and number of
patients, the need for extrication, and the need for additional help. Dispatch and the
nearest appropriate trauma center will be notified, as soon as possible, of "Trauma Alert"
patient(s). Dispatchers shall immediately transfer this information, using the words
"Trauma Alert" to the supervisor on duty.
B. EMS personnel shall transport patient(s) to the nearest appropriate trauma center
(catchment area identified in the Broward County Trauma Plan).
C. EMS personnel shall submit the treatment data for each trauma patient to the trauma
center as required in 64J-1.014, F.A.C. and their respective agency.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 49
III. TRANSPORT PROCEDURE (Rescue Helicopter)
Three steps to follow when Broward Sheribrs Office, Dept. of Fire Rescue's (BSODFR)
Rescue Helicopter is used for rapid transport of the trauma patient. The first two are directed
toward the safety of the helicopter pilot and crew, ground personnel, patient, and bystanders;
and the third is to establish operational guidelines as to when and/or if the helicopter is used
to transport these patients.
A. Severe weather at scene, helicopter hanger, landing zone (LZ), or Trauma Center reduces the
use of the Rescue Helicopter.
B. Safety considerations for landing zone (if any of 4 below, use ground transport or move the
landing zone):
1. Power lines around landing zone;
2. Trees, signs, poles, or other obstacles in immediate landing area;
3. Pedestrians and large gatherings of civilians in the area;
4. An expectation that the area may not remain safe.
C. Rescue helicopter to be used if:
1. The Trauma Center that the patient would be transported to by ground, is farther away
than twenty (20) minutes (30 Minutes for Level II patients) driving time;
2. Ground transportation is not available and is not expected to be available within a reasonablf
time;
3. The helicopter is needed to gain access to a patient for transport from an inaccessible area;
4. Extrication time greater than twenty (20) minutes.
D. Operational Guidelines by ground EMS crews for Rescue helicopter use:
1. Secure a TAC radio channel through the County's dispatch center and keep open until
Helicopter has left scene.
2. Ground Crew PRE -ALERT Trauma Center.
3. Start CUTT REPORT (County Unified Trauma Telemetry Report) or respective agency's
modified patient treatment form. (see 1.10.1)
4. Airway - advise Air Crew on airway status and if airway assistance or RSI (Rapid Sequence
Intubation) is required.
NOTE: (for pediatric patients only) if using the landing pad at North Broward Medical Cente
and crew feels that the patient requires immediate attention, advise helicopter crew that th
patient will be seen by the Trauma Services physicians prior to transport to pediatric traum,
center (BGH or Memorial)
5. Begin Packaging Patient (remove shoes and clothes from vital areas). Advise Air Crew of the
weight of the patient.
6. Have a minimum of three (3) unobstructed lanes of traffic for roadway landings whenever
possible.
7. Pilot may require traffic stopped in both directions.
8. Landing Zone units must remain at their post until helicopter has left the scene.
9. Headlights should be turned off at night.
Only clear landing zone upon direction of Air Rescue crew and law enforcement on scene.
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 50
IV TRAUMA ALERT CRITERIA
The following guidelines are to be used to establish the criteria for a "Trauma Alert" patient
and determine which patient(s) will be transported to a trauma center. Any patient that meets
any one of the `'RED" criteria will be a trauma alert, while any patient that meets any two of
the "BLUE" criteria will be a trauma alert.
A. ADULT TRAUMA SCORECARD METHODOLOGY
1. Each EMS provider shall ensure that upon arrival at the location of an incident, EMS
personnel shall:
a. Assess the condition of each adult trauma patient using the adult trauma scorecard
methodology, as provided in this section to determine whether the patient should
be a trauma alert.
b. In assessing the condition of each adult trauma patient, the EMS personnel shall
evaluate the patient's status for each of the following components: airway,
circulation, best motor response (a component of the Glasgow Coma Scale),
cutaneous, long bone fracture, patient's age, and mechanism of injury. The
patient's age and mechanism of injury (ejection from a vehicle or deformed
steering wheel) shall only be assessment factors when used in conjunction with
assessment criteria included in # 3 (Level II) of this section. (NOTE: Glasgow
Coma Scale included for quick reference.)
2. The EMS personnel shall assess all adult trauma patients using the following `'RED"
criteria in the order presented and if any one of the following conditions is identified,
the patient shall be considered a trauma alert patient:
a. AIRWAY: Active ventilation assistance required due to injury(ies) causing
ineffective or labored breathing beyond the administration of oxygen.
b. "IR(AILATION: Patient lacks a radial pulse with a sustained heart rate greater
than 120 beats per minute or has a blood pressure of less than 90mmHg.
c. BEST MOTOR RESPONSE (BNIRI: Patient exhibits a score of four or less on
the motor assessment component of the Glasgow Coma Scale; exhibits the
presence of paralysis; suspicion of a spinal cord injury; or the loss of sensation.
d. (A ITA N E 0tIS: 2nd or 3rd degree burns to 15 percent or more of the total body
surface area; electrical burns (high voltage/direct lightning) regardless of surface
area calculations; an amputation proximal to the wrist or ankle; any penetrating
injury to the head, neck, or torso (excluding superficial wounds where the depth of
the wound can be determined).
e. LONGBO E F'RA "TITRE: Patient reveals signs or symptoms of two or more
long bone fractures sites (humerus, radius/ulna, femur, or tibia/fibula).
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 51
3. Should the patient not be identified as a trauma alert using the red criteria listed in 42
of this section, the trauma patient shall be further assessed using the `BLUE" criteria
in this section and shall be considered a trauma alert patient when a condition is
identified from any two of the seven components included in this section.
a. AIRWAY: Respiratory rate of 30 or greater.
b. CIRCULATION: Sustained heart rate of 120 beats per minute or greater.
c. BEST MOTOR RESPONSE (BMR): BMR of 5 on the motor component of the
Glasgow Coma Scale.
d. CUTANEOUS: Soft tissue loss from either a major degloving injury, or a major
flap avulsion greater than 5 inches, or has sustained a gunshot wound to the
extremities of the body.
e. LONGBONE FRACTURE: Patient reveals signs or symptoms of a single long
bone fracture resulting from a motor vehicle collision or a fall from an elevation of
10 feet or greater.
f. AGE: Patient is 55 years of age or older.
g. MECHANISM OF INJURY: Patient has been ejected from a motor vehicle,
(excluding any motorcycle, moped, all terrain vehicle, bicycle or the open body of
a pick-up truck), or the driver of the motor vehicle has impacted with the steering
wheel causing steering wheel deformity.
4. If the patient is not identified as a trauma alert after evaluation using the criteria in
sections 2 or 3 above, the trauma patient will be evaluated using all elements of the
Glasgow Coma Scale. If the score is 12 or less, the patient shall be considered a trauma
alert (excluding patients whose normal Glasgow Coma Scale Score is 12 or less, as
established by medical history or pre-existing medical condition when known).
5. Where additional trauma alert criteria has been approved by the medical director of
the EMS service and approved for use in conjunction with Broward County trauma
alert criteria as the basis for calling a trauma alert shall be documented as required in
section 64J-1.014, F.A.C. of the patient care record. Such local trauma assessment
criteria can only be applied after the patient has been assessed as provided in sections
42, 43, and 44 above of the Adult Trauma Alert Criteria.
6. In the event that none of the conditions are identified using the criteria in sections 42,
43, 44 or 45 above, during the assessment of the adult trauma patient, the paramedic
can call a trauma alert if, in his or her judgment, the patient's condition warrants such
action. Where paramedic judgment is used as the basis for calling a trauma alert, it
shall be documented on all patient data records as required in section 64J-1.014,
F.A.C.
7. The results of the patient assessment shall be recorded and reported on all patient data
records in accordance with the requirements of section 64J-1.014, F.A.C.
Patients found to meet Trauma Alert criteria upon arrival at or subsequent to arrival at a non -
trauma center will be expeditiously transferred to the appropriate trauma center. (See Section V)
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 52
TY
Mff1W*W1-MK?2"-
Broward Count%,
C)FfICE OF MEDICAL EXAMINER ANID TRAUMA, SERVICES
COUNTY UNIFIED TRAUMA TELEMETRY REPORT
Res,ue U'r(t 4: - TrE urna Al ert Type: Adult 0,13 > 20 vv e eks Pe&atric !915 YOA
Mode of Tra n sportatfon: Ground n.ir E T.A
Meets &o lor Criteria: Red Blue— (1 red or 2. b,lLje = Trauma Alert]
Meets Level 2 Criteria:
Level I Adult'Trat..�rna Alert CriteHa
z e f to (I R e,,q u i red
Blue Criteria (2 Required,
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�wa-r ars1-,ta,nC e., recpu rerl
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Br"' R = 5
Response :BMR)
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M ercha n ism of Injury
Ejecror -h-orn vehcle 'EX_ Udirg Ogren
ve9 tic1e,,2'. o, de'ormed steering wnee
Age
Age. `5
Mist:
n, ed ic j .dg nn, e rit
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Pedi'atric Trauma Aiert Criteria
Re d C rlti.,H a 1, 1 R-'q'j la?, )
Blue Criteria (2 Required',
Airway
oi Ad--,,,c- c ,, rvar
Co nscio usness
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— Arr-asia o, re iRbde X oLOC
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0, r c u I a tr on
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— C a rc n c j r fem o ra. i p�., Ise pa p a b le or sy s-
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to is BP 30-510
Fracture
.�j V open lorigl o' e �x cr�r rnuhdple F�� oi
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Level 2, Trauma Criteria with SIGNAFICANT �11NJU RRY (Adult and Pediatric)
Falls >12 ft. Adult
Death of an occupant in the same
Pedestrian struck by ve h i -1,e
Falls >Gft. Pediatric
passengercompErzment
Adult <15 mph, Ped. <Srrpli
Extrication time IS min.
— NlEj or intrusion
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Ra ilove r motor-velti c le c,rash
— Eje ctfor, from, BhzycPe
Anti Coagulartzs
Anti Plste=.ets
�aramed[c jadI-Irnerit:
� F rvr 11 1, - 2, 11
Version 4 Version 2, 3/1/15 Florida Regional Common EMS Protocols 53
County Unified Trauma Telemetry Report
InAi'al Viral Signs: BP:
Ass.essed Injuries:
Treatment Interventions: (Check all zhat apply)
:1 Drug Therapy:
:1 Other:
Current Vita I Signs: SP Pulse Resp. Raze
Glasgow Coma Scare
Glasgow Coma Score
Best F�e
Best Ve rba I Res po nse � S,,
Bes-z Motor Response �Gl
4 Eyes open sport'snecusly
4 Confused
4 'Withdrawal from pain
6 Obeys Commands
Eye
Verbal
Motor
Note the Glasgow Coma Scale meas:,ures rcagnitive abilizyThereforerif injury (.ch,,rc-nic or acurel has. caused paTEplegia
or quadripleg�a, alternate methods of assessing
motor, response must be u:,ed (e.g.,
ability to blink eves = obeys corn -
Version 4Version 2.3/l/l5 Flonida Regional Common EMS Protocols 54
Florida Regional Common
EMS Protocols
Section 7
Hazardous Materials Exposure
4th Edition, Version 2, March 1, 2015
Version 4 3/1/2015 Florida Regional Common EMS Protocols
Hazardous Material Exposure Table of Contents `
Introduction
7.1 Adult Hazardous Material Exposure (Chemicals)
7.1.1 Acids and Acid Mists
7.1.2 Alkaline Compounds
7.1.3 Ammonia (Liquid and Gas)
7.1.4 Aromatic Hydrocarbons (Benzene, Toluene, Xylene) and Ketones
7.1.5 Arsenic Compounds (Heavy Metal Poisoning)
7.1.6 Carbamate (Insecticide Poisoning)
7.1.7 Carbon Monoxide Poisoning
7.1.8 Chlorinated Hydrocarbons
7.1.9 Chlorine Gas And Phosgene (CG)
7.1.10 Cyanide: Hydrogen Cyanide, Hydrocyanic Acid (AC), Cyanogen Chloride (CK), Potassium
Cyanide, Sodium Cyanide
7.1.11 Dinitrobenzene (DNB)
7.1.12 Ethylene Glycol
7.1.13 Hydrofluoric Acid (HF)
7.1.14 Hydrogen Sulfide, Sulfides, and Mercaptans
7.1.15 Methanol
7.1.16 Methylene Biphenyl Isocyanate, Ethyl Isocyanate, and Methylene Dilsocyanate (MDI)
7.1.17 Mustard (Sulfur Mustard): Lewisite, Blister Agents (H, HD, HS)
7.1.18 Nitrogen Products and Other Products Causing Methemoglobinemia
7.1.19 Organophosphates: Insecticide Poisoning and Nerve Agents (GA, GB, GD, GF, VX)
7.1.20 Phenol
7.1.21 Phosphine
7.1. G Chemical Treatment Guide Index
Chemical Treatment Guide IA: Yellow
Chemical Treatment Guide 2A: Blue
Chemical Treatment Guide 3A: Gray
Chemical Treatment Guide 4A: Green
Chemical Treatment Guide 5A: Red
Chemical Treatment Guide 6A: Pink
Chemical Treatment Guide 7A: Orange
Chemical Treatment Guide 8A: Purple
Chemical Treatment Guide 9A: White
7.2 Adult Hazardous Material Exposure (Biological Agents)
7.2.1 Anthrax
7.2.2 Botulism
7.2.3 Cholera
7.2.4 Plague
7.2.5 Q Fever
7.2.6 Ricin
7.2.7 Smallpox
7.2.8 Staphylococcal Enterotoxin B
7.2.9 Trichothecene Mycotoxins (T2)
7.2.10 Tularemia
7.2.11 Venezuelan Equine Encephalitis (VEE)
7.2.12 Viral Hemorrhagic Fevers
7.3 Adult Hazardous Material Exposure (Radiological Agents)
7.3.1 Radiation Exposure/Contamination
7.3.2 Acute Radiation Syndrome
Version 4 3/1/2015 Florida Regional Common EMS Protocols 3
Introduction
These protocols have been developed to address the specialized treatment of patients exposed to
hazardous materials. Some of the agents covered in these protocols may be used as a weapon of
mass destruction (WMD) in a terrorist attack. In these instances, scene safety and a need to stage
at a safe distance from the scene should be a primary concern for all personnel.
