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HomeMy WebLinkAboutItem C15 C15 BOARD OF COUNTY COMMISSIONERS COUNTY of MONROE Mayor James K.Scholl,District 3 The Florida Keys Mayor Pro Tern Michelle Lincoln,District 2 Craig Cates,District 1 David Rice,District 4 Holly Merrill Raschein,District 5 Board of County Commissioners Meeting March 25, 2025 Agenda Item Number: C 15 2023-3717 BULK ITEM: Yes DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: R.L. Colina N/A AGENDA ITEM WORDING: Approval for issuance (renewal) of a Class A Certificate of Public Convenience and Necessity (COPCN) to Key Largo Volunteer Ambulance Corps., Inc. for the operation of an advanced life support (ALS) and basic life support (BLS) transport ambulance service for the period of April 20, 2025, to April 19, 2027. ITEM BACKGROUND: On April 19, 2023, a Class A COPCN was issued to Key Largo Volunteer Ambulance Corps., Inc. (KLVAC) to operate an ALS and BLS transport ambulance service. The current COPCN expires on April 19, 2025. KLVAC has submitted an application for BOCC approval to renew their Class A COPCN which, if approved, will become effective April 20, 2025. PREVIOUS RELEVANT BOCC ACTION: On August 17, 2016, Item C.12, the MCBOCC approved the issuance of a COPCN to KLVAC for the operation of an ALS transport ambulance service for the period August 25, 2016 through August 24, 2018. On August 15, 2018, Item C.5, the MCBOCC approved the issuance of a COPCN to KLVAC for the operation of an ALS transport ambulance service for the period August 25, 2018 through August 24, 2020. On August 19, 2020, Item C.4, the MCBOCC approved the issuance of a COPCN to KLVAC for the operation of an ALS transport ambulance service for the period August 25, 2020 through August 24, 1117 2022. On April 19, 2023, Item C12, the MCBOCC approved the issuance of a COPCN to KLVAC for the operation of an ALS transport ambulance service for the period April 20, 2023 through August 19, 2025. INSURANCE REQUIRED: Yes CONTRACT/AGREEMENT CHANGES: The renewal will cover the period April 20, 2025 through April 19, 2027. STAFF RECOMMENDATION: Approval. DOCUMENTATION: Key_Largo—Volunteer—Ambulance—Corp_Class—A—Certificate-04.20.2025_through-04.19.2027(LegaI Stamped).pdf Key Largo Volunteer Ambulance Corps, Inc. Class A Application—Redacted.pdf FINANCIAL IMPACT: Effective Date: 04/20/2025 Expiration Date: 04/19/2027 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 1118 County Match: N/A Insurance Required: Yes,per COPCN Class A application Additional Details: N/A 1119 0 q _ _ t o \ k o 0 0 . z o « 2 0 '/ Co Lo 6 a o / d 2 $ / Cl) \ [ 0 ƒ o U Co \ @ Q [ / g E o o y o u o 2 U \ 0 « ° 0 / � � \ e % U \ Co ( U ƒ Cl) / ¥ '\ § / t 0 w \ \ ( k \ k \ \ H P w o 0 \ \ w - [ \ ° 'co » = t »1 e / U U w } o / o \ _ ~ } 4 \ QL) ƒ / d 1 o b \ o Q \ � »1 \ k \ 0 \ [ k 2 ƒ \ / / \ U w 0 / o e coe U « � w 06 � \ a) CD ¥ \ / m ° t ® ƒ / m a 2 ul « kQZ> ( ° { \ \ 2 \ . { \ ƒ / / w 7 2 ) t o t ■ — Z .3 t S t 2 w ,o o w I 0 k ƒ � � � CN � \ / / U t m = CD@ e E k co \ �� \ � � \ m / $ k 0 § [ Zo 0 } \ W 7 '/ § \ % 2 \ / / 6 ± / o Q 5 ± Eeo , ?® \ m 2 ° § w o .o f 0 •� ( • 2 = o m @ U 7 3 ( - \ \ % 0 U ° LOU [ \ , $ \ E / � / 0.4� / \ 2 { ƒ U \ / � ƒ f \ / 1-4 U » { § o t t 2 ) § k & W \ / § / 2 « ( t / \ 3 > ° ? ° ] Z) ° O N U $ f 2 / $ \ / 6 / \2 0 ( ^ t f / \ ® % [ 2 § 41 o t U 2 \ / / / E ƒ k ƒ / »ƒ »— CO \ o k 2- $ \ C'� � » o [ Z ® 3 \ a) \ & } 9 \ z f fof ° fU / ? ow e £ o e e } \n m ' m w mu m o t c 7 a ) a = a Co a o �y 2 m -Z 2 f c ` \»2 ® A te # = n / / / ~ A\\ ) Q� \ Z b Q 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: # 23-03 1. NAME OF SERVICE Key Largo Volunteer Ambulance Corps., Inc. BUSINESS MAILINGADDRESS 98600 Overseas Hwy, Key Largo, FL 33037 BUSINESS PHONE NUMBER 305-451-2766 EMERGENCY PHONE NUMBER 911 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) 501.c.3 non-profit Corporation DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 12-05-1971 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS (Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITION/TITLE Scott Robinson 69 98600 Overseas Hwy,Key Largo, FL 33037 305-451-2766 President Dawn DeBrule 52 98600 Overseas Hwy,Key Largo, FL 33037 305-451-2766 Vice President Bonnie Tess Marra 70 98600 Overseas Hwy,Key Largo, FL 33037 305-451-2766 Treasurer Tina Wyatt 51 98600 Overseas Hwy,Key Largo, FL 33037 305-451-2766 Director Daniel Powers 71 98600 Overseas Hwy,Key Largo, FL 33037 305-451-2766 Director Don Bock 67 98600 Overseas Hwy,Key Largo, FL 33037 305-451-2766 Chief 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): All 2400 and 2025 Series Fire Boxes. Geographically, from South Bay Harbor Drive and Lobster Lane (mile marker 95) north to the Dade/Monroe County Line (mile marker 113) and north on CR905 to the 3-way stop intersection, and as directed by Central Dispatch. 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION 98600 Overseas Highway, Key Largo, FL 33037 SUB-STATION 220 Reef Drive, Key Largo, FL 33037 Page 1 of 6 7. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC licenses): FRE UENCIES CALL NUMBERS #OF MOBILES ww. #OF PORTABLES 400 MHz recieve only Pager Frequency N/A N/A 800 MHz bidirectional Rescue 23, Rescue 123&Rescue 25 8 12 8. LIST THE NAMES AND ADDRESSES OF THREE(3)U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: _ NAME ADDRESS Thomas 0. Morrison, MD 100450 Overseas Hwy., Key Largo, FL 33037 Anthony Allen 101640 Overseas Hwy., Key Largo, FL 33037 Joanne Mahoney 95360 Overseas Hwy., Key Largo, FL 33037 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. O� O' 'ATURE OF APPLICANT/AUTHORIZED REPRESENTATIVE SUZMM Lkwm MANIFOLD Notary Public NOT RY'SEAL State of Florida Corgi HH379M6 res 3/28/2O2 NY N R a D ATE Page 2 of 6 PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Daniel Alvarez PMD 578342 12-01-2026 Austin Arrieta PMD 543726 12-01-2026 David Artega PMD 541722 12-01-2026 Leonardo Bello PMD 514794 12-01-2026 Deleted (Ariel Bentancourt) N/A Don Bock PMD 008122 12-01-2026 Runny Hernandez PMD 539339 12-01-2026 Arley Gonzalez PMD 523011 12-01-2026 Edwardo Gonzalez PMD 535771 12-01-2026 Giulano Gonzalez PMD 544849 12-01-2026 Ozzie Opporta PMD 530520 12-01-2026 Jorge Orbeta PMD 511439 12-01-2026 Roxana Perez PMD 530680 12-01-2026 Oscar Pizon PMD 514901 12-01-2026 Joseph Ricci PMD 542108 12-01-2026 Michael San-Pagan PMD 515180 12-01-2026 Adam Schussheim PMD515180 12-01-2026 Sarah Strab PMD 533924 12-01-2026 Luis Tuero PMD 532000 12-01-2026 Fernando Flores PMD 545446 12-01-2026 Franklin Rivero PMD 544750 12-01-2026 Julliano Serrano PMD 542141 12-01-2026 Keivins Rigoyoso PMD 547112 12-01-2026 Page 3 of 6 PERSONNEL—EMERGENCY MEDICAL TEC'HNICI'ANS ......... NAME EMT CERTIFICATION First,Middl Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Dylon Baron EMT 585468 1201-2026 Charles Berrane EMT 585804 12-01-2026 Kevin Fernandez EMT 589685 12-01-2026 Daniel Gomez EMT 581542 12-01-2026 Edward Hilson EMT 583932 12-01-2026 Melanie Isaza -- EMT 583924 12-01-2026 Jose Posada EMT 569849 12-01-2026 Michael San-Pagon EMT 572091 12-01-2026 Christopher Sefcik -- EMT 586003 12-01-2026 Roberto Ycaza EMT 588038 12-01-2026 Jose Zuniga -- EMT 583847 12-01-2026 -------------- ..... m-- .. -....... ......... Page 4 of 6 w A O 00 00 CO 00 N M 00 O I` f` 00 O ^11 CO O 00 w O �{ o z w w a U W W � J J J J J J J J 04 LL LL LL LL LL LL LL LL LL LL LL LL LL LL LL LL LL LL LL J J J J J J J J J C a O F W O O o 0 0 0 0 0 0 0 w O � 0 a -' � A o ;� cg Z v, � O Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z G F OA aW. H �r a W WO � aw d U ! Ors }�yI O � / N W OV r WF N N m a� E co NN C NNNN 6 N N p N L_N Q O U OO > 07 O �wFO CL O O � U)Q O O U O c � cu �'oO c32 F Q a 2 CO ca rn (C O O O O E J d cc H� pUdzz�w Q LL a WF xa 0 VEHICLES For Euh Amb Lila nee Overated By You r Service.Please Proy ift,tho F_gjloisping In formatioue0 Ise'ieparato SbMLffNK!!2a0l -S SPECIFY LICENSE VEHICLE SPECIFY TRANSPORT or V YEAR MILEAGE PEW LICE] IC U AMBULANCE TYPE MODEL CHASSIS# TAG NUMBER Rmrr# ALS or BLS NON TRANSPORT Type I Ford 2022 36820 1FDUD5GT8NDA06671 TD5409 244000 ALS Transport ...... ............................... Type I Ford 2022 39267 1FDUF5GT6NDA06247 TD4508 24401 ALS Transport .................. ..............-- Type III Chevy 2015 102349 1GB6G5CL8F1157923 TE7171 24113 ALS Transport Type III Chevy 2016 129947 1GB6GUCL2G1141812 TAII 874 19546 ALS Transport .................. . ................. .......... ....................... ............ ............ ....................... ....................... ....... ...... ............................ .................... .................. .................................... .............. ...................... ...................... ................. ---------- .................. ................... ........................... .................... .................... Page 6 of 6 1 dbock@ke iar ofire.or From: Don Bock <dbock@keylargofire.org> Sent: Thursday, February 13, 2025 9:45 AM To: Don Bock Subject: Fwd: FEE SCHEDULE ---------- Forwarded message --------- From: PPS Ambulance Billing< Lll tors elr c:,r cc@ ie iil,o�om> Date:Thu, Feb 13, 2025 at 08:44 Subject: FEE SCHEDULE To: cdasrgoVmi.0 AO425 Ambulance Mileage $14.00 AO426 ALS Non-emergent $675.00 AO427 ALS Emergent $675.00 AO428 BLS Non-emergent $627.00 AO429 BLS Emergent $627.00 AO433 ALS2 $921.00 1 y" BOARD OF COUNTY COMMISSIONERS County of Monroe `"�� Mayor James K.Scholl,District 3 The Florida Keys Mayor Pro Tem Michelle Lincoln,District 2 Craig Cates,District t David Rice,District 4 Holly Merrill Raschein,District 5 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: February 25, 2025 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check M dated February 13, 2025, in the amount of$475.00 per check to be deposited in revenue account 141-342000-RC 00345. This check has been issued for the renewal application of a Class A Certificate of Public Convenience for Key Largo Volunteer Ambulance Corps., Inc. Thank you, c�� �O � Cara Johnson Key Largo Volunteer Ambulance Corps., Inc. 8600 Overseas Hwy. ! Key largo,FL 33037 305-451-2766 Q5- 10AT ' � PAY TO THE ORDER O c CPI.LARsVAYidde— r.s, P ares r,. i l"N48�tlC:4W:149 m¢,XVC7iEG'�4!§i CAM#,i�YY C7'1N T11fi h��4AtpTSd U'$'M AV 1, 8 ' DATE(MMIDD/YYYY) ACC>R" CERTIFICATE OF LIABILITY INSURANCE 09/03/2024 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). PRO11 DUCER CONTACT Lilliam Reyes NAME: )852-3234 Regan Insurance Agency 305 PHONE: ( FAX (305)852-3703 I AIC Ne 90144 Overseas Ht^'Y• E-MAIL lreyes r(x reganinsuranceinc.conl ADDRESs: INSURERS AFFORDING COVERAGE NAIC t1 Tavernier FL 33070 INSURER,. National Union Fire Ins Cc of Pittsburg PA INSURED INSURER B: Key Largo Volunteer Ambulance Corps INSURER C; 98600 Overseas Hwy INSURER D INSURER E Key Largo FL 33037 INSURERF: COVERAGES CERTIFICATE NUMBER.. 24-25 GL&Auto REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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. IPOLICY EXP L" TYPE OF INSURANCE INS yD POLICY NUMBER WRMA0 (mFF MM/DOIVYYY LIMBS "' ...COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE � PRE OCCUR DAMAGET --- MISES R occurrence $ MED EXP(Any one person) $ 5,000 A VFNU-TR-0014338-04 06/06/2024 06/06/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN't AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO. LOC PRODUCTS-COMP/OPAGG $ 3,000,000 POLICY El JECT OTHFR: $ AUTOMOBILE LIABILITY COMBINED ccident' '�MNG'LE UNIT $ 1,000,000 x.ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED Y VFNU-CM-0014337-04 06/06/2024 06/06/2025 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY JPOF am"ideal PIP-Basic $ 10,000 I UMBRELLA LIAB 'OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ .WORKERS COMPENSATION PER OTH- Y/N ...AND EMPLOYERS'LIABILITY STATUTE LER ANY PROPRGETOR PARTNERIEX'ECUTIVE NIA E.L EACH ACCIDENT $ _- OFEICLLRIoMEMBFR EXCLUDED? (Mandatory In NH) E.L,DISEASE-EA EMPLOYEE $ Il yes describe.undeff - --- 'DESCRIPTION OF OPERATIONS below E,L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Key Largo Volunteer Ambulance Corp ACCORDANCE WITH THE POLICY PROVISIONS. 98600 Overseas Highway AUTHORIZED REPRESENTATIVE Key Largo FL 33037 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis January 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees 11,731.02 0.00 0.00 0.00 11,731.02 Interest Revenue 49.87 63.29 2.29 0.25 115.70 Reimbursements 105,600.89 0.00 0.00 0.00 105,600.89 Total Income 117,381.78 63.29 ....... 2.29 0.25 117,447.61 Gross Profit 117,381.78 63.29 2.29 0.25 117,447.61 Expense Bank Service Charges 69.38 0.00 0.00 0.00 69.38 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Dues &Memberships 0.00 0.00 125.00 0.00 125.00 Payroll Expenses 105,389.95 0.00 9,713.38 0.00 115,103.33 Postage and Delivery 42.68 0.00 0.00 0.00 42.68 Repairs 943.76 0.00 0.00 0.00 943.76 Supplies 411.86 _.._ 0.00 20.99 0.00 432.85 Total Expense 106 _� ....... �..._857.63 1,733.00 9,859.37 0.00 118450.00 Net Ordinary Income 10,524.15 -1,669.71 -9,857.08 0.25 -1,002.39 Net Income 10,524.15 -1,669.71 -9,857.08 0.25 -1,002.39 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis February 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees -1,906.86 0.00 0.00 0.00 -1,906.86 Interest Revenue 41.02 59.24 2.10 0.23 102.59 Reimbursements 109,559.82 0.00 0.00 0.00 109,559.82 Total Income 107,693.98 59.24 2.10 0.23 107,755.55 Gross Profit 107,693.98 59.24 2.10 0.23 107,755.55 Expense Advertising 46.34 0.00 0.00 0.00 46.34 Bank Service Charges 61.44 0.00 0.00 0.00 61.44 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Payroll Expenses 105,530.66 0.00 7,544.55 0.00 113,075.21 Supplies 303.92 0.00 20.99 0.00 324.91 .�..�.�.... Total Expense 115,240.90 105,942.36 1,733.00 7,565.54 0.00 Net Ordinary Income _ 0.23 7,485.35 1,751.62 1 673.76 7 563.44 Net Income 1,751.62 -1,673.76 -7,563.44 0.23 -7,485.35 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis March 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees 3,411.27 0.00 0.00 0.00 3,411.27 Interest Revenue 38.68 63.35 2.19 0.25 104.47 Medical Transcripts 0.00 0.00 250.00 0.00 250.00 63.23 Reimbursements 19,063.23 � 0.00 �0.00 0.00 19,0_ Total Income 22,513.18 63.35 252.19 0.25 22,828.97 Gross Profit 22,513.18 63.35 252.19 0.25 22,828.97 Expense Advertising 44.34 0.00 0.00 0.00 44.34 Bank Service Charges 70.70 0.00 0.00 0.00 70.70 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Payroll Expenses 145,537.65 0.00 7,118.63 0.00 152,656.28 Professional Fees 0.00 0.00 312.50 0.00 312.50 Repairs 1,445.93 0.00 0.00 0.00 1,445.93 pp 20.99 0.00 -32.43 Supplies -53.42 �.........�. 0.00 �W.......�. Total Expense 147,045.20 1,733.00 7,452.12 0.00 156,230.32 Net Ordinary Income -124,532.02 1,669.65 7,199.93 0.25 -133,401.35 Net Income -124,532.02 -1,669.65 -7,199.93 0.25 -133,401.35 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis April 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees 30,105.38 0.00 0.00 0.00 30,105.38 Interest Revenue 15.65 61.33 2.10 0.24 79.32 Reimbursements 37,542.75 0.00 0.00 �0.00 37,542.75 .�........ .... Total Income 67,663.78 61.33 2.10 0.24 67,727.45 Gross Profit 67,663.78 _ 61.33 2.10 0.24 67,727.45 Expense Meals& Entertainment 76.10 0.00 0.00 0.00 76.10 Advertising 2,038.18 0.00 0.00 0.00 2,038.18 Bank Service Charges 61.77 0.00 0.00 0.00 61.77 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Licenses and Permits 0.00 0.00 61.25 0.00 61.25 Payroll Expenses 100,130.96 0.00 8,810.14 0.00 108,941.10 Repairs 440.00 0.00 0.00 0.00 440.00 Supplies 1,340.32 0.00 20.99 0.00 1,361.31 Total Expense 104,087.33 1,733.00 8,892.38 0.00 114,712.71 Net Ordinary Income -36,423 55 -1,671.67 -8,890.28 0.24 -46,985.26 Net Income -36,423.55 -1,671.67 -8,890.28 0.24 -46,985.26 u i See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis May 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees 114,793.89 0.00 0.00 0.00 114,793.89 Interest Revenue 31.27 63.40 2.15 0.25 97.07 Medical Transcripts 0.00 0.00 475.00 0.00 475.00 Reimbursements 158,836.86 0.00 0.00 0.00 158,836.86 Total Income 273,662.02 63.40 477.15 0.25 274,202.82 Gross Profit 273,662.02 63.40 477.15 0.25 274,202.82 Expense Advertising 292.87 0.00 0.00 0.00 292.87 Bank Service Charges 97.54 0.00 0.00 0.00 97.54 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Payroll Expenses 120,101.15 0.00 11,674.76 0.00 131,775.91 Supplies 175.35 ... 0.00 20.99 0.00 196.34 Total Expense 120,666.91 1,733.00 � 11,695.75 0.00 134,095.66 Net Ordinary Income 152,995.11 1,669.60 -11,218.60 0.25 140,107.16 Net Income 152,995.11 -1,669.60 -11,218.60 0.25 140,107.16 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis June 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees 39,776.63 0.00 0.00 0.00 39,776.63 Interest Revenue 48.83 61.38 2.26 0.24 112.71 Reimbursements 211,599.61 0.00 0.00 0.00 211,599.61 Total Income 251,425.07 61.38 2.26 0.24 251,488.95 Gross Profit 251,425.07 61.38 2.26 0.24 251,488.95 Expense 99 Advertising 124.99 0.00 0.00 0.00 166.28 Bank Service Charges 66.28 0.00 0.00 0.00 . Depreciation Expense 0.00 1,733.00 0.00 0.00 1,73333.0000 Payroll Expenses 135,596.66 0.00 13,747.99 0.00 149,344.65 Professional Fees 307.58 0.00 0.00 0.00 307.58 Repairs 480.00 0.00 0.00 0.00 480.00 Supplies 20.99 0.00 0.00 0.00 20.99 Total Expense 136 596.50 1,733.00 13,747.99 0.00 152,077.49 Net Ordinary Income 114,828.57 -1,671 62 -13,745.73 0.24 99,411.46 Net Income 114,828.57 -1,671.62 -13,745.73 0.24 99,411.46 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis July 2024 Billing Building Corp CPR-Training TOTAL . Ordinary Income/Expense Income Fees 65,156.71 0.00 0.00 0.00 65,156.71 Interest Revenue 59.40 63.45 2.28 0.25 125.38 Reimbursements 130,763m19 0.00 0.00 0.00 130,763.19 Total Income 195,979.30 63.45 2.28 0.25 196,045.28 Gross Profit 195,979.30 63.45 2.28 0.25 196,045.28 Expense Advertising 124.99 0.00 0.00 0.00 124.99 Bank Service Charges 64.30 0.00 0.00 0.00 64.30 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Dues& Memberships 159.90 0.00 0.00 0.00 159.90 Licenses and Permits 179.25 0.00 0.00 0.00 179.25 Payroll Expenses 139,201.87 0.00 11,919.45 0.00 151,121.32 Professional Fees 1,550.16 0.00 0.00 0.00 1,550.16 Supplies 210.49 0.00 525.00 0.00 735.49 Total Expense 141,490 96 1,733.00 12,444 45 0.00 155,668.41 ry -12,442.17 0.25 �40,376.87 Net Ordinary Income 54,488.34 1 669.55 Net Income 54,488.34 -1,669.55 -12,442.17 0.25 40,376.87 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis August 2024 Bill Ing Building CorpPR-Training TOTAL g g _... p 9 _.. - Ordinary Income/Expense Income Fees 12,220.70 0.00 0.00 0.00 12,220.70 Interest Revenue 58.70 63.48 2.11 0.25 124.54 Reimbursements 54,933.15 0.00 0.00 0.00 54,933.15 Total Income 67,212.55 63.48 2.11 0.25 67,278.39 Gross Profit 67,212.55 63.48 2.11 0.25 67,278.39 Expense Advertising 124.99 0.00 0.00 0.00 124.99 Bank Service Charges 64.52 0.00 0.00 0.00 64.52 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Payroll Expenses 198,417.61 0.00 12,275.42 0.00 210,693.03 Repairs 1,652.50 0.00 0.00 0.00 1,652.50 Supplies 1,086.83 0.00 0.00 0.00 1,086.83 Taxes 24.75 0.00 0.00 0.00 24.75 Total Expense 201,371.20 1,733.00 12,275.42 0.00 215,379.62 Net Ordinary Income -134,158.65 -1, 0.25 -148 101.23 669.52 _ -12,273.31 Net Income -134,158.65 -1,669.52 -12,273.31 0.25 -148,101.23 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense Accrual Basis September 2024 Sep 24 Jan-Sep 24 Ordinary Income/Expense Income Fees Billing Medical Fees Primary Insurance 19,378.97 157,251.03 Other Payments 6,259.89 23,826.56 Medicare 745.00 112,446.27 Medicaid 913.75 21,093.79 Total Medical Fees 27,297.61 314,617.65 Deferred Income Credit Adjustments -9,208.67 -229,711.02 Deferred Income-Other 108,869.17 317,340.22 Total Deferred Income 99,660.50 87,629.20 Total Billing 126,958.11 402,246.85 Total Fees 126,958.11 402,246.85 Interest Revenue Building Account 61.46 560.38 Checking Interest 40.65 403.51 Total Interest Revenue 102.11 963.89 Medical Transcripts 0.00 725.00 Reimbursements KL Fire Rescue& EMS 137,506.52 965,406.02 Total Reimbursements 137,506.52 965,406.02 Total Income 264,566.74 1,369,341.76 Gross Profit 264,566.74 1,369,341.76 Expense 76.10 Meals& Entertainment 0.00 Advertising 124.99 2,921.69 Bank Service Charges 67.05 622.98 Depreciation Expense 1,733.00 15,597.00 Dues&Memberships 0.00 284.90 Licenses and Permits 0.00 240.50 Payroll Expenses 62 Health Insurance 7,236.72 1, . Employee's Share Health Insuran -1,151.44 -11,51414.40 Payroll Taxes Medicare 1,846.72 16,143.63 Social Security 7,896.16 69,027.82 SUTA Form UCT6 35.08 1,342.33 Total Payroll Taxes 9,777.96 86,513.78 See Compilation Report- For Mangement Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis October 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees 40,950.92 0.00 0.00 0.00 40,950.92 Interest Revenue 20.33 58.75 2.11 0.25 81.44 Total Income 40,971.25 58.75 2.11 0.25 41,032.36 .... .......... Gross Profit 40,971.25 58.75 2.11 0.25 41,032.36 Expense Advertising 124.99 0.00 0.00 0.00 124.99 Bank Service Charges 64.08 0.00 0.00 0.00 64.08 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Payroll Expenses 150,971.25 0.00 7,433.34 0.00 158,404.59 Professional Fees 255.21 0.00 0.00 0.00 255.21 Supplies 990.78 0.00 0.00 0.00 990.78 Total Expense 152,406.31 1,733.00 7,433.34 0.00 161,572.65 -7,431.23 0.25 -120,540.29 Net Ordinary Income 111,435.06 -_ 1,674.25 Net Income -111,435.06 -1,674.25 -7,431.23 0.25 -120,540.29 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis November 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees 71,176.75 0.00 0.00 0.00 71,176.75 Interest Revenue 13.92 36.21 2.05 0.24 52.42 Reimbursements 78,746.71 0.00 0.00 0.00 78,746.71 Total Income 149,937.38 36.21 2.05 0.24 149,975.88 Gross Profit 149,937.38 �36.21 2.05 0.24 149,975.88 Expense 99 Advertising 124.99 0.00 0.00 0.00 1 Bank Service Charges 108.50 0.00 0.00 0.00 108..50 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Payroll Expenses 149,049.23 0.00 6,971.12 0.00 156,020.35 Professional Fees 175.46 0.00 0.00 0.00 175.46 Supplies 22.99 0.00 0.00 0.00 22.99 Total Expense 149,481.17 .. 1,733.00 6,971.12 0.00 158,185.29 07 0.24 -8,209.41 Net Ordinary Income 456.21 1,696.79 -6,969_ � , Net Income 456.21 -1,696.79 -6,969.07 0.24 -8,209.41 See Complilation Report- For Management Use Only Key Largo Volunteer Ambulance Corp., Inc. Statement of Financial Income and Expense - By Division Accrual Basis December 2024 Billing Building Corp CPR-Training TOTAL Ordinary Income/Expense Income Fees -8,420.87 0.00 0.00 0.00 -8,420.87 Interest Revenue 51.90 28.84 1.61 0.25 82.60 Medical Transcripts 0.00 0.00 300.00 0.00 300.00 Reimbursements 274,807.68 0.00 0.00 0.00 274,807.68 Total Income 266,438.71 28.84 301.61 0.25 266,769.41 Gross Profit 266,438.71 28.84 301.61 0.25 266,769.41 Expense Advertising 400.87 0.00 0.00 0.00 400.87 Rent- Equipment 925.18 0.00 0.00 0.00 925.18 Bank Service Charges 109.97 0.00 0.00 0.00 109.97 Depreciation Expense 0.00 1,733.00 0.00 0.00 1,733.00 Payroll Expenses 150,897.05 0.00 9,548.16 0.00 160,445.21 Professional Fees 1,585.49 0.00 1,200.00 0.00 2,785.49 Supplies 90.98 0.00 150.00 0.00 240.98 Total Expense 154,009.54 1,733.00 10,898.16 0.00 166,640.70 Net Ordinary Income 112,429.17 -1,704.16 -10,596.55 0.25 100,128.71 Net Income 112,429.17 -1,704.16 -10,596.55 0.25 100,128.71 See Complilation Report- For Management Use Only � ry ry ry .. ry m m m ry ry ry ry g m e e m e e e e m e m O a e m m ry ry m ry ry m m N O N Vf V N N J J a z 0 N W J W M. Y o � i r Department of Health HEALTH THOMAS O'GLENN MORRISON License Number: ME79946 Profession Medical Doctor License Status CLEAR/ACTIVE Year Began Practicing Not Provided License Expiration Date 01/31/2026 Controlled Substance Yes Prescriber (for the Treatment of Chronic Non- malignant Pain) Primary Practice Address THOMAS O'GLENN MORRISON 105030 OVERSEAS HWY KEY LARGO,FL 33037 Medicaid This practitioner does NOT participate in the Medicaid program. Staff Privileges This practitioner currently holds staff privileges at the following hospital/medical/health institutions: Institution Name City State MARINERS HOSPITAL TAVERNIER FLORIDA SOUTH MIAMI HOSPITAL SOUTH MIAMI FLORIDA Email Address Please contact at:tgmmedicalcorp@gmail.com Other State Licenses This practitioner has not indicated any additional state licensures. Florida Birth-Related Neurological Injury Compensation Association If you are a Florida Allopathic(MD) or Osteopathic(DO) Physician,you are required to provide proof of payment of the Florida Birth-Related Neurological Injury Compensation Association (NICA) assessment as required by section 766.314, Department of Health HEALTH THOMAS O'GLENN MORRISON License Number: ME79946 Data As Of 31412024 Profession Medical Doctor License ME79946 License Status CLEAR/ACTIVE Oualifications Dispensing Practitioner License Expiration Date 1/31/2026 License Original Issue Date 03/06/2000 Address of Record 105030 Overseas Hwy KEY LARGO,FL 33037 Controlled Substance Prescriber(for the Treatment of Chronic Non-malignant Pain) Yes Discipline on File No Public Complaint No The information on this page is a secure,primary source for license verification provided by the Florida Department of Health,Division of Medical Quality Assurance.This website is maintained by Division staff and is updated immediately upon a change to our licensing and enforcement database. i Firefox about:bla r AGREEMENT FOR MEDICAL DIRECTOR SERVICES This Agreement for Medical Director Services is made and entered into as of the date last written below, by and between the Hey Largo Fire Rescue and Emergency Medical Services District ("DISTRICT"), and TGM Medical Corp.,, 102901 Overseas Highway, Hey Largo, FL 33037 ("DOCTOR"), licensed to practice medicine in the State of Florida with a principle location Monroe County. In exchange for good and valuable consideration,the receipt and sufficiency of which are hereby acknowledged,the pasties hereto agree as follows: WITH SSRTH: I Prevision qf Service. DISTRICT provides emergency services in the Key Largo area through its DISTRICT charter under Florida Law. DOCTOR is a medical doctor licensed and insured to practice medicine in the State of Florida, DISTRICT desire$to enter into this Agreement with DOCTOR to serve as Medical. Director and provide medical supervision and control far the DISTRICT,Key Largo Volunteer Ambulance Corps, and Ivey Large Voluntecr Fire Departrncnt,in Ivey Largo Florida,and DOCTOR is wilting to ,accept such engagement upon the terms set forth in this Agreement. 2. Desi atvo and Duties 1"�Iedical I,�irector. By execution hereof. DISTRICT hereby designates DOC I-OIL as the Medical Director for DISTRICT operations wwithirt DISTRICT'S.jurisdiction. In that capacity, DOCTOR will be responsible to provide all necessary and appropriate medical authority and direction for the Medical 'Teams operating in the area. DOCTOR shall be responsible for all medical aspects of, and all medical decisions and directions relating to,Basic Life Support,Advanced Life Support, and immunizations, DOCTOR shall meet at least once each month with the DISTRICT and appropriate Medical Team(s)personnel on site to review,among other things,patient records for appropriateness of transport, patient care, and other areas of quality Page I of S I of 8 7/17/2020,7:35 AHD Firefox about:blaj improvement DOCTOR or appropriate designee shall at minimum provide monthly education. DOCTOR shall meet all standards of the Florida Department of Health and the Commission on the Accreditation of Medical Transport Systems (CAMTS) for a Medical Director. DOCTOR will also be responsible for compliance with federal, state and other governmental requirements pertaining to the operation and provision of the emergency medical care services, DOCTOR shall also serve as liaison between DISTRICT and the various health care facilities or other health care providers for whom DISTRICT provides service in the area covered by this Agreement, Such liaison shall include coordinating the medical operations of DISTRICT to comply with the by-laws, policies, rules and regulations applicable to any such health care facility or health care provider for whom DISTRICT is providing services. DOCTOR shall also assist in evaluating the technical medical aspects of DISTRICT medical personnel working for DISTRICT who may assist in providing emergency medical assistance. 3. a. Insurance R '_- �gquLrements. The Parties shall provide,during the Term of this Agreement, the following minimum insurance coverage and provide appropriate certificates of insurance to the other Party: i. DISTRICT will provide all risk insurance,as provided herein, 1 DISTRICT has liability insurance and to the extent that its existing policy will allow it will provide coverage to DOCTOR. iiL DISTRICT will provide liability insurance to DOCTOR acting within the scope of his duties to the extent that its present policy allows. iv. Both Parties agree to provide workers' compensation insurance for their employees as required by law, b. Communications Equipment. DISTRICT will provide all necessary communication equipment, upon approval of written request(s) presented to DISTRICT for review; including but not limited to:cellular phone,two-way radio,or pager. Page 2 of 8 2 of 8 7/17/2020,7:35 AM Firefox about:blan 4. Indemnification. DISTRICT shall indemnify and hold DOCTOR,and his employees and agents harmless from and against claims, damages, liabilities and expenses (including reasonable attorneys' fees and costs) (collectively, "Losses") arising directly from DISTRICT'S performance of emergency services to the extent such Losses arise out of negligent or intentional act of omission of DISTRICT or its officers,directors,employees or agents,except and to the extent such Losses directly result from DOCTOR'S failure to perform his duties as outlined in this agreement. DOCTOR shall indemnify and hold DISTRICTand its officers, directors, employees and agents harmless from and against Losses arising directly from DOCTOR'S performance of services hereunder to the extent such Losses arise out of negligent or intentional acts or omissions of DOCTOF, except and to the extent such Losses directly result from DISTRICT'S failure to comply with DOCTOR'S directives hereunder. DIS'TRJCT and DOCTOR shall promptly notify the other of arty event or circumstance that may lead to a request for indemnification hereunder,provided that,no failure to provide such notice shall prevent either party from obtaining indemnification hereunder unless and only to extent that the indemnifying party was demonstrably prejudiced by such failure to provide notice, 4, Relationship of the Parties. The relationship between DISTRICT and DOCTOR will be that of contractor and independent contractor. Nothing in this Agreement is intended or shall be construed as creating any kind of partnership,joint venture,employer-employee relationship or any other agency relationship between DOCTOR and DISTRICT. The parties shall be solely responsible for the method and manner in which they or their respective: employees carry out the duties imposed by this Agreement, and neither party shall exercise any control or dil`Wi011 over the methods by which the other party performs their respective functions hereunder, except as may otherwise be provided in this Agreement. DOCTOR specifically acknowledges that he is not an employee of DISTRICT. Page 3 of 8 3 of 8 7/17/202017.35 AM Firefox about:blan 6. Compensation for Medical Director Services. DISTRICT agrees to pay to DOCTOR the sum of$18,000 per year during the term of this Agreement. A cost of living adjustment of no greater than 4(four)percent as determined by the DISTRICT will be added to the annual fee each year at the beginning of the respective budget year. Payment shall be made biweekly, 7. Payment of h Lxpenses. DISTRICT agrees to reimburse DOCTOR for DOCTOR's reasonable and necessary travel and business expenses in accordance with state and federal law,and further,pursuant to any DISTRICT travel policies. Any conflict between requirements set out by law and a DISTRICT travel policy shall result in the provisions created by law controlling resolution of the conflict. A copy of any DISTRICT travel policy,whenever created if not already in existence at the time of this Agreement,will be provided to DOC"FOR, DOCTOR may also be reirribursed for expenditures made on behalf of the DISTRICT program, with the: prior approval of the DISTRICT. Bills or invoices for fees or compensation under this Agreement shall be submitted in detail sufficient for a proper pre-audit and post-audit thereof. 