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Item D02 D2 BOARD OF COUNTY COMMISSIONERS COUNTY of MONROE Mayor Craig Cates,District 1 The Florida Keys Mayor Pro Tern Holly Merrill Raschein,District 5 Michelle Lincoln,District 2 James K.Scholl,District 3 David Rice,District 4 Board of County Commissioners Meeting July 19, 2023 Agenda Item Number: D2 2023-1164 BULK ITEM: Yes DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: Chief Callahan N/A AGENDA ITEM WORDING: Issuance (renewal) of a Class A and Class B Certificate of Public Convenience and Necessity (COPCN) to Elite Medical Transport Inc. for the operation of an ALS and BLS Transport Service, as well as a Non-Emergency Transport Service, for the period July 22, 2023 through July 21, 2025 for responding to requests for inter-facility transports. Elite Medical Transport Inc. is not permitted to perform 911 emergency response work in Monroe County. ITEM BACKGROUND: On July 21, 2021, a new Class A and Class B COPCN was issued to Elite Medical Transport Inc. for the operation of an ALS and BLS Transport Service, as well as Non-Emergency Transport Service, for the period July 22, 2021 through July 21, 2023 for responding to requests for inter-facility transports. Elite Medical Transport Inc. is not permitted to perform 911 emergency response work in Monroe County. Elite Medical Transport Inc. has submitted an application to renew their Class A and Class B COPCN Certificates which would become effective July 22, 2023 and expire on July 21, 2025. PREVIOUS RELEVANT BOCC ACTION: On July 21, 2021, agenda item (R2), the BOCC approved the issuance of a Class A and Class B COPCN to Elite Medical Transport for the operation of an ALS and BLS Transport Service, as well as a Non-Emergency Transport Service, for the period July 22, 2021 through July 21, 2023 for responding to requests for inter-facility transports. Elite Medical Transport Inc. is not permitted to perform 911 emergency response work in Monroe County. CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval 174 DOCUMENTATION: Elite Medical Transport Inc. Class A Renewal Application—Redacted.pdf Ellite Class A Certificate.pdf Elite Class B Certificate.pdf FINANCIAL IMPACT: Effective Date: 07/22/2023 Expiration Date: 07/21/2025 Total Dollar Value of Contract: N/A Total Cost to County: N/A Current Year Portion: N/A Budgeted: N/A Source of Funds: N/A CPI: N/A Indirect Costs: N/A Estimated Ongoing Costs Not Included in above dollar amounts: N/A Revenue Producing: N/A If yes, amount: N/A Grant: N/A County Match: N/A Insurance Required: Yes, per the Statutory Requirements Additional Details: N/A 175 cfl ti MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) L] INITIAL APPLICATION-$950.00 ■ RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # 21-03 1. NAME OF SERVICE Elite Medical Transport Inc. BUSINESS MAILING ADDRESS 101413 Overseas Highway BUSINESS PHONE NUMBER 7864786064 EMERGENCY PHONE NUMBER 3053045609 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor, Partnership,Corporation,etc.) Corporation DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 09/30/2016 3. LIST ALL OFFICERS, DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITION/TITLE Schrage Goldblatt 48 2905 Praire Ave Miami Beach,FL 33440 3053045609 President 4. LEVEL OF CARE TO BE PROVIDED: BLS or ■ ALS IF ALS: ■ TRANSPORT or[] NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): Monroe County Inter-facility i. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION 101413 Overseas Highway Key Largo, FL 33037 SUB-STATION Page I of 6 ti ti 7, DESCRIBE YOUR COMMUNICATION SYSTEM (Attach copy of all FCC licenses): � FREQUENCIES CALL NUMBERS #OF MOBILES #OF PORTABLES 800 MHz P25 Elite R40-R44 2 6 MCSO S. LIST THE NAMES AND ADDRESSES OF THREE(3) U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: ....... NAME ADDRESS George Lima 9825 NW 122nd Terrace, Hialeah Gardens, FL 33018 Isabel Rodriguez 7320 N Augusta Dr, Hialeah, FL 33015 Dr. Sandra Schwemmer 101413 Overseas Highway, Key Largo, FL 33037 9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. 1. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. 12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. 1,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE, DO HEREBY ATTEST MY SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN THIS APPLICATION,TO TfJE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. SIGNAT R OF A CAiYT/A MORIZED REPRESENTATIVE NOTARY S �'A' .m � tBABEL MARE RODPAUEZ NOTARY 51 ` D�S Aid 2L2 7 DATE Page 2 of 6 00 ti PERSONNEL-PARAMEDICS NAME PARAMEDIC CERTIFICATION First Middle Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Angel Jesus Diaz PMD541388 12/01/2024 James Faktor PMD514804 12/01/2024 Brandon Ferbeyre PMD535697 12/01/2024 Gregory Gutierrez PMD527883 12/01/2024 Jose Puri PM D523375 12/01/2024 Cody Robertson PMD537412 12/01/2024 !............................... --------------------------- Page 3 of 6 ti PERSONNEL—EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICATION First Middles Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Carl Cadet EMT 576712 12/01/2024 Christopher Cash EMT579991 12/01/2024 Jose R Chacon EMT574901 12/01/2024 Misael Diaz EMT569210 12/01/2024 Sebastian Gomez EMT563341 12/01/2024 Grayson Gomez EMT575266 12/01/2024 Michael Guerra EMT571969 12/01/2024 Ruben Roldan EMT570262 12/01/2024 Robert Sarmiento EMT569203 12/01/2024 Michael Souffront EMT546096 12/01/2024 Keilor Zuniga EMT574828 12/01/2024 Ashley Rios EMT560460 12/01/2024 Page 4 of 6 O w co F � M 11) O r In O M LO r O r (D LO CD N N M M N N N N N (M O M M N N CN N N z O O O O O O O O O N O N O O O O O O O C 0 O N N N N N N N N N O N O N N N N N N N F 04 04 N N F' ti O co O N O N NLO ti Ce) 1+ � O 1� O 1` z r M N C= N N -- M N � N N N w M 00 0_D r N r O r 00 co N r U) W OTC m wz 55 ti LL LLLL LL L LL LL L LL LL LL L LL L LL LL w I� F v� Q w O F' F CA z z U a > or � w � > � Q x z w x � F o w o � > O Co ............. 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Z co N N N 0 N F F- F- F- F-- F- F- >4 z � Q Q Q Q Q Q Q r o w CO m 1` :3 U � ��rr I�1 ��,,// T iT T.- rF T.- ter} L = E a V V V O° > a � a V Z Z Z Z Z Z a F 3 O 0 N M CEO O CN Q Q Q Q U Q wcM co X (� S La U') LL LL LL LL u � X ci X 3: ❑ ❑ ❑ ❑ ❑ ❑ LL LL LL LL LL LL L W Y' [7 Ln CO � LLO C(O 0) N 00 CD N CN w L 6i G p4 0 In O r ip N o o T T r r W O o o O 0 0 c N N N N N N Q o 0 o 0 0 o c LLB m Lo Lo Lo Lo W L6 L6 Lb Lb LJ Lb L a w a >4 W — _ — — _ d _ V W W W W W W oa H H H Q N 00 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) �F-1 INITIAL APPLICATION-$950.00 ■ RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # 21-03 1. NAME OF SERVICE Elite Medical Transport Inc. BUSINESS MAILING ADDRESS 101413 Overseas Highway BUSINESS PHONE NUMBER 64 EMERGENCY PHONE NUMBER 305304Jr"609 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor, Partnership,Corporation,etc.) Corporation DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 09/30/2016 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITIONITITLE Schrage Goldblatt 48 2905 Praire Ave Miami Beach,FL 33140 3053045609 President 4. LEVEL OF CARE TO BE PROVIDED: ■ BLS or ALS IF ALS: TRANSPORT or❑ NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): Monroe County Inter-facility C, LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION 101413 Overseas Highway Key Largo, FL 33037 SUB-STATION ----------------- Page I of 6 M 00 7. DESCRIBE YOUR COMMUNICATION SYSTEM (Attach copy of all FCC licenses): � m........................ .................... . .......... ,,,,,,,.. ... ........—....................----.... .. .________ ......... __ ...__.. FRE UENCIES CALL NUMBERS #OF MOBILES #OF PORTABLES 800 MHz P25 Elite R40-R44 2 5 MCSO S. LIST THE NAMES AND ADDRESSES OF THREE(3) U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: �_. ........ w„ ...... ---- --....__ __. ..........................._ ......... _._ ............... ... NAME ADDRESS George Lima 9825 NW 122nd Terrace, Hialeah Gardens, FL 33018 Isabel Rodriguez 7320 N Augusta Dr, Hialeah, FL 33015 Dr. Sandra Schwemmer 101413 Overseas Highway, Key Largo, FL 33037 9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. 11. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. 12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. 1,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN THIS APPLICATION,T THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ....mm......... SIGN TURE OF PPLICANT 1 AUTHORIZED REPRESENTATIVE NOTARY SE L ARM, MAXOPAM a 2.82 . NOTARY SIGN 1* Af c4mmS m#H{91M DATE VWM..Ap t 2Z 2W ..N.N Page 2 of 6 dq 00 PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First Middle Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE _...... Angel Jesus Diaz _.. PMD541388 12/01/2024 James Faktor _-m._........�.....,._................... PMD514804 12/01/2024 _. _......... ............................................ Brandon Ferbeyre .._...................... ......................... ._......... PMD535697 12/01/2024 ........................ _.... Gregory Gutierrez ...... ....................,.. PMD527883 12/01/2024 Jose Puri _. ......-�............................_._ PMD523375 12I0112024 ........ Cody Robertson ........ .. PMD537412 12/01/2024 .._....... T ........w.......... ........vm . A, m ...............mm.. i _. ... ................... . .ry._........... ...... . ...............--- . .................... .................. ..............._........... Page 3 of 6 Uj 00 PERSONNEL®EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICATION First. Middle Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Carl Cadet EMT 576712 12/01/2024 Christopher Cash EMT579991 12/01/2024 Jose R Chacon EMT574901 12/01/2024 Misael Diaz EMT569210 12/01/2024 Sebastian Gomez EMT563341 12/01/2024 Grayson Gomez EMT575266 12/01/2024 Michael Guerra EMT571969 12/01/2024 Ruben Roldan EMT570262 12/01/2024 Robert Sarmiento EMT569203 12/01/2024 Michael Souffront EMT546096 12/01/2024 Keilor Zuniga EMT574828 12/01/2024 Ashley Rios EMT560460 12/01/2024 Page 4 of 6 cfl co w F o Q M U) O M M Oqqr LO O � 0 LO q O u Q N N M M N N N N N M O M m N N N N N w n z O O O O O O O O O N O N O O O O O O O O N N N N N N N N N O N 04 O N N N N N N N 1, O w O N O N N — 1- M 1�-- O 1` O 1~ Z M N M N N 07 N Q N N NT- NTM- w r O M 00 �- 0�0 � N M r O O r 00 fl0 N r Lo w w w U w J J J J J J J J J J J J J lr-j Q Q LL U w � a w a A'' w v� Q a z w E■ m A a Q m W O F > o q w w __ ............. a U a � Q � > � F � a � O s oa zw N O �o W. w w Qa � C I N � C � O O U0 O N U ( O+N Ncv � o, OG w " Cc t N M � z LL . 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EL Q 00 00 BOARD OF COUNTY COMMISSIONERS County of Monroe Mayor Craig Cates,District I @ Florida Keys Mayor Pro Tern Holly Merrill Raschein,District 5 Michelle Lincoln,District 2 James K.Scholl,District 3 David Rice,District 4 Monroe County Fire Rescue 490 631 Street Ocean Marathon,FL 33050 Phone(305)289-6004 so an MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit-COPCN DATE: May 31, 2023 Attached please find Check-dated May 29, 2023 in the amount of$475.00 to be deposited in revenue account 141-342000-RC 00345.The check has been issued for the renewal application of a Class A Certificate of Public Convenience for Elite Medical Transport Inc. Thank you, Cara Johnson City National Bank NEI ELITE MEDICAL TRANSPORT INC. 63-0436M60 i 786-478-6064 areas Raw! PIOfEofflll for&p10E49 r� 9° 5/29/2023 PAY TO THE ORDER OF Monroe County Board of County Commission $ 475.00 Four Hundred Seventy-Five and 001100ts:1fftffftf*f!!ff*RfR*!lfffflR!llfffttt:fftffR*!!tf**ifRRflftffftRft*fRlRRlRRRflYR DOLLARS Monroe County Board of County Commission MEMO ✓� � �. ...MP �un+owzw sarr+iniRe ELITE MEDICAL TRANSPORT INC. - Monroe County Board of County Commission 5/29/2023 475.00 City National Amb Op 475.00 o t �h 5 b i.a. M1°: omiu�mw Donn iminimnim i mmmro m i u � � V w w o m W uj r, U. WL au Lim j U. war kFA 42 u w. ti v o -w m d �WNW��mumuumm aii. a"" f ��m�uuu m �m�l N mm ts f k a � r � I � o M y,/ g q ,� � ;• . �. tile. fry/��%tnr�ur Monroe County EMS Rates i ww mw � im BLS RESPONSE CHARGE $650.00 ALS RESPONSE CHARGE $800.00 ALS 2 RESPONSE CHARGE $900.00 CRITICAL CARE TRANSPORTS(CCT) $1,000.00 MILEAGE(PER MILE) $12.00 OXYGEN $35.00 d' DATE o rW2a2DY ACORO CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(iss)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such andorsement(s). PRODUCER CONTACT NAME: Cornell insurance Cornell Insurance Services PHONE tsrd: (732)902-2420 AAC Na: (732)902-2424 Raritan Plaza III IL ADDRESS: 105 Fieldcrest Ave,Suite#104 INSURER(S)AFFORDING COVERAGE NAIC N Edison NJ 08837 INSURER A: Coverys Specialty Insurance Company 15686 INSURED INSURER B: National Indemnity Company of the South 42137 Elite Medical Transport Inc INSURER C: Benchmark Insurance Company 41394 101413 Overseas Highway INSURER D: INSURER E: Key Largo FL 33037 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 Elite Transport REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS POLICY EXP LTR TYPE OF INSURANCE I D WVD POLICY NUMBER AUUL MUM POLICY WOD YYYY MWD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTEIT_ CLAIMS-MADE N OCCUR PREMISES Ea occurrence $ 50.000 X Professional Liability MED EXP(Any are person) y 5.000 A X Abuse&Molestation 005FL000041345 07/31/2022 07/31/2023 PERSONAL&AOV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000.000 RO- POLICY E JECT El LOC PRODUCTS-COMPIOPAGG S 1,000,000 OTHER: Professional Liability S 1M1$3M AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1.000,000 Ea wddent ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED 74APBOO5737 08/31/2022 08/31/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OVYNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident Uninsured motonst S 250.000 CSL UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LtAB CLAIMS-MADE AGGREGATE S DED I I RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERlEXECUTIVE EL EACH ACCIDENT $ 1,000,000 C OFFICERIMEMBEREXCLUDED? NIA BID370622-00 0$11812022 0$l1812023 (Mandatory In NH) E,L DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S Each Claim $1.000,000 A Professional Liability OOSFL000041345 07/31/2022 07/31/2023 Aggregate $3,000,000 Retention $15.000 DESCRIPTION OF OPERATIONS!LOCATIONS f VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more apace Is required) Professional Emergency Services CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ��+ 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD A BETWEEN ELJTE MEDICAL TRANSPOWF, LLC-. AND PROFESSIONAL EMERGENCY SERVICES, INC, For ALERK,AL 'C—T2R SERVI(,"LS This is an Agreement between Elite Medical Transport, 1jC, a limited liability company organized and existing under the laws of the State of Florida(together with its successors and assigns, hereinafter referred to as"ELITE-i") AND Professional Emergency Services, Inc., (hereinafter referred to as the CONSULTANT) whose principle place of business is P 0 Box 379, Tavemier,, FL 33070 and who is represented by Dr Sandra Schwernmer. WHEREAS, ELITE, is a provider of basic and advanced life support medical transport services, and is required by Chapter 40 1, Flujida.Statutes, to contract with a licensed physician to serves ELITE'S "MEDICAL DIRECTOR",, and WREREAS, the CONSULTANT provides Medical Director services and ELITE desires to utilize the services of the CONSULTANT, NOW, THEREFORE, in consideration of the mutual terms and conditions, promises, covenants and payments set forth below, ELITE and CONS ULTANT agree as follows: AKUO,E I aCQrLQXLERV ES 1.1 Under the direction of ELITE Director of Operations and as defined in Florida Administrative Code Chapter 64J-1.004 for medical transport only, the CONSULTANT shall provide a qualified physician to serve as Medical Director for the ELITE'S Emergency Medical Transport Services Program as more particularly set forth herein. 1.1.1 Develop transport protocols that permit specified ALS and BLS procedures when communication cannot be established vAth a physician during medical transport when a delay in patient care and treatment would threaten the life or health of the patient. 1.1.2 Medical Director will be available "off-line" to resolve administrative problems, system conflicts, and provide services in an emergency as that to is defined by Section 252.34(3), Florida Statutes Such "off-line" services will be provided at a rate t, cfl of$250 00 per hour or at a rate mutually agreed upon by the CONSULTANT and ELITE Chief of Operations. 1 13 Develop and implement a transport patient care quality assurance program to assess the medical performance of ELITE Paramedics and EMTs Clerical and is five support will be provided by ELITE. 