HomeMy WebLinkAboutItem C05 COUNTY of MONROE BOARD OF COUNTY COMMISSIONERS
� Mayor Michelle Lincoln,District 2
The Florida Keys Mayor Pro Tern David Rice,District 4
y Craig Cates,District 1
James K. Scholl,District 3
�f
Holly Merrill Raschein,District 5
Regular Meeting
January 28, 2026
Agenda Item Number: C5
25-0195
BULK ITEM: Yes DEPARTMENT: Fire Rescue
TIME APPROXIMATE: N/A STAFF CONTACT: R.L. Colina
AGENDA ITEM WORDING: Approval to renew a Class A Certificate of Public Convenience and
Necessity (COPCN) to Elite Medical Response LLC for the operation of an Advanced Life Support
(ALS) and Basic Life Support (BLS) emergency medical transport service, as well as a non-
emergency medical transport service in Monroe County, Florida, except for within the city limits of
Marathon, for the period of February 1, 2026 through January 31, 2028.
ITEM BACKGROUND: Elite Medical Response LLC currently has a Class A COPCN for the
period starting on February 1, 2024 and ending on January 31, 2026. In view of the foregoing, Elite
Medical Response LLC has applied to renew this Class A COPCN which, if approved, will become
effective February 1, 2026. This will enable Elite Medical Response LLC to provide inter-facility
transports, except for those within the city limits of Marathon. Of note, Elite Medical Response LLC
is not permitted to perform 911 emergency response work in Monroe County.
PREVIOUS RELEVANT BOCC ACTION:
01/31/24 BOCC approved the renewal of Elite Medical Response LLC's Class A COPCN for the
period 02/01/24 through 01/31/26.
INSURANCE REQUIRED: Mandated by SOF.
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATION: Approval.
DOCUMENTATION:
COPCN Certificate; COPCN Application.
FINANCIAL IMPACT:
Effective Date: 02/01/2026
Expiration Date: 01/31/2028
Total Dollar Value of Contract: N/A
Total Cost to County: N/A
Current Year Portion: N/A
Budgeted: N/A
Source of Funds: N/A
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount: N/A
Grant: N/A
County Match: N/A
Insurance Required: Mandated pursuant to State of Florida licensing requirements.
C5. Approval to renew a Class A Certificate of Public Convenience and Necessity (COPCN) to
Elite Medical Response LLC for the operation of an Advanced Life Support(ALS) and
Basic Life Support (BLS) emergency medical transport service, as well as anon-emergency
medical transport service in Monroe County, Florida, except for within the city limits of
Marathon, for the period of February 1, 2026 through January 31, 2028.
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MONROE COUNTY, FLORIDA
APPL,ICXrl,ON FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN)
CLASS A EMERGENCY MEDICAL SERVICE
(PRINT OR TYPE)
El 'INITIAL APPLICATION-$9510.00 RENEWAL APPLICATION-$475.00
01 24-01
IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE. 4
NAM I ELITE MEDICAL, RESPONSE LAC
1. E OF SERVICE
BUSINESS MAILING,ADDRESS 10 1 13 Overseas Highway, Key Largo, FL 3,3037
BUSINESS PHONE NUMBER 786-478:-6064 EMERGENCY PH ONE,N'UMB'Ea:R7'86-478-6064
LLC
TYPE OF OWNERSHIP(i" etor, Partnership,Corporation,etjc,,)
21 meol Sole Pi-opri I
DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION08/24/210231
a
3* LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necessary).
NAME AGE ADDRESS TELEPHONE# POSITJONrrIT'LE
Joel Ke i enb a 43 4 ain Strut,Brooklyn, NY 11201 718- President
Isabel Rodriguez 55 7320 N Augusta Dr, Hialeah,F'L 33015 786-889-1663 Admi I nistrator
Bill Hall 59: 11612 163RD PL N,Jupiter,FL 33478 954-553-22,98 CEO
arah Rosenfe S 52 24 Rutledge Sti, Brooklyn, NY 1211 917-842-03162 CFO ld
4. LEVEL OF CARE,TO BE PROVIDED. BLS or ALS
IF ALS. TRANSPORT or NON TRANSPORT
50 DESCRIBE'SHE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use sepwrate sheet if necessary):
Monroe County
6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB-
STATIONS Use separate sheet ifnecessary' 41
,BASE STATION 11,01413 Overseas Highway Key Largo, F'L 33037
SUB-STATION
Nage I of 6
A
70, DESCRIBE YOUR COMMUNICATION SYSTEM (Attach copy of all FCC licensts),.,
FRE N C ' S, CALL NUMBERS OF MOBILES OF PORTABLES
.................. ................; —
800 MHz, P2,5 Elite R50-51, M3 2" 3
mcsol
8. LIST THE,NAMES,AND ADDRESSES OF THREE(3),U.S.CITIZENS WHO WILL,ACT AS REFERENCES FOR
11
YOUR SERVICE;
NAME ADDRESS
Dir. Sandra Schwernmer 101413 Overs i , Key, Largo, FL 33037
Brandon Ferbeyre 211 O� l Cults , FL 33189
Jose Puri 20610, Marl'in Rd, Cutler, Bay, FL 33,189
96, ATTACH,A,SCHEDULE OF RATES WHIGH.YOUR SERVICE,WILL CHARGE DURING THE COPCN PERIOD,
10. � RO'V',',[,DE,,,o'VERIFICATI,'O,N OF ADEQUATE INSUr RANGE COVERAGE,DURING THE COPC'N PERIOD.
1 1,41 ATTAC.1-1 A,COPY OF YOUR SEIIWICE'S CONTRACT WITH A MIEDICALDIRECTOR.
12# ATTACH A,COPY OF ALL STAN'DING,ORDERSAS, ISSUED,BY YOUR MEDICAL,DIRECTOR*
13. ATTACH A CHECK ORMOXEIVORDER IN THEAPPROPRIATE AMOUNT,-MADE PAYABLE TO THE
MONROE COUNT'Y BOARD OF'COUNTY COMMISSIONERS.,
1,THE UNDERSIGN'E'D IIE'PRESENTATIVE,OF THE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE
MEE'rS ALL OF REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE
COUNTY AND THE STATE OF FLORIDA. LFURTHER ATTEST'THAT ALL THE INFORMATION CONTAINED IN
THISAPPLICATION,T 0 l EST F Y KNOWLEDGE,,IS TRUE,AND CORRECT.
Yr
siGNA"117URE OF APPI ICANT/AUTHORIZED' EPRESENTATIVE
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NOTARi, SEAL EXPMAW, 2Z2W'
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NOTARY Sid NATURE DATE
Page 2 of 6
rERS�ONNEL—PARAMEDICS
CERTIFICATION
NAME PARAMEDIC
Firs tl Middle Last SOCIAL SEC URIT"Y# CEWI".IFICATION# EXPIR ATION DATE
—------- SEEM=
...............
Christian cep PMD,532319 12/01/2026
Brandon Febeyre PMD5,�35�697 12/01/2026
PMD527883 12/01/2026:
Gregory Gutierrez
Jose P 52337 2/01/2026
Keilor Zaniga PMD546929 12/01/2026
.....................
Seynefte D am e PMD54573 2/01'/2026
PMD5411135 1,2/01/2026
Michae l Colon
PMD531179 12/01/20�2�6
�.�.. _ ��
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�� ��
Wilfredo Salgado
-iffil mwivN vim�.Ihk-A 1�641Al Am 0
MW mmON--
........................... ......................
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Pa,ge 3 of 6
PERSONNEL-EMERGE,NC MEDICAL
TECHNICIANS
"NMMMmnranmn.w.n�M".. aW,+'w«pmnri�". ..
NAM EMT CERTIFICATION
Till's iced fast SOCIAL SECUR,,I"TY# CERTIFICATION 4 EXPIRATION DATE
Matthew Guerra EMT587300 12/01/2026
EMT5669146 1,2/01/2026
Kristian, Mosc,os,o
Ash-ley Rias EMT5160460 12/01/2026
Ruben �Rolidan EMT570262
1,2/01/2026
Jose Chace EM'T574901 12/0 1/120261
Michael Sun 96 12/01/202
............
................
AN
Page 4 of 6
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Bite Medlical "Transport
Accounts Payable
1014,13 Overseas Hwy
Key Largo, FL 331037
April 25, 2025
Greetings,
Attached youmil f'inl,d the annual billing for the Sharield Use of the MCSO P25 Radi,o,
System:. You will also, find a niew agreement to extend your participation through
September 30, 2029. Please sign and rieturn thie fully executedcopy, to me at".
MCS0
Emergency Comm unications
Laura Whfte
21945 Overseas �Hwy
Marathon, FL 33050
Or
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1white 1@ keys o.net
I would also is advise YOU thiat we will doing maintenance work to severial towers
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this year, so your cost next year may increase dule to the ongoing suppl�y chain and tarifif
IN
issues.
Regards,
(NAN_3�
Laura White
Director,, Emergency Communications
i ), 1
,5525 KEY VLE
33040 (30w s700,1
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Monrae CountlyRates
BLIS RESPONSE CHARGE" $6,50,001
ALS
ESP E $8010.001
L ' 2, RESPONSE .
CRITICAL CARETRANSPORTS, T) $1,),Oojo,
i
MILEAGE
1
OXYGEN $35.00,
DATE(MMfDDfYYYY)
Ate' CERTIFICATE OF LIABILITY INSURANCE 12/2312025
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 policies)must have ADDITIONAL INSURED provisions or he endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Courtney Stuart
NAME:
Brown&Brown Insurance Services,Inc. PHONE Ext: (863)385-5171 FA C,Nod:
32313 Broadway Street E-MAIL Courtney.Stuart a bbrown.corn
ADDRESS:
Suite 200 INSURER(S)AFFORDING COVERAGE NAIL#
Sebring FL 33870 INSURERA: National Interstate Insurance Company 32620
INSURED INSURER B:
Positive Mobility LLC;Elite Medical Response INSURER c:
Visionary Healthcare Solutions LLC;Elite Medical Response LLC INSURER a:
201 Commercial Court INSURER E:
Sebring FL 33876 INSURER F:
COVERAGES CERTIFICATE NUMBER: 20-27 Master Cert REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDILSUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDfYYYY) (MMIDDIYYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE Fx] OCCUR -PREMISES(Ea occurrence) 1 0'000
MED EXP(Any one person) $ 5,000
LJG455001807 04/01/2025 04101/2026 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3,000,000
POLICY PRO- LOC PRODUCTS-COMPfOPAGG $ 3,000.000
JECT
OTHER: Abuse or Molestation $ 1,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANYAUTO BODILY INJURY(Per person) $
A OWNED X SCHEDULED AGA45500180 04/01/2025 04/0112026 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE $
/� AUTOS ONLY /� AUTOS ONLY (Per accident)
PIP-Basic $ 10,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y f N STATUTE I IER
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT 1'000'0 0
A OFFICER/MEMBER EXCLUDED? ❑ N/A AC1J1 455001$-00 01J0112020 0410112027
000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000°
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $
Professional Liability Aggregate $3,000,000
A LPL455001807 04/01/2025 04/0112026 Each Medical Incident $1,000,000
DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
***Insured's Copy*** ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
MEDICAL DIRECTOR AGREEMENT
This Medical Director Agreement (this "Agreement") is entered into on 1st day of
February, 2025, to be effective February 1, 2025, between and between Visionary Healthcare
Solutions, LLC, on the one hand, and Professional Emergency Services, Inc. and Dr. Sandra
Schwemmer(collectively "Medical Director"), on the other hand.
WHEREAS, Visionary Healthcare Solutions, LLC, as parent company for Positive
Mobility, Inc d/b/a Elite Medical Response Medical and Elite Medical Response, LLC
(collectively referred to herein as "EMR"), provides basic and advanced life support medical
transport services in various locations throughout the State of Florida, and is required by Chapter
401, Florida Statutes, to contract with a licensed physician to serve as Medical Director for each
location; and
WHEREAS, Dr. Sandra Schwemmer owns and practices through Professional
Emergency Services, Inc., which provides EMS and Medical Director services, and
WHEREAS, Dr. Sandra Schwemmer of Professional Emergency Services Inc. is a duly
licensed Osteopathic Physician who is qualified to serve as Medical Director for EMR; and
WHEREAS, the Parties wish to enter into this Agreement to retain Dr. Schwemmer and
Professional Emergency Services, Inc. to serve as Medical Director for EMR desires to utilize
the services of the Medical Director,
NOW, THEREFORE, in consideration of the mutual terms and conditions, promises,
covenants and payments set forth below, EMR and Medical Director agree as follows:
ARTICLE I
SCOPE OF SERVICES
1.1 Medical Director is being retained to provide EMR medical services and
oversight consistent with Florida law. Professional Emergency Services, Inc. will
be designated EMR's Medical Director and Dr. Sandra Schwemmer will serve as
EMR's Chief Medical Officer ("CMO"). This Agreement is conditioned upon Dr.
Schwemmer remaining duly licensed and authorized to practice medicine in the
State of Florida and meeting all of the qualifications required to serve as Medical
Director of Emergency Medical Service providers in the State of Florida.
Medical Director's services will include oversight of emergency medical services,
training and compliance functions for all EMR medical personnel. Medical
Director will perform such duties for EMR as are customarily performed by one
holding such position in other, same or similar professions as that engaged in by
EMR. The parties agree that Dr. Schwemmer's services are personal in nature
given the degree of skill required of Medical Director in performance of his
services, that Dr. Schwemmer will provide all services contracted for in this
Agreement either directly or under her express supervision and control.
1
1.2 Medical Director's relationship to EMR will be that of an independent contractor,
not an employee. Nothing in this Agreement is intended to create an employment
relationship, or to empower Medical Director to act on behalf of EMR except as
specifically set forth in this Agreement. Medical Director shall not be entitled to
(1) participate as a member in any plans or programs maintained by the Company
from time to time for the benefit of its employees, including but not limited to all
insurance plans and programs relating to medical, hospitalization, dental, vision,
disability, life insurance, accidental death and dismemberment, and travel and
accident; (ii) participate in any medical and hospitalization plans and programs of
the Company or other employee insurance plans and programs; (iii) enjoy paid
vacation; (iv) be reimbursed for business expenses, travel, and entertainment
expenses incurred by Medical Directors, unless approved by the Director of
Operations in writing and in advance; (v) Medical Director will be reimbursed for
the fees related to acquiring and maintaining the DEA certificate(s) assigned to
EMR at each location and for the direct cost of educational programs and/or
seminars required by EMR for advancing the services of EMR, (vi) Medical
Director shall be responsible for the payment of all federal, state, and local taxes
(including federal, state, and local self-employment taxes) that are in any way
connected with this Agreement, and specifically indemnifies and holds EMR
harmless for any tax liability that arises out of the payment to Medical Director
for Medical Director's professional services.
1.3 Medical Director is free to provide services or work for any other company or
third party so long as Medical Director does not violate the terms of this
Agreement and provided other engagements do not interfere with Medical
Director's ability to fully and faithfully perform all services required as Medical
Director.
ARTICLE 2
MEDICAL DIRECTOR RESPONSIBILITIES
2.1 The Medical Director has reviewed applicable state, county, regional and local
laws, rules, and regulations concerning the administration of ALS/BLS
ambulance services and the responsibilities of the Medical Director in
performance of such services. The Medical Director will faithfully and to the best
of Medical Director's ability perform all services required of a Medical Director
for an ALS/BLS transport ambulance licensed under Florida law. Medical
Director will provide guidance to EMR to advise EMR to ensure compliance with
all pertinent laws relating to the provision of medical transport services, including
but not limited to the following:
2.2 Medical Director will conduct medical audits of EMR's clinical performance,
when requested, that involve a reported incident, a review requested by a patient's
personal physician, when a paramedic requests an audit of a case, when EMR
requests an audit of clinical care or if the Medical Director believes that an audit
should be conducted.
2
2.3 The Medical Director will supervise, set standards, and establish procedures for
the clinical performance of all Emergency Medical Technicians, Paramedics,
Nurses, and other clinical personnel as allowed or required under the laws and
regulations of the State, County and/or Municipality in which EMR operates. All
EMT's, paramedics and independently licensed nurses employed by EMR will be
required to follow EMR standing orders approved by the Medical Director.
2.4 Medical Director will develop transport protocols that permit specified ALS and
BLS procedures when communication cannot be established with a physician
during medical transport when a delay in patient care and treatment would
threaten the life or health of the patient.
2.5 Medical Director will maintain 24-hours-per-day 7-days-per-week availability to
provide continuous medical direction. Medical Director will also maintain timely
availability to resolve administrative problems, system conflicts, and provide
services in an emergency as that term is defined by Section 252.34(3), Florida
Statutes. Medical Director may designate an alternate Medical Director, when
needed, who shall be available in the absence of the Medical Director. The
Alternate Medical Director will have an understanding of ALS and BLS medical
transports and report to the Chief of Operations.
2.6 Medical Director will oversee the development and implementation of a medical
transport patient care quality assurance program to assess the medical
performance of Paramedics, EMTs and nurses. Clerical and administrative
support will be provided by EMR to assist Medical Director in the performance of
this function.
2.7 Medical Director will audit the performance of medical transport personnel from
time to time and will take steps to ensure that all medical transport personnel
perform their job duties appropriately. Medical Director will make
recommendations for changes to the EMR quality improvement program to
address any weaknesses, and upon request, will promptly review transport reports
and when appropriate, will provide performance standards for drugs, equipment,
protocols and procedures.
2.8 Medical Director will maintain a Controlled Substances Registration Certificate
for EMR and will monitor the administration of all medications, including
controlled substances, as needed. Medical Director's DEA registration shall
include the EMR address where controlled substances are stored. Proof of such
registration shall be maintained on file shall be readily available for inspection.
Renewal notification(s) received by EMR will be promptly delivered to Medical
Director who is responsible for maintaining this registration in good standing and
will notify EMR if any changes occur regarding this registration.
3
2.9 Medical Director will review applicable security procedures for medications,
fluids and controlled substances to insure EMR's compliance with all applicable
laws, including Chapters 499 and 893, Florida Statutes, and Chapter 64F-12,
Florida Administrative Code.
2.10 Medical Director will work closely with the Operations Chief to develop and
implement written operating procedures creating, authorizing and ensuring
adherence to rules and regulations regarding all aspects of the handling of
medications, standing orders and protocols to ensure transports are performed at a
level of care appropriate to the patient's condition, standards and procedures
relating to Do Not Resuscitate (DNR) orders, and policies and procedures relating
to fluids and controlled substances, as well as other standards and protocols for
the efficient performance of emergency medical transportation services, in
accordance with State and Federal regulations.
2.11 Medical Director will review and approve training for EMT/Paramedic
continuous education training and/or refresher courses for the purpose of EMT re-
certification.
2.12 Medical Director will develop and implement a plan for prompt medical review of
possible infectious exposures reported to the Operations Chief and provide
medical follow-up when indicated, in compliance with State and Federal
requirements.
2.13 Medical Director will have the authority to temporarily suspend from clinical duty
any employee whose job performance is deemed hazardous to patient care and
shall immediately inform the suspension to EMR's Chief of Operations.
2.14 Medical Director acts in the capacity of a liaison with EMR and the medical
providers in the community.
2.15 In accordance with Section 401.265, Florida Statutes, and Rule 64J-2.004, Florida
Administrative Code, the Medical Director shall possess and maintain through the
term of this Agreement a Florida license to practice medicine.
2.16 Medical Director shall perform such other duties and responsibilities as now are
imposed or may be imposed during the term of this Agreement by Florida law,
including but not limited to the applicable provisions of Chapters 252 and 401,
Florida Statutes, and Rule 64J-1.004, Florida Administrative Code, as may be
amended from time to time.
2.17 Medical Director shall oversee the administration, acquisition and control of
controlled or non-controlled substances as deemed necessary for the provision of
care prescribed in the medical treatment protocols/standing orders. In the event no
such procedure exists, or is deemed inadequate, Medical Director will advise and
assist in development and implement such a system.
4
ARTICLE 3
COMPENSATION AND METHOD OF PAYMENT
3.1 EMR agrees to pay the Medical Director as full compensation for the services
described in this Agreement a monthly fee of Nine Thousand Five Hundred
Dollars ($9,500.00). This fee includes all costs and expenses of Medical
Director/Chief Medical Officer. EMR may increase compensation during the
course of this Agreement and renewals for additional services required of the
Medical Director or CMO.
3.2 EMR agrees to pay the Medical Director on the first day of the month for each
month in which Medical Director's service are to be rendered.
ARTICLE 4
EMR'S RESPONSIBILITY
4.1 EMR shall assist the Medical Director by placing at its disposal all available
information pertinent to the services to be performed by the Medical Director,
including access to all EMR's EMT/Paramedic/Nurse employment records and
patient medical transport records.
5.2 EMR will provide Medical Director appropriate administrative support including
secretarial support services and other equipment as may be needed from time to
time to provide oversight to EMTs, Paramedics and Nurses employed by EMR.
5.3 EMR will comply with FL Chapter 64J-1 in all aspects related the performance of
medical transport operations.
ARTICLE 6
TERM
6.1 This Agreement shall commence on February 1, 2025 and will be for a one year
term. This Agreement will automatically renew each year unless terminated
pursuant to Article 7, below.
ARTICLE 7
TERMINATION
7.1 If through any cause, the Medical Director fails to fulfill its obligations under this
Agreement, EMR shall have the right to terminate this Agreement upon 30 days
written notice or payment in lieu thereof at EMR's sole discretion.
7.2 This Agreement may be terminated by EMR without cause upon ninety (90) days
written notice to the Medical Director. If EMR terminates without cause, the
Medical Director shall be compensated for all services performed prior to the
5
termination date, provided that all property belonging to EMR is returned prior to
release of final compensation to the Medical Director.
7.3 Medical Director may terminate the Agreement, with or without cause upon
providing written ninety (90) day notice to EMR. If Medical Director terminates
without cause, EMR shall compensate Medical Director for all services performed
prior to termination date.
ARTICLE S
MISCELLANEOUS
8.1 Any files, documents, studies, transport report reviews, patient records, training
curriculum and other data prepared by the Medical Director for EMR shall belong
to and shall remain the property of EMR.
8.2 Medical Director shall not discriminate against any employee or applicant for
employment for work under this Agreement because of race, color, religion, sex,
gender identity, sexual orientation, age, marital status or national origin, physical
or mental disability, or any other protected class under federal, state or local law.
8.3 Medical Director is an independent contractor under this Agreement. Services
provided by the Medical Director shall be by employees/contractors of the
Medical Director and subject to supervision by the Medical Director, and not as
officers, employees, or agents of EMR. Personnel policies, tax responsibilities,
social security and health insurance, employee benefits, purchasing policies and
other similar administrative procedures applicable to service rendered under this
Agreement shall be those of the Medical Director.
8.4 The parties recognize that the service contemplated by the Chief Medical Officer
are of a unique and personal nature and as such this Agreement shall not be
assigned, transferred or otherwise encumbered by the Medical Director, without
the prior written consent of EMR.
8.5 It is further agreed that no renewal, modification, amendment or alteration in the
terms or conditions of the Agreement, shall be effective unless contained in a
written document executed with the same formality as the Agreement.
ARTICLE 9
INSURANCE
9.1 EMR shall provide professional and general liability insurance with minimum
limits of$1,000,000.00 per occurrence for the Medical Director with Professional
Emergency Services, as additional named insured during the term of this
Agreement. EMR shall be responsible for maintaining this professional liability
insurance for a minimum of three years from the date of termination of this
6
Contract. The Professional and General Liability Insurance certificate will
specify coverage for"BLS/ALS Medical oversight".
9.2 EMR will provide certificate or proof of such insurance to the Medical Director
on an annual basis. Medical Director will be provided thirty (30) days notice of
cancellation and/or any restrictions placed on coverages of the professional and
general liability insurance provided/procured by EMR during the term of this
Agreement. EMR will be responsible for the payment of any deductible and/or
self-insured retentions in the event of a claim.
9.3 It is recognized that questions in the day-to-day conduct of this Agreement will
arise. EMR designates the Chief of Operations, or designee, as the person to
whom all communications pertaining to the day-to-day conduct of this Agreement
shall be addressed.
9.4 This document incorporates all negotiations, correspondence, conversations,
agreements or understandings applicable to the matters contained in this
Agreement and the parties agree that there are no commitments, agreements, or
understandings concerning the subject matter of this Agreement that are not
contained in this document. Accordingly, it is agreed that no deviation from the
terms shall be predicated upon any prior representations or agreements, whether
oral or written. This Agreement specifically supersedes and replaces the
Agreement Between Elite Medical Transport, LLC and Professional Emergency
Services, Inc. for Medical Director Services.
