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Item R1 R1 BOARD OF COUNTY COMMISSIONERS COUNTY of MONROE �� i Mayor Holly Merrill Raschein,District 5 The Florida Keys Mayor Pro Tern James K.Scholl,District 3 Craig Cates,District 1 Michelle Lincoln,District 2 ' David Rice,District 4 Board of County Commissioners Meeting January 31, 2024 Agenda Item Number: R1 2023-1917 BULK ITEM: No DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: James K. Callahan N/A AGENDA ITEM WORDING: A public hearing to consider an application for issuance of a Class A Certificate of Public Convenience and Necessity COPCN to Elite Medical Response for the operation of an ALS and BLS Transport Service, as well as a Non-Emergency Transport Service in Monroe County, Florida, except for within the city limits of Marathon. for the period 02/01/2024 through 01/31/2026 for responding to requests for inter-facility transports. Elite Medical Response is not permitted to perform 911 emergency response work in Monroe County. ITEM BACKGROUND: Elite Medical Transport Inc. currently has a Class A and Class B COPCN for the period 7/22/23 and ending on 7/21/25. However, due to a name change, they are requesting a new Class A COPCN only in the name of Elite Medical Response for the period 02.01.2024 through 01.31.2026. Monroe County Code Sections 11-171 et seq., requires the BOCC to hold a public hearing to consider the application for a new certificate. At the hearing, the Board may receive a report from the County Administrator or his designee, testimony from the applicant or any other interested party, and other relevant information. The Board will consider the public's convenience and necessity for the proposed service and whether the applicant has the ability to provide the necessary service(s). The Board shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reason(s) for denial. Per County Ordinance, all existing COPCN holders were notified via email of the Public Hearing for the new COPCN. PREVIOUS RELEVANT BOCC ACTION: On July 19, 2023, agenda item(D2), the BOCC approved the issuance(renewal) of a Class A and Class B COPCN 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 22,2023 through July 21,2025 for responding to requests for inter-facility transports. On July 21, 2021, agenda item(R2),the BOCC approved the issuance of a new Class A and Class B COPCN to 4457 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. INSURANCE REQUIRED: No CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval DOCUMENTATION: Notice of Public Hearing-Elite Class A COPCN.pdf Elite Class A COPCN Certificate - Expires 01.31.2026.pdf Elite Medical Response Class A Application—Redacted.pdf FINANCIAL IMPACT: Effective Date: 02/01/2024 Expiration Date: 01/31/2026 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, mandated by the State of Florida 4458 NOTICE OF PUBLIC HEARING NOTICE IS HEREBY GIVEN TO WHOM IT MAY CONCERN that on January 31, 2024, at 9:00 A.M. or as soon thereafter as the matter may be heard, at the Marathon Government Center, 2798 Overseas Highway, Marathon, Florida, the Board of County Commissioners of Monroe County, Florida, intends to consider the following: ISSUANCE OF A CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY TO ELITE MEDICAL RESPONSE FOR THE OPERATION OF A CLASS A ALS AND BLS AMBULANCE TRANSPORT SERVICE WITHIN MONROE COUNTY, FOR THE PERIOD FEBRUARY 1,2024 THROUGH JANUARY 31,2026. The public can participate in the January 31, 2024 meeting of the Board of County Commissioners of Monroe County, FL by attending in person or via Zoom. The Zoom link can be found in the agenda at „Po......J,,,ll;�1, , ;ar oe,l,.;o �„n, y.... ,ll;1, „a, izensJdel`ai.!ltaas� . ADA ASSISTANCE: If you are a person with a disability who needs special accommodations in order to participate in this proceeding,please contact the County Administrator's Office,by phoning(305)292- 4441, between the hours of 8:30a.m.-5:00p.m.,prior to the scheduled meeting; if you are hearing or voice-impaired, call "711': Live Closed-Captioning is available via our web portal @ t l„W g., for meetings of the Monroe County Board of County Commissioners. DATED at Key West,Florida, this day of January, 2024. (SEAL) KEVIN MADOK, Clerk of the Circuit Court and Ex Officio Clerk of the Board of County Commissioners of Monroe County, Florida Publication Dates: Keys Citizen: Keys Weekly: Thur., News Barometer: Fri., 4459 0 � � � o � o o / \ ( / Co co ° / \ 0 \co » / \ ( / 'E •2 2 I \ co co 0 g c g C,) E § 2 ƒ } \ � H ( 0 2 0 [ [ 0 7 E / co _ � / / \ @ 7 \ } ± \ 0 0 0 Q co o [ _ o § / Z = = o w \ _ CY) \ Z \ / / ƒ 0,) ) \ \ 0 \ / \ 7 IL) \ Z, E / 14Z, C,) � \ / 2 ƒ W Q o \ o \ \ / / .§ < { t } 2 / o ) / « Q_ > w 7 2 ) t _ ' = o 5 ■ Z It S t2 w ,om o w c e ■ Q • c = Q .§ » 3CD _ u 2 k ) ƒ \ 0 \ Q \ 2 E § \% 2 ® / u 14Z 2 \ ) [ � j 2 ® 004zt � Zr, � m 0 0 0 QL) / % 6 \ ( � °2 \ / J \ ) a) / ƒ co $ k( � ) / \ / } R I 1-4 0 o / \/ \ Z) \ co/ E QL) ® 0 f 7 \ \ \ ¥ �0 co� / \ 1-0 k \ / CN « \ \ 0 a) @ 0 / \ U- § k / / « / co / / \ \ / \ co / � $ •� � / 2 § au)) § / / / � / / / cfl d m r d, MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A EMERGENCY MEDICAL SERVICE .. IlfOlilffftllAlllfWdIINIM1IMriMXillllllmlllfill .. WIIW (PRINT OR TYPE) ❑■ INITIAL APPLICATION-$950.00 RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE:# 1. NAME OF SERVICE ELITE MEDICAL RESPONSE BUSINESS MAILING ADDRESS 101413 Overseas Highway, Key Largo, FL 3.3037 BUSINESS PHONE NUMBER 786-478-6064 EMERGENCY PHONE NU 7m NUMBER 86-478-6064 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) LLC DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 08/24/2023 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITIONITITLE Joel Kestenbaum 41 45 Main Street,Brooklyn,NY 11201 718-907-7707 CEO Isabel Rodriguez 52 7320 N Augusta Dr, Hialeah,FL 33015 786-889-1663 Administrator 4. LEVEL OF CARE TO BE PROVIDED: HBLSorKALS IF ALS: M TRANSPORT or❑ NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): Monroe County 6. 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 N to d' 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 8. LIST THE NAMES AND ADDRESSES OF THREE(3)U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: NAME ADDRESS Dr. Sandra Schwemmer 101413 Overseas Highway, Key Largo, FL 33037 Brandon Ferbeyre 21100 Bluewater Rd, Cutler Bay, FL 33189 Jose Puri 20610 Marlin Rd, Cutler Bay, FL 33189 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 O 'THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND HE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN THIS APPLIC ON, THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. SIGNATURE OF APPLICANT 1 AUTHORIZED REPRESENTATIVE ;: ►w NEISY N.ALVERNIA *. COMMISE1011II HH 05851 E "} v'.'Expires Demnber 11 2024 NOTARY SEAL '•.Y%wR 'Bad�dThuTroyrFainN�wrmcet003lS70i! NOTARY SIGNATURE DATE Page 2 of 6 M tG d' PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Angel Jesus Diaz 12/01/2024 Brandon Ferbeyre 12/01/2024 Gregory Gutierrez 12/01/2024 Jose Puri 12/01/2024 Cody Robertson 12/01/2024 Leandro Hernandez 12/01/2024 Michael Colon 12/01/2024 Matthew Moscoso 12/01/2024 Page 3 of 6 dq to d PERSONNEL--EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Michael Guerra 12/01/2024 Kristian Moscoso 12/01/2024 Ashley Rios 12/01/2024 Ruben Roldan 12/01/2024 Robert Sarmiento 12/01/2024 Michael Souffront 12/01/2024 Keilor Zuniga 12/01/2024 Christopher Cash 12/01/2024 Jose Chacon 12/01/2024 Bags 4 of LO (D d' d� w F- ° c w i k W w LL LL LL LL LL LL LL LL LL LL LL. LL. LL LL LL LL LL LL LL0-3 Q z U w a � a a w c A w z x O a � c F o0 A ; w Qz Q � r W � J Gz Q OQ U zw nr ,+ O '� lV LT. o � WW t N N _ E�- �QN N p W cc o m v O U .n N a) o q °w o z '0 sl O 4 F•�Q •L o rn c rn Q c U CU U Q m ww z � cx � U cfl cfl d � a U) U) U) U) U) U} a. zz z Z Z Z ch zHHHHHH n U) U) U) U) U) U) � JJJJJJ mmmmmm w U) U) co U) (n U) z r V— � CD CO 0 0 CD w > co co Cfl (D CD CD m z � yz Z Z _ z _ 0 C3 C3 C3 PC co ® r � y a s (L x N cVo a U W W W W W W r o 0 o a ❑ V m a d r- 0 0 0 C) C) 0 N N 041 N N 1 N a a 0 0 0 0 0 Lo 0 0 0U-5 w z w w w w w w d �� BOARD OF COUNTY COMMISSIONERS County of Monroe ' 'IP t Mayor Holly Merrill Raschein,District 5 The Florida Keys 1 Mayor Pro Tem James K.Scholl,District 3 Craig Cates,District 1 Michelle Lincoln,District 2 r. David Rice,District 4 Monroe County Fire Rescue 490 63Td Street Ocean Marathon,FL 33050 Phone(305)289-6004 �" MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: December 1, 2023 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check- dated November 22, 2023 in the amount of$950.00 to be deposited in revenue account 141-342000-RC 00345. This check has been issued for the initial application of a Class A Certificate of Public Convenience for Elite Medical Response. Thank you, c�� ?;'6 v Cara Johnson 4467 @ &\ 2 § ( � a ( o § q } 0 - 6 LO �0) $ ( U 2 \ � \ i q 2 \ k E $ ■ 2 @o , 7q ` � 2 � . R . kq . . m r f g . \ k R . d § z 0 k E CL z / ¢ t § q o o -2 g / § « � ■ c o w c a gao$ 22 & 2@ E U k kaq 2 § 2 Ch 3Ea � � � O ■ 00 § « § CL kiTL U >%= E w ¥ 2 2 @ 7 20 � 2 2 § q § % « q % \ w� U I 2 & 2 f- &o t � « 2» �u Q O . . . ƒk LLJ d . iqI!i"g, ,("wq it ip'::v'f