Item F39 F.39
Coty f � ,�� ,' BOARD OF COUNTY COMMISSIONERS
�� Mayor David Rice,District 4
The Florida Keys � Mayor Pro Tem Craig Cates,District I
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.39
Agenda Item Summary #11391
BULK ITEM: Yes DEPARTMENT: Emergency Services
TIME APPROXIMATE: STAFF CONTACT: Steven Hudson (305) 289-6342
N/A
AGENDA ITEM WORDING: Approval to renew a Class A Certificate of Public Convenience
and Necessity (COPCN) to Florida Keys Ambulance Service, Inc. (FKAS) which lapsed due to their
late submittal of the renewal application and required application fee. The renewal COPCN is for
the operation of an ALS transport ambulance service; specifically for inter-facility transports for the
period November 16, 2022 to November 15, 2024.
ITEM BACKGROUND:
Florida Keys Ambulance Service (FKAS) has submitted an application for BOCC approval to renew
their Class A Certificate of Public Convenience and Necessity (COPCN) which lapsed due to the
untimely submittal of their renewal application and the required application fee. The renewal
COPCN is for the operation of an ALS transport ambulance service; specifically for inter-facility
transports for the period November 16, 2022 to November 15, 2024.
PREVIOUS RELEVANT BOCC ACTION:
On August 19, 2020, Item C.2, the MCBOCC approved the issuance (renewal) of a Class A COPCN
to FKAS for the operation of an ALS transport ambulance service (specifically inter-facility) for the
period September 22, 2020 to September 21, 2022.
On August 15, 2018, Item C.16, the MCBOCC approved the issuance (renewal) of a Class A
COPCN to FKAS for the operation of an ALS transport ambulance service (specifically inter-
facility) for the period September 22, 2018 to September 21, 2020.
On September 21, 2016, Item C.26, the MCBOCC approved the issuance of a Class A COPCN to
FKAS for the operation of an ALS transport ambulance service (specifically inter-facility) for the
period September 22, 2016 to September 21, 2018.
CONTRACT/AGREEMENT CHANGES:
N/A
Packet Pg. 1900
F.39
STAFF RECOMMENDATION: Approval
DOCUMENTATION:
FKAS COPCN A RENEWAL2022_Redacted
FKAS Class A COPCN Renewal 11.16.2022 thorugh 11.15.2024
FKAS Existing Class A COPCN Certificate
FINANCIAL IMPACT:
Effective Date: 11/16/2022
Expiration Date: 11/15/2024
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 11/01/2022 3:45 PM
Steven Hudson Completed 11/01/2022 3:47 PM
Purchasing Completed 11/01/2022 3:59 PM
Budget and Finance Completed 11/01/2022 4:01 PM
Brian Bradley Completed 11/01/2022 4:09 PM
Lindsey Ballard Completed 11/01/2022 5:32 PM
Board of County Commissioners Pending 11/15/2022 9:00 AM
Packet Pg. 1901
MO�NROE CO'UNTV, FLORIDA
APPLICATION FOC R CERTIFICATE OF PUBLIC CONVENIENCE AND NECE.SSITY (COPCN)
("LASS A EMERGENCYNIEDICA1, SERVICE
(P`RtN`t' OR TYPE)
INII'IAI,, API'[,,ICA'I'ION -,$ 51).00 A RENEWAL APPLICATION -S475.00
lt," IIENf,',WAI,, PI,L,XSI*, I,ISTNUNIBEROFP,Rf,N,,'10(fS('.ER,r]Fl( I'E: # 20-03
Bt.lStNESS M�Aft,,$N(; AI)I�)Rt,:SS P.�O�. BOX 1259 , TA VERNIER, FL. 330�70
PHNE 3 �5438 3:
BtISINESS PHONE NJJNMBER 305-414-8136 F1N'1ERC C N,FN ` O NLfN1BER 0 -97'5- 7 0
TVPE OF OWNERSHIP (i.e.,Sole Proprietor, Partnership, Corporation, etc.) CORP.
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DATE OFINCORPORATtON OR FORIN/tATION (WTHE B1JSl[NESS ASSOCIATION 0
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.1 LIST ALL OFFICERS, DIR[.'CTOl1S,,AND SHAREHOLDERS (Use separate sheet ifnecessary): <
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NAME AGE ADDRIKSS TELEPHONE# POSITION/TITI
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Eddy Bonilla 54 91421 Overseas Hwy. 305-97 -43,87 CEO
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Tavernier, Fl. 33070
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4. LEVEL OF CARE,TO BE PROVIDED: fil, or At's z
IT'ALS: [WTRANSPORT or E] NONTRANSPOR'l' U
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ZONES(S) TIIAT YOU'R SERVICE DESIRESTO SERVE (Use separate sheet if necessary).
Inter-facility transports in alil geographical locations of Monroe County, Florida,
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6. LIST THE ADDRESS AN r D/OR DESCRIBE THE LOCATION OF VOLIR BASE STATION ANI) ALL SLJB-
STATIONS (Use separate sheet if necessary):
BASE STATION 91421 O rs,eas Hwy. #1- . Tavernier, Fl. 33070
SUB-STATION 11 Overseas Hwy. #1 . Marathon, Fl. 33050
Page of 6
Packet Pg. 1902
7. DESCRIBE YOUR COMMUNICATION SVSTEM (Attach copy of all FCC licenses):
............
—MOBILES #CIF. -PO..R.TABLES
FREQUENCIIES CALL NUMBERS
Monroe County FKAS-0�01-M 6
.............
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8. I',IST'FHFNAN'IES AND ADDRESSES oF'r"REE (3) U.S. CITIZEN'S WHO WILL ACT AS REFERENCES FOR
VOUR SF111VICE:
NAME ADDRESS
Dr. Thomas Steed 91500 verse us Hwy. Tavernier, FL, 33070
-—---------------- ..................
Edgard Miranda SE 7 DR. Hmestead, Fl. 330
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Rafael D.....0 damel 70NE 13DR. Homeste'ad, Fl. 30 0
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9. ATTACH A SCHEDULL OF RATES WHICII 'VOIJR SERVICE WILL(.,"HAR(,,;E DURING ,r"t,.,, co PERIOD. U)
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10. PROVIDE VERIFICATION CIF.ADEQUATE INSURANCE COVERAGE DURING THE COPC'N PERIOD. u
11, ATTACH A COPY OF YOUR SERNJ('E'S CONTRACTNVIT11 A N'IEDICAI.., DIRECTOR.
12. ATTACHA COPV CIF AI. STANDING ORDERS AS ISSUED BY" YOURAIEDICAL DIRECTOR.
13. ATTACH A CHECK OR MONTEV ORDER IN THE APPROPRIATE APB' OUN'F,,N'IAIH'!, PAVABLE TOTHI,"
NIONROE(7,C)UN111 BOARD OF COUNTY COMMISSIONERS.
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1,1-11F UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERNIACT,DO HEREBY ATTESTMYSERVICT' <
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MEETS ALL OF THE RrQUIRLME'AS 'S FOR OPERATION OF. AN ENJFRGF1NCV MEDICAL SERVICTIN MONROE. I.I.
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COUNTV AND THE STATE' OF FLOI DA, I F(JRTHER A'T"FEST'rHAT ALL THE INFORMATIO'NCONTAINED IN W
THIS AP LI V1101W, '0 THE 'S O ' MY KNONN'Ll"DGE, ISTRUF, AND CORRE'CT.
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PERSONNEL- PARAMEDICS
NAME PARAMEDIC C'ERTIFICATION
First,Middle,Last SOCIAL SECTRITY4 CERTIFICATION EXPtRATION DATE
Eddy Bonilla 12/2022
Edgard Miranda 206162 12/20:22
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Rafael Dudamel 521228 12/20,22
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Florida Keys Ambulance
P.O. Box 1259 Tavernier, FL. 3-3070
Ph,: '786.203.6576 Fax: 305.96.5889 Email:
CLASS COP,C APPLICATION IOC 2
ITEM , SCHEDULE E � RATES 0-
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"Fr°ansp ort, Base Fee Basic Life Support (BLS)S) $750.00
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Transport Base Fee ---- A rr danced Life S U Pert (AL a1 $850.0
Transport sport Base Fee — Advanced Life rrPP01-t (, L 2) $950.00
Transport ort Base Fee Special Care Transports (SCT) 1 ,20 .00
Mileage Charge Loaded mile $15.00
` hese rates include all medically necessary sr.rl�p�rlie , equipment,ment, and medications
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CERTIFICATE OF LIABILITY INSURANCE
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THIS CERTIF11CATE IS ISSUED AS A MATTER OF INFCIRMATK]IN ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIF CATS 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(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTlFICATE HOLDER,
........................ 1-1-1111-1111............
IMPORTANT: If the certificate holder is an ADDIflONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be enclorsed,
if SUBROGATION IS WAIVED, subject to the terrors and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not center rights to the certificate holder in lieu of Such endorsement(s)
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PRODUCER License#L096220 C�NTACT
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JAG Insurance Grov, LLC PHONE FAX
99 [AND,No Exl). (305) 842-3600 (A(C,No��(305) 842-3600
9 Ponce De Leon 1vd MAIL
SuiteADDRESS:
800 ADDRESS:
Coral Gables, FL 33134 INSURERiS)AFFORDING COVERAGE NAIC
INSURER A WESTERN WORLD INSURANCE CO. 13196
INSURED INSURER B National IndernnIty Company 20�087
Florida Keys Ambulance,Inc. INSURER C
91421 Overseas Highway INSURER D
Tavernier,FL 330710 INSURER 15
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COVERAGES CERTIFICATE NUNIBER� REVISION,NUIMBER� CL
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TMS, IS 'To C['-'.R'T'1FY THAT THE POLICIES OF INSURANCE [AS I'ED BELOW HAVE BE,FN ISSUED TO THE INSLIRED NAMED ABOVE FOR 71iE Pou(-Y FIERIOX�
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EX(.'I US° C)NS AND CONDI I"IONS(DF SUCH POLICIES,,LIMITS SHOWN MAY HAVE BEEN ME'DUCED BY PAID CLAIMS, U)
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DESCRIPTION OF OPERATIONS I LOCATIONS J VEHICLES (ACORD 101,Add0ional Remarks Schedule,ma beattach d I eF more space is req d�uire
Two(2)2017 Braun Express Ambulances,VIN.-1GB3GRCGSH1196107,IG63GROGA1116598 iContract:#3350519) E
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CERTIFICATE HOLDER CANCELLATION
-----------
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
FOR PROOF OF INSURANCE ONLY ACCORDANCE WITH THE POLICY PROVISIONS,
AU'THORaElD REPRESENTATIVE
............................................... ............. ........... ........._I
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ACORD 25(20161'03) Q 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD narne and logo are registered marks of ACORD Packet Pg. 1909
F.39.a
.. N Florida m : u secs
P.O. Box 1259 Tavernier, FL 33070
89 E,frnaut: Flakecysaruhaularrae.etmtWl,eom
This agreement darted September 30 ._2022 Fay and lnemt%veen I llorid a Ke Arr l�ttl!�t11CC._.h rein t�c1+:Mt..red to
as the ,Awnlnanla nce Service. and 1 Dra. q�ln,oma s St��,d, Physician. herein referred to as t ne� Medical
Director. The lnurl',)ose of this agreement is to provi(ler the Arnnhularnace' Service with a. medical director to
eanarhle them to provide Basic, car Advanced life support to the community they serve,
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I his rclationshilr may be terminated by written notice served upon the Medical Director at 'Icaast seven
business alas prior to the effective date:of said termination.ation. 0°h edicali 1iDircelor may suspend of
terminate tine relationship at will for ea use, as del'ined hereina ber. car rrinrrrn seven business day notice U
without cause.
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The Medical Director agrees to: U)
L Meet: regularly with An°rinnlaunec Service and providers at least:truce pereluarter or as often asm
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necessary.
2. Be Medical Director ol'recoref leer they Arnbularnce Service as reeltnired and Pursuant:to r I�"iorir[ar.
Sttrtute� Chapter 401, and F°°Iorielan elntiristr�aativea Code 64J-1,4'104 and will lrerforrn all duties U-
associated thr:remJth.
. Be aavaailaalalc,to Ambulance service calTice°rs �Nhe n needed to advise on EMS issues,
4. Provide oversight to the agency"s, pre-hospital quality aasstrnurce/quaahly umprovc nie nt lnra°:rg a rn, c�
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The Ambulance ncem Service Agrees to: CNI�
1. Re responsible for the transmission cal call Comnarnnicat:ions frcmn the Medical Director to ill N
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Anrhularice Service providers.
. laaketi necessary stems to ensure participation by its providers in all programs and courses �
required by the Medical l: ireclor including hert rrcat lirnitee.l to protocol require^rnerit.s, continuing
Medical I cl, ucation and Quahty improvemem. w
. Monitor-the activities of each provider ind keel)accurate records, which shall be rfaale �
availat.)lc to the Medical Director or designee rmlaear rcelraest. An officer shall be appointed to
rararintairn such rewcorc.Es. u
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4. Fonvaarti innrneeliatemly°to the medical dirwor°any and all complaints,ants, notificalions, sulmilonses, 0
suh oerrars, letters and comnnuruication ot.any nature received which in any %vary" hears ern the �
eluarlit,.y ot`scrvice rendered, is srr,gll„estmwe (if an.), possiinrlea lawsuit or legal proc°cedint of, in any
ways bears on the c,onipetence ot'anry arrnn tit,larua�ee service; provider„
y and strictly adherc to all standards and protocols and other requirements by the �
Medical Director and agrees to suspend any Ai.,S nnedicaal privileges liar tang "prov tiler"µ tor
iiailure to conniply Milt this lnrovisiorn„
Signed
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F.39.a
Florida Keys Ambulance
P.O. Box 1259 Tavernier, FL. 330,70
Ph— "786203 6576 - Fax: .,rr5..96.5889 Fri aiL NwNar��°} rru�Vardl arrc�rr,rcrN.r roe?
CLASS A COPCN APPLICATION
ITEM 1 -, S
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l'us letter certifies that 1, Dr. ,.l.homa M. Steed, tactlrr ,,,Is Medical director for.
Florida Keys AnlibUlance, a proves the Florida Regional Medical protocols to be u
Used by, H radar K,e.),,s AnibUlance, as standing orders for int.e f cility transports
and also that at. this time there are no changes to these protocols,
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F.39.a
y" BOARD OF COUNTY COMMISSIONERS
County of Monroe `"�� Mayor David Rice,District 4
The Florida Keys Mayor Pro Tem Craig Cates,District 1
Michelle Coldiron,District 2
James K.Scholl,District 3
Holly Merrill Raschein,District 5
Monroe County Fire Rescue
490 63Td Street Ocean
Marathon,FL 33050
Phone(305)289-6088 '
as
MEMORANDUM
0.
TO: Nicole Rhodes
FROM: Cara Johnson
SUBJECT: Check for Deposit- COPCN
as
DATE: October 24, 2022 i
CD
Attached please find Check=dated September 30, 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 Florida Keys Ambulance Service, Inc.
CL
Thank you,
as
F
Cara Johnson
Packet Pg. 1912
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FLORIDA KEYS MEDICALTRANSPORTATION LL�C
PO BOX 1269
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F.39.a
Florida Regional Common
EMS Protocols
Section 1
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General Protocols
5th Edition, Version 1 September, 2016 ,
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5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 1
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F.39.a
General Section Table of Contents
1.1 Intent and Use of Protocols
1.2 Behavioral Emergencies
1.3 Critical Incident Stress Management (CISM)
1.4 Death in the Field
1.5 Emergency Worker Rehabilitation
1.6 Helicopter Safety
1.7 Medical Communications
1.8 Refusal of Care
1.9 Mass Casualty Incidents
1.9.1 MCI Organizational Chart 2
1.9.2 Active Assailant Organizational Chart Z
1.10 Crime Scene Management 0-
1.11 Protocol Revision Procedure is
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F.39.a
1.1 Intent and Use of 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 paramedic/EMT must use
his/her judgment in administering treatment in the following manner:
• The paramedic may determine that no specific treatment is needed; or
• The paramedic may consult medical direction before initiating any specific treatment; or
• The paramedic may follow the appropriate treatment protocol and then consult medical
direction. '
• The paramedic/EMT may contact medical direction at any time he/ she deems necessary. Z
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When the paramedic/EMT is unable to make contact with other forms of medical direction, U
he/she may contact the receiving hospital for consultation with the emergency department <
physician. It is recommended that the paramedic/EMT make contact with the physician for U)
consultation on complicated patients whenever possible. When the paramedic is unable to make U
contact with a physician for medical direction, the paramedic may administer BLS treatment
according to his/her judgment. In this instance, the paramedic may administer ALS treatment _
only as authorized in the treatment protocols.
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Transport destination determination may include hospital and Free Standing Emergency
Department (FSED), refer to the Hospital Capability Form in Section 6 and on-line forms.
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The definition of pediatric patients will be described below. It is imperative to understand that the
medical decision making for a pediatric patient should be based on the definitions provided
below. Transport (destination) decisions should be made using the Hospital Capability Form in W
Section 6.
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Pediatric Medical Decision Definitions:
Newborn: A patient who has just been delivered.
Neonate: A patient who is younger than 6 weeks of age. 0-
Infant: A patient who is under 1 year of age. 0
Child: A patient ranging from 1 year of age to puberty (pubic hair, facial hair, breast development)
Adolescent: A patient who has reached puberty. Treat these patients using adult protocols.
Transport Decision Definitions:
Pediatric: Trauma patient-15 years of age or younger
Medical patients - 17 years of age or younger.
The treatment protocols are divided into adult and pediatric sections, each with three parts:
Supportive Care: Actions authorized for the EMT or paramedic that are supportive in nature.
EMT (BLS) and paramedic (BLS and ALS) actions are specified within each of these protocols.
ALS Level 1: Actions authorized for the paramedic or the EMT (only with specific Medical
Director approval, i.e. establishing an IV), prior to physician contact.
ALS Level 2: Actions authorized only for the paramedic that require a physician consult.
Authorization of procedures prior to physician contact in Level 1 allows the paramedic to initiate
care promptly while getting a better idea of the patient's condition and evaluating his/her
response to initial treatment.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 3
Packet Pg. 1916
F.39.a
1.1 Intent and Use of Protocols (continued)
The general protocols outline care for a typical case. As the protocol continues, the assumption is
usually made that previous steps were ineffective. For example, the protocol for ventricular
fibrillation authorizes three unstacked countershocks; however, the second countershock and
third countershock are given only if the previous countershock was unsuccessful and the patient
remains in ventricular fibrillation. If the patient went into asystole/PEA following the first
countershock, the second countershock would not be given. The paramedic would then use the
asystole/PEA protocol to guide further treatment. In this or other situations where a switch is
made to a different protocol during the course of care, the paramedic's judgment must determine
where entry into the new protocol sequence is appropriate. 2
It would be impractical to write protocols that specify every possible sequence of events. The Z
order of treatment listed here may not be appropriate for all situations. In fact, not all treatment 0-
options may be indicated in every situation. The paramedic's judgment must be relied upon to i
determine which of the authorized treatment procedures are appropriate for a given situation. The <
treatment guidelines are given in bulleted list form as a general order of the steps necessary to U)
treat the patient; however, it is assumed that interventions such as patient assessment, airway U
management, establishing medication access, applying AED/heart monitor, and so forth can be
performed simultaneously.
Orders listed in ALS Level 2 may be expected from the physician. They may or may not be the
orders that are actually given, however. The intention in listing ALS Level 2 orders is to allow
for appropriate preparation and to guide the paramedic who wishes to request specific orders.
The physician directing care in the field retains discretion in ordering specific treatment, even if Wi
that treatment conflicts with these protocols. ALS Level 2 orders require consultation with a N
physician. N
The name of the physician authorizing ALS Level 2 orders must be documented in the patient
care report (PCR). Physicians authorized to approve ALS Level 2 orders include the following
Z
individuals: W
1. EMS provider's medical director(a).
2. Receiving hospital emergency department physician(a).
3. Physician present in his/her own office (b). 0-
4. Online medical control physician (a). U
5. Bystander physician personally known to the paramedic(c).
6. Bystander physician who presents a valid M.D. or D.O. (c).
7. Poison information center(d).
Note: as
(a) Contact for ALS Level 2 orders by the EMS provider's medical director, online medical control E
physician, or emergency department physician should be initiated in the following order:
1. Medcom.
2. Telephone.
3. Relay of information via dispatch.
(b) Only verbal or written orders that are signed by the physician that are given directly to the paramedic
by a physician in his/her office are acceptable.
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1.1. Intent and Use of Protocols (continued)
(c) A bystander physician, as described above, must accept full responsibility for patient care and
accompany the patient in the ambulance to the hospital to give Level 2 orders.
(d) The Poison Information Center is authorized to direct all medical care(Supportive Care,ALS Level
1, and ALS Level 2) for the toxicology and hazardous material exposure patient. The Poison
Information Center must be contacted via telephone at 800-222-1222
This policy is intended to provide emergency departments with sufficient notification of
incoming patients to allow appropriate preparations to be made. Direct contact with the
physician in the emergency department needs be made only when seeking consultation or
authorization for ALS Level 2 orders.
c,
An EMT or paramedic should evaluate all patients on responses to 911 emergencies, as deemed U
appropriate by the individual EMS provider's medical director.
The treatment protocols have been designed as clinical guides, not as educational documents.
The therapeutic rationale behind the treatment protocols reflects the general principles of field U
care outlined in the following standard EMS references.
Standard List of EMS Resources
Porter R, et al.: Essentials of Paramedic Emergency Care, Brady, Englewood Cliffs, NJ, current U
edition
a�
Nancy Caroline's Emergency Care in the Streets current edition i
American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, Boston, 2014.
American Heart Association/American Academy of Pediatrics, Textbook of Pediatric Advanced N
Life Support, Dallas, 2015.
American Heart Association, "2015 Guidelines for CPR and ECC," Supplement to Circulation
American Heart Association: ACLS Provider Manual, Dallas, TX, 2010. W
American Heart Association/American Academy of Pediatrics: Textbook of Pediatric Advanced <
Life Support, Dallas, TX, current edition 2015.
Walraven, G: Basic Arrhythmias, 7th edition, Brady, Englewood Cliffs,NJ, 2005. 0-
Garcia, T. Miller, G; Arrhythmia Recognition, Jones and Bartlett, Sudbury Massachusetts. U
Trauma NAEMT, Frame, Salomone: Pre-hospital Trauma Life Support, 7th edition, Mosby, St.
Louis, MO, current edition.
Campbell JE: Basic Trauma Life Support, Advanced Pre-hospital Care, 5th edition, Brady,
Englewood Cliffs,NJ.
Pain Control Paris P, Stewart R: Pain Management in Emergency Medicine, Appleton & Lange,
Norwalk, CN, 1988.
McCaffrey M, Pasero C: Pain Clinical Manual, 2nd edition, Mosby, St. Louis, MO, 1999.
Toxicology and Hazardous Materials Exposure, State of Florida Hazardous Material Protocols
Additional educational materials, supplementary to these references, are included in this manual as
Chapter 4 Medical Procedures.
Chapter 5 contains Drug Summaries for each of the drugs authorized in the treatment protocols.
These documents are provided to clarify protocol items and issues that might differ from the
preceding references, or in which conflicts between references may occur.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 5
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F.39.a
1.1. Intent and Use of Protocols (continued)
(a) A bystander physician, as described above, must accept full responsibility for patient care and
accompany the patient in the ambulance to the hospital to give Level 2 orders.
(b) The Poison Information Center is authorized to direct all medical care(Supportive Care,ALS Level
1, and ALS Level 2) for the toxicology and hazardous material exposure patient. The Poison
Information Center must be contacted via telephone at 800-222-1222
This policy is intended to provide emergency departments with sufficient notification of
incoming patients to allow appropriate preparations to be made. Direct contact with the
physician in the emergency department needs be made only when seeking consultation or
authorization for ALS Level 2 orders.
Z
U
An EMT or paramedic should evaluate all patients on responses to 911 emergencies, as deemed
appropriate by the individual EMS provider's medical director. U
The treatment protocols have been designed as clinical guides, not as educational documents.
The therapeutic rationale behind the treatment protocols reflects the general principles of field U)
care outlined in the following standard EMS references. U
W
Standard List of EMS Resources
Porter R, et al.: Essentials of Paramedic Emergency Care, Brady, Englewood Cliffs, NJ, current ap
edition i
Nancy Caroline's Emergency Care in the Streets current edition
American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, Boston, 2014.
American Heart Association/American Academy of Pediatrics, Textbook of Pediatric Advanced N
Life Support, Dallas, 2015. N
American Heart Association, "2015 Guidelines for CPR and ECC," Supplement to Circulation
American Heart Association: ACLS Provider Manual, Dallas, TX, 2010. W
American Heart Association/American Academy of Pediatrics: Textbook of Pediatric Advanced W
Life Support, Dallas, TX, current edition 2015.
Walraven, G: Basic Arrhythmias, 7th edition, Brady, Englewood Cliffs,NJ, 2005. Z
Garcia, T. Miller, G; Arrhythmia Recognition, Jones and Bartlett, Sudbury Massachusetts. 0-
Trauma NAEMT, Frame, Salomone: Pre-hospital Trauma Life Support, 7th edition, Mosby, St. U
Louis, MO, current edition.
Campbell JE: Basic Trauma Life Support, Advanced Pre-hospital Care, 5th edition, Brady,
Englewood Cliffs,NJ.
Pain Control Paris P, Stewart R: Pain Management in Emergency Medicine, Appleton & Lange,
Norwalk, CN, 1988.
McCaffrey M, Pasero C: Pain Clinical Manual, 2nd edition, Mosby, St. Louis, MO, 1999.
Toxicology and Hazardous Materials Exposure, State of Florida Hazardous Material Protocols
Additional educational materials, supplementary to these references, are included in this manual as
Chapter 4 Medical Procedures.
Chapter 5 contains Drug Summaries for each of the drugs authorized in the treatment protocols.
These documents are provided to clarify protocol items and issues that might differ from the
reced.ng references, or in which conflicts between references may occur.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 6
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F.39.a
1.2 Behavioral Emergencies
GUIDING PRINCIPLES
1. Respect the dignity of the patient.
2. Assure physical safety of the patient and EMS personnel.
3. Diagnose and treat organic causes of behavioral disturbances such as hypoglycemia, hypoxia, or
poisoning.
4. Use reasonable physical restraint only if attempts at verbal control are unsuccessful. Every attempt
should be made to avoid injury to the patient when using physical restraint(Medical Procedure 4.23).
5. Teamwork between EMS personnel and law enforcement will improve patient care. 3:
a�
GENERAL APPROACH
1. Communicate in a calm and nonthreatening manner. Z
2. Offer your assistance to the patient. 0-
3. Use reasonable physical force via law enforcement if the patient is a threat to themselves or to others. U
d
USE OF RESTRAINTS U)
1. Physical. U
a. Use standard restraining techniques and devices (Medical Procedure 4.23,Physical Restraints).
Use sufficient padding on extremity restraints on elderly patients or others with delicate skin.
2. Chemical.
a. Use chemical restraints in conjunction with physical restraints if the latter are unsuccessful in
controlling violent behavior.
b. Agents (Adult Protocol 2.5.2,Violent, Impaired Patient/Excited Delirium Syndrome).
3. Any type of restraints.
a. Constantly monitor and observe the patient to prevent injury. If physical and/or chemical restraints N
are used,place the patient on an ECG monitor and pulse oximeter. N
b. Carefully document the rationale for the use of restraints.
w
TREATMENT PROTOCOL
See Adult Protocol 2.5.2,Violent and/or Impaired Patient, for specific treatment protocols.
It may be appropriate for law enforcement to execute an involuntary certificate for psychiatric examination
(Baker Act - FS Chapter 394.463). However, such a certificate shall not be an absolute condition for U
hospital transport. 0
TRANSPORTATION U
1. All individuals being transported for psychological evaluation under the premises of the Baker Act
should be accompanied by a police officer. The paramedic in charge shall determine whether the police U-
officer will ride in the back or follow behind the Rescue Unit.
2. In those situations where a female patient is being transported and a female is not part of the rescue
crew, the paramedic should attempt to have a female police officer accompany the patient to the a
hospital. (This is imperative in situations such as possible rape.) Also document the beginning and
ending mileages with dispatch via radio communication. <
BAKER ACT
Florida Statute Chapter 394.463—Mental Health relates to the authorization of police, physicians, and the
courts to dictate certain medical care for persons who pose a threat to themselves or to others
INCAPACITATED PERSONS LAW
Florida Statute Chapter 401.445 allows for examination and treatment of incapacitated persons in
emergency situations. (Patients who are not capable of informed consent as provided in FS Chapter
766.103 cannot refuse medical care.) Florida Statutes may be viewed online at www.leg.state.fl.us/statues
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 7
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F.39.a
1.3 Critical Incident Stress Management
PURPOSE
Critical Incident Stress Management (CISM) is a comprehensive, integrated, multicomponent,
systematic program of crisis intervention. Its purpose is to provide education, support,
assessment, and intervention for emergency ser-vice personnel who are often exposed to and/or
affected by critical incidents. CISM was born out of emergency services and has become a world
standard of care for first responders. Formulated and standardized by the International Critical
Incident Stress Foundation (ICISF), CISM has proven to be effective in mitigating many of the
common symptoms of critical incident stress. The goal when applying any of the CISM
components is to assess, educate, and intervene as necessary and return individuals to their work 2
with the tools and support needed to reduce the effects of a critical incident. The benefits of the z
intervention include a reduction in symptoms of post-traumatic stress, quicker return to normal 0-
productive functioning, increased job satisfaction, reduced worker's compensation claims, U
reduced absenteeism and presenteeism, reduced errors, enhanced group cohesion, increased <
personal confidence and extended longevity. U)
U
OVERVIEW
The Broward County CISM Team (Broward Region X CISM) is made up of trained and
credentialed members of law enforcement, fire/rescue, corrections, communications, and others,
as well as trained, credentialed, and licensed mental health professionals, all of whom have
completed at least three (3) of the core ICISF courses. Broward's CISM Team is independent of
any other organization or department in Broward County. The team is designed and organized to Wi
respond to any incident that occurs in any emergency services department or agency in Broward �
County on a 24 X 7 X 365 basis, within a maximum of two (2) hours after a critical incident has N
occurred and CISM services are requested. The team meets on a periodic basis for additional
training and information.
Z
CONFIDENTIALITY
Florida Statute 401.30(4) (e) protects the discussions held during a CISM intervention as being
"confidential and privileged communication under section 90.503." Therefore, all information 0-
shared during any part of a CISM intervention is held in the strictest of confidence. 0
CISM SERVICES
The following types of services can be provided by the Broward CISM Team.
A. Pre-event planning and preparation.
1. Educational and informational programs about CISM.
2. Pre-incident planning and education.
B. Strategic planning and assessment.
1. Pre- and post-incident assessment of needs.
2. Development and implementation of a strategic plan for major events.
C. Individual intervention.
1. One-on-one services with a qualified CISM team member.
2. Individual support and follow-up.
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F.39.a
1.3 Critical Incident Stress Management (continued)
D. Small group defusing.
1. Recommended within the first 12 hours after a critical incident occurs.
2. Best delivered as soon as possible after a critical incident.
3. Homogeneous groups.
4. Assessment and education with possible referral and follow-up.
E. Small group debriefing.
1. 12-72 hours post-critical incident.
2. Prior to demobilization from extended deployment or upon return home from extended
deployment.
3. Events of significant personal loss (expanded-phase defusing within first 12 hours). 2
F. Crisis management briefing. Z
1. Appropriate for large incidents, incidents with high media involvement, respite/rehab 0-
centers, and demobilizations. is
2. Best for large groups or mixed groups. <
3. Primary focus on assessment and information. U)
G. Family crisis intervention. U
H. Organizational consultation.
I. Assessment of organizational needs. _
J. Development and recommendation for coordination and delivery of services.
K. Pastoral/spiritual crisis intervention.
L. Referral and follow-up.
a�
CISM CALL-OUT BASIS
N
A critical incident is any situation that is either out of the norm or that challenges or would Q
appear to challenge a person's normal coping mechanisms. Examples include the following
situations: W
• Pediatric injury or death W
• Multiple youth fatalities
• Events with severe operational challenges
• Line-of-duty death or line-of-duty injury 0-
• Officer involved in a shooting U
• Off-duty death, suicide, homicide, or injury
• Events with multiple or mass casualties
• Prolonged events with loss of life
• Events when the victim(s) is (are) known
• Events with excessive media interest
c�
• Any incident that could perceivably cause emotional impact
Emergency responders work under stressful conditions and situations. Training and continuing
education about stress management contribute to the development and maintenance of improved
emotional health, stress resistance, and resilience. Statistics demonstrate significantly higher
instances of drug and alcohol abuse, marital and family strife, intimate-partner and domestic
violence, heart attack, and suicide rates among emergency services personnel compared to the
general population. These facts underscore the need for CISM services in any situation similar to
those in the preceding list. Because one of the positive benefits of a group intervention is
stronger group cohesion, all members of the group are encoura ed to be present.