8. Lgrin of 4g reent, This Agreement shall cornmence on February 1, 2020 and shall —pM q_ continue for a period of three(3)years, and will awornatically renew an additional three (3) years, unless terminated by either party as contained in this paragraph. This Agreement may be terminated by either party by giving. ninety(90)days written notice to the other party, termination effective upon the other pany's receipt of the notice of tennination, said receipt of the notice being documented by a return receipt other than via electronic mail. DOCTOR shall be entitled to compensation through the effective date of termination of this Agreement, provided services continue to be provided through such date as contained herein. Page 4 of 8 4 of 8 7/17/2020,7:35 AM F refox about:blar 9. Limitation Of Liabili In no event whether as a result of contract,tort.,strict liability or otherwise, shall either Party be liable to the other for any punitive, special, indirect, incidental or consequential damages, including without limitation,loss of profits, loss of use or loss of contract. 10. Severability. In the event that any provision of this Agreement is determined to be unlawful or contrary to public policy, such provision shall be severed herefrolrt and shall be deemed null and void, but shall in no way affect the remaining provisions outlined herein. 11. Complete Aareernent. This Agreement sets forth the complete understanding of the parties hereto and any modification of the terms hereof must be in a writing signed by both parties hereto. 12. Governing Law, The terms of this Agreement shall be governed by and interpreted in accordance with the laws of the State of Florida, with venue agreeably set in :'Monroe County,Florida. 13, Contract Records Retention. DOCTOR .agrees to comply with all state and federal regulations governing contracts with public entities, including but not limited to cooperation with public records requests as provided by law, and cooperation with comptrollers and auditors as provided by law. 14. Waiver. Any act or lack thereof that is determined to be a waiver by either pasty of a. breach or failure to perform hereunder shall not constitute a waiver of any subsequent breach or failure to perform. Page 5 of 8 5 of 8 7/17/2020,7:35 AM Firefox about:blar 15. Representations and Warranties. DOCTOR represents and warrants to DISTRICT, upon execution and throughout the term of this Agreement that: a) DOCTOR is not bound by any contract or arrangement which would preclude him from entering into, or from fully performing the services required under this Agreement; b) None of DOCTOR'S agents, employees or officers have ever had his or her professional license or certification in the State of Florida, or of any other jurisdiction, denied.. suspended,revoked,terminated and/or voluntarily relinquished under threat of disciplinary action,or restricted in any way; c) DOCTOR has not been convicted of a public entity crime as provided in F.S. §287.133,and d) DOCTOR and DOCTOR'S agents,employees and officers have,and shall maintain throughout the term of this Agreement, all appropriate licenses, certifications and insurance coverage that are required in order for DOCTOR to perform the functions assigned to him in connection vvith the provisions of this Agreement, 16. ALipnment, Neither DISTRICT nor DOCTOR may assign or transfer any interest in this -_ Agreement without the prior written consent of both parties. Should an assignment occur upon mutual written consent, this Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective heirs,representatives,successors and assigns. Page 6 of 8 6 of 8 7/17/2020,7:35 AM Firefox about:blan 17. Notices. All notices required by this Agreement, unless otherwise provided herein, by either party to the other shall be in writing,delivered personally,by certified or registered mail, return receipt requested, or by Federal Express or Express Mail, and shall be deemed to have been duly given when delivered personally or when deposited in the United States mail,postage prepaid,addressed as follows: DISMCT: Key Largo Fire Rescue&Emergency Medical Services District P.O.Box 371023 Key Largo,Florida 33037-1023 Attention:District Clerk P-9-CIOR: TGM Medical Corporation c/o Thomas Morrison,.M.D, 102901 Overseas Highway Key Largo,FL 33037 [RE,MAINIDER OF PAGE LFFT INTENTIONALLY BLANK) Page 7 of 8 7 of 8 7/17/2020,7:35 AM Firefox ab out:blar. IN WITNESS WHEREOF, the parties hereto have executed this agreement, as of the day and year first written above. Key Largo Fire Rescue and Emergency TGM Medical Corp, Medical Serv' Print:An y Gillen __rint: homas Morrison,MD Chairman Dated: bated: 4,t ttest: District ler. Print:Vicky F°ay Dated: W forrrr and suf ckney: ounsel Print:Gaelan P.Jones Dated: Page 8 of 8 8 of 8 7/17/2020,7:35 AM KEY LARGO EMS �4I„µ R f// . i I� U TWO 2023 Medical Treatment Protocols w MER AmBULANC..w CORPS, 98600 0verseas tligfiwayP y .cyl.,arpo,l°oi-iadi3303'7 Phone:305-451-2766 Fa :305-451-6211 To Whom It May Concern: I, Dr.Thomas Morrison have reviewed and approved Key Largo Volunteer Ambulance Corps, Inc., Medical Treatment Protocols. Date: 11/24/2023 Alu SIGNATURE: ............ _..... Medical Director for KLVAC "Excellence a " www.k1vac-,org INDEX Key Largo EMS Medical Protocols Dr. Thomas Morrison -Medical Director Section 1 — Airway 1.1 Airway Rescue Protocol 1.2 SOB, COPD, CHF, & Asthma 1.3 Basic & Advanced Airway Management 1.4 Stridor Section 2 — Cardiac 2.1 Asystole 2.2 Bradycardia 2.3 Cardiogenic Shock 2.4 Chest Pain& ACS 2.5 Post Arrest Resuscitation 2.6 PEA 2.7 PVC's & ACS 2.8 Tachycardia 2.9 Pulseless Arrest Chapter 3 — Environmental 3.1 Anaphylaxis —Allergic Reaction 3.2 Diving Sickness 3.3 Electrocution/Lightning 3.4 Envenomations - Bites and Stings 3.5 Spider& Scorpion Illustrations 3.6 Marine Envenomations 3.7 Overdose—Poisoning 3.8 Hyperthermia 3.9 Hypothermia 3.10 Pepper Spray 3.11 CO—Cyanide—Smoke Inhalation INDEX Key Largo EMS Medical Protocols Section 4 — Medical Emergencies 4.1 Abdominal Pain—Acute Abdomen 4.2 Altered Mental Status —Unconscious States —ETOH 4.3 GI Bleed 4.4 Nausea—Vomiting 4.5 Psychiatric—Behavioral 4.6 Seizures 4.7 Stroke Section 5 — OB 5.1 APGAR—Newborn Scoring 5.2 Childbirth—Complications 5.3 Childbirth—Labor and Delivery 5.4 Childbirth—Labor and Delivery—Illustrations 5.5 Eclampsia—Preeclampsia 5.6 Postpartum Vaginal Bleeding—Vaginal Bleeding of Unknown Origin Section 6 — Pediatric 6.1 Anaphylaxis —Pediatric 6.2 Asthma—Pediatric 6.3 PEA —Pediatric 6.4 Bradycardia—Pediatric 6.5 Glucose Values —Pediatric 6.6 Post Arrest Resuscitation—Pediatric 6.7 Seizure—Pediatric 6.8 Tachycardia—Pediatric 6.9 Pulseless Arrest—Pediatric INDEX Key Largo EMS Medical Protocols Section 7 - Traumatic Emergencies 7.1 Amputatioins 7.2 1" and 2nd Degree Burns 7.3 2nd and 3rd Degree Burns 7.4 C-Spine Range of Motion 7.5 Glasgow Coma Score-Adult 7.6 Glasgow Coma Score-Pediatric 7.7 Head Injury & ICP 7.8 Shock& Combativeness -Trauma Related 7.9 Taser Injuries 7.10 Tension Pnumothorax-Hemothorax 7.11 Trauma Alert-Adult 7.12 Trauma Alert-Pediatric 7.13 Trauma Alert Criteria Scorecard-Adult 7.14 Trauma Alert Criteria Scorecard-Pediatric 7.15 Traumatic Cardiac Arrest Section 8 - Procedures 8.1 Chest Decompression 8.2 CPAP-Concepts 8.3 CPAP-Assembly with Nebulizer 8.4 EtCO2 Waveform 8.5 Duo Dote 8.6 M.A.D. Device 8.7 External Jugular IV 8.8 EZ-IO Insertion 8.9 EZ-IO Landmarks 8.10 I Gel Device 8.11 Nasotracheal Intubation -Concepts 8.12 Nasotracheal Intubation 8.13 Nasogastric Tube 8.14 Oral -Endotracheal Intubation 8.15 King Vision 8.16 King Vision w/Bougie 8.17 Spinal Motion Restriction 8.18 Surgical Cricothyroidotomy 8.19 Synchronized Cardioversion 8.20 Transcutaneous External Pacing 8.21 Pediatric Vitals 8.22 Blood Draw for Law Enforcement 8.23 C.A.T Tourniquet INDEX Key Largo EMS Medical Protocols Section 9 — References 9.1 12-Lead Reference Guide 9.2 APGAR Scoring 9.3 Determination of Death in the Field 9.4 EMT Care & Transport 9.5 Refusal of Care—Page one of two 9.6 Refusal of Care—Page two of two Approved Medications Pg 1-29 Pg 30 - 39 Cardiac Arrest for Suspected/Confirmed COVID-19 Pg 40-46 POCUS > L �• ♦��♦ 0) � � O m 0)2) L > X .a ;°a O ♦ U L.L .L cn 0 j m O m CU Q - E C J w ri O Cn c O Q E o x a) CU O `= a) O N Z oa) � Z Q >, to U O L N to Y Q ♦ (B 0 E 0 :5 N ._ to U CB > c a) o U O -1 >+ > " ? ca N 7 Q 0 y E C „ ,,,, c O - �. 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IIIII 0 1-1 Key Largo EMS Legend Respiratory Distress - Adult EMT-Basic Asthma - COPD -Acute Decompensated Heart Failure Paramedic 'Ityciclan ¢ r(rvc r �$i II , 0 Determine responsiveness/Check ABCs ■ Acquire Patient SAMPLE history& OPQRST Check Vital Signs ■ Oxygenate via NC or NRB y IV NS KVO C7ns' der CPAP in severe ® :::::1 respiratory distress o tl� � 5 ECG Monitor T Q N Asthma COPD CHF _77 __j T Atir 0u gas^ul"ml: ","' Consider AlUteiiunl Administered III n � ura� � 0 talxolll 2 5ui"mmg "mmg Acute Decompensated Heart Failure Administered by nebulizer y ebulizer connected to 6-8 Ipm 02 connected to 6-8 Ipm 02 Can be administered continuously Can be administered continuously as long HR is not> 140 as long HR is not> 140 CCons%er- t is wheezing CPAP max EEP with Allllsu..rtercd If patient is extremely If patient is extremely 2.5u ,ig bronchoconstricted bronchoconstricted 06lu.,urnedirv6l 125 rng allow IV push S6u rnedurvall 125 u'rg sllow IV push over 5 rnln, over 5 rnln NTG 0 4,, i 1g sULlllliiagu4ll 15 in In As long as BP > 90 mmHg and no If patient SOB refractory If patient SOB refractory contraindications (+V4R, Viagra) to Duo Neb & to Duo Neb & Solumedrol Solumedrol 0asliix 40...80 ui 1g IV PUSS pContfinues —CPAP max BP>90mmHg with Alllk�uu,udaurvall Consider—CPAP max 5cm PEEP with Allll.�uUtei all r.n lis 50c.c. 110g over 0rlp (���I u;Jtts/su�°�c) OB with CPAP If patient develops 10 Severe Respiratory Distress go to Airway Manaaement Protocol or Airway Rescue Protocol � IICIICII"�Shortness of Breath Adult �_2 (Asthma,COPD & Acute Decompensated Heart Failure) c� a � N m rn p a > uu as rn O J w a ^„ 0 N 0 cV > w H 0 N .� 1, Q z a s o Q 0 0-0 = Z Q = a N X o m 0 L O _ ca Lu 0C� 0 �. a� 04> W o — �1 a d c0i � u U Q _cu o Q > �jnjss933nS O 0 � a a U 0 0 a = cu �. 0 m °' 75 O ova ' cn 2 `� 2 Ucn Q� E �= L � a E � �= � � N °' 0 ca U o -- a� o 0 rn a) WT ly O � aNi � z � � J aE _ U 0 Lu 0 Ecu 0 0 _ M CMW d > Q o �' 0 L O coJ = cu c, Q >. o 0 ui �, rn � T- c d > v N n Al a = V °i II H to O 3: cam U ill 7 � �S Q III l" +3+ •- � � � � a Q 0 Il.11"a to a)a� Z Z U _ � = �++ o,w.7 0 a d 7 0 � N to � U C� _ ; 0 m 0 00 a � m U) Q u II N z V N m W m ,c U) 0 U N > LO Q Ali. 0 d Q v N U d � 0 L � a 0 m a�i .X a a� mCY � O a = � a oil 0 u-0i 04 d O U LD U 0 0 O LI- E ti � � � a) 0 � m w -00 0 t E 0 Q cn L) 0 cn ~ of � d a a L) N0U 1-3 a WI w 0 m a. E ri E = w c L Sr- w 0cC 42 r_ 0 O .S = W - ct E > 0 0 0 0 ch E 0 ch E 3: a 4) Rq ILL E E CL —j 0 1-12 0 U L (L z 0 —j 0 m 0 12 -.0 0 0 0 cil —j LUa co > LU C.) CL Co 0 LU z e 0 co Co m c o E 0 a) -6 .1— cn 0 -0 a) co 0 a) to co C) CL S E Co (n c a) -) V) Y) E 04 > a) Co 2 V) cm (n (n -a cL a a) . a) 0) 0 0 0 C) C) 0 5tl 7 CL 0 co w C.) 0 0 c CL O 0 U) E c,u —Om :3 LL a) a) u -a 0) IIIIIIIII CO E cu cil cu 0 C.) >, Z cu cu �) 0 0 a o 0 E :) CU ILOhnu CU (.) CO > = .— Z .M oa 0 w " L E 0 0 0 a) "Ia�i pa - CU -a a (n 0 o !:: a m U) z 0 a LL 0 > E 0 — .— >1 0 0 y ll� a) U) LO CU CL > -0 C) Z- U) cu -0 W cu Cil 0) co -> :E cu C) 0)— = — 0 = V) 07 cu > 21) 0 a C.) — 4) C F- w 0 -S� E 2 0 C) o z� ��2 C) ........... C) E > Asystole N Determine need for resuscitation Obvious death / Assess ABCs L active DNRO Inadequate or NO CPR II II u IIIUs � ^W u 200 CCC* ' > 100/ min. " Quicklook, determine Synchronous Activities: and Confirm Asystole in • 02, Place, Confirm & Secure Advanced Airway ** 3 leads • Obtain IV / 10 access • Fluid Bolus of NS 250 cc Review H's & T's: Consider: Hypovolemia Tablets (Drug OD) 2nd Fluid Bolus of NS 250 cc Hypoxia Tension Pneumothorax Sodium Bicarbonate 1 mEq/kg IV/10 Hydrogen Ion (Acidosis) Tamponade Cardiac (if existing hyperkalemia Hx) Hyper/hypokalemia Thrombosis Coronary (ACS) D50 25 gm IV/10 if BS < 60 mg/dl Hypothermia Thrombosis Pulmonary (PE) Narcan 2 mg IV/10 Hypoglycemia Trauma (if opiate OD suspected) Calcium Chloride 1 gm IVP (1f on calcium channel blockers) 2 g of MgSO4 over 1 to 2 mins IVP (if s existing hypomagnesium states) Pause compressions 5 seconds only in e liu �: ug II / uliu Check pulse & ECG Resume CCC for 2 minutes Contact Medical Control *Continuous Chest Compressions **Confirmation of an advanced airway, includes using ETCOZ monitoring. Obvious death is defined as rigormortis,lividity,and/or decomposition 2-1 Bradycardia N Heart Rate < 60 BPM and/or inadequate perfusion _j Synchronous Activities: Obtain -Oxygen based on O= Saturation -Assess Vitals Signs SAMPLE history -Obtain IV (NS / KVO) & OPQRST, 12 lead ECG -ECG Monitor -Pulse Oximetry / Capnography •IFACS suspected ASA 324IIIG Asymptomatic u u Monitor NSTEMI2 or VS STEMI1 STEMI ST depression, + Hypotension NO Hypotension Non Diagnostic ECG Acute Inferior MI lg I g 4,, uinig is 5 iniliiin x 2 I'f"I""G g 4. uinig is 5 uiniliiin x 2 with or without if not imouiimaViugiimaiad if not V4R ST Elevation Trendelenberg (lungs clear) If pain continues If pain continues Fluid Bolus 250-500cc �lg im° [i iii.in e 2 n i o ii"I u iuna 2 n.ig (repeat as needed) �t i�iun N i�iax 10 img (a � iniun intax 10 inig If V4R present, up to 2 L 01 Aiimoll° liiine g 5 inig is 5 in i lii in N in i ax 2 in i g pi External Pacingg, (lungs ) If Atropine is ineffective, Hypotension develops: W Trendelenber lun s clear �. Fluid Bolus 250-500cc W 01 (repeat fluid bolus if Persistent hypotension, no improvement) Cardiogenic Shock 11 evopllliim!d 1 11111iaghn lin -External Pacing: PRN for severe and symptomatic bradycardia or 2°or 3°Heart blocks, sedate with Versed 1-2 mg, repeat if needed for pain x1. -Atropine 0.5 mg ( max 2 mg) IV may be given if: QRS complex is narrow in 2"d or 3,d degree blocks, or sinus bradycardia; repeat at 0.5 mg if bradycardia related hypotension continues. 