I:� ,p,m I"g Uj,:14r 11,10;1, l,ei,ViiitdR V) "V") 0�/ ,ilk W :1 q I J I � lrf[ 1 j,to i. "W'Y"XI s 4 1 wu3 ifl 0 ,IWW t, r K. mo,,,m(lp UfP pop(la,[) 0 ti i t Monroe County Rates 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 $35.00 ti d' d' C Oaf3lmDmvY) CERTIFICATE OF LIABILITY INSURANCE DATE(MM 2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAME: JDseph Stein Cornell Insurance Services PH ' (732)902-2420 (732)AIC 902.2424 ..Na Raritan Plaza III )stein(r�comellins cornADDRE'S: 105 Fieldcrest Ave,Suite#104 INSUREi S AFFORDING COVERAGE NAIC I Edison NJ 08837 INSURER A: Coverys Specialty Insurance Company 15686 INSURED INSURER B: National Indemnity Company Of the South 42137 Elite Medical INSURERC: Benchmark insurance Company 101413 Overseas Highway INSURER D: INSURER E: Key Largo FL 33037 INSURERF: COVERAGES CERTIFICATE NUMBER; 23-24 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. LTR TYPE OF INSURANCE INSO WVD POLICYNUMBER tMMIDONYYYJ (MM/DDNM) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIM$MADE ®OCCUR PREMISES Ea occurrence $ 50,000 Professional Liability MED EXP oneperson) S 5,000 A X Abuse&Molestation TBD 08/31/2023 08/3M024 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE S 3,000,.000 POLICY ❑JECT PRO- ❑LOC PRODUCTS-COMPIOPAOG S 1,000 000 HPRO- OTHER: Professional Liability a 1MJS3M AUTOMOBILE LIABILITY BIND N L LI IT $ 1.000,000 Ea a,ddE,t ANY AUTO BODILY INJURY(Par person) S B OWNED SCHEDULED 74APBOO7071 08/31/2023 08/31/2024 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON•ONNED PR PERTY MA S AUTOS ONLY AUTOS ONLY Per aCCldeM Uninsured motorist s 5D 000 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS 1 $ WORKERS COMPENSATION PER OTH• AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT S 1,000,D00 C OFFICERIMEMBER EXCLUDED? N IA BID370623-01 04/18/2023 04/18/2024 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Evidence of Insurance 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 01988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD N ti d' d' M November 13,2023 As per the existing MEDICAL DIRECTOR SERVICE AGREEMENT between Elite Medical Transport and Professional Emergency Services, Inc. signed and dated December 11t,2020, is now in effect and in agreement between Elite Medical Response and Professional Emergency Services, Inc. By signing below both parties agree to the following term changes.This agreement will be auto-renewed yearly on November 11 of each calendar year. The compensation is structured for an annual 5%increase every renewal year.The current rate in November 2023 is$5,209.31. Additionally, any and all protocol amendments, policies,or exceptions are also in effect and assigned to Elite Medical Response, LLC Professional Emergency Services, Inc. C/O Dr.Sandra Schwemmer P.O. Box 379 Taverns r, F 47 Isabel Rodriguez Elite Medical Response LLC 101413 Overseas Highway Key Largo, FL 33037 M t ti d' d' AGREEMENT BETWEEN ELITE MEDICAL TRANSPORT,LLC. AND PROFESSIONAL EMERGENCY SERVICES,INC. For NZDIC"IMECTORMLIKES This is an Agreement between Elite Medical Transport,LLC, 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") AND Professional Emergency Services, Inc., (hereinafter referred to as the CONSULTANT) whose principle place of business is P.O. Box 379, Tavernier,FL 33070 and who is represented by Dr. Sandra Schwemmer„ WHEREAS, ELITE,is a provider of basic and advanced life support medical transport services, and is required by Chapter 401, Florida Statutes, to contract with a licensed physician to serve as ELITE'S "MEDICAL DIRECTOR7, and WHEREAS,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 CONSULTANT agree as follows: ARTICLE 1 AQ=OF SER CES 1.1 Under the direction of ELITE Director of Operations and as defined in Florida Administrative Code Chapter 64J-i.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 with 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 term is defined by Section 252.34(3), Florida Statutes. Such"off-fine" services will be provided at a rate I d ti d d of$250.00 per hour or at a rate mutually agreed upon by the CONSULTANT and ELITE Chief of Operations. 1.1.3 Develop and implement a transport patient care quality assurance program to assess the medical performance of ELITE Paramedics and EMTs, Clerical and administrative support will be provided by ELITE. L 1.4 Audit the performance of ELITE 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. 1.1.5 Provide a DEA registration for ELITE in order to provide equipment, medications, including controlled substances to ELITE, if needed. DEA registratiop shall include the address at which controlled substances are stored. Proof of such registration shall be maintained on file with ELITE and shall be readily available for inspection. ELITE will forward any and all renewal documents and correspondence received regarding the DEA to CONSULTANT to assure continuous registration, and will pay for the cost of the DEA certificate or reimburse CONSULTANT for cost of such registration. 1.1.6 Review ELITE's security procedures for medications, fluids and 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. 1.1.9 Notify the Department of Health in writing, when applicable, of each substitution by the FUM of equipment or medication. 1.1.9 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 EMT/P 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 State and Federal requirements. Medical follow-up care to ELITE employees will be billed at$250.00/hr. W) ti d d ARMLE 2 ,AEON A -"MUM OF EAXMI 2.1 ELITE agrees to pay the CONSULTANT as full compensation for the services described in Article 1 an annual fee of 154,00, to be paid to the 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 will be invoiced separately at a rate of$250.00 per hour, subject to approval of ELITE Chief of Operations. 2.2 ELITE agrees to pay the CONSULTANT on the first day of the month for each month in which CONSULTANT'S service are rendered, ALU LE 3 MEMEMM 3.1 "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. 3.3 "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. 3.6 "Operations Chief' means the highest-ranking Paramedic in charge of ELITE medical transport services. AUK N 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 to the Director of Operations. 3 cfl ti d d 4.3 The CONSULTANT shall perform such other 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 time. ARU%Fds LLME P 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 Mvff/P and EMT employment records and patient medical transport records. 5.2 ELITE will provide CONSULTANT appropriate administrative support including secretarial support services and other equipment as may be needed from tune to time to provide oversight to EMT/P and EMTs. 5.3 ELITE will comply with FL Chapter 60-1 in all aspects related the performance of medical transport operations. AMCLE TERM 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 the option to renew this Agreement for five additional one year terms subject to the 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 (S%) annually for each subsequent year. ARIHJ,E URMULA77011 7r 1 If through any cause„ the CONSULTANT fails to fulfill its obligation under this Agreement, ELITE shall have the right to terminate this Agreement upon providing written ninety(90)day notice to the 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 to the 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 ELITE. If CONSULTANT terminates without cause, ELITE shall compensate CONSULTANT for all services performed prior to termination date. ti ti d d ,�R1`ICLE$ SC .A OUS 8.1 Qmmra13 livgrables. Any files, documents, studies, transport report reviews, training curriculum and other data prepared by the CONSULTANT, (excluding standing medical orders and medical treatments protocols, infection control manuals), in connection with this Agreement are and shall remain the property of CONSULTANT, and shall be delivered to the CONSULTANT, upon request; no later than sixty (60)days after termination of this Agreement. 8.2 No CM, n=t Fee. 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 for the CONSULTANT to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual or firm, other than a bona fide employee working solely for the CONSULTANT, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making 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 amount of such fee, commission,percentage,gift or consideration. 8.3 P The CONSULTANT shall not discriminate against any employee 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. 8.4 ladg=dent_Co,tractor. The CONSULTANT is an independent contractor under this Agreement. Services provided by the CONSULTANT shall 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, purchasing policies and other similar administrative procedures applicable to service rendered under this Agreement shall be those of the CONSULTANT. 