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F.39.a
1.3 Critical Incident Stress Management (continued)
CISM ACTIVATION PROCESS EXAMPLE (BROWARD COUNTY)
A. Requesting agency officer contacts the Communications Captain on duty at the
Broward Regional Communications Center, requesting a CISM Team response.
B. Communications Center number: 954-476-4720
C. Requesting agency shall supply the following information:
1. Agency name.
2. Type of incident.
3. Number of members involved.
4. Call-back contact number or pager number. 2
D. The Communications Captain shall page out the on-call CISM Team Leader. Z
0-
CISM CALL-OUT PROCEDURE U
1. When a critical incident event occurs or when an on/off scene command determines that an
incident may or could have an emotional impact on the responding personnel, department, or U)
agency, any person authorized to do so shall contact the NORTH Regional Communication U
Center at 954-476-4720 and ask for the Duty Officer to requests a CISM response, giving a
brief description of the event, the caller's name, and his/her contact information. The
Regional Communication Center shall contact the on-call CISM Team coordinator and, at the
same time, pages and/or sends a text message to all members on the CISM Team list.
2. The Broward Regional Communication Center shall contact the on-call CISM Team
coordinator and, at the same time, pages and/or sends a text message to all members on the Wi
CISM Team list. N
3. The CISM Team Coordinator contacts the CISM Team Clinical Director or designee and N
provides the incident contact name and number. The CISM Team Coordinator then begins <
assembling peer team members for a response. No team member from the affected
department, agency, or organization will be part of the responding CISM Team. W
4. The CISM Clinical Director contacts the site or incident contact person, receives details
about the incident, and advises the contact of the appropriate type and timing of the response.
5. Once the type, timing, and location of the response are determined, the Clinical Director 0-
contacts the Team Coordinator with the information necessary to conduct the appropriate 0
intervention. The Clinical Director then contacts mental health members for the intervention
as needed.
6. Upon arrival at the determined site, the CISM Team members assemble for a briefing with
the Team Leader and then meet with the contact person or designee.
7. Personnel are assembled according to type, in a quiet and secure location. All personnel shall a
be either off-duty or out of service for the duration of the intervention and related services.
8. In the case of a critical incident stress defusing or debriefing, personnel are assembled
according to rank, involvement in the incident, proximity to the incident, as determined by
the responding Team Leader.
9. No written, audio, or video recording of the intervention shall be permitted.
10. The CISM Team consults with the contact person to provide general recommendations or for
possible follow-up.
11. The CISM Team gathers for a team debriefing.
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F.39.a
1.4 Death in the Field
This protocol is divided into separate sections that cover the different situations involving death
in the field that the paramedic will encounter. All patients found in cardiac arrest will receive
cardiopulmonary resuscitation unless an exception is met as outlined in the following sections:
I. Advanced Directives/Do Not Resuscitate Orders (DNRO).
II. Determination of Death.
III. Discontinuance of CPR. _
IV. Documentation
I ADVANCED DIRECTIVES/DO NOT RESUSCITATE ORDERS (DNRO)
LIV.1 Legislative authority. Under Florida Administrative Code (FAC) 64J-2.018. Do Not 2
Resuscitate Order (DNRO) Form and Patient Identification Device. The Florida DNRO form is the
only form approved in the State of Florida. If there is a DNRO/POLST/MOST/MOLST (see 1.8) 0-
form from another State presented by the patient or family, contact Medical Control as soon as U
possible for direction. <
LIV.2 An EMT or paramedic shall withhold or withdraw cardiopulmonary resuscitation: U)
LIV.2.1.1 Upon the presentation of an original or a completed copy of DH Form 1896, t j
Florida Do Not Resuscitate Order Form, December 2004, which is incorporated by reference and
available from DOH at no cost, or, any previous edition of DH Form 1896; or
LIV.2.1.2 Upon the presentation or observation, on the patient, of a Do Not Resuscitate U
Order patient identification device.
LIV.3 The Do Not Resuscitate Order:
a. Form shall be printed on yellow paper and have the words "DO NOT RESUSCITATE
ORDER" printed in black and displayed across the top of the form. DH Form 1896 may be NI
duplicated, provided that the content of the form is unaltered, the reproduction is of good quality, and N
it is duplicated on yellow paper. The shade of yellow does not have to be an exact duplicate;
b. Patient identification device is a miniature version of DH Form 1896 and is
incorporated by reference as part of the DNRO form. Use of the patient identification device is
voluntary and is intended to provide a convenient and portable DNRO which travels with the patient. W
The device is perforated so that it can be separated from the DNRO form. It can also be hole- <
punched, attached to a chain in some fashion and visibly displayed on the patient. In order to protect Z
this device from hazardous conditions, it shall be laminated after completing it. Failure to laminate 0-
the device shall not be grounds for not honoring a patient's DNRO order, if the device is otherwise U
properly completed.
LIV.4 The DNRO form and patient identification device must be signed by the patient's
U-
physician. In addition, the patient, or, if the patient is incapable of providing informed consent, the
patient's health care surrogate or proxy as defined in Section 765.101, F.S., or court appointed
guardian or person acting pursuant to a durable power of attorney established pursuant to Section E
709.08, F.S., must sign the form and the patient identification device in order for them to be valid.
The form does not need to be notarized, once signed the form does not expire. <
LIV.5 An EMT or paramedic shall verify the identity of the patient who is the subject of the
DNRO form or patient identification device. Verification shall be obtained from the patient's driver
license, other photo identification, or from a witness in the presence of the patient. If a witness is
used to identify the patient, this fact shall be documented in the EMS Run Report, which must
include the following information:
a. The full name of the witness.
b. The address and telephone number of the witness.
c. The relationship of the witness to the patient
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F.39.a
1.4 Death in the Field (continued)
LIV.6 During each transport, the EMS provider shall ensure that a copy of the DNRO form
or the patient identification device accompanies the live patient. The EMS provider shall
provide comforting, pain-relieving and any other medically indicated care, short of
respiratory or cardiac resuscitation.
LIV.7 A DNRO may be revoked at any time by the patient, if signed by the patient, or the
patient's health care surrogate, or proxy or court appointed guardian or person acting
pursuant to a durable power of attorney established pursuant to Section 709.08, F.S. Pursuant
to Section 765.104, F.S., the revocation may be in writing, by physical destruction, by failure
to present it, or by orally expressing a contrary intent.
1.IV.8 Oral orders from nonphysician staff members or telephoned requests from an absent 2
physician do not adequately assure EMT/paramedics that the proper decision-making process Z
has been followed and are NOT acceptable. 0-
LIV.9 In the near future Florida will be adopting POLST (Physician Orders for Life U
Sustaining Treatment Paradigm) The National POLST Paradigm is an approach to end-of-life <
planning that emphasizes patients' wishes about the care they receive. The POLST Paradigm U)
is an approach to end-of-life planning emphasizing: (i) advance care planning conversations U
between patients, health care professionals and loved ones; (ii) shared decision-making
between a patient and his/her health care professional about the care the patient would like to _
receive at the end of his/her life; and(iii) ensuring patient wishes are honored. As a result of
these conversations, patient wishes may be documented in a POLST form, which translates
the shared decisions into actionable medical orders. The POLST form assures patients that
health care professionals will provide only the care that patients themselves wish to receive,
and decreases the frequency of medical errors. POLST is not for everyone. Only patients N
with serious illness or frailty should have a POLST form. For these patients, their current N
health status indicates the need for standing medical orders. For healthy patients, an Advance
Directive is an appropriate tool for making future end-of-life care wishes known to loved W
ones. Several States use the POLST program and there several other forms used by these W
States, Medical Orders for Life Sustaining Treatment(MOLST), Medical Orders for Scope
of Treatment(MOST) and the Physician Orders for Scope of Treatment(POST) form.
U
Specific Authority 381.0011, 401.45(3)FS. Law Implemented 381.0205, 401.45, 765.401 FS. U
History—New 11-30-93, Amended 3-19-95, 1-26-97, Formerly IOD-66.325, Amended 2-20-00, W
11-3-02, 6-9-05, Formerly 64E-2.031.5.
II. DETERMINATION OF DEATH a
The EMT or paramedic may determine that the patient is dead/non-salvageable and decide not to a
resuscitate the patient under the following guidelines.
A. The patient may be determined to be dead/non-salvageable and will not be resuscitated
or transported if all four(4)presumptive signs of death and at least one (1) conclusive sign of
death are identified.
1. The four presumptive signs of death that MUST be present are:
a. Unresponsiveness.
b. Apnea.
C. Pulseless.
d. Fixed dilated pupils.
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F.39.a
.4 Death in the Field (continued)
2. In addition to the four presumptive signs of deaths, at least one (1) of the following
conclusive signs of death MUST be present:
a. Injuries incompatible with life (e.g., decapitation, massive crush injury,
incineration).
b. Tissue decomposition.
c. Rigor mortis of any degree with warm air temperature. (Hardening of the muscles of _
the body, making the joints rigid).
d. Liver mortis (lividity) of any degree, (venous pooling of blood in dependent body
parts causing purple discoloration of the skin, which does blanch with pressure). 2
3. Patients with suspected hypothermia, barbiturate overdose, or electrocution require full Z
ALS resuscitation unless they have injuries incompatible with life or tissue 0-
decomposition. U
4. EMS personnel may contact medical direction for a "determination of death" whenever <
support in the field is desired. Clearly state the purpose for the contact as part of the initial U)
hailing. U
5. Children are excluded from this protocol unless EMS personnel make contact with W
medical direction for consultation. Only in cases of obvious, prolonged death should CPR
not be started or discontinued on infants, children, or young adults, or in cases in which an
unexpected death has occurred.
B. A trauma victim who does not meet the "Determination of Death" criteria listed above may
be determined to be dead/non-salvageable based on the following criteria: N�
1. Pulselessness and apnea associated with asystole (confirmed in two leads) and N
a. Blunt trauma arrest.
b. Prolonged extrication time (more than 15 minutes) where no resuscitative measures W
can be initiated prior to extrication. W
c. Arrest from primary brain injury or with no brain stem reflexes; arrest from blunt
multiple injuries.
2. If there is any concern regarding leaving the patient at the scene, begin resuscitation and 0-
transport. U
3. Consideration should be given for the possibility of organ harvest; however, this should
not be the sole reason for resuscitation.
U_
C. Absence of pulse or spontaneous respiration in a multiple-casualty situation where EMS
resources are required for stabilization of living patients.
c�
The local law enforcement agency that has jurisdiction will be responsible for the body once
death has been determined. The body is to be left at the scene until a disposition has been made
by the Medical Examiner's Office or the local jurisdiction.
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F.39.a
1.4 Death in the Field (continued)
III. DISCONTINUANCE OF CPR
A. Resuscitation that is started in the field by EMS personnel cannot be discontinued without an
order from online, EMS Medical Director or online medical control.
B. EMS personnel are not obligated to continue resuscitation efforts that were started
inappropriately by others at the scene.
C. When there is a delay in presenting a DNRO to EMS personnel, resuscitation must be started
However, once the DNRO is presented to EMS personnel, the EMT or paramedic with an orde
from medical direction may terminate resuscitation.
D. A paramedic with an order from medical direction may terminate resuscitation provided the
following criteria are met:
I. Appropriate BLS and ALS have been attempted without restoration of circulation and z
breathing. c.
2. Advanced airway (supraglottic or ET) has been successfully accomplished. U
3. Intravenous (IV, 10, ETT) medication and countershocks for ventricular fibrillation have
been administered according to the appropriate treatment protocol(s) (Adult Protocols or
Pediatric Protocols). U
4. Persistent asystole (20 minutes and ETCO2 less than 10mmHg) or agonal ECG
patterns are present and no reversible causes are identified.
5. Patients with suspected hypothermia, barbiturate overdose, or electrocution require full
ALS resuscitation, unless they have injuries incompatible with life or tissue
decomposition.
E. Provide appropriate grief counseling or support to the patient's immediate family, Wi
bystanders, or others at the scene. N
CD
1. Provide family members with appropriate referral information, if available. N
F. Patient preparation.
I. Once it has been determined that the patient has died and resuscitation will not W
continue, cover the body with a sheet or other suitable item. Do not remove any W
property from the body or the scene for any purpose.
2. If the death is a suspected homicide (crime scene), do not cover the body (General z
Protocol 1.10). 0.
3. Immediately notify the appropriate law enforcement agency (if not done already), and U0
remain on scene until their arrival. W
4. Advanced airway placement may be verified by two paramedics for patients who are
determined to be dead in the field or for whom resuscitation measures have ceased.
Improperly placed advanced airway tubes should be left in place and reported to the r
appropriate personnel. (Proper advanced airway tube placement must be confirmed
prior to terminating resuscitation.).
5. Consult the patient's family for"organ donor" information, if appropriate.
IV. DOCUMENTATION
A. All death in the field patient reports need to have proper documentation on the EMS run report.
B. ECG rhythm documentation must be attached to the EMS Run Report.
C. The advanced airway should be left in place and its confirmation should be recorded on the
EMS Run Report.
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F.39.a
1.5 Emergency Worker Rehabilitation
MEDICAL EVALUATION OF EMERGENCY WORKERS ON EMERGENCY
INCIDENTS OR TRAINING EVOLUTIONS
A. Purpose: Emergency operations require significant physical activity, but no rescuer will
be required to perform emergency operations beyond safe levels of physical or mental
endurance. This protocol is intended to examine and evaluate the physical and mental
status of emergency workers working on an emergency incident or a training exercise and
determine which treatment, if any, is necessary. Personnel rehabilitation using
appropriate protocols in this area will decrease injury risk and enhance recovery for later
emergency operations.
B. Implementation: A Rehabilitation Area (Rehab Area) will be set up at the discretion of 2
the Incident Commander. It is recommended that a Rehab Area be utilized at all working Z
incidents to provide a staging area for on-scene personnel, as well as an immediate source 0-
of personnel for rescue or aid, and an area for recovery and rehabilitation of emergency is
workers. When a Rehab Area has been deemed necessary by the Incident Commander <
(IC), the first available EMS unit will be responsible for the management and U)
coordination of the Rehab Area. U
C. Location: Establish a Rehab Area away from environmental hazards (e.g., in a shady,
cool place that is, upwind and away from smoke and traffic) that is readily accessible to _
rescue personnel for transport and supplies. Air truck and canteen service will be
stationed in this area. Multiple Rehab Areas may be needed on large incidents. If a
specific location has not been designated by the IC, the Rehab Officer shall select an
appropriate location based on the following site characteristics:
I. The Rehab Area should be in a location that will provide physical rest by allowing the N
body to recuperate from the demands and hazards of the emergency operation or N
training evolution.
2. It should be far enough away from the scene that members may safely remove their W
turnout gear and self-contained breathing apparatus (SCBA) and be afforded mental W
rest from the stress and pressure of the emergency operation or training evolution.
3. It should provide suitable protection from the prevailing environmental conditions.
During hot weather, it should be in a cool, shaded area. During cold weather, it 0-
should be in a warm, dry area. U
4. It should enable members to be free of exhaust fumes from apparatus, vehicles, or
equipment(including those involved in the rehabilitation group operations).
5. It should be easily accessible by EMS units.
6. It should allow prompt reentry back into the emergency operation upon complete
recuperation.
D. Resources: The Rehab Officer shall secure all necessary resources required to adequately
staff and supply the rehabilitation area. The supplies should include the following items:
I. Fluidswater, activity beverages, oral electrolyte solutions, and ice.
2. Food (for extended operations where crews are engaged for 3 hours or more) soup,
broth, or stew in hot/cold cups.
3. Medical equipment—blood pressure cuffs, stethoscopes, oxygen administration
devices, cardiac monitors, intravenous solutions, thermometers, and pulse oximeters
(which include the ability to monitor SpCO).
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 15
Packet Pg. 1928
F.39.a
1.5 Emergency Worker Rehabilitation (continued)
4. Other - awnings, "cool zone" misting fans, cooling chairs, heaters (according to
climate), towels, and tarps.
E. Staffing: Assign a minimum of two rescue personnel to monitor and assist fire fighters in
the Rehab Area. An appointed Rehab Officer shall oversee the rehab operations. Their
responsibility is to oversee provision of food, fluids, medical monitoring, establish and
maintain an appropriate environment for rehab and rehabilitation operations in the area.
These personnel will oversee the rehabilitation and availability for work of all emergency
responders placed in this area.
F. Medical evaluations: When the Incident Commander has established a Rehab Area, fire 2
fighters and other emergency responders shall be evaluated following (a): Z
1. The use of two SCBA bottles and/or 30 minutes of strenuous activity (e.g., use of 0-
chemical PPE, advancing hose lines, forcible entry, ventilation) (b). is
2. SCBA failure.
3. Weakness, dizziness, chest pain, muscle cramps, nausea/vomiting, altered mental
status, difficulty breathing, and other stress-related symptoms (c). U
4. At the discretion of the Incident Commander, Rehab Officer, Safety Officer, CISM
Coordinator, and Company Officer.
Note:
(a) A medical evaluation form shall be completed on all personnel entering the
Rehab Area and before they return to emergency work.
(b) This does not preclude an officer from having a team member evaluated if he/she
deems it appropriate. A member may be evaluated any time he/she feels it N
necessary. N
(c) All personnel receiving ALS treatment and transport will have a patient care
report completed for them. W
G. Examination: EMS personnel should evaluate persons arriving to the Rehab Area as W
they appear. Arriving emergency workers must be questioned regarding any medical
symptoms, be asked about any injury resulting from incident work, and have assessment
of appropriate vital signs. Examination shall occur at 10-minute intervals and will involve 0-
0
a minimum of: U
1. Glasgow Coma Scale (GCS) score.
2. Pupillary response.
U_
3. Vital signs (BP, P, R, CR).
4. ECG (if applicable).
5. Lung sounds.
6. Skin condition.
7. Signs and symptoms.
8. Oral temperature.
9. Pulse oximetry.
a. Arterial oxygen saturation(SPOz).
b. Carboxyhemoglobin saturation(SpCO).
An EMS Run Report and a Casualty Report shall be completed for each fire fighter or
other emergency worker who is not routinely returned to emergency operations.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 16
Packet Pg. 1929
F.39.a
1.5 Emergency Worker Rehabilitation (continued)
H. Guidelines for rehab: The following will occur: REVIEW AGAINST FORM
1. Normal presentations: The emergency responder will rehydrate and rest before
reporting to Manpower. Rest shall not be less than 15 minutes.
2. Abnormal presentations:
a. Blood pressure values that are higher or lower than the person's usual level.
b. Sp02 values less than 94%.
c. Values for the pulse rate in an emergency responder will normally be less than
100 beats per minute (BPM) at rest and less than 120 BPM at a working incident.
At no time should the pulse exceed 180 BPM.
d. Values for carbon monoxide (CO) oximetry will normally be 5% for a nonsmoker 2
and less than 8% for a smoker. A CO oximetry reading of more than 12% z
indicates moderate CO inhalation; a reading of more than 25% indicates severe 0-
inhalation of CO. is
3. Body temperature greater than 100.6 F <
U)
4. Management. U)
a. The emergency responder will rehydrate and rest. The emergency responder will U
report to Manpower when presentations are normal. Presentations should return to
normal within 15 minutes.
b. If a team member's heart rate exceeds 110 BPM, an oral temperature should be
taken. If the oral temperature exceeds 100.6 F, the member should not be
permitted to wear protective equipment and should be treated for heat stress and
monitored for worsening of the heat emergency (i.e., heat exhaustion and heat
stroke). N
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c. The emergency responder will receive ALS treatment and transport if 2
presentations are abnormal for more than 15 minutes. Abnormal presentation
includes the following signs and symptoms: W
1) SP02 value less than 94%. W
2) Persistent heart rate greater than 120 BPM (lasting for 15 minutes or longer).
3) Any emergency worker with a CO oximetry reading of more than 8% but less
than 15% must be given the opportunity to breathe ambient air for 5 minutes. 0-
4) If the CO oximetry reading is still higher than 8%, the emergency worker U
should be given oxygen via mask until the value drops below 5%. Any worker
with a CO oximetry reading of more than 25% must be completely evaluated
and removed to a hospital, preferably one that has a hyperbaric chamber. No
emergency worker should leave the Rehab Area until his/her CO level is less
than 8%.
5) Blood pressure above or below the emergency worker's normal level.
6) Symptoms of heat stroke.
7) Oral temperature greater than 100.6 F, lasting longer than 15 minutes (after
oxygen administration).
d. Any emergency responder with chest pain, difficulty breathing, and altered mental
status will receive immediate ALS treatment and transport.
e. Any other abnormal presentation not specified herein, where the examining
paramedic's judgment determines a need for treatment and transport will be
managed accordingly.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 17
Packet Pg. 1930
F.39.a
1.5 Emergency Worker Rehabilitation (continued)
F. Treatment: Treatment will consist of one or more of the following measures. Prior to
taking anything orally, the emergency responder will clean his/her hands and face. On-
scene rescue personnel will provide water and a cleaning agent.
1. Remove bunker gear
2. Rest
3. Oral rehydration and nutrition (air truck, canteen service); minimum of 1 to 2 quarts
of fluids over a 15-minute time period (water then full strength electrolyte drink). 76
Avoid any substance containing caffeine(e.g., sodas, coffee, tea).
a. Members should consume at least 1 quart of water per hour. 2
b. Members shall rehydrate with at least 8 ounces of fluid while SCBA Z
cylinders are being changed. 0-
4. Oxygen. U
5. Cool environment utilizing "cool zone" fans and/or "cooling chairs" if available (e.g.,
shade, electric fan, air conditioning, showers). U)
6. For extended operations lasting 3 or more hours, the Rehab Area should provide food U
such as soup, broth, or stew; these items are digested much faster than sandwiches
and fast-food products. In addition, foods such as apples, oranges, and bananas _
provide supplemental forms of energy replacement. Fatty and/or salty foods should be
avoided.
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7. Follow ALS/BLS protocols for further treatment.
i
G. Return to emergency duties: Members assigned to the rehabilitation group shall enter N
and exit the Rehab Area as a crew. The crew designation, number of crew members,
and the times of entry to and exit from the Rehab Area shall be documented by the <
Rehab Officer or his/her designee on the check-in/out sheet. Crews shall not leave the �
Rehab Area until authorized to do so by the Rehab Officer. Report to Manpower or W
Incident Commander when the following criteria have been met:
a) Vital signs within normal limits.
b) Absence of abnormal signs and symptoms. 0-
c) Minimum period of 15 minutes for rest and rehydration. U
d) Released by Rehab Officer.
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H. Documentation: A Rehab Medical Evaluation Form shall be completed for all personnel
evaluated in the Rehab Area and forwarded to the appropriate Rescue (EMS) Division
following all applicable patient confidentiality guidelines (e.g., HIPAA). A complete a
patient care report (PCR) shall be completed for any member who receives
treatment/transport.
See Section 6 or Online Forms for the Emergency Worker Rehabilitation Form
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 18
Packet Pg. 1931
F.39.a
1.6 Helicopter Safety
COMMUNICATION PROCEDURES
The standard dispatch for an Air Rescue assignment should be one (1) engine company and one
(1) rescue. The need for additional units should be dictated by the incident circumstances. It
should be kept in mind that the unit assigned as the heli-spot (HS) group may need all of its
personnel to properly secure the HS site. This may create the need for additional units to address
patient care needs. Dispatchers should not take it upon themselves to modify this assignment, nor
should they suggest modification of the assignment. As with any Fire Department assignment,
the only personnel who can modify the assignment are Uniformed Fire Department Officers.
a�
See General Protocol 1.10, Trauma Transport, Helicopter Transport Protocol. Z
c,
HELI-SPOT PROCEDURES L)
Rescue Units, when requesting an Air Rescue assignment, should not concern themselves with
an HS unless they know of one at or very near the incident site. The rescue personnel should U)
concern themselves with proper and rapid patient packaging. In the event that the unit assigned t i
as the HS group experiences difficulties in finding an HS, they should wait until Air Rescue
arrives. Air Rescue has a better vantage point in choosing an HS, and its personnel will advise
the HS group.
In the event that the HS is remotely located and appears to be safe for landing, the Pilot in
Command (PIC) may elect to land without the assistance of an HS sector. This does not mean
that the unit assigned to the HS should be canceled. These team members will be utilized for Wi
security, safety, and patient loading once the helicopter is on the ground. The Pilot in Command N
(PIC) is both legally and operationally responsible for the safety of the aircraft. There-fore, the N
final decision of the suitability of the HS site is that of the PIC.
When setting up an HS, there are several things to keep in mind: W
I. The HS should be set up as to facilitate takeoffs and landings into the wind. (Do not rely on W
dispatch for correct wind direction; use visual indicators.)
2. If the HS group Officer in Command (OIC) is not sure of the wind direction or the direction
from which the helicopter should approach, then he/she should wait until the helicopter is in 0-
the area and confer with the Air Crew on this decision. 0
U
3. The approach and departure ends of the HS should be clear of obstacles (any object more
than 40 feet tall that is within 100 feet of the HS).
4. Debris such as wood, cans, and plastic should be removed from the HS. Flying debris can do
damage to both the helicopter and personnel on the ground. u
5. To minimize the hazard of blowing sand and dust, the HS should be hosed down (may be
hosed down as necessary).
6. Once the helicopter has landed, the Marshaller should post a minimum of one tail rotor
guard (two, if available). This person should be someone other than the Marshaller. The
Marshaller shall remain at his/her post until the aircraft departs.
7. No unauthorized personnel shall be permitted to approach the helicopter. This is the general
responsibility of all Fire Department personnel, but it is most definitely the overall combined
responsibility of the PIC and the HS group OIC.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 19
Packet Pg. 1932
F.39.a
1.6 Helicopter Safety (continued)
8. The HS group should assure that the Rescue Unit personnel are supplemented with an
appropriate number of personnel to assist in the safe and efficient loading of patients into the
helicopter.
9. Once the helicopter has landed, the Marshaller should confer with the Air Crew as to the
helicopter's departure.
10. It is not necessary to have a hose line pulled and charged. In the event of a catastrophic event
involving the helicopter, tactics and strategy will be left up to the Incident Commander.
The Marshaller is one of several tools that are at the disposal of the PIC for the accomplishment
of a safe landing and departure. The PIC considers several factors when making an approach or 2
departure into a confined area. As a consequence, he/she may not always follow the exact
direction of the Marshaller. Note that most approaches will be to the ground, not to a hover. The 0-
PIC, at his/her discretion, may elect to land without the assistance of a Marshaller and may U
request that the Marshaller remain clear of the HS until after the helicopter has landed. If the PIC <
does not follow the exact direction of the Marshaller, be assured there are reasons for his/her U)
actions. U
REVIEW YOUR MARSHALLING HAND SIGNALS
A. Marshalling.
1. Positioning.
a. The Marshaller will stand at the outer edge of the HS perimeter on the windward
side, with his/her back to the wind.
b. The Apparatus Lieutenant/Captain will have the primary responsibility for the N
marshalling duties. N
c. An additional fire fighter who is assigned to the Marshaller will maintain constant <
radio contact with the helicopter as well as visual and verbal contact with the
Marshaller.
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d. Remain in eye contact with the pilot at all times.
e. Do not approach the helicopter; remain vigilant at your post.
2. Equipment. 0-
a. Helmet with chin strap tightly secured. 0
b. Goggles on or visor down.
C. Gloves.
d. Full bunker gear with collar up.
e. Flash lights with wands for night operations.
3. Safety precautions and procedures.
a. Stay well clear of the tail rotor area.
b. Use caution when traversing uneven terrain.
c. Approach the helicopter in the pilot's field of vision and ONLY after an "All
Clear" signal has been given by a helicopter crewmember.
d. Use low crouch when approaching and departing the helicopter.
e. Do not use road flares. Do not shine spotlights or headlights at the helicopter or
into the HS. The pilot will utilize the "night sun" to light up the HS as needed.
Shining lights or strobes at the HS may cause vertigo, night blindness, or seizures
of the pilot.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 20
Packet Pg. 1933
F.39.a
1.6 Helicopter Safety (continued)
RESCUE UNIT PROCEDURES
The Rescue Unit OIC has the primary responsibility of patient care and should not become
overly concerned with the availability of an appropriate HS. The following points should be kept
in mind when deciding on Air Rescue as the mode of transport for the patient:
1. Make the decision to transport by air early. Have Air Rescue dispatched by the
Incident Commander. Even if you are not sure that a patient meets the established
criteria for air transport, place Air Rescue on standby status. You can always cancel
the standby.
2. It is imperative that the ground Rescue Unit contact the receiving facility prior to 2
Air Rescue's on-scene arrival. This will preclude any delay in transportation in the
event the receiving facility cannot accept the patient. This early advisory is also 0-
necessary to allow the hospital time to prepare for an Air Rescue arrival. Air Rescue U
may monitor the medical channel and receive patient information while it is given <
to the receiving facility from the ground Rescue Unit. U)
3. Relaying information concerning HS location and any hazards is a priority (this t i
information may be relayed to the Air Rescue team after they are airborne). The
only patient information that the Rescue Unit needs to advise the Incident
Commander about when requesting Air Rescue is the number of patients and the
designated receiving facility. The ground Rescue Unit should not spend time
advising Air Rescue of patient conditions over the incident frequencies. That time
would be better spent communicating with the receiving facility.
4. There is no reason to provide the Air Rescue crew with a completed EMS Run N
Report. This may create an undue delay in the transportation of the patient. A "hard N
copy" of whatever information you do have should be provided to the Flight Medic.
5. All bandages and dressings shall be affixed securely W
6. The patient will be secured to a backboard with a minimum of three (3) straps, unless W
contraindicated by his/her medical condition. If the patient is unruly, place an
additional strap above the knees. Having a patient lie on a backboard with the head
immobilized and nothing securing the body is unacceptable. In the event that straps 0-
are not available, another method of securing the patient should be improvised. U
7. A minimum of four (4) personnel, one of whom will be a member of the Air Rescue LO
crew, will carry the stretcher. Each member of this team should have a helmet with
face shield and chin strap in place when loading the patient.
8. If the patient is difficult to carry, a stretcher may be utilized, provided the sheets,
pillow, and mattress are removed.
9. The key to saving a trauma patient who requires surgical intervention is speed. Do not
delay transport for invasive procedures other than those necessary to maintain the
patient's airway. Most invasive procedures can be done while en route to the Trauma
Center.
10. Be aware of the time you are on the scene with the patient. Attempts at certain
procedures may be perceived as progressing at a rapid pace, but in reality they are
taking an extended period of time that can better be used in moving the patient.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 21
Packet Pg. 1934
F.39.a
1.6 Helicopter Safety (continued)
ed
11. Advise the Air Rescue Unit if you have any need for additional equipment or
assistance(e.g., for managing patient airway difficulties).
12. Remain at the incident side (or at least 100 feet from the HS) until the helicopter has
landed.
13. Absolutely no personnel should approach the helicopter unless cleared "in" by an Air
Rescue crew member.
a. Do not approach the helicopter with a patient unless escorted by an Air Rescue
crew member.
b. It is the responsibility of all Fire/Rescue/EMS personnel to ensure that any and all 2
unauthorized persons are prevented from approaching the helicopter. This is
usually accomplished with visual and verbal warnings, but in some instances may 0-
require physical intervention. t,
14. In the event that the Air Rescue crew requires assistance with patient care, the <
ground paramedic in charge of patient care will accompany the patient during air U)
transport. In this event, the ground paramedic, with Air Crew approval, will bring t i
any equipment necessary to affect patient care during air transport. Any additional
Fire/Rescue personnel will be determined by the Air Rescue crew and the ground _
paramedic in charge of patient care.
