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Item P05
P5 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 April 17, 2024 Agenda Item Number: P5 2023-2322 BULK ITEM: No DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: James K. Callahan N/A AGENDA ITEM WORDING: A public hearing to consider an application for issuance of a Class A Certificate of Public Convenience and Necessity COPCN to Southernmost Medical Transport for the operation of an ALS and BLS Transport Service in Monroe County, Florida, except for within the city limits of Marathon, for the period 04/18/2024 through 04/17/2026 for responding to requests for inter- facility transports. Southernmost Medical Transport is not permitted to perform 911 emergency response work in Monroe County. ITEM BACKGROUND: Southernmost Medical Transport has submitted an application for a Class A COPCN. Once approved, the Class A COPCN certificate will be for the period commencing on 04/18/2024 and ending on 04/17/2026. Monroe County Code Sections 11-171 et seq., requires the BOCC to hold a public hearing to consider the application for a new certificate. At the hearing, the Board may receive a report from the County Administrator or his designee, testimony from the applicant or any other interested party, and other relevant information. The Board will consider the public's convenience and necessity for the proposed service and whether the applicant has the ability to provide the necessary service(s). The Board shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reason(s) for denial. Per County Ordinance, all existing COPCN holders were notified via email of the Public Hearing for the new COPCN. PREVIOUS RELEVANT BOCC ACTION: N/A INSURANCE REQUIRED: No 3840 CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval DOCUMENTATION: Southernmost Medical Transport Class A COPCN Application Redacted.pdf Notice of Public Hearing-Southernmost Class A COPCN.pdf COPCN Certificate for Southernmost.pdf FINANCIAL IMPACT: Effective Date: 04/18/2024 Expiration Date: 04/17/2026 Total Dollar Value of Contract: N/A Total Cost to County: N/A Current Year Portion: N/A Budgeted: N/A Source of Funds: N/A CPI: N/A Indirect Costs: N/A Estimated Ongoing Costs Not Included in above dollar amounts: N/A Revenue Producing: N/A If yes, amount: N/A Grant: N/A County Match: N/A Insurance Required: Yes, mandated by the State of Florida 3841 N d' 00 MONROE COUNTY,FLORA M APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY(COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) IN uanAL APPLICATION-sq%eo 0 RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE-P 1. NAME OF SERVICE i1 0,,'a9ySP0d BUSIN&SS MAILING ADDRESS 34114 Dus*Ave ISTE10, Key West,n,,,.33W BUSINESS PHONE NUMBER � � EMERCZP(C`V PHONE NUMBER L TYPE OF OWNERSHIP(Le.,Sole Proprktor,PartmershV,Corpandaa,etc.) LIB DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 70 "��" ' 22 3. LIST ALL OFFICERS,DIREC.TOR.%AND SHAREHOLDERS(Use separate sheet If®eeensrp): NAME 1-1 AGB ADDRESS .,T ELEPHONES POSITIONIi'[ILIa+ Paula Tumer 41 1608 Jamaica Dr, KW, FL 727-697.1668 Operating Manager 1-111,.....,-mm,---",,-�---.,.",,-,.""�������-s .. ...11 .��� .�,� .� , �, �.��,� 58 719 Thomas St. KW. FL 434-9W-1SO Member AnabeQe 51 719 Thoma9 St,�� n KW.�.FL. 434-962 �.. � . s1589 Member , „ ...„ .„ ......................... . ..........:m w o. w.,.nmw.,,....,........... „ 4. LzvEL OF CARE TO BE PROVIDED: BLS or 0 ALS IF ALS:5 TRANSPORT or 0 NON TRANSPORT S. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate if eecenary): Inter fadlity traWem In Monroe County. No 911 response cads will be performed. & L14T THE ADDRESS AMOR DESCRIBE THE LOCATION OF YOUR BASE STATIO.�i ARID ALL SUB- STATIONS(Use upwate street if neeesssR): BASE,STATION 3414 Duck Ave STE 10, Key West FL 33M SUS-STATION no a an Is necessary as Oftmmspart cow►will only senfte tt�e lower keys I, I of M d' 00 7. DESCRIBE YOUR COMMUNICATION SY5r MM(Attach copy of all FCC Hamm): M U m,,, �„ �,�, m �" UENCIES CALL f OF MOBILE'S OF PORTABLES aiu �' mimummmir immnmumrrr«rnrtr«r —mn ru u u u uiu rm ui g a iuuuuuw mmm.u.u. LL., .... ................... . . .. .......... ....:,._ .o. . � 8. LIST THE NAMES AND ADDRESSES OF THREE(3)U.S.CI'17F M WHO WILL ACT AS REFERENCES FOR YOUR SERVICE-- NAME � m„ ��ADDRESS 0° ltea Stu III F ftasd' m ., �w Boll LAYl inchio ��ri c e Key, FL. �� ..... .. , A ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD. 10- PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. 11. ATTACH A COPY OF YOUR SERVICE'S CO.NT'RACT WITH A MEDICAL DIRECTOR, IL ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. LL ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. I,THE UNDERSIGNED REPRESENTATIVE OF THIS:ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE MEM ALL OF THE RKQUIR.EMENT'S FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORATATION CONTAINED IN THIS APPLICATION,TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. m rym, SH2"Tl=OF APPLICART AUTKORUZD R ITATIVE TARA STANSBl1RY Notary Public•State of Florida Commission x HN 163921 NOT Y SEAL o.N MY Comm.Expires Aug 10,2025 Bonded through Natiora;tiotary Assn. ?"rARY SIGNAin U i DATI�C dq dq co M MMbM ..-I~ARAMXRjQ 1, NAME, OFlr� � Lastw «ISOCIAI SECUMT # CER WICA< ONE EXPIRATION DATE � P FWDS I sm �. . ° �. ...,.. If i� Y .... ....... ........ j ..... .. .,, .. .�� ..m .. .... . .. ,.�a ��„�� �. ........ ................... ......... ........, . � r t .w ... .R��..,. ...._.......... .. � o .... ...... w dq co M NAME �,,...,�d. ,,,,,,.... �,,,,,. � . .�������� mm... EMT CERTIl icAlrioN� Mlddle Lad 90CIAi.SBCUItITYt� CBItTIgICATION# E"JIMMON OATg MwlO�NIN�.fwilYw �„'u rDN MUW rNNAW914MMMfw�4Mw�iuv m 011" um0u ffff ..uuum uuu uwwuum M�^kUN4NfNu4'W�uOar+wWT�VP41�H ud!MurvmmMlmuR�R uuum M IC �M'#w,l If uuuu�m mmmm n Min*l Morales ( e j "gym . ' i I I 1 m„ .,� ....,:.r. .�„... �� 1 If r � I �....................._......... ,,,, .. . ... ............. � ��,�., � .............. �.� ..... ...o.w.,. �, -.m ... � .. .... ------ �. _ �,�,, ________� m� ���..�.�,, ..,,, ....................,1,,,,,,, (D co, ws d� M t ti 0 41 . ......... z r � 1 , I f o U 1 O � J t ............ .., ., ... w w dti� G*r I I 2' 1 r€ LL LLco z P 1 w. jai t T Y vsrA A © O 1 H I P I w 4 a r u W O d 71 t C C IP1 VJ E oNO 1 � 10 U �1 co LL +.� C LL F a� 0 O W F 3847 co co M all ..........- .......... f � I y r n� f JI, 7 � Y rr / I I t 1 l c o o I I 0) dq 00 M it C51 k", December 7, 2023 'To Whom It May Concern: Pfter discussion with Dr. Antonio Gandia, Medical Director of City of Key,West Fire Rescue, and thorough review of their trauma protocols, I approve the City of Key West FM Rescue Trauma brotocols for use by Southernmost Medical Transport. Southernmost Medical Transport was also given permission to utilize the City of Key West Fire Rescue's phone application with all protocols listed within this application. This application will be on every device in the transport vehicle for easy access. Should you require any further informatibn, please contact me. Lawrence wBlis, M.D., FA.C.S edical Director lawrenceblass@yahoo.com I(305) 741-7707 TranVort p 3R3 4 (727) 7-166 0 00 M �iuu�cnmow xiui�o����sii"�ti�' Southernmost Medical Transport Method of Call Screening if ,< J Southernmost Medical Transport takes pride in regards to how we set up'�our,new dispatch process. As we are a new operation, no existing process has been in""place. Our goal is to ensure patient safety first and foremost, give amazing patient 'using our extremely trained, local staff and provide easy, friendly and professi n t.cis at h° and call services. , if Dispatch Form Questionnaire: �, t Name of Client: Age of Client: Reason for transport: Pick up location: Drop off location: .'` Level of service requested: � ❑ Wheelchair ❑ Stretcher ❑ Ambulatory ❑ Baker Act�- ,� Q ALS Critical Care Transport Souffiffnmw NedkW Traeuport 3414 I live SIT 1 Wey'Wew, -t ( ) - '75 T_ LO 00 M Y Emma onaaoaa�aaa hisoi�iioiu°uiu91 Southernmost Medical Transport Fee Schedule U,a BLS Transport Base Fees: f, Basic Life Support $650 11 Loaded Miles $12/mile ALS Transport Fees: ❑ Advanced Life Support LEVEL 1 ❑ Advanced Life Support (LEVEL 2) $9 0 Critical Care Transports (CCT) $1,000 ❑ Loaded Miles "I'l-2/mile Non-Emergent Base Fees: ❑ Wheel Chair (WC) '' $45 ❑ Gurney/Stretcher T' ar„ $150 ❑ Ambulatory (AA ) $45 ❑ Baker Acts 1 $45 ❑ Loaded Ik Fles $9.501mile rt' All fees billed are inclusive to include the correct licensed staff members, f4uipment and supplies for each transport. All fees are in accordance with regulatory standards and found to be in line with today's market for service and in line with Medicare reimbursement fee schedules. 3414 DwA 4ve STE 1 Wey UK 4 (3d ) - 7 C14 Lf) 00 (RAW,rAmrw, .................................................. ............... Southernmost Medical Transport Dispatch Process Southernmost Medical Transport takes pride in regards to how we set up our n-d" dispatch process. As we are a new operation, no existing process has been in plaice Our goal is to ensure patient safety first and foremost, give amazing patient car, usin,gi our extremely trained, local staff and provide easy, friendly and professional dispatch and call services. al'ijJr We are currently working with the Federal Communications�:Gomri,isiio' n to obtain private FCC frequencies in order to ensure that our company is providing the highest level of service to our community. Our dedicated FRN# is 0034537969. Wea"re'6waiting the FCC to issue us the d frequency as of 12/8/2023. p a, Our current system that will beli�""IF6156 I'/" " operations begin before the FCC has issued us our private frequency is,as follows as is the same for BLS, ALS, CCT, and non-emergent calls: Frequency: fall numbers: Number of Portables: Number of Mobile: Pending 305-393-9275 2 2 3414 V"ylve 3 '10 Wey'WW,T1,A3040 (305)393-.9275 M LO 00 M ,rpIl pp 91111 �K?l�Ihll�Y Illllllll�lllllli���',11��� ,f Southernmost Medical Transport Fee Schedule BLS Transport Base Fees: f �� Basic Life Support $650 '° ❑ Loaded Miles $12/mile ALS Transport Fees: Advanced Life Support (LEVEL 1) $800 y ❑ Advanced Life Support (LEVEL 2) $900 ❑ Critical Care Transports (CCT) $1, D0` ❑ Loaded Miles „$12imile Non-Emergent Base Fees: e. ❑ Wheel Chair (WC) , ���° $45 ❑ Gurney/Stretcher ( , �� $150 ❑ Ambulatory;s(A1UlVi?� ) $45 ❑ Baker Acts', $45 ❑ Leaded �M Ins $9.50/mile � All fees billed are inclusive to include the correct licensed staff members, equipment and supplies for each transport. All fees are in accordance with regulatory standards and found to be in line with today's market for service and in line with Medicare reimbursement fee schedules. SOUU&Wnn"Me"TranApart 414 Duch sae SIM t Wei Wed,FC33040 (3 )39X9275 dq 00 M -Zl, x,, ( 1Nti. P.14nJu644�111�� i r r Southernmost Medical Transport Audit Report Southernmost Medical Transport takes pride in our professionalism and application organization. As we are a new operation, no existing audit F� orf']Es abl to be provided. Once awarded the Monroe County Certificate of,PubtIib Convenience and Necessity, we can begin operation as the only lower keys based transpor(company. iV w s r • See attached email correspondence with Cheri Tamborski, Executive Administrator for Monroe County Fire Rescue. U " 'rr I - /4'Duch ilve 8"ff 1 ( 5)393- 7 12/8123,3:27 PM Mai!-Mike Tumer-Outlook Lf) u7 Co M Re: email thread Paula Turner <southernmostmt@gmail.com> Fri 12/8/2023 3:26 PM To:miketurner9@hotmaii.com <miketurner9@hotmail.com> On Fri, Dec 8, 2023 at 3:22 PM Paula Turner < i > wrote: Tamborskl-Cheri <' ` Q ii y- g2v> Fri, Dec 8, 2023 at 2:07 PM To: Paula Turner<soujhemmostmt@gmail.com> Cc:Johnson-Cara< Q 9qMQj.y_ v> Good afternoon Paula, Happy Friday! You can ignore the audit report request. That is only fdr renewal COPCNs. Relative to insurance,we can't process yq_lr requp, t until we have everything. Please email your completed application to us as soon as your insurance is in order. We will also need you to either drop off the original notarized package or overnight it to us. With the upcoming holidays and out of office schedules,we are quickly coming up on the agenda cutoff for January. Once you submit your application and we've had a chance to review it to make sure everything is in order and check the newspaper publication dates for the required public notice, I will advise as to whether your COPCN application will be heard at the January or February BOCC. i Thanks, Cheri Cheri Tamborski Executive Administrator Monroe County Fire Rescue I 490 63rd Street, Ocean, Suite 140 Marathon, FL 33050 305-289-6088 (Office) Tam borski-Cheri@monroecounty-fl.gov 1 https:i/oufook.live.com/mail/0/lnboxrid/AQMkADAwATE2ZTEwLWY3YjUtYWQxNlowMAItMDAKAEYAAAPhplI R4Ge4TKl d75fKygAFVwcA4QrfrEjASO... 1I1 to In 00 02/01/2024 C����IIR IIIIF-'IC�°"�"IEOF !IIN S' " �IIN 1",, `�' PRODUCER AND THE NAMED INSURED THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY Prime Property&Casualty Insurance Inc. AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE OF INSURANCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND,OR ALTER THE COVERAGE AFFORDED 8722 S.Harrison St. BY THE INSURANCE POLICIES BELOW. Sandy,UT 84070 801 304-5500 INSURERS AFFORDING COVERAGE INSURED INSURER A: Prime P Southernmost Medical Transport LLC Property 8 Casualty Insurance Inc. INSURER B: DBA: 1608 Jamaica Dr INSURER C: -Company#27876 East Rockland Key, FL 33040 COVERAGES "LIMITS SHOWN ARE THOSE IN EFFECT AS OF POLICY INCEPTION" 711631 The policies of Insurance listed below have been issued to the Insured named above for the policy Indicated. Notwithstanding any requirement,tens or condition of any contract or other document with respect to which this certificate may be issued or may pertain,the Insurance afforded by the policies described herein Is subject to all the terms,exclusions and conditions of such policies.Aggregate limits shown may have been reduced by paid claims. POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDNY) DATE(MWODrM LIMITS Commercial Llability Claims Made Exclude Products 0 Exclude Completed Operations 0 Commercial Auto Liabill PC24020008 01/26/2024 01/26/2025 © Any Auto SSO .000 CSL All Owned Autos $126,000 Physical Damage-total scheduled value Scheduled Autos $70,000 P.I,P Per Person Hired Autos Non-Owned Autos $100.000 U.M.Per Accident Drive Away Specifically Described Autos ❑ Commercial Garage Liability G.K.L.L. O.T.R.P.D. D.O.C. C3 Cargo On Hook Employee Dishonesty Wrongful Repossession Exclude Completed Operations Exclude Products Claims Made Excess Liablllty Claims Made OTHER DESCRIPTION OF OPERATIONILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS ® CERTIFICATE HOLDER ❑ ADDITIONAL INSURED LOSS PAYEE WAIVER OF SUBROGATION PRIMARY AND NON- CONTRIBUTORY PROOF OF rNSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NO WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE C ti to too M INSURANCE IDENTIFICATION CARD THIS VEHIICLE FORRODUICTION UP INSURED MOTOR N STATE OF FLORIDA NUPON DEMAND. Prime Property&Casualty Insurance Inc.-Company#27876 �'- EXAMINE POLICY EXCLUSIONS CAREFULLY.THIS FORM DOES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. N 8722 S.Harrison St.,Sandy,UT 84070-(800)257.5590 IF YOU HAVE AN ACCIDENT OR LOSS: N N -Get medical attention it needed. Insured Policy Number U uSouthernmost Medical Trans PC24020008 - Notify the police immediately. 