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Item F42 F.42 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.42 Agenda Item Summary #11393 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 MCT Express, Inc. 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 Service in Monroe County, Florida, excluding the City of Marathon, for the period November 16, 2022 to November 15, 2024 for responding to requests for inter-facility transports. MCT Express, Inc. is not authorized to perform 911 scene response work within Monroe County. ITEM BACKGROUND: MCT Express, Inc. has submitted an application for BOCC approval to renew their Class A COPCN which lapsed due to their late submittal of the renewal application and the required application fee. The renewal COPCN is for the operation of an ALS Transport Service in Monroe County, Florida, excluding the City of Marathon, for the period November 16, 2022 through November 15, 2024 for responding to requests for inter-facility transports. MCT Express, Inc. is not authorized to perform 911 scene response work within Monroe County. PREVIOUS RELEVANT BOCC ACTION: On July 15, 2020, Item PA, BOCC granted approval for the issuance of a Class A COPCN to MCT Express, Inc. for the operation of an ALS transport ambulance service in Monroe County beginning June 17, 2020 and ending June 16, 2022. CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval DOCUMENTATION: MCT Express Inc Application 2020-2022 (Redacted check nos 6 8 20) MCT Express, Inc. Renewal Class A COPCN Certificate 11.16.2022 through 11.15.2024 Packet Pg. 2156 F.42 MCT Express, Inc. Existing Class A COPCN Certificate 06.17.2020 through 06.16.2022 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: N/A Additional Details: N/A N/A REVIEWED BY: James Molenaar Completed 11/01/2022 3:47 PM Steven Hudson Completed 11/01/2022 3:48 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 4:02 PM Lindsey Ballard Completed 11/01/2022 4:06 PM Board of County Commissioners Pending 11/15/2022 9:00 AM Packet Pg. 2157 t O ° L°L L u n°au O °9 L°L L94eoijpJ83 NDdOD V sseID l mOu 'Oral `ss aci :4u8wWe44V co a LO � N U. G. Q� J4 co RS G. 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BAJ' i IN do t3 15 U " Its U P 13 00 rill .0,- 9 m � I __CLA_S_S__A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) El INITIAL APPLICATION $950.00 N RENEWAL APPLICATION-$475.00 APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY(COPCN) IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE.-# 20-02 NAME OF SERVICE NICT I. ■ BUSINESS PHONE NUMBER BUSINESS MAILING ADDRESS 2766 NW 62nd Street 779-0505 EMERGENCY PHONE NUMBER 305-779-0505 TYPE OF OWNERSHIP y * ; � Corporation • ; r ; Miami,DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 02/14/2019 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheetif necessary),: NAME AGE ADDRESS TELEPHONE# MEMENEEME POSITION/TITLE Ray Gonzalez 51 2766 NW 62nd Street FL i Miami,Rene Gonzalez 56 2766 NW 62nd Street FL 33147305-562-9021 C.F.O. ------------ . LEVEL OF CARE TO BE PROVIDED: El BLS or FE]AL.S IF ALS: p TRANSPORT or❑NON TRANSPORT 5. DESCRIBE THEZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): : All Zones within Monroe County . N OF YOUR BASE STATIONS(Use separate sheet'if necessary),-, BASE STATION 2766 NW 62nd Street Miami FL 33147 ne lar DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC # + i Y #OF PORTABLES WQYY554 60 FREQUENCIES CALL NUMBERS #OF MOBILES a LIST THE NAMES AND ADDRESSES OF THREE(3)U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR i SERVICE:YOUR Robert Dean 418 Simonton Street Key West FL 33040 NAME ADDRESS Mey Lan Wader 1 Diamond DOve Big Coppitt Key FL 33037 John Salvesen 989 SW McDevitt Ave Port • 4 e FL 34953 PERIOD.ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN i PERIOD.PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN i ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. DIRECTOR.ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL i COMMISSIONERS.ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY I,THE UNDERSIGNED IGNED REPRESENTATIVE OF THE.ABOVE NAMED SERVICE,ISO HEREBY.ATTEST MY SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN M NR E COUNTY AND THE STATE OF FLORIDA,A, I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED I THIS APP'LIIC , , t , v,, ° rY T OF MY KNOWLEDGE,WLEDGE IS TRUE AND CORRECT. SIGNATURE A►TIJRE OF A►I PLt RI ZED REPRESENTATIVE TATIVE r II m ,p � • WCOMMUDNOMN2472 II # ff#w ti► r r,,,,,,oi,,,ii rmararrrrrrdrrr' ,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,iAi»roiaiiiiiiiicc,,,iaaiciiiiec� ..,�••m N[ ICY N"JI GNATU � FJ Page 2 of 6 w ti PERSONNEL—PARAMEDICS NAME IPARAMEDIC CERTIFICATION Fi rat Middle Last SOCIAL SECURIT #� CERTIFICATION## EXPIRATION DATE "'7� nn............116-11,In.............n In n..nn..........................Ifi-nn ............nn............... ............... __;==MftPII D 349 1 7"" 1211 �022 ...........nn............Jal� elin Acevedo ............................. 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Page�� f"6 PERSONNEL—EMERGENCY MEDICAL TECHNICIANS NAME EMT E IEI ATI 1 ,m....... fl"'147 Middy Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, E lT 7 1 21 2 Rolando lr� �........................... ,�,,, „��, ,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, EMT 371 1 �,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, E MT57 1 21 22 2 J rr .......................... EMT 4 01 12 1 2 Vanessa Bautista EMT566732 12 1 Robbie Espana ��, ,m..................... EMT563683 12 11202 Lisa j E 1T 334 12/1/2022 ............................................................................................................... .................. ... EMT540887 12/1/2022 Akira t�l� �� .................................................. Mi ariah P ink E11 T567 03 12/1/2022 JorgePilot Piloto E 1T53 134 12/1/2022 Alan Rodriguez EMT560963 12/1/2022 ,,, ........................................................................................................................................................................................... ........ .................................................................. ...................................... Page (,,if 6 I , i Iru 1 Imo' IIIIIIIIII IIII ry IN" I IIII Illlp I Ulllllllllllh I ^^�^il liy Irl� IIII Ilm ' � Ili�ilm U� UIII �� Um mIU �''''''I Iwo I i � Illllllllllllh I I � I IWOUIIIIIIIIIII I I I I I UIIIIIIIIIII I i , I I I UII I IIII�IIII I j I I IIIII�II i.,i� UluluulU IIII III I i I I�IIIII I z I IIII IIII Blow Irlu I Illnnnnll ui lllr IIIIIIIIII (IIII IIIIIIIIII Ira; ------------- � IIIII I IIII III IIIIIIIIIIIIII �� ' I �ulll I hiliillli Un I Iwo UIIIIIIIIIII IIII IIII IIIIIIIII h I I I unnnnll I IIII IIII.� ILL , � � � Ullnlllllll� i I � I I I I� IIIIIII I I lip I I i I II III�IIIIIY 'mill I IIIIIIIII UIIIIIIII Iw I V I U UIIIIIIIIIII, � I 1 IIli�litll I , I I I lb I I Im IIIIIIII IIII IIII 1 Aw i I� I I UIIIIIIIII 1 I I I�I4 ,m I I I I flil�illlR ��` lllli�nllll 4 I IcaI I IIIIIIIII Ix Inl�ilUp rlmoi IIIIII I IIII 1 1 , I I I IIIIIIIIII IIII Illllllllllllr I MCT EOR � J �r r r , ,,,,,,,, , ,,u�,,., ,,ruN,rrxr rr,x,ar „,,,r,r,,N,rr, r �r r/r.:r/noiv^ria,. ...J, .:.yr M',la,ol vniaJ e, ,.xxmrm.uo�mdnfiaNiamtfrnnnorm�AURrmwuarwrnumrrn!xnr�tiiauarirmtvrmrirrmuf�miw6auaaviireiiiiiiiiiruni/,miriw�mmJk: aioovNiafiW' I 1nx'ar'r avwrmnrcwiriuuuwrmnrimuaommrrma�wrcr inia�v:,uuuauwauaomauinaurmiiiuwednwarudinumam�urrnrammrminiramanmiiuiJir«rxerrmuuiuxi�ii,miuiruu�:rrNiainiwiaoi�iiioocuumiweriamnurrirvauuru»urmrimrmiwimuai�rcnrrmowui�rcrueua ariu�rmmuw,�iu;rmnururdrvrnmrn»,vu�iouv�roruuxr�nxxxrrrrmr�rrraranurmrxxmumiuuumarrnmiiiiinaonur+:reuanrrxmrrrrieUwymuurouamrmvnimirerrmrnoi��.raueniromyr�rrnr�rrroriam�umrrrmaurrarrrirrri,. 1 N!G' rw l r r r 6mi... !m W , ",: ....., ,".:. rw.�....�.e.. ..... ... ,_.1r .._. .._. _. v�'wvl°7m.. WW ,.. mw: wrmfiffi((fififuuuVmfiluuuuWuruul�.fififuu:y.fi(((mm i,.w:w:uufmuuwwow:w:w:�wiui uuuuuuuuuuuuuuuuuuumuiiuuuuuuuuuuuuuuuuuuuuuuuuuuuuumuiuuuuuuuuuuuuuuuuuuuuuuuuuuuuummuuuuuuuuuuuuuuuuuuuuuuuuuuiuuiuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuiiuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuiuiuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuiuuuuoimuu:r f� 1 r � J YII r Rate Schedule r` P YAo40..................... ............ � I A0426 ALS Non-Emergency $474.10 A04 7 ALS Emergency o. o A04 BLS Non-Emergency $328-30 US Emergency $492-30 Specialty Transport Y .. ... . $300.00 r hour r any fraction Stand-By thereof m�nn-mr!.�srmrm�,rxunnrmm>�nx»rmma,,,,,,,,,,,,, �,,,,, ,,,�r,,,rrvnu�»cr,mmrr.,,rir rm.��,,,�,,,rrrraiiiiiiai,:,r ricaiiiiciiioiioiirxiiicm,✓iiioiriii:rrrsnrir,c�rwrrwiiui raornixwr�m�rrrrrrrrra¢,rsrrrwrrrar�+�� r ,enrr" r��anrwww"wmwwr�.,:,,,,:, s. CERTIFICATE OF LIABILITY INSURANCE CONFERSCERTWW,ATE DOES PKIT AFFROMTIVELY OR NEGATIVELY AMEND,EXITM OR ALTER THE µ COVERAGE BELOW. THIS CERT*ICATE OF UOURANCE DOES NOT CON"MM A CONTRACT BETWEEN THE ISSUNG y �.n�pn J""N"1i er.S tyro',:owon ryuy. YYyxw .en i wiq+..,ryi vo,;i�,,.-� u,w v P vm ii` mmm Yo nm. iii �r rime o �nnxmmmmm of �,wi.:.urv ..ywyy n rmn. i roomFM"' P"xxwn llrt'r .1�r+N+► r 's jn&N � (305)7404469 '9 SW 7 th Ct. tQ%ami,FL 33155 FOM � � n Phme ( ii)740-4460 Fax (305)74GA469 89NNM A- CANEFM SP C LTY 94SURANC COMPANY �15M 91SUMED WSURERS: Md 7 . `ba Komi Daft AmbLdanmSuper Nice Sts,ine Amedca,Supernice Cab Corp.MeffmW COVERAGES CERT11FICATE o REMPON NUMBER: TM IS TO CERTIFY IMT THE PQJ=OF MCRANCE LETED BELOW HAVE BEEN WAUM TO THE&VANtED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDNG ANY y TEM OR C0NW1ON OF ANY {o. D PERTAIN,CE"FICATE MAY BE WSLIED OR MAY EXCLUSKM AND C00MONS OF SUCH POLICIES.I-RAITS SHOYM MAY HAVE BEEN REDUCED BY PAID CLAW, THE MURANCE AFFORDED BY THE POLKNIES DESCRIBED H13ZEIM IS StOJECT 70 ALL THE TERMS,,, ICI GPoucymummm us" Ii CMXAATJtENM ■ ■ CUU10-MM OCCUR El OOSFLOD0037077 r 000.00 1000 t r 000-00 GENERAL w w 4,000,000.00 II' p0my v, AUTW EJ ATNow"EDtfpft.0 El 0 .N .... y� IIIIIIIII mm AND EMPLOVRW LL48LWY if I M ANY PFt0PR1E� MIA EL EACH� # OFFXNERNBAER�� . ==undur OF OPERATK)M Wow E.L DMFASE-POUCY UW S ).. A Mad Prof oral LivabiRY Irk 005 L000037077 0811W=1 08/16M 1,000,000 EACH CLAIM/$3,000.00OAGG 40ARM ACOW ■ 000 SEXUAL ABUSE-EACH CLAAW 3,000,000 GENERAL-LIABIUTY' 10,000 DEDUCTIBLE, A PROFESSIONAL LIABILITY i COMPANY- WD DEDUCTIBLE TRANSPORTATION INCLD.EMERGENCY VEHICLES AND NON EMERGENCY VEHICLES. The Monm GDusty Board Of Courdy Commftskmm are addMorml hawed as respects to the general flabifty-30 days no**of cmxxftbon appfies., NOTIM IN CORDANCEVMTM PR nn Y WESTlulu FAUrNOREWD REPRESMA, CORPORATION,L 33040 reserved. I,I Ac"Rfy DATE PDNDDNYYY) "I'll" CERTIFICATE OF LIABILITY INSURANCE 6o"10/2022 THIS ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 40 E P LD 0 E L R IC T IE H S IS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED I �U I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,, IMPORTANT: Of the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed,,,o I f SUBROGATiON IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not con PRODUCER Global Affinity Managers 1949 No)-, 2:0ililil 909 Castle Point Terrace ADDRESS: onesourcewcInsiRigmad.1cont INSURER(S)AFFORDING COVERAGE NSIC 01 Hoboken NJ 07030 INSURER A.- Hartford Fire Insuran�cie Company 196821 114SURED INSURER 8: General Star National Insumnce Compan',y 1196'"";" MCT Express,Inc INSURER c. Hanford Fire insurance Company 19682 2766 NW 62nd Street INSURER D INSURER E: Miami FL 33147 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 1NDICATED. NOTWITHSTANDING ANY REQUIREMENT,,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCR18ED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE E OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S PRO. E] .POLICY 0 JECT LOC PRODUCTS-COMPIOP AGG S _OTHER- MTJW9TRFD-STRGUlF1TMTr� AUTOMOBILE LIABILITY $ 300,000 (Ea accldenq, X ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED 12CSES50302 ouoi,lo22 01101/2023 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS XHIRED NON-OWNED AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAS OCCUR EACH OCCURRENCE S 700,000 B EXCESS LIAS CLAIMS-MADE NXG9277724E 01/01&1"2022 01101,,,2023 AGGREGATE S rB 4DED iFRETEN?TION$ 1 11'1111�'fill WORKERS COMPENSATION AND EMP LOVE RTUAIBI LnV YIN ANY PROPRIETOWPARTNERIEXECUTIVE N I A E,L,EACH ACCIDENT-S 1,000,000 C OFFICER/MEMBER EXCLUDED? 12WNS50301 01101/2022 '2023 andatoq in NHI) E,L DISEASE-EA EMPLOYEE S 1,000,000 If rs Sd descd be under 0 RI PTIO N 0 F 0 PE R AT IONS below E L DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if mews space is"WeM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Monroe County ACCORDANCE WITH THE POLICY PROVISIONS,, CCO' 490 63rd Street Ocean Suite 140 AUTHO R:1Z ED R E PRE SE NTATIVE Marathon FL 33050 1 0 1988-2015 ACORD CORPORATION. All rights reserved,. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD `I" '' fur I"SM361; lMel 1 D A D E ,111, AINOULANCK SIERVIC11 ANOULANC11 SERVICE 0IIIIIIIIIm 04IImI*mui�� iva MII fifeRp gjp ........... ........... AGREEMENT This is an agreement. entered into this I'day of June 2021, made and entered into by and hy x f,�,ref6rred to as SERVICL and Dr. Rudolph Moise, between MCT 1,11,,','xpress Inc., hereinattet whose address i's 671 N.W. I I 91h Street North Miami., Florida 33168, hereinafter referred to as ot MEDICAL DIRECTOR WITNESSETH WHEREA&I, Inter-facility transport and emergency medical services are provided by the SERVICE for citizens in need,, WHEREAS; the delivery of Basic and Advanced Life Support by trained Emergency Medical Techrill''clans i(EMT' moo m s)and Paramedics requires the administration of resuscitative drugs and peribrimance of sophisticated technical emergency procedures., and WH E RA SIIthe adml'nl stration of drugs and perform ance o f such emergency procedures endotracheal intubation., cardiopulmonary resuscitation and any other invasive emergency procedures may only be performed under the direction ofa Florida licensed physician according to Florida Administrative Code 64J 1 004:-, and WH ER EA S�, the S ERVI C E i s des irous,o f obtaining services of the MED ICA L D I R ECTOR to provide all MEDICAL DIRECTOR services as contained in Flon"da Administrative(,"ode 64J 004 to the S ERV IC E and employees; and WHEREA& MEDICAL DIRECTOR is desirous of providing such services to the SERVICE and is a licensed physician "in the State of Florida; and WHEREAS" the SERVIC,U wishes,to comply Statutes, Administrative rule and regulations State of Flon da., NOW THEREFORE,in consideration of the mutual terms andconditions, promises, covenants and payments hereafter set forth, SERVICE and MEDICAL DIRECTOR hereby agree as follows-,, M:CT � I��'' Rt �� RBI �11q�� „i A,M. I * ,D A D ��'II��1111'M F �M. l NI M )I U f'.I II OEM"/llf I IINII\ IWlll..//GrIIlA0X4(YINV/1,1 1 rncmu�ii��xioai� uuu��uuuuuumrvuuuum�ffmfuuummnu�}oio�rimuti�Smt�o(Sw;miooiom�m�m�oioi(hioPramuuiao�fi(��mfmi�oi�S(fi((fi6i�wiiNYifiMiil�ifr�muK�((fimK�im�fi4umw'//rRf�h��0iflifd0l/HMV(MuitdWMiv�mVm(fi'�mYYrotfimlWK�BVHfi(nIVIN�o.i19�1WU1'77'!?1Y6610�INVh111NImiNX'N1fII�IMpim'T(xftn IIIIIVIIWf( S,wli�r- sirrcraueiurwrcrmraivuirai�iiv�oNuoco��`�iiiirnierrmi0000ioa�rcrtaiowiiiii000iimorcnauum}�uowmowrwoii's��4ttiotSaui}�VIIWNVNm�1iI�1YIIlU(iNvu(fl�lYf�(V�'�idl�,�iFII4.M1i(YfiVk�IIV(fVo�11B11(�V�fIIIIYII�I&'M1RX"%tlflIIIIIIIIIIIIIIiiItl01111011nIfKflllOnlf01111�fIIIdI�IN9SYW'IN�11W1,fRfY'hSNI%D)�W,1171.,�7/VMNIC�'�.NUI;,.... r7 I.... vwuu w I a m�r u 1 i��iuraimw ur��rn�v�v�rvmmm f�� ^ "M�Y' I uuuuuuuuuuuuuuuuuuuuuuuummmmuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuulVuuulVuuuuuuuuu uuuumwm u u��i i�i uVVu!� im W �r �J. 1 AMBULANCE 96RVICE AMBULANCE SERVICR ........... MEDICAL DIRECTOR shall provide the following service&� m iv Develop and BLS procedures when A. standing ng 0 supervisingcommunication cannot be established with a kN a "s condition or m� m life. ,. eatment would threaten the The MEDICAL DIRECTOR shall issue standing orders and protocols to the SERVICE to B. ensure that that the SERVICE transports each patient to facilities that offer the type and l k6¶��"0 patient I r a c o n ,F, ,w 'm urva.ilable within i region.��m service best able to treat the C. or +a e m 7- day-per-week standing orders, direction of personnel of the� m o plll�� ICE,as to availability of medical m m line,direction off and provide in an to resolve Y system services emergency as that term is defined by section . , F m D. patient Quality Assurance(QA) program to assess the medical perfon-nance of EMT's and Paramedics. The MEDICAL DIRECTOR shall audit the perforrnance of personnel MEDICAL DIRECTOR shall be responsible for development and implementation of by use of the QA program to include but, not be limited to a prompt rev iew of patient care records,direct observation, and comparison of performance standards for drugs, equipment, system protocols and m procedures. responsible for participating in programs developed by the Florida Department of Heafth for EMS services. Ilie MEDICAL Director shall maintain Florida licensure as a physician and maintain a DEA license through the Drug Enforcement Administration that is registered to the MEDICAL DIRECTOR and SERVICE to allow for use of controlled substances as outlined through the DEA. Ens fluids ® re and certify that that secun'ty procedures of the SERVICE for °u and controlled substances are compliant with chapters 499 and 893, F. C. �il t ,. authorize and ensurer regarding medications, t s by the SERVICE. Yi`. Notify t t of Health in writingsubstitution by the SERVICE of equipment r medication. a a Assume responsibility for the use of a glucometer, the administration of aspirin , the use a of any medicated auto injector, the performance of airway patency techniques including airwwy,ad not to include endotracheal® a � ak uncts, ion- and on routine transports , ,the M.CT Yr ;-� �� 1 � n, i h"�,! I, ll� M., 1,A,M1 DADE , AMBULANCE E 81INVt K AMBULANCE RYICK Ill. �'��, t >�'h!ft��:!:mt��U�VN1IIlONInwnN�l'mlttRfM0�WM1YM�lll'MWIWIN'MMh�VY'�'!N<<<lulpllF�11f�61VV�ri1�1�i�OVhi�nINM:@ffill011MIIfdWU:l!ifmlfomni�4�f(filu�o9NIIImo��it�uf11164�NIlIrn6(fifRfG';ai�wwo�w,romilu(i�luvw41111ufif(,WVGfi6(�(VGfiO III:��tir�li r kum�tYimouiu�I16u6 mli iti�tn�r�riv iNu IK. ,I �}u � i i m iawrrt�vVo r' Im o ir»a rrvnrviiwflrc mwuliwrr of mimiV� trr Nrnmwt� �"Mffffaronll�fifi�S°�niriD�IdC'f10dfl�M1@�(fn'INN,W>X�61NrNld!(f�IINIIII�IXi�'IIII'VVi�(J�(PrR�1"�Vlli�'fi��'r'h��4nfilNlli16'�uowlfNlu�(�N(nkWAfifid(fiII�IIGw:WmUn�Y(WN7�✓e�I�IMfl'�4RIl4�idat&iivi(IYtIM1n'�(�((:��u(!i(lav�llifuv�dkwi((�Iml(fNieu(i1G(nKi�l�4n,,�u�fi(ma�GO IIIfi��S I�if�(��'w'I�uwiAIIIIII�t�IIR'�'M14Ki�uuU.JWII�11�RmIIlufWf>«477,. h011�111111011�'i 'PIXI�ufdln��s4- ,.�'W,'�oaV�rliu�,nn'�r/o„c.. �!?r ^��r�wlriis�IlV>u i��Yriiv�yYry➢r��w.w>!w»��nw+.,. wlvvvw,w,w,w,wlvvvw,w,w,w,w:wwo .. .. uuuuuuuuuuuuuuiuiiuuuuuuuuuuuuuuuuuuuuuuiililiiuuuuuuuuuuuuum ,auw:w... eulmuuuuuuuummmm�u rruuwi7luiw,w:wrwuuwlwziuv�uy�vr0uuuw:w;will aw�Niul„wc� ww � umomnmRWAI P i ul�v w J, NIFI)ICAIR, DIRECTOR ,shall develop and revise when necessary TTP"s for SERVFCI��_�`.`, r, MEDI(I'lug r . 'in . with !� personnel. following:ARTICLE1111 The SERVICE agees to the (a) Service will provide adm inistrative liaison to MEDICAL DIRECTOR through the direction of its-, Director of Operations and will cooperate to the'greatest possible extent in, the delivery of the policies nla ,' , DIRECTOR, MEDICAL Im VS�I„w�a> , OR as , ($7 �„II yw e .,,000.00 Seven Thousand Dollars per ARTICLE WJ1 Thi ll f(2) r' June,119' 202 m This agreement shall continue for successive yearly terms unless either party gil ves notice to the w Ibe sent via certified mail not later than (30)days prior to the expiration of this its intent not to renew th"i's agreement for another yearly term. Said intent must te party of opposi 4 agreement- The upon the following,h (1) That MEDICAL DIRECTOR has failed to comply with the terms of this agreement. ,}" MEDICAL.. 2,) That (3) That MEDR,-"""AL DIRECTOR is unable to perform services as provided for herein for some reason not attributable to the ," C`CIVIVI ARTICLE q.V) Itis further agrevd that no difi cat"ions, or alterations in the terms or conditions contained herein shallbe effective l ,ydignity. 8 � NX,P11 E` R ,A,M� ,'' DE P hir AMOULANG11 SERVICE )fl�' //% �l% AMBULANCE DERVIC9 w. IN WITNESS WHEREOF. the parties have hereunto set their hands and seals the day and year first above written. AP17EST- mid pltl ........................ ........................................ ler By- MEDICA DIRECTOR pi,�: Chief Ex Uti ........... ......... Ray o ,,,,,, Dr. Rudolph Mol"Se ae!............... ............ ..........t� 7`141I A:. Manager'Director of Operations By Assistant Director of Operations gg 1111c��11.111 elo Bob Beers BOARD OF COUNTY COMMISSIONERS County of Monroet Mayor David Rice,District 4 FloridaThe Mayor Pro Tem Craig Cates,District 1 f Michelle Coldiron,District 2 James K.Scholl,District 3 . Holly Merrill Raschein,District 5 Monroe County Fire Rescueti` 490 631d Street Ocean Marathon,FL 33050 1. Phone(305)289-6088 ' MEMORANDUM TO: Nicole Rhodes FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: June 13, 2022 Attached please find Check dated June 10,2022 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 MCT Express, Inc. Thank you, Cara Johnson �n�I�I�Ivf U aefyf r�r�.�opuurp�r�iN�re�r, r of _ ism llrsi wrvlt�'°F,6r7Yi�G r a 11 i f{f „3, 11111115,�4r �Y N. 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Cardiac Arrest Standing Ordersi 1 dult Cardiac Arrest Adult Post Resuscitation 71 Pediatric Cardiac Arrest p. 73 SpecialConsiderations i/IIII i 000000 / / %/ / / / / / i i / / / / aaa�aaaai/ r i / / / / / / as , r r i a • r U I I( r i r 1' (I h� / / /1 r /f / / / / / / i / / / / / a r r, r, r% r ri/ rr„ r�iii �Yli� umpuuu � IwU'Wm' IIIIVw �vU�l" III INN �w W Y 4 mI�M I I II I u i t it Il�la um I 16�' Ij ti ! I I luwlww ICI I�W�I r pp r= d pp � iml�mllm ��' IIII I �w1�9 V v ��QQ IIII IIII I I�, � P iM'M'M' I �m IIII IIII i� UMAnI I i wl r 1 I. Y u �I P t Table of Contents ig!��Imjm III INNER ME ----------- --------------------------------------------------- ------------ ------------------------------- --- r rrrr/rrrrrrrrrrrrrrrrr ,,,,/„ ,,,,, r / rrr / r r r �f r r / , / / / rrrrrrrrrrrrrrrrr / 0 / / �IIr �P00/NN�fltn �� ti to, Diu l �wA"NBukhl�H�oA�� IIpN��VI" liol�100 $� Editors & Contributors FIRE RESCUE ADMINISTRATOR . Chief Michael Mackey DIVISION CHIEF OF MEDICAL SERVICES • Chief Rich Ells DIVISION CHIEF OF TRAINING AND SAFTEY • Chief Sean Pamplona MEDICAL DIRECTORS • Dr. Kenneth Scheppke, MD, Chief Medical Officer • Dr. Peter Antevy, MD, Medical Director Pediatric Division • Dr. Paul Pepe, MD, Medical Director of Research and Development EDITORS • Charlie Coyle, EMS Training Captain Paul Leser, EMS Captain . Michael Okrent', EMS Captain . James Glass, EMS Captain Jeremy Hurd, EMS Captain . Neal Niernczyk, Special Operations Captain • Kurt Ruby, Lieutenant • Rafael Suarez, Firefighter/Paramedic . Alec Myers, Firefighter/Paramedic CONTRIBUTORS . Dr. AID Malek, Interventional Neurologist • Dr. Nicholas Sama, Orthopedic Surgeon • Dr. Larry Bush, Infectious Disease . Dr. Lawrence Lottenberg, Trauma Surgeon • Dawn Altman, RN Medical Di*rector's Page 1% Protocols for Palm Beach County'The following Emergency Medical Services Protocols are the Official Advanced and Basic Life Support utilizethe department to care for the sick and injured. Only those Paramedics and EMTs approved by the Mledl- . c Kenneth A. Scheppke, MD r Chief Medical Officer J Peter i u „r r� i M. Medical Director of III Pediatric Care Paul E. Pepe, MD Medical Director of Research & Development r r. f; 't, um vn :IIIIIIVI ��sV.. Wry �Ispipll�l«ti q1 kl ^11� QQII��µmmOQ �II �Jlll� I '°��IIQII�l1�y�1p11��11'I� I g �111 m, W�nlsn "p�➢�� mu�IIQ �I �j�11V1W�0IW1V�11'jo�W �i W�I�WIQW lb ��nn�nn�ll�m�SS514y� �Qy�Q»��` m�1W I ioo�6111u�� mq� �imts11V111'I��s l� 'u 4 Illkl:\ 110, 351 V n, ,"jili" mti��1 000 1� � r1/ , / n f y i j j rf, i / i/ / / / /r i/ r / / / r / / / / 0 / r r I/ / / /r ni ram% , 0/ ��/ �/,,/� ,/r//i,//,.,.... ,...!„� ,.