9.5 Whenever either party desires or is required under this Agreement to give notice
to the other, it must be given by written notice, sent by overnight mail or certified
United States mail, with return receipt requested, along with an email copy sent,
addressed to the party for whom it is intended, at the place last specified, and the
place for giving of notice in compliance with the provisions of this paragraph.
For the present, the parties designate the following as the respective places for
giving of notice, to wit:
For EMR:
Visionary Healthcare Solutions, LLC
201 Commercial Ct.
Sebring, FL 33876
Attn: William J. Hall, CEO
For the Medical Director/Chief Medical Officer:
Professional Emergency Services, Inc.
c/o Dr. Sandra S chwemmer
3577 NW Clubside Circle
Boca Raton, FL 33496
sschwen-liyier(� giri.aiLcon].
9.6 Consent to Jurisdiction. The Parties agree that any dispute between the Parties,
including without limitation those relating to or arising under this Agreement, will
be resolved through arbitration under the procedures outlined in the Commercial
Arbitration Rules and Mediation Procedures of the American Arbitration
Association (AAA), a nonprofit organization that administers the arbitration
process. The arbitration will be pursuant to the Federal Arbitration Act and the
Parties may, if necessary, invoke the AAA Emergency Measures of Protection.
9.7 Governing Law/Attorney's Fees. The parties agree that this Agreement shall be
construed in accordance with and governed by the laws of the State of Florida. If
either EMR or the Medical Director is required to enforce the terms of this
Agreement by court proceedings or otherwise, whether or not formal legal action
is required, the prevailing party shall be entitled to recover from the other party all
such costs and expenses including but not limited to court costs, and reasonable
attorney's fees.
9.8 Headi . Headings are for convenience of reference only and shall not be
considered on any interpretation of this Agreement.
9.9 Exhibits. Each Exhibit referred to in this Agreement forms an essential part of
this Agreement. The Exhibits, if not physically attached, should be treated as part
of this Agreement, and are incorporated by reference.
9.10 Severability. If any provisions of this Agreement or its application to any person
or situation shall to any extent be held invalid or unenforceable, the remainder of
this Agreement, and the application of such provision to persons or situations
other that those as to which it shall have been invalid or unenforceable shall not
be affected, and shall continue in full force and effect, and be enforced to the
fullest extent permitted by law.
IN WITNESS WHEREOF, the parties hereto have set their hands and seal the day and
year first written above.
8
PROFESSIONAL EMERGENCY SERVICES, INC.:
.''',
. ,.
BY:
Name: Dr. Sandra S chwemmer
President
VISIONARY HEALTHCARE SOLUTIONS, LLC:
BY: 86(4 HA&
Name: William J. Hall
Chief Executive Officer
9
ALS-TOTAL
Month 2024 2025
January 0 64
February 0 56
March 0 57
April 0 44
May 0 54
June 0 37
July 0 42
August 0 41
September 0 44
October 52 59
November 49 60
December 45 0
Tota is 146 558
BLS-TOTAL
Month 2024 2025
January 0 6
February 0 5
March 0 5
April 0 4
May 0 7
June 0 11
July 0 6
August 0 6
September 0 9
October 12 12
November 7 19
December 13 0
Tota is 32 90
CCT-TOTAL
Month 2024 2025
January 0 0
February 0 0
March 0 0
April 0 0
May 0 0
June 0 0
July 0 3
August 0 5
September 0 5
October 0 2
November 0 2
December 0 0
Tota is 0 17
Tota is
Month 2024 2025
January 0 70
February 0 61
March 0 62
April 0 48
May 0 61
June 0 48
July 0 51
August 0 52
September 0 58
October 64 73
November 56 81
December 58 0
Grand Total 178 665
Call Volume-YTD
Report Date: 12/29/202517:09:57
Filters:
Pickup Time10/01/2024 to 11/30/2025
Billing StatuBilled or Closed or Complete or Validated
Call Type: ALS or BLS orCCT
BOARD OF COUNTY COMMISSIONERS
County of Monroe Mayor Michelle Lincoln,District 2
The Florida Keys t' �� ���� Mayor Pao Tem David Rice,District 4
� ��
Craig Cates,District 1
y � James K. Scholl,District 3
mw N Holly Merrill Raschein,District 5
Monroe County Fire Rescue
7280 Overseas Highway
Marathon,FL 33050
Phone(305)289-6004
w
MEMORANDUM
TO: Nicole Lyons
FROM: Cara Johnson
SUBJECT: Check for Deposit- COPCN
DATE: January 2, 2026
Attached please find Check dated December 29, 2025, in the amount of$475.00 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 Elite Medical Response LLC.
Thank you,
Cara Johnson
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Revised 0710512025
Clinical Guidelines
• Universal Care
• Critical Care
• Blood Transfusion
• Patient Safety
• Airway—Ventilation—Oxygen Management
• Pain Management—Procedural Sedation
• Nausea—Vomiting Management
• Spinal Motion Restriction
• Patient Restraint
• Transport Destination
• Air Medical Transport
• Refusal of Care
• Death in the Field
• Mass Casualty Triage
• Firefighter Rehabilitation
• AHA Adult BLS
• AHA Pediatric BLS
• AHA Adult Cardiac Arrest Algorithm
• AHA Adult Cardiac Arrest
• AHA Pediatric Cardiac Arrest
• AHA Neonatal Cardiac Arrest
• AHA Adult Immediate Post-Cardiac Arrest Care
• AHA Pediatric Immediate Post-Cardiac Arrest Care
• AHA Adult Bradycardia
• AHA Pediatric Bradycardia
• AHA Adult Tachycardia
• AHA Pediatric Tachycardia
• Abdominal Pain
• Allergic Reaction—Anaphylaxis
• Behavioral Emergencies—Baker Marchman Acts
• Chest Pain—Acute Coronary Syndrome—STEM
• Congestive Heart Failure—Pulmonary Edema
• Diabetic Emergencies—Hypo & Hyperglycemia
• Excited Delirium Syndrome (ExDS)
• Reactive Airway Disease
• Seizure
• Sepsis
• Stroke
• Toxidrome Emergencies/Overdose & Poisoning
• Blunt Force Trauma
• Penetrating Trauma
Clinical Guidelines (cont.)
• Isolated Closed Head &Traumatic Brain Injury
• Isolated Spinal Cord Injury
• Burn/Electrocution/Smoke Inhalation
• Amputation/Blast/Crush Injury
• Isolated Eye Injury
• Bites/Envenomations
• Drowning/Submersion
• Exposure Emergencies/Hypo & Hyperthermia
• Eclampsia
• Childbirth
• Vaginal Bleeding
• Pharmacology Reference
Date Notes
3/25/2024 Added Push Dose EPI Addendum
5/7/2024 Added Severe Hypertension Addendum
5/31/2024 Added 1-gel Supraglottic Airway Procedure Guidelines
10/25/2024 Added Baker Act Protocol
11/18/2024 Added Oral Glucose Protocol Addendum
07/08/2025 Added Protocol Addendum - Patient Soft and Chemical Restraint
1 ICIa g el
Goals:
To facilitate appropriate initial assessment and management of any EMS patient and link to appropriate
specific guidelines as dictated by the findings within the universal care guideline
The following represents age/weight classification:
• Adult: 8 years of age or greater than 40kg (8yo or>40kg)
Pediatric: 1—8 years of age or between 10—40kg(1—8yo or>10 but<401<g)
Infant: 1 month— 1 year of age or between 5—10kg (1mo—1 or>5 but<10kg)
Neonate: Birth—1 month of age or less than 5kg(Birth—1mo or<5kg)
General Actions:
Response
1. Review dispatch information
2. Consider need for additional resources
Scene Arrival and Si
1. Use appropriate body substance isolation (BSI)
2. Use appropriate personal protective equipment(PPE)
3. Evaluate and ensure scene safety
4. Determine number and location of persons involved versus patients
5. Consider need for additional resources
Patient Approach
1. Determine mechanism of injury (MOI) and/or nature of illness(NOI)
2. If appropriate, begin triage and initiate mass casualty incident (MCI) procedures
A. START
B. Jump START
Primary Assessment and Life-Saving Interventions
1. General Impression—Sick versus Not Sick: „°
A. Appearance
B. Work-of-Breathing
C. Circulation to Skin
2. Mental Status:
A. Awake/Alert
B. Responds to Verbal Stimuli (RVS)
C. Responds to Painful Stimuli (RPS)
D. Unconscious/Unresponsive C1FK;ULAP0 N
2 a g e
Patient Awake or Responding to Verbal Patient Responding to Physical Stimuli or
Stimuli, use: A-B-CAssessment Unresponsive, use: C-A-B Assessment
3. Airway Status: 3. Circulation Status:
• Natural • Central and Peripheral Pulses—
• Artificially Secured present, absent, rate & quality
• Compromised Absent, Hypotensive or Hypoperfused?
P
Proceed to appropriateGuideline roceed to Airway Ventilation I
Oxygenation Management Guideline • Major Hemorrhage
• Obstructed Hemorrhaging? Proceed to
P
appropriate Trauma Guideline roceed to Airway Ventilation I
Oxygenation Management Guideline • Skin Color,Temperature and Condition
4. Breathing Status: 4. Airway Status:
• Work-of-Breathing 0 Natural
• Respirations—present, absent., rate & 0 Artificially Secured
quality • Compromised
• Auscultate Lung Sounds Proceed to Airway Ventilation
Adventitious?Proceed to appropriate Oxygenation Management Guideline
Guideline • Obstructed
Proceed to Airway Ventilation
Oxygenation Management Guideline
5. Circulation Status: 5. Breathing Status:
• Central and Peripheral Pulses— • Work-of-Breathing
present., absent, rate & quality • Respirations—present, absent, rate
Absent, Hypotensive or quality
Hypoperfused? Proceed to • Auscultate Lung Sounds
appropriate Guideline
Adventitious?Proceed to appropriate
• Major Hemorrhage
Guideline
Hemorrhaging?Proceed to
appropriate Trauma Guideline
• Skin Color,Temperature and
Condition
6. Disability Status: 6. Disability Status:
• Defibrillation required? 0 Defibrillation required?
• Gross Motor/Sensory Function? 0 Gross Motor/Sensory Function?
* Moves all extremities? Eyes? 0 Moves all extremities? Eyes?
• Blood Glucose? 0 Blood Glucose?
• Cervical Motion Restriction? 0 Cervical Motion Restriction?
7. Exposure: 7. Exposure:
• Evaluate illness or injury, remove 0 Evaluate illness or injury, remove
clothing as necessary clothing as necessary
• Medic Alert bracelets or IN 0 Medic Alert bracelets or IN
3 ICI : g e
SAMPLE History and Physical Examination
1. Obtain a SAMPLE and OPQRST History
2. Conduct an Adult: Head-to-Toes exam or Pediatric:Toes-to-Head examor
3. Conduct a focused, detailed or ongoing systems exam:
A. Neurological
• AVPU
• Glasgow Coma Score
• Stroke Assessment
• Pupil Response
• Pain Scale
• Sedation Scale
B. Pulmonary
• Auscultate Lung Sounds
C. Cardiovascular
D. Gastrointestinal & Genitourinary
E. Integumentary
F. Musculoskeletal (Trauma Exam)
4. Assess Vital Signs:
A. Pulse
B. Blood Pressure
C. Respirations
D. Skin Color,Temperature and Condition
E. Capillary Refill
S. Non-Invasive Monitor Assessment(as applicable or indicated):
A. Cardiac
• Standard monitoring
• 12 Lead ECG
B. Blood Pressure
C. Pulse Oximetry
D. Blood Glucose
E. Temperature
6. Collect and transport documentation related to patient's history (e.g., emergency information
form, medical records, Medic Alert, DNR form, etc.)
Impression
1. Develop differential impression of the case
A. Triple Differential Impression
• e.g.,Altered Mental Status: Hypoglycemia vs. Stroke vs. Organic BrainSyndrome
• e.g.,Acute Coronary Syndrome: STEMI vs. Unstable Angina vs. PulmonaryEmboli
Treatment
• Refer to appropriate clinical guideline(s)
• General control measures and principles:
A. Establish an airway as prescribed by the Airway I Ventilation I Oxygenation Management
Guideline
4 a
Ah
B. Ensure adequate ventilation as prescribed by Airway I Ventilation I Oxygenation
Management Guideline
• Ventilation target: etCO2 40mmHg; normocapnogram
C. Administer oxygen as prescribed by Airway I Ventilation I Oxygenation Management
Guideline
• Oxygenation target: SpO2 94%—99%; normopletysmograph
D. Correct tension pneumothorax with pleural needle decompression—
• Primary approach: Anterior—2ndor 3rd intercoastal space, midclavicular line
• Secondary approach: Lateral—4t"or 5t"intercoastal space, midaxillary line
E. Correct open pneumothorax with an appropriate occlusive dressing
F. Establish vascular access as appropriate and indicated for condition
• Intravenous-certified EMTs may start IVs under the supervision of a credentialed
Paramedic(upper extremity only)
G. First-line therapy for closed-system hypotension/hypoperfusion is crystalloid fluid
resuscitation
• Lactated Ringer's Solution is the preferred crystalloid for hemorrhaging patients
that are operative candidates
H. Arrest compressible hemorrhages by direct pressure, pressure dressing, tourniquet use,
rapid transport, and crystalloid fluid resuscitation to temporize physiology
• BP target: permissive hypotension—restoration of peripheral pulses (unless
otherwise stipulated)
I. Mitigate non-compressible hemorrhages by rapid transport and crystalloid fluid
resuscitation to temporize physiology
• BP target: permissive hypotension—restoration of peripheral pulses (unless
otherwise stipulated)
J. Any patient that receives IV or 10 medications must have a running crystalloid infusion
PEARL I No medications will be administered directly via medication port or saline lock
K. Correct hypoglycemia as prescribed by appropriate Guideline
• Blood Glucose target: bG >60mg/dL and <300mg/dL
L. Provide Spinal Motion Restriction as prescribed by appropriate Guideline
M. Splint/immobilize suspected pelvic fractures with a commercial pelvic binder
N. Splint/immobilize fractured/dislocated limbs in a natural or functional position, above and
below the fracture site,to prevent further soft tissue or neurovascular injury
0. Manipulate/realign angulated, isolated, limb fractures or dislocations with neurovascular
compromise to restore distal circulation—then splint/immobilize
P. Traction splint isolated, closed, femur fractures
Q. Provide environmental protection and thermopreservation to all high acuity patients
unless otherwise stipulated by specific Guideline
• Temperature target: 98.6°F (37°C)
PEARL I Cold blood does not clot—Hibler's Method preserves body heat and mitigates
Lethal Triad
R. Provide corneal protection to unconscious patients
(continued)
5 a g el
Assign Clinical Priority
1. Priority 1 — unstable advanced life support patient; requiring immediate emergent medical
attention for a life and/or limb threatening illness or injury
2. Priority 2 — stable advanced life support patient; requiring medical attention but not immediately
endangering patient's life
3. Priority 3 — basic life support patient; requiring non-emergent medical attention
Determine Disposition
1. Mode—Consider mode of transport (air or land)
2. Status—Evaluate need for emergent (lights and sirens)versus non-emergent transportation
Communications
1. Notification to the receiving facility should be made for all Priority 1 or 2 patient transports
2. Medical Control contact must be made for termination of cardiopulmonary resuscitation efforts
3. Medical Control consultation is encouraged for any out-of-the-ordinary cases
Reassessment
1. Re-vital sign unstable patients every 5 minutes
2. Re-vital sign stable patients at a minimum of every 15 minutes
3. A minimum of 2 assessments are required for every patient transport
Transfer of Care
1. Relay assessment findings and care provided to providers assuming responsibility for patient(s) in
accordance with EMR SOG 112
PEARL I Transfer of Care between the emergency personnel and EMR units
is essential for patient care
. . .
CCT 1. Balloon Pumps
• The goal with transporting these patients is to keep the equipment connected to the patient
and support the RN with appropriate patient care.
• The pump may be very heavy and must be appropriately lifted and secured.
• The RN accompanying transport is solely to monitor the balloon pump; all other aspects of
patient care should be handled by the PMT Paramedic.
CCT 2. PICC Line Access
• Indications: Fluid and medication access through Peripherally Inserted Central Catheters
• If possible,fluid boluses should be given through a large bore IV in preference to a PICC line.
• Aspirate blood before use. High concentration heparin may be in line and can not be flushed into the
patient.
Procedure:
1. Identify shut-off, clamps, caps, etc., and unclamp line.
2.Access the device after cleansing with alcohol prep.
3.Aspirate with minimum 10 ml of blood with 10-20 cc syringe. (If unable to obtain blood site may
be functional, only use these lines if the patient or family can verify that the device is normally
functional despite the lack of blood return.)
6 a
4. Discard syringe with aspirated fluid in appropriate container.
5. Flush lumen or port with 10 cc saline prior to use, avoiding excessive pressure.
6. Establish IV connection, avoiding air bolus.
7. Secure connections with tape or Vein-1-guard.
8. Utilize port as standard venous access, an IV pump may be necessary to run fluids.
9. Once complete flush line with 10cc N.S., clamp and secure line.
CCT 3. Sodium Nitroprusside (Nipride—Nitropress)
• Action: Peripheral arterial and venous dilation
Lowers BP due to CHF or Hypertension (above) and increases cardiac output.
• Indications: Hypertension, CH F
• Side Effects: Hypotension, Nausea,Vomiting, Palpitations, Diaphoresis,Tachydysrhythmias,
Dizziness
• Standard Drug Dose/Route: 0.5-5 mcg/kg/min IV titrate to effect.
CCT 4. Norepinephrine(Levophed°)
• Indications: Inotropic support for SBP<70 mmHg and signs of decompensation. Hemodynamically
significant hypotension refractory to other sympathomimetic amines
• Contraindications: Hypotension associated with hypovolemia
• Adverse Reactions: Headache, Dysrhythmias &tachycardias, Reflex bradycardia,Angina/Cardiac
ischemia/infarction, Hypertension
• Special Consideration: May cause fetal anoxia when used in pregnancy, infuse norepinephrine through
a large stable vein to avoid tissue necrosis, use infusion pump to ensure precise flow rate.
• Standard Dose: 0.5—30 mcg/min titrated to effect. Average adult dose is 2-12 mcg/min
CCT 5. Propofol (Diprivan)
• Indications: IV sedative-hypnotic agent
• Contra-indications: Hypersensitivity (including egg lecithin, soybean oil and glycerol).
• Adverse Effects: Bradycardia, hypotension, hypertension, decreased cardiac output.
• Sedation & resedation bolus of.3-.7mg/kg, titrated to adequate sedation,without signs of
hypoperfusion.
• Initial infusion 5 mcg/kg/min for 5 minutes. Increase rate at 5-10 minute intervals in increments of 5 to
10 mcg/kg/min until desired level of sedation is achieved. Rates of 50 mcg/kg/min or higher require
from medical direction.
CCT 6. Diltiazem (Cardizem) Infusion:
• The standard rate for a Cardizem infusion is 5-15 mg/hr for 24 hours after the first dose.
• Cardizem must have a dedicated IV site.
• IV tubing must be PVC lined and approved for Nitro/Cardizem.
• Discontinue immediately with signs or symptoms of Beta Blocker overdose. (Bradycardia, Hypotension,
etc)
7 a g el
CCT 7. Eptifibatide (Integrilin°)
• Indications:Treatment of ACS
• Contraindications:Active internal bleeding, uncontrolled severe Htn,Trauma or major surgery in the
past 6 weeks,Thrombocytopenia, Hypersensitvity
• Adverse Reactions: Bleeding, most commonly from venous and arterial access sites, Hemorrhagic
stroke and intracranial bleeding,Thrombocytopenia
• Special Consideration: Should be administered with Heparin
• Standard Dose: Loading dose 135-180 mcg/kg Infusion 0.2-2 mcg/kg/min
CCT 8. Metoprolol (Labetolol)
• Indications:Tachycardia and Hypertension
• Contraindications: 2nd or greater A-V Block, Sick-Sinus Syndrome, Decompensated CHF, Asthma or
COPD with severe bronchospasm, severe aortic stenosis, reaction to beta-blockers
• Standard Dose: 5mg Slow IV push, 0.25-2.5mg/hour IV drip
CCT 9. Oxytocin (Pitocin)
• Indications: Bleeding control post-labor. Initiate or continue labor.
• Contraindications: Except in unusual circumstances, oxytocin should not be administered in the
following ® prematurity, borderline cephalopelvic disproportion,
section, previous major surgery on
the cervix or uterus including Caesarean overclistention of the
grand multiparity or
uterus,
invasive cervical carcinoma. The contra i nd ications for induction are the same as the contra i nd ications
for a vaginal ® Examples include vasa ° J placenta ° J myomectomy with entry into
cavity,uterine previous classical
active genital herpes
umbilical cord
J outbreak, prolapse,
or transverse fetal lie.
• Adverse Reactions: Nausea and Vomiting, Hypertension. Uterus Rupture, Cardiac Dysrhythmia
• Standard Dose: 10/20 units per hour continuous infusion.
CCT 10.
. . .
indications:lne
ciln) CCT and Special Detalill ONLY
• Indications: Drug facilitated rapid sequence intubation
• Contra
muscular
crush injuries>eight
J J disorders, hours,
extensive burns >eight hours
Adverse Reactions: Hyperkalemia changes on
• J short duration, sweating, nausea and vomiting,
heartbeat,rapid . J increased CO2 production, high fever,
• Standard Dose:Adult: 1.0—1.5 mg/kg IVP over I minute. Pediatric: 1.0 mg/kg IVP over I minute
muscle rigidity Sedative medication such as Midazolam must be administered prior to paralysis
consistent patient care during the transport.The goal is to maintain appropriate ALS care and assist the RN or Perfusionist as needed to assure
CCT 12. Chest tube to water seal
8 1 a g el
Blood Transfusion
The following protocol is designed to facilitate the transport of patients actively undergoing blood infusion
as demanded by our local ER's.All blood products to be infused must be initiated by the transferring
facility. This protocol does not authorize the paramedic to start, hang or otherwise initiate the infusion of
any blood products.
• Before accepting responsibility for the patient, confirm together with a nurse or physician from the
transferring facility that the name on the patient's armband is the same as the name on the unit(s) of
blood which is (are) infusing.
• Vital signs including temperature must be recorded prior to the transport and every 5 minutes during
transport.
• If the patient develops any sign of reaction, the blood products AND Tubing should be immediately
disconnected. Aggressive crystalloid (saline) infusion must be initiated at the site. Attempts should
be made to contact the receiving hospital for medical direction.True anaphylactic reactions are treated
with epinephrine, fluids and antihistamines. Hemolytic reactions may require a diuretic in addition to
large amounts of fluid to maintain intravascular volume.
• Discontinued blood and tubing should be placed in a bio bag and transported with the patient for
analysis.
• All untoward reactions to the administration of blood products must be reported directly to
Management within twenty-four hours.
• The below form must be completed for each transport involving any blood product:
Common issues in blood administration
Immediate Reactions: Most reactions from blood transfusions occur immediately and severely,the below are
the most encountered types of reactions.
Hemolytic Reactions:The most serious immediate transfusion reaction, the hemolytic transfusion reaction, is
any antigen or antibody-induced reaction that results in the destruction of transfused cells.
Intravascular destruction may be rapid, with lysis of all the transfused red cells occurring within minutes.
As a result, hemoglobin is released, producing hemoglobinemia and hemoglobinuria.
Clinically, the immediate transfusion reaction includes fever, chills, and a burning sensation at the site of
the infusion. Other common symptoms include a sensation of chest restriction, shock, and joint or low back
pain. The onset of such a reaction may occur after the transfusion of a relatively small amount of blood and
most commonly appears before the whole unit of blood is transfused.This rapid destruction of red cells may
also trigger disseminated intravascular coagulation (DIC) as a result of damaged red cell debris activating
the coagulation system. The diagnosis of an intravascular transfusion reaction is most difficult in pediatric,
unconscious, or anesthetized patients in whom the only clues may be hypotension, oozing from the
needle puncture sites, and hemoglobinuria.
The treatment of patients with an acute intravascular transfusion reaction must be directed toward the
prevention of shock and renal cortical hypo perfusion. If an intravascular transfusion reaction is suspected,
the transfusion should be terminated immediately. Vigorous intravenous fluid therapy should be initiated
and an intravenous dose of 80 to 100 mg. of furosemide (Lasix) administered.This potent diuretic increases
9 1 ag
the renal cortical flow as well as urine output. A urine output of at least 30 ml/hr should be maintained.
Oliguria following a transfusion does not always indicate an incompatible transfusion reaction.
Hypovolemia may result in hypotension followed by decreased renal output, creating a clinical picture
resembling that of acute renal failure. Other therapies for intravascular hemolytic transfusion reactions exist
but are not suitable for field use.