'STEMI = ST Segment Elevation MI 2NS STEMI = Non ST Segment Elevation MI Contact Medical Control 2-2 � � ( � ( 2 . p .. E � O O � U O W CL cn m R � U U 2 W UJ D O UJ0 � U O / U g » o c I k ® » 2 ) \ � \ \ 0 0 0 § \ \ \ \ E \ "Co c = = e 2 \ \ c Coo \ / 2 \ Co Co k / 0 2 2 \ = 7 ^n \ Co0- / \ \ / 2 q § 2o4 »W Z d \2U) / \ �U / (of % E ¥ E0Z + 5 ƒ 2 � = m 2 ° R = « f < 2 o \ § f 7 0 . ) k / � �\ \ \ \ \ DZ > < c o o > o �_ o 2 $ / 7 % 2 ° 2 0 �_ ^ 2 = = � 222 � � a \ / \ f § 2 E / E ® / e < I IRO < @ �2 / � - - - - - - - � . 2 @ 7-j i Chest Pain / Acute Coronary Syndromes Determine responsiveness Synchronous Activities: Assess ABCs -Oxygen based on O= Saturation -Assess Vitals Signs Obtain SAMPLE history -Obtain IV (NS / KVO) & OPQRST -ECG Monitor -Pulse Oximetry / Capnography -Cardiac Assessment Sheet -ASA 324 u g Obtain 12 Lead and categorize patient into 1 of 3 boxes below Check WR for all Inferior Wall MI's & if positive withhold NTG _j ST-Elevation MI Non ST—Elevation ( NSTEMI) Non Diagnostic (STEMI) ST-Depression and/or ECG Or T-Wave Inversion ***New LBBB Unstable Angina *III" III°°G 0 4, i S III q 5 rn ur,in X 2 If pain continues Administer**III oui 111 III°iuuiui c Sulfate 2 ui IIV q 5 urnuiinn umax 111uniug 110 11111111�11111111 Tf,11,111,I ii,11191111111 iii W�11 1111,iIl,,I I 11iiiiii ,1�ii;111111 I I will, I Stable Vital Signs Monitor and contact HR < 60 BPM HR > 150 BPM Medical Control Follow Hypotensive Follow Bradycardia Tachycardia protocol protocol %r Fluid Bolus NS •NTG:use only if systolic BP> 90 mmHg 250 cc IV * No NTG if sexual enhancement drugs used If no crackles within 48 hours * No NTG if V4R is positive on Inferior Wall MI's If BP does not increase &: I W or crackles IIL...evopllhed W ., *** Left Bundle Branch Block: new onset 1 11111(mgNun l in Morphine Sulfate if BP> 100 mmHg If patient has crackles go to CPAP Protocol Contact Medical Control 2-4 i i r� � uuuu N O i. �tl U 0 U) N (�I 0 m E H +r d co Uco �o U (6 70 V co m L � L o U) O O O C/) O U a F- a cn U N co W'W',W � E O L o E , U1 to n Oo �.W �� N v p U E co co V '— E W u) U `� coN �i C �. O 0 � a � � ... I J �c o � � cil o NW L c W N it W'N ii i U) co � N cil U � � Y /^O 0 a� Y U co _ U � N o c -a cn O o y o � O co Z N co U W�W c _ � O J III QO y O _ N N 7 L N N m Q 7 N U) Ali O N Z N O N N D 0 W 0) C U N a C N L O -a a •N > N — . J ~ N � N Q L � N to cu O O 7 .O a) U E N p O U Q o U Cfl i Pulseless Electrical Activity N Determine need for resuscitation Obvious death / Assess ABCs L active DNRO Inadequate or NO CPR IIIIIIII u IIIUs � � u 200 CCC* ' > 100/ min. " Quicklook determine Synchronous Activities: Rhythm and Confirm • 02 ,Place, Confirm & Secure Advanced Airway ** PEA • Obtain IV / 10 access • Fluid Bolus NS 250 cc Review H's & T's: Consider: Hypovolemia Tablets (Drug OD) 2nd Fluid Bolus of NS 250 cc Hypoxia Tension Pneumothorax Sodium Bicarbonate 1 mEq/kg IV/10 Hydrogen Ion (Acidosis) Tamponade Cardiac ......-, (if existing hyperkalemia Hx) Hyper/hypokalemia Thrombosis Coronary (ACS) NarcD50 25 gm g IV/1 if BS< 60 mg/dl Hypothermia Thrombosis Pulmonary (PE) (if 2 mg IV/10 H o I cemia Trauma (If opiate OD suspected) yp g y Calcium Chloride 1 gm IVP (if on calcium channel blockers) 2 g of MgSO4 over 1 to 2 mins IVP (if existing hypomagnesium states) Pause compressions 5 seconds only in e liu �: ug II / uuu Check pulse & ECG Resume CCC for 2 minutes Contact Medical Control *Continuous Chest Compressions **Confirmation of an advanced airway, includes using ETCOZ monitoring. Obvious death is defined as rigormortis, lividity and/or decomposition. 2-6 N n n ai • ai p ai u. n n n m mf a, m n m n n n V! ai ai ry a ^ O ai ai • o CL cn cn cn 0 ~ U Q wa uC: a J W ° H o W Zui Yp c o _ °- (Ii w U o co E o _ o L co o M Q co v7 U J a co E co o c � ° CD y- cq + & U ° a CD L L � o 0 o (n o c m o z o m ° � o � Co c N C) F E W _ W U) 0 N 0) Q E -0 ca U a vi c 0" a a) a)0) o Q ;E ° n3 ca Q �_ co "0o > U) vc°i o E - c E �° gym . o o oN co > �co w n3 ._ CIA o c o o v u � Q c .E LO o o � , In o Q Y n3 E U n3 � �10 - Ems 4- Q Q m L Q > �� ° `m o ° a) vi Q o z n3 E >u a > _ � v°i d QO- > c0 0 j x cn as '' > 2-7 N a (U) "�..........................................................................53-) ICU I 0 ...... . . III, 0 _ N L a .. ¢ ...... i > C a in Cn Q oiiiiiiiu v U a L — to �c a 0 2) '^ 70 U) z o U a� O c6 --:t' c -0 » o X y a� �jOQOwa E ' I �A, /�� CD En L N W •\ G II � 70 �I6�°H °�h„w � O L °h# '` CDICU Q u " CL Q 70 70 C) U Cu -0 7 Cu Al U O NO • U — � � O o � Cu 0- � �n� o m � O m � �, � N C.1 O RJ 0 ,gym co �, �, u l ^r' Q C C a LO a� O � CDcoaA y V cQ w � J � LU r a Q co oA 0 N %r m R 0 0 N d L N � d *n ) N d � o U Q z is � O c ra 'ta + = ty fn _ 0 a * U Cu VI h z '' L r�!''H a r'H > � rp � 'w' c °H ............. U) a) �i �N w� a Q N N o6 8u C.) ' Ik"lz� o ii, 0 .� V-Fib / Pulseless V-Tach 00 CV Determine need for resuscitation Obvious death / Assess ABCs L active DNRO Inadequate or NO CPR a II II IIUs u 200 CCC* > 100/min. Quicklook + defib Initial Biphasic If Asystole / PEA 200J (LP15)x 1 See Protocol Synchronous Activities: Immediately perform . 02, Place, Confirm & Secure Advanced Airway 200 c Obtain IV / 10 access > 100/min. afterr every shock e • III.....!Ip'iI unli e Ip Ih In lii unli e 1�„10,0 0 0 1 irn g III V q 3 5 irn lii unli Quicklook + defib Biphasic 300J (LP15)x 1 (See Notes below) Immediately perform 200 CCc urn- lii Adarounl�e 300 irng III /111 *** > 100/min. after every shock Quicklook + defib Biphasic 360J (1-1015)x 1 (See Notes below) Consider: Magnesium Sulfate 2 gm IV/10 push Review H's & T's: (Based on clinical presentation) Hypovolemia Tablets (Drug OD) Fluid Bolus of INS 500 cc IV/10 Hypoxia Tension Pneumothorax Sodium Bicarbonate 1 mEq/kg IV/10 Hydrogen Ion (Acidosis) Tamponade Cardiac (If preexisting hyperkalemia Hx) Hyper/hypokalemia Thrombosis Coronary(ACS) D50 25 gm IV/10 if BS<60 mg/dl Hypothermia Thrombosis PE Narcan 2 mg IV/10 Hypoglycemia Trauma (If opiate OD suspected) Contact Medical Control *Continuous Chest Compressions **Confirmation of an advanced airway, includes using ETCO. monitoring. ***Amiodarone 150 mg IWO may be repeated once if V. Fib is persistent Obvious death is defined as rigormortis, lividity, and/or decomposition 2-9 C M O O 0 E cn m V cn LUE a) CL _ ,g � M a) E co 0 (D c RS d L _ co cn N n )� > � *' ns E E � n3 c m a) v7 u O O = ++ O = O E W O ,tn ° o ° � o � o = U O E � � °' � — >, cn L cc O 'L cc d c cm U o aCL Q- E p E m Q ' cn cn , C C> � 0 cn cn CM co _> M V . O O O mCL c = o = • CLcoECL _ M cn m � cn O m cn d 7 d d O cn .� N a) N •J •J V L U) � � • = o � o O m � Q L _ m � c�a m 0 o m a 0 C1 "� i cZ E c 0 a �N 0 � � O o = mo � � m00 � U 0LU Co c v7 E — o H =c m ccn co CL `a � � Co E �' � v7 E ° M 0 wUa . 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" Quicklook determine Synchronous Activities: Rhythm and Confirm • Place, Confirm & Secure Advanced Airway ** PEA • Obtain IV / 10 access-Administer Epinephrine • Fluid Bolus NS Review H's & T's: liiuimxlllui liipim III III xiiiiii2lxlllui uiuim III III Hypovolemia Tablets (Drug OD) Hypoxia Tension Pneumothorax Ages 0 -13 y/o Ages 14 and over Hydrogen Ion (Acidosis) Tamponade Cardiac Hyper/hypokalemia Thrombosis Coronary (ACS) ( 10, Hypothermia Thrombosis Pulmonary (PE) �3 u�"�V/Ilia H o I cemia Trauma iliuxs �r .0 niliuxs Yp g Y Pause compressions 5 seconds only Check pulse & ECG Ages 0-8 y/o Ages 8-17 y/o Resume CCC for 2 minutes Fluid Bolus NS 20 cc/kg Fluid Bolus NS 20 cc/kg q i�: n() 1 irg/kg IIWO Gray irg) q i�: n 2 incg IIWO Neonate( 1-30 days old) BS<40 mg/dl Pediatric(31 days-8 y/o) BS <60 mg/dl Contact Medical Control *Continuous Chest Compressions **Confirmation of an advanced airway, includes using ETCO2 monitoring. 6-3 Pediatric Bradycardia Determine responsiveness, Assess ABCs Synchronous Activities: Obtain -Oxygen based on 02 Saturation SAMPLE history -Check Vitals Signs & OPQRST 'Obtain IWO (NS / KVO) -ECG Monitor -Pulse Oximetry / Capnography Asymptomatic ; puilR "11111, m 9.1iiiiiii, Ii,P,111.11�111�11111� Ili, 111 11j,111111M 11 Monitor NO YES VS Assist ventilations Signs of Poor perfusion/clinical presentation: BVM to T HR Infants: Children: •Irritability Hypotension •Tachypnea Heart Failure Begin CCC :Poor feeding Shock If HR< 60 min -Seizures Decreased LOC -Children: Pallor f lllllll 11 lii a ell 111 mmlii u e 0 01 ium g hkg III NIIIC Rule out any reversible H's & Ts: Hypovolemia Tablets(Drug OD) If increased vagal tone Hypoxia Tension Pneumothorax and/or Hydrogen Ion(Acidosis) Tamponade Cardiac primary AV block: Hyper/hypokalemia Thrombosis Coronary Almmoll,gliine 0 02 inig hkg Hypothermia Thrombosis PE N IIIC Hypoglycemia Trauma Consider Pacing Causes of Bradycardia: If Pulseless Arrest -Sinus Brady with AV block •Infection develops go to -Trauma Asystole/ PEA -Vomiting -Congenital Heart Disease Contact Medical Control -Consider External Pacing -Consider performing 12 lead ECG -If Pulseless Arrest develops go to Asystole/PEA protocol -Cardiac output in children, particularly infants younger than 6 months, is heart rate dependent. -Bradycardia with poor systemic perfusion must be treated regardless of normal blood pressure. 6-4 v, W O 0 w w J W W W 0 0 J �� J 0 0 6-5 M1111111111,111111 Oacoof >s(D U � V W = m O O Z 0 O U) 0 H � 7 Q > 9 C: H � � o U 0 a w W Y � � H N E LNU 42 co ch LPL W L C � N 0 E c-) c O �I O Q U �LU U o All O Q H a� N Y E :t2 U N J m QQ� p 0 L c ` O CO `N y 0 a N Q Q � � O (1) Ah =a � a 4 Q ::. x W O (U) m y L c LL N y O a N �' a N ch 0 E 0 L 0 p 0) cu cC Y to G1 a) E a) 7 O spa �N 0 O U a z is O O ° O �- N LL cu 70 CID . C+ N CID .. z � 6-6 x U bA N a) Cu a) Q 76 a U) a) Cu �Z _ U — 0 V Cu V WcC O 0 S E `� W �W 0 co o a o o W ❑ Co aq v7 O N O � a) co o ooc) 0 W o .0 a 5 E >, a, co ui V ° Q CL M Co Q t QL ,J J M W O O c i°" o � Q .0 w E Y 0 ' w � � s � W > E o- z a) O a °�' a�i W o cO -00 co co CL uj m x(0 N ca O '"b',V Y W J J Q N Q Q 0 m a m � � -o • _czEE � — � O O a) d CO V Cu O (0 a) a) a) Z V V ) � m , > L > a) O EC� cncn� O O � O_ O N � a) U) U) O Q OV m m � WwOQw E 2 0 0 W � wUUa W d � m :a Q d d c u (� a 'a � Q 6-7 ayi DO O co a a C0 U Q 0 0) 0 ^^� L r� LL O - - O 0 �� } E OO } - O p o- 0 CIn a> U) � a -0o E � Im � 0 2 .E o .E 0 >, >, O� — Cu C3 Q N N Cu _0 -0 0 N Cn O 0 (o O c � Al �„ha }i N •> Y V j rr V 0 �Cn \ i (A , L LL Ik Q 70 Cn Z �, O 0 N O ++ L y--� y--� (n U to U i Mii a3 0 0 (n 0 >r 0 (o _Ln(o O 0 N a) fC N _ \ 0 Cu N N c y c C � 0 X W Q d o v O y Cu 7- •� O N 0 O J N O a 7 c 70 (.� 0) 0 U to L O V " 0 O `° 2 `° >, a) U No c L c x U DQ to CL > 0) d � Co �j000wacn Q -1N >, V E 3 � � a) U L � 11) -a `� L6 Q No L a� a� a� a> > a•+ (ndo � f2 a>i U = = o 2 1 p O L0 o2Q � �� U _ _o _o v T-- 0 70 o o a) " " ,+ .L V EE O C MCh,I& N 0 0 �.� _ N CC) °� Q co `� O L co N U w V M„hd& a) o "O += II M"h a) n n O c N -a U O O 2 ��� a) C 0 � LO a) C �_ z LL LJ� "r .--� .0-� (n U Y N "a O j, cm C) N z O � N Y� E � Co. co 0 70 Q L 0 N N N 0- 0 Zrp o Ylllllw O -a0 L N _ ufl000- O N ,II.;......... 11 ] lil N C a) M;h s °°°°°''' 2? c� u N cn co ca k O IIL.....���� ���8f���� 4- � O Co co V C Whlh RIB „I111116 > :' 6-8 �� ��' � ' � �� U U �� ^~� o� U�� �U�~ U U �%o� o��%�% ��� �—~~��.~=�. .~° � �—~=U~°~~U~~~°~° ���. . ~~��� | C.6 | Determine need for resuscitation Obvious death Assess ABCs active IDINIRO Inadequate or F NO CPR C\uioNook±defib Bi phasic 2J kg (Vfib. Pu|oo|000V-taoh) Synchronous Activity Immediately perform :Place, Confirm & Secure Advanced Airway 2OOCCC ^ * 1OO/ min. after every shock Obtain IV 10 access � � C\uiok|ook±dofib (1 max. oroquiv. biphaoio) � � Immediately perform 2OOCCC * 1OO/ min. after every shock Rule out any reversible H's & T's: Consider: Hypovolemia Tablets (Drug OD) Magnesium Sulfate 25 to 50 mg/kg IV 10 Hypoxia Tension Pneumothorax Fluid Bolus of NS 20ml/kg IV/10 Sodium Hydrogen Ion (Acidosis) Tamponade Cardiac Bicarbonate 1 mEq/kg IV/10 D25 0.5-1g/ Hypothermia Thrombosis PE Narcan 0.1 mg/kg IV/I 0 (max dose 2 mg) Hypoglycemia Trauma Contact � � ^~� Medical U Control � � U `�������� n�o���U��n `�������n ^Continuous Chest Compressions ^^ Confirmation ofan advanced airway, includes using ETCO2monitoring. mmAmiodarone15Omg |VY|O may be repeated once ifV. 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II �;u�f��urvr;�;u��u�;u�l on r,�;u��; Oxygenate via BVM with & OPA I NS large bore IV/10 KVO li Continuous ETCO2 monitoring pliu eplI Ii in °I a'np IV/10 p p...k r nlin IF Pause compressions &shock @ 200J** (if V-Fib persists) Wi as Resume continuous Manual compressions for 2 minutes W W W Bilateral pleural decompression W Follow PEA & Bradycardia W , durvc pliu u p l�/ I u..dp d ku p urnlodaron 300 ling/kg IV/1 ifVForVT Pause compressions &shock @ 300J** (if V-Fib persists) Resume continuous Manual compressions for 2 minutes Pause compressions &shock @ 360J** (if V-Fib persists) Resume continuous Manual compressions for 2 minutes � I W IIIIIIII �� � W �� „ Illi � Ills �� �„ Hyperoxygenate patient for 30 sec *** II W Place, confirm &secure ETT II (Max 2 attempts x 30 sec each) IIIIIIII If ETT intubation fails ***Place, confirm&secure I Gel Airway li I w u consider I II Contact II k)sp t 11 / Il:llk II Ihysk dad Traumatic Cardiac Arrest 7-15 x CL O Q- U Q 0 � N O O V 0 0 a) co O O Q O A L O rr _ +�+ O Cocn fn > 0 U Z CL O — _ �° N a) W v o ` co # co N V) U❑ � > O x O OW V 0 CL (6 > O O Z u a) O O W O � O CL a o o 0 W o a ¢ y co U) E 2 aAp W J 0 Q > m Q Q m coo a co N U O co U 00 = i a) 2 ❑ O o Q +� O J co W o a > — V =a o V co �-• a) -p a o '3 W W cc a) co *0 = ❑ Y Z U) U) a) n3 O Co cocn co CL °1 U) �Q CL = Uns= p O0 CL O = O cn a X O N .�- E � Q V V co N a p> N O 'J co V CDy >, Co = Q'= Q m a�N N cn m O � O N 0 O ` N .0 O 0 Co r N= N V coO c. a�N _ o Q O d Q in V) M*0 mpE � c°� � J cn aa)io � *0 a= " � � >v v0- Q L Co O O O 0 O O �o w a) p 0 0 0 0 a) 0.) 