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Item C13
C.13' i�` CountCounty ��Monroe. ,y, ? "tr, BOARD OF COUNTY COMMISSIONERS y M T� \�1a� Mayor Michelle Coldiron,District 2 �1 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 July 21, 2021 Agenda Item Number: C.13 Agenda Item Summary #3423 BULK ITEM: Yes DEPARTMENT: Emergency Services TIME APPROXIMATE: STAFF CONTACT: Steven Hudson (305) 289-6342 N/A AGENDA ITEM WORDING: Issuance (renewal) of a Class A Certificate of Public Convenience and Necessity (COPCN)to National Health Transport, Inc., for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2021 through August 16, 2023. National Health Transport, Inc. is not permitted to perform 911 emergency response work in Monroe County. ITEM BACKGROUND: In July of 2017 a Class A COPCN was renewed for National Health Transport, Inc. to operate an ALS inter-facility transport ambulance service in all geographical locations of Monroe County, Florida. This certificate will be expiring on August 16, 2021. In view of the foregoing National Health Transport, Inc. is applying to renew this COPCN which would become effective August 17, 2021 and expire August 16, 2023. PREVIOUS RELEVANT BOCC ACTION: 7/15/15: MCBOCC approved the issuance (renewal) of a Class A COPCN to National Health Transport, Inc. for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2015 through August 16, 2017. 7/19/17: MCBOCC approved the issuance (renewal) of a Class A COPCN to National Health Transport, Inc. for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2017 through August 16, 2019. 7/17/19: MCBOCC approved the issuance (renewal)(C.10) of a Class A COPCN to National Health Transport, Inc. for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2019 through August 16, 2021. CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval. DOCUMENTATION: National Health Transport Inc. Renewal Application_Redacted National Health Transport, Inc. - Class A Certificate 08-17-2021 through 08-16-2023 Packet Pg. 538 C.13' FINANCIAL IMPACT: Effective Date: 08/17/21 Expiration Date: 08/16/23 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 N/A REVIEWED BY: Pedro Mercado Completed 07/06/2021 9:09 AM Steven Hudson Completed 07/06/2021 5:21 PM Purchasing Completed 07/06/2021 5:26 PM Budget and Finance Completed 07/07/2021 10:09 AM Maria Slavik Completed 07/07/2021 10:18 AM Liz Yongue Completed 07/07/2021 10:35 AM Board of County Commissioners Pending 07/21/2021 9:00 AM Packet Pg. 539 C.13.a "can T- The Florida Keys County of Monroe I Division of Emergency Services Fire Rescue Department 490 631d Street,Ocean Marathon,FL 33050 Phone: 305-289-6004 _ Fax: 305-289-63365} c 0 COPCN Class A Check List CL Please Attach all of the following documents when submitting your application: l/ The name, business mailing address,and telephone number of the service. E� 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, c / or, if the service is a volunteer organization,the officers of the organization. 'f�l �The date of incorporation or formation of the business association. EI 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. 1 The zones that the service desires to serve. f The applicant's present and proposed base station and all substations. C� The names of all emergency medical technicians,paramedics and drivers to be utilized by the applicant; i 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 E .S. citizens who will act as references for the applicant. iI A schedule of rates which the company will charge during the certificate period. 1� 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. A copy of the applicant's contract with a medical director. 9l A copy of all standing orders as issued by the medical director. IE: Medical Protocols. f Such other pertinent information as the administrator may request. a ;i An initial nonrefundable application fee of$50.00/$25.00 Renewal Packet Pg. 540 C.13.a BOARD OF COUNTY COMMISSIONERS MonroeCounty of Mayor Heather Carruthers,District 3 Mayor Pro Tern Michelle Coldiron,District 2 The Florida Keys Craig Cates,District i 0. $f, David Rice,District 4 Sylvia J. Murphy,District S Monroe County Fire Rescue 490 63r4 Street Ocean Marathon,FL 33050 Phone(305)289-6088 ' 0 MEMORANDUM CL TO: Nicole Rhodes 0 FROM: Cara Johnson SUBJECT: Check for Deposit DATE: June 23, 2021 i Attached please find Check dated 06/01/2021 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 National Health Transport Inc. Thank you, Cara Johnson Packet Pg. 541 C.13.a NATIONAL HEALTH TRANSPORT INC VARIABLE ACCOUNT O NW 110AVENUE MLAW,FL 1 I-275/ PAY c TO THE m ORDER C� DOLLARS LL L) CL t � 0 U U U U Packet Pg. 542 SSBID 10 1 Guy ) p9j3ep — ®b all lemoueU -3ul :podsuej_L q4lBGHIBU014BN :4u8wq3B44V th li 10 m LO r U a' m ';tC a F.. .. `. 1 } f}, ui �z _ n2 i, k l� Tu cr LL to l OLU ay C.13.a MONROE COUNTY,FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY(CC ) N CD CLASS A EMERGENCY MEDICAL SERVICE 0 0. (PRINT OR TYPE) ❑ INITIAL APPLICATION-$50.00 RENEWAL APPLICATION-$25.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE:# 1 -0 1, NAME OF SERVICE NATIONAL HEALTH TRANSPORT INC. BuslNEss MAILING D 22 11T AVENUE, S T ATE FL 17 u.. ,.n, . r w._ . .. _. _ ._ BUSINESS PHONE NUMBER 305` 3 -5509 EMERGENCY PHONE NUMBER 05 7 - 71 m 2. TYPE OF OWNERSHIP (Le., Sole Proprietor,Partnership,Corporation,etc.) S-CORPORATION CL u --.., DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 0111 /2010 U 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet ifnecessary): y ACE ADDRESS TELEPHONE# OSITIN/TITL RAU L F. RODRIGUEZ 42 215 SW 125 Ave,Miami,FL 33184 305-479-3471 CEO ll 1 a I 4 .......... ...��,..n,.w,.w,.w.,.w,.w...:,n.m.m.....:, .v�_ .... �... ... i nip.. °f il 1 ..... — 2 4. LEVEL OF CARE TO BE PROVIDED. HBLSorNALS IF A :H TRANSPORT or NON TRANSPORT 5. DESCRIBE THEZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet ifn sary): MONROE COUNTY—INTERFACILITY TRANSPORTS IN ALL GEOGRAPHICAL LOCATIONS WITHIN MONROE COUNTY, FLORIDA. 0. . .. _ w... w.,.. 6. LIST THE ADDRESS AND/ORE STATION AND ALLSUB- STATIONS se separate sheet ifnecessary): 19970 L AS STATION 2 SUB-STATION .. Page I of6 Packet Pg. 544 7. tall FCC licenses). FREI w m- # c� .emuCALL . F RadiosIAttached � J � I I . S. LIST THE NAMES AND ADDRESSES OF THREE(3)U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: ._..... .. _ E NAM ADDRESS 0 1 T r i Fernandez 1 hPlace, ! 1 �a..•..m..._... ...... ........ �.� aee.�...._. � �a••••••••�•.. ••••_. �n �.. Z .M l i nt Riviera Drive, CoralGables, 1 . ...W.�.... �..Na �..u••W . �,••, rw..n��n..•.•,m,.nw .. ............... Daniel n 1 r Drive, Miami . . .�.�W.. �L .A�. _. . y 9. ATTACH A SCHEDULE OF RATES WHICH YOURSERVICE WILL CHARGE DURING THE COPCN PERIOD. CJ 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE D I1. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITHIL 2. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUEDI /13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE ,MADE PAYABLE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. SERVICE,1,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED ATTEST MY SERVICE MEETS ALL OF THE REQUIREU1kNTSI IN MONROE COUNTY AND THES l I:Oi F RIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED I CAk" ,IS TRUECORRECT. v� Sala ;R APFI i�A IORMI)REPRESE�ITATIYE ZA I' 000 06 its fc Sum i %TU [ e. g gage of'6 Packet iPg. 545 Pago 1 of I CERTIFICATE OF LIABILITY INSURANCE 03/2 /2o21 THIS CFER17FICATE 13 ISSUED A MATTER OF INFORMATION LY AND CONFERS UPON THE CERTIFICATE HOLDER. I CERTIFICATE DOES NOT AFFIRMATIVELY LY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDEDE POLICIES r- BELOW. THISIC INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING I S), AUTHORIZED I. REPRESENTA71VE OR PRODUCER,AND THE CERTIFICATE HOL v' If the certificate e_ holder to an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED to or be endorsed. if SUBROGAMN IS AI D,subject to Ow terms and conditionsII in policies may require an endorsement A statemem on this certificate not c holder In 11su of S hen PRODUCER Willis Towers Watson ftruficate. Willis Towers watsm Southeast, NAW 1- 77- 45-737 PAS 1-988-4 7-2376 a/o 25 Centwy BlvdK&V-mIA10.No): P.o. Roz 303191 �ADDRESS: ti i s6 i111s. Nashville, TH 372305191 USK INSURZNSy AFFORDING _COVERAGE__ G INSUMRA: Old lie Xasuranos Coaqmny 24147 SOURED Mumma, z National Health Transport Inc 2290 PW 110th Avenue Qt O Swastimter, M 33172 INSURER 0. MURER E:.. 0940 P CL COVERAGES CERTIFICATE NUMBER: 1100265 REVISION NUMBER-. 0 IS IS TO CER71FY THAT THE POLICIES OF I NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT%MTHSTANDING ANY REQUIREMENT, OR CONDITION ANY CONTRACT OR OTHER DOCUMENTRESPECT TO WHICH THIS CERTIFICATE Y BE ISSUED OR MAY PERTAJN. THE INSURANCE FORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. y EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOVM MAY RAVE BEEN REDUCED BY PAID CLAIMS. g u TYPE L YNUM R r Y MUM 4 .. LIMITS COMMERCCALGINERALLgAELITYRE s OCCUR R ID — CLAM PRISES IEs i t8 IAED FXP p4 � i _ � 0) ................i _.... ............„ INJURYN 3 W GE rL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE is PRO W POLICY ..... ..........m.. JECTT ..a., OTHER. _..... ® $- P i i L I i ll-.... u....... ...... .. ....... ...-A L �E : "D i 1,000,000 X ANY AUTO BODILY INJURY I... _ A OYMED AUTOS LY SCHEAUTODULED MM 313612-21 06/Di/2021 06/01/2022 BODILY INJURY( t HIRE D ONLY N ONLY H, DAMAGE S AUTa.d.... ......,._.....mm...... 3 P. UMBRELLA UABI OCCUR EACH OCCURRENCE S U EXCESS LAASE GtA1M REtTE S .u.. P D I RETEf. t YIN ATUTE .. ANYPROPRIETORIPARTNERIEXECUIIVE N JA E L ACCIDENT S OFFICEWMEMBERPn NMI El, g E.L 3 -EA_EMPLOYEE S WORKERSCOMPERIATION FUNAPTION OF OPERATIONS bobw El DISEASE-POLICY LIMIT 8 0..4... .. OPWATIONS1 S1 N".MfflkmdftmhaI. I� Proofof Coverage. CANCELLATION CERTIFICATE HOLDER .,,, .. m.......0................. SHOULD ANY OF THE ABOVE DESCRIBED POLICIESF CANCELLED BEFORE THE TIN A E ICE DELI RED IN ACCORDANCE WITH THE POLICY PROMS! S. VA=o u , .u._.._._.®.........,... OBB-201 6 ACORDCORPORATION. ll rights o ACORD 26(201010 ) The ACORD name and logo are registeredaACORD Or M 21149277 wffefls 221.1263 Packet;Pg. 546 CD 0 Fl"!tMLiddit, EXPIRATION DATE CINDY TAHUICO f 12/01/2022 BELF �.—",—CIOI,R,RINE ..m.m.m.m.m.m..m2022 .. : ,. w �_..�..�..�..�..........__ m,.�.m... ............ _e:.,u ..��...... J NATHAN CANO PM 530851 � 12/01 02 ... w_ Nw., m .._ 8 H 1 / �.. �� .d ca CL �.��. ............. --—— .W .— _..n _. _ ..... -----. ......_a , ........ .r,.... � ��... ..mm _.�� . .....__ w...._�_....�.. . ..�...mm..........�__.M. ���m. .....:.M i ..................._.�� ,..K nuvw ---: ..._.� uuuu m,. ..... .... ...u..H....� � .M_.M ��.n ....� ._ ...u.... __ .. ... .. _. — a. — ° �. — z E Page 3of'6 Packet;Pg. 547 CD cv CERTIFICATION 0 NAME First Middl Last SOCIAL SECURITY# CERTIFICATION# � EXPIRATION DATE , 0. .. MADELIN LiRRA EMT556020 121011 022 NICOLE GONZALEZ —EMT538M2 12/01/2022 SAN ISO ILL E MT559865 12/01/2022 T_ z ... �..� � ..ADRIAN FLEURIZARDw .e_.�.�..m.... T 1—_1. 1 0� v ..... CL .�.w.w.wr. .. ,.w,. ..... y __.n._..rom . ._ � �,.. „ ..._. .a g � o.. _ ..w ..... t I �.e. _ .: .�_... .._. .. . ..... s � s n. _........ ......... .� .. O PW dof6 Packet iPg. 548 ---- �.._ _. E e � F � r , r 1 n 1 E �y�l111lH1+it000i N E C r }d UK UO J1P111f1100 to ( rA S r ®p f E � E i � y E s Packet;Pg. 549 _ I i C44 0 of cv I �..m... Co CO Co u � C idl m 0 Go FA CL I .. de � I 3 I R I W o a NLa 3 I I wow I i LL 1 i w CD r I . ...... �... .�_. _. �..� _... .. ........' - Co � 3 t �.au. �� ti��. .... ..... t........._ . 3 [ I LL W s O CL U I Packet;Pg. 550 cv CD cv r- 0 0. v comavycFederal Communications Commission PubliciSecurity RADIO STATION AUTIFIORIZATION >k® a LICE SEE: NATK04t all i File � 762 0007636306 Radio Service � PW-Public Safe Pool Conventional AT1N:RAUL RODRI �� h` NA �U ' CL 2950 NW 7TH AVE MIAMI,FL 33127 Regulatory Status U PMRS Z~requeney Coordination Number 20170200029 FCC Registration Number 002 U Grant Date Effec-01 1% Expiration Datet Date 02-06-2017 02- 017 �� ��''°° 02- -2027 02-07.2017 .� . . .,,, STATION'I ' Y L SPECIFICATIONS 7 ,:: Fi x 'on dr or Mobile of onl Loc.l Area of operation ° Countywide:MONROE,FL � Antennas c Ant Frequencies Ste. No. No. EffAsiop, " t t. Ant. Construct No. o. ) s. U Pagers 13 si` a r o (watts) line (Wa meters meters Date 1 1 00 63.1125 00 O 20 11' E 100. 0 1 .000 02-06-2018 1 1 OOD468.11250000 MO 20 I iK2F3E 11AM`N`100. 0 02- -2019 1 1 000463.13750000 MG 20 llK2F3E 100 02- -2018 1 1 000 %13750000 MO 20 11 F3E 10 100.0 ` 02 201 1 1 0004611625GO00 MO 20 11 ME 1 J 02- 2018 y 1 1 000468.16250000 MO 20 llK2F3E 100.000 "100.0 02 -201 t Conditions: Pursuant to (h)of the Communications Act of 1934,as amended,47 U.&C. 09(h),this license is subject to the following conditionr. This license shall not vest in the licensee right tooperate the station nor any right in the use of the fi-equencies designated in the license beyond the term thereof nor in any other manner than authorized . Neither the license not the right granted thereunder shall be assignedor otherwise transferred in violation of the Communications Act o 1934, amended. See 47 U.S.C.§3 10( ). This license is subject in terms to the right of use or control conferred by§706 of e Communications Act of 1934, ended. See 47 U.S.C.§ 06. FCC 1- S1 Page t of 4 August 2007 Packet iPg. 55'1 Licensee Name. NATIONAL HEALTHTRANSPORT[NC C44 CD cv Call Sign:WQYV762 File Number: 0007636306 Print ate:0 -07-2017 0. Antennas Loc t Frequencies Sta. No. No. Emission Output ERP Ant. Ant. Construct o. No. ( Cis. Units Pagersr Power (watts) Hurp AAT Deadline (watts) meters meters Date 1 1 000462.95000000 MO 20 1 IK2F3E 100.000 100.0 02.06-201 l 1 000 7.9500000i MO 20 1 lK2F3E 100.000 100.000 02- 2018 2 Z 1 1 000462.96250000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000467.96250000 20 HUME IM000 100.0 02-06-2018 U e1- 1 1 000462,97500000 t} HOME 100.000 100.000 02-06-2018 U 1 1 000463.02300000 lIK2F3E 100.000 100.000 02-06-2018 1 1 000468-02500000 �; f© , 11 K2F3E 100.000 IM000 02- 2018 U f � 0 1 1 000463.05000000 26 ' 11K2F3E 100.000 100.000 02-06-2019 1 1 400463.00000000 MO IIK2173E 100,000 100.000 02.06.2018 r 1 1 000468.00000000 MO 20'` 11123E 100.OD0 100.000 02-06-2018 .� 1 1 00 68.175 O 20 "'AW313 100.000 100.000 02- -201 t8 1 l 000463,18750000 MO 20 �` 11K2F3E I00.000 100.000 02-06-2018 1 1 000468.187500M MO 20 II 3 1"0 100.000 02 -2018 2 1 1 000463.01250000 MO 20 11 ME 1 .0 - 100.000 02-06-201 I I 000468,012500DO MO 20 11 I 100.000 02-06-2018 1 1 000463-03750000 MO 20 HUME 1,, 1R70. 900 100.000 02-06-2018 � 1 I 000468.03750000 MO 20 11 V,2F3E 100.'000 f6o�00 02-06-201 � 1 1 00 63.06250000 MO 20 1 IK2F3E 0� 1 . 0y 02-06-2018 1 1 000468.06250000 MO 20 11 K2F3E 100.000 1 .00 02- 2018 1 1 000463.08750000 O 20 11 K2 100.000 1,V� 02 -2018 FCC 601-ULBHSI Page 2 of 4 August 2007 Packet;Pg. 552 Licensee Name: NATIONAL HEALTH TRANSPORT INC CD cv r- Call Sip:WQYV762 FileNumber: 0763636 Print ate: -07-217 0. Antennas Loc t Frequencies Ste. No. No. Emission OutputAnt Ant. Construct o. No. (MHz) Cis. Units Pagers Designator Power (watts) line (Watts) meters 1 1 000468.087s 00 MO 20 1 IK2F3E 100.000 100.0 02 -201 0 I 1 000462.9875WOO 20 11 F3E 100.000 100.0 02 -201 1 1 67.9 7500 \r MO 20 11 K2F3E 100.000 100.00002-06-201 U- 1 1 000467.97500000 , ` ; 20 11 K2F3E 100,000 100.000 02 2018 U CL 1 1 000468.05000000 ,N) 1IK2F3E 100.000 100.000 02-06-2018 F CC I I 000463.075000GO I K2173E 100.000 10.000 02-06-2018 y ok � I 1 000468.07500000 �., ` f0,. 0 . 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.10000000 O 2 '< 11 K2F3E 100.000 100.000 02-06-2019 I 1 000468.10000DOG MO 11 K2F3E 100.000100.000 02-06-2018 1 1 000463.12500000 MO 201' i 1l�f3E 100.000 100.000 02-06-2018 1 1 000468.12500000 MO 201 3 1 .0 I00.0 02- -2018 1 1 000463.15000000 MO 20 11K2F3E 100.000 100.00002 -2018 I 1 i 000469,15000000 MO 20 I1} 3 10 . N I 02 -2019 I 1 00 63.175 0 O 20 11 3E 1 '100.000 02 -201 Control Points Control o.I Address.295 7th Ave City:Nfismi County: - State:FL Telephone Number:r:(30 .;_ o 0 Associated Call Sips � <NA> FCC60]-ULSHSI e 3 of 4 August 2007 Packet iPg. 553 ice Name: NATIONAL HEALTH TRANSPORT INC CD cv r- Call Sip:WQYV762 File Number: 0007636306 Print Date: 2- - 017 0. live Co ° ions: NONE 0 CL is t' k( tl I rt z � FCC 601-ULSKSI Page 4 of4 August 2007 Packet iPg. 554 cv CD cv r_ 0. rRANspoRr ' Schedule of Rates for Monroe County U CL Ambulatory patients will 15.00 flat rate( ithin15 mile radius)each additional mile$1.00 Wheelchair bound patients will be$45.00 flat rate(within 15 mile radius)each additional mile$1.50 Non-Medical Stretcher patients will be$75.00 fiat rate(within 15 mile radius)each additional at$2. i 0 19970 Overseas Highway,Sugarloaf Key fL 33040 IOFFICE: - 3 - 5 1 FAX:305-636-5503 WWW.NA-nONALHEALTHTRANSPORT.COM Packet iPg. 555 cv CD cv r- 0 0. AGREEMENT This constitutes the 4Xcement betweenNational Health Transport(corporation) n d Z Medical,LLC( )effective 1, 2021. A) RECITALS in accordance with Florida Medical WHEREAS, o ' is include v life Statutes operates er ncy 0 authorityc J. (Physician)who is z duly licensed to practicec' i e Medical Director of s ny U CL advanced life support vi accordance iFlorida Statutes. 0 e Corporation desires Physicianto serve as its Medical Director o Emergency Medical Services, a to the following: B) RIGHTS AND RESPONSEBILITEES OF PHYSICIAN 1. Physician all b le i for of Emergency 1 Services r the Corporation.Physiciani of er qualified director(as on to serve as acting a `cal Director in periods of his absence.Corporation will be notified advance of such periods. 2. Physician or his designee will be available for 24 hoursa 6 telecommunications. i 3. Physician shaU comply with all state and HRS regulations medical direction and advancedlife support i — 4. Physician solely Maintains the right set all standards and protocols regardingpatient care including, u not limited t ,determination o `e employee's eligibilitye t care. y 5. Physician shall oversee and provide medicaldirection for the paramedics and T's working for the Corporation. r- 5. Physician shall develop and review standing orders and protocols. 7. Physician i spolicies(including )to assure patients ll triaged. & Physician shall assist withcontinuing °cal education of personnel under his supervision. Packet;Pg. 556 cv cv 0 0. 9. Physician will help in the development andl nt 'o of a patient cam qualityc s 10. Physician wille in the EMS system minimumof 1 (ten)hours annually. 1RIGHTS AND RESPONSIBiLTiEs OF CORPORATION 1• Corporation shall employ appropriate personnel and havemaintain L- appropriate equipment to provide optimal EmergencyMedical a ices U- dictated by the Slate of Florida and the Physician. CL 2• Corporation shall appoint a pararnedic to assist Physiciani n 0 implementation of quality assurance system. 0 3. Corporation shall provide clerical, and material support to allow Physicianto carry out duties outlined in this document, 0 Cl) LIABELITY I Corporation shall maintain liability ce covering the acts and omissions of its employees cl without limitation t paramedics, �-- emergency i ci ambulance drivers,attendants,etc. 2. Corporation shall include Physician on its liability insurance li to cover all his dutiesc yr in amount not less than one million dollars. Corporation to indemnify hold the Physician y and all claims,actions,liability,Jos S,expenses,or damages 0. whatsoever including out of acts or omissions e o © 's employees or contractors. CII) COMPENSATION I Z Medical,LLC shall be regarded independent contractor and will be paid two thousand dollarsr month.for Services of Physician, le by the 5h of each ofollowing the month of service. 0 CHI) TERM 1. The term of this agreement shall be from August 1,2021 through July 1, 2022. 2. This agreement may be terminated immediatelyfor breach of any of the covenants contained a i . Packet lPg. 557 i cv CD cv r- 0 0. 3., All notices hereundershall be in writingdelivered in person, l y, i il;totefollowing: y a For the Physician: Michael J. Medical,LLC 316 Courtyard Lane Fayetteville,NC 2 0 For the Corporation: National` o U 2290 NW I I L 33172 c, ZMED/PHYSICIAN is `onal I th Tray.. o P f � . _ _. . .._. cu Date Bate o=i CD 0 Packet iPg. 558 Business Tax Receipt CD Cft'ITY OF KEY WEST, FLORIDA businessThis Document is a i HolderII City zoningprovisions. 0. FloridaP.O. Box 1409, Key West ) 809-3955 Business NATIONAL HEALTH TRANSPORT INC Location r 1 Lie NBRICless 26341 TRANSPORtATION SERVICES issued 1 1 OTHERBUS AMBULANCE OR . tI tU Comments* NON-EMERGENCY MEDICAL Ass1VANdE CL ca Restrictions: LIAB LHC783109( ) NATIONALT t must be prominenffydisplayed. 2290 NW 11 UTH AVIERODRc, I, L 1 I L t i 0 Packet;Pg. 559 cv CD MONROE COUNTY BUSINESS TAX RECEIPT 0 0. EXPIRES SEPTEMBER r 2021 RECEIPT* 4717-107075 Business Name: NATIONAL HEALTH TRANSPORT INC UL ROGRIGU 1970 OVERSEASH Y Owner Name: Business Location: SUARLOF , FL 3 MailingAddress: 2290 NW 110 AVE Business Phone: -636-5555 SWEETWATER, FL 33172 Business Type: TAXI COMPANIES&DRIVERS(NON EMERGENCY MEDICALTRANSPORTATION) z O Employees 1 U CL Tax Amount-- T Hafer Fee Ta ! natty Prior Yeas Clie Ion C t Total Paid y m 22.OQ� 0.001 22.00 0 00 0.00 B 0 ...... 22.00 O Paid 11 -1 - 1392 07/20/2020 22.00 THIS BECOMES A TAX RECEIPT I ,Tax Collector THIS IS ONLY A TAX. a WHEN VALIDATED PO Box 1129, Key West, FL 33041 YOU MUST MEETALL COUNTY AND/ R MUNICIPALITY PLANNING, ZONING AND LICENSING REQUIREMENTS. MONROE COUNTY BUSINESS TAX RECEIPT 1129, Key West, FL 33041-1129y EXPIRESE 3 , 21 RECEI 7147-1077 Business Name: NATIONAL HEALTH TRANSPORT INC 1970 OVERSEAS Y Business Cation: SUGARLOAF KEY, FL 33042 = Owner am : RAUL ROGRIGUEZ Mailing Address: Business Phone: 05-636-5555 2290 NW 110 AVE Business Type: TAXI COMPANIES&DRIVERS( N EMERGENCY MEDICAL TRANSPORTATION) S ATER, FL 3172 ) Employees 1 Tax Amount Transfer F Sub Total Penalty Prior Yea I Collection Cost �Ttal Paid 22.0010.00 22 00 i 0.00' 0.00 1 0.00 22 Paid 112-19-000013 2 07/20/2020 22.00 Packet,Pg. 560 .� br CD J y 0 N C o- Cu tiwa C (} awe41 Cu en CS 0 CL 66 Dan 1 +� wi r ®ma®yy k y�g V 101. an'° + SS ` n�7 +4fi tiR1s C+xY Eyy.� 1dJ 'i'd tt �S.T,A'X'3 tL%11fS ak t k+16` 1%4F h& 7':: C y 7.) A yyls r'+ t � "p\u '- "Ira'111 A 9(�t�rn Sl trey ! E k OF i Packet;Pg. 56`1 C.13.a N - ® O OM N�r O3 tI) 't ic � m o0N6) r� _ CD _ M II'T1 0-�, oCN ..a�a_ o2o 1 CA) � M —q D C7C CM .tea- ® C DD 0. _ ® MC-n m. ® ® ® t') w r— M ` Q ; O ® CO) � m i� ® '� CD c T® n " tt3 - M X C — > M ad®Ayf Y' T m M lilt .Cn.� n W c�Dcn = c � gam= z -- ® WWUR M U) CO c, A� ® o CO N r N.. m mom r ® W _ ZprpC C C ` N N C y W Z Z $ C) �► -- F 0 ® CA) X 1— O mtsttesstm� 56DJ3&'Q71FE4A After printing this label: cl 1.Use the'Print'button on this page to print your label to your laser or inkjet printer. 