Item F05 F.5
Coty f � ,�� ,' BOARD OF COUNTY COMMISSIONERS
�� Mayor David Rice,District 4
The Florida Keys � Mayor Pro Tem Craig Cates,District 1
y Michelle Coldiron,District 2
James K.Scholl,District 3
Ij Holly Merrill Raschein,District 5
County Commission Meeting
November 15, 2022
Agenda Item Number: F.5
Agenda Item Summary #11279
BULK ITEM: Yes DEPARTMENT: Emergency Services
TIME APPROXIMATE: STAFF CONTACT: Steven Hudson (305) 289-6342
NA
AGENDA ITEM WORDING: Approval for renewal of a Class A Certificate of Public
Convenience and Necessity (COPCN) to the City of Key West Fire Department (KWFD) for the
operation of an ALS transport ambulance service (including inter-facility transports on an as needed
basis), for the period December 10, 2022 through December 9, 2024.
ITEM BACKGROUND:
The City of Key West Fire Department's (KWFD's) existing Class A COPCN certificate will be
expiring on December 9, 2022. In view of the foregoing, KWFD is applying to renew this Class A
COPCN for the period December 10, 2022 through December 9, 2024.
PREVIOUS RELEVANT BOCC ACTION:
On November 17, 2020, the MCBOCC approved (Item G.6) the renewal of a Class A COPCN to
City of Key West Fire Department for the operation of an ALS transport ambulance service
(specifically inter-facility) for the period December 10, 2020 through December 9, 2022
On November 20, 2018, the MCBOCC approved (Item G.6) the renewal of a Class A COPCN to
City of Key West Fire Department for the operation of an ALS transport ambulance service
(specifically inter-facility) for the period December 10, 2018 through December 9, 2020.
On November 22, 2016 the MCBOCC approved (Item F.32) the issuance of a Class A COPCN to
City of Key West Fire Department for the operation of an ALS transport ambulance service
(specifically inter-facility) for the period December 10, 2016 through December 9, 2018.
CONTRACT/AGREEMENT CHANGES:
None
STAFF RECOMMENDATION: Approval
DOCUMENTATION:
Packet Pg. 229
F.5
KWFD-Class A COPCN Application Redacted
KWFD Class A Certificate 12.10.2022 - 12.09.2024
KWFD Existing Class A Certificate 12.10.2020 - 12.09.2022
FINANCIAL IMPACT:
Effective Date: 12/10/2022
Expiration Date: 12/09/2024
Total Dollar Value of Contract: N/A
Total Cost to County: N/A
Current Year Portion: N/A
Budgeted: N/A
Source of Funds: N/A
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount: N/A
Grant: N/A
County Match: N/A
Insurance Required: Yes
Additional Details: N/A
REVIEWED BY:
James Molenaar Completed 10/27/2022 1:18 PM
Steven Hudson Completed 10/28/2022 10:37 AM
Purchasing Completed 10/28/2022 3:06 PM
Budget and Finance Completed 10/30/2022 11:30 AM
Risk Management Completed 11/01/2022 11:34 AM
Lindsey Ballard Completed 11/01/2022 12:45 PM
Board of County Commissioners Pending 11/15/2022 9:00 AM
Packet Pg. 230
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MONRE COUNTYt FLORIDA
APPLICATION FOR CERTUICATE OF PUBLIC CON ENjENCE AND I E ESSIT (CopCN)
CLASS A EN[E GE TCY MEDICAL SERVICE
(PRINT OR TYPE)
El INITIAL APPLICATION-$ .00 IN RENEWAL APPLICATION-$475,00
IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: 20-05A
1. NAME OF SERVICE Cry of Key Nest Fire Department
B S NESS MAILING ADDRESS 1600 N- Roosevelt Blvd.
BUST]KESS PHONE 30 - 09-3 96 3O ,8O � 3
NMER MERENCY PHONE NxrE
. 'TYPE OF OWNERS H (Le.,Sole Proprietor,Partnership,Corporation,etc.) City Government
DATE OF INCORPORATION OR FORMATION OF THE BUSMM ASSOCIA110N City of l ey West
LIST ALL OFFICERS,DIRECTORS,AND S AREHOLDERS(Use separate sheet ff necessary),
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4. LEVEL of CARE TO BE PROVIDED: ❑BLS or 1Z AIDS
IF ALS:00 TRANSPORT or 0 NON TRANSPORT
51 DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet If neeenary):
City of Key west property, Induding the areas of north Stec Island and U.S. Naval.
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Pr per es belonging tD the Nagai Air Station Key West k ated within the Key Vilest Cfty Limits.
Provide inter-facilitytrans ort thro hout Monroe
Wo on are a needed basis.�
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. LIST THE ADDRESS ANDIOR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB-
STATIONS ]se separate sheet if oecar ;
BASE STATION Station #3 = 1499 Kennedy Drive, Key West FL, 33040
S TATION Station # - 1600 North Roosebeft Blvd, Key West FL, 33040
Station #2 - 616 Simonton Street, Key best FL 33040
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Page 1 of 6
. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC nccn ):
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81 LIST T FLAMES AND ADDRESSES OF THREE US.CI=NS WELL ACT AS REFERENCES FOR
YOUR SERVICE.
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NAME AwDDRESS
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Patti McLauchiin, City Manager R0. Box 1409 Key West FL, 33040
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Alan Averette, Fire Chief KWFD 1600 N. Roosevelt
Blvd. Key feet FL 33040
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Edward Peru, Deputy Chief KW1600 I i Rooseveft Blvd. Key West FL 33040
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* ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD,
10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD.
11. ATTACH A COPY OF YOUR SERVICE'S CONITtACT WITH A 11 DICAL DIRECTOR.
12, ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR.
13, ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE
MONROE COUNTY BOARD OF COUNTY CommiSSIONER ,
L THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE
MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY b=ICAL SERVICE IN MONROE
COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST TRAY ALL THE INFORMATION CONTAINED I
THIS APPLICATION,TO THE BEST OF My KNOWLEDGE,LEDGE,IS TRUE AND CORRECT.
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CREW MEMBER LEVEL EMT/MED# EXPIRATION
ABREU, FRANK EMT-P PMD532633 12/1/2022
ACEVEDO,JESUS EMT-P PMb16498 12/1/2022
ANDERSON,MICMAEL EMT-P PMD532768 12/1/2022
AM50N,TIM EMT-P PMD519511 12/1/2022
ARENCIBIA, BLAKE EMT-B EMT578600 12/31/2024
AVERETTE,ALAN EMT-P PMD502241 12/1/2022
BARBA, CARLOS EMT-P PMD515113 12/1/2022
BARBER, RIELY EMT-P PMD529644 12/1/2022
BARROSO, GREG EMT-B EMT80693 12/1/2022
BARROSO,JASON EMT-B EMT88454 12/1/2022
BELLINGHAM,THOMAS EMT-P PMD532853 12/1/2022
BELLO,ARAM IS EMT-B EMT565445 12/1/2022
BERGER,DERECK EMT-P PMQ532607 12/1/2022
BIXLER,ISAAC EMT-P PMD525843 12/1/2022
BLANCO, BRANDON EMT-B EMT548902 12/1/2022
BOGOEFF,}ASON EMT-P PMD523492 12/1/2022
BOUCHARD,THOMAS EMT-S EMT516809 12/1/2022
BRINGLE,GREG EMT-$ EMT22205 12/1/2022
BROGI.I,DUDE EMT-P PMD528169 12/1/2022
BUTLER, COLTON K EMT-B EMT307364 12/1/2022
CATENA,IONATHAN EMT-B EMT307779 12/1/2022
CERVANTES,T1fRONE EMT-B EMT85206 12/1/2022
CLINE,SHAWN EMT-B EMT545188 12/1/2022
COLL,ARiEL EMT-P PMD513622 12/1/2022
pIETZ,WILLIAM EMT-B EMT540873 12/1/2022
FRANCO, RAUL EMT-B EM7505500 12/1/2022
FRANCO, ROBERT EMT-P PMQ205393 12/1/2022
GEREZ,GREG EMT-B EMT76153 12/]./2022
GOMEZ, RiCHARD EMT-P PMD522218 12/1/2022
GUIEB,ANDRE EMT-P PMD532804 12/1/2022
GUIEB,ANGELO EMT-6 EMT564500 12/1/2022
GURNICZ,STEPHEN EMT-P PMD528281 12/1/2022
HAMEL, REINHART EMT-P PMD543537 12/1/2022
HARRIS,ANDY EMT-P PMD515372 12/1/2022
HERNANDEZ, KEITH EMT-P PMp525105 12/1/2022
HERNANDE2, KEVIN EMT-B EMT556356 12/1/2022
JONES,TODD EMT-P PMD531865 12/1/2022
JONES,TYLER EMT-B EMT553363 12/1/2022
JONES,WESLEY EMT-P PMD518354 12/1/2022
KIELMAN, MICHAEL W EMT-B EMT530186 12/1/2022
KIMBLER,AUSTIN EMT-B EMT55846$ 12/1/2022
KLOTHAKIS,JASON EMT-B EMT515355 12/1/2022
KOCIS, BRANDON EMT-B EMT520215 12/1/2022
KOURI,JENNIFER EMT-P PMD511737 12/1/2022
LAROSA, BRITTAIVY EMT-B EMT573044 12/1/2022
LOWS, BENJAMIN EMT-B EMT515496 12/1/2022
MALONE, KYLE EMT-P PMD531866 12/1/2022
MALOTT,JOHN PETER EMT-B EMT562480 12/1/2022
MALTESE,ANGELINA EMT-B EMT520864 12/1/2022
MATAS,HILARY EMT-P PMD527300 12/1/2022
MEANS,IASON EMT-B EMT82448 12/1/2022
MEANS,TODD EMT-B EMT548521 12/1/2022
MERA,JORDAIN EMT-P PMD517225 12/1/2022
MILLER, DARREN EMT-B EMT563944 12/1/2022
MONAHAN,RANDY EMT-P PMb532433 12/1/2022
MONSALVATGE,STEVEN EMT-P PMD533244 12/1/2022
MORALES, DANIEL EMT-P PMD533497 12/1/2022
MOSBLECH,WILLIAM EMT-B EM7567921 12/i/2022
NELLER, LOGAN EMT-B EMT568855 12/1/2022
PARKA, DANIEL EMT-B EMT553989 12/1/2022
PELLICIER,SCOTT EMT-B EMT73981 12/1/2022
PEREZ, EDWARD M EMT-P PMD507572 12/1/2022
PEREZ,ANDREW EMT-P PMD531864 12/1/2022
PERRY,JAKE EMT-B EM770631 12/1/2022
PERRY,KENNAN EMT-B EMT567985 12/1/2022
PICHARDO,JOSE EMT-B EMT509099 12/1/2022
RATCLIFF, FRANK EMT-B EMT561434 12/1/2022
RODRIGUEZ, KORfY EMT-P PMD532619 12/1/2022
ROGERS,JAMES EMT-P PMD535286 12/1/2022
ROSE, BRIAN EMT-P PMD521924 12/1/2022
RUBLE,BOBBY EMT-B EMT558649 12/1/2022
SAUNDERS,CHRIS EMT-B EMT74014 12/]./2022
SELLERS, KEITH EMT-B EMT76645 12/1/2022
SELLERS, MARK EMT-B EMT62428 12/1/2022
SELLERS, MARK L. EMT-B EM7576426 12/1/2022
SMITH,TERRANCE EMT-B EMT578475 12/31/2024
STEHLY,JERAMY EMT-B EMT563193 12/1/2022
TORRES,JQHN EMT-P PMD518522 12/1/2022
VARELA,FREDDY EMT-B EMT55955 12/1/2022
VEGA,VINCENT EMT-P PMb532$09 12/1/2022
WAGNER, KARL M EMT-B EMT531497 12/1/2022
WALKER,JACK EMT-B EMT510238 12/1/2022
WARD, BRANDQN EMT-6 EMT304563 12/1/2022
WILLIAMS,KYLE G EMT-B EMT518288 12/1/2022
ZARATE, bAVID L EMT-6 EMT88441 12/1/2022
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THE CITY F KEY WEST
.....................Post................I I..........a..........................O111ffice........11.........................................Box........................1409 Ike' l t, FL 33041 1.........140 0 ,Il 09-.............3939
To: Cheri Tanmborski
From: Keith Hernandez
Date: October 1, 2022
Reference: City of Ivey West Fire Dept Rate Schedule
Cheri,
The rate schedule below is our current list of rates previously approved by the City
Commission for ambulance services within the City of Ivey West. It is the City's desire to
provide complete disclosure of all charges and fees associated with the delivery of
ambulance services. As such the City shall provide any proposedchanges to this current
rate schedule to the . .C.C. during this C. .P.C.N. period.
Base Date for all levels of transport:
Basic Life Support Emergency$600.
Advanced Fife Support Emergency (Medicare ALS-1) $750.
Advanced Life Support Emergency Medicare ALS-2 $950.
Mileage charge $14.50 per loaded mile.
Emergency stand-by charge at any incident- No charge for stand-by.
Non-emergency or scheduled stand-by event- 1 f a unit is committed to the scene, the
city may charge a reasonable fee.
u
U
Keith W. Hernandez
Division Chief of EMS
Key West Fire Department
1499 Kennedy give
Phone 0 - 79
khernande @cityofl eHest-fl.Gov
Serving the Southernmost City
DATE(MMIDOfYYYY)
CERTIFICATE OF LIABILITY INSURANCE 10/ /2 2
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER( ), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsements.
PRODUCER CONTACT
kmF,. Jenna Jennings
World Risk Management PHONE .4tip- 445 414 FMa
o:4 7 4 5
2 .Orainge Ave., 41AL
Suite 500 AwgEssn jenniferjennings COM
Orlando FL 32801 INSURE s AFFORDING CO E1 AGE HAIC 0
INSURER A:Public Risk Management of FL
INSURED KE WEST i INSURER B:
City of Key West
1 White Street INSURER
Key Vilest EL 33040 INSURER D:
WSURER E
IsuaER F
COVERAGES CERTIFICATE NUMBER:1450480454 REVISION NUMBER:
L
HIS I TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED T THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
DICATED. NOTWITHSTANDING ANY RE UIREMENT.TERRA OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I SUBJE T TO ALL THE TERMS,
CCLUSION AND CONDITIONS OF SUCH POLICIESrADOLBUO.LIMITS SI-IIV AAAI HARE BEEN REDUCED BY PJ#ID LAilS.
TYPE OF INSURANCE R POLICY NUMBER POLICY EFF POLICY E�IP OMITS
A X COMMERCIAL GENERALLIABILITY PRM022-009 73 1011/2022 I(Vl/2023 EACH OCCURRENCE A 1,0D0,000
CLAIMS-MADE OCCUR DAMAGE TO-RENTED PREMISES Ea omnen �O ,O D
MED EXP(Arty one persm) EXCLUDED
PERSONAL s ADV INJURY S 1,000,000
GENIL AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $
PRO-
POLICY JECT LO PRODUCTS-COMP/OP AGG $
OTHER- SELF INS.RETENTION $100,000
A AUTOMOBILE LuslLMY PRM0 -00 -07 10111 0 1011I 0 Ms NED s NGLE L IT 1,000, 0
Ea aoddent
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per aooida t)
AUTOS ONLY AUTO$
X HIRED X NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTO$ONLY P t
X APO I I I SELF INS.RETENTION $25.000
UMBRELLA LIAR OCCUR EACH OCCURRENCE
EXCESS LIAR CLAIM$4WADE AGGREGATE $
DED I I RETENTION
A WORKERSCOMPENSATION PRM02 -M4D7J 1011/20 1011/202
-
AND EMPLOYERS!LIABILfff YIN
STATUTE ER SIR 25 000
ANYPROPRIETORJPARTNERIEXECUTIVE N 1 l E.L.EACH ACCIDENT $1,000,000
OFFICERWEMBER EXCLUD ED?
(Manda ry In NH) E.L.DISEASE-EA EMPLOYEE $1,000,0W
If ,describe under
0 6RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT1.DOO.DOQ
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Addilfwal ftmrks SdW dine.may be a#la sd If morn space Is"Ire)
E:Advanced/Basic Life Support Service License
With respects to the listed coverage held by the named insured,as evidence of insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICtES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
State of Floridan Department of Health Emergency Medical ACCORDANCE W"THE POLICY PROVISIONS.
Services
4052 Bald Cypress Way Biro C-30 AUTHOR D REPRESENTATIVE
Tallahassee FL 3399-1 73
1988, 1 ACORD CORPORATION. All rights reserved.
ACORD 25( 01610 ) The ACORD name and loge are registered mars of A ORD
w
Medical
AGREEMENT THIS AGREEMENT entered this 13 day of December 2021,by and between the
CITY OF KEY WEST,a Municipal Corporation organised and existing under the laws ofthe State
of Florida (hereinafter referred to as CITY), and Antonio Gandia, M.D, whose address is 9593
Tavernier Drive,Boca Raton,FL 334 h r ina er referred to as MEDICAL DIRECTOR).This
agreement will remain in effect for a period of 12 full months,terminating January I,2023 unless
modified or terminated by either party.
ARTICLE
SCOPE OF SERVICES MEDICAL DIRECTOR shall provide the following services:
1 Full-time medical direction by a competent,Florida,board-certified,licensed physician,either
MEDICAL DIRECTOR or designate,will be on call and available 24-hours a day for the CITY to
answer questions within the scope of this agreanent.
2 MEDICAL DIRECTOR shall be responsible for any certifications, advice,or participation of
his designate as if MEDICAL DIRECTOR were directly performing the service.
3 Protocol Development - protocols will be developed and revised as needed. MEDICAL
DIRECTOR will review and approve the training of emergency medical technicians and
paramedics who will function under the MEDICAL DIRECT Ws direction.
4 Quarterly Meetings # in concert witb the Fire Chief and his staff, the MEDICAL DIRECTOR
ill establish quarterly meetings for the purpose of education and duality review.
5)Record Keeping-necessary continuing medical education records will be kept by the CITY OF
KEY WEST FIRE DEPARTMENT,TENT, EIS Division, along with documentation of meeting
attendance.Additionally,the MEDICAL DIRECTOR will assist in license recertification.
6) Quality Assurance - MEDICAL DIRECTOR will establish a Continuous Quality Assurance
program and committee for the purpose of developing a process that will include the establishment
of a methodology for quality.improvement.
7)Provide all services as are specifically contained in Section 64&2 of the Florida Administrative
Code,as amended.
8)Shall approve any new equipment and see to that proper training is provided to all personnel on
its use prior to any use in the field. An addendum shall be made to the protocols if this piece of
equipment is not already included in the protocols and shall be signed by the MEDICAL
DIRECTOR.
City o, 'Key West— andid Me&cal Director Agreement
Par I ofs
9 Shall maintain a valid IDEA license for the purpose of storing and administering narcotic
medications for the City of Ivey west Dire Department.
1 Shall provide a method of administering or approving a Continuous Education Program for
ffic purpose of training and recertification of all personnel.
11 Shall attend quarterly EMS meetings to discuss any emergency medical services activities and
to implement new policies and procedures when necessary.The Medical Director shall be the chair
of these meetings.
1 2 Shall provide a process and mechanism for the recertification of ACLS,BLS/CPR,PALS,and
any other certification that the Medical Director requires.
1 Shall be available to handle any Infectious Control situations that should arise during daily
activities.The Medical Director or Designee will educate the crew on the proper handling of these
situations. This shall be in conjunction with the policies and procedures of the CITY OF KEY
WEST FIRE DEPARTMENT,
T,
14 Shall assist in managing any Critical Incident Stress Debriefing that may be needed and work
closely with the CISD team to assure the safety and wellbeing of all personnel.
1 Shall meet with the Fire Chief or Designee on a monthly basis to update him on the status of
the emergency medical service being provided by the CITY OF KEY WEST FIRE
DEPA T.
l Shall create and maintain a valid Florida Shots account with the City of Ivey west Fire
Department as a provider.
ARTICLE LE H
The CITY agrees to the following:
1 The CITY OF KEY WEST FIRE DEPARTMENT ARTh ENT will provide administrative liaison through
the Fire Chief to MEDICAL DIRECTOR through the direction of its Fine Chief and will
cooperate to the greatest passible extent in the delivery of competent amergency medical care,
including implementation of the policies set by MEDICAL DIRECTOR.
2 To pay MEDICAL DIRECTOR as follows:The sum of$2166.66 per month commencing on
January 1,2022,for the services provided pursuant to this agreement,and such payments shall
be made with forty-five 4 days following the receipt of MEDICAL III T OR!s invoice
for such services rendered.
For each in omplete monthly service,payment shall be prorated accordingly based on the number
f days of service.
City of Key West—Gan&a Medical Director Agreement
Wage 2 o,f
"TILE M
1) CITY agrees to provide adequate liability insurance coverage for its employees while under
the training and supervision of MEDICAL DIRECTOR.
2 MEDICAL DIRECTOR. covenants and agrees to indemnify and hold CITY and any of its
employees harmless from any liabilities and allcgations arising out of this agreement if such
liability shall be a result of any acts or omissions on the part of MEDICAL DIRECTOR.
06
MEDICAL DIRECTOR shall maintain a minimum liability insurance coverage of
l 9,000,000 3,000,000 for the term of the contract.
LE 1PV
l It is understood and agreed by the parties hereto that should it be determined that any
participant in the EMT paramedic training program,as set forth herein, does not have the
requisite skills to continue in such training or to perform services as an EDIT or paramedic,
MEDICAL DIRECTOR shall immediately notify the CITY in writing ofthe name ofsuch
employee and the reason for belief of such participant's lack of skills to serve as an EMT
or paramedic. within forty-five 4 days after receipt of MEDICAL DIRECT R's notice
as to training, the CITY shall determine whether the participant may continue in such
training, However, should the CITY fail to notify MEDICAL DIRECTOR within forty-
five days as to the participants termination from such training, or should the CITY
allow the participant to continue such training,CITY agrees that MEDICAL DIRECTOR
shall not be liable for any injuries directly resulting from the acts of the said participant
and MEDICAL DIRECTOR shall be held harmless as set forth in Article III above. In no
event shall an EMT or paramedic who has been cited by MEDICAL DIRECTOR as lacking
the adequate skills required of the said profession be pernitted to service and ride as an
EMT or paramedic unless the person is deemed qualified as determined in the sole
discretion of MEDICAL DIRECTOR. The parties hereto acknowledge that all EMS and
paramedics are performing duties under the license of MEDICAL L DIRECTOR.
ARTICLE
1 Either party shall have the right to terminate this agreement upon giving thirty 0
days'written notice to the other party. Also, this Agreement is subject to a sufficient
appropriation under the 2022-2023 fiscal year budget.