8.5 Amigment 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 00 ti dq d ALE 9 MURANU 9.1 The ELITE shall maintain in force and effect for the term of this Agreement the insurance described below: 9.1 l ProfeWonal-nd GentrA Liability. ELITE shall provide professional and general liability insurance with minimum limits of$1,000,000.00 per occurrence for the CONSULTANT and Medical Director during the term of this Agreement. ELITE shall be responsible for maintaining this professional liability insurance for a minimum of three years from the date of termination of this Contract. The Professional and General Liability Insurance certificate will specify coverage for"BLVALS Medical oversight". 9.2 ELITE will provide certificate or proof of such insurance to the CONSULTANT on an annual basis. CONSULTANT will be provided thirty (30) days notice of cancellation and/or any restrictions placed on coverages of the professional and general liability insurance provided/procured by ELITE during the term of this Agreement. ELITE will be responsible for the payment of any deductible and/or self-insured retentions in the event of a claim. 9.3 ti . It is recognized that questions in the day-to-day conduct of this Agreement will arise. ELITE designates the Chief of Operations, or designee, as the person to whom all communications pertaining to the day-today conduct of this Agreement shall be addressed. 9.4 All Prior Agreements Super. 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 from the terms shall be predicated upon any prior representations or agreements,whether oral or written. 9,5 Notio&. 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 E = Elite Medical Transport, LLC c/o Schraige Goldblatt 1200 N.Federal Highway, Ste. 200 Boca Raton, FL 33432 4 ii V the CONSULANZ Professional Emergency Services, Inc. c/o Dr. Sandra Schwemmer P.O.Box 379 Tavernier, FL 33070 9.6 COMI . The parties irrevocably submit to the jurisdiction of any Florida state or federal court in any action or proceeding arising out of or relating to the Agreement, and unanimously agree that all claims in respect of such action or proceeding may be beard and determined in such court Each party further agrees that venue of any action to enforce this Agreement shall be in Monroe County,Florida. 9.7 Fee a. The parties agree that this Agreement shall be construed in accordance with and governed by the laws of the State of Florida. If either ELITE or the CONSULTANT is required to enforce the terms of this Agreement by court proceedings or otherwise, whether or not formal legal action is required, the prevailing party shall be entitled to recover from the other party all such costs and expenses including but not limited to court costs, and reasonable attorney's fees. 9.8 HrgAngs. 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 this Agreement. The Exhibits, if not physically attached, should be treated as part of this Agreement, and are incorporated by reference. 9.10 SWURbilitY 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 the application of such provision to persons or situations other that those as to which it shalt have been invalid or unenforceable shall not be affected, and shall continue in Hilt force and effect, and be enforced to the fullest extent permitted by law. IN 'WITNESS 'WHEREOF, the parties hereto have set their hands and seal the day and year first written above. 0 co Iq PROFESSIONAL EMERGENCY SERVICES,INC. BY: Nair Sandra Schwemm;er Witnes Title: President s: � �P��nd`c�2� LCi 5 Nl c'7 ELITE MEDICAL TRANSPORT,INC. aging ember: Schraige Goldblatt Witness: T- oo dq d� Elite Medical Response 2023 ALS BLS, MEDICAL t PROTOCOLS November 1, 2023 1 approve the most recent version of the Florida Regional Common EMS Protocols for use by Elite Medical Response personnel for interfacility transports. These protocols may be amended from time to time as needed. Sandra Schwemmer,D.D. Medical Director, Elite Medical Response .p .p oo N M 00 d' d' Elite Medical Response MEDICAL PROTOCOL Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS AIRWAY MANAGEMENT 1 RESPIRATORY. MERGENCiES` , ; SECTION1 Airway Rescue for the Endangered Airway Revised1-1 Basic and Advanced Airway Management 1-2 Respiratory Distress Asthma, COPD, CHF 1-3 ADULT;CARDIAC EMERGENCIES SECTION 2 Asystole 2-1 Brad cardia 2-2 Cardiogenic Shock 2-3 Chest Pain 1 Acute Coronag S ndromes 2-4 STEM 1 ACS Checklist (MCFRF- 075) 2-4 Induced Hypothermia 1 ROSC 2-5 PEA(Pulseless Electrical Activity) 2-6 Post Arrest 2-7 Pulseless Arrest(V-Fib, V-Tach) 2-8 PVC's 2-9 Tachycardia-Acute with Pulses 2-10 'tc;;nrtia��ti,r.:;i� r ,�aa a,�o��Z r i i��ri�rrr,�i iii „��.,r:ai,�� ;,..ii /., �.,o ✓�,;,.,_�i /car,,,_�i�,i,r�,1.r,,�,i��rr.F.k ruHa,r�/u,��;iri. o i»,�,n;� r r .,,�.�ia�,au�l. Anaphylaxis 1 Allergic Reactions 3-1 Cyanide Poisoning 1 Smoke Inhalation 3-2 Diving Sickness 3-3 Electrocution 1 Lightning 3-4 Envenomation I Bites 1 Stings 3-5 Hyperhhermia 3-6 Hypothermia 3-7 Marine Envenomation's 3-8 Overdose 1 Poisoning 3-9 Pepper Spray Exposure 3-10 NtEDICAL EMERGENCIES` N�4, v«L,�ci,,,�„ �1. � � 4, Abdominal Pain 1 Acute Abdomen 4-1 Altered Mental Status 1 Unconscious States 1 ETOH 4-2 GI Bleed 4-3 Psychiatric/Behavioral 4-4 Seizures 4-5 Stroke 4-6 Stroke Alert Checklist(MCFRF-073) _ 4-6 Elite Medical Response MEDICAL PROTOCOL Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS OBSTETRICAL:/GYNECOLOGICAL EMERGENCIES SECTION 5 APGAR - ewborn Scoffla, A Childbirth - Labor and a live 5-2 Childbi h - Com ilications 5-2 Childbirth - Illustrations 5-2 Postpartum Vaginal Bleed I Vaginal Bleed Unknown Origin 5-3 Pre-Eclam sia/Eclam sia 5-4 PEDIATRIC]ADOLESCENT EMERGENCIES -SECTION'6 Acute Traumatic Pain- Pediatric Addendum 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 6-8 Tachycardia- Pediatric 6-9 Trauma Alert Criteria - Pediatric 6-10 Trauma Alert Criteria Form MCFRF-097 - Pediatric 6-10 PEDIATRIC/ADOLECENT PROCEDURES „ PP SECTION 6 Cricohroid Pediatric fiP- otomy- Needle eatr , Y.�„ _.. , ,m _ , m ........� 1 PEDIATRIC 1 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 13' and 2"d Degree Revise 7-2 Burns 2"d and 3rd Degree/Chemical Burns Risvism 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 Taser Injury 7-8 p Tension Pneumothorax/Hemothorax 7-9 0000 Trauma Alert Criteria 7-10 .p Trauma Alart rrifAria Fnrm (MOFRF-096) 7-10 LO co dq d Elite Medical Response MEDICAL PROTOCOL Dr. Sandra Schwemmer, D.U. Medical Director TABLE OF CONTENTS PROCEDURES - SECTION i8 Bougie - Endotracheal Tube Introducer Addendum A8-1 Chest Needle Decompression 8-1 CPAP Concepts 8-2 CPAP Assembly with Nebulizer Revised 8-2 Cricoth roidotom -Surgical 8-3 DuoDote Auto Injector 8-4 Endotracheallntubation (Oral) 8-5 External Ju ular IV Access 8-5 EZ-10 Insertion 8-7 EZ-10 Landmarks 8-7 -Gel Revised 8-8 Infectious Diseases (coming soon) 8-9 Lucas Device 8-10 Nasal Atomizer Addendum A8-11 Nlasotracheal Intubation 8-11 Nasogastric Tube NG Tube) 8-12 Spinal Motion Restriction 8-13 Stroke 1 Stemi Action Sheet 8-14 Synchronized Cardioversion 8-15 Telemedicine PolyCom 8-16 Tourniquet-C.A.T. (Combat Application Tourniquet) Addendum A8-17 Transcutaneous External Pacing 8-17 Ventilator Concepts (Page 1 of 3) 8-18 Ventilator Control Module (Page 2 of 3) 8-18 Ventilator Diagram (Page 3 of 3) 8-18 Video La n osco e- King Vision 8-19 REFERENCE �'� 1�w ECTIO � 12 Lead Reference Guide 9-1 Determination of Death 1 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 Nines 9-6 Stroke Scale (Cincinnati, Mend, NIHSS) 9-7 Termination of Efforts 9-8 Trauma Transport Protocols 9-9 �l Elite Medical Response MEDICAL PROTOCOL Dr. Sandra Schwenlmer, D-U. Medical Director u TABLE OF CONTENTS SECTION 10 DRUG FORMULARY > 10-1 Adenosine Tri 10-2 phosphate (Adenocard) 10 2 Albuterol (Proventil,Ventolm) 10-4 Amiodarone (Nexterone) 10-5 Aspirin 10-6 Atropine Sulfate as Cardiac Agent 1 Q-7 Atropine Sulfate as Antidote for Poisonings 10-8 Calcium Chloride 10% 10-9 Cyanokit 10-1 Dextrose 50% and 25% d-glucose) 10-1 Diaze Pam (Valium) Diphenhydramine HCL (Benadryl) 10-1 Hydrochloride (Intropin) 10-1 Dopamine Hy J0-14'10-15 ine Phrine 1.1000 A , .,,, ��n�d�� n�c,i�i�,.i�m 10- E E inephrine 'I'. 10,000 10-16 Fentany!- A10-1-1 Furosemide (Lasix) Addy"' Ketamin (Ketalar) 10-18 Magnesium Sulfate 50% A-Methapred) 10-19 Methylprednisone (Solu-Medral, 10-20 Midazolam (Versed) 10-21 Mor Nine Sulfate MS) 10-22 Naloxone Hydrochloride (Narcan) Al -22 Nitroglycerin (Nitrostat, Nitrolingual Spray) Addendum 10-23 Odansetron Zofran) 10-24 Oral Glucose (Insta Glucose Sodium Bicarbonate 8.4% and 4.2% .p .p oo rn ti co dq r 77o , .0 10 ..... r J O LM N C g s CLo ..] E 'H O µ i u W l „C 0 I � � ll��Jn 11 V ¢ a A f• � Q y � �� LD �f M G? 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Obtain 2nd IV& eve fluids if h otenstve Nitroglycerin: X1,__ x2 x3 Morphine, x1 x2 Presence of any of above Total fluids van: ml "STEMI Alert" criteria A V P<;V Launch Trauma Star&complete this form TPA EXCLUSION CRITERIA .� OPQRST Bleeding problem? Onset Of Events: — Previous stroke? Provocation: �nAcute hypertension? Quality: -„mm Streptokinase? � „ A Street within 8 months- Region: Recent surgery( � Radlat(ng: - [Coumadin/Warfarin? Severity(1-10): _ Time(Duration): Other medications:w Constant or Intermittent Other medical history: _ SIGNIFICANT HISTORY — Comments: Prior MI? If yes Date: - mm --- -�— — Angina? � Diabetes Meflitus? LNitro taken Prior toArrival?