Febrile Reactions:The most common and least serious transfusion reaction is the simple febrile transfusion
reaction characterized by fever, chills, and malaise.These reactions are usually secondary to anti leukocyte and
anti platelet antibodies. Leukocyte and platelet antibody testing is not performed routinely. Febrile
transfusion reactions rarely progress to include hypotension and respiratory distress. Once a febrile
transfusion reaction is recognized, the current transfusion should be terminated immediately, because
there is usually insufficient clinical evidence to differentiate the simple febrile reaction from the more serious
immediate hemolytic reaction. The patient should be evaluated for possible red cell destruction. Like the
hemolytic transfusion reaction, the simple febrile transfusion reaction may be difficult to detect in infants
incapable of shivering. The only clue may be a refusal to feed, pallor, and cool skin. Unconscious and
anesthetized patients are also incapable of demonstrating or reporting the clinical symptoms of a febrile
transfusion reaction.
Allergic Reactions:Another possible immediate transfusion reaction is the allergic reaction. Immediate
anaphylactic reactions are characterized by skin flushing, laryngeal edema, chills, and hypotension. Such a
reaction occurs once in about 20,000 transfusions. In the majority of reported cases the reaction occurs before
10 ml of blood has been infused. When an immediate hypersensitivity reaction occurs in an adult, the
transfusion should be immediately terminated and the standard treatment for anaphylaxis should be
instituted. The treatment should include 1mg IV epinephrine 1:10,000 concentration, 50 mg of intravenous
diphenhydramine (Benadryl),40 mg Pepcid PO, and intravenous steroids(Solu-Medrol). Children should
receive size- related smaller doses. Patients with a history of allergies should be watched closely during
transfusions. A patient with a known history of allergic transfusion reactions should be given
antihistamines before the transfusion. Drugs should not be added to the blood.
Hypocalcaemia: (citrate toxicity): Other acute complications of blood transfusion are most commonly
associated with multiple unit transfusions. All commonly used preservative-anticoagulants for stored blood
contain an excess of citrate. One advantage in the use of citrate as a preservative-anticoagulant is that
it is not metabolized or otherwise changed during storage. When transfused the citrate is neutralized
because it is a normal intermediary metabolite. When multiple units are transfused, however, citrate can
bind enough of the recipient's ionized calcium to impair cardiac function.The clinical signs of citrate toxicity
include skeletal muscle tremors and a prolongation of the QT segment of the electrocardiogram. Higher
citrate concentrations may cause cardiac arrest. The treatment of citrate toxicity is intravenous
administration of 1 to 10 g of a 10% solution of calcium chloride. The prophylactic administration of
intravenous calcium chloride is not recommended, because of the possible toxic effects of calcium
administration and the rapid metabolism of citrate.
Delayed Reactions:The major delayed transfusion reactions may be classified into hemolytic and allergic
reactions.
Extravascular Hemolytic Reaction: The delayed hemolytic transfusion reaction results in the extravascular
destruction of red cells most often caused by nonagglutinating antibodies. Fever and chills commonly occur
but may not develop until hoursafterthe transfusion is completed. Therefore, with the onset of fever and
chills, it is important to investigate each unit of a multiple-unit blood transfusion. The reaction may not
have been caused by the unit of blood running at the time of the reaction. The diagnosis may be even more
difficult because an occasional hemolytic transfusion reaction may be a combination of both intravascular and
10 1IIII a g e
extravascular cell destruction. When either an intravascular or extravascular hemolytic transfusion
reaction is suspected clinically, the transfusion should be immediately terminated, and intravenous fluids
should be instituted. Lasix may be useful in maintaining urine flow and should be administered in a dose of
40 mg intravenously.
Allergic Reaction:The last major category of delayed transfusion reactions is the delayed allergic
reaction. Unlike the immediate type of hypersensitivity reaction, a milder reaction commonly characterized by
urticaria may occur.These reactions are referred to as anaphylactoid reactions. If an anaphylactoid reaction
occurs,the transfusion should be immediately terminated and intravenous fluids should be implemented, 40
mg Pepcid PO, intravenous steroids (Solu-Medrol), and 50 mg of Benadryl should be administered
intravenously.
Source: Peter Rosen, Emergency Medicine Concepts and Clinical Practice
DISCUSSION
• The above should only be maintained, not initiated during transport.
• Under no circumstances are these procedures to supersede the standing orders of the transferring
physician.
• In the event of patient catastrophe during transport all drips should be immediately disconnected
and medical direction sought from the receiving facility.
11 IIII a „
1 ,
Blood Product Transport Form
Patient Name: Date:
Report Number:
Instructions:All sections of this form must be completed and a copy must be left with the receiving nursing
staff.
Transferring Facility: Time:
Receiving Facility: Time:
Total transport time:
Product and Amount Infused
Whole Blood ml PTA / ml during transport
Packed Cells ml PTA / ml during transport
Plasma ml PTA / ml during transport
Platelets ml PTA / ml during transport
Were there any adverse affects? Y / N If yes, describe in report.
Transporting Paramedic:
Signature:
Sending RN:
Signature:
Receiving RN: Signature:
121Page
Goal(s):
To provide a consistent and standardized foundation for patient, provider, department and system safety.
General Actions:
• Maintain, at all times, a heightened situational awareness for patient and provider safety
PEARL I Provider safety takes precedent over patient care and apparatus
• Providers will don Body Substance Isolation protection as appropriate/necessary
• Providers will don Respiratory Isolation protection as appropriate/necessary
• Providers will be aware of legal issues and patient rights as they pertain to and impact patient care
(e.g., Patients with functional needs, Children with special needs, and Baker& Marchman Act patients)
• Providers will function within and will not exceed their defined Scope-of-Practice
• Every patient contact is to have a Patient Care Report(ePCR) unless defined otherwise in this Guideline
Basic Life Support Actions:
• Safety belts/restraints and side rails will be used during any stretcher movement in accordance with
manufacturer recommendations
• Environmental protection will be provided to all patients—Hibler's Method of Thermopreservation will
be provided to all patients in or potentially in hemorrhagic shock states
• Corneal protection will be provided to unconscious patients
Advanced Life Support Actions/Considerations:
• Be prepared to adjust management based on patient age and/or co-morbidities
• Ensure six(6) Medication Rights before the administration of any pharmacology agent:
1) Right patient
2) Right drug
3) Right dose
4) Right route
5) Right time
6) Right documentation
• Maximum weight-based dose of medication administered to pediatric patients should not exceed the
maximum adult dose except where specifically stated in a patient care guideline
• Pediatric medications are administered in accordance with Length-Based Resuscitation Tape
• Reduced medication dosages may apply to patients with co-morbidities and renal disease (e.g., on
dialysis, diagnosis of chronic renal insufficiency, severe cirrhosis or end-stage liver disease)
• Any medication errors, clinical misadventures, near miss events or unanticipated patient outcomes will
be reported immediately to the receiving physician and respective department supervisor(s)
Medical Control Actions/Orders/Requests:
• Medical Control Physicians will provide sound medical direction in accordance with evidence-based
standards. Documentation of online orders is required in ePCR.
13 : g el
Goal(s):
To provide evidence-based and reasoned logic core principles for Progressive Airway,Ventilation and
Oxygenation management.
General Actions:
AIRWAY
Airway management is a clinical mindset and a constellation of skills, tools and techniques that are deployed
to establish and/or manage non-natural airways. Airway management is not one treatment modality; it is a
progression of interventions ranging from least invasive(BLS)to the most invasive(ALS)as necessary to achieve
sufficient ventilation and adequate oxygenation.
PEARL I The primary goal of progressive airway management I's to start simple,
work through the various levels and stop when the airway is patent
PEARL I When placing an advanced airway, every effort must be made to avoid iatrogenic
The risk versus benefit relationship of prehospital endotracheal intubation must be weighed carefully.
Endotracheal intubation is associated with worse outcomes among pediatrics, closed head/traumatic brain
injuries and poly-trauma patients when compared to BLS airway care. Endotracheal intubation is also
associated with interruptions in chest compressions during CPR, which is associated with worse patient
outcomes.
Generally speaking, indications for prehospital endotracheal intubation can be narrowed to the following:
I. inability to ventilate and/or oxygenation with non-invasive tools and techniques,
II. inability to manage secretions with conventional methods,
III. high index of suspicion for laryngeal edema
PEARL I If endotracheal intubation i's required,providers will adhere to the "2 and out.",philosophy—2
laryngoscopic attempts per case to yield a successful tracheal intubation
PEARL I Airway axis alignment i's crucial to endotracheal intubation—the heads-up sniffing position
substantially increases the likelihood of obtaining a better laryngeal view
PEARL I An endotracheal intubation attempt i's defined as passing the laryngoscope blade andlor
endotracheal tube beyond the teeth with the intent to intubate the trachea
PEARL I Cervical collars can help reduce the risk tube dislodgment and
should be used with any advanced airway
PEARL I Advanced airways will be secured with the appropriate commercial restraint or
other clinically recognized technique
14 IIII a g e
The below graph illustrates the desired pathway for Progressive Airway Management:
",
"I'co,t.,�tyroldotonli,y
Advanced
a p d r b v
Head Positioning — Airway Axis Alignment
(Heead Tilt-chiLift, � ,Thrust,Sni i i siilt ' f Bed Up,Ram, n i
t
'tall �"�f>>„ll�,,.,�rM���„�„��, A iu,w,,
gUg19
VENTILATION AND OXYGENATION—AN IMPORTANT RELATIONSHIP
Ventilation is the mechanical aspect of breathing in which air moves into the lungs and CO2(normal byproduct
of metabolism) moves out of the lungs. Proper ventilation requires both adequate tidal volume and
respiratory rate.Oxygenation is defined as, "The addition of oxygen to any system, including the human body.
Oxygenation may also refer to the process of treating a patient with oxygen, or of combining a medication or
other substance with oxygen."
With ventilation serving as the mechanical means of adding oxygen to the body, the patient must have
sufficient oxygen, and the ability for that oxygen to be utilized (02/CO2 exchange). While ventilatory volume
and rate are the key components, other factors can affect whether or not the patient is being adequately
oxygenated. Even if the ventilation volume and rate are adequate, every patient must be evaluated for the
need to have supplemental oxygen delivered and the most appropriate mechanism for that to occur.
Considerations in determining a patient's need for supplemental oxygen are determined from the patient's
presenting condition coupled with History and Physical Exam.
Hyperventilation is a condition where a patient's respiratory volume and rate can create uncertainty.The lack
of adequate CO2 causes a drop in the acid levels resulting in alkalosis. latrogenic hyperventilation by
prehospital providers is very controversial for the following reason. CO2 is a potent vasodilator. When CO2
drops as a result of iatrogenic hyperventilation (aggressive positive pressure ventilation), blood vessels
constrict.When arterial vessels constrict, blood flow to vital organs is minimized. In the case of a brain injured
patient, iatrogenic hyperventilation will reduce blood flow to the injury/ischemic zone (penumbra)
15 1IIII a g e
resulting in an increase in morbidity/mortality and poor patient outcome.
When inadequate oxygenation is recognized (SpO2 <94%), it is essential to supplement the patient's oxygen
intake. Primary treatment goals for patients suffering from inadequate oxygenation include:
I. Preventing or correcting hypoxia
II. Optimizing etCO2 and SpO2
III. Minimizing the effects of secondary and/or iatrogenic injury
IV. Decreasing airway resistance
Positive End-Expiratory Pressure,or PEEP, is an effective way to improve oxygenation in patients that are non-
invasively or invasively ventilated. In patients who have respiratory embarrassment and increased work-of-
breathing, PEEP stents open closed alveoli and recruits lung thus increasing surface area for gas exchange.
PEEP also increases functional residual capacity (FRC) which improves pulmonary reserve between breaths.
In prehospital care, the range of PEEP is generally 5 — 15cmH20 (classic settings: 5, 7.5, 10, 12.5, and 15).
Providers should routinely start low and titrate as needed. PEEP is not a "if a little is good, more must be
better"theory. To that end, tight-lung patients (reactive airway disease)typically do better at 5cmH20 while
wet-lung patients(congestive heart failure/pulmonary edema) may require 7.5—15cmH20. PEEP greater than
15cmH20 can result in an increase in intrathoracic pressure thus causing a decrease in venous return and
cardiac output.
PEARL I PEEP/as contraiandicated in cardiopulmonary arrest&grossly hypotensive patients
The below graph illustrates the desired pathway for Progressive Ventilation/Oxygenation Management:
Invasive
Vet'it'�'�lat'liol,i/Oxy,,gei,iat"i,o�n
PEEP, Bag Mask Vientilation-PEEP)
N o iri,a �v a s ii v e
Veil i t l'l at l o n/O x"�,��` `���'��i i g al N ��,,'�r,
,r�� N � wI� A ,,
,'i
'J`� a��;.�"r�/���;y!t�'"A��y'1 �„N,��i'i?'V' �ir�,�f,l�;,,�"�,dJ�,%1 IN'ly"i�,d�ry�y Il��r��N f�'�,.�,����Ir {h,�l;(wig�"���W��m��,'�r,
�pp� Mask
h
",EIP,r t g
Passive Oxygenation
(Nasal Canniula, High-Filow da sail Cannula, Nion-Rebreather N11I s ,
INebulizer,, ControlIIIIed I e I nical V il,,,a,,tion, Bag Mask Ventilation)
TIr nC l Positioning I Alignment
Tilt-Chin i ;,haw gist",Sniffing Po,sitilon, 'Head,of Bed Up, Ramping)
f rated
Star `U II
t�QQ o � `f) �r�y e r�v !n�u�I,.�/fl,,,y f,,�T,.�o� M rl l„t h'r i;e� � ��Y 1„�„�r pP r l„�Jf,,.l� �s pp �, 1 Ill F J �!
I�V w. d„, e ,.w� w f rl E ,,,r�u^,G,, w 1, ,L ;,,1"4, r di
16 a g el
. Oxygenationsaturation in .
PEARL I
c Nasal
. . . . .
c patients during advanced airway management placement
VENTILATION/PERFUSION—YET ANOTHER CRITICAL RELATIONSHIP
A common pitfall in ventilation is to over-ventilate patients by providing too much tidal volume (Vt) or too
fast a minute rate (Vf). The physics that allow mammals to move air in and out of the lungs can also have a
major impact on blood circulation. When a normally breathing patient takes a breath, intrathoracic pressure
decreases allowing air to be drawn into the lungs as a result of the pressure gradient. In patients that receive
positive pressure ventilation (PPV), intrathoracic pressure is increased as the lungs are inflated.This increase
can squeeze the heart and impair filling and forward blood movement. Unregulated PPV will have a dramatic
adverse effect on circulation/perfusion. When attention is not paid to PPV volume and rate, the patient can
be harmed as a result of an imbalance between alveolar ventilation and pulmonary capillary blood flow. This
imbalance is known as ventilation/perfusion(V/Q)mismatching. latrogenic V/Q mismatching can be mitigated
by the use of controlled mechanical ventilation (CMV) devices or automated transport ventilators (ATVs).
Ventilation volume and rate should be guided by the use of waveform capnography or etCO2 in concert with
American Heart Association Guidelines.
PEARL I Supine positioning can result in a marked reduction in functional residual capacity—
Airway/Pulmonary patients should be transported in semi-Fowler-s position whenever possible
PEARL I Controlled Mechanical. Ventilation Ventilator
is preferential to Bag Mask Ventilation (BMV)
intubated patients
. .
17 IIII a g e
Foreign Body Airway Obstruction
ej Encouragecioughing- do,not interfere
Partial
Plart'llk'all or Co mplete FBAO?,
e, Re-evaluate forineffectivie cough,
inabili'tv tospeak, and/or breathe
Comlodet ---------------------------
--------------
Adult: Heimlilch Maneuver(or Chesrt
Thrustu if pregnantorob,ese) until
foreign body is expel III eed or,patiient
gots uncollISICIOUS
Hekr;.kch rNlIarieuver unb�
'Con'sc"i"Ous,
Consclous or,Unconsvious, foreigr,,i bod-,)y is ex;')elled or
pab ire rit goes ur",imV,",iscioLjs
Infant, 5 Back-Slaps, 5 Ches,"t-,
T'KrG..,ts l,ts until foreign bcady is
expelled or patient goes
U1,vcon'sc 1"0"U-6 1.1,rvc o r"i i 4c,�u s
Openand'visualize the airway,
w i en Removefoire'gr body if se
No,foreign bady present.-I
AdUlt BLS Heallthcare Prov"ider
Chiflld" Pec.,fiab,,,"ac BLS
Healtl-icare Pi,Ii:,ividei
Neot'iatal l Cardiac nl,a n�t
A r r"e,.st
—-----------
ID i r ector Video Larye 'c ''
Fareign Body Dirstodged? N o Mlagill Fore FBA emoval,,
Ab[eto,'Ven'filate?
Slurgical Criicothyrotoiivy
yes,I
.....................................
# Universal Care Guideli
Appropriate in al Guideline A-HAM. 15.1
18 ICIa g e
Differential Impressions:
• Musculoskeletal Pain (Fractures,Crush Injuries,Burns, • Neurogenic Pain (Herpes/VaricelllaZoster)
Chronic Back/Vertebral or Inflammation DiseaseProcess) • Sickle Cell Crisis
• Skin/Integumentary Pain (Burns,Soft Tissuelnjuries) • Peridontal Pain
• Ischemic Cardiac Pain (Acute Corona rySyndromes) • Severe Anxiety
• Abdominal Pain (Renal Colic/Inf lam mationDisease, • Procedural Sedation (Cardioversion,Splinting,
Cholecystitis,Diverticulitis,Bowe lObstruction) Airway/Pulmonary Management)
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Cryotherapy(for simple Musculoskeletal&Skin/Integumentary TraumaPain)
Pediatric: Cr h r p (for simple Musculoskeletal&Skin/Integumentary Trauma Pain)
Advanced Life Support Actions/Considerations:
• Promethazine 6.25-12.5mg IV or 25mg IM
PEARL I Promethazigne increases effectiveness of MS and prophylactically treats NIV
• Morphine Sulfate 2-5 mg IV/IM PRN 10 minutes.Titrate to pain relief. Max dose 0.2mg/kg
Pediatric: Morphine 0.1-0.2mg/kg
PEARL I Titrate Fluid's to hypotension caused by MS
OR
• Ketorolac 30mg IV or 60mg I M
Pediatric: I c 0.5mg/kg IV max 30mg lmg/kg IM max 60mg
Procedural Sedation
• Midazolam 5mg SIVP titrate to total sedation
Pediatric: i m 0.1mg/kg I
Pediatric:Atropine . I
PEARL I Midazolam& adequate sedation BEFORE paralytic
• Vecuronium 0.08-0.1 mg/kg IV
• Midazolam 2-5mg IV PRN to maintain complete sedation
PEARL I EtC62 waveform i's early indication of pts regaining consciousness,re sedate early
• Crystalloid Resuscitation 10cc/kg as necessary/indicated
Pediatric: r t ll i it i casnecessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
19 1IIII a g e
Differential Impressions:
• Central Nervous System origins • Neurological origins
• Digestive Tract disorder • Oncology origins
• Food poisoning/Alcohol use • Pregnancy
• Gastrointestinal distress • Psychological disorders
• Genitourinary origins • Sepsis
• Infectious origins • Stroke
• Metabolic origins • Traumatic Brain Injury
• Medication/Toxin induced • Viral origins
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Place in cool, well ventilated environment
• Reduce outside stimulus (lights, noise,motion,etc.)
Advanced Life Support Actions/Considerations:
• Crystalloid Resuscitation 10cc/kg as necessary/indicated
Pediatric: Crystalloid Resuscitationsr in is
PEARL I Maintain strict NPO status
Ondansetron (Zofran)Adult: 4mg IM or slow IV/10 over 2 minutes. Pediatric: 0.1mg/kg IM or slow IV/10
over 2 minutes. Max dose 4mg.
Side Effects: Blurred vision, dizziness, anxiety, headache
Contraindications: None
PEARL I First-line therapyfor nausea and vorniting
• Diphenhydramine 50mg IV/IM
Pediatric: iph nh r min m k I 1
PEARL I First-line therapyfor motion sickness
PEARL I Second-line therapyfor nausea and vorniting
• Consult as necessary/indicated
20 1 ag el
Goal(s):
• To provide evidence-based and reasoned logic core principles for spinal motion restriction in patients
that have sustained injury/trauma
• Rigid Spine Devices are extrication/transfer tools—not a therapeutic intervention
PEARL I Blunt-Force Trauma Alerts require a rigid spine device for ease of transfer and patient safety
PEARL I Penetrating Trauma Alerts do not benefitfrom or require a rigid spine device
PEARL I Precautionary spinal immobilization offers no patient value;may result ion iatrogenic ionjoury
Basic Life Support Actions:
IH R1sk Pafigl t Criteria Yes
C-Collar/c�e icali lotion Restriction
• t,,w' �`c e T i i �i ,rt ,
Scoop r Long Sine Board
Occipital Padding as, necessary
No
t Risk Pat"I"en't..Criteria
• It r Ie t�al� S t s CS < yes ol'lar e call Motion Restriction
Lacks Decisional aci , Transport insition L f comfort
f
• Neurolloglical efi" its
• Distraicting,Injury?
• Alcohol/Drug Im I ,s iir, ie it'°
ICI
;I
No
C-Collar/Ceiical Motioni Restriction
i t, Ilic. to or require
• Transport, if necessary, in,position of
LE O.Im foll nt,
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
21 a g el
Goal(s):
• To establish a guideline for the management and documentation of restraining patients
• Primary consideration: The use of patient restraints is authorized in all instances where a patient's
behavior may jeopardize the safety of the patient or crew
• Secondary consideration: Restraints may be used when a patient lacks decisional capacity to make
rational decisions and exhibits behavior that may disallow necessary medical treatment
General Actions:
• Crew safety—Escaping Violent Encounters (EVE)
• Request law enforcement
PEARL I Carefully evaluate the risk-benefit of mechanical patient restraint versus
chemi'CallpharmacologifCal restraint
• When appropriate, attempt less restrictive means of management including, verbal de-escalation
• Excited Delirium Syndrome Guideline as necessary/indicated
Patient Positioning
• Patients will be restrained in the supine, head-up position
• Patients may be restrained in a lateral recovery, head-up position as an alternative
• Patients will be mechanically restrained using a commercial soft restraint system or, if in custody,
hand-cuffs or shackles as deemed appropriate by law enforcement
• Patients will not be restrained in the prone position
Assessment and Documentation
• When a patient is restrained, the restraints shall be placed only tight enough to secure the extremity
without compromising neurovascular function. Distal neurovascular function shall be checked and
documented after application and every 10 minutes thereafter using the following test procedures:
❖ Grip strength—should be equal and strong on most patients
❖ Sensations—upper and lower extremities must have good sensations and absence of numbness
❖ Capillary refill—upper and lower extremities must result in a capillary refill time of less than 2
seconds
• The reason for restraining a patient and the results of all the above tests shall be documented in the
patient care report
• Grip strength, sensation and capillary refill tests are to be performed and the results documented every
10 minutes
• In the event of a short transport time,the results of a minimum of 2 sets are to be documented with
one set to be completed upon arrival at the receiving facility
Hospital Notification
• The receiving facility shall be notified prior to arrival that a patient is in restraints and security should
be available upon arrival
22 IIII a g e
Goal(s):
• First consideration: patients shall be transported to a local facility of their choice
PEARL I Informed consent i's key to delivering the right patient, to the right ...
the first time
• Second consideration: patients should be transported to the closest appropriate facility for treatment
of their primary illness and/or injury
General Actions:
• Mode of transport (ground, air or water) is determined by the highest medical authority providing
direct patient care; it should not be determined by any other emergency responder(s), bystander(s), or
family member(s)
Refer to Aelr Medilcal Transport Guildelilneia*lr mode of transport
• Status of transport (lights and siren use) is determined by the EMS Transport Provider with the highest
medical authority providing direct patient care.The decision to run lights and sirens should be justified
by the need for time sensitive medical intervention that is beyond the capabilities of the transport unit.