1fi08 Jamaica Dr Effective Date Ending Date -Obtain names,addresses,phone numbers(work home),and license East Rockland Key,FL 33040 O 1126I2024 1/2612025 numbers'of all persons involved,including passengers and witnesses. G yCard i � � � and license plate number and state of each vehicle involved. If Prim Company Issuingerty& asually Insurance Use -Contact Claims Direct Access immediately at(877)585-2849. 8722 S.Harrison St.,Sandy,UT 84070 Inc.c © Pers nal(PL)CL)u Not valid more khan one year from effective date Year Make!Model State ID Vehicle Identification No. Section 316,646,F.S..'Misrepresentation of insurance is a first degree misdemeanor,' 2023 Ram Paratransit 3C6LRVDG1PE579399 �o wl Lift(1-8 Pass) NOW, THEREFORE, in consideration of the mutual terms and conditions, promises, covenants and payments set forth below, SMT and CONSULTANT agree as follows: ARTI SCOPLDE3ERVICES 1 .1 Under the direction of SMT Director of Operations as defined in'-E, Florida Administrative Code Chapter 64J-1 .004 for medical transport only, the CONSULTANT shall provide a qualified physician to serve as Medical`' Director for the SMT's Emergency Medical Transport Services Program as more particularly set forth herein: 1 .1 .1 Develop transport protocols that permit specified AL.S and BLS procedures when communication cannot be established with a physician during medical transport when a delay in patient care and treatment would threaten the life or the health of the patient 1 .1 .2 Medical Director will be available "off-line" to resolve administrative problems, system conflicts, and provide services in an emergency as that term is defined by Section 252.34(3), Florida Statutes. Such "off-line" services will be provided at a rate of $300.00 per hour or at a rate mutually agreed upon by the CONSULTANT and SMT's Chief of Operations. 1 .1 .3 Develop and implement a transport patient care quality assurance program to assess the medical performance of SMT's Paramedics, EMT's and Critical Care Nurses. Clerical and administrative support will be provided by SMT. 1 .1 .4 Audit the performance of SMT's personnel from time to time by use of a quality improvement program, to include but not limited to, a prompt review of transport reports, direct observation, and comparison of performance standards for drugs, equipment, protocols and procedures. 1 .1 .5 Provide a DEA registration for SMT in order to provide equipment, medications, including controlled substances to SMT, if needed. 3858 ARTICLE 2 COMPEN N AND M THC YMEN 2A SMT agrees to-pay the CONSULTANT as-full compensation for the services described in Article 1 an annual fee of $40,000.00 to be paid to the CONSULTANT in twelve consecutive equal monthly installments of $3,333.34. This fee includes all costs and expenses of CONSULTANT. SErvices requested beyond the scope of this contract will be invoiced separately as a rate of $300.00 per hour, subject to approval of SMT Chief of Operations. 2.2 SMT agrees to pay the CONSULTANT on the first day of each month for which the CONSULTANT'S service are rendered. ARTICLE 3 DEFINIT NS, 3.1 "Department" means the Department of Health, Bureau of EMS 3.2 "Emergency Medical Technician" or "EMT" means a person who is certified by the.Department to perform basic life support. 3.3 "Medical Director" means a physician who is employed or contracted by CONTRACTOR who provides medical supervision, including appropriate quality assurance but not including administrative and managerial function, for daily operations and training. 3.4 "Paramedic" means a person who is certified by the Department to perform basic and advanced life support. 3.5 "Physician" means practitioner who is licensed under the provisions of Chapter 458 and Chapter 459, Florida Statutes. 3.6 "Chief of Operations" means the highest ranking medical professional in charge of SMT's medical transport services. SI 101 )IJ c,a it M1t 3, �.Yrtt�,�ilY 3859 ARTICLE 6 TERM 6.-1 This agreement,shall commenc&on January 1., 2024 and shall- continue through terminated rir under ArticleT shall have the option to renew this t for 4 additional r terms subject to the same terms and conditions, by providing the CONSULTANT writtenrenew prior to the expirationa If thisr is renewed under Article .6, entitledthe CONSULTANT shall be increase f five percent annually for each subsequent renewal, TERMI ARTICLE 7 7.1 If through any cause, the CONSULTANT fails # i its obligation under this agreement, right terminate i upon providing writtennotice . 7.2 This agreement may be terminated noticedays written . If SUIT terminates , the CONSULTANT shall be compensated r all servicesprior to the termination da ,prior r ,t r i returned fi nal i to the CONSULTANT. 7.3 CONSULTANT may terminate i writtenupon providing i f CONSULTANT terminates without cause, I for all services performedr to termination date. ARTICLE 8 'd'V�u thz h r M1ht D Ir rr,�,15) 3860 arising out of or relating to the agreement, and unanimously agree that all claims in respect of such action or proceeding may be heard and determined in such court. Each party further agrees that venue of any action to enforce this agreement shall be in Monroe County; Florida. 9.3 Headings: Headings are for convenience of reference only and shall not be considered on any interpretation of this agreement. 9.4 Exhibits: Each Exhibit referred to in this agreement forms an essential part of this agreement. The Exhibits, if not physically attached, should be treated as part of this agreement, and are incorporated for reference. 9.5 Severability: If any provisions of this agreement or its application to any person or situation shall to any extent be held invalid or unenforceable, the remainder of this agreement, and the application of such provision to persons or situations other that those as to which it shall have been invalid or unenforceable shall not be affected, and shall continue in full force, and be enforced to the fullest extent permitted by law. IN WITNESS WHEREOF, the parties hereto have set their hands and seal the day and year first written above. Lawrence William Blass, M.D. tl WITNESS: 'a� Cr c, Pa"(4 c Southernmost Medical Transport, LLC. BY Chief Operations Officer: ° Paula Turner WITNESS .s �---- �`c� -Tr ��,� 34'1)"' 1)o'u d y>"Ib 10 3861 y" BOARD OF COUNTY COMMISSIONERS County of Monroe ''��`;�� Mayor Holly Merrill Raschein,District 5 The Florida Keys Mayor Pro Tem James K. Scholl,District 3 Craig Cates,District t Michelle Lincoln,District 2 David Rice,District 4 Monroe County Fire Rescue '; ������� 490 63Td Street Ocean Marathon,FL 33050 Phone(305)289-6004 " MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: February 15, 2024 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check dated February 5, 2024 in the amount of$950.00 per check to be deposited in revenue account 141-342000-RC 00345. This check has been issued for the initial application of a Class A Certificate of Public Convenience for Southernmost Medical Transport. Thank you, ra4"' zz—tr Cara Johnson 3862 tG 00 Cashier's Check BANK OFAMERICA , 1 1 " 1 f11 , , Y EY411BST FUkGL " 160� 1 [5" � -� " J 50-. AMORIC $9, 04* BANP(lb 4y > Nine un�ri�Fift:y'andOOilo'ODOII'ar�*-� To The Order Of MONROE C()bNTY BOARD OF COUNTY COMMISSIONERS COPCN APPLICATION Remitter(Purchased][1y): sob'rilERNMOSTMr.DICAL*rPANSPORTI.1,C Bank or America,N.A. SAN ANI'ONIOTX A I ITHC IMAN I I SMNM= 01","'THE ORIGINAL DOCUMENT HAS WHITE REFLECTIVE WATERMARK ON THE 8ACX.0( HOLD AT AN ANGLE TO VIEW WHEN CHECKING THE ENDORSEMENTS. . ~__- -�_-__- __-_____-^___� -~ " / " ���N . »,,,flllllllllll firm, 1 r �'tahc�ing Protorco/.v 3865 3866 3867 "I'll"a-ble of Contents, t Medic Al reek opt Pro twolf -------------------- IN 11 3868 3869 "I'a-ble of Contents, t Medic Al reek 0'rp opt Pro twolf 3870 "I'a-ble of Conte�n�ts, t Medic Al reek 0'rp opt Pro twolf ....................................................................... 3871 Table of Contents, t Medic Al reek 0'rp opt Pro twolf 3873 i Ff. iuv li i 0114101.Ilt PAULA TURNER @f;°@[; Ii C iG,. Dr. LAWRENCE BLASS, M.D. 11.°'I; liTOi' S • Bill McGrath; North Lauderdale Fire Rescue; Battalion Chief of EMS • Dr. Antonio Gandia MD FACEP NREMT • Dr. Lawrence Blass, M.D. Special Recognition: A special thank you to Dr. Ken Scheppke of Palm Beach County Fire Rescue and Dr. Jim Roach of Broward Sheriff Fire Rescue and their staff for permission to utilize their protocol template and publishment of protocols. 3874 The following Emergency Medical Services Protocols are the Official Advanced and Basic Life Support Protocols for the City of Key West Fire Department and are approved for such use by Paramedics and EMTs of the department to care for the sick and injured. Only those Paramedics and EMTs approved by the Medical Director shall be authorized to utilize these protocols. These medical treatment protocols have been developed as a part of the medical direction program for participating Emergency Medical Services (EMS) agencies. The medical director of an individual EMS provider may choose to modify certain treatment recommendations. In addition, some patients may require therapy not specified in these protocols. The treatment protocols should not be construed as prohibiting such flexibility. The paramedic/EMT must use his/her judgment in administering treatment. When the paramedic/EMT is unable to make contact with other forms of medical direction, he/she may contact the receiving hospital for consultation with the emergency department physician. It is recommended that the paramedic/EMT make contact with the physician for consultation on complicated patients whenever possible. When the paramedic is unable to make contact with a physician for medical direction, the paramedic may administer BLS treatment according to his/her judgment. In this instance, the paramedic may administer ALS treatment only as authorized in the treatment protocols. 3875 Medl"CAI TrAAqo,vt Pretocok All adult protociols in this, document will be llisteld with this icion before, any in- structions., In addition► the lull Iportion, of the protocol will have a, red outline. ,All pediatric, protocols in this document will the listed with this icion before any instructions, In, addition, the pediatric portion of the protocol will have a, blue outline. 3876 3877 3878 3879 fllf %�idH,wiY� �ia� d;Nf�l° i 1 3880 45—Woo- Med�'PAI ADULT& PEDIATRIC �IEDICATIQN ADf�IINISTRATION • Prior to administering any medication, inquire about medication allergies or adverse reactions to medications • A true allergy to a medication causes a rash, SOB, swelling of the tongue, face and/or throat INTRAOSSEQUIS SITEL(LZ-101 • An 10 should be placed for patients with emergency medical conditions that require urgent vascular access in whom an IV is not immediately obtainable or is deemed to have insufficient access • Adult: • Proximal Humerus • Proximal Tibia • Distal Tibia • Pediatric: • Distal Femur • Proximal Tibia * Preferred • Distal Tibia • Proximal Humerus (only if the surgical neck can be palpated) IM INJECTIONS • All IM injections shall be administered in the lateral thigh or Deltoid • Adults: • 21-23 gauge 1.5 inch needle • 4mL maximum per site • Pediatric: • 23 gauge 1 inch needle • 1mL maximum per site • If> 1mL needs to be administered, split the dose between both thighs MUCOSAL ATOMIZATION DEVICELMADI • The following medications can be administered via the MAD: • Versed • Ketamine • Narcan • Glucagon • Ativan • Desired dose: • 0.3mL- 0.5mL per nostril • Max 1mL per nostril 3881 PEDIATRIC Patients who have not reached puberty are considered pediatric patients and shall be treated under the pediatric guideline section of these protocols Patients who have reached puberty shall be treated as an adult 10 is the preferred method of vascular access during pediatric cardiac arrest T T Y"SYSTEM The "Handtevy" system shall be utilized in the resuscitation and treatment of all pediatric patients The child's age should be used as the primary reference point for determining the appropriate patient care If the child appears shorter or taller than stated age or if the age is unknown use the "Handtevy" system length based tape Refer to the "Handtevy" system for the following: • Medication Dosages/Infusions • Equipment • Electrical Therapy • Vital Signs PEDIATRIC AGE CSI I TI Newborn: • Birth to 24 hours Neonates: • 1 Day to 1 month Infants: • 1 month to 1 year Children: • 1 year to puberty Pediatric patients for medical transport will be considered 17 years and 364 days old Pediatric patients for trauma transport will be considered 15 years and 364 days old PUBERTY Female pub rtV is deflned as breast developiment. Male pubert y is defined as underarm, chest oir facial hair. 3882 Onze a child reaches pubierty,use the a juult gtildefines for treatment. Back to Table General information 14 3883 prmlocmk ADULT& PEDIATRIC Patiern with Altered Mental Statuis Consider; 4 Alcohol MENTALSTATUS Alert:to person, place,time, and event (AAOX4) Verbal: responds only to verbal stimuli �ain: responds only to painful stimuli 0 Psychiatric Unresponsive o sxrmlkmts hock VITAL SIGNS w Pulse (rate, rhythm and quality) w Respirations (rate and quality) w Skin (color, condition) w Temperature w Pu|seOxinnetry w Blood Pressure (capillary refill) ° EtCOz w BGL w Pain Scale (1'10 scale or Wong Baker Scale) ALL patients shall receive at least 2 sets ofvitals Unstable patients shall receive vitals every Sminutes A manual Blood Pressure shall be taken to confirm any abnormal or significant changes of an automatic Blood Pressure cuff reading Blood Pressure shall be checked before and after administration ofadrug Hypotension for adults is defined as Systolic BP < 9UnnnnHB ETCO2 Shall be utilized for the following patients: w Patients requiring ventilatory support (e.g., BVM, ET tube, SGA, CPAP) w Patients in respiratory distress w Patients with Altered Mental Status w Patients who have been sedated w Patients who have received pain medication 3884 ,,ram • Seizure patients GLUCOSE A BGL shall be documented for patients with any of the following: • H istory of d is betes • Altered mental status • General weakness • Seizure • Syncope/lightheadedness • Dizziness • Poisoning • St ro ke • Cardiac arrest 3885 ADULT& PEDIATRIC ECG MONITORING All ALS patients shall be continuously monitored in lead II 12 lead/15 lead ECG shall be performed on the following patients: • Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort • Palpitations • 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 ROSC • When transporting, leave cables connected until patient is turned over to the Emergency Department (ED) staff PATIENT HISTORY CHIEF COMPLAINT: Why did the person call 911? S.A.M.P.L.E. HISTORY("'!^µ.A.11l "i.11l'"".IIL..IIIIIIII� SIGNS &SYMPTOMS • ALLERGIES • "IEDICATIONS: Prescribed, over the counter, or not prescribed to patient °^AST MEDICAL HISTORY(patient's and immediate family's) • ILl AST ORAL INTAKE • III VENTS PRECEDING HISTORY OF THE PRESENT ILLNESS(I .III'"".I j.11l''L"'!^' °""" ) µ III A • ONSET: Did the symptoms appear gradually or suddenly? • "IALLIATIVE: What makes the symptoms better? • "IROVOKE: What makes the symptoms worse? • "IREVIOUS: Previous similar episodes? • QUALITY: (What kind of pain?) pressure, squeezing, aching, dull, etc. • IADIATION: Does the pain or discomfort radiate?Where? • SEVERITY OF PAIN: 1-10 scale (utilize "Faces" pain scale for pediatrics) • II IME: What time did the symptoms begin? • ASSOCIATED: What are the associated signs &symptoms? 