2. Fold the printed page along the horizontal line. 3.Place label in shipping pouch and affix it to your shipment so that the barcode portion of the label can be read and scanned. Warning: Use only the printed original label for shipping. Using a photocopy of this label for shipping purposes is fraudulent and could result in additional billing charges,along with the cancellation of your FedEx account number. Use of this system constitutes your agreement to the service conditions in the current FedEx Service Guide,available on fedex.com.FedEx will not be responsible for any claim in excess of$100 per package,whether the result of loss,damage,delay,non-de livery,m isdelivery,or misinformation, unless you declare a higher value,pay an additional charge,document your actual loss and file a timely claim.Limitations found in the current FedEx Service Guide apply.Your right to recover from FedEx for any loss,including intrinsic value of the package,loss of sales,income interest,profit, W attorney's fees,costs,and other forms of damage whether direct,incidental,consequential,or special is limited to the greater of$100 or the authorized declared value.Recovery cannot exceed actual documented Ioss.Maximum for items of extraordinary value is$1,000,e.g.jewelry, precious metals,negotiable instruments and other items listed in our ServiceGuide.Written claims must be filed within strict time limits,see current FedEx Service Guide. 0 Packet Pg. 562 N MICHAEL J. ZAPPA, MD, FACED EMERGENCY MEDICINE 2250 Seven Oaks Lane, Palm Beach Gardens Florida 33410 0. The following document is designed to enhance the delivery of state of the art emergency cars to all °® those we serve. It reflects the latest in pre-hospital research as well as guidelines promulgated by local, state and national organizations, including the American Heart Association. The general and cardiac treatment protocols once again use icons for rapid scanning. The icons indicate Signs and Symptoms, Basic and Advanced Life Support intervention, Physician Consult indications, Pediatric Care, Cautions, and Contraindications for procedures and medication administration. 0 Field personnel are reminded that"patients do not know protocols." More precisely, patients often present with an injury or illness which dictates the use of multiple protocols at one time. Each patient CL should be evaluated thoroughly to assure the most prudent use of the appropriate protocol(s). Key information during obtained during the initial physical evaluation, medical questioning, and the scene survey are ail-important components of a patient care plan.Areas of concern regarding the patient's y surroundings,questionable history and/or other"red flags"should always be reported to the receiving hospital personnel. 0 I hereby authorize use of these protocols by EMT's and Paramedics working for National Health Transport. v / =?1 Michael J. Zappa, M.D., FACED Medical Director CD d 0 0 Packet Pg. 563 C.13.a cv CD cv r- 0 0. cu cu 0) c cu 0 U NATIONAL HEALTH TRANSPORT CL TREATMENT PROTOCOLS cD 0 0. cn cu Packet Pg. 564 C.13.a HOW TO USE ICON PROTOCOLS The protocols use an icon system, which places all the treatment modalities for each problem in the same location. BLS,ALS, adult and pediatric protocols are grouped together by topic. CD r- 0 SAS Information listed under this icon points out signs, symptoms, and other pertinent points relating to the specific protocol. BASIC LIFE SUPPORT Information listed under this icon indicates the treatment that is authorized for EMT's and Paramedics to use either CL when arriving first on scene or in conjunction with the ALS rescue crew. ADVANCED LIFE SUPPORT 0 Information listed under this icon indicates the treatment that is authorized for Paramedics to use without having to contact medical control. 4rPHYSCIAN CONSULT Treatments listed under this icon require physician's orders prior to treatment either from the receiving facility or Medical Director. J—�7� PEDIATRIC This icon indicates treatments for pediatric patients �nnn�nnr�n 0 Information under this icon serves as cautionary notes related to that particular protocol. DMGER Information under this icon identifies treatments or conditions, which are contraindicated for that particular protocol, 3 Packet Pg. 565 C.13.a BILS STANDARD REQUIRMENTS N SECURE AIRWAY r- 0 ❑ Positioning: 0. • Recovery position:Altered mental status,seizures(Contraindicated in cervical spine injuries). • Head tilt chin lift • Modified jaw thrust(Cervical spine injury) 0 • Nasal pharyngeal airway for conscious patients • Oral pharyngeal airway for unconscious patients o ASSSESS BREATHING/VENTILATION c.0 CL ❑ Low flow oxygen:For all patients not requiring high flow oxygen or assisted ventilation's ❑ High flow oxygen: For patients with a ventilatory rate greater than 24 breaths per minute CJ ❑ BVM:respiratory arrest or an altered mental status with a respiratory rates less then 8 breaths per minute ❑ EOA:after hyperventilation if ALS crew is delayed CIRCULATION ❑ Carotid&radial:rate&quality VITAL SIGNS ❑ Blood pressure ❑ Pulse:rate&quality ❑ Respiration's:rate&quality ❑ Pulse ox:on room air,prior to oxygen administration 0 0. Apply AED on all unconscious patients. 4 Packet Pg. 566 C.13.a To be performed on all ALS patients cv Primary Survey 0 ❑ Airway:secure airway as appropriate y ❑ Breathing ❑ Circulation:check carotid and radial pulses ❑ Disability:AVPU c ❑ Neurological Exam:level of consciousness,gross motor&sensory Oxygen ❑ Pulse ox:pre&post oxygen administration U ❑ Ventilation:support as needed Lung Sounds ECG ❑ ECG monitoring ❑ 12 lead when applicable Vitali ❑ Blood pressure ❑ Pulse:rate&quality ❑ Respiration:rate&quality ❑ Skin:color,condition,temperature IV CD Blood Glucose level ❑ known diabetics and altered mental status patients 0 History i t Examy ❑ see protocol Patients will be transported to the most appropriate facility as directed by the patient's condition. 5 Packet Pg. 567 C.13.a HISTORY AND PHYSICAL EXAM When applicable the following history and physical exam should be performed on all medical patients, Refer to BTLS for trauma patients. `CD V cv r_ History c ❑ Chief Complaint ❑ History of the present illness:O, P,0, R,S,T,A o O-On set(time/gradual or sudden) ` o P-Provoke(palliative,previous episodes) c o Q-Quality(of pain) 0 o R- Region(radiation) CL o S-Severity(1-10) U o T-Time(frequency,duration) y o A-Associated(signs&symptoms) 0 ❑ Past medical History o Allergies to medications o Medications(prescription&non-prescription) Limited i i Exam General.position,level of distress ❑ Neck:Jugular Venous Distension (J ),trachea midline 13 Chest.lung sounds(presence,type) El Heart.(rate/rhythm) ❑ Abdomen:soft or firm,tenderness,distended,palpable masses ❑ Extremities:distal pulses,edema,cyanosis ❑ Neurological.level of consciousness,gross motor&sensory 0 ❑ Skin:color,temperature,rashes,lesions,bites&lacerations ` ` 6 Packet Pg. 568 C.13.a cv CD cv r- 0 0. cu cu 0) cu CARDIAC z ca 0 TREATMENT CL PROTOCOLS c 7 Packet Pg. 569 C.13.a CHEST PAIN S/S � cv A cardiac alert is called when ST elevation> 1 mm exists in 2 or more contiguous leads. Inferior leads- II, III or AVF,Anterior leads- 0. V1-V4, Lateral leads- I,AVL,V5—V6 BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Allow patient to sit to maintain their own airway. ❑ EMT's may assist patient in taking their own prescribed nitroglycerin providing their BP is greater than 110mm/hg systolic and they have not taken more than 3 prior to our arrival. ❑ Set up EKG. ❑ Set up IV. CL ADVANCED LIFE SUPPORT ❑ ALS standard requirements. U ❑ 12 lead EKG. Perform a V4r if ST elevation is noted in II, III or AVF. If noted in V4r run IV @ 250cc/hr. ❑ Aspirin 162 mg PO(if not contraindicated). ❑ Nitroglycerin 0.4mg S/L. May repeat to a total of 3 doses as long as systolic remains above 100mm/hg. If patient is a cardiac alert you may go directly to IV Nitro. ❑ If ST elevation is noted in 2 or more contiguous leads or pain is not fully relieved with sublingual Nitro: • IV Nitroglycerin 10 mcg/min via IV pump. Increase 10mcg/min every 3-5 mins until pain is relieved or minimum BP is met. (Min. BP is 100mm/hg sys. Must have saline line primed and hanging in case hypotension ensues). PEDIATRIC ❑ Call for orders for treatment of pediatric chest pain. ❑ Administration of nitrates should be accomplished with caution in patients with right ventricular infarct. These patients may be sensitive to nitrates. ❑ Other forms of nitroglycerin should be discontinued when IV Nitroglycerin is initiated. ❑ While IV Nitro is being administered monitor patients blood pressure to ensure the BP does not fall below 100mm/hg systolic. ❑ Morphine Sulfate for pain control. Can be given concurrently with Nitro.3mg slow IVP. May repeat twice for a total of 9mg. (B/P> 100 mm/hg systolic) DER COMMAi',GJDIIM& ,naM D Baby aspirin is contraindicated in patients 16 or younger, if the patient has a history of ulcers, recent abdominal surgery or is allergic to aspirin based products. ❑ Do not use nitroglycerin in any form in patients who have taken erectile dysfunction meds, e.g.Viagra, Levitra or Cialis in the past 24 hours. Packet Pg. 570 C.13.a VENTRICULAR FIBRILLATION1PULSELESS VENTRICULAR TACHYCARDIA N CD K 0 BASICLIFE SUPPORT Attach AD and analyze rhythm. Follow AED instructions. Ll Open patient's airway. 13 Assess breathing. Assist with BVM if necessary. 13 Check fora pulse. Initiate compressions if absent. c ADVANCEDLIFE 0 Defibrillate patient 200j,300j and 360j. Repeat defibrillation 3 -60 secs after each drug is administered or as appropriate. If patient converts after initial set of defibrillations no antiarrhythmic should be given. If patient CL returns to V-fib then administer antiarrhytmic upon successful conversion. Intubate patient. Verify tube placement via 2 means. Secure tube using approved method. El Initiate IV access(preferably large ore). v, Vasoressin 40 units IVP. Single one time dose only. Epinephrine 1 mg IVP eve 3-5 minutes. If vasopressin was given wait 10 minutes before giving epinephrine. 13 Amioarone 300mg IVP(if available) Or/then Lidocaine 1.5 mg/kg IVP c Arniodarone 150 mg IVP(5 mins after 1"dose) Lidocaine 1.5 mg/kg IVP Initiate drip of antiarrytmic that terminated rhythm o Amiodarone Maintenance drip: Using a mini drip mix 150 mg in 10cc's D5W(1.5mg/cc)run @ 1 mg/min (40gtts/min) Sodium Bicarbonate 1 meq/kg after 20 minutes of resuscitation. Ll Magnesium Sulfate 2s IVP for Torsae's. PEDIATRIC ®Defibrillate patient u to 3 times j/k ,4Ag,4j/kg. Repeat defibrillation after 0-60 secs after each drug is 2 administered or as appropriate. ®Intubate patient. Verify tube placement via 2 means. Secure tube using approved method. ®Epinephrine 0.1 mg/ (1:1000 solution)via ETT if IV access is not available after intubation. ®Initiate IV access. If IV cannot be established in 3 attempts or 90 sec's initiate an 10. Epinephrine 0.01 mg/kg (0,1 n,k ) 1:10,000 solution IV or 10 0.1 mg/kg 1:1000 solution 2"d and subsequent doses. Every 3-5 minutes ci ®A iodarone 5mg/kg IVP Or/then Lidocaine 1.0 mg/kg IVP 0 9 Packet Pg. 571 C.13.a TACHYCARDIAVENTRICULAR cv cv BASIC LIFE SUPPORT 0. ❑ BLS standard requirements. ❑ Set up EKG. ❑ Set up IV. 0 ADVANCED LIFE SUPPORT 0 •ALS standard requirements. •12 lead EKG if time permits. CL •Initiate IV access (preferably large bore). •If Stable: • Amiodarone Infusion.150mg over 10 mins y (150mg/100mis: 150gtts/min on a macro) ❑ If Unstable:(Hypotension,Altered LOC, CP, SOB,CHF/Pulmonary Edema) • May give a trial period of medications. o • Sedate patient(refer to SEDATION GUIDELINE). • Synchronize cardiovert patient at 100j,200j,300j and 360j 44 PEDIATRIC • If Stable: i • Amiodarone 5mg/kg IV bolus over 20 mins Or Lidocaine 1 mg/kg IVP. Repeat every 5-10 minutes to a total of 3mg/kg. Initiate maintenance drip 20-50 mcg/min if rhythm terminates after bolus. ❑ If Unstable: • May give a trial period of medications. • Sedate patient(refer to SEDATION GUIDELINE). • Synchronize cardiovert patient at 0.5j/kg,subsequent shocks at 1.0j/kg. • Lidocaine 1 mg/kg IVP. Initiate Maintenance drip at 20-50mcg/kg/min when arrhythmia terminates. 0 @MM PIM ❑ Although the loading dose of lidocaine does not need to be reduced,the maintenance dose should be decreased by 50%in the presence of impaired hepatic blood flow, acute MI, CHF or in patients older than 70 years of age to prevent lidocaine toxicity. ❑ Rates of less than 150 BPM usually do not require immediate cardioversion. 10 Packet Pg. 572 C.13.a ASYS'TOLE N CD 0. S/S • Consider the following causes when treating Asystole: • Drug Overdose • Hypokalemia • Hypothermia • Hypoxia • Pre-existing acidosis • Hyperkalemia 0 95 BASIC LIFE SUPPORT CL ❑ Attach AED and analyze the rhythm. Follow AED instructions. ❑ Open patient's airway. y ❑ Assess breathing. Assist with BVM if needed. ❑ Check for a pulse. Initiate compressions if absent. 0 ADVANCED LIFE SUPPORT *Confirm asystole in 2 leads •Intubate patient. Verify tube placement via 2 means. Secure tube using approved method. •Initiate IV access(preferably large bore). -Consider Transcutaneous Pacing early along with drug therapy. •Epinephrine 1 mg IVP every 3-5 minutes. i -Atropine 1mg IVP every 3-5 minutes to a maximum of 3mg. •Perform appropriate procedures to reverse possible cause of the Asystole. 4r PHYSICIAN CONSULT ❑ Call Medical Director for possible termination of efforts if following criteria is met:1) Documented asystole for 10 mins. 2)All ALS interventions have been correctly completed. 3)2 paramedics have confirmed proper tube placement.4) Social support group is in place for the family. 0. cn �Y= PEDIATRIC 2 ❑ Intubate patient. Verify tube placement via 2 means. Secure tube using approved method. ❑ Initiate IV access. If IV cannot be established in 3 attempts or 90 sec's initiate an 10. ❑ Epinephrine 0 0.01 mg/kg (0,111'e 3 g" 1:10,000 IV or 10 � 0 0 0.1 mg/kg 1:1000 IWO 2"d. &subsequent doses 0 0.1 mg/kg (0.1 cc/kg) 1:1000 ETT ❑ Atropine 0.02mg/kg IVP every 3-5minutes to a maximum of 0.04mg/kg. • Minimum dose 0.1mg. E • Maximum single dose 0.5mg for a child, 1.Omg for an adolescent. 11 Packet Pg. 573 C.13.a PULSELESS ELECTRICAL ACTIVITY T- cv CD cv BASICt rx- 1 0. LIFE SUPPORT El Attach AED and analyze the rhythm. Follow AD instructions. El Open patients Airway. Ll Assess Breathing. Assist with BVM if absent. Check for a pulse. Initiate compressions if absent. c ADVANCED LIFE T 0 El ALS standard requirements. • Intubate patient. Verify tube placement via 2 means. Secure tube using approved method. ® Perform appropriate procedures to reverse possible cause of the PEA. CL Epinephrine 1 mg IVP every 3-5 minutes. c, ® May try Transcutneous pacing and fluid boluses. '� fJ PEDIATRIC c ru ® Intubate patient. Verify tube placement via 2 means. Secure tube using approved method. • Initiate IV access. If IV cannot be established in 3 attempts or 90 sec's initiate an 10. W • Epinephrine 0.01mg/kg (0.1 cc/kg) 1-10,0 0 IV or 10 .1mg/kg 1:1000 IWIO 2nd. &Subsequent doses .1 / (0.1 cc/kg) 1:1000 ETT G�LaC�J-i?GO�1 i Consider the following causes when treating PEA: 2 ® Hypovoleia • Hypothermia • Hyoxia • Hydrogen Ions(acidosis) ® yer/ okalemia ® Tablets(drug overdoses) ® Tension Pneuotorax ® Tamponae,cardiac ® Thrombosis,Coronary ® Thrombosis, Pulmonary y 12 Packet Pg. 574 C.13.a SUPRAVENTRICULAR TACHYCARDIA BASIC LIFE SUPPORT CD El BLS standard requirements Ll Set up EKG y El Setup IV ADVANCED LIFE SUPPORT eALS standard requirements c ®12 lead EKG , Ll Vagal maneuver If Stable: • Adenosine 6mg rapid IVP • Adenosine 12 mg rapid IVP. May repeat once if no conversion. CL • Monitor patient throughout transport. ❑ If Unstable: (Hypotension,Altered LOC, CP,SOB, CHF/Pulmonary Edema) cn *May attempt trial bolus of adenosine 6mg rapid IVP if time permits. *Sedate patient(refer to SEDATION GUIDELINE)as needed. c •Synchronize cardiovert patient at 100j,200j,300j and 360j. *May try adenosine(6mg, 12mg and 12mg). PHYSICIAN CONSULT ❑ Cardizem 15mg slow IVP over 2 minutes for the stable patient or for the unstable patient after other treatments have failed. If no response in 15 minutes repeat @ 20 mg slow IVP. (B/P> 100mmhg). Y � PEDIATRIC ❑ If Stable: U • Adenosine 0.1 mg/kg rapid IVP(max initial dose of 6mg) • Adenosine 0.2mg/kg rapid IVP if initial dose fails(max of 12mg) ❑ If Unstable: • May give a trial period of medications. • Sedate patient(refer to SEDATION GUIDELINE). • Synchronize cardiovert patient at 0.5j/kg,subsequent shocks at 1.0j/kg. 0 ❑ Carotid sinus massage is contraindicated in adults but may be used in pediatric patients. ❑ PSVT in pediatrics is considered rates over 220 bpm. ❑ Minimum blood pressure must be greater than 100mm/hg systolic for Cardizem to be administered. ❑ Use Cardizem with caution in patients on beta blockers or oral calcium channel blockers DMIGEP ❑ Do not use Cardizem in patients that have a history of W PW, or sick sinus syndrome. 13 Packet Pg. 575 C.13.a BRADYCARDIA S/S 1m 0 0. ❑ Symptomatic bradycardia,otherwise known as unstable bradycardia, exists with a slow heart rate(<60 beats/min) and hypotension (systolic BP<90mm/hg). #N BASIC LIFE SUPPORT 0 ❑ BLS standard requirements. ❑ Set up EKG. z ❑ Set up IV. o U CL ADVANCED LIFESUPPORT El ALS standard requirements. If Stable: ® Monitor patient during transport to the ER. o If Unstable:(Hypotension<90mmlhg systolic) • Atropine 0.5mg IV , repeat q -5 min pm, maximum dose 3mg, if unsuccessful then: ® Transcutaneous pacing (consider sedation), or W ® Dopamine 5-20 m / /min. Titrate to desired heart rate, or • Epinephrine Infusion -1mcg/min,titrate to heart rate a60. � PEDIATRIC °— Chest compressions if HR<60 after oxygenation. Asappropriate. Epinephrine 0.01mg/kg IVP every 5 minutes as needed. _ 13 Atropine 0.0m / g to a total of 0.04 mglkg. (minimum single dose 0.1 mg) urs��r 0 ❑Bradycardia in children is usually secondary to a respiratory problem and hypoxia. Ensure good oxygenation prior y to administering any medication. ❑Do not use atropine in children less than 1 year of age. MER C�O[vl 'G3Qi���I'tSCa'."'OC�1 ❑ Never treat bradycardia with PVC's with anti arrhythmic drugs. 14 Packet Pg. 576 C.13.a ATRIAL FIBRILLATION ATRIAL FLUTTER CD A IC LIFE SUPPORT 0. El LS standard requirements. El Scene survey to identify cause of overdose. • Protect patient's airway and monitor for vomiting. • Set up EKG. • Set up IV. c ADVANCED LIFE T - U -ALS standard requirements, CL ®12 lead EKG. eVaal maneuver(have patient bare down only). y Ll If Stable: Monitor patient throughout transport U 0 El If Symptomatic and Normotensive(with rate> 10D_): Cardizem (diltiazem) 15 mg slow IVP over 2 minutes. If no response in 15 minutes repeat @ 20mgslow IVP. (13P> 10 / ). ❑ If Symptomatic and Hypotensive(with rate>1 pm): Sedate patient(refer to SEDATION GUIDELINE). ® Synchronize cardiovert patient at 100j,200j, 300j and 360j. If cardioversion fails Cardizem(diltiazem) 15 mg slow IVP over 2 minutes. If no response in 15 minutes i repeat @ 20mg slow IVP. (13P> 10mm/ ). ,TPHYS,C1AN CONSULT If cardioversion fails Cardizem(diltiazem) 15 mg slow IVP over 2 minutes. If no response in 15 minutes repeat 20mg slow IVP. (13P> 10 / ), �SLaLU15�'uU�[`rJ ❑ Use with caution in patients who are taking oral beta-blockers or oral calcium channel blockers. ❑ Carotid sinus massage is contraindicated in adults but may be used in pediatric patients. DANGER ❑ Do not use Cardizem(diltiazem) in patients that have a history of WPW,sick sinus syndrome.Carotid sinus massage is contraindicated in adults but may be used in pediatrics. 15 Packet Pg. 577 C.13.a HYPERTENSIVE CRISIS cv CD cv r- 0 r � � _ S/S ❑ Patients are considered to be having a hypertensive crisis when the BP is greater than 200 systolic or 120 diastolic and is accompanied y: Headache, Eistaxis, Nausea and Vomiting or Visual disturbances. 10 SIC LIFE SUPPORT c 13 BLS standard requirements. El Check the blood pressure in the other arm if the initial reading is abnormal. • Set up EKG. • Set up IV U CL CJ ADVANCED LIFE T -ALS standard requirements -0.4 mg nitroglycerin S/L. May repeat every 5 minutes to a total of 3 doses or until a drop of %of the original systolic or diastolic pressure C�GaNJ i�JOG�I � ❑ Patients who maintain a chronic hypertensive status may require a higher than normal systolic pressure to maintain cerebral perfusion. This should be considered when administering treatment to lower the blood pressure. • Monitor blood pressure every 5 minutes. 13 o not treat B/P if patient exhibits SS of a stroke,see stroke protocol. Ll If patient is pregnant,see Eclampsia protocol. 9 0 16 Packet Pg. 578 C.13.a CONGESTIVE HEART FAILURE/ PULMONARY ' CV BASIC LIFE SUPPORT ❑ BLS standard requirements. 0. ❑ Allow patient to sit up supine to maintain their own airway. ❑ Set up EKG. ❑ Set up IV. ADVANCED LIFE SUPPORT ❑ ALS standard requirements. ❑ 12 lead EKG. Perform a V4r if ST elevation is noted in II, III or AVF. ❑ If patient is in mild/moderate distress place patient on CPAP while other therapies are being initiated. If patient is in severe respiratory distress, prepare to intubate. ❑ Nitroglycerin 0.4mg S/L. May repeat to a total of 3 doses as long as systolic remains above 100mm/hg. CL ❑ Lasix(furosemide) tJ • 40 mg IVP if patient is not taking Lasix • 80 mg IVP if patient is taking Lasix or has a hx of renal insufficiency. ❑ Morphine Sulfate 3mg slow IVP.Can be given concurrently with Nitro. May repeat twice for a total of 9mg.(B/P t, > 100 mmhg systolic) ❑ Use PEEP for intubated patients. 4r PHYSICIAN CONSULT ❑ Lasix(furosemide)with a patient who is febrile. PEDIATRIC i ❑ Lasix(furosemide) 1.Omg/kg slow IVP. ❑ Morphine sulfate 0.1 mg/kg slow IVP. GLIC�J�COfi`� `� ❑ Administration of nitrates should be done with caution in patients with right ventricular infarct. These patients may be sensitive to nitrates. GEC tOGV1�?G'�GQO ]D[ICG�' "170fn1� ❑ Do not use NTG in any form in patients who have taken erectile dysfunction meds,e.g.:Viagra, Levitra or Cialis in the past 24 hours. 17 Packet Pg. 579 C.13.a CARDIOGENIC SHOCK N N 0. WID BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Allow patient to sit to maintain their own airway. ❑ Set up EKG. ❑ Set up IV. c 0 ADVANCED LIFE SUPPORT CL ❑ AILS standard requirements. c, ❑ 12 lead EKG. Perform a V4r if ST elevation is noted in II, III or AVF. • If patient has elevation in V4r,and patient is hypotensive(<90mm/hg systolic)administer fluid boluses of up to 2000 cc's of fluid(contraindicated if lung sounds are not clear). ❑ Dopamine 5-20mcg/kg/minute titrated to a BP of 100mm/hg systolic. ❑ Nitrates for chest pain after BP has been increased. PEDIATRIC ❑ Dopamine 5-20mcg/kg/min. ER ❑ Withhold all fluid boluses if patient has pulmonary edema. 0 18 Packet Pg. 580 C.13.a cv CD cv r- 0 0. cu cu 0) c cu L. 0 CL 0 GENERAL L) TREATMENT HROTOCOLS rmft CD 0 0. cn cu 19 Packet Pg. 581 C.13.a N ALLERGIC REACTIONS N S/S 0 ❑ Generalized allergic reactions are characterized by: Itching,urticaria rash,shortness of breath,difficulty swallowing, edema of the tongue and facial swelling. ❑ If the patient is hypotensive and/or has severe shortness of breath follow the anaphylaxis guideline. BASIC LIFE SUPPORT c BILS standard requirements. 