The protocols cover exposure to chemical (7.1), biological (7.2), and radiological (7.3) agents. A
color code is assigned to each protocol in the Chemical section (7.1), which coincides with the
chemical treatment guide. The Chemical Treatment Guides have the adult and pediatric dosages
combined.
The protocols are intended to include a comprehensive overview of hazardous materials for use
by hazmat teams and/or hazmat tox medics. The availability of these specialized teams and
medics precludes the need for the participating Broward County Fire -Rescue departments to
carry all of the medications listed in this protocol.
Version 4 3/1/2015 Florida Regional Common EMS Protocols
7.1 Adult Hazardous Material Exposure (Chemicals)
This protocol is to be used for those patients suspected of exposure to hazardous materials via
any route of exposure (e.g., inhalation, absorption). The protocols give specific considerations
for each type of exposure as well as general treatment guidelines. Scene safety should be of
primary concern, with special attention being paid to the need for personal protective equipment.
Additional assistance may be necessary in certain cases (e.g., hazardous materials team for toxic
exposure, police for scene control, including a violent and/or impaired patient - see Adult
Protocol 2.5.2 or Pediatric Protocol 3.7.5).
A history of the events leading to the illness or injury should be obtained from the patient and
bystanders, to include the following information:
1. To which poison or other substances was the patient exposed?
2. When and how much?
3. Duration of symptoms?
4. Is there any pertinent medical history?
5. Accidental? Nature of accident?
6. Duration of exposure (if applicable)?
If risk of exposure from fumes is high, call the hazardous materials team. In this instance, refer
to the appropriate hazardous materials PPE protocol, as the risk of secondary contamination is
very high. All patients who have been exposed to hazardous materials must be properly
decontaminated prior to initiation of extensive medical treatment and transportation to the
hospital.
Contact the Poison Information Center (1-800-222-1222) for consultation regarding specific
therapy, and then contact the receiving emergency department for confirmation of Level 2
orders.
It is imperative that the emergency department be made aware early that a contaminated patient
is being transported so that the proper preparations can be made to receive the patient.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 6
7.1.1 Acids and Acid Mists
TREATMENT
Chemical Treatment Guide 1: YELLOW
DESCRIPTION
Acids are colorless to yellow liquids with strong irritating odors. Some acids may be flammable
agents. Acids act as direct irritants and corrosive agents to moist membranes and to intact skin to
a lesser extent.
SIGNS AND SYMPTOMS
Low concentrations of airborne acids can produce rapid onset of eye, nose, and throat irritation
Higher concentrations can produce cough, stridor, wheezing, chemical pneumonia, and non-
cardiogenic pulmonary edema. Ingestion of acids can result in severe injury to the upper airway,
esophagus, and stomach. In addition, there may be circulatory collapse, as well as partial- or full -
thickness burns.
End -stage symptoms may resemble organophosphate poisoning. However, patients will have
normal or dilated pupils (patients will not have pinpoint pupils). These patients should not be
given atropine or 2-PAM.
Note:
This protocol does not include hydrofluoric acid (see Adult Protocol 7.1.13).
EXAMPLES
• Sulfuric acid (battery acid)
• Muriatic acid (pool cleaner)
• Hydrochloric acid (HCI)
• Some drain cleaners
Version 4 3/1/2015 Florida Regional Common EMS Protocols
7.1.2 Alkaline Compounds
TREATMENT
Chemical Treatment Guide 1: YELLOW
DESCRIPTION
Most alkaline compounds are solids. Alkalis will impart a soapy texture to aqueous solutions.
Alkalis act as direct irritants and corrosive agents to moist membranes and to intact skin to a
lesser extent. The extent of tissue penetration and severity of injury is usually greater with alkalis
than with acids.
SIGNS AND SYMPTOMS
Low concentrations of airborne alkalis can produce rapid onset of eye, nose, and throat irritation.
Higher concentrations can produce cough, stridor, wheezing, chemical pneumonia, and non-
cardiogenic pulmonary edema. Ingestion of alkalis can result in severe injury to the upper
airway, esophagus, and stomach. In addition, there may be circulatory collapse, as well as
partial- or full -thickness burns.
End -stage symptoms may resemble organophosphate poisoning. However, patients will have
normal or dilated pupils (patients will not have pinpoint pupils). These patients should not be
given atropine or 2-PAM.
EXAMPLES
• Lye (baseball field line chalk)
• Cement
• Some drain cleaners
• Sodium hydroxide
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7.1.3 Ammonia (Liquid and Gas)
TREATMENT
Chemical Treatment Guide 1: YELLOW
DESCRIPTION
Ammonia is a colorless gas having an extremely pungent odor, which may be in an aqueous
solution or gaseous state. Liquefied compressed gas may produce a cryogenic (freezing) hazard
as it is released into the atmosphere. Common household ammonia contains 5-10% ammonia. It
is a direct irritant and, in much higher concentrations, an alkaline corrosive agent to moist
mucous membranes and, to a lesser extent, to intact skin. A chloramine gas can be liberated
when household ammonia is mixed with a hypochlorite solution (bleach), which may injure the
airway.
SIGNS AND SYMPTOMS
Low concentrations of airborne ammonia can produce cough, stridor, wheezing, and chemical
pneumonia (non-cardiogenic pulmonary edema). Ingestion of concentrated ammonia (e.g., > 5%)
may cause corrosive injury to the esophagus, stomach, and eye.
End -stage symptoms may resemble organophosphate poisoning. However, patients will have
normal or dilated pupils (patients will not have pinpoint pupils). These patients should not be
given atropine or 2-PAM.
EXAMPLES
• Component of household cleaners
• Refrigerant gases
• Used in manufacture of plastics, explosives, and pesticides
• Corrosion inhibitor
• Used in water purification process
• Component of fertilizers
Version 4 3/1/2015 Florida Regional Common EMS Protocols 9
7.1.4 Aromatic Hydrocarbons (Benzene, Toluene, Xylene) and Ketones
TREATMENT
Chemical Treatment Guide 2: BLUE
DESCRIPTION
Aromatic hydrocarbons may be found as colorless liquids or in a solid form with an ether -like or
pleasant odor. These compounds may be highly flammable. Ketones are organic compounds
derived from secondary alcohols by oxidation. They generally have low viscosity, low to
moderate boiling points, moderate vapor pressures, and high evaporation rates. Most ketones are
chemically stable liquids. Routes of exposure include absorption through the skin and eyes,
inhalation, and ingestion.
SIGNS AND SYMPTOMS
Mild exposure: cough, hoarseness, headache, drowsiness, dizziness, weakness, tremors, transient
euphoria, vision and hearing disturbances, nausea/ vomiting, salivation, and stomach pain.
Moderate to severe exposure: cardiovascular collapse, tachydysrhythmias (especially ventricular
fibrillation), chest pain, pulmonary edema, dyspnea, tachypnea, respiratory failure, paralysis,
altered mental status, seizures, excessive salivation, and delayed carcinogenic effects.
Halogenated hydrocarbons (chloride, bromide, iodide, fluoride) may present with ventricular
tachycardia, ventricular fibrillation, and supraventricular tachycardias. Aromated hydrocarbons
may present with altered mental status.
End -stage symptoms may resemble organophosphate poisoning. However, patients will have
normal or dilated pupils (patients will not have pinpoint pupils). These patients should not be
given atropine or 2-PAM.
EXAMPLES
• Components of gasoline
• Methyl benzene
• Methyl benzol
• Phenyl methane
Version 4 3/1/2015 Florida Regional Common EMS Protocols 10
7.1.5 Arsenic Compounds (Heavy Metal Poisoning)
TREATMENT
Chemical Treatment Guide 2: BLUE
DESCRIPTION
Arsenic compounds may be found as white, transparent, or colorless crystals; colorless liquids;
or colorless gas (e.g., ant poison). They are either odorless or have a garlic -like odor. Some are
flammable. Exposure can be fatal or cause severe injury at concentrations too low to detect.
Lewisite is a blistering agent made from arsenic that causes immediate pain, irritation, and
blistering of skin and mucous membranes. It is very similar in action to mustard and may be
treated as mustard (Protocol 7.1.17).
Arsine gas is made from arsenic and causes renal failure and destruction of red blood cells. Most
exposures commonly occur when arsine gas is used to extract precious metals from ore.
SIGNS AND SYMPTOMS
Severe gastrointestinal fluid loss, burning abdominal pain, watery or bloody diarrhea, muscle
spasm, seizures, cardiovascular collapse, tachycardia, hypotension, ventricular dysrhythmias,
shock, and coma. There may be respiratory or cardiac arrest and acute renal failure may occur
with bronze urine within a few minutes.
EXAMPLES
• Component of wood preservatives, insecticides, and herbicides
• Arsine gas: used to extract precious metals from ore
Version 4 3/1/2015 Florida Regional Common EMS Protocols 11
7.1.6 Carbamate (Insecticide Poisoning)
TREATMENT
Chemical Treatment Guide 4: GREEN
DESCRIPTION
Carbamate may be found in a solid, powder, or liquid form; it has a white or gray color and a
weak odor. This reversible acetyl cholinesterase inhibitor is found in insecticides, herbicides, and
some medicinal products.
Many carbamates are well absorbed through intact skin, so they pose a serious exposure risk to
rescuers. Simple water washing may be sufficient to remove oily compounds. Carbamates affect
both the parasympathetic nervous system (muscarinic effects) and the sympathetic nervous system
(nicotinic effects). Although the muscarinic effects may be reversed with atropine, the nicotinic
effects may cause respiratory paralysis and require incubation and aggressive ventilatory support.
Carbamates may be incorporated in a flammable base.
SIGNS AND SYMPTOMS
Muscarinic effects are the same as seen with organophosphates, which are described as the classic
SLUDGE syndrome (excessive Salivation, Lacrimation, Urination, Diarrhea, Gastrointestinal
distress, and Emesis). Additional muscarinic effect include bronchorrhea, bronchospasm, and
bradycardia. The patient will have constricted pupils (miosis) 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/fasiculations, and seizures.
EXAMPLES
Insecticides used for house tenting: Temic, Metical, Isolan, Furadan, Lannae, Zectran, Mesurol
Dimetialn, Bagon
Note:
PPE (usually Level A) with SCBA must be worn in the hazardous area when carbamates are
present. PPE with a minimum of Level C protection must be worn for treatment outside the
hazardous area.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 12
7.1.7 Carbon Monoxide Poisoning
TREATMENT
Chemical Treatment Guide 2: BLUE
DESCRIPTION
Carbon monoxide (CO) poisoning should be suspected when the patient has been exposed to the
products of combustion (e.g., smoke, automobile exhaust, exhaust fumes from fuel -powered
machinery) and is experiencing symptoms. These symptoms may vary with the level of CO
exposure.
SIGNS AND SYMPTOMS
Mild CO exposure: headache, nausea/vomiting, poor concentration, irritability, agitation, and
anxiety. May resemble flu -type symptoms. Suspect CO exposure during a cold snap with use of
charcoal heaters and other types of furnaces, and where there are multiple victims in the same
house or building.
Moderate to severe CO exposure: altered mental status, chest pain, cardiac dysrhythmias, pale
skin, cyanosis, seizures, and rarely cherry -red skin.
EXAMPLES
• Suspect CO poisoning when multiple victims in same building exhibit symptoms.
• Use of petroleum -fueled heaters, machinery, and other devices inside a building (especially
with improper ventilation).
• Incomplete burning of natural gas, LP gas, gasoline, kerosene, oil, coal, wood, or any other
material containing carbon.
• Fire fighters working at a fire scene, especially during overhaul operations.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 13
7.1.8 Chlorinated Hydrocarbons
TREATMENT
Chemical Treatment Guide 2: BLUE
DESCRIPTION
Methylene chloride is a volatile liquid that yields heavy vapors. At room temperature, it is a
clear, colorless liquid with a pleasant (ether -like) odor. Exposure can occur through skin
absorption, eye contact, inhalation, and ingestion. Methylene chloride is converted inside the
body to carbon monoxide.
SIGNS AND SYMPTOMS
Cardiovascular collapse, ventricular dysrhythmias, respiratory arrest, pulmonary edema, dyspnea
and tachypnea, headache, drowsiness, dizziness, altered mental status, seizures, nausea/vomiting,
diarrhea, abdominal cramps, and chemical burns.