3886 D,erterirn ination nf-Ovat Rerson should be considered d'ead/non-salvageable that have all of the following presiumptive., signs of cleath and one conclusive sign of death� P Ila[�e 15!5 Fixilaid, Dilateod Piiq�)Os call"clu.5i'MR, 0 Deco mpositi on 0 Risor mortis 0 Liver mortis (Lividity) 0 Injuries,incompatUe with life 4 Patients with suspected hypotherrnia,, barbiturate overdo�se, or electrocution require fuill ALS resuscitation un- less they have injuries incomplatible with life or tissue decomposition 4 Children are excluded from,this protocol unless EMS personne�l make contact with medical direction for consuk tatilcn. Only in cases of obvious,, p�rolonged death should CPR not be started or discontinuled on infants, chil- dren or young adults, or in cas,es in which an, ulnexpected death �has occuirred, '3887 � Basic Le �� � p� rt ADULT& PEDIATRIC AIRWAY AIRWAY NQSUTUQNUNG- w Medical patient: w Position patient with external auditory meatus (a.k.a. "The Earhole") on the same external plane as the sternal notch w Trauma patient with suspected spinal cord injury: w Modified jaw thrust NASQPHARYNGEAL AIRWAY (NP4)- w Senni'consciouspatientsvvithanintactBaBrefexsha|| haveanasopharynBea| airway inserted, un|esscontmindicated QRQPHARYNGEAL AIRWAY ((`XPA)- w UnresponskepatientsvvithoutaBaBrefexsha|| haveanovopharynBea| airwayinserted, un|esscontnaindicated OXYGEN ADMINISTRATION �)O NIOT withhold Oxygen if the patient isdyspneicorhypoxic S�Qz� w Maintain SpOz at least 94%for w All patients w Exception: COPD&Asthnna w Maintain SpOzof9U%for: w COPD &Asthnna OXYGEN ����U�UST�ATUQ�� ° 15 LPM via NRB regardless ofSpOz w All 3rd trimester pregnancy trauma patients w Decompression sickness w Carbon Monoxide exposure w Cyanide exposure If oxygen saturation cannot be maintained, ventilatory support should be provided CIRCULATION Ad u It: w Carotid and radial pulse present, assess capillary refill, assess skin color, condition and temperature w Refer to the "Cardiac Arrest" algorithm,for all patients found pu|se|ess w Carotid and radial pulse present (brachial in infants), assess capillary refill, assess skin color, 3888 Basic Life Su �rc � ls condition and temperature • Refer to the "Cardiac Arrest" algorithm,for all patients found pulseless • Refer to the "Bradycardia" protocol, for pediatric patients found bradycardic with signs of poor perfusion and AMS 3889 INFORMATION In certain patients, excessive ventilation rates may be harmful. Overzealous positive pressure ventilation can impair: • Venous return • Cardiac output • Cerebral perfusion Ultimately the patients SpOzand EtCO2should determine the ventilation rate for the patient (ideally EtCO2should be 35-45 mm Hg). ...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...u...0 ADU YEA 11IL ,1,028 "RAILS e`L ro,'rg I NTS W"TRA KAfouSiv • 1 breatlh revery 6,seconds FIA;l1 II HEN I S V�h� I V,[11'6NJ If' IPU I&IE, 1 breath every 10 seconds • Maintain IEtC 2bet reein 301-35 m,m Hg and SpO2 chile co,ntirmuoUsly rnionitoriing BP PEDIATRI r'va �iE Pal is wu"rH II'�LII1I.,.�,IE.: 1.breath emreiry 2-3 secands. E 1 s oxv�8o,B� P,� U>II,jgsII 1. breath eveiry 2-3 5too d 0 PA r V ,r V T..S )PA'11 F-11 @ r.,.V • Maintain Et Oz bet reerm -35 rrn r HS,and Spi0z>90while coxitinuo,usly mormitorkig BIB WRIIIIIIPS �DO ISInSIr 5�"�II IEI I1YT TO A,GGlRl�„SI'V'E[,,Y' N,DlRIVIAL�lZlE REA IPPIGS' INT$III FOIIiPSIC1 1lll1" G Ill�IIAMIiENTSw Cardiac arrest pare/post RiD C 8ron lhosp sm (Le,astfirna,COP ) 3890 Back to Table Ventilatory Assistance19 3891 INFORMATION w Priority-1- Patients in Cardiac or Respiratory Arrest ri rit Unstable patients with immediate life-threatening conditions ri rit Stable patients with no immediate life-threatening conditions WA 11 li li IN G IPlacing patients in,the Iprone(position is contraindicated due to the risks of asphyxiation.. However,impalement or other situations may mandate the prone position,.in these instances, clear documentation of justificatIon and attention to airway maintenance is mandatory. ADULT PRIORITY TI T ('M IFRIC'DII ('M/IFRIESsPI IIFR II"("')IFRM IRIRES11"m Transport to the closest ED PRIORITY 2 PATIENTS Shall be transported to the closest ED ll.R I_I ICI L IE R II" IPA11 II IE 115 • Shall be transported to the closest Trauma Center per catchment area. If on bypass,transport patient to the next closest Trauma Center • On-scene times for Trauma Alert patients should be < 10 minutes. On-scene times> 10 minutes shall have the reason for the delay documented in the ePCR report. • If ground transport is> 20 minutes transport by air if available • Trauma patients who arrest in the presence of Fire Rescue personnel, shall be transported to the closest Trauma Center. PIREGl 11 'll. 11"RA_VIII ILEIRII"S (Vlsllbly oir Iby hnlsI:oir of gearlaIalon > 20 weeks)-Pregnant patients meeting Trauma Alert criteria should be transported to closest OB Trauma Facility 3892 PRIORITY 2 PATIENTS CONTINUED SIRElMI/C"ANCDII C" ILERTS- • Shall be transported to the closest ED • Patient presentations that are indicative of myocardial ischemia that III';)0 NJOT meet "STEMI Alert Criteria" should still be transported to the closest ED S11.W"DIKIEALERTS- 9 All Stroke Alerts shall be transported to the closest ED SEPSIS ALERT- • All Sepsis Alerts shall be transported to closest ED HIXIPEIFtIBARIC"C"HA IIEIEIR (ff ineeded)- ShOkAld Ike Iarainspoiimted to the closest IED Examples liinnclII Ade (IHoinn-tiraklimatk,) • Decompression Sickness • Carbon Monoxide Exposure • Hydrogen Sulfide Exposure • Cyanide Exposure • transport by air if available I IH 1IR_I IE IRE ICD II IH I IE RI: C"11II1I.Y 1RR IH&I:E R S • Should be both paralyzed and sedated by the sending facility • If the sending facility physician refuses to administer paralytics: • Follow the Advanced Airway protocol PRIORITY 3 PATIENTS ("DI13SI EI RIIC"A m • Obstetrical (OB) patients are defined as gestation > 20 weeks • Unstable OB patients should be transported to the closest OB ED • Post-Partum up to 2 weeks BAKER C"T IPAT II IE IH T S 3893 E'I�IM�kT�I , CC T RANA5 F'OR "TO i H 0 Pediatric patients who, have re ainn d a RrOSC 10, (pediatric respiratory arrest cases that have,successful airway mrnana errnernt (i.e., good compliance wlitlhn the BVM arnd airway adjuncts, positive IEtC z waveform,form, iirmnprovi-i n pulse x.irmntr' ) 61 Eulsell ss (pediatric(patients 10 Pediatric respiratory arrest patients who have an lunstabile airway(Le., uanablle to veinti]ate or oxygenate) IF li'i i..t lei A A II Ir_R IF lFIA,.T 11 lh=NI F S 10 Shaul be transported to the closest E', * On-scene times for Trauma Alert patients should be< 19 uTniirnunjc, .. On-scene times > 10 minutes shalll have the reason for the dl lay documented in the ePCR report. 0 Traurrrrna patients who o arrest in the presence of Fire Rescue personnel,shall be transport d to, the closest ED NI F'hFlu"KF Fd~RTS/ xlRDIA(1'1:u lI,IRT' All Stroke Alerts or Cardiac Alerts shall be transported to the closest ED S E PS III E litli: 10 All Sepsis Alerts shall be transported to cllcns st ED CC F1'n'°Pi:Rl°tAIFIC F;iP4AMBIII°ER (if' n ew.iu,O SInn,nlll L to..ajn,�i.nm;aed to tlwie dlcv�e5l ED l f.,.7xairr pli1a s ulumclude �iawla iww t.ic �i.�rt°iww w ii ;,l ► Decompression ick n ss Carbon Monoxide noxid Exposure Hydra rn Suffidle Exposure Cyanide IExposure PRIORITY IPATIENTS , 3894 & er .ost meditd rrmqport Prot000k ADULT&PEDIATRIC HELICOPTER TI L CRITERIA: • Mass Casualty Incidents (MCI) involving multiple patients with traumatic injuries HELICOPTER • For patients weighing 350lbs-500lbs, discretion should be used as to whether air transport is the preferred method of transport • The flight crew must be capable of loading, unloading, and treating the patient within the confines of the aircraft • The flight crew has final authority to accept or reject the transport HELICOPTER LL NOT BE USED: • Bariatric patient known or estimated to be five-hundred pounds (500lbs) (227kg) or greater • Patient who is unable to lay supine (when clinically indicated for air transport) • Patient who is combative and cannot be physically and/or chemically restrained • Hazmat contaminated patient 3895 3896 3897 MMw� ,n u „ , Illudll� io ADULT&PEDIATRIC vs ALLERGIC REACTION Allergic reactions are characterized by any of the following: • Generalized Urticaria • Airway,Tongue, or Facial Swelling, Respiratory Distress, Bronchospasm • Nausea,Vomiting, or Diarrhea • Loss of Radial Pulse or SBP of< 90 mm Hg Determine the source of the allergic reaction (insect, food, medications, etc.) If patient presents with airway swelling/respiratory distress/bronchospasm/tongue and/or facial swelling/loss of a radial pulse or SBP of< 90 mm Hg: • Assist patient with prescribed Epi-Pen CARDIACT Refer to the "Cardiac Arrest" algorithm (pg. 70),for all patients found pulseless OVERDOSE/POISONING Try to identify source of the overdose/poisoning Assist patient with II IRC"AI if available/applicable Consider contacting the Florida Poison Control Center at 1-800-222-1222 SEIZURES Consider the possible causes: • Drugs • Alcohol • Meningitis • Diabetic • Fever • Poisoning • Head trauma • Hemorrhagic stroke Protect patient from injury if actively seizing ALTERED MENTAL STATUS Check and record BGL If BGL is < 60 mg/dL, and patient is able to protect their airway/swallow: ("D R IL G LLJ C`("') IE- 15g, if able to swallow and follow commands 3899 May repeat 1x prn :Flat u�uiitlls NAII'u) auu� riot c ouI.ISClIIOIIU.5 Ell"II101Ugill V:O .;WaIIII(:)NAI :�'I at u w u ii tls < 2 3900 ADULT&PEDIATRIC EXEDSE As a general rule, only remove as much of the clothing as necessary to determine the presence or absence of an injury. Cover the patient as soon as possible to keep the patient warm. SPINAL TIRESTRICTION Perform manual Spinal Motion Restriction by providing manual cervical stabilization and apply an appropriately sized cervical collar as appropriate if the patient meets any of the following criteria: Complaint or finding of focal neurologic deficit on motor or sensory exam Complaint or finding of pain to the neck or back Presence of a distracting injury Altered level of consciousness with an MOI (Mechanism of Injury) Intoxication with an MOI present The key objective is to move the patient in the safest, most anatomically neutral position possible If an appropriately sized collar is not available or if the collar compels the patient to move, remove the collar and provide Spinal Motion Restriction Place rolled towels on the sides of the patient's head and neck Secure with tape or other similar devices to allow for comfortable cervical stabilization/ immobilization The cervical collar should not cause the patient discomfort such that they are compelled to move Place the patient on the stretcher cushion, supine If the patient is unable to tolerate this position, place in a position of comfort,that also respects normal anatomical alignment and document appropriately. HELM T Helmets without shoulder pads should be removed from all patients Le motorcycle If applicable, protective pads should also be removed Athletic trainers should be consulted in the helmet/protective pad removal process if applicable Spinal motion restriction should be "manually" performed during the removal process BURNS 3901 Refer to the "Burn Injuries" protocol (pB. 11S) EYE EMERGENCIES [HEMU[ALEXPQS0NES- Rennovecontact |ensifpresent Irrigate the affected eye(s) with NQRMALSALINE Be careful not to contaminate the unaffected eye with runoff PENETRATUNG EYE INJURIES- Stabilize any penetrating object Cover both eyes with gauze and an eye shield Keep the patient calm, as crying, screaming or coughing can force more of the tissue outward �)O NIOT attempt to replace or move the protruding tissue 3902 CLOSED FRACTURES Fractures should be splinted in the position found Exception: No pulse present UI''t the patient cannot be transported due to the extremity's unusual position 2 attempts can be made to place the injured extremity in a normal anatomical position Discontinue attempts if: The patient complains of severe pain I III: If there is resistance to movement felt Reassess neurovascular status before and after repositioning of patient's extremity C'IIM)S IE ICD I I II ICD-S IH Ii:..I- Ii:E ICI I_I R Ii:R C`11"I_I KE S Apply a Traction Splint ..I. uV? li:,s gill.;V) i;°i ,mlln,* NV'„"tl:DV°tlI DN:dkdc ln'i:lctIui'V:' I Ilu a Gifu �)Ip wfu II �i7r71ini IIn ::Dnni Lllu uu li�1 gill.;u) a h°ulillu Llluuwuu li�1 Gifu �)i Ilu u:V: ,"�uw';pu:� b tlI U) iinJ� l ., n illy lu:i771i..ni,. Reassess neurovascular status before and after repositioning of patient's extremity FRACTURESOPEN Refer to the "Open Fracture" protocol (pg. 119) HIP FRACTURES & HIPIL TI S Consider hip fractures in an elderly patient who fell and complains of pain in the knee, hip or pelvis A scoop stretcher should be used whenever possible to move patients with a suspected hip fracture Splint in position of comfort with pillows and blankets Reassess neurovascular status before and after moving the patient Traction splints shall NJOT be used on suspected hip fractures or hip dislocations K)SI IERIKDR HIP ICYIISIL("')C`A11"III'"DI S 3903 Most often present with the leg flexed and internally rotated, and will not tolerate having the extremity straightened ICI IF IE EI II C EI IH II IFS ICD II S LC)C" 1I II C ICI S Present with lateral rotation and shortening of the affected leg PELVIC Assess and treat for shock )O IINIOT perform a pelvic rock. Assess the pelvis by applying gentle pressure anterior to posterior and from the sides to identify crepitus or instability. III')O IINIOT repeat. Stabilize if possible A scoop stretcher should be used whenever possible to move patients with suspected pelvic fracture Reassess neurovascular status before and after moving the patient 3904 BLEEDING T L E IFR E I I IFF Y INJURIES' Direct pressure (utilizing manual pressure and pressure dressings) Combat Application Tourniquet (C.A.T.) Apply high and tight on a single long bone until the bleeding stops )O IINIOT apply C.A.T. directly over injury site or joint. If bleeding persists after initial C.A.T, apply a second C.A.T. Hemostatic Agent (If 2nd C.A.T application fails to control bleeding): Pack wound Maintain pressure for a minimum of 1 minute or until bleeding controlled Apply a pressure dressing DI_IINC`111KDINA IHIIEI KDEIEIIHAGE (e.g., ineck, axIIIIlairy, IpeIIVr s and giim6 irl) Hemostatic Agent Pack wound Maintain pressure for a minimum of 1 minute or until bleeding controlled Apply a pressure dressing (Occlusive if neck wound) ALL EXTREMITY TRAUMA Gross contamination, such as leaves or gravel, should be removed if possible Determine mechanism of injury (MOI) and evaluate Assess neurovascular status of extremity Color,temperature, capillary refill, crepitus AMPUTATION Rinse off Wrap in sterile gauze and place in a sealed plastic bag Place the sealed bag into a second bag with ice packs Label the bag with the patient's: Name Date 3905 Time of the amputation Time the part was wrapped and cooled ABDOMINAL T IMPALED ("D IB J IE C"11"S Impaled objects shall be stabilized to prevent movement and subsequent further damage If bleeding occurs around the impaled object, it should be controlled by holding direct pressure )O IINIOT apply