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References
Broward County Aeromedical Transport Program
Miami-Dade Air Rescue Assignment Procedures N�
U.S. Coast Guard Helicopter Procedures N
d
The heli-spot shall be a minimum of 100' X 100' (HS size may be increased by local
protocol). W
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5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 22
Packet Pg. 1935
F.39.a
1.7 Medical Communications
Hospital prenotification of all BLS or ALS (Non-Interfacility) transported patients is
recommended. On initial contact by the paramedic with the supervising emergency physician,
the following information should be communicated in this sequence:
1. Priority code and receiving facility
2. Rescue number/paramedic's name
3. Patient's age/sex _
4. Patient complaint or major problem/time of onset
5. Assessment: mental status, ROM, pupils, skin, BBS, BP, P, R, ECG, hemodynamic
condition 2
6. Glasgow Coma Scale (GCS) score z
7. Mechanism of injury 0-
8. History of illness, medications used, allergies U
9. Treatment given <
10. Estimated time of arrival U)
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MEDCOM PRIORITIES
Priority I: Critical
Used only for patients who present with an immediately life-threatening illness or critical injury.
As outlined in Trauma Alert Protocol.
Priority II: Serious
Used for those patients who present with an illness or injury requiring immediate medical
intervention and that has the potential for becoming life-threatening if not treated promptly. CCN
Priority III: Stable CN
Used for those patients who present with an illness or injury not requiring immediate medical <
intervention or that is so easily managed that medical direction is not required. Also used for W
notification of impending patient arrival to the receiving facility. W
Priority IV: Administrative Traffic (Optional)
Used for all transmissions not involving care of a patient, such as radio checks, calibration test, z
and administrative traffic. 0
U
MEDCOM CLASSIFICATIONS: Adult or Pediatric, Cardiac, Medical, OB, Trauma
TRAUMA PRE-ALERTS
A Trauma Pre-alert is communicated via Fire Dispatch after initial patient contact (a second
contact must be made via Medcom en route to the hospital) and must include the following
information:
1. Rescue number/paramedic's name calling the alert.
2. Name of receiving trauma center.
3. Category (adult, pediatric, or obstetrical).
4. Trauma alert criteria.
5. Patient's sex.
6. Number of patients.
7. Estimated time of arrival to the receiving facility, via ground or air.
See the County Uniform Trauma Telemetry (CUTT) Report located in section 6 and on-line forn
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 23
Packet Pg. 1936
F.39.a
1.8 Refusal of Care
POLICY
Any and all individuals who are involved as patients or potential patients should receive proper
evaluation, treatment, and transportation to the appropriate medical facility. There may be times
when this policy may not be carried out due to a refusal of care. The refusal of care procedure
should be utilized in situations in which a patient refuses evaluation, treatment, and/or
transportation by prehospital personnel. Persons should be presumed competent to make
decisions affecting their medical care. In cases of minors, attention should be given to signs of
child abuse (Appendix 6.2).
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DEFINITIONS U
A. Patients able to refuse care.
1. A person can refuse medical care based on the following guidelines: U
a. Competent—defined by the ability to understand the nature and consequences of U)
his/her actions by refusing medical care and/or transportation, and U)
b. Adult- eighteen (18) years of age or older, except:
1) An emancipated minor.
i. A self-sufficient minor.
ii. A married minor.
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iii. A minor in the military.
2) A legal representative for the patient (parent or guardian). (Appendix 6.6, Consent
for the Care of a Minor.) Ni
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B. Patients not able to refuse care.
1. A person may be considered incompetent to refuse medical care and/ or transportation
if the severity of his/her medical condition prevents the patient from making an informed,
rational decision regarding medical care. Therefore, the individual may not refuse W
medical care and/or transportation based on the following guidelines: <
a. Altered level of consciousness (e.g., head injury or under the influence of alcohol Z
and/or drugs). 0-
0
b. Suicide (attempt or verbal threat). U
c. Severely altered vital signs. W
d. Mental retardation and/or deficiency.
e. Not acting as "a reasonable person would do, given the same circumstances."
f. Younger than eighteen (18) years of age (except those persons outlined in A [1] [b]).
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Implied consent.
1. If a person is determined to be incompetent, he/she may be treated and transported under
the principle of "implied consent" (what the reasonable individual would consent to
under the same circumstances). Also see General Protocol 1.2, Behavioral Emergencies.
2. If the patient is transported and/or treated on the basis of implied consent, field personnel
should use reasonable measures to ensure safe transport to the closest appropriate facility.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 24
Packet Pg. 1937
F.39.a
1.8 Refusal ohm r (continued)
ed
REFUSAL PROCEDURE
A. Single patient.
1. Determine that the individual is involved in the incident.
2. Determine that the individual is refusing to allow the proper evaluation, or necessary
treatment, or necessary transport to the appropriate medical facility.
3. Determine the mental status and extent and history of injury, mechanism, or illness.
a. Ensure that the patient is conscious, alert, and oriented and understands (mental
reasoning) his/her condition(patient GCS = 15).
a�
b. Unless the patient specifically refuses, do a complete physical assessment. 2
4. Inform the patient and/or responsible party (parent or guardian) of the potential U
consequences of the decision to refuse treatment and/or transport to a definitive-care 0
facility (loss of life or limb, irreversible sequelae), and ensure that the patient and/or U
responsible party fully understands the explanation. U)
5. All measures should be taken to convince the patient to consent, including enlisting the 2
help of family or friends.
U
6. If the patient continues to refuse, the patient and/or responsible party may then sign a
"Refusal of Care" form. Ensure that the following information is provided:
a. The release is against medical advice.
b. The release applies to this instance only.
C. EMS should be requested again if necessary or desired.
7. After the "Refusal of Care" form is signed, it must be witnessed (including legibly �i
printed name, contact information, and signature of witness). N
8. If the patient or responsible party will not sign the release, then document this refusal on
the EMS Run Report. If available, witness signatures should be obtained.
9. Where possible, patients should be left in the care of family, friends, or responsible
w
parties. W
10. Carefully document the assessment and vital signs, including all issues and circumstances <
z
indicated. U
0-
B. Multiple patients. U
The protocol does not allow for more than one refusal on a single EMS Run Report. However,
individuals who refuse ALL assistance, including proper evaluation, can be combined on a single
report (e.g., all parties deny injury). Once an examination is begun on an individual, a separate
EMS Run Report must be filled out to record the examination. Also, any later refusal of care
requires following the complete protocol outlined previously. The use of multiple refusals of care U
is primarily designed for incidents that have numerous participants (potential patients) where it
becomes evident that some participants are not injured at all or refuse to be examined when
approached by EMS personnel.
1. Complete Steps 1 through 10 in section A.
2. Document all names, addresses, and witnesses.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 25
Packet Pg. 1938
F.39.a
1.8 Refusal of Care (continued)
C. Medical Direction: (The Physician at the destination facility or the agency's Medical
Director).
1. Medical direction should be contacted for consultation under the following circumstances
(high risk refusal):
a. A low-severity patient who is under 18 years of age.
b. A patient whose refusal of care represents a significant risk to the patient or EMS
system/agency.
c. A patient who is not his/her own legal guardian.
d. A patient who refuses transport after administration of any IV medication (also U
consider calling the Police Department for assistance). 0
2. If any questions on the assessment of competency or refusal of care occur, contact <
medical direction for further guidance. U)
U
D. Refusal of transport or transport destination. LO
1. Patients who refuse to be transported to the closest appropriate facility and are adamant
about being transported to a different facility should be considered to be refusing
transport. The local department's supervisor should be contacted for further consultation 2
on the transport destination according to local policy.
2. When a patient refuses to be transported to any facility, medical direction should be 0
considered for further consultation, when such refusal represents a significant risk to the Ni
patient or the EMS system/agency. Refer to local policy for further direction. Q
N
U
U
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5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 26
Packet Pg. 1939
F.39.a
PURPOSE
To efficiently triage, treat, and transport victims of mass/multiple-casualty incidents (MCIs). The
following protocol is applicable to all multiple-victim situations. This protocol is intended for the
everyday MCI when the number of injured exceeds the capabilities of the first-arriving unit as
well as for large-scale MCIs.
PROCEDURE
A. The officer of the first-arriving unit will establish Command and:
1. Perform a size-up, estimating the number of victims.
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2. Request a Level 1, 2, 3, 4, or 5 response, and request additional units and/or specialized is
equipment as required. 0
U
3. Identify a staging area.
4. If it is an active assailant incident or any tactical environment with a MCI establish a W
Unified Command (UC) with Law Enforcement (LE). Consider establishing Liaisons for
FD and LE, the Liaisons can interact with each other allowing the transfer of info between
agencies. Law Enforcement will make entry with their contact team and provide feedback
to the UC and the decision may be made to establish a Rescue Task Force (team of LE
officers providing forced protection for rescue personnel). The Rescue Task Force will
initiate triage and provide immediate life saving treatment(i.e hemorrhage control).
N
N
5. If the area is deemed safe to enter direct the remaining crew members and any additional N
personnel arriving to initiate triage.
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6. Triage will be performed in accordance with START or JumpSTART.
Prioritize victims utilizing color-coded ribbons: <
Red Immediate care
U
Yellow Delayed care
Green Ambulatory (minor) is
Black Deceased(non-salvageable) W
7. Locate and direct the "walking wounded" to one location away from the incident, if
possible. These victims need to be assessed as soon as possible. Assign someone to keep
the walking wounded together.
8 Active assailant incidents considerations: Be on high alert for suspicious
individuals, packages, vehicles or potential LEDs. Integrated active assailant response
should include the critical actions contained in the acronym THREAT
Threat suppression
Hemorrhage control
Rapid Extrication to safety
Assessment by medical providers
Transport to definitive care
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 27
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F.39.a
1.9 MassCasualty Incidents (continued)
B. As additional units arrive, Command will designate the following officers:
1. Triage (Initially the responsibility of the first-arriving officer).
2. Treatment.
3. Transport.
4. Staging.
C. Additional branches/sections may be required depending on the complexity of the incident.
These officers may include, but are not limited to:
1. Medical Branch.
a�
2. Landing Zone/Heli-spot.
3. Extrication.
4. Hazardous Materials (hazmat). U
5. Rehabilitation. 0
6. Safety. U
7. Public Information Officer(PIO).
8. Medical Intelligence - to assist with suspected or known WMD (weapons of mass 2
destruction) events for decontamination, antidotes, and treatment.
D. MCI: predetermined response plan.
1. Considerations:
a�
a. An MCI shall be classified by different levels depending on the number of victims.
The number of victims will be based on the initial size-up, prior to triage.
b. Levels of response will augment the units already on the scene, and units enroute will �i
be included in the assignment. The exception would be in conjunction with a Fire N
Alarm assignment i.e., a fire with multiple victims may be a Second Alarm with an
MCI Level 3 response; this will be two separate assignments.
c. Command can downgrade or upgrade the assignments at any time.
d. All units will respond to the staging area emergency response unless otherwise
directed by Command.
e. When announcing an MCI, specify the general category (e.g., trauma, hazardous U
materials, smoke inhalation). CL
f. Any victim meeting trauma transport criteria must be reported to a state-approved U
trauma center for determination as to transport destination. Trauma transport criteria
will be determined during the secondary triage in the treatment phase. When the
trauma center(s) are overwhelmed they will notify MedCom of the need for units to
transport to other trauma centers or non-trauma centers
g. Consider the use of air transport for patients with special needs, mass-transit U
resources for multiple"walking wounded"patients, and private BLS transport units.
h. Consider the use of mobile command vehicles, medical supply trailers, and
communication trailers as needed.
i. Upon notification of an MCI, Medical Control (Medcom/MRCC) will gather
information about each hospital's capability and relay this information to the
Transport Officer or Medical Communication Officer.
j. On a large-scale incident, consider sending a Hospital Coordinator to each hospital to
assist with communications.
k. Request law enforcement to set up a safety parameter.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 28
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F.39.a
1.9 MassCasualty Incidents (continued)
2. Definitions.
a. Active assailant: The Department of Homeland Security's (DHS) definition of an active assailant
is an individual actively engaged in killing or attempting to kill people in a confined, populated
area; in most cases, active shooters use firearms and there is no pattern or method to their
selection of victims.
b. Active assailant Incident: Active assailant situations are unpredictable and evolve quickly;
most are over within 10 to 15 minutes.
c. Casualty Collection Point (CCP): A safe location(s) where fire rescue personnel can receive
victims. Victims may have to be carried or dragged to the CCP. This may be inside a structure
or exterior. This may be the same as the treatment area if located in the cold zone.
d. Concealment: Concealment is a law enforcement term that represents an object that only Z
provides protection from observation. 0-
e. Contact Team: Contact team is a law enforcement term used to designate the team of law is
enforcement officers that make entry with the specific intention of ONLY going after and <
U)
neutralizing the perpetrator. U)
f. Cover: Cover is a law enforcement term that represents an object or location that provides t i
protection from direct gunfire.
g. Improvised Explosive Device (IED): The Department of Defense (DOD) definition of an IED is
a device placed or fabricated in an improvised manner incorporating destructive, lethal, noxious,
pyrotechnic, or incendiary chemicals and designed to destroy, incapacitate, harass, or distract. It
may incorporate military components, but is normally devised from nonmilitary components.
h. Litter Bearer: A team of personnel assigned to Triage to move victims from the incident site to
the treatment area or Transport Units. N�
i. Rescue Task Force: Rescue personnel and Law Enforcement personnel formed to make entry c
into a structure to triage victims and provide life saving immediate treatment as needed i.e
stopping hemorrhage.
j. Strike Team: Five of the same type of units, including common communications and a leader
(i.e., an ALS Transport Unit Strike Team would consist of five ALS Transport Units with a W
leader).
k. Tactical Environment—Any environment that Law Enforcement has a tactical objective due to Z
a threat assessment(which may require a Fire Rescue/EMS component). 0-
1. Task Force: Five different types of units, including common communications and a leader. U
MCI Task Force: May be two ALS Transport Units, two BLS Transport Units, and one
Suppression Unit, including common communications and a leader.
m. THREAT: acronym for Threat suppression, Hemorrhage control, Rapid Extrication,
Assessment by medical providers, and transport to definitive care.
n. Zones in relation to Active assailant/Mass Casualty Incidents
1. Hot Zone — Direct Threat Care/Care Under Fire - This zone shall be designated at the area
of the structure that has not been cleared by law enforcement or the area that the perpetrator
is currently in.
2. Warm Zone — Indirect Threat Care/Tactical Field Care - This zone shall be designated at
any area of the active assailant incident that has been declared available for entry by Fire
Rescue/EMS personnel with armed LE coverage to perform immediate life saving
treatment and triage to victims prior to their removal from the initial hazard.
3. Cold Zone — Evacuation Care/Tactical Evacuation Care - This zone extends beyond the
warm zone and is not reachable by the perpetrator. This zone shall encompass positions
such as the command post, staging and other functional groups.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 29
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F.39.a
1.9 MassCasualty Incidents (continued)
MCI Level 1 (5-10 victims)
• 4 ALS Transport Units
• 2 Suppression Units
• 1 Shift Supervisor
• 1 EMS Supervisor
Note - The two hospitals and trauma center closest to the incident will be notified by Medical
Control(Medcom or local communications center).
MCI Level 2 (11-20 victims) (any active assailant incident until an accurate victim count can be made) 0
a�
• 6 ALS Transport Units 2
• 3 Suppression Units i
• 2 Shift Supervisors 0
• 2 EMS Shift Supervisors U
Note - The three hospitals and two trauma centers closest to the incident will be notified by U)
Medical Control (Medcom or local communications center). U
MCI Level 3 (21-100 victims) W
• 8 ALS Transport Units
• 4 Suppression Units
• 3 Shift Supervisors
• 3 EMS Shift Supervisors
• Command Vehicle as
• MCI Trailer Ni
• Operations Chief
Note—The four hospitals and three trauma centers closest to the incident will be notified by
Medical Control (Medcom or local communications center). The Warning Point will notify the
Emergency Management Agency.
w
MCI Level 4 (101-1000 victims)
• 5 MCI Task Forces (25 units) U
• 2 ALS Transport Strike Teams (10 units) 0
• 1 Suppression Unit Strike Team(5 units) U
• 2 BLS Transport Strike Teams (10 units)
• 2 Mass Transit Buses U_
• 2 MCI Trailers
• Command Vehicle
• Communications Trailer
• 5 Shift Supervisors
• 3 EMS Shift Supervisors,) EMS Chief
• Operations Chief
Note - The 10 hospitals and 5 trauma centers closest to the incident will be notified by Medical
Control. The Warning Point will notify the Emergency Management Agency.
In an ongoing, long-term MCI, the Metropolitan Medical Response System (MMRS) and the
State Medical Assistance Response Team (SMRT), Medical Reserve Corp (MRC), Florida
Advanced Surgical Team (FAST) Disaster Medical Assistance Team(DMAT) may be notified.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 30
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F.39.a
1.9 MassCasualty Incidents (continued)
MCI Level 5 (more than 1000 victims)
• 10 MCI Task Forces (50 units)
• 4 ALS Transport Strike Teams (20 units)
• 2 Suppression Unit Strike Teams (10 units)
• 4 BLS Transport Strike Teams (20 units)
• 4 Mass Transit Buses
• 2 Command Vehicles
• 4 Supply Trailers
• Communications Trailer
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• 10 Shift Supervisors 2
• 6 EMS Shift Supervisors U
• 2 EMS Chiefs
• 2 Operations Chiefs UU
Note -The 20 hospitals and 10 trauma centers closest to the incident will be notified by Medical
Control. The Warning Point will notify the Emergency Management Agency. In an ongoing,
long-term MCI, the MMRS, DMAT, SMRT, MRC, FAST and the International Medical and
Surgical Response Team (IMSURT) may be notified.
Strike Team: Five of the same type of units, including common communications and leader.
Task Force: Five different types of units, including common communications and leader. MCI
Task Force: May be two ALS Transport Units, two BLS Transport Units, and one Suppression Ni
Unit, including common communications and leader. N
N
U
U
LL
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F.39.a
1.9 MassCasualty Incidents (continued)
OFFICER RESPONSIBILITIES - See Online Forms for Field Operating Guides.
A. Command.
1. Established by the first arriving officer. Radio designation"Command."
2. Follow Field Operation Guide (FOG) ##1.
3. If active assailant or tactical environment incident get briefing from LE, establish a 3:
Unified Command and co-locate with LE. Consider establishing Liaisons for FD and LE,
the Liaisons can interact with each other allowing the transfer of info between agencies. 2
z
U
4. Remain in a safe, fixed, and visible location, uphill and upwind of the incident.
5. Determine the MCI Level (1, 2, 3, 4, or 5). If unknown victims in an active U
assailant/tactical environment initiate a MCI level 2 until a count can be determined. U)
6. Designate a staging area. U)
7. Assign personnel to perform the functions of Triage, Rescue Task Force (if needed), W
Treatment, Transport, and Staging.
8. Advise the Communications Center of the number of victims and their categories once
triage is complete.
9. During large-scale or complex MCIs (e.g., a fire with multiple victims/tactical
environment incident), designate a Medical Branch to reduce the span of control.
10. If the incident is due to a known or suspected weapon of mass destruction (WMD event), Ni
refer to WMD FOG ##8 and designate a Medical Intelligence Officer to assist with N
decontamination, antidotes, and treatment of victims.
11. If active assailant/tactical environment refer to FOG ##9
12. Ensure proper security of the incident site, treatment area, and loading area; also provide
for traffic control and access for emergency vehicles, including law enforcement. W
B. Medical Branch. z
I. Radio designation"Medical."Follow FOG ##2.
2. Assure Triage, Treatment, and Transport has been established. If established by U
Command, Triage, Rescue Task Force, Treatment, and Transport will now report to the
Medical Branch.
3. Work with Command, and direct and/or supervise on-scene personnel from agencies such
as the Medical Examiner's Office, Red Cross, private ambulance companies, and hospital
volunteers.
4. Ensure notification of Medical Control(Medcom/MRCC).
5. If the incident is due to a known or suspected WMD, refer to WMD FOG ##8 and
designate a Medical Intelligence Officer to assist with decontamination, antidotes, and
treatment of victims.
6. If active assailant/tactical environment refer to FOG##9
7. Ensure proper security of incident site, treatment area, and loading area; also provide for
traffic control and access for emergency vehicles, including law enforcement.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 32
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F.39.a
1.9 MassCasualty Incidents (continued)
C. Triage Officer.
Reports to Command or the Medical Branch. Supervises the Triage Personnel, Rescue Task
Force (if needed) and Litter bearers. Also directs Medical Examiner personnel locate deceased
victims.
1. Radio designation "Triage", follow FOG #3.
2. Organize the Triage Team to begin initial triaging of victims. Assemble the walking wounded
and uninjured in a safe area. Use bullhorns or a public address (PA) system if necessary.
3. Advise Command (or the Medical Branch, if established) as soon as possible if there is a
need for additional resources.
4. Coordinate with Treatment to ensure that priority victims are treated first.
5. Ensure that all areas around the MCI scene have been checked for potential victims, walking Z
wounded, ejected victims, and so forth. 0-
6. Maintain security and control of the triage area. Request the assistance of law enforcement. U
7. If a RTF is formed designate a Triage Aide to communicate with the RTF. <
8. If there is more than one RTF team, designate the teams as RTF 1, RTF 2 etc. U)
9. Have the RTF mark the doors with the victim count using a grease pencil R= , Y= , t j
G= , B= (greens should have left the area but may stay to assist with care or supervision,
i.e. a teacher).
10. Report to Command/Medical Branch upon completion of duties for further assignments.
D. Treatment Officer.
Reports to Command or the Medical Branch. Supervises the Treatment Managers of the Red,
Yellow, and Green Areas. Coordinates the retriage and tagging of all victims and the on-site Ni
medical care. Directs the movement of victims to the loading area(s). Q
1. Radio designation "Treatment", follow FOG#4.
2. Consider assigning a Documentation Aide to assist with paperwork.
3. Direct personnel to either begin treatment on the victims where they lay or establish a
centralized treatment area. W
4. Considerations for a treatment area:
a. Capable of accommodating the number of victims and equipment.
U
b. Consider weather, safety, and the possibility of hazardous materials.
c. Designate entrance and exit areas, which are readily accessible (funnel points). is
d. On large-scale incidents, divide the treatment area into three distinct areas based on
priority. Designate a Treatment Manager for each area (Red, Yellow, Green). Use
appropriate-color tarps if available.
5. Complete a Treatment Log as victims enter the area.
6. Ensure that all victims are retriaged through a secondary exam and the assessment is a
documented on a triage tag (Disaster Management System [DMS] - All Risk Triage tag). The
rescuer filling out the All Risk Triage tag will keep a corner of the tag for future
documentation.
7. All red-tagged victims will be transported immediately as transport units become available.
These victims should not be delayed in the treatment area.
8. Ensure that enough equipment is available to effectively treat all victims.
9. Establish communications with Transport to coordinate proper transport of the appropriate
victims. Direct movement of victims to the ambulance loading areas.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 33
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F.39.a
1.9 MassCasualty Incidents (continued)
E. Transport Officer.
Reports to Command or the Medical Branch. Supervises the Medical Communication
Coordinator and Documentation Aide(s). The Transport Officer is responsible for the
coordination of victims and maintenance of records relating to victim identification, injuries,
mode of transportation, and destination.
1. Radio designation"Transport", follow FOG##5.
2. Assign a Documentation Aide with a radio to assist with paperwork and communications.
3. Assign a Medical Communication Coordinator to establish continuous contact with
Medical Control (Medcom or MRCC).
a�
4. Establish a victim loading area. Advise Staging of the location and direction of travel.
Consider requesting law enforcement assistance for ensuring the security of the loading U
area. 0
5. Arrange for the transport of victims from the treatment area. Maintain a Hospital U
Transportation Log ##5B. Keep a piece of the triage tag for future documentation. U)
6. Communicate with the Landing Zone (LZ)/Heli-spot Officer and relay the number of 2
victims to be transported by air. Air-transported victims should be assigned to distant
hospitals, unless the victims' needs dictate otherwise(e.g., trauma center, burn unit).
F. Medical Communications Coordinator.
Reports to the Transport Officer and is responsible for maintaining communication with Medical
Control to assure proper victim transport information and destination.
1. Radio designation"Communication."Follow FOG ##5A. Ni
2. Establish communication with Medical Control (Medcom or MRCC1). Advise Medical N
Control of the overall situation (e.g., smoke inhalation, trauma, burns, hazardous
materials exposure) and the number and categories of victims. Medical Control will
survey area hospitals to determine their capabilities and capacities and then relay this
information to the field. Document this information on the Hospital Capability Worksheet
##5C and maintain this document for the duration of the incident.
3. When units are prepared to transport, advise Medical Control and supply of the following U
information: 0
a. The unit transporting. U
b. The number of victims to be transported.
C. Their priority: Red, Yellow, or Green.
d. Any victims with special needs (e.g., cardiac, burn, trauma).
4. The Medical Communication Coordinator, in conjunction with Medical Control, will
determine the most appropriate facility. Ground-transported victims should be assigned to U
hospitals on a rotating basis.
5. Once Medical Control receives the information from the Medical Communication
Coordinator, Medical Control will notify the appropriate hospital. Transporting units will
not contact the individual hospital on their own, unless there is a need for medical
direction/care outside of protocols.
i Medical Resource Coordination Center (MRCC): The MRCC's prime function is to maintain
status information—that is, the number of victims and the hospital readiness status to accept
victims, to coordinate transportation, and to direct patients to the appropriate hospital during a
disaster or other situation characterized by a high demand for medical resources
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 34
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F.39.a
1.9 MassCasualty Incidents (continued)
G. Medical Supply Coordinator.
Reports to the Medical Branch and is responsible for acquiring and maintaining control of all
medical equipment and supplies.
1. Radio designation"Supply", follow FOG ##6.
2. Assure necessary equipment is available on the transporting vehicle.
3. Provide an inventory of medical supplies at the staging area for use on scene.
4. Assure support vehicles are requested. (Broward County has four MCI supply trailers and
Region 7 has three large MCI supply trailers available for use during a large-scale MCI.)
U
H. Staging Officer. U
Reports to Command and is responsible for managing all activities within the staging area. U)
I. Radio designation"Staging", follow FOG ##7. U)
2. Establish the location of a staging area and notify the Communication Center to direct
any incoming units.
3. Maintain a Unit Staging Log ##7A.
4. Ensure that all personnel stay with their vehicles unless otherwise directed by Command.
If personnel are directed to assist in another function, ensure that the keys stay with each
vehicle.
5. Coordinate with the Transport Officer the designation of a location for victim loading and NI
the best route to the area. N
Q
6. Maintain a reserve of at least two transport vehicles. When the reserve is depleted,
request additional units through Command.
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DOCUMENTATION
A. The Incident Commander will, at the completion of the incident, coordinate the gathering
of all pertinent documentation. z
B. A Post-Incident Analysis (PIA) will be completed. 0-
0
U
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5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 35
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F.39.a
1.9 MassCasualty Incidents (continued)
MCI Kits For Responder Vehicles
Each unit should carry an MCI bag. The following items are recommended:
A. Two (2) triage packs recommend to have:
1. Four(4) combine dressings
2. Four(4) 4 X 4's
3. Gloves
4. One (1) pediatric face mask
5. Colored ribbons (Red, Yellow, Green& Black) either rolls or ribbons.
6. Trauma Tourniquets (2)
7. Hemostatic Dressing (2) z
8. Chest Decompression Needles(2) 0-
0
9. Chest Seals (2) U
B. Fifty (50) triage tags-Disaster Management Systems (DMS)All Risk Triage tags. U)
C. Pencils/grease pencils and pens. U)
D. Additional tourniquets, hemostatic dressing, chest seals & chest decompression needles (10) U
E. The following MCI FOGs, logs, and associated paperwork for each officer:
1. Command FOG#1 - White
2. Medical FOG #2 - Blue
3. Triage FOG #3 - Yellow
4. Treatment FOG #4 - Red
5. Treatment Area Log#4A- Red
6. Transport FOG#5 - Green N
7. Medical Communication FOG#5A - Green N
8. Hospital Transport Log#513 - Green. (10 logs)
9. Hospital Capability Worksheet#5C - Green
w
10. Medical Supply FOG#6 - Blue
11. Staging FOG #7 - Orange
12. Unit Staging Log#7A- Orange
z
13. MCI-WMD/Terrorist Event FOG#8 - Beige U
0
MCI SUPERVISOR KIT U
A. Complete vest set with the following identification vests:
1. White for Command. U_
2. Blue for Medical Officer.
3. Yellow for Triage Officer.
4. Red for Treatment Officer.
5. Green for Transport Officer.
6. Green for Medical Communication Coordinator.
7. Blue for Medical Supply Officer.
8. Orange for Staging Officer.
B. Clipboard which contains paperwork for each officer, pens/pencils/grease pencils, and paper.
C. EMS Command Board.
D. Tarp set: red,yellow, green, black tarps.
E. Patient tracking device/Scanner(if available)
F Bullhorn if available
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 36
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F.39.a
1.9 MassCasualty Incidents (continued)
START SYSTEM OF TRIAGE
This procedure is based on the Simple Triage and Rapid Treatment (START) process for adult
victims and the JumpSTART adaptation for pediatric victims.
PROCEDURE
A. Initial triage: Using the START or JumpSTART method (described in the following two
sections):
1. Locate and direct all of the walking wounded to one location away from the incident if
possible. Assign someone to keep them together (Fire Rescue Department personnel, Law '
Enforcement officer, or capable bystander). Z
2. Begin assessing all non-ambulatory victims where they are found. 0-
3. Utilize the triage ribbons tied to an upper extremity in a visible location. U
4. Independent decisions should be made for each victim. Do not base triage decisions on the <
perception of too many reds, not enough greens, and so forth. U)
5. If borderline decisions are encountered, always triage to the most urgent priority (e.g., for a t j
Green/Yellow patient, tag as Yellow).
B. Secondary triage.
1. Performed on all victims during the Treatment phase. If a victim is identified in the initial 'a
Triage phase as a Red and transport is available, do not delay transport to perform a 2
secondary assessment.
2. Utilize a triage tag (Disaster Management System [DMS] All Risk Triage tag) and attempt to 0
assess for and complete all information required on the tag (time permitting). Affix the tag to Wi
the victim and remove the ribbon. Q
3. The triage priority determined in the Treatment phase should be the priority used for
transport. If trauma-related, the trauma transport criteria will be applied to trauma victims
during the secondary triage in the Treatment phase. W
Z
Remember the mnemonic RPM (Respiration, Perfusion, Mental status). The first assessment that
produces a Red stops further assessment. Only correction of life-threatening problems, such as Z
airway obstruction or severe hemorrhage, should be managed during the triage phase. Any major 0-
external bleeding should also be controlled at this time. Depending on the victim's injuries (burns, t,u
fractures, bleeding), it may be necessary to prioritize as Yellow
START modified 912015
Move the Walking Wounded IGREEN
No Respiration after head tilt IBLACK
Control Severe Bleeding
Respirations over 30/min/Respiratory Distress
Perfusion(No radial pulse)
Mental Status (unable to follow commands)
Stable RPM/Walking GREEN
Stable RPM/Non ambulatory YELLOW
Conduct Secondary Triage in the Treatment Phase
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 37
Packet Pg. 1950
F.39.a
1.9 Mass asualty Incidents (continued)
JUMPSTART TRIAGE
Physiological differences in children necessitate adaptation of the standard START triage
method in children 8 years of age or younger, or in those victims with the anatomical or
physiological features of a child in the age group. The same parameters (RPM) are utilized, with
the adaptations indicated here.
JumpSTART modified 912015 t3
Move the Walking Wounded access as soon aspossible) GREEN U
No Respiration after head tilt/No peripheral pulse BLACK
Respirations 45/min or 15/min( Work of Breathing) U)
No resp with pulse give 5 ventilations via harrier U
Respirations resume
Nos ontaneous respirations BLACK
Control Severe Bleeding
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Perfusion(No radial pulse)
Mental Status (AVPU)Alert/Verbal YELLOW
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Pain/Unresponsive CN
cN
Stable RPM/Walking GREEN cN
Stable RPM/Non ambulatory YELLOW <
Conduct Secondary Triage in the Treatment Phase 3:
w
Note -Infants who are developmentally unable to walk should be triaged using the JumpSTART
algorithm either during initial triage or in the Green area if carried out by a nonrescuer. During
triage, if the infant does not fulfill the criteria of a Red victim and has no other outward signs of L)
significant injury; he/she may be triaged as a Green victim. 0
Note -The START Triage system was developed by Newport Beach Fire Rescue and Hoag
Hospital. The JumpSTART Triage system was developed by Dr. Lou Romig.
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5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 38
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F.39.a
1.9 Mass����Casualty Incidents (continued)
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5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 39
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F.39.a
1.10 Crime Scene Management
This protocol will be used when law enforcement personnel advise EMS that they have
responded to a crime scene or EMS determines that a crime scene may exist.