PEARL I Provider and public safety takes precedent over patient care and apparatus health
• Regionalized systems of care and/or specialty care centers (e.g., STEM {ST Elevation Myocardial
Infarction}, Stroke,Trauma, etc.) may necessitate transport to a hospital beyond the nearest facility
Refer to Specilalty Care Center table
❖ CardioPulmonary Arrest: Patients, regardless of age, who are transported in CardioPulmonary
Arrest or deteriorate to CardioPulmonary Arrest in transit, shall be transported to the closestfacility
•:� Cardiac:STEMI Alert,Acute Coronary Syndrome(ACS), and Return of Spontaneous Circulation
(ROSC)patients should be transported to the closest STEMI/Percutaneous Coronary Intervention
(PC/)facility
•'• Stroke:Stroke Alert patients should be transported to the most appropriate Stroke facility based
upon the clinical differential(Primary versus Comprehensive Stroke Center) as determined by the
Florida Stroke Triage Checklist
•'• Trauma: Trauma Alert patients, regardless of age, shall be transported to the closest trauma
center
•:� Adult Orthopedic:Adults with simple extremity fractures(SEFx) or dislocations may be transported
to any facility
Pediatric Orthopedic- Children withtr.., it r r s EF )or dislocations, excluding
the elbow, may be transportedci i
PEARL I SEFx=isolated, closed, distal extremity(below the elbow or knee)fracture or
dislocation without neurovascular compromise or need for surgical intervention
PEARL I Elbowfracturesldislocations in children are not considered SEFx
23 ag e,
24 a g el
❖ Adult Orthopedic Surgery:Adults that may require orthopedic surgery or have a neurovascular
injury should be transported to the closest adult orthopedic admitfacility
Pediatric Orthopedic Surgery: Children that may require orthopedic surgery should be
transported to the closest pediatric orthopedic admitfacility
❖ Adult Medical-Surgical:Adults that have a high probability for general medical-surgical admission
(GMSA) can be transported to any facility
I Ped' I atr*c Medical-Surgical- Children that have a high probabilityfor general medical-surgical I I
admission (GMSA)should be transported to the closest pediatric admiffacility
PEARL I Pediatric GMSA=possible appendicitis, bowel obstruction andlor
❖
any signs of peritoneal irritation
Obstetrical/Gynecology: High-risk obstetrical patients shall be transported to a neonatal intensive
care facility
PEARL I Patients with an imminent obstetrical emergency shall be transported to the
closest OBIGYN facility
• Freestanding Emergency Departments are becoming more prevalent in the community. Freestanding
EDs are licensed through the Florida Department of Health but their ambulance reception capabilities
can vary from facility to facility.
• The EMS Transport Provider shall advise the receiving facility, as early as possible, of a patient en-route
to that facility. The typical receiving facility notification should include the following patient
information in a clear and concise manner:
❖ Priority
❖ Age and gender
❖ Chief complaint
❖ Current condition
❖ Vital signs; including AVPU/GCS, ECG,Temp, Sp02 and etCO2 values
❖ Pertinent assessment findings
❖ Any prehospital diagnostic test results and pertinent treatment rendered
• A comprehensive list of Florida Trauma, Cardiac, and Stroke Centers is located in appendix
25 a g el
Goal(s):
• To provide a guideline for the use of air medical transport
• Primary consideration: Air medical transport should be used when a critically ill and/or injured patient
will benefit from faster transport and reduced out-of-hospital time
General Actions:
Procedure&Criteria
1. Place "air medical transport" on standby when:
A. Call information obtained by Dispatch suggests the need for air medical transport
2. Request "air medical transport"within the first 2 minutes of patient contact for:
A. Priority 1 scene patients that would benefit from air, if drive time exceeds (helicopter ETA+
15minutes for landing and takeoff+flight time to destination)
B. Priority 1 or 2 patients that are inaccessible by roads (e.g., remote wilderness areas and
bridgeless barrier islands)
3. Offer to give air crew brie report while they're in the air, so they can bring necessary
equipment
Landing Zones(LZ)
4. Fire department personnel are responsible for preparing/securing LZs and assuming the LZ
Controller role
5. It is necessary for fire personnel to separate themselves from the EMS operation as soon as
possible in order to begin LZ preparations
A. All LZs should be a minimum of 100'x 100' (day or night)
• LZs must be illuminated at the corners with strobe and/or a steady-burn light source
• Hard surface LZs (highway, parking lots, etc) are preferential to soft surface LZs
B. Once established,the LZ Controller will ensure LZ security the duration of the event
C. When requested by the pilot,the LZ Controller will provide a LZ report.This report should
include the type of LZ (hard versus soft surface),wind direction and speed and any potential
hazards that may be identified from the ground (wires,fences, signs, etc.).
6. After the patient has been loaded in the aircraft, the pilot will advise the LZ Controller that the
aircraft is ready to depart.The LZ Controller should clear the aircraft for take-off by looking
around the LZ and to the sky for any other aircraft traffic in the vicinity.
7. If at any time the LZ becomes unsafe for takeoff or landing, the LZ Controller will transmit
"ABORT, ABORT,ABORT" over the radio and halt the operation until the unsafe condition is
corrected.
PEARL I Ground to air radio traffic should be limited to LZ information only—no patient information
26 IIII a g e
Transfer of Care
• Prepare patient in treatment area or, preferably, in the ambulance
• Complete a paper run report with as much information as conditions allow
• Relay assessment findings and care provided to the Air Crew Members (ACM)
• The primary ACM will immediately assume team leader role and assume and/or direct the remaining
patient care issues and treatment modalities
• The ACM will perform an appropriate patient assessment and determine the need for further
emergent treatments based upon flight physiology
• The ground crew will follow directions from the flight team regarding the transfer and loading of the
patient from the scene
PEARL I Transfer of Care between the non-transport and the transport providers
is essential for good patient outcome
27 IIII a g e
Goal(s):
• To establish a guideline for the management and documentation of situations in where patients or
potential patients refuses evaluation,treatment, and/or transportation to a hospital in accordance
with state and local statute
General Actions:
Definitions
• Patient: a patient shall be defined as an individual who meets one of more of the following criteria:
❖ Any individual with a medical or traumatic complaint
❖ Any individual with an illness or injury
❖ Any individual with a new altered mental status
❖ Any individual in the same event as a significantly ill and/or injured party(e.g., motor vehicle crash,
structural collapse, explosion, toxic fume environment, etc.)
❖ Any individual who, at the discretion of the highest medical authority providing direct patient care,
demonstrates a high index of suspicion for illness or injury (EMT or Paramedic judgment)
• Responsible Party: a designated decision maker (DDM) when a patient is not of decisional capacity or
has legally transferred their healthcare decision making to another party(legal guardian, power of
attorney, healthcare surrogate, etc.)
• Unable to Locate or No Patient Found: unit arrives in the vicinity of a given location but no event or
Person Involved (PI) could be found could be located
• No Care Required: unit arrives on-scene and the Person Involved (PI) does not meet"patient" criteria
• Treated, No Transport: unit arrives on-scene, makes contact with the Person Involved (PI),the PI is
determined to be a Patient, an evaluation and/or intervention is performed and the Patient ultimately
declines to be transported to a hospital (Patient Refusal Form required)
• Treatment and Transport Refused: unit arrives on-scene, makes contact with the Person Involved (PI),
the PI is determined to be a Patient ultimately refuses evaluation,treatment and declines to be
transported to a hospital (Patient Refusal Form required)
Refusal of Care
• There are three components to a valid refusal of care. In the absence of any of these components,the
refusal can be deemed legally invalid;thus, resulting in high liability for the providers,their respective
department and their respective medical director. The three components are:
❖ Competence: 1)Any patient who is of adult age (18 years of age or older) or legally emancipated is
competent to refuse care. 2)A parent or legal guardian (responsible party)who refuses care on
behalf of their minor child (or children).
•:� Decisional Capacity: Any patient who is Alert& Oriented x4 (person, place,time and situation)
with the ability to understand the nature and consequences of their actions by refusing evaluation,
treatment, and/or transportation
•'• Informed Refusal: Patients must be fully informed about his/her medical condition,the risks and
benefits associated with the proposed treatment and the risks associated with refusing evaluation,
treatment, and/or transportation
28 IIII a g �
Emancipation
Medical: A female less than 18 years of age who is unmarried, pregnant and/or has a minor
child may consent to medical care relating to her pregnancy and can make medical decision on
behalf of the unborn or born child.
•'• Legal:A person less than 18 years of age but at least 16 years of age who is married, enlisted in
military service or has been declared emancipated by court order
Patients able to refuse care
1) Must be competent
2) Must have decisional capacity
3) Must be informed of the risks associated with refusing evaluation,treatment, and/or
transportation
Patients not able to refuse care
1) Incompetent—less than eighteen (18)years of age or not legally emancipated
2) Lacks Decisional Capacity—not acting as a "reasonable person would do,given the same
circumstances"
3) Altered mental status (e.g., head injury or under the influence of alcohol and/or drugs)
4) Suicidal ideations or gestures
5) Mental defect, disability or deficiency(e.g., mental retardation)
6) Severely altered or impaired vital signs
Implied Consent
1) If a patient is determined to be incompetent and/or lacks decisional capacity,they may be
evaluated, treated and transported under"implied consent" (what the reasonable individual
would consent to under the same circumstances)
2) If the patient is evaluated,treated and transported on the basis of implied consent, providers
should use reasonable measures to ensure safe transport to the closest appropriate facility
Refusal of Care Procedure
1) Perform a Primary Assessment, History and Physical Examination; including a complete Vital
Sign Assessment
2) Fully inform the patient or responsible party about his/her medical condition,the risks and
benefits associated with the proposed treatment and the risks associated with refusing
evaluation,treatment, and/or transportation
3) Ensure the patient or responsible party fully understands the potential consequences of their
decision
4) Attempt to convince the patient or responsible party to consent; including enlisting the help
of family or friends
5) Reattempt to convince the patient or responsible party to consent; including enlisting the
help of family or friends
6) If the patient or responsible party continues to refuse:
a. complete a Refusal of Care in its entirety,
b. obtain the patient's or responsible party signature
c. obtain a witness name and signature
7) Where it is possible, patients will be left in the care of family,friends, or responsible parties
PEARL I All patient contact results in either a transport or a completed Refusal of Care
29 IIII a g
Goal(s):
This protocol is divided into three separate sections that cover the different situations involving death in
the field that the paramedic will encounter.All patients found in cardiac arrest will receive
cardiopulmonary resuscitation unless an exception is met as outlined in the following sections:
I. Advanced Directives/Do Not Resuscitate Orders (DNRO)
II. Determination of Death
III. Discontinuance of CPR
General Actions:
ADVANCED DIRECTIVES/DO NOT RESUSCITATE ORDERS(DNRO)
Legislative authority. Under Florida Administrative Code (FAC) 64J-2.018. Do Not Resuscitate Order
(DNRO) Form and Patient Identification Device.
1. An EMT or paramedic shall withhold or withdraw cardiopulmonary resuscitation:
a. Upon the presentation of an original or a completed copy of DH Form 1896, Florida Do Not
Resuscitate Order Form, December 2004,which is incorporated by reference and available
from DOH at no cost, or, any previous edition of DH Form 1896; or
b. Upon the presentation or observation,on the patient,of a Do Not Resuscitate Order patient
identification device.
2. The Do Not Resuscitate Order:
a. Form shall be printed on yellow paper and have the words "DO NOT RESUSCITATE ORDER"
printed in black and displayed across the top of the form. DH Form 1896 may be duplicated,
provided that the content of the form is unaltered,the reproduction is of good quality, and
it is duplicated on yellow paper.The shade of yellow does not have to be an exact duplicate;
b. Patient identification device is a miniature version of DH Form 1896 and is incorporated by
reference as part of the DNRO form. Use of the patient identification device is voluntary
and is intended to provide a convenient and portable DNRO which travels with the patient.
The device is perforated so that it can be separated from the DNRO form. It can also be
hole-punched, attached to a chain in some fashion and visibly displayed on the patient. In
order to protect this device from hazardous conditions, it shall be laminated after
completing it. Failure to laminate the device shall not be grounds for not honoring a
patient's DNRO order, if the device is otherwise properly completed.
3. The DNRO form and patient identification device must be signed by the patient's physician. In
addition, the patient, or, if the patient is incapable of providing informed consent, the patient's
health care surrogate or proxy as defined in Section 765.101, F.S., or court appointed guardian or
person acting pursuant to a durable power of attorney established pursuant to Section 709.08, F.S.,
must sign the form and the patient identification device in order for them to be valid. The form
does not need to be notarized, once signed the form does not expire.
4. An EMT or paramedic shall verify the identity of the patient who is the subject of the DNRO form
or patient identification device. Verification shall be obtained from the patient's driver license,
other photo identification, or from a witness in the presence of the patient. If a witness is used to
identify the patient, this fact shall be documented in the EMS Run Report, which must include the
following information:
a. The full name of the witness
30 IIII a g e
b. The address and telephone number of the witness
c. The relationship of the witness to the patient
5. During each transport, the Providers shall ensure that a copy of the DNRO form or the patient
identification device accompanies the live patient. The Providers shall provide comforting, pain-
relieving and any other medically indicated care, short of respiratory or cardiac resuscitation.
6. A DNRO may be revoked at any time by the patient, if signed by the patient, or the patient's health
care surrogate,or proxy or court appointed guardian or person acting pursuant to a durable power
of attorney established pursuant to Section 709.08, F.S. Pursuant to Section 765.104, F.S., the
revocation may be in writing, by physical destruction, by failure to present it,or by orally expressing
a contrary intent.
7. Oral orders from non-physician staff members or telephoned requests from an absent physician do
not adequately assure EMT/paramedics that the proper decision-making process has been followed
and are NOT acceptable.
8. In the event of death of Hospice pt,transport should be continued to receiving Hospice house.
Specific Authority 381.0011,401.45(3)FS.Law Implemented 381.0205,401.45,765.401 FS.History—New 11-30-93,Amended 3-19-95,1-26-97,
Formerly 10D-66.325,Amended 2-20-00,11-3-02,6-9-05,Formerly 64E-2.031.5.
DETERMINATION OF DEATH
The EMT or paramedic may determine that the patient is dead/non-salvageable and decide not to
resuscitate the patient under the following guidelines.
A. The patient may be determined to be dead/non-salvageable and will not be resuscitated or
transported if all four(4) presumptive signs of death and at least one (1) conclusive sign of death
are identified.
1. The four presumptive signs of death that MUST be present are:
a. Unresponsiveness
b. Apnea
c. Pulseless
d. Fixed dilated pupils
2. In addition to the four presumptive signs of deaths, at least one (1) of the following
conclusive signs of death MUST be present:
a. Injuries incompatible with life (e.g., decapitation, massive crush injury,
incineration)
b. Tissue decomposition
c. Rigor mortis of any degree with warm air temperature. (Hardening of the muscles
of the body, making the joints rigid)
d. Liver mortis (lividity) of any degree (venous pooling of blood in dependent body
parts causing purple discoloration of the skin,which does blanch with pressure)
3. Patients with suspected hypothermia, barbiturate overdose, or electrocution require full
ALS resuscitation unless they have injuries incompatible with life or tissue decomposition.
4. Providers may contact medical direction for a "determination of death"whenever support
in the field is desired. Clearly state the purpose for the contact as part of the initial hailing.
5. Children are excluded from this protocol unless EMS personnel make contact with medical
direction for consultation. Only in cases of obvious, prolonged death should CPR not be
started or discontinued on infants, children, or young adults, or in cases in which an
unexpected death has occurred.
B. A trauma victim who does not meet the "Determination of Death" criteria listed above may be
determined to be dead/non-salvageable based on the following criteria:
31 IIII a g e
1. Pulselessness and apnea associated with asystole (confirmed in two leads) and
a. Blunt trauma arrest
b. Prolonged extrication time (more than 15 minutes)where no resuscitative
measures can be initiated prior to extrication
• An additional rhythm assessment is required, followed by at least one
reassessment after 15 minutes
c. Arrest from primary brain injury or with no brain stem reflexes; arrest from blunt
multiple injuries
2. If there is any concern regarding leaving the patient at the scene, begin resuscitation and
transport.
3. Consideration should be given for the possibility of organ harvest; however,this should not
be the sole reason for resuscitation.
C. Absence of pulse or spontaneous respiration in a multiple-casualty situation where EMS resources
are required for stabilization of living patients.
PEARL I The local law enforcement agency that has Jurisdiction will be responsible for the body once
death has been determined. The body i's to be left at the scene until a disposition has been made by the
Medical Examiner's Office or the locaijurisdiction.
DISCONTINUANCE OF CPR
A. Resuscitation that is started in the field by EMS personnel cannot be discontinued without an order
from medical direction. EMS personnel are not obligated to continue resuscitation efforts that were
started inappropriately by others at the scene. However, contact with medical control is necessary
to cease resuscitative efforts in ALL situations.
considerationPEARL I Resuscitations involving pediatrics and emergency serw'ces personnel are highly charged and
emotional—careful .
B. When there is a delay in presenting a DNRO to EMS personnel, resuscitation must be started.
However,once the DNRO is presented to EMS personnel,the EMT or paramedic with an order from
medical direction may terminate resuscitation.
C. A paramedic with an order from medical control may terminate resuscitation provided the
following criteria are met:
1. Appropriate BLS and ALS have been attempted without restoration of circulation and
breathing.
2. Advanced airway has been successfully accomplished.
3. Intravenous (IV, 10, ET) medication and countershocks for ventricular fibrillation have been
administered according to the appropriate treatment protocol(s) (see Adult Protocols or
Pediatric Protocols).
4. Persistent asystole or agonal ECG rhythm patterns are present and no reversible causes are
identified.
5. Patients with suspected hypothermia, barbiturate overdose, or electrocution require full
ALS resuscitation, unless they have injuries incompatible with life or tissue decomposition.
PEARL Unless deemed a crime scene,place of business resuscitations will not be terminated in the field
.®
retail stores,restaurants,places of worship,etc.)
PEARL I Matemal resuscitations(pregnancy>24weeks)will not be terminated in the field
D. Provide appropriate grief counseling or support to the patient's immediate family, bystanders, or
others at the scene.
1. Provide family members with appropriate referral information, if available.
32 IIII a g e
E. Deceased patient preparation:
1. Once death has been determined and resuscitation will not continue, cover the body with
a sheet or other suitable item. If the death is a suspected homicide (crime scene), do not
cover the body. Do not remove any property from the body or the scene for any purpose.
2. Immediately notify the appropriate law enforcement agency (if not done already), and
remain on scene until their arrival.
Examiner'sPEARL I The local law enforcement agency that has Jurisdiction will be responsible for the body once
death has been determined. The body is to be left at the scene until a disposition has been made by the
Medical
3. Contact the Medical Examiner's office: Consult with local law enforcement for appropriate
district contact.
4. Complete an electronic patient care report (ePCR) as soon as possible, documenting the
previously mentioned criteria, and post or upload the ePCR for retrieval by the Medical
Examiner's Office.
5. In the absence of an ePCR program linked to the Medical Examiner's Office, the ePCR can
be faxed or emailed to the Medical Examiner's Office
6. ECG rhythm strips or ECG electronic file must be attached to the ePCR.
7. Advanced airway placement may be verified by two paramedics for patients who are
determined to be dead in the field or for whom resuscitation measures have ceased. The
advanced airway should be left in place and its confirmation should be recorded on the
ePCR. Improperly placed advanced airway tubes should be left in place and reported to the
appropriate personnel (proper advanced airway tube placement must be confirmed prior
to terminating resuscitation).
8. Consult the patient's family for"organ donor" information, if appropriate.
33 ag el
Goal(s):
To provide a consistent and standardized foundation for triage and treatment of mass casualty incidents.
General Actions:
• If first on-scene, ensure radio transmitted scene size-up prior to exiting vehicle
• Establish Incident/Unified Command
• Perform a Needs Assessment based upon:
o Level 1 MCI: 6—10 Patient Transports
o Level 2 MCI: 11—20 Patient Transports
o Level 3 MCI: 21—100 Victims
o Level 4 MCI: 101-1000 Victims
o Level 5 MCI: 1000+Victims
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Perform START or JumpSTART
o R— Respirations
o P—Perfusion
o M—Mental Status
Advanced Life Support Actions/Considerations:
• None
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
34 ag el
t / Triage
CAN YOU YES Usingthe JS algorithm,
WALK? / evaluate all chgdren first
NO eir awn po u,
first
'Ing I NO Plost111010 1UPperrAirway
I� HING
SREAT si
BreathW'r�'�II�,,n� rp,, },i entire JS algotilthm
APNEIC
ADULT
HASA
NO PULSE
PULSE
I #EDINeurological Assessment
YIE
�� �
�� d l�
Responds, o
ADULT 30 Resp Respoinds,to
. � �t il� Painful
t PEDI Ul iiloiv
IS-46 PEDII ADULT
INIO PALPASLC PULSEI
JA
YES P T POSTURING OR t#WG
I ntal o-i
T OBEY COMMANDS PEDIATRIC
Stamus I? ADULT
" If" 71 OR " 'A RIB,
*'I ww.Starttr ............... '' Cole
��. .... . �� ..:.... ....... .....
35 IIII°
Goal(s):
• To establish procedures for Emergency Services Personnel Rehabilitation
• Primary consideration: Emergency operations require significant physical activity, but no personnel will
be required to perform emergency operations beyond safe levels of physical or mental endurance
• Purpose:This guideline is intended to examine and evaluate the physical and mental status of emergency
services personnel working on an emergency incident or a training exercise and determine which
treatment, if any, is necessary/indicated
General Actions:
Responsibilities
• Emergency Services Personnel (ESP):
1) Are responsible for reporting to the Rehab Group when ordered to do such by a commanding
officer
2)To advise the commanding officer when any member of his/her crew is in need of Rehab.
• Incident Commander (IC)/Unified Command (UC): Must ensure all personnel receive the proper rest,
refreshments, medical evaluation, monitoring, and clearance
• Rehab Supervisor(RS):
1) Is ideally led by a paramedic
2) Reports directly to the IC/UC and the Incident Safety Officer(ISO).
3) Function includes:
■ Report to the IC/UC and obtain rehabilitation requirements
■ Locate and establish a rehab site
■ Identify the EMS requirements and request additional personnel to assist as required
■ Provide required resources for rehabilitation
■ Check vital signs, monitor for heat stress, and signs of medical issues
■ Provide medical care and transportation to medical facilities as required
■ Inform the IC/UC and ISO when personnel require transportation to the treatment at a
medical facility
■ Ensure documentation of any medical care provided
a. Any and all injuries will require a Patient Care Report to be completed
Establishment of the Rehab Group
• Location:
1) If a specific location has not been designated, the RS shall select an appropriate location
based on site characteristics and designations such as fire apparatus, ambulance, nearby
garage, or make-shift rehab structure.
2) The RS shall notify the IC/UC where the rehab area has been established
• Site Characteristics:
1) Preferably upwind
2) Far enough away from hot zone/tactical area that members may safely remove their Personal
Protective Equipment (PPE)
3) Large enough to accommodate the number of personnel expected with a separate area for
members to remove PPE
36 IIII a g e
4) Preferably shaded; protected from elements
5) Away from exhaust fumes
6) Provide access to SCBA/SCUBA replenishment/refill equipment
7) Easy ingress and egress for ambulance traffic
8) Able to accommodate prompt re-entry back into the operation upon complete rehabilitation
9) Away from spectators and the media
• Resources:
1) Fluids/food—potable drinking water, sports beverages, ice,food, and snacks
2) Medical monitoring equipment
3) Tarps
4) Water supply for active cooling(wet towels, misting fans, ice vests,forearm immersion chairs)
5) Blankets and warm, dry clothing for winter months
6) Chairs (if available)
Rehab Procedure
• Entry:
1) Collect accountability passports)/tags and place on status board
2) Log names
3) Dress-down incoming personnel
4) Assign to the seating area
PEARL I Have high index of suspicions for and be prepared to act on Life Threatening Signs&Symptoms
• Initiate Cooling:
1) Passive
❖ Removal of PPE
❖ Remove to a cooler environment
2) Active
•'• Cold packs
❖ Cool, wet towels
❖ Forearm immersion
❖ Misting fans
•'• Ice vests
• Begin Hydration:
•'• Water/fluids
PEARL I Avoid caffetone and carbonated beverages
• Rest time:
❖ Minimum: 10 minutes
✓Normal Vital Signs, may be released
✓Abnormal Vital Signs, 10 additional minutes in rehab
✓Abnormal Vital Signs, move to Medical Treatment Area
• Release:
1) ESP that cannot be cleared shall be reported to the IC/UC and ISO
PEARL I The RS and ISO retain final authority to ground any ESP
2) All ESP departing rehab shall retrieve their Passports from the RS
37 IIII a g e
I 1 9 D AN a 0 As 0 0 Ab
Adult, Basic Life,Support Algorithm for Healthcare Providers,
ve!'rity'sclowtv S41,6ty.
..............
Cheolk,f or resp*rvsivenesss.
Shout for no.wby, help.