✓raid„�r/: -: ,��,i� �-. G 1; i/ 1 r r/ � o / / /0 i o / Information .............. General Iluy , INFORMATION It is recognized that the EMS protocols cannot address every possible scenario. mmmor44rrJumfM` Therefore, EMS Captains and Trauma Hawk personnel are given the r authority deviate as • ��m.. a; r ■ needed. Clear documentation of the on is ent's best required. Good judgment and the considered interest must be uuu ADULT&PEDIATRIC a � MEDICATION ADMINISTRATION • Prior to administering any medication, 'inquire about medication allergies or adverse reactions to medications Follow/the b Rights of drug administration • Person • Time • Drug • Route • Dose • Documentation • A true allergy/to a medication causes a rash,SOB, swelling of the tongue,face and/or throat • The administering paramedic shall use closed-loop communication With a second paramedic t ensure proper drug,dose and any/contraindications prior to administration.. • Are ICE should be placed four pat+ents with emergen y medicaI con ditions that re+quire urgent vascular access in whom an IV is not immediately obtainable or is deemed to have insufficient access • Ad u It: • Proximal Humerus • Proximal Tibia • Distal Tibia Pediatric.. • Distal Femur 0 Proximal Tibia 0 Distal Tibia • Proximal Humerus(only if the surgical neck can be palpated) IM INJECTIONS fie All IM injections shall be administered in the lateral thigh Adults: • 21-23 gauge 1.5 inch needle • 4 L maximum per Site Pediatric: • 23 gauge 1 inch needle • 1 L maximum per site If> 1mL needs to be administered,split the dose between both thighs MUCOSALATOMIZATION w.w.wwww-wIw w-ww.ww- w w.v�naw.v,.,.sm'urwrwrv.uw.wu The following medications can be administered via the MAD. i Versed • Fentanyl i s rca n • b eta m i n e • Desired dose: • 0. mL-I . mL per nostril • Max 1 L per nostril rrrrrrr rrrrrrr / ///%%%%/ v / rrrrrrrrr ,....,.... ✓ .,;,,r /, %%��/r rrrrr�� rrrrr / aaaaaaii/ / /i rrrrr i J r , r rr /r / / r 131, j >wm ll fy NU General Information condnued.. MEDICATION DILUTION INSTRUCTIONS • PUSH-DOSE PRESSOR EPINEPHRINE (1-.100,000)1- •ADULT&PEDIATRIC Dilute: Discard 9 ml.of Epi 1:10,000(0.1mg/ Q and draw up 9 mL of NORMAL SALINE to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg mL. 0 Dilute with 9mL NORMAL SALINE for IV/110 administration • Ensure KETAMINE is diluted per specific protocol m n(� r PEDIATRIC Patients who have not reached puberty are considered pediatric patients and shall be treated under the pediatric guideline section of these protocols • Patients who have reached puberty shall be treated as an adult • ICE is thre preferred method of vascular access during pediatric cardiac arrest THE "HANDTEVY"SYSTEM 0 The "Handtevy" system shall be utilized in the resuscitation and treatment of all pediatric patients 0 The child's age should be used as the primary reference point for determining the appropriate patient care * If the child appears shorter or taller than stated age or if the age is unknown use the"H ndtevy" system length based tape • Refer to the "Handtevy"system for the following,. • Medication Dosages/Infusions • Equipment • Electrical Therapy • Vital Signs PEDIATRIC AGE CLASSIFICATIONS • Neonates: • Birth to 1 month 0 I nfa rats: 1 month to 1 year 0 Children: 1 year to puberty PUBERTY Female puberty is defined as breast development Male pubertyis defined as underarm,chest or facial hair Once a child reaches puberty,use the adult guidelines for treatment ,aaaaa / /,,, 14, rrrr / c ✓i / / i rrr............ / r i i Patient Assessment / ADULT&PEDIATRIC Patient with Altered MI consider.MENTALT � A1P � AIOU-TIPS • Alert:to person, place,time, and event 0 Alcohol 0 Epilepsy(Seizures) 'Verbal: responds ly to verbalstimuli�Ilu��!�� i : r n canly to ref uI f (Hyper-/Hypoglycemia) Overdase/O (Kidneyxygenstion Uremla i ;r VITAL SIGNS 111111`rauma Pulse (rate, rhythm n quality) Infection Respirations(rate lity `Psychiatric Temperature Stroke/Shock Pulse ill Bloodr r (capillary refill) 2 • Priority is shall receive t least 2 sets of vitals • Priority 2 patients shall receive it is every 5 minutes • A manual Blood Pressureshall be taken to confirm any abnormal or significant automatic Bloodr ss r reading • Blood Pressureshall be checked beforen r administration of a drug Hypotension for adults is defined Systolic ETCOZ MONITORING • Shall be utilized for the following patients; • Pati+ents requ"ihng vent!latory support(e.g., BVM,. ET trube,S A, CPAP) • Patients n respiratory distress • Patients with Altered Mental Status • Patients who have been sedated • Patients who have received pain medication • Sei ure patients GLUCOSE • A B L shall be documented for patients with any of the following: • History of diabetes • Altered mental status a General weakness • Seizure • Syncope,/lightheadedn+ess 0 Dizziness '• Poisoning • Stroke • Cardiac arrest / / / / / / i f / i PatientAssess entcontinued... ® / UI i% 4ib r ADULT&PEDIATRIC ECG MONITORING • All ALS patients shall be continuously monitored in lead II • 12 and 15 lead E+CGs shall be performed on the following patients: • Chest/arm/neck/jaw/upper back/shoulder/epigastrlllc pain or discomfort • Palpitations • Syncope, lightheadedness,general weakness, or fatigue • CHE,SOB, hypertension or hypotension • Unexplained diaphoresis or nausea • • 12 and 15 lead E+C+Gs shall be repeated every 10 minutes and upon ROSC • When transporting, leave cables connected until patient is turned over to the Emergency Department(ED)staff PATIENT HISTORY »> 0 CHIEF COMPLAINT: Why did the person call' 11? • S.A. i.P.L.E. HISTORY�'IuuN II' IIIII IiNNnI I�'N I�pGi • �Ili�OIU�h4 �I�Illh IGNS F S�Y PTOM • ALLERGIES • M EDICATIO NS: Pr+escribed,o er th+e coun e r,or not pre + ribe+d to.p atient • 1"'AST MEDICAL HISTORY(patient's and immediate anvil s) • L,AST ORAL INTAKE E • IE,VEI TS PRECEDING • HISTORY OF THE PRESENT ILLNESS • ONSET: Chid the symptoms appear gradually or suddenly? • PALLIATIVE: What awakes the symptoms better? • F�1111R VO E:What makes the symptom worse.? ' • 11,,11REVIOUS: Previous similar episodes? • as'I lALITY: (What kind of pain? pressure, squeezing,aching,drill,etc. RADIATION: Does)the pain or discomfort radiate?Where? SEVERITY CAP PAID: 1-10 scale (utilize it Faces"' pain scale for pediatrics) • r"IIIIIE: What time did the symptoms begin? • ASSOCIATED:What are the associated signs& symptoms? / ., aiii ..,,., ✓ ,, .....ilia ;: is i / / / / i as / / ,,,/i� / /// a/i / / / // / / //, /�i /, / a / / / a / ....ail/////// / /� ,�/. /i%��/ / / / / , / as / � // / / / i/ / 16 / .,.,. / ,........................ as �........ /aaaaaaaaaaaaaaaa/aai,,,,,, / / a � / /��/ ��, / ii / ail / >, / / °//�/ � ,,,, %�// ,,,,,,,,,aa / / aaaaai/ / aaaaa/ � � / / BasicIY rr �EEEMA V11 ADULT&PEDIATRIC ru G AIRWAY • AIRWAY POSITION I p, • Medical patient: • Position patient with eternal auditory meatus (a.k.a. "rhe Earhole")on the same external plane as the sternal notch • Traumapatient with suspected spinal cord injury: • Modified jaw thrush • (NPA)- Semi-conscious patients with an Inta+ t gag reflex shall have a nasopharyngeal airway inserted, unless contraindicated • OROPHARYNGEALAIRWAY ( A)�:T, • Unresponsive patients without a gag reflex shall have an oropharyrrgeal airway'Inserted, unless contraindicated I HIM 111111°)0 I111 , 'T withhold Oxygen if the patient is dyspneic or hypoxic r SIP ru udlll:III • Maintain SP02 Of "i for: • III patients 0 Exception: C P D &Asthma • Maintain SP02 Of 0 for: 0 +COPD&Asthma OXYGEN ADMINISTRATION N m i 2 LPN NC 0 All Stroke patients(increase oxygen therapy as needed) • 15 LPN via NRB regardless of SpO2 • All 3rd trimester pregnancy trauma patients • All head injury patients a Decompression sickness • Carboni Monoxide exposure • Cyanide exposure 116 If oxygen saturation cannot he maintained,ventilatory support should be provided CIRCULATION i Adult: • Carotid and radial pulse present,assess capillary refill, assess skin color, condition and temperature • Refer to th+e "Irdlac Arrest's a Igo rithm (pgl,,l 0),for all pati gents found pu Ise less • Pediatric: • Carotid and radial pulse present(brachial in infantassess capillary refill,assess skin color, condition and temperature Refer to the "Cardiac Arrest"'algorithm (pg. ),for all patients found pulseless Refer t+ the � ra+dy�car�dI "' pr tocal(pg. I car pediat is pat+ents�found radycar+d+c�+ ith sign of poor perfusion and AI iS 17 / ii rrrrrrrrrrrrrrrrrrrr, _ r / �: rrrrr rr . rrrr. / / / aaaaaoi ar / //Oi r' / �� / rrrrrrrrrrrrrrr .// / i rrrrrrrrrrrrrrr. / � �///// i /rrrrrrrrrrrrr,� / /// � � /✓ / / / rrrrr i Ventilatory Assl'ostance .......... r INFORMATION • In certain patients,excessive ventilation rates may be harmful. • Overzealous positive pressure ventilation +cart impair. • Venous return • Cardiac output • Cerebral perfusion * Ultimately the patients SpO2 and EtCO,,? should determine the ventilation rate for the patient(ideally EtCO2 should be 35-45 rnm Hg). PULSE:ADULT VENTILATORY RATES • PATIENTS WITH A 16 1 breath every b seconds • PATIENTS WITHOUT A PULSE: 16 1 breath every 10 seconds. Coordinate compressi,ons and ventilations to avoid simultaneous delivery. • Maintain EtCO2,between 30-35 mm Hg and SpQ " 0%while continuously monitoring BP inl� 7� PEDIATRIC PULSE:VENTILATORY RATES PATIENTS WITH A i 1 breath every 3 seconds PULSE:PATIENTS WITHOUT A • 1 breath emery 6 seconds. Coordinate compressions and ventilations to avoid simultaneous delivery. • PATIENTS WITH ICPa E • Maintain Et+C 2 between - 5 mm Hg and SpO2>90%while continuously mon 1toring BP The preferred method for ventilating pediatric patients is with a BVM In conjunction with an oral or nasal airway.Pediatric patients who can not protect their airway,are unable to maintain omen saturation despite BVM ventilation,and/or can not be effectively ventilated with a B M,should be upgraded to a Supraglottic Airway (age specific) fdildw d by Intub tiwn If needed. I mu i" i uu ��umm,I ��w n�I IIu Dui„� �� u��wm�'i� � I ��m o V uu�u1 II I�mMM'IIII II u�"emu i��i �wu i II uml�� II I i i uo��i u�m m E III II �, ��m V umuu„ Vu I I i I u1,i �1� V uuum�t iV�� m��,i m V I� mul" S ul �� m��. V i�pl '�luiwo' umo, min w Vmi II • Cardiac arrest pre/frost ROSC • Bronchosprasrrn(I.e.,,asthma,,C PID) • High EtC0z levels are acceptable and even desired In these patients IIII. of i i i i i r o . i i �� ii Adult Tport Destinations / INFORMATION rr r" ata tnr Pi o u «i�'z Priorlty Cardiac0 Patients in i patientsPrionly 20. 0 Unstable I - Iconditions Stableimmediate life-threatening condi "` It is expend that the Lieutenant will be in the patient care compartment dukin transport r all rior�t� 1 and patients.The Lieutenant ay,�u discretion with priority �# n p�c� ,buthall be in the patient care compartment for the majority of the transports. ------------------------- i�1, III'' Placing patients in the prone position is contraindicated dine to the risks of asphyxiation. [However, impalement or other situations may mandate the prone position. In these instances, +Clear documentat on of justification and attention to airway f'1'1ai1'ntenance is mandatory. ADULT PRIORITY 1 PATIENT dl • PRIMARY CARDIAC ARREST,: If transport time is<20 minutes: • 'Transport to the closest STEMI facility If transport time is>20 minutes'. "Irransport to the closest ECG(excluding free standing ED) • RESPIRATORY ARREST/SECONDARY ARREST-,,,, Transport to the closest ED (excluding free standing ED) PRIORITY 2 PATIENTS °Shiall be transported to the closest appropriate ED TRAUMA r Shall be transported to the closest Traurna Center. If can bypass,transport patient to the next closest 'raurrra Center • A minimum of 1 param ed'+c and 1 EMT must accompany a trauma alert patient in the back of the rescue, provided Ft does not cause a significant delays in transport Ito Can-scene times four Trauma Alert patients should be<10 rninutes.on-scene times >10 .minutes shall have the reason for the delay documented in the ePCR report If,ground transport is>25 minutes transport by air flip Trauma patientswho arrest in the presence of Eire Rescue personnel, shall be transported to the closest Trauma Center Pregnant patients meeting Tra u m a Alert criteria should be transporte+d to St. Mary"s Trauma Center byalir whenever passible TRAUMA ARREST: If Trauma Hawk is not available and ground transport is greater than 40 minutes, it is acceptable to transport to the nearest ED 19/ .......... ....... r r . r / / / r, / r. r r r r . ............. Adult PRIORITY 2 PATIENTS CONTINUED • STEMI ALERTS:' • Shall be transported to the closest STEMI facility • If ground transport is>40 minutes transport by air to the closest STEMI facility with surgical backup • Patient presentations that are ind'i cative of myocardial "Is hemia that'DO 114011T meet"STEMI Alert riter a" should still be transported to a STET II facility • STROKE lo„ • All Stroke Alerts shall be transported to a Comprehensive Stroke Center Exception Known terminal illness or Hospice Care patients can still be treated as a ° IROI(E IL I I1111 t 'Transport these patients to the closest Stroke Center(Primary OR Comprehensive),. • If ground transport is>40 minutes transport by air to the closest Comprehensive Stroke Center • SEPSIS ,- • All Sepsis Alerts shall be transported to closest ED (excluding free standing ED • ST,,, MARYS HYPERBARIC CHAMBER(encode prill'or to transport to confirm availability): • Decompression Sickness • If ground transport is>40 minutes transport by air • Carbon Monoxide Exposure • Hydrogen Sulfide Exposure • Cyanide Exposure • Should be bath paralyzed and sedated by the sending facility • If the sending facility physician refuses to administer paralytics,the EMS Captain must: • Be contacted • Follow the Advanced Airway protocol • Accorrrpany tyre patient to the receiving facility PRIORITY 3 PATIENTS • Should be transported to the closest appropriate ED of their choice within 40 minutes.The EMS Captain may approve/decline transport requests longer than 40 minutes0 FREESTANDING ED: • Stable patients may be transported to a `"Free Standing ED"after: • Being informed if they creed to be admitted,they+will be transferred to another facility • Signing an Emergency Transport Disclaimer • Obstetrical (013) patients are defined as gestation >20 weeks • Unstable CAB patients should be transported to the closest ]B ED • Stable CAB patients should be transported to the CAB ED of their choice within 40 minutes • Suable Baker Act patients shall be transported to the closest appropriate facility • Unstable Baker Act patients shall be transported to the closest ED for stabilization o / / o / /oo / f / / /000000000000/ ,, / / / / / o// f / f r I 6 i r Pediatric Transport Destinations INFORMATION a FOR THE PURPOSES OF TRANSPORT,A PEDIATRIC PATIENT IS CONSIDERED< IS YEARS OLD PRIMARY PEDIATRIC EMERGENCY DEPARTMENT IIIIIIIThese hospitals�,DO N10 IImOi ry�d inpatient pediatric y y capabilities u:;p have lim.. illnesses VIV S. 'IlV pediatric R COMPREHENSIVE PEDIATRIC EMERGENCY DEPARTMENT These hospitals have pediatric Gil admitting i !capabilities options. They can also provide a bridge to+ pediatric ^ n- Iw- lam ve care. IPn tr� PEDIATRIC IC PRIORITY 1 PATIENTS `RAN POR TO COMPREHENSIVE PEDI T IC ECG: • Pediatric patients who have regained a RISC • Pediatric respiratory arrest cases that have successful airway ay management i.e.,,good compliance with the BVI I and airway adjuncts, positive EtCO,waveform,Jmprov11 11 � pulse oxirrretry) TRANSPORT TO CLOSEST APPROVED PEDIATRIC ED PRIMARY OR, :II • Pulseless pediatric patients • Paediatric respiratory arrest patients who have an unstable airway("i.e., unable to ventilate or oxygenate) PATIENTS:PRIORITY 2 PATIENTS • TRAUMA ALERT • ball be transported to th+e c losest Trauma Center„, If can bypass,transport patient to the next closest Trauma Center • A minimum of 1 paramedic and 1 EMT must accompany a trauma alert p bent in the back of the rescue, provided it does not cause a significant delay in transport • 0n-s+cenel times for Trauma Ale rt patients shouId be< 10 minutes. 0 n-scerne times>10 m 1 notes sllnall have the reason for the delay documented in the ePCR report • If ground transportis L 5 minutes transport by air • Trauma patients who arrest in the presence of Fire Rescue personnel, shall be transported to the closest Trauma Center • TRAUMA ARREST: • If Trauma Hawk is not available and ground transport is greater than 40 rninutl s, it loll acceptable to transport to the nearest ED • STROKE ALERTS,: • All Stroke Alerts shall be transported to St Mary's • If ground transport is 0 minutes transport by air to St,, I'' ar(s • SUSPECTED SEPSIS: • Shull be transported to closest Comprehensive Pediatric ED ' PRIOR AVAILABILITY).p i Decompression Sickness. • If ground transport is 40 minutes transport by air • Carbon Monoxide Exposure • Hydrogen Sulfide Exposure • Cyanide Exposure PRIORITY 3 PATIENTS • Should be transported to theclosest appropriate pediatric ED. // ri ail, aia / / / /rrrr, i.... ///rrrrrrrrrrrrrrrrrrrrrrrrrrrrr//rrrrrrrc r r r %/ / rrrrrrrrrrroiiiiiiiirr / it r//aiiaiiiiiiiiiiiiiii ,;- ✓ %/ rrrr>r ��/ %%%%%/ /........ 1...... i / rrrr r >rr ,,rrrr, ✓iii/////i r r r.. .✓i ,,,,, ,/„ ,, r//r.. :,,,, iii�/%%/...,.„ %//, ,,,,,��.... rill,, / ;. ;, � ,,rrrr aril a %% /ilia / / r r / r a rr, r r / / / r r / rr / r /rr / r / / / r / r r aaaaa,r / /rr% rr as/, rrrr r r is ✓ / / rm r / / / / %/ rrrrrrrrrrrrrrrr/�rrrrr r r / i / r ate/r r r/rr/ rrr. r i Helicopter Transport Mw pk y ir, per-f ADULT&PEDIATRIC HELICOPTER OPERATIONAL CRITERIA FOR TRAUMA PATIENTS,',', • Pre-hospital ground transport to a Trauma Center is>25 minutes • Pre-hospital scene extrication time>15 minutes • Pre-hospital ground response time to the scene is> 10 minutes • Mass Casualty Incidents(MCI) involving multiple patients with traumatic injuries HELICOPTER MAYKIE USED: 0 For patients weighing 0lbs-500lbs,discretion should be used as to whether air transport i the preferred method of transport • The flight crew must be capable of loading, unloading, and treating the patient within the confines of the aircraft • The flight crew has final authority to accept or reject the transport HELICOPTER SHALL NOT BE USED: • Bariatric patient known or estimated to be five-hundred pounds(500lbs) ( )or greater • Patient who is unable to lay supine(when clinically indicated for air transport) • Patient who is combative and cannot be physically and/or chemically restrained • Harat contaminated patient ZZ"' / / aaaiiaaaaiiii / ✓, i / r, r / /..�� „r aaaaaaaaaaaii/ / / rrrrrrr , / r, aao r j / 0 / 1 / / / w / / w lNlll�l'ttFi�Il1��.., "all gill\k�111��k@�11� .01 mu .00) NIL d v,"al I ��n, IMF gin, lilh 00 n� r ''f ' rri I r / / V fill ANO i / o / o r j J/f ,r d / r rr / III /.r 2'/ / G i /�� //i/ rrr/mg/�� ? ri r, r //' r t i i i BLS Medical Emergencies V + ADULT&PEDIATRIC �tllllu�9'IIIIIIUN�l n Rfiol.< ALLERGIC REACTION • Allergic reactions are characterized by any of the following: • Generalized urdcaria • Airway, tongue, or facial swelling, respiratory distress, bron h spa m, nausea,vomiting,, or diarrhea • Loss of radial pulse or SBP of<90 mm H • Determine the source of the allergic reaction (insect,food, medications, etc.) • If patient presents with airway swelling/respiratory di tress/broncho paysm, t ngu+e and/or facial swelling/loss swelling/loss of a radial pulse or SBA'of<90 mm Hg: • Assist patient with prescribed Epi-e'en CARDIAC ARREST • Refer to the `"Cardila+c Arrest►, algorithm (pg. 70),f rr all patients found plulseless OVERPPSr'wurEPOISONING o'w • Try to i1dentifV source of the overdose/poisoning • Assist patient with NARCAN if available, applicable • Consider contacting the Florida Poison Control Center at 1-800-222-1222 SEIZURES • (Consider the passible causes: • Meningitis a Drugs • Fever 0 Alcohol • Head trauma 0 Diabetic • Hemorrhagic stroke P Poisoning • Protect patient from injury if actively seizing ALTERED MENTAL STATUS • Check and record B L • If B L is<60 mg/+dL, and patient is able to protect their airway/swallow:- ORAL GLUCOSE: • 15g, if able to swallow and follow commands • May repeat Inc prn NmIIINI� .o„�� mi:,�� m��q,m� ��, mn to n.��q.��q.� n �� „��, ��I�m�.,o,��q n��l�,im�l o��,o,��q. �i.i. ,.��m��.�•.�m�� IIP,, muoo I !', �I I 41 m l� i�fl � '��pf` ��I��III III i41,,�m�. ICI,III�G��,��I��I�� nP�w�,��Ch��i�I�I�I��Ih��N ipC,�I��1��ICI a��N��I�l m��IDf IIV��f�,��l�lu i��m��1�iul �I� ��,��,��ml�I�u�S�i�li4��11��,��li��ll�m� 2 II wq" i, BLS Trauma Emergencies "I.......... ADULT&PEDIATRIC EXPOSE Asa general rule,only remove as much o, the clothing as necessary to determine the presence or absence of an injury Corer the patient as soon as possible to keeps the patient warm. SPINAL MOTION RESTRICTION • Perform manual Spinat',Motion Restriction by providing manual cervical stabilization and apply an appropriately sized cervicaI collar ass appropriate if t h a patient meets any of the following criteria: • Complaint or finding of focat neurologic deficit ors motor or sensory exam • Complaint orf riding of pain to the neck or back • Presence of a distracting injury • Altered level of consciousness with an I IOI (Mechanism f injure • Intoxication with are MOI present * The key objective is to move the patient in the safest, most anatomically neutral position possible *� If an appropriately sized collar is not available or if the collar compels the patient to move, remove the collar and provide Spinal Motion Restriction • Place rolled towels on the sides of the patient's head and neck • Secure with tape or other similar devices to allow for comfortable cervical stabilization/ IR immobilization • The cervical collar should not cause the patient discomfort such that they are compelled to move • Place the patient on the stretcher cushion,supine 0 If the patient is unable to tolerate this position, place in a position of comfort,that also respects normal anatomical alignment ,HELMET REMOVAL • Helmets should be removed from all patients • If applicable, protective pads should also be removed • Athletic trainers should be consulted in the helmet/protective pad removal process if applicable • Spinal motion restriction should be ""'manually" performed during the removal process BURNS rRrRrRrwRrrRrrrarmRRRRwRrrRvwrrwwar • Refer to the "#Burn Injuries" protocol (pg. 10 ) YE EMERGENCIES • CHEMICAL E Remove contact lens if present Irrigate the affected eye(s)with NORMAL SALINE Be careful not to li ontaminate thre unaffected eye with runoff PENETRATING• INJURIES: Stabilize any penetrating object Cover both eyes with gauge and an eye shield Keep the patient calm,as lcry►ing,screaming or coughing can force more of the tissue outward O 11* 11111 r attempt to replace or move the protrudi rig tissue t R BLS Trauma Emergencies * ,• %�unusual CLOSED FRACTURES Fractures should be splinted in the position found Exception: No pulse present Of the patient cannot be transported due to the extremity"s position patient0 2 attempts can be made to place the injured extremity in a normal anatomical position 0 Discontinue attempts if: The W III IIIIII II Il is resistance0 Reassess neurovascular status before and after repositioning of patient"s extremity FRACTURESIf there CLOSED MID-SHAFT FEMUR • Apply a Sager Tracbon Splint Co In t Ii"'', IIII'IIIII Id Ii ic t,,i is ��'u�.III " I�� "��I�I i iu 0j1' �"��101"°�I� ICI' I �I�� '� �� I '�I '�I��°m � II I!� 11 1 l 'It e 10 lug i 'q�III)i„. i fie mur fiI111111,aictulrie 14 Y,,III tllt Ii s is sio a sus IIIII ieic'tied fri l c lug III"II,e is i°I' i ° o" I 'e r fo c i IV5u VI°'i��is i�"u IIIIImI a I� Ipll''r Ipl lm Q ft i' IIIII dull • Reassess neurovascularr status before and after repositioning of patient's extremity OPEN FRACTURES Refer to the "open Fracture" protocol (pg. 112) HIPFRACTURES&HIP DISLOCATIONS Consider hip fractures in an elderly patient who fell and complains of pain in the knee, hip or pelvis, stretcher should be used whenever possible to move patients with a suspected hip fracture Splintlin position of comfort with pillows and blankets 0 Reassess neurovascular status before and after roving the patient Sager Traction splints shall INGT11 be used on suspected hip fractures or hip dislocations 0 POSTERIOR HIP DISLOCATIONS,,, Most often present with the leg flexed andinternally rotated, and will not tolerate having the extremity straightened 0 ANTERIOR HIP ,)r Present with external rotation and shortening of the affected leg treatPELVIC FRACTURE • Assess and r shock perform rock. i i pressure rposterior and from the sides to iidentifV crepitusr instability. DO N1011111 repeat. • Stabilize if possible • A►scoop stretcher I,should be used whenever possible to move patients with suspected pelvic fracture • Splint in position of comfort with plillow and blankets • Reassess neurov►as+ ularrstatus before and after moving the patient BLS Trauma Emergencies continued.. BLEEDING CONTROL EXTREMITY INJURIES: • Direct pressure(utilizing manual pressure and pressurie dressings) • Combat Application Tourniquet(C.A.T.) Apply high and tight on a single long bone until the bleeding stops • IIDO i 1 a I C.A.T. directs over nuray .pp 1� � rte or point. • if bleeding persists after initial C.A.T, apply a second C.A.T., • Celo c Rapid (if 2 nd C. .TappIication fails to controI bleeding): • Pack wound with Celox Rapid • Maintain pressure for a minimum of 1 minute • Apply a pressure dressing JUNCTIONAL HEMORRHAGE (e.g.,, neck, axillary, pelvis and groin)- • Celox Rapid • Pack wound with Cel x Rapid • Maintain pressure for a minimum of 1 minute • Apply a pressure dressing ALL EXTREMITY TRAUMA • Gross contamination,such as leaves or gravel, should be removed if passible • Determine mechanism of in ure (MO I) and evaluate • Assess neurovas ular status of extremity • Color,temperature, capillary refill, crep tus AMPUTATION • Rinse cuff 0 Wrap in sterile gauze and place in a sealed plastic bag 0 Place the sealed bag into a second bag with ice packs • Label the bag with the patient's: • Name • Date • Time of the amputation • Time the part was wrapped and cooled OBJECTS.' yJ, rr naawscr • IMPALED impaled objects shall be stabilized to prevent movement and subsequent further damage If bleeding occurs around the impaled object, it should be controlled by holding direct pressure • II'11' 1'� apply excessive pressure • D10 N01111'palpate the abdomen, as it may cause further organ injury from the distal-bp of the object • ,: 0 Protect the tissue from further damage i n g tiss.ue with a mo i st ste ri le d ressi ng the n cove r w i .ing r - - 0 Keep the patient calm, as ng,,screami"ng or coughing can force more of the tissue outward 0 DO Ill11 111111i1111" BLS Bl*tes and tin S jj 1 INFORMATION a : Prre s�iiir;m,intrF` • Consider contacting the Florida Poison Control Center at 1 I 2 2-12,22 OR DAN (Divers Alert Network)at 919)684-4326 as soon as possible for treatment recommendations.. ADULT&PEDIATRIC Rey,r ALL BITES AND STINGS i Clean the wound area with soap and water or sterile water • Exception Marine animal stings 0 DO 11111111 use hydrogen peroxide on deep Puncture wounds or wounds exposing fat • Refer to the ""AIler,gllc Rea c on" protocol (pg. 3 1), if applicable Advise dispatch to Icontalct anImaI controI or the po11ce department if necessary SNAKE BITES • DO NOT apply ice pa cks,tourniquets or co nst ricti ve bands 0 Mark area of edema with a pen i Remove any(constrictive jewelry or clothing 0 Splint any extremity that has received a bite and ensure it remains below the heart 0 if the DEAD snake is on scene,take a picture of the head ("Including the eyes)with the eP g device if passible 0 For hypotension refer to the "Fluid Resuscitation" protocol (pg,,,,,3 ) "INSECT, • Remove ove the stinger by scraping the patient's skin with the edge of a flat surface(e.g., al credit card) a DO N01"111111"attempt to pull the stinger out, as this action may release more venom MARINE ANIMAL •STINGRAY ,,c,SCORPIONFISHCATFISH'',WEEVERF,11504,5,,TA.RFI.SH,,S.EA.URC.Hi.N, • Immerse the punctures in non-scalding hot water if available)to achieve pain relief 0 Gently wash the wound with soap and water, and then irrigate it vigorously with sterile water (avoid scrubbing) • - - NNyy ; ,,, ,.,, ,..min wnrmn,,,,,,,,,, ., .. ,rmnrrmlmm-mn✓,wrvrmr;,m,«minuvarcsreammrrnm.mmrw,rrr RE CORAL nrrrrrrrrrrrrrHYDROID I u�Nrnam!L^, • Rinse the shin with sea water(if available) • DO NOTuse fresh or sterile water III°' �N 101Tl y i ce DO NOT rub the skin * Ap p l i r i ica I ly to i nvo Ive a rea u nti I t h e pa I li ifeg u a rd s m ay ca rry this) large6 Remove ragments using forcepsr PPE on and stay upwindperforming this procedure QVI TO Hoc I. ...... WIN I FF lot 'rp j.F /1', ............... 