#Taken Lead Paramedic Signature: Sexual Enha�m ncement Meds Taken<24hrs �� u.,u+�..� tul�l�nl r�:,:,rai., ,�^�4 iro�pi., SPY),, SKM A W yl a.,. ***CALL JMH W/ PT REPORT& ETA 305-585-1248***ATTACH CODE SUMMARY*** PINK TO RESCUE WHITE TO FLIGHT CREW YELLOW TO HOSPITAL MCFR-075(09/2016) Dr.Sandra Schwemer,0.0. 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WITHOUT SYMPTOMS - V0 I 119 F A V PU GLUCOSE J4*MRS OR'WAKE UPSTROKE"} CA 1101,41S Ai:tull' ,Aks P("S"7 11,IEnICAJ' 01,15 11c)'A"t 1,41F i-'V.sP/f4'w iul��G =Sf IN CINCINNATI Stroke Scale MEND Exam SPEECH(Check box Indicating response) Only Check Box IF ABNORMAL I ---LICARI "You can't teach an old dog now tricks" SPEECH [ �1h,Repeats Sentence Correctly A" 3,113g,b "You can't teach an old dog new tricks"Aphask(Wrong or Inappropriate Words) r. Age, Month 10011111111, Question Patient for: Commands:Close Eyes,Open Eyes Dysarthrla(Slurred or Unable to Speak) CRANIAL NERVES CRANIAL NERVES L R Facla I Droop:Show Teeth or Smile Facial Droop:Show Teeth or Smile g Normal No Facial Droop Visual Fields:Four Quad a��m/1,121� Quadrants IN OWNS q, Abnormal=Left Sided Droop Horizontal Gaza:Side To Side X Abnormal R(ght Sided Droop LIMBS(Motor) L R LIMBS(Motor) MOTOR: Arm Drift;Close ey!&Hold both arms out Arm Drift:Close eyes,Hold both arms out Log Drift: Opens eyes and lifts each leg separately Normal=No drift SENSORY(Ask patient to close eyes) qp1q Arms:Check sensation by touch then p!nch ,11,111111, 11 0�'I I Z/ 1/1101/11/20/1'Abnormal 4 Left drift or unable to move Legs:Checksan sation by touch then pinch COORDINATION: Abnormal Bj&drift or unable to move gg/gw /p Arms:Finger to nose *Any falls&6kame>60 put Trauma Star on MW 11 IF flyl Leos:Heel to Sh In J/ then comp�lato MEND Exam* 1 1/111 IV NS KVO Gouge 11'111111'W �11)111///"' *Any fogs LaWa Trauma Sur tMI Nif Site "'Y'/ Tobroodki M"* 02 LPM % NIHSS: ELEVATE HEAD 306 r ACCEPTING NEUROLOGIST. 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OC CJAM Elite MEDICAL PROTOCOLSr MCFR PEDIATRIC TRAUMA CRITERIA FORM Date Crew ► ,Launch TL',aI 4f..a'Star And 'rel y: Pediatric Pt Name DOB Age OCk#: MOL' Time of Injury >PRJ MM-,Rescue Unit# Illfeight: HeNspbt: = I O Respiratory Rate<20(Infant c 1yr) AIRWAY Active AirvoyAssistance .� ❑ CIRCULATION Faint or NON-Palpable Carotid or Femoral Pulse <10 stoic BP P �„sy P<50 ❑ Altered Mental Status � DISABILITY � ` 0' PARALYSIS e Suspicion of Spinal Cord injury ❑ Ql p" r l o Loss of Sensation 2nd or 3rd Degree Bums x 10 eb TBSA :' e Amputation gt or above the Wrist or Ankle SOFT TISSUE e Any Penetrating injury to the Head,Neck,or Torsos ❑ " e GSW or Penetrating Injury to Extremities jL2L1hW Knee or Elbow a Chest Wall Instability or Deformity(Hail Chest) a Major Soft Tissue Dlsrutption3 ol Major Avulslon of Skin a Major De-Gloving u 6�k LONG ONr Open Lon Bone` " FXI SKFJ.ETAL R Q$ Multiple Dislocations or Fracture Sites ❑ " 10e Severe Facials InjurylFractures wlpotential Airway Compromise e Electrocution orLightning injury wl LOC or Visible Signs of injury p , e Blun ABD or Chest trauma in patlent W HX of Paralysis MECHANtls(IA (Paraplegia/Quadriplegia) ❑ ,a OF INJURY a Ejection from Automobile,Motorcycle,Golf Cart or Horse e Blunt Head,Chest or ABD Trauma In Patients on Anticoagulants u j • Auto vs PedashianlBl ist Thrown Run Over or wl I act>20 MPH ANY TWOGTRAUMA ALERT (9ply cho SIB we lighl 20 kg ❑ CIRCULATION Radial or Pedal Pulse not Palpable ,Systole BP a 90 r 131SABIUTY Amnesia or Loss of Consciousness ❑ $OFT TISSUE GSW or Penetrating Injury below th$Elbow or Knee ❑ LANs BONE Single Long Bone Fracture Site or Dislocation ❑ ,Y FV SKELETAL. e Death In Same Passenger Compartment MECHANISM a Intrusion Including Roof>12 inches on Occupant Site or>18 incises of An ❑ OF INJURY Site into PassengerP Any Compartment. :L o Fall> 10 Feet OR 2-3 Times the height of the Child Mabove cdteda are not met 6 patient condition warrants a trauma alert.Select paramedic Judgment,Include briefdescdpdon, Paramel Judgment: ❑ 1.Airway assistance includes manual jaw fhrosR continuous suctlawhg,or use ofofher adjuncts to assist venBleby of rill 2.Attemdmentalstates Include drowslness,tethargy,Inabli to Now commands,unresponsiveness to voice&total unresponslveness S.Ekcluding superficial wounds In which the depth of the wound can be determined. 4.Long bane fracture axes are defined as the(1)shaft of the humerus,M redlus and ulna,ill femur,(4)tlbla and Ill COMMENTS: **CALL NICKLAUS CHILDRENS W/PT REPORT 305-663-3560*"ATTACH CODE SUMMARY*** PINK-RESCUE WHITE-FLIGHT CREW YELLOW-TRAUMA CENTER MCFRF-097(09/2016) Dr,Sandra Schwemmer, DO evised 7-20-17 TRAUMA w PEDIATRICe�+ise .p N d' LO d' L' O c - V C v � = p fn p v °o d >, Z y E p W o y Q 0 �Cc 7 c`a p °d QU CL G a c y p.. 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" � N N ILL-cu cisa � O 7-9 M O C O m 46cs cD Q: A � d � C)l ap L a mCD 3 t � C e E ' N � N � N C` o, Tr ry G ui N, UP U too 00 L Now, w At gry r r rM C yam .v LV fi e— r, •� O �,r: 3 m 'O NO o m of; D o , o � E'. 0 O CL 7�� 0 ao t LO MEDICAL PROTOCOL I Elite Medical Response MCFR ADULT TRAUMA CRITERIA FORM Date Crew Launch Trauma Starand : Patient Name DOB Age_ OCA#: MOI: Time of Injury P/U MM Rescue Unit# Weight; Heli pot; AIRWAY Active Airway Assistance'21,Respiratory Rai 10,or>29 IRCU No Radial Pulse BP 90 BP�110 in Patient over 85 y/o E I �y , DISABILITY GCS< 13* PARALYSIS Suspicion of Spinal Cord injury Loss of Sensation [� -��2nd or 3rd Degree Bur-.��- .� ns a 15%TBSA a' + Amputation Wrist or Ankle r Any Penetrating injury to the Head,Neck,or Torso 0;` FTTISSUE • • GSW or Penetrating injury to Extremities at or a Knee or bow • Chest Wall Instability or Deformity(Flail Chest) • Crushed,Mangled, De-gloved or Puiseless Extremity LAND BONE FRACTURES 2 or more Long Bone Fractures' ElSevere Facial Injury/Fractures w/potentlal Airway Compromise + Electrocution or lightning Injuryw/LOC or Visible Signs of injury MECHANISM v Blunt ABD or Chest trauma in patient w/HX of Paralysis [� OF INJURY (Paraplegia/Quadriplegia) �' • Pregnancy 20 weeks w/ABD pain and Blunt Trauma AN'Y 1A0—-'TI UMA AL R,T fotwly chloo9 CIRCULATION Patients WRenaI Failure on Dialysis DISABILITY Head injury wdLOC,Amnesia or New Altered Mental Status Ell SOFT TISSUE ' Soft Tissue Loss injury(crush,de-gloving)or Deep Flap,Avulsion>5 inch Penetratln fn u to the Extremities to the Elbow or Knee LAND BONE Single Long Bone Fracture due to MVC or in a Patient on AnticoagulantsEl FRACTURES Z 55 Years Old El Ilk • Ejection from Automobile,Motorcycle,Gaff Cart or Norse + Blunt Head,Chest or ABD Trauma in Patients on Anticoagulants • Death In Some Passenger Compartment MECHANISM . Intrusion,Including Roof>12 inches on Occupant Slte or>18 Inclhles of Any Ej OF INJURY Site into Passenger Compartment. • Fall?10 Feet + Auto vs Pedestrian/Bicyclist,Thrown, Run Over or w/impact>20 MPH %. . Motorc icle,Goff Cart or ATV Crash>20 MPH if above crilet9a are not met 6 pai condldon warrants a trauma alert Select paramedic Judgment,lnclu&brief descrlp8on. Paramedic Judgment: El 1.Airway assistance Includes manual jaw 11rus;continuous sucWhg,or use ofot1w adjuncts to assist ventilatory efrorts. 2.Ekoluding aupe lklat wounds In whkh the depth of wound can be delermined. 3.Long bone fracture sites are defined as the(1)ahaft of the humerus,(2)radius and ulna,(8)ft m ,(4)tibia and Abuto COMMENTS, ***CALL RYDER W/PT REPORT 305-585-1148*"ATTACH C *** PINK-RESCUE WHITE-FLIGHT CREW YELLOW-TRAUMA CENTER CFRF--096(09/2016) Dr.Sandra Schwemer,D.Q. Revised 7-20-17 M TRAUMA CRITERIA FORM n r m ti `yi i� '`'Mir!" 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N c O O O CD O3 �i' u3, ° � C cL o ¢¢ mac m cco � o ° �I � -a c tea ._ o a xwC 3 tm QL 0 cc. ca `� Os1. � - OC V c p CE4O N N A cp E Y N .r O C O ° € ' ~ E cNm c � E ° � � a a C: O N E c n o c c❑ 0 3 orb N � c € '(n c o oc 3a) ct Q? c � �. . � � CL vCoro '0 �m m OH O to rn = c. rn2 ,a ,• v •� p o •c U `-' Z a 'v—, � Q � ❑ c�a o con N U�- ..' o � A A A 4 CA zl W d ELITE MEDICAL RESPONSE TRAUMA AND TREATMENT T LS � • d^n ;, ,mumomuuuuuuuuuuuuuuunmmmmuouuuuuuuraummmwimmuuuumurioi¢gum,wcuummr,imwimmmuuouemuummm,µuuuuminr�;w;i, wm._w„��...: mmmurva^unmww,mmma!,:uwummuumuummrrammmuuuuuuuuuuuouuumwwmmmmuuuuuuuouuuuummuumuuoumouuuummiwmmmouwu�m ream iwmuuuur,wmm mm rim., uumuuut, ummmw�mmr mra,« +m0000rtoi laDISPATCH PROCEDURES 9. 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. 6. 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. Dr. Sondra Schwemmer, D.O. page 1 of 1 Elitel Response TRAUMA TRANSPORT !1. 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; longbone 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 o Glasgow Coma Score(itemized) • ETA to receiving facility a A Elite Medical Response 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 Response 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 Response 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 aH tmuma v-kti= scene, Dr.Sandra Sch wemmer, D.O. Page 2 of 15 co ct, cfl Eliteedic l ResponseTRAUMA TRANSPORT TREATMENT P T � ,w, , umm uuuu mum riwmmirwmm rw uum� m,mw.mitimrv. a::m umm,mwm ulf uu. .:mami wm , mm..^^.wnarnmixwuiui^m+ wrw^mw�mmrm � o� maarw u msw.