2 The CITY shall have the right to terminate this agreement upon written notice upon the
following:
a That MEDICAL DIRECTOR has failed to comply with the teens of this
agreement.
b That MEDICAL DIRECTOR has failed to provide competent services as
medical director.
City o bey West---Gandia Medical Director Agreement
Page
c That MEDICAL DIRECTOR is unable to perform services as pmvided for
herein for some reason not attributable to the CITY.
3) That services delivered by the CITY changes substantially to the extent that the services
of a medical director are no longer required.Should the CITY terminate this agreement
for any of the above reasons, CITY agrees to pay MEDICAL DIRECTOR for all
services rendered up to the time of termination. Such payments shall be made tan(10)
drays after the termination of this agreement, provided that all property belonging t
CITY shall be returned prior to the release of monies owed to MEDICAL DIRECTOR..
ARTICLE V1
1 This Agreement incorporates and includes all prior negotiations, correspondence,
conversions,agreements,or understandings applicable to the matters contained herein and
the parties agree that there are not commitments,,agreements,or understandings conceming
the subject matter of this agreement that are not contained in this document.Accordingly,
it is agreed that no deviation from the terms hereof shall be predicated upon any prrior
representations or agreements,whether oral or written.
2 It is further agreed that no modifications, amendments, or alterations in the terns or
conditions contained herein shall be effective unless contained in a written document
executed with the same fonnality and of equal dignity herewith.
RENDER of PAGE INTENTIONALLY DEFT BLANK
City of Key West—Gandia Medical Director Agreement
Page 4 of
Di%Tnqws ,the pmrdm have hwVMtD sit ter ids seals to day year
fim above wflum
THE CrrY OF KEY WEST
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Peke 5 of
BOARD OF COUNTY COMMISSIONERS
County of Monroet Mayor David Rice,District 4
FloridaThe
Mayor Pro Tem Craig Cates,District 1
f
Michelle Coldiron,District 2
James K.Scholl,District 3
. Holly Merrill Raschein,District 5
Monroe County Fire Rescueti`
490 631d Street Ocean
Marathon,FL 33050 1.
Phone(305)289-6088 '
MEMORANDUM
TO: Nicole Rhodes
FROM: Cara Johnson
SUBJECT: Check for Deposit- COPCN
DATE: October 18, 2022
Attached please find Check dated October 7, 2022 in the amount of$475.00 to be deposited
in revenue account 141-342000-RC 00345. This check has been issued for the renewal application of
a Class A Certificate of Public Convenience for the City of Key West Fire Department.
Thank you,
C-"'
Cara Johnson
The City of Key West VENDOR ID VENDOR NAME CHECK DATE CHECK NO.
Post Office Box 1409 V0008308 MONROE COUNTY BOARD OF COUNTY 10, °G�7 "2
Key West,Florida 33041
INVOICE DATE PO NUMBER DESCRIPTION ION ACCOUNT NET AMOUNT
0— 5 10/ 1/22 P09703 APPLICATION FOR CERTIFICA 41175.00
TOTAL 4 7 -0 0
FIRST STATE BANK
The City of Key West OF,THE FLORIDA KEYS
Operating Account 83-43 DATE
Post Office Box 1409 ero 10/07/22
Key West,Florida 33041
PAID"ACTL1
PAY FOUR of SEENTY FIVE D an ER C 7 .0°0
VOID IF NOT CASHED WITHIN 6 I ONITHS
ITOTHE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
ORDER 500 WHITEHEAD STREET
OF
KEY WEST, FL 33040UIA)
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United States of America
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ALS Medical Emergencies
Al/ergic Reaction P. 33
Diabetic Emergencies P. 35
Aff
Dystionic Reaction p. 37
Fluid ResuscitationlDehydration P. 38
Hyperkalemia P. 39
NausealVomitin-q p. 40
Respiratory Distress p. 41
Seizure p. 43
Sepsts p. 44
Stroke p. 46
ii" BOOM-....... i
Table of Contents
MI
Back to Table
of Contents, Table 'Of Cdntients
Table of Contents
AP
.........................
Back to Table Table of Contents
of Contents,
ir,WF,
Table Of Contents
E n
Back to Table 6
of Contents, Table 'of Cdntients
Editors Contributors
CHIEF OF EMS
Division Chief Keith Hernandez
MEDICAL DIRECTOR
Dr. Antonio Gandia MD FACEP NREMT
Dr. Aldo Manresa DO
EDITORS
• Bill McGrath; North Lauderdale Fire Rescue; Battalion Chief of
EMS
• Dr. Antonio Gandia MD FACEP NREMT
Special Recognition:
A special thank you to Dr. Ken Scheppke of Palm Beach County Fire Rescue
and Dr. Jim Roach of Broward Sheriff Fire Rescue and their staff for
permission to utilize their protocol template and publishment of protocols.
Editors & Contributors 8
Medical Di*rector
kill",
Ent?'',
The following Emergency Medical Services Protocols are the Official Advanced and Basic Life Support Protocols for
the City of Key West Fire Department and are approved for such use by Paramedics and EMTs of the department to
care for the sick and injured. Only those Paramedics and EMTs approved by the Medical Director shall be authorized
to utilize these protocols.
These medical treatment protocols have been developed as a part of the medical direction program for
participating Emergency Medical Services(EMS)agencies. The medical director of an individual EMS provider may
choose to modify certain treatment recommendations. In addition, some patients may require therapy not
specified in these protocols. The treatment protocols should not be construed as prohibiting such flexibility. The
paramediclEMT must use his/herjudgment in administering treatment. When the paramediclEMT is unable to make
contact with otherforms of medical direction, helshe may contact the receiving hospitalfor consultation
with the emergency department physician. It is recommended that the paramediclEMT make contact with the
physician for consultation on complicated patients whenever possible. When the paramedic is unable to make
contact with a physicianfor medical direction, the paramedic may administer BLS treatment according to his/her
judgment. In this instance,, the paramedic may administer ALS treatment only as authorized in the treatment
protocols.
Medical DirectoiJs Page 9
Diesclaiamer and Desc tion
rip
All adult protocols in this document will be listed with this icon before any in-
structions. In addition, the adult portion of the protocol will have a red outline.
Fit,
All pediatric protocols in this document will be listed with this icon before any
instructions. In additionl the pediatric portion of the protocol will have a blue
outline.
Disclaimer and Description
"Af
...........
'R',R
SO
4Y,
loom=
Back to Table, 12,
of Contents, Standing Orders
General Information
ADULT& PEDIATRIC
MEDICATION ADMINISTRATION
• Prior to administering any medication, inquire about medication allergies or adverse reactions to
medications
• A true allergy to a medication causes a rash, SOB, swelling of the tongue,face and/or throat
INTRAOSSEOUS SITES (EZ-10)
• An 10 should be placed for patients with emergency medical conditions that require urgent vascular
access in whom an IV is not immediately obtainable or is deemed to have insufficient access
• Ad u It:
• Proximal Humerus
• Proximal Tibia
• Distal Tibia
• Pediatric:
• Distal Femur
• Proximal Tibia * Preferred
• Distal Tibia
• Proximal Humerus(only if the surgical neck can be palpated)
IM INJECTIONS
• All IM injections shall be administered in the lateral thigh or Deltoid
• Ad u Its:
0 21-23 gauge 1.5 inch needle
0 4mL maximum per site
• Pediatric:.
0 23 gauge 1 inch needle
0 1mL maximum per site
0 If> 1mL needs to be administeredl split the dose between both thighs
MUCOSAL ATOMIZATION DEVICE (MAD)
• The following medications can be administered via the
MAD:
• Versed
• Ketamine
• Narcan
• Glucagon
• Ativan
• Desired dose:
• 0.3mL-0.5mL per nostril
• Max 1mL per nostril
Back to Table General Infotmadwon 13
of Contents,
General Informationcontinued...
kill"
NMI
PEDIATRIC
0 Patients who have not reached puberty are considered pediatric patients and shall be treated under
the pediatric guideline section of these protocols
0 Patients who have reached puberty shall be treated as an adult
0 10 is the preferred method of vascular access during pediatric cardiac arrest
THE "'HANDTEVY""SYSTEM
• The "'Handtevy"'system shall be utilized in the resuscitation and treatment of all pediatric patients
• The child"s age should be used as the primary reference point for determining the appropriate patient
ca re
• If the child appears shorter or taller than stated age or if the age is unknown use the "Handtevy"
system length based tape
• Refer to the "'Handtevy-"system for the following:
• Medication Dosages/Infusions
• Equipment
• Electrical Therapy
• Vital Signs
PEDIATRIC AGE CLASSIFICATIONS
0 Newborn:
0 Birth to 24 hours
0 Neonates:
0 1 Day to 1 month
0 1 nfa nts:
0 1 month to 1 year
0 Children:
0 1 year to puberty
Pediatric patients for medical transport will be considered 17 years and 364 days old
Pediatric patients for trauma transport will be considered 15 years and 364 days old
PUBERTY
[* Female puberty is defined as breast development.
Male puberty is defined as underarm,chest or facial hair.
0 ol
nce a child reaches puberty, use the adult guidelines for treatment.
Back to Table General Infotmadwon 14
of Contents,
Patient Assessment
!2Z
ADULT& PEDIATRIC
Patient with Altered Mental Status consider:
MENTAL STATUS(AVPU)
AEIOU-TIPS
0 Alert:to person, place, time, and event(AAOX4) 0 Alcohol
0 Verbal: responds only to verbal stimuli 0 Epilepsy(Seizures)
0 Pain: responds only to painful stimuli 0 Insulin (Hype r-/Hypoglyce m ia)
0 Unresponsive 0 Overdose/Oxygenation
0 Uremia (Kidney Failure)
VITAL SIGNS
• Pulse (rate, rhythm and quality) 0 Trauma
• Respirations(rate and quality) 0 Infection (Sepsis)
• Skin (color, condition) 0 Psychiatric
• Temperature 0 Stroke/Shock
• Pulse Oximetry mi
• Blood Pressure (capillary refill)
• EtCO2
• BGL
• Pain Scale (1-10 scale or Wong Baker Scale)
• ALL patients shall receive at least 2 sets of vitals
• Unstable patients shall receive vitals every 5 minutes
• A manual Blood Pressure shall be taken to confirm any abnormal or significant changes of an automatic
Blood Pressure cuff reading
• Blood Pressure shall be checked before and after administration of a drug
• Hypotension for adults is defined as Systolic BP <90 mm Hg
ETCO2
Shall be utilized for the following patients:
• Patients requiring ventilatory support(e.g.,. BVM,. ET tube,SGA, CPAP)
• Patients in respiratory distress
• Patients with Altered Mental Status
• Patients who have been sedated
• Patients who have received pain medication
• Seizure patients
GLUCOSE
A BGL shall be documented for patients with any of the following:
• History of diabetes
• Altered mental status
• General weakness
• Seizure
• Syncope/lightheadedness
• Dizziness
• Poisoning
• St ro ke
• Cardiac arrest
Back to Table
P
a it A s
of Contents, , den , o se, sment is
ati"ent Assessmentcontinued...
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ADULT& PEDIATRIC
ECG MONITORING
0 All ALS patients shall be continuously monitored in lead 11
0 12 lead/15 lead ECG shall be performed on the following patients:
Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort
• Palpitations
• Syncope, lightheadedness,general weakness, or fatigue
• CHF., SOB., hypertension or hypotension
• Unexplained diaphoresis or nausea
0 12 lead ECGs shall be repeated every 10 minutes and upon ROSC
When transporting, leave cables connected until patient is turned over to the Emergency
Department(ED) staff
PATIENT HISTORY
• CHIEF COMPLAINT: Why did the person call 911?
• S.A.M.P.L.E. HISTORY(S.A.M.P.L.E)
• SIGNS&SYMPTOMS
• ALLERGIES
• MEDICATIONS: Prescribed, over the counter.,or not prescribed to patient
• PAST MEDICAL HISTORY(patient"s and immediate family's)
• LAST ORAL INTAKE
• EVENTS PRECEDING
• HISTORY OF THE PRESENT ILLNESS (O.P.Q.R.S.T.A)
• ONSET: Did the symptoms appear gradually or suddenly?
• PALLIATIVE: What makes the symptoms better?
• PROVOKE: What makes the symptoms worse?
• PREVIOUS: Previous similar episodes?
• QUALITY: (What kind of pain?) pressurel squeezing,aching,dull,etc.
• RADIATION: Does the pain or discomfort radiate?Where?
• SEVERITY OF PAIN: 1-10 scale (utilize "Faces," pain scale for pediatrics)
• TIME: What time did the symptoms begin?
• ASSOCIATED: What are the associated signs &symptoms?
Back to Table
P
a
of Contents, , dentAssessment 16
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Patio'ent Assessmentcontinued...
�E'nl'
Determination of Death
Person should be considered clead/non-salvageable that have all of the following presumptive signs of death and
one conclusive sign of death.
.Presu,miotiv
• Apneilc
• Pulseless,
• Fixed Dillated Pupils
Conclusive
• Decomposition
• Rigor mortis
• Liver mortis (Lividity)
Injuries incompatible with life
• Patients with suspected hypothermia, barbiturate overdose, or electrocution require full ALS resuscitation un-
less they have injuries incompatible with life or tissue decomposition
• Children are excluded from this protocol unless EMS personnel make contact with medical direction for consul-
tation.Only in cases of obvious, prolonged death should CPR not be started or discontinued on infants, chil-
dren or young adults,or in cases in which an unexpected death has occurred.
Back to Table W
'Am aq& 17
of Contents, Pal r'ien t A ish,s", e, s,;sment
Basic Life Support
�E,ni
ADULT& PEDIATRIC
AIRWAY
AMWAY F10S[fl0MNG,-.
• Medical patient:
Position patient with external auditory meatus(a.k.a. "The Earhole")on the same
external plane as the sternal notch
• Trauma patient with suspected spinal cord injury:
0 Modified jaw thrust
NASOPHARYNGEALX��RWAY (NPA):
Semi-conscious patients with an intact gag reflex shall have a nasopharyngeal airway inserted,
unless contrainclicated
G��RGFIHX�WNGEAL AMWAY(OPA):
Unresponsive patients without a gag reflex shall have an oropharyngeal airway inserted, unless
contrainclicated
OXYGEN ADMINISTRATION
* DO NOT withhold Oxygen if the patient is dyspneic or hypoxic
* SP02..
• Maintain SP02 at least 94%for:
All patients
0 Exception: COPD &Asthma
• Maintain SP02 Of 90%for:
0 COPD &Asthma
* OXYGE�N ADK��NISTRAT�0W.
15 LPM via NR13 regardlessOfSPO2
• All 3rd trimester pregnancy trauma patients
• Decompression sickness
• Carbon Monoxide exposure
• Cyanide exposure
* If oxygen saturation cannot be maintained,ventilatory support should be provided
CIRCULATION
• Adult:
• Carotid and radial pulse present,assess capillary refill, assess skin color, condition and
temperature
• Refer to the "Cardiac Arrest" algorithm,for all patients found pulseless
• Pediatric:.
• Carotid and radial pulse present(brachial in infants), assess capillary refill,assess skin color,
condition and temperature
• Refer to the "Cardiac Arrest" algorithm,for all patients found pulseless
• Refer to the "Bradycardia" protocol,for pediatric patients found bradycardic with signs of poor
perfusion and AMS
Back to Table
of Contents, 84 Life Support 18
Ventilatory Assistance
`00�" kill
INFORMATION
• In certain patients,excessive ventilation rates may be harmful.
• Overzealous positive pressure ventilation can impair:
• Venous return
• Cardiac output
• Cerebral perfusion
• Ultimately the patients SP02 and EtCO2 should determine the ventilation rate for the patient(ideally
EtCO2 should be 35-45 mm Hg).
ADULT
VENTILATORY RATES
• PATIENTS WITH A PULSE:
0 1 breath every 6 seconds
• PATIENTS WITHOUT A PULSE-.
0 1 breath every 10 seconds
• PATIENTS WITH ICP and/oir HERM�ATION:
Maintain EtCO2between 30-35 mm Hg and SP02> 90%while continuously monitoring BP
P PEDIATRIC
VENTILATORY RATES
• PATIENTS WITH A PULSE-.
0 1 breath every 2-3 seconds
• PATIENTS WMHOUT A PULSE:
0 1 breath every 2-3 seconds
• PATIENTS WIMH ���CP and/or HERM�ATION:
Maintain EtCO2 between 30-35 mm Hg and SP02> 90%while continuously monitoring BP
WARNING
DO NOT ATTEMPT TO AGGRESIVELY NORMALIZE CAPNOMETRY/ETCO2READINGS IN THE
FOLLOWING PATIENTS:
• Cardiac arrest pre/post ROSC
• Bronchospasm (Le,asthma,,CCIPD)
• High EtCO21eve1s are acceptable and even desired in these patients
Back to Table 0, 19
VenfilatoryAssista, nce
of Contents,
Adult Transport Destinations f
INFORMATION
Priorit
0 Patients in Cardiac or Respiratory Arrest
Priorit
0 Unstable patients with immediate life-threatening conditions
Priorit
Stable patients with no immediate life-threatening conditions
WARNING
P Placing patients in the prone position is contraindicated due to the risks of asphyxiation.
However, impalement or other situations may mandate the prone position. In these instances,
o"
C clear documentation of justification and attention to airway maintenance is mandatory.
ADULT
PRIORITY 1 PATIENTS
• CARD IAC/RESP���RATO RY ARREST:
• Transport to the closest ED
PRIORITY 2 PATIENTS
* Shall be transported to the closest ED
* TRAUMA ALERT PATIENTS:
• Shall be transported to the closest Trauma Center per catchment area. If on bypass,transport
patient to the next closest Trauma Center
• On-scene times for Trauma Alert patients should be< 10 minutes. On-scene
times >.10 minutes shall have the reason for the delay documented in the ePCR report.
• If ground transport is > 20 minutes transport by air if available
• Trauma patients who arrest in the presence of Fire Rescue personnel,shall be transported to
the closest Trauma Center.
* ��:'REGNANT TRAUMA ALB�RTS (visibly or by history of gestation >20 weel<s):
Pregnant patients meeting Trauma Alert criteria should be transported to closest OB Trauma
Facility
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20
of Contents, Adult Transport Destina, Bons
Adult Transport Destinati"onscontinued....
At'
PRIORITY 2 PATIENTS CONTINUED
• STEM I/CARDIAC ALERTS
0 Shall be transported to the closest ED
0 Patient presentations that are indicative of myocardial ischernia that DO NOT meet "STEMI
Alert Criteria"should still be transported to the closest ED
• STROKE ALERTS-.
0 All Stroke Alerts shall be transported to the closest ED
• SE�:ISIS ALERT:
0 All Sepsis Alerts shall be transported to closest ED
• HY�:IERBAR�C GHAMBER (if needed):Should be brainspoirted to the closest ED
• Exaimp�es iin6�We (Noin-tirauimatic)
• Decompression Sickness
• Carbon Monoxide Exposure
• Hydrogen Sulfide Exposure
• Cyanide Exposure
• transport by air if available
• �WTUBATED ��NTERFACIU[TY TRANSFERS:
Should be both paralyzed and sedated by the sending facility
If the sending facility physician refuses to administer paralytics:
0 Follow the Advanced Airway protocol
PRIORITY 3 PATIENTS
• OBSTETR�CAL:
• Obstetrical (OB) patients are defined as gestation > 20 weeks
• Unstable OB patients should be transported to the closest OB ED
• Post-Partum up to 2 weeks
• BAKER ACT PATIENTS-.
Baker Act patients shall be transported to the closest appropriate ED for medical clearance
Back to Table 21
of Contents, Adult TranSport DeStina, tions
P
ediatri"C Transport Destinations J
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4
FEff IATRIC
D_�
PRIORITY 1 PATIENTS
'T�IANS���:IORTTO'THECLOSES'TED:
• Pediatric patients who have regained a ROSC
• Pediatric respiratory arrest cases that have successful airway management(i.e., good
compliance with the BVM and airway adjuncts, positive EtCO2waveform, improving pulse
oximetry)
• Pulseless pediatric patients
• Pediatric respiratory arrest patients who have an unstable airway(i.e., unable to ventilate or
oxygenate)
PRIORITY 2 PATIENTS
• TRAUMAXLERTPATIENTS:
• Shall be transported to the closest ED
• On-scene times for Trauma Alert patients should be< 10 minutes. On-scene times > 10 minutes
shall have the reason for the delay documented in the ePCR report.
• Trauma patients who arrest in the presence of Fire Rescue personnel,shall be transported to
the closest ED
• STROKE ALERTS/CARD�AC ALERT:
0 All Stroke Alerts or Cardiac Alerts shall be transported to the closest ED
• SE�IISIS ALERTS-.
0 All Sepsis Alerts shall be transported to closest ED
• HYPERBARIC CHAMBER (if needed): Shall be transported to the closest ED
• Exampl�es include (Noin-trauimatic)
• Decompression Sickness
• Carbon Monoxide Exposure
• Hydrogen Sulfide Exposure
• Cyanide Exposure
PRIORITY 3 PATIENTS
0 Should be transported to the closest appropriate pediatric ED.
Back to Table 22
of Contents, Pediahic TranSpod Destinations
Helicopter Transport Criteria
E n....... ......
ADULT& PEDIATRIC
'HELICOPTER OPERATIONAL CRITERIA:
0 Mass Casualty Incidents(MCI) involving multiple patients with traumatic injuries
HELICOPTER MAY BE USED:
• For patients weighing 350lbs-500lbs, discretion should be used as to whether air transport is
the preferred method of transport
• The flight crew must be capable of loading, unloading,and treating the patient within the
confines of the aircraft
• The flight crew has final authorityto accept or reject the transport
HELICOPTER SHALL NOT BE USED:
• Bariatric patient known or estimated to be five-hundred pounds (500lbs) (227kg) or greater
• Patient who is unable to lay supine (when clinically indicated for air transport)
Patient who is combative and cannot be physically and/or chemically restrained
Hazmat contaminated patient
Back to Table Helicopter Tria".51svort Criteria 23
of Contents, AV
'AO
AdO,
,A
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.........
BLS Medical Emergencies
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1 4
ADULT& PEDIATRIC
ALLERGIC REACTION
• Allergic reactions are characterized by any of the following:
• Generalized Urticaria
• Airway,,Tongue.,or Facial Swelling, Respiratory Distress, Bronchospasm
• Nausea,Vomiting, or Diarrhea
• Loss of Radial Pulse or SBP of<90 mm Hg
• Determine the source of the allergic reaction (insect, food, medications, etc.)