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EO o b o L C °- , o E a c o cn `° m ° N m m o m �� 3C ° m a) c0 0 > p .N m F'E m C O O (D N - O m � � Q V Qom m � Emmm - Q Q co ccE "C a) "6a�ivoi � v5i > cc `° m m o > ° m •N m o L m � m o � � � w `° � m °c Q N Fn N 'a `-L° cn o o C cmi a p ° E m y m O O O 12 E d s a C o "' m m .in : c E o m E •— � — ca � o � � � om L tea) acu — -Cp0 Uo mpcN mmN � m a o m m m a� m a.2ac) mmx N � N C O m m °� `n 0 ° mom°' o o 0 0 m c � _ `n = = w � w =O `_ v; co oin ° Eo � —' cncn � cn Um m ?) p p U ,� U m ELL cn o) N N L N O �' E 0 0 0 E 0 0 0 0 ;C O c�0 RS = O N r N C a) N inn °0- 0 0 U N �� C C cn a� J O w c a � O � QQo � Q � QQ oQ ° `n Q Q C E «. m co c0 Nco cn Cm • • • • • L •d V V LB da O L O 'O O -0p w co QU O w 9-5 a m aci in c in N � °' ° 3 m L ° a) cn > in in ° in ° N O O ° cn Cin in O O E O N � w C O O cn 2L in O) in C O ° O O0 3: ina -C a) O V- m a) cn w ° a) -C y mCoCO r a) � � O) N m w Q a) •cA vi d cn O L O v � ° N C: -C c m m o m E9 J = in incn (� c Q d O V) O m _ a o Q o a a a) c 0) - aiCL cv Q E m b m m d -C uS m E W CL N m m a L t0/J o > N cnin ,� 0 Co o L o d m �' W Q ❑ m N ° �, LL JW °c a `° -05 ? 0 Z a- o O � a co a N ° = Z E 'c voi Fes. c m m J YZ o -C c m W E o W o m E Q O a� N � `° W moc � amio amm � cL � y- c Co � '� o N pA � ❑ O a C Q) ++ -O ''y N N V N O LL c 0 a p C > m o c E W U ° :cc�°iX o � � co aoo ° c Z � ° c � a O 'cn o cn = d E O E c s.� c d CD a 0 c O • O Q o con La Q ^ o m m cn _ a N °) U in c m y c m N a E E m E m a) «: omca o mmac oin A Joy m E c c° '� `��° '� o � �' N cmjm = E ° � � ° > Lu Z �, m o •-aa mmO aa) - 0 _ � oo0 - mE C C O s x = L 0 Co — T! a c c •� O m o Com m pA o °c m a) as o Lu 0 - L L a) ° o " E a' m � o N a1 � w a m m.5 � ° co cn cn m o m c d L o m o U E O a m c o c in a. 9 c O C m c6 O C cn a) L m o 0)m a a m ° d ° a m m m m m m y a Rs o cn .5 m m C cLc m � o .N : � � •`� (n m m ,= aCL m) aE m m a c m a. m c 9 aC x (n L O •L L m in cn 0 U ++ ° cn "dlreq{ p'kp "- m m c m - a) a) m m m m m m O a m o o = m o 9 •� L'� o = F- F- � � = w �' = w � �- E avmima) W5P Q E d d O c 0 - O C> • • • L 0 O E u N C L L Q • • co O ++ ++ U E uw� 9-6 APPROVED DRUG LIST This section contains a brief description of drugs used in the protocols. It is intended to supplement other standard references. Drugs are listed alphabetically, based on their generic names.Trade names may be shown in parenthesis. Adenosine Triphosphate (Adenocard) Page 2 Albuterol (Proventil°, Ventolin) Page 3 Amiodarone (Cordarone°) Page 4 Aspirin Page 5 Atropine Sulfate as Cardiac Agent Page 6 Atropine Sulfate as Antidote for Poisonings Page 7 Calcium Chloride 10 Page 8 Dextrose 50%, 25% (Pedi) Page 9 Diphenhydramine HCL (Benadryl) Page 10 Duo Dote Page 11 Epinephrine 1:1,000 Page 12 Epinephrine 1:10,000 Page 13 Etomidate Page 14 Fentanyl Page 15 Furosemide (Lasix) Page 16 Glucagon Page 17 Ipratropium Bromide (Atrovent) Lorazepam Page 18 (Ativan) Page 19 Magnesium Sulfate Page 20 Methylprednisolone (Solumedral°, Midazolm Page 21 ( Versed°) Page 22 Morphine Sulfate (MS) Page 23 Naloxone Hydrochloride (Narcan°) Page 24 Nitroglycerin (Nitrostat°, Nitrolingual° Spray) Page 25 Norepinephrine (Levophed) Page 26 Zofran (Ondansetron) Page 27 Oral Glucose (Insta Glucose) Page 28 Sodium Bicarbonate 8.4% and 4.2% Page 29 ,. Adenosine Triphosphate (Adenocard°) J� ACTIONS: Adenosine exerts its effects by decreasing conduction through the AV mode.The half-life of Adenocard (Adenosine)is less than 10 seconds.Thus, its effects, desired and undesired,and are self-limited. o/✓,� ,�1�� @VIA@" @ChnN�S�, Adenocard is indicated for paroxysmal supraventriculartachycardia (PSVT), including that associated with accessory bypass tracts (Wolf-Parkinson- White Syndrome). INJECTION USP A E�NOSINEFOR � 12mg/4ML ��� 00111wu oreu nbV�flll is contras USE ULME MOO CUSP I I G fl b S,rc Adenocardindicated in second-or third degree AV block and sick �FIX,ONLY N sinus syndrome(except in patients with a functioning artificial pacemaker), and known hypersensitivity to Adenosine. ✓jaM(Id(f�NWrr;, WARNINGS: Adenocard may produce a short lasting first, second, or third degree heart block. In extreme cases transient asystole may result.At the time of conversion to normal sinus rhythm,a variety of new rhythms may appear (PVC's, PAC's,sinus bradycardia,sinus tachycardia,skipped beats, and varying degrees of AV block)and generally last only a few seconds without intervention. The effects of Adenosine are antagonized by methylxanthines such as caffeine and theophylline.Thus, larger doses of Adenosine may be required for Adenosine to be effective.Adenosine effects are potentiated by dipyridamole(Persantine).Thus, smaller doses of Adenosine may be effective.Adenosine may produce bronchoconstriction in patients with asthma. ADVERSE REACTIONS AND SIDE EFFECTS: Cardiovascular:Facial flushing, headache,and rarely:sweating, palpitations,chest pain, and hypotension. Respiratory:Shortness of breath,chest pressure,and rarely:hyperventilating,metallic taste,tightness in throat and head pressure. CNS: Light headedness and rarely:dizziness, blurred vision,tingling and numbness in extremities, apprehension. DOSAGE: Adult dosage: 6 mg rapid IVP immediately followed by 20 ml NS flush. Repeat in 2minutes at 12 mg IVP followed by 20 ml NS flush PRN. I�lefflatidc dosage 0.1 mg/kg (maximum 6 mg) rapid IVP immediately followed by 5 ml NS flush. Repeat in 2 minutes,at 0.2 mg/kg(maximum 12 mg) rapid IVP followed by 5 ml NS flush PRN. Time/Action Profile: Onset Peak Duration IV: immediate unknown 1-2 minutes 2 Albuterol (Proventil, ° Ventolin°) ACTIONS: Albuterol is primarily a beta-2 sympathomimetic and as such produces bronchodilation. Because of its greater specificity for beta-2 adrenergic receptors it produces fewer cardiovascular side effects and more prolonged bronchodilation than isoproterenol. @NDICAnO S�� Albuterol inhaler is indicated for relief of bronchospasm in patients with reversible obstructive airway disease including asthma,and COPD. t Albuterol is contraindi Gated in patients with a history of hypersensitivity. 1 f t�L i WARNINGS: ' Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism,and diabetes. In adults, do not give Albuterol if heart rate is> 150. Exception: If patient remains in sinus tachycardia and systolic blood pressure remains> 100 Albuterol treatments may be continued.The �`��i� rationale must be clearly documented.The benefits must outweigh the risks.Administer cautiously to patients on MAO inhibitors or tricyclic anti- depressants. Beta-Blockers and Albuterol will inhibit each other. ADVERSE REACTIONS AND SIDE EFFECTS: Cardiovascular:Tachycardia, hypertension,and angina. CNS: Nervousness,tremor, headache,dizziness, and insomnia. GI: Drying of oropharynx,nausea,and vomiting, unusual taste. DOSAGE: If>1 year or>10 kg: 2.5 mg of Albuterol in 3 ml of NS(0.083%)to nebulizer and flow oxygen at 6-8 liters/min.(premixed) If<1 year or<10 kg: 1.25 mg of Albuterol in 3ml of NS(0.083%)to nebulizer and flow oxygen 3 liters/min. (2.5 mg divided in half).T treatment will be delivered over approximately 5 to 15 minutes. Time/Action Profile: Onset Peak Duration Inhaled: 5-15 minutes 60-90 minutes 3-6 hours ,. Amiodarone (Cordarone) ACTIONS: Amiodarone suppresses recurrent VF, prolongs intranodal conduction and refractoriness, negative inotropic effect. ,f INi1@C h"'nONS: •Ventricular Fibrillation I ,N ANNE HCI tl INJECTION >w, •Pulseless VT 1$0Ing/mL1 u •PVC's greater than 12 min with physician orders MUST DE DILUTED KOq IV USE ONLY J n41nDm,„�„ •Ventricular Tachycardias(Wide and narrow)with a pulse 111T!,A 1',)1i A11 01',)J: -Any known allergy •Cardiogenic Shock •Sinus Bradycardia •2nd and 3rd degree AV blocks ADVERSE REACTIONS AND SIDE EFFECTS: None in Ventricular fibrillation. DOSAGE: Adult dosage: Pulseless arrest: 300 mg IV/10 May repeat with 150 mg IV/10 With Pulses:Infusion loading dose:150 mg IV(150 mg in 100cc NS infuse on a macro drip 10 gtts/min (over 10 minutes,1 drop every 1.5 seconds) I�Iefflatidc dosage Pulseless Arrest: 5mg/kg mat be repeated once. No single dose greater than 300 mg. (15mg/kg max) With Pulses: Infusion loading dose:5mg/kg IV over 60 minutes(0.1cc/kg,when supplied 150mg/3cc)Add desired loading dose to 100cc NS and administer at 10gtts/ml IV set. Time/Action Profile: Onset Peak Duration ,. Aspirin (Bayer, ° Bufferin°) Ln ACTIONS: Aspirin is an analgesic, anti-inflammatory and anti-pyretic,which also appears to cause an inhibition of synthesis and release of prostaglandins. Aspirin also blocks formation of thromboxane A- 2. (Thromboxane A-2 causes platelets to aggregate and arteries to constrict). Reduces overall mortality Y from acute myocardial infarction.� INDICA"'nOVNS: Aspirin is indicated in the Acute Coronary Syndrome setting to prevent further clotting. A known allergy to Aspirin (i.e. urticaria,dyspnia,etc.), active GI ulceration or bleeding, hemophilia or other bleeding disorders,during pregnancy, children under 2 years of age. ADVERSE REACTIONS AND SIDE EFFECTS: GI: Nausea,vomiting, heartburn,and stomach pain. OTIC:Tinnitus. Hypersensitivity: Bronchospasm,tightness in chest, angioedema, urticaria,and anaphylaxis. DOSAGE: Ad'ull'L 324 mg(4)81mg chewable tablets)for Acute Coronary Syndromes Time/Action Profile: Onset Peak Duration (Oral) PO: 5-30 minutes 1-3 hours 3-6 hours III1 Atropine Sulfate as Cardiac Agent ACTIONS: Atropine is a potent anticholinergic(parasympathetic blocker, f parasympatholytic)that reduces vagal tone and thus increases I I automatically the SA node and increases A-V conduction. @Ni1ICA'"nONS: •Sinus Bradycardia accompanied by hemodynamic compromise, (i.e. hypotension,confusion,frequent PVC's, pale,cold, clammy skin). •In children (< 1 year)bradycardia of less than 60 beats/minute should be treated if symptomatic even if BP is normal. None in emergency situations 1 WARNINGS: Too small of a dose (<0.5 mg)or if pushed too slowly, may initially cause the heart rate to decrease.Antihistamines and antidepressants potentiate Atropine.A maximum dose of 0.04 mg/kg should not be exceeded. For 2nd degree AV block type II and 3rd degree AV block, omit Atropine and go to external pacer. ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Restlessness, agitation,confusion, psychotic reaction, pupil dilation, blurred vision, and headache Cardiovascular:Increase heart rate, may worsen ischemia or increase area of infarction,ventricular fibrillation,ventricular tachycardia,angina,flushing of skin. GI: Dry mouth, difficulty swallowing. Other: Urinary retention. Can worsen pre-existing glaucoma. DOSAGE: Adult Bradycardia: 0.5-1 mg IV/10, may repeat every 3-5 minutes until improved or total of 2mg is reached. 1'Iefflatudc� 0.02 mg/kg IV/1O(minimum dose is 0.1 mg and maximum single dose is 0.5mg child, 1 mg adolescent). May repeat once. Atropine Sulfate as Antidote for Poisoning ACTIONS: Atropine is a potent parasympatholytic that binds to acetylcholine receptors thus diminishing the actions of acetylcholine. INi1ICA'"nONS: Anticholinesterase syndrome poisoning such as;Organophosphate(e.g. parathion, Malathion, rid-a-bug)and carbamate(Baygon,Sevin and many common roach &ant sprays).Signs of organophosphate poisoning are: f Salivation Lacrimation Urination Defecation GI distress, r �r Emesis, Pinpoint pupils, bradycardia,and excessive sweating. None I ne when used 0 usedin the management of severe organophosphate g poisoning. WARNINGS: It is important that the patient be adequately oxygenated and ventilated prior to using Atropine as Atropine may precipitate ventricular fibrillation in a poorly oxygenated patient. Even after Atropine is administered,the patient may require intubation and aggressive ventilatory support. ADVERSE REACTIONS AND SIDE EFFECTS: Victims of organophosphate poisoning can tolerate large doses (1000 mg)of Atropine.Signs of atropinization are the end point of treatment:flushing, pupil dilation,dry mouth,and tachycardia DOSAGE: Adult 0.03 mg/kg IV/IO, repeat every 5-10 minutes until atropinization occurs. I'Iefflatudc� 0.05 mg/kg(maximum 3 mg) IV/IO, repeat every 5-10 minutes until atropinization occurs. Time/Action Profile: Onset Peak Duration IV/IO: Immediate 2-4 minutes 4-6 hours Calcium Chloride 10% ACTIONS: Calcium chloride increases the force of myocardial contraction;calcium may either increase or decrease systemic vascular resistance. In normal hearts,calcium's positive inotropic and vasoconstricting effects produce a predictable rise in systemic arterial pressure. @Ni1I,.C,h"'dr@OVI.S: Calcium chloride is indicated during resuscitation for the treatment of hypocalcaemia and calcium channel blocker toxicity(i.e.Verapamil or Cardizem overdose)and Magnesium Sulfate overdose. It also protects the heart from hyperkalemia as may occur in patients with end-stage renal disease. Cardiopulmonary arrest not associated with calcium channel blocker toxicity, hypocalcaemia,or orhyperkalemia. WARNINGS: Calcium chloride should not be administered in the same infusion with Sodium Bicarbonate,since calcium will combine with sodium bicarbonate to form an insoluble precipitate(calcium carbonate).Calcium chloride should be given with extreme caution, and in reduced dosage,to persons taking digitalis because it increases ventricular irritability and may precipitate digitalis toxicity. ADVERSE REACTIONS AND SIDE EFFECTS: If the heart is beating, rapid administration of calcium can produce slowing of cardiac rate. DOSAGE: Adult dosage: For hypotension following administration of calcium channel blockers(i.e. Cardizem, Verapamil): 1 gm IV slow with a 10cc NS flush If patient is taking digitalis, 2 mg/kg IV/IO,slowly. Repeat every 10 minutes PRN. For calcium channel blocker overdose and hyperkalemia:: 1 gm IV slow with a 10cc NS flush. l�Iefflatidc dosage For calcium channel blocker overdose:20 mg/kg IV/IO, slowly. ([iec{uiiet�:Ipl:lov�fl (iOnI fvleclicae Con,l 0 ) Time/Action Profile: Onset Peak Duration IV/IO: immediate immediate 2-5 hours Dextrose 50 % and 25 i ACTIONS: A monosaccharide,which provides calories for metabolic needs,spare body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. • Hypoglycemia Coma of unknown origin. J� ntracranial or intraspinal hemorrhage(in a patient with normal BGL). • Blood glucose Level>60 mg/dl. ADVERSE REACTIONS AND SIDE EFFECTS: Cardiovascular:Thrombosis Sclerosing if given in peripheral vein Local:Tissue irritation or necrosis if infiltrates. Others:Acidosis,alkalosis,hyperglycemia, and hypokalemia. DOSAGE: Ad'ull'L (>30 kg)50 ml of a 50%solution; (25 gm) IV/10. I1: rl 'Ib is (<30 kg)2 ml/kg slow IV/10 of a 25%solution. °4eW,'',worin (< 10 kg or< 1 month of age)5 ml/kg IV/10 of 10%solution(dilute D50 4:1 with NS). Time/Action Profile: Onset Peak Duration IV/10: < 1 minute depends on degree of hypoglycemia Diphenhydramine Hydrochloride (Benadryl°) ACTIONS: Diphenhydramine is an antihistamine with anticholinergic(drying)and sedative side effects. Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Diphenhydramine prevents, but does not reverse histamine mediated responses, particularly histamine effects on the smooth muscle of the bronchial airways,gastrointestinal tract, uterus,and blood vessels. I NDICA"'riQ NS: • Allergy symptoms, anaphylaxis. Sedation of violent patient. • Dystonic reactions from phenothiazine overdose (i.e. Haldol,Compazine, Thorazine,and Stelazine). TDiphenhydramine ' � is not to be used in newborn or premature infants. ' Diphenhydramine is not to be used in patients with acute asthma attack y U WARNINGS: In infants and children especially,antihistamines in overdose may cause hallucinations,convulsions,or death.As in adults,antihistamines may diminish mental alertness in children. In young children,they may produce excitation. Diphenhydramine has additive effects with alcohol and other CNS depressants (hypnotics,sedatives,tranquilizers,etc.).Antihistamines are more likely to cause dizziness,sedation,and hypotension in the elderly(60 years or older) patient ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Drowsiness, confusion,insomnia, headache,vertigo (especially in the elderly). Cardiovascular: Palpitations,tachycardia, PVC's and hypotension. Respiratory:Thickening of bronchial secretions,tightness of the chest,wheezing, nasal stuffiness. GI: Nausea,vomiting, diarrhea,dry mouth,and constipation. GU: Dysuria,urinary retention. DOSAGE: AdWt 25-50 mg IV/10 or 50 mg deep IM. "0c'.Iliia'tiiriiC 1 mg/kg IV/10 or IM (maximum 25 mg). Time/Action Profile: Onset Peak Duration IV/10: rapid unknown 4-8 hours IM: 20-30 minutes 1-4 hours 4-8 hours 1 qr- Duo-Dote TM (Atropine and Pralidoxime Chloride) AM"I'll 0 IN S: • Blocks nerve agents effects and relieves airway k constriction and secretions in the lungs and gastrointestinal tract. Acts to restore normal functions at the nerve ending by removing the nerve agent and reactivating natural a function iINDiCAiQla°° ai i Suspected or confirmed nerve agent exposure 011 � I� b..h l p.01� � Both med1o. ns in the kit should be used with caution r (but not withheld) in patients with preexisting cardiac disease, HTN, or CVA history. Z 29.55 1Bl..E . Y . . . . ("I . S AND SIDE EFFE "["S�Chest pain , .............................................................................................................. 51 exacerbation of angina, Myocardial infarction, Blurred vision , 93 al' Headache , Drowsiness, Nausea , Tachycardia , Hypertension , Hyperventilation DOSAGE: DUODOTE TM— Each auto injector contains BOTH: Atropine 2.1 mg and Pralidoxime 600 mg Adult: For Nerve Agent Exposure (SLUDGE symptoms): Up to 3 auto injectors may be used for one patient based on signs (1-2 kits for self treatment— up to 3 for buddy treatment with severe symptoms) DuoDotes TM are not authorized for the use of children under the age of 9 years. ,. Epinephrine 1:1.000 ACTIONS: Epinephrine is a sympathomimetic,which stimulates both alpha and beta- adrenergic receptors causing immediate bronchodilation,increase in heart rate and an increase in the force of cardiac contraction.Subcutaneous dose lasts 5-15 minutes. • Asthma Anaphylaxis A li Angioneurotic edema o�i�m�pnr:e,ti f All Pulseless Arrest rr s None in the cardiac arrest situation. Hyperthyroidism,hypertension, cerebral arteriosclerosis in asthma. Caution should be used with Epinephrine administration when the patient is older than 40 years old or has a history of heart disease.The benefit must outweigh the risk. Do not administer Epinephrine if heart rate is>150. WARNINGS: • Epinephrine is inactivated by alkaline solutions- never mix with Sodium Bicarbonate. Do not mix Isoproterenol and epinephrine- results in exaggerated response.Action's of catecholamine is depressed by acidosis -attention to ventilation and circulation is essential.Antidepressants potentiate the effects of epinephrine. ADVERSE REACTIONS AND SIDE EFFECTS: CNS:Anxiety, headache,cerebral hemorrhage. Cardiovascular:Tachycardia,ventricular dysrhythmias,hypertension,angina,palpitations. GI: Nausea and vomiting. DOSAGE: Ad'ull'L SQ 0.3 mg(0.3 cc). Repeat every 3-5 minutes(Asthma/Anaphylaxis may repeat once in 15 minutes). Il: rlufllil:is SQ 0.01 mg/kg up to 0.3 mg. Time/Action Profile: Onset Peak Duration SQ: 6-12 minutes 20 minutes 1-3 hours Epinephrine 1:10,000 .............. ACTIONS: Epinephrine is a sympathomimetic,which stimulates both Alpha and Beta- receptors.As a result of its effects, myocardial and cerebral blood flow are increased during ventilation and chest compression. Epinephrine increases systemic vascular resistance and thus may enhance defibrillation. INaf ICA"'nONS: All Pulseless Arrest Asystole • Ventricular Fibrillation unresponsive to defibrillation; • PEA. jda f/ Other pediatric indications: hypotension in patients with circulatory instability,bradycardia(before Atropine). None in the cardiac arrest situation. WARNINGS: Epinephrine is inactivated by alkaline solutions- never mix with Sodium Bicarbonate. Do not mix Isoproterenol and epinephrine-results in exaggerated response.Actions of catecholamines are depressed by acidosis -attention to ventilation and circulation is essential.Antidepressants potentiate the effects of epinephrine. ADVERSE REACTIONS AND SIDE EFFECTS: CNS:Anxiety, headache,cerebral hemorrhage. Cardiovascular:Tachycardia,ventricular dysrhythmias,hypertension,angina,palpitations. GI: Nausea and vomiting. DOSAGE: Ad'ull'L (1:10,000) 1 mg(10 ml) IV or 10,repeat every 3-5 minutes. Repeat every 3-5 minutes. If patient is in SEVERE anaphylaxis with marked hypotension,you may start an IV and administer 3-5 cc of a 1:10,000 solution IVP slow over 2 minutes. Ile dk'Il:is 0.01 mg/kg, (0.1 ml/kg IV or 10). Repeat every 3-5 minutes. Time/Action Profile: Onset Peak Duration IV/10: Rapid 1-2 minutes 20 minutes 3 Etomidate ACTIONS: Etomidate is a short acting, nonbarbiturate hypnotic,which lacks the analgesic NOW properties and is used for induction of general anesthesia. Its action occurs at the level of reticular activating system in the brain stem. Etomidate is generally considered to have minimal adverse effects on cardiac and respiratory function.The duration of action is 3-5 minutes, and excretion occurs through the renal system. Amidate" 11 11111 ATIO Sw �urvairdut�lu�jP.'a:Cir�rr,UiA u An authorized paramedic may induce general anesthesia to facilitate intubation. I)IIECX1� I I"IIOPI: Etomidate can decrease the adrenal gland's production of steroid hormones. Use caution, as this agent may act synergistically with other CNS depressants. Monitoring vital signs is important. POSSIBLE A VEIR E REAcTiONS AND I EFFE T ® ...................................................................................................................................................................................................................................................................... The most common side effects are nausea and vomiting. Etomidate can also cause uncontrolled skeletal muscle activity. Unstable blood pressures, dyspnea, and chronotropic dysrhythmias are possible as well. DOSAGE: Adult: 20mg Slow IVP over 1 minute (0.3m) 0.3 mg/kg (Intubation only) Time/Action r it e Onset 1::)ealk 1)uirat6oin IV 30-60 sec 1 minute 3-5 minutes 14 ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Fentanyl A IPIONS: Fentanyl Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain pathways. Fentanyl binds to brain receptors, relieving pain. It decreases the feeling of pain and a person's response to pain. Fentanyl is 50-100 times as potent as morphine; morphine 10 mg I.M. =fentanyl 0.1-0.2 mg I.M.; fentanyl has less hypotensive effects than morphine due to minimal or no F rkrum'a!,rr" histamine release. Fenta 'll Owe fn�,US p N-D IN mco FomayV2 MIL `°° Moderate to severe pain in patients>10kg o Acute Coronary Syndrome—Chest Pain (Adult) M I`vx Mv,lvm,10 MA pus ru.w�� Pain associated with isolated extremity fracture, renal colic, burns, etc. CII"�"III"III'tAlllll"�IIC'. IIICAIII"IIIOII"�S: ........................................................................................................... • Epistaxis or bilateral blocked nares • Known hypersensitivity to fentanyl • MAOI use in past 2 weeks • Unstable hemodynamics or altered WAII'1IN III IN G S ........................................................... Use with caution in patients with bradycardia, hepatic, renal, or respiratory disease or those with increased ICP, head injuries, or impaired consciousness; patients must be monitored until fully POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: .................................................................................................................................................................................................................................................. CNS: Drowsiness, sedation, increased intracranial pressure Cardiovascular: Bradycardia, hypotension, peripheral vasodilation GI: Nausea, vomiting GU: Urinary tract spasm Respiratory: Respiratory Depression SLOW IV PUSH-Rapid push may cause chest wall rigidity decreasing,or DOSAGE: eliminating ability to ventilate. Aduull9:�, 25 - 100mcg slow IV push for pain Pediatric(under 1..6yrs of age) call medical control for orders Time/Action Profile: Onset Peak Duration IN: 2-10 mins 20 mins IV: Immediate 1-2 minutes 20 mins ,11151 ,. Furosemide (Lasix°) ACTIONS: A sulfonamide derivative and potent diuretic,which inhibits the reabsorption of sodium and chloride in the proximal and distal renal tubules as well as in the Loop of Henley. Has a direct venodilating effect in acute pulmonary edema. With IV administration,onset of venodilating is generally within 5-10 minutes; diuresis will usually occur in 20-30 minutes INDI A'"nOVNS: • Pulmonary edema a FnL q �• Hypertension C;1fAj�j Cerebral edema I)Qctimn'usi. t �p���s�e.,l�aerone416EG" i%P 1"IT!,A 11',)1) A1101')S Hypotension (BP<100 systolic) or Anuria.Should be used in pregnancy only when benefits clearly outweigh risks WARNINGS: Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Dizziness,tinnitus, hearing loss,headache, blurred vision, weakness.GI:Anorexia,vomiting, nausea. Cardiovascular: Hypotension. Other: Pruritus, urticaria, muscle cramping. DOSAGE: Adult: For CHF: 80 mg IVP or double the patient dose up to max 100 mg. For Cardiogenic Shock:40 mg IV slowly over 2 minutes( if systolic blood pressure is>than 100 mmHg.) Time/Action Profile: Onset Peak Duration IV/10: 5 minutes 30 minutes 2 hours J ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Glucagon ACTIONS: Glucagon, which is produced naturally in the pancreas by the alpha cells of the islets of Langerhans, causes an increase in blood glucose concentrations. It is p' effective in small doses, and no evidence of toxicity has been reported with its use. 9VII I�udii o ���r�„r Glucagon acts only on liver glycogen, converting it to glucose if the patient has ade uate glycogen reserves. Glucagon possesses positive inotropic and chronotropic r r properties. GltucaGen'� Sterile Water for IN1111 f" Oi' S- I�nlwrry�uruw Reronstitulior ----..................................-- � � ��Illlllllllliiliuluiiliiuiiuiluiuuiiuuuliluuull ocumented hypoglycemia is a true medical emergency, IM glucagon should be administered rapidly if IV access is delayed. Glucagon is indicated for the treatment of hypoglycemia when an IV cannot be established and oral glucose is contraindicated. It may may be effective in symptomatic beta-blocker overdose. COP11 I IIAUMMCA1 .................................................................................................................... •Pheochromocytoma •Insulinoma •Known hypersensitivity •Should not be routinely used to replace dextrose when IV access has been obtained W A�t'J\411�\i mm Ai psis{: Glucagon should be administered with caution in patients with a history of insulinoma and/or pheochromocytoma. "ONLY 1imll of Sterile water should I e used fair irec nstiituiitii n. Normal saline cannot I e used as an alternative. POSSIBLE ADVEIR E REAcnONS AND SIDEEFFE rs: ...................................................................................................................................................................................................................................................................... Occasional nausea and vomiting Adult: (not less than 30 sec) 40llug 9.02-5mg/h, slow l / (not as effective in children as in adults) Time/Action r it e Onset l::)ealk 1'.)uiratloin IV 1-2 min 14-30 minutes Weight dependent 17 klll!1 ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Ipratropium Bromide (Atrovent) ACTIONS: NS: Ipratropium bromide is an anticholinergic (pa rasym path olytic) agent, which causes rtrt localized bronchodilation. NCaS;�Dn87-tl29i1®rt 1 J INI II A ION . r Ipratropium bromide is indicated for relief of bronchospasms associated with ,boYw, asthma and chronic obstructive pulmonary disease/ including chronic bronchitis and RON ORpY.X4?'•H4l,AYYON ONAY emphysema that is unresponsive to treatment with albuterol alone. +r C014IIIII „UIMI IIICA1Ill0 14 : Hypersensitivity to atropine or its derivatives. µ, POSSIBLE .................................,,,,.,, .............................................................................................. ............. ...........................................................................ADVERSE REACTION AN I EFFECTS: TIE°Lq Respiratory. Cough, exacerbation of symptoms • CNS: Nervousness, dizziness, headache • Cardiovascular: Palpitations • GI: Nausea, vomiting, GI distress • Other:Tremor, dry mouth, blurred vision Adult: .5mg at 6-8L/min (to be added to standard albuterol dose) Pediatric: Not Applicable Time/Action r it : Onset ealk I::)uirat6oii°: Nebulized 5-15 minutes 60-120 minutes 4-8 hours 1�'�� 111�7) ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Lorazepam ( Ativan ) ACTIONS: NS: Lorazepam is a benzodiazepine, so it depresses the central nervous system. It produces sedation, relieves anxiety, causes lack of recall, and provides for relief of � - IV skeletal muscle spasms. IN11111CATIIONSw • Adjunct seizure control �t� Ei'AI� LO • Control of violent patients 1.