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Item S5 S5 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 October 16, 2024 Agenda Item Number: S5 2023-3100 BULK ITEM: No DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: James Callahan N/A AGENDA ITEM WORDING: Approval to renew a Class A Certificate of Public Convenience and Necessity (COPCN) to Florida Keys Medical Transportation, LLC, doing business as Florida Keys Ambulance. The renewal COPCN is for the operation of an ALS (Class A) transport ambulance service; specifically for inter-facility transports for the period November 16, 2024 to November 15, 2026. ITEM BACKGROUND: Florida Keys Ambulance has submitted an application for BOCC approval to renew its Class A Certificate of Public Convenience and Necessity (COPCN). The renewal COPCN is for the operation of an Advanced Life Support(Class A) transport ambulance service; specifically for inter-facility transports for the period November 16, 2024 to November 15, 2026. PREVIOUS RELEVANT BOCC ACTION: On November 15, 2022, Item F.39, the BOCC approved the issuance(renewal) of a Class A COPCN to FKA for the operation of an ALS transport ambulance service (specifically inter-facility) for the period November 16, 2022 to November 15, 2024. On August 19, 2020, Item C.2, the BOCC approved the issuance(renewal) of a Class A COPCN to FKA for the operation of an ALS transport ambulance service (specifically inter-facility) for the period September 22, 2020 to September 21, 2022. On August 15, 2018, Item C.16, the BOCC approved the issuance(renewal) of a Class A COPCN to FKA for the operation of an ALS transport ambulance service (specifically inter-facility) for the period September 22, 2018 to September 21, 2020. On September 21, 2016, Item C.26, the BOCC approved the issuance of a Class A COPCN to FKA for the operation of an ALS transport ambulance service (specifically inter-facility) for the period September 22, 2016 to September 21, 2018. INSURANCE REQUIRED: Yes 5806 CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approve DOCUMENTATION: FKAS—Renewal(2).pdf Florida Keys Ambulance Class A COPCN Application—Redacted Updated 10.02.2024.pdf FINANCIAL IMPACT: Effective Date: 11/16/2024 Expiration Date: 11/15/2026 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 (State insurance nothing to stamp for Risk) 5807 co 0 co p 2 ° � � ( o \ Co \ \ \ § / § .B g w / Co ƒ Co / q � ° ' 14_,2 \ \ \ P � co � »± § ƒ \ Q Cl) COo = � w Co z \ CO k 2 * \ } \ \ o [ U t e » U 6 0 o a @ Q � _ po e Q 6 •° 2 = 4 U \ [ 2 2 ¢ / / - U Z o \ o / \ e a w \ U ¥ U o / Q ) o / 3 \ 4 z o o @ w o U o •� g 2 / o / « [ Z / / ) C 2 \ 2 U \ ' 7 k / U \ \ $ ° , Q 'Q = G § •° / o o z } j d S 2 / / { t § 1.4 \ 2 o w E E / / •/ 2 \ \ k co Cl) % 2 ƒ co 3 � _ 2 $ k 0 / / W o / co o / % ƒ / / ) \ $ / ( / @ U 7 % � / 2 / 2 \ a \ o t ■ 0 6 » » o o = k & \ % E co \ 2 { ) \ q W § % / [ { co IL)[ S /Q ( \ � / / ƒ / \ 'Cl) [ [ / / \ / { / E ? \ \ / IL) Q / o o \ \ Q E Q [ 3 Q ? / ° § / 2 m 2 « »Q, ) A 2 m U � © � � � » � « � » » •/ 2 ƒ � ■ / W WCo W W / •ƒ 0 \ % co % % .) % \ \ » m ) 7 c q d \ \ \ 0 Co 'Cl) / Co \ / / \� •/ % % \ /El 2 / U MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY(COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) ❑ INITIAL APPLICATION-$950.00 ON RENEWAL APPLICATION-$475.00 22-02 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # 1. NAME OF SERVICE FLORIDA KEYS AMBULANCE BUSINESS MAILING ADDRESS P.O. BOX 1259,TAVERNIER, FL.33070 BUSINESS PHONE NUMBER 305-414-8136 EMERGENCY PHONE NUMBER 305-975-4387 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) LLC 01/2021 DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS (Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITION/TITLE EDWARD F. BONILLA 55 917 RED BIRD RD, 305-975-4387 CEO KEY LARGO, FL. 33037 4. LEVEL OF CARE TO BE PROVIDED: ❑BLS or 0 ALS IF ALS: 0 TRANSPORT or❑ NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): ALL OF GEOGRAPHICAL AREAS OF MONROE COUNTY 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION 91421 OVERSEAS HIGHWAY #102, TAVERNIER, FL. 33070 SUB-STATION N/A EMAIL: Flakeysambulance@gmail.com Page Iof6 5809 T. DESCRIBE YOUR COMMUNICATION SYSTEM (Attach copy of all FCC licenses): FREQUENCIES CALL,NUMBERS #OF MOBILES OF PORTABLES CELL PHONE 895-975-488�7 1 n/ 8, LIST THE NAMES AND ADDRESSES OF THREE(3)U.S. CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: .................m.___._......__.._.___............_.............. ..._._..._ (NAME ADDRESS TH MA TEED, MD. 91500 OVERSEAS HIGHWAY., TAVER IFR, FL. 88070 JAMES FAKTOR 18720 SW 296 ST. HOMESTEAD, FL. 8808 EUGE qE FARFAN 158 PACIFIC AVENUE. TA' FIB IER, FL, 88070 9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCiN PERIOD, 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. IL ATTACHA COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. 12. ATTACI--IA COPY OFF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 1.3. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE To THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. 1,THE UN DERS G NEID REPRESENTATIVE OF'I THE ABOVE NAMED SERVICE, DO HEREBY ATTEST MY SERVICE MEETS,ALI,OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE; IN 1'Y ONROE COUNTY AND,'I THE STATE OF FLORIDA I FURTHER ATTEST THAT A LL T E INFORMATION CONTAINED IN THIS APP IC TION,TO'fHF, BEST OF 'Y K 1N WLELDGE,IS TRUE AND CORRECT. .+i !K � & fNA1T11 OF PI � C,t�4t° I"!AA1TIiHCi'�" n [ P,ID 1�E1'18.k�S ;�'N°I'A'1`1V1r; ARCDLY N R. HENRY NOTARY PUBLIC--STATE OF FLORIDA MY COMMISSION EXPIRES MARCH 23,2025 COMMISSION NO,HH 4954991 OTARV SEAL NOTY S1G NA" IFE DATE, � k Page 2 of 5810 T. DESCRIBE YOUR COMMUNICATION SYSTEM (Attach copy of all FCC licenses): FREQUENCIES CALL,NUMBERS #OF MOBILES OF PORTABLES CELL PHONE 895-975-488�7 1 n/ 8, LIST THE NAMES AND ADDRESSES OF THREE(3)U.S. CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: .................m.___._......__.._.___............_.............. ..._._..._ (NAME ADDRESS TH MA TEED, MD. 91599 OVERSEAS HIGHWAY., TAVER IFR, FL. 88079 JAMES FAKTOR 18720 SW 296 ST. HOMESTEAD, FL. 8808 EUGE qE FARFAN 158 PACIFIC AVENUE. TA' FIB IER, FL, 88079 9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCiN PERIOD, 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. IL ATTACHA COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. 12. ATTACI--IA COPY OFF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 1.3. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE To THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. 1,THE UN DERS G NEID REPRESENTATIVE OF'I THE ABOVE NAMED SERVICE, DO HEREBY ATTEST MY SERVICE MEETS,ALI,OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE; IN 1'Y ONROE COUNTY AND,'I THE STATE OF FLORIDA I FURTHER ATTEST THAT A LL T E INFORMATION CONTAINED IN THIS APP IC TION,TO'fHF, BEST OF 'Y K 1N WLELDGE,IS TRUE AND CORRECT. .+i !K � & fNA1T11 OF PI � C,t�4t° I"!AA1TIiHCi'�" n [ P,ID 1�E1'18.k�S ;�'N°I'A'1`1V1r; ARCDLY N R. HENRY NOTARY PUBLIC--STATE OF FLORIDA MY COMMISSION EXPIRES MARCH 23,2025 COMMISSION NO,HH 4954991 OTARV SEAL NOTY S1G NA" IFE DATE, � k Page 2 of 5811 PERSONNEL—PARAMEDICS NAME PARAMEDIC" CERTIFICATION IFIC;ATIO First, Middle,Last �� SOCIAL,SN CURI I Y4 CERTIFICATION# EXPIRATION DATE �y �p R_ J FA ^�8 %,�d1 4._.__- 14804 12/2024 DANIEL ALVAREZ _____. 538083 12/2 24 AARON FERNANDEZ _ 542 12/2024 ._......... Page 3 of 5812 PERSONNEL—EMERGENCY MEDICAIJECHNICIANS NAME EMT CERTIFICATION First, Middle, Last SOCIAL SEC URITY# CERTIFICATION# EXPIRATION DATE SANTOS RODRIGUEZ 505044 12/2024 IRA DI CECILIO ------------- 580596 12/2024 FRITZ JEAN-JACQUES 548571 12/2024 .............. .............. ............... ----—----- ............ -------- ........................ .......... ----------- ........... ............ ............. ........... ............. ---------- .............. .......... Page 4 of 5813 'Lon CO) ce �a >- o UJ _. .m... .... cad XW w0 >-4 h c) FM f CA �f a LL r LU 0 0 0 CL CL CL I i I CN Q- CD- w 0 LA CO cn LO CID CO CIO w �- c c C7 a �r LO 0 CO �- T_ 00 cr C C� CO CO M Ll co w' h*- >. 85 c) co F- a _. C) + ec. t"J N IN I E 0 0 C) 0, 0 0 a ' CD (0 I U LU ui L U O UL CL III ..r 4 Florida Keys Ambulance P.O. fox 1259 Tavernier FL,. 3307 r * Ph.: 305-414-81.36- 'Fax: 305.735.6607 -Emall: Fla:keysaiiibLilarrce(4)aol.cailI. CLASS APPLICATION SCHEDULEITEM 9-6 Transport lase Fee — Basic Life Support (BLS) 900.00 Transport Base Fee _ advanced Life Support (A , 1 ) $1,5010.00 Transport base .Tee advanced l-ifSupport (r ..., ) $1,750.00 1I1ransport Base Fee _ Special Care Transports ( T) 1,900.00 Mileage Charge - Loaded mile $16.00 These rates include all medically necessary supplies, equipment, and medications used during transport. 5816 FLORKEY-02 TECH CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDDIYYYY) 2/1412�024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREll AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. .......... IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the pohey(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and,conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements) .................................. PRODUCER CONTACT Michaell Lopez NAME ........ Sent Insurance Partners, LLC PHONE 1048YSW 88th St,Ste 202 JAM,No,Ext): RAJ.!�,No• Miarl Ill 33176 E-MA�L m lopez@si p.insure -A-QQRESS;- -—----------------------------- -...-2i�ULRER S)AFFORDING COVERAGE NAIC# INSURER A:Kinsale Insurance CompArry 38920 INSURED INSURER B:Cable Underwriters,Inc on behalf of Cable insurance Company 16572 Florida Keys Medical Transportation,LLC INSURER C 911421 Overseas Hwy ....... Ste 102 FI 33070 Tavernier, FIL 33070-2642 INSURERE: .............. ................... COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR All—SUBFi---"- 130,716Y EFF POLICY EXP -' --- TYPE OF INSURANCE I'NSD WV.D— POLICY NUMBER (MWDWYYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY LL A-CH o,�c R iF.N L,k... X CLAIE ,;IC RENTED LTl OCCUR 01 O�0283621-0 2/G/2024 21G/2�026 AIyAC M 60,000 R S dEa occupence) $ L,l EXID IAnv one Isar . 100 000,................... vUra L AGGI LIMIT APPLIES PER GENERALAGGRLGATE 300, X POLICY PRO- LOC Included JECT PROD LICTS-0 0 M P/0,P AGG $ OTHER $ COMBINED SINGLE LIMIT —dd-0—,000 t-;Y-T-0�MOB ILE LIAB ILITY IEa icddenO ANY AUTO CICFL001 146-00 21612,024 2/6/2026 erson)L P- OWNED SCHEDULED ALTOS ONLY AUTOS BODILY INJURY(Per Accident $ ................................ PRO,7R1,Y DAMAGE H I ocId nt) $IRED NO AUTOS ONLY AUTOS ONLY �Per ............................ ........ UMBRELLA LIAR OCCUR IEACH OCCURRENCE $ ................ EXCESS LIAB CLAIMS-MADE AGGREGAIT DED RETENTION$ $ !WORKERS COMPENSATION 7— ) 1 PER OTIP- ;AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNEMEXECUTIVE E_L._.CAC'LI.ACCIDENT $ IC:FFICERIMEMSER EXCLUDED'? N(A (Mandatory m NH) U yes,descnbe under, DESCRIPTION OF OPERATIONS below E I DISEASE POLICY LIMIT 5 .............. ....... —A Abuse Molestation 0100283621-0 216/2024 216/2026 lIAggregate 3010,000 10 A Prof. Liability 010028362111.0 2/6/2024 2t612026 Aggregate 30 ,000 DESCRIPTION OF OPERATIONS f LOCATIONS Y VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOWZED REPRESENTATIVE ACOIRD 25(2016103) Q 1988-2016 ACORD,CORPORATION, All rights Fes 5817 The ACORD name and logo are registered Marks of ACORD Florida Keys Ambulance P.O. Box 1,259 Tavemier, FL. 33070 Ph,: 305A14,8136- Fax: 305,396.5889 Email: Flakeysambulance @waol,coni GROtJND AMBULANCE SERVICE PROVIDER LICENSE APPLICATION ATTACHMENT 5: This agreement dated September 1,2024,by and between Florida Keys Ambulance, herein referred to as the Ambulance Service, and Dr. Thomas Steed,Physician, herein referred to as the Medical Director.'Fhe Purpose of this agreement is to provide the Ambulance;Service with a medical director to enable them to provide Basic,or Advanced life support to the community they serve. This relationship may be terminated by written notice served upon the Medical Director at least seven business days prior to the effective date of said termination, The Medical Director may suspend or terminate the relationship at will for cause,as defined hereinafter,or upon seven business day notice without cause. The Medical Director agrees to: 1. Meet regularly with Ambulance Service and providers at least once per quarter or as often as necessary. 2. Be Medical Director of record for the Ambulance Service as required and Pursuant to Florida Statute Chapter 401,and Florida.Administrative Code 64J-1.004, and will perform all duties associated therewith, 3. Be available to Ambulance service officers when needed to advise on EMS issues. 4. Provide oversight to the agency's pre-hospital quality assurance/quality improvement program, The Ambulance Service Agrees to- t. Be responsible for the transmission of all communications from the Medical Director to all Ambulance Service providers. 2. Take necessary steps to ensure participation by its providers in all programs and Courses required by the Medical Director including but not firnited to protocol requirements,continuing Medical Education and Quality improvement. 3. Monitor the activities of each provider and keep accurate records, which shall be made available to the Medical Director or designee upon request.An officer shall be appointed to maintain such records. 4. Forward inu-nediately to the medical director any and all complaints, notifications,SUMMOnSCS", subpoenas, letters and communication of any nature received which in any way bears on the quality of service rendered, is suggestive of any possible lawsuit or legal proceeding or in any ways bears on the competence of any ambulance service provider, 5. Abide by and strictly adhere to all standards and protocols and other requirements by the Medical Director and agree to suspend any ALS medical privileges for any"provider" for tailure to comply with this provision, Signed: THOMAS STEED,MD. MEDICAL DIRECTOR DATE 'DWARD F N OPERATIONS MANAGER DATE 5818 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 Cotuitv Fire Rescue '; �� 7280 Overseas Highway Marathon,FL 33050 Phone(305)289-6004 " MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: September 10, 2024 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check M dated September 9, 2024, in the amount of$475.00 per check to be deposited in revenue account 141-342000-RC 00345.This check has been issued for the renewal application of a Class A Certificate of Public Convenience for Florida Keys Ambulance. Thank you, Cara Johnson 5819 FLORIDA YS MEDICALFDBA LORIDA KEYS AMBULANCE P.O.BOX 1259 r 4q�a Paytathe Order of-- IAI Dollars FIRSIT For 1� 5820 '� 4 Florida Keys ,Anihuli I Mir Co iiniissimers: I his Jett-n- c r°t:l As that 1. Dr. 1 Kiwis M. S'we . acting as OW! rlirvctr.rw- 1hr used b ]laird K � a Mrs, �-onn din, ordcrs lair' hltcr•filc litw lrara sports ,rtr Y,,.rim) that at this tl.rne dune are no aah wrti;C.s to dicsc, pr-ot(")C(AS, ljuly YMarVS. .s t AT WITS TS SO N�U Y \11 DICA 1. DttwKC t f tt « I w.