A. Purpose: To ensure the protection of patient welfare as well as to ensure the ability to
conduct an effective and thorough investigation.
B. Response/on-scene situations.
I. Only those units assigned will respond to the call. Over-response tends to cause
confusion at the crime scene and destruction of evidence.
2. When approaching a potential crime scene that is being protected by law enforcement
personnel, the paramedic/EMT may request entry into the area to determine the life U
status of the individual. 0
3. If law enforcement personnel refuse access to the crime scene, do not become <
confrontational. Notify the EMS Agency Supervisor and complete an incident report as U)
required. U
4. When personnel are allowed access into the scene, the minimum number of required W
EMS personnel should enter to minimize disturbance of the crime scene.
5. Do not attempt resuscitation if the patient has no pulse, has no spontaneous respiration,
and meets criteria outlined in General Protocol 1.4, Death in the Field.
6. If treatment and/or resuscitation are warranted, follow the appropriate protocol.
7. When on scene:
a. Keep your medical equipment close to the victim. Ni
b. Stay close to the body.
c. Keep your hands out of any blood that has pooled.
d. Do not wander around the scene.
e. Minimize destruction of the patient's clothing. If the patient's clothing has a
puncture, do not use the hole in the clothing to start cutting. Begin cutting at another
part of the garment. Removed clothing should be left with the patient or turned over
to law enforcement personnel. U
f. Do NOT go through the victim's personal effects, clean the body, or cover the body 0
with a sheet or other material(if expired). U
g. Do NOT move, take, or handle any object at the scene or litter the crime scene with
medical equipment, dressings, bandages, or other supplies. U_
h. If resuscitation efforts are deemed necessary, transfer the victim from the scene to the a
vehicle expeditiously and stabilize the victim in the vehicle, when possible. E
i. If the patient relates any information relating to the crime while in transit to the
medical facility, inform law enforcement personnel at once.
5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 40
Packet Pg. 1953
F.39.a
1.11 Protocol Revision Procedure
Any person may submit input for changes to the Common Protocols. The following procedure
will be used to receive and process this input.
PROCEDURE (Electronic)
1. Any member of a participating EMS agency will be permitted to submit queries and
suggestions regarding the Common Protocols via the electronic web based version of the
protocols.
2. The protocols will be located on www.GBEMDA,org and a link will be located on the
Broward EMS Council's website www,Broward.org/BrowardEMS 2
3. Simply click on a protocol item and review its contents. U
4. At the bottom right hand portion of the screen click on the "Make a Suggestion" link. 0
5. Fill out the required fields: U
a. Department U)
b. Full Name U)
C. Telephone Number
d. Email address
e. Protocol number
f. Comments
a�
6. Press Submit
7. Your comment will be sent via email to the Medical Director and EMS Chief for your
particular EMS Agency Ni
8. Medical Directors will meet yearly (or sooner if more emergent) to discuss the submitted N
items, reviewing their merit, and bringing substantiated items up for discussion and potential
revision.
9. Once the changes to the Common Protocols have been implemented, the electronic protocols
will be updated on the Broward EMS website and all hospitals will be notified. W
10. It is the intent of this procedure that every EMS provider implements all approved changes <
to the Common Protocols.
U
11. The Medical Director of an individual EMS provider reserves the right to change portion of
the protocols, however, if they are unique to that specific department, the information will U
be located on a department specific page within the PDF.
LL
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5th Edition,Version 1 September 2016 Florida Regional Common EMS Protocols 41
Packet Pg. 1954
F.39.a
Florida Regional Common
EMS Protocols
a.
Section 2
Adult Protocols U
N
N
N
E
5th Edition, Version 1, February 2017
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 1
Packet Pg. 1955
F.39.a
Adult Section Table of Content
2.1 Adult Initial Assessment and Management
2.1.1 Initial Assessment
2.1.2 Airway Management
2.1.3 Medical Supportive Care
2.1.4 Trauma Supportive Care
2.1.5 Pain Management
2.2 Adult Respiratory Emergencies
2.2.1 Airway Obstruction
2.2.2 AsthmaBronchospasm
2.2.3 Emphysema and/or Bronchitis
2.2.4 Pulmonary Edema(CHF)
2.2.5 Suspected Pneumonia
Z
U
2.3 Adult Cardiac Dysrhythmias
2.3.1 Asystole/PEA U
2.3.2 Bradycardia U)
2.3.3 Narrow Complex Tachycardia(Supraventricular Tachycardia) U)
2.3.4 Premature Ventricular Ectopy (PVC) U
2.3.5 Wide Complex Tachycardia with a Pulse (Ventricular Tachycardia)
2.3.6 Wide Complex Tachycardia without a Pulse and Ventricular Fibrillation U-
2.3.7 Return of Spontaneous Circulation (ROSC)
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2.4 Other Adult Cardiac Emergencies
2.4.1 Cardiogenic Shock
2.4.2 Angina/Suspected AMI N�
2.4.3 Hypertensive Emergencies
2.5 Adult Neurologic Emergencies
2.5.1 Altered Mental Status Unknown Etiology
2.5.2 Violent, Impaired Patient and/or Excited Delirium (ExDS)
2.5.3 Seizure Disorders
2.5.4 Suspected Stroke (CVA) U
2.5.5 Syncopal Episode 0
U
2.6 Adult Toxicologic Emergencies
2.6.1 Bites and Stings U-
2.6.2 CNS Depressant Overdose
2.6.2.1 Benzodiazepines and Sedative Hypnotics
2.6.2.2 Opioid and Narcotic Overdose
2.6.3 CNS Stimulant Overdose
2.6.4 Digitalis Toxicity
2.6.5 Hallucinogen Overdose
2.6.6 Tricyclic Antidepressant Overdose
2.6.7 Unknown Toxicity
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 2
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F.39.a
2.7 Adult OB/GYN Emergencies
2.7.1 Complications of Labor and Delivery
2.7.2 Normal Labor and Delivery
2.7.3 Nontraumatic Vaginal Bleeding
2.7.4 Toxemia of Pregnancy
2.8 Other Adult Medical Emergencies
2.8.1 Allergic Reactions/Anaphylaxis
2.8.2 Hypoglycemia/Hyperglycemia
2.8.3 Nausea/Vomiting
2.8.4 Nontraumatic Abdominal Pain
2.8.5 Sickle Cell Anemia
2.8.6 Sepsis
2.8.7 Acute Adrenal Insufficiency
a�
2.9 Adult Environmental Emergencies z
2.9.1 Barotrauma/Decompression Illness: Dive Injuries 0-
0
2.9.2 Cold-Related Emergencies U
2.9.3 Heat-Related Emergencies U)
2.9.4 Drowning U)
2.9.5 Electrical Emergencies U
2.9.6 Electronic Control Devices (TASER)
2.10 Adult Trauma Emergencies
2.10.1 Head and Spine Injuries
2.10.2 Eye Injuries
2.10.3 Chest Injuries
2.10.4 Traumatic Chest Pain
2.10.5 Abdomino-Pelvic Injuries N
2.10.6 Extremity Injuries
2.10.7 Traumatic Arrest W
2.10.8 Burn Injuries W
2.10.9 Crush/Compartment Syndrome
z
2.11 Adults with Special Healthcare Needs t-
2.11.1 Home Mechanical Ventilator U
2.11.2 Tracheostomy
2.11.3 Central Venous Lines
2.11.4 Feeding Tubes
2.11.5 VAD Patients
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 3
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F.39.a
�I
GENERAL
GUIDELINES
Protocols in Section 2.1 are designed to guide the EMT or paramedic in his or her initial approach
General to assessment and management of adult patients. Supportive care is specified as being either EMT
Guidelines and Paramedic (BLS) or Paramedic Only (ALS).
Protocol 2.1.1 should be used on all adult patients for initial assessment. During this assessment,
if the EMT or paramedic determines that there is a need for airway management, Protocol 2.1.2
should be used for the management of the adult airway. These protocols are frequently referred to
by other protocols, which may or may not override them in recommending more specific therapy.
Protocol 2.1.3 presents the basic components of preparation for transport of medical patients. Due
to the significant differences in priorities and packaging in the prehospital care of trauma and
hypovolemia cases, a separate Trauma Supportive Care protocol has been developed. After U
following Protocol 2.1.1, this Medical Supportive Care protocol may be the only protocol used in 0
medical emergency situations where a specific diagnostic impression and choice of additional U
protocols cannot be made. Judgment must be used in determining whether patients require ALS or
BLS level care. This protocol is frequently referred to by other protocols, which may or may not
override it in recommending more specific therapy.
Protocol 2.1.4 presents the basic components of preparation for transport of trauma patients. Due
to the significant differences in priorities and packaging in the prehospital care of medical cases,
a separate Medical Supportive Care protocol has been developed. After following Protocol 2.1.1,
this Trauma Supportive Care protocol may be the only protocol used in trauma or hypovolemia
situations where a specific diagnostic impression and choice of additional protocols cannot be
made. Judgment must be used in determining whether patients require ALS or BLS level care. C4
This protocol is frequently referred to by other protocols, which may or may not override it in
recommending more specific therapy.
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 4
Packet Pg. 1958
F.39.a
10100
GENERAL GUIDELINES
EMT AND PARAMEDIC
General I. Scene Size-up.
Guidelines A. Review the dispatch information.
B. Assess the need for body substance isolation.
C. Assess for scene safety.
D. Determine mechanism of injury.
E. Determine the nature of the illness.
F. Determine the number and location of patients.
G. Determine the need for additional resources.
H. Consider c-spine immobilization.
a�
IL Initial Assessment. Z
A. General impression of the patient. 0-
B. Assess mental status; AVPU scale (Alert, Alert to Verbal, Responds to Pain, U
Unconscious); maintain spinal immobilization as needed. <
C. Assess circulation (rapid evaluation of pulse, major bleeding, skin color, and W
temperature). Assess need for defibrillation: VF/VT without pulse. U
D. Assess airway.
E. Assess breathing.
F. Assess disability: movement of extremities.
G. Expose and examine the patient's head, neck, chest, abdomen, and pelvis (check
the back when the patient is rolled on his/her side).
H. Identify priority patients.
1. Poor general impression. N
2. Unresponsive patients. N
3. Responsive but does not or cannot follow commands.
4. Difficulty breathing
5. Hypoperfusion or shock w
6. Complicated child birth
7. Chest pain with a systolic BP below 100 mm Hg.
8. Uncontrolled bleeding 0-
9. Severe pain anywhere U
10. Multiple injuries
U_
III. Initial Management. (Adult Protocol 2.1.3 or 2.1.4, Medical Supportive Care, or
Trauma Supportive Care).
IV. Secondary Assessment
A. Conduct a head-to-toe survey
B. Conduct a neurological assessment
1. Pupillary response
2. Glasgow Coma Scale (GCS) score
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 5
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F.39.a
GENERAL GUIDELINES
C. Assess vital signs
General 1. Respirations
Guidelines 2. Pulse
3. Blood pressure
4. Capillary refill
5. Skin condition
a. Color
b. Temperature
c. Moisture
6. Lung sounds
D. Obtain a medical history. (SAMPLE & OPQRRRST)
1. S - Symptoms: Assessment of chief complaint. U
a. 0 - Onset and location 0
b. P -Provocation U
c. Q - Quality
d. R - Radiation U
e. R - Referred w
f. R - Relief
g. S - Severity
h. T - Time
2. A - Allergies
3. M - Medications
4. P -Past medical history Ni
5. L- Last oral intake N
6. E- Events leading to illness or injury
V. Other Assessment Techniques.
1. Cardiac monitoring
2. Pulse oximetry (Medical Procedure 4.22)
3. Glucose determination (Medical Procedure 4.17) U
4. Monitor temperature 0
5. Capnography (EtCO2) U
w
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 6
Packet Pg. 1960
F.39.a
Ir
TREATMENT GUIDELINES
EMT AND PARAMEDIC
• Initial Assessment Protocol 2.1.1.
If spontaneous breathing is present without compromise:
• Monitor breathing during transport.
• Administer oxygen as needed to maintain 02 saturation of 94% or greater.
• Avoid over oxygenation: Wean oxygen concentration as tolerated.
If spontaneous breathing is present with compromise:
• Maintain airway patency (Medical Procedure 4.1.3).
• Administer oxygen via non-rebreather mask (10-15 L/min).
• If unconscious, insert oropharyngeal, nasopharyngeal as needed(Medical Procedure 4.2). U
• If patient accepts oropharyngeal airway, consider the need for a supraglottic device. EMT may 0
insert the supraglottic device if he/she has been authorized by that department's Medical L)
Director(Medical Procedure 4.4). U)
• Assist ventilations with a bag-valve mask (BVM) device attached to supplemental oxygen at
15-25 L/min as needed (Medical Procedure 4.1.5).
• Suction as needed (Medical Procedure 4.3.1, Flexible Suctioning, and Medical Procedure
4.3.2, Rigid Suctioning).
• Apply and monitor pulse oximeter(Medical Procedures 4.22).
• Apply and monitor capnography for wave form (Medical Procedure 4.10.1)
a�
If spontaneous breathing is absent or markedly compromised: N�
• Maintain airway patency (Medical Procedure 4.1.3). Q
• Assist ventilation with a BVM device attached to supplemental oxygen at 15-25 L/min as
needed (Medical Procedure 4.1.5). Maintain 02 saturation of 94% or greater. Avoid over
oxygenation: Wean oxygen concentration as tolerated Z
• If unconscious, insert oropharyngeal, nasopharyngeal as needed (Medical Procedure 4.2).
• If patient accepts oropharyngeal airway, consider the need for a supraglottic device. EMT may
insert the supraglottic device if he/she has been authorized by that department's Medical L)
Director (Medical Procedure 4.4). 0
U
• Suction as needed (Medical Procedure 4.3.1, Flexible Suctioning, and Medical Procedure
4.3.2, Rigid Suctioning).
U_
• Apply and monitor pulse oximeter(Medical Procedures 4.22).
• Apply and monitor capnography for wave form (Medical Procedure 4.10.1)
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 7
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F.39.a
MMM)
TREATMENT GUIDELINES
PARAMEDIC ONLY
If patient accepts oropharyngeal airway, consider the need for an advanced airway (see ALS
Level 1, Advanced Airway Management).
ALS Level 1: Advanced Airway Management
• Insert an advanced airway and document the following (Medical Procedure 4.4)
1. Confirm an advanced airway placement with an end-tidal CO2 monitoring device.
2. Additional confirmation methods may include the following options:
a. Visualization of the tube passing through the vocal cords.
b. Negative epigastric sounds.
c. Positive bilateral breath sounds.
U
3. Secure the advanced airway with a commercially available device. 0-
a. Application of a c-collar may be useful in preventing the advanced airway from U
becoming dislodged, U)
b. For trauma patients or for patients with head/neck injury use full spinal immobilization U)
U
• If unable to insert the advanced airway and patient cannot be adequately ventilated by other
means, perform cricothyroidotomy (Medical Procedure 4.5) and transport rapidly to the
nearest appropriate facility.
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➢ None i
cN
cN
cN
Nate • None
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 8
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F.39.a
TREATMENT GUIDELINES
EMT AND PARAMEDIC
• Initial Assessment Protocol 2.1.1.
• Airway Management Protocol 2.1.2.
• The EMT should apply the AED (Medical Procedure 4.1.1, AED
• Establish hospital contact for notification of an incoming patient.
PARAMEDIC
• Establish IV of normal saline with a regular infusion set(a) (b);unless overridden by the
specific protocol. (Medical Procedure, Medication Delivery 4.18.5)
• In a critical medical patient, an intraosseous (IO) line may be considered (Medical
Procedures 4.18.4) U
OR U
• Medication may be administered intranasal (IN)via the MAD device. (Medical Procedure
Medication Delivery 4.18.3) U)
• Monitor ECG as needed. U
W
➢ The paramedic should obtain consultation for ALS Level 2 orders.
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Note (a) Authorized IV routes include all peripheral venous sites. External jugular veins may be utilized c�
when other peripheral site attempts have been unsuccessful or would be inappropriate. A large-
CN
bore intracatheter should be used for unstable patients. Avoid use of access sites below the
diaphragm.
(b) An IV lock or MAP may be used in lieu of an IV bag in some patients, when appropriate W
(Medical Procedure 4.18.5).
d
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 9
Packet Pg. 1963
F.39.a
1 �
TREATMENT GUIDELINES
EMT AND PARAMEDIC
• Initial Assessment Protocol 2.1.1. Initiate Trauma Alert; if applicable (General Protocol
1.10, Trauma Transport).
• Airway Management Protocol 2.1.2. (Manually stabilize c-spine as needed.)
• Correct any open wound/sucking chest wound(with an occlusive dressing).
• Control hemorrhage.
• Immobilize fractures.
• Determine if the patient is taking any anticoagulant such as warfarin (Coumadin) or
antiplatelets such as dabigatran (Pradaxa). (b)
• Immobilize c-spine and secure the patient to a backboard as needed (Protocol 2.10.1. and
Medical Procedure 4.24, Spinal Immobilization). U
0-
• Expedite transport. 0
U
The following steps should not delay transport.
• Complete bandaging, splinting, and packaging as needed. U
• Establish hospital contact for notification of an incoming patient, and obtain consultation
for Level 2 orders.
PARAMEDIC ONLY
a�
• Consider advanced airway to assist with the correction of a massive flail segment that
causes respiratory compromise.
• Correct any tension pneumothorax (Medical Procedure 4.9, Chest Decompression). i
N
N
PARAMEDIC
• Establish IV of normal saline with a regular infusion set(a) (b), unless overridden by the
specific protocol. (Medical Procedure, Medication Delivery 4.18)
• In a critical trauma patient, an intraosseous (IO) line may be considered (Medical
Procedure, Medication Delivery 4.18)
Z
• Monitor ECG as needed. U
CL
➢ None U
(a) Authorized IV routes include all peripheral venous sites. External jugular veins may be
Nate utilized when other peripheral site attempts have been unsuccessful or would be
inappropriate. Two Ws using large-bore intracatheters should be initiated in unstable
patients. Avoid use of access sites below the diaphragm.
(b) If the exam reveals any new deficit, or if a witness actually saw the patient strike their head,
consideration shall be given to transport to the nearest appropriate Trauma Center as a High
Index of Suspicion Patient. Should the patient deteriorate enroute, to the point where they me(
Trauma Alert criteria, an immediate upgrade should be called into the Trauma Center.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 10
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F.39.a
GENERAL GUIDELINES
ISOLATED EXTREMITY FRACTURE
General The purpose of this procedure is to manage pain associated with isolated extremity fractures.
Guidelines ACUTE BACK STRAIN
This procedure should be used in the isolated back strain.
ABDOMINAL PAIN/RENAL COLIC
This procedure can be used for abdominal pain or with flank pain that is associated with kidney stones
SOFT-TISSUE INJURIES, BURNS, BITES, AND STINGS
This procedure is used for pain associated with multisystem trauma, soft-tissue injuries, burns, bites, and
stings
TREATMENT GUIDELINES
For Isolated Extremity Fractures
• Any extremity fracture should be immobilized as described in Adult Protocol 2.10.6, Extremity Injuries. Z
• Extremity fractures should be elevated,if possible, and cold applied. 13-
• Distal circulation, sensation, and movement in the injured extremity should be noted and recorded. u
d
When treating patients with altered mental status use CAUTION when considering any pain U)
management medication Patients should be asked to quantify their pain on an analog pain scale t j
(from 0 =least severe,to 10=most severe). This number should be documented and used to measure the en
effectiveness of analgesia:
Nitrous Oxide-Nitronox:
Self-administered analgesia with nitrous oxide should be given special consideration for pain management
during this procedure (Medical Procedure 4.20,Nitrous Oxide-Nitronox),if available.
i
OR �
Morphine Sulfate CN
May be given via slow IV in 5 mg increments may repeat once, titrated to pain and BP above 100 mm Hg,
up to a maximum of 10 mg.(a)
Z
OR
Fentanyl
May be given 100 mcg increments every 3-5 minutes to a maximum of 200 mcg IN, IM. U
IV dose is 1 mcg/kg (slow IV increments every 3-5 minutes, maximum initial dose of 100 mcg, titrated to 0
pain and BP remains above 100 mm Hg (a)(b) (Medical Procedure 4.18, Medication Administration). u
Second dose if needed, maximum total dose of 200 mcg IV, IN, IM.
OR
Ketamine -Adults Must dilute if using 100mg/ml concentration. 20 mg IV over 1 minute slow push.
May repeat x 1 in 5 minutes.(c)
➢ None
(a) When administering Morphine Sulfate or Fentanyl, closely monitor the patient's
Nate respiratory status. In the event that the patient's respirations/oxygenation is suppressed
(SP02 less than 94%), utilize basic airway maneuvers (open airway), administer oxygen
and if no improvement consider Narcan.
(b) If Fentanyl was initially given IN and an IV is then established, then one IV dose of 50 mcg. can
be given if needed.
Ll (c) Dilution instructions - add 20 mg (0.2 ml) to 0.8 ml Normal Saline
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 11
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F.39.a
I
GENERAL GUIDELINES
Assessment of the adult patient in respiratory distress requires specific attention to the function of
General the respiratory system. The EMT's and paramedic's assessment should be more concentrated in
Guidelines this area, to include the following considerations:
1. Assessment of chest wall movement, including the rate and depth of ventilation as well as the
presence of symmetrical rise and fall.
2. Assessment of accessory muscle use.
3. Auscultation of bilateral lung sounds.
4. Use of pulse oximetry.
5. Use of EtCO2, monitor wave form.
a�
The paramedic must be able to determine the adequacy of ventilation and understand its z
relationship to respiration. If signs of hypoxia and respiratory distress are present, immediate 6-
airway and ventilatory management should be initiated. These signs include altered mental status, is
tachypnea, and use of accessory muscles, nasal flaring, pursed lips, abnormal lung sounds, <
tachycardia, and cyanosis. In addition, the general signs of shock may be seen. Other signs of
respiratory insufficiency that should alert the paramedic to the need for immediate airway and F3
LO
ventilatory management, including placement of an advanced airway, are respiratory rate below
10/min or above 36/min, SP02 below 94%, or EtCO2 outside the normal range of 35-45mmHg.
In patients with chronic respiratory disease, the paramedic must be able to differentiate between
what is chronic and what is acute, as it pertains to the respiratory assessment. Specific questions
about the chief complaint and accompanying symptoms may prove to be invaluable in this setting. Wi
Assessment of lung sounds should be combined with patient history. For example, a patient with cN
a history of CHF who has wheezing on auscultation of lung sounds should not be automatically Q
classified as an"asthma patient." The paramedic must remember that patients with CHF may also
present with wheezing. If this patient does not have a history of asthma or allergic reaction, the W
more prudent assessment would be that of CHF. W
W
Specific treatments for the different causes of respiratory distress are outlined in the following
protocols. When the paramedic is unsure as to which protocol to follow, he/she should follow the 0-
protocols in Section 2.1 and contact medical control for further direction. 0
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 12
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F.39.a
GENERAL GUIDELINES
Causes of upper airway obstruction include the tongue, foreign bodies, swelling of the upper
General airway due to angio-neurotic edema (see Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis),
Guidelines and trauma to the airway. Differentiation of the cause of upper airway obstruction is essential to
determining the proper treatment.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3
• If air exchange is inadequate and there is a reasonable suspicion of foreign body airway
obstruction(FBAO), apply abdominal thrusts until the patient becomes unresponsive then
begin CPR, starting with chest compressions. Continue CPR with the addition of looking Z
in the mouth before delivering breaths. (Medical Procedure 4.1.6) (a). 0-
0
c)
U)• If unable to relieve FBAO, visualize it with a laryngoscope and extract the foreign body 2
with magill forceps.
• If the obstruction is due to trauma and/or edema, or if uncontrollable bleeding into the
airway causes life-threatening ventilatory impairment, utilize an advanced airway
(Medical Procedure 4.4, Advanced Airways).
• If unable to insert an advanced airway and the patient cannot be adequately ventilated by
other means,perform a cricothyroidotomy (Medical Procedure 4.5, Needle
Cricothyroidotomy). Ni
• Establish an IV; give normal saline KVO. Q
➢ None
Note (a) If air exchange is adequate with a partial airway obstruction, do not interfere; instead, U
encourage the patient to cough up the obstruction. Continue to monitor the patient for 0
U
adequacy of air exchange. If air exchange becomes inadequate, continue with the protocol. LO
U_
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 13
Packet Pg. 1967
F.39.a
GENERAL GUIDELINES
General This protocol is used for patients who are complaining of dyspnea and having wheezing. A patient
Guidelines with a history of CHF who has wheezing on auscultation of lung sounds should not be automatically
classified as an "asthma patient." If the CHF patient does not have a history of asthma or allergic
reaction, the more prudent assessment would be that of CHF (cardiac asthma) (Adult Protocol
2.2.4, Pulmonary Edema-CHF).
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1, Airway Management 2.1.2
• Place the patient in Fowler's position and assist ventilations as needed (Medical Procedure 4.1.5)
U
• Establish an IV; give normal saline.
• Give Albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Albuterol premixed U
with 2.5 mL normal saline (Medical Procedure 4.18.6). This treatment may be repeated twice <
as needed. U)
• If bronchodilators are administered, may add Ipratoprium bromide (Atrovent®) 0.5 mg (0.5 mL) U
to Albuterol nebulizer treatment.
• Consider the need for advanced airway management(Medical Procedure 4.4).
If patient continues to have severe respiratory distress, consider the following:
• Administer the following steroid
➢ Methylprednisolone sodium succinate (Solu-Medrol) 125mg IV, if IV cannot be established
then administer IM, if available(Medical Procedure, Medication Delivery 4.18) Wi
• Administer Epinephrine (1:1000) 0.3 mg IM (Medical Procedure, Medication Delivery 4.18)(a). c,',
If severe respiratory distress continues, consider the following:
• Administer Magnesium Sulfate 2 g IV (mixed in 50 mL or 100mLof D5W) given over 5-10
Z
minutes. w
• Repeat Epinephrine (1:1000) 0.3 mg IM, if the patient has not responded to the previous
treatments (a) (Medical Procedure, Medication Delivery 4.18)
• Administer CPAP with 2.5- 5 cm H2O PEEP (Medical Procedure 4.12). 0-
U
➢ Repeat Epinephrine (1:1000) 0.3 mg IM (a).
Note
(a) When administering Epinephrine caution should be used when the patient is older than 40
years of age or has a history of hypertension or heart disease.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 14
Packet Pg. 1968
WREMMMEW
GUIDELINESso
GENERAL
This protocol is used for patients with a history of emphysema and/or chronic bronchitis (COPD)
General who complain of dyspnea. If at any point the patient's respiratory status deteriorates, consider
Guidelines an advanced airway and administration of Albuterol via the ET tube nebulized, and transport the
patient immediately.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Place the patient in Fowler's position and assist ventilations as needed(Medical Procedure 4.4). 0)
a�
U
• Establish an IV; give normal saline KVO. U
• Give Albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Albuterol premixed V)
with 2.5 mL normal saline (Medical Procedure 4.18.6). This treatment may be repeated twice 2
as needed. U
• If bronchodilators are administered, may add Ipratoprium Bromide (Atrovent®) 0.5 mg (0.5
mL)to Albuterol treatment.
• Administer CPAP with 2.5-5 cm H2O PEEP (Medical Procedure 4.12).
• Consider the need for advanced airway management(Medical Procedure 4.4).
a�
If patient has severe respiratory distress you may administer: Ni
• Methylprednisolone sodium succinate (Solu-Medrol) 125mg, IV push. If IV cannot be Q
established then administer IM, if available. (Medical Procedure, Medication Delivery 4.18)
➢ None
c)
CL
Note
c)
LL
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 15
Packet Pg. 1969
F.39.a
GUIDELINESta � � H I I � =M11
GENERAL
This protocol is used for patients who are exhibiting signs of pulmonary edema-CHF, including
General dyspnea with rales and/or wheezing (cardiac asthma). The patient may also have diminished air
Guidelines exchange. Other treatments for the causes of pulmonary edema-CHF should be considered (e.g.,
supraventricular tachycardia, myocardial infarction, and cardiogenic shock). A patient with a
history of CHF who has wheezing on auscultation of lung sounds should not be automatically
classified as an"asthma patient." The paramedic must remember that patients with CHF may also
present with wheezing. If the CHF patient does not have a history of asthma or allergic reaction,
the more prudent assessment would be that of CHF (cardiac asthma).
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1. Z
• Place the patient in Fowler's position and assist ventilations as needed(Medical Procedure 0-
4.1.5). U
• If the patient is hypotensive (systolic BP below 90 mm Hg), Adult Protocol 2.4.1, U)
Cardiogenic Shock. U)
U
• If there is no improvement in thepatient's pulse oximetrY, ca no raPhY> and mental status,
consider use of an advanced airway (Medical Procedure 4.4).
• Establish an IV; give normal saline KVO.
• Do not administer nitroglycerin (NTG) if:
o The patient's systolic BP is below 100 mm Hg.
o The patient has taken any of the following erectile dysfunction medications. (Note the Q
following medications are also marketed under a variety of other trade names).
a. Stendra(Avanafil)— in the past 12 hours
b. Viagra(Sildenafil) —in the past 24 hours Z
c. Levitra(Vardenafil) or Cialis (Tadalafil)— in the last 48 hours W
• If the patient's systolic BP is between 100 and 160 mm Hg, give nitroglycerin (Nitrostae or
Nitrolingual® spray) 0.4mg SL, prior to applying CPAP. May repeat every 3 to 5 minutes U
(maximum of two additional doses (0.4mg/each) if the patient is symptomatic and the systolic 0
pressure is greater than 100 mmHg(b).
• If the patient's systolic BP is above 160 mm Hg, give nitroglycerin (Nitrostat® or Nitrolingual®
spray)0.8m SL prior to applying CPAP.Ma repeat as needed eve 3 to 5 minutes 0.4m each
p y) g ,p y p � ( � )
if the patient is symptomatic and the systolic blood pressure is greater than 160 mmHg(b)(c). u
• Administer CPAP with 10 cm H2O PEEP (Medical Procedure 4.12) (a).
• Reevaluate the need for advanced airway management. If there is no improvement in the
patient's pulse oximetry, capnography, and mental status, consider use of advanced airway
management(Medical Procedure 4.4, and Medical Procedure 4.10, Capnography).
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 16
Packet Pg. 1970
F.39.a
' 'MEER, Now =W11
TREATMENT GUIDELINES
➢ None
II �I plNII
m III
Sate (a) The CPAP mask must be tight fitting. Some patients may not tolerate CPAP at 10 cm H2O
PEEP initially, in which case you may start with lower pressures (5 —7.5cm H2O PEEP-CPAP
should not be used if the patient's systolic BP below 100 mm Hg.
(b) Consider withholding if the clinical presentation of the patient indicates signs of hypovolemia
(e.g.,poor skin turgor, decreased capillary refill, and elevated temperature).
(c) It is preferred to have an IV in place prior to NTG administration. However, if you are unable
to establish IV access, NTG may be administered with caution.
z
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 17
Packet Pg. 1971
F.39.a
GENERAL GUIDELINES
Patients complaining of dyspnea should be suspected of having pneumonia when they present
General with fever, productive cough, possible pleuritic chest pain, history of being bedridden, known
Guidelines immune-compromise, diabetes, elderly age, and lung sounds indicative of consolidation (rates
and/or rhonchi with egophony over area of consolidation).
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
"" ° " • Establish an IV; If lungs sounds are clear administer 500mL normal saline z
U
• Give albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Abbuterol premixed
with 2.5 mL normal saline (Medical Procedure 4.18.6). This treatment may be repeated twice U
as needed.
• If bronchodilators are administered, may add Ipratropium Bromide (Atrovene) 0.5 mg (0.5 W
mL)to albuterol nebulizer treatment. U
• Avoid the use of diuretics.
➢ None
cN
i
Nate Q
CN
U
CL
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 18
Packet Pg. 1972
F.39.a
GENERAL GUIDELINES
The paramedic should use these protocols to guide him/her through the treatment of cardiac patients
General with specific dysrhythmias and accompanying signs and symptoms. After stabilization of the patient,
Guidelines the paramedic may need to refer to additional protocols for continued treatment(e.g., other cardiac
protocols).
In cardiac arrest, a major component of the primary and secondary survey is to consider the
secondary, differential diagnosis and to think carefully about what could be causing the arrest. The
"H's and T's" chart will assist in the recognition of a possible underlying cause.