EXAMPLES
• Component (solvent) in paint, varnish strippers, and degreasing agents
• Used in production of photographic films, synthetic fibers, pharmaceuticals, adhesives, inks,
and printed circuit boards
• Employed as a blowing agent for polyurethane foams, as a propellant for insecticides, in air
fresheners, and in paint
Version 4 3/1/2015 Florida Regional Common EMS Protocols 14
7.1.9 Chlorine Gas and Phosgene (CG)
TREATMENT
Chemical Treatment Guide 1: YELLOW
DESCRIPTION
Chlorine is either a colorless to amber -colored liquid (aqueous chlorine is usually in the form of
hypochlorite [bleach] in variable concentrations) or a greenish -yellow gas (anhydrous) with a
characteristic odor. The liquid hypochlorite solutions are very unstable and react with acids to
release chlorine gas (e.g., bleach mixed with vinegar or a toilet bowl cleaner containing HCI).
Liquefied compressed chlorine gas may produce a cryogenic (freezing) hazard as it is released
into the atmosphere. Clothing that has been soaked in a hypochlorite solution can be a hazard to
rescuers. A chloramine gas may be liberated when a hypochlorite solution (bleach) is mixed with
household ammonia, which may cause injury to the airway.
Phosgene (CG) is a chemical warfare agent. Phosgene gas can be liberated when Freon or
chlorinated compounds (e.g., bleach mixed with ammonia) are heated. Phosgene has similar
effects on the body as chlorine; however, symptoms from phosgene may be delayed for several
hours.
SIGNS AND SYMPTOMS
Both agents: dyspnea, tachypnea, cough, choking sensation, rhinorrhea, acute or delayed
chemical pneumonia (non-cardiogenic pulmonary edema), ventricular dysrhythmias,
cardiovascular collapse, severe irritation and burns of the mucous membranes and lungs,
headache, dizziness, altered mental status, nausea/vomiting, and severe irritation and burns to the
eyes and skin.
EXAMPLES
• Chlorine gas is used in water purification processes at water plants and sewage treatment
plants, as well as in pesticides, refrigerants, and solvents.
• Hypochlorite solutions are used in cleaning solutions and as disinfectants for water (drinking,
waste, and swimming pools).
• Phosgene is used in paint removers, dry cleaning fluid, dyes, and pesticides.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 15
7.1.10 Cyanide: Hydrogen Cyanide, Hydrocyanic Acid (AC), Cyanogen Chloride (CK),
Potassium Cyanide, Sodium Cyanide
TREATMENT
Chemical Treatment Guide 5: RED
DESCRIPTION
Cyanide can be found in a liquid (solutions of cyanide salts), solid (cyanide salts), or gaseous
(hydrogen cyanide) form. In solid form, it is white and has a faint almond odor (20% of the
population is genetically unable to detect the odor). Hydrogen cyanide gas may be formed when
acid is added to cyanide salt or a nitrite or when plastics burn. If a large amount of liquid or solid
cyanide material is present on the victim's clothing or skin, it poses a significant risk of exposure
to rescuers. Exposure can occur through skin absorption, eye contact, inhalation, and ingestion.
If the patient is unconscious and is being rescued from a fire, there is a high probability of
concurrent carbon monoxide and cyanide poisoning; both conditions must be treated (also see
Chemical Treatment Guide 2: Blue for these patients).
SIGNS AND SYMPTOMS
Cardiovascular: initially, pulse decreases and BP rises; in later stages, dysrhythmias and
cardiovascular collapse can occur. There may also be palpitations and/or chest tightness.
Respiratory: can cause immediate respiratory arrest. Initially, there is usually an increase in the
rate and depth of respirations, which later become slow and gasping.
CNS: can cause immediate coma. Initially there is usually weakness, headache, and confusion;
seizures are common.
GI: nausea/vomiting, salivation.
Skin: pale, cyanotic, or reddish color. Death is caused by an inhibitory action on the cytochrome
oxidase system, preventing tissue usage of oxygen.
EXAMPLES
• Hydrogen cyanide is used in the production of organic chemicals (it may be called nitrite)
• Potassium and sodium cyanide are used primarily in electroplating and metal treatment.
• Cyanides may be present in smoldering fires (e.g., wool, foams).
Note:
o PPE (usually Level A) with SCBA must be worn in the hazardous area when cyanide
compounds are present. PPE with a minimum of Level C protection must be worn for
treatment outside the hazardous areas.
o Good medical supportive care, including airway management, is paramount and should
precede the use of the cyanide antidote kit. However, the rapid administration of the cyanide
antidote kit will be the only therapy that will reverse the life -threatening symptoms of
cyanide poisoning.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 16
7.1.10 Cyanide: Hydrogen Cyanide, Hydrocyanic Acid (AC), Cyanogen Chloride (CK),
Potassium Cyanide, Sodium Cyanide (continued)
Option 1
For cyanide exposures: administer Cyanokit (hydroxocobalamin).
Option 2
For cyanide exposures: administer sodium nitrite and sodium thiosulfate.
For cyanide exposure with smoke inhalation (structure fires) or carbon monoxide poisoning: only
administer sodium thiosulfate and 100% oxygen.
For hydrogen sulfide exposures: only administer sodium nitrite.
TREATMENT:
Cyanokit (Hydroxocobalamin for Injection) for use with cyanide exposures
This kit is for intravenous use. The hydroxocobalamin is to be reconstituted with 100 mL per
vial of 0.9% sodium chloride injection. The starting dose is 5 g. (may be packaged in one or two
vials). See Procedure 4.13 and Drug Summary 5.18, Hydroxocobalamin.
1. Start a dedicated IV line
2. Reconstitution: Add 100 mL of 0.9% sodium chloride injection to the vial using a transfer
spike. Fill to the line (with the vial in an upright position).
3. Mix: Rock or rotate the vial for 30 seconds to mix the solution. Do not shake.
4. Infuse the first vial: Use vented IV tubing to hang the bag and infuse over 7.5 minutes.
5. Infuse the second vial: Repeat Steps 2 and 3 before the second infusion. Use vented IV tubing
to hang the bag and infuse over 7.5 minutes.
1'
For cyanide or hydrogen sulfide
1. If intubated provide PPV utilizing a BVM
2. As soon as possible start an IV of normal saline and immediately give:
a) Sodium nitrite 10ml of a 3% solution IV over 2 minutes (300mg). Monitor BP, as
hypotension may occur (sodium nitrite converts approximately 20% of the circulating
hemoglobin to methemoglobin). Additional doses of sodium nitrite should only be done
once methemoglobin blood analysis is completed.
b) Children— Administer 0.33 ml / kg of a 3% solution over 10 minutes.
c) Sodium thiosulfate 50 ml of a 25% solution over 10 minutes. Monitor BP
d) Children— Administer 1.65 ml / kg up to 50 ml over 10 minutes.
3. Administer 100% (NRBM) oxygen after administering sodium nitrite.
Note: Do not administer sodium nitrite in cases involving smoke inhalation (structure
fires) or carbon monoxide poisoning. Administer only sodium thiosulfate and 100%
oxygen.
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7.1.11 Dinitrobenzene (DNB)
TREATMENT
Chemical Treatment Guide 3: GRAY
DESCRIPTION
DNB is a colorless, oily liquid with a characteristic and peculiar sweet odor. It can also be found
as a solid. DNB causes methemoglobinemia, resulting in a state of relative hypoxia due to the
inability of RBCs to carry oxygen. DNB is explosive; it is detonated by heat or shock.
SIGNS AND SYMPTOMS
Signs and symptoms of the methemoglobinemia caused by this exposure include chocolate -
brown -colored blood, headache, ataxia, vertigo, tinnitus, dyspnea, CNS depression, hypotension,
heart blocks, ventricular dysrhythmias, seizures (rare), cyanosis, and cardiovascular collapse.
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7.1.12 Ethylene Glycol
TREATMENT
Chemical Treatment Guide 6: PINK
DESCRIPTION
Ethylene glycol is an odorless, colorless, syrupy liquid found in antifreeze, brake fluid, and other
industrial products. Because it is readily available and relatively inexpensive, it is often used in
suicide attempts. Ingestion is the primary route of exposure. The potential lethal dose is reported
to be 100 mL (1.0-1.5 mL/kg) in adults. It is the toxic metabolites - not the parent compound -
that are responsible for the associated toxic effects. These effects include metabolic acidosis,
tetany, QT interval prolongation on the ECG, and irreversible kidney failure. Ethylene glycol
poisoning can be fatal, and quick diagnosis and intervention are imperative to prevent the
damaging effects of the metabolites. If the patient has concurrently ingested ethanol, symptoms
of ethylene glycol toxicity may be delayed.
SIGNS AND SYMPTOMS
The clinical manifestations of ethylene glycol poisoning occur in three phases:
• Phase I (30 minutes to 12 hours): ethanol -like inebriation, metabolic acidosis, seizures, and
coma.
• Phase 2 (12 to 36 hours): tachycardia, tachypnea, hypertension, pulmonary edema.
• Phase 3 (36 to 48 hours): crystalluria, acute tubular necrosis with oliguria - renal failure
EXAMPLES
• Component of antifreeze (including new -generation -type antifreeze)
• Brake fluids
• Inks in stamp pads and ballpoint pens
• Paints and plastics
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7.1.13 Hydrofluoric Acid (HF)
TREATMENT
Chemical Treatment Guide 7: ORANGE
DESCRIPTION
Hydrofluoric acid is a colorless to yellow liquid with a strong, irritating odor. Because the
boiling point of HF is 67°F, when exposed to air, HF will readily change to a gaseous state.
When HF comes in contact with metals, it forms hydrogen gas, which is extremely flammable.
Once HF is absorbed into the tissues, it binds to calcium and magnesium. This form of fluoride
poisoning can be fatal, even if exposure is due to a dilute solution (< 3%). Contact with as little
as 7 mL of 100% solution can cause death.
SIGNS AND SYMPTOMS
Hypovolemic shock and collapse, tachycardia with weak pulse, acute pulmonary edema,
asphyxia, chemical pneumonitits, upper airway obstruction with stridor, pain and cough,
decreased LOC, nausea/vomiting, diarrhea, possible GI bleeding, and possible blindness. HF
also causes severe skin burns. The damage may be severe with no outward signs, except that the
patient will complain of severe pain.
EXAMPLES
• Rust removers
• Metal plating
• Glass etching
• Computer manufacturing
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7.1.14 Hydrogen Sulfide, Sulfides, and Mercaptans
TREATMENT
Chemical Treatment Guide 5: RED
DESCRIPTION
Members of this class of gases are colorless but have a strong offensive odor, like rotten eggs or
sewer gas. When they are present at high levels, however, the olfactory senses will be
overwhelmed, making the gas odorless. These chemicals may be found in a liquid form at low
temperatures or high pressures. Clothing that has become soaked in sulfide solutions or
mercaptans may pose a risk to rescuers. These types of chemicals can cause severe respiratory
irritation, including pulmonary edema and respiratory paralysis (especially likely with hydrogen
sulfide).
SIGNS AND SYMPTOMS
Cardiovascular collapse, tachycardia, dysrhythmias, irritation of the respiratory tract, cough,
dyspnea, tachypnea, respiratory arrest, pulmonary edema, headache, altered mental status, garlic
taste in mouth, seizures, nausea/vomiting, diarrhea, profuse salivation, dermatitis, sweating, and
possible cyanosis.
EXAMPLES
Found in sewers, septic tanks, livestock waste pits, manholes, well pits, and similar settings
Found in chemical wastes, petroleum, and natural gas (28%)
Produced in industrial processes that work with sulfur compounds
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7.1.15 Methanol
TREATMENT
Chemical Treatment Guide 6: PINK
DESCRIPTION
Methanol is found as a highly volatile clear liquid and in mixtures. It is used in solvents,
additives, and emulsifiers. It is a frequent ingredient in windshield washer fluid. Routes of
exposure include skin absorption, eye contact, inhalation, and ingestion. Methanol has CNS
depressant properties that are highly toxic upon aspiration and can cause respiratory failure and
cardiac dysrhythmias. The metabolites that are formed following the metabolism of methanol -
formaldehyde and formic acid - can cause a severe delayed toxicity.
SIGNS AND SYMPTOMS
Cardiovascular: dysrhythmias and hypotension.
Respiratory: respiratory insufficiency or arrest, pulmonary edema, chemical pneumonitis, and
bronchitis.
CNS: CNS depression and coma, seizures, headache, muscle weakness, and delirium.
GI: GI bleeding, nausea/vomiting, and diarrhea. Eye: chemical conjunctivitis.
Skin: problems ranging from irritation to full -thickness burns.
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7.1.16 Methylene Biphenyl Isocyanate, Ethyl Isocyanate, and Methylene Dilsocyanate
(MDI)
TREATMENT
Chemical Treatment Guide 1: YELLOW
DESCRIPTION
MDI is found as a solid, whose color ranges from white to yellow flakes. Various liquid
solutions are also used for industrial purposes. There is no odor to the solid or liquid solutions.
The vapor is approximately eight times heavier than air.
This chemical is a strong irritant to the eyes, mucous membranes, skin, and respiratory tract.