1.14 Audit the performance of El.XfF personnel from time to time by use of a quality improvement program, to include but not limited to, a prompt review of transport reports, direct observation, and comparison of performance standards for drugs,, equipment, protocols and procedures, 1A 5 Provide a DFA registration for ELITE in order to provide equipment, medications, including controlled substances to FLMI, if needed. DEA registration shall include the address at which controlled substances are stored. Proof of such registration shall be maintained on file with 1111TE and shall be readily available for inspection. ELITE xvill forward any and all renewal documents and correspondence received regarding the'DEA to CGNSULTANT to assure continuous registration, and will pay for the cost of the DEA certificate or reimburse CONSULTANT for cost of such registration. 1 16 Review ELIT0s security procedures for medications, fluids mid controlled substances to insure they are in compliance with Chapters 499 and 893, Florida Statutes, and Chapter 64F-.12., Florida Administrative Code, 1.1.7 Assist and coordinate, with the Operations Chief, written operating procedures creating, authorizing and ensuring adherence to rules and regulations regarding all aspects of the handling of medications, fluids and controlled substances by ELITE certified personnel in accordance with State and Federal regulations, 1,1�8 Notify the pepartment of Health in writing, when applicable, of each substitution by the FLUE of equipment or medication, 1 19 Review and approve training for EMT/Paramedic continuous education training and/or refresher courses for the purpose of EMT re-certification. 1 1,10 Assume responsibility for the use by an EMTIP of an automatic or semi- automatic defibrillator;, the performance of esophageal intubation by an EMT/P, and the monitoring and maintenance of non-medicated TVs by an EMT/P, as well as the use of epinephrine for allergic reactions, when necessary, 1 1,11 Advise and implement a plan for prompt medical review of possible infectious exposures reported to the Operations Chief and provide medical follow-up when indicated ,, in compliance with to and Federal requirements. Medical follow-up care to ELITE employees will be billed at $2$0,00/hr. 2 ti AHPCLE2 LQ-WF,N ATI L_—QN An MIET W2 OLPAYAgNI 2.1 ELITE agrees to pay the CONSULTANT as full compensation for the services described in Article I an annual fee of J54,Q00.00 to be paid tot CONSULTANT in twelve consecutive equal monthly installments of$4,500-00. This fee includes all costs and expenses of CONSULTANT Services requested beyond the scope of this contract VAII be invoiced separately at a irate of$?50.00 per hour, subject to approval of ELITE Chief of Operations 12 ELITE agrees to pay the CONSULTANIT on the first day of the on for each month in which CONSULTANT'S service are rendered ARXLCLE 3 P&EINULON A 31 "Department"means the Department of Health, Bureau of EMS 3,2 "'Emergency medical technician" or "EMT"' means a person who is certified by the Department to perform basic life support- 33 "Medical Director" means a physician who is employed or contracted by CONTRACTOR who provides medical supervision, including appropriate quality assurance but not including administrative and managerial function, for daily operations and training, 3.4 "Paramedic" means a person who is certified by the Department to perform basic and advanced life support. 3.5 "Physician" means a practitioner who is licensed under the provisions of Chapter 458 and Chapter 459, Florida Statutes. 36 "Operations Chief' means the highest-ranking Paramedic in charge of ELITE medical transport services. ARTICLE 4 LQNLU_1;_r�kLNT 4.1 In accordance with Section 401.265, Florida Statutes, and Rule 64J-2.004, Florida Administrative Code, the Medical Director shall possess and maintain through the term of this Agreement a Florida license to practice medicine. 4.2 The Medical Director may designate an alternate Medical Director, when needed, who shall be available in the absence of the Medical Director, The Alternate Medical Director will have an understanding of ALS and BLS medical transports and report tote Director of Operations, 00 4.3 The CONSULTANT shall Perform such of duties and responsibilities as now are imposed or may be imposed during the term of this Agreement by Florida law, including but not limited to the applicable provisions of Chapters 252 and 401, Florida Statutes, and Rule 64J- 1, Florida Administrative Code, as may be amended from time to firne. AKUQ-LE 5 MIMIMMNafflam 5.1 'The ELITE shall assist the CONSULTANT by placing at its disposal all available information pertinent to the services to be performed by the CONSULTANT,including access to all EMTfP and EXIT employment records and patient medical transport records. 5.2 ELITE will provide CONSU1,TANT appropriate administrative support including secretarial support services and other equipment as may be needed from time to time to provide oversight to EMr/P and Ehfrs, S3 ETITE will comply PAth FL Chapter 64J-1 in all aspects related the performance of medical transport operations. ARD_CLE 6 U,RM 6,1 This Agreement shall commence on November 1, 2020, and shall continue through October 31, 2021, unless terminated earlier under Article 7. ELITE shall have tile option to renew this Agreement for five additional one year terms subject tot same terms and conditions, by providing the CONSULTANT with written notice to renew no less than thirty (30) days prior to the expiration date. If this Agreement is renewed under this Article 6, the CONSULTANT shall be entitled to a fee increase of five percent (5%) annually for each subsequent year. ARUGUE-1 E�'�A �N 71 If through any cause, the CONSULTANT fails to fulfill its obligation under this Agreement ELITE shall have the right toterminate this Agreement upon providing written ninety (90)day notice tote CONSULTANT. 7.2 This Agreement may be terminated by ELITE without cause upon ninety (90) days written notice to the CONSULTANT If ELITE terminates without cause, the CONSULTANT shall be compensated for all services performed prior tote termination date, provided that all property belonging to ELITE is returned prior to release of final compensation to the CONSULTANT. 7.3 CONSULTANT may terminate the Agreement, with or without cause upon providing written ninety (90) day notice to FLITE, If CONSULTANT terminates without cause, ELITE shall compensate CONSULTANT for all services performed prior to temlination date. ® �NE 8.1 QMM ens, studies, transport report reviews, trrain* SULTANF, (excluding standing medical control manuals), in connection with this S TANT, and shall C no 11 t ian Xty 0 d be delivered to the M9 P99 ays,after termination of this Agreement 8.2 NQfMW-nZ ant Jm The CONSULTANT warrants the he/she has not employed or retained any company or person other than a bona fide employee or agent contractor working solely forte CONSULTANT to solicit or secure this Agreement and that it has not paid or agreed to pay any person, any, corporation, individual or firm, of than a bona fide employee working solely for the CONSUIZANT any fee, conl.missi(yn, ercu,julge t r P , gift, 0 other sideration contingent upon or resulting from the award or inaking of this Agreement, For the breach or violation of this provision, ELITE shall have the right to terminate the Agreement without liability at its discretion, and to deduct from the contract price, or otherwise recover,the full arnout of such fee, commission, percentage, gift or consideration. 83 Po ii-e-y-m—Nog-Discrimination, The CONSULTANT shall not discriminate against any e'nPloycc or applicant for employment for work under this Agreement because of race, color, religion, sex, age, marital status or national origin, physical or mental disability 8. n t r ct r, The CONSULTANT is an independent contractor under this Agreement. Services provided by the CONSULTANT sball be by employees/contractors of the CONSULTANT and subject to supervision by the CONSULTANT, and not as officers, employees, or agents of ELITE. Personnel policies, tax responsibilities, social security and health insurance, employee benefits, pure basing policies and other similar administrative procedures applicable to service rendered under this Agreement shall be those of the CONSULTIVM. 8.5 Aaaiz�ent-�Arnen&mentgs 8.5.1 The parties recognize that the service contemplated by the CONSULTANT are of a unique and personal nature and as such this Agreement shall not be assigned, transferred or otherwise encumbered by the CONSULTANT, without the prior written consent of ELITE 8.5.2 It is further agreed that no renewal, modification, amendment or alteration in the terms or conditions of the Agreement, shall be effective unless contained in a written document executed with the same formality as the Agreement. 5 C) C) C14 9.1 The ELITE shall maintain in force and effect for the term of this Agreement the insurance described below. 91 1 all ide professional and general flabill ef occulTence for the CONSULT ent. ELITE shal I be responsible for a mini um of three years from the ate of ter ination oft s Contract. ofessional and General Liability Insurance certificate will specify coverage for"BLS/ALS Medical oversight" 9.2 ELITE will provide certificate or proof of such insurance tote CONSULTA.NT on an annual basis. CONSULTANT will be provi'ded thirty (30) days notice of caacellation aM/or any restrictions placed on coverages of the professional and general liability insurance pfovided/p roc ured by ELITE during the term oft his Agreement ELITE will be responsible for the payment of any deductible and/or self-insured retentions in the event of a claim. 9.3 Representative of ELDI.E. It is recognized that questions in the day-to-day conduct of this Agreement will arise. ELITF designates the Chief of Operations, or designee,, as the person to whom all communications pertaining to the day-to-day conduct of this Agreement shall be addressed. 9.4 AA1U1 PT _RdQLAaee ant arse e . This document incorporates all negotiations, correspondence, conversations, agreements or understandings applicable to the matters contained in this Agreement and the parties agree that there are no commitments, agreements, or understandings concerning the subject matter of this Agreement that are not contained in this document. Accordingly, it is agreed that no deviation frorn the to shall be predicated upon any pri or representati ons or agreeni ents, whether or or wri tten, 9,5 otis.. Whenever either party desires to give notice to the other, it must be given by written notice, sent by overnight mail or certified United States mail, with return receipt requested, addressed to the party for whom it is intended, at the place last specified, and the place for giving of notice in compliance with the provisions of this paragraph. For the present, the parties designate the following as the respective places for giving of notice, to wit: For MIJUIL- Elite Medical Transport,LLC c/o Schraige Goldblatt 1200 N Federal Hghway, Ste. 200 Boca Raton, FL 33432 6 V- C) C14 PrOfessiOnal Emergency Services, Inc. C/o Dr Sandra Schwemmer P.O. Box 379 Tavernier, FL 33070 9 M9111-10-24-fi—sdict'on The Parties irrevocably submit to thejurisdiction of any Florida state or federal court in any action or proceeding arising out of or relating to Ilse Agreement, and unanimously agree that all claims in respect of such action or proceeding may be heard and determined in such court, Each party ftuther agrees that venue of any action to enforce this Agreement shall be in Monroe County, Florida. 9.7 that this Agreement shall be construed in ac r ith ov t e la s of the Late of Florida If either ELITE, or the CONS ement by court proceedings or otherwise, requirereva party shall be entitled to recover fro expenses including, but not limited to court costs, and reasonab le attorney's fees. 9•8 Hodbnagas,, Headings are for convenience of reference only and shall not be considered on any interpretation of this Agreement. 9.9 Exhibits Each Exhibit referred to in this Agreement forms an essential part of t1tis Agreement. The Exhibits, if not physically attached, should be treated as part of this Agreement, and are incorporated by reference, 9.10 Spyn4bdii- If any provisions of this Agreement or its application to any person or situation shall to any extent be held invalid or unenforceable, the remainder of this Agreement, and die application of such provision to persons or situations other that those as to which it shall have been invalid or unenforceable shall riot be affected, and shall continue in full force and effect, and be enforced to the fullest extent permitted by law. IN WITNESS WBEREOF, the pailies hereto have set their hands and seal the day and year first written above 7 C14 C) C14 PROFESSIONAL EMERGENCY SERVICES, INC A 4 BY: Namei"Sandra Schwemrner Title", President witnes'sr, ELITE MEDICAL TRANSPOWI',INC,, . ......................................... tl �an a�g" i ng...... ember, Schraige Gold Witness. .... .......... ...................... . . ..... M O DocuSian Envelope ID:DCFBF719-2037-475D4)09"D938COC4280 N As per the agreement between Elite Medical Transport Inc and Professional Emergency Services,Inc, both parties agree to renew the Medical Director Services agreement for an additional year in accordance with Article 6 of the agreement. The agreement will be extended from November 1",2022,to October 3111,2023. DWAAkNWd W. 5 -4LU a#F Elite Medica Transport Inc. Professional Emergency Services,Inc dq 0 DocuSign Envelope ID:DCI=BF719-2037-475D-9098-0D938COC4280 N As per the agreement between Elite Medical Transport Inc and Professional Emergency Services, Inc, both parties agree to renew the Medical Director Services agreement for an additional year in accordance with Article 5 of the agreement. The agreement will be extended from November 1",2021,to October 31't,2022. oocuslpmd br. Elite a ica ransport Inc. -41-� Professional Emergency Services,Inc W) 0 N wu AGREEMENT between THE MONROE COUNTY SHERIFF'S OFFICE and ELITE MEDICAL TRANSPORT INC for USE OF P25 RADIO SYSTEM THIS AGREEMENT,made and entered into on the day and year last signed below,by the Monroe County SheritTs Office,a subdivision of the State of Florida C MCSa),and Elite Medical Transport Inc.,a private corporation,collectively("the parties"). WITNESSETH: WHEREAS,MCSO has purchased and is operating a radio system that is used by several local government,and emergency services entities{"Slum Users%and WHEREAS,Elite Medical Transport Inc.provides emergency transport services within Monroe County,Florida; and WHEREAS,the parties have determined that allowing Elite Medical Transport Inc. access to MCSO's radio system will result in a public safety benefit of mteroperability,and NOW THEREFORE,in conjunction with the mutual covenants,promises and representations contained herein,the Parties agree as follows, SECTION 1: PURPOSE AND DEFINMONS 1.01 The purpose of this Agreement is to set forth the parameters under which MCSO will make access to its 800 MHz P25 radio system("Systein"}available to Elite Medical Transport Inc. 1.02 System: The 800 MHz P25 radio system funded,purchased,installed,maintained and owned by MCSO. The system includes fixed transmitting and receiving equipment,T-1 telephone lines for communicating between sites, system control and management equipment,dispatch consoles,a controller located at the prime site,and other related equipment 1.03 Shared User Ec1wpment: Also known as"agency radios",are Elite Medical Transport Inc.or Shared User-awned 800 MHz P25 handheld and mobile radios and control stations that have the ability to be programmed and used on MCSO's 800 MHz P25 radio system. 1.04 System Administrator. The person designated by MCSO to be responsible for administration of the System and serving as designated contact person pursuant to this Agreement. Page 1 of 8 W 0 N 1.05 Ehte,Med'p4,TrVsj,,�prt j&:t The person designated by Elite Medical T Inc. as designated contact personiursuatit.to this Agreement. SECTION 2: SYSTEM ADMINISTRATION AND USE PROCEDURES 2.01 MCSO shall administer shared use of the System. - 2.02 The System Administrator will develop policies,procedures and standard operating Elite t actions required by these policies and procedures for misuse 2.04 Maintenance costs as described in Section 7 will be reallocated SECTION October aft a new ShareA User gains access to the System.SHARED USER EQUIPMENT AND RESPONSIBILrnES i All Shared User1 station equipment programmed for use on the System, The equipment used shall be 900 MHz compliantsystems administrator. Elite Medical Transport Inc.is required to keep their equipment in proper condition.operating Elite MedicalInc. is it equipmentof their radio 3.02 Withint t designate a Representative who will serve as its single point of contact for matters Agreement.relating to this ® 3 Within(15)days of the execution of this Agreement, Elite Medical Transport Inc.must provide MCSO with a list of persons who are authorized to request programming changes existingto . Elite approvalprogram radios without of the System Administrator. 