13 Try to determine the cause of the reaction. • T's may help patient self administer their own EPI-P . c • Set up EKG monitor 13 Set up IV ADVANCED LIFEU y ALE standard requirements. 13 enadryl 25mg IVP or 50 mg IM. Benadryl may be given IM if no IV access. Max.50 mg. Albuterol 2,5g via neulizer for bronchospasm or sensation of throat closing. El Epinephrine . cc SO. PEDIATRIC ALE standard requirements. • enadryl 1.5 mg/kg IVP. May be given IM if no IV access. — • Albuterol( roventil):for broncosasm ® >2 years old-2.5 mg via neb. <2 years old—1.25 m (1.5 cc)in 1.5 cc NaCl via neb. El Epinephrine 0. 1 cc/kg E (max dose 0.3cc SO). @&Mi I'M ❑ If EMT's are going to help patient administer their EPI-PEN,verify that the pen is prescribed for that patient and that it has not expired. y ❑ Epinephrine should be avoided in patients over 40 years of age. DER CcNom- lfm\i;MJ,--QA ii iloo M9 ❑ Do not give epinephrine to patients with allergic reactions who have a known hx of heart disease. 20 Packet Pg. 582 C.13.a ALTERED MENTAL STATUS cv c44 BASIC LIFE SUPPORT 0 ❑ BLS standard requirements. ❑ Scene survey for possible causes. ❑ Give oral glucose if patient has one or more of the following and Rescue is not on scene: ■ Pt has intact gag reflex ■ Altered mental status ■ Blood sugar<60 mg/dl ❑ Set up EKG. ❑ Set up IV. 0 U CL ADVANCED LIFE SUPPORT U ❑ ALS standard requirements. y ❑ Blood glucose level(refer to DIABETIC EMERGENCIES GUIDELINE). ❑ Narcan 2.Omg IVP (may give IM if no IV access). May repeat q 2-3 min pm. ❑ Sedation for the violent patient(refer to SEDATION GUIDELINE). W PEDIATRIC ❑ ALS standard requirements. ❑ Blood glucose level(refer to PEDIATRIC DIABETIC EMERGENCIES GUIDELINE). ❑ Narcan 0.1 mg/kg. Maximum single dose 2mg. May repeat q 2-3 min pm. LAfFiNalt. ❑ Consider possible causes for patient's condition i.e.Trauma,OD, Diabetes, Stroke. 0 76 21 Packet Pg. 583 C.13.a r ANAPHYLAXIS N S/S ❑ Anaphylaxis is defined as a severe allergic reaction with respiratory distress and/or hypotension. BASIC LIFE SUPPORT 13 BLS standard requirements. Try to determine the cause of the reaction. E T's may help patient self administer their EPI-PEN. Ll Set up EKG monitor. Set up IV. 0 ADVANCED LIFE 13 ALS standard requirements. Epinephrine 1:1000 0.3 mg S (withhold if patient used epi-pen). ®If cardiac arrest is imminent or patient is in profound shock give Epinephrine 1:1 ,000 in 1 ml increments up to a maximum of ml's. 13 CJ enadryl 50 mg IVP. May give IM if no IV access. AI uterol(proventil)2.5 mg via nebulizer for wheezing or absent breath sounds. ❑ If hypotensive refer to HYPOTENSIVE GUIDELINE. 4r PHYSICIAN CONSULT Physician orders should be obtained for Epinephrine if: Pulse rate is greater than 140 or systolic BP is greater than 200 mm/ g. <<,I` PEDIATRIC Ll ALS standard requirements. El Epinephrine 1:1000-0.01 mg/kg SO. Maximumdose of 0.3mg. 13 enadryl 1.5mg/kg IVP, Maximum dose of 50 mg. May give IM if no IV access. Aluterol(proventil)for roncosas : ® >2 years old-2.5 mg via neb ® <2 years old®1.25 mg in 1.5 cc NaCl via neb. Ll If hypotensive refer to PEDIATRIC HYPOTENSION GUIDELINE. 0 Ll If T's are going to help patient administer their EPI- E ,verify that the pen is prescribed for that patient and that it has not expired. 76 22 Packet Pg. 584 C.13.a BETA BLOCKER OVERDOSE cV w c44 f. S/S 0. ❑ Patients who have overdosed on Beta Blockers may present with: Decreased LOC, Bradycardia,Hypotension, and Diaphoresis. ❑ Common Beta Blockers are:blocadren (timolol), breviblock(esmolol),cartrol(carteolol),corgard (nadolol), inderal (propanolol),sectral (acebutolol),tenormin (atenolol),trandate/normodyne(labetolol)and visken (pindolol). ❑ Poison Control Center-1-800-282-3171 0 Aft U- 1W IC LIFE SUPPORT CL 13 BLS standard requirements. • Scene survey to identify cause of overdose. y • Protect patient's airway and monitor for vomiting. • CJ Set up EKG. Set up IV. ADVANCED LIFE SUPPORT • Glucagon 5mg IVP over 2-5 minutes if patient is unresponsive or hypotensive. i • Follow appropriate arrhythmia protocol if initial treatment does not work. PEDIATRIC ❑ Glucagon 1 mg IVP over 2-5 minutes if patient is unresponsive or hypotensive. ❑ Follow appropriate arrhythmia protocol if initial treatment does not work. 0 23 Packet Pg. 585 C.13.a CALCIUM CHANNEL BLOCKER OVERDOSE N �x 0 ❑ Patients who have overdosed on Calcium Channel Blockers may present with: hypotension, bradycardia, y altered mental status,decreased capillary refill. ❑ Common Calcium Channel Blockers are:cardizem ( iltazem),calan/isoptin(verapmil), norvasc(amiodiine),procardia/adalat(nifedipine),and cardene(nicardiie). CM IC LIFE Ll LB standard requirements. El Gene survey to identify cause of overdose. • Protect patient's airway and monitor for vomiting. c • Set up EKG. Bet up IV. CL ADVANCEDLIFE El LB standard requirements. Ll Blood glucose level (refer to DIABETIC EMERGENCIES GUIDELINE). El Calcium Chloride 1 m slow IVP. Follow appropriate arrhythmia protocol if initial treatment fails. PHYSICIAN CONSULT ❑ Additional Calcium Chloride. i PEDIATRIC ❑ Calcium Chloride 20mg/kg slow IVP. 0 ` ` 24 Packet Pg. 586 C.13.a CARBONI MONOXIDE EXPOSURE CD S/S r- 0 0. ❑ Signs and symptoms include: headache, irritability,vomiting,chest pain,confusion,loss of coordination, loss of consciousness and seizures. Cherry red skin or lips is a late sign. IV BASIC LIFE SUPPORT c ❑ Remove patient from the source/area. ❑ BLS standard requirements. ❑ Set up EKG. - ❑ Set up IV. CL ADVANCED LIFE 0 Ll ALS standard requirements. Blood glucose level (refer to DIABETIC EMERGENCIES GUIDELINE). 13 High Flow oxygen and transport to a facility with a hyperbaric chamber. c�A PEDIATRIC ❑ High Flow oxygen and transport to a facility with a hyperbaric chamber. 2 0. 0. ° 0 ❑ Remove patient from the hazardous atmosphere prior to treatment. y ❑ Due to CO having an attraction for Hemoglobin that is 200 times that of Oxygen patients with CO poisoning may have good pulse ox readings and still be hypoxic. F ° ° 25 Packet Pg. 587 C.13.a N COCAINE OVERDOSE CD S/S im 0 0. ❑ Patients who have overdosed on cocaine may present with the following:agitation, HTN,psychosis,anxiety, PVC's, hyperthermia,dysrhythmias,dilated pupils,seizures,tachycardia,chest pain. BASIC LIFE SUPPORT c ❑ BLS standard requirements. ❑ Scene survey to identify cause of overdose. ❑ Protect patient's airway and monitor for vomiting. c ❑ Set up EKG. ❑ Set up IV. CL CJ y ADVANCED LIFE SUPPORT 0 ❑ ALS standard requirements. ❑ Blood glucose level (refer to DIABETIC EMERGENCIES GUIDELINE). ❑ For seizures or combativeness: o Valium (diazepam)5mg slow IVP, may repeat once to a max.of 10mg. (B/P> 100mm/hg systolic). OR o Versed (midazolam) 1-2mg slow IVP. May repeat to a max of 4mg. BP must be> 100mm/hg. 4r PHYSICIAN CONSULT ❑ Call for orders for Lidocaine(xylocaine)for ventricular arrythmias. ° 0 ° ° 26 Packet Pg. 588 C.13.a DECOMPRESSION SICKNESS cv CD 0. / El Try to obtain accurate history of the dive i.e. number of dives,depth of dives, interval between dives and type of air fixture in tanks etc. Some signs of Decompression sickness are:SOB, altered LC,joint pain neurological deficits,and rash. ❑ If possible bring dive log,dive computer and associated equipment to the hospital. BASIC LIFE SUPPORT 13 LS standard requirements. El Set up EKG. 0u- Ll Set up Ill. El Spinal immobilization if trauma is suspected. CL El Place patient supine. ADVANCED CJ LIFE SUPPORT 13 ALS standard requirements. If patient is r o 500cc bolus 0.9%NaCl followed by a 0cc/ r infusion unless SOB. El If patient ishypotensive: o Rapid 500cc bolus 0.9%NaCl then 250 cc boluses every 5 minutes until a minimum systolic of 1 0mm/ . 13 Once BP has stabilized: infuse at 250cc's/ r if lungs clear. El Aspirin 324mg PO LI Transport to a facility with a hyperbaric chamber. ` PEDIATRIC ❑ As above with boluses based on body weight. 0 27 Packet Pg. 589 C.13.a DIABETIC EMERGENCIES N S/S N1m ❑ Hypoglycemia: rapid onset,altered LOC,dizziness,slurred speech,cool clammy skin,intoxication-like symptoms. 0. ❑ Hyperglycemia:gradual onset(12-24hrs),with polyuria, polydypsia,polyphagia,dehydration,dry,warm skin. If there is also NN,abdominal pain,fruity breath odor,confusion,tachycardia,tachypnea,and/or hypotension consider DKA(diabetic ketoacidosis). owl BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Give oral glucose if patient has intact gag reflex with one or more of the following: o Altered mental status 0 o Blood glucose<60 mg/dl ❑ Set up EKG monitor. CL ❑ Set up IV. 2 CJ ADVANCED LIFE SUPPORT ❑ ALS standard requirements. ❑ Check Blood Glucose Level. o If Blood glucose level is<60mg/dl: ■ D50 25g IVP or ■ Glucagon 1 mg IM if no IV access. o If Blood sugar level is>300mg/dl. ■ 500 cc bolus NaCl. If DKA is suspected give 1000cc bolus. May repeat if needed. ❑ Consider Zofran (ondansetron)4mg IVP overt min for nausea and vomiting. ❑ Repeat Blood Glucose Level. PEDIATRIC ❑ Hypoglycemia o >12 years old: D50 25g IVP. o < 12years old: D25 2-4cc/kg IVP. o <30 days(neonate): D10 2-4cc/kg IVP. ❑ If no IV access is available: o <20kg: Glucagon 0.5mg SO or IM. 0 o >20kg: Glucagon 1 mg SO or IM. ❑ Care should be taken when administering glucose to patients who could be suffering a stroke. ❑ Glucagon is intended for use only when IV access cannot be established. It is not intended to replace IV administration of dextrose. — 28 Packet Pg. 590 C.13.a DROWNINGiNEAR DROWNING 4 BAS IC LIFE SUPPORT 0 0. BILS standard requirements. Ll C-spine if applicable. CPR if no pulse. • Keep patient warm. • Set up EKG • Set up I 0 ADVANCEDISUPPORT ALS standard requirements. ❑ If patient is hypotensive: o Rapid 250cc bolus 0.9%NaCl every 5 minutes until a minimum systolic of 100mm/hg. El If no response to fluid bolus: y 0 Dopamine drip beginning at mc /k /min and titrate to effect. Treat the appropriate arrhythmia. 0 PEDIATRIC El ALS standard requirements. If patient is hypotensive.- 0 20cc/kg fluid bolus of 0.9%NaCl. 13 � ❑ Consider possible C-spine injury. ❑ If patient is in cardiac arrest follow appropriate arrhythmia protocol. ❑ No drowning victim is to be pronounced dead at the scene if the possibility of hypothermia exists. ❑ All near drowning patients must be transported to the hospital. Contact the Medical Director for assistance,as d needed. r- 0 29 Packet Pg. 591 C.13.a ECLAMPSIA AND SEVERE PRE-ECLAMPSIA CD S/S N 0 Severe pre-eclampsia usually begins in the third trimester and is characterized y; hypertension,generalized edema,altered mental status,visual disturbances and headache(not all signs may be present), 13 Eclamsia is characterized by the above signs along with seizures and possible coma. BASICLIFE T Ll c BLS standard requirements. El Set up EKG. El Set up IV. U ADVANCEDCL LIFE SUPPORT y El PALS standard requirements. 13 Blood glucose level(refer to DIABETIC EMERGENCIES GUIDELINE). 13 For Severe Pre-eclampsia: o Magnesium sulfate 4gm bolus over 20 minutes(4g in 50cc NaCl, 38 gtts/min macro drip set, 150 gtts/min W micro drip set). El For cl sI ®(patients actively seizing) o Magnesium sulfate 2m IVP over 2 minutes. May repeat once if seizure persists. If seizure subsides after first dose establish a maintenance drip of magnesium sulfate 2g in 5cc's NaCl at 2.5 cc's/min ( 3tts/minute using a macro drip set, 150 tts/min micro drip set). PHYSICIAN CONSULT ❑ Valium(diazepam)or Versed(midazolam)for seizures unresolved by magnesium sulfate. 9 ❑ Do not exceed 4gm of magnesium sulfate unless directed by physician. 0 30 Packet Pg. 592 C.13.a HAZARDOUS MARINE STINGSIBITES cv CD cv r- 0 0. BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Irrigate area with 0.9%NaCl,seawater,vinegar or ammonia. c ADVANCED LIFE SUPPORT 0 ❑ ALS standard requirements if necessary. ❑ If patient is having an allergic reaction refer to ALLERGIC REACTION GUIDELINE. CJ PHYSICIAN CONSULT y Ll Pain control: 0 Morphine sulfate 3mg IVP. c PEDIATRIC W ❑ ALS standard requirements. ❑ If patient is having an allergic reaction refer to appropriate protocol. urup�. . ' ❑ Observe patient for possible allergic reaction and follow appropriate protocol. CD UNGER 9@HV 1HP1Q%W1 U@H'T3 ❑ Do not use fresh water on affected area. c 31 Packet Pg. 593 C.13.a HAZARDOUS MATERIAL SURE AND WEAPONS OF MASS DESTRUCTION General Protocol N N r- 0 a ❑ Rapid extrication and transport are not the priority. Patient decontamination and personnel protection are of the utmost importance. ❑ When responding to a hazardous materials incident or a possible weapons of mass destruction (WMD) call dispatch to ensure a hazardous materials team is responding as per the county wide hazardous materials response protocol. 0 ❑ Medical treatment and patient preparation, including decontamination, will be based on information obtained from the Special Operations Team. c, ❑ The special operations team will brief EMS treatment personnel on the identity,type,quantity and hazard potential of the materials involved. ❑ Institute the appropriate personal protective measures for all personnel prior to patient contact. ❑ Paramedics, with special training in Hazardous Materials Toxicology, who are assigned to the responding i Special Operations Team,will oversee the research, decontamination and medical treatment of the patients. ❑ BLS procedures according to the America Heart Association may be implemented when safe to do so and when the patient presents no risk of secondary contamination. d ❑ Patients will be transported in the properly prepared ground transport units(usually Special Ops Rescue vehicles) to the appropriate facilities. If the number of patients overwhelms the amount of Special Ops transport units seek the advise of the Special Ops team about preparing the rescue unit for the transport of the patient. 32 Packet Pg. 594 C.13.a HEAT EXPOSURE cv CD cv agaps 0. 0 BASICLIFE Li BLS standard requirements. °® Lj Remove from the heat if possible and cool Remove excessive clothing. Ei Apply ice packs to neck, axilla, and groin for heat stroke. El Set up EKG Set up IV o 0 U ADVANCEDI ❑ ALS standard requirements. If t iv ® v o 250cc fluid bolus 0.9% NaCl. ❑ Ifhypotensive: o Rapid 250cc bolus 0.9% NaCl every 5 minutes until a minimum systolic of 1 00 / . PEDIATRIC ❑ If hypotensive: i o 20cc/kg fluid bolus 0.9% NaCl every 5 minutes until an appropriate systolic is reached. rr C�LaM`i�'CI(�a ❑ Do not cool patient to the point of shivering. ❑ Assess lung sounds before and after each fluid bolus. 0 76 33 Packet Pg. 595 C.13.a I S/S 0 0. ❑ Suspect hyperkalemia in patients with lethal or potentially lethal arrhythmias, elevated T waves and depressed P waves, and muscular weakness, especially with a history of renal failure/dialysis. BASICIW IF o BILS standard requirements. Li Set up EKG monitor. Li Set up IV. o ADVANCED I y standard requirements. • Calcium Chloride 1grn IV . Sodium Bicarbonate 1 amp IV . Follow appropriate arrhythmia Protocol. i ❑ Flush IV line thoroughly between medications. 0 34 Packet Pg. 596 C.13.a HYPOTENSION SHOCK cv CD w cV BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Place patient in the shock position unless SOB. ❑ Keep warm. ❑ Set up EKG. ❑ Set up IV. 0 ADVANCED LIFE SUPPORT CL ❑ ALS standard requirements ❑ 250 cc bolus of NaCl. May repeat 3 times or to a systolic of 100 mm/hg. y ❑ 12 lead ECG to rule out right ventricular infarct. ❑ Dopamine 5-20 mcg/kg/minute titrated to a BP of 100mm/hg systolic. 0 PEDIATRIC ❑ ALS Standard requirements 2 ❑ 20cc/kg bolus of NaCl. May repeat 3 times. i j Verify that the patient's lung sounds are clear prior to administering a fluid bolus or laying the patient supine. Li Assess lung sounds before and after each fluid bolus. Consider dehydration, sepsis, cardiac arrthymias and cardiogenic shock. 0 E DER Ci-�CUi ❑ No fluid boluses for patients with pulmonary edema. 76 35 Packet Pg. 597 C.13.a NARCOTICOVERDOSE cv CD _. S/S ❑ Patients who have overdosed on narcotics can present with any of the following: Constricted pupils, decreased LOC, decreased respirations, decreased BP, decreased heart rate, bradycardia, coma or pulmonary edema. ❑ Common Narcotics:codeine, darvon (propoxyphene), demerol (meperidine), dilaudid (hydromorphone), _ heroin, methadone (dolophine), morphine, oxycontin (oxycodone, percocet),talwin (pentazocine) and vicodin/lorcet/lortab (hydrocodone). ❑ Poison Control Center-1-800-282-3171 0 U CL 10 BASIC LIFE SUPPORT standard requirements. • Gene survey to identify cause of overdose. 13 Protect patient's airway and monitor for vomiting. • Set up EKG. • Set up IV. ADVANCED LIFE SUPPORT i standard requirements. • Blood glucose level (refer to DIABETIC EMERGENCIESI LI ). • Narcan 2mg IV .Titrate to respirations (may give IM if no IV access). May repeat q 2-3 minutes Q PEDIATRICd ❑ Narcan 0.1 mg/kg. Maximum single dose 2mg. May repeat q 2-3 minutes PRN. ❑ Blood glucose level (refer to PEDIATRIC DIABETIC EMERGENCIES GUIDELINE). 36 Packet Pg. 598 C.13.a NAUSEA AND VOMITING cv CD cv 0. BASIC LIFE SUPPORT ❑ BLS standard requirements. ADVANCEDI T standard requirements. If hypotensive refer to HYPOTENSION GUIDELINE. c If nor otensive 250 cc bolus of NaCl. U e Ian ( e oclopra ide) 10 mg IVP or Zofran (on a s tron) 4 g IVP over 2 minutes. CL PEDIATRIC 0 ❑ If hypotensive refer to PEDIATRIC HYPOTENSION GUIDELINE. i ❑ Prior to treating the nausea and vomiting rule out Angina, CVA, MI and HTN. If patient presents with any of these along with the N+V follow appropriate protocol. d 0 37 Packet Pg. 599 C.13.a EMERGENCIESOBSTETRICAL Oft BASIC LIFE III PORI! N 0 0. ❑ BLS standard requirements. �+ ❑ Set Up OB kit. ❑ Set up IV. ❑ If normal presentation (head): o Slow controlled delivery of the head; apply gentle perineal pressure. o Observe for meconium staining and if present vigorously suction the oropharynx during delivery with a bulb syringe and immediately after with a ET tube and meconium aspirator. o Once body is delivered, double clamp the cord 10-12 inch's from the abdomen. c o Stimulate the baby and maintain body temperature. o Record a 1 and 5 minute APGAR score. CL o If mother is bleeding heavily or placenta will not deliver try fundal massage. ❑ If breech presentation (buttocks or feet): o If the head is not delivered within 3 minutes of the body, elevate the mother's hips and insert gloved fingers into the vagina and push the vaginal wall away from the baby's nose and mouth. o Expedite transport with the mother's hips elevated while maintaining the baby's airway. ❑ If prolapsed cord: W o Place the mother in a knee to chest position with her hips elevated. o Check the umbilical cord for a pulse. If there is no pulse present insert a gloved hand into the vagina and push the baby up towards the uterus until a pulse returns. o Wrap the exposed cord with a moist sterile dressing and expedite transport. i ADVANCEDI o ALS standard requirements for the mother. 13 25 cc boluses of 0.9% NaCI if hypotensive. d 0 38 Packet Pg.600 C.13.a OBSTETRICAL EMERGENCIES (cont.) N PEDIATRIC N 0 0. ❑ If resuscitation of the newborn is needed follow the Neonatal Inverted Pyramid and current Ch NALS guidelines. Score 0 1 2 Appearance Blue, Pale Body Pink, extremities Completely pink blue 2 Pulse Absent Below 100 Above 100 Grimace No response Grimaces Cries CL Activity Limp Some flexion of Active motion extremities y Respiration's Absent Slow or irregular Good strong cry. Total W D i Warming,Positiong, Suction,Tactile Oxygen i Bag—Mask Ventilation Chest Compressions Intubation Medi- cations 0 t�QM��00M ❑ Try to obtain a accurate history of pregnancy including: Number of times pregnant (gravida), number of living children (parity), expected due date, possibility of multiple births, pre-natal care, whether her water has broken (if so was it clear or stained) and drug history. ❑ If labor is premature, prepare for the possibility of a respiratory depressed infant. ❑ If mother is not yet crowning,transport mother in position of comfort. ❑ If baby is crowning, and/or contractions are 2 minutes apart or less prepare for a field delivery. ns 39 Packet Pg.601 C.13.a RGANOP l SP ' P011SCM C CD Prior to entering a potentially contaminated area or makine contact with a contaminated patient request a `V Hazardous Material Team For Decontamination. Ensure all personnel are ade uatelr rot ete _from all routes of exposure prior to treating patients. y. S/S 0 ❑ Patients exposed to organophosphates will present with: Salivation, Lacrimation, Urination, Defecation, GI problems, Emesis (SLUDGE). CL ❑ Poison Control Center-1-800-282-3171 0 ID BASIC LffE SUPPORT T � ❑ BLS standard requirements. ❑ Protect patient's airway and monitor for vomiting. ❑ Set up EKG. ❑ Set up IV. ADVANCED LIFE SUPPORT • ALS standard requirements. • Atropine Sulphate 1 mg every 3-5 mins until atropinization occurs (reversal of symptoms). 40 Packet Pg.602 C.13.a PHYSICIAN CONSULT ❑ N/A CD r- 0 44 Ms PEDIATRIC L. ❑ Atropine 0.02mg/kg every 3-5 minutes until atropinization occurs. Minimum dose .1 mg L) CL i c 41 Packet Pg.603 C.13.a N Patients who have pain that is related to an isolated fracture, dislocation, musco-skeletal injury or 0 burn may receive pain medication for their injury providing they have a normal mental status. BASK LIFE SUPPORT 0 ❑ BLS standard requirements ❑ Splint affected area. y ❑ Set up IV. ❑ Set up EKG ADVANCED IFE SUPPORT i • ALS standard requirements. 2 • Nitrous oxide self administered by patient. • Morphine Sulfate 5mg IVP. May repeat once. (systolic >100mm/hg) PHYSICIAN CONSlwA:r ❑ Additional pain control. PEDIATRIC 42 Packet Pg.604 C.13.a ❑ ALS standard requirements. ❑ Request orders for pain control. N -- N 0 0. CAUTION ❑ When administering pain medications patient must be on EKG monitor, and pulse oximetry. ❑ Monitor patient's blood pressure and respirations prior to and after administering M.S. c 0 .®. U CL �t ❑ Nitrous oxide should not be administered to patients < 16 years old or> 70 years old. y ❑ Do not administer pain medications to patients with altered LOC, head injuries, multi-system trauma or abdominal pain. ❑ Do not administer Nitrous oxide to patients with a possible pneumothorax. i c 43 Packet Pg.605 C.13.a cv cv This includes respiratory distress: i.e. tachypnea, diaphoresis, use of accessory muscles, wheezing, 00. diminished breath sounds, etc. as seen in asthma, COPD, emphyseuna and RAD BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Set up EKG. CL ❑ Set up IV. ADVANCED LIFE SUPPORT • ALS standard requirements. • 100-cc/hr infusion of NaCl. (asthma) • Albuterol (proventil) for bronchospasm: -2.5 mg via nebulizer. May repeat after 15-20 minutes. W C i • Epinephrine 1:1000 0.3cc SQ if not contraindicated (if < 40 y/o with no hx of CAD). • Methylprednisolone (solumedrol) 125mg IVP. • If patient has bilateral rales and is normotensive or hypertensive refer to CHF guidelines. • If patient is hypotensive refer to Cardiogenic Shock Guidelines. • Intubate if no improvement and patient is in marked respiratory distress. Refer to Sedation Guideline if necessary. 