� w l 1��wrwllzr INA tO. (W 1 5821 INTERFACILITY TRANSFER PROTOCOL Table of Contents I. Policies and Procedures a. Introduction b. Documentation c. Transport Crew Levels d. Contacting Medical Control e. Transfering Patients with Drugs and Devices f. Requesting Additional Personnel II. Drugs a. Cardiovascular Drugs i. Antiarrythmic Agents 1. Flecainide (Tambocor) 2. Ibutilide (Corvert) 3. Magnesium Sulfate 4. Propafenone (Rhythmol) ii. Beta blockers 1. Atenolol (Tenormin) 2. Esmolol (Brevibloc) 3. Labetalol (Normodyne) 4. Metoprolol (Lopressor) 5. Sotolol (Betapace) iii. Blood Pressure Lowering Drugs (Other) 1. Hydralazine 2. Nicardipene (Cardene) 3. Nitroprusside (Nipride) 4. Nesiritide (Natrecor) iv. Calcium Channel Blockers 1. Diltiazem Drip (Cardizem) 2. Nicardipene Drip v. Glycoprotein Ilb/Ilia Inhibitors 1. Abciximab (Reopro) 2. Tirofiban ( Aggrastat) 3. Eftifibatide (Integrilin) vi. Heparin Drip 5822 vii. Inotropes 1. Inamnirone (Inocor) 2. Milranone (Primacor) 3. Dobutamine 4. Dopamine 5. Epinephrine 6. Norepinephrine (Levophed) viii. Nitroglycerine Drip ix. Thrombolytic Therapy 1. Streptokinase 2. APSAC 3. TPA 4. TNK 5. Retavase b. Sedation and Paralytic Agents i. Benzodiazepine Drips 1. Lorazepam (Ativan) 2. Midazolam (Versed) ii. Moderate Sedation Agents 1. Propofol 2. Barbiturates 3. Ketamine iii. Opioid Drips 1. Morphine 2. Fentanyl iv. Paralytic Agents 1. Pancuronium 2. Vecuronium 3. Rocuronium c. CNS Drugs i. Anticonvulsants 1. Phenytoin 2. Fosphenytoin (Cerebyx) 3. Valproic Acid ii. Mannitol iii. Steroids 1. Methyl prednisalone- High Dose 2. Dexamethasone (Decadron) 5823 d. HAL/TPN, Insulin and Electrolytes i. Hype raIimentation/TPN ii. Insulin Drips iii. Potassium Chloride e. Obstetric Drugs i. Magnesium Sulfate ii. Oxytocin (Pitocin) f. Anti-Infective Therapy i. Antibiotics and Antivirals ii. Antifungal g. Pain Control i. Opioid Drips 1. Morphine 2. Fentanyl 3. Hydromorphone (Dilaudid) ii. PCA pumps and Subcutaneous pumps iii. Anesthetic Sprays or Topical Gels h. Antidotes i. N-Acetyl Cysteine/NAC (Mucomist) ii. Cyanide Antidote Kit iii. Thiamine iv. Bicarbonate Drip v. Pyridoxine vi. Atropine/2PAM i. GI Drugs i. Antiemetics 1. Metoclopramide (Reglan) 2. Prochlorperazine (Compazine) 3. Promethazine (Promethazine) 4. Ondansetron (Zofran) and related ii. Acid Reduction 1. Pantoprazole (Protonix) 2. Lansoprazole (Prevacid) 3. Ranitidine (Zantac) iii. GI Bleed related medications 5824 III. Devices a. Temporary Cardiac Pacing b. Chest Tubes c. Ventricular Assist Devices d. Tracheostomy Care e. BiPaP Machines f. Cardiovascular monitoring i. Arterial Pressure Monitor lines ii. Swann-Ganz catheters g. Intracranial Pressure (ICP) monitors h. Insulin Pump i. Vascular Access i. Triple lumen CVLs ii. Indwelling Catheters 1. External 2. Implanted iii. Shiley iv. PICC lines IV. Pediatric Transfer Protocol a. Anticonvulsants b. Continuous Albuterol Nebulization c. Insulin Drip d. IV Antibiotics V. Special Situations a. The Hospice Patient b. The Pediatric patient and Consent Issues c. The Psychiatric Patient d. The Therapeutically Cooled Patient VI. Glossary VI I. Interfacility Transfer Checklist Document 5825 1. Procedures and Policies a. Introduction b. Documentation c. Transport Crew Levels d. Contacting Medical Control e. Transfering Patients with Drugs and Devices f. Requesting Additional Personnel 5826 a. Introduction The decision to transfer a patient rests with the transferring physician (or other care provider, such as a physician assistant).This physician bears responsibility for the transfer decisions. It is the transferring physician who must: 1) Determine whether the benefits of transfer outweigh the risks. 2) Ensure that the patient is properly stabilized prior to departure. 3) Be responsible for complying with currently accepted community standards of practice regarding interfacility transfer. The Paramedics/CCs and Medical Control Physician (MC) assume responsibility for management of the patient, given the circumstances of the patient's condition, while en route between facilities. This protocol recognizes there will be situations where potentially unstable patients will require transfer to another facility to obtain a higher level of care. It should be noted that the Interfacility Transfer Protocol is a supplement to the Regional 9-1-1 Protocols and requires additional training. In this light, patient care during transport can be defaulted to that delineated by the Regional 9-1-1 Protocols. b. Documentation It is the responsibility of the transfering hospital/physician to provide appropriate documentation which includes a transfer form or other documentation indicating compliance with current statutes or laws regarding patient transfers. Included should be patient identifying information (name, address, date of birth, etc.),treatments,test results, preliminary diagnosis, reason for transfer, names of transferring/accepting physicians/institutions, pertinent medical records and orders. C. Transport Crew Levels The following is a description of which levels of care may transport what drugs and devices. EMT Saline lock Patients with PCA pumps with settings unchaged for>6 hours Stable patient with no anticipation of further interventions en route EMT-I Above listed plus: Peripheral IV lines with no added drugs Stable, intubated patients with no anticipation of further interventions en route 5827 EMT-CC Above listed plus: Peripheral IV lines Cardiac monitor/defibrillator Intubated patients with stable ventilator settings Up to 3 IV drips and drugs except for those excluded from the list Only may transport patients on drugs SPECIFICALLY listed in the protocol EMT-P Above listed plus: Intubated patients Central venous lines/PICC lines that are running Permanent Lines that are already accessed and running Arterial and Swann-Ganz lines- not to be used for monitoring by paramedic The medical director of the transporting service shall insure that all transporting providers are credentailled and trained for interfacility transfer and may transport drugs in the so-named catagories at their discretion. d. Contacting Medical Control by Paramedics/CCs Medical Control(MC) may be defined as either the transporting service agency Medical Director,the transferring or receiving MD and as a last resort the ED physician of the transferring or receiving hospital. The Medical Director of the transporting service may set additional standards regarding contacting MC. Medical Control MUST be contacted in the following circumstances: 1. Ongoing administration of blood products or resuscitative medications 2. Intubated patients 3. Patients with chest tubes 4. Patients with temporary pacemakers 5. Changes in symptoms/signs/conditions potentially indicating deterioration 6. Unstable vital signs 7. Medications not specifically listed in the protocol Patients with the first four listed items should be contacted before arrival, and preferably before the patient leaves the sending facility. Patients with the 51"and 61" listed items should have MC called en route as these occur. Patients on medications not specifically listed in the protocol may be transported by EMT-Ps ONLY.These medications will need to be reviewed by their service medical director and must fall into a similar category as other drugs ALREADY LISTED in the protocol. A patient receiving a completely new category of drug may not be transported without further personnel trained in the use of that drug. 5828 e. Transferring Patients with Drugs and Devices During interhospital transfer crew members shall follow all regionally approved BLS/ALS protocols. In addition,the patients on the stated drugs and devices may only be transported if the respective drugs have been initiated at the transferring hospital by the transferring physician/care provider. None of these may be initiated en route. At the discretion of MC,the drug rates/doses may be altered or discontinued depending on the patient's clinical condition. Where indicated, EMT-Ps may titrate a drug up or down once depending on parameters delineated in the specific protocol. The following precautions should be kept in mind by transferring provuiders: 1. All medications have potential to cause allergic reactions. 2. Some medications cause local irritation around the IV site. Several may even cause tissue necrosis if there is infiltration. If there is infiltration of any line,the IV should be immediately discontinued. 3. Many of the listed drugs are incompatible with other medications.Therefore, additional medication should be given through a separate IV line, or, if one is not established,the infusion should be stopped and the line flushed before administering a second medication.This should only be done under direct MC guidance. 4. Most require infusion pumps and/or cardiac monitoring. 5. MC should be contacted if there is any change in patient condition or if any medication needs to be emergently discontinued during transport. 6. If the need arises for emergency medications to be given, infusions may need to be discontinued; contact MC. 7. The MC physician maydetermine that the number or types of drugs/devices may require the presence of additional personnel (such as a second paramedic, nurse or physician). 8. Transfer of patients with ongoing infusion of medication outside the scope of practice and training of the transporting crew (either because of lack of credentialling or medication not listed in the protocol) can not be accomplished without additional personnel who possess a higher level of training. f. Requesting Additional Personnel When the EMS provider anticipates that they will require more assistance to appropriately care for the patient during transfer,they shall request the transferring physician/health care provider to provide appropriately trained hospital staff to accompany the patient and assist. The EMS provider must contact MC for medical direction in all situations where they are not comfortable with the circumstances of the transfer.The transfer will not occur unless the EMS provider and MC are confident the personnel and equipment are appropriate for transfer. 5829 IL Drugs 5830 a. Cardiovascular Drugs i. Antiorrythmic Drugs ii. Beta Blockers iii. Blood Pressure Lowering Drugs iv. Calcium Channel Blockers V. Glycoprotein lib/Illa Inhibitors A Heparin Drip vii. Inotropes viii. Nitroglycerine Drip ix. Thrombolytic Therapy 5831 Cardiovascular Drugs Antiarrythmics Use: Treatment and cardioversion of Atrial Fibrillation or Atrial Flutter Treatment and prophylaxis of refractory Ventricular Tachycardia Adverse Effects: Hypotension, QT prolongation,Torsades, Ventricular Tachycardia AV Block Dosing: Flecainide(Tambocor) Infuse: 2 mg/kg over 20 minutes Ibutilide(Corvert) Infuse: 1 mg IV over 10 minutes Magnesium Sulfate Bolus: 1-2 grams over 5 minutes Infusion: 6-12 grams over 24 hours Propafenone(Rhythmol) Bolus: 2 mg/kg in 15-20 minutes;followed by Infusion: 0.0067-0.0078 mg/kg/minute Special Considerations: Use infusion pump for drips May not be compatible with heparin, lidocaine, amiodarone or bicarb Frequent BP checks for hypotension Increased risk for ventricular dysrythmias if on certain antihistamines or anti-nausea medications Transport by EMT-Ps only 5832 Cardiovascular Drugs Beta- Blockers Uses: Slow ventricular response in SVT, Atrial Fibrillation and Atrial Flutter Slow sinus node rate Adverse Effects: Hypotension, bradycardia Hypoglycemia (diabetics on medications); usual signs and symptoms are masked Bronchospasm Sinus node arrest Dosing: Atenolol (Tenormin) Infuse: 5 mg over 5 minutes May be repeated in 10 minutes Esmolol (Brevibloc) Bolus: 500 mcg/kg (0.5 mg/kg) over one minute Infusion: 50 mcg/kg/minute for 4 minutes If inadequate response, repeat bolus and increase drip rate by 50 mcg/kg/minute up to 3 times (total dose of 2000 mcg bolus and in fusion @ 200 mcg/kg/minute) Drug comes in a 100 mg (10 mg/ml)vial or 2500 mg ampule into 250 ml (10 mg/ml) or 500 ml (5 mg/ml) NS or D5W Labetalol(Normodyne) Infusion: 2 mg/minute (concentration 1mg/ml; 2ml/min) duration from 25 minutes to 2.5 hours Metoprolol(Lopressor) Inject: 2.5 mg IV slow push over 2 minutes May repeat dose up to 5 times every 5 minutes for a total dose of 15 mg Sotolol(Betapace) Bolus: 1-1.5 mg/kg;followed by Infusion: 0.008 mg/kg/minute=8 mcg/kg/min Special Considerations: Use infusion pump Check BP frequently; monitor heart rate Carefully monitor for hypotension, excessive bradycardia or new AV blocks Patient with DIABETES may have symptoms of hypoglycemia masked;watch carefully for mental status changes Contact MC if develop adverse reaction 5833 Cardiovascular Drugs Blood Pressure Lowering Agents Uses: Short term parenteral treatment when oral treatment is not feasible Nitroprusside may be used in CHF to reduce both preload and afterload (reduces work of the heart) Adverse Effects: Hypotension, bradycardia, dysrhythmias Palpitations,flushing, angina Headache, restlessness, drowsiness, confusion or slurred speech Dosing: Hydralazine 5-40 mg IV push over 1-2 minutes Usually given as repeat bolus doses every 20-30 min Rarely given as drip: 1-10 mg/hour Nicardipene(Cardene) Dilute to: 0.1 mg/ml Infusion: Start @ 50 ml/hr(5 mg/hr) May increase rate by 2.5 mg/hr every 15 minutes until desired BP is reached for a maximum dose of 15 mg/hr Nitroprusside Infusion: Continuous to maintain BP See dosage chart below; amount listed is in mL/hr Nesiritide(Natrecor) 2 mcg/kg IV push over 60 seconds 0.01 mcg/kg/min maintenance infusion Special Considerations: Use infusion pump Dedicated IV line-should not administer in same IV line as other meds Nicardipene: If hypotensive (BP<60) or tachycardic (HR>140), discontinue drip. May resume when stable @ 3-5 mg/hr Infusion site must be changed after 12 hours Use with caution in patients with liver failure, since it is metabolized in the liver. May be contraindicated in severe Aortic Stenosis as may decrease preload. Nitroprusside: Small boluses or slight increases in infusion rate may produce profound hypotension Solution must be wrapped in foil to protect it from light Do not mix other medications in the same line Check BP and heart rate every 5 minutes Hypotension can be alleviated by decreasing the infusion rate Nesiritide: Caution in pregnant or lactating patients Contact MC for worsening signs/symptoms, significant BP change or if BP<90 5834 NITROPRU53IDB DOSING CHART CONCENTRATION 200MCG1ML 10OMG15MML 5011<1Cd250ML Pat W MCGIKGIMINUT in Kg 0.5 1 2 3 4 5 6 7 8 9 110 11 12 13 14 15 35 5 11 21 32 42 53 63 74 84 95 105 116 126 137 147 158 40 6 12 24 36 48 60 72 84 96 108 120 12 144 156 168 180 45 7 14 27 41 54 68 81 95 108 122 135 149 162 176 189 203 50 8 15 30 45 50 75 90 105 120 135 150 165 180 195 210 225 55 8 117 33 50 56 83 99 116 12 149 165 182 198 215 21 248 60 9 18 36 54 72 90 108 126 144 162 180 198 216 234 252 270 65 10 20 39 59 78 98 117 137 156 176 195 215 234 254 273 293 70 11 21 42 53 B4 105 126 1147 168 189 21i0 231 252 273 294 315 75 11 23 45 68 90 113 135 158 180 - 203 225 248 270 293 315 338 80 12 24 48 72 96 120 144 168 192 216 240 264 288 315 336 360 85 13 26 51 77 102 128 1513 179 204 230 255 281 306 332 357 383 90 14 27 54 81 108 135 162 189 216 243 270 297 324 351 378 405 95 14 29 57 86 114 143 171 200 228 257 285 314 342 371 399 428 100 15 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 105 16 32 63 95 156 158 189 2211 252 284 315 347 378 410 441 473 110 17 33 66 99 132 168 196 231 264 297 330 363 396 429 462 495 115 17 35 69 104 138 173 207 242 276 311 345 380 414 449 483 518 120 18 36 72 108 144 180 216 252 288 324 360 396 432 46a 504 510 Blood Pressure Lowering Drugs should be transported by EMT-Ps only. 5835 Cardiovascular Drugs Calcium Channel Blockers Uses: Ventricular Rate Control in A Fib, Atrial Flutter, MAT or SVT Adverse Effects: May cause Atrial Flutter,AV Block, Bradycardia, Chest Pain, CHF, Ventricular Arrythmias nausea/vomiting, dyspnea or hypotension Dosing: Diltiazem (Cardizem) Bolus: 0.25 mg/kg over 2 minutes (20 mg for average patient) If needed may repeat bolus in 15 minutes @ 0.35 mg/kg (25 mg in the average patient) over 2—5 minutes Infusion: Dilute 125 mg(25ml) in 100 ml NS/D5W Drip @ 5—15 mg/hour titrated to heart rate Nicardipene(Cardene) Dilute to: 0.1 mg/ml Infusion: Start @ 50 ml/hr(5 mg/hr) May increase rate by 2.5 mg/hr every 15 minutes until desired BP is reached for a maximum dose of 15 mg/hr Special Considerations: Carefully monitor for hypotension/excessive bradycardia/new A/V block PVC's can occur with conversion to NSR Don't use in the presence of a WIDE COMPLEX TACHYCARDIA Nicardipene: If hypotensive or tachycardic, discontinue drip. May resume when stable @ 3-5 mg/hr Infusion site must be changed after 12 hours Use with caution in patients with liver failure, since it is metabolized in the liver. May be contraindicated in severe Aortic Stenosis as may decrease preload. 