• If patient presents with airway swelling/respiratory distress/bronchospasm/tongue and/or facial
swelling/loss of a radial pulse or SBP of< 90 mm Hg:
0 Assist patient with prescribed Epi-Pen
CARDIAC ARREST
0 Refer to the "Cardiac Arrest"' algorithm (pg. 70),for all patients found pulseless
'OVERDOSE/POISONING
• Try to identify source of the overdose/poisoning
• Assist patient with NX11CAN if available/applicable
• Consider contacting the Florida Poison Control Center at 1-800-222-1222
SEIZURES
• Consider the possible causes:
• Meningitis 0 Drugs
• Fever 0 Alcohol
• Head trauma 0 Diabetic
• Hemorrhagic stroke Poisoning
• Protect patient from injury if actively seizing
ALTERED MENTAL STATUS
• Check and record BGL
• If BGL is< 60 mg/dL, and patient is able to protect their airway/swallow:
ORAL GLUCOSE:
* 15g, if able to swallow and follow commands
* May repeat 1x prn
* Contra i nd ications:
• Patients who are not conscious enough to swallow
• Patients< 2 years old
W,
B
LS Trauma Emergencieles
Qr-
ADULT& PEDIATRIC
i,Wo
'EXPOSE
As a general rule, only remove as much of the clothing as necessary to determine the presence or
absence of an injury. Cover the patient as soon as possible to keep the patient warm.
SPINAL MOTION RESTRICTION
• Perform manual Spinal Motion Restriction by providing manual cervical stabilization and apply an
appropriately sized cervical collar as appropriate if the patient meets any of the following criteria:
• Complaint or finding of focal neurologic deficit on motor or sensory exam
• Complaint or finding of pain to the neck or back
• Presence of a distracting injury
• Altered level of consciousness with an MOI (Mechanism of Injury)
• Intoxication with an MOI present
• The key objective is to move the patient in the safest,. most anatomically neutral position possible
• If an appropriately sized collar is not available or if the collar compels the patient to move, remove the
collar and provide Spinal Motion Restriction
• Place rolled towels on the sides of the patient's head and neck
• Secure with tape or other similar devices to allow for comfortable cervical stabilization/
immobilization
• The cervical collar should not cause the patient discomfort such that they are compelled to
move
• Place the patient on the stretcher cushion, supine
• If the patient is unable to tolerate this position, place in a position of comfort,that also respects
normal anatomical alignment and document appropriately.
HELMET REMOVAL
• Helmets without shoulder pads should be removed from all patients Le motorcycle
• If applicable, protective pads should also be removed
• Athletic trainers should be consulted in the helmet/protective pad removal process if applicable
• Spinal motion restriction should be "'manually"' performed during the removal process
BURNS
0 Refer to the "'Burn Injuries" protocol (pg. 115)
EYE EMERGENCIES
• GHEW�CAL EXPOSURES:
• Remove contact lens if present
• Irrigate the affected eye(s) with NORMAL SAUNE
• Be careful not to contaminate the unaffected eye with runoff
• ��-'-IENET�RATING EYE INJU��T�1S:
Stabilize any penetrating object
• Cover both eyes with gauze and an eye shield
• Keep the patient calm, as crying, screaming or coughing can force more of the tissue outward
• DO NOT attempt to replace or move the protruding tissue
BLS Trauma Emergencteescontinued...
CLOSED FRACTURES
Fractures should be splinted in the position found
Exception: No pulse present OR the patient cannot be transported due to the extremity's
unusual position
0 2 attempts can be made to place the injured extremity in a normal anatomical position
0 Discontinue attempts if:
The patient complains of severe pain
OR
If there is resistance to movement felt
0 Reassess neurovascular status before and after repositioning of patient"s extremity
CLOSED K0--&HAFT FEMUR FRACTURES
Apply a Traction Splint
* Contra i nd ications
• There is also a suspected pelvic fracture
• There is an open femur fracture
• There is also a suspected hip fracture
• There is an avulsion/amputation of the ankle or foot
• Suspected fracture distal to mid shaft femur
* Reassess neurovascular status before and after repositioning of patient"s extremity
OPEN FRACTURES
Refer to the "'Open Fracture," protocol (pg. 119)
HIP FRACTURES& HIP DISLOCATIONS
* Consider hip fractures in an elderly patient who fell and complains of pain in the knee., hip or pelvis
* A scoop stretcher should be used whenever possible to move patients with a suspected hip fracture
* Splint in position of comfort with pillows and blankets
* Reassess neurovascular status before and after moving the patient
* Traction splints shall NOT be used on suspected hip fractures or hip dislocations
* POSTER- ��011 HW DlSLOCAT�UNS:
Most often present with the leg flexed and internally rotated., and will not tolerate having the
extremity straightened
* ANTER1011 �+�P D�61-OCA'TlONS:
0 Present with lateral rotation and shortening of the affected leg
PELVIC FRACTURE
• Assess and treat for shock
• DO NOT perform a pelvic rock. Assess the pelvis by applying gentle pressure anterior to posterior and
from the sides to identify crepitus or instability. DO NOT repeat.
• Stabilize if possible
• A scoop stretcher should be used whenever possible to move patients with suspected pelvic fracture
• Reassess neurovascular status before and after moving the patient
W,
BLS Trauma Emergencteescontinued...
f,DO
,BLEEDING CONTROL
EXTREM�TY hNJUII�ES:
• Direct pressure (utilizing manual pressure and pressure dressings)
• Combat Application Tourniquet(C.A.T.)
• Apply high and tight on a single long bone until the bleeding stops
• DO NOT apply C.A.T. directly over injury site or joint.
• If bleeding persists after initial C.A.T, apply a second C.A.T.
• Hemostatic Agent(If 2 d C.A.T application fails to control bleeding):
• Pack wound
• Maintain pressure for a minimum of I minute or until bleeding controlled
• Apply a pressure dressing
JUNCTIONAL HEMORRHAGE (e.g., ineck, axiHary, peMs and groin)..
Hemostatic Agent
• Pack wound
• Maintain pressure for a minimum of 1 minute or until bleeding controlled
• Apply a pressure dressing(Occlusive if neck wound)
ALL EXTREMITY TRAUMA
• Gross contamination,such as leaves or gravel, should be removed if possible
• Determine mechanism of injury(MOI) and evaluate
• Assess neurovascular status of extremity
0 Colorl temperature,.capillary refill, crepitus
AMPUTATION
• Rinse off
• Wrap in sterile gauze and place in a sealed plastic bag
• Place the sealed bag into a second bag with ice packs
• Label the bag with the patient"s:
• Name
• Date
• Time of the amputation
• Time the part was wrapped and cooled
ABDOMINAL TRAUMA
• UPALED OBJECTS-.
• Impaled objects shall be stabilized to prevent movement and subsequent further damage
• If bleeding occurs around the impaled object, it should be controlled by holding direct pressure
0 DO NOT apply excessive pressure
• DO NOT palpate the abdomen,as it may cause further organ injury from the distal tip of the
object
• EVBCERA'fl0N-.
• Protect the tissue from further damage
• Cover the protruding tissue with a moist sterile dres then cover with a dry sterile dres
• Keep the patient calm, as crying, screaming or coughing can force more of the tissue outward
• DO NOT attempt to replace or move the protruding tissue
BLS Bi'*tes and Stin s
9
kill
frroq
INFORMATION
Consider contacting the Florida Poison Control Center at 1-800-222-1222 OR DAN (Divers Alert
Network)at (919) 684-4326 as soon as possible for treatment recommenclations.
ADULT& PEDIATRIC
ALL BITES AND STINGS
• Clean the wound area with soap and water or sterile water
• Exception: Marine animal stings
• DO NOT use hydrogen peroxide on deep puncture wounds or wounds exposing fat
• Refer to the "Allergic Reaction"' protocol, if applicable
• Advise dispatch to contact animal control or the police department if necessary
SNAKE BITES
• DO NOT apply ice packs,tourniquets or constrictive bands
• Mark area of edema with a pen
• Remove any constrictive jewelry or clothing
• Splint any extremity that has received a bite and ensure it remains below the heart
• Keep patient supine if possible
• For hypotension:
0 Refer to the "'Fluid Resuscitation" protocol (pg. 38)
• If the DEAD snake is on scenel take a picture of the head (including the eyes)with the ePCR device if
possible
INSECT STINGS
Remove the stinger by scraping the patient's skin with the edge of a flat surface (e.g., a credit card)
0 DO NOT attempt to pull the stinger out,. as this action may release more venom
MARINE ANIMAL ENVENCIMATIONS:STINGRAY,SCORPIONFISH, LIONFISH,ZEBRAFISH,STONEFISH,
CATFISH,,WEEVERFISH,, STARFISH,, SEA URCHIN
• Immerse the punctures in non-scalding hot water(if available)to achieve pain relief
• Gently wash the wound with soap and water, and then irrigate it vigorously with sterile water
(avoid scrubbing)
MARINE ANIMAL STINGS:JELLYFISH, MAN-OF-WAR,SEA NETTLE, IRUKANDJI,ANEMONE, HYDROID,
FIRE CORAL
Rinse the skin with sea water (if available)
DO NOT use fresh or sterile water
DO NOT apply ice
DO NOT rub the skin
Apply white vinegar(if available)topically to involve area until the pain is relieved (lifeguards may carry
this)
Remove large tentacle fragments using forceps with proper PPE on and stay upwind when performing
this procedure
.... ......
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Allergic Reaction
INFORMATION
Allergic reactions are characterized by any of the following:
• Generalized urticaria
• Airway swelling., respiratory distress, bronchospasm,tongue and/or facial swelling
• Nausea.,vomiting,or diarrhea
• Loss of radial pulse or SBP of< 90 mrn Hg
Determine the source of the allergic reaction and remove potential allergen (insect, food, medications,)
SIM
ADULT
MILD—GENERALIZED URTICARIA ONLY
BENADRYL:
0 50mg IV/10/IM, over 2 minutes IV/10 usage
MODERATE—AIRWAY SWELLING /RESPIRATORY DISTRESS BRONCHOSPASM TONGUE AN
FACIAL SWELLING
• BP�NBPIKT��NE (1:1,000, Irng/imQ:
• 0.3mg (0.3mL) IM
• May repeat 2x prn, in 5 minute intervals
• BENAU11YL:
0 50mg IV/10/IM,, over 2 minutes for IV/10 usage
• COMBWENT(ALBUTEROL+ATROVENT)
• Albuterol 2.5mg via nebulizer
• Atrovent 0.5mg via nebulizer
• May repeat prn
• SOLU-d�\HDROL:
0 125mg IV/10/IM/PO,over 2 minutes for IV/10 usage
SEVERE—LOSS OF A RADIAL PULSE OR SBP OF< 90 mM H
* E�F'�NEPKT��NE (1:1,000, 1rng/rnQ-.
* 0.3mg (0.3mL) IM
* Contra indications- Hypotension secondary to blood loss
0
R a�,')i d aii��it,jte) o��risent, s��io��111t (5���10 ��'''nin�,tte)
�\Ao����iitor �iear�t rate&��id L)��ood �,)i'"IeSSL,Ire t�i��,-oi..ighOL,lt
* BP�NEPHRME W Infusion (if not responsive to W dose)
0 Epinephrine Infusion IV/10 5-15 mcg/min
* NORMAL SAU�NE:
• 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat Ix prn
0 c&�re ist be'ta�k&�i p��,-es&�����ice o�1"sig�����i[fic&��i t co���'o����i a�11�-y e a
d i s e a s e, C F a d �11e a fa i i i e a t i e t s
* BENADRYL: as noted above
* COM�B�V�ENT(AL�BUTE��RO�L+AT�IOV�ENT-.) as noted above
* SCILU.d�\HUROL: as noted above
Allergic Reaction 33
Allergic Reactioncontinued..
kill",
FPEDIATRIC
MILD—GENERALIZED URTICARIA ONLY
BENAIDRYL:
* lmg/kg IV/10/IM,. over 2 minutes for IV/10 usage (may repeat if necessary)
* Max Single dose 50mg
* Contra i nd ication- Neonates
MODERATE—AIRWAY SWELLING /RESPIRATORY DISTRESS BRONCHOSPASM TONGUE AN
FACIAL SWELLING
ER�NERHR��NE (1:1,000, 1rng/irnL)-.
• O.Olmg/kg IM, max single dose 0.3mg
• May repeat 2x prn, in 5 minute intervals
BENADRYL:
* lmg/kg IV/10/IM,. over 2 minutes for IV/10 usage
* Max dose 50mg
* Contra i nd ication- Neonates
COMB�VE��NT(ALBU'TEROL+A'TROVENT)
* Albuterol 2.5mg via nebulizer
* Atrovent 0.5mg via nebulizer
* May repeat prn
SOLU-MEDROL:
0 2mg/kg IV/10/IM/PO, over 2 minutes for IV/10 usage
9 Max dose 125mg
SEVERE-LOSS OF A BRACHIAL/RADIAL PULSE OR AGE APPROPRIATE HYPOTENSION
• ER�NBPHR��NE (1:1.000, limg/iml_):
* O.Olmg/kg IM, max single dose 0.3mg
* May repeat 2x prn, in 5 minute intervals
* Contra i nd ications- Hypotension secondary to blood loss
• EPINEPHRINE IV In-fusion (if not responsive-to IM dose)
0 Epinephrine Infusion IV/10 lmcg/kg/min
• NORMAL SAU�NE:
• 20mL/kg IV/10, assess lung sounds and BP frequently
• May repeat 2x prn,for age appropriate hypotension
• BENADRYL: as noted above
• AUBUTEIROL: as noted above
• SOLU-MEDROL: as noted above
Allergic Reaction 34
Diabetic Emergencies
ni,
,E n
INFORMATION
If f,IF
Symptoms of Diabetic Ketoaciclosis (DKA) include:
• Nausea/Vomiting
• Abdominal pain
• General weakness
• Kussmaul Respirations(deep rapid respirations)
• AMS
• Hypotension
• Tachycardia with an acetone smell on the patient's breath
Diabetic patients taking oral hypoglycemic medications should be transported (e.g., Glyburide,
Glimepiride,and Glipizide).
no=
ADULT
BGL< 60 mg/dL
• ORAL GLUCOSE:
* 15g
* May repeat 1x prn
* Contra i nd ications- Patients who are not conscious enough to swallow
• D50:
0 25ml of 50%solution total of 12.5 grams
• D101-1
0 100 mL IV/10
0 Retest glucose
0 May repeat 1x prn
BGL< 60 mg/dL IN CARDIAC ARREST
• D50:
0 50ml of 50%solution.,total dose 25 grams
• D10:
0 250 mL IV/10. Rapid infusion (if available)
IF UNABLE TO PROVIDE VASCULAR ACCESS
GLUCAGON:
0 1mg IN or IM if available
BGL>300 mg/dL WITH SIGNS&SYMPTOMS OF DKA
NORMAL SAUNE:
* 20ml/kg IV/10,,titrate to desired effect.Assess lung sounds and BP frequently.
* May repeat 1x prn
* [�)��,ecaijtioiis- ����)ail�ticular care nii..ist b(l ii�i the p�reseiice of sigi���flfic&�it coil'o i��i a i��y h e a rllll�,
disease, Cll�����H����', &�id �rena��� fafl�uii��,e pa�tie��l 111ts
almmommommmmommmmmm
Diabetic Emergencies 35
Dt'*abeti'c Emergeno'escontinued..
�E,ni
FREDIATRIC
BGL< 60 mg/dL
• ORAL GLUCOSE:
* 15g, if able to swallow and follow commands
* Contra indications:
• Patients who are not conscious enough to swallow
• Patients< 2 years old
• D50:
0 0.5gm/kg or
• D10:
• 5mL/kg IV/10
• May repeat 1x prn (if available)
IF UNABLE TO PROVIDE ABOVE TREATMENT
GLUCAGON:
0 < 20kg
0 0.5mg IM/IN (if available)
0 >_ 20kg
0 1mg IM/IN (if available)
BGL>300 mg/dL WITH SIGNS&SYMPTOMS OF DKA
NDTMAL SAUNE:
• 20mL/kg IV/10, assess lung sounds and BP frequently
• May repeat 2x prn,for BGL> 300 mg/dl
Diabetic Emergencies 36
wit,
Dystoniec Reaction
INFORMATION
If,1,#J ;
Dystonic reactions are characterized by intermittent spasmodic or sustained involuntary contractions
of muscles in the:
• Face
• Neck
• Trunk
• Pelvis
• Extremities
• Even the larynx
• The following classes of medications are typically responsible for dystonic reactions:
• Antipsychotic (e.g., Haldol, Risperdal, etc...)
• Antiemetic(e.g., Compazine, Reglan, Phenergan,etc...
• Antidepressant(e.g., Prozac'. Paxil, etc...)
• A dystonic reaction can occur immediately or be delayed for hours to days.
ADULT
BENADRYL
50mg IV/10/1M, over 2 minutes for IV/10 usage
PEDIATRIC
BENADRYL
* lmg/kg IV/10/lM, over 2 minutes for IV/10 usage
* Max dose 50mg
* Contra i nd ication- Neonates
Dystonic Reaction 37
Fluted Resusa"tationlDehydration
T,ni
INFORMATION
Indications for fluid resuscitation:
• Hypotension
• Fatigue
• Dark Color Urine
• Dry Mouth
• Headache
• Prolonged vomiting or diarrhea
• Non-traumatic bleeding(vaginal or GI)
• Suspected Rhabdomyolysis
• Paramedic discretion
ADULT
NGRIVIAL SAU�NE:
• 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat Ix prn
0 �11'e c a t ffioi�is- ����)&rtict cii��,"e 171LIS''I" be t�����ie p��,��eseiwe
It jr�,'e ��jatie��rits
PEDIATRIC
INGRIVIAL SALINE:
• lOmL/kg for infant/neonate. Assess lung sounds and BP frequently
• 20mL/kg IV/10, over 10 minutes, assess lung sounds and BP frequently
May repeat 2x prn,for age appropriate hypotension
Fluid ResuscitationlDehydration 38
Hyp
erkalemia
'E,a
INFORMATION
Consider hyperkalemia in patients with a confirmed history of renal failure/dialysis who are
pre-dialysis and present with any of the following:
• General weakness
• Cardiac arrhythmias& ECG abnormalities:
• Tall peaked T-waves (most prominent early sign)
• Sine wave
• Wide complex QRS
• Regular Really Wide Complex Tachycardia (RRWCT)
• Severe bradycardia
• High degree AV blocks
PEAKED T-WAVE SINE WAVE
PIN
INS
ADULT
FOR PATIENTS PRESENTING WITH ANY OF THE ABOVE CARDIAC ARRHYTHMIAS & ECG ABNORMALITIES
* CALO�UM CHLORIDE
* 1g IV/10, over 2 minutes
* 1)re(l:at,itimi—DO NOT in sai-ne IV/10 1kie �,]s SODIUM BICARBONATE wit�lou�t
t�`l 0�"`0 Ll g h y f I Ll S�1 i�1 g
* ALBUTEROL:
2.5mg via nebulizer
Continuous treatments(if an advanced airway is utilized,administer via in-line
nebulization)
* SOM�UM BICARBONATE-.
0 1 mEq/Kg IV/10, over 2 minutes
0 DO NOT adti�ii���iiste��,ki sarne ����V[0 N���ie as CALO�UM OHLOK01E wit��iot it
t o o t,i g h y f LA S�1 i�1 g
IF PATIENT IS HYPOTENSIVE
NORMALSALME:
• 20ml/kg IV/10.,titrate to effect.Assess lung sounds frequently.
• May repeat 1x prn
���)aitict i I a r ca re t�n t,i st b tak,(�,�li��i in the �,)��,��eset�ice o�f significai�it c&ro����i a il"y h a
disease, at���i(,] il'',et''ial failLk�,-e �3atients
PEDIATRIC
Call for orders
Hypej,*alemia 39
Nausea omiting
/V
T,D
INFORMATION
Consider differential diagnosis:
• Cardiac
• St ro ke
• Diabetic
• Head Injury
• Other
mom
ADULT
ZOI-RAW.
• 4mg IV/IO/IM/PO,. over 2 minutes for IV/10 usage
• May repeat 1x prn
If preginant Benadryl pirioir to Zofran (Zofran administration if Beinadryl ineffective)
0 50mg IV/IM
NORMAL SALINE (if needed):
• 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x prn
care iriust L)e i�n �0���ie p��,�esence co���'"on&�111-y ��iear't
disease, &���W faflV�e 1�:)a'tie��ri 11111's
mom
[PEDIATRIC
KA A 11 r,A 11 11 k1l I
NORMAL SALINE
10ml/kg for infant-neonate over 10 minutes
• 20mL/kg IV/IO,, assess lung sounds and BP frequently
• May repeat 2x prn,for age appropriate hypotension
ZOFRAN:
0.1mg/kg IV/IM/PO, over 2 minutes for IV usage
Nause"omiting 40
espiratory Di"Stress
4 I.AW'
'r, A
6
MEE
ADULT
MILD BRONCHOSPASM SECONDARY TO COPD or ASTHMA
• COM�B�V�ENT(AL�BUTE���lO�L+AT�ROVE�NT)
• Albuterol 2.5mg via nebulizer
• Atrovent 0.5mg via nebulizer
• May repeat prn
• SOLU-MEDROL:
0 125mg IV/10/IM/PO,over 2 minutes for IV/10 usage
MODERATE OR SEVERE RESPIRATORY DISTRESS: (INCLUDING COPD,ASTHMA,AND PNEUMO
CPAP- 10 cm H20..
Contra i nd ications:
• SBP < 90mm Fig
• Patients without spontaneous respirations
• Patients with a decreased LOC (lethargic)
• Patients< 30 kg
MODERATE TO SEVERE ASTHMA/COPD
• EF)INEPHRINE (1:1,000, lmg/mL)-.
• 0.3mg (0.3mL) IM
• May repeat 2x prn, in 5 minute intervals
• Do not administer Epinephrine to COPD patient
• CO�MB�V�ENT(ALBUTE���IOL.+AT�IOVE�NT)
• Albuterol 2.5mg via nebulizer
• Atrovent 0.5mg via nebulizer
• May repeat prn
• MAGNE&UM SUUFATE:
* IV Infusion: 2g of Magnesium Sulfate
0 Administer over 10 minutes IV/10
* Contra indication-2 d and 3 rd Degree Heart Blocks
Ra�pid i�-nay caLlse hy��jo�te��rlsiml
WARNING
I Immediately remove the CPAP for the asthmatic patient whose condition worsens after applying the
M,
F CPAP.
Consider the use of Ketamine as the induction agent for RSI in patients with bronchospasm requiring
advanced airway intervention.See Advanced Airway Protocol
Respiratory Distress 41
Respiratory Di"Stresscontinued..
k4fIll
4 nf'E?