4r E PHYSICIAN C NSULtl ii Additional breathing treatments. Ei Epinephrine SQ whenabove parameters are not met. ❑ Physician orders should e obtained for Epinephrine if: Pules rate is greater than 140 or systolic BP is greater than 200 mm/hg. e l re nisolone (s I edrol) 125mg IVP for COPD 44 Packet Pg.606 r. C.13.a PEDIATRIC N CD ❑ Albuterol (proventil):> 2 years old- 2.5 mg via neb. 0 0. < 2 years old— 1.25 mg (1.5 ccs) in 1.5 cc NaCl via neb. ❑ EPI 1:1000 0.01 mg/kg up to 0.3 mg SQ ❑ Bolus of 2cc/kg NaCl (asthma) ❑ Methylprednisolone (solumedrol) 2mg/kg c ❑ If patient appears to have croup or epiglottitis do not stress patient and transport in the position of comfort with blow- by oxygen if tolerated. U CL i CAUTONU ❑ Care must be taken to rule out wheezes that are secondary to CHF or Pulmonary edema (cardiac asthma). If in doubt request orders prior to administration of epinephrine. ❑ Use caution when administering high flow oxygen to patients with COPD; however, never withhold oxygen to patients with severe shortness of breath. ❑ Do not sedate asthmatics unless necessary to facilitate intubation. r r , •® ,,t 1 , 1 ,.,.r7 , t :.. ,.,,_. r ,r... , r, , { tt _.t , �)) .r„I. \ .� 1 r:,,).,. _., i`..45 Packet Pg.607 C.13.a N CD r- 0 0. 0 tJ CL tJ tJ 0 U I 46 Packet Pg.608 C.13.a PEDIATRIC UPPER AIRWAY OBSTRUCTION cv ` d CV ❑ If the patient presents with stridor, tripod positioning &drooling as well as the typical signs and symptoms of respiratory distress patient may have Croup or Epiglotitis, or a foreign body in the upper airway. 0 4 aft, z 17 BASIC LFE SUPPORT 0 ❑ Administer blow by oxygen if tolerated and transport with caregiver or parent if possible ❑ Do not touch or stress patient. ❑ Expedite transport. W i c 47 Packet Pg.609 C.13.a cV cv BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Set up EKG. c ❑ Set up IV. 0 U CL ADVANCED LWE SUPPORT 0 • ALS standard requirements. • For Combative patients: • Ativan 2mg slow IVP. May repeat once to a total of 4mg (B/P > 100 mmhg systolic) i Or • Valium 5mg slow IVP. (B/P > 100mm/hg systolic). May repeat once for a total of 10mg. • For Cardioversion/ Pacing_or Airway Management: • Etomidate 0.3mg/kg IVP over 15-30 secs or<1501bs=20mg, >150lbs= 40mg. • Ativan for continued sedation 2mg IVP. May repeat once for a total of 4mg. (B/P > 100mmhg systolic). PHYSICIAN CONSULT 0 ❑ Additional medication 48 Packet Pg.610 C.13.a APEDIATRIC cv CD cv r- 0 ❑ Ativan 0.1 mg/kg slow IVP to a max single dose of 2 mg. For blood pressures consult Broslow y Tape. c c CAUTION CL ❑Ativan, Valium and Etomidate may cause respiratory depression or respiratory arrest. If airway management is unsuccessful administer Romazicon to reverse the effects of Ativan. y ❑Use caution when using Etomidate in a patient with severe hypotension. ME OR ❑N/A i c 49 Packet Pg.611 C.13.a cv CD cv n r- 0 0. BASIC LIFE SUPPORT c standard requirements. • t up EKG. c Set up IV. CL o Protect r injury. ADVANCED LIFE SUPPORT • ALS standard requirements. • Valium 5mg slow IVP, may repeat once to a max.of 10mg. (B/P > 100mm/hg systolic). OR Ativan 2mg slow IVP. May repeat once to a max of 4mg. BP must be> 100mm/hg. • Blood glucose level (refer to DIABETIC EMERGENCIES GUIDELINE). 4r PHYS,C,AN CONSULT ❑ Additional Ativan or Valium to control seizures. PEDIATRIC ❑ ALS standard requirements. E ❑ Non-febrile seizures: Valium 0.2mg/kg slow IVP or 0.5mg/kg rectally. Max single dose of 5mg. 50 Packet Pg.612 C.13.a OR Ativan 0.1 mg/kg slow IVP. Maximumsingle ose of N CD ❑ Febrile seizures Cool Patient by sponging ith tepid water. r- 0 0. Consider valium at the above dose if seizure does not terminate or patient has another seizure without regaining consciousness. 2 Tylenol Syrup 15 mg/kg P.O. if not given in previous 3 hours by parents. O rin syrup /k if patient has received Tyl of syrup . c Li Blood I c s Level (refer to DIABETIC EMERGENCIES GUIDELINE). 0 CL A J�l"lt l J y o Use caution not to over cool a febrilepatient the pointof shivering. For seizures associated 0 with pregnancyrefer to ECLAMPSIA o If seizures are dueo a possiblecyclic antidepressant OD, treat seizures with Sodiumi r . i ❑ None Q c 51 Packet Pg.613 C.13.a SNAKE BITE N CD BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Set up EKG. ❑ Set up IV. 0 ❑ Mark area of initial edema. ❑ Remove any constrictive jewelry or clothing. 0 ADVANCED LIPS SUPPORT PT • ALS standard requirements. i • If patient is having an allergic reaction refer to ALLERGIC REACTION GUIDELINE. • Nitrous Oxide for pain control. • If patient is hypotensive, follow hypotension protocol. c PHYSICIAN CONSULT y ❑ Pain control. Morphine sulfate 3 mg IVP. PEDIATRIC 52 Packet Pg.614 C.13.a ❑ ALS standard requirements. CD ❑ If patient is having an allergic reaction refer to PEDIATRIC ALLERGIC REACTION GUIDELINE. 0. c CAUTION ❑ If a tourniquet is applied prior to arrival, physician consult is indicated prior to removing the tourniquet. CL ❑ The use of ice, tourniquets or constricting bands is contraindicated. i c 53 Packet Pg.615 C.13.a STROKE 1 CV _is r- 0 0. ❑ Signs and symptoms of a stroke are unilateral paralysis and/or paresthesia, visual or speech disturbances, BASIC LIFE. SUPPORT ❑ BLS standard requirements. ❑ Set up EKG. CL ❑ Set up IV. ADVANCED LIFE SUPPORT c • ALS standard requirements • Blood glucose level (refer to DIABETIC EMERGENCIES GUIDELINE) • Perform Stroke Scale and if no exclusionary criteria are met transport as a"Stroke Alert". • Expedite transport. i 4r PHYS0AN CONSULT ❑ Treatment of hypertension c CAUTION o If patient is hypertensive (>200 systolic and/or 110 diastolic) call for orders prior to treating the blood pressure. rj If patient does not appear to have difficulty breathing use low flow oxygen via cannula. Do not withhold high flow oxygen if patient is SOB. 54 Packet Pg.616 C.13.a u Rule out head trauma. Rule out Stroke Alert Exclusion Criteria: 1) Stroke > 3hrs old. 2) Prior stroke or serious head injury within the past 3 months. 3) Major surgery within the past 14 days. 4) Seizure prior to CD N the onset of stroke symptoms. 5) Known history of intracranial hemorrhage. 6) Gastrointestinal or urinary tract hemorrhage within the past 21 days. y No mo T � m .2 M o Do not administer aspirin. U CL 0 i c 55 Packet Pg.617 C.13.a PREHOSPITAL STROKE SCALE cv CD Facial Dr000 N r- 0 0. Have patient smile or show teeth Normal- Both sides of face move equally. Abnormal- One side of the face does not move as well as the other side. Arm Drift c Patient closes eye and holds out Normal- Both arms move the same or not at all. arms for a 10 second period Abnormal- One arm drifts when compared to the - other. CL Speech Have the patient say"you can't teach Normal- Patient uses correct words with no an old dog new tricks" slurring. c Abnormal- Words slur, inappropriate or no speech. i c 56 Packet Pg.618 C.13.a cv CD cv IS ❑ Patients that have overdosed on Cyclic Antidepressants (formerly TCA's) may present with: CNS depression, tachycardia, dilated pupils, respiratory depression, slurred speech, twitching, jerking, seizures, AV blocks, lethal arrhytmias, hot as hell (Elevated skin temperature) red as a beet (Flushed Skin) 0 dry as a bone (Dry skin and mucous membranes) CL blind as a bat (Visual disturbances) y mad as a hatter (Hallucinations and altered LOC) 4- 0 ❑Common TCA's are: asendin (amoxapine), elavil (amitriptyline), norpramin (desipramine), pamelor (nortriptyline), sinequan (doxepin), tofranil (imipramine), triavil (amitriptyline with perphenazine).J-7 4 W �i BASIC LIFE SUPPORT ❑ BLS standard requirements. ❑ Scene survey to identify cause of overdose. ❑ Protect patient's airway and monitor for vomiting. ❑ Set up EKG. ❑ Set up IV. ADVANCED LIFE SUPPORT • ALS standard requirements. 57 Packet Pg.619 C.13.a • Blood glucose level (refer to DIABETIC EMERGENCIES GUIDELINE). • Sodium Bicarbonate 1 amp every 5 minutes until symptoms resolve or 3 amps are given. N N 0 0. HY.SICIAN CONSULTr ❑ Additional Sodium Bicarbonate c 0 PEDIATRIC ❑ Sodium Bicarbonate 1 meq/kg 0 ❑ A ministration ot procainami e, magnesium sulfate an calcium ch on a is..... i contraindicated in tricyclic antidepressant overdose. c 58 Packet Pg.620 C.13.a G N CD 4 1J \ UMA, 0 0. . ..... 0 I �° �i 1 �f r l �'ll L + S 0 PROTOCOLS CL tJ 0 tJ tJ 0 U I 59 Packet Pg.621 C.13.a _...MULTIPLE......, .. . .. w.�._ , .......... .. Objective: To provide an initial organized approach to the victim of multiple trauma at a referring emergency facility. To prepare for transport to tertiary care facility. 0. 1. Airway maintenance and C-spine control. Assess and secure a patent airway by utilizing suctioning, oral or nasal pharyngeal airway, nasal or oral tracheal intubation, assuring protection of cervical spine. Z 0 U CL 2. Breathing Control. Assess respiratory status. Administer high flow oxygen. If assessment confirms tension pneumothorax, treat with needle thoracotomy. 3. Circulation a. Assess circulatory status. Establish 2 large bore IV's of normal saline or Lactated Ringers with trauma tubing. Peripheral IV's are preferable;however, intraosseous lines may be required in pediatric patients. CD b. Apply M.A.S.T. for pelvic, or lower extremity fractures. C. Control external bleeding with pressure. d. Do not delay transport of critical patients to establish IV's if transport time is short. a Necro E 60 Packet Pg.622 C.13.a Transport suspected spinal cord injuries with full spinal immobilization, regardless of x- ray results at referring institution. Consider the mechanism of injury as well as any complaints of neck pain. When in doubt, immobilize. 0. 5. Transport takes priority over secondary survey. c 0 L) CL i c 61 Packet Pg.623 C.13.a N CD The team should institute all measures deemed necessary for maintaining an adequate airway in the patient. CN Assess airway and ventilation utilizing C-spine precautions. 0. 1. All trauma patients should receive supplemental oxygen. c 2. Always suspect hypoxemia in the agitated or combative patient, treating with high flow oxygen and considering intubation. U CL 3. Any patient demonstrating evidence of glottic obstruction, except children suspected of having y epiglottitis, should have the airway examined for foreign body. If respiratory difficulty persists, the airway should be secured by intubation. 4. Hyperventilation of the unconscious trauma victim should be accomplished by tracheal intubation when appropriate. i 5. Intubation should be considered on patients with massive facial and/or neck injuries prior to 2 transport. 6. Any multiple trauma patient demonstrating cyanosis or respiratory distress should have an airway by tracheal intubation prior to transport. Re-assessment of underlying conditions should subsequently ensue. c 62 Packet Pg.624 C.13.a HEAD,rRAUMA CD Objective: Rapid assessment of the patient with a head injury, stabilzation and rapid transportation. N r- 0 0. Observation and institution of appropriate therapy: 1. Assure adequate airway oxygenation. Do not hyperventilate. 0 2. Complete spinal immobilization. U CL 3. Control obvious hemorrhage. y 0 4. Get a careful history including mechanism of injury and initial level of consciousness. 5. Note any disruptions in skin integrity of the head, neck and face. Allow drainage of blood or CSF 2 from nose or ear to flow freely. Do not attempt insertion of nasal gastric tube with presence of facial fractures. Consider oral intubation to establish an airway. Consider oral gastric tube, if this will not delay transport. 6. Consider elevating the head of bed 30 degrees, continuing to maintain spinal immobilization. 7. The head injured patient with deteriorating level of consciousness whose vital signs are stable,may be on a mannitol drip. 0 8. Closely observe for changes in level of consciousness and hypotension. 9. Observe for seizure activity. See seizure protocol. 10. Check blood glucose and administer 1350 if <60 mg/dl. Consider Narcan 2.0 mg IV push in all 63 Packet Pg.625 C.13.a unconscious patients. Pediatric dose 1 cc/kg D50 diluted 1/2 with normal saline or 2 cc/kg D25. 0.02 mg/kg Narcan IV, IM or SO. N N 0 0. CL c 0 i c 64 Packet Pg.626 C44 CD Assure that spinal injuries are evaluated, immobilized and not aggravated by transport. N r_ 0 0. 1. Immobilize any suspected spinal injury with full spinal immobilization. 2. Document the status of spinal cord function before transport in the alert patient, i.e., voluntary movement of all extremities. of sensory level in patient with spinal cord dysfunction. Z 0 U_ Z U 3. Do not delay transport for x-rays® Any unconscious patient, patient with altered sensorium or any CL 0 patient with a neurological deficit has an unstable C-Spine no matter what the x-rays say. 4. Consider naso or orogastric tube for prevention of aspiration. 0 .2 E 65 Packet Pg. 627 C.13.a CHEST T CD Remember the ABC's and observe for paradoxical chest movement, chest symmetry, open gurgling wounds, cN dyspnea, creptius, tracheal deviation, neck vein distention, decreased or absent breath sounds. 0. 1. Pneumothorax c a. Signs and symptoms - respiratory distress, decreased or absent breath sounds, asymmetrical chest wall movements. Check chest x-ray if available; feel for rib fractures on affected side. U CL b. Treatment-High FiO2. When necessary(tension pneumothorax)needle thoracotomy in 2nd, 1CS, MCL. y 0 2. Tension Pneumothorax a. Signs and Symptoms - Deviated trachea to unaffected side. Severe respiratory distress, distended neck veins, cyanosis, hypotension. i b. Treatment- Remove occlusive dressing from sucking chest wound if present. Needle ., thoracotomy.. Oxygen. CD 3. Sucking Chest Wound 0 a. Signs and Symptoms - Penetrating chest injury, gurgling or sucking sounds at chest wall, respiratory distress. b. Treatment-Tape 4" x 4"vaseline gauze on 3 sides of affected area creating flutter valve. Observe for signs and symptoms of tension pneumothorax. High Fi02. 4. Flail Chest 66 Packet Pg.628 C.13.a a. Signs and Symptoms - Pardoxical chest movement, splinting, movement of flail segment, crepitus, respiratory distress. N 0 0. b. Treatment- Support respiratory function; may require intubation. 5. Massive Hemothorax c a. Signs and Symptoms - Absent breath sounds, dullness to percussion, hypoxia, severe respiratory distress, chest x-ray shows white-out of lung field. CL b. Treatment- Do not drain hemothorax(prior to transport)unless respiratory compromise occurs. !V fluids, including blood transfusion. High F102. 0 6. Cardiac_Tamoonade a. Signs and Symptoms - Distended neck veins, hypotension, muffled heart sounds, pulsus paradoxicus, penetrating chest wound. b. Treatment- High flow R02, high flow IV, and prompt pericardiocentesis at the hospital. Obtain medical control if possible. 0 7. Myocardial Contusion a. Signs and Symptoms - Chest pain, history of blunt chest trauma, rib or sternal fracture, and cardiac dysrhythmia. 67 Packet Pg.629 C.13.a b. Treatment- High Fi02, monitor cardiac function. Lidocaine for PVC's, bolus 1 mg/kg followed by Lidocaine drip 2 mg/min. N N 8. Rib Fracture 0. a. Signs and Symptoms - Localized pain, splinting, guarding, subcutaneous emphysema, decreased breath sounds on affected side, rib deformity, crepitus. L. b. Treatment- High R02i observe for pneumothorax, morphine lV if pain causing respiratory compromise. L) CL i 0 68 Packet Pg.630 C.13.a ARD-O. -M-111NAL TRAUMA. cv CD 1. Blunt Trauma- Suspect with appropriate history or mechanism of injury; presence of ecchymosis, cN hematuria, hypotension, decreased or absent bowel sounds, guarding or rebound tenderness. . a. High Fi02. c b. Large bore IV's of Normal Saline in blood tubing. 0 L) C. Nasogastric tube. CL d. M.A.S.T. pants may be used. 0 e. Pelvic fractures may result in significant blood loss. 2. Penetrating Trauma i a. Stabilize, leave foreign body in place for transport. b. For evisceration - cover with sterile saline soaked dressing; cover wound with sterile dressing. C. High flow oxygen. d. Establish large bore IV's with blood tubing and Normal Saline. 69 Packet Pg.631 C.13.a ORTHOPEDIC INJURIES I Objective is to restore circulation, prevent further damage and alleviate pain in the affected limb. 0 0. 1„ Assure airway, breathing, circulation. 2. Control hemorrhage with direct pressure. 0 3. Evaluate the circulatory and neurological status distal to the site before and after splinting. CL 4. Consider M.A.S.T. suit for control of hemorrhage and splinting of affected extremity. y 0 5. If a limb is cyanotic and/or pulseless, attempt to restore circulation by reducing fracture. 6. If limb deformity inhibits transportation, reduce fracture. i 7. Continue to monitor circulatory status during transport. - 8. Apply traction to femur fractures. 9. Consider pain control with morphine sulfate, 2 mg IV;increments up to 10 mg, in isolated orthopedic injury. 70 Packet Pg.632 C.13.a cv Objective is to preserve limbs for possible reimplantation and prevent further damage to limb. 0 1. Assure ABC's with special consideration to controlling hemorrhage and treatment of hypovolemia. 2. Direct pressure with sterile dressing to control bleeding. Consider pressure dressing and elevation of limb if appropriate. 0 3. M.A.S.T. trousers may be used in lower extremity amputation. CL 4. For partial amputation, leave tissue intact. Apply moist sterile dressing. 0 5. For complete amputations, apply sterile dressing, control hemorrhage. 6. Pain control - morphine sulfate IV in 2 mg increments. Titrate to vital signs and pain. Pediatric dose- 0.2 mg/kg. 7. Care of amputated part: CD a. Attempt to recover severed part. W 0 b. Rinse part with normal saline. C. Wrap part in sterile gauze moistened with normal saline. d. Place in sterile towel moistened with normal saline. 71 Packet Pg.633 C.13.a e. �'Place in plastic bag. N f. Place in cool container with ice. c g. Never allow direct contact of tissue with ice. c 0 U CL 0 i c 72 Packet Pg.634 C.13.a FC cv CD 1. ABC's 0 0. 2. Thorough assessment of respiratory status in patients with facial, chest, neck burns. Early prophylactic intubation for severe burns of face and/or neck is indicated. c a. Singed nasal hair or eyebrows. 0 U CL b. History of confinement in burning environment. C. Carbon deposits in oropharynx. 0 d. Facial and neck edema- such injuries may require immediate airway support by intubation or cricothyrotomy. 3. Quickly estimate percent of body surface area burned using rule of 9's (2nd and 3rd degree only). 4. Establish 2 large bore IV's with normal saline in unburned tissue when possible. If such a site is not available, used burned tissue or central vein. 5. Normal saline 2-4 cc/kg x% of body surface burn with /2nd degree or worse, 1/2 of this amount should be given in first 8 hours, or sufficient fluid to maintain blood pressure greater than 90 mmHg systolic in adult, or urine output > 30 cc/hour. 6. Insert NG tube and foley if doing so does not delay transport. . Patients withs it tory compromise ihave bilateral midaxillary .. escharotornies done by attending physician prior to trans 73 Packet Pg.635 C.13.a 8. Morphine sulfate IV in 2 mg increments up to 15 mg. Monitor vital signs closely. Pediatric dose = 0.2 mg/kg. N N 9. Chemical burns should be copiously irrigated with water or sterile saline if possible. Prolonged . irrigation at site may be referable to transport if patient is stable. 10. Electrical burns - monitor closely for life threatening dysrhythmias. Suspect spinal injury secondary to _ tetanic muscle contractions, and use standard spinal immobilization. Check for entrance and exit wounds. 0 L) CL i c 74 Packet Pg.636 C.13.a PE-'1 1_ CONSIDERATIONS IN PEQ1 T I T'RAQM cv 1. The general principles of primary assessment and treatment for the pediatric patient are basically the cN same as for adults. Fluid resuscitation and normal vital signs for age are discussed in Section VI 0. Pediatric/Infant Assessment and Resuscitation. 2. Airway Guidelines c a. ET-tube insertion size-take age plus 16 divided by 4. May also estimate by size of fifth finger. U CL b. Use uncuffed tubes to age 8 years. y 0 C. Do not use nasal intubation in children under 8 years. 3. Circulation i a. Standard fluid challenge is 20 cc.kg of normal saline. Repeat if necessary. b. Altered mental status, pallor or respiratory distress may be the first sign of shock in children. C. Central IV access is relatively contraindicated in children. 0 d. Next to peripheral IV's, cut downs and intraosseous infusions are the IV avenues of choice. 75 Packet Pg.637 C.13.a cv CD cv r- 0 0. CU CU 0) c CU 0 L) CL Florida Medl Van CD Ambulance 76 Packet Pg.638 C.13.a cv CD cv r- 0 0. CU CU 0) c CU 0 L) CL Procedural Guidelines CD c CU 77 Packet Pg.639 C.13.a BROSELOW PEDIATRIC RESUSCITATION TAPE N N The Broselow Pediatric Resuscitation Tape should be used on all pediatric emergencies for accurate treatment. 0. Indications: — c All pediatric patients c U CL Contraindications: 0 NA Equipment: i Broselow Pediatric tape- located in outer and inner compartments of Broselow bag. d Procedure: 0 0. ® Place the Broselow tape, with muti-colored side facing up, on top of the supine child with the red tip at the head. °® Measure from the top of the head to the soles of the feet.Whichever color zone the bottom of the child's feet aligns with will provide the appropriate size and type of airway equipment to be utilized. If a patient's length falls at the extremes (upper or lower) of a respective color, consider the next highest color category and follow the clinical guidelines. Immediately next to the color zones are the weight, which provide the proper drug dosages for seizure, increased intracranial pressure, overdose, and cardiac resuscitation within a respective weight class. As with 0 the color/airway zones, consult the weight/dosage zone that aligns with the bottom of the patient's feet. 78 Packet Pg.640 C.13.a ♦ On the opposite side of the tape are weight zones which, when measured against the supine child in the above described manner, provide the appropriate calculations for infusions, fluid volume expansion, paralytics, defasiculating agents and induction agents. N 0 0. BURETTE ADMINISTRATION SET The Burrete administration set is used in when a medication needs to be mixed in less than 150 cc's of fluid or on any pediatric patient that requires IV therapy and falls within the parameters of the Broselow tape (medical or trauma related). The burette is distinguished from other administration sets by the 150 cc chamber located within the tubing. U CL Indications: v, The burrette should be used when dealing with pediatric patients and when fluid or medication administration is 4- crucial. The chamber can be filled with the exact required amount of fluid/medication to prevent overdosing or c bolusing with too much fluid. NOTE: The burette also comes in packaging for use with the IV infusion pumps. Follow set up guide for infusion 2 pump sets when using the burrete for the IV pump. Equipment: (1) Burrette solution set, desired amount and type of fluid, medication as needed. Procedure: ♦ Choose appropriate fluid. c ♦ Close the upper roller clamp on the tubing and spike the IV bag. ♦ Open the upper roller clamp and fill the burette to the desired level. Close the upper roller clamp. ♦ If applicable add medication to the chamber and gently invert to mix the drug with the fluid. ♦ Squeeze the drip chamber and fill to 1/3 full. ♦ Open the lower roller clamp and allow the solution to fill the entire set. ♦ Connect the solution set to the IV and set to the desired rate. 79 Packet Pg.641 C.13.a cv CERVICAL IMMOBILIZATION DEVICEA_C.LD. 0 Indications: Used in conjunction with a rigid cervical collar to secure a patient's head to a long spine board or similar device, when a neck injury is suspected. 