MDI is also a very potent respiratory sensitizer. Various industrial processes utilize MDI in
production and usage of (poly)urethane foams, lacquers, and sealants; MDI is also used in the
production of insecticides and laminating materials. These chemicals are not cyanide
compounds.
SIGNS AND SYMPTOMS
Irritation to the eyes, mucous membranes, skin, and respiratory tract (cough, dyspnea, and
pulmonary edema).
EXAMPLES
• Component of smoke in plastic fires
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7.1.17 Mustard (Sulfur Mustard): Lewisite, Blister Agents (H, HD, HS)
TREATMENT
Chemical Treatment Guide 1: YELLOW
DESCRIPTION
Mustard is a "blister agent" that causes cell damage and destruction. It is a colorless to light
yellow to dark brown oily liquid with the odor of garlic, onion, or mustard. It does not evaporate
readily, but may pose a vapor hazard in warm weather. Mustard is a vapor and liquid hazard to
skin and eyes, and a vapor hazard to airways. Its vapor is five times heavier than air.
Sulfur mustard has been used as a research tool to study DNA damage and repair. A variety of
military munitions are filled with mustard, including projectiles, mortars, and bombs. Mustard
damages DNA in cells, which leads to cellular damage and death. It penetrates the skin and
mucous membranes very quickly, and cellular damage begins within minutes.
Lewisite is a "blister agent" that has the same effect on the body as mustard; with the exception
that onset of symptoms begins immediately.
SIGNS AND SYMPTOMS
Mustard: Clinical effects begin within 2 to 24 hours. The initial effects include the following
issues:
Eyes: itching or burning, redness, corneal damage.
Skin: erythema with itching and burning, blisters.
Respiratory tract: epistaxis, hoarseness, sinus pain, dyspnea, and cough.
Lewisite: same effect on the body as mustard, with the exception that onset of symptoms begins
immediately.
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7.1.18 Nitrogen Products and Other Products Causing Methemoglobinemia
TREATMENT
Chemical Treatment Guide 3: GRAY
DESCRIPTIONS
These products can be found in a gas, liquid, or solid form. They are released from the
combustion or decomposition of substances that contain nitrogen. Depending on the individual
compound, these agents may pose a significant health hazard for rescuers. Many are well
absorbed through intact skin. Simple water washing may be sufficient to remove oil compounds.
Other routes of exposure include eye contact, inhalation, and ingestion. These products are
respiratory tract irritants that can cause a severe, delayed pulmonary edema or immediate upper
airway irritation and edema. They also change Fe to Fe (methemoglobinemia), which does not
bind to oxygen.
SIGNS AND SYMPTOMS
Cardiovascular: cardiovascular collapse with weak and rapid pulse.
Respiratory: a mild, transient cough and tachypnea (only symptoms at the time of exposure to
most agents). A delayed onset of dyspnea, tachypnea, violent coughing, cyanosis, and pulmonary
edema follows. Some agents work immediately on the upper airway, resulting in pain and
choking, spasm of the glottis, temporary reflex arrest of breathing, and possibly upper airway
obstruction spasm or edema of the glottis.
CNS: headache, dizziness, vertigo, fatigue, restlessness, and decreased LOC (usually delayed
signs).
GI: burning of the mucous membranes, nausea/vomiting, and abdominal pain.
Eye: chemical conjunctivitis.
Skin: irritation of moist skin areas, pallor, and cyanosis with normal SP02.
Note:
Symptoms may be immediate or may be delayed for 5 to 72 hours.
EXAMPLES
• Propellant fuels and agricultural fumigants
• Also used in laboratory research solvents, bleaching agents, and refrigerants
• Found in grain silos (silo filler's disease)
• Product of combustion in most fires (e.g., structure fires)
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7.1.19 Organophosphates: Insecticide Poisoning and Nerve Agents (GA, GB, GD, GF, VX)
TREATMENT
Chemical Treatment Guide 4: GREEN
DESCRIPTION
Organophosphate compounds are used as insecticides in residential applications as well as
commercial agriculture. They are found as liquids, dusts, wettable powders, concentrates, and
aerosols. Chemical nerve agents include Tabun (GA), Sarin (GB), Soman (GD), GF, and VX.
Many are well absorbed through intact skin, so they pose a serious hazard to rescuers. Simple
water washing may be sufficient to remove oily compounds. Routes of exposure include skin
absorption, eye contact, inhalation, and ingestion.
Organophosphates affect both the parasympathetic nervous system (muscarinic effects) and the
sympathetic nervous system (nicotinic effects). Although the muscarinic effects may be reversed
with atropine, the nicotinic effects may cause respiratory paralysis and require incubation and
aggressive ventilatory support. Organophosphates may be incorporated in a flammable base.
SIGNS AND SYMPTOMS
Exposure may produce 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 as long as 2 months) 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/fasiculations, and seizures.
EXAMPLES
• Pesticides (e.g., Chlorthion, Diazinon, Dipterex, Di-Syton, Maathion, Parathion, Phosdrin)
• Chemical warfare agents (e.g., VX, Sarin, Tabun, Soman)
Note:
PPE (usually Level A) with SCBA must be worn in the hazardous area when organophosphates
are present. PPE with a minimum of Level C protection must be worn for treatment outside the
hazardous areas.
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7.1.20 Phenol
TREATMENT
Chemical Treatment Guide 9: WHITE
DESCRIPTION
Phenol (carbolic acid), at room temperature, is a translucent, colorless, crystalline mass; white
powder; or thick, syrupy liquid. The crystals turn pink to red in air. Phenol has a sweet, tar -like
odor that is readily detected at low concentrations. It is soluble in alcohol, glycerol, petrolatum,
and, to a lesser extent, water.
Phenol is absorbed rapidly by all routes; however, the inhalation hazard is limited. In dilute
concentrations (1% to 2%), phenol may cause severe burns. Systemic toxicity can rapidly lead to
death.
Phenol is mainly used in the manufacture of phenolic resins and plastics. It is also used as a
disinfectant and has some medicinal applications (e.g., Campho Phenique®).
SIGNS AND SYMPTOMS
Nausea/vomiting, diarrhea, excessive sweating, headache, dizziness, ringing in the ears, seizures,
loss of consciousness, coma, respiratory depression, inflammation of the respiratory tract, shock,
and death. Exposure to skin can result in severe burns, which will cause the skin to have a white,
red, or brown appearance. Failure to decontaminate the skin may allow the phenol to be absorbed
systemically, resulting in death.
EXAMPLES
• Used in the manufacture of phenolic resins and plastics
• Used as a disinfectant
• Campho Phenique®
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7.1.21 Phosphine
TREATMENT
Chemical Treatment Guide 8: PURPLE
DESCRIPTION
Phosphine can be found in a gas, liquid, or solid form. Most gases are colorless to brown, and
have a sharp odor. Phosphine is used as a chemical warfare and protection agent, as a propellant
fuel, and as an agricultural fumigant. Some compounds are used in laboratory research, solvents,
and pesticides. They are released from the combustion or decomposition of substances that
contain nitrogen. A toxic exposure can result from working on or in grain silos.
Very small amounts of phosphene can be trapped in a victim's clothing after an overwhelming
exposure, posing a risk to rescuers. Routes of exposure include skin absorption, eye contact,
inhalation, and ingestion. Phosphine is a respiratory tract irritant that can cause a severe, delayed
pulmonary edema or immediate upper airway irritation and edema.
SIGNS AND SYMPTOMS
Cardiovascular: cardiovascular collapse with weak and rapid pulse. Patients may present with a
reflex bradycardia.
Respiratory: mild and transient cough (only symptom at the time of exposure to most agents). A
delayed onset of dyspnea, tachypnea, violent coughing, and pulmonary edema follows. Some
agents work immediately on the upper airway, resulting in pain and choking, spasm of the glottis,
temporary reflex arrest of breathing, and possibly upper airway obstruction spasm or edema of the
glottis.
CNS: fatigue, restlessness, and decreased LOC (usually delayed signs). GI: burning of the
mucous membranes, nausea/vomiting, and abdominal pain.
Eye: chemical conjunctivitis.
Skin: irritation of moist skin areas, pallor, and cyanosis.
Symptoms may be immediate or may be delayed for 5 to 72 hours.
EXAMPLES
• Pesticides (especially rodenticides). Also see description.
Note
PPE (usually Level A) with SCBA must be worn in the hazardous area where phosphene is
present. PPE with a minimum of Level C protection must be worn for treatment outside the
hazardous areas.
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7.1. G Chemical Treatment Guide Index
Chemical Name or Group Name
Treatment Guide
Acids and acid mists
Guide 1 -
YELLOW
Alkaline compounds
Guide 1 -
YELLOW
Ammonia (liquid and gas)
Guide 1 -
YELLOW
Aromatic hydrocarbons (benzene, toluene, xylene)
Guide 2 -
BLUE
Arsenic compounds (heavy metal poisoning)
Guide 2 -
BLUE
Blister agents (H, HD, HS)
Guide 1 -
YELLOW
Carbamates: insecticide poisoning
Guide 4 -
GREEN
Carbon monoxide poisoning
Guide 2 -
BLUE
Chlorinated hydrocarbons (methylene chloride)
Guide 2 -
BLUE
Chlorine gas
Guide 1 -
YELLOW
Cyanide
Guide 5 -
RED
Cyanogen chloride (CK)
Guide 5—RED
Methylene biphenyl isocyanate
Guide 1 -
YELLOW
Dinitrobenzene (DNB)
Guide 3 -
GRAY
Ethylene glycol
Guide 6 -
PINK
Ethyl isocyanate
Guide 1 -
YELLOW
Hydrocyanic acid (AC)
Guide 5 -
RED
Hydrogen cyanide
Guide 5 -
RED
Hydrofluoric acid (HF)
Guide 7 -
ORANGE
Hydrogen sulfide, sulfides
Guide 5 -
RED
Ketones
Guide 8 -
PURPLE
Lewisite
Guide 1 -
YELLOW
Mercaptans
Guide 5 -
RED
Methanol
Guide 6 -
PINK
Methylene biphenyl isocyanate
Guide 1 -
YELLOW
Methylene dilsocyanate (MDI)
Guide 1 -
YELLOW
Mustard (sulfur mustard)
Guide 1 -
YELLOW
Nerve agents (GA, GB, GD, GF, VX)
Guide 4 -
GREEN
Nitrogen products and other products causing
methemoglobinemia
Guide 3 -
GRAY
Organophosphate insecticide poisoning
Guide 4 -
GREEN
Phenol (carbolic acid)
Guide 9 -
WHITE
Phosgene (CG)
Guide 1 -
YELLOW
Phosphine Guide
Guide 8 -
PURPLE
Potassium cyanide
Guide 5 -
RED
Sodium cyanide
Guide 5 -
RED
Sulfur mustard (mustard)
Guide 1 -
YELLOW
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Chemical Treatment Guide 1A.
• Acids and acid mists
• Alkaline compounds
• Ammonia (liquid and gas)
• Chlorine gas and phosgene (CG)
• Methylene biphenyl isocyanate, ethyl isocyanate, and methylene dilsocyanate (MDI)
• Mustard (sulfur mustard): Lewisite, blister agents (H, HD, HS)
SIGNS AND SYMPTOMS
Low concentrations of airborne acids and alkalis can produce rapid onset of eye, nose, and throat
irritation. Higher concentrations (low concentrations of ammonia) can produce cough, stridor,
wheezing, and chemical pneumonia (non-cardiogenic pulmonary edema). Ingestion of acids and
alkalis can result in severe injury to the upper airway, esophagus, and stomach. In addition, there
may be circulatory collapse, as well as partial- or full -thickness burns.
End -stage symptoms may resemble organophosphate poisoning. However, patients will have
normal or dilated pupils (patients will not have pinpoint pupils). These patients should not be
given atropine or 2-PAM.
Supportive Care
• Remove the patient from the hazardous area (a).
• If the patient was exposed externally, remove his/her clothing and jewelry and decontaminate
with copious amounts of water. Provide ocular irrigation with normal saline (do not attempt
to neutralize with another solution) (see Medical Procedure 4.19, Morgan Lens).
• If the patient has external burns, see Adult Protocol 2.10.8, Burn Injuries.
• Medical Supportive Care Protocol Adult 2.1.3 or Pediatric 3.1.3. (Ipecac, charcoal, and NG
tube are contraindicated; avoid oral airways.)
• Contact the Poison Information Center (1-800-222-1222).
• If the patient has pulmonary edema, maintain adequate ventilation and oxygenation, and
provide pulmonary suction to remove fluid. Non-cardiogenic pulmonary edema should not be
treated with Lasix, but with positive end expiratory pressure (PEEP) or a CPAP mask (see
Medical Procedure 4.12).
ALS Level 1
If the patient has bronchospasm: Albuterol (Ventolin®): See Medical Procedure 4.18.6
Adult
o 1 nebulizer treatment containing 2.5 mg of albuterol pre -mixed with 3 mL normal saline
Pediatric
o If < 1 year old or < 10 kg: mix 1.25 mg in 1.5 mL of normal saline (0.083%).
o If > 1 year or > 10 kg: pre -mixed 2.5 mg in 3 mL of normal saline (0.083%). May repeat
twice PRN (a).
Adult and pediatric - may give terbutaline (Brethine®) 0.25 mg SQ, if available.