EMENEEMENEEMENEEM
F PEDIATRIC
BRONCHOSPASM
• COM BIVENT(ALBUTE ROL+ATROVENT)
Albuterol 2.5mg via nebulizer
Atrovent 0.5mg via nebulizer
May repeat prn
• SOLUWED�1101_:
• 2mg/kg IV/10/1M/P0, over 2 minutes for IV/10 usage
• Max dose 125mg
FOR SEVERE ASTHMA NOT RESPONDING TO ABOVE TREATMENT
• EPIN�E.-PHRINE (1-.1,000, lmg/m�L)-.
0.01mg/kg IM, max single dose 0.3mg
May repeat 2x prn,, in 5 minute intervals
• MAGNESIUM SULFATE:
* 50mg/kg over 20 minutes IV/10
* Contra i nd ication -2 Ind and 3 rd Degree Heart Blocks
0 Ra����jid i���ifi i��-nay cat ise
FOR CROUP
EPINEPHRINE (1:1,000, 1rng/mL):
0 3mg (3mL total) delivered via nebulizer
0
* DO NOT st����,ess tlie patie����it
* DO NOT a�tte����Y�ip�t to ki tuloa te o��,-p����ace ai��i OPA oii��,
• Ventilate via BVM as needed
• Expedite transport to closest Comprehensive Pediatric ED
FOR EPIGLOTTITIS
Avoid any procedures that may agitate patient
• Provide humidified blow-by 02 as needed
• Expedite transport to closest Comprehensive Pediatric ED
Croup: Epilglottltils,,.,
• Usually< 3 years old 0 Usually 3-6 years old
• "Sick"for a couple of days 0 Sudden onset
• Low grade fever 0 High grade fever
• Not toxic appearing 0 Poor general impression
0 Drooling
0 Tripod position
BOTH HAVE STRIDOR ANPLQR A "BARKY"' COUGH,
Respiratory Distress 42
Seizure
INFORMATION
Consider the possible causes:
• Meningitis 0 Drugs
• Fever 0 Alcohol
• Head trauma 0 Diabetic
• Hemorrhagic stroke 0 Poisoning
Monitoring of EtCO2shall be performed to determine the patient's respiratory status.
Refer to the "Eclampsia" protocol (pg. 118),for pregnant patients.
ADULT
IF ACTIVELY SEIZING
BENZODIAZB�:'�NE:
* Ativan 2mg IV/IO/IN/IM may repeat OR
* Versed 5mg IV/IO/IN/IM may repeat
* P������-ecautio������i - fo�r i����esjjiii�-atory dep��-essio���i
IF SEIZURE DOES NOT RESPOND TO ABOVE TREATMENT
K ETA�M I N E
* 100mg of Ketamine IV/10 slow over 1-2 minutes
* Contra indications:
Pregnant patients
Penetrating eye injury
* Non-traumatic chest pain
* P re c a t,,,i t i o s
[�'5e lai��-enp&�,,��ed advati(I-11 Rd ai��,-way �����ria age i���-n e t
fia��3id IV is associated witl���i dqpii���essi&�ri, a�pnea, and
1H:1 OR
hig���ie��-t�iall Llsua��� ii�������ic����-eases, i�n ls��ood �,,,,)ressu�res
IF: UNABLE TO ESTABLISH VASCULAR ACCESS
KETAMINE:
100mg IN/IM -CONTRAINDICATIONS AS NOTED ABOVE
PEDIATRIC
FEBRILE AND NOT ACTIVELY SEIZING (if patient receives Tylenol he/she must be transpo
If patient can tolerate PO administer Acetaminophen 15mg/kg PO
May administer post seizure if child can tolerate
FEBRILE SEIZURE
• PASSIVE COOLING: Remove the clothing
• DO NOT cover patient with a wet towel or sheet
• DO NOT apply ice or cold packs to the patient's body
IF ACTIVELY SEIZING
BENZOD�AZE�:)INE:
* Ativan 0.1 mg/kg IV/IO/IN/IM may repeat as needed OR
* Versed 0.1 mg/kg IV/IO/IN/IM may repeat as needed OR
* Ketamine lmg/kg IV/IO/lN or 2mg/kg IM may repeat once
eca u tim�i- Mml[tm���, dq�j��,essimi
Seizure 43
Sepsis
kill"
DIV.
INFORMATION
Sources, signs&symptoms of sepsis include, but are not limited to:
• Fever
• UTI (Increased urinary frequency, dysuria, and/or cloudy, bloody, or foul smelling urine)
• Pneumonia(productive cough,green/yellow/brown sputum)
• Wounds or insertion sites that are: Painful/red/swollen or have a purulent(pus) discharge
• Patient is on antibiotics and has significant diarrhea,abdominal pain or tenderness
• Recent history of surgery/invasive medical procedure (e.g., Foley Catheter,Central Lines, etc...
• AMS and/or poor oral intake over the past 24-48 hours(especially in the elderly)
• Bed sores, abscesses) cellulitis, or immobility
SEPSIS ALERT Criteria
If all of the following are met, call a SEPSIS ALERT-,
>_ 18 years and NOT pregnant
AND
• Suspected or documented infection
AND
• At least TWO (2) of the criteria
• Hypotension (SBP< 100 mm Hg)
• EtCO2 (< 25 mm Hg)
• Altered Mental Status or GCS :5 14 (new onset)
• Tachypnea (respiratory rate >20)
• Tachycardia HR >90
• Temperature greater than 100.4 F or less than 96.8F
WARNING
It is imperative once sepsis is identified,that the patient is kept from becoming hypotensive,as an
it is ir
Fepisoide of hypotension significantly increases morbidity and mortality.
WARNING
Pneumonia patients with rales still require IV fluids.
r
FIM onitor EtCO2and SP02during fluid administration.
0 . - - -- A:q
0
W,
Sepsiscontinued..
1 DO
ADULT
SEPSIS ALERT
NORMAL SALKE:
0 20 ml/kg IV/10,, assess lung sounds and BP frequently
0 May repeat 1x if time permits
0 Transport to Closest ED
0 Contra i nd ications- Renal Failure Patients
lei cai�'''e rnLISt �je tak&�i in the �ar�iesei��ice ofsigi�iific&ri�'t ci:)r oiiai,�iy �-ieart disei'lse,
C
If BP does not increase consider Dopamine 5 mcg/kg/min and titrate to effect (maximum dose 20mcg/kg/
min)
MENOMONEE=
[PEDIATRIC
cl r
SUSPECTED SEPSIS
* NO�RMAL SAUNE:
• 20mL/kg IV/10, regardless of blood pressure, assess lung sounds frequently
• May repeat prn,for age appropriate hypotension
• Transport to Closest ED
* If BP does not increase consider Dopamine 5-15 mcg/kg/min. Use a microdrip (60 gtt/mL) and refer to the
Handtevy Medication Guide for drip rate based on patient weight or age.
0 . - - -- A.:,q
Stroke I f
I 4414j,"
4
INFORMATION
d
Cincinnati Stroke Scale should be initial stroke assessment.
If Stroke suspected, patient shall receive a R.A.C.E. assessment.
Call a STROKE ALERT if:
0 Symptoms are within 24 hours with any of the following:
• Any new positive finding from the Cincinnati Stroke Scale
• R.A.C.E. (plus) assessment score >0
• Any patient who awakes with stroke symptoms
0 If the onset of symptoms are unable to be determined,transport patient as a STROKE ALERT
Obtain the following information:
• Last time seen asymptornatic
• Witness name
• Witness phone number(s)
• Patient's medications
• All Stroke Alerts shall be transported to a the closest ED
Exception: Dementia, known terminal illness or Hospice Care patients can still be
treated as a STROKE ALERT.Transport these patients to the closest ED
• Immediate notification of a Stroke Alert with the R.A.C.E (plus) score needs to be relayed to the ED
0—Absent(symmetrical movement)
'racial Palsy Ask the patient to show their teeth: 1— Mild(slightly asymmetrical)
"Smile"
2— Moderate to Severe(completely asymmetrical)
Extend the arms of the patient 90 degrees 0— Normal to mild(limb upheld>10 seconds)
Arm Motor Function (if sitting)or 45 degree(if supine)palms up 1— Moderate(limb upheld<10 seconds)
2— Severe(patient unable to raise arms against gravity)
0— Normal to mild(limb upheld>5 seconds)
Leg Motor Function Extend the leg of the patient 30 degrees 1— Moderate(limb upheld<5 seconds)
(if supine)1 leg at a time
2— Severe(patient unable to raise leg against gravity)
0—Absent(normal eye movement to both sides,
Head and Eye Gaze Observe range of motion of eyes and look and no head deviation was observed)
Deviation for head turning to 1 side.
1— Present(eyes and/or head deviation to 1 side was observed)
0— Normal(performs both tasks correctly)
Ask the patient to follow 2 verbal orders:
Aphasia 1— Moderate(performs 1 task correctly)
"'Close your eyes"and""Make a fist"'
2— Severe(performs neither task)
Ask the patient:"Who's arm is this?"when 0— Normal appropriate or correct answer
Agnosia showing him or her the weak arm or"Can 1— Moderate(does not recognize limb or cannot move it)
you move your arm?" 2— Severe(both of them)
If Cortical Signs are present add a"+"(plus)sign next to total score R.A.C.E.SCALE TOTAL: Max Score of 11
and include the verbiage"plus"with encode.
ALL ITEMS SHALL BE EVALUATED REGARDLESS OF LEFT OR RIGHT WEAKNESS
strokeContinued..
Of"ntv'
ADULT
• POSITIONING:
0 Supine:
0 All patients with the exception of those listed under 300 head elevation section
0 30'head elevation:
• A diagnosed intracerebral hemorrhage
• Patient is short of breath
• OXYGEN:
0 2 LPM NC if pulse oximetry less than 94%.
0 If the patient is in respiratory distress, manage airway as needed and consider advanced airway
intervention.
• IV ACCESS:
• Establish an 18g catheter minimum if possible,the antecubital is preferred
• Perform Glucose check
• HYPERTENSION
• If patient has B/P of systolic greater than 220 or diastolic greater than 120 AND possible signs of
stroke.
• Labetalol 10mg IV/10
MENEMEM
PEDIATRIC
0 FICISI�TI01\11NG:
0 Supine:
0 All patients with the exception of those listed under 30'head elevation section
0 300 head elevation:
• A diagnosed intracerebral hemorrhage
• Patients short of breath
• OXYG E�N:
0 2 LPM NC if pulse oximetry less than 94%.
0 If the patient is in respiratory distress, manage airway as needed and consider advanced airway
intervention.
• IV ACCESS:
• Establish a large catheter if possible, the antecubital is preferred
• Perform Glucose check
• TRANSPORT:
ALL PEDIATRIC Stroke Alerts SHALL be transported to the closest ED
0 r*jf�tOlAr:9 N�
AD
AM AIP
Am
AV
p
IF
At-
AD AD
17171711
Rapid AmFib AmFlutter f
INFORMATION
Rapid atrial fibrillation and atrial flutter are defined as ventricular rates> 150 beats per minute.
ADULT
Obtain a 12-lead and leave cables connected
STA����1�1LE
• CARDIZEM: 10mg IV/10 over 2 minutes. If no response in 15 minutes, repeat with 15mg IV/10
over 2 minutes. (Use Arniodarone if Cardizem not available)
• AMIODARONE: 150mg infusion over 10 minutes. If 10 minutes AFTER Arniodarone infu-
sion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10
minutes. (Use Cardizem if Arniodarone not available)
UN ..........
• Synchronized Cardioversion (Ascending Joule Setting: 200J, 300J, 360J)
• Atrial Flutter cardioversion will start at 100j and escalate as needed
• If still hypotensive: Normal Saline: 20ml/kg. Assess lung sounds every 500mL.
If Cardizem is administered:
• Con train dicatedfor hypotension, wide complex QRS, history of WPW or sick sinus syndrome.
• Use with caution for patients taking beta blockers.
• If hypotension develops after Cardizem administration, administer 500mL of Normal Saline and
500mg of Calcium Chloride over 2 minutes.
• May repeat 500mg of Calcium Chloride if needed. Delta Wave
VVolff�Parkinson�vvtiite Syndrome
'D I 7a
et wave
rl-Pa json-wwte S,
PEDIATRIC
Call for orders
Bradycardia
T n'
Ij
INFORMATION
Bradycardia is defined as a heart rate < 60 beats per minute.
ADULT
Obtain a 12-lead to rule out an MI and leave cables connected
..........
Monitor and transport
UNSTABLE:,,,
*ATROPINE: 1 mg rapid IVP. Repeat prn every 3-5 minutes. Max cumulative dose 3mg.
Contraindication- Bradycardia in the presence of an M1
IF 011 1111111111111YI)OTENSION
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
• TRANSCUTANEOUS PACING: Initial rate of 60 BPM and increase milliamps until capture is gained.
May gradually increase BPM to 80 if needed.
• If Pacing unsuccessful. Dopamine may be administered 5mcg/kg/min and titrate to max dose of
20mcg/kg/min
• DO NOT DELAY TRANSCUTANEOUS PACING TO ESTABLISH IV ACCESS
• VERSED: 5mg IN/IM/IV/IO. May repeat 1x prn.
If versed does not induce sedation., may administer KETAMINE 0.5mg/kg IV/IO/IM.
If patient complains of pain while being paced, administer FENTANYL lmcg/kg IV/IO/IM/IN.
BRADYCARDIA IN THE PRESENCE OF AN MI WITH HYPOTENSION
Go directly to transcutaneous pacing as Atropine increases myocardial ischernia and may
increase the size of the infarct.
HIGH DEGREE AV BLOCKS WITH HYPOTENSION
Immediate transcutaneous pacing is acceptable when IV access is not immediately
available.
W
51
13radycardiacontinued..
T f,n,
'E'n'
,n
MEN=
PEDIATRIC
FR
Obtain a 12-lead and leave cables connected.
..........
Monitor and transport
U N .......... D AS A C I I...........D WITI11,,,I AI\AS AND I)OOR PERFUS,,I,,,O,,,N,,,),,
....................................................................................................................................................................................................................................................................................................................................................................................................................
• OXYGENATION&VENTILATION: Ensure adequate oxygenation and ventilation first, as hypoxia is most
likely to be the cause of the bradycardia.
• After oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates (birth to
I month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor
perfusion (AMS).
IF NO ���USI)ONSE TO OXYGE���4ATION AND VEN`Tld��..........AT 10 1\1 A ..........OCK WITI11111111111 CPR IN
• EPINEPHRINE: (1:10,000)0.01mg/kg (O.lmL/kg) IV/10. Repeat every 3-5 minutes prn.
• If no response to Epinephrine, begin TRANSCUTANEOUS PACING. Begin pacing at 80 BPM and increase
the rate as needed until the patient is hemodynamically stable.
OR
IF NO TO AND VEN`T�1AT,1,,0,,N,' 0 '1
............[?�O�OR 30 AV 1111111111111EART 131- �C�K�)�
• ATROPINE: 0.02mg/kg IV/10(Minimum single dose 0.1mg) . Max single dose 0.5mg. May repeat Ix prn.
• If no response to Atropine, EPINEPHRINE: (1:10,000)0.01mg/kg (O.lmL/kg) IV/10. Repeat every 3-5
minutes prn.
• If no response to Epinephrine, begin TRANSCUTANEOUS PACING. Begin pacing at 80 BPM and increase
the rate as needed until the patient is hemodynamically stable.
If unable to obtain IV/10 access,. begin pacing until an acceptable blood pressure is obtained,then
administer VERSED O.lmg/kg IN/IM. Max single dose 5mg. Mayrepeatlxprn.
Contraindicated in hypotension.
Monitorfor respiratory depression.
W,
Cardiogenic Shock
INFORMATION
Cardiogenic shock is a condition in which the heart suddenly cannot pump enough blood to meet the
body's needs.This condition is most often caused by a severe heart attack. Cardiogenic shock is rare,
but often fatal if not treated immediately.
ADULT
Obtain a 12-lead and leave cables connected
Dopamine 5 mcg/kg/min and titrate to effect(maximum dose 20mcg/kg/min)
mmm� I=
PEDIATRIC
c 1 r
Dopamine 5-15 mcg/kg/min. Use a microdrip (60 gtt/mL) and refer to the Handtevy Medication Guide
for drip rate based on patient weight or age.
Once SBP is 100 mmHg or greater,.treat CHF/Pulmonary Edema and/or Chest Pain as applicable.
WITHHOLD NTG FOR THESE PATIENTS!
#1 �i
W,
Hypertension 1, L 'It
f,DO
INFORMATION
it A Hypertensive Emergency can be defined as a systolic BP >220 and/or Diastolic BP 120. Rule out manifesta-
tions that can cause hypertension prior to treating such as chest pain and heart failure.
Symptomatic patients with elevated blood pressure should be treated by the appropriate protocol based on
assessment of their signs and symptoms
Chest pain consistent with myocardial ischemia or infarction ( Chest pain Protocol pg.54)
Shortness of breath with signs and symptoms of acute pulmonary edema, ( CHF Protocol pg. 57)
Patients in the 2,d or 3rd trimester of pregnancy(over 20 weeks) or up to 6 weeks postpartum with elevated
blood pressure ( Pre-eclampsia/Eclampsia protocol pg 128)
Patients presenting with stroke like symptoms, obtain STROKE scale; (See Stroke protocol pg. 45)
ADULT
0 Obtain a 12 lead and leave cables connected
0 IV access
If patient is experiencing associated signs and symptoms of a hypertensive crisis
Labetolol kQm I Mav repeat gin 10 minutes.Llqo�ntra�*inc�rica�ted�for�u�ise�rat�e
g slow IVP over 2 menutes.
<50 or Wi h rade heart block
PEDIATRIC
Consult Medical control
Caution should be taken when administering Labetalol to patients experiencing a Stroke or suspected
bleed
Chest Pain
INFORMATION
For STEMI Alerts or suspected STEMI Alerts,the right hand and wrist should be avoided if at all possible for
IV ACCESS. The right AC and anywhere on the left is acceptable.
ADULT
0 IMMEDIATE 12 lead ECG. Leave cables connected and repeat every 5 minutes
0 ASPIRIN: 162-3 2 4 rn g b a b y aspirin chewed and swallowed.
Con train dica tions.- allergy, active G1 bleeding, <16 years old
0 Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered
less than 324mg of aspirin within 24 hours, administer full 324mg dose.
0 FENTANYL: 1mcg/kg slow IV/10/IM OR 100mcg IN. May repeat every 5 minutes prn. Max total dose
3 mcg/kg IV/10/IM or 300mcg IN.
In rare occasions, Fentanyl may cause hypotension.
If hypotension occurs, NORMAL SALINE: 1-2L.Assess lung sounds and blood pressure every
500mL.
If nausea and/or vomiting occurs, administer Zofran IV/10/IM 4mg. May repeat once prn.
(Nitroglycerine may be given as a first line drug ahead of Fentany1for stable patients with history
of opiate abuse or in whom drug seeking behavior i's suspected)
IF PEIIS���STS �hd�V��T���AL ..........
..............................................................................................................................................................................................................................................................................................................................................................................................
• NITROGLYCERINE: 0.4mg SL. May repeat every 3-5 minutes prn for pain. SBP must be 100 mmHg or
greater.
A 12 lead ECG must be obtained prior to the administration of NTG to rule out a right ventricular
infarction including complete right sided EKG.
• An IV must be established prior to NTG administration, even in normotensive patients.
CONTRAINDICATIONS
• SBP less than 90 mmHg or Heart Rate less than 50 BPM or greater than 100 BPM
• EDD(within 48 hours)
L..L=
PEDIATRIC
Call for orders
STEMIAlert
INFORMATION
STEMI Symptoms can be variable and include discomfort of the chest, arm, neck, back, shoulder
or jaw and also can be painless with syncope/near syncope (lightheadedness), general weak-
ness/fatigue, unexplained diaphoresis,, SOB, or nausea/vomiting.
ADULT
• IMMEDIATE 12 LEAD ECG WITH IMMEDIATE NOTIFICATION TO ED INCLUDING ECG RESULTS
• If Patient has Chest Pain, Follow Chest Pain protocol
Leave cables connected and repeat every 5 minutes
it Lt,,,1NG SOU�����\IDS ������illillillillYi����IOTENSION
NORMAL SALINE: 20ml/kg.Assess lung sounds and blood pressure every 500mL. May repeat x2 prn
ST IM 1 A 1..........E����lT C�����11TERIA
ST-Segment Elevation in two or more contiguous leads(2mm or greater in V2 and V3 or Imm or
greater in all other leads)with a "convex" (frown face) or"straight" morphology.
ST-Segment Elevation in two or more contiguous leads of 2mm or greater in any lead with a
It concave" (smiley face).
ST-Segment Depression with high amplitude R waves in VI (isolated),V2,and/or V3. "Carousel Seats"
Complete right sided 18 lead EKG should be performed.
Posterior EKG should be performed.
STEMIAlertcontinued..
Will",
4
"I S I'll T E"I'll,11 M"I'll",I A"I'll,L"I'll,E"I'll",R I'll T 11������11 Q"I'll"I"I'll 11 S I'll,Q 11111,11,L 11 1 1"I'll A"I'll L"I'll I"I'll",F"I'll"I'll"E"I'll",R"I'll S"I
The following are STEMI mimics:
• QRS complexes greater than 0.12 (LBBB, RBBB, Pacemaker, etc.)
• Left Ventricular Hypertrophy(LVH)
• Pericarditis
• Early Repolarization
• Less than 2mm of elevation with a Concave ST Segment(Smiley Face) Morphology
Patient presentations indicative of myocardial ischemia that do not meet""STEMI Alert Criteria"should still
be transported to a the ED
Left Ve��ftricular Hypertrolphy(LVH)
Take the largest negative deflection from the isoelectric line of VI and V2 ("S"wave), whichever is
larger,and count the small boxes.Then take the largest positive deflection of V5 or V6 ("R"wave),
whichever is larger,and add it to the total from VI or V2. If the result is greaterthan 35,your suspicion
for LVH should be high.
NOTES
Patients with ST segment elevation in two or more Inferior Leads (11, 111, AVF) or isolated abnormalities
in lead III (isolated) and/or V1 shall have a complete right side 18 Lead EKG (V4R-V6R) to determine if
there is ST segment elevation,indicating a right ventricular infarct(RVI).The right sided EKG shall be
labeled somewhere on the EKG.
If patient presentation is indicative of a myocardial ischemia and it is uncertain as to whether or not an
ECG meets STEM I Criteria OR the ECG shows a STEMI mimic.,the ECG should be transmitted to the
receiving STEM I facility for determination.
......................... .......................................
Righa-sided�Leads Left-sided cf�wst
V5 arl/6
,ST Elevation
............
if Intir",
j CoNTed(convex-
44
Still,'
...........
Concave up 0 0
Deep S wave in,V1 or V2 Tall R waves WS or V6)
3'Poin't
01tching
'The 5 wave ini V 1 is deep The Fltwave i n V5 a n d 116 i s h ig h
I n th is,exa mple above we m easure ln�this example above we measure
t�he 5,wave in V1 at 18 rnjirijii�, the R wave in 1415 at 23 irrurn.