�11 wi usa 2 ingfi,ii. Nflvwv 6' u�^YN�nauhr�,v�tarusWnl�I OPI I IIAi1MM A 1 III 0 14 S: p Known sensitivity to benzodiazepine; narrow-angle glaucoma. G IG'.Oiir,;CA.U,,,,J"'ll"'II;,,, II"""J,!fir; May cause respiratory distress POSSIBLE A VEIR E REACTIONS AND SIDEEFFECTS: ....................................................................................................................................................................................................................................................................... • CNS: Excessive CNS depression • Cardiovascular: Rarely hypotension/hypertension • Respiratory: Hypoventilation, partial airway obstruction • Local: Pain, burning, and redness at injection site • General: Nausea /vomiting and skin rash Adult: 1-2mg IV/IM/IN (MAX 5mg) Pediatric: 0.05 -0.1mg/kg IV/IO/IM (Max 2mg) Time/Action r it : Onset 1::)ealk 1'.)ulrat6oli°: IV 11-5 minutes 11 minute IM 15-30 minutes 1 ,. Magnesium Sulfate 0.III ACTIONS: Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end-plate by the motor nerve impulse. Magnesium is said / to have a depressant effect on the central nervous system, but it does not affect the mother,fetus or neonate when used as directed in eclampsia and pre-eclampsia. Magnesium acts peripherally to produce vasodilatation therefore a drop in systolic BP is to be anticipated. IND IIICATIIONS • Prevention and control of seizures in eclampsia. • Torsades de Pointes. • Suspected hypomagnesemic state(i.e. chronic alcoholism and chronic use of diuretics). Refractory ventricular fibrillation WARNINGS: Intravenous use of Magnesium Sulfate should not be given to mothers with toxemia of pregnancy with imminent delivery. Magnesium Sulfate Injection USP, 50%must be diluted to a concentration of 20%or less prior to IV infusion II II11,EC A,J f 11O N5 Because magnesium is removed from the body solely by the kidneys,the drug should be used with caution in patients with renal impairment. Monitoring the patient's clinical status is essential to avoid the consequences of overdose in eclampsia. Calcium Chloride should be immediately available to counteract the potential hazards of magnesium intoxication in eclampsia. Signs of hypermagnesium include respiratory depression; absence of patellar reflex,etc. ADVERSE REACTIONS AND SIDE EFFECTS: Adverse effects of Magnesium Sulfate IV are usually the result of magnesium intoxication.Signs of hypermagnesemia include:flushing,sweating, hypotension,depression of reflexes,flaccid paralysis,hypothermia, and circulatory collapse,depression of cardiac function and central nervous system depression.These symptoms can precede fatal paralysis. DOSAGE: For eclamptic seizures: 2 gm IV over 1-2 minutes. For Torsades de Pointes and refractory VF:1-2 gm (mixed in 50 ml of NS and administered over 1-2 minutes) followed by a maintenance infusion (1 gm in 250 ml of NS administered at 60 gtts/ml IV set. Time/Action Profile: Onset Peak Duration IV Drip: Immediate unknown 30 minutes ,. Methylprednisolone (Solumedrol°, A Methapred) III ACTIONS: Decreases inflammatory effects via its potent anti-inflammatory synthetic steroid i Asthma Anaphylaxis Head injury COPD Unconscious with known Addison's disease 0 one in the emergency setting ADVERSE REACTIONS AND SIDE EFFECTS: GI hemorrhage, reduces leukotrines of immune system, increases potential for infections. osa e: Ad'ull'L 125 mg IV slow over 2 minutes 'mfiatric: 2 mg/kg (max 125 mg) IV slow over 2 minutes Time/Action Profile: Onset Peak Duration IV/IO: Unknown Unknown Unknown ,. Midazolam ( Versed °) MJI III ACTIONS: Depresses CNS, muscle relaxant,strong sedative, hypnotic, amnesia Control of seizures,sedation for cardioversion&pacing, Sedation for airway management sscf olr' i Respiratory depression '0914o IINWsw?scWR Hypotension, ETOH and drugs WARNINGS: Monitor patient for respiratory and CNS depression Monitor vitals signs after administration ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Retrograde amnesia,altered mental status,dizziness Cardiovascular: Bradycardia, hypotension, PVC's,tachycardia,nodal rhythms GI:, nausea and vomiting,hiccoughs,coughing Respiratory: Respiratory depression, laryngospasm,bronchospasm DOSAGE: Adult: 2.5 mg increments up to 10 mg max Ad'ulllL Adult Airway: 5mg increments g5min up to 10mg max Pediatric: >1 years of age (0.1 mg/kg) Time/Action Profile: Onset Peak Duration IV 1-2 minutes 3-5 minutes Weight dependent ,. Morphine Sulfate (MS) MIII f�% ;" �;u /��i5rrrrr rr���r�rlrlrlrry�ih�i�F�r��tiifi�`�1F�rrr5f4N�Yh�Xwr` �/����� � Jf,G U � t ACTIONS: Morphine is a narcotic analgesic,which depresses the central nervous and respiratory system and sensitivity to pain. Morphine also increases venous capacitance,decreases venous return and produces mild peripheral vasodilatation. IND IIICATIIQNS • Pain. • Pain associated with isolated extremity fracture, renal colic, burns,etc �I I it AII11)KA I Ir �Id'd: • Volume depletion or hypotension. • Head trauma. • Acute asthma. • Known hypersensitivity to MS. • Contact Medical Control if Pt has Abdominal Pain for Orders. WARNINGS: Morphine is detoxified by the liver. It is potentiated by alcohol,antihistamines,barbiturates,sedatives and beta blockers ADVERSE REACTIONS AND SIDE EFFECTS: • CNS: Euphoria,drowsiness, pupillary constriction, respiratory arrest. • Cardiovascular: Bradycardia,hypotension. • GI: Decreases gastric motility, nausea and vomiting. • GU: Urinary retention. • Respiratory: Bronchoconstriction,decrease cough reflex. DOSAGE: AdWt 2 mg increments IV slowly. Repeat every 5 minutes until desired response is achieved (maximum dose 10 mg). Can be given IM. (Additional doses require approval from Medical Control.) 0c'.Iliia'tiiriiC 0.1 mg/kg IV slowly. May repeat the initial dose X1 in 3-5 minutes. (Additional doses require approval from Medical Control.) lriiarrt 0.05 mg/kg IV slowly. May repeat the initial dose X1 in 3-5 minutes. (Requires approval from Medical Control). Time/Action Profile: Onset Peak Duration IV: Rapid 20 minutes 4-5 hour ,. Naloxone Hydrochloride (Narcan°) ACTIONS: Naloxone antagonizes the effects of opiates by competing at the same receptor sites.When given IV,the action is apparent within two minutes. I or SC administration is slightly slower. I Illy I N CA"I"`I 011NS° • Naloxone is indicated for the complete or partial reversal of central nervous and respiratory system depression secondary to opiate narcotics or related drugs such as,but not limited to — Heroin — Meperidine (Demerol). — Codeine — Morphine — Methadone — Lomotil — Hydromorphone(Dilaudid) — Pentazocine(Talwin) — Propoxyphene(Darvon) — Percodan — Fentanyl(Sublimaze) (Known on the street as"white china") CONIIl A I N 1:': 1 CA I10N`=. Known hypersensitivity to Narcan. WARNINGS: Naloxone should be administered cautiously to persons including newborns of mothers who are known or suspected to be physically dependent on opiates it may precipitate an acute abstinence syndrome. If patient is intubated and airway is controlled do not administer Narcan(excludes cardiac arrest).May need to repeat Naloxone since duration of action of some narcotics may exceed that of Naloxone.Naloxone is not effective against a respiratory depression due to non-opiate drugs.Use caution during administration as patient may become violent as level of consciousness increases. ADVERSE REACTIONS AND SIDE EFFECTS: CNS:Tremor, agitation,belligerence, pupillary dilation,seizures, increased tear production,sweating, seizures secondary to withdrawal. Cardiovascular: Hypertension, hypotension,ventricular tachycardia,pulmonary edema,ventricular fibrillation. GI: Nausea,vomiting. DOSAGE: Ad'twll'L An initial dose of 2 mg may be administered IV/IO/IM/PRN. If no response after 4 mg,then condition is probably not due to narcotic. (Fentanyl may require large doses of Naloxone to reverse effects). 1e,J t r i c 0.1 mg/kg IV/IO/IM/PRN. Time/Action Profile: Onset Peak Duration • IV: 1-2 minutes unknown 45 minutes 24 • IM: 2-5 minutes unknown >45 minutes ,. Nitroglycerin Wtrostat° Nitrolingual° Spray) Ln ACTIONS: Nitroglycerin is a direct vasodilator,which acts principally on the venous system although it also produces direct coronary artery vasodilatation as well.There is a g p Y Y decrease in venous return,which decreases the workload on the heart and thus, ° decreases myocardial oxygen demand. Sublingual nitroglycerin is rapidly absorbed. Pain relief occurs within one to two minutes and therapeutic effects can last up to 30 minutes l � ololDolC„ rolol �S��, Chest pain or discomfort associated with suspected AMI. Pulmonary edema with hypertension. i • Systolic BP<100 mmHg • Children under 12 • Patients on Erectile Dysfunction drugs that fall within time parameters (do not administer Nitro if Erectile Dysfunction drug used<48 hours) • Know hypersensitivity to the drug • Evidence of a positive V4R in the setting of an Inferior wall MI Nitroglycerin tablets are inactivated by light, heat,air and moisture. Must be kept in amber glass containers with tight- fitting lids. Do not leave cotton in container.Once opened, nitroglycerin has a shelf life of 3 months. Do not shake Nitrolingual spray.Alcohol will accentuate venodilating and hypotensive effects. ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Headache,dizziness,flushing,nausea and vomiting. Cardiovascular: Hypotension, reflex tachycardia,bradycardia. DOSAGE: Ad'Ul'L 0.4 mg(1 tablet or 1 spray sublingual). May repeat up to two additional times in 3-5 minutes PRN. Time/Action Profile: Onset Peak Duration SL: 1-3 minutes unknown 30-60 minutes III1 10 , ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Norepinephrine (Levophed) ACTIONS: Norepinephrine is a naturally occurring catecholamine that acts on both alpha and beta adrenergic receptors.The action on alpha receptors is stronger and results in peripheral vasonconstriction.This increases the blood pressure in hypotensive states such as cardiogenic shock and sepsis. G 40d f 91 5'n VW 9, II' IXI ATIIOI' Sw )) uKW • Hypotension not related to hypovolemia I, s • Neurogenic shock • Hypotension caused by hypovolemia ICI° L X„ I ""014 • Monitor blood pressure closely • Ensure adequate fluid replacement before starting Norepinephrine** • Administer through largest vein possible to reduce risk of tissue necrosis • Use caution in cases of cardiac ischemia as Norepinehprine increases myocardial oxygen demand. POSSIBLE A VEIR E REACTIONS AND II EFFECT : ....................................................................................................................................................................................................................................................................... Usually dose related but may include tremors, headache, myocardial ischemia, nausea, vomiting, and dizziness. May also cause bradycardia (usually because of increased peripheral vasoconstriction. DOSAGE: Adult: Run infusion at 4mcg/min (lgtts/sec) using a microdrip set (60gtts/ml) • If blood pressure increases>120mmhg systolic,titrate infusion to 2mcg/min (1gtt/2sec) Preparation: Add 1mg of Levophed into a 250ml D5W for a concentration of 4mcg/ml. **Fluid Resuscitation: Ensure minimum of One (1) Liter of Normal Saline has been administered prior to administration of Norepinephrine. Time/Action r it : Onset l::)ealk I:.)uiratloin IV Immediate < 1 minute 1-2 minutes 26 IIIII" ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... (Zofran®) -Odansetron (Slow IV Push) ACTIONS: Antiemetic, Zofran blocks the actions of chemicals in the body that can trigger nausea and vomiting. Selective 5-HT3 receptor antagonist. Category B in pregnancy. �p�tt IN1"1111CAPI�; NS. Used for a patient with nausea unrelieved with comfort measures, uncomfortable due to :J�1S7 �wivnirmnr��imr.�u914`"i„,,, the nausea during transport and/or with a potential for airway compromise related to ao.rr��E Hacuaaro vomiting. „ 0�1, i�. • Nausea and vomiting due to chemotherapy. o Mimi Hm . Prophylactic use prior to administration of pain management medication. .,...I c.,L.A.F�..n,aL. • Nausea and vomiting with moderate to severe dehydration or electrolyte imbalance. C014""I III A1111NJD1C .................................................................................................................... Hypersensitivity(anaphylaxis)to Ondansetron or any of components of the formulation. or to any medicine similar to ondansetron, including dolasetron (Anzemet), granisetron (Kytril), or palonosetron (Aloxi). WAl i�'J\411�\l mm Ai S: Ondansetron is extensively metabolized in the liver and should be used with caution in patients with hepatic disease, hepatitis, or elevated hepatic enzymes. Patients with a history, or family history, of Long QT syndrome; transient EKG changes have been seen with IV administration including QT interval prolongation. PO II LE A VERSE REACTIION S AN D S..11 QE EIFIFECT . CNS: Headache, Dizziness, Drowsiness, Fatigue GI: Diarrhea, Constipation, Abdominal pain, Dry Mouth MISC: Rash, Shivering, Fever, Hypoxia, Urinary Retention, Muscle Pain RARE: Bronchospasm, Transient blurred vision after infusion Adult & Pediatiriics>�,40kg: 4mg slow IVP note: rapid administration will cause hypotension. �wc!diirr: tii ii 40kg 0.1mg/kg slow IVP Time/Action Profile: Onset Peak Duration IV 1-2 min 14-30 minutes Weight dependent 21111111" Oral Glucose ( Instal Glucose) 1 11 ACTIONS: Increases blood glucose levels slowly III INCH"I`IQII S BS<60 mgdl, patients who are altered but alert enough to take the command to swallow CONI1 AIIl[:IC/ I10N`=. Patients unable to swallow or Stroke symptoms IP IR IE C 18,1 J`'II0I°tJl S None when patient can swallow, risk of aspiration if given improperly ADVERSE REACTIONS AND SIDE EFFECTS: Cardiovascular: Unknown CNS: Unknown GI: Nausea DOSAGE: Adult: 1 tube Pediatric: 1 tube Time/Action Profile: Onset Peak Duration PO: 10 minutes Unknown Unknown ,. Sodium Bicarbonate 111 ACTIONS: i 1 Increases PH to reverse acidosis r Metabolic acidosis in cardiac arrest Tricyclic overdoses with QRS>0.1 Electrocutions Hyperkalemia M.� �whlwI�J Methanol/Ethylene glycol toxicity Severe ketoacidosis Compartment Syndrome �,rrt�w mel��ta�u�dck, dp tee lea, 0 1JI !,/ IIJ1JI` / 1101)S t CHF,Alkalotic states WARNINGS: Excessive therapy inhibits oxygen release, reduces the ability to defibrillate, may precipitate other medications and administration should be guided by blood gases. Do not give concurrently with any other medication,flush the line before and after administration. ADVERSE REACTIONS AND SIDE EFFECTS: Metabolic alkalosis,may crystallize in IV solutions DOSAGE: Adull'L 1 mEq/kg IV push,then%the dose q 10 mins. Electrocutions:2 mEq/kg IVP 11( dial uric: 1-2 mEq/kg diluted 50:50 with Normal Saline Time/Action Profile: Onset Peak Duration IV/IO: Unknown Unknown Unknown 29 *, A KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 A. CPR Guidelines B. Cardiopulmonary Resuscitation C. Ventricular Fibrillation/Pulseless Ventricular Tach cardia V / VT) D. As stole E. Pulseless Electrical Activit (PEA) F. Post Resuscitation Care (ROSC) A. CPR Guidelines CPR will be performed according to the most current American Heart Association (AHA) standards. Always keep in mind that high quality CPR with uninterrupted chest compressions is the top priority when attempting to resuscitate a pulseless and apneic patient. When performing CPR, the following guidelines will be adhered to: 1. Don all appropriate PPE. 2. Limit personnel in making contact with the patient to reduce provider exposure. 3. Check for responsiveness, looking for no breathing or occasional gasps and simultaneously checking for a pulse. 4. If no pulse, perform chest compressions at least 2" (5 cm) to 2.4" (6 cm) deep and ata rate of 100 to 120/min. I//;N:r,. ible, cd a er/gyp qienis IW� e prh, Ida Cd:Vnpre::r l� ans hd limit air dnw/ale t e m: rN wsu re. 5. Allow for full chest recoil after each chest compression by not leaning on the chest. 6. MINIMIZE INTERRUPTIONS in chest compressions. 7. Avoid excessive ventilation: a) When an advanced airway is in place, provide continuous compressions at a rate of at least 100 to 120/min and ventilate the patient once every 6 seconds using a IIIII'iii1�1t III iii[fllNm a fiiilll[teir. Protocol 1-1 8. High quality chest compressions are achieved when the ETCO2 value is at least 10-20 mmHg. 9. 4fl �u .NuM;;� airii:)sIs vvflll I rrr raN N II'i)ira� Ili)ast i�n'I ui°iii'iiiuir�utes irar s e ni ri rrl r Nlu InM�urrll rulM�tN rur rll' IIoi) IIDaflii)nN tir N„ 1Ciurlilnh,p ;u 3 *, A KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 B. Cardiopulmonary Resuscitation EMT-B/BLS 1. Don all appropriate PPE. 2. Limit personnel in making contact with the patient to reduce provider exposure. 3. Initial Assessment a) Assess for responsiveness. b) Simultaneously look for no breathing or occasional gasps and check for a pulse, in an effort to reduce the time to first chest compression. l his init W d a.se,.sti,ie ril a tili a�.ild take yid a rnd,are than h a cd:arnrd te. 4. If the patient has a pulse but is not breathing: a) Open the airway. b) Provide rescue breaths once every 5-6 seconds using a BVM with a filter and a tight seal. Reassess for a pulse every 2 minutes. h p ru: ible, cd Wislde the patient rap 111 hd an open air er inaWirn nt ld� J1,04Wo "O" the ain&aW,. 