Activate em,ergency response,
systemvia,mobfle device
01f,ajvro,P,,rl at4j,
Get AIED and,metgeoq equippment,
Orse, someonotoldOSO,
................................................................................................
narmal Provkfe,re,stwuo,bitroathlogm,
1 breath(,,Yve,�ry 6twiciorxis,ot
brivathing, birealt,"hiiim,
L ovk tot,no 1,vowwO I On
MM Ipulse folt 1 1,Aj t
for ondyq an d ch o c,k,
I ) ,Osping
J Chock pufseevery,2 movto%,
Offlkerfjl OXIC PW60(S"IfoultaneOU164,Y).
y
e Is pWise,doftaltoly,f oft
f sl vo
e o;Aoidordoso,
sit poit,;
r low
mo, x m It
No breathi n9g,
or onty glasping,01
pulse notfall"t
Ry't'hi'ssuirmt it)al!sci�,j nm lof';,
or Ibaaup ctivated"
andAEO e1quiperiv,nt afte,
.......................................................................................................... rot rievttd �i!�
Start,,CPIR
2 twooth's.
U,so,AED as,s"Mot as It isavaAW,
.....
AED,a,(otve&.;/.
SIR),40ka,No rhy
Yes,
shockable nonshackable
...............................
L * 04w 11 tsbock.Rostirine OPR Reswurne CPR,kvmine,di ahwAy for
Imumsdiately for 2 miritutes 2 ris"i Irml: (0 n U 1j),r(xTayt)1t,ed 1:)y AEED
WWW pro,mm iAe,d by,AE D We 11ow, rhythowcheic;,k).
CoM, µuotll ALS providers,tak a
* totwttnuo us)WALS,Pr),,ovidors take, 0"1 Ot victim,sta(ts to Owo�
ovef ot vfI( starts to move.
,020,20 Amort, ,art 0f(ratt As"isoc ski lon
38 a g el
BLS, Healthcare Provider
PediatHe Cardiac ArrestAlgorithm it i I '2 ar, More I Iers-20,15 Update,
Shoutfrot",nearby help.
Second rescuer activates en'tiergiency
'I breath every 3-5 secmdsi,,or
. .., ... No normial - d ll
bro
�L o r ono � t � �m I i , remains��," I signs, r
M onit or un t i I has pulse or only gaspingand check has, pulse of
��
I
Ns
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NN.uN u.NUNNUNN NUNNUNNu„NUNNUNN.,, ( ' mkiut .
w
withv
(�ontinue rescue,,I thin I;
ot,mck utf vY
No bmath1mg 2 r7ift It fw, Sul ' I I 1
or
l" Indbox" ,
Firstrescuer beglins CPR withI
r t' '(compressions to brI ' t. i
15:2 ratio(compressifonsto breaths).
When second rescuer retums, use.
it o ;; as, ,III to
r
.uw,wmwrororrororrororr�orormcaormcaowirorrcr�rrcr�rrcr�rrcr�rrcr�rrcr�rrcr�rrcrorrcrorrcroracroracrJcrrrcrorrcrormcrormcrormcrormcroracrorrcrormcrormcrormcrormcrormcrorrcrurJJu worJorJarJJarJJirJJifmifrir�rJir�rJir�rJir�rJir�rJir�rJirJorJorJorJorJor�rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJc��rJ�rJ�fJwofmifmifm..
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r �N�
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shodkia'ble \nn lop�n sh ac f
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Give shock. Imo- C R uI Ie CPR immediately fI I
I "' t ` , ,�^l G e' abOtlt 2 minutes, ill priampted
(until p'rompted �ill aflow,rhythmcl,heck).
rhythm tfff�Y�jj nue rr ;;dddd ALS providerstake
orvictimstarts,to rnOV101.
39 a g el
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' I 1,
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Actirvateemergen,icy response,
via''Mobile,device
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40 ICI a g e
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............ ,,.,.%or elvem y 2 mfnutes.lot solone r its`tte t trill,
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r,i1plo °' * "wa" °'
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m CPIR'cttaiv,
r
r
I� r
,hock Epinephrine
S r
u
faclur Of
in
Jf � i HN
i
4
A
� rr,r,✓,a i„oaivo,,,�w
,
At
( h riao MOO dotsalol
Yes
Y of < PhythmIW?
Amu,' ,,
Shalck
' .. !p�"�e^
' II
r
CAI'
i
advameetlakway, ,
I I
flyes
Shock, n,
)aridtw
r
cr.
I, r U i"�I ' f',Aij, I , ;, - � f'' �revef '� Y r' '` t. ��V"I. I�t^r"�'����ll��'"'�v�f'r',sJ�"'�m,'� I�oil,�,,Q��,`iiU 7�G r 1Vi �,1 i'S
� r � r �,
r
ff r
yowl"
r �0 i
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ssi ' e�: °, O pro' , ' T>fx'
"
pitilthmonwry
It Flose,go to
Post-Card,
r 3r o, c* *
(`; "n�a '
e I ,
42 a g el
Pediatric Cardiac Arrest Algiorithm
Start CPR, 1���iuiui MAZIP11PROMEM
Begin bag-maskven'tilation and give oxygen # Pusl,,i hard(2�16 of anteroposterior
Attach m,onitor/de"fibri""I'Illiato,r, diameter,of chest)andl feet
—...................................................................................."I...................................................................................-0.) (100-1 20/aiin)and allow coniple'te,
chest recoil
Minimize interruptionsib
'Yes Rhythm N1,1\11N No compressions,
Change compressor every
shocka,bile' 21 minutes,or sooner if fatigUed
If no advanced airway',15:2
.............................. 9 )l coi7nip,Irerssieintilrilt1on ratio
11....... V,FlpVT 7 Asystole/PEA If advanceld airway,provide
-------------------- ---------------------- .................................................................. continuous cornpressions,l
give a breath every-2-3,sleconids
3
Shock Epin�iephrine # First sholclk 2 J/kg
ASAP # Sletond shock 4 J/k,g
4 ..................
# Subsequent shocks.>c4J/kg,,I
CPR 2,min CPR 2 Min rnaximUrTI 10 J/kig or adult dose,
IWO access I'V/10 acicess
Epinephrine elvery,3-5 Min
Clonsider,advanced # Epinephrine 11VAO,dose:
afrwa: and capno,igraiphy 0.01;nig/kg(0.1 mll-ft of the
0
............... I mg/mL concentration).
!Nlo Max dose 11 m1g.
Rhythm Repeat every 3-5 mitiules.
shockable? If nlo IWO access,may glive
-------- ly, endotra6heal dose:01 mgi/kg
Yes Rhyth!m es (01 niUkg of the 1 rng/mL
,,shocka1b1,e? concentration),.
Shock Amiodarone IV/10 dose:
5 mgAg bloWs,during cardiac
No arrest.May repeat up to
(6 .................................,...-....................... 3,totlal d1loses,for refractory,
VF/pulseless,VT
CPR 2 min
Epinephrine every 3-5,min o ridocainie 1W10,dose:
Consider advaniceida"I"irway
CPR 2 in Initial:` tng/kg loading dose
T reat reversible causes
"Ofl/ Rhythmi I No End'otracheal irItUbation or
supraqlottic�advainced airway,
Shockable? Waveform capno,graphy or
capnometry to confirm and
!N�o Rhythm yOls
'Yes mlonitor tube,placlement,
7 Shock
Hypolvolemit-,i
8 �I
� �u
Hypoxia
MIN=
Hydrogen win(,aeidosis)
CPR'2 mlin
Amiodaroneor,1111docatne, 0 Hypoglycernia
Treat reversible causes # Hypo-/hyperka[eniia
# Hypothermia
# Terision pneumothorax
0 Tarnponade,,cardiac
# T6xins
(1121)...............................------------------------------------------------------------------------- # Thrornbosis,,PLOnionary
If nosigns of rieturn,of spontaneous Goto 7 # Thrombosis,clorionary
circulation(RIOSCI,go,to,1110 ...............................................
If ROSC,go,to Post-Cardlac Arrest
Care c �eckllst
202,10 American Heart,Associatioln
43 a g el
y
f
Neonatal Resuscitation Algorithmi
Birth
1 r r t M ittothot
r We
mor: i
,
m and,ml alotain norrnW
gomstj
ol'od W00,117, lito 1 �M Cloor
r
y.%v/a/oi//i/v�i/io//Ga 10,Aar
1�1 v
No
0 1 i
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„
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oe
//ai,r,//,iri//i�rrrnir.tu/ ru r�/r7i rr r/i,//i,«,mi1l� /mmmirrrnaai,mimomm//iriiia2aawrr/uwi9�iiarwo,rrrorr/r/�U��aoia//ii��ai�aiivr�/�
US
ra
ji
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r Ir ,
r � j
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r/r// rrrrrrrr/ /rrrrrrrr /////rr/iii
/ I
car
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of
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/
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rr//tv���r,tr�ri,rrr ri rnrr,rrcrrrrrrrr rrr ter,r=trr,�r�a✓r>"y'�/N
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70,04-7546
�1 � � ' rl
d ffc,
E1
/ 0
COO rowwolto With"PPV
0
/.!.fl,�mr�/l(f/If1,fWun�u�f/f lGGf GU rCr11.r m..ffrrl,rlitfQl Pl/lfrnrir�rullr✓l rl/ai(✓n/r✓rn RnrrJllrflG//
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err
ru,
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o,
..............................................................imr...........................................................................................................................................�mr�mr�mr�Mr�mr�w
44 a g el
do 0 dp fm
Adult,Post-Cardlac Arrest Care Algorithm
ROSC Obtained
............... ............
pl),artse,andrivny of the%e
attivities cairl Occut,c<>114clurrently,
if However, ationis,
y plammuient tjubv,Emv4",,
n ar W lifloften or
Initial Start lob;rIe.118, llim'141"
COP,)"OlytOtify to morvitor
Stabilization t c"I"),6,01"rac I've,i I lubew A im,�i� I n
Phase Pacq),3155-4.5,
Alat
mla"49'e,hemdyn'ti'm fifer' arametem' ' at'10 breaith,. nlin.,t1trieitertfol alf
35-145('I!,Irn Hf,;
11 Olww�rII I
Afdm, in fist,ct,,,r c r
V1411,510"P11,01ISSOlf OfIll Itotlo"'pe for("pio,
sy ic b1cwd pjrerszs�.mc 190 rrmu(14�
Cons,ld, for,ofnew;',(
Theme she,tj�4 bedom
3,0"0, 1 Ell"�Sglmm��
s,,*that tl,'*,cisio, on,
m ilirk, gew's'"ent,
("M(A)irl(rmeive I'vilghpriof Ay as
........ ......................... a 6,, iterve,tons
s comomandfIS? 12"'-fead
Continued NO ye's (EGG11;cons, e,,f'
0
s.
Management hr mo clynairr k,,,s for d(it 4 iion On
aodAdditional Comf atose vention
TT V I(p i)t itrrit to 11 omov,irwog
Em-argervit # T'TfO4 Olthelf clei 'clar'lo
Activities * Obt4axin,bumin CT
�E,E,G mvifl,tod,%; Ab b rf i.
e;,ivoat 32.1,65"C,foot 2,,,,4
bvy ijrsonrg�a co, e w
Other corlitical�co
fee,d,600c,MOO�p
.......... ........................................../..........................................................
re c t blN,,*,d de
E,,valwivt eand trfkat ra*ly red sible eta I-M,
InvoNe expef,tow),slitIOU,sloon/forco Mimed, P
'Ity
Prolviclt contiouou, w,
Hypo""xia
Hydrogen ion tacidosis)
Hf,
Hypot,he vimia
Teri '
T;i, ca-rd 4/w
Thrornbo,4,53,511,11,
45 a g el
0
Pediatric Immediate Post-Cardiac Arrest CareAlgorithm
optimitz"o vent"i,4"boomw ox"'Y"ftstj
ation'71"" F" MIMMUJI)ox�+Poff", stwin s, awro
*Awl, 0 saost*on it�ss 00%,,
Cons4w,advarkee,d airway placeownt as!,nd
W114"Iform 0 Alp" Ologralph,Y,
Aw",fOr and *P101 "ble
1*"t NWI Is,Isto"It"$hockfi9
Ido"Ofy,trwt,1coob ft" tiog,
IV rI
IVAO
b K P"I' *41 aiso"'of,i's ovyftoow
Consider*m Ow Wuso
0'j,"u "'If, 'Poor oordiwo"
No,ction su,.Spfttod,,,
wx T "Irwot C toe oowidw I*,nw,d1m
T-OXJAIISI
Pub
f0r, ThwtooKcororsmy,
T ra
.............
I f
I",vot"411"Sto* NOM) OW"ONo,Stock
E)O'bt
Dow*wo
"In
.................
# Mooitoi,for t maxt agitatJon and setno"
* Monitofrffow arxJtrssVhYrxff)gIYc
* i
Asse"�blood gas,serurn efocttolylm calcum
* Iff p tv,nains,com rodose aftef,resAwit fromoifiv
xyam eMw c*osidor thwa tic hy w a 020C-34111C)
* Cxxisidor consul i(oo,li aW pf ationil'transpon,to twtlaq
Clare Contler
46 a g el
Adult Bra i;,
Assess,ap,,,,p�rGpriia,,t�e�,�n�ess for cljn�cal condition.
Heart rate typically<50, if bradywirt1thmia.
.......................................................
uI i I.
to "n paterit airway-, s; rep itti,i , c s
* Oxygen(if l sic)
lVaccess
6
,"" -f
":; J .% l r ,;l l U ;,,y 1,
/r
,,,aaa aPersistent
aa
n
i. "'fir I C t ,,..Iitia s i
�f +M IIIIIIII IIIIIIIII
r f
( , er tal'status?
Monitor
. r a , b: 1
ml WAY c 4k c t, ,, � Atro " e se:'
Mute+�wr
,f
First,dose.
Yes Maximunni:3 mg,
pine
Usual infusiori rate is,
5-210 mcglkg per minute.
If i w pain , ;r Titrate tropatient, e ' ee
,an,Wor" taper slowly.
ine l ICI' " slio l
0 mg per 1 iinute infusion.
J lTitrateto paberit response.,,
17,f Causes:
rar��.rd1���
ac�k" ischemia(
r
untarctioln
Cons'., I i!� i�a„e f beta,bloc 4b s,� ww oxin
f Expert i H o i
nismenouspacirg
Electrolyte ahmormality
!� w
I
47 a g el
Pediatric it 4 I� rII li ,Alsorlithm
r, *Om
rI
0 wow,
j ,
l
sN ;men l * Support
pwossum ventAmum and oxyg—M * 12-LOM&ECO
look '�0 „
" � W 1 V` 11
I
l"t O;'R Of RR''4 i
..............................................
.ss
11,
.w
��yes
W110 acces"s
wl AtroplaefforN` a ,al
pime ,I I'
J0Ipµ��pYp �ry �I^I IQI �( IIpIV�(�ry��"9II Iw
Mli'Iq@,hl'�i1VVn rivo j!µW fikog,((JJ n'�ry,�yur n LAfi�J�@��9'��j�'MfWi t,:?
I�� ��,ym� ,��Il��I��j�'µ,!��I1� /�III
V Y "�V j➢GY�u'pW''�IIW 6W/gW�"Wh'/ W tl iIl��i;Ufl�
Atroplao,fV110wNo
r
0,"Hvlx',Iliav�,=rit"",v
GO to P"istrk,
l i,�rzai ,a i,un,ainr�
1 bmii"1144AO 1, �, „..
48 a g ei
Aldult''Uchyciardlia With a Pulse Algorithm
Asse,,,ss,approp,,(�ia,te,,ties,,s for clinical conditjonti.
I, Sul if c,,h,,Yarriiiiy,�thmial.
-ont,Syticlu� zed cairdlaversian,�
............... Refer to your specific devicel's recornmended energy level to
maximizefill,"st sh,ock,success.
Adenostne IV,dose:
First dose:6 ing rapW IIV NS fliush.
(...................................................................................................................
Wentity andtt-eat ta-,rh tluu," Infini rim f6j,Stable,Wi,de,-Q,RS TkIly,ciardia,
Ant" t y ic to
* Maintaiii patent ahwa,)r,assist breathning as necessary I Procainarniille I'Vdlase#
* 0.xYgen Of IIYPO,'X"P,,nl"c",,)
20-50 mqlmit wit'il arrhythmiia suppressed,hypotension ervsues,
QRS dLiraition increases>50%,or maXi"IL)m diose,17 mqlkg,given,,,,,
pres,sure and oximetry -olo
JV;ac,, Maintenance infusiion:1-4 rmg/miln.,Avoid if pr ii;lg,ed QTor CHF.
I
Am"o,dairone�IV dose:
A" First dose:l'i 50 mgovier 10 nii n�utles.Replealt as needled i'f V'TreClIrs.
Fodow by rnaintenance inftision of'I inghninfol r f irst 6 IiOU'S.
'Sat l illV close":
10,00 mg 11.5 mgIlkg)over 5 IlliflU ties.,Avoid if prolloaged QT,
Persistent ...............................................................................................
'ta,chyat-rhythrmia cauaing:
Sylinclitanized caludioveit sibn
1-typoteens-IoW,
Consider"sedlation
s—
Ilfregtiliat narrjow,coniplex,
Signsof's tf�rie,,f,,ract�ot-y,,,,, ,o,,,n�sidieir
�11�4� ,op midw,adeposine
schem,is ch/est di,,swomfort?
nr
Undedying,cause
Acuutelie, ,'artfa, ur,ell)",
NeW, to klic"rease
energy leviel fror next,
No cardljoverssidn
..............
',Addftn laf.
Gonder
Ye's 7 ft 9
lic, U ,
W',il,w eb QRS?
Adenosine only
second
Migullata,,nd mnanompriph,"/c, ..............
F'Antiarr"�hythmic,,1infuis,!,o°n
No
Adenost (Ifr erc, la ne gu, !f
0,70loic,'ker orcakk,,,/,,k c tine,,Ilb4iocke,,,,,,r
Consider e��ccnsd,taboft
C 202,0,Am,er i( n Heart As zsoc iation,
49 a g el
Pedlatr'tic Tachyeardla With, iI .
` �i� ill All I II IIIII II Ipllliilll uuuuuu uuu�u uuu uuuu I uuuuumiiiiiiiiiiuuum il'il'il I'il
�41111�,� IVill!bipiipllJ, i.
ill ' tee
Cardv
bkxidr s',I ' .""and�I,1' II Y E N °I I I
;I rl ��i l',iltiw, n 'IVy%;o rG a ,IM t,.
Probable
r , i,
to c ycar a ff" ;,,F'' Evoln l A � + y y I
IU 14N'..,.F'b'' IJvI `� +"11'M-. ..... ......... ......._ U(f,' wftb `, First, w�uwwsv, I �VN�IitiU
0 Pwave s., , I� III
I ,
�A A n,„ �,,,,A,,,�,, �i' �Io rI
CNki �Y � �
l,
;a 1 '
.................. , ... l;l 'o:12
t(
Yes
NO
', pAofAe4y'.`' '" 'Id
J
Y
k�
1 °iow Wide Narrow Wido
mrt I fIN Ip�.�'�°I N i/'< ' V!�!Rl�l�MllH IHM�ff�IViy %'y �J J) IWo'WNw&a N / '�iA �,N'"'Y4�Y"`r
Evalluato
vraltion. n if l
(Pro ` �",�I Ilvioular Possiblo,v otdc r, Probati4e, "supraiventricu,lat PossibleII'' "ul
'.yy�I+(. rry��yplI;I��1 �p�'�p: U�9'� q�rypw.g,Ip�QY I� Ylug�� �g 'II!µry���
'i'l�i'icy ,.sm.,,.,��y��N l'YIN�NF'1W o�9V'%' I J W^^,h'I �y.Ippµ�Ms'MII,'�fa F "WWI I YgIIrtV,a J'�F!.
,,,',rvit '�fl' �� tV v",rt t o RR,,
' � ii I � I..�',"� t iI r�NI'IVI
` hilfam o kwlant rate,to.,,ITV�,1 tlAJ
v <a III it I J
` �� '` It, �{IYr' V '.�.' ' III , ..�II G I'm,
Synchronizedregim
zardloveir ulon ORS monomorphloc,
V derminei.
adviso for
p
It I ` toIre IK t,* Cormalidor
Exper,t',consuftatfion.
` co loot"
....
If W10 accoss
" s 9,1
0,21,10Q0,Arno lK 4,1 to art Asmx;Aa t N
50 a g I
Differential Impressions:
• Acute Abdominal Syndrome
• Cholecystitis
• Colitis • Abdominal Aortic Aneurysm
• Crohn's Disease • Appendicitis
• Diverticulitis • Bowel Obstruction
• Pancreatitis • Ectopic Pregnancy
• Peptic Ulcer Disease • Incarcerated Hernia
• Pelvic Inflammatory Disease • Rupture Ovarian Cyst
• Renal Colic
• Urinary Tract Infection
•
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
Advanced Life Support Actions/Considerations:
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric: s t i i is e
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain I n i I Procedural Sedation Management Guidelines necessary/indicated
• Nausea I Vomiting Management Guideline as necessary/indicated
Pediatric- u 0 Vomiting ManagementGuideline n r in i t
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
Pediatric- Epinephrine m 1m min IV/I IV/10 Infusion
51 g
Differential Impressions:
• Localize Allergic Reaction
• Systemic Anaphylaxis Reaction 9 Systemic Anaphylactoid Reaction
• Anaphylactoid Shock e Transfusion Reaction
•
Anaphylactic •Shock
• Angioedema
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• EpiPen IM
Pediatric: EpiPen,Jr. IM
• Albuterol 2.5mg AT
Pediatric: Albuterol 2.5mgAT
Advanced Life Support Actions/Considerations:
• Epinephrine (1:1000)0.5mg IM
Pediatric: Epinephrine (1:1000) 0.01mg/kg IM (Maximum Dose: 0.4mgIM)
PEARL I First-line therapyfor anaphylaxils/anaphylactolid reactlions/shock
PEARL I Use with caution in the elderly and with known heart disease
PEARL I No absolute contraindication for anaphylaxislanaphylactoid reactionsIshock
• Crystalloid Resuscitation 10cc/kg IV/10; repeat PRN
Pediatric: Crystalloid Resuscitation 20cc/kg IV/10; repeatPRN
PEARL I Second-line therapyfor anaphylaxils/anaphylactoild react'lons/shock
• Diphenhydramine 50mg IV/IM
)P-- Pediatric: Diphenhydrarnine lmg/kgIV/IM
• CPAP 5—15cm/H20 PEEP
• Albuterol 2.5mg AT; repeat PRN
)�-- Pediatric: 2.5mg AT; repeat PRN
• M ethyl pred n isolone 125mg SIVP
Pediatric: M ethyl pred n isolone 1mg/kgSIVP
• Epinephrine 0.1—0.5mcg/kg/min IV/10 Infusion as necessary/indicated
• Epinephrine (1:10,000) 0.5mg IV/10
PEARL I For pre or peri-cardiopulmonary arrest states
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
Pediatric: Epinephrine 0.1—1mcg/kg/min I 0 Infusion
52 a g el
Differential Impressions:
• Mental Illness . Baker Act
• Psychiatric Emergencies • Marchman Act
• Substance Abuse
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Communicate in a calm and nonthreatening manner
• Respect the dignity of the patient
• Request law enforcement as necessary/indicated for:
Baker Act consideration:
Florida Statute Chapter 394, Part I, is also known as the Florida Mental Health Act. The Baker Act
provides legal procedures for patients with known or suspected mental illness.This includes mental
health examinations and treatment and provides authorization to police, physicians, mental health
professional and the courts to dictate certain medical care for persons who pose a threat of harm to
themselves or to others.
PEARL I Baker Act i's not intendedfor patients who are competent, are without mental illness,have
decisional capacity, and have been informed yet still desire to refuse care against medical advice
PEARL I Organic causes of behavioral change must be considered and ruled out
PEARL I Law enforcement will provide EMS with a Baker Act Form(3052a), and as required for EMS
safety, will accompany orfollow the ambulance to the hospital
or
Marchman Act consideration:
Florida Statute Chapter 397, Part V, provides legal procedures for patients with known or suspected
conditions involving substance abuse.This includes mental health examinations and treatment and
provides authorization to police, physicians, mental health professional and the courts to dictate
certain medical care for persons who are impaired and pose a threat of harm to themselves or to
others or is so impaired that he is incapable of appreciating his need for substance abuse services.
