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Item C08
C8 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 February 21, 2024 Agenda Item Number: C8 2023-2064 BULK ITEM: Yes DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: James K. Callahan N/A AGENDA ITEM WORDING: Issuance (renewal) of a Class A Certificate of Public Convenience and Necessity(COPCN) to Monroe County Fire Rescue for the operation of an ALS transport ambulance service for the period April 1, 2024 through March 31, 2026. ITEM BACKGROUND: In February of 2022, a Class A COPCN was renewed for Monroe County Fire Rescue to operate an ALS transport ambulance service in all geographical locations of Monroe County, Florida. In view of the foregoing, Monroe County Fire Rescue is applying to renew this COPCN which would become effective April 1, 2024. PREVIOUS RELEVANT BOCC ACTION: On February 16, 2022 the MCBOCC approved the issuance (renewal) of a Class A COPCN to Monroe County Fire Rescue for the operation of an ALS transport ambulance service for the period April 1, 2022 through March 31, 2024. On May 20, 2020 the MCBOCC approved the issuance (renewal) of a Class A COPCN to Monroe County Fire Rescue for the operation of an ALS transport ambulance service for the period April 1, 2020 through March 31, 2022. On February 21, 2018 the MCBOCC approved the issuance (renewal) of a Class A COPCN to Monroe County Fire Rescue for the operation of an ALS transport ambulance service for the period April 1, 2018 through March 31, 2020. On February 10, 2016 the MCBOCC approved the issuance (renewal) of a Class A COPCN to Monroe County Fire Rescue for the operation of an ALS transport ambulance service for the period April 1, 2016 through March 31, 2018. INSURANCE REQUIRED: No 408 CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval DOCUMENTATION: MCFR COPCN Application Class A 2024-2026.pdf MCFR—Class—A—COPCN—Renewal-2024-2026.pdf FINANCIAL IMPACT: Effective Date: 04/01/2024 Expiration Date: 03/31/2026 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: N/A 409 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) ❑ INITIAL APPLICATION-$950.00 ■❑ RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # 22-01 1. NAME OF SERVICE Monroe County Fire Rescue BUSINESS MAILINGADDRESS 490 63rd Street, Marathon, FL 33050 BUSINESS PHONE NUMBER 305-289-6004 EMERGENCY PHONE NUMBER 9-1-1 2. TYPE OF OWNERSHIP (i.e.,Sole Proprietor,Partnership,Corporation,etc.) Government Agency DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION NSA 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS (Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITION/TITLE Holly Merrill Raschein 102050Overseas Highway,Key Largo,FL33037 305-453-8787 Mayor James K. Scholl 530 Whitehead Street,Key West, FL 33040 305-292-3430 Mayor Pro Tern Craig Cates 500 Whitehead Street,Key West, FL 33040 305-292-3440 Commissioner Michelle Coldiron 243 Key Deer Blvd.,Big Pine Key,FL 33043 305-292-4512 Commissioner David Rice 9400 Overseas Highway,Marathon,FL 33050 305-289-6000 Commissioner 4. LEVEL OF CARE TO BE PROVIDED: ❑BLS or ■❑ALS IF ALS: ■❑ TRANSPORT or❑ NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): Generally from the west end of Cow Key Channel, to the west end of Seven Mile Bridge; from the west end of the Tom's Harbor Bridge (approximately MM60)to the west end of Channel 2 Bridge and the City of Layton; and from the west end of Tavernier Creek Bridge to South Bay Harbor Drive & Lobster Lane, or as otherwise directed by Monroe County Central Dispatch. 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION Headquarters- 490 63rd Street, Marathon, FL 33050 SUB-STATION See Attached. Page 1 of 6 410 d 7. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC licenses)- FREQUENCIES CALL NUMBERS— IS #OF PORTABLES State approved 800 MHz Radios Cellular Telephone 305-797-1136 Hard Line Telephone - - L- .. I............. -7:r . LIST THE NAMES AND ADDRESSES F THREE( )U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: NAME ADDRESS Dr. Sandra Schwernmer, Medical Director 160 Key Heights Drive, Tavernier, FL 33070 James K. Callahan, it ief 490 63rd Street, Marathon, FL 33050 Roman Gastesi, County Administrator 1100 Simonton Street, Key West, FL 33040 9. ATTACH A SCHEDULE OF RATES WHICH YOURSERVICE WILL CHARGE U ING THE C PCN PERIOD. 10. PROVIDE VERIFICATION OF ADEQUATEINSURANCE COVERAGE DURING THE COPCN PERIOD. 11. ATTACH A COPY OF YOURSERVICE'S CONTRACT WIT EDICAL DIRECTOR. 1 . ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 1 . ATTACH CHECK DE IN THE APPROPRIATE AMOUNT,MADE PAYABLE THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. I,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN THIS APPLICATION,TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. a'ou' SI70RE OF APPLICA 1 AUTHORIZED REPRESENTATIVE _ ! ""5. CHEM A.INAK AI 3 Notary Mlk State of f lorida i Con nizion N GG 913761 .;VF;°'i liy Came.Expires Mar 26,2024 NOTARY SEAL Banded through National Notary Assn. NOTARY SIGNATURE DATE Page 2 of 6 y" BOARD OF COUNTY COMMISSIONERS County of Monroe ''s��`;�� Mayor Holly Merrill Raschein,District 5 The Florida Keys Mayor Pro Tem James K.Scholl,District 3 ,� Craig Cates,District I Michelle Lincoln,District 2 David Rice,District 4 Monroe County Fire Rescue 490 63rd Street Ocean Marathon,FL 33050 „ r Phone(305)289-6004 6.List the address and/or describe the location of your base station and all substations(attach separate sheet if necessary). Base Station: 490 63Td Street,Marathon,FL 33050 Sub Stations: KWIA Station 7-3491 S.Roosevelt Blvd Key West,FL 33040(no ALS) Stock Island Station 8-5655 MacDonald Ave.Key West,FL 33040 Big Coppitt Station 9-28 Emerald Dr Key West,FL 33040 Sugarloaf Station 10- 17175 Overseas Highway Sugarloaf Key,FL 33042 Cudjoe Station 11-22352 Overseas Highway Cudjoe Key,FL 33042 Big Pine Key Station 13-400 Key Deer Blvd.Big Pine Key,FL 33043 Aviation Station 16(Air Ambulance)- 10100 Overseas Highway,Marathon FL 33050 Conch Key Station 17- 10 s. Conch Ave,Conch Key,FL 33050 Layton Station 18-68260 Overseas Highway Layton,FL 33001 Tavernier Station 22- 151 Marine Ave Tavernier,FL 33070 Page 1 of 1 412 y" BOARD OF COUNTY COMMISSIONERS County of Monroe ''s��`;�� Mayor Holly Merrill Raschein,District 5 The Florida Keys Mayor Pro Tem James K.Scholl,District 3 ,� Craig Cates,District 1 Michelle Lincoln,District 2 David Rice,District 4 Monroe County Fire Rescue 490 63rd Street Ocean Marathon,FL 33050 „ r Phone(305)289-6004 9.Attach a schedule of rates which your service will charge during the COPCN period. Monroe County Fire Rescue Ambulance Rates BLS ALS1 ALS2 GROUND MILEAGE A0429 A0427 A0433 A0425 $600 $750 $1,050 $14.50 Page 1 of 1 413 PERSONNEL-PARAMEDICS NAME PARAMEDIC CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE See Attached On File in MCFR All Expire 12/1/2024 Page 3 of 6 414 PERSONNEL-EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE See Attached On File in MCFR All Expire 12/1/2024 Page 4 of 6 415 cfl PERSONNEL DRIVERS ............................................................ ............................--. ................................................................................ ................ .................... NAME STATE . 'd I First,Middle,Last SOCIAL SECURITY# DATE OF BIRTH DRIVER LICENSE# OF ISSUANCE EXPIRATION DATE �MT,mms a ALL MCFR EMTs and Paramedics All Florida Recorded in TeleStaff ..................................................................... ...........................................................................——-—--------——------.................... .................. —7.71".11 ....................I........... .............. ............... -—----------------------- ........................................................ ................... ........................................................................................................................................................... .. .............. .......... ............................................. .............--- ..................................................................................................... ............ .....................................---1-.--.----..................................................................................... ..... ....... ............— ... .... ........ ................. ...................... ................. ...... ......................................... ............. .................................. .............. .............................................. ........................... .. ..................... ........................................................ .............. ................... . ............. ............... ..................... ------ ................................................................................................ ....................... .......... ................... ... .......... ......................................................................................................... :t... ..... ......... ............. ................................................. .............................................. ................. .......... ............................ .................................................................................................................................................................................... ................................ .................. ............................. ..... ..................................... ........... ----------- .......... ........... ........... I DO HEREBY ATTEST,TO THE BEST OF MY KNOWLEDGE,THAT ALL OF THE ABOVE NAMED DRIVERS DO MEET ALL OF THE REQUIREMENTS OF CHAPTER 401.281 F.S.AND CHAPTER 64E-2.012 FAC FOR AMBULANCE DRIVERS. NOTARY SEAL C C" CHEW A.TAOSORWJgal ...... Notary public,State of F NOTARY SIGNATURE Commission 0 GG 971767 My Comm.Expires AW 26�,Z:02 led through National Notary Last Name Rank City Zip Code Alonso, Luis FF-EMT Pembroke Pines 33029 Amezaga, Alejandro FF-EMT Pembroke Pines 33028 Andalia, Alexander FF-EMT Homestead 33031 Anderson, Morgan FF-EMT Tavernier 33070 Araque, Eliseo FF-PM Key West 33040 Araque, Porfirio Lieutenant Key West 33040 Aulet Jr, Arturo Lieutenant Tavernier 33070 Baguer, Alex FF-PM Miami 33186 Baird, Bradley FF-EMT Tavernier 33070 Baird,Jonathan FF-EMT Big Pine Key 33043 Barbee,Jamie FF-PM Key West 33040 Batchelor, Adam FF-PM Homestead 33031 Baylis, Christopher FF-PM Miami 33176 Bejerano, Diego FF-EMT Marathon 33050 Bentley, Alvin Division Chief Key West 33040 Bernard, Michael Lieutenant Homestead 33031 Bertini, Brandon Lieutenant Key West 33040 Bland, Michael FF-EMT Key West 33040 Bohl, Andrew FF-EMT Key Largo 33037 Brack,Jennifer Lieutenant Tavernier 33070 Cabrera, Nelson Lieutenant Miami 33155 Callahan,James Fire Chief Summerland Key 33042 Callahan, Samuel FF-EMT Key West 33040 Cane, Cassaundra Captain Key Largo 33037 Carmichael,Joshua FF-PM Summerland Key 33042 Carson,James Lieutenant Key Largo 33037 Castro, Andre FF-PM Miami 33174 Chang-del Cueto, Angel FF-EMT Key Colony Beach 33051 Chavez, Matthew FF-EMT Tavernier 33070 Clavelo Garcia, Victor FF-PM Miami 33177 Colina, Brandon FF-EMT Summerland Key 33042 Colina, RL Deputy Chief Sugarloaf Key 33042 Cossio, Kevin FF-EMT Miami 33186 Costa, Roberto FF-EMT Miami 33177 Cowart, Cameron Lieutenant Tavernier 33070 Devitt, Ryan Captain Marathon 33050 Dewhirst,Jordan FF-EMT Key Colony Beach 33051 Duran, Fernando Captain Miami 33176 Duran,Jordan FF-EMT Big Pine Key 33043 Echo, Krysten FF-EMT Key Largo 33037 Eitel,Joshua Lieutenant Little Torch 33042 Eriksen, Erik FF-EMT Tavernier 33070 Farfan, Sam FF-EMT Tavernier 33070 Fernandez, Cesar FF-EMT Key West 33040 Findlay,James FF-EMT Cutler Ridge 33189 Foster, Kaitlyn Lieutenant Marathon 33050 417 Fox, Desmond FF-EMT Islamorada 33036 Frystacky, Honzik FF-EMT Key West 33040 Garcia, Dayron FF-EMT Miami 33156 Garcia, Luis FF-PM Miami 33173 Gonzalez, Frank Lieutenant Miami 33194 Gonzalez, Lisandro FF-EMT Hialeah 33012 Gonzalez, Luis FF-EMT Miami 33176 Gonzalez, Randy FF-PM Homestead 33033 Gonzalez, Samuel FF-EMT Marathon 33050 Guardado, Luis FF-EMT Miami 33196 Guieb Jr,John FF-PM Key West 33040 Gutierrez, Gregory FF-PM Cutler Bay 33189 Hackworth,Jeremy FF-EMT Key West 33040 Ham, Pedro Lieutenant Homestead 33032 Hamburger,John Lieutenant Miami 33186 Hannert, David Lieutenant Key West 33040 Hatcher,Troy FF-PM Summerland Key 33042 Hemeyer, Mark Battalion Chief Tavernier 33070 Hernandez Lopez FF-PM Homestead 33030 Hernandez,Joseph FF-EMT Miami 33186 Hill, Matthew FF-PM Tavernier 33070 HodekJr, Oliver FF-EMT Key West 33040 Horachek, Robert FF-PM Marathon 33050 Hubman,Jesse Lieutenant Homestead 33030 Hunter, Rion FF-EMT Key Largo 33037 Iser, David FF-EMT Islamorada 33036 Jachelski, Micheal Lieutenant Summerland Key 33042 Jacoby, Elizabeth FF-PM Marathon 33050 Johnson,Jaedon FF-EMT Miami 33187 Johnson, Ryan Battalion Chief Key West 33040 Juiz, Candice FF-PM Homestead 33031 Kyburz, Patrick Lieutenant Tavernier 33070 Lascano, Christian FF-PM Miami 33193 Leon, Manny Lieutenant Homestead 33033 Lopez, Ariel FF-EMT Miramar 33027 Lopez, Cesar FF-PM Hialeah 33015 Lopez, Eric FF-EMT Maimi 33165 Lopez,Joel FF-PM Miami 33185 Lopez, Michael FF-PM Miami 33189 Lucio, Alejandro Captain Homestead 33033 Machado,Jorge Captain Miami 33170 Macias Ricard FF-PM Miami 33157 Manash, Michael FF-EMT Miami 33176 Marston, Craig Division Chief Key West 33040 Martin, Craig Lieutenant Virginia Gardens 33166 Martin, Michael FF-PM Miami 33186 Mather, Charles Battalion Chief Tavernier 33070 418 McCoy, Patrick FF-PM Homestead 33033 Meneses,Alfred FF-PM Islamorada 3333 Millan, David Lieutenant Miami 33186 Miller, Nicholas FF-EMT Homestead 33033 Miranda,Jesus FF-PM Homestead 33033 Mock, Gavin FF-PM Key West 33040 Montes, Alfredo FF-PM Homestead 33032 Moreno,Alexandra FF-EMT Key Largo 33037 Morris, Bradley Battalion Chief Cudjoe Key 33042 Muina, Stephanie FF-EMT Long Key 33001 Muller, Zachary FF-PM Miami 33176 Nava Orosco, Carlos FF-EMT Tavernier 33070 Neyra, Nick Lieutenant Miami 33032 Nieves, Aaron FF-PM Homestead 33032 O'Connor, Sean FF-EMT Key Largo 33037 O'Donnell, Matthew FF-PM Key West 33040 Ondarza, Kyle FF-PM Miami 33184 Parra, Adrian FF-PM Miami 33157 Perez, Antonio Lieutenant Miami 33177 Perez, Harold FF-EMT Miami 33185 Placido, Lee Lieutenant Miami 33177 Ptomey, Luke FF-EMT Tavernier 33070 Rangel, Lazaro FF-PM Key Largo 33037 Reategui, Luigi FF-EMT Hialeah Gardens 33018 Reyes, Alexis FF-EMT Key Largo 33037 Ribot, Dany Captain Miami 33187 Rivero,Joaquin FF-EMT Key West 33040 Roman, Nicholas FF-PM Hialeah 33015 Ruiz, Mia FF-EMT Tavernier 33070 Ruiz, Robert FF-PM Miami 33185 Saez, Adrian Captain Miami 33183 Sanchez Jr, Sergio FF-PM Miami 33165 Sebben, David Captain Tavernier 33070 Seco, Samantha FF-PM Islamorada 33036 Sellers, Eric ARFF CPT Key West 33040 Serrano, Mark FF-PM Homestead 33033 Shapiro,Jared FF-PM Plantation 33324 Simancas, Xavier FF-PM Miramar 33027 Sirven, Michael FF-EMT Miami 33189 Sotolongo, Alyssandra FF-EMT Key Largo 33037 Sparber, Aaron FF-PM Marathon 33050 Suarez, Damian FF-EMT Miami 33186 Summers, Michael FF-PM Hollywood 33024 Taylor, Austin FF-EMT Miami 33177 Tellez, Sergio FF-PM Key West 33040 Thompson, Andrea Division Chief Marathon 33050 Turner, Alberto FF-EMT Islamorada 33036 419 Vandervoort, Richard Captain Marathon 33050 Vargas, Ignacio FF-PM Homestead 33033 Vazquez, Alejandro FF-EMT Miami 33155 Vignati, Colloggero FF-EMT Miami 33177 Werner,Jake FF-PM Key Largo 33037 Wheaton, Bryce FF-EMT Tavernier 33070 Wright, William FF-PM Miami 33144 Yuque,William FF-EMT Hialeah 33015 Zlockie, Robert FF-EMT Tavernier 33070 420 T- c a o CN H O HO z � a cr w it %tea xW � � � a ocr W � U Z o H �3 0 0 � w a it cn a cn cn 4 U a 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COUNTY COMMISSIONERS Department of Insurance Services P.O.Box 538135 1111 12TH STREET,SUITE 408 Orlando,Florida 32853-8135 KEY WEST,FL 33040 COVERAGES THIS IS TO CERTIFY THAT THE AGREEMENT BELOW HAS BEEN ISSUED TO THE DESIGNATED MEMBER FOR THE COVERAGE PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE COVERAGE AFFORDED BY THE AGREEMENT DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH AGREEMENT COVERAGE PROVIDED BY: FLORIDA MUNICIPAL INSURANCE TRUST AGREEMENT NUMBER: FMIT 0386 COVERAGE PERIOD: FROM 10/1/23 COVERAGE PERIOD: TO 10/1/24 12:01 AM STANDARD TIME TYPE OF COVERAGE-LIABILITY TYPE OF COVERAGE-PROPERTY General Liability ❑ Buildings ❑ Miscellaneous ❑X Comprehensive General Liability,Bodily Injury,Property Damage, ❑ Basic Form ❑ Inland Marine Personal Injury and Advertising Injury ❑ Special Form ❑ Electronic Data Processing ❑X Errors and Omissions Liability ❑ Personal Property ❑ Bond ❑X Employment Practices Liability ❑ Basic Form ❑X Employee Benefits Program Administration Liability ❑ Special Form ❑X Medical Attendants'/Medical Directors'Malpractice Liability ❑ Agreed Amount ❑X Broad Form Property Damage ❑ Deductible N/A ❑ Law Enforcement Liability ❑ Coinsurance N/A ❑X Underground,Explosion&Collapse Hazard ❑ Blanket Limits of Liability ❑ Specific *Combined Single Limit ❑ Replacement Cost Deductible N/A ❑ Actual Cash Value Automobile Liability Limits of Liability on File with Administrator ❑ All owned Autos(Private Passenger) TYPE OF COVERAGE-WORKERS'COMPENSATION ❑ All owned Autos(Other than Private Passenger) ® Statutory Workers'Compensation ❑ Hired Autos ® Employers Liability $1,000,000 Each Accident ❑ Non-Owned Autos $1,000,000 By Disease $1,000,000 Aggregate By Disease Limits of Liability ❑ Deductible N/A *Combined Single Limit ❑X $500,000 Self Insured Retention Deductible N/A Automobile/Equipment-Deductible ❑X Physical Damage Per Schedule-Comprehensive-Auto Per Schedule-Collision-Auto NA-Miscellaneous Equipment Other The limit of liability is$5,000,000(combined single limit)bodily injury and/or property damage each occurrence in excess of a self-insured retention of$200,000. This limit is solely for any liability resulting from entry of a claims bill pursuant to Section 768.28(5)Florida Statutes or liability/settlement for which no claims bill has been filed or liability imposed pursuant to Federal Law or actions outside the State of Florida. Description of Operations/Locations/Vehicles/Special Items RE:Evidence of Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE AGREEMENT ABOVE. Designated Member Cancellations Monroe County Board of County Commissioners SHOULD ANY PART OF THE ABOVE DESCRIBED AGREEMENT BE CANCELED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 45 DAYS WRITTEN NOTICE TO THE 1111 12th Street Suite 408 CERTIFICATE HOLDER NAMED ABOVE,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE PROGRAM,ITS AGENTS OR REPRESENTATIVES. Key West FL 33040 AUTHORIZED REPRESENTATIVE 423 FMI7-CER7(10/2011) CERTIFICATE OF COVERAGE Certificate Holder Administrator Issue Date 10/17/23 MONROE COUNTY FIRE RESCUE Florida League of Cities,Inc. 490 63RD STREET Department of Insurance Services P.O.Box 538135 MARATHON,FL 33050 Orlando,Florida 32853-8135 COVERAGES THIS IS TO CERTIFY THAT THE AGREEMENT BELOW HAS BEEN ISSUED TO THE DESIGNATED MEMBER FOR THE COVERAGE PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE COVERAGE AFFORDED BY THE AGREEMENT DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH AGREEMENT COVERAGE PROVIDED BY: FLORIDA MUNICIPAL INSURANCE TRUST AGREEMENT NUMBER: FMIT 0386 COVERAGE PERIOD: FROM 10/1/23 COVERAGE PERIOD: TO 10/1/24 12:01 AM STANDARD TIME TYPE OF COVERAGE-LIABILITY TYPE OF COVERAGE-PROPERTY General Liability ❑ Buildings ❑ Miscellaneous ❑X Comprehensive General Liability,Bodily Injury,Property Damage, ❑ Basic Form ❑ Inland Marine Personal Injury and Advertising Injury ❑ Special Form ❑ Electronic Data Processing ❑X Errors and Omissions Liability ❑ Personal Property ❑ Bond ❑X Employment Practices Liability ❑ Basic Form ❑X Employee Benefits Program Administration Liability ❑ Special Form ❑X Medical Attendants'/Medical Directors'Malpractice Liability ❑ Agreed Amount ❑X Broad Form Property Damage ❑ Deductible N/A ❑ Law Enforcement Liability ❑ Coinsurance N/A ❑X Underground,Explosion&Collapse Hazard ❑ Blanket Limits of Liability ❑ Specific *Combined Single Limit ❑ Replacement Cost Deductible N/A ❑ Actual Cash Value Automobile Liability Limits of Liability on File with Administrator ❑X All owned Autos(Private Passenger) TYPE OF COVERAGE-WORKERS'COMPENSATION ❑X All owned Autos(Other than Private Passenger) ® Statutory Workers'Compensation ❑X Hired Autos ® Employers Liability $1,000,000 Each Accident ❑X Non-Owned Autos $1,000,000 By Disease $1,000,000 Aggregate By Disease Limits of Liability ❑ Deductible N/A *Combined Single Limit ❑X $500,000 Self Insured Retention Deductible N/A Automobile/Equipment-Deductible ❑X Physical Damage Per Schedule-Comprehensive-Auto Per Schedule-Collision-Auto NA-Miscellaneous Equipment Other The limit of liability is$5,000,000(combined single limit)bodily injury and/or property damage each occurrence in excess of a self-insured retention of$200,000. This limit is solely for any liability resulting from entry of a claims bill pursuant to Section 768.28(5)Florida Statutes or liability/settlement for which no claims bill has been filed or liability imposed pursuant to Federal Law or actions outside the State of Florida. Description of Operations/Locations/Vehicles/Special Items RE:Fire Station 7,KWIA;Fire Station 8,Stock Island;Fire Station 9,Big Coppitt,Fire Station 10,Surgarloaf;Fire Station 11,Cudjoe,Fire Station 13,Big Pine;Fire Station 17,Conch Key;Fire Station 18,Layton;Fire Station 22,Tavernier THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE AGREEMENT ABOVE. Designated Member Cancellations Monroe County Board of County Commissioners SHOULD ANY PART OF THE ABOVE DESCRIBED AGREEMENT BE CANCELED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 45 DAYS WRITTEN NOTICE TO THE 1111 12th Street Suite 408 CERTIFICATE HOLDER NAMED ABOVE,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE PROGRAM,ITS AGENTS OR REPRESENTATIVES. Key West FL 33040 AUTHORIZED REPRESENTATIVE 424 FMI7-CER7(10/2011) GVS COURTq c o: A Kevin Madok, CPA - �o ........ � Clerk of the Circuit Court& Comptroller Monroe County, Florida �z cooN DATE: October 5, 2023 TO: Cheri Tamborski Emergency Services Mayor Bruce Halle Fire & Ambulance District 1 Board of Governors FROM: Liz Yongue, Deputy Clerk SUBJECT: September 20, 2023 BOCC Meeting The following item has been executed and added to the record: C30/H2 1 st Addendum to the Agreement with Professional Emergency Services, Inc. for a Medical Director, for a one-year contract extension with a five percent increase from $55,000.00 to $57,750.00 for air ambulance medical direction and an increase from $58,000.00 to $60,900.00 for ground ambulance medical direction for a total contract amount of $118,650.00. Should you have any questions, please feel free to contact me at(305) 292-3550. cc: County Attorney_ Finance File KEY WEST MARATHON PLANTATION KEY 500 Whitehead Street 3117 Overseas Highway 88770 Overseas Highway Key West, Florida 33040 Marathon, Florida 33050 Plantation Key, Florida 33070 425 FIRST ADDENDUM TOAGREEMENT BETWEEN THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; THE BOARD OF GOVERNORS OF MONROE COUNTY FIRE &AMBULANCE DISTRICT 1, AND PROFESSIONAL EMERGENCY SERVICES, INC. FOR MEDICAL DIRECTION FOR MONROE COUNTY FIRE RESCUE THIS FIRST ADDENDUM TO AGREEMENT("Addendum") is entered into upon the date below written by and between Monroe County, Florida, acting through its Board of County Commissioners ("BOCC"), a political subdivision of the State of Florida, whose main business address is 1100 Simonton Street, Key West, Florida 33040; the Board of Governors of Monroe County Fire & Ambulance District 1 (collectively "County") and Professional Emergency Services, Inc. ("Contractor"). WHEREAS, the County entered into a Professional Services Agreement ("Agreement") with Professional Emergency Services, Inc. on September 15, 2021 for a period beginning October 1, 2021 and continuing through September 30, 2023 ("Initial Term") to provide professional Medical Director services to Monroe County Fire Rescue; and WHEREAS,the Agreement allows the parties to extend the employment term; and WHEREAS, the Contractor has satisfactorily performed her duties therefore the parties desire to update several terms and extend the term of the contract for a period of one year, becoming effective on October 1, 2023 and terminating September 30, 2024; and NOW THEREFORE, in consideration of the mutual promises contained herein, the County and Contractor mutually agree as follows: 1. Paragraph 1 of the Agreement is amended to read as follows: This Contract shall become effective on October 1,2023, and shall run through September 30,2024("Initial Term"), and shall be renewable thereafter at the option of County for four additional one-year periods.Upon expiration of the Initial Term,County may renew the contract for up to four additional one-year periods at an increase in the compensation rate of up to five percent (50/o), for each air and ground, at the discretion of the Fire Chief, over the prior Initial Term,unless otherwise agreed bythe parties. 426 2. Paragraph 2.1 of the Agreement is amended to read as follows to reflect a 5% pay increase for the 2023-2024 term: In return for performance ofthe duties set forth in the Agreement, including but not limited to specific duties assigned by MCFR from time to time, Contractor shall be paid at a rate o f $60,900 annually to provide ground ambulance medical direction. Payments shall be made monthly in arrears by County pursuant to the Florida Local Government Prompt Payment Act after receipt of proper invoice submitted by Medical Director. 3. Paragraph 2.2 of the Agreement is amended to read as follows to reflect a 5% pay increase for the 2023-2024 term: In return for performance ofthe duties set forth in the Agreement, including but not limited to specific duties assigned by MCFR from time to time, Contractor shall be paid at a rate of$57,750 annually to provide air ambulance medical direction. Payments shall be made monthly in arrears by County pursuant to the Florida Local Government Prompt Payment Act after receipt of proper invoice submitted by Medical Director. Note: This payment is contingent upon County's decision to continue to operate air ambulance services under its ALS license, and if, for any reason, County decides not to continue to operate air ambulance EMS services under its ALS license, then Medical Director shall have no responsibility to serve as Medical Director for the air ambulance service and County shall have no liability for this portion ofMedical Director's compensation. All other terms and conditions ofthe Initial Agreement dated September 15, 2021, not inconsistent herewith, shall remain in full force and effect (signatures on next page) 427 IN WITNESS WHEREOF, the parties have set their hands and seals, in the County of Monroe,Florida this 20th day of S_eptember ;2023. MONROE COUNTY FIRE RESCUE By: James Callahan,Fire Chief WITNESS: PROFESSIONAL RGENCY SERVICES,IN By: f By: . . i Professional Emergency Services, Inc; Dr. Sandra Schwemmer m BOARD OF COUNTY KEVIN MADOK,CLERK COMMISSIONS As Deputy Cl k By: Mayor MONROE COUNTY ATTORNEY BOARD OF GOVERNORS OF FIRE Approved as to form and content: AND AMBULANCE DISTRICT 1 OF MONROE COUNTY,FLORIDA By: By: Assistant County Attorney Mayor/Chairperson -n F �� rn Approved as to form and legal sufficiency Monroe County Attorney's Office Christina Cory,Assistant County Attorney M Date:8.31.23 � 428 4,1A PROFESSIONAL EMERGENCY SFR `1(.:ES August 28, 2023. To Whiom It May Concern: Professional Emergency Services, Inc. is not required to purchase Worker's Compensation Insurance per FL Statutes(less than 4 employees), Professional Emergency Services Inc, does not have commercial vehicles and does not carry general liability insurance, Please contact me should you have any questions, Sincerely, Sandra Sc vwrernmer, D.a., FACOEP-D, FACEP, FAAOE, H RM President, Professional Emergency Services, Inc. _.429 2018 E idon MONROE COUNTY, FLORIDA REQUEST FOR WAIVER OF INSURANCE REQUIREMENTS It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements,be waived or modified on the following contract. ContractorNendor: Professional Emergency Services Project or Service ContractorNendor Address&Phone#: Dr.Schwemmer-Medical Director General Scope of Work: Medical Director Reason for Waiver or Waive Additional Insured on Auto Liabililty, Dr Schwemmer, Modification: Prefessional Emergency Services,does not own any commercial vehicles Policies Waiver or Modification will apply to: Auto Liability Signature of CvntractorNendor, ' a„ e✓ Date 8/30/23 Approved Not Approved . ,..., ....... � .... Risk Management Signature v Date:.....,....8. .3.012Q2.3. County Administrator appeal: Approved: w Not Approved Date. Board of County Commissioners appeal: Approved Not Approved. Meeting Date: Administrative Instruction 7500.7 104 430 �r Kevin Madok, CPA Clerk of the Circuit Court$ Comptroller—Monroe County, Florida DATE: September 22, 2021 TO: Cheri Tamborski Fire Rescue FROM: Sally M. Abrams, D.C. SUBJECT: September 15th BOCC Meeting Attached is an electronic copy of Item C8, a two (2) year contract with Professional Emergency Services, Inc., for a Medical Director of Monroe County Fire Rescue with an increase from $54,000 to $55,000 per year for air ambulance medical direction, the same annual cost of$58,000 for ground ambulance medical direction and the option to renew for two (2) additional 2-year periods at an increase in cost of up to five percent (5%). This contract is pursuant to the exemption from the competitive bidding process for professional services under Chapter 4 of the purchasing policies and procedures. Should you have any questions, please feel free to contact me at ext. 3550. Thank you. cc: County Attorney Finance File KEY WEST MARATHON PLANTATION KEY PKIROTH BUILDING 500 Whitehead Street 3117 Overseas Highway 88820 Overseas Highway 50 High Point Road Key West,Florida 33040 Marathon,Florida 33050 Plantation Key,Florida 33070 Plantation Key,Florida 33070 305-294-4641 305-289-6027 305-852-7145 305-852-7145 431 CONTRACT BETWEEN THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AND THE BOARD OF GOVERNORS OF FIRE AND AMBULANCE DISTRICT 1 AND PROFESSIONAL EMERGENCY SERVICES,INC. FOR MEDICAL DIRECTION FOR MONROE COUNTY FIRE RESCUE THIS CONTRACT is made and entered into this 15th day of September 2021, by and between the Hoard of County Commissioners, The Board of Governors of Fire and Ambulance District I of Monroe County, Florida,hereinafter collectively referred to as the "COUNTY,"and Professional Emergency Services,Inc.,hereinafter referred to as"MEDICAL DIRECTOR'. WITNESSETH: WHEREAS,COUNTY provides fire and/or emergency medical services pursuant to Chapter 401,F.S.and Chapter 641-1,FAC;and WHEREAS,COUNTY is required to employ or contract with a MEDICAL DIRECTOR who shall'be a Florida licensed physician, Board Certified in Emergency Medicine with added qualification in Emergency Medical Services (EMS) and pre-hospital care experience, or a business entity that employs or contracts with similarly qualified physicians; and WHEREAS, COUNTY has determined it to be in the best interests of the residents of and visitors to Monroe County to contract with MEDICAL DIRECTOR for the purpose of providing direction to the Fire and Emergency Medical Services;and WHEREAS, MEDICAL DIRECTOR desires to provide professional services according to the terms and conditions stated herein. NOW THEREFORE, in consideration of the mutual understandings and Contracts set forth herein, COUNTY and MEDICAL DIRECTOR agree as follows: 1. Term This Contract shall became effective on October 1, 2021, and shall run through September 30, 2023(Initial.Term),and shall be renewable thereafter at the option of COUNTY fortwo additional two(2)-year periods. Upon expiration of the Initial Term, COUNTY may renew the contract for up to two additional two (2)-year periods at an increase in the compensation-rate of up to five percent(51/6) over the prior Initial Term,unless otherwise agreed by the parties. 2. Compensation 2.1 Ground Ambulance I 432 r MEDICAL DIRECTOR shall be paid at a rate of $58,000.00 annually to provide ground ambulance medical direction. Payments shall be made monthly in arrears by COUNTY pursuant to the Florida Local Government Prompt Payment Act after receipt of proper invoice submitted by MEDICAL DIRECTOR. 2.2 Air Ambulance MEDICAL DIRECTOR shall be paid at d rate of$55,000.00 annually to provide air ambulance medical direction. Payments shall be made monthly in arrears by COUNTY pursuant to the Florida Local Government Prompt Payment Act after receipt of proper invoice by MEDICAL DIRECTOR.Note: This payment is contingent upon COUNTY's decision to continue to operate air ambulance services under its ALS license, and 1� for any reason, COUNTY decides not to continue to operate air ambulance EMS service under its ALS license, then MEDICAL DIRECTOR shall have no responsibility to serve as MEDICAL DIRECTOR for the air ambulance service and COUNTY shall have no liability for this portion of MEDICAL DIRECTOR's compensation. 2.3 Physician"peer to peer"services for collection of denied medical claims will be paid,subject to administrative review, at a rate of$250.001hour in order to collect funds that would otherwise be unpaid. 2.4 COUNTY will reimburse MEDICAL DIRECTOR for any direct expenses associated with meetings required by COUNTY or Monroe County Sheriffs Office. For the purpose of this paragraph,the term "direct expenses"means per diem or subsistence allowances, transportation costs or mileage allowances, and miscellaneous travel expenses, as those terms are defined by Section 112.061,Florida Statutes. All compensation shall be according to County Ordinance and State law. 2..5 a.MEDICAL DIRECTOR will be provided a county phone and any other equipment required as approved by the Chief of Fire Rescue. b. COUNTY will reimburse MEDICAL DIRECTOR for the yearly application fee required for renewal of the County's Drug Enforcement Administration (DEA) certificate, if the MEDICAL DIRECTOR has paid the application fee in advance on behalf of the COUNTY. 2.5 Invoices received from MEDICAL DIRECTOR shall be reviewed and approved by COUNTY Fire Chief or his designee, indicating that services have been rendered in conformity with the Contract,and then will be sent to the Finance Department for payment. 2.7 In order for both parties to close their books and records, MEDICAL DIRECTOR must clearly state"FINAL INVOICE"on MEDICAL DIRECTOR's final and last billing to COUNTY. This certifies that all services have been properly performed and all charges and costs have been 2 433 invoiced to Monroe COUNTY. Since this account will thereupon be,closed,any and other future charges if not properly included in this final invoice are waived by MEDICAL DIRECTOR 2.8 Nothing in this Contract prohibits MEDICAL DIRECTOR from billing any third party for medical services rendered outside the scope of this Contract that may arise during or after the term of this ' Contract. 3. Ruripose The purpose of this Contract is to assure compliance of COUNTY in Medical Direction of Monroe County Fire Rescue in accordance with the provisions of F.S.,Chapter 401,and FAC Chapter 64J- 1.004. 4. Duties and Responsibilities. 4.1 MEDICAL DIRECTOR shall be responsible to Monroe County Fire Rescue and report directly to the Fire Chief,and/or his/her designee. 4.2 MEDICAL DIRECTOR shall adhere to the responsibilities as set forth in Chapter 401,F.S.,and Rule 641-1.004,FAC;the applicable rules of any goiernment agency implementing said chapter; and any duties upon writtednotice from the Florida Department of Health that such additional duties are required of .MEDICAL DIRECTOR. These include supervising and accepting responsibility for the medical performance of all certified/license response personnel functioning within the scope of their official duties while on duty with Monroe County Fire Rescue(MCFR), including,but not limited to,members of volunteer fire department under contract with COUNTY and/or Monroe County Fire and Ambulance District 1. While these duties will typically occur within the geographical Borders of unincorporated Monroe County and the'City of Layton, they also include duties performed at the Key West International Airport, during mutual performed during mutual aid to requesting municipalities outside those geographical borders and while transporting patient to out ofcounty medical facilities. For the purpose of this Contract,Dr.Sandra Schwemmer is the individual who meets the licensing and registration requirements of Chapter 401,F.S.and FAC Chapter 64J-1.004. 4.3 MEDICAL DIRECTOR shall be knowledgeable with the standards set by National Fire Protection Association,and in particular; Standard!582: Standard on Comprehensive Occupational Medical Program for Fire Departments. 4.4 Standards of Care MEDICAL DIRECTOR shall establish and maintain standards of care for EMS providers. ' 4.4.1 MEDICAL DIRECTOR shall gather agency input in the review and development of standards of care on an annual basis and establish and revise agency performance standards as necessary. 3 434 4.4.2 Develop pre-hospital practice parameters for Fire Rescue Personnel of all levels. The parameters shall Abe developed with consideration to budgetary and staffing limitations and the fiscal impact on MCFR and the citizens of Monroe County. 4.5 Patient Advocate MEDICAL DIRECTOR shall be a patient advocate in the fire rescue system and shall ensure that all aspects of the EMS systems are developed to place the needs of the patient first. 4.6 Protocols and Standing Orders. 4.6.1 MEDICAL DIRECTOR shall develop, revise, implement, and maintain basic and advanced life support protocols and standing orders under which MCFR personnel will function under medical control. 4.6.2 MEDICAL DIRECTOR shall review and revise existing protocols and standing orders to ensure that they meet nationally accepted standards of practice for use by all system providers, which permit specified ALS and BLS procedures when communication cannot be established with a supervising physician,or when any delay in patient care would threaten the life or health of the patient, These standards include,but are not limited to,Advanced Cardiac Life Support(ACLS), Basic Trauma Life Support(BTLS),and Pediatric Advanced Life Support(PALS). In addition to medical treatment,protocols shall address determination of patient destination. 