0 Equipment: An approved cervical immobilization device. 0 Procedure: NOTE:Apply the CID per the manufacturer's recommendations. a i ♦ Apply a rigid cervical collar per guidelines. ♦ Transfer the patient to a backboard using accepted technique. ♦ Attach patient to the LSB using approved method. ♦ Position approved device under patient's head and affix to board. ♦ Maintain neutral alignment of the head and neck and use straps provided to secure patient to the device. ♦ Clean or dispose of the devices per department policy. CRICOTHYROTO Y 80 Packet Pg.642 C.13.a Needle and surgical (scalpel) cricothyroidotomy are emergency airway procedures that involve puncturing the cricoid membrane with a needle or a scalpel in an effort to provide an emergency airway. 0 0. Indications: Needle and surgical (scalpel) cricothyroidotomy may be performed if more conventional techniques of controlling the airway are either unsuccessful or unobtainable as a result of edema, severe oropharyngeal hemorrhage, c severe facial trauma, anaphylaxis, inhalation injury, or other severe airway complication. Both procedures are temporary stabilizing techniques and are relatively easy to perform. U CL Contraindications: Surgical cricothyroidotomy is not to be performed on pediatric patients due to the size of their anatomy and the likely hood of penetrating the esophagus, other than this there are no contraindications in emergency setting, however, certain complications can arise. These are: ♦ Hemorrhage at the insertion site. ♦ Subcutaneous emphysema may occur. ♦ Aspiration of blood into the lungs. i ♦ Perforation of the thyroid or esophagus. Equipment: c For needle cricothyroidotomy: (2) Povidone-Iodine swabs, (1) 14g over the needle IV catheter for adults or 14g catheter for pediatric patients, (1) 10 cc syringe, (1) 15 mm adapter from 3.0 ett, (1) BVM. For Surgical cricothyrotomy: (2) Povidone-Iodine swabs, (1) Scalpel, (1) shortened 6.0 ett; (1) roll of tape, (1) SV Procedure: 81 Packet Pg.643 C.13.a Both procedures involve puncture of the cricothyroid membrane. To find the landmark palpate the patient's neck T starting at the top. The first prominence felt is the thyroid cartilage,while the second is the cricoid cartilage. The `D space between the two, noted by a small depression is the cricothyroid membrane (see fig 1). 0 0. r- a Thyroid cartilage - —^ Thyroid gland Cricoid cartilage Crkrothyroid L- membrane o U CL Fig.1 Location of the cricothyroid membrane cn CJ 0 Needle Cricothyrotomy ♦ Ensure the pt. is supine (ensure cervical spine immobilization if trauma is suspected). ♦ Stabilize the larynx with one hand, and locate the cricothyroid membrane with the other. ♦ Cleanse the site using betadine. a ♦ Attach a 10cc syringe to the back of a 14g catheter and insert the needle through the membrane at a 45-60 degree angle towards the pts. feet. Apply negative pressure to the syringe during insertion. The entrance of air into the syringe indicates passage into the trachea. ♦ Advance the catheter over the needle and remove the needle and the syringe. ♦ Secure the hub using tape taking care not to kink the catheter. ♦ Attach the 15mm adapter into the hub of the IV catheter. Attach the BVM and ventilate the patient. The ventilations will be much slower than normal ventilations due to the size of the catheter. For pediatric patients use the same procedure using a 14g catheter. a NOTE: This procedure does not protect the airway and does not allow for the elimination of carbon dioxide. Surgical (scalpel) Cricothyrotomy 82 Packet Pg.644 C.13.a ♦ Hyperextend the neck unless spinal injury is suspected. N ♦ Locate the cricothyroid membrane. Cleanse the site using betadine. 0 0. ♦ Make a vertical incision with a scalpel at the level of the membrane. ♦ Open the incision by inserting the handle of the scalpel into the incision and rotating it 90 degrees to allow for placement of a 6.0 ET tube. Inflate the cuff and secure the tube. ♦ Provide ventilation by a bag valve mask with the highest available oxygen concentration. c ♦ Observe for correct placement by way of auscultation and chest rise. E 0 U 0. 0 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) i CPAP is a non-invasive therapy that is used to manage and treat pulmonary edema that is secondary to Congestive Heart Failure or salt-water drowning. When used correctly, and in conjunction with other therapy, it is estimated that 50—90%of these patients can avoid endotracheal intubation. Most patients start to receive some benefit from CPAP after 5 minutes. During pulmonary edema, surfactant is washed out of the alveoli causing stiff air sacs that do not open fully under normal pressure. By using CPAP a positive inspiratory and expiratory pressure is created, below which the pressures in the patients' airways are not allowed to drop. This keeps smaller, dependent airways open at the end of expiration allowing for more 02 exchange to take place and fluid to be pushed out of the lungs. 2 Indications: Pulmonary edema secondary to congestive heart failure and salt water drowning. Patients can present with any or all of the following: rales, tachypnea, tachycardia, diaphoresis, hypertension,verbal impairment and decreased pulse oximetry. Contraindications: ♦ Respiratory arrest or impending respiratory arrest. 83 Packet Pg.645 C.13.a ♦ Severe facial trauma. ♦ Need for immediate intubation (unable to maintain own airway). cv ♦ Severe cardiorespiratory instability and impending arrest. ♦ Compromise of thoracic organs. (Pneumothorax, Pneumomediastinum etc). y Equipment: (1) CPAP flow generator. (1) mask and tubing kit. Procedure: 0 ♦ Connect flow generator to portable 02 regulator or to flowmeter(set at 151pm) if using it in the Rescue. o ♦ Connect white corrugated tubing to bottom port of flow generator labeled `outflow to patient". CL U ♦ Attach the bacteria filter to the"air entrainer"port located on the black flow generator. This also serves as a muffler. ♦ The flow generator is preset to the desired pressure and DOES NOT need to be set. ♦ Turn on the 02 bottle or if in the truck connect to the flow meter and set at 15 Ipm. o ♦ Hold the mask against the patients'face instructing them to inhale through the nose and out through the mouth. ♦ Secure the mask using the head strap. The white rubber straps come around by the ears and attach to the prongs on the mask. ♦ Adjust the mask to prevent any airleaks. i ♦ Reassess patient for effectiveness of treatment. 2 If no improvement is noted,or the patient's condition worsens,intubation may be needed. ESOPHAGEAL TRACHEAL DOUBLE LUMEN AIRWAY (COMBITUBE) Indications: E The combitube is used as a BLS airway control device or in the event endotracheal intubation is not successful. Some advantages of the combitube are its relative ease of placement and it does not require direct visualization of the vocal cords. Contraindications: Patient is under FIVE feet in height. ®I® Patient is under SIXTEEN years of age. 84 Packet Pg.646 C.13.a Active gag reflex. ❖ Patient has known or suspected esophageal disease. cv • Patient has ingested a caustic substance. 0 Procedure: ❖ Insure all necessary components and equipment are at hand. ❖ Position the patient's head in a neutral position. ❖ Hyperventilate for at least 2 minutes. •'• Lubricate tube for easier insertion. 0 ❖ Lift the tounge and lower jaw. U CL ❖ Insert COMBITUBE with curvature in same direction as natural curvature of pharynx. 44- Insert gently DO NOT FORCE tube. y •'• Stop when BLACK rings on the tube are positioned between the patient's teeth. 0 ❖ If tube does not advance easily,redirect it or withdraw hyperventilate and reinsert. To confirm tube placement. ❖ Inflate pharyngeal cuff through line#1 (BLUE)with 100 ml of air. ❖ Inflate distal cuff through line#2 (WHITE)with 15 ml of air. i ❖ Ventilate through primary(BLUE TUBE)Tube.Placement is confirmed by aus- cultating breath sounds(high axillary&bilaterally)and auscultating over stomach. Esophageal placement: ❖ Breath sounds are present bilaterally with epigastric sounds absent. ❖ Continue to ventilate through primary(BLUE TUBE). Tracheal placement: 0 ❖ Breath sounds absent and epigastric sounds present,ventilate through secondary (CLEAR TUBE)continue to ventilate through secondary tube. EMT ASSISTED MEDICATION ADMINISTRATION 85 Packet Pg.647 C.13.a The EMT may assist patients in taking their prescribed Nitroglycerin, Inhalers or their epi —pen. This procedure will outline the steps that must be taken. CD cv Indications: 0 0. Any patient who needs help taking their prescribed medication for the appropriate problem providing certain parameters are met for each of the medications. Contraindications: See individual medication outlined below. c Equipment: 0 Patient's prescribed medication. U Procedure: CL Respiratory Inhalers: ♦ Initial patient assessment. 0 ♦ Assure inhaler is prescribed for patient and check expiration date. ♦ If patient is short of breath, has wheezes, and has not administered more than one dose in the last hour, a assist the patient in administering inhaler. ♦ Initial patient assessment i ♦ Assure Nitroglycerin is prescribed for patient and check expiration date. ♦ If patient is having chest pain and systolic BP is >120 mmHg, administer Nitroglycerin by either placing tablet or spray under tongue, one dose. ♦ After 5 minutes, if chest pain continues, recheck BP. If systolic BP is d >100 mmHg, repeat dose. 0 0. ♦ After 5 minutes, if chest pain continues, recheck BP. If systolic BP is >100 mmHg, repeat dose. Do not repeat dose after third dose is given. 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 include: dyspnea, hives, flushing of the skin, wheezing, edema, and possible unstable vital signs. ♦ Initial patient assessment 86 Packet Pg.648 C.13.a ♦ Assure auto-injector is prescribed for patient (EPI-Pen®for adult patient and EPI-Pen Jr.®for pediatric patient), check expiration date and cloudiness or discoloration if possible. ♦ If patient is exhibiting signs of moderate to severe allergic reaction as described above, assist patient in administering Epinephrine via auto-injector. 0 0. ♦ Remove auto-injector safety cap. ♦ Select appropriate injection site. ♦ Thigh - lateral portion of thigh, midway between waist and knee. ♦ Shoulder-fleshy portion of upper arm. c ♦ Push auto-injector firmly against site until injector activates. ♦ Hold in place until medication is fully injected (minimum of 10 seconds). CL ♦ Record time. ♦ Dispose of injector in biohazard container. ♦ Reassess patient. i Indications: c End tidal Co2 detectors can be used as one of the methods to confirm ET tube placement. 2 O This device is unable to indicate right mainstem intubation and has been known to produce a"false positive"or"false negative" reading. It is imperative that 87 Packet Pg.649 C.13.a endotracheal tube placement be verified by alternate means. Documentation of verification is important especially in the incidence of a"false" reading. N N 0 0. Equipment: End Tidal Co2 detector. 0 Procedure: U CL ♦ Expiration date should be checked prior to being placed in service. ♦ Plug should not be unsealed longer then 24 hrs. (accuracy compromised) 4- 0 ♦ Verify initial color—should be dark purple. ♦ Attach regulator to bag valve device and attempt to verify plug seal by squeezing bag without plug removal. 2 ♦ Remove plug and squeeze bag again to verify valve will function properly. i ♦ Attach unit, as close as possible, to the expired air output and ventilate pt. ♦ Compare color change on full expiration after the 6th ventilation. -Variations in color range from light pink to bright yellow in the presence of CO 2. (Depending on the percentage of CO 2 detected.) -Fluctuation of color strip during ventilation is normal. -Attempts to read prior to the 6th ventilation can lead to a false positive or negative reading. ♦ If using device in conjunction with an endotracheal tube, verify placement by alternate means. ♦ The device can accurately monitor for up to 2 hours. ♦ Use of CO 2 regulator should be continued while utilizing a ventilator. Regulator should be placed between the endotracheal tube and ventilator tubing to maintain the most accurate reading. 88 Packet Pg.650 C.13.a If the litmus paper becomes wet a new EtCo2 unit must be attached. N N Note: The end tidal Co2 detector is available in adult and pediatric sizes. 0. c 0 L) CL Indications: ♦ Any patients unable to protect and maintain their own airway patency Contraindications: ♦ Patient with gag reflex c Equipment: -BSI equipment -Laryngoscope handle -Appropriate laryngoscope blade -Appropriate size ET tubes 89 Packet Pg.651 C.13.a -Malleable stylet -10cc syringes N Tube holder (Veniguard can be used for pediatric patients) c Lubricant Appropriate size OP airway Magill forceps Suction unit, catheters, and tubing Stethoscope to confirm tube placement 0 U CL Procedure: ♦ Assemble equipment. 4- 0 ♦ Choose proper blade. ♦ Connect to scope handle and check light. ♦ Choose appropriate size ET tube, insert appropriate size stylet ensuring end does not protrude from the distal 2 end of the tube. ♦ Inflate and test cuff, and pilot valve. ♦ Deflate cuff, leaving syringe attached. ♦ Hyperoxygenate the patient. ♦ Place patient in sniffing position if not contraindicated. a, ♦ Hold laryngoscope in left hand. ♦ Insert blade into the mouth, sweeping tongue to the left. ♦ Suction as necessary. y ♦ Visualize vocal cords. ♦ Insert ET tube, maintaining visualization as tube passes cords. ♦ Remove laryngoscope blade. ♦ Inflate cuff with 10cc's of air and remove syringe. ♦ Ventilate patient observing chest rise: auscultate epigastric and lung sounds. 90 Packet Pg.652 C.13.a ♦ Verify placement by two means: direct visualization, esophageal intubation detector, EtCo2 detector, and capnography. ♦ Note depth of tube. cv ♦ Insert OP airway. 0. ♦ Secure tube. 2 ♦ Immobilize patient on LSB with CID. ♦ Recheck ET Tube placement if patient color changes, increased ventilatory resistance, after moving patient, after defibrillation or cardioversion and upon transfer to ER staff. c 0 L) CL ca The pediatric patient is very reliant on oxygen, with hypoxemia the major cause of cardio-pulmonary arrest in this age group. Delivery of oxygen in the highest tolerable concentration is indicated with endotracheal intubation being the most definitive delivery method. Procedure: 2 ♦ The most experienced crewmember should be charged with pediatric airway control and great care should be made to avoid accidental extubation. ♦ Size the tube by any of the following: -Broselow tape -Sizing the patients largest nare -Sizing the patients' pinky finger ♦ Secure ET tube as soon as correct placement is confirmed by ascultation and other verification means. Tape should be applied to maxillary region of face only! ♦ When assessing the child post intubation for complications (Bradycardia, cyanosis, etc.) remember to assess the following causes using the acronym DOPE: -D=Displaced ET tube (right mainstem, esophagus) -O=obstructed ET tube (kinked, secretions, etc.) -P=Pneumothorax (spontaneous, trauma, etc.) 91 Packet Pg.653 C.13.a -E=Equipment failure (02 supply, BVM reservoir, ventilator malfunction, etc.) cv cv AnoWny 0. VEftr x, Tungm a e i anF p. ti d t8 d '6. 0 r i l U Landmarks For Endotracheal Intubation o ESOPHAGEAL TRACHEAL DOUBLE LUMEN AIRWAY CCOMBITUBE Indications: The combitube is used as a BLS airway control device or in the event endotracheal intubation is not successful. Some advantages of the combitube are its relative ease of placement and it does not require direct visualization of the vocal 76 cords. Contraindications: - o ❖ Patient is under FIVE feet in height. ❖ Patient is under SIXTEEN years of age. ❖ Active gag reflex. ❖ Patient has known or suspected esophageal disease. ❖ Patient has ingested a caustic substance. 92 Packet Pg.654 C.13.a Procedure: cv . cv ❖ Insure all necessary components and equipment are at hand. y ❖ Position the patient's head in a neutral position. ❖ Hyperventilate for at least 2 minutes. ❖ Lubricate tube for easier insertion. 0 ❖ Lift the tounge and lower jaw. 0 ❖ Insert COMBITUBE with curvature in same direction as natural curvature of pharynx. U ❖ Insert gently DO NOT FORCE tube. CL ❖ Stop when BLACK rings on the tube are positioned between the patient's teeth. y ❖ If tube does not advance easily,redirect it or withdraw hyperventilate and reinsert. c, 0 To confirm tube placement- Inflate pharyngeal cuff through line#1 (BLUE)with 100 ml of air. ❖ Inflate distal cuff through line#2 (WHITE)with 15 ml of air. ❖ Ventilate through primary(BLUE TUBE)Tube.Placement is confirmed by aus- cultating breath sounds (high axillary&bilaterally)and auscultating over stomach. Esophageal placement: 0 ❖ Breath sounds are present bilaterally with epigastric sounds absent. ❖ Continue to ventilate through primary(BLUE TUBE). Tracheal placement: ❖ Breath sounds absent and epigastric sounds present,ventilate through secondary 93 Packet Pg.655 C.13.a (CLEAR TUBE) continue to ventilate through secondary tube. cv cv 0 c 0 U CL i 0 94 Packet Pg.656 C.13.a GLUCOMETER N The glucometer is used to rule out hypoglycemia in the unconscious patient or patients with altered levels of consciousness, to avoid unnecessary administration of 50%dextrose, which under some circumstances can be detrimental. Use of the glucometer also makes it unnecessary to draw blood samples for hospital analysis prior to giving dextrose. Indications: c A patient's blood sugar should be checked in the following circumstances: 0 U CL 1.Any change from the patient's normal mental status. 2.U nco ncious/u n responsive patients. y 3.Stroke victims. 0 4.Alcoholic patients. 5.Siezure patients. a 6.Patients with known diabetes, if the complaint warrants glucose check. 7.Whenever the Paramedic feels it is necessary to check a glucose level. i NOTE: The blood sample for the test should be obtained from a finger stick (capillary blood) and not from a IV catheter as venous blood can register up to 7% higher due to increased oxygen saturation. Any time a new box of glucometer strips is used the machine should be coded to match the glucometer to the glucose strips. This is done using the calibration strip supplied in each box. The strip is inserted into the machine and a letter and number will appear, which should correspond to the letter and number on the strip packets. 0 Procedure: y ♦ Insert the lancet into the glucolet pen. ♦ Insert the test strip into the glucometer until you hear a beep. ♦ Cleanse the finger with a alcohol prep and allow a couple of seconds to dry. ♦ Perform a finger stick using the glucolet pen. Dispose of the tip once used. .. ♦ If necessary, gently squeeze the finger to obtain a sufficient blood sample. 95 Packet Pg.657 C.13.a ♦ Touch the tip of the strip to the blood. The blood will automatically be drawn into the test strip. Once the meter beeps remove the strip from the blood. ♦ The blood glucose level will be shown after 30 secs. N ♦ Once the bgl is obtained remove the strip and record the reading. 0. NOTE: A reading of"lo" indicates a blood glucose level less than 40mg/dl. A reading of "hi" indicates a level above 600mg/dl. 0 U CL Intraosseous infusion is the introduction of a large bore (usually a 14 or 16g) needle into the intramedullary space U of a long bone, usually the tibia. It is a safe, easy and effective way of treating critical pediatric patients where venous access via peripheral routes is unavailable within 3 attempts or 90 seconds. Medication and fluid administration via the 10 route is just as quick and effective as that given via peripheral veins and has few complications. i Indications: -Multi system trauma with associated shock and or severe hypovolemia. -Unresponsive and in need of immediate drug or fluid resuscitation due to: -Burns -Cardiac arrest -Anaphylaxis 2 -Near-drowning -Status asthmaticus -Severe dehydration associated with vascular collapse and or loss of consciousness 96 Packet Pg.658 C.13.a Contraindications: ♦ Fracture or crush injury to the same extremity. N ♦ Gross infection at the intended site of puncture. 0 0. ♦ Responsive patient(unless cardiac arrest is imminent). Equipment: (1) 10 needle, (1) 3 way stopcock, (4) Povidone-Iodine swabs, appropriate IV solution, and materials to stabilize the cannula once it is in place. 0 There are two sites available for intraosseous infusion in the tibia. Children under six years old, use the proximal CL tibia, which is located two finger widths below the tibia tuberosity on the anterior medial aspect of the leg. Children over seven years of age, use the flat portion of the lower tibia approximately 2cm above the medial malleolus (see diagrams below) this is due to the thickness of the proximal tibia compared to that of the distal tibia in that age group. 0 Proximal Tibia Distal Tibia c Procedure: ♦ Choose appropriate site and cleanse with betadine. Document sterile procedure on run report, due to rare but serious side affect of osteomyelitis (bone infection). 97 Packet Pg.659 C.13.a ♦ Insert the intraosseous needle, directed slightly inferior(to avoid the epiphyses), into the tibia (approximately 2 finger widths below the tibial tuberosity) using a firm pressure and a boring motion. Once you enter the medullary cavity,which is noted by a lack of resistance, the needle will feel firmly fixed in place. CD ♦ Remove the stylet and attach a 10cc saline filled syringe to the needle and flush looking for infiltration or excessive resistance. If infiltration around the site is noticed or the fluid will not flow in discontinue the y procedure, remove the needle and apply firm pressure for a minimum of 10 minutes. ♦ Once placement is confirmed flush the needle withl Occ's of saline and attach the fluid administration set to a 3-way stopcock. ♦ Secure the needle as you would an impaled object. ♦ If a fluid bolus is needed it must be given with a syringe or with a pressure infuser due to the increase in z resistance within the bone cavity. - U CL NOTE: No more than one insertion attempt per bone. If the needle becomes obstructed, attempt to clear by flushing with saline, if this is unsuccessful; insert a clean .2 needle of a smaller diameter through the center of the original needle. i Introduction of a catheter into a patient's vein to allow administration of medications or fluids. Indications: Patients requiring the administration of IV medication or IV fluid. 