'I, ,A: 're, Fi -INC HE 6 Not rwp"k 9�j (Q)YV 0 .............. po 7 In o n 03 0 0 M09#99!0 PO 3=9) #Do ............... % I Mr 0 .......... ............... Mon, PLO A"T, -%/All, 4A PO '�'f......... '4 7n J ,.wAilergi'c Reaction INFORMATION f" Allergic reactions are characterized by any of the following: Generalized swelling,0 Airway irespiratory distress,p ytongue and/or facial swelling, y I nausea, vomiting, i } B Determine the source of the allergic reaction } y food,- y/ medications,etc.),, ADULT MILD—GENERALIZED URTICARIA ONLY • SOmg IV IO IM,over 2 minutes IWIO usage Dilute with 9mL NORMAL SALINE for1V/ICE administration », ., f ACIAL Kurrrrrrrrr '�wYl,'��kwvmr�il�mriirt�mmr" • EPINEPHRINE uu (1:1.0001 i3m .3mL) IM 11 May repeat 2x prn, in S minute interval lump mIIIIU Nlllpl a4 k roe„ I' 1.�,,,, �,,,,, ✓�� I r moo,. r o II� <� ,../ /„ U! J-. I /Q��III� I j ,r, f I I / ��. I r I r I I, �� uum V��l�'Nmlllll�IVU" ��f f r r�r.�r��„�,�� <i�� . � � �.��l L;�F��,,� 1"IC 1��l „��; 1��>(,1.��k��,✓lR �I�,i"on lip 50m 1V I IM, over 2 minutes for I'll ID usage a Dilute with 9mL of NORMAL SALINE for IV/110 administration • A►LBUTEROLn • 2.5mg via nebulizer 0 May repeat prn • S L - E R L, • 1 5mg IWI IM, P ,over 2 minutesfor IV/III usage ,SEVERElLOSS OF A RADIAL PULSE OI Pm� ff? BP E 0 mm PLISH,DOSE PRESSOR EPINEPHRINE(1-6100,000)�', • Dilute: Discard 9 mL of Epi 1:10,000 (0-1m Q and draw up 9 mL of NORMAL SALINE to, create Push-Dose Pressor Epi 1 100,0001.This will yield 10m mL# • Administer 1 mL/mInute 1 I ,titr te to maintain SBP 100rr m Hg • May repeat 2x prn, max total dose)300mcg(30 mL) VMS, NIWW� r W: . W � IC� ��I l I4� �I�1�l I� W�VrIC CI@ - I �ID��I(lf 4 �W� I � h �f,II �I�C O r�Ir//r l� d Y' O /4,,,I,.I,.,,i� i �i f /„ /i f / %% I /rir p �l// � r/ lr / / r-r I� r lr � r-r fir / / �4 ��I,Ir f„ Ir I f,lI' °`,I� iV, 1 r: I,Ir�I' �„ 'f I I,,1 I.'ate' D f,f a �eF w+i ,.Ir r web ro ,r„ir lr U Y, G ,,o<, r i/.,/ r Oa r,��o r� /'/% /i t in ) o, ), o,I I/ I/'%I r Ii/ o / !r�;,,/ o', � �;i/ /Ir r, ri /r/ r�„I ,v r, r �„�// � ,�r%% /�,,,,i„r�-r„ r f �iir I.I,: If f rr1 r. w f !, I �. Ir.. I.1. r.,f j 1. rr rr r rs r.,. G �, L o l:rT w �, m y l: �. I.,,/lrT...,,9. lr�i� b �GweG rr r„w, � Ip 1, s,./i r.l�4 re (r.,er 1 I/ r.,e w,cr 7c �fi raly g r w:�.;zi/i I,�r� �/ NORMAL i • desired effect.trate to Assess lung sounds and BP frequently, a May repeat Ix prn f% J i P � 1 / r'/' r r r r'°, r r r ire ,,,J�, °,�/ ;/ r �; 7 ��;`J ( / ,/ ,,,1� r- f l r v r 1„, / /, r:'/ r 7 ,/ t I �/ � di �J ��la �� /� r r l 1'I I / / �% J r'' o �% / r r �, �r /�i �l r r ��1i, 'r �i,,,i,i,,,,,i„ie�,nr�,,.��,,,1/ �l � 'r,/ r- q.///r „/ r- i �%,,.//, I% /, r, Is I% '� I. 1- i ( / I S I / r F f o., �v i �;�rf'( �� ,,��o., G''a/r� o„,� ,,,,�. �w.. � �l'( �,.��,.., (,,..� �� ,/ ��r r. o G'�,y�r��a�., U�e/I,,,�G h�,��0 a l� I a T y�I a„ f r ` J(I y j G�Jl l /' I� Iyp G/I f/� l l lii I"!f/J/ /r//'7i, f 0 1 I Orr a l/r(ti J 'ISi",rva/n 1 a F,V,f��,�, �m I I F I m�i�I,�f �r r I��, V.1/��r I,�oJ/,I�s �,,t I F�I r,I,r n��,. E D Li as noted above as noted above L:-:as noted above Aliergi*c PEDIATRIC !�Iwtiw, MILD—GENERALIZED URTICARIA ONLY I'Y ( r �M 1� 1mg/kg IV 10 1M,,,over,2,m inut s for IV/1 0 usage • Dilute with 9mL NORMAL SALINE for I11/1 'administration • Max singledose 50mg Ilk I�' ' I�'IuG„ ICI 1'""1 IIII �nP IIII' IN 1 10 l 1 ':1 u RESS J( ASMI TONGUE AN wpR,armor; • EPINEPHRINE FACIAL SWELLING • 0.01mg kg IM, max single dose 0.3mg 0 May repeat 2,x prn, in 5, mill nute intervals y � ';�,�r li, "„�"' l�•I`rr Ili ,rr,% � � (rr, 3, "«)u"( rl �°I Jd ( 0 1rng/kg 1W10/IM0 over 2 minutes for IV/10 usage 0 Dilute with 9mL NORMAL SALINEfor IV ICE administration Flax single dose 5101rg r -- Neonates It • LBUTEI L • 2.5mg via nebuli er • May repeat prn • ro n, • g g 1W1 /IM/P ,over 2 minutes for IV/Io usage • Max single dose 1 5mg SEVERf,,- II %I ,�IIIIIII �� AGE APPROPRIATE HYPOTENSION r PUSH-DOSE PRESSOR EPINEPHRINE(1:1100 , • Dilute: Discard 3 mL of Ep i 1:10,000(0.1 L) and draw up 9 mL of NORMAL t,' '' create Push-Dose Pressor Epi 1:100,000. This will yield 10m g/mL. •► Administer 1 ml/rn nute I I ,t tr to to maintain age appropriate SBP • May repeat 2x prn, max total dose 300mcg(30 rl raw, A "IIII"'"I" IIII"'m" IIII IIIIY° IIII ,w,., I� SIP '� III"'III �I IIII 1 / ,r f 10 NOT;, I f'f f I,'`f ',sx,t t%'I° ('`f L (L i I`i,F f I' ,1,nni, i J I ,r r J „i G, f„1; f" / / / /t // /r, / ( j f% r r r r / 1 / / fr r / 7 ei ff r,,,l //// r� ( I> i I% 4 v, I I ( �s t� ( (s r �i�1 r I�It r i // r l i r I,, 'i F ��l�,� r ��/, r ��, e I.��,� ,f�i �. ,�,�a/I� f, �-(r,k/�,F„� 6 I,� .� �/ ro, Irm 6 r z//m �, ,/ I .�� !,!d � /��,�ii.mil ��I, r�/ r.�,r, r!�r/" / / / �r /i r�, ��„i i r�,�, fin,,,,,ii'^,,, / n,,.�, �.. .>.,, i r r,; / .�i r,,,d/a, /i�-��, �// o` r f I;S, G's i I r r t(r!la y.�, ;s 1 �.'J 1.i�� 's 1�tr s J'.I.tr r �: I,I r/ /1 I r /; fi 1m°�r r r.1/r(,Is rr �,/,� � �.�l� �a�r,.li//I.I,F,�I F./I�r�,mn 1 i��pia/r r„cG .�6.�/-�/ �rdG! i..mil.eC��mi. O.� !� �rG /�,,,,,,%��,n�I°7�� 4 i rr�� b�o v I i,-/✓<�,�I�1 i/i I i.I. NORMAL SALINEI-, i 20mL kg I1 'I 1, assess Dung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension BEUII'l as noted above LI TI IL,:as noted above SOLIUMEUROL: as noted above "' I. .... Dioabetic Emergena'Oes INFORMATION Poglrr,ariorr��HaZ�,i��°". Symptoms of hypoglycernia CMS Slurred speech Dilated pupils •► Seizures Coma • irritability • Symptoms of hypergly erniaM with Diabetic I etoa cidosis (DIVA) include: 0 Nausea/Vomiting 0 Abdominal pain 0 General weakness 0 f ussmaul respirations(deep rapid respirations) 0 M 0 Hypotension 0 Tachycardia with are acetone smell on the patient's breath •� Diabetic patients taking aural hypoglycemic medication (e.g.,Glyburide,Glimepiride,and li i lde should always be transported if treated. ADULT HYPOGLYCEMIA: ORAL GLUCOSE 0 May repeat 1x prn inn Iiio�. µn rn I uON !P FiiU&F�uyuu�µ.� gnu Ip�d I no.. mmn��4n linu pug�am i,��m� I' �.uu w�wq ,gym. pur,.mnu um u m i,.mnu m �uuu:, i, un� i�� I� I�� IQI I�'I u,m Ip �aw m��; i��u,. u��i „nm 101 Qwl ICI ICI Ian Ian.lw �r I m 1 u, II�Illlmr�i lug III r �� u�P�Q,�� IQn ICI t"Ip� I�m ^Ilu ' �� I u m II Ann I �°�� i )�P,�w Q r, Retest glucose May repeat Ix prn HYPOGLYCEMIA: .. ny�mirury mmni�m�mHuwumum,�rx�aruvr vu"c,.,� ,,ivrr� ..r • 250 mL I /I . Rapid infusion HYPERGLYCEMIA: BGL>300 MRAL WITH SIGNS&SYMPTOMS OF DKA NORMALSALINE' n m IV/10',titrate to desiredlung sounds and BP frequently,,, repeat 1x prn �,��„r- ,,.. r�� ;;.r �,1, ,-��., 1 �.�r,,, ,. ��,-.� r �; 1+ i, r r � i f f i i t r ( I t K V I l fi i,I 1,. ,f r 'Il 0 I f,.,l,,,,,II „J II,,r„ l I (,Il (,, V l( I,,,,,, �( llr I // ff,it', H�i �Ji�,;r J Y II,,,,,, I"/�„ r'� � (;,fl III,,II II,� �uu a' i j' IIII i///j All Diabetic EmergenCI'OeS continued.. PEDIATRIC ORAL GLUCOSE-,, • 1 g, if able to swallow and follow commands �Ih�O D I .n i m,4�'. �� Lill ie Ir,iI im n 1I1 �( qg l�o��C 7 pe �n1010k t � lilt, I C", 0 • mL/kg IV/Its • May repeat 1x pro �e „ ,,. OF DKA SALINE:NORMAL • rnL/kg lWICE, assess lung sounds and BP frequently • May repeat 2x prn,for BGL>300rng/dl Dystoni'c Reaction INFORMATION Dystonic reactions intermittent spasmodic, 'Involuntary contractions of muscles in the: Face 0 Neck • Trunk 0 Pelvis • Extremities * Even the larynx • The following i a 0 A nti r 0 Antiernetic(e.g.,Compazine, Reglan, Phenergan,etc... • Antidepressant(e.g., Prozac.. Paxil,, r.. * d rstc n is reaction days. ADULT • 50 I I E 11,over 2 minutes for IWIO usage • Dilute with 9mL NORMAL SALINE for IV/10 administration p �p PEDIATRIC * l g/kg IV/10 IM,,over 2 minutes for IWIO usage * [dilute with mL NORMAL SALINE for IV/10 administration * Max single dose 5 r g l ll DY°111 0111 III ICY ��ic ia IIIY°� I�' �,�� n , Fluid Resusa'tationlDehydration INFORMATION In+dicafi on s for fluid r suscita on Non-traumatic* Hypotension * Fatigue Dark Color Urine 0 Dry Mouth 0 Headache 0 Prolonged vomiting or diarrhea SALINE:Suspected Rhabdomyolysis Paramedic discretion ADULT NORMAL I .Assess lung sounds and BP frequently. , I f'fI f If I ( a f 111 ,I J 2 's�,�I«J'„a��,,, ��,,, a',,I r�� °'r„��I.�I '�i� I„ I�..�„ ��o,��0�r ''d II��(�.'S PEDIATRIC NORMAL SALINE". • 0mL IV/10,assess lung sounds and BP frequently 0 May repeat 2x prn,for age appropriate hypotension i u, I r��)hM)SMyr Hyperkalemia »ran�ra�ir��ravtuwif', INFORMATION i:. ,4 , i v r w`present with any of the following,,- s Con de r hype rka le r m Cardiac• General weakness • abnormalities: Tall peaked Iaves (most prominent early sign) * Sine wave * Wide complex QRS v CHLORIDE:High degree AV blocks ADULT 0 Obtain 12 and IS lead ECGs and leave cables connected FOR PATIENTS PRESENTING WITH ANY OF THE ABOVE CARDIAC ARRHYTHMIASAYP�OR�EC�G ABNORMALITIES * CALCIUM • 1g 1V/10, over 2 minutes �(i IIr:r„r y,1� „i�;II II l) r,i, ,,,q same !."%�!l I1I rrr III IIP' rl�"� �;,,, �,,,, SODIUM BICARBONATE p tol/n, J00 �� /IIffni I� IIII i� 7 IP II JI Al II II D>` ,'1 t r it J /e ,,i- 11, /III,r(i,, U m a U a, J ll. 4- U U U 4 ll U U ,rD t k 4 re v e - �I1 c��„t Ii f„,II„,+a r6, »�([f1, I 0 U,l;,,` 'r`f fl U,,,,t°, U t g • ALBUTEIOLO. lie 2.5mg Via nebulizer, I Continuous treatment (if an advanced a rway is utilized,administer via in-line nebulization) SODIUM 1 BONATE: 100 m Eq 1V 1o, over 2 minutes "r'i J r /1 r t ,,,. r.�I�r/ if,. ;I, �/m,/ /, ✓' /i r: r I V,i. �,,, I. ✓�,,,I.. 1 S I I% l io,,,,i,. �i a, s/ ,,,,,r,,, , rr,„< .0- r.,r „' i,.r / r`i %/r r / 1'I% 1 r f. ilI f -, Ir %i ,I, rJ; /a I r-, I I'f.I 10 . t. �` m,.�u .tI/,fib r�G r,�rt 6 1„r6 m�F� 1, � ,/�,,«'-k E � ,:ir rmG � � �/��..� ��E� � m,.� LC� �W e L I,If I Ii, � r I CA I �G I„�6�Il�J�0, f,��f� fl,,,,U'S',,,I I'`1 g IF PATIENT IS HYPOTENSIVE • 50 mL I 11,titrate to effect.Assess lung sounds frequently. i May repeat 1x prn 19111II� �� II I I�.....��. u�� „ �,Iu,� . r� � I I II r� II"III(r ,i�� I I r PEAKED T"W VE SINE WAVE I l � r r'�r �f A r s ! r r r r G W v u e- ., it, wMu I >°r rv,,,,.Pfilim ,,, ;. rri, ,,,,,IIVumw.,II'I o»,,,, ,,r,;a„IllloiG ,;,„ ,»„err;, 2 „Mau ,ro, ri ,!"Mrmrrrr a�.I.�ir r N4umwhr�v ^MI uuuuuuuuuml i , .l( �.. ,l � ,�ml lad r�y�, c. � _ruuumm�i�v�l g M I /r r rr rtr, f r mNw f m 0 Hyperkalemia �. ��'aIVU 'iw ( PEDIATRIC • Obtain 12 and 15 lead ECGs and leave cables connected 'A�'f!�9 9%iN%1�119 ➢flPIT ;°A91 i9!^,m11WM�MHIM5fili9DYA R ECG A BNOR MALITI ES 1IN1"R,iu.'M�WFWI�,,I i/A.....iMW1r(m�dbGn�k(bi'nvr/FI�RdW/d'6eGY rdlm'PlGNIdHGF�db(!lldddR(IGRA..rrr.,.rrrGfWRd4GJWIP�4Wkidkb�4id��/di6lfKldid(//bfifiRdl6�4GR6�6/Rk4�&1dk46(�wf66d�lnildta'dr�wir�m'r�.... i6r ,.� �� .�. W 5}WII'419 d;'9Il'+W+wpa��N�,�!^"��""v�l'�n��nm.'p�1MWro91I1nryyL;Mf1D19Pm19PIW!..��AflINfl➢1)W�➢P!A/):.1NMC91 MJM�".1PMD1119Nr",�11IDlY.MflY�f�/��'H��9ANJ,r%�AYlJD1PMA%NDl'�^H➢MrP,"'�'+�`WP;?!1A�,;,°A91',�!MMPP�N MM'l"�9WYI 11Yl P'Yi'Y'�.N,:w9�Y191?YV^�""%i";.�I ON PREVIOUS PAGE 16 CALCIUM CHLORIDE: • 0mg/kg IV/10, over 2 minutes f. i s �.. ,,1 i/i�,✓�r I'1 /r�r rr %rrrr�%// I mar„�/f /-/'".r- r pvrr,, �„�,, l 1"Ii � I.�,,,�, rn ,,,,��,,, I,=,. /f r r rr,1, r/ f r��l ,'; i r �. % „1 f;, ,rr "i,%�I,�l!;�t /f r I� It I;;,. ��/t r,/r� !S � I�� I¢W �I�rl r(�r f�,,,,,( 6 r(( �,a r,rm� p, .�/,, � r �rr[r r/ �r r � rm�p'& 4 IU IL Q I�P��1 I,�1�i d�(p ' ALBUTEROL.- a 2.5mg via neblulizer 0 Continuous treatments(if an advanced airway is utilized,administer via in-line nebulization) SODIUM BICARBONATE.",, 0 ImEq/k I1/Io, over 2 minutes, max single dose 50mEq • May repeat 1x plrn, in 5 minutes. Maxtotal dose 100mEq �lu III �I�J . „, II II III I II�C(m"-I" i/ h�,�,i thoroughly IF PATIENT IS HYPOTENSIVE • NORMAL SALINE: lOmL/kg 111 lo,titrate to effect.Assess lung sounds frequently. May repeat 1x prn i ,�I r r f I IYf .I i. r � I (�Y r I I I I I��f „�1 ��I, -i r, ��6 „' »»llb-i ��(H IC ��o�(I�r�, (,o(fp�rI�i��o�((i II I. III i 1�I r i rr I i r III I C l �.jI�r,. e. �� rrlr C �� I��r��f� �I�I II r�I�I I ,�I I„I�� .I,�,��I, �I I, �,� C �.I� I r �I� f � � ,I �I( � I J�� I �� I I I � I �� I�� II IL..II��L..J.. ��Ir��r II �� III II II I��IC��u L.. ��IU(�� II��r��l�,I��t��I�I� III III III II��III�� {�I��I I��,��,u��I,I�I�� 6��I�� III C�III��Ir��Il�III I�,Q�� I��I��III��,III.II.Il��r III y I ,d ICI�1 li�,a�r��rcl��i ��rr a 0�l6 Id ��I Ilr�� r�I�I1�1��!��4E, III h,I lu, '1 1,11,S ji + NausealVomiting Elm 0 Cardiac 0 Diabetic 0 Head Injury 0 Other 1 ADULT • Obtain 12 and 15 lead ECGs and leave cablesont • NORMAL SALINE," i IL 11,/I rtitrate to desiredeffect.Assess lung sounds and BP frequently. May repeat Ix prn W11I��JI I II I.. �Jp I.II I I 11�I II III I IIII d�1 II'I^ul�I��III� IIII III IIII�� I III JII II IIII�I I IIII II I III J I�I' I I III I'I I 0 4mg IyI I l P"E, over 2 minutes for IV/10 usage • May repeat 1x prn .:rr PE[ IATiI • Obtain 12 and 15 lead ECGs and leave cables connected g I 0 mL/kg I1/10,assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension * 0.1 g/ g I /10/II1r'l, PO,over 2 minutes for IWIO usage • Maxsingle dose 4mg • Respi"ilratiory Dil"Stress INFORMATION Patients with COPD & Asthma have prolonged exhalation secondary to bronchospasm, which causes r trapping resulting in hyper apnia (high levels of +C] j. Therefore,, EtCO2 guidelines should be disregarded for these patients,, as it is more important to maintain SP02 levels at 0%. Trying to maintain normal EtCO2 levels in these patients puts them at risk for developing Auto PEEPO which can result in a pneumothorax or hypotension. Auto PEEP occurs during assisted ventilations when air goes, in before the patient is allowed to fully exhale,,This causes the lungs to expand like a balloono putting the patient at risk for a pneumothorax. In addition, increasing intrathoracic pressure can decrease venous return to the heart which can result in hypotension. 01 COPD or Asthma patients who develop poor bag compliance or hypotension during positive pressure ventilation5 should have positive pressure ventilations discontinued to allow the patient to completely exhale before resuming positive pressure ventilations. If patient has an advanced airway,disconnect BVM to allow patient to exhale jj Positive pressure ventilations should be discontinued for: i Adults: 20-40 seconds Pediatric: 10-20 seconds APWT BRONCHOSPASM SECONDAR111Y PI)or ASTHMA /� (tii ;,. 0 ALB VTERoL; • 2,5mg aria nebulizer. May be administered simultaneously with CPAP • May repeat prn S 1.U-V ED R L 12 mg 1 /10 l M Po,over 2 minutes for IV 10 usage FOR'SEVERE ASTHMA NOT RESPONDING To ABOVE TREATMENT EPINEPHRINE ( ,000 1mg/mL): • 3mg(0. mL) IM • May repeat 2x prn, in S minute intervals MAGNESIUMSULFATE: •� Dilute: 2g of Magnesium Sulfate in a 50 L bag of NORMAL.SALINE • Administer over 10 minute III/ICI by utilizing a 15 gtt set delivering 75 gtts/rain (1.25 gtts/sec) ICI r� la I�'��d 31 � I�V "� ��dry" Y Pe � b/91 �i z)�i iJ s i m e Imi ! �rJ fi 1U i�l'�� yr."�i 1 Ul :b�i�'. iJ /r ,tff U1 p 111 o li a a[_Jt I�l.� �,n�'�nd ;�u Il��(��1, ��„ V�� ,rr.�J � �� <��0� ��" MODERATE ''Q��„SEVERE RESPIRATORY DISTRESS;ffNC L E"�, ��I ,+ + P �ASTH I4 Y A►I i P�JEU +'I[�IVIA • CP P 10 cm H20: 10 bieIiiits wICIlflllliiout l i IIII °�� , w Ii I Y111. i �� ' ILi l i it ii'ii i1c, JIR11 Illlll IIIIIP Immediately remove the PAP for the asthmatic patient whosecditionorenafr applying Respi'Pratory DlastreSS i A N PEDIATRIC BRONCHOSPASM & May repeat prn ........, * 2mg/kg IWIO/IM/PO,over 2 minutes for 1WI0 usage 6 Max single FOR SEVERE ASTHMA NOT RESPONDING TO ABOVE TREATMENT • I. 1mg,/kg IM, max single dose 0. mg • May repeat 2x pr ,, in 5 minute intervals. SULFATE:MAGNESIUM Dilute: 0mg/kg in a 50mL bag of NORMAL SALINE • Administer over 25 minutes IV/10 by utilising a lJ gtt set delivering gtts/min (lgfts/2sec) � , mn '�DIE!I r�i i�P W�n1 11Ymm� r (% j�r�j/%% `0 "%/�/r/I,/f �l rlIf//�I� r((��. -/�// %f/( (!/ f �r II ii,fly%is//'l o,(�,oi`,.I, `�'r./i%Irv% ri///, I(. G„% !I,.I, Is.�/ by FOR CROUPIEPIGLOTTITIS • mg ( mLtotal)delivered via nebulizer 1'41c ,6 0/% 6 l r e /d`�� !�.r t r r r Wu uuu r Jr ii l 1 J /r. r ✓ j r irr Ventilate via BVIVI as needed Expedite transport to closest Corn pre hensive Pediatric E s • Usually<3 years old • Dually 3-6 years old • "Sick"fora couple flays • Sudden onset • Low rade fever • ''H h grade fever • Nottoxic appearing . Poor general Impression • Drooling Tripodi BOT111111111111111 HAVE STRIDO,R . Sei'ozure INFORMATION ,Gfl((«lJffl fYf;n �, Consider the possible causes: • Meningitis i Drugs 0 Fever i Alcohol 0 Head trauma • Diabetic a Hemorrhagic strobe . Poisoning �► Monitoring of EtCO2shall be performed to determine the patient's respiratory staters. Refer to the "Ecla m ps ia" prr tocoI (pg. 12 1),for pregnant pati el ts. ADULT !FACTIVELY SEIZING is VERSED: Sang IV 10 IN IM •� May repeat Ix prn, in 5 minutes If seizure reoccurs or does not,subside f� r !;J I' � I!' I�I�r ,,, �!I�l„r �r i r i I,rr ire -r �1 r�to I a I r i�l�r,r r/i� la r, rr f r r r r f "6 ��,r,,rc aii Ire,/f#�,// � %�r�r I�c Ire..�j 1� F��y�r'�� lF �.,,✓1��7 l�i�f lw.f irf lF � i r,�J�� ",�'�'i >-o l?ITV IF SEIZURE DOES NOT RESPOND To ABOVE TREATMENT ETA M I N E with IIIIII liN a pproval oil Dilute. 100 g of I etamine in a 50mL bag of NORMAL SALINE • Administer IV/10 utilizing a So gft set, run wide open peii'vetria,ftq ielyle II Iiil I I Ir� chiest IiI',1'r ai Iii f �rllle c a Id Ir flr s for �I fl �r,��I�li r,D i Ir„1�! rr,;�II �-J l�/�( �J (�,I�' U map"i(r ✓,ar(Ill��; 1 g)omJ f 119 m t Ali &,m i r,iIJ!rlltr f t II II�1 U„i J rl! "rr III L„1J JJ I f II Il IJlmn II IJ Il,,, "H p1!I�' � rrrri rii� ry r i nm r,,,:r r� 1. "��„� � J-i, � 1. U o !1 I �II .e �1 I,. [i I.� i. i. i r, r,may" ,o� 'i� i it nnn".�c n1" 6 I� !1 1 ��.I: � h I. .1" +,I b� [v f I. piiU i r>r I 4 r 1 I I r I I [ r I I�r i�� r I� l r � 1 I 1 ,1 1 1- r 1 l�. 1 1,� J""I 1 ii.) I.�,� 11' 1 �, 1- iiiiilll.- �!n I u,,,/: Ilk i,,,c JJ)1 r �I rf Il �I 1' r 11 I IV I� I� �r �1,Ir 1 I Il 1 1,,J I 1, r r IIi,,,,,, I f u f r U �I,I I f / I � n>t r,, I� 1� rr I� 11�I,I 1 � r � �I � �r I I I r I I� r r V f � I l ��, r J I„ l l J i i J 1 � i 1 I �r J 1 ,1 r � � � I,.,,,�%I„1 ,,,,.�r, � 1�/!,,,oJJ" � ,. �� ,� ,1. ^^ 1- 1 i„ ,1 r,I I I r r: �� IIII r ��pp I" I- I. IIII �� " I -r I �6„ � � Ik �„%Ad m�„ak� ��nl �, �� ✓>�II I,P ,IJ�i„!� ��,�� rdJr �„if U -l„/-�m�U1 f II 1�h{�e�. �.U„JJ' ��'U I%,,,eJJ: �i IP��i �l I�I iD� ✓ " wpl '� ✓ �1 l�U Y r �Y U D I fl L�1>>r� � �u r e IIIn-- j IJI"/�l"III„o III n ji c Jan 1''to II I!Il S' 40\\kill\\.111N1.911&WIi1�9111�9111�9111.9111�9111�9111�9111�9111�9111�9111�9111�111&t s V1M1\\U1111\V1ll119III1W1111N111�N111�!11&WIII1t41111NX11�1&14111�9111�9111�9111�911&NII IF UNABLE To ESTABLISH VASCULAR ACCESS • E1TA t I N E r� 1 } rrng ITIM up ml nmi m �� on q o of I 9 t o II o�� m� q ^m i if i41�m�IQlll�f ll m°QII f��Q mC IQ'hlf miilm�� .. ��I��I�°Qi�� Q QICI IBC f�P��'��u1114@�� I�i��°��ll""11 i�C��°��I�'�II�hI�"Im`��,�ill� SIR I(��9/ f�Ir/�./Ji �j,t�f �i I�""" ✓l✓! I� ��r�J�/ �J�k I�J r li!. u r � l eim JfJ%!'r rLu�S��Yjn. Sei*zure PEDIATRIC roi,r i SEIZUREFEBRILE • ACTIVE COOLING, Remove the clothing i�u�wu la��k I�III' °u'm'Ir coder patient with a wet towel or sheet I1'1111°m l0 NOT apply ice or scold packs to the patient's body IF ACTIVELY SEIZING • .1 k IV ICE, max single dose 5mg • O,,I, kg II /lM, max single dose of 5r • May repeat either route 1x prn, 'In 5 minutes if;seizure reoccurs or does not subside P„a I ��iI Il�, 1�(,�"a i I lm n io 1,n e 0°ii l m i ni 101.°��I�'Illr j �I�/��/�f, I`r I/ r r °r�/Y' /r it i�IO�°°a I/ I/a��/ I IO ��r ��I�i�°��!' I�li��i I/ r �,„o zN''r/o n 1�Ji I,J." �. 1 I�lr rr o 1r ul��lr 1� e/�p lr lr',✓t J� ) �p i �„s�r��. IF SEIZURE DOES NOT RESPOND To ABOVE TREATMENT A!3 YEARS 0 „,,r»4 rrnmmmmm�nrmmmirmin,:m�wr�rremrer�awc�arr��wrrorr „,hKrr��s�ryw�r m^"fimnnrr,.nnnr�nrnrmrmm�mm�rnmmrm�rmmmmmr�z .. ... KETAMINEr�v� h :�� l)'TA appIrulivat, • 1 rnkg I N/I 'l • May repeat 1x prn, ire 5 minutes C"o 111 tIDr" I1 IDI111 i i a io�i��r IIII� ICI' let i1i'llati ��e� mar ,��, .,,✓ra,,,,,,fi -��i�� ,�„� r„rll ,,,,,,,,1� ��, ,�� i,i r r"� r,,,,,i. r� �,rr'� r,,, (f 4 i i rr i fi r �, u� �� I V ��r!�1 ,P s 1, i �1 i, Sepsl'gs INFORMATION °Geis✓a� �1 Sources, signs&symptoms,of sepsi&include, but are not limited to: Fever TI (increased urinary frequency,,, ysur and/or cloudy, bloody, or foul smelling urine) Pneumonia(productive sputum) Wounds or insertion sits that re: Painful/red/swollen or have a purulent s discharge Patientis on antibiotics and has significant diarrhea, abdominal pain or tenderness Recent history of surgery/'Invasive medIc I procedure (e.g., Foley Catheter, Central Lines,etc...) and/or r oral intake over the past 24-48 hours(especially"in the eI rly Bed sores, c ss , ll l'i s, or i I ity Transport ll Sepsis Alerts as Priority 2, li sIf a l f,ml um I IIV e I call, SEIPSI III mm IIII im' Adult m Suspected or documented infection At least TWO(2)POINTS of the H.,A,.T criteria(max score of 3 points) • E Hypotension (SBP< 100 mm Hg)�I point Alteredr GCS:5 14(new onset)= I point (respiratory rate>22) A14111VOIR,WARIIYING [it is imperative once sepsis is identified,that the patient is kept from becoming hypotensive, as a as an episode of hypotension smignificantlyincreases morbidity and mortality WARN1111% * Monitor EtCO2 and SpO2 during fluid administration * Pneumonia patients with rales,still require IV fluids. j �sepsit,os .. r Oil ADULT SEPSIS ALERT NORMAL i SALINE: 0 IL F assess lung sounds and BP frequently .. m slllllllir repeat 1x if a Imr me permits Pi rr; � Jd ,� � r r r I I a � �r/J �,(�,( ff r ( � 1, �i,,,� 0,, r / f (r,/, ,I, ,(.le � � o,,,,�„/i �,,,, � ,,,�,/ ,(1 1 r// I I ,� I ,� I,%/o,la:, I r c r(1�r,, 1(l �l c. �I I ,/U � � l (I r 1 I � /, r � I � l �l I f rr � ( l,i„ L. � .�..J �/ ,,.� , ,.,,,,,.,.��f� ,,,,o„/�c..,,,� �1 „l,.,/u�� 1,,,1�, ��.o �,d II c � „ ,�r ,,,,,1�„U ��,,,,,,, 0,1� rJ �,! ,�s i,,,�, r,, o,,,l J� J�(Q/� ��- d,,,�� . ��/�a 1,.,,ri rr,,,r„�or,J,w, CEFTRIAXONE (ROCEPHIN) (ADMINISTER BOTH ANTIBIOTICS UNLESS CONTRAINDICATED)" • Reconstitute 2g of Ceftriaxone using 20 mL of NORMAL SALINE in the medication via[ • Dilute: 2g of Ceftria one 'In a SO mL bag of NORMAL SALINE • Administer over 10 minutes IV/III by utilizing a 15 gtt set delivering 75 gtts/m n �n uw ..2.5 gtts/sec) �, � �� N � �m�mvm,. luuumm, � m �, p tl.. II �I m III m II III a n�ma m mo �,a i o Ilol � tll�u ull�, � �� IVIII'. IA�IIIII� Ilp o II I I'�rI III„� rw I IIIIIIII�N� a�a I I� a II�Nk IIII �i I �� I IIIIII�� III II I fo""�i I I I III I fi�I°��Nh'"I I II uu 1 A unn " n u ask 1114�11 � Ilm"I IIu,l k Iol III Ia nw IQIlnlll Ia iu a ll.I�wk: I( I!�uM"ry�l� iI° ion a��m Cie arxw"m II w ��mr,�ra�f m I�`IIII IIII I�r I11( l w�.x' N^" ^I�m PW II II II 0 ��nllll��r " ��II�inn i i 11I I II I r'I i�� o��"�Ir 71 Dill I��N� I� I�°�wm IIII II Illlllmlll I�'.