Adid theSwaveinN I plusthe Rwaveiini V15 or owoa, bt>thFnea-,tiromenitstotj4�,thorfro�m
V 6.14 the stim is-,V�num,then UVIA Is pres,ent. V I&V 5:::
V1)+R(VS)=41 mm
>35 mm is,significant Pi i s meet sth e crite ria for LVH
----------------------------------------------------------------------
TIv,wtv
CH
y
F (Pulmonar Edema)
MEE
ADULT
0 12 LEAD ECG
Leave cables connected and repeat 12 lead every 5 minutes
• CPAP(10 cm H20)
CONTRAINDICATIONS
SBP less than 90mmHg
Decreased LOC(Lethargic)
• ASPIRIN: Two to four 81mg baby aspirin chewed and swallowed, if not already administered.
160n""inill'i'llill'i'llil�,�,�l,,g
NITROGLYCERINE:0.8mg SL. Repeat at a dose of 0.4mg as needed every 3 minutes
IF SYSTOLIC 131-00���111111) PRESSU���ZE IS 3
NITROGLYCERINE: 0.4mg SL. Repeat as needed until BP is 120mmHg.
CONTRAINDICATIONS
• EDD(Viagra and Levitra within 24 hours and Cialis within 48 hours)
• Right Ventricular Infarction
• SBP less than 90 mmHg or Heart Rate less than 50 BPM
liimllI Gain IV access as soon as possible, but do not neglect correcting respiratory statusfirst.
PEDIATRIC
Call for orders
WARNING
If patient is febrile or from a nursing home and pneumonia is suspected withhold nitrates.
Supraventrl'gcular Tachycardia
INFORMATION
SVT is defined as a regular, narrow complex tachycardia of 150 BPM or greater without
discernible P-waves and/or flutter waves.
CAUTION:
DO NOT administer Adenosine to patients with a history of a heart transplant or if taking Tegretol
(Carbamazepine)or Persantine (Dipyridamole). In this case, administer Cardizem or Arniodarone as
indicated below.
Ruling out of secondary tachycardia must be performed prior to administration of cardiac medicine.
Check temperature,stimulant abuse, hydration status, possible sepsis, physical exertion, anxiety,
etc. If any of the previously mentioned are discovered,treat.
am
ADULT
STAB
"I'l""I'll""I'll'll""I'll""I'll",'ll",'ll""I'll""I'll",'ll""'ll""I'll""I'll",'ll""I'll""I'll","I.................
0 12 Lead EKG: leave cables connected
0 VAGAL MANEUVERS
9ADENOSINE: 12mg rapid IVP,with a simultaneous 20mL Normal Saline flush. May repeat once. If
rhythm fails to convert,
• CARDIZEM: 10mg IVP over 2 minutes. If no response in 5 minutes, administer CARDIZEM: 15mg IVP
over 2 minutes. (Use Arniodarone if Cardizern not availa
Contraindicatedfor hypotension, wide complex QRS, patients with a history of WPW or sick sinus
syndrome.
Use with caution for patients taking beta blockers.
• AMIODARONE: 150mg infusion over 10 minutes. If 10 minutes AFTER Arniodarone infusion has been
completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. (Use Cardizem if
Arniodarone not available.
If symptomatic hypotension (below 90mmHg) develops after Cardizem administration,
• NORMAL SALINE:500mL then
• CALCIUM CHLORIDE: 500mg over 2 minutes. May repeat Calcium 500mg one-time prn.
• Consider Sedation
• SYNCHRONIZED CARDICIVERSION: Ascending joule settings of 100j, 200j, 300j, 360j
• If cardioversion fails, contact medical control for further direction.
W
Supraventricular Tachycardiacontinued..
FRuiriing out of secondary tachycardia must be performed prior to administration of cardiac medicine.
Check temperature,stimulant abuse, hydration status,possible sepsis, physical exertion,,anxiety,,etc.
If any of the previously mentioned are discovered treat accordingly.
PEDIATRIC
..........�E
VAGAL MANEUVERS
ADENOSINE: O.lmg/kg rapid IV/10,with a simultaneous 10mL flush. Max dose 6mg.
If no change in one minute,ADENOSINE:0.2mg/kg rapid IV/10,with a simultaneous 10mL flush.
Max dose 12mg.
If no response administer fluid bolus 20ml/kg may repeat prn X1
IF PA TIENT IS ALERT
0 ADENOSINE: Administer as noted above.
IF PA TIENT HAS AN AL TERED MENTAL STA TUS
• Consider sedation prior to cardioversion. Versed:O.lmg/kg IV/10/IN. Max single dose of 3mg. May
repeat 1x prn. Max total dose 6mg.
• SYNCHRONIZED CARDICIVERSION: lj/kg. If not effective, increase to 2j/kg.
• If cardioversion fails, contact medical control for further direction.
VAGAI............
For young children, place a bag of ice water on the child's face completely obstructing their nose
and mouth for at least 15 seconds.
For older children,, ask them to try and blow through a kinked piece of oxygen tubing or syringe.
SVT in infants is considered greater than 220 BPM.
SVT in children is considered greater than 180 BPM.
Wide Complex Tachycardia
T,D
INFORMATION
Wide complex tachycardia (WCT) has a QRS greater than or equal to 0.12 (0.09 for pediatrics)and a
heart rate greater than or equal to 100 BPM without discernible P waves.
................................................................................................................................................................................................................................................................................................................................................................................................................................
ECG features that favor a diagnosis of Ventricular Tachycardia
• Very wide, bizarre QRS morphology
• Precordial concordance—all chest leads point in the same direction (either positive OR negative)
• Negative Lead V6
• Backward frontal plane axis: 11, 111,,and aVF are negative. aVL and aVR are positive.
• Presence of capture beats or fusion beats(sinus beats that interrupt the WCT)
.................................................................................................................................................................................................................................................................................................................................................................................................................................
ECG features that favor a diagnosis of supraventricular origin
• P waves before the QRS complexes
• Normal R wave progression in the chest leads
• Left bundle branch block or right bundle branch block pattern
• Only slight widening of the QRS
Irregularly-irregular rhythm
ALL REGULAR WCTs SHOULD BE TREATED AS V-TACH UNLESS PROVEN TO BE SUPRAVENTRICULAR!
If cardioversion terminates the VT and the patient returns to VT, begin cardioversion at the last
successful energy setting and increase as needed.
Wide Complex Tachycardiacontinued..
ADULT
S 11111111 1 11111111 A B L E I E G L I L A R W C T
• Perform 12 Lead EKG and leave cables connected
• Perform serial 12 leads every 5 minutes
• AMIODARONE INFUSION: 150mg INFUSION over 10 minutes. If 10 minutes AFTER Arniodarone infusion
has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes.
Administer all 150mg, even if the VT terminates.
DO NOT DELAY CARDIOVERSION TO ESTABLISH IVACCESS!
• Consider sedation prior to cardioversion.
• SYNCHRONIZED CARDICIVERSION: Ascending joule settings at 100 200j, 300j, 360j
• If unstable WCT fails to convert,AMIODARONE INFUSION: 150mg infusion over 10 minutes. If 10
minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat
150mg infusion IV/10 over 10 minutes.After the 150mg has been infused and the patient remains unsta-
ble, cardiovert with 360j every 2 minutes prn.
SPEO��A����..........�CO�N S 1 Al������TEI�l
................................. ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
For patient"s who convert after cardioversion OR after two or more shocks by their Implantable Cardioverter
(ICD)administer
AMIODARONE INFUSION: 150mg IV/10 over 10 minutes. If 10 minutes AFTER Amiodarone infusion has
been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes.
(if Amiodarone has not already been administered).
MEMENEEM
PEDIATRIC
..........�E
AMIODARONE INFUSION: 5mg/kg infusion IV/10 infused over 20 minutes. Max single dose 150mg. May
repeat until a max of 15mg/kg has been administered.
Consider sedation prior to cardioversion. VERSED:O.lmg/kglV/10/IN/IM. Maxsingle doseof3mg. May
repeat 1x prn. Max total dose 6mg.
SYNCHRONIZED CARDICIVERSION: lj/kg. If no response, increase to 2j/kg.
For patient's who convert after cardioversion OR after two or more shocks by their Implantable Cardioverter
(ICD)administer AMIODARONE INFUSION:5mg/kg in 100ml IV/10 infused over 20 minutes. Max single dose
150mg. May repeat until a max of 15mg/kg has been administered. (if Arniodarone has not already been
administered.
..................
Polymorphi'c VmTachl Torsades de Poi'ntes
1 4
INFORMATION
Torsades cle Pointes is an uncommon form of V-Tach characterized by a changing in am-
plitude or"twisting" of the QRS complexes.
11111111111111EM
ADULT
STAB 1)VT
MAG SULFATE: 2g IV/10 infusion over 5 minutes. May Repeat
U N B I..........E 1���)VT
DO NOT DELAY DEFIBRILLA TION TO ESTABLISH IVACCESS.1
• Consider sedation prior to DEFIBRILLATION.
• DEFIBRILLATION: Ascenclingjoule settings at 200j, 300j, 360j
• If unstable PVT converts prior to administration of Magnesium Sulfate, administer 2g infusion over 5
minutes.
Torsades
I W,
............
.......... ...........
................
f5
�/.........
...........
PEDIATRIC
STAB ����)VT
MAG SULFATE: 50 mg/kg IV/10 infusion over 10 minutes Max of 2g.
DO NOT DELAY DEFIBRILLA TION TO ESTABLISH IVACCESS.1
• Consider sedation prior to DEFIBRILLATION. VERSED: 0.1 mg/kg max of 3mg IV/10. Mayrepeatlx
prn. Max total dose of 6 mg.
• DEFIBRILLATION: 2jlkg, 4jlkg
If unstable PVT converts priorto administration of Magnesium Sulfate,administer 50mg/kg infusion
over 10 minutes.
If clefibrillation terminates the PVT and the patient returns to PVT, begin defibrillation at the last
successful energy setting and increase as needed.
W
Left Ventricular Assi"st Devices L VADs
kill
INFORMATION
Left Ventricular Assist Devices (LVADs), also known as Heart Pumps, are surgically implanted circulatory
support devices designed to assist the pumping action of the heart.Caring for these patients is complicat-
ed and every effort should be made to contact the patient"s primary caretaker(spouse,guardian etc.)and
the LVAD coordinator during your evaluation. Patients with a properly functioning LVAD may NOThave
a detectable pulse, measurable blood pressure or accurate oxygen saturation.
REEMENNESEEM
ADULT
Contact the LVAD coordinator immediately;the phone number will be on the device and the equipment
carrying bag.Take all equipment associated with the LVAD system to the ED.
Locate patient"s emergency"bag"with backup equipment.
Treat Non—LVAD associated conditions in accordance with the appropriate protocol.
Determine the type of device, assess alarms, auscultate for pump sounds. if needed,assist patient
(caretaker) in replacing the devices batteries or cables.
Locate the driveline site on the patient's abdomen. BE CAREFUL not to cause any trauma to the site or
driveline (wires).
If signs of hypo-perfusion,administer NORMAL SALINE: 500mL and reassess.
If there is bleeding at the site,, apply direct pressure.
EVALUATE UNRESPONSIVE PATIENTS CAREFULLY FOR REVERSIBLE CAUSES!
Perform a blood glucose level, if blood glucose is less than 60 mg/dI administer D50—25ml of 50%solu-
tion total of 12.5 grams.Secondary Option D10: 100mL.
Performing Chest Compressions risks rupturing of the ventricular wall leading to fatal hemorrhage.
ONLY perform chest compressions when the patient's LVAD is not working and no other options exist to
restart the LVAD.
PACKAGING AN LVAD PATIENT:
Be aware of the cables, controller, and batteries. It may be best to place the stretcher straps under the
LVAD cables to avoid creating torque on the device.At a minimum, be aware of this extra
hardware.
Transport to the closest ED
W
Digitalis Toxicity
INFORMATION
Digitalis is a cardiac glycoside with positive inotropic effects; slows AV conduction by enhancing parasym-
pathetic tone; and has a slow onset of action. Digitalis toxicity should be suspected in patients who are
taking digitalis and have signs and symptoms associated with digitalis toxicity-for example, fatigue and
visual disturbances (halos in field of vision).The most common arrythmias are ventricular ectopy and
bradycardia,often in association with various degrees of AV block.The following rhythm disturbances
should immediately suggest digitalis toxicity: atrial tachycardia with high degree AV block, nonparoxysmal
accelerated junctional tachycardia, multifocal VT, new onset bigeminy, regularized atrial fibrillation,spoon
-shaped ST segment, peaked T wave. Contact with the oleander tree, squill, lily of the valley, and toad skin
can also cause a digitalis-type toxicity, which will cause the same type of dysrhythmias and requires the
same treatment.
DIGITALIS: GENERIC NAME (TRADE NAME)
digoxin (Lanoxicaps, Lanoxin, Digoxin),cligitoxin (Crystodigin)
ADULT
• ADULT TREATMENT:
Contact Poison control 1-800-222-1222
Verify Digitalis Toxicity by confirmation from patient or by counting pills in bottle.
Avoid use of Calcium Chloride as it is contrainclicated in the setting of Digitalis Toxicity.
Perform 12 lead is clinical stability allows. Leave cables connected.
• Digitalis-Induced Symptomatic Bradycardias
Atropine 0.5mg rapid IVP followed by 20ml flush of NSS. May repeat once if needed.
Avoid pacing as patients with digitalis toxicity are more prone to pacemaker-induced ventricular
rhythm disturbances.
If wide complex Bradycardia is present administer Sodium Bicarbonate lmeq/kg.
• Digitalis-Induced Ventricular Arrythmias- Stable
Magnesium 2g IV over 2 minutes
Once initial 2g is administered,administer continuous infusion of Magnesium 2g over I hour.
• Digitalis-Induced Ventricular Arrythmias— Unstable
Consider sedation.
Synchronized Cardioversion at 25J. May repeat twice at 50J.
Patients with Digitalis Toxicity may develop malignant ventricular arrythmias or asystole
after cardioversion.
If patient suffers cardiac arrest refer to Cardiac Arrest protocol.
If no response, immediately reattempt cardioversion using clefibrillation doses—200J, 300J, 360J.
Maintain at 360J if needed.
PEDIATRIC: Contact Poison Control
.................
..................
.....................................
-- -------------
....................
..............
.....................
IS
..........
..........
............
..........
...........
............
AP AP
A
Standing Orders
INFORMATION
There is no scientific basis in trying to resuscitate an unwitnessed Asystolic patient who has succumbed
to the dying process of a terminal illness. Consideration should be given to not starting resuscitation
efforts in these cases.
In general, when the scene is safe, all Cardiac Arrests should be worked on scene,
011=
ADULT
0 Perform CPR per AHA (ACLS)
0 Emphasis is placed on minimizing interruptions in compressions to no more than 10 seconds.
0 Make all efforts to obtain a ROSC prior to leaving the scene.
0 Once available,apply the Lucas with minimal interruptions to chest compressions and set to
continuous compressions. Patient should be placed on the scoop stretcher for transport purposes.
• Medications should be delivered as soon as possible after the rhythm check(during compressions) and
circulated for 2 minutes.
• Follow all IVP medication administrations with a 20ml flush of Normal Saline.
• Search for possible causes and treat accordingly(i.e. H"s &T's, BGL, etc.).
Med*lcal Control should be contacted prilor to ceaslng resuscitation efforts on Cardiac Arrest patilents
Consider terminating efforts when:
• If presented with an up to date and valid DNR terminate resuscitation efforts.When conflicting requests
of family members continue resuscitation efforts and transport.
• Contact Medical Control to terminate efforts
Standing Orders 68
standing Orderscontinued..
T 131,
FPEDIATRIC
• Perform CPR per AHA (PALS)
• Emphasis is placed on minimizing interruptions in compressions to no more than 10 seconds.
• If applicable and once available,apply the Lucas (if patient is over 18 y/o)with minimal interruptions
to compressions and set to continuous compressions. Patient should be placed on the scoop
stretcher for transport purposes.
Make all efforts to obtain a ROSC prior to leaving the scene.
ICATIONS
• Medications should be delivered as soon as possible after the rhythm check(during compressions)
and circulated for 2 minutes.
• Follow all IVP medication administrations with a 10ml flush of Normal Saline.
�i.e.�H's�&T�'s, BG L, etc.).
ALL WITNESSED CARDIAC ARREST PATIENTS MUST BE TRANSPORTED.
EtCO2 LEVELS
During arrest, maintain EtCO2 levels greater than, 10mmHg. If EtCO2 levels are less than
10mmHg, increase effectiveness of compressions. Levels of less than 10mmHg have virtual-
ly no chance of achieving ROSC. An EtCO2 level of approximately 20mmHg is ideal.
H's
• Hydrogen Ion (Acidosis): Ventilation
• Hyperkalemia (Renal Failure): Calcium Chloride,Sodium Blicarb,Albuterol
• Hypoglycemia: Glucose
• Hypoxia: Oxygen& Ventilate
• Hypovolemia: Fluid Bolus
• Hypothermia: Warming
T's
eToxins or Tablets(OD): Opiates(Narcan)
Beta Blockers(Glucagon)
Tricyclic Antidepressants(Sodium Bicarb)
Calcium Channel Blocker(Calcium Chloride)
sTension Pneumothorax: Bilateral Pleural Decompression
Standing Orders 69
Adult Cardiac Arrest
f,DIVA,
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Adult Cardiac Arrest 70
Cardiac Arrest (Pediatric)
Ali thim
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Cardiac Arrest (Pediatric) 71
P ecial Considerations in Cardiac Arrest �0' kill
INFORMATION
The below treatments are in addition to standard therapy.
ADULT
• CALCIUM CHLORIDE: 1 gram,slow IV/10 over 2 minutes.
• SODIUM BICARBONATE: lmEq/kg,slow IV/10 over 2 minutes.
• Once intubated,ALBUTEROL: 2.5mg via nebulizer,continuous treatments.
EXOITE���'' ..........]��RIUM
• SODIUM BICARBONATE: lmEq/kg IV/10,each amp administered slow over 2 minutes.
• NORMAL SALINE: 20mL/kg IV/10. Maximum of 2L. Assess lung sounds every 500mL.
Immediate VENTILATION is a priority and treat as a SECONDARY ARREST.
THIRD TRIMESTER
• Manually displace the uterus to the left
• Transport to the closest ED
• Exception Trauma Alerts
• Rapid Transport Recommended
• Lucas Contra i nd ication in Pregnancy
Consider spinal motion restriction.
• Transport to closest ED
ELECTI�10Q ff��0114
• Immediate DEFIBRILLATION as applicable.
• Consider Spinal Motion Restriction.
Special Considerations 72
Adult Post Resuscitation
kill"
11 4
ADULT
Patients with a ROSC should be managed in the order of:
0 12 LEAD
0 RATE: If patient is Bradycardic,TRANSCUTANEOUS PACING: Initial rate of 60 BPM and in-
crease milliamps until capture is gained. (reference bradycardia protocol)
0 RHYTHM: (reference specific protocol)
0 BLOOD PRESSURE: (Goal is to maintain a SBP of 90mmHg)
If the patient is hypotensive, administer a NORMAL SALINE 20ml/kg bolus, may repeat
1x prn.
0 Maintain pulse oximetry of 94-99%
0 Maintain ETCO2 of 35-40 mm Hg
0 Maintain 10 breaths per minute
0 Monitor patient temperature and treat accordingly
M�
Administer AMIODARONE INFUSION:(150mg infused over 10 minutes)for patients who con-
verted after two defibrillations and have not received an Amiodarone bolus during arrest.
Administer MAG SULFATE: (2g IV/10 infusion over 5 minutes) if patient did not receive Mag
Su If ate d u ri ng a rrest.
Adult Post Resuscitation 73
P ediatri*c Post Resusci'*tation
rPEDIATRIC
POST ARREST
• Maintain adequate oxygenation and ventilation.
• Patients with a ROSC should be managed in the order of:
• If heart rate is less than 60 BPM, provide oxygenation and ventilation for one minute (30 seconds
for a neonate).
• If heart rate remains less than 60 BPM with S/S of poor perfusion (Altered Mental Status)
despite oxygenation and ventilation for one minute(30 seconds for a neonate), begin CPR.
• If after one minute of CPR the heart rate remains less than 60, administer EPINEPHRINE: (1:10,000)
0.01mg/kg (O.lmL/kg) IV/10. Repeat every 3-5 minutes prn for a heart rate less than 60 BPM.
RHYTHM
Reference specific protocol.
Minimum Pediatric Systolic Blood Pressure Values
Neonates: 60mmHg
Infants:70mmHg
Children 1-10 years old: 70+ (age in years x 2) mmHg
Children greater than 10 years old: 90mmHg
NORMAL SALINE: 20mL/kg bolus,titrated to a SBP as listed above. May repeat 1x prn
for hypotension.
Assess lung sounds and blood pressure often.
OF CARDIAC ARRI�����1111
All patients that are pulseless or have obtained ROSC shall be transported to the closest Emergency
Department
Pediahi'wc Post Resuscitation 74
AO
mm
.............
'Q I
............
------------------
IM,I-
VIP,
Standing Orders
n
INFORMATION
The goal for effectively managing patients with an overdose/poisoning is to:
• Support the ABCs
• Terminate seizures
• Terminate any lethal cardiac arrhythmias
• Reverse the toxic effects of the poison/medication with a specific antidote
The treating paramedic should consider contacting the Florida Poison Control Center at
1-800-222-1222 as soon as possible for additional treatment recommendations.
• Treatment recommendations from Florida Poison Control should be followed.
• Document the directed treatment and the name of the representative on the ePCR Report.
WARNING
• Use caution when supporting blood pressure with fluids. Many medications depress myocardial
contractility and heart rate,which predispose the patient to heart failure even with boluses as little
as 500mL. Assess lung sounds and blood pressure frequently.
• It may be necessary to limit the amount of fluids the patient receives.
eta Blocker Overdose
�E,ni
INFORMATION
Signs&Symptoms: Common Beta Blockers:
Bradycardia 0 Atenolol
Hypotension 0 Carvedilol
Cardiac arrhythmias 0 Metoprolol
Hypothermia 0 Propranolol
Hypoglycernia 0 Bystolic
Seizures
Follow the appropriate protocol if patient is symptomatic and treatment is not listed below.