excessive pressure )O IINIOT palpate the abdomen, as it may cause further organ injury from the distal tip of the object E VI S C"E EI IRKD ICI Protect the tissue from further damage Cover the protruding tissue with a moist sterile dressing,then cover with a dry sterile dressing Keep the patient calm, as crying, screaming or coughing can force more of the tissue outward )O IINIOT attempt to replace or move the protruding tissue 3906 BLS Bites and Stings INFORMATION • Consider contacting the Florida Poison Control Center at 1-800-222-1222 DAN (Divers Alert Network) at(919) 684-4326 as soon as possible for treatment recommendations. ADULT&PEDIATRIC ALL BITES AND STINGS • Clean the wound area with soap and water or sterile water • Exception: Marine animal stings • )O NJOT use hydrogen peroxide on deep puncture wounds or wounds exposing fat • Refer to the "Allergic Reaction" protocol, if applicable • Advise dispatch to contact animal control or the police department if necessary SNAKE BITES • )O NJOT apply ice packs,tourniquets or constrictive bands • Mark area of edema with a pen • Remove any constrictive jewelry or clothing • Splint any extremity that has received a bite and ensure it remains below the heart • Keep patient supine if possible • For hypotension: • Refer to the "Fluid Resuscitation" protocol (pg. 38) • If the DEAD snake is on scene,take a picture of the head (including the eyes) with the ePCR device if possible INSECT STINGS • Remove the stinger by scraping the patient's skin with the edge of a flat surface (e.g., a credit card) • )O NJOT attempt to pull the stinger out, as this action may release more venom MARINEI L TIONS: STINGRAY,SCORPIONFISH,LIONFISH ZEBRAFISHT I CATFISH, WEEVERFIS STARFISH, SEA URCHIN • Immerse the punctures in non-scalding hot water(if available)to achieve pain relief • Gently wash the wound with soap and water, and then irrigate it vigorously with sterile water (avoid scrubbing) MARINEI L STINGS:JELLYFI S TT I JI Y I FIRE CORAL • Rinse the skin with sea water(if available) • )O NJOT use fresh or sterile water • )O NJOT apply ice • )O NJOT rub the skin • Apply white vinegar(if available)topically to involve area until the pain is relieved (lifeguards may carry this) • Remove large tentacle fragments using forceps with proper PPE on and stay upwind when performing 3907 BLS BitesStings this procedure 3908 3909 %��� �mlVllllp!IIVI� i i t 1� / 11 ' I � MO i MO / / / / / / 3910 3911 Allergic Reaction reAkrP,00't Prolocok INFORMATION • Allergic reactions are characterized by any of the following: • Generalized urticaria • Airway swelling, respiratory distress, bronchospasm,tongue and/or facial swelling • Nausea,vomiting, or diarrhea • Loss of radial pulse or SBP of< 90 mm Hg • Determine the source of the allergic reaction and remove potential allergen (insect, food, medications,) 50mr"Ig III IO/IIM„ over 2, minutes IIV/10 uisage M ILRATF ...AI �Ay S ILLLINI�� IF�.. IPI A° OI " III "I I F,S� RIB 1N � II A "1LIQNfiVE AND OR l�. E.inlll+wNll° IPPRIIIINE (°.I Ij)(Y), "I nng/n, l I 0.3mmng (0.3 mnL) IIIv1 May repeat 2 prin, in 5 rzniinute Intervals I 50mrnig IWIO/PM, over 2 minutes,for IWIO, usage C:0IlIv IIIINVUNI (Ai IIi..JI "i.R(.ol � Al R NVII"NT) Allttnuter l ,2.'5mng via nebl ulizer Atrovernt 0;.5mng via nebullzer 7 May repeat prn I "�I'°:NII ill II�ILIII�IINIII.... I 125mmng IIV/100/IM/PO, over 2 mmirnutes,f6r IIV/10 usage SEVERE LOSS OF A O.AII FAIL PULSE 0IR SIIL P OF < 90,rnlirrm Wor .. EP,VINEPn...IIIIIPgE (1"1",u I��N; 1umnlgl/rrtL), U 0. m,g (0. mmnL) IM I H,ro,vpoDten,I ion '"IBC CNIlJ[VJO IP" i10 I ldIDICIl(d i4iss i e 11 nl`I I�,s w FNw )')%rI (]a' rn"ui0"7"u c""I�P1Y0::'a o�� �I'"Ou;;Bl,li (5-10II]�VIVI,q °oil ll`Vlil 1, he,'3V't r,Nrjd f^nlllWullll InI I�IIII"wIl Nf Vnninjiw0n. (if ir cd responsive to IIIIVIdose) I Epinephrine Infusion IWIO,5-15 mm>Icg/mm i n P40RII 14I " N"nII ILII= 20 m,l/kg I" /IO,fitrate t desired effect.Assess lung su unds and BF,frequently. 3912 MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM EDIATRIC MILD— GENERALIZED URTICARIA ONLY E BEIN IfsIRYIIL ;1mi k IV/0/U,over 2 rrmirniu;ut 's for IV/10 usage (many repeat if necessary) 1. i Max SiniglIe dose 50mg �.,opll��ll"a.'�6111�11�II11�'sU�III�::VIYII '�V°Q',ullVidlil''""'r� ICIERATIE—AIRWAY SWELLING CIJI'll E C IA L SW EV UNG I. l 1P,, Nili°ilP ili91L (,11,000, Inig„/rrd-), I ,I 0,.011rriig/'kg IM, rniax siniglle dose 03rng l I May,repeat 2x prru, in 5 minute intervals J 1rm g/k IV/0/1lM,over 2 rninu.utes for II 1I0 usage Max dose 5 4'. u� imn�i�urruu,iuu,„utrf� �i� I"�Ikwaooatu""s 1. CC)N11E-IVEN r(AI IiBII11"ICE 0 I + i""ai']'ROV III F) Ilbuteroll 2.5rTig via nebuili er J Atrovent O.Smg via, elbullz r ,I May repeat prof E S 1u�:.J III I R-M II DR I I. l ,1 m, /k l 'f*/Illy/P , over 2 rmmin,utes for IV/10 usage [ :I Max dose 1rn °E:' 'E E w L E" 'I ilkl, RAPIAL EMIR „III,,ABC ARPROBIAIE HYPOEN519,N1 E I Fli N E III I i iI V N I'll (,Il,�ill,000, 1,, rn I...."�: I 0,0,lmg/kg Ill, max siniglIe dose EI,3mg 11 May,repeat 2x prru, in 5 minute iuntervalls gn;�a07iY11"�;trVP"u ,IOC"�,kYID���i➢V � �°��„uu q�'II Vi�101� 'pi°�:��°,4"r0"�rri���l,��� uc) bbod olss EPINll,PI ERpN 17 1'V Ilhlu,ision (if not a eu;i;cirri ,, a e t,uo II'NA ose 3913 INFORMATION • Symptoms of Diabetic Ketoacidosis (DKA) include: • Nausea/Vomiting • Abdominal pain • General weakness • Kussmaul Respirations (deep rapid respirations) • AMS • Hypotension • Tachycardia with an acetone smell on the patient's breath Diabetic patients taking oral hypoglycemic medications should be transported (e.g., Glyburide, Glimepiride, and Glipizide). �uf ADULT 5 rnz,,/di. 0IIIRAL C.3 I L)C USE 1,Sg, 0 May, repeat 1x prn ,,ur°e ed)0114h �ci d,wafljc`oi 25mill of 50 solution total of II S grams I-) D O 100 mIL 1 /'110 Retest glucose 1 May repeat 1x prn I ; ir_ L lb!I,CARIDlAC ARREST------------- I i.n,50. I 50m,l of 5 %solution, total dose 25 grams I D 1,01: C 1 250 imL III"/I0. Rapid infusion (if available) IF i l is l ' PROIID ' �CUILAB.ANE55 GI.UCAG0ICI r . li VP � rate v l sired effect.Assess hung soondls and BP frequently. C May repeat 1x prn NOWll ' §A'h Ifq"�lV� n=qunri ,�onay InnO ure Ilral' er'lts 3914 RELti1;�4�I�IIdC AB RG LL<5 6 10 rn ; 1 , 15g, if addle to swallow and follow mmaiind "N. t���''�II��III14''^w'vdli 1i rNre"�E IFlCiit q°l�°UII11"o-u"IItl)JU V'11��",��I�d�� �f`II ��V s"0.�v dli4:�'vl, ���r�a��.� .is El May repeat Ix pm (if available) p IF UNABLE TO PROVIDE 5O TREATMENT Gd.LJ G0 Ii 0 available) 1m ll~a+/lN (if L, gg 0 0imL/k li /110, assess lung sounds,aind BLIP frequently 0 May repeat 2x pm, for, 95L�> 3,00 mg/cll 3915 ' INFORMATION • Dystonic reactions are characterized by intermittent spasmodic or sustained involuntary contractions of muscles in the: • Face • Neck • Trunk • Pelvis • Extremities • Even the larynx • The following classes of medications are typically responsible for dystonic reactions: • Antipsychotic (e.g., Haldol, Risperdal, etc...) • Antiemetic (e.g., Compazine, Reglan, Phenergan, etc...) • Antidepressant (e.g., Prozac, Paxil, etc...) • A dystonic reaction can occur immediately or be delayed for hours to days. AD • 5Dmg IV/ O,/IM, over 2 minutes for I /10 usage PEDIATRI BlE NNE)R L 1_1 lmg/k,g IWIO' 'I ,over 2 minutes for lWI�O usage, I Max dose 50mg NEE Oinates 3916 INFORMATION • Indications for fluid resuscitation: • Hypotension • Fatigue • Dark Color Urine • Dry Mouth • Headache • Prolonged vomiting or diarrhea • Non-traumatic bleeding (vaginal or GI) • Suspected Rhabdomyolysis • Paramedic discretion INJKIPiNYrvNNfJNNfKVFNfHJNIdiNVKfJNfJNlJN4FIdN✓KJ(Nti IJINJNIdiN4FIJIH✓K(4iNVKKKKK(aiNYFIdINJKIPiNYrvNNfJNNfKVFNfHJNIdiNVKfJNfJNlJN4FIdN✓KJ(Nti IJINJNIdiN4FIJIH✓K(4iNVKKKKK(aiNYFIdINJKIPiNYrvNNfJNNfKVFNfHJNIdiNVKfJNfJNlJN4FIdN✓KJ(Nti IJINJNIdiN4FIJIH✓K(4iNVKKKKK(aiNYFIdINJKIPiNYrvNNfJNNfKVFNfHJNIdiNVKfJNfJNlJN4FIdN✓KJ(Nti IJINJNIdiN4FIJIH✓K(4iNVKKKKK(aiNYFIdINJKIPiNYrvNNfJNNfKVFNfHJNIdiNVKfJNfJNlJN4FIdN✓KJ(Nti IJINJNIdiN4FIJIH✓K(4iNVKKKKK(aiNYFIdIN.....YrvNNfJNNfKVFNfHJNIdiNV AQYLI a' NDIVIO;1"I SALIIINE-1, 20irnl/kg IWOO, tifrate to desired effect,Assess lung sounds andl BP frequently. May rel eat::Yx Ipirn, ..... n '�"' wro,l4l oS4^a� �.. A G, I ll, » �': ;a�i'G�tV �.cil,,�aq„ II✓"wW€t��p,.byy 1 miL/,kg for irnfarmt,/mmearmat , A55ess Iluns smind5 and I II frequently C rnfVL III III I�aPem tip rrmiunurtes a:�s Ilu�n sounfrls and SP fre uierm�t • May repeat 2x Iparn for age aipprop,date Ihyp atten:sio,n 3917 Hyperkalemia reA0'rP,00't p'rolocok ' INFORMATION • Consider hyperkalemia in patients with a confirmed history of renal failure/dialysis who are pre-dialysis and present with any of the following: • General weakness • Cardiac arrhythmias& ECG abnormalities: • Tall peaked T-waves (most prominent early sign) • Sine wave • Wide complex QRS • Regular Really Wide Complex Tachycardia (RRWCT) • Severe bradycardia • High degree AV blocks PEAKED T WAVE SINE WAVE 55 _ �4 a ' '� w P,w ✓ F PATRENTS P E EII ITRIP'�'G ITH A OF THE ABO E CA MAC A RtER�"TI 11111AS ECG ABNO AL]"TIIES L,ALmlr�llulNII CR'1LORIIIDL 1Ig IW110,over 2 minutes, L"i,e c a iI r f d:p P L lh,1ilr„D VN C in, V/1 C), i i ini"r ,r� "wi LY11I IIo1 IIN/1 l LL 1 I II,R1,01L,; .5mg,via nebuli er 0 Continuicluis treatments(if an advan .ed airway is rutilil adl inistervia in lunQ nebuillization), n1O11"mlIPA [.11 CA I B0INAT11: 1 r iIEq/Kg IV/111 , over 2 rnin tes IIlK',R M011 aalm nistell ii�i sajri' 'V k"')" lhnv°�'� C. L.0 LJr 11 C1111..ORRIE)Ev��r�lrf`r�w;ml' �;rm�i:�wKru,kf!,ll°fill�7�r VI,Au :l��ili=i'r IE IPA"tllENI'l IISHY ,l R.N. HIVE. 1`4 r: E I AIL.. 'SA I1 I11 Irk I I 20mll/leg IV/IIO, tmtrate to efll"em;t..Assess Iluiing soI t`re uierntly.. May repeat ix prrw IT"IIINSI IN';'➢.: Lu.Vi+i(:",I"II III, k"INr" ^`6111,�11➢1111c'IiIn cioru°.°'IIV"p«II II'""yf hear" wn"d renal ..................................................................................................................................................................................................................................................................................................... DIAERIC Call for ordelrs 3918 Nausealvomiting 114,-,dital rraocpovt Prot000k INFORMATION • Consider differential diagnosis: • Cardiac • St ro ke • Diabetic • Head Injury • Other •, 41rn lil" /101/1 /P a over, 2 minm tes for IV/10 usage • May re ear 'Ix;Iprn 1 uF Vim„iro,,,r',iry� iiiroi 50 m NI 1IN I W.WNAAL N,00-UUNC (of ru rmd cW • 0rnl/k I Y10, tiwtr to to desked effect.Assess Jung sounds and BP frequuerurtly, May re am; Ix pm ca,, rmus�, ,,aken lrll the i NG iI�GL`;pear,e, C11-' F,obnVd, Iii en a fa 1:11 mr e I2rbY'1ui=1:"V'ts PEDIATRIC S II V IN ICE lOmrul/kg for infer t=iraeoumate°over 110 mninuates. • 2, mrhL/ m /1 , aas.sM1ss OUng sor.ods and; BP"frequermdlyrr •r May repeat 2x prna for age a ppirolp-Hate by otevaI�lon ZO F IRAlIN • 0,.1 mrg/kg:IWIfna"IIIXd"P0,,over 2 mi nutes.far r 'usage 0 Max close 4mru 3919 n I)P NIN/ N (AI I°I Ji11I Nw �AIPRCYVIEIFP V') I� Albu"Ir rol 2,5irn v^ie neblulliz r Atrovent 0,.Sm,g via n IbXunlizier I May repeat prn U--POEM HIROL I 125inig, W/11 JIlM/P , over 21, minutes for II'WIJO usage MODERATE ( IIR,SEVERE ......... ........m____.. R ESPI RTO DISTRESS,. � L I ST a.. ... I ....... .P ....................................................... ...... ......... ..... i .. w.,PAIx- 'I() tl.rn Hy0 0 CaD Lj,,a ri))rl#cad In'k'� "il IL Ib II u ' ,4710ir'rn i n; 14..I g II"6'' j,,,,) 44obMkljn ^'��➢,pp���u:I!'rai�rOY���",rtl�� �! Ou:�°M��,�q��l ..k�� VIA^�:Itlr�Ob���r" 'I"NNI,hI.8NN (11,1000 Iuinjg/r~unlP,)'� 0.3 m ( , rn l>) I IM May relpleat 2.x pirn„ in 5 minute intervals I� CAC'"'l)Il i("f V" i40 COI" P41" (AI B LJ'T'mROL � A"TROVUwr,r) Illbu,uterol 2.5mg via nebullizer May repleat Iprn W III'Iii' IIIIV Immediately remove the IP for the,asthimaltic patient whose condition worsens after applying tFw Prr P.. Consider the use of K t rnione as the Induction agent for IRSI in patients with brcnn hospasm irequnirirn, . advanced airway intervention. See Advanced Airway Protocol 3920 ..................................................................................................................................................................................................................................................................................................................................................... PEDIATRIC BRONCHOSPASM C"("D IIVI 13II V IE 1F ( L13 t_t 1F IE W"k IL i..All.IFS "' IE lF.) Albuterol 2.5mg via nebulizer Atrovent 0.5mg via nebulizer May repeat prn S("D ILt_t-IIVI IE IC'D IFS("D ILm 2mg/kg IV/l0/IM/PO, over 2 minutes for IV/10 usage Max dose 125mg FOR SEVERE ASTHMA T RESPONDING TO ABOVE TREATMENT E IP I INE IFS INI IRI INE (1-1, 00, l img/i m lQ- 0.01mg/kg IM, max single dose 0.3mg May repeat 2x prn, in 5 minute intervals MAGNESIUM S t_t LIF TIE 50mg/kg over 20 minutes IV/10 �iecautti )fu IRalpikJ liiruF'usk)iri ninny °ausr: IF'u 11 t i°u.^�li°:u°u FOR CROUP EPINEPHRINE ( -1,0 0, l img/imlQ- 3mg(3mL total) delivered via nebulizer • III:�"11�1n II���II��F ^�Ii��.^���.^��� Illu�� Il ���uli��i�°u�l': • )O NJOT aHAIript tt°: liiituIbart(, i II)IIaca rim Ventilate via BVM as needed Expedite transport to closest Comprehensive Pediatric ED FOR EPIGILOTTITIS Avoid any procedures that may agitate patient 3921 Provide humidified blow-by 02 as needed Expedite transport to closest Comprehensive Pediatric ED Usually Usually<3 years,Wd Usually 3- years Wdl Sudden,c n. et° ,"Slick" for a cupne of days Hh grade tear, Low grade fever Poor general iiirm r ssiioin Not toxic appearing RPIWOW............................. A 0 Trlpl ad position BOB i I IAVE STRID 1 P1, 1'" A "B I' °plum LI(l 3922 >etzure INFORMATION • Consider the possible causes: • Drugs • Meningitis • Alcohol • Fever • Diabetic • Head trauma • Poisoning • Hemorrhagic stroke ...........moo • Refer to the "Eclampsia" protocol (pg. 118), for pregnant patients. ADULT IF ACTIVELY SEIZING E IE IH Z("')IC'D IIAZIE IFS II IH IE Ativan 2mg IV/IO/IN/IM may repeat OR Versed 5mg IV/IO/IN/IM may repeat i e c i u u k)i ru \4(°:)i u i t )i IF SEIZURE DOES NOT RESPOND TO ABOVE TREATMENT KIE1i"AlIVI II IN IE 100mg of Ketamine IV/IO slow over 1-2 minutes G�; )iuti�uli rid]icat ki )u°u.u: iuu� i�,utaiiut uWEI iiu°iuu.uuy • :3(:, Il ielpai,etl] 'i'`:ui aidIvairicf:dl a i,%Ata i iiiiaiiiag(::iiiiii(:::Ii'ut': • is ass.^)c° at(:d] %ndt'—i i .^ Ilan°��!�t .i �::I �Ilai .^.^�V iuN allaiu(la, i' VI aiudl Iluig-i( i tlliaiiu ust4l iiucieas. .s liii hall )(:xJ Ilpi,e suie IF UNABLETO ESTABLISHVASCULAR KIE1i"AlIVI IIIH IE 100m IN IM - „" IIullllll' Alllllullll': m„"A"'III""Il0lu,l;"!^µ A,II!