3.04 Written authorization from the System Administrator and Elite " Representative are required or the Monroe County SherifTs Office Emergency Communications Division to program talk groups into Shared User radios. Elite Medical Transporta may not request that other User"s talk groups be programmed into their radios " Elite3.05 "will be required to program the Common Countywide Talk Groups that residet or use by Shared Usersinteragency communications into its radios. calling discipline,applicable e I- C) N These talk groups shall be in addition to the mutual aid channels required by the Florida. Regional Plan. 3.06 Elite Medical Transport Inc.is solely responsible for the performance and the operation of Shared User equipment and any damages or liability resulting from the use thereof Should MCSO identify oning Shared User equipment,MCSO will request the Shared User Representative to discontinue use of the specific device until repairs are completed. If a device is causing interference to the system,MCSO may disable the equipment from the system. In the case of stolen or lost equipment,Elite Medical Transport Inc.will immediately notify MCSO Emergency Communications in writing or via e-mail authorizing MCSO to disable the equipment.Elite Medical Transport Inc.will provide the Radio ID number and the serial number of the radio. MCSO Emergency Communications will advise back via e-mail when the radio has been disabled. Disabled radios will be reactivated only upon written request from a Elite Medical Transport Inc. Representative. 3.07 As of this time,the System does not support the use of roaming,private call,or telephone interconnect. In the future MCSO may activate some or all of these features should the loading of the system allow. Elite Medical Transport Inc.may not program these features into their radios. if roaming,private call,or telephone interconmect are allowed on the System in the future,Elite Medical Transport Inc-may,at their own expense,reprogram Shared User radios. MCSO will provide an amendment to this Agreement defining the uses and required programming should these features become available on the System. 3.08 Elite Medical Transport Inc.is required to provide to MCSO an inventory of the radios on the MCSO system. Elite Medical Transport Inc. shall provide the following information to MCSO: 1. Radio manufacturer and model numbers 2. Radio serial numbers 3. Requested aliases to be programmed 4. List of any n quested radio programming changes S. Talk groups required 6. Common talk groups required 7. Other agency talk groups required MCSO will compile this information and transmit back to Elite Medical Transport Inc. a matrix of the approved talk groups,aliases,and radio ID numbers prior to radios being programmed into MCSO's 800 MHz P25 radio system. Elite Medical Transport Inc.will be responsible for adhering to the talk group and radio ID allocations set up by MCSO. 3.09 Nothing in this Agreement shall represent a commitment by MCSO or be construed as intent by MCSO to fiord any portion of Elite Medical Transport Inc.'s equipment. SECTION 4: MCSO RESPONSIBEUITES Page 3ofa 00 0 N 4.01 MCSC shall be respowible for operation of the System 4.02 MCSC shall be respomible for all permitting,licensing,and fees associated with the operation of the System. Page 4 of 8 0) 0 N SECTION 6:ONE-TIME SYSTEM ACCESS CHARGE 6.01 Each subscriber unit added to MCSO System will be charged$50.00 at the time the unit is programmed for system access. 6.02 Elite Medical Transport Inc. will pay a fee of$25.00 per subscriber unit for any subsequent reprogramming of radio talk groups. 6.04 In the event of any termination of this Agreement, access and reprogramming charges will not be reimbursed. SECTION 7: MAINTENANCE COSTS 7.01 MCSO relies upon the MCSO Emergency Communications Division to secure routine and preventative maintenance on the System. This maintenance includes trouble shooting and making all repairs on a 24PI/365 basis as well as perfom ing preventive maintenance on the entire System,including,but not limited to,radio equipment,control, management,and alarm systems, towers and equipment shelters,backup power generators,and air conditioners. 7.02 Elite Medical Transport Inc. will pay maintenance costs one year in advance. The rate for 2021-2022 is$336.02 per unit. The annual cost of maintenance will be reviewed each year. Future maintenance costs may be adjusted for the following fiscal year. If future maintenance costs are adjusted,MCSO will send written notice to Elite Medical Transport Inc.in April before the next fiscal year. Maintenance costs will be shared on a pro rata basis based on the number of radios Elite Medical Transport Inc. and Shared Users are authorized to use on the System as of April I of each year. SECTIONS: BILLING SCHEDULE 8.01 Access and reprogramming charges are due in full,regardless of the time of the year that the additional unit is added to the System or reprogrammed. These fees will not be pro- rated from the time of programming. 8.02 System Users will pay maintenance charges as described in Section 7. Maintenance charges are due each October 1,one year in advance. Page 5 of 9 0 N 8.03 Upon receipt of any invoice,Elite Medical Transport Inc will immediately review it and report any discrepancies to MCSO within 10 days of receipt. Payment will be due to MCSO within 30 days of receipt of the invoice. Payments will be sent to. Radio System Administrator Monroe County Sheriffs Office 5525 College Road Key West,Florida 33040 Attn: 800 MHz P25 Interload Agreement SECTION 9: ANNUAL BUDGET INFORMATION TO BE PROVIDED 9.01 MCSO may review and update the fees and charges as identified in Sections 6,7 and 8 before April 1't of each year for the following fiscal year beginning October 11. These revised fees and charges will be applicable for the upcoming fiscal year and will automatically become a part of this Agreement on October 1 I of the applicable year. SECTION 14: INDEMNIFICATION AND LIABILITY 10.01 MCSO makes no representations about the design or capabilities of the MCSO System. Elite Medical Transport Inc.has decided to enter into this Agreement and use MCSO's system based on its review of the system design,system coverage,manufacturing and installation details contained in MCSO's contract with Motorola and subsequent field measurements and testing data that may exist. MCSO makes no guarantee as to the continual,uninterrupted use of the radio communication system,or its fitness for the communication needs of Elite Medical Transport Inc. 10.02 Elite Medical Transport Inc. agrees to hold harmless,indemnify and defend the Monroe County Sheriff's Office, Sheriff Richard A. Ramsay, and his predecessors and successors in offm and each and every one of his or their deputies,employees,and attorneys from any and all loss,damage.claim or judgment arising out of this agreement or Elite Medical Transport Inc.'s use of the System. 10.03 The terms and conditions of this Agreement incorporate all the rights,responsibilities, and obligations of the parties to each other. Page 6 of B N SECTION 11: OWNERSHIP OF ASSETS Shared User Equipment will remain assets of the Elite Medical Transport Inc. or Shared Users at all times. Any asset now owned by MCSO will remain MCSO's despite the Elite Medical Transport Inc. or Shared User's financial contribution to their maintenance, renewal,and replaceament. Any asset later incorporated into the System,will be owned by MCSO,regardless of cost reimbursement by Elite Medical Transport Inc. or Shared Users. SECTION 12: TERM OF AGREEMENT The initial term of this Agreement beghas March 19 2022 and ends September 30,2025. SECTION 13: TERMINATION 13.01 Either party can terminate this Agreement with or without cause upon(10)days written notice. SECTION 14:APPLICABLE LAW The laws of the State of Florida govern this Agreement. SECTION 15: FILING A copy of this Agreement may be filed with the Clerk of the Circuit Court in and for Monroe County. SECTION 16: ENTIRE AGREEMENT This Agreement and Exhibits attached hereto and forming a part thereof as if fully set foxth herein, constitute all agreements,conditions and understandings between MCSO and Elite Medical Transport Inc.concerning the System. All representations, either oral or written, shall be deemed to be merged into this Agreement,except as herein otherwise provided,no subsequent alternation,waiver,change or addition to this Agreement shall be binding upon MCSO or Elite Medical Transport Inc.unless reduced to writing and signed by both parties. Page 7 of 8 N T- N SECTION 17:THIS AGREEMENT SUPERSEDES ALL PREVIOUS AGREEMENTS Any prior agreements,whether oral or written,between Elite Medical Transport Inc. wing the subject matter of this Agnement are hereby terminated effective immediately upon full execution of this Agreement. IN WITNESS WHEREOF,the parties have caused this Agreement to be executed: MONROE :" AUNT.'SHERIFF'S OFFICE .. ro ... .. AP f l DVIM FORM: By: ... Title: Sh/ J.MOCULLAH OE[VRAL C Date. t m� 1W DATE: ...,,, Elite clr t Title. i �..a, 1 Page 8 of 8 Ell* te Medl* cal Transport NMI �I to A 2021 ALS BLS MEDICAL PROTOCOLS ® Schwemmer, 213 May 1, 2021 1 approve the most recent version of the Florida Regional Common EMS Protocols for use by Elite Medical Transport personnel for interfacility transports. These protocols may be amended from time to time as needed. Sandra Schwemmer, D.O. Medical Director, Elite Medical Transport 214 Elite Medical Transport MEDICAL PROTOCOL Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS AIRWAY MANAGEMENT J RESPIRATORY EMERGENCIES SECTION Airway Rescue for the Endangered Airway Revised 1®1 Basic and Advanced Airway Management 1®2 Respiratory Distress (Asthma, COPD, CH ) 1®3 ADULT CARDIAC EMERGENCIES SECTION 2 Asystole 2®1 Eradycardia 2®2 Cardiogenic Shock 2®3 Chest Pain /Acute Coronary Syndromes 2®4 STEMI /ACS Checklist (MCR ® 075) 2®4 Induced Hypothermia / ROSC 2®5 PEA (Pulseless Electrical Activity) 2®6 Post Arrest 2®7 Pulseless Arrest (V®Fib, V®Tach) 2®6 PVC's 2®9 Tachycardia ® Acute with Pulses 2-10 ENVIRONMENTAL EMERGENCIES SECTION Anaphylaxis /Allergic Reactions 3®1 Cyanide Poisoning / Smoke Inhalation 3®2 Diving Sickness 3®3 Electrocution / Lightning 3®4 Envenomation / Bites/ Stings 3®5 Hyperthermia 3®6 Hypothermia 3®7 Marine Envnomtion's 3®6 Overdose/ Poisoning 3®9 Pepper Spray Exposure 3-10 MEDICAL EMERGENCIES SECTION 4 Abdominal Pain /Acute Abdomen 4®1 Altered Mental Status / Unconscious States/ ETOH 4®2 GI Bleed 4®3 Psychiatric/ Behavioral 4®4 Seizures 4®5 Stroke 4®6 Stroke Alert Checklist (MCR ®073) 4®6 215 Elite Medical Transport MEDICAL PROTOCOL Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS OBSTETRICAL/GYNECOLOGICAL EMERGENCIES SECTION 5 APGAR e Newborn Scoring 5-1 Childbirth ® Labor an 5®2 Childbirth ® Complications 5®2 Childbirth ® Illustrations 5®2 Postpartum Vaginal Bleed /Vaginal Bleed Unknown Origin 5®3 Pre®Eclampsia / Eclampsia 5®4 PEDIATRIC/ADOLESCENT EMERGENCIES SECTION 6 Acute Traumatic Pain ® Pediatric Addendum°i A6®1 Anaphylaxis /Allergic Reactions ® Pediatric 6®1 Asthma ® Pediatric 6®2 Bradycardia ® Pediatric 6®3 PEA (Pulseless Electrical Activity) ® Pediatric 6®4 Post Arrest ® Pediatric 6®5 Pulseless Arrest (V-Fib, V- Tach) ® Pediatric 6®6 Seizure ® Pediatric 6®7 Stridor ® Pediatric 6®6 Tachycardia ® Pediatric 6®9 Trauma Alert Criteria ® Pediatric 6-10 Trauma Alert Criteria Form (MC R ® 097) ® Pediatric 6-10 PEDIATRIC/ADOLECENT PROCEDURES SECTION 6P, Cricothyroidotomy ® Needle Pediatric 6P®1 PEDIATRIC/ADOLECENT REFERENCE SECTION +6R Glasgow ® Pediatric 6R®1 Glucose Values ® Pediatric 6R®2 Pain Scale FLACC 6R®3 TRAUMA EMERGENCIES SECTION 7 Amputations Revised 7®1 Burns 1st and 2nd Degree Revised 7®2 Burns 2nd and 3 d Degree /Chemical Burns Revised 7®3 C®Spine Range Of Motion 7®4 Glasgow® Adult 7®5 Head Injury/ Increased ICP 7®6 Shock ® Trauma ® Combativeness in Trauma 7®7 Trier Injury 7®6 Tension Pneumothorax/ Hemothorax 7®9 Trauma Alert Criteria 7-10 Trauma Alert Criteria Form (MC R ®096) 7-10 216 Elite Medical Transport MEDICAL PROTOCOL Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS PROCEDURES SECTION 8 Bougie ® Endotracheal Tube Introducer Addendum°i A6®1 Chest Needle Decompression 6®1 CP,4P Concepts 6®2 CP,4P Assembly with Nebulizer Revised 6®2 Cricothyroidotorny ® Surgical 6®3 DuoDote ,4uto Injector 6®4 Endotracheal Intubation (Oral) 6®5 External Jugular IV Access 6®6 EZ-10 Insertion 6®7 EZ-10 Landmarks 6®7 I®Gel Revised 6®6 Infectious Diseases (corning soon) 6®9 Luce Device 6®10 Nasal Atomizer Addendum°i A6®11 Nasotracheal Intubation 6®11 Nasogastric Tube (NC Tube) 6®12 Spinal Motion Restriction 6®13 Stroke/ Stemi ,fiction Sheet 6®14 Synchronized Cardioversion 6®15 Telemedicine PolyCom 6®16 Tourniquet ® C.A.T. (Combat Application Tourniquet) Addendum°i A6®17 Transcutaneous External Pacing 6®17 Ventilator Concepts (Page 1 of 3) 6®16 Ventilator Control Module (Page 2 of 3) 6®16 Ventilator Diagram (Page 3 of 3) 6®16 Video L 6®19 REFERENCE SECTION 9 12 Lead Reference Guide 9®1 Determination of Death / Obvious Death 9®2 Dopamine Drug Formulary 9®3 ETCO2 Waveform 9®4 Refusal of Care (Page 1 of 2) 9®5 Refusal of Care (Page 2 of 2) 9®5 Rule of Nine 9®6 Stroke Scale (Cincinnati, Mend, NISS) 9®7 Termination of Efforts 9®6 Trauma Transport Protocols 9®9 217 Elite Medical Transport MEDICAL PROTOCOL Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS DRUG FORMULARY SECTION 10 Adenosine Triphosphate (Adenocard) 10®1 Albuterol (Proventil, Ventolin) 10®2 Arniodarone (Nexterone) 10®3 Aspirin 10®4 Atropine Sulfate as Cardiac Agent 10®5 Atropine Sulfate as Antidote for Poisonings 10®6 Calcium Chloride 10% 10®7 Cyanokit 10®6 Dextrose 50% and 25% (d®glucose) 10®9 Diazepam (Valium) 10-10 Diphenhydramine HCL (Eenadryl) 10-11 Dopamine Hydrochloride (Intropin) 10-12 Duo-Dote 10-13 Epinephrine 1:1000 10-14 Epinephrine 1: 10,000 10-15 entanyl ® Addendum°i A10®1 E urosemide (Lasix) 10-16 Ketamine (Ketalar) Addendum°i A10-17 Magnesium Sulfate 50% 10-17 Methylprednisone (Sulu®Medral, A®Methapred) 10-16 Midazolam (Versed) 10-19 Morphine Sulfate (MS) 10-20 Naloxone Hydrochloride (Narcan) 10-21 Nitroglycerin (Nitrostat, Nitrolingual Spray) 10-22 Odansetron (Zofran) Addendum°i A10-22 Oral Glucose (Insta Glucose) 10-23 Sodium Bicarbonate 6.4% and 4.2% 10-24 218 N 1 mas x E :2 _T o MVal r iiiiiiiiiiiiiiiiiiiiiiiiiiiiii 0 N y > - /iiiiiiiiiiiiii < Q L w N ca D ._ ° r Q y Cl) p 3 ZZ r 3 X V C N cw ♦+ 0 O o2S U o � ■ 0 O 0 n +„ LU ►' O U --r* �. v�io Q Qm c �n° (D \ C CL z o Q EL- U K ) L a U) � � _ � Cl) LL R a� W m Eof .� ilk a) a) o o '^ ��re�f E 2 a) � aEimQ > aUzoc oEo � La� .�cc � o E � O � � � � o tea, ugh ° . ,i, E m o m c m o E o o 3 o 0 o m .l w c a) R � > U mUQLL CO V UUCoCoCo Z (nHU � LL � q.i ':w p V V w f4 0 m- \ CN ~� \ § c E E �_ �> \ƒ §/ 2= 2} �\ O Q O O CL @ � Q � ± @ \ � ƒ 7 Q � � Q � � @ � � c £ � W ] -] 7 CN $ 2 = b CN t ) } \ \ i \ o k � � k � x @ w z � k $ gj \ e / x � \ $ < ƒ L ° _ # > E z@ ƒ u Q 's � � � k / 4a 70 \ ± ± o % ƒ / ■ 2 \ ±\ = m � � \ �0 0 \ 4a ry I 2 ( 2 k ■ ■ 0 / o / J o ' k \ / E $ \ \ » LU � 0 > § � 206 / ƒ \ L) E 2 § 2 6 x ® 0 n @ o a k/ S z z u \ ƒ £ _ 00 z� § \ 0� c s / . $ v \ ƒ LU ¢ I QE $ � Lu � � £ i e ƒ d 0 § x ƒ \ co z I = / ry \\ m 0 £ \ \ o u \ \ \ \ / \ /_ a � _ _ / \ @ _ / > E k / § cr k\ 3 /2 § in / / e ■ � o E ; _ < O 6 ± / 2 / k / ƒ O c N N N -►' IMMMM IMMMM IMMMM TiMMMI VIWI U C I 1 sss♦; N Q 7 U L 0 Q L w L j G W C � LL W �.C L R GI w R c U L LU Q c+� N a I ; M,lr. .. � t r ...... ,,,,, .............. iiiiiiiiI ,1 �� ,,, O .:: �� ii�. 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OR Elevations in 2 or more Leads To Other Med.? 3)Anterior Wall: I AVL V1-V6 4) Inferior Wall: II III AVF FIELD TREATMENT IF V411 POSITIVE L -ASA--3-24mg IT OLD NITRATES 02via NR13 Obtain 2 nd IV&give fluids if hypotensive Nitroglycerin: x1 x2 x3 Presence of any of above Morphine: x1 x2 ""STEMI Alert" criteria A V P U Total fluids given: -ml Launch Trauma Star & compWte this form TPA EXCLUSION CRITERIA Y, OPQRST Bleeding problem? Onset Of Events: Previous stroke? --------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- Provocation: Acute hypertension? Quality: --------------------------------------------------------------------------------- Streptokinase?-------------------------------------- Region: Recent surgery(within 6 months)? Radiating: Coumadin/Warfarin? 