If bronchodilators are administered, may add ipratropium bromide (Atrovene) 0.5 mg (0.5 mL)
to either albuterol or levalbuterol nebulizer treatment on first nebulizer treatment only (b) (c) (d).
Adult and pediatric if the patient has inhaled chlorine or hydrochloric acid (HCl) and has
significant respiratory distress, administer sodium bicarbonate via nebulizer (8.4% 3 mL
mixed with normal saline 3 mL or 4.2% in 6 mL).
Version 4 3/1/2015 Florida Regional Common EMS Protocols 30
Chemical Treatment Guide 1A. (continued)
If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18.)
o Diazepam (Valium) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg, may repeat to a max of 10 mg (a).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, IO, IM, or IN, Pediatric dose
0.1mg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (e)
OR
o Lorazepam (Ativan ) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg (a). Pediatric dose O.lmg/kg, maximum dose is 2 mg.
• If hypotension persists, administer 20 mL/kg normal saline IV PRN (maximum total dose is
60 mL/kg) Neonate IOmg/kg maximum total dose is 30mL/kg. (Adult Protocol 2.4.1).
ALS Level 2 - None
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. Refer to the
appropriate hazardous materials PPE protocol, as the risk of secondary contamination is very
high.
(b) Adult do not give albuterol or ipratropium bromide if the patient's heart rate 140.
(c) Pediatric do not give albuterol or ipratropium bromide if the patient's heart rate is above 200,
(d) Caution should be used when the patient is older than 40 years of age or has a history of
hypertension or heart disease.
(e) For IN administration, administer lml per nare, give half the volume in one nostril and the
other half of the volume in the other nare.
ALS Level 2 - None
Version 4 3/1/2015 Florida Regional Common EMS Protocols 31
Chemical Treatment Guide 2A: i-,UE
• Aromatic hydrocarbons (benzene, toluene, xylene)
• Arsenic compounds (heavy metal poisoning)
• Carbon monoxide poisoning
• Chlorinated hydrocarbons (methylene chloride)
SIGNS AND SYMPTOMS
Mild exposure signs and symptoms: Cough, hoarseness, headache, poor concentration, irritability,
agitation, anxiety, drowsiness, dizziness, weakness, tremors, transient euphoria, vision and
hearing disturbances, nausea/vomiting, salivation, diarrhea, stomach pain, and chemical burns
with chlorinated hydrocarbons. (For arsenic signs and symptoms, see below.)
Moderate to severe exposure signs and symptoms: Cardiovascular collapse, tachydysrhythmias
(especially ventricular fibrillation), chest pain, pulmonary edema, dyspnea, tachypnea, respiratory
failure, paralysis, altered mental status, seizures, excessive salivation, pale skin, cyanosis, rarely
cherry -red skin with carbon monoxide, and delayed carcinogenic effects. (For arsenic signs and
symptoms, see below.)
Signs and symptoms of arsenic exposure: Severe gastrointestinal fluid loss, burning abdominal
pain, watery or bloody diarrhea, muscle spasm, seizures, cardiovascular collapse, tachycardia,
hypotension, ventricular dysrhythmias, shock, and coma. There may be respiratory or cardiac
arrest, and acute renal failure may occur with bronze urine within a few minutes.
End -stage symptoms may resemble organophosphate poisoning. However, patients will have
normal or dilated pupils (patients will not have pinpoint pupils). These patients should not be
given atropine or 2-PAM. Products may be flammable.
Supportive Care
• Remove the patient from the hazardous area (a).
• Medical Supportive Care Protocol Adult 2.1.3 or Pediatric 3.1.3. (Ipecac and an NG tube are
contraindicated. Avoid oral airways.)
• If the patient was exposed externally, remove his/her clothing and jewelry and decontaminate
as appropriate. Provide ocular irrigation with normal saline (see Medical Procedure 4.19,
Morgan Lens).
• Administer high -flow oxygen (100%) (b).
• Contact the Poison Information Center (1-800-222-1222).
• If the patient has pulmonary edema, maintain adequate ventilation and oxygenation, and
provide pulmonary suction to remove fluid. Non-cardiogenic pulmonary edema should not be
treated with Lasix, but with positive end -expiratory pressure (PEEP) or a CPAP mask (see
Medical Procedure 4.12).
Version 4 3/1/2015 Florida Regional Common EMS Protocols 32
Chemical Treatment Guide 2A: BLUE (continued)
ALS Level 1
If the patient has dysrhythmias, treat PRN (see Adult Protocol 2.3 or Pediatric Protocol 3.3) (c).
If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18)
o Diazepam (Valium ) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg, may repeat to a max of 10 mg (d).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, IO, IM, or IN, Pediatric dose
O.lmg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (d)
OR
o Lorazepam (Ativan) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg (d). Pediatric dose O.lmg/kg, maximum dose is 2 mg.
If hypotension persists, administer 20 mL/kg normal saline IV PRN (maximum total dose is
60 mL/kg) Neonate IOmg/kg maximum total dose is 30mL/kg. (Adult Protocol 2.4.1).
ALS Level 2 - None
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. Refer to the
appropriate hazardous materials PPE protocol, as the risk of secondary contamination is very
high.
(b) Document the duration of exposure to CO and when oxygen therapy was started (this
information is needed to assist in making HBO decisions).
(c) Administration of epinephrine to patients in a pre -code status may not be desirable for this
group of patients. A physician or the Poison Information Center should guide the
administration of epinephrine in these cases.
(d) For IN administration, administer lml per nare, give half the volume in one nostril and the
other half of the volume in the other nare.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 33
Chemical Treatment Guide 3A: GRAY
Dinitrobenzene (DNB)
Nitrogen products and other products causing methemoglobinemia
SIGNS AND SYMPTOMS
Methemoglobinemia characterized by chocolate -brown -colored blood, CNS depression, headache,
dizziness, ataxia, vertigo, tinnitus, dyspnea, tachypnea, violent coughing, choking, possibly upper
airway obstruction spasm or edema of the glottis, abdominal pain, hypotension, heart blocks,
ventricular dysrhythmias, seizures (rare), pallor, cyanosis, and cardiovascular collapse.
Symptoms may be immediate or may be delayed for 5 to 72 hours.
Supportive Care
• Remove the patient from the hazardous area (a).
• Medical Supportive Care Protocol Adult 2.1.3 or Pediatric 3.1.3.
• If the patient was exposed externally, remove his/her clothing and decontaminate as appropriate.
• Administer high -flow oxygen (100%).
• Contact the Poison Information Center (1-800-222-1222).
• If nitrogen product ingestion occurred, adult and pediatric dose administer activated charcoal
lg/kg maximum dose is 50 g PO.
ALS Level 1
Adult and pediatric if the patient is dyspneic, is cyanotic , has normal SpO2 and has chocolate
brown colored blood, administer methylene blue (1%) 1 - 2 mg/kg slow IV over 5 minutes,
followed by a normal saline 30 mL flush to decrease pain at the IV site.
If the patient has dysrhythmias, treat PRN (see Adult Protocol 2.3 or Pediatric Protocol 3.3).
If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18)
o Diazepam (Valium) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg, may repeat to a max of 10 mg (b).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, I0, IM, or IN, Pediatric dose
O.lmg/kg, maximum single dose 4 mg IV, I0, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (b)
OR
o Lorazepam (Ativan ) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg Pediatric dose 0.1mg/kg, maximum dose is 2 mg (b).
If hypotension persists, administer 20 mL/kg normal saline IV PRN (maximum total dose is
60 mL/kg) Neonate IOmg/kg maximum dose is 30mL/kg. (Adult Protocol 2.4.1).
Do not induce vomiting.
ALS Level 2
• If cyanosis persists, adult and pediatric dose administer methylene blue (1 %) 1-2 mg/kg slow
IV over 5 minutes, followed by a 30 mL flush of normal saline to decrease pain at the IV site.
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. Refer to the appropriate
hazardous materials PPE protocol, as the risk of secondary contamination is very high.
(b) For IN administration, administer, Iml per nare, give half the volume in one nostril and the other half of
the volume in the other nare.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 34
Chemical Treatment Guide 4A:
Carbamates: insecticide poisoning
Organophosphates: insecticide poisoning and nerve agents (GA, GB, GD, GF, 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 as long as 2 months despite appropriate treatment) with inhalation
or skin exposure. Ingestion may or may not cause miosis. Stimulation of nicotinic receptors will
produce tachycardia, muscle paralysis (apnea), muscle twitching/fasiculations, and seizures.
Supportive Care
• Remove the patient from the hazardous area (a).
• Avoid exposure to the patient's sweat, vomit, stool, and vapors emitting from soaked clothes
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.3.
• Administer high -flow 02.
• If the patient was exposed externally, remove his/her clothing and decontaminate as
appropriate (place the patient's clothes in sealed bag).
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
If treating 1-4 patients:
• If the patient is bradycardic (patient is usually tachycardic) or has excessive pulmonary
secretions, adult dose administer atropine 0.03 mg/kg IV (2 mg/70 kg), pediatric dose
0.05mg/kg maximum dose is 3mg. Repeat every 5 minutes until secretions are inhibited (b) (c).
• In case of organophosphate poisoning, adult and pediatric dose consider pralidoxime
(Protopam ®, 2-PAM ) 1-2 g mixed in 100 mL NS IV drip over 30 minutes. In severe cases, 2-
PAM® may be given via IV at a maximum rate of 200 mg/min or 1 g/5 min (used when
nicotinic effects are present, as evidenced by fasciculation of large muscles). Observe patient
for hypertension. (May be needed with high exposure to carbamates.)
• If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18)
o Diazepam (Valium) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg, may repeat to a max of 10 mg (e).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, I0, IM, or IN, Pediatric dose
0.1mg/kg, maximum single dose 4 mg IV, I0, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (e)
OR
o Lorazepam (Ativan) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg. Pediatric dose 0.1mg/kg, maximum dose is 2 mg (e).
Version 4 3/1/2015 Florida Regional Common EMS Protocols 35
Chemical Treatment Guide 4A: (continued)
If treating 5 or more patients older than 5 years of age or treating self -exposure (with pinpoint
pupils): Adult and pediatric.
• Administer DuoDote(s) (combined Atropine and Pralidoxime) or Mark I Kit(s) (two auto -
injectors containing Atropine 2 mg in one and pralidoxime 600 mg in the other; see Medical
Procedure 4.18.1) as follows:
o For early symptoms (severe rhinorrhea or mild to moderate dyspnea): administer one
DuoDote or Mark I auto -injector kit. If no improvement in patient's status in 10 minutes,
administer another DuoDote or Mark I auto -injector kit (c) (d).
o For severe respiratory distress, coma, or seizures: administer three DuoDotes or Mark I
auto -injectors and one CANA/Valium auto -injector (diazepam 10 mg IM) (c) (d).
For all patients meeting the preceding criteria:
• Alert the emergency department to prepare for a contaminated patient.
• Do not induce vomiting or give Furosemide (Lasix®) or Morphine.
• If the patient is experiencing eye pain and/or blepharospasm, administer Scopolamine 1 drop
in each eye.
ALS Level 2 - None
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. PPE (usually
Level A) with SCBA must be worn in the hazardous area. PPE with a minimum of Level C
protection must be worn for treatment outside the hazardous area.
(b) If advised by the Poison Information Center, every other dose of Atropine can be increased
to 0.06 mg/kg IV.
(c) The endpoint for treatment is manifested by patient improvement with clear lung sounds.
(d) When possible, establish an IV and administer Atropine, Diazepam, Lorazepam, and
Midazolam IV and Pralidoxime IV drip.
(e) For IN administration, administer lml per nare, give half the volume in one nostril and the
other half of the volume in the other nare.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 36
Chemical Treatment Guide 5A: RED
Cyanide: hydrogen cyanide, hydrocyanic acid (AC), cyanogen chloride (CK)
Hydrogen sulfide, sulfides, and mercaptans
Azides
SIGNS AND SYMPTOMS
Cardiovascular: initially, pulse decreases and BP rises. In later stages, tachycardia, dysrhythmias,
and cardiovascular collapse can occur. There may also be palpitations and/or chest tightness.
Respiratory: can cause immediate respiratory arrest. Initially there is usually an increase in the
rate and depth of respirations, which later become slow and gasping. Irritation of the respiratory
tract, cough, dyspnea, tachypnea, and pulmonary edema may also occur.
CNS: can cause immediate coma. Initially there is usually weakness, headache, and confusion;
seizures are common.
GI: nausea/vomiting, profuse salivation, possibly garlic taste in mouth. Skin: pale, cyanotic, or
reddish color, dermatitis, sweating.
Note:
Good medical supportive care, including airway management, is paramount and should precede
the use of the cyanide antidote kit. However, the rapid administration of the cyanide antidote kit is
the only therapy that will reverse the life -threatening symptoms.
Supportive Care
• Remove the patient from the hazardous area (a).
• Avoid exposure to vapors emitting from soaked clothes.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric 3.1.3.
• Administer high -flow 02.
• If the patient was exposed externally, remove his/her clothing quickly and decontaminate.
• Contact the Poison Information Center (1-800-222-1222).
• If the patient is conscious, administer activated charcoal lg/kg maximum dose is 50 g PO for
oral ingestion.
• Only a physician or the Poison Information Center can authorize treatment beyond supportive
care for exposure to azides.
• Alert the emergency department to prepare for a contaminated patient.