4.6.3 MCFR shall publish and distribute,at its own cost,all protocols and standing orders. The protocols and standing orders shall be published in a form consistent with agency Standard Operating Procedures. Copies of the protocols and standing orders will be maintained on all MCFR ambulances (air and ground) and ALS engines, and will be distributed to certified/licensed response personnel. Personnel copies may be provided electronically. MCFR shall obtain and retain a receipt from each personnel member verifying receipt of the protocols and any changes. These receipts may be electronic, and shall state clearly that each person is individually accountable and obligated to follow all rules,regulations and protocols. All protocols and standing orders shall become public domain upon implementation, 4.6.4 MEDICAL DIRECTOR shall develop, review, and revise, when necessary, Trauma Transport Protocols (TTP) for submission to the Florida Department of Health, Bureau of Emergency Medical Services for approval in accordance with Rule 64d-2,FAC. 4.6.5 MEDICAL DIRECTOR shall develop enhanced protocols for specialty procedures or services including but:not limited to aeromedical(Trauma Star)transport. 4.6.6 MEDICAL DIRECTOR shall conduct an on-going review of all protocols and standing orders as may be necessary to ensure reliable service delivery,appropriate patient care,and the maintenance 4 435 of the current standard of care. This shall include,at a minimum,a comprehensive annual review and written approval of all protocols and standing orders. While conducting the annual review, MEDICAL DIRECTOR shall take into consideration the results of quality assurance reviews, review of current medical literature,and input from MCFR response personnel. Changes shall be developed with consideration to budgetary Iimitations and the fiscal impact on MCFR and the citizens of Monroe County. The annual review shall be completed, and all proposed changes forwarded to the Fire Chief,prior to the end of each Fiscal Year. 4.6.7 MEDICAL DIRECTOR shall ensure that appropriate training for new protocols and standing orders is conducted prior to implementation;shall ensure compliance with protocols and standing orders by all MCFR personnel; and ensure that additional training is conducted for any identified needs. 4.1 Availability. MEDICAL DIRECTOR or hiAer previously approved designee shall be available twenty-four (24) hours a day, seven (7) days a week for medical direction to MCFR personnel in order to resolve problems,system conflicts, and provide services in an emergency as that term is defined in Section 252.34(3),F.S. 4.8 Trauma Scorecard Methodologies. MEDICAL DIRECTOR shall ensure that all certified/licensed response personnel are trained in the use of the trauma scorecard methodologies,as provided in Chapter 64l-2.004,FAC, for adult trauma patients and 64J-2.005,FAC,for pediatric trauma patients. 4.9 Aeromedical Operations 4.9.1 MEDICAL DIRECTOR shall participate in Trauma Star safety and quality assurance committees, and shall attend quarterly meetings to review safety policies, procedures, unusual occurrences, safety issues,and audit compliance with safety policies and procedures. 4.9.2 Be knowledgeable with aeromedical requirements of patients and evaluate each patient in person, by telephone, or by delegated written protocol prior to each interfacility transfer flight for the purpose of determining,that the aircraft,flight and medical crew,and equipment meet the patient's needs. 4.10 Oversight of Medical Qualifications And Proficiency of MCFR Personnel A M 1 MEDICAL DIRECTOR shall ensure initial and continued medical qualifications and proficiency of MCFR personnel. 4.10.2 MEDICAL DIRECTOR shall establish and periodically update the minimum personnel training standards and certification requirements for all MCFR personnel who provide emergency medical 5 436 care. Such standards shall include the requirements for orientation and initial training, continuing medical education,standards for professional conduct and evaluation standards and procedures. 4.10.3 MEDICAL DIRECTOR shall ensure that all field personnel meet the initial requirements and continuously comply with established standards to attain and maintain approval to operate within the MCFR system. 4.10.4 MEDICAL DIRECTOR shall establish procedures for issuance, renewal, suspension, and revocation of practice privileges for MCFR personnel in concert with the Fire Chief,to include a process for remediation. The procedures shall contain due process provisions and all such provisions,shall be approved,in advance,by the Fire Chief. 4.10.5 MEDICAL DIRECTOR shall provide for direct observation of field level providers while performing their duties that meets or exceeds Section 401.265,F.-S.,and Rule 64J-1.004,FAC. 4.11 Quality Assurance 4.11.1 MEDICAL DIRECTOR,in coordination with MCFR,shall develop,implement, and maintain an effective patient care Quality Assurance System to assess the medical performance of all certified/licensed MCFR response personnel. 4.11.2 MEDICAL DIRECTOR shall develop, implement, and supervise a formal patient care Qualify Assurance System in accordance with Section 401.265(2), F.S. and Rule 64J-1.004, FAC, to include the formation and supervision of a quality assurance committee. 4.11.2.1 The purpose and tone of the quality assurance review process shall be positive and educational; however, MEDICAL DIRECTOR may, at any time and without limitation, conduct a quality assurance review investigation or audit to ensure that MCFR personnel comply with the Protocols and Standard of Care. 4.11.2.2 The method and extent of the investigation employed during any given quality assurance review shall be determined by MEDICAL DIRECTOR in consultation with the Fire Chief. As a result of said investigation, MEDICAL DIRECTOR may require remedial training of MCFR personnel and/or revocation of practice privileges. Remedial training may be conducted by MEDICAL DIRECTOR,MCFR personnel,or other personnel at MEDICAL DIRECTOR's discretion. 4.11.3 MEDICAL DIRECTOR or designee may also conduct special audits in response to observations or customer feedback provided by patients, family members, caregivers, bystanders, crewmembers,physicians and hospital personnel. 6 437 4.11.4 MEDICAL DIRECTOR may also develop procedures far routine auditing of EMS system performance and adherence to protocols on individual EMS incidents and overall EMS,system compliance. 4.11.5 MEDICAL DIRECTOR or designee shall review, in conjunction with MCFR battalion chiefs or their designees,patient care reports on an ongoing basis;review all protocol deviations and initiate or recommend corrective action. MEDICAL DIRECTOR or designee shall review at least 40 patient care reports per month.MCFR shall provide electronic copies of patient care reports. 4.11.6 MEDICAL DIRECTOR shall periodically visit and communicate with the hospital emergency departments to exchange information and review the quality of care provided by the MCFR personnel. 4.11.7 MEDICAL DIRECTOR shall participate in field activity and system monitoring to include the following; 4.11.7.1 Ride along and observe field activity as a crewmember on a rescue as needed. System monitoring shall include visiting fire stations when needed to discuss issues with MCFR personnel. 4.11.8 MEDICAL DIRECTOR shall document in a quarterly status report to the Fire Chief, evidence of the following required activities: 4.11.8.1 Reporting on issues identified with MCFR personnel; and 4.11.8.2 Communicating with hospital emergency department staff, and other medical and public safety personnel for quality assurance and education activities. 4.12 Educational Programs 4.12.1 KAPTUCAL DIRECTOR shall participate in educational programs at all levels, to include sII certified/licensed response personnel. 4.12.2 MEDICAL DIRECTOR or designee shall oversee a minimum of ten (10) -hours a year of continuing medical education related to pre;hospital care or teaching or a combination of both. 7 438 4.12.3 MEDICAL. DIRECTOR shall actively participate in the development and presentation of EMS continuing education programs by identifying educational topics, presenting lectures and providing other educational opportunities for the enhancement of the fire rescue system. MCFR shall pay the actual direct cost of any course materials, instructors, and certificates. 4.12.3.1 Education should be geared to reach the specific needs of the audience. As some providers are volunteers,consideration shall be given to scheduling some training on nights or weekends. 4.12.3.2 Course content should include system-specific issues and items resulting from audit and review. 4.12.4 Where MEDICAL DIRECTOR is not the presenter,and training services are conducted by other COUNTY personnel and/or are subcontracted to an outside provider,MEDICAL DIRECTOR will ensure the quality of the Continuing Medical Education (CME) training provided to EMS personnel by: 4.12.4.1 Reviewing and approving all curriculum and courses for continuing education units(CEU's)prior to MCFR personnel being trained; 4.12.4.2 Monitoring and auditing at least one (1) class session of every CME course held in which MEDICAL DIRECTOR is issuing CME; and 4.12.4.3 Evaluating the educational effectiveness of instruction,courses and programs in consultation with the CME contractor. 4.12.5 MEDICAL DIRECTOR shall maintain necessary and appropriate instructor certifications and participate as Medical Director for educational programs sponsored by MCFR such as ACLS, PALS,6TLS,etc, 4.12.6 Upon proof of completion, MEDICAL DIRECTOR shall sign documents and approve CME to those-EMT's and EMT-Ps that have completed a minimum of 30 hours or the required hours for biannual recertification training,as set forth in Section 401.2715,F.S. 4.13 Agency Liaison 4.13.1 MEDICAL DIRECTOR shall participate in interagency discussions about specific issues or problems as necessary. g 439 4.13.2 MEDICAL DIRECTOR shall notify MCFR of any pertinent concerns regarding patient care raised by other agencies and provide advice on a resolution. MEDICAL DIRECTOR shall also notify other agencies of any concerns regarding patient care, raised lay either MCFR or MEDICAL DIRECTOR. 4.13.3 MEDICAL DIRECTOR shall develop and maintain liaisons with the local medical community: hospitals, emergency departments, mental health agencies, physicians, providers, ambulance services,and other agencies impacting MCFR. 4.13.4 MEDICAL DIRECTOR shall assist in resolution of problems involving the delivery of pre- hospital care and other services in accordance with Rule 64]-1.004,FAC. 4.13.5 MEDICAL DIRECTOR shall interact with and inform local government officials on an as needed basis. 4.13.6 MEDICAL DIRECTOR shall participate in the Florida EMS Medical Director's Association or a statewide physician's group involved in pre-hospital care. 4.13.7 MEDICAL DIRECTOR shall be an active member of at least one national emergency medicine constituency group such as the National Association of EMS Physicians,the American College of Emergency Physicians, etc. 4.13.8 MEDICAL DIRECTOR shall interact with county, regional, state, and federal authorities, regulators and legislators .to ensure standards, needs, and requirements are met, and resource utilization is optimized when necessary. 4.13.9 MEDICAL DIRECTOR shall participate in grant application process for system funding, expansion,and research. 4.14 Stress Management Programs, MEDICAL DIRECTOR shall participate in stress management programs for providers within the system,as needed. 4.15 Community Access to Healthcare Initiatives. MEDICAL DIRECTOR, in conjunction with MCFR, shall coordinate community access to healthcare initiatives as needed. 9 440 4.16 EMT Oversight. 4.16.1 In accordance with Rules 64d-1004(g)and(h),FAC,assume direct responsibility for:the use of an automatic or semi-automatic defibrillator;the use of a glucometer;the administration of aspirin; the use of any medicated auto injector; the performance of airway patency techniques including airway adjuncts,not to include endotracheal intubation;and on routine interfacility transports,the monitoring and maintenance of non-medicated I.V.s by an EMT. 4.16.2 MEDICAL DIRECTOR shall ensure that all EMTs are trained to perform these procedures;.shall establish and/or maintain written protocols for performance of these procedures;and shall provide written evidence to the Florida Department of Health documenting compliance with provisions of these administrative rules. 4.17 Disaster Assistance and Planning 4.17.1 MEDICAL DIRECTOR shall be available for consultation and/or response during a disaster situation occurring in Monroe County. 4.17,2 MEDICAL DIRECTOR shall function as a liaison between field EMS operations, hospitals, and public health agencies during disaster situations. 4.17.3 MEDICAL DIRECTOR shalI provide specific information to assist in the mitigation of the EMS aspects during a disaster situation. 4.17.4 MEDICAL DIRECTOR.shall cooperate in planning,updating, and following applicable sections of the Monroe County Comprehensive Emergency Management Plan, including, but not limited to,participation in disaster drill and emergency management drills. 4.18 Controlled Substances,Medical Equipment and Supplies. 4.18.1 In accordance with F.S., Chapter 401 and Rule 64J-1.004(4)(c), FAC, MEDICAL DIRECTOR shall possess proofof current registration as a medical director with the U.S.Department of Justice, DEA, to provide controlled substances to an EMS provider. The DEA registration shall include each address at which controlled substances are stored. Proof of such registration shall be maintained on file with MCFR,which shall maintain the copies and make them readily available for inspection. MCFR will forward all renewal documents as received from DEA to MEDICAL DIRECTOR in order to ensure continuous registration and will reimburse MEDICAL DIRECTOR for the cost of such registration. Copies of physician license and registrations must be provided to MCFR. 10 441 4.18.2 MEDICAL. DIRECTOR shall formulate and ensure adherence to detailed written procedures to cover the purchase, storage, use, and accountability for medications, fluids, and controlled substances used by MCFR personnel, in accordance with Chapters 499 and 893, F.S., and Rule 641-1.021,FAC, 4.18.3 MEDICAL DIRECTOR shall ensure and certify that security procedures of all MCFR providers for medications, fluids and controlled substances are in accordance with Chapters 499 and 893, F.S.,and Rule 64J-1.021,FAC. 4.18.4 MEDICAL DIRECTOR shall approve a list of mandatory equipment, medications and medical supplies that must be-on board a Rescue or ALS Engine for it to respond to EMS incidents. 4.18.5 MEDICAL DIRECTOR shall advise MCFR on appropriate staffing, structural requirements, equipment and supplies necessary to ensure that the air ambulance-complies with Rule 64J-1.005, FAC,and Section 441.251(4), F.S. 4.18.6 MEDICAL DIRECTOR shall conduct an on-going and comprehensive review of all EMS medical equipment, medications and medical supplies as may be necessary to ensure reliable service delivery in the fire rescue System and excellence in patient-care when requested. 4.18.6.1 In conducting the review, MEDICAL DIRECTOR shall take into consideration the results of Quality Assurance Reviews, review of medical literature, input flom interested physicians, and MCFR personnel. 4.18.6,2 MEDICAL DIRECTOR, in conjunction with MCFR, shall assist in the comprehensive review of all EMS System medical supplies and equipment and present the proposed changes to the Fire Chief for approval prior to the end of each Fiscal Year, 4.18.7 MEDICAL DIRECTOR shall ensure that the following criteria are met prior to activating new medical equipment or supplies within the EMS System: 4.183.1 Proposed medical equipment or supplies have been thoroughly researched,supported by medical literature,a field evaluation completed when applicable,and the analysis of'available system data; 4,18.7.2 All Protocols related to the medical equipment or supplies have been evaluated and updated as appropriate,to ensure consistency and accuracy;and 11 442 4.18.7.3 Protocols, supporting documents and implementation instructions are distributed to MCFR personnel prior to training or-implementation,and training has-been completed,if necessary,prior to implementation. 4.19 Infectious Disease Control Policy 4.19.1 MEDICAL DIRECTOR shall formulate, monitor, evaluate and update as necessary, a policy complying with all applicable laws and rules necessary to control exposure of MCFR personnel to infectious diseases. This policy shall cover protective measures to be taken on incidents, inoculation procedures and recommendations,record keeping,follow up care recommendations as. well as storage and disposal policies for contaminated materials. 4.19.2 MEDICAL DIRECTOR shall be available, in conjunction with the MCFR Infection Control Officer, for consultation from field personnel to determine the significance of any body fluid exposure and suggest appropriate action for-such an exposure in accordance with Monroe County Fire Rescue's existing Workers' Compensation policies and procedures. 4.20 This Contract is a professional services contract based on the qualifications of Dr. Sandra Schwemmer and the services required hereunder shall be performed by Professional Emergency Services Inc.or under his/her supervision. Any additional personnel necessary for the fulfillment of the services required under this Contract shall be secured at MEDICAL DM=OR's sole expense and such personnel shall be fully qualified and,if required,authorized,or permitted under State and local law to perform such services. 5. Iusurans� COUNTY shall maintain in full force and effect for the term of this Contract,and any subsequent renewals,professional and General Liability Insurance with minimum limits of$1,000,000.00 per occurrence. The Professional and General Liability certificate will specify coverage for 'EMS oversight/medical direction". COUNTY will provide certificate or proof of such insurance to MEDICAL DIRECTOR on an annual basis.Medical Director will be provided thirty(30)days'notice of cancellation,change in policy limits, and/or any restrictions placed on coverage of the insurance.provided by COUNTY during the term of this Contract. COUNTY will be responsible for the payment of any deductible and/or self-insured retention in the event of a claim. The Contractor shall be responsible for all necessary Workers' Compensation and Vehicle Liability insurance coverage. Certificates of Insurance must be provided to Monroe County within fifteen-(15) days after award of contract,with Monroe County BOCC listed as additional insured as indicated. Policies shall be written by insurers admitted and licensed to do business in the State of Florida and having an agent for service of process in the State of Florida. Companies shall have an A.M.Best rating of VI or better. The required insurance shall be maintained at all times while Respondent is providing service to County. 12 443 Prior to commencement of work governed by this contract,the CONTRACTOR must obtain: Worker's Compensation Insurance with limits sufficient to respond to applicable state statutes. In addition, the Respondent must obtain Employer's Liability insurance with limits of not less than: $500,000 Bodily Injury by accident, $500,000 Bodily Injury by Disease policy limits, and$500,000 Bodily Injury by Disease,each employee. Coverage must be maintained throughout the entire term of the contract. Prior to commencement of work governed by this contract,the CONTRACTOR must obtain: Vehic]e Liability Insurance which shall cover owned,non-owned and hired vehicles. The minimum acceptable limits shall be$300,000 Combined Single Limit(CSL). If split limits are provided,the minimum limits acceptable shall be: $100,000 per Person $300,000 per Occurrence $50,000 Property Damage Monroe County Board of County Commissioners shall be named as an Addidonal.insured on Vehicle Liability policies. G: Termination 6.1 Early termination may occur as follows: A. This Contract may be terminated by MEDICAL DIRECTOR,with or without cause,upon not less than ninety(90)days written notice delivered to COUNTY. B. COUNTY may terminate this Contract in whole or in part and without cause,upon not less than ninety(90)days written notice,delivered to MEDICAL DIRECTOR. C. COUNTY may terminate this Contract immediately in the event that MEDICAL DIRECTOR fails to fulfill any of the terms,understandings or covenants of this Contract. 6.2 At such time as this Contract is terminated, whether at the natural ending date or at an earlier time,MEDICAL DIRECTOR shall: A. Stop work on the date and to the extent specified. B. Terminate and settle all orders and subcontracts relating to the performance of the work. C. Transfer all work in process,completed work,and other materials related to the terminated work to COUNTY. D. Continue and complete all parts of that work which have not been terminated, if any. 7. Payments Payments shall be made by COUNTY pursuant to the Florida Local Government Prompt Payment Act after the completion of the rendered services and proper invoicing by MEDICAL DIRECTOR. 13 444 S. Contineencv COUNTY's performance and obligation to pay under this Contract is contingent upon an annual appropriation by the Board of County Commissioners. 9. Sec_tion_HeadinU Section headings have been inserted in this Contract as a matter of convenience of reference only, and it is agreed that such section headings are not a part of this Contract and will not be used in the interpretation of any provision of this Contract. 10. Ownership of The Project Document Any documents submitted by MEDICAL DIRECTOR for this professional services contract belong to COUNTY and may be.reproduced and copied without acknowledgement or permission of MEDICAL DIRECTOR. 11. Successors and Assigns MEDICAL DIRECTOR shall not assign its right hereunder,except its right to payment,nor shall It delegate any of its duties hereunder without the written consent of COUNTY. Subject to the provisions of the immediately preceding sentence, each party hereto binds itself, its successors, assigns and Iegal representatives to the other and to the successors, assigns and legal representatives of such other party. 12. Na Third P Nothing contained herein shall create any relationship,contractual or otherwise,with or any rights in favor of,any third party. 13. Public Entities Crimes 13.1 A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a hid on contracts to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or MEDICAL DIRECTOR under a contract with any public entity,and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of the F.S.,for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. 13.2 By signing this Contract, MEDICAL DIRECTOR represents that the execution of this Contract will not violate the Public Entity Crimes Act (Section 287.133, F.S.). Violation of this section shall result in termination of this Contract and recovery of all monies paid hereto,and may result in debarment from COUNTY's competitive procurement activities. 13.3 In addition to the foregoing, MEDICAL DIRECTOR further represents that there has been no determination,based on an audit,that it or any SUBCONTRACTOR has committed an act defined by Section 287.133,F.S.,as a"public entity crime"and that it has not been formally charged with 14 445 committing an act defined as a"public entity crime"regardless of the amount of money involved or whether CON[3SULTANT has been placed on the convicted vendor list. 13.4 MEDICAL DIRECTOR will .promptly notify COUNTY if MEDICAL DIRECTOR or any subcontractor is formally charged with an act defined as a"public entity crime"or has been placed on the convicted vendor list. 14. Records MEDICAL DIRECTOR shall maintain all books, records, and documents directly pertinent to performance under this Contract in accordance with generally accepted accounting principles. Upon ten (10)business days written notice to the other party,representatives of either party shall have access, at all reasonable times, to all the other party's books, records, correspondence, instructions,receipts,vouchers and memoranda(excluding computer software)pertaining to work under this Contract for the purpose of conducting a complete independent fiscal audit. MEDICAL DIRECTOR shall retain all records required to be kept under this Contract for a minimum of five years,and for at least four years after the termination of this Contract. Storage of medical records required by Federal or State statute in excess of the times stated herein and subsequent to the termination of this Contract shall be revisited by the parties at such time as any transition period is established to accommodate the termination of this Contract. MEDICAL DIRECTOR shall keep such records as are necessary to document the provision of services under this contract and expenses as incurred, and give access to these records at the request of COUNTY, the State of Florida or authorized agents and representatives of said government bodies. It is the responsibility Of MEDICAL DIRECTOR to maintain appropriate records to insure a proper accounting of all collections and remittances. MEDICAL DIRECTOR shall be responsible for repayment of any and all audit exceptions which are identified by the Auditor General for the State of Florida,the Clerk of Court for Monroe County,the Board of County Commissioners for Monroe County,or their agents and representatives. 15. Governing Law,Venue,Interpretation This Contract shall be governed by and construed in accordance with the laws of the State of Florida applicable to contracts made and to be performed entirely in the State. In the event that any cause of action or administrative proceeding is instituted for the enforcement or interpretation of this Contract, COUNTY and MEDICAL DIRECTOR agree that venue shall lie in Monroe County, Florida, in the appropriate court or before the appropriate administrative body. The Parties waive their rights to a trial by jury. This Contract is not subject to arbitration. 1& Severability If uqterm, covenant, condition or provision of this Contract (or the application thereof to any circumstance or person) shall be declared invalid or unenforceable to any extent by a court of competent jurisdiction,the remaining terms,covenants,conditions and provisions of this Contract, shall not be affected thereby;and each remaining torm, covenant,condition and provision of this Contract shall be valid and shall be enforceable to the fullest extent permitted by law unless the enforcement of the remaining terms,covenants,conditions and provisions of this,Contract would prevent the accomplishment of the original intent of this Contract. COUNTY and MEDICAL 15 446 DIRECTOR agree to reform the Contract to replace any stricken provision with a valid provision that comes as close as possible to the intent of the stricken provision. 17. Attorney's Fees and Costs COUNTY and MEDICAL DIRECTOR agree that in the event any cause of action or administrative proceeding is initiated or defended by any party relative to the enforcement or interpretation of this Contract,the prevailing party shall be entitled to reasonable attomey's fees, court costs, investigative, and out-of-pocket expenses, as an award against the non-prevailing parry,and shall include attorney's fees,courts costs, investigative,and out-of-pocket expenses in appellate proceedings. Mediation proceedings initiated and conducted pursuant to this Contract shall be in accordance with the Florida Rules of Civil Procedure and usual and customary procedures required by the cinruit court of Monroe County. 18. Binding Effect The terms,covenants,conditions,and provisions of this Contract shall bind and inure to the benefit of COUNTY and MEDICAL DIRECTOR and their respective legal representatives, successors, and assigns. 19. Authority Each party represents and warrants to the other that the execution, delivery and performance.of this Contract have been duly authorized by all necessary County and corporate action,as required by law. 20. Claims for Federal or State Aid MEDICAL DIRECTOR and COUNTY agree that each shall be, and is,empowered to apply for, seek, and obtain federal and state funds to further the purpose of this Contract; provided that all applications,requests, grant proposals, and funding solicitations shall be approved by each party prior to submission. 21. Adiudication of DisRutes COUNTY and MEDICAL DIRECTOR agree that all disputes shall be attempted to be resolved by meet and confer sessions between:representatives of each of the parties. If the issue or issues are still not resolved to the satisfaction of the parties,then any party shall have the right to seek such relief or remedy as may be provided by this Contract or by Florida law. 22. Cooperation In the event any administrative or legal proceeding is instituted against either party relating to the formation, execution, performance, or breach of this Contract, COUNTY and MEDICAL DMECTOR agree to participate, to the extent required by the other party, in all proceedings, hearings, processes, meetings, and other activities related to the substance of this Contract or provision of the services under this Contract. COUNTY and MEDICAL DIRECTOR specifically agree that no party to this Contract shall be required to enter into any arbitration proceedings related to this Contract. 16 447 23. Nondiscrimination MEDICAL DIRECTOR and COUNTY agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Contract automatically terminates without any further action on the part of any party, effective the date of the court order. MEDICAL DIRECTOR and COUNTY agree to comply with all Federal and F.S.,and all local ordinances,as applicable,relating to nondiscrimination. These include but are not limited to: 1)Title VII of the Civil Rights Act of 1964(PL 88-352), which prohibit discrimination in employment on the basis of rare,color,religion,sex,and national origin;2)Title IX of the,Education Amendment of 1972, as amended(20 USC §§ 1681-1683,and 1685-1686),which prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC § 794), which prohibits discrimination on the basis of handicaps; 4) The Age Discrimination Act of 1975, as amended(42 USC§§ 6101-6107),which prohibits discrimination on the basis of age;5)The Drug Abuse Office and Treatment Act of 1972(PL 92-255),as amended,relating to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970(PL 91616),as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism;7)The Public Health Service Act of 1912,§§523 and 527(42 USC§§690dd-3 and 290ce-3),as amended,relating to confidentiality of alcohol and drug abuse patient records; 8)Title VIII of the Civil Rights Act of 1968 (42 USC §§ 3601 et seq.),as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USC §§ 12101), as amended from time to time, relating to nondiscrimination in employment on the basis of disability; 10)Monroe County Code Chapter I4, Article II, which prohibits discrimination on the basis of race, color, sex, religion, national origin, ancestry, sexual orientation,gender identity or expression,familial status or age; and 11)any other nondiscrimination provisions in any federal or state statutes which may apply to the parties to,or the subject matter of,this Agreement. 24. Covenant of No Interest MEDICAL DIRECTOR and COUNTY covenant that neither presently has any interest, and shall not acquire any interest,which would conflict in any manner or degree with its performance under this Contract, and that only interest of each is to perform and receive benefits as recited in this Contract. 25. Code of Ethics MEDICAL DIRECTOR agrees that officers and employees of COUNTY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section t 12,313, F.S., regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship;and disclosure or use of certain information. 26. No Solicitation/Payment MEDICAL DIRECTOR and COUNTY warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Contract 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 it, any fee, commission,percentage,gift, or other consideration contingent upon or resulting from the award 17 448 or making of this Contract. For the breach or violation of the provision, MEDICAL DIRECTOR agrees that COUNTY shall have the right to terminate this Contract without liability and,at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission,percentage,gift,or consideration. 27. Public Access MEDICAL DIRECTOR and COUNTY shall allow and permit reasonable access to,and inspection of,all documents,papers,letters or other materials in its possession or under its control subject to the provisions of Chapter 119, F.S., and made or received by MEDICAL DIRECTOR and COUNTY in connection with this Contract; and COUNTY shall have the right to unilaterally cancel this Contract upon violation of this provision by MEDICAL DIRECTOR. 28. Non-Waiver of Immunity Notwithstanding the provisions of Section 768.28, F.S., the participation of MEDICAL DIRECTOR and COUNTY in this Contract and the acquisition of any commercial liability insurance coverage,self-insurance coverage,or local government liability insurance pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage,nor shall any contract entered into by COUNTY be required to contain any provision for waiver. 29. Privileges and Immunities All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules and pensions and relief, disability,workers' compensation, and other benefits which apply to the activity of officers,agents, or employees of any public agents or employees of COUNTY, when performing their respective functions under this Contract within the territorial limits of COUNTY shall apply to the same degree and extent to the performance of such functions and duties of such officers,agents,volunteers,or employees outside the territorial limits of COUNTY. 30. Legal Obligations and Responsibilities This Contract is not intended to,nor shall it be construed as,relieving any participating entity from any obligation or responsibility imposed upon the entity by law except to the extent of actual and timely performance thereof by any participating entity, in which case the performance may be offered in satisfaction of the obligation or responsibility. Further,this Contract is not intended to, nor shall it be construed as, authorizing the delegation of the constitutional or statutory duties of COUNTY,except to the extent permitted by the Florida constitution, state statute,and case Iaw. 31. Non-Reliance by Non-Par ii No person or entity shall be entitled to rely upon the terns, or any of them, of this Contract to enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service or pram contemplated hereunder, and MEDICAL DIRECTOR MEDICAL DIRECTOR and COUNTY agree that neither MEDICAL DIRECTOR nor COUNTY or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any particular individual or group of individuals,entity or entities,have entitlements or benefits under this Contract separate and apart, inferior to, or superior to the community in general or for the purposes contemplated in this Contract. 18 449 32, Attestations and Truth in Negotiation MEDICAL DIRECTOR agrees to execute such documents as COUNTY may reasonably require, including a Public Entity Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement, Signature of this Contract by MEDICAL DIRECTOR shall act as the execution of a truth in negotiation certificate stating that wage rates and other factual unit costs supporting the compensation pursuant to the Contract are accurate, complete, and current at the time of contracting. 33. No Personal Liahil_i No,covenant or Contract contained herein shall be deemed to be a covenant or Contract of any member,officer,agent or employee of COUNTY in his or her individual capacity,and no member, officer,agent or employee of COUNTY shall be liable personally on this Contract or be subject to any personal liability or accountability by reason of the execution of this Contract. 34. Execution of Counterparts This Contract may be executed in any number of counterparts,each of which shall be regarded as an original,all of which taken together shall constitute one and the same instrument and any of the parties hereto may execute this Contract by signing any such counterpart. 35. Amendments and Assignments. No amendment or assignment of this Contract shall be valid without the prior written consent from COUNTY. 36. Indnende t Contractor. At all times and for all purposes hereunder,MEDICAL DIRECTOR is an independent contractor and not an employee of the Hoard of County Commissioners of Monroe County. No statement contained in this Contract shall be construed as to find MEDICAL DIRECTOR or any of its employees, contractors, servants or agents to the employees of the Board of County Commissioners of Monroe County, and they shall be entitled to none of the rights, privileges or benefits of employees of Monroe County. 37. Compliance with Law. In-carrying out its obligations under this Contract, MEDICAL DIRECTOR shall abide by all statutes, ordinances, rules and regulations pertaining to or regulating the provisions of this Contract, including those now in effect and hereafter adopted. Any violation of said statutes, ordinances,rules or regulations shall constitute a material breach of this Contract and shall entitle COUNTY to terminate this Contract immediately upon delivery of written notice of termination to MEDICAL DIRECTOR. ------------ 38. Licensing and Perm MEDICAL DIRECTOR shall have,prior to commencement of work under this Contract and at all times during said work, all required licenses and permits whether federal, state, county or municipal. 14 450 39. Signatures of Parties Required. THIS CONTRACT SHALL-NOT BE EFFECTIVE UNTIL EXECUTED BY BOTH PARTIES AND RECEIVED IN FINAL EXECUTED FORM BY AN AUTHORIZED REPRESENTATIVE OF MEDICAL DIRECTOR AT ITS PRINCIPAL PLACE OF BUSINESS. 40. Quaty By execution hereof the signer below hereby certifies that signer is duly authorized to execute this Contract on behalf of tho COUNTY. 41. Fed oral and State Tax. COUNTY is exempt from payment of Florida State Use and Sales Taxes. COUNTY will sign an exemption certificate submitted by MEDICAL DIRECTOR. MEDICAL DIRECTOR will not be exempted from paying state sales tax to its suppliers for materials used to fulfill contractual obligations with COUNTY, nor is MEDICAL DIRECTOR authorized to use COUNTY's Tax Exemption Number in securing such materials. 