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Item F09 F9 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 November 19, 2024 Agenda Item Number: F9 2023-3241 BULK ITEM: Yes DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: James K. Callahan N/A AGENDA ITEM WORDING: Approval to renew a Class A Certificate of Public Convenience and Necessity (COPCN) issued to the City of Key West, Florida, on behalf of its Fire Department (KWFD) for the operation of a Class A COPCN for Advanced Life Support transport ambulance service (including inter-facility transports on an as needed basis) for the period of December 10, 2024 through December 9, 2026. ITEM BACKGROUND: The City of Key West Fire Department(KWFD) has an existing Class A COPCN certificate that expires on December 9, 2024. In view of the foregoing, KWFD has applied to renew its Class A COPCN for the period of December 10, 2024 through December 9, 2026. Pursuant to Section 11-175, "Renewal," Monroe County Code of Ordinances, MCFR recommends renewal of the certificate without need of a formal public hearing per the Code, or additional notice to other certificate holders, since nothing has changed regarding KWFD services authorized under the previously-issued COPCN. PREVIOUS RELEVANT BOCC ACTION: On November 15, 2022, the BOCC approved (Item F.5) the renewal of a Class A COPCN to City of Key West Fire Department for the operation of an ALS transport ambulance service (specifically inter- facility) for the period December 10, 2022 through December 9, 2024. On November 17, 2020, the BOCC approved (Item G.6) the renewal of a Class A COPCN to City of Key West Fire Department for the operation of an ALS transport ambulance service (specifically inter- facility) for the period December 10, 2020 through December 9, 2022 On November 20, 2018, the BOCC approved (Item G.6) the renewal of a Class A COPCN to City of Key West Fire Department for the operation of an ALS transport ambulance service (specifically inter- facility) for the period December 10, 2018 through December 9, 2020. On November 22, 2016 the BOCC approved(Item F.32) the issuance of a Class A COPCN to City of Key West Fire Department for the operation of an ALS transport ambulance service (specifically inter- facility) for the period December 10, 2016 through December 9, 2018. 469 INSURANCE REQUIRED: Yes CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approve DOCUMENTATION: City of Key West Fire Department Class A COPCN Application_ Redacted Updated 11.0 1.2024.pdf City_of Key_West Class—A—COPCN—Renewal-12.10.2024---12.09.2026(LegaI Appd).pdf 2024 COI Key West signed exp 10 1 2025.pdf FINANCIAL IMPACT: Effective Date: 12/10/2024 Expiration Date: 12/09/2026 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, per Statutory requirements 470 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) ❑ INITIAL APPLICATION-$950.00 ■❑ RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # 22-03 1. NAME OF SERVICE City of Key West Fire Department BUSINESS MAILINGADDRESS 1600 N. Roosevelt Blvd Key West, FL, 33040 BUSINESS PHONE NUMBER 305-809-3795 EMERGENCY PHONE NUMBER 305-809-1 OOO 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) City Government DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION City of Key West 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS (Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITION/TITLE Danise Henriquez P.O. Box 1409, Key West, FL, 33041 305-809-3840 Mayor, City of Key West Todd Stoughton P.O. Box 1409, Key West, FL, 33041 305-809-3811 Manager, City of Key West Samuel Kaufman P.O. Box 1409, Key West, FL, 33041 305-809-3844 Commissioner,City of Key West Clayton Lopez P.O. Box 1409, Key West, FL, 33041 305-809-3844 Commissioner,City of Key West Mary Lou Hoover P.O. Box 1409, Key West, FL, 33041 305-849-2457 Commissioner,City of Key West Monica Haskell P.O. Box 1409, Key West, FL, 33041 305-809-3844 Commissioner,City of Key West Donald "Donie" Lee P.O. Box 1409, Key West, FL, 33041 305-809-3844 Commissioner,City of Key West Lissette Carey P.O. Box 1409, Key West, FL, 33041 305-809-3844 Commissioner,City of Key West 4. LEVEL OF CARE TO BE PROVIDED: ❑BLS or ■❑ALS IF ALS: ■❑ TRANSPORT or❑ NON TRANSPORT 5. DESCRIBE THE ZONES(S) THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): City of Key West property, including areas of north Stock Island and U.S. Naval. Properties belonging to the Naval Air Station Key West located within the Key West City Limits. Provide inter-facility transport throughout Monroe County on an as needed basis. 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION Station #3 - 1499 Kennedy Drive, Key West FL, 33040 SUB-STATION Station #1 - 1600 N. Roosevelt Blvd, Key West FL, 33040 Station #2 - 616 Simonton Street, Key West FL, 33040 Page 1 of 6 471 7. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC licenses): FREQUENCIES CALL NUMBERS #OF MOBILES #OF PORTABLES MCSO 800 MHz P-25 Rescue 1 1 2 Trunk System Rescue 2 1 2 Rescue 3 1 2 8. LIST THE NAMES AND ADDRESSES OF THREE(3)U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: NAME ADDRESS Todd Stoughton, City Manager P.O. Box 1409 Key West FL, 33041 Christina Bervaldi, Finance Director P.O. Box 1409 Key West FL, 33041 Alan Averette, Fire Chief 1600 N. Roosevelt Blvd. Key West FL, 33040 9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. 11. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. 12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. I,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN THIS APPLICATION, TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. SIGNATURE OF APPLICANT/AUTHORIZED REPRESENTATIVE NOTARY SEAL NOTARY SIGNATURE DATE Page 2 of 6 472 PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Page 3 of 6 473 PERSONNEL—EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Page 4 of 6 474 PERSONNEL DRIVERS NAME First,Middle,Last SOCIAL SECURITY# DATE OF BIRTH DRIVER LICENSE# OI �m. .,ti��„�� .. r �. . ........ ........................... .... .._. _...... ----- ------. _ ___ I DO HEREBY ATTEST,TO THE BEST OF MY KNOWLEDGE,THAT ALL OF THE ABOVE NAMED DRIVERS DO MEET ALI CHAPTER 401.281 F.S.AND CHAPTER 64E-2.012 FAC FOR AMBULANCE DRIVERS. NOTARY SEAL NOTARY SIGN (Al ve, tv, o c am"I . n ANISSA MICHELLE BALBI •:: *:Commission#HH 508368 ± 1 0�w;�°` Expims April 26,2028 M� 011, .. v 475 0 0 0 0 wa ° 0 0 0 0 0 0 ua U) U) U) U) U) U) Q Q Q Q a H Z Z Z Z Z Z z � z z z z Ho 0 0 0 0 �+ a J J J J J J J J J J a s Q Q Q Q Q Q Q Q Q Q w a H O M N M p O O O O O O W 00 00 ti M w CO I` CO M O O O M a0 X X X X X X X X X X � H c O _M o0 CO f` 00 CpCD N Wo ti O O N N N C M M Or-- W c, LO N CD LO LO LO p Lo Cfl M U 0 W 0 0 0 0 Q Q Q Q c = J Y LL LL u- M Z } 0 LML INi LOL Q LL LL LL LL LL LL 44 U d- co d- W W W Q > 44 0 0 0 0 0 � W 0 U') O dt CO T- T- m O 00 W I` M M M O O M - M O N T- d 00 Ln O CD 4 Ln W O O O O O O O O O O c c c c c c O D O O O O d O O O O O I Cj C O O o 0 0 0 O O Lo _ W 'IT M 'IT M M co > > o LL LL LL LL LL LL CD CD CD W F d' 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: November 1, 2024 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check_ dated October 18, 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 the City of Key West Fire Department. Thank you, ca4'e'- /6 1 Cara Johnson 477 The City of Key West 11VENDO ID CHIECK DATE I ERIEK Post Office Box1409 V0008308 MONROE COUNTY BOARD OF COUNTY 10/18/24 Key West,Florlda 33041 IAR4OlGE DATE PO N'UMBE OESGFIPT[gN k8 T 22-03 2024FY 10/01/24 P10243 COPCN ALS APPLICATION REN 1 475.00 i u� h TOTAL 475.00 iP i /✓✓ ✓/ The City of Key West ;,� / ✓/„ � Post O >K�-�S' er Dl4TE�/ ✓l�✓��/✓✓✓/ � r�1� IOfficeBox 1409 ' ✓✓✓/y✓✓ % A ✓,�l Key West,Florida 33041 ✓�� ✓;��/,%i� i✓' �� ✓��A z ........... i,,r,o.. i�/i it�Fn /✓l %��li�✓gyp r rri✓ui✓I� r�'' j o� PAY FOUR Hundred SEVENTY FIVE Dollars and ZERO, Cents �e� � �� / '' ✓,� VOIDIFNOT #49DW114A"'*mQwwwT �ii - ��i If i✓i i✓ �i�y J41pf✓ // it i /✓� l TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS %✓ ✓�„ �� ORDER 500 WHITEHEAD STREET ° ''�� i p% ✓� OF ° ✓f/� o✓ �° ; Y NEST, FL 33040` � wa war��, �, lri��/�%✓� iv/ H U'ited States of Atnezic.a I 478 1 V W i � , �� v ...L..ppL...N I:��p�� / ...L..`�,.,^ L...:��: II:��`pp p pl �p ...L.. p r� p p�,� p�,� :D su Offic,e �pk,,, 11u4) I'L4^y Wes I, I 33S.P4 II 1140 (3b4P��b);,,0 393b9 To: Cheri Tamborski From: Keith Hernandez Date: October 1, 2024 Reference: City of Key West Fire Dept Rate Schedule Irr Cheri, The rate schedule below is our current list of rates previously approved by the City Commission for ambulance services within the City of Key West. It is the City's desire to provide complete disclosure of all charges and fees associated with the delivery of ambulance services. As such, the City shall provide any proposed changes to this current rate schedule to the B.O.C.C. during this C.O.P.C.N. period. Base Rate for all levels of transport: II( 64 Basic Life Support Emergency $600. Advanced Life Support Emergency (Medicare ALS-1) $750. Advanced Life Support Emergency (Medicare ALS-2) $950. Mileage charge $14.50 per loaded mile. 0 Emergency stand-by charge at any incident- No charge for stand-by. 0 Non-emergency or scheduled stand-by event- If a unit is committed to the scene, the �arrrrrrrrr��' city may charge a reasonable fee. > Keith W. Hernandez Division Chief of EMS Key West Fire Department 1499 Kennedy Drive Phone (305)809-3796 khernandez2cityofkeywest-fl.gov Serving the Southernmost City fit.' rto teas 'a a aria a a vasaa as0 rasa a r tasmpe a h.tras 77 T' firenfie t. 479 KEYWEST-01 JJENNINGS FLORIDA COMMERCIAL AUTO INSURANCE THIS CARD MUST BE KEPT IN THE INSURED IDENTIFICATION CARD Public Risk Management of FL(800)749-3044 VEHICLE AND PRESENTED UPON DEMAND COMPANY: 11111 POLICY#: PRM023-010-073 DATECTIVE 10/01/2023 IN CASE OF ACCIDENT: Report all accidents to your PERSONAL INJURY PROTECTION BODILY INJURY Agent/Company as soon as possible. Obtain the BENEFITS/PROPERTY DAMAGE LIABILITY 1XI LIABLITY following information: NAMED City of Key West 1. Name and address of each driver, passenger INSURED: 13 y0 White Street ADDRESS: Key West,FL 33040 and witness. (optional) 2. Name of Insurance Company and policy number MAKE/ for each vehicle involved. YEAR: FLEET MODEL: VEHICLE ID#: MISREPRESENTATION OF INSURANCE IS A FIRST DEGREE MISDEMEANOR NOT VALID FOR MORE THAN ONE YEAR FROM EFFECTIVE DATE ACORD 51 FL(2009107) ©2007-2009 ACORD CORPORATION. All rights reserved. FLORIDA COMMERCIAL AUTO INSURANCE THIS CARD MUST BE KEPT IN THE INSURED IDENTIFICATION CARD COMPANY:Public Risk Management of FL(800)749-3044 11111 VEHICLE AND PRESENTED UPON DEMAND POLICY#: PRM023-010-073 DATECTIVE 10/01/2023 IN CASE OF ACCIDENT: Report all accidents to your F—xPERSONAL INJURY PROTECTION BODILY INJURY Agent/Company as soon as possible. Obtain the BENEFITS/PROPERTY DAMAGE LIABILITY LIABILITY following information: NAMED City of Key West 1. Name and address of each driver, passenger INSURED: 13 y0 White Street ADDRESS: Key West,FL 33040 and witness. (optional) 2. Name of Insurance Company and policy number MAKE/ for each vehicle involved. YEAR: FLEET MODEL: VEHICLE ID#: MISREPRESENTATION OF INSURANCE IS A FIRST DEGREE MISDEMEANOR NOT VALID FOR MORE THAN ONE YEAR FROM EFFECTIVE DATE ACORD 51 FL(2009107) ©2007-2009 ACORD CORPORATION. All rights reserved. FLORIDA COMMERCIAL AUTO INSURANCE THIS CARD MUST BE KEPT IN THE INSURED IDENTIFICATION CARD COMPANY:Public Risk ManagementofFL(800)749-3044 11111 VEHICLE AND PRESENTED UPON DEMAND POLICY#: PRM023-010-073 DATECTIVE 10/01/2023 IN CASE OF ACCIDENT: Report all accidents to your PERSONAL INJURY PROTECTION BODILY INJURY Agent/Company as soon as possible. Obtain the BENEFITS/PROPERTY DAMAGE LIABILITY 1XI LIABLITY following information: NAMED City of Key West 1. Name and address of each driver, passenger INSURED: 13 y0 White Street ADDRESS: Key West,FL 33040 and witness. (optional) 2. Name of Insurance Company and policy number MAKE/ for each vehicle involved. YEAR: FLEET MODEL: VEHICLE ID#: MISREPRESENTATION OF INSURANCE IS A FIRST DEGREE MISDEMEANOR NOT VALID FOR MORE THAN ONE YEAR FROM EFFECTIVE DATE ACORD 51 FL(2009107) ©2007-2009 ACORD CORPORATION. All rights reserved. FLORIDA COMMERCIAL AUTO INSURANCE THIS CARD MUST BE KEPT IN THE INSURED IDENTIFICATION CARD COMPANY:Public Risk Management of FL(800)749-3044 11111 VEHICLE AND PRESENTED UPON DEMAND POLICY#: PRM023-010-073 DATECTIVE 10/01/2023 IN CASE OF ACCIDENT: Report all accidents to your F—xPERSONAL INJURY PROTECTION BODILY INJURY Agent/Company as soon as possible. Obtain the BENEFITS/PROPERTY DAMAGE LIABILITY LIABILITY following information: NAMED City of Key West 1. Name and address of each driver, passenger INSURED: 13 y0 White Street ADDRESS: Key West,FL 33040 and witness. (optional) 2. Name of Insurance Company and policy number MAKE/ for each vehicle involved. YEAR: FLEET MODEL: VEHICLE ID#: MISREPRESENTATION OF INSURANCE IS A FIRST DEGREE MISDEMEANOR NOT VALID FOR MORE THAN ONE YEAR FROM EFFECTIVE DATE ACORD 51 FL(2009107) ©2007-2009 ACORD CORPORATION. All rights reserved. 480 DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 10/1/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jenna Jennings World Risk Management PHONE FAx 20 N. Orange Ave., A/c No Ext: 4074452414 A/C,Noy 407-445-2868 Suite 500 ADDRESS: jenna.jennings@wrmllc.com Orlando FL 32801 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Public Risk Management of FL( 11111 INSURED KEYWEST-01 INSURER B: City of Key West 1300 White Street INSURERC: Key West FL 33040 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1232055502 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD/YYY MMIDD/YYY A X COMMERCIAL GENERAL LIABILITY PRM024-011A-073 10/1/2024 10/1/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADE � OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $1,000,000 MED EXP(Any one person) $EXCLUDED PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: SELF INS.RETENTION $100,000 A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 PRM024-011A-073 10/1/2024 10/1/2025 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED A UTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X APD SELF INS.RETENTION $25,000 UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION PRM024-011A-073 10/1/2024 10/1/2025 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER SIR $325,000 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICE R/M EMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) RE:Advanced/Basic Life Support Service License With respects to the listed coverage held by the named insured,as evidence of insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN State of Florida Department of Health Emergency Medical ACCORDANCE WITH THE POLICY PROVISIONS. Services 4052 Bald Cypress Way Bin C-30 AUTHORIZED REPRESENTATIVE Tallahassee FL 32399-1738 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 481 RESOLUTION NO. 22-279 A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF KEY WEST, FLORIDA, APPROVING THE ATTACHED "MEDICAL DIRECTOR AGREEMENT" WITH DR. ANTONIO GANDIA AND DR. ALDO MANRESA FOR A THREE-YEAR TERM COMMENCING ON JANUARY 1, 2023, WITH UP TO TWO ONE-YEAR RENEWALS, PURSUANT TO SECTION 2-797 (4) (b) OF THE CODE OF ORDINANCES, BEST INTERESTS OF THE CITY; PROVIDING FOR AN EFFECTIVE DATE WHEREAS, professional services provided by Dr. Antonio Gandia, assisted by Dr. Aldo Manresa, were consistent and cost- effective in FY22, improving the standard of care inside the Key West Fire Department, and accordingly City staff recommends that exceptional circumstances exist and it is in the best interests of the City to continue to use the services of Drs. Gandia and Manresa by engaging their services for a three-year term, with the option of up to two one-year renewals upon terms and conditions in their current agreement, pursuant to Section 2-797 (4) (b) of the code of o..di.riances; and NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF KEY WEST, FLORIDA, AS FOLLOWS: Sectionmm1 : That the attached "Medical Director Agreement" with Dr. Antonio Gandia and Dr. Aldo Manresa, for a term of three years, plus up to two one-year renewals is hereby approved in an amount of $48, 000. 00 per year, pursuant to Section 2-797 (4) (b) of the code of ordinances, best interests of the City. Page 1 of 2 482 Section 2 : That funds for medical director services are budged in EMS/Contractual Services Account 001-2601-526-3400, and any necessary budget transfers or adjustments are hereby authorized. Section 3 : That this Resolution shall go into effect immediately upon its passage and adoption and authentication by the signature of the Presiding Officer and the Clerk of the Commission. Passed and adopted by the City Commission at a meeting held this 6th day of December 2022 . m w�........_.. Authenticated by the Presiding Officer and Clerk of the Commission on day of 2022 . Yw�7t December............. . Filed with the Clerk on December?. 2022. .... �,...........�....... �.. .......................— Mayor Teri Johnston Yes Commissioner Lissette Carey Yes Commissioner Mary Lou Hoover Yes Commissioner Sam Kaufman Yes Commissioner Clayton Lopez Yes Commissioner Billy Wardlow Yes Commissioner Jimmy Weekley Yes AT� r �.�,.: TE� oI JOHIN I'l,. �, MAYOR C} '"" "r�.a SMI�TH, CITY CLERK Page 2 of 2 483 Medical Director A reemen AGREEMENT THIS AGREEMENT entered this Day of December 2022, by and between the CITY OF KEY WEST, a Municipal Corporation organized and existing under the laws of the State of Florida(hereinafter referred to as CITY), and Antonio Gandia,M.D,whose address is 9593 Tavernier Drive Boca Raton,FL 33496,and Aldo Manresa D.O.,whose address is 5023 NW 114t'Ct Doral, Florida 33178 (hereinafter referred to as MEDICAL DIRECTOR). This agreement will remain in effect for a period of(3) years unless modified or terminated by either party. The City shall have two (2) one year renewal options upon the same terms and conditions contained in this agreement.This agreement shall be effective on the date of execution of the last party to sign the AGREEMENT and commence on January 1, 2023. ARTICLE I SCOPE OF SERVICES MEDICAL DIRECTOR shall provide the following services: 1)Full-time medical direction by a competent,Florida,board-certified, licensed physician,either MEDICAL DIRECTOR or designate,will be on call and available 24-hours a day for the CITY to answer questions within the scope of this agreement. 2)MEDICAL DIRECTOR shall be responsible for any certifications, advice, or participation of his designate as if MEDICAL DIRECTOR were directly performing the service. 3)Protocol Development-protocols will be developed and revised as needed. MEDICAL DIRECTOR will review and approve the training of emergency medical technicians and paramedics who will function under the MEDICAL DIRECTOR's direction. 4) Quarterly Meetings - in concert with the Fire Chief and his staff,the MEDICAL DIRECTOR will establish quarterly meetings for the purpose of education and quality review. 5)Record Keeping-necessary continuing medical education records will be kept by the CITY OF KEY WEST FIRE DEPARTMENT, EMS Division, along with documentation of meeting attendance. Additionally,the MEDICAL DIRECTOR will assist in license recertification. 6) Quality Assurance -MEDICAL DIRECTOR will establish a Continuous Quality Assurance program and committee for the purpose of developing a process that will include the establishment of a methodology for quality improvement. 7)Provide all services as are specifically contained in Section 64E-2 of the Florida Administrative Code, as amended. 484 8) Shall approve any new equipment and see to that.proper training is provided to all personnel on its use prior to any use in the field. An addendurn shall b(.,-made to the protocols if this piece of equipmentis not already included in the protocols and shall be signed by, the MEDICAL DIRT�.�UrOR 9) Shall maintain a valid DEA license for the purpose of storing and administering narcotic medications for the City,of Key, West Fire Department. 1.0) Shall provide a rnethod of administering or approving a Continuous.11ducation Program flor the purposeof training and recertification of all personnel. 11) Shall attend quarterly EMS meetings to discuss arty,emergency medical services activities and to implement new policies and procedures when necessary. The Medical.Director shall be the chair of these meetings. 12) 1131 Ihall provide as process a.nd mechanism for the rq ertiflcation of ACLS, B1..,S/(..`PR, PALS, and any other certification that the Medical Director requires. 13) Shall be available to handle any, Infectious Control situations that should arise during daily' activities., The Medical Director or Designee will educate the crew on the proper handling of these situations. 711is shall be in conjunction with the policies and procedures of the CITY 01117 KEY WEST FIRE DEPARTMEN'r, 14) Shall assist in managing any CriticaP. Iricident Stress Debriefing that may be needed and work f,losely with the CISD team to assii.,ire the safety and wellbeing oath personnel.. 15) Shall rennet with the Fire Chief orDesignee on as monthly basis to update him on the status of the erriiiergency rnedical service being provided by, the CITY OF KEY WEST'FIRE DEPARTMEN"I". 16) Shal I create and maintain a.valid.11111orida Shots account with the City of Key West Fire Department as as provider. ARTICLE 11 The C117Y agrees to the fol[owing: 1.) The (,ITY OF KEY WEST FIRE DEPARTM 1[:,1NT witil provide administrative haison through th Fi e re Chief to MEDICAL 1)111-11[?CTOR through.the direction of[its 1:�'ire Chief and will cooperate to the greatest possible extent in the delivery of cornpetent ernerA.!ency medical care,, including implementation of the policies set by MEDICA1.,DIRECTOR. 2) To pay MEDICAL D1REc,-r0R as follows: The surn of$4,tyPJu0.00 per month commencing on January 1, 2023, for the services provided pursiaant to this agreement, and such Paayrinents shall be made with forty five(45)days following the receipt of MEDICAL UIRECTOR's invoice lor such services rendered. For each incomplete rnonthly service,payment shall be prorated accordingly,based on the number of days of service,, 485 ARTICLE III 1)CITY agrees to provide adequate liability insurance coverage for its employees while under the training and supervision of MEDICAL DIRECTOR. 2)MEDICAL DIRECTOR covenants and agrees to indemnify and hold CITY and any of its employees harmless from any liabilities and allegations arising out of this agreement if such liability shall be a result of any acts or omissions on the part of MEDICAL DIRECTOR. MEDICAL DIRECTOR shall maintain a maximum liability insurance coverage of $1,000,000/$3,000,000 for the term of the contract. ARTICLE IV 1) It is understood and agreed by the parties hereto that should it be determined that any participant in the EMT/paramedic training program,as set forth herein, does not have the requisite skills to continue in such training or to perform services as an EMT or paramedic,MEDICAL DIRECTOR shall immediately notify the CITY in writing of the name of such employee and the reason for belief of such participant's lack of skills to serve as an EMT or paramedic. Within forty-five (45)days after receipt of MEDICAL DIRECTOR's notice as to training,the CITY shall determine whether the participant may continue in such training. However, should the CITY fail to notify MEDICAL DIRECTOR within forty-five(45)days as to the participant's termination from such training, or should the CITY allow the participant to continue such training, CITY agrees that MEDICAL DIRECTOR shall not be liable for any injuries directly resulting from the acts of the said participant and MEDICAL DIRECTOR shall be held harmless as set forth in Article III above. In no event shall an EMT or paramedic who has been cited by MEDICAL DIRECTOR as lacking the adequate skills required of the said profession be permitted to service and ride as an EMT or paramedic unless the person is deemed qualified as determined in the sole discretion of MEDICAL DIRECTOR. The parties hereto acknowledge that all EMS and paramedics are performing duties under the license of MEDICAL DIRECTOR. ARTICLE V Either party shall have the right to terminate this agreement upon giving thirty (30)days' written notice to the other party. 