^µ IINIOTEIII')AIII':'IOV PEDIATRIC FEBRILE AND NOT ACTIVELY SEIZING (Lf patient receives Tylenol he/she must be transported) If patient can tolerate PO administer Acetaminophen 15mg/kg PO 3923 jeaure FEBRIL PASSIVE [[QLUNG- Remove the clothing �)O NIOT cover patient with a wet towel orsheet �)O NIOT apply ice or cold packs to the patient's body IF ACTIVELY SEIZING BE�N ZC)DUAZE�PU�NE- Ativan 0.1 nnB/ko |V/|O/|N/|M may repeat as needed OR Versed 0.1 nnB/ko |V/|O/|N/|M may repeat as needed OR Ketannine 1nnB/kB |V/|O/|N or 2nnB/kB |M may repeat once Precaution Monitorforrespiratory�epression 3924 INFORMATION Sources, signs & symptoms of sepsis include, but are not limited to: Fever UTI (Increased urinary frequency, dysuria, and/or cloudy, bloody, or foul smelling urine) Pneumonia (productive cough,green/yellow/brown sputum) Wounds or insertion sites that are: Painful/red/swollen or have a purulent (pus) discharge Patient is on antibiotics and has significant diarrhea, abdominal pain or tenderness Recent history of surgery/invasive medical procedure (e.g., Foley Catheter, Central Lines, etc...) AMS and/or poor oral intake over the past 24-48 hours (especially in the elderly) Bed sores, abscesses, cellulitis, or immobility SOU"ill 'SllpS S°SSiSiIIIS'T r itwr I lli in Iff D�Ehuf llll a Sao illll �us�ii�uii 2 air°�� usmMA, r llllll a SEPSIS AILEftllr; ■ t years and NOT pregnant. Suspectzidl ordocium,ernted uiun(f ttio n >J IPOD At least TWO 12) of the criteria 01 Hypotension (SSPI< 100,mm Fig), 01 FtCO2(<25 mim Hg) 0 Altered Mental;Status or GCS 14 (renew Inset), 41 TarcU° noea tres,eiratorx rate 20 • Tachycardia HIR> ,1 • Temperature,greater than 100A IF or(less than 96,8F V'i1�Au R N 11 N i It is imperative once sepsis is iderntifled,gnat the patient is inept from Ibe orxning hypotensive,as an episode of hyp tensiion si rnifi anttyr ii'ntreases iermrnrbiidityr and rrmortalitV., WARMING Pneumonia patients with rates still re,glurire IV fluids. ri ne f I uld 'i , 3925 Sepsis continued... oat er,, oct Ma id"rrakygor ratowk w" .m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m.m 31 [�l NORMAL SAd N1 IE, ..1 20 mnl/k I "J10, assess,lung ound sled Bp frequently I May repeat Ix if time pelrmnlit 1 Transport to,Closest E 1 4"Rli'II'N:IIrYrIIYiNIrN,ur�'llrrllYi"w ' RelllalN rll lldl�i� '"igNII�Y"IY"IIN';> I, If BP does not increase c rn5ider Doparnine 6 cg/ g/rn1n and titrate to effect(u"mranuiimurn dose 0mcg/ g/ PEDIATRIC Iql , 1 NORMAL SAI II IM:. 0,mrrl/kg IIV110, re airdless of blood pre SUreo aSSeSS lung 5olundls frequently • May,repeat prn, for age appropriate hypotension • Transport to Cbsest ED I If 6p does not irncrea a co mail er Dopamine - 6 me i" , Irmrilrrr: Use a rn icrodlrip (60 tt/rnL) and refer to the Handtevy Medication Guide for drip rate based on patient weight or age. 3926 Stroke ra . r ;c4k/ -ra rPvr't Prot000k INFORMATION Cincinnati Stroke Scale should be initial stroke assessment. If Stroke suspected, patient shall receive a R.A.C.E. assessment. Call a "'!^ III""III'''tGIIU AIIL.IIIlllllll'' ""III"" if: Symptoms are within 24 hours with any of the following: Any new positive finding from the Cincinnati Stroke Scale R.A.C.E. (plus) assessment score >0 Any patient who awakes with stroke symptoms If the onset of symptoms are unable to be determined transport patient as a ""^�µ III""III''tGIU AIIl III Obtain the following information: Last time seen asymptomatic Witness name Witness phone number(s) Patient's medications All Stroke Alerts shall be transported to a ialh°iue m kmes.i Illllll Exception: Dementia, known terminal illness or Hospice Care patients can still be treated as a STROKE ALERT.Transport these patients to the closest ED Immediate notification of a Stroke Alert with the R.A.C.E (plus) score needs to be relayed to the ED III llliilllllllll III�IIII�III Illklllllllllllillllillll III IIIIIINIIiillllllllllilllllllllllllll�lll�lllllllll IIIIIIIII�IIII III�IIIIIIIIIkIIIIII IIIIIIIIIIII IIIIIIIII III uu��� u 0—Absent(symmetrical movement) Ask the patient to show their teeth: Facial Palsy 1— Mild (slightly asymmetrical) "Smile" 2— Moderate to Severe(completely asymmetrical) 0— Normal to mild(limb upheld>10 seconds) Extend the arms of the patient 90 degrees Arm Motor Function if sitting)or 45 degree if supine) alms u 1— Moderate(limb upheld<10 seconds) ( g) g (� p� ) p p 2—Severe(patient unable to raise arms against gravity) 0— Normal to mild(limb upheld>5 seconds) Extend the leg of the patient 30 degrees Leg Motor Function 1— Moderate(limb upheld<5 seconds) (if supine) 1 leg at a time 2—Severe(patient unable to raise leg against gravity) 3927 0—Absent(normal eye movement to both sides, Head and Eye Gaze Observe range of motion of eyes and look and no head deviation was observed) Deviation for head turning to 1 side. 1— Present(eyes and/or head deviation to 1 side was observed) 0— Normal (performs both tasks correctly) Ask the patient to follow 2 verbal orders: Aphasia 1— Moderate(performs 1 task correctly) "Close your eyes"and "Make a fist" 2—Severe(performs neither task) Ask the patient:"Who's arm is this?"when 0— Normal appropriate or correct answer Agnosia showing him or her the weak arm or"Can 1— Moderate(does not recognize limb or cannot move it) you move your arm?" 2—Severe(both of them) If Coirtiicalll Sigins are present add a" "(plus)sign next to total score and include the verbiage"plus"with encode. R.A.C.E.SCALE TOTAL: Max$COr2 Of 11 ....CI a S rc;,'... C�i CIP CI C;;9i',IIP"I" C;i;u.. CII,rcl�"S 1 C CVB CIIP "' 1 C;;lu C;;9i CI �""kii CII Ss L.�.. � L.. ����� L.�.. L.�L.. L.. L,,,I�RA � ��,�..,..rvA ��,L.N..V.....�s �..d L.� � �..d��, ��, ..ry 11 i �L..A i... s 3928 Stroke Continued... 'GOACO-MKOrtMedoCAIrr ' po t Protocolf rr� APHIM MIN a 1piiine„ 0 AIIII patients with the exception of those Iis.t d under 301head elevation section T a he dl elievatVr w, diagnosed trtr ceretaral hemorrhage Patient is,short of Ibreath LPM NC if peruse oxin,mixy less tharr 94 . � Nw6't:he Ipet�euA�lt N:s ii re�lp�ir�,tr�rr a�illtres , urr��wr� e �uNlrrer �'�� IrA�� ➢ �l{�Ir��U��°�rt� ulr Irpl�� °s�r^ r i ntervention. 0 Estab l ish an a; ,g catheter Irn inm miiuu m if possible,the- a me ualbitall is preferred 01 hFY 11 II~R1il n,;:lP4ISA 0 N 0 If ip bent he's INS/p of syst tic greater tban 220 our dial todi : r ,a't t,tban 1,20 ANZ,possible Signs of strdke. wM lL, ltbert tol 10mg W/10 Il l; uIATR1uC 41 Ki UI fl O IN i N G, 0 Supine: 0 Alll patients with the exception of those listed undlelr ''head elevation section 0 0"head elevatiion- • A diagnosed intracerebral hemorrhage • Patients short of breth O 'YG II'N 0 2 LPM INC If prullllse oximetry less th°aiin 9,4,%. 0 If the patient is in respiratory distress, manage airway as needed and consider advanced airway Intervention. WACCrE 5" ; 0 Establii5b a (large catheter if possible, the antecublital is preferred Perform Gluicose check 3929 3930 3931 i f r r�iiiii� III I r� / ncies 49 NO oil Im Mg ,...... ... i r f Raid A-Fib & A- re INFORMATION 1 ADULT Obtain a 12-lead and leave cables connected .A III'.... i IIL....IIIIIIII ..................... .......... CARDIZEM: 10mg IV/10 over 2 minutes. If no response in 15 minutes, repeat with 15mg IV/10 over 2 minutes. (Use Amiodarone if Cardizem not available) AMIODARONE: 150mg infusion over 10 minutes. If 10 minutes AFTER Amiodarone infu- sion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. (Use Cardizem if Amiodarone not available) Synchronized Cardioversion (Ascending Joule Setting: 200J, 300J, 360J) Atrial Flutter cardioversion will start at 100j and escalate as needed If still hypotensive: Normal Saline: 20ml/kg. Assess lung sounds every 500mL. If Cardizem is administered: Cdd"Ytrai"Yd kk at d for.hypoteWY°;niOrW ,, Wide�;oW"npl x QRS, h;';story of:WfMlor.nk sinus syndrome, L/se u, lth C GU110rr or Gtit M is taking beta blm kergin. If:hypotension develops af:ter Cdrdizern adrnini�tration, adrnini�ter 500ml of:Normal Saline REMATI I Call for orders 3933 Rapid A-Fib & A-Flutter Back to Table 3934 Braoycardia Tr'qA'q0rt Prot.0c,olf " INFORMATION Bradycardia is defined as a heart rate < 60 beats per minute. ADULT Obtain a 12-lead to rule out an MI and leave cables connected lU"I"!r. Monitor and transport UIN w""III""AIII'i IIL..III'i : III'°°I I'i IIIY S III'0IIIY -ATROPINE: 1 mg rapid IVR Repeat prn every 3-5 minutes. Max cumulative dose 3mg. ��'"u uulu°fuliuudlu� �Iai°:a°u uuu �fl aii IIIIfl I III Alll IIIIIL..IIIY III IIL. IIL..III IIL..IIIZII0III1AIII IIL..S QIt IIIIYIII 0III IIL..IIIYS III 0IIIY III Ill...11llllSlllS A 2 IIL. QSlll...S QII'° Alll III10114"'llllllllllllll .......................................................................................................................................................................................................................................................................................................................................................................................................................... TRANSCUTANEOUS PACING: Initial rate of 60 BPM and increase milliamps until capture is gained. May gradually increase BPM to 80 if needed. If Pacing unsuccessful. Dopamine may be administered 5mcg/kg/min and titrate to max dose of 20mcg/kg/min "wl::l:::Jl: A""III""III0IY QI'' ""III""III'1AIIIY "w °;U""III""AIIIYIII:::QUS III''"IA°:`IIIIIIYG DO NOT DELAY TRANSCUTANEOUS PACING TO ESTABLISH IV ACCESS VERSED: 5mg IN/IM/IV/IO. May repeat 1x prn. If versed does not induce sedation, may administer KETAMINE 0.5mg/kg IV/IO/IM. If patient complains of pain while being paced, administer FENTANYL lmcg/kg IV/IO/IM/IN. �I"9IIG AI��TtAII°tAIl I�.flI4 F O1" AN 141 W1 11Y1i10 TTW'1$ 0IIN Om directly,to Iran cutaneou.ua paucling as Atropine Increases,rmy c,ardlial iliactuemia and may increase,the size of the Infarct IIV11,)II!�GFREE AV 3T li 1w`AW1Ilplllll"""IIfYAA'1�I�'i'IP�'��1:1" 11� Ilrrmmediate traru- cw taneouua pacing is ac ptatale whoa IV access is not Immediately eva lllalle. 3935 fEIInT'RI l btain a -1eaid and leave cables connected Monitor and transport l IIUN i ND, I�ID I1 I 1 1" � I�Q OXYGENATION &VENTILATION:: Ensure adequate oxygenation and ventilatiuon first, as hypcuxia is most likely to be the cause of the Ibradycandia. After oxygenation and venitHation of 1 minute for infants/children and 30 seconds for neonates (birth to month), begin chest compressions if the heart rate remains,belong 60 BPM with signs of poor perfusion (AIMS). LIE N NK N-111 91'J"E'[ LIN' , I UI°I i>r;Af" UI if slip lik � I'm t Il l g u ffM EPINEPHRINE. (t JIL0uQln;;00),01, 11mmg/ikg (0,'InnL/lkg) IV/1 . Repeat every 3-5 rninuatels pm. If no response to Epinephrine, begins TRANSCUTA,NEOUIS PACING. Begin pacing at 8,0 BPM and increase the rate as, neededuntil the patient its hoer nodynamically stabile. 0 1 IND I IIESP0114S ll OXYGI�IIVATII.Od1 II" �Mo'!uII�II III_II_ IIIi1�II 60�, Ip " III!I, III r I 1 - p l ATROPINE: 0.0 mmg/kg IV/1 (I inirnuurn single douse n. mng) . Max single close 0.5 mg. May repeat; 1,x pirn. If'no response to,Atropine, IEPIIINEPHRINE (1."i tl,P0t) 0.01irrng/k (0.1rnrnlL/kg) II' l Repeat every - minutes plan. If'no response to, Epinephrine, begin'TRANNSC UTANEO US PACING. Begin paciin,g at 80 KPM and increase the gate as, needed until the patient is heir odlynaurmicallyvstable. If unable to obtain IIV/11 access, begin, pacing a intill an, acceptable blood pressure is obtained, then adrniunister VERSED 0, mg/kg INf llM, Max single dose Sirng, May repeat Ix prrn. ,.., .,.....I............ ............. .�. 3936 ro .. INFORMATION Cardiogenic shock is a condition in which the heart suddenly cannot pump enough blood to meet the body's needs. This condition is most often caused by a severe heart attack. Cardiogenic shock is rare, but often fatal if not treated immediately. ADU Obtain a 1 -head and heave cables connected Dopamine 5 mcg/ g, min and titrate to effect (maxiimuim dose 0mcg/kg,/irnin) PEDIATRIC epari S-IS mcg lkg/rn,in, use a rriicredrip (6 gtt/mL) and refer to tlhe (Hand evy(Medication, Guilde for drip irate based on patient weight or age, Once SB,P is 100 mmHg or greater, tr+eat CHP/PLAIl ruonary Edema and/or,Chest (Nib as applicable I ITH11,1°,°,ILI' IfNTiIG IIR" IIV'I I°IIIC C IlPIATIlllllf°`Ii 1511 3937 F INFORMATION A Hypertensive Emergency can be defined as a systolic BP > 220 and/or Diastolic BP 120. Rule out manifesta- tions that can cause hypertension prior to treating such as chest pain and heart failure. Symptomatic patients with elevated blood pressure should be treated by the appropriate protocol based on assessment of their signs and symptoms Chest pain consistent with myocardial ischemia or infarction ( Chest pain Protocol pg.54) Shortness of breath with signs and symptoms of acute pulmonary edema, ( CHF Protocol pg. 57) Patients in the 2nd or 3rdtrimester of pregnancy (over 20 weeks) or up to 6 weeks postpartum with elevated blood pressure ( Pre-eclampsia/Eclampsia protocol pg 128) Patients presenting with stroke like symptoms, obtain STROKE scale; (See Stroke protocol pg. 45) Obtain a 12 lead and leave cables coninected IV access lif Ipaitlent is experiencing associated slgris anci sym pto ns of a hypertensive crisis t.abet loll 10iii m show VIVID over 2 rnir tese re gat ie 1d1 r ir�uat �s ( . m o....................................................io , ini .i w ire iww „ ill imVINV ",.01...1 .I.,.,".�lu,a"��.IIf! .�II'� , PEDIATRIC Consult Medicail control) Cauaitiicin should be taken) when a dmiinisteiriing ILalbetalltui to pl' tiients experiencing a Stroke or suspected bleed 3938 Lnes Pain Aep"Mocemeiirol rrek ort raf&eok INFORMATION For STEMI Alerts or suspected STEMI Alerts,the right hand and wrist should be avoided if at all possible for IV ACCESS. The right AC and anywhere on the left is acceptable. ADULT + IMMEDIATE 12 lead ECG. Leave cables connected and repeat every 5 minutes ASPIRIN: 162 -3 2 4 m g b ab y aspirin chewed and swallowed. d dl r g,yl d�Ctive dJ F ale din , ` P 61, ye Us Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self-administered less than 324mg of aspirin within 24 hours, administer full 324mg dose. FENTANYL: lmcg/kg slow IV/IO/IM OR 100mcg IN. May repeat every 5 minutes prn. Max total dose 3 mcg/kg IV/IO/IM or 300mcg IN. In rare occasions, Fentanyl may cause hypotension. If hypotension occurs, NORMAL SALINE: 1-2L. Assess lung sounds and blood pressure every 500mL. If nausea and/or vomiting occurs, administer Zofran IV/IO/IM 4mg. May repeat once prn. Ate°? M �°erin m i be,given:°s a rst Minim `frU :°����!ac° f 4°: � ���� �,' �,' �� ���� .��" ���� .f kitany'M.fim stable patMints w�MtMi hM��!:hw � ? m°m. 1A I"A I III'i II I'6MS II MS III"' "w III'°""III""III''......III''M III III III""III""IIAIIL.... III'°III''......IIN II'AIII IIL.AIII': III II N III Sw""III""III' ""III""III M�MIII III„III'............................. ........................................................................................................................................................................................................................................................................................................................................ NITROGLYCERINE: 0.4mg SL. May repeat every 3-5 minutes prn for pain. SBP must be 100 mmHg or greater. A 12 lead ECG must be obtained prior to the administration of NTG to rule out a right ventricular infarction n farctIonIncIUdInc�o� I�et�er�In�tSI��e� EKG. g p g An IV must be established prior to NTG administration, even in normotensive patients. ',IIB less ttnm m 90 rnrnM::I He Ut R�!Ae less tfnd m.t BPN?�im dlre�:,Aer t:�tnm id?C?BPN? AA r''z���Hm���� ���� ) �.Mma�m .M�w Mmd�mma:'m 3939 mast Pain �P.E.DIAT.Rl ,all fir ordl rs 3940 STEMIAlert 511-lotAep"More M6.4r.%1 rrakeport Praf&cok INFORMATION STEMI Symptorns can be variable ndl include discornfort of the chest, arm, neck, back, shoulder or jaw and allso can be paiinless with syncope/near syncope (lightheadedness),general weak ne5sffati ue, unexplained diiaphoresi5,SOB, or nausea/vomiting. ADULT 4 IMMIEDIIATE 12 LEAD ECG WITH IMMEDIATE NOTIFICATION TO ED INCLUDING KG RESULTS 4 if Patient has Chest Pain, Fol[ow C hue st P,ain protocol eave cables connected and repeat every 5 minutes WkI31,41'VE NPR1Ck LA 11 111,1 LPT1 POSTIVE WdR, C� �`,�,XR LLING SO YNDS WPH HYPOPENSION ..................................................................................................................................... 