42. Notice -Any notice of other communication from either party to the other pursuant to this agreement is sufficiently given or communicated if sent by registered mail, with proper postage and registration fees prepaid,addressed to the party for whom intended,at the following addresses: For County: For Medical Director: County Administrator Dr. Sandra Schwemmer 1100 Simonton Street 10 High Point Road Key West,FL 33040 PO Box 379 And Tavernier,FL 33070 Monroe County Attorney's Office 111.1 12th St.,Suite 408 Key West,FL 33040 or to such other address as the party being given such notice shall from time to time designate to the other by notice given in accordance herewith. THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK. 20 451 s IN WITNESS WHEREOF,each party hereto has caused this wntrwt to be excwted.by its acrthorized repremtative. SRQT.} BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY,FL A T: KEVIN MADOV.,CLERK _ By. � 1` ��r6 Ely: . As D Clerk j.J Z 9 G I yor arrman BOARD OF GOVERNORS OF IROS ►PAN �o��r FIItE AND AMBULANCE DISTRICT 1, r%/� OF MONROE iTNTY,Fw ASS NW ATTORNEY By: DMe 9/17/21 Mayor/Chairman PROFESSIONAL CY WTrNFSSES: SERVICES,INC. 4-r—Q&W)/ - Witness Dr, as Schwcmmer of iA rr--[ I�b12o�.1 Print Name d TW Date; By. hipt Nqme and Titic Date: n C7 xI 452 SECTION TWO; FORMS Attachment A Public Entity Crime Statement Attachment D Drug Free Workplace Form Attacbment C Lobbying&Conflict of Interest Clause Sworn Statement under Ordinance No. 10-1990(Ethics Clause) Attachment D Indemnification and Hold EWmless Attachment E Insurance Documents u 453 Attachment A PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a proposal on a contract to provide any goads or services to a public entity,may not submit a proposal on a contract with a public entity for the construction or repair of a public building or public work,may not submit proposals on leases of real property to public entity,may not be awarded or perform work as a bidder,supplier, subbidder,or RESPONDENT under a contract with any public entity,and may not transact business with any public entity in excess ofthe threshold amount provided in Section 287.017, Florida Statutes,far CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list"' By executing this form,F acknowledge that Iltny company is in compliance with the above. STATE OF 0VJL Ax (Sifinatun of Respondent) COUNTY OF �(Aljn �04k ` 11)-t f zin t Date PERSONALLY APPEARED BEFORE ME,the undersigned authority, r , 6 �� who,after first being sworn by me,(name of in"dual signing)affixed his/her signature in the space provided above on this day of � expires: U"q p-1 Boa NOTARY PUBLIC Stan unr sanmr;•+ `,qY LPt6tt, ,r uepyu�7 dP d1o+�nS-,n4l-wT v vsnowstni 23 454 Attachment B DRUG-FREE lWOMI ACE FOAM The unders' ad dentin ante with Flori a Statute 287.087 hereby certifies that: l� (Name of Busine 1. Publishes a statement nodfyiag employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. Z. Informs employees about the dangers of drag abuse in the workplace,the business's policy of maintaining a drug-free workplace, any available drug counseling rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under proposal a copy of the statement gmdfYed In subsection(1). 4, In the statement specified in subsection (11 notifies the employees that, as a condition of worldog on the commodities or contractual services that are under proposal, the employee will abide by the terms of the statement and will notify the employer of any conviction of,or plea of guilty or polo contersdre to,any violation of Chapter 893 ('Florida Statutes)or of any controlled substance law of the United States or any state,for a violation occurring in the workplace no later than five(5)days after such conviction. S. Imposes a sanction on.or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintains a drug-free workplace through implementation of this section. As the person authorized to sign statement,I certify thatthis firm complies fully with the above requirements. Restfond&d Signature /G;z ea��.j Date OMB—MCP FORM 05 24 455 Attachment C LOBBYING AND CONFLICT OF INTEREST CLAUSE SWORN STATEMENT UNDER ORDINANCE NO.104990 MONROE COUNTY,FLORIDA ETHICS CLAUSE warrants that he11t has not employed,retained or otherwise had act on his f any former County officer or employee in violation of Section 2 of Ordinance No. 10-1990 or any Pounty officer or employee in violation of Section 3 of Ordinance No. 1 D-1990. For breach or violation of this provision the County may,in Its discretion,terminate this contract without liability and may also,in its discretion,deduct from the contract or porch or erwise recover,the fiill amount of any fee,commission, percentage,gift,or do 'd to the farmer County ofaeer or employee. (Signature) Date:_ k'yf STATE OF. -f�L;t �� COUNTY OF PERSONALLY APPEARED BEFORE ME,the undersigned authority, �;u 4{6,3 al M air _whop after first being sworn by me,affixed his/her Signature(name of individual signing)in the space provided above on this day of 20;\ f4OTAAY PUBLIC My commission expires: ,.nt{� . �• 031®-M,[:P FORM#4 Naerr 25 456 Attachment D MONROE COUNTY,FLORIDA RUSK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADAIN ST ATION MANUAL Indemnification and Hold Harmless The Medical Director covenants and agrees to indemnify and hold harmless the Monroe County Board of County Commissioners, its servants,agents and employees from any and all claims for bodily injury(includin death),personal injury,and property damage Qincludin8 property owned by Monroe County)and any other losses,damages,add expenses((ino u ng attorney's fees)which arise out o�in connection with or by reason of services provided by the Medical Director or any of its employees,subcontractors,or agents,in any tier,and occasioned by the negligence,errors, or other wrongful actor omission of the Medical Director,its employees,subcouUmors or agents, in any tier. The extent of liability is in no way limited to,reduced,or lessened by the insurance requirements contained elsewhere within thus Contract. pondent's Signature ail Date Zb 457 Attachment E VEHICLE LTABILITY INSURANCE REQU RENENTS FOR CONTRACT MEDICAL DIRECTOR BETWEEN MONROE COUNTY,FLORIDA AND PROFESSIONAL EMERGENCY SERVICES,INC. Recoga mo*that the work governed by this contract requires the use of vehicles,the Medical Director,prior to the commencement of work,shall obtain Vehicle Liability Insurance. Coverage shall be maintained throughout the life of the contract and include`as a minimum, liability coverage for: 11 Owned,Non-Owned,and Mired Vehicles The minimum limits acceptable shall be: $300,000 Combined Single Limit(CSL) If split limits are provided,the minimum limits acceptable shall be: $100,000 per Person $300,800 per Occurrence $50,000 Property Damage The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. V 2 27 458 Attachment E WORKERS'COMPENSATION INSURANCE REQUHZEMENTS FOR CONTRACT MEDICAL DIRECTOR BETWEEN MONROE COUNTY,FLORIDA AND PROFESSIONAL EM EREGENCY SERVICES,INC. Prior to the commencement of work governed by this contract,the Medical Director shall obtain Workers'Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition,the Medical Director shall obtain Employers'Liability Insurance with Iimits of not less than: $50%000 Bodily injury by Accident $500,000 Bodily Injury by Disease,policy limits $500,000 Bodily Injury by Disease,each employee Coverage shall be maintained throughout the entire term of the contract. Cov shall be provided by a company or companies authorized to transact business in the state If the Medical Director has been approved by the Florida's Department of Labor, as an authorized setf-insurer, the County shall recognize and honor the Medical Director's status. The Medical Director may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on the Medical Directors Excess Insurance Program. If the Medical Director participates in a self-insureace Rind, a Certificate of Insurance will be required. In addition,the Contractor may be required to submit updated financial statements from the hind upon request from the County_ WCS 28 459 MONROE COUNTY FIRE RESCUE TA do M40 A 'TA I t '!'B vvvowuuuuVVVVV � u , U1 uuq V 2021 Ground & Air Ambulance MEDICAL PROTOCOLS Dr. Sch wemmer, D. 0 460 The following Monroe County Fire Rescue 2021 Medical Treatment Protocols are the official protocols for this Agency, and are approved for use by EMT's/Paramedics/Registered Nurses of this agency for the care of the sick and injured. �w Sandra Schwemmer, D.O. Medical Director, Monroe County Fire Rescue 461 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOLS Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS Response Algorithm Page 1 Universal Patient Assessment/Care Page 2 to 7 AIRWAY MANAGEMENT/RESPIRATORY EMERGENCIES SECTION 'I Airway Management Basic& Advanced 1-1 Endangered / Difficult Airway 1-2 Respiratory Distress (Asthma, COPD, CHF) 1-3 Tracheostomy Emergencies 1-4 ADULT CARDIAC EMERGENCIES SECTION Bradycardia 2-1 Chest Pahrn /ACUte C a it°oir�air°w yirdir°oirne - ACS Alert Checklist (MCFRF- 074) 2-2 STEMI Alert Checklist (MCFRF - 075) 2-2 PEA (Pulseless Electrical Activity) /Asystole 2-3 Pulseless Arrest (V-Fib, V-Tach) 2-4 PVC's 2-5 R SC - IlirdUced IHlypotlr"ueirirnla -7 T'acIr"uvcair°dla - ACUte Mth IPLullse -3 ENVIRONMENTAL EMERGENCIES SECTION Anaphylaxis /Allergic Reactions 3-1 DIve Ilir°ulia.wrles / IBairotiraa.uiriria / I::er°¢ irirh iresslc: irn Illlllir.ness...&dlkir.ness Electrocution / Lightning 3-3 Envenomation / Bites / Stings 3-4 Envenomation's - Marine 3-5 Heat Emergencies 3-6 Hypothermia 3-7 462 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOLS Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS MEDICAL EMERGENCIES SECTION 4 Abdominal Pain /Acute Abdomen 4-1 Altered Mental Status/ Unconscious States/ ETOH 4-2 GI Bleed -d Hyperkalemia 4-4 Hypoglycemia/ Hyperglycemia 4-5 Nausea/Vomiting 4-6 Psychiatric/ Behavioral 4-8 Seizures 4-9 Shock -,I vI Stroke 4-12 Stroke Alert Checklist (MCFRF-073) 4-12 OVERDOSE E/;POISIONINO EMERGENCIES SECTION 5 Beta Blocker Overdose 5-1 Calcium Channel Blocker Overdose 5-2 Cyanide Poisoning /Smoke Inhalation 5-3 Overdose— Narc/ Benzo/ Stimulant 5-4 Pepper Spray Exposure 5-5 poil'Sr:X1liitn(1 5...3 se TRAUMA EMERGENCIES SECTION Ibdoirnr hrno-P&Vlc Ilirn!Lflr°lie 6-1 irrm�,)U tafioirn s 6-2 Burns 1 sc and 2nd Degree 6-3 Burns 2nd and 3,d Degree 6-4 Burns Chemical & Electrical 6-5 Chest Trauma 6-6 C-Spine Range of Motion 6-7 Extremity Trauma — Fractures 6-8 Eye Injuries 6-9 Hip Fractures — Dislocations 6-10 Head Injury/ Increased ICP 6-11 Non-Fatal Drowning / Fatal Drowning 6-12 Taser Injury 6-13 Trauma Alert Criteria 6-14 Trauma Alert Criteria Form (MCFRF-096) 6-14 463 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOLS Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS OBSTETRICAL/GYNECOLOGICAL EMERGENCIES SECTION 7 Childbirth - Labor and Delivery 7-1 Childbirth - Complications 7-2 Childbirth - Illustrations 7-3 Postpartum Vaginal Bleed /Vaginal Bleed Unknown Origin 7-4 Pre-Eclampsia/ Eclampsia 7-5 PEDIATRIC/ADOLESCENT EMERGENCIES SECTION 8 AIRWAY MANAGEMENT/ RESPIRATORY EMERGENCIES Respiiiratoiry Distress Pediatric 3-1 CARDIAC EMERGENCIES Biradycairdiia Pediatric 3-2 PEA (Pullselless Ellectriicall Activi-ty) /Asystolle - Pediatric 3-3 Pullselless Airirest iV-Fiilb, V- ..fach) - Pediatric 3-4 �?(') C )IPc� )t Arirest) ... IPedlilatirc 3... fachycairdiia - Pediatric 3-5 ENVIRONMENTAL EMERGENCIES Anaphylaxis /Alllleirgiic Reactiions - Pediatric 3-7 MEDICAL EMERGENCIES Seizure - Pediatric 3-3 TRAUMA EMERGENCIES Acute firauirnaliic Pain - Pediatric 3-0 firaurna Alert Ciriteiriia - Pediatric 3-10 firauirna Alert Ciriteiriia Foirm (IVICFRF- 007) - Pediatric 3-10 PEDIATRIC/ADOLECENT PROCEDURES SECTION 8P Handtevy App Instructions 3P-1 Ciricothyroiidotorny - Needle Pediatric 3P-2 PEDIATRIC/ADOLECENT REFERENCE SECTION 8R APCAR - Newboirn Scoiring 8R-1 Glasgow - Pediatric 8R-2 Pain Scale FLACC 8R-3 Pain Scale Faces 8R-4 Vi-tals (Noirmall Flange) / Glucose Values - Pediatric 8R-5 464 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOLS Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS PROCEDURES SECTION 9 Bougie - Endotracheal Tube Introducer 9-1 Chest Needle Decompression 9-2 CPAP Concepts 9-3 CPAP Assembly with Nebulizer 9-3 Cricothyroidotomy - Surgical 9-4 Endotracheal Intubation (Oral) 9-5 External Jugular IV Access 9-6 EZ-10 Insertion 9-7 EZ-10 Landmarks 9-7 I-Gel 9-8 Infectious Disease 9-9 Lucas Device 9-10 Nasal Atomizer 9-11 Nasotracheal Intubation 9-12 Nasogastric Tube (NG Tube) 9-13 Spinal Motion Restriction 9-14 Synchronized Cardioversion 9-15 Tourniquet - C.A.T. (Combat Application Tourniquet) 9-16 Transcutaneous External Pacing 9-17 Ventilator Concepts (Page 1 of 3) 9-18 Ventilator Control Module (Page 2 of 3) 9-18 Ventilator Diagram (Page 3 of 3) 9-18 Video Laryngoscope - King Vision 9-19 REFERENCE SECTION 10; 12 Lead Reference Guide 10-1 Determination of Death/Obvious Death 10-2 DNRO — Do Not Resuscitate Order (DH Form 1896, 2004 Revision) 10-2 ETCO2 Waveform 10-3 Glasgow Coma Score 10-4 Refusal of Care (Page 1 of 2) 10-5 Refusal of Care (Page 2 of 2) 10-5 Rule of Nines 10-6 Stroke Scale (Cincinnati, Mend) 10-7 Termination of Efforts 10-8 Trauma Transport Protocols 2021 10-9 465 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOLS Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS DRUG FORMULARY SECTION 11 Adenosine Triphosphate (Adenocard) 11-1 Albuterol (Proventil, Ventolin) 11-2 Amiodarone (Nexterone) 11-3 Aspirin 11-4 Atropine Sulfate as Cardiac Agent 11-5 Atropine Sulfate as Antidote for Poisonings 11-6 Calcium Chloride 10% 11-7 Cyanokit 11-8 Dextrose 10% and 5% (d-glucose) 11-9 Diphenhydramine HCL (Benadryl) 11-10 Dopamine Hydrochloride (Intropin) 11-11 Duo-Dote 11-12 Epinephrine 1:1000 11-13 Epinephrine 1: 10,000 11-14 Fentanyl 11-15 Furosemide (Lasix) 11-16 Ketamine (Ketalar) 11-17 Magnesium Sulfate 50% 11-18 M ethyl prednisone (Solu-Medral, A-Methapred) 11-19 Midazolam (Versed) 11-20 Naloxone Hydrochloride (Narcan) 11-21 Nitroglycerin (Nitrostat, Nitrolingual Spray) 11-22 Odansetron (Zofran) 11-23 Oral Glucose (Insta Glucose) 11-24 Sodium Bicarbonate 11-25 466 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOLS Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS TRAUMA STAR GENERAL PROTOCOLS SECTION 12 liar° Tr°airnsr,)oir°t Gd iidl dhi rn es "n -"n Flliqlht IPIr"nws liollow 1 - AIRWAY—TRAUMA STAR SECTION 13 R.apldI SeqUernce Ilitdbafioirn 0R III) 13-1 MEDICAL EMERGENCIES—TRAUMA STAR SECTION 14' oirfic IDlssec iorn "n _ OBSTETRICAL—HIGH RISK SECTION 15 [JrnlIv sir°saI IHlkih-Risk OIB Assessirneit/ C air°e IPirotocoll 15— Bir°eecIh IPir°es eitafioirn / SIr"Odldleir IDystoda 15- Ulabetes 611hitU liirn IPir°egrnarncy 15-5 Pahrn I airnageirneit / INaUs ea liirn IPir°egrnarncy 15-6 Rlaceita IPir°ewlia / IPir°oIIap,ed C oir°d 15-7 Post-Pair°tLfirn IHleir7r orir°Ir"nage /Airnirnbfic IFlLuld IEirnbdIU / C.sir°vllc:ill-PeidirneaI IL.aceir°afioirn 15- Pir°e-1L'eir°irn IL.aboir°/ IPir°e-1L'eir°irn IPir°eirnatUr°e IRU�,)Wir°e of IMeirnbir°arse (RRR.OW 15-10 NEONATAL EMERGENCIES SECTION 16 C oirnpiroirnIis ed INewlboir°irn 16-1 Neoirnatdl IEirdotir°acIr"ned II ltdbafioirn 16- Neoirnatdl Stablillli :afioirn 16-3 Neoirnatdl IPeir°§lst.it IPdlrrnornair°w IHlwpeir°teirnsbirn (RRHITN) 16- 467 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOLS Dr. Sandra Schwemmer, D.O. Medical Director TABLE OF CONTENTS PROCEDURES -TRAUMA STAR SECTION 17+ Blood Tr°alrnSfUSblrn 1 7-1 Blood Warirrrrwir (Brudldy IL.Jte) 1 7- edi Ilrriirr°ooblillllzeir° (I I .IC:1I..I IAPE) 1 7-6 Prw.rlMIc IRiirndlrwir (T'-POD) 1 7-7 ]..e rriirXJS IPro ICIornli oir°C t.fltir°aS0raiirn J 1 7- Veirtillrrtoir _ IDir°rrw it 1 7-: VeirtilIak,rir° .. IPirnerukYrn 1 7-10 REFERENCE TRAUMA STAR SECTION 18' OIB Abbirevbfioirnsn -"n Va orrrrtlive IlMrw.rdirra ioirn 1 - DRUG FORMULARY -TRAUMA STAR SECTION 19 r7rrlidlrrte (Etor7rrlidlrrte) 1 -1 rnrrrwf( rw.rfazdllir0 1 - C r ird° lerne (INllcair°dIIiphrne) 1 -3 C rrir°di eirn (Uillliflazeirn) 1 - Uillrrrudid (I ilydLir°oiririoirir.)r"noirne) 1 -5 Eirnrrllrripirr illrrt (Va otrw.rrr) 1 -6 .r"blirepIhirliirne.. IIirnftl§birn 1: -7 Esirrrdloll (Bir°rw.rvlibllorr) 1 - L.rrbrw.rtrrlloll (Tr°airdlrrte) 1 -10 L.evoir,)lr"nrwd 1 -11 L.opir°rws oir° Wrw.rtopir°olloll) 1 -1 PrrVrulloirn (IPalrnrrruir°oirnliruirrr) 1 -1 R.orrruiroirnliruirrr 1: -16 Roirrrrr licorn (Fllruir7rrr zeirnlill) 1 -1 &rrrrliirnyllrrlr"nollliirne ( irnrw.rrrliirne) 1 -1 1L'rw.rir°brutrrllliirne (Bir°rw.rtlh"hrne) 1 - 0 Vrw.rrrr.uit°oirnliruirrr 1: - 1 468 cfl d O cu on c� a V U N 0 O L _ > O W J CD p O 0 s. -p .� O)-p E cu _a L) (Q 70 W N 7 Q U 0cn O E cu O O +-' E L5 pil! L 4) U cu cu > 0 � O C III�II O L _ L cu O C] L O uuwxmma uuuuu � O O to t� � cn � z u g z � � g z � c o — O C c U O = l > E O ■� M CL E L a) cn tU D Q O_ Q ■O © U 0- (n Qcam. O 0 Q L CL W 0) c y ...... O c _ o u�i O O " o a cuCL a) N N c U aa) cu CO 'L L U) �cu X 0) O L O Q O 0 cu 06 O N O Q O O_ C� 7C) O 0 O O O 70 0 O O E E a� 3 U C 0 Monroe County Fire Rescue Universal Patient Assessment/Care IIII'° III'�IIIIIIII S IIP,'°° III' S III'�IIIIIIII Review the dispatch information and select appropriate response. S II IYIII'II IIIIIII''°IIII IIIII'f SIIIIII _LIII''°° • Consider Body Substance Isolation (BSI) • Consider Personal Protective Equipment (PPE) • Evaluate the scene safety • Determine the number of patients • Consider the need for additional resources III°° IIII III III' III IIII'°° IIII'° Illh°°t • Determine the Mechanism of Injury (MOI) / Nature of illness (NOI) • If appropriate, begin triage and initiate Mas Casualty Incident (MCI) procedures. II Y III"""III III IIII IIL IIII III • Correct life-threatening problems as identified • Stabilize cervical spine when appropriate III'II III ALALS I A""I""'tf ( )L) Alert- to person, place, time, and event (AAOX4) Verbal- responds only to verbal stimuli Pain: responds only to painful stimuli Unresponsive °e edu4trruic Ill afleiiits„cone'id r ucliiui g fie IIII)��duiaf�ic caccsunnueuinf t°°'uirliiaiin l III. � " Assess III aflein't usuwii Llll�uie I1aiiidtevy Systeirn PEDIATRIC ASSESSMENT TRIANGLE °ToneAbnormal Breath Sounds l Abnormal Position, Interactiveness Head Bobibing Consolability, Retractions Look/Gaze Gasping Speech/Cry nasal Flaring Palllor Absent or Beak Pulses I offling Abnormal Blood (Pressure Cyanoses Obviolus Signs of Bleeding Page 2 of 470 Monroe County Fire Rescue Universal Patient Assessment/Care IIII • Open and establish airway using appropriate adjunct • Place patient in appropriate position • Suction airway as needed, including tracheostomy tubes Positioning: Head-tilt/chin-lift or modified jaw thrust for suspected spinal cord injury. Semi-conscious patients with an intact gag reflex: shall have a nasopharyngeal airway inserted, unless contraindicated. Unresponsive patients without a gag reflex: shall have an oropharyngeal airway inserted, unless contraindicated. Supraglottic Airway (SGA): If ventilation is required for more than two minutes, an I-Gel should be inserted Exception -primary cardiac arrest. Recovery position for spontaneously breathing patients: Altered mental status, postictal, suspected drug overdose, etc., if no suspected spinal cord injury. Suction as needed. ILS A11111WAY ......,,, Paiirairnediic Only Intubation: Patients who require ventilatory support (and are unlikely to regain consciousness) for more than two minutes should be intubated (or other advanced airway), Exception -patients in cardiac arrest. Unsuccessful Intubation: If an airway cannot be secured within three ETT intubation attempts, an 1-Gel should be inserted. Surgical Cricothyrotomy: if an airway cannot be secured by any other means, and the patient cannot be effectively oxygenated or ventilated, a surgical cricothyrotomy should be performed on adult patients (or needle cricothyrotomy for pediatrics). OXYGIII1111111111]14 IIIIIIIIII' IIII Except as noted below, oxygen should ONLY be administered in order to maintain SpO2 of 94% or 90% for COPD & asthma patients. Do not withhold oxygen if the patient is dyspneic or hypoxic. Stroke patients shall be treated with a minimum of 2 Lpm NC regardless of pulse oximetry reading. Increase oxygen therapy as needed. Suspected Traumatic Brain Injury (TBI) patients shall receive 15 Lpm via NRB. 3rd trimester pregnancy trauma patients shall receive 15 Lpm via NRB. Pulse oximetry should be documented (pre and post oxygen administration) and applied for continuous monitoring on all ALS patients. If oxygen saturation cannot be maintained, ventilatory support should be provided. Page 3 of 471 Monroe County Fire Rescue Universal Patient Assessment/Care SA02 II IIIIIIII IIIIIIIII' G 02 Saturation Ranges General Patient Care 94 - 100% Normal Give oxygen as necessary Mild 91 - 93% Hypoxia Give oxygen as necessary Hyp 86 - 90% Moderate Give 100% oxygen assisting ventilation if necessary Hypoxia < 85% Severe Give 100% oxygen, assist ventilations. If indicated, Intubate Hypoxia INACURATE OR MISLEADING Sp02 READINGS MAY OCCUR IN THE FOLLOWING PATIENTS: Hypothermic, Hypoperfusion(Shock),Co Poisoning, hemoglobin Abnormality, Anemia, and Vasoconstriction. III t 2 IIII III" i I""' IIII IIII III' G Should be applied to all patients meeting the following criteria: MANDATORY • Requiring ventilatory support (ETT, 1-gel (SGA), CPAP, etc) The following patients should be monitored if EtCO2 is available: • Respiratory distress • Altered mental status • Sedated or receiving pain medication (including Ketamine) • Seizure patients Normal Capinogram IINormal Et'CO � 5 mmft i .. .... ..... .._ .._,. N„ The, is awayd'ann which represervis dwmying CCU tlle WayeformCharacteristics: AUB a i r D Erid iPdal,Canetmlrafion B-C Expiiat r ,Qpslroke D-E iiwi pwut i ri CID Expiratory Pkxteau, Page 4 of 472 Monroe County Fire Rescue Universal Patient Assessment/Care Ir IIIITIIIIII AMOM • Ventilatory support shall be accomplished via BVM with either an NPA/OPA, 1-gel, or ETT incubation. • The goal is to maintain an SpO2 of 95% and EtCO2 levels between 35-45 mmHg (with the exception of COPD and asthma patients). • Any patient with a pulse who requires ventilation with a BVM for greater than two minutes, should be incubated (excluding pediatrics). • Endotracheal incubation shall be confirmed by: visualization of the ETT passing through the vocal cords and continuous EtCO2 monitoring. I IITIIIIII T II° T IIII ""IIII )IIIIII III) Adults: 10 breaths/minute (1 breath every 6 seconds) Patients with an advanced airway should be ventilated at a rate of 8-10 breaths/minute (1 breath every 6-8 seconds) Children: 20 breaths/minute (1 breath every 3 seconds) Neonates: 40 breaths/minute I�R C D LA"""I IQlq II Carotid and radial pulse present, assess: • capillary refill • skin color, condition and temperature. Unconscious patients -Apply AED, LifePak, or Tern pus us on all unconscious patients. Cardiac Arrest patients - Perform continuous chest compressions (CCC) and apply Lucas device (if available) on all cardiac arrest patients and defibrillate as needed. Infants/children/Neonates: After oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates (birth to 1 month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor perfusion (AMS). C IIMQVI 114"" IIII M G All ALS patients shall be continuously monitored in lead 11. Patients who present with any of the following; shall have a 12 lead ECG performed: • Cardiac or possible cardiac symptoms • Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort • Palpitations Page 5 of 473 Monroe County Fire Rescue Universal Patient Assessment/Care • Syncope, lightheadedness, general weakness, or fatigue • CHF, SOB, hypertension or hypotension • Unexplained diaphoresis or nausea 12 lead ECGs shall be repeated every 10 minutes and upon a ROSC II S III CIIYS A complete set of vital signs shall be documented as follows • Respiratory (rate and quality) • Pulse (rate and quality) • Skin (color, condition, and temperature) • Pulse Oximetry • Capillary Refill • Blood Pressure o Priority 3 patients at least two sets or every 15 minutes o Priority 2 patients every 5 minutes o A blood pressure shall be checked before and 5 minutes after the administration of a drug known to effect blood pressure. o For the purposes of these protocols, adult hypotension is defined as a systolic blood pressure less than 90 mmHg. o Initially, all blood pressures shall be taken manually. A manual blood pressure should be taken to confirm any abnormal or significant change of an automatic blood pressure cuff reading. C III U I,. A BGL shall be documented for patients with any of the following: • History of Diabetes • Altered Mental Status • General Weakness • Seizure • Syncope/lightheadedness • Dizziness • Poisoning • Stroke • Cardiac Arrest Page 6 of 474 Monroe County Fire Rescue Universal Patient Assessment/Care IIIIII IIII IIIIS f' Illh°°I SIII CHIEF COMPLAINT: Why did the person call 911 HISTORY OF THE PRESENT ILLNESS (O, P, Q, R, S, T, A) • Onset- Did the symptoms appear gradually or suddenly? • III°:'alliative: What makes the symptoms better? • III°:1rovoke: What makes the symptoms worse? • III°:'revious: previous similar episodes? • Quality- (what kind of pain?) pressure, squeezing, aching, dull, etc. • Radiation- does the pain or discomfort radiate? where? • Severity of Pain: 1-10 scale, faces pain scale for pediatrics. • rime: what time did the symptoms begin? • Associated- what are the associated signs and symptoms? S.A.M.P.L.E HISTORY • Signs & Symptoms • Allergies • Medications- Prescribed, over the counter, or not prescribed to patient • Fast medical history: o Heart attack, asthma, COPD, diabetes, hypertension, stroke, etc. • Last Oral Intake • Events Preceding DCAP- BTLS • I[;; eformities & Discoloration • Contusions • Abrasions • III°:'unctures & Penetrations • Ilf;; urns • enderness • acerations • Swelling Page 7 of 475 cfl ti N O > N N p y z �� 0 o � 06 LU N d p Q = Z O ill a a I µm R R tl ,I W oa 3 � � N N ++ O CO N E a5 > — ^ a3 O > a3 o O ♦ > ♦ C) FMM V (� a) > LLU O N Q > Z °S voi Om � ♦+ _ a3 V Q > (6 C� ao Q T 0 � o 2 ° a� Qm U LM Q to E ♦ �—► E o L C o O c o > 0 � � o � IIII uuuuiiii�l Z � � Q � V ai pllllllll �s' �' � � a IIIIII° I a o cc pllllp o N co O � � 1111 � ao � � C5 CO A 6 > tz d� °IIII coo x "wlo p L�O� E ++ ' W Q Z Z � � Q 0 co06 N co cc c W a Wam Q ccCc � $ E � m LL � E aw �= Of 0 3 o .X om ' a` 0 CY z d 0) IrN Q� > � N C, o O oo 0 N x0 O 7 O a) C) -p E N 2 U) C - U) > ~ m V W a C: o y LL O '♦ �° m Lu ♦, E 3 0LO N Om U U Q C) 0 v Q Q O LU w cc U o ❑ ti a� ti � L � a' 2D W c O // Z Im 0 a) 'T 7 y 0 N 0 0 w U _ W a) L0 LF i1111111I *11111110 �00 s MelleMeMeMellIll N O V „ aa; aaaa; O m� qy O O n♦ p X � L W L N Illllllllli�' aaa Oillllll�u r rrrrrr r� CD C +�u N �e to CU LLB a �II Z) �_... 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CU c cu o-0 0 In � ' Q c o7— = fw� � co Q � c m N co�O � � U o o © v O �s fG�1 fJ c� Illw w �, cu 0 c �, � x m cn z o w a� ,,, � m o � c o E > O X U) =3 E 0) a) cB (� III o X (n -0 Q M OQOwo- z o MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOL CV N ACS A,III III llT C t UllIC/ III IIS""I III OR II RAUMA S ":&III'° Data: mtiii�r� t FD�:an�ri rllt . ,� /VI A IWNA, Rescue (,reaa I I Cd 4 � �nC �nm nm nm nm nm nm nm nm nm nm nm nm nm nm I'�4�1 I' II � 2 �i�mnm nm nm nm nm nm nm nm nm nm nm mm� II f�u�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m�m IIII h��rvmmNmmmmmmmmmmmm�%xmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm�n rimi iiurvmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm�m,NF A V P U GLUCOSE ROSC I Trauvaia star&begun cooliiing oR CS Alert ONE cirttefla ffriI EACH WC1.11un1 jlrrulintiiirrnuaiI O'Pt ,RST Ln Check all that apply Onset of IEvents: Provocation: Chest Palliim > 20"Irmmuln < 12 hours Quality: Regiioin: Time o Onset 5everltyr 1-m0): A tere l Mental Status Time,(Duration): Constant or Iln term itternt Shortness of BiI TPA Ex lulsion Criteria HemodynarnkMly Compirornillsed Bleeding Pirolalerns; rp (liowBP,,,WWFar lla ira yum,aar 'aa�Dia horns:s) IPirevlorus St,rolke: Streptokinase: iribir M111 Pricer Stents Recent Surgery( /in, Eo months): labete; Blood Thinner: Coironary Heart Disease e (CAD Pertinent (History tlI Rbrlflabon PiriorMII Date:: Hypertension ertension rtngIina: Nitro Taken Prior to Arrival: Sexual Enhancement I<241hrs: YES, N0: ? S:T Elievabon (STEW) Field Tr+eaittT e� nt Airrhyth mias Heart billocks ASA 324rmg: Paced I h tll vi 02 voa NIRB:. I�➢itrogly�cernn:�ce'1 x� "I�"Changes, Depression Pain iMeclicatiion: undlle Branch Mocks IBBB) Totall Fluids Given- rml Comments: i]]I M l A.UHL]f.'(f �I��/ I,3:,,,I & E U f a ""Al T A Cl'"l CODE ��1 I1,li IVI'Pvl,Irk R�„!'aY,, "Ilm4,il �"�Y�a1r�eC1,UIII. WHI1I111T I11:11:.IIIarr�III1CIR",V/ r"�����Pol�� ���m11 µ �°�t��"fir. Dr. Sandra Schwemmer, D.O. ACS ALERT CHECKLIST 482 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOL CV N I III IIIIII IIII IIII I I C1 1[1111CKLIS II FOR I RAUMA S T Ii Date� n til;ent Plu iRescn.te ,'K A M W q U g n A, i i+° ' A, V P U GLUCOSE Launch,Trauma ;star If Any Of''Th:e Below Criteria Are Preelint TPA IEcclulsicr� Criteria Bleeding Problems: I.. F`revialuls Stroke: Streptokinase: 1) New Onset LBBB with Cardiac El Recent Surgery(w/in 6 months • Sympt€ar s? Blood Thinner: 2)RBBB with ST elevaitnon? El Pertinent History r Prior M11 Date:: Aingiina: Diabetes,Mellitus: YES/NO l 31l Anterior,Wall: ElMtro Taken Prior to Arrival: I L Sexual Enhancement Mlleds<2417rs: 'YES 4) Inferior Wahl: Field Treatment IIII 111 AVF ❑ SSA 324mg:' 02 aria NRB: Inf'eIri r' all I—obtalin ' D'kiiitr€mBlyceriln:x:1 x2 111"WR POSITIVE WITHHOLD NITRATESP'aln Medicatilon: Obtain 2 i" IV&giviefluids tiff hypotensive TatalI FIuiids,Gilven:: rnI OIP RST a comments: 4 Onset of Events� � Provocation: i Qu a liity: Regiioin: Severity(1-10) Time (Duration): I Constant or Ilntermitteint. It l V,llw 11 f A"r /1 �,,c d," R IF'/10 I fi & i"I"A A U r A i';II I C O�1„1, PINK 'NU IRFSOUF IN II1II.tF irm ILIRu,pVUN tIIR AI YliIUUDU Ra1iM,5UouWIV 40i.l (°i,..q 75 Dr. Sandra Schwemmer, D.O. STEMI ALERT CHECKLIST 483 d co d l•� i N x ca a � � E a�� � � m � c O cu � C) a) Q o a) co a) to0pspy m j OU O co >, tn v9: C. 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O Fn � >+ �a > i 0- cu O > � 0EE Q (D- °� ° L /% W 0 > O " O ° OI E � U 00 E � � Ec) cu CL � (� L o Q L a) � o p E p 0 V 'Q U OaE� oo c f ^ am - � � mauJ Cn E UG Cl) ° jo > zonQn0 � oL �W W > uj UJ J ❑ % J J o W O U. cu O � L cc G) Cl)w cu o -i UJ N CL - Z cu Z w Q E 3 uJ 0- w OG M cu � o c>i > O uj a m U O © a, W w © E Z 2 ; l o O p y= c o }; � � cn � O E ca co cu C Q v _ Cc I— cU cn co - -a J a) cu µ E o f - O O w O 4 C N z = a) E � � Qj C a1 U Q E 2 0� �ww > L M O a) d x: >_ LL c 4- - a) L 75 ocn cu E E E c V L a) mcc 000 0 cu p U O CD N www o Q._ 0 0 0Co V OO N ,o C-- Q) CO +�+ E E LL to O � 6 'cD N aEi a.. 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W a 0- � v J Z J ca Q .2 > E OD U W O G cn >,uj � u CL W m �' �- W > � CL _ O 70 x x N � Z cc� o o O LL o CU cU OD ,. o 70 cU o E � oOD Co cn cUCo >, cu _ 7 � CU � p to O O L �53 � � � W O o cv70 4- � a) TO � a) > m m o 0 cn > � ,y �� = GHQ (D Z o • • • • • N a) • • • O • Q 3 U iy i^y I--i CN C) LO (3) 0 -0 (3) 0 cu 41 (n a) (3) cu =3 M c �+- E -0 a5 0 cu Uw m cu 0 -J FZ. a) -0 >1 (n M %( a) cu cu a) a) C: 0 a) 0) -0 cu > %0, 0 CD 0 ( OL-0 L- cu =3 a) 10 cu (n -0 =3 E c o 0) 0 L- E -cou _0 cu 0 0 CU 0 0- 0 (n 0) 0 -,e (n C: 0 cu (n CU _0 cu cu 0) -0 0 -0 0 0 0 a) a) oo > cu f E a) cu Etocu 0 5-- 0 o — —cu UJ cu cu (n CU 0 E _0 E 7o CU 70 -0 -0 0 0) to -cuLr- -0 cu E - cu =3 0 QL C:) a) 0 0- E o E Ln E LLIyr CU a) CU CO s= -0 0 cu wwmw —(n = o_ _0 cu 0- 0 a) L- cu c 0 cu uj ....................................................................................................................................................................................................................................................................................................................................................................... cn 2 CL wo 0 0 U. 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L m o w O o a) 0- E a) a L O L �� o00 cn U G W p a) O L a) O W O a) J 0 L1. p o 0) V V (n 'V a co _O OCL +-+ Y O I— 4 O U) O O � O Ln Tr a) © (n W V -- O (i5 V J O 4— -o a) U- O � a tea) � L0 O U °t5 Q a) a) CL O U .�.� a) o � c� a) — L a a _ a ao ace a� 0 MONROE COUNTY FIRE RESCUE N MEDICAL PROTOCOL SP11MIK E C1 flI CJCl IIIG I"" I DR ""IIP"°R I JMA STAR t. �Il��w� DOB A+lle Vie" Resciije CrewI �a 11. uor�y�k,WITH O @d7 l E PT SEE NI !W"�rTHD'TSYIPTOM1S GLUCOSE 24 F RS) "T CUNCINNA"ristroke Scal IVII, xa,iITI Lq l I r N ww ii � i ro3 Only heck Box IF ABNORMAL �.. you can"t teach,an,oId dog new triclrs" Repeats Sentence Correctly "Your ean't teach an alld dog newt ricks" Aphasic(Wrong our Inappropriate Words) Question Patient for: Age, Month Dypsarthirlia(Slurred or Unable to Speak) Commands:Close Eyes,Open Eyes N 1� 111�44 EI�'�ErSr CN� III(J .;1�i1E�1�E Faciall Droop:Slhow'Te et:h cam Simide Facial Droop:Show Teeth,or Smrniile Normal No Facial Droop Visual Fields:Four Quadrants, Abmnormal=Left Sided Droop Horizontal Gaze:Side To Side Abnormal=gktLt Sided Droop ","L` t R, Arm,Drift:Close eyes,Hold both arms out c II Aimrn Drik t:,Clos,e eyes, Hold(both arms out Lei Drift: � I Opens eyes,aind Ill s each IIeS setaarately � ry Norma I=olio drift SENSORY(Asllz patient to cllose eyes) V Arms:Check sensation by tcmuch then piing:lm Abnormal+Left drift or unable to move Legs Check serisation by touch,then pinch Abnormal*gktLt drift or unable to moue CCMORDINATIOMI Arms:IFinger to iniose "'Any faiik&Gluacrrse>60-Trauma Stair on STANDBY Legs;Heell to Shin "I!I 19MEDHATE,LY rnove PT to Re;ssuie them cownitntete at Army falls LAUNCH 7'irauma S,tair. EIS D'Exarnv I'yd CIS I{' C9 Caaus mq Site �� lf`, LEAD PARAMEDIC SIGNATURE: Ciz LPM 4 N COMMENTS: ELEVATE HEAD 30,". N ET'A HrSP: HCISP Contacted I % I 11"ut 'CALL RECEIVING FACIILITY PT REPORT ,ETA"'**ATTACH CODE SUMMARY"* PIIIIruUflu"DD II II S:'�UF W111111ITF II Ito Lli.11I rrH T I IItI!:W VEI U(WL"'FO II IV aa,H'NI/U Dr. Sandra Schwemmer, D.O. STROKE ALERT CHECKLIST 511 N LO M 0 c� a� i o c� O o � cQ •= © , E X i C2; O OQL L •� cu col cu O O W cQ CA 0 Q cu L a) • WV © pto 2 ca 0) o i W OI— UJ V U "O ON to Q U •� C O � a Z cu � a OG � cucnN o �' o A W W W U L cu o O � W cV U yC U O N' � O > -a W _ uct cu CD CA 0 rn a ; cu 0)N CU CD 3 w LO _ � � o � > � 0 N o cu ct 2LL CD n LJ I�NI O ^^✓(/]Cj) CD l Q� • • • • • • • • �$ V � O Q 3 O � 4 4 � Q Q M r I LO O O 70 � O N m O (t5 o s= a) C L E cis' U O 0 LO O s= cr L Wcu U © E cn ca LV CU J CL O O UJ to O s= CU LI.I Ml � � > U. U L cU 0 O ca o E m O z J U Q cu a) 0 4) O � ca U L m E cn a) CD s= O U ❑ ° o cu O cuJ LLI W O O U +) m O i-r � a) II to L a Z m m E �. uJ cn O V O ! 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U n3 III CU CA ) V wwww OiO � W � aZ \ a) L ° (D c 1 O ° N aD (D wVv W O 70 CO �w E O 7 QCU as wwwww �� U m O ca � W uw ww N � c 0 N W U J . . a' • Z (D • • • • 0 • m • • Q Z m = COH 0 0 3 U C 0 ti `O 4r L —i cu = L a) cB m o _ LO L a) cn cu V p O U Rf L _ _ C O �_ _ O Cl) O a) 70 a) 0, a) > 70 cu 7 (uc 0) cu O O a) O LCDL a) _ �- 5 S > >> cu U (n p O n E � L (n cu fn 7 > 0 O O 0 a) cu a) Q) CU CO -p a) L O) (u a) cu 0 O 0) 0 cu c- X to to >+ cB y O � O O 0 cu O cc � Ocu N = O � � 4= 'a) cu cU O O U cu 70 p to 'Q ,_ O L 4- E a) �- € cc O 0 a) O a) Co U B X y- O }� CU 70 L 0 a) � � �Q W A? cu (n cu O a) a) ._ cu cu � m "n E v > O cu 0- 0 a) (n CU uJ o ° o wow 0- = cu winU) D- U) Q. CO Z � - 0 W CL _ w ' a �s Wo � W �- U' z w c > �, O a _ ° cu V ' L c O Q 0 v c 0) aa) _ ,d cu -2 cu c O � L U W t � � 4- o 0 E o 0. uJ 02 cu � v y°' ° ° a) o _ z Z Rf Z cu — a) L a (DM 0. — a) p > o 0 � III a) C W ° cn am N = C C 4- U cL L -p C/3 O a) c cu 0 O i cn 70 O � 2 C ,Q .- a) � L cu O ° `1r fz q L III � ca n♦ L C (u (u o O O cu a) cu O C fn fn !Ep '�� V E a) Q ° 0 L y to ca 0 cu G CL a)Ua)O O O a) � a) p c +-� CDM � L '0- a) Z Co U O >, = L- � a)0 a) :3 �, O > .V Q— CoVj O 0° cum E cu a) O p ° o O O m Q Q co T— LO _6 CD CD w zCD m (1) m 06 0 to to m 2 E cb L as a, 0 cu QL i a) 0 E wO > 0 0 to to 0 0 uJ 0 cu 0 w cu cn �cu E = 0 cn cu cn c a) n cu cu E U? _j a)0 UJ 75 1211 U) -Iil 6 ULI UJ W 0 U. cu CD 0 E 0 z cu 0 aN V cz z E 0 a) 0 N CA 2 cn ou cuN E N < a 0 � CL 0 10 a)a) a) UJI ci >� " uJ N 0 0 M =3 L- cu N 4� E 70 a) N CL a) W ill U) a) 0 z CD :3 CD cu a) 8 0 2 -0 > 0 a) E N =CU CU E G-) 40- 11 a) 0 0 cn 7= E ch C14 (DL a) 012), 0 2 -0 0 CUcn E C: 11 CU 5, 0 :3 F— cn C., cu cn E a) Z CIS D-n 0 a) cn 0 LU 0 0 L— a) uj 75 (D E 12 0 OE a) CD 4- E cu -0 a) co Z a) 0 cuf) z 0cncLE 0 4- a) CO 'a CDM 0 L- a) ii.- L- -6 z cn a) U) — 10 10 0 Ln a) -0 -- =3 CL > =3 LL i 5 0 0 -0 0 0 0) a) 0 0 L- (DM cl) =3 D CL L- 2 a) = L- n (D U) =3 1 70 a) E o 0 0. .N 0 :) 0) a) c z a) 0 E a) a) (L 0 c a) a) _j CU 0 0 cQ 0 0 0 Z) z 0 z C z I U) 0 ca n o CO c: 0 cn b cn W cu cu 1 < 01 . . . >2= CL < E1 E ti i Lf� a W E cu2 LO cu L L M a) > a) cn 702 a) €3 a)cu J L © - a) QL O cu > LO a) O) O N a) cu E O U' W W 4 : cu W W [L �' o cu CIO W � O ca U. 0 o o W N Ucu 06 cn J W c( >, E Q cn U O k* °' ° LO eo cu O C " _ — L X cu CU 4— = X N � O) � —O ° 70 ocu �� CD v II Eo o cu U = i a) E °ca Z a) OD r p a] cu U N a) .G 0 C cn a) p a) L ca o U CD �. Q ct3 W m cu — cc C: o as cu o '�v—__ O cu W � � L_ CD CD V) W U U_ I— > C > E — J in L .y U O o m • • in COO O U .y W O O UE 2- _ +O+ C� c U Q cn cU U C 0 0 N LO r I 0 L 0 L- a) a) C - Cl) CL N i §-0 O N a) a) r (if X cO 0- a) (�l3 a)Q a)= cn O OOVLU _ cnW CD cn �� � � 0- ►� CL cn a) L 4-- � r O a) c� � 00 QUO a) a �0 cnO.S Z N Na) cn cn 0 U c 0 U 0 ccs ccs > � D-y-- 0 O O J a a) N cn N O N > C � �,, O W Z � c 7 -0 a) � 0 - 0_ 0- o. � v m Cl) m m >, m'� � a) UG a v) � � cLa) vOi Z w Cl) a) O 0 0 O) 70 O) V �.- a) �ti-- N N a) 0 cl) C co ., J_ m a) O a) c 1 V a) Cl) Q L cn L O L- a) 9 0) V Cl) Co > — > 0 co > a) p ,.., C a) L � V V to 0 V O m � 0 OVp •� 'sue (if (i3 0 . cL a) cL c •— •— cu to ,.., — N V a) w a) C a) a)a) a) 0 0 a) c o CL� o Q ;F, > > > p cn (if cn . a) Ocn � L U v 0 0 0 U. Q cn Q ai U IF E •E C • N • • • •� • • • • • • 3 0 •> a) .00 a wi a Q `) 0 T- N LO 16 E a) 0 Z N L f ,W — 0 0 CD �\ >% LV // 0 CD7.3 � O O 0- al � cn uj 0 _0 0 V 0 al O > > �i� 4- n - L O @ Q -0 (� Z U. H O _ _ Za a) � � m gym ' a' � (if L co fn C (11 ,N Q cn v - Q- 0 o Q ® L V Cl) a) o Q � � N Q QL -0co w L Q 0 cp p 0 0 L E 0 U0 Q (Dcn a a a c� _ c� L m Q 0 N N LO 16 C �' o Cl) o a) L CU Cl) a) .L o a) CL c 0 cn a) c L p ' � L � c m cu o - •� 0- :a w O O � -� W o E cn v a) � .a) � cn L W o — m 0 '''r z a) W _ _ Co — Q LL z - c� m m ;a I— O a) o o L \ ,� a) p Z W v m m 0 ccs a) > � 0 U = m c) - Cl) L m LL o `.' 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(n 0 0 i� 0 o In -,2 o — L) L- 0 U. 0- 0 0) 0 CU 0- 0 o 0- -0 0 Cc z CU 04 " .70 - w -0 >a) CL U) 0) uj a) cn CU+- z 0 -0 a) z CO > co cn co 0 'n 0 > 70 0 - w 0 c E CN 0 cn i>-' -0 (n z E N LJ) 0 0 4) -6 -0 m C: a) W a) 70 0 0" 2) a) Co C: 0 -E (n -0 co 0- =3 a) E: E 4) -- >.. ............................................ a) 0 Z a) 70 70 = UJ Eo 0 cu m a) rz. cu C: cn E A 0 0 a)c &- 7E) a) :3 m 0 cu 0 E a) a) LU > > 0 a) a) E 0 CU cn cn 0- 0 o a) — cu a) 0 o cn 0 0 0 b QQQODfY U) 2= CnU w cn cn cn E E dq N LO Lf� I 1 S= O :p cu O) L L 70 O O O cu �\ cu L v O O a) L a) 0 ;o E n3 s= O a) — o o o E CLIcn O -a L ccn o colE cu s s _ cu cn J ti U_ uj a o L m � Z Q � o Li � - C w ° 0 _ � a [L E cu aa)) CU w w o L o J uj U. U a) cua) O otS + s= L p v wco O OCL O L m J Lam ' a Z J Ri = O Cc U m O U rfi O O w to uj O cu L Z cu U N E o o Z �. n3 L Z 0 V CU �-, N O_ O O O CUO m s� Q O- V O >, U 70 = a) cr (Cf V O (QCA cm cu U to cu Q s= -0 O L V cu l:L. E O O LiO " U to E a) Q N a) U cn -0 a) a) � OV z cu s= Q Z S= — U O s. U cQ a) = to O CD t%) m0 an L Q II U E O Q p E a) p U a) U (� cu E c E2 W `~ cn Cl) • = fY L fi W J • • • m a U • • W cn 0 LO N LO I a) 70 a) > O) In U cn Q a) s= O S c c 4) cOn O V cu a) C U a) U O Cl) > O) a) �O U cu c6 70 S= S= a) a) O Ocn O L cn a)cn > E 7 a) O U +r D Q O O can O U E cu O) 4-- > a) a) U O to s cu — O_ L O cu s.3 M v ) o a) a) 0 O cu U) U 70 � to (Cf a) Q i 0 S= E O -0 O a) '_' O CU 4) cu cu W _0 0) C -0 4— J d- 'O co -p cu to O O cU (if °� to a) >, ) cu , a) Q mU O (t5 E aa)) � D f 0 c -a cn C.) cu = � f cu a) � � a > 0 L a) U (Q O I_ cn 0 a) cu a) O Cl) Q U 4U v -0 n cn aS T > W U w 0 N U O cu f a) � '� E Z uj O — f _0 �,f �' 0 E — E U o o c o o — 0 cu cn cu 4— cu N s= ��"�"s E Y � f p E cn cif Z N U �, -O cn 0 cu DL a) [CU, Q O x O Q. (Cf a) ^L♦ w . N ([j a) C cn to � a) O x a) > o cQ (Q CD O E 't i o �' U °� cn E U V O ,�- a) i s= -0 N vi = U C O N O Q O a) a) 0 _ ,_, O > > cQ a O p C c v-te cu o ca U s a)DL cn U - can LL E O O cnn >' x "p L O cn a) . O Ri cu 0 Ec>`Cf O p .� _ cn U Ecu my V c ''-� J U > o O O c sv cn a) E > x 'c� cn L' v O E U p = O a�c O CD U z U N cn cn L o j a- O � a) a Qn O Ua >_ > Lo N V E WU `� m U I— a E O (D N LO I 70 O CC' -C c O m 0� o � oa) � o m Cl) 2>2 mm 0 ) a) c� _0 a) a o o Co c E ,� m � a) � > � � ' o cno s= 0o o m cn m y >, w V CD cif =3 E cn E o 0 V O cif +� L U Q ' m O o x o ccf z cn >, cn v O p m _ w C E > 0 O o C 4 0- O � J c� � y- wO a L 7 � C C o .L m cn r- m .62 a) c c cp V U. U. O m m m O cn o .- � m m m O � m x = C .L � m � � c a) w a a� " c� � m p m � � � � � � o � O z � E �- m 7 > a) m po z L c w a) c a) m � cu O v a`) � � V cis 4— 06 � � a) � C 4 � o 0 � x O - a) � U ❑ �� a) m m ccf , � � zO v m o o a) a)E -o a O mr — Cl)z O p ' � cn O 0 --, a) O> � cO a) c cn � o'. � � U cn L cn W p E a) 'L x X O m CL O — Co LO � a) V m p c � Co r- '� (is cn V cn aj v cn L- Cl) a) o a) m O _ cn � o � p ti= X L V � x a) 6 �� L '� Co p E cn E p a) cif p O N c i o C� U V O a) � a) � > > co a) O V o s— fn co co c[f ci3 V V c� +r O a) cn �_ cis cif Cl) = O E CL (1) O o � z � � � � � � � oa -Cf) ! � JN a) • • • • • • • • • Q I— v 0 ti N co 6 c N c6 co c CU O1 U 0)C r 'F U — to O N i Q. (n Ni O _ LL y2 ftS E a) O O (6 — E Q C X N U ftS NCU N L N (6 E OCU N -0 C N to C — C ji C O� cu C C N ,. E cu CU � -0 C N C 75 Q N (n (6 a W W 0 °' � n N � y-- U Ccu ° O N /�f c C i i i U F_ O ._ 0 -0 ,U U C N > U E U c6 � N N E �O Q 0 In U Q Q U. 0L � (n O ftS f Q N Q cn CC .0 Up n O U E G Z J E O> N U O � f E N co N �- N - Q O V N E c� N N C cn = W � N N U U U — ( O N W Q n o O >, � � Q N o N 1= U cu cu m Cm � NOW_ O cu� 0) " , o . cu m o c W �O c�` cU � mCDL � C CO 0 5 o cu o - I— � X �> > � �5 o X D_ � � cu in o v -0 cu C C > a� c: "= C W N U cu o a°i Q N m > v cn m ° n = N Ucu C: cua�i — F- O N c6 n u co � — N N o c v �- - o cu N cu nx � �° 0 �U = o 0) a a cc D-U oE = N1 = = n. o 4 Oo cu U 03 nN CU i n '� �0 o 4— (c � o n o o a X cu c O C � t5 In C C cu N o >cu E C C � 4- oN o N u vi N vi N = c O C M O I— -�' .� s= C U L '' Q,( N � r N N N N N O a E C N O O N .0 O Q N N to >,In c N N �. N N N C 3 N to _ C N c6 co C C C cn C: (n cum m (n N ~ ° o a>i m E ) cu v°i QL m ?+ o 0 0 0 cu 0 0 Q a O = 0 U cn c E � = � n.Ui 0 0 � W li Q 0) 0 cn El El L Q 0 J • • • • • � • • • • � • • • • • • Q W W U. co N LO I to U) " ` o a w w O '� U = _ U) � p Mlc w U. H U as a) � O a) a _ -0 a) •— z J E CU cn z cn Q a) a) 00 w c� a, � L s= uW w O .Q � cu w z = a) • -p W a) " a) ca a) 0 � a) �.` L •� E cn O E ©- Q. E 0 W O) cQ 0 col �o cu CA suet) 4) t: o _ (L "= " W a) fn O ion Z � ME U Z o — a) a) N � O W O o ,p s= "" w .c "" W � a) v z N LL J cu cu N o Q cu (Cf 0p U L v m (n U W E J = W U Q U a 0 0) N LO C) r I a) ca o) L a) a) Q cn a) O a) .(n �+ C: cn , a) Q a) Q CU O -a = (Q 4- U O) c 4- U O > 4- E "O D S Q) O O. O a) c "a c O a)0- t O O " to U U L a) (� a) S= -0 O L a) = r a) Y fn cQ �-+ cu cn = cu cn s= cna) cCf W ��+ 70 O S= > cn cu c O U © cn L "� L to I -1-+ (('f a) cn © � � a) aa)) � a) Q ,- CU 4 � � v vi U O (Cf U U _ O �3 �_ L � a) cQ (Q O> 0 O O U Cl) ILO E � � � Ea) c a O O cn a) c O cn U a) a) a) a) cn 0- cn 0 WE cn V Q a�) a) a) O ' a)U VOW v " ° cn oO O > a) >a h Q — a) c a) c � a)Z � U. a) cn O o Z cn 0. cn (n c U C C cn M � U O Cps a) -ate s > 2C: -ate _ > D L (L c O '-' to as OCU "= y-+ ,� L L 10 � cu L L 0 � ^^♦♦ ^�♦♦ EL -1-+ O o ^' -F+ -1-+ O a) a) U) O_ O o E L cn cv a) O O E cn a) ccn � s ov '. � vim) O 0 a) U 0 Q L) a) cn ca cn cn cn -a Q 0- a) cn Q n Q c- a) Q N • • • • U. G a) s= J _ O • • • _ � CU '> • • • Q U = 0 0 M LO cn r a) � N O o _ U cn Q Q Ucu O p > Cl) 0 'cn n ftS �" a) c6 O 0- LU u MM� i O O w O C 'n •cn Ccu O O 0 O N = Q Q. cn �ct _ O O � Cl) C O : n c6 _ �n .v .o C a U 0 U > m o m ct= cn Cl) C _ m a) cucn cn cn L cu 0 cn cu 0- Fn _ w -a W 4, U >+ = 5% c6 " O C U O ) N " cn U) L Qm O O 0. U U U cn© cn U) a) C.)Q � a U o 0 0 G1 • • • • (D co = o O cn j N E LO i ftS (U E� Oa) a) M E m n = °cu 0 a) ° M m Z a N a) U N cn cuc y v 0 0 -a a) � Q W -a -02 � c 4 � W �U o 0V cu cn O cn o EQ cw U ❑ a) 0) cn a) v ink � W = LV W _ o o m c cU 2 � � � ocn � Uc � o Z 0 0 � a- 0 °Ca m � > oE o N > • U Q .0 d .� O U 3 Z ;��+ o co n cn .> Cl Q N ns 0 0 C Q O � W � F— cn cn N � a) :r .S E w a) cn N z C � C a) a) > N sue„ _ m CD > cu c p vi oo C) a) a) o o A� _ > -a cu a-0 E `�i —>' vi U 0 co cu U co o o uo +-� cn cn cu a) cu Q o U) m C m a) o n = U C co c6 0 cu U o CU o ? _ aa)) o L 7 cO o � � m C� > � � a) Ea) = cam o > .� cu cu a) cn a) � m a) a) r � Ecc >, a -0 �- `� _ °>,) n .o C Y m d � c o c u) -v a) a) U_ � ns L � � x � 0 a) a) cn 0 � L E co 0— cn 0 0 C E cu oa te C 0 ° o - = 0 � N -0 can E _ ) � � m 0 o o m 4 _ m n ,� cu cu o 0- 0- 0) CU L) o -0 >, n. () c N - C ° pU � oQc U Q 0 0 = cn o O -acu cn L,.cn r C cu o � '- cu O cm a) = ns U � = - - o 0 0 0 o m a) _ c � 4- co a m m � � co cu cm-0LO = cu n co cn C N N N Q N m a) O> .� > co co o °N U Q— a) C a) N 'a i a3 N n. n. N O cu (nU = W Qco > F0 OL0 0- _ "- CA n N � W "- "- � r. .........AEU • • • • • • N • • • i • • • • • • N • • • m Q U- r Q M LO N p Q co cu cu U_ i cn i O N U cn M N co cn C O c6 ` � to O © c6 i 0 A E cu cu �• _ cu N 0 0- E O ° cn cu cn E N O 0O cn � C� W G cn z cn cn C: p Z i — i Cl) O O cuCL w 0 p o c cm O p J O �, H 0 0 ( C (6 co c a) W O U. E cn O cu p E p O a) cn co — s- C: CU Z J O cn p O Q 4- U. 0 U N cu CU O c I— p J V ❑ ! O Q. C I cu W ^ Q W W _ v°i s' O o � c c uJ ~ 0 � p � C ° E o o cu U Q a�i Q — c- cn 0) � o ° cn E o Q cu LL Z E cn p = n. p cn c o O �' Z 0 g � O - - p '� o m o a p 0 p ca) En O A � � � ZQA� O >+cn Lr- N cn � E c6 v co cn c6 W p 4— CU (U Q C: cm p p (6 U cu cn O � cn 0 CU O � 0) 0) CU N E cu Q. � co (6 � © p 3 � 0 � 0) cn O c p c ` 0 CU o O p cn C� n cn 0 p CU o � n cn p c p c z_ n. p) m _cu c c cu m cu o � p a)CL CL o O _ = Q fA U 0 IL I—cu p IL 0 "- E CU a LL � • • • • • cn • O • O • Q • • • 1 0) p cn J • • J o cu U m Q Z 0- L 0 N M LO M T— O L cu cu c L cu a) cu a) >1 = -~ > L .0 0 L O cu cu 0 a) a) cu U co a) p cCf ) a) {.I L O 1-+ to 0 cu 0- a) O U) to E 0 c o p > W _ a) O a) W -0 cu 0) a) 0 Vcu G1 a) "a cu ccs U cu L-O a) U © U � L > •— -0 WQ a) 0 0) cu70 o U � 0. X U 0 O J 0) O N co 70 � a) v vi � >' � V ° cu aui 0 E a) 0 - U. O O U ! S - cv c O v y a) a) o ccs cn a =70 Z . a) _ a) Ea) Z a E 0 cu &- — CDO u C 0 W 0) V - Q Can O = > a) a) O j W Q U N a) O -p L E Q CU J - a U W °D cu a°)) 0 o o a) h W E( a) -a cu L c E H cn cu L L O "` U O W 'cn L > 0 O cn O O Q a) > 4- O o E -0) E 0 o � O ° te o Q �.0)a cm C _ x `/ 0 O U (Cf O a) >�co to c cu a 0 a) L cu m E (n 0) CU L ") a) �' w to cu +-' ''"' L > 0 V O w . E coia) LU m O w E a�� o~ v v o°E -0 �c c �a) E'Onc Wa) = Ucv Q 'W> x a OW �W 00U) (D O2= 00 W Z � M � • • w • • O • • • • • • • • • • • • • 8 _ o M M LO r I _ O = CD _ O O y_ Q LL O LL Q O CD Q O CD E O N N U U CD — z V L O E Qcu N N 't3 cn L O ca w CD p � CD O cu U. (o O ° W LCD CD r— W LL w 0 -c v �LL o = OU. y0 Q 0 CD UJ O O a) a) io m c F— CD � p y � Z o a) � = U U. L CL CD tea' Q U 04 CV)U W LU CD O a) N 0O OLU � L " CD CD � E— Fu o *' s= ZO >:, '� a) N Y 'L Q a) G � ,� c cn O °' 0) cu E Q E �= � � ca C: Z =3 CD L, w Z -0 a) � = o o � Q = =c G� E L -a o c� as CD ) U L p � E ca a�) uQ + ~ CD O Co - = = U Z o O 0 Q ° 40 o s � ca a) E o 75CDa- L U J75J0 ca C) Z rr� • • • W • • • • • y ° Q MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOL MCI, °' ADLIL'''r "FRAUMA CRI'l EWI A 1 OR pate Grew Launch Trauma Star& relay: Patient Name DOB Age— OCA#. M011- Time of Injury PIU MM Rescue Unit# Wftht LZ (22—CS ANY ONE :::; TRAUIVIA AILLIRT jonly choose one AI Actwe AIrway Assuistancel OR Respiratory Rate< 10 Or>29 RWAY Drowning or Non-Fatal Drowning C11IRCULAMN No,RadiIal Pulse 31P<90 OR BP'< 110 mi Patent oveir 135 y,�oi 01 ASTIL] GCS< 13 0 Paralysis 0 SUSI:P ricion of Spinall Cord injury S rY ID Loss of Sensalibn a 2nd Or 3rd Degree Burns 15 %TBSA a Amputation at oi, above the Wrist or Ankle - An', Penetrating InILI ry to the Head, Neck, or Tors,02 SOF-r TISSUE. @ Dislocaflofl of Hip, 'Knee or Ankle a GSW or.Penetrating injun/to Extremlities at girabove Knee or Ellb,ow a Chest Vda:11111 mstabIlity Of Defomirty (Flail Chest) 0 Clllsh,eid, Man,Wed, De-g�iovevd or PLIMI,ess Extrernfty LONG BONE' 2 or more Long SDne Fractiures3 FRACTURES, a Sevei,e:Facial:injiLiry/Fraicti,iresvi[1)o;teiitiallA,ii"wayCoimpi,omise a Electrociution or Lightningfinguiry w/LOC or VisflNeSlIgInS Of filljlffy MECHANISM - Bkinl A15t)or Chest trauma iIri patient M IHX of Paralysis OFANJURY (PaTaplegiiaQualftipiegia) a Pregnancy>20 weeks W ABD pain and 13,11iUnt Trauma ANYTWO, ® AU IA ALERT(only ctoose twol CIRCULATION Patients,wlRena I Falu re an Dila lysus IDI SABILITY Head injury w/1-0C,Arrinesia oir New Aftered Mental Status * Soft,Tilssule Loss injury(crush,de-gloving)or Deep Flap Avulslion>5 inch, SOFT TIS SUE, El Pe netirati ng mp ry to the IEXITem itles IDistaI to the Elbow or Knee LONG BONE Siingle Long Bone Fracture due to MVC or iin a Patient on Anti,coaglulants FRACTURES 55 Years 011d El Election from Alllomobfle, Motorcycle,Golf Carl or Horse Blunt Head:,Chest or ABD Trauma in Patients an Anticoal9julants Death in Same Passenger Compartment MECHANISM Intrusion, including Roof>12 mcn,es on Occupant Sate or> 18 inches of OF'INJUR.Y Any Sifte into Passenger Compartment. Fall> 10 Feet Auto vs Pedlestrlan]Bicycffst, Thrown, Run Over or vvl impact>20 MIPH M oto rcycle, Golf Ca rt or ATV Crash >20 IM PH If abo,ve cftda,are not met&padent condidan W2072MS 8 traunja alert.Sefece.parainediefudgment,larkide b6of descilption. Pairaffieft Judgment: I Afrivay assofaxxe oc)udes n7aaaaj jaw ftrust,coMinuous suctfoning,or use cf other adjuncts to assist veofflatory effo&. 2 Exchxhng sLperfxot wounds Pn whxh the ctepM of?wound car?be?defevrawned. 3-Long bone fracture sires are defined as the(I)shaft of the hurnefus.(2)radius and dnar(3)femur.f4)hNa and fibtda COMMENTS: ***CALL,TRAUMA CENTER W/PT REPORT ***A'TTACH CO'DE' UI RY"* %V111'IFF I F 1,1 G I I"F C"R FIV 117ILL(MV TR,kUlAIA CTNIT'R PI Ills 1t1iFS'CTT rd 4 f,11 (196 iICIG/2()2 I) Dr. Sandra Schwerrimer, D.O. 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E _ CL z �V E 4- z CA 3N > O75; .� E CD _ L LO W O Rf r." •L. Q Q p (A W O 2 LO 0 a) ��,. C LO r.+ O iu- a.r _ a) Cp i ; m Cp 0 O o Rf Q p E ca to •.L. ++ i E mN L 3 0 � O Q E ch O m � a Z m � �u— O �cn u— CD V N W i cn Cl) • J LLJ • cv • N • o m Q a wi A 0 L Q cn cn cnL _ O a) O cn x cn U U O V cn o L U O o � � � cn O cu cu m > � > U L) 0- cn > m m cu cn 0 m o cn cu r cu a)� a�i �' voi c>i 0 4 m �� � ai 0) � c m o .. _ .. cu 0 cn O - _� (L6 cn c6 c6 L ��— N N N cmcu ^ m CU cn O m w o U E a) _ 3 cn cu cn __ c6 "' O cn 0- 0 N CU >% CU O cu co coi U L N Li N a L L U .. W � � v°'i � o `Ucu 'o vi `� m0o o � m � a`ui i > _ Q c0 0).2 O) O c0 O cn _ O cn O) O) L ° n cu O 0NO 0 c O QO _ 0 0 ra) Y _ cu _ _ _ O U U c0O OcnOcu - n o-o Q cu r42a E ran0 o 0- 00 — m2 LU m �� U CL W O .. U Ml U) U- C4W 0 cn O r- CD c6 Z J O � op cm a En O N U Q U O O �_ N W co 2 p d .Q > W V W _ (n U o 0 0 cu cu co W cu c L N O O ai L 0 o ai > E Q .. _ N cu a) U z ( . CV u N "CD "�co � C 0. 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Q MONROE COUNTY FIRE RESCUE C) MEDICAL PROTOCOLS CID R 'R k'- I A",' Ill Chew„ Launch Trauma Star & relay: Ill IName DOB.—,Age.— OCA# mo'[� "T'lime Ilhrntluurry. plu IM Rescue Unk 0— Weight ILZ� r GCS ANY N OE= TRAUMA ALg ................................................................................................................................. E............................................ ......SAM!!212? Aa III ve Afiivvay Assilr.,.',Ia incle 1 0 1R. Respiratory lZate-< 210, .... ...... ..... A11IRWAY 111rowning Fatal Drowniing IF�espiral.orylIZail:r..,,,< ,110,(Clhlfd ,lyr ''I.5yii) ...........I CER(.1ll III A'710114 I�,m fr�,arotik:l oir Feinri,ofall I .0 I.R. Systolik.',BIP<50 pai ally sis II cvss of 11:11 SAIEHI 11 1"Y Alteiieic.t tAentall Status,2 1D ...........I .......... &..ppwci,on c.:A Spinfal Cor�.Jl vqUl�y 2mll 011 31W �.)e(,:�iree 1:13u i rs 10% f I "..I An ilputatllk:n at(yrabove ffife Wir Ist of Ank.1le ................................................................................ Any IFeinelratling in is tc.:)the Head, I c.:)ir Toirs(ru3 (..3,1.-.,W r::�ir Penetra[mg injuiry 11D Extrenmit�e,,-.�.a t(2 f or I S,OIF Ir ..... .... ..................... WaIll ni�,stat:�,illity or I)ercmirmly (Fladl Chst) 11) llcwcaflon(.4 the I I cn Ainkl,rL'!' Crushed. I'Aaris, leld, I)e:g1k:,wed ,.a Pi.flsdess Exltreinlly 11 (11W li:30NIE 11 X I &:M ri,,-.ysut� ENS11'U�Pticxnl I,:a I AVWS110PI Of E'RIM Op(:."'in I I OR Of :::'r;5rAUre SlItes SIKIE 11.111 All 3 .................. ...........I * Sevem I::adall 1!rTijiii.,iiiiiyllFia�c�.uiies vv!pf.:)tenflaI Airway Coirnpiiogn'tse, * Ellerftiroctilkxn m 1.1ghInling linjury w/I VilsibliH&gInS C)f irrILIIPV Mll:..:.C1HAN1S1M OF . I ABI)of Dies[ lirai.irria in patl,enl:oin Anrccpgullants ar w/HIX of INJURY Paiialysis (lPairaple�,.:lll,ai�'Qir.,ia(:!liiiijl:p,lleq. hI * Auto v,.,; Thircvxi, Flwn Oveir rar vvl impF,.ilct 20 MI:::1H ANY TWO= TRAUMA ALERT I only choose two] SIZE Weight<20 kig E] CIRCULATION Radial o,,r Pedla.1 Pull not Pallipablie OR.Systoflic BP<90 DISABILITY Amnesila or Loss,of Consclousness E] SOFTTISSUE * GSW or Penetrating injiury below the Elbow or Knee E] a Dislocation of the Upper Extremity LONG BONE FX I Single Long Bone Fracture Site El SKELIETAL * Death in Same Passenger Cornparfirnent MECHANISM OF - Intrusion, uinncliuding IFtoof>12 Inches on Occupant Sfle mr> 18,inches of INJURY Any Site into Passenger Compartment. E] z" * Fa,1111> 10 Feet OR 2-3 Times the heilght of the Child t� 0 Motoi,cycle, G,olr,Cart Jr ATV Crash'> 20 1 H above criteria are not miat&pationt 1-andificyn warrants as trauma afevi.Sekx.'t g3ararnedic jucklment,inchm.fe bficd d emsc-Hp6on, �ll::Iaiira.irin tlii,c,.Iudginnie!iir,iit::............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ I Airway assistance endudes mamaJAw thrys(confinuoos sur-fioMng,amuse oF oihar adjuncts to assist ventdatory efforts. 2. Afte�d mentad states incJude drowsiness,Pethargy°Oabdity to,fcUow commands,ume.sponvveness to voce�totaify unresponswe 3. Exc)ucfing superfivai murAs m which the demur of the,wound car?be datermined. 4 Loog bone ftcfure sites a�defined as the(1)shaft of the,hum eru,(2)radws and udna�,(3)femur,(4)ffWa and fi&da COMMENTS CALUTRAIUMA,CENTER W/ PTIREPORT ATTACH CODE SUMMARY VF 1,l'.0 W 11C,lk I I Nll'A C F N'11k'�14 INIVIK VICIP11 TRAUMA CRITERIA FORM - IIIIIIGIIIA 11711FZIC Dr. Sandra Schwernmer,DO 550 T- LO LO ITr- i 00 W O W W W J O w O +r w O L a OU > U � � 0 Z O 2 � O V1 O o d 3 U C 0 N LO LO O _ 06 O y.. O p CL �+ W s Q> ca 0 U) �` a) o Q 0 L 1r tom/) V C a) M L- E O CL J cn U) C 0 Q >, O W 0) CD v � V o o iL 'L L � mnnnnnn U � � �+ C Z a) 0 V W Y O Q a) o O Wcu V C U U a) 0 LU W t� V O O x u .f c W ca U c O �- W ca ''"' ca V ca � W �, V CL O ate) �-' 2 ° 3 00 Wwa. � .i. 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Z 0 > co + E N a m 0 � 0 p 0 0 O c 0) E N am C 0 co co 0 0 0 Qa N Co a c O m � � ° E m Q 0_ N uj O N C a' E — O co C Y s O O N co t� 2 sd N °° ' > � 0' Co 3N0c�O wn o 0 0 � aZ E ` 6E oa Omc = aNE a) U ° — 0 nO EP N QQ0 co oo 'o :o ` Co ` N ° C r O � N c a o � Q om O o : OZ _ � .Q 0 C: C: 0t Q � cc • 3 a � O N a m Q � a� Em = Q (n — coc' 0Oy W w co a Q � m Q 'a E ° E n °aEwwO—Q ' wi '0 04— a� a� o � '�, - — N E N rl, «s 4- C NLO a cm m a a _ 3 O N 0) N u) N " Q Q s N N u) Co M Y E Q O> co C O v~- C 07 ` m NN nE n � mn � `m0 cQEXm � to N ` +J � Q. .� � C a E n d N E a� Co a u) � o } � 'a oO = co 0 � cCf 2 .: � C � RS � � Q O V (�E a� Lo -In 0 W co E O Q +" OY ` N O > -a > W co d a - c C co '-a - 0 N U 0)t a N 'a a a)� -C } n O> d O W O N .> — T .0 d p ` > +�+ N Co � � N � a E O a �O � 0 G� t/J ++ N +t' m Q E O N m E d +O RS N co N ,N C > ` N a� Z0 � 7 (Cf C E N >.0 o N �_ (� E p >' O U 7 C E a '� 'a X O N 'a c = O C C ~ O c ` N co Q N m N m n O aLLW c ao- Q � a -iw .� c) m0 a -i cm � Ucn w ccQ � QWc� E E o o U N • • • • • • • • • • • V • • • • • • co J J d m 0 cfl cfl i ," n Arq Y � 10 ;" W W Jq- is W IL W Z :) O J r, O a �, O W W E ,W r a Al" � r a a ti Q Q ti cfl i 0 0 N O U 0) W t O �,�CD oj 1 O CD O ' o Q i/ > � _01 a� ° O ° _0 U LU ° o OU U Q D � CO a°i 0) ° — w aD ° (D y _0 � �.( D O O 0) D LU_ CO (D W w 'a� ° = c� �' ° U_ LL ? c� o C: U >, L c� ° Ow ° co ; V CL p ° .O 0 i N A N N V N (6 to 0 > i % % O O O H e O N O O O m 0- r-r U O ca O) O - i O N U Z 0) .—0) (1) C Q -° !::: �: o O G 0) 2 C � N 0 (D E.N O 0 V Q Q N o 0 -0 Z3 o N N 0- N N N p � 0CD (D N (DO) T O O) �. .QH (D (D0- O Z 0 ti N E N -o N (D to — / i Lo Lo to O O O to O LO co O N TVAT C) U Q Q N O1 V O C'J S N M V/ C (D (D ° _ ° (DZ CDfn o O ?� m W" c 0 Z o E Q Q � O a) c (D0 N % � 0 C 0 0- 0- 0 O O to 0 O 0 V) � — C U � Q Q m 2 IL N > U � 0 /,r d E .0. 0 � N Mco co 0 co (D LO i W O W W U W 0 J W W UO W � 0 ^ ❑ za IJ � Q U H U � W LL O W z_ z O 2 O V 1 O o 0 E E 3 U C 0 a) cfl O L O T CL 0u CL VJ O c 3 c CL CL E +' 7 C O C O Q E � U � � 'i. a1 GL U E U �' CL ++ E U Q A > f0 O yr i1 U 7 _ � C ++ E -a 7 Q C O U u ++ Q O E Y O a n L a) E O o O t Q' O c0 > i -a a O co CL c CL 7 O O n 7 C O O "a 0 E c p LU L ++ t CLO > L :3 O — C N U O CL O ++ > `1 > C L M 'C 7 C C C N U a O U O Q 0A i 7 a) a) J Cl) O L (0 U O C LU u > a1 >, � U 7 •E U -le > O w/ O LL v Y *L' ? ap O c E 4O LU > Q ° - m c of Y v }� w c LU v > _ ° U W E v t y E a v u — v t al o +� LL c +' ao a) Ll E o > CL LE E r Lu O 4H .� _ UN v E z ) _ 0 Ln OO E at v °' L p ° a ° U Y O Q o C 0 0�.0 Q 0 -a V a 1 v E ° ` +, = E E c L d u v CL O J U >, .LLU 4- o 0A ++ to E N C C (, O CLYc -E O t >� O a L 6L ?�. 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Monroe County Fire Rescue ALS transport vehicles are located at strategic points throughout the County, and are supplemented by numerous BLS Fire/Rescue vehicles, which may be activated as first responder support for Fire Rescue personnel. 1. Calls are received via an enhanced 911 system (Monroe County Sheriffs Office Central Dispatch Center) located in Marathon, which dispatches the appropriate Fire Rescue 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 a The Dispatcher selects the appropriate Fire Rescue 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 en route 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 Fire Rescue crew members, and all Fire Rescue Supervisory personnel. The Dispatcher may also elect to activate a BLS Fire Rescue vehicle for first response support. 4. With potential trauma patients or injuries that may warrant air transportation, the Dispatcher will tone the Monroe County "TRAUMA STAR" helicopter to standby and/or monitor the scene in case of TRAUMA ALERT patients. A request for "TRAUMA STAR" to respond may be made by a Monroe County Fire Rescue Battalion Chief or on scene EMT or Paramedic on duty. 5. The Dispatcher is in direct radio contact with the responding unit(s) and monitors the status of the crew (i.e., time enroute, arrival time on scene, time enroute to hospital, etc.). 6. On scene personnel may communicate requests for additional intra-agency resource support (e.g. manpower, equipment, additional vehicles, supervisory personnel), via the Dispatch Center. Requests for inter-agency support (e.g., law enforcement, utility company, fire suppression equipment and personnel, Marine Patrol, Coast Guard), may also be communicated via the Dispatch Center. =0-9591 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS II. PRE-HOSPITAL PROCEDURES 1. Upon arrival at the incident, Fire Rescue 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, d i s a b i l i t y ( motor response/Glasgow Coma Scale), soft tissue injury; longbone fracture/skeletel, 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 SATC or SAPTRC or the local receiving facility, if circumstances do not allow for helicopter access to a SATC or SAPTRC. Communications from field FIRE RESCUE personnel to the receiving facility will include the phrase "TRAUMA ALERT", and will include the following information- - Specific Trauma Alert Criteria - Mechanism of injury - Glasgow Coma Score (itemized) - ETA to receiving facility a A Monroe County Fire Rescue 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 Monroe County Fire Rescue Form MCFRF-011 "Street Form Worksheet" shall be completed for each patient and a copy shall accompany the patient to the receiving facility. a A Monroe County Fire Rescue electronic Patient Care Report will be completed as defined in section 64J — 1.001(18) F.A.C. by the Rescue personnel that were on-scene. A copy of the complete patient care report will be forwarded to the receiving facility when completed. The MCFR electronic Patient Care Report will also be completed for all trauma victims found deceased on scene. =0_9592 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS III. PRE-HOSPITAL FLIGHT PROCEDURES Two (2) sets of flight criteria must be considered. The first is directed toward the safety of the helicopter pilot and crew, the ground personnel, the patient, and bystanders. The second set establishes operational guidelines for when the helicopter should be requested for TRAUMA ALERT patients. 1. SAFETY CRITERIA: (Conditions when the helicopter will not be used) A.) Severe weather (as determined by the pilot or S.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 landingarea * 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: i Blockage of the main road, making ground access to the nearest receiving Hospital impossible. i Failure of the drawbridges, making ground access to the nearest Hospital impossible. i Extrication time greater than fifteen (15)minutes. N. If the helicopter is needed to gain access to the patient or needed to transport the patient out of an inaccessible area. V. If ground transportation is not available and is not expected to be available within a reasonable time (15-20 minutes, depending on injuries). vi MCI (mass casualty incident), as determined by on scene MCFR Paramedic/or on duty MCFR Battalion Chief. C.) The Paramedic on scene will notify the Battalion Chief when TRAUMA STAR is requested under the circumstances listed in Babove. =0_9593 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS IV. ADULT and PEDIATRIC TRAUMA ALERT CRITERIA F.A.C. 64J-2.004 ADULT TRAUMA SCORECARD METHODOLOGY 1. Each EMS provider shall ensure that upon arrival at the location of an incident, an EMT or paramedic shall: A. Assess the condition of each adult trauma patient using the adult trauma scorecard methodology, as provided in this section to determine whether the patient should be a "Trauma Alert". B. In assessing the condition of each adult trauma patient, the EMT or paramedic shall evaluate the patient's status for each of the following components: airway, circulation, disability (includes Glasgow Coma Scale), soft tissue (cutaneous) injury, Iongbone fracture/skeletal, patient's age, and mechanism of injury. The patient's age and mechanism of injury shall be used as assessment factors when used in conjunction with assessment criteria included in (3) of thissection. 2. The EMT or paramedic shall assess all adult trauma patients using the following criteria (RED criteria) in the order presented and if any one of the following conditions is identified, the patient shall be considered a Trauma Alert patient: A. Airway: The patient requires active airway assistance beyond the administration of oxygen or has a respiratory rate of less than 10 or greater than 29 breaths per minute. 1. Drowning or near drowning patients. 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 or GSW to the head, neck, torso orextremity; 4. chest wall instability or deformity (suspected flail chest); 5. crushed, degloved, mangled or pulseless extremity. 6. dislocations of the hip, knee orankle. Superficial wounds where the depth of the wound can be determined are excluded. E. Longbone Fracture/ Skeletal: The patient reveals signs or symptoms of two or more Iongbone fracture sites. Long bone fracture sites are defined as the (1) shaft of the humerus, (2) radius and ulna, (3) shaft of the femur, (4) tibia and fibula. F. Mechanism of Injury: Patients exhibiting any of the following are considered Trauma Alerts: 1. Head trauma in patients on Coumadin (warfarin) or other blood thinners; 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 blunttrauma. 10-9 594 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS 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 seven 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; 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: i. The patient has been ejected or thrown from an automobile, motorcycle or golf cart; ii. The patient has been ejected from a horse (with or without loss of consciousness) with suspected anatomical injury; iii. 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); iv. There is a traumatic death in the same passenger compartment of the motor vehicle; v. 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; vi. Vehicle telemetry data consistent with high risk of injury (vehicle telemetry data, when available, collected at the time of the crash and relayed to dispatch to assist in predicting serious injury); vii. Falls from 10 feet or more; viii. Pedestrians or bicyclists that are struck, thrown, or run over by motorized vehicles traveling at speeds greater than or equal 20 miles per hour; ix. Motorcycle, golf cart or ATV crash at speeds greater than 20 miles perhour; x. 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 aTrauma 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. 10-9 595 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS Monroe County Fire Rescue Adult Trauma Scorecard Methodology The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological characteristics of a person sixteen(16)years of age or older for the presence of at least one of the following three(3)criteria to determine whether to transport as a Trauma Alert. These three criteria are to be applied in the order listed, and once any one criterion is met that identifies the patient as a Trauma Alert,no further assessment is required to determine the transport destination: 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). 1"IIVIILII') BLUE AllIIRV`°AY SAC"I IVI f114"WVAY ASS 131ANGl;,h[n 141":d ,:1C1[n >29li,!'SI'''f1/I 1)I'4OVVINIING 014IN1 AI'41) 4OVVINIING "" '" " PATVENTS WITH RENAL FAVLURE ON DVALYSVS �t.� _. Q3 .., Cn r .�, ) .... , [,i S� I irri�rr c, Sk":11))IIN ""'A 11 N 1 CV 1'4 35 Y A4„3 111SABIIi_.II1hY CC^, :13 o1 I1Id1 ^,I!IINCI 01: 1::AIdAI Y^,Ir3,o1 3l I3::11CI()IN 01'::r HEAD VNJURY WITH LASS OF CONSCVOUSNESS, N,I'''IINAI Coi::41)IINlfl IIeY[n 1 033 01: S1:::N;A 1 ION AMNESVA or NEW ALTERED MENTAL STATUS S011=1I 11-1ISSU,)Ilx. 21`01::1 3"I)I!!ICIdI dlNi 1015%olV1101d1 IIS3A SOFT TOSSUE LOSS2 AVI'111A11ONAI 01::::1AI3()VI I111 VVI413"I oiAINIVL.1i,' ANY I'I INI 'I"'I':dA'I"'IING 11%fl II dY '10 1 11 AID,INI CIV I01::^r(101::::1 X"I l dl f1/11'I"'Y'` I)1„310CAII(;1\401: 111°' IVINI 1.1314AINIVI I,; CI 11 3'1"'VVAI1 IIN^,1A1:311 11Y of I::)I 01':1f1/11"I'Y(I 1 All CI 11 3 1") CI':::111^,111 ::),V1AING1 ::) I)I GI.OVl 1)[n 1:::'I, 1 31: 1 1::::::3 3 X"I dl:.f1/11"I"'Y _.OIING BOINII i. 1 :ZAC I II d1'.01: 1 Wo oI V11 l dl!'.I.01v4G 1 S 1NI �,r^ SVNGLE LONG BONE FX SVTE DUE TO MVC° =11LACII )11 II SKll=,:i_.11E.11 Ai_.^ SVNGLE LONG BONE FX VN PT ON HVGH RUSK ANTOCOAGULANTS s AGlli! 55 YEARS OR OLDER MECHANISM EJECTON FROM AUTOMOBVLE,MOTORCYCLE,GOLF 0II= IIII%!UII=L1( VI 141 ACIA1.,11%fl„II4Y/I I4AC I I I141 ;3 VV1 I I I O I"'I', IN I"'IA1.. CART or HORSE A11:WVAY C13f1/II'14 f1/I I;31,; BLUNT HEAD,CHEST,OR ABDOWNAL TRAUMA VN C 114OCI„I I ION 01:::,,4 I IG1°I"I"'INIING INJ II'4Y VVY I I I..,033 01' PATVENTS ON HVGH RUSK ANTOCOAGULANTS6 C13INSCI(II1;3INI AA 01:::,,4 V13113I 1::::::SIGNS 01 INJ II'4Y DEATH VN SAME PASSENGER COMPARTMENT 1411,.,1„IIN 1 AI:3I::)0 V1IINAI of CI 11 3"1""'111AI,.JV1A IIN I'A I IIi,IIN 1 V0 I I 111 3 101:dY 01:"" I'A11AIY;1;(I'AI':::1AI'1 I::GIA of Q IAI:)I':411'1 I::GIA) VNTRUSVON VNCLUDVNG ROOF>12 VNCHES OCCUPANT SVTE;>18 VNCHES ANY SVTE UNTO THE PASSENGER 111.CINAINCY >3C',)�NI; VV111 1 A1i,!'SI)� f�/ANAL. I:'AIN AND 1:31 .IN"I"' COMPARTMENT I"'I'"4Al,.lVA FALL 10 FT or MORE AUTO VS.PEDESTRVAN/BVCYCVST THROWN,RUN OVER or WVTH WPACT GREATER THAN 20 MPH MOTORCYCYLE,GOLF CART OR ATV CRASH>20rnph VEHVCLE TELEMETRY DATA CONSVSTENT WVTH HVGH RUSK OF VNJURY,VF AVAVLABLES �I al:)=any one(1)-transport as a trauma alert; BLUE=any two(2)-transport as a trauma alert. 1. Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Crushed, Major de-gloving injures,mangled extremity or deep flap avulsion(>5 in.) 3. Excluding superficial wounds in which the depth of the wound can be determined. 4. Long bone fracture sites are defined as the(1)shaft of the humerus, (2)radius and ulna, (3)femur,(4)tibia and fibula. 5. Vehicle Telemetry Data(if/when available)may be relayed to dispatch and can assist in predicting potential serious injuries from the data collected at the time of the crash. 6. See attached list of Anticoagulants with High Risk of Bleeding 10-9 596 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS PEDIATRIC TRAUMA SCORECARD METHODOLOGY 1. Each EMS provider shall ensure that upon arrival at the location of an incident, the EMT or paramedic shall assess the pediatric trauma patient by evaluating the patient's status for each of the following components: Size, Airway, Circulation, Disability, Soft Tissue, Long Bone Fracture/Skeletal, and Mechanism of Injury. In assessing the pediatric patient, the criteria for each of the components in (2) and (3) of this section shall be used to determine the transport destination for pediatric trauma patients. 2. The EMT or paramedic shall assess all pediatric trauma patients using the following RED criteria and if any of the following conditions are identified, the patient shall be considered a pediatric Trauma Alert patient: A. Airway: If the patient requires active airway assistance including manual jaw thrust, continuous suctioning, or use of other adjuncts to assist ventilator efforts, has a respiratory rate of < 20 in an infant less than one year of age, or a respiratory rate of <10 in children age 1-15 years old. 1. All drowning or near drowning patients. 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. The patient exhibits a dislocation of the hip, knee orankle. If there is any penetrating injury or GSW to the head, neck, torso or extremity. (Superficial wounds where the depth of the wound can easily be determined are excluded from this criteria head and extremity only), E. Long Bone Fracture/Skeletal: There is evidence of an open long bone fracture or multiple fracture sites. 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. F. Mechanism of Injury: Patients exhibiting any of the following criteria will be Trauma Alerts: i. Electrocution or lightning injury with loss of consciousness or visible signs of injury; ii. Severe facial injury with airway compromise or potential airway compromise; iii. Ejection from automobile, motorcycle, ATV, golf cart or horse with anatomic injury; iv. Blunt abdominal trauma or chest trauma in patient with history of paralysis (paraplegia or quadriplegia) v. 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). vi. Auto versus pedestrian or bicyclist thrown, run over, orimpact resulting from speeds more than 20 mph. 10-9 597 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS 3. Should the pediatric patient not be identified as a Trauma Alert using the RED criteria listed in (2) of this section, the trauma patient shall be further assessed using the BLUE criteria listed in this section and shall be considered a Trauma Alert patient when a condition is identified from any two of the five 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 dislocation of the upper extremity, excluding fingers. 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: i. Death in the same passenger compartment, ii. 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, iii. Vehicle telemetry data consistent with high risk of injury, iv. 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 herjudgment, 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. 10-9 598 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS Monroe County Fire Rescue 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). �I I:)=any one(1)-transport as a trauma alert; BLUE=any two(2)-transport as a trauma alert. 3111I) BLUE SIZE WEIGHT<22 Kg AIRWAY AC"I"'IVI',;;;;A11'4WAY ANNIS"1AINC1,1I'41 NI'I4A"11,; 3 C;I I IN I IN I:""A IN"I"' 1 Y 1:,,,4 4 3k kA 11:::::: ':1) 1 N C I'"111.. ) 4:::N 1 Y4 CIIRCIJr-All11ON AIIN"I"'of N(rlN II::1AI I'A1 SI 1::::CAl d01111(,I I !f//I()11AI CAROTID or FEMORAL PULSES PALPABLE,BUT THE '< RADIAL OR PEDAL PULSE NOT PALPABLE or SBP<90-u c, mmHg DIdrABILI'"Y AI 11 I::::il 17IVIII:::N"IAI 31A"1"'I I32(i, 1:'I::::i1 31: INCIi,:.01: I Al:::1A1 Y31 3 of AMNESIA or LOSS OF CONSCIOUSNESS SI ISI'ICIt rlN 011°'31'11NAI C01::d[:)IINJ 1::I Y[n 1..033 01 311 INSA I ION HOC=1 ''ISSUE IVIIAJ II:4 N( 1: 1 '11331II 1)13141II'II(:N IVIIAJ MI'4 I)1! UPPER EXTREMITY DISLOCATION,EXCLUDING FINGERS GI.OV11NG 11N%fl 1:�::dY,[rr f//IAJ r1 d AVl..11.sioiN or si 11N S 20oi"301:31 111NG 10 -101% 11:33A ANY I'I INI 11:1A"PIING;11N%�ll.,I1dY 01:::1 GSW Io fhio III AI:),IN II!.CIN, 10 11 3 r;;r rN l 1 L::X"I"'I d l.a f1/I I"I S AIVIII'I,.l"IAII('N A 1 01dA13( Vl 11 11::::::WId131"'oi AININ11i,: I)131.0CA I I ;/IN 01: 11 11:::::: 1°°III' ININ1 1::::::014 AININI,..I LONG 01'Ii,:IN 1 0 N G IS(;Nl I 1:1AC I I IId1!.3[)i f//II II 111:':'1 Ii,:. SINGLE LONG BONES FRACTURE SITE4 or DISLOCATION ONf.: dAC"I I II d1 311I:, 3 of IVIII,,,,II. I11'1 I ::)131 0CA"I"'It rlN 3 111 3 F RAC;:';"'1"U R E IVIf C1-fA NI1SIVl OF 1 C"I"I dl ICI I I'I(DIN 01:1 I IGI I'I"'INIING S 11 d K1:::.W1 I I I 1 rN,��3 01:::' EJECTION(PARTIAL or COMPLETE)FROM IINJURY CON;SCK III INI,;; , 01::,,,4 V131151 1::::::SIGINN 01' IINJI II'4Y AUTOMOBILE DEATH IN SAME PASSENGER NI VI.I'41 ACIA1 11N fl II'4Y W11I I A11'4WAY COf1/II'I4r f1/II,SI,; COMPARTMENT NI,."I dA'I"'IING 11N fl II:dY"10 11 11:::1iiX 1 1Y A I [n A1i:3(rVl I 1 11!'ii ANY SITE INTO THE PASSENGER COMPARTMENT KIN 1::::::1: VEHICLE TELEMETRY DATA CONSISTENT WITH HIGH RISK OF 1 I I,.,IIN"1 AI S1DOV IINAI of CI 11 S 1 111 MIA IN I'A 1 II:.IN"1"'W1 I I W11AL.YSI;(I''AI dAl'I I!:GIA of C'll AlIDI d11'I I::GIA) FALL>10 FT OR 2-3 TIMES THE HEIGHT OF THE CHILD I SI I,.,IIN"1' 1 II AI:),CI 11 S 1 A1:31',)OV IINAI 111A1,,,,1IVIIA IN I::11"'W11"'I II DIN(1141)I 14 01::, 01\4 CO3 IVIIAIIDIIN/AIN'IICOACl.,lI AN1,S W1II I I IIGI II 1 I )IING8 AU 1"r,N V^r I'I I)I!!I^r 11 dlAlN/I!ISICYCI ,r"1"' 11 II dC�3WlN I dl„IIN C„Vl 11[��' A141.A"1 14 I I IAN 20 IVIII'I I ti!I C"I"101v4 1:::::I::0 IVII AI 110,A I V G01.1 CA11"1"'01:d I I I d31: W1 I"'h..1 1 N 1. Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Altered mental states include drowsiness,lethargy,inability to follow commands,unresponsiveness to voice,totally unresponsive. 3. Long bone fracture sites are defined as the(1)shaft of the humerus, (2)radius and ulna,(3)femur,(4)tibia and fibula. 4. Long bone fractures do not include isolated wrist or anklefractures. 5. Includes major de-gloving injury. 6. Excluding superficial wounds where the depth of the wound can bedetermined. 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. s. See list of Anticoagulants with High Risk of Bleeding. 10-9 599 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS V. TRANSPORT DESTINATION CRITERIA 64J-2.002 F.A.C. 1. There are no state approved trauma centers in Monroe County. 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 Monroe County Fire Rescue has an agreement with the Monroe County Sheriff for the use of a rotor wing aircraft "TRAUMA STAR" for use in cr i t i ca I medical and TRAUMA ALERT patients in Monroe County. TRAUMA STAR is a county supported air Ambulance based in Marathon or Key West and will respond, when called to the trauma scene or local hospital to transport TRAUMA ALERT patients to a State of Florida, Department of Health approved trauma center as noted in these "Trauma Transport Protocols (TTP). a No patient shall be transported from the scene via air transport without appropriate immobilization, a secure airway allowing for adequate ventilation, and established IWO access. Inability to secure an airway is a contraindication to airtransport. 4. Trauma patients in full cardiac arrest (trauma code) on the scene do not quality as a Trauma Alert and should be taken by ground ALS to the nearest Hospital. 5. 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. 6. All TRAUMA ALERT patient air transport run reports will be forwarded to the MCFR Battalion Chief of EMS and Medical Director within 72 hours for QA review. 