H's Cause Treatment Protocol
Hypovocemia Fluid challenge NS 500 mL IV/IO Protocol 2.10 2
Hypoxia Airway management Protocol 2.1.2 Z
Hydrogen ion-acidosis Airway management, ventilate Protocol 2.1.2 0-
consider Sodium Bicarbonate Drug Summary 5.31 U
Hyperkalemia Consider Calcium Chloride 1 g Drug Summary 5.9 and "4
Consider Sodium 5.31 U)
Bicarbonatel mEq/kg U
Hypothermia Cold-related emergencies Protocol 2.9.2
Hypoglycemia If less than 60, consider Protocol 2.8.2
D50 or Glucagon Drug Summary 5.9 and a
5.16 s
Hypocalcemia Consider Calcium Chloride 1 g Drug Summary 5.7
T's Cause Treatment Protocol
Tablets Consult poison control Protocol 2.6 N
for specific therapy N
Tamponade, cardiac Consider fluid challenge, Protocol 2.4.
Dopamine drip
Tension pneumothorax Consider chest decompression Procedure 4.9
Thrombosis, coronary Consider AMI, cardiogenic shock Protocol 2.4.2
Thrombosis,pulmonary Protocol 2.4.1 L)
Trauma Protocol 2.10 0
U
LL
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 19
Packet Pg. 1973
F.39.a
2015 ADULT ASYSTOLE/PEA ALGORITHM
Adult Cardiac Arrest Alglorithm 015 Update
NII��I°I°uuI�IIII���YII l�lll��m m�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Push hard(at least 2 Inches
[5 cmD mid fast(100-120/rnin)
Start CPR and anow coaaapiete ctaesf recoil.
Give oxygen * Minimize irrtecruptinrr.s in
Attache Inepitvr/deflbritlatcr e ornpaea iura
* Avoid excessive vontrtratucna.
• Rotate compressor every
2 minutes,or socrier if fatigued.
ff no advanced air-w✓ay,
ry
Ye" Rhythm o 3ft2 compression venf lation
................... shookaknde?/ ratio �
N Quantitative Waveforn
VF/pVT Asystole/P"EA capnogr rhy
if firm-ice,<10 mean-1g,atternpt qp
®® to nnprove CPR qualify, �
• l ntra airderlaal pressure z
If relaxation axaation ph r.,ra(do- C)
Shock glolicy pressure<20 rnmii Hg,
attempt w umprove CPR 0
4 quality, U
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recommendation teg,inffor'al: t j
dose of 120 200 d$ if unknown,
Rhythm use and and
available.
"�,�, t� ,o Sc c earned�:fn¢i subsequent closes
r' shnoulyd be ecUivalent,and rnghaar U-
doses doses may be considered.
• Maanophfasic.350 3 Z3
hock IIIIII III I Rl,
• Epinepbrine W10 doses
#L 10 1 mg every 3-5 niinurtes
..., ..,. ...... ... .... . Arniodaarone IVAO dose:First
CPRmin CPR 2 min dose.3010 my bolus.Second N
(Epinephrine every 3-5 min * W/10 access dose 150 nag
CN
Consider advanced airway, Epinephrine every 3•5 rniru
capncgraphy * Consider advanced airway, fi V I
capnography Endotrachral intubation or
supraglottic`adv anCed arway W
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Rhythm
Rhythm y p y cl W
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shockable? " shockable? °r mondor ET tune pl acenlent
Once advanced raa
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`.....s ......: .......:✓ * rwaay in place,
<....
olive t breath every do seconds z
Yes (10 dareaths„frnin)vwith oontnraumr s L)
a chest compres ions
Shock No U
lu III I�ulu m ell VWU�I uulu�lu�u
f aUse and bloo Ian
d :„�frr
CPR d R 1 Trot r llhrupt su5tnine{!ancwe9s•e In L-
. Amiodaron r Treat reversible causes pc n'o,,(typically,AO artun Hg) 4i
Treat ireverselecausea ti �� Spontaneous arterial,pressure
* .
vnwcs with e eaart ratl
monitoring
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ia.shockable? . Hyd ovox ,e,rni a
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�� ` Hyy o g n ion(acidosis)
..L
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• If no signs of return of � o to 5 err T � '" Hypotherrna as
spontaneous CrrCaflstion • Tension pneunaothorax
(R,OSC),go to tit or 11 T ampunaade cardiac
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 20
Packet Pg. 1974
F.39.a
TREATMENT GUIDELINES
• Consider criteria for death/no resuscitation (General Protocol 1.4).
• Initial Assessment Protocol 2.1.1.
• Look for no breathing or only gasping and check pulse (simultaneously)
• If no pulse, begin CPR using cycles of 30 compressions and 2 breaths for 2 minutes while
monitor is being attached.
• Oxygenate with 15-25 L/min via bag-valve mask (BVM) with an appropriate airway adjunct
(Airway Management Protocol 2.1.2) (a).
• Do not interrupt the 2 minutes of CPR to check the heart rhythm. Continuous
uninterrupted CPR is paramount to patient survival.
• Check the heart rhythm; confirm asystole in two leads.
• Resume 2 minutes of CPR at a rate of 100-120 per minute; check the heart rhythm.
• Consider the H's and T's. U
0-
U
U)
U)
• Confirm airway adjunct placement with electronic EtCO2 and waveform on scene, during U
transport, and during transfer at the hospital.
• Establish IV or IO access; give normal saline KVO. Consider infusing saline wide open in
PEA.
• When IV or IO line is established: as
o Epinephrine (1:10,000) 1 mg IV/I0; repeat every 3-5 minutes.
• Give 2 minutes of CPR, check the heart rhythm. N�
• Search for and treat possible contributing factors; see the H's and T's charts. Q
• If the patient is taking a calcium-channel blocker or has known renal failure, give Calcium
Chloride 10% 1 g IV or I0.
• As soon as the patient regains spontaneous circulation (Return of Spontaneous Circulation z
(ROSC) Protocol 2.3.7
d
U
➢ None U
U.
Note (a) Provide a 30:2 compression to ventilation ratio.
Once an advanced airway is in place,provide 1 breath every 6 seconds.
(b) If EtCO2 less than 10mmHg: Attempt to improve CPR (compressions vs. ventilation).
If EtCO2 = 12 - 25mm Hg: Goal during resuscitation.
If EtCO2 = 35 - 45mm Hg: Check for ROSC
(c) If ROSC achieved, wean down oxygen to maintain a SPO2 equal to greater than 94%
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 21
Packet Pg. 1975
F.39.a
i
TREATMENT GUIDELINES
Patients who present with a heart rate less than 50 and are symptomatic (a).
Consider the potential causes:
Acute myocardial infarction Calcium-channel blockers
Head injury Clonidine
Atrio-ventricular block Digitalis (e)
Hypoxia Toxins
Hypoglycemia Sick sinus syndrome
Medications (beta blockers) Spinal cord lesion
Trauma
• Initial Assessment Protocol 2.1.1. z
• Access the CABS and vital signs. 0-
• Apply a SP02 monitor, and administer oxygen to maintain SP02 greater than or equal to 94% U
or assist with bag-valve mask(BVM) ventilations if indicated. <
U)
• Consider the H's and T's. U)
U
• Establish IV access; give normal saline KVO.
• Perform 12-lead ECG. If inferior wall MI is identified, perform additional 12-lead ECG with
V4R to confirm/rule out concurrent right ventricular MI(b).
a�
c�
Unstable (e.g., acutely altered mental status, ischemic chest pain/discomfort, acute heart failure m
hypotension (systolic BP below 100 mm Hg), dyspnea, heart blocks or ischemia/infarction on Wi
12-lead ECG or other signs of shock that persist despite adequate airway and breathing), N
• Atropine 0.5 mg IV/IO; repeat every 3 - 5 minutes, up to a maximum total dose of 3 mg
(a) (b) (c).
o If atropine is ineffective, consider pacing (e) (f)
w
OR
Dopamine drip infusion 5-10 mcg/kg/min, titrate to maintain minimum systolic BP of 100 U
mm Hg and maximum systolic BP of 120 mm Hg 0
U
OR
Epinephrine drip infusion 2-10 mcg per minute, titrate to maintain minimum systolic BP of
100 mm Hg and maximum systolic BP of 120 mm Hg
• Bradycardia with hypotension may be due to an inferior wall MI associated with right
ventricular MI(confirmed on 12-lead ECG as a V4R ST elevation). If the patient has an acute
inferior wall MI with hypotension and clear lungs, give normal saline 500 cc fluid challenge;
may repeat once (Adult Protocol 2.4.2, Chest Pain—Suspected AMI).
o When an inferior wall MI is associated with right ventricular MI, avoid the use of nitrates
(Nitroglycerin) and Morphine/Fentanyl.
o If bradycardia and hypotension exist, pacing and IV fluids may improve the patient's
hemodynamic status; consider pacing and IV fluids prior to the use of Atropine. Also refer
to Adult Protocol 2.4.2, Angina/Suspected AML (b)
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 22
Packet Pg. 1976
F.39.a
If the patient has persistent hypotension/cardiogenic shock, give Dopamine 5-10 mcg/kg/min
(1600 mcg/mL infusion concentration= 15-60 gtts/min). Titrate to maintain a minimum systolic
BP of 100 mm Hg and maximum BP of 120 mm Hg (f)If pacing is chosen as the second-line
treatment and it is also ineffective, begin an infusion of dopamine or epinephrine
• If the patient is conscious and aware of the situation during pacing, administer one of the
following benzodiazepines (d): (Medical Procedure, Medication Delivery 4.18).
Diazepam (Valium) 5 mg IV, IO, IM or IN; may repeat once, to a maximum dose of 10 mg.
OR
Midazolam (Versed) (5 to 10 mg) IV, IO, IM or IN (IN concentration 10mg/2ml) maximum a
dose of 10 mg (d).
OR U
0-
U
Lorazepam (Ativan) 2 mg IV, IO, IM, or IN; may repeat once, to a maximum dose of 4 mg.
U)
U)
➢ None W
Nate (a) Consider pacing before giving the maximum dose of atropine.
(b) For second-degree AV block type II and third-degree AV block, omit Atropine and use
an external pacer.
(c) Use atropine with caution in the presence of myocardial ischemia. N�
(d) Administer benzodiazepines slowly, titrate to effect, and be aware of associated Q
hypotension
d
(e) If suspected digitalis toxicity, Atropine improves AV nodal conduction. Caution should be
used with pacing because it can lower the fibrillatory threshold and induce arrhythmias. Refer z
to Protocol 2.6.4 Digitalis Toxicity. W
(f) If pacing is chosen as the second-line treatment and it is also ineffective, begin an infusion of
dopamine or epinephrine. U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 23
Packet Pg. 1977
2015 BRADYCARDIA ALGORITHM
Adult Bradycardia With a Pulse Algorithm
Assess appropriateness fo,r,clliiniical ,co,n,diiti,o,n.
Heart irate typically<50/mlin lif biradyarrhythirniia.
2
Identify and treat underlying cause
• Maintain patent airway; assist Ibreathiing as necessary z
• Oxygen, (if hypoxemic) U
CL
• Cardiac monitor to identify rhythm; monitor blood (pressure and oximetry 0
• IV access U
• 12-Lead li if available; don't delay therapy <
U)
U)
.2
U
3
---------------------------
Persistent
4 bradyarrhythmia causing:
No • Hypoteinsiion?
Monitor and observe Acutely altered mental statius?
//>
........... ............ ass
Signs of shock?
• Ischemiic chest discomfort?.
Acute heart failure?' CN
CN
Vcs III III
CN
III
5 .............................................
Atropine W
Atropine IV dose: z
W
If atropine ineffective: First dose: 0.5 mg bolus. w
• Transclutaneous pacing Repeat every 3-5 minutes. <
or Maximum: 3 mg. z
• Dopamine in L)fusion [dopamine IV infusion: CL
or 0
• Epinephrine infusion Usual infusion rate is L)
2-20 mc,11g per minute, 'n
Titrate to patient response;
111-
6 taper slowly.
Consider: Epinephrine IV infusion:
E
2-10 mcg per minute
• Expert consultation
infusion. Titrate to patient
• Transvenous pacing
Oc 2015 American Heart Association ........................... response.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 24
Packet Pg. 1978
F.39.a
GENERAL GUIDELINES
Patients suffering from tachycardia may or may not exhibit symptoms. It is important to note that
General narrow complex tachycardia has many origins. The atrial rate may be helpful in the differential
Guidelines interpretation of these types of tachycardia. The following rates should be considered:
Sinus tachycardia ranges from 100 to 160 beats per minute.
Junctional tachycardia ranges from 100 to 180 beats per minute.
Atrial tachycardia ranges from 150 to 250 beats per minute (atrial rate).
Atrial flutter ranges from 250 to 350 beats per minute (atrial rate).
Atrial fibrillation starts at 350 beats per minute (atrial rate).
a�
In addition,wide complex tachycardia(QRS greater than or equal to 0.12 seconds)should initially 2
be considered as ventricular in origin, unless proven otherwise (e.g., documented QRS z
morphology consistent with preexisting BBB; refer to Adult Medical Protocol 2.3.6, Wide 0-
Complex Tachycardia with a Pulse). is
Those patients who present with SVT may have evidence of cardiovascular dysfunction. Those U)
patients who present with symptomatic signs and symptoms may be treated with medications. L)
LO
Those patients who present with "unstable" signs and symptoms should be cardioverted
immediately. U-
The following table shows stable to unstable signs and symptoms:
Symptomatic Stable Critical Unstable
i
Alert and oriented Decreased level of consciousness N
SBP equal to greater than 100 mm Hg SBP below 100 mm Hg (shock) N
Mild chest discomfort Chest pain
Mild to Moderate Shortness of breath Severe Shortness of breath W
Diaphoresis W
Pulmonary edema/CHF
z
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 25
Packet Pg. 1979
F.39.a
GENERAL GUIDELINES
General NARROW COMPLEX TACHYCARDIAS
Guidelines Heart Rate greater than 150 BPM
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Determine hemodynamic stability and symptoms.
• Consider the H's and T's.
STABLE SVT, HEART RATE greater than or equal to 150 BPM
U
• Apply the ECG monitor, record a rhythm strip, and obtain a 12-lead ECG.
• Establish IV access; give normal saline KVO. U
• If the patient is asymptomatic,provide medical supportive care (Protocol 2.1.3) and transport
immediately. U
• If necessary,perform vagal maneuvers (Medical Procedure 4.26).
• If not resolved, administer Adenosine Triphosphate (Adenocard®) 12 mg rapid IVP, followed
by rapid 10 mL NS flush.
• If not resolved, after 2 minutes Adenosine Triphosphate (Adenocard) 12 mg rapid IVP, 2
followed by rapid 10 mL NS flush. (a).
• If available, administer Diltiazem (Cardizem) 0.25 mg/kg IV. Give in 5 mg increments
every 2 minutes up to maximum of 0.25 mg/kg. N�
o Stop the administration of Cardizem once the Heart Rate is less than 120 and/or Q
SBP is less than 100mmHg.
d
• If the tachyarrhythmia is not resolved in 15 minutes, may repeat Diltiazem (Cardizem) 0.35
mg/kg IV. Give in 5 mg increments every 2 minutes up to maximum of 0.35 mg/kg. z
U
U
Note
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 26
Packet Pg. 1980
F.39.a
GENERAL GUIDELINES
General STABLE ATRIAL FIBRILLATION OR ATRIAL FLUTTER
Guidelines Heart rate greater than or equal to 150 BPM
TREATMENT GUIDELINES r° �' ° • Apply the ECG monitor, record a rhythm strip, and obtain a 12-lead ECG.
• Establish IV access; give normal saline KVO.
• If the patient is asymptomatic,provide medical supportive care(Protocol 2.1.3)and transport
immediately.
• If the patient has borderline symptoms with a SBP of 100 mm Hg,then consider other causes �
of hypotension (e.g., hypovolemia or sepsis) 2
• If available,administer Diltiazem(Cardizem)0.25 mg/kg IV. Give in 5 mg increments every U
2 minutes up to maximum of 0.25 mg/kg. 0
o Stop the administration of Cardizem once the Heart Rate is less than 120 and/or SBP
is less than 100mmHg.
• If the tachyarrhythmia is not resolved in 15 minutes, may repeat Diltiazem (Cardizem) 0.35
mg/kg IV. Give in 5 mg increments every 2 minutes up to maximum of 0.35 mg/kg IV.
CN
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 27
Packet Pg. 1981
F.39.a
GENERAL GUIDELINES
General UNSTABLE NARROW COMPLEX TACHYCARDIAS
Guidelines
This patient group includes individuals who are hypotensive with a systolic BP less than 100 min
Hg and a heart rate greater than or equal to 150 beats/min and who are symptomatic (clinical
evidence of impending cardiac arrest) as evidenced by any of the following:
Diaphoresis, Shortness of breath, Decreased level of consciousness, Chest pain, Pulmonary edema
GUIDELINESTREATMENT
• Initial Assessment Protocol 2.1.1.
• Determine hemodynamic stability and symptoms.
• Consider the H's and T's. is
U
• Provide advanced airway management, if necessary (c).
• Establish IV access; give normal saline KVO.
• Evaluate lung sounds. If they are clear, administer a fluid challenge of normal saline 500 mL t)
IV.
• Perform synchronized cardioversion Start at the lower dose and increase to the higher
dose until appropriate clinical effect is obtained.
Narrow regular SVT, atrial flutter: 50-100 joules
Narrow irregular, atrial fibrillation: 120-200 joules (per manufacture recommendation)
• Escalate the second and subsequent shock doses as needed. Ni
• If the patient is conscious and aware of the situation, consider sedation with one of the
following benzodiazepines (d): (Medical Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, I0, IM or IN, maximum dose of 10 mg (e)
OR w
o Midazolam (Versed) 5 to 10 mg IV, I0, IM or IN (In concentration 10mg/2ml)
d
OR U
o Lorazepam (Ativan)2 mg IV, I0, IM, or IN; may rpat once,up to a max dose of 4 mg (e).
U
➢ None
Nate
(a) Adenosine Triphosphate should not be given to patients with known atrial flutter or atrial
fibrillation.
(b) Do not give diltiazem (Cardizem®)to patients with a known history of Wolff-Parkinson-
White (WPW) syndrome.
(c) Confirm airway adjunct placement with electronic EtCO2 and waveform on scene, during
transport, and during transfer at hospital.
(d) Administer benzodiazepines slowly, titrate to effect, and be aware of associated hypotension.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 28
Packet Pg. 1982
F.39.a
GUIDELINESGENERAL
Treatment of ventricular arrhythmias after MI has been a controversial topic for two decades.
General Similarly, management of ventricular arrhythmias during the acute phase of MI continues to
Guidelines evolve as treatment strategies are reviewed in the context of new information and changing
epidemiological data during the era of adjunctive medical and reperfusion therapy. At present,the
treatment of asymptomatic premature ventricular ectopy (PVC) is not recommended.
Current ACLS protocols recommend amiodarone for the treatment of hemodynamically stable VT
and prevention of recurrent VF.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1. z
• Medical Supportive Care Protocol 2.1.3
0
U
U)
" °" ➢ None U)
➢ If the patient is symptomatic, contact the physician for further orders
c�
Note
N
i
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N
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 29
Packet Pg. 1983
F.39.a
a ,
GENERAL CUIDELINES
General STABLE
Guidelines
GUIDELINESTREATMENT
ilia • Initial Assessment Protocol 2.1.1.
• Consider the H's and T's.
• Monitor the ECG. 2
• Establish IV access; give normal saline KVO. U
• Give Amiodarone infusion of 150 mg in 50 mL or 100 mL of D5W over 10 minutes IV 0
• If the patient has torsades de pointes, administer Magnesium Sulfate 2 g in 50 mL or 100 mL U
of D5W infused over 5-10 minutes IV. If the Magnesium Sulfate successfully converts the U)
rhythm, start Magnesium Sulfate maintenance infusion (1 g in 250 mL of D5W) at 30-60
gtts/min. with a 60 gtts set. U
➢ None
c�
Note C�
cN
cN
U
CL
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 30
Packet Pg. 1984
F.39.a
NMI,
GENERAL GUIDELINES
General UNSTABLE - Heart rate greater than 150 beats/min and systolic blood pressure less than
Guidelines 100 min Hg with one of the following signs and symptoms: chest pain, dyspnea,pulmonary
edema, diaphoresis, and altered mental status.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• If necessary, oxygenate with 15-25 L/min via bag-valve mask (BVM) with an
appropriate airway adjunct device at 10-12 BPM (Airway Protocol 2.1.2) (a).
• Confirm airway adjunct placement. 2
• Consider the H's and T's.
U
U
"^ • Monitor the ECG.
• For unstable monomorphic perform synchronized cardioversion at 100, 200, 300, or 360 U)
joules. If wide irregular/unstable or polymorphic and/or torsades: defibrillate at 200 joules U
(not synchronized). (c)(d)
• Establish IV or IO access; give normal saline KVO.
o If the patient is conscious and aware of the situation, consider sedation with one of the 0
following benzodiazepines (b): (Medical Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, IM or IN; maximum dose of 10 mg.
OR
i
o Midazolam (Versed) 5 to 10 mg IV, IO, IM or IN (In concentration 10mg/2ml) N
maximum dose of 10 mg. N
OR
o Lorazepam (Ativan) 2 mg IV, IO, IM or IN; may repeat once, up to a maximum dose of 4
mg W
➢ None U
CL
Note (a) Provide one breath every 5-6 seconds
Once an advanced airway is in place,provide 1 breath every 6 seconds. U_
(b) Administer benzodiazepines slowly, titrate to effect, and be aware of associated hypotension. a
If an antiarrhythmic medication was not administered prior to cardioversion, then administer E
an. Give Amiodarone infusion of 150 mg in 50 mL or 100 mL of D5W over
10 minutes IV.
(c) IV if patient's BP is above 100.
(d) If suspected digitalis toxicity, consider lowering initial cardioversion dose to 5-20 joules.
Protocol 2.6.4 Digitalis Toxicity
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 31
Packet Pg. 1985
F.39.a
77
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Determine the patient's responsiveness or unresponsiveness
• Look for no breathing or only gasping and check pulse (simultaneously)
• If no pulse, begin CPR using cycles of 30 compressions and 2 breaths for 2 minutes while
monitor is being attached.
• Oxygenate with 15-25 L/min via a BVM with an appropriate airway adjunct device.
(see Airway Protocol 2.1.2) (a) (e).
• Do not interrupt the 2 minutes of CPR to check heart rhythm. Continuous
uninterrupted CPR is paramount to patient survival.
• Check the heart rhythm. Confirm the rhythm and shock accordingly (b).
• Perform a focused rapid assessment.
• Consider the H's and T's. is
0-
U
• Confirm placement of the airway adjunct with electronic EtCO2 and wave-form while on U)
scene, during transport, and during transfer at hospital. U
• Establish IV or IO access; give normal saline KVO. LO
• Defibrillate at 200 joules (for a biphasic device based on manufacturer recommendation) (e).
Continue CPR while the defibrillator is charging.
• Immediately resume CPR for 2 minutes.
• Check the heart rhythm. If it is a shockable rhythm, defibrillate at 300 joules for a biphasic
device based on manufacturer recommendation) (e). Continue CPR while the defibrillator is Wi
charging. N
• When an IV or IO line is established N
a Give Epinephrine (1:10,000) 1 mg IV/IO; repeat every 3-5 minutes for the duration of the
arrest. w
• Immediately resume CPR for 2 minutes.
• Check the heart rhythm. If it is a shockable rhythm, defibrillate at 360 joules for a biphasic.
Continue CPR while the defibrillator is charging. z
• Immediately CPR for 2 minutes. 0-
• Administer Amiodarone 300 mg IV/IO once. If V-Fib/pulseless V-Tach continues after 3-5 U
minutes administer an additional 150 mg IV/IO once. Administer during CPR.
• Check the heart rhythm. If it is a shockable rhythm, defibrillate at 360 joules for a biphasic
device based on manufacturer recommendation) (e). Continue CPR while the defibrillator is
charging.
• Immediately resume CPR for 2 minutes.
• Check the heart rhythm.
• If the patient has torsades de pointes, administer Magnesium Sulfate 2 g in 50 mL or 100 mL
of D5W infused over 5-10 IV/IO (c).
• Continue treatment until there is a return of spontaneous circulation (ROSC), a rhythm
change, or termination of efforts.
• If the patient has Return of Spontaneous Circulation (ROSC), (Protocol 2.3.7).
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 32
Packet Pg. 1986
F.39.a
TREATMENT GUIDELINES
Note (a) Provide a 30:2 compression to ventilation ratio.
Once an advanced airway is in place,provide 1 breath every 6 seconds.
(b) The EMT should apply the AED. The paramedic should proceed to ALS Level 1 defibrillation.
(c) If Magnesium Sulfate successfully converts the heart rhythm, start a Magnesium Sulfate
maintenance infusion (1 g in 250 mL NS) at 30-60 gtts/min.
(d) If EtCO2 is less than 1 OmmHg: Attempt to improve CPR (compressions vs. ventilation).
If EtCO2 = 12-25mm Hg: Goal during resuscitation.
If EtCO2 = 35-45mm Hg: Check for ROSC
(e) For Zoll monitor biphasic device the manufacturer recommends the initial defibrillation at 120 76
joules and subsequent defibrillations at 150, 200 as the maximum.
a�
U
U
U
c�
N
i
c�
N
U
U
c�
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 33
Packet Pg. 1987
UPDATED ADULT CARDIAC ARREST ALGORITHM F.39.a
Adult Cardiac Arrest Circular Algorithm— pulilllllgllllllillllilMENNNNEEN
2015 Update Iluullull�llliullol
Push hard(at least 2 inches[5 cm])and fast(100-120/min)and allow
complete chest recoil.
Minimize interruptions in compressions.
w + Avoid excessive ventilation.
Start CPR + Rotate compressor every 2 minutes,or sooner if fatigued.
Give oxygen + If no advanced airway, 30:2 cornpression-ventilation ratio.
Attach monitor/def lbrilll for Quantitative waveform capnography
If PETCO2<10 mm Hg,attempt to improve CPR quality
Return,of Spontaneous
Intra-arterial pressure.
2minutes - If relaxation phase(diastolic)pressure<20 mm Hg,attempt to
Circulation(ROSC) � improve CPR quality.
Y..,,.. ......................................... . .. �Y��Y� ... 2
Check Post-Cardiac I � � I" L z
Rhythm If VF/p'VT arrest Cam ���1111111111 IIII IIIII I�ii 0-
Shock M Biphasic: Manufacturer recommendation(eg, initial dose of 120-200 J); U
if unknown, use rnaximum available.Second and subsequent doses U)
should be equivalent,and higher doses may be considered.
Drug Therapy • Monophasic:360 J U
WO access
Epinephrine every 3-5 minutes IIII rc
Amiodarone for refractory VF/pVT llu ui iiii
�p
Epinephrine NO dose:1 mg every 3-5 minutes
Amiodarone lWIt0 dose:First dose:300 mg bolus.Second dose: mg.
Consider Advanced Airway' u �
�Quantitative waveform,capnography �pllll IIIIII �,
N
. + Fndotracheal intubation or supraglottic advanced airway
Waveform capnography or capnometry to confirm and monitor
Treat Reversible Causes FT tube placement
Once advanced airway in place,give 1 breath every 6 seconds
(10 breaths/min)with continuous chest compressions
� IIIIIIIII III,.IIIII IIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIJIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIII II (IIIIIIIIIII IIIII IIII IIIII II �������������������������������������������������������������������������������
IIIII IIIIIIIIII II III IIIIIIII IV z
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« Pulse and blood pressure
Abrupt sustained increase in PETCC,(typically_A0 rnrn Hg)
LO
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ILL
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o
Hypovolemia # Tension pneumothorax
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Hydrogen ion(acidosis) w Toxins
« Hypo-/hyperkalemia . Thrombosis, pulmonary
Cc)2015 American Heart Association « Hypothermia . Thrombosis,coronary
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 34
Packet Pg. 1988
F.39.a
GENERAL GUIDELINES
Post-resuscitation is an extremely unstable period for the patient, so the patient should be monitored closely
and reassessed frequently. The immediate goals of post-resuscitation care are as follows:
General • Provide cardio-respiratory support to optimize tissue perfusion, especially to the brain.
Guidelines • Institute antiarrhythmic therapy to prevent recurrence of the arrest.
• Attempt to identify the precipitating cause of the arrest.
• Rapidly transport the patient to the closest appropriate facility.
� � • Initial Assessment Protocol 2.1.1.
• Reassess the CABS and vital signs.
°`' • Maintain an open airway with an appropriate airway adjunct device, administer 100% 02 to maintain U
SPO2 greater than or equal to 94%, and monitor with electronic EtCO2 capnography/waveform.
Ventilate at 10-12 BPM; avoid hyperventilation (d). U
0 Determine the patient's hemodynamic stability. If systolic blood pressure below 100 mm U)
Hg: U)
0 If the patient's lungs are clear, administer IV NS 500 mL; may repeat once to maintain U
systolic blood pressure above 100 mm Hg (a).
If systolic BP remains below 100 mm Hg: _
0 Give a Dopamine infusion at 5 — 10 mcg/kg/min; titrate to maintain minimum systolic
BP of 100 mm Hg and a maximum systolic BP of 120 mm Hg
• Manage dysrhythmias according to the specific protocol. i
• If the cardiac arrest was the result of VF or VT, manage the patient as follows: �
o If an antiarrhythmic medication was not used to convert the heart rhythm, administer CN
Amiodarone 150 mg in 50 mL or 100 mL of D5W over 10 minutes IV/IO (b).
o If Amiodarone was administered during resuscitation, do not administer additional
Amiodarone.
o If the patient is having frequent PVC or runs of VT, or if the transport time will exceed
30 minutes, start an Amiodarone drip (150 mg in 50 mL of D5W= 3:1 concentration). Z
Using a 60 gtt/mL set,initiate the flow at 1 gtt every 3 seconds. U
0
Transport the patient to the closest interventional cardiac facility (c).
➢ None
11611111111
Note; (a)If rales or crackles are auscultated in the lungs or the patient's systolic blood pressure remains less
than 90 mm Hg despite fluid therapy,proceed directly to dopamine administration.
(b) Do not use Amiodarone if the patient has a heart rate less than 60, second-degree type II AV block,
third- degree AV block or if patient is hypotensive
(c)If the patient's airway is compromised or crews are unable to manage the patient, transport the patient
to the nearest facility.
(d) If EtCO2 is less thanlOmmHg: Attempt to improve CPR(compressions vs. ventilation).
If EtCO2 = 12-25mm Hg: Goal during resuscitation.
If EtCO2 = 35-45mm Hg: Check for ROSC
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 35
Packet Pg. 1989
F.39.a
RIC
GENERAL GUIDELINES
This protocol is used for the patient who is hypotensive (systolic BP less than 100 mm Hg) with
General signs and/or symptoms that are cardiac in origin (Adult Protocol 2.2.4, Pulmonary Edema-CHF;
Guidelines Adult Protocol 2.3,Adult Cardiac Dysrhythmias;and Adult Protocol 2.4.2,Angina/Suspected AMI).
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Administer oxygen via non-rebreather mask (10-15 L/min). If the patient's airway is
compromised, assist ventilations by using the appropriate airway adjunct.
• Consider possible causes (e.g., the H's and T's).
a�
U
°" • Monitor the ECG.
• Perform a 12-lead ECG, and initiate a Cardiac Alert if AMI is present. U
• Start IV/IO normal saline. If time permits, establish a second IV/IO line if possible. U)
• If the patient is not experiencing pulmonary edema, administer a fluid challenge of 500 mL
normal saline. If this measure does not improve the patient's systolic blood pressure, the fluid w
challenge may be repeated once (a).
• If the fluid challenge does not improve blood pressure, or if the patient is experiencing rates (or
pulmonary edema), administer a Dopamine infusion at 5-20 mcg/kg/min (b).
• Titrate Dopamine to maintain a minimum systolic SBP of 100 mm Hg and a maximum systolic 2
BP of 120 mm Hg.
• If the heart rate is slow, less than 60/min, Adult Protocol 2.3.2, Bradycardia. C�
• If the heart rate is fast, greater than 150/min, Adult Protocol 2.3.3, Narrow Complex Q
Tachycardia, or Adult Protocol 2.3.6, Wide Complex Tachycardia with a Pulse, as appropriate.