• Do not induce vomiting.
ALS Level 1
• Adult and pediatric if the patient is unconscious, administer sodium bicarbonate 1 mEq/kg IV.
• If advanced airway in place provide PPV utilizing a BVM
• If the patient has dysrhythmias, treat PRN (see Adult Protocol 2.3 or Pediatric 3.1).
• If hypotension persists, administer 20 mL/kg normal saline IV PRN (maximum total dose is 60
mL/kg).For neonate, l OmL/kg maximum total dose is 30mL/kg. (Adult Protocol 2.4.1).
Version 4 3/1/2015 Florida Regional Common EMS Protocols 37
Chemical Treatment Guide 5A: RED (continued)
If the patient is exhibiting life -threatening symptoms (severe respiratory compromise or arrest,
shock, seizures, coma), administer the Cyanokit or if unavailable the cyanide antidote kit (3
parts) in the following order (to induce methemoglobinemia). If symptoms are not severe, or if
diagnosis is not certain, omit Steps 1 and 2 and only give sodium thiosulfate (Step 3).
Paramedics who are not part of a hazardous materials team and non -rescue supervisors can
only give sodium thiosulfate.
TREATMENT:
Option 1 Cyanokit (Hydroxocobalamin for Injection), for use with cyanide exposures
This kit is for intravenous use. The hydroxocobalamin is to be reconstituted with 100 mL per
vial of 0.9% sodium chloride injection. The starting dose is 5 g. (may be packaged in one or two
vials). See Procedure 4.13 and Drug Summary 5.18, Hydroxocobalamin.
1. Start a dedicated IV line
2. Reconstitution: Add 100 mL of 0.9% sodium chloride injection to the vial using a transfer
spike. Fill to the line (with the vial in an upright position).
3. Mix: Rock or rotate the vial for 30 seconds to mix the solution. Do not shake.
4. Infuse the first vial: Use vented IV tubing to hang the bag and infuse over 7.5 minutes.
5. Infuse the second vial: Repeat Steps 2 and 3 before the second infusion. Use vented IV tubing
to hang the bag and infuse over 7.5 minutes.
M
Option 2: For severe hydrogen sulfide exposures
Rescue Supervisor and Hazardous Materials Team Paramedic
1. Sodium Nitrite 10ml of a 3% solution IV over 2 minutes (300mg). Monitor BP, as
hypotension may occur. (Sodium Nitrite converts approximately 20% of the circulating
hemoglobin to methemoglobin). Additional doses of Sodium Nitrite should only be done
once methemoglobin blood analysis is completed. Administer 100% (NRBM) oxygen
after administering Sodium Nitrite.
Note: Do not administer sodium nitrite in cases involving smoke inhalation (structure fires) or
carbon monoxide poisoning. Administer only sodium thiosulfate and 100% oxygen.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 38
Chemical Treatment Guide 5A: RED (continued)
If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18)
o Diazepam (Valium) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg, may repeat to a max of 10 mg (c).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, IO, IM, or IN. Pediatric dose
0.1mg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (c).
OR
o Lorazepam (Ativan ) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg. Pediatric dose 0.1mg/kg, maximum dose is 2 mg (c).
ALS Level 2
• If symptoms persist after 20 minutes, repeat the cyanide antidote kit at 50% of the initial dose
• If the patient becomes cyanotic after administration of the cyanide antidote kit, contact the
Poison Information Center (1-800-222-1222) for further instructions.
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. Refer to the
appropriate hazardous materials PPE protocol, as the risk of secondary contamination is very
high.
(b) If the patient has IV access and received supportive care, Step 1 may be bypassed for Step 2.
(c) For IN administration, administer lml per nare, give half the volume in one nostril and the
other half of the volume in the other nare.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 39
Chemical Treatment Guide 6A 111 7-%, �
• Ethylene glycol
• Methanol
CLINICAL MANIFESTATIONS OF ETHYLENE GLYCOL POISONING
Phase I (30 minutes to 12 hours): ethanol -like inebriation, metabolic acidosis, seizures, and coma.
Phase 2 (12 to 36 hours): tachycardia, tachypnea, hypertension, pulmonary edema.
Phase 3 (36 to 48 hours): crystalluria, acute tubular necrosis with oliguria - renal failure.
SIGNS AND SYMPTOMS OF METHANOL EXPOSURE
Cardiovascular: dysrhythmias and hypotension.
Respiratory: respiratory insufficiency or arrest, pulmonary edema, chemical pneumonitis, and
bronchitis.
CNS: CNS depression and coma, seizures, headache, muscle weakness, and delirium.
GI: GI bleeding, nausea/vomiting, and diarrhea. Eye: chemical conjunctivitis.
Skin: problems ranging from irritation to full -thickness burns.
Supportive Care
• Remove the patient from the hazardous area.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
• If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18)
o Diazepam (Valium) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg IV, IM, IN or IO, may repeat to a max of 10 mg (a).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, IO, IM, or IN, Pediatric dose
O.lmg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (a)
OR
o Lorazepam (Ativan ) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg (a). Pediatric dose O.lmg/kg, maximum dose is 2 mg.
• If the patient's lungs are clear, administer normal saline at a rate of 100 mL/h IV.
• If the patient's respiratory rate is twice the normal rate, administer sodium bicarbonate 8.4%
1-2 mEq/kg IV.
• If the patient has dysrhythmias, treat PRN (see Adult Protocol 2.3 or Pediatric Protocol 3.3).
• Administer thiamine 100 mg IV if available
ALS Level 2 - None
Note: (a) for IN administration, administer lml per nare, give half the volume in one nostril and
the other half of the volume in the other nare.
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Chemical Treatment Guide 7A:.
• Hydrofluoric acid (HF)
• Vicane
SIGNS AND SYMPTOMS
Hypovolemic shock and collapse, tachycardia with weak pulse, acute pulmonary edema,
asphyxia, chemical pneumonitis, upper airway obstruction with stridor, pain and cough, decreased
LOC, nausea/vomiting, diarrhea, possible GI bleeding, and possible blindness. HF also causes
severe skin burns. The damage may be severe with no outward signs, except that the patient will
complain of severe pain.
Supportive Care
• Remove the patient from the hazardous area (a).
• Medical Supportive Care Protocol 2.1.3 or pediatric 3.1.3. (Ipecac is contraindicated.)
• If the patient was exposed externally, remove his/her clothing and jewelry and decontaminate
with copious amounts of water.
• Contact the Poison Information Center (1-800-222-1222).
• If the patient has pulmonary edema, maintain adequate ventilation and oxygenation, and
provide pulmonary suction to remove fluid. Non-cardiogenic pulmonary edema should not be
treated with Lasix, but with positive end -expiratory pressure (PEEP) or a CPAP mask (see
Medical Procedure 4.12).
ALS Level 1 for Adult and Pediatric
If the patient has burns to the eye(s): Immediately flush with copious amounts of water or
normal saline. Prepare an eye wash solution by mixing calcium gluconate (10%) 50 mL in
normal saline 500 mL (b).
Apply calcium gluconate eye wash using the Morgan lens (see Medical Procedure 4.45) and
continue until arrival at the receiving facility (b).
If the patient has burns to the skin for Adult and Pediatric
• Immediately flush with copious amounts of water.
• Prepare a skin gel by mixing calcium gluconate (10%) 10 mL into a 2-oz tube of KY Jelly
(making a 2.5% gel) (b).
• Apply a 2.5% calcium gluconate gel on the burned area. For burns to the hand(s), place the
hand in a glove filled with this gel (b).
Version 4 3/1/2015 Florida Regional Common EMS Protocols 41
Chemical Treatment Guide 7A:. " (continued)
For inhalation injures For Adult and Pediatric
• Immediately support ventilations.
• Administer calcium gluconate Treat inhalation injuries with oxygen and 2.5% calcium gluconate
nebulizer, aadminister 1mL mixed 3mL normal saline via a nebulizer.
• For severe respiratory depression/arrest and/or cardiac toxicity (dysrhythmia, prolonged QT
interval, hypotension), administer calcium gluconate (10%) 1-2 g slow IV over 5 minutes (b).
• If the patient has dysrhythmias, treat PRN (Adult Protocol 2.3 or Pediatric Protocol 3.3).
• If hypotension persists, treat PRN (Adult Protocol 2.4.1).
• If hypotension persists, administer 20 mL/kg normal saline IV PRN (maximum total dose is
60 mL/kg) Neonate IOmg/kg maximum total dose is 30mL/kg. (Adult Protocol 2.4.1).
ALS Level 2
If systemic symptoms persist, repeat calcium gluconate (10%) adult dose 1-2 g slow IV over 5
minutes pediatric dose 100mg/kg maximum dose is 1 g IV slow over 5 minutes (b).
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. Refer to the
appropriate hazardous materials PPE protocol, as the risk of secondary contamination is very
high.
(b) Do not use calcium carbonate, as the outcome can be disastrous.
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Chemical Treatment Guide 8A:
• Ketones
• Phosphene
SIGNS AND SYMPTOMS OF KETONE EXPOSURE
Cardiovascular: cardiac dysrhythmias and tachycardia.
Respiratory: upper respiratory tract irritation, dyspnea, tachypnea, a burning sensation in the chest
and pulmonary edema.
CNS: CNS depression to coma, confusion, tinnitus, disorientation, headache, drowsiness,
weakness, and seizures.
GI: pain and irritation of the mucous membranes, nausea/vomiting, and diarrhea.
Eye: chemical conjunctivitis.
Skin: irritation and dermatitis, cyanosis of extremities.
SIGNS AND SYMPTOMS OF PHOSPHINE EXPOSURE
Cardiovascular: cardiovascular collapse with weak and rapid pulse. Patients may present with a
reflex bradycardia.
Respiratory: mild and transient cough (only symptom at the time of exposure to most agents). A
delayed onset of dyspnea, tachypnea, violent coughing, and pulmonary edema follows. Some
agents work immediately on the upper airway, resulting in pain and choking, spasm of the glottis,
temporary reflex arrest of breathing, and possibly upper airway obstruction spasm or edema of the
glottis.
CNS: fatigue, restlessness, and decreased LOC (usually delayed signs). GI: burning of the
mucous membranes, nausea/vomiting, and abdominal pain.
Eye: chemical conjunctivitis.
Skin: irritation of moist skin areas, pallor, and cyanosis.
Note: Symptoms may be immediate or may be delayed for 5 to 72 hours.
Supportive Care Adult and Pediatric
• Remove the patient from the hazardous area (a).
• Avoid exposure to vapors emitting from soaked clothes.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric 3.1.3.
• Administer 100% high -flow oxygen.
• Ipecac is contraindicated.
• If the patient was exposed externally, remove his/her clothing and decontaminate as
appropriate (do not use water as an initial irrigating solution for phosphene exposure due to
possible reactivity). Provide ocular irrigation with normal saline (see Medical Procedure 4.45,
Morgan Lens).
• Contact the Poison Information Center (1-800-222-1222).
• For phosphene ingestions. Administer activated charcoal lg/kg maximum dose of 50g PO.
• If the patient has pulmonary edema, maintain adequate ventilation and oxygenation, and
provide pulmonary suction to remove fluid. Non-cardiogenic pulmonary edema should not be
treated with Lasix, but with positive end -expiratory pressure (PEEP) or CPAP mask (see
Procedure 4.12).
Version 4 3/1/2015 Florida Regional Common EMS Protocols 43
Chemical Treatment Guide 8A: (continued)
ALS Level 1
If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18)
o Diazepam (Valium) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg, may repeat to a max of 10 mg (a).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, IO, IM, or IN, Pediatric dose
0.1mg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (b).
OR
o Lorazepam (Ativan ) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg (a). Pediatric dose O.lmg/kg, maximum dose is 2 mg.
If the patient has dysrhythmias, treat PRN (see Adult Protocol 2.3).
If hypotension persists, administer 20 mL/kg normal saline IV PRN (maximum total dose is
60 mL/kg) Neonate IOmg/kg maximum total dose is 30mL/kg. (Adult Protocol 2.4.1).
ALS Level 2 - None
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. PPE (usually
Level A) with SCBA must be worn in the hazardous area. PPE with a minimum of Level C
protection must be worn for treatment outside the hazardous areas.
(b) For IN administration, administer lml per nare, give half the volume in one nostril and the
other half of the volume in the other nare.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 44
Chemical Treatment Guide 9A: WHITE
Phenol (carbolic acid)
SIGNS AND SYMPTOMS
Nausea/vomiting, diarrhea, excessive sweating, headache, dizziness, ringing in the ears,
seizures, loss of consciousness, coma, respiratory depression, inflammation of the respiratory
tract, shock, and death. Exposure to skin can result in severe burns, which will cause the skin to
have a white, red, or brown appearance. Failure to decontaminate the skin may allow the phenol
to be absorbed systemically, resulting in death.
Supportive Care
• Remove the patient from the hazardous area (a).
• Avoid exposure to vapors emitting from soaked clothes.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric protocol 3.1.3.
• Ipecac is contraindicated.
• If the patient was exposed externally, remove his/her clothing and decontaminate with
copious amounts of water. After thoroughly rinsing skin, apply vegetable oil to exposed
areas. (Isopropyl alcohol may be used for very small skin burns only.)