7. A hand written "Patient Care Field Report" containing information pertinent to the patient's identification, patient assessment and care given will be provided by the EMS ground crew to accompany all Trauma patients transported by Trauma Star. A final ePCR report must then be sent to the receiving Trauma Center as soon as completed, or within 24 hours of the incident. VI. EMERGENCY INTER-FACILITY TRANSFER OF TRAUMA PATIENTS As previously noted, there are no state approved trauma centers in Monroe County. On rare occasion and when air transport is not available, 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 to the trauma center. Should ground transport of the patient be necessary, supplemental personnel, such as medical or nursing staff, respiratory therapy staff, etc. may be necessary to assist the MCFR Rescue crew for optimal patient care. The transferring hospital will coordinate the necessary personnel to accompany the Fire Rescue ground transport personnel when needed. =0-9600 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS VII. APPROVED TRAUMA CENTERS AND INITIAL RECEIVING HOSPITALS Approved Trauma Centers and Pediatric Trauma Referral Centers 1. Level 1: Ryder Trauma Center at University of Miami/Jackson Memorial Hospital (Adult and Pediatric trauma care) 2. Level 1: Kendall Regional Medical Center (Adult and Pediatric trauma care) 3. Level II: Ryder Trauma Center at Jackson South Medical Center (Adult and Pediatric trauma care) 4. Nicklaus Children's Hospital (Pediatric traumacare only) Receivina Facilities 1. Lower Keys: Lower Keys Medical Center, Stock Island 2. Middle Keys: Fishermen's Hospital, Marathon 3. Upper Keys: Mariner's Hospital, Tavernier VIII. DISTRIBUTION OF TRAUMA TRANSPORT POLICY The SATC, SAPTC, and receiving facilities to which Monroe County Fire Rescue routinely transports patients have been provided with a copy of the criteria which are used to determine trauma transport destinations. IX. TRAUMA TRANSPORT PROTOCOLS MEDICAL DIRECTOR APPROVAL 64J-2.003 These protocols have been submitted by Monroe County Emergency Medical Services and have the approval of the agency Medical Director, Sandra Schwemmer, D.O., FACOEP-D, FACEP. 10-9 601 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS ANTICOAGULANT LIST High Risk of Bleeding: Trade Names: Generic names: Aggrenox (ASA+dipyridamole) Anagrelide(Agrylin) Agrylin (anagrelide) Apixaban (Eliquis) Brilinta (ticagrelor) Cilostazol(Pletal) Coumadin (warfarin) Clopidogrel (Plavix) Effient (prasugrel) Dabigatran (Pradaxa) Eliquis (apixaban) Dipyridamole(Persantine) Jantoven (warfarin) Dipyridamole +ASA (Aggrenox) Plavix (clopidogrel) Edoxaban (Savaysa) Persantine (dipyridamole) Pentoxifylline(Trental) Pletal (cilostazol) Prasugrel (Effient) Pradaxa (dabigatran) Rivaroxaban (Xarelto) Savaysa (Edoxaban) Ticagrelor (Brilinta) Ticlid (ticlopidine) Ticlopidine (Ticlid) Trental (pentoxifylline) Vorapaxar (Zontivity) Xarelto (rivaroxaban) Warfarin (Coumadin, Jantoven) Zontivity (vorapaxar) Injectables: Activase (alteplase) Aggrastat(tirofiban) Angiomax(bivalirudin) Argatroban Arixtra (fondaparinux) Fragmin(dalteparin) Heparin Innohep (tinzaparin) Integrilin (eptifibatide) Iprivask(desirudin) Lovenox(enoxaparin) Reopro (abciximab) Streptokinase Tenecteplase (TNKase) Urokinase April 2017 10-9 602 MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS TRAUMA TRANSPORT PROTOCOLS MEDICAL DIRECTOR APPROVAL I, Sandra Schwemmer, D.O., Pre-hospital Medical Director for Monroe County Fire Rescue certify to the Department of Health, Bureau of Emergency Medical Services that I have reviewed and approve the Trauma Transport Protocols, dated March 1, 2021. r s 3/1/2021 Sandra Schwemmer, D.O, FACOEP-D, FACEP Date FL OS 4022 10-9 603 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Adenosine Triphosphate (Adenocard®) ACTUIN S: 4 nV i,p(b fVY AMC 111 0;�14 &Mia �" Adenosine exerts its effects by decreasing conduction through the AV Adermode.The half-life of Adenocard is less than 10 seconds.Thus, its effects, desired and undesired, are self-limited. IND_I_ ATIONS Adenocard is indicated for paroxysmal supraventricular tachycardia (PSVT), For RapW Bolus For Rapid Bolus Intravmous Use including that associated with accessory bypass tracts (Wolf-Parkinson- inrr'avencol Use 00 White Syndrome). '„�ri7V,g��°mtuia,arc 1 mo(M'oe qu'd P"N a.nr°ap CONT I"A N ICAT]I �N :Al rrllia and 11,*'c v`tlr��rttl�oN s��rckyr,y Ps",„r.Y Adenocard (exce.p... If paVl'we � slu ��an dicated in second or third degree AV block and sick sinus s t in patients with a functioning artificial pacemaker), and known hypersensitivity to Adenosine. WA ll\1 l\1 G S ........................................................ 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 r ar�i,=;y,nr�d,o ui�,xis Gt�^P��d■ varying degrees of AV block) and generally last only a few seconds without intervention. The effects of Adenosine are antagonized by methylxanthines such as caffeine and theophylline.Thus, larger doses of Adenosine may be required for Adenosine to be effective.Adenosine effects are potentiated by dipyridamole(Persantine).Thus,smaller doses of Adenosine may be effective.Adenosine may produce bronchoconstriction in patients with asthma. P® 5J..B. .E AI .VkRSE REACTI®NS ANIP S1D1 EI=I=ECTS: ....................................................................................................................................................................................................................................... Cardiovascular: Facial flushing, headache, and rarely: sweating, palpitations, chest pain, and hypotension. Respiratory: Shortness of breath, chest pressure, and rarely: hyperventilating, metallic taste, tightness in throat and head pressure. CNS: Light headedness and rarely:dizziness, blurred vision,tingling and numbness in extremities,apprehension. DOSAGE: AdUIlt dosage„ 6 mg rapid IVP, immediately followed by 20 ml NS flush. Repeat in 2 minutes at 12 mg IVP followed by 20 ml NS flush PRN. ll'edoafidc dosage 0.1 mg/kg(maximum 6 mg) rapid IVP immediately followed by 5 ml NS flush. Repeat in 2 minutes, at 0.2 mg/kg(maximum 12 mg) rapid IVP followed by 5 ml NS flush PRN. Time/Action Prof le: Onset: Pealk Duration IV: Immediate Unknown 1-2 minutes Adenosine Triphosphate (Adenocard®) 11 -1 Dr. Sandra Schwemmer, D.O. 604 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Albuterol (Proventil@, Ventolin@) .,,,, mmsw,mmmmm /j»w;r ,l,^lyg{7„�,�d w'�,,1�"""'g7"i�'""°'�t"P'"��SyHrk�r✓�rr��(iy;" t a6�ro�Y(� aY ag AC"II IONS: Albuterol is primarily a beta-2 sympathomimetic and as such produces bronchodilation. Because of its greater specificity for beta-2 adrenergic receptors it produces fewer cardiovascular side effects and more prolonged bronchodilation than isoproterenol. IINDICA°I" aNS: Albuterol inhaler is indicated for relief of bronchospasm in patients with reversible obstructive airway disease including asthma, and COPD. COIII "1""III' IIII I IIIC 'l II 0 N S: ................................................................................................................... Albuterol is contraindicated in patients with a history of hypersensitivity. 1AVA IIC I`YYl III I`YYl(„3 m°1ii: .............................................................. 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 ADV1R5E R ACwI"IONS AND SIDE E F F1..C.".[..S..:.. Cardiovascular:Tachycardia, hypertension, and angina. CNS: Nervousness, tremor, headache, dizziness, and insomnia. GI: Drying of oropharynx, nausea, and vomiting, unusual taste. DOSAGE: Adult dosage., 2.5 mg of Albuterol in 3ml of NS to nebulizer and flow oxygen 8 liters/min. Child dosage: If> 1 year or> 10 kg: 2.5 mg of Albuterol in 3 ml of NS (0.083%) to nebulizer and flow oxygen 6 Ipm If< 1 year or< 10 kg: 1.25 mg of Albuterol in 1.5ml of NS (0.083%) to nebulizer and flow oxygen 3 Ipm (half of 2.5 mg).Treatment will be delivered over approx. 5-15 mins. Time/Action (Profile: Onset Desk Duration Inhaled 5-15 minutes 60-90 minutes 3-6 hours Albuterol (ProventilO, Ventolin0) 11 -2 Dr. Sandra Schwemmer, D.O. 605 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Amiodarone (NexteroneTM) Amiodarone suppresses recurrent VF, prolongs intranodal NE conduction and refractoriness, negative inotropic effect. 1 1urEil_-1 Ventricular Fibrillation Pulseless VT • PVC's greater than (>) 12 min Ventricular Tachycardias (Wide and Narrow) with a pulse CII FRAI N Q ICAI'l11 NS ����ab.1 Any known allergy Cardiogenic Shock • Sinus Bradycardia 2 and 3rd degree AV blocks n PO55 ..Bl J AD.V..E R51 &EAL.TIONS AND SJ Q..E C15.11 5. None in Ventricular fibrillation. DOSAGE: Adult dosage: Pulseless Arrest: 300 mg IV/10 May repeat with 150 mg IV/ 10 With Pulses: Infusion loading dose: 150 mg IV (150 mg in 100cc NS) infused on a macro drip over 10 mins1.5gtts/sec. Maintenance Infusion: 1mg/min Pulseless Arrest: 5mg/kg IV/10 may be repeated once. No single dose greater than 300 mg. (15mg/kg max) .Time/Action l'rol"ile: Onset Peak Duration IV/10: Unknown Unknown Unknown Amiodarone (NexteroneTM) 11 -3 Dr. Sandra Schwemmer, D.O. 606 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Aspirin (Bayer, ° Bufferin°) AC IFIGINS: 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 / „ 1 mortality from acute myocardial infarction. i EN ICAn N : Aspirin is indicated in the Acute Coronary Syndrome setting to prevent further clotting. w,«� u rm�ruu mraa�Gmn m �t14 CUM''I IIXI N DII CAI""IIIOIIICSm .................................................................................................................... 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 ADV1R5E R ..ACwI"IONS AND SIDE E F F1..C.".[..S..:.. GI: Nausea, vomiting, heartburn, and stomach pain. OTIC:Tinnitus. Hypersensitivity: Bronchospasm, tightness in chest, angioedema, urticaria, and anaphylaxis. DOSAGE: Adult dosage., 324 mg(4) 81mg chewable tablets for Acute Coronary Syndromes Time/Action (Profile: Onset Desk Duration (Oral) PO: 5-30 minutes 1-3 hours 3-6 hours Aspirin (Bayer, ® Bufferin®) 11 -4 Dr. Sandra Schwemmer, D.O. 607 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Atropine Sulfate as Cardiac Agent I� ,'' f:�'uu i i i uuuuuumiuuum i m mii' � AC1101NS: Atropine is a potent anticholinergic (parasympathetic blocker, parasympatholytic) that reduces vagal tone and thus increases automatically the SA node and increases A-V conduction. 1INDICA"1"pNS: • Sinus Bradycardia accompanied by hemodynamic compromise, (i.e. hypotension, confusion, frequent PVC's, pale, cold, clammy skin). • In children (< 1 year) bradycardia of less than 60 beats/minute should be treated if symptomatic even if BP is normal. C0111 ""1""III IIII II' IIIC 'l1"110111CS: .................................................................................................................... None in emergency situations 1AV ,IIC3I'�I`IYl III l`YYl(3 S: .............................................................. 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 RE.AC"I"IONS AND SIDE C"I"S: ....................................................................................................................................................................................................................................................................... CNS: Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, and headache. Cardiovascular: Increase heart rate, may worsen ischemia or increase area of infarction, ventricular fibrillation, ventricular tachycardia, angina and flushing of skin. GI: Dry mouth and difficulty swallowing. Other: Urinary retention. Can worsen pre-existing glaucoma. DOSAGE: Adult dosage., Bradycardia: 0.5-1 mg IV/10, may repeat every 3-5 minutes until improved or total of 2mg is reached. 1:'Iledi4tii,io::: dosage: 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/Action (Profile: Onset Peak Duration IV/10: Unknown Unknown Unknown Atropine Sulfate as Cardiac Agent 11 -5 Dr. Sandra Schwemmer, D.O. 608 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Atropine Sulfate as Antidote for Poisoning ,,,/��� li a u91�°iuul���u�l li li�uuu uiu�iuluuu�il��Vi VI� u��illll At II I O IN S Atropine is a potent parasympatholytic that binds to acetylcholine receptors thus diminishing the actions of acetylcholine. IINI ICA°I"IqNS: 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. COIII "I""III'° IIIIII �' IIIC "I""IIIOIIISm .................................................................................................................... None when used in the management of severe organophosphate poisoning. %AA/`A IIC�IJI"YI III�I"YI(„3 m°1ii: .............................................................. 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 REA w1"IONS AND SIDE E F F1..C.".[..S..:.. 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 dosage., 1 mg IV/10, repeat every 5-10 minutes until atropinization occurs.(max total dose 20mg) F'I"edi4tii,Tk dosage: 0.05 mg/kg (maximum 3 mg) IV/IO, repeat every 5-10 minutes until atropinization occurs. Time/Action IPurofHe: Onset Peak Duration Atropine Sulfate as Antidote for Poisoning 11 -6 Dr. Sandra Schwemmer, D.O. 609 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Calcium Chloride 10% A open 11C 76329-83Qa-� <L �l. Lu9r-Ina'Wrld Syringe 1�, �� C a I C I��I UM h 10r I d e Injection, USP 1 g/10 mL (100 mg/mL) (1.4 rnLq/mL) Single use,do not reuse or resterfllze. Rx only FOR SLOW INTRAVENOUS USE 10 rnL Single pose LITER-JETTm LUER-LOCK Prefillerl Syringe At°AFI GINS. i 1 Calcium chloride increases the force of myocardial contraction; calcium may either increase or decrease systemic vascular resistance. In normal hearts, calcium's positive inotropic and vasoconstricting effects produce a predictable rise in systemic arterial pressure. I IN I ICA"I"nNS: Calcium chloride is indicated during resuscitation for the treatment of hypocalcaemia and calcium channel blocker toxicity (i.e. Verapamil or Cardizem overdose) and Magnesium Sulfate overdose. It also protects the heart from hyperkalemia as may occur in patients with end-stage renal disease. COIII "I""III' IIIIII �' IIIC "I""Il1011lSm .................................................................................................................... Cardiopulmonary arrest not associated with calcium channel blocker toxicity, hypocalcaemia, or hyperkalemia. %,A/A IIC3I'�I`YYI III�I`YYI 1'„3 m°1ii t ........................ ............................................. 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 REAC"I"IONS AND SIDE E EC"I"Sn If the heart is beating, rapid administration of calcium can produce slowing of cardiac rate. DOSAGE Adult dosage., For hypotension following administration of calcium channel blockers (i.e. Cardizem, Verapamil): 4mg/kg IV slowly If patient is taking digitalis, 2 mg/kg IV slowly. Repeat every 10 minutes PRN. For calcium channel blocker overdose and hyperkalemia: 8-16 mg/kg IV slowly Asystole/PEA (if on calcium channel blockers) 1gm IVP Time/Action IProflle: Onset Desk Duration IV/IO: Immediate Immediate 2-5 hours Calcium Chloride 10% 11 -7 Dr. Sandra Schwemmer, D.O. 610 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Cyanokit® At"IFIONS: Hydroxocobalamin (CYANOKIT°) is an antidote to cyanide. It removes cyanide directly from the blood without converting any of the hemoglobin and therefore does not interfere with oxygen transport. It combines with the cyanide to form cyanocobalamin which is a derivative of vitamin B-12. Both the Hydroxocobalamin and B-12 are harmlessly excreted in urine. IINDICA°nqNS: 0 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 DO NOT RELY ON PULSE OXIMETRY FOR ACCURATE READINGS .w� .., .III ......IIC ........IILIII ..1.IIL. .......CAI`„Ill .,lll .S..m. None %AA/A III°IJIYi III I`YY(o S: Do not use any other medications in the same IV line: There are several drugs and blood products that are incompatible with Cyanokit, thus Cyanokit requires a separate intravenous line for administration. PROCEDURE for Cyanokit Administration: (See next page for additional information Each Cyanokit contains: (1) Vial (5 gm of (HYDRO OCABALAII MIN) (1) Intravenous administration set (1) Transfer spikes Reconstitute vial of the Cyanokit0)with 200 ml of N,S via the transfer spike that is provided. Do not remove the vial from the box it is contained in, because it will serve as a hanger for the medication. Gently rock the vial back and forth for 30 seconds to allow for mixing. Shaking should be avoided, as it will cause the medication to foam. Insert a macro-drip infusion set (provided) and drain as normal. DOSAGE: Infuse the vial over15 minutes. If the patient is critical use a faster rate and titrate to effect. Multi-dose kits are carried in the Battalion Chiefs vehicle Cyanokit® 11 -8 Dr. Sandra Schwemmer, D.O. 611 MONROE COUNTY FIRE RESCUE DRUG FORMULARY u 1. One 250 ml g lass vial � nP �� III IIIIII uumr r containing 5g of lyophilized hydroxocobalamin for injection nn 2. One sterile transfer spike r 3. One sterile intravenous if � infusion set 4. One quick use reference /a guide � o 5. One package insert p 10 For Intravenous Use To 15e reconstituted with 2,0,0 miL of 0.9%Sodium Chloride Injection .... .................................................. D�iluent Not Included Complete Starting Dose. 5 grams I.Reconstitute d r' Place time vial in an Upright position Add 2010 mt.of 0,9%Sodium Chloride Injection to the vial using the transfer spike, Fill to the I'une� 2.Mix !y ' The veal should be repeatedly inverted or rocked not shaken,for at least 50 sec,ornds prior to infusion. r r I fill to 3.Illntuuse Vial us ine Use vented intravenous tuUnig,hang and infuse over 115 minutes., One 5 g vial is a complete starting dose i. 0 See Package Insert for alternate diluents,incourupatibilitues with other drugs and full prescribing information, For more information visit www.cyan(ok t,com or call 1-800-438-1965MERIDIAN c uua a�.m See reversefor additional irnformahou W1f I oGdwL�ECHNOL001Es" .iic fk u.�. F6*~2���351 �VfJ 0-01 Cyanokit® 11 -8 Dr. Sandra Schwemmer, D.O. 612 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Dextrose 10 % and 5% AC"IFIONS: A monosaccharide, which provides calories for metabolic needs, spare body proteins and loss of 10%1"111 XT x electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. am unmra iu�ruulrrr rumrv�"vamuu wvca a�,i�,�'r TTP�%IYtaiWIIXIWwI IVII01 IJ�tlMI tlA'Y1YM�'III °' �y �pmp.M1Y'M!.IIV�✓!111AIV4��NII1N'31➢MPP i"'�^�➢% �ry�r I N 1)1 A.r i p� N S: Wuu Hypoglycemia 4",.V Coma of unknown origin. "1P REL ;)`IIVE COI' TR IINDII A"i`IIONS: �� im��o��m ...... Intracranial or intra-spinal hemorrhage (in a patient with normal BGL) Blood glucose Level > 60 mg/dl. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: • Cardiovascular:Thrombosis Sclerosing if given in peripheral vein • Local:Tissue irritation or necrosis if infiltrates. • Others: Acidosis, alkalosis, hyperglycemia, and hypokalemia. Diabetes Insipidus: Is the inadequate secretion or resistance of the kidney to the action of the antidiuretic hormone (ADH). Major S/S are polydipsia (thirst) and polyuria (frequent urination). Diabetes Mellitus Type I: Insulin-dependent. Usually occurs before the age of 30.The patient may need Insulin injections and dietary modifications to control blood sugar levels. Cells in the pancreas that produce Insulin are damaged —so they may produce little or no insulin. Diabetes Mellitus Type II: Non-insulin-dependent. Usually occurs in obese adults over the age of 40. The cells in the pancreas are able to produce insulin,just not enough. DOSAGE: Adult/Adolescent >8 y/o: (> 30 kg) 100 ml of 10% solution; IV/IO. OR 250ml of 5%Solution F'�Il adl4tii,Tloc: (< 30 kg) 2.5ml/kg slow IWIO of 10% solution. OR 6ml/Kg of 5%Solution I\JeyvA�tllao ii,' (< 5 kg or< 1 month old) 2.5 ml/kg IWIO of 10% solution OR 6ml/kg of 5% Solution Time/Action Profile: Onset Desk Duration IV/IO: < 1 minute Depends on degree of hypoglycemia Dextrose 10% and 5% (D10 or D5) 11 ::]613 Dr. Sandra Schwemmer, D.O. MONROE COUNTY FIRE RESCUE DRUG FORMULARY DILUTE D501NTO D10 If using 1350 and you want D10, for every 1 part of 1350, use 4 parts of NS. (1ml of 1350, 4ml of NS.) D50% (25g) NORMAL SALINE TOTAL D10 SOML 10ML 40ML 50ML 20ML 80ML 100ML (DRAW 20ML OUT F I OOCC NS , AND REPLACE I Iw1 20ML OF 50ML 200ML 250ML (DRAW 50ML OUT F 250CC NS , AND REPLACE I Iw1 50ML OF Dextrose 10% and 5% (1310 or 135) 11 ::]614 Dr. Sandra Schwemmer, D.O. MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Diphenhydramine Hydrochloride (Benadryl°) AC III Oi S: 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. iNMCA;TMS: • Allergy symptoms, anaphylaxis • Sedation of violent patient • Dystonic reactions from phenothiazine overdose (i.e. Haldol, Compazine,Thorazine, and Stelazine) CO IP'�"III"III'tA III IP'�IIC'. III CA"III"III O IP'�S: ........................................................................................................... Diphenhydramine is not to be used in newborn or premature infants. Diphenhydramine is not to be used in patients with acute asthma attack WXI''il V III V(2'�:�� ........................................................... 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 POSSIRt,P ADVPRSP RPACTIONS AND SIDE EEEECTS: .................................................................................................................................................................................................................................................. CNS: Drowsiness, confusion, insomnia, headache and vertigo (especially in the elderly). Cardiovascular: Palpitations, tachycardia, PVC's and hypotension. Respiratory:Thickening of bronchial secretions,tightness of the chest, wheezing and nasal stuffiness. GI: Nausea, vomiting, diarrhea, dry mouth, and constipation. GU: Dysuria and urinary retention. GAGE: Adult: 25-50 mg IWICI OR 50 mg deep IM Pediatric: 1 mg/kg IWICI or IM (maximum 25 mg) Time/Action Proffle: Onset Beak Duration IV/IO: Rapid Unknown 4-8 hours IM: 20-30 minutes 1-4 hours 4-8 hours Diphenhydramine Hydrochloride (Benadryl®) Dr. Sandra Schwemmer, D.O. 11 -10 s1 5 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Dopamine Hydrochloride (Intropin°) °IPIO S: Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic receptors of the sympathetic nervous system. It exerts an inotropic effect on the myocardium resulting in an increased cardiac output. Dopamine produces less y increase in myocardial oxygen consumption than does Isoproterenol and its use is usually not associated with a tachyarrhythmia. Dopamine dilates renal and mesenteric blood vessels at low doses that may not increase heart rate or 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. VN-MCA;TVONS: To treat shock and correct hemodynamic imbalances, improve perfusion to vital ill organs and to increase cardiac output. �.M CCU WIIIFIIPtAIII IP"TIC'.A CXIII"II0'1"9S: ........................................................................................................... Dopamine should not be used in patients with pheochromocytoma or hypovolemic shock. WXI VIII V(�!& ........................................................... Do not administer Dopamine in the presence of uncorrected tachydysrhythmias or ventricular fibrillation. Do not add Dopamine to any alkaline diluents solutions since the drug is inactivated in alkaline solution. Patients who have been treated with monoamine oxidase (MAO) inhibitors will require substantially reduced dosage.MAO inhibitors include: furazolidone (Furoxone°), isocarboxazid (Marplan°), pargyline hydrochloride (Eutonyl°),pargyline hydrochloride with methyclothiazide (Eutron°), phenelzine sulfate (Nardil°), procarbazine hydrochloride (Matulane®), tranylcypromine sulfate (Parnatee) 1 E SSdBLE APvE SE REACTIONS AND SaQE EFFECTS: l Cardiovascular:Tachycardia, palpitations, angina pain, ectopic beats, and hypotension GI: Nausea and vomiting Local: Necrosis and tissue sloughing with extravasations, use a large vein to reduce this incidence Other: Piloerection, dyspnea and headache. GAGE: Adult and F)eu;Niiatari(: Pre-mixed bag Begin infusion at 5 mcg/kg/min. and titrate to effect(Maximum dose 20 mcg/kg/min.) Vial (400 mg)To yield a concentration of 1600 mcg/ml mix 400 mg of Dopamine into 250 ml of D5W. Time/Action Profirlle: Onset Beak Duration 4 minutes 10-15 minutes Continuous with infusion t I Hydrochloride H nro in® 11 -11 Dr. Sandra Schwemmer, D.O. Dopamine y � p � 616 MONROE COUNTY FIRE RESCUE DRUG FORMULARY II IIIII � I II � II III � �� III DOPAMINE 400 mg in 250 mL D5W (1600 mcg/mL) Drops per minute Patient Weight in kg: (60 gtts/mL chamber) 30 40 Sp 60 74 8p 90 lap 6 8 9 11 13 15 17 19 11 15 19 23 26 30 34 38 17 23 28 34 39 45 51 56 30 38 45 53 60 68 75 t I Hydrochloride H nro in® 11 -11 Dr. Sandra Schwemmer, D.O. Dopamine y � p � 617 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Duo-Dote TM (Atropine and Pralidoxime Chloride) Ilk �'� �11Y �1'•f � ffi nw ��ik�U �u ° ,�' �� „^ 3 f✓�✓ri "� 41 ,u ,� r, At°;1'IOII' S: • Blocks nerve agents effects and relieves airway constriction and secretions in the lungs and gastrointestinal tract. • Acts to restore normal functions at the nerve ending by removing the nerve agent and reactivating natural function IINDICA°I"IqNS: Suspected or confirmed nerve agent exposure COIII "I""III IIII II' IIIC "I""IIIOIIICSm ................................................................................................................... • Both medications in the kit should be used with caution (but not withheld) in patients with preexisting cardiac disease, HTN, or CVA history. POSS,I.B.LE A.DVE. SE .EA "I"IONS AND SIDE EFFECTS:Chest pain , exacerbation of angina, ............................................................................................................................. Myocardial infarction, Blurred vision , Headache, Drowsiness, Nausea , Tachycardia , Hypertension , Hyperventilation DOSAGE: DUODOTE TM— Each auto injector contains BOTH: Atropine 2.1 mg and Pralidoxime 600 mg Adult: For Nerve Agent Exposure (SLUDGE symptoms): Up to 3 auto injectors may be used for one patient based on signs (1-2 kits for self treatment— up to 3 for buddy treatment with severe symptoms) �("N' ti�r'IC: DuoDotes TM are not authorized for the use of children under the age of 9 years. Duo-Dote TM Dr. Sandra Schwemmer, D.O. (Atropine and Pralidoxime Chloride) 11 -12 Page 1 of 2 618 MONROE COUNTY FIRE RESCUE DRUG FORMULARY 4 eaRaA," rrAlf f"7'Y � � � u l iG hlLlTIP�Nlrhlt�tEhl�bt� l"0E111 V Ct°.II L�� m �� quwa.rflfr.•exieod1G f+ap�arfl'y�f onl �� Do udafkr a' �e o ff t� khr�G. e anTlrprdur.,llrEnl. until heady to us4. NEVER touch farume'rr Tip Noodlo End q with fiingenI I NDC I17 62001 ,m:aa a,1 2 5'C f7N'F11l rr�K ru rs Ityn Dmue�pDol Yaaam<rI terra l aiuwuraaCIN WN v Nor b aa'r N w .d:antwdi arrroa!'. rrl Ju.ua�V i�ew, ;w unit lied qr i 10'C t,rme 9(1,'R rra�aa�8m earrrcukdrP'fdtrA¢vd,awn a x al W,,,. AuraInjy!cmUll, Xpfl)fru:PVIfmr.ezu' .n'aru,rtffornfYug,ht. CCgedlkalTecIinoiogles�'n, l.. a a T m rarr; On,k BuoDlfite' (atropine and Iplral,i oxi me chioldde ilnjectiont) �Lach auato injector r'Alw ra zI narcg of atropine iirjr+o,`lon. lbr use in: tOl.a arm,Aats I C 47 n,q gtlyu 06n,211 wig It herwl,lsua k"red aarulh Sodium rr rn")w o'rid dlsk Caa,d'f howl"CV A[,tfNT& (.00 niq of prraliodmIine chkwide injnr fion fr°SUfa.lKft:fE Ftl1ISO NIINi i Mire AILTe�,rauwc LOGIES° pAhu a.ramat�wns 40 anrd n azyI awtlurahufrol 225 mg>grm dneara id I ) Die Not open the plastic porich of reran ve the I)uoDo e"` Aulufdnjertor from thii poirich manful re.afiy fol°tJse. r IMPORTANT � Do Not le=vr^ the Gra0afety Rieleas'e Iflitil re"x"ly tto lt5e" r DuoDote'gym Do Not place gfraiutr fingers(m(the Green lI lia Needle End, � AUITO-IINJECTOR upon,,arriv�aatlpn't17>e Ileedle extends raprdily from the Green t olp Needle End, � p' NI IP I I ll l 9 S t 1 7 62001 r M It'i�s okay,to inii,ect thl�ra�fltjh ctothfng� Seek medlical atten lr n imim,edlately f o4loWing Injection. f' k-- �yir t rl m ,�w�aaa a�f� i` r a Move�ulflohgeeds urea � l f a � 1 �rC ,fl�rnwiAnawuu�alr�rt/�ar"f�uia� �i� drhe midi amr,mle r thigh), G i rpull, SoN (� � y� � otrwmVard m11p,aglosi,i ;a r sr f9 ,rdu Rw�fm l°,. Vati-tlr a;waa pr pull,of Ol e of y. foof rr rrh �'d� f �a atr dua4a.Yu oNm�r r,s uuGapAg area t1f r nrw,��y arf ttkraa. 41 Ir„ar;_ arr III�hPONT T Ml SfdiN a C7uar� I IRh!u4� ttlbf�NlPs,mea>t`7maf d'ruu!toytaaagC�^,io tTua.uwi", 9 nireDurpOcAui�"Auto- AutoIny-rraafr ril Y€�i...adx¢am alfi mllue l tUmr�pcwhandplaace,ituw,youardormabrmamtUroawmpdn tl�rr�aOw eaaYa,rysml toa Y d Y, W $dT�ureipy�ua�rv��u°,:k�Yrv�n�rw�u.w�N YNrcwau^rti����Nry aaoraidGs c�R:x�uonroaavnC,d°r W'Wtit�t "�Y"yNi win"f ll�f"dr n:KrBr„^. NIr1l'�.lahl r 77ic"➢d^�PN!H flr""ICI r7N" ipt�rj�^tl hi�ID4'i'�tlljd NGo4"�tl�l'�ictSROr 10 IFJVMnds.: PR,nat Ili drrtlr dmPrnYt, an�in!turasl m...................m ......�.������������.......................�. ...... .. .... 1. Remove the DuoDoteTM from its protective pouch. 1A11 FtII�DI) 1k11 2. Hold the unit in your dominant hand like a pencil with the Green Tip (needle end) pointing down. ,a 3. With your other hand remove the Gray Safety °'` � ��� Release. The DuoDoteTm Auto-Injector is now ready to be administered. 4. Grasp the unit like a pen and position the green tip of the on the DuoDoteTM on the outer thigh, midway between waist and knee. 5. Dispose of Auto-Injector or leave with the patient for identification purposes, document how many where used on the patient. Duo-Dote TM Dr. Sandra Schwemmer, D.O. (Atropine and Pralidoxime Chloride) 11 -12 Page 2 of 2 619 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Epinephrine 1:1,000 iiA10 U�i/ // .,��. 11Jd'I�1+111���� ,,f, ' IUIU'llllllllillk�lr m„ ACIPI N : 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. VND VCA;TV0NS: ___ Asthma • Anaphylaxis • Angioneurotic edema CC IP'�"III"III'tAIIIIP'�IIC'IACA'11C'lI0'1'9S: ........................................................................................................... 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. WXI' ' IIIIV(6�;�i� ........................................................... Epinephrine is inactivated by alkaline solutions - never mix with Sodium Bicarbonate. Do not mix Isoproterenol and Epinephrine - results in exaggerated response. Actions of catecholamine is depressed by acidosis-attention to ventilation and circulation is essential. Antidepressants potentiate the effects of epinephrine. RSSIBLE ADVERSE REACTdNS AND SdDE EEEECTS: .................................................................................................................................................................................................................................................. • CNS: Anxiety, headache and cerebral hemorrhage. • Cardiovascular:Tachycardia, ventricular dysrhythmias, hypertension, angina and palpitations. • GI: Nausea and vomiting ®SAGE: Aduft: IM:0.3-0.5 mg IM. Repeat dose in 5 minutes if needed. Nebulized: 1mg(1ml) diluted in 2 mL INS nebulized over 15 minutes @)eu;Niiatarii(� IM: 0.01 mg/kg IM max single dose 0.5 mg. (may repeat 2 x prn, in 5 min intervals) Nebulized: 1mg(1ml) diluted in 2 mL INS nebulized over 15 minutes Time/Action IProfirlle: Onset Peak Duration Epinephrine 1 :1,000 Dr. Sandra Schwemmer, D.O. 11 -13 s2o MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Epinephrine 1:10,000 ... o EPINEPHRINE I ),„ ISIff FDA INTRAVENDU�S USE PRVTE TIFRO 4laW Hltl�{.,E1621 fin,Xt I lfi'"FN AC"'1f"11015: EMLE 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: • All Pulseless Arrest • Asystole • Ventricular Fibrillation unresponsive to defibrillation; • PEA • Other pediatric indications: hypotension in patients with circulatory instability, bradycardia (before Atropine). TO IP"�"III"III'tA III IP"�IIC'.f III TA"III"III O IP"�S: ........................................................................................................... None in the cardiac arrest situation. \T XII�'il N III N G S ........................................................... 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. POSSIB 1 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. For SE'VE'IRE anaphylaxis with marked hypotension: O..Iirn (I rNl) (61luted in 91rnll,,,, of alllliiine) a irniiinlii tear lirWl/irWiin IV/10 (titrate to effect). Pediatric: 0.01I. mg/kg, (0.1 ml/I<g IV or 10). Repeat every 3-5 min LAtes. Pediatric : POST AIR IRII"ST: 0.JLrncg/kg/m i n IVlix tmg of Epi irito t000m1 NS = Coriceritratior7 of tmcg/ml Time/Action Profiulle: Onset Peak Duration IV/10: Rapid 1-2 minutes 20 minutes Epinephrine 1 :10,000 Dr. Sandra Schwemmer, D.O. 11 -14621 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Fentanyl A I IOI : Fentanyl Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain Z �- pathways. Fentanyl binds to brain receptors, relieving pain. It decreases the feeling of pain and a person's response to pain. Fentanyl is 50-100 times as " potent as morphine; morphine 10 mg I.M. =fentanyl 0.1-0.2 mg LM.; fentanyl has less hypotensive effects than morphine due to minimal or no 40c, rr' histamine release. Fenl�� I rat h3j. US INATI �N : ➢�, ._� __tt___It�______ 1100ocgFwitamY pit Moderate to severe pain in patients>10kg Acute Coronary Syndrome—Chest Pain (Adult) r—Aii°"wom RL :; Pain associated with isolated extremity fracture, renal colic, burns, etc. "� COII"'�"III"III'tAlllll"'�IIC'. IIICAIII"IIIOII"'�S: • Epistaxis or bilateral blocked nares • Known hypersensitivity to fentanyl • MAOI use in past 2 weeks CONCENTRATION Unstable hemodynamics or altered 100mcg/2ml WX1'il INl III INl(�I9�1�:������ 50mcg/ml .Use ...with caution in patients with bradycardia, hepatic, renal, or respiratory CONCENTRATION disease or those with increased ICP, head injuries, or impaired 250mcg/5ml consciousness; patients must be monitored until fully 50mcg/ml POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Drowsiness, sedation, increased intracranial pressure Cardiovascular: Bradycardia, hypotension, peripheral vasodilation GI: Nausea, vomiting GU: Urinary tract spasm Respiratory: Respiratory Depression SLOW IV PUSH -Rapid push may cause chest wall rigidity decreasing,or eliminating ability to ventilate. GAGE: Adult: 1-3 mcg/kg IV/IO/IN (Typical adult dose 50-100mcg) May repeat prn. F"iregiuYiaiuYicy Dose:0.5—1 mcg/kg IV/IO/IN Pediatric >10KG: 1 mcg/kg IV/IO/IN May repeat half the original dose administered 0.5mcg/kg Time/Action Profiule: Onset Beak Duration IN: 2-10 mins 30-60 mins Fentanyl Dr. Sandra Schwemmer, D.O. 11 -15 622 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Furosemide (Lasix®) 4 ml 11�1�1111111� n AC°I"IIONS: A sulfonamide derivative and potent diuretic, which inhibits the reabsorption of Injection,LISP sodium and chloride in the proximal and distal renal tubules as well as in the Loop of 40 mg/4 mL Henley. Has a direct vasodilating effect in acute pulmonary edema.With IV (10 rng�mL) administration, onset of vasodilating is generally within 5-10 minutes; diuresis will usually occur in 20-30 minutes VNMCA;1"MS: • Pulmonary edema CO IP'�"III"III'tA III IP'�IIC'. III CA"III"III O IP'�S: • Anuria. • Should be used in pregnancy only when benefits clearly outweigh risks. WX1� ' IIIIN(�2�:�� ........................................................... Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. P055.1§ 1 ADVFRSF REACTIONS AND SIDE EFFECTS: CNS: Dizziness, tinnitus, hearing loss, headache, blurred vision and weakness GI:Anorexia,vomiting and nausea Cardiovascular: Hypotension GAGE: 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 100mmHg.) Time/Action Profiulle: Onset Beak Duration IV/IO: 5 minutes 30 minutes 2 hours Furosemide (Lasix®) Dr. Sandra Schwemmer, D.O. 11 -16 s23 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Ketamine (Ketalar®) AC IAOII' S: Rapid acting general anesthetic, characterized by profound analgesia, normal pharyngeal- laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and G respiratory stimulation, and occasionally a transient and minimal respiratory depression. Disassociates the brain form the spinal cord thus inhibiting pain sensation. Ketamine increases cardiac output and may be considered advantageous in patients with hemodynamic compromise (trauma, sepsis, etc.). A patent airway is maintained partly by virtue of unimpaired pharyngeal and laryngeal reflexes. Ketamine ICI Ili DI A' ICI :' 501)1,111,4 N11(E 5 rrr1111 • Facilitation of pain control in patients with isolated extremity trauma, burns and/or entrapped patients. 4 "��° • Procedural Sedation err r • Violent/Combative/Aggressive Patients or "Excited Delirium" -r gU6�j n4uNa�o .III y�y .III III y�y .III OIIiW�lll•' IIIIIiWEA „III•IIO IiWSm .................................................................................................................... • Hypersensitivity to Ketamine • Condition in which an increase in Blood Pressure would be hazardous. • Acute Coronary Syndrome or STEMI CONCENTRATION • Ocular trauma (globe injury) 500mg/5ml 1 0mg/ml \,A�,f''A,8!�'`YYl.IIL.�'`Yvl..(;iil.mi.: IVP over 1-2 min, Ketamine may cause apnea if given too rapidly IV POSSIBLE ADVERSE RA "I"IONS AND SIDE "I" : ....................................................................................................................................................................................................................................................................... CNS: "Emergence Reaction" or hallucinations upon recovering Cardiovascular:Tachycardia, hypertension GI: Nausea and vomiting Respiratory: Hypersalivation, Respiratory depression/apnea, Laryngospasm. II R III I III III IIi 0 N III""'0 III""'A I Ii NIII Hypersalivation: Atiirqpline 0„51ang IIIV/IIIIII /IIIO Laryngospasm/Stridor: High flow 02, BVM assisted ventilations Laryngospasm is uncommon and is usually self-limiting. It almost always resolves with high flow 02 or brief ventilation via BVM. DOSAGE: Adult: Procedural Sedation/Pain: 1mg/kg IWIO over 1-2 min may repeat prn. Airway Management: 2mg/kg IWIO over 1-2 min_may repeat prn. (Trismus/Endangered Airway/RS11post intubation sedation for inhalation airway control) Violent/Combative/Aggressive Adult Patient 400mg IM_may repeat prn. @)eu;Niiatarii(� Procedural Sedation/Airway management 1mg/kg 1WIO/IM over 1-2 min may repeat prn. Time/Action Profile: Onset Beak Duration IV 1-2 minutes 3-5 minutes Weight dependent Dr. Sandra Schwemmer, D.O. Ketamine (Ketalar®) 11 -17624 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Magnesium Sulfate ACTMIIONS: Magnesium prevents or controls convulsions by blocking neuromuscular transmission and 1I1 mL decreasing the amount of acetylcholine liberated at the endplate by the motor nerve impulse. Magnesium is said to have a depressant effect on the central nervous system, but it does not affect the mother,fetus or neonate when used as directed in eclampsia and pre-eclampsia. Magnesium Magnesium acts peripherally to produce vasodilatation therefore a drop in systolic BP is to be Sulfate anticipated. Injection,USP ilN ilCA;Til0NSµ • Prevention and control of seizures in eclampsia 5 ydTCy mL i5a0 m04 Torsades de Pointes i4 mEy Nly*',+rnQ Suspected hypomagnesemia state (i.e. chronic alcoholism and chronic use of diuretics) • Refractory ventricular fibrillation • Refractory Asthma CO IP't"III"III'tA III IP't IIC'. IIIAC"III"III O IP't S m ........................................................................................................... Parenteral administration of the drug is contraindicated in patients with heart block or myocardial damage. WXI' N III N(16 ........................................................... CA1il'105: Intravenous use of Magnesium Sulfate should not be given to mothers with toxemia of iuiust be u]tillliufted pregnancy with imminent delivery. Magnesium Sulfate Injection USP,50%must be diluted to fair Viintra eiunmumuus muss. a concentration of 20%or less prior to IV infusion. I II'°il lE CA i YT III )I°ui Sig ....................................................................... Because magnesium is removed from the body solely by the kidneys,the drug should be used with caution in patients with renal impairment. Monitoring the patient's clinical status is essential to avoid the consequences of overdose in eclampsia. Calcium Chloride should be immediately available to counteract the potential hazards of magnesium intoxication in eclampsia. Signs of hypermagnesemia include respiratory depression, absence of patellar reflex,etc. ROSSIOLE ADVFRSF 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 svmotoms can precede fatal oaralvsis. DOSAGE: AduIVt: For Asthma: 2 gm mixed in 50 ml NS IV/10 over 10 min (Macro drip 1 gtts/sec) For eclamptic seizures:4 gm mixed in 50 ml NS IV/10- run wide open. For Torsades de Pointes and refractory VF: 1-2 gm mixed in 50 ml of NS and administered over 10 minutes,followed by a maintenance infusion 1 gm in 250 ml of NS administered at 60 gtts/min Pediatric: Pulseless Arrest/V-fib/V-Tach: 25-50 mg/kg (max dose 2g) IV/10 For Severe Asthma:40mg/kg (max 2g) mixed in 50ml NS IV/10 over 15-30 mins Time/Action IProfifle: Onset Beak Duration IV Drip: Immediate Unknown 30 minutes Magnesium Sulfate Dr. Sandra Schwemmer, D.O. 11 -18 s25 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Methylprednisolone (Solu-MedrolO, A Methapred) AC"IFIONS., Decreases inflammatory effects via its potent anti-inflammatory synthetic steroid. I IN D I "A"I" aNS: .