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LASTTIME PT SEEN WITHOUT SYMPTOMS A V P U GLUCOSE (<E FIRS OR"WAKE UP STROKE") 7-1 CI CI lV TI Strobe Scale MEND Exam SPEECH (Check box Indicating response) Only Check Box IF ABNORMAL ✓' "You can't teach an old dog new tricks" SPEECH Repeats Sentence Correctly "You can't teach an old dog new tricks" Aphasic(Wrong or Inappropriate Words) Question Patient for: Age, Month Dysarthria(Slurred or Unable to Speak) Commands:Close Eyes,Open Eyes CRANIAL NERVES CRANIAL NERVES L R Facial Droop:Show Teeth or Smile Facial Droop:Shove Teeth or Smile Normal=No Facial Droop Visual Fields: Four Quadrants Abnormal=Let Sided Droop Horizontal Gaze:Side To Side Abnormal=Right Sided Droop LIMBS(Motor) L R LIMBS(Motor) MOTOR: Arm Drift:Close eyes,Hold both arms out Arm Drift:Close eyes,Hold both arras out Leg Drift: Opens eyes and lifts each leg separately Normal=No drift SENSORY(Ask patient to close eyes) Arms:Check sensation by-touch then pinch Abnormal+Let drift or unable to move Legs:Check sensation by touch then pinch Abnormal+Right drift or unable to move COORDINATION: 17 Arms:Finger to nose *Any fails&Glucose a60 pact Trauma Star on ALERT then complete MEND Exam¢* --- Legs: Heel to Shin *Anyfails LAUNCH Trauma Star&PAGE NEUROLOGIST&Follow IV NS KVO Gauge Site Telemediclne procedure* Oz LPM Y V'''+ IH S: ELEVATE HEAD 30° Y N ACCEPTING NEUROLOGIST: ETA JMH: JMH Contacted Y N LEAD PARAMEDIC SIGNATURE: COMMENTS: PINK TO RESCUE WHITE TO FLIGHT CREW YELLOW TO HOSPITAL MCFR-073(08/2016) STROKE CHECKLIST Revise Sandra comer,D.O. 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L C _ 0 0 p t/) OCD J 'Z3 0 W c U 0 CL O p � cu 1= � y pp p � Z � =p cu CL hQ v a) J � � � � y U—, O Q O w -c a) ca c) ,c cu 0o _ ooW L WO _ = J CD LO cuL cQcu cn cu v cu cuL cn L if O 0 _ O � O = � W a) a) � Ocyv Q 16 4— O_ s= CU CDt� h O W O 4— J s= C N II s� ca "a) c a)CUQ a) O a) •2 cu CU� E , � o ° � Q �_ � p 0 c � E- 0 CU 0 c .0 C� � (n Q o •a) � o � � = o a) U_ a) s �_ L 1— E � O "a 70 Z = a) 70 > ca m V 40.4 U a) CU a) o O a) 'cu cu L _ E Z = �' cQ • • W a) N CD • • • a OC I . 6-10 Elite Medical Transport CD MEDICAL PROTOCOLS MCFR PEDIATRIC TRAUMA CRITERIA FORM Date.--Cre _/ haunch Trauma Star and relay, Pediatric Pt Name DOB Age O A#-, mol: Time of Injury PJU MM Rescue Unit ._ Weight: Heli pot: ANY ONE =TRAUMA ALERT Lon13L choose one) AIRWAY Active Airway Assistance' OR Respiratory Rate<20(Infant<lyr) ❑ Respiratory Rate< 10 Child 1 r-15 r CIRCULATION Faint or NON-Palpable Carotid or Femoral Pulse OR Systolic BP< 50 ❑ DISABILITYAltered Mental StatusZ OR e PARALYSIS a Suspicion of Spinal Cord injury ❑ Loss of Sensation e 2nd or 3rd Degree Burns? 10%TBSA e Amputation at or above the Wrist or Ankle SOFT TISSUE e Any Penetrating injury to the Head, Neck, or Torso3 ❑ ® GSW or Penetrating injury to Extremities at or above Knee or Elbow e Chest Wall instability or Deformity(Flail Chest) e Major Soft Tissue Disruption @ Major Avulsion of Skin ID Major De-Gloving LONG BONE Open Long Bone OR Multiple Dislocations or Fracture Sites ❑ FXISKELETAL e Severe Facial injury/Fractures w/potential Airway Compromise e Electrocution or Lightning injury w/LOC or Visible Signs of injury e Blunt ABD or Chest trauma in patient w/ HX of Paralysis MECHANISM (Paraplegia/Quadriplegia) ❑ OF INJURY e Ejection from Automobile, Motorcycle,Golf Cart or Horse e Blunt Head, Chest or ABD Trauma in Patients on Anticoagulants e Auto vs Pedestrian/Bicyclist,Thrown, Run Over or wl impact>20 MPH ANY MQ=DRAMA ALERT (only choose twol SIZE Weight<20 kg ❑ CIRCULATION Radial or Pedal Pulse not Palpable OR Systolic BP<90 DISABILITY Amnesia or Loss of Consciousness ❑ SOFT TISSUE GSW or Penetrating injury below the Elbow or Knee ❑ LONG BONE Single Long Bone Fracture Site or Dislocation ❑ FX/SKELETAL e Death in Same Passenger Compartment MECHANISM a Intrusion, including Roof>12 inches on Occupant Site or> 18 inches of Any ❑ OF INJURY Site into Passenger Compartment. e Fall> 10 Feet OR 2-3 Times the height of the Child lfalzcwe criteria are not asset&patient condition warrants a trauma alert.Select paramedic judgment,include brief description. Paramedic Judgment: ❑ 1.Airway assistance includes manual jaw thrust continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2.Altered mental states include drowsiness,lethargy,inability to follow commands,unresponsiveness to voice&total unresponsiveness 3.Excluding superficial wounds 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. COMMENTS; "CALL NICKLAUS CHILDRENS /PT REPORT 05-6 ® ,560*"ATTACH CODE SUMMARY*** PINK-RESCUE WHITE-FLIGHT CREW YELLOW-TRAUMA CENTER V CFRF-097(09/2016) Dr. Sandra Schwemmer,DO Revised?-20-17 TRAUMA CRITERIA FORM - II II IIG III 1711FZ1C If�.Pvised 274 LO ti N r O c 4) U 0 Cl) 70 N > O C� o ca CL mm W N s. 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Paramedic Judgment: El 1.Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2.Excluding superficial wounds in which the depth of wound can be determined. 3.Long bone fracture sites are defined as the(I)shaft of the humerus,(2)radius and ulna,(3)femur,(4)tibia and fibula COMMENTS: ***CALL RYDER W/PT REPORT 305-585-1148*"ATTACH CODE SUMMARY*** PINK-RESCUE WHITE- FLIGHT CREW YELLOW-TRAUMA CENTER MCFRF—096(09/2016) Dr. Sandra Schwernmer, D.O. Revised 7-20-17 TRAUMA CRITERIA FORM IT191 N a) N ro > ate+ C r t (6 _ Q A � O O +� E _ vOilf� � N U C E N O llij;; % +� C O N O a� cu fa 4a O U � O / U m W N p : /// +' — � a� U) ! > N X wLn O w 1i11111r E O U 0 ,apt � (6 ++ p Q m in N O C w +' (B v p hCA C _ O C a) O 0 ate.' D 7 U O 0 _ // /l fu O m in N iiNO, > Q ,n %i %% % U_ N ? V_ Q pan'. 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J a) a) to O C a) m > t" 0 .Q U Q _ +=' (� 0 0 a) cn 0 0 cn 0010 O a) E co O O o O O o 'cn cam a) _ Q.0 > cu OU Q co c4 "= d o O cn .� i cu LO � cn 4- ca6) Q . L . +3' - a) +La O a U Z p 0 M E _v z E O r > > m m Z 5 .o cn= � Z - O o vO _ na = v E co No a) a) Q a) r U — Z a n Q o 0 — co o N cn o N Co o CL o 1:I NI MI .4I A (6I til C6I Cn ELITE MEDICAL TRANSPORT TRAUMA AND TREATMENT PROTOCOLS I. DISPATCH PROCEDURES 1. Calls are received via an enhanced dispatch syste located in Miami, which dispatches the appropriate Ambulance response units. 2. The Dispatcher obtains information from the caller regarding: A. Name of person calling B. Nature of incident C. Type of injury D. Call back number E. Number of patients F. Location of incident G. Extent and severity of reported injury 3. The Dispatcher selects the appropriate Ambulance response vehicle(s) closest to the location of the incident. The Dispatcher immediately transmits the appropriate alert tone, followed by the command "Rescue (assigned unit), be enroute to..." after which the nature, location, and known details of the call are transmitted. This information is transmitted via 800 MHz radios carried by all Ambulance crew members, and all Ambulance Supervisory personnel. The Dispatcher may also elect to activate a BLS Ambulance vehicle for first response support. 4. With potential trauma patients or injuries that may warrant air transportation, the Dispatcher will tone the MonroeCounty "TRAUMA STAR" helicopter to place on alert and/or monitor the scene in case of TRAUMA ALERT patients. A request for "TRAUMA STAR" to respond may be made by a Ambulance EMS Commander or on scene EMT or Paramedic on duty. 5. The Dispatcher is in direct radio contact with the responding unit(s) and monitors the status of the crew (i.e., time enroute, arrival time on scene, time enroute to hospital, etc.). 6. On scene personnel may communicate requests for additional intra- Company resource support (e.g. manpower, equipment, additional vehicles, supervisory personnel), via the Dispatch Center. Requests for inter-Company support (e.g., law enforcement, utility company, fire suppression equipment and personnel, Marine Patrol, Coast Guard), may also be communicated via the Dispatch Center. 9_9 Dr. Sandra Schwemmer, D.O. Page 1 of 15 327 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS II. PRE-HOSPITAL PROCEDURES 1. Upon arrival at the incident, Ambulance personnel shall conduct a "scene size- up", to include safe entry, severity and number of patients, the need for extrication, and the need for additional resources. Multiple patients shall be immediately triaged. The condition of each trauma patient shall be assessed using the Florida Trauma Scorecard methodology criteria, as outlined in Chapter 64J-2.004 and 64J-2.005 F.A.C., to determine whether the patient should be a TRAUMA ALERT. This information shall be used to determine the patient's transport destination. In assessing the condition of each patient, the paramedic shall evaluate the patient's status for each of the following components: airway, circulation, disability ( motor response/Glasgow Coma Scale), soft tissue injury; Iongbone fracture/skeletal, patient's age, and mechanism of injury. 2 Upon determination that the patient meets Trauma Alert Criteria, the Paramedic in Charge will initiate communication with a State Approved Trauma Center (SATC) or State Approved Pediatric Trauma Center (SAPTC) or the local receiving facility, if circumstances do not allow for helicopter access to a SATC or SAPTC. Communications from field Ambulance personnel to the receiving facility will include the phrase "TRAUMA ALERT", and will include the following information: • Specific Trauma Alert Criteria • Mechanism of injury • Glasgow Coma Score (itemized) • ETA to receiving facility 3. A Elite Medical Transport Adult or Pediatric Trauma Street Form will be completed for every trauma alert patient and a copy shall accompany each patient to the receiving facility. 4. A Elite Medical Transport Form MCFRF-011 "Street Form Worksheet" shall be completed for each patient and a copy shall accompany the patient to the receiving facility. 5 A Elite Medical Transport electronic Patient Care Report will be completed as defined in section 64J — 1.001(18) F.A.C. by the Rescue personnel that were on- scene. A copy of the complete patient care report will be forwarded to the receiving facility when completed. The MCFR electronic Patient Care Report will also be completed for all trauma victims found deceased on scene. 9_9 Dr. Sandra Schwemmer, D.O. Page 2 of 15 328 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS III. PRE-HOSPITAL FLIGHT PROCEDURES Two (2) sets of flight criteria must be considered. The first is directed toward the safety of the helicopter pilot and crew, the ground personnel,the patient, and bystanders. The second set establishes operational guidelines for when the helicopter should be requested for TRAUMA ALERT patients. 1. SAFETY CRITERIA: (Conditions when the helicopterwill not be used) A. Severe weather (as determined by the pilot orS.O.) B. Landing area obstructions: (as determined by the pilot or LZ Command) • Power lines too close to landing area • Trees, poles, signs, or other obstacles in immediate landing area • Large gathering of civilians in the area C. An expectation that the area may not remain safe 2. OPERATIONAL CRITERIA: (Helicopter will be used) A. If the patient is considered a TRAUMA ALERT patient as outlined in this protocol. B. If the patient sustained a traumatic injury, but does not meet Trauma Alert criteria and any of the following conditions exist: A Blockage of the main road, making ground access to the nearest receiving Hospital impossible. B. Failure of the drawbridges, making ground access to the nearest Hospital impossible. C. Extrication time greater than fifteen (15)minutes. D. If the helicopter is needed to gain access to the patient or needed to transport the patient out of an inaccessible area. E If ground transportation is not available and is not expected to be available within a reasonable time (10 minutes, depending on injuries). F. MCI (mass casualty incident), as determined by on scene MCFR Paramedic/or on duty MCFR EMS Commander. C. The Paramedic on scene will notify the EMS Commander when TRAUMA STAR is requested under the circumstances listed in B above. 9_9 Dr. Sandra Schwemmer, D.O. Page 3 of 15 329 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS IV. ADULT and PEDIATRIC TRAUMA ALERT CRITERIA F.A.C. 64J-2.004 ADULT TRAUMA SCORECARD METHODOLOGY 1. Each EMS provider shall ensure that upon arrival at the location of an incident, an EMT or paramedic shall: A. Assess the condition of each adult trauma patient using the adult trauma scorecard methodology, as provided in this section to determine whether the patient should be a "Trauma Alert". B. In assessing the condition of each adult trauma patient, the EMT or paramedic shall evaluate the patient's status for each of the following components: airway, circulation, disability (includes Glasgow Coma Scale), soft tissue (cutaneous) injury, Iongbone fracture/skeletal, patient's age, and mechanism of injury. The patient's age and mechanism of injury shall be used as assessment factors when used in conjunction with assessment criteria included in (3) of this section. 2. The EMT or paramedic shall assess all adult trauma patients using the following criteria (RED criteria) in the order presented and if any one of the following conditions is identified, the patient shall be considered a Trauma Alert patient: A. Airway: The patient requires active airway assistance beyond the administration of oxygen or has a respiratory rate of less than 10 or greater than 29 breaths per minute. B. Circulation: The patient lacks a radial pulse or has a blood pressure of less than 90 mmHg or patients age 65 or older with a blood pressure of less than 110 mmHg. C. Disability: The patient exhibits a GCS score of 13 or less or exhibits the presence of paralysis or there is the suspicion of a spinal cord injury or the loss of sensation. D. Soft Tissue: Patients exhibiting any of the following are considered Trauma Alerts: 1. 2nd or 3rd degree burns to 15 percent or more of the total body surface area; 2. Amputation at or above the wrist or ankle; 3. Any penetrating injury to the head, neck, or torso; 4. Penetrating injury at or above the elbow or knee; 5. Chest wall instability or deformity (suspected flail chest); 6. Crushed, degloved, mangled or pulseless extremity. Superficial wounds where the depth of the wound can be determined are excluded. E. Longbone Fracture/ Skeletal: The patient reveals signs or symptoms of two or more Iongbone fracture sites. Long bone fracture sites are defined as the (1) 9_9 Dr. Sandra Schwemmer, D.O. Page 4 of 15 330 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS shaft of the humerus, (2) radius and ulna, (3) shaft of the femur, (4) tibia and fibula. F. Mechanism of Injury: Patients exhibiting any of the following are considered Trauma Alerts: 1. Head trauma in patients on Coumadin (warfarin); 2. Severe facial injury/fractures with potential airway compromise; 3. Electrocution or lightning injury with loss of consciousness or visible signs of injury; 4. Blunt abdominal trauma or chest trauma in patient with history of paralysis (paraplegia or quadriplegia); 5. Pregnant patients > 20 weeks with abdominal pain after blunt trauma. 3. Should the patient not be identified as a Trauma Alert using the RED criteria listed in (2) of this section, the trauma patient shall be further assessed using the BLUE criteria listed in this section and shall be considered a Trauma Alert patient when a condition is identified from any two of the following blue components included in this section: A. Circulation: The patient has renal failure and is on dialysis; B. Disability: The patient has head injury with loss of consciousness, amnesia or new onset of altered mental status; C. Soft Tissue: The patient has soft tissue loss from either a major de-gloving injury involving muscle and/or nerve, or a major deep flap avulsion greater than 5 inches, or a penetrating injury to the extremities distal to the elbow or knee; D. Long Bone Fracture/Skeletal: The patient has an obvious or suspected single long bone fracture due to MVC, or any patient with an obvious or suspected single long bone fracture on Coumadin or other anticoagulants; E. Age: The patient is 55 years of age or older; special consideration should be given to patients > 65 years of age with minimal signs/symptoms following a traumatic injury; F. Mechanism of Injury: Patients exhibiting any of the following criteria: 1. The patient has been ejected or thrown from an automobile, motorcycle or golf cart; 2. The patient has been ejected from a horse (with or without loss of consciousness) with suspected anatomical injury; 3. Patients with blunt head, chest, or abdominal trauma in patients on Coumadin or other high risk Anticoagulants (see list of Anticoagulants with High Risk of Bleeding); 4. There is a traumatic death in the same passenger compartment of the motor vehicle; 5. There is intrusion of more than 12 inches in the roof or occupant side of the motor vehicle or more than 18 inches intrusion into any site of passenger compartment; 6. Vehicle telemetry data consistent with high risk of injury(vehicle 9_9 Dr. Sandra Schwemmer, D.O. Page 5 of 15 331 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS telemetry data, when available, collected at the time of the crash and relayed to dispatch to assist in predicting serious injury); 7. Falls from 10 feet or more; 8. Pedestrians or bicyclists that are struck, thrown, or run over by motorized vehicles traveling at speeds greater than or equal 20 miles per hour; 9. Motorcycle, golf cart or ATV crash at speeds greater than 20 miles per hour; 10. Patients with renal failure on dialysis. 