ADULT
0 Obtain a 12-lead and leave cables connected
If confirmed Beta Blocker Overdose and patient unstable
Administer Glucagon 3 mg IV/10 if available
0 Refer to the "Bradycardia" protocol if applicable
ISOLATED HYPOTENSION
NGIIIVIAL SALINE:
• 20ml/kg IV/IO,.titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x prn
11`4k(:� t�ie �j��,-ese���ice of'si&lfican,t co��,'o���i&���-y
0 �P c�a U�t i 0�1 S F�l a i c u a (.:0
disease, C1............IF, &�id failure �jatie���i ts
FPEDIATRIC
0 Obtain a 12-lead and leave cables connected
0 If confirmed Beta Blocker Overdose and patient unstable
Administer Glucagon 0.1 mg/kg IV/10 if available (May repeat 1x prn)
0 Refer to the "Bradycardia" protocol if applicable
ISOLATED HYPOTENSION
NUTMAL SALINE:
20 mL/kg IV/10.Assess lung sounds and BP frequently
W
Calcium Channel Blocker Overdose
IM
INFORMATION
• Signs &Symptoms: Common Calcium Channel Blockers:
• Hypotension 0 Norvasc
• Syncope 0 Cardizem
N
CE
c
• Seizure 0 Cardene
0 Pr
• AMS F ocardia
• Non-Cardiogenic Pulmonary Edema
• Bradycardia
• Follow the appropriate protocol if patient is symptomatic and treatment is not listed below.
ADULT
0 Obtain a 12-lead and leave cables connected
0 CALCIUM CI-ILDTDE iii-f Illatieiirit Uinsta�N�e-.
0 1g IV/10, over 2 minutes
0 If patient reimains Hypotensive NORMAL SAUHNE:
• 20ml/kg IV/10,.titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x, prn
0 i�l""e c a Ll t i('11)�"l S- [�'a i c t lc&�-e �-nus't I)e ta��,11111.11l,et*i t�ie �oii��lese����-ice o'�fsig��rii'l'''icail i L coil oil i a le a�1�1
I C.............
disease IF, &��id fafl4,i��,-e patie����i 11111's
HYPOTENSION WITH BRADYCARDIA OR NON-RESPONSIVE TO ABOVE TREATMENT
0 Refer to the "'Bradycardia" protocol, if applicable
F—7—
PEDIATRIC
0 n t:a i n :3 I'm 3 f
btain a 12-lead and leave cables connected
• CALCIUM CI-ILGI11DE if Patient Uinsta�N�e-.
0 20mg/kg IV/10, over 2 minutes
• If patient ireimains Hypotensive NORMAL SALINE-.
• 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x, prn
HYPOTENSION WITH BRADYCARDIA OR NON-RESPONSIVE TO ABOVE TREATMENT
Refer to the "Bradycardia"' protocol, if applicable
Cocaine Overdose
Ent?'',
INFORMATION
Signs &Symptoms:
Tachycardia
Supraventricular and ventricular cardiac arrhythmias
Chest pain/STEMI
HTN
Seizures
Excited delirium
Hyperthermia
Follow the appropriate protocol if patient is symptomatic and treatment is not listed below.
ADULT
0 Obtain a 12-lead and leave cables connected
PATIENTS PRESENTING WITH STABLE SVT,, WCT,, CHEST PAIN, HTN,, OR SEIZURES
* VERSED/ATWAN:
* Versed 5mg IV/IO/IN/IM orAtivan 2mgIV/IO/IN
* May repeat 1x prn, in 5 minutes
* Contra i nd ication- Hypotension
�,,Iesph�,'a to��y
* Ketarnine (Secondary Option)
• 2mg/kg IM/IN
• lmg/kg IV if available
* Follow appropriate protocol if:
• Above treatment is unsuccessful
OR
• If the patient has an unstable cardiac arrhythmia
PEDIATRIC
0 Obtain a 12-lead and leave cables connected
0 VERSED:
0 0.1 mg/kg IV/10, max single dose 2.5mg
0 0.2 mg/kg IN/IM, max single dose of 5mg
0 May repeat either route 1x prn
0 Contra i nd ication-Hypotension
Mo���iiW�-N,1111)r ii es��,,)hi��'aW�-y de�p��-essio���i
Narcotic Overdose
E 00
Common Narcotics:
WARNING Suspected Narcotic 0 Fentanyl
Overdose 0 Codeine
Narcan is to be used PRN to 0 Dilaudid
improve intrinsic airway patency, 0 Heroin
ventilation and oxygenation. 0 Methadone
The goal is to restore spontane- 0 Lorcet
ous respiration,NOT"to wake 0 Vicodin
0 Oxycontin
the patient up" 0 Lortab
JP
NO
401 1
Reassess above vitals
Are all vitals within,
above parameters'.)
N 0
YES NO
Secure IV/10,Access? ------
Tricyclic Anti'*depressant (TCA) Overdose
INFORMATION
Signs &Symptoms: Common TCA:
• Mad as a hatter 0 Coma 0 Amitriptyline
omn
FA
0 Seizures 10 t
• Red as a beet Desipramine
0 Cardiac arrhythmia
• Hot as hell Doxepin
• Dry as a bone 0 Acidosis
• Blind as a bat
• Follow the appropriate protocol if patient is symptomatic and treatment is not listed below.
ADULT
0 Obtain a 12-lead and leave cables connected
FOR PATIENT WITH A QRS COMPLEX > .10 SECONDS (2.5 SMALL B
SODIUM BICARBONATE:
0 1 mEq/kg IV/10,. over 2 minutes
0 May repeat 2x prn, in 5 minute intervals, max total dose 150 mEq
e c a�,,ji t i o s- D i s c o t i u e t t"e a L��nen�t W��ie���i Q���lS c(''N���Ti�p��exes le, 10 sec("N��-ids (2.5 L)oxes)
If Patient remains HYPOTENSIVE
NORMAL SALINE:
• 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x, prn
c&�,-e js't be ta�ke���i in the p��-eser��Iice f!';i&���iific&rit coro��ri&�,-y he&�,t
disease, &��id fafl�t jiil��e pat�'&��'As
FPEDIATRIC
Obtain a 12-lead and leave cables connected
FOR PATIENT WITH A QRS COMPLEX >0.08 SECONDS(2 SMALL BgIESI
SODIUM BICARBONATE 8.4%-.
0 ImEq/kg IV/10,, over 2 minutes
If Patient remains HYPOTENSIVE
NORMAL SALINE-.
• 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x., prn
WARNING
TCA,4s. cause death primarily through lethal cardiac arrhythmias.Wide QRS complexes are an ominous
F sign and must be treated with SODIUM BICARBONATE immediately.
....... .......
IS
41
Old#
14m,
114110 Imp,
W,
Chemi'gcal Restraint
INFORMATION
Restrained patients shall NOT be placed in a prone position.
Chemical restraint may be used in addition to physical restraint for the following:
VIOLENT/COMBATIVE PATIENTS are Violent,agitated patients who place themselves and/or crew in
danger
EXCITED DELERIUM PATIENTS are Bizarre, aggressive behavior which may be associated with the use
of cocaine (crack), PCP (angel dust), bath salts, Flakka, metha m pheta mines and amphetamines
ADULT and PEDIATRICS
If possible utilize Law Enforcement to assist with restraint
FOR SPECIAL POPULATION VIOLENT/COMBATIVE/EXCITED DELERIUM
Special population patients:
0 Over 65 years old
0 Head trauma
0 < 50 kg
0 Already taken other sedatives (e.g., benzodiazepines, alcohol, etc.)
KETAM���N E:
• 2mg/kg IM/IN for the above patients
• If IV available lmg/kg IV
• May repeat 3x prn., in 5 minute intervals to gain control of the patient
• Contra indications:
• Pregnant patients
• Penetrating eye injury
• Non-traumatic chest pain
ecaLftiOIIS'.
p��,��e��j&�-ed advatwed ah�-way ��n a age t��n e it
lla��oid ����V is assoc4ted w[111h r��es��oiratml��'y dq�jii-essim�i, a��:)In(�lal &�id
t�i a n t jsua��� i��io��eases b��ood
If ineffective consider Versed 5mg IV/IO/IN or Ativan 2mg IV/IO/IN may repeat 1X prn
FOR ALL OTHER VIOLENT/COMBATIVE/EXCITED DELERIUM
KETA ����N E:
• 4mg/kg IM
• If IV available lmg/kg IV
• May repeat 1x prn, in 5 minutes
• Contra indications-as noted above
0 [) e c a t as ��Ioted above
0 If ineffective consider Versed 5mg IV/IO/IN or Ativan 2mg IV/IO/IN may repeat 1X prn
LARYNGOSPASM (STRIDOR) REACTION TO KETAMINE ADMINISTRATION
HighfIOW 02
Assist ventilations via BVM prn
0 Consider advanced airway procedures
����)recaUtiO��rl ........... is &��id iS USL4�H�y se[f-��kni'ting. a�����inos�t a�Ways ���es6�ves wit�i
�Iigll fi�OW 02,01,�� b��,��ief via BVI\A.
Chemical Restrai'ntcontinued....
HYPERSALIVATION REACTION TO KETAMINE ADMINISTRATION
ATROPINE:
* 0.5mg IV/10
* May repeat prn, in 3 minute intervals, max total dose 3mg
* Contra i nd ication- Bradycardia in the presence of an MI
AFTER KETAMINE ADMINISTRATION
• If patient begins to wake up:
VERSED:
* 5mg IV/10/IN/IM
* May repeat 1x prn, in 5 minutes
* Contra i nd ication-Hypotension
0 fo��11� �,���espi�t-atory dep����,essio�������l
• Obtain a temperature.
RAPID COOLING FOR A TEMPERATURE OF> 103 DEGREES F
* Apply ice packs to axilla and groin area
* COLD NGRIVIAL SALINE: (if avafl4ble)
20ml/kg IV/10.Titrate to desired effect. Assess lung sounds and BP frequently.
May repeat 1x, prn
0 P��,ecau'tiotis- flar cai-e n��ius�t tak&����i t����ie p��,-esetice t co���^o���iaii-y ��ie&r�t
disease, atid re���ia��� 'fafl�L,F�-e pa'�t"Je���'I ts
* SCIUUM BICX��RBCINATE:
lmEq/kg, IV/10, over 2 minutes
Pain Management
I.N.F RMATI—N
0 FENTANYL is the front line medication for pain, however KETAMINE is preferred for hypotensive
patients or patients who have opiate contra i nd ications (allergy, history of abuse, etc.).
0 KETAWHNE may be given with FENTANYL for severe pain.
7 on the pain scale is considered "severe pain"
Room
ADULT
FOR PAIN MANAGEMENT
FENTANYL:
• lmcg/kg IV/10/IN/IM
• May repeat 2x prn, in 5 minute intervals, max total dose 300mcg
Contra i nd ication- Pregnancy near term (32 weeks or greater)or in active labor
Piil�'ecat i t i o :
0�f q�z)ia�te a������)use or drtig se6�6�ig ����oehavior
0 ����\A o n i t o I,)a t i e t f'o r r e s p �1�IaM�-y
Xiscon�tint,ie if patiei�it �jecm��ii(,,�,%s dillowsy
C&�i be �eve������sed wi,t���i NARCAN [f tiecessary
KETAWNE if Fentanyl ineffective or Fentanyl not indicated:
• 50mg of Ketamine in NORMAL SALINE BAG
* Administer IV/10 infusion over 10 minutes
* Reassess pain scale after half of the infusion has been administered (5 minutes) or
25mg
0 Continue infusion if needed. Max total dose 50mg
* Contra i nd ications:
0 Pregnant patients
0 Penetrating eye injury
0 Non-traumatic chest pain
re c a Ll t i 0�1 S'.
0 Be adv&��iced ai����way t��na n age��I�T�i e n't
0 Ila���,)id IV is associa�ted w[tli apnea, atid
h i g h e t h a n i,isual iiicreases it��i lolood �,)iil��essu���-es
OR
0 25mg of Ketamine IN/lM
• May repeat 1x prn, in 5 minute intervals, max total dose 50mg
Contra i nd ications-as noted above
as i�ioted al��)ove
Pain Managementcontinued...
nt?,
EPEDIATIRIC
FOR PAIN MANAGEMENT
FENTANYL:
• lmcg/kg IV/10, over 2 minutes
• 1.5mcg/kg IN/1M
• Max single dose 50mcg
• May repeat 1x prn, in 5 minutes, max total dose 150mcg
• Contra i nd ications:
< 6 months old
Monitoii- N,11:)r res��j 11 1 11 11 a t&ry de�p����-essioi����i
Disc(,,N��Iiti��iue if�Da�tien�t beco���Itles drowsy
Cati be reversed with NARCAN if��������iecessa����,y
KETA�M���N E 3 ye a rs o I d)
* lmg/kg IN/lM
* May repeat 1x prn, in 5 minutes
* Contra i nd ications:
0 Penetrating eye injury
���Ii,��ecau�tions:
Be advancled airway t
PAIN i'M���E,.A,S�URE�M���E��N;T' S,CA,L,E
4e,
Ile
IN, d�1i em , ,
0 2 4, 10
NO HURT" HURTS HURT 5 HUNTS H—,,,U1R11TS HUR TS
LITTLE MIT LITTLE MORE EVEN1 MORE W—l'i'HOLE LOT 'WOR,,S,,T
11-........................all ............. ................................... ................................... ................L ................11
�O� 11 2( 3 4 16 117 a 1911 110,
a rvo,re., t pain
No, pain "I"IM,�i I'd MOder te Se Wors
imaginoible,
W
Adult Advanced Airwa
Position and Suction
FPre-oxygenate
Assist ventilations via
W
BV
M KETAM I N E:
200mg slow IV/10 push
over 1-2 minutes
Versed: May repeat IX
Precaution:
5-10mg IV/10 Pre-medicate: 0 Rapid IV administration is
Versed or Ketamine associated with higher
e rse'
5
May repeat 1X increases in BP
Indications:
* B�ro�r�li(-,�hoco�nst�r�ict�'�c)�r'li
F * Septic shock
* Flypotension
* Violent/combative
* Flead finjuries with
suspected ICP
YES Contra indications-,
• Pregnant Patients
• Penetrating Eye injury
• Non-traumatic chest pain
SUCCINYCHOLINE:
Paralysis Indications: 0 2 mg/kg IV/10 may repeat 1X
0 OR if contra indications
sUCC'
'x I I :J
2 1
* OF
• Apneic Status Epilepticus C
* ROCURONIUM:
I
m
• Head Injury/GCS 9 or less F g/kg IV/10 may repeat 1X
• Trismus(lock-jaw)or
clenched teeth
• Burn injuries to upper airway
Successful? NO
ROCURONIUM: (preferred) YES
1 mg/kg IV/10 may repeat 1 YES
OR
VERSED: Post intubation sedation(mandatory)
5-10 mg IV/10 may repeat X1
KETAMINE: OR
200mg IV/10 slow IV push may
repeat
IN
W
Pediatri'*c Advanced Airwa
Position and Suction
Pre-oxygenate
reAssist ventilations via
W
Versed: BVM KETAM I N E:
0 0.1 mg/kg IV/10 * lmg/kg slow IV/110 push
0 May repeat 1X over 1-2 minutes
0 May repeat 1X Max single
dose 50mg)
Pre-medicate: Precaution:
Versed or Ketamine Rapid IV administration is
associated with higher
increases in BP
Indications:
* Brorichoconstrictiori
* Septic shock
* Hypoterision
* Violent/combative
* Flead injuries with
Pre-treat for Paralytics?: suspected 1103
ATROPINE.02mk/kg IV/10 Contra ind ications:
Penetrating Eye injury
Paralysis Indications:
SUCCINYCHOLINE:
• Apneic Status Epilepticus 0 1 mg/kg IV/10 may repeat 1X
• Head Injury/GCS 9 or less 0 Or if contraindicated
• Trismus(lock-jaw)or 0 ROCURONIUM
0 1
clenched teeth r mg/kg IV/10 may repeat IX
• Burn injuries to upper airway
NO
ROCURONIUM:Preferred Successful? NO*
1 mg/kg IV/10 may repeat 1X
OR
VERSED: YES YES
0.1 mg/kg IV/10 may repeat X1 Post intubation sedation(mandatory)
OR
KETAMINE:
lmg/kg IV/10 slow IV push
may repeat X1
NNE
AO
AO so rag
low
.wood
)i� 4
AID,
f®r
AL
...... AdO,
All"
Decompression Sickness
INFORMATION
Signs &Symptoms
• Stroke-like symptoms
• Visual disturbances
• AMS
• Paralysis or weakness
• Numbness/tingling
• Bowel/bladder dysfunction
• Any patient with these signs& symptoms who has used SCUBA gear or compressed air within a
48-hour period shall be considered a decompression sickness patient.
• Transport to closest ED.
Contact DAN (Diver Alert Network) at(919) 684-4326 for medical consultation as needed.
• Treatment recommendations from DAN (Diver Alert Network)should be followed.
• Document the treatment and the name of the representative on the ePCR Report.
Try to obtain an accurate history of the dive:
• Depth of dives
• Air mixture type in tanks
• Number of dives
• Interval between dives
..................
ADULT& PEDIATRIC
* POS[MMNG:
0 Transport patient in a supine position
* For cardiac arrhythmias, refer to appropriate protocol
* Rule out a tension pneurnothorax
* OXYGEN
0 15 LPM via NRB regardless Of SP02
W11
NonmFatal Drowning
61
INFORMATION
Consider spinal motion restriction in the presence of trauma (e.g., diving, rough surf, vehicle
accident with subsequent submersion,etc.).
ADULT& PEDIATRIC
NON-FATAL DROWNING
• All non-fatal drowning patients MUST BE TRANSPORTED to the hospital
• For cardiac arrhythmias, refer to appropriate protocol
• 0�:IAP.- (10 cirn H20) for pulmonary edema secondary to near drowning:
Contra i nd ications-.
• S13P< 90 mm Hg
• Patients without spontaneous respirations
• Patients with a decreased LOC (lethargic)
• Patients< 30 kg
'IF PATIENT IS HYPOTENSIVE WITH CLEAR LUNG SOUNDS
NORMAL SALINE:
• Ad u It:
* 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
* May repeat 1x, prn
* Pi�-ecai.,,itio�����-is c&�e ����oe ta��<en the prese����ice ofsi&����i[ficant c&�11 o������i a �1 e a t�t
1, G�.............I
disease a d a I fa i I t jire �jatie����i 11111's
• Pediatric:
• 20mL/kg IV/10, assess lung sounds and BP frequently
• May repeat 2x prn,for age appropriate hypotension
'IF PATIENT IS HYPOTENSIVE WITH PULMONARY EDEMA
Dopaimine
• Ad u It:
Dopamine infusion 5mcg/kg/min-20mcg/kg/min titrate to effect
Contra i nd ications- Hypotension secondary to blood loss
P�recat j 1,1111 i�0�1
a�j i d (1 �ri i u t e) o i,se t., s o (5-J 0
0 �\4o����iitor he&rt�����,"ate&�,,�Iid b��ood p�ressu�re throug���ioi i t a d ni i ii i st atimi
• Pediatric:
* Epinephrine Infusion O.lmcg/kg/min—lmcg/kg/min titrate to effect
* Contra i nd ications- Hypotension secondary to blood loss
* P�recau��t,J�U�11".
DO NOT f'asteil�-than
js�����i-Dose has a (1 ���*�iu�te) o������ise.t, shoi11111.1 (5-1 0 ITI i�1 u te)
d u�,'"a lllibt���i
�ie&rt ��"a'te&��id b��ood ��j�r(:?ssi i re t�q 0 t i g 0 Ll t a d i i s b�,"a',tio���i
Heat Emergencies
INFORMATION
it f"'#r Signs&Symptoms of.heat stroke include any of the following:
• AMS When treating heat stroke:
• Seizures
• Hypotension '"COOL FIRST,TRANSPORT SECOND??
• Sweating may be absent
Patients with a heat-related illness associated with an altered mental status should be considered to
have heat stroke once all the other possibilities for the AMS have been ruled out(hypoglycemia,
drugs/alcohol,trauma,etc.).
ADULT& PEDIATRIC
ALL HEAT EMERGENCIES
• Move patient into the back of the rescue as soon as possible. Decrease the air-conditioning
temperature in the patient compartment.
• Obtain a temperature
• Remove excessive clothing
• Provide oral hydration (preferably water) if patient is able to swallow and follow commands
HEAT CRAMPS& HEAT EXHAUSTION
10 R A L SA LI N E
0 Adult:
* 20ml/kg IV/10.,titrate to desired effect.Assess lung sounds and BP frequently.
* May repeat 2x, prn
* I���)recakttimis,- 1���)&����ticular care rntJSt be takei��i t��ie p��-esence o�fsigi�iificw��A co��,'o���i&ry
e a�rl d i s e a s e, C a rd pa�dei�i Ls
0 Pediatric:
• 20mL/kg IV/10, assess lung sounds and BP frequently
• May repeat 2x prn,for age appropriate hypotension
HEAT STROKE WITH TEMPERATURE OF> 103 DEGREES F OR ALTERED MENTAL STATUS
* Apply ICE PACKS to axilla and groin area.
* Discontinue active cooling oincetemperature of 101 is reached
* NORMAL SALINE: (COUD NORMAL SALINE preferred, if available)
• Adult:
• 20ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x, prn
111111,io������is- care t��Int,,,ist be tak&����i p��es&�ic(� o�f sig�����i[fic&��it co��,��-o��i&ry
disease, ire pa'den'ts
• Pediatric:
• 20mL/kg IV/10, assess lung sounds and BP frequently
• May repeat 2x prn,for age appropriate hypotension
Carbon Monoxide Exposure
kill
INFORMATION
Carbon Monoxide (CO) properties:
• Chemical asphyxiant
• Colorless
• Odorless
• Tasteless
• Slightly less dense than air
• Toxic to humans when encountered in concentrations above 35 parts per million (ppm)
• Lower doses of CO can also be harmful due to a cumulative effect
Patients exposed to carbon monoxide (smoke inhalation,etc.) require a full head to toe patient
examination including SpCO monitoring.
• All rescuing crew members shall wear their SCBA if the patient is in a hazardous environment.
• Consider Cyanide Exposure.
Refer to the "'Cyanide Exposure" protocol, if applicable
ADULT& PIDIATRIC
* OXYGEN:
0 15 LPM via NRB regardless Of SP02, unless the patient requires ventilatory support
* Consider Advanced Airway Protocol if needed
IF SPCO IS>20%OR PATIENT PRESENTS WITH ANY OF THE FOLLOWING SYMPTOMS
• Headache
• Nausea/Vomiting
• Dizziness
• Altered Mental Status
• Chest pain
• Dyspnea
• Visual Disturbances
• Seizures
• Syncope
Transport to closest ED.
WARNING
Patients with CO exposures can have normal pulse oximetery readings and
st
F ill be hypoxic.