5836 Cardiovascular Drugs Glycoprotein lib/Ilia Inhibitors Use: Unstable Angina Non Q-wave MI Percutaneous Coronary Intervention AdverseEffects: Bleeding (usually at cath sites) Possible allergic reactions to ReoPro Dosing: Abciximab(ReoPro) Loading bolus: 0.25 mg/kg over 10-60 minutes Maintenance infusion: 0.125 mcg/kg/min for 12 hours following PCI or 18-24 hours for unstable angina Should be administered through a 0.2 or 0.22 micron filter Drip rates will vary depending on concentration that was mixed. Verify drip rates/dosage calculations with the transferring facility staff prior to transport. Tirofiban(Aggrastat) Loading infusion: 0.4 mcg/kg/min for 30 minutes Maintenance infusion: 0.1 mcg/kg/min Rate will be halved for patients with renal insufficiency Dosing table for Tirofiban HCI (concentration 50 mcg/ml) Patient Weight 30 Minute Loading Maintenance Infusion (Ib) (kq) rate(ml/hr) volume(30 min) rate(ml/hr) 66-82 30-37 16 ml/hr 8 ml 4ml/hr 83-100 38-45 20 ml/hr 10 ml 5 ml/hr 101-119 46-54 24 ml/hr 12 ml 6 ml/hr 120-137 55-62 28 ml/hr 14 ml 7 ml/hr 138-155 63-70 32 ml/hr 16 ml 8 ml/hr 156-174 71-79 36 ml/hr 18 ml 9 ml/hr 175-192 80-87 40 ml/hr 20 ml 10 ml/hr 193-210 88-95 44 ml/hr 22 ml 11 ml/hr 211-229 96-104 48 ml/hr 24 ml 12 ml/hr 230-247 105-112 52 ml/hr 26 ml 13 ml/hr 248-265 113-120 56 ml/hr 28 ml 14 ml/hr 266-283 121-128 60 ml/hr 30 ml 15 ml/hr 284-302 129-137 64 ml/hr 32 ml 16 ml/hr 303-319 138-145 68 ml/hr 34 ml 17 ml/hr 320-337 146-153 72 ml/hr 36 ml 18 ml/hr 5837 Eptifibatide(Integrilin) Loading bolus: 180 mcg/kg over 1-2 minutes Maintenance infusion: 2 mcg/kg/min up to 72 hours Dosing table for Epitifibatide Bolus drawn directly from "bolus-vial" (2 mg/ml) Maintenance given directly from "infusion vial" (0.75 mcg/ml) Patient Weight (kg) Bolus Volume (mL) Infusion Rate(mL/hr) 37-41 3.4 ml 6 ml/hr 42-46 4.0 ml 7 ml/hr 47-53 4.5 ml 8 ml/hr 54-59 5.0 ml 9 ml/hr 60-65 5.6 ml 10 ml/hr 66-71 6.2 ml 11 ml/hr 72-78 6.8 ml 12 ml/hr 79-84 7.3 ml 13 ml/hr 85-90 7.9 ml 14 ml/hr 91-96 8.5 ml 15 ml/hr 97-103 9.0 ml 16 ml/hr 104-109 9.5 ml 17 ml/hr 110-115 10.2 ml 18 ml/hr 116-121 10.7 ml 19 ml/hr >121 11.3 ml 20 ml/hr Special Considerations: Use infusion pump Should always be given WITH heparin; if bleeding occurs, need to turn off heparin as well as the GPllb/Ilia drug Eptifibatide dose will be decreased in patients with impaired renal function; settings to be determined by the patient's oredering physician 5838 Cardiovascular Drugs Heparin Drip Uses: Prevents blood clotting, especially in the following situations: Acute MI, Pulmonary Embolus, Deep Vein Thrombosis Adverse Effects: Hemorrhage from various sites including needle sticks, GI tract, CNS bleeds Dosing: Bolus: 15-18mg/kg Infusion: 800-1600 mg/hour Infusion rates may be outside this range and should not require adjustment during transport Special Considerations: Use infusion pump D/C immediately for onset of major blleeding or acute mental status change Contact MC for any bleeding such as IV sites or gums 5839 Cardiovascular Drugs Inotropes Uses: Short term intravenous treatment of patients with acute decompensated heart failure Severe CHF/Cardiogenic Shock To increase cardiac output by increasing myocardial contractility and stroke volume Hemodynamically significant hypotension not resulting from hypovolemia Adverse Effects: May develop hypokalemia resluting from increased cardiac output and/or diuresis May have tachycardia, ventricular dysrhythmias or ectopy, hypertension, angina or ischemic chest pain Dobutamine may also cause hypotension Dopamine may cause nervousness, headache, palpitations, dyspnea, nausea or vomiting Dosing: Inamrinone(Inocor): Loading dose over 2-3 minutes: 0.75 mcg/kg Maintenance infusion: 5-10 mcg/kg/min Milrinone(Primacor): Loading dose over 10 minutes: 50 mcg/kg Patient Weight(kg) 30 40 50 60 70 80 90 100 110 120(max) Loading Dose (mg) 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 Maintenance dose (mL/hr) 200 mcg/mL concentration mcg/kg/min 0.375 3.4 4.5 5.6 6.8 7.9 9.0 10.1 11.3 12.4 13.5 0.50 4.5 6.0 7.5 9.0 10.5 12.0 13.5 15.0 16.5 18.0 0.75 6.8 9.0 11.3 13.5 15.8 18.0 20.3 22.5 24.8 27.0 Dobutamine: 2.5-20 mcg/kg/min continuous infusion; onset may be 10 minutes See dosing chart below for different concentration solutions 5840 DOBLYTAMINE DOSING CHART CONCENTRATION 2MC3/'ML 1 G/SOOML OR 100MG150ML 500M /250ML PAT VVT MCG/KG/MINUTE 41 5 61 71 8 9 10 11 12 13 14 15 161 171 18 19 20126 30 35 40 35 112 3r7l 5 6 _ 7 8 9 11 12 13 14 15 16 17 18119 20 '21 26 32 37 42 40 112 4 6 7 8 10 11 12 13 14 16 17 18 19 2C1 22 23 24 30 3 4 48 45 113 4 7 8 9 11 12 14 15 16 18 19 20 22 23 24 26 27 34 41 47 54 50 2 3 5 8 9 11 12 14 15. 17 18 '2'0 21. 23 24 2 27 29 30 38 45 53 60 55 213 58 117 12 13 15 17118 2G 21 23 25 26 28 30 31 33'41 5¢Y 58 66 68 214 5 7 9 11 13 14: 16 18 20 22 23 251 27 29 31 321 34 36 45 54 63 72 65 2 4 6 8110 12 14 16' 18 20 21 23 25 27 291 31 33 35 37 39 49 59 681 78 70 .2 4 6 8 11' I 13 15 17 19 21 23 25 27 211 32 34 3638 40 42 53 63 74 84 75 5 7 9 11 14 16 18 20 23 25 27 29 32 34 36 38141 43 45 56 66 79 9C) 80 2 5 7 10 12 14 17 19 22 24 26 29 31 34 36 38 41143 46 48 60 72 84- 96 85 3 5 8 10 13 15 18 20 23 26 28 31 33 36 38 41 43, 46 48 51 64 77 89' 102 90 3 5 B 11 14 16 19 22 24 27 30 32 35 38 41 43 46 49 51 54 68 81 05 108 95 3 6 9 11 14 171 20 23 6 29131 34 37 40 43 46 48 51 54 57 71 86 100 114 100 3 6 9 1,2 15 18 21 24 27 30 33 36. 39 42 45140 51 541 57 66 75 901C75 12C1 105 3 -6—9 13 16 19 22 25 28 32 35 38 41 44 47 50 54 5'7 6C1 63 79 95 1 1 C7 1 2.6 110 3 7 10 13 17 29 23 26 3033 36 40 43 46 50 53 56 59 6 3 66 83 99 1 18 132 1 IS 3 7 16 14 17 21 24 2831 35 38 41 45 48 52 55 59 62 66 69 86 164 12'i 138 120 4'7 11 14 1'8 22 25 29 32 36 40 43147,150 54 581611 65 68. 72190. 108 126 144 in] 1 hr or drops/rain. using rninidrip tubing = 60 drops / n-il DOUBLE CONCENTRATION DOBUTAMIN'E DOSING CHART' CONCENTRATION 4M /ML 1 C.00MG/250ML. 5c'OMG/125ML PAT VVT MCG/1C4 /MINUTE 1N KG 11 2 31 41 61 6 7 ' 61 91 19 111 12113 141 151 161 17 181 191 20 251 301 35 40 35 1 1 21 21 31 3 4 4 5 5 61 6 7 7 81 8 9 91 10 11 13 16 18 21 40 1 1 21 21 31 4 4 5 5 6 71 7 8 8 91 10 10 1-11 11 12 16 18 21 24 45 1 1 2 31 3 4 6 5 6 7 7 8 9 9 14H 11 11 ' 12 13 14 17 21] 2:4, 27 50 1 2 2 3 4 5 5 6 7 8 8 9 10 11 1 1 12 13 14 14 ' 15 19 23 26 30 55 1 2 2 3 4 5 6 7 7 8 9 16 11 12 12 13 14 15 16 17 21 25 29 3 60 1 2 3 4 4 5 6 7 8 9 10 '11 12 13 14 '14 15 16 17 18 23 27 32 36 65 1 2 3 4 5 6 71 8 9 10 11, 1213 14 '15 16 17 18 19 20 24_ 29 34 39 70 1 2 3 4 5 6 7 8 9 1 1 12 13114 15 -16 17 18 19 20 21 2+6 32 37' 42 75 1 2 3 5 6 7 8 6 10 11 12 14115 16 117 18 19 20 21', 23 26 34 39 45 so 1 21 41 51 6 7 8 10 11 12 13 14116 17 IS 19 20 22 23 24 30 36 42 48 as 1 31 41 51 6 8 9 10 11 13 14 15117 18 19 20 22 23 24 26 32 38 45 51 90 1 3 4 5 7 8 9 i 11 12 14 15 16 18 19 20 22 23 24 26 27 34' 41 47" 54 95 1 3 4 6 7 9 10111 13 14 16 17 19 20 21 23 24 26 27 29 36 43 50 57 100 2 3 5 6 8 9 11 , 12 14 1 17 ' 18 20 21 23 24 26 27 29, 3M64 45 53 60 105 2 3 5 6 8P 11 1�- 14 16117 19 26 22 24 25 27 28 30 3 47 55 63 110 2 3 5 7 8 ' 112 13 115 17 18 20 21 23 25 26 2a3031 50 58 66 115 2 3 5 7i 9 12 14 116 17 19 1 22 24 26 28 29 31 3'3 3 52 60 69 1'2P1 2 4 5 7 9 13 14 116 181201 2f) 23 25 27 29 31 32 34 3 54 63 72 rn11/:hr or drops/rain. using mini drip tubing = 60 drops/nil 5841 Dopamine: 1-20 mcg/kg/min continuous infusion Onset may be 10 minutes See dosing chart below for different concentration solutions Derr uuaiine Dosing("llart Single Concentration 1_6 mg/nil 800 nu ,/500 nil 400 nig/250 nil nicg Ikg/minaute 1 2 3 4 5 10 15 2l 35 1 3 4 5 7 13 20, 26 40 2 3 5 6 8 15 23 3 45 2 3 5 8 17 25 34' rll 2, 4 6 8 9 19 28 35 55 2 4 6 81 16 21 31 41 6�t 60 2 5 7 E 11 23 34_ 45i t 65 2 5 7 1 C 12 24 3 7 4 n 70 3 5 8 11 13 26 3U 53 Kg 75 3 6 3 11 14 28 42 56 80 to 9 1 15 _ 3 4 66 85 36 10 1 16, 32 481 64, 90 3 7 101 14 17 34 511 68j 95 4 7 11 14 18 36 531 71 100 4 8 11 15 19 38 56 75 105 4 a 12 le 20 39 59 7 liq 41 8 12 1 2'1 41 62 83 11 4 9 13 17 22' 43 6 86 1201 5 9 14 18 2 45 68 9 ml,/hr or drops/min. lasing,rninirlrip tubing=60 clropds/rnl Y9op arnine (;Single) Dosing Chart 1)ocipsrliiiric:, E)osing CA'Sairrt: F>ouble C oo c:;c ntranticari :3.2 n'&Wnrnl 800 rn g/2 50 aci'n 1 - 1 1 2i 3 3 7 10 1 4 _ 1 2 233 7 11 15 45 1 2 3 3' 4 8 1.3 17 so 1 2 3 4 9 14 19 55 1 2 3 4 5 10 15 21 450 11 2 3 51 6 '11 1 65 1 2 4 5 6 1'2 I3 2 Pt wt 70 1 3, 6 7 13 20 2: in K 75 1 3 4 6 7 14 21 23 80 2 3 5 6 a 15 23 3 35 2 3 5 7, a 16 24 32 90 1 2 3 51 7 a 17 25 3. 5 2 4 5 a 9 is 27 36 1100 2 4 6 a 9 119 28 33 1015 2 4 6 8 10 20 30 3 110 2 4 6 9 10 21 31 41 115 2 4 9 1 1 22 32 4 . 120 21 51 7 91 11 231 34 45 nil/1rr crr drops/niin. using rriinicirjip tubing 60 chaps/rinl nation via irra: ("double-) nosing 42:trrart. 5842 Epinephrine: 1-10 mcg/min titrated to desired effect Norepinephrine: 0.5-1.0 mcg/min (Levophed) Titrated up to 30 mcg/min to desired hemodynamic effect Special Considerations: Use infusion pump For Inamrinone/Milrinone: do not mix with Lasix or dextrose-containing solutions should be transported by EMT-Ps only Monitor for cardiac dysrhythmias;these may be caused by hypokalemia, pre-existing arrythmias, abnormal drug levels, catheter placement, etc. Check blood pressure and heart rate frequently. Discontinue briefly if develop hypotension secondary to vasodilatation EMT-Ps may titrate up/down one increment without calling MC Contact MC for any adverse affects 5843 Cardiovascular Drugs Nitroglycerine Drip Uses: Acute Coronary Syndrome, CHF, Hypertension Decreases preload, and to a lesser extent, afterload Adverse Effects: Excessive hypotension which can provoke angina, headache, restlessness, palpitations, tachycardia or dizziness Dosing: Continuous infusion titrated to maintain therapeutic effect while avoiding hypotension. Usual range 10-200 mcg/min. May be higher in treatment of pulmonary edema. NITROGLYCERIN DOSING CI-TART DOUBLE CONCENTRATION CONCENTRATION 200MCGIML NITROGLYCERIN!DOSING CHART 100 N` G/500 ML CONCENTRATION 400MCG/M'L 50 MG/250 ML 100 MG/250 ML PUMP PUMP PUMP PUMP N!II'CG/MI'N BITTING MCGININ SErnNG MCGIMIN BETTING MCG/ IN 8'E"MIING 10 3 160 48 10 2 160 24 20 6 170 51 20 3 170 26 30 9 180 54 30 5 180 27 40 12 190 57 40 6 190 2.9 50 15 200 60 50 8 200 30 60 18 210 63 60 9 210 32 70 21 220 66 70 11 220 33 60 24 230 69 B01 12 230 35 90 27 240 72 90 14 240 36 100 30 250 75 100 15 250 38 120 36 260 78 120 18 260 39 130 39 270 81 130 20 270 41 140 42 280 84 140 21 280 42 150 45 150 23 Special Considerations: Use Infusion pump Monitor heart rhythm Check BP and HR frequently (every 5 minutes); may decrease to every 10 minutes if at the same rate for>1 hour Do not mix other medications in the same line Hypotension can be alleviated by decreasing the rate of infusion D/C infusion if BP systolic is<60mm Hg and contact MC Contact MC for worsening or persisting adverse signs/symptoms or for persisting BP<90 mmHg EMT-CCs may transport patients with a MAXIMUM rate of 100 mcg/min EMT-Ps may perform one titration of 10 mcg for escalating chest pain without contacting MC 5844 Cardiovascular Drugs Thrombolytic Therapy Uses: Dissolves clots in blood vessels Generally used in the setting of Acute MI or CVA; occasionally used Pulmonary Embolus Adverse Effects: Minor hemorrhages from IV sites and gums Major hemorrhage from GI and intracranial or spinal sites Reperfusion dysrhythmias often occur about 30-60 minutes after staring infusion Allergic reactions including anaphylaxis may occur with Streptokinase or APSAC Dosing: Streptokinase,APSAC or TPA: Dose to be detemined by transferring physician (determined by patient weight and indication for therapy) Rate should not require adjusting en route Tenecteplase(TNK): weight-based one time dose, administered over 5 seconds Pt weight: <60 kg Dose: 30 mg >_60 -<70 kg 35 mg >_70 -<80 40 mg >_80 -<90 45 mg >_90 50 mg Occasionally used as continous infusion for peripheral arterial thrombus 0.25-0.5 mg/hour up to 48 hours Retevase: Given in 2 doses of 10 mg each, 30 minutes apart Given as a 2 minute IV push Special Considerations: Use infusion pump Monitor heart rhythm Check BP and HR frequently Do not mix with other medications in the same line D/C infusion immediately if there is cardiac arrest, major hemmorhage, anaphylaxis or change in mental status AND call MC. 5845 b. Sedation and Paralytic Agents i. Benzodiazepine Drips ii. Moderate Sedation Agents iii. Opioid Drips iv. Paralytic Agents 5846 Sedation and Paralytic Agents Benzodiazepine Drips Uses: Sedation for patients who are intubated (and often concurrently on a paralytic drip) May be used to treat Status Epilepticus Adverse Effects: May be more prone to hypotension if used with an opioid drug Can cause paradoxical agitation, hypertension or tachycardia Dosing: Lorazepam (Ativan): Loading dose: 0.5-4.0 mg IV bolus; may be repeated in 10 min Infusion: 0.02-0.1 