4. In the event that none of the conditions are identified using the criteria in (2) or (3) of this section in the assessment of the adult trauma patient, the EMT or paramedic can call a Trauma Alert if, in his or her judgment, the patient's condition warrants such action. Where EMT or paramedic judgment is used as the basis for calling a Trauma Alert, it shall be documented as required in accordance with the requirements of Rule 64J-1.014, F.A.C. The results of the patient assessment shall be recorded and reported in accordance with the requirements of Rule 64-J-1.014, F.A.C. 9_9 Dr. Sandra Schwemmer, D.O. Page 6 of 15 332 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS Elite Medical Transport Adult Trauma Scorecard Methodology The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological characteristics of a person sixteen (16)years of age or older for the presence of at least one of the following three(3)criteria to determine whether to transport as a Trauma Alert: 1. Meets color-coded triage system (see below) 2. Meets local criteria(specify): 3. Patient does not meet the trauma criteria listed, but was transported to a trauma center due to EMT or paramedic judgment(reason for transport must be justified in run report). I'u''IIILII') BLUE All AC I IVI All::WVAY, ;;I,��1ANGI;i'.I[,, dl 'rl'IIdAI01::1Y11A11,' c1()oi >V'JISI°'Vl CIIIRCUL.AI�IIQ"' J: '� PATIENTS WTH RENAL FAILURE ON DIALYSIS �, NIN Cn � 4 ..) r,�a [,i S�� I irurr c, :11()IN -'A 1 II IN 1 OVI 14 65 YI'AI43 C:DIISAIf I L III FY G C 3 ,�13 o1 :':'I dI ;I INCI!I 01: I AI'':::1AI Y;I 3,o1 ;I I;I:'ICIOIN 01::::' HEAD INJURY WTH LOSS OF CONSCIOUSNESS, N,I'IINAI C01 el::)IN fl IIeY[n I 033 01: ;I IN,�i��+A 1 ION AMNESIA or NEW ALTERED MENTAL STATUS �OIF F FIISS UIE 21"01:d 3" )Ii,lCl dl dlN i 10 15%of 1 I53A SOFT TISSUE LOSS AVIII'111A11ON Al 0I'::1AI3(MVI 1"'h"II Wl::I1,,"1"'[n AININI Iii'. PENETRATING INJURY TO THE EXTREMITIES DISTAL TO ANY I'I NI 1 I'':::1A'1"'ING IN fl II dY 10 III AI) INI!!I CI of "1"'(, 14,t';ya THE ELBOW or KNEE CSWoi ' Nli;llldA'1"'INGINJIII':1Y"101II1 IiV11dl'.f//II"1"'YA"1 0I''4 AI s(]VI '1"'III ININI I' 014 I I ((rW CI I1i,l3 1 WAI..I IIN31A1&I1.I 1Y[n I)I'i,Il 0I:1f//II"1"'Y(I I AIL.CI II 3 1") CI':dl,.,l;I II ::),VIIAINCI ::),I)I CI.OVl I)[n I:'1,.,11.;I I I ;,,, A"1"'I''d 1::::::I//l I"I C..OI G,IBONIF. I::1AC 1 Il dl.01: 1 VV7 of VIIOI dl.1 0INC I StONI::::::3 SINGLE LONG BONE FX SITE DUE TO MVC' F I,.FU II II IKLEL..IE F/"tlLd SINGLE LONG BONE FX IN PT ON HIGH RISK ANTICOAGULANTS' AG,LF., 55 YEARS OR OLDER MECHANISM NI',;VI 141 I ACIAI IIN!I II''DY/I I4AC"1"'I I141 Y VV1'11 I I N I"'IAI.., EJECTON FROM AUTOMOBILE,MOTORCYCLE,GOLF OF III AII''4WAY CL f//II'14 f//IINI'',;;; CART or HORSE C I::OCI„I I ]IN 01::4 II IGI'°I"1"'INIINC IN fl II4Y W11 111..033 01::: BLUNT HEAD,CHEST,OR ABDOMINAL TRAUMA IN CONNCI fl I;;^INI NN 01''4 VINIISI VIGNG 01::: IN fl II4Y PATIENTS ON HIGH RISKANTICOAGULANTS' I L.L.11N 1 AI S1D(„VIIIINAI.of Cl II ;1""'1"'11AI,.JVIA IIN I'A 1 II!l1N"1 W1 I I I DEATH IN SAME PASSENGER COMPARTMENT 11131"01dY 0I''::'I'AIdAI Y,'�IS(I' :ZAl'I I.CIA of C',LL.IAI)I4I1'I I::GIA) INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE;>18 INCHES ANY SITE INTO THE PASSENGER dlii'.NINAINCY >VC',hNl VVY11 AI'SI::)�7f//ANAL.I'AIINAINI::)ISI UN"1"' COMPARTMENT 1"'I'"4AI,.IVIA FALL 10 FT or MORE AUTO VS.PEDESTRIAN/BICYCIST THROWN,RUN OVER or WTH IMPACT GREATER THAN 20 MPH MOTORCYCYLE,GOLF CART OR ATV CRASH>20rnph VEHICLE TELEMETRY DATA CONSISTENT WTH HIGH RISK OF INJURY,IF AVAILABLE' •;I i;:k=any one(1)-transport as a trauma alert; BLUE =any two(2)-transport as a trauma alert. 1. Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Crushed, Major de-gloving injures,mangled extremity or deep flap avulsion(>5 in.) 3. Excluding superficial wounds 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. Vehicle Telemetry Data(if/when available)may be relayed to dispatch and can assist in predicting potential serious injuries from the data collected at the time of the crash. 9_9 Dr. Sandra Schwemmer, D.O. Page 7 of 15 333 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS 6 See attached list of Anticoagulants with High Risk of Bleeding 9 9 9 PEDIATRIC TRAUMA SCORECARD METHODOLOGY 1. Each EMS provider shall ensure that upon arrival at the location of an incident, the EMT or paramedic shall assess the pediatric trauma patient by evaluating the patient's status for each of the following components: Size, Airway, Circulation, Disability, Soft Tissue, Long Bone Fracture/Skeletal, and Mechanism of Injury. In assessing the pediatric patient, the criteria for each of the components in (2) and (3) of this section shall be used to determine the transport destination for pediatric trauma patients. 2. The EMT or paramedic shall assess all pediatric trauma patients using the following RED criteria and if any of the following conditions are identified, the patient shall be considered a pediatric Trauma Alert patient: A. Airway: If the patient requires active airway assistance including manual jaw thrust, continuous suctioning, or use of other adjuncts to assist ventilator efforts, has a respiratory rate of < 20 in an infant less than one year of age, or a respiratory rate of < 10 in children age 1-15 years old. B. Circulation: The patient has a faint or non-palpable carotid or femoral pulse or the patient has a systolic blood pressure of less than 50 mmHg. C. Disability: The patient exhibits an altered mental status that includes: drowsiness, lethargy, the inability to follow commands, unresponsiveness to voice, totally unresponsive, or is in a coma or there is the presence of paralysis; or the suspicion of a spinal cord injury; or loss of sensation. D. Soft Tissue: The patient has a major soft tissue disruption, or major skin flap avulsion (greater than 5 cm) or 2nd or 3rd degree burns to 10 percent or more of the total body surface area or amputation at or above the wrist or ankle, or a major de-gloving injury. E. If there is any penetrating injury or GSW to the head, neck or torso or any penetrating injury or GSW to the extremity at or above the elbow or knee (Superficial wounds where the depth of the wound can easily be determined are excluded from this criteria head and torso only), F. Long Bone Fracture/Skeletal: There is evidence of an open long bone fracture or there are multiple fracture sites or multiple dislocations. Long bone sites are defined as the (1) shaft of the humerus, (2) radius and ulna, (3) shaft of the femur, (4) tibia and fibula. G. Mechanism of Injury: Patients exhibiting any of the following criteria will be Trauma Alerts: 1. Electrocution or lightning injury with loss of consciousness or visible signs of injury; 2. Severe facial injury with airway compromise or potential airway compromise; 3. Ejection from automobile, motorcycle, ATV, golf cart or horse with anatomic injury; 4. Blunt abdominal trauma or chest trauma in patient with history of paralysis (paraplegia or quadriplegia) 9_9 Dr. Sandra Schwemmer, D.O. Page 8 of 15 334 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS 5. Blunt head, chest or abdominal trauma in a patient with bleeding disorder or on anticoagulants with a high risk of bleeding (see list of Anticoagulants with High Risk of Bleeding). 6. Auto versus pedestrian or bicyclist thrown, run over, or impact resulting from speeds more than 20 mph. 3. Should the pediatric patient not be identified as a Trauma Alert using the RED criteria listed in (2)of this section, the trauma patient shall be further assessed using the BLUE criteria listed in this section and shall be considered a Trauma Alert patient when a condition is identified from any two of the following components included in this section: A. Size: The patient weighs < 20 kilograms (44 pounds). B. Circulation: The carotid or femoral pulse is palpable, but the radial or pedal pulses are not palpable or the systolic blood pressure is less than 90 mmHg. C. Disability: The patient exhibits symptoms of amnesia or there is loss of consciousness. D. Soft tissue: The patient sustains a GSW to the extremity below the elbow or knee, E. Long Bone Fracture/Skeletal: The patient reveals signs or symptoms of a single closed long bone fracture or dislocation. Long bone fractures do not include isolated wrist or ankle fractures. F. Mechanism of Injury: Pediatric patients exhibiting any of the following criteria: 1. Death in the same passenger compartment, 2. Intrusion of more than 12 inches in the roof or occupant side of the motor vehicle or more than 18 inches intrusion into any site of passenger compartment, 3. Vehicle telemetry data consistent with high risk of injury, 4. Fall > 10 feet or 2-3 times the length or height of the child, 4. In the event that none of the criteria in (2) or (3) of this section are identified in the assessment of the pediatric patient, the EMT or paramedic can call a "Trauma Alert" if, in his or her judgment, the trauma patient's condition warrants such action. Where EMT or paramedic judgment is used as the basis for calling a Trauma Alert, it shall be documented as required in accordance with Rule 64J-1.014, Florida Administrative Code. 9_9 Dr. Sandra Schwemmer, D.O. Page 9 of 15 335 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS Elite Medical Transport Pediatric Trauma Scorecard Methodology The EMT or Paramedic shall assess the condition of those injured individuals with anatomical and physical characteristics of a person fifteen (15)years of age or younger for the presence of one or more of the following three (3) criteria to determine the transport destination per 64J-2.005, Florida Administrative Code, (F.A.C.): 1. Meets color-coded triage system (see below) 2. Meets local criteria(specify): 3. Patient does not meet the trauma criteria listed, but was transported to a trauma center due to EMT or paramedic judgment(reason for transport must be justified in run report). "III....II'r BLUE &Z: WEIGHT<20 Kg All I� A°1f AC I IV1,;All:W1/AY ANNIN"1"FUNGI;;' I 41 NI'14A 11.":2()I IN IINI'AIN"I 1 YI'4 41 NI'14A1I 1()IINCI III I)I'41 IN1yl::::4 13YI'4 CH:R�CLJL�A"F0NI AIN'1"'[�i N��N I'AI,I'AISI I,l GA14� 1'II::)[,i /I�)I'4AI I'I II '�'�,I [�i CAROTID or FEMORAL PULSES PALPABLE,BUT THE RADIAL OR PEDAL 31 SI'''<3()inirrl k PULSE NOT PALPABLE or SBP<90-mmHg YlSAE;IIUTY AI 11 Idlill)f/III INIAI 31AIl.,I;3'o1 I'Id1ii:.31 INCI.01: I'AIIAIY313 AMNESIA [n 3 131''1ICIt 11N 01'::'3::11INAI C01:dlI IINJ II dY of 1 0 33 01'::' NI 1NGA"I"'I(:)IN LOSS OF CONSCIOUSNESS IVIIAJ()I::: 3()I 1 113s;r II 31'il II'I of IVIIAJOI:d AVI II '�'�,I��>IN or GSW TO THE EXTREMITY BELOW ELBOW OR KNEE tm U:1 :..t t11SSL'➢II 3"ui 3"1.3I II11NG '10 >1()% 111133A AIVIII'I I 1"A I I()IN A"'nil Al sOVI I 1 1I AI;I of AININI 1i,' ANY I'Ii,llNl I I4A I IING 11N fl IIdY 10 1 II IAI) INI!.CI ,of 1 NI I I':::1A'I"'IING 11N fl II dY 10 11 11 X"1"'I dl f//II"I"'Y A I [n AI S()Vli:: 11 (:)woI KIN 1::::::Ii,' IVIIAJ ]I'4 I',)1 GI.OVIING 11N%l1„II'4Y FIFt/°tr.;,.I�t!IF�IE , INI dAC I I,�11 NG I S1 NNI [n f�/II,IL."1 II'I I �i�� GA 1 I�;:':�1N3�,,[')r SINGLE LONG BONE FRACTURE SITE°or DISLOCATIONS Q3 G, :43 F S II II ILIF.',,.3AiL I�III_C�� ""�A°�Il�:i»M U: C 11'1� CI 11�:':NN[n I IGI I"I'INIING 3"1"'1411N1 A/1/1"I"'I I 1 0;3 01'::' DEATH IN SAME PASSENGER COMPARTMENT CONGClt II ^rlNl 3�r,',r[n VI^,Ili,!'SI 1 SIGING 01: IINJI,,,,II1Y INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE;>18 NI VI 141,; ACIA1..11N fl II'4Y W1 I I I A11'4WAY G:If//II''14 f//IINI,; INCHES ANY SITE INTO THE PASSENGER COMPARTMENT J1 C 11ON I'1(„IVII AI I I Of//IO1 S11 IVIIO I 01'1CYC1 GOO 1'::' VEHICLE TELEMETRY DATA CONSISTENT WTH HIGH RISK OF INJURY? CAld"1 AIV01:d 1"I'IIAINA'I"'OVICII%l.,l1"dY FALL>10 FT or 2-3 TOMES THE HEIGHT OF THE CHILD 1 I I IN"1"'AI SI)(„"rV IINAI of CI 11!!I31 111AI,.,IIVIIA IN 1::'A III:.IN"I"' 1 I I 1113101:::::dY 01 ::W Y^,IS(I'AIZAl'1 111'.GIA[n ()l AI)Id11'I 1!!ICIA) 1 I I IIN'1"'h 11 AID,CI 11 31 AI&I:)OV ANAL,IVIII 13CL I AI d 31N1 I.I!1 1'AI I I4AI MIA 11N I'A III;;IN I OIN AIN I ICOAG1 II AIN 13 W I I I I IIIGI II 1131N 01'::'I SI I I ::)IING AI 10 V;';r Y 11°°°I If//II'AG 1 GI°41 A 11 I'4'I 1 IAIN 20 IVIII'k1l =any one(1)-transport as a trauma alert; BLUE =any two(2)-transport as a trauma alert. 1. Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Altered mental states include drowsiness,lethargy,inability to follow commands, unresponsiveness to voice,totally unresponsive. 3. Long bone fracture sites are defined as the(1)shaft of the humerus, (2)radius and ulna, (3)femur, (4)tibia and fibula. 4. Long bone fractures do not include isolated wrist or ankle fractures or dislocations. 5. Includes major de-gloving injury. 6. Excluding superficial wounds where the depth of the wound can be determined. 7. 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. 9_9 Dr. Sandra Schwemmer, D.O. Page 10 of 15 336 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS See list of Anticoagulants with High Risk of Bleeding. 9 9 V. TRANSPORT DESTINATION CRITERIA 64J-2.002 F.A.C. 1. There are no state approved trauma centers in Company . Therefore, it is the decision of the Medical Director, Dr. Sandra Schwemmer, that it is in the best medical interest of trauma patients, who meet the criteria outlined in this protocol for designation as a TRAUMA ALERT, to be transported as expeditiously as possible to a SATC or SAPTC. If air transport is not possible, TRAUMA ALERT patients may be transported to a local hospital for stabilization until transport to the nearest SATC or SAPTC is available. 2. No patient shall be transported from the scene via air transport without appropriate immobilization, secure airway allowing for adequate ventilation, and established IWO access. Inability to secure an airway is a contraindication to air transport. 3. Trauma patients in full cardiac arrest on the scene should be taken by ground ALSto the nearest Hospital. 4. If circumstances prohibit direct scene transport to a Trauma Center (adverse weather conditions, disasters, mass casualties, prolonged TRAUMA STAR ETA) then patients will be taken to the nearest local hospital for stabilization and treatment prior to transport to the nearest Trauma Center. VI. INTER-FACILITY TRANSFER OF TRAUMA PATIENTS As previously noted, there are no state approved trauma centers in Monroecoounty Company . On rare occasion, a patient meeting Trauma Alert Criteria may need to be transported from the scene to a local hospital for stabilization/ treatment until appropriate transportation to the SATC or SAPTC is available. The hospital will arrange for appropriate transportation of the patient. Should supplemental personnel, such as medical or nursing staff, respiratory therapy staff, etc. be necessary to assist Elite Medical Transport crew for optimal patient care, the transferring hospital will coordinate the necessary personnel to accompany the Ambulance Crew. 9_9 Dr. Sandra Schwemmer, D.O. Page 11 of 15 337 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS transport personnel. 9_9 Dr. Sandra Schwemmer, D.O. Page 12 of 15 338 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS VII. APPROVED TRAUMA CENTERS AND INITIAL RECEIVING HOSPITALS Approved Trauma Centers and Pediatric Trauma Referral Centers 1. Level 1: University of Miami/Jackson Memorial Hospital (Adult and Pediatric trauma care) 2. Provisional Level 1: Kendall Regional Medical Center (Adult and Pediatric trauma care) 3. Provisional Level II: Jackson South Community Hospital 4. Nicklaus Children's Hospital (Pediatric trauma care only) Receivina Facilities 1. Lower Keys: Lower Keys Medical Center, Stock Island 2. Middle Keys: Fishermen's Hospital,Marathon 3. Upper Keys: Mariner's Hospital, Tavernier 9_9 Dr. Sandra Schwemmer, D.O. Page 13 of 15 339 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS ANTICOAGULANTS WITH HIGH RISK OF BLEEDING Trade Names: Generic names: Aggrenox(ASA+dipyridamole) Anagrelide(Agrylin) Agrylin (anagrelide) Apixaban (Eliquis) Brilinta (ticagrelor) Cilostazol(Pletal) Coumadin (warfarin) Clopidogrel (Plavix) Effient (prasugrel) Dabigatran (Pradaxa) Eliquis (apixaban) Dipyridamole(Persantine) Jantoven (warfarin) Dipyridamole +ASA (Aggrenox) Plavix (clopidogrel) Edoxaban (Savaysa) Persantine(dipyridamole) Pentoxifylline(Trental) Pletal (cilostazol) Prasugrel (Effient) Pradaxa (dabigatran) Rivaroxaban (Xarelto) Savaysa (Edoxaban Ticagrelor(Brilinta) Ticlid (ticlopidine) Ticlopidine (Ticlid) Trental (pentoxifylline) Vorapaxar (Zontivity) Xarelto (rivaroxaban) Warfarin (Coumadin, Jantoven) Zontivity (vorapaxar) .......................................................................... Injectables: Activase (alteplase) Aggrastat(tirofiban) Angiomax(bivalirudin) Argatroban Arixtra (fondaparinux) Fragmin (dalteparin) Heparin Innohep (tinzaparin) Integrilin (eptifibatide) Iprivask(desirudin) Lovenox(enoxaparin) Reopro (abciximab) Streptokinase Tenecteplase (TNKase) Urokinase 9_9 Dr. Sandra Schwemmer, D.O. Page 14 of 15 340 Elite Medical Transport TRAUMA TRANSPORT AND TREATMENT PROTOCOLS TRAUMA TRANSPORT PROTOCOLS MEDICAL DIRECTOR APPROVAL I, Sandra Schwemmer, D.O., Pre-hospital Medical Director for Elite Medical Transport certify to the Department of Health, Bureau of Emergency Medical Services that I have reviewed and approve the Trauma Transport Protocols, dated May 5, 2016. 