�� I a�rr I EITAIIH (ADMINISTER BOTH ANTIBIOTICS UNLESS CONTRAINDICATED): • go mg IIIJ'I lip 1Ij1°1bplllll" ICI°IIIIlid i1ciatiloDYlllll i m' m I I I I° Iplllll � I u I I(Ill III,iullll �ull� IIII ICI I�i. I �I IIII IIII I� " I�Pj'I Illplllln �I I' mlcl In ArtifiiciaI 11ileart v lv iII- Il i e IIII° iI I IF PATIENT REMAINS HYPOTENSIVE PUSH-DOSE PRESSOR EPINEPHRINE (1-100,000): • Dilute: Discard 9 mL of Epi 1;10, 0 (0.1mg/mQ and draw up 9 mL of NORMAL SALINE to create Pushy-Dose Pressor Epi 1:100, 0 . This will yield 10 g mL. Administer I mL/minute IV/lo,titrate to(maintain SBP 100mm H May repeat 2x prn, max total dose 00m g(30 m l I t 1 Ira Ii II II iI�I tiI IIII i Icy, 1I V II)I�i s,IIII I CI IIII iL�e c ICI IIII a ry I m Sul I�u�Iu Boss aYPP P r e c I,,,,,lr,I, o n s R r/ 's l-I^Jr V r Ir V�r I:lj"r i I�r!°fl„l �"f.� �„ll/1 11r- Ir%r�/r i'-i- I�� f�f Ir,,,�fi I�-;�I:'It Ire„��I� r i I/„� 1�PPa IV o1!; J 1 �I�i I,J(U`,V` !� l�;� Ii.,J I„J Me'l"„�, ,air U C�,ml „a �J�In r✓ I t L l� Uf Y�7 i�. I�„��,I, l>ra� 111,d e r 5 lm l ,�. i r, /- 1 rt- I I � � /,, 1 ! ,i �.1/ � f` i s l/'° J.Ir �-, r r°r / i� 1/'g. i �/'Ir, /.y ,�,,,;t /rr'r� / „e J, / di r /,,,,Il /, / rr, 1 a�/ 'tor i � r f I 1 I l II �s � It� i 'I �. rt (� -1-fir- �r �- / -7 I / �r +! f-,li i- l i, I ,m If ii i>`•,-Ir�, Ir ( / r, r I / r., r it IF r r.li �r li- I n� ,� U�F ,»„mJ �� ,»,J�� I:� �.,a„dl P ,. f � � 1,�r r,.,r.1 k„�.iir��1 �d .�,,,� rig�� ,m., rrr,1 1�� ,��r r/� 1,�,�,�,� 1,/,:if,,� k 16��„�i,�l ,�rt�r,»ad 1'r/ .,,r r,�-I „�1/„fie a�- i a � 6,n Ui, �� 1111 /`oj PEDIATRIC SUSPECTED SEPSIS �► R MA L S L I I' E 0mL/ IV/Ili, regardless of blood pressure, assess lung sounds frequently May repeat 2x prn,,for age appropriate h potensi'an IF PATIENT REMAINS IH�' POTENSI E ��All I R PRIATE HYPOTENSPJN • PUSH",".DOSE PRESSOR EPINEPHRINE 1:100,000),+, • Dilute: Discard 9 mL of Epi 1:10,000 (0.1mg/mL)and draw up 9 mL of NORMAL SALINE E to create Push,+Dose Pressor Epi 1:100,oo0,� This will yield 10mcg/rnL. • Administer 1mL/minute IV/I ),titrate to maintain age appropriate SBP JWM May repeat 2x prn,, mac total dose 300mcg(30 rnl.) 10 I (IIII t i r I , uu IVI I Ic I 'N �I IVV',,s ,,,,. IV VV VV'IVI S�I Iri 's I IIII Ic I II II I I i m t b ply, I d Ibis's ��I/Ji r(/ l f//O/ri/�" Il0 uIUVI III (IIII I�r�I�/�I r��l Ii fir,I,f r�l I r,�o.�� k0, / r. �., I..... i f. O° io a ✓ i„„ i, r r o I /r o f o 1 6, i/ r I, U l f f. / �.i .jai r� /I% n d i�ri a f r / /r r r 1 1 I/ r r / i t %r�� 1, � I �% I //o � s I!f'%I' r it �s I I r ff r�,e� �� I ,��I �I �Ij�I��, f lF o�r� I�r�dW ��l r��I ,r �,� ��,I(�,dam C rt I� r��1,l"� ,/;�� o�,�r� �� ,� 1,l�1,lF�r��r��I ,,.i it i o r "�i," /I': < o,�/ /-.,? �rlr, ,�,1 r/. I+ !�lV �l ,4,%/-- if/ %.y.,r- �/ r/ ri (i i. !',,a/, i�r;, r,�s�%I ,,I; Irs o i S o �.... ✓ -I(,, I (.I (i:� rr�.�,�! r v / I"I �-.��.r, f 1�f I...�� / �Is Ir,� Ir Ir i Ir Is I;f�Is f�l rPSN�(IF Ir I�far// 1';ri.Ifae/16 h-Ir m).I(i.�.,.r� '�/r IF fe-✓A ,�wF�e�arr%f d/far/, IAA/(�a.u"% fart IE wdi +u le�( �.r//re.. (f f �.'Iar afar/,le IF 1/(E Ir IE�,Ndl 16�r fae'�a le le FF fv� n' ■ i 1 1rTl; Stroke INFORMATION � S f, WITNESSED „J//11ryj�fjfFf(M611M1V'N'rr family, UNWITNESSED 0. Onset of signs and symptoms are unable to be determined ASSESSMENTS 0 Cincinnati Stroke Scale shall be "Initial stroke within 24 hours.Witnessed symptoms>24 hours shall not be considered stroke alerts patient6 If Stroke suspected, R.A.C.E. assessment CRITERIA STROKE ALERT CRITERIA: & Any new . .ve finding from the Cincinnati Stroke Scale R.A.C.E. assessment score 0 All witnessed (within 24 hours)a (unknown onset)strobes will be transported as stroke alerts TRANSPORT • All Stroke Alerts shall ONLY be transported to a ST I1II(IE CENTER Exception:Known terminal illness or Hospice Caere patients can still be treated as a STROKE ALERT Transport these patients to the closest Stroke Center(Primary OR Comprehensive). • Immediate . .cation of a Strobe Alert with the R.A.C.E (plus)score needs to be relayed to the RECEIVING STROKE CENTER. Absent(symmetrical movement) Ask the patient to show their teeth;- (slightly s trl l r r I� l� - Moderatet Severe c It rl f� r I titlilc raft t degrees(if soy r 45 degreeModerate l l 10 seconds) (ifs i ) I r (patient unable to raise ar s against gravity) I G � r y/ 1 � r 1 1 � r 0- formal to mild(limb upheld>5 seconds , Extend the le of he patent 0 degrees 1 r �. �. Moderate(limb upheld seconds) if u one 1 leg at a time Deere anent unable to raise leg against raw Head and Eye Observerange of motion of eyes and 0— Absent normal eye movement to both sides, and no head deviation observed) Gaze Deviation look for head turning to 1 side I— Present(eyes and/or head deviationto 1 side wasobserved) %NlNri; NY,, Normal(performs both tasks correctly) Ask the patient to follow�� verbal orders: II Aphasia 1— Moderate(performs I task correctly) "Close your and"Make afist" AY, Severe(performs n it rts ) Asks the patient:"Who's arm is thin?" 0— Normal appropriate or correct answer Agnosia when,showing i r hert r — Moderate(does not recognize limb Or"Can you move your arm"?)f — Severe(both of them) If Cortical Signs are present add a (plus)sign next to total andIncl Include the verbiage`�prlu,,V�with encode. tt� .C��;.SCALE TOTAL:TOTAL: Max Score of 11 score a ALL ITEMS S11111ALLE n FT OR RIG1111111TKt i /f ff StrokeCondnised.. J / u /i l r ADULT&PEDIATRICn�J , • Obtain the following information"` nfor adorn` • Last time seen asy ptornat c • Witness name • Witness phone number(s) • Patient's medications ADULT • POSITIONING: • Supine: 0 All patients with the exception of those listed under 300 head elevation section 'head elevation: 0 A diagnosed intracerebral hemorrhage (interfacillity transport) 0 Patient is short of breath • OXYGEN: 0 2 LPN NC regardless of pulse oximetry reading. Increase oxygen therapy as needed a Establish an 1 g catheter,,the antecubital is preferred • NORMAL SALINE: • 00mL I1, I , regardless of the blood pressure F PEDIATRIC 0 POSITIONING,: • Supine, • All patients with the exception of those listed under 30'head elevation section • 30'head elevation: • A diagnosed intra+cerebraI hemorrhage (interfacility) • Patients short of breath • 2 LP '1 NC regardless of pulse oximetryr reading. Increase oxygen therapy as needed IV ACCESS Establish an appropriate sized catheter • The antecubital is preferred NORMAL SALINEI: • 10rnL'kg I /10, regardless of the blood pressure, mars dose 2-50 rnL Stroke Alerts SHALL be transported to St. a rye's Comprehensive Stroke Center / I 1 it I i ip u +I r / I 1 / r J J el� / / r / / 1 1 / r lr Rapid AmwFib AawFlutter Y INFORMATION '19111 "1.Nl r' is Rapid atrial fibrillation and atrial flutter are defined as ventricular rates> 150 beats,per minute ADULT STABLE 0 If no response in 5 minutes,, repeat with 15 mg IV/110,Obtain 12 and 15 lead ECGs and leave cables connected 2 minutes (NA III io;n' iil',il of t'o n oil IMMIN Ipl ie in islii o in Delta Wave IIII I IIWolff-Parkinson-WhIte Syndrome I c.I Inli,IIII'I�)l i e� R N. Siliclicsuivus1 ICI 1 1� III l 1 k ul , ��!r I� I Id,, aJJJJ� ��r D m 1 r>k��f�>��,�i m Defta Wave U; 1 b Ill Jlr f t �Vuni Y >J;V ,n,,, 1f v�.,J1e'U-, 1J t.. II ��V ,e 7JJJ� i�,,,, 1:IgV 'ryryrtlim,: a�JJ1 � J�;U, %j D�U,�„�Q >l,m a�r��„��I�,��r� �DU„�� ,�i D,,,�j aJ,��)) �„,rr �„,1f`�i 1i t P,f II,J>li�a�a �JI D� a �I i l,' �I:ff IJ� I;I. „! I��Yf rr II'"I),�i»� I, y°� J;,��;'�Yfe r� J�e„f J�,,:.,,,,I I�.. (1 I d Ili D m '�III v III m ,,,I III fi �f �II o tlr r II'i, III III r Nr�, �I UNSTABLE HYPOTE ION NORMAL L 0 1L I1/10,titratle to desired effect.Assess lung sounds and BP frequently., • May repeat 1x plrn r r ,or ,, , r ,r / r r I/ r r 1 1 r/ I � I r r�" � I i i I I r � I � I r %r✓, r � r I r r rr o „r � ,i na N r,.l io ,..n..l xao I.@ �� rm ( � ��, �rtR,:�,� I��.i.,,,+ �'F J��I�I�� .r m i� m mi,�d/.„mi�"G �a � �w{w,�a nd,�1=�a c „�„�„ ii O I ,,,,�,�r „! i a,!r�IDr �r �,�.F, ,,I, ,,,,��c ,Ie Y i ail Ir I ,,I,,, ,e �p I f(rr�J„J n I,,,,„rc "IF PATIENT REMAINS HYPOTENSIVE AFTER FLUID ADMINISTRATION PUSK,DOSE PRESSOR EPINEPHRINE 100p000):1 • Dilute: Discard 9 mL of Ep" 1 1o,000 (0.1mg/m Q and draw up 9 mL of NORMAL SALI N E to create Push-Dose Pressor Epi 1:100,000. This will yield 10mcg mL. 0 Administer 1 mL, ml nute IV/10,Citrate to maintain SBP 100mm Hg • May repeat 2x prn, max total dose 300mcg(30 mQ siecimlid&I111111y to 111 11oioi &s r f r r r I/r rI %(i ✓r / Il/(Jro /r r/Ir /r tie r%(/, r///i I( � f G dill I� JG 1,a� , Iff C I,f,.,�9�i. Imo✓ r�N<loi� R�Jr�G f..Jl V� 1 rr �d6?i'�..C� �.I J L 4 i�f.,��id� f/✓G iu I, "1Em II f v�+G in i r r.i la i/ r lf, f l l ',rrr/rr ( I I'G I( rt I,,. �I[r ��, i%r;. 1 r.r I I�.�� I I �, I ri ��4 F,G� I,ro yG lU if 1,aeo-16r/lU lw. c„rl,�r,n �r��,.� I��,n r.�d f�lc lr�dr ��I�,�1,��a��L Irai� .NG91M1HHUDJI IDJIID ,.,. ,. IDJAkM9JDl��„ MhNI"N�A9�1�!�iS�N'd/�M'u�/GIA'B�dIIIIIrrRrrllf�lilNnJfiRNW.`6l(l/MVWN'JNH"IIIIIIIVIVIIIIIIIIIIII0111111011111111111111'�l(lfRcd(f! IF PATIENT BECOMES NORMOTENSIVE AFTER FLUID ADMINISTRATION 1101�4,PUSH-DOSE PRESSOR EPINEPHRIN"� I 1 IIIIII"rIN111111i�N�A y ,,, II s noted above Nwn .. IwwvmrYw'w�au�xlwwHrrrrRrrrrrrareorreirrrrrrrr CARDIZEM INDUCED HYPOTENSION NORMAL SALINE:as noted above WARN111141G CALCIUM CHLRIDEr O N1 111111111I°1+ca rdiovert A-P i b/A-P l utt+er. Gllrii •� 00m 11,/I0,over 2 (minutes Cardioversion of unstable A-FIb/A-flutter II�Ilrli"'iY may pint patients at high ri"sk PEDIATRIC for embolic stroke. • Call for orders , r it / / / / //i rr / / / / // r i/ /i/ y ,✓ / .. .,1rri/,,,, ✓/„/....,„,,....r �„/r r,l/,,./i,,., �,f/i./r//////i/�////,/iiiii//////,.li�/„i /i/ r/ r /��/�/ �� ,fy��k�,� I� �� >�/ � r r(r1/�//��/��/�>�/�r��///i� r / r/rrrr s 1 Bradycardia P&T INFORMATION Bradycardia is defined as a heart rate<50 beats per minute. i ObtainADULT ATROPINE:STABLE 0 Monitor and transport UNSTABLE(HYPOTENSIVEI • 0.5mg I IO • May repeat prn, in 3 minute intervals, max total dose 3mg ,i mi,.:a xx iw�� i� i,- n�� wM ii, i. ism,��,w�� uu��x I m "" uu m�� i ii� �i �"m✓ II IIII ICI II Iw ICI Iw l� Ili IIII I�'�I, IIII IIII Ii I�uu ICI.I� I'u If Ih wm I ' I� I� '� I�Iw 101 I, �I ICI f0 ICI IF PATIENT DETERIORATES OR HYPOTENSION PERSISTS AFTER 2 DOSES OF ATROPINE gyaruMfifiiJ.c^�liJ�rYMl�Id„ ,.;,,,,,:;,>m�»�il�nmm� ,>m■�irv>wi��,. mmmmm u�,��.,,�",^^,x�wiar ,.,TRANSCUTANEOUS ,r • Initial rate of 60 beats per mi nute and increase rin iIliamps.until+capture is gained • Increase the rate as needed until the patient is hemodynlaml cally stable ,SEDATION FOR TRANSCUTANEOUS PACING, IIIIII11 I T'�DELAY TRANSCUTANEOUS PACING TO ESTABLISH IV ACCESS 48 rig IV/ICE is May repeat Ix p I �f f ID, l r IF UNABLE TO ESTABLISH VASCULAR ACCESS AND PATIENT BECOMES NORMOTENSIVE SECONDARY ,;"W. .,. 1VN'A'r;■mmrwunwwm�rrrrrrrmu inr� TO TRANSCUTANEOUS PACING • VERSED. • 5 rig I N/I M May repeat 1x porn,,"in 5 minutes It)11�e i�li's 101 o Iif°ii, IF PATIENT REMAINS HYPOT G PLISH-I-DOSE PRESSOR EPINEPHRINE (1:100,000)- lullu' III 91'��II'Il��u�lll Ill�dl��U��II�IIi��Jli III IV III�lallll III III��JI III III'III��tll„��Jb III III��,JII III III III'��!I"',u�III„�JI'III III ulc��lll I�I�III„��dl III��III��I III��,�191��11�III JU III Ilh��°II'�!'��I�!!'��II�III III„��dl III'III. •� [ flute; Discard 9 mL of Epi 1:10,000 (0.1 mg/mL) and drag up 9 mL f NORMAL SALINE to create Push-Dose Pressor Epi 1:1000 + This will yield 1 mcg/mL. • Administer 1 ml./minute IV/I #titrate to maintain SBP 100mm H May repeat 2x prn, max total dose 300mcg(30 mL 11D A u„nu I�I'm' ICI" 101'N'm I�I 'Aa IIII'f" 'ilP 10 tlug.!IIIII I a I�''� lu A "'��"'N�m t io ib I io i uu Id I ir.')' ' it w,,,,.1�1 I,.0 j1'% i // /„ f J i/ %n✓f i i Oi ?;%f! /r,l ro,„ v%I / / /r / %rrr/ %rs l ,,,f l f.I;I, 1„,,.r f , ,,,1,F(„ k; 1, ;I. I,J, t if„7,, I,f; o„ i s f ,r i,vr.,y 1/"�r". I� � r/ �„/ �,r / �rrry, �,,,,�,,,,�/1/" ri"w,rrr �",./ r r,„� Ii r'r %, r f r r / J r�i'F, i rr l 'J f D,,, �% 4/; (f I%(%�'s I, ( 7/i/�, 9✓(rr ✓ �"pp(% �.'�/ r I. ( � r�a��„,�✓r r�,�e,�rr r� r,�i I��,,,, rmi r I,,,n� �Yr �,m� „1C �r r r,1,l,.�r � � IV IIIIIII 1I �m�� o directly to transcutaneous pacing for unstable bradyrcalydla in the presence of a myocardial M i nfa rction as ATROPI N E increases myocardlaI i ch mla and may Increase the size of the infarct. / r rrrr // r1� I ifI r r rr � Bradycardia continue+d... .......... ..... ..... PEDIATRI �/ Obtain 12 and 15 lead ECGs and leave cables connected �ulati y�« N STABLE r : qb Ensure te oxygenation first,as hypoxia "is most likely to be the causeof the bradycardia Monitor and transport LINSTABL j A11,14D AGE APPROPRIATE HYPOTENSION' • E rr s u re a deq uate oxyge n ati o n a nd ve nti latio n `rst,as hypoxi'a'is most I r kely to be t he ca use of t r yri • VENTILATION, • Neonates. • 1 breathire seconds for at least seconds • Infants/Children: • 1 breath every 3 seconds f r at least y minute • CHEST COMPRESSIONS: (IF PATIENT REMAINS UNSTABLE AFTER VENTILATIONS AND THE HEART RATE REMAINS BELOW 60 BEATS PER MINUTE) compressions every 2 minutes 'IF NO RESPONSE TO OXYGENATION.VENTILATION I AND CHEST COMPRESSIONS, PUSH-DOSE PRESSOR EPINEPHRINE 8 : • Dilute: Discard 9 mL of Ep 1-.1 ,000 (0.1mg/mQ and draw up 9 mL of NORMAL SALINE to create Push-Dose Presser Ep 1:100,00G This will yield 10mcg/mL. • Administer 1 mL/minute IV/1 ,titrate to maintain age appropriate SBP May repeat 2x prn, max total dose 3300mc 30 mQ Ii� idicaboil"is- �� ;u�IIII°�� o 1)[olold lioss U (101 7 a�cli°r 'nI III('1�el lr a''"�° i a r �r a, � 1 7 l r �� r<�i � �.. rn�� d.n ��✓�� ,��,,,,,or,i llf �� e l�i i �/r� i I I f i i l � Grp,p n r nrrr� mo, r�,� d ( d( p.I(((( d? ( V f l (li 1 11 ii C� I(��k�i�I� ��I��,�� F�� (f�� a�I�I III� ��II III�I�I�I I�� IV�r d��ii r�� 01��'��I�(F l�� Ii��, ��I III�I�III�I��(I��' I� t l�D III �„ ( C�9 I. �i I r o,� �i r � r �� 11� /r�S y r 1�� i i�r,i ��r, r i i/� �i Ir o /i�I,i r�r� i�,,,,rl r«� �l( ,;Lei, o„11ff( CffO �I i i( �I I �II r �( ( i .I I��r ff oC�� I�fr �it� 'J�� %� r„� iii ii,�„� �ff, ,,%,Il( i f""iii �r��Jl�III III III i�„((��G II II I�,,,��+r�,„�fr III'r;,, I..r��fr(I�„!„�„,,,� tr,��tr III II��,� ��„d��„��I(I�I�,„,� ��"III((��i,,�„(1��J11(��„�� ffl�,„ ,l�:III f�„„�!1 II�Jll�g,,,��III��f Ih��(�� f��„,��,f I((�i�k�L.III°III III��,t�l��III'°�r�r l III I��,,1 III T IF BRADYCARDIC AND AGE APPROPRIATE HYPOTENSION PERSISTS AFTER INITIAL DOSE OF EPINEPHRINE, TRANSCUTANEOUS PACING: Initial rate of 80 beats per minute and increase milllamps until capture is gained Increase the rate as needed until the patient is herr odyna i ally stable SEDATION,FOR TRANSCUTANEOUS,PACING 111°1 0 7"'DELAY TR,A SCUTAI EDUS PACING TO ESTABLISH IV ACCESS ! • O.1 I11 ICE,over 30 s+e nds max single dose 6mg • May repeat Ix prn TRAN J kNE0IUS 1146 a.nnmmr�mmnrmmnnnm'„,", ;� i�hlfiF,�N„(frFld�r�r �rir�',wWl�Ihini�nirli limn�4mnrwe/c? VERSED 2 mg/kg max single dose of 5mg + , ■ minutes ✓, rir! ' ' „i/,//, ' i i r r i/r/ r i/rr / S l// / 'r�!,J r , I/J I�f°r l'e .I�r ��.i��i.�,"/��I�� L �J/��1 L��4w'f �,<l 1=� �� o� � r �� r�o�/i'-�uiG��fr� �� ..� i✓ / IIIII.... i, / / 1 / 1 1 i f.r�, ,,.......,",,,....i%% ii....,c,,,/////i �,,,,,i...,,.,,,,,,,,../,✓i�iG,,,,,,,.i /L,,,�//////ii/��f ,,,„��/��////.ii��/I fl�l��l� �� III��,I I I 1 II/f 1 i 1 ��j��>��%��/�r�j��//////////////uric%,i/i,... Yf /„Cardiogenic Shock / INFORMATION Rare,& A condition in wh ich the heart suddenly can't pump enough blood to meet the body's needs 0 Most often caused by a severe heart attack ADULT but often fatal if not treated immediately 0 Obtain 12 and 15 lead ECGs and leave cables connected PULMONARY EDEMA WITH HYPOTENSION • PUSK-DOSE PRESSOR EPINEPHRINE P - r 0100000) , •� Dilute: Discard 9 mL of Epp 1:1 ,000 ( .1mg mQ and draw ups 9 mL of NORMAL SALINE to create Push-Dose Pressor Ep 1:100,00D. This will yield 1 m g/mL. • Administer'",', ml./minute IWID,titrate to maintain SBP 100mm Hg May repeat 2x prn, max total dose 300m+cg(30 mQ I Y 1)IC)I'tie luu �s i�l Io lil s I ic I o In d u1 y to io Io Id Ilo�s�s U1Jf P l e�'/lJ i J�/ Id(�U i/,, �,�%(Urr�� mfi „d/r ill J o:'f✓J/ �IJ Ir� �`%;,l 9i r %1�,,:ii%n �f�r„I'ir,�� i1,l r I /,Ilj I��i,. / 1�( �r/r I l� ,�b/J lbrr�ll. r!r rl,;I% 1'(��/fi..,(�i ,rr z/i i lmdl'I:U r� (r7h, ,�I,u t�.) ��,m.�r e f 1.1 r „l�I,r,»a��;�5 �r�rn!(l 1 r�,m.< I,�I,U e�°lr,�J J�e xr J J�,l!=�„aJ!l a��m��,,»„i 1�1 JJi,i%: i " i e I r �- rr� i,/.. �, it .�i rr.b rr. ��. 11: ,r i>- �./ r.,rr �J":, .r."' <�1� 1 /! 1 i-r r- � 7��.1 rim l '!' 1 r� I 1 / /r- m !/ /,� ism i' i"'r1-Il�r/",�,' � �, i-,,,%.�. ��."/: / ,i r1 i U, I r� 1"P" :ii.;1 1r -/ / a:/, (. I' Mll; (, / I�. ,1 ,1 lrrrrU ., ,l n Il%a f«rG i J �� «iC ,�,,,%, 1 J/r is /Ir r�£�/ I sl fe �� I ��% 1 i( r r,i �J l f ��lit f, „J. � r,,,,,,,J' i�.,,,r.„�I� ,,, I�rd,,,,,,,r. i(,,,,1 �,„�f fjr„Jr r. �l�,J-,,,�1 �ir,�d/( .��l„1J rrJ ,,,,,. li,,,IJ�,� �,,,r/ r�ilJ;,,Jf��„J,,,r�,,,, ,,,,,1�„dl/.,�� (� „I,,,,/„f rr,I;,,,JJ,�- • NORMAL u I /1 ,titrate to desiredlung sounds and BP frequently. May repeat 1x prn 1 ( ( 1 � � 1 r I r rl I rrd �� r f rrrdl ��rrdN l „dN ��„rr11, rrriir,,,, rrrdl, rrdl ,; �„! V�rrrdl U 11 i 1 „�i, it J �l W l f i 1, l 1 i t f 1� 1� 1, IJII I� I� 1 i J i r I� I�I Il / I 1� i I�r j I�f� r I� 1� r J' � ,r 1� 1� rFr I� 1 1� � r r,'� l 1 l � 1 1 1 f i� l I � I I ( I � l I � 11 IJi rl � � � � III ,J1 r1 /� 11 ( f �� I (� fI ( II, IIfI II �,rl � � r �� „,, ,�z� r m �. I I ,��r,��, rrt,� ��,,�„� I�(� nr��/lrt (rr�� l�,�� I.� ��. � ��, ��I ��,m i I� � �I ��I�;;,,�Il,�!I��,�I I� ��-��I nm��,��I.U� r„�, disease I ��,,, �,A 1-e�I ft,� U>>„°r I I�1J��I�I��.�» �'��t�le, III�m " IIIIIII ��ill �'u �• Once SBP is 200mm Hg or greater* • Refer to the"CHF(Pulmonary Edema)"protocol(pg. ) DO �� IIIIIII it°'� �� I ��I III°°°°1I1 RIIIB, 161,11111 i. III)ATI'E IIIIIII S PEDIATRIC r��b PULMONARY EDEMA WITH AGE APPROPTIATE HYPOTENSION PUSWDOSE PRESSOR EPINEPHRINE o • Dilute: Discard 9 r1''IL of Epi 1:1 ,0 ( .1mg/mQ and draw up 9 mL cif NORMAL SALINE to create Push-Dose Pressor Ep 1:100 C0C„ This w ll yield 10 m g/mL. • Administer 1 mL/minute IWID,titrate to maintain age appropriate SBP • May repeat 2x prn, max total dose 300mcg(30 mL) m pIcI°tie n tI�� I�� y I blood li s m r o nI"r/f I�r r I� r f r U r p Vi III III 'I�(,U % Ir I�I. I�,i6�„ l f fi i1,'r,�,/I. ,.JI,✓,,, 1`„ f I.�,,,,, f (r,,,,i%�V JC i i 1= r, J x�. ,i r; -i, �r� � / nip„ � 0 /� r �,// r�� -,c r I / / r r/i I f � I I IS� l f � /I / /I f � r I r'( r / r, ( ( i i/ � r, � I r r r I 1 � r ff //FF ff pp rr r �f �, �.tl m,/ r f ,m�.r.,rt1.rt,G r�a„e%f � �� ,�. �,�6� �! �,�,d x�� r ✓„ F I,I, �r„i��.� � U/rto. �, b� � �rtr/� ,u.��/ 4�r r IF��,./ y %i r r.,r /,. i ,;., /r r / r,,/fir i;,. , ,, N �./ ,.,,� /,�,,,., r// �,,..,i err i" I -„//"s i i s/. r/r rr/ / /r r; /;/iG„Jr ;i/is /,/ i / f, /,,,1, i/f ( /r r On,, pr,On /I / I f JII ,r,, p r,,,,rr r�,,'�,,,,%, r�,,,,,;,.i„�,�,, „�Grt,,,,,. i„,b�„d/ .,,,,,<,r,/„rr e! ;dF� „r,,a„I,„.A�, �'(r� / /( , �//(��, rya,ril�� +� �n, �c e, NORMAL SALINE, • 0 I IO,.assess lung sounds and BP frequently • May repeat 2x porn,for age appropriate hypotension 0 1 � / i Chest Pain INFORMATION r Urel • Assume chest pain to be cardiac its nature until ruled out. ADULT • Obtain 12 and 15 lead EC+Gs and leave cables connected a The right hand and right wrist should be avoided for Vascular access if at all possible.These sites may be utilized for+car+dla+c catheters ation. 0 The right AC and anywhere on the left is acceptable • ASPIII's • 24 rig IN u 116y1eilars olid '' e IIIII it I.I/ r, m l � � �r�, / i taken. J�✓r� f (� �' 214 hours, / //e . / l d m s r T • 100 cg lW10,/1 r /1 M • May repeat 2x prn, in 5 minute intervals �� ,ux m� �� xn �� n� �� , �,�� C � �� , �� n ux� xn m n�� I w a w �I me �w x�aw, � �nrc w m w w i.., w p�nrc �� mw m ICI ICI' ICI` �� I�I' I� II��i ICI'1 I� I��u�1 Ip� 'tie �� I"'I� III'��ICI ICI I�� I Ipl,�{ o Ii'' II p�V '"I�� i � 131 Io I@ "t�✓'fr opiate mo b lm,�<r O ✓✓Y r g 1 %rr / /�J / I, r �'r/ r �o r / r v r%r %rrr r /> r•r � �i o r � ,/ y y ff/,'I,I,,,,,� f(I,�,f,Jr �f�I �,I,�I.I I I I I re 1/Ir„J it l�,o fib d I e on r l f/ ' �/r 00 1'pet/' / I �r t ir„J r�-".�-onr I� o�, �� ,l,.�.��H � ��.n�� 1 ��m%�r„i� i�"'�/'y�oJ/.r%% i 1 NARCAN / 0O Can/, e Jre�r i�/lr/�/ej,,,,,,,Ji 'f f/,��, / I I %cI/lirl / / r/ IP'PAI1 DI �� OMFO�T PERUSTS AFTER MAXI UM FENTANYL ADM I ISTI ATI0 mI11 DRU SIEEI II 1jI�'41m ,, ¢ .. .. �NMW�WWW�Rrt�M� IIiWd&M'NIKKPo'&(�dl/w0i1YMYdlfF/JYuJ66/6J4�P?/611'W�lr Wam�6dWk"iYLI'M'(d'tlWk 1Vul % ",.,aTARliWF6 fNRTlRlr f fLaR�((�i�(f6Rrd,. .'Hu44i6Pv'lGlliGvl6!!lWJl6llLPl7IRRRIRI 11116,,,III III IIIIFr''//466iL/6f�P�/4�P��'�+flR�il&RGr' BEHAVIOR IS SUSPECTED • ITI L I • 0.4ring SL • May repeat 2x prn,in 5 minute intervals Co Iili Ii11I IEl ICI'n id i I Io I111i is u� <I � IiPI''Tl I�� VIII1ma1 'II m'. I IIII IIIIICI�i� "i o �� u I�at III) illl IIIII Ill �r IPR Sr.), r II II , II a��, I[I�Im I�'� I� I' luul�I ,III°I , Illl r�l IIIII°°I w t�tl I�c 14 I° I� ICI�Il Ilii lilt "°IIII IIII a ICI IuGry IMu 11111m� I u ��m�., � ��m�.,�a," Im�A��`^' 'uu'k' ��` ouuur..puum,.' I I r I °' r�� I...III � II�� „„ �uw �ux ,ww�� I... 1 I �� I�IIII w IIIII luu lui w II IIIIu�I w� lug I�' luuu� �� lui IIII IIII a ��i Irw I� IIII lug a IIIII a lui Ivie Iin't III ICI I II IA� fa Ii Il uIuulffie STE1111111A IIII A, 11111111�P PEDIATRIC • Call for orders Patients experiencing chr t pain shall have multiple 12 and 15 lead ECGs performed throughout assessment and,transport , �a ................ .✓ / /. / /...r�.r //.// / / / � / / ,,,,, / 1. !1 // � � / � / /.. rrrrrrr,/ �/,,,/ �>// ✓ % /� � i / rrr � 1 f � / / / /� / / / /� r ,,,,,,,,,,,,,,ri/i. ,,,,,,,,..,,./fir.,",,,,�ii%i/ice/„��,/ii/� .,..,,��,r�iii„i„i„:. ,,,,�„,.,,//ire, ....///////iii/i.�„✓/�/////i,�✓c„eii..,,rif%��%/i.aiiiai/,.,.%ii///i��///%/i% /i�/„��/�/��//��r��//�,�� 11 >�� I ��/ %/i//�/�rr�/ i�//��j///f/lrr��r%//j%/c/%/�r%/�� /��///IIIII,,, i Alert INFORMATION J ,wJ�l�ira�rrrrrmlSr?'�r,"%' This protocol may be run concurrent with the chest pain prapplicable. 0 STEMI Symptoms can be various c • Syncope6 Discomfort of the chest,arm, neck, back, shoulder or jaw 10 r near syncope General Unexplainedi r i 0 SOB Nausea/Vomiting STEMI ALERT CRITERIA ST-Segment Elevation in 2 or more contiguous leads: c r stra ight m o r i ng) r greater in V2 and V3 r greateri r I Elevation, Concave0 r 2mm car greater in any lead ��a,� �. � • .All TE I Alerts shall b transported s priority � Is Concave up 40 1 J Part The following are STEMImimics: ,,...� 1 0 Left Bundle Branch I s>0.12) Pacemaker with QRS complexes Left Ventricular Hypertrophy Early repolarization elevationi concave presentations0 Patient isative of myocardial ischeril "'STEM11 Alert Criteria" should still be transported I LEFT „ AR HYPERTROPHY FORMULA i LVH o Count the small boxes of V1 and V2("S"wave), Right-sidied 1,Leads Lieft-Wided c1liest Leads the f/U iria,,,rrr iJ� IO r r rt", f)IuvirW �Y fiiornaooi rc riir iriiiiori r aor ciiri aial� riiiri n i riifi V Y iir r I f r A + :� is+L l�e tri line (whichever is larger GrU c arrr f,F,.s„ � o,a `, rya e° o J1 Count the small boxes f V car ("R" wave), the largest positive deflection from the isoellectric line (whichever'is larger) / rrrriry mm / IIr it • Add the 2, if the result is> suspectLV � r �i� ill ri"dmfrlPk :- I%m,„ ryYunfJD,�urglJP»rJJI/lr^�i�/ni�U/l✓!rrr;Mvru;�iriWu(,yJiei%r„ /; ,.� �rar,,,•� iiU��n�ii��,o��i,ozrr,rrrr�!c;�:r ii�If ii oaaaiiii✓r„rig roi, ,�,i it r p S WOVOL w In V1 or V Tall$1 waves / fP, ft 10 @V w I IIIA,,.M000k,dvm0I i0""uw HAL W1 fil III`,ICI ��pp y IIIm'' VVI 1r IYv'IIIIII�W� ,Itl'r. C "�� M�iskmi, 1 1"111 r rr iii r r„i aiiii,r r r i ri ri r r r ri r r r r r r i,, r ri i t r r� r: r rrr r I r r r �„ r iiiri�, r rirrii,r riiiiii rill r roiravoi,,,, r .,,r of rii r r o is rii,,,,,ii r rii or r ro �, i o r,rr a r I » r r r r r,r, i i STEMI Alert continued.. MENNEN= i 15-LEAD ECG y, • Run the first 12 lead as always • The following patients shall receive a 15-lead ECG: All patients requiring a 12 lead ECG • Placement: • Unsnap wires for'V4,VS, and V leave the other leads where they are) Plane V4 on V4R(Sty, 1nitercostaI space, midclavi ular line right side) • Place VS on V81(5th intercostal space raids apular) • V6 for V9 as below (51h intercostal space between 18 and spine) • Run a 2nd 12 lead (whi h is now the 15 lead) • Relabel the new leads can the printed ECG uwwmmumwmmrn ,. ,. mmmuwmumnmBmimuuuuum uuuuuuuuuuuuuuuuuuuuuuuuuuuuuum nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnmwa�m�m�mm�mmionmsrm�mmmmmimmr�uuonnnmomuaam�mnmmomurrnoio«rm Pom m l a ,aA�JYII��';��Y�uiri)if, J//ilt�rr�i6i� � llndxru e � J lu V�u��l�'tiirr ,mmwbi� iW 1� u,D�m nq ai i II° VI , y� k A0 r Al nigj i dram our��0� ifma'luu„�� i u� mV +✓ S heir�fr ri�r flf' iNl'if uermii IINry m19W m�,�✓Vf' , ��y�J �n➢,v u I� �� a 1 n p m F II 4 III IGIp""' f ; ,,.u, 1 ,=a, ., „ .1,:,,- „A,� „,w,.. iii imlrlrl��m�m�m�uuamrnmmmmnmuuu on muuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuummm�mmaum�uuwwm�mr�mmnmmm�mmm��m�uu�m!m�uiwuumim,�� uomimmmomrmmmim�rrRmrr�mrnnm�mw,aa,mr. .:urrrrrrrrrrrmmraamrrR I G I-IT VEN T ICULIAR I~AIL I E- POSITIVE V4,R,CLEAR LU NG SOUNIDS WITH HY'P TEI SION NORMAL SALINE. • 1L I1 ICE,titralte to desired effect.Assess lung sounds and BP frequently. • May repeat Ix prn r r r, � r r i+ r � � � r ,�°i r ��I �u �i „/ r. �% i ��/ i,ri� r /i�„ ,�u, i i l r 1,1 �' Stu i l l i / r: 1 ✓: � J l r� iN 1 N� � �v 1�s I� ( I / I/ I I I � I% �r r i 1 ! r r .Ir/„�/, � ( ,i � ,�,it ,I-Ili � ,�i, f ie I� 'r �� t P n. -i / .i i 1 t m. � � i f Ira r� �rr ! �I e�,on,� ,rt ,� � ,�. ,rt ,�T�,� ,` ,,,��,� �T i ,../1,,. „a,»»� ,rt,�a ,,»,2 r ., 1 �,� �r�-,�� r.. „� I k,�i�, � �r di U ,.