4 NORMAL SALINE: 20m,l/kg, A55e55 lung sounds and blood pressure every 5,00ml-, May irepeat Q Iprin, STEM II At EIRT CR1'1 EWA ST-Segwent Elevation in two or more contiguous leads (21rnim or greater in V2 and V3 or lirnrn or greater In all other leads)with a "convex" (frown face) or "straight" morphology. 5T-Segiment Elevation in two or more contiguous leads of Zrnirn or g�reat�er in any lead with a "concave" (smiley face), ST-Segment Depression with high amplitude R waves in V1 (is6atedl),V2, and/or V3. "Carousel Seats," SY J;710� IS k1a,I]f EKG S�fpcwhl blic pe� frnwjarl, 3941 S Alert S..III.III'''''''Illlll „III The following are STEMI mimics: Q,Fks gnuIabli VI iair°u O p 2 r i i II yr l l�,.; V ll iairi a Q�)iris avi ' ' u i;�nn7�u i°uu: Q'in7�illu � II �i�°u Ili+flu i i::�ulh°uu llu i;� � Patient presentations indicative of myocardial ischemia that do not meet "STEMI Alert Criteria" should still be transported to a the ED II deft V'entii lciG,,illlar (tti"H) Talke the (largest negative deflection from the is,oelectriic line of VI andi'V ("S' wave),whichever its Ilairg;er, and counit the small go es. Then take the largest positive defllection o'f V5 or V6, ("R"wave), whichiever is Ilargeim, and add it to the totall from,VI or V2. If the result its greater than 35, your suspicion for LVH should be Ihigh. llt0t`Ili S� Patients with ST segment elevation in two or more Inferior Leads (ill, III, AVIF) or iisollated abnormalities in lead III (isolated), and/oir VI slhalll have a complete irighit side 18 head EKG (M- ) to determine if there is ST segment elevation, indicating a right ventricuilar infarct (RVII). The right sided EKG shalll be lab&led somewhere on the, EKG,. If patient Ipresweintation is indicative of a myocardial iischer nia and it is uncertain as to whether or not ain ECG meets STEIMIII Criteria OR the ECG shows a ST'EMII mimic.,the ECG(should he tran;snrmitted to the �r°ieceiving STEW facility for determination. 3942 S Alert FU Iht-sided Leads ^lc)Q, d rJh(i i I r T Elevation I Coved(convew down) ;J maVill,dle a4w Deep 5 wave In VI or V i TOR waves 1195 ar W�a The 5:wave in V t is diet The IVF wave in`uN:S and fif�h is high +��'Ql1�C�l�@ NIA r� � ,JfJ6lYk In the exampteabove we meal re 1 this ex pt abGve we measure £'ptchin ea the a bry at Yd4 theis a 't�v:R �� Atltl N el ✓ A A R 4';` w S db M emsure�m k qeY tram ik{ ,l�.If�b®srumii a �rvnn rtlhnn�V J141n prm..anY. Abf/'+= T,(v7),ReVSJ pimmi ko 44Y n] "s.5 mni,is significant '*Thk me ft thmW¢x65erue.far LVi4 Back to Table 3943 CHF (Pulmonary Edema) rrm, ,Port Peotecotr Back to Table A PY—LT 12 ILEAD ECG Leave tables con niec�ted and repeat:�.2 head ev8ry,5 irninutes CJPAP (10 cm H20) CD,1119'PRA,IIl 1119 D1 CAT]0 N 5 0 SBP iess thc�r�, 1901rrm'O Det-re 0,1,iiec'lt 0(1 (1 U'111c' ASPIRIN:Two to four 81mg babyaspirin chew ed and swalliowed, if not already administeired. l31 GOD-PRESSURE S GREATER THANI 1,10i'liuillift NITROGLYCERINE.0.8mg SL Repeat at a dose of 101.4mg as needled every 3 minlute5 NITROGLYCERINE:01.4mg SL Repeat as needed uinitil BP is 120MMift COIN RA MID ICATIONS ctnd C'u,,tfis wahhv� �18,hourtt) 1r13F'11 h,vi� fhor�� 190 nPnit"ki ru 1"I"r,11irl than 1`4'),RPNI 6oin hl ub�6"'SS US SU(J�) US pussifde, Lln,,Q du nil,)11 nelij,hTt I!!VIPE'(Mig sk;tus/"I"L PED I lRIC I Call for ordlers INAFUNIHNG If patient is fe bri le or from a nursing home and pneumonia is suspected withh1h old nitrates.. 3944 C (Pulmonary Edema` . 3945 INFORMATION DO NOT administer Adenosine to patients with a history of a heart transplant or if taking Tegretol (Carbamazepine) or Persantine (Dipyridamole). In this case, administer Cardizem or Amiodarone as indicated below. Ruling out of secondary tachycardia must be performed prior to administration of cardiac medicine. Check temperature, stimulant abuse, hydration status, possible sepsis, physical exertion, anxiety, etc. If any of the previously mentioned are discovered,treat. ADULT SIR ""III'XI'i L.... .................................. • 12 Lead EKG: leave cables connected • VAGAL MANEUVERS -ADENOSINE: 12mg rapid IVP, with a simultaneous 20mL Normal Saline flush. May repeat once. If rhythm fails to convert, • CARDIZEM: 10mg IVP over 2 minutes. If no response in 5 minutes, administer CARDIZEM: 15mg IVP over 2 minutes. (. s _ .irnd...d irr�irn..e if C.2ir.diix ir.n irn.21 gy .ii.11ablle..). � ;� „ n��i tl i�n � � n ",'r � d Aienl him� ii n 4;;� i F sinus syrug Use n,oH ith n.�niitid in ftia pre! ieails h!4,andl berhdn bh iicl,earum. • AMIODARONE: 150mg infusion over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. (Use Cardizem if Amiodarone not available. If symptomatic hypotension (below 90mmHg) develops after Cardizem administration, • NORMAL SALINE: 500mL then • CALCIUM CHLORIDE: 500mg over 2 minutes. May repeat Calcium 500mg one-time prn. Q IN S""III"'A Illll IIL....Illlllll .................................................. • Consider Sedation • SYNCHRONIZED CARDIOVERSION: Ascending joule settings of 100j, 200j, 300j, 360j • If cardioversion fails, contact medical control for further direction. 3946 SVT is defined as a regular, narrow complex tachycardia of 150 BPM or greater without discernible P-waves and/or flutter waves. 3947 uIin8 out of s;eccmndlary tachycardia, rnust be perforlmed prior to ad inistration of calydrlauc rxmedici nwe. heck temperature,stimulant abuse, hydration status, possible sepsis,physical;exertion, am,mmiety, etc.If ray of the previously mentioned are:discovered treat accordingly. PEDIAT tll " „II' Il..i'I.I: ADENOSINE. ,1m /kg Iralpid IV/1 ,with a slmlwnultaneou5 10mL flluushi, Max dose 6mg, If no change in one Im'iruu,ulte,ADIFI CIS IhNE: 01. mg/k;8 rapid IV/1 ,with a simu ltaneeolus 1 miL flush. Max dose 1 mg. If no resp rus admuruusterflijiid bolus ilmll/kg may repeat prn X1 IJNS'T"~ III (II ��III IlPPROIPIII IIId T II� II ��Ii "h�;lll'" ",III III" IF PA77ENT IS, LEAN' WPATIENT HAS AN ALTERED ENTSTATUS Consider sedation prior to cardloversion. Versed: A1mg/kg 1V/IO/lN. IMax single dose of 3mg. May repeat 1x Iprmm.,IMlax total close 6m . SYNCHRONIZED CARDIIOVERSION. 1ji/kg. If not effective, increase to,2jjk& If cardiiov rs,ion fails, contact medical control for forthelr direction. For young children, place,a bag of ice water on the child's face completely obstructing their nose and mouth,for at Ileast 15 seconds. For older childlreru,ask them to try and blow through a kinked piece of oxygen tubing or syringe. V7 iln Infants is considered greater than,220 RPM. 5' "T in children Is considered greater than 180 BP'M. 3948 INFORMATION Wide complex tachycardia (WCT) has a QRS greater than or equal to 0.12 (0.09 for pediatrics) and a heart rate greater than or equal to 100 BPM without discernible P waves. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ECG features,that favor a di aginiosis,of Wntricalor Tachycardi 0 Very wider, bizarre QRS morphology Precordiial con(cordaruce—all chest Ileads point inn the same direction (either positive OR negative) 0 Negative Lead' a, ua Backward frontal plane axis: Ili„ III, and a "IF are negative. a' L and aVR are positive. 0 IPreseunce of capture beats or,fusion beats(sinus beats that interrupt the WCT) --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- IECG features that favor a d!agruo is of suer ventricular°origin • P waves Ibefore the QIRS cornplexes • Normal IR wave(progression in the chest leads • teft bundle branch bluaclk or right bundle birainch block pattern • Only slight widening of the Q1R • Ir,regullairl ���airiregu ar rh thin n i om o i o i o i o i o ion i o om o i o i o i �r��nmmnmmnn�nmmnmm�rc�am�rc�amnmmnmrv�umnmmnmmnmmr�m�ammm�n,�nmmnmmnrnnmmnmmr�m�ammm�„r�am�rc�mn„rnnmmnmmn�r�amr�m�a�nnmmnmm�rc�m�xmmm�rnn�nmmnn�nmmnmmnmmnmmnrnnmmrnnmrv�um�rc�m�xmnmmnmmr�mnnannrnnmmrnnmmrnnmmnmmnmm�xmnmmnn�nmmnn�� III I IIW't'.IIP i(SUI AR,M I s S IMV�a lB ASV,"TACH ug lgPt I tSi,S PlIROV ;M i 0 VI IIIE'I ,,r,,F�U If cardioversion terminates,the VT and the patient returns to VT, begin cardioversion at the last successful energy setting and increase as needed, 3949 ADULT ""III'XII'i IIL....IIIIIIII tIIIIIIII'i!I i IIL.AIIIt WC III • Perform 12 Lead EKG and leave cables connected • Perform serial 12 leads every 5 minutes • AMIODARONE INFUSION: 150mg INFUSION over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. Administer all 150mg, even if the VT terminates. Q N S""III"'.A IIII IIL....IIIIIIII `:III O ll101 DEI,1 : ,'RD1 1 ER-',111 :111 .1..0 E 1.11!'011-5 H il, V:'CE-5,51''I • Consider sedation prior to card ioversion. • SYNCHRONIZED CARDIOVERSION: Ascending joule settings at 100j, 200j, 300j, 360j • If unstable WCT fails to convert, AMIODARONE INFUSION: 150mg infusion over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat 150mg infusion IV/10 over 10 minutes. After the 150mg has been infused and the patient remains unsta- ble, cardiovert with 360j every 2 minutes prn. wlll'"'llllllll °:`III AIIL. `:`'' III wlll lll': IIIIIIII III'tA""III""IIIl0IINS Alll'""III""IIIIIIII III't `:`Alll'tlll': III ''�VIIIIIIII III'tS 111�''�III ....................................................................................................................................................................................................................................................... IlDatk:1tu1,'.';N��, Ill ) C(°:Ylv�:Ii0 A1uIii' (','?A a:I,u::i a lO O11' Lily ull11�1 i Ilu�7r7�11::�ulltiuuilPillu� :� �u�::aliu���u�u0u u� • AMIODARONE INFUSION: 150mg IV/10 over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. (if Amiodarone has not already been administered). PEDIATRIC I'XII'i.....IIL....IIIIIIII .................... ......... • AMIODARONE INFUSION: 5mg/kg infusion IV/10 infused over 20 minutes. Max single dose 150mg. May repeat until a max of 15mg/kg has been administered. Q N S""III"'.A IIII IIL....IIIIIIII .................................................. • Consider sedation prior to cardioversion. VERSED: 0.1mg/kg IV/10/IN/IM. Max single dose of 3mg. May repeat 1x prn. Max total dose 6mg. • SYNCHRONIZED CARDIOVERSION: 1j/kg. If no response, increase to 2j/kg. IlDatk:11111t'.';N��, Il ) o:: iriv:Ii A:1 Ii' O11' 11y ulliu:ii IIi7r7�II::�uIl�tiuu �IP�II � �� ti::aliu �u�i0u i (IIC II ) AMIODARONE INFUSION: 5mg/kg in 100ml IV/10 infused over 20 minutes. Max single dose 150mg. May repeat until a max of 15mg/kg has been administered. (if Amiodarone has not already been administered. 3950 JW. ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ Back to Table of Contents X6 ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 3951 Polymorphic V-Tachl Torsades de Pointes INFORMATION Torsades de Pointes is an uncommon form of V-Tach characterized by a changing in am- plitude or"twisting" of the QRS complexes. QQA.D LET ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... STi,'01h�.IIE �)VT MAG SULFATE: 2g W/10, infusion over 5 rninlutes. May Repeat LJJ145TXW III TVT DO N01 I [)ELAYDEFIBRII I A 7 R,,')A°V I()Es 7/1BI I S i 11/A C,C,ES_5! Co,n5lder sedation Ipriior to DEFIBRILLAT1011N. DEFIBRILLATION;Ascending joule settings at 200j, 300, 360 1 WiN%ble PVT converts,prior to in'05tratiCIP ofi agne5ium Sulfate,,administer 2 g iinfu5ioin over 5 Irs PEDIATRIC S III"A II3[,E 0 IMAG SULFATE: 50, mg/kg IV/110 infusion over 110 minilutes Max of 2g. DO AR)T 1,C) ESTABU9,l P/Ai"CES" I Consider sedation prior to DEFIBRILLATION,, VERSED:0.1 mig/k,g max of 3mig 11V/10. May repeat Ix prn, Max total dose of 6 mg. DEFIBRILLATION:2)1kq, 4jlkg If unstable PVT converts prior to administration of Magnesium Sulfate, administer 50mg/kg infusion over 10 minutes. If defibrillation, terminates the PVT and true patient returns,to PVT, begin defibrillation at the (last successful energy;setting and increase as, needed. 3952 r '"-a �r INFORMATION Left Ventricular Assist Devices (LVADs), also known as Heart Pumps, are surgically implanted circulatory support devices designed to assist the pumping action of the heart. Caring fort hese patients is complicat-ed and every effort should be made to contact the patient's primary caretaker(spouse, guardian etc.) and the LVAD coordinator during your evaluation. Patients with a properly functioning LVAD may NOT have a detectable pulse, measurable blood pressure or accurate oxygen saturation. Contact the ILVAD coordinator immediately;the phone number will be on the device and the equipment carrying bag. Take all equipment associated with the LVAD system to the ED.. Locate patients emergency"bag" 'with backup equipment. Treat Non—LVAD associated conditions in accordance with the appropriate protocol. Determine the type of device, assess alarms, auscultate for pump sounds. if needed, assist patient (caretaker) in replacing the device's batteries,or cables. ocate the driveliine site on the patient's abdomen. 9E CAREFUL not to cause any traur°na to the site or driivel'ine (wires). f signs of hypo-perfusion, administer NORMIAL ALiINE:500mL and reassess. If there is bleeding at the site, apply direct pressure. i ViIILII;r i I'L ll I; 13AT11 L', 1 A T�i:"N S ('1A)r?,EFtJ1.LiP"FOR u.