mg/kg/hour Midazolam (Versed): Loading dose: 0.01-0.1 mg/kg IV bolus Infusion 0.02-0.1 mg/kg/hour Special Considerations: Only to be used in intubated patients 5847 Sedation and Paralytic Agents Moderate Sedation Agents Uses: Sedation for patients who are intubated (and often concurrently on a paralytic drip) May also be used for refractory seizures or therapeutic coma Adverse Effects: May be more prone to hypotension if used with an opioid drug Can cause paradoxical agitation, hypertension or tachycardia Dosing: Propofol: Loading dose: 0.5-5 mg/kg Maintenance infusion: 2-10 mg/kg/hour Barbiturates: Pentobarbital is most commonly used Loading dose: 10 mg/kg; infuse up to 25 mg/min Maintenance: 1-2 mg/kg/hour Ketamine: Loading dose: 1-5 mg/kg Maintenance infusion: 0.01-0.05 mg/kg/hour Special Considerations: Only to be used in intubated patients 5848 Sedation and Paralytic Agents Opioid Drugs/Drips Uses: Typically port of a sedation combination for patients who are intu bated Occasionally for pain control Adverse Effects: May cause hypotension, especially in volume depleted patients or those with right-sided heart failure Dosing: Morphine: Loading dose: 2 mg increments given every 5-10 minutes until adequate pain control;typically max dose is 10 mg-may be higher in patients on chronic pain therapy Infusion: 1-10 mg/hour Fentanyl: Loading dose: 1-5 mcg/kg given IV push Infusion: 1-5 mcg/kg/hour Special Considerations: Not adviseable to give patients on narcotic drips Naloxone, as this may preciptate acute withdrawal Antihistamines (both H1 and 112) may counteract hypotension;this is an MCO 5849 Sedation and Paralytic Agents Paralytic Agents Uses: Total muscular paralysis when patient movement may: 1. Compromise airway control (e.g. causing unwanted extubation) 2. Exacerbate a real or potential illness or injury(e.g. spinal cord injury from a spine fracture) 3. Endanger the patient, EMS care provider or others Adverse Effects: Bronchospasm,flushing, hypotension and tachycardia have been rarely reported Dosing: Pancuronium: Loading dose: 10 mg/kg May repeat dose every 1-2 hours as needed Vecuronium: Initial dose 10 mg IV push Repeat dose of 10 mg IV push every 20-40 minutes as needed Maintenance infusion may be an alternative: 0.01 mg/kg/min Rocuronium: Loading dose 0.6 mg/kg May rebolus 0.2 mg/kg every 30-45 minutes Maintenance infusion may be an alternative: 0.01—0.15 mg/kg/min Special Considerations: Produces COMPLETE APNEA;therefore an intact airway(e.g. endotracheal intubation), and adequate ventilation/oxygenation MUST BE ESTABLISHED PRIOR TO ADMINISTRATION. Likewise, personnel and equipment with the ability to restore an airway,ventilation and oxygenation must be available during transport. Causes paralysis only;therefore concommitant use of a sedative/hypnotic is indicated Note: Paralysis may alter the clinical exam.For example, motor seizure activity will not be seen, but the brain will continue to undergo seizure activity, and this must be treated! Also, conditions such as shock, hypoxia, pain, intracranial injury, hypoglycemia, etc. maybe the cause of this unwanted, spontaneous patient movement in the first place.These conditions must be addressed but may be masked by the paralytic agent! 5850 c. CNS Drugs i. Anticonvulsonts ii. Mannitol iii. Steroids 5851 CNS Drugs Anticonvulsants Uses: Prevention and treatment of seizures Adverse Effects: If intravenous phenytoin is given too rapidly, may result in: 1) Cardiac dysrhythmias inlcuding ventricular fibrillation or asystole 2) Hypotension Subcutaneous extravasation of intravenous phenytoin may cause tissue necrosis or pain at the IV site Dosing: Phenytoin: 100-1200mg IV piggyback in normal saline; Rate not to exceed 50 mg/min Fosphenytoin: dose expressed in phenytoin equivalents(PE) 15-20 PE/kg; rate up to 100-150 PE/min Valproic Acid: 40-60 mg/kg Rate up to 3 mg/kg/min Special Considerations: Use infusion pump Monitor heart rhythm Check BP frequently; vital sign monitor recommended D/C infusion and contact MC for any adverse effects 5852 CNS Drugs Mannitol Uses: Treatment of increased intracranial pressure or selected fluid overload states Adverse Effects: Hypernatremia Volume Depletion Dosing: 25-50 grams IV push or bolus infusion (in 50cc D5W over 20 minutes) Special Considerations: Patients receiving mannitol should have a Foley to monitor fluid status 5853 CNS Drugs Steroids Uses: Spinal cord injury to decrease edema Cerebral edema due to injury or CNS mass or lesion Adverse Effects: GI Bleed Electrolyte disturbance and hyperglycemia Hypertension oar Acute CHF Agitation Corticosteroid hormonal suppression (hypoglycemia, hypotension, hypothermia) Higher risk for infection or masking symptoms of infection Dosing: Methylprednisolone(Solumedrol): Initial bolus: 30 mg/kg over 15 minutes Start infusion 45 minutes later: 5.4 mg/kg/hour for 23 hours Dexamethasone: 0.1-0.6 mg/kg day (Decadron) May be given as IV drip of 2 mg/kg over 2 hours Special Considerations: Contact MC for question of adverse effects 5854 d. Hyperalimentation/TPN, Insulin and Electrolytes i. Hyperalimentation/TPN ii. Insulin Drip iii. Potassium Chloride 5855 Hyperalimentation/TPN, Insulin, Electrolyte solutions Hypera I i mentation/WN Uses: Intravenous nutrition Adverse Effects: Catheter related sepsis Air embolism if central venous IV tubing becomes disconnected Subcutaneous extravasation of solution can cause tissue necrosis Discontinuation of infusion may cause hypoglycemia Dosage: Continuous infusion usually through central venous catheter but occasionally through a peripheral IV line. Rate should not require adjustment enroute. Special Considerations: Use infusion pump. Do not administer any other medication through the same IV line. Contact MC for any adverse effects listed above Consider use of a cardiac monitor 5856 Hyperalimentation/TPN, Insulin, Electrolyte solutions Insulin Uses: Lowers blood glucose Used in diabetics especially with ketoacidosis or hyperosmolar nonketonic coma. Adverse Effects: Hypoglycemia related (tachycardia, diaphoresis, mental status changes, and seizures) Dosage: 5-15 units per hour but dosages outside this range may be used. Special Considerations: Use infusion pump Do not administer medications in the same IV line except D50. If symptoms of hypoglycemia develop: -turnoff infusion, -perform a D-Stick -administer 25 grams, (one AMP) D50) if glucose<80, -contact MC. Monitor blood sugar every 30 minutes during transport Cardiac monitoring required EMT-CCs may manage isolated insulin drip or with one additional drip 5857 Hyperalimentation/TPN, Insulin, Electrolyte solutions Potassium Chloride Uses: Replacement therapy for hypokalemia Adverse Effects: Cardiac dysrhythmias (prolonged PR interval;wide QRS complex; depressed ST segment; tall, peaked T-waves; heart block; cardiac arrest) Subcutaneous extravasation of solution can cause tissue necrosis Dosage: Usual range is up to 20 mEq/hr., continuous infusion. May be mixed with various IV solutions in various sized bags including "piggy back" solutions. Rate should not require adjustment enroute. Special Considerations: Monitor heart rhythm Often causes burning during infusion; contact MC if this is problematic Contact MC for changes in EKG configuration and/or dysrhythmias. 5858 e. Obstetric Drugs i. Magnesium Sulfate ii. Oxytocin 5859 Obstetric Drugs Magnesium Sulfate Uses: Treament of pre-eclampsia and eclamptic seizures Premature rupture of membranes Adverse Effects: Lethargy, nausea, vomiting, hypotonia, respiratory depression, dysrhythmia Dosing: Loading dose: 2-6 grams IV over 15 minutes (may give 2 grams over 5 minutes) Followed by either: 5 grams IM in each buttock Maintenance infusion: 1-2 grams/hr Special Considerations: Monitor reflexes For symtomatic toxicity: 10 mLs of 10%Calcium Chloride and contact MC MC may also request furosemide and/or NS bolus as MCO In renal failure, patient may require emergency dialysis 5860 Obstetric Drugs Oxytocin (Pitocin) Uses: Stimulates post-partum contraction of the uterus to control bleeding Adverse Effects: Hypertension,tachycardia, dysrhythmias Dosing: 10-40 units added to 1000 mL IVFluid to control hemorrhage Usual rate is 10-20 milliunits/min Special Considerations: Use infusin pump Monitor heart rhythm Check BP frequently; vital sign monitor recommended Contact MC for any adverse effects 5861 f Anti-Infective Therapy i. Antibiotics ii. Antifungals 5862 Anti-Infective Therapy Antibiotics and Antivirals Uses: Bacterial or Viral infections (treatment and prophylaxis) Adverse Effects: Allergic signs and symptoms, including anaphylaxis Dosage: Vary depending on the antibiotic Generally given as a "piggyback" solution Rate should not require adjustment en route Special Consideration: D/C infusions if there are any allergic signs or symptoms,then contact MC. Most Commonly used: Acylcovir Azithromycin (Zithromax) Cefazolin (Ancef) Ceftriaxone(Rocephin) Gentamicin Levofloxacin (Levaquin) Metronidazole (Flagyl) Piperacillin/Tazobactam(Zosyn) Vancom ycin 5863 Anti-Infective Therapy Antifungals Uses: Fungal infections Often in immune-compromised patients,those on chemotherapy or chronic antibiotics Adverse Effects: Nausea or diarrhea Amphotericin-fever, rigors, chills Dosing: Amphotericin 6,Azoles or"Fungins": Usually given as bolus dosing once daily to TID May be given as continuous bladder irrigation: 50 mg/liter Over 24 hours @ 42 ml/hour Special Considerations: Drug interactions may occur with statins, coumadin, antivirals, benzodiazepines, oral hypoglycemic drugs and transplant anti-rejections drugs Side effects can be pre-treated with Acetaminophen or Diphenhydramine 5864 g. Pain Control i. Opioid Drips ii. PCA Pumps and Subcutaneous Pumps iii. Anesthetic Sprays or Topical Gels 5865 Pain Control Opioid Drips Uses: Control of pain Adverse Effects: May cause hypotension, especially in volume depleted patients or those with right-sided heart failure Respiratory Depression Dosing: Morphine: Loading dose: 2 mg increments given every 5-10 minutes until adequate pain control;typically max dose is 10 mg-may be higher in patients on chronic pain therapy Infusion: 1-10 mg/hour Fentanyl: Loading dose: 1-5 mcg/kg given IV push Infusion: 1-5 mcg/kg/hour Hydromorphone(Dilaudid): Loading dose: 0.5-4 mg IV slow push Continuous infusion: 1-10 mg/hour Special Considerations: Avoid Naloxone as this could precipitate acute withdrawal Pump malfunction could precipitate withdrawal Antihistamines (both H1 and 112) may counteract hypotension;this is an MC option 5866 Pain Control PCA (Patient Controlled Anesthesia) Pumps and Subcutaneous Pumps Uses: Treatment for patients with palliative care or chronic pain conditions Often PO analgesia is not feasible Adverse Effects: Hypotension Respiratory depression Catheter site infection or irritation Dosing: PCA(Patient Controlled Analgesia) Pumps Morphine, Fentanyl and Hydromorphone are most commonly used. Pre-programmed settings for patient Patient may require assistance to "self-administer" medication Subcutaneous Catheter Pumps Morphine most commonly used. Up to 2 mLs volume at a time regardless of concentration May also give IV fluids at a usual rate of 1-10 mLs/hour; MAX of 25 mLs/hr Special Considerations: Encourage patient to use medication as needed Avoid Naloxone as this could precipitate acute withdrawal Pump malfunction could precipitate withdrawal Subcutaneous catheter sites need to be changed every 7 days 5867 Pain Control Sprays and Gels Uses: Topical pain control-usually prior to a procedure Adverse Effects: Allergy to medication Depressed gag reflex if used orally Dosing: Sprays: Usually 2-3 sprays to desired area Topical gels: Enough to thinly cover area Duration can be minutes to hours Special Considerations: Some can induce Methemoglobinemia. Watch for hypoxia 5868 h. Antidotes i. NAC ii. Sodium Thiosulfate iii. Thiamine iv. Bicarbonate Drip V. Pyridoxine A Atropine/2-PAM 5869 Antidotes N-Acetyl Cysteine or NAC (Acetadote) Uses: Acetaminophen overdose-toxic quantities Adverse Effects: Anaphylactoid type reactions (urticaria,flushing, hypotension and bronchospasm) Dosing: Loading dose: 150 mg/kg over 15-20 minutes Maintenance infusion: 50 mg/kg over 4 hours then 100 mg/kg over 16 hours Special Considerations: Ideal time of onset of treatment is within 8-10 hours of ingestion Anaphylactoid reactions may be treated with IV diphenhydramine Maintenance infusion must be doubled at the 4 hour period 5870 Antidotes Cyanide Antidote Kit (Amyl Nitrate, Sodium Nitrate, Sodium Thiosulfate) Uses: Cyanide poisoning Adverse Effects: May cause methemoglobinemia Dosing: Dosing as described in kit;weight based for children Special Considerations: Not to be used with Corbon Monoxide poisoning 5871 Antidotes Thiamine Uses: Wernicke's Encephalopathy Adverse Effects: Possible anaphylactic reactions Dosing: 100 mg IV over 15-30 minutes Special Considerations: Glucose administration in nutritionally depleted patients should be accompanied by thiamine 5872 Antidotes Bicarbonate Drip Uses: Tricyclic, aspirin or other acidotic overdoses Renal protection after IV contrast or with sever a muscle breakdown (rhabdomyolysis) Adverse Effects: Sodium load Dosing: Titrated to urine pH >7 by hospital staff Special Considerations: Usually will have a Foley to check urine pH and output May be associated with hypokalemia 5873 Antidotes Pyridoxine (Vitamin 66) Uses: Isoniazide (INH) Overdose Adverse Effects: GI upset Headache or sleepiness Tingling or burning of hands/feet Dosing: 5 grams IV over 3—5 minutes; repeat every 5-20 minutes until seizures resolve Special Considerations: Often patient is in status epilepticus; seizures may respond to benzodiazepines 5874 Antidotes Atropine/2-PAM Uses: For SEVERE Cholinesterase Inhibitor poisoning (e.g. pesticides, nerve agent) Adverse Effects: Dosing: Atropine: 2-4 mg given every 5 minutes until signs of atropinization (this may take 25-50 mg) 2-PAM (2-pyridinealdoxime) 1 gram slow IV injection; if muscle weakness persists,give additional 500 mg after 30 minutes Special Considerations: 2-PAM should be given WITH Atropine 5875 i. GI Drugs i. Antiemetic Agents ii. Acid Reduction GI Bleed Related Medications 5876 GI Drugs Antiemetic Agents Uses: For control of severe nausea and vomiting Adverse Reactions: Drowsiness, dizziness, blurred vision, skin reactions, hypotension Extrapyramidal symptoms (EPS)—motor restlessness, dystonic reactions, pseudo- parkinsonism,tardive dyskinesia with metaclopramide, prochlorperazine, or promethazine Headache or dizziness may occur with ondansetron Dose: Metaclopramide(Reglan) 10 mg IV over 2 minutes If needed, dose may be repeated oncein 10 minutes Prochlorperazine(Compazine) 5 mg IV over 2 minutes If needed, dose may be repeated oncein 10 minutes Promethazine(Phenergan) 25 mg IV over 2 minutes If needed, dose may be repeated oncein 10 minutes Ondansetron(Zofran) 4 mg slow IV over 2 minutes or