➢ None
U
Nate, (a) Avoid giving fluids if an anterior wall MI is suspected (evidenced by ST elevations in leads I, U
AVL, V1 through V6). W
(b) Dopamine 1600 mcg/mL infusion concentration = 15-60 gtts/min with a 60-gtt set. The
maximum dose is 20 mcg/kg/min.
c�
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 36
Packet Pg. 1990
F.39.a
1�
GENERAL
GUIDELINES
This protocol is used for the patient who is experiencing chest pain or discomfort due to angina
pectoris or suspected AML Other SS associated with acute coronary syndrome include dyspnea,
General diaphoresis, nausea/vomiting, and weakness/ fatigue. If these additional signs and symptoms are
Guidelines present in the absence of chest pain or discomfort, AMI may still be present.
If nontraumatic chest pain other than angina/AMI is suspected consider other potential causes;
dissecting aortic aneurysm, pericarditis, spontaneous pneumothorax, pulmonary embolism,
pneumonia, pleurisy, costochondritis, hiatal hernia, esophageal spasm, peptic ulcer, cholecystitis,
pancreatitis, and cervical disk problem These conditions should not be treated under this protocol,
refer to specific protocol and utilize Appendix 6.5, Chest Pain Differential.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1. a
• Consider oxygen if the SPO2 is less than 94% and/or the patient is in respiratory distress.
Maintain SpO2 of 94% (nasal cannula recommended). 0-
• EMTs should: 0
U
o Assist the patient in self-administration of previously prescribed Aspirin.
o Assist the patient in self-administration of previously prescribed Nitroglycerin. The total
dose should not exceed three doses (tablets or spray), including doses that the patient may U
have taken prior to your arrival. Do NOT administer Nitroglycerin if the SBP less than 100
mm Hg or The patient has taken erectile dysfunction medications within the last 24 hours
(Viagra) or within the last 48 hours (Levitra or Cialis) The patient has taken any of the -
following erectile dysfunction medications. (Note the following medications are also 0
marketed under a variety of other trade names).
a. Stendra(Avanafil)—in the past 12 hours
b. Viagra(Sildenafil)— in the past 24 hours N�
c. Levitra(Vardenafil) or Cialis (Tadalafil) —in the last 48 hours Q
• Monitor the ECG.
• If AMI is probable(c), initiate a Cardiac Alert and transport the patient to the appropriate cardiac
interventional facility. z
• Limit cardiac alert on scene time. (d)
• Establish IV access; give normal saline KVO. U
• Give aspirin 162 mg, up to 324 mg PO (chewable), unless contraindicated (a).
• Perform a 12-lead ECG and transmit the results to the destination hospital, as soon as possible. LL
• If an inferior wall MI is identified,perform an additional 12-lead ECG with V4R to confirm/rule
out concurrent right ventricular MI(b). (Medical Procedure 4.14)
• If the patient is hypotensive (SBP less than 100 mm Hg), see Adult Protocol 2.4.1, Cardiogenic CU
Shock.
• If the patient is experiencing chest pain or discomfort and systolic BP above 100 mm Hg,
administer Nitroglycerin (Nitrostae or Nitrolingual® Spray) 0.4 mg SL; repeat every 3-5
minutes (maximum dose is 1.2 mg or 3 doses).
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 37
Packet Pg. 1991
F.39.a
GUIDELINES
• Do NOT administer Nitroglycerin if:
�Ill��lllllll��l PI�I�I��IIII 4ti�� o SBP less than 100 min Hg.
o Patient taking drug classification phosphodiesterase-5 inhibitor (PDE-5)
o The patient has taken any of the following erectile dysfunction medications. (Note the
following medications are also marketed under a variety of other trade names).
a. Stendra(Avanafil)—in the past 12 hours
b. Viagra(Sildenafil)— in the past 24 hours
c. Levitra(Vardenafil) or Cialis (Tadalafil)—in the last 48 hours
• If pain continues and the patient is normotensive (systolic BP greater than 100 min Hg),
administer
o Morphine 5 mg IVP may repeat once in 5 - 10 min (maximum 10 mg) Titrated to pain and BP Z
greater than or equal to 100 min Hg,up to a maximum of 10 mg. Can also be given IM(Medical 0-
Procedure, Medication Delivery 4.18) U
OR
o Fentanyl may be given 100 mcg increments IN/IM, every 3-5 minutes to a maximum of
200 mcg IN/IM U
OR W
IV dose Imcg/kg SLOW IV increments every 3-5 minutes up to a maximum initial dose of 100
mcg, titrated to pain and BP remains above 100 min Hg. (Medical Procedure, Medication 0
Delivery 4.18).
Second dose if needed, maximum total dose of 200mcg IV/IN/IM.
If Fentanyl was initially given IN/IM and an IV is then established, one IV dose (50mcq) can
be given if needed. N
• Treat dysrhythmia per specific protocol. CN
➢None
U
(a) Allergies to ASA should be suspected in patients with anaphylaxis signs and symptoms (e.g.
Nate flushed itchy skin, increased heart rate, dyspnea, or urticaria). U
(b) Bradycardia with hypotension may be due to an inferior wall MI associated with right ventricular
MI (confirmed on 12-lead ECG by ST elevation in lead V4R); (Adult Protocol 2.3.2, �
Bradycardia). When an inferior wall MI is associated with right ventricular MI, avoid the use of a
nitrates(Nitroglycerin). If bradycardia and hypotension exist,pacing and IV fluids may improve
the patient's hemodynamic status.
c�
(c) AMI is probable when there is:
1. A minimum of lmm ST elevation in two or more related leads on the 12-lead ECG with a
history suggestive of AMI, signs and symptoms regardless of onset time.
2. A "new onset" left bundle branch block (LBBB) on the ECG with signs/symptoms and
history suggestive of AMI.
3. Patients meeting the above criteria should be transported to the nearest cardiac center and
pre-alert the hospital of a Cardiac Alert
(d)Minimize the Cardiac Alert on-scene time to 10 minutes or less.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 38
Packet Pg. 1992
F.39.a
GENERAL GUIDELINES
Hypertensive emergencies are commonly defined as accelerated blood pressures (systolic _greater
General than 220 mm Hg, diastolic greater than 120 mm Hg)with signs and symptoms of end organ failure.
Guidelines Neurologic end-organ damage due to uncontrolled BP may include hypertensive encephalopathy
and cerebral vascular accident. Cardiovascular end-organ damage may include myocardial
ischemia/infarction, acute left ventricular dysfunction, acute pulmonary edema, and aortic
dissection. Other organ systems may also be affected by uncontrolled hypertension,which may lead
to acute renal failure, and eclampsia.
Hypertension is rarely treated in the prehospital setting. Treatment should focus on the patient's 76
presentation and not the blood pressure by itself. Blood pressures that should not be treated in the w
prehospital setting include: 2
• Transient hypertension secondary to pain, anxiety, hypoxia, or drug intoxication. (treatment Z
should be directed at the underlying causes, not antihypertensive mediciations). 0-
• Chronic hypertension. (rapid reduction of blood pressure in asymptomatic patients may cause is
more harm than benefit) <
U)
• Thrombotic stroke. (elevated blood pressure is a normal physiologic response to brain ischemia,
excessively lowering of blood pressure in these patients may extend the area of injury) U
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3: Administer oxygen via nasal cannula at 4 L/min
(use a non-rebreather mask at 15 L/min if SPO2 less than 94%). If the patient is
asymptomatic, contact medical control. CN
cN
Symptomatic patients with accelerated blood pressures should be treated by the appropriate
protocol based on their symptoms.
• Chest pain consistent with myocardial ischemia or infarction, (Angina/AMI Protocol 2.4.2) U
• Shortness of breath with signs and symptoms of acute pulmonary edema, (CHF Protocol 2.2.4) 0
• Patients in the 2nd or 3rd trimester of pregnancy (over 20 weeks) or up to 6 weeks postpartum U
with accelerated hypertension and or seizures (Toxemia of Pregnancy Protocol 2.7.4)
U_
• Labetolol (Normodyne® or Trandate®) 10-20 mg IV over 2 minutes for hypertension not associated
with CVA (a),if available. May repeat in 20 minutes. (0.25mg/kg)
• (a) if available
Note
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 39
Packet Pg. 1993
F.39.a
GENERAL GUIDELINES
General
Guidelines This protocol is used for patients with altered mental status where the etiology is unknown (e.g.,
patients with a history of diabetes; Adult Protocol 2.8.2).
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3: Consider the need for cervical spine
immobilization.
• Consider restraining the patient(Medical Procedure 4.23, Physical Restraints).
• Contact the Poison Information Center (1-800-222-1222).
U
• Obtain 02 Sat above 94% and EtCO2
• Consider the need for an advanced airway (Medical Procedure 4.4) (a). U
• Perform a glucose test with a finger stick(Medical Procedure 4.17). U)
U)
• If blood glucose below 60 mg/dL, refer to Hypoglycemia/Hyperglycemia Protocol 2.8.2.(b) .2
• Administer Naloxone(Narcan) 0.4—2 mg IV/IO, IM, or IN to restore adequate ventilatory effort
and/or improve mental status and-titrate to effect. Usual doses should not exceed 1 Omg, Fentanyl
may require large doses of Naloxone to reverse Fentanyl's effects. (c).
o If administering Naloxone (Narcan)via IN,use concentration 2 mg/2 mL.
(Medical Procedure, Medication Delivery 4.18).
o If administering Naloxone (Narcan)via prepackaged product Nasal Spray
the dose is 4mg/0.1 ml spray IN
• If administering Naloxone (Narcan)via nebulization must use concentration 2 mg/2 mL(add 2 mg Q
of Narcan to 3 mL of saline) and titrate to effect.
• Reevaluate the need for an advanced airway (Medical Procedure 4.4).
Z
➢ None
U
U
Note (a) Use appropriate discretion regarding immediate placement of an advanced airway in patients LO
who may quickly regain consciousness, such as hypoglycemic after administration of DS or U-
opiateoverdose cases after administration of Narcan. If the patient is conscious with control of zi
the airway, oral glucose may be given
(b) To avoid infiltration and resultant tissue necrosis, Dextrose 50% should be given via slow IV
with intermittent aspiration of the IV line to confirm IV patency, followed by saline flush.
(c) Administration of Narcan to patients with chronic use of narcotics may induce withdrawal
and/or violent behavior.
(d) Recent increase of synthetic opioids may require higher initial doses of Naloxone. Consider
starting at 2 mg initial dose.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 40
Packet Pg. 1994
F.39.a
ME I 9MM01
GENERAL GUIDELINES
This treatment protocol is used in conjunction with General Protocol 1.2, Behavioral Emergencies.
General There are many reasons for patient to be impaired or violent like psychiatric, drug overdose, CVA,
Guidelines ETOH, hypoxia, hypoglycemia.
• If patient is violent and an immediate threat to the patient, EMS crew or bystander safety exists,
chemical and/or physical restraint should be used to prevent patient from harming him /herself or
others.
• If patient is not violent, be observant for possibility of violence and avoid provoking patient.
• Particular caution should be exercised when evaluating and treating any patient that was subdued
by a"non-lethal" law enforcement device with pepper spray or taser.
• Typical findings for any violent and/or impaired patient:
o P—Psychological issues
o R—Recent drug/alcohol use z
o I —Incoherent thought process
o O— Off(clothes) and sweating U
o R—Resistant to presence/ dialogue U)
o I —Inanimate objects / shiny/ glass —violent cu
o T—Tough, unstoppable, superhuman strength U
o Y—Yelling
• Excited delirium syndrome is a state in which a person is in a psychotic and extremely agitated
state. Mentally the patient is unable to focus and process any rational thought. The condition is
brought on by overdose on stimulant or hallucinogenic drugs, drug withdrawal, or psychiatric U
patient not taking medication for significant amount of time.
• Typical signs and symptoms to suspect excited delirium are elevated temperature, nudity,profuse
sweating, and change from aggressive behavior to "instant tranquility." These patients should bf C
closely observed for cardiac and respiratory changes. C4
TREATMENT GUIDELINES W
• Initial Assessment Protocol 2.1.1. Monitor the patient's glucose. U
• Follow Medical Supportive Care Protocol 2.1.3 0
• Consult with Law Enforcement about placing patient under Baker Act or Impaired/Incapacitated L)
Persons Act, and refer to the Impaired/Incapacitated Persons Act(see General Protocol 1.2).
• Rule out non-psychiatric causes e. drug overdose CVA ETOH h oxia hypoglycemia). U_
( g�� g yp �
• Apply Sp02 and administer oxygen to maintain Sp02 greater than or equal to 94%.
• Perform glucose test with finger stick. E
• Obtain body temperature.
• If appropriate, consider physically restraining patient.(Medical Procedure 4.23, Physical <
Restraints).
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 41
Packet Pg. 1995
F.39.a
999mil
TREATMENT GUIDELINES
.�. u� • If patient has elevated temperature above 100 degrees, consider cooling patient using cold packs
to patient's head, axilla and groin; if surface is ineffective consider cold fluid challenges of
500mL normal saline in increments, to a maximum of 30mL/kg to a maximum of 2 liters (goal
temperature less than 100 degrees F).
• Administer Ketamine 4mg/kg IM, or 2mg/kg IN (concentration 100mg/mL). May be repeated in 20
minutes if desired effects are not met.
OR
• Consider administration one of the following benzodiazepines: (Medical Procedure, Medication 0
Delivery 4.18) 2
o Diazepam (Valium®) 5 mg IV, IM or IN; may repeat to a max of 20 mg (a) (b).
U
OR U
o Midazolam (Versed) 2 mg increments IV, IO, or IN, up to a maximum dose of 10 mg (a).
OR U
o Lorazepam (Ativan®) 2 mg IV, IM, or IN; may repeat once (maximum dose of 4 mg)(a)
OR
• Administer Haloperidol (Haldol®) 5 mg IM or IV (a) (c).if available; Administer Haloperidol with
Diphenhydramine (Benadryl) 50 mg IM or SLOW IV.
i
• Initiate cardiac monitoring. N
• Once patient has been sedated establish an IV; give normal saline wide open. N
• Treat dysrhythmias per specific protocol (see Adult Protocol 2.3).
• Expedite transport— Transport Code 3 to closest appropriate facility.
w
➢ None z
U
Noe (a) In some instances, IV administration may present a safety concern; in this case, IM or IN
administration of sedatives may be the more desirable route. U-
c�
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 42
Packet Pg. 1996
F.39.a
GENERAL GUIDELINES
This protocol should be used when the patient has witnessed, continuous convulsions (generalized
General tonic-clonic seizure or grand mal)or repeating episodes without regaining consciousness or sufficient
Guidelines respiratory decompensation. Consider the underlying etiology, such as hypoglycemia, drug overdose,
head injury, or fever. Other types of seizures include absence (petit mal), simple partial (focal motor
and Jacksonian), complex partial (psychomotor or temporal lobe), atonic (drop attacks), and
myoclonic. When the patient is continuously showing signs of these other types of seizures, Medical
Supportive Care Protocol 2.1.3 should be initiated and the paramedic should contact medical control
for further direction.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1. 2
Z
• Medical Supportive Care 2.1.3. t)
0-
U
• If the patient is an eclamptic female, administer Magnesium Sulfate 4 g IV(mixed in 50 mL
cu
or 100 mL of D5W given over 5-10 minutes). (Toxemia of Pregnancy Protocol 2.7.4) (a). F3
• Administer one of the following benzodiazepines: (Medical Procedure 4.18, Medication
Administration)
o Midazolam (Versed) 10 mg Intranasal as first line (5 mg/mL concentration only).
Alternatively Midazolam (Versed) 5-10 mg increments IV, IO, IM every 3 - 5 minutes to a
maximum dose of 10 mg. (b)
N
N
OR N
o Diazepam (Valium®) 5 mg IV, IO, IM or IN; may repeat once, up to a max dose of 10
mg.(b) W
Z
OR
o Lorazepam (Ativan®) 2 mg IV, IO, IM, or IN; may repeat once as needed, up to a t-
maximum dose of 4 mg. (b) U
LO
• Perform a glucose test with a finger stick (Medical Procedure 4.17). If glucose is less than
60 mg/dL, refer to Hypoglycemia/Hyperglycemia 2.8.2. 4,
c�
P ➢ For additional benzodiazepine contact Medical Control
all
Note (a) Females in their second or third of pregnancy (over 20 weeks gestation) who are seizing
should be assumed to have eclampsia. It should also be noted that eclampsia can occur
postpartum (up to 6 weeks postpartum).
(b) For IN administration, administer lml per nare, give half the volume in one nostril and the
other half of the volume in the other nare.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 43
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F.39.a
GENERAL GUIDELINES
This protocol is used for those patients exhibiting signs consistent with acute stroke/cerebrovascular
accident(CVA)/"brain attack," such as altered mental status, slurred speech, loss of function of any
General body part, hemiplegia, loss of vision, weakness of facial muscles, loss of sensation, and drooling.
Guidelines Other causes should be ruled out (e.g., hypoglycemia, drug overdose, hypoxia).
History Signs and Symptoms Differential Diagnosis
Previous stroke/TIA Impaired understanding of speech TIA
Previous neurological deficit Aphasia/dysarthria Weakness Seizure
/hemiparesis Hypoglycemia
Hypertension Facial droop Drug ingestion
Heart disease Poor coordination/balance Tumor
Diabetes Loss of peripheral vision Trauma
Anticoagulant medications Syncope, dizziness/vertigo Stroke: Z
Family history Headache, vomiting, stiff • Ischemic 0
neck seizures U
Smoking • Hemorrhagic U)
2
STROKE ALERT INCLUSION CRITERIA
• Utilize the Rapid Arterial occlusion Evaluation (RACE) scale (Appendix 6.20 or online
forms).
• Time last seen normal is less than 24 hours (Includes Wake Up Stroke)
• Deficit not likely due to head trauma, TIA or stroke mimic.
• Blood glucose is greater than 60 OR symptoms don't resolve after correction of BGL.
• Paramedic judgment; altered mental status, vision (loss of vision or double vision), loss N�
of sensation,poor coordination &balance, severe headache, nausea&vomiting,
dizziness/severe vertigo, dysarthria/expressive aphasia.
TREATMENT GUIDELINES Z
• Initial Assessment Protocol 2.1.1. U
0-
• Determine and document the time of onset of stroke symptoms, defined as "the last time the 0
patient was seen without symptoms". If possible, get the witness name and contact numbers.
• If stroke is suspected, complete the RACE scale (Appendix 6.20 or online forms) to
determine if the patient meets criteria for Stroke Alert. (a) (b)
• Limit Stroke Alert on scene time and transport the patient to the closest appropriate stroke
center.
• If the patient is unconscious position the patient with head elevation of 30 degrees, unless
the patient cannot tolerate this position. supine,
• Administer oxygen according to following criteria:
o SP02 94% or above do not administer 02.
o SP02 less than 94% administer 02 by nasal cannula at 2 L/min.
o If SP02 cannot be maintained at 94%with nasal cannula at 2 L/min and/or the patient is
in respiratory distress, administer high-flow 02 and assist ventilations with a bag-valve
mask if indicated.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 44
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F.39.a
HIM
TREATMENT GUIDELINES
• If the patient has a decreased level of consciousness and does not have an intact gag reflex, insert
an advanced airway (Medical Procedure 4.4), confirm tube placement and oxygenation, and
monitor ventilations with EtCO2.
• Establish IV access; give normal saline KVO.
• Perform a glucose test with a finger stick (Medical Procedure 4.17). If glucose is less than 60
mg/dL, refer to Hypoglycemia/Hyperglycemia 2.8.2.
• If drug overdose is suspected, refer to Adult Protocol 2.6, Adult Toxicologic Emergencies.
• Perform a neurological exam, including assessment of the patient's level of consciousness,
Glasgow Coma Scale (GCS) score, and RACE scale score.
• Contact the stroke center, and advise its personnel of the time of symptom onset, baseline
neurological examination findings, including the RACE scale and any changes found in
reassessment. (b) U
0-
0
U
U)
U)
➢ Elevated blood pressure is commonly present with stroke. Severely elevated blood pressure en
cn
may be lowered with a physician order (Hypertensive Emergencies 2.4.3).
Note (a) Minimize the Stroke Alert on-scene time to 10 minutes or less. �
(b) Continually reassess the patient to determine if his/her symptoms are worsening or improving,
and advise the stroke center of any changes. C�
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U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 45
Packet Pg. 1999
F.39.a
III
GENERAL GUIDELINES
This protocol should be used for patients with a chief complaint of syncopal episode. Consider the
General Guidelines patient's history and the possibility of medication side effects, glucose imbalance, inner ear
disorders, CVA, TIA, and MI.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3 (refer to other protocols as appropriate): Treat the _
underlying cause, if it can be determined.
• All patients with a known syncopal episode, or a syncopal episode that was witnessed by
a reliable source, should be transported to the hospital via ambulance.
z
U
• Perform a 12-lead ECG. If an inferior wall MI is identified,perform an additional 12-lead
ECG with V4R to confirm/rule out concurrent right ventricular MI. Transmit the 12-lead U)
ECG results to the destination hospital, if possible (a). If acute coronary syndrome is U)
suspected, see Adult Protocol 2.4.2.
➢ None
c�
i
Note (a) Bradycardia with hypotension may be due to inferior wall MI associated with right ventricular `4
MI (confirmed on the 12-lead ECG by ST elevation in lead V4R); see Adult Protocol 2.3.2, C4
Bradycardia. When an inferior wall MI is associated with right ventricular MI, avoid the use
of nitrates (Nitroglycerin). If bradycardia and hypotension exist, pacing and IV fluid may
improve the patient's hemodynamic status.
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 46
Packet Pg. 2000
F.39.a
1
GENERAL GUIDELINES
This protocol is to be used for those patients suspected of exposure to toxic substances via any
General route of exposure (e.g., drug overdose, snake bite). The protocols give specific considerations for
Guidelines each type of exposure as well as general treatment guidelines. Additional assistance may be
necessary in certain cases (e.g., hazardous materials team for toxic exposure or police for scene
control, including management of a violent and/or impaired patient; see Adult Protocol 2.5.2). If
the toxic substance is unknown or cannot be readily determined,see Adult Protocol 2.6.7 Unknown
Toxicity
A history of the events leading to the illness or injury should be obtained from the patient and 3:
bystanders:
1. To which drugs,poisons,or other substances was the patient exposed? Consider exposure U
to multiple substances, especially on overdoses. 0
2. What was the route of exposure? U
3. When did the exposure occur, and how much exposure was there? U)
4. What is the duration of symptoms? U)
5. Is the patient depressed or suicidal? Does he/she have a history of previous overdose (if L)
applicable)?
6. Was the exposure accidental? What was the nature of the accident?
7. What was the duration of exposure (if applicable)?
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Collect all pill bottles, empty or full, and check for"suicide notes" (if applicable). Transport any/all
information or items that may assist in the treatment of the patient to the emergency department.
N
N
Contact the Poison Information Center (1-800-222-1222) for consultation regarding specific cJ
therapy.
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 47
Packet Pg. 2001
F.39.a
GENERAL GUIDELINES
This protocol includes the treatment for snake bites, dog and cat bites, insect stings, and marine
General animal envenomations and stings. All bite victims should be transported to the hospital. Contact the
Guidelines Poison Information Center (1-800-222-1222) for treatment and transport decision and consultation
in all cases involving bites and stings.
TREATMENT GUIDELINES
• Initial Assessment 2.1.1
• Trauma Supportive Care Protocol 2.1.4.
• Contact the Poison Information Center(1-800-222-1222).
• See General Protocol 1.12, Infectious Disease Exposure and 1.10.1 Exposure Reference
Sheet if needed z
U
SNAKE BITES U
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis.
• Splint the affected area.
• Place the patient supine, with extremities kept at a neutral level. U
• Keep patient quiet.
• Remove and secure all jewelry.
• Wash the area of the bite with copious amounts of water.
• Attempt to identify the snake, if it is safe to do so.
• Check the patient's temperature and pulse distal to the bite on an extremity, and mark the level
of swelling and time with pen every 15 minutes. Ni
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DOG, CAT,AND WILD ANIMAL BITES
• Wound care: BLS (do not use hydrogen peroxide on deep puncture wounds or wounds
exposing fat). Clean the wound area with soap and water.
• Advise dispatch to contact animal control and the police department for identification and w.
quarantine of the animal. <
z
INSECT STINGS (INCLUDING CENTIPEDES, SCORPIONS,AND SPIDERS) t-
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis. U
• Remove the stinger by scraping the patient's skin with the edge of a flat surface (e.g., a credit
card). Do not attempt to pull the stinger out, as this action may release more venom. U-
• Clean the wound area with soap and water.
a�
MARINE ANIMAL ENVENOMATIONS: STINGRAY, SCORPIONFISH (LIONFISH,
ZEBRAFISH, STONEFISH), CATFISH,WEEVERFISH, STARFISH, SEA URCHIN
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis.
• Immerse the punctures in nonscalding hot water to tolerance(110-113°F)to achieve pain relief
(30-90 minutes). Transport should not be delayed for this measure; immersion in nonscalding
hot water may be continued during transport.
Remove any visible pieces of the spine(s) or sheath. Gently wash the wound with soap and
water, and then irrigate it vigorously with fresh water(avoid scrubbing).
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 48
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F.39.a
TREATMENT GUIDELINES
MARINE ANIMAL STINGS: JELLYFISH, MAN-OF-WAR, SEA NETTLE,
IRUKANDJI,ANEMONE, HYDROID, FIRE CORAL
• Consider the need for Adult Protocol 2.8.1, Allergic Reactions/Anaphylaxis.
• Rinse the skin with sea water. (Do not use fresh water; do not apply ice; do not rub the skin.)
• Apply soaks of acetic acid 5% (vinegar) until the pain is relieved. If vinegar is not available,
use a paste of baking soda or unseasoned meat tenderizer.
• Remove large tentacle fragments using forceps (use gloves to avoid contact with your bare
hands). �
• Apply a lather of shaving cream or a paste of baking soda, and shave the affected area with the
edge of a flat surface (e.g., a credit card).
• Apply Zerym Spray if agency available U
0-
HUMAN BITES U
• Wound care: BLS (do not use hydrogen peroxide on deep puncture wounds or wounds
exposing fat). Clean the wound area with soap and water. U)
• Consider contacting the police department for investigation
LL
• Refer to Adult Protocol 2.1.5 for pain management guidelines.
• Consider OTC formulation for symptom relief(i.e. Zerym) (a)
a�
CN
i
➢ None Q
Note
(a) Caution to patient of known mesothelioma
Z
U
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LO
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 49
Packet Pg. 2003
F.39.a
GENERAL GUIDELINES
Benzodiazepines are used for anxiety, seizures, insomnia, agitation, muscle spasms, and alcohol
withdraw. Sedative hypnotics are used for inducing sleep. Signs and symptoms of overdose include:
• Altered mental status
• Slurred speech
• Hypotension
• Coma
• Dilated pupils (benzodiazepines)
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3 (refer to other protocols as appropriate): Treat the U
underlying cause, if it can be determined. 0-
0
• Contact Poison Information Center(1-800-222-1222) for consultation. U
• Obtain Pulse oximetry reading and administer oxygen as needed. Sp02 readings less than or
equal to 94%require oxygenation, or if indicated, assist with BVM ventilations. U)
U
• Consider the need for an advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick(Medical Procedure 4.17).
• If glucose is less than 60 mg/dL, refer to Adult Protocol 2.8.2 Hypoglycemia/Hyperglycemia.
• If the patient is seizing, administer one of the following benzodiazepines: (Medical
Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, I0, or IN; may repeat once, up to a max dose of 10 mg. C�
OR Q
o Midazolam (Versed) 2 mg increments IV, I0, IM or IN(IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR Z
o Lorazepam (Ativan) 2 mg IV, I0, IM or IN; may repeat once, up to a max dose of 4 mg. W
• If the patient is hypotensive (systolic BP less than 90 mm Hg), administer a fluid challenge of
500mL. U
• If the patient is combative, consider the need for physical and chemical restraints (Adult 0
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical W
Restraints).
LL
➢ None a
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 50
Packet Pg. 2004
F.39.a
r
GENERAL GUIDELINES
Signs and symptoms of opioid and narcotic overdose include:
• Altered mental status
General . Respiratory depression
Guidelines p Y p
• Constricted pupils
• Hypotension
• Bradycardia
• Coma
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3
• Contact Poison Information Center(1-800-222-1222) for consultation.
• Obtain Pulse oximetry reading and administer oxygen as needed. Sp02 readings less than or Z
equal to 94%require oxygenation, or if indicated, assist with BVM ventilations. U
0-
U
• Consider the need for an advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick(Medical Procedure 4.17). U
• If glucose is less than 60 m /dL Adult Protocol 2.8.2 Hypoglycemia/Hyperglycemia.
g g
• Administer Narcan 0.4-2 mg IV/IO, ITV, or IN(c),titrated to effect.Usual dose should not exceed _
10mg. Fentanyl may require large doses of Naloxone to reverse Fentanyl's effects. Narcan can
also be administered via nebulization(add 2 mg of Narcan to 3 mL of saline)and titrated to effect.
(Medical Procedure, Medication Delivery 4.18).
• If the patient is experiencing chest pain, Adult Protocol 2.4.2, Angina/Suspected AML
i
• If the patient is seizing, administer one of the following benzodiazepines: (Medical Procedure, 'cl
Medication Delivery 4.18) N
o Diazepam (Valium) 5 mg IV, I0, IM or IN; may repeat once, up to a max dose of 10 mg.
OR w
o Midazolam (Versed) 2 mg increments IV, I0, IM or IN (IN concentration 10mg/2ml) w
maximum dose of 10 mg.
OR Z
o Loraze am Ativan 2 m IV IO IM or IN; may repeat once a to a max dose of 4 m t-
p ( ) g Y p � p g�
• If the patient is hypotensive (systolic BP less than 100 mm Hg), administer a fluid challenge of U
500mL.
• If the patient is combative, consider the need for physical and chemical restraints (Adult
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical
Restraints).
➢ None
Note (a) Use appropriate discretion regarding immediate intubation of patients who may quickly regain
consciousness following treatment.
(b) If patient is a suspected opioid addict, the administration of Narcan should be titrated to increase
respirations to normal levels without fully awakening patient to prevent hostile and
confrontational episodes. Consider restraining patient. Narcan may need to be repeated in 20-30
minutes to maintain effect.
(c) If administering Naloxone (Narcan)via prepackaged product Nasal Spray then the dose is
4mg/0.1 ml spray IN.
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 51
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F.39.a
GENERAL GUIDELINES
Signs and symptoms of CNS stimulant overdose include dilated pupils, agitation,paranoia,bizarre
General behavior, PVC, tachycardia, hypertension, hyperthermia, and seizures. The following is a partial
Guidelines list of CNS stimulants.
GUIDELINESTREATMENT
• Initial Assessment Protocol 2.1.1. 2
• Medical Supportive Care 2.1.3. Z
• Contact the Poison Information Center(1-800-222-1222). 0-
0
U
• If the patient is experiencing chest pain, see Adult Protocol 2.4.2, Chest Pain/Suspected AML U)0 Establish IV access; give normal saline.
• If the patient is seizing, administer one of the following benzodiazepines: (Medical Procedure, en
Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, IM or IN; maximum dose of 10 mg.
OR
o Midazolam (Versed) 5-10 mg increments IV, IO, IM or IN(IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR Ni
o Lorazepam (Ativan) 2 mg IV, IO, IM or IN; may repeat once, up to a max dose of 4 mg. Q
• If the patient is hyperthermic (hot to the touch), aggressively cool the patient.
• If the patient is combative, consider the need for physical and chemical restraints (see
Adult Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Z
Physical Restraints).
d
U
➢ Treat tachydysrhythmias as per physician order.
U
Note (a) Beta blockers are contraindicated in cocaine overdose.
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 52
Packet Pg. 2006
F.39.a
GENERAL GUIDELINES
Digitalis toxicity should be suspected in patients who are taking digitalis and have signs and
General symptoms associated with digitalis toxicity - for example, bradycardia, AV blocks with rapid
Guidelines ventricular response, supraventricular tachycardias, ventricular ectopy, and other ECG changes:
wide PR interval greater than 0.20, short QT interval (rate dependent), spoon-shaped ST segment,
peaked T wave. Contact with the oleander tree can also cause a digitalis-type toxicity, which will
cause the same type of dysrhythmias and requires the same treatment.
DIGITALIS: GENERIC NAME(TRADE NAME)
digoxin (Lanoxicaps, Lanoxin, Digoxin) digitoxin (Crystodigin)
a�
TREATMENT
GUIDELINES
U
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3. U
• Contact the Poison Information Center(1-800-222-1222). �
U)
M
U
• Treat tachydysrhythmias with medication per specific protocol (Adult Protocol 2.3).