� .�= ii riMi la��,e�1 ( .)��m i�„��)� i J Ii 1%�mf d r li.�i V II/ �/ i I�i � //! li!Ill��I�� I;,,��o. i,�,��Y � �7 y�1'��,� ><i f I 1'/J, 1,IG. ;��f Ul�, fj li✓�l � `� If p u I m onaryr edema and hypotension pres+ent refer to Ca rd iogen ic Shock proto of (p 52) WITH OR WITHOUT CHEST PAIN ASPIRIN 24 mg §f 11 1.161 i�of Ilr milli 11C Ism IIIi�� Illll I�flu��I, '��„�„I Il „ i. I�, ,, I 214 ,,,,r f, ,,,i I� 1 d f i° i i 'r i i i q / i i u i/,�,) / „1 c i i q , r,i I,�(,(f,1 I ,,1 II I r��,,,,,�,,,,� ��,�II�,,,, ��,,,�I�,,, �0(,,,,,II fl�ff,, ��II i,,,�„i I I�i�,(,,,,II�� „1�r�, o�1((�rl � rr �r,,,r(,,,�II((°(I II'II(I II,�°,L.��,,II� �L„J1, f l iv 16 u i/ CHF (Pulmonary Edema) INFORMATION • Signs&Symptomsi " Hypertension Tachycardia• Orthopnea (SOB while lying flat) NITROGLYCERIN:* Rallies * Pedal Edema ADULT & Obtain 12 and 15 lead ECGs.and leave cables connected 0 M ay re peat with b 4 mg SL(I ta b I et), 2x p rn,eve ry 5 • n utes auI IIII'��md � I�� I111�I�' IIII��I "��. 'uu nr r I�p l I m III "mil Je f Ii IIII"a lwIV °°I Iu Ill' " I1111toiuIillls Ia it Icl Cfillli s witliiliiii 111miouiills) II IIl.l �1I�� 'Vie I nIi II II 1 I .i l i i 1 I c 1um i imT '" �� ICI IIII°1111�° vie Ii I�l�l��Iol�c I�'�°Il `I i�l ICI l�I�� ul S T I1 �i P 1 :. uu IBP<I90: mu� pp I I� m "��1� �� pp ill, 1� "� Q10 f m.i I I"i i� ��` I o u It �s II �i `��'�� Ie I `V�� i I C Y I�Iglu�� IIII-i� Iol� I�� p� I m,�l�� l I�� I��m alb I I'i i�� W�d�I i �ill: I u I r mu�l, Ie ias I l d L ICE. tlilllli&�,&ic�i. I��I�r IIIV < 30 I1I i • Apply 1"to the anterior upper chest ICI I1) <III III I� �I11 tie 51 I�I� IIII 101 01 IQI IQII � imn�� u�� Imo��C p�� u�� nn�u' i I I r�I u"'�D V �,'� IQII ICI"' d ��n ie I�t w t ll° 1i i AIL 1 ICI Illl��a I��m�Ii�� l Ii i �Iu I� ��""�'I 148 r�uu�it �� r��mn�� "�� '�� r'w � �' `I rm, Y�m� � �n�� I,�� I„�� mw n� �I,��mu� IIII I�6� I�,�I�� ICI �11� 'Vie,Iol� Ii�I I Ian I�I� IIII ��I� Ti IiL ��u °�� n�v 'V I1 IIII IIII �o �°. I L I�� Pi o �w��i�� ICI ,��uu �� I�� I IIII IIIIII��IulI��IIIII 'I illl I�I� r / / / i�, r% l �.I f �� iid �/ ..1 i ! f,. /i,/ In �,i% ,I% ;! �, � ,l, b /,"I l� o„G �,I � /o a%%,/ ii ( r„ G�-r, (%l IS i,- V. t I/ /r I' ;I(/�- r i r 1 P �; ��% �. / p I, l /�1/�/4��o,�' rf� �, v �1. ,tea ws!'��I l/R��. I�U��,I r0 o„a w�4�c � .(I dl//��,�/4�1=(,�.�a�,!,rJf 1= >,m�L L o�i ,1 ar my��Gr 1,� G d�I��,.�� v!�'��//u o I� � �V�°m�I:�roonoiq�� III�� uo��u�mui IIIV. � � ��,; I��IV �pl�IIII p p^� � I I i"� rr/O,i rl/i/m�Y r /�%, f r l(. �/ -% %r� !/r r,1 !/i�r sew 1 r � "�i/ �r f AIl�umo1011Vl��rtmuol� ��1Q��Ilolml��1V I,",1i a�e t�, 1� l„��i,��1+"i;,"��,b 1�,",�, 1 1,,, /��„�.Ir l,i I/,d J.I,��„�.�.,i oo�",�i� ,d��,.r, �I.�I,e ��i�,� � e 1�` 1II PEDIATRIC Call for orders '��I'�Mw��i�lllllllllu' I�I�I�IN�I If patient is febrile a r from a nursing home nd pneumonia is suspected withhold nitrates .��...... �/ /ii ooi,.,i„/ /i,✓ // , /" r � n 1 / 11 1 I / i / mll Supraventricular Tach rdia yCa INFORMATION J The distincln between Sinus Ta hy►cardia (ST)and Supralv►e ntricu lay r Tick r+d!a(SVT) can be dliffi uIt at very rapid rates. Utilize the following criteria to assist in determination of Sinus Tachycardia Vs T 0 SVT will generally have no discernible P-waves or there may be P-waves just after the CARS complex stroke,0 History that favors Sinus Tachycardia (e.g.,dehydration,fever, pain, anxiety, physical acitivity, exertional heat vers may ge ntly slow d own Si n u s.Ta chyca rd ia b ut wi I I le 1th le t n lot affect SVT 1'°' R abruptlyr i . sirnall afterRate > 150 beats per minute Sinus Tachycardia Pediatric: widthii I 0 SVT in pediatricsis consideredr minute 0 SVT in infants is considered >220 beats per minute ObtainADULT leave STABLE �AAOX4 11111llli OR WIT111111111OU'll" VAGAL MANEUVERS �► ADENOSINE", • 12mg rapid I /1 ,with aM simultaneous 20mL NORMAL SALINE flush • Print ECG during administration It ca tJ io IW�m I i V I a'nm a'n 1 i u �i��0i 1��I1a I Il IIII'l is�l�i I 1 IWW t i m I��.,1,l��x tl ie��l��i �q��A��.��IWI��I�A��I�� I11�� W I��I mn�" mP a wu uim. xnmPo ux n" 6 ti'n i� i �I m �� «„w m�u� i�� .w, i�� u� �� m� �� m� �� i�� 9 n�� ',�� u� m� �y I,N �� I. � Ill q i i s i. a y i i Vim"� U u u'.. u �Ism � lm I riu w �I m �..a i.�4�w�� :.�.� m ti'A'«��. ��« 1�� N w N i��i I��u��6��u" ;m� r, III 1�� I, u��"ry I�N �aa/ W � �.�� 1��i��„„ �kk�A y� �I^�y IIII I^ i��j i^ryw p� i I� III ��I� i p p pA� IImII I�i�� " I p�" u � � q y q 1p�` y p� � �ImI''Il�mp ,mC!lln n��IIII u'u��N��.�u„�� IQP II.� � �� IVU• ��a�u� � am I�axnmx I�w�w��mn��xn �wm W W.��W W n 14kmr��n��7 W,,.�I �I�n��,,i�� I1Vub,�P.W.I�mn�l^��x��m,.µ�W ��IG�n�� W� �� W IIII� �w��n IQI��6 I�,.I�ax,�m�,W I� �.�u„�� P�uu 1VIN��. pI ��uw a m 5 i Inu'y y��uae IIIII m In �,��m u u mni W n 1�ilm IIII W W "I��1VIn IVu n m.IIII IN� @ i IIUry n IAk IIII IIIII Nn l illlidiiaic I IIxmm+i�� pI Iu„�0. 1�� IIII^ µ�W�p I^Im',%�11 � ry4ym..�� difff �� b, �"Ih kwn W m`N�)11�ICI�I�v,�ntl AI�µr�)m�i��I n lillry un^W IIII lUlp IF SVT FAILS TO CO VERfT ADENOSINE l II �I Tel II�DI ITED lli�ll�� PATIENT HA. HISTORY E ATRIA. ti DYSRHTHMIAS CARDIE " • 1g 1V, Il ,over 2 minutes ave If n response in minutes,, repeat with 15 g IIJ, I ,overIa V ' minutes Wolff-Parkinson-White Srrrdrnnnn� a ti In I Hy tie WW°it s IW Io rit WIi Id le �x� oo�* � �` m��u m„ mu� o��w illu r,�. ��u,. ,�q �„�� ,�o„,. �,o ,gym „�.�v�m �o�x�� ix�, �OV1u 4dh I I ti h,�7 q ti �� ,�1�I u�l �P7 N @y III ti� 1�,,,7,>� lo..h ali....ail.........ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9.ii..9......ii..9......ii..9......ii...01111U7�, W�I�d IWW��,��,,.��,,,�,�I��IG�1 ��,,,mh�� II��li�td�� Ilia @Ih,{ R��,„.�I>W� ��,��ul IW I��,,.1�mx��,��u IW I�IIII IWI�„��,��,��>~Iu�,�WW IIIA II�,��I0��I�,„�a�III 1111 ll��.�� 1m IOI � 1�}�1 ^I1Q^1�'IhI I�}II IIu p i 1111\1Q �S��1jJ�t h^IIItV�11uv W�l��n �nu�IP^�'III A11 u"`�II6.,k�11x�^� u Iu��" Y� �;f f Q�I/ II I!f�� J li,,,x(f I„/f,1 r�,/ J�r 1 lI IF fl"x�l//j if /, �r I(/ I� i�III, �,J1 f i IJ l f„f "II fl ��I��I!r D / /r d„1 4 r r r i �< rii r .', 1 A r [„ a 1 1 I1 c,k,�„ fll'r� I 1 ( g ! I 11 I( '� Q !� ��J i %�, ��^ f, � ��, r r �-o ,q. I(,'//r 1 J/II� I!r JI I �ll I i 111 I er ii r/� r Di�ii (/(/ 1( fj(r/f o n; 0,,, i g le �7rl�rll �,,,„�7,J,„r(„ ��1��Jr„f..1,a��al�,/ ��,tl��„ I�,��., �„�((,�� 11�� ll �ff� II,�©1�� I ii / -- / / ✓,/ /ii / /IIII i � /i i /-tafflffi/,_, / / i,//r �/ /„iii /i.✓ it l if / � � / j Supraventricular Tachycardia continued... CARDIZEM INDUCED HYPOTENSION NORMAL SALINE, 1 titrate to desired frequently.Assess lung sounds and BP 0 May repeat Ix prn �. .rrr'/��.era �,r� ,,�r'.,, '� �r Ir��r rrr, ,��,. a'r y.,,�r,«rii"� ,.v'i��"'�r�. o„rrr �/ro r,�r ti ..r ,r�,. �7 r,.,,�a rill r rir,�.r,�rii ,.�r rrii,ri "r/ri �iirr ,7r. ,�� J r J; / r r r 1, / r�r f r Ir r�r ,/.r r r rr,% r of �,�r rp,,r ,ni", 'rill,! rrli Is / „ri dr, o, d,'„r7r, 4, (;` ((11 r I' r p P ! U r I' / !IJ I f,r1�1 ,LrJ,ll, l,� � I��I �,I L� 11 I L.L. � � I ( �1 r fr L � �f 11 1 � (�I„J I I r„r � ,r,,II „II ,, I/II ,,,r,,ri I II ff f.Jr„rl,( Irr�,,,r, (,Ir,,i I„,,rrrr�fl I I d Irr.,I�r.,rr, I��II ,-rr„,rrfl Ir,,,,l II rr,�,r, „li „I I�,��II I�II�(I rr,,;,,�I 0 Ir, ,,,r„rrr�r r„r,�II�u�II II r ,r,„„r,, r II'1rr'� I II" IIIr,11 'Ir,'II II 6„ ,1/, Jl111 III 07II,'1°iu 1rr f .CALCIUM , • 500mg IWI ,+Over 2 minutes �fP+ TE' SI�l�rTA►B�.k �.TERED MENTAL STATUS I I 11111111 H ONI DO iNo1ll"Ir DELAY CARDIOVERSION TO ESTABLISH Ill ACCESS ETOMIDIATE(consider for sedation)I� 0 +61mg IV/IO • May repeat 1x prn SYNCHRONIZED CARDIOVERSION�, • 100 j, 200 j, 300 j, 3160j • Repeat 360j until successfully,converted ��„p�11^m'I III�i�1011 Ia,n 111 ICI I�°ml�y �Ill ,n�lll��ICI I n!O ICI hill —A.,.,�„i Il'�1�I�rn I�Ilil ICI o�"Illy mn I��CIE��m��.��n I��i�Iir ronl I� ens onw�„I o I u�1 ;,,r I% / ir, Jr >,- r„ J, a, �, ,, ,r,,, r / r �- r r r / i �/,,,, ,, ,, �e� r r�,,, / r ,,rrr, / ,,, � �,,,,, a r r° /rr /r // i' / / r r ✓ v r r 1 r / l r � / i I;/ / / r / I r, /rr,/,�,,,, i r; 1, J "„rr 1 /. �r -�// G I% rr% 'r r, ,/ fir i%l�. � 9��r � �7% r r f. -,%// �,I r,r/ 13 / I' o I i, �I / � �� / / � 31 I r r/ � ��f s10 1, r r,. c I �I .I (, ��f G I �/ G I 1rr r „f,,,/(. l d e/ l ,.i .Jr I � /�/r ,o f ,r I .I J .,i L u r L. i � S Is lr ,/ „i 7 ram,.er a 6 G�� ' �i+t I �nr.� 6 s 6 a 'U .er.,r r� �,4 r,��,e.. �J �� r 6 r� ,m e rr r7�r,err .� �r �r+�nl ter., �r i,/ii' � ter/r,4 r+err ✓n, /.r / are o,r•••i,. /.,/,err, i,�,/I/r i r� "'rir„ i�"rirr r,r,,.r� ri„ n;,,, i,r r r /,d,�-/r, "f'r,+/v S (/ �� I I;v r,,,,� /,,,,,li /s I� !1�,'r f r g/r r / �� 'r r�,,,,1 �f / / / � / o, I�,/,,,ra, f L ,Ic it 1 1/ / l r,,,r,, a e' I,��I; „�1,„�J� ., r, r� L�, u h L r�1, I,,y I f g it,�`�r,,�r I, �„f �r � G b rr,", u PEDIATRIC * Obtain 12 and 15 lead EC Gs and leave cables connected STAIill#1Ili [AAO �II�� 1111111 li Ii1111111 AGE APPR � R,IATE HYP�OTENSI I ,wraiarrrrrMrwrrr ,u m,,,�� ,e r,��nrw� .ue�r m. ��, aa, zaaar� . .,„. V • VAGAL MANEUVERS • ADENOSINE': • 0rw2mg/kg rapid IV/IOt with a simult�, aneous 10mL NORMAL SALINE flush • Max single dose 12mg If no change in 1 minute: 0 0.2rng/kg raped I /10,wilth a simultaneous 101mL NORMAL SALINE flush • Max single dose 12 g Print ECG duringadministration ��11II1 IIIII� I' III III' °�II I� I11 I 11 I I� UTABLEj4LTERED ETAS.STATUSI �ii1111111 111111111111� 1111111� E APPROPRIATE HYPE TE l SION'' 9;MN9J9PflMfiMYM19N�ld'W!ll�A,�Dl,�n °91'9YH91M�WY,';�NRI��II NIWN>'•%N�;'1�%NM@>R�M^., ,. ,. N'M'�P�9Y90///NIA)fi?AflM,93fi��%,N'�I��IIIIIIIIIIIIIIIWWII�IVIIW'�Wl ,01111111 IVIIIIIIIIIIIIIIIIIIIIII IIIIIIIVIIIIV'IIIIVIVIV!'YINNIW"IIIIIIIIIIIIIIIIVU'.!W III�I�IIIW WYWIIIpIIIVWII..IY/'.!W IIIIIIIVIIIIVI INII ., ,. ,,.,.,„ ,. ,. ETOMIDATE (consider forsedation): i 0.1mg/kg IV/10, over 30 seconds, max single dose 6mg • May repeat 1x prrr, max total dose 1 rig SYNCHRONIZED I�a 0. j/kg • If not effective,�increase to 2) Repeat"2j kg until successfully Iconverted b ��u�ll��ll II I°IIh I�1111�III II`�rnllll I�Ili!II��,,IIIh�I��f Ili II H�III I II .0 II�4f,"' w 1 as r II��,III III��I I E! / a o / /// /fill/ / ✓ // r/ / / / / i./ / / I I I / / / // ,,rrrr .rrr/ / :,ratio „�/iiiiiiiiiia r � .�../,. / // „rr„.✓ ,,,,,,, / / // ,r 10 „ ....rrrr... ;r /i/ / / ✓fir./ / / /i / � / � / / .... ..✓/r, ........ /r /.. .. /�... r/ r.. //��.....„.. l/ / .. /�/./... 1/ /�r. ��/rrr r �, ��.. /�/ �� / �/ r,.... rrr,,.. .../,rrrr, ,,rrrr,,,,,,,,.„�%//r.r.� ,,,,,/r.r.r, //�/�i,,,./.,.�i//,,,,, ,,,,,r,,.,.,.i////L//C�/�i��i�„/��,,,/i//rr,,,,,,,,,,,,,,,,�//��/////��IIII��IIIIIIIIIIIIIIIIIII I��III��IIIII�� IIIIYiIIIIIIIIIIII II III��flPf♦/��.,./�/��%/��/��Il, 1. „, ,/1�� ,�l.r��,, 7 II r,..�� r, , i ,d Wide Complex Tachycardia INFORMATION I ECG FEATURES THAT FAVOR A DIAGNOSIS OF VENTRICULAR v v ,.,,,, mmn nHu�vrmrvymrrim„,mamim>mwmmmmrmr�r.+ammmmmmm>9mw�!„ .,!mmmmm^mmrrmxrimmrr,mw�>°.,,�u:arrw mrrr - 0 V-TACH has no discernible P waves f •All chest leads point in the same direction positivether axis:0 Negative Lead V6 a Backward frontal plane !and aVF are negative, aVL and aVR are positive 0 Presence of capture beats or fusion beats(sinus beats that interrupt the WCT) 0 Rate usually> 120 beats per minute + o ll I I�N '2 �� i��I I flJ t WCT 1V ........... I r m II ADULT • Obtain 12 and 15 lead E Gs and leave cables connected STABLE WIDE OMPLE C TAICHYCA iD1A I T �• A 'IIODARONE II' F 5IDN7 Dilute: 150mg of AMIODARONEin a 50mL bag of NORMAL SALINE • Administer ter over 10 rn nute I , 1D by utilizing a 15 gtt set delivering 75 gtt /m n (1+ 5 gtts, sec) • Ad m inister all 15 mg,even if the WCT t+ermin ate s 0 May repeat 1x prn 0 Vent.,rato 99Jb(of, m; pp qY � � p�pp "m m qp� ^@o i^No��i l�1111111 9 m N°V�I�IIII ir,�Jl 00l^� ^I�leg��4�f l��i�lr��i�I III 111 ��li o i�{gl'�@,IQ 654 IIII��, �I��mM��Illl�m��IIII m I p III Oax I�llu�'��`�mm�l�i41m UV��I i41��al�Irl Ii mi;p i 14��ti��IIp rii 5 mmm�ml y`�I a @io n�o�rm�"� ��Vgm��;` i^�i mm. mh4ti oppo��@��I m��I4�„m�� u9ililuuuuuululuu'I'I'lifuumfilulull(1i � •,m��m,noIV�, , 11 .... � � .,;i4,;]l uu� UNSTABLE WCT ONIAMI. �DO INOT delays+ca rd lover ion to establish IV access sl de"fo r se �a • 6mg IV', 10 • May repeat Ix prn • 100j,,200jo 300j,, 360j • Repeat 360j until successfully converted • If a W T converts with cardioversion and later returns to a WiCT, use the last successful energy setbng and increase as needed I�VVI IIII IIII I i �PW"r�w W V °u V VVIIUV VIIuV p III Im r Vily H-VV,iiii,VVIuu le iVuu r. a / / / a� Wide Complex Tachycardia c ed... / • Immediate mediate 12 lead to rule out any ��IIII Ica t1i1 Ir III°°Illll s to AMIODARONE AMIODARONE INFUSION,,,.a noted+ r�the prerr u page cif not already administered) Only for patient's who convert after(any of the following): • 2 +car+d overs ons by Fire Rescue • 2 or more shocks by their Implantable Cardioverter(ICD) •� �D�I��°,',11I�� administer rn o da rw n e f t h a patient has already received Ampodarone ry�(mvr. 11 1114 PEDIATRIC. • Pediatrics that have a CARS width ° • Obtain 12 and 15 lead EC+ s and leave cables connected STABLE WIDE COMPLEX TACHYCARDIA AMI DAR NE INFUSION: SION • Dilute: Smg/kg of A I CAARONE in a 50 ml.bag of NORMAL SALINE, max single dose 1 0m,g • Administer over 25 minutes IV/ICE by utilizing a 15 gtt set delivering 30 gtts/rain (I tt sec) 0 May repeat Ix r `I�f I�I11,I p 111 1m II id c I"i QN`i io IIII",i s Or ent`V 99' "bpm,., ratiei N I�IIIutl4 IVl i III�I�IIII@�IQ�°Ntiti,I�f iV�i,��0�Ill ill��INf ��°��m IIIII�� INI�N I�f mNn°IIII �� Ili IoNR'III onwnm�„ � hNtiti�yN1V I�I�Irr�mo�l��w�ll��IIIVu�mNr III 4�1��IIIII'i�o�Mlr.�411ioo�loY N`r�I DII�IlYr000 o�oo�V�II��glr��N'Y g1r��Im�11�� ,,, m v, #11 I�1�, C �o�m' �� Don o w w�o�� I� �� u u �� II�p f o� a R 61 4�°�111 IIII III�� om h`u III 9011��N,M1V9��I�VY I li Ilb mi ill I�IV IIIII i013 VI�I� �i�m 4G 1�I��f 1(�JN ni of,�oR boom ioNo ��000 loom rooa o o r o�oioo M1ooa ro��u�\\,io�o� .. r oo Imo nn i4P�,,,��1��'lIV i ° y �1mopV r IIIY�ou pawiV pool ggq1 py ^�` .. ��11 n�III I�l� imomm� �l Illl�o.•^ 9 o3� ",1I r:o� UNSTABLE I � uv ii .,,�#r�,,,I A14Y AMIODARONE CONTRAINDICATION ,,. i� mninrmurr�vniuusm�nmmriirrr�uwixrrmsrm'mzm,wu!, r�r , ,., .,, ,, , iDO N 01"I delay Ica rd ioversion to establish IV access ETCH M I CRATE" * 0.1rng/kg IV/10,over 30 seconds, max single dose bmg • May repeat 1x prn • 0. j/ g • If no res ponse, in crease to 2 j/leg • Repeat 2j/kg until successfully converted • If a 1ICT converts with+cardioversion and later returns to a WCT, use the last successful energy setting and increase as needed "n��rn4o �mmunn. r u i u i�i oo� i� i Ilro.��no uN uN''n um r V uuou VVi.� a �....pIW oIV lomp ou r. otliou u.q �N ��, 11r IIIII��IIII lu«, I�III i�� IIII,i��nn Inml��III n�IV III 1111„L �I 4G„n ��„,Nr 7� Ili mm171�1n, ITV III�Q;nn III@ICI ICI a1�,mm�n,IIIIIII,n�I�V��i�ll1 Il�llf��,�� IIII III@I III Q�UP�n Il�lll„IIII mu,�I�Illf PATIENT"S WHO CONVERT AFTER CARDIOVERSION 0 Immediate 12 lead to rule out any ��°,.i�h!li II@°Ills�`IIII'aN'°IIII IIII IIIP°I°IIII I^mmm�IIIIIry o'Imlll 1 7111,m"1t IIII'null IuIG°Nu to AMIODARONE 0 AMIODARONE INFUSION",as noted above(if not already administered) Implantable0 n ly fo r patient"s w ho conve rt afte r(a ny of th e fo I I ow 1 ng): 0 2 or more shocks by their I m N„��II'pm' ��NIII IIII"I�lllm lull nml u;administer Arniodarone if the patient has already received Amiodarone ✓ ✓/,, IIII // /,/ D / / / / / / I I r i / r / / ✓IIIII rrrrrDi / /.. / ao / r Regular Really Wide Complex Tachycardi'a /rr/r INFORMATIONECG FEATURES THAT FAVOR A DIAGNOSIS OF REGULAR REALLY WIDE COMPLEX Gi um I(�ful(fNli,: �,IV�,I�WII ",^"1'%f`rn�APJMY,'fY9M'9M%/91M/➢!'➢Aw"MJP 9➢P,?,91�MF?!:9hII,IYMT"+'MYIMIm�NMnl'fl�%NMXiufiflNW'M`IIOII III�I�MIJIIl011111111 TdwI.rI4WM'nM'JFliflrNkMrwm'IMWN0.'�mmi�r lr IMIiC�,"' ,r'NM^^1flM,P➢Y^r19IM„',t�IIfMIGM Pf�/f.M'MdWIW!Np(I�IINI'IMOWW�M"�'mm#:IM1idI�NNl�i l'WIWIIR��M'N',uMI TACHYCARDIA NN'IIIIII,IIIIIJJ MiiMY(nk8ku�w h i&ff(wmmmmu�rmumm(&�W�I!mm�rd�(J4fV.Mr fmlfl ffrJJM f�immmmflllllllll r�wuw:mm m. m rrrr fifG�ll/M" • RRWCT in adult and pediatric patients has a QRS widthado emus mI IIIIII boxes or 2 large box) • Rate usually< 120 beats per minute RRWCT I � lo G f ,; -,„r � c ➢y if iJll b ��, f Ir ADULT STABLE REGULAR REALLY WIDE COMPLEX TA Hit [ I w, RWgn • 1 I /I , over 2 minutes �,, IIIII IIIIII I I I ,r, ✓j, rf I� 1�'ei/i I"rOrr I % ,,,aioa., ��✓/r a p"r/ y.f-�1r//rr, ,�r I�"�, �I��ii� r,I�i!I 10 �t ":�" �i.l d I, '�+�yi �I ��{y��+°��,, I Jj,p.Q„�III r r. L�,�.�-fIR�J,d U, ,�,J ��, 4.1=J: �1=4.�1ii��,� �1= �,J� 1= ��,�� bl;lc�dr �m s 0DI 6.7 BICAR� TE IIIIIIIlit�ilI, (r I r 1 /„ P0 I I/�I r/f /I „1 s Ii I n�I J • SODIUM e u:. • 100 rnEq, IV/1 , over minutes IIIIIIII II�� . %r ✓. %,,i.,,." �N�� %'/'! r r r�"r."O' r' %r/'„ f II /"" line /,,, "r s CALCIUM CH LORII :1r p.,.., n,, uxHdW I' 6 ;f „r %;,, r% J ,`%„ r ,,,,, I f/!rJ(�,r ,,,i r o m� RRWCT WITH",HYPOTENSION SHILL BE TREATED AS INSTABLE DO 171111 delay+cardloversil'on to establish IV access I DATE(consider for sedation I� • 6mg IV/10 • May repeat 1x prn SYNCHRONIZED W: • If a RRWCT converts with cardiovers on and later returns to a W T, use the last successful energy setting and increase as needed ��I��I,II�� II1111 ial �� I �� II�� I�� IIII I IIII ICI'° IIIP IIII'°°� ✓ r r I , r r / � / r / //r , / / Regular ear ide Complex Tachycardia n, IV, r: ✓i ol�u�r` PEDIATRIC CALCIUMSTABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA � ,r 20mg/kg f over 2 minutes 1. ouoi @�o Ilouoll mo Iona" r, ,f'" / r l „ii r,(i r ,,,,, U�1 �yI��C°II III �J id r;1;, dr s to f, %,/ SODIUM BICARBONATE /�, ,��f,%�IG II, ��m��tll�ioi II'�I��m��i�VV �, � l �o.�.. �r� �.�,af I, �r.r,�, I;,,>-�d �rrir'r/ //r%�/ r 4 O r I i '1/�� 1Y rr r f n;�� i SODIUM BICARBONATE, 0 lmEq/kg IVII0. over 2 minutes, max single dose 50mEq • Maur repeat 1x prn, in 51 minutes. Max total dose 100mEq I ( � � �� of I I 11 .1 �,i d ;;Ylu o„ i, /i, r° r v Ji; m / ri I r r r I, Il, a �'- /� III I l�1 � a U I r �l 11 , 1[ r.,T r��r,�,,,�o�16� � ,d��II��.III II ��,�Il II�� :��ti��,��III��u� �,�� >��.,�� < I,1 lu,u I�-II G„J�„l��. �G,P f��>�II" h g UNSTABLE REGULAR REALLY WIDE COMPLEX TACHYCARDIA APPROPRIATE HYPOTENSIIO�!j dir DO T delay cardiovers on to establish IV access i 0.1 ng/kg IV/11 ,over 30 seconds, ma sIngle dose 6mg 10 May repeat 1x prn w .Sjg If no response, "increase to j/kg • If a W T converts Frith cardlovers lon and later returns to a WCT, use the last slulccessfuI energy setting and increase as needed iiil ni l i il,l�l 1�1 l,�;l� IF UNSTABLE RRW T FAILS To CONVERT AFTER CARDIOVERSION CALCIUM CHLORIDE: as noted above SODIUM BICARBONATE: as noted above SYNCHRONIZED CARDIO VERSION,,, SIO • 2j, kg every 2 minutes prn M Po orphi*C V=Tachl Torsades de Poi'ntes IYM INFORMATION • TOrsades de Pointes is are uncommon forma Of V-Ta+ch characterized by a changing in amplitude or ""twisting" of the QRS complexes. 0 Risk factors for Torsade : 0 CongenitaI long QT sy d ro rn e 0 Female gender Medications0 Renal/Liver failure . . anti-dysrhythmics,calcium channel blockers, psychiatricantihistamines) ADULT • Obtain STABLE POLYMORPHIC V-TACH MAGNESIUM ,m Dilute: of Magnesium Sulfatein e 50mL bag of NORMAL SALINE Administer IWIO utilizingset, run wide open is e i I��m�611111 o it� n'��o-�i I��i,,moil m q o��, � i^� n o °I m�� Ir�m��, �, imp m. 6 ,o��o�i m i o„ ii It�'1�1 I��I14P i°��i�Ii�P!@ Ii Ii � IIII pppp^�� m„�� m��41�oul��ull�II i��I��P��„ ��om��i�@��°�1�101��I� �'°��IpI ip��i�q ��^ �o Po^��m, in u��u �so0��, Ili^��IV��"Illiom��o i� m �Im l ma„e��^m ii� ��,� io II n�,"�m i� �1\�,mr��IO I io /rif r��/.../fi �� I�(Ir. if✓1/r/r�/ r/J( /J� �r�I�� /r may � %r I°.�V/J /�//f/ /�i/// �/ /r r��; R I mo I w r,/6.I.,.. �, Cio f I, I fu'ral'G G,i�I,I✓c U I,G r,�u.,n�i I,,,�%�U r,�a r�I>„rr 1„�,,,dr,,,,r. �. rl,p I:,d%I„u I,,,-l��lr i Imir/"}r UNSTABLE POLYMORPHIC 1DO NOT delay defibrillation to establish IV access ETOMIDATE (consider far sedation) • 6mg I' 10 • May repeat 1x porn DEFIBRILLATIONO. •� 00j.?300, 360j If a PVT converts with defibrillation and later returns to a PIT, use the last successful energy setting and 'increase as needed IF INSTABLE POLYMORPHIC V-TACH CONVERTS AFTER DEFIB R I LLATI 0 N AN D MAG NE'SIUM S 'LFATE HAS NOT ALREADY BEEN ADMINISTERED MAGNESIUM S LFATE�, • Dilut+e�:"2g of Magnesium Sulfate"in a 50ml-bag of NORMAL SALINE • Administer over 10 minutes IV/ICE by utilizing a 15 gtt set delivering 75 gtts/r rr %,,,: �q �o,I n e�, ,A1 o�,l J,o,e w„q,oml o�,,�,,,�,r �"pIY��Ifs Avon ooi mq �,iiVu�I��d�... ouq,��rr ly. iAm l mm�� 'mmo room'i,'. �,A�",nr��l tin '�,q�,�„ n��u�I��),��R�10�I;:,,��III,IIr i 4�,��V��,��I��'�,',ii 4�,�i I�I@ ��,,,. ��„� 9V��! �,,,,�,� ��m��,@��'��la I��II��,,,��I��,,,�� I lie,��,��III�I ��cG 1�I��p�n��li��1� I Imn� ,9' 1 I�IIK li�uiz �Unll (l��e 1mn��,�!II �i r I(O /rJ/i �/i� II��rr, rrp/!/, ' I%�/ r�if/r�S� r I�f%"�: %ire, f%�r //1 1,/1 r li li f1 I r�f i�"'%'"r; r „�rrr o,f,.G yer n ram,V k �s,,?;�p r,�r ,7p Ic�r L�I,�I��G r i ��a/y ,�,�a �G��,.I,(,��I r�,;l Jr E rr it r n r r t / ,,,,� ri ,i„� I,1��„ Torsades ,f ,. , �� f4 � r�� iu r 1 fir, r r / 4 .. _,.:;,,,,,,,,,,a J Jf r a /iiiiiiiiii riiiiiiiiiii// r ri r a� ri rood r %i r, r r r�r„ r /i / r r� / r ri / r / / /ii r / r r r r,i ri ✓ rrr r / r,.....� r" / r / � / � // / ram. 0/1 ✓ / / rim ri/// / / /�/�/ %%/////////�/%/, /�,r r �/ �,, � � / /,� � 1 / // r ��/�,/ i r r / r Polymorphl'gc V=Tachl Torsades de Pot'ffintes ..........W ................... .......... fluw,� �Y PEDIATRIC 0 Obtain 12 and 15 lead EC Gs and leave cables connected STABLE POLYMORPHIC V-TACH MAGNESIUM SULFATE�-, • Dilute:4 mg/kg in a 50mL bag of NORMAL SALINE 41 Administer over 10 minutes IV 10 by utilizing a 15 gtt set delivering gtts/r rr (1i5gttslsec) • Max dose 2g ^iNimmun�. o q��I�I'M�� IQ�IIII I Imp^ I�im ��l o�I,��i"im m�V i�o"�� o�� `I i ��mi I �If i mo i. o+mom ��l ICI."��i��IVI�I��........�ri��" „,` Ipm^'m Y IpI yI ¶I^III ��mim 4 ^�I��Ip4.��III Ipllpom�l�G IpI� IIIII[lei IV��N 6�jpo��o VIp 44ti �° 10�IQ�n1I tlu In tlou@i hou@ iONliouou� II IIII 14 IIII��1""�MmIIIIPi II��0 II �IIn IIII IIII n I��n o �ll��Yn o 4ltliu� ��w ��0 IYo oPr�rlm o imfl` A i j� vl�//I�//a ��I p i i%/�r rf ' I','r 0 i''''" '/ r r�I. r 'r /i/r 'I �i I.r�r'I�.la I��r r'I,!" 1 i a r.//t o�>, I a��,I,� � �Irr�.:I.� ��1 I,��i �,col Ir�rah�,,� 1 ��,e ,,1 m,�1 �f I,�.la ,UNSTABLE V-TAC AGE APPROPRIATE HYPOTENSION), ,IIII 11 11111110 ��111 delay defibrillation to establish IV access I ETOMIDATE (consider fair sedation) • 0.1rng/ g IWIO,over 30 seconds, max single dose 6mg • May repeat 1x porn DEFIBRILLATION,", jkgt 4a/kg If ar PVT converts with defibrillation and later returns to a PVT, use the last successful energy sung and increase as needed I U N STABLE PO LYMORPHIC V-TACH CO NVE RTS AFTER D E F I BRI LLATION AND MAGNE IIJM SUL ►TE HAS IT ALREADY BEEN ADMINISTERED • MAGNESIUM SULFATE- Dilute:40 mR g in s 50mL.burg of NORMAL SALINE Administer over 10 minutes 100 by utilizing a 15 gtt sett delivering 5gtts m'in (1. Sgtts/sec) • Max dose 2g iri I '" �I m I"n "rV m � ICI I '� I� IQ�� I��" � Ipl'' " �"" c i��"� I I i I I lics Il///r. r�%['i/i' 1/r /�( �f `,, i/'%%r( O r I�r f�6 Ir /r./�I ri.,//I - /i/t q /, F 1��a.o-�Fwe ' �k..G I'a III l�.rrr. Ii I r l I� I f Jfl.�,lc o L„e. �l/ m,�� e i r_r ✓i r /i r, / /�/ // /i /... / sir / /��/i/i � r/iiiia / ��,I / // // r / /, / /i/ lirrrrrr l / Y Left Ventricular Assi'mst Devices LVADs INFORMATION �n'vrm.idmlin 4 Al circulatory support devices designed to assist the pump ing action of the heart. ADULT • Every effort should be made to contact the patient's primary caretaker(spouse,guardian etc.)and the LVAD coordinator immediately 0 The phone number for LVAD coordinator will be on the device and the equipment carrying bag If needed, assist patient(caretaker) in replacing the device's batteries or cables Locate patient's emergency"'bag" with backup equipment Take all equipment associated with the LVAD system to the ED Treat Non—LVAD associated conditions in accordance with the appropriate protocol AUSCULTATE:• Determine the type of device,assess alarms,auscultate for pump sounds Patients with a properly functioning LVAD may NOT have a detectable pulse, measurable blood pressure or accurate oxygen saturation Auscultate chest and upper abdominal quadrants,ii Continuous humming sound=pump i working. • Locate the driveline site on the patient's abdomen 0 DO NOT cause any trauma to the driveline site or wires If there is bleeding at the drvelne site, apply direct pressure NORMAL SALINE: • 1L IV Io,titrate to desired effect.Assess lung sounds and BP frequently. • May repeat 1x, prn /,�,,, �„ ,,1 r, r, 1, l„ I� ,,, L„,r,,I.,,1[Il„i „r r Q,I „r1; ,,, l 6JJ (l. (,r„` r Il �(,,,Ir II J( „ ( II V („ [(;;, ((( r1 I[b „L(„II 1 II ��L., „i (. // � f f /( Ins R I'I,�,,,,. JII II I��Ir I°�I Ird,f Ilr f�(r+"ifQ,,. r f („l I II-,,%B UNRESPONSIVE PATIENTS ��@oII�IP'Illi��lllll°'Oi��N perform chest compressions when the patient's LVAD is not working and no other options exist to restart the LVAD Evaluate unresponsive patients IcarefuIly for reversible causes by assessing • A..E.I-0-U-4.1-P-S.. +� H's&T's CHECK BGL CHEST COMPRESSIONS- Position hands to the right of the sternum to avoid LVAD dislodgement m IBC.11 I1 ICI luoml 1v1mi41), I I Vl�ogl�II14 ml.... pnmo��m'u Pn ��me m„ono ��il In I�1p. Iri I^pI�Q��I�p�..,l^pm pp��QtiW... ��mim0lll. mmol�. uouoil�lly� III ml�l�N��QI II� m n�111 lll��im^III��Il�tt mi��IV��Y I..