IM If needed, dose may be repeated once in 10 minutes Special Considerations: Extra-pyramidal symptoms may be treated by administering Diphenhydramine (Benadryl) 50 mg IV over 2 minutes Confirm with MD regarding IV administration of Promethazine due to "black box warning" 5877 GI Drugs Acid Reduction Uses: Decrease secretion of gastric acid or chronic reflux Patients with UGI Bleed Adverse Effects: (all rare) Occasional CNS symptoms- more so in the elderly Jaundice GI upset Dosing: Pantoprazole(Protonix) Bolus: 80 mg over 5 minutes; Infusion: 8 mg/hour Lansoprazole(Prevacid) Bolus: 30-60 mg over 30 minutes Infusion: 6 mg/hour Ranitidine(Zantac) Bolus: 50 mg over 20-30 minutes Infusion: 150 mg over 24 hours Special Considerations: May be used for antihistamine effects 5878 GI Drugs GI Bleed Related Medications Uses: Variceal Upper GI Bleed Adverse Effects: Gall Bladder sludging or stones Diarrhea and GI Upset Hypoglycemia Dosing: Octreotide: 50 mcg IV bolus,then 50 mcg/hour Special Considerations: Alters the balance between insulin/glucagon; could result in either hypoglycemia or hyperglycemia Vasopressin is presently rarely used due to its potent vasoconstrictive and catacholamine inducing properties 5879 111. Devices a. Temporary Cardiac Pacing b. Chest Tubes C. VA Ds d. Trachesotomy Care e. BiPap Machines f. Invasive Cardiovascular Monitoring g. ICP Monitors i. Insulin Pumps j. Vascular Access 5880 Devices Temporary Cardiac Pacing Uses: To ensure adequate heart rate; Most common use is for symptomatic bradycardia or heart block Adverse Effects: Problems related to transvenous/transthoracic insertion: pericardial tamponade, pneumothorax, myocardial perforation, air embolus sepsis and thrombophlebitis Failure to pace due to: displacement of pacing electrode (most common complication), loose connection,faulty generator, myocardial ischemia Failure to sense due to: patient's native beatsnot sensed by the pacemakerand the output pulse may occur after a spontaneous beatwhich may induce dysrhythmias Catheter induced dysrhythmias Pacer Box Settings: Rote control: usually between 60-100 beats/minute Output(electric current used to stimulate myocardium): usually between 5-20 mAmps Sensitivity control: used to sense heart's native electricactivity (QRS deflection) Special Considerations: Monitor heart rhythm. A functioning pacemakerusually reveals a pacer spike followed by a bundle branch pattern on the monitor strip Contact MC if develops a bradycardia with no pacer spikesor non capturing of the QRS; consider initiating transthoracic pacing if patient is unstable 5881 Devices Thoracostomy Tubes (Chest Tubes) Uses: To evacuate an abnormal collection of air(pneumothorax), blood (hemothorax) or fluid (pleural effusion)from the pleural space Complications: Mechanical problems:tube dislodgement from the wall, air leaks from tubing, drainage site or skin site Blocked drainage: kinked tube or clots Bleeding: local incision hematoma, artery or vein laceration Visceral perforation Re-expansion pulmonary edema Procedure: Usually placed in the midaxillary line at the fifth-seventh intercostal space, or in the midclavicular line at the second intercostal space Tube is sutured to the chest wall and Vaseline gauze and an adhesive bandage are placed over the site The distal part of the chest tube is connected to a chest drainage system (under a water seal)which includes an air seal, a drainage reservoir and suction capability Special Considerations: Avoid traction on the chest tube;this could dislodge the tube The chest tube drainage system shouldremain below the chest level Avoid kinking or clamping the drainage system Contact MC if any of the above complications develop, or if the patient develops shortness of breath or change in vital signs 5882 Devices Ventricular Assist Devices (VADs) Uses: Implantable external heart pump used to treat patients with debilitating heart failure May be used in patients who are not candidates for transplant as well as those awaiting Transplant FAQs: There are many types of VAD units; some have pulses (usually pulse will not be in sync with the patient's rhythm) and some are continuous flow units resulting in no pulse Complications: VAD Pump Failure: Need to initiate hand pumping at a rate of 60-90 strokes/min; may be a Bi-VAD with two pumps VAD Working- Blood Flow Low- ECG Abnormal: Usually with a single VAD device; patient's function is influenced by arrythmia- may need to treat the rhythm if patient is symptomatic LVAD (Left-sided VAD) patient may require large amounts of IV fluids RVAD (Right-sided VAD)patient should not get IV fluids VAD Working- Blood Flow Low- ECG Normal: Hypovolemia; could be internal bleeding. If sympomatic initiate appropriate therapy to treat cause of hypovolemia Procedures: If need to transport a STABLE patient... Heart monitor: ECG may not match pulse Large bore IV should be started Bring companion with patient if available who is able to hand pump the VAD if needed Bring backup equipment: Hand pumps, extra batteries, primary and backup drivers, if available Special Considerations: Need to ask patient: 1. Can I perform CPR on you? 2. IF not- is there a hand pump? 3. If the device slows down-will alarms go off for low flow state? 4. How can I speed up the device? 5. Does patient need heparin if the device slows down? 6. Can patient be defibrillated while connected to the device? 7. If can be defibrillated, do I need to disconnect anything first? 8. Does the patient usually have a pulse with the device? 9. What are acceptable vital sign parameters? 10. Can patient be externally paced? Contact Patient's Cardiac Care Team ASAP for problems and prior to transfer Unsable VAD patients should be transferred with a higher level of care 5883 Devices Tracheostomy Care Uses: Inadequate airway Respiratory Insufficiency Excessive secretions Need for prolonged mechanical ventilation Adverse Effects: Dislodgement of tracheostomy tube Obstruction of tube or stoma Malfunction of mechnical ventilator or loss of 02 supply Procedures: Suctionning: Sterile gloves Suction with 120-150mmHg (adults); 80-100mm Hg (pediatric) Hyperventilate with 100%02 Suction up to 10 seconds (adult); up to 3-4 seconds (pediatric) If mucus plugs/thick secretions-may instill 3-5cc sterile saline Bronchodilator Administration: Assemble nebulizer assembly as usual Attach trach collar to reservoir tubing Connect to oxygen source at a flow rate sufficient to produce misting Fit trach collar over stoma and have patient breathe slowly and deeply Stoma Intubation: Select largest tube able to fit in stoma without force; cuffed for adult, uncuffed for pediatric Sterile gloves Hyperventilate with 100%02 Suction, if necessary. Pass the ET tube and inflate the cuff.The tube will protrude several inches. Hold the tube and watch for chest rise with ventilation; secure the tube. Auscultate the lung fields. Check for subcutaneous emphysema. Allow no longer than 30 seconds for the procedure. Special Considerations: Avoid oral intubation if possible DO NOT USE DEMAND VALVE WITH BVM! 5884 Devices BiPap Machines Uses: Obstructive Apnea Respiratory Insufficiency Adverse Effects: Chance of Pneumothorax Mechanical failure Disconnected tubing Misfit of facial/nasal mask Drying of mouth/nasal passages Special Considerations: Usually will not involve intervention by EMS-should be pre-set If fails, may need to switch to CPAP or supplemental 02; contact MC 5885 Devices Cardiovascular Monitoring Uses: Usually used to monitor Cardiac Output Used in ICU setting with ICU monitors-not for EMS use Complications: Arterial Line Pressure Monitor: Hematomas Distal ischemia Disconnection and hemorrhage Inadvertent drug injection Swan-Ganz catheter: Arrythmias Knotting and displacement Cardiac Valve trauma Pulmonary Artery Rupture Balloon Rupture Catheter thrombosis or embolism Monitor components: Arterial Line Pressure Monitor: Arterial cannula Monitoring line Transducer Monitoring system Swan-Ganz catheter: Balloon tipped catheter through central vein;floated through right side of heart into pulmonary artery Monitoring line Transducer Monitoring System Special Considerations: Require prolonged pressure if lines are pulled out 5886 Devices Intracranial Pressure (ICP) Monitors Uses: Measurement of Intracranial Pressure in ICU setting May also be used to relieve pressure as well Adverse Effects: Infection at skin site into brain Dislodgement of catheter Special Considerations: If pulls out-Apply sterile dressing, may have CSF leaking from site 5887 Devices Insulin Pumps Uses: Computerized device delivering a steady dose of insulin (basal rate)through a flexible subcutaneous catheter Adverse Effects: Hypoglycemia can occur Dosing: Patient has a pre-set basal rate and pre-programmed corrections Special Considerations: If hypoglycemic treat as per protocol If seemingly in DKA(Diabetic Ketoacidosis), make sure the pump is working or the catheter is intact SHOULD NOT REQUIRE ANY DIRECT INTERVENTION BY TRANSPORTING CREW UNLESS PATIENT BECOMES HYPOGLYCEMIC; IN THAT SCENARIO,TURN OFF THE PUMP 5888 Devices Vascular Access Uses: Specialty vascular access in patient with problematic access or requiring frequent infusion of medication or parenteral nutrition Adverse Effects: Line infection can cause bactermia/sepsis Complications can be related to insertion of line such as pneumothorax, hematomas, vascular rupture Different Types: Triple Lumen Central Venous Catheter: Can be in Femoral, Internal Jugular or Subclavian location Usually red hub is for blood draws-it is typically the most certain line of the three ports in emergency situations Indwelling Catheter External Access(Broviac, Hickamn, Groshung) catheters: Usually placed in Subclavian region Usually contains heparin; draw 10 mL waste before infusions Implanted ports(Part-a-cath, Bard Port): Require Huber needle to access Shiley: Usually used for dialysis Usually contains heparin; draw 10 mL waste before infusions,then flush with saline if needed in emergency situations Peripherally Inserted Central Catheter(PICC) line: Location usually in the antcubital regions Usually contains heparin; draw 10 mL waste before infusions Special Considerations: STERILE TECHNIQUE is imperative! Only to be accessed in emergency situations 5889 IV. Pediatric Transfer Protocols a. Anticonvulsonts b. Continuous Albuterol Nebulization c. Insulin Drip d. IV Antibiotics Pediatric Transfers 5890 Anticonvulsants Uses: Prevention and treatment of seizures Adverse Effects: Ventricular dysrhythmias or hypotension if phenyotin given too rapidly Respiratory depression, especially with benzodiazepines or phenobarbital Subcutabeous extravasation may cause tissue necrosis Dosing: Phenytoin: 10-20 mg/kg; IV piggy back in NS Rate not to exceed 50 mg/min Fosphenytoin: 15-20 PE/kg (phenytoin Equivalents) Up to 150 PE/min Propofol: Loading dose: 3 mg/kg Maintenance infusion: 50 mcg/kg/min May increase up to 250 mcg/kg/min Special Considerations: Monitor heart rhythm Use infusion pump Check BP frequently; vital sign monitor if available D/C Infusion and contact MC for adverse reactions 5891 Pediatric Transfers Continuous Albuterol Nebulization Uses: Treatment of status epilepticus Adverse Effects: Tachycardia Nervousness, headache, shakiness Nausea/vomiting Hypokalemia Dosing: 0.5 mg/kg/hour or otherwise directed by MC Special Considerations: Need to use a special large volume nebulizer designed for continuous administration Cardiac monitor Should have IV running concurrently 5892 Pediatric Transfers Insulin Drip Uses: Lower blood glucose and treat diabetic ketoacidosis Adverse Effects: Hypoglycemia (tachycardia, diaphoresis, mental status change, seizure) Hypokalemia (occurs as acidosis improves) Dosing: 0.05-0.1 units/kg/hour; may be varied depending on glucose respnse by patient Special Considerations: Glucose must be checked every hour If hypoglycemia occurs, D/C insluin drip and administer D25 (2-4 mL/kg) 5893 Pediatric Transfers IV Antibiotics Uses: Treat infections and prophylaxis Adverse Effects: Allergic signs and symptoms, including anaphylaxis Dosing: Varies depending on antibiotic and patient weight/size Generally given as a piggyback infusion Rate should not require change en route Special Considerations: D/C infusion if allergic signs and symptoms Contact MC 5894 V. Special Situations a. The Hospice Patient b. The Pediatric Patient and Consent Issues c. The Psychiatric Patient d. The Therapeutically Cooled Patient 5895 Special Situations The Hospice Patient I. Introduction The Hospice patient presents a unique situation in regards to care and transport.These patients have often been deemed to be in the terminal stages of a disease process,for which treatment is no longer effective in reversing or arresting the progress of the disease. Care becomes focused on patient and family comfort,which often flies in the face of usual resuscitative care.What might be considered as an unstable patient might well be in line with the course as planned by the patient's caregivers. Family members are often torn between sticking with the recognized treatment plan versus emotion as they see their loved one approach their end. It is important to keep in mind that these patients do not have a situation that can be fixed. It is often up to us to gently encourage the family to adhere to the goal of patient comfort. The Hospice patient truly has needs that are not those of the usual prehospital patient and special considerations need to be made in the response of the prehospital provider. II. Assessment The assessment of the Hospice patient requires a redefinition of what is considered an "unstable"vital sign requiring action. A terminal patient might have either lower or higher parameters in temperature, heart rate, respiratory rate or blood pressure.The ABC's might also be altered.This is not unexpected. An important part of the assessment is evaluation of the DNR status. IF the patient or family do not have a copy of the DNR or MOLST form, Hospice staff is often able to fax a copy, or at least confirm the existence of the DNR status if necessary. III. Treatment In general,the only measures that should be implemented are oxygen or stretcher positioning. Narcotic administration might be in order; however, medical control should be contacted if there are questions regarding administration. Typically, Hospice patients should not receive an IV or be placed on a cardiac monitor, unless there has been direction by Hospice to do so.Their medications are usually given orally(e.g. Roxanol),transcutaneously(e.g. opioid drug patch) or subcutaneously per Hospice. Morphine may be given as per ALS Pain Protocol if this has been approved in the patient's Hospice care plan. 5896 IV. Medical Direction The Hospice patient is still under Medical Control by a Base Station medical physician. However, since these patients are in a situation that is more similar to an "Interfacility