0 Patients who may require the administration of IV medication or IV fluid. y Contraindications: None in the presence of a life threatening condition. qi ment; - Antiseptic swab 98 Packet Pg.660 C.13.a - IV catheters Tourniquet cv Appropriate infusion set or MAP 0 - Intravenous fluid y Securing material,tape or veniguard Procedure: 0 ♦ Explain the procedure to the patient 0 ♦ Assemble the equipment needed: U -Appropriate infusion set CL -Intravenous fluid, checking for expiration date and appropriate solution -Select the catheter to be inserted -Antiseptic swab o -Tourniquet ♦ Apply tourniquet if appropriate ♦ Select a suitable vein ♦ Prepare the venipuncture site: i -Scrub the area with antiseptic swab starting above the vein and wiping vigorously in widening circles. Align the catheter with the bevel up, enter the skin at a 30 to 45 degree angle after entering the skin, and lower the catheter to approximately 15-degree angle to enter the vein. Enter the vein from the side or from the top. A"pop" should be felt upon entering the vein. A bevel down technique may be used in pediatric patients or patients with fragile veins Note blood return in the catheter. 0 Slightly advance the catheter beyond this point to insure placement inside the lumen the vein. Advance the catheter inside vein and withdraw the needle while holding the catheter steady. ♦ If blood is required, it can be drawn from the IV catheter using a 1cc syringe, prior to attaching IV fluid tubing of 99 Packet Pg.661 C.13.a 77-77 Catheter insertion c 0 U CL ♦ Release the tourniquet ♦ Attach the IV tubing, and allow unimpeded flow of the IV solution. The flow should be steady. If the fluid is unsteady in nature,the catheter tip may be against the vein wall; pull back slightly. 0 ♦ Secure IV in place with tape or veniguard. Note: i -Be aware of run away IV flow rates. -If no flow is noted or a hematoma forms at or near the insertion site remove the catheter and attempt the procedure 2 again above that site. 76 0 This is a spinal immobilization device that is used for patients found in a seated position. 2 Indications: — Any person suspected of having back or neck injuries. Patient should be stable and not have any life threatening conditions. Contraindications: 100 Packet Pg.662 C.13.a Life threatening condition exists. Size of the patient. cv Any unresolved failure of the initial assessment, which requires rapid extrication. 0 0. Equipment: Non-permeable vest with rigid vertical strips running the length of the vest. The vest has sewn on color-dyed straps and sewn on lifting straps. The kit also consists of a pad and two head straps. c E Procedure: c ♦ Place head in a neutral position and hold manual immobilization. CL ♦ Assess distal circulation, motor and sensory in all extremities. ♦ Detailed physical exam of the neck region sizes and apply C-collar. ♦ Open and lace KED behind the patient with the smooth side toward the patient. c p p p ♦ Center the KED on the patient. ♦ Pull the leg/thigh straps up and out of their retracted positions,then pull them down and out of the way. ♦ Wrap the chest supports around the patient. ♦ Pull the KED upward to snugly fit the chest supports up into the axilla (armpit). ♦ Connect the middle chest straps. ♦ Connect the bottom chest straps. ♦ Snug up both straps to the patient chest using the push-pull technique. ♦ Place the leg straps in position by crossing them under the legs and attaching them to the opposite buckle. (Option 1: Connect the straps to the same side buckle). 0 ♦ Use the pad as necessary to fill the gap between the patient's head and the KED. ♦ Attach the head and chinstrap. ♦ Buckle the top chest strap and snug. ♦ Check and retighten all straps and make sure KED is firmly under the patient's axilla. c Reassess distal circulation, motor and sensory in all extremities. ♦ Tilt lift or Swivel lift the patient. Then turn them so that they may be lifted out and on to a backboard assuring E knees remain in a flexed position. 101 Packet Pg.663 C.13.a ♦ After placing the patient on the backboard. Loosen the top chest strap and both thigh straps. Patient's legs may be extended on the backboard N N t 0 CL ♦ Secure the patient to the backboard. 0 Indications: i r_ -Any patient of an MVA, fall, or where mechanism of injury suggests possible spinal injury -Any trauma patient who complains of pain in the head, neck, or back -Any trauma patient who may have injury to the spine but whose evaluation is difficult due to altered mental status (i.e. drugs, alcohol, unconsciousness) c Equipment: r Cervical collar, long spine board, cervical immobilization device. Procedure: ♦ Manual C—spine immobilization 102 Packet Pg.664 C.13.a ♦ C—collar applied ♦ Halfback/KED applied (if applicable) N ♦ Position rescuer 1 at the head of patient(maintaining C—spine), rescuer 2 at the 0 0. shoulders, rescuer 3 at the hips; backboard is place alongside the patient ♦ Rescuer 1 commands all movements °- ♦ Log roll placement -rescuer 1 makes a preparatory count to three and the patient is gently log rolled up on the three count; Rescuers 2 and 3 perform the roll while rescuer 1 0 maintains neutral C—spine alignment -the backboard is slid into place by Rescuer 3 (with one hand) or by additional personnel -rescuer 1 makes a preparatory count to three and the patient is gently log rolled y down on the three count; Rescuers 2 and 3 perform the roll while rescuer 1 maintains neutral C—spine alignment ♦ Alternative placement techniques W -standing -sliding i -placement with scoop—type device 2 ♦ Strapping There are four preconnected sets of straps. One set of straps will be fastened in a X configuration across torso. A set of straps will be attached straight across the pelvis and the remaining set fastened straight across the legs. ♦ Apply Cervical Immobilization Device (as per package insert). Release manual C—spine immobilization; patient is ready for transport 0 The following guidelines will assist the paramedic during operations at Mass Casualty Incidents: .. For full details see the PBC Chief's Association MCI guidelines: 103 Packet Pg.665 C.13.a INDICATIONS: c44 CD cv r- 0 0. Level I MCI = 5-10 victims y Level II MCI = 11-20 victims Level III MCI = >20 victims c CONTRAINDICATIONS: 0 CL e( EQUIPMENT 0 MCI Kit i RED - 1st Priority, IMMEDIATE - YELLOW-2"d Priority, DELAYED GREEN -3`d Priority,AMBULATORY BLACK- Deceased, NON SALVAGEABLE BLUE-Contaminated, DECON REQUIRED (requires an additional color to show priority) 0 PROCEDURE: START ALGORITHM 104 Packet Pg.666 C.13.a ♦ Locate and move all the"walking wounded" into one location away from the incident if possible. These patients are initially triaged "AMBULATORY"with a GREEN ribbon. Assign someone to keep the walking wounded together(i.e., EMT, Law Enforcement) and notify Command of their location. cv cv 0 0. ♦ Begin by assessing all non-ambulatory victims where they lay if possible. Each victim should be triaged in 60 seconds or less. 2 c ♦ A. Assess RESPIRATIONS 0 1. If<30 min or> 10 min—go to PERFUSION CL 2. If>30 min or< 10 min—tag RED 3. If victim not breathing, open airway, remove obstructions if seen and assess for 1 and 2 above 4. If victim is still not breathing—tag BLACK c ♦ B. Assess PERFUSION i 1. Can be performed by palpating a radial pulse or assessing capillary refill time 2. If radial pulse is present or cap refill is 2 seconds or less, go to MENTAL STATUS 3. No radial pulse or cap refill >2 seconds = RED Any major external bleeding should be controlled at this time 0 ® C. Assess MENTAL STATUS 105 Packet Pg.667 1. Assess the victim's ability to follow simple commands and their orientation to person, place and time (Oriented X3) 2. If Victim follows command, is Oriented X3—tag YELLOW cv 3. If Victim does not follow commands, is unconscious, or is disoriented—tag RED 0. 0 0 Procedure of administering medication into the subcutaneous tissue. Indications: i Patients requiring subcutaneous medication as dictated by protocol or physician. Contraindications: Patients with known allergy to medication being administered. 0 0. Eauioment: -Antiseptic swab -1 cc syringe with short 25 to 30 gauge needle -Medication 106 Packet Pg.668 C.13.a Procedure: cv ♦ Explain the procedure to the patient 0 ♦ Verify the name and concentration of the medication;inspect the solution for discoloration, cloudiness, or particles; Can check expiration date. ♦ Select the appropriate site ♦ Disinfect the injection site using an antiseptic swab ♦ Verify that the patient has no known allergies to the medication ♦ Insert the needle at a 45-degree angle 0 ♦ Draw back to insure no blood U CL ♦ Administer medication ♦ Reassess patient for any changes or reactions. ♦ Document time, medication and dose 0 Note: Be aware of any untoward effects associated with subcutaneous medications. i Procedure of administering medications via the pulmonary system when IV access cannot be established. Indications: Patients requiring medication as dictated by protocol or physician when IV access is not available. Contraindications: Patients with known allergy to medication being administered. 107 Packet Pg.669 C.13.a Equipment: cv Properly place endotracheal tube cv Medication y Procedure: c ♦ Ensure ET tube is properly placed. ♦ Verify the name and concentration of the medication; inspect the solution for discoloration, cloudiness, or particles; c check expiration date. U CL ♦ Uncap the needle. ♦ Recheck the medication insuring proper dose and concentration. y ♦ Verify that the patient has no known allergies to the medication. 0 ♦ Remove the bag valve mask or ventilator and inject drug down ETT (most drugs given via ETT are given at 2-2.5 time the normal IV dose). a, ♦ Attach the BVM or ventilator and resume assisting ventilations to disperse drug. ._ ♦ Document time, medication and dose. i Note: 2 -Drugs that may be given via the ET tube are: (LEAN) -Lidocaine -Epinephrine 0. -Atropine 2 -Narcan -Do not administer more than 10 cc's of fluid via the ET tube at a time. -Drugs should be diluted to a max of 10cc'c for adults, 5cc's for children and 2cc's for infants. 108 Packet Pg.670 C.13.a cv Procedure of administering medication into the muscle tissue. r- 0 0. Indications: Patients requiring intra-muscular medication as dictated by protocol or physician. c Contraindications: c U CL Patients with known allergy to medication being administered. Eouioment: c Antiseptic swab 3 cc syringe with 20 to 22-gauge needle, 1 to 1 'A inches in length. Medication. i Procedure: ♦ Explain the procedure to the patient ♦ Verify the name and concentration of the medication; inspect the solution for discoloration, cloudiness, or particles; check expiration date. 0 ♦ Select the appropriate site ♦ Disinfect the injection site using an antiseptic swab °® ♦ Verify that the patient has no known allergies to the medication a ♦ Insert the needle at a 90-degree angle ♦ Draw back to insure no blood ♦ Administer medication ♦ Reassess patient for any changes or reactions. � 109 Packet Pg.671 C.13.a ♦ Document time, medication and dose cv cv 0 Note: 0. c -�Q Dermis r � Ca - Muscle v� Be aware of any untoward effects associated with intra-muscular medications. c Intra-muscular Medication Administration i Procedure of administering intravenous medication and intravenous fluid to patient. 0 Indications: y Patients requiring IV medication as dictated by protocol or physician. Contraindications: Patients with known allergy to medication being administered. 110 Packet Pg.672 C.13.a Equipment: cv Antiseptic swab 0 Medication 0. Procedure: c ♦ Explain the procedure to the patient. ♦ Verify the name and concentration of the medication; inspect the solution for discoloration, cloudiness, or particles; c check expiration date. U CL ♦ Disinfect the drug administration port of the IV line using an antiseptic swab. ♦ Uncap the needle. y ♦ Recheck the medication insuring proper dose and concentration. 0 ♦ Verify that the patient has no known allergies to the medication. ♦ Insert the needle in to the administration port;take care not to jam the needle straight through and out the opposite 5 side. ♦ Pinch the tubing above the port to prevent back flow of medication into the IV bag. ♦ Pull back on syringe plunger to ensure IV patency. i ♦ Inject the appropriate medication at desired rate. ♦ Open the IV line clamp to flush any remaining medication from the IV line, reset the clamp to the proper flow rate. 2 ♦ Reassess patient for any changes or reactions. ♦ Document time, medication and dose. d Note: 0 Be aware of run away IV flow rate and any untoward effects associated with intravenous medications. 76 111 Packet Pg.673 C.13.a Procedure of administering medication into the rectal cavity. cv cv Indications: 0. For emergent medication administration when IV access is unobtainable. c Contraindications: c U CL Patients with known allergy to medication being administered. Equipment: Needless syringe. Catheter of a 14g IV catheter. Water-soluble lubricant. i Medication. Procedure: Verify the name and concentration of the medication; inspect the solution for discoloration, cloudiness,or particles; check expiration date. Draw medication into a needless syringe. + Verify that the patient has no known allergies to the medication. Attach the CATHETER ONLYto the syringe and lubricate. Insert the catheter past the anal sphincter. * Inject the medication and remove the syringe. g Reassess patient for any changes or reactions. Document time, medication and dose 112 Packet Pg.674 C.13.a cv CD cv r- 0 0. CU Full size spinal immobilization used for lifting and moving patients. Indications: — c Fullspinal immobilization. Buoyancy otr i nd icaion : CL None Equipment: Single piece reinforced plastic board with nine safety straps. ° Procedure: ♦ Assess distal circulation, motor and sensation ♦ Detailed physical examination of the neck region, size and apply the C-collar ♦ Open the harness system one strap at a time, folding it in half, velcro to velcro ♦ Align the shoulders with the shoulder pins on the miller board ♦ Place the chest straps loosely over the patients chest, excluding the arms ♦ Slide the shoulder straps into the chest straps ♦ Thread the chest straps through the metal pins ♦ Position the shoulder straps based on anatomical considerations and the condition of the chest c ♦ Adjust the chest straps first. Avoid over tightening as to obstruct chest expansion ♦ Adjust the shoulder straps ♦ Adjust the lower straps. Place the victims hands inside the lower torso strap ♦ Adjust the leg straps ♦ Adjust the leg straps ♦ Attach the head harness by: 113 Packet Pg.675 C.13.a a. Hold the head harness by the two outer foam rubber sections b. Hold the velcro fastener out away from the miller board cv c. Rest the center foam rubber section against the top of the patient's head and the bottom edge of the center section against the top surface of the miller board 0. d. Gently press the two outer foam sections against the side of the victim's head and connect the velcro flaps to the under surface of the head rest e. Apply the forehead strap/apply the chin strap as indicated f. Reassess distal circulation, motor and sensation 0 MORGAN THERAPUETIC LENSES Indications: The Morgan Therapeutic Lens is indicated for flushing of the eye to remove contaminates (eg. chemicals). Contraindications: It should not be used for patients with penetrating eye trauma or in cases where foreign material may be imbedded in the eye (eg. Broken glass, sand, etc.). Equipment: i Morgan Lens. Fluid for irrigation. Procedure: ♦ Remove contact lenses. ♦ Instill topical local anesthetic (Tetracaine HCI 0.5% Eye Drops) to the affected eye(s). Lavage with Sodium Chloride and set for high continuous flow. ♦ Have the patient look down, insert edge of the lens under the upper lid. Have the patient look up, retract the lower lid. ♦ Release lower lid over the lens and continue flow. Tape tube and adaptor to patient's forehead to prevent accidental lens removal. Absorb outflow with towels. Removal: 114 Packet Pg.676 C.13.a Have patient look up. Retract lower lid behind interior border of the lens. Hold position. Have patient look down, retract upper lid and slide lens out. N N c ° c 0 NASOTRACHEALINTUBATION Nasotracheal intubation is the insertion of an endotracheal tube through the nostril of the nose and into the trachea. This procedure is generally better tolerated by the conscious patient than orotracheal intubation. The c patient must have spontaneous respirations for nasotracheal intubation to be successful. Indication: Any patient who is need of intubation, that cannot maintain their own airway and who has spontaneous respirations. Contraindications: ❖ Apnea. ❖ Airway obstruction. ❖ Severe head injury or possible basilar skull fracture. ❖ Bleeding disorders or patients taking blood thinning medications. Equipment: c 6.Omm Endotrol tracheal tube. Nasal spray Syringe of Lidocaine jelly 1 Occ syringe BAAM airflow monitoring device, Procedure: Note: No stylet is used during this procedure. 115 Packet Pg.677 C.13.a ❖ Open kit and generously lube the distal end of the ET tube with Lidocaine jelly. Attach the BAAM to the 15mm adapter of the ET tube. cv ❖ Spray the nasal spray in the patients nostril, this will help to constrict the vessels within the nose and 0. minimize bleeding. ❖ Lubricate the patient's nostril with Lidocaine jelly. Place the patient's head in the neutral or slightly sniffing position. ❖ Choose the largest nostril and keeping the bevel next to the septum gently insert the tube. With gentle and even pressure, advance the tube in the pharynx. 0 ❖ Listen for high pitched whistling from the BAAM. This will get louder as you near the vocal cords. U ❖ Gently pull the trigger device on the tube. This will curve the distal end of the tube upwards. 0. U ❖ As the patient takes a breath advance the tube until the 15mm adapter sits against the nostril. ❖ Inflate the cuff, remove the BAAM device and confirm breath sounds and absence of epigastric sounds. 0 ❖ Ventilate the patient as appropriate. Note: The patient should not be able to talk if the tube is properly inserted. NASOGASTRIC TUBE INSERTION Nasogastric Tube insertion is the placement of a specialized catheter through the nostril, down the esophagus and into the stomach. Indications: NG tube insertion is indicated for the decompression of gastric distention in the intubated patient. a Contraindications: ♦ Severe facial or head trauma. ♦ Epiglottitis or croup. 2 Eguipment: Ng Tube, (1) 60cc syringe,Water soluble lubricating jelly, adhesive tape or veniguard. Procedure: ♦ Select proper size NG tube. ♦ Explain the procedure to the patient if indicated. 116 Packet Pg.678 C.13.a ♦ Measure the NG tube from the tip of the nose, to the patient's ear lobe and down to the xiphoid process. Mark with a piece of tape. ♦ Lubricate the tube generously with water-soluble jelly. ♦ Have suction ready and insert the NG tube into the largest nare while having the patient swallow. Keep 0. inserting until it is inserted to the depth of the tape. ♦ Check placement of the tube by auscultaing over the epigastric area and injecting 60 cc's of air. A gurgling should be heard if placement is correct. ♦ Secure the tube and attach to suction.Note:If the patient has excessive coughing or cannot speak when NG tube is inserted,tube may be in the Trachea. Remove and re-attempt. E 0 LL CL Indications Newborn patients to remove secretions and ensure patent airway a Newborn patients with presence of meconium staining Contraindications: N/A Equipment: Bulb syringe for suctioning without presence of meconium d Meconium aspirator, laryngoscope, ET tube for patients with presence of meconium staining 0 Pulse oximeter for monitoring of patients heart rate and SA02 during suctioning Procedure: Newborn-Upon delivery of head, and after delivery-suction mouth and nose with bulb syringe - Foi' 1Ar;conivkn st ;,;,Jg_ 117 Packet Pg.679 C.13.a ❑ Upon delivery of head- suction mouth and nose with bulb syringe ❑ Upon complete delivery- Place patient in sniffing position N ❑ Using a laryngoscope directly visualize the vocal cords using#1 Miller blade insert the appropriately sized ET CN tube attached to Meconium aspirator and suction. (suction should not exceed 100mm Hg). c ❑ Apply suction while withdrawing the ET tube. ❑ Attach a new ET tube and repeat the process until all meconium is removed from the trachea. Maximum 2 attempts. ❑ Oxygenate and ventilate patient as per inverted triangle. 0 U CL Note: If meconium staining is observed, the trachea should be suctioned before other resuscitative steps are taken. If meconium is absent but suctioning is required to ensure a patent airway, the mouth should be suctioned before the nose. 0 i Indications: - - Clinically significant shock,whether from volume loss, septic shock (suspected), 0 anaphylaxis, or CNS injury. y - Fractured pelvis or long bone leg fractures. - Pregnancy. Abdominal eviscerations. - Chest trauma with dyspnea where inflation of abdominal compartment will interfere with oxygenation. 118 Packet Pg.680 C.13.a Distended abdomen (aortic aneurysm is possible exception). N N Contraindications: 0. - Pulmonary edema. c - Cardiac tamponade. 0 - Vascular injuries of the chest with hemorrhaging that cannot be U controlled in the field CL .n m - Isolated head trauma 0 - Cardiogenic shock. Caution: - Guard trousers from damage by hospital personnel - Deflate trousers slowly and monitor blood pressure closely Procedure: ♦ Evaluate circulation (capillary refill), motor response, and sensorium. ♦ Apply garment to patient using an approved method (diaper, log roll or trouser method) ♦ Inflate as clinically indicated ♦ Recheck CMS. 119 Packet Pg.681 C.13.a Restraints have the potential to produce serious consequences such as physical and psychological harm, loss of dignity,violation of an individual's rights, and even death. Accordingly,the use of restraints will be limited to situations where other treatment interventions have clearly failed to address the patient's presenting clinical needs and safety. Examples of alternative interventions may include but are not limited to utilization of adjustable stretcher restraint straps, soft roller bandage to cover and protect IV sites. Restraint is any method of physically restricting a person's freedom of movement, physical activity or normal access to his or her body. Indications: c -Patients with Endotracheal tubes/trachs c -Patients with Invasive Catheters, lines and tubes CL -Patients with Brain pathologies or injury -Patients who are violent or could inflict potential harm to self or others due to an impaired psychological state and/or substance abuse c Contraindications: The potential risks of restraints are believed to be offset by the potential benefits of a better patient outcome (such i as the patient being safer from activities and behaviors that could cause physical harm and lead to a chance of increased morbidity) as well as being safer for crewmembers. Caution: -Loss of pulses, capillary refill and sensation can occur if restraints are over tightened -Neurovascular exams shall be performed at 5-minute intervals during restraint f L` � ;�� •,t :a ' `� i ��� '��_s � �r 1rj, x k` 'S' 41' `�s f�` s � ° _ � t � (B r- ? S,l2r st t� t t > i1F 1� i f { fY, S t 4 c it ll ;t SDI Srl 4 ! r rt I }t1 t 7 1 ,r<_ } U ♦ Explain reason for restraint to the patient, family, or significant other, prior to being initiated. 