5/5/16 Sandra Schwemmer, D.O, FACOEP, FACEP Date FL OS 4022 9_9 Dr. Sandra Schwemmer, D.O. Page 15 of 15 341 Elite Medical Transport DRUG FORMULARY ................ Adenosine Triphosphate (Adenocard®) Y g g Adenosine exerts its effects b decreasing conduction through the AV mode.The half-life of Adenocard is less than 10 seconds.Thus, its effects, i; desired and undesired, are self-limited. o—NDolCA oI--N�—: Adenocard is indicated for paroxysmal supraventricular tachycardia (PSVT), including that associated with accessory bypass tracts (Wolf-Parkinson- /� White Syndrome). �� ,� C �IT`II'�AlIIII�IVCATIV �IS': Ad.en.oca.rd...'.S...c.on.tra................� indicated in second or third degree AV block and sick sinus syndrome (except in patients with a functioning artificial pacemaker), and known hypersensitivity to Adenosine. Adenocard may produce a short lasting first, second, or third degree heart block. In extreme cases transient asystole may result.At the time of conversion to normal sinus rhythm, a variety of new rhythms may appear Y Y Y Y pp (PVC's, PAC's, sinus bradycardia, sinus tachycardia, skipped beats,and varying degrees of AV block)and generally last only a few seconds without intervention. The effects of Adenosine are antagonized by methylxanthines such as caffeine and theophylline.Thus, larger doses of Adenosine may be required for Adenosine to be effective.Adenosine effects are potentiated by dipyridamole(Persantine).Thus, smaller doses of Adenosine may be effective.Adenosine may produce bronchoconstriction in patients with asthma. P®SSOIR�.IE AIOVIERSIE REAC'�"IONS AND S.!2E EI=I=ECTS: ....................................................................................................................................................................................................................................... Cardiovascular: Facial flushing, headache,and rarely: sweating, palpitations,chest pain,and hypotension. Respiratory: Shortness of breath, chest pressure,and rarely: hyperventilating, metallic taste, tightness in throat and head pressure. CNS: Light headedness and rarely:dizziness, blurred vision,tingling and numbness in extremities, apprehension. DOSAGE: AdUIlt dosage„ 6 mg rapid IVP, immediately followed by 20 ml NS flush. Repeat in 2 minutes at 12 mg IVP followed by 20 ml NS flush PRN. 1ll'edoafidc dosage 0.1 mg/kg(maximum 6 mg) rapid IVP immediately followed by 5 ml NSflush. Repeat in 2 minutes, at 0.2 mg/kg (maximum 12 mg)rapid IVP followed by 5 ml NS flush PRN. Time/Action Prof le: Onset: Pealk Duration IV: Immediate Unknown 1-2 minutes Adenosine Triphosphate (Adenocard®) 10_1342 Dr. Sandra Schwemmer, D.O. Elite Medical Transport N DRUG FORMULARY ............................................... Albuterol (ProventiM, Ventolin®) AC"IFIOINS: Albuterol is primarily a beta-2 sympathomimetic and as such produces bronchodilation. Because of its greater specificity for beta-2 adrenergic receptors it produces fewer cardiovascular side effects and more prolonged bronchodilation than isoproterenol. I IN D I "A"r-i ; INS: Albuterol inhaler is indicated for relief of bronchospasm in patients with reversible obstructive airway disease including asthma, and COPD. CQVI I1XHNIYICXI""IIIOIIICS: ..................................................................................................................... Albuterol is contraindicated in patients with a history of hypersensitivity. WA IIC3I'I`IYI III I`YYI(„3 S: ................................................................. Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism, and diabetes. In adults, do not give Albuterol if heart rate is > 150. Exception: If patient remains in sinus tachycardia and systolic blood pressure remains > 100 Albuterol treatments may be continued. The rationale must be clearly documented.The benefits must outweigh the risks. Administer cautiously to patients on MAO inhibitors or tricyclic anti-depressants. Beta-Blockers and Albuterol will inhibit each other. POSSIBLE ADYERSE R A.C"I"IONS AND SIDE Eff EC"I"S: Cardiovascular:Tachycardia, hypertension, and angina. CNS: Nervousness, tremor, headache, dizziness, and insomnia. GI: Drying of oropharynx, nausea, and vomiting, unusualtaste. DOSAGE: Adult: 2.5 mg of Albuterol in 3ml of NS to nebulizer and flow oxygen 8 liters/min. Child: .............................. If > 1 year or > 10 kg: 2.5 mg of Albuterol in 3 ml of NS (0.083%) to nebulizer and flow oxygen 6 liters/ min. If< 1 year or< 10 kg: 1.25 mg of Albuterol in 1.5ml of NS (0.083%) to nebulizer and flow oxygen 3 liters/min. (2.5 mg divided in half).Treatment will be delivered over approximately 5 to 15 minutes. Time/Action (Profile: Onset Desk Duration Inhaled: 5-15 minutes 60-90 minutes 3-6 hours Albuterol (Proventil®, Ventolin®) 10-2 343 Dr. Sandra Schwemmer, D.O. Elite Medical Transport M DRUG FORMULARY O ..............I Amiodarone (NexteroneTM) I IONS-. Amiodarone suppresses recurrent VF, prolongs intranodal fax conduction and refractoriness, negative inotropic effect. IN@. @:CAT l:I NS-. Ventricular Fibrillation 4Z Pulseless VT • PVC's greater than (>) 12 min • Ventricular Tachycardias (Wide and Narrow) with a pulse m � 11 I„ AI I A I,1Q NS wot • Any known allergy 0 Cardiogenic Shock Sinus Bradycardia 2nd and 3rd degree AV blocks POSSIBLE ADVERSE REACTIONS AND SIDS; EFFECTS: None in Ventricular fibrillation. DOSAGE: Adult dosage: Pulseless Arrest: 300 mg IV/10 May repeat with 150 mg IV/ 10 With Pulses: Infusion loading dose: 150 mg IV (150 mg in 100cc NS) infused on a macro drip over 10 minsl.5gtts/sec. ll'h1'°d ia&II ILA:: Pulseless Arrest: 5mg/kg IV/10 may be repeated once. No single dose greater than 300 mg. (15mg/kg max) 1'inne/Action Profile: Onset Peak Duration IV/10: Unknown Unknown Unknown Amiodarone (NexteroneTM) 1 0-3 31 Dr. Sandra Schwemmer, D.O. Elite Medical Transport DRUG FORMULARY ..............I Aspirin (Bayer, ° Bufferin°) AC IFIONS: Aspirin is an analgesic, anti-inflammatory and anti-pyretic, which also appears to cause an inhibition of synthesis and release of prostaglandins. Aspirin also blocks formation of thromboxane A - 2. (Thromboxane A- 2 causes platelets to aggregate and arteries to constrict). Reduces overall mortality from acute myocardial infarction. � 1 t INI ICA"�"I ; NS: � Aspirin is indicated in the Acute Coronary Syndrome setting to prevent 'M � further clotting. are m»Ior a A known allergy to Aspirin (i.e. urticaria, dyspnia, etc.), active GI ulceration or bleeding, hemophilia or other bleeding disorders, during pregnancy, children under 2 years of age. POSSIBLE ADYE SE EAC"I"IONS AND SIDE E EC"I"S. GI: Nausea, vomiting, heartburn, and stomach pain. OTIC: Tinnitus. Hypersensitivity: Bronchospasm, tightness in chest, angioedema, urticaria, and anaphylaxis. DOSAGE: Adult: 324 mg (4) 81mg chewable tablets for Acute Coronary Syndromes Time/Action (Profile: Onset Desk Duration (Oral) PO: 5-30 minutes 1-3 hours 3-6 hours Aspirin (Bayer, ® Bufferin®) Dr. Sandra Schwemmer, D.O. 0_4 345 Elite Medical Transport LO DRUG FORMULARY 6 ........................ Atropine Sulfate as Cardiac Agent AC 11"101NS: Atropine is a potent anticholinergic (parasympathetic blocker, parasympatholytic) M that reduces vagal tone and thus increases automatically the SA node and Suiil ate increases A-V conduction. Injection,USP 1ND1CA"noNS: • Sinus Bradycardia accompanied by hemodynamic compromise,(i.e. hypotension, confusion, frequent PVC's, pale, cold, clammyskin). • In children (< 1 year) bradycardia of less than 60 beats/minute should be treated if symptomatic even if BP is normal. C0111 "1""III IIIIII' IIIC ""1""III0IIICS: ..................................................................................................................... None in emergency situations WA IIC31'�I`IY1 III�I`YY1(3 S: Too small of a dose (< 0.5 mg) or if pushed too slowly, may initially cause the A heart rate to decrease. Antihistamines and antidepressants potentiate Atropine. A urnaxlrnuirn doe of 0.04 mg/kg should not be exceeded. For 2nd degree AV block type II and 3rd degree AV block, omit Atropine and go to external pacer. POSSIBLE ADVERSE REACw1"I0NS AND SIDE E.ff EC"1"S: CNS: Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, and headache. Cardiovascular: Increase heart rate, may worsen ischemia or increase area of infarction, ventricular fibrillation, ventricular tachycardia, angina and flushing of skin. GI: Dry mouth and difficulty swallowing. Other: Urinary retention. Can worsen pre-existing glaucoma. DOSAGE: Adult., Bradycardia: 0.5-1 mg IV/10, may repeat every 3-5 minutes until improved or total of 2mg is reached. 1'°e64ll a i�c: 0.02 mg/kg IV/10 (minimum dose is 0.1 mg and arnaxirnuirn single dose is 0.5mg child, 1 mg adolescent). May repeat once. Time/Action (Profile: Onset Peak Duration IV/10: Unknown Unknown Unknown Dr. Sandra Schwemmer, D.O. Atropine Sulfate as Cardiac Agent 1 0-5 346 Elite Medical Transport C.0 DRUG FORMULARY ............................................... Atropine Sulfate as Antidote for Poisoning AC"IFIOINS., Atropine is a potent parasympatholytic that binds to acetylcholine receptors thus diminishing the actions of acetylcholine. Suffate i IN i iCA"°r- INS: Anticholinesterase syndrome poisoning such as; Organophosphate (e.g. Parathion, Malathion, Rid-a-Bug) and Carbamate (Baygon, Sevin and many common roach & ant sprays). Signs of organophosphate poisoning are: Salivation Lacrimation Urination Defecation GI distress, Emesis, Pinpoint pupils, bradycardia, and excessive sweating. None l Iwhenused 1XHNIYCXIII��Ilthe management of severe organophosphate poisoning. WA IIC3�'�I"Y�III�'Y�(6�S It is important that the patient be adequately oxygenated and ventilated prior to using Atropine as it may precipitate ventricular fibrillation in a poorly oxygenated patient. Even after Atropine is administered, the patient may require intubation and aggressive ventilatory support. POSSIBLE ADVERSE RE.AC"["IONS AND SIDE E E ][.Sn ...................................................................................................................................................................................................................................................................... Victims of organophosphate poisoning can tolerate large doses (1000 mg) of Atropine. Signs of atropinization are the end point of treatment: flushing, pupil dilation, dry mouth, and tachycardia. DOSAGE: Adult: 0.03 mg/kg IV/IO, repeat every 5-10 minutes until atropinization occurs. F'°'Ie64Itii,'k: 0.05 mg/kg (maximum 3 mg) IV/IO, repeat every 5-10 minutes until atropinization occurs. Time/Action IProfHe: Onset Peak Duration IV/IO: Immediate 2-4 minutes 4-6 hours Dr. Sandra Schwemmer, D.O. Atropine Sulfate as Antidote for Poisoning 10-6 347 Elite Medical Transport I` DRUG FORMULARY Calcium Chloride 10% AC."IFIGNS., fiJutr L n10 00,1014 Calcium chloride increases the force of myocardial contraction; calcium 6 1 , 1 may either increase or decrease systemic vascular resistance. In normal l60 hearts, calcium's positive inotropic and vasoconstricting effects produce a CALCIUM predictable rise in systemic arterial pressure. CHLORIDE 1 j j IINI I " "I" oN : ILISP isp Calcium chloride is indicated during resuscitation for the treatment of JJ, , hypocalcaemia and calcium channel blocker toxicity (i.e. Verapamil or ' Cardizem overdose) and Magnesium Sulfate overdose. It also protects the heart from hyperkalemia as may occur in patients with end-stage renal disease. OIII l`„III IIIIIII, III I III„! IIIS ///////////////%�%/////%i//!�� Cardiopulmonary arrest not associated with calcium channel blocker toxicity, hypocalcaemia, or hyperkalemia. WA 111 l q m i Calcium chloride should not be administered in the same infusion with Sodium Bicarbonate, since calcium will combine with sodium bicarbonate to form an insoluble precipitate (calcium carbonate). Calcium chloride should be given with extreme caution, and in reduced dosage, to persons taking digitalis because it increases ventricular irritability and may / precipitate digitalis toxicity. POSSIBLE ADVERSE REA wi"IONS AND SIDE EFFE wi"Sn If the heart is beating, rapid administration of calcium can produce slowing of cardiac rate. DOSAGE: Adult dosage., For hypotension following administration of calcium channel blockers (i.e. Cardizem, Verapamil): 4mg/kg IV slowly If patient is taking digitalis, 2 mg/kg IV slowly. Repeat every 10 minutes PRN. For calcium channel blocker overdose and hyperkalemia: 8-16 mg/kg IV slowly Asystole/PEA (if on calcium channel blockers) 1gm IVP Time/Action IProfiie: Onset Peak Duration IV/IO: Immediate Immediate 2-5 hours Dr. Sandra Schwemmer, D.O. Calcium Chloride 10% 10-7 348 Elite Medical Transport op DRUG FORMULARY O ............................. Cyanokit® 8("IFIGNS., Hydroxocobalamin is an antidote to cyanide. It is marketed as CYANOKIT° in % the US. It removes cyanide directly from the blood without converting any of the hemoglobin and therefore does not interfere with oxygen transport. It combines with the cyanide to form cyanocobalamin which is a derivative of vitamin B-12. Both the Hydroxocobalamin and B-12 are harmlessly excreted in urine. 0 Exposed to products of combustion in an enclosed space • Soot present in their nose, mouth, or sputum Altered mentation 10101 • Does not meet trauma alert criteria At least 18 > years old Common Signs &Symptoms include: Symptoms Sins Headache Altered Mental Status Confusion Seizures Dyspnea Mydriasis (dialated pupils) Chest Tightness Tachypnea (early) Bradypnea (late) Nausea Hypertension (early) hypotension(late) Cardiovascular collapse Vomiting COIII 1 I1X N[YICXI""IIIOIIICSm .................................................................................................................... None Do not use the following medications in the same IV line: • Diazepam Propofol Ascorbic acid • Dobutamine Thiopental • Fentanyl Sodium Nitrite • Nitroglycerin SodiumThiosulfate • Pentobarbital Whole Blood DO NOT RELY ON PULSE OXIMETRY FOR ACCURATE READINGS DOSAGE: Please refer to detailed infusion instructions located within the CYANOKIT° itself. or in protocol 3-2. Several multi-dose kits are carried in the Battalion Chiefs vehicle Cyanokit® 1 0_8 349 Dr. Sandra Schwemmer, D.O. Elite Medical Transport 00 DRUG FORMULARY O Dextrose 50 % and 25 % (d-glucose) AC IFIOINS: A monosaccharide, which provides calories for metabolic needs, spare body proteins and loss of o` electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. I N D I w ""A" I� N : " I cemia XT yp g Y • Coma of unknown origin. III „ III ........IIL.III I.III .......I III .III .S..I. • Intracranial or intraspinal hemorrhage (ina patient with normal BGL). 