• Provide ocular irrigation with normal saline (see Medical Procedure 4.19, Morgan Lens).
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
Assess the need for an advanced airway (Medical Procedure 4.4).
If seizures continue for 5 minutes, Administer one of the following benzodiazepines:
(Medication Delivery Procedure 4.18)
o Diazepam (Valium) Adult dose 5 mg IV, IM or IN; may repeat to a max of 20 mg.
Pediatric dose 0.2 mg/kg, may repeat to a max of 10 mg (a).
OR
o Midazolam (Versed) Adult dose 2 mg increments IV, IO, IM, or IN, Pediatric dose
0.1mg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg (b)
OR
o Lorazepam (Ativan ) Adult dose 2 mg IV, IM, or IN; may repeat once as needed, up to a
max dose of 4 mg (a). Pediatric dose O.lmg/kg, maximum dose is 2 mg.
If hypotension persists, administer 20 mL/kg normal saline IV PRN (maximum total dose is 60
mL/kg) Neonate IOmg/kg maximum total dose is 30mL/kg. (Adult Protocol 2.4.1).
ALS Level 2 - None
Note:
(a) If risk of exposure from fumes is high, call for a hazardous materials team. Refer to the appropriate
hazardous materials PPE protocol, as the risk of secondary contamination is very high.
(b) For IN administration, administer Iml per nare, give half the volume in one nostril and the other half
of the volume in the other nare.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 45
7.2 Adult Hazardous Material Exposure (Biological Agents)
This protocol is to be used for those patients suspected of exposure to biological agents via any
route of exposure (e.g., inhalation, absorption). It gives specific considerations for each type of
exposure as well as general treatment guidelines. Scene safety should be of primary concern,
with special attention being paid to the need for personal protective equipment. Additional
assistance may be necessary (e.g., hazardous materials team, police).
Because many biological agents are spread through an airborne route, scene safety must include
use of protective masks by all personnel, and must include containment of the unknown
substance to prevent its airborne spread. Any victim who has a cough, respiratory symptoms, or
a flu -like syndrome should be considered as potentially infectious to others by the respiratory
route, until proven otherwise. Both patients and healthcare workers should wear protective
masks. If a patient needs low -flow oxygen therapy, it may be given by nasal cannula under a
protective mask. If a patient needs high -flow oxygen therapy, it may be given by non-rebreather
mask, which should not be covered by a protective mask; instead, the healthcare workers must
wear protective masks.
Symptoms that would develop after a biological weapon (BW) attack would be delayed and
nonspecific, making the initial diagnosis difficult. A BW attack should be considered if any of
the following factors are present:
o Large epidemic with unprecedented number of ill or dying
o HIV -positive individuals who demonstrate first susceptibility ("canary in a coal mine")
o High volumes of patients complaining primarily of respiratory symptoms that are severe and
are associated with an unprecedented mortality rate
o A cause of infection that is unusual or impossible for the particular region (such as the Ebola
virus, which is rarely seen outside Africa)
o Multiple, yet simultaneous outbreaks
o An epidemic caused by a multi drug-res i stant pathogen, previously unknown
o Sick or dead animals of multiple types
o Identification of the delivery vehicle for the agent
o Prior intelligence reports or claims by aggressors of a BW attack
SIGNS AND SYMPTOMS
After a characteristic incubation period following aerosol exposure, most BW agents present as
an initial influenza syndrome characterized by the following signs and symptoms:
• Fever
• Chills
• Malaise
• Headache
• Myalgia
Version 4 3/1/2015 Florida Regional Common EMS Protocols 46
7.2 Adult Hazardous Material Exposure (Biological Agents) (continued)
Some BW agents rapidly develop into a pulmonary syndrome characterized by the following
signs and symptoms:
• Dyspnea
• Cyanosis
• Chest pain
• Radiological abnormalities
• Liver involvement, indicated by rising liver enzymes, with or without jaundice
• Encephalitis (may occur with some viral agents), typified by photophobia, confusion, and
nuchal rigidity
• Maculopapular, vesicular pustular, or ulcerative skin lesions, with or without bleeding
abnormalities
Unexplained death or flaccid paralysis (may indicate a biological toxin) A history should be
obtained from the patient and bystanders, to include the following information:
• Duration of symptoms
• Pertinent medical history
• Patient's recent history of travel
• Infectious contacts
• Employment
• Activities over the preceding 3-5 days
If a biological agent exposure is suspected, call for a hazardous materials team. In this instance,
refer to the appropriate hazardous materials PPE protocol, to protect against secondary
contamination. All patients who have been exposed to hazardous materials must be properly
decontaminated prior to initiation of extensive medical treatment and transportation to the
hospital.
Contact the Poison Information Center (1-800-222-1222) for consultation regarding specific
therapy, and then contact the receiving emergency department for confirmation of ALS Level 2
orders.
It is imperative that the emergency department be made aware early that a contaminated patient
is being transported so that proper preparations can be made to receive the patient.
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7.2.1 Anthrax
Bacillus anthraces is a gram -positive, rod -shaped organism that becomes infectious when it
converts into a spore and enters the host. The spore germinates inside a macrophage, which is
then transported to regional lymph nodes. There, local production of toxins causes edema and
necrosis of the tissue, leading to bacteremia, toxemia, and death. Symptoms vary with the
method of exposure:
• Cutaneous Anthrax: Skin lesions appear in 1-5 days, consisting of 1- to 2-cm vesicles with
regional edema and lymphadenitis. Most patients with small lesions will be afebrile. Lesions
develop into a painless necrotic ulcer with a black eschar base.
• Gastrointestinal Anthrax: Signs and symptoms include fever, nausea/ vomiting, abdominal
pain, bloody diarrhea, sometimes rapidly developing ascites, and possibly acute abdomen.
Oropharyngeal cases show primary involvement of the tonsils.
• Inhalation Anthrax: A 6-day incubation period is followed by fever, myalgias, cough, and
fatigue. Initial improvement is followed by abrupt onset of respiratory distress, shock, and
death in 24-36 hours. Physical findings are nonspecific, pneumonia is rare, and 50% of cases
have associated hemorrhagic meningitis.
Supportive Care
• Remove the patient from the hazardous area (a).
• If the patient was exposed externally, remove his/her clothing and decontaminate as
appropriate.
Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
If there is a high suspicion of significant exposure to anthrax, then Medical Control or the Poison
Information Center may order preventive treatment with oral ciprofloxacin (Cipro ) 500 mg PO
bid or doxycycline 100 mg PO bid.
Note:
(a) If risk of exposure is high, call for a hazardous materials team. Refer to the appropriate
hazardous materials PPE protocol, as the risk of secondary contamination is very high.
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7.2.2 Botulism
The botulinum toxins are a group of seven related neurotoxins produced by the bacillus
Clostridium botulinum. When inhaled, these toxins produce a clinical picture very similar to that
associated with foodborne intoxication, although the time to onset of paralytic symptoms may
actually be longer than for foodborne cases, and may vary by type and dose of toxin. The clinical
syndrome produced by one or more of these toxins is known as "botulism." Botulism toxin is
also a licensed medicine that is used for the treatment of dystonias and can be found in some
hospital pharmacies.
SIGNS AND SYMPTOMS
The onset of symptoms of inhalation botulism may vary from 24-36 hours to several days
following exposure. Symptoms include the following:
Bulbar palsies produce loss of function in nerves originating in the brain stem, causing the
following symptoms:
• Blurred vision
• Mydriasis
• Diplopia
• Ptosis
• Photophobia
• Dysphagia
• Dysphonia
Following bulbar palsies, skeletal muscles become weak, leading to a symmetrical descending
paralysis (head -to -toe).
These symptoms may progress acutely to respiratory failure and death within 24 hours.
Patients usually remain awake and alert.
Supportive Care
• Medical Supportive Care Protocol 2.1.3 or Pediatric Protocol 3.1.3.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
None
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7.2.3 Cholera
Vibrio cholerae is a short, curved, motile, gram -negative, non-sporulating rod. Cholera is the
prototype toxigenic diarrhea, which is secretory in nature. Transmission of the pathogen occurs
through direct and indirect fecal contamination of water or foods, and by heavily soiled hands or
utensils. V. cholerae can survive for as long as 24 hours in sewage, and as long as 6 weeks in
certain types of relatively impure water containing organic material. Because cholera does not
easily spread from human to human, for this pathogen to be an effective biological weapon,
major drinking water supplies would have to be heavily contaminated.
Cholera is an acute infectious disease, characterized by sudden onset with nausea, vomiting,
profuse diarrhea with "rice water" appearance, rapid loss of body fluids, toxemia, and frequent
collapse. If untreated, mortality may by 50%.
SIGNS AND SYMPTOMS
The following signs and symptoms occur within 12 to 72 hours of exposure:
• Intestinal cramping
• Painless diarrhea
• Vomiting
• Malaise
• Headache
• Low-grade fever
Supportive Care
• Remove the patient from the hazardous area.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Consider fluid replacement.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
In -hospital treatment may include the use of tetracycline 500 mg qid for 3 days or doxycycline
300 mg once or 100 mg bid for 3 days. If the organism is tetracycline resistant, use ciprofloxacin
500 mg bid for 3 days or erythromycin 500 mg qid for 3 days.
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7.2.4 Plague
The plague is spread to humans from either the bite of an infected flea or inhalation of the
organism. Infection occurs in three forms:
• Bubonic: involves lymph nodes closest to the bite of infected flea.
• Pneumonic: an infection of the lungs.
• Septicemia: a generalized infection in the blood, caused by the bacteria escaping through the
lymph nodes or lungs.
SIGNS AND SYMPTOMS
Two to three days after inhaling the plague organism, the patient will develop the following
signs and symptoms:
• High fever
• Myalgia
• Chills
• Headache
• Cough with bloody sputum
• Signs of overwhelming infection (including pneumonia)
Chest X-ray may show patchy infiltrates or consolidation, with a rapidly progressing pneumonia
causing dyspnea, stridor, and cyanosis. The patient will experience eventual respiratory failure
and circulatory collapse; laboratory evidence will show disseminated intravascular coagulation
(DIC).
Supportive Care
• Remove the patient from the hazardous area (a).
• Respiratory isolation is mandatory for the first 48 hours of treatment.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
• Antibiotic treatment must be started within 24 hours of the onset of symptoms. In -hospital
treatment may include the use of streptomycin 15 mg/kg IM bid for 10 days or doxycycline
200 mg IV initially, followed by 100 mg bid for 10 days. For plague meningitis, administer
chloramphenicol 12.5-18.75 mg/kg qid.
• If there is a high suspicion of significant exposure to plague, then Medical Control or the
Poison Information Center may order preventive treatment with oral ciprofloxacin (Cipro )
500 mg PO bid or doxycycline 100 mg PO bid.
Note:
(a) If risk of exposure is high, call for a hazardous materials team. Refer to the appropriate
hazardous materials PPE protocol, as the risk of secondary contamination is very high.
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7.2.5 Q Fever
Q fever is caused by a rickettsia organism, Coxiella burnetii, that is highly infectious and
resistant to heat and drying. Its natural reservoir is sheep, cattle, and goats. Humans acquire the
disease by inhalation of aerosols contaminated with the organism. Following a 10- to 20-day
incubation, Q fever generally occurs as a self-limiting febrile illness lasting 2 days to 2 weeks,
and is characterized by headaches, fatigue, and myalgias. Pneumonia occurs in 50% of all
patients, with half of these patients (25% total) presenting with a cough (usually non -productive)
or rates.
SIGNS AND SYMPTOMS
• High-grade fever
• Rigors
• Severe headache
• Photophobia
• Myalgias
• Nausea/vomiting
• Diarrhea
Supportive Care
• Remove the patient from the hazardous area.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Decontaminate as appropriate.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None.
ALS Level 2
Most cases will resolve even without antibiotic therapy. To shorten the duration of the illness, in -
hospital treatment may include the use of tetracycline 500 mg qid or doxycycline 100 mg bid for
5 to 7 days.
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7.2.6 Ricin
Ricin is a potent cytotoxin that is derived from the beans of the castor plant and is a by-product
in castor oil production. When inhaled as a small -particle aerosol, this toxin may produce
pathologic changes within 8 hours and severe respiratory symptoms followed by acute hypoxic
respiratory failure in 36-72 hours. When ingested, ricin causes severe gastrointestinal symptoms,
followed by vascular collapse and death. This toxin may also cause disseminated intravascular
coagulation, microcirculatory failure, and multiple -organ failure if given intravenously.
SIGNS AND SYMPTOMS
After inhalation:
• Fever
• Chest tightness
• Cough
• Shortness of breath
• Nausea
• Joint pain within 4 to 8 hours of exposure
• Necrosis of the lower airway epithelium and severe pulmonary edema
• Death within 36-72 hours
After ingestion:
• Nausea
• Vomiting
• Severe diarrhea
• Gastrointestinal hemorrhage with necrosis of the liver, spleen, and kidneys
• Shock leading to death within 3 days
After injection:
• Marked death of muscles and lymph nodes near the site of injection
• Multiple -organ failure, leading to death
Supportive Care
• Remove the patient from the hazardous area (a).
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Decontaminate as appropriate.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1 None
ALS Level 2
If ingested, aggressive gastric lavage and activated charcoal should be administered in the
hospital.