Transport", input may be made by the Hospice physician.The patient's plan of care may be confirmed with them. V. Transport If the decision is made for the patient to be transported to the Hospice Inpatient Unit either for an acute intervention or for an inpatient bed,then there are considerations to be made. The destination of the patient should be as directed by Hospice.This might include direct transport to an inpatient unit at a hospital, bypassing the Emergency Dept. The medications that the patient is on should accompany the patient to the Hospice Inpatient Unit. However, if the patient is being brought to a Hospice Unit in a hospital, family members should bring the medications (a list is adequate). In keeping with the goal of patient comfort, lights and sirens should not be used during transport. If the patient expires in the ambulance anytime during transport,the patient should be taken to the previously instructed facility. DO NOT take the patient back home. 5897 Special Situations The Pediatric Patient and Consent Issues I. Introduction Transport and treatment of a pediatric patient is met with unique issues.The pediatric patient is unable to give consent/refusal as they are a minor. Usually,the patient's parent or guardian will be available to give consent. However,there are times when either the legal guardian is not available or does not have legal ability to consent. In New York State a pediatric patient is considered a minor until the day that they reach 18 years of age. The following is a review of situations where consent might be given by someone other than the child's legal guardian. II. The Emancipated Minor New York's case law defines the status of an emancipated minor as being characterized by renunciation of parental rights. Also, a minor is considered emancipated if the following events have occurred: He or she is married. He or she is in the armed services. He or she has established a home and isfinancially independent. His or her parent has failed to fulfill parental support obligations and the minor seeks emancipation. W. The CPS patient Occasionally a child presents with a picture of abuse or negligience, and the suspected perpetrator is the legal guardian. Mandated reporters must make a report to New York State Child Protective Services (CPS). After a preliminary investigation, CPS might decide to take custody of the child.There should be documentation of the CPS custody with the patient's chart.This will allow care of the child to proceed. IV. The Guardian is Unavailable In situations where a child's guardian is unable to be reached or are incapacitated, administratvie consent might be obtained.This can be confirmed with the transferring facility. 5898 Special Situations The Psychiatric Patient I. Introduction Psychiatric patients often present to facilities where there is no ability to perform a psychiatric assessment or offer treatment for psychiatric illness. In these situations, patients need to be transported to a facility able to offer psychiatric intervention. Needless to say,these patients are often not desirous of such intervention. New York State Mental Hygiene law makes provision to allow caregivers the ability to hold a patient against their will until they are psychiatrically evaluated or treated and deemed safe for discharge with no lethality or risk of harm to self or others. However, in order to assure that a patient's rights are not violated,there exist various NYS forms which must be filled out by a physician or designated peace officer.The following is a review of what forms are required for which situation.They are required for a transporting agency to transport a patient against their will. II. Section 9.27 This form is called the Application for Involuntary Admission of Medical Certification.This form is filled out by a physician who must certify that a patient requires in-patient psychiatric admission. In order for this to be effected,there must be TWO physicians in agreement of the need for admission.Thus,there will be two physicians having signed the form accompanying the patient. III. Section 9.37 This form is titled Application for Involuntary Admission on Certificate of a Director of Community Services or Designee. This form can be filled out when a patient is transferred from a facilty with staff able to make an itial psychiatric assessment and deem that the patient requires inpatient psychiatric admission.The originating facility, however, is unable to provide inpatient treatment and has the patient transferred to a facility that is able to provide the inpatient services.This form is completed by the sending facility to apply to send the patient to the inpatient facility. IV. Section 9.55 and 9.57 This form is for Custody/Transport of a Person Alleged to be Mentally 111 to a Hospital Approved to Receive Emergency Admissions. The 9.55 portion is to be filled out by a psychiatrist directing transport of a patient to a facilty able to offer Emergency Psychiatric care.The 9.57 portion is to be filled out by an Emergency physician requesting similarly. 5899 Special Situations The Therapeutically Cooled Patient I. Introduction There has been a recent resurgence of therapeutic cooling used in patient care scenarios. These require maintenance of specific hypothermic target temperature.The current two most likely indications are those of the post cardiac arrest patient,the stroke patient and the traumatic brain or spinal cord injury patient. The theory behind therapeutic hypothermia is to decrease circulation of ischemic and injury mediators. Further, metabolism is decreased thus preventing further inflammatory response.The balance that must be maintained is to provide adequate coling to achieve the above but to avoid acidosis and damage from the hypothermia itself. Patients must be intubated and paralyzed to prevent shivering. The hypothermia is achieved by surface and internal cooling. Surface cooling is achieved with ice (applied at head, neck, axillae and groin), cooling blankets and/or heat exchang surface cooling devices. Internal cooling is achieved either by cooled fluids or by endovascular heat exchange catheters.These usually involve a femoral line placement. II. Clinical Uses of Therapeutic Hypothermia a. The Post Cardiac Arrest Patient In 2005 the American Heart Association offered guidelines regarding the use of hypothermia in unconscious patients with return of spontaneous circulation after out-of-hospital cardaic arrest. It is recommended that these patients be cooled to 32-34TC for 12-24 hours.The cooling should occur within 6 hours post cardiac arrest.They should have a systolic blood pressure of>90mm Hg. b. The Acute Stroke Patient There is evidence that hypothermia reduces the volume of infarct and may preserve brain tissue. However, a large study has yet to be done showing clear benefit. c. The Traumatic Brain Injury(TBI)Patient Mild therapeutic hypothermia has been shown to be effective in TBI with high intracranial pressure.These patients have better outcomes with longer hypothermia (5 days). d. The Traumatic Spinal Cord Injury(SCI)Patient There have not been large scale reviews or studies to demonstrate benefit of hypothermia with SCI. However, case reports suggest that there may infact be some advantage in using hypothermia to treat patients with SCI. 5900 lll. Transporting the Therapeutically Cooled Patient These patients are often critical and may require additional personnel. Not only must the cooling apparatus be kept in attention, but the patient must be carefully watched with frequent vital signs (every 10-15 minutes during transport). Consideration should be given for backup cooling alternatives should there be device failure. 5901 IV. Glossary and Abbreviations 5902 AILS Provider (Advanced Life Support Provider) Includes EMT-I, EMT-CC and EMT-P BiPAP Bi-phasic Positive Airway Pressure BP Blood Pressure BVM Bag-Valve Mask CHF Congestive Heart Failure CNS Central Nervous System COPD Chronic Obstructive Pulmonary Disease CPAP Continuous Positive Airway Pressure D/C Discontinue DKA Diabetic Ketoacidosis DNR Do Not Resuscitate EMT-D (Emergency Medical Technician-Defibrillation) An individual trained to perform patient assessment, handleemergencies using Basic Life Support equipment, perform CPR, control hemorrhage, provide non-invasive shock treatment,fracture and spinal stabilization, manage environmental emergencies, emergency childbirth and use a defibrillator. EMT-I (Emergency Medical Technician-Intermediate) An individual trained to use all EMT-D skills and utilize Basic Life Support equipment. In addition, may supply Advanced Life Support, using IV therapy and ET or other advanced airway for airway control. EMT-CC (Emergency Medical Technician-Critical Care Technician) An individual trained to perform all EMT-I skills and utilization of equipment. In addition, is trained to supply Advanced Life Support, using the EMT-I skills and equipment, and administer appropriate medications. EMT-P (Emergency Medical Technician-Paramedic) an individual trained to perform all EMT-I skills and utilization of equipment. In addition, is able to perform under Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support Standards (ATLS), is knowledgeable and competent in the use of cardiac monitor/defibrillator, IV drugs and fluids.The EMT-P has reached the highest level of pre- hospital certification. EPS (Extrapyramidal Symptoms) A variety of motor and sensory nervous system disorders related to medications or disease processes. ETA Estimated Time of Arrival ET tube Endotracheal tube 5903 FB Foreign Body GI Gastrointestinal H/O History of HR Heart rate Huber needle A needle designed to access an indwelling vascular port. It has a ninety-degree bend. IM Intramuscular IV Intravenous JVD Jugular Venous Distention KVO Keep Vein Open; usually indicates an IV rate of 20-60mL/hour Large Bore IV 14 or 16 gauge IV Loading dose Initial amount of medication required to establish a therapeutic effect LR Lactated Ringers Solution MC (Medical Control or Medical Command) 1. A physician (Medical Director or designee) responsible for the care of a patient who is being served by an EMS provider. 2. (aka Medical direction) The process of providing responsibility for the care of a patient who is being served by an EMS provider. MCO Medical Control Option Medical Director The physician who has authority and responsibility over all clinical and patient care aspects of the EMS provider.This includes reponsibility for off-line MC Methemoglobinemia a condition where the hemoglobin is altered in a way which decreases its ability to carry and release oxygen to tissues mg milligram MI Myocardial Infarction mL millileter NS Normal Saline; usually refers to 0.9 normal saline OD Overdose 5904 Off-line Medical Control Provision of care in accordance with patient care protocols developed and promulgated by physicians.This also includes training,testing, certifications, continuing education, operational policy and procedures development and continuous quality improvement. On-line Medical Control Provision of care via direct voice communication with a physician PO Orally PRN As needed PVC Premature ventricular contraction Q Every SL Sublingual SQ Subcutaneous Standing Orders Treatment algorhythms for the ALS provider to follow prior to comatcting MC Status Epilepticus Ongoing seizure activity or a series of seizures with separation of less than or equal to one hour Syst Systolic TID Three times per day VS Vital signs 5905 DocuSign Envelope ID: E154363B-3303-45B1-845A-1C705BD65B66 T February 26th,2024 Informationi Solutions, LLC To Whom It May Concern: DLT Solutions, LLC("DLT") is the legal entity with which you are doing business. DLT is a single member limited liability corporation owned by Tech Data Corporation. It is a fully disregarded entity and does not file its own tax return with the IRS.As such, and per IRS guidelines, the beneficial owner of your payment/income is Tech Data Corporation and is listed on line 1 of the W-9 accordingly along with TDC's federal employer identification number ("FEIN").Tech Data Corporation is structured as a C-Corp so no other informational reporting(i.e. 1099) or back- up withholding is required. For clarity, DLT's FEIN, 54-1599882,is not used for corporate income tax purposes. DLT's corporate income tax FEIN is pursuant to its disregarded entity status and below W-9. The undersigned certifies and represents that they are an officer or authorized representative of DLT Solutions, LLC,and that the information contained within this document is true and accurate to the best of its knowledge. Signature: lS46 PAL Staci Patel Name: Title: vice President and General counsel Date: Feb 26, 2024 5906 DocuSign Envelope ID: E154363B-3303-45B1-845A-lC705BD65B66 Form W=9 Request for Taxpayer Give Form to the (Rev.October2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ►Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. TECH DATA CORPORATION 2 Business name/disregarded entity name,if different from above DLT Solutions LLC G0 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to C following seven boxes. certain entities,not individuals;see Ca a instructions on page 3): o ❑ Individual/sole proprietor or 0 C Corporation ElS Corporation ElPartnership ElTrust/estate N single-member LLC Exempt payee code(if any) 5 ai c ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► p Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting +' to LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is de(if any) another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that co is disregarded from the owner should check the appropriate box for the tax classification of its owner. o ❑ Other(see instructions)► (applies to accounts maintained outside the U.S.) aL y5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional) a 5350 Tech Data Drive U) 6 City,state,and ZIP code Clearwater, FL 33760 7 List account number(s)here(optional) Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number backup withholding.For individuals,this is generally your social security number(S However,for a resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN, later. or Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. 