______ __-Asthma y • Anaphylaxis • Head injury 'f • Unconscious with known Addison's disease tit OIII "�""III' IIIIIIl�' III "�""IIIOIIISm �t None in the emergency setting. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: ...................................................................................................................................................................................................................................................................... we a GI hemorrhage reduces leukotrienes of immune system and increases potential for infections. DOSAGE: Adult: 125 mg IV slow over 2 minutes F''Il adi4Ib,u oc: 2 mg/kg (max 125 mg) IV slow over 2 minutes Time/Action Puroflle: Onset Desk Duration IV/IO: Unknown Unknown Unknown Methylprednisolone (Solu-Medrol®, A Methapred) Dr. Sandra Schwemmer, D.O. 11 -19 s2s MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Midazolam (Versed®) AC"IFIONS: Depresses CNS, muscle relaxant, strong sedative, hypnotic, and amnesia. IINDICA°I"IqNS: Control of seizures, sedation for cardioversion & pacing, sedation for airway management. sedation of violent/combative patients. OI I I I Ip lly .. Respiratory r� . depression Hypotension %AY/A III I J'`Y III I'Yi(o m u: kW Ilum Monitor patient for respiratory and CNS depression and vital signs after administration, particularly in patients with recent ETOH and Drug use. POSSIBLE ADVERSE REACwI"IONS AND SIDE EFFEC"I"S: ....................................................................................................................................................................................................................................................................... CNS: Retrograde amnesia, altered mental status and dizziness Cardiovascular: Bradycardia, hypotension, PVC's, tachycardia and nodal rhythms GI: nausea and vomiting, hiccoughs and coughing Respiratory: Respiratory depression, laryngospasm and bronchospasm DOSAGE: Adult: Procedural Sedation (pacing, cardioversion etc.) • 2.5 -5mgIV Endangered Airway, Passive Cooling, • 5 mg IV/IM/IN/10 up to 10 mg (max single dose) Seizures, Violent/Combative Patients, Alcohol /drug induced psychosis, or Stimulant OD • 5-10mg IM/IN OR 2.5 -5mg IV up to 10 mg (max single dose) F''Iledi4tii,Tk: (0.1 mg/kg) (max single dose < 6 y/o—6mg, max single dose > 6 y/o - 10mg) Time/Action Profile: Onset Peak Duration IV 1-2 minutes 3-5 minutes Weight dependent Midazolam (Versed®) Dr. Sandra Schwemmer, D.O. 11 -20 s27 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Naloxone Hydrochloride (Narcan®) A open f Rx Only I NDC 76329-3369-1 1 STOCK NO. Lae r-LockPreliVled Syringe NALOXONE 2rng HYDROCHLORIDE per {1 m"rg]mtiL) FOR INTRAVENOUS INTRAMUSCULAR LEVER-JETW LUER-LGGIK PREFILLEID SYRINGE OR SUBCUTANEOUS USE 2 mL I v2ea dose disposable preiRe d ,z ACTIN : ASANOPIOID ANTAGONIST egle use,da no[reuse orreskor �e. Naloxone antagonizes the effects of opiates by competing at the same receptor sites. When given IV,the action is apparent within two minutes. I or SC administration is slightly slower. II NDOIC..ATl_0NS� �MMMMMNaloxone is indicated for the complete or partial reversal of central nervous and respiratory system depression secondary to opiate narcotics or related drugs such as, but not limited to: — Heroin, Meperidine (Demerol), Codeine, Morphine, Methadone, Lomotil, Hydromorphone (Dilaudid), Pentazocine(Talwin), Propoxyphene (Darvon), Percodan, Fentanyl (Sublimaze) (Known on the street as "White China") CCU NT]RAlI IC II YV CAT IV O NS ...................................................................................................... Known hypersensitivity to Narcan. WC,IR II\If II\M S: ........................................................ Naloxone should be administered cautiously to persons including newborns of mothers who are known or suspected to be physically dependent on opiates it may precipitate an acute abstinence syndrome. If patient is intubated and airway is controlled do not administer Narcan (excludes cardiac arrest). May need to repeat Naloxone since duration of action of some narcotics may exceed that of Naloxone. Naloxone is not effective against a respiratory depression due to non-opiate drugs. Use caution during administration as patient may become violent as level of consciousness increases. P®ssoBL.E AD.ERSE REA."�o®Ns AND SODE Eu=u=EC.Ts: ....................................................................................................................................................................................................................................... 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 gr. IPledi '>20 Ikg: An initial dose of 2 mg may be administered lWl0/IM/IN 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). F)edo atu ou�< 20 Ilifil" 0.1 mg/kg lW10/IM PRN. Tune/Action IProfillle: Onset Beak Duration IV: 1-2 minutes unknown 45 minutes Naloxone Hydrochloride (Narcan®) Dr. Sandra Schwemmer, D.O. 11 -21 s2s MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Nitroglycerin (Nitrostat® Nitrolingual® Spray) AC"IFIONS: Nitroglycerin is a direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilatation as well. There is a decrease in venous return, which decreases the workload on the heart and thus, decreases myocardial oxygen demand. Sublingual nitroglycerin is rapidly absorbed. Pain relief occurs within one to two minutes and therapeutic effects can last up to 30 minutes. IINDI "A°I"I�; INS: 0 Chest pain or discomfort associated with suspected AMI. • Pulmonary edema with hypertension. OIIL... I III( I�III t�olll c B�II�OIII �� • S 0 mmHg : .,;. • Children under 12 • Patients on erectile dysfunction drugs that fall within time parameters (i.e. < 36 hours) • Know hypersensitivity to the drug • Evidence of a positive V4R in the setting of an Inferior wall MI PIRECAU" LOINS: -------------------- 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 vasodilating and hypotensive effects. POSSIOLE ADVERSE RAC"I"IONS AND SIDE C"I"S: ....................................................................................................................................................................................................................................................................... CNS: Headache, dizziness, flushing, nausea and vomiting. Cardiovascular: Hypotension, reflex tachycardia, and bradycardia. DOSAGE: Adult: 0.4 mg (1 tablet or 1 spray sublingual). May repeat in 3-5 minutes PRN. Time/Action (Profile: Onset Peak Duration SL: 1-3 minutes unknown 30-60 minutes Nitroglycerin (Nitrostat® Nitrolingual® Spray) Dr. Sandra Schwemmer, D.O. 1 1 22 s29 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Odansetron (Zofran®) C"INOII' S: Antiemetic, Zofran blocks the actions of chemicals in the body that can trigger nausea and vomiting. Selective 5-HT3 receptor antagonist. Category B in 4Ls'nole-doseVial Nnca�� re Wane 4��IIri�uar �ii�!II�' p g Y. iicul� r�nua e nIo0 f S Croup/ r�aP�. a�261� I I DICA°ngNS:° µ�ourFnoMu�Nr ib, Used for a patient with nausea unrelieved with comfort measures, uncomfortable due to V,a,Inc.,Lake Forest the nausea during transport and/or with a potential for airway compromise related to vomiting. CONCENTRATION • Nausea and vomiting due to chemotherapy. 4g/2rnl • Prophylactic use prior to administration of pain management medication. 2rng/rnl • Nausea and vomiting with moderate to severe dehydration or electrolyte imbalance. COIII "I""III' Illlllf' IIIC "I""IIIOIIIS: .................................................................................................................... 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). %,A/AIICII�\lIII�\l(3S: 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 REACwm"IONS AND SIDE EFFEC][S: ....................................................................................................................................................................................................................................................................... CNS: Headache, Dizziness, Drowsiness, Fatigue GI: Diarrhea, Constipation, Abdominal pain, Dry Mouth MISC: Rash, Shivering, Fever, Hypoxia, Urinary Retention, Muscle Pain DOSAGE: Adult & Pediatrics >� 40kgo, 4mg slow IVP (not less than 30 sec) or IM max dose 8mg 1'°edi4tii,i�c 4(fl(g: 0.1mg/kg slow IVP Time/Action Puroflle: Onset Peak Duration IV 1-2 min 14-30 minutes Weight dependent Dr. Sandra Schwemmer, D.O. Odansetron (Zofran®) 11 -23 630 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Oral Glucose (Insta Glucose) Gina, uc6p s4 UCOW AC,"IFI NS: Increases blood glucose levels slowly. IINl ICA°I"IqNS: BS > 60 mg/dl, patients who are altered but alert enough to take the command to swallow. CIII "I""III'( IIII1IIIC "I""IIIIIIS: ................................................................................................................... Patients unable to swallow or Stroke symptoms. .............................................................................. None when patient can swallow, risk of aspiration if given improperly. ADVERSE REAL"I"IONS AND SIDE Eff EC"I"S: GI: Nausea DOSAGE: Adult: 1 tube F'Il ,dl4tii,,, mc: 1 tube Time/Action Profiled Onset: Peal4 Duration PO: 10 minutes unknown Unknown Oral Glucose (Insta Glucose) Dr. Sandra Schwemmer, D.O. 11 -24 s31 MONROE COUNTY FIRE RESCUE DRUG FORMULARY .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Sodium Bicarbonate Rx Only El FOR UNTRA'60EM"'SUSE LUER-ET""LUER-LOCK PREPVLLED SYRINGE'IN METABOLIC ACIDOSIS AC;II101' S: Increases PH to reverse acidosis. 11ND1CA"I"pNS: • Metabolic acidosis in cardiac arrest • Tricyclic overdoses with QRS > 0.1 • Electrocutions • Hyperkalemia • Methanol / Ethylene glycol toxicity • Severe ketoacidosis C0111 "1""III' IIIIII �' IIIC "1""11101115: .................................................................................................................... CHF and Alkalotic states %AA/`A IIC 11"Yi III 1"Yi(„3 m"1ii: .............................................................. Excessive therapy inhibits oxygen release, reduces the ability to defibrillate, may precipitate other medications and administration should be guided by blood gases. Do not give concurrently with any other medication, flush the line before and after administration. POSSIBLE ADVERSE REA wI"IONS AND SIDE E F F1..C.".[..S..:.. Metabolic alkalosis, and may crystallize in IV solutions. SODIUM BICARBONATE 4.2%(PEDI): DISCARD 25ML OF 8.4% AND DRAW UP 25ML OF NORMAL SALINE DOSAGE: Adult: 8.4% - 1 mEq/kg IV push, then %the dose q 10 mins. Adult Electrocutions: 2 mEq/kg IVP F''Il edi4tii,Tioc: 4.2% - 1-2 mEq/kg diluted 1:1 with Normal Saline to make Sodium bicarb 4.2% Pedi Electrocutions: 1mEq/kg IVP (Sodium Bicarb 4.2%) Time/Action Pero- le: Onset Peak Duration IV/10: Unknown Unknown Unknown Sodium Bicarbonate Dr. Sandra Schwemmer, D.O. 11 -25 s32 633 MONROE C UNI"'Y' RESC U'E 2021 A,,,i.r A,,ryibulanl. (,1! M't',',,",,dl',,)ICA.L PROTOCOLS e fidl6wiii °e ns a-r�e addit o malt°cat°o ols thatpertairt to a( riedica flights and critical care ground transports. 71jes,eprotocols, are to he utili7ed Icy traii jed medical.m i ,rh t personnel only. 634 Monroe County Fire Rescue Trauma Star Medical Protocols is lot AIR TRANSPORT GUIDELINES9 Trauma Star is intended for use in in Monroe County as a primary air transport ambulance for: • Trauma Alert • STEMI Alert • ACS Alert • Stroke Alert • Interfacility transfers Flight Limitations Any special considerations regarding the patient or patients (Weight/ height/special equipment needs, etc.) must be discussed with the Pilot in Command prior to loading the patient in to the aircraft. • Critical Neonates (newborns <28days of age or <5kg in weight requiring transfer to a NICU-neonatal ICU) • High risk OB patients with imminent delivery. Special consideration maybe given to complicated pregnancies, where the mother or infant's life is at risk if not transferred to a higher level of care.(No obstetric patient will be transported without internal exam to determine the state of labor, and an evaluation/monitoring of the fetus prior to transport) • Contaminated Hazmat patients • Patients with CPR in progress *Exception- when TS is 1st response • Intra-Aortic Balloon Pumps (IABP) without an accompanying perfusionist • Ventricular Assist Devices (VAD/BIVAD) • Deceased patients Interfacility Transfers All requests for interfacility transfers must go through the Monroe County Central Dispatch 911 System. Critical Care/ALS interfacility patients transported by Trauma Star include, but are not limited to: • Any State of FL recognized "Trauma Alert" criteria patients and/or patients that meet the State of Florida Interfacility Transfer Guidelines • Cardiac care not available in Monroe County • Respiratory conditions requiring care not available in Monroe County • GI Bleed with unstable vital signs and/or active hemorrhage • Metabolic emergencies, including DKA • Sepsis patients • Complicated OB patients who are not in active labor • Vascular emergencies, including DVT, PE AIR TRANSPORT GUIDELINES 2-� 635 Dr. Sandra Schwemmer, DO Page 1 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols • Dissecting or leaking aneurysms Request for emergency air interfacility transfer, Flight Crew shall: • Contact the sending facility to determine the patient's condition and need for air transportation. • If patient meets criteria, weather is favorable and flight is accepted, the sending facility will be given an approximate ETA. • If the patient is not stable enough for air transport or does not meet flight criteria the flight shall be declined. (must advise Medical Director or Chief Flight Nurse) Prior to departure • History of Present Illness/Injury • Past Medical History • Care/Procedures Received Prior to Arrival • Results of Pertinent Diagnostic Studies • Any medications required or possibly required and not carried on Trauma Star should be sent by the sending hospital with the flight crew. • Obtain a completed MCFRF-101 "Trauma Star Medical Necessity for Air Transport" • Obtain two (2) copies of the patient medical record and face sheet Field Transfers • Trauma Star to shall provide stabilization and any needed or anticipated critical interventions prior to departing the location of patient loading. • Assessment, treatment and transfer of the patient is to be completed by the flight team. • When possible, patients should be advised of the transport process, destination, safety and care procedures that will continue throughout the flight. • Trauma patients are required to have adequate spinal immobilization prior to transport. • Active bleeding sources must be identified and controlled prior to transport. • Confirm patient report including alert type, status, critical interventions, and vitals are relayed to the receiving specialty resource center by the ground crew. • Flight crew will make the ultimate decision on destination facility for MCFR field alerts.(Closest appropriate hospital to provide definitive care) Flight crew will honor destination requests by other fire rescue agencies when prior communication with the receiving facility has occurred prior to Trauma Star arrival. AIR TRANSPORT GUIDELINES 2-� 636 Dr. Sandra Schwemmer, DO Page 2 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols FLIGHT PHYSIOLOGY OVERVIEW Patients who require air medical transport can present with a variety of disease processes, as well as varying degrees of physiologic alteration. The flight crew need to be aware of, and able to anticipate, the potential problems that may arise from changes in altitude and barometric pressure. By understanding the basics of altitude physiology, and being able to anticipate, correlate, and react to such alterations in the patients' physiology, will ensure a safe and uneventful transport. Flights will be completed at ambient air pressures of less than 7000 feet in most helicopter transport situations, due to the unpressurized cabin. HOWEVER, the flight crew must understand that rapid, explosive-type barotraumas occur most frequently with the rapid ascents and descents associated with rotor-wing transports. The following general information is to aid the flight crew with planning, designing, and delivering appropriate therapeutic modalities. Altitude affects the delivery and utilization of oxygen Aircraft altitude adjustments may be necessary to provide the patient with optimal oxygen delivery. Remain alert for the early signs of hypoxia Trapped gases EXPAND as the aircraft ASCENDS, and CONTRACT as the aircraft DESCENDS; this phenomenon is known as "Boyle's Law" Patient populations as risk include: • Thoracic injuries/problems ("air-leak" potential). • Gastrointestinal injuries/problems. • Penetrating head injuries/severe CHI. • Ocular and/or severe facial injuries. • Orthopedic injuries • "Crushing-type" soft tissue injuries and/or severe soft tissue swelling Medical equipment effected include: • ETT pilot balloons. • Foley catheter balloons. • BP cuffs. • Air splints/orthopedic "casts"/MAST. FLIGHT PHYSIOLOGY OVERVIEW 12-2 637 Dr. Sandra Schwemmer, DO Monroe County Fire Rescue Trauma Star Medical Protocols FLIGHT PHYSIOLOGY OVERVIEW Humidity and temperature decrease as you increase altitude. For every 1000 ft. increase in altitude, the outside temperature drops 2 degrees Celsius. Physiologic changes As the aircraft accelerates, multiple physiologic changes can occur *Effects on HR, BP, RR, SVR, and ICP can be seen. Increased noise and vibration levels occur especially in helicopters; protect your patient accordingly. Unconscious patients respond physically to these stressors as well and should be provided hearing protection if able. All the factors discussed previously can lead to the development of motion sickness, and/or spatial disorientation. Treatment of motion sickness includes: • Loosening of restrictive clothing. • Visual fixation on a stationary object. • Passive cooling measures. • Oxygen administration. • Supine positioning and restriction of head movement. • Antiemetic therapy. FLIGHT PHYSIOLOGY OVERVIEW 12-2 638 Dr. Sandra Schwemmer, DO Monroe County Fire Rescue lid Trauma Star Medical Protocols is RAPID SEQUENCE INTUBATION Securing the airway for air transport is one of the most critical and important events. Intubation should be considered appropriate for any patient that has an unsecured airway, ventilatory compromise, or at risk for aspiration RSI Indications: • Respiratory rate <10 or >30 • GCS < 8 • Burn, inhalation injuries, blast injuries • Suspected acute loss or impending airway failure • Head/injury patient exhibiting combative behavior (unsafe for air transport) Contraindications for RSI: • Anticipated difficulty ventilating with a BVM after paralysis Caution RSI use in: • Major facial or laryngeal trauma • Distorted facial or airway anatomy • Soft tissue/penetrating injury to the neck (gunshot wound, stab wound with hematoma compromising airway) Pre-oxygenate and prepare for incubation • See endotracheal intubation procedure 9-5 Sedate patient as indicated with ONE of the following medications: • Il liidazolllairn (Versed) 2 5 rng slow IV push over 1 -2 minutes Hold if BP less than 80 mmHg • Ilf;;;;t°ournliidat°e 0,3 urn /kg (12 20 urn ) IVP over 30 — 60 seconds (max single dose 20mg) • 11 et°aurnliine 21rng/kg slow IV push over 1-2 minutes • In line cervical spine stabilization by second caregiver (in trauma setting) Administer short acting paralytic: • Succliinylllcholllliine inect°liiine) 1,5 urn /kg (60 — 150 mg) rapid IVP May repeat Succliinylllcholllliine nect°liine) at 0,51rn /k (20-50mg) if inadequate relaxation Dr Sandra Schwemmer, DO RAPID SEQUENCE INTUBATION 13-1 639 Monroe County Fire Rescue lid Trauma Star Medical Protocols is After successful incubation administer ONE of the following long acting paralytics: • Vecuronliiuirn 0 051rng/kg IVP duration 20-30 min • I ocuronliiuirn 0 061rng/kg IVP duration 20-30 min • III°Iancuronliiuirn 0 051rng/kg IVP duration 90 — 180 minutes Attach patient to ventilator when indicated, maintain end tidal CO2 of 35 — 45 mmHg (See Ventilated Patients protocol 13-2) Unsuccessful Incubation: • Resume ventilations for 30 seconds • Re- attempt incubation • If unsuccessful, resume ventilations for 30 seconds and insert I-Gel airway • Monitor ETCo2 If Unable to Ventilate: If still unable to ventilate, remove I-Gel and perform cricothyroidotomy (see cricothyroidotomy- surgical procedure 9-4) Pediatric: • Utilize Handtevy System • If patient is less than 8 yrs (or if age is unknown and using ET tube smaller than 60), pretreat with Atrojpllne 0,02 a /kg rng/kg IIVIII°1 (minimum dose of 0.1 mg, maximum dose of 0.5mg) Dr Sandra Schwemmer, DO RAPID SEQUENCE INTUBATION 13-1 640 Monroe County Fire Rescue Trauma Star Medical Protocols VENTILATED PATIENT / USE OF PEEP All incubated patients will be transported on a ventilator if possible. • Patients will have continuous cardiac monitoring. IV's will be maintained on infusion control devices or monitored closely. • Multiple parameters will be documented at least every 10 minutes. These include PIP, Sa02, ETCO2 reading, chest rise and fall, etc. • A BVM with appropriate face mask and manometer will be kept in close proximity to any ventilated patient ventilated patient. PEEP attachment for BVM will be used if patient's condition warrants. • Suction will be set up and readily available. • The medical crew must verify ETT placement. This may be done by noting the depth of the tube (appropriate depth for patient), ETCO2 detector, breath sounds, epigastric check and mist in the tube may be documented. Prior to an interfacility transport • Chest x-ray may be obtained if there is any question regarding the correct placement of the tube. • The medical crew may request arterial blood gases. In the presence of any abnormal values, the medical team may consult with the Medical Director or referring physician in an attempt to stabilize the patient's respiratory/acid-base status prior to departure. Upon arrival at the receiving facility • The medical crew must document the confirmation of tube placement. Sedation • Appropriate sedation/analgesia with IFent°anylll, A,fivain, Versed or edat°liion/Ipa14lly leiWith Ilf;;;;t°oirnmldat°e, Succliinylllcholllliine may be necessary for safe transport. • Initially, the medical crew may medicate the patient with Versed 2 41rn , t°liivain T 21rng, or IFent°anylll 1 irnc /k , • Both analgesia and sedation must be considered in the chemically paralyzed patient. Dr. Sandra Schwemmer, Do VENTILATED PATIENT / USE OF PEEP 13-2 641 Monroe County Fire Rescue Trauma Star Medical Protocols VENTILATED PATIENT / USE OF PEEP Ventilator Settings • Settings should be managed to maintain ETCO2 35-45mmHg (in the absence of COPD) and oxygen saturation > 96%. • Attempt to bring down PIP as much as possible by lowering TV to maintain parameters above. General guideline for TV is 6-10ml/kg/minute. Recommended Ventilator Settings: Tidal Volume 6-10ml/kg/minute Rate 12-20 breaths per minute. Higher rates may be necessary in pediatrics and some adults Fi02 50-100% PEEP 5cm/H20 average adult settings. May increase to 10cm/H20 for pulmonary edema, ARDS and near-drowning patients L-time 0.5-1.0 seconds with I/E ratio of 1:2 PIP 20-25cm/H2O. Increase settings to obtain adequate chest rise and oxygen exchange to maximum setting of 40cm/H2O. Indications for use of PEEP: • Patient with decreased Sa02 with use of 100% Fi02. • Any patient with evidence of moderate to severe alveolar infiltrate specifically: • Pulmonary edema, near-drowning, COPD and ARDS Contraindications for PEEP: • Hypotension Equipment and Supplies: • PEEP Valve • Appropriate size BVM with Manometer • Intubation Equipment • Cardiac monitor • Oxygen Dr. Sandra Schwemmer, Do VENTILATED PATIENT / USE OF PEEP 13-2 642 Monroe County Fire Rescue Trauma Star Medical Protocols VENTILATED PATIENT / USE OF PEEP Procedure: • Perform oral incubation of patient. • Attach PEEP valve to adapter end of BVM. • Set PEEP pressures as follows: Adult: • Begin at 5cm/H20 • May increase to a maximum of 10cm/H2O. COPD-Asthma patients: • Begin at 5cm/H20 • Increase to maximum of 8cm/H20 Pediatric: • Begin at 2cm/H20 • Titrate to effect to a maximum of 5cm/H2O. • Attach BVM to oxygen and ET tube in usual manner. • Ventilate patient in normal manner. • Observe ECG and vital signs. PEEP may cause dysrhythmia and/or changes in vital signs. • Discontinue or decrease PEEP if any significant adverse responses occur. Dr. Sandra Schwemmer, Do VENTILATED PATIENT / USE OF PEEP 13-2 643 Monroe County Fire Rescue Trauma Star Medical Protocols ANXIETY IWdazolllairn (Versed) Route: IV/IO/IM/IN Onset of action in 2-3 minutes; Peak occurs within 5 minutes; Most amnestic of benzodiazepines. • Adult: 0,5 5 rrrm • Pediatric: 0,T,,,, 0 21rng/kg max. 5mg. II,,,,.oirazelpairn ( t°lii ain) Route: IWO Much longer half-life than Versed, peak effect occurs in 30 minutes; Half-life is 10-12 hours; Less likely to cause hypotension than Versed. • Adult: T,,,, , rr - titrate to effect • Pediatric: 0,05 0,1 irng/kg IV. NOTE: Narcotic antagonist = INaircain (INallloxone) 0,4 21rng sIllowIIVIII°1 (maximum of 10mg) Benzodiazepine Antagonist = IFlluirnazenli]l (Il oirnaz'icon) 0 21rng IIVIII°1 over 30 sec, after 30 sec., 0 31rng IIVIII°1 over 30 sec, After 1 min 0,5 over 30 sec., May repeat g20min to a total of 3mg ANXIETY Dr. Sandra Schwemmer, DO 14-1 644 Monroe County Fire Rescue Trauma Star Medical Protocols AORTIC DISSECTION Have a `high-index' of suspicion when treating patients with history of an aortic dissection. Indications: Patients presenting with sharp tearing like chest and/or back pain. Patients usually have history of HTN and/or aortic dissection. There are three types. DeBakey I, II, & III. Patient's usually present with varied pulse pressures in upper extremities, possible decreased carotid pulses on one or both sides, rupture may include AMS or neurologic deficits from vascular disruption. Commonly originate in the thoracic aorta. May extend through entire aorta. Caused by arterial HTN. RUPTURED AORTIC DISSECTION IS A TRUE SURGICAL EMERGENCY • Maintain ABC's, oxygenation/ventilation. • Minimum 2 large bore Vs. • KEEP PATIENT CALM!!! • Consider Pain Management Protocol 4-7 • Full VS parameters will be initiated and continued until patient is delivered to receiving facility. FOR HYPOTENSION If a ruptured aortic dissection is suspected • Fllluliid clhallllllen e Wide open unt°liilll 2 Illliit°ers adurrmliinliist°ered then adurnliiin, 500cc bollluses x2 to max of 3 liters and re-evaluate hemodynamic status. If volume replacement is ineffective • Consider IDolpaurnli @iine 3,,,,15 urnc lk lurnliiin to maintain SBP >90mmHg. FOR HYPERTENSION • Consider II,,,,.albet°olllolll 10irng slow IVP q 5 min. intervals, max dose = 300mg. Target HR 60-80 bpm and SBP 100-130 mmHg. • Consider II,,,,.albet°olllolll Illnfusiiion @ 2,,,,8 urn lurnliiin (Mix 200mg (40ml) in 160cc of D5W for a concentration of of 1 mg/m1. Start @ 2mg/min. Or • Can be used by itself. IIf;;;l;surnolllolll (II..: revliibllloc) liinfusliioin @ 50 200 urnc lk lurnliiin (see drug formulary 19-8) do not drop HR to low. Do not administer if heart rate is already low. AORTIC DISSECTION Dr. Sandra Schwemmer, DO 14-2 645 Monroe County Fire Rescue Trauma Star Medical Protocols CENTRAL VENOUS LINES Central venous lines are indicated for administration of medications, delivery of chemotherapy, nutritional support, infusion of blood products, and blood draws. Types of central venous lines include: Broviac/Hickman, Port-acath/Med-a-port, and percutaneous intravenous catheters (PIC). Signs of blood embolus, thrombus, air embolus, and internal bleeding.- Chest pain. • Cyanosis. • Dyspnea. • Shock Central venous line emergencies include: catheter coming completely out, bleeding at the site, catheter broken in half, blood embolus, thrombus, air embolus, and internal bleeding. Catheter is completely out • Apply direct pressure to site. Bleeding at the site • Apply direct pressure. Catheter is broken in half • Clamp end of remaining tube Suspected blood embolus, thrombus, or internal bleeding: • Clamp line Suspected air embolism • Clamp line and place patient on left side. CENTRAL VENOUS LINES Dr. Sandra Schwemmer, DO 14-3 646 Monroe County Fire Rescue Trauma Star Medical Protocols HYPERTENSIVE EMERGENCIES Normal blood pressure LIMITS are systolic 160mmHg and diastolic 85mmHg. When blood pressure is severely elevated over these limits, acute end-organ damage may result. In these cases, it is important to control elevated BP before and during flight. In cases of mild blood pressure elevation without other underlying illness, treatment can be deferred until patient is delivered to destination facility. Remember that fever, pain and anxiety are frequent causes of moderately elevated BP and should be treated appropriately. Hypertensive end-organ damage is often marked by symptoms such as altered mental status and intracerebral hemorrhage. Treatment: The goal (in the treatment of malignant hypertension) should be decreasing mean arterial blood pressure (MAP) or the diastolic blood pressure (DBP) by 25% over one hour. Then decrease the MAP to 120 -130mmHg or the DBP to less than 110mmHg and maintain within parameter. May multiply DBP by 0.75 to quickly calculate 25%. (Example: DBP 120 x 0.75 = 90). Malignant Hypertension — MUST ADDRESS EMERGENTLY • SBP >220mmHG or DBP >120mmHg May use any of the following medications as indicated for patient condition: CALCIUM CHANNEL BLOCKADE: • Cardene ( INliicardliilpliine): 5 u /hir. (MIX 50 MG/250 NS = 0.2 MG/ML) If desired blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 2.5mg every 5 minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum 15 mg/hr, until desired blood pressure reduction is achieved. (Goal is to reduce BP by 25% over 1 hour) BETA BLOCKADE: • II,,,,.albet°alllolll 10irng IIVIII°1 over T 2 rn�lnutes May repeat as 20mg again in 10 minutes. If necessary, may repeat every 20 minutes thereafter as 40 mg up to a total max dose of 300mg. Target for 10-20% reduction in the systolic BP. • Ilet°olprolllolll (II,,,,.olpireor)„ 1,25 5 rng IV every 6 hours. In HTN associated with STEMI/Non-STEMI ML May administer 5mg every 5 (five) minutes as tolerated up to 3 (three) doses in early treatment. Titrate to heart rate and blood pressure. CENTRAL VENOUS LINES Dr. Sandra Schwemmer, DO 14-4 647 Monroe County Fire Rescue Trauma Star Medical Protocols HYPERTENSIVE EMERGENCIES Ilf;;;;surnolllolll 1 000iimcgilkg bolus dose over 30 seconds Followed by a 150 urnc /Ik /urnliiin liinfusliion, if necessary. Adjust the infusion rate as required up to 300 mcg/kg/min to maintain desired heart rate and/or blood pressure. (max dose 300mcg/kg/min) Can be used by itself: Ilf;;;;surnolllolll (Il;; irevliibllloc) liinfusliioin @ 50 300 urnc /Ik /urnliiin Do not drop HR to low. Do not administer if heart rate is already low (max dose 300mcg/kg/min) (see drug formulary 19-8) ACE INHIBITION- in a 1l a 1p ir i 1l at 1, 5 urn /dose. Give over 5 minutes every 6 hours. Doses as high as 5 mg/dose have been tolerated. CENTRAL VENOUS LINES Dr. Sandra Schwemmer, DO 14-4 648 Monroe County Fire Rescue Trauma Star Medical Protocols HIGH RISK OB TRANSPORTS Sending Facility /Acceptance Procedure for JMH: JMH Women's Hospital will accept all high-risk obstetrical patients in need of transfer from the Keys to a higher level of service. Since these transfers are typically time sensitive, the following procedure should be followed on every patient transferred: 1. The Transfer Center for JMH Women's Hospital must be called on 855-462- 4658 immediately by the referring physician, and caller should state "we are requesting transfer of a High-Risk OB patient from the Keys". The sending physician's direct contact phone number should be given to the Transfer Center along with any other contact information. 2. Trauma Star Dispatch should be notified of the OB transfer and Trauma Star should proceed to the sending hospital. 3. Within 15 minutes, the sending physician should receive a call back from the Transfer Center to connect for peer-to-peer discussion, with the on-call JMH MFM accepting the patient and providing additional instruction if necessary, to stabilize the patient prior to transport. Physician-to-physician communication is required prior to transport in order to allow JMH adequate preparation for the patient. Internal Transfer Center escalation protocol is executed as needed to expedite transfer. 