��omm�. �r��um�.IIIYp��m�l QI �I��oo� 1111m��.oar��QII�4 Illp�woM1.QI IIII ��m�IIIY��o-IIIIidV��IB IIIV o gl'ro��^ I "r r /r( r. � 1, J,",,�, ,,,,,,,,:.�,,, „/,�. / i r, � is,,,,, ,„ ,., r :f g ,y" 1',../ ''f / 6� ( / fl./ �""t ,.fl( .,r (. / i/! ,''4.. f ,i!n r/re.. '"f / 'I,' 'Y.,f i(„�; I(e r, L„Jr'`��% m /�„r,,,,,. / 1" ,/ I// ` r�Jl // �l (" h,,,r r„ ,„I. 1, I a 1 l ( f,. r.�(' „�,a 1 r,,.o 1„ 1 "/` y:,,9 I v ,,,,1„11 a ((l �r� ��r � � �11, �� ! � I., �� I f J� �� f r. I� �� rrI r 1 „/ �/ � 1�� ( �c � ( I�, r .;�� n.;�,/ r /I� � I •, ,, i;�) r s I I � 1 c 1 1 r, ( i;� G � r 1 r, J r� / J( I ( �( I I �I I �I ,;( f � ( � 1 �I� ,� � (,( �1 .r � 1�� l l 1 ��. da,da �,1�d 1 � d�d d�1. <<<1/ �,�� .do-,�I r,a 1 ��t l�!.1 U/� 1��1 a d� J„J o,oI I, l�, �,J I oW 1 u ,v,.a/ l�,dJ a o,,� I�o�11 a duw,,�o�,.� � f i e // i i /, // /.,, / � /// ✓ail /� / / .,.,iii ///�,,/IIII/�// // ��,, //iii�/a/ �r/// a i/ ��% i � �%i /.1 /�i/,,,/ /�� //✓ / � / f I , e Left Ventricular Assi&st Devi*ces LVADs T. T •TRANSPORT I con-LV D chief complaints should be transported according to the "Transport Destinations"' protocol JFK MEDICAL CENTER LVAD COORDINATOR: (561) 548-5823, Any LVAD issue should be transported to JFK W cables, i I cal Center Be aware of the r scc controller,and batteries when preparing for transport. It may be best to place] creatings:cpt:heab t f tc r stra i the stretcher straps under the LVAD cables so you are not ceW ------------- .,,<.r,.//„/i//�, �ii.//,f„ ,/,,,,,.,.,✓//////„i,,.,.,.. /i,,,,,,.,,,r,,,.,�i,ciidi/ii/c%,u/d,,,/�i,,,,.,,ii//%ii��ii //�/�//�r�/��e,��%////i//l%iia��//�l��dflfAlJJf��Jrr r,�/��lYfff�r�IIViRI��r�/��1��///I//%��r�r�/rr��/��/��f f��fl Il��I�I ( rrr ff�/��r�r�/ %// iir<,/��i��i,,r,,,ni/%i i ,r, ire /'ii//�'✓/�' i„'/%%/ /�%�f�/�ii�. / /r// i no no Z,4 In Pox UCT no ff 3# 0 PeCJ997 no 0 10� 0 N r f 3 v i Ilul 'll � i! �'Illlllp� I r / �i { p„ map J /AO Standing ---------- - it �J INFORMATION 4 ° • There is no scientific basis in trying to resuscitate an runwitne sed A y tolic patient who has succumbed to the dying process of aterminal illness. Consideration should be given to not starting resusc,itation efforts in these cases., • All witnessed cardiac arrest patients must be transported • Exception- Hos�p ce/DN patients a in general, when the scene is safe,all Cardiac Arrests should be worked on scene., ADULT&PEDIATRIC ",for '` DETERMINATION OF DEATH The Paramedic may determine that the patient"'is dead/nonsalvageable and decide not to resuscitate if-, • At least 1 of the following conditions is present: • I,N ty decomposition• Rigor mortis • Tissue • A valid DNRO is presented or discovered ,��' minutes• If all of the following are present: Known down time >30 Pupils fixed and dilated Apneic Asystole Without hypothermic mechanism for arrest PRIMARY VS.SECONDARY CARDIAC ARREST Determine if Primary or Secondary cardiac arrest and refer to the age appropriate p Arrest" algorithmCardiac Immi �wum 'n uI _ lumulrr i �J+ ri r III uu� uuuuommmmwuuuummir p mmnnmm mum a i 4 I * AMI ALL PEDIATRICS (e.g, ., Hanging) * Cocaine Overdose Drown a + Electrocutionng (Alternating * Unknown Origin Lightning Strike (Direct Current) Trauma Cyanide Exposure Third Trimester Pregnancy MICCR—MINIMALLY INTERRUPTED CARDIO-CEREBRAL RESUSCITATION JJJ .. �911H11 .. NIItnMnmll� 'm'YIMXND@ Wml YDWIIWMgWImRWN,'MIIO,YWWOIIWWi i Emphasis is placed on minimizing"Interruptions in compressions to no more than 5 second • Perform all assignments in Pit Crew fashion and rake all efforts to obtain a R SC prior to leaving the scene and set to continuous compressions if applicable. Patient should be placed on the scoop stretcher 0 Once available,apply the LUCAS Compression Device with minimal interruptions to chest compressionst availabletransport purposes 0 When possible elevate the patients head 15*or utilize Head-Up CPR Device if 0 II 1111procedures, 4 Standing Orders condnued.. NMI= ADULT&.PEDIATRIC(continued MEDICATIONS 0 Medications should be delivered as soon as possible after the rhythm check(during compressions) and circulated for 2 minutes NORMAL SALINE. 0 Follow all IVP medication administrations with: possible0 Search for r (i.e., Hill Vi BGL,,etc.) _.RES ResQPOD should be used for all cardiac arrest patients Iirl,li ria i ICI 4011 i ti ie ihiIVt 101[s � �� °��I�'�°'1��°i��a�a'h I�� mC,��,mP�°n �ljllfA��lll�r°� ��4f��';;; ��^��ti��fjjll IIIil�e is It P ll ii It I'll a is u 15 i�1,, I;)Iau s s IIry ie TERMINATION OF EFFORT PQ! LT o L • Consider terminating efforts when an E 1 5 Capta n is on scene and: • `"Persistent Asystole"for 15 minutes • EtCO2 of< 10 m m #fig • Patient is normothermic administereda NORMAL SALINE. 0 All reversible causes have been addressed 0 All ALS interventions have been completed a Social support group is in place for the family if needed. �* Hydrogen Ion(Acidosis): Ventilation Hyperl l mlaw(Renal F llur ). Calci'um Chloride,Sodium Bicarb,Albur erg l Hypoglycemiam Glucose Hypoxia. Oxygen& Ventilate H p v lemia laid"Bolus • Hypothermia. Worming w *Toidns or Tables ),, Opiates(Narcan) Tricyclic Antidepressants(Sodium ica Calcium Channel Blocker(Calcium Chloride) @Tension Prieu othoraBilateralPleural Decompression ion / / Adult Cardiac Arrest r WARNING 011 i�� f INTUBATIONIntubat i on should only be performed if you are unable to successfully manage the patient's 4 F 4 ,oM�„,,��rrr;,.r;c rrr,,ii„a d 6r,� Once working an arrest,,no / V further pulse checks shall be performed until a spike in EtCO,z or signs of life present / I w I 9 m I� II" a I "w 'It � IwIfflI� m ..a....m...... . rir rptliii+ r�,C� ni IIIIIIIIYY i iin a{� '.i r I IIIIIIIIII p, _ .,I.jn. ,.,w�°rI""it Grp wryerw;N m'"n yuv�r w r mr,lml�ri° I.,. IE ly„ i III � a wu o 'I I e 00/10 AS Ar"Y" ,,, / r, AL til r Minutts:-,- V O e� I r Adult Post Resuscitation ADULT P O T ARREST Patients with a ROSC should be managed in the following N, 0 Obtain 12 and 15 lead ECGs and leave cables connected a RATE UNSTABLE arurr�rrar�rrarrfrrnr��urrgur�w�urr�cruy�n��ru� w,Syr,„y�riay�yp�yag�yrytyxiy�nrmir»i1r�65LN'sw�Hnrrm�hs�',;,;.;;,InmNr�m{vi " �rrmrnmmm�mmirmv v v v i, ,. TRANSCUTANEOUS PACING,r m • Initial rate of 60 beau per minute and increase milliamps until capture is gained • Increase the rate as needed until the patient is hemodynamically stable Reference specific protocol BLOOD PRESSURE,u (Goal is to maintain a SBP of 100 mm H ) * NORMAL :' • 1L I11 IO,tltrate to desired effect.Assess lung sounds and BP frequently. • May repeat 1x.. prn I i, r l „ a" 1. r /,a .,/ „1, e 1.� ,I I ,,,U. ,i, I%- i. � %I: �, ✓ ��/S ,J,J r. rr r. a.ii�V � r i r.r I ✓<r �i I � /1 fr l r l / rr I �l/ I I. I / i rr � r II I r II i rr ""'I" r� r i, r� ((II I I(r I I � I I r io raa>/ �1� � y y f�� lF �,1 � �1/ � a� �ra,, ,�,�1p 1.lV I, r � j 1 �o�.r� G� u,,�a ra ov r�+F o 1/ ra� f �eF r r,�r � w 7 r�, �/, ,ad % r%O,r% r. Or/� f O r,. ��/lr l i I l�!1 I/ ,O�i roo, J/ /( %%1,� 1 !� fi �r�% / )� I. �o% �.ri rrf/ I.I,r�oi,I�i I�I. r.o�;I�-S 1 oi,I� ,,r,. �.iii.� 7 il,(,�.Fr,.i.1 � �r I it, IG 1 �,i.�i I�/� ;,%I li If patient remains hypotensive Dilute: Discard 9 mLof Ep 1:1 ,000 (0.1mg/m1L)and draw up 9 mLof NORMAL SALINE to create push-Dose Pressor Epi 1:10 ,000. This will yield 10mcg/mL. • Administer 1 r1 L/minute III IC ,t1"trate to maintain SBP 100mm H • May repeat 2x prn, max total dose 300mcg( 0 mL) 4 Ili r° secioiidiai y blicold lio,ssi Aft /;I,c 10 �,%�r��/-�%�� I � I/r�"I,�, or//lrf �r%I�✓"��i, 1i.1% /��%�i i l�� I/r% %rI °/�%j� r� I/rr lr G„„�1'°, r� F kriro lr ,.i�V�. �, �,,,,.r� „lmr.�,,; o��i�.li�,�i/r�� 1L �I�„�, 1. lr 1?1 lam ,I� r �r„G 1 ,r,�.I��.�� 1� l� ii., ri% o r;r::.,, ,n lr- F !i., ,.r;,,,✓.7 �,,i %,,d'i/, �c i% � g /..:,, �%� ��!' / t., �. ��„li i;./ r� I;D�.% �^' li,zo, ,r r ,! /e it � ,, r, / I„ .I//, r, �G I,la i%, .1 %�so�„i i „dr. l ( I. I, I� i, r Il. �a �r a r, I I f�I I ��lr I,��/G I, c I�r,r,,,�6<I, m ,�,T„mr rz�6<��ml� !�r�!,,T/,./ �F r a,err w,!�r//.� mr m W�n i /��, ,�1!r ro ,�6<,,,IG�W I��I�I��'�� ',�„G ro � f • Apply ICE PACKS to the a illa and grain for patients who remain unresponsive IMP MP 49P .. Adult Post Resuscitation POST IV-TACH CONSIDERATIONS IF NO IVP AMIODARONE WAS ADMINISTERED AND 2 SHOCKS .". J��n.rmr��nrmrm�m";^TM�.r!;m, +imm�rrmnwmnr�mmymnmm�mmmmrmmnr�n»»m„d,>»:�mn>smn"M^m,n��mmrmv��mmmmmmnnmm�>r�r�nmr,7mvn,�nm�.mmm��mrm;,:mvrmmmmvvmrmmmmmmrrcnimmmmmn� !�xwrrvmnm,arnmaowmnmmumn>�vuwtinMmwammwma..mn�m��Nc r�rr�rrir�rrar�rrrrrrrrrrrrrrrrrrhrhr�rur�rrar�rrir�rrar�rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr HAVE BEEN DELIVERED AMIODARONE INFUSION',', • Dilute: 150mg of AMIODARONEin a 50 L bag of NORMAL SALINE • Administer over 10 minutes IV 10 by utilizing a 15 gtt set delivering 75 gtts min (1.25 gtt,s/,see) 0 Administer all 150mg,even if the WCT terminates • May repeat Ix prn PM99 b n� �I�mIII IIppIppIP I III^II�� 1,1 II I� ��Y G v' II 1 Im I`�I.I��QI IQ�gI� '°^°olS��IQ��I Il��oq � mini m "�� °��I mud m IIII �� Vououo �� 1°q h. I'�V 1�`"mom Ik�m �u I�a�� ^ ii�� ICI�@�� i�i,l 1 hti9^��r��,^��^��I@�I^�lu II``^pp ^��llppll ,. o@II��^� IQ�°��o`,l�I II�Y m m��^mo. h��wo I"o"`^`mill �^��^�^�u, a�o-�u,� I r o I^ I GrulVu�l /� yr. y119u1�011111111�� -� '� fo: ��mlm�ml'I��Vii�"II�Ip�")[�^I�I�^!'"I'll mi,��ol�III I��;��I1111 r ales19 )""mm v v p �@uouol�I��I�mq1 Illyy_ Ill�i rmmwm4�, I111.m m,m°NII P T CONSIDERATIONS ATI NS IF MAGNESIUM ESIUM SULFATE HAS NOT ALREADY EEN ADMINISTERED ^ �m^rb�,om�rmmmmmmmnn;4e9rrmmmmn>�m�»nmHm!rr,�vrmm�rnm��nv>rmnmmrmmmrm�n> �nimmmnm�mvw�rmm�mmmnmvmvn�rrn�v>rmr�mmmv�n ............. vmvn�r�nmmm�nr+!m�rm�»m�wlrzm�rmam,r��,ur�rarrrrrdrrrurmmrrtr� �a'rrrrwrrrr�.,..' ,.... r. ,,.a: MAGNESIUM ,y • Dilute: 2g of Magnes urn Sulfate in a 50mL bag of • Administer over 10 minutes IV/1 1 by utilizing a 15 gtt set delivering 75 gtts/rain (1- 5 gtts "sec) p i� p RI p q1 p p p g4 III ,«�u N01 'I�lu pPints@ n p 0 41« `% �HHHH. r r ^ p r r r/ (r / > F( � ��,ti ��r I,o Torsades ;I r � r i II 011 �I iii�l IL•pl. tll Illo VII�V d�M� 1/e d a� uM�1 ^ 16= � q) �� I 1 V % I I�l ! (� 1 I ( !� 1 J AN �r, f PIZ 1 r u jr r - � e r r r J f / / 1 Cardiac Arrest (Pediatric) "I'll,I......... I� i �II wV IIIIIIII G INTUBATION Intublation should only be performed if you are unable to successfully manage Of Once working an ar- rest,no further pulse checks shall be per- I I .,,. ,,,. �',' '.. �„//..�„r ✓% ".,,�o ,/ i/�% %;;IIII///O/ /,,,,, /; , formed until a spike KI A �j CIA �m a, r ry. iU I IIII a liiiiwii I �' i /, o I@¢ II"Mtt 9ro" RUG �w : �Rio //Oi i /pill, Q. �// /�i/,iiii/��i�/%��/�i��% /%,,,,,/�� w r/. !i r r , 'ti, , to / ESr S n N , PA '�� ",m t 'uw Iww "�ryw ' w into r / ,,,,, :/„ i 'r,,, r EPI- i ', (p� , r D/ ' r r r 1' / ,,,,,, �,;✓,,,, ro,,,,,,W , ;- , ,,,,,, w/ e am / , ram ,�/..../ i // // / , ,/, /r , , , „r ; r / ' V,3,x,,e%*v y / ...............f,1/� iirr/i ............ 'S nu M ,ffi ;,r o ale / t//j , ', ,,,s; ma...."Affi /r ,r, r;r a / /iir, allay„ <, /, /„ / / /i,,,,ri c,,,, /%/ ///„r /, //i , r,// /arr,,ii... //,ri,r,// %/r/r /, Z� (dti� r/ i /ii ,,,,, ,,,, :;% .,;,„ ," //f, �r/%/ ,j,o0/ ��irriii��ar„ro i/��a ,,,a/, re e i r, „r/: c ",64, mw7tliiiiiii/////iiiii// fill r / i %Il /i r�6Grr Peatatric Post Resuscitation ON PEDIATRIC i POST ARREST Patients with a ROSC should in the following order: r i-gel Obtain 0 RATE: Reference specific protocol Reference sci , protocol BLOOD PRESSURE-(Refer to the r' , system) • NORMAL SALINE IW10.Assesslung sounds n frequently " repeat 2x prn,,for age appropriatey1 Cif si n • f patient remainshypotensive: • PUSH-DOSE PRESSOR EPINEPHRINE r • i Discard of Epi : (0.1mg/mQ and draw SALINE to create Push-DosePressor i 1:100,000. This will yield c L. • Administer 1 mL/minute IWI ,,titrate to maintain age appropriate 0 May repeat 2x prn, x total doseL � , �jI p�, �^ I my"" '�ry �,y y III uwiM�' ��'tie��P�"�iI�N��u1 us e��n I "a ii �VG�� m dull o i� uw � �uxxn i lu m d IIND ��III M � ,f i ll�i(!l' ,� (�o i if ��!r�1� �l/%�r 1 n �l fr �l III I i n �Il J"I NOT�,�f a,�! �� l�„li I ,� �1,�l;J 1„��„U J�� „�l�l`. ,n/n�, ��r�� fmnf��„�, �r �ii i� i r li-r i F .l r. p,� r I' r r io, it i l,. !„� ii, r� r�: r t ,,,/ ,r 1 l,,,r r 1/ »/ / f..la ,IIf %`%! I,,,,rn r ✓, 1/ I!„o(/ s i l 'rri !,l"s (de Ile x ,J U, 1 li✓ U�, rh VI u„, l,M: „a a i;��p d f � �f G � � m y ��1 1 �, � I II , f II r / r s��I,,,,,�'f`�G,Jrf,,l% ,,,��% I�p�� n I,Ji I,,,��,�I, r„iJ�I r��I�it 11 t I�Ir ie t 1J�Jf .J' � a„ �f ` 1 I /„ �l 1 l-/ / i i i, �� / i r,. V l.. F. /,.ir",i r./, ¢. / 1,r a-r ✓i r. ir'�,, t r f hear li. / ai ol/ o , / D li,,,l � � t o✓ I�Jjl'r J I r s I/ �,.i, / r i �U l/I.!�v r �- 1 �� fnd� �li �/ r l� �f: �Ir !;, 1. �1, .�>r�1 1,,,�)� �„��,r�l l f,�rP �1 �� F�� .�I,.��1 �;I� ,�,w,�„>r� �m, 1,,,��>f,h J I G�J�1 ml„�lr,, ��r,,�� I�1,„��I,„1>>,�m,�>r;>t • Apply ICE PACKS to the axilla and groin for patients who remain unresponsive IIIP°" IDII'' r IIII" , POST HAVE BEEN DELIVERED AMIODARONE INFUSION: • Dilutes: 5r g l g of AMIODARONE in a 50 mL bag of NORMAL SALINE, max single dose 150mg • Administer over 25 minutes IWIO by utilizing a 15gtt set delivering 30 gtt /min (lgtts/2sec) • May repeat Ix prn Vent.,rat,6, q pp� pp p p p r� I�\V„II1mp loll��l�mi m��RI��,��CmV�1�.��6�Rll�I�RR��q°��. ul,i��''��4 1I'��I�IIf M k, �,. ,"'Jaervill ISO �a IIR IIII�P�� '��' ��I��p�i�l li��si�ICI�� I�u6„ IQ� ��R°��I�I�� i��'��P'��iph ��°�'�� :w �,i�� o ��iu i��i�� Y d�m i� 6 m�6umim 1Y��o��. ` �u��uu� �A��i��A��l�� i m � pp 4 i nun u i v our��q ry��r. ..., Ii�lllgml`lilglgglqViliiiiiiP(I ,. ,, � �. !/ �I�S��I� p `-'p'uww�'u�m'umiu�uuuul�fm01111111111111Vlyiuuuuy�uuuuuuumiii��f�l °; o�ll�r �I II (�I IV ��Vumioio ,gyp w min �m��i I6��des NES11UM SULFATEHAS NOT ALREADY BEEN ADMINISTERED • MAGNESIUM SULFATE: • Dilute: 4 g/ g in a 50mL bag of NORMAL SALINE • Administer over 10 minutes IV/ICI by utilizing a 15 tt set delivering 75gtts/min (1. 5gtts, sec) • Max dose 2g l/ P��I r�/ j �%�/ , ��, rf/ ,�� %r�r i i� i- i i"' �i i. p-. l..i Ill �r/�,ii -, r/�,�,�.��o';(��J��ir;;,%, �I„ ,I,,,,� ,, I,L...d,I�,,,,�I, I,t I,a l ��rr,,'i1,1,J',I/ I�rl/I�al.I,��a „I/o/i s I,o in / N / rrj Special Consi*derations / INFORMATION • The below treatments are in addition to standard therapy, ADULT HP E IALE IA 0 CALCIUM CHLORIDE". 0 i I /10 ��1 r recaur///ibn IN IOT a ni,s,er Syr atrj�le I v L0 1Iji,re a s S DDIU M BI CA RB 0 HATE ItItrl%/LJ't tIJ r t„1 ., 1,g I'( '`iN%(I r,,,,1,;,f , y • . mg aria nebullzer • Continuous treatments if an advanced airway is utilized, administer aria in-line nebulization) 0 SODIUM BICARBONATE': • 100 mEq II IO fr%I% >J I �.I f'ti 1. I% r i ,I, %l �1 -/ I»N /, J r 9 i�r �r r I(/�,,,,II/ 4 �t„��,,,r f�f�,��i r,r fro„�/�4' "� ��,.(�,,,�i � I S�,,,1 I,�,.,,..r C� ,,;�� ,�c;o��, �� s%,.�� i� s I f I r l�,,,�r� r 11„ �.I,J I II,,, I / F c, I l q,0 � /'i,,, i 1 i,,,� � h iii,(;f;g EXCITED DELIRIUM • SODIUM BICARBONATE:',, „ • 100 m Eq IW10 • COLD NORMAL SALINE(if availableY, • IL I ID,titrate to desired effect.Assess lung sounds and BP frequently. • May repeat 1x, prn J r / 1 1 „1 „, r ,,,,f 1 Ir r„r � / f � 1, I i„ �� I� � �� I�,�� h 1, � �,� � I J � �� ,�-�� I�r� n/ a,��a r C�� r� ��)��J I �r� r,��/ r, "11 disease�r,. r,,,,ir r J r t �G r dr r iil//�,r„D I, f Ir I...il I/�D / ��/r I,��1 In �s/ i / t.,r/ THIRD TRIMESTER • Manually displace the uterus to the left • All third trimester patients in cardiac arrest should be treated as if they are in SECONDARY ARREST • Transport to the closest OB hospital Exception:Trauma alerts pp /r G / y„ t ii, IA��ISiY N DRUG OVERDOSE 0 Treat all drug overdoses as a SECONDARY ARREST 0 Exception: Cocaine overdose , l S ecial Consi'Oderations contivued... ADULT CPR INDUCED CONSCIOUSNESS Defined as patients without a spontaneous heartbeat who gain consciousness while receiving CPR • Dilute: 200mg of I etamine in a 50ml.bag of NORMAL SALINE • Administer IW10 utilizing a 60 gtt set, run wide open • May repeat Ix prn u'C I1111 It I111111118IIII 11 11d'11cialtilo Iii li IIII"� Iilllli ; ,a b iel Iill-itis IIII'"1, ill �V'� ��c�� i Iii �j�u Ii1'° � IIII'i a IIII'la' ICI- � It c c IP"" ;�m ICI IIII"" HYPOGLYCEMIA • D • o L I /ICE, rapid infusion REF -Flyy, H • Defined as persistent V-Fib -Ta h with no transient interruption of I -Fib V-Tach after 5 def br ll ti ns • If Ali.Iliiiii, of the below treatments have failed to convert the refractory 1 -Fib/1-Ta h. • or more standard de fibrillations have been delivered • Correctable causes(�111111,e., H's&-rs) have been addressed • 450mg of AI IODA O E has been administered 0 DOUBLE SEQUENTIAL UENTIAL DFFI RILLATI+C N:1, 0 Apply are additional set of external defibrillation pads anterior/lateral anterior/posterior depending can here the initial pads were placed rift'both mon tors de ibrillators are attached and confirm V-Fib/1-Ta h rhythm on both monitors Charge both monitors to the maximum um energy setting and ensure allteam members are clear of the patient a Defibrillate by pressing both shock buttons as synchronously as passible Repeat emery 2 minutes until termination of Refractory rrrg lWI0 over 1 minute ySTILL PRESENT),I /J� ESMOLOL INFUSION (IF REFRACTORY V-FIB/V-TACH Is Dilute: 60mg of ESMOLOL in a 50mL bag of NORMAL SALINE • Administer over 10 minutes IV/10 by utilizing a 15 gtt set delivering 75 gtt min (1,25 gtts sec ecial Consi'Oderations 10 i/ ADULT&PEDIATRIC ELECTROCUTION L I T • Treat as a PRIMARY ARREST • Immediate DEFIBRILLATION as applicable • Consider Spinal Motion Restriction • Transport patient as a Trauma Alert LIGHTNING STRIKE JDfRE+CT �RE� • Treat as a SECONDARY ARREST • Immediate DEFIBRILLATION as applicable 0 Consider Spinal Motion Restriction • Transport patient as a Traurna Alert CYANIDE EXPO ARE • Treat as a SECONDARY ARREST 0 Any firefighter who suffers cardiac arrest during or within b hours after a fire incident,shall be treated for a Cyanide Exposure Refer to the "'Cyanide Exposure,"' protocol(p n, 100) for Cyanokit dosing HANGING • Treat as a SECONDARY ARREST • Consider spinal motion restriction • Transport to closestfacility DROWNING • Treat as a SECONDARY ARREST 0 N cy drowning victi rn is to be prono un ced dead at the scene if the possibility of hypothermia exists 0 Remove patient's wet clothes,d rye and cover with bIankets Ili�l �i�im ai, ��lilr ��11dpi ��1\cG oo>Sio �II��mo10 oon111� �1AD htiw�,�u„n1o�m �" �,�o141u u',oihhl�h�° ohvti��19��`h1�� tttiyluilgli "I Il��Ily 00, �olsllll��° I // qq ff I 1 1 I I I , I I I I {I 1 � ill I I IL. I; I r 11 I I I i:. f lyllu I L. Y I If I'III ItillYlllllti � u I:. / 1 1 I I l f. i. I IIII I. I I ul I fi P� lyj �I �I IIII II I; if p//,i / v IIicV�I I IIVry�6,I v III it iljV m uuuuuuumlllluuu II�i\��II��PI�i� / I ,�y I �f II° I I II I I I I I N Y, II I I u.. III liuul' ! IIIIIIAil i QlV M t 7 I I� Y I V l I�Y u I�}wjl �I f 1 iI IlrEN f / I r d IIII / I ('I tl{IIII, l II r 1 III,II iii11114'I ;�I II 41``r 11 11111ld i'r, p,� / , /i /i III I I I u I I R(((yli I III r r/� I 9f ri I I�I �IVI°((��/I rwJMlll Vri lllprl��rii, I YIII,: P 1 / I�1/�I+lieu l / I IWW�Ii li: I P' R I " �i� r uri�rt r I II IVY ,: k Standing Orders INFORMATION „UifidlWt,'m 1, The goal for effectively managing patents with are+� erd+� pa� onin ��,� to:. 0 Support the ABCs 0 Terminate seizures followed,0 Terminate any lethal cardiac arrhythmi'as 0 Reverse the toxic effects of the poison/medication with a specific antidote The treating paramedic should consider contacting the Florida Poison Control Center at 1-800-222-1222 as soon as possible for additional treatment recommendations. @ Treatment recommendations from Florida Poison Control should be 0 Document the directed treatment and the name of the representative on the ePCR Report. • Use caution when supporting blood pressure with fluids. Many medications depress myocardial contractility and hurt rate,which predispose the patient to heart failure even with boluses as little as 5L. • It may be necessary to limit the amount of fluids the patient receives.Assess lure sounds and BP frequently* r �!t N % , j, Beta Blocker Overdose INFORMATION 'fry,deiRli�moo^yP" • Signs p + Common Beta Blockers. • Bradycardia 0 Atenol # • Hypotension a Carvedil # • Cardiac arrhythmias 0 I' et6pr+ lol • Hypothermia a Props lol • Hypoglycemia • 'Seizures listedFollow the appropriate protocol if patient is symptomatic and treatment is not ADULT 0 Obtain 12 and 15 lead ECGs and leave cables connected ISOLATED HYPOTENSION NORMAL SALINE-. 0 1L 100,titrate to desired effect.Assess lung sounds and BP frequently.,, • May repeat 1x prn J a r � r � , / r v � r/ r � r I S I (,I,,, � I (( U(r i I( � r G r I"• I � I r � � / "'r b 1 f o i � r t r' r, r � � I rr �ff ff i,i,�„� „,,./ �i r ,,/ „�„�,..„�� ,,� r ,,�,..„i., „�,., r.,rti.,,!r e ,�,.,.n. r,� �.a, � � '(�o �:c d,.Jr r,o.o. i�. ,o,G„ ,�r� r��r I,b,�.i r� �i.od od��, ��i � ,,,, err r,,,,,fr a ,i 1 e n r /I,a r i e %rf IrL le Ir 4,s • Deferto the Bradycardia" protocol(pg. 50),if appIi able OF 'lur(�r PEDIATRIC • Obtain 12 and 15 lead ECGs and leave cables connected ISOLATED HYPOTENSION NORMAL SALINE: • 20 L/ g IV/1 .Assess lung sounds and BP frequently May repeat 2x prn, for age appropriate hypotension Refer to the "Bradyr ardia" protocol(pg. SDI), if applicable f /j Calcium Channel Blocker Overdose i INFORMATION ainr. I,rp Signs&Symptoms: Common Calcl"um Channel Mockers.: • Hypotension No s • Syncope Cardlel • Non-Cardiogenic Pulmonary Edema Bradycardia appropriateFollow the if patient is I . ObtainADULT lead ECGs and leave cables connected "ISOLATED CALCIUM CHLORIDEI i 1g IV, 11,oveltr 2 minutes NORMAL I�� 0 1L I Io,t irate to desired effect.Assess lung sounds and BP frequently., • May repeat x, prn r r r n�/I .,(r r P i(/ I( � I I J d ,rl �� „a J I��ol d f ,�rl ro r r I I r I I r u ,r lrr Op „J II df a; ,r I� I r � C� I ( I I I( � r I III ;.III I I ( I J I I I r I III al� ��fG�(II�� r f,l I �C�� a� I I, ( III � �� ;� I II II II II L...1 r lr III r II ar,,,,,,II(I „f(,,„ f II Ir III f III I(,,,,,.Ir lr III Ipl h„,,rr,III C(„,,,!Cr f 11 Irl r III rl III III G,df III ICI �r��,,� I(1 d 01�s e, C F 2 a�I °fi if c! pa HYPOTENSION WITH BRADYCARDIA► Iw ION-RESPONSIVE To ABOVE TREATMENT • Refer to the "`Bradycard a" protocol (pg. 50),"if applicable , Ilr PEDIATRIC Obtain 12 and 15 lead EC Gs and leave cables connected ISOLATED HYPOTENSION ION Nil? CALCIUM CHLORIDE:` a 0 g/kg I /lo,over 2 minutes May repeat emery 10 minutes until symptoms resolve, max total dose I • NORMAL SALINE." l mL,/I g 1WI0.Assess lung sounds and BP frequently. May repeat 2x prn, for age appropriate hypotension HYPOTENSION R IA ON:REOSIVE TO ABOVE TREATMENT � �dWWW �• Refer to the "Bradycakrdia" protocol pg,, 50), if applicable f f i Cocaine Overdose / /f INFORMATION r` �MNl�arr.�i u��iiii(6V Symptoms,: • Tachycardia • Supraventricular • Chest pain/STEMII • HTN • Seizures • Excited delirium • Hyperth+ermia • Follow the appropriate protocol"if patient is symptomatic and treatment is not listed below. ADULT • Obtain 12 and IS lead E + s and leave cables connected PATIENTS PRESENTING WITH STABLE SVT,W r,CHEST PAIN , HTN,OR SEIZURES a VERSED-,, • 5mg I11 IO/II1/II' • May repeat 1x prn, in 5 minutes Qj@ Follow appr priate protocol if : • Above treatment is unsuccessful X11 • If the patient has an unstable cardiac arrhythmia PEDIATRIC +► Obtain 12 and 15 bead ECGs and leave cables connected PATIENTS PRESENTING WITH STABLE SVT WCT CHEST PAIN HTN OR SEIZURES rr�srsr+mare;�xswur.rw'�,kr17^ ?,al��r^.;rw+�mrn,„ ,r,^�,�=M., ..,. ,,,,,,,,,, ,,,,,,,, i .... .. i VERSED: IWIO, max single dv 01 6 . IN/1M, max single y repeat either route Ix prn �rn II�4'�'i�,,,��%�6„rJ'�Q,(I,J IP 91 I��``'��;J'II"fl II �;l I�' �(��'J Ir � d'� j/ lr Narcotic Overdose FFeiCorftanyl mmonNarcotics. / I,^�� m ml m I I r ii r r / J I I. I III� I IV �� III� ��i h��II I� II I@ IIIII III IV III ,, ,,;/ 0 Codeine Improve Intrinsic airway tency, Y Dilaudid ventilation and I . 0 Methadone The goal Is to restore spontaneous R gasp ir'ation,,I "to wake the 0 Vicodin patient up." Lab A , 10 ,r_urn✓��P,rr r�.!r�i��"��& ,rlc;,,�a; nse,. r", lr 2% -� ,� / l r A (44i6if u r. u� I MM I a,- r/Ill /%ii /I , /iiiiiiiii/////� ai///// rrrrrrrrrrr r/r / MY W rrr / dpto kh � , � ,,,, r r ' '� „ i''' � Q r %,// ell i Ian °, �r III��IInmIIIIIIIIY �� // /r r�/ ri/rr i //,",-/. .........-,j1;1 opx/ wc " CA I wS i/iiiI I, 4 May .. ...........reppot In,"",2,*,,1 Yes r o_ r� „rr I� r I��-€: / achlevell orri , r r / r, r / �If" Isr s / rr „rr r, / Vft Max l�, Tricyclic Antidepressant (TCA) Overdose a/ INFORMATION i II fll i Mad as a hatter Coma mmon To t + ptyline pt9 Red as a beet Des"Ipramine Cardiac Hot as hell Seizures p AcidosisDry as a bone Follow the appropriate protocol"if patient is symptomatic and treatment is not listed below.. ADULT Blind as a bat COMPLEX IVumi IVi Vuum dr �,. . WITH,„.�:, g H SODIUM E,, • 100 mEq I'V/10, over 2 minutes If no change in 5 minutes: • 50 mEq l 1110,over 2 minutes • Maxtotal dose 150 mEq r ri r r 1 � ,. d�I an. �J € / � r .� � / . n „ , I / r,r , � N J w x e�;„ / ISOLATED HYPOTENSION • I' R MAkL 5A►LI I E. 1L IV 1 ,titrate to desired effect.Assess lung sounds and @P frequently. a May repeat 1x, prn J i I(/ f 1 I/ ,r, r r i ( ,/ i :/r r r -I ,+! If ,.