PEARL I Marchman Act i's not intendedfor patients who are competent, have decisional capacity, and
have been informed yet still desire to refuse care against medical advice
PEARL I Organic causes of behavioral change must be considered and ruled out
• Patient Restraint Guideline as necessary/indicated
PEARL I Teamwork between m
tal providers and law enforcement improves patient care
• Excited Delirium Guideline as necessary/indicated
Advanced Life Support Actions/Considerations:
• Excited Delirium Guideline as necessary/indicated
Pediatric: Excited Delirium uideline asnecessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
53 1 ag el
Differential Impressions:
• Acute Coronary Syndrome (Acs)
• Chest Pain—Cardiac Pathology . Unstable Angina Pectoris
• STEM I (ST Elevation Myocardial Infarction) g
• NSTEMI (Non-ST Elevation Myocardiallnfarction)
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Aspirin 324mg PO (chewable)
PEARL I Withholdfor patients with known contraindications or if prior to arrival
aspirin administration has been confirmed-full dose and chewable
Advanced Life Support Actions/Considerations:
• 12 Lead ECG
PEARL I STEMI Alert and Acute Coronary Syndrome(ACS)patients should be transported
to the closest STEMIlPercutaneous Coronary Intervention(PCI)facility
PEARL I Repeat q 10 minutes for high index of suspicion of evolving cardiac condition
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
PEARL I for Right Ventricular Infarct(RVI)—repeat as necessarylindicated
while in the absence of pulmonary edema
• Nitrolingual Spray 0.4mg SL; may repeat q 5minutes for as long as symptoms persist without evidence
of hypoperfusion
PEARL I Nitrates should be withheld in patients with initial systolic blood pressures less
than 90mmHg, in patients with marked bradycardia or tachycardia, and
in patients with known or suspected right ventricular infarction(RVI)
PEARL I Contraindicated in patients who have used Viagra, Cialis, Levitra
or other erectile dysfunction medication in the previous 48 hours
PEARL I Nitrates should be withheld in patients with initial systolic blood pressures less
than 90mmHg, in patients with marked bradycardia or tachycardia, and
in patients with known or suspected right ventricular infarction(RVI)
• Pain Anxiety I Procedural Sedation Management Guideline as necessary/indicated
PEARL I for severe pain unresponsive to nitroglycerin or in cases where nitrates cannot
be given due to hypoperfusion
• Nausea &Vomiting Management Guideline as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
54 IIII
IL
ead
aVR
Copyright 2,0001-Ainerican
55
0 An fib
Differential Impressions:
• Right Heart Failure
• Congestive Heart Failure . Left Heart Failure
• Pulmonary Edema . Non-Cardiac PulmonaryEdema e. . Drownin
� g, g)
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Nitro lingual Spray 1.2mg (x3 0.4mg) SL; may repeat q 1minute PRN for as long as symptoms
persist with evidence of hypoperfusion
PEARL I Nitrates should be withheld in patients with hypotension,marked bradycardia or tachycardia,
and in patients with known or suspected right ventricular infarction(RVI)
PEARL I Nitrates are contraindicated in patients who have used Viagra, Cialis,Levitra or other
erectile dysfunction medication in the previous 48 hours
Advanced Life Support Actions/Considerations:
• CPAP 5—15cm/H20 PEEP
• 12 Lead ECG
PEARL I STEMI Alert and Acute Coronary Syndrome(ACS)patients should be transported
to the closest STEMIlPercutaneous Coronary Intervention(PCI)facility
PEARL I Repeat q 10 minutes for high index of suspicion of evolving cardiac condition
PEARL I Fever,productive cough, andlor rhonchif may indicate advanced pneumonia,see reactive
airway disease protocol
• Continuous Nitrate Therapy
and in patients with known or suspected right ventricular infarction(RVI)
PEARL I Nitrates should be withheld in patients with hypotension, marked bradycardia or tachycardia,
• Morphine 2-5mg IV(Max 0.2mg/kg)
• Furosemide 40-100 mg IV
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
PEARL I For Right Ventricular Infarct(RVI)and hypotension1hypoperfusion
• Epinephrine 0.1—0.5mcg/kg/min IV/10 Infusion as necessary/indicated
PEARL I For Right Ventricular Infarct(RVI)and hypotension1hypoperfusion
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
56 a g el
NO
Differential Impressions:
• Hypoglycemia (blood glucose <60mg/dL) * Hyperglycemia (blood glucose >300mg/dL)
• Hypoglycemic Insult * Diabetic Ketoaciclosis(DKA)
• latrogenic Hypoglycemia * Hyperosmolar Hyperglycemia State (HHS)
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
Advanced Life Support Actions/Considerations:
• bG<60mg1dL with vascular access:
Dextrose 50% 12.5gm—25gm IV titrated to return of normal mental status
�-, Pediatric-. Dextrose 25%5cc/kg IV titrated to return of normal mentalstatus
PEARL I As normal mental status i's restored,stop infusion and re-check blood glucose.-
•
bG>300mg1dL with vascular access:
Crystalloid Resuscitation 20cc/kg IV/10; repeat PRN
Pediatric-. Crystalloid Resuscitation 20cc/kg IV/10; repeatPRN
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
57 a g el
Differential Impressions:
• Psychiatric or Psychological behavioral violence
• Pharmacological or Substance Abuse violence
• Toxidrome rage
• Metabolic storm
• Infectious agitation
• Conditions that result in agitated,violent, or uncooperative behavior that pose imminent threat or
danger to self or others
PEARL I Exclusion Criteria.-Agitated or violent behavior due to medical conditions including. but not
limited to,.-1)Head trauma,2)Hypoglycemi'a..3)Hypoxia
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
lights,PEARL I Reduce external stimuli—
sirens,horns, etc.
• Patient Restraint Guideline
PEARL I Must be adequately controlled prior to loading and transporting
PEARL I ExDS patients shall not be packaged or transported prone,hog-tied or
in any position that may impede pulmonary function
• Hyperthermia Guideline as necessary/indicated
Advanced Life Support Actions/Considerations:
Midazolam 5mg IM/IN/IV
• Crystalloid Resuscitation 10cc/kg IV/10
Pediatric: Crystalloid Resuscitationcc I
• Hyperthermia Guideline as necessary/indicated
• If patient emerges from loading dose:
Midazolam 2.5—5mg IV/10/IM/IN
Or
Diphenhydramine 25-50mg IV/IM prn sedation
Loraze am Ativan
Seizures Sedation A itatioon
ADULT • 1-2 mg given slowly IV over 1-2 minutes,then repeated at 5-to 15-minute intervals until the
desired effect is achieved • Maximum total dose is 10 mg
Pediatric Infants and children: 0.05-0.1 mg/kg IV over 2-5 minutes; not to exceed 4 mg/dose; may repeat
q10-15min PRN
Alternatively, 0.1 mg/kg at slow IV rate not to exceed rate of 2 mg/min; not to exceed dose of 4 mg
Adolescents: 4 mg slow IV; if seizure persists after 10-15 minutes, administer 4 mg IV again
Pediatric Sedation/Agitation
Children: 0.05 mg/kg/dose PO q4-8hr; not to exceed 2 mg/dose
58 1IIII a g e
Ab 9 0 Am
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
)P-- Pediatric: Contact Medical Control
59 a g e,
Differential Impressions:
9 Aspiration
• Asthma and Asthma-Like Syndrome 9 Toxic Inhalation (vapor,fume, or smoke)
• Chronic Obstructive Pulmonary Disease e Upper Respiratory or Pulmonary Viral Infection
9 Pneumonia
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Albuterol 2.5mg AT
Pediatric: Albuterol 2.5mgAT
• EpiPen IM
Pediatric- EpiPen,Jr. IM
Advanced Life Support Actions/Considerations:
• CPAP 5—15cm/H20 PEEP
PEARL PEEP not to exceed 7.5cmIH20 in ""tight lung"pathology
PEARL CPAP i's contraindicated w1signs of severe hypoperfusion
• Albuterol 2.5mg AT in-line with CPAP; repeat PRN
Pediatric: 2.5mg AT(repeat as necessary)
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric: Crystalloid Resuscitation 20cc/kg IV/10 asnecessary/indicated
PEARL I For evidence of dehydration or to mobilize secretions in prolonged"'tight lung"pathology
• M ethyl pred n isolone 125mg SIVP
Pediatric: M ethyl pred n isolone lmg/kgSIVP
• Magnesium Sulfate 2grn in 100cc D5W IV Infusion over 10 minutes
)F-- Pediatric: Magnesium Sulfate 50mg/kg in 100cc D5W IV Infusion over 10minutes
• Epinephrine (1:1000)0.5mg IM
Pediatric: Epinephrine (1:1000) 0.01mg/kg IM (Maximum Dose: 0.3mgIM)
Pediatric: Normal Saline 3cc AT (for suspected Croup)
PEARL I For suspect croup or laryngotracheobronchitis
Pediatric: Epinephrine (1:1000) 3mg in 3cc NSAT
PEARL I For extremis epiglottitis orbronchoilitt's
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
• Epinephrine 0.1-0.5mcg/kg/min IV/10 Infusion as necessary/indicated
Pediatric: Epinephrine 0.1—lmcg/kg/min IV/10 Infusion
60 a g el
Ah
Differential Impressions:
• Epilepsy • Neurological origins
• Central Nervous System origins • Oncology origins
• Closed Head/Traumatic Brain Injury • Pregnancy(i.e.,Eclampsia)
• Infectious origins (i.e.,Febrile) • Psychological disorders
• Metabolic origins • Stroke
• Medication/Toxin induced • Viral origins
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• bG <60mg/d L:
Diabetic Emergencies I Hypo & Hyperglycemia Guideline
Advanced Life Support Actions/Considerations:
61 1 ag el
In
Loraze am Ativan
Seizures Sedation A itatioon
ADULT • 1-2 mg given slowly IV over 1-2 minutes,then repeated at 5-to 15-minute intervals until the
desired effect is achieved • Maximum total dose is 10 mg
Pediatric Infants and children: 0.05-0.1 mg/kg IV over 2-5 minutes; not to exceed 4 mg/dose; may repeat
q10-15min PRN
Alternatively, 0.1 mg/kg at slow IV rate not to exceed rate of 2 mg/min; not to exceed dose of 4 mg
Adolescents: 4 mg slow IV; if seizure persists after 10-15 minutes, administer 4 mg IV again
Pediatric Sedation/Agitation
Children: 0.05 mg/kg/dose PO q4-8hr; not to exceed 2 mg/dose
Midazolam
• bG Normal, Not Pregnant:
Midazolam 2.5—S.Omg IV//10; may repeat q 10minutes PRN
Pediatric: .1
or
Midazolam S.Omg IM/IN; may repeat q 10minutes PRN
Pediatric:
• bG Normal, Mid to Late Trimester Pregnancy or early post-partumphase:
Eclampsia Guideline
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric: Crystalloid Resuscitation c k IV/10 asnecessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
62 IIII a g e
Ah
Differential Impressions:
• Pneumosepsis
• Systemic Inflammatory Response Syndrome • Meningeal Sepsis
• Sepsis • Gastro-Intestinal Sepsis
• Severe Sepsis • Septicemia
• Septic Shock I Distributive Shock • Urosepsis
• Skin/Wound Sepsis
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
PEARL I Early recognition and goal-directed therapy reduces mortality
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emer en i s 0 I lypo & I lyperthermia Guidelineasnecessary/indicated
PEARL I Cold blood does not clot—Hibler's Method preserves body heat and reduces Lethal Triad
PEARL I If hyperthermic.. do not attempt to cool-feverfights the infection
Advanced Life Support Actions/Considerations:
• CPAP 5—15cm/H20 PEEP
PEARL I Use with caution—contraindicatedfor hypoperfused conditions
• Crystalloid Resuscitation 20cc/kg, repeat PRN
Pediatric: Crystalloid Resuscitation , repeatPRN
PEARL I First-line therapyfor hypotension secondary to Distributive Shock—target MAP=70mmHg
PEARL I Crystalloid is paramountfor survival;do not Withhold in normotensive patients
PEARL I If hyperthermic, do not attempt to cool-feverfights the infection
• Epinephrine 0.1—0.5mcg/kg/min IV/10 Infusion as necessary/indicated
PEARL I Initiate only after 2L crystalloid infused
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
Pediatric: in hri .1 m k min IV/10 Infusion
63
Seps'll's Checkilist,
I. SIRS lat, least 2), 3. SEVERE SEPSIS
13 Te n)p. :5 9 6 0 o�r,�! 1,00.4"' F Meets:SIRS+Itifectioin+
ICI IgandySfUnction (e,.,g AMSI,
Cl sp.. �t 210 Ofilgut,ia, Mottling.—
SEPSIS C
Wets:,s1R.S, + Meets,.*SIRS+Infection+Ci.,, ,tip.
11 Infection d LI`' e 's " I
stilsplected) 0 Hypotenslon (SBP<90,or MAP
615):
ADULTRX REDI RX
11 Consider CPAP S,p,0 < 92% 10 Consider CPAP S 02, < 12
C] NormalkSaMe 20 mL/'kg rapid O'Normal Sallne 20 mL/ �kg,rapid
0 Repeat El Repeat
0 EfA 0.1-0.5 ailcg/kg/rn"I't-i for 13 Epl'10.1-1 nicg/kg/a,iin,far hypo-
L S,ion p e,rf
1:11 FLUID RESUSITATION IS PARAMOUNTI.
ICI , aggressive cooling e si lr s
El Clearly Sr i 'AlfI it gate "SEPSIS: ' , receiving fad
ity
YOUlmpatlent does NOT gneed to be f it l e tio be, selpfic�!
64 IIII
AN 0 AMR Ah
4w do
Differential Impressions:
• Ischemic
• Transient Ischemic • Hemorrhagic
• Large Vessel Thrombotic g
• Small Vessel Thrombotic
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• bG <60mg/d L:
Diabetic Emergencies I Hypo & Hyperglycemia Guideline
• Perform Cincinnati Stroke Scale Assessment
PEARL I Acutely positive=Stroke Alert
Advanced Life Support Actions/Considerations:
• Perform Stroke Triage Checklist
PEARL I Stroke facility based upon the clinical differential(Primary versus Comprehensive Stroke
Center)as determined by the Stroke Triage Checklist
PEARL I "Worst headache of lifeindicates bleed, transport Comprehensive Stroke Center
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric:
PEARL I Crystalloid Resuscitation i's aimed at maintaining cerebral perfusion
• Nausea I Vomiting Management Guideline as necessary/indicated
PEARL I Antiemetic therapy i's aimed at reducing intracranial pressure
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
65 ag el
AN 0 AMR Ah
4w do
Differential Impressions:
• Opioid Ingestion (Opium, Heroin,Codeine,Codones,
Meperidine,Methadone,etc.)
• Sedative-Hypnotic Ingestion (Benzodiazepines,GHB, • Hallucinogen Ingestion (PCP,LSD,Cannabinoids,
Antihistamines,Alcohol,Barbiturates,etc.) Ecstasy,Flakka, Bath Salts,etc.)
• Cholinergic Exposure (Organophosphates,Nerve • Toxic Inhalation (Smoke,Cyanide,etc.)
Agents,Mushrooms,etc.) • Alkali
• Anticholinergic Ingestion (Antihistamines,Tricyclics, . Pol -Pharmacolo is
Phenothaiazines,Antidiarrheals,etc.) y g
• Sympathomimetic Ingestion (Cocaine,
Ampehtamines, Methamphetamines,Ecstasy,MDPV,etc.)
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Patient Restraint Guideline
PEARL I Patients must be adequately controlled prior to loading and transporting
PEARL I Patients shall not be packaged or transported prone,hog-tied or
in any position that may impede pulmonary function
• Refer to Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
• Dermal Decontamination as necessary/indicated
• Contact Poison Control for consultation: Poison Control Centerl-800-222-1222
Advanced Life Support Actions/Considerations:
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric: Crystalloid Resuscitationt....
PEARL I Crystalloid may be repeated as PEARL I For the majority of Toxidromes, the solution to pollution i's dilution
ndicated
• Consider CPAP 5—15cm/H20 PEEP
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
IW 11!/NIWAIFJI/Up/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U/f(4lUlUlf/N4/4/Ff4/U/U///G/4/U/f(4!U!(�ll/NN/4/Ff4/U/U/f/Np/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U/f(4lUlUlf/N4/4/Ff4/U/U///G/4/U/f(4!U!(�ll/NN/4/Ff4/U/U/f/Np/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U/f(4lUlUlf/N4/4/Ff4/U/U///G/4/U/f(4!U!(�ll/NN/4/Ff4/U/U/f/Np/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U/f(4lUlUlf/N4/4/Ff4/U/U///G/4/U/f(4!U!(�ll/NN/4/Ff4/U/U/f/Np/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U/f(4lUlUlf/N4/4/Ff4/U/U///G/4/U/f(4!U!(�ll/NN/4/Ff4/U/U/f/Np/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U/f(4lUlUlf/N4/4/Ff4/U/U///G/4/U/f(4!U!(�ll/NN/4/Ff4/U/U/f/Np/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U/f(4lUlUlf/N4/4/Ff4/U/U///G/4/U/f(4!U!(�ll/NN/4/Ff4/U/U/f/Np/p/1(tl(tl(Ul1/N//U/AIU/U/p///Ur'4/U/f!P!P(Plf/N4/4/Ff4/N/U/HN4/U//!4lUlGN
• Opioid (Narcotic):
Naloxone 0.5mg IV/10/IM/IN; may repeat q 5minutes PRN until respiratory depression is improved
Pediatric: .1m k I I I ; maximum se 2mg
PEARL I Primary indication for Naloxoned-respiratory depression unmanageable with
non-invasive airwaylventilationloxygenation techniques
PEARL I Naloxone i's contraindicated in patients with or planned advanced airway placement and in
cardiopulmonary arrest states
• Sedative-Hypnotic:
Supportive Therapy
• Hallucinogen:
Excited Delirium Syndrome Guideline
66 ag el
• Cholinergic:
Atropine 1—2mg IV q 5minutes till resolved
• Sympathomimetic:
Midazolam 2mg IV/10/IM/IN may repeat q 5minutes PRN until heart rate & blood pressure normalize
PEARL I For hyperadrenergi'c states with heart rate>120bpm
• Toxic Inhalation:
Burn I Electrocution I Smoke Inhalation Guideline
• Dystonic Reactions/Extrapyramidal Symptoms:
Diphenhydramine 50mg IV/IM
• Consult as necessary/indicated
Medical Control Actions/Orders/Requests:
ri111111111111111111111111111111111111J111JJJNl7ff!!!!!!///////////////!!///L///////%/'Illllllllll ll/llll/Jlllll11111/1„/////////H((ffflfff(l//////11f/l//!((!/////%///%/Rfffffffffll fflllffffff!!!!!lfflf///////%Hffffflfffff!!!//lfff!l1f111f!!!!,%//%/%/,'((fffffff((ff!llffflfl((!((lfflf,/%////%Hlllllllllll ll/11/llJll///II/ll/1///////////II71111111111111111111111111111111J111JJJNl7ff!!!!!!///////////////!!///L///////%/'Illllllllll ll/llll/Jlllll11111/1„/////////H((ffflfff(l//////11f/l//!((!/////%////%Rfffffffffll fflllffffff!!!!!lfflf///////%Hffffflfffff!!!//lfff!l1f111f!!!!,/%/%/%/,'((fffffff((ff!llffflfl((!((lfflf,/%///%/Hlllllllllll ll/11/llJll///II/ll/1///////////II71111111111111111111111111111111J111JJJNl7ff!!!!!!///////////////!!///L///////%/'Illllllllll ll/llll/Jlllll11111/1„/////////H((ffflfff(l//////11f/l//!((!/////%///%/Rfffffffffll fflllffffff!!!!!lfflf///////%Hffffflfffff!!!//lfff!l1f111f!!!!,%//%/%/,'((fffffff((ff!llffflfl((!((lfflf,/%///%/Hlllllllllll ll/11/llJll///II/ll/1///////////II7111111111111111111111111111
67 ag el
D 9 0
Differential Impressions:
• Falls e Battery
• Motor Vehicle Crash 9 Hanging
• Pedestrian e Other Impact Injury
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Spinal Motion Restriction Guideline
:�, Pediatric: Spinal Motion Restriction Guideline
• Hemorrhage Control:
Direct Pressure
)�-- Pediatric: Direct Pressure
Pressure Dressing
Pediatric: Pressure Dressing
Tourniquet
Pediatric: Tourniquet
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emergencies I I lypo& I lyperthermia Guideline asnecessary/i ndicated
PEARL I Cold blood does not clot—Hibler's Method preserves body heat and mitigates Lethal Triad
• Pelvic Splinting as necessary/indicated
Pediatric: Pelvic Splinting as necessary/indicated
• Extremity Splinting as necessary/indicated
Pediatric: Extremity Splinting as necessary/indicated
• Perform Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue, GCS<12 or Paramedic Discretion=Trauma Alert
Pediatric: Perform Pediatric Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue,Altered Mental Status or Paramedic Discretion=Trauma Alert
Advanced Life Support Actions/Considerations:
• Pleural Needle Decompression as necessary/indicated
Pediatric: Pleural Needle Decompression asnecessary/inn dicated
• Crystalloid Resuscitation IV/10 as necessary/indicated
Pediatric: Crystalloid Resuscitation I 0 asnecessary/indicated
PEARL I Perfusion target.,,permissive hypotension;peripheral pulses present—restrict crystalloid
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
• Pericardiocentesis as necessary/indicated
Medical Control Actions/Orders/Requests:
* Consult as necessary/indicated
68 a g el
Differential Impressions:
le Gunshot Wound • Impalement
le Stab Wound • Other Sharp Force injury
Basic Life Support Actions:
le Universal Care Guideline
le Patient Safety Guideline
le Hemorrhage Control:
Direct Pressure
Pediatric: Direct Pressure
Pressure Dressing
Pediatric: Pressure Dressing
Tourniquet
Pediatric:Tourniquet
Occlusive Dressing
Pediatric: Occlusive Dressing
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emergencies I I lypo& Hyperthermia Guideline asnecessary/indicated
PEARL I Cold blood does not clot—Hibler-s Method preserves body heat and mitigates Lethal Triad
•
Extremity Splinting as necessary/indicated
Pediatric-, Extremity Splinting as necessary/indicated
• Perform Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue, GCS<12 or Paramedic Discretion=Trauma Alert
Pediatric: Perform Pediatric Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue,Altered Mental Status or Paramedic Discretion =Trauma Alert
Advanced Life Support Actions/Considerations:
le Pleural Needle Decompression as necessary/indicated
)�-- Pediatric: Pleural Needle Decompression asnecessary/indicated
• Crystalloid Resuscitation IV/10 as necessary/indicated
Pediatric: Crystalloid Resuscitation IV/10 asnecessary/indicated
PEARL I Perfusion targetl permissive hypotensison;peripheral pulses present—restrict crystalloid
•
Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
• Pericardiocentesis as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
Pediatric: Pericardiocentesis asnecessary/indicated
69 a g el
Differential Impressions:
e Subdural Hematoma
• Isolated Closed Head Injury
• Traumatic Brain Injury e Epidural Hematoma
e Intracranial Hemorrhage
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Spinal Motion Restriction Guideline
Pediatric: Spinal Motion Restriction Guideline
• Hemorrhage Control:
Direct Pressure
Pediatric: Direct Pressure
Pressure Dressing
Pediatric: Pressure Dressing
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emergencies I Hypo & Hyperthermia Guideline asnecessary/indicated
PEARL I Cold blood does not clot—Hiblers Method preserves body heat and reduces Lethal Triad
• Perform Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue, GCS<12 or Paramedic Discretion=Trauma Alert
Pediatric: Perform Pediatric Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue,Altered Mental Status or Paramedic Discretion=Trauma Alert
Advanced Life Support Actions/Considerations:
• Crystalloid Resuscitation lOcc/kg IV/10; repeat PRN
Pediatric: Crystalloid Resuscitation 20cc/kg IV/10; irepeatPRN
PEARL I First-line therapyfor hypotension to reduce secondary brain insult
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
• Nausea I Vomiting Management Guideline as necessary/indicated
Pediatric: Nausea J Vomiting Management Guideline asnecessary/indicated
PEARL I Antiemetic therapy is aimed at reducing intracranial pressure
• Seizure Guideline as necessary/indicated
Pediatric: Seizure Guideline as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
• Epinephrine 0.1—0.5mcg/kg/min IV/10 Infusion as necessary/indicated
)�-- Pediatric: Epinephrine 0.1—lmcg/kg/min I 0 Infusion
PEARL I Second-line therapy for hypotension to reduce secondary brain insult—target MAP 70mmHg
70 1 a g el
0 0 ds 41 0
Differential Impressions:
e Complete & Incomplete Cord Injury
• Isolated Spinal Cord Injury e Central Cord Syndrome
• Neurogenic Shock e Anterior Cord Syndrome
• Spinal Shock e Posterior Cord Syndrome
e Brown-Se'quard Syndrome
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Spinal Motion Restriction Guideline
)�-- Pediatric: Spinal Motion Restriction Guideline
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emergencies I I lypo & I lyperthermia Guideline asnecessary/indicated
PEARL I Cold blood does not clot—Hibler's Method preserves body heat and mitigates Lethal Triad
• Perform Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue, GCS<12 or Paramedic Discretion=Trauma Alert
Pediatric: Perform Pediatric Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue,Altered Mental Status or Paramedic Discretion=Trauma Alert
Advanced Life Support Actions/Considerations:
• Crystalloid Resuscitation 10cc/kg IV/10; repeat PRN
Pediatric: Crystalloid Resuscitation 20cc/kg IV/III 0; repeatPRN
PEARL I First-line therapyfor hypotension secondary to Distributive Shock
• Atropine 0.5mg IV/10; repeat x1
Pediatric: Atropine 0.02mg/kg IV/1 ;0 repeat x1 (minimum dose O.Irn /m aximum do s eO.5mg)
1 9
PEARL I Second-line therapyfor hemodynamically significant bradycardia
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
• Nausea I Vomiting Management Guideline as necessary/indicated
Pediatric: Nausea I Vomiting Management Guideline asnecessary/indicated
PEARL I Antiemetic therapy i's aimed at reducing airway compromise from vomiting
• Seizure Guideline as necessary/indicated
Pediatric: Seizure Guideline as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
• Epinephrine 0.1—0.5mcg/kg/min IV/10 Infusion as necessary/indicated
)�-- Pediatric: Epinephrine 0.1— lmcg/kg/min IV/10 Infusion
PEARL I Third-line therapyfor hypotension secondary to Distributive Shock—target MAP=70mmHg
7 11 a g el
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73 a g el
0 0
Differential Impressions:
• Burns (Thermal,,Chemical, Electrical,Radiation) e Smoke Inhalation
• Electrocution (AC,DQ e Toxic Fume Inhalation
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Spinal Motion Restriction Guideline
Pediatric: Spinal Motion Restriction Guideline
PEARL I Electrocutions may be coupled with Blunt Force Trauma
• Hemorrhage Control:
Direct Pressure
Pediatric: Direct Pressure
Pressure Dressing
Pediatric: Pressure Dressing
Tourniquet
Pediatric: Tourniquet
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
�-' Pediatric: Exposure Emergencies I I lypo & I lyperthermia Guideline asnecessary/indicated
PEARL I Burns=hypothermia—Hiblers Method preserves body heat and mitigates Lethal Triad
• Burn Care:
<15% BSA—Stop the burning process, Watedel Dressing
Pediatric: <15% BSA—Stop the burning process,Wateriel Dressing
>15% BSA—Stop the burning process, Dry Dressing
Pediatric: >15% BSA—Stop the burning process, Dry Dressing
Remove jewelry and constricting items
Pediatric: Remove jewelry and constricting items
P EAR L I Critical Bums.-All bums>25%BSAA;30 bums>1 0%BSA;20 and 30 bums to the face, eyes, hands,
feet or genitalia;inhalation bums;bums with extremes of age or co-morbidities;electrical bums.