2) The CITY shall have the right to terminate this agreement upon written notice upon the following: a) That MEDICAL DIRECTOR has failed to comply with the terms of this agreement. b) That MEDICAL DIRECTOR has failed to provide competent services as medical director. c)That MEDICAL DIRECTOR is unable to perform services as provided for herein for some reason not attributable to the CITY. 486 3) That services delivered by the ("ITY changes substantially to the extent that the services of a medical director are no longer required. Should the CITY terminate this agreement for any of the above reasons, CITY agrees to pay MEDICAL, DIRECTOR for all services rendered to to the firne of tennination. Such payments shall be made ten (.H))days after the termination of this agreement, provided that all property behmging to CITY shall be retumed prior to the release of monies owed to MEDICAL, DIRE(.170R.. ARTICLE VI 1) This Agreement incorporates and includes all prior negotiations,corresi.)ondence, conversions,agreements, or understandings applicable to the matters contained herein and the parties agree that there are not commitments, agreements, or understandings concerning the sulject matter of this agreement that are not cantained in this document. Accordingly, it is agreed that no deviation from the tennis hereof shall be predicated upon any prior representations or agreements, whether oral or written. 2) It is further agreed that no modifications, amendments,or alterations in the terms or conditions contained herein shall Ibe efiective runless contained in a written docurnent executed with the same formality and of equal dignity herewith. INT WFINESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above'written. THE CITY OF KEY WEST By: P*oAA puelt�J`ft, City Manager V Attest Ar lerk 487 - Dated this `� day of ��.LQYYI�J .2022 e,„ v By: � Dr.Antonio �Gkn—�fS,i uis . dI ay of e 2022 Manresa, DO Dated this 1 � day ofi]rd ,2022 488 ABREU, FRANK EMT-P PMD532633 ANDERSON, MICHAEL EMT-P PMD532768 ANSON ,TIM EMT-P PMD519511 ARENCIBIA, BLAKE EMT-B EMT578600 AVERETTE,ALAN EMT-P PMD502291 BARBA,CARLOS EMT-P PMD515113 BARBER, RIELY EMT-P PMD529644 BARROSO ,GREG EMT-B EMT80693 BARROSO ,1ASON EMT-B EMT88454 BELLINGHAM,THOMAS EMT-P PMD532853 BERGER, DERECK EMT-P PMD532607 BISHOP, BRENT EMT-B EMT584333 BIXLER, ISAAC EMT-P PMD525843 BLANCO, BRANDON EMT-B EMT548902 BOAN,JAM IE EMT-B EMT581984 BOGOEFF,JASON EMT-P PMD523492 BOUCHARD,THOMAS EMT-B EMT516809 BRINGLE,GREG EMT-B EMT22205 BROGLI,JUDE EMT-P PMD528169 BUTLER,COLTON K EMT-B EMT307364 CATENA,JONATHAN EMT-B EMT307779 CECILIO, BRANDI EMT-B EMT580596 CERVANTES,TYRONE EMT-B EMT85206 CLINE,SHAWN EMT-B EMT545188 COLL,ARIEL EMT-P PMD513622 DONATE,LOSE EMT-P PMD541537 FERNANDEZ,AARON EMT-P PMD543526 FRANCO, RAUL EMT-B EMT505500 FRANCO, ROBERT EMT-P PMD205393 FUNDORA, MIKAELLE EMT-B EMT585661 GARCIA, HENRIQUE EMT-B EMT577284 GEREZ,GREG EMT-B EMT76153 GOMEZ, RICHARD EMT-P PMD522218 GONZALEZ, DAVID EMT-B EMT582313 GUIEB,ANDRE EMT-P PMD532804 GUIEB,ANGELO EMT-B EMT564500 GURNICZ,STEPHEN EMT-P PMD528281 HAMEL, REINHART EMT-P PMD543537 HARRIS,ANDY EMT-P PMD515372 HERNANDEZ, KEITH EMT-P PMD525105 HERNANDEZ, KEVIN EMT-B EMT556356 HUGHES,CARSON EMT-B EMT580878 HUGHES,JOEY EMT-P PMD205795 ZONES,STEPHEN EMT-B EMT582124 489 10NES,TODD EMT-P PMD531865 10NES,TYLER EMT-B EMT553363 10NES,WESLEY EMT-P PMD518354 KIMBLER,AUSTIN EMT-B EMT558468 KLOTHAKIS,1ASON EMT-B EMT515355 KOCIS, BRANDON EMT-B EMT520215 LAROSA, BRITTANY EMT-B EMT573044 LOWE, BENJAMIN EMT-B EMT515496 MALONE, KYLE EMT-P PMD531866 MALOTT,JOHN PETER EMT-B EMT562480 MALTESE,ANGELINA EMT-B EMT520864 MATAS, HILARY EMT-P PMD527300 MEANS,JASON EMT-B EMT82448 MEANS,TODD EMT-B EMT548521 MERA,IORDAIN EMT-P PMD517225 MICHEL,JOHN EMT-B EMT557202 MILLER, DARREN EMT-B EMT563944 MONAHAN, RANDY EMT-P PMD532433 MONSALVATGE,STEVEN EMT-P PMD533244 MORALES, DANIEL EMT-P PMD533497 MOSBLECH,WILLIAM EMT-B EMT567921 NELLER, LOGAN EMT-B EMT568855 PARKA, DANIEL EMT-B EMT563989 PELLICIER,SCOTT EMT-B EMT73981 PELLICIER, LOGAN EMT-B EMT581473 PEREZ, EDWARD M EMT-P PMD507572 PEREZ,ANDREW EMT-P PMD531864 PERRY,1AKE EMT-B EMT70631 PERRY, KENNAN EMT-B EMT567985 PICHARDO,LOSE EMT-B EMT509099 RATCLIFF, FRANK EMT-B EMT561430 RODRIGUEZ, KOREY EMT-P PMD532619 RODRIGUEZ, MEGAN EMT-P PMD532686 ROGERS,LAMES EMT-P PMD535286 ROSE, BRIAN EMT-P PMD521924 RUBLE, BOBBY EMT-B EMT558649 SAUNDERS,CHRIS EMT-B EMT74014 SELLERS, KEITH EMT-B EMT76645 SELLERS, MARK EMT-B EMT62428 SELLERS, MARK L. EMT-B EMT576426 SMITH,TERRANCE EMT-B EMT578475 STEHLY,IERAMY EMT-B EMT563193 TEMPLE,SIERRA EMT-B EMT582170 TORRES,JOHN EMT-P PMD518522 490 VARELA, FREDDY EMT-B EMT55955 WAGNER, KARL M EMT-B EMT531497 WALKER,JACK EMT-B EMT510238 WARD, BRANDON EMT-B EMT304563 WILLIAMS, KYLE G EMT-B EMT518288 WRIGHT, DENNIS EMT-B EMT580861 ZARATE, DAVID L EMT-B EMT88441 491 wmom uoin Ri THE CITY OF KEY WEST Post Office Box 1409 Key West, FL 33041-1409 '(305)80973939 _ October 1, 2024 To Whom it May Concern, I, Dr. Antonio Gandia, approve of the attached City of Key West Fire Department's Standing Orders and Protocols. Than�k(ou, i - ntonio Gandia, MD,FACEP Key West Fire Department ' 1499 Kennedy Drive Key West, Florida 33040 � Office: 305-809-3795 Serving the Southernmost City tP l ` Uric o r iulM� nEy to the Caribbean average yearly teuiperature 77 ° 'i'alinwheit 492 ( '.unr iyWY)I _gym qq 1 p �i; mmmmmmmm: 493 494 Table of Contents y • ------------------------------ • • B IME MEMO • MEN Mill • IN • o Back to Table of Contents Table of Contents 3 495 ww Table of Contents TableBack to of Contents Table of Contents 4 496 Table of Contents010 m Back to Table of Contents Table of Contents 5 497 Table of Contents ARE Do, TableBack to of Contents Table of Contents 6 498 499 Editors & Contributors CIH Ewe. OF EMS Division Chief Keith Hernandez EwDIIC ,. DIRECTOR Dr. Antonio Gandia MD FACEP NREMT Dr. Aldo Manresa DO EDITORS • Bill McGrath; North Lauderdale Fire Rescue; Battalion Chief of EMS • Dr. Antonio Gandia MD FACEP NREMT Special Recognition: A special thank you to Dr. Ken Scheppke of Palm Beach County Fire Rescue and Dr. Jim Roach of Broward Sheriff Fire Rescue and their staff for permission to utilize their protocol template and publishment of protocols. 500 �W Medical Director E Dt? The following Emergency Medical Services Protocols are the Official Advanced and Basic Life Support Protocols for the City of Key West Fire Department and are approved for such use by Paramedics and EMTs of the department to care for the sick and injured. Only those Paramedics and EMTs approved by the Medical Director shall be authorized to utilize these protocols. These medical treatment protocols have been developed as a part of the medical direction program for participating Emergency Medical Services(EMS)agencies. The medical director of an individual EMS provider may choose to modify certain treatment recommendations. In addition, some patients may require therapy not specified in these protocols. The treatment protocols should not be construed as prohibiting such flexibility. The paramedic/EMT must use his/her judgment in administering treatment. When the paramedic/EMT is unable to make contact with other forms of medical direction, he/she may contact the receiving hospital for consultation with the emergency department physician. It is recommended that the paramedic/EMT make contact with the physician for consultation on complicated patients whenever possible. When the paramedic is unable to make contact with a physician for medical direction, the paramedic may administer BLS treatment according to his/her judgment. In this instance, the paramedic may administer ALS treatment only as authorized in the treatment protocols. 501 Disclaimer and Description ueti.Wmx+1 uuuuuuuuuuuumuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu K�/%�ul. All adult protocols in this document will be listed with this icon before any in- structions. In addition, the adult portion of the protocol will have a red outline. All pediatric protocols in this document will be listed with this icon before any instructions. In addition, the pediatric portion of the protocol will have a blue outline. 502 503 @I ME I w� r I r Back to Table o Contents Standing Orders 1504 General Information �IIa SIRE b , ADULT& PEDIATRIC MEDICATION ADMINISTRATION • Prior to administering any medication,inquire about medication allergies or adverse reactions to medications • A true allergy to a medication causes a rash,SOB, swelling of the tongue,face and/or throat I T A SSE US SITES • An 10 should be placed for patients with emergency medical conditions that require urgent vascular access in whom an IV is not immediately obtainable or is deemed to have insufficient access • Adult: • Proximal Humerus • Proximal Tibia • Distal Tibia • Pediatric: • Distal Femur • Proximal Tibia * Preferred • Distal Tibia • Proximal Humerus(only if the surgical neck can be palpated) IM INJECTIONS • All IM injections shall be administered in the lateral thigh or Deltoid • Adults: • 21-23 gauge 1.5 inch needle • 4mL maximum per site • Pediatric: • 23 gauge 1 inch needle • 1mL maximum per site • If> 1mL needs to be administered,split the dose between both thighs UC SAL ATOMIZATION DEVICE( A ) • The following medications can be administered via the MAD: • Versed • Ketamine • Narcan • Glucagon • Ativan • Desired dose: • 0.3mL-0.5mL per nostril • Max 1mL per nostril TableBack to is Genera/Information 1505 II WI,µ4� YY . YT II General Information continued.... PEDIATRIC • Patients who have not reached puberty are considered pediatric patients and shall be treated under the pediatric guideline section of these protocols • Patients who have reached puberty shall be treated as an adult • 10 is the preferred method of vascular access during pediatric cardiac arrest T " A TVY" SYSTEM • The "Handtevy"system shall be utilized in the resuscitation and treatment of all pediatric patients • The child's age should be used as the primary reference point for determining the appropriate patient ca re • If the child appears shorter or taller than stated age or if the age is unknown use the "Handtevy" system length based tape • Refer to the "Handtevy"system for the following: • Medication Dosages/Infusions • Equipment • Electrical Therapy • Vital Signs PEDIATRIC AGE CLASSIFICATIONS • Newborn: • Birth to 24 hours • Neonates: • 1 Day to 1 month • Infants: • 1 month to 1 year • Children: • 1 year to puberty Pediatric patients for medical transport will be considered 17 years and 364 days old Pediatric patients for trauma transport will be considered 15 years and 364 days old PUBERTY • Female puberty is defined as breast development. • Male puberty is defined as underarm,chest or facial hair. • Once a child reaches puberty, use the adult guidelines for treatment. Back to Table is Genera/Informationjdffl 506 m Patient Assessment µ_ ADULT& PEDIATRIC Patient with Altered Mental Status consider: TAL STATUS JAV Ua AEIOU-TIPS • Alert: to person, place,time, and event (AAOX4) • Alcohol • Verbal: responds only to verbal stimuli Epilepsy(Seizures) • )ain: responds only to painful stimuli • insulin (Hype r-/Hypoglycemia) • Unresponsive 0 Overdose/Oxygenation • Uremia (Kidney Failure) VITAL SIGNS • Pulse (rate, rhythm and quality) • Trauma • Respirations(rate and quality) • infection (Sepsis) • Skin (color, condition) • Psychiatric • Temperature • Stroke/'Shock • Pulse Oximetry • Blood Pressure (capillary refill) • EtCO2 • BGL • Pain Scale (1-10 scale or Wong Baker Scale) • ALL patients shall receive at least 2 sets of vitals • Unstable patients shall receive vitals every 5 minutes • A manual Blood Pressure shall be taken to confirm any abnormal or significant changes of an automatic Blood Pressure cuff reading • Blood Pressure shall be checked before and after administration of a drug • Hypotension for adults is defined as Systolic BP <90 mm Hg ETC 2 • Shall be utilized for the following patients: • Patients requiring ventilatory support(e.g., BVM, ET tube,SGA, CPAP) • Patients in respiratory distress • Patients with Altered Mental Status • Patients who have been sedated • Patients who have received pain medication • Seizure patients GLUCOSE • A BGL shall be documented for patients with any of the following: • History of diabetes • Altered mental status • General weakness • Seizure • Syncope/lightheadedness • Dizziness • Poisoning • Stroke • Cardiac arrest Back to Table is Patient Assessment 1507 f�111Patient Assessmentcontinued... Z, ADULT& PEDIATRIC ECG MONITORING • All ALS patients shall be continuously monitored in lead II • 12 lead/15 lead ECG shall be performed on the following patients: • Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort • Palpitations • Syncope, lightheadedness,general weakness, or fatigue • CHF, SOB, hypertension or hypotension • Unexplained diaphoresis or nausea • 12 lead ECGs shall be repeated every 10 minutes and upon ROSC • When transporting, leave cables connected until patient is turned over to the Emergency Department(ED) staff PATIENT HISTORY • CHIEF COMPLAINT: Why did the person call 911? • S.A.M.P.L.E. HISTORY(S.A.IIILIII'),IL..III':w;) • SIGNS&SYMPTOMS • ALLERGIES • MEDICATIONS: Prescribed, over the counter,or not prescribed to patient • )AST MEDICAL HISTORY(patient's and immediate family's) • lLAST ORAL INTAKE • 'EVENTS PRECEDING • HISTORY OF THE PRESENT ILLNESS (f;'),III').("),.III' S`IIII""A) • t;)NSET: Did the symptoms appear gradually or suddenly? • )ALLIATIVE: What makes the symptoms better? • )ROVOKE: What makes the symptoms worse? • )REVIOUS: Previous similar episodes? • t'),UALITY: (What kind of pain?) pressure, squeezing,aching,dull,etc. • I1ADIATION: Does the pain or discomfort radiate?Where? • SEVERITY OF PAIN: 1-10 scale (utilize "Faces" pain scale for pediatrics) • II IME: What time did the symptoms begin? • ASSOCIATED: What are the associated signs &symptoms? Back to Table of Contents Patient Assessment 1F508 0""_ n Patient Assessment continued.... Determination of Death Person should be considered dead/non-salvageable that have all of the following presumptive signs of death and one conclusive sign of death. F)resur tuiv�. • Apneic • )ulseless • fixed III')Hated III')uisils Conclusive • Decomposition • Rigor mortis • Liver mortis(Lividity) • Injuries incompatible with life • Patients with suspected hypothermia, barbiturate overdose,or electrocution require full ALS resuscitation un- less they have injuries incompatible with life or tissue decomposition • Children are excluded from this protocol unless EMS personnel make contact with medical direction for consul- tation. Only in cases of obvious, prolonged death should CPR not be started or discontinued on infants,chil- dren or young adults,or in cases in which an unexpected death has occurred. TableBack to of Contents Patient Assessment 1509 Basic Life Support E BEV , N%.0� ADULT& PEDIATRIC AIRWAY AMWAY POSH10UNG • Medical patient: • Position patient with external auditory meatus(a.k.a. "The Earhole")on the same external plane as the sternal notch • Trauma patient with suspected spinal cord injury: • Modified jaw thrust NAS4::dPI_IlARYNGEAL.AMWAY (NPA): • Semi-conscious patients with an intact gag reflex shall have a nasopharyngeal airway inserted, unless contraindicated OROPI_IIARYNGEAL AMWAY)0PA): • Unresponsive patients without a gag reflex shall have an oropharyngeal airway inserted,unless contraindicated OXYGEN ADMINISTRATION • f"' Il fV' III""withhold Oxygen if the patient is dyspneic or hypoxic • Maintain SP02 at least 94%for: • All patients • Exception: COPD &Asthma • Maintain SPOzof 90%for: • COPD &Asthma • 15 LPM via NRB regardless of SP02 • All 3rd trimester pregnancy trauma patients • Decompression sickness • Carbon Monoxide exposure • Cyanide exposure • If oxygen saturation cannot be maintained,ventilatory support should be provided CIRCULATION • Adult: • Carotid and radial pulse present,assess capillary refill, assess skin color, condition and temperature • Refer to the "Cardiac Arrest"algorithm,for all patients found pulseless • Pediatric: • Carotid and radial pulse present (brachial in infants),assess capillary refill,assess skin color, condition and temperature • Refer to the "Cardiac Arrest"algorithm,for all patients found pulseless • Refer to the "Bradycardia" protocol,for pediatric patients found bradycardic with signs of poor perfusion and AMS Back to Table of Contents Basic Life Support 1F510 Ventilatory Assistance INFORMATION • In certain patients,excessive ventilation rates may be harmful. • Overzealous positive pressure ventilation can impair: • Venous return • Cardiac output • Cerebral perfusion • Ultimately the patients SP02 and EtCO2 should determine the ventilation rate for the patient(ideally EtCO2 should be 35-45 mm Hg). ADULT VENTILATORY RATES • 1 breath every 6 seconds • 1 breath every 10 seconds • PATIENTS WIT1-11 1CP andlor FIIERNIATIOU • Maintain EtCO2 between 30-35 mm Hg and SP02> 90%while continuously monitoring BP PEDIATRIC VENTILATORY RATES • 1 breath every 2-3 seconds • 1 breath every 2-3 seconds 11EUTS OCF'li ICP aind/oir FIIERUIATUN • Maintain EtCO2 between 30-35 mm Hg and SP02> 90%while continuously monitoring BP O11'U1S III I1SO 11"�0 IIV0III'0""III""Ti' III III')"III"" "III""0 OOOII�II;ISIIIVII III C IISO11'�"111OO111 IIISl1i1 CO111)11'5O111M11 III"ll'%: "'III""COS ll�ll ll':�IIIII �S III II III 111;1 11:0111..111..OW I 1 VG I I RA I I I""111111111 I1 S""I I I""S: • Cardiac arrest pre/post ROSC • Bronchospasm(i.e., asthma,COPD) • High EtCO2 levels are acceptable and even desired in these patients Back to Table of Contents VendlatoryA ssistance 1511 Adult Transport Destinations K � w INFORMATION Priority 1e • Patients in Cardiac or Respiratory Arrest riority 2m • Unstable patients with immediate life-threatening conditions Priority 3m • Stable patients with no immediate life-threatening conditions All'wll' III II' A Placing patients in the prone position is contraindicated due to the risks of asphyxiation. However,impalement or other situations may mandate the prone position. In these instances, clear documentation of justification and attention to airway maintenance is mandatory. o ADULT PRIORITY 1 PATIENTS • CAwwMA /wwESi M/l\J'(.) Y ARREST: • Transport to the closest ED PRIORITY 2 PATIENTS • Shall be transported to the closest ED I'FwAa.JlIMA A..w F"l' PAI'IENI'S: • Shall be transported to the closest Trauma Center per catchment area. If on bypass,transport patient to the next closest Trauma Center • On-scene times for Trauma Alert patients should be< 10 minutes. On-scene times> 10 minutes shall have the reason for the delay documented in the ePCR report. • If ground transport is> 20 minutes transport by air if available • Trauma patients who arrest in the presence of Fire Rescue personnel,shall be transported to the closest Trauma Center. PwwEGI'`+VAI'` T TRAa.YMA ALERTS (viisflbk ly oir Ik y lhiistoiry of itie�tat oin > 20 weeks): • Pregnant patients meeting Trauma Alert criteria should be transported to closest OB Trauma Facility Back to Table of Contents Adult Transport Destinations 2V512 �,001 II -0."'lf Adult Transport Destinations continued... r rPRIORITY 2 PATIENTS CONTINUED • Shall be transported to the closest ED • Patient presentations that are indicative of myocardial ischemia that III': ("°) II t)° III"" meet "STEMI Alert Criteria"should still be transported to the closest ED STROKE ALERTS: All Stroke Alerts shall be transported to the closest ED SEPS6 ALERT: All Sepsis Alerts shall be transported to closest ED I-YPERBAMC CHAMBER )iif irneeded) Slipou..aiIId Ikee transported to the c:IIosest ED Exa irn rfl c.s i in c h..ai d e (N o ire...t ira..ai irn a d c:) • Decompression Sickness • Carbon Monoxide Exposure • Hydrogen Sulfide Exposure • Cyanide Exposure • transport by air if available IUD"I.JBATED INN'EFwFAC:I..Il'Y 'FwA VSFEFF S: • Should be both paralyzed and sedated by the sending facility • If the sending facility physician refuses to administer paralytics: Follow the Advanced Airway protocol PRIORITY 3 PATIENTS • OBSTE"I"FKAL • Obstetrical (OB) patients are defined as gestation > 20 weeks • Unstable OB patients should be transported to the closest OB ED • Post-Partum up to 2 weeks • BAKER ACT PA11ENTS: Baker Act patients shall be transported to the closest appropriate ED for medical clearance TableBack to of Adult Transport Destinations 2 513 m w Pediatric Transport Destinations E Dt? PEDIATRIC PRIORITY 1 PATIENTS • Pediatric patients who have regained a ROSC • Pediatric respiratory arrest cases that have successful airway management (i.e.,good compliance with the BVM and airway adjuncts, positive EtCOZ waveform, improving pulse oxi metry) • Pulseless pediatric patients • Pediatric respiratory arrest patients who have an unstable airway(i.e., unable to ventilate or oxygenate) PRIORITY 2 PATIENTS • TRAUMA ALERT PAIIENTS: • Shall be transported to the closest ED • On-scene times for Trauma Alert patients should be< 10 minutes. On-scene times> 10 minutes shall have the reason for the delay documented in the ePCR report. • Trauma patients who arrest in the presence of Fire Rescue personnel,shall be transported to the closest ED • STROKE AL.ERTS/C/l\F �': /�\ ALERT: • All Stroke Alerts or Cardiac Alerts shall be transported to the closest ED • All Sepsis Alerts shall be transported to closest ED • I-YPERBAMI CHAMBER BER )iif irneeded) Sli4I II Ikee transported to the c:IIosest ED • Exairnr Iles iirnc:11u..aide )Noire titau..aiirnadc:) • Decompression Sickness • Carbon Monoxide Exposure • Hydrogen Sulfide Exposure • Cyanide Exposure PRIORITY ATIE TS • Should be transported to the closest appropriate pediatric ED. TableBack to of Contents Pediatric Transport Destinations 2 51 4 W, �^ Helicopter Transport Criteria . ADULT &PEDIATRIC S HELICOPTER OPERATIONAL CRITERIA: • Mass Casualty Incidents(MCI) involving multiple patients with traumatic injuries HELICOPTER A USE • For patients weighing 350lbs-500lbs,discretion should be used as to whether air transport is the preferred method of transport • The flight crew must be capable of loading,unloading,and treating the patient within the confines of the aircraft • The flight crew has final authority to accept or reject the transport HELICOPTER SHALL NOT BE USE • Bariatric patient known or estimated to be five-hundred pounds(500lbs) (227kg) or greater • Patient who is unable to lay supine (when clinically indicated for air transport) • Patient who is combative and cannot be physically and/or chemically restrained • Hazmat contaminated patient TableBack to of Contents Helicopter Transport Criteria 2 51 5 516 # I �. I I A A AAWP /r/Ui J/ r/%,g Al , r 517 0— vE+s BLS Medical Emergencies ADULT &PEDIATRIC ALLERGIC REACTION • Allergic reactions are characterized by any of the following: • Generalized Urticaria • Airway,Tongue,or Facial Swelling, Respiratory Distress, Bronchospasm • Nausea,Vomiting,or Diarrhea • Loss of Radial Pulse or SBP of< 90 mm Hg • Determine the source of the allergic reaction (insect,food, medications,etc.) • If patient presents with airway swelling/respiratory distress/bronchospasm/tongue and/or facial swelling/loss of a radial pulse or SBP of< 90 mm Hg: • Assist patient with prescribed Epi-Pen CARDIAC ARREST • Refer to the "Cardiac Arrest"algorithm (pg. 70),for all patients found pulseless OVERDOSEIPOISO I G • Try to identify source of the overdose/poisoning • Assist patient with NARCAN if available/applicable • Consider contacting the Florida Poison Control Center at 1-800-222-1222 SEIZURES • Consider the possible causes: • Meningitis • Drugs • Fever • Alcohol • Head trauma • Diabetic • Hemorrhagic stroke • Poisoning • Protect patient from injury if actively seizing ALTERED E TAL STATUS • Check and record BGL • If BGL is< 60 mg/dL, and patient is able to protect their airway/swallow: ORAL GLUCOSE: • 15g, if able to swallow and follow commands • May repeat 1x prn Co Icyt Iira li Icy ffl cafii o Icy m 3afients who a ire not conmmblous enough to swa�llow ti r "NN 8 �rertm V`M 8 518 BLS Trauma Emergencies ADULT &PEDIATRIC EXPOSE • As a general rule,only remove as much of the clothing as necessary to determine the presence or absence of an injury. Cover the patient as soon as possible to keep the patient warm. SPINAL TIRESTRICTION • Perform