0 Blood glucose Level > 60 mg/dl. POSSIBLE ADVERSE REACwI"IONS AND SIDE CwI"S: ............................................................................................................................................................................................................... Cardiovascular:Thrombosis Sclerosing if given in ��III peripheral vein Local: Tissue irritation or necrosis if infiltrates. r Others: Acidosis, alkalosis, hyperglycemia,and v W I III aft hypokalemia. DOSAGE: Adult: ( 30 kg) 50 ml of a 50% solution; (25 gm) IV/IO. F'°e64tii,'loc: 30 kg) 2 ml/kg slow IV/IO of a 25% solution. I`\JeyvA�tI°:o 11,' 10 kg or<� 1 month of age) 5 ml/kg IV/IO of 10% solution (dilute D50 4:1 with NS). Time/Action IProfiie: Onset Desk Duration IV/IO: < 1 minute Depends on degree of hypoglycemia Dextrose 50 % and 25 % (d-glucose) 1 0-9 350 Dr. Sandra Schwemmer, D.O. Elite Medical Transport DRUG FORMULARY O Diazepam Hydrochloride (Valium®) I � G 1 ACtf`I YIN'S: A member of the benzodiazepine family, Diazepam,depresses the limbic system,thalamus,and hypothalamus resulting in calming effects. Diazepam produces a sedative effect and is also a muscle relaxant. IIIINI' IICATIOIIN° : • Status epilepticus, Premedication prior to cardioversion,Agitation due to acute alcohol withdrawal, Drug induced psychosis,Short-term relief of acute anxiety,Cocaine intoxication CON'TRAINDICA'i MSON • Alcohol Intoxication • Pregnancy(except for seizure control associated with eclampsia) • Neonates WA,II°,II"4 II II"4G Sl ...................................................... Do not mix Diazepam with any other drug, precipitates with almost all medications.When injecting IV administer slowly through the IV tubing as close as possible to the vein insertion. Do not administer into small veins such as those on dorsum of the hand—causes local irritation and possibly venous thrombosis in small veins. I511ll CAWIF II Ill:11\,1S: ..................................................................... • Pregnancy(except for control of seizures associated with status epilepticus oreclampsia) • Neonates. POssoBL.E AIDVERSE REAC" oON.S ANID SIIDE EI=I=ECTS: ....................................................................................................................................................................................................................................... • CNS:Confusion, muscular weakness, blurred vision, drowsiness, respiratory depression, respiratory arrest, and slurred speech. • Cardiovascular: Bradycardia, hypotension, and cardiovascular collapse. • G.I.: Nausea,vomiting, abdominal discomfort and hiccups. • Respiratory: Respiratory depression. • Other: Potentiates MAO's, barbiturates,tricyclics and phenothiazines Potentiated by Cimetidine, ETOH and other CNS depressants. DOSAGE: Adult: To be administered in 5 mg increments. Dosing ranges from 5-20 mg IV/IO/IM depending on specific protocol.The IV route should be administered slowly-no faster than 5 mg/min. IM 20 mg maximum dose per injection. IM injections are painful. If IM route used inject deeply into the deltoid for maximum absorption. 1e(,Jk' a is Status epilepticus 0.2 mg/kg IV/IO slowly(max 5mg). Rectal Dose 0.5 mg/kg, may repeat either route x 1 in 5 mins. Time/Action IPiroiiile: Onset Pealc Duration (Sedation)IV/IO: 1-5 minutes 15-30 minutes 15-60 minutes IM: 15-20 minutes. 5-1.5 hours Unknown Rectal: Unknown 1-2 hours 4-12 hours Dr. Sandra Schwemmer, D.O. Diazepam Hydrochloride (Valium®) 1 0-1 0 351 Elite Medical Transport DRUG FORMULARY O Diphenhydramine Hydrochloride (Benadryl°) AC"1.a�;�ONSw .................................... Diphenhydramine is an antihistamine with anticholinergic(drying)and sedative side effects.Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Diphenhydramine prevents, but does not reverse histamine mediated responses, particularly histamine effects on the smooth muscle of the bronchial airways,gastrointestinal,uterus,and blood vessels. I NDICATION S • Allergy symptoms,anaphylaxis • Sedation of violent patient • Dystonic reactions from phenothiazine overdose(i.e. Haldol,Compazine,Thorazine,and Stelazine) C �NTIIAIININ'�IICATIV �NS': ...................................................................................................... Diphenhydramine is not to be used in newborn or premature infants. Diphenhydramine is not to be used in patients with acute asthma attack W l°idNIfIINGS: ....................................................... In infants and children especially,antihistamines in overdose may cause hallucinations,convulsions,or death.As in adults,antihistamines may diminish mental alertness in children. In young children,they may produce excitation. Diphenhydramine has additive effects with alcohol and other CNS depressants(hypnotics,sedatives, tranquilizers,etc.).Antihistamines are more likely to cause dizziness,sedation,and hypotension in the elderly(60 years or older) patient POSSIBLE ADVERSE REACTtlONS AND SIDE EFFECTS: CNS: Drowsiness,confusion,insomnia, headache and vertigo(especially in the elderly). Cardiovascular: Palpitations,tachycardia, PVC's and hypotension. Respiratory:Thickening of bronchial secretions,tightness of the chest,wheezing and nasal stuffiness. GI: Nausea,vomiting,diarrhea,dry mouth,and constipation. GU: Dysuria and urinary retention. DOSAGE: Adu ftV 25-50 mg IV/IO or 50 mg deep I M I1e,Jufl)trEc 1 mg/kg IV/IO or IM (maximum 25 mg) Time/Action IPirofiile: Onset Pealc Duration IV/IO: Rapid Unknown 4-8 hours IM: 20-30 minutes 1-4 hours 4-8 hours Diphenhydramine Hydrochloride (Benadryl®) Dr. Sandra Schwemmer, D.O. 10-11352 Elite Medical Transport DRUG FORMULARY CV O Dopamine Hydrochloride (Intropin°) ACTIONS: T Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic receptors of the sympathetic nervous system. It exerts an inotropic effect on the myocardium resulting in an increased cardiac output. Dopamine produces less increase in myocardial oxygen consumption than does Isoproterenol and its use is usually not associated with a tachyarrhythmia. Dopamine dilates renal and mesenteric blood vessels at low doses that may not increase heart rate or 1 blood pressure.Therapeutic doses have predominant beta adrenergic receptor stimulating actions that result in increases in cardiac output without marked increases in pulmonary occlusive pressure.At high doses, Dopamine has alpha receptor stimulating actions that result in peripheral vasoconstriction and marked increases in pulmonary occlusive pressure. iiND—l-CATol0NS� To treat shock and correct hemodynamic imbalances,improve perfusion to vital organs and to increase cardiac output. CONT IIAII N II tll CAT IIONSI: Dopamine should not be used in patients with pheochromocytoma or hypovolemic shock. Alltll\llll\l �" l,, aS Do not administer Dopamine in the presence of uncorrected tachydysrhythmias or ventricular fibrillation. Do not add Dopamine to any alkaline diluents solutions since the drug is inactivated in alkaline solution. Patients who have been treated with monoamine oxidase(MAO) inhibitors will require substantially reduced dosage.MAO inhibitors include:furazolidone (Furoxone°), isocarboxazid (Marplan°),pargyline hydrochloride (Eutonyl°),pargyline hydrochloride with methyclothiazide(Eutron°), phenelzine sulfate(Nardil°), procarbazine hydrochloride(Matulane°), tranylcypromine sulfate(Parnate°). POSSIIBLE& V .ESE �2EACTIIONS AND SIIDE [EEJECTS: ............................................................................................................................................................................................................................ Cardiovascular:Tachycardia, palpitations,angina pain,ectopic beats,and hypotension GI: Nausea and vomiting Local: Necrosis and tissue sloughing with extravasations,use a large vein to reduce this incidence Other: Piloerection,dyspnea and headache. DOSAGE: Adlulllt and I11,1erJk'I a ic: Pre-mixed bag Begin infusion at 5 mcg/kg/min.and titrate to effect(Maximum dose 20 mcg/kg/min.) Vial(400 mg)To yield a concentration of 1600 mcg/ml mix 400 mg of Dopamine into 250 ml of D5W. Time/Action IPirofiile: Onset Pealc Duration 4 minutes 10-15 minutes Continuous with infusion Dr. Sandra Schwemmer, D.O. Dopamine Hydrochloride (Intropin®) 1 0_1 2 353 Elite Medical Transport M DRUG FORMULARY O Duo-Dote TM (Atropine and Pralidoxime Chloride) AC,1 IONS: • Blocks nerve agents effects and relieves airway constriction and secretions in the lungs and gastrointestinal tract. Acts to restore normal functions at the nerve ending by removing the nerve agent and reactivating natural 7. function iINDICA°noN : Suspected or confirmed nerve agent exposure a a ` m OIIIIII °III O III o�III III II 10 Both medi cations in the kit should be used with caution �p (but not withheld) in patients with preexisting cardiac IPJAI ZI disease, HTN, or CVA history. I. .LE &D.Y . . .... . ."] 0 N50 &N D... .'. . ...E F FI..C."I"..S..;...Chest pain , exacerbation of angina, Myocardial infarction, Blurred vision , Headache, Drowsiness, Nausea , Tachycardia , Hypertension , Hyperventilation DOSAGE: DUODOTE TM — Each auto injector contains BOTH: Atropine 2.1 mg and Pralidoxime 600 mg Adult: For Nerve Agent Exposure (SLUDGE symptoms): Up to 3 auto injectors may be used for one patient based on signs (1-2 kits for self treatment— up to 3 for buddy treatment with severe symptoms) DuoDotes TM are not authorized for the use of children under the age of 9 years. Duo-Dote TM Dr. Sandra Schwemmer, D.O. (Atropine and Pralidoxime Chloride) 10-13 354 Elite Medical Transport 't DRUG FORMULARY O Epinephrine 1:1,000 r III IIII IIIIII�n15�16�1� III ��II � ��JJJ AC' II NS: Epinephrine is a sympathomimetic,which stimulates both alpha and beta-adrenergic receptors causing immediate bronchodilation, increase in heart rate and an increase in the force of cardiac contraction. Subcutaneous dose lasts 5-15 minutes. of NicolCATJ0NS: _. Asthma • Anaphylaxis • Angioneurotic edema • All Pulseless Arrest CI1`IIAII III�IICATIIIS': ...................................................................................................... None in the cardiac arrest situation. Hyperthyroidism, hypertension, cerebral arteriosclerosis in asthma. Caution should be used with Epinephrine administration when the patient is older than 40 years old or has a history of heart disease.The benefit must outweigh the risk. Do not administer Epinephrine if heart rate is > 150. W4,R IINI If NI G S ....................................................... Epinephrine is inactivated by alkaline solutions-never mix with Sodium Bicarbonate. Do not mix Isoproterenol and Epinephrine-results in exaggerated response.Action's of catecholamine is depressed by acidosis- attention to ventilation and circulation is essential.Antidepressants potentiate the effects of epinephrine. P®SSOBL.IE ADVERSE REAC" l®NS AND SOME EI=I=EATS: ....................................................................................................................................................................................................................................... • CNS:Anxiety, headache and cerebral hemorrhage. • Cardiovascular:Tachycardia,ventricular dysrhythmias, hypertension, angina and palpitations. • GI: Nausea and vomiting DOSAGE: AdUIlt: SQ 0.1-0.3 mg(0.3 cc). Repeat every 3-5 minutes (Asthma/Anaphylaxis may repeat once in 15 minutes). Ill'e:o„:Jiiiafidc� I 0.01 mg/kg up to 0.5 mg. Time/Action Prof le: Onset: Pealk Duration SQ: 6-12 minutes 20 minutes 1-3 hours Epinephrine 1 :1,000 Dr. Sandra Schwemmer, D.O. 10-14 355 Elite Medical Transport LO DRUG FORMULARY O Epinephrine 1:10,000 Epinephrine is a sympathomimetic, which stimulates both Alpha and Beta- receptors. As a result of its effects, myocardial and cerebral blood flow are increased during ventilation and chest compression. Epinephrine increases 01 systemic vascular resistance and thus may enhance defibrillation. _Nth CATIONS: aw �luaJ All Pulseless Arrest Asystole • Ventricular Fibrillation unresponsive to defibrillation; a� �u w ,new PEA �" �� °"� ° �''�'• Other pediatric indications: hypotension in patients with circulatory Ip�+�M��.Y�uq��r�aalll'rer instability, bradycardia (before Atropine). l � ��i�1';Ar:l��u�'.°r "' COIF"�"III"III'ItAIIIIP'�IIC'. IIICAIIIIIIOIP'�S: None in the cardiac arrest situation. WA II1I N 111 l P �ule Epinephrine n is inactivated by alkaline solutions -never mix with Sodium Bicarbonate. Do not mix Isoproterenol and Epinephrine- results in exaggerated response. Actions of catecholamines are depressed by acidosis -attention to ventilation and circulation is essential. Antidepressants potentiate the effects of epinephrine. POSSIB. E ADVERSE REACTIONS AND SIDE EFFECTS: .................................................................................................................................................................................................................................................. CNS: Anxiety, headache and cerebral hemorrhage. Cardiovascular:Tachycardia, ventricular dysrhythmias, hypertension, angina and palpitations. GI: Nausea and vomiting. ®SAGE: Adult: (1:10,000) 1 mg (10 ml) IV or IO, repeat every 3-5 minutes. Repeat every 3-5 minutes. If patient is in SEVERE anaphylaxis with marked hypotension, you may start an IV and administer 3 -5 cc of a 1:10,000 solution IVP slow over 2 minutes. Pediatric: 0.011L mg/kg, (O.J.. mI/kg IV or IO). Repeat every 3,,,.5 minutes. Pediatric : POST ARREST: 0ALrncg/kg/rnin I ix J..mg of Epi into 11.000H INS w Concentration of JLrncg/rnI Tiirne/Actiion Profiule: Onset Beak Duration IV/IO: Rapid 1-2 minutes 20 minutes Epinephrine 1 :10,000 Dr. Sandra Schwemmer, D.O. 10-15 35s Elite Medical Transport DRUG FORMULARY CD Fentanyl AC'111ONS: ..................................... Fentanyl Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain pathways. Fentanyl binds to brain receptors, relieving pain. It decreases the feeling of pain and a person's response to pain. Fentanyl is 50-100 times as potent as morphine; morphine 10 mg I.M. =fentanyl 0.1-0.2 mg I.M.; fentanyl has less hypotensive effects than morphine due to minimal or no � � -n r�ut • rrr histamine release. fetitan i(citrate 1 N DIICA'1110 N S: lmj, IN mq FlontaNY14 MA Moderate to severe pain in patients>10kg Acute Coronary Syndrome—Chest Pain(Adult) Pain associated with isolated extremity fracture, renal colic, burns, ICI etc. CO II"'�"III"III'tAlll II"'�IIC'. MICA III"II1011'�S: • Epistaxis or bilateral blocked nares • Known hypersensitivity to fentanyl • MAOI use in past 2 weeks CONCENTRATION Unstable hemodynamics or altered 1 cg/ SOmcg/ml . .... .L ........ Use.IP'��.� ..�u 1i1� .; i caution in patients with bradycardia, hepatic, renal, or respiratory disease or those with increased ICP, head injuries, or impaired consciousness; patients must be monitored until fully POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Drowsiness, sedation, increased intracranial pressure Cardiovascular: Bradycardia, hypotension, peripheral vasodilation GI: Nausea, vomiting GU: Urinary tract spasm Respiratory: Respiratory Depression SLOW IV PUSH -Rapid push may cause chest wall rigidity decreasing,or DOSAGE: eliminating ability to ventilate. rip° u�lllk: 1-3 mcg/kg IV/IO/IN (Typical adult dose 50-100mcg) May repeat half the original dose administered. Pediatric >10KG: 1 mcg/kg IV/IO/IN May repeat half the original dose administered 0.5mcg/kg Time/Action Profifle: Onset Beak Duration IN: 2-10 mins 30-60 mins IV: Immediate 30-60 mins Dr. Sandra Schwemmer, D.O. Fentanyl Revised 02-14-18 ddelndL lr 1 1 31 Elite Medical Transport C.0 DRUG FORMULARY O Furosemide (Lasix®) C°I"IIONS: A sulfonamide derivative and potent diuretic, which inhibits the reabsorption of sodium and chloride in the proximal and distal renal tubules as well as in the Loop of Henley. Has a direct venodilating effect in acute pulmonary edema.With IV administration, onset of venodilating is generally within 5-10 minutes; diuresis will usually occur in 20-30 minutes VNIMCA;TMNS: • Pulmonary edema OIP'�"III"III'tAIIIIP'�IIC'. III XIIFII0'19S: Anuria. Should be used in pregnancy only when benefits clearly outweigh risks. WA II1 IN III IN G S Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. POSSdBlE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Dizziness, tinnitus, hearing loss, headache, blurred vision and weakness GI:Anorexia,vomiting and nausea Cardiovascular: Hypotension Other: Pruritus, urticaria and muscle cramping. DOSAGE: Adult: CHF: 80 mg IVP or double the patient dose up to max 100 mg. Cardiogenic Shock:40 mg IV slowly over 2 minutes (If systolic blood pressure is than 100 mmHg.) Tiirne/Actiioin IProfiulle: Onset Beak Duration IV/IO: 5 minutes 30 minutes 2 hours Furosemide (Lasix®) Dr. Sandra Schwemmer, D.O. 10-16 35s Elite Medical Transport DRUG FORMULARY u CD Ketamine Ketalar ®) ACTIIG1 m ......................................... Rapid acting general anesthetic, characterized by profound analgesia, normal pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Disassociates the brain form the spinal cord thus inhibiting pain sensation. Ketamine increases cardiac output and may be considered Ketamine A advantageous in patients with hemodynamic compromise (trauma U P 500 sepsis, etc.). A patent airway is maintained partly by virtue of u1�Y@ unimpaired pharyngeal and laryngeal reflexes. III' K'.; 1'1 II' �mNh • Facilitation of pain control in patients with isolated extremity trauma, burns and/or entrapped patients. • Procedural Sedation CONCENTRATION • Violent/Combative/Aggressive Patients or "Excited Delirium" 500rng/5rnl 100mg/ml . .III .. II NI III ..DIII. ........CAI.°.Ill.. .11l .S..m. • Hypersensitivity to Ketamine • Condition in which an increase in Blood Pressure would be hazardous. • Acute Coronary Syndrome or STEMI • Ocular trauma(globe injury) WAIII! I`1YIII`1YGS ................................................................ IVP over 1-2 min, Ketamine may cause apnea if given too rapidly IV POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: "Emergence Reaction" or hallucinations upon recovering Cardiovascular: Tachycardia, hypertension GI: Nausea and vomiting Respiratory: Hypersalivation, Respiratory depression/apnea DOSAGE: Adu ftV Procedural Sedation/Pain *0,,,5rniY Ic ,,,,IV,/,-G�,/,I-PJ,,,-ov „i,�„-1-,2,,,-In„ii� may repeat prn. Airway Management *21"ng/..!g IV/IG�„c�v „i„�,? in„i„i�„may repeat prn. (Trismus/Endangered Airway/RS11post intubation sedation for inhalation airway control) Violent/Combative/Aggressive Adult Patient 4..0...1,.n..g IM/11V may repeat prn.Consider combining with intronosol Versed. Il: rlufl'ftrk Procedural Sedation/Airway management 1rnF/h�. IV/IG?�/IMlllV over 1-2 min may repeat prn.Time/Action IPirofiile: Onset Pealc Duration IV 1-2 minutes 3-5 minutes Weight dependent Dr. Sandra Schwemmer, Ketamine (Ketalar®) A10 """" 359 D.O. Revised 0 ..1 6-1 8 d d�"�'�fi d�,�rI Elite Medical Transport DRUG FORMULARY O Magnesium Sulfate A ;'TIONS Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end-plate by the motor nerve impulse. Magnesium is said to have a depressant effect on the central nervous system, but it does not affect the mother,fetus or neonate when used as directed in eclampsia and pre-eclampsia. Magnesium acts peripherally to produce vasodilatation Wtherefore a drop in systolic BP is to be anticipated. Injection,UP 11IIMDICATIIOIIRS: • Prevention and control of seizures in eclampsia • Torsades de Pointes j Suspected hypomagnesemic state(i.e.chronic alcoholism and chronic use of diuretics) • Refractory ventricular fibrillation • Refractory Asthma CQN'TRAINDIAC'710NC� ................................................................................................. Parenteral administration of the drug is contraindicated in patients with heart block or myocardial damage. WA,II°,II"4 II II"4 G S W Intravenous use of Magnesium Sulfate should not be given to mothers with toxemia of C r i� pregnancy with imminent delivery. Magnesium Sulfate Injection USP,50%must be must be 16111"teld diluted to a concentration of 20%or less prior to IV infusion for ILY,use. I"II11E CAI LY II Il011\NSW Because magnesium is removed from the body solely by the kidneys,the drug should be used with caution in patients with renal impairment. Monitoring the patient's clinical status is essential to avoid the consequences of overdose in eclampsia.Calcium Chloride should be immediately available to counteract the potential hazards of magnesium intoxication in eclampsia.Signs of hypermagnesium include respiratory depression; absence of patellar reflex,etc. 1,0 95 24li t,V POSSIBLE ADVERSE REACTIONS AND SIIDE EFFECTS ts �tt,1 PJ .......................................................................................................................................................................................................................... Adverse effects of Magnesium Sulfate IV are usually the result of magnesium intoxication. Signs of hypermagnesemia include:flushing,sweating, hypotension,depression of reflexes,flaccid paralysis, hypothermia,and circulatory collapse,depression of cardiac function and central nervous system depression.These symptoms can precede fatal paralysis. DOSAGE: Adult: • For eclamptic seizures: 2 gm in 20 cc IV over 2 minutes • For Torsades de Pointes and refractory VF:1-2 gm(mixed in 50 ml of NS and administered over 1-2 minutes)followed by a maintenance infusion (1 gm in 250 ml of NS administered at 60 gtts/min). Time/Action IPirofiile: Onset Pealc Duration IV Drip: Immediate Unknown 30 minutes Magnesium Sulfate Dr. Sandra Schwemmer, D.O. 10-17 3so Elite Medical Transport 00 DRUG FORMULARY O Methylprednisolone (Solu-MedrolO, A Methapred) o A(mil"IOII' S: Decreases inflammatory effects via its potent anti-inflammatory synthetic steroid. o / IINDI "A"I" oN : 0 Asthma y % • Anaphylaxis • Head injury • COPD / t • Unconscious with known Addison's disease III I �n III III [ II nnliiii III III S m None in the emergency settin g• OSSI LE ADVERSE REA ."]IONS AND SIDE "hSn ' .................................................................................................................................................................................................................................................................. GI hemorrhage, reduces leukotrines of immune system and increases potential for infections. DOSAGE: Adult: 125 mg IV slow over 2 minutes F'Ile64Ilr,om c: 2 mg/kg (max 125 mg) IV slow over 2 minutes Time/Action IProflle: Onset Desk Duration IV/IO: Unknown Unknown Unknown Methylprednisolone (Solu-Medrol®, A Methapred) Dr. Sandra Schwemmer, D.O. 1 0—1 8 361 Elite Medical Transport 00 DRUG FORMULARY O Midazolam (Versed®) AC"II"IG S: Depresses CNS, muscle relaxant, strong sedative, hypnotic, and jamnesia. IINDI "A"I"IoINa' Control of seizures, sedation for cardioversion & pacing, and sedation for airway management. Ii I HN I, y i S / • Respiratory depression l • Hypotension • ETOH and drugs WAI,IJ lF.11 I PY(II II L� Monitor patient for respiratory and CNS depression and vital signs after administration. POSSIBLE ADVERSE REACwi"IONS AND SIDE Cwi"S: ....................................................................................................................................................................................................................................................................... CNS: Retrograde amnesia, altered mental status and dizziness Cardiovascular: Bradycardia, hypotension, PVC's,tachycardia and nodal rhythms GI: nausea and vomiting, hiccoughs and coughing Respiratory: Respiratory depression, laryngospasm and bronchospasm DOSAGE: Adult: Ap].:::. ....R . ....�.. ....i.:h::...11 .2.�.!LiinLEr'. 2.5-5 mg based on patient's weight up to 10 mg amax F'(Il a64tii,,ik: > 1 years of age (0.1 mg/kg) Do Not Administer to pediatric less than 1 year of age Time/Action IProfiie: Onset Desk Duration IV 1-2 minutes 3-5 minutes Weight dependent Midazolam (Versed®) Dr. Sandra Schwemmer, D.O. 10-19 3s2 Elite Medical Transport CD DRUG FORMULARY CD Morphine Sulfate (MS) AC°11'10NS: ...................................... Morphine is a narcotic analgesic, which depresses the central nervous and respiratory system and sensitivity to pain. Morphine also increases venous capacitance, decreases venous return and produces mild peripheral vasodilatation. 1 N DIICA'1f"110NS: • Pain • Pain associated with isolated extremity fracture, renal colic, burns, etc. C IP'T"III"III'tA III IP'T IIC'. III CA"III"III IP'T S: ........................................................................................................... • Volume depletion or hypotension • Acute asthma • Known hypersensitivity to MS WA II'k INl III INl(II'��iu S .......................................................... Morphine is detoxified by the liver. It is potentiated by alcohol, antihistamines, barbiturates, sedatives and beta blockers. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Euphoria, drowsiness, pupillary constriction and respiratory arrest. Cardiovascular: Bradycardia and hypotension. GI: Decreases gastric motility, nausea and vomiting. GU: Urinary retention. Respiratory: Bronchoconstriction, and decrease cough reflex. ®SAGE: Adult: 2 mg increments IV slowly. Repeat every 5 minutes until desired response is achieved (u 1i)Xliu r1U'n dose 10 mg). Can be given IM. @)er;Niiatrk� 0.1 mg/kg IV slowly. May repeat the initial dose X1 in 3-5 minutes. llrifl°airit1,�� 0.05 mg/kg IV slowly. May repeat the initial dose X1 in 3-5 minutes. Tune/Action Profirle: Onset Peak Duration IV: Rapid 20 minutes 4-5 hour Dr. Sandra Schwemmer, D.O. Morphine Sulfate (MS) 1 Revised 7-20-17 Revised 363 Elite Medical Transport Ir- DRUG FORMULARY N O Ir- Naloxone Hydrochloride (Narcan®) ww.c�ww��waw�.(r�wwG�r�uw�ww.wwaw.cr�% (��1�'w�w w ACTfl O NS: Naloxone antagonizes the effects of opiates by competing at the same receptor sites.When given IV,the action is apparent within two minutes. I or SC administration is slightly slower. If ND-1 CAT]0NS: • Naloxone is indicated for the complete or partial reversal of central nervous and respiratory system depression secondary to opiate narcotics or related drugs such as, but not limited to: — Heroin, Meperidine (Demerol), Codeine, Morphine, Methadone, Lomotil, Hydromorphone (Dilaudid), Pentazocine (Talwin), Propoxyphene (Darvon), Percodan, Fentanyl (Sublimaze) (Known on the street as"White China") C �NT`IfAll NII�IVCATIVONS': ...................................................................................................... Known hypersensitivity to Narcan. W 4,R II\If II\M S ........................................................ Naloxone should be administered cautiously to persons including newborns of mothers who are known or suspected to be physically dependent on opiates it may precipitate an acute abstinence syndrome. If patient is intubated and airway is controlled do not administer Narcan (excludes cardiac arrest). May need to repeat Naloxone since duration of action of some narcotics may exceed that of Naloxone. Naloxone is not effective against a respiratory depression due to non-opiate drugs. Use caution during administration as patient may become violent as level of consciousness increases. POSSIBLl ADVERSE REAC"1"oONS AND SIDE EI-I=ECTS: ....................................................................................................................................................................................................................................... CNS:Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear production, sweating and seizures secondary to withdrawal. Cardiovascular: Hypertension, hypotension,ventricular tachycardia, pulmonary edema and ventricular fibrillation. GI: Nausea and vomiting. DOSAGE: AdUIltP An initial dose of 2 mg may be administered IV/IO/IM/PRN. If no response after 4 mg,then condition is probably not due to narcotic. (Fentanyl may require large doses of Naloxone to reverse effects). fll'eo„:Jiiiafidc� 0.1 mg/kg IV/IO/IM/PRN. Time/Action Profile: Onset: Pealk Duration IV: 1-2 minutes unknown 45 minutes Naloxone Hydrochloride (Narcan®) Dr. Sandra Schwemmer, D.O. 1 0-2 1 364 Elite Medical Transport N DRUG FORMULARY N O Nitroglycerin (Nitrostat® Nitrolingual® Spray) t"IFIONS: Nitroglycerin is a direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilatation as well. There is a decrease in venous return, which decreases the workload on the heart and thus, decreases myocardial oxygen demand. Sublingual nitroglycerin is rapidly absorbed. Pain relief occurs within one to two minutes and therapeutic effects can last up to 30 minutes. lNDICA"l"loN : • Chest pain or discomfort associated with suspected AMI. • Pulmonary edema with hypertension. ��°� � s,. � OIII ""l""III° IIIIII �' III ""l""IIIOIIISm •.... Systolic BP 10�• � 0 mmHg • Children under 12 • Patients on erectile dysfunction drugs that fall withintime parameters (i.e. < 36 hours) • Know hypersensitivity to the drug • Evidence of a positive V4R in the setting of an Inferior wall MI PIRECAU"lwlOINS: ....................................... Nitroglycerin tablets are inactivated by light, heat, air and moisture. Must be kept in amber glass containers with tight-fitting lids. Do not leave cotton in container. Once opened, nitroglycerin has a shelf life of 3 months. Do not shake Nitrolingual spray. Alcohol will accentuate venodilating and hypotensive effects. POSSIBLE ADVERSE REAC"l"IONS AND SIDE EEC"l"S: ........................................................................................................................................................................................................................................................................ CNS: Headache, dizziness, flushing, nausea and vomiting. Cardiovascular: Hypotension, reflex tachycardia, and bradycardia. DOSAGE: Adult: 0.4 mg (1 tablet or 1 spray sublingual). May repeat in 3-5 minutes PRN. Time/Action (Profile: Onset Peak Duration SL: 1-3 minutes unknown 30-60 minutes Nitroglycerin (Nitrostat® Nitrolingual® Spray) Dr. Sandra Schwemmer, D.O. 1 0 22 365 Elite Medical Transport DRUG FORMULARY CD Odansetron (Zofran®) ........ ......... m�uwwu�ru�i��J!��➢'U9U Antiemetic, Zofran blocks the actions of chemicals in the body that can trigger nausea and vomiting. Selective 5-HT3 receptor antagonist. Category B in pregnancy. CONCENTRATION g/2 I lllkDlt°,AWIIWIOIIkS: Used for a patient with nausea unrelieved with comfort measures, uncomfortable due to 2 g/ I the nausea during transport and/or with a potential for airway compromise related to vomiting. • Nausea and vomiting due to chemotherapy. • Prophylactic use prior to administration of pain management medication. • Nausea and vomiting with moderate to severe dehydration or electrolyte imbalance. C011lk"I""III' IIIIIIkII' IIIC "I""IIIOIIIkS: ..................................................................................................................... Hypersensitivity(anaphylaxis)to Ondansetron or any of components of the formulation. or to any medicine similar to ondansetron, including dolasetron (Anzemet), granisetron (Kytril), or palonosetron (Aloxi). WA III'°t I`Y U I`Y G USG: ................................................................. Ondansetron is extensively metabolized in the liver and should be used with caution in patients with hepatic disease, hepatitis, or elevated hepatic enzymes. Patients with a history, or family history, of Long QT syndrome; transient EKG changes have been seen with IV administration including QT interval prolongation. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: CNS: Headache, Dizziness, Drowsiness, Fatigue GI: Diarrhea, Constipation, Abdominal pain, Dry Mouth MISC: Rash, Shivering, Fever, Hypoxia, Urinary Retention, Muscle Pain RARE: Bronchospasm, Transient blurred vision after infusion DOSAGE: Adult ' Pediatrics >40kg: .4 „k:; slow IVP (not less than 30 sec) I'°r.: a°ILu imULUIIaIII: .:a.mg Time/Action Puroflle: Onset Peak Duration IV 1-2 min 14-30 minutes Weight dependent Dr. Sandra Schwemmer, D.O. Odansetron (Zofran®) Revised 02..16-18 ddendL llr m 1 2-2 366 Elite Medical Transport M DRUG FORMULARY N O Oral Glucose (Insta Glucose) � a gogg AC"IFT INS: Increases blood glucose levels slowly. I IN I I A"r-io NS: BS > 60 mgdl, patients who are altered but alert enough to take the command to swallow. CIII "I""III' IIIIII �' IIIC "I""IIIIIIS: ..................................................................................................................... Patients unable to swallow or Stroke symptoms. ............................................................................... None when patient can swallow, risk of aspiration if given improperly. ADVERSE REAC"II"IONS AND SIDE "II"S: .................................................................................................................................................................................................................... GI: Nausea DOSAGE: Adult: 1 tube F''I ,64tii,,' mc: 1 tube Time/Action Profiled Onset: Peal4 Duration PO: 10 minutes unknown Unknown Oral Glucose (Insta Glucose) Dr. Sandra Schwemmer, D.O. 10-23 3s7 Elite Medical Transport DRUG FORMULARY N O Sodium Bicarbonate �, 1JI lU1 l ("IFIOII' S., Increases PH to reverse acidoses. IINIIC"A°noIN : • Metabolic acidosis in cardiac arrest • Tricyclic overdoses with QRS > 0.1 • Electrocutions • Hyperkalemia • Methanol / Ethylene glycol toxicity • Severe ketoacidoses pqi i COIII 1III' IIII II' IIIC "I""IIIOIIICSm and Alkalotic states C H F a es WA C3'"Y I I'Y(„ m Excessivethe rapy inhibits oxygen release, reduces the ability to defibrillate, may precipitate other medications and administration should be guided by blood gases. Do not give concurrently with any other medication, flush the line before and after administration. POSSIBLE ADVERSE R ACwI"IONS AND SIDE wI"Sn ....................................................................................................................................................................................................................................................................... Metabolic alkalosis, and may crystallize in IV solutions. DOSAGE: Adult: 1 mEq/kg IV push, then % the dose q 10 mins. Electrocutions: 2 mEq/kg IVP F'''I e64Itii,'ioc: 1-2 mEq/kg diluted 50:50 with Normal Saline Time/Action IPuroflle: Onset Peak Duration IV/IO: Unknown Unknown Unknown Sodium Bicarbonate Dr. Sandra Schwemmer, D.O. 10-24 ass � � M o ( / Co \ co 2 w » ® \ \ ) § •\ •\ IL) / \ U % o U Cl) / 'B o Cl) .) § '/ •g ƒ 1.4 ( 0 2 o E [ o b ® / ° u a � 2 W o •2 = ® \ 2 E [ § c o Q w } / / [ _ _ } q R / / •� = U § § \ 0 o G o co n c 4 \ [ 2 2 k ° § ) 2 % k ) � F C Q / ~ � w / 6 � g / Q / co / ( » 2 { ) \ k § Z 4 « U ( 7 / { / u * § ( 7 / / ■ — I t S t 2 2 ,o o w ¥ c � ƒ � � �% Q \ Q w [ t m =0 2 / / o u1.4 � » / � \ \ f \ Z co 3 2 = ./ ' .g � 0 $ k � § � iz)co \ 3 0 w \ % 2 / coDO ° ' El / \ q / — \ .) 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