• Extremity Splinting as necessary/indicated
Pediatric- Extremity Splinting as necessary/indicated
• Perform Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue, GCS<12 or Paramedic Discretion=Trauma Alert
Pediatric: Perform Pediatric Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue,Altered Mental Status or Paramedic Discretion=Trauma Alert
Advanced Life Support Actions/Considerations:
• Crystalloid Resuscitation lOcc/kg IV/10 as necessary/indicated
➢ Pediatric: Crystalloid Resuscitation 20cc/kg IV/10 asnecessary/indicated
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain O Anxiety I Procedural Sedation Management Guideline as necessary/indicated
(continued)
74 a g el
0 0
• High Voltage Electrical Injury or Direct Lightning Strike with significant tissue destruction:
Sodium Bicarbonate ImEq/kg IV/10
Pediatric: Sodium Bicarbonate lmEq/kg IV/10
• Smoke Inhalation:
Reactive Airway Disease Guideline
Pediatric: Reactive Airway Disease Guideline
• Smoke Inhalation, Carbon Monoxide or Cyanide Toxicity:
Cyanokit 5grn (1 Kit) IV/10 over 15minutes
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
Pediatric: Cyanokit 70mg/kg IV/10 overl5minutes
9%
NA
Ant "o
Posterior
N
IN
Ant nor
AM
%
postof
%I NO
14%
AdUlt Child
75 a g ei
Differential Impressions:
• Explosion e Amputations
• Structural Collapse e Crush Injury Syndrome
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Spinal Motion Restriction Guideline
Pediatric: Spinal Motion Restriction Guideline
PEARL I Blast injuries may be coupled with primary and secondary Blunt Force Trauma
PEARL I Crush injuries may be coupled with Blunt Force Trauma
• Hemorrhage Control:
Direct Pressure
Pediatric: Direct Pressure
Pressure Dressing
Pediatric: Pressure Dressing
Tourniquet
Pediatric: Tourniquet
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emergencies I Hypo& I lyperthermia Guideline asnecessary/indicated
PEARL I Cold blood does not clot—Hibler's Method preserves body heat and reduces Lethal Triad
• Burn Electrocution I Smoke Inhalation Guideline as necessary/indicated
Pediatric: Burn I Electrocution I Smoke Inhalation Guideline as necessary/indicated
PEARL I Burns may be coupled with Blast Injury
• Pelvic Splinting as necessary/indicated
Pediatric: Pelvic Splinting as necessary/indicated
PEARL I Blast injuries may be coupled with primary and secondary Blunt Force Trauma
PEARL I Crush injuries may be coupled with Blunt Force Trauma
• Extremity Splinting as necessary/indicated
Pediatric: Extremity Splinting as necessary/indicated
• Perform Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue, GCS<12 or Paramedic Discretion=Trauma Alert
Pediatric: Perform Pediatric Trauma Triage Criteria & Methodology Assessment Checklist
PEARL 11 Red,2 Blue,Altered Mental Status or Paramedic Discretion=Trauma Alert
Advanced Life Support Actions/Considerations:
• Pleural Needle Decompression as necessary/indicated
Pediatric: Pleural Needle Decompression asnecessary/indicated
• Crystalloid Resuscitation IV/10 as necessary/indicated
Pediatric: Crystalloid Resuscitation IV/10 asnecessary/indicated
PEARL I Perfusion target.-permissive hypotension;peripheral pulses present—restrict crystalloid
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
76 a g el
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
77 a g el
Differential Impressions:
• Lacerated Globe
• Foreign Body/Substance (not embedded) • Global Rupture
• Foreign Body(impaled object) • Protruding Eye
• Corneal Abrasion • Orbital Fracture
• Retinal Artery Occlusion
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Foreign Body/Substance (not embedded) &Corneal Abrasion:
Normal Saline Irrigation 2L or 20 minutes
PEARL I Remove any caustic powder prior to irrigation
�Lmrmimroiumimuvunnmr�rUwrmr�iUmimao�a�m�mnrw�mmiUwra�aivrnarcmuwimmimr�imr�iautmmiUmimmiUwm�mnrm�amaUwra�miUmimroiumumuiumimr�rUwrmr�iUmimaiaa�m�mnrw�mmiUwra�aivrnarcmuwimmimr�imr�iaummmiUmimmiUwm�mnrm�a�miUwra�miUmimroiumumuiumimr�rUwrmr�iUmimaiaam�mnrw�mmiUwramovrnarcmuwimmimr�imr�iautmmiUmimmiUwm�mnrm�a�miUwra�miUmimroiumumuvumimr�rUwrmr�iUmimaiaa�m�mnrw�mmiUwra�aivrnarcmuwimmimr�imr�iautmaaUmimmiUwm�mnra�a�miUwra�miUmimroiumumuiumimr�rUwrmr�iUmimaiaa�m�mnrw�mmiUwra�aivandrcmuwimmimr�imr�iautmmiUmimmiUwm�mnrm�a�miUwra�miUmimroiumumuiunnmr�rUwrmr�iUmimao�a�m�mnrw�mmiUwra�aivrnarcmuwimmimr�imr�iautmmiUmimmiUwm�mnrm�amaUwra�miUmimroiuwimmimr�mu
• Foreign Body(impaled object), Globe Injury and/or Protruding Eye:
i. Shield or cup dress affected eye
ii. Consider loose cover to unaffected eye to reduce eye movement
iii. Protect loss of fluids: apply saline moistened dressing as necessary
iv. Consider C-Collar to reduce head movement
v. Elevate stretcher head
• Orbital Fracture and Retinal Artery Occlusion
i. Shield or cup dress affected eye
ii. Consider loose cover to unaffected eye to reduce eye movement
iii. Consider C-Collar to reduce head movement
iv. Elevate stretcher head
Advanced Life Support Actions/Considerations:
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
• Nausea &Vomiting Management Guideline as necessary/indicated
PEARL I ic therapy i's aimed at reducing
• Crystalloid Resuscitation IV/10 as necessary/indicated
Pediatric: r s ll i sus i i n IV/I IV/10 asnecessary/indicated
PEARL I Perfusion target,,,permissive hypotension;peripheral pulses present-
restrict crystalloid
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
78 1 ag el
Adult Trauma Triage Criteria & Methodology
The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological
characteristics of a person sixteen (16) years of age or older for the presence of at least one of the following
four (4) criteria to determine whether to transport as a trauma alert. These four criteria are to be applied in the
order listed, and once any one criterion is met that identifies the patient as a trauma alert; no further
assessment is required to determine the transport destination.
Criteria:
1. Meets color-coded triage system (see below)
2. GCS < 12 (Patient must be evaluated via GCS if not identified as a trauma alert after application
of criterion 1.)
3. Meets local criteria(specify):
4. Patient does not meet any of the trauma criteria listed above but, in the judgment of the
EMT or paramedic, should be transported as a trauma alert(document)
COMPONENT
AIRWAY RESPIRATORY RATE OF 30 or GREATER ACTIVE AIRWAY ASSISTANCE'
B
CIRCULATION SUSTAINED HR OF 120 BEATS PER LACK OF RADIAL PULSE WITH SUSTAINED
MINUTE or GREATER r BP <90 mmHg
B
BEST MOTOR BMR =5 BMR = 4 or LESS or PRESENCE OF PARALYSIS,
RESPONSE or SUSPICION OF SPINAL CORD INJURY or
LOSS OF SENSATION
CUTANEOUS SUF F TISSUE LOSS2or r MORE TBSA
GSW TO THE EXTREMETIES or AMPUTATION PROXIMAL TO THE WRIST or
ANKLE r ANY PENETRATING INJURY TO
HEAD,
NECK, or TORS03
LONGBONE SINGLE FX SITE DUE TO MVA or FALL FRACTURE OF TWO or MORE LONGBONES
FRACTURE 10 ` or MORE
B
AGE 55 YEARS or OLDER
B
MECHANISM EJECTION FROM VEHICLE or
OF INJURY DEFORMED STEERING WHEEL6
B
=any one(1)-transport as a trauma alert Bany two(2)-transport as a trauma alert-transport as a
trauma alert
1. Airway assistance beyond administration ofoxygen.
2. Major degloving injuries, or major flap avulsion (>5 in.)
3. Excluding superficial wounds in which the depth of the wound can bedetermined.
4. Longbone(Including humerus, (radius, ulna),femur, (tibia orfibula).
5. Excluding motorcycle, moped,all terrain vehicle, bicycle,or open body of a pickup truck.
6. Only applies to driver of vehicle.
79 a
Pediatric Trauma Scorecard Methodology
The EMT or Paramedic shall assess the condition of those injured individuals with anatomical and physical characteristics
of a person fifteen (15)years of age or younger for the presence of one or more of the following three(3)criteria to determine
the transport destination per 64E-2.001, Florida Administrative Code, (F.A.C.):
1)Pediatric Trauma Triage The individual is assessed based on each of the six (6)
physiologic components listed below (left column). The single, most appropriate criterion for each
components is selected (along the row to the right). Refer to the color-coding of each criteria and legend below
to determine the transport destination:destination:
COMPONENT
SIZE WEIGHT 11 Kg or
LENGTH<33 INCHES ON A PEDIATRIC
LENGTH AND WEIGHT EMERGENCY
TAPE
G L G L B
AIRWAY NORMAL SUPPLEMENTED 02 ASSISTED
T T 1
CONSCIOUSNESS AWAKE AMNESIA OR LOSS OF ALTERED MENTALSTATUS
CONSCIOUSNESS COMA or PRESENCE OF PARALq%IS
SPINALOR SUSPICION OF CORD
INJURY or LOSS OF SENSATION
CIRCULATION GOOD PERIPHERAL CAROTID OR FEMORAL FAINT OR NON-PALPABLE
PULSES; PULSES PALPABLE, BUT THE CAROTID OR FEMORAL
RADIAL OR PEDAL PULSE NOT PULSE or
PALPABLE or SBP<90-mmHg
L R
FRACTURE NONE SEEN OR SINGLE CLOSED LONG OPEN L T )
SUSPECTED BONE (3) FRACTURE (4) OR MULTIPLE FRACTURE SITES OR
I MULTIPLE DISLOCATIONS( )
B L R
CUTANEOUS NO VISIBLE INJURY CONTUSION OR ABRASION MAJOR SOFT TISSUE
(6)OR MAJOR FLAP AVULSION OR 20
OR 30 BURNS T %TBSA OR
AMPUTATION (7) r ANY
INJURYPENETRATING ,
LECK, OR TORSO(8)
_RED,any one(l)-transport as a trauma alert =BLUE,any two -transport as a trauma alert G_GREEN,follow local protocols
2) Meets local criteria (specify): all pediatric trauma alert patients will be transported to the closest facility if air support is not
available.
3) Patient does not meet any of the trauma criteria listed above, but the EMT or Paramedic can call a"Trauma Alert" if, in
his or her judgment,the trauma patient's condition warrants such action. Must be documented on run report pursuant to
64E-2.013, (F.A.C.)
1. Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts.
2. Altered mental states include drowsiness,lethargy, inability to follow commands,unresponsiveness to voice,totally unresponsive.
3. Long bones include the humerus,(radius, ulna),femur, (tibia orfibula).
4. Long bone fractures do not include isolated wrist or anklefractures.
5. Long bone fractures do not include isolated wrist or ankle fractures ordislocations.
6. Includes major degloving injury.
7. Amputation proximal to wrist or ankle.
8. Excluding superficial wounds where the depth of the wound can bedetermined.
80 a
Differential Impressions:
• Human bite
• Animal bite
• Snake bite/envenomation • Cnidaria sting (jellyfish)
• Spider bite/envenomation • Stringray/Catfish sting
• Hymenoptera bite/envenomation (ants,bees,
sawflies,wasps)
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Human &Animal:
Highly infectious—irrigate and dress wounds as necessary/indicated
• Snake &Spider:
Immobilize extremity in neutral position—no ice,tourniquets, cutting or sucking injury site
• Hymenoptera
Remove/scrape off stingers/venom sacs with a blunt-edge object (e.g., credit card or tongue depressor)
• Cnidaria:
Remove from skin with sea water, rinse with vinegar(if available) and immerse in very warm water
• Stringray/Catfish:
Do not remove barb—immerse in very warm water
• Allergic Reaction I Anaphylaxis Guideline as necessary/indicated
Pediatric: Allergic Reactionl uasnecessary/indicated
Advanced Life Support Actions/Considerations:
• Allergic Reaction I Anaphylaxis Guideline as necessary/indicated
Pediatric: Allergic Reaction Anaphylaxis n r in i
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric: r s ll i Resuscitation c k IV/10 asnecessary/indicated
• Pain I Anxiety I Procedural Sedation Management Guideline as necessary/indicated
Pediatric: Pain I AnxietyJ Procedural Sedationt Guideline as necessary/indicated
• Nausea I Vomiting Management Guideline as necessary/indicated
Pediatric: Nausea I Vomiting ManagementGuideline n n i
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
81 a g el
a
Differential Impressions:
e Drowning • Submersion
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emergencies I Hypo & I lyperthermia Guideline asnecessary/indicated
• Reactive Airway Disease Guideline as necessary/indicated
Pediatric: Reactive Airway Disease Guideline asnecessary/indicated
Advanced Life Support Actions/Considerations:
• CPAP 5—15cm/H20 PEEP
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
Pediatric: Exposure Emergencies I Hypo & I lyperthermia Guideline asnecessary/indicated
• Reactive Airway Disease Guideline as necessary/indicated
�-, Pediatric: Reactive Airway Disease Guideline asnecessary/indicated
• Crystalloid Resuscitation lOcc/kg IV/10 as necessary/indicated
Pediatric: Crystalloid Resuscitation 20cc/kg I 0 asnecessary/indicated
PEARL I Resuscitate cold water drowning until warm—transport
• Epinephrine 0.1-0.5mcg/kg/min IV/10 Infusion as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
)P-- Pediatric: Epinephrine 0.1—0.5mcg/kg/min IV/10infusion
82 a g ei
Ah 0
Differential Impressions:
e Hypothermia • Hyperthermia
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Hypothermia
Passive External Rewarming
Remove from cold environment, remove wet clothing
Hibler's Method of Thermopreservation
Pediatric: Passive External Rewarming
Pediatric: Remove from cold environment, remove wetclothing
Pediatric- I libler's Method of Thermopreservation
PEARL I Handle gently to reduce lethal arrhythmias
•
Hyperthermia
Passive External Cooling—fans, misting, and/or ice packs to groin, axilla and neck
Remove from hot environment, remove clothing
)'o- Pediatric: Passive External Cooling—fans, misting, and/or ice packs to groin, axilla andneck
Pediatric: Remove from hot environment, removeclothing
PEARL I Withdrawal cooling as core temperature approaches 100.07137.7T
Advanced Life Support Actions/Considerations:
• Hypothermia
Warm Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
)P-- Pediatric: Warm Crystalloid Resuscitation 20cc/kg IV/10 as necessary/indicated
PEARL Rough patient handling may cause ventricularfibrillation
PEARL Hypothermia i's susceptible to progressive bradycardias
• Hyperthermia
Cool Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric: Cool Crystalloid Resuscitation 20cc/kg IV/10 asnecessary/indicated
PEARL I Withdrawal cooling as core temperature approaches 100.07137.7T
Medical Control Actions/orders/Requests:
• Consult as necessary/indicated
83 a g el
Differential Impressions:
• 3rdTrimester Hypertension
• 3rdTrimester Proteinuria
• 3rdTrimester Headache
• Pre-Eclampsia • 3rd Trimester Edema
• Eclampsia • 3rdTrimester Visual Chan es
• Post-Partum Eclampsia (<4weeks postpartum) g
• 3rdTrimester Seizure Activity
• Early Post-Partum Seizure Activity (<4weeks
post partum)
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Place in left lateral recumbent position
• bG <60mg/d L:
Diabetic Emergencies I Hypo & Hyperglycemia Guideline as necessary/indicated
Advanced Life Support Actions/Considerations:
• bG<60mg/dL with vascular access:
Diabetic Emergencies I Hypo & Hyperglycemia Guideline as necessary/indicated
• bG Normal, is Pregnant or early Post-Partum:
Magnesium Sulfate 4gm in 100cc D5W IV Infusion over 20 minutes
MagnesiumPEARL I -i r
or
Magnesium Sulfate 4gm IM (2gm in each gluteus)
or
Midazolam 2.5—5.Omg IV/10; may repeat q 10minutes PRN
m
Magnesium Sulfate i's otherwise unavailable or ineffective
c seizure activity when
or
Midazolam S.Omg IM/IN; may repeat q 10minutes PRN
PEARL I Midazolam i's second-line therapyfor eclamptic tonic-clonic seizure activity when
Magnesium Sulfate i's otherwise unavailable or ineffective
IW 1WAIF11fUltl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/U/U///N4/4/Ff4/U/U(f(4141U!/l4/U/�//f/NN/4/Ff4/U/UlflNtl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/U/U///N4/4/Ff4/U/U(f(4141U!/l4/U/�//f/NN/4/Ff4/U/UlflNtl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/U/U///N4/4/Ff4/U/U(f(4141U!/l4/U/�//f/NN/4/Ff4/U/UlflNtl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/U/U///N4/4/Ff4/U/U(f(4141U!/l4/U/�//f/NN/4/Ff4/U/UlflNtl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/U/U///N4/4/Ff4/U/U(f(4141U!/l4/U/�//f/NN/4/Ff4/U/UlflNtl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/U/U///N4/4/Ff4/U/U(f(4141U!/l4/U/�//f/NN/4/Ff4/U/UlflNtl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/U/U///N4/4/Ff4/U/U(f(4141U!/l4/U/�//f/NN/4/Ff4/U/UlflNtl(tl!//p/p/p///N//U/AIU/U/pll(NPIP!//4/U/u///N4/4/Ff4/N/U/flN4lU!//4/UlUlf(U(e'
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
84 a g el
Differential Impressions:
• Normal Spontaneous Vaginal Delivery 9 Stillborn Delivery
• Complicated Spontaneous Vaginal Delivery e Newborn Distress Delivery
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Exposure Emergencies I Hypo & Hyperthermia Guideline as necessary/indicated
)P-- Pediatric-. Exposure Emergencies I Hypo& I lyperthermia Guideline asnecessary/indicated
PEARL I Cold blood does not clot—Hibler-s Method preserves body heat and mitigates Lethal Triad
• Normal Delivery Procedure
❖ Place the mother on a firm surface and elevate hips
❖ Inspect the vaginal area for impending delivery(crowning), or any signs of abnormal presentation
—prolapsed amniotic sac, limb presentation, cord presentation, or breech presentation
PEARL I Signs of imminent delivery include,.-membrane rupture or bloody show, contractions,
❖
urge to move bowels andlor urge to push
Apply gentle palm pressure to the infant's head to prevent explosive delivery and tearing of
perineum
As delivery occurs, suction mouth then nose
❖ If amnion is still intact as head delivers, instruct mother to stop pushing and gently tear open
membrane and immediately suction mouth, then nose
❖ Keep newborn warm and dry
❖ Maintain the newborn at vaginal level until cord is cut
❖ Clamp the cord 6 and 9 inches away from baby and cut between the clamps
❖ Stimulate the newborn as necessary/indicated
❖ Document the time of delivery and perform APGAR score at 1 and 5 minutes
• Complicated Delivery Procedures
Nuchal Cord:
❖ Place the mother on a firm surface and elevate hips
❖ Inspect the vaginal area for impending delivery(crowning), or any signs of abnormal presentation
—prolapsed amniotic sac, limb presentation, cord presentation, or breech presentation
❖ Apply gentle palm pressure to the infant's head to prevent explosive delivery and tearing of
perineum
❖ As delivery occurs, attempt to slip the umbilical cord over the newborn's head
❖ If umbilical cord is too tight to maneuver, immediately clamp and cut
❖ Continue with delivery, suction mouth then nose
Prolapsed Cord:
.e Do not delay transport
❖ PEARL I Primary objective.-maintain a pulsatile umbilical cord
Place the mother in Trendelenberg or knee-chest position
❖ Instruct the mother to pant and not push with each contraction
❖ Apply upward manual pressure through the vagina lifting the presenting newborn anatomy away
85 a g el
from and off the umbilical cord
❖ With the umbilical cord now pulsating, maintain that position and transport
iuUim�mmimmimuimmioimraimioarimmroimiaiwiar�rUimiowiaimroiUtarwiaiwraimiorrammrr�wivudiaiumuuimmiada�mUarudian�iyuwuiUiuuwaiw�vda�L�U�vuu�vimiaiarvivimmiaiwiaiwiaruimaronuimaioiUidimimwiaiarvivimaioimiaiiaiaiuimmioimiaimioiUmiiaiawiano�oivmrratarmiaimiaiUimiuioimiaimioiU�mmioimiai�ioiUimmioariaimioiUronUiaimiaimioiUmimi�mianoiaiumnviaimiaimioiUmnuian�immimUmnu�mmiono�mUimiuioimiaimioiUimmioimimiaioiUmimiowianoioiUmnuioiwiaimioiUmnuiaimiaimiaiuimaiaimraimiorramwiavimmimuiUim�mmimmimuimmioimraimioarimmroimiaiwiar�rUimiowiaimroiUtarwiaiwraimiorrammrr�wivudiaiumuuimmiada�mUarudian�iyuwuiUiuuwaiw�vda�L�U�vuu�vimiaiarvivimmiaiwiaiwiaruimaronuimaioiUidimimwiaiarvivimaioimiaiiaiaiuimmioimiaimioiUmiiaiawiano�oivmrratarmiaimioiUmnuioic
Limb Presentation:
•'• Do not delay transport
❖ Place the mother head down with pelvis elevated position
❖ Instruct the mother to pant and not push with each contraction
❖ Maintain that position, do not pull on the exposed limb and transport
Breech Presentation:
•'• Do not delay transport
❖ Place the mother head down with pelvis elevated position
❖ Instruct the mother to pant and not push with each contraction
❖ Deliver the anterior shoulder in a gentle, controlled fashion,then deliver the posterior shoulder
and the remainder of the newborn
❖ As the newborn's head passes the pubis, apply gentle upward pressure until the mouth appears
over the perineum and immediately suction the mouth,then nose
❖ If the head does not deliver, form a "V" with the index and middle finger on either side of the
infant's nose.