manual Spinal Motion Restriction by providing manual cervical stabilization and apply an appropriately sized cervical collar as appropriate if the patient meets any of the following criteria: • Complaint or finding of focal neurologic deficit on motor or sensory exam • Complaint or finding of pain to the neck or back • Presence of a distracting injury • Altered level of consciousness with an MOI (Mechanism of Injury) • Intoxication with an MOI present • The key objective is to move the patient in the safest, most anatomically neutral position possible • If an appropriately sized collar is not available or if the collar compels the patient to move, remove the collar and provide Spinal Motion Restriction • Place rolled towels on the sides of the patient's head and neck • Secure with tape or other similar devices to allow for comfortable cervical stabilization/ immobilization • The cervical collar should not cause the patient discomfort such that they are compelled to move • Place the patient on the stretcher cushion, supine • If the patient is unable to tolerate this position, place in a position of comfort,that also respects normal anatomical alignment and document appropriately. HELMET REMOVAL • Helmets without shoulder pads should be removed from all patients Le motorcycle • If applicable, protective pads should also be removed • Athletic trainers should be consulted in the helmet/protective pad removal process if applicable • Spinal motion restriction should be "manually" performed during the removal process BURNS • Refer to the "Burn Injuries" protocol (pg. 115) EYE EMERGENCIES • Remove contact lens if present • Irrigate the affected eye(s) with NORlMAL.SAL. NE • Be careful not to contaminate the unaffected eye with runoff • PENETL'wA11NG EYE IINJLJL'wlES: • Stabilize any penetrating object • Cover both eyes with gauze and an eye shield • Keep the patient calm, as crying,screaming or coughing can force more of the tissue outward • f"' Il fV' III"" attempt to replace or move the protruding tissue r a "NN 1 �rertm V M RII fli. w 519 BLS Trauma Emergencies continued.... �WIY ry � mm CLOSED ACTU S • Fractures should be splinted in the position found • Exception: No pulse present t;YII''1"the patient cannot be transported due to the extremity's unusual position • 2 attempts can be made to place the injured extremity in a normal anatomical position • Discontinue attempts if: • The patient complains of severe pain • If there is resistance to movement felt • Reassess neurovascular status before and after repositioning of patient's extremity CLOSED IIM0...Si-IIAFT FEMUR FRACTURES • Apply a Traction Splint Contiralin lcafionm 11P .'L heire is a iso a suspected ted OVIc fi aactV.ire 11PI IIi e re limy a in o IIo ein feunquui- fracttu it mm 1.hei"e Its aIso a suspected NiIII i aa'tu.uire 11PI Iheir limy an avu.ullsloiii/aiiqIl u.utatloiii ofth ank it foot Suspected firactuire ffls aII to q d shaft feunqu.uir • Reassess neurovascular status before and after repositioning of patient's extremity OPEN FRACTURES Refer to the "Open Fracture" protocol (pg. 119) HIP FRACTURES& HIPISL CATI S • Consider hip fractures in an elderly patient who fell and complains of pain in the knee, hip or pelvis • A scoop stretcher should be used whenever possible to move patients with a suspected hip fracture • Splint in position of comfort with pillows and blankets • Reassess neurovascular status before and after moving the patient • Traction splints shall IlfV` III"" be used on suspected hip fractures or hip dislocations • Most often present with the leg flexed and internally rotated,and will not tolerate having the extremity straightened • Present with lateral rotation and shortening of the affected leg PELVIC FRACTURE • Assess and treat for shock • :fi(°) II (°)°"III"" perform a pelvic rock. Assess the pelvis by applying gentle pressure anterior to posterior and from the sides to identify crepitus or instability. III': f"' Ilf"'°"III"" repeat. • Stabilize if possible • A scoop stretcher should be used whenever possible to move patients with suspected pelvic fracture • Reassess neurovascular status before and after moving the patient r u 1 �rertm V"M RII nrn 520 Iq W • I m w w BLS Trauma Emergencies continued.... BLEEDING CONTROL EX:TREII F'Y IN.➢I.JMES: • Direct pressure(utilizing manual pressure and pressure dressings) • Combat Application Tourniquet(C.A.T.) • Apply high and tight on a single long bone until the bleeding stops • : f") Ilf")°"III"" apply C.A.T. directly over injury site or joint. • If bleeding persists after initial C.A.T, apply a second C.A.T. • Hemostatic Agent (If 2"d C.A.T application fails to control bleeding): • Pack wound • Maintain pressure for a minimum of 1 minute or until bleeding controlled • Apply a pressure dressing JUNCT )NAI.. HEMORRHAGE (e.g., irneck, axiiIIIIaity, p6Ms and Ibit6irn) • Hemostatic Agent • Pack wound • Maintain pressure for a minimum of 1 minute or until bleeding controlled • Apply a pressure dressing(Occlusive if neck wound) ALL EXTREMITY TRAUMA • Gross contamination,such as leaves or gravel, should be removed if possible • Determine mechanism of injury(MOI) and evaluate • Assess neurovascular status of extremity • Color,temperature,capillary refill,crepitus AMPUTATION • Rinse off • Wrap in sterile gauze and place in a sealed plastic bag • Place the sealed bag into a second bag with ice packs • Label the bag with the patient's: • Name • Date • Time of the amputation • Time the part was wrapped and cooled ABDOMINAL TRAUMA • Impaled objects shall be stabilized to prevent movement and subsequent further damage • If bleeding occurs around the impaled object, it should be controlled by holding direct pressure • : f") Ilf")°"III"" apply excessive pressure • f"' Il fV' III"" palpate the abdomen,as it may cause further organ injury from the distal tip of the object • Protect the tissue from further damage • Cover the protruding tissue with a moist sterile dressing,then cover with a dry sterile dressing • Keep the patient calm, as crying,screaming or coughing can force more of the tissue outward • f"' Il fV' III"" attempt to replace or move the protruding tissue r p "NN 1 �rertm V M RII fli. nrn 521 BLS Bites and Stings 4 INFORMATION • Consider contacting the Florida Poison Control Center at 1-800-222-1222 UI1 DAN (Divers Alert Network)at (919) 684-4326 as soon as possible for treatment recommendations. „ram ADULT &PEDIATRIC ALL BITES AND STINGS • Clean the wound area with soap and water or sterile water • Exception: Marine animal stings • : f") II t)° III"" use hydrogen peroxide on deep puncture wounds or wounds exposing fat • Refer to the "Allergic Reaction" protocol, if applicable • Advise dispatch to contact animal control or the police department if necessary SNAKE ITES • :fi(°) IlV(",")"III""apply ice packs,tourniquets or constrictive bands • Mark area of edema with a pen • Remove any constrictive jewelry or clothing • Splint any extremity that has received a bite and ensure it remains below the heart • Keep patient supine if possible • For hypotension: • Refer to the "Fluid Resuscitation" protocol (pg. 38) • If the DEAD snake is on scene,take a picture of the head (including the eyes) with the ePCR device if possible INSECT STINGS • Remove the stinger by scraping the patient's skin with the edge of a flat surface (e.g., a credit card) • :fi(°) II (°)°"III"" attempt to pull the stinger out, as this action may release more venom MARINE ANIMAL E VE ATI S:STING RAYSCORPI ON FIS LI ON FISH E AFIS STONEFISH CATFIS EEVE FIS STA FIS SEA U C I • Immerse the punctures in non-scalding hot water(if available)to achieve pain relief • Gently wash the wound with soap and water, and then irrigate it vigorously with sterile water (avoid scrubbing) MARINE ANIMAL STINGS:JELL FIS A - F- A SEA ETTLE I RU KAN DJI A EMON E,__HYDROI FIRE CORAL • Rinse the skin with sea water(if available) • :fi(°) II (°)°"III"" use fresh or sterile water • i)(') II ,YlIII""apply ice • : f") II t)° III"" rub the skin • Apply white vinegar(if available) topically to involve area until the pain is relieved (lifeguards may carry this) • Remove large tentacle fragments using forceps with proper PPE on and stay upwind when performing this procedure rreu M mu r 522 523 /':'/' ""/'/"/ 'rr'�'l" "' '/ '// %/�' //'/ '//J+ + '" ',� '�� IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII��J J�. / ,,,,,„, ,-,, ,,,, / I� //.m, ,✓ ;�// �/�� i�/o /�r%��/� r III' l(� I 1 r��r� ////// /./,, ",''',;; ��/ ��/; :- /'/li ;,r.. rr /ia�/11��.1'�yfi/�i%i✓�/ %%//�///�i//�� r l �. � /�� ";:�,' ,,, ,, ' ��r✓///„t / iiir,, r j r, �r //'/i/�r%i/,/i��/�� t;l /' /l' l r �I�i� / ru/ / ,, /�c,ym,r��Nur�rfraNK�r�rtu��NNNv��w��f�pNrN�sr�d�fl�y�ili✓9,�1r(r �iAkf+' +'�h�Yra�tYh�Gllr/%�%l�/l�llfF{��i�r�� lNV y i r JIr�N, r it /J Jf EST, ��1�� %//rr/,:�i/� //r/// ri rrr, ,,,r„r,-,'i,rr ,/r, ,,r„ r r,,r: r%//// / /,%/ f,.,✓�-�//l��/ �JJ� l I 524 mw Allergic Reaction E Dt? INFORMATION Allergic reactions are characterized by any of the following: • Generalized urticaria • Airway swelling, respiratory distress, bronchospasm,tongue and/orfacial swelling • Nausea,vomiting,or diarrhea • Loss of radial pulse or SBP of< 90 mm Hg • Determine the source of the allergic reaction and remove potential allergen (insect,food, medications,) ADULT MILD®GENERALIZED URTICARIA ONLY • 50mg IV/10/IM, over 2 minutes IV/10 usage MODERATE—AIRWAY SWELLING /RESPIR TORY DISTRESS/ BRONCHOSPASM/TONGUE AND/ FACIAL SWELLING • EP1NEPI_IIFUNE (1:1,000, 11rng/Irrrf1..) • 0.3mg(0.3mL) IM • May repeat 2x prn,in 5 minute intervals • BENADRYL: • 50mg IV/10/IM, over 2 minutes for IV/10 usage • COI MVENT(Ao-BUlTEROL + ATROVENT) • Albuterol 2.5mg via nebulizer • Atrovent 0.5mg via nebulizer • May repeat prn • 125mg IV/10/IM/PO,over 2 minutes for IV/10 usage SEVERE®LOSS OF A RADIAL PULSE �..III'l SBP OF.... ........................ ....<.... . ................................g EP1NEPI-IIFUI` E (1:1,000, 11rng/Irrru1..) • 0.3mg(0.3mL) IM Imo oIIrrtIlaallll'rrfflcafil lns I"" yl of ll'rrmrllollrr mecoiiiiidaii"yt �:91ood loss mi P ire au.YfiI In,;m' .. um' ( n u.r t d u.r ur a fii n Mons toir wa art urate and II)IIood II ire,;,Suuire th irouu Ih.n uut adimti n ,Airafion EP1NEPHF 1NE 1f/1Irufu..alsioIru (ilf not IrespoIrusive to HM dose) Epinephrine Infusion IV/10 5-15 mcg/min NORMAL ":A1..1NE • 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x prn Purecau.ufion; I:lautuccurllau cau" uriur;t �:)etaIl a uu UlnaII a :; a ce f ;IILu ufficca iii c u" a au"yIlueau"t &,Sea S , 0 Af , and Ir naI falHu.ulr"e II a fi BENADRYL: as noted above Cf".dMMf/ENT(A1-Ba.JlTERf". L + ATRf".df/ENT:) as noted above • Sf".dLUI lMEDRf". L: as noted above w Allergic Reaction continued... ", yQ . . E DEP PEDIATRIC IL ®GENERALIZED tJ TICA IA ONLY • 1mg/kg IV/10/IM, over 2 minutes for IV/10 usage (may repeat if necessary) • Max Single dose 50mg 11111 ontiralinfflcafion Neonates MODERATE—AIRWAY SWELLING / RESPIR TORY DISTRESS/ BRONCHOSPASM/TONGUE AND/ FACIALSWELLING • E P N E P I_II FU N E (1:1,000, 11rn g/Irn L.) • 0.01mg/kg IM, max single dose 0.3mg • May repeat 2x prn,in 5 minute intervals • BENADRYL.: • 1mg/kg IV/10/IM, over 2 minutes for IV/10 usage • Max dose 50mg :ontiralinfflcafion Neonates • Albuterol 2.5mg via nebulizer • Atrovent 0.5mg via nebulizer May repeat prn • 2mg/kg IV/10/IM/PO, over 2 minutes for IV/10 usage • Max dose 125mg SEVERE-LOSS OF A AC IAL/ A IAL ULSE f;YII'l" AGE APPROPRIATE HYPOTENSION E P N E P I_II FU N E )1:1,000, 11rn g/Irn L.) • 0.01mg/kg IM, max single dose 0.3mg • May repeat 2x prn,in 5 minute intervals 11P ,Ppnti aallll ffllcafil lns L�yI oteiiiismmlollil "ecoiiliidall"yt �;91ood loss EPNEPHF 1NE 1f/1Irnfu..alsioIrn )itf Ireot IrespoIrnsive tr N dose) 11111 Epinephrine Infusion IV/10 lmcg/kg/min • NORMAL ":A1..1NE • 20mL/kg IV/10, assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension • BENADRYL.: as noted above • A1..Ba.JITERf" L.: as noted above • Sf".dLUI lMEDRf" L.: as noted above Diabetic Emergencies E DO , N%.. � INFORMATION Symptoms of Diabetic Ketoacidosis(DKA) include: • • Nausea/Vomiting • Abdominal pain • General weakness • Kussmaul Respirations(deep rapid respirations) • AMS • Hypotension • Tachycardia with an acetone smell on the patient's breath • Diabetic patients taking oral hypoglycemic medications should be transported (e.g., Glyburide, Glimepiride,and Glipizide). ADULT BGL< 60 m /dL • ORAL GLUCOSE: • 15g • May repeat 1x prn mo� C ntIlaallnfflcafil lns IlatIeliiits wm li all"e Iiiiot coiiiscc' ups I'll" ou�gli t s all • D0: • 25ml of 50% solution total of 12.5 grams • D10 • 100 mL IV/10 • Retest glucose • May repeat 1x prn GL< 60__mg/d L I N CARD IAC ARREST • D0: • 50ml of 50% solution,total dose 25 grams • D10 • 250 mL IV/10. Rapid infusion (if available) IF UNABLE TO PROVIDE VASCULAR ACCESS • 1mg IN or IM if available GL>300 mgjdL WITH SIG S& SYMPTOMS OF DKA NORMAL SA�JNE: • 20ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently. • May repeat 1x prn Purecau.ufion; I:lautuccuulau cau" uiiuu;t �:De taIl ui uui tIln II a :; uice f ;IILuiuflica iii c u" uiau"y Iluea ii"t &,Sea,Se, 0 flf and urenaI falHu.uure Il afient,; ® 527 Diabetic Emergencies continued... �WIIY ry � mm PEDIATRIC GL< e/ L • 15g, if able to swallow and follow commands CDiceiralinfflcafii ns::: llattleiiits i 1p aii"e Iiiiotcoiiisc I V�"m eiii V�g"pit "m rc�ll II "° IV' a�� tints° .N yea�I"s �pld • D50:: • 0.5gm/kg or D 10:: • 5mL/kg IV/10 • May repeat 1x prn (if available) IF UNABLE TO PROVIDEABOVE T EAT T G1_I.11CAGON < 20kg • 0.5mg IM/IN (if available) • >_ 20kg • 1mg IM/IN (if available) GL >300 mgjdL ITH SIGNS&SYMPTOMS F DKA NORMAL SALANE: • 20mL/kg IV/10, assess lung sounds and BP frequently • May repeat 2x prn,for BGL>300 mg/dl Pqw ® 528 II m w w Dystonic Reaction INFORMATION Dystonic reactions are characterized by intermittent spasmodic or sustained involuntary contractions • of muscles in the: • Face • Neck • Trunk • Pelvis • Extremities • Even the larynx • The following classes of medications are typically responsible for dystonic reactions: • Antipsychotic (e.g., Haldol, Risperdal,etc...) • Antiemetic(e.g., Compazine, Reglan, Phenergan,etc...) • Antidepressant(e.g., Prozac, Paxil, etc...) • A dystonic reaction can occur immediately or be delayed for hours to days. .„s ADULT B E NAD RYL: • 50mg IV/10/IM,over 2 minutes for IV/10 usage PEDIATRIC • 1mg/kg IV/10/IM,over 2 minutes for IV/10 usage • Max dose 50mg ontira�nfflcafion Neonates Fluid Resuscitation/Dehydration " �u µi E DO , INFORMATION • Indications for fluid resuscitation: • Hypotension • Fatigue • Dark Color Urine • Dry Mouth • Headache • Prolonged vomiting or diarrhea • Non-traumatic bleeding(vaginal or GI) • Suspected Rhabdomyolysis • Paramedic discretion o00 ADULT 0 NORMAL SAI..IUE • 20ml/kg IV/IO,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x prn I': irec u.ufioi ; . Pairficu.ullai caire nquu; �:De taken in the II a e,Sence of ;giq hcaiqt coiroi airy wair: &,Sea,Se, 0 flf and ureigaII falillu. ire II afieu t,; PEDIATRIC NORMAL":AI..IUE • 10mL/kg for infant/neonate. Assess lung sounds and BP frequently • 20mL/kg IV/IO, over 10 minutes, assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension Hyperkalemia14 SIRE DIE?, INFORMATION • Consider hyperkalemia in patients with a confirmed history of renal failure/dialysis who are pre-dialysis and present with any of the following: • General weakness • Cardiac arrhythmias& ECG abnormalities: • Tall peaked T-waves (most prominent early sign) • Sine wave • Wide complex QRS • Regular Really Wide Complex Tachycardia (RRWCT) • Severe bradycardia • High degree AV blocks PEAKED T-WAVE SINE WAVE 7 f ADULT FOR PATIENTS PRESENTING WITH ANY OF THE ABOVE CARDIAC ARRHYTHMIAS& ECG ABNORMALITIES • 1g IV/10, over 2 minutes I'irec u.ufioiq i)(') IIW")IIi adinqliq ,Aeir in ;sues I /VO Illiuge&S SODR.YM MCARBONATE wlthout thoirouFllully fIlu.t^dding • 2.5mg via nebulizer • Continuous treatments(if an advanced airway is utilized,administer via in-line nebulization) • SODR.YM MCARBONATE • 1 mEq/Kg IV/10, over 2 minutes Purec u.ufioiq i)(') II t)°III adinqliq ,Aeirlii aim I /VO Iluuge&S CALCKYM CHLORME wuthout thoirouFllully fIlu.t^dding IF PATIENT IS HYPOTENSIVE NORMAL":A1..1NE • 20ml/kg IV/10,titrate to effect.Assess lung sounds frequently. • May repeat 1x prn I'irec u.ufioi ; I:lautuccuull u c u" a quu;t �:De t II uq uuq tIl II a :; ugce ;uLuglfflcaiiq c u" uq u"y Ilue u"t &,Sea,Se, 0 flf and ureig III falillu.uure II afient,; PEDIATRIC • Call for orders "is 531 Nausea/Vomiting INFORMATION Consider differential diagnosis: • • Cardiac • Stroke • Diabetic • Head Injury • Other ADULT • 4mg IV/10/IM/PO, over 2 minutes for IV/10 usage • May repeat 1x prn �f pir&'°gnant. Bena diryl pir'oir to �^'�ofiran (�^'�ofiran a dirr'fllrflstir'afloin H' BeIrnadIr'yfl Illrn&':"ff&"flutll\/e) • 50mg IV/IM • NORMAL SA1-N E (ilf Irueedc.d): • 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x prn • PIre u.ufiioll ; PairfilcIt ll lr cair umur;t I:De taken uin the Ilia ;ence of S gnu 'hicant c Irr hairy Ilwairt &,Sea,Se, 0 flf and Irclna falillu. ire II aflient,�a PEDIATRIC • Nf"".dRidAL ":AL ICE 10ml/kg for infant-neonate over 10 minutes • 20mL/kg IV/10, assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension • 0.1mg/kg IV/IM/PO,over 2 minutes for IV usage • Max dose 4mg 'A mof I 532 Respiratory Distress IRE OV, ,�4 ADULT MILD BRONCHOSPASMSECONDARY TO COPD or ASTHMA • C(.)IMBIVENI-)Al..B(.JI EFF C)l.. -i-AI'FF ()VENI') • Albuterol 2.5mg via nebulizer • Atrovent 0.5mg via nebulizer • May repeat prn • 125mg IV/10/IM/PO,over 2 minutes for IV/10 usage MODERATE '),III1.SEVERE RESPIRATORY IST ESSm (I CLU I COPD,_ASTHMA,AND PNEUMONIA) CPAP 10 c:Irn 1-I2("') Contirralinfflcafionm II3II1 . a) urqurq IH �11P [lafiIents wIthout sIIIoIintaineours II"es III II II"afiIons f°la hints wlth a decireased II.00 (IethaIrglc) I:la fients< 30 II MODERATE TO SEVERE ASTHMA/COP • EPIINEPI_IIRIIN E )1:1,000, 11rng/IrY)L.) • 0.3mg(0.3mL) IM • May repeat 2x prn,in 5 minute intervals • IC)o III o t a d unq li III li s t e u" II',C III li III e III Ihi u"li III e t o CO I[1 IC) II at ue I t • CC))M BIVENI-)Al..B(.JI EFF C)l.. -i-AI'FF ()VENI') • Albuterol 2.5mg via nebulizer • Atrovent 0.5mg via nebulizer • May repeat prn • IV Infusion: 2g of Magnesium Sulfate • Administer over 10 minutes IV/10 ontiralinfflcafion 21"u and '"u IDegiree II N a art II3II cIk ea�u.ufioiq I a�lpH Ii yII �� I"�uc ,. u�"uu;Ilu� u"ti�ua�� u�a�u.u; a oteuq 1311111 Alf''"III III IIA Immediately remove the CPAP for the asthmatic patient whose condition worsens after applying the CPAP. Consider the use of Ketamine as the induction agent for RSI in patients with bronchospasm requiring advanced airway intervention.See Advanced Airway Protocol m Respiratory Distress continued... ' f r Dt? PEDIATRIC BRONCHOSPASM • C(.)IMB�VENI-(A..B(.JIIWEFm C)o.. -i—AI'Ft()V NI') • Albuterol 2.5mg via nebulizer • Atrovent 0.5mg via nebulizer • May repeat prn • 2mg/kg IV/10/IM/PO, over 2 minutes for IV/10 usage • Max dose 125mg FOR SEVERE ASTHMA NOT RESPONDING TO ABOVE T EAT T • EPiNEPFIIFUNE (1:1,000, 11rng/IrY i..) • 0.01mg/kg IM, max single dose 0.3mg • May repeat 2x prn,in 5 minute intervals • 50mg/kg over 20 minutes IV/10 Contiralnfflca on 21-"u Ic d 3l"l Il)e u" e IIN ut Il 11 cll s IIIIIP Pirec u.ufioi Gt Il li liu uu li u a uu r IIn II a li u FORCROUP EPiNEPFIlFUNE )1:1,000, 11rng/Irrrui..) • 3mg (3mLtotal) delivered via nebulizer IIIIIP Pirec u.ufioiiq, IIIIIPtt Il tV III Ai e,r,r the Iloafient IIIIIPtt Il tV III atteimpt to lntuulbat Ir IIDIIace ain OPA oir NPA • Ventilate via BVM as needed • Expedite transport to closest Comprehensive Pediatric ED FOR E IL ITIS • Avoid any procedures that may agitate patient • Provide humidified blow-by 02 as needed • Expedite transport to closest Comprehensive Pediatric ED CuI^oulll ' EIl4lilglllottliltlils • Usually< 3 years old • Usually 3-6 years old • "Sick"for a couple of days • Sudden onset • Low grade fever • High grade fever • Not toxic appearing • Poor general impression • Drooling • Tripod position mw Seizure w E Dt? INFORMATION Consider the possible causes: • • Meningitis • Drugs • Fever Alcohol • Head trauma • Diabetic • Hemorrhagic stroke Poisoning • Monitoring of EtCO2shall be performed to determine the patient's respiratory status. • Refer to the "Eclampsia" protocol (pg. 118),for pregnant patients. ADULT IF ACTIVELY SEIZING BEITV OMAZEPIITVE: • Ativan 2mg IV/IO/IN/IM may repeat OR • Versed 5mg IV/IO/IN/IM may repeat 11111 Pir cau.afii n IA uautaau,..f u u e�l:;ll lia t u"y Sell a �ll;,,i:;li ua IF SEIZURE DOES NOT RESPOND TO ABOVE TREATMENT ® KETAWN E • 100mg of Ketamine IV/IO slow over 1-2 minutes Penetira VunL eye nku.uiry Non tir u.uumafic chest lloaln Pirec u.ufiion, e lloirepaired four advanced lh"way umanagcum en apO IV adimllnu 11, afioncir ,a �, in II�IIa a y'&1;,Sodated II � u�uu tIl� iea,.�� liirat iryy'epir ;�,�.;l 1pin i n, ea, and t 111 nlyllneur tIhan uu,ry IF UNABLE TO ESTABLISH VASCULAR ACCESS KETAW N E • 100mg IN/IM -CAIIV III°ll'1AllIISIII')l� CA III l(YNS AS IIW)III llw lll': NX,Wll: PEDIATRIC FEBRILE A T ACTIVELY SEIZI fI atient receives Tylenol helshe must be transported • If patient can tolerate PO administer Acetaminophen 15mg/kg PO • May administer post seizure if child can tolerate FEBRILE SEIZURE • PASSWE C0(1 INN: Remove the clothing • f"' IISf"')°"III"" cover patient with a wet towel or sheet • f"' IISf"')°"III"" apply ice or cold packs to the patient's body IF ACTIVELY SEIZING Ativan 0.1 mg/kg IV/IO/IN/IM may repeat as needed OR • Versed 0.1 mg/kg IV/IO/IN/IM may repeat as needed OR Ketamine 1mg/kg IV/IO/IN or 2mg/kg IM may repeat once P irecau.ufi on IA uautoii" fou a eel:;ll uu t u"y Sell a �lla,,i:;li ua 535 w Sepsis 'ry INFORMATION • Sources, signs &symptoms of sepsis include, but are not limited to: • Fever • UTI (Increased urinary frequency,dysuria,and/or cloudy, bloody, or foul smelling urine) • Pneumonia (productive cough,green/yellow/brown sputum) • Wounds or insertion sites that are: Painful/red/swollen or have a purulent(pus)discharge • Patient is on antibiotics and has significant diarrhea,abdominal pain or tenderness • Recent history of surgery/invasive medical procedure(e.g., Foley Catheter,Central Lines, etc...) • AMS and/or poor oral intake over the past 24-48 hours(especially in the elderly) • Bed sores, abscesses, cellulitis, or immobility SLRSIIS ALERT Ciirteui^lila if allllll of till e follllllowl i g auire inet, aallllll a SLRSIIS ALERL" • >_ 18 years and NOT pregnant AIRIR • Suspected or documented infection AIRIR • At least TWO(2) of the criteria • Hypotension (SBP < 100 mm Hg) • EtCO2(< 25 mm Hg) • Altered Mental Status or GCS<_ 14 (new onset) • Tachypnea (respiratory rate >20) • Tachycardia HR >90 • Temperature greater than 100.4 F or less than 96.8F AII'UI'S III II'SG It is imperative once sepsis is identified,that the patient is kept from becoming hypotensive,as an episode of hypotension significantly increases morbidity and mortality. AII'UIS III IISG • Pneumonia patients with rales still require IV fluids. • Monitor EtCO2 and SP02 during fluid administration. ® d536 m Sepsis continued... BEY .