5 9 - 1 5 7 8 3 2 9 Certification Under penalties of perjury,I certify that: 1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and 2.1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding;and 3.1 am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part 11,later. Sign Signature of Here U.S.person► C' Date► January 1, 2024 General Instructions • Form 1099-DIV(dividends, including those from stocks or mutual funds) Section references are to the Internal Revenue Code unless otherwise . Form 1099-MISC(various types of income, prizes,awards,or gross noted. proceeds) Future developments.For the latest information about developments • Form 1099-B(stock or mutual fund sales and certain other related to Form W-9 and its instructions,such as legislation enacted transactions by brokers) after they were published,go to www.irs.gov/FormW9. • Form 1099-S(proceeds from real estate transactions) Purpose of Form • Form 1099-K(merchant card and third party network transactions) An individual or entity(Form W-9 requester)who is required to file an • Form 1098(home mortgage interest), 1098-E(student loan interest), information return with the IRS must obtain your correct taxpayer 1098-T(tuition) identification number(TIN)which may be your social security number . Form 1099-C(canceled debt) (SSN),individual taxpayer identification number(ITIN),adoption •Form 1099-A(acquisition or abandonment of secured property) taxpayer identification number(ATIN),or employer identification number (EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident amount reportable on an information return.Examples of information alien),to provide your correct TIN. returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might •Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding, later. Cat.No.10231 X Form W-9(Rev.10-2(5907 DocuSign Envelope ID: E154363B-3303-45B1-845A-lC705BD65B66 Form W-9(Rev.10-2018) Page 2 By signing the filled-out form,you: Example.Article 20 of the U.S.-China income tax treaty allows an 1.Certify that the TIN you are giving is correct(or you are waiting for a exemption from tax for scholarship income received by a Chinese number to be issued), student temporarily present in the United States.Under U.S.law,this student will become a resident alien for tax purposes if his or her stay in 2.Certify that you are not subject to backup withholding,or the United States exceeds 5 calendar years.However,paragraph 2 of 3.Claim exemption from backup withholding if you are a U.S.exempt the first Protocol to the U.S.-China treaty(dated April 30, 1984)allows payee.If applicable,you are also certifying that as a U.S.person,your the provisions of Article 20 to continue to apply even after the Chinese allocable share of any partnership income from a U.S.trade or business student becomes a resident alien of the United States.A Chinese is not subject to the withholding tax on foreign partners'share of student who qualifies for this exception(under paragraph 2 of the first effectively connected income,and protocol)and is relying on this exception to claim an exemption from tax 4.Certify that FATCA code(s)entered on this form(if any)indicating on his or her scholarship or fellowship income would attach to Form that you are exempt from the FATCA reporting,is correct.See What is W-9 a statement that includes the information described above to FATCA reporting, later,for further information. support that exemption. Note:If you are a U.S.person and a requester gives you a form other If you are a nonresident alien or a foreign entity,give the requester the than Form W-9 to request your TIN,you must use the requester's form if appropriate completed Form W-8 or Form 8233. it is substantially similar to this Form W-9. Backup Withholding Definition of a U.S.person.For federal tax purposes,you are considered a U.S.person if you are: What is backup withholding?Persons making certain payments to you •An individual who is a U.S.citizen or U.S.resident alien; must under certain conditions withhold and pay to the IRS 24%of such payments.This is called"backup withholding." Payments that may be •A partnership,corporation,company,or association created or subject to backup withholding include interest,tax-exempt interest, organized in the United States or under the laws of the United States; dividends,broker and barter exchange transactions,rents,royalties, •An estate(other than a foreign estate);or nonemployee pay,payments made in settlement of payment card and •A domestic trust(as defined in Regulations section 301.7701-7). third party network transactions,and certain payments from fishing boat operators.Real estate transactions are not subject to backup Special rules for partnerships.Partnerships that conduct a trade or withholding. business in the United States are generally required to pay a withholding You will not be subject to backup withholding on payments you tax under section 1446 on any foreign partners'share of effectively receive if you give the requester your correct TIN,make the proper connected taxable income from such business.Further,in certain cases certifications,and report all your taxable interest and dividends on your where a Form W-9 has not been received,the rules under section 1446 tax return. require a partnership to presume that a partner is a foreign person,and pay the section 1446 withholding tax.Therefore, if you are a U.S.person Payments you receive will be subject to backup withholding if: that is a partner in a partnership conducting a trade or business in the 1.You do not furnish your TIN to the requester, United States,provide Form W-9 to the partnership to establish your 2.You do not certify your TIN when required(see the instructions for U.S.status and avoid section 1446 withholding on your share of Part II for details), partnership income. In the cases below,the following person must give Form W-9 to the 3.The IRS tells the requester that you furnished an incorrect TIN, partnership for purposes of establishing its U.S.status and avoiding 4.The IRS tells you that you are subject to backup withholding withholding on its allocable share of net income from the partnership because you did not report all your interest and dividends on your tax conducting a trade or business in the United States. return(for reportable interest and dividends only),or •In the case of a disregarded entity with a U.S.owner,the U.S.owner 5.You do not certify to the requester that you are not subject to of the disregarded entity and not the entity; backup withholding under 4 above(for reportable interest and dividend •In the case of a grantor trust with a U.S.grantor or other U.S.owner, accounts opened after 1983 only). generally,the U.S.grantor or other U.S.owner of the grantor trust and Certain payees and payments are exempt from backup withholding. not the trust;and See Exempt payee code, later,and the separate Instructions for the •In the case of a U.S.trust(other than a grantor trust),the U.S.trust Requester of Form W-9 for more information. (other than a grantor trust)and not the beneficiaries of the trust. Also see Special rules for partnerships,earlier. Foreign person.If you are a foreign person or the U.S.branch of a What is FATCA Reporting? foreign bank that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use the appropriate Form W-8 or Form 8233(see The Foreign Account Tax Compliance Act(FATCA)requires a Pub.515,Withholding of Tax on Nonresident Aliens and Foreign participating foreign financial institution to report all United States Entities). account holders that are specified United States persons.Certain Nonresident alien who becomes a resident alien.Generally,only a payees are exempt from FATCA reporting.See Exemption from FATCA nonresident alien individual may use the terms of a tax treaty to reduce reporting code, later,and the Instructions for the Requester of Form or eliminate U.S.tax on certain types of income.However,most tax W-9 for more information. treaties contain a provision known as a"saving clause." Exceptions Updating Your Information specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise You must provide updated information to any person to whom you become a U.S.resident alien for tax purposes. claimed to be an exempt payee if you are no longer an exempt payee If you are a U.S.resident alien who is relying on an exception and anticipate receiving reportable payments in the future from this contained in the saving clause of a tax treaty to claim an exemption person.For example,you may need to provide updated information if from U.S.tax on certain types of income,you must attach a statement you are a C corporation that elects to be an S corporation,or if you no to Form W-9 that specifies the following five items. longer are tax exempt.In addition,you must furnish a new Form W-9 if 1.The treaty country.Generally,this must be the same treaty under the name or TIN changes for the account;for example,if the grantor of a which you claimed exemption from tax as a nonresident alien. grantor trust dies. 2.The treaty article addressing the income. Penalties 3.The article number(or location)in the tax treaty that contains the saving clause and its exceptions. Failure to furnish TIN.If you fail to furnish your correct TIN to a 4.The type and amount of income that qualifies for the exemption requester,you are subject to a penalty of$50 for each such failure from tax. unless your failure is due to reasonable cause and not to willful neglect. 5.Sufficient facts to justify the exemption from tax under the terms of Civil penalty for false information with respect to withholding.If you the treaty article. make a false statement with no reasonable basis that results in no backup withholding,you are subject to a$500 penalty. 5908 DocuSign Envelope ID: E154363B-3303-45B1-845A-1C705BD65B66 Form W-9(Rev.10-2018) Page 3 Criminal penalty for falsifying information.Willfully falsifying IF the entity/person on line 1 is THEN check the box for... certifications or affirmations may subject you to criminal penalties a(n)... including fines and/or imprisonment. Misuse of TINS.If the requester discloses or uses TINS in violation of • Corporation Corporation federal law,the requester may be subject to civil and criminal penalties. • Individual Individual/sole proprietor or single- - Sole proprietorship,or member LLC Specific Instructions • Single-member limited liability company(LLC)owned by an Line 1 individual and disregarded for U.S. You must enter one of the following on this line;do not leave this line federal tax purposes. blank.The name should match the name on your tax return. . LLC treated as a partnership for Limited liability company and enter If this Form W-9 is for a joint account(other than an account U.S.federal tax purposes, the appropriate tax classification. maintained by a foreign financial institution(FFI)),list first,and then . LLC that has filed Form 8832 or (P=Partnership;C=C corporation; circle,the name of the person or entity whose number you entered in 2553 to be taxed as a corporation, or S=S corporation) Part I of Form W-9.If you are providing Form W-9 to an FFI to document or a joint account,each holder of the account that is a U.S.person must . LLC that is disregarded as an provide a Form W-9. entity separate from its owner but a. Individual.Generally,enter the name shown on your tax return.If the owner is another LLC that is you have changed your last name without informing the Social Security not disregarded for U.S.federal tax Administration(SSA)of the name change,enter your first name,the last purposes. name as shown on your social security card,and your new last name. Note:ITIN applicant:Enter your individual name as it was entered on • Partnership Partnership your Form W-7 application,line 1 a.This should also be the same as the • Trust/estate Trust/estate name you entered on the Form 1040/1040A/1040EZ you filed with your Line 4, Exemptions application. b. Sole proprietor or single-member LLC.Enter your individual If you are exempt from backup withholding and/or FATCA reporting, name as shown on your 1040/1040A/1040EZ on line 1.You may enter enter in the appropriate space on line 4 any code(s)that may apply to your business,trade,or"doing business as"(DBA)name on line 2. you. c. Partnership,LLC that is not a single-member LLC,C Exempt payee code. corporation,or S corporation.Enter the entity's name as shown on the • Generally, individuals(including sole proprietors)are not exempt from entity's tax return on line 1 and any business,trade,or DBA name on backup withholding. line 2. • Except as provided below,corporations are exempt from backup d. Other entities.Enter your name as shown on required U.S.federal withholding for certain payments,including interest and dividends. tax documents on line 1.This name should match the name shown on the . Corporations are not exempt from backup withholding for payments charter or other legal document creating the entity.You may enter any made in settlement of payment card or third party network transactions. business,trade,or DBA name on line 2. • Corporations are not exempt from backup withholding with respect to e. Disregarded entity.For U.S.federal tax purposes,an entity that is attorneys'fees or gross proceeds paid to attorneys,and corporations disregarded as an entity separate from its owner is treated as a that provide medical or health care services are not exempt with respect "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii).Enter to payments reportable on Form 1099-MISC. the owner's name on line 1.The name of the entity entered on line 1 should never be a disregarded entity.The name on line 1 should be the The following codes identify payees that are exempt from backup name shown on the income tax return on which the income should be withholding.Enter the appropriate code in the space in line 4. reported.For example,if a foreign LLC that is treated as a disregarded 1—An organization exempt from tax under section 501(a),any IRA,or entity for U.S.federal tax purposes has a single owner that is a U.S. a custodial account under section 403(b)(7)if the account satisfies the person,the U.S.owner's name is required to be provided on line 1.If requirements of section 401(f)(2) the direct owner of the entity is also a disregarded entity,enter the first 2—The United States or any of its agencies or instrumentalities owner that is not disregarded for federal tax purposes.Enter the disregarded entity's name on line 2, "Business name/disregarded entity 3—A state,the District of Columbia,a U.S.commonwealth or name."If the owner of the disregarded entity is a foreign person,the possession,or any of their political subdivisions or instrumentalities owner must complete an appropriate Form W-8 instead of a Form W-9. 4—A foreign government or any of its political subdivisions,agencies, This is the case even if the foreign person has a U.S.TIN. or instrumentalities Line 2 5—A corporation If you have a business name,trade name,DBA name,or disregarded 6—A dealer in securities or commodities required to register in the entity name,you may enter it on line 2. United States,the District of Columbia,or a U.S.commonwealth or possession Line 3 7—A futures commission merchant registered with the Commodity Check the appropriate box on line 3 for the U.S.federal tax Futures Trading Commission classification of the person whose name is entered on line 1.Check only 8—A real estate investment trust one box on line 3. 