5. If the patient has no pulse, declare a cardiac arrest over the air and request additional assistance for personnel: a) Perform 200 chest compressions (2 minutes)with passive oxygenation only. h: a. :1���1� Y co,er patient's h me pr ar h� cd arnp re s.iI,;n s hd llrnit air do rrdet e,l,�pd�stire. h�.����1 �;��� oral l M� ���l d��a����� .d,r �1 l�W � 1�;��� ��l�;�h �� am l N rr rill a m an rebreather at 10 1 Lo"inin, then inust be cd a� ered z&fth asur�,ic. q rnask �n�� rip:?155hle z&°lll l d �a:a °l l l ::1urin these firSl '" rninu1 u:. �..,.IiI � ii.,ul,i n.0 ��1) (. hi::)Sl, r i a ii.li; +,pnu;, � u.0 .l ., u� ii;:li ui it a wm l u� :I re uu d uLaLoon :) ,%::)n s �:!�` :Il ii)ur ffiiiii,) uirfoLoa 14.0 d:oiinpireseons have k~eu:in deNuveired. 3 ro, KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 b) After the first 2 minutes continue with 30 compressions and oxygenation for 5 cycles of CPR. (Consider the AutoPulse Chest Compression device once available) 6. Attach the AED patches as soon as possible: a) Allow the AED to analyze the patient's rhythm and if shockable, deliver shock as soon as possible. If rN rs s1bl , cd�,,,°er lip:qi nt's k e prh ar Ida :��h� rck1ng h� limit air dn wplet r N wstire. b) Leave the AED on the patient and turned on throughout the resuscitation effort. c) The AED will prompt reassessment of a pulse and rhythm analysis every 2 minutes. d) If a shock is advised, minimize interruptions in chest compressions before and after shock. If rid r s s1bl , cd::�,er patient's h me prhar hd shd�c "lng Id� limit air dn rplet e) Resume CPR beginning with chest compressions immediately after each shock. If r�N�ss1b1e, c:°d er p: gien1"s kme prh r ld:a c.d rnpres sh:an s ha.bruit air dnd plea rN:r.ure. 3 KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 Hea. ftlicaire PiroVideir,Adult lt Card la Aurilres Alllgoirliil uspected or Cou l"''liiirurnied COVID-19 Patients f Aprd 2b2D Victim is unresponsive Request ALS Get AED and emergency equipment mask device with filter and tight seal. 1 breath every 5-6 seconds,or about 1 Q 12 breaths/min • Request ALS Continue rescue breathing;check pulse - - every 2 minutes.If no pulse,begin CPR. If possible opioid overdose administer naloxone if available. -------------------------------- -------------- CPR Begin continuous compressions with passive oxygenation using non rebreather i AED arrives. W -'' Check rhythm. Shockable rhythm? 11 _._._._._- rmmarr.IlMr----� _._._._. ______ ___��ri�1rroumullhuo1r,lk��llku�l----___ *Give 1 shock.Resume CPR Resume CPR immediately for immediately for about 2 minutes about minutes(until prompted (until prompted by AED to allow by AED to allow rhythm check). rhythm check). Continue until ALS providers take Continue until ALS providers take over or victim starts to move. 7'110 1 0 er pl:ilie nl's kdl.e prh w hd 1a I.d v.i.pr . .rld:asi. lid a king hd:a llri.iil air dn plel P(aSUM ro, KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 r r, r r r r rrr � r r r r r r r r i r r i 7. Attach and turn on the Monitor/ Defibrillator a) Apply the defibrillator pads and switch the monitor to "paddles." b) Analyze for a shockable rhythm: a. Ventricular Fibrillation (V-Fib or VF) b. Pulseless Ventricular Tachycardia (Monomorphic V-Tach or VT) c. Torsades De Pointes or Polymorphic VT c) If the patient presents with a shockable rhythm, deliver shock as soon as possible. a. Defibrillate at 200 joules and repeat defibrillation every 2 minutes as needed. If pad s.isle, c.d a,erpahent'.~ lA me prh:�r h� .~hd�c1 ing h�� llrn it air dn�plet b. Resume CPR beginning with chest compressions immediately after each shock, 30 compressions 2 breaths for 5 cycles (2 minutes). d) If the patient does not present with a shockable rhythm: Resume CPR beginning with chest compressions after each reassessment. e) Reassessment shall be done after every 2 minutes of CPR, simultaneously checking fora pulse and confirming the underlying rhythm. 8. Establish vascular access via IV or 10 as soon as possible without delaying chest compressions. a) Deliver medications in accordance with the rhythm-based protocol the patient is being treated under the proceeding sections in this protocol. 9. Secure an advanced airway Protocol - IfrN:r,. ibl� , �.dr�i':id rth r �l;�id rernd:a ��l dW th � rN:Itie nt hd:a C��� Ial:d �� �l�~ �� ��aas���� m��l. � ��; �� ll� pna:,id r arid appn a:Ich z h the best chance dal firSt pas succe.s d: inluN qh,n. a) Pause chest compressions for insertion of an advanced airway. (Consider video Iaryngoscopy) b) If intubation is delayed, consider a supraglottic airway (iGel) or BVM with filter and a tight seal. B1," ll ar 1 lilt rshd uld be utili e l ani tirne ain&ai,has been established. c) Ensure that a filter is connected to the end of the airway device. hh� NNWryry r„Epp ry p I� II^ry I� h hII h ry I� I� p I� II^ry I� p m� mp- hIIry I� I� „A I",,,,,,, �4 IX II 4 t::)I II�s M�M'II�,„II �II d"IX I tl IId IX b I„A � I„) b I A ry s Ili N f II d IX l M',IX I "�"' III „�„II d IX I tl I II I d,, II� � d IX I I, d IX� d,;;IX I II )s�, `�"�� I„A ry II IIII �'N d IX�I°:) MIX II �III�' �;�,,, III 11 1 II II), II I; II Procedure 8®1 II I �I1 I 'Ili 11 II II �lll ll I1 �II';I?IIIII II' II I I III �II I � „ II� �I�" M .s T l I, I I) t, , 11. Attach and monitor End Tidal CO2 and waveform capnography after filter. 3 *, A KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 GII �,airdi alc for in°��st Illm ohlii'thirrml �, b .or Su ,llpeAu.ted or Co nfirmed DID -19 Patients MEMEEMEM • Push hard lat least 2 inches c A t5 m)i and far>t(1pp-12dhrn, B and aII Iow corn l']lete chest re'crcil.. Don PPE Minimize interrUptlons'n Limit personnel cornprE Swinn:s •.'kvoicl excessiveventilraticor. • Chan'..gacompr'essorevary 1 2 rninul:d^,or;ooneir if 4rtigijed • Ir no advanced airway,30:2 Start CPR pre]sinn ventuartia]nr tiro.. •Give oxygen Ili�mlt aerosol'lization 0 uurrtitetive,wa vef'ct rrr •Attach monitorfdefibrillatnr capnography "(Prepare t{D lntUbate H IR T(,l] <YFJ r1YPM H j.3CC 9rYlll7t to irnl)rove(PR(Iuelity IIV'mm� Intro erteroaUprc ;t1rc yes 1 rtlnxation ptt r'E.(di a-mnli4) Shlhytlh to?' * 9 I quality, k attempt 2 1 '�� tclmproauCPR pyp�p]re we rnm r r nw .e. r VFfPVT �` Asystole/PEA muul0uuumlmuVuil��r ..... �..... ..- Biphasrc:MOnLAOCAurnr rer ar Wend rtion(ey rnilial 3 kullmcUiallk close of'120 200 J);if unknown, us[usa rrtnxlitwm cwailablc, second cord subsequent doses should he eowvalent,and highar Secure Airway/Resume CPR do n.ul,,yt ,oans;,( rod- • Pause chest compressions for intubation Monophai ice 3613J • If intubation delayed,consider supraglottic airway with bag-mask device with filter and VVIVuNI au lmutN�u tight seal Minimize closed-circuit 4 y 10 �. disconnection •USB iintulbalRYr wikh hii hest p.. likelihood of first pass CPR 2 MIN CPR 2 MIN success IV/IOaccess IV/IOaccess ' consldervideo laryngoscopy s Epinephrine every 3-5 min j End atr ashcal mtubation or rtrrtfrrtrgrrt�rrgrrtrrtfrrtrrtrrtarrrtrrtrrtarrrtrgrrt�rrgrrtrrtfrrtrrtrrtarrrtrrtFrtarrrtrrtrrtarrrtrrtrrtarrrtrpyrajrtrPgarWp'd(rtrPgarWpyf?,,, ` ; s ul)r ag lutt a ad v r n cC d�A f' ay Ixxx,rt'rrtmrrtrrtraxCUrrtrararwrrtmrrtmrrt�GaaCUrrtrrtrrtrrtrkrrt(ramrrtrrtrrtrrtrkrrtmrrtmrrtrrtrrmrrmrrtrrtrrtrrtrkrrtm mrrtrrtrfyJ,w %V nv of c rrn e ,t]n ray r a p by or N' I ." N,., call to confirm end rtla color E1 tut]t pl it r mr nt t,,, .,.,. es Qnce 1dvjrcPd 31ry'ay it place Rhythm Vm'm / (Rhythm give 1 breath every 6 iseconds "shockable? ",,, shockable? 1d hn?dths,nwrl witlr r.rvr wu uaiJ ` ........ .........f chest compressions yes/ e �uuuuuuuuu 1U11111 Illllul III III 5 llwlllmsrum�pllk Ilhlm;m Epinephrine WHO dose: I I mg every3 S mirILRCS' 6 1 11 Amiodarone IV110 dose:Firsl'. ( _ .... [ close:300 mg bolus Second CPR 2 MIN CPR; min do r�:15ru mg. • Epinephrine every 3-5 Treat reversible causes a, min ." LldocaVneWtOdose: Fir Idotl(o 1-15rny7/kg Socond �rtmmyyrtmfrhrty�rry7marrxrtmarrxrtmarrxrtmarrxrtmm�fmaawaxwmaawaxwmaaw�akyyakrmpv,, dos 0 5-0 l5 inrlJkrp, VIU SEEM IVIIIIIIII IIII III IIII IIIII IIIII IIIII IIIVIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Rhythm wmm tau - Rhythm yes n shockable?v shockable? PulndamdbIacdprasurn n Ahrtupt Subt ri ied inc" rse'in ....yes P co (typecally?40mmHg) 3 p0 n to rn H 0 rl s,Cl r C AY r is l p r es o Va rP, Ilhomalk *ru�rvea"NRh irrtr.r-arterial monitoring g �, Uu IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIV u I uu I uml um I uu um ull ull uulmiiillil°u CPR 2 MIN H9ypovole,nia • Hlyfa(a., Amiodarone i( Hlydrogeimon(acidosis) Treat reversible causes S Hypo-fhypr rkalemiia �rtmmCaarrtm�rfyrtm�rrarrtm�ryrtmarfarrtmarfarrtm�rrarrtm�rfyrtm�rrarrt arfarrtmarfarrtmarfyrtm�rrarrtm�rfyrtR�lrarrtm�rr,,,: 12 Hypol:Irer rr r,<i If FtOSC, o to Post—Cardiactol0Arrest Care Tiro on pncumothanax TL n;l •Ifno signsofreturn of spontaneous Go to5an7 T In ronadr rardiw •curculatian dROSC1,go to 10or tt � To rvs' gntbosis pulmonary .�., Thrombosis cardrnarY 7,10 1... c,avi r pr :qie n s kcol.e prh w h a C Vmmpr . ~l, hs: m llrmmll air dnsl pll l eli�pc,asure *, A KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 C. Ventricular Fibrillation / Pulseless Ventricular Tachycardia (VF/pVT) For a patient in VF/pVT, initially perform 200 uninterrupted chest compressions. Establish IV/ 10 access as soon as possible. Ith���d;ss,ikle, c.da�,er p:itient's k�ce prh;�r hd CdVnpressllI, ns h llrnllair 1. Defibrillate at 200 joules and repeat defibrillation every 2 minutes, if rhythm is shockable. 1):pd a.slbl , cd�,,°er patient's kme prh ar hd �h� rck1n g ld� llrnit air do rh let e,11�hN�sur . 2. Administer Epinephrine, 1 mg, IV/10 push, circulate with 2 minutes of CPR. d Wish:ler an a6,,and.ed a1n&ai d: { ide^ w If inlubath+Wi i.s d lai,,e, c.dWisider supragh;4ti ain&°ai (7(3:l) d:ar I,Ji)n Il i)biri!)afl iiiDir a; 10 1": II hrrilin 3. Defibrillate at 300 joules, if rhythm shockable. Resume CPR. 4. Administer Amiodarone 300mg, IV/10 push, circulate with 2 minutes of CPR. 5. Defibrillate at 360 joules, if rhythm shockable. Resume CPR. 6. Administer Epinephrine, 1 mg IV/10 push, circulate with 2 minutes of CPR. 7. Defibrillate at 360 joules, if rhythm shockable. Resume CPR. 8. Administer Amiodarone 150mg IV/10 push, circulate with 2 minutes of CPR. 9. Defibrillate at 360 joules, if rhythm shockable. Resume CPR. 10. Administer Epinephrine, 1 mg IV/10 push, circulate with 2 minutes of CPR. 11. Defibrillate at 360 joules, if rhythm shockable. Resume CPR. 12. If the rhythm fails to convert, continue CPR with Epinephrine IV/10 every 3-5 minutes and defibrillation as needed. a. At any time consider underlying causes and manage as indicated in "Potentially Reversible Causes in Cardiac Arrest" (H's and T's) in Section E. 13. If patient is in polymorphic ventricular tachycardia (Torsades de Pointes). Magnesium Sulfate 2 gm IWO over 1-2 minutes may be given at any time after the first epinephrine. 14. After ROSC, refer to the Post Resuscitative Care Protocol Protocol 2-5. 3 KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 D. Asystole Agonal Rhythm, Idioventricular rhythm with a rate<_20 bpm, or Pulseless Bradycardias a. Perform CPR. b. Establish TWO IV/10 lines as soon as possible. c. Administer Epinephrine 1 mg IV/10 every 3 Minutes d. Consider underlying causes and manage as indicated in "Potentially Reversible Causes in Cardiac Arrest" (H's and T's) in Section E. e. Administer Sodium Bicarbonate 1 mEq/kg IV/10 in cases of preexisting metabolic acidosis is suspected such as in near drowning, renal dialysis, or DKA patients.* f. After 20 minutes of resuscitation efforts with no rhythm change call medical control for further orders. `l�:u l IC: II u�:'u Il l� u l M:�I.lu�luuinu�sll)u (. M;;�II ull.uu�lu (:: Il�lll umll:ll ;�uul:l SI :llill.,uu�lu II a °M;;�uN �uuM;;�ll il�uml ugh thu,l s ;�u�l°ur II � lu . 11ll i , 0. il; ills Ilil.lil)ll I)slab llshIIn sil;)� si::)paIIab::) &';;' tl ss. Ilf unab,iil) bil) i alln hpvill si::)paIIab::) M;°;4 c tl ss, 11D Ills.uuI IH11111D Is s 1,fl:f ° 1::)1n l°y IIlliushi:)I.I w0h a iiAA-PuM;; saIlHnii Il wll�am lI� M;�I:lu�luuuuu�lnM;��nl�uu. ------ --------- with no rhythm change contact medical *, A KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 E. Pulseless Electrical Activity (PEA) 1. Perform CPR. 2. Administer Epinephrine 1 mg IV/10 every 3-5 Minutes. 3. Consider underlying causes and manage as indicated in "Potentially Reversible Causes in Cardiac Arrest" (H's and T's). Potentially Reversible Causes in Cardiac Arrest (H's and T's) Hypovolemia Fluid bolus of up to 1000 mL, rapid transport wwiiiiiuuuuuuuuuiiuuuuuuuuuwwii uwuiuwuiwuiuwwif 1W w­w­uljjl iw iwuufll ill III III III III III III IIIll llI III IIIIII III x�wwxu�uuuwuwuiwiwwiwiauwwuiwtaxrcrcrcnnuuwuiuwuiuwuiuwiwiauuuauiwiiu�uauuiuwwi�wu�xrcrcrcaiui�iuwuimuuuiuwuiuwuimiu�.wrcaw�aauiuwui�uuui�iuwuiu�iuiuuuuuu Hypoxemia Confirm adequacy of oxygenation and hyper- oxygenate. Hydrogen-ions (Acidosis) Give Sodium Bicarbonate, 1 mEq/kg IV/10 Hypothermia Warming of patient Hypoglycemia D10 10 gm (100 mL) IV/10 Hyperkalemia Calcium Chloride and/or Sodium Bicarbonate. Tension Pneumothorax Needle decompression per Procedure 3-1 Tamponade, Cardiac Dopamine 5 mcg/kg/min (Toxin): Beta Blocker OD Glucagon IVP 3 mg slow IV/10 (Toxin): Calcium Channel Block OD OD " Calcium Chloride 1 gm IV/10 *, A KEY LARGO EMS CARDIAC ARREST FOR SUSPECTED/CONFIRMED COVID-19 F. Post Resuscitation Care (ROSC) 1. Optimize ventilation and oxygenation a) Maintain oxygen saturation >_ 94% to avoid potential oxygen toxicity due to excessive ventilation, titrate to target ETCO2 35-40 mmHg. b) Glycemic control measures should be implemented since there is an increased riskfor hypoglycemia in the post-arrest phase. Measure and maintain BG levels. If BG level < 80 mg/dL administer D10 10 grams (100 mL) IV/10. 2. If blood pressure is <90 mm Hg systolic: a) Administer a fluid bolus of up to 500 mL of NS KVO. Monitor B/P and lung sounds often it is not mandatory to administer the entire liter of fluid prior to proceeding to Dopamine. Clinical judgment should be utilized in determining when to proceed to Dopamine. b) Dopamine Infusion at 5 mcg/kg/minute and titrate to a blood pressure of 90-100 mmHg systolic. Appendix 9.1, f i;m f cat dif ac at eist mafmmrrmfn rrilflm syistolh Wood mrm sure, /ess flmarr')('? ini Zit el a mJat d rrlflm In lmmrr.rm°motfaflfy and rfinfirm1 1mmrrf ftirmm thfl imrmal r°°m ism!°:mvv„r. rr1m11rm istolh °mrm slit els mmt rm lat �lr f1m�m�rm 1t��0 mrin at a mmm meat drrlflm bettm�lr rm si! mr���ry. 3. 12-Lead EKG. If STEMI, treat and transport per Protocol 2-4 ST Elevation Myocardial Injury/STEMI. 3 9 o j � GjC Q. j'. U O U U °U Z5 -� Ou Z5 4—J y m O (f Gj Gj O (1) O W o • ° 3j w 4-J o A O bA � U O •O S-. V l o p O4-J u vOi c� y A" U '� � ° a c° C 4—J GA bA �, U �, O 4-J c� sue, sue, DC O 4-, 4-, +-J +1 _ 4—Jcn cz u .� '> '3 a) W 'Q • • • • • j' e.e i.. ..i..n.e i.. .a a .. ..i..e.e i.. .i..e.e i.. ..i..e.e i.. .i..e.r III NO n wI a YES ..:.:, 2.CARDIAC PELVIC 1/5 w,Auld In areasl- 4.Areas 5,6,fdenti,61,if pletamothorax is Present. NO At no flawsbiould an tilt ad exam deby .............................................................. 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