� ADULT SEPSIS ALERT NORMAL ":AI..IUE • 20 ml/kg IV/10, assess lung sounds and BP frequently • May repeat 1x if time permits • Transport to Closest ED • Contirai nfflcafi ns R&4I II lHuire 3afi nt Pirec uufion,; Pairfiicuullai cure umu.u;t IIDe taken liin the ll ire,;e ce of S gnu cant c ironairy wairt &,Sea e, C,' I: • If BP does not increase consider Dopamine 5 mcg/kg/min and titrate to effect (maximum dose 20mcg/kg/ min) PEDIATRIC SUSPECTED SEPSIS UORidA1. SA1..1UE • 20mL/kg IV/10, regardless of blood pressure,assess lung sounds frequently • May repeat prn,for age appropriate hypotension • Transport to Closest ED • If BP does not increase consider Dopamine 5-15 mcg/kg/min. Use a microdrip (60 gtt/mL)and refer to the Handtevy Medication Guide for drip rate based on patient weight or age. Wei" 537 "' i " Stroke 012 INFORMATION " • Cincinnati Stroke Scale should be initial stroke assessment. • If Stroke suspected, patient shall receive a R.A.C.E. assessment. • Call a S°"III""It( IIC lll':w; A IL.III':w;lll1'111 III"" if: • Symptoms are within 24 hours with any of the following: • Any new positive finding from the Cincinnati Stroke Scale • R.A.C.E. (plus) assessment score >0 • Any patient who awakes with stroke symptoms • If the onset of symptoms are unable to be determined,transport patient as a S°"III""It( JClll':w; AIL.III':w;lll1°"III"" • Obtain the following information: • Last time seen asymptomatic • Witness name • Witness phone number(s) • Patient's medications • All Stroke Alerts shall be transported to a the closest III':w;lll'a • Exception: Dementia, known terminal illness or Hospice Care patients can still be treated as a STROKE ALERT.Transport these patients to the closest ED • Immediate notification of a Stroke Alert with the R.A.C.E (plus) score needs to be relayed to the ED u��Iuuuu�uMlu��u u�1u�ICuuuui'PuiultlilluMlu��u�uuu�u�u�u� M uilllmu ui uisuu ui uuuiu ui uuuui ui ��uuu a uiou uu�� c 0—Absent(symmetrical movement) Facial Pals Ask the patient to show their teeth: 1— Mild(slightly asymmetrical) y htl"Smile" ( g y y ) 2— Moderate to Severe(completely asymmetrical) 0— Normal to mild(limb upheld>10 seconds) Extend the arms of the patient 90 degrees Arm Motor Function if sitting)or 45 degree if supine) alms u 1— Moderate(limb upheld<10 seconds) ( g) g (� p� )p p 2—Severe(patient unable to raise arms against gravity) 0— Normal to mild(limb upheld>5 seconds) Leg Motor Function Extend the leg of the patient 30 degrees 1— Moderate(limb upheld<5 seconds) (if supine)1 leg at a time 2—Severe(patient unable to raise leg against gravity) 0—Absent(normal eye movement to both sides, Head and Eye Gaze Observe range of motion of eyes and look and no head deviation was observed) Deviation for head turning to 1 side. 1— Present(eyes and/or head deviation to 1 side was observed) 0— Normal(performs both tasks correctly) Ask the patient to follow 2 verbal orders: Aphasia 1— Moderate(performs 1 task correctly) "Close your eyes"and"Make a fist" 2—Severe(performs neither task) Ask the patient:"Who's arm is this?"when 0— Normal appropriate or correct answer Agnosia showing him or her the weak arm or"Can 1— Moderate(does not recognize limb or cannot move it) you move your arm?" 2—Severe(both of them) If Corflc 11 Signs are present add a"u"(plus)sign next to total score and include the verbiage"plus"with encode. R.A.C.E.SCALE TOTAL: Max Score Of 11 AIR..II II III IIStS SII IA14..IR..IIIII' II:MX ISAI II':Ilt Iltll'a AlltlA II:SS till II I ttllt II'' IIOIII"'I"'SSII AIICIISII':SS ® 538 mw Stroke Continued... w ^ IRE DOO., tf ADULT PO S H'l 0 M N IG: • Supine: • All patients with the exception of those listed under 30'head elevation section • 30'head elevation: • A diagnosed intracerebral hemorrhage • Patient is short of breath • OXYGEN: • 2 LPM NC if pulse oximetry less than 94%. • If the patient is in respiratory distress, manage airway as needed and consider advanced airway intervention. • WACCES°: • Establish an 18g catheter minimum if possible,the antecubital is preferred • Perform Glucose check • I-IIYP E RTE N S K)N • If patient has B/P of systolic greaterthan 220 or diastolic greaterthan 120 AND possible signs of stroke. • Labetalol 10mg IV/IO PEDIATRIC PO S H'l 0 M N IG: • Supine: • All patients with the exception of those listed under 30'head elevation section • 30'head elevation: • A diagnosed intracerebral hemorrhage • Patients short of breath • OXYGEN: • 2 LPM NC if pulse oximetry less than 94%. • If the patient is in respiratory distress, manage airway as needed and consider advanced airway intervention. • WACCES°: • Establish a large catheter if possible,the antecubital is preferred • Perform Glucose check • TRANSPORT: All..11.. III' III':w;lll': IIA°"III""ll'1iC Stroke Alerts SHALL be transported to the closest ED ® 539 540 Rapid A-Fib & A-Flutter I if �; INFORMATION • Rapid atrial fibrillation and atrial flutter are defined as ventricular rates> 150 beats per minute. ADULT Obtain a 12-lead and leave cables connected S""III""A IIII IIL....IIIIIII • CARDIZEM: 10mg IV/10 over 2 minutes. If no response in 15 minutes, repeat with 15mg IV/10 over 2 minutes. (Use Amiodarone if Cardizem not available) • AMIODARONE: 150mg infusion over 10 minutes. If 10 minutes AFTER Amiodarone infu- sion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. (Use Cardizem if Amiodarone not available) U INS III AI11 1 flII IU11)O 11i 111%S111O11" ) • Synchronized Cardioversion (Ascending Joule Setting: 200J, 300J, 360J) • Atrial Flutter cardioversion will start at 100j and escalate as needed • If still hypotensive: Normal Saline: 20ml/kg. Assess lung sounds every 500mL. If Cardizem is administered: Cdntt°aindacwated foi hypotension, Wide complex QR5, hist iyof MIPMI psi,.sack Si :LISsynSi.onle, If hypotension develops aftei.Caidizeni adniinistiation, adtninistei S'UUssit of IVcss.,nal Saline and S'USssIg of CGICiL ssl Chloiide csves,.2 111it)LIteS, k4ay s sspeat S'UUssig of CGICiL ssl Chloiide if needed, Delta Wave Wolff-Parkinson-White Syndrome dal&a Wan A PEDIATRIC • Call for orders J J1 J1JJ 1 JJ J JJ J J J . r r r r I r � 42 Brad cardia INFORMATION • Bradycardia is defined as a heart rate < 60 beats per minute. ADULT Obtain a 12-lead to rule out an MI and leave cables connected sr,"I'AIllr",Il..11l;i;, ........................ • Monitor and transport U INS"°III°"All 111 II;:(II°l'iY11)0"°III°"11 II%SIIIO% •ATROPINE: 1 mg rapid IVP. Repeat prn every 3-5 minutes. Max cumulative dose 3mg. Contira� nfflcafio n 3iradycairffla in the Iloiresence of an IAII II II IIPA""III""III II IIS III" 11': 11 III II IPUOIRA III II;IS 011 III°°IYllPO III II %SIIIO% IIPi 1P66III S All""III"II 112 1)0SII;IS All A III""1401l)lllll i1; ............................................................................................................................................................................................................................................................................................................................................................................................................................. • TRANSCUTANEOUS PACING: Initial rate of 60 BPM and increase milliamps until capture is gained. May gradually increase BPM to 80 if needed. • If Pacing unsuccessful. Dopamine may be administered 5mcg/kg/min and titrate to max dose of 20mcg/kg/min Si i)A""III""IIIO%011' III il4AlNSCU""III""All%1I!OUS IIIPACIIIING • DO NOT DELAY TRANSCUTANEOUS PACING TO ESTABLISH IV ACCESS • VERSED: 5mg IN/IM/IV/IO. May repeat 1x prn. If versed does not induce sedation, may administer KETAMINE 0.5mg/kg IV/IO/IM. If patient complains of pain while being paced, administer FENTANYL lmcg/kg IV/IO/IM/IN. II' ADYCAV II A, II19 III : II II I CIII V" CII: UII AN IIIYIII Wi III"'Ih 111 II IIYII')O"'III II V"��IIIOII"� Go directly to transcutaneous pacing as Atropine increases myocardial ischemia and may increase the size of the infarct. IIICII III :: II':...CIIV IL: AA IL. If....00I°(C Wi II I II llYIk)OIII IL:V" IIIOII" Immediate transcutaneous pacing is acceptable when IV access is not immediately available. 11 111) 1 JJ)) ) � 543 IIIIII��IIIIIIIII��IIIII��III��II�II��III��II�II IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIII IIII�IIIIIIIIIIIIIIII IIIIIIIII�IIIIII Bradycardia continued... �u PEDIATRIC • Obtain a 12-lead and leave cables connected. S"111i Aill!)111..111111 .................................... Monitor and transport U1NS III A 11 III II : II III110II II' AS A 0111 IIIIIII III Wi II II I Ai AS AII%i) III) i1 III II �I!fII USSIIIOIIS) • OXYGENATION&VENTILATION: Ensure adequate oxygenation and ventilation first,as hypoxia is most likely to be the cause of the bradycardia. • After oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates(birth to 1 month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor perfusion (AMS). III NO 141 Si1)O1NSI III 0 0 YG III 11"SA III 1i011%AIISII')Vi 11i111 A III 111 0 110 (115Ng AV I III Aii III 11 111..00111 II II II I Ci)ii 111110 III14004Ii1S ) • EPINEPHRINE: (1:10,000)0.01mg/kg(0.1mL/kg) IV/10. Repeat every 3-5 minutes prn. • If no response to Epinephrine, begin TRANSCUTANEOUS PACING. Begin pacing at 80 BPM and increase the rate as needed until the patient is hemodynamically stable. II INO 141 Si1)OII" SI III 0..SI AAII' 11"SA III 1i011%A110II'„ II 110 III IIIIII A III 111110 0® .11i S®A.... III III A11 III 111110II0I • ATROPINE: 0.02mg/kg IV/10(Minimum single dose 0.1mg) . Max single dose 0.5mg. May repeat 1x prn. • If no response to Atropine,EPINEPHRINE: (1:10,000)0.01mg/kg (0.1mL/kg) IV/10. Repeat every 3-5 minutes prn. • If no response to Epinephrine, begin TRANSCUTANEOUS PACING. Begin pacing at 80 BPM and increase the rate as needed until the patient is hemodynamically stable. Si il)A""III""111O11S 1''0111 III""ifA1NSCU""III""AINII;OUS III')A01111NG • If unable to obtain IV/10 access, begin pacing until an acceptable blood pressure is obtained,then administer VERSED 0.1mg/kg IN/IM. Max single dose 5mg. May repeat 1x prn. Cdnfroindicofed in hyyolension, i orworfbrrespirolory depression, J J1 1111 1 JJ J 1J J J . IIIIII��IIIIIIIII��IIIII��III��II�II��III��II��IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIII IIII�IIIIIIIIIIIIIIII IIIIIIIII IIIIIIII Cardiogenic Shock �i '04 I e� INFORMATION ADULTCardiogenic shock is a condition in which the heart suddenly cannot pump enough blood to meet the body's needs. This condition is most often caused by a severe heart attack. Cardiogenic shock is rare, but often fatal if not treated immediately. � Obtain a 12-lead and leave cables connected 0 Dopamine 5 mcg/kg/min and titrate to effect(maximum dose 20mcg/kg/min) PEDIATRIC Dopamine e' m��.�a ,e�., �o,�e�.� ,..� M.a�..,�o�� for drip rate e.,edono.ti.,,t ..ie��tor,e.. v a Once SBP is 100 mmHg or greater,treat CHF/Pulmonary Edema and/or Chest Pain as applicable. �IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII w Hypertension u` n a _ INFORMATION A Hypertensive Emergency can be defined as a systolic BP > 220 and/or Diastolic BP 120. Rule out manifesta- tions that can cause hypertension prior to treating such as chest pain and heart failure. Symptomatic patients with elevated blood pressure should be treated by the appropriate protocol based on assessment of their signs and symptoms Chest pain consistent with myocardial ischemia or infarction( Chest pain Protocol pg.54) Shortness of breath with signs and symptoms of acute pulmonary edema, ( CHF Protocol pg. 57) Patients in the 2nd or 3rd trimester of pregnancy (over 20 weeks) or up to 6 weeks postpartum with elevated blood pressure( Pre-eclampsia/Eclampsia protocol pg 128) Patients presenting with stroke like symptoms,obtain STROKE scale; (See Stroke protocol pg. 45) ADULT • Obtain a 12 lead and leave cables connected • IV access If patient is experiencing associated signs and symptoms of a hypertensive crisis Lab etoIoi 10im slow iVP over 2 minutes. Ma ire eat iin 10 minutes. Co!]tEgindicated°I"o� wise E2te ......................................................................g.........................................................................................................................................a............... .........................................................................................(..................................................................................................i............................................. °.0 or high grgog hgprt i iock PEDIATRIC • Consult Medical control Caution should be taken when administering Labetalol to patients experiencing a Stroke or suspected bleed J J1 J1JJ 1 JJ J JJ J J J . , r a , l r r � 4 IIIIII��IIIIIIII��IIIIIIII IIIIIIIIIIII��IIIIIIII��IIII��II�II��IIII��IIII��II��IIII��II��III��II��II�IIII��II�� IIIIIIIIIIIIIIII mw Chest Pain E Dt? � INFORMATION For STEM Alerts or suspected STEM Alerts,the right hand and wrist should be avoided if at all possible for IV ACCESS. The right AC and anywhere on the left is acceptable. ADULT • IMMEDIATE 12 lead ECG. Leave cables connected and repeat every 5 minutes • ASPIRIN: 162-324 mg b a b y aspirin chewed and swallowed. Csn froindicotaisns, ollergy, octive(31 bleeding, <16yeors old • Withhold if patient self-administered 324mg of aspirin within 24 hours. If patient self- administered less than 324mg of aspirin within 24 hours,administer full 324mg dose. • FENTANYL: lmcg/kg slow IV/IO/IM OR 100mcg IN. May repeat every 5 minutes prn. Max total dose 3 mcg/kg IV/IO/IM or 300mcg IN. In rare occasions, Fentanyl may cause hypotension. If hypotension occurs, NORMAL SALINE: 1-2L.Assess lung sounds and blood pressure every 500mL. If nausea and/or vomiting occurs, administer Zofran IV/IO/IM 4mg. May repeat once prn. (Nitro/tlyceritie oiity be/tiveri ins i First//ric i/'sip/t idici i/'off'Feri ftmy/for skiblc/si tierits w itli lflstosy off' opkitc g /ybusc or/ri imliorci i/'sip/t seekiri/t beligw/os/s suspectci/ II III AIIIIIy IItIIIS O111 II 011tIII I)II IP SIIISIIISAll III II IIt IIIJly%iIII IAlll.. II II IlyIII ANYlI A I)V1 IIy%iSIIIIItAIII°°Il1011y • NITROGLYCERINE: 0.4mg SL. May repeat every 3-5 minutes prn for pain. SBP must be 100 mmHg or greater. A 12 lead ECG must be obtained prior to the administration of NTG to rule out a right ventricular infarction including complete right sided EKG. • An IV must be established prior to NTG administration, even in normotensive patients. CON'lll"°II'tAlIll%ll')lIICA III I()NS • SBP less thon 90 nin iHg or,Heort Rote less thon. 0 BPA,4 or,greoter,thou 100 BPAS 4 PEDIATRIC • Call for orders J J1 J1JJ 1 JJ JJ J J J . r l , f i � 47 mw STEMI Alert ' f r Dc? INFORMATION STEM Symptoms can be variable and include discomfort of the chest, arm, neck, back,shoulder orjaw and also can be painless with syncope/near syncope (lightheadedness),general weak- ness/fatigue, unexplained diaphoresis, SOB, or nausea/vomiting. ADULT • IMMEDIATE 12 LEAD ECG WITH IMMEDIATE NOTIFICATION TOED INCLUDING ECG RESULTS • If Patient has Chest Pain, Follow Chest Pain protocol Leave cables connected and repeat every 5 minutes ii'i iIOIII I III Vl IIS III it „IIICQIIi Ali II AIIIIII uiii : III) SIII III I ill V4140 Ol II Aili 111 LIIISO SOQII%II „S II II I il'MI)O III II IISSIII„ III „ • NORMAL SALINE: 20ml/kg.Assess lung sounds and blood pressure every 500mL. May repeat x2 prn S""III i'llll 111 II A lli..illlll ilf""III"" C lPUll III""illlll iPU A ST-Segment Elevation in two or more contiguous leads (2rnrn or greater in V2 and V3 or rnrn or greater in all other leads)with a "convex" (frown face)or"straight" morphology. ST-Segment Elevation in two or more contiguous leads of 2rnrn or greater in any lead with a "concave" (smiley face). ST-Segment Depression with high amplitude R waves in V1 (isolated),V2,and/or V3. "Carousel Seats" Gasrnplefe right sided 18 leod EKG should be pe: os:~nied, Posterior,EKG should be perfornied, J JJ JJ l JJ J l J r 1 rrrrrrrrtl t � a 548 f4 , STEMI Alert continued... S""III""ball III II A IILi III if""III"" IC: III SQU A IIL.III 1!!III ball IPf S The following are STEMI mimics: • QlliS coimlplex s Su°exteu°than 0A 2 (Il lh!��Il�ll�a II' Ih!��Il�ll��a IfPaceimakeu°a etc,) • I eft Ventir cuflair Ih N y 11 e u°t are 11 h y(IL Ih..I) • Peir�caurfflfi • !aur]y IIiqo6airuzafion • I ess than 21mim of 6eva on wuth x Concave y i Segim n (yumlHey II ace) IAeu°II Ihi6loSy Patient presentations indicative of myocardial ischemia that do not meet "STEMI Alert Criteria"should still be transported to a the ED 11 eft Ventricuiar Ili..i i ertrelll i (III.. Ill i) Take the largest negative deflection from the isoelectric line of VI and V2 ("S"wave), whichever is larger,and count the small boxes. Then take the largest positive deflection of V5 or V6 ("R"wave), whichever is larger,and add it to the total from VI or V2. If the result is greaterthan 35,your suspicion for LVH should be high. ASS""III"°ES Patients with ST segment elevation in two or more Inferior Leads (II, III,AVF) or isolated abnormalities in lead III (isolated) and/or V1 shall have a complete right side 18 Lead EKG (V4R-V6R) to determine if there is ST segment elevation,indicating a right ventricular infarct(RVI).The right sided EKG shall be labeled somewhere on the EKG. If patient presentation is indicative of a myocardial ischemia and it is uncertain as to whether or not an ECG meets STEMI Criteria AA the ECG shows a STEMI mimic,the ECG should be transmitted to the receiving STEMI facility for determination. Rlglht-sidad lL vu acfis fl I.h,slabed dhest i l V5 ant"116 T Elevation I i C d1w'ed(con vex tiou,n) Y Concave n]1 0 0 Deep Wave in V1 or V2 % Tall R waves WS or V6i i point Notching The S wave to V�Is deep The n wave In V5 and V6 Is high ✓""+ In th s aximpb aheve a maasure Y th pl h ddd tlhe,wawa in VP tl at I A„mie the II,wave In wl 5 at 2 X 77 A theS wmve rn V l p4.a nhe a—RV V^,orc Soweaddb.*,memvuremevuts.,.h.,1— r..umnhnsomis n,mhr,rt,iru.w.rcs�oo. v,s.s, SdVt9 I CY(VS)=g1mmd. >nnp >35vnrn%sslgnd6 aanit w'Vhda—t,thm aaReeta f.,&. H Now Jr i i r tl � 4 5 9 w CHF (Pulmonary Edema) µ ADULT • 12 LEAD ECG Leave cables connected and repeat 12 lead every 5 minutes • CPAP(10 cm H2O) CON III""1 AllII0111': IICA°III"IIf)NS • ASPIRIN: Two to four81mg baby aspirin chewed and swallowed, if not already administered. III°!SYSTOLIC II'' III..00II': PRESSURE IIIS GREATER THAN �.00rnrMl°°Ig......................................................................... . • NITROGLYCERINE: 0.8mg SL. Repeat at a dose of 0.4mg as needed every 3 minutes I1P!SYS"°III°"OIIL.IIIC IIIIIIIL.00II III' II'fIII.....SSUII'fIII..... IIIS 12:0rnr IlI Ig 00: m: mIlh°°I • NITROGLYCERINE: 0.4mg SL. Repeat as needed until BP is 120mmHg. CON III""II'1AII II0111')lIICA III IIt NS • Right soon os possible, but do not neglect correcting respirolory s. °,s.. PEDIATRIC • Call for orders All'fl'VII IIOG If patient is febrile or from a nursing home and pneumonia is suspected withhold nitrates. J J1 J1JJ 1 JJ JJ J J J . l a a r r r l IIIIIII�II��IIIIIIII��IIIIIII��II��IIIIII�IIIIIIIIIII��IIIIIIII IIII��II��II��II��II��II��IIII��II��IIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIII IIIII II II IIIII IIIII Supraventricular Tachycardia K .� INFORMATION SVT is defined as a regular, narrow complex tachycardia of 150 BPM or greater without discernible P-waves and/or flutter waves. SA ..L.IIAIY4 DO NOT administer Adenosine to patients with a history of a heart transplant or if taking Tegretol (Carbamazepine)or Persantine (Dipyridamole). In this case, administer Cardizem or Amiodarone as indicated below. Ruling out of secondary tachycardia must be performed prior to administration of cardiac medicine. Check temperature,stimulant abuse,hydration status, possible sepsis, physical exertion,anxiety, etc. If any of the previously mentioned are discovered,treat. o ADULT S IIL A IIIP III IIIII!! •..............12...Lead EKG: leave cables connected • VAGAL MANEUVERS •ADENOSINE: 12mg rapid IVP,with a simultaneous 20mL Normal Saline flush. May repeat once. If rhythm fails to convert, • CARDIZEM: 10mg IVP over 2 minutes. If no response in 5 minutes, administer CARDIZEM: 15mg IVP over 2 minutes. (.UJ.s2_ rm.iad.ara. .e if C..a r.d.i.z..e rm_ 21_aYa.ila. .12.). CbrVroindicotedf6r,hypotension, wide cornplex QRS, potients with o history of WIPW or,sick sinus syn rorne, • AMIODARONE: 150mg infusion over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. (Use Cardizem if Amiodarone not available. If symptomatic hypotension (below 90mmHg) develops after Cardizem administration, • NORMAL SALINE:500mL then • CALCIUM CHLORIDE: 500mg over 2 minutes. May repeat Calcium 500mg one-time prn. U IIS""III""AIIII)IIL.IIIIIII ................................................... • Consider Sedation • SYNCHRONIZED CARDIOVERSION: Ascending joule settings of 100j, 200j,300j, 360j • If cardioversion fails, contact medical control for further direction. J J1 J1JJ 1 JJ JJ J J J . rr r r� r� 55 `^0, I Supraventricular Tachycardiacontinued.. Ruling out of secondary tachycardia must be performed prior to administration of cardiac medicine. Check temperature,stimulant abuse, hydration status,possible sepsis, physical exertion,anxiety,etc. If any of the previously mentioned are discovered treat accordingly. PEDIATRIC 6""III""A IIII IIL.IIIIIII • VAGAL MANEUVERS • ADENOSINE: 0.1mg/kg rapid IV/10,with a simultaneous 10mL flush. Max dose 6mg. If no change in one minute,ADENOSINE: 0.2mg/kg rapid IV/10,with a simultaneous 10mL flush. Max dose 12mg. • If no response administer fluid bolus 20ml/kg may repeat prn X1 U INS i All III 11 �AOII All �l' II OII II IIIA 11111 III VAIIPO 111 ll II" 6IIIOII" IF PATIENT IS ALERT • ADENOSINE: Administer as noted above. IF PATIENT HAS AN ALTERED MENTAL STATUS • Consider sedation prior to cardioversion. Versed: 0.1mg/kg IV/10/IN. Max single dose of 3mg. May repeat 1x prn. Max total dose 6mg. • SYNCHRONIZED CARDIOVERSION: 1j/kg. If not effective, increase to 2j/kg. • If cardioversion fails, contact medical control for further direction. III':: W RK AAAAL OA14 l'::U.0 lll':M For young children, place a bag of ice water on the child's face completely obstructing their nose and mouth for at least 15 seconds. For older children,ask them to try and blow through a kinked piece of oxygen tubing or syringe. SVT in infants is considered greater than 220 BPM. SVT in children is considered greater than 180 BPM. J J1 J1JJ 1 JJ JJ J J J . r r „ rr r r� r� 55 Wide Complex Tachycardia INFORMATION Wide complex tachycardia (WCT) has a QRS greater than or equal to 0.12 (0.09 for pediatrics) and a heart rate greater than or equal to 100 BPM without discernible P waves. ECG features that favor a diagnosis of VentricularTachycardia • Very wide, bizarre QRS morphology • Precordial concordance—all chest leads point in the same direction (either positive OR negative) • Negative Lead V6 • Backward frontal plane axis: II, III,and aVF are negative. aVL and aVR are positive. • Presence of capture beats or fusion beats (sinus beats that interrupt the WCT) ECG features that favor a diagnosis of supraventricular origin • P waves before the QRS complexes • Normal R wave progression in the chest leads • Left bundle branch block or right bundle branch block pattern • Only slight widening of the QRS • Irregularly-irregular rhythm M II all OA!IL..k l WC""I s All IIOA!ILO AI4 ""I""Ilal4 A 1 li:M AS V..""I AG II U'441 14CAA PIlZOVIID1''q 10 AI4:: AA!AII'ZAVI 1441"II'aIIAA!II.Mw U If cardioversion terminates the VT and the patient returns to VT, begin cardioversion at the last successful energy setting and increase as needed. J J1 J1JJ 1 JJ JJ J J J . rr r „r r r I �r 553 Wide Complex Tach cardia continued... a y . w IRE ADULT S""III""A llll IIL.IIIIIII if IIIIIII G U IIL.A ll'f WC""IILi • Perform 12 Lead EKG and leave cables connected • Perform serial 12 leads every 5 minutes • AMIODARONE INFUSION: 150mg INFUSION over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. Administer all 150mg, even if the VT terminates. U IN S""III""A 11 IILi 1llll WC""IILi ............................................................................ DO NOT DEI AV C"ARDIOi ERSION TO ES ABI ISH WAC'C'S" ! • Consider sedation prior to cardioversion. • SYNCHRONIZED CARDIOVERSION: Ascending joule settings at 100j, 200j, 300j, 360j • If unstable WCT fails to convert,AMIODARONE INFUSION: 150mg infusion over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed,and rhythm has not changed, may repeat 150mg infusion IV/10 over 10 minutes.After the 150mg has been infused and the patient remains unsta- ble, cardiovert with 360j every 2 minutes prn. Si)1IIIICIIIAIII..CCU%SIIIII.)iI I RA III IIIAIISS All III ll.ilif CAII'fll': IIIC ll.illl'fSIIIC IIS ��oir afient's who conveirt afteir cair&oveirs on OR aftcur two oir mmire shocks II«yth ec ir impl lantabIe Cain llioveirtei (II C ICE) adimlnlsteir • AMIODARONE INFUSION: 150mg IV/10 over 10 minutes. If 10 minutes AFTER Amiodarone infusion has been completed, and rhythm has not changed, may repeat 150mg IV/10 over 10 minutes. (if Amiodarone has not already been administered). PEDIATRIC S""III""A llll IIL.lllllll ................................... • AMIODARONE INFUSION: 5mg/kg infusion IV/10 infused over 20 minutes. Max single dose 150mg. May repeat until a max of 15mg/kg has been administered. U INS""III""Allll IIL.11lllll ................................................... • Consider sedation prior to cardioversion. VERSED: 0.1mg/kg IV/10/IN/IM. Max single dose of 3mg. May repeat 1x prn. Max total dose 6mg. • SYNCHRONIZED CARDIOVERSION: 1j/kg. If no response, increase to 2j/kg. oir Il fiient's who cony in afteir cair oveirm;uon OR afteir two oir moire shocks by thelir impl lantab Cair&oveirtei (IICID) adimlnlsteir AMIODARONE INFUSION:5mg/kg in 100ml IV/10 infused over 20 minutes. Max single dose 150mg. May repeat until a max of 15mg/kg has been administered. (if Amiodarone has not already been administered. i J J)1� J 1J J1JJ 1 , r r 55 Iq W II m w w Polymorphic V-Tach/ Torsades de Pointes µ� INFORMATION Torsades de Pointes is an uncommon form of V-Tach characterized by a changing in am- plitude or"twisting" of the QRS complexes. ADULT S'F BEE IIfPV'°'l° ............................................................ • MAG SULFATE: 2g IV/10 infusion over 5 minutes. May Repeat Q IN S""III""A IIII IIL.III Ilf "III ........................................................................ DO NO DEI AV D5F.IBRII I.ATION TO ES ABOSH W ACCS" ! • Consider sedation prior to DEFIBRILLATION. • DEFIBRILLATION: Ascendingjoule settings at200j, 300j, 360j • If unstable PVT converts prior to administration of Magnesium Sulfate, administer 2g infusion over 5 minutes. Torsades r J J Y ,. 1. ,, r PEDIATRIC S'F BEE IIfPV°'l ........................................................ • MAG SULFATE: 50 mg/kg IV/10 infusion over 10 minutes Max of 2g. DO NOT DEI AV D F.IBRII I.ATIOA TO ES ABI ISH W ACC'S" ! • Consider sedation priorto DEFIBRILLATION. VERSED:0.1 mg/kg max of 3mg IV/10. May repeat 1x prn. Max total dose of 6 mg. • DEFIBRILLATION:2j/kg, 4j/kg If unstable PVT converts prior to administration of Magnesium Sulfate,administer 50mg/kg infusion over 10 minutes. If defibrillation terminates the PVT and the patient returns to PVT, begin defibrillation at the last successful energy setting and increase as needed. J J1 J1JJ 1 JJ JJ J J J . Illlll��lllllllllll�ll��lllllll��l��llllllllllllllllllllllllllllllllllllll�llll��llll��ll��lll��llll IIIIII��IIIIII��IIIIIII��II��IIII��IIII��IIIIIII��IIIIII��II��III��III��II�� IIII��IIIII��III��II��IIIIIIIIIII�IIIIIIII��IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIII� Left Ventricular Assist Devices - LVADs K � I INFORMATION Left Ventricular Assist Devices (LVADs),also known as Heart Pumps, are surgically implanted circulatory support devices designed to assist the pumping action of the heart.Caring for these patients is complicat- ed and every effort should be made to contact the patient's primary caretaker(spouse,guardian etc.)and the LVAD coordinator during your evaluation. Patients with a properly functioning LVAD may NOT have a detectable pulse, measurable blood pressure or accurate oxygen saturation. f ADULT Contact the LVAD coordinator immediately; the phone number will be on the device and the equipment carrying bag.Take all equipment associated with the LVAD system to the ED. Locate patient's emergency"bag"with backup equipment. Treat Non—LVAD associated conditions in accordance with the appropriate protocol. Determine the type of device,assess alarms,auscultate for pump sounds. if needed,assist patient (caretaker) in replacing the device's batteries or cables. Locate the driveline site on the patient's abdomen. BE CAREFUL not to cause any trauma to the site or driveline (wires). If signs of hypo-perfusion,administer NORMAL SALINE:500mL and reassess. If there is bleeding at the site, apply direct pressure. C IIS II II;I S ll O IISSIII II IIPA""III III II IIS""III""S EVAI.VATE UNRESPONSIVE PATIENTS CAREFUI.I Y FOR REVERSIBI E CAUSES! Perform a blood glucose level, if blood glucose is less than 60 mg/dl administer D50—25ml of 50%solu- tion total of 12.5 grams.Secondary Option D10: 100mL. Performing Chest Compressions risks rupturing of the ventricular wall leading to fatal hemorrhage. ONLY perform chest compressions when the patient's LVAD is not working and no other options exist to restart the LVAD. °'i°Ilf IISSIIPOR'F )ACII AOIIIISO AN lLVAIII III)A°"III""lull IIS°"III Be aware of the cables,controller,and batteries. It may be best to place the stretcher straps under the LVAD cables to avoid creating torque on the device.At a minimum, be aware of this extra hardware. Transport to the closest ED J J1 J1JJ 1 JJ J JJ J J . 11111111 „ � � 111111111;r « i 111 r �lll r r� Digitalis Toxicity Euum INFORMATION Digitalis is a cardiac glycoside with positive inotropic effects; slows AV conduction by enhancing parasym- pathetic tone; and has a slow onset of action. Digitalis toxicity should be suspected in patients who are taking digitalis and have signs and symptoms associated with digitalis toxicity -for example,fatigue and visual disturbances(halos in field of vision).The most common arrythmias are ventricular ectopy and bradycardia,often in association with various degrees of AV block.The following rhythm disturbances should immediately suggest digitalis toxicity: atrial tachycardia with high degree AV block, nonparoxysmal accelerated junctional tachycardia, multifocal VT, new onset bigeminy, regularized atrial fibrillation,spoon -shaped ST segment, peaked T wave. Contact with the oleandertree,squill, lily of the valley,and toad skin can also cause a digitalis-type toxicity,which will cause the same type of dysrhythmias and requires the same treatment. DIGITALIS: GENERIC NAME(TRADE NAME) digoxin (Lanoxicaps, Lanoxin, Digoxin),digitoxin (Crystodigin) ADULT • ADULTTREATMENT: Contact Poison control 1-800-222-1222 Verify Digitalis Toxicity by confirmation from patient or by counting pills in bottle. Avoid use of Calcium Chloride as it is contraindicated in the setting of Digitalis Toxicity. Perform 12 lead is clinical stability allows. Leave cables connected. • Digitalis-Induced Symptomatic Bradycardias Atropine 0.5mg rapid IVP followed by 20ml flush of NSS. May repeat once if needed. Avoid pacing as patients with digitalis toxicity are more prone to pacemaker-induced ventricular rhythm disturbances. If wide complex Bradycardia is present administer Sodium Bicarbonate lmeq/kg. • Digitalis-Induced Ventricular Arrythmias- Stable Magnesium 2g IV over 2 minutes Once initial 2g is administered,administer continuous infusion of Magnesium 2g over 1 hour. • Digitalis-Induced Ventricular Arrythmias— Unstable Consider sedation. Synchronized Cardioversion at 25J. May repeat twice at 50J. Patients with Digitalis Toxicity may develop malignant ventricular arrythmias or asystole after cardioversion. If patient suffers cardiac arrest refer to Cardiac Arrest protocol. If no response, immediately reattempt cardioversion using defibrillation doses—200J, 300J, 360J. Maintain at 360J if needed. PEDIATRIC: Contact Poison Control J J1 J1JJ 1 JJ J JJ J J . 11111111 „ � � 111111111,r « i 111 r �lll r r� 558 aim; �dp m � n 1 o Iq W II m w w Standing Orders . . 00 INFORMATION • There is no scientific basis in trying to resuscitate an unwitnessed Asystolic patient who has succumbed to the dying process of a terminal illness. Consideration should be given to not starting resuscitation efforts in these cases. In general, when the scene is safe, all Cardiac Arrests should be worked on scene. nm ADULT j • Perform CPR per AHA (ACLS) • Emphasis is placed on minimizing interruptions in compressions to no more than 10 seconds. • Make all efforts to obtain a ROSC priorto leaving the scene. • Once available,apply the Lucas with minimal interruptions to chest compressions and set to continuous compressions. Patient should be placed on the scoop stretcher for transport purposes. III II')MI CA""III""III O II S ...................................................................... • Medications should be delivered as soon as possible after the rhythm check(during compressions) and circulated for 2 minutes. • Follow all IVP medication administrations with a 20ml flush of Normal Saline. • Search for possible causes and treat accordingly(i.e. H's &T's, BGL, etc.). III....iPf III II I A""III""III O II 01! III.....II''"II''"O II'f""IILi S e fic l Control shou id be contacted Ijrror to ceash S resuscitalJori efforts on C rufi c Arrant ijalJ nits Consider terminating efforts when: • If presented with an up to date and valid DNR terminate resuscitation efforts.When conflicting requests of family members continue resuscitation efforts and transport. • Contact Medical Control to terminate efforts Standing Orders •560 Standing Orders continued... r k DEV PEDIATRIC • Perform CPR per AHA(PALS) • Emphasis is placed on minimizing interruptions in compressions to no more than 10 seconds. • If applicable and once available,applythe Lucas (if patient is over 18 y/o)with minimal interruptions to compressions and set to continuous compressions. Patient should be placed on the scoop stretcher for transport purposes. Make all efforts to obtain a ROSC prior to leaving the scene. IP;III II')MI CA""III""III IIC S ...................................................................... • Medications should be delivered as soon as possible after the rhythm check(during compressions) and circulated for 2 minutes. • Follow all IVP medication administrations with a 10ml flush of Normal Saline. • Search for possible causes and treat accordingly(i.e. H's &T's, BGL, etc.). IIL..IIL.. I""'llI IIII:S S IIII:III':'I �I'° III':'I III �I'° �I IIII:S""'I""' III) ""'I""'III III' III�I""'1""S MUSS""'I""' IIII' III';: ""'I""I III S III))Q ""'I fls IIL..IIII L..S During arrest,maintain EtCO2 levels greater than,10mmHg. If EtCO2 levels are less than 10mmHg, increase effectiveness of compressions. Levels of less than 10mmHg have virtual- ly no chance of achieving ROSC.An EtCO2 level of approximately 20mmHg is ideal. II I's • Hydrogen Ion (Acidosis): Ventilation • Hyperkalemia (Renal Failure): Ca lciiuin'n Chloride,Sodiiuin'n Biica irb,Albutei:°ol • Hypoglycemia: Glucose • Hypoxia: Oxygen& Ventilate • Hypovolemia: ihfici Bohis • Hypothermia: I, firmin II's -Toxins or Tablets(OD): Opicites( arcan) Beta 1ockvr (G1ucagon) Tricyclk A ntidepres,san is(S'ociiur karb) Calcium Channel Blockvr(Ccilciurn Chloricife) -Tension Pneumothorax: Bilatercil171eura1Decompression Standing Orders 561 w Adult Cardiac Arrest ,. E DO, Eil a imuuuuuuuuuuuuuuuuuu��u u mu ,��„��„��„�,�� ?4u✓lu �riru7"ai ile itt w,ilt%,rgif:A ",w�r, ieH�m ry.rarwosi�s,urii,e 11 �� fh ,Jiq N o gyp. zn N U w7 01,,ti o u @r f i +m m r i n s =wwtt e r rf a y. na�4 ,:r „d�, w iokuU wirm))IIII VF PVT WII i www y,i ft v r10 N H Jd hi„,r'r r EEE,E,. ... a„pare � w Diu w s mro ......,, ofmw aq i or o-r a,4'tII Ow..... .... �V ill@°WI �Wry �r9kr �&�&V9��0°9&& & 1 rtq&il� &il" III U U AYI. TM r �'�!9N��udn•�re�. oNs m�fui irY V Ali(,� 4 To..................... .... ...................uM Idm uiJ x" e kgj� i v,iVU 0 1 dnTe k ; iNd U ui r asruu� e.. ��sl ' U„nw`� W� i 'mV IV Nr NYY fiU « a 1 s . ... .......... �MN V r «V u r uih rer ce di ri A uyWO irmprII'a "Irr m r urr� ., HA,6 �MSriurn �uN� R�rPul R 2 1p1m; r wqN �Ywur�rr i� . '. nvuw.rmr uuUll�ll, onwdat �� IIIIIIiImii uolloufNio��lllll��llll��mllllllll��lll ll��ullmmflllllll��md ..,.,. �,�oupmPora sn hr n.m iirio�mim r,m;mrav Ro r ° an�a mr�wmi4V m r wNu �r,,,, z e Q ! r srru s IY e gg�� V PYN 9 the ;� I'r, "I a" „�� i�Jr� it ii r roe 1�?hs asrJ4"i i r�+F;a ,W¢a7tif,;rrw'wVrrp.', �T,sr,. 1 NUUW1P k, ' �� 11111(l' ( dl�� i. ..................... .., p.?kr ei non i i w i,�1 aY ,I n iiq or >q v "1mi CPR '' N� n r �u�ut rr ium�l, �r � �. 1 'r �r�w��, Jx �wx �r�rNAFn�i I ffj7'oL, m+,9ilcf�IIR 112 F mm Ih� r,.e rgs w�w x wa,o,-��nulry fU,"rvo "r%1,wf1 f W.aN I rj�,,rx G)"co,III��Y� Ot 7, ei rr ,rrm,mu krrrc.l ui, „m.r r o u z-,A)3Loo Q 911 v ��m�`reuo-�rm��!ry�.ir��yr�o�aM�°C�u r imw�.rrrdm Back to TabNn ��.��,. ,✓n�Nk,tea,,,'mw°P�iv� r'W N��r:Xae� raP„�..: ,. �„�, ,»�, ,mm, ,»�, 562 Cardiac Arrest (Pediatric) all " „... „...... 01 CPR :, « w, ImAnt"tfimP"wif e w idt u''1j '` ".II"' d iar,netwry a iuf ci Er p mr1df,("i F �fIQI 11 V OVR0,miw f�t,www Owr��Ullmar r Nvwral uiw Is w wom 5kv is I ww V h Qhl,rio[j>mh a iliI lR "IV „i i��,,,,„%�� Nm liNVire dN mmVln i t � �VNNl im, KIP d ��"V,�wm�tlr �tirov1mwPVu ,wVf i 4 @.riu��% vi AmyhiN - u�" �71�,v�0t%wa'wJPY( 14°m�w�VNU•9a;V� NJ9��IomNviO+N'�r��w✓ rJ4`�111`1 0 tIM wiW 41`j'dli w�'m w • NN�criwrw�i wb7u�,)i W 'IUJ'N d ad �� xw"r w N91u�mn w "43f" ism i IW- Ut _ n N Y k�y ii N � � wi OrVn �r Fl � l, m 1 ;;�� ire�1iuf�rrr" wwx�ti�uw,., w iPl6w r��N.;'ou"tiv10r i r i w „tea",� �� iawrww wvm�wrma mr �,rmw��rr � mm�m r n"H i�i' A m"W i� Ili VuW>' �u o a u i t,w'� � °�°W�WV�'. VYV��SVWl�9�,�✓l M�Y(rl' ��WVIwWYtilw ��!�i! ��'u',�w I Li flinp tall V�,VwA y innIui n91Shuck � i / y w�WVII��H m'm�lw d�y1l��`IPV, t ,,,:,�� ,o,��✓�' ��wmV�rmpY 8rm1��4Nr��"',� �uwr,M"wiwY4��iwuy%4u1, ai w m i(iu uW"?Y 1 !w Ater w dk`N" a' Uimmin Mumu�w�m p�'D ,vmW'Vi "p,bwj -gwluiw a;m ,1„�,, "�°mm ;rym� L IINMM „, �r,o i��rv�.v x m V 41'�""'I w r me o;» V nirG7IfAwp9'0 01" Iffflimoomi f"no mn,t", N rll VN�`ydVaU�,n'�'tl�WV 114 o ues �s �� mmdmqi ma�� m�fwPmw m 7 R' 71 CPR 2 VWwvim ��rim�ww � , ` � • U�W��'rL�m��"�u1rwiY�mB r M U��Vm@��'lllV'wi m mwtil�m�iii ..,,"vFrz ,,,,,,...., I u,?InpC�� iw Vw riU IN I u"wrs m,ns �,ww im, T hu Ofk Umwrr.J�"Jw 'y 111 m if im"Otuimwfu`m 'fc;, w*7 a, DIY Ur whnlJ ,w�m yW I,usrwr,wyw�rwm'9�^ awl fi[",'34,5C 1,N Cr y � Cardiac ' ' 563 �pwwwu special Considerations in Cardiac Arrest INFORMATION The below treatments are in addition to standard therapy. 'f ADULT II I III' III.....II'f III A IIL....IIIIIII III II A • CALCIUM CHLORIDE: 1 gram,slow IV/10 over 2 minutes. • SODIUM BICARBONATE: 1mEq/kg,slow IV/10 over 2 minutes. • Once intubated,ALBUTEROL: 2.5mg via nebulizer,continuous treatments. IIIIIII OII III""IIIIIII iI: iI: IIIIIII IIL.III iIf III LI III ............................................................................................ • SODIUM BICARBONATE: 1mEq/kg IV/10,each amp administered slow over 2 minutes. • NORMAL SALINE: 20mL/kg IV/10. Maximum of 2L. Assess lung sounds every 500mL. II': RO ISIIIIISO .......................................................... • Immediate VENTILATION is a priority and treat as a SECONDARY ARREST. THIRD TRIMESTER • Manually displace the uterus to the left • Transport to the closest ED • Exception Trauma Alerts • Rapid Transport Recommended • Lucas Contraindication in Pregnancy IIIIAIIOIIIIISO � • Considerspinal motion restriction. • Transport to closest ED 1I!IIi.II CIII"IIiocu"'III""IIIOIIS L.JIIOIIII III IISIIIIISO SIIIi ii l�i K ikllll • Immediate DEFIBRILLATION as applicable. • Consider Spinal Motion Restriction. Specialto Tal[)Nn Considerations 564 u Adult Post Resuscitation ADULT SOS""III""AiiiiIII S""IILi ................................................................. Patients with a ROSC should be managed in the order of: • 12 LEAD • RATE: If patient is Bradycardic,TRANSCUTANEOUS PACING: Initial rate of 60 BPM and in- crease milliamps until capture is gained. (reference bradycardia protocol) • RHYTHM: (reference specific protocol) • BLOOD PRESSURE: (Goal is to maintain a SBP of 90mmHg) If the patient is hypotensive,administer NORMAL SALINE 20ml/kg bolus, may repeat 1x prn. • Maintain pulse oximetry of 94-99% • Maintain ETCO2 of 35-40 mm Hg • Maintain 10 breaths per minute • Monitor patient temperature and treat accordingly SOS III ...-II III 11,N. III ACIII I'I CQ%SIIIi)II II4A III°IIIO% • Administer AMIODARONE INFUSION: (150mg infused over 10 minutes)for patients who con- verted after two defibrillations and have not received an Amiodarone bolus during arrest. SOS""III""""III""0i4SAII': IIIIIIIS COI ISSIIIII')iIIIIII'fA""III""IIIOIISS • Administer MAG SULFATE: (2g IV/10 infusion over 5 minutes) if patient did not receive Mag Sulfate during arrest. of Contemts 565 Pediatric Post Resuscitation �E D PEDIATRIC POST ARREST • Maintain adequate oxygenation and ventilation. • Patients with a ROSC should be managed in the order of: II'fA""III""IIIIII ......................... • If heart rate is less than 60 BPM, provide oxygenation and ventilation for one minute (30 seconds for a neonate). • If heart rate remains less than 60 BPM with S/S of poor perfusion (Altered Mental Status) despite oxygenation and ventilation for one minute (30 seconds for a neonate), begin CPR. • If after one minute of CPR the heart rate remains less than 60, administer EPINEPHRINE: (1:10,000) 0.01mg/kg(0.1mL/kg) IV/IO. Repeat every 3-5 minutes prn for a heart rate less than 60 BPM. Y7 HM ........................................... • Reference specific protocol. BLOODPRESSURE ...................................................................................... Minimum Pediatric Systolic Blood Pressure Values Neonates: 60mmHg Infants:70mmHg Children 1-10 years old: 70+ (age in years x 2) mmHg Children greaterthan 10 years old: 90mmHg • NORMAL SALINE: 20mL/kg bolus,titrated to a SBP as listed above. May repeat 1x prn for hypotension. Assess lung sounds and blood pressure often. II III &II') ik I III''"' III IIII:III':` III IW III':° III III';,'S I... All patients that are pulseless or have obtained ROSC shall be transported to the closest Emergency Department • ' 566 567 ,' w w / 7 "I d 40 K �l Iqi + „ 568 Standing Ordersu y INFORMATION • The goal for effectively managing patients with an overdose/poisoning is to: • Support the ABCs • Terminate seizures • Terminate any lethal cardiac arrhythmias • Reverse the toxic effects of the poison/medication with a specific antidote • The treating paramedic should consider contacting the Florida Poison Control Center at 1-800-222-1222 as soon as possible for additional treatment recommendations. • Treatment recommendations from Florida Poison Control should be followed. • Document the directed treatment and the name of the representative on the ePCR Report. All! III III II A • Use caution when supporting blood pressure with fluids. Many medications depress myocardial contractility and heart rate,which predispose the patient to heart failure even with boluses as little as 500mL. Assess lung sounds and blood pressure frequently. • It may be necessary to limit the amount of fluids the patient receives. 569 Beta Blocker Overdose INFORMATION • Signs &Symptoms: Common Beta Blockers: • Bradycardia • Atenolol • Hypotension • Carvedilol • Cardiac arrhythmias • Metoprolol • Hypothermia • Propranolol • Hypoglycemia • Bystolic • Seizures • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. mm�c ADULT • Obtain a 12-lead and leave cables connected If confirmed Beta Blocker Overdose and patient unstable Administer Glucagon 3 mg IV/IO if available • Refer to the "Bradycardia" protocol if applicable ISOLATED y T SI NORMAL °:Ai iNE • 20ml/kg IV/IO,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x prn I'irec u.ufiion; I:lautlic.:Ilau c u" a iu:l.;t I:et II ui liui t:Il e II ue�l:;auks ;u uilfflcaiii c u" ui u"y Ilue u"t &,Sea,Se, 0 flf and urenaI falHu.uure II afiient,: PEDIATRIC • Obtain a 12-lead and leave cables connected • If confirmed Beta Blocker Overdose and patient unstable Administer Glucagon 0.1 mg/kg IV/IO if available (May repeat 1x prn) • Refer to the "Bradycardia" protocol if applicable ISOLATED y T SI lei.. SAi..iNE • 20 mL/kg IV/IO. Assess lung sounds and BP frequently 570 "' i " Calcium Channel Blocker Overdose : INFORMATION • Signs &Symptoms: Common Calcium Channel Blockers: • Hypotension 0 Norvasc • Syncope • Cardizem • Seizure • Cardene • AMS 0 Procardia • Non-Cardiogenic Pulmonary Edema • Bradycardia • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. Nod, ADULT • Obtain a 12-lead and leave cables connected 0 CALDLYM CHi_OMDE if Patieirut Uirustab. e • 1g IV/10, over 2 minutes 0 if patieirut ireirnaiirus Hypoteirusive NORMAL SAi..iNE • 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x, prn I'irec u.ufiiou ; I:lautlic.:Ilau c u"c a qu:l.;t I:e t Il cuq liuq t:Il e II a eel:; ugce ;u uglfflcaugf c u" uq u"y Ilue u"t &,Sea Sc, 0 flf and reigaIl faHu.uure Il fient,; HYPOTENSION WITH BRADYCARDIA f'';')III'l" NON-RESPONSIVE TO ABOVE TREATMENT • Refer to the Brad cardia protocol, y " p , if applicable PEDIATRIC • Obtain a 12-lead and leave cables connected 0 CAi.DL M CI-Ii-f".dMDE if Patiieint aJiirustak.:Ie: • 20mg/kg IV/10, over 2 minutes 0 if patieirut ireirnaiirus Hypoteirusive NORMAL SAi..iNE • 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x, prn HYPOTENSION IT A YCA IA f'';')III'1 NON-RESPONSIVE TO ABOVE T EAT E T • Refer to the Brad cardia protocol, y " p , if applicable 571 w �b Cocaine Overdose � INFORMATION • Signs &Symptoms: • Tachycardia • Supraventricular and ventricular cardiac arrhythmias • Chest pain/STEMI • HTN • Seizures • Excited delirium • Hyperthermia • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. ADULT • Obtain a 12-lead and leave cables connected PATIENTS PRESENTING WITHSTABLE SVT CT CHEST AI T SEIZURES VERSEDWWAN: • Versed 5mg IV/IO/IN/IM or Ativan 2mg IV/IO/IN • May repeat 1x prn, in 5 minutes I'irec u.ufiiouq IMoiiq itoii" foii" ii"el:;Ilouii"atoii"ydeIIoii" ;,i:;IlollI Ketairrraiiirue )Sec:oirudaity Orffioiru) • 2mg/kg IM/IN • 1mg/kg IV if available • Follow appropriate protocol if: • Above treatment is unsuccessful • If the patient has an unstable cardiac arrhythmia PEDIATRIC • Obtain a 12-lead and leave cables connected 0 VERSED • 0.1 mg/kg IV/IO, max single dose 2.5mg • 0.2 mg/kg IN/IM, max single dose of 5mg • May repeat either route 1x prn I': irecau.ufioiq GV uqut u,..f u u eel:;II Vu t u"y yell a �ll;,,i:;li uI 572 Narcotic Overdose Common Narcotics: Iq1Illll Suspected Narcotic • Fentanyl Overdose • Codeine • Narcan is to be used PRN to • Dilaudid improve intrinsic airway patency, • Heroin ventilation and oxygenation. I • Methadone • The goal is to restore spontane- + Lorcet ous respiration,II 'i""to wake „ul" Illpllll l l l'4°I°I' 11 VI • Vicodin `IIII '111111i uV�IP�SJllyup'��VVI��l�yyl,@4u1m111�1111�11�111��111�1�11��`III�I,I�11 ,(,i�Niol,Ni@1@ II�lll1',�iub;l�pumulml the patient up" Oxycontin �10��1��0�1��11��1��1��1��1��11�1�1�0�1�01�1�111�1o1�Q�11�1 Lortab 1 III 411�;�"" nnn,nn,gll�ulliiliiVi�lp I II 'i111��1111gi'I,V,N�@u4V,11V,11V,11V„��, Illllllllllllllllll�i��i�iii'Vi'V,nV,nV,nV,nV,n,iiiV,nV,� �,,4111y 1111�� ,i 11QIVV,1„�11 I1�� ,ionou,,,,,ij°P"'"' Illuuluul111 �',�� 1�1) IIIVIVIIIVIV41 �� Imluulll nm.uhm.i.�fl m ,,;;11;P,'"111y'I 1111V41 ��ow�uum'„1u,;;��uuuuiVu�uumuluuui allulilulilulilulqulgl! pu\�11111UIVI11��I1111 ti'RtiSN5ti5ti5ti55ti ® � ��® � o^��Ilyyllylyl lti�000a�lo�l�mltio�ll 11 v' • Reassess above vitals • Are all vitals within above parameters? NARCAN(prefilled syringe /MAD) NARCAN IY/10/1M * 2►fig IN * 4.4--22.0 mg(Adult) YES ? Secure IV/10 Access. * May repeat prn.Max dose 1mil per Hare * 4.1 mg/kg(Pediatric) * May repeat prn to achieve adequate respiratiom :: - :: 573 Tricyclic Antidepressant (TCA) Overdoseµ' 1 INFORMATION INP° Signs &Symptoms: Common TCA: • Mad as a hatter • Coma • Amitriptyline • Red as a beet • Seizures • Desipramine • Hot as hell • Cardiac arrhythmia . Doxepin • Dry as a bone • Acidosis • Blind as a bat • Follow the appropriate protocol if patient is symptomatic and treatment is not listed below. 'F ADULT • Obtain a 12-lead and leave cables connected FOR PATIENT IT A S C LE > .10 5IIEC0ll0lll')S (2.5 SIIIOIAII..II.. Ill t;' IIIES • 1 mEq/kg IV/10, over 2 minutes • May repeat 2x prn, in 5 minute intervals, max total dose 150 mEq 11111 I'irec u.ufion: I.)u:coiiitliuiuuetu" atu eiii Ilu u f couiiIllle; u" < .