`3! erforrn a blood glucose INevel, if(blood glucose is less than 60 rng,/dl admiNster D mA of O' s iu- tion total of 12.5 grains, Secondary Option D Dw 100mL, Performing Chest Compressions rises rupturing of the ventricular wall leading to fatal hemorrhage. ONLY perform chest compressions when the patients LVAD is not working and no other options exist to restart the LVAD.. DI R I' S P(AT,Y �PACKAGING AN LVAII) i°wniLAT,, e aware of the cables, controller, aund batteries. It may be best to place the stretcher straps under the LVAD cables to avoid creating,torque on the device. At a minimum, be aware of this extra ardware, Transport to the closest ED, 3953 7°�1 INFORMATION Digitalis is a cardiac glycoside with positive inotropic effects; slows AV conduction by enhancing parasym- pathetic tone; and has a slow onset of action. Digitalis toxicity should be suspected in patients who are taking digitalis and have signs and symptoms associated with digitalis toxicity-for example, fatigue and visual disturbances (halos in field of vision). The most common arrythmias are ventricular ectopy and bradycardia, often in association with various degrees of AV block. The following rhythm disturbances should immediately suggest digitalis toxicity: atrial tachycardia with high degree AV block, nonparoxysmal accelerated junctional tachycardia, multifocal VT, new onset bigeminy, regularized atrial fibrillation, spoon -shaped ST segment, peaked T wave. Contact with the oleander tree, squill, lily of the valley, and toad skin can also cause a digitalis-type toxicity, which will cause the same type of dysrhythmias and requires the same treatment. DIGITALIS: GENERIC NAME (TRADE NAME) digoxin (Lanoxicaps, Lanoxin, Digoxin), digitoxin (Crystodigin) Contact Poison control 1-3 -222-1212 Verify Digitalis Toxicity by confirrnatiion from patient or by counting pillls in bottle,Avoid use of Calcium Chloride as it its contraindicated in the setting of Digitallis'Toxicity. IPeirformo 12 lead is clinical) stability allows. Leave cables connected. Digital §ymptomatic Rrady gardias tiropine d .Smg ragpid IVP followed by 20ml flush, of NSS� May repeat once if needled, Avoid pacing as patients with digitalis toxicity are more prone to pacemaker-induced ventricular rhythm dlistunurlbances, f wide complex I radycardiia is present admiinilster Sodium, Bicarbonate lmecl/lug. Di italics-linduiced_Ventricular Ar thmnaiaus -Stable Magnesium 2g IV over 2, minutes Once initial 2g its administered, administer continuous infusion of Magnesium 2g,over 1 hour. Di italics-lncl ucedl VeintriicullairArn hmiias—Unstable Consider sedation. Synchronized Cardioversiion at 25J. May repeat twice at 50J. IPatients with Digitalis Toxicity may develop malignant ventricular arrytlhmias or asystole after cardioversiion. f patient suffers cardiac;arrest refeir to Cardiac Arrest protocoL If'no response, immediately r attempt rardii versa n using defibrilllatii n doses—200Ji, 300J, JI., E!DINATRIC„ Contact IRoison u�ontroll 3954 3955 3956 alb ,i / Back to Table of Contents V IIII' 01 o", �t mm/�; d ��1111 l � I 3957 Standing urders INFORMATION y ' • There is no scientific basis in trying to resuscitate an unwitnessed Asystolic patient who has succumbed to the dying process of a terminal illness. Consideration should be given to not starting resuscitation efforts in these cases. In general, when the scene is safe, all Cardiac Arrests should be worked on scene. ADU Perform CPR. per A!HA (A L. ) Emphasis is, placed on minimizing interruptions in,compressions to no more than 10 seconds. Flake all efforts to obtain a RO (prior to leaving the scene.. Once available, apply the Il.ucais with rniniimall interruptions to chest com pressiions and set to continuous compressions, Patient should be placed on the scoop stretcher for transport(purposes,. I r III--- AL----------- Medications should be delivered as soon ais (possible after the rhythm check(during compressions) and circulated for 2 minutes. Follow alll IIVP medication administrations with a 20ml flush of Normal Saline. Search for Pos5ible causes and treat accordingly (Le, H's& T's,, Lmm, etc.)' OE.EHE991 : shotd cantacli16 d I rk""r�� to cea"Mh,q3:0 eff VIts an CardiIa q A19"re t pi�,AieIIds onsidler termiinating efforts when: If presented with an up to date and valid DNR terminate resuscitation efforts, When conflicting requests of family members coirnflnue resuscitation efforts and transport, Contact Medical Control to terminate efforts llliiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiI 3958 Perform CPR per AHA(PALS) Emphasis is placed on minimilzIng interruptions in compressions to no more than 10 seconds. L, if apphcable ands once available,apply the Lucas(if patient is over 18 y/lo) with minimal interruptions to compressions andl set to,cointinuolus compressions. Patient should be placed on the,scoop stretcher for,transport purposes. E Make all efforts to obtain a ROSC,' prior to leaving the scenie. MEPICA1105 i Medlications should be delivered as soon as possiNe after the rhythm,check (during compressions) and circulated for 2 minutes. loIllow,all IVI rnediicafion administrations with a 10ml flush of Normal Saline. I Search for possible causes and treat accordllngly (i,e, H's& T's, IBGL, etc.). If WM4EIIIISSE1111111) Cklkl"AAC ARICES'r l 7 �11111COR LIEVEIS During arrest, maintain IEtCO2 levels greater than, 10mmiNg., If EtCO2 levels are less than 10mirnft increase effectiveness of cornpressions. Levels of less than 10mmHg have virtual- ly no chance of achieving ROSC. An EtCO2 level of approximatelly 20mimHg is ideal. I's • Hydrogen Ion (Acidosis): Ventilation • Hyperkalernia (Renal Failure): Calcluirn Chkiirldi--.u, Sodiurn ISicarlb, Albish--.uirol • Hypoglycemia: Glucose • Hypoxia: Oxygen • Hypovolernia: & • Hypothermia: Ventilat e Fluid Bolus Warniin a 3959 *Toxiinis or Tablets (100): Opiates (Aliarcan) Beta Bloig,',kers (Glen gon) Tr,icprcll,ic,Ant,iLl*?,I)re,s,sonts(Sodiluen Bicarb) Calcium Channef Blocket-(CeTkiurn Chl(widel -Tension, Pneuimothiorax: Bilateral P�e,t,iral,t),ecom;�r)elssflc�I)I Back to Table 3960 Adult Cardiac Arrest Back to Tabi Stwot CPR, h=mmmmmm 1 ` Y;Woffm �= 011, /AJL >7u (� f°✓NY ; i �,� ' id�dwuA��Aw� w�w 0!�m;ava 1 ,. %ufrb'yovrw,%wWOwr n d-m 01, ._ �,,, i t „n,,,,,,,,;, rfr, m »r,,� 4 mo :nq;& i„�n,A OJu »r �i�,GAfi4r Vd i� r �raald�Aaa� r my � iur �qu PAdmY d�Innu�» I, A ; J,, MW rreN iwi Wd N 14�bp,�A�Wrc 'd SIN;-aNW,r�fa U„G, ✓� " qxw AA ., .✓ �`�� °'f�PP J wi lr vi moo. ir. �IGWV W rd� Ids » y ;I I 'sMM.N k6UJwP1 Wgrm�mwreN 9MN irv�%;�,1WII@a� rrt ?R 7 '� !(.MVYVNPWi,�eH�4V'mY^r,N�7�Y Ni ujII�WIWhld�Aid71 uMdV"�d Tk(�✓iIIDMID��Y�^� �, � j 1 ' ellof R 0%iDy J lY /1D.i'W'd N9/%. !r✓ e, it v,^`a„I<.A ,,J �,; i✓/', d uuA�gMrt iry re ,/I ol 'l Gia NIVoAp / f N N. n www"I I � �0�90��0����I�Nu9�V�� n00000000000000000000000000000001 I IF A I w IXrer» dm uireJ� roVlurra « k»vim ,..,, , � r-u; r.,. 0 ..,..., ,... € o�� �u,,,', rArz��^,,,,,. A� Pl � miul iuiuiuuuuo�uiui�uiuui��iuu0�fo�i u � x ,.,,,,,,...... gw"Ire m,,,v(w gm,,. J121LYI�A" frd%e,,dUA@Yrno p (N,�nrrddi�iR ��; � »��„�i,r m�rm ride atl sdr�ea, ki"6(NII���'idN °°Yi��rill�liVl"�14�r✓44d` " �AJ7d�Po�,%�$y "�',d�'Iw", '%U 3961 Adult Cardiac Arrest, 3962 " st top OR r,�Ney.rdp Ooof mrmtjun � � . IC ....._.....,I n ��n un 1 , �w w �� 0 w�r nF IMP a i�;�ro F __. M i r z "�+r,ruxuar" N�ru �Nm t YOB w� iN�urhm��mtiu���,o`V � WI Y M;; P,kiuY m r o ��'ri�Vli�dkDo f .((a " VW4WTu AstyFE, OIGm()Jtow,WJxwrG ( Vb 9 i00 �9bivi RO(((G 111111 ,>- AURP _ Sys "uVl Mh,nnAO a 4 � �, ll� J R�Vf�iuu�9V'rr�i rrrWr� �P", , U,i ;'i'N rn"vom hem ,,., CPA 21 �J .� g,W Me I I, U N Jl w5 1101 t M'I "aps(01 "` % It",k N�l l pla 01 i' ,Ir.l(rq u iY 9.....rrrrrr.....) »»»r AtonpIonu �'Jrr/V0� mi IV$'�l,V� Now Wlr �rr`� virw gif 0 "' OIL d ° 4) T�vmi L 11n III nxll VI V vIm, ((w1 fi N7r , Ynw� � �Vg we�.q, r 01" s "'��.. ��u:o��nIV u�P�nrorri��bH V�Nn I�w„M"w u ��Lm�,��•�(� �0 ° min W u n m It,Wood;b wi m u,................ n�riowam�.Rm wr"w 'Jby, Duilwrvuimm�'� wcnN amok May 6W iLl u: i r IN . I�V� �i ��i� ) e pPrmn'�rr�,Jt tlry l,r;( Nr#1rwrfour(fka lrP..ow r oelf"6a OPIR, wAn 6od �, ni� drr��V�u@ Yro mn� iA,. W¢� ib"�Wf «!�N➢b��W I a V�"N� � d�'"'+bnr�'nrir �n«��oyoib 14 y 1a(0rV tnmoJ,q 11(r Ilvig, N*c�ry�WnV � �,yni��u(uwNm� � , MJuwr�amUnIwa ��II�w� ��G � - , her Back to Table 3963 3964 Special Considerations in Cardiac Arrest ' INFORMATION • The below treatments are in addition to standard therapy. I "IPFaAI Al EJV� I lBack to Talble I. 'AL, IIOM CHLORIDE: IL Rir m, slow IV/10 over 2 minl utes. I... SODIUM BICARBONATE., lrmEq/kg, slow IlV/IID osier 2 minutes. I 0nce Intuubated,ALBUTEROL® 2,,5mg via nebuallizer, confinuous treatments,. [KEEP MiUItUIu!?mflM„ E SODIUM BICARBONATE. ImEq/kg lW10;, each anmip administered show over 2 minutes. E NORMAL SALINE., 2 rnL,/kR 11V/I0.. Maximum of 2JL. Assess IiuunR sounds every 500mL,. IIR „ I..: Immediate VENTILATION its a prioriity and treat as a SECONDARY ARREST. 1„ Manually displace the uterus to the left I Transport to the closest IFD I Exception Trau rna Alert , I.. Rapid Transport Recommended I„ Lucas Contraindication In Pregnancy � „t ............(���� I4AJVGVlVG 0 Consider spinal motion restriction. Transport to elo;sest EID iI IJI il,,I III U ] I NY; S, 5 131 I➢ IU,;. 0 Immediate DEFIBRILLATION as applicable. 3965 3966 Adult Post Resuscitation s )Veda" I' r h POP rOMO ADU RIPHA RIIi Patients with,a ROSC should be ima na ,ed in the order of: LEA PATE: If patient Is Br dycairdic,TRANSCUTANEOIUS PA IiNG, Initial rate of 60 BPM arnd In- crease milllarnlps until capture Is gained. (reference Ibradycardla protocol) RHYTHM: (reference specific protocol) 6LOOD PRESSURE. (Gosh is to maintain a SBP of 9 mHg) f the patient is hypotensive, administer a NORMAL SALINE rruM/kg bolus, may repeat 1x purn. Maintain pUlse oxiimetuy of 94 99 , Maintain ETCO2 of 5.40 m m, Hg Maintain 10 breaths per,minute Monitor patient terniperature and treat accordln ll'y P110WI III III„„ Ill illl III II Administer AMIODARONE INFUSION: (150irng infused over 10 minutes)for patients who con- verted after two d fiibrlllletlonns wind have not received an Amiodaroine bolus,during arrest. III"t��wlll' 'It�E � llll �^w �"�t" IU" "'�IUllulll°;114� 111lllin" IIW 'a"� Administer I'4PIAG SULFATE.(2g IV/I IV/IO infusion over S min lutes)utes) if patient did inot receive Mag Suffate duiring arrest. 3967 hont Afed;e AlTeAhrrOPt PrOtMOk' Back to Table 3968 Pediatric Post Resuscitation c r"Mace me'diral rruqport Prot000k Maintain adequ iatue oxygenation,and ventilation. Patients with a ROSC should be managed in the order of- RATE If heart rate is less than 66 9P +1, pravidne oxygenation and ventilation for one milnute(30 seconds for a neonate). If heart rate remains Vass tbain 60 BPM With S/S of poor perfusion (Altered) Mentall Status) desjpit nuy;gemnatd rn and vent ilat io n for uane minute (30,seconds for a neonate),begin CPR. if aftem one rrniinute of APR the Iheart rate rermai ns less thaurn 60, administer EPINEPHRINE (°t d 110,000) . lmg/kg (O.lrnnL,/ g), I Il0- Repeat every 3-5 minutes prru for a heart rate less than 60 BPM. RHYTHNT ............................. Reference specific protocol. niu ' P "E,wN ,"d ":, I' innd�rmi �mr, Pediatric Systolk IBUmod Pressure Values, eornates:6 r"wrrmraHg lnfan:ts.- '70rnmHg Children 1-10 years old: (age in years x ),mmHg Children greater than 10 years old:90rnrnH NORMAL SALINE. 0mL/kg bolus,nitrated t;o,a SOPas listed above, iMay repeat Ix prin for Ihyp of ns.d n. Assess luiing wn,unds and blood pressure often. 3969 ",I OF," PIEUIXTRIC CAI[,,tDU%C AR['U'11111�'131' ,A,ll patients that are pulseless or h,ave obtained ROS,C shall be,transported to the closest Emergency Department 3970 3971 3972 r, , r 1 Iq6 ir`P� r lu 3973 A� INFORMATION • The goal for effectively managing patients with an overdose/poisoning is to: • Support the ABCs • Terminate seizures • Terminate any lethal cardiac arrhythmias • Reverse the toxic effects of the poison/medication with a specific antidote • The treating paramedic should consider contacting the Florida Poison Control Center at 1-800-222-1222 as soon as possible for additional treatment recommendations. Treatment recommendations from Florida Poison Control should be followed. • Document the directed treatment and the name of the representative on the ePCR Report. WARAING 41 Use caution when supporting blood pressure with fluids. Many medications depress myocardial contractility and heart rate,which predispose the patient to heart failure even with boluses as little as 0OrnL..Assess Iurn,g sounds and blood (pressure frewquentlly. It may be necessary to Iliirnit the amount of fluids the patient receives.. 3974 3975 reA0,rP,00't Prolocok INFORMATION Common Beta Mockers: Ateindol CarvedHol • Signs&Symptoms: MetoprolloP • Bradycardia Proeiranollal • Hypotension 0 Bystolic • Cardiac arrhythmias • Hypothermia • Hypoglycemia • Seizures • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. ADULT Obtain a 1.2-lead aiind leave cables connected I if ronfirmed Beta Blocker Overclose,and patient:un5table Admin[ster'Glucagion 3 mgIV/1 10 if available Refer to the "Bradlycardia' protocol if applicable NORPOAL SALINE 20mII/kg IV/101, titira(te,to desired)effect. Assess lung sounds and BP'frequently. May repeat I x pirin uuuuuuuuu FObtainia 12-lead and leave cables connected If confirmed Beta Blacker Overdose and patient unstabil4e Ndminister Glucagon 01.1 mg/kg IWIlO if avalIable(May repeat Ix prn) I Refer to the "Bradlycardia"protocol if applicable 20 mt/kg W/[O� Assess lung sounds andl IBIP fr". uently 3976 3977 UCU nel Blocker Overdose INFORMATION • Signs&Symptoms: Common Ca1clum,Chainii alo leers:., • Hypotension 4 No asc • Syncope 4 Cardizern • Seizure Ca;rd,ene • AMS rocar ua • Non-Cardiogenic Pulmonary Edema • Bradycardia • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. 01- Obtain a 12-11ead aind leave tables connected i t.,„;p"1hIU C t.YUM (.'V UI C)RHDE it Patient II,Uh ist hile I lg 11'V,/11011,over 2 minutes I If P 0tllm"nt a a7GVUains 1niyIlw'pol u° skore Nif I Ai`,MAL SAIIJINIII.,, I 20ni IV 1'O, titrate to desired effect. Assess lung sounds and BIB fre,gluently. 11 May repeat fay, prn I'°n '. :9e I,.P,I ¢iil hn 110�".`tJIIP„,�,I����.P. I Refdr to the ' radycardla" purot call, if alppllcablle PE IATFG.IC N, Obtain a 12-11ead and heave cables connected C1AItC.:alwtllClll_ if hafli ent Jriu to le^ 0 20ni IWIO, over 2 minutes �. If l'afie t re iain- IHypiicAeniisive NORMIAII_ * 20ni 11W1 w, tutrate to desired effect. Assess Ruing souundls.and IBIP frequently. May repeat Ix, prnn �"P "l"FN ,IIOIN IIIf"HI PRA�yCAIIIA III IVil-CIF 't�f";tN l' I� "f"O AOF Ti IFA�" IIFN°f e er tta t e �ra yr na prcp ioco q app ua e 3978 A014—, a 9 A-i� (.1 t Meal,"tAl TrAkvpopt Proloodc (XICIUM Lnonnel Blocker Ove?ftse Back to Table 3979 UCU nel Blocker Overdose ' INFORMATION • Signs&Symptoms: • Tachycardia • Supraventricular and ventricular cardiac arrhythmias • Chest pain/STEMI • HTN • Seizures • Excited delirium • Hyperthermia • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. Obtain a 1112-lead and Weave cables c-r`oneclte 'V E IIR S II°IC;/owl ll IIIVAJN�: "Versed rng,IPV/[Q, 11N/J M or AU"� rh 2rng IW10/IiIIN E May retoeat ',1 x pr n, in 5, rnri nu tes mg./kig,O 1WI L Img/kg.HIV!if a ada le u�iliow Ip'�"roprloate rr�it�a"000c) '�"r, E Above treatment is u rssuccessfuI ( R L If the Ipadent: has an SunnistabIle cardilac alrrhyth imia Obtain a, 12-le,ad and heave rabies connected %(E u11,�u.:u` .1 mg/kg 11W110,.Irrtiax single close 2.5rng O.2 Img/'kg I IN/111M,Irnax sin le doss*of Sm'g May repeat either (route Ix Ip,rn �, '�r�V'�°u�`ullron'ltb �nV'u�""rr'Ki INb�p`ra:'ut�^u7°bB�"1i0''� 3980 LC nel Blocker Overdose Back to Table 3981 &,R% aC11C 0 0-1. L. 1,Um unannel Blocker Overdose Ccymman VVARNIN(�'9' Suspected Narcotic 4 Feintanyl Overdose 4 Cod&Iinue Narcain is to be used IPIRN tG 4 Dillaudid improve in"Jinsfir air way potency, Herolin ventiWilon and oxygenatloin. methatione The goal Is to restore spontane- LorcIet owes respiration, NOT'"to wake "Vicoeltin the patient up"' 0 Oxycentin 0 UrAab MIIUII � iuiiuill�l�'�«���`�``��i����111������������������li��I������������ 0 Fte ass essabove Vitals Are all vitals within, above N11 0 Secure IV/110 Access? YES mmmmm 3982 ( CIU nel Blocker Overdoes ' Ogtkeili A46d'C:Al uTrao rrort Peotecok ' INFORMATION Signs&Symptoms: • Coma • Mad as a hatter • Seizures • Red as a beet • Cardiac arrhythmia • Hot as hell • Acidosis • Dry as a bone • Blind as a bat • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. O 1taii n a t -lead and leave ra l te5 coninected p�tll�hlFlI� "ryy"4hMph➢ �A( ylq������ � �I !F°i��iF ��,;�;,,,„�'��,�r�,Ur,;!x�,������,�,,1 ,,�, r�x�,��,N°� �'"u„��,i�,,����,��^�,��,�6�, Si �I.)IIUY' I IfItrI�u. Y�kI 4.�N�A'rL 1 I ran /kg II /10,over n"ninjnnnues I May repeat 2x prm,.in,5 minute intervals, max t tall dose 150 rnFlq Ei V" all irmi N'r; °),d'iI "ry Ql "'Yn Are <� l 'b 5 '^yG 0"l i'p Ilf Plat ent IrenI U YP TIIrNl ,lVIE ,mi/k IIV/11 ,t4r to tQii desired effect.Assess lung so,u.unds and Bp frequ ientlly. �a� repeat"°���A prn ca' Ist hi,! talke l In P,"'en' ',YV i'F�r,P� r g r" f m y I�YaearI: 'Ytl.�,� r,p� ;�w0 �"V1=�Jf,.titr I, V,,,HV'dYVV�,tr�Po rlri .asi � d,,,l , rid 4+"gl`r "vUl iatllld4`e 1151 P "IATRI�C I, : Obtain of 12-lead and Ileave cabllies,connected FOI ,IPA.T..1E T ^ CTIHII I I S C I IF ', � 0 :;�I iY If,�, S � SI l I! IBOXIES • ImE,q/kg IIWlIIO,over 2 minutes I„ `,J UR IM A i S k ll Ilil Il: mr 01mil/k I" 10, tiitrate to desired effect.Assess Iulung,sounds and BIP frequenitl . 