Note:
(a) Risk of exposure via the airborne route is high. Refer to the appropriate hazardous materials
PPE protocol, as the risk of secondary contamination is very high.
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7.2.7 Smallpox
Smallpox is caused by the Variola virus. Although the fully developed cutaneous eruption of
smallpox is unique, earlier stages of the rash could be mistaken for varicella. Secondary spread
of infection constitutes a nosocomial hazard from the time of onset of a smallpox patient's
exanthem until scabs have separated. Quarantine with respiratory isolation should be applied to
secondary contacts for 17 days post -exposure.
SIGNS AND SYMPTOMS
• Fever
• Rigors
• Headache
• Malaise
• Nausea/vomiting
• Back ache
• Approximately 15% of patients develop delirium.
• Approximately 10% of light -skinned patients exhibit an erythematous rash.
• Two to three days later, an enanthem appears concomitantly with a discrete rash about the
face, hands, and forearms.
• Following eruptions on the lower extremities, the rash spreads to the trunk over the next
week.
• Lesions quickly progress from macules to papules, and eventually to pustular vesicles.
• With smallpox, lesions are more abundant on the extremities and face, as opposed to
varicella (chickenpox), in which lesions on various segments of the body remain generally
synchronous in their stage of development and primarily start on the trunk and spread to the
extremities.
Supportive Care
• Remove the patient from the hazardous area (a).
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Decontaminate as appropriate.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
Immune globulin for variola and the vaccines (vaccinia and VIG) may be obtained through the
CDC.
Note:
(a) Risk of exposure via the airborne route is high. Refer to the appropriate hazardous materials
PPE protocol, as the risk of secondary contamination is very high.
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7.2.8 Staphylococcal Enterotoxin B
Staphylococcal enterotoxin B (SEB) is a fever -producing exotoxin produced by the bacteria
Staphylococcus aureus. This toxin commonly causes food poisoning in improperly handled
foods that have an overgrowth of the staph organism and then are ingested. SEB symptoms will
vary with the route of exposure (inhaled versus ingested).
SIGNS AND SYMPTOMS
• From 3-12 hours after aerosol exposure, there will be a sudden onset of the following signs
and symptoms:
• Fever (103-106°F), lasting 2 to 5 days
• Chills
• Headache
• Myalgia
• Nonproductive cough, which may persist for up to 4 weeks
• In some patients, shortness of breath and retrosternal chest pain
If ingested, symptoms include the following:
• Nausea
• Vomiting
• Diarrhea
High exposure can lead to septic shock and death.
Supportive Care
• Remove the patient from the hazardous area.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Decontaminate as appropriate.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
None
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7.2.9 Trichothecene Mycotoxins (T2)
The trichothecene mycotoxins are nonvolatile compounds produced by filamentous fungi
(molds). They are relatively insoluble in water, but are highly soluble in ethanol, methanol, and
propylene glycol. Exposure usually occurs through inhalation, ingestion, and/or absorption.
Aerosol attack in the form of "yellow rain" will present as droplets of yellow fluid contaminating
clothes and the environment.
SIGNS AND SYMPTOMS
Exposure to skin
Severe poisoning by
any route:
Exposure to airway
Skin pain
Prostration
Nose and throat pain
Pruritus
Weakness
Nasal discharge
Redness
Ataxia
Itching and sneezing
Vesicles
Collapse
Cough
Necrosis
Shock
Dyspnea
Sloughing of epidermis
Death
Wheezing
Chest pain
Hemoptysis
Supportive Care
• Remove the patient from the hazardous area.
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Decontaminate as appropriate.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
If ingested, aggressive gastric lavage and activated charcoal should be administered in the
hospital.
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7.2.10 Tularemia
Francisella tularensis is a nonmotile, gram -negative coccobacillus that typically causes disease in
animals. Humans can become infected by either handling diseased animal fluids or by being
bitten by infected deerflies, mosquitoes, or ticks. The organism can also remain viable for weeks
in a number of media and is easily spread by aerosol. After infection, bacteremia results, with a
secondary spread to the lungs and other organs.
SIGNS AND SYMPTOMS
The following signs and symptoms will appear within 2-10 days of inhalational exposure
• Fever
• Chills
• Headache
• Generalized muscle pain
• Nonproductive cough
• Pneumonia
If the organism was ingested or inoculated, symptoms will also include regional
lymphadenopathy, with or without cutaneous ulcers. Clinical diagnosis is both difficult and
problematic. Physical findings are usually nonspecific, although chest X-ray may reveal
pneumonic process, mediastinal lymphadenopathy, or pleural effusion. Routine culture is
possible but hazardous to lab personnel. Diagnosis can be established retrospectively by
serology.
Supportive Care
• Remove the patient from the hazardous area (a).
• Medical Supportive Care Adult Protocol 2.1.3 or Pediatric Protocol 3.1.3
• Decontaminate as appropriate.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
Antibiotic therapy for 10 days includes streptomycin 1 g q 12 hours IM or 15 mg/kg IM bid
If not available, administer gentamicin 3 mg/kg/day.
Prophylaxis with tetracycline or doxycycline is effective if warning of BW attack is
provided or if there is a high suspicion of significant exposure, as ordered by Medical
Control or the Poison Information Center.
Note:
(a) If risk of exposure is high, call for a hazardous materials team. Refer to the appropriate
hazardous materials PPE protocol, as the risk of secondary contamination is very high.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 57
7.2.11 Venezuelan Equine Encephalitis (VEE)
VEE virus is a mosquito -borne alphavirus that is endemic in certain parts of the world (Central
and South America, Mexico, and Florida), where it infects horses, mules, and donkeys. If this
agent was intentionally released as an aerosol, disease might occur simultaneously in both horses
and humans, but this pattern would not be commonly recognized.
SIGNS AND SYMPTOMS
After exposure, a sudden onset of symptoms begins in 1-5 days:
• Generalized malaise
• Spiking fever (up to 104°F)
• Rigors
• Severe headache
• Photophobia
• Myalgias in the legs and lumbosacral area
• Nausea and vomiting
• Cough
• Sore throat
• Diarrhea
These symptoms last up to 3 days, and then are followed by a period of weakness and lethargy.
Most patients recover in 1-2 weeks. Some patients, especially children, may develop signs of
CNS infection, with meningismus, convulsions, coma, and paralysis. There is a 20% mortality
rate in children who develop encephalitis.
Supportive Care
• Remove the patient from the hazardous area (a).
• Medical Supportive Care Protocol 2.1.3 or Pediatric Protocol 3.1.3.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
None
Note:
(a) Risk of exposure via the airborne route is low. However, patients should be isolated from
mosquitoes for 72 hours to prevent spread by vectors.
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7.2.12 Viral Hemorrhagic Fevers
The VHF are a diverse group of illnesses caused by a variety of RNA viruses; they demonstrate
a wide range of morbidity and mortality. These viruses include: Ebola, Marburg, Dengue,
Yellow fever, Crimean -Congo fever, Hantaan viruses, Lassa fever
Each of these viruses has a unique history and is capable of being spread in most cases by an
aerosol or formite (except dengue virus). VHF agents, especially Marburg and Ebola, have
allegedly been considered for weaponization. The clinical syndrome that these viruses cause in
humans is called VHF.
SIGNS AND SYMPTOMS
• Fever
• Easy bleeding
• Petechiae
• Hypotension and shock
• Flushing of the face and chest
• Edema
• Malaise
• Myalgias
• Headache
• Vomiting
• Diarrhea
Supportive Care
• Remove the patient from the hazardous area (a)(b).
• Medical Supportive Care Protocol 2.1.3 or Pediatric Protocol 3.1.3.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1 - None
ALS Level 2 - None
Note:
(a) Risk of exposure via the airborne route is high. Refer to the appropriate hazardous materials
PPE protocol, as the risk of secondary contamination is very high.
(b) Risk of exposure from a symptomatic patient via blood or body secretions is high. Full PPE
with masks, goggles, sleeves, and gowns is appropriate. If the patient is not severely ill, IV
access should be delayed until hospital arrival_ If IV access is needed for immediate patient
resuscitation, extra care is appropriate to protect the healthcare worker, and IV attempts
should not be made on combative patients or in a moving vehicle.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 59
7.3 Adult Hazardous Material Exposure (Radiological Agents)
This protocol is to be used for those patients suspected of exposure to radiological agents via any
route of exposure (e.g., ingestion, absorption). It gives specific considerations for each type of
exposure as well as general treatment guidelines. Scene safety should be of primary concern,
with special attention being paid to the need for personal protective equipment. If a radiological
agent exposure is suspected, call for a hazardous materials team. In this instance, refer to the
appropriate hazardous materials PPE protocol to protect against secondary contamination. All
patients who have been exposed to hazardous materials must be properly decontaminated prior
to initiation of extensive medical treatment and transportation to the hospital.
Contact the Poison Information Center (1-800-222-1222) for consultation regarding specific
therapy, and then contact the receiving emergency department for confirmation of ALS Level 2
orders.
It is imperative that the emergency department be made aware early that a contaminated patient
is being transported so that the proper preparations can be made to receive the patient.
TYPES OF RADIATION INJURY
• External irradiation occurs when all or part of the body is exposed to penetrating radiation
from an external source. Following external exposure, an individual is not radioactive and
can be treated like any other patient.
• Contamination means that radioactive materials in the form of gases, liquids, or solids are
released into the environment and contaminate people externally, internally, or both. An
external surface of the body, such as the skin, can become contaminated quite easily. If
radioactive materials get inside the body through the lungs, gut, or wounds, the contaminant
can become deposited internally.
• Incorporation refers to the uptake of radioactive materials by body cells, tissues, and target
organs such as bone, liver, thyroid, or kidney. Incorporation cannot occur unless
contamination has occurred.
These three types of accidents can happen in combination and can be complicated by physical
injury or illness.
Irradiation of the whole body or some specific body part does not constitute a medical
emergency, even if the amount of radiation received is high. The effects of irradiation usually are
not evident for days or weeks; thus, while medical treatment is needed, it is not needed on an
emergency basis. In contrast, contamination accidents must be considered medical emergencies,
because they might lead to internal contamination and subsequent incorporation. Incorporation
can result in adverse health effects several years later if the amount of incorporated radioactive
material is high.
Treatment priorities are established as follows:
• Treat life -threatening problems first.
• Limit the radiation dose to both victims and healthcare personnel (time, distance, shielding).
• Control the spread of radioactive contaminants.
Serious medical problems should have priority over concerns about radiation, such as radiation
monitoring, contamination control, and decontamination. However, attention should be given to
PPE for medical personnel.
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7.3.1 Radiation Exposure / Contamination
Radiation exposure/contamination may be a health risk to both the patient and the rescuer,
depending on the type of radiation, time of exposure, distance from the radioactive source, and
level of shielding from the radioactive source. Not all exposures will require medical treatment,
however. In exposures where traumatic injuries are not present, the following steps should be
taken.
Supportive Care
• Remove the patient from the hazardous area (a)(b).
• Decontaminate as appropriate (b).
• Medical Supportive Care Protocol 2.1.3 or Pediatric Protocol 3.1.3.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1
None
ALS Level 2
Additional treatment should be administered in the hospital.
Note:
(a) Use of radiological monitoring devices is essential, as risk of exposure may be high. Call for
a hazardous materials team.
(b) In mild to moderate exposures without traumatic injuries, self -decontamination may be
recommended for the patient at his/her home. Self -decontamination should include removing
one's clothing, placing the clothes into a plastic bag, and showering with soap and water.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 61
7.3.2 Acute Radiation Syndrome
Acute radiation syndrome (ARS) is an acute illness that follows a roughly predictable course
over a period of time ranging from a few hours to several weeks after exposure to ionizing
radiation. It occurs if enough radiation reaches enough sensitive tissue. The following factors are
important in determining whether ARS will develop:
• High dose
• High dose rate
• Whole -body exposure
• Penetrating irradiation
Other factors to be considered include age (young and old), sex, genetics, and medical history.
Regardless of the source of radiation, if the dose is high enough, it will produce the same effect.
SIGNS AND SYMPTOMS
Signs and symptoms that develop in the ARS occur in four distinct phases:
Prodromal phase. Depending on the total amount of radiation absorbed, patients may experience
a variety of symptoms, including:
• Loss of appetite
• Nausea
• Vomiting
• Fatigue
• Diarrhea
After high radiation doses, the following additional symptoms may develop:
• Prostration
• Fever
• Respiratory difficulties
• Increases in excitability
This is the stage at which most victims seek medical care.
Latent phase. During this transitional period, many of the initial symptoms resolve. This phase
may last for as long as 3 weeks, depending on the original dose. This time interval decreases as
the initial dose increases.
Illness phase. In this phase, overt illness develops, often characterized by the following signs and
symptoms:
• Infection
• Bleeding
• Electrolyte imbalance
• Diarrhea
• Changes in mental status
• Shock
Recovery or death phase. This phase follows the period of overt illness, which may take weeks
or months to resolve.
• Remove the patient from the hazardous area.
• Medical Supportive Care Protocol 2.1.3 or Pediatric Protocol 3.1.3.
• Decontaminate as appropriate.
• Contact the Poison Information Center (1-800-222-1222).
ALS Level 1: None.
ALS Level 2: Additional treatment should be administered in the hospital.
Version 4 3/1/2015 Florida Regional Common EMS Protocols 62
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