`i.0 l;ecui0, (2,5 ^.;uiiIIII I:::o ^.; If Patient remains HYPOTENSIVE NORlidAI..S I..INE • 20ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently. • May repeat 1x, prn IIIIIP I'irec u.ufion; I':lautlic.:Ilau c u" a iu:;t I:::e t II ui liui t:Il e II a l:;auks ;u uilfflcaiii c u" ui u"y Ilue u"t 01:e« e, 0 flf and urenaI falillu.uure II afiient,: PEDIATRIC • Obtain a 12-lead and leave cables connected FOR PATIENT WITH A QRS COMPLEX 0.05 SIII':w;C0110111': S 2:51110IA ll..11.. Ill ) III':w;S S 4::d M l.YM Ind I C A R Ind O N AT E 8.4-%: • 1mEq/kg IV/10,over 2 minutes If Patient remains HYPOTENSIVE NORlidAI..S I..INE • 20ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently. • May repeat 1x, prn AII'UI II VG TCAs cause death primarily through lethal cardiac arrhythmias.Wide QRS complexes are an ominous sign and must be treated with "50DII..IM MCARBONA1T immediately. ® - 574 575 t ,� �uIIII�IIIIIIIIIIII11�011111111111111111i1uir�� ,� �, �Illllll h`I11i x � Chemical Restraint µ INFORMATION Restrained patients shall IW; III""be placed in a prone position. • Chemical restraint may be used in addition to physical restraint forthe following: • VIOLENT/COMBATIVE PATIENTS are Violent,agitated patients who place themselves and/or crew in danger • EXCITED DELERIUM PATIENTS are Bizarre,aggressive behavior which may be associated with the use of cocaine (crack), PCP (angel dust), bath salts, Flakka, methamphetamines and amphetamines ADULT and PEDIATRICS • If possible utilize Law Enforcement to assist with restraint FOR SPECIAL POPULATION VI LE T/C ATIVE/EXCITE L IU • Special population patients: • Over 65 years old • Head trauma • < 50 kg • Alreadytaken othersedatives (e.g., benzodiazepines, alcohol,etc.) KETAW N E • 2mg/kg IM/IN for the above patients • If IV available 1mg/kg IV • May repeat 3x prn, in 5 minute intervals to gain control of the patient C ntiralinfflcafionm [1u"e ina n ll a fient flenetiraf ou ny eye uinku.uiry 11PVyon tirauurgafic chest ll a n r'III"ecau.ufii uq^ e ll a"ell au"ed four advanced «dill"wary uma inageim n I' a pO II a�du��liu�u Ai a fioi� u; a�^;,a dated li y mii ry „p II�"!.; IIII"'a��;Q"uII"'y '�" II�"�i;'IIQ"ullllr a� Illl�'a�r a�Illl pII '�"peII" thna in u.u,;u.uaI liuncu"ea e,; in IIDIIood ll ue,;^Suuu" ,; • If ineffective consider Versed 5mg IV/IO/IN or Ativan 2mg IV/IO/IN may repeat 1X prn FOR ALL OTHER VI LE T/C ATIVE/EXCITED DELERIUM KETAW N E: • 4mg/kg IM • If IV available 1mg/kg IV • May repeat 1x prn, in 5 minutes 11P ContiraInfflcafions as noted albove I'III"ecau.fioi ; as anoted above • If ineffective consider Versed 5mg IV/IO/IN or Ativan 2mg IV/IO/IN may repeat 1X prn LA SAS (ST I ) REACTIO TO KETAMINE ADMINISTRATION • High flow Oz • Assist ventilations via BVM prn • Consider advanced airway procedures G�Iir cau.ufioiq L, a iryingo,;ll a im li^1; uuncoimi ion and ; u.u^,;uu lllly^Is6lf liingV ouqy. 6t aIlunq ,;t aIl a y,; a e,;Alva,; Mth ulgh fIlow 0,,oir IDu"uef v uqfolla fioiq Vag f[W% Nil577 Chemical Restraint ron,nue .. T ,y,� t Pain Management INFORMATION • 1=ENTANYl.. is the front line medication for pain, however KEl AWNE is preferred for hypotensive patients or patients who have opiate contraindications(allergy, history of abuse,etc.). • KEl"AWNE may be given with 1=ENl"ANYL for severe pain. • >_ 7 on the pain scale is considered "severe pain" ADULT FOR PAINA AGE T • 1=ENTANYL: • lmcg/kg IV/10/IN/IM • May repeat 2x prn,in 5 minute intervals, max total dose 300mcg f::`ontirralin llca�l�li eg y Ic a�u"leIruic (32 e II s oii real u") u" l Luc II a uca�lccc °m. � Icc acluve a:cu'. IIIIIP Pirecau.ufion IIIIIP V flu;t iry of op ate abu,;e oir di rug Ise6ding beha Voi IIIIIP Moiqltoir lea fienl foura„ ;Ilcliira t iry depire,3,13110111 IIIIIP DI rcou finu e it ca fienl becoinge,; dirow,ry IIIIIP Can Ilea II eves ^Sed wlth NARCAN li.f ucece;,Sa iry • KETAWNE itf FeIrutaIruy11 iIIrueffectiIve olr FeIrutaIruy11 not iIIrudiIccated: • 50mg of Ketamine in Nf".dllMAL ,°:lAl_NE BAG • Administer IV/10 infusion over 10 minutes • Reassess pain scale after half of the infusion has been administered (5 minutes) or 25mg • Continue infusion if needed. Max total dose 50mg C ntiralincllica fi nm Diteyucaucl Il alai nts Denetiral ii ny eye uucku.uiry VNon tirauuurca fic chest Il a n Pi„ccau.ul li uc, : le Ilcirepaired f ir advanced a h"r any umaucageim nt • RaIlcay' IV adarcliucu;liral:liouc u; &s;odated wlth a e�,;Ilcliitat iry deIlcare,;,Sli nM aIlcuceaM and nIIyllu irthauc u.u,;uuaI liuccirea e,; in II)IIood Ilcire,;;uuire,; Ili • 25mg of Ketamine IN/IM • May repeat 1x prn,in 5 minute intervals, max total dose 50mg � f.ontiramucclnca fi ns as noted above mi Pirecau.Yl';IIoII m as noted above lIIIIIII 1� � � � � �� ,�-�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII u. 575 Pain Management ,e.t.u. .. . PEDIATRIC FOR PAIN MANAGEMENT • Max single dose 50mcg • May repeat 1x prn, in 5 minutes, max total dose 150mcg PAIN MEASUREMENT SCALE OOOUO Adult Advanced Airway 's IRE 1W Position and Suction Pre-oxygenate • Assist ventilations via BVM rKETAMINE: 200mg slow IV/10 push overt-2 minutes Versed: • May repeat 1X Precaution: • 5-10mg IV/10 Pre-medicate: • Rapid IV administration is associated with higher Versed or Ketamine • May repeat 1X ~— increases in BP Indications: � V&uutiuu Ilrrru utui:��UuuurP�uurir�u °oq'AIC, slPrdiu.l � hLH�i�:wart¢�:^ir�uUxliarir�u 11 l) 01/Il /t/1 1 V oll¢ irillcoro°olb�., lire �M1a utiginiuiuuuuw FWrlitly SlUsa ,wetted K'IP 1 Cointirallindiicatiio1 mu Iru egu�un It IlIafleu^uts I�einetiratuu�ug Eye hn^ uriry YES mi Idouu tirau rnatiic surest leniiu^u SUCCINYCHOLINE: FApneic sis Indications: • 2 mg/kg IV/IO may repeat 1X 011,it contraindications atus Epilepticus • ROCURONIUM: ry/GCS 9 or less • 1 mg/kg IV/IO may repeat 1X • Trismus(lock-jaw)or j Imp" p I ~m r: tr.w.u.r.:.pr. clenched teeth * m m m • Burn injuries to upper airway m � . mm r II mm. Successful? NO � �Illf'lllll�li °�Ilil ROCURONIUM: (preferred) YES �I 1 m /k IV/I m repeat 1• O a e ea 9 9 y p i II III II't. � YES VERSED: 4— Post mtubation sedation(mandatory) mm IIII • 5-10 mg IV/IO may repeat X1 IIIII III IIII IIIII,� , KETAMINE: 011'1 • 200mg IV/IO slow IV push may repeat X1 1 V l V 581 17 Pediatric Advanced Airway i, '� E DO , Position and Suction Pre-oxygenate • Assist ventilations via Versed: BVM rKTAMINE: • 0.1 mg/kg IV/10 1mg/kg slow IV/10 push �, over 1-2 minutes • May repeat 1X • May repeat 1X Max single dose 50mg) Pre-medicate: Precaution: Versed or Ketamine Rapid IV administration is associated with higher increasesin BP Indications: sq"Aiu sill mu.l Hi�.wa��¢:^iruUxlia�iru V oll¢ irillcoro°olb�.' lire � I�M1a utiNliir�u)uruuw �an;rli��ll� Pre-treat for paralytics?: UxlUs�.wected Ika'IP V/10 g Cou"ntll can�li�^�rotuiuoun ATROPINE.02mk/kg I Eye iiun,�nuu.y ZI Paralysis Indications: SUCCINYCHOLINE: • Apneic Status Epilepticus • 1 mg/kg IV/IO may repeat 1X • Head Injury/GCS 9 or less oil iifContiralindicated low"Pill Iu..:.w . • Trismus(lock-jaw)or • ROCURONIUM clenched teeth • 1 mg/kg IV/IO may repeat 1X • Burn injuries to upper airway m II IV 'iu II III NO ..s.�. COCURONIUK PreferredSuccessful?1 mg/kg IV/10 may repeat 1 XIl YEsERSED: YES 0.1 mg/kg IV/10 may repeat X1 0II'1 Post intubation sedation(mandatory) mm mml I lii iiii Illllpil, I I I�ul KETAMINE: • 1mg/kg IV/10 slow IV push may repeat X1 J r V l n 582 583 i op (Ulm n rl/r a" I „ii w r � F s 0' v f e �'r l Grp 4 Decompression Sickness �..� INFORMATION • Signs &Symptoms • Stroke-like symptoms • Visual disturbances • AMS • Paralysis or weakness • Numbness/tingling • Bowel/bladder dysfunction • Any patient with these signs &symptoms who has used SCUBA gear or compressed air within a 48-hour period shall be considered a decompression sickness patient. • Transport to closest ED. • Contact DAN (Diver Alert Network) at 919 584v45 :5 for medical consultation as needed. • Treatment recommendations from DAN (Diver Alert Network) should be followed. • Document the treatment and the name of the representative on the ePCR Report. • Try to obtain an accurate history of the dive: • Depth of dives • Air mixture type in tanks • Number of dives • Interval between dives ADULT& PEDIATRIC 42 • Transport patient in a supine position • For cardiac arrhythmias, refer to appropriate protocol • Rule out a tension pneumothorax * OXYGEN 11111 15 LPM via NRB regardless of SP02 Non-Fatal Drowning �"0 INFORMATION Considers spinal motion restriction in the presence of trauma e. diving, rough surf, vehicle • p• p � g•, g, g , accident with subsequent submersion,etc.). ADULT &PEDIATRIC NON-FATAL DROWNING 41 • All non-fatal drowning patients MUST BE TRANSPORTED to the hospital • For cardiac arrhythmias, refer to appropriate protocol • CPAP )10 cirau 1-120) for pulmonary edema secondary to near drowning: Contiralin lcafionsa' 11P S I3 P < 1)0 11111111 I"" �11P PafiIeII'ats wlthout spoiin aIlleou, s respm lirafiI II"s Pa hints r litlh a c ecir ased II.00 )Iletlha irgL c) PafiIents. 30 II E IF PATIENT IS HYPOTENSIVE WITH CLEAR LUNG SOUNDS NORMAL SA�JNE: • Adult: • 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x, prn Pirecau.ufion; l�lautlic'.ullau cau" uriuu;t 1:aetaIl a liu t:Il e II a :; a ce ;Il a liflica iii c u" a au"yIluea ii"t alli ea e, 0 flf � and urenall falHu.uu•e a fi • Pediatric: • 20mL/kg IV/10, assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension IF PATIENT IS HYPOTENSIVE WITH PULMONARYA DopaIraaitIrue • Adult: Dopamine infusion 5mcg/kg/min-20mcg/kg/min titrate to effect �11P CoInti aaIIII"aawlllcafiIoIns I"" ypoteII"ammIlon mrecoII"ac'IaII"y o 191oo l loss 11P P1ire aV.Yfila"uln,;m' I" a�IIIliawl )`l inu.ut� onset ;Iln urn amp `l.0 imli ) �� u"ti�u' � ) u�u.u� awlu.uurafiin Mons toir wa art rate and IIDIIood aawlim nu atirafion • Pediatric: Epinephrine Infusion 0.1mcg/kg/min—lmcg/kg/min titrate to effect �11P CoIIatiraa III"aawlllcafiIoIns I"" ypoteII"ammIlon mrecoII"ac'IaII"y o 191oo l loss 11P P1ire aV.Yfila"nll : t1 II f""" III aawlumlin ,Steer f ;teir :Ilea n linq /inq nute Puu;Ilu 1) ,e Per ,sour f Ipunell hire ne ha,,; a uraIl lH (I umti nut ) on,;e:a ';Ihoir: )amp `l.0 umti nut ) awlu.uira fi n M nlit u• IIwairt rate and IIDIIood II u•e,;',;uuu•ethu•ouu hcau.ut a�awlamanaatira1:li n u Heat Emergencies ' INFORMATION • Signs&Symptoms of heat stroke include any of the following: • AMS When treating heat stroke: • Seizures • Hypotension "COOL FIRST,TRANSPORT SECOND" • Sweating may be absent • Patients with a heat-related illness associated with an altered mental status should be considered to have heat stroke once all the other possibilities for the AMS have been ruled out(hypoglycemia, drugs/alcohol,trauma,etc.). ADULT& PEDIATRIC it ALL HEAT EMERGENCIES • Move patient into the back of the rescue as soon as possible. Decrease the air-conditioning temperature in the patient compartment. • Obtain a temperature • Remove excessive clothing • Provide oral hydration (preferably water) if patient is able to swallow and follow commands EAT CRAMPS EAT EXHAUSTION NORMAL SAil..1i`> E • Adult: • 20ni IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 2x, prn Pirec u.ufi on; I:)autlic.ullau c u" a quu;t I:Det II uq liuq t:Il e II a lu ugce ;uLuglfflcaiiq c u" uq u" wair:Ali^area Se, 0 and iteuq II f lillu.uire II afi • Pediatric: • 20ni IV/10, assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension EAT STROKE WITH TEMPERATURE OF > 103 DEGREES F YII''1" ALTERED E TAL STATUS • Apply 10E PACKS to axilla and groin area. • Discoirffiiruu..aie ac:tiive c:ooIIiiiru1b oiruc:e teirrrapeitatu..aiite of 101 is ireached NORMAL SAil..1NE: (COLD NORMAL SAil..1NE preferred, if uuu,vuuu,iilluuu,Ik:lle) • Adult: • 20ni IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x, prn Pirec u.ufi on; 1: airfiicu.ullaur caire unquu t I:De taken in the II a eSence of ;uLuqlihcaiqt coiroi air wair:Ali^area S , 0 and iteuq II f lillu.uire II afi, • Pediatric: • 20ni IV/10, assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension � o We Carbon Monoxide Exposure w r DO INFORMATION Carbon Monoxide(CO) properties: • • Chemical asphyxiant • Colorless • Odorless • Tasteless • Slightly less dense than air • Toxic to humans when encountered in concentrations above 35 parts per million (ppm) • Lower doses of CO can also be harmful due to a cumulative effect • Patients exposed to carbon monoxide (smoke inhalation,etc.) require a full head to toe patient examination including SpCO monitoring. • All rescuing crew members shall wear their SCBA if the patient is in a hazardous environment. • Consider Cyanide Exposure. • Refer to the "Cyanide Exposure" protocol, if applicable ADULT& PEDIATRIC * OXYGEN: • 15 LPM via NRB regardless of SPOZ, unless the patient requires ventilatory support • Consider Advanced Airway Protocol if needed IF SPCO I >20%t;YII1 PATIENT PRESENTS WITHANY OF THE FOLLOWING SYMPTOMS • Headache • Nausea/Vomiting • Dizziness • Altered Mental Status • Chest pain • Dyspnea • Visual Disturbances • Seizures • Syncope Transport to closest ED. All''"III III IIA • Patients with CO exposures can have normal pulse oximetery readings and still be hypoxic. 0- vWEs Cyanide Exposure u INFORMATION Signs &Symptoms: • AMS • Coma • Pupil Dilation • Shortness of breath • General Weakness • Headache • Confusion • Dizziness • Bizarre behavior • Seizures • Excessive sleepiness • Cyanide exposures may result from inhalation,ingestion or absorption from various cyanide containing compounds, including exposure to fire or smoke in an enclosed space. • Direct cyanide exposure (non-smoke inhalation) is a Hazardous Materials Incident. • Consider Carbon Monoxide Exposure. • Refer to the "Carbon Monoxide Exposure" protocol (pg. 96), if applicable ADULT& PEDIATRIC is CONFIRMED SUSPECTED CYANIDE EX SU • 15 LPM via NRB regardless of SPOz, unless the patient requires ventilatory support • Consider Advanced Airway Protocol if needed • Transport to closest ED 590 4 W � ' IIIIIIIII I �. I tl ra f", ` P ! Stan ing ers (p. i 10 ilp '0 Trau a Arr- tanding' rders (pl. lol) �' Start, Jum, P, Qg. �° r � 103) f,✓°"� t' � ,� '� �)n �"", r. y 7 8 ^ �• o- ° y. ° i d rid ....... ... 'Ttau i ter^ � � le We$ B p 5:9 Chest �Tr , um' a t• Head, ,n ! M a n : . .,eS "(#. 119) r ,m^ yy Hemorrhagic ock " '2 0) ,fir ^ id Neuroyenic Shoce Trauma in , regn r r v III V � UIVVUVI � u IIVI�D U� 0- '00 Trauma Standing Orders µ INFORMATION ADULT &PEDIATRIC • The following conditions should be managed as soon as they are discovered: • M-Massive hemorrhage • A-Airway control • R-Respiratory Support • C-Circulation • H-Hypothermia • Unless otherwise noted, IV fluids should be given for a SBP < 90 mm Hg and should be given at a rate (boluses) necessary to maintain peripheral pulses(which is typically a SBP of 80-90 mm Hg). • ULTRASOUND FAST EXAM if available: • A FAST exam can be performed during transport of the following injuries: • Blunt force trauma to abdomen or thorax • Penetrating injury to abdomen or thorax • Undifferentiated hypotension in the presence of trauma • Can be performed to identify possible: • Intra-abdominal hemorrhaging • Intra-thoracic hemorrhaging • Pericardial hemorrhaging • Cardiac motion in PEA This exam shall be done in a prompt fashion and should IIN01 delay transport FAST Exam findings shall be communicated to the receiving facility and documented in the ePCR Glasgow Coma Scale Score Eye Opening Spontaneously 4 To Speech 3 To (Pain 2 hione 1 Verbal Response Orientated 5 Confused 4 Inappropriate 3 Incomprehensible 2 Done 1 Motor Response Obeys Commancls 6 Localizes to (Pain 5 Withdraws from (Pain 4 Flexion to (Pain 3 Extension to Pain 2 None 1 Maximum Score 15 I=- 12111111M Trauma Arrest Standing Orders I II�i ti l: nr ADULT &PEDIATRIC DETERMINATION OF EAT • Resuscitation should IltV' III"" be attempted for trauma patients that have All..11.. of the following presumptive signs of death present: • Apneic • Asystole • Fixed and dilated pupils • Injuries incompatible with life (e.g., decapitation, massive crush injury, incineration,etc.) SPECIAL CONSIDERATIONS PENETI'wATM OR Bl..I.JIl'` I'CI-IIESI'I'F'A(.JlIMA • Bilateral needle decompression may be performed in an attempt to achieve ROSC • Resuscitation efforts III')f") II t)° III"" need to be started if the patient did not regain pulses immediately following the bilateral needle decompression SPECIAL CONSIDERATIONS IN PENETRATINGAND BLUNT TRAUMA • Consideration should be taken to continue care for organ donation. I M=1 - 111MM •� r START Triage k Move the walking wounded No respirations after head tilt 'respirations > 301rnin. ° erfusian o radial pulse Cap refill > 2 sec � o� ental Status Unable to follow simple commands Otherwise DELAYED The goat of the START paro rainn s, pprovide+the "greatest goad for the gireatest number of ppat oats. 594 JumpSTART Triage 1-8 years old K , w ABLE TO YES Secondary ... .... .!wow .... .... � WALK? Triage* *Evaluateinfantsfirst in secondary triage using the entireJamp- STA4RTalgorithm NO BREATHING Breathing? > Position Airway APNEI+C Pulse NO YES YES APNEIC 5 Breathss s BREATHING q a 15oir>45 Respiratory r5 Rae? 15-45 NO Pulse? 0 > YES "P"(iinalppirelpiriate) Posturing eir"Ul„ AWPU "A" r,r ry rr ax A V oir P (Appropriate) > DELAYED f�,"V Trauma Communication Dispatch Procedure A.The City of Key West Fire Department(KWFD)utilizes the Key West Police Department Communication Center's (KWPD) 911 phone system in conjunction with computer-aided dispatch(CAD)programs. All emergency information,including address and call-back data,is confirmed by the call taker prior to the end of the telephone conversation. Emergency information is immediately transmitted to the Fire/Rescue dispatcher who selects the closest available unit for response.Units are dispatched at this time by the Fire/Rescue dis- patcher,who provides responding units with all available information concerning the incident. B. The Dispatcher obtains information from the caller regarding: C.Name of person calling D.Nature of Incident E.Type of Injury F. Call back number G.Number of patients H.Location of Incident L Extent and severity of reported Injury C. In the best interest of patient care,the closest available ALS transport unit shall be dispatched to all 911 emergency calls,regardless of response zones. Dispatch,Rescue Lieutenant,or Shift Commander shall identi- fy the closest unit. Closest Unit is defined as the nearest in terms of estimated response time,not necessarily the nearest in mileage. D. As soon as on-scene personnel recognize a need for other emergency agencies(e.g., law enforcement,fire, EMS, Coast Guard,or other services), they shall notify dispatch immediately. On-scene personnel must iden- tify the agencies needed and the specific amount of personnel,equipment, and other resources required. Dis- patch shall then make telephone contact with the appropriate services. Mutual aid contracts exist between all adjacent services. Additionally, a master phone list of all available emergency services is maintained at KWPD Communication Center. 596 f�,"V Trauma Alert Criteria The following guidelines are to be used to establish the criteria for a Trauma Alert patient and to determine which patient(s)will be transported to a trauma center. Any patient that meets any one of the ]CLJC�:L criteria will be classified as a Trauma Alert,while any patient that meets two of the 131.,i.J 1],,criteria will be classi- fied as a Trauma Alert. ADULT TRAUMA SCORECARD METHODOLOGY LUpon determination that the patient meets TRAUMA ALERT Criteria,the Paramedic in Charge or Incident Commander will initiate direct radio communications with the SATC, SAPTC or local receiving facility. Communications from field EMS personnel to the receiving facility will include the phrase "TRAUMA ALERT", and will include the following information: 1. Specific Trauma Alert Criteria,Mechanism of Injury, Glasgow Coma Scale (Itemized) 2. ETA to receiving facility 2. Each EMS provider shall ensure that upon arrival at the location of an incident,an EMT or paramedic shall: 1. Assess the condition of each adult trauma patient using the adult trauma scorecard methodology, as provided in this section to determine whether the patient should be a trauma alert. 2. In assessing the condition of each adult trauma patient,the EMT or paramedic shall evaluate the patient's status for each of the following components: airway, circulation,best motor response (a component of the Glasgow Coma Scale which is defined and incorporated by reference in section 64J-2.001(6),cutaneous,long bone fracture,patient's age and mechanism of injury. The patient's age and mechanism of Injury shall only be assessment factors when used in conjunction with assessment criteria included in(4)of this section. 3.The EMT or paramedic shall assess all adult trauma patients using the following criteria in the order presented and if any one of the following conditions is Identified, the patient shall be considered a trauma alert patient: aa. /lok c /l nN aav /luaskgaa icc LLa~apn:anivd ana°LLcsj)u aagafnv Raw 10 o1n `29 b. Lack o1'Raa&,d a'uukc aa,nGVi as S usuda icg q I ,110 By 'M oin By ' 90 na nu�lx a`. (_daas'u(m Conanaa Sc,,dc oll'i 3 oip Acss �. Lxan )n s p'n°a;sca lcc o a'aan V`^ak, adg4`^aj,)ll6wi hiJm4 V oi, Loss ( adcnisaaGnG, i e. Loam NLx,ive oin 31d NLx,ive Bnanis(_u caawia fli,,nu 1 L'%a ]'BS , FIccoic,,d Bnanis(f BiLanu V(4 aa.gc/ iu°a o Lig,;igauigg) LLa~kgnvdVcss(nll"Sud° acc Aivaa b`. Anaq)waap(wi N' oxnnnud w flue; Wiis� oin 4nuiallc L, anu° Man v Loqu awic II a°aac nanv ,anws Ca. l'a~umn°aaquuw inunn:nay w lua~aaal, nicck oin gan,so i.(_SW of l'a~Ion°'16: w Qnunu:au°y w Lxovnnniq;cs'm anu°aal)an c IIK nlce ann° Lhasa' n L"1cs� W,, ll Qnusud)d4 of, NllLnaala 4 01,ad L"Va sa) k. Bcsa Manp:m� LLesi)un ise Less]lu aua oin Equu,,d pan 4 1.L`a°auu icd, M,, nugleg, N...gllmcd oi, l'nukc➢css Lx:ovnnnwl(.y nx. l'vg ,,ni;y , 20 Weeks as%11Wonn6i i,,ll l'aaina ,nid Mum l n°aaauunaaa n. l'aaa°aannncdg ;J uduc nna in I ... ... iiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuiiiiiiiii f�,"V Trauma Alert Criteria Cont. Should the patient not be identified as a trauma alert using the criteria listed above this section,the trauma patient shall be further assessed using the criteria below and shall be considered a trauma alert patient when a condition is identified from any two of the components included in this section: su 11ead pnoury w/1-,0 `, Aran sia., or New Altered Nl(¢rxntal Stattis pr daft l hme Loss Injury (crush, degloving)lovinag) or Deep Flap Avulsion> 5 inch c Penetrating Injury to To p:r acurug.es Distal to the L,,lbow or Knee d Single Io ngg bone 1 .ul siges due to llyVA or single pong bonne fla gtac she diner to fall g,ntater tan or equal to 10 foci, e Nl(gjor deglovinng, nap evu lsio n greater g.hwxn 5 inches, or (;JSW to er(,,grcrri g.ics g Best,Nl(a;rtor response ::: 2 E?,j¢rs:g.uon ams a vehicle or upeforrrie p sg.e¢r bg wheel h Death in Sarri- Passennger p`orrip arn.urr.e ng. i. FAI => 20 let, ,Y Auto vs. Pedestrian /Bicyu.piing., ' hrowxn, Run Over or w/uurrpra g.-> 20N4111-1 k Nl(a;rtorcycle, (Jolf`p`tort.or ATV'Crash`rash > 20N4PH p. Age 55 or older 5.In the event that none of the criteria above are identified in the assessment of the adult patient,the EMT or paramedic can call a"Trauma Alert" If, in his or her judgment based upon the criteria noted in section"C"below, the trauma patient's condition warrants such action. Where EMT or paramedic judgment is used as the basis for calling a trauma alert,it shall be documented as required in 64J-1.004 of the Florida Administrative Code. 6.If the patient is not identified as a trauma alert patient after using the above criteria, the trauma patient will be evaluated using all elements of the Glasgow Coma Scale. If the patient's score is less than or equal to 12,the pa- tient will be considered a"TRAUMA ALERT"patient(excluding patients whose normal GSC is less than or equal to 12 by past medical history or known pre-existing medical condition). 