� .,.� '(ll. ��,�. // 1�� j n, ��« Ili r/l ,r/ >�b U�JI 1 l „�J'F .,,,Jl�it 7a��lh ,��de ;�/r i,��,� '' „-,�d; I ,,�f,,��(,��II�� r,r, �� 6,J r,�� i,r I ��,r ,� �,� L ( r �„ �„,,,,,,,,,,,, „� �,:, �� ,,: ( ,,:,,,,,�,I,,, „�„,:,II ,,:�,,. III fl,::,��[: ��,„ (,,,::, ,,:,,,II'll II I�� I.�r,::,,,, ��„�II ,::,,,,r,,�,�,,,�II I��,,,, ,,, �;,�II s��r,;l"„1 II,', I�r,,,�,l� I�`b id II %,,b J i J�r r?�I 1„!(`I° �1,'r„ '�(1 I;..IJ IN &' PEDIATRIC I{C • Obtain 12 and 15 lead EC Gs and leave cables connected FOR PATIENT WITHL&QR§COMPLEX >0111,09 ' ICIBOXEI�j SODIUM BICARBONATE 8.4%: • 1mEq lg I '/ICE,over 2 minutes, mac single dose 50 rnEq • May repeat 2x prn, In 5 minute intervals, max total dose 150 mEq �� „�� „ � II� NORMAL SALINE,." 0 20 mL/kg IV/10.Assess lung sounds and BP frequently 0 May repeat 2x for age appropriate hypotensibn ISOLATED HYPOTENSION IKIIII (IIII TCAs cause death pr'Imarilly through lethal cardiac.arrhythmias.Wide QRS complexes are an ominous I I�o�ilu�oi�iWoj �1@\glpVll�llugid s,��11��Sti 01 n rR 4o)ill,� �nns olmll� l� oil looll�,� '�� I��Illiu� Illl�l�� m�oo� r / , rr / r / / / I1;I 41 I' IIIIIIIVVIIIIIIIIII 'iih'liiuuuuuuum I�I�uI uuuuui ilia IIIIIIIIIIIIIIIIIIIIIII uuuuuuu I // IIIIIIIIIIIIIIIIIIIIIIIIIII�I�IIIIIIIIIIIIIIIIIIIIII / / / a f l i °I III I I r J f 1 H r r r r ✓� ,/r II po offir F fmi i l §PO /ri /r /r JI 97 V r/ II I / ulum�i�r(M IRS OPA D [ r i r i r I Iy u /rrr /lam a , I. II�I I I „I rl ' l it u r I p ' I :0 i i Olen F o J / r /i t' rii r ,a frr 1" 1/ fir 1 Chemical Restraint INFORMATION ........................... 0 Restrained patients shall NOT'be placed in a prone position. 0 Chemical restraint may be usedin addition to physical restraint for the following"." 0 VIO LENT/COM BATIVE PATI ENTS a re ag 1 tated pati e nts w h o p la ce t h e rin se Ives a n d/o r c rew 'I n d a nger 0 0 EXCITED DELIRIUM PATIENTS have bizarre,,1,aggressive behav lor which may be associated with the use of cocaine (crack), PCP (angel dust), bath salts, Flakka, methamphetamines and amphetamines ADULT 0 Law enforcement must first gain physical control of the patient FOR SPECIAL POPULATION VIOLENILCOMBATIVE EXCITED DELIRIUM 0 Special population patients: 0 Over 65 years old 0 Head trauma 0 < 50 kg 0 Already taken other sedatives(e.g., benzod"lazepines, alcohol,etc.) 0 KETAMINE: 6 200mg IM for the above patients 0 May repeat 3x prn, In 5 minute intervals to gain control of the patient ic:l I I i IC iltl 10 1111�S, ..111 '1'1111 ,t ,(Ifjy �E!11111 le�t I a 1 11 ji?ie Y 111"Y MIDI cill''ilelist pw!1"i ........t'o n S �Be prepared f'or ad,,,wtancerf',",i ir,)�.),vaj%f��,� rr'i ,', /,,�anage r'f",e,,,"",t V adrni�nistr,,,, "' on coted with re,,�,;#iratory depres,sd.,,,c,',�,','/,'i,,n apnea,,, and lr/'fi��g"�'/,,"///Ie� usua�� m �"",,,!il,,ay r�,jrf',t,,orease scK�z�� phremc sj,,)��"/j/�rf"�,)"),��,pto�rf""F"",,�"j",,�,", EOR ALL OTHER VIOLEIIII ICOMB EXCITED DELIRIUM K ETAM I N E: 0 400mg IM 0 May repeat Ix prni 5 minutes �C�D �t I�,i��11111111diicialbicrns - as noltield all)iovie P�r�eci,(�/�,/,,lu'/,r,"��l�,,,,,,,,�,//),,,.,�ns as LARYNGOSPAS III 1!!'STRID11:, REACTION TO KETAMINE ADMINISTRATION 15MW 0 High flow 07 a Assist ventilations via BVM prn 0 Consider advanced airway procedure,J15 '�d Al a S At t I'l, '�j, I f '�r ir/,/("2 1, rl", 1.a f-y 1,)girnr,�tff 1""" ["'11(' �""Y'1��M i 'a r" "AW P �g o IN �O Chemi*cal Restrai*nt condnued.. HYPERSALIVATION REACTION TO KETAMINE ADMINISTRATION ATROPINE,-, • 0.5mg IV/10 • May repeat prn, in 3 minute"Intervals, max total dose 3mg � I �, AFTER KETAMINE ADMIN1,11STRATION 0 If patient begins to wake up: VERSED�, 0 5mg IWI0/IN/1M 0 May repeat Ix prn,,"in 5 minutes Cmiltriaiiiid iicattoii I 1 r f�/ �r r t/ i�r depressiion �Preca�/,;,,,,,�r,�,�"f�on�-�,,,iff,�//,Io�r,/,/i/ to ,,,,":�,,sp atorr 0 Obtain a temperature. RAPID COOLING FOR A TEMPERATURE OF>103 DEGREES IF * Apply ice packs to axilla and groin area 0 COLD NORMAL SALINE,.,(if availablel� 1L IV/10.Titrate to desired effect. Assess lung sounds and BP frequently. May repeat 1x, prn ... ....... [a re 11- �11 11�11, ��pi�V//,/,/, �1��tj, [J�E�11' "'r,F'111, l�, fl,Cjjjjj]�� 3�r rIP, �), '�,`3 ill,"'lj�, A, Ell se C'1�11111111��F le I fa i' 0 SODIUM BICARBONATE,,, 100 mEq, IV/10, over 2 minutes Paign Management INFORMATION r 0 F E NTA N Y L is the fro nt I i n e m ed icatio n To r pa i n.. h oweve r KETA M I N E i s p refe rred fo r htypote n sive patients or patients who have opiate contraindications(allergy, history of abuse,etc.). 0 KETAMINE may be given with or instead of FENTANYL for severe pain., 7 on the pain scale is considered "severe pain" ADULT FOR PAIN MANAGEMENT FENTANYL�, 0 100mcg IV/10/IN/IM 0 May repeat 2x prn, in 5 minute intervals I dicatiio��111�ii R��egnanic"V nie,aill",te�ii,��111111ni �,,,"32 wieieii(is oil"gii'eiatie��111-1) or i�n� aftive lia��)iior r e o n�l �S, .0'y al P a t e u s o d��-LJt g s e e e a o r OR �14,U11 a, n t fo r r e s p a t off�ffff,,,,,t e,�p r e s s i o r-,fl 3, D P L L C r s e d t�,i N A R CA N f jj,,l e c e S s a FOR SEVERE PAIN MANAGEMENTI,PAIN SCALE 7 OR HIGHER"' 6-11 KETAMINE., Dilute: 25mg of Ketamine in a 50mL bag of NORMAL SALINE 0 Administer IV/10 utilizing a 60 gtt set, run wide open 0 Reassess pain scale after half of the infusion has been administered 0 Continue infusion if needed 0 May repeat 2x prn is �Cio�illi�t�il-�ia�i�illild�ilcia�tlio�n,s ��)iabenits Pie�11111iiet�1111111alh eyle it''quill"lly c1l''I'lles"t 1�)iaiillll i1b, P r e c a�u o r�,/,,,s,,.f If// Be prep i red for a,/) vanilced i irwaiyli mianagerrr",ie�r tvt OR Rapk,:11 Pfffuv`admini/s,tra"r,,�,,/,//,,,,,//,,,/tn �is assooiated with nt,/,�fsperatory depress�,o,,,//,r',,f/,,,apnea, and ii] vr-t, li)/.,,,,:�(�od pressiii,./ires sliui%l g lr"fi e r t h a"I U�S U,2,3 D �R, May rnolrease sc�h�i�zo�p�,�'�l/ren,"//,J,/,,- sy�r//,�,r-fiptorns IF UNABLE TO ESTABLISH VASCULAR ACCESS KETAMINE,-, • 25mg IN/IM • May repeat 2x prn, "in 5 minute intervals as 10 INFUSION PAIN MANAGEMENT LIDOCAINE.- 0 40mg 10,over 2 minutes • Allow LMOCAINE to dwell"in 10 space for 1 minute • Flush with NORMALSALIWE 10mL 0 May repeat at 20mg 10, Ix prn Paion Managementcontinued.... PEDIATRIC FOR PAIN MANAGEMENT "T RENTAKYL: a Imcg/kg 100,over 2 minutes 0 1.5mcg/kg IN/IM 0 Max single dose 100mcg 0 M ay repeat e it he r ro ute Ix prn i n 5 m in utes, max tota I d ose 200 m cg Clo t ria dic"I'llati ic:i �s, Q�J�� < �6 ri�'i(,, ill"'it P r e c;i u o��i s, 4 for respiri,,,�iaorry do,,,�,�:��presslion 11/0 �becor"/,,,,,,//,f,��/�,�,",�,,,s drowsy J611 Can be reversejr:/Ji with NARCAN �f ji "FOR SEVERE PAIN MANAGEMENT(PAIN SCALE 7 OR HIGHER I KE TAMINE (2:3 years old),, 0 lmg/kg IN/IM 0 May repeat Ix.prn,, in 5 minutes ontraindicabons. Penetrating eye injury c a "t ii,o J, Y1.,0", 1 1,jjjjffffT),, "j, f B ��j,jj,e�p a e d i'))),1, J�Il �j,))'i. ...... V"".j j j a 0 i"'91H A a c��,e a s e s c Z,0 P r e!jf--11 i C U Y"/,TH 10 INFUSION PAIN MANAGEMENT LIDOCAINE:" 0.5mg/kg 10,over 2 minutes 0 Allow LIDOCAINE to dwell in 10 space for 1 minute 0 Flush with NORMAL SALINE 10ml- Max total dose 40mg PAIN MEASUREMENT SCALE 00 ... ..... 10 001011 0 2 4 6 8 io NO HURT HURTS KURTS HURTS HURTS "URTS LMI.E BIT LffTLE MORE EVEN MORE IkIPMOLE LOT WORST 0 1 2 3 4 S "IF a 9 10 No pain Mild Moderate Sel,%irere Worst pain imaginablo Adult Advanced Airway I -T KIE AI1V1IPF,1IE'w Dilute:200 mg In a 50ml.bag of N111DIRINK11-SAILI h Administer utlilzing a 60 gtt set,run wide open May repeat ix for Induction 15 LPM%do NC Precaultions: Assist vendlations via Rapid�IV adryflnistne flon Irs associated P ETOMIDATE, BVM Prn. lAnth highler hufaases In RP �May increasse iwhftophrenlic • 30mg or 0.3mg/kg IWIO over I 3D-W seconds • May repeat 1x. .1w Bi,,onc,��iolco�n�,%,tric�tio�n indlicaltJollits1�1 Ile Nilegnant paitiw�iiivt% cjl.j� ETOMIDATEa R KETAMINE Hy;K)tensian I or,an IV otillverl�lea illid I a ic "IT111jr "'I jim I j"r Violient/iCombativift Illness Hiesid Injuries with su*pectied TOPI greatierthan 20110! 9 Pr(ttgnant piafle��1%11's, .1v lk IY,ir,,on-tiriuv�iiiA-�itiic,chas�t pain ..............I I I I I I I I I......... RO CURONIUM: ke 100 mg or lmg/kg 1WI0 May repeat 1x prn I........I.............................I..I............... NNW Max single dose 100mg Wc Tft4ust "'d ckW,, distre"a -........... ......... NO IX .......... YES , K ETAM III N E:,wp Dilute:200 mg In A SOmL bag of NORMAL SAILINE ,VIEFtS1IE.IDq* 34WX 1414 AdmInister utilizing a 60 gtt set, 5mg 100 run wide open May repeat Ix prn,In 5 minutes may repeat Ix.prn f WW Max single dose 200mg Preicaudons-See abolve 3 years old Advanced Airway ' 'MOO, 1W F7 KIETA holl 11,111 E ...... Dilutle;2mg/kg In a SOmLbag of IPI11I0'1JkIL III IN11 IIE Administer utillOng a 60 gn set,run wide"on If May repeat Ix for Induction Max sIngle dose 50mg • IS LPM via NC Precaltifions. • Asi ventilations via IN, Rapid IV administmt!on is assoclialteld BVM prin. 1i k I higher firticreasies in OP May Inicrease schbophrank: ETO M I DATE: Cridicaltions': 0.3mg/kg lWlO over 3040 ETA seconds.Max single dose ETOMID-ATE 1C.)IR K: IMIN Sleptlic SlLwoick 21 30 mg Hypotension May repeat IX V10118"t/Combative h1ildicattom" Head in uries with suspleicted 1CP 01111,1 O'Cliver ciaindiat 111niess L InIg ey"i lquil y Niori�llltrauii inatic drivost goa iil,w ROCURONIUM: lmgtkg IV/10 May repeat Ix prin e "'EVAIAL I4k gol, 'ApaWe'Stitin", Tl child ikl, Jft/l/ 'h S,COP"'n,or Fl M ......................11..........................................I I............... .........."'I'll' NO YES "VERSEIR., KIETAIM11NE1, O.lmg/kglV/IO iattnm D I lute:Zmg/kg I n a 5 Om L bag of N OR;NA A L May repeat lx prin SAILIIINE E ft////,� Administer udlizing a 60 gtt seto, Max single dose of 5mg iry 111 run Max total dose 10mg wide open May repeat Ix for Induction Max single dose 50mg Pmacautlaris S'ee abovt-� -See wII)ovel < 3 years old Advanced Airwa y 1W 4 .I I I I I I I I I I 1111`�, .............."I'll"..............111111-I, 15 LPM via NC Assist ventilations via BVM ............... ATROPINE, 0.02mg/kg lW10 ETOMIDATE: 0.3mg/kg lW10 over 306�W seconds May repeat 1x pm 71 Toismus, ench" -im In 1wix crow," ROCURONIUK, lmgtkg 1W10 May repeat 1x pm max slngle dose of 100"W ............ "R-,,,,......... ,T ...........................................................................I I I I.... ................. 77 7, 77 NO ...I..I..I..I.... YES I ED, 0.1mg/kg 1W10/lM `ft, May repeat Ix pm Max single dose of 5mg max total dose 10mg Precaution—Hypotenslon Decompression Sickness I Ism INFORMATION Signs&Symptoms 0 Stroke-like symptoms 0 Visual disturbances 0 AMS 0 Paralysis or weakness 0 Numbness/tingling 0 Bowe l/b I adde r dysfu n ctio n A ny pati ent w ith the a bove s igns&sym ptorns who h as used SCU BA gea r 0 r co m p ressed air with i n a 48-hour period shall be considered a decompression sickness patient 0 Tra nspo rt to St. M a ry's Hype r ba ri c Cha m.be r(e n code p r 1"o r to tra n s port to co nfi rm ava"I I a b I lity) 0 If unavailable transport to closest ED 0 Contact DAN (Diver Alert Network)at(919)68"326 for medical consultation as needed • Treatment recommendations from DAN (Dilver Alert Network)should be followed • Document the treatment and the name of the representative on the ePCR Report 0 Try to obtain an accurate history of the dive: 0 Depth of dives & Air mixture type in tanks 0 Number of dives 0 Interval between dives 0 All dive equipment must be brought to the hospital ADULT&PEDIATRIC a POSITIONING- Transport patient"'in a supine position 0 For cardiac arrhythmias, refer to appropriate protocol 0 Rule out a tension pneumothorax a OXYGEN, 0 15 LPM via NRB regardless of SpO2 a NORMAL SALINE- 0 Ad'Y"I''t-0 0 500mL IV/10, regardless of the blood pressure 0 Pediatric: 10mL/kg IV/10, regardless of the blood pressure, max dose 25OmL Non=Fatal Drowning INFORMATION .......... 0 Consider spinal motion restriction in the presence of trauma (e.g, diving, rough surf, vehicle accident with subsequent submersion,etc.). 0 All non-fatal drowning patients MUST BE TRANSPORTED to the hospital ADULT&PEDIATRIC IV,10111111 CPAP (10 cm H20)for pulmonary edema secondary to near drowning without hypotension jj�l 1),ialtiiei�itis Mt!"ilout 11 zu"I'velous 11V ��)iatiieii'lvts witli a decill''eirlisleid Iii,ii,101C tcj' Ig < �30 �111(g IF PATIENT IS HYPOTENSIVE WITH CLEAR LUNG SOUNDS NOIRMALSALINE: Ad u lt.� 1L IV/10,titrate to desired effect.Assess lung sounds and BP frequently,,,. May repeat 1x, prn ')p 't A I�U IL 1r/"/':1 K IF"' r le s,,,//,, ig'yr�n fi ic a n t cl/,,// U L I'k-),I I F"'iE,rI C U l d tr;,'11' I'Wl t r",ve ea,.,�,,'/n c c::'�r lo n a �h s le a s C H F, a r1,',,11':",1,(1'f �r f ai, e 1p, Pediatric: • 20rnL/kg IV/10,assess lung sounds and BP frequently • May repeat 2x prl for age appropr late hypotension IF PATIENT IS HYPOTENSIVE WITH PULMONARY EDEMA PUSH�DOSE PRESSOR ENNEPHRINE (1-100,000)T 0 Ad u It: Dilute: Discard 9 mL of Epi 1:10,000(0.1mg/mL)and draw up 9 mL of NORMAL SALINE to create Push-Dose Pressor Epil 1:100..000. This will yield 10mcg/mIL, Administer 1 mL/minute lWI0,t1trate to maintain SBP 100mm Hg May repeat 2x pril max total dose 300mcg(30 mQ I l diiciatiio��,Iiis' loss Pr e c i�........�,o r!�,.s OF �R a p��d r,"r,",t jiir,"'i at e)o in s e t, siln o r It(5 10 rn��n u t e) d u r a t o n IF Momtor [tteai,,r"11c,, �rate pressif.,,,�tre throughout adr"r"it i 0 Pediatric: Dilute: Discard 9 mL of Ep'i 1:10,000(0.1mg/mQ and draw up 9 mLof NORMAL SALINE to create Push-Dose Pressor Epil 1:100,000. This,will yield 10mcg/mLl Ad rn in ister I mL/minute IV/10,,titrate to maintain age appropriate S131P May repeat 2x prn,max total dose 300mcg(30 rl id �cia t'i(:)ii�li�s �y�p lo It le �s��ic��i�il") is ie�c o�ri id a It I �b cil')io c"J, ic��i is S r C 1101 0 �1114 01T a "I"S t f"a s t o,,�',)/')),!)), t h a r�f, 1 L')),/`//nn t I il u u s,��i,,��Dose Pressor a 1 11['�'J,'t e',il o�i� s e It,. S t e d u t d �i��i fl,��"j):5",t 1�"" 10 Heat Emergenaes INFORMATION Signs&Symptoms of heat stroke "Include any of the following: 0 AMS When treating,heat stroke: a Seizures Hypotension "COOL FIRST,TRANSPORT SECONDOW 0 Sweating may be absent Patients with a heat-related illness associated with an altered mental status should be considered to have heat stroke once all the other possibi'lities for the AIMS have been ruled out(hypoglyceni drugs/alcohol,trauma, etc.). ADULT&PEDIATRIC ALL HEAT EMERGENCIES Move patient into the back of the rescue as soon as possible., Decrease the air-conditioning temperature in the patient compartment, Obtain a temperature Remove excessive clothing P rovid e o ra I hyd ratio n (prefera b ly wate r) 'if patie nt i's a b le to swa I low a n d fo I I ow co rn ma nd s HEAT CRAMPS&HEAT EXHAUSTION NORMAL SALINEIIII. Adult,.��I 0 1L IV/10,titrate to desired effect.Assess lung sounds and BP frequently. May repeat 1x, prn ik la ir ic a ir ir Li st b le ii n ir,�h p e s e n, D f g cjl I Y , '' / /u cc ir lo in"a,r",,/, ir je ii/.�i in s Pa rih/ �h e//I�rt�/,: d,,;,,1,/1//".'1"1 s je, C I F, aar/t,,,,:,JJ'/, ir le�,i�a I fa i��iu re �p ot.," le Pediatric: • 2OmL/kg IV/10,, assess lung sounds and BP frequently • May repeat 2x prn,,for age appropriate hypotension HEAT STROKE WITH TEMPERATURE OF>103 DEGREES F OR ALTE RED MENTAL STATUS 111111MI1111YANIIIIIIII 010INKIM 0 Apply ICE PACKS to axilla and groin area. a NORMAL SALINE: (COLD NORMAL SALINE preferred, if available) 0 Ad u It: & U IV/10,,titrate to desired effect.Assess lung sounds and BP frequently. 0 May repeat lx,, prn ldw P ir e jic::,a u"I........f�,,o r,�f�,s P a C�u"11 a r c a r e u s t �'/,,,,,,,,,",/�e t a k e in i n It h e p ir ir', O'N -f P�,�I v%," h c a in t c o r o n a � 0� 5 1 g I I I h e,,,/,,,,,,,.i�i t d s e, C H F a ri d r e n a��f a u r e p a e ti,,t s 0 Ped iat,r!& a 20mL/kg IWIO,assess lung sounds and BP frequently 0 May repeat 2x prn,for age appropriate hypotension Carbon Monoxi*de Exposure INFORMATION 0 Carbon Monoxide(CO) properties: • Chemical asphyxiant • Colorless • Odorless • Tasteless • Slightly less dense than air • Toxic to humans when encountered in concentrations above 3S parts per million(ppm) • Lowe r doses of CO ca n a Iso be h a rmfu I d u e to a cu m u;lative effect 0 Patients exposed to carbon monoxide(smoke inhalation,etc.) requ Ire a full head to toe patient examination including SpCO monitoring with the rainbow sensor(located on the EMS Captains," and Special Operations" vehicles). 0 All rescuing crew members shall wear their SCBA if the patient"is in a hazardous environment, 0 Consider Cyanide Exposure. Refer to the ""Cyanide Exposure"' protocol (pg. 100), if applicable ADULT&PEDIATRIC 0 Apply rainbow sensor and obtain SpCO readings 0 OXYGEN,"' 15 LPM via NRB regardless0fSP02, unless the patient requires ventilatory support IF SPCO IS>20%0,��R PATIENT PRESENTS WITH ANY OF THE FOLLOWING SYMPTOMS jp� Headache Nausea/Vomiting Dizziness Altered Mental Status Chest pailin Dyspnea Visual Disturbances Seizures Syncope Transport to St. Mary's Hyperbaric Chamber(encode prior to transport to confirm availability) If unavailable transport to closest ED. WARIIW��WG Fpaltients with CO exposures can have normal pulse oximetry readings and still be hypoxic. Strong consideration for hyperbaric treatment should be given to all pediatric and obstetrical patients with confirmed CO exposures due to their higher susceptibility to the effects of CO exposures regardless of SpCO level or symptoms. C aniae txposure INFORMATION Signs&Symptoms,,& • AMS a Coma • Pupil Dilation 0 Shortness of breath • General Weakness 0 Headache Confusion a Dizziness • Bizarre behavior 0 Seizures • Excessive sleepiness • Cyanide exposures may result from "Inhalation, ingestion or absorption from various cyanide contaiining compounds, including exposure to fire or smokein an enclosed space. • Direct cyanide exposure (non-i�smoke"Inhalation) is a Hazardous Materials Incident, • Cyanok its are located on the EMS Captains and Special Operations" vehicles 16 Consider Carbon Monoxide Exposure. Refer to the "Carbon Monoxide Exposure" protocol (pg. 99),"'if applicable A ADULT&PEDIATRIC CONFIRMED OR SUSPECTED CYANIDE EXPOSURE • OXYGEN: 0 15 LPM1 via NRB regardless of SpO2, unless the patient requires ventilatory support • CYANOKIT,111111� 0 Ad u It: a Preparation: Reconstitute 5g vial by adding 200 mLof NORMAL SALINE to the Vial by using the transfer spike. With the vial in the upright position,fill to the"'fill line" Mix the solution by rocking or rotating the vial for 30 seconds. D01 N01T,5111111A11(E Use vented IV tubing and infuse as indicated below 0 5g IV/10,, infused over 10-15 minutes 0 Sgtts/sec(broken infusion stream) a May repeat 1x prn. 0 The Cyanokit should be administered through a separate/dedicated lW10 line a Pediatric: Preparation and dosing-Refer to "'Handtevy"' system May repeat 1x prn The Cyanokit should be administered through a separate/dedicated 1WI0 line • Transport to St. Mary's Hyperbaric Chamber(encode prior to transport to confirm availability) If unavailable transport to closest ED IMP, LAE J"I'll Trauma Standing Orders INFORMATION ADULT&PEDIATRIC m2l; • The fo I lowi ng co nd iti ons sh o u Id be rn ana ged as soo n as th ey a re d iscove red 0 M-Massive hemorrhage 6 A-Airway control 0 R-Respiratory Support 0 C-Circulation 0 H-Head Injury/Hypothermia • Unless otherwise noted, IV fluids should be given for a SBP<90 mm Hg and should be given at a rate (boluses) necessary to maintain peripheral pulses(which is typically a SBP of 80-90 mm Hg),,, ULTRASOUND FAST EXAM 0 A FAST exam can be performed during transport of the following injuries,,,,, a Blunt force trauma to abdomen or thorax 0 Penetrating injury to abdomen or thorax 0 Undifferentiated hypotension in the presence of trauma 0 Can be performed toidentifV possible: 0 Intra-abdominal hemorrhaging 0 Intra-thoracic hemorrhaging 0 Pericardial hemorrhaging 0 Cardiac motion in PEA 0 This exam shall be done in a prompt fashion and should 114101171111 delay transport 0 FAST Exam findings shall be communicated to the receiving facility and documented in the ePCR Glasgow Come Scale Score Eye Opening Spontaneously 4 To Speech 3 To Pain 2 None 1 Verbal Response Orientated 5 Confused 4 Inappropriate 3 Incomprehensible 2 None I Motor Response Obeys Commands 6 Localizes to Pain 5 Withdraws from Pain 4 Flexion to Pain 3 Extension to Pain 2 None 1 Maximum Score is Trauma Arrest Standing Orders ADULT&PEDIATRIC I'll"W., DETERMINATION OF DEATH Resuscitation should �N,01"11"11"111"be attempted for trauma patients that have A111i,iti,ii 3 of the following presumptive signs of death present: 0 Apneic 0 Asystole 0 Fixed and dilated pupils 09111 0 Injuries incompatible with life(e.g... decapitation,, massive crush"injury, incineration,etc.) SPECIAL CONSIDEIMIONS * P EA 110 Defi ned as a n o rga n ized rhyth m greate r th a n 20 b p m-Anythi ng less i's co n s id e red asysto le and s,,hould be treated as such. * PENETRATING CHEST TRAUMA: 10 Bi late ra I n eed le deco m p re ss ion m ay be pe rform ed i n a n atte mi pt to a ch leve ROSC lie Resuscitation efforts 1)01 NOT need to be started if the patient did not regain pulses 0, i m m ed i ate ly fo I lowi ng th e b i late ra I need le d ecom p ressio n * TRANSPORT,,,, If Trauma Hawk is not available and ground transport is greater than 40 mi'lnutes,, it I I s acceptable to transport to the nearest ED ------------------ O� ONLY '11TRAMMED EIVIS CREW PERS MWEL. ULTRASOUND To confirm an�observation of cardiac motion in PEA Cardiac motion'p resent: Continue resuscitation efforts and treat reversible"causes Cardiac motion U011111111",,present: Resuscitation efforts can be discontinued FINGER THORACOSTOMY Indications: Known or suspected injury to the� chest and/or abdomen Site: 4th/5 th,intercostal space of the midaxillary' line le VIN S,to ff il,"e�d cailllidiiac ari,llest tr&i,,,i��! 11a 111�110ssi cair,t:[itiac i lh,l ----------------- START Triage Move the walking wounded No respirations after head tilt 0 Respirations> 301min. Perfusion No radial pulse Cap refill>2 sec Mental Status I lig Unable to follow simple commands Otherwise DELAYED "ThO In/ "'IMM JumpSTART Triage 1mm8 years old Ell vol ABLE TO YES io� Secondary WALK? Triage* *ftalmte Infanuftrw In sftvndarV triage (iD uang the entireJump- STARTaloorkhm NO NO BREATHING Breathing? Posit*on Airway APNEIC NO Pulse DECEASED I YES YES APNEIC 5 Breaths DECEASED BREATHING Respiratory <15 or>45 ...................................... ............................................. Rate? NO Pulse? YES "PI(inappropriate)Posturing or&Un AVPU R "A"N"or"P"(Appropriate) ............ ......................................... ............. DELAYED Trauma Criten'a (Adult) A A I PSM A]MUM I mi I M_W11UUUU1 Active airway assistance'or respiratory rate<10 or>29 BPM Lack of radial pulse with a sustained HR>120 BPM or BP<90'MmH Glascow Coma Scale JGCS):5 13 or presence of paralysis,,or suspicion of spinal cord injury or lo ss'"6i 2nd or P degree burns to 10%or more TBSA* ............. /0//4/1,11 Amputation at or above the wrist or ankle* Any penetrating injury to the head,neck,or torso'* 0 Penetrating injury to the extremity at or above the elbow or knee* 0 GSW to the extremity at or above the wrist or ankle* "Chest wall instability or deformitV(flail chest) shed,mangled,,degloved,or pulseless extremity ctvre of two or more long bonee pelvic fractures fractures with potential'airway compromise rauma in patient with bistory of paralysis(paraplegia or quadriplegia)* 51 dMinal pain after blunt traumas ............ -P�rr-- �F/,� Ith loss.,,O OnWousness or visible signs of injury Rol IN 0 Sustained heart rate of 2:120 0 H ead inj u ry w it h loss of co n sclo u sn ess,am n esia o r n ew a ttered rn e 0 Soft tissue 10552 Non GSW penetrating injury to the extremities distal to the elbow or distal to the knee .............. gk, /.................. Single long bone fracture site due to We S I ngle long bo ne fractu re o r pelvi c:fract u re i n pati e nt wit h bleed i n g d I sorde r o r a nti co ag ulated 55 years or older Eje cti o n o r t h rown from a uto m a bi leo m oto rcycle,a r golf Ca rt Ejection or thrown from a horse with anatornicalinjury ath/in"sa'm e passenger compartment* I s,i I on lnc�q,ing oof:>12 inches at occupant site or>18 inches at any other site into the passenger compartment* '011�,t0letnet slistent with high risk of injury rion over,or with impact and signs of anatomical Injury Any o ne(1)o r mo re R E 1113 "r ra u m a Al erI A ny two(2)o r m o re 8 5U if,, "Tra u m a A le rt" 0 1, Airway assistance includes.manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts- 2, Includes deep flap avulsion 1>5 inches,l 3. Excluding superficial wounds of the head and torso in which the depth of the wound can be determined. 4. Long bone fracture sites are defined as the(1)shaft of the humerus,,,(2)radius and ulna,(3)femur,(4)tibia arjt,,,d fibula. 