120 Packet Pg.682 C.13.a ♦ Reassure the patient that this is not a punishment, but a safety precaution. ♦ Select the appropriate restraint, this should be adjusted to provide for patient comfort, N but secure enough to assure effectiveness of device. Apply according to the manufacturer's instructions. When wrist restraints are used concurrently with ankle restraints, the restraint should be applied to one arm 0. and the opposite leg (two point restraint) or to all four extremities (four point restraint) you should be able to slip one finger between the restraint and the patient's skin. ♦ Tie with easily released hitches (Quick—release knots) out of patient's reach. ♦ Position patient to prevent aspiration and to allow visual contact, maintain proper body alignment. 0 ♦ Check pulses below the point of restraint to ensure circulation. U CL ♦ Check restraint integrity. 0 Spinal immobilization of pediatric patients i Indications: Spinal immobilization of pediatric patients who fit within the height and weight guidelines (infants and children up to 75 pounds). Contraindications: 0 Excessive weight and height Equipment: Rigid board with multiple securing straps. The boards also consist of lifting straps. Procedure: 121 Packet Pg.683 C.13.a ♦ Place a cervical collar on the patient while applying gentle in line immobilization ♦ Place the immobilization behind the patient for extrication, or beside them if application is only for a backboard type use. For this type of application a"log rolling "technique should be used. N ♦ While continuing to hold manual c-spine, apply the straps to the body and extremities. 0. ♦ Secure the head with the CID, supplied by the manufacturer, and release manual c-spine. 2 ♦ Device should be secured to stretcher or bench seat, prior to transportation. c E 0 L) CL The procedure for introducing a catheter into the pleural space in the presence of a Tension Pneumothorax to relieve y trapped air. 0 Indications: Absent lung sounds on the affected side. Tympany(hyperresonnance) on the affected side. Jugular vein distention. i Tracheal shift towards the unaffected side of the chest. 2 Contraindications: None in the presence of a life-threatening condition. Equipment: Antiseptic swab 14 or 16 gauge catheter = One-way valve device Procedure: Administer High Flow 02 and ventilatory support as needed 122 Packet Pg.684 C.13.a Primary site:Midclavicular line cv ♦ Select site at the 2nd or 3rd intercostal space, midclavicular line on the affected side. 0 ♦ Cleanse the site with antiseptic swab. ♦ Insert a large bore over the needle catheter (14 or 16 gauge)just above the lower rib at a ninety-degree angle. ♦ Advance the needle until the sound of escaping air is emitted. a ♦ Advance the catheter and remove the needle. c ♦ Apply appropriate one-way valve device. 0 ♦ Secure catheter in place. U CL Alternate site MidaxillarX line 0 ♦ Select site at or around the 5th intercostal space at the rnidaxillary line. ♦ Complete procedure in same manner as midclavicular approach. i Notes: After perform ino a oleural decompression in the effort to relieve a tension oneu_mothorax, it is essential that an airtight one-way valve be utilized to prevent the condition from recurring.. dr F N Miclaxillary Landmark Midclavicular Landmark 123 Packet Pg.685 C.13.a cv CD cv r_ 0 0. CU Pulse oximetry is used for detection of hypoxemia in arterial hemoglobin. The following guidelines should be followed for measuring the severity of respiratory distress: c - Severe distress=<80% - Moderate distress=80-89% c - Mild distress=90%or> CL Indications: 0 - All ALS patients. - To monitor distal oxygenation of extremity fracture or dislocation *** Initial Pulse Ox should be obtained prior to providing oxygen to patient*** i Contraindications: -N/A d Equipment: 0 -Pulse oximeter y Procedure: ♦ Select site; clean as necessary. ♦ Apply probe. ♦ Observe pulse indicator for synchronization of signal with pulse. 124 Packet Pg.686 C.13.a ♦ Record oxygen saturation prior to oxygen administration if possible. ♦ Record oxygen saturation after oxygen administration. N ♦ Monitor for changes cV 0 0. A reading of<90%may call for aggressive oxygenation, ventilatory assistance,and possible intubation c Note: 0 U - Patients with Carbon Monoxide inhalation have a normal 02 saturation reading but still can be hypoxic. CL - Patients wearing false fingernails may affect the accuracy of the reading. Low flow states, such as severe hypotension, cardiac arrest, etc., will cause the PULSEOX to not register. 4- 0 i Sager splint can be used for single or double femur fractures. Indications: 0 Midshaft or Distal Femur Fractures y Contraindications: -Pelvis fractures. -Fractures distal to the femur fracture 125 Packet Pg.687 C.13.a Equipment: N CD r- 0 0. Sager splint Procedure: c ♦ Check Pulses, Motor And Sensation prior to and post splinting 0 ♦ Apply manual traction to the leg by grasping the ankle and calf and gently pulling until the patient feels a relief from the pain or after approximately 15 lbs. of tension has been applied. CL ♦ The second rescuer positions the splint between the patients' legs with the cushion resting against the patients' ischial tuberosity. ♦ Around the upper thigh of the fractured leg, apply the thigh strap ♦ Extend the inner shaft of the splint until the end rests at the victims' heel. ♦ Position the ankle harness beneath the heel and around the ankle snugly. ♦ Connect the ankle strap to the bracket. ♦ Grasp the inner shaft with one hand and the outer shaft with the other hand and pull until the gauge i registers 10% of the patients' weight or until approximately 15 lbs. of pressure has been applied. ♦ Apply Leg strap. 2 ♦ Recheck and record distal Pulses, Motor And Sensation. (See Figure on next page) yyy .E+ k 1, i , t c� E Placement of Sager in groin area Traction being applied to splint 126 Packet Pg.688 C.13.a cv CD cv r- 0 0. This piece of equipment is use for lifting and moving patients ° c Indications: c U CL Lifting and moving of patient when a minimum of movement is required. 0 Contraindications: Weight limit is 300 lbs. Not recommended for patients with suspected spinal injuries. i Equipment: Two piece Metal frame stretcher with three straps. Note:Additional straps may be necessary to secure the patient to the stretcher carrying patients on inclines or declines. 0 Procedure: E ♦ Place the stretcher next to the patient. ♦ Open the locks and lengthen the stretcher to the appropriate size. ♦ Close locks and make sure that the extensions are securely fastened. ® Open the end releases and place one half on each side of the patient. ♦ Place one half under the patient as far as it will go. 127 Packet Pg.689 C.13.a ♦ Attach the head end of the scoop stretcher. ♦ Slowly close the remaining side, making sure not to pinch the patient, lifting slightly on one side or the other. Latch the foot end of the stretcher. `V cv ♦ Pad the patient head and any bony prominence with a pillow or a folded sheet. 0. ♦ Secure the patient with at least three straps. 2 c 0 0 Indications; - Suction equipment should ideally be taken to the scene of any patient suspected of having trouble managing their airway, i.e. cardiac arrest, seizures, respiratory arrest, overdose, comatose patients, trauma. - Suction unit is a mandatory piece of equipment that must be set up and readily available for ALL intubation attempts. i Contraindications: - N/A 0 Equipment: - Suction unit - Appropriate suction catheters and tubing - Sterile water, gloves 128 Packet Pg.690 C.13.a Procedure: N Pharyngeal suctioning: 0 0. ♦ Inspect unit for proper function and parts. ♦ Switch on suction and clamp tubing to note if pressure dial registers at least 300 mm/Hg. ♦ Attach suction tip to tubing. ♦ Open patient's mouth. ♦ Insert suction tip into the mouth and apply suction only on the way out. 0 ♦ Do not suction for more than 15 seconds. U CL ♦ Re-oxygenation should occur prior to repeated suctioning. Tracheal suctioning: (May be needed if vomitus, frank blood in tube, or increased resistance to ventilating after reconfirming proper tube placement): ♦ Prepare equipment. ♦ Wear universal precautions (sterile gloves should be utilized). ♦ Hyperoxygenate the patient. ♦ Grasp the suction catheter with gloved hand. ♦ Insert suction catheter into the ET tube until resistance is felt, without application of suction. 2 ♦ Apply intermittent, pulsating suction (on withdrawal only) while rotating catheter. ♦ Do not suction for more than 15 seconds. ♦ Remove the catheter. ♦ Insert catheter tip into sterile water and fully activate suction to flush tubing. 0. ♦ Hyperoxygenate patient. ♦ Reassess effectiveness of suctioning. ♦ Repeat as necessary. 129 Packet Pg.691 C.13.a The vacuum splint is a soft splint, which is easily applied around an injured extremity. The air is then removed forming a rigid splint, which immobilizes the injured area. `V cv 0 0. Indications: = A vacuum splint is used any time an extremity is fractured or injured and requires immobilization. c Contraindications: None CL Equipment: Appropriate sized vacuum splint and vacuum pump. Procedure: ♦ Take C—Spine precaution as indicated by mechanism of injury ♦ Manually stabilize the extremity i ♦ Expose the injury ♦ Assess circulation, sensation and motor response ♦ Choose appropriate size vacuum splint and form to injury;consider application of ice or cold pack to injury ♦ Close straps and evacuate air from splint;discontinue air evacuation when splint is rigid 0 ♦ Further immobilize as needed ♦ Reassess circulation, sensation and motor 130 Packet Pg.692 C.13.a { r CD a t � Vacuum Splint Vacuum splint applied 0 0 U CL 0 Indications Patients requiring ventilatory assistance with 100%oxygen. Contraindications: -Pediatric patients <18kg (40lbs) -Patients exhibiting signs of or experiencing Cheyne-Stokes respirations Equipment: -Automatic Transport Ventilator -Airway device, i.e. ETT,facemask -Oxygen supply source (portable 02) Procedure: ♦ Connect supply hose to oxygen regulator ♦ Set Breaths Per Minute (BPM) and Tidal Volume (TV) appropriate for patient: 131 Packet Pg.693 C.13.a BPM: -ADULT: Normal resuscitation rate= 12 BPM cv Head trauma hyper-oxygenation rate= 15BPM 0 0. -CHILD: Normal resuscitation rate=20BPM TIDAL VOLUME: - Tidal volume (VT) = 10 to 12 ml/kg (5ml/lb). ♦ Connect ATV Patient Valve to oxygen respiration circuit z 0 ♦ Open oxygen cylinder valve U CL ♦ Connect circuit to airway device, i.e. ETT or face mask. Observe patient for equal chest rise, auscultate lung sounds, ensure rate and volume are properly set, time number of ventilations/minute, and adjust as appropriate. ♦ Monitor patient at all times. If audible alarm sounds, turn control down one position. If other problems occur, take appropriate corrective action by manually ventilating patient with BVM until problem is identified and resolved. Note: in patients that are significantly overweight, the standard 10-12-ml/kg calculation will give an artificially high VT. Therefore, Tidal Volume (VT) to be delivered should be based upon "Lean Body Mass."To correct this calculation in overweight patients, use the following formula based upon average lean body weights (SEE TABLE) Weight divided by 2x 10 m1=Tidal Volume Table of Tidal Volume Based on Average Lean Body weight: Control Position 1 2 3 4 5 6 7 0 Tidal Volume VT (ml) 0 200 300 400 600 800 1100 Frequency(BPM) F 20 15 15 12 12 12 Automatic flow rate (LPM) F 12 13.5 18 21.6 28.8 39.6 _ .... Body Weight(kg) 13.3-20 20-30 26.7-40 40-60 53.3-80 73.3-110 132 Packet Pg.694 C.13.a cv CD cv 0 CU Ambulance 0 L) 0 CL i Drug Reference c Guide 134 Packet Pg.695 C.13.a cv ADENOSINE fAdenocard) c Action: Conversion of paroxysmal supraventricular tachycardia (PSVT) to sinus rhythm. Slows conduction through the AV node, interrupts Av nodal reentry pathways and can convert PSVT associated with Wolf-Parkinson White Syndrome (WPW). U CL Indication: Symptomatic PSVT with decreased blood pressure and EKG showing rates >150 with narrow QRS c complexes. Also, patients in PSVT with altered mental status, chest pain, SOB, CHF, due to hypotension. Contraindications: i 1. Second or third degree AN block (except in-patients with a functioning artificial pacemaker). 2. Sick sinus syndrome without cardiac pacemaker in place. 3. Persons taking Carbamazepine (Tegretol). 4. Known hypersensitivity to Adenosine. 5. Persons undergoing active bronchospasm. c 6. Persons with known atrial flutter, atrial fibrillation, or ventricular tachycardia. y Precautions: 1. Persons taking Dipyramidole (Persantine). Half dose may e administered. . Persons taking Aminophylline, Theophylline, or Slo-131d. Higher doses a bye reguired. � 135 Packet Pg.696 C.13.a Side Effects: N Flushing, headache, chest pain, and dyspnea are transient and will abate in 1-2 minutes after administration. CrN Transient periods of sinus bradycardia and ventricular ectopy are common after the termination of PSVT. y Dosage: c Adult— 6-mg rapid intravenous bolus through a large catheter (preferably in the antecubital) followed by a 20-ml flush. A second bolus of 12 mg. may be administered after 1-2 minutes if the PSVT is not eliminated. Never administer doses greater that 6 mg. via external jugular vein. Pediatric—For children with known WPW administer 0.1 mg./kg. rapid IVP as the initial bolus followed in 1-2 y minutes by a second bolus of 0.2 mg./kg. rapid IVP if PSVT continues. 0 * An ECG should be recorded with the administration of adenocard. i c 136 Packet Pg.697 C.13.a ALBUTEROL SULFATE N N c Action: Albuterol is a potent beta 2-adrenergic stimulant producing bronchodilation rapidly. c Indications: 0 U CL Broncospasm resulting from: 1. Bronchial asthma y 2. Reversible bronchospasm (i.e. allergic reaction) 0 3. Bronchitis 4. Emphysema W 5. Pneumonia 2 i Contraindications: 1. Cardiac arrhythmia's associated with tachycardia. 2. Allergy to Albuterol Sulfate. 0 Precautions: 1. Hypertension 2. Coronary artery disease 3. Congestive heart failure ® Hyperthyroidism 137 Packet Pg.698 C.13.a 5. Diabetes N CD Dosaae: 0 0. Adult— Administer 1 vial (2.5 mg.) of premixed single unit does via a nebulizer at 6 Uminute. Pediatric— Less than 2 years old. administer 1.25 mg. (1.5 ml of vial) diluted in 2 ml of Normal Saline. More than 2 years old, administer adult dose. U CL 4- 0 i c 138 Packet Pg.699 C.13.a AMIODARONE HYDROCHLORIDE Cordarone N Action: CD r- 0 0. Amiodarone blocks sodium channels at rapid pacing frequencies and exerts a non- competitive r 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 also 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. c 0 Indication: CL Indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation and hemodynamically unstable ventricular tachycardia in patients refractory to other therapy. 0 Contraindications: Contraindicated in patients with known hypersensitivity to amiodarone, or in patients with cardiogenic shock, marked sinus bradycardia and second or third degree AV blocks. Precautions: May worsen existing or precipitate new dysrhythmias, including torsade de pointes and VF. Use with beta W blocking agents could increase the risk of hypotension and bradycardia. Amiodarone inhibits AV conduction and decreases myocardial contractility, increasing the risk of AV block with verapmil or cardizem or of hypotension with the use of any calcium channel blockers. Use with caution in pregnancy or nursing mothers. Side Effects: Hypotension 139 Packet Pg.700 C.13.a Dosq e: N Adult—Cardiac Arrest- 300mg slow IVP. Repeat 150mg in 3-5 minutes. (Max. dose 450mg) 0 0. V-Tach with apulse- 150mg/100cc's over 10 minutes (150gtts/min on a macro). Maintence drip: Using a mini drip mix 150 mg in 100cc's D5W (1.5mg/cc) run @ 1 mg /min (40gtts/min). 0 Pediatric—Cardiac arrest- 5mg/kg slow IVP. One time dose. CL c i c 140 Packet Pg.701 C.13.a ASPIRIN cv cv Action: 0. Aspirin is an analgesic, anti-inflammatory and antipyretic which also has anti platelet activity (it decreases platelets ability to stick together and clot). c Indication: U 0. Aspirin 162 mg. is indicated in the acute MI setting to prevent further clotting. Aspirin 325 mg. is indicated in decompression sickness to inhibit the synthesis and release of prostaglandins. Contraindications: W Hypersensitivity to salicylates or known aspirin induced asthma. History of GI ulceration or bleeding, �I hemophilia or other bleeding disorders. During pregnancy, Children under 16 years of age. Side Effects: Nausea, vomiting, heartburn and stomach pain are common. Tinnitus (ringing in the ears) has been reported usually with chronic use or overdosage. Bronchospasm, tightness in chest, angioedema, urticaria and anaphylaxis may occur if the patient is allergic. Dosaae: Adults —2 chewable tablets, 162-mg. PO for suspected AMI. Instruct patient to chew then swallow, if tolerated. 141 Packet Pg.702 C.13.a Pediatric-There is no approved dose for children. CL N c c c u 0 i c 142 Packet Pg.703 C.13.a ATROPINE N Action: 0 0. Atropine is a potent parasympatholytic anticholinergic that reduces vagal tone and thus increases automaticity of the SA node and increases A-V conduction. Indications: c 1. Symptomatic sinus bradycardia. E 2. Second and third degree A-V blocks (may be useful). c 3. Asystole (may be useful). 0. U 4. Organophosphate, carbamate, or similar acting nerve gas poisonings. 0 Contraindications: None in emergency situations. Patient's allergic to "sulfa drugs" are not allergic to Atropine Sulfate. Side Effects: CNS Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, headache. Cardiac Increase heart rate may worsen ischemia or increase area of infarction, ventricular fibrillation, .9u ventricular tachycardia, angina, flushing of skin. GI Dry mouth, difficulty swallowing. GU Urinary retention. Other Worsened pre-existing glaucoma. 0 Anticholinergic effects can be remembered by "red as a beet, dry as a bone & mad as a hatter" Warnings: Administering less than 0.5 mg. to an adult patient, 0.1 mg. to a child, or if pushed too slowly may initially cause the heart rate to decrease. Atropine is potentiated by antihistamines and antidepressants. n the cardiac setting a maximum dose of 3 mg. or (0.04 mg./kg.) should not be exceeded. 143 Packet Pg.704 C.13.a Dosage: N N 0 0. Adult (for cardiac use) — 0.5-1.0 mg. IVP or 1-2 mg. ET. Repeat every 5 minutes until a maximum dose of 0.04 mg/kg. is reached. Adult (for poisonings) — 1 mg. IVP every 3-5 minutes until drying of the secreations (atropinization) occurs. c 0 U 0. Pediatric (for cardiac use) — 0.02 mg./kg. IVP or 0.04 mg./kg. ET. The minimum dose is 0.1 mg. and the maximum single dose is 1 mg. Not to be used in Pt's less than 1 y.o. 4- 0 Pediatric (for poisonings) — 0.02 mg./kg. IVP. Contact MCP for subsequent doses. i c 144 Packet Pg.705 C.13.a cv CD cv r_ AKA: N/A y Class: Electrolyte Action: c Calcium Chloride increases the force of myocardial contraction, calcium may either increase or decrease systemic vascular resistance. In normal hearts, calcium's positive inotropic and vacoconstricting effects produce a predictable rise in systemic arterial pressure. Replaces and maintains Calcium. CL Indication: y 0 Calcium Chloride is indicated during resuscitation for the treatment of hypocalcemia and calcium channel blocker toxicity, e.g., verapamil, diltiazem and nifedipine overdose and hyperkalemia. In suspected calcium channel blocker toxicity rapid intervention of early airway support, blood pressure support and early external pacing will achieve the best results. Hyperkalemia, drug overdose. i Contraindications: -Cardiac arrest (unless patient receives dialysis, is known to be hypocalcemic or is in cardiac arrest secondary to calcium channel blocker overdose). -V-Fib -Hypercalcemia -Digitalis Toxicity Side Effects: If the heart is beating, rapid administration of calcium can produce slowing of the heart rate, tissue necrosis, cardiac arrhythmia's, cardiac arrest, N/V, bradycardia, tingling sensations. Warninns; 145 Packet Pg.706 C.13.a Calcium Chloride should not be administered in the same infusion with sodium is r n , since calcium ill combine i sodium icar onate to form an insoluble pr ci is (calcirn carbonate). alciu lori e , should iven with extreme caution, and in reduced to persons taking i it lis because it increases ventricular irritability n precipitate digitalis toxicity. 0 0. Dosager Adult— Overdose on Calcium channel lock rs— 1 g slow IV . Hyperkalemia— 1 g slow I (consider for - ac , Asystole in patients with history of renal failure. 0 Pediatric— Overdose on Calcium Channel Blockers - 20 mg./kg. slow IVP. Maximum dose of 200 mg. CL U 0 i c 146 Packet Pg.707 C.13.a cv cv AKA: N/A c Class: Caloric Action: c A monosaccharide which provides calories for metabolic needs, spares body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. CL Indication: 0 Documented Hypoglycemia less than 60 mg./dl. coma of unknown origin. Contraindications: Diabetic Coma W r- i Intracranial hemorrhage Severe dehydration Intracranial or intraspinal hemorrhage. Side Effects: c Thrombosis, sclerosing if given in a small peripheral vein. Tissue necrosis occurs if any dextrose infiltrates through the IV catheter. Dosage: Adult— 50 ml of a 50% solution; (25 gms.) IV. Repeat 1 X pm, for glucose < 60 mg./dl 147 Packet Pg.708 C.13.a Pediatric— More than 12 years old, 25g/50cc. D50 Less than 12 years old, 2-4cc./kg. D25 (Dilute D50 1:1) N Neonates less than 30 days old—2-4cc./kg. D10 CN 0 0. Retest and repeat 1 X prn c 0 U CL 0 i c 148 Packet Pg.709 C.13.a Action: N N c A member of the benzodiazepine family, Diazepam, depresses the limbic system, thalamus, and hypothalamus, resulting in calming effects. Diazepam is a sedative, anxiolytic, anticonvulsant and muscle relaxant. c Indications: 0 U CL 1. Seizures 2. Status epilepticus. y 3. Premedication prior to cardioversion or external pacing. 4- 0 4. Agitation due to acute alcohol withdrawal (DT's) 5. Short-term relief of acute anxiety. 6. Cocaine O.D. i Side Effects: Confusion, muscular weakness, blurred vision, drowsiness, respiratory depression, respiratory arrest, slurred speech, bradycardia, hypotension, and cardiovascular collapse. Avoid administering into small veins such as those on the dorsum of the hand since it can cause local irritation and possibly venous thrombosis in small veins. c Blood Pressure Guideline: Minimum systolic BP greater than 100 mmHg. Dosage. 149 Packet Pg.710 C.13.a Adult— 5mg. IVP. IV route should be administered slowly, no faster than 5 mg./min. May repeat to a maximum of 10 mg. Contact Medical Control for additional doses. N N Pediatric— 0.5 mg./kg. rectally or 0.2 mg./kg. slow IVP or 10. Maximum single dose of 5 mg. 0. CL c U 0 i c 150 Packet Pg.711 C.13.a DILTIAZEM HYDROCHLORIDE Cardizem N CD Action: 0 0. 