7.The results of the patient assessment shall be recorded and reported in accordance with the requirements of section 64J-1.014 Patients who are found to meet the Trauma Alert criteria on arrival at or subsequent to arrival at a non-trauma center will be expeditiously transferred to the appropriate trauma center. IIII III II�III 598 I ... ... iiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuuuuuuuuuuuuuuuuuuuuuuuuuiiiiiiiiiiuuuiiiiiiiii II Pediatric Trauma Alert Criteria �� µ I PEDIATRIC TRAUMA ALERT CRITERIA 64J-2.005 PEDIATRIC TRAUMA SCORECARD METHODOLOGY For children,the term "pediatric trauma" applies to those injured persons with anatomical and physiological char- acteristics of a person fifteen (15)years of age or younger. If there is doubt as to whether or not the patient should be considered to be a pediatric patient,the EMT or Paramedic may measure the patient using a length-based resus- citation tape. If the patient falls within the maximum length of the tape,the patient should be considered a pediatric patient. LUpon determination that the patient meets TRAUMA ALERT Criteria,the Paramedic or EMT on scene will initiate direct radio communications with the SATC,SAPTC or local receiving facility. a. Communications from field EMS personnel to the receiving facility will include the phrase "TRAUMA ALERT",and will include the following information: 1. Specific Trauma Alert Criteria 2. Mechanism of Injury 3. Glasgow Coma Scale (itemized) 4. ETA to receiving facility 2. The EMT or paramedic shall assess all pediatric trauma patients using the following red criteria and if any one of the following conditions is identified, the patient shall be considered a pediatric trauma alert patient: ,E. Ann°aa aay A aa`^aV*ada2laicc or uunp:uaaaaawd b. Rcsj)uraawry Raw 20(lnullaam llyr) Rcsj)uraap. ry Raw 10 (0idd llyn 15yr) c. 111p.a°rcd V"Vncm,,d *aTl:a$dg s, p:uaandysk, `^auisjnca"da"41 4."a',brd or �G,bass o `^adann`^a$a6wl G�. Weak or gw j),,dj:),,dflc caan°o6d or lla~nwnA 1)ud cs, Sy*aG;0.h� c Mood N°6"*a*ag4 v 1css fli,,nn 50 e. Ary olmi iabuuy;a)wis 1raac uire or nuuud6lula; 1raaa;p.ire s ws or pwaa0fle dkVaba;aap.iwls b".MaJor solo. 6ss is dkruapu6wi, a auunluuapaapuwl J)rox.inu ,'d w NN,rku o r aauWc, sccwid or fliird degree Ninis w ll 0"%a BSA, a~Va~a;G6c,,d anu:an is 01n5_" l a(dG,aa.,a"%41Vn°co hg,�ad;VaVgg) re.aau°a11a ss o aiu:auIlicc area g. Naa16 ra2dVgal" VViJ 4ay w �icaad, Va16;4."A" or d0.hrso Ca. aIaaraanu cdic hadgcnuua iu 3. In addition to the criteria listed above, a trauma alert shall be called when a condition is identified from any two of the D lw-components included below. au Arri nesiau or reliable 1I of'l,i:1( 1) Carotid or i¢auxroraa➢ lrudse paa➢paaD hn l no pedal pidarea or systolic: 11111ess than 90 as Single Long bone 1'aaaa:tim, Sit ai Red, llanu"ple less than 1 lkg(less than 24 lbs) II Pediatric Trauma Alert Criteria Cont. �� µ I 4. In the event that none of the criteria above are identified in the assessment of the adult patient, the EMT or para- medic can call a"Trauma Alert" if,in his or her judgment based upon the criteria noted in section -C below,the trauma patients condition warrants such action. Where EMT or paramedic judgment is used as the basis for calling a trauma alert. It shall be documented as required in 64J-1.014 of the Florida Administrative Code if the patient is not identified as a trauma alert patient after using the above criteria,the trauma patient will be evaluated using all elements of the Glasgow Coma Scale. If the patients score is less than or equal to 12,the patient will be considered a TRAUMA ALERT patient(excluding patients whose normal GSC is less than or equal to 12 by past medical history or known pre-existing medical condition). The results of the patient assessment shall be recorded and re- ported in accordance with the requirements of section 64J-1.014 Patients who are found to meet the Trauma Alert criteria on arrival at or subsequent to the arrival at a non-trauma center will be expeditiously transferred to the ap- propriate trauma center. II Transport Destination Criteria u . TRANSPORT DESTINATION CRITERIA 64J-2.002 There are no state approved trauma centers in Monroe County. Therefore,it is the decision of the Medical Direc- tor,Dr. Antonio Gandia, that it is in the best medical interest of patients who meet-TRAUMA ALERT-criteria as set forth in 64J-2.004,F.A.C. and 64J-2.005 F.A.C. and as outlined in these Trauma Transport protocols to be transported as expeditiously as possible to a SATC, SAPTRC or in certain circumstances to the local hospital clos- est to the scene for evaluation and stabilization,prior to transfer to Ryder Trauma Center,Kendall Regional Medi- cal Center,Jackson South Community Hospital,Nicklaus Children's Hospital or another facility. LKWFD has access to a public use helicopter, "TRAUMA STAR",operated by the Monroe County Sheriff and licensed for emergency medical transport by Monroe County Fire Rescue. TRAUMA STAR has aircraft based in Key West and Marathon both Air Ambulances will respond to incidents,when summoned,to transport TRAUMA ALERT patients to the closest Trauma Center to the location of the incident. The current closest Trauma Centers to our response area are Ryder Trauma Center,Kendall Regional Medical Center,Jackson South Community Hospi- tal and Nicklaus Children's Hospital,or to a local receiving hospital for emergent stabilization prior to transport to a SATC, SAPTC,or other receiving facility. 2.An agreement with Monroe County and Jackson Memorial Hospital/Ryder Trauma Center allows for TRAU- MA ALERT notification to be immediately shared with Ryder Trauma Center in order to facilitate the most expe- ditious transport of the patient to the appropriate trauma receiving facility in Dade County, from the scene,or from the local receiving hospitals. 3.Any patient meeting Trauma Alert Criteria will be considered a TRAUMA ALERT PATIENT and should be transferred as expeditiously as possible from the scene or local receiving hospital(depending on the location of the incident)to SATC or SAPTC. TRAUMA ALERT patients injured in the Key West Fire Department response area may be flown directly from the scene of the accident provided access to Trauma Star is the most expeditious meth- od of transfer. TRAUMA ALERT patients unable to be flown or requiring emergency airway management that is unable to be secured on scene should be taken by ground ALS to Lower Keys Medical Center ED for emergent stabilization prior to transfer to the SATC or SAPTC. 4.If circumstances prohibit direct scene transport to SATC,then Trauma Alert patients will be taken to the nearest emergency facility(Lower Keys Medical Center)by the most expeditious means(air or ground) for stabilization and treatment prior to possible transport to SATC or SAPTC. 5. Definitions: a.Trauma Center: A State Approved Trauma Center(SATC)or State Approved Pediatric Trauma Center (SAPTC).Appropriate SATC for Monroe County Is the Ryder Trauma Center at Jackson Memorial Medical Cen- ter in Miami, Kendall Regional Medical Center,Jackson South Community Hospital. The appropriate SAPTC for Monroe County Is the Ryder Trauma Center at Jackson Memorial Medical Center or,Kendall Regional Medical Center,Jackson South Community Hospital and Nicklaus Children's Hospital. b.Emergency Facility: A hospital emergency department capable of providing care to most emergency patients and meeting the five emergency department criteria in 64J-2.002 F.A.C. (Does not include freestanding emergency walk-in-clinics.) The emergency facilities in Monroe County are Lower Keys Medical Center in Key West and Fisherman's Hospital in Marathon. The destination is determined by the closest hospital,in terms of transport time. IIIIIII IIIIII IIIII II Transfer of Trauma Patient Care �� µ I TRANSFER OF PATIENT CARE INFORMATION A Trauma Work Sheet shall be completed for every Trauma Alert patient on-scene by KWFD personnel and will accompany the patient to the receiving helicopter crew and/or emergency facility. An Electronic Patient Care Re- port(Eper) shall be completed as defined in section 64J-2.001(9)F.A.C.by the KWFD personnel that were on- scene care providers for every patient. Additionally, The KWFD Eper will be forwarded to the receiving facility when completed. A KWFD Eper shall be completed for each trauma patient including victims found dead on sce- ne,regardless of whether KWFD transports the body. This emergency call data will then be submitted to the Flori- da Dept. of Health as required. �uuiii I°1lllllluuuiii ai� II Trauma Alert Transport Procedures u A. Upon arrival at the scene,paramedic and emergency medical technician(EMT)personnel shall con- duct a size up of the scene,to include the Trauma Alert Criteria as outlined in this protocol including the Trauma Scorecard Methodology in 64J-2,safe entry,the need for extrication, and the need for additional help. Multiple patients shall be immediately triaged. KWPD and the primary receiving hospital will be notified, as soon as possi- ble,of"Trauma Alert"patients. The paramedic,emergency medical technician,or dispatch shall immediately re- lay this information,using the words"Trauma Alert",to the hospital and/or Trauma Star. B.In the best interest of patient care, seriously injured patients that meet Trauma Alert Criteria shall be transported directly to a State Approved Trauma Facility by means of an Air Ambulance Helicopter. Trauma Star,operated by Monroe County Sheriff's Office and Monroe County Fire Rescue,is the primary State Approved Air Ambulance Helicopter to be utilized for emergency patient transport for Key West Fire Department Trauma Alert patients. Key West Fire Department protocols shall be followed in determining a patient's status and need for immediate air transport by Key West Fire Department Paramedics on scene. EFFECTIVE JUNE 1,2017,THE AIR AMBULANCE HELICOPTER REQUEST AND DISPATCH PROCESS WILL BE AS FOLLOWS: Key West Fire Department shall directly contact Monroe County Sheriff's Communications(MCSO)to request Trauma Star be placed on STANDBY upon initial dispatch of the emergency call for service if air transport is sus- pected to be necessary. If/when the patient is confirmed to be a TRAUMA ALERT,and air transport is neces- sary, KWFD will contact MCSO to request Trauma Star to LAUNCH.When the request is made to launch Trau- ma Star,the following information must be given: • Helispot location (Lower Keys Medical Center,Key West Int. Airport, Trumbo Point,Truman Annex NAS) • Mechanism of injury(MVA, fall, stabbing, etc.) • Current Patient Status(primary impression,vital signs, airway status) • Patient Weight KWFD may request KWPD to contact MCSO for Trauma Star requests if needed. KWFD or KWPD shall also contact Lower Keys Medical Center ED to advise that KWFD is bringing a TRAUMA ALERT patient to the Lower Keys Medical Center Helipad for a patient transfer with Trauma Star. The direct number into Monroe County Sheriff's Office Communication Center is (305)289-2371. The direct number to Lower Keys Medical Center ED is(305) 294-9691. If Trauma Star is not immediately available for patient transfer, the patient will be transported to Lower Keys Medical Center ED for treatment. KWPD dispatch may be requested by the Key West Fire Department to contact additional agencies for aircraft to respond for the transport of Trauma Alert patients if the need arises. 11111911111!!111°°IIIIIIIIIIIIIIIIIIIIIIIIII 603 II Helicopter Transport Criteria �� µ I Two sets of criteria must be considered. The first is directed toward the safety of the helicopter pilot and crew,the ground personnel,the patient, and bystanders. The second is intended to establish operational guidelines for when the helicopter is to be requested for Trauma Alert patients. 1. Safety criteria(helicopter will not be used). A.Severe weather B.Power lines too close to landing area C.Trees, signs,poles,or other obstacles in immediate landing area D.Large gatherings of civilians in the area E.An expectation that the area may not remain safe 2. Operational Criteria(helicopter will be used) F.If the patient is considered a Trauma Alert patient as outlined in this protocol G.Blockage of the main road or failure of a bridge making ground access to the nearest receiving hospital impossi- ble H.If ground transportation is not available and is not expected to be available within a reasonable amount of time LIf the helicopter is needed to gain access to the patient or needed to transport the patient out of an inaccessible area J.Extrication time greater than(20)minutes K.Mass Casualty Incident I IIIIII f�, Emergency Inter-Facility Transfer01 A.There are no state approved trauma centers in Monroe County. The closest available service for air transport of Inter-facility Medical Transfers (out of county)is in Monroe County. On occasion, a TRAUMA ALERT patient may be transported by air or ground to a local hospital for stabilization/treatment prior to transport to a SATC or SAPTC. B.If after Initial evaluation and stabilization of the patient,the initial receiving facility deems transfer to another facility to be necessary and in the best medical interest of the patient. This may be accomplished either by ground or air transport. C.Should air transport be deemed to be the appropriate method for the transfer, the Initial receiving facility direct- ly contacts TRAUMA STAR or another air medical provider. Landing facilities are available for rotor wing air- craft at all local hospitals. D.Should the initial receiving facility deem ground transport appropriate the hospital will arrange transportation of the patient. Key West Fire Department may be called upon to assist the local hospital in ground transportation of a trauma patient. E.Should supplemental personnel such as medical or nursing staff respiratory therapy staff, etc.be necessary to assist the EMS crew for optimal patient care,the transferring hospital will coordinate the necessary personnel to accompany the EMS ground transport personnel. F.Key West Fire Department may transport adult"Trauma Alert" patients to Jackson Memorial Ryder Trauma Center(305) 585-1152,Kendall Regional Medical Center(305)223-3000,Jackson South Community Hospital (305)251-2500 and Nicklaus Children's Hospital if appropriate staffing and ALS transport units are available. G.Key West Fire Department may transport pediatric "Trauma Alert"patients to the following Pediatric Trauma Centers:Jackson Memorial Ryder Trauma Center(305) 585- 1152,Kendall Regional Medical Center,Jackson South Community Hospital and Nicklaus Children's Hospital (305)666-6511 if appropriate staffing and ALS transport units are available. IIII III III�III I III f�, YMedical Director Approval A. These protocols have been submitted by Key West Fire Department and have the approval of the � agency Medical Director,Dr. Antonio Gandia MD FACEP NREMT. a.Approved trauma centers and initial receiving hospitals 64J-2.002.Approved trauma centers and pediatric trauma referral centers. LRyder Trauma Center,University of Miami,Jackson Memorial Medical Center Adult and Pediatric Trauma Care. 2.Kendall Regional Medical Center 3.Jackson South Community Hospital 4.Nicklaus Children's Hospital b. Approved Local Receiving Facilities 1.Lower Florida Keys Medical Center,Key West 2.Fishermen's Hospital,Marathon B. Distribution of trauma transport policy The SATC, SAPTC,and receiving facilities to which Key West Fire Department routinely transports patients have been provided with a copy of the criteria which are used to determine trauma transport destinations C. Transport deviation Any deviation from these Trauma Transport Protocols must be documented and justified on the run report. D. Pre-hospital providers included Pre-hospital providers covered under this Trauma Transport Protocol are for the Key West Fire Department. ulm w Burn Injuries fill INFORMATION • Advanced airway procedures shall be considered for patients with respiratory involvement (i.e., hoarse voice,singed nasal hairs,carbonaceous sputum in the nose or mouth,stridor or facial burns). FIRST DEGREE BURNS • Involves only the epidermis and are characterized as red and painful SECOND DEGREE BURNS • Involves the epidermis and varying portions of the underlying dermis with blistering THIRD E EE BURNS • Involves deep tissue damage and will appear as thick, dry,white, leathery burns(regardless of race or skin color) ADULT& PEDIATRIC • Stop the burning process by irrigating with copious amounts of room temperature water or NORlMAL. SAL.IIyVE for 2 minutes. lWv it apply ice fflirec lly to Ibu.uirins. • Determine Total Body Surface Area (TBSA) percentage of the burn • :fi(°) II (°)°"III""attempt to remove tar, clothing,etc., if adhered to the skin • Remove jewelry and watches from burned area • Consider Pain Management Protocol • :fi(°) II (°)°"III"" use IM route for medication administration • Consider Carbon Monoxide and Cyanide Exposure 1st 2nd DEGREE U S G 15%T SA or 3rd DEGREE U S G 5%T SA • pp y a ry steri e dressing 2nd DEGREE U S> 15%T SA or 3rd DEGREE BURNS >5%T SA **Trauma Ale ** • pp y a ry s eri a urns ee NORMAL SA�JNE * 5 yeasts and you..iiruibeit 1 5irrraII pelt lirrm.iit * 6 13 yeasts 6Id 50 irrraII pelt lirrm.iit * 14 yeasts and 6Ideit 500irrraII pelt lirrm.iit ELECTRICAL BURNS • Treat associated burns as indicated. • If patient is in cardiac arrest,follow appropriate protocol. CHEMICAL U S • Irrigate liquid chemical burns with copious amounts of water or sterile saline. Brush off dry chemicals prior to irrigation. • Remove patient's clothing and ensure that the patient is decontaminated prior to transport, in order to avoid contaminating personnel and equipment. Personnel shall wear protective clothing and/or respiratory protection as needed when removing chemicals. i 607 Burn Injuries continued... ya o ADULT& PEDIATRIC Adult Child 44 U% wr 18% p u ,5 4.5. 1 tam � ti y 4.5% r, w 9% Infant 1:8 18 Palm and fingers 13.5 43.5 of patient = 1% TBSA "sos �W w Chest Trauma INFORMATION FLAIL CHEST • Occurs when 2 or more adjacent ribs are fractured OPEN PNEUMOTHORAX (SUCKI GCHESTWOgND) • Occurs when air enters the pleural space,causing the lung to collapse TENSION EU T A • Occurs when air continues to enter the pleural space without an exit or release, causing an increase in intrathoracic pressure • Intrathoracic pressure decreases cardiac output and gas exchange. ADULT& PEDIATRIC it PENETRATING OJECTS • Stabilize with a bulky dressing FLAIL CHEST • Stabilize with a bulky dressing. • Consider Advanced Airway if needed OPEN PN EU MOTH ORAX(SUC I NG CHEST WOVYD) • Apply a vented chest seal or occlusive dressing to all open chest wounds and monitor for signs & symptoms of a tension pneumothorax • Apply on expiration if possible TENSION EU T A • Needle decompression should be performed when Ail. of the following findings are present: • Respiratory distress or difficulty ventilating with a BVM • Decreased or absent breath sounds to the affected side • Primary site: • 2nd or 3rd intercostal space, midclavicular line • Secondary site: • 5t" intercostal space of the midaxillary line mµ Head Injuries w " EDOA INFORMATION • Patients with a depressed LOC may be unable to protect their airway. • Adequate oxygenation of the injured brain is critical to preventing secondary injury. • Consider Advanced Airway Management. • Especially for patients with a GCS of< 9 • If patient becomes combative refer to the "Chemical Restraint" protocol (pg. 85-86) INTRACRANIAL PRESSURE/HERNIATION SIGNS INCLUDE: • A decline in the GCS of 2 or more points • Development of a sluggish or nonreactive pupil • Paralysis or weakness on 1 side of the body • Cushing'sTriad: • A widening pulse pressure(increasing systolic, decreasing diastolic) • Change in respiratory pattern (irregular respirations) • Bradycardia ADULT &PEDIATRIC ALL HEAD INJURIES • OXYGEN: • As needed to maintain SP02 of 94%. Ventilate as necessary to maintain ETCO2 of 30-35mmHg • Consider Advanced Airway Protocol • NORMAL SALINE: • Adult: (only enough to maintain SBP of 110-120) • 20ml/kg IV/I0,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x, prn I'irec u.ufioi ; I:lautlic.ull u c u" a quu;t I:::et II uq liugt:Il e II a :; ugce ;uLuglfflcaiiq c u" uq u" na airt Ali^Sea�e, 0 flf and ureuq II fain. ire Il afi • Pediatric: (only enough to maintain an age appropriate SBP within normal range. Refer to"Handtevy" system) • 20mL/kg IV/I0, assess lung sounds and BP frequently • May repeat 2x prn for age appropriate hypotension DEPRESSED E SKULL FRACTURE • Pressure dressings should not be applied to depressed or open skull fractures unless there is significant hemorrhage present,as this can cause an increase in ICP !gELHERNIATION • 30'head elevation AII'flIJIIIING A SINGLE INSTANCE OF HYPOTENSION OR HYPDXIA(SP02<90%) IN PATIENTS WITH A BRAIN INJURY MAY INCREASE THE MORTALITY RATE BY 150%. i I mill= I1610 w Open Fracture ADULT and PEDIATRIC • Gross contamination,such as leaves or gravel, should be removed if possible • Consider Pain Management Protocol • Cover open fractures with a moist sterile dressing • Fractures should be splinted in the position found • Exception: No pulse present t;YII''I" the patient cannot be transported due to the extremity's unusual position • 2 attempts can be made to place the injured extremity in a normal anatomical position. • Discontinue attempts if the patient complains of severe pain or if there is resistance to movement felt • Reassess neurovascular status before and after repositioning of patient's extremity m w Hemorrhagic Shock w ,m r Dt? INFORMATION COMPENSATED SHOCK C SATE SHOCK • Anxiety • Decreased LOC • Agitation • Hypotension • Restlessness • Peripheral cyanosis • Normotensive • Delayed capillary refill • Capillary refill normal to delayed • Inequality of central/distal pulses • Tachycardia • Tachycardia ADULT &PEDIATRIC 01 • Maintain body temperature with blankets and consider increasing the temperature in the patient compartment • Control all major external bleeding • Establish bilateral vascular access, utilizing largest catheter size possible • NORMAL SA1.N E: (only enough to maintain peripheral pulses or Systolic BP of 80mmHg) • Adult: • 20 ml/kg IV/10,titrate to desired effect.Assess lung sounds and BP frequently. • May repeat 1x, prn I'irec u.ufioi ; I': airfiicu.ullai caire nquu; 1:De taken in the a e,Sence of ;u uqli.hcaiqt coiroi air na airt Ali^Sea Se, 0 flf and ureuq II faHu.uire Il afi • Pediatric: • 10 mL/kg for infant/neonate.Assess lung sounds and BP frequently. • 20 mL/kg IV/10. Assess lung sounds and BP frequently. • May repeat 2x prn,for age appropriate hypotension Neurogenic Shock INFORMATION Signs &Symptoms: • Warm/Dry skin (especially below the area of the injury) • Hypotension with a heart rate within normal limits • Paralysis ADULT • Maintain body temperature with blankets and consider increasing the temperature in the patient compartment 0 NORMAL SAI..IUE • 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 2x, prn I': irec u.ufii u ; Pairficu.ullai caire nquu; I:De taken in the II a e,Sence of Sgiq hcaiqt coiroi airy wair: Ali^,ea Se, 0 flf and ureuq II faHu.uire Il afi • If BP does not increase consider Dopamine 5 mcg/kg/min and titrate to effect (maximum dose 20mcg/ kg/min) PEDIATRIC • Maintain body temperature with blankets and consider increasing the temperature in the patient compartment 0 NORMAL SA1..1UE • 20mL/kg IV/10, assess lung sounds and BP frequently • May repeat 2x prn,for age appropriate hypotension • If BP does not increase consider Dopamine 5-15 mcg/kg/min. Use a microdrip (60 gtt/mL) and refer to the Handtevy Medication Guide for drip rate based on patient weight or age. � Ir^ 613 "' i u Trauma in Pregnancy ko "" INFORMATION PHYSIOLOGICAL CHANGES DURING PREGNANCY • Due to the following physiological changes in pregnancy, it is often difficult to assess for shock: • Mother's heart rate increases. • By the third trimester,the HR can be 15-20 beats per minute above normal. • Both the systolic and diastolic blood pressures drop 5-15 mm Hg during the second trimester. • The mother's cardiac output and blood volume increases. • Therefore,the pregnant patient may lose 30-35%of her blood volume before the signs &symptoms of shock become apparent. • Supine hypotension usually occurs in the third trimester. ADULT • Assess for vaginal bleeding and a rigid abdomen • In the third trimester,this could indicate an abruptio placenta or a ruptured uterus POSH10NNG: • Pregnant patients not requiring spinal motion restriction shall be transported on their left side • If a pregnant patient requires spinal motion restriction, place 4-6 inches of padding underthe patient's right side while maintaining normal anatomical alignment ALL THIRD TRIMESTER PREG A CY TRAUMA ATIE TS OXYGEN • 15 LPM via NRB regardless of SpOZ, unless the patient requires ventilatory support IF HYPOTENSIVE • Establish bilateral vascular access, utilizing largest catheter size possible • NORMAL.SAI-N E (only enough to maintain peripheral pulses or systolic BP 100mmHg): • 20ml/kg IV/IO,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x, prn I': irec u.ufioi ; . Pairficu.ullai caire nquu; L:De taken in the II a e,Sence of S�giquhcaiqt coiroi airy wair: &,Sea Se, 0 flf and ur uq II fain. ire Il afi 614 615 1 o th /%,,,?find,yiyil� / %//Pl' it rr� yi/ice , / %/ ��r%r 616 Standing Orders ' E rat? INFORMATION • Obstetrical patients are defined as gestation >20 weeks. PHYSIOLOGICAL CHANGES U I G PREGNANCY • Mother's heart rate increases. • By the third trimester,the HR can be 15-20 beats per minute above normal. • Both the systolic and diastolic blood pressures drop 5-15 mm Hg during the second trimester. • The mother's cardiac output and blood volume increases. • Therefore,the pregnant patient may lose 30-35%of her blood volume before the signs &symptoms of shock become apparent. • Supine hypotension usually occurs in the third trimester. o ADULT • Perform initial assessment POSH IOMNG: • Transport patients in their third trimester and not in active labor on their left side IF WATER HAS BROKE • Document: • Time • Color of fluid IF BLOOD PRESENT • Document: • Time • Volume IF CROWNING • Prepare for a field delivery • : O Il f")III""delay transport to the closest appropriate hospital FOCUSED IST • Obtain: • Number of previous pregnancies (GRAVIDA) • Number of previous viable births(PARA) • Documented multiple births? • Gestational Diabetes? • Narcotic use? • Due date? • Frequency and length of contractions? • Feeling of having to push or have a bowel movement? 