Cyanide Exposure f
10, kill"
INFORMATION
it f",#F Signs &Symptoms:
• AMS * Coma
• Pupil Dilation 0 Shortness of breath
• General Weakness 0 Headache
• Confusion 0 Dizziness
• Bizarre behavior 0 Seizures
• Excessive sleepiness
• Cyanide exposures may result from inhalation,ingestion or absorption from various cyanide
containing compounds, including exposure to fire or smoke in an enclosed space.
• Direct cyanide exposure (non-smoke inhalation) is a Hazardous Materials Incident.
• Consider Carbon Monoxide Exposure.
Refer to the "Carbon Monoxide Exposure" protocol (pg. 96), if applicable
ADULT& PEDIATRIC
CONFIRMED OR SUSPECTED CYANIDE EXPOSURE
OXYGEN-.
0 15 LPM via NRB regardless Of SP02, unless the patient requires ventilatory support
0 Consider Advanced Airway Protocol if needed
0 Transport to closest ED
IN
if
............................................................................................ ....................... .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Trauma Standing Orders
n
INFORMATION
ADULT& PEDIATRIC
• The following conditions should be managed as soon as they are discovered:
• M-Massive hemorrhage
• A-Airway control
• R-Respiratory Support
• C-Circulation
• H-Hypothermia
• Unless otherwise noted, IV fluids should be given for a SBP < 90 mm Hg and should be given at a rate
(boluses) necessary to maintain peripheral pulses(which is typically a SBP of 80-90 mm Hg).
• ULTRASOUND FAST EXAM if available:
A FAST exam can be performed during transport of the following injuries:
Blunt force trauma to abdomen or thorax
Penetrating injury to abdomen or thorax
Undifferentiated hypotension in the presence of trauma
Can be performed to identify possible:
0 Intra-abdominal hemorrhaging
0 Intra-thoracic hemorrhaging
0 Pericardial hemorrhaging
0 Cardiac motion in PEA
This exam shall be done in a prompt fashion and should NOT delay transport
FAST Exam findings shall be communicated to the receiving facility and documented in the ePCR
Gilaisgow Comia,Scaille Score
E�ye Open'lin,g Spontaneously 4
To Speech 3
To Pia�i�n 2
None 1
VerlbaJ Response 0rientiated 5
Conf used 4
Iniaip,p,rop,riaite 3
Incom,prehensib,le 2
None 1
Motor Response O,beys Comimiainds 6
Locia]izes�to Pa�in 5
W[thdraws,�from� Pa�in 4
Fl�exion�to Paiin 3
E,xtension�to Pa�in 2
None 1
Maiximiuimi Score 15
W,
Trauma Arrest Standing Orders
ADULT& PEDIATRIC
,DETERMINATION OF DEATH
Resuscitation should NOT be attempted for trauma patients that have ALL 3 of the following
presumptive signs of death present:
• Apneic
• Asystole
• Fixed and dilated pupils
OR
• Injuries incompatible with life (e.g., decapitation, massive crush injury, incineration,etc.)
SPECIAL CONSIDERATIONS
�PM ET�RAT�NG OR BLUNT CH EST TRAUMA:
• Bilateral needle decompression may be performed in an attempt to achieve ROSC
• Resuscitation efforts DO NOT need to be started if the patient did not regain pulses
immediately following the bilateral needle decompression
SPECIAL CONSIDERATIONS IN PENETRATING AND BLUNT
TRAUMA
Consideration should be taken to continue care for organ
donation.
11111111 M1111111111111111
START Triage
�E,ni
Move the walking wounded
No respirations after head tilt
is 660 is
Respirations > 30/min.
Perfusion
1010110
No radial pulse
Cap refill > 2 sec
Mental Status
Unable to follow simple commands
Otherwise DELAYED
The goal of the,START program is to provide the
"greatest,good for the greatest number of patients."
m Immm illillillimmlijillillillillillillilillilillillillilI lifillill,,Plllllllll1;11illillI Imm,"1111111111,�Oi,11111111, 8111111iii-Ilimil
JumpSTART Triage 1�8 years old
F 'E'a
YES
ABLE TO Seconclary
WALK? Triage* *Evaluate infantsfirst
in,secondary triage
using thlie entireJump-
STARTalgorithim
IIIIIIN NIF
NO, BREATHINGI
Position Airway
CBreathing?) AP'NEI�C > mom
NO
Pulse, .................................................................
YES
NV
YES APNEIC
5 Breaths
BREATHINGI
OMEN
< 15 or>45
Respiratory
Rate?
15-45
NO
Pulse? ......................................................................................................................................................................................................................................................................................................................................................................>
",E) �
YES
dipl?(inappropriate) Posturing or""U"
(AVPU )
"A"11VA?or dipyl(Appropriate)
............... DELAYED
Trauma Communi'cati*on Dispatch Procedure
A.The City of Key West Fire Department(KWFD)utilizes the Key West Police Department Communication
Center's(KVvTD) 911 phone system in conjunction with computer-aided dispatch(CAD)programs. All
emergency information, including address and call-back data,is confirmed by the call taker prior to the end of
the telephone conversation. Emergency information is immediately transmitted to the Fire/Rescue dispatcher
who selects the closest available unit for response. Units are dispatched at this time by the Fire/Rescue dis-
patcher,who provides responding units with all available information concerning the incident.
B. The Dispatcher obtains information from the caller regarding:
C.Name of person calling
D.Nature of Incident
E.Type of Injury
F. Call back number
G.Number of patients
H.Location of Incident
1. Extent and severity of reported Injury
C.In the best interest of patient care,the closest available ALS transport unit shall be dispatched to all 911
emergency calls,regardless of response zones. Dispatch,Rescue Lieutenant, or Shift Commander shall identi-
i
fy the closest unit. Closest Unit is defined as the nearest in terms of estimated response time,not necessarily
the nearest in mileage.
D.As soon as on-scene personnel recognize a need for other emergency agencies(e.g., law enforcement, fire,
EMS, Coast Guard, or other services),they shall notify dispatch immediately. On-scene personnel must iden-
tify the agencies needed and the specific amount of personnel,equipment, and other resources required. Dis-
patch shall then make telephone contact with the appropriate services. Mutual aid contracts exist between all
adjacent services.Additionally, a master phone list of all available emergency services is maintained at
KWPD Communication Center.
Trauma Alert Criteria
f,DO
The following guidelines are to be used to establish the criteria for a Trauma Alert patient and to
determine which patient(s)will be transported to a trauma center.Any patient that meets any one of the RED
criteria will be classified as a Trauma Alert,while any patient that meets two of the BLUEE criteria will be classi-
fied as a Trauma Alert.
ADULT TRAUMA SCORECARD METHODOLOGY
I.Upon determination that the patient meets TRAUMA ALERT Criteria,the Paramedic in Charge or Incident
Commander will initiate direct radio communications with the SATC, SAPTC or local receiving facility.
Communications from field EMS personnel to the receiving facility will include the phrase "TRAUMA ALERT",
and will include the following information:
1. Specific Trauma Alert Criteria,Mechanism of Injury, Glasgow Coma Scale(Itemized)
2. ETA to receiving facility
2. Each EMS provider shall ensure that upon arrival at the location of an incident,an EMT or paramedic shall:
I. Assess the condition of each adult trauma patient using the adult trauma scorecard methodology, as
provided in this section to determine whether the patient should be a trauma alert.
2. In assessing the condition of each adult trauma patient,the EMT or paramedic shall evaluate the patient's
status for each of the following components: airway, circulation,best motor response(a component of the
Glasgow Coma Scale which is defined and incorporated by reference in section 64J-2.001(6), cutaneous,long
bone fracture,patient's age and mechanism of injury. The patient's age and mechanism of Injury shall only be
assessment factors when used in conjunction with assessment criteria included in(4)of this section.
3.The EMT or paramedic shall assess all adult trauma patients using the following criteria in the order presented
and if any one of the following conditions is Identified, the patient shall be considered a trauma alert patient:
a. Active Airway Assistance Required or Respiratory Rate< 10 or>29
b. Lack of Radial Pulse with a Sustained HR>I 10 BPM or BP<90 nu-nHg
c.Glasgow Coma Scale of 13 or less
d. Exhibits Presence of Paralysis, Suspicion of Spinal Injury or Loss of Sensation
e. 2nd Degree or 3rd Degree Burns Greater than 15%TBSA,Electrical Burns(High Voltage/Direct Lightning)
Regardless of Surface Area
f.Amputation Proximal to the Wrist or Ankle
g.2 or More Long bone Fracture Sites
h. Penetrating injury to head,neck or torso
i.GSW or Penetrating Injury to Extremities at or above Knee or Elbow
j.Chest Wall Instability or Deformity(Flail Chest)
k.Best Motor Response Less Than or Equal to 4
1.Crushed,Mangled,De-gloved or Pulseless Extremity
m. Pregnancy>20 Weeks w/Abdominal Pain and Blunt Trauma
n. Paramedic Judgement
.....................................................
.................................................................................... .......... ........................ ..........
Trauma Alert Criteria cont.
f,DO
Should the patient not be identified as a trauma alert using the criteria listed above this section,the trauma patient
shall be further assessed using the criteria below and shall be considered a trauma alert patient when a condition is
identified from any two of the components included in this section:
a. Head.1r1jury w/.LOC,Amnesia, or New AlteredMenfal Status
b. Soft Tissue Loss Iqj ury(crush, de-gloving) or.Deep.Flap Avulsion>5 inch
c. Penetrating Injury to the Extremities Distal.to the Elbow or Knee
d.Sin.gle long bone.FX sites due to MV.A.or single long bone fracture site due to Eall greater than or equal to 1-0
feet
e. Major degloving, �flap evulsion greater than 5 inches, or GSW to extremities
f..Best.Motor response:---5
g..Ejection from a vehicle or d6ormed steering wheel
h.. Death.in Same Passenger Compartment
i.Fall.>20 feet
j.Auto vs. Pedestrian/Bicyclist, Thrown.,R.un Over or w/impact>20MPH
k.MotorcycJe, Golf Cart or ATV Crash>20MPH
1.Age 55 or older
5.1n the event that none of the criteria above are identified in the assessment of the adult patient,the EMT or
paramedic can call a"Trauma Alert" If, in his or her judgment based upon the criteria noted in section"C" below,
the trauma patient's condition warrants such action.Where EMT or paramedic judgment is used as the basis for
calling a trauma alert,it shall be documented as required in 64J-1.004 of the Florida Administrative Code.
6.1f the patient is not identified as a trauma alert patient after using the above criteria,the trauma patient will be
evaluated using all elements of the Glasgow Coma Scale. If the patient's score is less than or equal to 12,the pa-
tient will be considered a"TRAUMA ALERT"patient(excluding patients whose normal GSC is less than or equal
to 12 by past medical history or known pre-existing medical condition).
7.The results of the patient assessment shall be recorded and reported in accordance with the requirements of
section 64J-1.0 14 Patients who are found to meet the Trauma Alert criteria on arrival at or subsequent to arrival at
a non-trauma center will be expeditiously transferred to the appropriate trauma center.
Pediatric Trauma Alert Criteria
f,DO
PEDIATRIC TRAUMA ALERT CRITERIA 64J-2.005
PEDIATRIC TRAUMA SCORECARD METHODOLOGY
For children,the term"pediatric trauma" applies to those injured persons with anatomical and physiological char-
acteristics of a person fifteen(15)years of age or younger. If there is doubt as to whether or not the patient should
be considered to be a pediatric patient,the EMT or Paramedic may measure the patient using a length-based resus-
citation tape.If the patient falls within the maximum length of the tape,the patient should be considered a pediatric
patient.
I.Upon determination that the patient meets TRAUMA ALERT Criteria,the Paramedic or EMT on scene will
initiate direct radio communications with the SATC, SAPTC or local receiving facility.
a. Communications from field EMS personnel to the receiving facility will include the phrase "TRAUMA
ALERT11,and will include the following information:
1. Specific Trauma Alert Criteria
2. Mechanism of Injury
3. Glasgow Coma Scale (itemized)
4. ETA to receiving facility
2. The EMT or paramedic shall assess all pediatric trauma patients using the following red criteria and if any one
of the following conditions is identified,the patient shall be considered a pediatric trauma alert patient:
a. Airway Assistance or intubated
b. Respiratory Rate<20(Infant< I yr) Respiratory Rate< 10 (Child I yr-I 5yr)
c.Altered mental status,paralysis, suspected spinal cord injury or loss of sensation
d. Weak or no palpable carotid or femoral pulses, Systolic Blood Pressure less than 50
e. Any open longbone fracture or multiple fracture sites or possible dislocations
f.Major soft tissue disruption, amputation proximal to wrist or ankle, second or third degree burns to 10%BSA,
electrical bums(high voltage/direct lightning)regardless of surface area
g.Penetrating injury to head,neck or torso
h. Paramedic Judgement
3. In addition to the criteria listed above, a trauma alert shall be called when a condition is identified from any two
of the blue components included below.
a. Amnesia or reliable I-IX ofLOC
b. Carotid or femoral pulse palpable;no pedal pulse or systolic BP less than 90
c. SingleLong bon.e.Fracture site
d. Red, Purple less than I I kg(less than.24 lbs)
Pediatrl"c Trauma Alert Criteri'ga Cont.
f,DO
4. In the event that none of the criteria above are identified in the assessment of the adult patient,the EMT or para-
medic can call a"Trauma Alert" if, in his or her judgment based upon the criteria noted in section -C below,the
trauma patients condition warrants such action.Where EMT or paramedic Judgment is used as the basis for calling
a trauma alert. It shall be documented as required in 64J-1.0 14 of the Florida Administrative Code if the patient is
not identified as a trauma alert patient after using the above criteria,the trauma patient will be evaluated using all
elements of the Glasgow Coma Scale. If the patients score is less than or equal to 12,the patient will be considered
a TRAUMA ALERT patient(excluding patients whose normal GSC is less than or equal to 12 by past medical
history or known pre-existing medical condition).The results of the patient assessment shall be recorded and re-
ported in accordance with the requirements of section 64J-1.0 14 Patients who are found to meet the Trauma Alert
criteria on arrival at or subsequent to the arrival at a non-trauma center will be expeditiously transferred to the ap-
propriate trauma center.
Transport Destination Criteria
f,DO
TRANSPORT DESTINATION CRITERIA 64J-2.002
There are no state approved trauma centers in Monroe County. Therefore,it is the decision of the Medical Direc-
tor,Dr. Antonio Gandia,that it is in the best medical interest of patients who meet-TRAUMA ALERT-criteria as
set forth in 64J-2.004,F.A.C. and 64J-2.005 F.A.C. and as outlined in these Trauma Transport protocols to be
transported as expeditiously as possible to a SATC, SAPTRC or in certain circumstances to the local hospital clos-
est to the scene for evaluation and stabilization,prior to transfer to Ryder Trauma Center,Kendall Regional Medi-
cal Center,Jackson South Community Hospital,Nicklaus Children's Hospital or another facility.
l.KWFD has access to a public use helicopter, "TRAUMA STAR",operated by the Monroe County Sheriff and
licensed for emergency medical transport by Monroe County Fire Rescue.TRAUMA STAR has aircraft based in
Key West and Marathon both Air Ambulances will respond to incidents,when summoned,to transport TRAUMA
ALERT patients to the closest Trauma Center to the location of the incident. The current closest Trauma Centers to
our response area are Ryder Trauma Center,Kendall Regional Medical Center,Jackson South Community Hospi-
tal and Nicklaus Children's Hospital, or to a local receiving hospital for emergent stabilization prior to transport to
a SATC, SAPTC,or other receiving facility.
2.An agreement with Monroe County and Jackson Memorial Hospital/Ryder Trauma Center allows for TRAU-
MA ALERT notification to be immediately shared with Ryder Trauma Center in order to facilitate the most expe-
ditious transport of the patient to the appropriate trauma receiving facility in Dade County, from the scene, or from
the local receiving hospitals.
3.Any patient meeting Trauma Alert Criteria will be considered a TRAUMA ALERT PATIENT and should be
transferred as expeditiously as possible from the scene or local receiving hospital(depending on the location of the
incident)to SATC or SAPTC. TRAUMA ALERT patients injured in the Key West Fire Department response area
may be flown directly from the scene of the accident provided access to Trauma Star is the most expeditious meth-
od of transfer. TRAUMA ALERT patients unable to be flown or requiring emergency airway management that is
unable to be secured on scene should be taken by ground ALS to Lower Keys Medical Center ED for emergent
stabilization prior to transfer to the SATC or SAPTC.
4.1f circumstances prohibit direct scene transport to SATC,then Trauma Alert patients will be taken to the nearest
emergency facility(Lower Keys Medical Center)by the most expeditious means(air or ground) for stabilization
and treatment prior to possible transport to SATC or SAPTC.
5. Definitions:
a.Trauma Center:A State Approved Trauma Center(SATC)or State Approved Pediatric Trauma Center
(SAPTC).Appropriate SATC for Monroe County Is the Ryder Trauma Center at Jackson Memorial Medical Cen-
ter in Miami,Kendall Regional Medical Center,Jackson South Community Hospital.The appropriate SAPTC for
Monroe County Is the Ryder Trauma Center at Jackson Memorial Medical Center or,Kendall Regional Medical
Center,Jackson South Community Hospital and Nicklaus Children's Hospital.
b.Emergency Facility: A hospital emergency department capable of providing care to most emergency patients
and meeting the five emergency department criteria in 64J-2.002 F.A.C. (Does not include freestanding emergency
walk-in-clinics.) The emergency facilities in Monroe County are Lower Keys Medical Center in Key West and
Fisherman's Hospital in Marathon. The destination is determined by the closest hospital,in terms of transport time.
Trans
.Ler oj Trauma Patient Care
TRANSFER OF PATIENT CARE INFORMATION
A Trauma Work Sheet shall be completed for every Trauma Alert patient on-scene by KWFD personnel and will
accompany the patient to the receiving helicopter crew and/or emergency facility. An Electronic Patient Care Re-
port(Eper) shall be completed as defined in section 64J-2.001(9)F.A.C. by the KWFD personnel that were on-
scene care providers for every patient.Additionally, The KWFD Eper will be forwarded to the receiving facility
when completed.A KWFD Eper shall be completed for each trauma patient including victims found dead on sce-
ne,regardless of whether KWFD transports the body. This emergency call data will then be submitted to the Flori-
da Dept. of Health as required.
Trauma Alert Transport Procedures
f,DO
A. Upon arrival at the scene,paramedic and emergency medical technician(EMT)personnel shall con-
duct a size up of the scene,to include the Trauma Alert Criteria as outlined in this protocol including the Trauma
Scorecard Methodology in 64J-2, safe entry,the need for extrication,and the need for additional help. Multiple
patients shall be immediately triaged.KWPD and the primary receiving hospital will be notified, as soon as possi-
ble,of"Trauma Alert"patients.The paramedic,emergency medical technician, or dispatch shall immediately re-
lay this information,using the words"Trauma Alert",to the hospital and/or Trauma Star.
B.In the best interest of patient care, seriously injured patients that meet Trauma Alert Criteria shall be transported
directly to a State Approved Trauma Facility by means of an Air Ambulance Helicopter. Trauma Star,operated by
Monroe County Sheriff s Office and Monroe County Fire Rescue,is the primary State Approved Air Ambulance
Helicopter to be utilized for emergency patient transport for Key West Fire Department Trauma Alert patients.
Key West Fire Department protocols shall be followed in determining a patient's status and need for immediate air
transport by Key West Fire Department Paramedics on scene.
EFFECTIVE JUNE 11 20179 THE AIR AMBULANCE HELICOPTER REQUEST AND DISPATCH
PROCESS WILL BE AS FOLLOWS:
Key West Fire Department shall directly contact Monroe County Sheriff s Communications(MCSO) to request
Trauma Star be placed on STANDBY upon initial dispatch of the emergency call for service if air transport is sus-
pected to be necessary. If/when the patient is confirmed to be a TRAUMA ALERT,and air transport is neces-
sary, KWFD will contact MCSO to request Trauma Star to LAUNCH.When the request is made to launch Trau-
ma Star, the following information must be given:
• Helispot location(Lower Keys Medical Center,Key West Int. Airport, Trumbo Point, Truman Annex NAS)
• Mechanism of injury(MVA, fall, stabbing, etc.)
• Current Patient Status(primary impression,vital signs, airway status)
• Patient Weight
KWFD may request KWPD to contact MCSO for Trauma Star requests if needed. KWFD or
KWPD shall also contact Lower Keys Medical Center ED to advise that KWFD is bringing a TRAUMA ALERT
patient to the Lower Keys Medical Center Helipad for a patient transfer with Trauma Star.
The direct number into Monroe County Sheriff s Office Communication Center is (305)289-2371. The direct
number to Lower Keys Medical Center ED is(305)294-9691.
If Trauma Star is not immediately available for patient transfer,the patient will be transported to Lower Keys
Medical Center ED for treatment.
KWPD dispatch may be requested by the Key West Fire Department to contact additional agencies for aircraft to
respond for the transport of Trauma Alert patients if the need arises.
Helicopter Transport Criteria
f,DO
Two sets of criteria must be considered.The first is directed toward the safety of the helicopter pilot and
crew,the ground personnel,the patient, and bystanders. The second is intended to establish operational guidelines
for when the helicopter is to be requested for Trauma Alert patients.
1. Safety criteria(helicopter will not be used).
A.Severe weather
B.Power lines too close to landing area
C.Trees, signs,poles, or other obstacles in immediate landing area
D.Large gatherings of civilians in the area
E.An expectation that the area may not remain safe
2. Operational Criteria(helicopter will be used)
F.If the patient is considered a Trauma Alert patient as outlined in this protocol
G.Blockage of the main road or failure of a bridge making ground access to the nearest receiving hospital impossi-
ble
H.If ground transportation is not available and is not expected to be available within a reasonable amount of time
I.If the helicopter is needed to gain access to the patient or needed to transport the patient out of an inaccessible
area
J.Extrication time greater than(20)minutes
K.Mass Casualty Incident
Emerqency IntermFacility Transler
A.There are no state approved trauma centers in Monroe County. The closest available service for air
transport of Inter-facility Medical Transfers(out of county) is in Monroe County. On occasion,a TRAUMA
ALERT patient may be transported by air or ground to a local hospital for stabilization/treatment prior to transport
to a SATC or SAPTC.
B.If after Initial evaluation and stabilization of the patient,the initial receiving facility deems transfer to another
facility to be necessary and in the best medical interest of the patient. This may be accomplished either by ground
or air transport.
C.Should air transport be deemed to be the appropriate method for the transfer, the Initial receiving facility direct-
ly contacts TRAUMA STAR or another air medical provider. Landing facilities are available for rotor wing air-
craft at all local hospitals.
D.Should the initial receiving facility deem ground transport appropriate the hospital will arrange transportation of
the patient. Key West Fire Department may be called upon to assist the local hospital in ground transportation of a
trauma patient.