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bank under section 584(a) 11—A financial institution 12—A middleman known in the investment community as a nominee or custodian 13—A trust exempt from tax under section 664 or described in section 4947 5909 DocuSign Envelope ID: E154363B-3303-45B1-845A-1C705BD65B66 Form W-9(Rev.10-2018) Page 4 The following chart shows types of payments that may be exempt M—A tax exempt trust under a section 403(b)plan or section 457(g) from backup withholding.The chart applies to the exempt payees listed plan above, 1 through 13. Note:You may wish to consult with the financial institution requesting IF the payment is for... THEN the payment is exempt this form to determine whether the FATCA code and/or exempt payee for... code should be completed. Interest and dividend payments All exempt payees except Line 5 for 7 Enter your address(number,street,and apartment or suite number). Broker transactions Exempt payees 1 through 4 and 6 This is where the requester of this Form W-9 will mail your information through 11 and all C corporations. returns.If this address differs from the one the requester already has on S corporations must not enter an file,write NEW at the top.If a new address is provided,there is still a exempt payee code because they chance the old address will be used until the payor changes your are exempt only for sales of address in their records. noncovered securities acquired Line 6 prior to 2012. Barter exchange transactions and Exempt payees 1 through 4 Enter your city,state,and ZIP code. patronage dividends Part I. Taxpayer Identification Number (TIN) Payments over$600 required to be Generally,exempt payees Enter your TIN in the appropriate box.If you are a resident alien and reported and direct sales over 1 through 52 you do not have and are not eligible to get an SSN,your TIN is your IRS $5,000' individual taxpayer identification number(ITIN).Enter it in the social security number box.If you do not have an ITIN,see How to get a TIN Payments made in settlement of Exempt payees 1 through 4 below. payment card or third party network If you are a sole proprietor and you have an EIN,you may enter either transactions your SSN or EIN. 1 See Form 1099-MISC,Miscellaneous Income,and its instructions. If you are a single-member LLC that is disregarded as an entity separate from its owner,enter the owner's SSN(or EIN, if the owner has z However,the following payments made to a corporation and one).Do not enter the disregarded entity's EIN.If the LLC is classified as reportable on Form 1099-MISC are not exempt from backup a corporation or partnership,enter the entity's EIN. withholding: medical and health care payments,attorneys'fees,gross proceeds paid to an attorney reportable under section 6045(f),and Note:See What Name and Number To Give the Requester, later,for payments for services paid by a federal executive agency. further clarification of name and TIN combinations. Exemption from FATCA reporting code.The following codes identify How to get a TIN.If you do not have a TIN,apply for one immediately. payees that are exempt from reporting under FATCA.These codes To apply for an SSN,get Form SS-5,Application for a Social Security apply to persons submitting this form for accounts maintained outside Card,from your local SSA office or get this form online at of the United States by certain foreign financial institutions.Therefore,if www.SSA.gov.You may also get this form by calling 1-800-772-1213. you are only submitting this form for an account you hold in the United Use Form W-7,Application for IRS Individual Taxpayer Identification States,you may leave this field blank.Consult with the person Number,to apply for an ITIN,or Form SS-4,Application for Employer requesting this form if you are uncertain if the financial institution is Identification Number,to apply for an EIN.You can apply for an EIN subject to these requirements.A requester may indicate that a code is online by accessing the IRS website at www.irs.gov/Businesses and not required by providing you with a Form W-9 with"Not Applicable"(or clicking on Employer Identification Number(EIN)under Starting a any similar indication)written or printed on the line for a FATCA Business.Go to www.irs.gov/Forms to view,download,or print Form exemption code. W-7 and/or Form SS-4. Or,you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 A—An organization exempt from tax under section 501(a)or any business days. individual retirement plan as defined in section 7701(a)(37) If you are asked to complete Form W-9 but do not have a TIN,apply B—The United States or any of its agencies or instrumentalities for a TIN and write"Applied For"in the space for the TIN,sign and date C—A state,the District of Columbia,a U.S.commonwealth or the form,and give it to the requester.For interest and dividend possession,or any of their political subdivisions or instrumentalities payments,and certain payments made with respect to readily tradable D—A corporation the stock of which is regularly traded on one or instruments,generally you will have 60 days to get a TIN and give it to more established securities markets,as described in Regulations the requester before you are subject to backup withholding on section 1.1472-1(c)(1)(i) payments.The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until E—A corporation that is a member of the same expanded affiliated you provide your TIN to the requester. group as a corporation described in Regulations section 1.1472-1(c)(1)(i) Note:Entering "Applied For"means that you have already applied for a F—A dealer in securities,commodities,or derivative financial TIN or that you intend to apply for one soon. instruments(including notional principal contracts,futures,forwards, and options)that is registered as such under the laws of the United Caution:A disregarded U.S.entity that has a foreign owner must use States or any state the appropriate Form W-8. G—A real estate investment trust Part II. Certification H—A regulated investment company as defined in section 851 or an To establish to the withholding agent that you are a U.S.person,or entity registered at all times during the tax year under the Investment resident alien,sign Form W-9.You may be requested to sign by the Company Act of 1940 withholding agent even if item 1,4,or 5 below indicates otherwise. —A common trust fund as defined in section 584(a) For a joint account,only the person whose TIN is shown in Part I J—A bank as defined in section 581 should sign(when required).In the case of a disregarded entity,the K—A broker person identified on line 1 must sign.Exempt payees,see Exempt payee L—A trust exempt from tax under section 664 or described in section code,earlier. 4947(a)(1) Signature requirements.Complete the certification as indicated in items 1 through 5 below. 5910 DocuSign Envelope ID: E154363B-3303-45B1-845A-lC705BD65B66 Form W-9(Rev.10-2018) Page) 1.Interest,dividend,and barter exchange accounts opened For this type of account: Give name and EIN of: before 1984 and broker accounts considered active during 1983. 14.Account with the Department of The public entity You must give your correct TIN,but you do not have to sign the certification. Agriculture in the name of a public entity(such as a state or local 2.Interest,dividend,broker,and barter exchange accounts government,school district,or opened after 1983 and broker accounts considered inactive during prison)that receives agricultural 1983.You must sign the certification or backup withholding will apply.If program payments you are subject to backup withholding and you are merely providing your correct TIN to the requester,you must cross out item 2 in the 15.Grantor trust filing under the Form The trust certification before signing the form. 1041 Filing Method or the Optional 3.Real estate transactions.You must sign the certification.You may Form 1099 Filing Method 2(see cross out item 2 of the certification. Regulations section 1.671-4(b)(2)(i)(B)) 4.Other payments.You must give your correct TIN,but you do not List first and circle the name of the person whose number you furnish. have to sign the certification unless you have been notified that you If only one person on a joint account has an SSN,that person's number have previously given an incorrect TIN."Other payments"include must be furnished. payments made in the course of the requester's trade or business for 2 Circle the minor's name and furnish the minor's SSN. rents,royalties,goods(other than bills for merchandise), medical and health care services(including payments to corporations),payments to 3 You must show your individual name and you may also enter your a nonemployee for services, payments made in settlement of payment business or DBA name on the"Business name/disregarded entity" card and third party network transactions,payments to certain fishing name line.You may use either your SSN or EIN(if you have one), but the boat crew members and fishermen,and gross proceeds paid to IRS encourages you to use your SSN. attorneys(including payments to corporations). 'List first and circle the name of the trust,estate,or pension trust.(Do 5.Mortgage interest paid by you,acquisition or abandonment of not furnish the TIN of the personal representative or trustee unless the secured property,cancellation of debt,qualified tuition program legal entity itself is not designated in the account title.)Also see Special payments(under section 529),ABLE accounts(under section 529A), rules for partnerships,earlier. IRA,Coverdell ESA,Archer MSA or HSA contributions or *Note:The grantor also must provide a Form W-9 to trustee of trust. distributions,and pension distributions.You must give your correct Note:If no name is circled when more than one name is listed,the TIN,but you do not have to sign the certification. number will be considered to be that of the first name listed. What Name and Number To Give the Requester Secure Your Tax Records From Identity Theft For this type of account: Give name and SSN of: Identity theft occurs when someone uses your personal information 1.Individual The individual such as your name,SSN,or other identifying information,without your 2.Two or more individuals(joint The actual owner of the account or,if permission,to commit fraud or other crimes.An identity thief may use account)other than an account combined funds,the first individual on your SSN to get a job or may file a tax return using your SSN to receive maintained by an FFI the account' a refund. 3.Two or more U.S.persons Each holder of the account To reduce your risk: (joint account maintained by an FFI) •Protect your SSN, 4.Custodial account of a minor The minor' •Ensure your employer is protecting your SSN,and (Uniform Gift to Minors Act) •Be careful when choosing a tax preparer. 5.a.The usual revocable savings trust The grantor-trustee' If your tax records are affected by identity theft and you receive a (grantor is also trustee) notice from the IRS,respond right away to the name and phone number b.So-called trust account that is not The actual owner printed on the IRS notice or letter. a legal or valid trust under state law If your tax records are not currently affected by identity theft but you 6.Sale proprietorship or disregarded The owner3 think you are at risk due to a lost or stolen purse or wallet,questionable entity owned by an individual credit card activity or credit report,contact the IRS Identity Theft Hotline 7.Grantor trust filing under Optional The grantor' at 1-800-908-4490 or submit Form 14039. Form 1099 Filing Method 1 (see For more information,see Pub.5027,Identity Theft Information for Regulations section 1.671-4(b)(2)(i) Taxpayers. (A)) Victims of identity theft who are experiencing economic harm or a For this type of account: Give name and EIN of: systemic problem,or are seeking help in resolving tax problems that 8.Disregarded entity not owned by an The owner have not been resolved through normal channels, may be eligible for individual Taxpayer Advocate Service(TAS)assistance.You can reach TAS by s.A valid trust,estate,or pension trust Legal entity" calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059. 10.Corporation or LLC electing The corporation Protect yourself from suspicious emails or phishing schemes. corporate status on Form 8832 or Phishing is the creation and use of email and websites designed to Form 2553 mimic legitimate business emails and websites.The most common act 11.Association,club,religious, The organization is sending an email to a user falsely claiming to be an established charitable,educational,or other tax- legitimate enterprise in an attempt to scam the user into surrendering exempt organization private information that will be used for identity theft. 12.Partnership or multi-member LLC The partnership 13.A broker or registered nominee The broker or nominee 5911 DocuSign Envelope ID: E154363B-3303-45B1-845A-lC705BD65B66 Form W-9(Rev.10-2018) Page 6 The IRS does not initiate contacts with taxpayers via emails.Also,the privacy Act Notice IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers,passwords,or similar secret access Section 6109 of the Internal Revenue Code requires you to provide your information for their credit card,bank,or other financial accounts. correct TIN to persons(including federal agencies)who are required to If you receive an unsolicited email claiming to be from the IRS, file information returns with the IRS to report interest,dividends,or certain other income paid to you;mortgage interest you paid;the forward this message to phishing@irs.gov.You may also report misuse of the IRS name,logo,or other IRS property to the Treasury Inspector acquisition or abandonment d secured property;the cancellation of General for Tax Administration(fIGTA)at 1-800-366-4484.You can debt;n contributions you made to i IRA,Archer the for to The forward suspicious emails to the Federal Trade Commission at person collecting this form uses the information o the form to file spam@uce.gov or report them at www.ftc.gov/complaint.You can information returns with the IRS,reporting the above information. contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT(877-438-4338). Routine uses of this information include giving it to the Department of If you have been the victim of identity theft,see www.IdentityTheft.gov Justice for civil and criminal litigation and to cities,states,the District of and Pub.5027. Columbia,and U.S.commonwealths and possessions for use in administering their laws.The information also may be disclosed to other Visit www.irs.gov//dentityTheft to learn more about identity theft and countries under a treaty,to federal and state agencies to enforce civil how to reduce your risk. and criminal laws,or to federal law enforcement and intelligence agencies to combat terrorism.You must provide your TIN whether or not you are required to file a tax return.Under section 3406,payers must generally withhold a percentage of taxable interest,dividend,and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. 5912