617 1" & 2nd Trimester Complications INFORMATION 1"TRIMESTER • Weeks 1 - 12 of the pregnancy 2nd TRIMESTER • Weeks 13 - 27 of the pregnancy ECTOPIC PREGNANCY(usually first trimester) • Signs &Symptoms: • Sudden onset of severe lower abdominal pain • Vaginal bleeding • Amenorrhea (absence of menstruation) • Referred pain to the left shoulder • Cullen's Sign (periumbilical ecchymosis) • Grey Turner's sign (ecchymosis of the flanks) • Abdominal distention and tenderness SPONTANEOUS A TI (usually efore 20 wee s of gestation) • Signs &Symptoms: • Abdominal cramping • Vaginal bleeding • Passage of tissue or fetus f ADULT • Assess and treat for shock • Rapidly transport to any approved OB or GYN facility FOR ACTIVE BLEEDING • Place loosely placed trauma pads over the vagina in an effort to stop the flow of blood • )t"°) II (°)°"III"" pack the vagina IF HYPOTENSIVE NORlidAI.. ":AI..INE • 20ml/kg IV/10,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat 1x, prn I': irec u.ufioi ; I:l utuccuull u c u" a quu;t �:De t II uq uuq Ulna II a :; ugce f ;uLuquflicaiiq c u" uq u"y Ilue u"t &,Sea Se, 0 flf and ur uq II faHu.uire Il afi iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillillillillI MINI n WEST 3rd Trimester Complications � f BEV INFORMATION THIRD TRIMESTER • Weeks 28 -delivery PLACENTA ABRUPTIO • Signs &Symptoms: • Sudden onset of severe abdominal pain and tenderness • Painful uterine contractions • Vaginal bleeding with dark red blood • Patient may present in shock PLACENTA PREVIA • Signs &Symptoms: • Painless vaginal bleeding(bright red blood) UTERINE RUPTURE • Signs &Symptoms: • Sudden,intense abdominal pain • Vaginal bleeding o ADULT • Assess and treat for shock • If in cardiac arrest referto the "Cardiac Arrest Special Considerations" protocol • During transport, place 4-6 inches of padding underthe patient's right side while maintaining normal anatomical alignment FOR ACTIVE BLEEDING • Loosely place trauma pads over the vagina in an effort to stop the flow of blood • :fi(°) II (°)°"III"" pack the vagina IF HYPOTENSIVE (BP less than systolic 100mmHjd NORMAL ":AI_NE • 20ml/kg IV/IO,titrate to desired effect. Assess lung sounds and BP frequently. • May repeat as needed I�Illl llllllllllllllllllllllllllllllllllllllllllllllllllllf Illllllllllllllllllfpllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Placenta P wr v i a Placenta 9nternal separated frcarrea Bleeding fj �hi23 uterus %{ 1 rr r a External Bleeding � 619 Pre-Edam psia/Eclam psia jRE 08 INFORMATION SEVERE PRE-ECLAMPSIA • A rare pregnancy complication characterized by high blood pressure that usually begins after 20 weeks of pregnancy. • Signs &Symptoms: • HTN (SBP > 160 mm Hg (Ylf''1" a DBP of> 110 mm Hg) with any of the following: • AMS • Visual disturbances • Headache • Peripheral edema ECLAMPSIA • Signs &Symptoms: • Any of the severe pre-eclampsia signs &symptoms associated with: • Seizures f;Ylf''1" Coma • Either condition can occur for up to 30 days postpartum. ADULT Check blood glucose level SEVERE E-ECLA SIA T I ACTIVE LA ) • 2g of Magnesium Sulfate infusion • Administer over 5 minutes Imo .,oIIrr�:Ilaallll'rr�Illa�afi 1" ;; rri iree I�ea art flock�m�" purr � a�urrcl .� II��L I"�,.e Ica�u.ufioirr Gf Il li li III urr"uu;Ilurr u�rra�� u�a�u.u; a ��urr;liurr • L.ALfETAL.OL. )If arystolhc: Iblreateir Ali ain 160irrrulrrruFig): 10 mg Slow IVP over 2 minutes ECLAMPSIA If ac:tilv6y seizr it g adirrruillruilsteir Beinzodc azep ine c:oIruc:u..allrlrc.Min wil h IMaIblruesh..allrn S..i lfate • 4g of Magnesium Sulfate in a 50mL bag of Nf".dRlMAL. S,/fI-NE • Administer IV/10 push Imo ,fplllltirallll"ll��llca fi 1" ;; rri iree I�ea in "TIock�m f" purr f a�urrcl .L II��L I': irecau.ufioirr Gf l II liuo..uu;Ilurr u�rra�� u�a�u.u; ,.u�"II ��axiurr.;liurr • L.ALfETAL.OL. )If systolhc: Iblreateir tlirralru 160irrrulrrruFig): 10 mg Slow IVP over 2 minutes IF UNABLE TO ESTABLISH VASCULAR ACCESS A G i`aL E S I a.JI IM SULFATE: • 4g IM (must be divided in two separate sites) Imo ,fpll�l�:Ilaallll 'Enka fi 1" ;; rri iree I�ea in �Iock�m f" purr f a�urrcl .L II��L If severe Hypertension exists without signs of pre-eclampsia. (Systolic greater than 160mmHg) consider hypertensive protocol. Meconium Staining N INFORMATION Meconium will appear as a yellow to dark green substance that may be noted in the amniotic fluid, • coming from the vagina or covering the neonate's head. NEONATE MECONIUM STAINING • If upon delivery of the head there is meconium staining present: • Use a bulb syringe to clear secretions from the mouth and then nose before delivery of the shoulders • Meconium aspirators are rarely needed, however consideration for usage may be given in patients whose airway is obstructed by meconium that cannot be cleared by simpler methods 621 Normal Delivery K w , . ADULT NORMAL DELIVERY • POSFIONNG: • Place patient on her back with knees flexed and feet flat on the floor • Control delivery of the head,with gentle perineal pressure • f"' Ilf"'°"III"" apply manual pressure to the uterine fundus prior to the birth of the child • f"' III"" pull or push on the neonate • f"' III""allow sudden hyperextension of the neonate's head • Once the head delivers: • Suction the mouth and then the nose • Support the neonate's head as it rotates to align with the shoulders,gently guide the neonate's head downward to deliver the anterior shoulder • Once the anterior shoulder delivers,gently guide the neonate's head upward to deliver the posterior shoulder and the rest of the body UPON DELIVERYF THE NEONATE • Dry,warm, and stimulate the neonate • Keep the neonate at the same level of the placenta • Once the umbilical cord stops pulsating(usually 3-5 minutes): • Clamp the cord in the following fashion: • Place the first clamp 4" away from the neonate's body • Milk the cord away from the neonate and towards the mother(this will minimize splatter) • Place the second clamp 2" away from the first,towards the mother • Cut the cord between the 2 clamps • Place the neonate on the mother's chest,skin-to-skin, and cover with a dry blanket • Record and encode an APGAR score at 1 and 5 minutes and document the delivery time • Apply firm continuous pressure, manually massaging the uterine fundus after the placenta delivers • Preserve the placenta in the bag provided with the OB Kit or a "Red Bio-Hazard bag"for inspection by the receiving hospital P N�. curm ripe 1 mud 5 fna nute5 after birth CRITERIA „i 0 2 2 Activity No movement 1A� i Some movement Active aaacaw�m�aent (irmu.us¢ie tone) �0N q`o Pulse No Pufse Less than.100 bpin Greater than 100 bpm Grimace r �.d No respanse'to Grimace car feeble Active motion4f (ireffYex,iridtabi ity) .xtim uirrtion cry w^1strra elation P", wwlstun ufatioua Appearance trdrre off over Bady park; Completely pink (skhi color) extremities P hje Respiration No Breathing Slow,irregular Strong Cry breo thing 4-6 Moderately Depressed:IMModerate Resuscitskiion Needed l Delivery Complications K w �I ADULT BREECH BIRTH (FEET OR BUTTOCKS PRESENTATION • If the head does not deliver within 3 minutes of the body: • Elevate the mother's hips (knee to chest position) • Insert a gloved hand into the vagina • Push the vaginal wall away from the neonate's nose and mouth • Expedite transport while maintaining the knee to chest position and the neonate's airway * OXYGEN • Administer blow-by OXYGEN to the neonate W ;d, Nl„ d ENE �...... .. 1, SHOULDER DYST CIA(DIFFICULTY IN DELIVERING THE S UL E S) MCROBERI"S PROCEDURE: • Hyperflex the mother's legs tightly to her abdomen • It may be necessary to apply suprapubic pressure (mother's lower abdomen) • Gently pull on the neonate's head r J WE is/aa lie I / %% i ie ��%< NN i rrro�r� r �ir�ar�✓U �U((' �� / i i � 623 Delivery Complications Continued... . E BLIP NUCHALCORD • Check for the presence of a nuchal cord after delivery of the head • If the cord is around the neck: • Gently hook your finger underthe loop • Pull it over the neonates head • You may have to repeat this if there is more than 1 o loop present • If you are unable to free the cord: • Clamp the cord in 2 places • Cut the cord between the clams d, PROLAPSED UMBILICAL CORD 1y POSH K.dll`+,VIII`+,VG. • Place mother in the knee to chest position • Manually displace the uterus to the left • Insert a gloved hand into the vagina • Push the neonate up and away from the umbilical cord regardless if there is a pulse present or not • Maintain this position during transport • Frequently reassess the umbilical cord for the presence of a pulse, as contractions are likely to compress the umbilical cord • Wrap the exposed cord in a moist sterile dressing • Expedite transport to closest OB facility ell I um umNN^ww i i. „w.i„�✓�. wn ww.+.ew.....aw,is..,.r i �V ( 1A viie�Ylpllll � /� w Manual displacement of the uterus Ell NINE IN- 624 City of Key West, Florida Responsibilities of Management for the Financial Statements Management is responsible for the preparation and fair presentation of the financial statements in accordance with accounting principles generally accepted in the United States of America, and for the design, implementation, and maintenance of internal control relevant to the preparation and fair presentation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, management is required to evaluate whether there are conditions or events, considered in the aggregate, that raise substantial doubt about the City of Key West's, Florida, ability to continue as a going concern for twelve months beyond the financial statement date, including any currently known information that may raise substantial doubt shortly thereafter. Auditor's Responsibilities for the Audit of the Financial Statements Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor's report that includes our opinions. Reasonable assurance is a high level of assurance but is not absolute assurance and therefore is not a guarantee that an audit conducted in accordance with generally accepted auditing standards and Government Auditing Standards will always detect a material misstatement when it exists. The risk of not detecting a material misstatement resulting from fraud is higher than for one resulting from error, as fraud may involve collusion, forgery, intentional omissions, misrepresentations, or the override of internal control. Misstatements are considered material if there is a substantial likelihood that, individually or in the aggregate, they would influence the judgment made by a reasonable user based on the financial statements. In performing an audit in accordance with generally accepted auditing standards and Government Auditing Standards, we: • Exercise professional judgment and maintain professional skepticism throughout the audit. • Identify and assess the risks of material misstatement of the financial statements, whether due to fraud or error, and design and perform audit procedures responsive to those risks. Such procedures include examining, on a test basis, evidence regarding the amounts and disclosures in the financial statements. • Obtain an understanding of internal control relevant to the audit in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the City of Key West, Florida's, internal control. Accordingly, no such opinion is expressed. • Evaluate the appropriateness of accounting policies used and the reasonableness of significant accounting estimates made by management, as well as evaluate the overall presentation of the financial statements. • Conclude whether, in our judgment, there are conditions or events, considered in the aggregate, that raise substantial doubt about the City of Key West, Florida's, ability to continue as a going concern for a reasonable period of time. We are required to communicate with those charged with governance regarding, among other matters, the planned scope and timing of the audit, significant audit findings, and certain internal control-related matters that we identified during the audit. 2 625 City of Key West, Florida Required Supplementary Information Accounting principles generally accepted in the United States of America require that the management's discussion and analysis, budgetary comparison schedules, and the schedules related to pensions and other post-employment benefits on pages 5-16, 82-83 and 84-90, respectively, be presented to supplement the basic financial statements. Such information is the responsibility of management and, although not a part of the basic financial statements, is required by the Governmental Accounting Standards Board who considers it to be an essential part of financial reporting for placing the basic financial statements in an appropriate operational, economic, or historical context. We and other auditors have applied certain limited procedures to the required supplementary information in accordance with auditing standards generally accepted in the United States of America, which consisted of inquiries of management about the methods of preparing the information and comparing the information for consistency with management's responses to our inquiries, the basic financial statements, and other knowledge we obtained during our audit of the basic financial statements. We do not express an opinion or provide any assurance on the information because the limited procedures do not provide us with sufficient evidence to express an opinion or provide any assurance. Supplementary Information Our audit was conducted for the purpose of forming opinions on the financial statements that collectively comprise the City of Key West, Florida's basic financial statements. The accompanying combining and individual nonmajor fund financial statement and schedules are presented for purposes of additional analysis and are not a required part of the basic financial statements. Such information is the responsibility of management and was derived from and relates directly to the underlying accounting and other records used to prepare the basic financial statements. The information has been subjected to the auditing procedures applied in the audit of the basic financial statements and certain additional procedures, including comparing and reconciling such information directly to the underlying accounting and other records used to prepare the basic financial statements or to the basic financial statements themselves, and other additional procedures in accordance with auditing standards generally accepted in the United States of America by us and other auditors. In our opinion, based on our audit and the report of the other auditors, the combining and individual nonmajor fund financial statements and schedules are fairly stated, in all material respects, in relation to the basic financial statements as a whole. Other Information Management is responsible for the other information included in the annual report. The other information comprises the introductory and statistical sections but does not include the basic financial statements and our auditor's report thereon. Our opinions on the basic financial statements do not cover the other information, and we do not express an opinion or any form of assurance thereon. In connection with our audit of the basic financial statements, our responsibility is to read the other information and consider whether a material inconsistency exists between the other information and the basic financial statements, or the other information otherwise appears to be materially misstated. If, based on the work performed, we conclude that an uncorrected material misstatement of the other information exists, we are required to describe it in our report. 3 626 City of Key West, Florida Table 20 Operating Indicators by Function/Program Last Ten Fiscal Years Function/Program 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 General government: Building permits issued 6,187 S,46S 6,429 4,843 3,854 4,951 3,800 4,029 3,718 3,499 Building inspections performed 11,812 11,642 11,018 8,910 8,837 9,147 S,S37 9,537 8,245 4,358 Business Tax 10,087 10,642 9,799 8,604 9,139 9,188 9,666 8,827 9,345 9,644 Fire: Emergency responses 1,945 4,818 * 7,194 ** 5,877 6,902 7,145 6,029 6,857 S,7S1 7,017 Inspections 2,310 2,100 2,077 1,700 2,560 3,722 2,298 2,268 2,318 2,928 Police: Physical arrests 2,171 2,100 1,753 1,264 1,486 1,722 1,423 1,564 1,647 1,622 Parking violations 27,897 33,261 32,199 31,382 23,940 26,OSS 16,276 18,422 22,801 27,939 Traffic violations 4,018 3,092 2,529 2,257 3,115 2,865 2,952 1,362 3,063 4,170 Cemetery: Burials 94 102 117 109 118 91 82 111 136 120 Sewer: Average daily flow (millions of gallons per day) 4 4 4 4 4 4 4 4.4 4.8 4.6 Solid Waste: Refuse annually tons 44,064 40,563 41,OS6 41,045 42,766 40,560 40,726 44,375 40,841 40,278 Recycle annual in tons 5,333 5,381 5,371 5,223 S,S6S 5,477 4,747 4,905 4,823 4,751 Marinas: Key West Bight: Diesel gallons pumped 128,548 168,924 219,435 206,963 217,097 298,895 217,351 258,439 204,947 178,754 Gas gallons pumped 133,580 150,826 177,291 142,394 189,860 21S,37S 189,900 233,694 197,600 210,344 Transient customers 1,365 1,394 1,617 1,730 1,021 1,189 798 1,445 1,175 1,137 Ferry terminal: Boat landings 364 389 482 3S8 372 362 279 371 373 3S2 Passenger disembarkments 166,677 192,073 184,662 186,817 169,728 189,596 12S,24S 161,197 190,428 136,129 Diesel gallons pumped 7,743 333,S4S 383,926 347,119 3S7,OS2 322,785 253,707 320,577 401,873 372,442 Garrison Bight: Transient customers 438 674 S81 691 296 9S8 180 414 269 46S Mooring field monthly permits 133 377 S1S 623 270 917 238 14S 190 37S Ramp usage 5,893 5,178 4,703 3,927 4,931 4,332 4,363 4,122 3770 4,018 Transportation: Cruise ship passengers 800,752 745,864 696,224 745,781 865,939 913,323 500,320 - 127,899 483,617 Sidewalks repaired/ replaced 20,250 10,000 5,000 6,221 52,380 36,530 89,985 20,583 92,502 95,000 *Fire Department started Emergency Medical Services(EMS)services in April 1,2015. **First full fiscal year for Fire Department Emergency Medical Services(EMS). 131 627 City of Key West, Florida Table 21 Capital Asset Statistics by Function/Program Last Ten Fiscal Years Function/Program 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Fire: Fire Stations 3 3 3 3 3 3 3 3 3 3 Engines 7 6 6 7 8 8 8 8 8 7 Aerial 1 1 1 1 1 1 1 1 1 1 Heavy duty rescue - - 1 1 1 1 1 1 Light duty rescue 1 1 1 1 6 6 6 6 6 4 Ambulances - 4 * 4 5 5 6 6 6 6 6 Fire boat - - - - 1 1 1 1 1 1 Police: Stations 1 1 1 1 1 1 1 1 1 1 Patrol units 117 118 118 118 119 114 114 114 114 116 Parking enforcement units 6 6 6 6 6 6 7 7 7 7 Police boat - - - - 1 1 1 1 1 3 Parks and Recreation: Acreage 69.25 69.25 69.25 69.25 105.25+ 105.25 105.25 105.25 105.25 105.25 Playgrounds 3 3 3 3 3 3 3 3 5 5 Baseball/softball diamonds 7 7 7 7 7 7 7 7 7 7 Soccer/football fields 4 4 4 4 4 4 4 4 2 2 Basketball courts 5 5 5 5 5 5 5 5 5 5 Pools 1 1 1 1 1 1 1 1 1 1 Splash - - - 1 2 2 2 2 2 2 Sewer: Length of system 60 60 60 60 60 60 60 60 60 60 Plant daily capacity (millions of gallons per day) 10 10 10 10 10 10 10 10 10 10 Stormwater: Length of system 12 12 12 12 12 12 12 12 12 12 Key West Bight: Slips: Transient slips 92 92 92 92 92 95 95 102 102 102 Commercial slips 42 42 42 42 42 42 42 42 42 42 Other slips 15 15 15 15 15 12 12 12 12 12 Fuel capacity(gallons): Gasoline 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 Diesel 20,000 20,000 20,000 20,000 20,000 20,000 20,000 20,000 20,000 20,000 Leasable retail space: (square feet) 96,384 96,434 101,108 101,108 105,348 108,098 111,632 112,335 111,384 111,384 Ferry Terminal: Commercial slips 4 4 4 4 4 4 4 4 4 4 Diesel capacity(gallons) 20,000 20,000 20,000 20,000 20,000 20,000 20,000 20,000 20,000 20,000 Garrison Bight: Transient slips available 42 42 51 51 51 51 51 56 74 74 Live aboard/pleasure 167 167 158 158 146 146 146 146 128 128 Commercial/charter 37 37 37 37 37 37 37 37 37 37 Mooring field 149 149 149 149 149 149 149 149 149 149 Transportation: Number of buses 14 17 18 15 21 21 20 24 24 24 Cruise ports 3 3 3 3 3 3 3 3 3 3 Ferry terminals 1 1 1 1 1 1 1 1 1 1 *Fire Department started Emergency Medical Services(EMS)services on April 1,2015. + Reflects Addition of the Truman Waterfront Park 132 628 00 00 -:* N r, N r-I I, O Ln M r-I lD lD O O 01 M I, Ln M N N M qt M r-I Ln N O N rl N N M I, Ln r1 M O M N N Ln N O N 00 M O, qt N N r1 N M M Ol N O N 00 lD M 00 N N r1 00 I, Ln N r1 M r1 r1 01 M I, Ln M N ri M M Ln N O N 00 lD O 00 N N r1 I, r, Ln N r1 Ol M I, Ln M N r1 M M N Ql ri Ln r-I O N 00 lD I- N N Cr) r, r, Ln N r1 N Cr) Ln Ol M I, Ln N N r1 M M N 00 r1 Ln r-I O N cn 00 lD lD M N M lD -tt r, Ln N r1 ro Ol M I, Ln N N r1 M M O ri Ln r-I O N 00 I- M N N Cr) lD M I, Ln N r1 O M 00 M Mr- rr4 N r1 M N m i ba O N i a O Il M M 00 � N N r-i Ln r1 r,, 00 N r1 U Ln r-i Ln � r-I 3 O LL N A N 0) Ln I- N N N M lD r1 Ln r1 O lD r- 00 M r rr4 N r1 N N Q � N W m Y i U N LL }.� •L V f6 L6 N > } O N O 'L S L6 �, W ll0 QJ L L a QJ Lp 0) 0) LL m E w O O O v N +' O N E a' L N O w H H U O v v aJ v fC 75 'm a' a' O L 0 E 4J O 4J 4J L6 U H LL J U U f° aC L.L d d CO LI Ln aC Ln Ln Ln aC 629 0 M tG w Cl a O .� U) a � O w � Cd U) 0 O o Cd U14_ QL) � o � o � z 4� Q U O F' w N N O Cl) cl) U co v, O Wco .N O � O z N 0,) "Q� CdQ W z O O N Z 2 — cd O H U 0 0 0 U p � Z X N ° O Z co O twiiz uU Wf:4 co 11) � U � Co — r. Uo � z o aiAZ � f�° W � . � � •� ,� o 4N U VDU A QL) o 0 U O O 1.4 coW ) r PA co 4 Cd N 4 ai a ° a fJ1 Z ~O N bf O O w � � � ct- �o °o W Q N W �O N U N �❑ O � +QL) (QL) p N 0 ^� 0 cd , U O W � � w U N H � � a .QL) Q � bf bf 0 O) �..� N J2 o O O ® � O zn O �s bf cd W H O y o O N W WcoWUWQL) � � ° ° o o W W co CO co o U) x o o aCdW ca DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 10/1/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jenna Jennings World Risk Management PHONE FAx 20 N. Orange Ave., A/c No Ext: 4074452414 A/C,Noy 407-445-2868 Suite 500 ADDRESS: jenna.jennings@wrmllc.com Orlando FL 32801 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Public Risk Management of FL( 11111 INSURED KEYWEST-01 INSURER B: City of Key West 1300 White Street INSURERC: Key West FL 33040 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1232055502 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD/YYY MMIDD/YYY A X COMMERCIAL GENERAL LIABILITY PRM024-011A-073 10/1/2024 10/1/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADE F7�vl OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $1,000,000 MED EXP(Any one person) $EXCLUDED APPROVED BY RISK MANAGEMENT PERSONAL&ADV INJURY $1,000,000 BY. :.u„, n ... .. .a GEN'L AGGREGATE LIMIT APPLIES PER: ,' - GENERAL AGGREGATE $ POLICY❑ PRO ❑ LOC DATE �.r1�7. JECT 07.4 PRODUCTS-COMP/OPAGG $ OTHER: WAIVER N/A_YES_ SELF INS.RETENTION $100,000 A AUTOMOBILE LIABILITY PRM024-011A-073 10/1/2024 10/1/2025 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED A UTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X APD SELF INS.RETENTION $25,000 UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION PRM024-011A-073 10/1/2024 10/1/2025 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER SIR $325,000 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICE R/M EMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) RE:Advanced/Basic Life Support Service License With respects to the listed coverage held by the named insured,as evidence of insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN State of Florida Department of Health Emergency Medical ACCORDANCE WITH THE POLICY PROVISIONS. Services 4052 Bald Cypress Way Bin C-30 AUTHORIZED REPRESENTATIVE Tallahassee FL 32399-1738 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 631