°.:^anmrwmnuM,mmm,mmw 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. R Failure of the drawbridges, making ground access to the nearest Hospital impossible. G 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 (1 Q 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. Dr.Sandra Schwemmer, D.O. Page 3 of 15 Elite Medical Response TRAUMA TRANSPORT AND TREATMENT PRo,roCOLSI 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, longbone 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 requites 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 longbone fracture sites. Long bone fracture sites are defined as the (1) Dr.Sandra Schwemmer,D.O. Page 4 of 15 .p ct, co 4 Elite Medical Response TRAUMA TRANSPORT AND TREATMENT PROTOCOLS art�rmnrshaft of the humerus' ��(2) rad4iius -� �wmwuuwwrvooioMi ��mnmmrawamn W'4f�mwmwmwmwmwmwiamrrw;�' wFa'". rrn . 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 EliteisResponse TRAUMA TRANSPORT AND TREATMENT PROTOCOLS e telemetry data, whert avai able, 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. Dr. Sandra Schwemmer, D.O. Page 6 of 13 .p v, co co _ c C to Elite Medical Response TRAUMA TRANSPORT AND TREATMENT PROTOCOLS Elite Medical Response Adult Trauma Scorecard Methodology The EMT or paramedic shalt 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 Allert: 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). DIED BLUE AIRWAY EEI1VE AIRWAY AS'EIETANCE0Io. 11::IE,C"roEIWI'EIII"EIL"Y uIZA I E<1 0 of>TE 1)PM CIRCULATION I.ACK OF F"tEMEL.III:111W'SE w 1111111113<00 a'tm'Hq PATIENTS WITH RENAL FAILURE ON DIALYSIS E,Pr 1.0 IIII14 F°,E"'I IIIl°IWrI"I OVER i6E'YEI'irl'IE DISABILITY EE..E..�'IE fir'I""'"EEEEEE�E'ET W"'"EI" TT°E'IE'� �EEI'TEITI'�EI'L EE HEAD INJURY 4NT'H LO55 OF CONSCIOUSNESS, SEIII'uAt E�`�II`iu��u�IIIELTII''1'T or LOSS OF EEI!&kTION AMNESIA or NEW ALTERED MENTAL STATUS SOFT TISSUE EE'Yd DEGREE EI. kNS TO°W 5%or MORE"'I'EE'E SOFT TISSUE LOSS' AMPLW"r"EI"III"'I10IT AT OR EV':IOVE TI`CE V"W ''IST c4 ANKLE PENETRATING INJURY TO THE EXTREMITIES DISTALTO ANY PEEE I'W TWG INAII'Y TO HEAD,,EEI'X,w EFII,I'O' THE ELBOW or KNEE G&W r FIEwalC7RATWE IIIELLVIRY 1"'1E,TI"'M E'.XTREEWP„.T„E.IL. OR ABOVIII'IIIII TI`1E KNEE TTII!'L II'IIIII.JII'LErLTI C IEE.I WALL INSTABIILLI"E or DEFORMITY('FLAk TCLWr,81) I'IHL.WEEII'IIIIL.II! +'IEETEIE,IIIIEEW.iuEVE'EI of Illu1p„II.SEIII..EE', W','I XTRE`PATY LONG BONE FIMC I"W.WEE E',WI''"""1"A0 0"WEEI''IE ONG BONES' I SINGLE LONG BONE FX SITE DUE TO MVC4 FRACTURE/SKELETAL4 SINGLE LONG BONE FX IIN PT ON'HIGH RISK ANTICOAOULANTS6 AGE 55 YEARS OR OLDER MECHANISM SEVER U. II'I' i1"AL inVTl'LIE'T'IT'E:EL I t MES)MTE POI EN TWAL EJECTON FROM AUTOMOBILE,MOTORCYCLE,GOLF OF INJURY AIRWAY C I'I1PROWS'E CART or HORSE IIII.L.IIIIIP:.ETErOCUTN10N OR L GI 11I'MNG INJURY VATH T(")ES OF BLUNT HEAD,CHEST,OR ABDOMINAL TRAUMA IN E0 NSC0.6NEEE()R E0BI 11l'ii:..TlGNS OF MJ1,PRY PATIENTS ON HIGH RISK ANTICOAGULANTS° ELI'LE"I''IrSDOMINAL r CHEST'1I'I' ,7111 IE EET°I'E'IT"I"'E+r'ITH DEATH IN SAME PASSENGER COMPARTMENT I°IM"I'ORY OF IDMZAL"r'SM(EEI''IEEI..EiGA of I:IUADRIIEM..LGIA) INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT" SITE;;>18 IINCHES ANY SATE INTO THE PASSENGER 1,1EETIEAI'La'Y2WAS VVI'TH AEDONIPLPuL I1111EIE AND ISLUI'T,I COMPARTMENT TEEUN'Ek FALL 10 FT or MORE AUTO VS.PEDESTRIANIBICYCIST THROWN,RUN OVER or WITH IMPACT GREATER THAN 20 MPH OTORCYCYLE„GOLF CART OR ATV CRASH>20mph VEHICLE TELEMETRY DATA COUMSTENT WITH HIGH RISK OF INJURY,IF AVAK A LEO IT9ELI=any one(I)-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, Dr. Sandra Schwemmer, D.0. Page 7 of 15 Elite Medical Response TRAUMA TRANSPORTE E T PROTOCOLS 6 See attached list of Anticoa4ulants with High Risk of Bleeding 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 a 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) Dr.Sandra Schwemmer, D.O. Page 8 of 15 .p rn 0 Elite Medical Response TRAUMATRANSPORT AND TREATMENT PROTOCOLS OCO Eccios .gaum 'i64-, -, 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. a 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. Dr.Sandra Schwemmer, D.O. Page 9 of 15 Elitea icaTRAUMA TRANSPORT AND TREATMENT PROTOCOLS Elite Medical Response 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). �RED BLUE SIZE WEIGHT a 20 Kg AIRWAY ACTIVE AIRWAY ASSISTANCE° RESP RATE 20 M INFANT c 1 YR RIESP RATE 10 BIN CMILDREN 1YR--1 a YR CIRCULATION FAINT or NON-PALIPAIDLE CAROTID or FEMORAL PULSE or CAROTID or FEMORAL PULSES PALPABLE,BUT THE RADIAL OR PEDAL SBP<So ux MHg PULSE NOT PALPABLE or SBP<90-mmHg DISABILITY ALTERED MENTAL,STATUS'or PRESENCE OF PARALYSIS AMNESIA orSUSPICION OF SPINAL CORD INJURY or LOSS OF SENSATION LOSS OF CONSCIOUSNESS SOFT TISSUE MAJOR.SOFT TISSUE MSRU IOINI or MAJOR AVULSION of GSW TO THE EXTREMITY BELOW ELBOW OR KNEE SKIN 20or 30 BURNS TO 210 TIDSA P A"noun AT On AISOVLTHE WRIST or ANKLE ANY PENETRATING INJURY TO HEAD,NECK,or TORSO6 PENETRATING INJURY TO THE EXTREMITY AT or ABOVE (ELBOW or KN EIE OR DE-GLOVING INJURY LONG BONE OPEN LONG BONE or MULTIPLE DISLOCATIONS,or FRACTURE/ FRACTURE SITES'° SINGLE LONG BONE'FRACTURE SITE'or DISLOCATION SKELETAL MECHANISM OF ELECTROCUTION or LIGHTNING STRIKE WITH LOSS OF DEATH IN SAME PASSENGER COMPARTMENT INJURY CONSCIOUSNESS or VISIBLE SIGNS OF INJURY INTRUSION i INCLUDING ROOF>12 INCHES OCCUPANT SITE;>18 SEVERE FACIAL INJURY WTH AIRWAY COMPROMISE INCHES ANY SITE INTO THE PASSENGER COMPARTMENT EJECTION FROM AUTOMOBILE,MOTORCYCLE,GOLF VEHICLE TELEMETRY DATA CONSISTENT WITH HIGH RISK OF INJURY? CART,ATV OR HORSE WITH ANATOMIC INJURY FALL>10 FT or 2-3 TIMES THE HEIGHT OF THE CHILD BLUNT or CHEST TRAUMA IN PATIENT NTH HISTORY OF PARALYSIS(PARAPLEGIA or QUADRIPLEGIA) BLUNT HEAD,CHEST,ABDOMINAL,MUSCULAR SKELETAL TRAUMA IN PATIENT ON AN'TTCOAGUILANTS WITH HIGH RISK OF BLEEMING4 AUTO VS.PEDE-STR1ANfMCYC1ST THROWN,RUN OVER or TN IMPACT GREATER THAN 20 MPH RED=any one(1)-transport as a trauma alert;BLUE=any two(2)-transport as a trauma alert. t. 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. B. 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. .p 9�9 Dr, Sandra Schwemmer, D.O. Page 10 of 15 rn 0 w j Elite is Response ';�T S 8 Sep' Ilfs of k�9iccaa aal h High Risk of O�eedkng . V. TRANSPORT DES TINA TION CRITERIA 64J-2.002F.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. W. 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 Response 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 Elite ........... Ical Response TRAUMA TRANSPOR T AND TREATMENT PROTOCOLS transport r n 1. Dr. Sandra Schwemmer, D.O. Page 12 of 15 .p rn 0 v, cfl Elite Medical Response S V11. APPROVED TRAUMA CENTERS AND INITIAL RECEIVING HOSPITALS Am)royneadd T j®rammalCienters and Pediatric Trauma Referral Ce 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) Receiving Facilities 1. Lower Keys: Lower Keys Medical Center, Stock Island 2. Middle Keys: Fishermen's Hospital,Marathon 3. Upper Keys: Mariner's Hospital, Tavernier Dr,Sandra Sch wernmer, D.0. Page 13 of 15 Elitea is e TRAUMA TRANSPORT AND TREATMENT PROTOCOLS ANTICOAGULANTS. Trade Names: Generic names: Aggrenox(ASA+dipyridarnole) Anagrelide(Agrylin) Agrylin (anagrelide) Apixaban (Eliquis) BrIlinta (ticagrelor) Cilostazol(Pletal) Coumadin (warfarin) Clopidogrel (Plavix) Efflent(prasugrel) Dabigatran (Pradaxa) Eliquis(apixaban) Dipyridamole(Persantine) Jantoven (warfarin) Dipyridamole+ASA ( renox) Plavix(clopidogrel) Edoxaban (Savaysa) Persantine(dipyridamole) Pentoxifylline(Trental) Pletal (cilostazol) Prasugrel (Effient) Pradaxa (dabigatran) Rivaroxaban (Xarelto) Savaysa (Edoxaban Ticagrelor(Brilinta) Ticlid (ticlopidine) Ticlopldlne(Ticlid) Trental (pentoxifylline) Vorapaxar(Zontivity) Xarelto(rivaroxaban) Warfarin (Coumadin, Jantoven) Zontivity (vorapaxar) ....................................................................I I n jectables: Activase(alteplase) Aggrastat(tirofiban) Anglomax(bivalirudin) Argatroban j Arixtra(fondaparinux) ! Fragmin (dalteparin) Heparin Innohep(tinzaparin) Integrifin (eptifibatide) Iprivask(desirudin) ; Lovenox(enoxaparin) Reopro(abciximab) , Streptokinase Tenecteplase(TNKase) Uroklnase K� Dr. Sandra Schwemmer, D.O. Page 14 of 15 .p rn 0 4 00 � o Elitedic l Response TRAUMA TRANSPORT AND TREATMENT PROTOCOLS W C.I 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. 515116 Sandra Schwemmer, D.O, FACOEP, FACEP Date FL OS 4022 Dr. Sandra Schwemmer, D.D. Page 15 of 15 Response . wm. Elite Medical DRUG FORMULARY ' Ade' nosine T'riph p ua a (A►denocard0) ACTIONS: Adenosine exerts its effects by decreasing conduction through the AV mode.The half-life of Adenocard is less than 10 seconds.Thus,its effects, desired and undesired,are self-limited. INDICATIONS: Adenocard is indicated for paroxysmal supraventricular tachycardla(PSVT), including that associated with accessory bypass tracts (Wolf-Parkinson- White Syndrome). CONTRA{NDI CATIONS: Adenocard is contraindicated in second or third degree AV block and sick sinus syndrome(except in patients with a functioning artificial pacemaker), and known hypersensitivity to Adenosine. WARNINGS, 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 (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, PRECAUTIONS: The effects of Adenosine are antagonized by methylxanthlnes 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. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: 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: Adult 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. {pediatric dosage: 0.1 mg/kg(maximum 6 mg) rapid IVP Immediately followed by 5 ml NSf lush. Repeat in 2 minutes,at 0,2 mg/kg(maximum 12 mg)rapid IVP followed by 5 ml NS flush PRN. Time/Action r I : onset, Peak Duration IV: Immediate Unknown 1-2 minutes .p Adenosine Triphosphate (Adenocard®)to 1 0-1 ur,.Sandra 5chwemmer„DO, lit iDRUG FORMULARY cal Response ..................I� Albuterol r c al ACTIONS: Albuterol is primarily a beta-2 sympathomimetic and as such produces bronchodiiation. Because of its greater specificity for beta-2 adrenergic receptors it produces fewer cardiovascular side effects and more prolonged bronchodiiation than isoproterenol. INDICATIONS: Albuterol inhaler is indicated for relief of bronchospasm in patients with reversible obstructive airway disease including asthma, and COPD. QNTI ZAIINDIIIIICATIiONS: Albuterol is contraindicated in patients with a history of hypersensitivity. MI'A It ill' III!ISO : 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 ADVERSE REACTIONS AND SIDE EFFECTS: 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. Thne/Action Profile: Onset Peak Duration Inhaled: 5-15 minutes 60-90 minutes 3-6 hours Albuterol ® O, Dr.Sandra Schwemmer, DO, DRUG FORMULARY Elite Medical Response C—V) Ami• T odarone ACTIONS, Amiodarone suppresses recurrent VF, prolongs intranodal „ conduction and refractoriness, negative inotropic effect. '( EC1rG4Ypf,'Y,�, �Nl7�iCATIONS: Ventricular Fibrillation Pulseless VT PVC s greater than 12 min • Ventricular Tachycardias (Wide and Narrow) with a pulse %IlfWALW%X e' r"Oft"r+aj Q +. Any known allergy Cardiogenic Shock Sinus Bradycardia _ 2nd and 3rd degree AV blocks V- W POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: None in Ventricular fibrillation. POSAU; Adult dosage: Pulseless Arrest: 300 mg IV/10 May repeat with 150 mg IV/ IO With J!ulses: Infusion loading dose: 150 mg IV(150 mg in 100cc NS) infused on a macro drip over 10 minsl.5gtts/sec. Pediatric dosage. Pulseless Arrest: Smg/kg IV/10 may be repeated once. No single dose greater than 300 mg. (15mg/kg max) Time/Action Profile: Onset eDuration IV/10: Unknown Unknown Unknown Amlodarone T iandra Schwemmer,D.O. — N Elitei dam DRUG FORMULARY i ' Aspirin r ACrIONS: 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. INDICATIONS: �I Aspirin is indicated in the Acute Coronary Syndrome setting to prevent further clotting. A LTRAINDICA�TI011lly'' :' 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 ADVERSE REACTIONS AND SIDE EFFECTS: 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 Realk Duration (Oral) PO: 5-30 minutes 1-3 hours 3-6 hours Aspirin r Dr Sandra Schwemmer, D.O. Elite Medical Response DRUG FORMULARY Atropine ACTIONS: Atropine is a potent anticholinergic(parasympathetic blocker, parasympatholytic) that reduces vagal tone and thus increases automatically the SA node and increases A-V conduction. you INDICATIONS: • Sinus Bradycardia accompanied by hemodynamic compromise,(Le. 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. COT INDICATI IIS: ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, None in emergency situations WARNINGS: Too small of a dose (< 0.5 mg) or if pushed too slowly, may initially cause the heart rate to decrease. Antihistamines and antidepressants potentiate Atropine. A maximum dose 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 REACTIONS AND SIDE EFFECTS: 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. Pediatric, 0.02 mg/kg IV/10 (minimum dose is 0.1 mg and maximum single dose is 0.5mg child, 1 mg adolescent). May repeat once. Time/ActionProfile: Onset PeakDuration IV/10: Unknown Unknown Unknown Atropine L >andra Schwemmer,D.O. W Elitei DRUG FORMULARY Atropine Sulfate as Antidote for Poisoning ACTIONS: Atropine is a potent parasympatholytic that binds to acetylcholine receptors thus, + diminishing the actions of acetylcholine. INDICATIONS: °R! {D.lmghni{ 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. N�o'�Ilne whlenVlIIIi��A�I10i" S°�used in the management of severe organophosphate poisoning. ` ' 'AJi'"tIliIIII G 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 REACTIONS AND SIDEEFFECTS: 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/10, repeat every 5-10 minutes until atropinization occurs. Pediatric: 0.05 mg/kg(maximum 3 mg) IV/10, repeat every 5-10 minutes until atropinization occurs. Time/ cUon Profile: Onset Peak, Duration IV/10: Immediate 2-4 minutes 4-6 hours Dr.Sandra Schwemmer,D.O. Atropine Sulfate as Antidote for Poisoning Elite Medical Response DRUG FORMULARY r CD Calcium Chloride 10%o al Calcium chloride increases the force of myocardial contraction; calcium may either increase or decrease systemic vascular resistance. In normal I hearts, calcium's positive inotropic and vasocon strict!ng effects produce a predictable rise in systemic arterial pressure. INDICATIONS: Calcium chloride is indicated during resuscitation for the treatment of hypocalcaemia and calcium channel Mocker 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. CONTRAINDICATIONS: Cardiopulmonary arrest not associated with calcium channel blocker toxicity, hypocalcaemia, or hyperkalemia. WARNINGS: 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 REACTIONS AND SIDE EFFECTS: 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: 8-15 mg/kg IV slowly Asystol_e/PEA (if on calcium channel blockers) 1gm IVP Time/Action Proit Onset Peak Duration IV/10: Immediate Immediate 2-5 hours Calcium % iandra 5chwemmer,D.O. 10-7 tJ1 cfl Elite Medical Response 0C to DRUG FORMULARY r d' ICyanoki S ACTIONS: 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 cy combines with the cyanide to form anocobaiamin which is a derivative of y 1 ° vitamin B-12. Both the Hydroxocobalamin and B-12 are harmlessly excreted in urine. INDICATIONS: • Exposed to products of combustion in an enclosed space • Soot present in their nose, mouth, or sputum • Altered mentation • Does not meet trauma alert criteria • At least 18>years old Common Signs &Symptoms include: Symptoms S. inns Headache Altered Mental Status Confusion Seizures Dyspnea Mydriasis (dialated pupils) Chest Tightness Tachypnea (early) Bradypnea (late) Nausea Hypertension (early) hypotension(late) Cardiovascular collapse Vomiting C I' TSAIIII''' DICAIIOIIINS. None WARNINGS: Do not use the following medications in the same IV line: � Dlazepam 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® Dr.Sandra Schwemmer.D.O. 50-_81 Elite Medical Response DRUG FORMULARY u' lextrose 50 % and 25 % [d-glucose) ACTIONS: ,, Il�ml ,4V18111�p000yuol9�0oi�uui�ol��l ulor o RV" , A monosaccharide, which provides calories for 11 d6 ldtllliiu'Rdi"' "'!III " w metabolic needs, spare body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. DEXTROSE+ N ti,J t � INDICATIONS: • Hypoglycemia Coma of unknown origin. I1 CONTRAINDICATIONS: • Intracranial or intraspinal hemorrhage (Ina patient with normal BGL). ea • Blood glucose Level> 60 mg/dl. VAthMWOIwrlecM.d. �r POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: • Cardiovascular:Thrombosis Sclerosing if given in LAP RU'V20TJ peripheral vein • Local:Tissue irritation or necrosis if infiltrates. • Others:Acidosis, alkalosis, hyperglycemia,and m hypokalemia. DOSAGE: Adult: (> 30 kg) 50 ml of a 50%solution; (25 gm) IWIO. Pediatric- (e, 30 kg) 2 ml/kg slow IV/10 of a 25% solution. Newborn: (< 10 kg or< 1 month of age) 5 mi/kg IV/IO of 10%solution (dilute DSO 4:1 with NS). Time/Actionit Peak Duration IV/10: < 1 minute Depends on degree of hypoglycemia Dextrose 50 % and 25 % (d-glucose) Sandra Schwemmer,D,O. 00 Elitei to DRUG FORMULARY m� Diazepam Hydrochloride (Vallum@) 'l��/l/(�1y��//�/�I��O///yuvi�l,W' i/�r�r�t�r�„'°�oMFrr��,��f/��'rP✓�i��i%��r��„��i"111�1➢� ��1�""��i M�.'%YJ ��I �r'/" �'{'��a„" lyi n rppi�' �� "�lr'� r' 'i��% ru r ACTIONS: A member of the benzodiazepine family,Diazepam, depresses the liimbic system,thalamus,and hypothalamus resulting In calming effects. Diazepam produces a sedative effect and Is also a muscle relaxant. INDICATIONS: Status epilepticus, Premedication prior to cardioversion,Agitation due to acute alcohol withdrawal,Drug Induced psychosis,Short-term relief of acute anxiety,Cocaine intoxication CONTI'IAIIIII DICATIONS, • Alcohol Intoxication • Pregnancy(except for seizure control associated with ecIampsia) • Neonates WAI"IINIIND : Do of 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 Vocal irritation and possibly venous thrombosis in small veins. I')'R IICAD'"1 I O I'4T Pregnancy(except for control of seizures associated with status epilepticus oreclampsia) Neonates. POSSIBLE ADVERSE REAL 10. S AND SIDE EFFECTS: • 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. F Respiratory: Respiratory depression. Other: Potentiates MAO's, barbiturates,tricyclics and phenothiazines Potentiated by Cimetidilne, ETOH and other CNS depressants. D AGI� Adult: To be administered in 5 mg increments. Dosing ranges from 5-20 mg IV/10/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 IIM route used Inject deeply into the delltoid for maximum absorption. Pediatric:Status epilepticus 0.2 mg/kg IV/10 slowly(max 5mg). Rectal l Dose 0.5 mg/kg,may repeat either route x 1 in 5 miens. 