❖ Push the vaginal wall from the face, maintain that position and transport
Postpartum Hemorrhage:
❖ Massage the uterus/fundus from pubis toward umbilicus
PEARL I Do not pack vagina to arrest bleeding
❖ Encourage newborn breast feeding
Newborn Distress:
Pediatric-. l 1A Neonatal Cardiac ArrestIasnecessary/indicated
Advanced life Support Actions/Considerations:
• Complicated Delivery Procedures
Meconium Aspiration Syndrome:
❖ If meconium is present and the newborn is not vigorous (poor muscle tone,weak respiratory
effort, or heart rate<100), perform laryngoscopy and oro endotracheal tube suctioning via
meconium aspirator
❖ Suction until meconium is no longer present (may require repeat intubations); re-intubate with a
new endotracheal tube
le Vaginal Bleeding Guideline as necessary/indicated
Pediatric-. I Cardiac Arrest Algorithm asnecessary/indicated
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
Pediatric- l 1A Neonatal Cardiac Arrest Algorithmasnecessary/indicated
• Nausea I Vomiting Management Guideline as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
86 a g el
Normal vaginal delivery:
Yagiii,,W birtfi
C[amp" , R)intaf ircislon
IJ ww''
"MIA,14
........... ............
ARR/E III
Baby @11
As Se babys head
J�dt',�Iive,,i�'ed,support it with
nds,[twill rtatut"'allyIr ' 1 ,
Oil OLK tii a ,d turn to OM02 I'l,P,
Other defivery,presentations:
Ce phak p�resemtation SrEICCII pre-sentation V Sammie rwsftion Placenta a6aiptio,Ari0tf'iDrI1%,Of the hrmch pre�ocntxt'ion
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Delivery pre erl.aUtm fs the pusit'Joinof the
presevafg part.of the f'etus(head,feet,etc) Complete I ncom p le te F ma n k,
ai Tt irr,,irnes dliowrii the b,iirth canal bretech tweech breech
Fetus fins pustierier,presei"itanion! Fetus in transverme lie pir"esentation
................ ........
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88 a g e
40
Differential Impressions:
• Abrutio placenta
• Ectopic pregnancy rupture • Endometrosis
• Placenta previa • Memorrhagia
• Inevitable abortion • Postpartum hemorrhage
• Spontaneous abortion • Sexual battery/Vaginal trauma
• Therapeutic abortion • Uterine rupture
• Threatened abortion
Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
• Provide emotional support
PEARL I Any products of conception should be collected and transported with the patient
PEARL I In the case of a sexual battery, attempt to preserve evidence
• If pregnant and if delivery is not imminent,transport in left lateral recumbent position
• If postpartum, massage the uterus/fundus and encourage newborn breast feeding
vaginaPEARL I Do not pack
Advanced Life Support Actions/Considerations:
• Crystalloid Resuscitation 10cc/kg IV/10 as necessary/indicated
• Epinephrine 0.1—0.5mcg/kg/min IV/10 Infusion as necessary/indicated
Medical Control Actions/Orders/Requests:
• Consult as necessary/indicated
89 a g el
Medication Class Indications Contraindications Adverse Effects
Adenosine * Stable Narrow-Complex Tachycardia * Chest Pain
(Adenocard) * Supraventricular Tachycardia * Dizziness
e Paraoxsysmal Supraventricular Tachycardia e Dyspnea
Antiarrhythmic * Headache
* Known Atrial Fibrillation or Flutter * Facial Flushing
o 2nd and 3rd Degree Heart Block * Palpitations
* Sick Sinus Syndrome o Transient Asystole
e Known Allergy/Hypersensitivity e Nausea/Vomiting
Albuterol * Reactive Airway Disease * Anxiety
(Proventil) * Anaphylaxis * Dizziness
(Ventolin) * Toxic Fume Inhalation * Palpitations
* Paradoxical Bronchospasm
Bronchodilator,
Selective Beta2Agonist * Symptomatic Tachycardia * Tachycardia
o Ischemic Chest Pain * Tremors
* Known Allergy/Hypersensitivity 9 Nausea/Vomiting
Arniodarone 9 Ventricular Fibrillation * AV Conduction
(Cordarone) * Wide-Complex Tachycardia Abnormalities
* Pulseless Ventricular Tachycardia * Bradycardia
Antiarrhythmic, * Headache
Sodium,Calcium,and e Hypotension * Hypotension
Potassium Channel Blocker e 2nd and 3rd Degree Heart Block * Torsade de pointes
* Congestive Heart Failure * Nausea/Vomiting
* Symptomatic Bradycardia
* Known Allergy/Hypersensitivity
Aspirin 9 Ischemic Chest Pain * Anaphylaxis
(None) e Occult Bleeding
9 Bleeding Disorders * Gastrointestinal Irritation
NSAI D. * Gastrointestinal Bleeding * Tinnitus
Platelet Aggregation e Peptic Ulcer Disease * Nausea/Vomiting
Inhibitor, e Known Allergy/Hypersensitivity
Antipyretic
Atropine Sulfate 9 Symptomatic Bradycardia (pulse producing) e Blurred Vision
(Atropen) * Heart Blocks * Dilated Pupils
e Organophosphate Poisoning 9 Dizziness
Parasympathetic Blocker, * Nerve Agent Exposure * Dry Mucus Membranes
Anticholinergic * Palpitations
* None in Emergency Situations * Reflex Bradycardia
* Tachycardia
e Nausea/Vomiting
90 a g el
Medication Class Indications Contraindications Adverse Effects
Dextrose e Hypoglycemia o Extravasation injury
(D25%) * Hyperglycemia
(D50916) * Intracranial Hemorrhage * Tissue Necrosis
(InstaGlucose-oral) * InstaGlucose: Inability to Protect Airway * Thrombophlebitis
(swallow or manage secretions) * Rebound Hypoglycemia
Glucose,
Caloric Supplement
Diltiazern e Atrial Fibrillation with Rapid Ventricular e Asystole
(Cardizem) Response e Bradycardia
e Atrial Flutter 9 Dizziness
Calcium Channel Blocker 9 Refractory Paroxysmal Supraventricular * Heart Blocks
Tachycardia * Hypotension
* Nausea/Vomiting
e Hypotension/Hypoperf usion
* 2nd and 3rd Degree Heart Block
* Ventricular Tachycardia
* Wolfe-Parkinson White Syndrome
* Known Allergy/Hypersensitivity
Diphenhydramine * Allergic Reactions e Central Nervous System
(Benadryl) 9 Anaphylaxis Depression
* Motion Sickness/Nausea * Palpitations
Antihistamine(1-11), * Dystonia/Extrapyramidal Symptoms (EPS) * Tachycardia
Anticholinergic, * Thickened Bronchial
Antiemetic * Known Allergy/Hypersensitivity Secretions
* Nausea/Vomiting
Epinephrine 9 CardioPulmonary Arrest e Anxiety
(Adrenalin) * Anaphylaxis * Chest Pain
(EpiPen) * Reactive Airway Disease * Headache
(EpiPen,Jr) * Pediatric Croup * Palpitations
* Bradycardia * Tachycardia
Sympathomimetic,
* Shock •* Tremors
Alpha &Beta Adrenergic
* Ventricular Ectopi
Agonist
e None in Emergency Situations e Nausea/Vomiting
91 a g el
Medication Class Indications Contraindications Adverse Effects
Famotidine • Blood Transfusion Reactions • Dizziness
(Pepcid) • Headache
• Nausea/Vomiting
Hstamine-2 antagonist • Upset Stomach/Diarrhea
• Palpitations
• Seizures
Furosemide • Blood Transfusion Reaction • Chest Pain
(Lasix) • CH F • Shortness of Breath
• Abdominal Pain
Loop Diuretic 0 Hypovolemia • Nausea/Vomiting
Pneumonia • Diarrhea
Hydroxocobalamin • Smoke Inhalation • Headache
(Cyanokit) • Suspected or Known Cyanide Poisoning • Chromaturia (Red Urine)
• Erythemia/Skin Rash
Cyanide Poisoning Antidote o None in Emergencyi • Facial Flushing
• Diarrhea
• Nausea/Vomiting
Lactated Ringer's • Crystalloid Resuscitation • Fluid overload
Solution • Thrombophlebitis
(Lactated Ringer's Injection) e None in EmergencySituations
Isotonic Crystalloid
Medication Class Indications Contraindications Adverse Effects
Magnesium Sulfate e Torsades de Pointes o Central Nervous System
(none) 9 Refractory Ventricular Tachycardia Depression
9 Refractory Pulseless Ventricular Tachycardia * Hypotension
Intracellular Electrolyte, * Reactive Airway Disease * Respiratory Depression
Calcium Channel Blocker * Eclampsia Seizure * Nausea/Vomiting
e 2nd and 3rd Degree Heart Block
* Patients on Digitalis
e Known Allergy/Hypersensitivity
M ethyl pred n isolone 9 Reactive Airway Disease 9 Dizziness
(Solumedrol) * Anaphylaxis e Hypertension
* Gastrointestinal Irritation
Glucocorticoid Steroid * Known Hypersensitivity * Vertigo
* Age<2year old * Nausea/Vomiting
Midazolam * Seizure Disorders * Bradycardia
(Versed) e Procedural Sedation * Bronchospasm
e Central Nervous System
Benzodiazepine, e Hypotension Depression
Anticonvulsant, * Known Allergy/Hypersensitivity e Laryngospasm
Sedative * Hypotension
* Nausea/Vomiting
Naloxone * Opiate Overdose * Withdrawal Symptoms
(Narcan) * Cardiac Irritability
(Evzio) o Post Advanced Airway Management * Hypothermia
e Known Allergy/Hypersensitivity e Skeletal Tremors
Narcotic Antagonist 9 Nausea/Vomiting
Nitroglycerin e Acute Coronary Syndromes 9 Dizziness
(Nitrostat) * Unstable Angina * Facial Flushing
(Nitrobid) 9 STEM I 9 Headache
(Nitropaste) * Congestive Heart Failure/Pulmonary Edema * Hypotension
(Tridal) * Palpitations
Vasodilator, o Hypotension * Nausea/Vomiting
Antianginal, e Right Ventricular Infarct
Smooth Muscle Relaxant * Erectile Dysfunction Medication intake in the
past 24 hours
e Known Allergy/Hypersensitivity
Normal Saline Solution e Crystalloid Resuscitation * Fluid overload
(Saline 0.9%Injection) * Thrombophlebitis
e None in Emergency Situations
Isotonic Crystalloid
93 1 a g el
Medication Class Indications Contraindications Adverse Effects
Oxygen • Conditions with increased oxygen demands, Respiratory Depression in
(none) respiratory distress/insufficiency, or illness or COPD
injury resulting in impaired ventilation and/or
perfusion
• Nitrogen Wash-Out for Airway Management
None in Emergency Situations
Pralidoxine • Nerve Agent Exposure • Blurred Vision
(2-Pam) • Organophosphate Poisoning • Dilated Pupils
(Protopam Chloride) • Dizziness
(Duodote—when premixede None in Emergency Situations • Dry Mucus Membranes
with Atropine) • Palpitations
Nerve Agent Antidote
• Tachycardia
• Nausea/Vomiting
Promethazine • Nausea/Vomiting • Sedative when mixed with
(Phenergan) opiates
comatose or large amount of CNS • Seizures
Phenothiazine depressants (e.g. alcohol). • Hypotension
Children under 12 .
Sodium Bicarbonate • CardioPulmonary Arrest • Metabolic Acidosis
(none) • Metabolic Acidosis • May crystallize in IV solutions
• Tricyclic Overdose when mixed with Epinephrine
Alkanlinizing Buffer Agent . Known Hyperkalemia
Alkalosis
Thiamine • Adults with evidence of alcohol abuse or signs • None
(Vitamin B1) of malnourishment prior to the administration
of Dextrose
Carbohydrate Metabolite
e Known Allergy/Hypersensitivity
Vecuronium • Facilitation of Endotracheal Intubation • Prolonged respiratory
depression
• Bradycardia
• Bronchospasm
94 a g el
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Protocol Addendum 3/2512024
Epinephrine ( "Push
Push Dose Pressor"
INDICATIONS: Hypotension that fails fluid resuscitation (loss of radial pulse OR S B P less than 90 mmHg). Severe
allergic reaction/anaphylaxis. B[a d yca[dia refractory to Atropine/Pacing.
CONTRAINDICATIONS: Hypotension secondary to blood loss.
ECA u Rapid onset (1minute)with short duration (5-10 min) Monitor H R and BPthroughout
administration.
MEDICATION DILUTION INSTRUCTIONS: Dilute: Discard 9 m Ls of E pi 1|10,000(0.1 m R/m Q
a n d draw up 9 m L of NORMAL SALINE to create Push-Dose Pressor E pi 1| 100,000. This will yield 10 m cg/m L.
ADMINISTRATION
ADULT: Titrate 0.1 m R(10 m L) at a rate of 1 m L/m|n ute |V/10 to maintain S B P of 90 m m H G. May repeat 1x P R N.
PEDIATRIC: Tit[ate 0.1 mg(10 m Q at [ate of I m L/min ute |V/|0 to maintain age-appropriate S B P. May repeat 1k
P R N. Max dose 0.2mg .
95 | d g e
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ITE'
MEDICAL RESPONSE
Protocol Addendum 5/7/2024
SEVERE HYPERTENSION
When blood pressure is severely elevated over 180-190mmHg systolic and diastolic 100-110 these limits,acute
end-organ damage may result. When possible, it is important to control elevated BP to normal limits(160/90
mm Hg).
Variations is BP and P rates are common during ground transport and repeated assessment is recommended
that P rate be considered before treating elevated BP alone.
Incases of mild blood pressure elevation without other underlying illness,treatment can be deferred until patient is
delivered to destination facility. Defer treatment of hypertension when STROKE is a primary concern.
Remember that fever, pain and anxiety are frequent causes of moderately elevated BP and should be treated
appropriately.
Hypertensive end-organ damage is often marked by symptoms such as altered mental status and intracerebral
hemorrhage.
Treatment:
Malignant Hypertension—MUST ADDRESS EMERGENTLY
• SBP>220mmHG or DBP>120mmHg
May use the following medications, if available,
when indicated for malignant hypertension or
severe hypertension (BP >190/100) with rapid
pulse rate:
BETA BLOCKADE:
• Labetalol 10mg IVP over 1-2 minutes May repeat as 20mg again in 10 minutes. If
necessary, may repeat additional 20 mg after 20 minutes.
Target is a 10-20%reduction in the systolic BP.
• Metoprolol (Lopressor),-, 1.25-5 mg IV over 2 minutes
In HTN associated with STEMI/Non-STEMI MI: May administer 5mg every 5 (five) minutes as tolerated up
to 3 (three)doses,titrating to maintain BP and P within normal range.
96 age
1-gel Supraglottic Airway
Procedure Guidelines
9.391-gel Supraglottic Airway
1-gel is a second generation supraglottic airway, made of a medical grade thermoplastic elastomer,
designed to create a non-inflatable anatomical seal of the pharyngeal, laryngeal and perilaryngeal
structures. 1-gel comes in four pediatric and three adult sizes available.
Key components and their functions:
• Soft non-inflatable cuff
• Gastric channel for regurgitation, which significantly reduces potential for regurgitation to
get past the cuff and therefore aids in reducing the chance for aspiration. Please note size
one i-gel does not have a gastric channel.
• Provides "vent" for gastric pressure and stomach decompression.
• Epiglottic rest keeps the device from moving upwards out of position and prevents
the epiglottis from down folding or obstructing the distal opening
• Buccal cavity stabilizer has a built in natural curvature and propensity to adapt its
shape from the patient's anatomy, the widened design also provides vertical
strength and prevents rotation.
G2
iiav h 9r
a%
rl o%ivi/o�t ttr !S IIG,�i rrr
-Gel
INDICATIONS:
• Airway management in cardiac arrest
• Inability to intubate when rapid control of airway is essential
• Difficult airway cases
• Passive oxygenation during cardiac arrest
CONTRAINDICATIONS:
• Responsive patient with intact airway—protective reflexes
• Patients with known esophageal disease
• Caustic ingestions
• Upper-airway obstructions due to foreign bodies or pathology
• Trismus, limited mouth opening, airway abscess, trauma or mass
EMT/ Paramed'IC�
Equipment Needed: Appropriate size I-Gel Tube based onweight, securing device,water
based gel, ETCO2, pulse ox, stethoscope, NG Tube (10-12 French)
• Choose correct size tube from chart below.
* Remove I-Gel from the packaging and its cradle.
• Apply lubricant inside the packaging.
* Apply lubricant to the green-tinted areas of the I-Gel and inside tip.
Position patient's head in "sniffing" position
Hold tube with one hand (like a pencil) and apply chin lift, lift tongue and jaw to insert.
Following the hard palate, push downward, until resistance is met, continue pushing
downward until complete resistance is felt.
• Use the black horizontal "teeth line" on the bite block as a guideline for correct depth.
Ventilate patient with 100% 02 with BVM.
0 Confirm placement by auscultation of the lungs andcontinuous ETCO2and oximeter
monitoring.
• Insert NG tube see NG tube procedure -12 in open area of the tube.
Secure the I-Gel using securing strap.
' 1115
�.
/lam
-Gel Tube Sizing Chart: r
98 a g
Docusign Envelope ID: CB558053-F68C-41 BE-93EF-57C39CFF7AC9
ITE
MEDICAL RESPONSE
October 16,2024
ADDENDUM TO PROTOCOL BEHAVIORAL EMERGENCIES BAKER ACT / MARCHMAN ACT
Patients under Psychiatric Hold (Baker Act):The patient is to be secured to the stretcher using normal
safety belts PLUS a posterior belt strap with electrical tie over buckle.
The additional strap is to be placed around the patient's torso then around the stretcher and secured
tightly and buckled in the back using an electrical tie,without inhibiting breathing or causing pain.
When turning the patient over to the receiving facility,the electrical tie should be cut using trauma shears.
Remove and save the belt strap.
ostgd b :
Hin a reeve, D.0 Medical Director
: 863-655-0030 : 863-655-0062
ITE
u.. MEDICAL ESP' ONSE"
ADDENDUM TO DIABETIC EMERGENCIES PROTOCOL— HYPOGLYCEMIA
ORAL GLUCOSE (Insta Glucose)
ACTIONS:
Increases blood glucose levels slowly
INDICATIONS:
Patients with a known history of diabetes, or when a patient presents with symptoms like altered mental
status, seizures, unexplained weakness, confusion, or sudden changes in behavior, regardless of a known
diabetic history
BGL> 60 mgls, patients who are altered but alert enough to take the command to swallow.
Patients unable to swallow or Stroke symptoms
PRECAUTIONS:
None when patient can swallow, risk of aspiration if given improperly.
ADVERSE REACTIONS AND SIDE EEFECTS:
GI: Nausea
DOSAGE
Adult: 1 tube
Pediatric: 1 tube
TIME/ACTION PROFILE:
PO: Onset 10 minutes. Peak unknown. Duration unknown
1
rrrrrrrrrrrrrrrrrrrrrrrrrrrrr;
: 863-655-0030 : 863-655-0062
Ah
PATIENT SOFT RESTRAINT(ALS/BLS)
Baker Act consideration: Florida Statute Chapter 394, Part I, is also known as the Florida Mental Health
Act. The Baker Act provides legal procedures for patients with known or suspected mental illness. This
includes mental health examinations and treatment and provides authorization to police, physicians,
mental health professional and the courts to dictate certain medical care for persons who pose a threat
of harm to themselves or to others.
Baker Act is not intended for patients who are competent, are without mental illness, have decisional
capacity, and have been informed yet still desire to refuse care against medical advice.
Organic causes of behavioral change must be considered and ruled out.
• Patient Safety Guideline •
Communicate in a calm and nonthreatening manner
• Respect the dignity of the patient
• Request law enforcement as necessary/indicated for:
Law enforcement will provide EMS with a Baker Act Form (3052a), and as required for EMS safety, will
accompany (if handcuffed) or follow the ambulance to the hospital.
Contact Online Medical Control (OMC) for restraint approval before or as soon after as possible.
Must be adequately controlled prior to loading and transporting.
101 a g e.
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Goal(s):
• To establish a guideline for the management and documentation of restraining patients
• Primary consideration:The use of patient restraints is authorized in all instances where a patient's
behavior may jeopardize the safety of the patient or crew
• Secondary consideration: Restraints may be used when a patient lacks decisional capacity to make
rational decisions and exhibits behavior that may disallow necessary medical treatment
General Actions:
• Crew safety—Escaping Violent Encounters (EVE)
• Request law enforcement
PEARL I Carefully evaluate the rifsk-benefit of mechanical patient restratent versus
chemi'callph arm acologlecal restraint
• When appropriate, attempt less restrictive means of management including, verbal de-escalation
• Excited Delirium Syndrome Guideline as necessary/indicated
Patient Positioning
• Patients will be restrained in the supine, head-up position
• Patients may be restrained in a lateral recovery, head-up position as an alternative
• Patients will be mechanically restrained using a commercial soft restraint system or, if in custody,
hand-cuffs or shackles as deemed appropriate by law enforcement
• Patients will not be restrained in the prone position
Assessment and Documentation
• When a patient is restrained, the restraints shall be placed only tight enough to secure the extremity
without compromising neurovascular function. Distal neurovascular function shall be checked and
documented after application and every 10 minutes thereafter using the following test procedures:
Grip strength—should be equal and strong on most patients
❖ Sensations—upper and lower extremities must have good sensations and absence of numbness
❖ Capillary refill—upper and lower extremities must result in a capillary refill time of less than 2
seconds
• The reason for restraining a patient and the results of all the above tests shall be documented in the
patient care report
• Grip strength, sensation and capillary refill tests are to be performed and the results documented every
10 minutes
• In the event of a short transport time,the results of a minimum of 2 sets are to be documented with
one set to be completed upon arrival at the receiving facility
Hospital Notification
• The receiving facility shall be notified prior to arrival that a patient is in restraints and security should
be available upon arrival
ADDITIONAL CHEMICAL RESTRAINT/EXCITED DELIRIUM (ALS)
102 a g e.
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• Psychiatric or Psychological behavioral violence
• Pharmacological or Substance Abuse violence
• Toxidrome rage - Metabolic storm
• Infectious agitation - Conditions that result in agitated, violent, or uncooperative behavior that pose
imminent threat or danger to self or others PEARL I Exclusion Criteria: Agitated or violent behavior due
to medical conditions including, but not limited to:
1) Head trauma
2) Hypoglycemia
3) Hypoxia Basic Life Support Actions:
• Universal Care Guideline
• Patient Safety Guideline
Reduce external stimuli— lights, sirens, horns, etc.
• Patient Restraint Guideline
Contact Online Medical Control (0MQ for restraint approval before or as soon after as possible.
Must be adequately controlled prior to loading and transporting .
Soft restraints may be placed to upper, lower or all extremities.
Have scissors readily available in case the restraints need to be rapidly removed.
Patients shall not be packaged or transported prone, hog-tied or in any position that may impede
pulmonary function
Indicated Advanced Life Support Actions/Considerations:
Midazolam 5mg IM/IN/IV
• Crystalloid Resuscitation 10cc/kg IV/10 Pediatric: Crystalloid Resuscitation 20cc/kg IV/10
• Hyperthermia Guideline as necessary/indicated
• If patient emerges from loading dose: Midazolam 2.5—5mg IV/10/IM/IN Or Diphenhydramine 25-50mg
IV/I M prn sedation.
Lorazepam (Ativan) Seizures/Sedation/Agitation ADULT • 1-2 mg given slowly IV over 1-2 minutes, then
repeated at 5-to 15-minute intervals until the desired effect is achieved
• Maximum total dose is 10 mg Pediatric Infants and children: 0.05-0.1 mg/kg IV over 2-5 minutes; not to
exceed 4 mg/dose; may repeat q10-15min PRN Alternatively, 0.1 mg/kg at slow IV rate not to exceed rate
of 2 mg/min; not to exceed dose of 4 mg Adolescents: 4 mg slow IV; if seizure persists after 10-15 minutes,
administer 4 mg IV again Pediatric Sedation/Agitation Children: 0.05 mg/kg/dose PO q4-8hr; not to exceed
2 mg/dose
• Consult as necessary/indicated );--- Pediatric: Contact Medical Control
103 a g e.