5. P regnant patie n Its m eeti ng Tra u m a Al e rt crite r ia s h o u I d be t ra nsp o rted to St Mar)(s.Trauma Center by air whenever possible, 6. Vehicle Telemetry Data when avallable can be relayed to dispatch;the data can assist in predicting potential serious injuries from the data collected at the time of the crash. in the event that a patient does not meet either 1,Red or 2 Blue criteria during the assessment of the trauma patient,the paramedic can call a trauma alert,if in his/her judgement,the patient's condition warrants such an action,Where paramedic judgement is used,it shail be documented. Any of the above criteria that has an asterisk(*'l,next to it represents criteria that i,s the same for both Adult&Pediatric Trauma Criteria (Pediatric) '101 Hill )AAN,1i4WAlff&WN, Mai 0..............oz, Active a irway ass i sta n ce o r resp i ratory rate<20 i n i nN nts,resp i rat6ry ra Faint or nan-palpable carotid or femoral pulse or SBP<50 mmHg Altered mental status"or presence of paralysis or suspicion of spinal cord injury or I sis f s S'', e Major soft tissue disruptions or major flap avulsion 2rdor 3rddegree burns to 10%or more TBSA* Any pe netrati ng i ni u ry to t he head,nec k,o r to rso Ile 10 Penetrating injury to the extremity at or above the elbow or knee* GSW to the extremity at or above the wrist or ankle* Amputation at or above the wrist or ankle" 4 Open long bone fracture or multiple fracture sites or multiple dislocations Linstable pelvic fracture* vere facial'Injury w�ith potential airway compromise t-a bd o/oilininal or chest trauma in patient with history of paralysis(paraplegia or quadriplegia)* chest abdominal trauma in patient with bleeding disorder or on anticoagulants with a high risk of bleeding e,s,tri 16yclist thr'//o'wn,,run over or with impact and signs of anatomical injury 0/u/m/ orn �;ATV,golf cart or horse with signs of anatomical injury ------------------ ------------------------------- ,//////�,/,//-//,(,�,,�............)",—, op le Weight:520 kg e Carotid or femoral pulses palpable,but the radial or pedal pulse not palpable or SOP, Loss of consciousness or amnesia 0 Penetrating injury to the extremities distal to the elbow or distal to the knee . ......... MVC4 or 0 Single long bone fracture or dislocation due to pelvic fracture"in patient on Cournadin/anticoagulants with hAsk'Of bleeding E action(partial or complete)from automobile ith Yin'...... passenger compartment* of.,>12'inches at occupant site or>18 inches at any other site into the passenger compartment* nt with high risk of injurl Any one(1)or moreJ141$,,,,i!f,:tt"'Trauma Alert`%-Any two(2)or more F,,J1,k,,J E;;,"Tra u m a Al ert" 1. Airway assistance includes manual jaw thrust,continuous suctioningill,or use of other adjuncts to assist ventilatory efforts. 2- A Ite red m enta I st ate s i ncl ude d rowsi n es s,I et h a rgy,ina b i I ity to fo I low co m m a nds,u n resp o n s ive ne ss to voice,tota I ly u n res pon s ive 3. Excluding superficial wounds of the head and torso in which the depth of the wound can be determined,,, 4. Long bone fracture sites are defined as the(1)shaft of the humerus,(,2)radius and ulna,(3)femur,(4)tibia and fibula. 5- Includes major de-gloving injury 6. Vehicle Telemetry Data when available can be relayed to dispatch-,,the data can assist in predicting potential serious injuries from the data collected at the time of the crash. in the event that a patient does not meet either 1 Red or 2 Blue criteria during the assessment of the trauma pattent,the paramedic can call a trauma alert,if in his/her judgement,the patient's condition warrants such an action,Wheret,paramedic judgement is used,it shall be documented. Any of the above criteria that has an asterisk(*)next to it represents criteria that is the same for both Adult&Pediatric Bum injuries INFORMATION Advanced airway procedures shall be considered for patients with respiratory involvement (i.e., hoarse voice,singed nasal hairs, carbonaceous sputum 'in the nose or mouth, stridor or facial burns) FIRST DEGREE BURNS Involves only the epidermis and are characterized as red and painful SECOND DEGREE BURNS Involves the epidermis and varying portions of the underlying dermis with blistering 'THIRD DEGREE BURNS Involves deep tissue damage and will appear as thick,dry,white, leathery burns (regardless of race or skin color) ADULT&PEDIATRIC 0 Stop the burning process by"'Irrigating with copious amounts of room temperature water or I NORMAL SALINE for 2 minutes,,, IN�Jlieivet-� iic:e &H,�ieir,::t�y tic-) 0 Determine Total Body Surface Area (TBSA) percentage of the burn W DO �No'r attempt to remove tar, clothing, etc., if adhered to the skin 0 Remove jewelry and watches from burned area 0 Consider Pain Management Protocol 0 �DO 11140T use IM route for medication administration Co n side r Ca rbo n Mo n ox ide a nd Cya n id e Ex posu re nd IN 1"&2 DEGREE BURNS< 1C;.1.JBSAor3dDEGREE BURNS<5%TBSA Apply a dry sterile dressing 2'DEGREE 13URNS>15%TBSA or 3rd DEGREE BURNS>51%TBSA Apply a dry sterile burn sheet NORMAL SALINE, * Adult: 0 500m1L IV/iO,, regardless of the blood pressure * Pediatric: 0 10mLI IV/10, regardless of the blood pressure, max dose 25OmL ELECTRICAL BURNS & Treat associated burns as indicated a If patient isin cardiac arrest,follow appropriate protocol CHEMICAL BURNS Irrigate liquid chemical burns with copious amounts of water or sterile saline. Brush off dry chemicals prior to irrigation. Re move pati e nt's cloth i ng a n d e n su re th at th e patie nt i s d eco nta m i nated p rio r to tra n s po rt, i n o,rde r to avoid contaminating personnel and equipment. Personnel shall wear protective clothing and/or respiratory protection as needed when removing chemicals. Bum Injuries continued.... El ADULT&PEDIATRIC V�r�Ir Adult C NO I d ................. .......... IIIP 14 61 L01, 9% IU1jL Infant. 111111, Aft, Palm and fingers 31.5 of patient Mom 1% TBSA Chest Trauma INFORMATION FLAIL CHEST 0 Occurs when 2 or more adjacent ribs are fractured OPEN PNEUMOTHORA MUCKING CHEST WOUND 4",%*ffh" 2) Occurs when ai r enters the pleural space,causing the lung to collapse TENSION PNEUMOTHORAX Occu rs wh e n a 1 r co nti n ues to e nter th e p le u ra I space wit ho ut a n ex'It o r re lease, ca u sing a n increase 'in intrathoracic pressure Intrathoracic pressure decreases cardiac output and gas exchange,,, 41 ADULT&PEDIATRIC PENETRATING OBJECTS Stabilize with a bulky dressi,ng FLAIL CHEST 0 Stabilize with a bulky dressing,, OPEN PNEUMOTHOMX(SUCKING CHEST WOU Apply a vented chest seal or occlusive dressing to all open chest wounds and monitor for signs & symptoms of a tension pneumothorax 0 Apply on expiration if possible TENSION PNEUMOTHORAX • Needle decompression should be performed when Aiiiiii.,of the following findings are present: Res pi ratory d ist ress o r d ifficu Ity ve nti lati ng with a BV M Decreased or absent breath sounds to the affected side Decompensated shock(SBP<90 mm Hg) • Primary sitelim 5 th intercostal space of the midaxillary line • Secondary site,, 2nd or 3rd intercostal space, midclavicular line Head Injuries INFORMATION 0 Patients with a depressed LOC may be unable to protect their airway a Adequate oxygenation of the injured brain is critical to preventing secondary InJury 0 Consider Advanced Airway Management. a Especially for patients with a GCS of<9 0 If patie nt beco m es co m bative refer to th e"Che m 1ca I Rest ra i nt" p rotoco I (pg.88) F INTRACRANIAL PRESSURE/HERNIATION SIGNS IINCLUDE�;, 0 A dech"ne in the GCS of 2 or more points 0 Development of a sluggish or nonreactive pupil 6 Paralysis or weakness on 1 side of the body 0 Cushing's Triad: 0 A widening pulse pressure (increasing systolic, decreasing diastolic) 0 Change in respiratory pattern (irregular respirations) 0 Bradycardia ADULT&PEDIATRIC ALL HEAD INJURIES • OXYGEN�,,,,,, 0 15 LPM via NRB regardless Of S1302, unless the patient requires ventilatory support • NORMAL SALINE", 45 Adult: (only enough to maintain SBP of 110-220) • IL IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat Ix,, prn [�r e C a U"" o n.,xii, �- P a r C-1 Ll I a�r c a�r e M Lus;;'t b e t a k e n i/n �t�h e p r e s e r"i c e o f s i/g nit fi c a n t c o r o n a hear disease,, 0111', and renal faikire Pat Pediatric: (only enough to maintain an age appropriate SBP within normal range. Refer to "HandteW system) 0 2OmL/kg IV/10,assess lung sounds and BP frequently a May repeat 2x prn for age appropriate hypotension DEPRESSED OR OPEN SKULL FRACTURE * Pressure dressings should not be applied to depressed or open skull fractures unless there 'i's significant hemorrhage present,as this can cause an increase in ICIP ERNIATION * POSITIONING"-, 0 30'head elevation * Maintain EtCO,,z between 30-35 mm Hg and SP02>90%while continuously monitoring 1313 A SINGLE INSTANCE OF HYPOTENSION OR HYPDXIA(SpOz<90%)IN PATIENTS WITH A BRAIN INJURY MAY INCREASE THE MORTALITY RATE BY 250%* .............;................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ................................................................................................................................'............ .......................................................................... Open Fracture ................."S, "WEN, INFORMATION OPEN FRACTURE Broken bone with extensive tissue damage and/or gross contamination and/or visible bone 0 Gross contamination,such as leaves or gravell,should be removed if possible a Cover open fractures with a moist sterile dressing 0 Fractures should be splinted in the positon found Exception: No pulse present,1�1�1111YP,,,the patient cannot be transported due to the extremity's unusual Position 0 2 attempts can be made to place the injured extremi,ty,in a normal anatomical position 0 D i sco nti n ue attem pts if th e patie nt co m pla i n s of seve re pa i n o r if t h ere 'is res i sta nce to movement felt 0 Reassess neurovascular status before and after repositioning of patient's extremity ADULT CEFTRIAXONE (ROCEPHIN)-, • Reconstitute 2g of Ceftriaxone using 20 mL of NORMAL SALINE in the medication vial • Dilute: 2g of Ceftriaxone i n a 50m L bag of N 0 RMAL SA Ll N E Administer over 10 minutes IWIO by utilizing a 15 gtt set delivering 75 os/min (1-25 gtts/sec) A 1 eil,gy t iciii �Cle�p 1111i a I lo is 1�)lo ill Atlicief,,, Cecli&�111% ��(eflex,/, 41111111�blfiib,ial 11,11ilear t vialivie J01 Nielor"ItIaXties PEDIATRIC CEFTRIAXONE (ROCEPHIN),I, • Reconstitute 2g of Ceftriaxone using 20 mLof NORMAL SALINE in the medication vial • Dilute: 50mg/kg of Ceftrilaxone in a 50mL bag of NORMAL SALINE Ad m i n i ste r ove r 10 mi n utes IV/10 by uti I i zi ng a 15 gtt set de I ive ri ng 75 gtts/m i n(1.25 gtts/sec) Refe r to Handtevy fo r pro per dosing. dit�'ii�iiill, 1(10`11e,xj� 1,01), -111M -Iliieliai,l vi; Ivie ilill Aill", 11 1 RiO �N ii ii,�ii I le si Hemorrhagic Shock 7- INFORMATION COMPENSATED SHOCK DECOMPENSATED SHOCK a Anxiety Decreased LOC 0 Agitation Hypotension 0 Restlessness Peripheral cyanosis 0 Normotensive Delayed capillary refill 0 Capillary refill normal to delayed 0 Inequality of central/distal pulses 0 Tachycardia 0 Tachycardia 4 ADULT&PEDIATRIC • Maintain body temperature wilth blankets and considerincreasing the temperature"in the patient compartment • Control all major external bleeding • E sta b I i sh b i late ra I va scu la r a ccess, uti 1 111 zi ng I a rgest cath ete r s ize possi b le • N 0 R MA L SA LI N E., (only enough to maintain periphe ral pu Ises) Adult,." 0 1L IWIO,titrate to desired effect.Assess lung sounds and BP frequently. 0 May repeat Ix,, prn I'll", 1))" 0"! 11.1,31 1, U t CO r . ..... e ni�wst �ta It �r e c a u if I') P,jj�' i�Is U e P at l�� C[ Pediatric: 20 mL/kg IW10. Assess lung sounds and BP-frequently. May repeat 2x prn,,for age appropriate hypotension Neurogeni*c Shock INFORMATION Signs&Symptoms: Wa rm/D ry ski n (especia I ly be low the a rea of th e I nj u ry) Hypotenslon with a heart rate within normal limits Paralysis ADULT Ma i nta i n body te m perat u re with b la n kets a n d co n s i de r I n creasi ng th e te m peratu re i n th e patie nt compartment NORMAL SALINE,,, a 1L IV/10,fitrate to desired effect.Assess lung sounds and BP frequently. 0 May repeat lx,, pirn II C, 1,111(g, 1,1 ��E?�,11�i 1 11 1 1 1 If �11 I , t", [,,, �'c� III Ii C ol�i,o a ir-,ii Ir-le�,Ci �1 l� 10)1�,, 0 f 5 111'�g�"�I C F , i ��I��I l� l�E,!' fa iiI iie��i 1p�E1/111�,�At �Ff lr",II �5 IF PATIENT REMAINS HYPOTENSIVE PUSH-DOSE PRESSOR EPINEPHRINE (1-100,000),� a Dilute: Discard 9 rnL of Epil:10,000(0.1mg/mL)and draw up 9 mL of NORMAL SALINE to create Push-iDose Pressor Epj 1:100,000. Thi's will yield 10mcg/mL,, 0 Administer 1 mL/minute IV/10,titrate to maintain SBP 100mm Hg 0 May repeat 2x prn, max total dose 300mcg(30 mQ siec,U�11111111da II111111y tic) blioloid �ios-s r iell ic,i(;:ii, 11"11 iiIJ II,i,n,",o�! 1� �I IF ic)nI iiI o r �riE! 1111$1111 CA/11. 11 lcf�fjl, �11�v 1113 f,',z Cl '911,F51 Clfl it, 9 ?10 PEDIATRIC MaIntai n body temperature with blan kets a nd conside rincreasilng the temperatu re 'in the patient compartment NORMAL SALINE]: 0 20mLi IWIO,assess lung sounds and BP frequently 0 May repeat 2x prn,for age appropriate hypotensi"on ,�.AIIENT REMAINS HYPOTENSIVE PUSK-DOSE PRESSOR FF'PINEPHRINE (1:100'.000)"111 0 D11 ute'. D isca rd 9 m L of E pil 1:10,000 (0.1mg/m Q and draw u p 9 m L of NO RMAL SALI N E"to create Push*Dose Pressor Epi 1:100,000,. This will yield 10mcg/mL. 0 Administer I ml./mil''nute IWIO,titrate to maintain age appropriate SBP 0 May repeat 2x prn., max total dose 300mcg(30 mL) Ir"lildicit"! rl,�ii L,11[01� C1 0 fr'��,io n ir, o ri�,i o1i id i,ii"ir,,�,,�I n s e f St�e Yr t ri"'II 1/�/,?/�,, I r I�II P S I'S 10 IIf" E p I i,'ii, III, a Is III, p Ii d I r',�n in 0 Il/(�I t i id & V1111 I/ ""�i o j�jj 3, I�Jl III'e 'ij LJ �)J ii/)id h��'l II If I..I..... Fi`Y�,III, a id c;,//1i(, f"6),','//" IN)l ul Trau a in Pregnancy INFORMATION PHYSIOLOGICAL CHANGES DURING PREGNANCY Due to the following physiological changes in pregnancy, it is often difficult to assess for shock,,-, 0 Mother's heart rate increases 0 By the third trimester,,the HR can be 15-20 beats per minute above normal 0 Both the systolic and diastolic blood pressures drop 5-15 mm Hg during the second trimester a The mother's cardiac output and blood volume increases Therefore,the pregnant patient may lose 30-35%of her blood volume before the signs &symptoms of shock become apparent 0 Supine hypotension usually occurs in the third trimester ADULT * Assess for vaginal bleeding and a rigid abdomen 0 In the third trimester 4F this could indicate an abruptio placenta or a ruptured uterus * POSITIONING:1 Pregnant patients not requiring spinal motion restriction shall be transported on their lefts'lide If a pregnant patient requires spinal motion restriction, place 4-6 inches of padding under the patient's right side while maintaining normal anatomical alignment ALL TH I RD TRI M ESTER PREG NA N CY TRAU MA PAIII E ,�NTS OXYGEN ie 15 LPM via NRB regardless Of SP02, unless the patient requires ventilatory support IF HYPOTENSIVE 0 Establish bilateral vascular access, utilizing largest catheter size possible 0 NORMAL SALINE(onty enough to maintain peripheral pulses): 0 11-IV/10,titrate to desired effect.Assess lung sounds and BP frequently May repeat 1x, prn 1' UF1 kZ" �1 IL 0 n t r r, I 1�15, 11`1 `T,7' K �h ctc//i/i aa,ry h U U :p r d C�H�F �r e u'r I �p ziv �n't s a ri�,tJ f All ........... ---1-7 no I�K a V 0 no 0 Sk dffi/ LF PO 0 loft I Im 09/9 0 "0 no i/ E/5/ , /j, .no if ill, Standing Orders INFORMATION Obstetrical patients are defined as gestation >20 weeks PHYSIOLOGICAL CHANGES DURING PREGNANCY * Mother's heart rate increases * By the third trimester,the FIR can be 15-10 beats per minute above normal * Both the systolic and diastolic blood pressures drop 5-15 mm Hg during the second trimester * The mother's cardiac output and blood volume"increases Therefore,the pregnant patient may lose 30-35%of her blood volume before the signs&symptoms of shock become apparent * Supine hypotension usually occurs in the third trimester ADULT POSITIONING-, a Transport patientsin their th'ird trimester and not in active labor on their left side IF WATER HAS BROKE Document: Time Color of fluid IF BLOOD PRESENT Document: 0 Time 0 Volume IF CROWNING Prepare for a field delivery 0 D01 delay transport to the closest appropriate hospital FOCUSED HISTORY Obtain: • Number of previous pregnancies(GRAVIDA) • Number of previous viable births(PARA) • Documented multiple births? • Gestational Diabetes? • Narcotic use? • Due date? • Frequency and length of contractions.? • Feeling of having to push or have a bowel movement.? .Is nd 2 Trimester Complications .......... INFORMATION 151 TRIMESTER 0 Weeks I-12 of the pregnancy 2 nd TRIMESTER 0 Weeks 13��-27 of the pregnancy ECTOPIC PREGNANVUunialiv first trimester Signs&Symptoms: 0 Sudden onset of severe lower abdominal pain a Vaginal bleeding 0 Amenorrhea (absence of menstruation) 0 Referred pain to the left shoulder 0 Cullen"s Sign (periumbilical ecchymosis) 0 G rey"Tu rn e r's sign (ecchymos'l s of t he fla n ks) 0 Abdominal distention and tenderness SPONTANEOUS ABORTION(usually.before 20 weeks of zestationj Signs&Symptoms: • Abdominal cramping • Vaginal bleeding • Passage of tissue or fetus ADULT 0 Assess and treat for shock & Rapidly transport to any approved OB or GYN facility FOR ACTIVE BLEEDING 0 Loosely place trauma pads over the vagina 'in an effort to stop the flow of blood 0 DO 1401T pack the vagina IF HYPOTENSIVE NORMALSALINEI: • 1L IV/10,, titrate to desired effect.Assess lung sounds and BP frequently. • May repeat Ix,, prn P r e c a u irib n s a rit--ji c u��a r c r",,rn u s It�b e t,:�a k ji�r',t ��n t h e p r e s e n ce o f s��g r"r��fi c a ri� C 0 r"D r-if a �ri e a rt ir"] a n d re r-fi a I f a i��u re P a I'l t Jo i s e a s e C 1,�,i FIJI rd 3 Trimester Complications INFORMATION TH I R D TRI M ESTER Weeks 28 del'i'very PLACENTA ABRUPTIO Signs&Symptoms: 0 Sudden onset of severe abdominal pain and tenderness 0 Painful uterine contractions 0 Vaginal bleeding with dark red blood 0 Patient may presentin shock PLACENTA PREVIA Signs&Symptoms: 0 Painless vaginal bleeding(bright red blood) UTERINE RUPTURE Signs&Symptoms: • Sudden,intense abdom"I'nal pain • Vaginal bleeding ADULT 0 Assess and treat for shock 0 If i n ca rd iac a rrest refe r to th e "Ca rdia c Arrest Specia I Co n si'd erations" protoco I (pg. 75) 9 POSITIONING:' During transport,, place 4-6 inches of padding under the patient"s right side while maintaining normal anatomical alignment FOR ACTIVE BLEEDING Loose ly p la ce t ra u ma pads ove r the vagi na i n a n effort to sto p th e flow of 1p lood ��[)10 1110111"T'pack the vagina IF HYPOTENSIVE NORMAL,SALINE,.- 1L IV/10,,titrate to desired effect.Assess lung sounds and BP frequently. May repeat 1x, prn PrecaUlt ons �- Partrfcd/i/�r care rr Ust be 4ket ur-i the pireser,/ice af sign,,//��,/�,/�"/�,�,i,/,,,,/?,�//,��n"r/ coronarti., hear ic J/1 i s e a s e, C H F,, n d �r e r-ti,a f a u�r e p a e �t s Placenta Prev'la Plawnta Internal Sep araW fmm Bleeding uterus j "0 Extei,,na I Bleeding ................................ ........... ................................. .................... PremwEclampsl'wdlEclampsla INFORMATION SEVERE PRE-ECLAMPSIA a A rare pregnancy complication characterized by high blood pressure that usually begins after 20 weeks of pregnanity. 0 Signs&Symptoms,,, HTN (SBP�> 160 mm Hg OR a DBP of> 110 mm Hg)with any of the following; imp AMS Visual disturbances Headache Pulmonary edema ECLAMPSIA Signs&Symptoms,: Any of the severe pre-eclampsia signs&symptoms associated with: 0 Selzures,0114,,Coma Either condition can occur for up to 30 days postpartum. ADULT * OBTAIN A BGL SEVERE PRE-ECLAMP51AJNQ11NAg!YK1AM MAGNESIUM SULFATE�11'11 Dilute: 2g of Magnesium Sulfate in a 50ml-bag of NORMAL SALINE Administer over 10 minutes 100 by utilizing a 15 gtt set delivering 75 gds/min (1.25 gfts/sec) MUS11111T repeat Ix 2 aili�id �D ie 1�1c)clii(�s griele 111111111111eart 1" Precai,�/,,,,,�,�,�tioif�"",f,�, - Rapi,�,d May ECLAMPSIA VERSED,� a 5mg IV/10/IN/IM 0 May re peat 1x p rn,, i n 5 m i n utes if seizu re reocc u rs o r does n ot su bsi'de U,,) id iii if atiif, P r e c a o lii,�ff �,v I o ri,,"i ir fc",,f,/r r e,s p i,",r'�';,:ij,t o r y d r e s i,i r,1, MAGNESIUM SULFATE:' Dilute:4g of Magnes lum Sulfatein a 50mL bag of NORMAL SALI N E Administer lW10 utilizing a 60 gtt set, run wide open �2 na ainid 3"' Diegill''ele 1111111111ea 11111"t��B 10 C��'('s r1l,ekr rwe., rN/p, P�r le cecii iu n R a�p ii in'f LX/';�I crl"","'�i in im c"'i/i C�a L""i"s,i ffffl, IF UNABLE TO ESTABLISH VASCULAR ACCESS MAGNESIUM SULFATE: 0 4g IM (8 mL total) 0 4 mL per injection site max.This will require 2 in)ection sites q, ',"I� C d ac'iiid 3 111)1e�giii�ieie ir/,fus�jan if(//(,ria'�y�r caii./)/(,se hypotens.�,,on Meconium Staining INFORMATION .......... Meconium will appear as a yellow to dark green substance that may be noted in the amniotic fluidl coming from the vagina or covering the neonate's head,. NEONATE WK .MECONIUM STAINING If upon delivery of the head there 'is meconium staining present: 0 Use a bulb syringe to clear secretions from the mouth and then nose before delivery of the shoulders 0 Meconium aspirators are rarely needed, however consideration for usage may be given 'in patients whose airway is obstructed by meconium that cannot be cleared by simpler methods Normal Delivery ADULT NORMAL DELIVERY 0 POSITIONING:, 0 Place patient on her back with k"nees flexed and feet flat on the floor 0 Control delivery of the head,with gentle perineal pressure 0 DO IYOT apply manual pressure to the uterine fundus pri"or to the birth of the child 0 !��)10 NOT pull or push on the neonate 0 1110 1�)101 11410T allow sudden hyperextension of the neonate's head 0 Once the head delivers: a Suction the mouth and then the nose 0 Support the neonate's head as it rotates to a lig n wil"t h the s h o u Id e rs,ge ntly gu ide th e neonate's head downward to deliver the anterior shoulder 0 0 n ce the a nterl o,r sho u Ide r d el ive rs,ge nt ly gu 1 de th e neo nate"s hea d u pwa rd to de I ive r th e poste no r sh o u Ide r a nd th e rest of th e body UPON DELIVERY OF THE NEONATE 0 Dry,warm,and stimulate the neonate 0 Keep the neonate at the same level of the placenta 0 Once the umbilical cord stops pulsating(usually 3--5 minutes): Clamp the cord "in the following fashionr.,� • Place the first clamp 4"'away from the neonate"s body • Milk the cord away from the neonate and towards the mother(this will minimize splatter) • Place the second clamp 2" away from the first,towards the mother Cut the cord between the 2 clamps Place the neonate on the mother's chest,skin-to-skin,and cover with a dry blanket Record and encode an APGAR score at I and 5 minutes and document the delivery time Apply firm continuous pressure,, manually massaging the uterine fundus after the placenta delivers Preserve the placenta in the bag provided with the OB Kit or a "'Red Blo-Hazard bag"for inspecbon by the receiving hospital APGAR SCORE ir,ll�l a I ic ir oid.15 l ilai,,il",111-5,1 ic:iltelr bill CRITERIA AXW"W No n*Dve"xw %NW nXrov"Wint Active nwm&mvnt toP (muscle tone) Ful" NO Pwse Less than.100 bWn Greater than 100 bpm W IWO Grimm or feeble ZIP` AdW iiiiilln (mflex.Iffftablifty) III'16,�,/, '611~ WISUMUlk&M W/sumuloom .1100W Body po* i9lue aft over CAw"pletely p k in (skin color) wremities bhje Respiraftn W Breathing Strong Cry breathing Moderate Resuscitation Needed Deliver Complications y ADULT BREECH BlRT"j(FEgT OR BUTTOCKS PRESENTATION1 If the head does not deliver within 3 minutes of thie body,,�, a Elevate the mother's hips(knee to chest position) a Insert a gloved hand into the vagina 0 Push the vaginal wall away from the neonate's nose and mouth Expedite transport while maintaining theknee to chest position and the neonate s airway OXYGEN Administer blow-by OXYGEN to the neonate 41 0000� 01 iiP 11, t 0, �#101F�ffi,, 000 lip 0 41 0i, 1��1 ' 1�1�,,�,,, olo liq M-04i III S, F' ",NMI 111I 0 A/ ga hil gliF F 41 jLIA� 01011 )�,Opdll %q IN jjjj� P,Aj,�fffffffV" SHOULDER DYSTOCIA(DIFFICULTY IN DELIVERING THE SHOULDERS) MCROBERrS PROCEDURL, * Hyperflex the mother's legs tightly to her abdomen * It may be necessary to apply suprapubic pressure(mother's lower abdomen) * Gently pull on the neonate's head "AAA. J1611 '55 Delivery ComplicationsiCandnued... NUCHALCORD * Check for the presence of a nuchal cord after delivery of the head * If the cord is around the neck: 0 Gently hook your finger under the loop 0 Pull it over the neonates head 0 You may have to repeat thi's if there is more than 1 loop present * If you are unable to free the cord; Clamp the cord 'in 2 places Cut the cord between the clamps J6 far PROLAPSED UMBILICAL CORD POSITIONING:', Place mother in the knee to chest position 0 Manually displace the uterus to the left 0 insert a gloved hand "Into the vagina * Push the neonate up and away from the umbilical cord regardless if there is a pulse present or not * Maintain this position during transport 0 F req ue ntly rea ssess t he u m b i I ica I co rd fo r the p rese n ce of a p u Ise, as co ntra ctio ns,a re I i ke ly to compress the umbilical cord 0 Wrap the exposed cord in a moist sterile dressing Ex ped ite tra nsport to closest 0 B fa cil I Ity 111,11,11111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIJIJIJIJIJIJIJJJJ�'��, oeillpoo 0 RIM 011 Manual displacement of the uterus