'Time/Action Profuie: ICI:,-inset Ptak 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 Diazepam Hydrochloride (Valium®) Dr.Sandra Schwernmer,D,O. li�j�] r Elite Medical Response DRUG FORMULARY I ® mine Rydrochloride (Benadryl®) n fp ACTIONS: 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. INDICATIONS: • Allergy symptoms,anaphylaxis • Sedation of violent patient • Dystonic reactions from phenothiazine overdose(i.e. Haldol,Compazine,Thorazine,and Stelazine) CO RAINDICATIONS: Diphenhydramine is not to be used In newborn or premature Infants.Diphenhydramine Is not to be used In patients with acute asthma attack WARNINGS: 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 REACTIONS 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: Dysurla and urinary retention. DOSAGE: Adult: 25-50 mg IV/10 or 50 mg deep IM Pediatric: 1 mg/kg IV/10 or IM(maximum 25 mg) 111me/Action Profile: Onset Peak Duration IV/10: Rapid Unknown 4-8 hours IM: 20-30 minutes 1-4 hours 4-8 hours Diphenhydramine Hydrochloride (Benadryl®) A Sandra Schwemmer,D,O. 10-11 to 0 Elite Medical Response to N DRUG FORMULARY Ni Dopamnine Hydrochloride (Introp i °) ACTIONS: ' Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic F� N 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 t' 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 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. INDICATIONS: To treat shock and correct hemodynamic Imbalances,improve perfusion to vital organs and to increase cardiac output. V „ III''c llll„III' IIII ......................................................................... Dopamine should not be used in patients with pheochromocytoma or � hypovolemic shock. WAIWINGS: Do not administer Dopamine in the presence of uncorrected tachydysrhythmias or ventricuilar 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'x),Isocarboxazid(Marplan ), pargyline hydrochloride (Eutonyll$),pargyline hydrochloride with methyclothiazide(Eutron ), phenelzine sulfate(NardilO),procarbazine hydrochloride(Matulane"'), tranylcypromilne sulfate(Parnate ). PO SIBLE ADVE 'S O S AND SIDE EFFE Cardiovascular:Tachycardla, palpitations,angina pain,ectopic beats, and hypotension GI:Nausea and vomiting Local: Necrosis and tissue sloughing with extravasations,use a large vein to reduce thus incidence Other: PiJloerection,dyspnea and headache. DOSAGE: Adult and Ilrl'edlllatrlc; Pre-mixed_baig Begin Infusion at 5 mcg/kg/min.and titrate to effect(Maximum dose 20 mcg/kg/min.) Vial(400 m-R)To yield a concentration of 1600 mcg/ml mix 400 mg of Dopamine into 250 ml of D5W. Time/Action Profhdlbe: Ons'M Peak ["Wiraiion 4 minutes 10-15 minutes Continuous with Infusion Dr,Sandra Schwemmer.D.O. DRUG FORMULARY T Elite Medical Response e . Duo-Dote"' (Atropine and Pralidoxime Chloride) ACTIONS: Blocks nerve agents effects and relieves r- r 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 function o INDICATIONS: Suspected or confirmed nerve agentexposure Q . . CONTRAINDICATIONS: S: 1' Both medications in the kit should be used with � ` i .� 1 caution (but not withheld) in patients with preexisting cardiac disease, HTN, or CVA history. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS:Chest pain , exacerbation of angina, Myocardial infarction, Blurred 2 vision , Headache , Drowsiness , Nausea , Tachycardia31 , 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) eitaric: DuoDotes TM are not authorized for the use of children under the age of 9 years. Duo-DoteTm (Atropine anr I I l _ N wdra Schwemmer,D.O. N to d r DRUG FORMULARY Epinephrine Elite Medical Response I 1,000, r ACTIONS: 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. INDICATIONS: �• Asthma ■ Anaphylaxis Angioneurotic edema All Pulseless Arrest CONTi'I'AIINDICATIO S 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. WA.RN..I : .... m. .., Epinephrine is inactivated by alkaline sollutions-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. ,POSSIBLE ADVI RSE REACTIONS AND SIDE E CTS: • CNS:Anxiety, headache and cerebral)hemorrhage, • Cardiovascular:Tachycardia,ventricular dysrhythmias, hypertension,angina and palpitations, • GI: Nausea and vomiting DOSAGE: Adult: SQ 0.1.0.3 mg(0.3 cc). Repeat every 3-5 minutes(Asthma/Anaphylaxis may repeat once in 1' minutes), le,°Illlatiulic: IM 0,01 mg/kg up to 0.5 mg. Time/Action Profile: Onset Peak Duiraflioin SQ, 6.12 minutes 20 minutes 1-3 hours Epinephrine 1:1,000 Dr,Sandra Schwemmer,D.O. Elite Medical Response DRUG FORMULARY • • . 0,0 0 ACTIONS: n. 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 systemic vascular resistance and thus may enhance defibrillation. INDICATIONS: tltd® All Pulseless Arrest • Asystole • Ventricular Fibrillation unresponsive to defibrillation; PEA Other pediatric indications: hypotension in patients with circulatory instability, bradycardia (before Atropine). LOT �3-- U None in the cardiac arrest situation. U WARNINGS- Epinephrine 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. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS:Anxiety, headache and cerebral hemorrhage. Cardiovascular:Tachycardia,ventricular dysrhythmias, hypertension,angina and palpitations. GI: Nausea and vomiting. DOSAGE: Adult: (1:10,000) 1 mg(10 ml) IV or 10, 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: 0.01 mg/kg, (0.1 ml/kg IV or 10).Repeat every 3-5 minutes. Pediatric : POST ARREST:O.imcg/kg/min Mix 1mg of Epi into 1000ml NS=Concentration of lmcg/ml Time/Action : Onset Peak Duration IV/10: Rapid 1-2 minutes 20 minutes Epinephrine 1 10-15 N iandra Schwemmer,D.Q. EliteIq ��~�� \��U�se to �� ° DRUG FORMULARY Fentanyl Binds with stereospecific receptors at many sites within the CNS, to increases pain threshold, alters pain reception, inhibits ascending pain pathways. Fentany| binds to brain receptors, relieving pain. |t decreases the feeling of pain and a person's response to pain. Fentanyl is 50-100 times as potent as morphine; morphine 10 mg II.W4.=fentany1O.1'O.Z noQ |.K8.; fentanyl has less hypotensive effects than morphine due to minimal Prnp ° histamine release. -asp =0qFoWnKQmL Moderate to severe pain |n patients*1Oke Acute Coronary SVndronm$—[he�t9a|n(�du!t\ ' (Adult) - ° Pain associated with isolated extremity fracture' renal colic, burns, n � mtc ' ° Epistawisorbilateral b|ockednanea ~ Known hypersensitivity tofentany| ° K8&O| use in past 2weeks CONCENTRATION ° Unstable henlodynom|oyoraltered ��N�� Use with caution in patients with bradycmvd|a, hepatic, renal, or respiratory disease or those with increased |[P, head Injuries,orirnpuined consciousness; patients must be monitored until fully CNS; Drowsiness, sedation, increased |ntracnynie| pressure Cardiovascular: Bradyca,dia, hypotension, pedphena|vasmdi1adon GI: Nausea,vomiting GU: Urinary tract spasm Respiratory: Respiratory Depression SLOW IV PUSH-Rmp|d push may cause chest wall rigidity decreasing,or ellrnYnmK|mg ability to ventilate. Adult: 1-3nmcg/kuUV/|D/kN (Typical adult dose 5O-l0Onoc0) May repeat half the original closie administered. Pediatric>10K0: 1mc0/k0 |V/|0/|N May repeat half the original dose administered 0.5mcu/ko Time/Action Profile: Onset Peak Duration IN: 2-10no|ns 30'60nn|ns iv: Immediate 30-60 no|ns, � D:Sandra Snhwommm� ��D.�. ~ ~^ t��N=~ � ~ RevimedO244-1O Addler-idiurn U A"I 0--16 U 1 i Elite Medical Response DRUG FORMULARY ACTIONS: 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 INDICATIONS: Pulmonary edema CONTRAINDICATIONS: Anuria.Should be used in pregnancy only when benefits clearly outweigh risks. 'WARNINGS: Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Dizziness,tinnitus, hearing loss, headache, blurred vision and weakness GI:Anorexia,vomiting and nausea Cardiovascular: Hypotenslon Other: Pruritus, urticarla and muscle cramping. /� N 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.) Time/Action Prod : Onset Peak Duration IV/10: 5 minutes 30 minutes 2 hours r i R M andra Schwemmer,DO, 10-16 W Elite Medical Response N DRUG FORMULARY 1 _.mm.. r .. mm.. .. mm... . mm. . ....... mm. mm .. . e amine [Ketalar @ ] .W�. w ACTIONS: 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. y Disassociates the brain form the spinal cord thus inhibiting pain o0195fl „ PIN MAu111u0(s sensation. Ketamine increases cardiac output and may be considered � ll etamine HCi advantageous inpatients with hemodynamic compromise (trauma, �i��p�e�non,liSiP � "'� iJjJ:J rn is>nt f sepsis, etc.). A patent airway is maintained partly by virtue of °wn `" � u�r unimpaired pharyngeal and laryngeal reflexes. uA a awr'� aV wuo i � �R�k dlW4,uN;�nwwi tlm m rd m au �� INDICATIONS: • 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" 5oomg/sml 100mg/mI ! ! IIINY IAAI�� I„III', IIII'C I110 u. • Hypersensitivity to Ketamine • Condition in which an increase in Blood Pressure would be hazardous. + Acute Coronary Syndrome or STEMI • Ocular trauma(globe injury) � i'tIlIlki�ld : 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 Adult: Procedural Sedation/Pain Ii „lipwp 1 ��l�r may repeat prn. Airway Management I11LQ a '� �i may repeat prn.. (TrismuslEndangered Alrway/RSl/post lntubatlon sedation for Inhalation airway control) Violent/Combative/Aggressive Adult Patient ��og IIIIV/ilpq may repeat prn. Consider combining with Intranasal Versed. Pledlia rir. Procedural Sedation/Airway management,/ VV Q ii �2 1�n may repeat prn. �me/A �tl�i� r'�Il��ro�ti�i��r:; i"Nlset P D u�u�atioirn IV 1.