0 May repeat;l' ,, prn W iu I'III" III ING T As cause death primarily through lethal cardiac irirhythmi s„'ide QRS complexes are an orninous sign and (must I e treated with,SOIII'IU1IM BiCA,R,BI0N AIT irrmrn d lately. 3983 3984 3985 { uuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu uuuuuuuuuuuu P muuui� / I i / I , We of contents saw I ff r% IIr� r I r t t / 3986 VgAermpwrtme p°CAS'TrAA qopt Proloaolr INFORMATION Restrained patients shall IINJOT be placed in a prone position. Chemical restraint may be used in addition to physical restraint for the following: VIOLENT/COMBATIVE PATIENTS are Violent, agitated patients who place themselves and/or crew in danger EXCITED DELERIUM PATIENTS are Bizarre, aggressive behavior which may be associated with the use of cocaine (crack), PCP (angel dust), bath salts, Flakka, methamphetamines and amphetamines ��((�"„ AD'IULT a��d PEIDIiATkiCS I. if possible utilize Law Enforcement to assist with restraint. I Special 1popvilaition patiernts. I ::I Over 65 years,old I I Head trauma 0 < 50 kg El Already taken other sedatives,(e.g., benzodiazepines, alcohol, etc.) I KETAPAIHWIEr 11 ,mg/'kg I M/III for the above patients, El If IV available lmlg,/kg IV May repeat x prin, in 5 minute intervals to,gain a ontr0 of the patient cod jja[ lnjffii uww�l.ru:: �uu'1�i;�li'Y �I`Iei0e411a�Jinlpr" kuyie� IIr�IV.xIi')° d0�wwl�1fn"iIl1(,-, 411 es ppat"u°V Sitlr Jti.R�7"epa iei��J IulY advainci" 'd V°v9 wW't, V"'i,"', I"u�'A:: HII°b' �, d°,il o,.!.!,�:Vli„ ,.6l')n a ain'd Hghfe' flih(lan usirii:d IhnV"� 0n hl noMri p,�)e',w11"II'''C" I I If ineffective consider Versed 'Sing IV/110/II^ or Ativaln 2m,g I'V/I0/1N may repeat IX prin FOR ALL,OTHER" IOLFNT/COMBATIVE/EXi.-IiTED DFILERILI I<E.i uViu tiiIF 4Img/kg II M I If IV amaiilable 1mmug/ g IV I May repeat ix prn, in 5 minutes El C1U1111 1` ,dgll`G(fi pAllUns ' qis IIW,uUld uPihi4X"^Pe 3987 AT ROP�IN E � ) 0.5mg 1WIIQ El May irepeat err , 113 rnintste I ntervals,max totall dlose 3 rylig I I Ci-j o lit,�a I q u cj in - 13radyc a� cJ f"a o rl I,� S,e 11 c I o, a AEUR U."IMMIKE APM If patient begins to wake up, I VEIR,5ED�� 1 51ni IV/111Q�INII/Jmi I May repeat I,x Iprn, in 5 minutes i t It�3 6I I IiC�3 t ii 0 11 11 111,e I'D C3 I q2 I-Is k3ii III re", it,V "," I",I r,d 4 p 4 t"C),a° "'q")t I,C,-,,I i 1,3,,C,"Ir",j, (:�q^ uU u 2 5', 1. Obtaiiini a tcmperaturv- Apply ice, packs to axilla and groin area C"CM D NIC)FRIMAIL SALINE I�,,Av.flL,,vb Ile) I 20m I/k,g [WII0., Titiratieto desired effect. Assess lungsounds a rid BP frequently. El Flieil'-' liborr, Pai'Jicuih-v caPe nusi be II1-Y 0,lhe sij,, mificant o ,,r,nnc61`1, -1(,jjr�� LIHIF, mind n2inial fai uine jjmtsient�s ljr,:Eq/kg, I'V/P0,over 2 rninutes 3988 PainManagement Med,' Al Trap oport Poo ecolr INFORMATION FIEINIIA YL is the front line medication for pain, however IKIEIF II III II IE is preferred for hypotensive patients or patients who have opiate contraindications (allergy, history of abuse, etc.). KIEIF II III II IE may be given with IFIEII IIANYL for severe pain. AD. • 1mcg/ g lWl1O/IIN/IM • May rep-eat 2x pr°ins, in 5 minute iimntervalls, max total dose 3010mcig �,d llll�l",IIn 1tl OP��N Ih�:;Y 11 FlI"g1;,Oi i t 4III (3 " 'a+ve,Rk Dif gmardeIP') dGh 11ni active ('kll alrlus,I° ii y✓h ",eei'tiiniq.a lb d11 piatil :,l"0'i[', f�Mn II"'es,' 'rii,ati:ry G epa r, nsi,",n n IF)i ,i dwijiIniii , i pm€exit', yutl�nnin,our , dircovsy 11 (`,'ain it^e V'k!'vey EnJ, °,vInh NAIRCAN II IYF9, E: Sw'oi>l U') KETANIINE of lFen.ylr un yV Fe ntaiuiyo uio • 50mg of K tairn line in, 1NO QEMAIL 5ALJP4E BAG Administer IV/L,O, ' I; � ve,r 10,minutes :I Reassess pain scale after half of the infusion has been administered (5 minutes), cur . ring 1Continue infusion if needed. Max total)dose 50 g I I lv^°�",°n_wI�':�ghV° OkriFV'��",fi"11m�iu I i lBe Dp"d'"cUa eciR ip cPd iair' P 8 aIII-vk,da'^ III"�.i 11�.8k"d!u Illlk Ilnn: I I IV.ziwpkA IIV I'v t"'_�e"� Nino° id',�� �,Il �'� 0' "'�Qbll 76'NyVI"�k dVifr:°Qi � ➢�frlY,. v.MpKl . ai-11 1 iliV�,7hi 'I" flli:WO td�G,a� III1 hh-),D(I • 2 m,g of Ketani IIN/IIM • May r p alt 1x prnll, in 5 minuite intervals, max tatalll dose 50mg >_ 7 on the pain scale is considered "severe pain" 3989 Nor, Med"CAIrraocport,Protmok EPSE=AnTRUI C ,F FENTANY�� 0 Irri,cg/kg 1W10, over,2 mOnmes I1 .5m, /k IIN/IM MI ax single dose 50mcg Mlay repeat Ix prn, hi 5 rnMuteq nnax WWI dose 150niq C9 G vrll rlftlh c)h"A hvcauUono� [�l MOlf-IltM PZ:it lEaIlc for O k grin-aU)ry depi,esslon El msommimue, if patlejr0l b1?C0l7HDS (I'l,cmmsy I I Can be vevused wAh NARCAN H Pmon5my, KE IAfIANE ( t 3 yi6-,,ars 0 1rqg/kg ICl/N 11 May repeat Ix pim, in, 5 minutes El ConuaMdkmlom� EJ PeneUaOng eye hjuq, U F& Be pmpww,'J rvm, tl>rvv)y IN MEASURE MEET S%CALE 0 2 6 a 10 NO HURT HURTS HURTS HURTS HURTS HURTS LMTLE EMT LITTLIE MORE EVEN MORE MMOLS LOT WORST 2 3 4 51 7 a gi 10 No pain Midd Moderate Severe, Worst pain imagil 3990 A dult Advanced Airway 6t el-ji A1,I l' r o port Pro to-c oh- Pre-oxygeinate Assist ventilations via RVm rKEITAM111111NE: > .slow NV II pmusower In,ut s erse�l, ' repeat I t,+om q I. p.IN f h4 GfY d IN ad mirmimirafion iiin OP may repeat t ,1i-1a ��u fVefatiirnu ut�rmrOhm,Oii�m,m`���i� II n �a,��uwuk �Ilasmml�, f, 114,y1paterfaijori .F.�, T m�"6mnllo,�irt��a,,mNmru➢u�b�mugr�,^z J PDi vuaI iiurw r,.,,lvvirt1,a btHm pals m`<�'�a�Um'�t'r� II uauumm eOiWII� r�i m mn ulL-Vir:ri^uIl lms leir ,airuug II-Oirf uIaI :Ii�iti�i ry SUMNYCHOLINE: 2mg,/Kg UV/10,may relpeat �. lll ofI'm d°rb"funclMrat11 i,11;5 0 Apnelc Status EptlepxtilcalL.us I.� ��,��IV/1��may repeat immd pluu�ua� tGS- Ness I: 0 Tirlsmuus(Ilocks jaw)or clenched teeth, Burn Injurii s tia upper alir air Jill N ' O II�� YES 11 1 migiI MOO rota y iropea1,1`= YES 01111'� VE,IRSEO. .5-1.10 mg IW10 may rellpeat X 1, I�curt prutcu��tpcum s�dl�tpu�n�lum�rud� wuuiwl, KETA "NCNE C14I1t 200m g RVf 10 slow IIIV pfmush may rep ea mill 3991 Pediatric Advanced Airway O t et 5t ew",cap"rraA rplort Protecok Posafian,aaJ_ Pre-oxygeinate Assist veintil bons via, �`"m'r��dl; a'wilei CKTAMINE; • ICt"1i mg/kg JII'r/10 1l slow IIIWI (push • May repeat 1' over 1 2 minutes 0 Maly repeat 11 Max Pre ass,ociat d with higher rncr ases'oln RP 1a III{p��ru�,�-a-a°�;,�irnlhp� U 'sou+�U,�ir�r�o„r�u�n�u��ilrtna�" fHm ,11IIrl. uij 1"with) ATROPINE,O' il t.�rullWO 0 °uiturmamn�mllll�s�m curs ° Fleneti tlijling Eye,injulll'y it SWUJCCINYCHOUNiE Apnek Status,Epllllepticus :i 1 rng/lkg I�MO may repeat IX Head InjuryU/M 9 or Jess 1 �,m�u°oU m rw�ni o°�mrumla�v�i���m"r1 13 Tirismus(lock-jam)or V ROCURONIIU i iu 'iu r r L lenchi� d teeth U �3, mg/lkgl IV/II0 im ay relpeat�`t rmrmm In umril'as ter yrl rIrwaV NO RO I liROIIIUUlMIM!IPlvisrmd 11 mglkg IWO may repeal IX YES 01IIT VERSED- YES 0 l l IV/IIO may repeat X1, 'HI"t pant Intro hi l n�design I'm mod wrwrwl I�ET�I'w�UINNEm �""' 40 1rngjkg Ilya"/IIO show IV push 3992 3993 3994 I s y rJf r d 7 3995 q INFORMATION Signs&Symptoms Stroke-like symptoms Visual disturbances AMS Paralysis or weakness Numbness/tingling Bowel/bladder dysfunction Any patient with these signs& symptoms who has used SCUBA gear or compressed air within a 48-hour period shall be considered a decompression sickness patient. Transport to closest ED. 91 9 1) ��iii68�,,11',i....��:i.S���I��.��iii6,for medical consultation as needed. Contact DAN Diver Alert Network at �i*111.� Treatment recommendations from DAN (Diver Alert Network) should be followed. Document the treatment and the name of the representative on the ePCR Report. Try to obtain an accurate history of the dive: Depth of dives Air mixture type in tanks Number of dives Interval between dives ADULT&PEDIATRIC '62 P("')SII1"K"D II G: Transport patient in a supine position For cardiac arrhythmias, refer to appropriate protocol Rule out a tension pneumothorax 15 LPM via NRB regardless of SP02 3996 . 04 et-Al PKoct Med"CAIrraocppe,Protmok Back to Table 3997 ' INFORMATION Consider spinal motion restriction in the presence of trauma (e.g., diving, rough surf, vehicle accident with subsequent submersion, etc.). ADULT&PEDIATRIC 42 NON-FATAL DROWNING All non-fatal drowning patients MUST BE TRANSPORTED to the hospital For cardiac arrhythmias, refer to appropriate protocol C"PAP - (10 ulim IH12()) for pulmonary edema secondary to near drowning: u�:�;ufutiuliu°ud;lu� itli�;uu°urn: SIf"II < 90 11717u7r7 Il...wism uArfl"Iu() ut NAJ llu a OC (lhl lh°uaiglic) "0I<t'�� IF PATIENT IS HYPOTENSIVE WITH CLEAR LUNG SOUNDS ()IFR IIVI A IL SA IL I lE m Adult: 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. May repeat 1x, prn �'I id,Jct.fllai caii,e ri7ius, Il)(I takf:uu uuu flIu(:W dafis:Was:W, 0 NIIw ai`iud] ieiu4 ialillu.ui,e Ipa J(:uiut':s Pediatric: 20mL/kg IV/10, assess lung sounds and BP frequently May repeat 2x prn,for age appropriate hypotension IF PATIENT IS HYPOTENSIVEIT L Y EDEMA Dopaimliine Adult: Dopamine infusion 5mcg/kg/min-20mcg/kg/min titrate to effect u;'�:u�futi�uliu°udlu� itaiu°:ufu.� . Ip..N��lluu�uuuu�°u.��uu�uu .muRtl°u�fudlrfu.�r t"u;u IPuillu�u��l Ilu,u.�u.�u • f i III k:I (a rn li u°u u.0 t , u u°u..^,ua t w nu Ih°u°:u i t (5 a. ) iI�a li u°u u.0 t(:0 • D4 )fuitt(°:)i Ilu �aid, airiu l Ilbkl )(°xJ Il uessuuue tah°uuouugli(:)uut 3998 i s l't, 1 reA04,POPt Prd&COIC Epinephrine Infusion 0.1mcg/kg/min—lmcg/kg/min titrate to effect ��'�:u�iu�i�uliu°udiu� i�aiu°:uiu.� . Ih-N��Iluu�puuu°u.��uu�uu .muRtl°u�iudiriu.�r V"u;� IPuillu�u��i Ilu,u.��.� • )OINJ � " i �V�, rind Vh p ./ rr a°u V( n n � ,n n :Iluuu�.,llll.uu iiu�� Iluas a i�:ullki p rniiuuuV('u) w (�)iu.�a V'; rn7 iriuuV(!u) diuui arV':lka)i`i • MO)ird(()i IIu ,ai , airiu i IIbkI )(°xJ II iessu i,e fl-iiauug-i(:)u Back to Table 3999 INFORMATION Signs&Symptoms of heat stroke include any of the following: AMS '► hero treating heat stroke: Seizures 'TOOL IFIR'ST,T ;ANSIPORTSECOND"' Hypotension Sweating may be absent Patients with a heat-related illness associated with an altered mental status should be considered to have heat stroke once all the other possibilities for the AMS have been ruled out (hypoglycemia, drugs/alcohol,trauma, etc.). + ADULT& PEDIATRIC C2 ALL HEAT EMERGENCIES Move patient into the back of the rescue as soon as possible. Decrease the air-conditioning temperature in the patient compartment. Obtain a temperature Remove excessive clothing Provide oral hydration (preferably water) if patient is able to swallow and follow commands HEAT CRAMPS &HEAT EXHAUSTION H C)IFR IIVI A li~SA li~II IN IE Adult: 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. May repeat 2x, prn �'Iai ,Jctfllai caii,e rii7iust Il)(I tell<a:uu uuru flu(:, 0NIIw rind] ueiu II ialillu.ui,e II atklirit':s Pediatric: 20mL/kg IV/10, assess lung sounds and BP frequently May repeat 2x prn, for age appropriate hypotension HEAT STROKE WITHTEMPERATURE > 103 DEGREES F Oit ALTEREDL STATUS 4000 Apply U[E PA[KSto axi||a and groin area. DiscmmtimmeacbveclmmUimg once tenmpematmremf101isreached NQRMAL SALINE ([[ LD NQRMAL SALINE preferred, ifaVaiUabUe) 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. May repeat Ix, prn Pre�autions Particu|arcare rnust )eta�ken in the presen�e ofsi�nifi�ant�ormnary heaid, , 0H� an� ren4| fai|urepatients 2Unn| /ko |V/|O, assess lung sounds and BPfrequently May repeat 2xprn, for age appropriate hypotension 4001 CCarMonoxide Exposure � ���h,,W Ad;eA/ T?,A oqopt rohoeo `i INFORMATION Carbon Monoxide (CO) properties: Chemical asphyxiant Colorless Odorless Tasteless Slightly less dense than air Toxic to humans when encountered in concentrations above 35 parts per million (ppm) Lower doses of CO can also be harmful due to a cumulative effect Patients exposed to carbon monoxide (smoke inhalation, etc.) require a full head to toe patient examination including SpCO monitoring. All rescuing crew members shall wear their SCBA if the patient is in a hazardous environment. Consider Cyanide Exposure. Refer to the "Cyanide Exposure" protocol, if applicable ADULT& PEDIATRIC ("')XY�u IE IN 15 LPM via NRB regardless of SP02, unless the patient requires ventilatory support Consider Advanced Airway Protocol if needed IF SPCO I > ®%GII'°t PATIENT PRESENTS WITH ANY OF THE FOLLOWINGSYMPTOMS Headache Nausea/Vomiting Dizziness Altered Mental Status Chest pain Dyspnea Visual Disturbances Seizures 4002 Carbon Monoxide Exposure Syncope Transport to closest ED. N' 'AI Ft INI IIYG Patients with COxposures can have normial pulsie oxi mete r readings and still be h9dlpoxi . 4003 Cyanide Exposure ' INFORMATION Signs&Symptoms: • Coma AMS • Shortness of breath • Headache Pupil Dilation • Dizziness General Weakness • Seizures Confusion Bizarre behavior Excessive sleepiness Cyanide exposures may result from inhalation, ingestion or absorption from various cyanide containing compounds, including exposure to fire or smoke in an enclosed space. Direct cyanide exposure (non-smoke inhalation) is a Hazardous Materials Incident. Consider Carbon Monoxide Exposure. • Refer to the "Carbon Monoxide Exposure" protocol (pg. 96), if applicable ADULT& PEDIATRIC 10 CONFIRMEDTED CYANIDE EXPOSURE ("')XY�IE IN • 15 LPM via NRB regardless of SPOz, unless the patient requires ventilatory support • Consider Advanced Airway Protocol if needed • Transport to closes 4004 4005 4006 NOTICE OF PUBLIC HEARING NOTICE IS HEREBY GIVEN TO WHOM IT MAY CONCERN that on April 17, 2024, at 9:00 A.M. or as soon thereafter as the matter may be heard, at the Marathon Government Center, 2798 Overseas Highway, Marathon, Florida, the Board of County Commissioners of Monroe County, Florida, intends to consider the following: ISSUANCE OF A CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY TO SOUTHERNMOST MEDICAL TRANSPORT FOR THE OPERATION OF A CLASS A ALS AND BLS AMBULANCE TRANSPORT SERVICE WITHIN MONROE COUNTY, FOR THE PERIOD APRIL 18, 2024 THROUGH APRIL 17,2026. The public can participate in the April 17, 2024 meeting of the Board of County Commissioners of Monroe County, FL by attending in person or via Zoom. The Zoom link can be found in the agenda at „jj,j,.://�, ,nroecoiint 1`Vaial1112.otii/ itizens/default.asl,� ,. ADA ASSISTANCE: If you are a person with a disability who needs special accommodations in order to participate in this proceeding,please contact the County Administrator's Office,by phoning(305)292- 4441, between the hours of 8:30a.m.-5:06p.m.,prior to the scheduled meeting; if you are hearing or voice-impaired, call "711': Live Closed-Captioning is available via our web portal @ for meetings of the Monroe County Board of County Commissioners. DATED at Key West,Florida, this day of April, 2024. (SEAL) KEVIN MADOK, Clerk of the Circuit Court and Ex Officio Clerk of the Board of County Commissioners of Monroe County, Florida Publication Dates: Keys Citizen: Keys Weekly: Thur., News Barometer: Fri., 4007 co 0 0 o N p�j O N N fx O ° o $4 a N Z o O a O Co N N Cl) N Cd - O O U a •� Oco co U E U Cl) co 0 O N Co N •- 11bO U C� co f!1 O U U C CO r.� COCl) CO co O C� (V� � — aj O CO ,N `o a) ° O z � � o �z 1" ") -(� a) Q u � � U � Uz U O -!:� U Co N '^ N ° u oCdrx � Vco Cl) co co � � UN o N 0 C� ul U QL) o z cd u co GJ a o o N U W o co CO °� 'a El N —Z r.� N _ Q" V � N � 4" co � N U � � N � � pcd ai N U 00 O * N '� QL) N d o �� p W p Z) � N H U U Cd � W W W U W N N � ai coa' � a' tq ai O O � O s M