4. Complete patient medical records, along with any lab or any diagnostic testing should be prepared by the sending hospital and should include fetal monitor recording verifying fetal heart rate, contractions and/or any variability. Records should be ready for the Trauma Star flight crew upon arrival to avoid delay. Federal transfer regulations require patient medical records to accompany the patient at time of transfer. S. Upon arrival at the sending hospital Trauma Star flight crew will receive information, any patient specific orders/medications, and proceed with patient stabilization and transport to JMH. • Flight crew must contact JMH Transfer Center at 855-462-4658 to provide ETA. • Flight nurse will provide follow-up call to sending physician/hospital after transport is completed. • 15 minutes prior to arrival, Flight crew must notify JMH Trauma Resus Dispatch at 305-585-1148 to clear arrival at helipad. HIGH RISK OB TRANSPORTS 15-1 Dr. Sandra Schwemmer, DO Page 1 of 2 649 Monroe County Fire Rescue Trauma Star Medical Protocols HIGH RISK OB TRANSPORTS The need for transfer by air should be discussed with the sending OB physician, via the labor nurse, or MCFR Medical Director prior to initiation of transport if the Flight Nurse has questions about patient's needs beyond available resources and/or medical necessity for air transport. Prior to lift off, the sending and receiving physicians should have communicated and established that the receiving facility and physician have the specialized medically necessary resources to take care of the pregnant patient and newborn. Additional details and orders for transport, as well as the need for appropriate transport personnel may be needed prior to lift off and once the patient has been stabilized. Contraindications to flight: Trauma Star crews should NOT transport patients when delivery is imminent. Suspected imminent delivery • Patient response to contractions is changing (i.e., increase vaginal pressure, increased pain with contractions, difference in pain from prior contraction pattern experience) • Vaginal bleeding beyond spotting • Bloody show (may or may not indicate imminent delivery, however should be followed up with further exam) • Uterine contractions greater than 6 per hour • Cervical dilatation of 4-5 cm or greater (especially significant when patient is multiparous) • Station = 0, fetal presenting part is engaged in the birth canal • Any presenting fetal part observed • Prolapsed umbilical cord observed If any of the above criteria are observed, the medical crew may decline the patient until the patient has been stabilized/delivered and they are able to determine transport/transfer needs based upon an updated assessment of the patient and newborn. HIGH RISK OB TRANSPORTS 15-1 Dr. Sandra Schwemmer, DO Page 2 of 2 650 Monroe County Fire Rescue Trauma Star Medical Protocols F©llaw, Universal Patient Assessment/Care Protocol as appr©priate UNIVERSAL HIGH-RISK OB ASSESSMENT / CARE PROTOCOL MCFR Flight Crew should perform basic patient assessment and initiate standard medical care. OBSTETRICAL HISTORY • Prenatal care, obstetrician and delivery hospital; • Number of pregnancies and live births (Gravida, para, multiple gestations, miscarriages); • Problems with this pregnancy or previous pregnancies; • Last menstrual period (LMP) and due date (EDD); • Contraction status, frequency, duration and,quality, • Membranes intact/ruptured; • Current medications and IV fluids and amounts; ; • Lab values including Glucose level; • Copy of all medical and surgical records; • Pertinent social/medical HX and medications taken; F • Blood type and Rh factor, if known; • Determination of presentation, station, effacement and cervical dilation and time of last vaginal or speculum exam; • Vaginal bleeding/ bloody show/discharge (color, odor, etc.) VITAL I ICJ • VS's q 15 minutes or more frequently as patient's condition warrants • Pt. weight • Maternal VS's including EKG, Temp Sp02, EtCO2, and Fetal HR pattern AIRWAY • Maximize oxygenation/ventilation and provide oxygen as indicated by patient's condition. URINARY OUTPUT • Void/ Foley. If there is no need for fluid resuscitation during transport, clamp Foley (a full bladder can delay fetal descent to slow delivery) UNIVERSAL HIGH-RISK OB ASSESSMENT / CARE 15-2 Dr. Sandra Schwemmer, DO Page 1 of 2 651 Monroe County Fire Rescue Trauma Star Medical Protocols HEMODYINAMICS • Maintain large bore IV or 10 access and infuse AIMS at 1 50urlll1Ihir (unless otherwise ordered) Hemorrhage, Shock or profound Hypotension • Maintain bilateral IV's or 10 access • Administer fluid boluses of AIMS 500urrmlll as needed for hypotension, maintaining a systolic BP at least 90mmHg. If BP is dropping quickly; Vasopressors maybe needed to maintain BP- * IE)olpaurrmliine 5urrmc lk hrrmliiin up to 20 urns ilk iurnmliin t°li'tirat°ed OR o II,,,,.evolplhed 4,,,,,12 u c hmlln TR INJ P R'T • Position patient in left lateral tilt to maximize uteropiacental blood flow; • Secure patient with safety straps- low on pelvic girdle (not across abdomen); • Tocolytics to slow or stop labor as indicated by patient status or referring facility; • Fetal monitor applied, • There is always the possibility of having to DIVERT during transport. UNIVERSAL HIGH-RISK OB ASSESSMENT / CARE 15-2 Dr. Sandra Schwemmer, DO Page 2 of 2 652 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk le 013 Assessment/Care Protocols as appropriate ABRUPTIO PLACENTA The separation of the placenta from the uterine wall occurring as early as 20 weeks gestation, at various stages, and before delivery. There may be an internal or concealed hemorrhage, external hemorrhage, or complete separation of the placenta from the uterine wall. Signs and symptoms may be: vaginal bleeding, extremely tender or rigid abdomen or an increase size of the abdomen. Treatment: • Monitor for signs of shock • Observe for signs/symptoms of impending DIC: bruising or petechia, oozing from venipuncture sites, hematuria, epistaxis, hemoptysis, and bleeding gums and document. UTERINE RUPTURE The complete disruption of all layers of the uterine wall. This allows abnormal communication between the uterine and peritoneal cavities, the majority of which occur in women with previous c-section. Rupture can occur before or during labor and in the total absence of any risk factors. Sharp sudden abdominal pain, report of tearing sensation, loss of FHR, cessation of contractions, referred shoulder or chest pain, pallor, hypotension, tachypnea, and hemorrhagic shock. Should this occur during transport proceed with the following: DIVERSION WILL BE NECESSARY. THIS IS A SURGICAL EMERGENCY. Treatment: • Monitor/ Treat for Hypotension and Hemorrhagic Shock • Monitor for vaginal blood loss. ABRUPTIO PLACENTA / UTERINE RUPTURE 15-3 Dr. Sandra Schwemmer, DO Page 1 of 1 653 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate BREECH PRESENTATION Breech presentation is used to describe the situation when the fetus's buttocks or legs present first. Treatment: • If delivery is in progress, allow the buttocks and trunk of the baby to deliver spontaneously; • Direct the mother to push with contractions; • Do not pull on the newborn; • Once the legs and arms are delivered, support the body on the palm of your hand; • Insert your finger into the baby's mouth and bring chin down to allow the head to deliver; • Have an assistant provide supra-pubic pressure to facilitate delivery of the head; • If the head is not delivered within 3 minutes, place gloved hand in the vagina with your palm towards the newborn's face; • Form a `V' with your index and middle fingers on either side of the newborn's nose and push the vaginal wall away from the face to create an airspace for the newborn until delivery of the head; • Suction as needed; • Transport and divert immediately while maintaining the airspace for the newborn. SHOULDER DYSTOCIA In cases of shoulder dystocia, delivery of the fetal head is followed by impaction of the fetal shoulders against the pubic symphysis and sacrum, within the pelvis. This complication becomes obvious when the head retracts slightly as it is pulled against the perineum (turtle sign). Treatment: • Place the pt.in a semi-fowlers position; flex the pts. legs with the knees pulled back up onto the thighs. Hips are abducted out as much as possible increasing the AP diameter of the pelvis. • Suprapubic pressure can be used to attempt and push the anterior shoulder under the symphysis pubis; • DO NOT USE FUNDAL PRESSURE; • Consider reaching into the vagina to deliver the anterior shoulder by trying to rotate it in the pelvis, extraction of the posterior arm, or using the Woods' corkscrew maneuver to rotate the shoulders 180 degrees out of the pelvis; • Delivery of the anterior shoulder must occur within several minutes. BREECH PRESENTATION / SHOULDER DYSTOCIA 15-4 Dr. Sandra Schwemmer, Do Page 1 of 1 654 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk 013 Assessment/Care Protocols as appropriate DIABETES MELLITUS IN PREGNANCY A common medical complication in pregnancy. Diabetes in pregnancy increases the risk of several maternal and fetal complications and even mild maternal hyperglycemia is associated with adverse pregnancy outcomes. Continuous monitoring is important because the fetus can be affected if mom is not properly monitored and treated when the need arises. Treatment: • Current BG >250mg/dl determines need for insulin before leaving facility • Obtain last dose of insulin Time/Type (short or long acting) • Monitor for Hypertension • Fetal Monitor - FHR, baseline and any variability, • Monitor Contractions — duration /frequency / strength • Monitor for DKA / Hypoglycemia • Blood sugar <40mg/dl treat with o D10100irrmIII OR o D5 250irWl DIABETES MELLITUS IN PREGNANCY 15-5 Dr. Sandra Schwemmer, Do Page 1 of 1 655 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk 013 Assessment/Care Protocols as appropriate PAIN MANGAGEMENT Pregnant patients who have pain from labor or from an illness or injury who are HEMODYNAMICALLY STABLE. These patients may be medicated to help reduce or alleviate pain. Treatment: Assess patient's hemodynamic status and level of pain • Fent°anylll 0,5,,,,1 urnc /I (max dose 100mcg) over 1-2 minutes IV q 30 minutes x 1 Reassess and document level of relief of pain and/or nausea. NAUSEA Pregnant patients who have nausea and/or vomiting may be treated to relieve symptoms and increase comfort. • Ondainsetroin ( ,ofiran) @ 4rng IIV over 2,,,,5 inliiin PAIN MANGAGEMENT / NAUSEA IN PREGNANCY 15-6 Dr. Sandra Schwemmer, Do Page 1 of 1 656 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate PLACENTA PREVIA The implantation of the placenta in the lower segment of the uterus. With this condition, the placenta is located on or near the uterine opening. The previa may be complete, partial, or marginal. Signs and symptoms: Bright red, painless vaginal bleeding usually beginning in the third trimester. Treatment: • Monitor uterine activity every 5-10 min. • Transport in a lateral position, preferably left, or with a left pelvic tilt. DO NOT PERFORM VAGINAL EXAM. • Monitor/ Treat for hypotension • Continuously monitor fetal heart rate and record any variability. PROLAPSED CORD Prolapsed cord occurs when the umbilical cord is at or below the level of the presenting fetal part. Fetal brain damage or death may result if the blood and oxygen supply are obstructed or cut off. Signs and symptoms: cord protruding from vagina, slowing of FHR, meconium stained amniotic fluid, pulsating cord felt on vaginal exam by sending OB physician. Treatment: • FHR continuously, and record every 5 minutes. • To stop/slow uterine contractions "'Terll ut°alllliine 0 251rng SQ q 20 min PRN, (max dose 1 mg) • Position patient in a left recumbent position with pelvis elevated on two pillows. • If FHR slows (less than 100 bpm), insert a sterile gloved hand into the vagina and exert continuous pressure on the presenting part in attempt to push the presenting part away from the cord to allow blood flow to the umbilical cord. Do not attempt to place the cord inside the vagina. Do not permit additional cord to escape from vagina. Hand must remain in vagina until baby is delivered, or continuous monitoring shows normal fetal heart tones with contractions. • If the cord is protruding from the vagina, cover it with sterile saline dressing. • Definitive therapy for a prolapsed cord is Caesarean Section. PLACENTA PREVIA / PROLAPSED CORD 15-7 Dr. Sandra Schwemmer, Do Page 1 of 1 657 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate POST-PARTUM HEMORRHAGE (PPH) Blood loss >500ml's after vaginal delivery or >1000ml's of blood after c- section is considered a post-partum hemorrhage. Signs and symptoms include, flaccid and no uterine contractions, indications of shock post-delivery. Treatment: • Determine onset of bleeding • Evaluate perineum, vagina, cervix for injuries and bleeding and apply direct pressure or ice packs for hematomas; • May require bi-manual fundal massage q 5-15 min as indicated by bleeding and clots; • Left lateral tilt to relieve pressure of the vena cava AMNIOTIC FLUID EMBOLUS Occurs when amniotic fluid gains access to the maternal circulation during labor or delivery resulting in obstruction of the pulmonary vasculature. Signs and Symptoms: Acute shortness of breath, agitation, signs of hypoxia, chest pain, cyanosis, etc. Treatment: • Intubation may be indicated for rapidly deteriorating patient; • Ventilator supported patients may require PEEP: start @ 5cmH2O; • Monitor mother and fetus (fetal monitor) frequently and treat mother's symptoms as indicated; • Watch for evidence of D.I.C. CERVICAL OR PERINEAL LACERATIONS Treatment: • Direct pressure until it can be repaired; • Make note on how many cc's of blood and how many pads and/or dressings used to control bleeding; • Fluid resuscitation as indicated POST PARTUM HEMORAGE / AMNIOTIC FLUID EMBOLUS / CERVICAL OR PERINEAL LACERATIONS Dr. Sandra Schwemmer, Do Page 1 of 1 =5- g 658 Monroe County Fire Rescue Trauma Star Medical Protocols Fellow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate PRE-ECLAMPSIA A condition of pregnancy characterized by hypertension, edema, and proteinuria, which occurs usually after 20 weeks gestation. Treatment: • Assess uterine activity initially and get recording, if available. • Change in FHR, re-position patient • If labor is not present and seizures occur, observe for sudden onset of labor or evidence of abruption of placenta. Treat systolic BP greater than160mmHg and/or diastolic BP greater than 100mmHg: Administer: • II,,,,.albet°al1l61l5,,,,10urn g IIVIl::1 If patient's BP does not normalize. Administer • loading dose of I a nesliiuirn Sulllfat°e„ o Mix 4g (8ml of 50% solution) in 100ml NS and infuse as tolerated over 20- 30 minutes; followed by a maintenance 2-4g/hr infusion (4g in 1000 ml NS), if needed. Discontinue infusion If signs/symptoms of Magnesium Sulfate Toxicity develop: • if respiratory rate becomes less than 12/minute o Calllcliiuirn Chlllorliide 10%, 1 girn slllow IIVIII°1 over 3 urnliinut°es. o Assist ventilations with supplemental oxygen and ventilatory support as needed. o Have airway, suction, and oxygen ready for immediate use should seizures occur. o Assess for the development of or increasing severity of frontal headache, blurred vision, spots before the eyes, nausea, vomiting and/or epigastric pain. These indicate central nervous system involvement and worsening condition. Epigastric pain frequently precedes seizures. PRE-ECLAMPSIA / ECLAMPSIA F Q Dr. Sandra Schwemmer, DO " " 659 Page 1 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate ECLAMPSIA Signs and Symptoms: Grandmal seizure / Coma in patients with severe pre-eclampsia If Seizure Occurs: • Make sure the patient is in a lateral position and protect from injury. • Secure airway as necessary. Administer high-flow oxygen via NRB. Suction as needed to maintain an open airway. • Administer o Versed 2 51rng every 2 3 urnliinut°es III III°1 OR o t°livain T 21rng II III°1 If loading dose of Magnesium Sulfate was not previously given during pre-eclamptic phase • Administer loading dose of Ilia nesliiuurn SW'fat°e„ o Il liix 4,g (Ournlll of 50% solllut°liion) liiin 100urnlll IIINS and infuse as tolerated over 20-30 minutes; • Followed by maintenance infusion of Ilia nesliiuurn Sulllfat°e (dliilllut°ed) 2,,,, , urnlhir, o 4,,,,,6 of a 20% solllut°liioin is suggested. (Dilute the 50% solution by half to obtain the 20% dilution required). Example: 8ml (4g of the 50% solution diluted with 20ml of NS would give a 20% solution) Discontinue infusion If signs/symptoms of Magnesium Sulfate Toxicity develop: • if respiratory rate becomes less than 12/minute o Calllcliiuurn Chllloidde 10%, 1 girn slllow II III°1 over 3 urnliinut°es. o Assist ventilations with supplemental oxygen and ventilatory support as needed. PRE-ECLAMPSIA / ECLAMPSIA F Q Dr. Sandra Schwemmer, DO " " 660 Page 2 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate PRETERM LABOR Preterm labor is labor that occurs between 20 and 37 weeks gestation. To assess maternal/fetal status, provide physiological and psychological support and monitor tocolytic effects when attempts are made to slow/stop labor. Tocolytic drugs are used to delay labor for a short time (< 48hr) and include terbutaline, nifedipine, and NAISDs and are not usually used before 24 wks gestation. Treatment: • Contractions can be caused by dehydration in the mother so initiate 500cc bolllus 1pirliioir t°o t°ocolllyt°liic t°Iheiralpy when there is a history of fluid depletion; • Monitor contraction frequency and duration, observe for pooling of possible amniotic fluid and collect a sample if possible. Vaginal exams are not to be performed by Trauma Star crewmembers unless delivery is imminent • Be prepared for delivery; • Maintain antibiotics if sending hospital initiated; • Antepartum steroids may have been administered to the patient prior to your arrival to accelerate fetal lung maturity this information should be provided to receiving facility. Contractions occurring every 10 minutes or less and lasting at least 30 seconds administer • "'Teirlbut°alllliine 0 251rng SQ if maternal HR is <120 bpm and there is no history of cardiac disease. Second dose may be administered within 20min if needed and patient HR remains <120 bpm and show no signs of tremors, flushing or restlessness. o If Terbutaline has been administered >60 min prior to take off, may repeat dose as needed and tolerated by patient every 20 min. up to a maximum total dose of 1 mg. • I a nesliiuirn Sulllfat°e o Loading DOSE: 4 urns liiin 1001cc IIINS over 20 30 urnliiinut°es. o Maintenance DOSE: 2,,,, , irnihir (diluted to 20% solution) (Dilute the 50% solution by half to obtain the 20% dilution required). Example: 8ml (4g of the 50% solution diluted with 20ml of NS would give a 20% solution) Discontinue infusion If signs/symptoms of Magnesium Sulfate Toxicity develop: • if respiratory rate becomes less than 12/minute o Calllcliiuirn Chlllorliide 10%, 1 girn slllow IIVIII°1 over 3 urnliinut°es. PRETERM LABOR / PPROM Dr. Sandra Schwemmer, DO 115-10 661 Monroe County Fire Rescue Trauma Star Medical Protocols PRE-TERM PREMATURE RUPTURE OF MEMBRANES (PPROM) Rupture of the amniotic membranes in a pregnancy of preterm gestation (prior to 37 weeks). • Obtain History of PPROM- time, color, amount, and odor • Avoid letting the patient sit or bend to avoid pressure on the cervix during transport. • Monitor contraction frequency and duration without vaginal exams if the membranes are ruptured, unless delivery is imminent, fetal bradycardia or prolapsed cord; • The major complication associated with pre-term labor is delivery of an immature fetus: Be prepared for delivery and resuscitation. PRETERM LABOR / PPROM Dr. Sandra Schwemmer, DO 15-10 662 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk ©B Assessment/Care Protocols as appropriate VAGINAL DELIVERY Every attempt should be made to determine if delivery is imminent prior to accepting patient for air transport. However, delivery should always be anticipated. If in flight delivery occurs consider DIVERSION if newborn is in distress. Prior to departure from Hospital: • Obtain additional blankets, multiple towels from hosp. • Ensure a body bag is placed on stretcher to contain membranes / amniotic fluid • Move OB kit and Handtevy Pediatric bag to main patient compartment Treatment: • Determine if delivery is imminent o Visible presenting part, bulging perineum, pt. stating `I have to push' • Assess perineum- bulging, bleeding, cord, meconium, presenting part • Apply pressure/ support to perineum • If membranes are intact and the fetus is crowning, then perforate them before the head is delivered, remove them from face • Slowly deliver the head, firmly supporting it and the perineum • Bulb suction the infant's mouth than nose before delivering the body • Guide baby's head down to assist delivery of anterior shoulder then up to assist with posterior shoulder Nuchal Cord — cord wrapped around infants' neck • During delivery of head, check for nuchal cord, if present and loose, attempt to reduce it by slipping overthe baby's head; • If cord is tight, unable to reduce- clamp twice and carefully cut between clamps • Once cord is removed or cut then prepare for delivery Once delivery is complete Late cord clamping (performed approximately 1-3 min after birth) is recommended for all births, while initiating simultaneous essential neonatal care. Early umbilical cord clamping (less than 1 min after birth) is not recommended • Hold baby securely and stimulate by drying or flicking soles of feet • Place baby on mother's chest or stomach and assess airway / need for resuscitation. VAGINAL DELIVERY Dr. Sandra Schwemmer, DO Page 1 of 2 15-11 663 Monroe County Fire Rescue Trauma Star Medical Protocols • Do not clamp / cut cord unless the neonate is asphyxiated and needs to be moved immediately for resuscitation. For basic newborn resuscitation, if you can provide effective positive-pressure ventilation without cutting the umbilical cord, ventilation can be initiated before cutting the cord. • If the placental circulation is not intact, such as in the case of abnormal placentation, placental abruption, umbilical cord avulsion, maternal hemodynamic instability or the need for immediate resuscitation of the newborn immediate cord clamping is appropriate. • Second flight crew member - assess / treat neonate according to appropriate neonatal protocol (Section 16) 1-3 minutes after birth Clamping "not earlier than one minute" should be understood as the lower limit period supported by published evidence. • Clamp the cord at least 1" from the stump and again 1" from that clamp and cut between them • If possible, retain sample of cord blood • Assess perineum for tears/ lacerations and bleeding • Allow placenta to separate on its own • Apply fundal pressure/ massage as needed for bleeding/ placenta delivery • Apply ice to perineum for control of swelling and/or bleeding from tears/ lacerations needing repair • Watch for signs of postpartum hemorrhage; frequent fundal checks with massage as needed VAGINAL DELIVERY Dr. Sandra Schwemmer, DO Page 2 of 2 15-11 664 Monroe County Fire Rescue Trauma Star Medical Protocols COMPROMISED NEWBORN Treatment: • Dry, warm, and stimulate infant. • Clear and maintain a patent airway • If infant is not responding, rub vigorously and administer oxygen by mask. • Suction mouth first and then nose with bulb syringe. If the infant is not effectively breathing after 15-30 seconds of stimulation and oxygen • Ventilate with BVM. Use neutral or sniffing position, ventilating enough to observe good rise and fall of the chest. Ventilations should be at a rate of 40- 60/minute. Monitor response: chest movement, breath sounds, color, tone, and heart rate. • Insert NG/OG tube to prevent gastric distention if prolonged ventilation. If heart rate does not improve and infant does not begin to breath • Intubate and continue to ventilate. • Begin chest compressions at a rate of at least 100/min if heart rate is less than 60 despite adequate ventilation for 30-60 seconds. • Monitor cardiac rhythm as possible. • Establish IV/IO access. • Continue resuscitation COMPRIMISED NEWBORN Dr. Sandra Schwemmer, Do Page 1 of 1 16-1 665 Monroe County Fire Rescue Trauma Star Medical Protocols NEONATAL ENDOTRACHEAL INTUBATION While preparing for incubation, ventilate via BVM and supplemental oxygen to restore good skin color and adequate heart rate. Select proper tube size: o Tiny premature (<2.5lbs): 2.5mm o Other premature and average size (3-7lbs): 3.Omm o Larger infants: 3.5mm Treatment: • Place patient's head in proper head positioning which is the neutral or sniffing position. • Insert laryngoscope with small straight blade along the right side of the mouth; push tongue to left. • Prolonged pharyngeal stimulation will induce bradycardia and even heart block in some infants. • Visualize cords and suction as required. • Insert tip of endotracheal tube 1-2cm past glottis. Stabilize endotracheal tube with fingers. • Confirm endotracheal tube placement via no auscultation of epigastric sounds and auscultation of clear, equal breath sounds. • Secure endotracheal tube via tape. Until tube is secured, place middle finger of dominant hand on endotracheal tube and press tube into hard palate to secure tube. The rest of the hand will hold the jaw and provide a secure hold on endotracheal tube. • Document endotracheal tube depth marking at gum line. • Utilize ETCO2 detector and document waveform. • Insert Ng/OG tube and decompress stomach to allow for more effective ventilations. NEONATAL ENDOTRACHEAL INTUBATION Dr. Sandra Schwemmer, Do Page 1 of 1 =6- 666 Monroe County Fire Rescue Trauma Star Medical Protocols NEONATAL STABILIZATION Provide warmth • dry thoroughly • remove wet towels • cover head • keep out of draft Open airway, sniffing position: • bulb suction, suction both mouth and nares, avoid prolonged suction • Particulate meconium or depressed baby- incubate and perform direct tracheal suctioning • Stimulate respirations- rub back, flick soles of feet No active response- respirations or crying after two attempts • Provide PPV via BVM-15-40 cm/H20 @ 40-60 bpm with Fi02=100% for 30 seconds and observe easy rise and fall of chest Pause to evaluate: APGAR @ 1 minute and 5 minutes • 02 blow-by of 80% for HR >80, RR adequate w/central cyanosis- DO NOT OVERSTIMULATE, slowly withdraw 02 if baby stays pink; • 02 PPV/BVM @ 100% HR <80 not increasing, RR- gasping/apneic w/central cyanosis; • Continue PPV/BVM until HR>100 w/adequate respirations; • PPV >5 min consider OG tube, if available, for gastric decompression; • Reassess HR after 30 seconds and @ 2 minutes • BVM/PPV ineffective or prolonged need for ventilation, then ETI • HR<60 or 60-80 and not increasing w/vent. and stimulation, begin chest compressions Respiratory depressed infant known or suspected maternal drug use • Narcain 0 lirng/kg IV,IM, SQ or ET q 2-3 min up to 1 mg. Glucose <40 mg/di: • IG)10 2,,,, , cc/kg IV / IO over 3-5 min • Re-check BS q 15-30 minutes NEONATAL STABILIZATION Dr. Sandra Schwemmer, Do Page 1 of 1 =6- 667 Monroe County Fire Rescue Trauma Star Medical Protocols NEONATAL PERSISTANT PULMONARY HYPERTENSION Avoid stressors: Hypoxia, acidosis, pain, agitation, hypoglycemia, hypovolemia Assess respiratory status closely and support with Fi02 & ventilation as necessary. Monitor pre- and post-ductal oxygen saturations. Treatment • Correct metabolic acidosis. • Sedate: o Fent°anylll 1,,,,2 rrnc /I and/or Illiidaolllarrn 0 1irng11kg if blood pressure stable. • Monitor glucose level closely. • Monitor for hypotension & hypoperfusion. o Dolparrnliine 10,,,, 0 imcgilkg1irnl1in may be initiated o Consider Il ocuronliiuirn 0,6 rng11kg IV to facilitate ventilation. Consult receiving neonatologist prior to administration. Dr. Sandra Schwemmer, DO 16-4 668 Monroe County Fire Rescue Trauma Star Medical Protocols BLOOD TRANSFUSION Step Action 1 Obtain Consent from patient or family if possible 2 0- (0 negative) PRBC will be used for transfusion Ensure PRBCs have been maintained per policy (temperature WNL, ports WNL) 3 Verify Unit number and blood type are the same on unit and transfusion form. If there are any problems with blood temperature, ports, or discrepancy in unit number or blood type, document problem and return to Oneblood. Ensure IV access and patency. 18 gauge or larger preferred. IO is acceptable 4 No other medications can be given through blood administration IV line. Ensure you have a 2nd IV line for all other medication. 5 Adults give 1-2 units Pediatrics <13 give 1-2 10mi/kg bolus Ensure appropriate equipment and supplies 1L bag 0.9% NS 6 Pressure bag Y Blood tubing Blood filter Blood warmer. Adult Prime Blood tubing and filter with 0.9% NS and insert filter into blood warmer. Ensure all clamps on blood tubing and filter are clamped off. 7 Pediatric Prime syringe pump tubing and filter and insert into blood warmer. Ensure all clamps on blood tubing and filter are clamped off. Prime 1000ml bag of 0.9% NS with 10 tt set and have ready to infuse. Adult Place blood on pressure bag and Spike blood bag. 8 Pressure bag should not exceed 300mmHg of pressure Pediatric Draw up blood amount into 60cc syringe and attach to syringe um tubing. 9 Obtain baseline Temperature, B/P, HR, RR, and Sa02 Start Blood Transfusion. Monitor for cardiac rhythm, and signs and symptoms of reaction. 10 If reaction occurs, document reaction and follow transfusion reaction guidelines. Document Temperature with VS every 15 minutes during transfusion. (Temperature should not exceed 39 C When the transfusion is complete Flush blood line with NS Document final Temperature with VS 11 Remove blood tubing and discard. Flush IV site Continue to monitor for reactions. Complete Uncrossmatched Emergency Blood Release Form and Transfusion Record Completed and partially used units and original completed transfusion report is to be given 12 to receiving facility nurse. (make copy of transfusion report for TS records). Have receiving nurse sign Uncrossmatched Emergency blood release form. 13 Send email to Chief Flight Nurse for Usage Notification / Re-ordering BLOOD TRANSFUSION 17-1 669 Dr. Sandra Schwemmer, DO Page 1 of 5 Monroe County Fire Rescue Trauma Star Medical Protocols Blood Transfusion Reaction Guidelines Reaction Treatment For mild skin itching, do not stop transfusion Allergic Reaction administer Diphenhydramine. • Adults o 2 n'ng IIVII::pry • Pediatric o "q mg/kg not to exceed 2 nng • Immediately Discontinue transfusion. Fever and Chills • Hang 0.9% NS to keep vein open. (If SBP less than 90 administer NS at a rate to maintain SBP >90.) • Notify Medical Director • Closely monitor VS and 1&0 • Give remaining blood to receiving facility • Immediately Discontinue transfusion. Anaphylactic Reaction • Hang 0.9% NS to keep vein open. (If SBP less than 90 administer NS at a rate to maintain SBP >90.) • Notify Medical Director • f::ollllowAirnallplhyllactJic protocol • Closely monitor VS and 1&0 • Give remaining blood to receiving facility Febrile Transfusion Reaction • Immediately Discontinue transfusion. Defined as increase in temperature during Hang 0.9% NS to keep vein open. (If SBP transfusion. less than 90 administer NS at a rate to maintain SBP >90.) Symptoms include temperature increase of 1- 0Notify Medical Director degree C greater than baseline. Other symptoms • Administer in 2nd IV line include chills, headache, facial flushing, 2 nng IIVII::� palpitations, cough, chest tightness, increase in pulse rate and flank pain. 0 Closely monitor VS and 1&0 • Give remaining blood to receiving facility Hemolytic Transfusion Reaction • Aggressive NS infusion Defined as immediate lysis of transfused red 0Notify Medical Director blood cells can result in fever and or tachycardia. 0 Closely monitor VS and 1&0 Immediately Discontinue transfusion Symptoms include chills, back/flank pain, 0 Give remaining blood to receiving facility nausea/vomiting, dyspnea, flushing, bleeding, hypotension, increase in baseline temperature by 1-degree C, headache, facial flushing, palpitation, chest tightness, and cough. BLOOD TRANSFUSION 17-1 Dr. Sandra Schwemmer, DO Page 2 of 5 670 Monroe County Fire Rescue Trauma Star Medical Protocols Reaction Treatment Dilutional Thrombocytopenia Defined as platelet loss due to absence of viable platelets in PRBC. Generally seen in large 0 Immediately Discontinue transfusion. quantities of PRBC transfusions to treat trauma or Hang 0.9% NS to keep vein open. (If SBP massive hemorrhage. It is caused by platelet loss less than 90 administer NS at a rate to out of the body and platelet dilution with replaced red cells and crystalloids. maintain SBP >90.) • Notify Medical Director This is generally not seen with infusion of 1-2 • Closely monitor VS and I&O units, unless a patient has pre-existing • Give remaining blood to receiving facility thrombocytopenia or disseminated intravascular coagulation(DIC). Symptoms include oozing from mucosa, wounds or puncture sites, petechial spots, ecchymosis, and S/S of DIC Potassium Intoxication • Hold Transfusion Defined as hyperkalemia, and is a common 0 Consult Medical director to see if infusion complication in mass transfusion of stored blood. should be continued. Stored RBC usually contains more than 60MEQ/L 0 Ilurrilifiate III°lyperkalleirr is protocol of potassium. Closely Monitor VS, and I&O Symptoms include flaccidity, muscle twitching, • If cardiac arrest occurs, follow cardiac bradycardia, EKG changes, (tall peaked T-waves, arrest protocol prolonged P-R interval, and QRS)and cardiac arrest. Hypocalcemia • Hold Transfusion (from citrate intoxicity that binds Ca) 0 Consult Medical director to see if infusion Patients with acute or chronic hepatic insufficiency should be continued. are at relatively higher risk of citrate toxicity. To dirriii-0ster Callcliu rri Gllucouriate "q girn avoid Citrate toxicity, adirrdir0ster IlfDllf1I13C at a show IIVlID in 2nd IV. irriii-0irnu rri rate of"q a init over 6 mii-m-tes and • Closely Monitor VS, and I&O avoid rapid transfusion. Symptoms include arrhythmias, hypotension, muscle cramping, nausea, vomiting seizure activity, and tingling sensation in the fingers. Hypothermia 0 Hold Transfusion Symptom include chills, shivering, hypotension, 0Consult Medical director to see if infusion arrhythmias, bradycardia, cardiac arrest. should be continued. • Warm patient • Obtain 12 lead EKG • Warm blood if transfusion is resumed • If cardiac arrest occurs, follow cardiac arrest protocol BLOOD TRANSFUSION 17-1 Dr. Sandra Schwemmer, DO Page 3 of 5 671 Monroe County Fire Rescue Trauma Star Medical Protocols Documentation of Transfusion Form C MIKk Y IItII r:,�",49 ,/ i r UC,�h.NS J1%K. IN)Rd V rw',fl,Rn 75915 f C'Iu14Wrii r"1....7.21 .5M.i 14—:ifaluarrm Order; Lo IltcwaRw.m.il W."C awiirwwr L7y'pI t,R t:a,irmm. Phly'Wii6.n P4M a rm A f W5,111JI I_u'.I:ryne 'nM"t'd'k,.3 C.x Nt637RtU1 -ii➢ tlulnk rw.my(Xiltrr m""ii n,lartint IN 1~0J82 t A lL., IJ'R, ' JCWIL"M'lUi NC'vEll`-M Cblm lz.ae:ra iLMmluu ma' rr#n-ws: 11'2/311 w"2:0'1.113,23:41919" �a';TA I.II�Y'Ni�tl. 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' baseline, it iyasalllllae ifis r ueaaf r than or T.�r`NI ENDED at0,a9 9Ft ra'"IF 3 C ca it Ilan a�.� Armurltlllmfu Infused, M,a &>a9dt6IFf3TC" I r"ItlAls Shock, In Il,alrjucaria c 5.1p,Change „.'"vP,e F'l ^aurralh 'Tk+4iadlld..at Record V.II N1 R�',.I) ;u �11uw�;tl"R¢n,wsrr r3f P¢�,l,renth,1"IIL yepnea IWt�usm�2s I imu" M P PT.... ':'P PIULSC I^ to raa Jauadndirae vast Lo anion R;IM,t, x'n ea�at Q t............. . 7'D,. ................ .. F"l°u"r s+nc:laill notified a,�t Itr�apnusRiuJsiion ineartl^rwn:'�' ,-.. `w' :� 1� TI airrslma wean xSer%dca notified of�r ctiionw, �.�YES .... Sarg iruaN.i9 Tee Send rama,inaM9e>fr of lalesod,,.with a orw plole ntia.nnnwtunsuixyn savl, ,Q%-;Iy ....... ......... uafi lha;,ae-rri,rk.and rmesh ss'arr,Pate tea thin,Transtuason Seroice ----------------------------- is y IR auction OI servedl � Tea lerll 1 CR M'onnImne am,ptart af 01,0,Uri iietttR rc.�.rs..,.., ......, ................................ :. u-tR-'. 1Ruro^cmw'U uGo.u�:wnrvv:&. T,i w A pIvi-lu.aik.n.'dtr.a®—I orth6.s r va Nil, ST, "ku,wa.Il,a,t uu re. ,lay mn aC:P,mnalllfllood. Rrne. CO3A1alhjmt 1b,iIItI1t Mum,orf,9nl'1@e t^^RIV dM IB^NNN£M I-M A"'IlAxu'0'0u1 R"ela,I:avl,til4a„&.`9tla� U It.aM1.NIAr"nrl4h () pI Ali,At W`0:9,6811I'8a37 189amm0 Urrl'zulllrrailik5+un �IgAN t..D lbll l.:F This farm is attached to blood unit and must be completed during transfusion. Bottom portion MUST remain attached to blood unit bag, Original Form and blood unit bag is given to Receiving Hospital. A copy of the completed form is needed for TS record. BLOOD TRANSFUSION 17-1 Dr. Sandra Schwemmer, DO Page 4 of 5 672 Monroe County Fire Rescue Trauma Star Medical Protocols Uncrossmatched Emergency Blood Release Form plc ;o nii,',, b 10 c."),d E--rg—cy'Release,Blond Release Form Patrent's IName: Date: Flight Number: Crevw: Receiving Hospital&Room# Atte-nding Phqsician Blood Cartifiled as Cnmpatibile for this panent cannnt b-esuppilied due,to urgent need.,Compatib,illity testing JABO/Rh,Antibody detectiian andcrqssFyaat5jqpgj was mat preformed pnior to trainsfusion. Patrent received unrts of Red IBlood Cellis i=O Positive c3 0 Negatwe Liquid Plasma Units Farnalle of chilidbearing age ireceived units of 4D Positive Red Cellis and m ay need JRh,g The above-uiriit3 were infused in the interest of protecting this patient from exsanguinati,an,-we do inot take responsilbi lity for completion�of compatibil Ity of the Ibluod with the patient. The unit nuirdberi s)transfused are: Unit# Sload Compmnent Start, End Turna AM, r�jnfujseol Type Tiime Vital Signs at Receiving Hospital Time: HR: BP R ESP TEJMP / I I Patient exhiltmed sigins/symptmms of transfusion reaction during transpo,rt tto YES 1=No(irnairk ones If Yes Signs ands m toms noted: I Tirne of reaction: Data: Flight Crew it signature Printed narnL-, Data: Flight Crew 2 sig)nature P'irinitedl narnL-, I understand the re,,ffardirE t1he erne,rgarry administration of blood and airn aware of the need to complete com pat3bil ity testing and the Ipossible inead far ad ministrati on Of Rh, jg- Signed: RN Date: Receiving INiurse The clinica I condition for the a bo%e nairned patment iiis sufficiently urgent to,necessitate this ernergencV transfusion before compatilbillivo tasting could ba completed.The banefits of the transfUsian olutweigh, the potential risk. Signed-- rQq 1) Data:: FteceiirVing Physician IFlight crewwilli Ipronmide a phatc,copy afthis foxim,iiin acldffian to the cornplieted PCR including all vital signis,to the raceiViing.The m4giinal willi Ibe maintadrad%with the patient's Rig;ht rerairds—' orieblitc>r, d mp 1 4 g I nf 'I RVANXIEWARMINEW Form needs to be completed and signature of receiving nurse obtained. MD signature is not required. This form is for TS records. BLOOD TRANSFUSION 17-1 Dr. Sandra Schwernmer, DO Page 5 of 5 673 Monroe County Fire Rescue Trauma Star Medical Protocols BELMONT BUDDY BLOOD WARMER �P, rviiiivirwikr,rPSXa,m,rm o,00airiiy `,Ww,vJry ii,>U'//G'1//Or,,,,. 4 and i/ �I smourrranrrNOMYV�➢�'nrnrrrrrrq!�%wrurrrn� rriNav 4r il/ iy w rr is w.GiaMoou, nrrNi wwiall/%w,w sllr,tiai 6VA 1�1w!' . y „ 1 . Battery Pack 2. Dual heater plates 3. Large venting membrane Filter 4.Clamp to close line off 5. Pressure regulating valve 6.One-way valve 7. Bed sheet clamps BELMONT BUDDY BLOOD WARMER 17-2 674 Dr. Sandra Schwemmer, DO Page 1 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols BELMONT BUDDY BLOOD WARMER Step Action • Place buddy set into heater • Align red end of filter with red end of heater. Set U • Close the heater. Click should be heard when closed. • Prime Blood tubing with Normal Saline Priming • Connect blood tubing to IIIti�lll���iee end of buddy set. • Prime the set by running NS through set tap heater while priming set to discourage bubbles. There is no need to remove red cap for priming. • Turn the heater on. A tiee light confirms Operation operation. • Connect the red end to patient IV site. • Secure the heater to the sheet with the green clip. • Start Blood infusion. • Alarms are indicated by red LED on battery Alarm housing. • Alarm cleared by turning off and on again. • Indicator is located on the base of the unit Battery l " Charge BELMONT BUDDY BLOOD WARMER 17-2 675 Dr. Sandra Schwemmer, DO Page 2 of 2 cfl ti cfl M ti W h� O W W U � O h� UJO ^ O za O J OU H W G OW z0 O 2 O h� O � 0 3 U C 0 ti ti cfl i ti W O W W U � O ^ U L UJO �- a OU vo a u > z O � O h� O � 0 3 U C 0 Monroe County Fire Rescue Trauma Star Medical Protocols Baxter AS50 Pump Syringe Status Display /� �aill�ll`I �iels �I�oh11119dIIIIIIII Plunger Clamp /i /// w fwu'ru'�VYrvvikry 4rwwwr Out+V WP Ipl//j ,,,/1,i v,lrl / Key Pad I j Flange Slot f , Barrel Clamp„ r IE f �r r Ji - / i /,Ji ////✓ ii p}Y�f\Ir JAW))IiNN1191➢Al➢IIPm9111 ✓ f6 M V / I f i II Charger Port e ON/OFF Switch Barrel Release Clamp BAXTER AS50 SYRINGE PUMP 17-5 s7s Dr. Sandra Schwemmer, DO Page 1 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols SYRINGE PUMP SET UP Luer Lock Tip Barrel Flange Plunger Pump Tubing r r�e, )' NOR i i /l I / Pull out plunger clamp, place syringe plunger into clamp and press clamp /1 firmly to capture l Jff iouuuNuuuuuulllU�NuuNw000i�a uMPpluu a 1 ma I f Release Barrel Clamp, place Flange of syringe into flange slat m��nw..��«„�,,,,,�n«,�����«n«,,,�,n«,,, and press barrel clamp firmly i against syringe at- IN r M Secure pump tubing to leer lock on syringe. BAXTER AS50 SYRINGE PUMP 17-5 s79 Dr. Sandra Schwemmer, DO Page 2 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols Step Action 1 Draw up medication/Fluid into syringe. Secure IV tubing to luer lock end of syringe. Prime medication through IV tube. Clamp tubing. 2 Release Barrel Clamp and ensure plunger clamp is at the top of the pump. 3 Place Flange of syringe into Flange slot and press barrel clamp firmly against syringe, then pull plunger clamp,pull plunger clamp out all the way, slide clamp down to the end of plunger then release, then press clamp firmly around plunger so plunger captures. 4 Turn on Pump. Check battery power by pressing and holding confirm button while pump turns on. 5 First menu that will appear will be the Library menu use down arrow on key ad and select None and press confirm button 6 Mode Menu will be your next menu use down arrows to select ML/HR and press Confirm button. 7 MFR with will be the next menu use down arrows to select the brand of syringe you have with will either B-D or Monojet press Confirm button once brand has been selected. 8 Select size will be the next menu use down arrows to select to the syringe size and press Confirm button once size has been selected. 