-2 minutes 3-5 minutes Weight dependent Dr.Sandra Schwemmer, Ketamine (K ar@) _.............................. D.O.Riay'Nalsd"w-402-w164 ddendlu m Elite DRUG FORMULARY Magnesium Sulfate ACTIONS: Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end-plate by the motor 1 f 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 eclampsla and pre-eclampsia. Magnesium acts peripherally to produce vasodilatation therefore a drop in systolic BP is to be anticipated. ATE INDICATIONS: • Prevention and control of seizures in eclampsia II Torsades de Pointes • Suspected hypemagnesemic state(i.e.chronic alcoholism and chronic use of diuretics) • Refractory ventricular fibrillation • Refractory Asthma CONTRAINDIACTIONS, Parenteral administration of the drug is contraindicated in patients with heart block or myocardial damage. Intravenous use of Magnesium Sulfate should not be given to mothers with toxemia of tx� 11;' pregnancy with Imminent delivery. Magnesium Sulfate Injection USP,50%must be diluted to a concentration of 20%or less prior to IV infusion PRE IITIO : 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 availabile to counteract the potential hazards of magnesium Intoxication In eclampsia.Signs of hypermagnesium include respiratory depression; absence of patellar reflex,etc. r �a�irl/G//��pj�'///�rL0 ��li��/ ✓%'„ POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS, 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/ActionProfile: Onset Peak Duration IV Drip: Immediate Unknown 30 minutes .P NMagnesium 1171 1 p_ ur.Sandra 5chwemmer.13,0.. 00 ResponseElite Medical to dq DRUG FORMULARY L . Methylprednisolone r ACTIONS: Decreases inflammatory effects via its potent anti-inflammatory synthetic steroid. `lu INDICATIONS: - Asthma - Anaphylaxis * Head injury r, COPD Unconscious with known Addison's disease » CDNTRAIN,ll� ICA FIIIOI@' S: None in the emergency setting. POSSIBLE ADVERSE REACT ONS AND SIDE EFFECTS: Gi GI hemorrhage, reduces leukotrines of immune system and '°%�=�`�% ��'�✓��''� increases potential for infections. 51 DOSAGE: Adult: 125 mg IV slow over 2 minutes Pe atiu°°I'ir: 2 mg/kg (max 125 mg) IV slow over 2 minutes Ililrru�irw^/��iK:tl� n Piriu)fmle: Onset Peak Dw rratson IV/IO: Unknown Unknown Unknown Dr.Sandra Scherremr,D.O. Elite Medical Response CY) i DRUG FORMULARY CY id (Versedfl IONS: Depresses CNS, muscle relaxant, strong sedative, hypnotic, and y. amnesia. INDICATIONS: Control of seizures, sedation for cardioversion & pacing, and ;� il ,ar �� sedation for airway management. CONTRAINDICATIONS, Respiratory depression Hypotension ETOH and drugs oq"' ✓rj WARNINGS: Monitor patient for respiratory and CNS depression and vital signs � z after administration. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Retrograde amnesia, altered mental status and dizziness Cardiovascular:Bradycardia,hypotension,PVC's,tachycardia and nodal rhythms Gl: nausea and vomiting, hiccoughs and coughing Respiratory:Respiratory depression,laryngospasm and bronchospasm DOSAGE: Adult: r' -2 I}J ifacin "® 2.5-5 mg based on patient's weight up to 10 mg imiax Pediatric: > 1 years of age (0.1mg/kg) Do Not Administer to pediatric less than 1 year of age Time/Action Profile: Onset Peak Duration IV 1-2 minutes 3-5 minutes Weight dependent i I r iandra Schwemmer,D.O. 10-19 Elite Medical Response DRUG FORMULARY Morphine Sulfate (MS) Morphine ba 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. ° Pain ° Pain associated with isolated extremity fracture, renal colic, burns,etc. ° Volume depletion orhypotension ° Acute asthma ° Known hypersensitivity tmMS WARNINGS- Morphine is detoxified by the liver. It is potentiated by alcohol, antihistamines, barbiturates, sedatives and betab|ockers. POSSIBLE ADVER�J.&E_ACTJONS AND SIDE EFFECTS: C90S: Euphoria,drowsiness, pup|Uery constriction and respiratory arrest. Cardiovascular: Bnadycardie and hypotension. GI: Decreases gastric motility, nausea and vomiting. GLI: Urinary retention. Respiratory: 8ronchoconathct|¢n, and decrease cough reflex. Adult: 2 mg increments IV slowly. Repeat every 5 minutes until desired response is achieved (mmax�mnmmn dose 1Dmg).Can be given|M. ��idKatii�4c: 01 mg/km |V slowly. May repeat the initial dnseX1 in 3'5 minutes. Want: O.O6 mg/kg|V slowly. May repeat the initial dose X1 |n3'5minutes. TKrne/Aicitfi�:im Onset Peak Duration IV, Rapid 20m|nuten 4'5hour Dr.Sandra Schwemme,.D.O. Morphine Sulfate (MS) Elite Medical Response Ir- I I ACTIONS: Naloxone antagonizes the effects of opiates by competing at the same receptor sites. When given 1V,the action is apparent within two minutes.IM or SC administration is slightly slower. INDICATIONS: • 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 (Dllaudid), Pentazocine(Talwin),Propoxyphene(Darvon), Percodan, Fentanyl(Sublimaze) (Known on the street as"White China") CONTRAINDICATIONS: Known hypersensitivity to Narcan. WARNINGS: 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. POSSIBLE ADVERSI RE O S ND Dg iEFFECfS: 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: Adult: An initial dose of 2 mg may be administered IV/10/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). Pediatric: 0.1 mg/kg IV/10/IM/PRN. Time/Action „ Onset Peak Duration IV: 1-2 minutes unknown 45 minutes � Naloxone Hydrochloride (Narcan@) 10-21 Sandra Schwemmer,D.O. N M EliteMedical Resjjplon iio� DRUG W 10 Nitrog I yc er in [Nitrostat@ NitroIi n g ua I® S p r ) ACTIONS: 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 WIp I nitroglycerin is rapidly absorbed. Pain relief occurs within one to two minutes and therapeutic effects can last up to 30 minutes. INDICATIONS: • Chest pain or discomfort associated with suspected AMI. • Pulmonary edema with hypertension. CO,I' i i�i ,lilt' III ICATIIO,NS: • Systolic BP< 100 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 V411 in the setting of an Inferior wall MI FPREI(ALiTION ................. 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 REACTIONS AND SIDE EFFECTS: 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 SIi: 1-3 minutes unknown 30-60 minutes Nitroglycerin Dr.Sandra Schwemmer,,,D.O. 10-22 Elite Medical DRUG FORMULARY 04 ACTIONS: Antlemetic,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 4rng/2ml INDICATIONS: 2mg/ml Used for a patient with nausea unrelieved with comfort measures, uncomfortable due to 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 oreiectrolyte imbalance. CONTRAINDICATIONS: 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). WARNINGS, 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 ADVERSE 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: 4m s (not less than 30 sec) Pediatric ® slow Time/Action Profile: Onset Peak Duration IV 1-2 min 14-30 minutes Weight dependent .p wandra Sahwemmer,D.O. dansetr®n (ZOfran@) ® - je 2®16a1S Addendijm Al its Medical Response (Y q DRUG FORMULARY C" .........................-.................... ........................................................... ..................... ..............--............... --'-................................--......................................................-'-...............................'-................ ............ -——------—-------- -- ---------- ..... . ............... ........................................ ............................ ............. Oral Glucose (Insta Glucose) ACTIONS: Increases blood glucose levels slowly. INDICATIONS: BS> 60 mgdl, patients who are altered but alert enough to take the command to swallow. COIIII4TRAIIIINDIC,ATIIIIOIIII4S�� Patients unable to swallow or Stroke symptoms. PItECAU I [ONS., None when patient can swallow, risk of aspiration if given improperly. ADVERSE REACrIONS.AND SIDE EFFECTS: GI: Nausea DOSAGE: Adult: 1 tube Plediatric, I tube Tkne/Action Profile": Oins,et: Peak Duration Po' 10 minutes unknown Unknown Dr.Sandra Schwemmer,D.O. Oral Glucose (Insta Glucose) :10-:23:] Eliteicy DRUG FORMULARY Sodium Bicarbonate A IONS: Increases PH to reverse acidoses. r I" � I INDICATIONS: • Metabolic acidosis in cardiac arrest I • Tricyclic overdoses with QRS >0.1 • Electrocutions • Hyperkalemia • Methanol/ Ethylene glycol toxicity • Severe ketoacidoses CONTRAINDICATIONS:CHF and Alkalotic states WARNINGS: �: - Excessive therapy inhibits oxygen release, reduces the ability to tr�aya 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 REACTION AND SIDE EFFECTS: Metabolic alkalosis, and may crystallize in IV solutions. DOSAGE: Adult: 1 mEq/kg IV push,then''/x the dose q 10 mins. Electrocutions: 2 mEq/kg IVP Pediatric: 1-2 mEq/kg diluted 50:50 with Normal Saline Time/ActionProfile* Onset Peak Duration IV/10: Unknown Unknown Unknown pSodium Bicarbonate rn >andra Schwemmer,D.O.