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, interrupts the reentry circuit in AV nodal re-entrant tachycardias and reciprocating tachycardias (e.g. Wolff-Parkinson- White syndrome). Diltiazem also prolongs the sinus cycle length and decreases peripheral vascular resistance. 0 Indication: 1. Symptomatic Atrial Fibrillation or Atrial Flutter with the rapid ventricular response. 2. Symptomatic PSVT. Contraindications: i 1. Sick sinus syndrome. 2. Second or third degree AV block. 3. Severe hypotension or cardiogenic shock. 4. Sensitivity to the drug. 5. WPW syndrome. c 6. Ventricular tachycardia. Precautions: Diltiazem should be used with caution in patients with impaired liver or renal function. IV Diltiazern administered to a patient who is taking oral beta-blockers may cause bradycardia, AV block, and/or 5 depression of contractility. Caution should be taken when administering with anesthetics. Caution should 11 Packet Pg.712 C.13.a also be used in pregnant females and mothers who are nursing. Use caution if administered in the presence of CHF. N N Side Effects: 0. Hypotension, itching or burning at the injection site, flushing of the skin. c Dosage 0 Adult—A-fib/A-flutter, SVT- 15mg IVP over 2 minutes. Pediatric— N/A 0 i c 152 Packet Pg.713 C.13.a Action: CD - 0 0. Diphenhydramine is an antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Indications: 0 Rhinitis, allergy symptoms, anaphylaxis (as an adjunct to epinephrine), cL Dystonic reactions caused by phenothiazines and related compounds such as phenegan, compazine, reglan, U haldol and thorazine. 0 Contraindications: Benadryl is not to be used in newborn or premature infants or in nursing mothers. Benadryl is also not to be used in patients with lower respiratory tract symptoms, including asthma. i Side Effects: CNS Drowsiness, confusion, insomnia, headache, vertigo (especially in the elderly). Cardiac Palpitations, tachycardia, PVC's, hypotension. GI Nausea, vomiting, diarrhea, dry mouth, constipation. 0 GU Dysuria, urinary retention. Resp Thickening of bronchial secretions, tightness of the chest, wheezing, nasal congestion_ Warnings: In infants and children especially, antihistamines in overdosage may cause hallucinations, convulsions, or death. 153 Packet Pg.714 C.13.a As in adults, antihistamines may diminish mental alertness in children. In young children, they may produce N excitation. N 0 0. Benadryl has additive effects with alcohol and other CNS depressants (hypnotics, sedatives, tranquilizers, etc.) Antihistamines are more likely to cause dizziness, sedation, and hypotension in the elderly (60 years or older) patient. 0 U CL Dosaae: U Adult— 25mg IVP, 50 mg IM. y Pediatric— 1.5 mg./kg. slow IVP or IM. Maximum 50 mg. i CD c 154 Packet Pg.715 C.13.a N CD - V 0. Action: Epinephrine is a sympathomimetic which stimulates both alpha and beta adrenergic receptors causing immediate bronchodilation, increase in heart rate (positive chronotrope) and an increase in the force of cardiac contraction (positive inotrope) and increases peripheral vascular resistance (i.e. blood pressure). Subcutaneous dose lasts 5-15 minutes. - U 0. Indication: 0 1. Asthma 2. Anaphylaxis 3. Angioneurotic Edema 4. Allergic reactions in patients 40 and under without coronary artery disease. i Contraindications: In anaphylaxis there are no contraindications. Dosage: Adults— 0.3-0.5 mg. (0.3-0.5 cc.) subcutaneously for allergic reactions. Pediatric-- 0.01 mg./kg. up to 0.3 mg. subcutaneously for allergic reactions. In cardiac arrest, administer 0.01 mg/kg IVP or 0.1 mg/kg ET followed by 0.1 rng/kg IVP or ET every 3 minutes. 155 Packet Pg.716 C.13.a cv CD cv r- 0 0. cu cu 0) c cu 0 L) CL i a- c 156 Packet Pg.717 C.13.a N N 0 0. Action: Epinephrine is a sympathomimetic which stimulates both Alpha and Beta-receptors. It may improve myocardial and cerebral blood flow during resuscitation. 0 Indications: CL 1. Pulseless patients in cardiopulmonary arrest. 2. Severe anaphylactic reactions. c 3. Bradycardia and/or hypotension not responsive to Atropine or TCP especially in the pediatric patient. Side Effects: i Tachycardia, ventricular dysrythmias, hypertension, angina, and palpitations. Warnings: Epinephrine is inactivated by alkaline solutions, never mix with Sodium Bicarbonate. Tricyclic antidepressants potentiate the effects of Epinephrine. y Dosage: Adult-- 1 mg. Its push every 3 minutes during cardiac arrest, When given via the ET route, administer 2 mg. 157 Packet Pg.718 C.13.a Pediatric— 0.01 mg/kg (0.1 ml/kg.) IVP, repeat every 3 minutes at 0.1 mg/kg (1:1,000) as necessary. N N 0 0. CL 0 i c 158 Packet Pg.719 ETOMIDATE �AMIDATE) cv cv r— Class: Ultra short acting, nonbarbituate hypnotic. Action: c Facilitates intubation by rapidly inducing anesthesia with minimal cardiovascular and respiratory side effects as well as not causing a histamine release. A beneficial side effect is decreased intracranial pressure. Onset: 1-2 minutes U CL Duration: 5-10 minutes Indications: To induce sedation for endotracheal intubation and cardioversion. Contraindications: Known hypersensitivity to etomidate. Pediatrics less than 12 years old. Precautions: 0 0. Use with caution in patients with severe hypotension, severe asthma or severe cardiac disease. Side Effects: Apnea, hypoventilation, laryngospasm, hypotension (rare, can be corrected with fluid), tachycardia, dysrhytmias, nausea, vomiting and muscle jerking. 159 Packet Pg.720 C.13.a Dosa e: N CD r- 0 0. Adult- 0.3mg/kg IVP over 15-30 seconds or <150lbs=20mg, >150lbs= 40mg. Pediatric- Over 12 years old same as adult c 0 L) CL i c 160 Packet Pg.721 C.13.a FUROSEMIDE Lasix cv CD cv r- 0 0. Action: Lasix is a sulfonamide derivative and potent diuretic which inhibits the reabsorption of sodium and chloride in M the proximal and distal renal tubules as well as in the loop of Henle. With IV administration, the effect is seen before the onset of diuresis, within 10 minutes; peaks in 30 minutes; and has a duration of 2 hours. Lasix also has a direct venodilating effect which is useful in the acute treatment of pulmonary edema. 0 L) CL Indication: Acute pulmonary edema. c Contraindications: Lasix is contraindicated in anuria and in patients who are allergic to sulfa. Should be used in pregnancy only when benefits clearly outweigh risks. ' Side Effects: Dizziness, tinnitus and hearing loss if administered too fast. Hypotension, pruritus, urticaria, muscle cramping. 0 Warnincs: Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. Do— sage: 161 Packet Pg.722 C.13.a Adult— 0.5-1.0 mg./kg. (40-80 mg.) slow IVP. 40mg for Pts not taking Lasix, 80mg for Pts currently taking Lasix or with Hx of Renal Insufficiency (Dialysis/Kidney Failure) CD r- 0 0. Pediatric_ 1 mg/kg for infants and children. Do not give to neonates. c 0 U CL i c 162 Packet Pg.723 C.13.a cv CD cv r_ 0 0. CU Action: 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. Therapeutic doses have predmoninant beta-adrenergic receptor stimulating actions that result in increases in cardiac output. At high doses, Dopamine has alpha-receptor stimulating actions that result in peripheral c vasoconstriction. CL Indications: y 0 To treat shock and correct hemodynamic imbalances, improve perfusion to vital organs and to increase cardiac output in the absence of hypovolemia. Contraindications: i Dopamine should not be used in patients with pheochromocytoma (tumor which stimulates the release of catecholamines). Like other catecholamines, Dopamine may precipitate a hypertensive crisis in patients with pheochromocytoma. Side Effects: 0 0. Severe tissue necrosis and sloughing with extravasation from an infiltrating IV. Warnings: Dopamine is inactivated by alkaline solutions such as Sodium Bicarbonate. Patients who have been treated with monoamine oxidase (MAO) inhibitors will require substantially reduced dosage (1/10`h of the regular dose). 163 Packet Pg.724 C.13.a Dosage: CD CN r- 0 0. Adult Dopamine premixf 400 mg. in 250 ml D5W yields 1600 mcg./ml. This will be run at 5 c / ./ ie (usually 15-30 dropsrminute) and titrated to a BP of 100 mmHg systolic. Pediatric— Dopamine mixed . in 500 ml D5W yields 800 mcg/ml. This will be run at 5-20 c / ./ inu (usually 15-30 drops perminute) and titratedo a BP. c 0 Note: Take patients weight in pounds (I s), knock off the last number and then minuso U CL estimate drops per minute to start at 5mcg/kg/min. 0 i c 164 Packet Pg.725 C.13.a GLUCAGON ACTION; N CD GLUCAGON INCREASE BLOOD GLUCOSE LEVELS BY STIMULATING THE BREAKDOWN OF GLYCOGEN IN THE LIVER, WHERE IT IS STORED AS A FORM OF GLUCOSE. GLUCAGON IS DEPENDENT ON THE LIVER BREAKING y DOWN GLYCOGEN (GLYCOGENESIS) AND THEREFORE MAY BE INEFFECTIVE IN PATIENTS WITH LIVER DYSFUNCTION OR INADEQUATE GLYCOGEN STORES DUE TO CHRONIC STATES OF HYPOGLYCEMIA OR STARVATION. Indications: c 0 Hypoglycemic states where no IV access is possible and the patient's mentation does not permil administration of oral glucose. CL Contraindications: 0 Known hypersensitivity and pheochromocytoma. Side effects: I Occasional nausea and vomiting. On rare occasions allergic reactions have been reported. Dosage: Glucagon comes in (2) 1 ml vials. One contains the drug in powder form, the other contains a liquid. Prior tc administration the liquid is put into the vial with the powder and gently swirled until mixed. The solution is then drawn up and administered IM. Hyl2ogl cemia: AdUIts: 1mg l Pe Wric: 0.5mg-1.0mg I 165 Packet Pg.726 C.13.a Beta-Blocker O.D: Adults: 5mg slow IVP N Pediatric: 1 mg slow IVP 0 0. CL c 0 i c 166 Packet Pg.727 C.13.a L 0 R A Z E P A M AIty_k L� N CD Action: N 0 0. Lorazepam is a benzodiazepine and thus depresses the central nervous system resulting in sedation, relieving anxiety, causes lack of recall and relief of skeletal muscle spasms. c Indications: 0 U CL Seizures U Sedation for combative patients y Adjunct to RSI medications for pediatrics 0 Contraindications: Known hypersensitivity, narrow angle glaucoma. i Side Effects: Excessive CNS depression, respiratory depression, hypo/hypertension( rare), nausea and vomiting, pain, burning or rash at injection site. c Blood Pressure Guideline: Minimum systolic BP greater than 100mmHg for an adult. Dosage: 167 Packet Pg.728 C.13.a Adult: 2mg slow IVP. May repeat once to a maximum of 4mg N Pediatric: 0.1 mg/kg slow IVP. Maximum single dose of 2 mg 0 0. CL c U 0 i c 168 Packet Pg.729 C.13.a MAGNESIUM SULFATE , cv CD cv r- AKA: N/A0. Class: Electrolyte c Action: 0 U Decreases Acetylcholine released by nerve impulses, relaxes smooth muscles, bronchodilation. CL Indications: 0 Severe Pre-Eclampsia, Eclampsia, Torsades de Pointe Contraindications: i 2nd and 3rd Degree Heart Blocks Side Effects: Circulatory Collapse, Respiratory Paralysis, Heart Block Antagonist N/A osa e: 169 Packet Pg.730 C.13.a Adults— V-Fib/Pulseless V-Tach—2g. IVP over 2 minutes N Pre-Eclampsia—4g. bolus over 20 minutes—4g. into 50 cc. NS (approximate 38 gtts/minute c CN macrodrip or 150 gtts/minutes c minidrip). 0. Eclampsia—2g IVP over 2 minutes, repeat if seizure persists. If seizure subsides, then administer 2g in 25cc NS and administer at a rate of 2.5cc/minute (approximate 38gtts/minute c macrodrip or 150 gtts/minute c minidrip). c Pediatric— N/A 0 L) CL i c 170 Packet Pg.731 C.13.a METHYLPREDNISOLONE Solumedrol N Action: 0 0. Solu-medrol is a potent anti-inflammatory synthetic steroid. °— Indication: c 0 Control of severe allergic reactions, asthmatic attacks and bronchospasm associated with COPD that do not respond to other treatments. CL Contraindications: 0 1. Known hypersensitivity 2. Neonates 3. Patients with systemic fungal infections. i Side Effects: Cardiovascular: Fluid retention, Hyper/hypotension, dysrhythmias, CHF. CNS: Headache, vertigo, seizures. GI: N+V, abdominal distension, GI bleeding. Dosage: Adult— 125mg IVP Pediatric—2mg/kg IVP 171 Packet Pg.732 C.13.a cv CD cv r- 0 0. cu c 0 CL i c 172 Packet Pg.733 C.13.a cv CD cv r- 0 0. Action: Morphine is a narcotic analgesic, which depresses the central nervous system and sensitivity to pain. It increases venous capacitance, decreases venous return and produces mild peripheral vasodilatation. Morphine also decreases myocardial oxygen demand. z 0 U 0. Patient's allergic to "Sulfa drugs" are not allergic to Morphine Sulfate. Indications: 0 1. Pain from acute MI. 2. Pulmonary edema. 3. Burn patients without multiple trauma or head trauma. i 4. Acute pain as per protocol. Contraindications: Morphine is contraindicated in patients with pain due to trauma or acute abdomen. It should not be given to a patient with volume depletion or hypotension. It is contraindicated in patients with head trauma, acute alcoholism, acute asthma, severe chronic obstructive lung disease, and in those who are hypersensitive to the drug. Side Effects: Euphoria, drowsiness, pupillary constriction, respiratory arrest, bradycardia, hypotension, decreases gastric 0) motility, nausea and vomiting. 173 Packet Pg.734 C.13.a Blood Pressure Guideline: N Minimum systolic BP greater than 100 mmHg. 0 0. Dosage: °— Adult— 3mg. slow IVP. 3mg increments. 9mg. Max for C/P, 6mg. Max for CHF. 10mg. Max for Burns. 0 Pediatrics— 0.1 —0.2 mg./kg. slow IVP. CL i c 174 Packet Pg.735 C.13.a cv CD cv r- 0 0. Action: The mechanism of action is not fully understood. It does appear that Narcan antagonizes the effect of opiates by competing at same receptor sites. When given IV, the action is apparent within 2 minutes. IM or SC administration is slightly less rapid. 0 U CL Indication: U Narcan is indicated for the complete or partial reversal of narcotic depression and respiratory depression secondary to narcotics or related drugs. Narcan can also be used for suspected acute opiate overdosage. Note for Demerol (meperidine) O.D. higher doses may be needed. Contraindication: i Narcan is contraindicated in patients known to be hypersensitive to it. - Warnings: Narcan should be administered cautiously to persons including newborns of mothers who are known or suspected to be physically dependent on opiates because it may precipitate an acute abstinence syndrome. Use caution during administration as patient may become violent as level of consciousness increases. Doggg le. Adult- 2 mg. may be administered IVP or ET. May repeat in 2-3 minutes. 175 Packet Pg.736 C.13.a Pediatric— 0.1 mg./kg. IVP or ET. N N 0 0. CL c u 0 i c 176 Packet Pg.737 C.13.a cv CD cv r_ 0 0. Action: Reduces cardiac oxygen demand by decreasing left ventricular end-diastolic pressure (pre-load) and to a lesser extend systemic vascular resistance (after-load). Also increases blood flow through the collateral coronary vessels. 0 U CL Indications: 1. Chest pain associated with angina pectoris or suspected acute MI. 0 2. Symptomatic hypertensive crisis. 3. Acute pulmonary edema with hypertension. Contraindications: i 1. Patients with increased intracranial pressure and systolic BP less than 100 mmHg. 2. Patients taking or suspected of taking Viagra should not receive Nitroglycerin for at least 24 hours. Use nitrates with great caution in patients,showing evidence of a right ventricular infarction. 0 Side Effects: Headache, dizziness, flushing, nausea and vomiting, hypotension, reflex tachycardia. Have the patient sit or lie down during administration, use trendelenburg or fluid bolus to avoid postural hypotension. Blood Pressure Guidelines: 177 Packet Pg.738 C.13.a Minimum systolic BP greater than 100mm/hg. N N 0 0. Dosaae: Adult— 1 spray sublingually, 0.4 mg. May repeat two additional times every 3-5 minutes. 10mcg/min via IV infusion Pump until symptoms are relieved or minimum BP is met. 0 Pediatric— Not indicated. CL i c 178 Packet Pg.739 C.13.a NITROUS OXIDE cv AKA: Nitronox CD 04 - 0 0. Class: Anesthetic, analgesic Action:- c 0 CNS depressant that has analgesic properties in lower doses. U CL Indications: y 0 Musculoskeletal pain, Skin burns without respiratory involvement. Contraindications: i Any Altered LOC (i.e., Alcohol Intoxication) Head Injury Burns with respiratory involvement Hypotension Shock Minors (under the age of 18) COPD Acute PE N/V Pregnancy Chest Trauma (especiafiy ec of orax) Elderly atiens with HipFractures 179 Packet Pg.740 C.13.a Side Effects: N CD r_ 0 0. N/V Anta onist: c High flow 02 CL Dosage: Adults— Self-administered Pediatrics— N/A i c 180 Packet Pg.741 C.13.a _PR_d_C A I N A M,I,D.,E AKA: Pronestyl N r- Class: Antiarrhythmic, anesthetic . Action: c Decreases excitability, and reduces the automaticity of all the pacemakers. c Indications: U PVC's, Stable V-Tach, Unstable V-Tach 0 Contraindications: Hypersensitivity to Procaine i High degree Heart Blocks Side Effects: Hypotension, V-Fib, Bradycardia, N/V Antagonist: c N/A Dosage: uit— VC's —20 mg./minute (11-4 mg./minute if terminated) Stable/Unstable V- c —30 mg./minute (11-4 mg./minute if terminated) 181 Packet Pg.742 C.13.a Pediatrics — N/A CL N c c c 0 i c 182 Packet Pg.743 C.13.a EGLAN AKA: Metoclopramide 0 0. Class: Antiemetic Action: c 0 Blocks Dopamine Receptors U CL Indications: 0 Nausea/Vomiting 12 years old and up. Contraindications a CVA AMI Hypertension Patients with history of dystonic reactions to antiemetics Side Effects: c Hypertension, restlessness, anxiety, drowsiness, H/A, extrapyramidal symptoms (dystonic reaction). Antagonist; Benadryl 25 mg. I.V. may counteract the extrapyramidal side effects. 183 Packet Pg.744 C.13.a Dosage N CD r- 0 0. Adult— 10 mg. slow IVP over 2 minutes Pediatric— N/A c 0 U CL i c 184 Packet Pg.745 C.13.a ROMAZICON AKA: Flumazenil CD r- 0 0. Class: Benzodiazepine Antagonist Action: c 0 Inhibits the actions of Benzodiazepines Indications: y 0 Complete or partial reversal of the sedative effects of Benzodiazepines Contraindications: i Patients with hypersensitivity to Romazicon or Benzodiazepines Patients with evidence of tricyclic antidepressant OD. Patients that have received Benzodiazepines to treat life threatening condition (such as status epilepticus) Patients with history of chronic use c Side Effects: y H/A, seizures (TX with Valium), dizziness, blurred vision, arrhythmia's, N/V a Precautions: Use with caution in patients with high risk for developing seizures 185 Packet Pg.746 C.13.a Antagonist: N CD r- 0 0. Treat seizures with Valium Dosage: c Adult— 0.2 mg./minute (2 ml./minute) until mental status, blood pressure, or respiration's improve. L. Maximum 1 mg. U CL "May cause seizures in patients dependent on Benzodiazepines—TX with Valium. Pediatric— 0.1 mg./minute (1 mi. Minute) until mental status, blood pressure, or respiration's improve. Maximum 1 mg. **May cause seizures in patients dependent on Benzodiazepines—TX with Valium i c 186 Packet Pg.747 C.13.a �v ,u 17 N CD r- Action: c0. An alkalizing agent used to buffer acids present in the body during and after severe hypoxia. Restores bodies buffering capacity and neutralizes excess acid. 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 with adequate ventilation and oxygenation. 0 Indications: CL U Suspected metabolic acidosis due to: 1. Prolonged cardiac arrest, more than 10 minutes. c 2. Salicylate (aspirin) overdose. 3. Barbiturate overdose. 4. Ketoacidosis associated with hyperglycemia. 5. Hyperkalemia. 6. Cyclic antidepressant overdose. Cyclic OD, Hyperkalemia, V-Fib, Pulseless V-Tach, Asystole, PEA Contraindications: c CHF Respiratory or Metabolic Alkalosis Congestive heart failure and known alkalotic states. Side Effects: 187 Packet Pg.748 C.13.a Metabolic alkalosis, hypernatremia, and cerebral acidosis. Gastric distension. N N 0 0. Warnings: y Excessive bicarbonate therapy inhibits the release of oxygen. Bicarbonate does not improve the ability to defibrillate. May inactivate simultaneously administered catecholamines. Will precipitate if mixed with calcium chloride. Administration should be guided by arterial blood gas analysis and pH measurement. L. Dosage: L) CL Adult— Cardiac arrest-1 meq/kg. IVP. After 20 minutes Cyclic OD— 1 amp. IVP q 5min prn maximum 3 amps. Hyperkalemia— 1 amp IVP. c Pediatric— 1 meq/kg. IVP. Repeat with 0.5 meq/kg. in 10 minutes. Cyclic OD — 1 mEq/kg. i CD c 188 Packet Pg.749 C.13.a VASOPRESSIN N CD Action: r- 0 0. Vasopressin is the naturally occurring antidiuretic hormone. In high doses, vasopressin acts as a non- °— adrenergic peripheral vasoconstrictor. Vasopressin acts by direct stimulation of smooth muscle V1 receptors. In recent studies, after a short duration of VF, vasopressin during CPR increased coronary perfusion pressure, vital organ blood flow, VF median frequency and cerebral oxygen delivery. 0 Indication: U 0. Vasopressin is indicated for shock-refractory VF and VT without a pulse. When Vasopressin is given y epinephrine should not be given for at least 10-20 minutes. 0 Contraindications: None in cardiac arrest. i Side Effects: None in cardiac arrest. Dosage: c Adult—40 units IVP Pediatric— N/A ,,, ti r ti t t 7 r - y 1 l 1 1 1 1 i t ? iyt r 1 ti s s itS 7: i, 189 Packet Pg.750 C.13.a cv CD cv r- 0 0. cu cu 0) c cu 0 L) CL i c 190 Packet Pg.751 C.13.a N CD r_ 0 0. Action: Decreases ventricular automaticity and raises the ventricular fibrillation threshold. c Indications: U CL 1. PVC's; Greater or equal to 6/minute, R on T phenomenon, multifocal, or 2 or more in a row in suspected y myocardial infarction or acute ischemia. 2. Ventricular tachycardia. 3. Ventricular fibrillation. Contraindications: i Lidocaine is contraindicated in second-degree heart block, Mobitz II; complete AV block; and Stokes-Adams syndrome. If PVC's occur in conjunction with sinus bradycardia, the bradycardia should be treated first. Side Effects: Drowsiness, numbness, dizziness, blurred vision, tinnitus, muscle twitching, and seizures. I.E. Lidocaine y Toxicity. Warnings. Lidocaine is metabolized in the liver. In patients with liver disease and low cardiac output states, e.g., acute MI shock, congestive heart failure; patients older than 70 years, the drip should be run at 1-2 mg./minute or Q half the regular rate. 191 Packet Pg.752 C.13.a Dosage N CD r- 0 Adult— 1.0-1.5 mg./kg. IVP, repeat with 0.5-0.75 mg./kg. every 8-10 minutes if necessary to a total of 3 mg./kg. For infusion, mix 1 gram in 250 ml D5W and run at 2-4 mg./minute (30-60 drops per minute). Pediatric— 1 mg./kg. IVP, For infusion, mix 100 mg. Lidocaine in 100 ml Normal Saline to infuse at a rate of 20-50 mcg. /kg. /min. 0 U 0. 0 i c 192 Packet Pg.753 C.13.a cv CD cv r- 0 0. cu cu 0) c cu 0 L) CL i c 193 Packet Pg.754 l u ) CZOZ-9L-qo u n ayl L -LV W aigw ss l - -a ':wodsuej_L q4lBGH lBuOl4BN :4u8wq3B44V LO M 11A cr U a d ';tC a N � N N O N 41 O N N N O Uc) U co o U O (y co N N N ~ N 1O O � U U c� _ U ,c N W p co O U co aj p � _ [x z � c W o co f� U p o W z p W o a co z � U co � z a o ul z Cl) � co , ") ° U � W O � W �No0 co � t a) o oco ° UCZ w U 1 00 O a' GW 'a N W O L N O U p ❑ O O O N Q N U C} W W O Cl) � � � U) O H co U Q a FUGZ.� co co Z, � W u co z co z o co E U .d o in o Cl) a) W w N co 0 G4 d W '" W co ,c o Cl) a 0 H Q