Avoid the use of Calcium Chloride.
• If unstable tachycardia(heart rate greater than 150 beats/min),synchronize and cardiovert.
Energy settings for synchronized cardioversion should be in the range of 5-20 joules.
• If the patient has unstable bradycardia with wide QRS (greater than 0.12 seconds), 0
administer Sodium Bicarbonate 1 mEq/kg IV. Wi
N
cN
➢ None
Note
U
CL
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 53
Packet Pg. 2007
F.39.a
1 IN
GENERAL GUIDELINES
This protocol includes the hallucinogenic drugs: LSD (acid, microdot), mescaline and peyote
General (mesc, buttons, cactus), and similar agents (e.g., DET, EMT, psilocybin). Signs and symptoms of
Guidelines hallucinogen overdose include illusions and hallucinations, poor perception of time and distance,
possible paranoia, anxiety, panic, unpredictable behavior, emotional instability, possible
flashbacks, dilated pupils, and rambling speech.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3: "Talk down" the patient.
• Contact the Poison Information Center(1-800-222-1222).
Z
U
• Consider the need for ventilation assistance and advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick. If glucose is less than 60 mg/dL, see Adult Protocol U
2.8.2, Hypoglycemia/Hyperglycemia. U)
• If respiration is depressed, administer Narcan 0.4- 2 mg IV/IO, IM, or IN (c), titrated to effect.
Usual dose should not exceed 10mg. Fentanyl may require large doses of Naloxone to reverse
Fentanyl's effects. Narcan can also be administered via nebulization(add 2 mg of Narcan to 3 mL
of saline) and titrated to effect. (Medical Procedure, Medication Delivery 4.18).
If administering Naloxone (Narcan) via prepackaged product Nasal Spray
the dose is 4mg/0.1 ml spray IN.
• If the patient is experiencing chest pain, see Adult Protocol 2.4.2, Angina/Suspected AML
• If the patient is seizing, administer one of the following benzodiazepines: (Medical Procedure,
Medication Delivery 4.18) Q
o Diazepam (Valium) 5 mg IV, IO, IM or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 5-10 mg increments IV, IO, IM or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, IO, IM or IN; may repeat once, up to a max dose of 4 mg. is
• If the patient is combative, consider the need for physical and chemical restraints (Adult o
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical W
Restraints).
LL
➢ Treat tachydysrhythmias as per physician order.
➢ Additional benzodiazepine
Note (a) Use appropriate discretion regarding immediate placement of an advanced airway in patients
who may quickly regain consciousness, such as hypoglycemics after D5o administration or
opiate overdose patients after Narcan® administration.
(b) If the patient is a suspected opioid addict, the administration of Narcan® should be titrated to
increase respiration to normal levels without fully awakening the patient, so as to prevent
hostile and confrontational episodes. Consider restraining the patient(Medical Procedure 4.23,
Physical Restraints).
51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 54
Packet Pg. 2008
F.39.a
GENERAL GUIDELINES
Universally found EKG cases in all three classifications include:
General Wide QRS complex greater than 0.12 seconds R waves in lead aVR
Guidelines ST and T wave changes S waves in lead aVL and lead I
Barbiturates are used as sleep aids, antianxiety medications, and anticonvulsants. Signs and
symptoms of overdose include:
Lethargy Hypotension
Altered mental status Coma
Respiratory depression
Tricyclic antidepressants are used as antidepressants. Signs and symptoms of overdose include: 2
CNS depression Slurred speech
Tachycardia Twitching and jerking
Dilated pupils Seizures is
Respiratory depression Hypotension/hypertension
U)
U)
Selective Serotonin Reuptake Inhibitors (SSRI)is used as antidepressants, antianxiety U
medications, and personality disorders. Signs and symptoms of overdose include:
Agitation Hypotension/hypertension
Nausea and vomiting Seizures
Muscluar rigidity Tachycardia
Teeth chattering Hallucinations
Dilated pupils Hyperthermia
N
c�
N
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 55
Packet Pg. 2009
F.39.a
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care 2.1.3: "Talk down" the patient.
• Contact the Poison Information Center(1-800-222-1222).
• Obtain pulse oximetry reading and administer oxygen as needed. Sp02 readings less than or
equal to 94%require oxygenation, or if indicated, assist with BVM ventilations.
• Consider the need for ventilation assistance and advanced airway (Medical Procedure 4.4) (a).
• Perform a glucose test with a finger stick. If glucose is less than 60 mg/dL, see Adult Protocol
2.8.2, Hypoglycemia/Hyperglycemia.
• Perform 12 lead, if QRS is greater than 0.12 seconds, Sodium Bicarbonate 1 mEq/kg IV. 2
• If the patient is seizing, administer one of the following benzodiazepines: (Medical Procedure, L)
Medication Delivery 4.18) 0
o Diazepam (Valium) 5 mg IV, I0, IM or IN; may repeat once, up to a max dose of 10 mg.
OR
o Midazolam (Versed) 5-10 mg increments IV, I0, IM or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg.
OR
o Lorazepam (Ativan) 2 mg IV, I0, IM or IN; may repeat once, up to a max dose of 4 mg.
• If the patient is combative, consider the need for physical and chemical restraints (Adult 60
Protocol 2.5.2, Violent and/or Impaired Patient, and Medical Procedure 4.23, Physical
Restraints).
N
i
c14
C14
➢ None
Note
U
CL
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 56
Packet Pg. 2010
F.39.a
GENERAL GUIDELINES
General This protocol is to be used for those patients suspected of exposure to toxic substances via any
Guidelines route of exposure, where the toxic substance is unknown or cannot be readily determined.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3. If the patient has an altered mental status, dyspnea,
or SP02 is less than 94%, administer oxygen to maintain Sp02 at or above 94%.
• If the patient has an altered mental status, see Adult Protocol 2.5.1.
If bronchospasm is present, administer Albuterol (Ventolin®): one nebulizer treatment i
containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline (Medical Procedure 0
4.18.6). This treatment may be repeated twice as needed (a). u
• If Albuterol is administered, may add Ipratropium Bromide (Atrovent®) 0.5 mg (0.5 mL) to
the Albuterol nebulizer treatment.
• Treat dysrhythmias with medication per specific protocol (Adult Protocol 2.3).
• If the patient has unstable bradycardia with wide QRS (greater than 0.12 second), administer
Sodium Bicarbonate 1 mEq/kg IV (Adult Protocol 2.6.6). U-
lf the patient is hypotensive and not in pulmonary edema, administer a fluid challenge of 00
normal saline 500 mL IV (Adult Protocol 2.4.1).
• If the patient is seizing, administer one of the following benzodiazepines: (Medical Procedure,
Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, I0, IM or IN; may repeat once, up to a max dose of 10 mg. Q
OR
d
o Midazolam (Versed) 5-10 mg increments IV, I0, IM or IN (IN concentration 10mg/2ml)
maximum dose of 10 mg. Z
OR W
o Lorazepam (Ativan) 2 mg IV, I0, IM or IN; may repeat once, up to a max dose of 4 mg.
u
u
oil U-
➢ None
Note
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 57
Packet Pg. 2011
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GENERAL GUIDELINES
The paramedic should use these protocols to guide him/her through the treatment of patients who
General are pregnant. These protocols cover complications of pregnancy and normal and abnormal labor
Guidelines delivery. In addition to these protocols, the paramedic may need to refer to other protocols (e.g.,
protocols for seizures). The assessment of these patients should follow the normal approach to
patient assessment as well as ask specific questions related to the history of the pregnancy.
Questions for pregnancy history include:
1. Number of previous pregnancies (gravida). _
a. Miscarriages.
2. Number of previous live births (para).
3. Expected date of delivery or due date. '
4. When did contractions begin? Z
5. Any history of labor complications?
a. Premature births? U
U
b. C-section?
c. Multiple births? U)
6. What are the duration and frequency of contractions? U
a. Duration is timed from when the contraction starts to when the contraction stops (e.g.,
45 seconds, 1 minute).
b. Frequency is timed from the beginning of one contraction to the beginning of the next
contraction (e.g., 2 minutes apart, 4 minutes apart).
7. Evidence of blood show or spotting?
8. Did the water break?
a. When?
N
N
b. What was the color (e.g., clear, greenish, brownish)? N
C. Did it have an unusual odor?
9. Does the patient have an urge to push?
10. Does the patient feel like she has to move her bowels? If the patient complains of uterine W
contractions, an external visual examination for crowning should be done to determine if the
delivery is imminent. Z
U
U
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51 Edition Version 1,February 2017 Florida Regional Common EMS Protocols 58
Packet Pg. 2012
F.39.a
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4. Notify the nearest appropriate OB-capable hospital
early and prepare for transport to an OB-capable hospital.
PROLAPSED CORD
• Place the mother in a knee-chest position or supine position with pillows under the buttocks.
• Do not attempt to push the cord back. Wrap the cord in a warm, sterile-saline-soaked dressing.
• With a gloved hand,palpate the cord for a pulse.
• If a pulse is absent in the umbilical cord, and positioning of the mother does not restore the
pulse, insert a gloved hand into the vagina and lift the fetal head, or other presenting part, off 0a
of the umbilical cord while gently pushing the fetus into the uterus. With the other hand,press t
on the lower abdomen in an upward or cephalic direction. Push the fetus back only far enough 'U
to regain a pulse in the umbilical cord. 0-
• Transport immediately,while maintaining fetal position so as to maintain umbilical pulse. U
d
U)
BREECH BIRTH U)
• Do not pull on the newborn. Allow the delivery to proceed normally, supporting the U
newborn with the palm of your hand and arm, and allowing the head to deliver.
• If the head does not deliver within 3 minutes,place a gloved hand in the vagina with your _
palm toward the newborn's face. Form a"V"with your index and middle fingers on either
side of the newborn's nose, and push the vaginal wall away from the newborn's face to
create an airspace for the newborn until delivery of the head. Suction may be provided as
needed.
i
• Transport immediately, while maintaining the airspace for the newborn. N
N
LIMB PRESENTATION
• Place the mother in either a knee-chest position or a supine position with pillows under
the buttocks. z
• Transport immediately.
SHOULDER DYSTOCIA U
• Determine the presence of shoulder dystocia as follows: The newborn's head will deliver
normally, and then it will retract back into the perineum because the shoulders are trapped
between the symphysis pubis and the sacrum (the "turtle sign").
• If this occurs, do not pull on the newborn's head. U_
• Have the mother drop her buttocks off the end of the bed and flex her thighs upward to
facilitate delivery. E
• Apply firm pressure with an open hand immediately above the symphysis pubis.
• If delivery does not occur, transport immediate) .
• None
➢ None
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GENERAL GUIDELINES
General This protocol should be used when the paramedic encounters an imminent delivery prior to
Guidelines arrival at the hospital. Imminent delivery is evidenced by crowning at the vaginal opening.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4. Notify the nearest appropriate OB-capable hospital
early and prepare for transport.
• Place the mother in a comfortable, supine position.
• Prepare the OB kit. (Also have a pediatric kit on standby.)
• Gently and carefully assist expulsion of the newborn from the birth canal in its natural descent. U
Do not pull or push the newborn. 0
• Upon complete presentation of newborn's head: U
o Instruct the mother to stop pushing. U)
o Inspect and palpate the newborn's neck for the umbilical cord. If it is present, carefully 2
unwrap the cord from the neck. If unable to remove the cord, apply two umbilical clamps
and cut between the clamps to release the cord.
o Once the newborn's cord is free from around its neck, instruct the mother to push on her
next contraction to complete delivery.
• Upon complete delivery of the newborn:
o Keep the newborn at the level of the placenta (vagina) to prevent over - or under- 0
transfusion of blood from the cord. Wi
o Never "milk" the cord, after infant delivery wait at least 30 seconds up to 3 minutes Q
or until the cord stops pulsatinI to clamp/cut the cord. Apply two umbilical cord
clamps (2 inches apart and at least 8 inches from the navel), and then cut the cord
between the clamps.
o Avoid holding the newborn by the legs, allowing the head to hang below the body, as this W
may cause cerebral hemorrhage to occur. <
o Only if the airway is compromised (obstructed), gently suction the newborn's mouth and Zu
nose with the bulb syringe. 0
o If meconium is noted in the airway, see Pediatric Protocol 3.4.1, Newborn Resuscitation. U
o Dry and wrap the newborn in a blanket to preserve body heat. Be sure to cover the
newborn's head, as this is a major area of heat loss. 11-
• Evaluate the newborn:
a�
o If the newborn is not breathing, see Pediatric Protocol 3.4.1, Newborn Resuscitation. E
o Evaluate the APGAR scores at 1 and 5 minutes (Appendix 6.3).
o If APGAR score is less than 7, see Pediatric Protocol 3.4.1, Newborn Resuscitation.
• Following delivery of the newborn, the mother's vagina will continue to ooze blood. Do not
pull on the umbilical cord.
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TREATMENT GUIDELINES
• If active hemorrhage is noted from the vagina, apply firm continuous massage manually
to the uterine fundus. If the mother wants to breastfeed, encourage her to do so; this will
aid in the contraction of the uterus,which will help stop the bleeding and facilitate delivery
of the placenta. (Do not attempt to examine the patient internally. Never pack the vagina
to stop bleeding.) Apply a sanitary napkin to the vaginal opening.
• If the placenta does deliver,preserve it in a plastic bag and transport it with the mother. It
is not necessary to delay transport to wait for the placenta to deliver.
After delivery of the placenta, clean the perineal area and remove soiled drop sheets from
under the mother's buttocks. Visually inspect the perineal area for tears. If active bleeding
is present, apply direct pressure with sterile gauze. Apply a sanitary napkin to vaginal
opening. Z
U
U
➢ Administer Nitronox for pain control during a normal, uncomplicated delivery (Medical U)
Procedure 4.20) )
c�
Note
c°N
cN
CN
U
CL
LO
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GENERAL GUIDELINES
This protocol should be used for female patients who may or may not be pregnant and who present
General with nontraumatic vaginal bleeding. Examples of causes include antepartum hemorrhage
Guidelines (abruption placenta, placenta previa, and uterine rupture), postpartum hemorrhage, ruptured
ectopic pregnancy, ruptured ovarian cyst, and spontaneous abortion.
TREATMENT GUIDELINES
� � • Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Place all products of delivery (e.g., undeveloped fetus, placenta) in a plastic bag and
transport with the patient to the hospital.
z
U
CL
°" • If the patient is hypotensive (systolic BP less than 100 mm Hg), administer a fluid U
challenge of 500 mL to start. Repeat as needed. U)
L)
➢ None
c�
Note
cN
i
cN
cN
U
CL
c�
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mmmmolqi
GENERAL GUIDELINES
This protocol should be used for the patient in her second or third trimester of pregnancy (above
General 20 weeks gestation) who is exhibiting signs of pre-eclampsia or eclampsia. The signs of toxemia
Guidelines include proteinuria (dark-colored urine), excessive weight gain, and hypertension. The presence
of two of these signs constitutes pre-eclampsia; the presence of all three constitutes eclampsia.
The seizing patient in her second or third trimester of pregnancy should be assumed to be
eclampsic and treated as specified below. However, consideration of another underlying etiology,
such as hypoglycemia, drug overdose, head injury, or fever, should also be considered. Eclamptic
seizures can also occur postpartum (< 6 week after giving birth). Witnessed continuous
convulsions (generalized tonic-clonic seizure or grand mal) or repeating episodes without
regaining consciousness or sufficient respiratory decompensation demonstrate a need for 0
immediate treatment. 2
Z
TREATMENT n i U
U
� � • Initial Assessment Protocol 2.1.1.
U)
• Trauma Supportive Care 2.1.4. U)
U
°" • If the patient is seizing, administer Magnesium Sulfate 4 g IV (mixed in 50 in or
mL of D5W given over 5-10 minutes). May repeat once at 2 g IV (mixed in 50 mL or
a�
100 mL of D5W given over 5-10 minutes) as needed.
a�
i
• If the patient continues to seize, administer one of the following benzodiazepines. N
(Medical Procedure, Medication Delivery 4.18)
o Diazepam (Valium) 5 mg IV, IO, IM or IN; maximum dose of 10 mg.
OR w
Z
o Midazolam (Versed) 5-10 mg increments IV, IO, IM or IN (IN concentration 10mg/2ml
maximum dose of 10 mg.
OR U
c,
o Lorazepam (Ativan) 2 mg IV, IO, IM or IN; may repeat once, up to a max dose of 4 mg.
• Perform a glucose test with a finger stick(Medical Procedure 4.17) if glucose is less than U
60 mg/dL refer to Hypoglycemia/Hyperglycemia Protocol 2.8.2.
LL
➢ None
c�
Note
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IN
GENERAL GUIDELINES
This protocol should be used for patients exhibiting signs and symptoms consistent with allergic
General reaction, as follows:
Guidelines • Skin: flushing, itching, hives, swelling, cyanosis.
• Respiratory: dyspnea, sneezing, coughing,wheezing, stridor, laryngeal edema, laryngospasm,
bronchospasm.
• Cardiovascular: vasodilation, increased heart rate, decreased blood pressure.
• Gastrointestinal: nausea/vomiting, abdominal cramping, diarrhea.
• CNS: dizziness, headache, convulsions, tearing.
Treatment is outlined here according to the severity of the allergic reaction (mild, moderate, and 0a
severe or anaphylaxis). 2
Z
U
MILD REACTIONS
These reactions consist of redness and/or itching, stable vital signs with a systolic BP greater U
than 100 mm Hg without dyspnea. U)
MODERATE REACTIONS U)
These reactions are evidenced by edema,hives,dyspnea,wheezing,"lump in throat"feeling,
difficulty swallowing, facial swelling, and stable vital signs with a systolic BP greater than
100 mm Hg.
SEVERE REACTIONS
Signs and symptoms include edema, hives, severe dyspnea and wheezing, unstable vital signs 5
with a systolic BP less than 100 mm Hg, and possibly cyanosis and laryngeal edema.
i
TREATMENT n i CN
N
For all Allergic Reactions and Anaphylaxis:
w
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4
• Remove offending agent, if possible L)
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°`' MILD REACTIONS
• Diphenhydramine HCl (Benadryl®) 50 mg IM or SLOW IV (Medical Procedure
Medication Delivery 4.18).
a�
• If bronchospasm is present, administer Albuterol (Ventolin®): one nebulizer treatment E
containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline (Medical Procedure
4.18.6). May be repeated twice as needed.
• If bronchodilators are administered, may add Ipratoprium bromide (Atrovent®) 0.5 mg (0.5
mL)to Albuterol nebulizer treatment
• Epinephrine(1:1000)0.3 mg IM (Medical Procedure,Medication Delivery 4.18) (a)(b).
• Consider the need for advanced airway management(Medical Procedure 4.4).
• SOLU MEDROL 125 mg IV/IM
• May repeat Epinephrine (1:1000) 0.3 mg A4 (Medical Procedure, Medication Delivery 4.1
(a) (b).
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MODERATE REACTIONS
• Epinephrine(1:1000)0.3 mg IM (Medical Procedure,Medication Delivery 4.18) (a)(b).
• Diphenhydramine HCl (Benadryl®) 50 mg IM or SLOW IV (Medical Procedure,
Medication Delivery 4.18).
• If bronchospasm is present, administer Albuterol (Ventolin®): one nebulizer treatment
containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline (Medical Procedure
4.18.6). May be repeated twice as needed.
• If bronchodilators are administered, may add Ipratoprium bromide (Atrovent®) 0.5 mg (0.5
mL)to Albuterol nebulizer treatment
• Consider the need for advanced airway management(Medical Procedure 4.4).
• SOLU MEDROL 125 mg IV/IM
• May repeat Epinephrine(1:1000)0.3 mg IM(Medical Procedure,Medication Delivery 4.18) ra
(a) (b).
SEVERE REACTIONS t-
• Administer Epinephrine 1:100,000 (0.1 mg/10 mL) IV diluted; To dilute Epinephrine from U
1:10,000 to 1:100,000; <
o Remove 9 ml of Epi 1:10,000 from the 10 ml prefilled syringe U)
o Fill the syringe back up with 9 mLs of normal saline, You now have Epi 1:100,000 L)
o Administer the 10 mL Epinephrine (1:100,000) solution IV slowly over 5-10 minutes
titrate to clinical effect and systolic BP greater than 90. Close hemodynamic
monitoring is required when providing Epinephrine 1:100,000 IV
a�
c�
➢ None
i
cN
cN
cN
Nate (a) Caution should be used with administration of Epinephrine when the patient has
a history of hypertension or heart disease.
(b) The EpiPen® may be used if other means of Epinephrine administration are not
available (Medical Procedure 4.18.1).
z
U
U
c�
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if 4
ul lI I I:' III =M
GENERAL GUIDELINES
General This protocol is to be used for those patients whose blood glucose is less than 60 mg/dL or
Guidelines more than 300 mg/dL
TREATMENT GUIDELINES
� � • Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
°" • Perform a glucose test with a finger stick(Medical Procedure
• If glucose is less than 60 mg/dL:
o If the patient is conscious and has an intact gag reflex administer oral glucose 15g (1 U
tube), if possible. 0
o If the patient is stuporous or unconscious, administer D5o 50 mL via slow IV (a). U
o If unable to start an IV/IO access, provide Glucagon 1 mg IM. This can be repeated V)
once in 20 minutes. (Medical Procedure, Medication Delivery 4.18) V)
o Perform a second glucose test with a finger stick. If glucose remains less than 60
mg/dL, administer D5o 50 mL IV (a).
• If blood glucose greater than 300 mg/dL:
o Administer normal saline 500 mL IV, unless contraindicated.
c�
➢ None
cN
cN
cN
Note (a) To avoid infiltration and resultant tissue necrosis, D50 should be given via slow IV with
intermittent aspiration of the IV line to confirm IV patency, followed by saline flush.
w
U
U
c�
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U
GENERAL
GUIDELINES
To enhance patient comfort and safety,the treatment of nausea and vomiting may be appropriately
General accomplished in the field. The symptoms of nausea and vomiting may occur as a result of acute
Guidelines illness or as a medication side effect.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
Administer Zofran® (Ondansetron hydrochloride)
• Oral 4 mg PO oral disintegrating tablet (ODT) placed under the tongue. May u
CL
repeat at 10-15 minutes with maximum dose is 8 mg 0
u
OR U)
U)
• Injection 4 mg slow IV push over 2-3 minutes OR IM lateral thigh. May be u
repeated once if no improvement within 10-15 minutes. Do not exceed 8 mg total
dosage.
c�
➢ None CNi
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cN
Note
u
CL
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GENERAL GUIDELINES
This protocol should be used for patients who complain of abdominal pain without a history of
General trauma. Assessment should include specific questions pertaining to the GFGU systems.
Guidelines Abdominal physical assessment:
• Ask the patient to point to the area of pain (palpate this area last).
• Gently palpate for tenderness,rebound tenderness, distention, rigidity, guarding, and pulsatile
masses. Also palpate the flank for CVA tenderness.
Abdominal history:
o History of pain (OPQRRRST)
o History of nausea/vomiting (color, bloody, coffee grounds) '
o History of bowel movement(last BM, diarrhea, bloody, tarry) z
o History of urine output(painful, dark, bloody) CL
o History of abdominal surgery i
o History of acute onset of back pain <
U)
o SAMPLE history (attention to last meal) W
U
Additional questions should be asked of the female patient regarding OB/GYN history (Adult
Protocol 2.7, Adult OB/GYN Emergencies).
All female patients of childbearing age who complain of abdominal pain should be considered to
have an ectopic pregnancy (even if vaginal bleeding is absent) until proven otherwise.
An acute abdomen can be caused by appendicitis, cholecystitis, duodenal ulcer perforation a
diverticulitis, abdominal aortic aneurysm, kidney infection, urinary tract infection (UTI), kidney Wi
stone,pelvic inflammatory disease (PID female), or pancreatitis (Appendix 6.1, Abdominal PainCN
Differential). CN
d
TREATMENT
GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
c)
10
c)
l
°I • If the patient is hypotensive (systolic BP less than 100 mm Hg), administer a fluid challenge
of normal saline 500 mL. U-
• See Pain Management Protocol
c�
➢ None
Nate
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GENERAL GUIDELINES
Sickle cell anemia is a chronic hemolytic anemia occurring almost exclusively in African
General Americans; it is characterized by the presence of sickle-shaped red blood cells. Sickle cell crisis
Guidelines results from the occlusion of a blood vessel by masses of these misshapen blood cells. Pain is the
principal manifestation and represents the most common type of crisis. Typical pain occurs in the
joints and back. Hepatic, pulmonary, or central nervous system involvement can occur, with each
type being associated with its own group of symptoms. Keep in mind that patients with sickle cell
disorder have a high incidence of life threatening disorders at a very young age.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1. 2
• Medical Supportive Care Protocol 2.1.3. Administer 100% oxygen via non-rebreather Z
mask at 15 L/min. 0-
0
• Provide emotional support. U
U)
U)
• Fluid challenge of normal saline 500 in may repeat once to a maximum of 1000 in IV.
• If pain persists and systolic BP is greater than 100 mm Hg, Administer
8 Morphine Sulfate may be given via slow IV in 5 mg may repeat once in 5-10 minutes,
titrated to pain and BP above 90 mm Hg, up to a maximum of 10 mg (a)
a�
OR
a Fentanyl
May be given 100 mcg increments every 3-5 minutes to a maximum of 200 mcg IN, IM. Ni
IV dose is 1 mcg/kg (slow IV increments every 3-5 minutes, maximum initial dose of 100 CN
mcg, titrated to pain and BP remains above 100 mm Hg (a)(b) (Medical Procedure 4.18 CINJ
Medication Administration). Second dose if needed, maximum total dose of 200 mcg IV 3:
IN, IM.
w
• Consider Diphenhydramine in conjunction with opioid—25 mg SLOW IV over 2 U
minutes or IM 0
U
➢ None
Nate • Extreme caution should be used with administering narcotic analgesics to a patient with a
SP02 less than 94%.
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GENERAL GUIDELINES
Sepsis is a rapidly progressing, life threatening condition due to systemic infection. Sepsis must
General be recognized early and treated aggressively to prevent progression to shock and death.
Guidelines Appendix 6.19 Sepsis Alert form.
Definitions SEPSIS ALERT = Patient Meets the Definition of Sepsis (#2) Below
1. Systemic Inflammatory Response Syndrome (SIRS)
•Temperature greater than 38' C (100.4' F) OR less than 36' C (96.8° F)
•Respiratory Rate greater than 20 breaths/min
•Heart Rate greater than 90 beats/min
2. Sepsis a�
• SIRS +Documented OR Suspected Infection
o Documented infections include but are not limited to pneumonia, UTI, wounds, skin Z
and decubitus ulcers. 0-
o Suspected infection may be determined via the presence of high risk criteria such as a) U
nursing home resident b) recent surgery c) immunosuppression or d) indwelling device.
o Symptoms such as cough, increased work of breathing, stiff neck, ALOC, urinary pain U)
or frequency, abdominal pain-distension-firmness, or inflamed joint may determine U
suspicion of infection.
3. Severe Sepsis
• Sepsis + Sepsis-induced organ dysfunction or tissue hypoperfusion
• Organ dysfunction or tissue hypoperfusion defined as either
o Cardiovascular: Hypotension (Mean Arterial Pressure (MAP) less than 65 mmHg)(a)
o Metabolic: Lactate greater than or equal tom 4 mg/dL(if available)
8 ETCO2 less than 25 mmHg CN
TREATMENT n i CN
• Initial Assessment Protocol 2.1.1.
• Apply cardiac monitor: Document rhythm
• Administer oxygen according to following criteria: W
o SPO2 94% or above do not administer 02.
o SPO2 less than 94% administer 02 by nasal cannula at 2 L/min. Z
• Utilize the Broward Sepsis Alert Form Section 6.19 or on-line forms. U
°" • Notify hospital of incoming Sepsis Alert(Meets definition of Sepsis).
• Place one large bore IV (18g or larger).
FOR SEVERE SEPSIS ONLY
• Administer Normal Saline 30 mL/kg, may repeat to a maximum of 2 Liters (a)
o Titrate fluid volume to MAP of at least 70 mmHg.
➢ None
(a) Mean Arterial Pressure is located on your monitor can be determined using the grid below.
N6 • Alternatively it can be calculated using the following formula
• MAP = [(2 x diastolic)+systolic] /3
(b) Monitor for pulmonary edema by clinical status and physical exam (auscultation) especially
in the elderly.
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GENERAL GUIDELINES
NOTE: Use this protocol for patients confirmed to have Acute Adrenal Insufficiency by either
General the presence of a medical alert bracelet, designation of medical records or other patient, family
Guidelines or medical confirmation.
• Adrenal insufficiency or Addison's disease is an endocrine disorder that occurs when the
adrenal glands do not produce sufficient amounts of cortisol and other glucocorticoid
hormones needed to respond to stress and inflammatory reactions.
• Early signs and symptoms of patients in crisis include pallor, dizziness, headache,
weakness/lethargy, abdominal pain, nausea/vomiting and hypoglycemia.
a�
TREATMENT
GUIDELINES
U
• Initial Assessment Protocol 2.1.1.
• Determine hemodynamic stability and symptoms. U
U)
U)
• Administer Oxygen to maintain a saturation of 94 o or above. W
• Provide advanced airway management, if necessary (a).
• Initiate cardiac monitoring
• Establish IV access
a�
• Administer a fluid challenge of normal saline 500 cc IV or IO to maintain SBP of>90 mmHg,
repeat as needed.
• Check blood glucose level (BGL) i
N
N
• Administer steroids
o Assist with administration of patient's Hydrocortisone Sodium Succinate (Solu- cN
cortef) if present(b) (c). 3:
o If Solu-cortef not available, administer Methylprednisolone (Solu-medrol) 125 mg
slow IVP (if available) W
• If the patient has persistent hypotension start Dopamine 5 — 10 mcg/kg/min (1600 mcg/mL <
infusion concentration= 15 — 60 gtts/min). U
o Titrate to maintain a minimum systolic BP of 90 mm Hg and maximum BP of 120 mm 0
Hg (maximum dose 20 mcg/kg/min).
➢ None
N6te, (a) Confirm airway adjunct placement with electronic EtCO2 and waveform on scene,
during transport, and during transfer at hospital.
(b) The patient or family shall provide the medication, dosage and route information.
(c) Typical stress dose of Hydrocortisone Sodium Succinate is 100 mg IV/IM yet may
vary per patient.
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r
GENERAL GUIDELINES
The following protocols cover a range of problems attributable to the environment, including
General trauma due to changes in atmospheric pressure, exposure to heat and cold extremes, water
Guidelines submersion, and exposure to electricity. Initial efforts should focus on removing the patient from
the harmful environment.
U
c,
U)
U)
L)
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CN
i
CN
CN
U
U
4i
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GENERAL GUIDELINES
Barotrauma and decompression illness are caused by changes in the surrounding atmospheric
General pressure beyond the body's capacity to compensate for excess gas load. These injuries are most
Guidelines commonly associated with the use of SCUBA (Self-Contained Underwater Breathing Apparatus).
SCUBA diving emergencies can occur at any depth, with the most serious injuries manifesting
symptoms after a dive. If a patient took a breath underwater, from any source of compressed gas
(e.g., submerged vehicle, SCUBA)while greater than three (3) feet in depth, the patient may be a
victim of barotrauma. Barotrauma may cause several injuries to occur, including arterial gas
embolism (AGE), pneumothorax, pneumomediastinum, subcutaneous emphysema, and the
"squeeze." Decompression illnesses may also include decompression sickness ("bends").
a�
TREATMENT
GUIDELINES
• U
Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4. Administer 100% oxygen via non-rebreather is
mask at 15 L/min. <
U)
• Place the patient in a supine position. U)
• Complete the Dive Accident Signs and Symptoms checklist(Appendix 6.7). U
• Obtain a Dive History Profile, if possible (the patient's dive buddy may be helpful in
answering many of these questions).
• Whenever possible, have the legal authority in charge(e.g.,police, Florida Marine Patrol,
U.S. Coast Guard) secure all of the victim's dive gear and maintain the proper chain of
custody for testing, analysis, and other measures.
• Manage the patient according to the appropriate protocol(s). Ni
• Transport the patient to the closest emergency department or trauma center with a N
helipad(air transport of diving accident victims must remain at an altitude of less than
1000 feet).