9 Enter Rate will be the next menu. Enter your desired rate by using the number on the key pad and press Confirm button once the rate has been entered. 10 Vol Limit will be the next menu. Enter desired volume limited using the numbers on the key pad, limit will dependant upon the size of syringe you have choosen, and can not exceed the amount of the size of the syringe choosen. Press Confirm button once volume limit as been entered. 11 Once all menu have been completed and confirmed. Assess IV tubing and IV site to make sure all clamps are unclamped and tubing is not kinked, then press Start button. Pump should show running on screen and Green light should show in Run section on pump. BAXTER AS50 SYRINGE PUMP 17-5 sso Dr. Sandra Schwemmer, DO Page 3 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols Alarm Correction Check Barrel Make sure the syringe is centered in the barrel clamp, and that the syringe Pump has detected that the barrel flange is in the flange slot. To ensure clamp is not fully closed on the that the syringe is properly seated. syringe barrel, or the syringe barrel Press the barrel clamp firmly against is not properly seated in the Flange the syringe. slot. Check Flange Make sure the syringe is centered in the barrel clamp, and that the syringe Pump as detected that the syringe flange is in the flange slot. To ensure flange is noted seated in the flange that the syringe is properly seated. slot. Press the barrel clamp firmly against the syringe. Check Plunger Grasp the finger frip on the plunger clamp and pull it all the way out. Slide Pump has detected that the plunger the clamp down until it contacts the capture mechanism has not syringe plunger. Push in firmly. captured the syringe lun er. Check Syringe Check flange, barrel, and plunger, and ensure that they are mounted At least two of the three syringe correctly. mounting points (flange, barrel, plunger) are not correctly positioned. Line Occluded Check for empty syringe, kinked tubing, clogged IV catheter, and There is an occlusion, line foreign material preventing movement constriction, or other condition that of the pump mechanism. causes excess plunger force. Releieve residual syringe pressue by releasing the plunger clamp. If plunger clamp is not released an unintentional bolus may occur when blockage is cleared. BAXTER AS50 SYRINGE PUMP 17-5 ss� Dr. Sandra Schwemmer, DO Page 4 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols BAXTER AS50 PUMP GUIDELINE 1 When To Check Library Battery appears power J use Press and ,, gaoq qq Imq` down hold w to Confirm q° .— BW#ton IggaW�l�aq��in'twlm�igalva select Done while and then turning Confirm on. % anq�� u�uuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuiuuuuuuuuuuuuuuuuuuuuuuuuuuumo l �. uuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu � y @gggqYY���pp� i iarmo%iN%CIA/I1t1J007111�W1i1iJ110u�INM9rnP,YObyNtiDN61Yi➢/2 ` �7��,�YW>iL9 iYu 09g9� ' galq'RX�q%�W'rgfl'+uuroiywn,;: _... To Select To Select mode, MFR use �� down down / arrow and arrow to MUHR select and then your press `�� 1 ,,°qqq Syringe Confirm U ,, 'ram type Buton either B- D or Monoaet Rio Iommmglllw�mow and then 0mglalgauwl uuum dress �J1106q�0 uummmuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu BAXTER AS50 SYRINGE PUMP 17-5 ss2 Dr. Sandra Schwemmer, DO Page 5 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols BAXTER AS50 PUMP GUIDELINE To Select To Enter 11 syringe Rate, size use type the down desired arrow, rate and %r select j then size of press syringe Confirm and then Button press 000 Con-firm 000 muuuuuuuuuuuuuuuuuuuuuuuuuuuuuumiuuuumi ��� .. iNm� '''��i�ar�9NnimGu'(^wiu�rw�n,littwim, UJMWll@IWwNINNOIWUIW,uliwYlV4�` Once all menus have been To Enter and selected Volume confirmed Limit, type �� Press the Start amount ' Button. based on �F syringe � \�o� Green S %� �' i '' � „.. then and 4��Qu� light 0 size .....m.__ should press appear in Confirmuu,u,,u,,u,,u,,u,,u,,u,,u,,u„ Button Run � ' ��II��� uuuumiuuuuuuuuuuuuuuuuuuuuuuuuuuuuuumuuuuuuuuuuuuuuuuuuuuuuuuuuuuuumumd i A� o1�Pt�ie� OVUM ((ffffiell, 11171711 MI, BAXTER AS50 SYRINGE PUMP 17-5 6s3 Dr. Sandra Schwemmer, DO Page 6 of 6 dq co (D i ti W O W W � W U ~ Q WCL U ❑ � � W Za I W J N J Q UOQ ca O W W 2 02 2 Z O ❑ � O a h� O b 0 E 3 U C 0 Monroe County Fire Rescue Trauma Star Procedures PELVIC BINDER The pelvic binder will be used to provide stabilization, aid in pain management, and attempt to lower the mortality rate when caring for patients that have possible pelvic fractures. Use the pelvic binder as initial treatment of a suspected pelvic fracture to help prevent blood loss and aid in pain control. Indications: • Known or suspected pelvic fractures and/or `Open-Book' type fractures with orw/o hemorrhage. Contraindications: • Not to be used if there is an impaled object in the area within confines of binder. T-POD@l Pelvic Stabilization Device -rah Detectable Tab 41 o; kyir, ! ail , IT�2N Myl Wif r Application 71,7J'W t �1 Hli tcry Label t 1 lli >>� Pull Tab Mechanical Advantage Pulley System Dr. Sandra Schwemmer, DO PELVIC BINDER 17-7 Page 1 of 3 685 Monroe County Fire Rescue Trauma Star Procedures Application Pracedure 1 . Slide Bolt under su�piin patient and into position under the pelvis. r 2. Trim the Belt, leaving a 6-8511 gap over the center of the %j pelvis. 4 ` , . Apply Velcro-hacked Mechanical Advantage TAN Pulley System to each, side of the, trimmed Belt. 1 Y U �ivc . Slowly draw tensioni on the, Dull doh, creating simultaneous, circumferential , t r compression. ) Dr. Sandra Schwemmer, DO PELVIC BINDER 17-7 Page 2 of 3 686 Monroe County Fire Rescue Trauma Star Procedures 5. Secure the Velcro-backed u ° T,, , a"A , Pull Tatra to the Belt. , „rru Jfi� l� 6. Record the date and time of , rl11{ sir 4 ,u � i' application, on the space ,;,, d,�l provided. � gb, , Dr. Sandra Schwemmer, DO PELVIC BINDER 17-7 Page 3 of 3 687 co co (D i ti W O W Z � O WU J Ha O OU � U1 O W W w2 a O z O O 2 a r^ W V 1 ~ O o 0 E 3 U C 0 Monroe County Fire Rescue Trauma Star Medical Protocols VENTILATOR — DRAGER OXYLOG The Oxylog 3000 plus is a time-cycled, volume-controlled and pressure-controlled emergency and transport ventilator for patients requiring mandatory or assisted ventilation with a tidal volume from 50 mL and up. Ventilation functions of the Oxylog 3000 Plus Ventilation Modes: • Volume Controlled Ventilation o VC-CMV/VC-AC o VC-SIMV • Pressure Controlled Ventilation o PC-BIPAP • Support of spontaneous breathing o Spn-CPAP Additional settings for ventilation: • Pressure Support in the following ventilation modes o VC-SIMV, PC-BIPAP, Spn-CPAP • NIV in the ventilation in the following ventilation modes o PC-BIPAP (PS), VC-CMV, VC-SIMV Special Procedures: • Inspiration hold • 02 inhalation with an inhalation mask VENTILATOR — DRAGER OXYLOG 17-9 Dr. Sandra Schwemmer, DO Page 1 of 3 689 Monroe County Fire Rescue Trauma Star Medical Protocols A Eniergency aiir n itake CAUTION: IDO IR T BLOCK EMERAG iN, IR INTAKE P l ino , to, secure the battery compartment cover C Connectors for flow mea&ururing (lines D Gas outlet for breathing hoseIN E Connector for 0 2 SUPPly �alr�rRry ' r J / /4 RF Connector for power suuagpil Gi Connector for CO 2 sensor J, E H Connector for data, c011TuMuulicatiioin cable JJ/iiI /9(Nlyjf, � °11yj°jT1N1 Ji� ;�pX,/ddJ lb% ;U(VIIUI� Ty G%rJT,r,r l�ld�,rf i �,,,, 1 �� J , PEDIATRIC CIRCUT "l=V %M,Wu ', � �� JJ ��f°" raj 8 OR �a of/Jii r ADULT CIRCUT W ,,,,�,,,/ 0�//� VENTILATOR — DRAGER OXYLOG 17-9 Dr. Sandra Schwemmer, DO Page 2 of 3 690 Monroe County Fire Rescue Trauma Star Medical Protocols B, DPPGI �r�c IK IL /�j � �� � �L%lU� � Jfr✓,f//'r�rr � d % UIJ;/✓�' ��a S R Q P O N A Screen with screen pages for the specific IL Key Insp. RHlold for initiating a manual inrs ira.- alpplllcationl flan or for extending the current inmspuratary time. B Key Alarms O to display the alarm settings M l ey )StartrStandby in the"Settings and Allarms"window and to IN display symbols for the power supplly change screen pages Charge status of the internal battery C Huey Setbngs, >( " to display ventillation Mains power supply connected parameters(ventilation screen) in the S-etNigs' 0 Rotary knob for making selections, changing and Alarms"window,and to change screen) and confirming settings paigies �'Control) Iknob for settling the 0 2 conc,enitr'atiilen Ivey for setting the ventilation made SpnCPr P Fi02 E Key for setting the venUatuon modes V -CMV 0 Q Control knob for setting the maximruM VC-"AC inspiiratory pressure Pmax E Key for settling the ventilation mode VG-&IlMV R Control knob for setting the respiratory rate RR G Ivey for setting the ventilation, made PC BIIPAP S Control) Iknob for settung the tidal voluime VT RH Red and yellow alarm indicators T Expdanatiion of color codes for quick pre-settiing I Ivey for suppressing time acoustic alarm sig- of RR and VT nal for 2 minutes tl Key Curves 14) to change between the J Key Alarm Reset for acknowledging alarm presSrure,flow or CC} 2 (opbo,nal)curve in small rnessalgles and large presentation; K Key 0 2 inhalation for 0 2 inhalation or key V Key Values C>> to,change screen pages iin `100%O 2 for 100%0 2 application, dependiing the "Measured Values"window on the option iinmstallIed at manufacture VENTILATOR — DRAGER OXYLOG 17-9 Dr. Sandra Schwemmer, DO Page 3 of 3 691 N tG C) r I r W O W W UJO � W Oa, a Z J I O0 0 25 U J W W Z w O > Z � O V 1 O o 0 E 3 U C 0 M tG r r I r W O W U � Q U W U �1 a UO � a O MQ I z UOV >- W W02 J Z O W O G 2 O > V 1 O b 0 E 3 U C 0 Monroe County Fire Rescue Trauma Star Medical Protocols OB ABBREVIATION LIST ACD- advanced cervical dilation AFI- amniotic fluid index (measure of fluid around fetus) AMA- advanced maternal age (generally >35 y/o) AROM- artificial rupture of membranes ASVD- assisted vaginal delivery- forceps, vacuum, manual rotation BBOW- bulging bag of water (bulging membranes) C/S- cesarean section CEFM- continuous external fetal monitoring CPD- cephalopelvic disproportion CTXS- contractions D&C- dilation and curettage DIC- disseminated intravascular coagulation DTR's- deep tendon reflexes EDC- estimated date of confinement (due date) FHT- fetal heart tones FM- fetal movement G/P- gravida=(pregnancies) / parity=(deliveries >20 weeks GA) GA- gestational age (weeks/days i.e. 24 2/7= 24 wks. 2 days) GBS- group Beta streptococcus (vaginal) GDM- gestational diabetes mellitus IUFD- intrauterine fetal demise IUGR- intrauterine growth restriction LGA- large for gestational age LMP- last menstrual period LTV- low transverse abdominal approach cesarean section OLIGO- oligophydramnios (low amniotic fluid) PIH- pregnancy induced hypertension POLY- polyhydramnios (>than normal AR) PPH- post-partum hemorrhage (EBL >500cc/vaginal del or >1000cc c/s) PPROM- prolonged premature rupture of membranes PROM- prolonged rupture of membranes PTC- preterm contractions (not considered labor) PTD- preterm delivery PTL- preterm labor SAB- spontaneous abortion (miscarriage) SGA- small for gestational age SROM- spontaneous rupture of membranes SSE- sterile speculum exam SVD- spontaneous vaginal delivery SVE- sterile vaginal exam TAB- therapeutic abortion TOL- trial of labor (attempted VBAC) VBAC- vaginal birth after cesarean section OB ABREVIATION LIST Dr. Sandra Schwemmer, Do Page 1 of 1 18-1 694 Monroe County Fire Rescue Trauma Star Medical Protocols VASOACTIVE MEDICATIONS DRUG NAME ONSET CONC UNIT OF MEASURE DRUG TITRATE CLASS Amiodarone Non-specific 450mg/250mg 150mg IVP over 3 min Antiarrhythmic (1mg/ml) 300mg IVP in cardiac D5W only! arrest Infusion 33.3ml/hr over 6 hours Cardizem Minutes 100mg/100ml Continuous infusion- Ca Channel Increase rate 5mg/hr Q (Dilitazem) Can mix in NS or mg/hr Blocker 15 min to desired HR D5W Dose: 5-15mg/hr Diprivan Seconds 1000mg/100mg Continuous infusion- Conscious Increase 5mcg/kg/min (Propofol) vial Mcg/kg/min sedation every 5 minutes to 10mg/ml Dose range: 5-50 desired sedation Pre-mixed me /k /min 1-10 minutes 500mg/250ml Continuous infusion- Vasopressor Increase rate 1-4 Dobutamine Can mix in NS or mcg/kg/min mcg/kg/hr every 10 D5W Dose range:2-20 minutes to desired BP me /k /min Dopamine 5 minutes 400mg/250ml Continuous infusion- Vasopressor Increase rate 1- (16mcg/ml) mcg/kg/min 4mcg/kg/hr every 10 Can mix in NS or Dose range:2- minutes to desired BP D5W 20mc /k /min Epinepherine Minutes 4mg/250ml Continuous infusion Vasopressor Increase 0.01 (16mcg/ml) mcg/kg/min OR mcg/min Cardiac mcg/kg/min Q 15 Can mix in NS or Usual range: 1-10 Stimulant minutes.Titrate to BP D5W mcg/min OR 0.05- effect 1mc /k /min Heparin Seconds 25,000u/250ml Continuous infusion Anticoagulant Based on PTT and per Can mix in NS or units/hr protocol D5W Dose:weight or PTT based Insulin 30 minutes 100 units/100ml Continuous infusion Hormone Based on blood glucose NS ONLY units/hr and per protocol Dose based on blood glucose Lovophed Seconds 4mg/250ml Continuous infusion Vasopressor Increase rate by (Norepi) (16mcg/ml)OR mcg/kg/min OR mcg/min 5mcg/min every 3-5 16mg/250ml Usual range: 0.5-30 minutes to desired ((64mcg/ml) mcg/min OR 0.01- systolic BP Can mix in NS or 3mcg/kg/min (or MAP) D5W Seconds 10mg/250ml Continuous infusion- Vasopressor Increase rate 5mcg/min Neosynephrine (40mcg/ml) mcg/min every 3-5 minutes to (Phenylephrine) Can mix in NS Therapeutic dose:40- desired systolic BP and D5W 60mc /min Nitroglycerin Seconds 50mg/250ml Continuous infusion Vasodilator Increase by 5mcg/min (200mcg/ml) mcg/min every 3-5 minutes to Dose range: 1-200 20mcg/min. If no mcg/min response, may increase by 10-20mcg/min every 3-5 minutes <2 minutes 50mg/250ml Continuous infusion: Vasodilator Increase 0.5mcg/kg/min Nipride D5W ONLY mcg/kg/min increments. (Nitroprusside) (200mcg/ml) Dose: 0.3-4mcg/kg/min Maximum 10mcg/kg/min KEEP PROTECTED FROM LIGHT Minutes 20units/100ml Continuous infusion Vasopressor Increase rate in 0.2-0.5 Vasopressin Can mix in NS or units/min Cardiac units/hr every 15 D5W Range: 0.01-0.1units/min Stimulant for minutes Usual dose: 0.04units/min Septic Shock OR 0.2-0.9 units/hr VASOACTIVE MEDICATIONS Dr. Sandra Schwemmer, DO Page 1 of 1 8-2 695 Monroe County Fire Rescue Trauma Star Drug Formulary AMIDATE (ETOMIDATE) A,(°°III`IIQNS: short acting sedative hypnotic with rapid onset of action and recovery. Minimal cardiac and respiratory depressive effects causes no histamine release and may be useful in patients with compromised cardiopulmonary function. 1 I114 Q I C.'A'I'll 0 1114 S. ' 6 Short acting intravenous anesthetic agent used for the NF')'wV4"Iom q V)A Win induction of general anesthesia, procedural sedation and tracheal intubation ifoim,ido:( lnj,E�oion iJSP p 0111 l lll ' III IIIIIIS Hypersensitivity to Etomidate or any component in the formulation. WA,III! l0`1'GS: ster oid.r roid production: Etomidate inhibits 11-B hydroxylase, an enzyme important in adrenal steroid production. A single induction dose blocks the normal stress induced increase in adrenal cortisol production for up to 8 hours. ADMINISTRATION BY CONTINUOUS INFUSION IS NOT RECOMMENDED BY CONCENTRATION ATI THE MANUFACTURER. 40mg/ 0mi mg/ml Decreases cerebral metabolism and cerebral blood flow while maintaining perfusion pressure. Premedication with opioids or benzodiazepines can decrease myoclonus. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: CNS: Myoclonus Endocrine: Adrenal Suppression GI: Nausea and vomiting Ophthalmic: Nystagmus DOSAGE: Adult dosage., 0.3mg/kg IVP over 30-60 sec. Time/Action IProflle: Onset Peak Duration IV/10: 30-60 seconds 1 min 4-10 min 19-1 Dr. Sandra Schwemmer, DO AMIDATE (ETOMIDATE) Page 1 of 1 696 Monroe County Fire Rescue Trauma Star Drug Formulary ANCEF (CEFAZOLIN) A,( IIFIIGNSm A beta-lactam antibiotic similar to penicillin's. Broad spectrum antibiotic. Action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine. Antibiotic used to treat a wide variety of bacterial ,r infections. It may be used before and during surgeries to help prevent infection. Used in the pre-hospital setting in sepsis, wounds that penetrate the fascia and for open fractures. For 0A or RV U tlh � 01 �"li III II1 S Hypersensitivityto cef am zolin, other cephalosporin antibiotics, penicillin s, or beta-Lactams, or any component of the formulation. WA,III! ' II 1Y GS ............................................................... May be associated with increased INR. Hypersensitivity reactions including anaphylaxis. If allergic reaction occurs, discontinue treatment and institute appropriate supportive measures. CONCENTRATIONPOSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: gram Vial CNS: Seizure Derm: Rash, pruritus, Stevens-Johnson's Syndrome. GI: N/V/D. Abdominal cramps DOSAGE: Adult dosage., 1 GM IV over 30-60 minutes. Time/Action IProflile: Onset Desk Duration IV/10: Within 5 min 9-2 Dr. Sandra Schwemmer, DO ANCEF (CEFAZOLIN) Page 1 of 1 697 Monroe County Fire Rescue Trauma Star Drug Formulary CARDENE (NICARDIPINE) Short acting calcium channel blocker, potent vasodilator that produces more selective responses in the coronary versus the vascular circulation. III' I IC.'WIFIONS: MDC0143.9689-10 Short term treatment of hypertension Nicardipine Hydrochloride <25 m /10 mL Patients h advanced lllced Injection OIII i""Ills III L' 9 � nts with aortic stenosis due to afterload 1, 12,5;M01M J a reduction. Reduction of diastolic pressure in these patients Jill "' INC may worsen rather than improve myocardial oxygen 10 ni L 8Mg1e 1JRVu Discard Unxusr d Pas✓V balance. For Intravenous UH,01 wr vi ............................................................... Reflex tachycardia may occur resulting in angina and or MI in patients with obstructive coronary disease. CONCENTRATION ATI Use in caution. 25mg�'10 l m1 2 mg/,1 POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: CNS: Headache CV: Hypotension, tachycardia, ST segment depression, inverted T wave. GI; N/V, indigestion. Peripheral edema. DOSAGE: Adult dosage: 5 mg/hr. If desired B/P is not achieved at above dose: Infusion rate may be increased by 2.5mg every 5-15 minutes to a maximum of 15 mg/hr. *Administer as a slow continuous infusion, centrally or via a large peripheral vein. Time/Action Profile: Onset leak Duration IV/IO: Rapid 10-15 min 30 min (once discontinued) 19-3 Dr. Sandra Schwemmer, DO CARDENE (NICARDIPINE) Page 1 of 1 698 Monroe County Fire Rescue Trauma Star Drug Formulary CARDIZEM (DILTIAZEM) A( lFlQNS: Antianginal, Antiarrhythmic Agent, Anti hypertensive, Calcium Channel Blocker. f ill' IOit°,AWIFIG1' S., Control of rapid ventricular rate in atrial fibrillation or atrial flutter or conversion of PSVT. �v ly %ra ili, L � r � H01peirlsens tllvrt tlolllS � xszl'a �"°�' ''�'� y diltiazem or any component of the '(0R � ,,GT N�B 11-W' ii,1p"JI[ ; formulation. Sick Sinus Syndrome (except in patients with a A" C���'�110JOUSIV �u`��'���` functioning artificial pacemaker). Second or third degree heart block (except in a patient with a functioning artificial Now pacemaker), severe hypotension or cardiogenic shock. WA,III! IY IV IY GS: ............................................................... May cause first, second or third degree AV block or ....... .. ........ �....... sinus bradycardia. Hypotension/syncope. CONCENTRATION 25mg/5ml 5mg/ml POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Conduction abnormalities, hypotension, dizziness. Potential for transient dermatologic reactions. DOSAGE: Adult dosage: 0.25 MG/KG IV over 2 minutes (average adult dose 20 mg). Repeat bolus dose may be administered after 15 minutes if response is inadequate. Time/Action IPro-Me: Onset Peak Duration IV/10: Rapid 3 min 1-3 Hours CARDIZEM (DILTIAZEM) 19-4 Dr. Sandra Schwemmer, DO Page 1 of 1 699 Monroe County Fire Rescue Trauma Star Drug Formulary DILAUDID (HYDROMORPHONE) A( III1 0 IN Sm ......................................... Narcotic analgesic, which depresses the central nervous and CONCENTRATION respiratory system as well as decreases sensitivity to pain. mg/ml Dilaudid also produces mild to moderate peripheral mg/1mI vasodilation. I11' DIC.' WIFIOII' S., Moderate to Severe Pain Pain associated with isolated extremity fracture, renal colic, burns, etc. CQVI I1XHNIYCXI""IIIOIIICSm .................................................................................................................... Hypotension/volume depletion,Respiratory depression, Gastrointestinal obstruction WCI,III! 1Y 111Y GS ............................................................... Use in caution in patients with acute MI POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS Depression, Hypotension, Decreased gastric motility. DOSAGE: Adult dosage: 0.5 mg- 1 mg IV (May repeat dose in 0.5 mg increments up to 2 mg max) Time/Action Profile: Onset Peak Duration IV/IO: Rapid 3 min 1-3 Hours DILAUDID (HYDROMORPHONE) 19-5 Dr. Sandra Schwemmer, DO Page 1 of 1 700 Monroe County Fire Rescue Trauma Star Drug Formulary ENALAPRILAT (VASOTEC) AA("°1u'I I : Used alone or in combination with other medications to treat hypertension. It is also used in combination with other medications to treat heart failure. Enalaprilat is in a class of ' medications called angiotensin-converting enzyme (ACE) t ` inhibitors. Hypertension, Heart Failure, Asymptomatic LV dysfunction 1.25 im " l. 01il lltoOena Hypersensitivity lapril or any component of the formulation. Angioedema related to previous ACE inhibition treatment/idiopathic/hereditary angioedema DO NOT USE IN PATIENTS WITH ACUTE MYOCARDIAL ..... INFARCTION CONCENTRATION 1. 5mg/ml 1. 5mg/1ml POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Angioedema, Dry Cough, Hematologic effects including anemia/thrombocytopenia DOSAGE: Adult dosage: 1.25 mg/dose given over 5 minutes. May repeat dose after 30 minutes if effect inadequate. **In profound hypertension: 5 mg/dose is accepted x 1 Time/Action Profile: Onset Peak Duration IV/10: 15min 1-4hr 4-6hr Dr. Sandra Schwemmer, DO ENALAPRILAT (VASOTEC) 19-6 Page 1 of 1 701 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOL COMING SOON - PLACE HOLDER EPINEPHRINE INFUSION 19-7 Dr. Sandra Schwemmer, D.O. 702 Monroe County Fire Rescue Trauma Star Drug Formulary ESMOLOL (BREVIBLOC) Decreases the force and rate of heart contractions by blocking beta-adrenergic receptors of the sympathetic nervous system,which are found in the heart and other organs of the body. Esmolol prevents the action of two naturally occurring substances: epinephrine and norepinephrine. I III D It°;AWIIW IOII' S: For treatment of hypertensive emergencies, SVT, atrial fibrillation/flutter or non-compensatory sinus tachycardia. Useful in acute coronary syndromes when relative contraindications to beta blockade exist I � SIlle�°Illisllnll �slllbradlyllla d ia, Heart block greater than first degree (except in patients with functioning artificial pacemaker), Allergy to beta blockers, Pulmonary Hypertension CONCENTRATION POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: 100m g/'10m I 10mg/ml Anaphylactic reactions (repeated exposure to beta blockade), Extravasation-Vesicant Hyperkalemia (associated with elevations in serum potassium), Hypotension DOSAGE: Adult dosage: Immediate control: BOLUS: 1000 mcg/kg over 30 seconds followed by a 150 mcg/kg/min infusion. Gradual control: BOLUS: 500 mcg/kg over 1 minute followed by a 50 mcg/kg/min infusion. "Adjust infusion rate as needed to maintain desired blood pressure (max 300 mcg/kg/min) Time/Action Profile: Onset leak Duration IV/10: 5-10min 30min 2-6hr Dr. Sandra Schwemmer, DO ESMOLOL (BREVIBLOC) 19-8 Page 1 of 1 703 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOL COMING SOON - PLACE HOLDER HYDRALAZINE 19-9 Dr. Sandra Schwemmer, D.O. 704 Monroe County Fire Rescue Trauma Star Drug Formulary LABETALOL (TRANDATE) AA("°Iu"IG S: Beta-blockert hat affects the heart and circulation and is used to treat hypertension. �� Yp 1 1114 DIC.Wfi 0 1114 S. Hypertension (acute/chronic), Arterial hypertension in acute ischemic stroke/intracranial hemorrhage, Hypertensive emergency in pregnancy La b e to 1 �0111 `Illi bllllady ardll.� lll ,. Heart block >first degree (except in patients with functioning artificial pacemaker), Cardiogenic shock, Obstructive Airway Disease r r Aru OWY POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Hypotension/syncope, Anaphylactic reactions (increased sensitivity with repeated exposure to beta blockers) CONCENTRATION '100m g/20m i mg/mi DOSAGE: Adult dosage: Acute Hypertensive Emergency: 10-20 mg IV push over 2 minutes. May administer additional injections using double the dose (maximum dose: 80 mg/dose) at 10-minute intervals until target SBP is reached. Total maximum dose 300 mg. Hypertensive Emergency In Pregnancy: (SBP >160 or DBP > 110) 20 mg IV. If BP continues to exceed thresholds, may increase dose every 10 minutes in increments of 20-40 mg to a maximum single dose of 80 mg. Pediatric: 0.2 to 1 mg/kg/dose. Maximum dose 40 mg. Should be reserved for severe hypertension. Time/Action (Profile: Onset Peak Duration IV/IO: 2.5min 15min 3-6hrs Dr. Sandra Schwemmer, DO LABETALOL (TRANDATE) 19-10 Page 1 of 1 705 Monroe County Fire Rescue Trauma Star Drug Formulary ------------------------- LEVOPHED (NO REPINEPHRINE) A( 1u'I I S: Functions as a peripheral vasoconstrictor(alpha-adrenergic action) and as an inotropic stimulator of the heart and dilator of coronary arteries (beta- adrenergic action). H14QK'.'A1'1Q114S., For blood pressure control in certain acute hypotensive states (e.g., myocardial infarction, septicemia, blood transfusion, and drug reactions). Used as an adjunct in the treatment of cardiac arrest and p hypotension. i profound h ofension. FOR rVNFUSENON III ,III1. III 1� III III S WMAIIPCava Should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed. If Levophed is continuously administered to maintain ... ... ... blood pressure in the absence of blood volume replacement, the CONCENTRATION following may occur severe peripheral and visceral vasoconstriction, 4mg/4ml decreased renal perfusion and urine output, poor systemic blood flow '1mg/ml despite "normal" blood pressure, tissue hypoxia, and lactate acidosis. WA,III'°t IY IV IY G S: ................................................................. Use with extreme caution in patients receiving monoamine oxidase inhibitors (MAGI) or antidepressants of the triptyline or imipramine types, because severe, prolonged hypertension may result. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Extravasation: Vesicant. Must ensure proper IV catheter placement prior to and during infusion. Use in patients with profound hypoxia or hypercarbia may produce ventricular tachycardia or fibrillation. Use in extreme caution. DOSAGE: Adult dosage: 4-12 mcg/minute. Titrate to desired response. Usual maintenance range: 2-4 mcg/minute. ACLS (ROSQ: 7-35 mcg/minute Sepsis/Septic Shock: 4-30 mcg/min IPe6a iriiio, 0.05,,,, „1 mcg/Ikg/miiin„ 1 iitirate to desliired iresponse. USUaal rnalintenance Grange: 0.1 2 me /Ik /irilln Time/Action IProfHe: Onset Peak Duration IV/IO: Rapid 1-2 min L Dr. Sandra Schwemmer, DO EVOPHED (NOREPINEPHRINE) 19-11 Page 1 of 1 706 Monroe County Fire Rescue Trauma Star Drug Formulary ------------------------- LOPRESSOR (METOPROLOL TARTRATE) Selective,m. ����� � betal-adrenoreceptor blocking agent used for the treatment of hemodynamically stable patients with definite or suspected acute myocardial infarction to reduce cardiovascular mortality. NDC6,,M E606006 U DiC.,Ail"IG S., METOPROLOL Angina, Hypertension, Improved survival post Myocardial TAIRTRATE Infarction INJECTION, U P V "MM11111 II 1 1"1,`� o �u Sinus grlall�LcllardiaOS Sn OIII i III orIWrus y / ig ificant first degree heart block/SBP Wnly 5N LsngleuseVia[ <100, Cardiogenic Shock, Severe peripheral arterial circulatory disorders POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: AV Block, Bradycardia/Hypotension, CNS depression CONCENTRATION 5mgl5ml '1 mglml DOSAGE: Adult dosage: STEMI /ACS/ HTN: 5 mg IV. May repeat dose every 5 minutes for u to 3 doses as needed based on heart rate and blood pressure. Maximum dose 15 Mg. Acute Ventricular Rate Control: 2.5 to 5 mg over 2 minutes. May repeat dose every 5 minutes as needed to a maximum dose of 15 mg Time/Action IPro- le: Onset Peak Duration IV/IO: Immediate 20 min 5-8 hrs LOPRESSOR (METOPROLOL TARTRATE) Dr. Sandra Schwemmer, DO 19-12 Page 1 of 1 707 Monroe County Fire Rescue Trauma Star Drug Formulary NITROGLYCERIN DRIP to; Belongs, ;- g the group of medicines called nitrates. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its work load. ., 1 1114 DIC.;Ail1GI S., Hypertension, Angina, Congestive Heart Failure K 4„ 1u 11:11211 mom" 604 OIII iIll III III III0Sm ir 0 Concurrent use with PDE-5 inhibitors (Sildenafil, Viagra, Rtl MW p� �yry,rye {F.y adalafil or Vardenafil), Do not use with solutions containing 1��; ©/�"RTWHJb �m1"Yp µdry. , ) 0 P 0� dextrose, Increased Intracranial Pressure, Hypovolemia, �14 ;!;� Restricted Cardiomyopathy POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: Headache, Hypotension, Bradycardia, Increased ICP CONCENTRATION 50mg/250mi 200mog/ml DOSAGE: Adult dosage: ANGINA/CAD: 5 mcg/min, increase by 5 mcg/min every 3-5 minutes to 20 mcg/min. If no response at 20 mcg/min, may increase by 10-20 mcg/min every 3-5 minutes to a maximum dose of 400 mcg/min. Time/Action (Profile: Onset Peak Duration IV/10: NITROGLYCERIN DRIP Dr. Sandra Schwemmer, DO 19-13 Page 1 of 1 708 Monroe County Fire Rescue Trauma Star Drug Formulary PAVULON (PANCURONIUM) A,( III'II6:�II S: Non depolarizing neuromuscular blocking agent that causes neuromuscular blockade for endotracheal intubation/mechanical ventilation. l III D It°,AWIIW IOII' S: Provides skeletal muscle relaxation for endotracheal intubation and mechanical intubation � pnL 11 1�1"�D II!C�'�����a� �m� um I Sensitivity tol)pancuro IY m t II l uronium bromide or any component of IIIJ � ti0% UP the formulation kn'piio'V :,'UM riwei"AMI POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Anaphylaxis DISEASE SPECIFIC CONCERNS: BURNS: Resistance may occur in burn patients Conditions that ANTAGONIZE Neuromuscular Blockade: CONCENTRATION Respiratory Alkalosis, Hypercalcemia, peripheral 10mg/10m1 neuropathies, denervation and muscle trauma '1mg/ml Conditions that POTENTIATE Neuromuscular Blockade: Severe Hypokalemia, hypocalcemia. Hypermagnesemia. Metabolic Acidosis, Respiratory Acidosis. DOSAGE: Adult dosage: 0.05 mg/kg after dose of Succinylcholine for intubation Time/Action IProflle: Onset Peak Duration IV/10: 2-3 min 60-100 min Dr. Sandra Schwemmer, DO PAVULON (PANCURONIUM) 19-14 Page 1 of 1 709 MONROE COUNTY FIRE RESCUE MEDICAL PROTOCOL COMING SOON - PLACE HOLDER Dr. Sandra Schwemmer, D.O. ROCEPHIN 19-15 710 Monroe County Fire Rescue Trauma Star Drug Formulary ROCURONIUM (ZEMURON) A,('°°III"116: I S: Aminosteroid non-depolarizing neuromuscular blocker or muscle relaxant used to facilitate tracheal intubation by � Ja providing skeletal muscle relaxation, most commonly required for surgery or mechanical ventilation. n�i��Y,nw �wa�a syN � I III D 11°;AWII"IOII' S: 1 � law Provides skeletal muscle relaxation for endotracheal ""'°��'l°' ` `oil wulk Ana 16 intubation and mechanical intubation UAW 0111 ""III III 1' III ""1110111 S: grub, Hypersensitivity to rocuronium, other neuromuscular ° a blocking agents or any component of the formulation Hw aPOSSIBLE A VERSE REACTIONS A SIDE EFFECTS: �, Anaphylaxis DISEASE SPECIFIC CONCERNS: BURNS: Resistance may occur in burn patients Conditions that ANTAGONIZE Neuromuscular Blockade: CONCENTRATION Respiratory Alkalosis, Hypercalcemia, peripheral 100mg/10m1 neuropathies, denervation and muscle trauma 10mg/ml Conditions that POTENTIATE Neuromuscular Blockade: Severe Hypokalemia, hypocalcemia. Hypermagnesemia. Metabolic Acidosis, Respiratory Acidosis. DOSAGE: Adult IRSII dosage., 0.6 mg/kg IV Pediatric: 0.6 mg/kg IV Time/Action Profile: Onset Peak Duration IV/10: 60-70 Sec 30sec- 13 min 15-85 min Dr. Sandra Schwemmer, DO ROCURONIUM (ZEMURON) 19-16 Page 1 of 1 711 Monroe County Fire Rescue Trauma Star Drug Formulary ROMAZICON (FLUMAZENIL) A,( IIFIIGNS: Used as an antidote in the treatment of benzodiazepine overdoses. It reverses the effects of benzodiazepines by competitive inhibition at the GABAa binding site of benzodiazepine receptors, which are present through about 70% of the body. There are many complications that must be taken into consideration when used. These include lowered seizure threshold, agitation, and anxiousness. Flumazenil's short half-life requires multiple doses. Because FIIlII aze!!Illl r%� of the potential risks of withdrawal symptoms and the Injection, USP ' drug's g's short half-life, patients must be carefully monitored yaw to prevent recurrence of overdose symptoms or adverse (°.'ing per mQ ° i side effects. Sterile �F For Intravenous Use only a RKoniy 5 rm l_ e P r �P Multiple Dow ftl Il l lt,°;AIIOi S: y� Benzodiazepine reversal CQVI I1XlYIYCXI""IIIOIIICS: .................................................................................................................... Hypersensitivity to flumazenil, benzodiazepines. CONCENTRATION POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: 0.5mg/5ml 0.1 m ml Amnesia, CNS depression, Respiratory depression, Seizures DOSAGE: Adult dosage: Initial: 0.2 mg slow IVP over 15 seconds. After 30 sec: 0.3mg Slow IVP After 1 min: 0.5 Slow IVP May repeat q 20min to a total of 3mg Time/Action IProfiie: Onset Peak Duration IV/IO: 1-2 min 6-10 min ROMAZICON (FLUMAZENIL) Dr. Sandra Schwemmer, DO 19-17 Page 1 of 1 712 Monroe County Fire Rescue Trauma Star Drug Formulary SUCCINYLCHOLINE (ANECTINE) A("°1u'I I Sm Short term neuromuscular blockade 1II IC.'A1 GI S., Facilitation of endotracheal intubation/mechanical ventilation UN''I I1XI I I III I1"i1 0 N S m Hypersensitivity formulation. Personal s or family history of Malignant cinylcholine or any component of the ,�i�ioi ��'�1 ��������� Hyperthermia, Skeletal muscle myopathies, Injury following A," y � u ��r �� � % major burns. WAlllUt.belp..�. t � : v associated with acute onset of malignant hyperthermia. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Hyperkalemia, Anaphylaxis, Bradycardia, increased intraocular pressure, transient increase in intracranial CONCENTRATION pressure, may increase intragastric pressure, resulting in mg/1 ml regurgitation and possible aspiration mg/ml DOSAGE: Adult dosage: RSI: 1.5 MG/KG IV (duration of action 3-5 minutes) Re-dose: 1- 1.5mg/kg at appropriate intervals as needed for effect Time/Action Puroflle: Onset Peak Duration IV/10: Rapid 3-5 min Dr. Sandra Schwemmer, DO SUCCINYLCHOLINE (ANECTINE) 119-18 Page 1 of 1 713 Monroe County Fire Rescue Trauma Star Drug Formulary TRANEXAMIC ACID (TXA) (CYKLOKAPRON) A,( IIFIIGNS: Antifibrinolytic hemostatic that competitively inhibits l the activation of plasminogen to plasmin, an enzyme that degrades fibrin clots, fibrinogen, and other plasma %rn proteins. i 1 IIIIDIC.'WIFIOII' S: Mai � Blunt or penetrating trauma, signs and symptoms of Tranerribc hemorrhagic shock (SBP <90 mmHg and HR > 110 major = ° blunt or penetrating torso or pelvic fracture, one or more For Intravenous Use major amputations, and/or evidence of severe bleeding), Only P ,y external manual efforts to control the hemorrhage have SIN-nevll u been instituted, < 3 hours since incident. X' w More ...than ....3....hours ....post incident. CONCENTRATION ��I"A,III �I�II�I��;i'uIG: 1000m g/'10m I ..................�........................................... Patents taking estrogens, progestins, or oral tretinoin(a 100mg/ml chemotherapy agent used to treat leukemia) may have enhanced thrombogenic effects from TXA. Dose reductions are necessary in patients with severe renal impairment. If TXA has been administered, ensure that the receiving facility is aware that the patient has received TXA prior to arrival. POSSIBLE A `JERSE REACTIONS AND SIDE EFFECTS: Headaches, back aches, nasal sinus problems, abdominal pain, diarrhea, pulmonary embolism, deep vein thrombosis, anaphylaxis, visual disturbances. DOSAGE: Adult dosage., 1 gram mixed in 100ml NS administered over 10 mins. If TXA has been administered by the sending facility, continue or initiate an additional 1 gram of TXA at a rate to complete the 211 dose over 8 hours. Time/Action Profile: Onset Peak Duration IV/IO: 1-2 minutes 3-5 minutes TRANEXAMIC ACID (TXA) (CYKLOKAPRON) Dr. Sandra Schwemmer, DO 119-19 Page 1 of 1 714 Monroe County Fire Rescue Trauma Star Drug Formulary TERBUTALINE Al III"110II S: Terbutaline is a Beta 2 agonist used in the event of preterm labor to help relax uterine muscles and stop contractions. III DK'.'AWII"IOII' S: Short term treatment of preterm labor � T�L� E ' Hypersensitivity I sits lvit to 111 r 0111 i" : � F rsensit� y Terbutaline, sympathomimeticami:es or any component of the formulation. J ' Prete'r Im liab.TM. S or: Terbutaline is not FDA approved for % prolonged tocolysis (>48-72 hours) POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: Tachycardia, Transient Hyperglycemia, Myocardial ......,CONCENTRATIONischemia, Pulmonary edema '1 mg/1 m I '1 mg/ml DOSAGE: Adult dosage: 0.25 MG SQ every 20 minutes to 3 hours for a max dose of 1 mg. Hold for pulse > 120. Time/Action IPro-Me: Onset Peak Duration 100: 6-15min 30-60min 90 min-4 hrs. TERBUTALINE Dr. Sandra Schwemmer, DO 119-20 Page 1 of 1 715 Monroe County Fire Rescue Trauma Star Drug Formulary VECURONIUM A,( II"116 I S: Non-depolarizing Neuromuscular blocking agent used to relax muscles and facilitate endotracheal 1 intubation/mechanical ventilation. °` iII Di1°,AWIIWiOII S: Provides skeletal muscle relaxation for endotracheal g811U intubation and mechanical intubation. � w 014 my at ow Hypersensitivity eir llvit loll .m. p d� b. ypsens t y t Ve curonium or any component of the formulation POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: �......�......�. Anaphylaxis CONCENTRATION '10mg DISEASE SPECIFIC CONCERNS: ,1mg/ml (Reconstituted to '10 MI) BURNS: Resistance may occur in burn patients Conditions that ANTAGONIZE Neuromuscular Blockade: Respiratory Alkalosis, Hypercalcemia, peripheral neuropathies, denervation and muscle trauma Conditions that POTENTIATE Neuromuscular Blockade: Severe Hypokalemia, hypocalcemia. Hypermagnesemia. Metabolic Acidosis, Respiratory Acidosis DOSAGE: Adult IRSII dosage., 0.08-0.1 mg/kg IV Time/Action Profile: Onset Peak Duration IV/10: 1.5-2 min 3-5 min 25-40 min VECURONIUM Dr. Sandra Schwemmer, DO Page 1 of 1 19-21 716 ti ti Z w z3 0 o o Cl) QL) Cl) o Q o o ~ 0. U U �w O U U O O rn O U U Z C) U U w O w Otu Qa U U w U W Z U Cl) QL) VA W .„ . ' r Z O Cl) U +- w U O N a) x ,..... .,.. W a U U O Q > a z � W O Z3 �N a °� ° w ZN Co ED � o m w 3 Of � � � Op ° o W � o o�w cn z ElW W o 'a � z3 � Cl) >, co a� ;z) Z z3 Y U w �� � U C3 U U C3 O XQL) L Q W W o Q ' 0 QL) Cl) U a) LD o N z a� �� w H co O Wes^ W co � � o >, a3 v G4 d �" � x � x "15w x o p O p O W