E.Should supplemental personnel such as medical or nursing staff respiratory therapy staff, etc. be necessary to
assist the EMS crew for optimal patient care,the transferring hospital will coordinate the necessary personnel to
accompany the EMS ground transport personnel.
F.Key West Fire Department may transport adult "Trauma Alert" patients to Jackson Memorial Ryder Trauma
Center(305) 585-1152,Kendall Regional Medical Center(305)223-3000,Jackson South Community Hospital
(305)251-2500 and Nicklaus Children's Hospital if appropriate staffing and ALS transport units are available.
G.Key West Fire Department may transport pediatric "Trauma Alert"patients to the following Pediatric Trauma
Centers: Jackson Memorial Ryder Trauma Center(305) 585- 1152,Kendall Regional Medical Center,Jackson
South Community Hospital and Nicklaus Children's Hospital(305)666-6511 if appropriate staffing and ALS
transport units are available.
Medical Director Approval
f,DO
A. These protocols have been submitted by Key West Fire Department and have the approval of the
agency Medical Director,Dr.Antonio Gandia MD FACEP NREMT.
a.Approved trauma centers and initial receiving hospitals 64J-2.002.Approved trauma centers and
pediatric trauma referral centers.
I.Ryder Trauma Center,University of Miami,Jackson Memorial Medical Center Adult and Pediatric
Trauma Care.
2. Kendall Regional Medical Center
3. Jackson South Community Hospital
4.Nicklaus Children's Hospital
b. Approved Local Receiving Facilities
1. Lower Florida Keys Medical Center,Key West
2. Fishermen's Hospital,Marathon
B.Distribution of trauma transport policy
The SATC, SAPTC, and receiving facilities to which Key West Fire Department routinely transports patients have
been provided with a copy of the criteria which are used to determine trauma transport destinations
C. Transport deviation
Any deviation from these Trauma Transport Protocols must be documented and justified on the run report.
D. Pre-hospital providers included
Pre-hospital providers covered under this Trauma Transport Protocol are for the Key West Fire Department.
Bum Injuries
kill
Ent?'' ,
INFORMATION
Advanced airway procedures shall be considered for patients with respiratory involvement(i.e., hoarse
voicel singed nasal hairs, carbonaceous sputum in the nose or mouth, striclor or facial burns).
FIRST DEGREE BURNS
0 Involves only the epidermis and are characterized as red and painful
SECOND DEGREE BURNS
0 Involves the epidermis and varying portions of the underlying dermis with blistering
THIRD DEGREE BURNS
Involves deep tissue damage and will appear as thick, dry,white, leathery burns(regardless of
race or skin color)
ADULT& PEDIATRIC
• Stop the burning process by irrigating with copious amounts of room temperature water or
NORMAL SAU�NE for 2 minutes. Never apply ice directly to burns.
• Determine Total Body Surface Area (TBSA) percentage of the burn
• DO NOT attempt to remove tar, clothing, etc., if adhered to the skin
• Remove jewelry and watches from burned area
• Consider Pain Management Protocol
• DO NOT use IM route for medication administration
• Consider Carbon Monoxide and Cyanide Exposure
1st& 2 nd DEGREE BURNS< 15%TBSA or 3 rd DEGREE BURNS < 5%TBSA
0 Apply a dry sterile dressing
2 nd DEGREE BURNS > 15%TBSA or 3 rd DEGREE BURNS > 5%TBSA **Trauma Alert"
Apply a dry sterile lourn sneet
NORMAL SAUNE
* 5 years and younger: 125mi per hour
* 6-13 years old: 250 iml per hour
* 14 years and older: 500iml per hour
ELECTRICAL BURNS
• Treat associated burns as indicated.
• If patient is in cardiac arrest,follow appropriate protocol.
CHEMICAL BURNS
Irrigate liquid chemical burns with copious amounts of water or sterile saline. Brush off dry chemicals
prior to irrigation.
Remove patient's clothing and ensure that the patient is decontaminated prior to transport, in order
to avoid contaminating personnel and equipment. Personnel shall wear protective clothing and/or
respiratory protection as needed when removing chemicals.
um Injuriescontinued...
ADULT& PEDIATRIC
Adult Child
4.51%
K IA-)
A I r
18%
44L S
A.5%
9% 9% 91%, 9%
4-59
..........
nfa nt,
.... ...............
TI-
.......................
V0
x 0110
Palm and fingers
'I�3.5 00111 13.51 of patient
CA
1% TBSA
1111W�
Chest Trauma
INFORMATION
FLAIL CHEST
0 Occurs when 2 or more adjacent ribs are fractured
OPEN PNEUMOTHORAX(SUCKING CHEST WOUND)
0 Occurs when air enters the pleural space, causing the lung to collapse
TENSION PNEUMOTHORAX
Occurs when air continues to enter the pleural space without an exit or release, causing an
increase in intrathoracic pressure
0 Intrathoracic pressure decreases cardiac output and gas exchange.
ADULT& PEDIATRIC
'PENETRATING OBJECTS
0 Stabilize with a bulky dressing
FLAIL CHEST
• Stabilize with a bulky dressing.
• Consider Advanced Airway if needed
OPEN PNEUMOTHORAX(SUCKING CHEST WOUND)
Apply a vented chest seal or occlusive dressing to all open chest wounds and monitor for signs
symptoms of a tension pneumothorax
0 Apply on expiration if possible
TENSION PNEUMOTHORAX
• Needle decompression should be performed when ALL of the following findings are present:
• Respiratory distress or difficulty ventilating with a BVM
• Decreased or absent breath sounds to the affected side
• Primary site:
0 2 nd or 3 rd intercostal space, midclavicular line
• Seconcla
5 th intercostal space of the miclaxillary line
W,
ead Injuries
INFORMATION
• Patients with a depressed LOC may be unable to protect their airway.
• Adequate oxygenation of the injured brain is critical to preventing secondary injury.
• Consider Advanced Airway Management.
0 Especially for patients with a GCS of<9
• If patient becomes combative refer to the "'Chemical Restraint" protocol (pg. 85-86)
INTRACRANIAL PRESSURE/HERNIATION SIGNS INCLUDE:
• A decline in the GCS of 2 or more points
• Development of a sluggish or nonreactive pupil
• Paralysis or weakness on 1 side of the body
• Cushing's Triad:
• A widening pulse pressure(increasing systolic, decreasing diastolic)
• Change in respiratory pattern (irregular respirations)
Bradycardia
ADULT& PEDIATRIC
ALL HEAD INJURIES
* OXYGEN:
• As needed to maintain SP02 of 94%. Ventilate as necessary to maintain ETCO2 of 30-35mmHg
• Consider Advanced Airway Protocol
* NORMAL SAL�NE:
0 Adult: (only enough to maintain SBP of 110-120)
* 20ml/kg IV/10,.titrate to desired effect.Assess lung sounds and BP frequently.
* May repeat 1x., prn
* P��,�-ecai�,i t i o n s c&�,��e L)e �t,ake����i t�ie presence of sig�nific&�it coro������Iali.y
heaii-t disease, and rei��ml ����oa tiei�its
0 Pediatric: (only enough to maintain an age appropriate SBP within normal range.
Refer to"Handtevy"system)
• 20mL/kg IV/10, assess lung sounds and BP frequently
• May repeat 2x prn for age appropriate hypotension
DEPRESSED OR OPEN SKULL FRACTURE
Pressure dressings should not be applied to depressed or open skull fractures unless there is
significant hemorrhage present, as this can cause an increase in ICP
PO&[T�0MNG:
300 head elevation
WARNING
A SINGLE INSTANCE OF HYPOTENSION OR HYPDXIA(SP02< 90%) IN PATIENTS WITH A BRAIN INJURY
F MAY INCREASE THE MORTALITY RATE BY 150%.
Open Fracture
441441"
ADULT and PEDIATRIC
• Gross contamination,such as leaves or gravel, should be removed if possible
• Consider Pain Management Protocol
• Cover open fractures with a moist sterile dressing
• Fractures should be splinted in the position found
Exception: No pulse present OR the patient cannot be transported due to the extremity"s
unusual position
0 2 attempts can be made to place the injured extremity in a normal anatomical position.
0 Discontinue attempts if the patient complains of severe pain or if there is resistance to
movement felt
0 Reassess neurovascular status before and after repositioning of patient"s extremity
Hemorrhagic Shock
INFORMATION
COMPENSATED SHOCK DECOMPENSATED SHOCK
• Anxiety 0 Decreased LOC
• Agitation 0 Hypotension
• Restlessness 0 Peripheral cyanosis
• Normotensive 0 Delayed capillary refill
• Capillary refill normal to delayed 0 Inequality of central/distal pulses
• Tachycardia 0 Tachycardia
ADULT& PEDIATRIC
• Maintain body temperature with blankets and consider increasing the temperature in the patient
compartment
• Control all major external bleeding
• Establish bilateral vascular access, utilizing largest catheter size possible
• NORMAL SAU�NE: (only enough to maintain peripheral pulses or Systolic BP of 80mmHg)
• Ad u It:
0 20 ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently.
0 May repeat 1x., prn
0 Pi��'�ecat c&I-e �I��nt,jist ����oe ta��<&i i�IIi t�ie p��-es&I�ice o��fsi&Iiificatit co��,���oti&I,y
e a d i s e a s,e, C I............ &IIid �-&��ial failuire �oati&��its
• Pediatric:
0 10 mL/kg for infant/neonate.Assess lung sounds and BP frequently.
0 20 mL/kg IV/10.Assess lung sounds and BP frequently.
0 May repeat 2x prn,for age appropriate hypotension
Neurogeni'c Shock
INFORMATION
Signs &Symptoms:
• Warm/Dry skin (especially below the area of the injury)
• Hypotension with a heart rate within normal limits
• Paralysis
ADULT
Maintain body temperature with blankets and consider increasing the temperature in the patient
compartment
NORMALSALINE
• 20ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 2x,. prn
care rnt is,t [ie in 1111111�ie 1:x�-esence(.-Yf sig���iific.&��it
disease, C[����IF, &��A fafl�w�e patie���its
If BP does not increase consider Dopamine 5 mcg/kg/min and titrate to effect(maximum dose 20mcg/
kg/min)
PEDIATTRIC
Maintain body temperature with blankets and consider increasing the temperature in the patient
compartment
NORMAL SALINE
• 20mL/kg IV/10, assess lung sounds and BP frequently
• May repeat 2x prn,for age appropriate hypotension
If BP does not increase consider Dopamine 5-15 mcg/kg/min. Use a microdrip (60 gtt/mL) and refer to
the Handtevy Medication Guide for drip rate based on patient weight or age.
Trauma in Pregnancy
INFORMATION
PHYSIOLOGICAL CHANGES DURING PREGNANCY
Due to the following physiological changes in pregnancy, it is often difficult to assess for shock:
• Mother's heart rate increases.
• By the third trimester,the HR can be 15-20 beats per minute above normal.
• Both the systolic and diastolic blood pressures drop 5-15 mm Hg during the second trimester.
• The mother's cardiac output and blood volume increases.
Therefore,the pregnant patient may lose 30-35% of her blood volume before the signs
&symptoms of shock become apparent.
• Supine hypotension usually occurs in the third trimester.
ADULT
0 Assess for vaginal bleeding and a rigid abdomen
0 In the third trimester,this could indicate an abruptio placenta or a ruptured uterus
0 POSITIUMNG:
• Pregnant patients not requiring spinal motion restriction shall be transported on their left side
• If a pregnant patient requires spinal motion restriction, place 4-6 inches of padding under the
patient's right side while maintaining normal anatomical alignment
ALL THIRD TRIMESTER PREGNANCY TRAUMA PATIENTS
OXYGEN
0 15 LPM via NRB regardless Of SP02, unless the patient requires ventilatory support
IF HYPOTENSIVE
• Establish bilateral vascular access, utilizing largest catheter size possible
• NURMALSALINE (only enough to maintain peripheral pulses or systolic BIR 100mmHg):
• 20ml/kg IV/10,,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat 1x, prn
c a t ji"�t i o n s- a rt i c ti a�11-(,-,.a e �i jist ����)e ta��<&���i C���ie
disease, (1-11.............I FY a n d e a I fa i I t j �j a d&rAs
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IS
W
Standing Orders
INFORMATION
Obstetrical patients are defined as gestation >20 weeks.
PHYSIOLOGICAL CHANGES DURING PREGNANCY
• Mothers heart rate increases.
• By the third trimester,the HR can be 15-20 beats per minute above normal.
• Both the systolic and diastolic blood pressures drop 5-15 mm Hg during the second trimester.
• The mother's cardiac output and blood volume increases.
Thereforel the pregnant patient may lose 30-35% of her blood volume before the signs
&symptoms of shock become apparent.
• Supine hypotension usually occurs in the third trimester.
OEM
ADULT
* Perform initial assessment
* POSIT0MM:
0 Transport patients in their third trimester and not in active labor on their left side
IF WATER HAS BROKE
Document:
• Time
• Color of fluid
IF BLOOD PRESENT
Document:
• Time
• Volume
IF CROWNING
Prepare for a field delivery
DO NOT delay transport to the closest appropriate hospital
FOCUSED HISTORY
Obtain:
• Number of previous pregnancies (GRAVIDA)
• Number of previous viable births(PARA)
• Documented multiple births?
• Gestational Diabetes?
• Narcotic use?
• Due date?
• Frequency and length of contractions?
• Feeling of having to push or have a bowel movement?
st d
& 2 Trimester Complications
INFORMATION
ls'TRIMESTER
0 Weeks 1 - 12 of the pregnancy
2 nd TRIMESTER
Weeks 13 -27 of the pregnancy
ECTOPIC PREGNANCY(usually first trimeste
Signs &Symptoms:
• Sudden onset of severe lower abdominal pain
• Vaginal bleeding
• Amenorrhea (absence of menstruation)
• Referred pain to the left shoulder
• Cullen's Sign (periumbilical ecchymosis)
• Grey Turner's sign (ecchymosis of the flanks)
• Abdominal distention and tenderness
SPONTANEOUS ABORTION (usually before 20 weeks of gestation)
Signs &Symptoms:
• Abdominal cramping
• Vaginal bleeding
• Passage of tissue or fetus
ME=
ADULT
0 Assess and treat for shock
0 Rapidly transport to any approved OB or GYN facility
FOR ACTIVE BLEEDING
• Place loosely placed trauma pads over the vagina in an effort to stop the flow of blood
• DO NOT pack the vagina
IF HYPOTENSIVE
NUT��\AAL SAU�NE:
• 20ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat Ix, prn
0 eca t Aio�����is- c&�,e ����,nust be t��ie
disease, Cl�����1F? &�����id �-er'4��fafl�U�"'e
Ij
3" Trimester Complications
T,D
INFORMATION
THIRD TRIMESTER
0 Weeks 28 delivery
PLACENTA ABRUPTIO
Signs &Symptoms:
• Sudden onset of severe abdominal pain and tenderness
• Painful uterine contractions
• Vaginal bleeding with dark red blood
• Patient may present in shock
PLACENTA PREVIA
Signs &Symptoms:
0 Painless vaginal bleeding(bright red blood)
UTERINE RUPTURE
Signs &Symptoms:
• Suddenl intense abdominal pain
• Vaginal bleeding
ADULT
0 Assess and treat for shock
0 If in cardiac arrest refer to the "Cardiac Arrest Special Considerations"' protocol
0 POSITIOM�NG:
During transport, place 4-6 inches of padding under the patients right side while maintaining
normal anatomical alignment
FOR ACTIVE BLEEDING
• Loosely place trauma pads over the vagina in an effort to stop the flow of blood
• DO NOT pack the vagina
IF HYPOTENSIVE (BP less than systolic 100mmHg)
NORMAL SAU�NE:
• 20ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently.
• May repeat as needed
P1 acentaPrev"Ca
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relf
Plat,ceota Internal
�Bleediing
siepav�i ted fro,rn
Z'
oomalloolowev
the uterwlg
External
Bleeding
IE
Pre Eclampsta clampst'a
INFORMATION
SEVERE PRE-ECLAMPSIA
0 A rare pregnancy complication characterized by high blood pressure that usually begins after
20 weeks of pregnancy.
0 Signs &Symptoms:
HTN (SBP > 160 mm Hg OR a DBP of> 110 mm Hg) with any of the following:
• AMS
• Visual disturbances
• Headache
• Peripheral edema
ECLAMPSIA
Signs &Symptoms:
Any of the severe pre-eclampsia signs &symptoms associated with:
0 Seizures OR Coma
Either condition can occur for up to 30 days postpartum.
ADULT
Check blood glucose level
SEVERE PRE-ECLAMPSIA(NOT IN ACTIVE L
• I\11AGNESIUM SULFATE:
2g of Magnesium Sulfate infusion
0 Administer over 5 minutes
Contra indication—2 d and 3 rd Degree Heart Blocks
Ra����3id illfLlSi&�l cause hy��,)o�tensio����l
• LABETALOL(If systolic greater than 160rnrnIIIg)-. 10 mg Slow IVP over 2 minutes
ECLAMPSIA
If activ6�y seizing administer Benzodiazepiine concurrent with Magnesium Sulfate
• I\4AGNESIUM SULFATE-.
* 4g of Magnesium Sulfate in a 50mL bag of NORMAL SALINE
0 Administer IV/10 push
* Contra indication—2 nd and 3 rd Degree Heart Blocks
* [�)recaLltiG�`l Ra�pi('J illfL'111`3'iO��l ������iiay caLlse hy��jo�tensio���l
• LABETALOL(Iff systolic greater than 160rnrnIIdg): : 10 mg Slow IVP over 2 minutes
IF UNABLE TO ESTABLISH VASCULAR ACCESS
MAGNESIIUM SULFATE:
* 4g IM (must be divided in two separate sites)
* Contra indication—2 nd and 3 rd Degree Heart Blocks
17 If severe Hypertension exists without signs of pre-eclampsia. (Systolic greater than 160mmHg)
consider hypertensive protocol.
AP
11 jil:
W,
Meconium Staining
INFORMATION
Meconium will appear as a yellow to dark green substance that may be noted in the amniotic fluid,
coming from the vagina or covering the neonate"s head.
No=
NEONATE
MECONIUM STAINING
If upon delivery of the head there is meconium staining present:
• Use a bulb syringe to clear secretions from the mouth and then nose before delivery of the
shoulders
• Meconium aspirators are rarely needed, however consideration for usage may be given in
patients whose airway is obstructed by meconium that cannot be cleared by simpler methods
Normal Delivery
ADULT
NORMAL DELIVERY
• PO&��T�U�WNG:
0 Place patient on her back with knees flexed and feet flat on the floor
• Control delivery of the head,with gentle perineal pressure
• DO NOT apply manual pressure to the uterine funclus prior to the birth of the child
• DO NOT pull or push on the neonate
• DO NOT allow sudden hyperextension of the neonate's head
• Once the head delivers:
• Suction the mouth and then the nose
• Support the neonate"s head as it rotates to align with the shoulders,gently guide the
neonate's head downward to deliver the anterior shoulder
Once the anterior shoulder delivers,gently guide the neonate's head upward to deliver the
posterior shoulder and the rest of the body
UPON DELIVERY OF THE NEONATE
• Dry,warm, and stimulate the neonate
• Keep the neonate at the same level of the placenta
• Once the umbilical cord stops pulsating(usually 3-5 minutes):
Clamp the cord in the following fashion:
• Place the first clamp 4" away from the neonate's body
• Milk the cord away from the neonate and towards the mother(this will minimize
splatter)
• Place the second clamp 2" away from the first,towards the mother
• Cut the cord between the 2 clamps
• Place the neonate on the mother's chest, skin-to-skin, and cover with a dry blanket
• Record and encode an APGAR score at 1 and 5 minutes and document the delivery time
• Apply firm continuous pressure, manually massaging the uterine fundus after the placenta delivers
• Preserve the placenta in the bag provided with the OB Kit or a "'Red Bio-Hazard bag"for inspection
by the receiving hospital
111111 j!�L, ;G S C 0 F I I
fori-,rr at 1, ailid5rmfnoutes affe%r-birth
.............
CRITERIA ,W, /m/nom
O� 1 2
Artivity
C,"
MY,
Some movemen,t
No,mcl,vemlent Activemovement
(muscle ton�e) j
Pulse il Ptilse Less than,100 bipiTT, Gre'ater t1lan 100 bpm,
Grimace
7� 0�, ActUvelmoVoi17,
Ndiresponselo Grirn,ace,'or felebte
(r,effex,trritability), l w)'s"timulatidn,,
on,
,st,,ofmulabbn crywl ulat-o,
Appearanice (.....
Bhieaff over Body pink, 10,
Ik coiTl?,pIe,teI' pink
,p Y
(skin,color) 'extre,initiesbitie
Respirat',ion No 9,reathling Sbw;,ofirregular Sft'ong,Cily
I breathing
70 7
7
7
70
77
77
,77/7
7
7
77
M!
4-�6 Modell ly Depressed:Moderate Ressusc`itation N',,aedeed
--------------
Delivery Complications
ADULT
BREECH BIRTH (FEET OR BUTTOCKS PRESENTATI
If the head does not deliver within 3 minutes of the body:
Elevate the mother's hips (knee to chest position)
Insert a gloved hand into the vagina
Push the vaginal wall away from the neonates nose and mouth
Expedite transport while maintaining the knee to chest position and the neonate's airway
OXYGEN
Administer blow-by OXYGEN to the neonate
"00
pill'
"A,
elfZ
NOW,
'1 01,
i0f:
i"'mrow'I
001
;,Aow
SHOULDER DYSTOCIA(DIFFICULTY IN DELIVERING THE SHOUL
MOIIOBE�11'i PROCEDURE:
• Hyperf lex the mother's legs tightly to her abdomen
• It may be necessary to apply suprapubic pressure (mother's lower abdomen)
• Gently pull on the neonate's head
I
Delivery ComplicationsContinued..
kill
NUCHALCORD
• Check for the presence of a nuchal cord after delivery of the head
• If the cord is around the neck:
• Gently hook your finger under the loop
• Pull it over the neonates head
• You may have to repeat this if there is more than 1
loop present
If you are unable to free the cord:
Clamp the cord in 2 places
Cut the cord between the clamps
Alo,
PROLAPSED UMBILICAL CORD
POS[T�OMNG-
0 Place mother in the knee to chest position
• Manually displace the uterus to the left
• Insert a gloved hand into the vagina
• Push the neonate up and away from the umbilical cord regardless if there is a pulse present or
not
• Maintain this position during transport
• Frequently reassess the umbilical cord for the presence of a pulse, as contractions are likely to
compress the umbilical cord
• Wrap the exposed cord in a moist sterile dressing
• Expedite transport to closest OB facility
44
01
010
1000
Manual displacement of the uterus