• Contact the Diver's Alert Network(DAN) at Duke University Medical Center, by calling
919-684-4326, for further assistance (a).
• Bring the dive computer to the hospital if available.
Z
U
�;� r �, �, u ➢ None
➢ None
c�
Note (a) DAN may be contacted while on scene or after arrival at the hospital_ If the contact is
made at the hospital,provide DAN with the name of the ED physician and the ED phone
number.
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Hill
GUIDELINES
Factors that predispose and/or cause a patient to develop hypothermia include geriatric and
General pediatric age, poor nutrition, diabetes, hypothyroidism, brain tumors or head trauma, sepsis, use
Guidelines of alcohol and certain drugs, and prolonged exposure to water or low atmospheric temperature.
Patients can be classified into three categories based on their degree of hypothermia: mild
(temperature = 94-97 17), moderate (temperature = 86-94°F), and severe (temperature below
86°F). Most oral thermometers will not register below 96°F. However, some tympanic
thermometers (Braun ThermoscanTM Pro-1 and Pro 3000)will register in the range of 68-108°F.
Mild to moderate hypothermia patients will generally present with shivering, lethargy, and stiff, _
uncoordinated muscles.
Severe hypothermia patients may be disoriented and confused to the point of stupor and coma. 0
Shivering will usually stop and physical activity will be uncoordinated. In addition, severe 2
hypothermia will frequently produce an Osborn wave or J wave on the ECG, as well as
dysrhythmias (bradycardia, ventricular fibrillation). 0-
U
TREATMENT GUIDELINES
U)
U)
t • Initial Assessment Protocol 2.1.1. U
• Airway Management 2.1.2
• Trauma Supportive Care Protocol 2.1.4 (a).
• Remove all wet clothes and dry the patient.
• Protect the patient from heat loss and wind chill_
• Maintain the patient in a horizontal position.
• Avoid rough movement and excess activity.
i
• Monitor the patient's temperature. N
• Add heat to the patient's head, neck, chest, and groin. N
• For severe hypothermia, warm IV fluids.
• For severe hypothermic cardiac arrest: Start CPR.
Z
For VF or pulseless VT, (Adult Protocol 2.3.6)
Z
U
• Utilize warm humidified oxygen, if available
• Establish an IV with warm normal saline. U
If temperature is above 86°F: Follow the appropriate dysrhythmia treatment(Adult Protocol
2.3).
If temperature is below 86°F: Continue CPR and transport immediately. Do not treat
dysrhythmias in patients with severe hypothermia(warm the patient prior to treatment)
➢ None
(a) Cases of frostbite should be bandaged with dry sterile dressings and transported without
Note attempting rewarming in the prehospital setting.
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ta
GENERAL GUIDELINES
Hyperthermia occurs when the patient is exposed to increased environmental temperature and can
manifest as heat cramps, heat exhaustion, or heat stroke. Certain drugs may cause an increase in
General temperature (e.g., cocaine, Ecstasy)
Guidelines . Heat cramps: Signs and symptoms include muscle cramps of the fingers, arms, legs, or
abdomen; hot, sweaty skin; weakness; dizziness; tachycardia; normal BP; and normal
temperature.
• Heat exhaustion: Signs and symptoms include cold and clammy skin, profuse sweating,
nausea/vomiting, diarrhea, tachycardia, weakness, dizziness, transient syncope, muscle
cramps,headache,positive orthostatic vital signs, and normal or slightly elevated temperature.
• Heat stroke: Signs and symptoms include hot dry skin (sweating may be present), confusion
and disorientation, rapid bounding pulse followed by slow weak pulse, hypotension with low
or absent diastolic reading, rapid and shallow respirations (which may later slow), seizures,
coma, and elevated temperature greater than 105°F.
U
TREATMENT GUIDELINES
HEAT CRAMPS AND HEAT EXHAUSTION U
• Initial Assessment Protocol 2.1.1. U)
• Trauma Supportive Care Protocol 2.1.4. U
• Remove the patient from the warm environment; cool the patient.
• Monitor the patient's temperature.
• For mild to moderate heat cramps and heat exhaustion, if the patient is conscious and alert,
encourage the patient to drink salt-containing fluids (e.g., half-strength Gatorade®). 2
HEATSTROKE
• Initial Assessment Protocol 2.1.1. i
• Trauma Supportive Care Protocol 2.1.4.
• Remove the patient from the warm environment; aggressively cool the patient. Remove the N
patient's clothing, and wet the patient directly with ice water. Also, turn air-conditioning units
and fans on high, and apply ice packs to the patient's head, neck, chest, and groin. W
Z
• Monitor the patient's temperature. Cool the patient to 102°F, then dry the patient, remove any
ice packs, and turn off fans (avoid lowering the patient's temperature too much). <
Z
U
HEAT CRAMPS AND HEAT EXHAUSTION
°'"�r° �' �' ° • If heat cramps are severe or if the patient's level of consciousness is diminished, administer a U
fluid challenge of normal saline 500 mL IV.
U_
HEATSTROKE
• Treat hypotension (systolic BP less than 90 mm Hg)with IV fluids. Avoid using vasopressors
and anticholinergic drugs; they may potentiate heat stroke by inhibiting sweating. Administer
a fluid challenge of normal saline 500 mL IV.
➢ None
Note
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Im III
It III I ' M , =M1,
GENERAL GUIDELINES
Drowning is a process resulting in primary respiratory impairment from submersion in a liquid
General medium. Implicit to this definition, is that a liquid-air interface is present at the entrance to the
Guidelines victim's airway, which prevents the individual from breathing oxygen. Outcome may include
delayed morbidity or death, death, or life without morbidity. The terms wet drowning, dry
drowning, active or passive drowning, near-drowning, secondary drowning, and silent drowning
should be discarded. The proper terms should be drowning, fatal or drowning, non-fatal.
Persons who have been submerged in fresh or salt water may or may not be conscious. If the
patient is still in the water upon arrival of EMS, a Dive Rescue Team should be used to remove
the patient from the water whenever possible. Additional protocols may be needed for treatment 0
decisions (e.g., Adult Protocol 2.9.1, Barotrauma/Decompression Illness: Dive Injuries). 2
Drownings are NOT Trauma Alerts, unless there is a specific traumatic component associated
with the event. 0-
0
U
TREATMENT GUIDELINES
U)
U)
• Initial Assessment Protocol 2.1.1. U
• Trauma Supportive Care Protocol 2.1.4 (protect the c-spine).
• Determine any pertinent history (e.g., duration of submersion, depth, water temperature,
possible seizure, drug and/or alcohol use).
• Maintain the patient's body temperature; dry and warm the patient.
• All non-fatal drowning patients should be transported to the hospital, regardless of how well
they may seem to have recovered. Delayed death or complications due to pulmonary edema
or aspiration pneumonia are not uncommon. N
CN
• Consider contacting the police department for investigation.
d
°i • Treat dysrhythmias per specific protocol (Adult Protocol 2.3).
c)
CL
➢ None W
Note
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GENERAL GUIDELINES
A wide range of injuries can be caused by a lightning strike or contact with electricity. Electrical
General injury can occur from direct contact, an arc, or a flash of the electricity, and from a direct hit or a
Guidelines splash from lightning. The movement of electrical current through the body can cause violent
muscle contractions that can lead to fractures; as a consequence, the patient's c-spine should be
protected. The thermal energy can cause external burns,but in many cases the majority of thermal
damage is internal, with few external signs of injury. Dysrhythmias are also common (e.g.,
ventricular fibrillation). The rescuer should be sure that the patient is no longer in contact with the
electrical current before initiating treatment.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1. Z
• Trauma Supportive Care Protocol 2.1.4 (protect the c-spine) (a). 0-
0
• Treat burns per Adult Protocol 2.10.8. U
• Try to determine the amps, volts, and duration of contact with the electricity, if possible. U)
(500 volts or more should be categorized as high voltage). W
• Consider the need to transport the patient to a trauma center (General Protocol 1.10). U
°" • Treat dysrhythmias per specific protocol (Adult Protocol 2.3).
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➢ None i
c14
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Nate, (a) Asystole is a common presentation with lightning strikes. These patients should be
aggressively resuscitated unless their injuries are incompatible with life.
w
U
U
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GENERAL GUIDELINES
All EMS personnel will treat and transport any patient who has been Tasered. At minimum,
General all electronic control device-event patients will receive the supportive and ALS Level 1 care
Guidelines outlined below. In the event that a patient resists the delivery of care,these actions will be carried
continued out with the safety of the crew in mind. If a patient is violent, a police officer will be required to
accompany the patient in the rescue unit during transport and appropriate chemical restraints will
be utilized according to Adult Protocol 2.5.2, Violent and/or Combative Patient and Excited
Delirium.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
a�
• Establish that the scene has been secured and determine which events led up to the individual 2
being subdued with an electronic control device. U
• Determine whether the patient wants to be treated. If the patient refuses treatment, (General �OL
Protocol 1.8) (a). U�
• Provide general supportive care, including: U)
o C-spine precautions, unless a cervical spine injury can be definitively ruled out. U
o Oxygen as needed.
Determine how many 5-second cycles of energy the individual was exposed to, and document
this information in the Patient Care Report
c�
• Initiate cardiac monitoring including 12 Lead EKG if possible. Treat dysrhythmias per specific
protocol (Adult Protocol 2.3).
N
N
• Monitor the patient's glucose. Q
• Establish an IV; give normal saline KVO. If patient is exhibiting signs of excited delirium and
is hyperthermic, use "cool" normal saline and/or apply ice packs to groin and axilla. (Adult 3.1.:
Protocol 2.5.2)
w
• If the patients is under police custody then the patient will be automatically transported to a
hospital for medical evaluation by EMS.
U
CL
➢ None U
Note
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1
r
GENERAL GUIDELINES
These protocols cover specific types of injuries and their treatment. The initial assessment of the
General trauma patient should include determination of trauma alert criteria (see General Protocol 1.10,
Guidelines Trauma Transport). When the situation demands it (e.g., when Trauma Alert criteria are met),
scene time should be limited as much as possible (e.g., 10 minutes) and the patient should be
expeditiously transported to a trauma center. Do not delay transport to establish vascular access or
bandage and splint every injury. Priority should be given to airway management and rapid
preparation for transport (e.g., full immobilization on a backboard) and control of gross
hemorrhage.
If a vascular access is obtained and hypovolemia is suspected (e.g., the patient shows signs and 0
symptoms of shock, such as systolic BP less than 90 mm Hg),a fluid challenge of 1-2 L(20 mL/kg) 2
may be administered until a systolic BP of 90 mm Hg is maintained. If the patient is still in shock z
after receiving 2 L of fluid, an additional 1 L of fluid may be administered (maximum total fluid o-
administration= 3 L). However, administration of large volumes of IV fluids has been found to be t
deleterious to the survival of patients with uncontrolled hemorrhage, internally or externally.
Studies (NEJM, 1994) have shown that maximal fluid resuscitation may increase the bleeding, U)
thereby preventing the formation of a protective thrombus or dislodging it once the intraluminal U
pressure exceeds the tamponading pressure of the thrombus. For this reason, consult with the
physician should be made prior to the administration of large volumes of IV fluids when the
transport time is relatively short (e.g., less than 20 minutes).
a�
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A female in her second or third trimester (greater than 20 weeks) of pregnancy should be placed
on her left side for transport. If the injuries require the use of a backboard, following full Wi
immobilization to the backboard, the backboard should be tilted to the left. Failure to follow this cN
practice may cause hypotension due to decreased venous return. CN
If history, symptoms, or signs of head or spinal injuries are present, manually immobilize the
patient's head and neck while maintaining a patent airway using a modified jaw-thrust method. ZW
Immobilization of the entire spine is indicated following initial stabilization. Cases involving W
hangings that do not meet Trauma Alert criteria are not considered Trauma Alert patients (e.g., a
"suffocation type" patient without c-spine deformity). 0-
0
U
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i
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (Procedure Spinal Immobilization 4.24).
• If the patient is not hypotensive (systolic BP greater than 90 mm Hg), elevate the head of the
backboard to 30 degrees (12-18 inches).
• If signs of brain stem herniation exist(e.g.,pupillary dilation, asymmetric pupillary reactivity
or motor posturing), consider placement of an advanced airway and hyperventilate the patient
to achieve an optimal EtCO2 of 30-40 mm Hg(Medical Procedure 4.4 and Medical Procedure 3:
4.10).
• If the patient is seizing, refer to Adult Protocol 2.5.3; avoid administration of glucose- 2
containing solutions and medications. U
• Apply a hemostatic gauze on severe wounds to the head, neck, face, or axilla that cannot be 0
controlled by other means (direct pressure) Medical Procedure Hemostatic Gauze 4.27.1 U
U
➢ None
NQte'
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N
i
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N
U
U
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GENERAL GUIDELINES
General This protocol covers a variety of injuries to the eye. If other injuries to the body exist,priority
Guidelines of care should be given as appropriate.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (establish an IV as needed).
• Remove, or ask to the patient to remove, contact lenses, if still in the affected eye(s).
• For a penetrating object, stabilize the object and cover the affected eye with an ocular shield
or similar rigid device. Cover both eyes to minimize eye movement. Avoid direct pressure on
either the eye or the penetrating object. 2
• If the eyeball has been forced out of the socket, cover the entire eye area with a rigid container, L)
such as a disposable drinking cup. Avoid contact with the exposed globe. If bleeding is present, 0
control it by administering direct pressure with a sterile dry dressing. U
• If there are signs and symptoms or suspicion of ocular exposure to chemicals or foreign body,
without obvious or suspected penetrating injury or laceration of the cornea or globe, irrigate U)
the eye with a normal saline IV solution (Medical Procedure 4.19, Morgan Lens).
°" • If the patient is experiencing eye pain, administer Tetracaine, 1 drop in each affected eye. 0
Tetracaine may NOT be given in penetrating eye injuries or in patients with allergies to
Lidocaine.
CN
i
CN
CN
➢ None
NQte'
U
CL
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GENERAL GUIDELINES
General This protocol covers both blunt and penetrating chest trauma and should be part of initial
Guidelines resuscitation if the patient's breathing is compromised.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Penetrating injuries to the chest or upper back should be covered immediately with a vented
chest seal_ If needed, "burp" the dressing to prevent/relieve a tension pneumothorax.
• Do not attempt to remove an impaled object; instead, stabilize it with a bulky dressing or other
means. If the impaled object is very large or unwieldy, attempt to cut object to no less than 6
inches from the chest. Z
c)
CL
• For tension pneumothorax, decompress the chest on the affected side (Medical Procedure 4.9). cn
• For massive flail chest with severe respiratory compromise, insert an advanced airway and U
assist ventilations (Medical Procedures 4.1.5 and 4.4). If flail chest does not cause severe LO
respiratory compromise, stabilize the chest externally by placing the patient's ipsilateral arm
in a sling and swathe.
• For traumatic asphyxia refer to Crush Protocol 2.10.9
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➢ None C�
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Note
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CL
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GENERAL GUIDELINES
Chest pain due to blunt trauma may be an indication of underlying injury. Blunt injuries such as
General pulmonary contusion and cardiac contusion may cause respiratory insufficiency and/or myocardial
Guidelines infarction.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Treat dysrhythmias per specific protocol (Adult Protocol 2.3). 2
• Consider the need for other protocols (Adult Protocol 2.4.2). U
0-
U
➢ None U)
U)
U
Nate
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i
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GENERAL GUIDELINES
General This protocol covers blunt and penetrating abdomino-pelvic trauma. Penetrating injuries may also
Guidelines include the chest(Adult Protocol 2.10.3, Chest Injuries).
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• For penetrating injuries, apply an occlusive dressing (e.g., Vaseline gauze).
• For evisceration, cover the organs with a saline-soaked sterile dressing and then cover it with
an occlusive dressing (e.g., foil). Do not attempt to put the organs back into the abdomen.
• Do not log-roll any patient with a suspected pelvic fracture (may use scoop stretcher).
• If a pelvic fracture is suspected, stabilize the patient with a "sheet sling" or a commercial Zu
available pelvic splint. 0
U
U)
U)
• None U
➢ None
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i
N
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U
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GENERAL GUIDELINES
General This protocol covers open and closed injuries to the extremities, including amputation.
Guidelines
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4 (establish an IV as needed).
• Any fracture or suspected fracture should be splinted appropriately, with ice being applied to
the affected area. Remove and secure all jewelry. Check pulse sensation and movement before
and after splinting.
• Closed angulated fractures should be aligned using proximal and distal traction during
splinting, except in fractures that involve joints, which should be splinted in the position in 2
which they are found. U
CL
• Traction splints should be used in cases of closed femur fractures, unless a pelvic fracture is
suspected. U
• Amputations should be dressed with bulky dressings. The amputated part should be placed in cn
a plastic bag and then the bag placed on ice for transportation to the hospital. U
• Apply direct pressure for hemorrhage control. If direct pressure does not stop the hemorrhage LO
apply a trauma tourniquet(Procedure Wound Care Trauma Tourniquet 4.27.2).
• Apply a hemostatic gauze on severe wounds to the head,neck,face, axilla,buttocks that cannot
be controlled by other means (direct pressure/tourniquet) Medical Procedure Hemostatic
Gauze Procedure 4.27.1.
N
i
m cN
• See Adult Protocol 2.1.5 for pain management guidelines Q
CN
➢ None
Nate CL
U
U
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01
I 1 1 :" =mm
GENERAL GUIDELINES
The decision to attempt resuscitation of a traumatic arrest should be based on the paramedic's
General judgment as to the possibility of survival and/or the possibility of organ harvest. There are
Guidelines instances where resuscitation of a traumatic arrest is not warranted (General Protocol 1.4, Death
in the Field).
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Rapidly prepare the patient for transport and then expeditiously transport the patient to the
trauma center.
z
U
• If IV(s) can be established, infuse to a maximum of 3 L of fluid. U
• Avoid use of vasopressors in cases of suspected hypovolemia. U)
L)
➢ one
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GENERAL GUIDELINES
Burns can be caused by thermal, chemical, and electrical sources. If an electrical burn is suspected,
General also see Adult Protocol 2.9.5, Electrical Emergencies. Remember that burn patients are volume
Guidelines depleted. However, burns do not bleed, so you should look for other sources of bleeding. Many
burn injuries are associated with inhalation injury. The signs and symptoms of inhalation injury
include nasal and oropharyngeal burns, charring of the tongue or teeth, sooty (blackened) sputum,
singed nasal and facial hair, abnormal breath sounds (e.g., stridor, rhonchi, wheezing), and
respiratory distress.
In cases of inhalation injury, attention should be given to the patency of the airway. Acute swelling
can cause an airway obstruction. The paramedic should consider the need for early intubation to 76
avoid a complete airway obstruction that requires a cricothyroidotomy
a�
TREATMENT
GUIDELINES
U
• Initial Assessment Protocol 2.1.1. is
• Trauma Supportive Care Protocol 2.1.4. <
• Stop the burning process: U)
o Thermal turns: Lavage the burned area with tepid water (sterile, if possible) to cool the U
skin. Do not attempt to wipe off semisolids (e.g., grease, tar, wax).
o Dry chemical burns: Brush off dry powder, then lavage with copious amounts of tepid
water(sterile, if possible) for 15 minutes.
o Liquid chemical burns: Lavage the burned area with copious amounts of tepid water
(sterile, if possible)for 15 minutes. (When phenol has caused the burn, also see Hazardous
Material Exposure Section Phenol 7.1.20.)
• Remove clothing from around the burned area, but do not remove/peel off skin or tissue. N
• Remove and secure all jewelry and tight-fitting clothing. N
• Assess the extent of the burn using the Rule of Nines and the degree of burn severity(Appendix
6.4, Burn Severity Categorization, and Rule of Nines).
• Apply a dressing to the burned area as follows: W
o If there is greater than or equal to 20% second-degree burns or 5% third-degree burns, <
cover the burned area with dry sterile dressings or Water Ge1TM wraps. U
o If there is less than 20% second-degree burns or 5% third-degree burns, apply wet sterile 0
dressings to the burned areas for 15 minutes to aid in pain control. Alternatively, Burn t)
FreeTM gel pads or Water Ge1TM wraps may be applied continuously to aid in pain control.
• Prevent hypothermia by keeping the patient warm and ensuring that all outer layers of LL
dressings are dry.
• Pain Management Protocol (Adult Protocol 2.1.5).
➢ None
Nate
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GENERAL GUIDELINES
Crush injuries are rarely seen in pre-hospital medicine but are common in times of disaster, both
General natural and manmade.Early and aggressive treatment of victims suspected of having a crush injury
Guidelines is paramount. Without aggressive pre-hospital treatment, the victim may die during extrication or
weeks later from complications of the injury.
In the crush injury syndrome,the initial injury is at the site of the muscle crushed by the mechanical
force of an object. The muscle cells die as the result of the following.First,the force of the crushing
object ruptures muscle cells. Second, the direct pressure of the object on the limb causes muscle
cells to become ischemic. The combination of mechanical force and ischemia can cause muscle 76
death within an hour. Third,the force of the crush injury compresses large vessels,resulting in the w
loss of blood supply to muscle tissue. Muscles can normally survive circulatory ischemia for up to 2
four hours before the cell death. After four hours,the cells begin to die as a result of the circulatory z
compromise. 0-
U
The damaged muscle tissue produces and releases many toxins that can have detrimental effects
on the body. The longer the victim is trapped, the longer the toxins are given to build up distal to U)
the crush site. The crushing force acts as a dam that prevents these toxins from being released into L)
the rest of the body. Once the force is removed,the toxins are allowed to run freely throughout the
body, causing a myriad of problems. Along with the release of toxins after extrication, the victim
can become severely hypovolemic from the third spacing of fluid, and the rapid swelling of the
injured area can cause acute compartment syndrome
Toxins Released by Dama ed Muscle Tissue
i
Toxin Effect N
Histamine Vasodilitation and Bronchoconstriction N
Lactic Acid Acidosis and dysrhythmias
Nitric Oxide Vasodilitation W
Potassium Hyperkalemia W
Thromboplastin DIC
Z
U
TREATMENT GUIDELINES
U
• Initial Assessment Protocol 2.1.1.
• Trauma Supportive Care Protocol 2.1.4.
• Spinal immobilization follow 2.10.1
• Apply cardiac monitor
• Administer oxygen according to following criteria:
o SPO2 94% or above do not administer 02.
o SPO2 less than 94% administer 02 by nasal cannula at 2 L/min.
• Rapidly prepare the patient for transport and then expeditiously transport the patient to the
trauma center.
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TREATMENT GUIDELINES
Nil
"7 CRUSH INJURY or COMPARTMENT SYNDROME
• Establish IV access; give Normal Saline 1 Liter.
• Pain management: If patient is normotensive (systolic BP greater than 90 mm Hg), administer
o Morphine Sulfate 5 mg via slow IV may be repeated once in 5-10 minutes, titrated to
pain and BP greater than or equal to 90 mm Hg, up to a maximum of 10 mg.
OR
o Fentanyl
May be given 100 mcg increments every 3-5 minutes to a maximum of 200 mcg IN, IM.
IV dose is 1 mcg/kg(slow IV increments every 3-5 minutes,maximum initial dose of 100 mcg,
titrated to pain and BP remains above 100 mm Hg(a)(b) (Medical Procedure 4.18, Medication
Administration).
Second dose if needed, maximum total dose of 200 mcg IV, IN, IM. Z
CL
• For crush injury release compression and extricate patient 0
CRUSH SYNDROME U
If unable to release compression and situation progresses to CRUSH SYNDROME U)
• Entrapment with compression lasting longer than 4 hours OR on the thorax for 20 LO
minutes.
• Suspicion of hyperkalemia (Peaked T-waves, absent P waves or widened QRS).
• Establish IV access, 2 large bore IVs recommended in order to separate CaCL and Bicarb;
• Pain management: If patient is normotensive (systolic BP greater than 90 mm Hg), administer
o Morphine Sulfate 5 mg via SLOW IV may be repeated once in 5-10 minutes, titrated to
pain and BP greater than or equal to 90 mm Hg, up to a maximum of 10 mg. Wi
OR Q
o Fentanyl
May be given 100 mcg increments every 3-5 minutes to a maximum of 200 mcg IN, IM.
IV dose is 1 mcg/kg (slow IV increments every 3-5 minutes, maximum initial dose of 100 wZ
mcg, titrated to pain and BP remains above 100 mm Hg (a)(b) (Medical Procedure 4.18,
Medication Administration).
Second dose if needed, maximum total dose of 200 mcg IV, IN, IM. U
• Calcium Chloride 1 g into 50 mL or 100 mL bag of normal saline and administer SLOW IV 0
over 10 minutes (follow with minimum of 20 mL flush). U
• Sodium Bicarbonate Bolus at 1 meq/kg
• Continue IV fluids at 500 mL/hr U-
• Administer Albuterol (Ventolin): one nebulizer treatment containing 2.5 mg of Albuterol
premixed with 2.5 mL normal saline (Medical Procedure 4.18.6).
c�
➢ None
Nate Ideally Calcium and Sodium Bicarb should not be administered through the same IV line due to
crystallization within the tubing therefore 2 large bore IVs are recommended.If 2 IVs are not possible
administer 20 mL flush in between Calcium and Sodium Bicarb.
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11
GENERAL GUIDELINES
These protocols cover specific types of special healthcare needs in adult patients. Adults with
General special healthcare needs are those who have or are at risk for chronic physical, developmental,
Guidelines behavioral, and emotional conditions that necessitate use of health and related services of a type
or amount not usually required by typical adults.
The general approach to adults with special healthcare needs includes the following:
1. Priority is given to the CABS.
2. Do not be overwhelmed by the machines.
3. Listen to the caregiver.
4. If a nurse is present, rely on his/her judgment.
5. Remember that the patient's cognitive level of function may be altered. '
6. Assume that the patient can understand exactly what you say. z
7. Bring all medications and equipment to the hospital. 0-
U
Obtaining a history includes asking the parent/caregiver about the following issues:
1. The patient's normal vital signs. U)
2. The patient's actual weight. U
3. Developmental level of the patient.
4. The patient's allergies, including to latex.
5. Pertinent medications/therapies.
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i
N
N
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GENERAL GUIDELINES
Home mechanical ventilators may be indicated for chronically ill adults with abnormal respiratory
General drive, severe chronic lung disease, or severe neuromuscular weakness. Some patients require
Guidelines continuous mechanical ventilations, whereas others require only intermittent support during sleep
or acute illness. Home ventilators may either be volume limited or pressure limited. All are
equipped with alarms.
TYPES OF VENTILATOR ALARMS
• Low pressure or apnea- may be caused by a loose or disconnected circuit or an air leak in the _
circuit or at the tracheostomy, resulting in inadequate ventilation.
• Low power- caused by a depleted battery.
• High pressure-can be caused b a plugged or obstructed airway or circuit tubing,b coughing,g P Y P gg Y g� Y g g,
or by bronchospasm. z
• Setting error- caused by ventilator settings outside the capacity of the equipment.
• Power switchover - occurs when the unit switches from alternating- current power to the U
battery. U)
U)
TREATMENT GUIDELINES U
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• If a ventilator-dependent patient is in respiratory distress and the cause is not easily
ascertained and corrected, remove the ventilator and provide assisted manual ventilations
with a BVM. Suction as needed. i
N
• Consider the need for other protocols (e.g., Adult Protocol 2.2, Adult Respiratory Q
Emergencies).
• None
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GENERAL GUIDELINES
Tracheostomies are indicated for long-term ventilatory support to bypass an upper airway
General obstruction and to aid in the removal of secretions. Tracheostomies come in a variety of sizes and
Guidelines can either be single lumen or double lumen. Special attachments include a tracheostomy nose
(filtration device), tracheostomy collar (for oxygen or humidification), and Passy-Muir valve
(speaker valve).
SIGNS OF TRACHEOSTOMY OBSTRUCTION
■ Excess secretions
■ No chest wall movement
■ Cyanosis
■ Accessory muscle use 2
■ No chest wall rise with bag-valve ventilations Z
U
TREATMENT GUIDELINES U
U)
• Initial Assessment Protocol 2.1.1. U)
• Medical Supportive Care Protocol 2.1.3. U
• If an obstruction is present, inject 1-3 mL of normal saline into the tracheostomy tube
and suction as needed.
• If unable to clear the obstruction by suctioning, remove the tracheostomy tube and insert
a new tube (either of the same size or one size smaller). Do not force the tube.
• If unable to insert a new tracheostomy tube, or if one is unavailable, insert an
endotracheal tube of similar size into the stoma and ventilate with a BVM as needed.
i
• If unable to insert an endotracheal tube, ventilate with a bag-valve mask over the stoma N
or over the patient's mouth while covering the stoma as needed.
• Consider the need for other protocols (e.g., Adult Protocol 2.2, Adult Respiratory
Emergencies). Z
• None U
U
➢ None
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GENERAL ri
GUIDELINES
Central venous lines are indicated for administration of medications, delivery of chemotherapy,
General nutritional support, infusion of blood products, and blood draws. Types of central venous lines
Guidelines include Broviac/Hickman, Port-a-Cath/ Med-a-Port, and percutaneous intravenous catheters
(PIC). Central venous line emergencies include the catheter coming completely out, bleeding at
the site, the catheter broken in half, blood embolus, thrombus, air embolus, and internal bleeding.
Use of SQ ports requires special training; these ports should not be used for IV access.
Signs of blood embolus, thrombus, air embolus, and internal bleeding are as follows:
• Chest pain
• Cyanosis
• Dyspnea
• Shock z
TREATMENT GUIDELINES U
U)
• Initial Assessment Protocol 2.1.1. U)
• Medical Supportive Care Protocol 2.1.3. CVP and PIC lines may be used for emergency U
IV access under sterile conditions.
• If the catheter has come completely out, apply direct pressure to the site.
• If there is bleeding at the site, apply direct pressure.
• If the catheter is broken in half, clamp the end of the remaining tube.
• If blood embolus, thrombus, or internal bleeding is suspected, clamp the line.
• If air embolus is suspected, clamp the line and place the patient on his/her left side. CNI
• Consider the need for other protocols (e.g., Adult Protocol 2.2, Adult Respiratory Q
Emergencies).
• None
U
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HAI
GENERAL GUIDELINES
Feeding tubes are indicated for administration of nutritional supplements and in patients who have
General an inability to swallow. Types of feeding tubes include nasogastric tubes (temporary) and
Guidelines gastrostomy tubes(G tube). Types of G tubes include those that are surgically placed,percutaneous
endoscopic gastrostomy tubes (PEG tubes), and jejunal tubes (J tube). Potential complications
include leaks, bleeding around the site, and displacement of the tube.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• If the catheter has come completely out, cover the site with Vasoline gauze and apply
direct pressure to the site.
U
• If there is bleeding at the site, apply direct pressure. CL
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• None
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F.39.a
GENERAL
GUIDELINES
Ventricular-Assist devices(VADs)also known as heartpumps are surgically implanted circulatory
General support devices designed to assist the pumping action of the heart. Caring for these patients is
Guidelines complicated, and every effort should be made to contact the patient's primary caretaker (spouse,
guardian etc.) and the VAD coordinator during your evaluation. Patients with properly
functioning VADs may NOT have a detectable pulse, normal blood pressure or oxygen
saturation.
TREATMENT GUIDELINES
• Initial Assessment Protocol 2.1.1.
• Medical Supportive Care Protocol 2.1.3.
• Treat non-VAD associated conditions in accordance with the appropriate protocol_
U
• Determine the type of device, access alarms, auscultate for pump sounds, if needed assist
patient(caretaker) in replacing the device's batteries or cables. U
• Contact the VAD coordinator phone number will be on the device and the equipment U)
carrying bag. U)
• If there is bleeding at the site, apply direct pressure.
• Monitor capnography to access ventilation and perfusion
• Perform a blood glucose level if any weakness, altered mental status or history of diabetes
(Medical Procedure 4.17). If blood glucose is less than 60 mg/dl, refer to
Hypoglycemia/Hyperglycemia protocol 2.8.2. N�
• If signs of hypoperfusion administer 500 mL bolus of normal saline Q
• Evaluate unresponsive patients carefully for reversible causes <
• CPR risks rupturing of the ventricular wall leading to fatal hemorrhage. Only perform
CPR when the patient's VAD has no hand pump and no other option exists.
w
• Transport to the closest appropriate facility based on the patient's chief complaint. If a
cardiac issue or VAD mechanical issue is identified (alarm sounds) then transport to the
most appropriate Broward County VAD receiving center, if possible (see hospital U
capabilities). 0
U
➢ None
Nate • Take all equipment associated with the VAD system to the ED
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